T.E.D. McDermott

THE ROLE OF ORCHIECTOMY IN TH MANAGEMENT OF POSTPUBERTAL CRYPTORCHIDISM

PURPOSEnOwing to the risk of future malignancy, many postpubertal male subjects presenting with unilateral cryptorchidism undergo orchiectomy rather than orchiopexy. We examined the incidence of spermatogenesis and carcinogenesis in whole orchiectomy specimens removed from postpubertal cryptorchid male subjects. We review the concept that orchiectomy is justifiable in these patients.nnnMATERIALS AND METHODSnA total of 52 patients with postpubertal cryptorchidism (unilateral in 48, bilateral in 4) were retrospectively analyzed from 1984. Patient age ranged from 15 to 66 years (mean 26). Six patients presented with primary infertility (unilateral in 3, bilateral in 3). The undescended testicles were palpable in 32 cases (62%). All patients underwent unilateral orchiectomy and whole specimens were examined histologically.nnnRESULTSnHistology showed normal spermatogenesis in only 1 orchiectomy specimen, while 15 had maturation arrest, 6 testicular agenesis and 30 seminiferous tubular atrophy and/or Sertoli-cell-only syndrome with no spermatogenesis. The location of the undescended testis was the superficial inguinal pouch in 32 cases, inguinal canal in 6 and inside the deep ring in 8. Absent spermatogenesis was significantly associated with a high level of maldescent and with increasing age. Two patients (4%) had carcinoma in situ of the testicle. Torsion of an undescended testicle occurred in 1 patient (2%).nnnCONCLUSIONSnThis analysis of cryptorchid testes in postpubertal male subjects confirms that the majority cannot contribute to fertility, have significant malignant potential and may undergo torsion. Therefore, orchiectomy remains the treatment of choice for the majority of postpubertal male subjects presenting with unilateral cryptorchidism.

'Firm' versus 'soft' double pigtail ureteric stents : a randomised blind comparative trial

It is generally considered that firm double pigtail ureteric catheters, while easier to insert and less prone to migration, may cause more patient discomfort than the softer variety of stent. Objective support for these perceptions is however lacking. The aim of this study was to compare firm and soft stents regarding their ease of insertion, positional stability, biocompatibility and patient tolerance. 155 patients were randomised to receive firm (polyurethane, n = 78) or soft (Sof-Flex, n = 77) stents. Ease and mode of insertion was recorded at time of initial placement. Positional stability, degree of bladder inflammation, stent encrustation and patient tolerance were recorded at the time of removal. Patient tolerance was assessed by symptom score in double-blind fashion. Results showed no significant difference in ease of insertion, positional stability, degree of bladder inflammation or stent encrustation between the two groups. There was a significantly higher incidence of dysuria, renal and suprapubic pain in the firm stent group. There was no significant difference in the incidence of urgency, frequency, nocturia or haematuria. Normal activity and return to work were reported in 67 and 45% of patients with soft and firm stents, respectively. The data indicates that patient tolerance appears to be related to the softness of the stent material.

Double pigtail Ureteric stent versus percutaneous nephrostomy : Effects on stone transit and ureteric motility

OBJECTIVES AND METHODSnThe effects of double pigtail ureteric catheters (JJS) and percutaneous nephrostomies (PN) on ureteric motility and artificial stone transit was assessed in 12 dogs. Each animal underwent bilateral nephrostomies and an artificial stone insertion into each upper ureter (n = 20). A 4-Fr JJS was inserted on one side (group 1) while a PN was left on the contralateral side (group 2). In 4 stone-only control ureters (group 3), the PN was sealed after 72 h. Stone passage was assessed by plain x-rays. Pelvic and ureteric motility was assessed prior to stone insertion and again at 2 weeks.nnnRESULTSnIn group 1, only 1 of 8 stones (12.5%) passed completely. Four reached the midureter, 3 remained static. Six of 8 stones (75%) in group 2 passed completely. Two stones remained in the distal ureter. All 4 stones (100%) in group 3 passed by day 3 postoperatively. At laparotomy the J-stented ureters were dilated and both pelvic and ureteric contractions were diminished. Ureteric diameter was normal on the PN side. The ureters contracted with normal amplitude, but diminished rate of contraction above the stones in the ureters with residual calculi (n = 2), and in the 6 ureters from which spontaneous stone passage had occurred. A similar pattern was found in the 4 group 3 ureters.nnnCONCLUSIONSnDouble J stents are associated with ureteric dilatation, diminished peristalsis and impaired stone passage. APN preserves ureteric peristalsis and facilitates stone passage. In the initial phase, raised hydrostatic pressure appears to the most important factor determining stone passage.

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

BACKGROUND AND PURPOSEnNoncontrast 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.nnnPATIENTS AND METHODSnIn 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.nnnRESULTSnRenal 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.nnnCONCLUSIONSnThe 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.

An 11-year analysis of the prevalent uropathogens and the changing pattern of Escherichia coli antibiotic resistance in 38,530 community urinary tract infections, Dublin 1999–2009

BackgroundKnowledge of local antimicrobial resistance patterns is essential for evidence-based empirical antibiotic prescribing, and a cutoff point of 20xa0% has been suggested as the level of resistance at which an agent should no longer be used empirically. We sought to identify the changing incidence of causative uropathogens over an 11-year period. We also examined the trends in antibiotic resistance encountered in both the pooled urine samples and those where the causative organism was Escherichia coli.Patient and methodsA retrospective analysis of the antimicrobial resistance within the positive community urine isolates over the 11-year period, 1999 to 2009, in a single Dublin teaching hospital was performed.ResultsIn total 38,530 positive urine samples processed at our laboratory originated in the community of which 23,838 (56.7xa0%) had E. coli as the infecting organism. The prevalence of E. coli has been increasing in recent years in community UTIs with 70.4xa0% of UTIs in the community caused by E.coli in 2009. Ampicillin and trimethoprim were the least-active agents against E.xa0coli with mean 11-year resistance rates of 60.8 and 31.5xa0%, respectively. Significant trends of increasing resistance over the 11-year period were identified for trimethoprim, co-amoxyclav, cefuroxime and gentamicin. Ciprofloxacin remains a reasonable empirical antibiotic choice in this community with an 11-year resistance rate of 10.6xa0%. Higher antibiotic resistance rates were identified in the male population and in children.ConclusionResistance rates to commonly prescribed antibiotics are increasing significantly. This data will enable evidence-based empirical prescribing which will ensure more effective treatment and lessen the emergence of resistant uropathogens in the community.

Delayed contrast-enhanced MRI to localize Botox after cystoscopic intravesical injection

AbstractPurposenThere is a lack of studies to show localization of botulinum toxins (BoNT) within bladder wall and/or absorption rates. Our study examined the later distribution of BoNTA/gadolinium within the bladder wall by performing a delayed MRI scan after intravesical injection. This potentially may help to explain the level and mechanism at which BoNT may be producing its effect.MethodsA prospective study enrolled 20 consecutive patients with neuropathic or idiopathic overactive bladders. The Aim of the study was to perform MRI 3xa0h post procedure. Botox 100–200xa0IU was reconstituted with 19xa0ml saline and 1xa0ml of gadolinium contrast. Intradetrusor injections were administered using a rigid 21F cystoscope with a total of 20 injections into bladder wall, including two into the trigone. The depth of injection was approximately 2xa0mm, without raising a bleb. One radiologist reviewed films and reported on the number of bladder walls with contrast, location, the presence of extravesical extravasation, contrast in distal ureter(s), and bladder wall thickness.ResultsNinety percentage of patients had contrast within bladder wall. There was a variation in the number of bladder walls involved; 85xa0% had contrast seen in at least two walls. Also, a variation was noted in the extent of extravasation; 80xa0% showed some evidence.ConclusionsDiffusion of BoNT after intravesical injection is very common once bladder wall is breeched. Precise injection localization into muscle layer may not be as relevant to outcome as previously assumed. The assumption in our study that localization and diffusion of contrast also represents the localization of BoNT is open to critique as BoNT diffusion is potentially slower (Mehnert et al. in World J Urol 27(3):397–403, 2009). The absence of systemic symptoms after the injection in our series supports guidelines concerning the safety of procedure.

The effect of a Rapid Access Prostate Cancer Clinic on prostate cancer patient and disease characteristics, primary treatment and surgical workload

BackgroundIn 2009, Rapid Access Prostate Cancer Clinics (RAPC) were introduced to St. James’s Hospital to improve the access and organisation of patients to prostate cancer investigations and treatment.AimsTo observe the effects of the RAPC on prostate cancer diagnosis, primary treatment and overall workload.MethodsUsing a prospectively designed patient database, the records of all prostate cancer patients between 2007 and 2011 were retrieved and analysed. Data were obtained for age, PSA, biopsy Gleason score and primary treatment modality and charted for the observation and comparison of trends.ResultsSeven hundred and eighty-nine patients had a new diagnosis of prostate cancer between 2007 and 2011. The median PSA prior to the RAPC was 9.7–13.1xa0ng/ml, which decreased to 7.79–9xa0ng/ml after the RAPC. Prior to the RAPC, 77–81 biopsies were performed annually versus 149–271 in the post-RAPC era. Annual requirements for radical prostatectomy also increased from 12 to 27 in the post-RAPC era. Conversely, an initially increasing percentage of patients for radiotherapy was reversed in the post-RAPC period. An increasing trend for higher grade PCa (Gleason score 4xa0+xa04 and higher) was also reversed.ConclusionsThe introduction of a RAPC improves the overall pathological characteristics of patients with prostate cancer. However, RAPCs are also associated with a considerable increase in surgical workload. These are important considerations for units considering the incorporation of a similar facility in their institutions.

Incidence of Visible Hematuria Among Antithrombotic Agents: A Systematic Review of Over 175,000 Patients

OBJECTIVEnTo determine the probability of visible hematuria with antithrombotic agents and to evaluate association of urologic etiology in antithrombotic-related hematuria.nnnMETHODSnPreferred Reporting Items in Systematic Reviews and Meta-Analyses guidelines were followed to conduct a systematic review using search engines PUBMED and SCOPUS with the terms (hematuria) OR (haematuria) OR urinary bleeding)) AND ((anticoagulants) OR anticoagulation) OR noac) OR novel anticoagulants) OR antiplatelet) OR dabigatran) OR rivaroxaban) OR apixaban) OR warfarin) OR aspirin) OR heparin) OR dipyridamole). Raw data were used to perform a pooled analysis. Chi-square and logistic regression analysis were used for statistical analyses.nnnRESULTSnTwenty-two studies describing 175,114 patients met inclusion criteria. Odds ratio of hematuria with warfarin to rivoraxaban was 33 and warfarin to dabigatran was 16. The odds ratio of hematuria for oral anticoagulant (26.7%) to prophylactic parenteral anticoagulant (1.1%) agents was 9.6. Antiplatelet agents are 76 times less likely to cause hematuria compared to anticoagulants. Odds of hematuria with aspirin were 6.7 times the odds with clopidogrel and 3.5 times the odds with ticagrelor. Dabigatran was 198 times more likely to cause major hematuria compared to warfarin, whereas clopidogrel is 1.2 times more likely to cause major hematuria compared to aspirin. Urologic pathology was identified in 44% (234/532) of cases, malignancy in 24%.nnnCONCLUSIONnWarfarin use poses the greatest risk for hematuria but is unlikely to cause major hematuria, whereas novel antithrombotic agents are more commonly associated with major hematuria. This review further characterizes the risk profile of antithrombotic agents and associated hematuria to equip clinicians with knowledge to choose an appropriate antithrombotic agent in patients with high-risk hematuria.

Radical prostatectomy in the presence of ongoing refractory ESBL Escherichia coli bacterial prostatitis

A 44-year-old Indian national with a prostate-specific antigen of 5.4u2005ng/mL underwent 12-core transrectal ultrasound-guided prostate biopsies. Following this, he had three hospital admissions with severe urosepsis secondary to extended spectrum β lactamase (ESBL) producing Escherichia coli. He had recurrent sepsis immediately after discontinuation of intravenous meropenem to which the ESBL was sensitive. He proceeded to radical prostatectomy for intermediate-high risk Gleason 7 prostate cancer, while still on intravenous meropenem, 2u2005months after his biopsy. His prostatectomy involved a difficult dissection due to inflammatory changes and fibrosis after multiple septic episodes. He had complete resolution of infection after surgery with discontinuation of antibiotics on the third postoperative day, without any recurrence of sepsis.

A prospective audit on the effect of training and educational workshops on the incidence of urethral catheterization injuries

INTRODUCTIONnThe incidence of iatrogenic urethral catheterization (UC) injuries is approximately 0.3%. Resultant complications are associated with patient morbidity and unnecessary healthcare costs. Our aim was to investigate whether educational training workshops decreased the incidence of UC-related injuries.nnnMETHODSnA prospective audit was performed to calculate incidence, morbidity, and costs associated with iatrogenic UC injury from January to July 2015. Educational workshops were then conducted with healthcare staff and training modules for junior doctors. UC-related incidence, morbidity, and costs in the subsequent six-month period were recorded prospectively and compared with the previous data.nnnRESULTSnThe incidence of iatrogenic UC injuries was reduced from 4.3/1000 catheters inserted to 3.8/1000 catheters after the intervention (p=0.59). Morbidity from UC increased in the second half in the form of increase in cumulative additional inpatient hospital stay (22 to 79 days; p=0.25), incidence of urosepsis (n=2 to n=4), and need for operative intervention (n=1 to n=2). The cost of managing UC injuries almost doubled in the period after the training intervention (€50 449 to €90 100).nnnCONCLUSIONSnCurrent forms of educational and training interventions for UC did not significantly change morbidity or cost of iatrogenic UC injuries despite a decrease in incidence. Improved and intensive training protocols are necessary for UC to prevent avoidable iatrogenic complications, as well as a safer urethral catheter design.