UK national bladder outlet obstruction surgery snapshot audit.

OBJECTIVES: To determine the preoperative assessment and perioperative outcomes of men undergoing bladder outlet obstruction (BOO) surgery in the UK. PATIENTS AND METHODS: A retrospective cohort study was conducted of all men undergoing BOO surgery in 105 UK hospitals over a 1-month period. The study included 1456 men, of whom 42% were catheter dependent prior to undergoing surgery. RESULTS: There was no evidence that a frequency-volume chart or urinary symptom questionnaire had been completed in 73% or 50% of men, respectively in the non-catheter-dependent group. Bipolar transurethral resection of the prostate (TURP) was the most common BOO surgical procedure performed (38%). Monopolar TURP was the next most prevalent modality (23%); however, minimally invasive BOO surgical procedures combined accounted for 17% of all procedures performed. Of the cohort 5% of men had complications within 30 days of surgery, only 1% had Clavien-Dindo Grade ≥III complications. Less than 1% of the cohort received a blood transfusion after BOO surgery and 2% were re-admitted to hospital after their BOO surgery. In total only 4% of the whole cohort were catheter dependent after BOO surgery. Pre- and postoperative paired International Prostate Symptom Score scores reviewed suggest that minimally invasive surgical procedures achieved comparable levels of improvement in both symptoms and bother at 3 months postoperatively in men who were not catheter dependent preoperatively. CONCLUSIONS: There has been a substantial shift in the available choice of procedure for BOO surgery around the UK in recent years. However, men can be reassured that overall BOO surgery treatments are safe and effective. Evidence of adherence to guidelines in the preoperative assessment of men with lower urinary tract symptoms undergoing surgery was poorly documented and must be improved.

Intravesical onabotulinumtoxinA injections in patients on antiplatelet and anticoagulation therapy.

AIMS: To determine the bleeding risk in patients taking anticoagulants (AC) and antiplatelets (AP) before onabotulinumtoxinA (BoNT-A) injections and improve peri-operative decision making and counseling. METHODS: We performed a retrospective review of patients having intravesical BoNT-A in three teaching hospitals from January 2016 to July 2018. Demographic data, indication for intravesical BoNT-A injection, and side-effects of significant bleeding requiring intervention were recorded. RESULTS: Five hundred and thirty-two patients had intravesical BoNT-A injections during this time. Sixty-three patients of mean age 69 years (range 19-89) had a total of 114 separate rounds of BoNT-A injections whilst on treatment dose AC/AP therapy. Of the 63, there were 33 males, with 46 having idiopatic detrusor overactivity and 17 with neurogenic detrusor overactivity. Each patient had between 1 and 7 repeat injections during the studied period. AC/AP use across the 114 episodes included; aspirin 44, clopidogrel 37, warfarin 19, and NOAC (novel/non-vitamin K oral anticoagulant) 14. Patients on warfarin who had point of care testing all had international normalized ratio less than 3. BoNT-A dose varied from 100U to 300U-modal dosage was 200U.1/114(0.88%) injection episodes resulted in postinjection hematuria requiring overnight admission. This resolved spontaneously, with an overnight catheter. This patient was on rivaroxaban and had 300U of BoNT-A injected through 20 sites, on a background of previous prostate radiotherapy and self-catheterization. CONCLUSIONS: Continuation of AP/AC therapy during intravesical BoNT-A injection treatment appears to be safe-with a 0.88% rate of spontaneously resolving hematuria.

The use of urethral bulking injections in post-prostatectomy stress urinary incontinence: A narrative review of the literature.

AIMS: Post-prostatectomy stress urinary incontinence (PPI) is a common condition with significant impact on patient quality of life. With rising numbers of prostatectomies performed, recognition of incontinence during survivorship care is growing. With increasing hesitance of the use of suburethral mesh in females, urethral bulking injections in this patient population as a minimally invasive alternative to surgery are evaluated. This review aims to evaluate the existing evidence base for urethral bulking therapy in PPI and provide a summary of its efficacy, durability, and side-effect profile. METHODS: A literature search of Medline/Pubmed and Cochrane databases was conducted to identify publications reporting the clinical outcomes of urethral bulking injections in patients with PPI, up to and including October 1st, 2018. Case reports, letters and reviews were excluded. RESULTS: We identified 25 studies that fit our inclusion criteria, comprised of one RCT, two large retrospective cohort studies, and 22 case series. The success rates reported varying widely from 13%-100% with reports of symptomatic control deterioration. Complication rates remain low. This review highlighted a poor performance using the more historic bulking agents (BA), and the lack of strong evidence with the more novel BA in PPI and discussed challenges regarding optimal patient selection and techniques. CONCLUSIONS: There exists poor clinical evidence base concerning the use of urethral bulking in PPI with few high-level studies and a significant lack of consistency between studies. Further study in this area is required to evaluate the role of BA in this patient population.

Clinical and Patient-reported Outcome Measures in Men Referred for Consideration of Surgery to Treat Lower Urinary Tract Symptoms: Baseline Results and Diagnostic Findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM).

BACKGROUND: Clinical evaluation of male lower urinary tract symptoms (MLUTS) in secondary care uses a range of assessments. It is unknown how MLUTS evaluation influences outcome of therapy recommendations and choice, notably urodynamics (UDS; filling cystometry and pressure flow studies). OBJECTIVE: To report participants' sociodemographic and clinical characteristics, and initial diagnostic findings of the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM). UPSTREAM is a randomised controlled trial evaluating whether symptoms are noninferior and surgery rates are lower if UDS is included. DESIGN, SETTING, AND PARTICIPANTS: A total of 820 men (≥18 yr of age) seeking treatment for bothersome LUTS were recruited from 26 National Health Service hospital urology departments. INTERVENTION: Care pathway based on routine, noninvasive tests (control) or routine care plus UDS (intervention arm). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome is International Prostate Symptom Score (IPSS) and the key secondary outcome is surgery rates 18 mo after randomisation. International Consultation on Incontinence Questionnaires were captured for MLUTS, sexual function, and UDS satisfaction. Baseline clinical and patient-reported outcome measures (PROMs), and UDS findings were informally compared between arms. Trends across age groups for urinary and sexual PROMs were evaluated with a Cuzick's test, and questionnaire items were compared using Pearson's correlation coefficient. RESULTS AND LIMITATIONS: Storage LUTS, notably nocturia, and impaired sexual function are prominent in men being assessed for surgery. Sociodemographic and clinical evaluations were similar between arms. Overall mean IPSS and quality of life scores were 18.94 and 4.13, respectively. Trends were found across age groups, with older men suffering from higher rates of incontinence, nocturia, and erectile dysfunction, and younger men suffering from increased daytime frequency and voiding symptoms. Men undergoing UDS testing expressed high satisfaction with the procedure. CONCLUSIONS: Men being considered for surgery have additional clinical features that may affect treatment decision making and outcomes, notably storage LUTS and impaired sexual function. PATIENT SUMMARY: We describe initial assessment findings from a large clinical study of the treatment pathway for men suffering with bothersome urinary symptoms who were referred to hospital for further treatment, potentially including surgery. We report the patient characteristics and diagnostic test results, including symptom questionnaires, bladder diaries, flow rate tests, and urodynamics.

Penile lesion in end-stage renal failure - cancer or otherwise?: Calcific uremic arteriolopathy presenting with a penile lesion.

Calcific uremic arteriolopathy or calciphylaxis is a rare condition that can present with clinical features similar to penile cancer. It is a diagnosis to consider in patients with end-stage renal failure (ESRF) presenting with a penile lesion. We describe one such case, where a patient with ESRF presented with a solid, tender penile mass and underwent surgery for presumed penile cancer. Histopathological analysis however confirmed a diagnosis of calcific uremic arteriolopathy, without evidence of malignancy. The clinical diagnosis of calcific uremic arteriolopathy relies on a high index of suspicion, and lesion biopsy is controversial due to a high risk of poor wound healing and sepsis. New treatment options are encouraging, and have been reported, albeit in small numbers. Delayed diagnosis can adversely affect both quality of life and prognosis in a condition with an extremely high mortality rate.

The economic benefit of photodynamic diagnosis in non-muscle invasive bladder cancer.

Non-muscle invasive bladder cancer is the most expensive cancer to manage on a per patient basis due to the high recurrence rate, low mortality and the need for long term, often lifelong surveillance. Current white-light endoscopic surgery leads to a significant number of patients having "recurrent" cancer at their first follow-up cystoscopy. The introduction of a single dose of intravesical chemotherapy immediately after the initial resection has helped to reduce the recurrence rate but it can be toxic and should not be administered to patients with potential bladder perforations after transurethral resection of bladder tumour (TURBT). Photodynamic diagnosis cystoscopy has been shown to significantly improve the quality of the initial TURBT leading to a 20% reduction in tumour recurrences at 3 months. This benefit is sustained for at least 8 years, leading to a reduction in further invasive procedures and treatment. Despite the initial increased cost related to introducing a photodynamic diagnosis service there is clearly long-term significant cost savings to be made, as well as improving the patient experience and quality of life.

Plexin-B1 mutations in prostate cancer.

Semaphorins are a large class of secreted or membrane-associated proteins that act as chemotactic cues for cell movement via their transmembrane receptors, plexins. We hypothesized that the function of the semaphorin signaling pathway in the control of cell migration could be harnessed by cancer cells during invasion and metastasis. We now report 13 somatic missense mutations in the cytoplasmic domain of the Plexin-B1 gene. Mutations were found in 89% (8 of 9) of prostate cancer bone metastases, in 41% (7 of 17) of lymph node metastases, and in 46% (41 of 89) of primary cancers. Forty percent of prostate cancers contained the same mutation. Overexpression of the Plexin-B1 protein was found in the majority of primary tumors. The mutations hinder Rac and R-Ras binding and R-RasGAP activity, resulting in an increase in cell motility, invasion, adhesion, and lamellipodia extension. These results identify a key role for Plexin-B1 and the semaphorin signaling pathway it mediates in prostate cancer.

Secondary hypospadias repair in two stages.

INTRODUCTION: Following failed primary reconstruction, various single-stage reconstructive techniques have been proposed for secondary hypospadias repair. Unfortunately, these frequently fail to achieve a satisfactory cosmetic and functional outcome. We review a single surgeon's experience of two-staged reconstruction in this scenario. PATIENTS AND METHODS: Of 104 patients with hypospadias treated in two stages, between July 1998 and June 2003, 42 were secondary reconstructions. The site of the meatus after initial failed repair was glanular (5), subcoronal (11), distal shaft (12), mid-shaft (6) or peno-scrotal (8). Factors associated with the choice of two-stage reconstruction included moderate/severe chordee (14), excessive scarring (15), shallow/no groove or poor glans (8), and balanitis xerotica obliterans (4). The grafts used were post-auricular skin (PAWG, 29) buccal mucosa (BMG, 6), inner prepuce (IP, 6) and one composite graft. The mean age of our patients was 131 months and the average follow up after the second stage was 26.3 months. RESULTS: In 40 of the 42 cases the graft took well. In one patient a PAWG developed keloid scarring which was excised and later successfully replaced with a BMG. In another, severe shrinkage of a BMG led to revision with a PAWG. Following the second stage, complications were experienced in five: the repair broke down in two BMG patients and was successfully reconstructed with a PAWG in both, and three developed fistulae that were repaired (1 PAWG, 1 BMG, 1 IP). CONCLUSIONS: The two-staged reconstruction is a versatile and technically straightforward secondary procedure for this difficult patient cohort. Excellent cosmetic and functional results can be achieved with only a small risk of a revision operation. Four of our six BMG patients experienced problems and PAWG appears more satisfactory with superior results.