Incidence, Cost, Complications and Clinical Outcomes of Iatrogenic Urethral Catheterization Injuries: A Prospective Multi-Institutional Study.

PURPOSE: Data on urethral catheter related injuries are sparse. To highlight the dangers inherent in traumatic urethral catheterization we prospectively monitored the incidence, cost and clinical outcomes of urethral catheter related injuries. MATERIALS AND METHODS: This prospective study was performed during a 6-month period at 2 tertiary referral teaching hospitals. Recorded data included method and extent of urethral catheterization injury, setting and time of injury, number of catheterization attempts, urological management provided, additional bed days due to urethral injury and clinical outcomes after followup. The additional cost of managing urethral injuries was also calculated. RESULTS: A total of 37 iatrogenic urethral injuries were recorded during the 6-month period. The incidence of traumatic urethral catheterization was 6.7 per 1,000 catheters inserted. Thirty (81%) patients sustained a complication Clavien-Dindo grade 2 or greater. The additional length of inpatient hospital stay was 9.4 ± 10 days (range 2 to 53). Of these patients 9 (24%) required an indwelling suprapubic catheter and 8 (21%) have an indwelling transurethral catheter. In addition, 9 (24%) are performing self-urethral dilation once weekly and 4 (11%) have required at least 1 urethral dilation due to persistent urethral stricture disease. The additional cost of managing iatrogenic urethral injuries was €335,377 ($371,790). CONCLUSIONS: Iatrogenic urethral catheterization injuries represent a significant cost and cause of patient morbidity. Despite efforts to educate and train health care professionals on urethral catheterization insertion technique, iatrogenic urethral injuries will continue to occur unless urinary catheter safety mechanics are altered and improved.

Predictive value of PI-RADS classification in MRI-directed transrectal ultrasound guided prostate biopsy.

AIM: To correlate the results of transrectal ultrasound (TRUS)-guided targeted prostate biopsies (performed in the setting of at least one previous negative biopsy) with the Prostate Imaging Reporting and Data System (PI-RADS). MATERIAL AND METHODS: Fifty-two patients (mean age 64 years, range 52-76 years), with previous negative prostate biopsy underwent magnetic resonance imaging (MRI)-directed TRUS-guided targeted and sectoral biopsy. A retrospective review of MRI examinations was carried out, blinded to biopsy results. PI-RADS scores (T2, diffusion-weighted imaging [DWI] and overall) were assigned on a per lesion basis, and localised to sextants. The scores were correlated with biopsy results, and the positive predictive values (PPV) of PIRADS scores for positive biopsies were calculated. RESULTS: Overall, biopsies were positive in 23/52 (44.2%) patients. Eighty-one areas were targeted in 52 patients. On a per lesion basis, there was significant correlation between positive targeted biopsy and both T2 and overall PI-RADS score (p<0.001). The correlation between biopsy and DWI score was significant for peripheral zone tumours only, not for transitional zone tumours. The PPV of overall PI-RADS scores of 3, 4, and 5 were 10.6%, 44%, and 100%, respectively. The PPV of T2 PI-RADS scores of 3, 4, and 5 were 19.6%, 60%, and 100%, respectively. The PPV of DWI PI-RADS scores of 3, 4, and 5 were 50%, 27.3%, and 33%, respectively. When transitional tumours were excluded, the PPV of DWI PI-RADS 3, 4, and 5 were 40%, 43%, and 78%. CONCLUSION: The PIRADS score provides an effective framework for determining the likelihood of prostate cancer on MRI. The DWI PI-RADS score correlates well with the presence of peripheral zone tumour on targeted biopsy, but not with transitional zone tumours.

Peri-operative management in urinary diversion surgery: A time for change?

INTRODUCTION: Bowel preparation was established as part of the pre-operative course for patients undergoing ileal conduit formation since the late 1970's. Rationales for its use include reduction in infection and wound complications, technically easier anastomosis and earlier return to bowel function. However, recent reports have challenged this practice. Traditionally antibiotics were also administered for several days prior to surgery with the assumption that bacterial load was reduced. Modification of antibiotic protocols resulted from evidence-based findings. Furthermore, publications emphasizing the benefit of Enhanced Recovery Protocols/Programmes (ERP) have become contemporary. METHODS: An online multiple-choice questionnaire (via Monkey Survey) was administered to all consultant urologists in Ireland. This national cross-sectional study evaluated the use of bowel preparation and antibiotic prophylaxis prior to urinary diversion. In addition, we also assessed consultant urologists' awareness of ERP and their views on the introduction and implementation of such a national program. RESULTS: Of the 41 consultant urologists surveyed, 80.4% (n = 33) responded. 63.6% routinely used bowel preparation. Klean Prep was the most commonly used bowel preparation. 80.9% of urologists admit their patient's one-day pre-operatively for bowel preparation, with 87.8% using antibiotic prophylaxis at anesthesia induction, and 18.1% continuing the antibiotics for 24-48 h post-operatively. Although 74% of consultants are aware of ERP, only 66.6% are in favor of their national implementation. CONCLUSION: The majority of Irish urologists use bowel preparation prior to ileal conduit formation. Substantial recent evidence has emerged showing no difference in infective complications or anastomotic leakage when bowel preparation was not used. National guidelines would be beneficial regarding the use of bowel preparation, antibiotic prophylaxis and ERP for urinary diversion surgery.

Incidentalology: A developing urological sub-specialty.

OBJECTIVE: To identify the incidence and features of significant incidental findings discussed at our departmental multidisciplinary team meeting (MDM). The improved quality of radiological imaging has resulted in increased rates of incidental findings. Although some may be trivial, many have clinical significance and early diagnosis and treatment may be beneficial. METHODS: A retrospective analysis was performed of all cases discussed at the MDM between January 2012 and February 2013. Cases were divided into two groups--Group 1 consisted of patients whose initial imaging was performed for a urological presentation which resulted in a synchronous finding; Group 2 consisted of patients who were referred with a synchronous urological finding for discussion following investigation of an initial benign urological condition or a non-urological condition. RESULTS: 696 patients were discussed at 53 MDMs. 109 (15.7%) patients had incidental findings. 61 (56%) of these were in Group 1. 16 (26.2%) were synchronous malignant diagnoses, 25 (41%) were benign and 20 (32.8%) were indeterminate. 48 (44%) patients in Group 2 - 40 (83.3%) were renal in origin and 30 (75%) of these proceeded to surgery. The median tumour size was 3.2 cm (Range: 1.2 cm-10 cm). One patient had radio-frequency ablation. Two were referred for palliative care. Seven patients are under ongoing surveillance--the median size of these lesions is 3.6 cm (Range: 2.1 cm-8.3 cm). CONCLUSION: A substantial workload is generated from the investigation of incidental findings discussed at MDM--these now represent the majority of the caseload for renal cancer surgery.

Two hit hypothesis: an unusual complication following supra-pubic catheter insertion.

Osteomyelitis is an inflammation of the bone caused by an infection. Though bone is normally resistant to bacterial infection, events including trauma, presence of foreign bodies including prosthesis can act as a nidus for infection. Osteomyelitis is a rare but recognised complication of radiotherapy. Osteomyelitis of the pubis has scarcely been reported as a complication following urological procedures- prostatectomy, sling surgery and catheterisation. We report a rare complication of a gentleman post radiotherapy presenting with delayed osteomyelitis of the pubis following supra-pubic catheterisation.

Double trouble--ureteric obstruction due to bilateral urothelial carcinoma.

Upper tract urothelial carcinoma (UTUC) represents -5% of all urothelial carcinomas. Synchronous bilateral tumors are extremely rare with only 19 reports in the literature. Haematuria is the main presenting complaint. We report a case of synchronous bilateral tumors of the ureters in a gentleman with frank haematuria treated with staged aggressive resection.

Radical prostatectomy outcome when performed with PSA above 20 ng/ml.

Many centres currently do not offer radical prostatectomy (RP) to men with high-risk localised prostate cancer due to concerns regarding poor outcome, despite evidence to the contrary. We identified 18 men undergoing RP with serum PSA >20 ng/ml (high-risk by National Comprehensive Cancer Network definition) and minimum follow-up of 12 years (mean 13.5). Mean preoperative PSA was 37.0 ng/ml (Range 21.1-94.0). Prostatectomy pathology reported extracapsular disease in 16 (88.9%), positive surgical margins in 15 (83%) and positive pelvic lymph nodes in 5 (27.8%). Overall and cancer-specific survival at 5 and 10-years was 83.3%, 88.2%, 72% and 76.5% respectively. With complete follow-up 11 (61.1%) are alive, and 5 (27.8%) avoided any adjuvant therapy. Complete continence (defined as no involuntary urine leakage and no use of pads) was achieved in 60%, with partial continence in the remainder. We conclude that surgery for this aggressive variant of localised prostate cancer can result in satisfactory outcome.

Out-patient management and non-attendance in the current economic climate. How best to manage our resources?

Outpatient non-attendance is a considerable source of inefficiency in the health service, wasting time, resources and potentially lengthening waiting lists, Given the current economic climate, methods need to be employed to reduce non-attendance. The aim was to analyse outpatient non-attendance and determine what factors influence attendance. A prospective audit over a two-month period to a tertiary-referral Urological service was performed to determine the clinical and demographic profile of non-attendees. Of 737 appointments, 148 (20%) patients did not attend (DNA). A benign urological condition was evident in 116 cases (78%). This group of patients also accounted for the majority of new patients not attending 40/47, returning patients not attending 101/148 and the majority of patients who missed multiple appointments 43/49. Patients with benign conditions make up the majority of clinic non-attendance. Consideration may be given to discharging such patients back to their general practitioner after one unexplained non-attendance until other alternatives of follow up are available.

Managing ureteric colic in a smaller hospital without urological support.

No official guidelines exist on managing ureteric colic in small hospitals without urological support. We reviewed the logistics of managing this condition by examining all cases of ureteric colic over two years. Seventy nine of 118 cases had hydronephrosis; a criteria for urology referral. Thirty nine patients passed their stone spontaneously but 40 of these cases could not and required transfer. Twenty two (55%) patients were transferred (mean time to transfer: 3.29 days). The other 18 (45%) were discharged to await a urology outpatients clinic (mean time to discharge: 3.00 days). Patients that passed their stone spontaneously generally had stones under 5mm (mean stay: 2.09 days). We would recommend that patients with stones over 5mm or with hydronephrosis be referred immediately to prevent urological sepsis and or renal impairment.

Can pre-assessment of patients with LUTS result in early discharge from urology clinic?

Waiting times for appointments for urological out-patients in Ireland and the U.K. can be excessively long. Nurse-led Lower Urinary Tract symptom (LUTs) pre-assessment clinics have been introduced to streamline patient care pathways. We examined whether a nurse-led pre-assessment LUTS clinic could result in the rapid assessment and discharge of patients following their first out-patient visit. A pilot study was undertaken whereby patients referred with LUTS were sent for pre-assessment prior to their out-patients appointment. 214 consecutive patients underwent pre-assessment. Of these, 39 (18%) patients were discharged following their first out-patient visit and 27 (13%) patients were discharged after a second attendance. A further 35 (16%) patients continued to attend but underwent no further investigations or treatment, and possibly should have been discharged earlier. Overall 46% of pre-assessed patients could have been discharged early from the urology clinic. In conclusion a nurse-led pre-assessment LUTS clinic could result in the rapid assessment and discharge of patients following their first out-patient visit.

Prospective evaluation of a virtual urology outpatient clinic.

BACKGROUND: Outpatient department (OPD) clinics account for a significant proportion of healthcare expenditure. We report on a pilot study of a virtual outpatient clinic (VC) for urology patients as an alternative to a general urology clinic review. AIMS: The study aims to assess the safety and cost-effectiveness of a virtual clinic as an alternative to general OPD review. METHODS: A prospective study performed between March 2015 and December 2015 investigated the effectiveness of a VC in our institution. Eligible patients were recruited from general urology outpatient visits, from medical team members and from general practitioners (GP). Data recorded on each VC review included patient demographics, indication for referral to VC, outcome of VC and method of communication with the patient and their GP after the VC. RESULTS: Three hundred eighty-five patients were registered for the VC. Indications for referral included review of imaging results (n = 136), doctor or patient query (n = 112) and review of laboratory results (n = 67). Outcomes after VC review included general OPD follow-up (n = 134), discharge from urology care (n = 39), referral for urological intervention (n = 29) and referral for radiological investigation (n = 23). VC review prevented 217 OPD clinic visits, saved €17,360 and provided a failsafe mechanism for reviewing investigation results. Two patients booked for OPD review following VC review did not receive appointments. CONCLUSIONS: Virtual clinic is a safe and cost-effective alternative to general OPD review in appropriately selected patients.

Primary endourologic realignment of complete posterior urethral disruption.

The management of posterior urethral disruption is controversial. Debate continues on whether primary realignment at results in a higher incidence of incontinence and impotence compared to delayed reconstruction. We report on our experience using early endoscopic realignment. Between 1994 and 2002 ten male patients, diagnosed with complete posterior urethral disruption, had attempted early endoscopic realignment. All patients were evaluated for incontinence, impotence and stricture formation post-operatively. Six patients had endoscopic retrograde realignment, two proceeded to endoscopic rendezvous realignment and two patients had delayed reconstruction of the urethra. At follow-up, mean 41.4 months, all patients were continent four were impotent and four patients developed strictures. Endoscopic retrograde realignment is a simple atraumatic technique for early posterior urethra realignment. If unsuccessful a rendezvous approach can be attempted at the same operation. Manipulation of the periprostatic issue is minimal thus preventing iatrogenic complications.

The effect of Rapid Access Prostate Clinics on the outcomes of Gleason 7 prostate cancer: does earlier diagnosis lead to better outcomes?

INTRODUCTION: Rapid Access Prostate Clinics (RAPC) were introduced in Ireland by the National Cancer Control Programme bringing about expedited referral pathways and increased detection rates of prostate cancer. Lower Gleason (G) grade at diagnosis due to RAPC has been previously reported but grade at prostatectomy has not been assessed. The aim of this study was to assess the impact of RAPC on the outcomes of patients with G7 disease on radical prostatectomy (RP). METHODS: A retrospective analysis was carried out of all RPs performed over a 9-year period (2006-2014). Outcomes for G7 prostatectomies were compared before and after the introduction of the RAPC, with a further sub-analysis of G4 + 3 versus G3 + 4. The primary outcome was biochemical recurrence (BCR). Other outcomes were adjuvant/salvage radiotherapy, extra prostatic extension, positive surgical margins, seminal vesicle involvement and tumour stage. RESULTS: In total, 240 RPs were performed with 167 cases graded G7 (70 graded G4 + 3 and 97 graded G3 + 4). Since the introduction of RAPC the proportion of G4 + 3 compared to G3 + 4 has increased from 37.9 to 42%. There was no statistical difference in outcomes for G4 + 3 treated before and after the introduction of RAPC. G4 + 3 was associated with higher rates of BCR (24.4 vs. 0%, p < 0.0001, radiotherapy (41.1 vs. 4.8%, p < 0.0001) and worse histological features than G3 + 4. CONCLUSION: Despite the benefits in diagnosis of prostate cancer brought about by RAPC in Ireland, this has not translated to a lower grade for surgically treated patients. There has been no improvement in outcomes especially for higher grade G4 + 3 disease.

Development and evaluation of a centralised computerised registry for ureteric stents: completing the audit cycle.

INTRODUCTION: A forgotten ureteric stent may result in severe renal impairment leading to nephrectomy. AIM: To compare the effectiveness of a centralised computerised registry for monitoring ureteric stent activity with a previously established theatre stent logbook system. METHODS: This prospective audit was performed in two 9-monthly intervals. During the first interval, insertion/removal of a ureteric stent was documented in a specific theatre stent logbook. In the second interval, an electronic centralised computerised registry was developed to document insertion/removal of a ureteric stent onto an accessible hospital server. A computerised traffic-light system was also developed to identify patients with an indwelling stent for >3 months. The primary outcome variable was the number of prolonged indwelling ureteric stents in both groups. RESULTS: During the first time interval, 188 ureteric stents were inserted and 182 (96%) were removed or changed. Six (4%) patients underwent insertion of a ureteric stent for a prolonged period of time (>6 months). This subgroup required complex endourological intervention for stent removal due to encrustation. During the second time interval, 157 ureteric stents were inserted and all patients had their stent removed or changed within 6 months. No patients in this group were lost to follow-up. CONCLUSION: This study demonstrates that a centralised computerised ureteric stent registry is superior to a conventional logbook for monitoring ureteric stent activity. We propose the introduction a centralised nationalised ureteric stent registry for eliminating the potential for prolonged or forgotten ureteric stents.

Secondary screening system for preclinical testing of human lung cancer therapies.

The National Cancer Institute has instituted a primary screening system for testing new agents against cultured cancer cell lines. The purpose of this study was to determine the feasibility of using a nude rat orthotopic (organ-specific) human lung cancer model system as an in vivo secondary screen for general evaluation of new anticancer agents and therapies active against lung cancer. To make this determination, we tested whether this system allows measurement of uptake and tumoricidal activity of anticancer therapies. Tumor-bearing lungs from 53 Rowett nude rats with orthotopically implanted human large-cell undifferentiated lung carcinoma (NCI-H460) were perfused ex vivo for 1 hour with or without each of two anticancer modalities. Lungs were perfused with blood-free perfusate alone (untreated control), perfusate with 100 micrograms/mL doxorubicin (treated positive control), or perfusate with lymphokine-activated killer cells plus human recombinant interleukin-2 (LAK/rIL-2). Weight gain during perfusion was the criterion used to quantitate lung injury. Treatment efficacy was measured by clonogenic assay after enzymatic disaggregation of the perfused tumors. Doxorubicin levels in the tumor and in the uninvolved lung were measured by high-performance liquid chromatography. Both treatment groups showed only slight increases in lung weight compared with that in the untreated control group, suggesting good lung tolerance of the procedure. Lung and tumor levels of doxorubicin were 320 +/- 21 ng/mg of tissue and 32 +/- 5 ng/mg of tissue (means +/- SE), respectively. Clonogenic assay demonstrated a fivefold to 10-fold reduction in the surviving fraction of tumor cells with doxorubicin but no change with LAK/rIL-2.(ABSTRACT TRUNCATED AT 250 WORDS)

Irradiated nude rat model for orthotopic human lung cancers.

The development of improved animal models for biological and preclinical studies of human lung cancer is important because lung cancer is the leading cause of cancer death in the United States. To determine whether the Rowett nude rat could serve as an orthotopic (organ-specific) model of this disease, nude rats (CR: NIH-RNU), with and without 500 rads of prior gamma-irradiation, were implanted intrabronchially with 10(7) cultured cells from 3 human lung cancer lines. Without irradiation, the NCI-H460 large-cell undifferentiated carcinoma had a 54% take-rate, whereas the NCI-H125 adenosquamous carcinoma and A549 adenocarcinoma had take-rates of 7 and 33%, respectively; irradiation increased the respective take-rates to 100, 83, and 90%. In irradiated rats, tumor age versus weight measurements showed progressive growth for all three tumors, with growth rates in the order: NCI-H460 greater than A549 greater than NCI-H125, requiring approximately 3, 5, and 9 weeks, respectively, for average tumor sizes to exceed 500 mg. The small-cell carcinoma cell line NCI-H345 was implanted only into irradiated rats and resulted in more slowly growing tumors. Histopathological study showed all model tumor types to have histological characteristics consistent with the clinical tumors from which the cell lines were derived. Each tumor type had a different growth pattern, with some of the the A549- and NCI-H125-derived tumors metastasizing to contralateral lung and/or regional lymph nodes. There was no evidence for immunological rejection in irradiated, tumor-bearing rats. Nonirradiated, implanted rats without gross tumor exhibited peribronchiolar mononuclear cell infiltration with or without fibrosis, suggesting prior immunological rejection. The successful orthotopic growth of these 4 human lung cancer cell lines in irradiated nude rats suggests that this model could be useful for biological and preclinical studies of human lung cancer, both in intact rats and via ex vivo perfusion of their tumor-bearing lungs.

A Narrative Review on the Pathophysiology and Management for Radiation Cystitis.

Radiation cystitis is a recognised complication of pelvic radiotherapy. Incidence of radiation cystitis ranges from 23 to 80% and the incidence of severe haematuria ranges from 5 to 8%. High quality data on management strategies for radiation cystitis is sparse. Treatment modalities are subclassified into systemic therapies, intravesical therapies, and hyperbaric oxygen and interventional procedures. Short-term cure rates range from 76 to 95% for hyperbaric oxygen therapy and interventional procedures. Adverse effects of these treatment strategies are acceptable. Ultimately, most patients require multimodal treatment for curative purposes. Large randomised trials exploring emergent management strategies are required in order to strengthen evidence-based treatment strategies. Urologists encounter radiation cystitis commonly and should be familiar with diagnostic modalities and treatment strategies.

Endothelial cell proliferation is induced by radiation in cultured explants of human urothelium and oesophageal mucosa.

Normal oesophageal mucosa obtained during upper abdominal surgery or urothelium obtained from kidney transplants was placed in explant culture and exposed to 60Co gamma radiation after 48 h. Cultures were maintained for two to six weeks after exposure and were monitored at various intervals for the development of features associated with malignant transformation. Endpoints examined included proliferation rate, frequency of proliferating cells, cell type distribution and degree of differentiation of the different cell types. The results indicate that following exposure to gamma rays (2.5-10 Gy) an increased overall growth rate of the surviving cells can be observed 2-4 weeks later. Analysis of the results using autoradiography confirms that a higher level of cell proliferation occurs in treated cultures than in the control untreated cultures. When the distribution of different cell types in the culture is examined, the increase in growth can be seen to be due to greatly increased numbers of endothelial cells. These proliferated over the surface of the epithelial cells and are more strongly positive for endothelial cells markers than endothelial cells occurring in control cultures. The degree of differentiation of endothelial cells into capillary like structures is also more apparent in carcinogen treated cultures. Foci expressing both epithelial and endothelial markers also occur. The results suggest that exposure of tissue fragments to radiation stimulates the growth and development of endothelial cells in resulting cell cultures. The effect may be due to a direct action of the treatment on the endothelial cells but it is more likely that it results from a secondary effect mediated by traumatic response of damaged epithelial cells.

Extracellular flush solution that contains blood, mannitol, albumin, and prostacyclin protects rat lungs from six hours of ischemia.

We have used an isolated rat lung model to compare the quality of preservation of different flush techniques with each other and with topical cooling alone. Lung injury was assessed by recording lung weights after reperfusion after 4 and 6 hours of ischemia. The flush solutions studied were intracellular (Collins-Sacks), traditional extracellular, extracellular with low potassium plus dextran, and extracellular containing blood, mannitol, albumin, and prostacyclin (Wallwork's solution). Flushing with Wallwork's solution before both 4 and 6 hours of ischemia gave superior protection from lung edema after reperfusion over all the other methods.

Local skin burn causes systemic (lung and kidney) endothelial cell injury reflected by increased circulating and decreased tissue factor VIII-related antigen.

Inasmuch as xanthine oxidase (XO)-derived O2* metabolites may contribute to vascular endothelial injury and Factor VIII antigen (F8Ag) is a component of endothelial cells, we hypothesized that XO-derived O2* might damage and cause distant organ endothelial cells to release F8Ag in rats subjected to skin burn. We found that serum F8Ag (ELISA) increased in the blood of rats subjected to skin burn (70 degrees C water to shaved dorsal skin for 30 seconds) but not in sham control rats (30 degrees C water). Coincidentally, F8Ag levels also decreased in lung and kidney tissue sections (immunofluorescent staining) of burned rats but not sham rats. Increases in circulating F8Ag levels and decreases in tissue F8Ag levels appeared to result from XO-derived O2* metabolites: F8Ag levels did not increase in the blood and did not decrease in the tissues of rats pretreated with allopurinol (a specific XO inhibitor, 50 mg/kg) or dimethylthiourea (DMTU) (a permeable O2* metabolite scavenger, 250 mg/kg). Lung injury as assessed by permeability studies (I125-albumin leak) paralleled changes in blood F8Ag levels in sham, burn, allopurinol-, and DMTU-treated groups. We conclude that skin burn causes a systemic vascular injury that can be inhibited by allopurinol or DMTU and is reflected by increased circulating and tissue decreased Factor VIII antigen levels. Release of Factor VIII antigen may serve as a valuable marker of distant organ injury in patients with skin burn.