Current process and outcomes of the surgical management of LUTS due to benign prostatic enlargement: how consistent are we? - results from the multi-institutional audit of surgical management of BPE (AuSuM BPE) in the United Kingdom.

OBJECTIVE: In view of changing landscape of surgical treatment for LUTS secondary to BPE, this audit was undertaken to assess key aspects of the processes and outcomes of the current interventional treatments for BPE, across different units in the UK. MATERIALS AND METHOD: A multi-institutional snapshot audit was conducted for patients undergoing interventions for LUTS/BPE over 8-week period. Using Delphi process two-part proforma was designed to capture data. RESULTS: 529 patients were included across 20 NHS trusts in England and Wales. Median age was 73 years. Indications for surgery were acute retention (47%) and LUTS (45%). 80% of patients had prior medical therapy. TURP formed the commonest procedure. 27% patients had <23 hour hospital stay. Immediate (21%) and delayed (18%) complications were Clavien-Dindo <2 category. High proportion of patients reported residual symptoms. Type and indication of surgery were significant predictor of complications, length of stay and failure of TWOC outcomes, on multivariate analyses. There were variations in departmental processes, 50% centres used PROMs. CONCLUSION: Monopolar TURP still remains the commonest intervention for BPE. Most departments are adopting newer technologies. The audit identified opportunities for development of consistent, effective and patient centric practices as well as need for large-scale focused studies.

Understanding virtual urology clinics: a systematic review.

OBJECTIVES: To perform a systematic review to identify the clinical, fiscal and environmental evidence on the use of urological telehealth and/or virtual clinic (VC) strategies, and to highlight research gaps in this rapidly evolving field. METHODS: Our PROSPERO-registered (CRD42019151946) systematic search of Embase, Medline and the Cochrane Review Database was performed to identify original research articles pertaining to adult urology telehealth or VC strategies. Risk-of-bias (RoB) assessment was performed according to the Cochrane 2.0 RoB tool or the Joanna Briggs Institute Checklist for non-randomized studies. RESULTS: A total of 5813 participants were included from 18 original articles (two randomized controlled trials [RCTs], 10 prospective studies, six retrospective studies). Urology sub-specialities comprised: uro-oncology (n = 6); general urology (n = 8); endo-urology (n = 2); and lower urinary tract symptoms and/or incontinence (n = 2). Across all sub-specialties, prospective studies using VCs reported a primary median (interquartile range [IQR]) VC discharge rate of 16.6 (14.7-29.8)% and a primary median (IQR) face-to-face (FTF) clinic referral rate of 32.4 (15.5-53.3)%. Direct cost analysis demonstrated median (IQR) annual cost savings of £56 232 (£46 260-£61 116). Grade II and IIIb complications were reported in two acute ureteric colic studies, with rates of 0.20% (3/1534) and 0.13% (2/1534), respectively. The annual carbon footprint avoided ranged from 0.7 to 4.35 metric tonnes of CO2 emissions, depending on the mode of transport used. Patient satisfaction was inconsistently reported, and assessments lacked prospective evaluation using validated questionnaires. CONCLUSION: Urology VCs are a promising new platform which can offer clinical, financial and environmental benefits to support an increasing urological referral burden. Further prospective evidence is required across urological sub-specialties to confirm equivalency and safety against traditional FTF assessment.

Clinical, fiscal and environmental benefits of a specialist-led virtual ureteric colic clinic: a prospective study.

OBJECTIVES: To evaluate the clinical, fiscal and environmental impact of a specialist-led acute ureteric colic virtual clinic (VC) pathway. PATIENTS AND METHODS: All patients with uncomplicated acute ureteric colic, referred to a single tertiary centre, were prospectively entered into the study over a 4-year period (January 2015-December 2018). Inclusion criteria were: low-dose non-contrast computed tomography of kidneys, ureters and bladder; white blood cell count <16 × 109/L; pain controlled; normal renal function; and no clinical concern. Primary outcomes were: time (days) from referral to VC outcome; VC outcome (discharge, further VC, face-to-face [FTF] clinic, extracorporeal shockwave lithotripsy [ESWL], ureterorenoscopy [URS], percutaneous nephrolithotomy [PCNL]); and adverse events (sepsis or obstruction). Secondary outcomes were patient and stone demographics, cost and environmental analysis. The minimum follow-up was 3 months. RESULTS: A total of 1008 patients entered the study, of whom 91.5% (n = 922) were of working age. The median (interquartile range) time from presentation to VC outcome was 2 (4) days. VC outcomes were as follows: 16.3% of patients (n = 164) were discharged; 18.2% (n = 183) were discharged after further VC; 17.2% (n = 173) underwent an intervention; and 48.4% (n = 488) were referred to an FTF clinic. Interventions comprised: PCNL 0.5% (n = 5); ESWL 7.7% (n = 78); and URS 8.9% (n = 90). Stone demographics were as follows: 570 patients (56.5%) had lower, 157 (15.6%) had upper, 96 (9.5%) had mid-ureteric and 163 (16.2%) had renal calculi, and in 22 patients (2.2%) the stones had recently passed. The mean (sd) stone size was 3.5  (2.3) mm. Two adverse events (0.2%) were reported. Introducing a VC saved £145,152 for Clinical Commissioning Groups, the equivalent NHS tariff payment of performing 106 URS procedures or 211 ureteric stent insertions. Overall, 15,085 patient journey kilometres were avoided, equal to 0.70-2.93 metric tonnes of carbon dioxide equivalent production and the need to plant 14.7 trees to achieve carbon balance. CONCLUSION: A specialist-led acute ureteric colic VC reduced time to treatment decision to a median of 2 days. This creates additional clinic capacity and reduces the fiscal burden of traditional clinics and their associated carbon footprint.

Engagement of Other Emergency Services in the Management of Penile Ring Entrapment.

Penile ring entrapment is a rare urological emergency, which may risk tissue loss if not managed appropriately. We present the case of a 59-year-old man with penile ring entrapment secondary to the placement of 14 metallic rings for sexual pleasure. We recommend involvement of the fire emergency service if local equipment is inadequate for urgent penile ring removal.

Single-Center Experience with Three Metallic Ureteral Stents (Allium® URS, Memokath™-051, and Resonance®) for Chronic Ureteral Obstruction.

Purpose: Patients with chronic ureteral obstruction (CUO) are traditionally managed with polymer stents/nephrostomy. However, these are prone to failure and require regular exchange. This study evaluates the efficacy of Allium® URS, Memokath™-051, and Resonance® metallic ureteral stents in managing patients with CUO. Methods: Following institutional approval (Imperial College Healthcare NHS Trust, UK, Registration Number SPS_045), operating theater records were reviewed to identify patients with CUO managed with Allium® URS, Memokath™-051, or Resonance® metallic ureteral stents (September 2015/July 2020). Baseline patient variables (age, gender, underlying etiology, and American Society of Anesthesiologists score) and stricture characteristics (length, level, and continuity) were extracted. Intraoperative and postoperative clinical and radiologic assessments at 6 weeks, 3 months, and then every 6 months, as well as any emergency attendances, were reviewed. The primary outcome was duration of functional stent survival. Secondary outcomes included intraoperative placement success and, as an estimate of renal function, mean serum creatinine over time. Results: One hundred twenty-nine stent insertion episodes (SIEs) (Allium® URS: 23; Memokath™-051: 48; Resonance®: 58) occurred in 76 patients (Allium® URS: 16; Memokath™-051: 31; Resonance®: 29). Kaplan-Meier estimates demonstrated that Resonance® provided superior functional stent survival. Overall median actual functional stent follow-up was 11.4 months for Allium® URS, 5.5 months for Memokath™-051, and 11.7 months for Resonance®. 47.8% of Allium® URS (11/23), 64.6% of Memokath™-051 (31/48), and 19% of Resonance® SIEs (11/58) failed. No Resonance® SIEs for benign indication ended in failure. Intraoperative placement success was high (Allium® URS: 95.7%; Memokath™-051 and Resonance®: both 100%). In the first year following SIE, creatinine ranged from +21.3% to +46.7% for Allium® URS, -7.8% to +8.9% for Memokath™-051, and -9.4% to +27.3% for Resonance®. Conclusions: Allium® URS, Memokath™-051, and Resonance® metallic ureteral stents are all viable management options of CUO. In this cohort, Resonance® provided superior functional stent survival. Prospective large-scale comparisons with long-term follow-up are needed to help inform stent choice dependent on individual patient and stricture characteristics.

Ureteric guidewire damage by Holmium:YAG laser: preliminary results.

Typically, guidewires are regularly used to provide access or act as a guide during laser lithotripsy. This may result in the tip of the fibre being in close proximity to the guidewire during the firing period and consequently, this could result in accidental damage to the guidewires during the procedure. To replicate this scenario, an experimental model was designed enabling accurate and reproducible positioning of the laser fibre relative to the guidewire. The guidewire was exposed to the laser energy for a range of typical settings used in the clinic. The results demonstrate that the guidewire is susceptible to laser energy damage, especially in close proximity to the fibre.

Metallic Ureteric Stents in Malignant Ureteric Obstruction: A Systematic Review.

The effectiveness of metallic stents in the management of malignant ureteric obstruction is unclear. This systematic review evaluates the use of 4 commercially available metallic stents (Resonance, Memokath 051, Uventa, and Allium URS). Twenty-one studies met eligibility criteria. Overall success rates ranged from 88% for the Allium stent to 65% for Memokath 051. Resonance demonstrated the lowest migration rate (1%). Uventa had the lowest obstruction rate (6%). Metallic ureteric stents offer a viable alternative in the management of malignant ureteric obstruction. Further high quality studies are required to assess cost effectiveness and refine specific indications based on etiology and level of the ureteric obstruction.

Endourologic Management of an Iatrogenic Ureteral Avulsion Using a Thermoexpandable Nickel-Titanium Alloy Stent (Memokath 051).

Background: The use of ureteroscopy in the management of urolithiasis is well established. Ureteral avulsion is a rare but challenging complication of the procedure. Postureteral injury strictures are a common result of such injuries and are typically managed with reconstructive surgery or endoscopically with polymer stent. This case represents the first effective management of ureteral avulsion and subsequent ureteral stricture using a Memokath ureteral stent. Case Presentation: A 54-year-old gentleman presented to the Department of Urology with right loin pain as a result of right renal calculi, previously treated with extracorporeal shockwave lithotripsy. The patient was investigated with ultrasonography and noncontrast CT of his urinary tract, revealing mild right-sided hydroureteronephrosis and two right proximal ureteral stones, measuring 9 and 4 mm, respectively. He underwent a right semirigid ureteroscopy and laser stone fragmentation with complete stone clearance, but on withdrawal of the ureteroscope, a right ureteral injury occurred with ureteral mucosal avulsion extending from the L3/L4 vertebrae to the right vesicoureteral junction. Upon consideration of several options for management of this ureteral avulsion, the patient opted for endourologic stenting. After 10 months, the patient developed a ureteral stricture as a result of the avulsion. He was troubled with stent-related symptoms and wanted to avoid reconstructive surgery and, therefore, opted for a Memokath ureteral stent. The patient recovered well with excellent renal function and drainage on subsequent mercaptoacetyl-triglycyl renogram. Conclusion: Ureteral avulsion is a rare but important complication of ureteroscopy with numerous options available for management. Discussions should be had with the patient to weigh the various options, and metallic stents should be considered in the long-term management of such injuries and their sequel.

What is better in percutaneous nephrolithotomy - Prone or supine? A systematic review.

OBJECTIVE: To review the literature reporting the technique of percutaneous nephrolithotomy (PCNL) and outcomes for prone and supine PCNL, as PCNL is an established treatment for renal calculi and both prone and supine PCNL have been described, but there has been much debate as to the optimal position for renal access in PCNL. METHODS: A review of the medical literature was conducted using the PubMed database to identify relevant studies reporting on prone and supine PCNL published up until July 2015. Only publications in English were considered. Search terms included 'supine', 'prone', 'percutaneous nephrolithotomy', 'PCNL' and 'randomised controlled trial'. Articles relevant to the particular aspect of PCNL discussed were selected. RESULTS: In all, 30 articles were included in the literature review. Nine of these articles were of Level 1 Evidence as graded by the Oxford System of Evidence-based Medicine. CONCLUSION: The present systematic review highlights the benefits and disadvantages of supine and prone PCNL. The published data on supine and prone PCNL have shown no significant superiority of either approach. Whether prone or supine PCNL is optimal, remains a debatable topic.

The role of open stone surgery.

OBJECTIVE: To highlight the role of open stone surgery in the management of urolithiasis in the current era of minimally invasive therapies. The introduction and continuous development of extracorporeal shockwave lithotripsy (ESWL), ureterorenoscopy and percutaneous nephrolithotomy (PCNL) over the past 30 years have led to a significant change in the current management of urolithiasis, where the indications for open stone surgery have been narrowed significantly, making it a second- or third-line treatment option. METHODS: We reviewed the most recent guidelines published by the European Association of Urology and the American Urological Association, and reviewed reports through a MEDLINE search to identify the indications and current role of open stone surgery. RESULTS: From the MEDLINE search, it was obvious that the number of papers published on open renal stone surgery has decreased during the last three decades, soon after the introduction of ESWL and PCNL. CONCLUSION: Although currently most patients with stones can be managed by minimally invasive therapy, we believe that open surgery still has a role, and therefore it is of great importance to recognise that a small group of patients with complex stone disease, and those with anatomical and physiological anomalies, will benefit from this treatment option.

Simultaneous antegrade/retrograde upper urinary tract access: Bart's modified lateral position for complex upper tract endourologic pathologic features.

OBJECTIVE: To determine whether the Bart's modified lateral position is safe and effective for achieving simultaneous anterograde and retrograde access in complex upper urinary tract pathologic features. METHODS: From November 2006 to September 2010, 45 procedures were performed, with the patients in the modified lateral position. The indication for these procedures was the presence of complex unilateral upper urinary tract pathologic features. The patients with muscular and/or skeletal abnormalities were excluded. All procedures were performed using simultaneous anterograde and retrograde access with the patient under general anesthesia. RESULTS: The preoperative investigation protocol included assessment of the stone burden and location using enhanced abdominal computed tomography. The patients were routinely examined 6 weeks after the procedure with a combination of plain abdominal radiography and renal ultrasonography. For patients treated for conditions causing upper urinary tract obstruction (pelviureteral junction obstruction and/or ureteral strictures), a mercaptoacetyltriglycine renography was performed at 4, 12, and 24 months postoperatively. The mean patient age was 51.2 years (range 17-79). Stone clearance was achieved by a single combined procedure in 36 patients (80%). Successful recanalization was achieved in all patients with pelviureteral junction obstruction and ureteral strictures. In 4 patients (8.8%), persistent hematuria was noted, and 2 patients (4.4%) developed postoperative urinary sepsis and were treated conservatively. CONCLUSION: Modification to the lateral position compares equally with contemporary percutaneous nephrolithotomy series. It provides wide exposure of the flank, allowing the choice of multiple access sites, enhanced control, and a wide angle for handling of the antegrade instruments. Two surgeons can work simultaneously, addressing complex endourologic pathologic features in high-risk patients.

Transurethral ethanol ablation of the prostate for symptomatic benign prostatic hyperplasia: long-term follow-up.

BACKGROUND AND PURPOSE: Over the past decade, a variety of new minimally invasive therapies (MIT) have been developed for the treatment of patients with bladder outflow obstruction from benign prostatic hyperplasia (BPH). Transurethral ethanol ablation of the prostate (TEAP) has been introduced as a minimally invasive alternative treatment for patients with BPH. In this study, we present our experience and results of long-term follow-up of 54 months after treatment of symptomatic BPH with TEAP. PATIENTS AND METHODS: Fifty-six men with symptomatic BPH were enrolled in our study; all patients were medically high-risk patients with multiple comorbidities. Procedures were performed under intravenous sedation combined with local urethral instillation of lidocaine jelly and a transrectal ultrasonography (TRUS)-guided periprostatic block. Dehydrated ethanol in a concentration of 95% to 98% was injected transurethrally by means of the Postaject Ethanol Injection System using a rigid cystoscope. RESULTS: The following data were collected: International Prostate Symptom Score, prostate-specific antigen level, prostate volume using TRUS, maximum urine flow rate, and postvoid residual. There was sufficient response in 73% of our patients, while the remaining 23% showed an insufficient response and needed alternative treatment. CONCLUSION: TEAP is an effective minimally invasive treatment option for medically high-risk symptomatic patients with BPH that can be performed as an outpatient procedure under regional anesthesia. The procedure is easy, available, inexpensive, safe, and rapid. Further larger-scale, long-term multi-institutional trials are needed.

'An interventional urology list' - a novel concept for UK urological services.

INTRODUCTION: Almost all patients in the UK with obstructed and/or infected kidneys are referred to interventional radiology for percutaneous nephrostomy and/or placement of an anterograde JJ stent. Although this 'tradition' is going strong in the UK, urologists throughout the world have evolved their practice to encompass such interventional procedures in their remit. We have set up a local anaesthetic list 'interventional urology list' in our ESWL suite. We present our 4-year experience and discuss the benefits that this interventional list brings to our patients, our trainees, our interventional radiology colleagues and to the hospital trust. PATIENTS AND METHODS: From May 2005 to May 2009, we have been running this list, twice-weekly, performing procedures such as nephrostomies, anterograde stents, nephrostograms and stent exchanges all under local anaesthetic. RESULTS: A total of 580 procedures have been carried out on this list over this period. Our success rate for nephrostomy insertion is 96% with three failures, as a result of patient discomfort. No major complications and three minor complications were reported. We had four failed anterograde stenting procedures (out of 80). All other procedures including nephrostograms, stent exchanges/removals/insertions, as well as renal cyst aspiration and sclerotisation were successfully carried out. CONCLUSIONS: Our results of percutaneous nephrostomy and antegrade stenting are favourable when compared with published data on nephrostomies. This novel set up has resulted in several improvements to the service we offer patients and also provided significant improvement in training for our residents. We encourage other departments to try and develop this type of 'interventional urology list'.

Endovascular covered stenting for the management of post-percutaneous nephrolithotomy renal pseudoaneurysm: a case report.

INTRODUCTION: Intrarenal pseudoaneurysm is a rare, yet clinically significant, complication of percutaneous nephrolithotomy. A high index of clinical suspicion is necessary in order to recognize pseudoaneurysm as the cause of delayed bleeding after percutaneous nephrolithotomy and angiography confirms the diagnosis which allows endovascular management. CASE PRESENTATION: We present a case of a 65-year old Caucasian woman who underwent percutaneous nephrolithotomy in the supine position for a two centimetre renal calculus. The postoperative course was complicated by persistent bleeding due to a renal pseudoaneurysm. The vascular lesion was successfully managed by endovascular exclusion through the use of a covered stent graft. We report the first successful use of this method for the management of iatrogenic pseudoaneurysm in a branch of the left renal artery and we focus on the imaging findings, technical details, advantages and limitations of this technique. CONCLUSION: As a result of its high efficacy, interventional radiology has largely replaced open surgery for the management of renal pseudoaneurysm related to percutaneous nephrolithotomy. Recent technical advancements have allowed the use of covered stent grafts as an alternative to embolisation for the angiographic management of visceral artery pseudoaneurysm located in other organs. This novel technique allows the endovascular exclusion of the pseudoaneurysm, without compromising arterial supply to the end-structures - an advantage of critical importance in organs supplied by segmental arteries - in the absence of collateral vasculature, such as the kidney.

Comparison of stent-related symptoms between conventional Double-J stents and a new-generation thermoexpandable segmental metallic stent: a validated-questionnaire-based study.

INTRODUCTION: Double-J stents revolutionized the minimally invasive management of ureteral strictures, but have significant morbidity. We compare stent-related symptoms and quality of life between a conventional Double-J stent and a novel thermoexpandable metal segmental ureteral stent (Memokath) in patients with ureteral strictures. MATERIALS AND METHODS: Seventy patients with a conventional Double-J stent or a Memokath stent for ureteral strictures were mailed a validated ureteral stent symptom questionnaire, which is a multidimensional measure that evaluates stent-related morbidity in six sections: urinary symptoms, body pain, general health, work performance, sexual matters, and additional problems. Statistical analysis compared the differences in these parameters between the two groups. RESULTS: Forty-one patients (58.5%) responded, 23 with a Double-J stent and 18 with a Memokath stent. A subgroup of 10 patients had both a Double-J and a Memokath stent. Nearly 70% of patients with Double-J stents experienced urine frequency

A technique to flush out renal stone fragments during percutaneous nephrolithotomy.

There are a number of graspers and baskets to snare and remove stones during percutaneous nephrolithotomy (PCNL). These instrumental techniques can, however, cause inadvertent trauma to the renal mucosa and can be time consuming. Increasingly, these graspers and baskets are disposable, which also has financial implications. We use a simple technique to flush out fragments from the kidney during PCNL. Once fragments have been identified as a size that can pass through the Amplatz sheath, a cut nasogastric tube is inserted through the sheath--if possible next to or behind the fragments. It is repeatedly moved forward and backward in a jerking motion while saline is instilled under some pressure to create some turbulence. This results in the mechanical flushing out of stone fragments. We have found this to be a safe, effective, and reliable technique of stone extraction during PCNL.

Percutaneous endourologic procedures in high-risk patients in the lateral decubitus position under regional anesthesia.

BACKGROUND AND PURPOSE: The prone position is the most commonly used position for percutaneous endourologic procedures. It is usually combined with a general anesthesia. In high-risk patients, this approach can lead to circulatory and respiratory compromises. Operating on such patients in a full lateral position will minimize the hemodynamic and respiratory risks and-if combined with spinal anesthesia-will allow for increased patient comfort and safety. PATIENTS AND METHODS: After rigorous preoperative assessment, 27 medical high-risk patients (12 men) with a mean age of 62 years and an American Society of Anesthesiologists score of 3+ were included in this study. The majority (78%) had regional anesthesia and were fully awake and alert during the operation. The procedures consisted of an initial retrograde renal study/filling with contrast medium with the patient in the lithotomy position to aid kidney puncture. The percutaneous procedure was then performed with the patient in the lateral decubitus position, and access was performed under fluoroscopic and/or ultrasonographic guidance. RESULTS: Twenty-two percutaneous nephrolithotomies (PCNL), 3 anterograde endopyelotomies (AEP), 1 percutaneous resection of renal pelvic transitional-cell carcinoma, and 1 percutaneous renal cyst sclerotization were performed. After PCNL, 11 patients were stone free postoperatively, and a further 8 were stone free after adjuvant shockwave lithotripsy. Two patients needed temporary Double-J stents. One renal access failed. Two procedures were aborted because of hemorrhage. One patient died in the recovery room from uncontrollable renal bleeding. A renal scan after 3 months showed relief of obstruction in the three patients who had undergone AEP. Ultrasonography confirmed complete resolution of the sclerotized renal cyst. Neither of the patients with regional anesthesia needed conversion to general anesthesia. In two patients who experienced moderate pain, a "top-up" with local anesthesia solved the problem. CONCLUSION: The full lateral position-while necessitating expertise and some learning for renal puncture from an unusual angle-is safe in medical high-risk patients. It can be safely performed using regional anesthesia, avoiding the risks of general anesthesia and allowing for patient-anesthetist communication throughout the procedure. Cardiac and respiratory parameters are improved, stable, and easily controlled. As opposed to the supine position, the awake patient is more comfortable, and morbid obesity is not a problem.