Rationalising the use of investigation for urinary tract infections: Analysis of 700 patients and proposal for a diagnostic algorithm.

AIMS: To evaluate the diagnostic yield of investigations performed on patients with a history of urinary tract infections (UTI). METHODS: A retrospective review was conducted on patients who underwent cystoscopy and imaging for a history of UTI between 2014 and 2019 in a single UK teaching hospital. Data were collected on demographics, cystoscopy and radiological findings requiring further management. The cohort was stratified by age, gender and a confirmed history of recurrent UTI (rUTI). The subsequent algorithm was re-tested in a second cohort to validate its use. RESULTS: Seven hundred patients were included in the primary analysis-427 female and 273 males. Three hundred and thirty-one met the criteria of rUTI. The median age was 64 years (18-97). Imaging abnormalities were equally frequent in men 6.3% (15/241) and women 8% (30/380) and the majority noted in patients aged ≥55 years, 30/45 (66.7%). Amongst those who did not meet the definition of rUTI, abnormal imaging was identified in 5%-7% regardless of age group and gender. Cystoscopy abnormalities (n = 24) were twice more likely in males, 5.5%(15/273) than females, 2%(9/427). About 88%(21/24) were identified in patients ≥55 years. There were no positive findings in women <55 years. Applying baseline imaging but confining cystoscopy to those aged ≥55 years and men with a confirmed history of rUTI would have saved 44% of procedures, missed no abnormalities with an overall diagnosis detection rate of 9.8% (69/700). This algorithm was validated in a separate cohort of 63 patients; applying it would have saved 46% (29/63) of cystoscopies with a positive diagnostic rate of 9.5% and no missed findings. CONCLUSION: To our knowledge this is one of the largest studies reporting the outcomes of investigations for UTI and rUTI. Our result suggests that imaging is a useful baseline assessment, but cystoscopy should be limited to specific subgroups. We propose and validate a simple decision algorithm to manage investigations for referrals for UTI in secondary care.

The Modified Prone Jack-knife Position for the Excision of Female Urethral Diverticula.

BACKGROUND: Female urethral diverticula (UD) are an uncommon and often overlooked aetiology in women presenting with lower urinary tract symptoms, urethral pain, and recurrent urinary tract infection. With increasing awareness, appropriate imaging is more commonly undertaken with consideration given to surgical management. OBJECTIVE: The video presented demonstrates the technique for excising large and/or complex UD using a modified prone jack-knife position-a position that offers excellent surgical access and allows the surgeon to operate in a more ergonomic position. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of the data on patients undergoing excision of UD at a tertiary referral unit was performed. SURGICAL PROCEDURE: Urethral and suprapubic catheters (±insertion of ureteric stents) were placed in supine position. UD excised in the modified prone jack-knife position (±placement of a Martius flap). MEASUREMENTS: Subjective cure rate, recurrence rate, rates of postoperative urinary incontinence, need for secondary incontinence procedure, and postoperative complications were measured. RESULTS AND LIMITATIONS: A total of 121 patients were operated on in the study period. The mean follow-up time was 10 mo (range 3-40). The most frequent presenting symptoms included a vaginal mass (n = 76, 63%), followed by dysuria (n = 72, 60%) and pelvic pain (n = 71, 59%). An identifiable aetiological factor was present in 45 patients, including traumatic vaginal delivery (18, 15%), prior periurethral surgery (17, 14%), and urethral dilatation (10, 8%). All patients underwent postvoiding magnetic resonance imaging (MRI) to confirm the diagnosis and plan surgery. UD ranged in maximum diameter from 8 to 48 mm, with a mean of 43 mm (standard deviation 9.24). The most common anatomical location was midurethral (55, 46%), followed by distal (36, 30%), proximal (25, 21%), and full length (5, 4%). Most UDs were single in configuration (74%), followed by multiloculated (15%), saddle shaped (7%), and circumferential (5%). On preoperative videourodynamics, 17 (14%) had stress urinary incontinence. UD excision was undertaken in the modified prone jack-knife position in all cases. A Martius flap was utilised in 36 (30%). The median postoperative postvoiding residual was 26 ml (interquartile range 0-40). In total, 88 (73%) patients were continent postoperatively and 16 (13%) experienced de novo stress urinary incontinence. Of the 37 with pre-existing stress incontinence symptoms, 20 (54%) were continent after operation. A total of 14 patients had subsequent autologous fascial sling at 6 mo. In total, five symptomatic recurrences occurred (4%); of these patients, three elected to undergo surgical excision, all of whom had symptom resolution and were continent after operation. A total of 11 patients (9%) experienced a Clavien-Dindo grade I-II complication within 90 d after operation. Five patients complained of dyspareunia, which resolved by 6 mo. CONCLUSIONS: The modified prone jack-knife position facilitates excellent access for excision of both simple and complex UDs. This positioning of the patient is not widely recognised amongst urologists. Using this approach, there were low rates of symptomatic recurrence and de novo stress incontinence at medium-term follow-up. Associated urinary incontinence resolves in over half of patients following UD excision; hence, we advocate deferring any incontinence procedure until after the results of surgery are established. PATIENT SUMMARY: Surgical removal of urethral outpouching (diverticula) in women is challenging due to its potential to damage the nearby sphincter muscle, which controls continence, or the urethra tube. Placement of patients on their front, rather than on their back, provides excellent access for the surgical removal of urethral diverticula. With this approach, we achieved excellent rates of cure and low rates of urinary incontinence at an average follow-up of 10 mo.

Use of a Simulated Model to Teach Male Adult Circumcision in Sub-Saharan Africa.

Male adult circumcision (MC) has been shown to reduce the risk of HIV transmission in men by 50-60 %. An upscaling in the training of providers to perform circumcision is necessary to meet demand since MC is a key component of essential surgery in the context of universal health coverage. We piloted a low-cost, high-fidelity model for training adult circumcision. Multi-centre, multinational data were collected on 74 trainees and clinicians (trainers) in sub-Saharan Africa. Both trainers and trainees gave excellent feedback for the model (content and face validity). The simulated model enables a safe and realistic simulation experience to perform MC. The model is quick to set up and easily transportable to multiple teaching sites.

Management of symptomatic urethral diverticula in women: a single-centre experience.

BACKGROUND: Urethral diverticula (UDs) affect between 1% and 6% of adult women. A total of 1.4% of women with stress urinary incontinence (SUI) have a UD. Clinically significant diverticula are rare and can be challenging to manage. OBJECTIVE: To review results of surgery on UDs in a single surgical centre. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively evaluated a group of 89 patients with symptomatic UDs referred for surgical intervention to one teaching hospital. Data were from two surgeons over an 8-yr period between October 2004 and November 2012. Follow-up period ranged from 3 mo to 20 mo, and all patients were physically reviewed postoperatively in an outpatient setting. INTERVENTION: The surgical technique involved placing the patient prone, ureteric catheterisation, dissection and removal of the diverticulum, and layered closure. Where a large defect was present following excision, a Martius flap was interposed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Outcome data collected included symptomatic cure, continence, de novo SUI, early versus late complications, and recurrence. RESULTS AND LIMITATIONS: Early complications included one urinary tract infection and one Martius graft infection, both requiring intravenous antibiotics. Overall, 72% of patients were dry and cured postoperatively; 13 patients had de novo SUI following surgery. Those with bothersome SUI went on to have an autologous sling at 6 mo. All were dry; three (23%) required clean intermittent self-catheterisation. Three patients had a recurrent residual diverticulum (3.4%) following surgery. One chose conservative management. The other two had a redo diverticulectomy performed via a dorsal approach. They have recovered well and are dry. Two (2.2%) diverticula revealed unexpected abnormal pathology. The first was a leiomyoma; the second was a squamous cell carcinoma requiring further surgery. CONCLUSIONS: The recommended preoperative imaging is postvoid sagittal magnetic resonance imaging and appropriate use of urodynamic assessment at baseline. The 72% dry rate (including a number with preoperative incontinence) is comparable with the literature as is the development of de novo SUI in 15% of patients. There is a small risk of unexpected tumours (2%). PATIENT SUMMARY: A urethral diverticulum should be excluded as a diagnosis in anyone troubled by symptoms of a swelling of the urethra often associated with discomfort, pain on intercourse, urinary dribbling after passing urine, and/or recurrent urinary infections. In these circumstances patients should seek advice from their doctors and consider referral for a specialist assessment. If the diagnosis is made and the problem is symptomatic, surgery is likely to resolve the problem but should be carried out in a specialist centre with expertise in the management of this condition.

Diagnostic value of written referral and/or images for skin lesions.

We examined whether it is possible for a dermatologist to diagnose benign and malignant skin lesions by telemedicine, given a comprehensive history and/or clinical images. A medical student recorded a standardized history and description of 109 skin lesions and took digital photographs of the presenting lesion(s) immediately prior to a normal outpatient dermatology consultation. About 52 dermatologists were invited to participate in online diagnosis. In all, 38 took part and they were provided with the text and/or the image(s) online on a secure Website. When the images and text were provided, 53% of teledermatology diagnoses were the same as the face-to-face diagnosis. When images alone were provided, 57% of diagnoses were the same. When text alone was provided, 41% of diagnoses were the same. The relatively low diagnostic concordance may have been due to the inexperience of many teledermatologists and poor quality image display systems. The teledermatologists were less confident in their diagnoses than face-to-face specialists, especially in the absence of images. The teledermatology management plan was more likely to include biopsy, excision or review than was the case at the face-to-face consultation. Teledermatology may result in an increase in follow-up appointments and surgical procedures.