A prospective audit on the effect of training and educational workshops on the incidence of urethral catheterization injuries.

INTRODUCTION: The incidence of iatrogenic urethral catheterization (UC) injuries is approximately 0.3%. Resultant complications are associated with patient morbidity and unnecessary healthcare costs. Our aim was to investigate whether educational training workshops decreased the incidence of UC-related injuries. METHODS: A prospective audit was performed to calculate incidence, morbidity, and costs associated with iatrogenic UC injury from January to July 2015. Educational workshops were then conducted with healthcare staff and training modules for junior doctors. UC-related incidence, morbidity, and costs in the subsequent six-month period were recorded prospectively and compared with the previous data. RESULTS: The incidence of iatrogenic UC injuries was reduced from 4.3/1000 catheters inserted to 3.8/1000 catheters after the intervention (p=0.59). Morbidity from UC increased in the second half in the form of increase in cumulative additional inpatient hospital stay (22 to 79 days; p=0.25), incidence of urosepsis (n=2 to n=4), and need for operative intervention (n=1 to n=2). The cost of managing UC injuries almost doubled in the period after the training intervention (€50 449 to €90 100). CONCLUSIONS: Current forms of educational and training interventions for UC did not significantly change morbidity or cost of iatrogenic UC injuries despite a decrease in incidence. Improved and intensive training protocols are necessary for UC to prevent avoidable iatrogenic complications, as well as a safer urethral catheter design.

Quantification of User and Manufacturer Variabilities in Urinary Catheter Anchoring Balloon Inflation and Mitigation of Variability by Flow Resistance.

OBJECTIVE: To quantify user variability and manufacturer variability in urinary catheter anchoring balloon inflation pressure and to mitigate any significant variance by incorporating flow resistance into the anchoring balloon inflation process. METHODS: Inflation of a urinary catheter anchoring balloon was performed at atmospheric pressure by different users (n = 8) to investigate user variability. A calibrated pressure transducer measured inflation pressures, and a video extensometer measured balloon inflation profiles. Manufacturer variability was investigated by applying constant forces to the plunger of conventional syringes to mimic "heavy-," "intermediate-," and "light"-handed users for 3 brands of catheter. Flow restrictors of variable reduced cross-sectional areas were introduced to the outflow of the inflation syringes to investigate the effect of flow resistance on anchoring balloon inflation profiles. RESULTS: Variations in maximum inflation pressures (range: 75-355 kPa) were observed among the different users. There were no significant differences in maximum inflation pressure between brands at any of the 3 simulated hand forces (P = .97). Increasing the flow resistance significantly reduces the applicable inflation pressure of all hand forces (P < .001). Specifically, the difference in inflation pressure between heavy- and light-handed forces is reduced from over 405 kPa to under 65 kPa. Introducing flow resistance does not result in a significant difference in inflation pressure between brands (P = .254). CONCLUSION: There is significant user variability in urinary catheter balloon inflation pressure. This variation can be significantly reduced by introducing flow resistance to the inflation technique.

A comparative assessment of irrigation and drainage characteristics for commercially available urethral catheters.

INTRODUCTION: We aimed to investigate irrigation and drainage characteristics of commercially available urethral catheters and determined which catheter offers the best flow characteristics. MATERIAL AND METHODS: Twelve different commercially available urethral catheters from three companies (Bard™, Rusch™ and Dover™) were investigated to compare their irrigation and drainage properties. Irrigation port, drainage port and overall cross-sectional areas for a 24Fr 3-way catheter was measured and compared. The maximum (Qmax) and average (Qavg) irrigation and drainage flow rates for each catheter was measured for 20-40 seconds using uroflowmetry. The primary endpoint was to determine which catheter offers optimal irrigation and drainage parameters. RESULTS: Overall cross-sectional area, irrigation port cross-sectional area, and drainage port cross-sectional area differed significantly for each 24Fr 3-way catheter assessed (p <0.001). The 24Fr 3-way Rusch Simplastic™ catheter consistently demonstrated the greatest maximal flow rate (Qmax: 5 ±0.3 ml/s) and average flow rate (Qavg: 4.6 ±0.2 ml/s) for irrigation. The 24Fr 3-way Dover™ catheter provided the greatest drainage properties (Qmax: 19.7 ±2 ml/s; Q avg: 15.9 ±5 ml/s). In the setting of continuous bladder irrigation, the 24Fr 3-way Rusch Simplastic™ catheter provided the highest irrigation rates (Qmax: 6.6 ±1.8 ml/s; Q avg: 4.6 ±0.9 ml/s). CONCLUSIONS: Three-way catheters demonstrate significant differences in their irrigation and drainage characteristics. The type of catheter selected should be based on the appropriate prioritization of efficient bladder irrigation versus efficient bladder drainage.

The Variable Flow Characteristics for Different Brands of 3-Way Urinary Catheters: Proposing an Alternate and Accurate Standardised Labelling System.

OBJECTIVE: To evaluate an alternative catheter labelling approach for 3-way catheters based on the drainage channel and irrigation channel cross-sectional area (CSA), which impacts catheter flow rate characteristics. MATERIALS AND METHODS: Three-way 22Fr catheters from Bard (Bard Limited), Rusch Simplastic (Teleflex Medical), Dover (COVIDIEN), and Rusch Golden were included in the study. Irrigation channel, drainage channel, and overall CSAs were digitally measured with an image-processing program. Irrigation channel and drainage channel flow rates were measured and correlated with their corresponding catheter CSA values. RESULTS: Catheter CSA and French value did not predict flow-rate characteristics, but irrigation channel CSA and drainage channel CSA were predictive. The 22Fr Rusch Simplastic catheter had the largest irrigation channel CSA (2.87 mm(2)) and drainage channel CSA (12.6 mm(2)), and had the greatest irrigation (5.27 ± 0.02 ml/s) and drainage flow rates (14.42 ± 0.22 ml/s). Twenty-two French gauge Rusch Golden catheters had the smallest irrigation channel CSA (1.34 mm(2)) and drainage channel CSA (7.82 mm(2)) and the lowest irrigation (1.83 ± 0.03 ml/s) and drainage flow rates (1.83 ± 0.03 ml/s). CONCLUSION: An alternative catheter labelling system to include overall CSA, irrigation channel CSA, and drainage channel CSA values would provide more accurate and transparent data relevant to anticipated drainage and irrigation flow rates. The proposed labelling method will assist urologists in selecting 3-way catheters for bladder irrigation.

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.

Bricker versus Wallace anastomosis: A meta-analysis of ureteroenteric stricture rates after ileal conduit urinary diversion.

INTRODUCTION: Data comparing the incidence of ureteroenteric strictures for Bricker and Wallace anastomoses are limited. This study compares both anastomotic techniques in terms of ureteroenteric stricture rates after radical cystectomy and ileal conduit urinary diversion. METHODS: Electronic databases (Medline, EMBASE, and Cochrane database) were searched for studies comparing Bricker and Wallace ureteroeneteric anastomoses for ileal conduit urinary diversion after radical cystectomy. Meta-analyses were performed using the random effects method. The primary outcome measure was to determine differences in postoperative ureteroenteric stricture rates for both surgical techniques. Four studies describing 658 patients met the inclusion criteria. The total number of ureters used for ureteroeneteric anastomoses was 1217 (545 in the Bricker group and 672 in the Wallace group). RESULTS: There were no significant differences in age (p = 0.472), gender (p = 0.897), duration of follow-up (p = 0.168), and duration to stricture development between groups (p = 0.439). The overall stricture rate was 29 of 1217 (2.4%); 16 of 545 ureters (2.9%) in the Bricker group and 13 of 672 ureters (1.9%) in the Wallace group. The Bricker anastomosis was not associated with a significantly higher overall stricture rate compared to the Wallace ureteroenteric anastomosis (odds ratio: 1.393, 95% confidence interval: 0.441-4.394, p = 0.572). CONCLUSION: Accepting limitations in the available data, we found no significant difference in the incidence of ureteroenteric stricture for Bricker and Wallace anastomoses.

Preventing Urethral Trauma from Inadvertent Inflation of Catheter Balloon in the Urethra during Catheterization: Evaluation of a Novel Safety Syringe after Correlating Trauma with Urethral Distension and Catheter Balloon Pressure.

PURPOSE: We investigated urethral diametric strain and threshold maximum inflation pressure for rupture during inadvertent inflation of a catheter anchoring balloon in the urethra. In addition, we evaluated a novel safety device to prevent trauma based on these parameters. MATERIALS AND METHODS: Inflation of a urethral catheter anchoring balloon was performed in the bulbar urethra of 21 ex vivo porcine models using 16Fr catheters. Urethral trauma was assessed with retrograde urethrography. Urethral rupture was correlated with internal urethral diametric strain and maximal urethral pressure threshold values in kPa. Urethral catheters were then inflated in the bulbar urethras of 7 fresh male cadavers using a standard syringe and a prototype syringe. The plunger of the standard syringe was depressed until opposing resistance pressure generated by the urethra prevented further inflation of the anchoring balloon. The plunger of the prototype safety syringe was depressed until sterile water in the syringe decanted through an activated safety threshold pressure valve. RESULTS: Retrograde urethrography demonstrated that porcine urethral rupture consistently occurred at an internal urethral diametric strain greater than 40% and a maximum inflation pressure greater than 150 kPa. The mean ± SD maximum human urethral threshold inflation pressure required to activate the safety prototype syringe pressure valve was 153 ± 3 kPa. In comparison, maximum inflation pressure was significantly greater using the standard syringe than the activated prototype syringe (mean 452 ± 188 kPa, p <0.001). CONCLUSIONS: Internal urethral diametric strain and threshold maximum inflation pressures are important parameters for designing a safer urethral catheter system with lower intrinsic threshold inflation pressures.

Interstitial cystitis/painful bladder syndrome: the influence of modern diagnostic criteria on epidemiology and on Internet search activity by the public.

Interstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic debilitating condition that is characterised by suprapubic pain and urinary symptoms such as urgency, nocturia and urinary frequency. The prevalence of the condition is increasing due to more inclusive diagnostic criteria. Herein, we review the evolving epidemiology of IC/PBS and investigate health seeking behaviour for the condition through Internet search activity. Study selection was performed in accordance with PRISMA. In addition, global search trends for the terms 'Interstitial Cystitis' and 'Painful Bladder Syndrome' from 2005 to 2015 were also evaluated using the 'Google Trends' search application. The mean search activity per month was recorded and mean activity at annual intervals calculated. Regional search activity by country and city was also measured. Prevalence rates for IC/PBS vary according to diagnostic criteria and range from 2% to 17.3% among the general population. Increased prevalence is associated with female gender and females with one first-degree relative affected. There has been an increase in global mean search activity for IC/PBS on an annual basis since 2005. The greatest increase in search activity was in USA, Canada, United Kingdom, Australia, Ireland and India respectively. The top five cities for search activity for IC/PBS were in the USA. As diagnostic criteria for IC/PBS continues to become more inclusive it is likely that the prevalence will continue to increase. This is particularly true for the USA and Canada as these regions have demonstrated the greatest increase in Internet search activity for IC/ PBS.

Prospective study of antibiotic prophylaxis for prostate biopsy involving >1100 men.

We aimed to compare infection rates for two 3-day antibiotic prophylaxis regimens for transrectal ultrasound-guided prostate biopsy (TRUSgbp) and demonstrate local microbiological trends. In 2008, 558 men and, in 2009, 625 men had TRUSgpb. Regimen 1 (2008) comprised 400 mg Ofloxacin immediately before biopsy and 200 mg 12-hourly for 3 days. Regimen 2 (2009) comprised Ofloxacin 200 mg 12-hourly for 3 days commencing 24 hours before biopsy. 20/558 (3.6%) men had febrile episodes with regimen 1 and 10/625 (1.6%) men with regimen 2 (P = 0.03). E. coli was the most frequently isolated organism. Overall, 7/13 (54%) of positive urine cultures were quinolone resistant and (5/13) 40% were multidrug resistant. Overall, 5/9 (56%) patients with septicaemia were quinolone resistant. All patients were sensitive to Meropenem. There was 1 (0.2%) death with regimen 1. Commencing Ofloxacin 24 hours before TRUSgpb reduced the incidence of febrile episodes significantly. We observed the emergence of quinolone and multidrug-resistant E. coli. Meropenem should be considered for unresolving sepsis.

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.

Prospective randomised controlled trial comparing trigone-sparing versus trigone-including intradetrusor injection of abobotulinumtoxinA for refractory idiopathic detrusor overactivity.

BACKGROUND: Botulinum toxin A is effective for treatment of idiopathic detrusor overactivity (IDO). The trigone is generally spared because of the theoretical risk of vesicoureteric reflux (VUR), although studies assessing injection sites are lacking. OBJECTIVE: Evaluate efficacy and safety of trigone-including versus trigone-sparing intradetrusor injections of abobotulinumtoxinA in patients with IDO. DESIGN, SETTING, AND PARTICIPANTS: Twenty-two patients from one centre were randomised to trigone-including or trigone-sparing injections. INTERVENTION: Injection of 500 U abobotulinumtoxinA diluted to 20ml into 20 trigone-including or trigone-sparing sites. MEASUREMENTS: The primary outcome measure was total overactive bladder symptom score (OABSS) at 6 wk. The OABSS questionnaire was completed at 0, 6, 12, and 26 wk. Baseline and postinjection urodynamic studies and micturating cystourethrograms were performed. Baseline values and subsequent time points were compared by t test. A mixed-effect model was used for repeated measures in time. RESULTS AND LIMITATIONS: For symptom scores at baseline compared with scores at 6 wk postinjection, the mean total OABSS improved from 22.4 to 8.7 (p<0.001) in the trigone-including group compared with 22.7 to 13.4 (p<0.03) in the trigone-sparing group. The difference in mean change from baseline was 4.4 points in favour of the trigone-including group (p=0.03). The total OABSS at 12 and 26 wk and the urgency subscale scores at 6, 12, and 26 wk showed significant improvement in favour of the trigone-including group. Mean postvoid residual volumes and clean intermittent self-catheterisation rates between the two groups were similar. No patients developed VUR. Performing injections under general anaesthetic was a limitation, as tolerability under local anaesthetic was not assessed. A further limitation is the lack of a trigone-only arm. CONCLUSIONS: Trigone-including injections are superior to trigone-sparing injections for the treatment of refractory IDO and did not cause VUR in this study.

Terminology and details of the diagnostic process for testis cancer.

PURPOSE: We examined the process and causes of diagnostic delay, defined as the interval from symptom onset to diagnosis, for testis (germ cell) cancer and the change with time. Diagnostic delay influences disease burden and may be subdivided into symptomatic interval, defined as symptom onset to first presentation, and diagnostic interval, defined as first presentation to diagnosis. MATERIALS AND METHODS: We performed a single center review of 100 consecutive cases. Diagnostic delay in weeks, and symptomatic and diagnostic intervals in days were calculated, and related factors were recorded. Previous reports by the senior author (JT) in the same health care system allowed the examination of change during 2 decades. RESULTS: Mean±SD diagnostic delay was 12.5±17.4 weeks (median 6, range 1 to 104), a substantial decrease in the mean of 10 months reported by one of us (JT) in 1987. Mean symptomatic interval was 65.4±100.9 days (median 29, range 0 to 720). Mean diagnostic interval was 21.9±63.5 days (median 7, range 1 to 540). Symptomatic interval exceeded or was equal to diagnostic interval in 80 men. CONCLUSIONS: This terminology allows detailed examination of the diagnostic process for testis cancer. Aberrant diagnostic delay for testis cancer is decreasing and is now dominated by patient dependent factors. Select cases suggest that physician error remains a factor in a minority.

Public awareness of testis cancer and the prevalence of testicular self-examination-changing patterns over 20 years.

OBJECTIVES: Delay in treatment of testis cancer (TC) has a proven negative impact on disease stage, treatment outcome, and mortality. Poor public awareness of the disease and lack of testis self-examination (TSE) may account for late presentation. The aim of this study was to examine the knowledge of TC and performance of TSE in a group of men over 2 time periods 20 years apart. METHODS: In the current study, 677 men from a banking institution were surveyed on their knowledge of TC and their performance of TSE. Comparisons were made from the current data and those from the original study in 1986. RESULTS: This study demonstrates an increase in public awareness and modest concomitant increase in TSE since first studied in this country in 1986. There was no difference in knowledge across age groups in this study. Furthermore, men who demonstrate a superior degree of knowledge were more likely to perform TSE. Limitations included possible selection bias in the 2 studies conducted in a banking institution. CONCLUSIONS: Increased testicular cancer knowledge combined with TSE may have a role in improving detection of significant testicular pathology.

Prolonged lymphatic leak after retroperitoneal lymph node dissection: a case report.

INTRODUCTION: Persistent lymphatic drainage following retroperitoneal lymph node dissection for testicular tumor is an uncommon complication. CASE PRESENTATION: We describe a 21-year old man of Caucasian origin who had metastatic non-seminomatous germ cell tumor of the testis, and underwent retroperitoneal lymph node dissection, nephrectomy and partial inferior vena cava excision for a residual mass. The patient subsequently developed persistent lymphatic drainage causing foot drop that eventually responded to conservative medical and surgical measures. CONCLUSION: This postoperative condition usually responds well to conservative measures but has the potential for serious morbidity if it is not managed appropriately.

Joaquin Maria Albarran Y Dominguez: microbiologist, histologist, and urologist--a lifetime from orphan in Cuba to Nobel nominee.

Joaquin Albarran was an extraordinary late 19th century urologist. His early career was in the field of microbiology and histopathology in Paris at a time of great medical developments and innovations. His later contributions to urology included the Albarran lever, Albarrans sign, Albarran-Ormond syndrome and seminal works on testicular and renal tumors. He also wrote treatizes on the pathophysiology of acute urinary retention, nephritis and calculus ureteric obstruction. He died at the young age of 52 from the effects of tuberculosis and in this same year was nominated for the Nobel prize in medicine.

Anaplastic large cell lymphoma: a unique presentation with urinary bladder involvement: a case report.

Anaplastic large cell lymphoma (ALCL) is a T-cell lymphoma composed of large pleomorphic CD30-positive cells. While systemic ALCL frequently involves extranodal sites, involvement of the urinary bladder is extremely rare. We report a case of systemic ALCL presenting with bladder involvement. A 28-year-old man presented with hematuria, dysuria, and lower abdominal pain. Imaging revealed pelvic lymphadenopathy and a thickened bladder wall. Bladder biopsies showed diffuse infiltration of the lamina propria by large pleomorphic cells, with preservation of the overlying urothelium. Immunohistochemistry demonstrated cell membrane and Golgi region staining for CD30 and epithelial membrane antigen. This is the first documented instance of systemic ALCL presenting with bladder symptoms.

Pelvic recurrence in stage I seminoma: a new phenomenon that questions modern protocols for radiotherapy and follow-up.

OBJECTIVE: To highlight the increased risk for pelvic relapse in patients with stage 1 seminoma treated with adjuvant radiotherapy limited to para-aortic template alone. PATIENTS AND METHODS: Over a four-year period, three patients presented with early pelvic recurrence after radical orchidectomy and adjuvant irradiation for stage 1 seminoma. In each case, radiotherapy had been limited to the para-aortic region with omission of the ipsilateral hemi pelvis. RESULTS: Pelvic recurrences occurred on the ipsilateral tumor side. Durable complete remission was achieved in each case; however, treatment was complex and there was associated morbidity. CONCLUSION: This significant incidence of pelvic recurrence questions the validity of modern radiotherapy protocol which excludes the ipsilateral pelvis from the radiation field.

Keratinising squamous metaplasia of the bladder: natural history and rationalization of management based on review of 54 years experience.

OBJECTIVE: To review our experience of keratinising squamous metaplasia of the bladder as a predictor for the development of cancer and other complications, and formulate a policy for its management. MATERIALS AND METHODS: A retrospective review (1945-1999) identified 34 patients with histologically proven keratinising squamous metaplasia (27 males and 7 females, average age 50 years, range 13-80 years). The histological criteria used to diagnose keratinising squamous metaplasia were squamous metaplasia of the urothelium with keratinisation and/or hyperkeratosis and/or acanthosis. Female patients with non-keratinising squamous metaplasia (vaginal metaplasia) were excluded. RESULTS: Four patients had synchronous bladder carcinoma (three advanced with early death; one localised, cured by cystectomy). Another 14 patients had extensive metaplasia (Group A, >50% of mucosal involvement). Three cases had cystectomy and cure. Six cases (out of 11) developed subsequent cancer (4 advanced and early death, two localised and cured by cystectomy). One other case died of obstructive uropathy secondary to squamous metaplasia. Two cases died of unrelated causes. Sixteen patients had limited squamous metaplasia (Group B, <50% involvement mucosal surface). Twelve patients had endoscopic resection, extraction bladder calculus etc. with no further complications. Another two patients underwent urinary diversion. Two patients (out of 16) developed subsequent cancer both with advanced disease and early death. CONCLUSION: Keratinising squamous metaplasia of the bladder is a significant risk factor for vesical carcinoma and complications, such as bladder contracture and ureteral obstruction. This risk of complications increases with more extensive bladder mucosal involvement. The wide variation in lag time to the development of complications necessitates indefinite follow-up. Selected patients with extensive bladder involvement and long life expectancy should be offered cystectomy.