R. Grainger

An audit of 2273 ureteroscopies — a focus on intra-operative complications to justify proactive management of ureteric calculi

BACKGROUND At the national Stone Centre we have adopted a proactive management approach involving early ureteroscopy for ureteric calculi. As the efficacy of ureteroscopy is known this study focuses on the low intra-operative complication rate as justification for a proactive management protocol. PATIENTS AND METHODS A retrospective study (1987-1997) identified 1936 patients undergoing 2273 ureteroscopies. A database was created from inpatient hospital records. The male to female ratio was 3 to 1, age range was 25 to 84 years. RESULTS Twenty-three patients (1%) had an intra-operative complication during ureteroscopy. Immediate ureteric JJ stenting was performed in 16 cases with ureteric injury. Two cases underwent percutaneous drainage and delayed antegrade ureteric stenting, ureteroscopy was terminated because of poor visibility. Five patients (0.22%) underwent open surgery for: ureteric perforation (n = 2); Dormia basket ureteric avulsion (n = 1); impacted Dormia basket and stone (n = 1); and impacted balloon dilator and stone (n = l). Ureteroscopic complications were not related to the level of ureteric calculus. CONCLUSION A protocol of proactive management of ureteric calculi facilitates rapid turnover of large patient numbers. This approach is supported by the low intra-operative complication rate, most of which can be managed by further endoscopic procedures. In the event of corrective open surgery a favourable outcome has resulted.

A comparison of the functional durability of the AMS 800 artificial urinary sphincter between cases with and without an underlying neurogenic aetiology

AbstractAim To compare the efficacy and functional durability of the American Medical Systems 800 (AMS 800) artificial urinary sphincter (AUS) device for patients with neurogenic and non-neurogenic incontinence. Methods From 1985 to 2000, 38 patients underwent implantation of an AMS 800 AUS at our institution. Thirty of these patients had complete records and follow-up data available. The mean follow-up for these two groups of patients was six years. Seventeen devices (57%) were implanted for non-neurogenic indications including incontinence after prostatectomy or hysterectomy. Thirteen devices (43%) were implanted for neurogenic conditions including spina bifida, spinal cord injury or severe pelvic trauma. The primary end point measured was continence. Secondary end points included mechanical and non-mechanical device failure, re-operation and complication rates between the two groups. Results In the neurogenic group, only two patients (15%) have their original device in situ without revisions. Only three patients (23%) in this group are entirely dry. In contrast, seven patients (41%) in the non-neurogenic group are completely dry with their original device in situ. A further four (23%) are entirely dry after device revision or replacement surgery. The rates of mechanical failure were not statistically different between the two groups. The rate of non-mechanical failure (NMF) was statistically greater in the neurogenic group in comparison to that in the non-neurogenic group (p<0.05). Conclusions Insertion of an AMS 800 artificial sphincter remains a durable means of regaining urinary continence. Patients who are incontinent as a result of an underlying neurological deficit should be counselled that they might have a higher risk of non-mechanical device failure, requirement for re-operation and that their overall long-term continence rates may be poor.

Transanal endoscopic microsurgical repair of iatrogenic recto-urethral fistula

BACKGROUND Recto-urethral fistula formation following radical prostatectomy is an uncommon but potentially devastating event. Traditional surgery for such fistulae is technically demanding, jeopardizes continence and usually necessitates a diverting colostomy. We present the case of an iatrogenic fistula treated by a transanal endoscopic microsurgical approach, without recourse to a stoma. METHOD A 71-year-old man had recently undergone a radical prostatectomy, complicated by significant intra-operative haemorrhage. He subsequently developed a recto-urethral fistula, confirmed clinically and endoscopically. Due to his bleeding diathesis, he was considered for, and underwent, a transanal endoscopic microsurgical (TEMS) repair. CONCLUSION TEMS is a safe and reliable minimally-invasive surgical technique for the treatment of this difficult condition.

Evaluation of suspected renal colic with noncontrast CT in the emergency department: a single institution study.

BACKGROUND AND PURPOSE Noncontrast CT (NCCT) has become the standard Imaging study in the emergency department (ED) diagnosis of nephro- and ureterolithiasis. We undertook to audit the results from the first 500 NCCTs performed for patients presenting to the ED with suspected renal colic. PATIENTS AND METHODS In a retrospective study at one institution from October 2003 to February 2006, 500 patients with suspected stone disease were investigated. In the study, NCCT findings, patient clinical records, and urinary microscopy results were evaluated for 166 women and 334 men. RESULTS Renal or ureteral calculi were identified in 279 (56%) of NCCTs performed. Of the 500, 112 (19%) NCCTs performed identified unexpected intra-abdominal pathology. When the findings deemed to be of low clinical significance were excluded, the number of scans with additional pathology amounted to 67 (13%). These included vascular emergencies, new cancer diagnoses, and gastrointestinal conditions. CONCLUSIONS The variety of diagnoses found unexpectedly on the NCCT that alter a patients treatment demonstrates the pivotal role of NCCT in the triage of these patients rapidly toward optimal therapy. The rapid acquisition time of NCCT has enabled definitive ED patient diagnosis and less bed occupancy for clinically insignificant calculi.

The Distribution of PSA Age-Specific Profiles in Healthy Irish Men between 20 and 70

Background. Ireland is estimated to have the highest European incidence rate of prostate cancer (Pca) in 2006 which will increase by 275% by 2025. This study aimed to determine PSA cutoff values in different age groups of healthy male patients without Pca. Methods. 660 men in a pilot mens health programme, aged 18–67, had PSA assayed. Men were grouped into 8 age groups at 5-year intervals: 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, and 64–70. Results. Linear regression demonstrates a PSA velocity of 0.024 ng/ml/year. The 95% confidence interval demonstrates a near flat line of PSA values from age 20 to 50 and rises after. When transformed logarithmically, PSA correlates highly with expected values from the normal distribution (0.98). A fractional polynomial quantile regression model was used to predict median and 95th percentile for PSA as follows: 30–34 (0.73, 1.57), 35–39 (0.71, 1.65), 40–44 (0.73, 1.85), 45–49 (0.78, 2.17), 50–54 (0.88, 2.63), 55–59 (1.01, 3.25), 60–64 (1.20, 4.02), and 64–70 (1.43, 4.96). Conclusions. PSA levels are similar to other racial groups but not as high as US Caucasians until 65 years. These data define the predicted PSA for the Irish population and provide a reference for future screening programmes.

Rupture of the male membranous urethra.

BackgroundManagement of traumatic rupture of the male membranous urethra remains controversial. Long-term morbidity can include urinary incontinence, urethral stricture and erectile dysfunction.AimsTo review management and outcome of urethral rupture to improve treatment protocols.MethodsA retrospective study of 47 patients presenting with traumatic urethral rupture over 25 years was performed.ResultsAll patients underwent emergency suprapubic catheterisation, 32 patients had open surgical realignment at 1–2 weeks; 78% of whom developed strictures. Ten patients unsuitable for early repair underwent delayed transabdominal transpubic urethroptasty at three months; 40% of whom developed strictures. Five patients with partial rupture were managed by cystoscopy and urethral catheter. Erectile dysfunction correlated to initial injury rather than treatment.ConclusionsIf the patient is stable and requires emergency laparotomy for other abdominal injuries, he should have immediate realignment of the urethra. Early realignment of the urethra at taparotomy at 1–2 weeks can be combined with orthopaedic fixation of pelvic fractures. Patients who remain unstable due to associated injuries should have delayed urethroplasty at three months.

Haemospermia: how to proceed?

Haemospermia is an alarming symptom but does it signify serious disease andhow should it be investigated? A retrospective review of 44 men showed no evidence of malignancy and infection as the commonest cause. Standard investigation with midstream specimen of urine, intravenous pyelogram and cystoscopy is unhelpful. Microscopy and culture of a first stream specimen of urine or expressed prostatic secretions is the investigation of choice. Cystoscopy should be reserved for patients with recurrent haemospermia.

Results and implications of a pilot prostate cancer screening programme

ConclusionThere were 1,244 new cases of prostate cancer diagnosed in Ireland in 1998.1 If the prevalence of cancer detected through this screening programme is extrapolated to the Irish male population between 40 and 70 years, there would an additional 4,700 cases diagnosed each year. Any proposed screening programme would have major manpower and resource implications.