Not-so-simple nephrectomy: Comparative analysis of radical and simple nephrectomy in a high-volume tertiary referral center.

OBJECTIVES: Simple nephrectomies can be challenging with significant morbidity. To prove the hypothesis of "not-so-simple" nephrectomy, we compared demographics, perioperative outcomes, and complications between simple and radical nephrectomy in a tertiary referral center. METHODS: We analyzed 473 consecutive radical nephrectomies (January 2018-October 2020) and simple nephrectomies (January 2016-October 2020). Univariate and multivariate analysis of perioperative outcomes utilized the Mann-Whitney U test, Chi-squared test, Mantel-Haenszel test of trend, and multiple linear regression. Radical nephrectomies were classified in cT1, cT2a, and cT2b-T3 subgroups and compared to simple nephrectomies. Minimally invasive and open techniques were compared between the two groups. Infected versus non-infected simple nephrectomies were compared. RESULTS: A total of 344 radical and 129 simple nephrectomies were included. Simple nephrectomy was an independent predictor of increased operative time (p = 0.001), length of stay (p = 0.049), and postoperative complications (p < 0.001). Simple nephrectomies had higher operative time (p < 0.001), length of stay (p = 0.014), and postoperative morbidity (p < 0.001) than cT1 radical nephrectomies and significantly more Clavien 1-2 complications than cT2a radical nephrectomies (p = 0.001). The trend was similar in minimally invasive operations. However, conversion to open rates was not significantly different. Infected simple nephrectomies had increased operative time (p < 0.001), length of stay (p = 0.005), blood loss (p = 0.016), and intensive care stay (p = 0.019). CONCLUSIONS: Patients undergoing simple nephrectomy experienced increased operative time and morbidity. Simple nephrectomy carries higher morbidity than radical nephrectomy in tumors ≤10 cm. Robotic simple nephrectomies may reduce open conversion rates. Postoperative intensive care and enhanced recovery may be essential in simple nephrectomy planning with infected pathology.

Radiation Safety Knowledge and Practice in Urology Theaters: A Collaborative Multicenter Survey.

Objective: To evaluate the knowledge and current radiation safety practice among health care professionals undertaking fluoroscopic procedures in urology. Materials and Methods: A 14-question survey was disseminated to multidisciplinary urology theater staff. Questions included demographic data, usual radiation safety practice, and knowledge. The questions were selected based on guidelines from the International Commission of Radiological Protection and Health and Safety Executive. The survey was disseminated through regional collaborators and social media. Results: The survey received a total of 309 completed responses, including 272 from the United Kingdom. Responses from the United Kingdom multidisciplinary team included 164 (60.3%) urologic surgeons, 68 (25.0%) theater nurses, 27 (9.9%) from the anesthetic team, and 13 (4.7%) radiographers. Results from the United Kingdom demonstrated use of lead aprons and thyroid shields as 99.3% and 52.2%, respectively. Lead glasses and lead glove use were 7.4% and 0.7%, respectively. Lack of availability was cited as a reason for noncompliance with shielding guidelines in 208 (76.5%) of the respondents. No form of training in radiation safety was reported by 120 (44.1%) respondents. However, there was no association between answering knowledge questions correctly and having completed some form of radiation safety training (p = 0.41). There was an association between dosimeter use and those who had received radiation safety training (p = 0.02). Consultant urologists were also more likely to use a dosimeter than training grade urologists (p = 0.035). Conclusion: Suboptimal compliance with radiation safety guidelines is prevalent in contemporary urologic practice, and presents a significant occupational health concern. Availability of protective equipment needs to be urgently addressed.

Pilonidal sinus disease of the penis: A case report and review of the literature.

Pilonidal sinus disease (PSD) is an acquired pathological condition more commonly seen in the natal cleft of the sacrococcygeal area, although its presentation is not limited to the natal cleft and it can present in other regions of the body such as the breast, umbilicus, scalp and penis. We present the case of a 28-year-old gentleman who presented to his local Urology outpatient clinic with an unusual penile lesion that was later identified as a pilonidal sinus. This was treated with radical circumcision and penile reconstruction with a good functional outcome. For surgeons unaccustomed to PSD presenting on the penis, there is a potential for delay in diagnosis and sub-optimal management of this rare lesion.

Low-cost simulation models in Urology: a systematic review of the literature.

INTRODUCTION: Simulation models have been found to be effective and valid for training in Urology. Due to increasing costs of surgical training, there is a need for low-cost simulation models to enable Urology trainees to improve their skills. MATERIAL AND METHODS: A literature review was performed using the PubMed and Embase databases until March 2020. A total of 157 abstracts were identified using the search criteria, of which 20 articles were identified describing simulation models for Urology training. Articles reviewed described simulation models created from materials costing less than $150. Data was extracted from the relevant articles in order to critically assess each paper for validity, ease of construct and educational impact. RESULTS: Models were found pertaining to suprapubic catheterization (6), cystoscopy (3), percutaneous nephrolithotomy (5), scrotal examination (1), circumcision (1), ureteroscopy (1), transurethral resection of the prostate and bladder (2), and open prostatectomy (1). 18/20 (90%) assessed for either face, content, or construct validity. None of the papers evaluated assessed for transferability of skills to performance in real patients. CONCLUSIONS: A plethora of low-cost simulation models for urological procedures are described in the literature, many of which can be easily constructed from cheap and accessible materials. However there is a need for further efforts to validate or assess for transferability of skills to clinical practice.

Defining a national reference level for intraoperative radiation exposure in urological procedures: FLASH, a retrospective multicentre UK study.

OBJECTIVES: To define reference levels for intraoperative radiation during stent insertion, ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL); to identify variation in radiation exposure between individual hospitals across the UK, between low- and high-volume PCNL centres, and between grade of lead surgeon. PATIENTS/SUBJECTS AND METHODS: In all, 3651 patients were identified retrospectively across 12 UK hospitals over a 1-year period. Radiation exposure was defined in terms of total fluoroscopy time (FT) and dose area product (DAP). The 75th percentiles of median values for each hospital were used to define reference levels for each procedure. RESULTS: Reference levels: ureteric stent insertion/replacement (DAP, 2.3 Gy/cm2 ; FT, 49 s); URS (DAP, 2.8 Gy/cm2 ; FT, 57 s); PCNL (DAP, 24.1 Gy/cm2 ; FT, 431 s). Significant variations in the median DAP and FT were identified between individual centres for all procedures (P < 0.001). For PCNL, there was a statistically significant difference between DAP for low- (<50 cases/annum) and high-volume centres (>50 cases/annum), at a median DAP of 15.0 Gy/cm2 vs 4.2 Gy/cm2 (P < 0.001). For stent procedures, the median DAP and FT differed significantly between grade of lead surgeon: Consultant (DAP, 2.17 Gy/cm2 ; FT, 41 s) vs Registrar (DAP, 1.38 Gy/cm2 ; FT, 26 s; P < 0.001). CONCLUSION: This multicentre study is the largest of its kind. It provides the first national reference level to guide fluoroscopy use in urological procedures, thereby adding a quantitative and objective value to complement the principles of keeping radiation exposure 'as low as reasonably achievable'. This snapshot of real-time data shows significant variation around the country, as well as significant differences between low- and high-volume centres for PCNL, and grade of lead surgeon for stent procedures.

Pancoast tumour presenting as shoulder pain with Horner's syndrome.

A 54-year-old man presented to the emergency department with a 4-week history of right shoulder pain radiating down his arm, with some associated sensory loss. Further questioning and examination in the department revealed a classical Horner's syndrome; miosis, partial ptosis and hemifacial anhidrosis. An initial chest X-ray was deemed to be unremarkable; however, further review by a radiologist noted asymmetrical right apical thickening. A subsequent high-resolution CT scan of the chest revealed a right-sided Pancoast tumour. This case highlights the importance of a thorough history and examination in identifying a rare cause of shoulder and/or back pain.