Long-term outcomes of en-bloc renal transplantation from paediatric donors into adult recipients.

INTRODUCTION: Transplant units are exploring strategies to increase the availability of donor kidneys. The use of en-bloc kidney transplantation (EBKT) from paediatric donors represents one potential solution. We present our long-term experience with paediatric EBKT among adult recipients. METHODS: Twenty-three paediatric to adult EBKTs were performed by the Irish National Kidney Transplant Service between 1990 and 2016. The primary outcome variable was long-term en-bloc allograft survival rate. Secondary outcome variables were incidence of allograft thrombosis, incidence of delayed graft function, overall patient survival and serum creatinine at most recent follow-up. Outcomes were compared to single kidney transplant recipients from the same time period. RESULTS: Mean donor age was 1.8 ± 0.97 years (range: 7 months to 3 years). Recipient age was 46 ± 12 years. Mean follow-up was 133 ± 64 months (range: 36-264). Overall graft survival was 100%, 91% and 80% after 1, 5 and 10 years respectively, compared to 92%, 79% and 61% in single kidney transplant recipients (p = 0.04). There were 5 cases of allograft failure, 3 due to death from unrelated causes. Median time to graft failure was 108 months (range: 36-172). Mean serum creatinine was 72.6 ± 21.6 µmol/l after the follow-up period. There were no cases of graft thrombosis or delayed graft function. Overall survival was 96.4%, 88.0%, 76.23% and 50.5% at 1, 5, 10 and 20 years respectively. CONCLUSION: En-bloc paediatric kidney transplantation is associated with excellent long-term allograft and patient survival and is a feasible strategy for increasing the transplant donor pool in carefully selected recipients.

The effect of Rapid Access Prostate Clinics on the outcomes of Gleason 7 prostate cancer: does earlier diagnosis lead to better outcomes?

INTRODUCTION: Rapid Access Prostate Clinics (RAPC) were introduced in Ireland by the National Cancer Control Programme bringing about expedited referral pathways and increased detection rates of prostate cancer. Lower Gleason (G) grade at diagnosis due to RAPC has been previously reported but grade at prostatectomy has not been assessed. The aim of this study was to assess the impact of RAPC on the outcomes of patients with G7 disease on radical prostatectomy (RP). METHODS: A retrospective analysis was carried out of all RPs performed over a 9-year period (2006-2014). Outcomes for G7 prostatectomies were compared before and after the introduction of the RAPC, with a further sub-analysis of G4 + 3 versus G3 + 4. The primary outcome was biochemical recurrence (BCR). Other outcomes were adjuvant/salvage radiotherapy, extra prostatic extension, positive surgical margins, seminal vesicle involvement and tumour stage. RESULTS: In total, 240 RPs were performed with 167 cases graded G7 (70 graded G4 + 3 and 97 graded G3 + 4). Since the introduction of RAPC the proportion of G4 + 3 compared to G3 + 4 has increased from 37.9 to 42%. There was no statistical difference in outcomes for G4 + 3 treated before and after the introduction of RAPC. G4 + 3 was associated with higher rates of BCR (24.4 vs. 0%, p < 0.0001, radiotherapy (41.1 vs. 4.8%, p < 0.0001) and worse histological features than G3 + 4. CONCLUSION: Despite the benefits in diagnosis of prostate cancer brought about by RAPC in Ireland, this has not translated to a lower grade for surgically treated patients. There has been no improvement in outcomes especially for higher grade G4 + 3 disease.

Single centre experience of hypothermic machine perfusion of kidneys from extended criteria deceased heart-beating donors: a comparative study.

INTRODUCTION: Kidneys from extended criteria donors are associated with higher rates of delayed graft function (DGF). Hypothermic machine perfusion (MP) for storage is associated with more favourable outcomes. METHODS: A retrospective analysis was performed in 93 patients where the kidney was stored using hypothermic MP (LifePort(®)) and compared to an age-matched control group where the kidney was stored in cold static storage (CSS) using University of Wisconsin solution. RESULTS: Median age was similar in both groups (59.2 years in MP vs 59.9 years in CSS, p = 0.5598). Mean cold storage time was 15.6 h in MP vs 17.9 h in CSS. Post transplant mean serum creatinine was as follows; MP group-144.7 µmol/L at 1 month; 138.3 µmol/L at 3 months and 129.5 µmol/L at 12 months. In the CSS group-163 µmol/L at 1 month; 154.9 µmol/L at 3 months and 140.2 µmol/L at 12 months. There was a statistically significant difference at 1 month (p = 0.0096) and 3 months (p = 0.0236). DGF was defined as the need for haemodialysis within 7 days post transplant. In the MP group, DGF occurred in 17.2 % patients with mean of 6 days (range 1-18). In the CSS group, 25.8 % patients with mean of 8.1 days (range 3-25). One-year graft survival rate was better in the MP group (97.85 vs 96.77 %). CONCLUSION: Our experience to date recommends the use of hypothermic MP for storage of kidneys from extended criteria deceased heart-beating donors.

Stability and accuracy of total and free PSA values in samples stored at room temperature.

INTRODUCTION: In 2010, an estimated 476,076 total PSA tests were performed in Ireland, at a cost of €3.6 million with the majority ordered by general practitioners. We aimed to replicate storage conditions at room temperature and see if prolonged storage affected total and free PSA values. METHODS: Blood samples were taken from 20 male patients in four VACUETTE® Serum Separator tubes (Greiner-Bio-One, Austria) and stored at room temperature (22 °C) for different time intervals (4, 8, 24, 48 h) before being centrifuged and analyzed. Total PSA (tPSA) and free PSA (fPSA) values were determined using the Tosoh AIA 1800 assay (Tokyo, Japan). RESULTS: Mean tPSA values were measured at 4, 8, 24 and 48 h with values of 7.9, 8.1, 7.8 and 8.0 µg/L, respectively. Values ranged from -1.26 to +2.53 % compared to the initial 4 h interval reading, indicating tPSA remained consistent at room temperature. The tPSA showed no significance between groups (ANOVA, p = 0.283). Mean fPSA values at 4, 8, 24 and 48 h were 2.05, 2.04, 1.83, 1.82 µg/L, respectively. At 24 and 48 h there was 10.73 and 11.22 % reduction, respectively, in fPSA compared to the 4-h time interval, indicating prolonged storage resulted in reduced fPSA values. After 24 h, there was an 8.8 % reduction in the free/total PSA %. The fPSA showed significant differences between groups (ANOVA, p = 0.024). CONCLUSIONS: Our recommendation is that samples that have been stored for prolonged amounts of time (greater than 24 h) should not be used for free PSA testing.

Evaluation of Presenting Symptoms and Long-Term Outcomes of Patients Requiring Excision of a Transobturator Tape (TOT).

The transobturator tape (TOT) is an effective treatment for stress urinary incontinence (SUI). Erosion of TOT mesh is a recognised complication requiring excision. A retrospective analysis of 228 females undergoing a TOT procedure over 4 years identified 16 patients (7%) that underwent excision of eroded mesh. Mean age of patients requiring excision was 48.8 years and mean weight was 72.7kg. Mean time to re-presentation was 14.5 months. Presenting symptoms included dyspareunia in 9 patients (56.2%), dysuria in 3 (18.7%), persistent incontinence in 3 (18.7%) and groin pain in one patient. Ten patients (62.5%) had a prior urogynecological procedure. After excision of eroded tape-mesh, 7 (43.7%) required a rectus fascial sling and 4 (25%) underwent repeat TOT for recurrence of SUI. Five patients (31.2%) required no further surgery. At present 10 patients (62.5%) report resolution of SUI, 4 (25%) report mild SUI and 2 (12.5%) patients have moderate/severe SUI. Resolution of symptoms occurred in the majority of patients after excision of eroded mesh and an additional anti-incontinence procedure.

Avoidable iatrogenic complications of male urethral catheterisation and inadequate intern training: a 4-year follow-up post implementation of an intern training programme.

OBJECTIVE: To assess the impact of a structured training programme in urethral catheterisation (UC) targeted at newly qualified junior doctors on rates of iatrogenic catheter morbidity within a tertiary care referral centre. SUBJECTS AND METHODS: Male UC-related morbidities were retrospectively identified from our computerised inpatient urology consultation system over a 1-year period from July 2010 to June 2011. Relevant medical records were also reviewed. Results were compared with an initial study performed between July 2006 and June 2007, prior the introduction of a structured training programme in our institution. An anonymous questionnaire was used for the subjective assessment of interns about confidence in catheterising post introduction of the programme. RESULTS: Of 725 urological consultations, 29 (4%) were related to complications arising from male UC during the 1 year period. This reflected a statistically significant decrease when compared to our 2007 figures, 51/864 (6%) (p < 0.05). Again, the most common indication for UC was monitoring urinary output for acute medical illness (19/29, 66%). The most common complication was urethral trauma (16/29, 55%). Of the 29 cases of UC-related morbidity, 18 (62%) resulted from interns performing UC, a decrease of 12% from our original paper. A drop of 27% was seen in the rates of UC related morbidity attributable to interns during the first 6 months of internship (July-December). Overall, 70% (vs 40% original study) of interns felt that their practical training was adequate since introduction of the programme (p < 0.01) with 53% considering theoretical training adequate (vs 16% original study (p < 0.01). When asked were they confident in performing UC, 63% said they were compared to 35% before introduction of the programme (p < 0.05). CONCLUSIONS: UC-related iatrogenic morbidity is not uncommon even in a tertiary-care teaching hospital. Implementation of a structured training programme in UC prior to the commencement of intern year has been shown to result in a significant decrease in the amount of iatrogenic UC related morbidity.

A prospective audit of emergency urology activity in a university teaching hospital.

INTRODUCTION: Urology cover is commonly available out-of-hours in most teaching hospitals. However, increased pressure to reduce hospital expenditure has forced many institutions to consider removing middle grade cover outside of normal working hours. The aim of this study was to audit the emergency urology activity in our institution over a 12-month period. METHODS: A prospective logbook was maintained for all urology referrals from the emergency department between August 2012 and March 2013. The diagnosis and patient outcome was recorded for each referral. The emergency theatre logbook was retrospectively evaluated for all emergency urology procedures carried out over the same time period. A basic cost analysis was performed to calculate the cost of providing the on-call service. RESULTS: A total of 752 patients were referred to the urology service over a 12-month period. The most common reasons for referral were renal colic and scrotal pain. Approximately 41 % of referrals were discharged directly from the emergency department. There were 167 emergency operations performed in total. The majority of emergency operations and referrals from the emergency department took place outside of normal working hours. A basic cost analysis revealed an associated cost saving of €58,120. CONCLUSION: Emergency urology activity constitutes a large proportion of the workload at our institution. Restricting emergency urology cover would limit essential training opportunities for urology trainees, increases length of stay and delay treatment of urological emergencies. Urology "out of hours" cover is a cost-efficient method of service provision.

Autotransplantation of a single functioning kidney following rupture of renal artery aneurysm.

Renal artery aneurysms (RAA) are the second most common visceral artery aneurysm. In cases of rupture they pose a significant and emergent surgical challenge. Extracorporeal arterial reconstruction and autotransplantation is often necessary in certain complex cases that are not amenable to aneurysm repair in vivo. We report a case of a 35 year old female with a RAA in a solitary functioning kidney, requiring ex vivo reconstruction and autotransplantation to the iliac vessels.

A single centre experience of active surveillance as management strategy for low-risk prostate cancer in Ireland.

INTRODUCTION: Active surveillance (AS) is a management strategy for addressing the widely acknowledged problem of over diagnosis and over treatment of clinically indolent prostate cancer. METHODS: A total of 80 patients were enrolled on the AS program in our institution between January 2008 and June 2012. All data were collected prospectively in a secure database. RESULTS: The mean age of patients enrolled was 62.7 years (range 50-72). Median PSA at enrolment was 5.6 ng/mL (range 1.2-13.4). The mean follow-up was 32 months (range 2-54). In total, 85 % of patients had a repeat biopsy after 1-year with 30 % having another biopsy after 3 years. Overall, 45 % of patients remain on AS. In the remainder; 42.5 % of patients have been removed from AS for definitive treatment, while 8.75 % of patients are now on watchful waiting, 2.5 % of patients self discharged from the program and one patient died of cardiovascular disease. The prostate cancer specific survival rate is 100 %. Reasons for removal from AS and referral for treatment were; 67.6 % of patients had upgrade of disease on repeat biopsy, 17.6 % of patients had PSA progression, 11.8 % patients had progression of disease on MRI, and one patient developed a palpable nodule. Regarding definitive treatment; 52.9 % of patients have been for referred for external beam radiotherapy, 14.7 % have been referred for brachytherapy, 29.4 % have been referred for surgery and one patient has refused definitive treatment. CONCLUSION: Our findings to date support active surveillance as a valid strategy for early, localised prostate cancer.

A review of inpatient urology consultations in an Irish tertiary referral centre.

INTRODUCTION: Our institution is a 680-bed tertiary referral centre with broad medical and surgical subspecialty services. We retrospectively audited the pattern of inpatient consultations from all specialities within our institution to the urology department over a 1-year period. METHODS: All consultations to the urology service were identified from our computerised inpatient consultation system from July 2010 to June 2011. Follow up data on investigations, interventions and subsequent outpatient appointments were also identified by review of individual patient discharge letters. RESULTS: Seven hundred and twenty five inpatient consultations were received over the period. The male to female ratio was 7:3. Mean age of patients was 66 (15-96) years. Seventy three percent of referrals were from medical sub-specialities, most commonly nephrology (17%), gastroenterology (11%) and respiratory medicine (9%). The remainder were from general surgery (16%) and other surgical sub specialities (11%). Interns (66%) and senior house officers (SHO) (28%) communicated the majority of consults. Male lower urinary tract/benign prostate related issues resulted in 25% of all consultations. Less than half of consults (47%) resulted in interventions initiated by urology, most commonly of which were catheter insertions (48%) and endoscopic procedures (35%). Only 43% of consultations were followed up in the outpatients setting. CONCLUSIONS: Inpatient consultations constitute a significant workload for urology services. The majority of these referrals did not require any urological intervention and could have been seen routinely in the outpatient setting. Providing structured referral guidelines and achieving better communication with referring teams may help to optimise this service.

Management of recalcitrant urethral strictures with self-dilatation balloon catheter.

INTRODUCTION: Urethral strictures constitute a significant clinical problem that often requires long-term management. OBJECTIVE: To report the long-term outcomes of adjuvant home self-urethral dilatation of recurrent urethral strictures using a balloon catheter. MATERIALS AND METHODS: Male patients (N = 11), performing self-dilatation with a balloon catheter (minimum 24 months) were assessed by patient-reported outcome measures (PROMs) health questionnaire specific for post treatment assessment of men with urethral stricture disease. RESULTS: Median duration of balloon catheter use is 46.5 months, IQR (24-150). Patients performed self-balloon dilatation on average 1.4 times a week, median 1, IQR (1-2) to maintain the patency of their urethra. The mean PROMs LUTS score of the patients was 2.45, median 2, IQR (1-4). The median and mean Peeling score was 2 IQR (1-2). 100 % patient reported that they either very satisfied or satisfied with the overall outcome and QoL. CONCLUSIONS: Our initial experience of outpatient self-dilatation with a balloon dilatation is encouraging and is an acceptable inexpensive and simple treatment for patient maintains urethral patency and potentially decreases stricture recurrence.

Ureteric angioplasty balloon placement to increase localised dosage of BCG for renal pelvis TCC.

Endoscopic percutaneous resection of a renal pelvis transitional cell carcinoma (TCC) is a viable treatment option in those who would be rendered dialysis dependent following a nephroureterectomy. We report endoscopic percutaneous resection of an upper tract TCC recurrence in a single functioning kidney followed by antegrade renal pelvis BCG instillation with novel placement of inflated angioplasty balloon in the ureter to help localise its effect.

A rapid access diagnostic clinic for prostate cancer: the experience after one year.

BACKGROUND: The National Cancer Control Programme is developing standards for access to diagnostics and treatment of prostate cancer. The Rapid Access Prostate Cancer (RAPC) clinic in St. James's Hospital commenced in May 2009 allowing general practitioners (GPs) more streamlined access for patients. AIMS: To demonstrate that RAPC clinics allow GPs direct access to a designated cancer centre improving the prostate cancer referral process. This ultimately should reduce referral delays. METHODS: A prospective analysis of all patients referred to the RAPC clinic in St. James's Hospital over a 12-month period beginning from May 2009. RESULTS: Over the 12-month period 215 patients were referred to the RAPC clinic. The median age was 63 years (range 45-78). The median waiting time between referral and review at the RAPC clinic was 13 days (range 1-37). The median PSA was 7.7 µg/L (range 2.6-150). In total 199 TRUS biopsies were performed, of which 46% were positive for prostate cancer. We found that 70% of all patients had a PSA ≤ 10 µg/L and of these 32% were positive for prostate cancer. For the remaining 30% of patients who had a PSA > 10 µg/L, we found 63% were positive for prostate cancer. Regarding patients diagnosed with prostate cancer 56% have been referred for radiotherapy, 13% for surgery, 13% for hormonal treatment, 10% for active surveillance and 8% watchful waiting. CONCLUSION: RAPC clinics allow GPs easier access to specialist urological opinion for patients suspected of having prostate cancer.

Initial experience with transperitoneal laparoscopic nephrectomy in an Irish hospital setting.

INTRODUCTION: Laparoscopic nephrectomy has gained widespread acceptance as a treatment for both benign and malignant conditions and is becoming increasingly popular in Irish hospitals. We report a single surgeon, single centre experience with 20 consecutive laparoscopic nephrectomies comparing them to 20 open cases performed prior to the establishment of a laparoscopic service. METHODOLOGY: A retrospective comparative analysis was carried out over an 18 month period. Transperitoneal approach was used in the laparoscopic group with renal vessels divided using an Endo GIA stapling device. Parameters examined included age, weight, indication, operative time, blood loss, tumour size, length of stay and analgesic requirements. Comparison was made with 20 open nephrectomies. RESULTS: Mean age (p=0.26) and weight (p=0.08) were similar in both groups. Average tumour size was similar (4.98 cm [range 2.8-9] in laparoscopic group versus 6.4 cm [range 3-10], p=0.61). Mean operative blood loss was reduced in the laparoscopic group (65 ml (range 50-200) versus 351 ml (50-1740) (p=or<0.05 L.N. versus O.N.). Laparoscopic patients were discharged earlier; 3.9 days (range 3-6) versus 6.5 (range 5-11) postoperatively (p=or<0.05 L.N. versus O.N.). Analgesia requirements were reduced in terms of both total hours using PCA (25.05 hours [range 1-45] versus 41.6 hours (range 7-226)) (p=or<0.05 L.N. versus O.N.) and total morphine requirements (35.5 mg [range 2-94] versus 72.4 mg [range 18-113] [p=or<0.05 L.N. versus O.N.]). There were no complications in the laparoscopic group, while one patient developed an incisional hernia in the open group. CONCLUSION: Laparoscopic nephrectomy is less invasive and demonstrates improved results in terms of analgesia, blood loss and reduced overall stay.

An unusual penpal: case report and literature review of posterior urethral injuries secondary to foreign body insertion.

We report the case of a 57-year-old male who attended the emergency department after inserting a ballpoint pen into his urethra 24 hours earlier during a sexual encounter. Rigid cystoscopy was performed and confirmed the foreign body to have caused a partial rupture of the posterior urethra. It was subsequently removed using a combination of graspers and stone retrieval baskets. Self insertion of foreign bodies into the urethra is often as a result of psychiatric disturbance, alcohol intoxication or as a means of sexual gratification. Posterior urethral injuries are more commonly associated with pelvic trauma and iatrogenic injuries. Injury secondary to self insertion of a foreign body is infrequently reported. Temporary insertion of a urethral catheter may be necessary. We reviewed the literature in relation to this unusual problem.