Learning curves for urological procedures
K Ahmed*,H Abboudi†, M S Khan† and P Dasgupta†
*Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
†MRC Centre for Transplant, King's College London, Guy's Hospital, London, England, UK
Background: It is important for urologists to be aware of the number of cases they need to perform of a particular technique before they are deemed fully competent. Therefore the aim of this study was to conduct a systematic review to determine the number of cases a urologist must complete to master the learning curve across all procedures studied. Methods: The MEDLINE, EMBASE and PsycINFO databases were systematically searched until January 2012. References from retrieved articles were reviewed to broaden the search. The procedure name, statistical analysis, number of participants, procedure setting, level of participants and outcomes were reviewed. Results: Eighty-one studies investigating the learning curves from a variety of urological procedures encompassing both upper and lower urinary tract operations were identified. The majority of papers (21) looked at the learning curves for robot-assisted laparoscopic prostatectomy, with results ranging from 60 to 330 cases. Variables used to determine the learning curves often included oncological measures, complication rates, blood loss, operative time and functional outcomes. Nineteen papers looked at various procedures within renal surgery such as single site and robot-assisted (5-25 cases) partial nephrectomy; laparoscopic, single site and robot-assisted radical nephrectomy; laparoscopic (30 cases), single site (30 cases) and robot-assisted pyeloplasty (15-20); and cryoablation. Ten papers investigated techniques for the management of benign prostatic disease such as transurethral resection of prostate (TURP), Holep and photoselective vaporization. The remaining procedures studied included laparoscopic prostatectomy (250-700 cases), radical retropubic prostatectomy (29 cases), perineal prostatectomy, urethrovesical anastamosis, transrectal ultrasound biopsy, artificial sphincter surgery, transvaginal (15 cases) and transobturator tape (undetermined), laparoscopuc sacropexy, robotic sacrocolpopexy, percutaneous nephrolithotomy (45-105 cases), ureteroscopy (undetermined), robotic cystectomy (30 cases), transvesicoscopic ureteral re-implantation (26 cases), sutureless circumcision, laparoscopic single site, adrenelectomy and sentinel node biopsy for penile oncology cases (undetermined). Conclusion: The current studies provide a rough guide for developing urologists to follow during their training. The parameters that determine the learning curves in a procedure are not standardized and, therefore, it is difficult to compare studies. The vast majority of learning curve trials have focused on the latest surgical techniques with a paucity of data pertaining to basic urological procedures such as circumcisions, scrotal explorations, TURPs, flexible and rigid cystoscopies, which would be an important guide for junior trainees.
DOI: 10.1258/smj.2012.012087
Introducing the productive operating theatre programme in urology theatre suites
K Ahmed*, N Khan†, D Anderson†, J Watkiss†, B Challacombe†, M S Khan†, P Dasgupta† and D Cahill†
*Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
†MRC Centre for Transplant, King's College London, Guy's Hospital, London, England, UK
Background: The productive operating theatre (TPOT) is a module-based programme designed by the National Health Service (NHS) to improve value/efficiency, teamwork, patient experience, staff wellbeing and the safety and reliability of care in operating theatres. The aims of the study were to evaluate the effectiveness of introducing TPOT in urology operating theatres and to identify obstacles to running an ideal operating list. Methods: TPOT was introduced in two urology operating theatres in September 2010. Multidisciplinary team discussions took place to identify obstacles to running an ideal operating list and implement solutions. A brief/debrief system was introduced as part of the ‘team-working’ module and efforts to organize the work environment were made as part of the ‘well-organized theatre’ module. ‘Measures workshops’ were conducted to monitor efficiency and audit start/overrun times and patient experience. Results: Start times were measured from September 2010 to June 2011 involving 1365 cases. There was a 39-41% increase in the percentage of operating lists starting on time in 11 June compared with September 2010. Cost of monthly overrun was reduced by £3030 in theatre 1 and £510 in theatre 2 between September 2010 and June 2011. A total of 54 urology patients returning for follow-up were surveyed. A high degree of satisfaction regarding level of care (77%), staff hygiene (71%) and information provided (72%) was recorded. Negative comments regarding staff shortages and environment/facilities were recorded. Conclusion: The introduction of TPOT has shown improvements in efficiency measures such as start and overrun times with high patient satisfaction. Further work will involve introducing new modules and implementing the programme in other specialties.
DOI: 10.1258/smj.2012.012088
How to set up an ideal female urology incontinence service based on the analysis of 359 patients seen in a clinic
A N Qureshi and S Khan
Guys and St Thomas’ Hospital, London, England, UK
Background: Incontinence is a common problem that requires multidisciplinary input. No clear guidelines are available on the establishment of incontinence clinics. We aim to develop guidelines for establishing incontinence clinics by studying patient characteristics. Methods: We conducted a retrospective review of outpatient data systemically recorded in a female incontinence clinic over a one-year period. Results: The total number of patients, which included both men and women seen in the continence clinic between 2005 and 2006, was 420 patients, of whom 359 were women (85.47%) and 61 were men (14.53%). The predominant age group was 40-49 years (24.23%). A majority was either overweight (28.57%) or obese (57.83%), while 19.04% were smokers. Psychiatric or neurological problems were prevalent; 6.96% were on antidepressants and 14.48% had history of neurological symptoms problems. Type distribution of urinary incontinence (UI) was varied: 13.71% had stress UI, 22.02% had urge UI, 53.79% had mixed UI, 4.69% had continuous urinary leakage and 5.77% had nocturnal enuresis. A further 7.24% of patients had pelvic organ prolapse. Predominant disposal in the clinic was referral for pelvic floor exercises (14.04%), urodynamics (11.48%) and anticholinergics (18.49%). Conclusion: Our findings suggest that not only female patients but male patients should also be considered while considering requirements for incontinence services. UI clinics need to be multidisciplinary with a special need for dieticians and physiotherapists. Primary care physicians may be given guidelines to initiate basic treatment or investigations at the time of referral.
DOI: 10.1258/smj.2012.012089
Early outcomes following introduction of green light XPS for treatment of benign prostatic obstruction
E C G Tudor, A C P Riddick and S Phipps
Department of Urology, Western General Hospital, Edinburgh, Scotland, UK
Introduction: We have introduced green light laser prostatectomy (GLLP) (180W Green Light XPS Laser with MoXy liquid-cooled fibre; AMS, Minneapolis, MN, USA) for the surgical management of benign prostatic obstruction (BPO) within our institution. We assessed early outcomes after one year. Methods: We prospectively collected data from all patients undergoing GLLP between September 2010 and December 2011, who had failed medical therapy or were catheterized for retention. Preand postoperative International Prostate Symptom Score, quality of life, Qmax and postvoid-residual (PVR) were assessed, along with length of stay and length of postoperative catheterization. Results: One hundred and nine patients underwent GLLP (mean age, 68.7; range, 39-91) undertaken by two surgeons. Changes from pre- to postoperative parameters were as follows (median, range): IPSS, 20 (8-33) to 5 (0-23); QoL, 5 (2-6) to 1 (0-6); Qmax, 7.85 mL/s (4-16) to 16.5mL/s (7-44); and PVR, 166 mL (0-590) to 37 mL (0-500). Fourteen patients (12.8%) were discharged within 12 hours, 90 patients within 23 hours (82.6%) and five patients within 48 hours (4.6%). Ninety patients (82.6%) had a successful trial-without-catheter (TWOC) before discharge. Of the remainder, 14 passed their subsequent TWOC and three required long-term catheterization. Complications included bleeding (5), broken laser-fibre (1) and postoperative sepsis (1). Conclusion: We have successfully established GLLP for the management of BPO within our unit. The majority of our patients are discharged catheter-free within 23 hours. Early outcome parameters demonstrate an excellent response to treatment. GLLP is associated with short inpatient stay and length of catheterization and a low risk of bleeding.
DOI: 10.1258/smj.2012.012090
Comparison of closure versus non-closure in buccal mucosal urethroplasty: a prospective randomized control trial – preliminary results
A Fernando, A Alhasso and L Stewart
Department of Urology, Western General Hospital, Edinburgh, Scotland, UK
Background: Buccal mucosal graft in urethroplasty has been described as an easily accessible, durable substrate with high capillary concentration. Oral complications have been described in small series with reported rates of 0-8.3%. We have prospectively analysed postoperative morbidity in our initial 20 patients. Methods: Twenty men were randomly allocated to closure or non-closure groups prospectively. Two surgeons were involved in all urethroplasties. Ethical approval was gained from the National Health Service (NHS) Lothian Ethical committee. A 10-point visual analogue scale for five parameters – pain, numbness, tightness, ability to eat and ability to drink – was administered to the patients preoperatively, at days 1 and 3, three weeks and three months thereafter for 12 months in total. Results: Twenty patients were recruited from May 2008 to March 2011. They were randomized to the two groups. Mean age of study population was 47.6 years. The score was averaged for the indices. Conclusions: The average score was lower in patients in the closure group. An increase in the score was noted after day 180 (P = 0.25). Our findings are not in keeping with the current published literature. The aetiology of this remains unclear. The questionnaire evaluated a range of indices and we have summarized the discomfort by averaging the scores. The data-set was incomplete. We are currently accruing patients.
DOI: 10.1258/smj.2012.012091
Early experience of insertion of gold seed fiducial markers for image-guided prostate radiotherapy: do patients have increased pain or morbidity?
B Corr, K Mackenzie, K Laing, N McPhail and D Douglas
Department of Urology, Raigmore Hospital, Inverness, Scotland, UK
Background: Prostate motion during a course of radical radiotherapy occurs on a day-to-day basis. Due to this, National Health Service (NHS) Highland now practices image-guided radiotherapy using gold seeds as fiducial markers. The insertion procedure is carried out under transrectal ultrasound guidance using the same antibiotic prophylaxis and local anaesthesia as is used for transrectal ultrasound-guided prostate biopsy (TRUS BX). As this procedure was new to NHS Highland it was important to assess our patients’ experiences and toxicities. We aimed to compare the complications of gold seed insertion to that of a biopsy. We also assessed the patients’ level of discomfort compared with that of their diagnostic biopsy. Methods: Details of the first 85 patients who had seeds inserted between October 2010 and October 2011 were acquired. Questionnaires and a covering letter were drawn up with the assistance of our clinical effectiveness team and posted out. A postage-paid return envelope was included and the returned questionnaires were anonymous. The questionnaires asked whether the initial diagnosis of cancer was made by biopsy or transurethral resection of prostate (TURP). Those diagnosed by TURP did not answer the question regarding pain of seed insertion compared with biopsy. All participants were asked to answer questions regarding complications of the seed insertion procedure (i.e. haematuria, per rectal bleeding, haematospermia urinary difficulties and infection). They were also asked how long they had been on neoadjuvant androgen deprivation therapy. Results: A total of 62 (75%) questionnaires were returned. Fifteen (25%) experienced less pain with only two (3%) saying it was more painful than their biopsy. Eleven (18%) experienced urinary symptoms that settled spontaneously and two (3%) required a catheter. Twenty (32%) experienced haematuria. Four patients had haematospermia. Eleven (18%) patients had rectal bleeding and one patient was admitted to hospital due to this. There were no cases of infection. There were no correlations to be made with the above complications and the duration of neoadjuvant androgen deprivation therapy. Conclusion: Insertion of fiducial markers incurs no additional discomfort or morbidity than prostate biopsy.
DOI: 10.1258/smj.2012.012092
Quill barbed suture reduces the rate of anastomotic leak following laparoscopic prostatectomy
E C G Tudor and S A McNeill
NHS Lothian, Western General Hospital, Edinburgh, Scotland, UK
Background: Laparoscopic prostatectomy may be complicated by anastomotic leak associated with prolonged urethral catheterization. In our unit, patients undergo a day 10 postoperative cystogram, confirming anastomotic integrity prior to catheter removal. The Quill suture (Angiotech, Vancouver, BC, Canada) is barbed along its length, enabling evenly distributed wound tension and allowing continuous sutures and reduced need for knots. This pilot study aimed to compare the anastomotic leak rate and cost implications using standard interrupted Vicryl sutures, to the Quill suture. Methods: Day-10 cystograms were reviewed for evidence of anastomotic leak. Consecutive patients undergoing laparoscopic prostatectomy during a four-month period received the Quill suture. A similar number of patients who had previously received interrupted Vicryl were compared. Results: A total of 23 patients (mean age, 61; range, 47-73) received the Quill suture. No patients had anastomotic leak. Thirty-three patients (mean age, 63; range, 42-73) received interrupted vicryl sutures. Three patients (9%) had anastomotic leak, all underwent successful catheter removal after repeat cystogram at a later date. Use of a Quill suture costs £26 while use of Vicryl costs £10. A cystogram costs £100. Total costs per patient (excluding nursing costs and patient inconvenience) were estimated to be £126 for a patient using a Quill suture and £119 for Vicryl. Conclusion: Our pilot study suggests a reduction in the anastomotic leak rate when using a continuous Quill compared with interrupted Vicryl (0% versus 9%). The increased suture cost is offset by the reduction in repeat cystograms and the associated morbidity of a prolonged period of catheterization.
DOI: 10.1258/smj.2012.012093
Is it time for change? Experiences with day case flexible ureteroscopy
A Kamalasanan, J Harikrishnan and G Jones
Department of Urology, Southern General Hospital, Glasgow, Scotland, UK
Background: Rigid and flexible ureteroscopy (FURS) are commonly regarded as inpatient procedures. Studies have shown that patients undergoing rigid ureteroscopy can often be discharged on the day of admission. Previous work in our centre has shown that with careful patient selection FURS for diagnosis or stone removal is feasible, but numbers in this study were small. We now perform FURS on a regular basis as a day case procedure. Our aim was to review whether FURS remains a feasible day case procedure in a dedicated urology theatre. Methods: Over a six-month period all FURS for renal calculi and diagnosis performed by a single surgeon in a dedicated urology day case theatre were identified. Data were collected for patient age, stone size, discharge, transfer and readmission rates. Results: Over a period of six months 67 FURS were performed in the day surgery unit. Mean patient age was 48 years (range, 22-88). Mean stone diameter was 4.9 mm. One patient required transfer to an inpatient ward for intravenous antibiotic treatment for sepsis and three patients were re-admitted for pain and infection. Thirty-seven patients were discharged on the day of their operation and 29 patients required a 23-hour bed stay for social, medical, surgical or anaesthetic reasons. Conclusion: With careful patient selection flexible ureteroscopy for removal of ureteric calculi or diagnostic purposes is feasible as a day case procedure and should be considered for inclusion in day surgery basket. This can improve patient service and reduce the overall cost of admission.
DOI: 10.1258/smj.2012.012094
Can urine cytology pre–Bacillus Calmette–Guérin instillation detect disease recurrence or progression?
F Housami and C McIlhenny
Department of Urology, Forth Valley Royal Hospital, Larbert, Scotland, UK
Background: We performed a retrospective study of urine cytology, which is used at our institution as a part of surveillance in patients receiving Bacillus Calmette–Guérin (BCG) treatment. Methods: Data collected included the timing of urine cytology in relation to BCG instillation, cytology grade and any subsequent evidence of recurrence or progression. Results: The records of 90 out of 94 patients on the BCG database were available. There were 550 pre-BCG instillation cytology tests. Analysis of Pre-BCG instillation urine cytology grades showed no significant differences in detecting disease recurrences or progression (P = 0.132). Conclusions: These results indicate that urine cytology pre-BCG instillation has no role in detecting disease recurrence or progression.
DOI: 10.1258/smj.2012.012095
Diagnostic accuracy of image-guided biopsy in small and indeterminate renal masses: which imaging modality and what needle size?
I El-Mokadem, D N Nicolson, L B Baker, C T Tait, C C Chuen, C G Goodman and G N Nabi
Academic Section of Urology, Medical Research Institute, University of Dundee, Dundee, Scotland, UK
Background: Our aim was to determine which imaging modality and needle size is most accurate in distinguishing between benign and malignant renal lesions in image guided biopsies. Methods: A highly sensitive search strategy was developed in collaboration with the Cochrane Urological Cancers and Prostate Diseases group to identify relevant publications. Only English language studies reporting on adults with image-guided biopsy (IGB) in small or indeterminate renal masses were included. Two researchers independently screened the studies to assess their suitability for inclusion. In each study, the biopsy needle size and imaging modality used were identified. Diagnostic accuracy of IGB (sensitivity, specificity, negative and positive predictive value) was compared with final histopathological outcome following surgical procedure or follow-up imaging for at least five years. The association between IGB and histopathology was investigated by two-sided Fisher's exact test. Results: Of 2249 studies, only 36 matched our inclusion criteria. However, seven of these studies could not be tabulated for analysis. Of the remaining 29 studies, ultrasound (US) was the modality of imaging in eight studies, computerized tomography (CT) in seven and more than one imaging modality (usually CT and US) in 14 studies with combined results which made it difficult to identify the results of each imaging modality. The diagnostic accuracy of US and CT IGB was 79% and 83%, respectively, from studies using single imaging modality. Pooled sensitivity, specificity, positive and negative predictive values were, respectively, 82%, 71%, 87% and 62% for US IGB studies compared with 86%, 69%, 92% and 57% for the CT IGB studies with no statistically significant difference. Of the 29 studies, 19 (65.5%) showed a positive association between IGB and histopathology, eight (27.6%) showed no association and two (6.9%) showed a negative association. The two studies reporting negative outcomes used fine needle aspiration using 21 G needles. Of the 29 studies, 20 (69%) employed size 18 G needles, of which 80% had positive association with final histopathology compared with only 25% in the four studies employing needles smaller than 18 G. In the remaining five studies the needle size was not reported. Conclusion: The quality of the studies was generally poor. Imaging modalities and size of needle used to provide tissue for diagnosis also varied between the included studies. However, it appears that both CT and US have comparable results from this review. An 18 G needle size or larger yields adequate tissue for diagnosis. Further research is required to standardize the biopsy technique.
DOI: 10.1258/smj.2012.012096
Upper urinary tract calculi in a contemporary Scottish population
S L Reid, M Holliday and C McIlhenny
Urology and Biochemistry Department, Forth Valley Royal Hospital, Larbert, Scotland, UK
Background: Urolithiasis incidence and prevalence in Western countries has been reported to be increasing and changing since the last quarter of the twentieth century. A common theory for the drive of this increase is the obesity epidemic. It is well documented that increased body mass index (BMI) results in increased uric acid urinary supersaturation. The hypothesis would therefore be an increase in calculi related to a greater number and proportion of uric acid stones. We studied the relationship between age, sex and stone composition in a contemporary UK population, comparing our results with those reported in a similar UK series by Sutor et al. from 1974. Methods: Retrospective study was conducted of 380 stone samples submitted for analysis from April 2006 to October 2011. Results: A total of 371 upper tract stone samples were sent for analysis. Of these, 75 (20.2%) were insufficient and therefore excluded. Calcium oxalate stones with or without phosphate were the most common stone in our population, making up 75%. The third most common stone in 1974 was struvite at 16%. This is ranked in the same position in our population but with a smaller percentage at 9%. Calculi containing uric acid rarely occur in the adult upper tract group in 1974. In our population they account for 5.4%. Conclusion: Stone composition in our population by percentage is similar to that found in 1974, but with less Struvite stones and an increased percentage of urate stones. This is similar to other population-based epidiemiology studies.
DOI: 10.1258/smj.2012.012097
The Edinburgh Penile Cancer Audit 2005-2011
S McFee, S Ramsay, G Stewart and R Donat
Western General Hospital, Edinburgh, Scotland, UK
Background: Penile cancer is a rare disease requiring a variety of procedures to obtain cancer control while optimizing cosmetic and functional outcomes. We audited our experience over the last six years to assess current local treatment results. Methods: This retrospective study included all identifiable patients undergoing penile cancer treatment between 2005 and 2011 in our unit. Results: A total of 112 patients were identified of whom 100 were evaluable. Mean patient age was 62.2 years (range, 35-93 years). Penile procedures included circumcision (22), local excision (15), glans re-surfacing (9), meatoplasty (2), glansectomy (graft) 37 (27), partial penectomy (graft) 21 (10) and radical penectomy (11). Lymph node procedures included sentinel lymph node biopsy (52), superficial lymph node excision (12 groins), radical lymph node-ectomy (40 groins), local recurrence excision (1), groin dissection and rectus abdominis flap (3) and pelvic lymph node dissection (8). Ninety-one patients were treated with curative intent (9 patients palliative). With a mean follow-up of 23.7 months (2-68 months), 79.1% of these patients (72) are alive and recurrence free, 13.2% (12) had recurrent cancer and 7.7% (7) died from penile cancer. There were 6.6% (6) deaths from other causes. Conclusion: Modern penile cancer management offers good cure chances for localized disease.
DOI: 10.1258/smj.2012.012098
Independent factors affecting stone clearance rates in 76 prospective ureteroscopies
M T Macmillan, S L Reid, P Rajan and C McIlhenny
Forth Valley Royal Hospital, Larbert, Scotland, UK
Background: Anatomical and stone factors are known to influence stone clearance rates after lithotripsy. In this study we aimed to investigate whether independent patient factors such as sex, body mass index (BMI) and American Society of Anesthesiologists (ASA) grade influenced the rate of stone clearance following ureterorenoscopic lithotripsy. Methods: Data were collected prospectively from October 2010 to November 2011. All patients underwent single treatment with Ho:YAG Laser lasertripsy; stones were visualized using either semi-rigid ureteroscopy or flexible ureteroscopy with the Olympus URFP5. Stone size and site were recorded by a single investigator. The same investigator determined stone clearance rates by review of pre- and postoperative computerized tomography (CT) of the kidney, ureter and bladder (KUB) and X-ray KUB. Complete stone clearance was defined as no visible fragments on follow-up imaging. Results: A total of 104 cases were considered for this study. Of these, 28 cases were excluded due to either radio opaque stones or insufficient follow-up; 67.1% of patients were men and 32.9% were women. The majority of patients had an ASA of two (65.8%). The mean BMI was 28.6. After treatment, 77% of patients had complete stone clearance. The mean length of retained calculus was 4.25 mm. The site of the stone, the size of the largest stone and the number of stones present were significantly associated to complete clearance rate (P < 0.001, P = 0.013 and P = 0.019, respectively). No patient factors were found to be significant in stone clearance rates. Conclusion: Stone factors are significant in relation to stone clearance rates. None of the patient factors investigated were found to be significantly associated with stone clearance rates in this study.
DOI: 10.1258/smj.2012.012099
An audit of Bacillus Calmette–Guérin treatment at a district general hospital
F Housami and C McIlhenny
Forth Valley Royal Hospital, Larbert, Scotland, UK
Background: A retrospective study of patients who had Bacillus Calmette–Guérin (BCG) treatment over the past eight years was conducted. Data collected included indication for BCG treatment, length of time to progression and outcome of treatment. Methods: The records of 90 out of 94 on the BCG database were available. Indications for BCG treatment were: CIS (48%), G3pT1 (29%), G3pTa (18%) and G2pT1 (7%). Results: The majority of patients (59%) remain on surveillance with the recurrence-free time being 39 months; 41% of patients dropped out of treatment (16% had disease progression, 14% stopped due to side-effects, 8% due to poor health and 3% died of other disease). Conclusion: In our series it seems that BCG treatment is well tolerated, which is better than the reported literature where only 16% completed three year maintenance.
DOI: 10.1258/smj.2012.012100
Can emergency department patients with ureteric colic be effectively managed as outpatients?
R Vint*, G W McNaughton†, E McMillan†, S Crorie† and Z Latif*
*Department of Urology, Royal Alexandra Hospital, Paisley, Scotland, UK
†Department of Accident and Emergency, Royal Alexandra Hospital, Paisley, Scotland, UK
Background: Our aim was to audit our management of patients suspected of having renal colic and identify any possibility to safely discharge more patients instead of admitting them to surgical receiving unit. Methods: Using the Emergency Department Information System and Picture Archiving and Communication System (PACS) we retrospectively identified and audited all 63 patients in a three-month period diagnosed with a suspicion of ureteric colic. A local protocol for management of these patients aimed to allow certain patients to be discharged. Following a gap period a longer audit of 121 patients was performed to evaluate safety and effectiveness of protocol. Results: The first group had 24/63(38%) discharged from the emergency department. The second group had 46% (56/121). Our second audit identified lower discharge rates depending on the reviewing doctor. In the second group three patients re-presented following discharge. Median time to an inpatient Computerized tomography was 1.17 days. Conclusion: It is feasible to manage ureteric colic patients as outpatients with a protocolbased approach.
DOI: 10.1258/smj.2012.012101
Development of three-dimensional stereoscopic imaging for teaching of renal anatomy: pilot study
David Minnoch*, Thomas Lam†, John McDonald*, Neil Hamilton* and Alan Denison‡
*Medi-CAL Unit, School of Medicine, University of Aberdeen, Aberdeen, Scotland, UK
†Academic Urology Unit, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
‡Department of Radiology and Division of Medical and Dental Education, University of Aberdeen, Aberdeen, Scotland, UK
The objective of this study was to develop the use of three-dimensional (3D) imaging technology in the teaching of renal anatomy to undergraduate biomedical sciences and applied sciences students. Anonymized computerized tomography scans were collected from patients who had renal cell carcinoma of various stages. Appropriate images in terms of image resolution and quality were rendered into 3D stereoscopic images using ‘BBEdit’ and ‘Present3D’ software and were further maximized using innovative colouring schemes. A 3D renal anatomy tutorial was developed for viewing in a darkened room using a 3D projector and 3D screen and watched with 3D spectacles. The tutorial was assessed by a group of final year biomedical sciences and applied sciences students. The assessment of the teaching system was performed via a set of validated questionnaires and the main outcome measures were quality of images, ease of understanding and whether the 3D system facilitated learning of renal anatomy. Out of 30 patients, 10 cases were considered appropriate for 3D rendering and these cases were incorporated into the anatomy tutorial. Twenty-five students received the tutorial and provided feedback on the teaching system. The response was overwhelmingly positive, with 95% of students rating the quality of images positively and 95% finding that the 3D system facilitated their learning. Limitations encountered included the inability to distinguish between tissues of similar densities. However, 3D stereoscopic imaging appears extremely promising as a teaching tool. As software continues to improve, the technology has the potential to revolutionize medical education, especially in the teaching of anatomy.
DOI: 10.1258/smj.2012.012102
Adult experience of circumcision under local anaesthetic defies consultant beliefs
C Robin, H Mustafa and D Ian
Monklands Hospital, Airdire, Scotland, UK
Background: Circumcision is performed under local, regional or general anaesthetic. Current practice in Scotland for adults favours general anaesthesia. We offer circumcision under local anaesthetic to most patients. We audited their experience, as well as the attitudes and current practice of consultant urologists in Scotland with regard to anaesthesia for circumcision. Methods: We conducted a prospective audit on the day of surgery for consecutive patients undergoing local anaesthetic circumcision. A questionnaire was used to assess perioperative factors such as anxiety, pain, satisfaction and future recommendation of local anaesthetic circumcision. Consultant urologists in Scotland were additionally sent a questionnaire enquiring about individual anaesthetic preferences for adult circumcision. Results: Completed questionnaires were returned by 63 patients with 17 (27%) experiencing some pain during the procedure (range, 1-7/10; mean, 3.4). All patients reported satisfaction with their choice of anaesthetic and would recommend the same to a friend. Of consultant urologists in Scotland, 17/26 (65%) do not offer local anaesthetic circumcision, believineg both that it induces severe discomfort and that patients prefer general anaesthesia. Conclusion: Local anaesthetic circumcision avoids the need for preassessment, and offers potential cost-savings. It is acceptable to patients. Approximately a quarter will experience mild discomfort during administration. Our results challenge the beliefs of a substantial number of consultant urologists, that local anaesthetic circumcision is unacceptable to patients.
DOI: 10.1258/smj.2012.012103
A generation of laparoscopic nephrectomy: stage-specific surgical and oncological outcomes for laparoscopic nephrectomy in a single centre
A Laird, G D Stewart, J Zhong, J Ang, A C P Riddick, D A Tolley and S A McNeill
Department of Urology, Western General Hospital, Edinburgh, Scotland, UK
Background: The aim of this study was to determine the stage-specific operative, postoperative and oncological outcomes for patients undergoing a laparoscopic radical nephrectomy (LRN) for renal cell cancer (RCC) in a single centre. Methods: From December 1997 to February 2011, data were collected prospectively for 854 consecutive LRNs. In total 397 patients had pathologically confirmed RCC. Follow-up data were completed retrospectively. Results: Patients were grouped by tumour stage (pT1-4) with 206, 71, 118 and two patients in each group, respectively. Comparing surgical outcomes in stages pT1–T3, median operating time was significantly shorter in those with pT1 tumours, while median blood loss was greater in those with pT3 tumours. There was no significant difference in all cause postoperative morbidity and median postoperative stay. Conclusion: Departmental experience has resulted in improved surgical outcomes for localized RCC with reduced operation time and estimated blood loss. There has been an increase in complex LRN for advanced RCC. LRN for advanced disease is more technically demanding but is operatively safe.
DOI: 10.1258/smj.2012.012104
Proteomic analysis of pre- and postsunitinib treated renal cancer tissue to assess tumour heterogeneity and differential protein expression
G D Stewart*†, F C O'Mahony*†, L Eory‡, J Nanda*†, A Laird*†, M O'Donnell*†, P Mullen*, A C P Riddick*†, S A McNeill*†, M Aitchison†§, D Berney**, J Peters††, A Rockall**, A Sahdev**, A Bex‡‡, D Faratian*†, S Chowdhury§§, D J Harrison*†, I Overton‡ and T Powles**
*Edinburgh Urological Cancer Group, University of Edinburgh, Edinburgh, Scotland, UK
†Scottish Collaboration on Translational Research into Renal Cell Cancer (SCOTRRCC), Edinburgh, Scotland, UK
‡MRC Human Genetics Unit, MRC IGMM, University of Edinburgh, Edinburgh, Scotland, UK
§Gartnaval Hospital, Glasgow, Scotland, UK; **St Bartholomew's Cancer Institute, Experimental Cancer Medicine Centre and Queen Mary University of London, England, UK
††Whipps Cross University Hospital, London, England, UK
‡‡Netherlands Cancer Institute, Amsterdam, The Netherlands
§§Guys, King's and St Thomas’ Hospital, London, England, UK
Background: In order to evaluate acquired resistance to sunitinib, we evaluated heterogeneity and differential protein expression in sunitinib-treated and untreated clear cell renal cell carcinoma (ccRCC) samples using high-throughput proteomics. Methods: Fresh frozen tissue was obtained from 23 sunitinib naïve ccRCC specimens and 27 nephrectomy samples from patients treated with neoadjuvant sunitinib. Reverse phase protein arrays were performed to assess the levels of 58 proteins relevant to ccRCC pathogenesis and sunitinib activity. Results: To assess heterogeneity, intratumoural protein expression variance was analysed. Higher intratumoural median variance was found in the sunitinib-treated group for 43 proteins. Despite exacerbation of tumour heterogeneity by sunitinib treatment, there was significant differential expression for 29 of the 55 proteins evaluated. Conclusion: Protein expression in ccRCC is heterogeneous and key proteins showed significantly increased variance of expression with sunitinib therapy. Despite heterogeneity, significant changes in protein expression can be identified with sunitinib treatment and will be correlated with outcome.
DOI: 10.1258/smj.2012.012105
Does transrectal ultrasound-guided prostate biopsies based on single-raised PSA lead to unnecessary biopsies?
R S Khan, R R Marri, S Moghal, M H Khan and R M Gurun
Urology Department, Ayr Hospital, Ayr, Scotland, UK
Background: Prostate cancer is the second most common cancer in men. Transrectal ultrasound (TRUS)-guided prostate biopsies are used in diagnosing prostate cancer. The European Association of Urology has published guidelines that outline the standard to be followed for prostate biopsies. Methods: We retrospectively reviewed the records for all patients undergoing TRUS-guided prostate biopsies in our unit between August 2009 and January 2010. Patients having the first set of biopsies were assessed further for compliance with the standards outlined in the guidelines. Results: A total of 181 biopsies were performed during the study period. Of these, 70% (n = 126) were first set of biopsies with average patient age of 67 years (range, 49-83). All patients received appropriate antibiotics and anaesthetic and had at least eight biopsy cores taken (100% compliance with guidelines in all above mentioned areas). A further 8% (n = 10) of these patients underwent biopsies based on single prostate-specific antigen (PSA) with no documented evidence of abnormal prostate on rectal examination. The age range for these 10 patients was 54-72 years. Six patients (60%) were diagnosed with prostate cancer and are currently receiving either treatment or surveillance, three patients (30%) had benign tissue and one patient (10%) had prostatitis. All patients with benign histology or prostatitis had lower PSA when repeated after biopsy. Conclusion: If TRUS biopsies are performed based on a single PSA, it does lead to unnecessary biopsies as highlighted in our study population. At least 3% of patients could have avoided biopsies and the potential morbidity and anxiety associated with the procedure.
DOI: 10.1258/smj.2012.012106
