Ian Dickinson

A Review of Studies Reporting on Complications of Upper Urinary Tract Stone Ablation Using the Holmium:YAG Laser:

Purpose: A review of the literature of studies reporting complications of ureteroscopic urinary tract stone ablation using the holmium:YAG laser was performed. Patients and methods: Electronic databases were searched using specific keywords to identify relevant studies. Reference lists of identified articles were scrutinised for other studies and searches were conducted using the names of authors known to have published widely in this field. Two reviewers assessed retrieved articles for inclusion criteria. Patients <16 years old were excluded. Results: Overall, 48 studies published between 1994 and 2007 were included. Half were published since 2000. In total, 4454 patients were identified. Around half of studies were performed in North America (25). The number of patients per study varied from 8 to 598. The study populations were very heterogeneous in terms of stone position and size, and ureteroscope size and rigidity. Overall, 303 (6.8%) complications were identified. Post-operative ureteric stricture and perforation rates were both 1.0%. There were only six major complications identified (0.1%). The post-operative sepsis rate was 2% and one death was reported. Conclusions: Upper urinary tract stone ablation using the holmium:YAG laser is both safe and reliable. Follow-up imaging to detect procedure-specific complications would not appear to be routinely indicated given this low complication rate.

Fournier's Gangrene Associated with Intradermal Injection of Cocaine

INTRODUCTION Cocaine abuse is associated with a number of medical complications, most notably arrhythmias, myocardial infarction, and cerebral hemorrhages. The injection of cocaine in the penis has been predominantly recorded into the corpus cavernosae and is associated with priapism. AIM Here we describe the injection of subcutaneous cocaine within the penile shaft skin producing ischemic necrosis and Fourniers gangrene. MAIN OUTCOME MEASURES We sought to highlight the effects of cocaine use within the penis and emphasize the different effects that may ensue. METHODS We reviewed a recent clinical case and conducted a literature review on the use of cocaine within the penis. RESULTS The use of cocaine has been reported previously within the literature and is mainly limited to case reports. Cocaine use within the corpora and the subcutaneous tissues produces significantly different consequences ranging from priapism to Fourniers gangrene. CONCLUSIONS The case illustrates the growing use of cocaine and other illicit drugs and emphasizes the importance of this issue to all clinicians.

The story of the condom.

Condoms have been a subject of curiosity throughout history. The idea of safer sex has been explored in ancient and modern history, and has been used to prevent venereal diseases. We conducted a historical and medical review of condoms using primary and secondary sources as well as using the RSM library and the internet. These resources show that the first use of a condom was that of King Minos of Crete. Pasiphae, his wife, employed a goats bladder in the vagina so that King Minos would not be able to harm her as his semen was said to contain “scorpions and serpents” that killed his mistresses. To Egyptians, condom-like glans caps were dyed in different colours to distinguish between different classes of people and to protect themselves against bilharzia. The Ancient Romans used the bladders of animals to protect the woman; they were worn not to prevent pregnancy but to prevent contraction of venereal diseases. Charles Goodyear, the inventor, utilized vulcanization, the process of transforming rubber into malleable structures, to produce latex condoms. The greater use of condoms all over the world in the 20th and 21st centuries has been related to HIV. This account of the use of condoms demonstrates how a primitive idea turned into an object that is used globally with a forecast estimated at 18 billion condoms to be used in 2015 alone.

Use of the ‘labelled key-ring clock’: a simple technique for urethral-bladder neck anastomosis

Radical retropubic prostatectomy is widely accepted as a potentially curative operation for localized prostate cancer [1]. One of the crucial steps during this procedure is the anastomosis of the circular cut end of the urethra to the circular refashioned bladder neck, after removing the prostate. The exact placing of the sutures at the corresponding points of the ‘clock’ at both these structures is important and there can be entangling of these sutures during this part of the procedure. A similar problem is encountered during orthotopic neobladder reconstruction at the time of the anastomosis of the urethra to the neobladder. We describe a simple ‘labelled key-ring’ technique which facilitates ‘tangle-free’ anastomosis with accurate opposition of the edges. We have used this successfully in several patients.

Efficacy of flexible ureteroscopy and laser lithotripsy for lower pole renal calculi

Objective: Our aim was to determine whether flexible ureterorenoscopy and laser lithotripsy is efficacious and safe in treating lower pole renal calculi. Materials and methods: Patient, procedure and stone data of patients who underwent flexible ureterorenoscopy and laser lithotripsy at our referral centre were collected prospectively between November 2005 and November 2011 and entered into a designated database. In all, 242 procedures were performed in 198 patients. Results: The mean age was 51.2 years. The mean calculi size was 10.51 mm (range 4–27 mm). Thirty seven patients had more than one stone in the lower pole. An access sheath was used in 19 patients (9.6%), 171 (86.4%) had a ureteric stent inserted after the procedure, and 165 patients had a single procedure. Re-operation rate was 16.7%. Stone-free rates after one procedure were 89%, 80% and 41%, respectively, for calculi measuring 4–10 mm (n=107), 11–20 mm (n=76) and > 20 mm (n=15). The overall stone-free rate was 83%, 91% and 95% after one, two and three procedures, respectively. Conclusion: Flexible ureterorenoscopy and laser lithotripsy is a safe and effective minimally invasive treatment option for patients with 4–20 mm lower pole calculi. Staged procedures, however, become necessary as the size of the stone increases greater than 20 mm, and this should be mentioned when counselling patients for their primary procedure.

Evaluation of the pressure leak test in increasing the lifespan of flexible ureteroscopes

Flexible ureteroscopes are expensive and delicate instruments that are integral in the offering of a minimally invasive technique of diagnosis and treatment of urolithiasis. Published literature has identified the importance of early damage recognition in preventing frequent use of the scope that would lead to further damage and high repair and replacement costs. Our study was designed to examine the outcome of the pressure leak test on the condition of flexible ureteroscopes after every use and analysing the damage and costs of maintenance.

Bipolar Transurethral Resection of Prostate: Current Status in the Management of Bladder Outflow Obstruction

Monopolar transurethral resection of prostate has been the preferred surgical treatment of benign prostatic hyperplasia. Even in modern series there are significant risks such as haemorrhage requiring transfusion and TUR syndrome, although their incidence is lower than previously. Over the last decade or so newer technologies have emerged that have proven to be at least equivalent to monopolar TURP. Bipolar transurethral resection of the prostate in normal saline is a potentially safer option to monopolar resection but with equivalent efficacy in the medium term. This is supported by 2 recent meta-analyses. This review describes the technology, efficacy and safety profile of bipolar transurethral resection of the prostate.

Surgical Treatment: Transurethral Resection of the Prostate

Transurethral resection of the prostate (TURP) is the standard recommended surgical procedure for men with bothersome lower urinary tract symptoms between 30–80 mL. For prostates larges than this, open prostatectomy has been traditionally performed. Current practice however advocates minimally invasive techniques of Holmium Laser Enucleation of the Prostate (HoLEP) and bipolar enucleation. This requires surgical experience and skill and according to current guidelines, should ideally be performed in a specialist centre or where there is a mentorship programme in place. This is not always freely available. The urological surgeon commonly encounters BPH causing LUTS, and a TURP is a core surgical skill learnt throughout urological training. With adequate experience, a TURP can be performed in the enlarged prostate >100 mL. Use of bipolar TURP limits the risk of dilutional hyponatraemia from TURP syndrome, which can be seen after prolonged resection or capsular perforation with monopolar TURP. We therefore recommended bipolar TURP in the case of a potentially difficult surgical procedure.

Proteus: Mythology to modern times

Aims: It is common knowledge that proteus bacteria are associated with urinary tract infections and urinary stones. Far more interesting however, is the derivation of the word proteus. This study examines the origin of the word proteus, its mythological, historical and literary connections and evolution to present-day usage. Materials and Methods: A detailed search for primary and secondary sources was undertaken using the library and internet. Results: Greek mythology describes Proteus as an early sea-god, noted for being versatile and capable of assuming many different forms. In the 8th century BC, the ancient Greek poet, Homer, famous for his epic poems the Iliad and Odyssey, describes Proteus as a prophetic old sea-god, and herdsman of the seals of Poseidon, God of the Sea. Shakespeare re-introduced Proteus into English literature, in the 15th century AD, in the comedy The Two Gentleman of Verona, as one of his main characters who is inconstant with his affections. The ‘elephant man’ was afflicted by a severely disfiguring disease, described as ‘Proteus syndrome’. It is particularly difficult to distinguish from neurofibromatosis, due to its various forms in different individuals. The Oxford English Dictionary defines the word ‘protean’ as to mean changeable, variable, and existing in multiple forms. Proteus bacteria directly derive their name from the Sea God, due to their rapid swarming growth and motility on agar plates. They demonstrate versatility by secreting enzymes, which allow them to evade the hosts defense systems. Conclusions: Thus proteus, true to its name, has had a myriad of connotations over the centuries.

Accordion—Music to the endourologist

age analgesic requirement in the post-operative period was 47.2 mg morphine equivalent and 162 mg diclofenac equivalent respectively. 11.8% developed post-operative pyrexia which settled with antibiotics. Compared to the BAUS outcome, this series had a higher percentage of staghorn stones and higher stone clearance rates. 75.8% were rendered stone free, while the rest had ancillary procedures (ESWL/flexible ureterorenoscopy). Discussion: ‘Tubeless PCNL’ or ‘nephrostomy free PCNL’ is a safe procedure associated with reduced morbidity and shorter hospital stay when compared to standard PCNL. The analgesic requirements are also diminished with this technique.