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.

What is the best method to evaluate urine pH? A trial of three urinary pH measurement methods in a stone clinic.

BACKGROUND: Monitoring of urinary pH is an important part of the assessment of patients with urinary tract stones. It provides valuable information about the future stone risk of certain patients and further allows the effective tailoring of medical intervention. Accurate measurement is therefore essential in these patients. OBJECTIVE: The purpose of this study was to determine the most accurate method of measuring urinary pH in an outpatient setting. Materials, Methods, and Participants: Urine samples were collected from 200 patients attending stone clinics at The University Hospital of South Manchester. pH was measured by three commonly used methods: Siemens Clinitek Status pH meter, a hand-held pH meter, and litmus paper read visually. Results were compared with readings simultaneously obtained from a bench-top laboratory pH machine, which is the reference method for pH measurement. STATISTICAL ANALYSIS: The pH readings obtained were analyzed using the Bland-Altman plot. RESULTS AND LIMITATIONS: When compared with the reference method, the hand-held pH meter differed the least with a mean bias of 0.0073 and a maximum under-read of -0.2 pH units and maximum over-read of +0.2 pH units. The Siemens Clinitek pH meter differed most with a mean bias of -0.108, with a maximum over-read of +0.99 pH units and a maximum under-read of 0.78 pH units. The pH values obtained with the litmus paper gave similar results to that of the Clinitek pH meter with a mean bias of -0.069, with a maximum over-read of 0.96 and maximum under-read of 0.82 pH units. CONCLUSION: The hand-held pH device gave urinary pH readings that most closely and consistently matched those of the reference bench-top laboratory machine. This method of pH measurement should be considered in stone clinics in patients with pH-dependent stone risk.

National practice and outcomes of laparoscopic pyeloplasty in the United Kingdom.

BACKGROUND AND PURPOSE: Laparoscopic pyeloplasty is now widely practiced in the United Kingdom and considered the gold standard in the treatment of patients with ureteropelvic junction obstruction. The aim of this audit was to determine the national practice and outcomes for this procedure. PATIENTS AND METHODS: The British Association of Urological Surgeons sent out standardized audit proformas in May 2008 to units across the United Kingdom inviting surgeons who were performing laparoscopic pyeloplasties to submit their results over the last 4 years. Data on the presentation, preoperative investigations, intra-perative details, and postoperative follow-up were collected centrally and inserted into a national database for analysis. RESULTS: There were 323 returns from a total of 30 surgeons. At a median follow-up of 4 months (1-24), the overall symptomatic and renographic failure rates were 10.3% and 8.7%, respectively. Mean operative time was 181 minutes (3--425 min); there were 18 (6%) conversions, 33 (10.5%) complications, and one (0.3%) mortality. Surgeons who submitted 10 or more returns had a lower conversion rate than surgeons submitting fewer than 10 (2.9% vs 14.7%). The median hospital stay was 3 days (1-34 d). There was no difference in failure and complication rate for the retroperitoneal and transperitoneal approaches, although the conversion rate was higher with the retroperitoneal approach. CONCLUSIONS: The results show that laparoscopic pyeloplasty, although achieving acceptable outcomes at a national level in the United Kingdom, had areas of practice that could be improved. It highlights the importance of a high-volume practice in achieving optimum results and the potential problems associated with the retroperitoneal approach.

Citrate inhibits growth of residual fragments in an in vitro model of calcium oxalate renal stones.

BACKGROUND: Alkaline citrate is thought to be helpful in reducing recurrences of calcium oxalate stones. The evidence for this is incomplete, there have been few good trials, all with their own limitations, and not all reported any significant benefit. In vitro studies are usually cited to support the clinical studies but these too have their drawbacks, in particular they relate to crystals and microscopic aggregates and not to actual stone growth. Here we test citrate in vitro using a model of macroscopic calcium oxalate stone enlargement. METHODS: Twelve calcium oxalate stones were grown at a time in a stone farm. Six were grown with 2 mmol/L citrate and six with 6 mmol/L citrate. Three protocols were tested; artificial urine, artificial urine with urinary macromolecules (UMM) from male controls and artificial urine with UMM from male stone formers. The stones were grown continuously for at least 24 days. RESULTS: In all three experiments the higher citrate concentration significantly reduced the growth rate of stones by more than 50% (P < 0.001). There was a small decrease in ionised calcium in the stone growth media (P < 0.001) and significant (P < 0.001) but small increase in pH (about 0.07 pH units). The inclusion of UMM also brought about a decrease in stone growth, particularly at 2 mmol/L citrate. CONCLUSION: Citrate inhibited stone growth in this laboratory model. This was true both in defined media and with addition of UMM. This adds to evidence justifying the use of alkaline citrate in calcium oxalate nephrolithiasis.