An Update on Evaluation and Management in Cystinuria.

Cystinuria is the most common cause of inherited stone disease and is caused by the failure of absorption of filtered dibasic amino acids including cystine in the proximal tubules. It is associated with a very high recurrence rate in affected patients, with the potential for significant morbidity in such patients due to the need for repeated surgical interventions. A multimodal and multispecialty approach in a dedicated centre is the key to improving treatment outcomes and patient adherence to the treatment. This article reviews the latest knowledge on the clinical and diagnostic features and summarises key developments to aid clinicians in diagnosis and management options, together with future directions for the care of these patients.

Changes in UK renal oncological surgical practice from 2008 to 2017: implications for cancer service provision and surgical training.

OBJECTIVE: To determine and analyse the temporal changes in oncological nephrectomy practice and training opportunities using data obtained from the UK British Association of Urological Surgeons nephrectomy register from 2008 to 2017. PATIENT AND METHODS: All nephrectomies within the dataset for this time period were analysed (n = 54 251). Cases were divided into radical nephrectomy (RN), partial nephrectomy (PN) and nephroureterectomy (NU). Simple nephrectomy, donor nephrectomy and benign PN were excluded. The annual frequencies for each oncological nephrectomy method, surgical approach, grade of surgeon, hospital caseload numbers and short-term surgical outcomes were determined. RESULTS: Reported annual nephrectomy numbers increased by 2.5-fold in the 9-year time period. The number of hospitals performing nephrectomies decreased by 22%, however, more than 40% of centres performed more than 70 cases a year. There was a trend towards a decrease in overall length of hospital stay (9 vs 5 days; P < 0.01) and decreased transfusion rates. The proportion of minimally invasive procedures increased from 57% to 75%, with nephron-sparing rates increasing from 8.9% overall to 24.8%. With regard to surgical technique, robot-assisted surgery saw a mean annual increase of 222%. Overall, there was a 10% decrease in the proportion of PNs performed by trainee surgeons. CONCLUSIONS: Renal surgery has changed considerably with regard to volume and also surgical approach, with rates of nephron-sparing surgery and minimally invasive surgery significantly increasing. Increasing hospital centralization and institutional experience, and a shift to robot-assisted surgery appear to have contributed to the observed improved patient outcomes. The increasing utilization of robot-assisted surgery has potential implications and challenges for the training of future urology surgeons.

Assessment of Age and Duration of Symptoms on Outcomes of Emergency Scrotal Exploration for Acute Scrotal Pain.

OBJECTIVE: To study the effects of age and duration of symptoms on the outcomes of scrotal explorations for acute scrotal pain at our institution. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Bradford Teaching Hospital NHS Trust, from January 2006 to December 2017. METHODOLOGY: Retrospective data was collected from electronic case records of the patients who required scrotal exploration for suspected torsion of the testis. Group difference between continuous variables (age and duration of symptoms) were assessed by Kruskal Wallis and independent samples Mann-Whitney U-tests. The Fisher Exact and Chisquare tests were used to analyse relationships between categorical data. RESULTS: In total, 502 patients required scrotal exploration. The median age (years) and duration of symptoms (hours) were 16.4 years (1.3 - 77) and 4 hours (1 - 336), respectively. Torsion of the testis was found in 231 (46%), torsion of the testicular appendix in 126 (25%), epididymal inflammation in 46 (9.2%), and no cause identified in 99 (19.7%). Immediate orchidectomy for non-viable testis performed in 34 (14.7% of TT group and 6.8% of the overall cohort). Duration of symptoms was significantly associated with risk of orchidectomy in torsion patients 4 vs. 27 hours (p <0.0001). Overall 47 (9.3%) patients presented after 12 hours, 22 (46.8%) had TT. There were 13 (2.6%) patients older than 40 years and 8 (61.5%) of these had torsion. CONCLUSION: The most commonest diagnosis for patients presenting with acute scrotal pain was torsion of the testis followed by torsion of appendix testis. Testicular salvage was inversely related to the duration of symptoms. Patient's age did not predict the need for orchidectomy. This data supports the practice of urgent scrotal exploration for acute scrotal pain with a clinical suspicion of torsion regardless of age and duration of symptoms.

Do prostate cancer nomograms give accurate information when applied to European patients?

OBJECTIVE: The aim of this study was to validate and compare the performance of preoperative risk assessment tools in a population of men treated with radical prostatectomy at a single European institution. MATERIAL AND METHODS: Patients were identified from databases of radical prostatectomy between 1996 and 2011 from a single UK centre. Information was obtained on demographics, prostate-specific antigen, staging, biopsy and specimen histopathology, and follow-up. Data were inputted into the Memorial Sloan-Kettering Cancer Center (MSKCC), Partin 1997 and Makarov/Partin 2007 nomograms, and the University of California San Francisco-Cancer of the Prostate Risk Assessment tool (UCSF-CAPRA). The risks of extracapsular extension (ECE), seminal vesicle invasion (SVI) and lymph-node involvement (LNI) were calculated and compared with known outcomes. Nomogram performance was measured using Hosmer-Lemeshow (HL) goodness-of-fit tests, calculating concordance indices (c-indices) and calibration curves. RESULTS: Data were obtained for 541 patients. Prediction of ECE was relatively poor using all nomograms, with the Makarov/Partin 2007 the most accurate at prediction over the range of risk stratification (HL 9.9, c-index 0.62). Predictions of SVI and LNI were better than for ECE, with the MSKCC nomogram performing best for SVI (HL 10.9, c-index 0.73) and all nomograms performing well for LNI prediction (c-indices 0.8 to 0.815). CAPRA predicted best for SVI (OR 1.49, 95% confidence interval 1.27-1.74). CONCLUSIONS: To the authors' knowledge, this is the first head-to-head comparison of the accuracy of these commonly used risk calculators in a North European population. Caution should be used when counselling patients using nomograms. Although nomograms may be used as a guide, patients should be warned that they often have not been validated on different European populations and may give misleading information regarding a patient's specific risks.

Surgical simulators in urological training--views of UK Training Programme Directors.

What's known on the subject? and What does the study add? The role of surgical simulators is currently being debated in urological and other surgical specialties. Simulators are not presently implemented in the UK urology training curriculum. The availability of simulators and the opinions of Training Programme Directors' (TPD) on their role have not been described. In the present questionnaire-based survey, the trainees of most, but not all, UK TPDs had access to laparoscopic simulators, and that all responding TPDs thought that simulators improved laparoscopic training. We hope that the present study will be a positive step towards making an agreement to formally introduce simulators into the UK urology training curriculum. To discuss the current situation on the use of simulators in surgical training. To determine the views of UK Urology Training Programme Directors (TPDs) on the availability and use of simulators in Urology at present, and to discuss the role that simulators may have in future training. An online-questionnaire survey was distributed to all UK Urology TPDs. In all, 16 of 21 TPDs responded. All 16 thought that laparoscopic simulators improved the quality of laparoscopic training. The trainees of 13 TPDs had access to a laparoscopic simulator (either in their own hospital or another hospital in the deanery). Most TPDs thought that trainees should use simulators in their free time, in quiet time during work hours, or in teaching sessions (rather than incorporated into the weekly timetable). We feel that the current apprentice-style method of training in urological surgery is out-dated. We think that all TPDs and trainees should have access to a simulator, and that a formal competency based simulation training programme should be incorporated into the urology training curriculum, with trainees reaching a minimum proficiency on a simulator before undertaking surgical procedures.

Endoscopic management of upper tract transitional cell carcinoma.

Upper urinary tract transitional cell carcinoma (TCC) accounts for up to 10% of cases of neoplasm of the upper urinary tract. The "gold standard" management of upper tract TCC is nephroureterectomy. Technological innovations, miniaturisations and increased availability of energy sources such as Holmium laser fibers have improved the armamentarium of endoscopic management of upper tract TCC. Endoscopic management of upper tract TCC includes the percutaneous (antegrade) and retrograde approaches. Modern flexible ureterorenoscopy allows retrograde approach to small (<1.5cm), low grade and noninvasive tumors, which is inaccessible to standard rigid ureteroscopes without breaching the urothelial barrier. In patients with large tumors or in whom retrograde access is difficult, the percutaneous approach to the renal pelvis, although more invasive, provides an alternative access and control. Both retrograde and percutaneous approaches allow instillation of various chemotherapeutic agents. Careful selection of patients is the key point in the successful endoscopic management of upper tract TCC. Patient selection is based on tumor size, grade and multifocality and other patient factors such as comorbidities, single kidney, post kidney transplant and patient choice. Both motivation and compliance of patients are needed for long-term successes. However, until large randomized trials with long term follow-up are available, endoscopic management of upper tract TCC should be reserved for only selected group of patients. This review summarizes the current techniques, indications, contraindications and outcomes of endoscopic management of UTTCC and the key published data.

Technical description and outcomes of a continuous anastomosis in open radical prostatectomy.

OBJECTIVE: To describe the surgical technique, objective and subjective medium-term outcomes of a novel continuous vesico-urethral anastomotic suture in open radical prostatectomy (ORP). PATIENTS AND METHODS: A continuous anastomosis comprising separate anterior and posterior monofilament 3-0 polydioxanone sutures, with the bladder neck 'parachuted' down on to the urethral stump, was used in 39 consecutive patients. A cystogram was taken after ORP in the first 23 patients. The catheter was removed as soon as patients were fully mobile. A validated postal questionnaire to determine continence and its effect on quality of life was sent to all patients ≥3 months after ORP. RESULTS: The mean follow-up was 18 months; there were no major complications. There was an insignificant or no leak in 91% of the patients who had a cystogram. Before discharge, 33 patients reported that they were continent, whilst five required a pad(s) for stress incontinence, and one was discharged with a catheter after failing the first catheter removal. Of the 95% who completed the questionnaire, 95% either did not leak urine, or only leaked a small amount; 84% of patients reported that leaking had a minimal effect on everyday life. No patients developed symptomatic urethral or bladder neck stricture/contracture. CONCLUSIONS: Our technique of continuous anastomotic suturing for ORP is safe, reliable and well tolerated. Further randomized studies are warranted to compare the outcome with the standard interrupted vesico-urethral anastomosis.

Emphysematous pyelonephritis in type II diabetes: A case report of an undiagnosed ureteric colic.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a severe acute necrotising infection of the renal parenchyma and perirenal tissue, characterised by gas formation. 90% of cases are seen in association with diabetes mellitus. We report a case of undiagnosed ureteric obstruction in a type II diabetic, leading to EPN requiring emergency nephrectomy. CASE PRESENTATION: A 59-year-old type II tablet controlled diabetic woman presented complaining of a five day history of right sided abdominal pain associated with vomiting, abdominal distension and absolute constipation. There were no lower urinary tract symptoms. Past surgical history included an open appendectomy and an abdominal hysterectomy. On examination, she was haemodynamically stable, the abdomen was soft, distended, and tender in the right upper and lower quadrants with no bowel sounds. Investigations revealed a CRP of 365 and 2+ blood and nitrite positive on the urine dipstick. The AXR was reported as normal on admission, however when reviewed in retrospect revealed the diagnosis. She was managed, therefore, as having adhesional bowel obstruction and a simple UTI. After four days, a CT was organised as she was not settling. This showed a right pyohydronephrosis with gas in the collecting system secondary to an 8 mm obstructing ureteric calculus. The kidney was drained percutaneously via a nephrostomy and the patient was commenced on a broad spectrum intravenous antibiotics. Despite this, she went on to need an emergency nephrectomy for uncontrolled severe sepsis. She was discharged in good health 15 days later. CONCLUSION: EPN carries a mortality of up to 40% with medical management alone. Early recognition of EPN in an obstructed kidney is essential to guide aggressive management, and in the presence of continued severe sepsis or organ dysfunction an urgent nephrectomy should be carried out. Diabetic patients who are known to have renal or ureteric calculi, whether symptomatic or not, should be considered for percutanous or ureteroscopic treatment. In the acute abdomen, the plain abdominal radiograph should always be viewed with respect to general surgical, vascular and urological differential diagnoses.

Extracorporeal shockwave therapy for Peyronie's disease: who benefits?

BACKGROUND AND PURPOSE: Extracorporeal shockwave therapy (ESWT) has been reported to improve the symptoms of Peyronie's disease. However, the response rates to this treatment appear to be variable. This study aimed to determine whether any patient or plaque characteristics are associated with a better outcome. PATIENTS AND METHODS: A series of 36 patients with Peyronie's disease received ESWT as a primary treatment. Subjective response rates were compared on the basis of patient age, degree of pretreatment penile curvature, predisposing medical factors, duration of disease, and extent of plaque calcification. RESULTS: Ten men (27.8%) reported subjective improvements in curvature after ESWT. Of the factors considered, only age and pretreatment curvature influenced outcomes: 50% of the men below the mean age reported improvement compared with 5.6% of older men and 62.5% of men with mild curvature reported improvement compared with 8.3% of those with severe curvature. CONCLUSION: The response to EWST is not the same for all men with Peyronie's disease. Younger men and those with milder curvature have the best outcomes.