Paul P. Irwin

A prospective study of conservatively managed acute urinary retention: prostate size matters

Objective To evaluate in a prospective study the medium‐ to long‐term outcome of a policy of conservatively managing acute urinary retention (AUR), arising solely by bladder outlet obstruction caused by benign prostatic enlargement (BPE), and to identify the factors favouring a positive outcome of a trial without catheter (TWOC).

Interstitial Cystitis Versus Detrusor Overactivity: A Comparative, Randomized, Controlled Study of Cystometry Using Saline and 0.3 M Potassium Chloride

PURPOSE We compared cystometric findings in interstitial cystitis and detrusor overactivity using 0.3 M KCl and 0.9% normal saline. MATERIALS AND METHODS Female patients with established diagnoses of IC (7 patients according to NIDDK criteria) and urodynamically proven DO (10 patients) underwent consecutive cystometrograms using 0.9% normal saline and 0.3 M KCl, the order of which was randomized for each patient. Individual CMGs were performed by separate investigators, and patients and investigators were blinded to the order in which the solutions were used and to the results of the other CMG. The results were analyzed on a comparative basis using a 2-tailed t test for comparison of the means and a Kolmogorov-Smirnov z test was used for group comparison. A ROC curve was used to plot sensitivity to the false-positive rate. RESULTS Irrespective of the diagnosis or the type of infusion used, the volume at FDV was slightly lower with the first CMG compared to the second (mean 76.1 vs 94.2 ml) but did not reach statistical significance (p = 0.20). However, Cmax was similar for first and second CMGs (mean 214 vs 213.2 ml, p = 0.98). Although lower with KCl, there was no significant difference in FDVs obtained with either solution (mean 78.2 vs 92.2 ml for KCl and NS, respectively, p = 0.33). However, KCl produced a significant reduction in Cmax across the whole group (mean 244.5 vs 182.7 ml, p = 0.008). This was most marked in the DO group in which there was a 23% reduction in Cmax with KCl compared to NS, while the IC group showed only a 15% reduction in mean Cmax. The ROC curve, comparing Cmax values for NS with KCl cutoff values of 15% and 30%, resulted in poor positive predictive values (51% and 66%, respectively) for comparative cystometry in distinguishing IC from DO. CONCLUSIONS The 0.3 M KCl reduces Cmax in IC and DO, the effect being more pronounced in DO. Urothelial hyperpermeability is not specific to IC. Comparative cystometry using NS and 0.3 M KCl does not help to differentiate IC from DO.

Summary of the Urodynamics Workshops on IC Kyoto, Japan

Urodynamics has traditionally played a valuable role in the diagnostic evaluation of patients with irritative bladder symptoms. The investigation allows the clinician to distinguish the oversensitive bladder (interstitial cystitis) from the overactive bladder (detrusor overactivity or instability). The importance of urodynamics was exemplified by the NIDDK consensus committee on interstitial cystitis (IC) who included cystometry as an essential diagnostic tool in selecting patients for clinical trials related to IC. 1 However, since then, as a wider choice of more effective medical therapies for urgency, frequency, and even urge incontinence have become available, there has been a shift away from urodynamics as a firstline investigation of these patients and a move towards empiral treatment on the basis of symptoms alone. This appears to be the case in interstitial cystitis (IC) also. 2

Avoid cruising on the uroflowmeter: evaluation of cruising artifact on spinning disc flowmeters in an experimental setup.

The aim of our study was to access the variability of maximum flow rate (Qmax), average flow rate (Qav) and flow pattern while varying the point of impact of flow on the flowmeter.

Public interest warning: should we ban wooden/ornamental toilet seats for male infants?

Sir, There is increasing evidence that lymphovascular invasion (LVI) is one of important prognostic indicators in upper urinary tract urothelial carcinoma (UUT-UC) [1]. A recent report from Akao et al. [2] in the BJU Int suggested LVI status might be a better predictive marker for cancer-specific survival in patients UUT-UC and treated by radical surgery. They also reported that patients with pT3N0M0 disease without LVI had a significantly better prognosis than those who were pT3N0M0 with LVI. The presence of LVI represents a higher probability of metastasis, so many investigators who respectively evaluated the role of retroperitoneal lymph node dissection in UUT-UC concluded that lymphadenectomy has a therapeutic effect, especially for patients with advanced UUTUC [3–5]. We totally agree with the conclusion of the authors, as LVI is a good prognostic factor for predicting the outcome of pT3 disease, especially for patients who have a primary tumour in the renal pelvis. Traditionally, the prognosis of UUT-UC is strongly correlated with pathological stage, especially with invasion of the muscularis. The muscular layer of the ureter is much thinner than in the renal pelvis. Ureteric UC is associated with a greater local or distant failure rate than renal pelvic UC [6]. However, the TNM staging system combines renal pelvic and ureteric carcinomas, despite their different anatomy. However, different from the ureter and the urinary bladder, lamina propria is lacking beneath the urothelial lining, and the renal papillae in the renal pelvis, and is quite thin along the minor calyces. Moreover, within the renal sinus, the muscularis propria might be very thin or imperceptible near the calyces, and is surrounded by sinus fat. Renal sinus fat invasion is not addressed in the TNM staging system. Guinan et al. [7] suggested a modification of the TNM staging system, separating renal pelvic and ureteric tumours, and reported a significant survival difference between stage T3 and stage T4N + M + in renal pelvic tumours. They concluded that renal parenchyma is a relative anatomical barrier to the spread of renal pelvic tumours, and that stage T3 renal pelvic tumours invading the renal parenchyma are not comparable with stage T3 ureteric tumours invading peri-ureteric tissues. Wu et al. [8] evaluated 72 patients with pT3 UUT-UC and concluded that superficial renal parenchymal invasion should be considered as a lower-stage disease. They also indicated that vascular involvement is the only independent prognostic factor for pT3 disease. The concept could be supported by the findings of Akao et al. , who indicated that LVI status is the most useful independent factor for predicting cancer-specific survival by multivariate analysis using Cox proportional hazard model. We could consider LVI status for risk stratification of patients with pT3 UUT-UC, to decide whether adjuvant chemotherapy will be added [9]. PUBLIC INTEREST WARNING: SHOULD WE BAN WOODEN/ORNAMENTAL TOILET SEATS FOR MALE INFANTS?

Unplanned urology readmissions in a district general hospital: are we meeting the standard?

Background Recent changes in practice standards and remuneration to UK Trusts have been refined to penalise institutions for patient readmission within 30 days of discharge. The purpose of this study was to determine if the target rate of less than 6.5% was attained within the setting of a district general hospital (DGH) and also to comment on readmission trends. Materials and methods A retrospective study was performed over 12 months examining all unplanned readmissions to hospital 30 days following discharge from Urology. Elective as well as emergency cases were audited. Results A total of 4124 patients were treated and discharged by the department over 12 months. One hundred and eighty-four (4.4%) patients were readmitted: 93 (51%) patients following acute presentations and 91 (49%) following elective procedures. The commonest causes for unplanned readmission were haematuria, 29 cases (16%), acute urinary retention, 28 cases (15%) and ureteric colic, 25 cases (14%). Readmission rates following flexible cystoscopy and TRUS biopsy were 1% and 3%, respectively. Only six of 70 patients (9%) were readmitted following TURP. Five (3%) of the 184 readmissions required a second procedure. Conclusion Our department met the predetermined standard in achieving an unplanned readmission rate of less than 6.5%. This study also highlighted the need for discharge policies for common acute presentations.

Patient reported outcomes of abobotulinumtoxinA injection treatment for idiopathic detrusor overactivity: a pragmatic approach to management in secondary care

Aims: To evaluate the medium and long-term results of abobotulinumtoxinA (aboBTX-A) injection treatment in the management of refractory overactive bladder (OAB) symptoms owing to idiopathic detrusor overactivity. Methods: Prospective data were collected from consecutive patients who underwent intravesical injection of 250 units of aboBTX-A under general anaesthetic for OAB symptoms that were refractory to antimuscarinic therapy. Overactive bladder symptom scores (OABSS), Likhart quality of life (QoL) indices and post-void residual volumes (PVR) were compared before and 6 weeks after treatment. The Wilcoxon Signed Ranks test was used to compare changes in OABSS, QoL and PVR from baseline scores. Results: Seventy-three patients received 93 aboBTX-A injection treatments over a 5-year period. Overall, OABSS and QoL improved by a mean of 3.7 + 4.17 (p<0.001) and 2.1 + 2.06 (p<0.001), respectively. An improvement in the combined OABSS and QoL scores of two or more points was observed following 68 (70.8%) procedures. De novo self-catheterisation was required following 16 procedures (16.8%) but was discontinued by 3 months in nine cases. In patients undergoing repeat injection treatment, the mean (+ SD) duration of symptomatic relief (until the resumption of antimuscarinic therapy) was 12.3 + 9.8 months, while the mean (+ SD) interval between injection treatments was 26.7 ± 14.3 months. Conclusion: AbobotulinumtoxinA injection treatment, employing a dose of 250 units per treatment, confers results that compare very favourably with those reported for onobotulinumtoxinA.

Concomitant testicular seminoma and ectopic adrenal tissue of the cord in a 45-year-old male

Aberrant adrenal tissue near the adrenal gland is common, but the finding of ectopic adrenal tissue in structures around the spermatic cord and testis is rare. We describe a case of concomitant seminoma and ectopic adrenal tissue of the spermatic cord occurring in an adult patient who had undergone orchidopexy as a child.

Urethral involvement of myeloma: A rare case of visible haematuria leading to a diagnosis of relapsed multiple myeloma after curative stem cell transplantation

Extramedullary multiple myeloma involving the urinary tract is extremely rare. We report an unusual case of visible haematuria in a 45-year-old male who had a stem cell transplant for multiple myeloma 18 months previously. Cysto-urethroscopy revealed a mid-urethral lesion that was then fully excised by endoscopic resection. Histology confirmed malignant plasma cell infiltrate with subsequent staging and skeletal biopsy of a rib lesion confirming relapse of multiple myeloma. We believe this is the first case of urethral involvement to reveal a relapse of multiple myeloma after autologous stem cell transplant.

Intravesical botulinum toxin-A: Does the injection template matter?

Objective: The efficacy of intravesical botulinum toxin-A (BTX-A) for the treatment of idiopathic detrusor overactivity (IDO) is well-established and evidence-based. The optimal regime in terms of dose, distribution, depth of injection and number of injections has not been determined and there is still considerable variation throughout clinical practice. We aim to establish the optimum template for bladder injections. Patients and methods: All patients had urodynamically-proven IDO which had failed conservative and medical management. AbobotulinumtoxinA (250 units) was injected into the detrusor and sub-urothelium in one of five injection templates under general anaesthetic. An Overactive Bladder Symptom Score (OABSS) and International Prostate Symptoms Score (IPSS)-Likert quality of life (QoL) score was completed pre-operatively and at six weeks post-operatively. In those who underwent repeat treatments the time to re-commencement of pharmacological therapy was recorded. Results: In total 111 patients received 170 treatments. The average age of patients was 57 (range: 17–86) and the male: female ratio was 0.18:1. Overall there was a mean improvement in the OABSS by −3.7 points±4.29 (standard deviation (SD) (p<0.01) and an average change in the QoL score of −2.18±2.17 (SD) (p<0.01) with BTX-A treatment. When analysed by template subgroup there was no statistically significant difference in the magnitude of change for any template over the other four for either the OABSS (p=0.78) or QoL scores (p=0.56). Forty-one patients had multiple treatments and had data collected for the duration to treatment failure. The overall average time to treatment failure was 11.2±7.9 months. Subgroup analysis showed that there was no statistically significant (p=0.783) difference in time to treatment failure for any one of the injection distributions. Conclusion: This study has shown that altering the injection protocol of BTX-A did not affect the clinical outcome in terms of symptoms, QoL or in the time to treatment failure.