Formalin disinfection of biopsy needle minimizes the risk of sepsis following prostate biopsy.

PURPOSE: We describe a simple and effective method to reduce the risk of infection after prostate biopsy. MATERIALS AND METHODS: A total of 1,642 consecutive prostate biopsy procedures during a 4-year period (2008 to 2012) were included in the study. Inclusion criteria consisted of pre-biopsy negative urine culture, bisacodyl enema and fluoroquinolone antibiotics (3 days). Formalin (10%) was used to disinfect the needle tip after each biopsy core. All patients were monitored for post-biopsy infection. The rate of infection was compared to that of a historical series of 990 procedures. Two ex vivo experiments were conducted to test the disinfectant effectiveness of formalin against fluoroquinolone resistant Escherichia coli, and another experiment was performed to quantitate formalin exposure. RESULTS: Post-biopsy clinical sepsis with positive urine and blood cultures (quinolone resistant E. coli) developed in 2 patients (0.122%). Both patients were hospitalized, treated with intravenous antibiotics and had a full recovery without long-term sequelae. Mild uncomplicated urinary infection developed in 3 additional patients (0.183%). All were treated with outpatient oral antibiotics and had a complete recovery. The overall rate of urinary infection and sepsis using formalin disinfection was approximately a third of that of a prior series (0.30% vs 0.80%, p=0.13). Ex vivo experiments showed a complete lack of growth of fluoroquinolone resistant E. coli on blood and MacConkey agars after exposure to formalin. The amount of formalin exposure was negligible and well within the safe parameters of the Environmental Protection Agency. CONCLUSIONS: Formalin disinfection of the biopsy needle after each prostate biopsy core is associated with a low incidence of urinary infection and sepsis. This technique is simple, effective and cost neutral.

Patient Acceptance of Teleurology via Telephone vs Face-to-Face Clinic Visits for Hematuria Consultation at a Veterans Affairs Medical Center.

INTRODUCTION: We evaluated the experience and preferences of patients undergoing hematuria consultation via teleurology compared to a conventional face-to-face clinic visit. METHODS: Patients evaluated for hematuria with teleurology or face-to-face clinic visit were surveyed regarding their experience and preferences. The survey consisted of 27 questions evaluating overall acceptance and satisfaction (8 questions), impact factors (17) and preference (2). RESULTS: A total of 450 patients participated in the survey at a 2-to-1 ratio (300 via teleurology, 150 via face-to-face visits). Overall, patient satisfaction level was higher with teleurology compared to face-to-face clinic visits (mean score 9.2 vs 8.4, p <0.0001). This finding was observed in all 8 domains (acceptance, efficiency, convenience, friendliness, quality of interview, communication and care, provider professionalism and privacy protection, all p <0.001). Transportation related issues were the most common underlying reason that influenced patient opinion, with at least 1 transportation factor being reported by 280 of 300 teleurology patients (93.3%) and 133 of 150 patients seen face-to-face (88.7%). Clinic operation and provider interaction factors similarly impacted patient satisfaction and preference. Time to access was significantly better for teleurology (12 days) compared to face-to-face clinics (72 days, p <0.001). Overall incidence of bladder cancer was 5.6% (25 of 450 patients), which was observed in 6.3% of the teleurology group (19 of 300) and 4.0% of the face-to-face group (6 of 150, p = 0.386). CONCLUSIONS: Patients prefer teleurology to face-to-face clinic visits for the initial evaluation of hematuria. Teleurology positively impacts compliance and access by potentially eliminating common challenges facing patients, and by improving efficiency, convenience and flexibility.

A +20% adjustment in the computed tomography measured ureteral length is an accurate predictor of true ureteral length before ureteral stent placement.

PURPOSE: The correct length of a ureteral stent is important in minimizing postplacement discomfort and stent migration. We describe and validate a method to accurately measure the ureteral length. MATERIALS AND METHODS: The ureteral length in 48 patients undergoing ureteral stent placement for urolithiasis was measured by computed tomography (CT) (total thickness of axial slices between the ureteropelvic junction and ureterovesical junction) and adjusted up by 20%. The adjusted CT measurement of ureteral length was compared with direct intraoperative measurement using scatter plot and Pearson correlation coefficient. Correlation coefficients were also calculated between intraoperative ureteral length and various body habitus measurements such as the height, weight, and waist circumference. RESULTS: Median patient age was 62 years. The median stone diameter was 7.5 mm (1-20). The ratio of left- to right-sided stones was 2:1. The stone location was in the proximal ureter in 45.8%, distal ureter in 37.5%, kidney in 10.4%, and midureter in 6.3%. Symptoms included adnominal/flank pain (93.8%) followed by nausea/vomiting (39.6%) and gross hematuria (16.7%). Median creatinine was 1.4 (0.8-3.6 mg/dl) and median WBC was 8.6 (2.8-17.6). The median ureteral length was 25.8 cm (19.2-29.4) on the CT scan and 25.5 cm (19.0-29.0) on the intraoperative measurement (p=0.57). The Pearson correlation coefficient between the two measurements was 0.979. In contrast, the height, weight, and waist circumference correlated poorly with intraoperative ureteral length measurements (r=0.34, 0.19, and 0.40, respectively). CONCLUSION: CT-measured ureteral length adjusted up by 20% is a reliable method to accurately measure the true ureteral length. This method is superior to traditional indirect methods that rely on body habitus measurements.

Elective versus routine postoperative clinic appointments after circumcisions performed under local anesthesia.

OBJECTIVE: To evaluate a model of elective postoperative clinic appointments after a minor urological procedure and to compare it to the traditional practice of routine appointments. METHODS: A total of 104 consecutive patients undergoing adult circumcision under local anesthesia were divided into 2 groups; group A (n = 45) received routine postoperative clinic appointments and group B (n = 59) were given the option to make an appointment on an as-needed basis. Both groups received detailed postoperative instructions on the early signs of symptoms of potential adverse events. The 2 groups were compared regarding demographics, clinical profile, postoperative recovery, and outcome. RESULTS: Group A patients ("routine appointments") were younger (51 vs 60 years, P <.0001) and included fewer African Americans (57.8% vs 78.0%, P <.03) compared to group B patients ("elective appointments"). Postoperative clinic appointments were categorized as unnecessary in 84.4% (38/45) and 71.1% (42/59) of the patients in groups A and B, respectively. Of the remaining 17 patients in group B who elected to make an appointment, only 1 patient (1.7%) had a true procedure-related issue that justified the visit and required management. Overall, there was no statistical difference between the 2 groups with regard to the number of patients with perceived postoperative issues (P = .36). CONCLUSION: The traditional practice of routine clinic appointments after uncomplicated adult circumcision is medically unnecessary and provides little value in the majority of cases. The practice of open access elective postoperative evaluation based on clearly defined clinical criteria is efficacious, safe, convenient, and enhances resource utilization.

Pelvic nephroureterectomy for renal cell carcinoma in an ectopic kidney.

We present a case of an ectopic renal tumor in a 61-year-old morbidly obese man with a pelvic kidney found after presenting with hematuria and irritative voiding symptoms. The mass, along with the ectopic kidney and ureter, was radically resected through an open operation that involved removing both them and the renal vessels from the underlying iliac vessels. Pathological analysis demonstrated an 8.3 cm papillary renal cell carcinoma (RCC) with oncocytic features, Fuhrman nuclear grade 3, with angiolymphatic invasion and negative margins. The patient has been recurrence-free for over four years since tumor resection.

Incidence and clinical characteristics of lower urinary tract symptoms as a presenting symptom for patients with newly diagnosed bladder cancer

PurposeThe incidence of lower urinary tract symptoms (LUTS) as the sole presenting symptom for bladder cancer has traditionally been reported to be low. The objective of this study was to evaluate the prevalence and clinical characteristics of newly diagnosed bladder cancer patients who presented with LUTS in the absence of gross or microscopic hematuria.Materials and MethodsWe queried our database of bladder cancer patients at the Atlanta Veteran’s Affairs Medical Center (AVAMC) to identify patients who presented solely with LUTS and were subsequently diagnosed with bladder cancer. Demographic, clinical, and pathologic variables were examined.Results4.1% (14/340) of bladder cancer patients in our series presented solely with LUTS. Mean age and Charlson Co-morbidity Index of these patients was 66.4 years (range = 52-83) and 3 (range = 0-7), respectively. Of the 14 patients in our cohort presenting with LUTS, 9 (64.3%), 4 (28.6%), and 1 (7.1%) patients presented with clinical stage Ta, carcinoma in Situ (CIS), and T2 disease. At a median follow-up of 3.79 years, recurrence occurred in 7 (50.0%) patients with progression occurring in 1 (7.1%) patient. 11 (78.6%) patients were alive and currently disease free, and 3 (21.4%) patients had died, with only one (7.1%) death attributable to bladder cancer.ConclusionsOur database shows a 4.1% incidence of LUTS as the sole presenting symptom in patients with newly diagnosed bladder cancer. This study suggests that urologists should have a low threshold for evaluating patients with unexplained LUTS for underlying bladder cancer.