A prospective audit on the effect of training and educational workshops on the incidence of urethral catheterization injuries.

INTRODUCTION: The incidence of iatrogenic urethral catheterization (UC) injuries is approximately 0.3%. Resultant complications are associated with patient morbidity and unnecessary healthcare costs. Our aim was to investigate whether educational training workshops decreased the incidence of UC-related injuries. METHODS: A prospective audit was performed to calculate incidence, morbidity, and costs associated with iatrogenic UC injury from January to July 2015. Educational workshops were then conducted with healthcare staff and training modules for junior doctors. UC-related incidence, morbidity, and costs in the subsequent six-month period were recorded prospectively and compared with the previous data. RESULTS: The incidence of iatrogenic UC injuries was reduced from 4.3/1000 catheters inserted to 3.8/1000 catheters after the intervention (p=0.59). Morbidity from UC increased in the second half in the form of increase in cumulative additional inpatient hospital stay (22 to 79 days; p=0.25), incidence of urosepsis (n=2 to n=4), and need for operative intervention (n=1 to n=2). The cost of managing UC injuries almost doubled in the period after the training intervention (€50 449 to €90 100). CONCLUSIONS: Current forms of educational and training interventions for UC did not significantly change morbidity or cost of iatrogenic UC injuries despite a decrease in incidence. Improved and intensive training protocols are necessary for UC to prevent avoidable iatrogenic complications, as well as a safer urethral catheter design.

Evaluating the cost of iatrogenic urethral catheterisation injuries.

INTRODUCTION: Technique is vital to prevent urethral trauma during urethral catheterisation (UC). Education programmes are helpful but are not compulsory and safe UC remains operator dependent. Traumatic UC is associated with increased morbidity, length of stay, resource utilisation and surgical intervention. AIM: To determine the cost of iatrogenic urethral injuries managed in a tertiary referral centre over a 6-month period. METHODS: A 6-month prospective study monitored iatrogenic urethral injuries secondary to traumatic UC. Included were referrals from district hospitals and inpatient consultations relating to urethral injury caused by traumatic UC. The added cost of management was estimated. RESULTS: Thirteen iatrogenic urethral injuries were recorded in 6 months. Management included open surgery for a ruptured bladder (n = 1), flexible cystourethroscopy (n = 10), suprapubic catherisation (n = 4), 3-way catheterisation (n = 4) and catheter re-insertion under direct vision (n = 6). The cost of acute management of these injuries was approximately €50,000 including theatre costs, ambulance transfer, hospital stay, procedural and equipment costs and short-term follow-up care. CONCLUSION: Iatrogenic injuries during UC represent a significant cost burden to the healthcare system. Training programmes should be compulsory for all healthcare professionals routinely involved in catheterisation procedures.

An Unusual Case Of Urinary Bladder Arteriovenous Malformation.

A 45-year-old male presented with haematuria and urinary frequency. Computed Tomography (CT) urogram revealed gross thickening of the left bladder wall. Histology showed large vessels cuffed by eosinophonilic material suggestive of urinary bladder arteriovenous malformation (AVM). No further intervention was carried out as symptoms resolve after the resection. Follow up rigid cystoscopy and CT at 3 months showed resolution of all visible pathology and no evidence of recurrence.

Transurethral resection of the prostate--"now and then".

The number of transurethral resections of the prostate (TURP) performed each year is decreasing. The aim of this study was to assess a cohort of patients undergoing TURP and compare this to one twenty years earlier in terms of procedure, complications and outcomes. A retrospective comparative analysis of one hundred consecutive TURPs performed in 2010 was compared to one hundred cases performed in 1990. Fifty-five (55%) had a urinary catheter (UC) in situ pre-operatively in 2010 compared to 22 (22%) in 1990. The length of catheterisation time was significantly longer in 2010 compared with 1990 (average 65 days vs 20 days). Infective complications occurred in six (6%) patients in 2010 and three (3%) in the 1990 cohort. Patients who had UCs in situ preoperatively for longer periods had a higher rate of infective complications and more serious complications. This highlights the importance of early specialist referral for patients diaqnosed with urinary retention.

Delayed contrast-enhanced MRI to localize Botox after cystoscopic intravesical injection.

PURPOSE: There is a lack of studies to show localization of botulinum toxins (BoNT) within bladder wall and/or absorption rates. Our study examined the later distribution of BoNTA/gadolinium within the bladder wall by performing a delayed MRI scan after intravesical injection. This potentially may help to explain the level and mechanism at which BoNT may be producing its effect. METHODS: A prospective study enrolled 20 consecutive patients with neuropathic or idiopathic overactive bladders. The Aim of the study was to perform MRI 3 h post procedure. Botox 100-200 IU was reconstituted with 19 ml saline and 1 ml of gadolinium contrast. Intradetrusor injections were administered using a rigid 21F cystoscope with a total of 20 injections into bladder wall, including two into the trigone. The depth of injection was approximately 2 mm, without raising a bleb. One radiologist reviewed films and reported on the number of bladder walls with contrast, location, the presence of extravesical extravasation, contrast in distal ureter(s), and bladder wall thickness. RESULTS: Ninety percentage of patients had contrast within bladder wall. There was a variation in the number of bladder walls involved; 85 % had contrast seen in at least two walls. Also, a variation was noted in the extent of extravasation; 80 % showed some evidence. CONCLUSIONS: Diffusion of BoNT after intravesical injection is very common once bladder wall is breeched. Precise injection localization into muscle layer may not be as relevant to outcome as previously assumed. The assumption in our study that localization and diffusion of contrast also represents the localization of BoNT is open to critique as BoNT diffusion is potentially slower (Mehnert et al. in World J Urol 27(3):397-403, 2009). The absence of systemic symptoms after the injection in our series supports guidelines concerning the safety of procedure.

A 30-year experience of Millin's retropubic prostatectomy: Has this classic operation derived by a President of the College in Ireland stood the test of time?

INTRODUCTION: In patients with large gland volume, open prostatectomy/adenoma enucleation remains a valuable surgical option in treating large obstructing prostates. We report our series of open prostatectomies spanning 32 years from a single institution. PATIENTS AND METHODS: We retrospectively reviewed all patients who underwent open prostatectomy between 1980 and 2012. Patient demographical, clinical, pre- and postoperative data and final histology were retrieved from hospital in-patient enquiry system and chart review. RESULTS: A total of 161 patients underwent Millin's prostatectomy by seven surgeons between 1980 and 2012. The mean blood loss was 1,381 mls (range 300-3,675 mls). One-third (34%) of patients (n = 55) received a blood transfusion. The mean weight of prostate tissue removed was 119 g (median 112 g, range 17-372 g). 6.6 % of pathological specimens revealed incidental prostate cancer, of which 78% were well differentiated (Gleason score ≤ 6). The mean weight of prostate tissue removed in patients who received a transfusion was 124 g. Trial of micturition (TOM) was performed at a mean of 9 days (median 9 days, range 5-25 days) with 94% of patients having a successful trial of voiding. 6% of cases early in the series failed to void initially, but did so at later removal of catheter while still in hospital. 45 patients (28%) of patients developed peri- or postoperative complications. There were three deaths (1.9%). CONCLUSION: Open Millin's prostatectomy popularized over half a century ago continues to be a valuable option for the surgical treatment of high-volume prostate glands with excellent outcomes for patients.

Radical prostatectomy in the presence of ongoing refractory ESBL Escherichia coli bacterial prostatitis.

A 44-year-old Indian national with a prostate-specific antigen of 5.4 ng/mL underwent 12-core transrectal ultrasound-guided prostate biopsies. Following this, he had three hospital admissions with severe urosepsis secondary to extended spectrum ß lactamase (ESBL) producing Escherichia coli. He had recurrent sepsis immediately after discontinuation of intravenous meropenem to which the ESBL was sensitive. He proceeded to radical prostatectomy for intermediate-high risk Gleason 7 prostate cancer, while still on intravenous meropenem, 2 months after his biopsy. His prostatectomy involved a difficult dissection due to inflammatory changes and fibrosis after multiple septic episodes. He had complete resolution of infection after surgery with discontinuation of antibiotics on the third postoperative day, without any recurrence of sepsis.

A patient reported outcome measure (PROM) assessing quality of care in the urology hospital outpatient setting.

A prospective blind PROM (patient reported outcome measure) study performed in our urology department examined the outpatient-clinic experience. 104 questionnaires were completed. 23 patients (22%) felt the waiting times for appointments was excessive. 13 patients (13%) experienced difficulty in contacting administrative staff. 98 patients (94%) considered the waiting areas good but 31 patients (31%) considered lack of privacy an issue. Consultants saw 65 patients (63%). 62 patients (60%) expected to be seen by a consultant. 32 patients (31%) felt consultation with a different doctor on return visits was unsatisfactory. 76 patients (73%) "fully trusted" their doctors. 78 patients (75%) rated their visit excellent, 10 patients (10%) added comments. Despite frustration with waiting times, the experience of patients reflects a positive rapport and trust between patient and doctor.

An 11-year analysis of the prevalent uropathogens and the changing pattern of Escherichia coli antibiotic resistance in 38,530 community urinary tract infections, Dublin 1999-2009.

BACKGROUND: Knowledge of local antimicrobial resistance patterns is essential for evidence-based empirical antibiotic prescribing, and a cutoff point of 20% has been suggested as the level of resistance at which an agent should no longer be used empirically. We sought to identify the changing incidence of causative uropathogens over an 11-year period. We also examined the trends in antibiotic resistance encountered in both the pooled urine samples and those where the causative organism was Escherichia coli. PATIENT AND METHODS: A retrospective analysis of the antimicrobial resistance within the positive community urine isolates over the 11-year period, 1999 to 2009, in a single Dublin teaching hospital was performed. RESULTS: In total 38,530 positive urine samples processed at our laboratory originated in the community of which 23,838 (56.7%) had E. coli as the infecting organism. The prevalence of E. coli has been increasing in recent years in community UTIs with 70.4% of UTIs in the community caused by E.coli in 2009. Ampicillin and trimethoprim were the least-active agents against E. coli with mean 11-year resistance rates of 60.8 and 31.5%, respectively. Significant trends of increasing resistance over the 11-year period were identified for trimethoprim, co-amoxyclav, cefuroxime and gentamicin. Ciprofloxacin remains a reasonable empirical antibiotic choice in this community with an 11-year resistance rate of 10.6%. Higher antibiotic resistance rates were identified in the male population and in children. CONCLUSION: Resistance rates to commonly prescribed antibiotics are increasing significantly. This data will enable evidence-based empirical prescribing which will ensure more effective treatment and lessen the emergence of resistant uropathogens in the community.

Percutaneous nephrolithotomy in adult patients with spina bifida, severe spinal deformity and large renal stones.

AIMS: To present our experience in patients with spina bifida with severe spinal abnormality undergoing percutaneous nephrolithotomy (PCNL) for large stone burden. PATIENTS AND METHODS: A retrospective review identified five spina bifida patients with abnormal spinal curvature who had a PCNL for large kidney stones. The mean age was 28 years. In two patients, stones were on the concave side of the scoliotic spine further limiting percutaneous access. Mean stone burden was 940 mm2. All patients were paraplegic, three patients had symptomatic stone disease. We performed initial percutaneous renal access in radiology department and staged nephrolithotomy in operating room. Tract dilatation was accomplished using Amplatz dilators and a 24 Ch or 26 Ch nephroscope was used. Fragmentation and stone removal were accomplished in all patients using pneumatic and or ultrasound lithotripter and a retrieval grasper. RESULTS: No anaesthetic complications were recorded. One patient required multiple percutaneous tracts, four had single tract to access stones. Three patients were stone free after PCNL. One required second PCNL through the same tract and another patient had multiple adjunctive ESWL. All five patients were stone clear after the final procedure. Two patients required blood transfusion. No patient had major complication or admission to intensive care unit. CONCLUSIONS: Percutaneous nephrolithotomy in patients with spina bifida is challenging but safe. Detailed pre-operative anaesthetic assessment and precise uroradiological evaluation of renal anatomy is essential. Second-look PCNL and additional ESWL/URS treatment may be required to completely clear stones.

Management of recalcitrant urethral strictures with self-dilatation balloon catheter.

INTRODUCTION: Urethral strictures constitute a significant clinical problem that often requires long-term management. OBJECTIVE: To report the long-term outcomes of adjuvant home self-urethral dilatation of recurrent urethral strictures using a balloon catheter. MATERIALS AND METHODS: Male patients (N = 11), performing self-dilatation with a balloon catheter (minimum 24 months) were assessed by patient-reported outcome measures (PROMs) health questionnaire specific for post treatment assessment of men with urethral stricture disease. RESULTS: Median duration of balloon catheter use is 46.5 months, IQR (24-150). Patients performed self-balloon dilatation on average 1.4 times a week, median 1, IQR (1-2) to maintain the patency of their urethra. The mean PROMs LUTS score of the patients was 2.45, median 2, IQR (1-4). The median and mean Peeling score was 2 IQR (1-2). 100 % patient reported that they either very satisfied or satisfied with the overall outcome and QoL. CONCLUSIONS: Our initial experience of outpatient self-dilatation with a balloon dilatation is encouraging and is an acceptable inexpensive and simple treatment for patient maintains urethral patency and potentially decreases stricture recurrence.

Survival after incidental prostate cancer diagnosis at transurethral resection of prostate: 10-year outcomes.

BACKGROUND: The most appropriate management of incidental prostate cancers diagnosed at transurethral resection of prostate has been debated. It is important to determine the long-term outcomes to establish an appropriate management in patients with incidental prostate cancer. AIMS: We aim to determine 10-year survival and to identify the factors of worse prognosis of incidental prostate cancers diagnosed at transurethral resection of prostate. METHODS: A retrospective analysis of patients with pT1a-pT1b prostate cancers diagnosed between 1998 and 2003. Medical notes, PSA and pathology results were reviewed. Overall and cancer specific survival was calculated at mean 10-year follow-up. RESULTS: Sixty patients with incidental prostate cancer were identified (pT1a = 18, pT1b = 42). Fifty-one percents of the patients were managed on a watchful waiting strategy with overall 84% survival and 9.7% cancer specific mortality. Twenty patients (all with pT1b) received hormone therapy. Overall survival in this cohort was 50% with 20% cancer specific mortality. Nine patients received curative therapy (Radical prostatectomy = 4, Radiotherapy = 5). In this group, overall survival was 88% with no cancer specific mortality. CONCLUSIONS: Stage pT1a disease and preoperative low PSA were associated with favourable survival. However, for pT1b and/or high Gleason score (≥7), mortality was comparatively higher. Hence, patients with high Gleason score and/or pT1b disease should be considered for curative therapy. Additionally, active surveillance may have a role in selected men with incidental prostate cancer.

Extended long term functional outcome of inflatable penile prosthesis in a single institution.

We sought to evaluate the extended long term functional outcome of the AMS700 three piece inflatable prosthesis in men with erectile dysfunction in a single urological department and assess our revision rates. Patients that underwent first-time insertion or revision of an AMS700 3 piece inflatable penile prosthesis between 1984-2007 were included. Data was obtained from medical records and long term follow up of patients was conducted by telephone interview. The medical records of 38 patients were available for review. Of these 38 men, 56 prostheses were inserted. The mean follow up was 8.4 years (101 months). The revision rate at 50 months postoperatively was 7/38 (18%). The overall revision rate was 18/38 (47%). The mean time to revision in these 18 patients was 72 months (12-156 months) after initial insertion of AMS700 penile prosthesis. This study highlights that with longer follow u revision rates markedly increase after 72 months.

Scrotal signs and symptoms in the general population, the value of testis self-examination and the pitfalls of a scrotal screening programme: is the two-week rule relevant?

PURPOSE: Testicular symptoms/lumps are a cause of concern, anxiety and possible diagnostic dilemma for patient and general practitioner. The majority of scrotal pathology is benign in nature and results in a huge workload. The main aim of this study was to determine the relationship between scrotal symptoms, previous scrotal surgery, testicular self-examination and awareness of scrotal abnormalities. Secondarily, we sought to determine the scrotal findings in men enrolled in a consultant urologist-directed screening programme. METHODS: There were 677 men surveyed on their performance of TSE. They were also asked about scrotal symptoms and prior surgery, before undergoing blinded physical examination by one of four consultant urologists. RESULTS: Among the participants, 9.8% of men had scrotal symptoms with 55% of these having a normal scrotal examination and the rest having benign pathology. A number of men who had undergone previous scrotal surgery (13%) had no clinical findings detected on scrotal examination. No subject was found to have testis cancer; 20.9% had a benign scrotal or inguinal condition detected with the majority (65%) not aware of the abnormality. Men who demonstrate a superior awareness of their scrotal abnormalities were more likely to perform TSE. CONCLUSIONS: Increased awareness of scrotal abnormalities combined with TSE may have a role in improving detection of significant testicular pathology. However, the high prevalence of benign scrotal conditions, of which most men were unaware, may serve to raise anxiety in the patient and general practitioner. We believe there is no role for a one-stop scrotal anxiety clinic, as the costs do not justify the benefits.

Fistulization in a locally advanced case of squamous cell carcinoma of the prostate.

Squamous cell carcinoma of the prostate gland is very rare, constituting 0.5%-1% of all prostatic malignancies. Though it has a similar clinical presentation to prostate cancer, the tumor is more aggressive, spreading to bone, liver and lung. The median survival time is approximately 14 months. Diagnosis is exclusively by histology. Therapeutic options may include radical surgery, radiotherapy, chemotherapy, hormonal therapy or a combination of these treatments. We present a case of locally advanced squamous cell carcinoma of the prostate and comment on its management and subsequent disease related complication.

A review of repeat prostate biopsies and the influence of technique on cancer detection: our experience.

BACKGROUND: Follow-up of patients with an initial negative prostate biopsy, but surrounding whom a suspicion of prostate cancer persists, is difficult. In addition, debate exists as to the optimal technique for repeat prostate biopsy. AIMS: To assess the cancer detection rate on repeat prostate biopsy. METHODS: We reviewed patients who underwent prostate biopsy in our department in 2005 who had >or=1 previous biopsy within the preceding 5 years. Cancer detection rate on repeat biopsy and the influence of the number of biopsy cores were recorded. RESULTS: Cancer detection rate on repeat biopsy was 15.4%, with approximately 60% detected on the first repeat biopsy, but approximately 10% not confirmed until the fourth repeat biopsy. Gleason score was similar regardless of the time of diagnosis (6.1-6.5). Mean interval between first biopsy and cancer diagnosis (range 18-55 months) depended on the number of repeat procedures. There was an association between the number of biopsy cores and cancer detection. CONCLUSIONS: This study supports the practice of increasing the number of cores taken on initial and first repeat biopsy to maximise prostate cancer detection and reduce the overall number of biopsies needed.

Evaluation of suspected renal colic with noncontrast CT in the emergency department: a single institution study.

BACKGROUND AND PURPOSE: Noncontrast CT (NCCT) has become the standard Imaging study in the emergency department (ED) diagnosis of nephro- and ureterolithiasis. We undertook to audit the results from the first 500 NCCTs performed for patients presenting to the ED with suspected renal colic. PATIENTS AND METHODS: In a retrospective study at one institution from October 2003 to February 2006, 500 patients with suspected stone disease were investigated. In the study, NCCT findings, patient clinical records, and urinary microscopy results were evaluated for 166 women and 334 men. RESULTS: Renal or ureteral calculi were identified in 279 (56%) of NCCTs performed. Of the 500, 112 (19%) NCCTs performed identified unexpected intra-abdominal pathology. When the findings deemed to be of low clinical significance were excluded, the number of scans with additional pathology amounted to 67 (13%). These included vascular emergencies, new cancer diagnoses, and gastrointestinal conditions. CONCLUSIONS: The variety of diagnoses found unexpectedly on the NCCT that alter a patient's treatment demonstrates the pivotal role of NCCT in the triage of these patients rapidly toward optimal therapy. The rapid acquisition time of NCCT has enabled definitive ED patient diagnosis and less bed occupancy for clinically insignificant calculi.

Urology out-patient non-attenders: are we wasting our time?

BACKGROUND: Out-patient non-attendance leads to inefficiency and patient morbidity. AIMS AND METHODS: A phone survey of urology out-patient non-attenders over 1-month was performed to determine reasons for non-attendance, to identify patients who could be discharged, and the manner in which patients want reminders. RESULTS: Seventy-six non-attenders were contacted. Fourteen were GP referred new patients. The reason for non-attendance (n = 10) was due to patient issues. Of the patients due for review (n = 62), it was a first non-attendance in 56. Only 41 (66%) claimed to have received notification or appointment cards. Eight patients said they were written to and 13 (21%) denied either receiving a written notification or an appointment card. Only eight patients rang to confirm/change their appointment. Ninety-nine percent said that they would like a further appointment by text message (34%), phone (37%), letter (36%) or email (6%). CONCLUSIONS: We now hope to implement a number of methods to further reduce non-attendance rates based on the findings in this study.