Suresh Venugopal

Prospective Implementation of Enhanced Recovery After Surgery Protocols to Radical Cystectomy

BACKGROUND Multimodal enhanced recovery after surgery (ERAS) regimens have improved outcomes from colorectal surgery. OBJECTIVE We report the application of ERAS to patients undergoing radical cystectomy (RC). DESIGN, SETTING, AND PARTICIPANTS Prospective collection of outcomes from consecutive patients undergoing RC at a single institution. INTERVENTION Twenty-six components including prehabilitation exercise, same day admission, carbohydrate fluid loading, targeted intraoperative fluid resuscitation, regional local anaesthesia, cessation of nasogastric tubes, omitting oral bowel preparation, avoiding drain use, early mobilisation, chewing gum use, and audit. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary outcomes were length of stay and readmission rate. Secondary outcomes included intraoperative blood loss, transfusion rates, survival, and histopathological findings. RESULTS AND LIMITATIONS Four hundred and fifty-three consecutive patients underwent RC, including 393 (87%) with ERAS. Length of stay was shorter with ERAS (median [interquartile range]: 8 [6-13] d) than without (18 [13-25], p<0.001). Patients with ERAS had lower blood loss (ERAS: 600 [383-969] ml vs 1050 [900-1575] ml for non-ERAS, p<0.001), lower transfusion rates (ERAS: 8.1% vs 25%, chi-square test, p<0.001), and fewer readmissions (ERAS: 15% vs 25%, chi-square test, p=0.04) than those without. Histopathological parameters (eg, tumour stage, node count, and margin state) and survival outcomes did not differ with ERAS use (all p>0.1). Multivariable analysis revealed ERAS use was (p=0.002) independently associated with length of stay. CONCLUSIONS The use of ERAS pathways was associated with lower intraoperative blood loss and faster discharge for patients undergoing RC. These changes did not increase readmission rates or alter oncological outcomes. PATIENT SUMMARY Recovery after major bladder surgery can be improved by using enhanced recovery pathways. Patients managed by these pathways have shorter length of stays, lower blood loss, and lower transfusion rates. Their adoption should be encouraged.

The clinical need for undergraduate urology

Urologists have highlighted the lack of urological exposure amongst undergraduate students, voicing concerns that it may adversely affect patient care in the future, particularly with a global aging population. 4,5 This viewpoint has been mirrored by newly qualifi ed doctors, as only 9.7 per cent of UK foundation trainees (junior doctors) deemed their undergraduate urological exposure adequate. 4 This article refl ects upon the importance of this issue and also discusses our experience of an outcomebased teaching plan to address this need.

RE: “What factors influence British medical students’ career intentions?” Location and social relationships

We read with great interest the article by Ibrahim et al. (2014) regarding factors influencing British medical students’ in their future career intentions. The article highlighted that undergraduate experience and prestige, both significantly influenced British medical students’ future career aspirations. The Foundation Programme is the first 2-years of UK postgraduate medical training consisting of a training programme with six 4-monthly specialities. Recruitment for the 21 foundation schools is an annual national process in which applicants rank their choice of deanery and are accordingly given their rotations depending on the overall score they obtain on their online application. Recently our group assessed the factors influencing final-year medical students in their choice of their Foundation Programme. All 361 participants from 9 medical schools – Edinburgh, Swansea, Imperial, Peninsula, Leicester, Keele, Sheffield, Liverpool and Glasgow – had applied to the Foundation Programme. Twelve choices (year 1 specialities, year 2 specialities, undergraduate experience, prestige of foundation school, competitiveness, availability of academic post, location, family, partner, friends, finance and recommendations) were ranked in a 5-point Likert scale. Additionally, all respondents stated the single most important factor influencing their choice of foundation school. 67.6% of respondents either strongly agreed or agreed that undergraduate experience was an important factor for foundation school choice. When asked to give the single most important factor when embarking on their choice of foundation training school, 44% chose location with 26% choosing partner, family or friends. Only 3% and 1.6% of finalyear medical students stated that undergraduate experience and prestige was the most important factor in the choice of foundation school, respectively. Our study confirms that under-graduate experience is an important factor for the choice of future career intentions of British medical students. However, it appears that geographical and social factors are also important issues that shape early post-graduate training for British medical students. Saiful Miah, Suresh Venugopal & Karl Pang, Department of Urology, Royal Hallamshire Hospital, Sheffield, UK. E-mail: s.miah@sheffield.ac.uk

Surgical Tips and Tricks During Urethroplasty for Bulbar Urethral Strictures Focusing on Accurate Localisation of the Stricture: Results from a Tertiary Centre

BACKGROUND There are several techniques for characterising and localising an anterior urethral stricture, such as preoperative retrograde urethrography, ultrasonography, and endoscopy. However, these techniques have some limitations. The final determinant is intraoperative assessment, as this yields the most information and defines what surgical procedure is undertaken. OBJECTIVE We present our intraoperative approach for localising and operating on a urethral stricture, with assessment of outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of urethral strictures operated was carried out. All patients had a bulbar or bulbomembranous urethroplasty. All patients were referred to a tertiary centre and operated on by two urethral reconstructive surgeons. SURGICAL PROCEDURE Intraoperative identification of the stricture was performed by cystoscopy. The location of the stricture is demonstrated externally on the urethra by external transillumination of the urethra and comparison with the endoscopic picture. This is combined with accurate placement of a suture through the urethra, at the distal extremity of the stricture, verified precisely by endoscopy. OUTCOME MEASURES AND STATISTICAL ANALYSIS Clinical data were collected in a dedicated database. Intraoperative details and postoperative follow-up data for each patient were recorded and analysed. A descriptive data analysis was performed. RESULTS AND LIMITATIONS A representative group of 35 male patients who had surgery for bulbar stricture was randomly selected from January 2010 to December 2013. Mean follow-up was 13.8 mo (range 2-43 mo). Mean age was 46.5 yr (range 17-70 yr). Three patients had undergone previous urethroplasty and 26 patients had previous urethrotomy or dilatation. All patients had preoperative retrograde urethrography and most (85.7%) had endoscopic assessment. The majority of patients (48.6%) had a stricture length of >2-7 cm and 45.7% of patients required a buccal mucosa graft. There were no intraoperative complications. Postoperatively, two patients had a urinary tract infection. All patients were assessed postoperatively via flexible cystoscopy. Only one patient required subsequent optical urethrotomy for recurrence. CONCLUSIONS Our intraoperative strategy for anterior urethral stricture assessment provides a clear stepwise approach, regardless of the type of urethroplasty eventually chosen (anastomotic disconnected or Heineke-Mikulicz) or augmentation (dorsal, ventral, or augmented roof strip). It is useful in all cases by allowing precise localisation of the incision in the urethra, whether the stricture is simple or complex. PATIENT SUMMARY We studied the treatment of bulbar urethral strictures with different types of urethroplasty, using a specific technique to identify and characterise the length of the stricture. This technique is effective, precise, and applicable to all patients undergoing urethroplasty for bulbar urethral stricture.

Bochdalek's hernia causing functional upper ureteric obstruction

A 65-year-old male presented with recurrent intermittent right flank pain induced by the consumption of 4—5 pints of beer. There were no lower urinary tract symptoms or haematuria. He had a past history of left renal calculi which where treated endoscopically and had been stone free for the past decade. Clinical examination was unremarkable and urine dipstick testing showed no evidence of blood or infection. Serum urea and creatinine were within normal limits and he subsequently underwent an abdominal ultrasound scan. This demonstrated bilateral hydronephrosis as well as a large simple cyst of the left kidney. A CT urogram performed for further evaluation demonstrated minimal right hydronephrosis with a cranially traversing right ureter through a

Renal colic and childbirth pain: female experience versus male perception

Renal colic is often described by patients as the worst pain ever experienced.1 Pain during childbirth is also similarly described.2 To date, no study has comparatively evaluated the pain of renal colic to that of childbirth in female patients who have experienced both. Furthermore, no such study has evaluated the perception that men with renal colic have with respect to the pain experienced during childbirth. Here we present our cross-sectional observational study to address these questions. The primary objectives of our study were to answer these questions and highlight the severity of renal colic which is not always faced and treated aggressively.

Excision of a symptomatic unusual duplicated urethra in an adult male

A 52-year-old male presented with a history of recurrent urinary tract infections (UTIs). In the five months prior to presentation he had had five symptomatic UTIs. There was no history of lower urinary tract symptoms outside the episodes of infection. There was no prior history of traumatic urethral instrumentation. Uroflometry demonstrated a maximal flow of 19 ml/s and a post voiding ultrasound showed the bladder emptied completely. Two urethral lumens were demonstrated at flexible cystoscopy at the bulbar level (Figure 1), with one lumen ending blindly (accessory urethra), confirmed on urethrography (Figure 2). The patient elected to undergo excision of the accessory urethra. In lithotomy position, a vertical perineal incision was made and the bulbar urethra exposed. A rigid cystoscope was inserted to the point of bifurcation, where a marking suture was placed. The accessory urethral lumen was identified and marked (Figure 3), then opened vertically. The bladder was catheterized via the external urethral meatus and the duplicated urethra was excised. Urethral closure was undertaken using the Heineke–Mikulicz principle, with the soft tissue dead space closed by buttressing the peri-urethral corpus spongiosum. A catheter was left for 10 days. The postoperative retrograde urethrogram demonstrated no leakage and the patient successfully passed a trial without catheter. At six month follow-up there have been no further UTIs and the patient continues to void normally to completion on post void bladder scan. Histology confirmed an epithelium lined urethral lumen. The only residual problem is a degree of post-micturition dribbling.

Islam and the Urinary Stoma: A Contemporary Theological and Urological Dilemma

BACKGROUND The prayer ritual is an essential component of Islam that requires entry into a state of physical purity (wudhu) through ablution, which is invalidated by voiding. An important dilemma for patients and surgeons may arise when a Muslim patient is counselled on cystectomy because of the belief by some that an incontinent urinary diversion will automatically invalidate their wudhu. OBJECTIVE To determine if there are any religious barriers and implications for Muslim patients undergoing an incontinent urinary diversion. DESIGN, SETTING, AND PARTICIPANTS A questionnaire was distributed to all UK mosques, addressed to the imam (n=804). RESULTS AND LIMITATIONS A total of 134 imams (response rate 16.7%) responded. There was general agreement among imams, with >90% answering that it is possible for a Muslim to perform ablution, pray, and enter a mosque with a urinary stoma. The majority of imams (86.6%) also stated that refusal of a urinary stoma was not justified by religious teachings. When asked if patients should choose the option of a neobladder despite this surgery having greater risk, 57.5% of respondents stated that they were either unsure or agreed with this alternative. CONCLUSIONS The majority of imams agreed that Muslims with a urinary stoma are able to maintain their ablution, allowing them to conduct their daily prayers, and that this form of surgery should not be refused on religious grounds. Our study suggests that the consensus view is that a urinary stoma is not contraindicated with regard to the practice of Islamic prayer rituals. PATIENT SUMMARY In this study we investigated if having a urinary stoma would be a religious barrier for Muslim patients in performing their obligatory prayer rituals. The overwhelming majority of imams stated that having a urinary stoma should not stop Muslim patients practising important aspects of their faith.

What factors influence UK medical students' choice of foundation school?

Background We aimed to identify the factors influencing UK medical student applicants’ choice of foundation school. We also explored the factors that doctors currently approaching the end of their 2-year program believe should be considered. Methods A cross-sectional study was conducted during the 2013–2014 academic year. An online questionnaire was distributed to 2092 final-year medical students from nine UK medical schools and 84 foundation year-2 (FY2) doctors from eight foundation schools. Participants were asked to rank their top 3 from a list of 12 factors that could potentially influence choice of foundation school on a 5-point Likert scale. Collated categorical data from the two groups were compared using a chi-square test with Yates correction. Results Geographic location was overwhelmingly the most important factor for medical students and FY2 doctors with 97.2% and 98.8% in agreement, respectively. Social relationships played a pivotal role for medical student applicants. Clinical specialties within the rotations were of less importance to medical students, in comparison to location and social relationships. In contrast, FY2 doctors placed a significantly greater importance on the specialties undertaken in their 2-year training program, when compared to medical students (chi-square; p=0.0001). Conclusion UK medical schools should make their foundation program applicants aware of the importance of choosing rotations based on specialties that will be undertaken. Individual foundation schools could provide a more favorable linked application system and greater choice and flexibility of specialties within their 2-year program, potentially making their institution more attractive to future applicants.

Failed phlebotomy? Think universal precautions.

Dorrington and Aronson’s article provided useful tips for obtaining a venous blood sample in an antegrade manner, especially from smaller veins on the dorsal aspect of the hand.1 It provided anatomical and physiological insight into …