Optimising pre-operative imaging-surgery intervals for stones.

Introduction and objectives: The NICE guidelines for acute ureteric colic recommend diagnostic imaging, definitive management and definitive care within 24 and 48 h of symptoms and 4 weeks of temporisation, respectively. However, the NHS reality is fraught with long waiting times to definitive treatment, further compounded by a progressively increasing stone burden, paucity of on-site lithotripters and a decrease in non-cancer elective theatre sessions during the COVID-19 pandemic. By the time patients attended the elective surgeries, their reference images (RIs) were often significantly out of date. Scant direction exists on what interval between imaging and surgery invalidates the usefulness of the RIs in providing surgical guidance.This study aimed to evaluate the role of imaging-surgery intervals (ISIs) on upper tract stone negative surgery outcomes and derive a cut-off ISI warranting updated images, with a view to improving efficiency and patient safety. Materials and methods: Upper tract stone surgeries were retrospectively assessed. Each renal unit was considered independently in bilateral stones. Cases were grouped into renal/pelvic (referred to as 'RENAL') and URETERIC stones. Data retrieved included the ISI, intra-operative disparity (IOD) between stone-related features on RIs and the surgical findings. Receiver operating curves (ROCs) were used to determine ISI cut-offs more predictive of IODs. Results: Four hundred and twenty-seven surgeries on 174 (40.7%) RENAL and 253 (59.3%) URETERIC stones were appraised. No stones were found intraoperatively in 52 (12.1%) patients. Longer ISIs were associated with IODs, especially with URETERIC stones (p = 0.011, CI95 0.63; 4.84). The derived ROC ISI cut-offs beyond which IODs, including negative surgeries, were more likely were 9 weeks for URETERIC (AUC: 63%, CI95 0.56; 0.70) and 19 weeks (AUC: 58.6%, CI95 0.50; 0.68) for RENAL stones, respectively. Conclusion: There is a need to update reference imaging done more than 9 or 19 weeks before surgery for URETERIC and RENAL stones, respectively.

Combined intrarectal lidocaine gel and periprostatic nerve block: A 'balanced' anaesthesia for transrectal ultrasound-guided prostate biopsy?

BACKGROUND AND AIM: Periprostatic nerve block (PNB) which appears to be the gold standard for pain relief during transrectal ultrasound-guided prostate (TrusP) biopsy has been proven to be lacking in providing satisfactory anaesthesia during transrectal ultrasound (Trus) probe insertion into the anorectum necessitating the addition of another technique to produce a 'balanced' anaesthesia. The aim of this study was to determine whether combined intrarectal lidocaine gel and periprostatic nerve block (cGPNB) will provide adequate anaesthesia at all stages of TrusP compared with caudal block (CB). PATIENTS AND METHODS: Data were prospectively collected from patients with indications for TrusP who were randomly assigned to either cGPNB (Group A) or CB (Group B). Comparative analysis of the numerical rating pain score (NRS) between two groups was done after administration of anaesthesia, Trus probe insertion, biopsy needle puncture of the prostate and 1 h after biopsy. RESULTS: There were 56 patients in Group A and 53 in Group B. There was no significant difference in NRS grouping between the two arms of the study after administration of anaesthesia (P = 0.93), biopsy needle puncture of the prostate (P = 0.28) and 1 h after the procedure (P = 0.39). There was no statistically significant difference in the number of patients with no/mild pain between the two arms of the study during probe insertion (P = 0.65). None of the patients in both arms of the study had severe pain. Across Group A and B, 35 (62.5%) versus 40 (75.5%), 20 (35.7%) versus 11 (20.8%) and 1 (1.8%) versus 2 (3.8%) adjudged the procedure as very tolerable, fairly tolerable and intolerable respectively (P = 0.20). All the patients in Group A versus 49 (92.5%) in Group B will choose the same anaesthesia for subsequent biopsies (P = 0.11). CONCLUSIONS: cGPNB provides balanced anaesthesia at all stages of TrusP with excellent patient tolerability.

The role of transrectal ultrasound-guided fine-needle aspiration biopsy in the diagnosis of prostate cancer: Sextant versus extended protocol.

AIM AND OBJECTIVES: The aim of this study is to compare the prostate cancer detection rates of sextant and extended transrectal ultrasound (TRUS)-guided fine-needle aspiration biopsy (FNAB) protocols. MATERIALS AND METHODS: This was a prospective study of 96 patients investigated for prostate cancer. An extended 10-aspiration TRUS-guided FNAB using a 22G Echotip Chiba needle was performed. Inclusion criteria included the presence of one or more of the following: Abnormal digital rectal examination (DRE) findings, persistently elevated prostate specific antigen, and abnormal prostatic imaging. A set of traditional sextant aspirations were carried out as well as four laterally guided aspirations taken from the middle base of the peripheral zone on either side. The cancer detection rates of sextant and extended (combination of sextant and lateral) FNAB protocols were determined and compared. The value of P < 0.05 was considered statistically significant. RESULTS: The overall cancer detection rate was 24%. Benign cases were reported in 71.8% of patients and 4.2% reported as suspicious. Of the 23 patients' aspirations positive for malignancy, 16 (69.6%) were detectable by the sextant protocol while the lateral protocol detected 21 (91.3%). Two cancers were detected by the sextant protocol only (where the lateral technique was negative for malignancy), 7 cancers were detected by the lateral protocol only while 14 cancers were positive in both the sextant and lateral protocols. The extended protocol showed a statistically significant 30.4% increase in cancer detection over the traditional sextant (P = 0.007). CONCLUSION: The extended protocol rather than the sextant protocol should be offered to patients who require FNAB of the prostate as the optimum FNAB protocol.

Renal cell carcinoma in a horseshoe kidney: Report of a rare disease.

A horseshoe kidney (HSK) is the most common congenital renal fusion anomaly. HSKs are more likely than normal kidneys to have associated problems of stones, ureteropelvic junction obstruction, stasis and infection. However, they do not have an increased incidence of renal cell carcinoma when compared to normal kidneys. Due to its rarity, accurate diagnosis may be difficult. Of similar significance is the fact that problems may arise during surgery on these kidneys due to altered anatomy and aberrant blood supply. We report a case of HSK with a renal tumour in a 69-year-old woman and highlight our challenges in the management of the case. To the best of our knowledge, this is the first reported case of a tumour in an HSK in West Africa.

Extraperitoneally Ruptured, Everted, and Prolapsed Bladder: A Very Rare Complication of Pelvic Injury.

Traumatic rupture of the bladder with eversion and protrusion via the perineum is a rare complication of pelvic injury. We present a 36-year-old lady who sustained severe pelvic injury with a bleeding right-sided deep perineal laceration. She had closed reduction of pelvic fracture with pelvic banding and primary closure of perineal laceration at a private hospital. She subsequently had dehiscence of repaired perineal laceration with protrusion of fleshy mass from vulva and leakage of urine per perineum five weeks later. Examination revealed a fleshy mucosa-like mass protruding anteriorly with a bridge of tissue between it and right anterolateral vaginal wall. Upward pressure on this mass revealed the bladder neck and ureteric orifices. She had perineal and pelvic exploration with findings of prolapsed, completely everted bladder wall through a transverse anterior bladder wall rent via the perineum, and an unstable B1 pelvic disruption. She had repair of the ruptured, everted, and prolapsed bladder, double-plate and screw fixation of disrupted pelvis and repair of the pelvic/perineal defect. She commenced physiotherapy and ambulation a week after surgery. Patient now walks normally and is continent of urine. We conclude that the intrinsic urethral continent mechanism plays a significant role in maintaining continence in females.