Discrete-choice experiment to analyse preferences for centralizing specialist cancer surgery services.

BACKGROUND: Centralizing specialist cancer surgery services aims to reduce variations in quality of care and improve patient outcomes, but increases travel demands on patients and families. This study aimed to evaluate preferences of patients, health professionals and members of the public for the characteristics associated with centralization. METHODS: A discrete-choice experiment was conducted, using paper and electronic surveys. Participants comprised: former and current patients (at any stage of treatment) with prostate, bladder, kidney or oesophagogastric cancer who previously participated in the National Cancer Patient Experience Survey; health professionals with experience of cancer care (11 types including surgeons, nurses and oncologists); and members of the public. Choice scenarios were based on the following attributes: travel time to hospital, risk of serious complications, risk of death, annual number of operations at the centre, access to a specialist multidisciplinary team (MDT) and specialist surgeon cover after surgery. RESULTS: Responses were obtained from 444 individuals (206 patients, 111 health professionals and 127 members of the public). The response rate was 52·8 per cent for the patient sample; it was unknown for the other groups as the survey was distributed via multiple overlapping methods. Preferences were particularly influenced by risk of complications, risk of death and access to a specialist MDT. Participants were willing to travel, on average, 75 min longer in order to reduce their risk of complications by 1 per cent, and over 5 h longer to reduce risk of death by 1 per cent. Findings were similar across groups. CONCLUSION: Respondents' preferences in this selected sample were consistent with centralization.

The economic implications of unsuspected findings from CT urography performed for haematuria.

OBJECTIVES: We set out to determine the prevalence of unsuspected findings from CT urography (CTU) performed for haematuria and to evaluate the economic implications associated with the subsequent management of these findings. METHODS: We analysed the results of 778 consecutive CTU scans performed in a haematuria clinic between 2008 and 2010. We excluded cases where diagnosis of an abnormality had been made prior to CTU. Costs incurred during the follow-up of unsuspected findings were calculated following guidance set out in the NHS Costing Manual 2009/10. RESULTS: 778 CTU scans were performed for patients attending a haematuria clinic from 2008 to 2010. 455 men and 323 women underwent CTU scan; they had a median age of 62 years. 56% of scans were found to have unexpected extra-urinary findings (587 abnormalities in 439 scans). Common findings included diverticular disease (138, 17.7%), adrenal masses [85, 10.9%; 40 (5.1%) of which were indeterminate], lung abnormalities (67, 8.6%), gall bladders containing calculi (44, 5.7%), adnexal cysts (25, 7.7% of women) and aortic aneurysms (18, 2.3%). These findings led to a total of 136 outpatient appointments, 88 radiological investigations and 11 procedures (4 of which were major). The overall cost incurred was £47,366, or £60 per patient. CONCLUSION: CTU is associated with a high rate of unsuspected findings. There is an economic implication to performing CT scanning in this setting, in which further unanticipated investigation and treatment cost is approximately £60 per patient.

National review of urology outpatient practice in the UK.

OBJECTIVE: To audit the current UK outpatient workload and compare this to the national standards as set out by the British Association of Urological Surgeons (BAUS) in A Quality Urological Service for Patients in the New Millennium published in October 2000. PARTICIPANTS: 520 UK (NHS) and 21 Republic of Ireland (non-NHS) consultant urologists registered with BAUS in 2000. MAIN OUTCOME MEASURES: Extent to which consultant urologists are able to comply with guidelines set out by their specialist association, the BAUS and by the Royal College of Surgeons of England. RESULTS: The questionnaire return rate was 61% (318/520; regional range 42%-75%). The median "routine" clinics/week was two (1-5) with a mean of 13 (1-40) new and 26 (7-80) follow ups. Fifteen percent (49/318) of consultants worked alone in clinic; of the remainder assistance included specialist registrar 67% (212/318), staff grade/associate specialist 32% (102/318), senior house officer 53% (172/318), and pre-registration house officer 2% (7/318). Only 21% (66/318; regional range 0%-46%) of responding consultants followed the BAUS recommendations for outpatient workload/manpower. CONCLUSIONS: A minority of consultants are able to adhere to the outpatient workload guidelines as set out by BAUS council in 2000. In addition, there appears to be significant variations within and between training regions. Development of this project into a regional audit tool may allow intraregional guideline formation governing hospital outpatient workload.

Comparison of the cellular molecular stress responses after treatments used in bladder cancer.

OBJECTIVE: To investigate the molecular stress responses related to the quality of recovery of normal tissue after various treatments for bladder cancer, i.e. hyperthermia, ionizing radiation, mitomycin-C and 5-aminolaevulinic acid photodynamic therapy (ALA-PDT). MATERIALS AND METHODS: The study focused particularly on intracellular fibroblast levels of heat-shock protein-47 (HSP47) and HSP72, which are associated with collagen metabolism and the development of tolerance to repeated treatment, respectively. Iso-effective treatment doses (50% clonogenic cell survival) of each method were delivered to a 3T6 murine fibroblast model. Intracellular extracts were analysed at 3, 6, 9, 12 and 24 h after treatment, using Western blot analysis to compare the levels of HSP47 and HSP72. Time-matched treatment and control groups were quantified by comparison with actin and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) expression using appropriate software. RESULTS: There were various changes in levels of HSP expression with treatment method; HSP47 levels were significantly higher after hyperthermia and radiation but not with mitomycin-C or ALA-PDT. HSP72 levels were significantly higher with all methods except ALA-PDT. CONCLUSIONS: Hyperthermia and ionizing radiation are associated with early increases in levels of HSP47 (a marker of collagen metabolism), in contrast to ALA-PDT and mitomycin-C. These findings are compatible with clinical findings where fibrosis/scarring is common with the first two but not the last two methods. In addition, all methods except ALA-PDT are associated with an increase in HSP 72 (a protein associated with cellular tolerance) and this may help to explain, at a cellular level, why resistance to repeated ALA-PDT treatments does not seem to occur.

Photodynamic therapy for superficial bladder cancer under local anaesthetic.

OBJECTIVES: To evaluate the use of local anaesthesia (LA) in 5-aminolaevulinic acid (ALA) photodynamic therapy (PDT) for superficial transitional cell carcinoma (TCC) of the bladder, and to provide further toxicity and tolerability data on this new method within the context of a phase 1 trial. PATIENTS AND METHODS: ALA PDT was administered to 19 patients with recurrent superficial TCC (stage Ta/carcinoma in situ, grades 1-3) using escalating doses of ALA (3-6%) and 633 nm laser light (25-50 J/cm2) under various LA (lignocaine) protocols. Pain was assessed using a linear analogue scale from 0 to 10. The endpoints of tolerability and toxicity were assessed for the different LA, light and ALA doses, with lignocaine levels. RESULTS: ALA PDT is painful and requires some form of anaesthesia. The discomfort was immediate, associated with bladder spasm, and was a function of the ALA concentration rather than the total light dose given. Simple passive diffusion (PD) of 2% lignocaine instilled for 40 min before PDT gave adequate anaesthesia with 3% ALA (n=8; median pain score 1, range 0-2). With 6% ALA the pain was dramatically increased using PD (n=6; median pain score 8, range 5-10) and therefore the more potent LA technique of electromotive drug administration (EMDA) of 2% lignocaine was used, with excellent results (n=3; median pain score 1, range 0-2). All patients had transient bladder irritability that typically lasted 9-12 days, with no subjective/objective change in long-term bladder function. No other toxicity was reported. Serum lignocaine levels were minimal. CONCLUSION: Bladder ALA PDT is both safe and feasible under LA. At a dose of 3% ALA, the procedure was well-tolerated using PD of lignocaine. At higher doses (6% ALA) more effective anaesthesia is required and this can be obtained satisfactorily with EMDA of lignocaine. With refinement, ALA PDT may be feasible as an outpatient treatment for superficial bladder TCC.

The community-based morbidity of flexible cystoscopy.

OBJECTIVE: To evaluate patients' experience after flexible cystoscopy (FC), particularly concentrating on the prevalence and degree of symptoms, the frequency of visits to their General Practitioner (GP), subsequent antibiotic rates and the actual incidence of urinary tract infection (UTI). PATIENTS AND METHODS: Consecutive patients (420) presenting for FC were audited prospectively. A pain score for the procedure was recorded immediately afterward (linear scale 0-10) and a self-administered questionnaire completed at 7 days, to assess the objective and subjective symptoms and their duration, and the incidence of GP visits and subsequent antibiotic provision noted. An interim analysis was conducted on the initial 274 datasets received. To estimate the incidence of FC-induced UTI, the final 110 patients were asked not to consult their GP but to present to the urology department at 3 days after FC (or the emergency department if clinically necessary). These patients had initially provided a mid-stream urine (MSU) sample before FC and were assessed symptomatically with a subsequent sample obtained if a urinary dipstick test 3-days after FC was abnormal. RESULTS: In all, 384 (91%) evaluable forms were returned. The median (range) pain score for FC was 1.1 (0-8.5), with seven patients (1.8%) recording a pain score of > 5 (all men); 382 patients (99.5%) declared they would be happy to undergo an identical procedure in the future if medically indicated. Pain on voiding was reported in 190 patients (50%), urinary frequency in 142 (37%) and gross haematuria in 73 (19%). Eighteen of the initial 274 patients (6.6%) visited their GP, with 15 (5.5%) of these receiving antibiotics. The MSU data from the final 110 patients showed a FC-mediated infection in three (2.7%). CONCLUSION: Although FC is well tolerated, gross haematuria, urinary frequency and dysuria occur afterward much more frequently than expected. Patients should be thoroughly counselled before FC about these potential symptoms, to reduce their concern, any unnecessary GP visits and the use of antibiotics.

Photodynamic therapy for superficial bladder cancer.

In photodynamic therapy, a photosensitizing drug is activated by visible light and in the presence of oxygen, results in local cell death. This evolving modality is now being used to treat and palliate a very wide variety of human solid tumors and carcinoma-in-situ lesions. With regard to bladder cancer, advances in drug development and modern light delivery techniques mean that photodynamic therapy shows promise in the treatment of superficial bladder cancer resistant to conventional treatments.

The staged management of complex entero-urinary fistulae.

OBJECTIVE: To present the results of the staged management of complex entero-urinary fistulae. PATIENTS AND METHODS: Ten patients with complex entero-urinary fistulae were reviewed; all patients were referred to a national intestinal failure unit after failed treatment in other centres. Each patient was treated in three stages. The acute stage involved proximal defunctioning and distal drainage of both the gastrointestinal and urinary tracts to isolate the fistula, together with the eradication of sepsis. The recovery stage involved total parenteral nutrition, organ support, radiological planning of surgical reconstruction and intensive nursing. The reconstructive stage followed when the patient was stable, nutritionally replenished and intra-abdominal sepsis was controlled. Surgery was undertaken jointly by urological and gastrointestinal surgeons. RESULTS: The fistulae were treated successfully in all patients, with functional restoration in four, and/or diversion of the gastrointestinal and urological tracts in six. The mean (range) time to reconstruction was 5 (1-20) months. There were no postoperative deaths. CONCLUSION: A staged multidisciplinary approach with delayed reconstruction can achieve a successful outcome in the management of complex entero-urinary fistulae.

Light penetration in bladder tissue: implications for the intravesical photodynamic therapy of bladder tumours.

OBJECTIVES: To assess (i) the optical properties and depth of penetration of varying wavelengths of light in ex-vivo human bladder tissue, using specimens of normal bladder wall, transitional cell carcinoma (TCC) and bladder tissue after exposure to ionizing radiation; and (ii) to estimate the depth of bladder wall containing cancer that could potentially be treated with intravesical photodynamic therapy (PDT), assuming satisfactory tissue levels of photosensitizer. Materials and methods The study included 11 cystectomy specimens containing invasive TCC (five from patients who had previously received external-beam bladder radiotherapy, but with recurrent TCC) and three 'normal' bladders removed from patients treated by exenteration surgery for extravesical pelvic cancer. Full-thickness bladder wall and tumour samples were taken from these specimens and using an 'intravesical' and a previously validated interstitial model, the optical penetration depths (i.e. the tissue depth at which the light fluence is 37% of incident) were calculated at wavelengths of 633, 673 and 693 nm. RESULTS: There were no significant differences in light penetration between normal and tumour-affected bladder tissue at each wavelength. There were significant differences in light penetration among wavelengths; light at 693 nm penetrated approximately 40% further than light at 633 nm (P < 0.002). The light currently used in bladder PDT (633 nm) has a mean (SEM) optical penetration depth of 4.0 (0.1) mm within TCC. In addition, at this wavelength, there was 29% greater light penetration in previously irradiated than in unirradiated bladder wall (P = 0.001). This did not occur in the tumour-affected bladder. CONCLUSIONS: Bladder tissue is relatively more translucent than other human tissues and there is therefore great potential for PDT in the treatment of bladder cancer. As there is no difference in light penetration between TCC and normal bladder tissue, a tumour-specific response with diffuse illumination of the bladder will depend on drug localization within the tumour. The currently used wavelength of 633 nm can be expected to exert a PDT effect within bladder tumour up to a depth of 20 mm. Increasing the wavelength will allow deeper pathology to be treated.

Staging laparoscopic pelvic lymphadenectomy in prostate cancer.

OBJECTIVE: To assess the results of transperitoneal laparoscopic pelvic lymphadenectomy as a separate staging procedure in patients with early prostate cancer. PATIENTS AND METHODS: The results were reviewed from the first 27 patients with prostate cancer admitted for laparoscopic lymphadenectomy between January 1994 and March 1998. Initially, all patients with a negative bone scan and either a negative computed tomography or negative magnetic resonance scan were admitted for laparoscopic staging. After several reports detailing ways of reducing the number of negative lymphadenectomy operations, from July 1996 only those patients with a preoperative prostate specific antigen (PSA) serum level of >10 ng/mL were admitted to the study. All procedures were performed by one experienced laparoscopic surgeon. A radical retropubic prostatectomy was performed as a separate procedure by a consultant urologist within 2 weeks. The effectiveness of the staging operation was analysed by assessing the nodal yield, and the results, including operative duration, complications and length of stay, were compared with other published series. Further analysis was provided by reviewing the PSA levels, Gleason grade sum and clinical digital staging. RESULTS: The nodal yield was similar to that published in series from other institutions, with a median (range) of 6.5 (0-12). However, the operation was significantly quicker, at a median (range) of 55 (40-110) min for a bilateral dissection. There were only minor complications, with no detectable reduction in complications with experience; the median (range) postoperative stay was 1 (1-4) days. Two of the 27 patients had metastatic disease within the lymph nodes. If a PSA level of >10 ng/mL had been instituted as an entry criteria at the start of the study, six patients would have been excluded and thus the positive lymphadenectomy rate would have been two of 21 patients (10%). Of 54 patients eligible to enter the study, half did not require a lymphadenectomy. CONCLUSIONS: Laparoscopic transperitoneal lymphadenectomy can be performed expeditiously and safely. A two-stage procedure in some patients with prostate cancer is the management of choice. Attention to carefully closing the peritoneum with sutures minimizes any retropubic adhesions and no problems associated with the staging procedure were encountered during subsequent radical retropubic prostatectomy. In efforts to reduce negative staging lymphadenectomies, the exclusion values for staging should not be set too high (PSA and Gleason grading sum). Such practice, despite a relatively safe staging procedure, would lead to unnecessary radical prostatectomy.

Closure of the skin defect overlying infected non-union by skin traction.

Skin traction based on an Ilizarov frame has been used to achieve skin closure in five cases of infected non-union of the tibia including one case of infected knee arthrodesis. Five patients presented with infected non-union of the tibia (all Staph. aureus, two of them MRSA) with overlying sinuses discharging pus at an average 16 months from injury (range 3-36 months). The infections were treated by excision of the sinus and infected skin, excision of the infected non-union, stabilisation of bone with an Ilizarov circular frame and either acute shortening with compression followed by distraction (3 patients), or bone transport (2 patients). After excision of the sinus, the skin defect was gradually closed using a skin traction device placed on an Ilizarov circular frame. The size of the wounds ranged from 5 x 14 cm to 3 x 5 cm and skin traction was completed at 4 weeks (range 2-8 weeks). When the wound edges were approximated, the wires were left in place until healthy granulation tissue built up to seal the remaining gap (sutures were used in two patients). At follow-up assessment at 18 months (range 7-24 months), all non-union were solidly united with no signs of infection of either the bone or underlying skin. The quality of skin at the stretching site was found to be of normal sensation, colour, mobility but thinner than normal. The quality of the skin at the docking site (left to granulate) was found to be adherent to the underlying bone, red or pink in colour, hypersensitive in 2 patients and numb in 3 patients.