The objective of this article is to establish current levels of activity and interest in global urology amongst British urologists, in order to inform BAUS Urolink and guide future strategic decision making.

Voluntary online surveys were sent to all BAUS members in May 2014.

This survey demonstrated a significant level of interest and engagement by BAUS members in global urology. Over 40% of respondents had participated in overseas work, predominantly in the form of short-term visits. Motivating factors for involvement included a desire to help, but personal and organisational benefits were also noted.

There was consensus that Urolink represents an important part of BAUS, with a clear desire for improvements in dissemination of opportunities to widen engagement amongst the BAUS membership.

Ultra-mini percutaneous nephrolithotomy (UMP) is a novel technique recently introduced allowing percutaneous renal access to stones using a specially modified 11 or 13 Fr sheath, a 6 Fr nephroscope, and permits laser fragmentation and stone evacuation. This study aimed to review the early practice of UMP in the UK.

All centres in the UK which had performed UMP were contacted to submit data. Data were submitted to a central database from nine centres around the UK who performed UMP between July 2013 and December 2014. Data were collected on patient, stone, operative factors and outcomes.

A total of 32 UMP cases were performed in the contributing centres. Stone size ranged from 7 mmx5 mm to 24 mmx24 mm across the 32 cases, with a mean of 13 mmx10 mm. Stone-free rates were excellent with 31/32 cases stone-free post procedure; 26/32 patients were left without a nephrostomy tube. Complications were uncommon; there were two Clavien 1 complications in this series (6%).

This study has shown the efficacy of UMP during its introduction into UK practice. It is likely that UMP will become a useful addition to the armamentarium to treat renal stones, especially smaller stones in the lower pole calyx, and in specialised cases such as paediatric stone disease and in patients with stones in calyceal diverticulae.

Admissions for ureteric colic are relatively common, with up to 80% of stones passing spontaneously. In patients with refractory pain, drainage with stenting, percutaneous nephrostomy or stone removal can be performed. Due to the financial restrictions of the NHS, it is paramount to ensure patients are receiving optimal cost-effective care. We present a cost effectiveness analysis between primary ureteric stenting and emergency ureteroscopic stone removal in patients with refractory pain secondary to acute ureteric calculi.

Fifty patients were analysed who underwent either primary ureteric stenting or emergency ureteroscopic stone removal in our institution. Each group contained 25 consecutive patients. The primary outcomes compared were: time to stone-free status, number of hospital re-admissions, and overall cost of treatment until stone free.

Both stenting (n=25) and ureteroscopic stone removal (n=25) groups were comparable with respect to age, sex, stone size and location. The hospital re-admission rate secondary to stone-specific issues was significantly lower in the ureteroscopy group, two versus 20. Patients became stone free significantly quicker in the ureteroscopy group (2.5 days vs. 61.9 days). The total overall cost until being declared stone free was significantly lower in the ureteroscopy group (£3104 vs. £4041, P<=0.001).

This study highlights that those patients undergoing ureteric stenting take significantly longer to become stone free, leading to increased hospital re-admissions, potentially increased morbidity and inevitably greater cost implications. We advocate that primary ureteroscopic stone removal should be consider instead of ureteric stenting in patients with ongoing, painful ureteric colic.

To assess the clinical outcomes of patients diagnosed with Bosniak IIF renal cysts, in order to rationalise our surveillance policy.

We identified all patients diagnosed with a Bosniak IIF cyst between September 2011 and September 2014. Patient demographics, duration, frequency and modality of surveillance were recorded. Changes in the size, appearance or characteristics of the cyst(s) were recorded, as well as any subsequent surgery and histology. We also estimated the overall cost of imaging and follow up.

We identified 198 patients. The majority of IIF cysts were incidental findings (86.5%), with 56% of cysts > 3 cm at diagnosis. Median follow-up time was 27 months. We found that 98% of cysts were unchanged in their Bosniak score and 66% did not change in size. We followed up on 86 patients (43%) beyond two years: None had radiological progression. Four patients (2%) underwent partial nephrectomy secondary to radiological progression: One (0.5%) had histological malignancy. Features of malignancy were noticed in the first 24 months of the follow-up period.

Radiological progression of Bosniak IIF cysts is low and progression to malignancy lower still, typically occurring within 24 months of diagnosis. Our data suggested that ceasing radiological follow-up surveillance after a minimum of two years of stable surveillance could be considered. Rational follow-up protocols for Bosniak IIF cysts would have significant cost-saving implications for the National Health Service (NHS) and alleviate pressure on radiology and urology services.

Local education training boards (LETBs) and deaneries are under pressure to demonstrate delivery of high quality specialist urology training. There is at present no quality tool used routinely to demonstrate this quality regionally or nationally. Differences in training could therefore exist between different regions, and locally between different training units. A trainer/trainee questionnaire tool previously piloted by the specialist advisory committee was used to evaluate urology training posts in the North London LETB over 3 years. The findings were used to compare trainee scores in North London with those in the North West region of England.

Questionnaires were circulated electronically to all higher surgical urology trainees in the 18 training units affiliated to the North London LETB. Three years of trainee data were collated, statistically analysed and compared to those collected by Oates and colleagues, looking for any differences in regional trainee scores for higher surgical training posts in North London and North West of England regions.

The mean trainee response rate was 28 questionnaires per year from all 18 units in the North London region. Combined mean and median scores were 83.3 and 84, respectively. This compares to 86.2 and 88.1 from North West England region comprising eight units. There was no statistically significant difference in scores between the two regions (two-tailed t test, P=0.31).

There is no statistical difference in trainee scores for the evaluation of urological training posts between the two regions. The questionnaire tool can be used effectively to look at overall differences in training standards between geographically distinct regions from a trainee perspective. Both regions offer higher surgical training with high levels of trainee satisfaction. This questionnaire tool can provide insight into subjective differences in training posts within a region.

Fluoroquinolone (FQ) resistant (FQR) bacteria are a major cause of infection after transrectal prostate biopsy (TRPB). We determined the prevalence of FQR in initial and subsequent rectal cultures from men undergoing repeat prostate biopsies.

After IRB approval, men presenting for TRPB at the San Diego Veterans Affairs Medical Center between January 1, 2010, and February 6, 2014, underwent pre-TRPB rectal culture. The rectal swab was collected from the patient immediately prior to TRPB. Rectal swabs were streaked onto locally prepared ciprofloxacin-supplemented (4 mg/L) MacConkey agar plates. A representative colony was selected for identification and susceptibility testing.

Of 617 patients who had rectal cultures done, 7% (43/617) had a repeat rectal culture performed in relation to a second prostate biopsy. All cipro-resistant bacteria isolated were Escherichia coli. The median time and interquartile range between first and second biopsy was 2.3 years (range 1.2–3.6 years). On first biopsy, 16.3% (7/43) had FQR, which was not statistically different from the 18.6% of patients who had FQR on their second biopsy (p=0.78). Overall, 74% (32/43) of patients tested absent for FQR at both prostate biopsies, and 9.3% (4/43) tested present at both (p=0.015). However, 9.3% (4/43) converted from absent to present FQR, and 7.0% (3/43) converted from present FQR to absent (p=0.69). Seventy percent of the FQR E. coli were also resistant to gentamicin, and 22% were resistant to cefepime.

Patients undergoing prostate biopsy should be examined for FQR prior to each individual biopsy because prior culture results do not always predict whether a patient will be colonized with FQR E. coli.

Choice of reconstruction following bladder removal is often between neobladder or ileal conduit diversion. Identifying patient concerns about this little understood choice should provide better understanding of factors important in making surgical decisions. The current study used a qualitative technique to identify patient concerns and values influencing patient choice of bladder reconstruction following radical cystectomy.

Thirty-two patients (neobladder: 11 male, 6 female; ileal conduit: 9 male, 6 female) participated in semi-structured interviews conducted at a Hospital Clinical Research Unit, and their responses were analysed by content analysis.

Many procedure and lifestyle factors were secondary to survival considerations. Most patients adapted to reconstruction. Patients chose neobladder because of perceptions of normality and less-restricted activities (including sex life), or chose ileal conduit because of perceived simplicity of this operation, or the fear of urinary incontinence, and extra ‘work’ for the patient involved in having a neobladder. Male and female reasons were consistent with one another, except that body image was a greater issue for females in choosing neobladder.

Pre-existing concerns influenced the choice that patients made between undergoing illeal conduit or neobladder reconstruction after removal of their bladder. These findings are a step towards developing a tool to aid joint decision making when planning exenterative and reconstructive surgery for bladder cancer.

This study aims to assess the use of primary X-ray beam collimation during ureteroscopy and its effect on patient radiation dose.

A retrospective review of images and radiation doses of patients undergoing ureteroscopy.

The use of primary X-ray beam collimation during ureteroscopy is associated with lower radiation doses to the patient. Only 3% of images had evidence of collimation.

We studied our hypothesis that patients with private health insurance (PHI) with prostate cancer present with more favourable pathological outcomes.

Data were analysed from 554 patients undergoing radical prostatectomy from 2002 to 2010. A total of 328 patients under the NHS and 226 men had PHI. Two groups were compared for age, PSA, Gleason score, number of cores involved, maximum tumour length on biopsy core, socioeconomic status, imaging and pathological outcomes.

PHI presented at a younger age (63 vs 61, p = 0.008) and lower mean PSA (9.5 vs 8.04, p = 0.0005). Staging MRI showed a significant difference in usage (77% vs 45% p < 0.001). Importantly there was significant difference in the total tumour volume (4 cc vs 8 cc, p = 0.001). There were significantly more wealthy patients being seen privately (p < 0.0001). However, on the final Cox regression model only grade, stage and insurance status were significant predictors of BCR.

Patients with PHI were younger, had a lower presenting PSA and were wealthier. There is a significant difference in the social profile seen, but wealth itself is not protective yet health insurance is. Insurance status and not social status represents a factor in predicting final pathological outcomes after RRP.

Bladder cancer is the commonest cancer of the urinary tract. Transurethral Resection of Bladder Tumour (TURBT) is the gold standard for diagnosis and treatment of non-muscle invasive bladder cancer. The absence of muscle in a TURBT specimen is associated with a significantly higher risk of residual disease, early recurrence and tumour under staging.

TURBT and bladder biopsy specimens were examined before and after the introduction of an open reporting system as a quality improvement exercise. All specimens from the 4th quarter (between 2010 and 2014) were examined to determine the effect of open reporting on our inadequate resection rates.

A total of 244 cases were performed under the care of 5 consultant urologists. Analysis revealed a significant improvement in quality of both T1 and Ta resections (p=0.04*; p=0.02*) after the introduction of open reporting. The total number of TURBT cases increased per year, however the percentage of inadequate resections has significantly decreased (p=0.02*).

Individual reporting provided surgeons with direct, personal and timely feedback on their performance. It did not negatively impact on trainee participation, but led to improved training outcomes. We have demonstrated that our simple intervention has improved quality of patient care.

The purpose of this study was to investigate the short-term results of extended pelvic lymphadenectomy (ePLND) during laparoscopic radical prostatectomy (LRP).

Of 1330 consecutive patients undergoing LRP during a 90-month period 1000 (75%) had an ePLND for d’Amico intermediate- or high-risk prostate cancer.

Operating time, blood loss, conversion and transfusion rates and hospital stay were similar in patients having standard pelvic lymphadenectomy (sPLND) and ePLND. Median lymph node count was significantly greater following ePLND vs sPLND (17 vs 6; p<=0.0001). Complication rates were also similar but trended (p=0.06) towards a greater rate after ePLND vs sPLND: 9.0% and 5.5%. Lymph node involvement (LNI) was detected more frequently following ePLND in patients with: prostate specific antigen (PSA)=0–9.9 (p=0.01) and PSA=10–19.9 (p<=0.0001); biopsy Gleason sum <=8 (p<=0.0001 to 0.03); intermediate- (p<=0.0001) and high-risk (p<=0.0001) cancer; pathological Gleason grade 7 (p<=0.0001) and pathological stage T3 (p=0.0009 for pT3a and p<=0.0001 for pT3b).

ePLND is a more effective tool than sPLND in detecting LNI for patients in all prognostic clinical groups. This can be achieved without significant penalty with respect to operating time or complication rates.

The efficacy of intravesical botulinum toxin-A (BTX-A) for the treatment of idiopathic detrusor overactivity (IDO) is well-established and evidence-based. The optimal regime in terms of dose, distribution, depth of injection and number of injections has not been determined and there is still considerable variation throughout clinical practice. We aim to establish the optimum template for bladder injections.

All patients had urodynamically-proven IDO which had failed conservative and medical management. AbobotulinumtoxinA (250 units) was injected into the detrusor and sub-urothelium in one of five injection templates under general anaesthetic. An Overactive Bladder Symptom Score (OABSS) and International Prostate Symptoms Score (IPSS)-Likert quality of life (QoL) score was completed pre-operatively and at six weeks post-operatively. In those who underwent repeat treatments the time to re-commencement of pharmacological therapy was recorded.

In total 111 patients received 170 treatments. The average age of patients was 57 (range: 17–86) and the male: female ratio was 0.18:1. Overall there was a mean improvement in the OABSS by –3.7 points±4.29 (standard deviation (SD) (p<0.01) and an average change in the QoL score of –2.18±2.17 (SD) (p<0.01) with BTX-A treatment. When analysed by template subgroup there was no statistically significant difference in the magnitude of change for any template over the other four for either the OABSS (p=0.78) or QoL scores (p=0.56). Forty-one patients had multiple treatments and had data collected for the duration to treatment failure. The overall average time to treatment failure was 11.2±7.9 months. Subgroup analysis showed that there was no statistically significant (p=0.783) difference in time to treatment failure for any one of the injection distributions.

This study has shown that altering the injection protocol of BTX-A did not affect the clinical outcome in terms of symptoms, QoL or in the time to treatment failure.

The objective of this study was to review the effectiveness and safety of a one stop urology clinic led by a consultant diagnostic urologist.

Data were collected prospectively on all patients seen by a single consultant diagnostic urologist from February 2007 to February 2008. In 2013, patient records were reviewed and cross-referenced to identify if any patients had been re-referred to the urology service and why.

From 889 referrals, 799 patients attended, of these 689 (86%) were discharged after a single visit with 110 (14%) booked follow-up appointments. Ninety patients were re-referred, only two of these had a significant diagnosis. Thirty-four (38%) had a new referral reason.

The one stop method of consultation is effective and efficient across a range of presenting complaints in urology. It is safe for patients and leads to a high discharge rate with a low re-referral rate without missing clinically significant diagnoses.

We present our experience using oral bicarbonate as a dissolution therapy for radiolucent kidney stones in the pre-dual energy CT era.

A retrospective analysis of dissolution therapy was undertaken over a four-year period. Stones were diagnosed as radiolucent on conventional KUB X-ray in combination with either ultrasound or CT KUB. Oral bicarbonate was given at a dose of 2 g tds orally, increased to 2 g five times daily according to urinary pH. Patients monitored their own urine dipstick daily to achieve a pH of at least seven.

Altogether 27 patients were identified with radiolucent stones. Stone size varied from 4–40 mm. Average length of therapy was nine weeks. Of the patients, 17 had renal U/S and six had CT KUB as end point imaging. We found that 39% had complete dissolution, 18% had a partial response and 43% showed no response. A high serum uric acid level correlated with a higher incidence of dissolution. Cost-benefit analysis shows bicarbonate therapy to be more cost-effective than lithotripsy, ureteroscopy or nephrolithotomy.

Bicarbonate therapy remains an attractive option for the treatment of radiolucent kidney stones. The presence of hyperuricaemia or hyperuricosuria appears to influence the success rate. Further prospective randomised studies are needed to identify the most tolerable and effective treatment regime as well as the optimal duration of treatment. Dual-energy CT may hold the key to identifying patients most likely to benefit from treatment.

YouTube^TM has provided a platform that is utilised by millions. Patients are increasingly utilising this source of information. We set out to systematically analyse the quality of ureteroscopy videos.

YouTube^TM was searched using the term ‘ureteroscopy’. Content was assessed using the British Association of Urological Surgeons website criteria. Information relating to management options, procedural description, stent insertion, recovery and complications was rated. An overall rating was given. Videos were also analysed in terms of country of origin, view count, likes, dislikes, source and technical quality. The kappa statistic was used.

A total of 59 videos were analysed. The total number of viewings was 557,896 (range: 42– 121,943), with an average number of 9456 viewings per video. The information content was either poor or average in 98% (n = 58) of videos, with only 2% (n=1) rated as good and 0% achieving an excellent rating. Technical quality was rated as poor in 28 videos, average in 22 and good in nine videos. Most videos were broadcast by surgeons or surgical institutes (48/59).

The quality of videos is variable. Patients should not be encouraged to use this for education. Opportunity has arisen for the endourology community to produce high quality video broadcasts to optimise patient understanding.

On-demand irrigation warmers are widely used to provide a convenient way of irrigating warmed fluids for endoscopic procedure. However, concern has been raised that flow rates via these devices are inadequate for safe operating. Holmium enucleation of prostate (HoLEP) requires significant volume and flow rate of irrigation. Poiseuille’s Law states the resistance of a tube will result in reduced flow and a reduction in pressure across the tube. The aim was to compare the irrigation rates provided by one such warming device compared to a standard giving set whilst simulating HoLEP and to monitor intravesical pressure.

A simulated apparatus was set up to replicate HoLEP surgery. Simulated design rather than ‘real-life’ apparatus was used to allow for repeated testing in a more controlled environment and to avoid other variables due to operative differences. Comparison of irrigation rate and pressure difference was measured whilst using a standard irrigation set (Fresenius Kabi) with pre-warmed fluid and the Ranger irrigation warming system (3M). Pressure was measured using a pressure line passed via the working channel of the laser resectoscope.

The standard giving set demonstrated lower resistance and higher irrigation rates. The irrigation rate was 31% higher (7.2 vs 5.5 ml/s). A lower change in pressure across the standard giving set was found (20 vs 38 cm H₂O). The resistance therefore is much higher in the Ranger irrigation system, which gave a much slower flow and greater drop in pressure.

This unique demonstration has led to a quantitative assessment of commonly used giving sets and has shown irrigation rates via a standard giving set are 31% greater than through the Ranger irrigation warming system. On-demand fluid warmers are felt to result in poor intraoperative vision and pose a potential risk to patient safety during HoLEP and other urological procedures requiring high fluid volumes.

To investigate the accuracy of electronic discharge summaries (EDSs) written for patients who had undergone acute scrotal exploration for suspected testicular torsion.

We reviewed the operation notes and EDSs for 169 admissions over a 52-month period where patients had undergone acute scrotal exploration for suspected acute testicular torsion and reviewed the correlation between what was written in these documents, focusing on laterality of pain, operative findings and procedure performed.

We found that the side of testicular pain was not mentioned in 14.8% of EDSs, the operative findings recorded on the EDS did not correlate to those on the operation notes in 17.2% of cases and the overall procedure performed did not correlate in 35.5% (with most of these relating to the laterality of the operation). The fact that an operative procedure happened at all was not mentioned in 4.7% (n = 8) of the EDSs.

The information in such an important medical document needs to be accurate, and we advocate that the person performing the operation should initiate the discharge summary process, where EDS use is the norm for discharge. Junior doctors entering urology departments must also be trained on the key information to be included in urological EDSs.

The objective of this article is to review the outcomes of our updated single-centre extended experience of an innovative enhanced recovery pathway to perform catheter- and drain-free laparoscopic pyeloplasties, achieving safe discharge within 23 hours of surgery.

We conducted a retrospective review of patients who underwent a standard trans-peritoneal laparoscopic pyeloplasty repair over an antegrade stent in our centre by a single surgeon, between 1 September 2007 and 1 February 2015.

Patients who had a urinary catheter and/or peri-nephric drain inserted intraoperatively and were not planned for day-case discharge were excluded.

Data were collected for duration of in-patient stay, readmission rates and reasons for these. Successful outcome was deemed both in subjective improvement of patient symptoms and/or objective improvement in post-operative MAG-3 renogram curve.

Fifty-eight patients were included. A total of 74% (n = 43) were successfully discharged as day-case, and four of these were readmitted. Fifteen patients required in-patient stay, of whom two were readmitted. Successful outcome was recorded in 93% (n = 54).

The insertion of a drain and catheter are not essential in laparoscopic pyeloplasty. Avoidance of unnecessary tubes facilitates day-case surgery with no adverse effect on outcome.

At our institute all patients are now offered the enhanced recovery protocol for laparoscopic pyeloplasty with resulting benefits both to patients and the local health economy.

Recurrent urinary tract infections (UTIs) in women are common despite anatomically normal urinary tracts and are frequently referred to secondary care for further assessment.

Clinic letters and pathology reports of 244 women referred to our centre over a 2-year period with uncomplicated recurrent UTIs were reviewed to determine the investigations they underwent in both primary and secondary care.

A significant proportion of women do not meet the criteria for recurrent UTIs as their infections are not proven on culture. The majority of women undergo both renal tract ultrasound scan (USS) and flexible cystoscopy. Though USS was found to demonstrate relevant pathology, flexible cystoscopy, however, did not reveal any relevant pathology.

Investigation of women with recurrent uncomplicated UTIs should be done with adequate cultures and renal tract USS.

Biopsy of the prostatic urethra is an integral part of clinical staging in patients prior to radical cystoprostatectomy (RC) and urinary diversion. We examined whether preoperative transurethral resection (TUR) biopsy was associated with final apical urethral margin status and hypothesized that a negative biopsy could replace intraoperative frozen section for decision making regarding the feasibility of orthotopic neobladder reconstruction.

TUR biopsy, frozen section, urethrectomy, and final apical urethral margin pathologic data were extracted from the charts of men who had undergone RC at the Houston Methodist Hospital between 1987 and 2013. TUR biopsies were performed at five and seven o’clock adjacent to the verumontanum. A positive biopsy was defined as the presence of in situ or invasive urothelial carcinoma. Clinical and perioperative variables were analyzed using descriptive and inferential statistics.

We reviewed the medical records of 272 men. Preoperative TUR biopsies of the prostatic urethra were negative in 74% (200/272) and positive in 26% (72/272) of men. The overall incidence of apical urethral margin positivity on final pathology was 2.2% (six of 272). Four men underwent primary or secondary urethrectomy. TUR biopsy negative and positive predictive values for apical urethral margin positivity were 99.5% (95% confidence interval (CI): 97.2 to 99.9) and 6.9% (95% CI: 2.3 to 15.5), respectively.

The incidence of a positive apical urethral margin was low in patients undergoing RC. A negative preoperative TUR biopsy of the prostatic urethra was reliably associated with a negative final margin, obviating the need for intraoperative frozen section. Furthermore, a positive biopsy was not reliably associated with final margin status. These data will aid in the counseling of patients regarding the feasibility of neobladder reconstruction.

Ionising radiation is commonly used in urological practice in the form of fluoroscopy. To date there is a remarkable scarcity of information concerning patient exposure to ionising radiation during urological procedures and the potential risk of developing of a lethal malignancy due to excessive radiation exposure.

We aimed to determine the radiation exposure for a patient during the most commonly performed urological procedures, and to assess the potential risk of developing a fatal cancer as a result of endourological fluoroscopy.

Data was collected prospectively in two institutions on endoscopic urological operations. Procedures were classified as retrographic, semi-rigid ureteroscopic and flexible ureterorenoscopic (FURS). Data collected included procedure type and difficulty, Dose Area Product [DAP (Gy*Cm2)]. The effective dose (ED) measured in millisievert (mSv) was determined from the DAP by using the Monte Carlo calculation.

In total 395 consecutive operations from two institutions were assessed. The mean ED for all procedures in this study was 0.394 mSv, IQR (0.1184–0.7583). The maximum ED was 5.93 mSv. The radiation exposure for all procedures was relatively small; for diagnostic retrographic procedures the median ED was 0.112 mSv. For retrograde procedures that involved stent insertion, the median ED was 0.438 mSv. The median ED for all ureteroscopic surgeries was 0.295 mSv, and the median ED for all FURS procedures was 0.491.

The findings of this study are reassuring. Endoscopic urological procedures appear to expose patients to relatively small radiation compared with other procedures requiring fluoroscopy, thus conferring a very low lifetime risk of malignancy.

In patients scheduled for radical prostatectomies (RP), preoperative (pre-op) erectile function (EF) characterization may be complicated by social and medical factors. We investigated pre-op use of phosphodiesterase type 5 inhibitor (PDE5i) as a simple metric for predicting long-term postoperative EF.

Electronic medical records (EMRs) for consecutive men who underwent RP between January 2004 and March 2009 at our institution were retrospectively reviewed. Data extracted included demographics, pre-op PDE5i use, cancer treatment details, post-op EF and ED treatment. Predictor variable data were categorical pre-op PDE5i use (pre-op PDE5i use vs. pre-op PDE5i naïve). ANOVA and Chi squared test were used.

A total of 250 individuals out of 436 charts met inclusion criteria. Mean follow-up length was 4.2 years (range 2–7). Thirty-seven men (15%) used PDE5i preoperatively. There were no differences in mean age at RP, type of nerve-sparing surgery (NSS), or medical comorbidities between groups. No men with pre-op PDE5i use regained unassisted EF but 37% regained PDE5i-assisted EF after bilateral nerve sparing (BNS). No men with pre-op PDE5i use regained unassisted or PDE5i-assisted EF after unilateral (UNS) or non-nerve-sparing surgery (NNS).

Pre-op PDE5i use predicts poor long-term EF outcomes after RP and should be included in pre-op patient counseling.

The aims of this article are to correlate two multi-domain patient questionnaires for overactive bladder (OAB) and to assess their performance against quality-of-life measures.

Patients with OAB symptoms due to idiopathic detrusor overactivity completed an Overactive Bladder Symptom Score (OABSS), an ICIQ-OAB questionnaire and a Likert quality of life (QoL) score before and six weeks following intravesical botulinum toxin treatment. They also listed lifestyle goals to which they aspired following treatment. Correlations between domains, total scores, QoL and goal achievement were calculated.

Fifty-seven patients returned 113 sets of questionnaires for analysis. A very close correlation was found between individual symptoms scores (Spearman r ranging from 0.93 for nocturia to 0.74 for urgency incontinence) and between the total scores of the two questionnaires (r = 0.83). The sum of the OABSS+QoL scores also correlated strongly with total ICIQ-OAB scores (r = 0.85). The correlation between total problem scores on the ICIQ-OAB and the Likert QoL was lower (r = 0.689) but remained significant. The effect sizes (ES) were large (ranging from r = 0.6 to r = 1.0) and the standard response means (SRM) varied between 0.6 and 1.1, indicating a good correlation between the two questionnaires.

Both questionnaires provide similar information in terms of symptom presence or absence and their impact on QoL. The addition of the QoL score to the standard OABSS did not add to its benefit.

Active surveillance (AS) is a valid option for localised prostate cancer and should be offered to patients who are suitable for radical treatment in conjunction with current NICE guidelines. The aim of this study was to evaluate the consensus on AS selection and follow-up criteria in the United Kingdom (UK).

An electronic survey (Appendix 1) was emailed to 500 British Association of Urological Surgeons (BAUS) members to determine their local criteria for active surveillance in prostate cancer.

Of the 134 (26.8%) BAUS members who responded, PSA ≤ 10 ng/ml, Gleason score ≤ 6 and clinical stage ≤ T1c were the preferred selection criteria used in the UK. However, only 51.5% will perform MRI for disease staging. Most urologists (65.6%) preferred three-monthly PSA follow-up visits for the first year then six-monthly thereafter. A digital rectal examination (DRE) is not performed by 57.1%. Increased Gleason score and PSA doubling time were the two main criteria that would trigger intervention.

There is a lack of consensus on criteria used for selection, follow-up and repeat biopsy for prostate cancer patients on active surveillance in the UK.

Our aim was to determine whether flexible ureterorenoscopy and laser lithotripsy is efficacious and safe in treating lower pole renal calculi.

Patient, procedure and stone data of patients who underwent flexible ureterorenoscopy and laser lithotripsy at our referral centre were collected prospectively between November 2005 and November 2011 and entered into a designated database. In all, 242 procedures were performed in 198 patients.

The mean age was 51.2 years. The mean calculi size was 10.51 mm (range 4–27 mm). Thirty seven patients had more than one stone in the lower pole. An access sheath was used in 19 patients (9.6%), 171 (86.4%) had a ureteric stent inserted after the procedure, and 165 patients had a single procedure. Re-operation rate was 16.7%. Stone-free rates after one procedure were 89%, 80% and 41%, respectively, for calculi measuring 4–10 mm (n=107), 11–20 mm (n=76) and > 20 mm (n=15). The overall stone-free rate was 83%, 91% and 95% after one, two and three procedures, respectively.

Flexible ureterorenoscopy and laser lithotripsy is a safe and effective minimally invasive treatment option for patients with 4–20 mm lower pole calculi. Staged procedures, however, become necessary as the size of the stone increases greater than 20 mm, and this should be mentioned when counselling patients for their primary procedure.

To improve communication and decision making between specialists, multidisciplinary teams (MDTs) were introduced with the premise they would improve cancer care for patients. Minimal evidence exists on MDT functionality. We investigated MDT members’ views on barriers to optimal functioning and explored their suggestions for improvements.

Twenty urology MDT members from seven hospitals including surgeons, oncologists, pathologists, radiologists and clinical nurse specialists took part in a semi-structured interview study. Interviews focused on information presentation, case discussion, factors affecting the multidisciplinary team meeting (MDM) and potential improvements. Interviews were transcribed and analysed through emergent theme analysis.

Factors negatively influencing the MDMs included insufficient time to prepare cases so that enough information is available to make appropriate decisions; absence of the clinician in charge or not knowing the patient; and lack of a systematic approach to case discussion. Recommendations included protected time for case preparation, focusing on performance and comorbidities of the patient, standardising the MDT meeting and improving case selection.

MDTs in urology have contributed to advances in cancer care but there is significant scope for further improvement. Implementing recommendations from team members on the front line may help drive quality in this sensitive domain.

Until a decade ago, augmentation ileocystoplasty (AIC) was the only major advancement over anti-muscarinics for intractable idiopathic detrusor overactivity (IDO). Clam ileocystoplasty has been proposed to restore continence and preserve urethral voiding. While intravesical botulinum and neuromodulation have revolutionised the treatment of this condition, arguably there remains a place for bladder augmentation in the surgical armamentarium.

This study presents a single surgeon experience of clam ileocystoplasty performed for intractable IDO at our institution.

A retrospective case-note review was performed over a 9-year period. Data on basic patient demographics, urodynamic findings, pre-operative treatments administered, post-operative complications and response to surgery were documented.

In total, 22 patients were identified with a median age of 42.4 years. The predominant symptoms were urgency (100%) and urge incontinence (96%). All our patients were incontinent pre-operatively with 59% using pads. Ambulatory cystometry was helpful in 27% patients in whom standard +/- video studies were inconclusive. Of the cohort, 100%, 82% and 55% had one, two and three anticholinergics, respectively. Only 18% received intravesical botulinum toxin A pre-operatively. Some 77% were cured of their storage symptoms and incontinence; 18% had residual incontinence. Of these, genuine urodynamic stress incontinence was demonstrated in 9% and improved with tension-free vaginal tape. Some 9% had Clavien 3b complications requiring laparotomy. Mortality was nil.

In young patients with refractory IDO, clam ileocystoplasty serves as a permanent, effective technique for symptom reduction and restoration of continent urethral voiding with few complications.

To assess the quality of abstracts presented at the British Association of Urological Surgeons (BAUS) annual meeting using standardized reporting guidelines and examine whether abstract quality is associated with conversion to full-text publication.

Two standardized assessment forms based on CONSORT/STROBE guidelines were used to score abstracts from the 2009 BAUS meeting retrospectively. A high score ratio was defined as >50% of criteria. Kaplan–Meier analysis examined effect of score ratio on time to publication; logistic regression examined predictive potential of variables including; session topic, study design, country of origin and number of institutions to high score ratio and the effects the above factors and a high score ratio on the likelihood of full-text publication.

In total, 127 abstracts were included. The mean score ratio was 63.6% (SD 13.3%) for observational studies and 62.7% (SD 9.5%) for randomized controlled trials (RCTs). Nine RCT abstracts and 91 non-RCT abstracts achieved a high score ratio. Abstract topic, study design, country of origin and number of institutions did not predict a high score ratio or subsequent full-length publication using multivariate logistic regression. Full-length publication was achieved for 43 (33.9%) abstracts. Mean time to publication was 17.2 months. Abstract quality did not predict time to publication (p=0.706).

BAUS abstracts are of high quality, and compare favourably with other urological meetings. While abstract quality does not independently predict full-length publication, most abstracts do not progress to full-length publication and thus we advocate the use of standardized reporting guidelines to ensure accurate interpretation of study methodology and results.

Our aim was to establish whether there is a difference in prognostic indicators for bladder urothelial carcinoma (UC) between the patients referred via the 2-week wait (2WW) and those presenting to the emergency department (ED).

We performed a retrospective cohort study of all patients referred with visible haematuria, comparing tumour stage and grade between patients diagnosed with bladder UC via the ED and 2WW at two London hospitals.

From 09/2009–09/2011, 51 patients referred from the ED, and 146 from the 2WW clinic were diagnosed with bladder UC. Regarding tumour stage: 57% of the ED group had muscle-invasive UC compared with 23% from 2WW (p=0.001). Regarding tumour grade: 82% of the ED group had G3 tumours, versus 54% from 2WW (p<0.001). ED referrals were significantly older than those from the 2WW (p<0.001).

Patients with UC who present as emergencies had worse prognostic indicators and were older than those referred from the 2WW pathway. This supports the need for the inclusion of haematuria in the out-of-hours urology guidelines within the Acute Oncology Service.

Prostate specific antigen (PSA) has been used as a biomarker for prostate cancer for the last 20 years. Traditionally, a serum PSA <4 ng/ml has been used as a general cut-off between normal and abnormal readings. There is evidence to demonstrate that men with a normal serum PSA can develop prostate cancer. The aim of this study was to investigate the clinico-pathological features of prostate cancer in a non-screened Irish cohort with serum PSA <4 ng/ml.

A retrospective analysis was performed of all patients who underwent radical retropubic prostatectomy (RRP) in a tertiary referral unit over a 10-year period (2000–2010). Clinico-pathological characteristics were collated including those from trans-rectal ultrasound-guided (TRUS) prostate biopsies and radical prostatectomy specimens.

Between 2000 and 2010, 651 men underwent an RRP, with 43 (6.6%) having a serum PSA <4 ng/ml. The median PSA was 3.2 ng/ml (range 0.8–4.0). Nineteen (44.2%) had palpable disease on direct rectal examination (DRE). Following prostatectomy, 28 (65.12%) had Gleason 6 disease, 14 (32.56%) had Gleason 7 disease and one (2.32%) had Gleason 8 disease. Five (11.63%) patients were upgraded from TRUS biopsy to final histopathology. Six (13.95%) patients had pathological evidence of extracapsular extension on final pathology. Three (6.98%) patients experienced biochemical recurrence and received salvage radiation therapy after a median time of 24 months. The median follow-up was 106 months (range 36–158). Twenty (46.51%) patients had a first-degree family history of prostate cancer.

A PSA cut-off of 4 ng/ml has commonly been used in the detection of prostate cancer. Our study emphasizes that this cut-off is inappropriate and that no specific level of PSA can be used. Management decisions need to be individualized based on index of suspicion with concomitant counselling and rectal examination.

The purpose of this study was to compare the cost of photoselective vaporization of the prostate (PVP) with transurethral resection of the prostate (TURP) in the treatment of men with bladder outflow obstruction (BOO).

Men underwent PVP or TURP for clinical BOO or urinary retention. We developed a cost framework to calculate the costs of theatre, recovery and ward time in our publically funded institution and calculated a cost for each procedure including the initial stay and any associated admissions over the first 60 days. These costs were statistically analyzed.

A total of 99 men underwent PVP and 97 had TURP. Groups were well matched for age and operative indication. The American Society of Anesthesia (ASA) grade was higher for the PVP group with more taking anticoagulants (36% versus 3.1%). PVP was 74% more expensive (median AUD$4243 vs AUD$2439, p<0.001) than TURP, even in a sub-set analysis excluding the anticoagulated patients. This was because of longer operating time and unavoidable disposable costs.

Previous cost studies have all had significant flaws. Using our "bottom up" cost framework suggests that the unavoidable costs of purchasing a laser, single use laser fibers and other paraphernalia will almost always exceed the costs associated with in-patient stay. We caution against establishing a PVP service in a public hospital setting.

An estimated 60,000 people in the UK are currently performing some form of intermittent catheterisation, using 57.5 million catheters yearly. Current policy in the UK is to utilise single use, disposable catheters: however, this is not worldwide policy as repeated catheter use is common in many nations. The aim of this study was to determine UK patients’ views on re-using catheters and their willingness to re-use catheters.

Patients attending the clean intermittent self catheterisation [CISC]/urethral dilatation (UD) clinic over an eight-month period were asked to prospectively complete a standard, anonymous questionnaire.

A total of 100 questionnaires were returned, of which two-thirds were from men. Mean age was 61 years, (median 63 years). Indications for CISC/UD were urethral or meatal stenosis (7%), urethral stricture (25%) and residual volume in (67%). The majority of patients (71%) are unwilling to reuse catheters. Women were statistically very significantly more likely to refuse to re-use their catheters, (p<0.01, Fisher’s exact test). Patients aged 70 years and older were significantly more likely to agree to re-use their catheters compared to those under 70 years, (p=0.02, Fisher’s exact test). Patients performing intermittent self catheterisation [ISC] up to a maximum of twice per day were statistically more likely to agree to catheter re-use, (p=0.03, Fisher’s exact test). Risk of infection was the main reason cited (by 87%) to not re-use a catheter. Lack of lubrication and less convenience were other quoted reasons. Finances and less waste were stated reasons to re-use catheters.

Certain patient cohorts, men, patients over 70 years old and those performing CISC/UD less than three times daily are significantly more likely to agree to catheter re-usage.

In February 2008 the National Institute for Clinical Excellence introduced guidelines for active surveillance of prostate cancer, with close monitoring including at least one set of repeat biopsies 12 months after diagnosis. We aim to establish the impact on workload caused by repeat biopsy rate in active surveillance and whether they impacted on management.

We retrospectively reviewed all transrectal (TRUS) ultrasound biopsies (n=1105) in our institution from 2009 to 2010 to determine which were repeat biopsies for active surveillance (n=107). We reviewed the histology and case notes of these active surveillance patients to determine whether there was histological progression and change of management.

Some 9.7% (n=107) of TRUS biopsies were for active surveillance. Histological disease progression (Gleason score 6 to ≥7) was seen in 32% (n=23) cases. One patient (1%) developed locally advanced prostate cancer on restaging and was started on hormone therapy; 35% patients (n=25) were changed from active surveillance to radical treatment post repeat biopsy.

Repeat prostatic biopsy in active surveillance, although a considerable workload, has a justifiable outcome on treatment. One patient, who initially had intermediate-risk prostate cancer (Gleason 7) and had been preferentially offered radical treatment, developed incurable disease.

The objective of this article is to critically assess the value of a medical student and junior doctor weekend introduction to urology course.

All UK medical students and foundation doctors were invited to attend an introductory course held at The Royal Society of Medicine, London, organised by the Section of Urology. The course included consultant-delivered lectures, practical skills sessions and an academic competition.

Pre- and post-course feedback questionnaires were used to assess (a) perceptions of urology as a specialty, (b) career aspirations and (c) confidence performing basic urological surgical skills.

Sixty delegates attended from a variety of UK medical schools and hospitals. Seventy-three per cent of respondents were more likely to pursue a career in urology post-course. The most common negative perceptions included being a competitive career with long training and lacking glamour. Confidence in suturing, knot tying, suprapubic catheterisation, basic laparoscopy and cystoscopy were significantly improved following this course (p < 0.005).

A short urology course should be offered to medical students by urology departments and surgical societies; it will benefit students as well as the specialty. It is important that medical students are exposed early to urology given both positive and negative perceptions. Such initiatives may help strengthen the positive perceptions and dispel negative perceptions while increasing delegates’ desire to pursue a urology career.

Our aim was to understand patient-reported toxicities resulting from treatment of prostate cancer using various different modalities that have similar oncological endpoints.

An Internet-based survivorship care plan tool was used to collect patient-reported toxicity data for men who had undergone prostate cancer treatment.

A total of 127 users of the survivorship care plan tool reported to have been treated for prostate cancer. The median age of the patients at diagnosis in this group was 60 years (range = 25–74 years) and median time since diagnosis was 4 years (range 1–15 years); 61 (48%) received radiation as primary treatment, 44 (35%) received surgery as primary treatment and 22 (17%) received both surgery and radiation (adjuvant or salvage). Hormonal treatment was given to 50 (39%) patients. Some 15% (7/48) in the radiation group versus 50% (21/42) in the surgery group (p < 0.001) developed urinary incontinence; 61% (33/54) in the radiation group and 86% (37/43) in the surgery group (p = 0.02) reported having erectile dysfunction since treatment. Most users (84%) had not been offered a survivorship care plan previously.

Men with prostate cancer experience significant urinary and sexual sequelae from treatment regardless of the modality used. Patients treated with surgery reported more urinary and sexual side effects than those treated with radiation. The majority of these men are not offered a survivorship care plan to deal with these long-term effects. Survivorship planning tools to assess such side effects and design long-term individualized plans are essential for all prostate cancer patients.

Ureteral double J stent placement is a common urological procedure. A stent placement is performed for multiple conditions but some of them are contraindicated, mainly in pregnant female patients, because of X-rays. This work aims to suggest a mathematical model to predict female ureteral length by finding a link among different physical data.

Between June 2007 and July 2009, 100 female patients who had undergone ureteral stent placement were enrolled in the present study with the exception of those with septic conditions, history or evidence of TCC, congenital and acquired kidney or ureteral malformations, and previous ureteral surgery. The physical data of each patient were collected (mean age 55.8 years, range 18–89 SD 15.27, mean height 173 cm, range 160–182 SD 6.31, mean weight 75.33 kg, range 62–94 SD 8.81). A previous ureteral retrograde pyelography was performed during the procedure to individualise the pyeloureteral junction. Ureteral length was estimated through a graduated ureteral catheter with a final result between 24 and 27 cm. The length was read in cystoscopy examining the ureteral orifice while the catheter tip reached the pyeloureteral junction. The collected data were then analysed.

A link between the female patients’ ureteral length and height was observed. The following mathematical model can predict female ureteral length starting from the patient’s height: Result: y = 0.151712487 (height expressed in cm) ± 0.12; correlation coefficient: r = 0,973, residual sum of squares: rss = 5.285. No link was found between ureteral length and patients’ age and weight.

A good estimation of the length of the ureter to be cannulated enables us to choose in advance the proper one to use. Female patient height correlates with ureteral length. A cost reduction can also be obtained, avoiding an intra-operative X-ray control. An X-ray-free ureteral stenting procedure can be described simply through an ultrasound control mainly in pregnant women. Further studies are needed to obtain a similar mathematical model for male patients.

A list of all the Primary Care Trusts (PCTs) in England, Scotland and Wales was obtained from the websites of National Health Service (NHS) choices’, NHS Scotland and NHS Wales.

Each PCT’s website was visited to find the email address for their Freedom of Information (FOI) department. FOI requests were made to each PCT asking questions regarding their criteria for funding and the number of requests made and implants funded in the previous 12 months.

A total of 129 PCTs were emailed with a 95% response rate. Thirty-one per cent of the PCTs that replied funded penile prostheses and 22% did not. A further 45% of PCTs would fund under exceptional circumstances, but only 20% of these had any clinical criteria on which to base their decision making. Twenty-three per cent of clinical criteria used were based on guidelines. Non-funding PCTs were spread in patches throughout the country, but the West Midlands stood out as a particularly black spot. On reviewing PCTs that had received requests for funding in the preceding 12 months, 46% did not fund any of the requests, 17% funded 50% or less and 37% funded all the requests received. Of the PCTs funding under exceptional circumstances, only 37% actually funded any of the requests received.

Despite guidelines on the management of erectile dysfunction, there remains variability in access to penile prosthesis surgery. The West Midlands and the Southeast (excluding London) are the worst places to live with regards to access to prostheses; Scotland and Wales appear to be the best. Guidelines are rarely used in decision making. Funding remains an important factor in determining who receives potentially life-changing treatment for erectile dysfunction refractory to all other management options. A patient’s address and personal wealth appear to have a larger impact than guidelines.

The objective of this article is to study the outcome of management of 62 consecutive cases of Fournier’s gangrene (FG).

We conducted an observational study of all cases of FG admitted to the Urology and General Surgery departments of Farwaniya Hospital, Kuwait, between 2004 and 2013. We recorded the laboratory and clinical findings on admission. Operative and postoperative data were also recorded.

Our study included 62 cases of FG. Patients were divided into two groups: Group A (survival) consisted of 55 cases and Group B (mortality) of seven cases. The mean duration of symptoms before admission was significantly longer in the mortality group (3.86 days versus 1.96 days in survival group) (p < 0.05). The mean duration of symptoms until time of first debridement was also significantly longer in the mortality group (4.39 days versus 2.35 days in survival group) (p < 0.05). There was also a statistically significant difference between the two groups regarding the percentage of the affected area in relation to total body surface area (4.6% in Group A versus 8% in Group B) (p < 0.05). The Fournier Gangrene Severity Index score (FGSI) was significantly higher in Group B (10.26) in comparison to Group A (6) (p < 0.01). The mean duration of hospital stay was significantly higher in the survival group (22.24 days versus 14.28 days) (p < 0.01). Diabetes and renal failure were significantly higher in the mortality group (100% and 57.1% in Group B versus 54.5% and 9.1% in Group A, respectively) (p < 0.05). The number of patients presenting with severe sepsis was higher in the mortality group (71.4% in Group B versus 12.7% in Group A) (p < 0.05).

We concluded that FG is a serious, potentially fatal disease. Higher mortality is related to severe sepsis on admission, renal failure, diabetes, extensive disease involving extra-genital areas and late presentation. A multidisciplinary approach in diagnosis and management of the disease can achieve good outcome with low mortality rate.

Acute urinary retention (AUR) is a common urological emergency; however, when approaching a difficult catheterization, this is an evidence-free zone. Our objective is to investigate current practice with the intent to reach a workable consensus for the management of patients in AUR who cannot be easily catheterized urethrally.

We performed a hypothetical scenario-based, multideanery survey with urology consultants and ST3+ trainees. Participants were asked how they would manage three patients who prove difficult to catheterize using standard methods: benign prostatic obstruction (BPO), urethral stricture, and meatal stenosis.

Of respondents, 38% (n=23) indicated that a 16F curved-tip silicone catheter would be their first choice in managing a patient with BPO, followed by a suprapubic catheter (SPC) (20%, n=12) if this failed. SPC would be the first-line option for patients with a urethral stricture for 67% (n=40) consultants, and for those with meatal stenosis, 60% would use a meatal dilator followed by SPC (22%, n=13) if this failed.

Although there are general trends in preference towards managing a patient who is difficult to catheterize with AUR, there still remains considerable variation in practice due to lack of evidence in this area. We would recommend further multicentre data determining guidelines for best practice.

C-reactive protein (CRP) is a serum marker of systemic inflammation which has been suggested to predict need for emergent surgical intervention in patients with acute renal colic at a value of > 28 mg/l on admission.¹ We aimed to determine if this applied to our patients.

We prospectively collected data from all patients admitted with symptomatic urolithiasis, confirmed by CT-KUB, over three months. Fifty-nine patients were included; however, four were excluded because of co-morbidites which could influence CRP, or recent urological surgery, giving N = 55, age 50.0±14.6 years (mean±SD), M:F 40:15. The decision to proceed to intervention was made by each patient’s clinical team and not by the authors; however, there was no blinding to CRP.

A total of 24 of 55 patients required intervention on their index admission (22 retrograde ureteric stent, one nephrostomy, one ureteroscopic stone extraction), and 31 were managed conservatively. Those undergoing intervention had higher CRP on admission (mean 16.3 vs 9.4 mg/l, p = 0.06) and higher maximum CRP (mean 94.7 vs 25.7 mg/l, p < 0.001) than those managed conservatively. Nineteen (79%) of those requiring intervention had CRP < 28 mg/l on admission. There were no deaths, no intensive care admissions and all were discharged to outpatient follow-up.

Rising CRP during admission is a strong predictor of the need for emergency surgical intervention in patients with acute renal colic; however, CRP at admission is less useful.

Self-inserted urethral foreign bodies are relatively uncommon with few cases reported in the literature. Urethral sounding may result in a retained urethral foreign body commonly occurring in men as a form of masturbation. We present a retrospective case review from a single facility over an eight-month period; discuss the limited literature available rationale and management of self-inserted urethral foreign bodies.

In an 8-month period of time, there were eight reported cases of intentional self-inserted urethral foreign bodies, involving three male patients. The patient characteristics varied in age, race, and type of foreign body. The reasons for placement also varied, with sexual gratification being most common. All three patients had a diagnosis of schizophrenia. Diagnosis was made using clinical history, physical examination, imaging studies, and confirmation done with endoscopic visualization of the foreign body.

All eight cases were successfully treated via minimally-invasive procedures, either with endoscopic removal or by manual expression of the foreign body out of the urethra. None of the eight required open surgery, and most were treated successfully at the bedside in the emergency room. Only two of the cases required endoscopic removal under anesthesia. After removal of the foreign bodies, all of the patients were able void without difficulty, and also underwent psychiatric evaluation prior to discharge.

Urethral foreign bodies can be a result of sexual foreplay in the form of urethral sounding. It has been reported that 10% of 2122 men surveyed admitted to recreational urethral sounding. Common motivations were sexual or erotic in nature. Risky behavior including substance abuse was also reported. Psychiatric disorders have also been reported and psychiatric evaluation is recommended in all cases. A minimally invasive approach should always be attempted. Although rarely reported in the literature, self-inserted urethral foreign bodies should be on the differential in a patient with appropriate symptoms. This is especially true if the patient has a history of substance abuse, psychiatric illness, mental retardation or dementia.

To determine if the practice of active surveillance for prostate cancer (PCa) at the District General Hospital (DGH) level produces outcomes in keeping with those published from clinical trials.

A cohort of 47 patients started on active surveillance for prostate cancer in 2002–2003.

Retrospective review of case notes, electronic records and the regional cancer register.

This cohort of patients had significantly higher disease-specific mortality and greater progression to palliative forms of management compared to previously published studies.

The implementation of AS in routine clinical practice may be inconsistent, potentially leading to compromised patient outcomes.

Laparoscopy allows minimally invasive approaches for procedures traditionally performed openly, with associated lower morbidity. Nephron-sparing surgery (NSS) is mostly regarded as an open procedure because laparoscopic partial nephrectomy (LPN) is technically challenging. We evaluated our centre’s experience with LPN and open partial nephrectomy (OPN).

All patients over five years (2005–2010) undergoing NSS were identified retrospectively from our operating room management information system. Case notes, diagnostic and post-operative surveillance imaging were reviewed. Post-operative morbidity, histopathology and serum full blood count and urea and electrolyte reports were recorded.

A total of 97 OPNs and 23 LPNs were performed. Median length of stay was six days for OPNs and three days for LPNs (p = 0.005). Mean drop in haemoglobin (Hb) was 2.6 g/dl for both OPNs and LPNs. No significant difference in transfusion rates was observed. Median warm ischaemia time (WIT) for OPNs was 14 minutes and 32 minutes for LPNs (p < 0.0001). No significant difference was seen in changes from baseline serum creatinine when comparing OPNs with LPNs at day 1 (p = 0.7572) and at 12 months (p = 0.7406) post-operatively. Surgical margins were positive in 20 (21.5%) OPNs and negative in all LPNs (p = 0.038). One patient developed local recurrence following OPN (clear margins) and two patients developed distant metastases.

Benefits of LPN include shorter hospital stay and satisfactory long-term preservation of renal function, despite longer WITs. This demonstrates the benefits of LPNs in patients with single exophytic renal tumours performed by highly experienced, regionally selected laparoscopists.

The objective of this article is to determine retrospectively if a one-stop clinic for all new urology referrals improved the efficiency and quality of our outpatient pathway. We considered any improvement in productivity (e.g. waiting times) to indicate improved efficiency as resources were not increased. We considered any improvement in the level and continuity of specialist care to indicate improved quality as these factors have both been associated with measures of quality such as patient satisfaction.

Quality and efficiency markers were recorded and compared for 100 consecutive urology referrals from 1 October before (2010) and after (2011) introduction of the clinic. Efficiency markers recorded were waiting times, discharge rate, number of dictated letters and clinic attendance. Quality markers recorded were grade and continuity of specialist care.

The new appointment wait dropped from seven to two weeks. The commonest tests (flexible cystoscopy and ultrasound) were virtually all completed at first attendance. Median hospital visits before diagnosis dropped from two to one (p < 0.001). The discharge rate rose from 5/100 to 19/100 (p < 0.001). More patients (72/100 versus 42/100) were seen by a consultant and more cystoscopies (23/25 (92%) versus 1/28 (3.3%)) were performed by the urologist requesting them (p < 0.0001). The median number of dictated letters per diagnosis dropped from three to two in the one-stop clinic (p = 0.002).

The one-stop clinic significantly improved efficiency and quality markers for all new referrals, thereby improving access and reducing inequality. The clinic was inexpensive to introduce, and wider adoption of similar clinics could improve access to urological care.

The objective of this article is to obtain up-to-date epidemiological statistics of bladder cancer in England.

We collected incidence from the National Cancer Data Repository (NCDR), survival from the national Cancer Information System (CIS), ethnicity information from the Hospital Episode Statistics (HES), mortality and smoking rates from the Office for National Statistics (ONS).

Incidence of bladder cancer has fallen continuously. Mortality has reduced less, leading to worsening survival. Bladder cancer mainly affects men, the most deprived, and the elderly. The gender gap is decreasing, and the deprivation gap is unchanged. Mortality is unchanged in the youngest, oldest and least deprived females. Mortality has recently increased in the oldest males. The highest incidence and mortality is found in industrial areas. This study is limited by i) its retrospective design using existing databases, allowing identification of associations and statistical differences, but not causation; and ii) very restricted ethnicity data.

Reductions in bladder cancer incidence and mortality in England coincide with a decrease in high-risk occupations and public health measures to reduce smoking. Some risk factors in modern living may as yet be unidentified. It remains paramount to ensure equity of access and treatment regardless of gender, age, region and social deprivation to further improve mortality.

There is considerable challenge in transmitting the complicated information contained in the Prostate Cancer Risk Management (PCRM) programme in the primary care setting.1 The practices surrounding requesting of PSA should be clearly understood by both GP and patient before requesting this investigation, and in order to further understand the needs and requirements of primary care practitioners in this regard we undertook an audit comparing practices in the Avon region of the Southwest of England compared to the guidelines of the PCRM programme.¹

Our study identified a consistent year-on-year increase in PSA requests over the study period across all age categories and regions of the southwest of England.

Questionnaire review of practices surrounding the PCRM programme revealed overall good practice but with space for improvement surrounding advice regarding the limitations of prostate biopsy and the relevance of testing in the elderly.

Despite requesting practices generally conforming to NICE guidelines, nearly half of all abnormal primary-care PSA tests are repeated. Requests in some cases may fall short of best practice.

Patient information leaflets (PILs) are commonly used to improve the understanding of conditions and treatments. The Flesch-Kincaid Grade Level (FKGL) is a test used to evaluate the readability of a text with the score corresponding to the grade level of a student in the United States. The objective of our study was to assess the readability of PILs produced by the British Association of Urological Surgeons (BAUS), patient.co.uk and the American Urological Association (AUA).

All PILs from the BAUS and AUA websites and urology-related PILs on the patient.co.uk site were assessed. PILs were individually analysed to derive the word count, number of characters per word and the FKGL (readability score). The mean values from each source were compared.

Patient.co.uk PILs were significantly the most readable on average with an FKGL of 8.09 (p value < 0.0001). The mean FKGL of PILs by BAUS was 11.61, which was insignificantly lower than that of AUA (mean 11.94; p value 0.059). Overall, only 54 (16.4%) of all 330 PILs had an FKGL less than 10, the readability level for a 15-year-old.

Although PILs produced by these large organisations may be easily readable by well-educated adults, comprehension may be difficult for a significant proportion of the United Kingdom adult population.

The objective of this paper is to assess the ability of Prostate HistoScanning^TM (PHS) to accurately identify tumour volume, index lesion characteristics and pathological stage. PHS is a novel technology employing transrectal ultrasound scanning and software analysis of radiofrequency data to produce signatures for benign and cancerous tissues. Recent reports have suggested PHS is capable of characterising the index cancer lesion and disease multifocality and detecting extraprostatic extension (EPE).

The index test was preoperative PHS on patients undergoing radical prostatectomy (RP). The reference test was the whole-mount pathological analysis of the RP specimen. PHS analysis estimated total tumour volumes, tumour volumes by prostate sextant, the locations and volumes of index lesions, and the presence and location of EPE.

There was no correlation between PHS and histology total tumour volume estimates (Pearson coefficient –0.099), despite accounting for specimen fixation shrinkage (Pearson coefficient –0.070), nor among 144 prostate sextants in 24 patients (Pearson coefficient 0.14). Sensitivity and specificity of PHS in detecting foci > 0.2 ml were 63% and 53%, respectively; and 37% and 71%, respectively, for foci > 0.5 ml. Pearson correlation coefficient for index lesion volumes identified at pathology vs PHS was 0.065. PHS failed to locate accurately index lesion and pathological EPE.

PHS fails to identify total tumour volumes, tumour volumes prostate sextant, index lesion volumes and locations, and presence and location of EPE compared to RP pathology. PHS appears unsuitable for routine diagnostic clinical use in prostate cancer.

Laparoscopic radical prostatectomy (LRP) is an established treatment option for patients with prostate cancer in selected centres with appropriate expertise. The goal of LRP is to achieve excellent cancer control whilst attempting to preserve normal urinary continence and erectile function. We studied our single-centre experience evaluating the oncological outcomes in patients undergoing LRP.

Three hundred and six patients underwent LRP between 2005 and 2011. Patients were divided into D’Amico low-, intermediate- and high-risk groups.

The mean age was 61.9 years (range 46–74 years). The two most important factors predictive of positive surgical margins (PSMs) at LRP were the initial prostate-specific antigen (PSA) level and tumour stage at diagnosis. The overall PSM rate was 26.7%. For low D’Amico-risk patients, the PSM was 24.5%, intermediate-risk patients had a PSM of 32.4%, while high-risk patients had a PSM of 13.6%; 6.4% (nine of 139) of patients sampled had evidence of lymph node-positive disease. Five-year PSA progression-free survival rates were 83% in low-risk patients, 57% in intermediate-risk and 41% in high-risk patients.

LRP offers good oncological outcomes in the low- and intermediate-risk groups with low incidence of biochemical recurrence for patients with localised disease. Our high-risk group has a low incidence of PSM and a five-year PSA progression-free survival rate of 41%. Patients with high-risk, but non-metastatic, prostate cancer can be offered a minimally invasive prostatectomy in an experienced centre.

Recent changes in practice standards and remuneration to UK Trusts have been refined to penalise institutions for patient readmission within 30 days of discharge. The purpose of this study was to determine if the target rate of less than 6.5% was attained within the setting of a district general hospital (DGH) and also to comment on readmission trends.

A retrospective study was performed over 12 months examining all unplanned readmissions to hospital 30 days following discharge from Urology. Elective as well as emergency cases were audited.

A total of 4124 patients were treated and discharged by the department over 12 months. One hundred and eighty-four (4.4%) patients were readmitted: 93 (51%) patients following acute presentations and 91 (49%) following elective procedures. The commonest causes for unplanned readmission were haematuria, 29 cases (16%), acute urinary retention, 28 cases (15%) and ureteric colic, 25 cases (14%). Readmission rates following flexible cystoscopy and TRUS biopsy were 1% and 3%, respectively. Only six of 70 patients (9%) were readmitted following TURP. Five (3%) of the 184 readmissions required a second procedure.

Our department met the predetermined standard in achieving an unplanned readmission rate of less than 6.5%. This study also highlighted the need for discharge policies for common acute presentations.

To determine the role of staging pelvic magnetic resonance imaging (MRI) in men with intermediate risk prostate cancer.

We identified all patients diagnosed with intermediate risk (NICE definition: PSA 10–20 ng/ml, or Gleason score 7, or clinical stage T2b/T2c) prostate cancer between 1st January 2007 and 31st December 2008. Through retrospective case note review, we determined the number of patients who had undergone a pelvic MRI and whether such an investigation had altered the patient’s management by increasing tumour stage.

A total of 222 men (mean age 66 years; range: 48–88) were diagnosed with intermediate risk prostate cancer during our study period. The mean PSA was 11.8 ng/ml (range: 3–20 ng/ml). Of these, 112 (50.5%) underwent an MRI. Overall, in 25/112 (22.3%) patients, pelvic MRI findings impacted significantly upon patient treatment by demonstrating either extra-prostatic extension of cancer, lymph node involvement or bone metastases.

Our retrospective study has demonstrated that a pelvic MRI in men diagnosed with intermediate risk prostate cancer may influence treatment decision in approximately a quarter of patients. Routine pelvic MRI is indicated in men with intermediate risk prostate cancer where radical treatment is contemplated.

To evaluate whether "cross-leg lithotomy" (CL) is better position for digital rectal examination (DRE) than left lateral (LL) position from urologist and patient’s perspective.

Two urologists performed DRE in 120 patients in LL and CL positions. Each patient was randomised, sequentially examined in both positions and responses were objectively assessed using a questionnaire and statistically analysed.

Men found DRE uncomfortable [LL (81.7%), CL (85.0%)] and embarrassing [LL: (81.7%), CL (78.3%)] in both the positions. DRE was painful [LL (11.7%), CL (8.3%)] with a mean pain score of 1.92 and 1.85 respectively. Patient apprehension regarding pain was significantly higher [LL (62.5%) vs. CL (21.7%), p < 0.001] in LL position. Overall, men preferred CL to LL position [CL (78.3%), LL (21.75%), p < 0.001] for DRE. From urologist perspective, the extent of prostate felt in CL position was significantly higher (CL: 11.15 ± 1.96/12 vs. LL: 9.25 ± 2.50/12, p < 0.001). Withdrawal response was significantly higher in LL and urologist had to sit down to perform DRE in LL position.

Men preferred CL to LL position for DRE and CL allowed more complete examination of the prostate from urologist perspective. CL position is a better alternative for performing DRE of the prostate.