British Journal of Medical & Surgical Urology

Editorial Board

2010-09-01

Why British urology should support RADICALS despite initial slow recruitment

Roger Kockelbergh — 2010-09-01

There is a history of trials being derailed by the emergence of new evidence, EORTC 30944 evaluating adjuvant chemotherapy for bladder cancer is an example. The emergence of a survival benefit for neoadjuvant chemotherapy meant that there were few suitable patients available to be recruited.

Upper urinary tract fungal infections

Sachin Agrawal, Christian T. Brown, Steve Miller, Clive Grundy, Ravi Kulkarni — 2010-09-01

Summary: Upper urinary tract fungal infections are rare, under-reported and potentially fatal. Infections often develop in patients with significant co-morbidity and are difficult to identify and treat. They can manifest as local (funguria) or systemic infection (fungaemia). The management is complex and mortality appears unchanged in the past 20 years. Unlike lower urinary tract funguria, which is classified as low risk, upper ureteric infections and fungaemia are classified as high risk. The incidence is increasing and may be associated with changing population demographics, advances in medical diagnostics, and new stent and catheter technologies with longer durations of insertion. We review the current literature and report on six cases.

When should radiotherapy be used after radical prostatectomy? The RADICALS-RT Trial

Christopher C. Parker, Noel W. Clarke, Howard Kynaston, Matthew R. Sydes — 2010-09-01

Abstract: Despite two recent trials of the role of early radiotherapy following radical prostatectomy, there remains no consensus as to best practice and clinicians tend to base their decisions around MDT discussion and pathological risk factors. This paper develops the argument for international Intergroup trial, RADICALS-RT, which is now recruiting, and which is our opportunity to resolve this important issue.

A one-day frequency-volume chart is representative of a 3-day chart in the assessment of lower urinary tract symptoms suggestive of bladder outflow obstruction

Prabhakar Rajan, Kevin J. Turner, Paramananthan Mariappan, Laurence H. Stewart — 2010-09-01

Summary: Introduction: 24-h frequency-volume (FV) charts are often used to assess patients with lower urinary tract symptoms suggestive of bladder outflow obstruction (LUTS/BOO). There are no clear guidelines regarding the optimum chart duration. We aimed to determine whether a one-day FV chart is representative of a 3-day equivalent.Patients and methods: Men presenting with LUTS (including nocturia) were prospectively recruited and completed a 3-day FV chart. Exclusion criteria were previous bladder outflow surgery and anti-cholinergic medication.Results: 285 patients were recruited (mean age, 67 years; range 26–93 years). There were no significant inter-day differences in 24-h urine volume (24HUV) (p=0.10) and functional bladder capacity (FBC) (p=0.19). However, there were significant differences identified between days 1 and 2, and 1 and 3 for both nocturnal urine volume (NUV) (p<0.001) and actual nocturnal voids (ANV) (p<0.001) despite significant correlation of these parameters on each day with their respective 3-day means.Conclusion: Our data suggest that a one-day FV chart is representative of a 3-day equivalent for the assessment of 24HUV and FBC in patients with LUTS/BOO. Further studies are required to compare the repeatability and clinical utility of a one-day chart compared with 3- and 7-day charts, particularly in patients with nocturia.

Analgesia for shock wave lithotripsy

George Yardy, Nimish Shah, Oliver Wiseman — 2010-09-01

Summary: Since its introduction nearly three decades ago, extracorporeal lithotripsy has become an established treatment for kidney and ureteric stones. Treatment using early lithotripsy devices was efficacious but painful, requiring general anaesthesia. Modern lithotripters are better tolerated: shock wave lithotripsy (SWL) is now usually an outpatient procedure undertaken after administration of analgesia, with or without sedation. Many different analgesia regimens have been investigated. In this article the characteristics of the ideal painkiller for shock wave lithotripsy are described and evidence of the suitability of a variety of different analgesic protocols is reviewed.

Three-year outcomes of a visible haematuria clinic—No initial role for urine cytology?

2010-09-01

Summary: Objective: To review patients presenting in a specialist macroscopic (visible) haematuria clinic during 2005, incorporating 3 years of follow-up, and to assess the role of urine cytology.Patients and methods: All patients attending the 2005 macroscopic haematuria clinic were identified. All subsequent admissions, pathology and imaging for each patient were captured from the hospital IT system during 3 years of follow-up and reviewed retrospectively.Results: Five hundred and three patients were assessed. No significant abnormalities were diagnosed in 52%, benign disease in 27% and malignant disease in 21% (including 14% urothelial cancer, 3% renal cancer and 4% prostate cancer). All bladder tumours were diagnosed with flexible cystoscopy and the 3 upper-tract urothelial tumours by ultrasound. Overall, cytology had a sensitivity of 66% and specificity 90% but did not diagnose tumours that were not identified with other investigations. Patients with abnormal cytology without apparent cause underwent various investigations including IVU, cystoscopy and biopsy and no tumours were identified. After 3 years no occult diseases became apparent.Conclusions: Half of all those attending with visible haematuria had significant urological diagnoses (21% urological cancer). Urine cytology did not appear to add significant information in the initial assessment of visible haematuria.

An evaluation of current surgical techniques used for vesicoureteric anastomosis in paediatric renal transplantation in the United Kingdom

Nikhil Vasdev, David Rix, Naeem Soomro, David Talbot — 2010-09-01

Summary: Introduction: Kidney transplantation is the best treatment available for end stage renal disease at any age. Vesicoureteric reflux (VUR) following paediatric renal transplant can lead to loss of graft function. We present a summary of a survey evaluating current surgical techniques used for vesicoureteric anastomosis in paediatric renal transplantation in the United Kingdom (UK) developed in our unit.Methods and results: In the UK, 70% of paediatric transplant surgeons use the Lich–Gregoir technique and 70% place a transanastomotic double-J stent at the time of vesicoureteric anastomosis. 80% of the double-J stents are removed at 6 weeks following transplant.Conclusion: Paediatric renal transplant grafts are at risk of developing segmental pyelonephritic scars if infected urine refluxes into the graft either through a transanastomotic stent or later from vesicoureteric anastomosis. These scars may reduce the renal function with time. Consideration should be given within the UK for the development of more effective anti-reflux surgery for vesicoureteric anastomosis in paediatric renal transplantation.

Benchmarking competency in paediatric groin surgery

J. Wilson, A. Younis, J. Lewis-Russell, P. Jones — 2010-09-01

Summary: Introduction: A diminishing number of surgeons are performing paediatric groin surgery in large district general hospitals due to loss of expertise. The British Association of Urological Surgeons (BAUS) is currently engaged with the Royal College of Surgeons (RCS) to resolve this gradual loss of subspecialist expertise.We have adopted a user-friendly approach to quantify training in this field.Methods: In our centre we undertake approximately 150 paediatric groin cases per year with 3 specialist registrars (SpRs) rotating through the post every 4 months. Using existing Intercollegiate Surgical Curriculum Project (ISCP) tools, Direct Observation of Procedural Skill (DOPS) assessments were undertaken for each groin procedure performed by the SpR then scored by the trainer from 2 (unsatisfactory) to 6 (above expectations), with 4 being considered satisfactory/competent to perform the procedure. Three SpRs were assessed over a period of 4 months each.Results: Competency was determined by 5 successive DOPS scores of 4. Case numbers over 4 months were 23–35 with a mean number of cases to achieve competency being 16 (range 10–18).Conclusion: These results indicate that it is feasible and practical for a trainee to acquire adequate experience in DGH paediatric groin surgery and we suggest a minimum performance of 25 procedures.

Non-seminomatous germ cell tumour of a testis in an 80-year-old man: A rare case

Krishna Narahari, Mathew Shaw, Babett Disep, Ian Pedley, Andrew Thorpe — 2010-09-01

An 80-year-old man referred to the urology clinic for lower urinary tract symptoms also complained of a painless left testicular swelling which he had noticed for the last 3–4 months. Physical examination revealed a firm non-tender smooth left scrotal swelling. The initial clinical impression was that of a tense hydrocoele. A scrotal ultrasound showed a 7.5cm×3.5cm×3.5cm mixed reflectivity area entirely replacing the left testes with large cystic areas within it. The appearances were suggestive of a seminoma (). Alpha fetoprotein (AFP), beta human chorionic gonadotropin (HCG) and lactate dehydrogenase (LDH) were elevated at 770kU/L (normal range 0–10kU/L), 553IU/L (normal range 0–10IU/L), and 337U/L (normal range 0–215U/L), respectively. The patient underwent left radical orchidectomy. The histology demonstrated malignant undifferentiated teratoma with multiple areas of embryonal carcinoma and a small area of yolk sac differentiation (). Staging CT scan showed evidence of para-aortic and aortocaval lymphadenopathy up to 1.9cm in size (). Twenty two days post-operatively the tumour markers had decreased, with an AFP=78kU/L, HCG=163IU/L and LDH=30IU/L.

Erosion of vascular graft into the bladder 5 years after original surgery

John H. Saunders, Priyadarshi Kumar, Owen J. Cole — 2010-09-01

We present the case of a 68-year-old lady who presented with haematuria. Subsequent cystoscopy noted an abnormal area which was later characterised as a vascular graft. In this article we review the available literature, discuss the rare occurrence of vascular graft erosion into the bladder and offer insights into management of this situation.