Emergency Urology procedures during the COVID-19 pandemic in the UK: A 3-month prospective study.

OBJECTIVE: COVID-19 resulted in Regional tiered restrictions being introduced across the UK with subsequent implications for planned and emergency surgical care. Specific to Merseyside, Tier 4, Tier 2 and Tier 5 restrictions were introduced in late 2020 and early 2021. The purpose of this study was to examine the nature and workload of emergency urological procedures during three different national lockdown Tiers in the North West of England. METHOD: A 3-month prospective study examining all emergency urological activity was conducted from November 2020 when Tier 4 restrictions were introduced and included Tier 2 restrictions in December and then concluded at the end of January 2021 when Tier 5 restrictions were in place. Data was obtained by identifying patients using the electronic theatre listing system. RESULTS: A total of 71 emergency cases were performed (24 in November (Tier 4), 28 in December (Tier 2), 19 in January 2021 (Tier 5)) with 15 different types of procedures performed. The most frequently performed procedure was stent insertion (36), followed by scrotal exploration (10). The least commonly performed procedure was suprapubic catheter insertion under general anaesthesia (1). One patient required transfer to a different hospital. In total 6 calls were made by general surgery and 3 by gynaecology for urgent urological assistance in theatre. Three urology patients returned to the theatre as emergencies following elective procedures. CONCLUSION: Unlike the Spring lockdown, acute urological presentations requiring operative intervention still presented daily. Of the 71 cases performed, most occurred in Tier 2. Stent insertion was the most commonly performed procedure, with the majority of the cases performed by registrars.

The role of dry-lab and cadaveric simulation for cystoscopy and intravesical Botulinum toxin injections.

BACKGROUND: The aim of this study is to assess validity of the ETXY Multifunctional trainer (ProDelphus, Olinda, Pernambuco, Brazil), a bench-top dry-lab model for simulation of cystoscopy and intravesical injections of Botulinum Toxin A (BTX-A) injections, in terms of educational value, feasibility and acceptability as well as evaluating the use of fresh frozen cadavers for intravesical BTX-A injections. METHODS: Prospective study with novice trainees and urologists (n=58) trained by experts (n=14) in a 30-min hands-on training session in intravesical administration of BTX-A over 6 training sessions throughout one year. Outcome measures were demonstrated through distribution and analysis of evaluation surveys on a 5-point Likert scale. RESULTS: There were 56 participants (96.6%) believed that the model has a role in training for the procedure. Participants also reported the training being an important confidence-booster for performing BTX-A injections (mean: 4.05/5) and useful for teaching procedural steps (mean: 3.89). Experts highly rated the realism of the simulator especially in simulation of needle penetration (mean: 3.98) and delivery (mean 4.03). Fresh frozen cadavers had a mean realism rating of 4.54 and participants affirmed that they should be routinely used for training and assessment (mean: 3.92). CONCLUSIONS: This study demonstrated face and content validity in addition to establishing the feasibility and acceptability of the ETXY Multifunctional model in the training of intravesical BTX-A administration. Additionally, the simulator demonstrated educational value and fresh frozen cadavers were shown to be the preferred simulation modality for this procedure. Further evaluation in randomised controlled studies is needed to demonstrate higher evidence quality.

A novel cadaveric simulation program in urology.

OBJECTIVE: To evaluate the urology human cadaver training program developed by the British Association of Urological Surgeons. DESIGN: This prospective, observational comparative study recruited urology residents, with different levels of experience, in 2 sessions of a 3-day modular cadaveric operative urology training. Participants performed various procedures on fresh-frozen cadaveric specimens, as per module, supervised by certified urological surgeons. At the conclusion of each module, all residents and faculty were invited to complete an evaluation survey. SETTING: The training days were hosted by the British Association of Urological Surgeons at the University of Manchester Surgical Skills and Simulation Centre. PARTICIPANTS: A total of 81 urology residents were recruited, with a maximum of 14 participants attending each module, over 2 sessions. We allocated 2 participants to each cadaver with access to all necessary equipment and guidance. RESULTS: A total of 102 evaluation surveys were received from the trainees and faculty; a response rate of 94%. All procedures scored a mean of 3 on 5 for face validity, which is higher than the acceptability range. Regarding content validity, participants and faculty rated all aspects ≥3 on 5. Respondents held a positive view of the cadaver sessions and believed them to be useful for learning anatomy and steps of an operation (mean = 4.54) and as a confidence booster for performing a procedure (mean = 4.33). Furthermore, it was thought that the training program significantly improved skills (mean = 4.11), gave transferrable skills for the operating room (mean = 4.21), and was feasible to be incorporated into training programs (mean = 4.29). Human cadaveric simulation was rated as the best mode of simulation-based training for all the procedures in the curriculum. CONCLUSIONS: This study on cadaveric simulation training demonstrated face and content validities. It also showed feasibility, acceptability, a high value for educational influence and cost-effectiveness for cadaveric simulation. A simulation-based training pathway has been proposed for effective procedural training in urology.

UK radical prostatectomy outcomes and surgeon case volume: based on an analysis of the British Association of Urological Surgeons Complex Operations Database.

OBJECTIVE: To undertake a detailed analysis of the British Association of Urological Surgeons (BAUS) Section of Oncology Complex Operations Database to report UK outcomes of radical prostatectomy (RP) with particular reference to the case volume of the operating surgeon. MATERIALS AND METHODS: All RP entries on the BAUS complex operations database were extracted from its commencement in January 2004 to September 2009. Patient age, prostate-specific antigen (PSA) levels, clinical tumour stage and biopsy Gleason score were analyzed together with operative variables, including the surgical approach, lymphadenectomy status, blood loss, hospital length of stay and individual surgeon case volume. The postoperative variables assessed included surgical specimen Gleason score and pathological tumour stage, prostate weight and the presence of positive surgical margins (PSM), as well as evidence of biochemical recurrence. RESULTS: A total of 8032 RP cases were entered on the database and Follow-up data was available on 4206 cases. Mean patient age was 61.8 years and the mean presenting PSA was 8.3 ng/mL. Open RP procedures were performed on 5429 patients and laparoscopic RP on 2219. The positive surgical margin (PSM) rate for the entire series was 38%. Analysis of PSM by pathological stage revealed a pT2 PSM rate of 24%. Multivariate analysis of variables which might affect PSM revealed pre-operative clinical TNM stage, surgeon case volume, RP specimen Gleason score and pathological TNM stage were significant parameters (P < 0.01). When prostate weight and PSM status were analysed, these was a significant association between smaller prostate weight and PSM status. Interestingly, 45% of high grade Gleason 8-10 needle biopsy cancers were downgraded to Gleason scores 7 or less on RP analysis. Analysis of annual surgeon caseload revealed that 54% of surgeons performed an average of less than 10 procedures per annum and 6% of surgeons performed an average of 30 or more procedures per annum. When individual outcome variables where examined against surgeon case activity it was demonstrated that outcomes are clearly improved beyond 20 cases and there is a trend to continued improvement up to the series maximum of 40 cases per annum. CONCLUSIONS: High volume surgeons have less peri-operative and postoperative complications and better surgical and disease-free outcomes than low volume surgeons. In the UK, raising the current minimum Improving Outcomes Guidance threshold from five RP cases per surgeon per annum to no less than 20 (and ideally to 35 or more cases per annum) could potentially improve overall outcomes.

Radical prostatectomy practice in England.

PURPOSE: As there is paucity of data on radical prostatectomy (RP) as a primary treatment for patients with localized prostate cancer, we analyzed the trends in the RP practice in England. MATERIALS AND METHODS: This study was carried out on 14 300 patients who underwent RP for carcinoma of the prostate. Database was prepared from hospital episode statistics of the Department of Health in England. National trends in RP practice were summarized as well as volume outcome analysis. RESULTS: Annual number of RPs exponentially increased from 972 (1998 to 1999) to 3092 (2004 to 2005). Laparoscopic RPs increased from 2 to 257 over the study period. Median waiting duration increased by more than 10 days (13 days). Significant decrease in median length of hospital stay from 8 (range, 7 to 10) days to 6 (range, 5 to 8) days was observed (P < .001). More than 90% mortality was seen in patients of ≥ 60 years of age. Significant inverse correlation was found between the hospital volume (Odds Ratio: 0.40) and in-hospital mortality rate following RP. High volume surgeons (≥ 16) and high volume hospitals (≥ 26) had significantly lower mortality (Odds Ratio: 0.32) and shorter in-hospital stay in comparison to low volume surgeons and hospitals. CONCLUSION: There is an exponential increase in the number of RPs with an increasing trend towards laparoscopic RP in England. This study showed a significant inverse correlation between provider volume (hospital and surgeon) and outcome (in-hospital mortality and hospital stay) for RP in England; thus, supporting the recommendations for centralization of care for complex radical procedures, including RP.

Orchidopexy for undescended testis in England: is it evidence based?

BACKGROUND: Current evidence-based recommendations are that orchidopexy for undescended testis should be performed before 18 months of age. We examined hospital episode statistics data for all orchidopexies performed in England over a 9-year period to see how well this guideline was implemented in current practice and examine trends. METHODS: Hospital episode statistics data were extracted from 1997 to 2005. Boys with both an Office of Population, Census and Surveys Fourth Revision code for orchidopexy and an International Classification of Diseases, 10th Revision code for undescended testis were included. RESULTS: Four thousand ninety-four (+/-21) orchidopexies were performed annually. Between 1997 and 2005, the proportion of boys who were younger than 2 years at the time of orchidopexy increased from 15.8% to 28.5% (P < .005, chi(2) test). When adjusted for age and population, there was a secondary peak of incidence at 8 to 10 years. Overall, 46.0% of procedures were performed by paediatric surgeons, 32.1% by general surgeons, and 21.2% by urologists. Over the 9-year study period, an increasing proportion of orchidopexies were performed by paediatric surgeons (P < .001, chi(2)). CONCLUSIONS: Only 1 in 5 boys is operated on at an "evidence-based" age. The trend has been for more boys to receive surgery at an appropriate age, although the level remains unacceptably low. The reasons are likely to be multifactorial but may partly be explained by secondary testicular ascent.

Radical cystectomy: defining the threshold for a surgeon to achieve optimum outcomes.

BACKGROUND: The reorganisation of cancer services in England will result in the creation of specialist high volume cancer surgery centres. Studies have suggested a relationship between increasing surgical volume and improved outcomes in urological pelvic cancer surgery, although to date, they have pre-defined the definition of "high" and "low" volume surgeons. AIM: To derive the minimum caseload a surgeon requires to achieve optimum outcomes and to examine the effect of the operating centre size upon individual surgeon's outcomes. METHODS: All cystectomies performed for bladder cancer in England over 5 years were analysed from Hospital Episode Statistics (HES) data. Statistical analysis was undertaken to describe the relationship between each surgeon's annual case volume and two OUTCOME MEASURES: in-hospital mortality rate, and hospital stay. The surgeon's outcomes were then analysed with respect to the overall level of activity in their operating centre. RESULTS: A total of 6308 cystectomies were performed; the mean number of surgeons performing them annually was 327 with an overall mortality rate of 5.53%. A significant inverse correlation (-0.968, p<0.01) was found between case volume and mortality rate. Applying 95% confidence interval estimation, the minimum caseload required to achieve the lowest mortality rate was eight procedures per year. Increasing caseload beyond eight operations per year did not produce a significant reduction in mortality rate. CONCLUSION: Analysis of HES data confirms an inverse relationship between surgeon's caseload and mortality for radical cystectomy. A caseload of eight operations per year is associated with the lowest mortality rate.

A randomized controlled trial of topical glyceryl trinitrate before transrectal ultrasonography-guided biopsy of the prostate.

OBJECTIVES: To evaluate the use of topical glyceryl trinitrate (GTN) ointment as an adjunct to periprostatic nerve block in reducing pain associated with transrectal ultrasonography (TRUS)-guided prostatic biopsy. PATIENTS AND METHODS: In all, 148 consecutive patients (mean age 67.0 years) having their first TRUS-guided biopsy were randomized to receive either 0.2% GTN ointment or placebo 10 min before biopsy. All patients had a biopsy preceded by an injection with 10 mL of 1% lidocaine local anaesthesia. A 10-point visual analogue score was used to record 'Overall discomfort due to the presence of the probe', the biopsy itself and pain after the procedure. RESULTS: There was no significant difference in age, PSA level and prostate volume between the groups. There was a significantly lower mean pain score due to probe insertion in the GTN than placebo group (1.94 vs 3.24, P < 0.01); pain perception was lower for the whole procedure in the GTN group, and was most pronounced in men aged <60 years (2.13 vs 4.61, P < 0.005). CONCLUSIONS: Topical GTN ointment is safe and effective in reducing the discomfort associated with TRUS-guided biopsy of the prostate, in particular the insertion of the ultrasound probe. It might be of maximum benefit in the younger patient and those having a repeat biopsy who previously failed to tolerate the procedure well.

Site of local anaesthesia in transrectal ultrasonography-guided 12-core prostate biopsy: does it make a difference?

OBJECTIVE: To prospectively compare the efficacy of bi-basal vs bi-apical periprostatic nerve block (PPNB) during 12-core prostate biopsy guided by transrectal ultrasonography (TRUS), and to evaluate the pain experienced on inserting the probe compared to the biopsy procedure, as PPNB with lignocaine local anaesthesia has been used for over a decade for minimizing pain during prostatic biopsy. PATIENTS AND METHODS: In all, 143 men who were to have a TRUS-guided prostate biopsy were systematically randomized to two groups, to receive PPNB at the apex or base. A 10-cm visual analogue score was used to record the pain experienced during probe insertion, the biopsy and just before to leaving the department . RESULTS: The mean pain score on biopsy in the apical group was similar to that of the basal group (apex 1.9, base 1.6, P = 0.36). Probe introduction produced a significantly higher pain score (probe 2.2, biopsy 1.7, P < 0.001) than at the biopsy. CONCLUSIONS: Patients who experienced greater pain with the introduction of the probe also reported more pain with the biopsy procedure. The site of local anaesthetic before prostatic biopsy showed no significant difference in pain scores. Older men tolerated the procedure better. Analgesia after PPNB at near either the apex or base appears equal, regardless of the site of injection. We suggest that topical perianal anaesthetic agents could significantly reduce not only pain perception, but also improve tolerance.

Defining the minimum hospital case-load to achieve optimum outcomes in radical cystectomy.

OBJECTIVE: To define 'high-' and 'low-' volume hospitals for radical cystectomy, and the minimum caseload required for a hospital to achieve optimum outcomes, as a relationship between increasing surgical case volume and improved outcomes in radical urological surgery has been suggested in recent North American studies. METHODS: All cystectomies for urological cancer in England over 5 years were analysed from Hospital Episode Statistics (HES) data. The data were analysed statistically to describe the relationship between each hospital's annual case volume and two outcome measures: in-hospital mortality rate (MR) and hospital stay. RESULTS: In all, there were 6317 cystectomies in 210 centres, with an overall MR of 5.6%. There was a significant inverse correlation (-0.733, P < 0.01) between hospital case volume and MR. Applying 95% confidence intervals, the minimum caseload required to achieve optimum outcomes was 11 procedures/year. Increasing the caseload beyond this minimum did not produce a significant reduction in MR. CONCLUSION: Analysis of HES data confirms an inverse relationship between hospital caseload and mortality for radical cystectomy. A caseload of 11 operations/year is associated with the lowest MR.