Said Fadel Mishriki

Good quality white‐light transurethral resection of bladder tumours (GQ‐WLTURBT) with experienced surgeons performing complete resections and obtaining detrusor muscle reduces early recurrence in new non‐muscle‐invasive bladder cancer: validation across time and place and recommendation for benchmarking

Study Type – Therapy (cohort)

TURP and sex: patient and partner prospective 12 years follow-up study.

Study Type – Symptom prevalence (prospective cohort)

Half of Visible and Half of Recurrent Visible Hematuria Cases Have Underlying Pathology: Prospective Large Cohort Study With Long-Term Followup

PURPOSE Visible hematuria has a cancer yield of up to 24.2%. A large proportion of cases will have no etiology. In this study we determined the incidence of pathology (benign and malignant) in patients with visible hematuria and those with persistent and recurrent visible hematuria, and evaluated the policy for investigations. MATERIALS AND METHODS Data were prospectively collected for 1,804 patients with visible hematuria at a United Kingdom teaching hospital from January 1999 to September 2007. In October 2010 the comprehensive hospital electronic database was checked for every individual patient to ensure no urological pathology was missed. All patients underwent standard hematuria investigations, including renal tract ultrasound and excretory urography or contrast enhanced computer tomography urogram, flexible cystoscopy and urine cytology. RESULTS The male-to-female ratio was 4.8:1. Median age ± SD was 67 ± 17.0 years (range 21 to 109). Median followup was 6.6 ± 2.5 years (range 1.5 to 11.6). No urological pathology was found in 965 (53.5%) patients. Malignant urological disease was found in 386 (21.4%) patients, of whom 329 had bladder tumors. There were 32 patients with persistent visible hematuria and no malignancy. Repeat investigation was performed in 69 patients reporting recurrence. Of these patients 35 received a significant urological diagnosis, including 12 (17.4%) urological malignancies, while 34 (49.3%) still had no diagnosis. Limitations include the possibility of missing pathology. CONCLUSIONS Almost 50% of patients presenting with visible hematuria will have a diagnosis. Therefore, all cases of visible hematuria require full standard investigations. Patients with no diagnosis can be discharged from followup. Recurrent visible hematuria after full initial negative findings requires repeat full standard investigations because 11.6% will have malignant pathology.

Routine Urine Cytology has No Role in Hematuria Investigations

PURPOSE Urine cytology has been a long-standing first line investigation for hematuria and is recommended in current major guidelines. We determined the contribution of urine cytology in hematuria investigations and its cost implications. MATERIALS AND METHODS Data were prospectively collected for 2,778 consecutive patients investigated for hematuria at a United Kingdom teaching hospital from January 1999 to September 2007 with final analysis in October 2010. All patients underwent standard hematuria investigations including urine cytology, flexible cystoscopy and renal tract ultrasound with excretory urogram or computerized tomography urogram performed in those with visible hematuria without a diagnosis after first line tests. Patients with positive urine cytology as the only finding underwent further cystoscopy, retrograde studies or ureteroscopy with biopsy under general anesthesia. Outcomes in terms of eventual diagnosis were cross-referenced with initial urine cytology results (classified as malignant, suspicious, atypical, benign or unsatisfactory). Costs of urine cytology were calculated. RESULTS Of the patients 124 (4.5%) had malignant cells and 260 (9.4%) had atypical/suspicious results. For urothelial cancer cytology demonstrated 45.5% sensitivity and 89.5% specificity. Two patients with urine cytology as the only positive finding had urothelial malignancy on further investigation. For the entire cohort the cost of cytology was £111,120. CONCLUSIONS Routine urine cytology is costly and of limited clinical value as a first line investigation for all patients with hematuria, and should be omitted from guidelines.

Incidence of Recurrent Frank Hematuria and Urological Cancers: Prospective 6.9 Years of Followup

PURPOSE The majority of patients presenting with frank hematuria have no diagnosis. There is a paucity of literature on the recurrence of frank hematuria and the incidence of urological cancers in these patients, and this study addresses both issues. MATERIALS AND METHODS We performed a prospective cohort study of 578 consecutive patients referred with frank hematuria between 1999 and 2001 who underwent full investigations with a mean followup of 6.9 years. The primary outcome measure was the probability of frank hematuria recurrence after the initial negative investigations and the incidence of urological cancers in these patients. RESULTS Diagnosis was made in 206 (35.6%) patients at initial presentation. Diagnosis was not made at initial presentation in the remaining 372 (64.4%) patients, of whom 81 died without a diagnosis during followup (32 within 2 years of presentation). A total of 81 patients (21.8%) with no diagnosis died during the followup period (32 within 2 years of the investigations). A questionnaire was mailed to the remaining 291 patients and 202 (69.4%) responded. Of the responders 41 (20.3%) reported frank hematuria recurrence (single episode in 10 and multiple episodes in 31). A significant urological diagnosis was made upon repeat evaluation in 21 (10.4%) patients which included urological malignancy in 4 (2%). CONCLUSIONS Approximately 80% of cases cleared by initial investigation remained clear and 9.8% with frank hematuria recurrence were diagnosed with a urological malignancy. Frank hematuria recurrence requires vigilance and repeat investigations as appropriate.

NICE forgot surgical skill

The guidelines on preventing and treating wound infection from the National Institute for Health and Clinical Effectiveness (NICE) overlook the most important single issue in wound infection: surgical …

Baseline Symptom Score and Flow Rate Can Predict Failure of Medical Treatment of Lower Urinary Tract Symptoms: Prospective 12-year Follow-up Study

OBJECTIVE To assess predictors of failure of medical treatment of lower urinary tract symptoms (LUTS) and evaluate long-term outcome. METHODS Between January 1993 and September 1994, 178 men referred with LUTS were prospectively recruited. Assessments included maximum urine flow (Qmax), postvoiding residuals (PVR), transrectal ultrasound (TRUS) prostate volumes, American Urological Association symptom score, and validated quality of life (QOL) and bother scores. Treatment failure was defined as need for transurethral resection of the prostate (TURP). Data were collected at baseline, with final follow-up at 12 years. Univariate and multivariate analyses used Kaplan-Meier and the Cox proportional hazards regression model, respectively, to assess covariates on risk of failure and independent variable prognostic values. RESULTS Median follow-up was 7.9 years (range, 0-12 years). The mean QOL baseline score of 7.1 improved to 3.6 at 6 years and to 3.3 at 12 years (P <.05 for all). Fifty patients (28%) underwent TURP, with 36 undergoing TURP within 3 years. By univariate analysis, Qmax, AUA and bother scores, and PVR were significantly associated with treatment failure. Independent predictors of failure by multivariate Cox regression were Qmax (>15 vs <15 mL/s; hazard ratio, 3.37; 95% confidence interval, 1.74-6.52; P <.0001) and bother score (<13 vs >13; hazard ratio, 2.37; 95% confidence interval, 1.29-4.35; P = .005). At 12 years, AUA, QOL, and bother scores statistically improved compared with baseline (13 vs 8, 10 vs 6, and 5 vs 2, respectively). Limitations included attrition bias from nonresponders. CONCLUSION The beneficial effect of medical treatment persisted for up to 12 years. Treatment is more likely to fail within the first 3 years in patients with low baseline Qmax and high bother scores.