Impact of untreated preoperative asymptomatic bacteriuria in patients undergoing holmium laser enucleation of prostate.

INTRODUCTION: Treatment of preoperative asymptomatic bacteriuria (ASB) before endoscopic surgery is recommended by European Association of Urology (EAU) guidelines. United Kingdom (UK) practice varies, however, owing to the historical nature of the evidence behind the guidelines, risk of increased antimicrobial resistance, the paradoxical view that treatment of ASB leads to increased infection and inefficiencies in rescheduling. We do not routinely treat ASB in our practice before holmium enucleation of the prostate (HoLEP). To determine the safety of this, we examined our experience focusing on the infective complications. METHODS: Retrospective data collection was performed on consecutive patients undergoing HoLEP between 2015 and 2020. Indication, preoperative urine cultures and infective complications were recorded. No patients were pretreated with oral antibiotics. All patients received intravenous antibiotics on induction and routine postoperative oral antibiotics at the surgeon's discretion. RESULTS: Some 443 patients were studied. No urosepsis occurred in the 125 patients with ASB compared with 2 of 318 patients (0.6%) with no growth on preoperative urine culture. Twenty-nine (7%) patients were treated with oral antibiotics for symptomatic postoperative complications (urinary tract infection without fever, epididymitis and haematuria). ASB did not predict for infective complications (urosepsis odds ratio [OR]: 0.50 p=0.66; oral antibiotics OR: 0.97 p=0.93). CONCLUSION: Not treating ASB before a HoLEP procedure is safe. This supports the judicious use of antimicrobials preoperatively. Other modalities of endoscopic surgery should be similarly assessed.

Day-case holmium laser enucleation of the prostate: feasibility, safety and predictive factors.

Introduction Transurethral resection of the prostate has remained the most common operation for bladder outlet obstruction in the UK, but it is associated with potential morbidity and median two-day length of hospital stay. Holmium laser enucleation of the prostate (HoLEP) provides an alternative procedure. Provision of day-case HoLEP would improve patient care through increased efficiency. We assessed the feasibility and safety of day-case HoLEP and examined predictive factors for increased length of hospital stay. Materials and methods Patients presenting for HoLEP by a single surgeon from September 2013 to September 2016 were considered for day-case surgery. Patients were discharged following assessment by the operating surgeon and met predetermined discharge criteria. Factors contributing to day-case success were identified. Results In total, 210 patients (mean age 70.3 ± 8.5 years) underwent HoLEP, with 74 (35.3%) discharged as true day-cases and a further 84 (40.0%) discharged within 23 hours. Readmission rate was 5.5%, with all complications Clavien-Dindo grade I or II. Factors associated with successful day-case operation included low-volume prostates (≤ 40 g) (odds ratio, OR, 3.097, 95% confidence interval, CI, 1.619-5.924, P = 0.0001) and morning surgical lists (OR 6.124, 95% CI 2.526-14.845, p<0.001). Discussion and conclusion Day-case HoLEP is both feasible and safe, with low readmission rates. Two factors were significantly associated with successful day-case surgery: small volume prostate and morning theatre lists. Addressing these factors through preoperative planning can improve day-case surgery rates and improve bed throughput.

Introducing holmium laser enucleation of the prostate alongside transurethral resection of the prostate improves outcomes of each procedure.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) is recognised as an alternative to transurethral resection of the prostate (TURP). HoLEP has been demonstrated to be at least as effective as TURP with less morbidity but its introduction to practice has been limited in part by the learning curve of a novel procedure. This study examined the effects of introducing HoLEP alongside an established practice of TURP on early morbidity and length of hospital stay (LOS). METHODS: A retrospective review of all patients who underwent HoLEP and TURP between April 2007 and July 2011 was undertaken. HoLEP was introduced in April 2008; patients undergoing TURP before this were considered as a historical control group. Data were collected concerning resection/enucleation weight, blood transfusions and LOS. RESULTS: Overall, 772 patients underwent HoLEP or TURP within the 52-month study period: 164 underwent TURP prior to the introduction of HoLEP (TURP-A), 425 had TURP after the introduction of HoLEP (TURP-B) and 183 underwent HoLEP. The mean removed weight was 24g (standard deviation [SD]: 21g) for TURP-A, 19g for TURP-B (SD: 16g) and 38g (SD: 32g) for HoLEP (p<0.005). Blood transfusion rates were 5.5%, 2.2% and 1.6% for the TURP-A, TURP-B and HoLEP groups respectively (p<0.05). For TURP-A patients, the mean LOS was 5.6 days (SD: 3.5 days, 95% confidence interval [CI]: 5.3-6.0 days). The mean LOS for TURP-B patients was 4.4 days (SD: 4.4 days, 95% CI: 4.2-4.8 days). HoLEP patients had a mean LOS of 3.0 days (SD: 3.0 days, 95% CI: 2.6-3.4 days). CONCLUSIONS: The introduction of HoLEP alongside TURP is associated with lower rates of blood transfusion and shorter LOS for all patients. This is likely to be due to the use of HoLEP rather than TURP in patients with larger prostates, who are more likely to have complications.

Ureteric bupivicaine infusion for loin pain haematuria syndrome.

INTRODUCTION: Loin pain haematuria syndrome is a common problem with complications including opiate dependence. Morbidity treatments include intra-ureteric capsaicin infusion, nephrectomy, autotransplantation and nephrolysis. We explored the use of flexible cystoscopic infusion of intra-ureteric bupivicaine. PATIENTS AND METHODS: Patients presenting with chronic loin pain underwent urological and nephrological evaluation. Bupivicaine (0.5%, 20 ml) was infused via an intra-ureteric catheter under flexible cystoscopic guidance. Repeat infusions were offered if indicated. RESULTS: Sixteen of 17 patients with 1-year follow-up responded and were satisfied. Twelve of these required repeat infusions (mean, 2.9 infusions). The procedures were well tolerated by all patients without adverse effects. CONCLUSIONS: Intra-ureteric bupivicaine infusion has a place in the management of patients with chronic renal pain. It offers a minimally invasive alternative to other treatments. This procedure warrants further investigation within a randomised, controlled trial setting.

An update on localised prostate cancer.

Prostate cancer remains a most intriguing condition, which poses unique challenges. On reviewing recent literature on localised disease (confined within the capsule T1 or T2, N0, M0), it would seem that it is over treated, resulting in significant morbidity. We now have strong evidence, however, that there can be mortality associated with 'watchful waiting'. Clinicians should, therefore, aim to identify men at risk of progression in order that they should be treated effectively with minimal adverse effects. In this paper, we report on recent developments in the expanding array of management options available.

Permanent prostate brachytherapy: a century of technical evolution.

PURPOSE: To summarise the practical aspects of the development of techniques of interstitial permanent prostate brachytherapy (PPB) implantation. Prostate brachytherapy dates back to Pasteau's publication in 1913 describing the insertion of a radium capsule into the prostatic urethra to treat carcinoma of the prostate. Various implantation methods were employed but with unsatisfactory results until the development of the transrectal ultrasound in the 1980s. The subsequent two-stage Seattle technique allowed for a planned homogenous distribution of radioactive sources throughout the gland resulting in biochemical control comparable to surgical and external beam radiotherapy series. With the advent of advanced computer software and improved imaging, the technique has developed accordingly to a single stage procedure with on-table dosimetric assessment. The principles of targeting dose to the prostate while avoiding surrounding organs at risk remain as relevant today as nearly a century ago. There is an array of techniques to consider for the novice PPB provider. Whether the evolution of PPB techniques will translate into improved biochemical control is yet to be seen.

Using combined x-ray and MR imaging for prostate I-125 post-implant dosimetry: phantom validation and preliminary patient work.

Post-implantation dosimetry is an important element of permanent prostate brachytherapy. This process relies on accurate localization of implanted seeds relative to the surrounding organs. Localization is commonly achieved using CT images, which provide suboptimal prostate delineation. On MR images, conversely, prostate visualization is excellent but seed localization is imprecise due to distortion and susceptibility artefacts. This paper presents a method based on fused MR and x-ray images acquired consecutively in a combined x-ray and MRI interventional suite. The method does not rely on any explicit registration step but on a combination of system calibration and tracking. A purpose-built phantom was imaged using MRI and x-rays, and the images were successfully registered. The same protocol was applied to three patients where combining soft tissue information from MRI with stereoscopic seed identification from x-ray imaging facilitated post-implant dosimetry. This technique has the potential to improve on dosimetry using either CT or MR alone.

Iron-deficiency anaemia and delay in the diagnosis of colorectal cancer.

AIMS: Iron-deficiency anaemia (IDA) is a recognized complication of colorectal cancer (CRC) especially with right-sided tumours, and failure to investigate the anaemia in older patients may lead to a delay in diagnosis. The aims of this study were to establish the proportion of patients with CRC shown to have an IDA for more than six months before diagnosis and to establish the proportion of patients with IDA who subsequently prove to have CRC. METHODS: All patients presenting with confirmed CRC in a health district (catchment population 280000) in the 4 years 1996-9 were identified from the pathology database after ethical approval. The criteria for IDA were haemoglobin (Hb) < 10.1 g/dl plus mean corpuscular volume < 78 fl and/or mean corpuscular Hb concentration < 32 g/dl. The haematology data-base serving the same population was searched for evidence of: 1. IDA at diagnosis of CRC; 2. IDA more than 6 months and more than one year before the diagnosis of CRC; 3. The number of haematology referrals per annum in women over 55 and men over 50 years of age meeting the criteria for IDA. RESULTS: Of 440 patients with colorectal cancer, 166 (38%) had IDA at diagnosis and of the latter 54 (12%) were known to have IDA for more than six months before diagnosis and 26 (6%) had IDA more than one year before diagnosis. IDA was more common in right sided tumours (65%) than in those arising in the left side of the colon and rectum (26%). The annual incidence of IDA in the sampled population was 1366 in the stated age group. CONCLUSION: The investigation of iron-deficiency anaemia in older patients is important but in order to detect 26 patients with colorectal cancer a year earlier, the investigation of approximately 5000 patients would be required--a detection rate of less than 1%.