Introduction of Rezum system technology to Ireland for treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: a pilot study on early outcomes and procedure cost analysis.

OBJECTIVE: Rezum technology uses heat from radiofrequency-generated water vapour to ablate prostate tissue. We evaluate the introduction of this thermal therapy to an Irish teaching hospital for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia. METHODS: A pilot study of men with moderate to severe lower urinary tract symptoms who underwent Rezum treatment to the prostate was performed. Perioperative efficacy was evaluated using international prostate symptom score (IPSS), quality of life score (IPSS-QOL), uroflowmetry and post-void residual (PVR) volumes. Costs were evaluated and compared against matched patients undergoing the standard of care, transurethral resection of the prostate (TURP). RESULT: Ten patients with a mean age of 70 ± 9 years who met the inclusion criteria underwent Rezum treatment. Mean PSA was 4.73 ± 4 ng/mL and mean prostate volume 72 ± 30 cc. Rezum therapy significantly improved both IPSS by 74% from mean baseline score of 20.8 ± 4 to 5.3 ± 1.49 (p < 0.001) and IPSS-QOL score by 84% from mean baseline score of 4.4 ± 0.7 to 0.6 ± 0.7 (p < 0.001) at 3 months. Maximum flow rate increase by 44% from 9.26 ± 2.5 to 13.34 ± 2.3 mL/s (p < 0.001). When compared to ten matched patients undergoing TURP in the same period, there was a significant cost saving of €1986.52 per patient for Rezum, overall up-front cost saving of €22,819 with an additional 19 bed days and 5 theatre hours spared. CONCLUSION: Rezum, a minimally invasive thermal therapy, provides significantly improved symptom relief and quality of life with a significant cost saving to the institution.

Does postal consent for flexible cystoscopy work?

BACKGROUND: Informed consent is an integral part of the process prior to any surgical procedure [1]. Flexible cystoscopy is a common day case urological procedure and it is the gold standard investigation for visible haematuria [2]. AIM: To assess if postal consent is a suitable form of gaining informed consent for flexible cystoscopy. METHODS: Patients booked for a flexible cystoscopy are initially reviewed in clinic. An information leaflet with an attached consent form is then posted to their home 2 weeks prior to their procedure. We designed a short questionnaire, to assess patient's satisfaction and understanding of the literature, given to them after the procedure. RESULTS: Sixty-seven questionnaires were completed. The mean age was 54. Sixty patients (93%) think that postal consent is of benefit to the patient. Sixty-one patients (91%) read the information sheet and felt that there was enough information regarding the procedure on it. Fifty-four patients (81%) had no difficulty understanding the consent form. Forty patients (60%) signed the form prior to arrival in the hospital. CONCLUSION: Postal consent is commonly used for gastro-intestinal endoscopy procedures. Postal consent for flexible cystoscopy is not well reported in the literature. Our study shows postal consent to be a suitable form of gaining informed consent for flexible cystoscopy.

Ipsilateral robot assisted laparoscopic side to side ureteroureterostomy in a duplex collecting system - A video case report with 1 year follow up.

A 26-year-old male presented with an obstructing calculus in the mid superior-moiety ureter in a duplicated urinary collecting-system. A sequela of the obstruction resulted in a symptomatic stricture in a functional superior-moiety ureter, unresponsive to endoscopic interventions. An ipsilateral robot-assisted laparoscopic side-to-side ureteroureterostomy was performed thus bypassing the stricture in the superior-moiety ureter. Follow up endoscopic visualisation showed a healthy, patent anastomosis. This video presentation shows appropriate positioning, operative technique and follow up for a robot assisted side-to-side ureteroureterostomy. Our minimally invasive novel method is a feasible and safe treatment of a duplex collecting system with a symptomatic ectopic ureter.

Intraductal carcinoma of the prostate in an Irish prostate cancer patient cohort-an aggressive pathology and a strong familial link.

BACKGROUND: The prevalence of intraductal carcinoma of the prostate (IDC-P) is poorly studied in the Irish population. This study investigated the incidence and clinicopathologic characteristics of IDC-P in an Irish prostate cancer (PCa) patient cohort. The study also discusses the rationale for genetic counseling and screening in Irish patients with familial risk factors for IDC-P. MATERIALS AND METHODS: This study investigated patients diagnosed with IDC-P on prostate biopsy from 2012 to 2016. Primary outcome measurements were incidence, management, and clinical outcomes after follow-up in patients with IDC-P. The secondary outcome measurement was to identify a familial link for IDC-P. RESULTS: A total of 1,143 patients were diagnosed with PCa on needle biopsy, of which 30 (2.3%) had concomitant IDC-P. Mean age and prostate-specific antigen at diagnosis were 68.6 ± 10.5 years (range 53-85 years) and 9.15 ± 8.65 ng/mL (range 2.1-166 ng/mL), respectively. In total, 17 of 30 patients (57%) were diagnosed with concomitant high-grade (i.e., ≥Gleason score 8) PCa. Eight patients (27%) were treated with radical prostatectomy; of which five had biochemical recurrence (BCR) after 10.55 ± 25.9 months. Eleven patients (37%) received radical radiotherapy; of which one had BCR after 36 months. Eleven patients (37%) presented with advanced PCa and were managed with androgen deprivation therapy ± chemotherapy. A family history for PCa in first-degree relatives was found in eight patients (27%). CONCLUSIONS: IDC-P is associated with more aggressive clinicopathologic features and an increased risk of BCR after treatment. In Ireland, clinical guidelines and a genetic screening pathway are required to provide early detection and appropriate multimodal management of patients with IDC-P.

Significance of spermatic cord invasion in radical inguinal orchidectomy: Will a modified subinguinal orchidectomy suffice?

INTRODUCTION AND OBJECTIVES: Radical inguinal orchidectomy with ligation and division of the spermatic cord at the deep inguinal ring is the treatment of choice for testicular mass suspicious of cancer. In the era of organ preserving and minimally invasive surgery, it may be possible to propose a less radical sub-inguinal orchidectomy that may avoid the morbidity associated with opening the inguinal canal. The effect of this approach on oncological margins is not known. The aim of this article was to investigate the presence of spermatic cord involvement after a radical inguinal orchidectomy with a view to test feasibility of a modified sub-inguinal approach for testicular tumour excision. MATERIALS AND METHODS: A retrospective study on all orchidectomies performed for suspected testicular cancer was performed at a single hospital from over an 8-year period from January 2005 to December 2013. Non-cancerous lesions were excluded after histopathological review. All testicular malignancies were included and detailed histopathological review was performed. RESULTS: A total of 121 orchidectomies were performed over the 8-year period. Three patients had spermatic cord involvement. Spermatic cord involvement did not adversely affect the outcome in these patients after a median follow-up of 5 years irrespective of tumour histology. The proximal spermatic cord was not involved in any testicular germ cell tumours on further cord sectioning, the only patient with proximal cord involvement had a B-cell lymphoma. CONCLUSION: We postulate that a sub-inguinal modified orchidectomy may be a less invasive alternative to radical inguinal orchidectomy, with comparable oncological outcomes based on low risk of spermatic cord involvement, which in itself is not a prognostic factor. We require further long-term follow-up studies on patients who have undergone this approach to validate the oncological outcomes and report the possible advantage of lower post-operative complications with this technique.

Ureteric stenting with magnetic retrieval: an alternative to traditional methods.

INTRODUCTION: Ureteric stents are frequently placed following endo-urological procedures. These stents cause significant morbidity for patients. Standard ureteric stents are removed by flexible cystoscopy. This procedure can be unpleasant for patients and requires additional resources. A newly designed magnetic stent allows removal in an outpatient setting. The aim of our study is to compare the magnetic stent and standard ureteric stents with regard to morbidity, pain on stent removal and cost-effectiveness. METHODS: This study was carried out across two sites between September 2016 and July 2017. In site A, a magnetic stent (Urotech, Black-Star®) is removed by magnetic retrieval device. Fifty consecutive patients completed the validated Ureteric Stent Symptom Questionnaire (USSQ) and visual analogue scale (VAS) at the time of stent removal. On site B, a soft polyurethane stent (Cook Universa) was removed by flexible cystoscopy. Fifty patients were identified retrospectively and completed questionnaires by post. Cost analysis was also performed. RESULTS: One hundred questionnaires were included for analysis. No significant difference in stent morbidity as assessed by the USSQ was shown between both groups. Median duration of stenting was significantly shorter in the magnetic stent group (5.5 versus 21.5 days, p < 0.001). Mean pain on stent removal was significantly less with magnetic retrieval (2.9 versus 3.9, p < 0.05). Complication rates were similar in both groups. Cost analysis showed a cost saving of €203 per patient with the magnetic stent group. CONCLUSION: Magnetic stents cause similar morbidity for patients compared with standard stents removed by flexible cystoscopy; they are associated with less pain at removal and are cost saving.

Admission of patients with acute urinary retention leads to a definitive management decision.

BACKGROUND: Acute urinary retention (AUR) is a common urologic emergency. However, its management is not standardized due to lack of clinical guidelines. AIMS: We retrospectively reviewed the treatment of all male patients admitted to our institution with AUR over 12 months. METHODS: Data was obtained from the HIPE (Hospital Inpatient Enquiry) data system, each patient's electronic discharge summary and from patient medical records. RESULTS: There were 130 AUR admissions during the period. About 74 admissions were due to benign prostatic enlargement (BPE). Of these, 45.9% (n = 34) passed their trial without catheter (TWOC). The remainder (n = 40) failed their TWOC necessitating recatheterization and consideration for transurethral resection of prostate (TURP) or re-TWOC. An indwelling urinary catheter (IDC) was inserted for 27.5% (n = 11) of patients with a failed TWOC secondary to comorbidities. This group had a mean age of 78 years (range 68-96 years). Of those who failed their TWOC, 32.5% (n = 13) had a TURP on index admission. Of the remaining 16 patients with failed TWOC, 75% (n = 12) were discharged with an IDC and readmitted for an elective TURP with a median waiting time of 55 days (range 17-138 days). 18.75% (n = 3) passed a re-TWOC and thus offset the need to have any surgical intervention and 6.25% (n = 1) proceeded to a radical retropubic prostatectomy for biopsy proven prostate adenocarcinoma. CONCLUSION: Admission of patients with acute urinary retention leads to a definitive management decision and reduced prolonged catheterization.

Patient experience after transperineal template prostate biopsy compared to prior transrectal ultrasound guided prostate biopsy.

INTRODUCTION: Transperineal template prostate biopsy (TTPB) is reported to have higher cancer detection and lower complication rate compared to transrectal ultrasound guided prostate biopsy (TRUSPB).However, there is no report of the same patient's experience with both types of biopsy.To compare the patient reported experience in the same cohort of patients who underwent both TRUSPB and TTPB, using validated questionnaires. MATERIAL AND METHODS: We retrospectively utilised the Patient Reported Outcome Methods (PROM) tool validated for TRUSPB and the International Index of Erectile Function (IIEF-5) questionnaire to collect longitudinal data at follow-up in the same cohort of patients who underwent both TTPB and TRUSPB between January 2015 and February 2016. RESULTS: Out of 44 TTPB performed during the period, 35 patients had undergone both TRUSPB and TTPB. Patient reported pain post biopsy was significantly higher with TRUSPB (86% vs. 61%; p = 0.01). Post-biopsy urinary retention rates were significantly higher in the TTPB group (16.7% vs. 5.7%; p = 0.05, t test). Furthermore, the incidence of patient reported sexual dysfunction rates based on the IIEF-5 was significantly higher in the TTPB group (p = 0.001, t test). CONCLUSIONS: Although overall TTPB was better tolerated in this cohort of patients with lower risk of health care contact, patients reported higher incidence of urinary retention and sexual dysfunction after TTPB compared to TRUSPB. Thus, patients should be adequately informed about potential risks with each biopsy as they may have significant impact on quality of life.