Samuel McClinton

Surgical treatments for men with benign prostatic enlargement: cost effectiveness study

Objective To determine which surgical treatment for lower urinary tract symptoms suggestive of benign prostate enlargement is cost effective. Design Care pathways describing credible treatment strategies were decided by consensus. Cost-utility analysis used Markov modelling and Monte Carlo simulation. Data sources Clinical effectiveness data came from a systematic review and an individual level dataset. Utility values came from previous economic evaluations. Costs were calculated from National Health Service (NHS) and commercial sources. Methods The Markov model included parameters with associated measures of uncertainty describing health states between which individuals might move at three monthly intervals over 10 years. Successive annual cohorts of 25 000 men were entered into the model and the probability that treatment strategies were cost effective was assessed with Monte Carlo simulation with 10 000 iterations. Results A treatment strategy of initial diathermy vaporisation of the prostate followed by endoscopic holmium laser enucleation of the prostate in case of failure to benefit or subsequent relapse had an 85% probability of being cost effective at a willingness to pay value of £20 000 (€21 595,

Outcomes of Ureteroscopy for Stone Disease in Pregnancy: Results from a Systematic Review of the Literature

28 686)/quality adjusted life year (QALY) gained. Other strategies with diathermy vaporisation as the initial treatment were generally cheaper and more effective than the current standard of transurethral resection repeated once if necessary. The use of potassium titanyl phosphate laser vaporisation incurred higher costs and was less effective than transurethral resection, and strategies involving initial minimally invasive treatment with microwave thermotherapy were not cost effective. Findings were unchanged by wide ranging sensitivity analyses. Conclusion The outcome of this economic model should be interpreted cautiously because of the limitations of the data used. The finding that initial vaporisation followed by holmium laser enucleation for failure or relapse might be advantageous both to men with lower urinary tract symptoms and to healthcare providers requires confirmation in a good quality prospective clinical trial before any change in current practice. Potassium titanyl phosphate laser vaporisation was unlikely to be cost effective in our model, which argues against its unrestricted use until further evidence of effectiveness and cost reduction is obtained.

Therapeutic Transarterial Embolisation in the management of benign and malignant renal conditions

Introduction: Our aim was to evaluate the clinical efficacy and safety of ureteroscopy as a primary treatment for pregnant women with symptomatic ureteric stones who have failed conservative management. Materials and Methods: A systematic review of the literature from January 1990 to June 2011 was performed, including all English language articles. Outcome measures were clinical efficacy, in terms of stone clearance and need for additional procedures, and safety in terms of complications. Results: A total of 239 abstracts were screened and 15 studies were identified reporting on 116 procedures. The surgical methods of stone management employed were stone extraction with basket only (n = 55, 47%), laser fragmentation (n = 27, 23%; holmium, n = 20, pulse dye, n = 7), impact lithotripsy (n = 21, 18%), ureteroscopic lithotripsy (n = 6, 5%) and a combination of methods (n = 6, 5%). A post-operative stent was inserted in 64 of 116 procedures (55%). Complete stone clearance was seen in 100 of the 116 procedures (86%). There were 2 major complications (1 ureteral perforation and 1 case of premature uterine contraction) and 7 minor complications (5 urinary tract infections and 2 cases of post-operative pain). Conclusion: This review suggests that stone clearance using ureteroscopy is a relatively safe option in pregnancy with a high success rate.

Fate of Indeterminate Lesions Detected on Noncontrast Computed Tomography Scan for Suspected Urolithiasis: A Retrospective Cohort Study With a Minimum Follow-up of 15 Months

PURPOSE The aim of this study was to critically appraise the efficacy and complications of Therapeutic Transarterial Embolisation (TAE) in various benign and malignant renal conditions. MATERIAL AND METHODS The records of all patients who underwent renal embolisation procedures, at a single institution, between March 1992 and March 2004, were reviewed. The patients were identified from hospital records via the procedure coding system and the radiology department procedures book and were analysed retrospectively. Twenty-nine patients were analysed, looking at indications, clinical outcome, complications and long-term results. RESULTS Twenty-nine patients underwent 35 embolisation procedures during this period. Fourteen patients with benign diseases underwent 17 embolisation procedures for haematuria or intractable pain. In the haematuria group, selective embolisation was used to treat bleeding post percutaneous nephrolithotomy (PCNL) (n=4), angiomyolipoma (n=2), arteriovenous (AV) malformation (n=l1), renal artery aneurysm (n=1) and renal trauma (n=2). In the renal pain group (n=3), non-selective embolisation was done. Two of these patients had recurrence of pain despite repeat embolisation and subsequently underwent nephrectomy. Fifteen patients with advanced renal malignancy, who were deemed unfit for surgery, underwent 18 embolisation procedures for symptomatic haematuria. Twelve of the 15 patients had successful outcomes with cessation of haematuria. Three patients required repeat embolisation procedures for continuing haematuria with success. There were no major embolisation-related complications. Minor complications were self-limiting and settled with conservative management. CONCLUSION Renal artery embolisation is effective in managing haematuria in benign and malignant renal conditions where indicated, with minor and easily treatable adverse effects

Metastatic Crohn's disease of the penis: two cases

OBJECTIVE To investigate the fate of indeterminate lesions incidentally found on noncontrast computed tomography (NCCT) for suspected urolithiasis. METHODS A retrospective review of 404 consecutive cases of suspected urolithiasis was undertaken between May 2010 and April 2011. Data were collected for patient demographics, presence of calculus disease, and additional urologic or nonurologic pathologies and their clinical relevance. The indeterminate or suspicious lesions were followed up and the data were reviewed in September 2012. RESULTS In total, 404 patients underwent NCCT for renal colic (mean age, 50 years [range, 13-91 years]; 165 females). Minimum follow-up period was 15 months. Fifty-eight patients (14%) had ureteric, 85 (21%) had renal, and 39 patients (10%) had combined ureteric and renal stones. Noncalculus pathologies were found in 107 patients (26%). Sixty patients (15%) had indeterminate lesions. Of these patients, 6 required operative intervention, 35 had a benign diagnosis after further imaging and multidisciplinary team meeting, and 13 remained under surveillance after 1 year. Indeterminate pulmonary lesions (8 of 16) were the commonest lesions to remain under surveillance. CONCLUSION NCCT is vital for the diagnosis of urolithiasis with a pick up rate of 45% and remains the standard of care. However, with incidental detection of potential malignant lesions, a significant minority will need close monitoring, intervention, or both. In our study, approximately one-third of these lesions either remained under surveillance or had intervention.

Technique of radiological localisation and endoscopic retrieval of unusual foreign body from urinary bladder

Metastatic Crohn’s disease is a rare inflammatory process that is non-contiguous from the bowel. It can affect the penis and is variable in presentation and onset in relation to bowel symptoms. It has been treated with oral, topical, systemic, and surgical therapies. We describe our experience with two cases of penile metastatic Crohn’s disease and their management in comparison with other cases described in the literature. Both our patients were of the lymphoedematous type and had sexual and voiding dysfunction. They were treated with topical and intra-lesional steroids and circumcision after unsuccessful systemic treatments.

CorrespondenceUreteric colic and clinical evidence – Authors' reply

Minimal invasive endoscopic retrieval of an unusual foreign body (Allen key) from urinary bladder in a young female patient is presented. The technique of radiological localisation using plain X-ray, often the only investigation available in small centres, is described.

2016 FATE OF INDERMINATE/SUSPICIOUS LESIONS FOUND INCIDENTALLY ON CTKUB FOR SUSPECTED RENAL COLIC ? OUTCOMES AFTER A MINIMUM FOLLOW-UP OF 15 MONTHS

1 Pickard R, Starr K, MacLennan G, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 2015; 386: 341–49. 2 Sur RL, Shore N, L’Esperance J, et al. Silodosin to facilitate passage of ureteral stones: a multi-institutional, randomized, double-blinded, placebo-controlled trial. Eur Urol 2015; 67: 959–64. 3 Furyk JS, Chu K, Banks C, et al. Distal ureteric stones and tamsulosin: a double-blind, placebo-controlled, randomized, multicenter trial. Ann Emerg Med 2015; published online July 17. DOI:10.1016/j. annemergmed.2015.06.001. 4 Gargon E, Williamson PR, Altman DG, Blazeby JM, Clarke M. The COMET Initiative database: progress and activities from 2011 to 2013. Trials 2014; 15: 279. 5 de la Rosette J, Laguna MP. Ureteric colic: evidence empowers responsible treatment. Lancet 2015; 386: 315–16. expulsive therapy and therefore we did not record this factor. We would expect, in view of the independent randomisation and full masking, that patients with uncomplicated dilatation were distributed evenly between study groups. We do not know whether the presence of dilatation differentially affected outcome between study groups in our trial. However, we would suggest that even if prognostic, this variable is not straightforward to measure on a CT of the kidneys, ureters, and bladder and is unlikely to be useful in routine care. With respect to our choice of outcome measure, we would maintain that need for further intervention was a highly relevant outcome for patients, urologists, and health-care planners, and was straightforward to measure. Placebo-controlled trials with imaging evidence of stone clearance showed overall proportions of 48% and 84% at 4 weeks. We suggest that seekers of evidence should consider the properties, relevance, and completeness of data collection for the primary outcome in each trial as part of their judgment of the worth of a trial in guiding clinical practice. Standardisation of outcome measures across trials is an important aim to allow valid and reliable synthesis of evidence. For urinary tract stone disease, this standardisation could be facilitated by international urological associations, as suggested in the Comment accompanying our paper. Finally, whilst we support the need for standardised (but relevant and easily measurable) outcome measures, we would maintain that unnecessarily restricting trial participation is not the way forward to establish the worth of novel interventions in routine clinical practice.

Surgical management for upper tract transitional cell carcinoma

INTRODUCTION AND OBJECTIVES: CT-KUB is the gold standard for the investigation of suspected renal colic. In addition to stone diagnosis additional pathology can be found in 5-20% of CTKUBs. Although most additional findings are minor, sometimes suspicious/indeterminate lesions are found. With increasing incidence of renal colic and stones these incidental but potentially serious lesions will pose a dilemma to surgeons and patients alike.The aim of this study was assess the fate of these indeterminate lesion found CT-KUB. METHODS: A retrospective review of 404 patients having CTKUB’s for suspected acute renal colic was undertaken between May 2010 and April 2011. Data was collected for patient demographics, presence or calculus disease and additional urological or non-urological pathologies and its clinical relevance. The indeterminate/suspicious lesions were followed up and the data was reviewed in September 2012. RESULTS: The mean age was 50 years (Range: 13-91 years), with 165 females (41%). Ureteric stone was found in 58 (14%), with renal stones in 85 (21%), combined ureteric and renal stones in 39 (10%) patients.The minimum follow up for each patient was 15 months. Clinically relevant non-calculus pathologies were found in 107 patients (26%). A total of 54 patients (13.4%) had indeterminate/suspicious lesion, which required either a follow-up or intervention or further imaging. Of these 6 (11%) patients required operative intervention for malignant or serious condition. A further 13 (24%) patients are still under follow-up imaging after one year. This was specially the case in incidental lung nodules where half of them (8/16) were still under follow-up after 15 months. In 35 (65%) patients a benign diagnosis was made after further imaging and or specialist multidisciplinary team meeting. CONCLUSIONS: CTKUBs are vital for stone diagnosis with a pick up rate of 45%.However, it does pick up other important potential malignant lesions which may need monitoring or intervention. In our study, a third of these lesions were either still under follow-up or had intervention after 15 months of being diagnosed.

Urethral injection therapy for urinary incontinence in women

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the best surgical management of upper tract transitional cell carcinoma. The following comparisons are pre-stated: 1.Whether open radical nephroureterectomy is better than laparoscopic nephroureterectomy 2.Whether nephroureterectomy is better than conservative localised resection of ureter, where indicated 3. Whether open surgical resection (local or nephroureterectomy) is better than endoscopic resection and surveillance, where indicated 4.Whether open surgical method of handling lower end of ureter is better than endoscopic or laproscopic assisted methods 1 Surgical management for upper tract transitional cell carcinoma (Protocol) Copyright