Introduction of a dedicated colic clinic reduces referral to treatment times in patients managed expectantly with acute ureteric colic: a quality improvement project.

Ureteric colic constitutes a large proportion of acute hospital attendances, across the UK, putting pressure on urological services. The British Association of Urological Surgeons (BAUS) guidelines indicate that for patients managed expectantly, a clinic review should be undertaken within 4 weeks of presentation. This quality improvement project reports the benefit of a dedicated virtual colic clinic to facilitate an efficient care pathway and reduce patient waiting times. A retrospective cycle analysed patients referred from the emergency department (ED) with uncomplicated acute ureteric colic (excluding those admitted for immediate intervention) over 2 months in 2019. A further cycle was carried out 12 months later following the introduction of a new dedicated virtual colic clinic with updated ED referral guidance. The mean time from ED referral to urology clinic review fell from 7.5 to 3.5 weeks. The percentage of patients reviewed in clinic within 4 weeks increased from 25% to 82%. The mean time from referral to intervention including shockwave lithotripsy and primary ureteroscopy fell from 15 to 5 weeks. The introduction of a virtual colic clinic improved the time to definitive management of ureteric stones for patients managed expectantly as per BAUS guidelines. This has reduced waiting times for both clinic review and stone treatment which has enhanced patient experience within our service.

Clinical outcomes of anterior prostate cancers treated with robotic assisted radical prostatectomy.

Introduction: A prospective cohort study comparing peri- and postoperative outcomes for patients with predominantly anterior prostate cancer (APC) identified preoperatively against non-anterior prostate cancer (NAPC) treated via robotic-assisted radical prostatectomy (RARP). Patients and Methods: Of the 757 RARP's completed between January 2016 and April 2018, two comparative cohorts for anterior and an equivalent group of non-anterior prostate tumours each consisting of 152 patients were compared against each other. Data were collected on the following variables: patient age; operating consultant; preoperative PSA, ISUP grade, degree of nerve sparing; tumour staging; presence and location of positive surgical margins; PSA density, postoperative ISUP grade; treatment paradigm and postoperative PSA, erectile function, and continence outcomes with 2-year follow-up. Results: APCs were found to have significantly lower ISUP grading postoperatively; increased diagnosis via active surveillance over new diagnosis; more frequently undertaken bilateral nerve-sparing and long-term poorer continence outcomes at 18 and 24 months postoperatively (p < 0.05). Pre- and post-op PSA levels, erectile function, PSA density, positive surgical margins (PSM), age and tumour staging showed no significant differences between the APC and NAPC cohorts (p > 0.05). Conclusion: The lower ISUP grading could indicate APC as overall being less aggressive than NAPC, whereas the poorer long-term continence outcomes require further investigating. The non-significant differences amongst tumour staging, PSA density, preoperative PSA levels and PSM rates suggest that APC may not be as significant as predicted in diagnostic evaluation. Overall, this study provides useful information on the growing literature of anterior prostate cancer. Being the largest comparative cohort study to date on APC post-RARP, these results indicate the true characteristics of anterior tumours and their functional outcomes to help improve education, patient expectations and management.

Recent Advances in Systematic and Targeted Prostate Biopsies.

Prostate biopsy is the definitive investigation to diagnose prostate cancer. The ideal procedure would be one that offers fast and efficient results safely as an outpatient procedure. Historically, transrectal ultrasound (TRUS) biopsy is considered the gold standard but transrectal biopsy can under-sample the anterior and apical regions of the prostate and is associated with a risk of prostate biopsy-related sepsis, which may require intensive care admission. Transperineal (TP) biopsy addresses the inefficient sampling of TRUS biopsy but historically has been done under general anaesthetic, which makes it difficult to incorporate into timed diagnostic pathways such as the National Health Service (NHS) 2-week cancer pathway. TRUS biopsy has remained the mainstay of clinical diagnosis because of its simplicity; however, the recent development of simpler local anaesthetic transperineal techniques has transformed outpatient biopsy practice. These techniques practically eliminate prostate biopsy-related sepsis, have a shallow learning curve and offer effective sampling of all areas of the prostate in an outpatient setting. The effectiveness of TP biopsy has been enhanced by the introduction of multiparametric MRI prior to biopsy, the use of PSA density for risk stratification in equivocal cases and combined with more efficient targeted and systematic biopsies techniques, such as the Ginsburg Protocol, has improved the tolerability and diagnostic yield of local anaesthetic TP biopsies, reducing the risk of complications from the oversampling associated with transperineal template mapping biopsies. Areas where the literature remains unclear is the optimum number of cores needed to detect clinically significant disease (CSD) in patients with a definable lesion on MRI, in particular, whether there is a need for systematic biopsy in the face of equivocal MRI findings to ensure no CSD is missed. The Covid-19 pandemic has had a profound impact on prostate cancer referrals and prostate biopsy techniques within the UK; prior to the pandemic 65% of all prostate biopsies were TRUS, since the pandemic the proportions have reversed such that now over 65% of all prostate biopsies in the NHS are transperineal.

Safety of "hot" and "cold" site admissions within a high-volume urology department in the United Kingdom at the peak of the COVID-19 pandemic.

OBJECTIVES: To determine the safety of urological admissions and procedures during the height of the COVID-19 pandemic using "hot" and "cold" sites. The secondary objective is to determine risk factors of contracting COVID-19 within our cohort. PATIENTS AND METHODS: A retrospective cohort study of all consecutive patients admitted from March 1 to May 31, 2020 at a high-volume tertiary urology department in London, United Kingdom. Elective surgery was carried out at a "cold" site requiring a negative COVID-19 swab 72-hours prior to admission and patients were required to self-isolate for 14-days preoperatively, while all acute admissions were admitted to the "hot" site.Complications related to COVID-19 were presented as percentages. Risk factors for developing COVID-19 infection were determined using multivariate logistic regression analysis. RESULTS: A total of 611 patients, 451 (73.8%) male and 160 (26.2%) female, with a median age of 57 (interquartile range 44-70) were admitted under the urology team; 101 (16.5%) on the "cold" site and 510 (83.5%) on the "hot" site. Procedures were performed in 495 patients of which eight (1.6%) contracted COVID-19 postoperatively with one (0.2%) postoperative mortality due to COVID-19. Overall, COVID-19 was detected in 20 (3.3%) patients with two (0.3%) deaths. Length of stay was associated with contracting COVID-19 in our cohort (OR 1.25, 95% CI 1.13-1.39). CONCLUSIONS: Continuation of urological procedures using "hot" and "cold" sites throughout the COVID-19 pandemic was safe practice, although the risk of COVID-19 remained and is underlined by a postoperative mortality.

Presentation, follow-up, and outcomes among African/Afro-Caribbean men on active surveillance for prostate cancer: experiences of a high-volume UK centre.

BACKGROUND: Experiences of African/Afro-Caribbean men on active surveillance (AS) for prostate cancer (PCa) in the United Kingdom (UK) are not well documented. We compared follow-up appointments, adherence, and clinical outcomes among African/Afro-Caribbean men on AS at a high-volume UK hospital with other ethnicities. METHODS: Men with confirmed low-intermediate risk Pca who attended the AS clinic (2005-2016) and had undergone ≥1 follow-up biopsy (n = 458) were included. Non-adherence (defined as >20% missed appointments), suspicion of disease progression (any upgrading, >30% positive cores, cT-stage > 3, PIRADS > 3), any upgrading from diagnostic biopsy and conversion to active treatment (prostatectomy, radiotherapy or hormone therapy) according to ethnicity (African/Afro-Caribbean versus other ethnicities) were assessed using multivariable regression analysis. RESULTS: Twenty-three percent of eligible men were recorded as African/Afro-Caribbean, while the remainder were predominantly Caucasian. African/Afro-Caribbean men had slightly lower PSA at diagnosis (median 5.0 vs. 6.0 ng/mL) and more positive cores at diagnosis (median 2 vs. 1). They had a substantially higher rate of non-attendance at scheduled follow-up visits (24% vs. 10%, p < 0.001). Adjusted analyses suggest African/Afro-Caribbean men may be at increased risk of disease progression (hazard ratio [HR]: 1.38; 95% confidence interval [CI] 0.99-1.91, P = 0.054) and upgrading (HR: 1.29; 95% CI 0.87-1.92, P = 0.305), though neither reached statistical significance. No difference in risk of conversion to treatment was observed between ethnic groups (HR: 1.03; 95% CI 0.64-1.47, P = 0.873). CONCLUSIONS: African/Afro-Caribbean men on AS for PCa in the UK are less likely to adhere to scheduled appointments, suggesting a more tailored service addressing their specific needs may be required. While African/Afro-Caribbean men were no more likely to convert to treatment than Caucasian/other men, findings of a potentially higher risk of disease progression signal the need for careful selection and monitoring of African/Afro-Caribbean men on AS. Larger prospective, multicentre studies with longer follow-up are required to provide more definitive conclusions.

Targeted and systematic cognitive freehand-guided transperineal biopsy: is there still a role for systematic biopsy?

OBJECTIVES: To assess whether targeted cognitive freehand-assisted transperineal biopsies using a PrecisionpointTM device still require additional systematic biopsies to avoid missing clinically significant prostate cancer, and to investigate the benefit of a quadrant-only biopsy approach to analyse whether a quadrant or extended target of the quadrant containing the target only would have been equivalent to systematic biopsy. PATIENTS AND METHODS: Patients underwent combined systematic mapping and targeted transperineal prostate biopsies at a single institution. Biopsies were performed using the Precisionpoint device (Perineologic, Cumberland, MD, USA) under either local anaesthetic (58%, 163/282), i.v. sedation (12%, 34/282) or general anaesthetic (30%, 85/282). A mean (range) of 24 (5-42) systematic and 4.2 (1-11) target cores were obtained. Magnetic resonance imaging (MRI) scans were reported using the Likert scale. Clinically significant cancer was defined as Gleason 7 or above. Histopathological results were correlated with the presence of an MRI abnormality within a spatial quadrant and the other adjoining or non-adjoining (opposite) quadrants. Histological concordance with radical prostatectomy specimens was analysed. RESULTS: A total of 282 patients were included in this study. Their mean (range) age was 66.8 (36-80) years, median (range) prostate-specific antigen level 7.4 (0.91-116) ng/mL and mean prostate volume 45.8 (13-150) mL. In this cohort, 82% of cases (230/282) were primary biopsies and 18% (52/282) were patients on surveillance. In all, 69% of biopsies (195/282) were identified to have clinically significant disease (Gleason ≥3 + 4). Any cancer (Gleason ≥3 + 3) was found in 84% (237/282) of patients. Of patients with clinically significant disease, the target biopsies alone picked up 88% (171/195), with systematic biopsy picking up the additional 12% (24/195) that the target biopsies missed. This altered with Likert score; 73% of Likert score 3 disease was detected by target biopsy, 92% of Likert score 4 and 100% of Likert score 5. Target biopsies with additional same-quadrant-only systematic cores picked up 75% (18/24) of significant cancer that was missed on target only, found in the same quadrant as the target. CONCLUSION: Systematic biopsy is still an important tool when evaluating all patients referred for prostate biopsy, but the need is decreased with increasing suspicion on MRI. Patients with very high suspicion of prostate cancer (Likert score 5) may not require systematic cores, unless representative surrounding biopsies are required for other specific treatments (e.g. focal therapy, or operative planning). More prospective studies are needed to evaluate this in full.

Initial outcomes of local anaesthetic freehand transperineal prostate biopsies in the outpatient setting.

OBJECTIVES: To evaluate the histopathological outcomes, morbidity and tolerability of freehand transperineal (TP) prostate biopsies using the PrecisionPoint™ access system (Perineologic, Cumberland, MD, USA) under local anaesthetic (LA) in the day surgery and outpatient environments, as systematic and targeted biopsies can be taken with the potential for reduced morbidity, particularly sepsis. PATIENTS AND METHODS: In all, 176 patients underwent freehand TP prostate biopsies from May 2016 to November 2017. The procedure was carried out either under LA alone or with the addition of sedation. Magnetic resonance imaging (MRI) scans were reported using the Prostate Imaging-Reporting and Data System (PI-RADS), version 2. Tolerability was assessed using a visual analogue scale pain score for each procedural stage. Histopathological outcomes and complications were recorded. RESULTS: The mean (range) age was 65 (36-83) years, median (range) prostate-specific antigen level was 7.9 (0.7-1374) ng/mL, and the mean (range) prostate volume 45 (15-157) mL. Biopsies were taken under LA alone (160 patients, 90%) or under LA with sedation (16, 9%). The main indication for biopsy was primary diagnosis (88.6%). In all, 91 (52%) patients underwent systematic TP biopsies (mean 24.2 cores). Cognitive MRI-targeted biopsies alone were performed in 45 patients (26%; mean 6.8 cores), and 40 (23%) had both systematic and target biopsies (mean 27.9 cores). Of the 75 patients who had primary systematic biopsies alone, 46 (61%) were positive, and 28/46 (60.9%) were diagnosed with clinically significant disease (Gleason ≥3+4). VAS pain scores were greatest during LA administration. There were five complications (2.8%, Clavien-Dindo Grade I/II). No patients developed urosepsis. CONCLUSIONS: Freehand TP biopsies using the PrecisionPoint access system is a safe, tolerable and effective method for systematic and targeted biopsies under LA in the outpatient setting. It has replaced transrectal biopsies in our centre and has potential to transform practice.

Can surgical treatment for benign prostatic hyperplasia improve sexual function? A systematic review.

INTRODUCTION: Erectile dysfunction is an established, well known risk of any operative management of benign prostatic hyperplasia (BPH). However, there are some cases reported in which surgical treatment has paradoxically improved erectile function. Here, we present a systematic review of the literature pertaining to the effect of surgery on sexual function, focusing on reports of improvement in erectile function following surgery. MATERIALS AND METHODS: We searched PUBMED, EMBASE, Web of Knowledge, and SCOPUS databases for the following keywords: (("sexual function" OR "erectile function") AND "improvement" AND "benign prostatic hyperplasia" AND "surgery"). RESULTS: Sixteen studies (total n = 2087) were reviewed which reported a significant improvement in any aspect of erectile function. Ten of these studies had a follow-up period of 12 months or more while five had a follow up less than 12 months. Various surgical methods were included in the 16 studies; however, five reported TURP outcomes specifically. Eleven studies reported outcomes using the International Index of Erectile Function (IIEF). Overall, a further 87 studies showed no significant change and 8 studies showed a significant reduction. CONCLUSIONS: The majority of studies report no change in erectile function following surgical intervention for BPH. There seems to be no obvious correlating factor between the studies reporting an improvement in erectile function. Further research is needed to guide us in how to consent our patients for erectile function outcomes for BPH surgery.

Hypertension and renal impairment in patients with cystinuria: findings from a specialist cystinuria centre.

Higher blood pressures (mean systolic difference 16.8 mmHg) when compared to matched individuals are already reported in patients with calcium urolithiasis. We present the prevalence of hypertension and renal impairment in patients with cystinuria from our specialist single centre. We analysed our prospective database of adult patients with cystinuria who attend our cystinuria service. This included details of the medical and operative management of their disease. Descriptive statistics were used to analyse and present the data. 120 patients were included with a median age of 40 (19-76) years, 66 were male (55%) and 54 were female (45%). 54/120 patients (45%) were taking medications to prevent stone formation. 78% (94/120) patients reported having undergone one or more stone-related procedure. 59% (55/94) of these having required at least one PCNL or open procedure during their lifetime. Prevalence of hypertension was 50.8% (61/120), and double in males compared to females (62.1% vs. 37.0%, P = 0.0063). Mean baseline creatinine was 88.2 (49-153) µmol/l and eGFR was 77.6 (32-127) ml/min/1.73 m2. When categorized by CKD stage, only 24.6% (27% vs. 21%, M vs. F) patients had normal renal function (being an eGFR > 89 ml/min/1.73 m2). 57.6% patients were CKD stage 2 and 17.8% CKD stage 3. Females had a slightly greater incidence of renal impairment. All patients who have previously undergone a nephrectomy (n = 10) or have a poorly functioning kidney (n = 19) have renal impairment (CKD stage 2 or 3). Incidence of hypertension in patients with cystinuria is 51%, with a male preponderance. Only 25% of patients with cystinuria have normal renal function. This highlights the long-term cardiovascular and renal risks that the metabolic effects of cystinuria pose, in addition to the challenges of managing recurrent urolithiasis in a young population.

Factors influencing urinary retention after transperineal template biopsy of the prostate: outcomes from a regional cancer centre.

INTRODUCTION: Multi-parametric MRI (MP-MRI) prior to prostate biopsy is the investigation of choice for an elevated age-related PSA and abnormal digital rectal examination. MP-MRI in combination with transperineal template mapping biopsy has facilitated the development of the concept of targeted biopsies, either cognitively or with software fusion. Urinary retention is a recognised complication of transperineal prostate biopsy, with reported incidence being 1.6-11.4%. We present patient and procedure-related factors, which influence occurrence of urinary retention after transperineal template biopsy. PATIENTS AND METHODS: Retrospective data collection of 243 consecutive cases of transperineal template biopsies performed at a single institution were recorded and analysed. Biopsies were taken using a standard 5-mm template in 4-6 sectors, depending on the prostate volume. RESULTS: 31/243 (12.8%) patients developed urinary retention, defined as patient discomfort and inability to micturate and bladder scan of ≥ 600 ml. Patients in the retention group were significantly older (mean 68.7 vs. 65.8 years, P = 0.034). Prostate volume was significantly greater in comparison with the non-retention group (mean 75.4 vs. 57.2 cc, P = 0.0016). The number of biopsies taken was positively correlated with urinary retention (median 35 vs. 32 biopsies, P = 0.045), and this was independent of prostate size (R2 = 0.2). Presenting PSA, pre-operative flow and histopathological outcome were independent of urinary retention. CONCLUSIONS: Factors resulting in an increased risk of urinary retention are advancing age (> 68.7 years); a larger prostate volume (> 75 cc); greater number of biopsies (> 35); greater severity of lower urinary tract symptoms prior to biopsy and diabetes. Targeted biopsies alone, instead of a full template, may avoid urinary retention in the high-risk groups identified.

Extra-Anatomic Stents in Ureteric Obstruction: Our Experience.

OBJECTIVES: To present our experience of the Detour extra-anatomic stent (EAS; Porges-Coloplast, Denmark) to bypass ureteric obstruction. Use of the EAS is indicated in patients with complex ureteric strictures or malignant disease, where long-term nephrostomy drainage is undesirable. MATERIALS AND METHODS: Between December 2001 and October 2017, 20 Detour EAS were implanted into 13 patients. The primary indication was ureteric obstruction or injury secondary to metastatic malignancy, or from treatment for malignancy. Five patients required bilateral EAS, with two patients having bilateral EAS following initial unilateral insertion. In 11 patients, the stent was inserted into their bladder, with 2 diverted into a double-barreled stoma. The mean age at the time of implantation was 64 years (range: 50-83 years), and the median follow-up was 12 months (range: 1.5-42 months). RESULTS: Four patients required stent revision for urinary leaks, and two developed recurrent urinary tract infections in their stent requiring intravenous antibiotics. All EAS continued to drain successfully following treatment or revision. One patient died due to complications from dislodgement of the stent, leading to laparotomy and intra-abdominal sepsis. Seven patients died due to progression of metastatic malignant disease, and the Detour EAS was functioning in all seven at time of death. The remaining five patients are well with functioning Detour EAS. CONCLUSIONS: The Detour EAS system provides a suitable alternative option for urinary diversion, affording a good quality of life to carefully selected patients with multiple comorbidities and malignant disease.

Do stones still kill? An analysis of death from stone disease 1999-2013 in England and Wales.

OBJECTIVES: To analyse the trends in the number of deaths attributable to urolithiasis in England and Wales over the past 15 years (1999-2013). Urolithiasis has an estimated lifetime risk of 12% in males and 6% in females and is not perceived as a life-threatening pathology. Admissions with urinary calculi contribute to 0.5% of all inpatient hospital stays, and the number of deaths attributable to stone disease has yet to be identified and presented. MATERIALS AND METHODS: Office of National Statistics data relating to causes of death from urolithiasis, coded as International Classification of Diseases (ICD)-10 N20-N23, was collated and analysed for the 15-year period from 1999 to 2013 in England and Wales. These data were sub-categorised into anatomical location of calculi, age, and gender. RESULTS: In all, 1954 deaths were attributed to urolithiasis from 1999 to 2013 (mean 130.3 deaths/year). Of which, 141 were attributed to ureteric stones (mean 9.4 deaths/year). Calculi of the kidney and ureter accounted for 91% of all deaths secondary to urolithiasis; lower urinary tract (bladder or urethra) calculi contributed to only 7.9% of deaths. The data revealed an overall increasing trend in mortality from urolithiasis over this 15-year period, with an increase of 3.8 deaths/year based on a linear trend (R(2) = 0.65). Overall, the number of deaths in females was significantly higher than in males (ratio 1.5:1, P < 0.001); kidney and ureteric calculi causing death had a female preponderance (1.7:1, female:male); whereas calculi of the lower urinary tract was more common in males (1:2.2, female:male). CONCLUSIONS: Stone disease still causes death in the 21st century in England and Wales. This trend of increasing deaths must be placed in the context of the concurrent rising incidence of urolithiasis in the UK and the number of stone-related hospital episodes. The primary cause of death relating to complications of stone disease for each individual case should be further investigated to facilitate prevention of complications of urolithiasis.

Validation of the RobotiX Mentor Robotic Surgery Simulator.

OBJECTIVES: To assess face, content, and construct validity of the RobotiX Mentor virtual reality simulator, to assess its acceptability as a robotic surgery training tool and feasibility of its use, and to develop a supplementary training curriculum. SUBJECTS AND METHODS: This prospective, observational, and comparative study recruited novice (n = 20), intermediate (n = 15), and expert (n = 11) robotic surgeons as participants from institutions across the United Kingdom and at the 30th European Association of Urology Annual Meeting. Each participant completed nine surgical tasks across two modules on the simulator, followed by a questionnaire to evaluate subjective realism (face validity), task importance (content validity), feasibility, and acceptability. Outcome measures of novice, intermediate, and expert groups were compared using Mann-Whitney U-tests to assess construct validity. RESULTS: Construct validity was demonstrated in a total of 17/25 performance evaluation metrics (p < 0.001). Experts performed better than intermediates with regard to time taken to complete the first (p = 0.002) and second (p = 0.043) module, number of instrument collisions (p = 0.040), path length (p = .049), number of cuts >2 mm deep (p = 0.033), average distance from suture target (p = 0.015), and number of suture breakages (p = 0.038). Participants determined both the simulator console and psychomotor tasks as highly realistic (mean: 3.7/5) and important for surgical training (4.5/5), with system pedals (4.2/5) and knot tying task (4.6/5) scoring highest, respectively. The simulator was also rated as an acceptable (4.3/5) tool for training and its use highly feasible (4.3/5). CONCLUSION: Construct, face, and content validity was established for the RobotiX Mentor, and feasibility and acceptability of incorporation into surgical training were ascertained. The RobotiX Mentor shows potential as a valuable tool for training and assessment of trainees in robotic skills. Investigation of concurrent and predictive validity is necessary to complete validation, and evaluation of learning curves would provide insight into its value for training.

Critical appraisal of the differential effects of antihypertensive agents on arterial stiffness.

Increased central arterial stiffness, involving accelerated vascular ageing of the aorta, is a powerful and independent risk factor for early mortality and provides prognostic information above and beyond traditional risk factors for cardiovascular disease (CVD). Central arterial stiffness is an important determinant of pulse pressure; therefore, any pathological increase may result in left ventricular hypertrophy and impaired coronary perfusion. Central artery stiffness can be assessed noninvasively by measurement of aortic pulse wave velocity, which is the gold standard for measurement of arterial stiffness. Earlier, it was believed that changes in arterial stiffness, which are primarily influenced by long-term pressure-dependent structural changes, may be slowed but not reversed by pharmacotherapy. Recent studies with drugs that inhibit the renin-angiotensin-aldosterone system, advanced glycation end products crosslink breakers, and endothelin antagonists suggest that blood pressure (BP)-independent reduction and reversal of arterial stiffness are feasible. We review the recent literature on the differential effect of antihypertensive agents either as monotherapy or combination therapy on arterial stiffness. Arterial stiffness is an emerging therapeutic target for CVD risk reduction; however, further clinical trials are required to confirm whether BP-independent changes in arterial stiffness directly translate to a reduction in CVD events.