Outcome of Operated Colorectal Cancers in Relation to the Type of Initial Referral.

Aim Since the introduction of the target referral system, there has been controversy about its value and whether it affected the short- and long-term outcomes of colorectal cancer surgeries. With contradicting results, this study highlights differences in personal and tumour characteristics, management differences, and outcomes in each referral pathway, including target pathway referrals for suspected cancers, emergency presentations, routine referrals, and incidentally discovered cancers during screening. Methods A retrospective study of colorectal cancer (CRC) patients operated on between January 1, 2010, and December 31, 2014, with records dating to the end of the five-year follow-up, was extracted anonymously from the database of CRC outcomes at the North Middlesex University Hospital NHS Trust, London. The total number of patients operated on through the four pathways was 176, with full records and competent follow-ups. Patients were classified according to the mode of referral: two-week wait (2WW or target), routine, emergency, and incidental discovery referrals. Comparisons were made between these groups with regard to personal and tumour characteristics, management, and outcome. Results It has been demonstrated by this study that target referrals present mainly with stage I cancers as compared to emergency referrals that present with more stage II (IIa+ IIb+ IIc). The highest percentage of cancer locations within the large bowel was rectal, followed by sigmoid in both target and emergency groups; 8.8% of target patients needed neoadjuvant chemoradiotherapy in the form of FOLFOX (folinic acid, 5-fluorouracil, and oxaliplatin) chemotherapy protocol with the addition of radiotherapy in patients with advanced rectal cancers, compared to 13.3% of emergency patients. Conclusion The colorectal 2WW system was the main pathway supplying colorectal cancer operations; it mostly showed earlier cancers than the other referral groups; its cancers were mostly rectosigmoid with less need for adjuvant chemotherapy; fewer recurrences; and it also showed a lower five-year mortality rate than the emergency group.

Experience of a District General Hospital With a Diverse Community in Operated Colorectal Cancers According to Ethnic Background.

Background This study aimed to investigate disparities in colorectal cancer (CRC) patients' demographics according to the five major ethnicities of patients living in the catchment area of North Middlesex Hospital. Methodology This retrospective study included CRC patients operated on between January 1, 2010, and December 31, 2014. Records dating to the end of the five-year follow-up were extracted anonymously from a database of CRC outcomes at the North Middlesex University Hospital NHS Trust. Comparisons were made according to ethnicity, patient demographics, type of presentation, cancer location, stage at diagnosis, recurrence, and mortality. Results A total of 176 adult patients were operated on for CRC between January 1, 2010, and December 31, 2014. The majority of the patients were referred as two-week wait target referrals. Emergency presentation of CRC was the highest in White non-UK patients. The White British Irish patients had their tumors mostly in the cecum, followed by the sigmoid colon, while the rectum followed by the sigmoid colon were the most common sites in the Black population. All study populations mainly presented with stage I disease, and the next highest incidence of cancers according to stage and ethnicity was stage IIIb in the Black population. Conclusions Differences in the ethnic background are important factors, especially in a diverse community, which can impact the age and mode of presentation of the disease, as well as the stage it starts to present. The location of the primary tumor, metastases, and recurrence sites are all affected by the ethnic background, which, subsequently, affect the survival of the patient.

The Accuracy of Different Modalities Used for Preoperative Primary Tumour Localisation in Operated Colorectal Cancer Patients.

Aim Colonoscopy and computed tomography (CT) scans of the abdomen and pelvis are routine pre-operative assessment tools in colorectal cancer (CRC) patients. There have been some discrepancies regarding the location of cancer when seen by colonoscopy versus CT scan. The purpose of this study was to compare the accuracy of a colonoscopy with a computed tomography (CT) scan of the abdomen and pelvis with contrast, which is done routinely before surgery to localise the exact site of the tumour within the large bowel, whilst comparing both to the operative, gross and histopathology findings of the exact location. Methods A retrospective study was carried out on 165 colorectal cancer patients operated on between January 1, 2010, and December 31, 2014, using electronic hospital records that were reviewed anonymously, comparing the location of cancer within the large bowels as was found on colonoscopy and CT scan of the abdomen and pelvis with contrast, comparing both to post-operative histopathology specimen or intra-operative assessment in cases where no resection of the primary tumour was performed. Results CT and colonoscopy were both accurate in diagnosing 70.5% of cases that had done both investigations pre-operatively. The best results were obtained when the cancer was located in the caecum as confirmed post-operatively; the combined accuracy rate was 100%. CT was accurate, whilst colonoscopy was not in eight (6.2%) cases (all are rectal or sigmoid cancers), and colonoscopy was accurate and CT was not in 12 cases, 10 of them were rectal and two were ascending colonic. Colonoscopy was not performed in 36 (21%) cases for a variety of reasons, including large bowel obstruction or perforation on presentation. In 32 of these cases, CT scan managed to accurately predict the location of cancer (mostly rectal and caecal), and CT scan was inaccurate in 20.6% of cases (34 out of 165), whilst colonoscopy was inaccurate in 13.9% of cases (18 out of 129). Conclusion Colonoscopy is more accurate in localising colorectal cancers than CT scan of the abdomen and pelvis with contrast. CT scan diagnoses regional and distant spread of colorectal cancers such as nodal status, invasion of neighbouring organs and/or peritoneum and the presence of liver metastases, whilst colonoscopy is limited to intraluminal diagnosis but can be both a diagnostic and therapeutic tool, with higher accuracy, in general, in localising colorectal cancers. Both CT scan and colonoscopy were equal in appendicular, caecal, splenic flexure and descending colon cancer localisation accuracy.

Haematuria in children.

Haematuria is a common finding in children and can be macroscopic or microscopic. In contrast to adults, haematuria in children very rarely indicates an underlying malignant pathology. The differential diagnosis is broad, with the most common underlying causes being infection, glomerulonephritis and hypercalciuria. It is useful to distinguish between nephrological or upper urinary tract and lower urinary tract pathologies, as this will guide investigations and referral. This review discusses the causes of haematuria in the paediatric population.

Radiation Safety Knowledge and Practice in Urology Theaters: A Collaborative Multicenter Survey.

Objective: To evaluate the knowledge and current radiation safety practice among health care professionals undertaking fluoroscopic procedures in urology. Materials and Methods: A 14-question survey was disseminated to multidisciplinary urology theater staff. Questions included demographic data, usual radiation safety practice, and knowledge. The questions were selected based on guidelines from the International Commission of Radiological Protection and Health and Safety Executive. The survey was disseminated through regional collaborators and social media. Results: The survey received a total of 309 completed responses, including 272 from the United Kingdom. Responses from the United Kingdom multidisciplinary team included 164 (60.3%) urologic surgeons, 68 (25.0%) theater nurses, 27 (9.9%) from the anesthetic team, and 13 (4.7%) radiographers. Results from the United Kingdom demonstrated use of lead aprons and thyroid shields as 99.3% and 52.2%, respectively. Lead glasses and lead glove use were 7.4% and 0.7%, respectively. Lack of availability was cited as a reason for noncompliance with shielding guidelines in 208 (76.5%) of the respondents. No form of training in radiation safety was reported by 120 (44.1%) respondents. However, there was no association between answering knowledge questions correctly and having completed some form of radiation safety training (p = 0.41). There was an association between dosimeter use and those who had received radiation safety training (p = 0.02). Consultant urologists were also more likely to use a dosimeter than training grade urologists (p = 0.035). Conclusion: Suboptimal compliance with radiation safety guidelines is prevalent in contemporary urologic practice, and presents a significant occupational health concern. Availability of protective equipment needs to be urgently addressed.

Clinical Management of Bladder Pain Syndrome/Interstitial Cystitis: A Review on Current Recommendations and Emerging Treatment Options.

Bladder pain syndrome (BPS) is a chronic condition characterized by pelvic pain or pressure which is perceived to be originating from the bladder, accompanied by one or more urinary symptoms, including frequency, urgency and nocturia. The precise etiology of BPS is not fully understood. Chronic bacterial infection, defective glycosaminoglycan (GAG) layer of the bladder urothelium, inappropriate activation of mast cells in the suburothelial layer of the bladder, autoimmune-mediated mechanisms and autonomic nervous system dysfunction have all been implicated. Treatments targeted at each of these mechanisms have been developed with mixed outcomes. High-quality research into the treatment options is lacking and it is difficult to draw definite conclusions. The treatment approach is multimodal and should be patient specific, targeting the symptoms which they find most bothersome. Conservative treatment, including patient education, behavioural modification, dietary advice, stress relief and physical therapy is an essential initial management strategy for all patients. If no response is observed, oral treatments such as amitriptyline are likely to offer the greatest response. Cystoscopy is essential to phenotype patients, and Hunner lesion directed therapy with fulguration or resection can be performed at the same time. Intravesical instillation of DMSO or lidocaine, detrusor injections of botulinum toxin A and neuromodulation can be used if initial management fails to improve symptoms. Oral cyclosporin can be trialled in those experienced with its use; however, it is associated with significant adverse events and requires intense monitoring. Lastly, radical surgery should be reserved for those with severe, unremitting BPS, in which quality of life is severely affected and not improved by previously mentioned interventions. Future work investigating exact aetiological factors will help target the development of efficacious treatment options, and several promising oral and intravesical treatments are emerging.

Vesico-Ureteric Junction Obstruction and Calyceal Rupture Secondary to a UroLift Implant.

Prostatic urethral lift is a minimally invasive procedure used to improve the symptoms of benign prostatic enlargement. It utilizes the UroLift device to insert small implants through occlusive lateral lobes of the prostate, thereby creating an open anterior channel through the prostate. We describe a previously unreported complication of UroLift whereby a patient presented with loin pain post-procedure and was found to have a UroLift clip across the vesico-ureteric junction , leading to ureteric obstruction, hydronephrosis and calyceal rupture.

A care bundle to improve perioperative mitomycin use in non-muscle-invasive bladder cancer.

PURPOSE: Intravesical chemotherapy administered within 24 h of the first resection of non-muscle-invasive bladder cancer (NMIBC) reduces recurrence rates and prolongs recurrence-free intervals. However, there is considerable variation in the use of intravesical chemotherapy amongst urologists. In our hospital, we use mitomycin C (MMC), and our usage was inconsistent. Therefore, we devised a care bundle to improve MMC usage. The objective of this study was to evaluate the effectiveness of the care bundle on postoperative MMC use. METHODS: We measured baseline postoperative MMC use during the first quarter of 2013. In 2014, we implemented a care bundle by changing MMC delivery, through computer-based clinical information systems and repeated training of key stakeholders. We studied the performance of the bundle through snapshot audits in the last quarter of 2014, a 6-month period in the middle of 2015 and again in the final quarter of 2016. RESULTS: We observed an increase in intravesical chemotherapy usage after implementing the care bundle. Instillation rates in our samples increased from 46% (6/13), in 2013 to 89% (8/9), in 2014, 90% (9/10), in 2015 and 100% (12/12), in 2016. CONCLUSION: Compliance rates of intravesical chemotherapy in NMIBC can improve by devising care bundles to modify team behaviour.