Impact of frozen section on long-term outcomes in robot-assisted laparoscopic prostatectomy.

OBJECTIVES: To compare 1-year functional and 5-year oncological outcomes of men undergoing robot-assisted laparoscopic prostatectomy (RALP) with neurovascular structure-adjacent frozen-section examination (NeuroSAFE) with those in men undergoing RALP without NeuroSAFE (standard of care [SOC]). SUBJECTS AND METHODS: Men undergoing RALP in our centre between 1 January 2009 and 30 June 2018 were enrolled from a prospectively maintained database. Patients were excluded if they had undergone preoperative therapy or postoperative adjuvant therapy or were enrolled in clinical trials. Patients were grouped based on use of NeuroSAFE. Follow-up was censored at 5 years. The primary outcome was difference in time to biochemical recurrence (BCR) on multivariable analysis, defined as prostate-specific antigen (PSA) >0.2 ng/L on two consecutive measurements. Secondary outcomes were difference in 1-year erectile dysfunction and incontinence. RESULTS: In the enrolment period, 1199 consecutive men underwent RALP, of whom 1140 were eligible, including 317 with NeuroSAFE and 823 with SOC. The median PSA follow-up was 60 months in both groups. Rates of 5-year BCR were similar on Kaplan-Meier survival curve analysis (11% vs 11%; P = 0.9), as was time to BCR on multivariable Cox proportional hazards modelling (hazard ratio 1.2; P = 0.6). Compared with the SOC group at 1 year, the NeuroSAFE group had similar unadjusted rates of incontinence (5.1% vs 7.7%) and lower unadjusted impotence (57% vs 80%). On multivariable analysis, NeuroSAFE patients had equivalent risk of incontinence (odds ratio [OR] 0.59, 95% CI 0.17-1.6; P = 0.4) but significantly reduced risk of erectile dysfunction (OR 0.37, 95% CI 0.22-0.60; P < 0.001). CONCLUSIONS: For men undergoing RALP, compared with SOC, NeuroSAFE patients had equivalent time to BCR and risk of 1-year incontinence, and significantly lower risk of 1-year erectile dysfunction.

Xanthogranulomatous pyelonephritis: a systematic review of treatment and mortality in more than 1000 cases.

OBJECTIVES: To systematically review the current demographics, treatment and mortality rate associated with xanthogranulomatous pyelonephritis (XGP) and to test the hypothesis that the weighted pooled peri-operative mortality rate will be <10%. METHODS: Searches were performed of the Cochrane, Embase and Medline databases and the grey literature for studies published during the period 1 January 2000 to 30 August 2021. Eligible studies reported cohorts of ≥10 predominantly adult patients with XGP and described either average patient age or mortality rate. RESULTS: In total, 40 eligible studies were identified, representing 1139 patients with XGP. There were 18 deaths, with a weighted pooled peri-operative mortality rate of 1436 per 100 000 patients. The mean age was 49 years, 70% of patients were female and 28% had diabetes mellitus. The left kidney was more commonly affected (60%). Four patients had bilateral XGP, and all of whom survived. Renal or ureteric stones were present in 69% of patients, including 48% with staghorn calculi. Urine culture was positive in 59% of cases. Fistulae were present in 8%. Correct preoperative diagnosis occurred in only 45% of patients. Standard treatment continues to comprise a short cause of antibiotics and open radical (total) nephrectomy. Preoperative decompression occurred in 56% of patients. When considered at all, laparoscopic nephrectomy was performed in 34% of patients. Partial nephrectomy was conducted in 2% of patients. CONCLUSIONS: Xanthogranulomatous pyelonephritis has a lower mortality rate than historically reported. A typical patient is a woman in her fifth or sixth decade of life with urolithiasis. While open radical nephrectomy remains the most common treatment method, laparoscopic, and to a lesser degree partial nephrectomy, are feasible in well selected patients.

Systematic review of urological injury during caesarean section and hysterectomy.

INTRODUCTION AND HYPOTHESIS: We aim to review iatrogenic bladder and ureteric injuries sustained during caesarean section and hysterectomy. METHODS: A search of Cochrane, Embase, Medline and grey literature was performed using methods pre-published on PROSPERO. Eligible studies described iatrogenic bladder or ureter injury rates during caesarean section or hysterectomy. The 15 largest studies were included for each procedure sub-type and meta-analyses performed. The primary outcome was injury incidence. Secondary outcomes were risk factors and preventative measures. RESULTS: Ninety-six eligible studies were identified, representing 1,741,894 women. Amongst women undergoing caesarean section, weighted pooled rates of bladder or ureteric injury per 100,000 procedures were 267 or 9 events respectively. Injury rates during hysterectomy varied by approach and pathological condition. Weighted pooled mean rates for bladder injury were 212-997 events per 100,000 procedures for all approaches (open, vaginal, laparoscopic, laparoscopically assisted vaginal and robot assisted) and all pathological conditions (benign, malignant, any), except for open peripartum hysterectomy (6,279 events) and laparoscopic hysterectomy for malignancy (1,553 events). Similarly, weighted pooled mean rates for ureteric injury were 9-577 events per 100,000 procedures for all hysterectomy approaches and pathologies, except for open peripartum hysterectomy (666 events) and laparoscopic hysterectomy for malignancy (814 events). Surgeon inexperience was the prime risk factor for injury, and improved anatomical knowledge the leading preventative strategy. CONCLUSIONS: Caesarean section and most types of hysterectomy carry low rates of urological injury. Obstetricians and gynaecologists should counsel the patient for her individual risk of injury, prospectively establish risk factors and implement preventative strategies.

Systematic Review of Local Anaesthetic Systemic Toxicity in Urology.

OBJECTIVE: To systematically evaluate cases of local anaesthetic systemic toxicity (LAST) in adult urological patients. METHODS: A search of the Cochrane, Embase, and Medline databases as well as grey literature from 1 January 1974 to 1 February 2023 was performed using reported methods. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible studies were published in English, described LAST secondary to local anaesthetic administration by urological medical staff to an adult patient, and reported >1 symptom of LAST. RESULTS: One hundred fifty-seven publications were screened, and six eligible studies (all case reports) were identified, representing six cases of LAST in adult urological patients. Patients were aged 29-54 years and one was female. Cases occurred secondary to penile dorsal nerve block (two cases), scrotal self-injection (two), circumcision (one) or trans-vaginal tape insertion (one). Causative drugs were lidocaine (three patients; median dose 600mg) and bupivacaine (three; 200mg). While one patient was found deceased at home and received no treatment, five experienced LAST as inpatients and were discharged with no deficit. Three patients (50%) experienced a state of reduced consciousness or seizures, one experienced psychosis and one had asymptomatic tachyarrhythmia. Management consisted of supportive management (five patients), intravenous lipid emulsion (three) or intravenous thiopental and diazepam (one). Recommended tools suggested that two of these studies were at moderate or high risk of bias. CONCLUSION: LAST is seen only rarely in adult urology. Most iatrogenic cases occur due to penile dorsal nerve block and most patients have no long-term sequelae. Urologists should be familiar with its presentation and management, and minimise risk by adhering to local anaesthetic maximum safe dose ranges.

The impact of catheter-based bladder drainage method on urinary tract infection risk in spinal cord injury and neurogenic bladder: A systematic review.

AIMS: To systematically compare the impact of catheter-based bladder drainage methods on the rate of urinary tract infections (UTIs) amongst patients with neurogenic bladder. METHODS: A search of Cochrane Library, Embase, Medline, and Grey literature to February 2019 was performed using methods prepublished on PROSPERO. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible studies were published in English and compared UTI incidence between neurogenic bladder patients utilizing bladder drainage methods of the indwelling urethral catheter (IUC), suprapubic catheter (SPC) or intermittent self-catheterization (ISC). The odds ratio of UTI was the sole outcome of interest. RESULTS: Eight nonrandomized observational cohort studies were identified, totaling 2321 patients who utilized either IUC, SPC, or ISC. Studies enrolled patients with neurogenic bladder due to spinal cord injury (seven studies) or from any cause (one study). UTI rates were compared between patients utilizing IUC vs SPC (four studies), IUC vs ISC (six studies), and SPC vs ISC (four studies). Compared with IUC, five of six studies suggested ISC use was associated with lower rates of UTI. Studies comparing IUC vs SPC and SPC vs ISC gave mixed results. Meta-analysis was not appropriate due to study methodology heterogeneity. CONCLUSIONS: Low-level evidence suggests amongst patients with neurogenic bladder requiring catheter-based drainage, the use of ISC is associated with lower rates of UTI than IUC. Comparisons of IUC vs SPC and SPC vs ISC gave mixed results. Future randomized trials are required to confirm these findings.

Patient Satisfaction in Emergency General Surgery: A Prospective Cross-Sectional Study.

BACKGROUND: The importance of the patient experience is increasingly being recognised. However, there is a dearth of studies regarding factors affecting patient-reported outcomes in emergency general surgery (EGS), including none from the Southern Hemisphere. We aim to prospectively assess factors associated with patient satisfaction in this setting. METHODS: In this prospective cross-sectional study, all consecutive adult patients admitted to an acute surgical unit over four weeks were invited to complete a validated Patient-Reported Experience Measures questionnaire. These were completed either in person when discharge was imminent or by telephone <4 weeks post-discharge. Responses were used to determine factors associated with overall patient satisfaction. RESULTS: From 146 eligible patients, 100 (68%) completed the questionnaire, with a mean overall satisfaction score of 8.3/10. On multivariate analyses, eight factors were significantly associated with increased overall satisfaction. Five of these were similar to those previously prescribed by other like studies, being patient age >50 years, sufficient analgesia, satisfaction with the level of senior medical staff, important questions answered by nurses and confidence in decisions made about treatment. Three identified factors were new: sufficient privacy in the emergency department, sufficient notice prior to discharge and feeling well looked after in hospital. CONCLUSIONS: Factors associated with patient satisfaction were identified at multiple points of the patient journey. While some of these have been reported in similar studies, most differed. Hospitals should assess factors valued by their EGS population prior to implementing initiatives to improve patient satisfaction.

Intra-operative cell salvage in urological surgery: a systematic review and meta-analysis of comparative studies.

OBJECTIVE: To evaluate systematically the safety and efficacy of intra-operative cell salvage (ICS) in urology. METHODS: A search of Medline, Embase and Cochrane Library to August 2017 was performed using methods pre-published on PROSPERO. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible titles were comparative studies published in English that used ICS in urology. Primary outcomes were allogeneic transfusion rates (ATRs) and tumour recurrence. Secondary outcomes were complications and cost. RESULTS: Fourteen observational studies were identified, with a total of 4 536 patients. ICS was compared with no the blood conservation technique (seven studies), preoperative autologous donation (PAD; five studies) or both (two studies). Cohorts underwent open prostatectomy (11 studies), open cystectomy (two studies) or open partial nephrectomy (one study). Meta-analysis was possible only for ATRs within prostatectomy studies. In this setting, ICS reduced ATR compared with no the blood conservation technique (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.76) but not PAD (OR 0.76, 95% CI 0.39-1.31). In the non-prostatectomy setting, ATRs amongst patients who underwent ICS were significantly higher or similar in one and two studies, respectively. Tumour recurrence was found to be significantly less common (two studies), similar (eight studies) or not measured (four studies). All six studies reporting complications found no difference in their ICS cohorts. Regarding cost, one study from 1995 found ICS more expensive than PAD, while two more recent studies found ICS to be cheaper than no blood conservation technique. As a result of inter-study heterogeneity, meta-analyses were not possible for recurrence, complications or cost. CONCLUSION: Low-level evidence exists that, compared with other blood conservation techniques, ICS reduces ATR and cost while not affecting complications. It does not appear to increase tumour recurrence post-prostatectomy, although follow-up durations were short. Small study sizes and short follow-ups mean conclusions cannot be drawn with regard to recurrence after nephrectomy or cystectomy. Randomized trials with long-term follow-up evaluating ICS in urology are required.

Strategies for success: a multi-institutional study on robot-assisted partial nephrectomy for complex renal lesions.

OBJECTIVE: To describe our technique, illustrated with images and videos, of robot-assisted partial nephrectomy (RAPN) for challenging renal tumours. PATIENTS AND METHODS: A study of 249 patients who underwent RAPN in multiple institutions was performed. Patients were identified using prospective RAPN databases. Complex renal lesion were defined as those with a RENAL nephrometry score ≥10. Data were analysed and differences among groups examined. RESULTS: A total of 31 (12.4%) RAPNs were performed for complex renal tumours. The median (interquartile range [IQR]) patient age was 57 (50.5-70.5) years and 21 patients (67.7%) were men. The median (IQR) American Society of Anesthesiologists score was 2 (2-3). The median (IQR) operating time was 200 (50-265) min, warm ischaemia time was 23 (18.5-29) min, and estimated blood loss was 200 (50-265) mL. There were no intra-operative complications. Two patients (6.4%) had postoperative complications. One patient (3.2%) had a positive surgical margin. The median (IQR) length of stay was 3.5 (3-5) days and the median (IQR) follow-up was 12.5 (7-24) months. There were no recurrences. RAPN resulted in statistically significant changes in renal function 3 months after RAPN compared with preoperative renal function (P < 0.001). CONCLUSION: Our results showed that RAPN was a safe approach for selected patients with complex renal tumours and may facilitate tumour resection and renorrhaphy for challenging cases, offering a minimally invasive surgical option for patients who may otherwise require open surgery.

Implementation rates of uro-oncology multidisciplinary meeting decisions.

OBJECTIVES: To assess implementation rates of the consensus plans made at the uro-oncology multidisciplinary meeting (MDM) of an Australian tertiary centre, and analyse obstacles to implementation. METHODS: A retrospective review was performed of all patients discussed at the uro-oncology MDM at our institution between 1 January and 30 June 2015. Rates of referral for MDM discussion after a new histological diagnosis of malignancy, categorised by tumour type, were assessed. Patient records were interrogated to confirm MDM plan implementation, with the outcomes examined being completion of MDM plan within 3 months and factors preventing implementation. RESULTS: During the enrolment period, from 291 uro-oncological procedures, 240 yielded malignant histology of which 160 (67%) were discussed at the MDM. Overall, 202 patients, including 32 females, were discussed at the uro-oncology MDM. MDM consensus plans were implemented in 184 (91.1%) patients. Reasons for deviation from the MDM plan included delay in care, patient deterioration or comorbidities, patient preference, consultant decision, loss to follow-up, and change in patient scenario due to additional new information. CONCLUSION: The MDM is increasingly important in the care of uro-oncology patients, with about two-thirds of new diagnoses currently captured. There appear to be few barriers to the implementation of consensus plans, with nearly all patients undergoing the recommended management.

Mini PCNL for renal calculi: does size matter?

OBJECTIVE: To evaluate the minimally invasive percutaneous nephrolithotomy (MIP) system for renal calculi. PATIENTS AND METHODS: Consecutive patients undergoing mini-percutaneous nephrolithotomy (mPCNL) procedures with the MIP system were enrolled. Patient position, American Society of Anesthesiologists classification, puncture location, stone clearance, postoperative drainage and complications were recorded, and features unique to MIP were noted. RESULTS: In all, 30 patients underwent 32 mPCNL procedures. The mean stone size was 17 (10.75-21.25) mm and the mean number of stones was 1 (1-2). The median stone clearance rate was 96.5 (95-100)%. The complication rate was 9.3%. No patient required a transfusion. In addition to these outcomes, we noted that the MIP system has many advantages over conventional PCNL (cPCNL). It is easy to learn and can be performed in both supine and prone positions. It is safe for supracostal puncture, provides excellent access to nearly all calyces and upper ureter, has multiple stone treatment options, can be used as an adjunct to cPCNL, and can be performed as a tubeless procedure. CONCLUSION: Our experience with the MIP system has shown several advantages over cPCNL. mPCNL with the MIP system has several features that suggest it should be considered as an alternative or adjunct to cPCNL, ureteroscopy and extracorporeal shockwave lithotripsy.

Prostate cancer outcomes for men who present with symptoms at diagnosis.

OBJECTIVE: To compare clinical features, treatments and outcomes in men with non-metastatic prostate cancer (PCa) according to whether they were referred for symptoms or elevated prostate-specific antigen (PSA) level. PATIENTS AND METHODS: This study used data from the South Australia Prostate Cancer Clinical Outcomes Collaborative database; a multi-institutional clinical registry covering both the public and private sectors. We included all non-metastatic cases from 1998 to 2013 referred for urinary/prostatic symptoms or elevated PSA level. Multivariate Poisson regression was used to identify characteristics associated with symptomatic presentation and compare treatments according to reason for referral. Outcomes (i.e. overall survival, PCa-specific survival, metastasis-free survival and disease-free survival) were compared using multivariate Cox proportional hazards and competing risk regression. RESULTS: Our analytical cohort consisted of 4 841 men with localized PCa. Symptomatic men had lower-risk disease (incidence ratio [IR] 0.70, 95% confidence interval [CI] 0.61-0.81 for high vs low risk), fewer radical prostatectomies (IR 0.64, CI: 0.56-0.75) and less radiotherapy (IR 0.86, CI: 0.77-0.96) than men presenting with elevated PSA level. All-cause mortality (hazard ratio [HR] 1.31, CI: 1.16-1.47), disease-specific mortality (HR 1.42, CI: 1.13-1.77) and risk of metastases (HR 1.36, CI: 1.13-1.64) were higher for men presenting with symptoms, after adjustment for other clinical characteristics; however, risk of disease progression did not differ (HR 0.90, CI: 0.74-1.07) amongst those treated curatively. Subgroup analyses indicated poorer PCa survival for symptomatic referral among men undergoing radical prostatectomy (HR 3.4, CI: 1.3-8.8), those aged >70 years (HR 1.4, CI: 1.0-1.8), men receiving private treatment (HR 2.1, CI: 1.3-3.3), those diagnosed via biopsy (HR 1.3, CI: 1.0-1.7) and those diagnosed before 2006 (HR 1.6, CI: 1.2-2.7). CONCLUSION: Our results suggest that symptomatic presentation may be an independent negative prognostic indicator for PCa survival. More complete assessment of disease grade and extent, more definitive treatment and increased post-treatment monitoring among symptomatic cases may improve outcomes. Further research to determine any pathophysiological basis for poor outcomes in symptomatic men is warranted.

Achieving trifecta outcomes in robotic-assisted partial nephrectomy within a fellowship training centre.

To assess the robotic-assisted partial nephrectomy (RAPN) trifecta rate within a fellowship program. Patients undergoing RAPN 01/01/2010-01/07/2023 were enrolled from a prospectively maintained database. All cases were performed jointly with surgical fellows, except when privately insured. Patients were excluded if they were converted to open or radical nephrectomy. The primary outcome was achieving the 'trifecta' of negative surgical margins, no complications < 30 days post-operatively and warm ischaemia time (WIT) < 25 min. The secondary outcomes were factors associated with trifecta success. Ethics approval was obtained. In the enrolment period, 355 patients underwent intended RAPN, of whom seven were excluded due to conversion to conversion to radical nephrectomy (6 patients) or conversion to open (one). Amongst the 348 eligible patients, median age was 60 years, 115 (33%) were female and 19 were private patients. WIT was < 25 min for 324/337 patients (96%), surgical margins were negative in 325 (93%), 294 (84%) were complication-free at 30 days and 301/320 (94%) had a < 30% decline in estimated glomerular filtration rate at 3-6 months postoperatively. Subsequently, trifecta outcomes were achieved in 253/337 (75%) patients. Comparing with patients without those with trifecta success were similar in all thirteen measured patients and tumour factors. In a teaching hospital, with a fellowship training programme, trifecta outcome is achievable for most RAPN patients, and at a rate comparable to international standards. Fellowship centres should monitor their outcomes to ensure high patient outcomes are maintained alongside training requirements.

Concordance between renal tumour biopsy and robotic-assisted partial and radical nephrectomy histology: a 10-year experience.

We aimed to assess concordance between renal tumour biopsy (RTB) and surgical pathology from robotic-assisted partial nephrectomy (RAPN) or robotic-assisted radical nephrectomy (RARN). Patients with preoperative RTB undergoing RAPN or RARN for suspected malignancy (9 September 2013-9 September 2023) were enrolled retrospectively from three sites. Patients were excluded if the tumour had prior cryotherapy or if biopsy or nephrectomy histology were unavailable or inconclusive. The primary outcome was concordance with the presence/absence of malignancy. Secondary outcomes were concordance with tumour subtype, World Health Organisation nuclear grade (patients with RTB clear cell or papillary RCC only), false-negative rate, false-positive rate, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). In the enrolment period, 332 and 132 patients underwent RAPN and RARN, respectively. Of these, 160 received preoperative RTB, with nine patients excluded, leaving 151 eligible patients. Median age was 63 years, and 49 (32%) were female. On surgical specimens, 144 patients had malignant histology. RTB was highly concordant with presence/absence of malignancy (147/151, 97%). Concordance with tumour subtype occurred in 141 patients (93%), while concordance with nuclear grade was seen in 42/66 patients (64%, RTB grade missing in 53 patients). False-negative rate, false-positive rate, sensitivity, specificity, PPV, and NPV were 2%, 14%, 98%, 86%, 99%, and 67%, respectively. Limitations include absence of complication data and exclusion of patients biopsied without surgery. In patients undergoing RAPN or RARN, preoperative RTB has high concordance with surgical pathology, both in the presence of malignancy and RCC subtype.

Systematic review of the ophthalmic complications of robotic-assisted laparoscopic prostatectomy.

This study aims to review ophthalmic injuries sustained during of robotic-assisted laparoscopic prostatectomy (RALP). A search of Medline, Embase, Cochrane and grey literature was performed using methods registered a priori. Eligible studies were published 01/01/2010-01/05/2023 in English and reported ophthalmic complications in cohorts of > 100 men undergoing RALP. The primary outcome was injury incidence. Secondary outcomes were type and permanency of ophthalmic complications, treatments, risk factors and preventative measures. Nine eligible studies were identified, representing 100,872 men. Six studies reported rates of corneal abrasion and were adequately homogenous for meta-analysis, with a weighted pooled rate of 5 injuries per 1000 procedures (95% confidence interval 3-7). Three studies each reported different outcomes of xerophthalmia, retinal vascular occlusion, and ophthalmic complications unspecified in 8, 5 and 2 men per 1000 procedures respectively. Amongst identified studies, there were no reports of permanent ophthalmic complications. Injury management was poorly reported. No significant risk factors were reported, while one study found African-American ethnicity protective against corneal abrasion (0.4 vs. 3.9 per 1000). Variables proposed (but not proven) to increase risk for corneal abrasion included steep Trendelenburg position, high pneumoperitoneum pressure, prolonged operative time and surgical inexperience. Compared with standard of care, occlusive eyelid dressings (23 vs. 0 per 1000) and foam goggles (20 vs. 1.3 per 1000) were found to reduce rates of corneal abrasion. RALP carries low rates of ophthalmic injury. Urologists should counsel the patient regarding this potential complication and pro-actively implement preventative strategies.

Massive inguinal herniation of the bladder with bilateral hydronephrosis, complicated by psychosis.

Massive inguinal herniation of the bladder is rare. This case was made more dramatic by the late presentation and simultaneous psychiatric condition. A man in his 70s was found in his burning house and admitted for smoke inhalation. Initially refusing examination or investigation, on the third day, he was found to have massive inguinal bladder herniation, bilateral hydronephrosis and acute renal failure. After urethral catheterisation, bilateral ureteric stent insertion and resolution of postobstructive diuresis, the patient underwent open right inguinal hernia repair and return of the bladder to its orthotopic position. He also diagnosed with schizotypal personality disorder with psychosis, malnutrition, iron deficiency anaemia, heart failure and chronic lower limb ulcers. Four months later and after multiple failed trial of voids, the patient underwent transurethral resection of prostate with successful resumption of spontaneous voiding.

The Carbon Footprint of Single-Use Flexible Cystoscopes Compared with Reusable Cystoscopes.

Introduction: Single-use devices for endourologic procedures are becoming more popular. The environmental impact of single-use instruments is relatively unknown. This study aimed to compare the carbon footprint of single-use vs reusable flexible cystoscopes based on waste production and estimated carbon emissions. Methods: An analysis of the solid waste produced when using the aScope™ 4 Cysto (Ambu®) single-use flexible cystoscope compared with the reusable Cysto-Nephro Videoscope CYF-VA2 (Olympus®) was performed. The solid waste generated was measured (grams) and recorded as either recyclable, landfill, or contaminated, and carbon dioxide (CO2) produced by disposal, manufacture, and cleaning was calculated. Results: A total of 40 flexible cystoscopies (20 single-use and 20 reusable) were analyzed. Median total weight of waste produced was 622 g (interquartile range [IQR] 621-651) for the single-use cystoscope compared with 671.5 g (IQR 659-677.5) for the reusable cystoscope (p < 0.0001). More waste was disposed of by incineration after single-use than reusable cystoscopy (496 g [IQR 495-525] vs 415 g [IQR 403-421.5], p < 0.0001). However, more waste went to landfill after reusable cystoscopy (256 g ± 0 vs 126 g ± 0, p < 0.0001). There was no difference in weight of waste produced based on the indication for cystoscopy (p = 0.1570). A total of 2.41 kg of CO2 (IQR 2.40-2.44) was produced per case for the single-use flexible cystoscope compared with 4.23 kg of CO2 (IQR 4.22-4.24) for the reusable cystoscope (p < 0.0001). Conclusion: Environmental accountability is essential in modern health care. This study highlights that disposable flexible cystoscopes have a significantly lower impact on the environment in terms of carbon footprint and landfill. We propose that environmental impact studies should be a routine part of device development for a sustainable future.

A systematic review of magnetic versus conventional ureteric stents for short term ureteric stenting.

Ureteric stents play an essential role in urology. However, patients can suffer a range of stent-related symptoms with stent in situ and during removal. Conventional ureteric stents are removed using a flexible cystoscopy, whereas magnetic stents may be rapidly removed with a smaller catheter-like retrieval device. The primary aim of this systematic review was to compare the morbidity including pain associated with conventional versus magnetic ureteric stents. The secondary aim was cost comparison. Searches were performed across databases, including Medline, Scopus, Embase and Cochrane. This review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search from the 5 databases returned a total of 358 articles. After duplicates were removed as well as the inclusion and exclusion criteria applied, a total of 6 studies were included in the final review. Ureteric Stent Symptoms Questionnaire (USSQ) and Visual Analogue Score (VAS) were used in most of the studies. All the studies reported that magnetic ureteric stents resulted in a reduction in the pain on the removal of magnetic ureteric stents, and no statistically significant difference with indwelling ureteric stents. Furthermore, majority of the studies reported a reduction in the cost associated with magnetic ureteric stents. There is no significant difference in pain from indwelling ureteric stents. There is a reduction in pain with the removal of magnetic ureteric stents compared to conventional removal via cystoscopy and an associated reduction in cost.

Bilateral staghorn kidney stones in Megacalycosis: Non operative management of complex kidney stone disease.

What happens when kidney stone clearance is not feasible? We report the case of a 46-year-old male who presented for review with bilateral congenital non-obstructive calyceal dilatation (megacalycosis) and high volume bilateral renal calculi in the setting of stage four chronic kidney disease. Since complete stone clearance was deemed futile, thus a consensus was made between Urology and Nephrology, and treatment goals were focused on addressing symptoms, preserving renal function and preventing urinary tract infections until renal transplantation is needed. This case highlights that for some patients with severe complex kidney stone disease, an alternative management plan is needed.

Large and rapid local recurrence of clear cell renal cell carcinoma.

After radical nephrectomy, clear cell renal cell carcinoma (ccRCC) recurs locally in <3% of patients. Recurrences typically occur 1-2 years postoperatively and grow at 5-20 mm per year. In contrast, this patient's recurrence was unexpectedly large and swift. A 71-year-old woman was initially found on workup for recurrent urinary tract infections to have a 12 cm left renal tumour. After negative staging scans, she progressed to left open radical nephrectomy. Histology revealed a stage T2b 12 cm ccRCCwith sarcomatoid differentiation, International Society of Urological Pathology (ISUP) grade 4, with clear margins. Only 3 months later, the patient developed left-sided abdominal pain, and CT scans revealed a 15 cm left retroperitoneal local recurrence, as well as widespread peritoneal tumours. In discussion with her treating team, the patient and her family elected not to undergo biopsy or systemic therapy. The patient was palliated and passed away 8 days after re-presentation.