Unrecognised paraganglioma of the urinary bladder precipitating hypertensive crisis.

Bladder paragangliomas (bPGLs) account for only 0.06% of all bladder tumours, most commonly presenting with post-micturition syncope and hypertensive crisis. Silent paragangliomas are very rare, and failure to recognise them in the perioperative setting can precipitate a hypertensive crisis in the absence of sufficient alpha-blockade. Here, we describe a case of unrecognised bPGL in a woman with pre-existing hypertension and a single prior episode of haematuria thought to be related to urothelial carcinoma. She was found to have a low-grade non-invasive papillary urothelial carcinoma (potentially the cause of her haematuria) and an unrelated vascular-appearing tumour causing hypertensive crisis and broad complex tachycardia on resection. This was confirmed to be a bPGL on histology for which she underwent definitive management with a partial cystectomy following blood pressure management.

Genitourinary toxicity in patients receiving TURP prior to hypofractionated radiotherapy for clinically localized prostate cancer: A scoping review.

BACKGROUND: When compared with conventional external beam radiotherapy, hypofractionated radiotherapy has led to less treatment sessions and improved quality of life without compromising oncological outcomes for men with prostate cancer. Evidence has shown transurethral prostatic resection prior to brachytherapy and external beam radiotherapy is associated with worsening genitourinary toxicity. However, there is no review of genitourinary toxicity when TURP occurs prior to definitive hypofractionated radiotherapy. In this review, we seek to illustrate the genitourinary outcomes for men with localized prostate cancer who underwent transurethral resection of the prostate prior to receiving definitive hypofractionated radiotherapy. Genitourinary outcomes are explored, and any predictive risk factors for increased genitourinary toxicity are described. METHODS: PubMed, Medline (Ovid), EMBASE and Cochrane Library were all searched for relevant articles published in English within the last 25 years. This scoping review identified a total of 579 articles. Following screening by authors, 11 articles were included for analysis. RESULTS: Five studies reported on acute and late toxicity. One article reported only acute toxicity while 5 documented late toxicity only. While most articles found no increased risk of acute toxicity, the risk of late toxicity, particularly hematuria was noted to be significant. Risk factors including poor baseline urinary function, prostate volume, number of prior transurethral prostatic resections, timing of radiotherapy following transurethral prostatic resection, volume of the intraprostatic resection cavity and mean dose delivered to the cavity were all found to influence genitourinary outcomes. CONCLUSION: For those who have undergone prior TURP hypofractionated radiotherapy may increase the risk of late urinary toxicity, particularly hematuria. Those with persisting bladder dysfunction following TURP are at greatest risk and careful management of these men is required. Close collaboration between urologists and radiation oncologists is recommended to discuss the management of patients with residual baseline bladder dysfunction prior to commencing hypofractionated radiotherapy.

Defining the good surgical resident: a resident and registrar perspective.

BACKGROUND: Surgical residency provides insight into the essential skills required to become a successful surgical registrar. However, the role of the surgical resident remains largely undefined. While the Royal Australasian College of Surgeon (RACS) JDocs framework provides a useful guide, no published research explores what defines a highly performing surgical resident. We investigate what constitutes a 'good' surgical resident from the surgical resident and accredited surgical registrar perspectives. We hope this knowledge will improve patient care and assist surgical residents towards becoming valuable team members and successful accredited surgical training candidates. METHODS: A qualitative research approach was utilized employing reflexive thematic analysis. Using semi-structured interviews, 10 surgical residents and 10 accredited surgical registrars across eight surgical specialties were interviewed. RESULTS: Amongst surgical residents five themes were identified: efficiency: mastering the mundane, 'stepping up' to more responsibility, enthusiasm to learn, first do no harm: a safe practitioner, and lastly no resident is an island: a team player. Four themes described by accredited registrars included: somebody you can trust, finding a safe 'balance', a perfect fit: teamwork and communication and finally eagerness to improve. CONCLUSION: Themes correlated well with eight of 10 RACS competencies and the JDocs Framework. Our results reaffirmed the importance of developing early career non-technical skills. Explicit knowledge and understanding of these attributes used in conjunction with the core competency and JDocs frameworks may help those contemplating a career in surgery throughout their early surgical years.

Clinical Utility of a Single-Use Flexible Cystoscope Compared with a Standard Reusable Device: A Randomized Noninferiority Study.

Objective: A noninferiority assessment of single-use digital flexible cystoscopy (FC) compared with standard reusable FC for bladder cancer surveillance, and investigation of lower urinary tract symptoms. Patients and Methods: Patients requiring FC who met inclusion criteria were randomly assigned to have their procedure performed using a single-use cystoscope (Ambu® aScope™ 4 Cysto System) or a standard reusable cystoscope (Olympus CYF-VH flexible video cystoscope). Primary outcomes were noninferiority of the single-use cystoscope, in terms of effective procedure completion rate, image quality, light quality, and maneuverability. Secondary objectives compared safety, operative, and perioperative time. The noninferiority margin was set at -10%. Results: One hundred one patients completed the study (n = 50 trial, n = 51 control). All primary outcomes demonstrated noninferiority of the single-use cystoscope, compared with standard reusable FC. Effective completion rate, image quality, light quality, and maneuverability between single-use and reusable cystoscopes were 100% and 98% (confidence interval [CI]: -0.059 to 0.019); 96% and 100% (CI: -0.014 to 0.092); 98% and 100% (CI: -0.018 to 0.058); and 98% and 100% (CI: -0.018 to 0.058). There was no difference in operation time (p = 0.415) or total theater use time (p = 0.441) between groups. Adverse event rates were 4.08% and 4.16% in the trial group and control groups, respectively. Conclusion: The single-use Ambu flexible cystoscope is noninferior to standard FC in terms of procedure completion and light quality, image quality, and maneuverability. Single-use flexible cystoscopes are an effective and safe alternative to reusable flexible cystoscopes and may act as a suitable alternative or adjunct in the urologist's armamentarium.

The role of a urine dipstick in the diagnosis of the acute scrotum.

Objective: To evaluate the role of a urine dipstick in the assessment of acute scrotal pain emergency department presentations. Methods: A single institution, prospective case series, from February 2020 to February 2021. All patients who received a bedside review by a urology doctor for acute scrotal pain were included. Urine dipstick results were pre-defined as having had an impact on the emergency clinician's diagnosis if it showed pyuria and/or nitrituria and the final diagnosis was epididymitis-orchitis or haematuria and the final diagnosis was ureterolithiasis. Results: 139 patients presented to the emergency department with a complaint of acute scrotal pain. 85 (61%) were referred for bedside urology review. Median age of 17 years (P25 12 yrs, P75 31 yrs). 2.3% (n = 2) had proven testicular torsion, 28.5% (n = 24) had epididymitis-orchitis and 8.2% (n = 7) had ureterolithiasis. 68 (80%) of patients received a primary diagnosis of testicular torsion by the emergency department clinician. Following review by a urology unit doctor, 14 proceeded to scrotal exploration for concern of testicular torsion. 7 patients were diagnosed with ureterolithiasis, all of whom had haematuria on their urine dipsticks (100%, 95% CI: 59-100%), 100% of these urine dipsticks were initiated by the urology unit doctor following bedside review. 22 patients were diagnosed with epididymitis-orchitis. 8 of these had pyuria, nitrituria and/or haematuria on their urine dipstick (36%, 95% CI: 17-59%) and only one urine dipstick was completed prior to referral. 20.6% of patients perceived to have testicular torsion by the emergency department had a positive urine dipstick that aligned with their final alternative diagnosis (95% CI: 12-32%). Conclusion: A collection of clinical findings is required to diagnose the aetiology of acute scrotal pain. Information that can be easily, quickly, cheaply, and reliably collected, such as a urine dipstick, can assist in clinical decision making.

Prostate cancer survival in South West Victoria.

OBJECTIVE: To explore reasons for survival disparities for patients with prostate cancer in the Barwon South West area of Victoria. DESIGN, SETTING AND PARTICIPANTS: We have described incidence, diagnostics, treatment pathways, and survival for four regions of the Barwon South Western Victoria. Analysis included all newly diagnosed prostate cancer patients from 2009 to 2015 in the Evaluation of Cancer Outcomes Barwon South West Registry. Regions included 1: Queenscliffe 2: Geelong, Colac Otway and Corangamite 3: Moyne, Warrnambool and Southern Grampians and 4: Glenelg. Across the four regions, variables were compared using a chi square statistic or analysis of variance and survival data was assessed with the Kaplan-Meier curves. MAIN OUTCOME MEASURES: Incidence, treatment pathways and survival for prostate cancer patients. RESULTS: A total of 1776 patients were diagnosed with prostate cancer from 2009 to 2015 in the Barwon South West area. In regions 1-4, there were 298 (1.04%), 1085 (0.92%), 273 (0.97%) and 120 (1.2%) cases, respectively. There was no significant difference in Gleason score and treatment. The 5-year survival rate was 85%, 76%, 71% and 80%, respectively, as compared with the national average of 95%. PSA scores >20 ng/ml at diagnosis, as a surrogate for high-risk disease, occurred in 23%, 29%, 22% and 21%, respectively (p < 0.01). The proportions presenting with stage IV disease were 17%, 26%, 21% and 6%, respectively (p = 0.10). CONCLUSION: Men diagnosed with prostate cancer in South West Victoria have a considerably lower 5-year survival compared with the national average with later disease at presentation in some areas.

Long-term outcomes of peritoneal dialysis catheters inserted by laparoscopic and percutaneous techniques in a single regional dialysis centre.

BACKGROUND: Minimally invasive insertion of catheters for peritoneal dialysis can be performed laparoscopically or percutaneously under image guidance. In Geelong (Victoria, Australia) both methods are used. Our aim was to analyse the outcomes of all catheters inserted by both laparoscopic and percutaneous techniques and compare them against published studies from tertiary referral centres. METHODS: Data were collected retrospectively on all patients who had their catheter inserted (since 2006) within the Geelong regional service. We compared the outcomes of percutaneous catheter insertion under image guidance (percutaneous group, n = 29) with the laparoscopic catheter placement technique (laparoscopic group, n = 61). Perioperative, follow-up and catheter outcome data were collected. There were no exclusion criteria. Analysis was performed using the unpaired student t-test and chi-squared test. RESULTS: Ninety catheters were inserted between 2006 and 2017 in mostly male patients (63%) with a mean age of 60 ± 0.4 years. The most common aetiology of chronic kidney disease was diabetic nephropathy (34%). Percutaneous insertion required less operative time, shorter hospital stay and earlier initiation of peritoneal dialysis. In the longer term, percutaneous catheters were more likely to migrate and laparoscopic catheters were more durable but more often associated with peritonitis. Thirty-day complication rates did not differ between both groups. No Clavien-Dindo grade 3 or 4 complication was reported. CONCLUSIONS: Laparoscopic insertion of peritoneal dialysis catheters at our centre is performed safely and with patient outcomes comparable to published literature. Percutaneous insertion represents a safe and effective alternative based on the study findings.

Optimizing surgical training in the time of COVID-19-Victorian regional teaching hospital experience.

BACKGROUND: Reductions in elective surgery due to the COVID-19 pandemic led to a paralleled reduction in patient based surgical training opportunities. METHODS: To quantify the impact of COVID-19 on surgical training, we completed a retrospective audit of the Urology Department activity during Victorian pandemic waves in 2020 at our large regional teaching hospital. Corresponding weeks in the year prior were used as the control. Interviews with department members illustrated the adaptive approach to surgical training used at our institution. RESULTS: A State of Disaster Surgical Triage Team was assembled and surgical operations were split between one public and two private hospitals. A pandemic triaging protocol was established and 335 Category-2 patients were re-triaged. The first wave saw a 13.8% reduction in clinic reviews, with the second wave having an overall increase of 8.8% with 56% being telehealth. The second wave saw an 11.0% reduction in overall operating, with reduced emergency operating in both the first and second wave of 17.4% and 45.5%, respectively. Reductions impacted surgical technical skill training, resulting in surgical education provided through technology platforms including webinars, podcasts and pre-recorded operative videos. The unique challenges trainees were faced with due to the pandemic encouraged development of non-technical RACS competencies. CONCLUSION: The COVID-19 pandemic presented significant challenges for service delivery and training. Reduced direct patient contact and procedures, but opportunities to develop the non-technical skills required to respond to the pandemic. The use of variable educational opportunities and tools ensured our trainees continued to progress through their training.

Transrectal ultrasound-guided prostate needle biopsy remains a safe method in confirming a prostate cancer diagnosis: a multicentre Australian analysis of infection rates.

PURPOSE: Worldwide, transrectal ultrasound-guided prostate needle remains the most common method of diagnosing prostate cancer. Due to high infective complications reported, some have suggested it is now time to abandon this technique in preference of a trans-perineal approach. The aim of this study was to report on the infection rates following transrectal ultrasound-guided prostate needle biopsy in multiple Australian centres. MATERIALS AND METHODS: Data were collected from seven Australian centres across four states and territories that undertake transrectal ultrasound-guided prostate needle biopsies for the diagnosis of prostate cancer, including major metropolitan and regional centres. In four centres, the data were collected prospectively. Rates of readmissions due to infection, urosepsis resulting in intensive care admission and mortality were recorded. RESULTS: 12,240 prostate biopsies were performed in seven Australian centres between July 1998 and December 2020. There were 105 readmissions for infective complications with rates between centres ranging from 0.19 to 2.60% and an overall rate of 0.86%. Admission to intensive care with sepsis ranged from 0 to 0.23% and overall 0.03%. There was no mortality in the 12,240 cases. CONCLUSION: Infective complications following transrectal ultrasound-guided prostate needle biopsies are very low, occurring in less than 1% of 12,240 biopsies. Though this study included a combination of both prospective and retrospective data and did not offer a comparison with a trans-perineal approach, TRUS prostate biopsy is a safe means of obtaining a prostate cancer diagnosis. Further prospective studies directly comparing the techniques are required prior to abandoning TRUS based upon infectious complications.

The Use of a Polytetrafluoroethylene Membrane-Covered Stent in the Management of Urine Extravasation After Radical Cystectomy and Ileal Conduit Formation.

Radical cystectomy for urothelial carcinoma is a challenging operation that is associated with significant morbidity and mortality rates. In the literature, the complication rates have been described up to 68%. We describe a unique method of managing a ureteroileal anastomotic leak in a patient with limited ureteral length. The use of polytetrafluoroethylene-covered ureteral stents has been described in the management of ureteral strictures, but this is the first time they have been used in the treatment of a urinary leak after radical cystectomy.

Primary basal cell carcinoma of the prostate with concurrent adenocarcinoma.

INTRODUCTION: Prostatic basal cell carcinoma is an extremely rare tumor, exhibiting various histopathological features and clinical spectrums of disease. CASE PRESENTATION: A 69-year-old male presented to our department with 2 years of voiding difficulty and intermittent macroscopic hematuria. With a presumed diagnosis of benign prostatic hyperplasia, he underwent a transurethral resection of the prostate. Pathological examination revealed atypical basaloid cells forming solid nests. Robot-assisted radical prostatectomy was subsequently performed, confirming a diagnosis of basal cell carcinoma with coexisting acinar adenocarcinoma. CONCLUSION: Although more cases of basal cell carcinoma are indolent than aggressive, there is no reliable method of differentiation between these presentations. Thus, we recommend radical surgery and 6-monthly disease surveillance until more is discovered about this very rare malignancy.

Male urethral stricture disease in a regional centre: 10 years of experience.

BACKGROUND: Male urethral stricture disease is a challenging condition with a propensity for recurrence following endoscopic management. In recent years, earlier definitive urethral reconstruction has been advocated through international guidelines, prompted by series suggesting the underutilization of urethroplasty at rates of 0.6-0.8%. However, little local data exists to characterize our urethral stricture patients and we aimed to characterize the management of patients with urethral stricture disease presenting over a 10-year period to a single regional centre. METHODS: Patients with urethral stricture disease and admitted to a regional health service were identified. Retrospective chart review was undertaken for patients detailing basic demographics, stricture characteristics, clinical management and follow up. RESULTS: We identified 360 patients with median age 69 years (interquartile range 56-77). A total of 191 (53%) presented with lower urinary tract symptoms, 122 (34%) urethral strictures were incidental, and 13% presented in urinary retention. Bulbar urethral strictures were the commonest strictures at 40% with most being spontaneous or idiopathic (67%). A total of 339 patients had treatment during their first admission, 48% of patients had subsequent treatment on a second episode, and over 20% had a third or subsequent treatment. Only 21 (5.8%) underwent urethroplasty. Urethral dilatation and optical urethrotomy were most commonly performed (54%). With follow up 19 months (interquartile range 2-56), 205 (57%) were voiding, 38 (11%) were performing intermittent catheterization, and 59 were catheterized permanently. CONCLUSION: Definitive urethral reconstruction appears underutilized in our cohort of patients. A high proportion of incidentally presenting urethral strictures emphasizes the importance of wider education to optimize patient outcomes.

Lessons Learned and New Challenges: Re-evaluation of End-User Assessment of a Skills-Based Training Program for Urology Trainees.

OBJECTIVES: To re-assess the perceived benefit and relevance of simulation sessions to Victorian urology trainees and to identify areas for potential improvement. SUBJECTS AND METHODS: All trainees attending skills training sessions between 2011 and 2016 were asked to complete a structured questionnaire at the completion of the session. The questionnaire included 11 topic areas ranging from the year of surgical training to degree of usefulness of the session, including several sections for free-text response to offer more detailed feedback. Sessions were examined both individually and collectively to assess end-user satisfaction with the structure and content of the program. RESULTS: In total, 24 individual skills sessions were held over the 6-year period, with a total of 355 attendees. Of these, 331 attendees completed the majority of the questionnaire, a response rate of over 93%. Overall 88% of the surveyed attendees stated that they had both the support of their supervising consultant and the flexibility of workload to attend the session; 90% of trainees felt that there was adequate reading material provided prior to the skills session, an improvement from 76% in the previous study period; and 97% of those surveyed felt that the existing session structure was appropriate and the same proportion found the sessions both useful and interesting, compared with just 63% in the previous study period. Analysis of individual topics demonstrates some variability in outcome measures, but for nearly every assessed parameter, greater than 90% of participants agreed that the session fulfilled the expected criteria. New topics developed since the 2011 analysis, including renal transplant and vascular repair, also had high levels of satisfaction. The practical models used have been refined and achieved higher scores than those in the previous assessment period. CONCLUSION: The urology skills-based training program has been well received by the surveyed trainees and is now embedded and accepted as part of the Victorian training program. The format of the sessions has matured and the overall rating, both individually and collectively, was high. There has been a clear increase in satisfaction across most areas assessed when compared with previous feedback. Despite this, there remain areas that can be improved, such as the amount and quality of available equipment and the inclusion of video demonstrations of operative techniques.

Establishment of a urology service in a developing country: an observational study of outcomes in transurethral prostate resection procedures in Vanuatu.

BACKGROUND: The Royal Australasian College of Surgeons (RACS) via the Pacific Island Program (PIP) administer yearly urology visits to Vanuatu to perform surgery and deliver training in the management of urological conditions. In conjunction with the Vanuatu Ministry of Health a self-sufficient urology service has developed, specifically performing transurethral resection of the prostate (TURP) procedures. We review the TURP outcomes for the PIP and detail the development and outcomes of the first independent TURP service in the Pacific. METHODS: With retrospective local and RACS medical records, an observational study was performed of TURP procedures undertaken in Port Vila Central Hospital, Vanuatu over 6 years. Outcome measures comprised significant morbidity, prolonged post-operative admission, blood transfusion, TUR syndrome, successful trial of void, postoperative urinary incontinence, and perioperative mortality. Comparisons were made with univariate analysis between the RACS, local team, and international standardised values, with t-tests for continuous variables, and with Fisher's exact test for binary variables. FINDINGS: Since 2009, a total of 117 TURP procedures were performed. 84 by the PIP team and following training both in Vanuatu and Australia; the local team independently performed 33 TURPs. Comparisons of all outcomes measured between the local and PIP teams showed no statistically significant differences (appendix). 29 patients overall (22 in the PIP group and seven in the local group) required blood transfusions, eight (seven and one) failed their trial of void, 10 (seven and three) had a prolonged post-operative admission (>7 days); two patients died in the post-operative period both in the PIP group). 10 (seven and three) had postoperative urinary incontinence. There was no difference between mean length of stay (4·07 days vs 4·7 days; p=0·2081) and haemaglobin loss with no cases of TUR syndrome. Only the rate of transfusion was statistically significantly higher in the Vanuatu cohorts when compared with international standards (appendix). INTERPRETATION: The development of a local urological service and in particular a TURP service is a first for a Pacific Island Nation. Baseline data were obtained with encouraging outcomes reflecting careful patient selection, cautious management, and expertise accumulation. Planned prospective audit should overcome some of the difficulties encountered in performing a longitudinal study in a developing nation with suboptimum follow-up and challenging medical records. Through linkage between the PIP and the Vanuatu Ministry of Health capacity building an independent service provision can be achieved. This model could be replicated to establish a sustainable and self-sufficient surgical service in a developing country. FUNDING: None.

Trainee underperformance: a guide to achieving resolution.

BACKGROUND: Underperformance and the disharmony it can cause are not commonly faced by trainees. However, when it occurs, a process to recognize and manage the issues compassionately must be put in place. METHOD: A literature review was undertaken to outline processes and themes in addressing and resolving these types of issues. A PubMed search using 'surgical underperformance' and 'remedial teaching' was used as a broad template to find papers that illustrated key concepts. One thousand four hundred and fifteen papers were identified. In papers where the titles were in line with the stated topic, 294 abstracts were reviewed. Key papers were used to develop themes. Additional cross-referenced papers were also included where relevant. RESULTS: There can be a variety of reasons for trainee underperformance. The root cause is not always clear. Disharmony can result in a surgical unit during this time. The involved trainee as well as the members of the clinical unit may experience a variety of stressors. A systematic process of management can be used to evaluate the situation and bring some resolution to difficulties in working relationships. CONCLUSION: Early constructive intervention improves outcomes. There should be a process to systematically and compassionately resolve underlying issues. This paper outlines the disharmony that can result from trainee underperformance and offers guidance for resolution to those involved.

The impact of laparoscopic nephrectomy on patient outcome: a community perspective.

BACKGROUND AND PURPOSE: Despite laparoscopic nephrectomy now being established as the favored technique for extirpative renal surgery, adoption of the technique is not universal, particularly in the community setting. We describe our experience with establishing a laparoscopic program in a regional hospital and the benefits that have accrued to our community as a result. PATIENTS AND METHODS: We performed a retrospective review of all patients undergoing nephrectomy in Geelong during the 10-year period that spanned the introduction of the laparoscopic approach. Patients were divided into two groups based on the timing of their surgery in relation to the first attempted laparoscopic nephrectomy in Geelong-"prelaparoscopic" (n = 129) or "postlaparoscopic" (n = 208). In the latter group, this was regardless of the actual approach used. Demographic, clinical, and operative details were recorded and compared between the two groups. RESULTS: Since the first attempt in 2001, the number of laparoscopic nephrectomies has increased annually, such that now 56% of all nephrectomies are performed via this approach. In the prelaparoscopic and postlaparoscopic groups, 73% and 78% of nephrectomies were performed for malignancy, respectively; the remainder were performed for a variety of benign conditions or trauma. Since the introduction of laparoscopy, the mean operative time for nephrectomy has increased by 1 hour (141 vs 201 min, P < 0.001), mean length of stay has decreased by 3.9 days (12 vs 8.1 d, P < 0.002), and the incidence of both minor and major complications has fallen (P < 0.05). CONCLUSIONS: The introduction of laparoscopic nephrectomy results in significant benefits to the community by reducing cohort morbidity and length of stay.