Use of Temporally Validated Machine Learning Models To Predict Outcomes of Percutaneous Nephrolithotomy Using Data from the British Association of Urological Surgeons Percutaneous Nephrolithotomy Audit.

BACKGROUND AND OBJECTIVE: Machine learning (ML) is a subset of artificial intelligence that uses data to build algorithms to predict specific outcomes. Few ML studies have examined percutaneous nephrolithotomy (PCNL) outcomes. Our objective was to build, streamline, temporally validate, and use ML models for prediction of PCNL outcomes (intensive care admission, postoperative infection, transfusion, adjuvant treatment, postoperative complications, visceral injury, and stone-free status at follow-up) using a comprehensive national database (British Association of Urological Surgeons PCNL). METHODS: This was an ML study using data from a prospective national database. Extreme gradient boosting (XGB), deep neural network (DNN), and logistic regression (LR) models were built for each outcome of interest using complete cases only, imputed, and oversampled and imputed/oversampled data sets. All validation was performed with complete cases only. Temporal validation was performed with 2019 data only. A second round used a composite of the most important 11 variables in each model to build the final model for inclusion in the shiny application. We report statistics for prognostic accuracy. KEY FINDINGS AND LIMITATIONS: The database contains 12 810 patients. The final variables included were age, Charlson comorbidity index, preoperative haemoglobin, Guy's stone score, stone location, size of outer sheath, preoperative midstream urine result, primary puncture site, preoperative dimercapto-succinic acid scan, stone size, and image guidance (https://endourology.shinyapps.io/PCNL_Demographics/). The areas under the receiver operating characteristic curve was >0.6 in all cases. CONCLUSIONS AND CLINICAL IMPLICATIONS: This is the largest ML study on PCNL outcomes to date. The models are temporally valid and therefore can be implemented in clinical practice for patient-specific risk profiling. Further work will be conducted to externally validate the models. PATIENT SUMMARY: We applied artificial intelligence to data for patients who underwent a keyhole surgery to remove kidney stones and developed a model to predict outcomes for this procedure. Doctors could use this tool to advise patients about their risk of complications and the outcomes they can expect after this surgery.

Worldwide trends of practice and intervention in paediatric endourology: comparison of European versus Non-European responses.

Introduction: The area of paediatric endourology is unique and is recognised to be challenging, and it requires a certain level of focused training and expertise. Our aim was to conduct a worldwide survey in order to gain an overview regarding the current practice patterns for minimally invasive treatments of paediatric upper urinary tract stone patients. Material and methods: The survey was distributed between December 2021 and April 2022 through urology sections and societies in United Kingdom, Latin America and Asia. The survey was made up of 20 questions and it was distributed online using the free online Google Forms (TM). Results: 221 urologists answered the survey with 56 responses each from India, South America and UK and 53 responses from the rest of Europe (15 countries). In total, 163 responders (73.7%) managed paediatric stone patients in their daily practice. Of the responders, 60.2% were adult urologists and 39.8% were paediatric urologists. 12.9% adult urologists and 20.4% paediatric urologists run independent clinics while some run combined adult and paediatric clinics sometimes with the support of the nephrologists. Only 33.9% urologists offered all surgical treatments [extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureteroscopy (URS) and retrograde intrarenal surgery (RIRS)]. Conclusions: Treatment of paediatric stones can vary according to country and legislations. Based on the results of this survey, minimally invasive methods such as URS and mini PCNL seem to have become more popular. In most institutions a collaboration exists between adult and paediatric urologists, which is the key for a tailored decision making, counselling and treatment success.

Challenges and options for management of stones in anomalous kidneys: a review of current literature.

Introduction: Congenital anomalies of the kidney and urinary tract (CAKUT) represent a wide range of disorders that result from developmental abnormalities of the kidneys, urinary collecting tract, and lower urinary tract. There has been extensive development in approaches to the management of stones in normal kidneys with the advent of retrograde intra-renal surgeries (RIRS)/ureteroscopies, extracorporeal shock wave lithotripsy (ESWL) percutaneous nephrolithotomy (PCNL), and minimally invasive surgery (laparoscopy/robotics). However, the management of stones in CAKUT is not straightforward and is often challenging for urologists. There are no clear guidelines available to help navigate stone management in such patients. Materials and methods: The aim of this literature review was to focus on stone management in anomalous kidneys. Most common abnormalities were considered. The studies were very heterogeneous with different approaches. The methodology involved evaluating studies looking into individual surgical approaches to the management of stones in these anomalous kidneys as well as looking at different approaches to stone management, in particular renal abnormality. Results: We found RIRS is a feasible approach in most stones with sizes <20 mm and PCNL holds the upper hand in stones more than 20 mm. However, ESWL, laparoscopy, and robotics have their places in managing some of these cases. Conclusion: We concluded that stones in anomalous kidneys can be challenging but can be managed safely. There is no straightforward answer to the right technique but rather the right planning based on the anatomy of the kidney in terms of vascularity and drainage, stone size and density, and expertise available.

The design and validation of a low-cost trans perineal (TP) prostate biopsy simulator for training: improving trainees' confidence and cognitive targeting skills.

PURPOSE: The aim of this research was to create a novel and low-cost TP prostate biopsy simulator that has face, content and construct validity with high educational value. METHODS: This research developed a trans perineal prostate (TP) biopsy simulator using 3D-printed moulds and tissue-mimicking materials. Important regions (anterior, mid, and posterior zones) were coded with different colours. Ultrasound visible abnormal lesions were embedded in the prostate phantom. Expert and novice participants in TP biopsies were recruited. Essential skills were identified through the consensus of six experts. These skills were assessed through tasks performed by participants. This included the accuracy and timing of systematic and target biopsies. Immediate feedback was determined by the colour of the biopsy cores taken. A survey was distributed to evaluate its realism and educational value. RESULTS: The material cost of one simulator was £7.50. This simulator was proven to have face, content, and construct validity. There was a significant difference (p = 0.02) in the accuracy of systematic biopsies between both experts and novices. Significant difference was also observed (p = 0.01), in accurately identifying target lesion on ultrasound between both groups. Participants rated the overall realism of the simulator 4.57/5 (range 3-5). 100% of the experts agreed that introducing this simulator to training will be beneficial. 85.7% of the participants strongly agree that the simulator improved their confidence in TP biopsies. CONCLUSION: There is value in integrating this proof-of-concept TP prostate biopsy simulator into training. It has highly rated educational value and has face, content, and construct validity.

Complications After Radical Nephrectomy According to Age: Analysis from the British Association of Urological Surgeons Nephrectomy Audit.

Introduction: To compare complication rates in radical nephrectomy (RN) for renal cell carcinoma (RCC) across different age groups. Methods: Retrospective analysis of the British Association of Urological Surgeons Nephrectomy audit database between January 1, 2012, and December 31, 2017, was performed. Comparisons were made between different age groups (<60, 60-79, and ≥80) in patients undergoing RN for RCC. Results: Eighteen thousand four hundred thirty-eight patients with RCC underwent RN: 6128 (33.2%) <60 years of age, 10,785 (58.5%) 60-79 years of age, and 1525 (8.3%) ≥80 years of age. There was a significantly lower preoperative hemoglobin and estimated glomerular filtration rate with advancing age (p < 0.001). Patients ≥80 had a higher Charlson comorbidity index and World Health Organization (WHO) performance status (p < 0.001). There was also significant variability in the approach to RN (p < 0.001): laparoscopy was most commonly performed (68.8% vs 69.3% vs 75.0%). Patients ≥80 years of age were found to have the shortest operating time (p < 0.001). There were significant differences in T stage between groups with patients ≥80 years of age having a higher T stage (p < 0.001). The incidence of intraoperative complications did not significantly differ between age groups (p = 0.18). The incidence of postoperative complications was 15.7%, 18.2%, and 20.5% and major postoperative complications was 1.4%, 2.1%, and 2.8% in patients <60, 60-79, and ≥80 years of age, respectively (p < 0.001). The most common complication in all age groups was blood transfusion (7.6% <60, 8.6% 60-79, and 9.1% ≥ 80 years of age). Stepwise logistic regression analysis adjusting for additional variables found the odds of a postoperative complication increased with age with an odds ratio of 1.25 in patients ≥80 years of age and an odds ratio of 1.09 in patients 60-70 years of age compared with <60 years of age. Conclusion: Overall complications in all age groups are low, but advancing age should be considered an independent risk factor for postoperative complications after RN and should be appropriately considered when counseling elderly patients before treatment.

Management of the Distal Ureter in Radical Laparoscopic Nephroureterectomy for Upper Tract Urothelial Carcinoma.

Introduction: Management of the distal ureter during laparoscopic nephroureterectomy (LNU) for upper tract urothelial carcinoma (UTUC) is controversial. The aim of this review was to determine whether this affects oncological outcomes. Methods: A literature review was conducted searching MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials in June 2019. Studies reporting outcomes of LNU in UTUC using either open, laparoscopic, or endoscopic approaches to excise the distal ureter were identified. All eligible studies underwent critical appraisal and were excluded if not of sufficient quality. Cumulative analysis of the results was performed. Results: Nine studies with a total of 383 patients (168 open, 159 laparoscopic, and 56 endoscopic excision of distal ureter) were eligible for inclusion. Study design and outcome reporting were variable between studies. Mean age of patients was comparable (67.7 years versus 65.0 years versus 66.6 years). Mean follow-up duration was comparable between open and laparoscopic groups (46.2 months versus 45.5 months) but reduced in the endoscopic group (33.4 months). The open group had a higher proportion of high grade/G3 tumors and pT2-4 tumors when compared to the laparoscopic and endoscopic groups (P < .001 and P = .002). The open group had a higher rate of intravesical recurrence and the laparoscopic group had a higher rate of distant metastases (P < .001). Conclusion: This review has identified differences in oncological outcomes between different techniques of managing the distal ureter in LNU for UTUC. However, the poor reporting of potentially confounding factors does not enable any one technique to be recommended as superior and requires further research.

How to maximize the efficacy of shockwave lithotripsy.

Since its introduction in the early 1980s, extracorporeal shockwave lithotripsy (ESWL) has proven to be a minimally invasive and efficient procedure for the management of renal calculi. It is currently one of the most recommended treatments for small- and medium-sized stones (<20 mm) in most guidelines internationally. The recent coronavirus disease 2019 (COVID-19) outbreak could lead to a further increase in ESWL use as it avoids a general anesthetic and its potential complications in patients with COVID-19 infection. Most publications exhibit ESWL stone-free rates (SFRs) of 70%-80%; however, this is often not the case in many centers, with multiple factors affecting the efficacy of the intervention. Various stone and patient factors have been shown to influence the ESWL success. Stone position, density and size, skin-to-stone distance, and body-mass index contribute to SFRs. Modifications in the lithotripter design and revisions in the technique have also improved the SFRs over the years, with slower shock rates, power-ramping protocols, combined real-time ultrasound, and fluoroscopy imaging technology, all enhancing the efficacy. The adjuvant use of pharmacological agents, such as alpha-blockers, potassium citrate, and the emerging microbubble technology, has also been investigated and shown promising results. Arguably, the most significant determinant of the success of ESWL in a particular unit is how the lithotripsy service is set up and monitored. Careful patient selection, dedicated personnel, and post-treatment imaging review are essential for the optimization of ESWL. Through an analysis of the published studies, this review aimed to explore the measures that contribute to an effectual lithotripsy service in depth.

Is Thulium laser enucleation of prostate an alternative to Holmium and TURP surgeries - A systematic review?

To assess efficacy and safety of Thulium laser enucleation of prostate (ThuLEP) for benign prostatic hyperplasia. It is a systemic review based on a comprehensive search of PubMed, Cochrane, and Google scholar databases from inception to 31 March 2020. All studies in English evaluating ThuLEP as well as those comparing it with Transurethral resection of prostate (TURP) and Holmium Laser enucleation of prostate (HoLEP) were enrolled. The primary outcome was to evaluate operative, postoperative, and functional outcomes (IPSS, QoL, Qmax, PVR) in patients undergoing ThuLEP. Secondary outcome was to compare operative, postoperative, and functional outcomes with TURP and HoLEP in comparative studies. Fourteen studies with a total of 2,562 patients were included in this review. 2,034 underwent ThuLEP, 349 underwent TURP, and remaining 139 had HoLEP. We found that ThuLEP is safe as well as efficacious in all age groups as well as across all prostate sizes and with all four functional outcomes (IPSS, QoL, Qmax, PVR) revealing marked improvement at 3, 6, 12, and 24 months. Compared to TURP and HoLEP, Thulep is non-inferior in terms of operative and functional outcomes and, in fact, is associated with lesser catheterization duration as well as shorter hospital stay. Further, Thulium fiber laser (TFL) has advantages of being light weight, having high frequency, less fiber degradation, and less energy consumption, making it cost effective for operational and maintenance purpose. ThuLEP is a safe, efficacious, and cost-effective procedure for BPE.

Laparoscopic Nephrectomy in Patients with Previous Abdominal Surgery.

Laparoscopic nephrectomy is a minimally invasive procedure that provides significant benefits to the patient, such as reduced analgesic requirements and shorter recovery time. While the popularity of laparoscopy has grown substantially, there are associated risks of injury to the blood vessels and/or viscera during the insertion of the laparoscopic ports. Such injuries can lead to a significant increase in mortality rates. Patients who have had previous abdominal surgery have a higher risk of adhesions; this has been shown to increase the risk of complications from port placement. Consequently, previous abdominal surgery was viewed as a relative contraindication to laparoscopic surgery. However, studies have demonstrated the advantages of laparoscopic surgery over an open radical approach; hence, previous abdominal surgery is no longer viewed as a contraindication. Here, we describe the case of a 62-year-old man who presented with an incidental finding of right renal cell carcinoma (RCC). We performed a radical nephrectomy on this patient who had undergone multiple previous abdominal surgeries. During this procedure, a small bowel injury occurred. Herein, we review the available evidence and describe the risk factors and techniques to avoid injury from laparoscopic port-site placement in patients undergoing nephrectomy with a history of previous abdominal surgery.

Laparoscopic Nephrolithotomy in a Horseshoe Kidney.

Horseshoe kidney (HSK) is the common renal fusion congenital anomaly, affecting about 0.25% of the global population. Although most HSKs are detected incidentally, they may present with clinical findings, including urinary tract infections (UTI), stone formation, and obstruction. Nephrolithiasis, observed in 20% of patients with HSK, is a frequent indication for surgery. Due to the caudal and medial locations of calyces and the abnormal anterior position of the kidney, extracorporeal shock wave lithotripsy has shown a relatively low success rate in treating HSK. Percutaneous nephrolithotomy has also been associated with major complications in anomalous kidneys. Advances in laparoscopic instrumentation and techniques have made laparoscopic surgery a promising alternative for stone treatment in HSK. This report describes a 61-year-old woman who presented initially with recurrent UTI unresponsive to multiple courses of antibiotics. Urine cultures were positive for Escherichia coli. A computed tomography scan showed a right HSK with multiple renal stones (35 mm in the right lower pole with eight stones 2-4 mm in size), along with severe hydronephrosis. The patient was treated successfully with laparoscopic nephrolithotomy, indicating that laparoscopy is an effective and safe approach in the treatment of renal stones >2 cm in HSK.

Renal Function Loss After Cryoablation of Small Renal Masses in Solitary Kidneys: European Registry for Renal Cryoablation Multi-Institutional Study.

Objectives: To estimate and quantify the loss of kidney function in solitary kidneys with small renal masses (SRMs) after laparoscopy-assisted renal cryoablation (LARC), from the European Registry for Renal Cryoablation (EuRECA) database. Patients and Methods: Of the 808 patients from eight European centers in the database, 102 patients had SRMs in solitary kidneys. Patient demographics, body mass index (BMI), American Society of Anesthesiologists (ASA) grade, Charlson comorbidity index, and tumor characteristics including nephrometry (PADUA) score where available were collected. Renal function data in the form of estimated glomerular filtration rate (eGFR) and chronic kidney disease (CKD) stratification both preoperatively and at 3 months postoperatively were collected. Results: The median (interquartile range [IQR]) age was 67 (59-81) years, the median (IQR) BMI was 26 (23.9-28.9) kg/m2, and the median (IQR) ASA score was 2 (2-3). The median Charlson score was 4 (range: 0-10). The median (IQR) tumor size in cross-sectional imaging was 26 (19-38) mm. The follow-up data were available for 72 patients with a median follow-up for this group of 38 (range: 10-132) months. The mean preoperative eGFR was 55.0 mL/minute/1.73 m2 (standard deviation [SD] = 18.1), and the mean postoperative eGFR was 51.8 mL/minute/1.73 m2 (SD = 18.8). The change was -3.1 mL/minute/1.73 m2 (95% confidence interval -5.2 to -1.0) units, which was statistically significant (p = 0.004). The change in the CKD stages comparing before and after LARC was not significant (paired two-tailed t-test, p = 0.06). Critically, the decrease in the eGFR did not translate to any significant adverse outcome and zero patients required dialysis. Conclusion: To the best of our knowledge, this is the largest study of renal function after LARC in SRMs in solitary kidneys. Cryotherapy in this imperative situation is safe, carries clinically insignificant reduction in renal function, therefore providing an option to minimize the risk of developing renal failure necessitating dialysis.

Radiation Exposure during Ureterorenoscopy and Laser Lithotripsy: An Analysis of Stone Characteristics.

INTRODUCTION AND OBJECTIVES: Stone formers often have a chronic exposure to significant quantities of ionising radiation from radiological investigations and interventions. Predicting radiation exposure would allow the clinician to quantify expected cumulative radiation and find strategies to minimise exposure. We evaluated radiation exposure during ureteroscopy and laser lithotripsy (URS + LL) for a single stone episode and correlated the results to stone characteristics. METHOD: Data was collected retrospectively for all patients undergoing URS + LL in our institution over a 1 year period. Patients with multiple stones, staghorn stones or incomplete stone clearance were excluded to simplify the analysis. Patient characteristics, fluoroscopy data and stone characteristics were recorded. RESULTS: We included 302 consecutive patients in the study. The majority of stones were located in the renal calyces/pelvis (54%) with the rest located in the upper (18%), middle (13%) and lower ureter (15%). Mean stone diameter was 9.9 mm (range 4-30 mm). Mean radiation exposure time during URS + LL was 44 s (range 12-119 s) with a mean total radiation exposure of 7.5 milligray (mGy; range 1.2-29.7 mGy). Renal stones were associated with 27% higher radiation exposure compared to ureteral stones (8.3 vs. 6.7 mGy; p = 0.02). There was a positive correlation between stone diameter and radiation exposure (Spearman's correlation coefficient ρ = 0.28; p < 0.001). Stones with diameter greater than 10 mm were associated with 37% higher radiation exposure compared to smaller stones (9.1 vs. 6.6 mGy; p < 0.001). CONCLUSION: There is a direct correlation between stone burden, as well as location, and radiation exposure during URS + LL. Clinicians should consider strategies to reduce total radiation exposure in recurrent stone formers at risk of high radiation exposure by limiting screening time, using pulsed rather than continuous fluoroscopy, management with primary URS + LL, or using ultrasound guidance.

Oncological outcomes and complication rates after laparoscopic-assisted cryoablation: a European Registry for Renal Cryoablation (EuRECA) multi-institutional study.

OBJECTIVE: To assess complication rates and intermediate oncological outcomes of laparoscopic-assisted cryoablation (LCA) in patients with small renal masses (SRMs). PATIENTS AND METHODS: A retrospective review of 808 patients treated with LCA for T1a SRMs from 2005 to 2015 at eight European institutions. Complications were analysed according to the Clavien-Dindo classification. Kaplan-Meier analyses were used to estimate 5- and 10-year disease-free survival (DFS) and overall survival (OS). RESULTS: The median [interquartile (IQR)] age was 67 (58-74) years. The median (IQR) tumour size was 25 (19-30) mm. The transperitoneal approach was used in 77.7% of the patients. The median postoperative hospital stay was 2 days. In all, 514 patients with a biopsy-confirmed renal cell carcinoma (RCC) were available for survival analyses. The median (IQR) follow-up for the RCC-cohort was 36 (14-56) months. A total of 32 patients (6.2%) were diagnosed with treatment failure. The 5-/10-year DFS was 90.4%/80.0% and 5-/10-year OS was 83.2%/64.4%, respectively. A total of 134 postoperative complications (16.6%) were reported, with severe complications (grade ≥III) in 26 patients (3.2%). An American Society of Anesthesiologists score of 3 was associated with an increased risk of overall complications (odds ratio 2.85, 95% confidence interval 1.32-6.20; P = 0.005). CONCLUSIONS: This large series of LCA demonstrates satisfactory long-term oncological outcomes for SRMs. However, although LCA is considered a minimally invasive procedure, risk of complications should be considered when counselling patients.

A unique presentation of a complex haemorrhagic adrenal pseudocyst.

A man aged 33 years presented with a 3-day history of left-sided testicular discomfort. Clinical examination revealed a large left-sided varicocele. He was referred for a testicular ultrasound, which demonstrated a moderate left-sided varicocele and an associated large suprarenal mass. An urgent (CT) scan was arranged which confirmed this, with associated compression of adjacent structures, including the left kidney and left renal vessels. The patient was admitted 1 week following the CT scan with features of sepsis. An inpatient adrenal MRI scan suggested the presence of a large left-sided haemorrhagic adrenal cyst. This was removed surgically through a left subcostal incision. Histology confirmed there was no malignancy. The patient was discharged and a follow-up CT scan at 6 months showed complete resolution of the cyst with no further testicular discomfort. This is the first known case of an adrenal cyst presenting with a varicocele.

Urolithiasis following urinary diversion.

Urolithiasis is a well-known occurrence after cystectomy and urinary diversion. With high incidence and recurrence rates of urolithiasis, complex anatomy and associated morbidities, these patients remain a management challenge for urologists. The purpose of this review is to examine the literature and consider the risk factors for stone formation in this group of patients and reflect on the reported outcomes with the range of available treatment options.

Partial vs radical nephrectomy for T1 renal tumours: an analysis from the British Association of Urological Surgeons Nephrectomy Audit.

OBJECTIVES: To analyse and compare data from the British Association of Urological Surgeons Nephrectomy Audit for perioperative outcomes of partial (PN) and radical nephrectomy (RN) for T1 renal tumours. PATIENTS AND METHODS: UK consultants were invited to submit data on all patients undergoing nephrectomy between 1 January and 31 December 2012 to a nationally established database using a standard pro forma. Analysis was made on patient demographics, operative technique, and perioperative data/outcome between PN and RN for T1 tumours. RESULTS: Overall, data from 6 042 nephrectomies were reported of which 1 768 were performed for T1 renal tumours. Of these, 1 082 (61.2%) were RNs and 686 (38.8%) were PNs. The mean age of patients undergoing PN was lower (PN 59 years vs RN 64 years; P < 0.001) and so was the WHO performance score (PN 0.4 vs RN 0.7; P < 0.001). PN for the treatment of T1a tumours (≤4 cm) accounted for 55.6% of procedures, of which 43.9% were performed using a minimally invasive technique. For T1b tumours (4-7 cm), 18.9% of patients underwent PN, in 33.3% of which a minimally invasive technique was adopted. The vast majority of RNs for T1 tumours were performed using a minimally invasive technique (90.3%). Of the laparoscopic PNs, 30.5% were robot-assisted. There was no significant difference in overall intraoperative complications between the RN and PN groups (4% vs 4.3%; P = 0.79). However, PN accounted for a higher overall postoperative complications rate (RN 11.3% vs PN 17.6%; P < 0.001). RN was associated with a markedly reduced risk of severe surgical complications (Clavien Dindo classification grade ≥3) compared with PN even after adjusting for technique (odds ratio 0.30; P = 0.002). Operation time between RN and PN was comparable (141 vs 145 min; P = 0.25). Blood loss was less in the RN group (mean for RN 165 vs PN 323 mL; P < 0.001); however, transfusion rates were similar (3.2% vs 2.6%; P = 0.47). RN was associated with a shorter length of stay (median 4 vs 5 days; P < 0.001). A direct comparison between robot-assisted and laparoscopic PN showed no significant differences in operation time, blood loss, warm ischaemia time, and intraoperative and postoperative complications. CONCLUSIONS: PN was the method of choice for treatment of T1a tumours whereas RN was preferred for T1b tumours. Minimally invasive techniques have been widely adopted for RN but not for PN. Despite the advances in surgical technique, a substantial risk of postoperative complications remains with PN.

An unrecognised case of metabolic acidosis following neobladder augmentation cystoplasty.

INTRODUCTION: We present a case where there was a delay in the diagnosis of severe metabolic acidosis in a patient with an orthotopic neobladder. There are a growing number of patients with orthotopic neobladders and a wider range of clinicians are encountering these patients. A delay in the diagnosis can lead to significant morbidity but if identified early it can be easily treated. PRESENTATION OF CASE: A 59-year old patient with a recent neobladder augmentation cystoplasty was admitted under the medical team with a metabolic acidosis which was incorrectly presumed to be secondary to urosepsis. His condition rapidly deteriorated until a surgical review identified hyperchloremic metabolic acidosis secondary to neobladder augmentation. The patient required admission to the intensive care unit where he was treated with intravenous alkalising therapy which produced rapid metabolic improvement. Following a full recovery, he underwent neo-bladder excision and ileal conduit formation. DISCUSSION: Hyperchloraemic metabolic acidosis develops due to the bowel segment absorbing urinary constituents including ammonium, hydrogen ions and chloride in exchange for sodium and bicarbonate. It can be diagnosed by careful interpretation of the arterial blood gas and calculation of the anion gap. This hyperchloraemic metabolic acidosis can be corrected with alkalizing agents combined with catheterisation. CONCLUSION: Hyperchloremic metabolic acidosis is a well-established complication of urinary diversion. Patient with orthotopic neobladder with high residual urine and large capacity are at even higher risk of metabolic acidosis. This information should be clearly documented in the post-operative discharge documentation to ensure early recognition by non-specialists.

Prostate cancer with metastases to the kidney: a rare manifestation of a common disease.

A 66-year-old Caucasian man with a background of prostate cancer presented with a progressive history of nausea, reduced appetite, shortness of breath and a distended abdomen. Radiological imaging revealed a left-sided renal mass and gross ascites suggestive of metastatic renal cell carcinoma (RCC). Subsequent histological examination and immunostaining of renal mass biopsy revealed features characteristic of metastatic moderately differentiated to a focally poorly differentiated, large duct type of prostatic adenocarcinoma.

The story of the condom.

Condoms have been a subject of curiosity throughout history. The idea of safer sex has been explored in ancient and modern history, and has been used to prevent venereal diseases. We conducted a historical and medical review of condoms using primary and secondary sources as well as using the RSM library and the internet. These resources show that the first use of a condom was that of King Minos of Crete. Pasiphae, his wife, employed a goat's bladder in the vagina so that King Minos would not be able to harm her as his semen was said to contain "scorpions and serpents" that killed his mistresses. To Egyptians, condom-like glans caps were dyed in different colours to distinguish between different classes of people and to protect themselves against bilharzia. The Ancient Romans used the bladders of animals to protect the woman; they were worn not to prevent pregnancy but to prevent contraction of venereal diseases. Charles Goodyear, the inventor, utilized vulcanization, the process of transforming rubber into malleable structures, to produce latex condoms. The greater use of condoms all over the world in the 20(th) and 21(st) centuries has been related to HIV. This account of the use of condoms demonstrates how a primitive idea turned into an object that is used globally with a forecast estimated at 18 billion condoms to be used in 2015 alone.