Transurethral resection of bladder tumour (TURBT) as a day-case: A real-world practice and patients' perspective from a district general hospital (DGH).

INTRODUCTION: Day-case transurethral resection of bladder tumour (TURBT) is currently only performed in 18% cases across the United Kingdom. To determine 30-day readmission rate and morbidity after day-case TURBT in a district general hospital (DGH) and to report patient demographics, quality of TURBT and early recurrence rate as well as patient feedback after day-case TURBT. METHODS: A retrospective audit of day-case TURBTs over a 3-year pre-COVID19 (2017-20) was performed. We only included patients who underwent a TURBT and excluded any cystoscopy and biopsy or fulguration. A day-case TURBT pathway is in place in this centre. Feedback was obtained using hospital patient feedback forms. RESULTS: We included 77 patients who underwent TURBT in the day-case theatre, of these 5 patients required in-patient stay after the surgery. Of the remaining 72 discharged on the same day, 8 were re-admitted (11%) for Clavien-Dindo I complications. The readmission/failed discharge group had a higher rate of older patients, with higher ASA scores and longer operative times, however resection quality and tumour characteristics were not different from the day-case TURBTs. All patients reported an overall positive experience (good or very good). CONCLUSIONS: In the first of its kind audit reporting patient feedback after day-case TURBT, the data obtained can provide us and other centres adopting day-case TURBTs guidance to employ better patient selection to reduce readmission rates. Hence, day-case TURBT can be a feasible option in appropriately selected patients, with a suitable pathway in place.

Perspective of Botox for treatment of male lower urinary tract symptoms.

PURPOSE OF REVIEW: Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH) are frequently encountered in ageing men. The medical treatment for lower urinary tract symptoms/BPH is not totally effective or without side effects. The use of transurethral resection of the prostate, the 'gold standard' surgical intervention for BPH is progressively changing to minimally invasive surgical therapies. But none of them provided clear long-term results, with no complication. Thus, there has been much interest in the development of alternative treatments such as the injection of botulinum toxin type A (BTX-A) into the prostate. RECENT FINDINGS: There are two main factors that contribute to lower urinary tract symptoms in BPH: the excessive growth (static component) and increase in smooth muscle tone (dynamic component). BTX-A seems to be the first therapeutic agent to target both factors. Its use inhibits the autonomic efferent effects on prostate growth and contraction and also inhibits the abnormal afferent effects on prostate sensation. BTX-A injected into prostate appears to be well tolerated and effective. SUMMARY: Although the clinical series demonstrate efficacy of minimum 6 months, more studies are necessary in order to identify the mechanisms by which BTX-A affects the prostate, the ideal dose and the duration of effect. BTX-A use in prostate disease is currently 'off-label'.

Robot-assisted laparoscopic nephroureterectomy for urothelial carcinoma with inferior vena cava incision and repair.

Locally advanced urothelial carcinoma of the renal collecting system presents a unique challenge to the urologist performing nephroureterectomy, particularly if the tumor invades the renal vein or the IVC. Preoperative planning and a multidisciplinary approach are important to optimize the outcomes for these patients. The use of robotic assistance for laparoscopic nephroureterectomy has become common, but a simultaneous robotic assisted IVC excision has yet to be reported. This case report describes a robotic assisted laparoscopic right nephroureterectomy with IVC resection and retroperitoneal lymphadenectomy for locally advanced urothelial carcinoma. For a patient with locally advanced urothelial carcinoma of the renal collecting system which obliterates the renal vein, robotic assisted surgery provides a minimally invasive alternative to open surgery.

Endourologic management of patients with upper-tract transitional-cell carcinoma: long-term follow-up in a single center.

PURPOSE: To evaluate the outcome of endoscopic management of upper-tract transitional-cell carcinoma (TCC). PATIENTS AND METHODS: From March 1991 to March 2006, 40 patients with upper-tract TCC were treated by an endoscopic approach as the primary management: 37 (90.2%) by ureteroscopy and by percutaneous techniques or both approaches in 2 cases each (5%). Follow-up was between 5 and 115 months (mean 41.6 months). Most of the patients, 26 (65%), had a normal contralateral kidney, and the indication for conservative management was low tumor grade or tumor size (<2 cm) and patient commitment to a rigorous follow-up protocol. Absolute and relative indications for conservative management such as solitary kidney were met in 14 patients (35%). RESULTS: Treatment consisted of electrocautery only in 15 cases (36.6%), neodymium:YAG or holmium:YAG laser only in 11 (26.8%), and combinations in 15 (36.6%). Most of the patients (74.3%) had an upper-tract recurrence. The renal-preservation rate was 70.7%, and the survival rate was 80%. CONCLUSIONS: Conservative treatment is preferred in patients with bilateral disease, a solitary kidney, or co-morbidities that contraindicate major surgery. Patients with low-grade, low-stage disease and normal contralateral kidneys also benefit from this approach provided adequate endoscopic follow-up can be achieved and the surgeon has a low threshold for carrying out ablative surgery.

Day case laparoscopic nephrectomy.

PURPOSE: To report our initial experience with day case surgery (DS) laparoscopic nephrectomy (LN) and to assess its feasibility and safety. PATIENTS AND METHODS: Twenty-six consecutive patients, planned for DS LN between January 2006 and December 2009 at a single urologic center, were enrolled in this retrospective observational study. Every patient underwent LN after a standard pathway of care for DS. We collected data regarding demographic information, medical comorbidities, preoperative and postoperative symptoms, admission as well as discharge time and date. The success rate of DS and reasons for unplanned overnight admission and readmission were collected and evaluated. RESULTS: There were 12 (46.15%) women and 14 (53.84%) men with a median age of 46 years (range 11-77 y). The LN was on the left side in 15 (57.7%) patients and on the right side in 11 (42.3%) patients. Fifteen (57.7%) patients had benign diseases associated with nonfunctioning kidney and 11 (42.3%) patients had renal masses. The most common symptom was loin pain-53.3% for the patients with nonfunctioning kidneys; the majority of patients with tumors (45.6%) were asymptomatic. Twenty-two (84.61%) patients were successfully discharged the same day. Six (23.07%) patients were readmitted after surgery. CONCLUSIONS: The DS LN is feasible and safe. We believe that the results should be easily reproducible. Increasing experience may help to develop more rigorous preoperative, intraoperative, and discharge criteria to increase the success rate and to decrease the readmission rate for DS LN.

Routine day-case laparoscopic pyeloplasty: a paradigm shift?

PURPOSE: To determine whether day-case surgery (DS) laparoscopic pyeloplasty (LP) is feasible and safe. PATIENTS AND METHODS: Thirty-two consecutive patients, planned for DS LP between March 2006 and January 2010 at a single urologic center, were enrolled in this retrospective observational study. Every patient underwent LP after a standard pathway of care for DS. We collected demographic and medical information, including renographic data. The success rate of DS and reasons for unplanned overnight admission and readmission were collected and evaluated. RESULTS: There were 20 (62.5%) females and 12 (37.5%) males with a median age of 37 years (range 11 to 69 y). The pelviureteral junction obstruction was on the left side in 19 (59.3%) patients and on the right side in 13 (40.6%) patients. The most common symptom was loin pain (68.75%). The majority of patients were classified according to their physical status as American Society of Anesthesiologists (ASA) 1 (59.37%), ASA 2 (37.5%), and only one patient (3.1%) as ASA 3. Surgical time varied from 90 to 210 minutes (mean 148.9 min, standard deviation 34.70). Twenty-five (78.12%) patients were successfully discharged on the same day. Two (6.25%) patients were readmitted after surgery. On follow-up renography, 96.15% had improved drainage. This is a small retrospective study reporting initial experience. CONCLUSIONS: The DS LP is feasible and safe. To improve the success rate and to decrease the readmission rate, objective preoperative, intraoperative, and discharge criteria should be developed for DS and validated in randomized studies.

Intraprostatic botulinum toxin injection in patients with benign prostatic enlargement.

Histological evidence of benign prostatic hyperplasia (BPH) exceeded 50% in men over 50 years of age and rose to 75% as men entered the eighth decade. Therapeutic options for BPH generally fall into one of the three categories: watchful waiting, medical treatment and surgery. Excluding watchful waiting, the other forms of intervention directed at modifying the physiologic effects of BPH with or without directly altering the prostatic mass or its configuration come with varying effectiveness and risk. Botulinum toxin (BTX-A) produce inhibition of acethylcholine release at the neuromuscular junction causes paralyzing effects and atrophy of striated as well as the smooth muscle fiber. BTX-A also causes inhibitory effects on the ganglionic and post-ganglionic fibres of autonomic nervous system inducing diffuse atrophy and apoptosis of nasal and prostate glands. Clinical series demonstrates efficacy of BTX-A in alleviating symptoms induced by BPH. Larger randomized clinical trials studies are necessary in order to identify the mechanisms by which BTX-A affects the prostate, the ideal dose and the duration of effect. BTX-A injected into prostate appears safe and effective.

Painful ejaculation.

We reviewed previous publications on post-orgasmic pain with reference to prevalence, epidemiology and treatment options, using the Ovid and PubMed (updated May 2006) databases to comprehensively search MEDLINE for reports on post-orgasmic pain that included peer-reviewed English-language articles. Official proceedings of internationally known scientific societies were also assessed. Because of the heterogeneity of the studies we did not apply meta- analytic techniques to the data. The incidence of post-orgasmic pain is 1-9.7%. The ejaculatory pain is associated with prostatitis, chronic pelvic pain syndrome, benign prostatic hyperplasia, and ejaculatory duct obstruction; it is also described in patients after procedures like radical prostatectomy. Aetiopathogenic theories include those referring to bladder neck closure and pudendal neuropathy. The treatment options vary from self-care, a 'perineal hyperprotection programme' to medication with the alpha-blocker, topiramate, and even surgical procedures like removing a section of the sacrotuberous ligament, neurolysis of the pudendal nerve or removing a section of the sacrospinous ligament. This is the first update of the subject, with reference to prevalence, epidemiology and treatment options. There is a need for adequately powered, prospective randomized trials on aetiology and treatment options.

Idiopathic retroperitoneal fibrosis: the case for nonsurgical treatment.

OBJECTIVE: To review a 10-year experience of medical treatment for idiopathic retroperitoneal fibrosis (RPF), a rare condition of unknown causes, which may obstruct the ureter and for which treatment includes ureterolysis and relief of obstruction, and medical treatment with steroids with or without immunosuppressive medication. PATIENTS AND METHODS: Of 31 patients with RPF treated between 1996 and 2004, 28 had idiopathic disease. Ureteric stents were used to relieve the obstruction in all patients, 12 had previous nephrostomies, 16 were given steroids and only one was treated with ureterolysis. RESULTS: In all, 28 patients were followed for a mean of 51.17 months; the symptoms were relieved in all cases. Renal function, where impaired, improved dramatically in all patients. Fifteen patients (54%) are free of stents and medication after a mean (range) follow-up of 60.9 (24-110) months. CONCLUSION: Idiopathic RPF responds well to conservative management consisting of relief of urinary tract obstruction and steroids.