Delineating Which Patient-reported Symptoms Are Associated with Satisfaction After Urethroplasty.

OBJECTIVE: To determine which patient-reported symptoms are associated with satisfaction after urethroplasty. METHODS: From 2011 to 2018, patients were offered enrollment in a prospective study assessing patient-reported outcomes after urethroplasty. Outcomes were assessed preoperatively and 6-months postoperatively including patient satisfaction, voiding function (International Prostate Symptom Score), erectile function (International Index of Erectile Function 5) and ejaculatory function (ejaculatory component of brief sexual function inventory). Additionally, penile curvature/appearance, genitourinary pain, postvoid dribbling, and standing voiding function were also evaluated using either 3 or 5 point Likert scales. Stricture recurrence was defined as the inability to easily pass a 16Fr flexible videocystoscope. Multivariable binary logistic regression was used to examine the associations between outcomes and patient satisfaction. RESULTS: A total of 387 patients completed the study with a mean age of 49.5 years and a mean stricture length of 4.5 cm. Location was bulbar (59.4%), penile (19.6%), posterior (13.7%) and pan-urethral (7.2%). At 6-months, 96.1% of patients were stricture-free, 81.6% reported being satisfied with surgery and 8% were unsatisfied. On multivariable binary logistic regression, improvement in International Prostate Symptom Score (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.1-1.2, P = .04), new erectile dysfunction (OR: 0.5, 95% CI: 0.2-0.9, P = .04), new penile curvature (OR: 0.4, 95% CI: 0.2-0.9, P = .03) and improved standing voiding function (OR: 1.3, 95% CI: 1.1-1.5, P = .004) were associated with patient satisfaction. Cystoscopic success (P = .60), change in pain score (P = .14), postvoid dribbling (P = .69), change in penile length (P = .44), and ejaculatory dysfunction (P = .51) were not. CONCLUSION: Improved voiding function, patient-reported penile curvature, new erectile dysfunction and improved standing voiding are independently associated with patient satisfaction after urethroplasty and should be incorporated into any patient-centered approach to urethral stricture management.

Development of New Comorbidities in Patients Awaiting Urinary Incontinence Surgery Following Radical Prostatectomy.

OBJECTIVE: To examine the incidence and factors associated with the development of new comorbidities in men undergoing anti-incontinence surgery after prostate cancer (PCa) surgery. Post-prostatectomy incontinence (PPI) may deter men from engaging in physical activities and increase the risk of developing comorbidities after prostatectomy. METHODS: Patients undergoing surgery for PPI from 2006 to 2019 were identified. A retrospective review was performed to document patient characteristics noted at the time of PCa surgery and compare these with parameters recorded at the time of anti-incontinence surgery. RESULTS: A total of 229 patients were included. Mean age was 68.8 years at time of incontinence surgery. Median duration of incontinence was 3.5 ± 4.6 years. There was a significant increase in CCI comorbidities between PCa surgery and PPI surgery (2.7 ± 1.5 vs 4.1 ± 1.9, P < .0001). Almost half of patients (45.2%) developed a new comorbidity while awaiting incontinence surgery including an increase in the incidence of diabetes (21.9% vs 12.7%; p<0.0001), hypertension (56.2% vs 36.7%; P < .0001), coronary artery disease (14.6% vs 8.9%; P = .008) and arrhythmia (11.0% vs 3.8%; P = .008). On multivariable analysis, duration of incontinence was significantly associated with development of new comorbidities (O.R. 1.2, P = .01) while age (P = .20) and incontinence severity (P = 1.0) were not. There was no change in weight (P = .34), obesity (P = 1.0) or BMI (P = .18) between PCa surgery and PPI surgery. CONCLUSION: Patients with PPI appear at risk of developing new comorbidities while awaiting anti-incontinence surgery. Strategies which expedite return of continence for example, early surgical intervention, may facilitate resumption of physical activity and minimize the risk of future comorbidity.

Multicentered Assessment of Clinical Outcomes and Factors Associated With Failure of the Adjustable TransObturator Male System (ATOMS).

OBJECTIVE: To assess postoperative outcomes from the Adjustable TransObturator Male System (ATOMS) and identify factors influencing failure to achieve continence. PATIENTS AND METHODS: A multicentered analysis was performed on all patients treated for postprostatectomy incontinence using the third-generation ATOMS at 9 Canadian tertiary referral centers. The primary outcome was continence (defined as requiring ≤1 pad postoperatively for patients requiring ≥2 pads preoperatively and 0 pads for those requiring 1 pad preoperatively). Secondary outcomes included improvement (>50% change in pad use), patient satisfaction, explantation, and postoperative complications. RESULTS: Two hundred and eighty nine patients with a mean age of 68.9 years were analyzed. Pre-operatively mean pad per day use was 4.2 (1-12), 31.5% of patients reported severe incontinence (≥5 pads/day), 33.9% had concurrent radiotherapy and 19.4% had failed previous incontinence surgery. Overall continence rate was 73.3% (n = 212) at a mean follow-up of 19.6 months. More than eighty nine percent (89.3%) (n = 258) of patients experienced >50% improvement, 84.4% (n = 244) of patients were satisfied with the results of surgery. More than seven percent (7.9%) (n = 23) required device explantation. On multivariate Cox regression analysis, concurrent radiotherapy (hazard ratio [H.R.] 2.3, P < .001), diabetes (H.R. 2.2, P = .007) and increased pre-operative pad usage (H.R. 1.1, P = .02) were each associated with failure to achieve continence, while patient age (P = .60), obesity (P = .08), prior urethral stenosis (P = .56), and prior incontinence surgery (P = .13) were not. Radiation therapy was also associated with device explantation (H.R. 2.7, P = .02). CONCLUSION: ATOMS is a safe and efficacious for treatment of postprostatectomy incontinence. However, patients with prior radiation, increased pre-operative pad use, or diabetes are less likely to achieve continence.

Contemporary management of pediatric high grade renal trauma: 10 year experience at a level 1 trauma centre.

BACKGROUND: Current guidelines advocating the conservative management of renal injuries in children are primarily extrapolated from adult series due to a dearth of evidence in the pediatric population. OBJECTIVES: The aim of this study was to review our experience in the management of pediatric high-grade renal trauma and to clarify the role of conservative management in this cohort of patients. STUDY DESIGN: The Alberta Trauma Registry (ATR) is a comprehensive web-based registry which functions to prospectively collect data on all trauma patients in the province who sustain a severe injury (i.e. Injury Severity Score (ISS) ≥12). The ATR was used to identify all pediatric patients who attended hospitals within the Edmonton region with high grade renal injuries (grade III-V) between January 2006 and December 2018. Hospital records and imaging were reviewed to identify patient demographics, mechanism of injury, AAST grade, haemodynamic stability, associated injuries, management, length of hospital stay (LOS), complications, and follow-up outcomes. RESULTS: A total of 53 children (38 boys, 15 girls) were identified with a mean age of 13 years (1-16). The mechanism of injury was blunt trauma in 92.5% (49/53) of cases (Supplementary Table). AAST grade distribution was 37.8% Grade III (20/53), 49% Grade IV (26/53) and 13.2% Grade V (7/53). All Grade III injuries were successfully managed conservatively. Overall 11 patients with Grade IV/V injuries required urological intervention (ureteral stenting (5 patients), angioembolization (4 patients), bladder washout with clot evacuation (1 patient), emergency nephrectomy (3 patients)). The overall renal salvage rate was 92.4% (49/53). DISCUSSION: Our series confirms the safety of expectant management in high grade pediatric renal trauma. All grade III injuries in our study were managed conservatively without the need for intervention. This suggests that these injuries may be managed safely outside of designated trauma centres. One third of children with grade IV/V injuries required intervention. Therefore we recommend that patients with these injuries are transferred to specialized units with the capacity to provide such procedures if required. CONCLUSION: This study supports the conservative management of pediatric renal trauma in the setting of high-grade injury. Expectant management was associated with acceptable rates of intervention and excellent renal salvage rates.

Augmented Anastomotic Urethroplasty is Independently Associated with Failure after Reconstruction for Long Bulbar Urethral Strictures.

PURPOSE: Controversy exists regarding the optimal urethroplasty technique, particularly for long bulbar urethral strictures requiring buccal mucosal graft. We assessed the relative outcomes of augmented anastomotic urethroplasty vs dorsal onlay in the setting of bulbar urethroplasty using a dorsal buccal mucosal graft. MATERIALS AND METHODS: A retrospective review was performed on all patients who underwent bulbar urethroplasty with dorsal buccal mucosal graft between October 2003 and March 2019. Around 2011 institutional technique shifted from routinely performing transecting augmented anastomotic urethroplasty to nontransecting dorsal onlay. Anastomotic urethroplasty without buccal mucosal graft, ventral onlay, staged, flap and circumferential reconstructions were excluded. The primary outcome was stricture recurrence defined as less than 16Fr on cystoscopy. Secondary outcomes included 90-day complications and de novo erectile dysfunction at 6 months. RESULTS: Of the 836 patients who underwent bulbar urethroplasty during the study period 507 met inclusion criteria. Of these, 221 patients received an augmented anastomotic urethroplasty while 286 underwent dorsal onlay urethroplasty. Mean patient age and stricture length were 45.4±14.8 years and 4.4±1.5 cm, respectively. Overall success rate was 93.9% (476 of 507) with a mean followup of 78.9 months. On multivariate analysis augmented anastomotic urethroplasty (HR 4.8, p=0.002), increasing stricture length (HR 1.2, p=0.002) and iatrogenic strictures (HR 3.2, p=0.03) were independently associated with stricture recurrence, while comorbidity (p=0.06), prior endoscopic treatment (p=0.41), prior urethroplasty (p=0.89) and other etiologies were not. There was no difference between cohorts with respect to Clavien 2 or greater complications (3.6% vs 4.2%, p=0.74) or de novo erectile dysfunction (5.9% vs 5.6%, p=0.89). CONCLUSIONS: Augmented anastomotic urethroplasty is independently associated with stricture recurrence when compared to a pure dorsal onlay technique.

Deficits in urological knowledge and skills among family medicine residents in Canada.

INTRODUCTION: The last 10-15 years has seen a decline in formal undergraduate urological education throughout Canada. Given the large volume of urological presentations in family practice, trainees need to acquire the requisite urological knowledge and skills to serve their patients. The objective of this study is to determine the perceived level of urological knowledge and skills among Canadian family medicine residents. METHODS: A 15-item, anonymous, online survey was distributed via email to all Canadian family medicine program directors from September to December 2018 and distributed to their residents. The survey obtained data on demographics, training, undergraduate urology experience, self-reported proficiency in interpreting urological investigations, performing common urological procedures, and managing common urological conditions. Descriptive statistics were used to summarize data. RESULTS: The questionnaire was completed by 142 family medicine residents with representation from Western Canada (27.5%), Ontario (32.4%), and Quebec (40.1%); 39.4% of respondents had completed a urology rotation during medical school and only 29.1% felt that their medical training prepared them for the urological aspects of family medicine. Although the majority of respondents felt proficient in performing a digital rectal examination (58.5%) or managing urinary tract infections (97.9%), only a minority felt competent in performing male genitourinary examination (40.1%), uncomplicated male (34.5%), female (45.8%) or difficult (9.2%) urethral catheterization. Likewise, the minority of respondents felt comfortable managing erectile dysfunction (41.5%), scrotal swelling (34.7%), and scrotal pain (25.7%). CONCLUSIONS: There are significant deficiencies in urological knowledge and skills among family medicine residents in Canada, possibly because of insufficient educational experiences during medical training.

The utility of stent on strings in clinical practice.

INTRODUCTION: Various types of ureteric stents are used in the management of ureteric stones. Stents on strings (SOS) are an attractive option as they may be removed without the need for instrumentation. There is some hesitation using SOS due to perceived complications and the risk of premature dislodgement. The aim of this study was to evaluate the utility of SOS compared with the conventional stent (CS). METHODS: A retrospective review was performed on all ureteric stents removed in the urology department over a 7-month period. Only stents inserted during the endoscopic management of ureteric stones were included in analysis. Patients were contacted to identify the incidence of those seeking medical attention while the stent was in situ or within 2 weeks of stent removal. A basic cost analysis was performed. RESULTS: One hundred and sixty cases were identified (98 CS, 62 SOS). No SOS was dislodged prematurely. One SOS was removed cystoscopically due to a broken string. There was no significant difference in the number of patients with SOS seeking medical attention following stent placement compared with those with CS (38.1% (12/51) vs 25.6% (22/86), p = 0.48). There was an estimated cost saving of €23,790 associated with the use of SOS during the study period (€390/case). The use of SOS created additional capacity which was utilised for diagnostic cystoscopy. CONCLUSION: The SOS appeared to be well tolerated and showed similar complication rates as the CS. The use of SOS resulted in a significant cost saving and increased the availability of cystoscopy for other indications.

Seasonal Variation in the Frequency of Presentation with Acute Ureteral Colic and Its Association with Meteorologic Factors.

Introduction: A seasonal variation in the frequency of acute stone presentations has been observed in studies from the United States, Africa, and Asia. The increased incidence of acute stone presentations during periods of warm weather has been attributed to both the dehydrating effect of elevated temperatures and the vitamin D related increase in calciuria during periods of increased sunshine. The aim of this study is to establish whether the association between various meteorologic parameters and the frequency of acute stone presentations also exists in a European climate. Methods: All computed tomography kidneys, ureters and bladder scans performed by Emergency Departments within the Dublin Midland Hospital Group between June 2017 and September 2018 were identified from the national radiologic database. The date of scan in addition to stone parameters (site, size, and side) was recorded. These data were then correlated with weather recordings obtained from the Irish meteorologic office. Results: A total of 2441 patients were investigated for suspected renal colic during the study period of which 781 were confirmed to have ureteral stones. An increased frequency of acute stone presentations was observed during the summer months of both years (June, July, and August). Unexpectedly, the heat wave of summer 2018 was not associated with an increased frequency of nephrolithiasis compared with summer 2017. Conclusion: There is an increased frequency of acute nephrolithiasis during the summer months in Ireland. Health care services should be tailored to expect an increase in service needs during these periods of increased activity.

Write2me: using patient feedback to improve postconsultation urology clinic letters.

Letters between hospital clinicians and general practitioners following an outpatient clinic (OPD) consultation have generally not been shared with patients. Recent guidelines from the Academy of Medical Royal Colleges recommend that all OPD letters should be written directly to the patient. While the benefits of this approach are recognised, additional attention is required to ensure readability, accuracy and acceptability. Our aim was to improve urology OPD letters in a university teaching hospital to ensure suitability for sharing with patients over a 3-month period as measured by patient feedback. In one OPD, 71% of patients stated that they wished to receive a copy of their letter. We designed, tested and implemented two paper-based, self-explanatory prompts to ensure doctors used paragraphs and a structured letter format when dictating OPD letters. This was achieved using a 90-day improvement cycle supported by a quality improvement learning collaborative and evaluated by measurement of Flesch Reading Ease Score, use of paragraphs, use of letter structure and patient feedback. Following the implementation of the intervention, letters were sent to 120 patients and feedback was obtained from 63 patients with either a feedback postcard or telephone interview. Of the 53 patients who agreed to participate in the telephone feedback, 39 (74%) found the letter easy to understand, 49 (92%) reported it was accurate and summarised the consultation as they remembered it and 38 (72%) reported that reading the letter improved their understanding of their OPD visit. All patients said they would like to receive similar letters from future OPD consultations. This improvement report describes the implementation of an intervention to improve the quality of OPD letters and the acceptability and value of these letters to patients.

The Effect of Bladder Filling Rate on the Voiding Behavior of Patients with Overactive Bladder.

PURPOSE: Many self-help guides advise patients that spreading fluid intake throughout the day can reduce overactive bladder symptoms. However, although animal studies suggest a link between a faster filling rate and increased afferent nerve firing, to our knowledge the relationship between the filling rate and bladder sensation has not been examined in humans. The aim of this study was to investigate the effect of bladder volume and the bladder filling rate on the bladder sensation and voiding patterns of patients with overactive bladder. MATERIALS AND METHODS: A control group of 40 female volunteers were recruited by open advertisement. A further 24 female patients with overactive bladder were recruited from the urology outpatient department. Each participant completed the UDI-6 (Urinary Distress Inventory, Short Form), the IIQ-7 (Incontinence Impact Questionnaire, Short Form) and a 3-day sensation related bladder diary. RESULTS: The proportion of urgent voids in the control group increased with increasing voided volume and bladder filling rates (each p ≤0.001). The proportion of urgent voids in patients with overactive bladder also increased with increasing voided volume and bladder filling rates (p = 0.004 and 0.013, respectively). On regression analysis the rate of bladder filling was an independent predictor of urgent voids in patients with overactive bladder but not in the control group. Patients with overactive bladder were less tolerant of higher bladder filling rates, and experienced most grades of bladder sensation at lower voided volumes and filling rates than the control group. CONCLUSIONS: The bladder filling rate appears to influence the intervoiding interval and the sensation associated with each void in patients with overactive bladder. Advising patients to lower the bladder filling rate should help reduce urinary frequency, urgency and urge incontinence.

The influence of dietary supplementation with cranberry tablets on the urinary risk factors for nephrolithiasis.

PURPOSE: Cranberry supplements are commonly used as a natural deterrent to urinary tract infection. However, one small study (n = 5) which showed an increase in urinary oxalate levels following cranberry supplementation has led to its use with caution among patients susceptible to nephrolithiasis. Furthermore, most commonly available cranberry tablet preparations contain vitamin C, which has been independently shown to increase urinary oxalate excretion. The aim of this study is to investigate the influence of cranberry supplementation on urinary oxalate excretion. METHODS: Fifteen participants were randomised to receive cranberry tablets alone or cranberry tablets containing vitamin C. Tablets were taken at the manufacturers recommended dosage for a period of 14 days. Participants provided a 24 h urine collection at trial entry and day 14. Urinary variables were compared to assess for changes in oxalate levels. RESULTS: The median age was 27 years (21-43). There was no difference in the 24 h urine volume pre or post commencement of cranberry tablets (1.7 vs 2 L, p = 0.07). An increase in median urinary oxalate excretion was observed in participants taking both cranberry-only tablets (0.10 mmol/day) and tablets containing vitamin C (1.15 mmol/day). CONCLUSION: Dietary supplementation with cranberry increases urinary oxalate excretion and should be avoided in patients at risk of urolithiasis.

Hospital burden of long-term genitourinary and gastrointestinal toxicity after radical radiotherapy for prostate cancer.

INTRODUCTION: Treatment options for prostate cancer (PCa) include radical radiotherapy (RT) and radical prostatectomy, both of which have comparable oncological outcomes. The aim of this study was to investigate the hospital burden of long-term genitourinary and gastrointestinal toxicity among patients with PCa who were treated with radiotherapy at our institution. METHODS: The radiotherapy department database was used retrospectively to identify all patients who underwent radiotherapy for PCa from January 2006 to January 2008. The patient administration system from each public hospital in the region was interrogated and all patient points of contact were recorded. Minimum follow up was 5 years. Individual patient charts were reviewed and factors that might influence outcomes were documented. RESULTS: We identified 112 patients. The mean age at diagnosis was 66 (44-76) and the median PSA was 12.1 (3.2-38). The mean duration of follow-up was 7.8 yrs. Twenty-three patients (20%) presented to the Emergency Department (ED) with late onset toxicity. Nine patients had more than 2 ED attendances. Twenty-five patients (22%) were investigated for genitourinary toxicity. Forty-seven patients (42%) underwent investigation for gastrointestinal side-effects and 45% of these required argon therapy (21/47). CONCLUSION: We found a significant hospital burden related to the management of gastrointestinal and genitourinary toxicity post radical radiotherapy for prostate cancer. As health care reforms gain momentum, policy makers must take into account the considerable longitudinal health care cost related to radiotherapy. It is also important that patients are counselled carefully in relation to potential long-term side-effects.

Methicillin-resistant Staphylococcus aureus as a uropathogen in an Irish setting.

Urinary tract infections are one of the most common infectious diseases diagnosed in the community and in the hospital setting. Their treatment is complicated by drug-resistant pathogens and the colonization by microbes of indwelling urinary catheters. This study assessed the occurrence and antimicrobial susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) uropathogens isolated for 5 consecutive years at University Hospital Waterford between 2010 and 2014. We created 4 clinically relevant subdivisions, based on urine source: hospital inpatients, patients from the Emergency Department, patients referred from their General Practitioner, and Nursing Home patients. We performed a retrospective review from the hospital's electronic microbiological system and calculated resistance rates for each of the standard antimicrobial agents. During the 5-year study period, we studied 151 urine isolates obtained from 128 patients who had an MRSA cultured in their urine sample. There was 100% resistance of all MRSA isolates to Flucloxacillin and Coamoxiclav. Ninety-eight percent of isolates were resistant to Ciprofloxacin. The resistance rate for Trimethoprim was 7.4% and there was only 2.7% resistance for Nitrofurantoin. For a clinical subset of patients, we also demonstrated 100% sensitivity for samples tested against Teicoplanin and Vancomycin. Urinary MRSA is an infrequently studied phenomenon, but with the rising trend of hospital superbugs nationally, its management is of critical importance. Suitable agents to address this within our population include Nitrofurantoin in the well patient requiring urinary MRSA eradication or Vancomycin/Teicoplanin in the unwell patient requiring intravenous therapy. In all groups, fluoroquinolones should be avoided due to significant resistance rates.

The role of reconstructive surgery in patients with end-stage interstitial cystitis/bladder pain syndrome: is cystectomy necessary?

INTRODUCTION: Interstitial cystitis is a debilitating condition that has a profound effect on quality of life. Although many approaches to treatment have been explored, no consistently effective treatment has been identified. Reconstructive surgery is offered to patients with refractory IC/BPS; however, expert opinion is divided as to whether simultaneous cystectomy is necessary to achieve symptomatic cure. The aim of this study was to report our experience in the surgical management of IC/BPS in a university teaching hospital. METHODS: The hospital inpatient enquiry (HIPE) system was used to identify patients with IC/BPS who underwent surgery between 1997 and 2013. Medical records were examined and patients were invited to complete three symptom-based questionnaires. RESULTS: Twelve patients were identified (8 female, 4 male). Reconstructive procedures included urinary diversion without cystectomy (9) and augmentation ileocystoplasty (4). One patient failed to have a sustained improvement in symptoms following ileocystoplasty and later underwent successful urinary diversion. All other patients noted a "marked improvement" in overall symptoms on global response assessment (GRA) and the resolution of bladder pain on a visual analogue sale (VAS). There were no persistent symptoms or complications related to the retained bladder following diversion. CONCLUSION: Our study adds to the existing evidence that cystectomy is not necessary to provide symptomatic cure in patients with end-stage IC/BPS. Urinary diversion without cystectomy is a highly effective operation and a successful outcome was achieved in all patients. Ileocystoplasty may be offered in carefully selected cases.