Post-prostatectomy incontinence: a guideline of guidelines.

AIM: To provide a comprehensive review of guidelines from various professional organisations on the work-up and management of post-prostatectomy Incontinence (PPI). MATERIALS AND METHODS: The following guidelines were included in this review: European Association of Urology (EAU 2023), American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU 2019), International Consultation on Incontinence (ICI, 2018), the Canadian Urological Association (CUA, 2012) and the Urological Society of India (USI, 2018). RESULTS: In general, the guidelines concur regarding the significance of conducting a comprehensive history and physical examination for patients with post-prostatectomy incontinence (PPI). However, there are variations among the guidelines concerning the recommended additional investigations. In cases of troublesome PPI, male slings are typically recommended for mild to moderate urinary incontinence (UI), while artificial urinary sphincters are preferred for moderate to severe UI, although the precise definition of this severity remains unclear. The guidelines provided by AUA/SUFU and the ICI have offered suggestions for managing complications or persistent/recurrent UI post-surgery, though some differences can be observed within these recommendations as well. CONCLUSION: This is a first of its kind review encompassing Guidelines on PPI spanning over a decade. Although guidelines share overarching principles, nuanced variations persist, posing challenges for clinicians. This compilation consolidates and highlights both the similarities and differences among guidelines, providing a comprehensive overview of PPI diagnosis and management for practitioners. It is our expectation that as more evidence emerges in this and other areas of PPI management, the guidelines will converge and address crucial patient-centric aspects.

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

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

Quality of life with pharmacological treatment in patients with benign prostatic enlargement: results from the Evolution European Prospective Multicenter Multi-National Registry Study.

BACKGROUND: Lower urinary tract symptoms due to benign prostate enlargement (LUTS/BPE) can lead to significant disturbances to health-related quality of life (HRQoL) and psychological well-being. The aim of this study was to evaluate the effect of pharmacological treatment of LUTS/BPE on disease specific and generic QOL measures. METHODS: Evolution was a European prospective, multicenter multi-national, observational registry collecting real-life clinical data over 2 years on the management of LUTS/BPE in primary and secondary care. This study investigated disease-specific QOL using questionnaires such as IPSS Q8, BPH Impact Index (BII) and generic QOL using questionnaires like EuroQOL Five Dimension (EQ5D) which encompassed EQ5D VAS and EQ5D health index. RESULTS: The registry enrolled 1838 BPE patients and 1246 patients were evaluable at the end of 24 months. Nearly 70% of patients in the study were previously treated with medical therapy and 17% of these had already discontinued medical treatment previously for various reasons with lack of efficacy being the most common. The mean time since diagnosis of LUTS in the previously treated group was 4.7 years (0-26 years). Medical management produced statistically significant improvement in QOL (disease specific and generic) in previously untreated patients and an insignificant change in generic QOL in previously treated patients. CONCLUSIONS: After 5-years from the onset of symptoms, LUTS/BPE patients previously treated with medication had significantly impaired QOL in patients in a manner comparable to other chronic diseases. Earlier intervention with minimally invasive surgical techniques (MIT) should be considered in LUTS/BPE patients that do not show a significant improvement in QOL with medical therapy.

Contemporary use of phytotherapy in patients with lower urinary tract symptoms due to benign prostatic hyperplasia: results from the EVOLUTION European registry.

BACKGROUND: To use the European Association of Urology Research Foundation (EAURF) registry data to determine the proportion of contemporary Lower Urinary Tract Symptoms associated with Benign Prostatic Enlargement (LUTS/BPE) patients prescribed phytotherapy, and to determine their subjective quality of life and clinical progression responses. METHODS: This was a prospective multicenter multinational observational registry study, conducted over 2 years. Men ≥ 50 years seeking LUTS/BPE were divided at baseline into two cohorts, presently/recently untreated patients (PUP) commencing pharmacotherapy at baseline and presently/recently treated patients (c-PTP) continuing previously received pharmacotherapy, with 24-month follow-up (FU). RESULTS: Overall, 2175 patients were enrolled with 1838 analyzed. Of the PUP cohort (n = 575), 92 (16%) received phytotherapy and 65 (71%, n = 65/92) completed 24-month FU, with France prescribing 34% (n = 30/89) the highest proportion of phytotherapy among all LUTS/BPE medications. In the c-PTP group (n = 1263), only 69 (5%) patients were using phytotherapy, falling to n = 35/69 (51%) at 24-month FU (highest in France 20% (n = 43/210)). Though defined disease progression occurred in ≤ 20%, with only 1% proceeding to surgical intervention, in both groups, clinically meaningful improvement was lower and symptom persistence was higher in PUP but similar in the treated (c-PTP) patients on phytotherapy compared to the other LUTS/BPE medication. CONCLUSION: Low heterogeneous prescribing rates for phytotherapy were reported in both PUP and c-PTP cohorts over the 24-month FU. Although phytotherapy led to subjective improvements, healthcare practitioners should prescribe them with caution until higher quality evidence and guideline recommendations supporting its use are available.

Bladder bowel dysfunction in children with Down's syndrome.

INTRODUCTION: Bladder Bowel Dysfunction (BBD) has been described in patients with Down's Syndrome (DS). Our aim was to report the incidence, demographics, presentation, complications and management of the bladder in DS patients with BBD. METHODS: A systematic review was performed using PRISMA guidelines and search terms "{[(trisomy 21) OR down's syndrome]} AND [("non-neurogenic") OR voiding dysfunction]" in the search engines MEDLINE and SCOPUS. We also include a case series from two paediatric urology centres. RESULTS: A total of 38 patients with BBD and DS were included. Mean age was 12 years (newborn to 21 years), the male:female ratio was 2:1. Functional constipation (90%), recurrent urinary tract infections (38%) and enuresis were common at presentation (56%), while over 56% patients required surgical intervention. Medical treatment and behavioral modification were less successful while intermittent catheterisation did not work. CONCLUSION: This study reviews the largest cohort of patients with BBD in DS. It is common with serious consequences requiring operative intervention. Usual interventions are unreliable due to poor compliance. Early identification and management protect the renal tract. Regular screening for urogenital anomalies in DS is currently not performed. We recommend a thorough history of bladder function in DS patients to identify these cases early.

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.

Evidence based management of polyps of the gall bladder: A systematic review of the risk factors of malignancy.

BACKGROUND: There are no evidence-based guidelines to dictate when Gallbladder Polyps (GBPs) of varying sizes should be resected. AIM: To identify factors that accurately predict malignant disease in GBP; to provide an evidence-based algorithm for management. METHODS: A systematic review following PRISMA guidelines was performed using terms "gallbladder polyps" AND "polypoid lesion of gallbladder", from January 1993 and September 2013. Inclusion criteria required histopathological report or follow-up of 2 years. RTI-IB tool was used for quality analysis. Correlation with GBP size and malignant potential was analysed using Euclidean distance; a logistics mixed effects model was used for assessing independent risk factors for malignancy. RESULTS: Fifty-three articles were included in review. Data from 21 studies was pooled for analysis. Optimum size cut-off for resection of GBPs was 10 mm. Probability of malignancy is approximately zero at size <4.15 mm. Patient age >50 years, sessile and single polyps were independent risk factors for malignancy. For polyps sized 4 mm-10 mm, a risk assessment model was formulated. CONCLUSIONS: This review and analysis has provided an evidence-based algorithm for the management of GBPs. Longitudinal studies are needed to better understand the behaviour of polyps <10 mm, that are not at a high risk of malignancy, but may change over time.

Introducing WASHOUT: A Large-scale Observational Study of Inpatient Haematuria.

WASHOUT is an international, multicentre, prospective observational study aiming to describe the management of unscheduled haematuria admissions. Preregistration can be done using the following link: https://redcap.link/WASHOUT.

The Intersection of Artificial Intelligence and Social Media in Shaping the New Digital Health Frontier: Powers and Perils.

Use of artificial intelligence (AI) in social media (SoMe) in health care is increasing. Benefits include personalisation of SoMe content for individual patients and identification of trends to prompt timely generation of relevant content. Data security, ethical considerations, medical accuracy, patient engagement, and regulatory compliance are issues to address for this evolving AI use.

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.

Social Media Interventions for Patients and Public: Opportunities and Challenges for the Urology Community.

Interactive interventions represent a new application of social media in urology that involves multidirectional communication within a group. Such interventions have the potential to influence health behaviours in patients and the public and result in a significant impact on urological diseases.

Navigating the Next Wave of Social Media: Future Plans to Boost Dissemination of the European Association of Urology Guidelines.

The uptake and utilisation of social media (SoMe) in medicine are rapidly increasing, and several new platforms and media have come to the forefront in recent times. The European Association of Urology Guidelines Office Dissemination Committee is at the forefront of this evolution and has a multifaceted strategy with content on appropriate use of SoMe that includes a new guidelines chapter, cheat sheets to present existing guidelines, precision SoMe content, social audio, and greater patient advocacy in its content and dissemination.

The Power of Hashtags in Social Media: Lessons Learnt from the Urology Tag Ontology Project.

Standardisation of hashtags for urologic diseases in the Urology Tag Ontology (UTO) project has facilitated more efficient filtering of social media content. Hashtags must be recognisable and easy to understand. The UTO list should be expanded to include hashtags for urologic procedures and the hashtags could be used on social media platforms other than Twitter to reach a wider audience.

Dissemination of the European Association of Urology Guidelines Through Social Media: Strategy, Results, and Future Developments.

Over the past decade, social media (SoMe) platforms have been embraced by the medical community across all specialties. This engagement creates a valuable opportunity for scientific organizations to use the broad reach, accessibility, functionality, and informal environment of SoMe to raise awareness, reinforce trust with stakeholders, and disseminate scientific information. In this field, the European Association of Urology (EAU) Guidelines Office has been a pioneer and has constantly set out to disseminate the recommendations established annually by its guidelines panels. Here we describe the dissemination strategy used by the EAU Guidelines Office and the results obtained in the past few years. The EAU Guidelines Office proposes various types of content to disseminate on the different SoMe platforms. An ad hoc dissemination committee adapts attractive content for different target audiences to fit the specific requirements of the platforms on which it is published. Over the past 5 yr, the dissemination committee has been able to constantly improve the engagement of different audiences, especially using Twitter, Facebook, and, more recently, Instagram. It has been shown that use of a multifaceted strategy to improve dissemination of the guidelines, such as campaigns for awareness days, is successful. PATIENT SUMMARY: We describe the strategy used by the European Association of Urology Guidelines Office to disseminate recommendations from the association's guidelines to different target audiences via social media and we summarize the main results.

Asymptomatic emphysematous pyelitis-a rare clinical entity.

A 62-year-old asymptomatic woman with diabetes was referred to the urology department from nephrology due to deterioration in renal function with accompanied right-sided hydronephrosis on ultrasound. CT imaging subsequently revealed a right-sided staghorn calculus and a significant volume of gas in the right collecting system from the kidney to the distal ureter, in keeping with emphysematous pyelitis. She was admitted and managed with antibiotics and insertion of right nephrostomy in the first instance, followed by percutaneous nephrolithotomy to definitively manage the stone. The patient remained asymptomatic throughout the process.

Knowledge, skills, and confidence among healthcare staff in urinary catheterization.

INTRODUCTION: There is an increasing volume of urology referrals for urinary catheterization (UC). The aim of this study was to determine the confidence and knowledge among healthcare staff on UC. We also assessed their satisfaction with training and support received during catheter education and clinical practice. METHODS: This was a mixed-methods model using an anonymous, online survey circulated among all hospital staff. Weekly reminders were sent, quantitative data was obtained from closed-ended questions, and thematic analysis was performed for qualitative, open-ended questions. RESULTS: The response rate was 26% (n=90/350), from a heterogenous group of doctors and nurses from various specialties and grades in the hospital and community frequently dealing with UC. There was decreasing confidence levels in female UC (54%, n=47/87), three-way catheters (33%, n=29/89), and managing suprapubic catheters (25%, n=21/85). Female UC was reported as the most difficult of catheter insertions (35%, n=31/90). Although 83% (n=74/89) of respondents received catheter education, 53% (n=48/90) felt this was insufficient for clinical practice. Fifty-one percent (n=45/89) believed more support with UC in clinical practice was required and 64% (n=57/89) recommended changes in catheter education. The most common theme identified was the need for ongoing education and more practical supervision in clinical practice. CONCLUSIONS: Catheter training should focus on different types of catheters and management of difficult catheter scenarios. Standardizing safe catheter education during undergraduate training and including this as a part of regular annual or biannual mandatory training for healthcare staff involved in dealing with catheters in clinical practice would be the way forward.

The prognostic value of testicular microlithiasis as an incidental finding for the risk of testicular malignancy in children and the adult population: A systematic review. On behalf of the EAU pediatric urology guidelines panel.

INTRODUCTION: The exact correlation of testicular microlithiasis (TM) with benign and malignant conditions remains unknown, especially in the paediatric population. The potential association of TM with testicular malignancy in adulthood has led to controversy regarding management and follow-up. OBJECTIVE: To determine the prognostic importance of TM in children in correlation to the risk of testicular malignancy or infertility and compare the differences between the paediatric and adult population. STUDY DESIGN: We performed a literature review of the Medline, Embase and Cochrane controlled trials databases until November 2020 according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) Statement. Twenty-six publications were included in the analysis. RESULTS: During the follow-up of 595 children with TM only one patient with TM developed a testicular malignancy during puberty. In the other 594 no testicular malignancy was found, even in the presence of risk factors. In the adult population, an increased risk for testicular malignancy in the presence of TM was found in patients with history of cryptorchidism (6% vs 0%), testicular malignancy (22% vs 2%) or sub/infertility (11-23% vs 1.7%) compared to TM-free. The difference between paediatric and adult population might be explained by the short duration of follow-up, varying between six months and three years. With an average age at inclusion of 10 years and testicular malignancies are expected to develop from puberty on, testicular malignancies might not yet have developed. CONCLUSION: TM is a common incidental finding that does not seem to be associated with testicular malignancy during childhood, but in the presence of risk factors is associated with testicular malignancy in the adult population. Routine monthly self-examination of the testes is recommended in children with contributing risk factors from puberty onwards. When TM is still present during transition to adulthood a more intensive follow-up could be considered.

Survey on ureTEric draiNage post uncomplicaTed ureteroscopy (STENT).

Objectives: To assess the feasibility of conducting a randomised controlled trial (RCT) to assess whether avoiding ureteric drainage is superior to performing ureteric drainage after Uncomplicated Ureteroscopy and/or Flexible Ureterorenoscopy (URS/FURS) treatment of a urinary tract stone in improving patient reported outcome measures (PROMs) and 30-day unplanned readmission rates. A secondary objective was to understand current practice of urologists regarding ureteric drainage after uncomplicated URS/FURS (UU). Material and methods: We undertook an online survey of urologists, circulated amongst members of international urological societies and through social media platforms. Uncomplicated URS/FURS was defined as completion of URS/FURS treatment for a urinary tract stone, with the absence of: ureteral trauma, residual fragments requiring further lithotripsy procedures, significant bleeding, perforation, prior urinary tract infection or pregnancy. The ureteric drainage options considered included an indwelling stent, stent on a string or a ureteric catheter. The primary outcome was to determine the proportion of urologists willing to take part in a RCT, randomising patients after UU to a "no ureteric drainage" arm or ureteric drainage arm. Secondary outcomes included determining in their current practice, the proportion of clinicians performing routine ureteric drainage after UU, the reasons for performing ureteric drainage following UU and their preferred optimal duration for ureteric drainage if it is used. The study was reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). Results: Total of 468 respondents from 45 countries took part in the survey, of whom 303 completed the entire survey (65%). The majority agreed that they would be willing to randomise patients (244/303, 81%) in the proposed RCT. Perceived lack of equipoise to randomise was the most common reason for not being willing to participate (59/303, 19%).92% (308/335) reported that they use ureteric drainage after UU. This was most often due to wanting to prevent possible complications from post-operative ureteric oedema (77%) or to aid passage of small fragments (43%). Complexity of the case (i.e. impacted stone 90%) and length of the procedure (46%) were the most important intraoperative factors influencing the decision to use ureteric drainage post procedure. If required, the median stated ideal duration of ureteric drainage was 5 days (IQR: 3-7 days) after UU. If having UU personally, 30% would want no stent postoperatively and over half would prefer a stent on a string. Conclusion: We have highlighted wide variation in practice regarding ureteric drainage after UU. Our results support the feasibility of an RCT evaluating if no ureteric drainage is superior to ureteric drainage in improving PROMs and 30-day unplanned readmission rates following UU.