Impact of COVID-19 on the management and outcomes of ureteric stones in the UK: a multicentre retrospective study.

OBJECTIVES: To determine if management of ureteric stones in the UK changed during the coronavirus disease 2019 (COVID-19) pandemic and whether this affected patient outcomes. PATIENTS AND METHODS: We conducted a multicentre retrospective study of adults with computed tomography-confirmed ureteric stone disease at 39 UK hospitals during a pre-pandemic period (23/3/2019-22/6/2019) and a period during the pandemic (the 3-month period after the first severe acute respiratory syndrome coronavirus-2 case at individual sites). The primary outcome was success of primary treatment modality, defined as no further treatment required for the index ureteric stone. Our study protocol was published prior to data collection. RESULTS: A total of 3735 patients were included (pre-pandemic 1956 patients; pandemic 1779 patients). Stone size was similar between groups (P > 0.05). During the pandemic, patients had lower hospital admission rates (pre-pandemic 54.0% vs pandemic 46.5%, P < 0.001), shorter mean length of stay (4.1 vs 3.3 days, P = 0.02), and higher rates of use of medical expulsive therapy (17.4% vs 25.4%, P < 0.001). In patients who received interventional management (pre-pandemic 787 vs pandemic 685), rates of extracorporeal shockwave lithotripsy (22.7% vs 34.1%, P < 0.001) and nephrostomy were higher (7.1% vs 10.5%, P = 0.03); and rates of ureteroscopy (57.2% vs 47.5%, P < 0.001), stent insertion (68.4% vs 54.6%, P < 0.001), and general anaesthetic (92.2% vs 76.2%, P < 0.001) were lower. There was no difference in success of primary treatment modality between patient cohorts (pre-pandemic 73.8% vs pandemic 76.1%, P = 0.11), nor when patients were stratified by treatment modality or stone size. Rates of operative complications, 30-day mortality, and re-admission and renal function at 6 months did not differ between the data collection periods. CONCLUSIONS: During the COVID-19 pandemic, there were lower admission rates and fewer invasive procedures performed. Despite this, there were no differences in treatment success or outcomes. Our findings indicate that clinicians can safely adopt management strategies developed during the pandemic to treat more patients conservatively and in the community.

External validation of a risk model predicting failure of salvage focal ablation for prostate cancer.

OBJECTIVES: To externally validate a published model predicting failure within 2 years after salvage focal ablation in men with localised radiorecurrent prostate cancer using a prospective, UK multicentre dataset. PATIENTS AND METHODS: Patients with biopsy-confirmed ≤T3bN0M0 cancer after previous external beam radiotherapy or brachytherapy were included from the FOcal RECurrent Assessment and Salvage Treatment (FORECAST) trial (NCT01883128; 2014-2018; six centres), and from the high-intensity focussed ultrasound (HIFU) Evaluation and Assessment of Treatment (HEAT) and International Cryotherapy Evaluation (ICE) UK-based registries (2006-2022; nine centres). Eligible patients underwent either salvage focal HIFU or cryotherapy, with the choice based predominantly on anatomical factors. Per the original multivariable Cox regression model, the predicted outcome was a composite failure outcome. Model performance was assessed at 2 years post-salvage with discrimination (concordance index [C-index]), calibration (calibration curve and slope), and decision curve analysis. For the latter, two clinically-reasonable risk threshold ranges of 0.14-0.52 and 0.26-0.36 were considered, corresponding to previously published pooled 2-year recurrence-free survival rates for salvage local treatments. RESULTS: A total of 168 patients were included, of whom 84/168 (50%) experienced the primary outcome in all follow-ups, and 72/168 (43%) within 2 years. The C-index was 0.65 (95% confidence interval 0.58-0.71). On graphical inspection, there was close agreement between predicted and observed failure. The calibration slope was 1.01. In decision curve analysis, there was incremental net benefit vs a 'treat all' strategy at risk thresholds of ≥0.23. The net benefit was therefore higher across the majority of the 0.14-0.52 risk threshold range, and all of the 0.26-0.36 range. CONCLUSION: In external validation using prospective, multicentre data, this model demonstrated modest discrimination but good calibration and clinical utility for predicting failure of salvage focal ablation within 2 years. This model could be reasonably used to improve selection of appropriate treatment candidates for salvage focal ablation, and its use should be considered when discussing salvage options with patients. Further validation in larger, international cohorts with longer follow-up is recommended.

Bioengineering solutions for ureteric disorders: clinical need, challenges and opportunities.

OBJECTIVES: To summarise the causes of ureteric damage and the current standard of care, discussing the risks and benefits of available therapeutic options. We then focus on the current and future solutions that can be provided by ureteric bioengineering and provide a description of the ideal characteristics of a bioengineered product. METHODS: We performed a literature search in February 2021 in: Google Scholar, Medline, and Web of Science. Three searches were conducted, investigating: (a) the epidemiology of ureteric pathology, (b) the current standard of care, and (c) the state of the art in ureteric bioengineering. RESULTS: The most-common causes of ureteric damage are iatrogenic injury and external trauma. Current approaches to treatment include stent placement or surgical reconstruction. Reconstruction can be done using either urological tissue or segments of the gastrointestinal tract. Limitations include scarring, strictures, and infections. Several bioengineered alternatives have been explored in animal studies, with variations in the choice of scaffold material, cellular seeding populations, and pre-implantation processing. Natural grafts and hybrid material appear to be associated with superior outcomes. Furthermore, seeding of the scaffold material with stem cells or differentiated urothelial cells allows for better function compared to acellular scaffolds. Some studies have attempted to pre-implant the graft in the omentum prior to reconstruction, but this has yet to prove any definitive benefits. CONCLUSION: There is an unmet clinical need for safer and more effective treatment for ureteric injuries. Urological bioengineering is a promising solution in preclinical studies. However, substantial scientific, logistic, and economic challenges must be addressed to harness its transformative potential in improving outcomes.

A BURST-BAUS consensus document for best practice in the conduct of scrotal exploration for suspected testicular torsion: the Finding consensus for orchIdopeXy In Torsion (FIX-IT) study.

OBJECTIVES: To produce a best practice consensus guideline for the conduct of scrotal exploration for suspected testicular torsion using formal consensus methodology. MATERIALS AND METHODS: A panel of 16 expert urologists, representing adult, paediatric, general, and andrological urology used the RAND/UCLA Appropriateness Consensus Methodology to score a 184 statement pre-meeting questionnaire on the conduct of scrotal exploration for suspected testicular torsion. The collated responses were presented at a face-to-face online meeting and each item was rescored anonymously after a group discussion, facilitated by an independent chair with expertise in consensus methodology. Items were scored for agreement and consensus and the items scored with consensus were used to derive a set of best practice guidelines. RESULTS: Statements scored as with consensus increased from Round 1 (122/184, 66.3%) to Round 2 (149/200, 74.5%). Recommendations were generated in ten categories: consent, assessment under anaesthetic, initial incision, intraoperative decision making, fixation, medical photography, closure, operation note, logistics and follow-up after scrotal exploration. Our statements assume that the decision to operate has already been made. Key recommendations in the consent process included the discussion of the possibility of orchidectomy and the possibility of subsequent infection of the affected testis or wound requiring antibiotic therapy. If after the examination under anaesthesia, the index of suspicion of testicular torsion is lower than previously thought, then the surgeon should still proceed to scrotal exploration as planned. A flow chart guiding decision making dependent on intraoperative findings has been designed. If no torsion is present on exploration and the bell clapper deformity is absent, the testis should not be fixed. When fixing a testis using sutures, 3 or 4-point is acceptable and non-absorbable sutures are preferred. CONCLUSIONS: We have produced consensus recommendations to inform best practice in the conduct of scrotal exploration for suspected testicular torsion.

LEARN: A multi-centre, cross-sectional evaluation of Urology teaching in UK medical schools.

OBJECTIVE: To evaluate the status of UK undergraduate urology teaching against the British Association of Urological Surgeons (BAUS) Undergraduate Syllabus for Urology. Secondary objectives included evaluating the type and quantity of teaching provided, the reported performance rate of General Medical Council (GMC)-mandated urological procedures, and the proportion of undergraduates considering urology as a career. MATERIALS AND METHODS: LEARN was a national multicentre cross-sectional study. Year 2 to Year 5 medical students and FY1 doctors were invited to complete a survey between 3rd October and 20th December 2020, retrospectively assessing the urology teaching received to date. Results are reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). RESULTS: 7,063/8,346 (84.6%) responses from all 39 UK medical schools were included; 1,127/7,063 (16.0%) were from Foundation Year (FY) 1 doctors, who reported that the most frequently taught topics in undergraduate training were on urinary tract infection (96.5%), acute kidney injury (95.9%) and haematuria (94.4%). The most infrequently taught topics were male urinary incontinence (59.4%), male infertility (52.4%) and erectile dysfunction (43.8%). Male and female catheterisation on patients as undergraduates was performed by 92.1% and 73.0% of FY1 doctors respectively, and 16.9% had considered a career in urology. Theory based teaching was mainly prevalent in the early years of medical school, with clinical skills teaching, and clinical placements in the later years of medical school. 20.1% of FY1 doctors reported no undergraduate clinical attachment in urology. CONCLUSION: LEARN is the largest ever evaluation of undergraduate urology teaching. In the UK, teaching seemed satisfactory as evaluated by the BAUS undergraduate syllabus. However, many students report having no clinical attachments in Urology and some newly qualified doctors report never having inserted a catheter, which is a GMC mandated requirement. We recommend a greater emphasis on undergraduate clinical exposure to urology and stricter adherence to GMC mandated procedures.

Effect of medical school attended on the chances of successfully embarking on a clinical-academic career in the UK.

PURPOSE OF THE STUDY: This study aimed to investigate whether, in the UK, medical school attended influences the propensity to apply to and be successful in obtaining an offer from the Academic Foundation Programme (AFP), thus taking the first step to embarking on a clinical-academic career. STUDY DESIGN: A retrospective observational study was performed. Using the UK Foundation Programme's yearly statistical report data, mean application rates to, and mean offer rates from the AFP were calculated by medical school, between the years 2017-2019. Mean application and mean offer rates were subsequently correlated with metrics of medical school academic performance and research focus. RESULTS: Mean application rates to the AFP were higher in medical schools that had a mandatory intercalated degree as part of the undergraduate medical curriculum (mean=33.99%, SD=13.93 vs mean=19.44%, SD=6.88, p<0.001), lower numerical rank in the Times Higher Education 2019 World Rankings (correlation with higher numerical rank, r=-0.50, p=0.004), and lower numerical rank in the Research Excellence Framework 2014 UK rankings (correlation with higher numerical rank, r=-0.37, p=0.004). Mean offer rates from the AFP were not correlated with any metric of medical school academic performance or research focus. CONCLUSIONS: Students attending a medical school with greater academic performance and research focus are more likely to apply and subsequently embark on a clinical-academic career. However, students wishing to embark a clinical-academic career from any medical school have an equal chance of success.

The genetic landscapes of urological cancers and their clinical implications in the era of high-throughput genome analysis.

OBJECTIVE: With the advent of high-throughput genome analysis, we are increasingly able to sequence and hence understand the pathogenic processes underlying individual cancers. Recently, consortiums such as The Cancer Genome Atlas (TCGA) have performed large-scale projects to this end, providing significant amounts of information regarding the genetic landscapes of several cancers. PATIENTS AND METHODS: We performed a narrative review of studies from the TCGA and other major studies. We aimed to summarise data exploring the clinical implications of specific genetic alterations, both prognostically and therapeutically, in four major urological cancers. These were renal cell carcinoma, muscle-invasive bladder cancer/carcinoma, prostate cancer, and testicular germ cell tumours. RESULTS: With these four urological cancers, great strides have been made in the molecular characterisation of tumours. In particular, recent studies have focussed on identifying molecular subtypes of tumours with characteristic genetic alterations and differing prognoses. Other prognostic alterations have also recently been identified, including those pertaining to epigenetics and microRNAs. In regard to treatment, numerous options are emerging for patients with these cancers such as including immune checkpoint inhibition, epigenetic-based treatments, and agents targeting MAPK, PI3K, and DNA repair pathways. There are a multitude of trials underway investigating the effects of these novel agents, the results of which are eagerly awaited. CONCLUSIONS: As medicine chases the era of personalised care, it is becoming increasingly important to provide individualised prognoses for patients. Understanding how specific genetic alterations affects prognosis is key for this. It will also be crucial to provide highly targeted treatments against the specific genetics of a patient's tumour. With work performed by the TCGA and other large consortiums, these aims are gradually being achieved. Our review provides a succinct overview of this exciting field that may underpin personalised medicine in urological oncology.

Publication Fate of Abstracts Presented at Four British Surgical Meetings: An 11-Year Follow-Up.

BACKGROUND: The gold standard for research is publication within a peer-reviewed journal. There is a discrepancy between the number of abstracts presented at scientific meetings and the number published as full articles. We identified publication rates for the 2012 meetings of four British surgical societies. These were the Association of Surgeons of Great Britain & Ireland (ASGBI), the Vascular Society of Great Britain and Ireland, the British Transplantation Society (BTS), and the Association of Coloproctology of Great Britain and Ireland (ACPGBI). We also compared publication rates with these societies' 2001 meetings and identified univariate factors associated with publication. MATERIALS AND METHODS: PubMed was searched to identify publications stemming from meeting abstracts. We extracted abstract characteristics to identify factors associated with publication and also characteristics of subsequent publications to enable comparison. RESULTS: Publication rates were 24.1% (ASGBI), 24.6% (BTS), 21.7% (ACPGBI), and 39.4% (Vascular Society of Great Britain and Ireland). Rates for ASGBI, BTS, and ACPGBI meetings were significantly lower compared to 2001 meetings (P = 0.001-0.026). Mean time to publication was 12.1-22.0 mo. Mean 5-y impact factor differed significantly between meetings (P = 0.001), with the BTS meeting having the highest mean 5-y impact factor (4.658). Factors associated with publication included being an oral presentation (ASGBI P = 0.001), multi-institution study (ASGBI P = 0.003), or randomized-controlled trial (BTS P = 0.049). CONCLUSIONS: Reduced publication rates may represent increased acceptance of low-quality abstracts at meetings or a more competitive journal submission process. Further data are required to strengthen conclusions. Nonetheless, authors and meeting organizers should push for higher quality abstracts to promote future peer-reviewed journal publication.

Pre-designed consent forms for total hip replacement, total knee replacement, and caesarean section: A national observational study of current English practice.

BACKGROUND: Pre-designed procedure-specific consent forms (PCFs) have potential advantages over handwritten forms for improving the consent process and disclosing material risks, as necessitated by the 2015 'Montgomery' ruling. We aimed to assess the use and quality of English NHS Trust PCFs for total hip replacement (THR), total knee replacement (TKR), and caesarean section (CS). METHODS: All 233 English NHS Trusts were sent a Freedom of Information request seeking PCFs for these operations. Listed risks, and whether their incidence was quoted, were compared against those listed in published PCFs from the British Orthopaedic Association (BOA) and the Royal College of Obstetricians and Gynaecologists (RCOG). RESULTS: 203/233 (87.1%) Trusts responded, contributing 17 THR PCFs, 15 TKR PCFs, and 33 CS PCFs. Overall, the type of risks listed for each operation was highly variable. 5.9% of THR PCFs contained all 18 BOA-quoted risks. No TKR PCF contained all 19 BOA-quoted risks. 24.2% of CS PCFs contained all 17 RCOG-quoted risks. For each operation, few PCFs listed incidences for quoted-risks. CONCLUSIONS: Very few Trusts use PCFs for these common operations. When PCFs are used, the reporting of risks and their likelihood is variable and insufficient. BOA- and RCOG-approved PCFs are high quality and influential on Trust-PCF design but still omit important risks. We fear PCFs analysed here do not sufficiently improve the consent process compared to handwritten forms. PCFs have potential to improve the quality of consent, however they need greater uptake and to be of greater quality.

Peri-operative outcomes and complications after laparoscopic vs robot-assisted dismembered pyeloplasty: a systematic review and meta-analysis.

OBJECTIVE: To analyse the current difference between dismembered robot-assisted pyeloplasty (RAP) and laparoscopic pyeloplasty (LP) in the treatment of pelvi-ureteric junction (PUJ) obstruction as of 26 June 2017, focusing on operating time, length of hospital stay, complication rate, and success rate. PATIENTS AND METHODS: We searched PubMed, Medline and Embase databases, consulted experts, reviewed reference lists, used the 'related articles' PubMed feature, and reviewed scientific meeting abstracts for eligible articles published between 1993 and 26 June 2017. A modified Newcastle-Ottawa scale was used to assess study quality. Subgroup analyses were performed regarding patient age, single or multisurgeon experience, presence of complex renal anatomy, study quality, Clavien-Dindo grades, and length of follow-up. RESULTS: From 4101 identified articles, 17 studies meeting our eligibility criteria were included for data extraction. All were observational studies, with 10 deemed to be of low quality. Meta-analysis showed that RAP resulted in a 27-min shorter operating time (weighted mean difference [WMD] -26.71 min, 95% confidence interval [CI] -44.42 to -9.00; P = 0.003) and a 1.2-day shorter length of hospital stay (WMD -1.21 days, 95% CI -1.84 to -0.57; P = 0.003). The quality of evidence for these outcomes was rated as very low. Significant heterogeneity was found when analysing operating time (P < 0.001) and length of hospital stay (P < 0.001), which could not be fully explained through subgroup analyses. We also identified other potentially significant sources of bias for which we could not adjust our analysis. RAP was also associated with a lower complication rate (odds ratio [OR] 0.56, 95% CI 0.37 to 0.84; P = 0.005) and higher success rate (OR 2.76, 95% CI 1.30 to 5.88; P = 0.008); however, whether statistical advantages for these two outcomes translated into clinically significant advantages was unclear. The quality of evidence for these outcomes was rated as low. CONCLUSION: For patients with PUJ obstruction, our meta-analyses show that RAP is advantageous concerning operating time, length of hospital stay, complication rate and success rate. Our conclusions, however, are weakened by poor quality of evidence and significant study heterogeneity. In addition, whether the statistical significance observed in the present meta-analysis translates into clinical significance is an important question. Further high-quality studies, particularly randomized controlled trials, are necessary to strengthen conclusions.

Systematic review of infant and young child complementary feeding practices in South Asian families: the India perspective.

OBJECTIVE: Suboptimal nutrition among children remains a problem among South Asian (SA) families. Appropriate complementary feeding (CF) practices can greatly reduce this risk. Thus, we undertook a systematic review of studies assessing CF (timing, dietary diversity, meal frequency and influencing factors) in children aged <2 years in India. DESIGN: Searches between January 2000 and June 2016 in MEDLINE, EMBASE, Global Health, Web of Science, OVID Maternity & Infant Care, CINAHL, Cochrane Library, BanglaJOL, POPLINE and WHO Global Health Library. Eligibility criteria: primary research on CF practices in SA children aged 0-2 years and/or their families. Search terms: 'children', 'feeding' and 'Asians' and derivatives. Two researchers undertook study selection, data extraction and quality appraisal (EPPI-Centre Weight of Evidence). RESULTS: From 45 712 abstracts screened, sixty-four cross-sectional, seven cohort, one qualitative and one case-control studies were included. Despite adopting the WHO Infant and Young Child Feeding guidelines, suboptimal CF practices were found in all studies. In twenty-nine of fifty-nine studies, CF was introduced between 6 and 9 months, with eight studies finding minimum dietary diversity was achieved in 6-33 %, and ten of seventeen studies noting minimum meal frequency in only 25-50 % of the study populations. Influencing factors included cultural influences, poor knowledge on appropriate CF practices and parental educational status. CONCLUSIONS: This is the first systematic review to evaluate CF practices in SA in India. Campaigns to change health and nutrition behaviour and revision of nationwide child health nutrition programmes are needed to meet the substantial unmet needs of these children.

Phase locking of 2.324 and 2.959 terahertz quantum cascade lasers using a Schottky diode harmonic mixer.

The 23rd and 31st harmonics of a microwave signal generated in a novel THz balanced Schottky diode mixer were used as a frequency stable reference source to phase lock solid-nitrogen-cooled 2.324 and 2.959 THz quantum cascade lasers. Hertz-level frequency stability was achieved, which was maintained for several hours.