A Prospective Multi-institutional Study Using a Novel Safety Valve for the Prevention of Catheter Balloon Inflation Injury of the Urethra.

PURPOSE: We prospectively assessed the ability of a novel transurethral catheterization safety valve to prevent urethral catheter balloon injury in a multi-institutional clinical setting. MATERIALS AND METHODS: A prospective, multi-institution study was conducted. The safety valve was introduced for urinary catheterization in 6 hospital groups (4 in Ireland; 2 in the UK). The safety valve allows fluid in the catheter system to vent through a pressure relief valve if attempted intraurethral inflation of the catheter's anchoring balloon occurs. Device usage was studied over a 12-month period, with data recorded using a 7-item data sticker containing a scannable QR code. "Venting" through the safety valve during catheterization was indicative of prevention of a urethral injury. An embedded 3-month study was conducted in 3 centers, with any catheter balloon injuries occurring during catheterization without safety valve use referred to the on-call urology team recorded. Health economic analyses were also performed. RESULTS: During the overall 12-month device study phase, 994 urethral catheterizations were performed across study sites. Twenty-two (2.2%) episodes of safety valve venting were recorded. No urethral injuries occurred in these patients. In the embedded 3-month study, 18 catheter balloon injuries were recorded in association with catheterizations performed without the safety valve. Based on confirmed and device-prevented urethral injuries, the injury rate for urethral catheterization without safety valve use was calculated to be 5.5/1,000 catheterizations. CONCLUSIONS: The safety valve has the potential to eliminate catheter balloon injury if widely adopted. It represents a simple, effective, and innovative solution to this recurring problem applicable to all patient cohorts.

A Prospective Multi-Institutional Evaluation of Iatrogenic Urethral Catheterization Injuries.

OBJECTIVES: To perform a multi-institutional investigation of incidence and outcomes of urethral trauma sustained during attempted catheterization. PATIENTS & METHODS: A prospective, multi-center study was conducted over a designated 3-4 month period, incorporating seven academic hospitals across the UK and Ireland. Cases of urethral trauma arising from attempted catheterization were recorded. Variables included sites of injury, management strategies and short-term clinical outcomes. The catheterization injury rate was calculated based on the estimated total number of catheterizations occurring in each center per month. Anonymised data were collated, evaluated and described. RESULTS: Sixty-six urethral catheterization injuries were identified (7 centers; mean 3.43 months). The mean injury rate was 6.2 ± 3.8 per 1000 catheterizations (3.18-14.42/1000). All injured patients were male, mean age 76.1 ± 13.1 years. Urethral catheterization injuries occurred in multiple hospital/community settings, most commonly Emergency Departments (36%) and medical/surgical wards (30%). Urological intervention was required in 94.7% (54/57), with suprapubic catheterization required in 12.3% (n = 7). More than half of patients (55.56%) were discharged with an urethral catheter, fully or partially attributable to the urethral catheter injury. At least one further healthcare encounter on account of the injury was required for 90% of patients post-discharge. CONCLUSIONS: This is the largest study of its kind and confirms that iatrogenic urethral trauma is a recurring medical error seen universally across institutions, healthcare systems and countries. In addition, urethral catheter injury results in significant patient morbidity with a substantial financial burden to healthcare services. Future innovation to improve the safety of urinary catheterization is warranted.

Diagnostic Tests for Female Bladder Outlet Obstruction: A Systematic Review from the European Association of Urology Non-neurogenic Female LUTS Guidelines Panel.

CONTEXT: Female bladder outlet obstruction (fBOO) is a relatively uncommon condition compared with its male counterpart. Several criteria have been proposed to define fBOO, but the comparative diagnostic accuracy of these remains uncertain. OBJECTIVE: To identify and compare different tests to diagnose fBOO through a systematic review process. EVIDENCE ACQUISITION: A systematic review of the literature was performed according to the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The EMBASE/MEDLINE/Cochrane databases were searched up to August 4, 2020. Studies on women ≥18 yr of age with suspected bladder outlet obstruction (BOO) involving diagnostic tests were included. Pressure-flow studies or fluoroscopy was used as the reference standard where possible. Two reviewers independently screened all articles, searched reference lists of retrieved articles, and performed data extraction. The risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). EVIDENCE SYNTHESIS: Overall, 28 nonrandomised studies involving 10 248 patients were included in the qualitative analysis. There was significant heterogeneity regarding the characteristics of women included in BOO cohorts (ie, mixed cohorts including both anatomical and functional BOO). Pressure-flow studies ± fluoroscopy was evaluated in 25 studies. Transperineal Doppler ultrasound was used to evaluate bladder neck dynamics in two studies. One study tested the efficacy of transvaginal ultrasound. The urodynamic definition of fBOO also varied amongst studies with different parameters and thresholds used, which precluded a meta-analysis. Three studies derived nomograms using the maximum flow rate (Qmax) and voiding detrusor pressure at Qmax. The sensitivity, specificity, and overall accuracy ranges were 54.6-92.5%, 64.6-93.9%, and 64.1-92.2%, respectively. CONCLUSIONS: The available evidence on diagnostic tests for fBOO is limited and heterogeneous. Pressure-flow studies ± fluoroscopy remains the current standard for diagnosing fBOO. PATIENT SUMMARY: Evidence on tests used to diagnose female bladder outlet obstruction was reviewed. The most common test used was pressure-flow studies ± fluoroscopy, which remains the current standard for diagnosing bladder outlet obstruction in women. TAKE HOME MESSAGE: The available evidence on diagnostic tests for female bladder outlet obstruction is limited and heterogeneous. The most common test used was video-urodynamics, which remains the current standard for diagnosing bladder outlet obstruction in women.

Appendix or Ileum-Which is the Best Material for Mitrofanoff Channel Formation in Adults?

PURPOSE: We report long-term data on a large cohort of adults who underwent formation of a continent catheterizable channel for various indications. We examined outcomes according to the tissue used for channel formation. MATERIALS AND METHODS: We retrospectively reviewed the case notes of 176 consecutive adult patients in whom a continent catheterizable channel was created using the Mitrofanoff principle for a broad range of indications a median of 142 months (range 54 to 386) previously. We evaluated outcomes in terms of continued use and continence for each type of material used for channel formation. RESULTS: At the time of this review 165 of the 173 patients (95.4%) included in this study were alive. We included 114 women (65.9%) and 59 men (34.1%) who underwent surgery at a median age of 42 years (range 18 to 73) with a mean followup of 78.6 months (median 60, range 2 to 365). The rate of revision for all causes was higher in the ileal group than in the group with an appendiceal channel (channel stenosis rate 22.7% vs 17.2%, p = 0.39, and channel incontinence rate 36.0% vs 19.5%, p = 0.03). Although 38.7% of patients underwent major surgical revision of the channel at some point, 75.9% of channels continued to be used, of which 90.2% were continent. CONCLUSIONS: This study provides a pragmatic overview of the outcome of these challenging cases. Mitrofanoff channel formation represents a durable technique. Appendix and ileum are each a viable choice for tissue use. Tissue selection depends on availability and individual patient factors.

Newsworthiness vs scientific impact: are the most highly cited urology papers the most widely disseminated in the media?

OBJECTIVE: To assess whether a correlation exists between newsworthiness (Altmetric score) and scientific impact markers, such as citation analysis, impact factors, and levels of evidence. METHODS: The top five most cited articles for the year 2014 and 2015 from the top 10 ranking urology journals (Scientific Impact Group) were identified. The top 50 articles each in 2014 and 2015 were identified from Altmetric support based on media activity (Media Impact Group). We determined the number of citations that these articles received in the scientific literature, and calculated correlations between citations with Altmetric scores. RESULTS: In the Scientific Impact Group, the mean number of citations per article was 37.6, and the most highly cited articles were oncology guidelines. The mean Altmetric score in these articles was 14.8. There was a weak positive correlation between citations and Altmetric score (rs = 0.35, 95% confidence interval 0.16-0.52, P < 0.001). In the Media Impact Group, the mean Altmetric score was 121.1 and most widely shared articles all related to sexual medicine. In this group, the mean number of citations was 9.7 and there was a weak negative correlation between Altmetric score and citations (rs = -0.20, P = 0.046). CONCLUSION: The top articles based on Altmetric scores were not highly cited, suggesting that publications receiving the most media attention may not be the most scientifically rigorous, or that this audience places greater value on different subjects than the scientific community.

Urological Management of Extramural Malignant Ureteric Obstruction: A Survey of Irish Urologists.

INTRODUCTION: The absence of guidelines in the management of extramural malignant ureteric obstruction leads to confusion in decision making and in the interaction between urology and other clinical disciplines. In this study, we surveyed consultant urologists with the goal of achieving a better consensus on optimal management options. METHODS: A multiple choice survey was sent via the online survey tool "SurveyMonkey" to all consultant urologists practicing in the Republic of Ireland. RESULTS: There was a response rate of 57.5% (n = 23). Twenty-two (96%) consultants consider the use of percutaneous nephrostomy with placement of antegrade ureteric stent but only 22% (n = 5) would consider using a metallic stent. Eleven (48%) respondents favor retrograde stenting in the first instance with an equal proportion choosing an antegrade method. Nine (39%) consultants perform the initial stent change at 4-6 months, 8 (35%) at 2-4 months, and 1 at < 2 months and 6-10 months respectively. Total 59% (n = 13) of respondents felt that the duration of expected patient survival influenced their decision and agreement to stent with 42% (n = 8) saying this survival would need to be > 6 months and 82% (n = 18) were generally happy with the level of ongoing communication between urology and the primary service managing the patient. CONCLUSION: There is a lack of consensus regarding the management of this challenging problem, particularly with regard to timing of first stent change and whether to initially use an antegrade or retrograde approach. This reflects the heterogeneous patient cohort and the important factors of life expectancy and patient co-morbidities.

The impact of day of surgery on the length of stay for major urological procedures.

INTRODUCTION: Surgery performed later in the week has been associated with longer length of stay (LOS). The aim of this study was to assess if the day of the surgery impacted the LOS for two major urological procedures in a tertiary referral university teaching hospital. METHODS: A retrospective review was performed of two major urological procedures consecutively performed by a single surgeon in our unit from March 2012 to December 2015. Patient demographics, histopathological characteristics, operative details, and LOS were obtained from the patients' medical records. Procedures performed on Monday or Tuesday were defined as early in the week and procedures performed on Wednesday, Thursday, or Friday were defined as late in the week. RESULTS: During the study period, 140 open radical prostatectomy (ORP) and 42 open partial nephrectomy (OPN) procedures were performed. There was a significant difference in median LOS for major urological procedures performed early in the week compared to late in the week (3 [3-4] days vs. 4 [4-5] days; p= 0.0001). There was a significant difference in median LOS for ORP performed early in the week compared to late in the week (3 [3-4] days vs. 4 [4-5] days; p= 0.0004). There was a similar significant difference in OPN performed early in the week compared to late in the week (4 [3-5.5] days vs. 5 [4-5] days; p= 0.029). CONCLUSIONS: The day of surgery impacts LOS for major urological procedures. Major procedures should be performed early in the week, when it is feasible to facilitate prompt safe discharge and better use of hospital resources.

Cost benefit analysis of the use of tranexamic acid in primary lower limb arthroplasty: A retrospective cohort study.

AIM: To examine the cost benefit conferred by the perioperative administration of intravenous tranexamic acid (TXA) in lower limb arthroplasty. METHODS: This study evaluates the use of TXA in 200 consecutive lower limb arthroplasties performed in a single surgeon series. The initial 100 patients (control group) underwent surgery without perioperative administration of TXA while the subsequent 100 patients (TXA group) all received 1 g TXA at the time of induction of anaesthesia. Pre- and post-operative haemoglobin, platelet count, haematocrit, the use of blood product post-operatively, length of stay were examined. A financial analysis of both groups was then undertaken. RESULTS: The mean age of patients in both groups was 63 ± 13 years. There were no significant differences between groups in terms of gender (P = 0.47), proportion of total hip replacement to total knee replacement (P = 0.25) or pre-operative haemoglobin (P = 0.43). In the control group, the transfusion rate was 22%. In the TXA group, the transfusion rate dropped to 2% (P < 0.001). The mean post-operative haemoglobin was 10.82 ± 1.55 g/dL in the control group vs 11.33 ± 1.27 g/dL in the TXA group (P = 0.01). The total cost of transfused blood products was €11055 and €603 respectively. The mean length of stay in the control group was 6.53 ± 5.93 d vs 5.47 ± 4.26 d in the TXA group (P = 0.15) leading to an estimated financial saving of €114586. There was one pulmonary embolus in the control group and one deep venous thrombosis in the TXA group. CONCLUSION: Intravenous TXA reduces blood loss in lower limb arthroplasty. This leads to lower transfusion rates, shorter length of stay in hospital and significant financial savings.