Defining a national reference level for intraoperative radiation exposure in urological procedures: FLASH, a retrospective multicentre UK study.

OBJECTIVES: To define reference levels for intraoperative radiation during stent insertion, ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL); to identify variation in radiation exposure between individual hospitals across the UK, between low- and high-volume PCNL centres, and between grade of lead surgeon. PATIENTS/SUBJECTS AND METHODS: In all, 3651 patients were identified retrospectively across 12 UK hospitals over a 1-year period. Radiation exposure was defined in terms of total fluoroscopy time (FT) and dose area product (DAP). The 75th percentiles of median values for each hospital were used to define reference levels for each procedure. RESULTS: Reference levels: ureteric stent insertion/replacement (DAP, 2.3 Gy/cm2 ; FT, 49 s); URS (DAP, 2.8 Gy/cm2 ; FT, 57 s); PCNL (DAP, 24.1 Gy/cm2 ; FT, 431 s). Significant variations in the median DAP and FT were identified between individual centres for all procedures (P < 0.001). For PCNL, there was a statistically significant difference between DAP for low- (<50 cases/annum) and high-volume centres (>50 cases/annum), at a median DAP of 15.0 Gy/cm2 vs 4.2 Gy/cm2 (P < 0.001). For stent procedures, the median DAP and FT differed significantly between grade of lead surgeon: Consultant (DAP, 2.17 Gy/cm2 ; FT, 41 s) vs Registrar (DAP, 1.38 Gy/cm2 ; FT, 26 s; P < 0.001). CONCLUSION: This multicentre study is the largest of its kind. It provides the first national reference level to guide fluoroscopy use in urological procedures, thereby adding a quantitative and objective value to complement the principles of keeping radiation exposure 'as low as reasonably achievable'. This snapshot of real-time data shows significant variation around the country, as well as significant differences between low- and high-volume centres for PCNL, and grade of lead surgeon for stent procedures.

Long-term Outcomes of Minimally Invasive Rendezvous Procedures to Treat Complex Ureteric Strictures and Injuries.

Background: Complex ureteric strictures and injuries occurring during major abdominal and pelvic operations may cause significant morbidity and distress to patients. A rendezvous procedure is an endoscopic technique used in case of such injuries. Objective: To evaluate perioperative and long-term outcomes of rendezvous procedures to treat complex ureteric strictures and injuries. Design setting and participants: We retrospectively reviewed patients undergoing a rendezvous procedure for ureteric discontinuity including strictures and injuries, treated between 2003 and 2017 at our Institution and completing at least 12 mo of follow-up. We divided patients into two groups: early postsurgical obstruction, leakage, or detachment (group A) and late strictures (oncological/postsurgical; group B). Outcome measurements and statistical analysis: If appropriate, we performed a retrograde study ± rigid ureteroscopy to assess the stricture 3 mo after the rendezvous procedure, followed by a MAG3 renogram at 6 wk, 6 mo, and 12 mo, and annually thereafter for 5 yr. Results and limitations: Forty-three patients underwent a rendezvous procedure, 17 in group A (median age 50 yr, range 30-78) and 26 in group B (median age 60 yr, range: 28-83). Ureteric strictures and ureteric discontinuities were stented successfully in 15 out of 17 patients in group A (88.2%) and 22 out of 26 patients (84.6%) in group B. For both groups, the median follow-up was 6 yr. In group A, of 17 patients, 11 (64.7%) were stent free with no further interventions, two (11.7%) had a subsequent Memokath stent insertion (38%), and two (11.7%) required reconstruction. Of 26 patients in group B, eight (30.7%) required no further interventions and were stent free, ten (38.4%) were maintained with long-term stenting, and one was managed with a Memokath stent (3.8%). Of the 26 patients, only three (11.5%) required major reconstruction, while four patients with malignancy (15%) died during follow-up. Conclusions: With a combined antegrade and retrograde approach, the majority of complex ureteric strictures/injuries can be bridged and stented with an overall immediate technical success rate of above 80%, avoiding major surgery in unfavourable circumstances and allowing time for stabilisation and recovery of the patient. Additionally, in case of technical success, further interventions may be unnecessary in up to 64% of patients with acute injury and about 31% of patients with late stricture. Patient summary: The majority of complex ureteric strictures and injuries can be resolved using a rendezvous approach, avoiding major surgery in unfavourable circumstances. Moreover, this approach can help avoid further interventions in 64% of such patients.

Obstructive urosepsis secondary to ureteric herniation into the sciatic foramen.

A 65-year-old female patient presented with a 2-day history of worsening right-sided abdominal pain and clinical signs of sepsis, on the background of a recent admission for pancolitis. Imaging revealed right ureteric herniation through the sciatic foramen with subsequent hydroureteronephrosis and radiological signs of severe pyelonephritis. The patient underwent emergency decompression with a percutaneous nephrostomy, followed by insertion of an antegrade stent to correct the ureteric hernia once the sepsis was appropriately treated. We describe the presentation and management of this unusual case of herniation of the right ureter into the sciatic foramen.

The Role of Tandem Double-J Ureteral Stents in the Management of Malignant Ureteral Obstruction.

AIM: The management of malignant ureteral obstruction (MUO) is a challenging but common problem for urologists. The different techniques currently used to address this complicated issue include percutaneous nephrostomy, extra-anatomical stents, retrograde (single) stent insertion, and metallic stents. In those situations where single ureteral stent insertion has failed, retrograde tandem or twin ureteral stent (TUS) insertion can be completed. The aim of this study was to report our clinical experience and also assess the efficacy of TUS insertion within our tertiary referral center. METHODS: Data were prospectively collected from patients requiring TUSs over an 8-year period between January 1, 2006, and December 31, 2014. A number of variables, including the improvement in renal function following TUS insertion, were recorded. RESULTS: Twenty-two TUS insertion procedures were performed on 15 patients between the period of January 1, 2006, and December 31, 2014. The mean patient age was 68.0 years (39-85 years). There were 15 primary insertions as well as 7 subsequent stent changes. The average prenephrostomy creatinine was 428 µmol/L; an average improvement of 196 µmol/L was observed after percutaneous drainage. Serum creatinine after TUS remained stable on discharge, 214 µmol/L vs 227 µmol/L preoperatively, p = 0.34. Eleven patients died at a median 131 days post-TUS insertion. TUS failure occurred in three patients; this was characterized by rising creatinine and worsening hydronephrosis. Patients with failing TUS had a median life expectancy of 45.6 days compared with 162.5 days for those with functioning TUS (p < 0.05). Overall, the patency rate at 3 months was 80%. CONCLUSION: TUS insertion is a technically efficient and effective procedure in the management of MUO, with the majority of patients treated dying of the underlying condition with functioning stents in situ.

Extended Ureteral Stricture Corrected With Appendiceal Replacement in a Kidney Transplant Recipient.

OBJECTIVE: To present our technique of ureteral replacement with an appendicovesicostomy for the treatment of extended ureteral stricture after kidney transplantation. Ureteral stricture represents a urologic complication that may cause progressive function impairment and graft loss. Symptomatic ureteral stenosis is generally treated with a percutaneous nephrostomy and ureteral stenting. This approach may be initially effective, but often does not offer a long-term solution. METHODS: A 48-year-old Caucasian man underwent kidney transplantation from a heart-beating deceased donor. The graft was transplanted to the right iliac fossa. Ureterovesical anastomosis was performed following the Lich-Gregoir technique. The postoperative period and follow-up were uneventful. Six months later the patient experienced an episode of acute pyelonephritis with hydronephrosis. A percutaneous nephrostomy was inserted, and an anterograde pyelography confirmed proximal dilatation with severe distal stenosis involving the entire ureter including the ureterovesical anastomosis. A 9 French Double-J stent was inserted antegradely and the patient was prepared for surgery. RESULTS: We decided therefore to use the appendix as a conduit between the proximal transplant ureter and the bladder It was interposed with an isoperistaltic orientation and anastomosed to the ureter proximally and to the bladder distally (Lich-Gregoir reimplantation) using interrupted absorbable 5/0 sutures over a 10-Fr Double-J stent. The urethral catheter was removed on day 9 postoperatively and the patient was discharged with normal parameters. At 1 year follow-up the patient remains well. CONCLUSION: The positive outcome confirms how the use of appendix as ureteral replacement is feasible and effective, allowing the salvage of the renal allograft.

'A reservoir within a reservoir' - An unusual complication associated with a defunctioned inflatable penile prosthesis reservoir.

INTRODUCTION: Inflatable penile prostheses (IPP) have been a successful method of treating men with erectile dysfunction since the early 1970s. IPP are comprised of two intracorporal cylinders, a scrotal pump and a fluid reservoir. PRESENTATION OF CASE: We present a case of a retained reservoir in a sixty eight year old gentlemen presenting with a cystic abdominal mass and bothersome LUTS, 15 years after the removal of the penile components of a three-piece penile prosthesis. Percutaneous drainage of the cyst was performed, with four litres of purulent fluid evacuated. A midline laparotomy was required to remove the reservoir and drain the collection completely. DISCUSSION: Inflammatory reaction and subsequent erosion of an IPP reservoir is an infrequent but severe complication of IPP insertion, replacement or infection. Infection remains the primary indication for penile prosthesis removal and in this setting removal of the reservoir is routine. A thorough literature search has identified that in the non-infective setting, the routine removal of the original reservoir is not standard practice during three-component IPP replacement. In patients with a history of IPP presenting with new LUTS, reservoir erosion should be considered in the differential diagnosis and investigation with cystoscopy and computed tomography included early in the investigatory armament of the urologist. CONCLUSION: It is our belief that a defunctionalized reservoir serves no purpose; rather it can only cause trouble in the future. Consequently, at our institution we do not leave defunctionalized reservoirs in situ.

Significant upper urinary tract hematuria as a rare complication of high-pressure chronic retention of urine following decompression: a case report.

INTRODUCTION: Hematuria has been described following bladder drainage in 2% to 16% of high-pressure chronic urinary retention treatments by decompression and is generally self-limiting. We describe a case of significant bilateral upper urinary tract hematuria following drainage of high-pressure chronic retention. To the best of our knowledge, the only similar case reported in the literature was in 1944. CASE PRESENTATION: An 82-year-old Caucasian man was referred to our department with nocturnal enuresis and a palpable bladder. He was catheterized, produced a residual volume of 2900mL, and ended up becoming oliguric. Following investigations, he had bilateral nephrostomies. He was discharged 18 days after presentation. CONCLUSIONS: Clinicians should keep in mind the presentation discussed in this case report to be able to swiftly manage this extremely rare complication of decompression in patients with high-pressure chronic retention.

Treatment of carcinoma in situ of the glans penis with topical chemotherapy agents.

BACKGROUND: The use of topical agents in the treatment of carcinoma in situ (CIS) of the penis has been well described in the literature. Previous studies have been limited by small sample size and imprecise end points. OBJECTIVE: Establish the response rate of 5-fluorouracil (5-FU) and imiquimod (IQ) in the treatment of penile CIS in a large contemporary series in a supranetwork centre. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of all primary and recurrent cases of penile CIS treated with 5-FU and IQ identified from a prospective database over a 10-yr period. Therapy was standardised in all cases with application to the lesion for 12h every 48 h for 28 d. INTERVENTION: 5-FU was the first-line therapy, and IQ was the second-line topical agent. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary end point was defined as complete response (CR; i.e., resolution of lesion), partial response (PR; i.e., lesion reduced in size and or visibility), or no response (NR; ie, no improvement in lesion size and or visibility). The secondary end points included local toxicity and adverse events. No statistical analysis or software was used. RESULTS AND LIMITATIONS: A total of 86 patients were diagnosed with CIS of the penis over the 10-yr period. Forty-four (51%) received topical chemotherapy. The mean follow-up was 34 mo. CR to topical chemotherapy was seen in 25 (57%), PR was seen in 6 (13.6%), and NR was seen in the remaining 13 (29.5%) patients. Local toxicity was experienced by 10% of patients, and 12% had an adverse event following application of 5-FU. The retrospective design and short follow-up were the major limitations of this study. CONCLUSIONS: Topical chemotherapy agents are moderately effective first-line therapy in the treatment of penile CIS. Toxicity and adverse events were few with our treatment protocol. The issues of long-term surveillance and assessment of partial responders remain a challenge. Topical chemotherapy should remain a first-line treatment option for penile CIS.

Mid-term evaluation of Sorin Soprano bioprostheses in patients with a small aortic annulus

We set to examine the mid-term outcome after aortic valve replacement (AVR) with Soprano pericardial stented bioprosthesis measuring