Intrarenal pressure with hand-pump or pressurized-bag irrigation: randomized clinical trial at retrograde intrarenal surgery.

BACKGROUND: The aim was to ascertain the impact of irrigation technique on human intrarenal pressure during retrograde intrarenal surgery. METHODS: A parallel randomized trial recruited patients across three hospital sites. Patients undergoing retrograde intrarenal surgery for renal stone treatment with an 11/13-Fr ureteral access sheath were allocated randomly to 100 mmHg pressurized-bag (PB) or manual hand-pump (HP) irrigation. The primary outcome was mean procedural intrarenal pressure. Secondary outcomes included maximum intrarenal pressure, variance, visualization, HP force of usage, procedure duration, stone clearance, and clinical outcomes. Live intrarenal pressure monitoring was performed using a COMETTMII pressure guidewire, deployed cystoscopically to the renal pelvis. The operating team was blinded to the intrarenal pressure. RESULTS: Thirty-eight patients were randomized between July and November 2023 (trial closure). The final analysis included 34 patients (PB 16; HP 18). Compared with PB irrigation, HP irrigation resulted in significantly higher mean intrarenal pressure (mean(s.d.) 62.29(27.45) versus 38.16(16.84) mmHg; 95% c.i. for difference in means (MD) 7.97 to 40.29 mmHg; P = 0.005) and maximum intrarenal pressure (192.71(106.23) versus 68.04(24.16) mmHg; 95% c.i. for MD 70.76 to 178.59 mmHg; P < 0.001), along with greater variance in intrarenal pressure (log transformed) (6.23(1.59) versus 4.60(1.30); 95% c.i. for MD 0.62 to 2.66; P = 0.001). Surgeon satisfaction with procedural vision reported on a scale of 10 was higher with PB compared with HP irrigation (mean(s.d.) 8.75(0.58) versus 6.28(1.27); 95% c.i. for MD 1.79 to 3.16; P < 0.001). Subjective HP usage force did not correlate significantly with transmitted intrarenal pressure (Pearson R = -0.15, P = 0.57). One patient (HP arm) developed urosepsis. CONCLUSION: Manual HP irrigation resulted in higher and more fluctuant intrarenal pressure trace (with inferior visual clarity) than 100-mmHg PB irrigation. REGISTRATION NUMBER: osf.io/jmg2h (https://osf.io/).

Upper urinary tract pressures in endourology: a systematic review of range, variables and implications.

OBJECTIVES: To systematically review the literature to ascertain the upper tract pressures generated during endourology, the relevant influencing variables and clinical implications. MATERIALS AND METHODS: A systematic review of the MEDLINE, Scopus and Cochrane databases was performed by two authors independently (S.C., N.D.). Studies reporting ureteric or intrarenal pressures (IRP) during semi-rigid ureteroscopy (URS)/flexible ureterorenoscopy (fURS)/percutaneous nephrolithotomy (PCNL)/miniaturized PCNL (mPCNL) in the period 1950-2021 were identified. Both in vitro and in vivo studies were considered for inclusion. Findings were independently screened for eligibility based on content, with disagreements resolved by author consensus. Data were assessed for bias and compiled based on predefined variables. RESULTS: Fifty-two studies met the inclusion criteria. Mean IRP appeared to frequently exceed a previously proposed threshold of 40 cmH2 O. Semi-rigid URS with low-pressure irrigation (gravity <1 m) resulted in a wide mean IRP range (lowest reported 6.9 cmH2 O, highest mean 149.5 ± 6.2 cmH2 O; animal models). The lowest mean observed with fURS without a ureteric access sheath (UAS) was 47.6 ± 4.1 cmH2 O, with the maximum peak IRP being 557.4 cmH2 O (in vivo human data). UAS placement significantly reduced IRP during fURS, but did not guarantee pressure control with hand-operated pump/syringe irrigation. Miniaturization of PCNL sheaths was associated with increased IRP; however, a wide mean human IRP range has been recorded with both mPCNL (lowest -6.8 ± 2.2 cmH2 O [suction sheath]; highest 41.2 ± 5.3 cmH2 O) and standard PCNL (lowest 6.5 cmH2 O; highest 41.2 cmH2 O). Use of continuous suction in mPCNL results in greater control of mean IRP, although short pressure peaks >40 cmH2 O are not entirely prevented. Definitive conclusions are limited by heterogeneity in study design and results. Postoperative pain and pyrexia may be correlated with increased IRP, however, few in vivo studies correlate clinical outcome with measured IRP. CONCLUSIONS: Intrarenal pressure generated during upper tract endoscopy often exceeds 40 cmH2 O. IRP is multifactorial in origin, with contributory variables discussed. Larger prospective human in vivo studies are required to further our understanding of IRP thresholds and clinical sequelae.

In vivo ureteroscopic intrarenal pressures and clinical outcomes: a multi-institutional analysis of 120 consecutive patients.

OBJECTIVES: To evaluate the pressure range generated in the human renal collecting system during ureteroscopy (URS), in a large patient sample, and to investigate a relationship between intrarenal pressure (IRP) and outcome. PATIENTS AND METHODS: A prospective multi-institutional study was conducted, with ethics board approval; February 2022-March 2023. Recruitment was of 120 consecutive consenting adult patients undergoing semi-rigid URS and/or flexible ureterorenoscopy (FURS) for urolithiasis or diagnostic purposes. Retrograde, fluoroscopy-guided insertion of a 0.036-cm (0.014″) pressure guidewire (COMET™ II, Boston Scientific, Marlborough, MA, USA) to the renal pelvis was performed. Baseline and continuous ureteroscopic IRP was recorded, alongside relevant operative variables. A 30-day follow-up was completed. Descriptive statistics were applied to IRP traces, with mean (sd) and maximum values and variance reported. Relationships between IRP and technical variables, and IRP and clinical outcome were interrogated using the chi-square test and independent samples t-test. RESULTS: A total of 430 pressure traces were analysed from 120 patient episodes. The mean (sd) baseline IRP was 16.45 (5.99) mmHg and the intraoperative IRP varied by technique. The mean (sd) IRP during semi-rigid URS with gravity irrigation was 34.93 (11.66) mmHg. FURS resulted in variable IRP values: from a mean (sd) of 26.78 (5.84) mmHg (gravity irrigation; 12/14-F ureteric access sheath [UAS]) to 87.27 (66.85) mmHg (200 mmHg pressurised-bag irrigation; 11/13-F UAS). The highest single pressure peak was 334.2 mmHg, during retrograde pyelography. Six patients (5%) developed postoperative urosepsis; these patients had significantly higher IRPs during FURS (mean [sd] 81.7 [49.52] mmHg) than controls (38.53 [22.6] mmHg; P < 0.001). CONCLUSIONS: A dynamic IRP profile is observed during human in vivo URS, with IRP frequently exceeding expected thresholds. A relationship appears to exist between elevated IRP and postoperative urosepsis.

ExPeCT: a randomised trial examining the impact of exercise on quality of life in men with metastatic prostate cancer.

PURPOSE: All patients living with cancer, including those with metastatic cancer, are encouraged to be physically active. This paper examines the secondary endpoints of an aerobic exercise intervention for men with metastatic prostate cancer. METHODS: ExPeCT (Exercise, Prostate Cancer and Circulating Tumour Cells), was a multi-centre randomised control trial with a 6-month aerobic exercise intervention arm or a standard care control arm. Exercise adherence data was collected via heart rate monitors. Quality of life (FACT-P) and physical activity (self-administered questionnaire) assessments were completed at baseline, at 3 months and at 6 months. RESULTS: A total of 61 patients were included (69.4 ± 7.3 yr, body mass index 29.2 ± 5.8 kg/m2). The median time since diagnosis was 34 months (IQR 7-54). A total of 35 (55%) of participants had > 1 region affected by metastatic disease. No adverse events were reported by participants. There was no effect of exercise on quality of life (Cohen's d = - 0.082). Overall adherence to the supervised sessions was 83% (329 out of 396 possible sessions attended by participants). Overall adherence to the non-supervised home exercise sessions was 72% (months 1-3) and 67% (months 3-6). Modelling results for overall physical activity scores showed no significant main effect for the group (p-value = 0.25) or for time (p-value = 0.24). CONCLUSION: In a group of patients with a high burden of metastatic prostate cancer, a 6-month aerobic exercise intervention did not lead to change in quality of life. Further exercise studies examining the role of exercise for people living with metastatic prostate cancer are needed. TRIAL REGISTRATION: The trial was registered at clinicaltrials.gov (NCT02453139) on May 25th 2015.

Men's sexual help-seeking and care needs after radical prostatectomy or other non-hormonal, active prostate cancer treatments.

OBJECTIVE: To examine prostate cancer (PCa) survivors' sexual help-seeking intentions, behaviours, and unmet needs. METHODS: In this prospective cohort study, men who underwent active, non-hormonal treatment completed baseline (N = 558) and 6-month follow-up (N = 387) questionnaires. Theory of planned behaviour (TPB) constructs (sexual help-seeking intention, perceived behavioural control (PBC), subjective norm, attitude), masculine values (e.g., sexual importance/priority, emotional self-reliance), sex life and functioning, sexual supportive care needs, distress (anxiety, depression), and sexual help-seeking behaviour were assessed. RESULTS: Most men (M age = 64.6 years; M years post-diagnosis = 4.0) received prostatectomy (93%), reported severe erectile dysfunction (52%), ≥ 1 unmet sexual care need (66%), and sought help from a doctor (baseline 52%, follow-up 42%). Sexual care needs were significantly associated with poorer erectile function, reduced satisfaction with sex-life, valuing sex as important/integral to identity (masculine values), and increased depression (p ≤ 0.001). Sexual help-seeking intentions were significantly associated with valuing sex as important/integral to identity, recent help-seeking, greater confidence/control, perceiving support from important others, and positive attitudes, for sexual help-seeking (p < 0.001). Significant predictors of sexual help-seeking (follow-up) were baseline intentions, recent help-seeking (p < 0.001), and increased anxiety (p < 0.05). CONCLUSIONS: Men's unmet sexual care needs, sexual help-seeking intentions, and behaviour appear driven by the importance/value attributed to sex, distress, positive feelings, support from others, and confidence for help-seeking. Psychosocial providers are well-placed to address men's concerns, yet few sought their assistance. Interventions to improve men's access to effective sexual care are needed, particularly focused on reframing masculine values about the importance of sex and leveraging TPB-based predictors of help-seeking.

Incidence and immediate management of genitourinary injuries in pelvic and acetabular trauma: a 10-year retrospective study.

OBJECTIVE: To report the incidence of genitourinary (GU) injuries in pelvic and acetabular (P + A) fractures, to investigate associations between P + A fractures and GU injury patterns, and, as a secondary objective, to evaluate prospectively P + A fracture referrals with regard to adherence to the British Orthopaedic Association Standards for Trauma (BOAST) guidelines over a 12-month period. METHODS: A retrospective review of GU injuries associated with P + A fractures was performed for the period January 2006 to December 2016 in a national pelvic trauma centre in Ireland. Patient demographics, mechanism of injury and details of injuries were recorded. In addition, P + A fracture referrals were prospectively monitored in 2016 and reviewed for adherence to guidelines. RESULTS: The incidence of urological trauma in P + A fractures was 2.4% (n = 28/1 141). The median (range) patient age was 45 (19-85) years and the male to female ratio was 2.1:1. Urethral injuries occurred most frequently (n = 12, 43%), followed by bladder (n = 9, 32%), combined bladder and urethral (n = 3, 11%) and kidney (n = 4, 14%). Bladder and urethral injuries were associated with high-energy pelvic trauma. Renal injuries were associated with acetabular fractures in isolation and in combination with pelvic trauma (P = 0.01). In 2016, there were 175 P + A fracture referrals and 19 patients had suspected urotrauma (visible haematuria, n = 5; non-visible haematuria, n = 2; trauma imaging, n = 11); 9 of these 19 patients had no urological investigations performed. CONCLUSION: In P + A trauma cases GU injuries may be underreported because of inadequate evaluation and diagnostic investigations in these patients. We advocate robust, uniform and guideline-based evaluation of GU injuries in P + A trauma to avoid the significant long-term morbidities that are associated with misdiagnosis.

Prospective randomised controlled trial of written supplement to verbal communication of results to patients at the time of flexible cystoscopy.

PURPOSE: This trial assessed if written information on procedural findings and subsequent treatment improved understanding and reduced anxiety among patients undergoing day case flexible cystoscopy (FC). METHODS: Participants completed pre- and post-procedure questionnaires self-rating anxiety and feeling well informed on 5-point Likert scales. Supplemental written information was provided after FC to half the patients on a standardized template, according to randomized allocation. Comparisons between the groups were undertaken using the Wilcoxon test. RESULTS: Two hundred patients were recruited, with 171 evaluable questionnaires (83 from written group). The distribution of age, sex and prior FC, as well as the pre-procedure self-assessment of anxiety and understanding, was similar between the two groups. Patients receiving written information reported feeling better informed, with median (range) Likert score of 5 (4-5) compared to 4 (1-5) out of 5 (p < 0.0001) and less anxious (score 1 [1-4] compared to 2 [1-5] out of 5, p < 0.005), although all except four patients had an accurate understanding of the information provided (p = NS). CONCLUSIONS: Written information at the time of FC leads to patients feeling better informed and less anxious, although verbal information alone appears to lead to an adequate understanding. CLINICAL TRIAL REGISTRATION NUMBER: ACTRN12616000288426.

Newsworthiness vs scientific impact: are the most highly cited urology papers the most widely disseminated in the media?

OBJECTIVE: To assess whether a correlation exists between newsworthiness (Altmetric score) and scientific impact markers, such as citation analysis, impact factors, and levels of evidence. METHODS: The top five most cited articles for the year 2014 and 2015 from the top 10 ranking urology journals (Scientific Impact Group) were identified. The top 50 articles each in 2014 and 2015 were identified from Altmetric support based on media activity (Media Impact Group). We determined the number of citations that these articles received in the scientific literature, and calculated correlations between citations with Altmetric scores. RESULTS: In the Scientific Impact Group, the mean number of citations per article was 37.6, and the most highly cited articles were oncology guidelines. The mean Altmetric score in these articles was 14.8. There was a weak positive correlation between citations and Altmetric score (rs = 0.35, 95% confidence interval 0.16-0.52, P < 0.001). In the Media Impact Group, the mean Altmetric score was 121.1 and most widely shared articles all related to sexual medicine. In this group, the mean number of citations was 9.7 and there was a weak negative correlation between Altmetric score and citations (rs = -0.20, P = 0.046). CONCLUSION: The top articles based on Altmetric scores were not highly cited, suggesting that publications receiving the most media attention may not be the most scientifically rigorous, or that this audience places greater value on different subjects than the scientific community.

Rates of self-reported 'burnout' and causative factors amongst urologists in Ireland and the UK: a comparative cross-sectional study.

OBJECTIVES: To determine the incidence of 'burnout' among UK and Irish urological consultants and non-consultant hospital doctors (NCHDs). The second objective was to identify possible causative factors and to investigate the impact of various vocational stressors that urologists face in their day-to-day work and to establish whether these correlate with burnout. The third objective was to develop a new questionnaire to complement the Maslach Burnout Inventory (MBI), more specific to urologists as distinct from other surgical/medical specialties, and to use this in addition to the MBI to determine if there is a requirement to develop effective preventative measures for stress in the work place, and develop targeted remedial measures when individuals are affected by burnout. SUBJECTS AND METHODS: A joint collaboration was carried out between the Irish Society of Urology (ISU) and the British Association of Urological Surgeons (BAUS). Anonymous voluntary questionnaires were sent to all current registered members of both governing bodies. The questionnaire comprised two parts: the first part encompassed sociodemographic data collection and identifying potential risk factors for burnout, and the second used the MBI to objectively assess for workplace burnout. To evaluate differences in burnout, 2 × 2 contingency tables and Fischer's exact probability tests were used. RESULTS: In all, 575 urologists responded to the online survey out of a total of 1380 invites, yielding a 42% response rate. All respondents were aged <75 years (median age 45 years), with men representing 87.5% of respondents. In all, 75% of respondents worked in England, followed by the Republic of Ireland (9%), Scotland (8%), Northern Ireland (4%), and Wales (3%). In all, 79% of respondents were consultants, with 13% representing training posts, and 40% of respondents held a professorship/clinical lead position. Respondents' countries of origin included England, Scotland, Ireland, India, Wales, Malaysia, Pakistan and Sri Lanka. Overall, the mean emotion exhaustion (EE) score was 23.5, representing a moderate level of EE. The mean depersonalisation (DP) score was 8.2, representing a moderate level of DP. The mean personal achievement (PA) score was 17.1, representing high levels of PA. In all, 86 respondents (15%) reported self-medication with non-prescription drugs or alcohol to combat signs and symptoms of burnout, while 46 (8%) sought professional help for symptoms of burnout. In all, 460 respondents (80%) felt that burnout should be evaluated amongst members of the ISU/BAUS, and 345 (60%) would avail of counselling if provided. CONCLUSIONS: This is the first study to address the issue of burnout across two separate health systems in the UK and Ireland. This study has shown previously undescribed high levels of burnout characterised by EE and DP, with associated significant levels of self-medication amongst a male-predominant cohort. Burnout was attributed to non-surgical administrative/institutional factors, with most respondents reporting support for staff evaluation and the provision of counselling services. This pilot study lends itself to the creation of risk stratification for urologists, and an opportunity to provide educational resources, training/development programmes, and collegial and administrative support pathways.

The emerging use of Twitter by urological journals.

OBJECTIVE: To assess the emerging use of Twitter by urological journals. METHODS: A search of the Journal of Citation Reports 2012 was performed to identify urological journals. These journals were then searched on Twitter.com. Each journal website was accessed for links to social media (SoMe). The number of 'tweets', followers and age of profile was determined. To evaluate the content, over a 6-month period (November 2013 to April 2014), all tweets were scrutinised on the journals Twitter profiles. To assess SoMe influence, the Klout score of each journal was also calculated. RESULTS: In all, 33 urological journals were identified. Eight (24.2%) had Twitter profiles. The mean (range) number of tweets and followers was 557 (19-1809) and 1845 (82-3692), respectively. The mean (range) age of the twitter profiles was 952 (314-1758) days with an average 0.88 tweets/day. A Twitter profile was associated with a higher mean impact factor of the journal (mean [sd] 3.588 [3.05] vs 1.78 [0.99], P = 0.013). Over a 6-month period, November 2013 to April 2014, the median (range) number of tweets per profile was 82 (2-415) and the median (range) number of articles linked to tweets was 73 (0-336). Of these 710 articles, 152 were Level 1 evidence-based articles, 101 Level 2, 278 Level 3 and 179 Level 4. The median (range) Klout score was 47 (19-58). The Klout scores of major journals did not exactly mirror their impact factors. CONCLUSION: SoMe is increasingly becoming an adjunct to traditional teaching methods, due to its convenient and user-friendly platform. Recently, many of the leading urological journals have used Twitter to highlight significant articles of interest to readers.

Renal track creation for percutaneous nephrolithotomy: the history and relevance of single stage dilation.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) was described in the 1980s and revolutionized the treatment of stone disease. The crucial component to this surgery is satisfactory track creation. We examine how the development and production in the 1980s of a single stage dilator (SSD) subsequently modified for pediatric PCNL has become the ideal access tool for mini percutaneous nephrolithotomy (mPCNL) today. MATERIALS AND METHODS: The conception, production, scientific and clinical development of the original SSD is described. The pitfalls of track dilation in general according to method of dilation are also discussed and outlined. RESULTS: This study provides evidence clarifying commonly held misconceptions about the origin of SSD which is the mainstay of the mPCNL technique. CONCLUSIONS: Percutaneous renal surgery continues to evolve. In less than 40 years stone surgery has transformed from a morbid open operation to a number of minimally invasive, routine techniques. The SSD has been an innovation that has played a crucial role in this change.

Surgical Approach for Partial Nephrectomy in the Management of Small Renal Masses: A Systematic Review and Network Meta-Analysis.

Background: A variety of surgical and nonsurgical management options for small renal masses (SRMs) now exist. Surgery in the form of partial nephrectomy (PN) has three different approaches. It is unclear which PN approach, if any, offers superior clinical outcomes. Aim: The aim of this study is to compare outcomes in patients with SRMs <4 cm undergoing PN through the open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), or robotic partial nephrectomy (RPN) approach and to establish the advantages and disadvantages of the various approaches. Methods: A systematic literature search was conducted for studies comparing at least two of the above techniques. Eighteen studies and 17,013 patients were included in our study. A network meta-analysis with a frequentist framework was performed. OPN was used as the baseline comparator. The prespecified primary outcome was R0 resection rates. Secondary outcomes included operating time, ischemia time, blood loss, transfusion rates, urine leak rates, significant morbidity, length of stay, and recurrence. Results: There was no significant difference between the techniques in terms of R0 rates, tumor recurrence, urine leak rates, renal function, and >3a Clavien-Dindo complications. LPN had a longer ischemic time and operating time. OPN had a longer length of stay and higher average intraoperative blood loss. RPN had lower blood transfusion rates. Discussion: All approaches are acceptable from an oncological perspective. The minimally invasive approaches (i.e., RPN and LPN) offer advantages in terms of morbidity; however, LPN may increase ischemic time and operative duration. Variations between perioperative outcomes may influence the choice of approach on a case-by-case and institutional basis.

IMPROVER (Involving Men with Prostate Cancer in Engaged Research): Assessing Patient Experience With Testing, Diagnosis, And Surveillance.

BACKGROUND: Our understanding of patient experiences with prostate cancer testing for diagnosis and surveillance is limited. The aim of this study was to collaborate with patients and clinicians to understand their lived experience and unmet needs around the early detection, diagnosis and monitoring (active surveillance) of prostate cancer. METHODS: Two focus groups were held with patients (n = 20) and healthcare professionals (n = 16), to identify the main challenges in prostate cancer detection, diagnosis, and monitoring. This information formed the basis of an online questionnaire for broader dissemination. RESULTS: A total of 1138 analyzable responses were obtained from people tested for prostate cancer (69% tested positive) in Europe and the US. Only 29 healthcare professionals completed the survey. Almost one-third of people reported knowing very little/nothing about prostate cancer prior to testing. Prior disease awareness was significantly higher in those who tested negative (P < .0001). Most respondents (n = 857; 75%) felt informed about the steps involved in testing. Receiving written information was a key factor; 91% of those who felt uninformed were not given any written information. Overall, most people felt "satisfied" with the typical prostate cancer tests: PSA, DRE, mpMRI, and biopsy. However, dissatisfaction for prostate biopsy (12%) was almost double that of other tests (P < .0001). Most patients understood why each test was done, and felt that their results and next steps were clearly explained to them; though PSA scored lowest in all of these fields. Apart from PSA, test satisfaction was lower when used repeatedly for surveillance, compared to once-off detection/diagnosis. CONCLUSIONS: Greater public awareness and education around prostate cancer, as well as clear and accessible written information for patients at the beginning of their cancer journey is needed. Further research is needed into alternative, less invasive tests, particularly when used repeatedly in the surveillance population.

Introduction of an advanced nurse practitioner (ANP)-led male lower urinary tract symptom (LUTS) clinic and development of integrated referral pathway.

INTRODUCTION: Ireland's population is living longer, and the prevalence of any LUTS is estimated to be 63-83% in adult men, increasing with age. Ireland has one of the lowest urologists per population ratio in Europe, at approximately 1:127,027. The patients waiting the longest are those with routine benign conditions such as men with LUTS. The impact on quality of life for men experiencing LUTS can be profound. METHODS: Sláintecare funded an ANP post in TUH to develop an integrated referral pathway for male LUTS and develop a secondary care nurse-led clinic for LUTS and tackle the ever increasing new and return waiting lists. The initial focus of this role was on reducing pre-existing outpatient (OP) waiting lists. This is a review of the first 12-month outcomes of this ANP post. RESULTS: A total of 410 new patients were assessed over the 12-month period. The mean waiting time from referral to review was 24 months; however, some referrals dated back to 2014. Four hundred forty-two return patients were reviewed in the 12-month period. All these patients were waiting longer than 18 months for a return appointment. In absence of the ANP-led clinic, there was no capacity for any of these patients to be reviewed in the general urology clinics. Overall outcomes were as follows: 38% were given advice and education and discharged. Treatment was initiated in 42% and follow-up arranged. Physical review was deemed necessary for 11% of patients. Only 6% of patients reviewed required referral back to consultants' clinic. CONCLUSION: This study demonstrates the safety, efficacy and financial advantage of an ANP-led clinic for adult men presenting with lower urinary tract symptoms previously triaged by a consultant urologist.

Implementing a physiotherapy led cancer exercise programme in a National Cancer Centre: the FIXCAS study.

OBJECTIVES: To examine the feasibility of implementing a 10-week exercise-based cancer rehabilitation programme in a national cancer centre. DESIGN: A single-arm prospective feasibility study. SETTING: An outpatient physiotherapy department. PARTICIPANTS: Forty de-conditioned cancer survivors (<1 year post completion of treatment). INTERVENTIONS: A 10-week programme of twice weekly group-based supervised exercise sessions. MAIN OUTCOME MEASURES: A mixed methods approach was used. The primary outcome of the study was feasibility, evaluated in terms of recruitment, adherence, attrition and stakeholder acceptance of the programme. Secondary outcomes examined the effect of the exercise intervention on physical function and quality of life measures. RESULTS: Forty patients (age 60 (SD 10.6) years; n = 12 breast cancer, n = 11 lung cancer, n = 7 prostate cancer, n = 5 colorectal cancer, n = 5 other) participated. In total 82% (n = 33) participants completed the post-programme assessment. Deterioration of health and concerns over COVID-19 were the most common reasons for dropout (both n = 2). Adherence to both the supervised exercise classes and home exercise programme was high (78% and 94% respectively). No adverse events were recorded during the intervention or assessments. Qualitative feedback from stakeholders highlighted the acceptability of the programme as well as many perceived benefits of the exercise programme. Improvements in three quality of life sub-scales (physical function, role function and emotional function), physical activity levels and aerobic fitness levels were found post-intervention. CONCLUSION: It appears feasible to offer a 10-week exercise programme to patients attending a national cancer centre, with adequate recruitment, retention and adherence rates and high acceptability among stakeholders. CONTRIBUTION OF THE PAPER.

Perceptions and Practice Patterns of Urologists Relating to Intrarenal Pressure During Ureteroscopy: Findings from a Global Cross-Sectional Analysis.

Objectives: To explore beliefs and practice patterns of urologists regarding intrarenal pressure (IRP) during ureteroscopy (URS). Methods: A customized questionnaire was designed in a 4-step iterative process incorporating a systematic review of the literature and critical analysis of topics/questions by six endourologists. The 19-item questionnaire interrogated perceptions, practice patterns, and key areas of uncertainty regarding ureteroscopic IRP, and was disseminated via urologic societies, networks, and social media to the international urologic community. Consultants/attendings and trainees currently practicing urology were eligible to respond. Quantitative responses were compiled and analyzed using descriptive statistics and chi-square test, with subgroup analysis by procedure volume. Results: Responses were received from 522 urologists, practicing in six continents. The individual question response rate was >97%. Most (83.9%, 437/515) respondents were practicing at a consultant/attending level. An endourology fellowship incorporating stone management had been completed by 59.2% (307/519). The vast majority of respondents (85.4%, 446/520) scored the perceived clinical significance of IRP during URS ≥7/10 on a Likert scale. Concern was uniformly reported, with no difference between respondents with and without a high annual case volume (p = 0.16). Potential adverse outcomes respondents associated with elevated ureteroscopic IRP were urosepsis (96.2%, 501/520), collecting system rupture (80.8%, 421/520), postoperative pain (67%, 349/520), bleeding (63.72%, 332/520), and long-term renal damage (26.1%, 136/520). Almost all participants (96.2%, 501/520) used measures aiming to reduce IRP during URS. Regarding the perceived maximum acceptable threshold for mean IRP during URS, 30 mm Hg (40 cm H2O) was most frequently selected [23.2% (119/463)], with most participants (78.2%, 341/463) choosing a value ≤40 mm Hg. Conclusions: This is the first large-scale analysis of urologists' perceptions of ureteroscopic IRP. It identifies high levels of concern among the global urologic community, with almost unanimous agreement that elevated IRP is associated with adverse clinical outcomes. Equipoise remains regarding appropriate IRP limits intraoperatively and the most appropriate technical strategies to ensure adherence to these.

The changing pattern of antimicrobial resistance within 42,033 Escherichia coli isolates from nosocomial, community and urology patient-specific urinary tract infections, Dublin, 1999-2009.

OBJECTIVE: To investigate the changing pattern of antimicrobial resistance in Escherichia coli urinary tract infection over an eleven year period, and to determine whether E. coli antibiotic resistance rates vary depending on whether the UTI represents a nosocomial, community acquired or urology patient specific infection. PATIENT AND METHODS: A retrospective analysis of the 42,033 E. coli urine isolates from the 11-year period 1999-2009 in a single Dublin teaching hospital was performed. WHONET(TM) software was used to analyse the changing pattern of sensitivity and resistance of E. coli to commonly used antibiotics over the study period. The origins of the urine samples were stratified into three groups: inpatients with nosocomial UTIs; urine originating from the emergency department and general practice (community UTIs); and UTIs in urology patients. RESULTS: Urinary tract infections in the urology patient population demonstrate higher antibiotic resistance rates than nosocomial or community UTIs. There were significant trends of increasing resistance over the 11-year period for ampicillin, trimethoprim, gentamicin and ciprofloxacin, and significant differences in co-amoxyclav, gentamicin, nitrofurantion and ciprofloxacin resistance rates depending on the sample origin. Ampicillin and trimethoprim were the least active agents against E. coli, with total 11-year resistance rates of 58.3 and 33.8%, respectively. The overall gentamicin resistance rate was 3.4% and is climbing at a rate of 0.7% per year (P < 0.001). Within the urology patient population the resistance rate was 6.4%. Ciprofloxacin resistance approaches 20% in the nosocomial UTI population and approaches 30% in the urology population; however, it remains a reasonable empirical antibiotic choice in this community, with an 11-year resistance rate of 10.6%. CONCLUSIONS: E. coli remains the commonest infecting uropathogen in the community and hospital setting with its incidence climbing from 50 to 60% of UTIs over the 11-year period. Neither penicillins nor trimethoprim represent suitable empirical antimicrobials for UTI and ciprofloxacin resistance in this Dublin-based study renders it unsuitable empirical therapy for nosocomial UTIs and UTIs in the urology population. The dramatic 11-year rate increase in gentamicin resistance is of paramount concern.

An investigation of the basic physics of irrigation in urology and the role of automated pump irrigation in cystoscopy.

OBJECTIVE: To investigate the effects of height, external pressure, and bladder fullness on the flow rate in continuous, non-continuous cystoscopy and the automated irrigation fluid pumping system (AIFPS). MATERIALS: Each experiment had two 2-litre 0.9% saline bags connected to a continuous, non-continuous cystoscope or AIFPS via irrigation tubing. Other equipment included height-adjustable drip poles, uroflowmetry devices, and model bladders. METHODS: In Experiment 1, saline bags were elevated to measure the increment in flow rate. In Experiment 2, saline bags were placed under external pressures to evaluate the effect on flow rate. In Experiment 3, flow rate changes in response to variable bladder fullness were measured. RESULTS: Elevating saline bags caused an increase in flow rates, however the increment slowed down beyond a height of 80 cm. Increase in external pressure on saline bags elevated flow rates, but inconsistently. A fuller bladder led to a decrease in flow rates. In all experiments, the AIFPS posted consistent flow rates. CONCLUSIONS: Traditional irrigation systems were susceptible to changes in height of irrigation solution, external pressure application, and bladder fullness thus creating inconsistent flow rates. The AIFPS produced consistent flow rates and was not affected by any of the factors investigated in the study.