'I Did No Harm': Compliance with GMC Guidelines for the Use of a Chaperone in Urology Outpatient Clinic.

OBJECTIVE: To assess the performance of our urology team against GMC guidelines for using chaperone during intimate clinical examination. BACKGROUND DATA: intimate physical examination is an integral part of our urological practice. There is a paucity of literature regarding the use of chaperones among urologists. Given the importance of this topic for both patient safety and providing support for the urologist, we decided to assess our performance as per the GMC guidelines for good medical practice. METHODS: We completed an audit loop to evaluate the performance of 12 members in our urology team as regards compliance with GMC guidance for the documentation of chaperone use in urology clinic. Based on our scoring system, we objectively assessed both overall team performance as well as individual scores for documenting chaperone use. RESULTS: There was a significant improvement in the overall documentation rate in both clinical notes (+9.85%) and clinic letters (+36.65%). Raising awareness among team members managed to increase the individual performance scores as well. CONCLUSION: This is the first report using a scoring system for objective assessment of a pertinent topic such as the use of chaperone and its documentation. This managed to achieve a significant improvement in our practice.

Urothelial Carcinoma in Bladder Diverticula: A Multicenter Analysis of Characteristics and Clinical Outcomes.

BACKGROUND: Urothelial carcinoma arising in a bladder diverticulum (UCBD) is uncommon, and data on treatment and outcome are sparse. OBJECTIVE: To analyze clinicopathological characteristics of UCBD and to compare outcome after radical cystectomy (RC) and partial cystectomy (PC). DESIGN, SETTING, AND PARTICIPANTS: Data of 115 UCBD patients treated with RC (n=81) or PC (n=34) between 2000 and 2016 were collected from 11 institutional databases and were analyzed retrospectively. Median follow-up was 5.0yr (95% confidence interval [CI]: 4.0-6.2). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Upstaging of tumor stage at diagnostic transurethral resection (TUR) to the RC/PC specimen was investigated. Overall survival (OS) and metastasis-free survival (MFS) after RC and PC were analyzed using Kaplan-Meier estimates, and compared using the log-rank test. Intravesical recurrences after PC were reported. A multivariable Cox proportional-hazard model was used to identify factors associated with OS. RESULTS AND LIMITATIONS: There were no statistically significant differences in clinicopathological characteristics between RC and PC groups. Fifty-five percent of patients with cTa/is/1 at diagnostic TUR had ≥pT2 tumors at RC/PC. Five-year OS and MFS were, respectively, 62% and 66% for RC and 66% and 55% for PC (p=0.9 and p=0.6). Intravesical tumor recurrence was seen in six of 34 (18%) PC patients. In multivariable analysis, positive surgical margins and extravesical disease (≥pT2) were associated with worse OS, whereas treatment modality was not (RC: reference; PC: hazard ratio 0.94, [95% CI: 0.47-1.90], p=0.9). CONCLUSIONS: Upstaging of UCBD was frequent, indicating an inaccuracy in clinical staging. We found no differences in OS or MFS between PC and RC groups; therefore, PC may represent a feasible surgical alternative to RC in selected UCBD patients. PATIENT SUMMARY: In this report, we looked at the treatment of urothelial carcinoma arising in a bladder diverticulum (UCBD). We found that bladder-sparing treatment by partial cystectomy may be an alternative to radical cystectomy in carefully selected UCBD patients.

Baseline Cytokine Profiles of Tuberculin-Specific CD4+ T Cells in Non-Muscle-Invasive Bladder Cancer May Predict Outcomes of BCG Immunotherapy.

Intravesical Bacillus Calmette-Guérin (BCG) immunotherapy preserves the bladder after resection of high-risk non-muscle-invasive bladder cancer (NMIBC). About 30% of patients experience treatment failure, which cannot be predicted a priori and carries a high risk of disease progression. We examined the in vitro tuberculin responsiveness of CD4+ T cells before BCG immunotherapy in 42 patients with high-risk NMIBC. The frequencies and functionalities of cytokine-expressing CD4+ T cells immediately before and after BCG immunotherapy induction were assessed by flow cytometry after overnight tuberculin stimulation. Tuberculin-induced secreted mediators were measured by electrochemiluminescence. We correlated the results with recurrence-free patient survival 6 months after induction. A tuberculin-induced, secreted, IL2 concentration > 250 pg/mL was the best predictor of recurrence-free survival, providing 79% sensitivity, 86% specificity (AUC = 0.852, P = 0.000), and overall correct classification in 78.6% of cases. In 50% of patients later experiencing recurrence, but not in any of the recurrence-free survivors, IL2 secretion was < 120 pg/mL. Other parameters predicting recurrence-free survival included secreted IFNγ (AUC = 0.796, P = 0.002) and the frequencies of TNF-producing (TNF+) CD4+ T cells (AUC = 0.745, P = 0.010). "Polyfunctional" CD4+ T cells (IFNγ+/IL2+/TNF+) were significantly associated with recurrence-free survival (AUC = 0.801, P = 0.002). Thus, the amount of IL2 secretion from CD4+ T cells after overnight in vitro incubation with tuberculin predicted the outcome of BCG immunotherapy. As many as half of potential BCG failures could be identified before induction therapy is begun, enabling better choices regarding treatment. Cancer Immunol Res; 6(10); 1212-9. ©2018 AACR.

Isolated bladder schwannoma: a rare presentation.

Bladder schwannoma is a rare tumour arising from Schwann cells in nerve sheaths. It is usually more common in patients diagnosed with neurofibromatosis. However, isolated cases of urinary bladder schwannoma is incredibly rare, attributing to <0.1% of bladder tumours. A literature review and analysis revealed that it presents in adulthood, is mostly symptomatic and diagnosis is established histologically. We report a case of isolated bladder schwannoma in 25 year-old female who presented with dyspareunia.

Knotted urethral catheter: an unusual complication in adults.

Knotting of feeding tubes or urinary catheters has been reported as a rare complication in paediatrics when draining the bladder. This is caused by inserting thin flexible tubes too far in, allowing it to coil. We present a case of a 70-year-old woman who was catheterised during a routine spinal surgery, and the catheter coiled and balloon failed to deflate requiring a cystostopic approach to puncture the balloon and remove it. Awareness of this complication in female catheterisation and education on length of catheter insertion is important to avoid this.

Prognostic value of inflammation or granuloma after intravesival BCG in non-muscle-invasive bladder cancer.

OBJECTIVE: To evaluate the prognostic value of inflammation or granuloma after intravesical bacille Calmette-Guérin (BCG) treatment in non-muscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS: Patients with NMIBC treated with intravesical BCG over a 5-year period were identified. The correlations between histopathological results and disease recurrence and progression were assessed, with survival analysis performed using the Kaplan-Meier method. Other relevant variables were also evaluated using univariate and multivariate analysis. A log-rank test was performed to compare time-to-event between groups. RESULTS: A total of 215 patients were treated with BCG for NMIBC and the median follow-up was 32 months. Granuloma was identified in 60 patients and inflammation in 125 patients. In 18 patients there was no evidence of either (normal histology group). A total of 12 patients did not have biopsies and were subsequently excluded. The mean recurrence-free survival rate was significantly higher in the granuloma and inflammation groups (65 months [95% CI: 58-72] and 56 months [95% CI: 49-63], respectively) than in the normal histology group (20 months [95% CI: 6-34]; log-rank P < 0.001). On the multivariate analysis, the absence of inflammation/granuloma was significantly associated with recurrence (log-rank P < 0.001). The progression-free survival rate was higher in the granuloma and inflammation groups (75 months [95% CI: 71-79] and 82 months [95% CI: 78-86], respectively) compared with the normal histology group (33 months [95% CI: 17-48]; log-rank P < 0.001). On multivariate analysis, the absence of inflammation/granuloma was significantly associated with recurrence (log-rank P < 0.001). CONCLUSION: Inflammation or granuloma in histology samples after intravesical BCG treatment for NMIBC are positive markers of response and their absence increases the risk of recurrence and progression.

Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy.

The incidence of prostate cancer in transsexual patients is very low with only few reported cases. Many years before presenting with prostate cancer, these patients receive hormone ablation as a part of their gender therapy. Their disease is already defined as castrate resistant, and the treatment and follow-up of such patients remains a challenge. We report a case of a male-to-female transgender woman who was diagnosed with metastatic prostate cancer, 31 years post-feminization.

Risk factors for heterotopic ossification in primary total hip arthroplasty.

Heterotopic ossification (HO) is a recognised complication of total hip arthroplasty (THA). This study aims to correlate demographics, surgical approach and type of arthroplasty to the incidence of HO in an attempt to quantify patient risk. A total of 920 primary THAs in 893 patients were performed between 2006 and 2008 in a single arthroplasty centre. Radiographic evaluation was conducted and all cases of HO were classified using the Brooker classification. Age, sex, arthroplasty type and surgical approach were all considered as variables. Arthroplasty type was classified into four groups; total cemented (TC), total uncemented (TU), hybrid (H) and reverse hybrid (RH). Two-level logistic regression analysis was conducted. The overall incidence of HO was 24%. Male sex [OR=3.57, 95% CI (1.79-7.10); p=0.001], lateral approach [OR=2.47, (95% CI 1.23-4.95); p=0.001] and total cemented implants [OR=3.14, (95%CI 1.37-7.23); p=0.007] were significantly associated with HO. The intra-class correlation coefficient was 0.52 [95% CI (0.21, 0.81); p=0.004], demonstrating that patients with previous HO to one THA were very likely to suffer HO in subsequent THA. The results demonstrate very large effects for sex, surgical approach, and implant type on HO incidence. This raises a three arm hypotheses that reaming of the femoral canal for the insertion of cemented implants contaminates the surgical field with bone marrow increasing the risk of HO, whereas modern cementless implants generally employ impaction broaching. In addition surgical insult to the hip abductors during exposure, particularly in males due to higher muscle mass, may also predispose to HO.

Sport participation in adolescents with sickle cell disease.

Adolescents with blood diseases should be encouraged to participate in exercise. Physical activity helps to build stronger muscles, to give better support to the joints, and to improve the patient's overall health and fitness. It also improves emotional well being by improving self-esteem and providing social interaction. Sports and exercise in sickle cell anemia and sickle cell trait need special consideration. Young athletes with sickle cell disease are at high risk of dehydration, heat-related injury, exhaustion, painful episodes, and hip joint problems. Gradual acclimatization to heat, humidity and high altitude, slow conditioning over weeks and avoidance of dehydration are recommended for all adolescents with sickle cell disease to make their sport activity safe. Effort should be made to educate those with sickle cell disease that their condition is not a handicap and that they are fit to lead a normal life.