Voiding efficiency: a predictor of failed trial off catheter after transurethral resection of prostate.

PURPOSE: Following transurethral resection of the prostate (TURP), there is no clear recommendation for the catheter duration, and objective criteria are needed to determine appropriate time for trial off catheter. Current study is aimed to identify the high-risk patients for failed trial off catheter and the association with preoperative voiding efficiency with postoperative failed trial without catheter. METHODOLOGY: This is cross-sectional single institutional study. All eligible patients who underwent TURP were followed preoperatively for symptoms and workup, including voiding efficiency based on ultrasound findings, intraoperatively for resection parameters, and postoperatively for a trial off a catheter. All the findings were documented, and the data were analyzed on SPSS(TM) 22. Demographic variables were calculated in the form of frequency and percentages. The association of voiding efficiency with failed trials off catheters was checked through Chi-square and binary logistic regression analysis. RESULTS: 132 patients were included in the study. The mean voiding efficiency was 57.5%. Based on voiding efficiency cut off, of 50%, patients were divided into two groups. The association between voiding efficiency and failed trials off catheters was not found to be statistically significant, with a p value of 0.79. Only prevoid volume, postvoid volume, duration of symptoms, and upper tract damage were found to be statistically significant predictors of failed trial off catheter, with a p value of < 0.05.

Urdu Translation and Linguistic Validation of the Bladder Cancer Index Questionnaire.

Background This study aimed to translate the Bladder Cancer Index (BCI) questionnaire to Urdu and validate it to assess the quality of life of patients with bladder cancer. Material and methods After forward and backward translation of the BCI questionnaire into Urdu, content validity was calculated using the content validity index (CVI) based on input from five health experts regarding the clarity and relevance of the questionnaire. Construct validity was measured by comparing the inter-scale domains and subdomains of BCI and by comparing BCI with Short Form 36 (SF-36) using correlations. For assessment of reliability, Cronbach's alpha was calculated to measure internal consistency and for test-retest reliability, the questionnaire was re-administered four weeks later and the correlation of responses at baseline and at a four-week time point was evaluated. Results The questionnaire has good content validity for clarity (0.91) and relevance (0.87). The construct validity of BCI was also adequately displayed by moderate to high correlation between different subdomains of BCI (Pearson's r: urinary - 0.62, bowel - 0.78, sexual function - 0.43) and low to moderate correlation between responses of BCI compared with SF-36 (Pearson's r mostly >0.45). Test-retest reliability was excellent (Pearson's r 0.90-0.98), and there was good internal consistency (Cronbach's alpha 0.79-0.92) in the different domains of the questionnaire. Conclusion The Urdu-translated BCI is a valid and reliable tool to measure the impact of bladder cancer on the quality of life of patients.

Access and Fluoroscopy Time Difference in Patients Undergoing Prone Percutaneous Nephrolithotomy (PCNL) With Ureteric Catheter Placement in Supine Versus Lithotomy Position.

OBJECTIVE: To compare the operative and fluoroscopy time in two different methods of ureteral stent insertion before prone percutaneous nephrolithotomy (PCNL). MATERIALS AND METHOD: Over 12 months, 124 patients with urolithiasis who went through prone PCNL were included in our study. All the patients had kidney stones and were divided into two groups based on the method of ureteral catheter insertion. This was done with the help of flexible or rigid cystoscopy in to group A and group B, respectively. Both groups had an equal number of patients, i.e., 62. The main outcome variables assessed were access time (from intubation to placement of access sheath) and fluoroscopy time during access. RESULTS: The categorical variables (age, gender, site of the stone) between the two groups were comparable. The access time in groups A and B were 48±4.30 and 77±10 minutes, respectively. The fluoroscopy times in groups A and B were 52±14.63 and 116±47.77 seconds, respectively. A statistically significant difference (p-value < 0.05) was observed for both the access and fluoroscopy time. None of the patients in either of the groups had a misplaced ureteral catheter requiring repositioning. CONCLUSION: Flexible cystoscope-assisted insertion of ureteral catheter prior to PCNL significantly reduces operative time, fluoroscopy time, and consequently radiation exposure during PCNL.

Utility of Post-ureteroscopy Lesion Scale (PULS) in Per-operative Decision-Making for the Need of Double J Stent.

OBJECTIVES: To assess the applicability of the post ureteroscopy lesion scale (PULS) as an objective measure to define the need for double J (DJ) stent placement after ureterorenoscopy (URS). METHODS: Between June and December 2020 a cross-sectional study was conducted at a university hospital. All patients fulfilling the inclusion criteria undergoing URS for renal or ureteric stones were included. At the completion of procedures, the ureter was carefully inspected for injury. Lesions were classified using PULS scoring by the operating surgeon, another consultant, and the resident. The primary outcome was to validate the PULS score against the surgeon's decision for postoperative stenting and to assess its reliability.  Results: A total of 126 patients were included with a mean age of 43.42±15.3 years. The mean stone size was 9.42±3.60mm. DJ stents were placed in 81 cases (62.4%). All of the 38 (30.1%) patients with a significant residual fragment were stented. Ureteric injury of grade 1 was observed in 66 patients (52.3%), of which 22 (33%) had DJ stenting. PULS grade 2 injuries were observed in 22 patients (17.4%), and 95% were stented. With a PULS score of > 2 almost all (97.8%) were stented. Inter-rater reliability of PULS scoring was high among the consultants (Kendall's W=0.89, p<0.005). CONCLUSION: DJ stent placement was observed in 33%, 95%, and 98% of patients with PULS grade 1, 2, and >2 injury respectively. In patients with no residual fragment, the need for DJ stenting can be objectively defined using the PULS scoring system as it has high specificity and good interrater reliability.

Perception of Dietary Influences on Renal Stone Formation Among the General Population.

Introduction Urolithiasis is a common disorder worldwide with an increasing prevalence and high recurrence rate. This makes preventive measures like dietary modification an essential part of patient care. This study focuses on gauging the perception of dietary habits favoring kidney stone formation. Materials and methods A cross-sectional questionnaire-based study was conducted at Aga Khan University, Karachi, Pakistan. For nine food items and 14 beverages, respondents chose one of four options with regards to their relationship with stone formation, i.e. "increasing", "decreasing", "no effect", and "do not know". Responses were matched against evidence from the literature to generate correct and incorrect responses, thereby gauging perception for individual items.  Results Seven hundred and three participants including 69 (9.6%) with a prior history of kidney stones, were recruited for the study. Participants with a personal history of kidney stone disease were older (odds ratio {OR}: 1.042 CI 1.020-1.064) with a significantly higher family history of stones (OR: 2.151 CI: 1.472-3.144). The majority were managed medically (87%) but never received dietary counseling (57%). Water, soft drinks, and tomatoes were the only three items out of 23 that were correctly identified by >50% of the participants with regards to their effect on stone formation. Responses did not differ significantly between those with stone disease and those without. Conclusion There is a lack of awareness among the general population, including individuals with a prior history of kidney stones regarding dietary prevention of kidney stone disease. This demonstrates a lack of existing dietary counseling thus necessitating the need for incorporating it at a mass level.

Translation and Validation of Bristol Female Lower Urinary Tract Symptoms Questionnaire for Urinary Incontinence in Urdu.

Background In this study, we aimed to translate and validate the 19-item version of the Bristol Female Lower Urinary Tract Symptoms (Bristol FLUTS) Questionnaire in Urdu among women experiencing urinary incontinence at a tertiary care hospital in Karachi, Pakistan. Methodology A cross-sectional validation study was conducted in the urology clinic at Aga Khan University Hospital, Karachi, Pakistan, between April and September 2021. After forward and backward translation of the Bristol FLUTS questionnaire, content validation was done by six experts, followed by the administration of the questionnaire to 10 respondents in the pilot phase of the study. In total, 207 participants were approached to fill the final version of the translated questionnaire. Overall, 188 respondents filled out the questionnaire, including 94 women with urinary incontinence and 94 women from the community to test construct validity. Finally, 30 women with urinary incontinence were asked to fill the form again two weeks later to determine test-retest reliability. Cronbach's alpha was employed to assess the internal consistency of the questionnaire. Results The questionnaire displayed good content validity for reliability (content validity index: 0.84) and clarity (0.89). The scores reported by cases were significantly higher than the controls in all but the sexual function domain, suggesting good construct validity. Cronbach's alpha of 0.81 signified good internal consistency, and a Pearson's coefficient of 0.993 (p < 0.001) comparing responses at baseline and after two weeks indicated good test-retest reliability. Conclusions The Urdu translation of the Bristol FLUTS is a valid and reliable questionnaire that can be used in the clinical setting.

An Assessment of the Impact of Flow Disruptions on Mental Workload and Performance of Surgeons During Percutaneous Nephrolithotomy.

Objective The aim of this study was to assess the impact of intraoperative disruptions on surgeons' workload and performance during percutaneous nephrolithotomy (PCNL). Materials and methods A structured and standardized tool was used to identify disruptions and interferences that occurred during 33 PCNL procedures. The surgical steps during PCNL were divided into four phases: ureteric catheter placement (phase I), puncture and tract dilation (phase II), intra-calyceal navigation and stone fragmentation (phase III), and tube placement (phase IV). Surgeons' workload was evaluated using a validated tool: Surgery Task Load Index (SURG-TLX), and correlated with the mean observed intraoperative disruptions. All operating team members evaluated the teamwork immediately after the procedure. Statistical analysis was performed using SPSS Statistics version 22 (IBM, Armonk, NY). Results A total of 1,897 disturbances were observed, with an average of 57.48 ± 16.36 disruptions per case. The largest number of disruptions occurred during phase III of PCNL (32.06 ± 14.12). The most common cause of the disruption was people entering or exiting the operating room (OR) (29.1 ± 10.03/case), followed by the ringing of phones or pagers (6.42 ± 2.4). The mean observed intraoperative disruptions were significantly associated with the operating surgeon's mental workload, and it had a significant impact on all domains of surgeons' mental workload as measured by SURG-TLX. Compared to other team members, surgeons' assistants experienced an inferior sense of teamwork (r=-0.433; p=0.012). Conclusion Significant intraoperative disruptions were observed during PCNL. They were observed to directly correlate with the surgeon's workload and had a detrimental effect on teamwork. Improving OR dynamics by reducing unnecessary disruptions would help establish an efficient and smooth surgical work environment for safe surgical care.

Non-Invasive Predictors of Response to Tamsulosin for Benign Prostatic Obstruction.

Objectives To identify non-invasive predictors of response to tamsulosin 0.4 mg in patients with benign prostatic obstruction (BPO). Methods Males ≥ 50 years of age with lower urinary tract symptoms (LUTS) suggestive of BPO for over three months were included in the study. We assessed change in the mean International Prostate Symptom Score (IPSS) and maximum flow rate (Qmax) after six weeks of medical therapy. Clinical and uroflowmetry parameters were compared between two groups of patients with >25% vs. <25% change in the IPSS after treatment. Pre- and post-treatment post-void residue (PVR), Qmax, and IPSS were compared by independent t-test, univariate/multivariate regression analysis. Results A total of 121 patients were included. At presentation, the mean prostate size was 35.7±12.2 grams and the mean IPSS was 16.3 ± 4.8. Improvement in the mean IPSS was 7.83, with more marked improvement in storage compared to voiding LUTS (5.26 vs. 2.57). Majority (58%) had a quality of life (QoL) score of 4-5 at presentation whereas after 6-weeks of medication (83.5%) had a QoL score of 0-2. Treatment failure was noted in 11 (9.1%) patients. IPSS was higher and Qmax was lower at the time of presentation in patients who had <25% improvement. However, the two groups were identical on the basis of demographic and other factors (BMI, age, prostate size, PVR). Conclusion Moderate LUTS secondary to BPO responds favourably to alpha-blocker (tamsulosin 0.4 mg) treatment. Uroflowmetry (UFM) parameters, that is, Qmax and IPSS are important factors in predicting short-term response to medical therapy.

Validation of a Bench-Top Training Model for Retrograde Intrarenal Surgery.

OBJECTIVE: To validate the in-house built Styrofoam box bench-top training model for retrograde intrarenal surgery (RIRS). MATERIALS AND METHODS: This study was performed in the setting of a half-day RIRS course. During the course, participants performed RIRS on a locally built bench-top model. We recruited 26 participants, comprising 20 trainees and 6 experts. Trainees and experts were asked to fill a self-administered questionnaire assessing various components of RIRS to assess the face and content validity. For construct validity, experts using Objective Structured Assessment of Technical Skills (OSATS) rated trainees and the mean OSATS score of junior versus senior residents was compared. RESULTS: As per trainees, the model was 86% (4.3/5) realistic, which was backed by experts who found this model to be 87.6% (4.38/5) realistic. The overall face validity of the model was 86.4% (4.32/5). The overall content validity of this model was 83.4% (4.17/5). Majority of the participants thought that this tool is useful for learning technique (4.38 ± 0.49) and safe-conduct (4.31 ± 0.73) of the procedure. The trainees concurred that the skills acquired are transferable to the operating room (4.23 ± 0.76). However, the construct validity by comparing mean OSATS score of junior versus senior residents was 19.5 ± 3.5 and 23 ± 4.5. A p value of 0.11 could not be established. CONCLUSION: This study has demonstrated the face, content, and construct validity of the bench-top training model for RIRS. Further evaluation is necessary to compare its effectiveness against other available models to demonstrate concurrent validity.

Predicting emergency interventions in patients with acute ureteral colic using acute renal colic scoring system in a Pakistani cohort.

OBJECTIVE: To evaluate the acute renal colic score (ARC) in predicting the need of emergency intervention (EI) in patients with ureteric colic secondary to a ureteral stone. PATIENT AND METHODS: In an emergency room (ER) of a university hospital, we conducted a prospective cohort study over a period of 6 months. ARC score was calculated using four parameters, i.e., serum creatinine, total white cell count (TLC), stone length and level. Primary outcome measure was EI, which was defined as the need of endourological intervention within 48 h of presentation. ARC was calculated for each patient against the two possible outcomes, i.e., EI vs. no EI. The need of intervention was based on patient-related clinical factors and the decision of the attending urologist. RESULTS: The study included 132 patients. EI was performed in 85 patients (64.4%). URS was the most common intervention performed in 81 (95.3%) patients, followed by the a insertion of a double J stent in two (2.4%) patients for forniceal rupture and high TLC count and percutaneous nephrostomy in two (2.4%) patients for raised creatinine and TLC. All four variables in ARC score including serum creatinine (p < 0.001), TLC (p < 0.001), stone size (p < 0.001) and stone level (p < 0.001) were found to be significantly associated with need for EI. Using ROC the sensitivity and specificity of the score was 92.9% and 87.5%, respectively, with AUC of 0.93. CONCLUSIONS: ARC score is highly sensitive and specific in determining the need of EI in patients with uncomplicated ureteric colic within 48 h of initial presentation.

The Correlation Between STONE Nephrolithometry Score and Hemoglobin Drop in Patients Undergoing Percutaneous Nephrolithotomy.

Objective In this study, we aimed to determine the correlation between the STONE score [(S)ize of the stone, (T)opography or location, degree of (O)bstruction of the urinary system, (N)umber of stones, and (E)valuation of Hounsfield units] and postoperative hemoglobin drop in patients undergoing percutaneous nephrolithotomy (PCNL). Methods This was a prospective observational study and all adult patients aged 18-65 years undergoing unilateral, single-tract PCNL using 26 Ch. Amplatz sheath for renal calculi were included. The five variables of the STONE nephrolithometry score were calculated prior to the procedure. The stone-free rates were assessed on imaging at four weeks and complications were graded using the modified Clavien system. Results Of the 142 patients included, 75% were below 55 years of age. More than half of our patients were diabetic with more than 60% having a body mass index (BMI) above 25 kg/m2. The mean STONE score was 7 with 33% having a high (>9) STONE score. The mean hemoglobin drop was 1.15 +0.92 g/dL with eight patients (5.63%) requiring transfusion and one (0.7%) requiring angioembolization; one patient required readmission for observation. Complete STONE clearance was achieved with PCNL alone in 78.2% of the patients. There was a significant correlation of hemoglobin drop with the STONE score, stone size, and preoperative creatinine clearance. Patients with a hemoglobin drop of >1 g/dL had a higher STONE score and mean stone size. The overall complication rate was significantly higher (10.5%) in patients with a hemoglobin drop of >1 g/dL as compared to those with a hemoglobin drop of <1 g/dL (2.8%). Conclusion Stone complexity as measured by the STONE score correlates with post-PCNL hemoglobin drop, stone clearance, and complication rates. The STONE score may be used for preoperative counseling and to evaluate the potential need for transfusion.

The Effect of Ureteric Stenting on Female Sexual Function: A Prospective Cohort Study.

Background and objective Urolithiasis is a highly prevalent disease worldwide, with Pakistan belonging to the stone belt of Asia. The usage of the double J (DJ) stent is highly effective when it comes to the management of urolithiasis. However, studies investigating the side effects of DJ stent placement on sexual function in individuals are scarce. In this study, we aimed to assess the impact of DJ stent placement on sexual function in women. Methods After obtaining ethical approval, a prospective study was conducted at a university hospital from June 2018 to September 2019. All sexually active women requiring semi-rigid ureteroscopy (URS) or flexible URS [retrograde intrarenal surgery (RIRS)] were enrolled. Women with DJ stent placement (Group A) were compared to women who did not require DJ stent (Group B). The outcome variable was to assess temporary sexual dysfunction after DJ stent placement using the standardized Female Sexual Functionality Index (FSFI) in English or its validated vernacular version. The FSFI was completed at four weeks, and again at three months, following URS/RIRS. Results Of the 106 sexually active women initially included in the study, 69 were found to be eligible for final analysis. In Group A, the mean FSFI score at the initial presentation was 31.54 ±4.37. The mean FSFI score at four weeks was lower compared to the baseline score (0 time): 13.96 ±5.5 (p<0.05). At three months, the mean FSFI score returned to near baseline at 32.053 ±5.35 with no significant difference (p=0.65). In comparison to women in Group B, the mean FSFI score at four weeks was significantly lower in Group A (28.87 ±6.59 vs. 13.96 ±5.49; p<0.05). However, there was no significant difference between the mean FSFI scores at any of the three time points within Group B. Conclusion DJ stent insertion results in transient postoperative sexual dysfunction in women, which resolves spontaneously within a span of three months after stent removal.

The Hidden Work of Urology Residents - A Cross-Sectional Study.

BACKGROUND: In a tertiary care hospital that caters to all kinds of patients in the clinical and emergency setting, consultation is an important service provided by the urology team. Profiling the spectrum of urologic disease encountered by trainees will assist in the planning of residency curricula and is bound to improve patient outcome for procedural education. METHODS: All urologic consultation requests received over a period of three months (November 22, 2019, to February 22, 2020) were identified and recorded in a prospectively maintained consult log. Information collected for each encounter included the time, date, reason for consult, primary service and diagnosis along with the final urologic diagnosis, any urologic intervention, and basic patient demographics (gender and age). RESULTS: Over three months, a total of 568 consult requests were reviewed. Of the patients consulted for, 74% were males; the mean age was 58.45 years (SD+/-19.5 years). The most common service seeking urology consult was the Emergency Room (n=240, 42.25%). The most common reason for consultation was hematuria (n=103, 18.13%) followed by obstructive uropathy (n=98, 17.25%). The majority (n=147, 26%) of the calls were placed between mid-day and 4 pm. Of the total, 26% required immediate attention. Urologic intervention was required in 226 (39.8%). The number of consults seen by junior team members was 478 (84.14%). CONCLUSION: Hematuria and obstructive uropathy are the most common reasons for urologic consultation requests. Nearly two-thirds of the consults either required immediate attention or intervention. Most of the consults were seen by junior residents, who required elaborate training to address these common issues independently. We believe that our results will be helpful in developing a curriculum for training junior residents.

Urdu translation and validation of premature ejaculation diagnostic tool (PEDT).

OBJECTIVE: To validate an Urdu translation of premature ejaculation diagnostic tool (PEDT) by analyzing the association of this diagnostic tool with the clinical diagnosis of premature ejaculation (PE) and intravaginal ejaculatory latency time (IELT). METHODS: This cross-sectional study was conducted at the urology section of the Aga Khan University Hospital, Karachi, for six months duration, from July 2018 to December 2018. In our study 108 subjects, aged 20 to 50 years, who were in a stable sexual relationship (heterosexual) for a minimum duration of six months, were asked to fill the Urdu version of PEDT, 61 with PE and 47 without PE. RESULTS: The two groups matched for mean age, duration of relationship and education level. The duration of 1.2 (±0.5) minutes was the mean self-estimated IELT in the PE group and 3.7±0.9 minutes in patients without PE. There was a significant negative correlation of 0.6 (p-value <0.001) between the PEDT score and self-estimated IELT. The test-retest reliability for each item was found to be significant for each individual item (≥ 0.84, p-value <0.001) and 0.94 was the correlation coefficients of the total score, showing an excellent test-retest reliability. 0.93 was the Cronbach's alpha score (95% Confidence interval = 0.905 - 0.948) indicating a significant internal consistency in the Urdu version of PEDT. CONCLUSIONS: The Urdu version of PEDT is a valid tool to define and quantify PE objectively, with adequate internal consistency. This version of PEDT has a good negative correlation with self-estimated IELT and excellent correlation with clinical PE.

The impact of post PCNL tube type on blood loss and postoperative pain.

OBJECTIVE: To evaluate the impact of nephrostomy tube type on postoperative pain and blood loss following percutaneous nephrolithotomy (PCNL). METHODS: This is a prospective non-randomized study performed at Aga Khan University Hospital from July 2017 to June 2018. In this study we prospectively studied adult patients (16 to 65 years) who underwent unilateral PCNL. Patients who had nephrostomy with balloon (12Fr Foley's catheter) were compared with patients who had nephrostomy without balloon (12Fr Nelaton™ catheter). STONE Nephrolithometry score was used to assess the stone complexity. Mean pain score at six and 24 hours and mean hemoglobin drop at 24 hours was compared between two groups using independent sample t-test, p-value of <0.05 was considered significant. RESULTS: Over one year, 198 PCNL were performed out of which 119 were included for analysis. Sixty-six had nephrostomy tube with balloon and 53 had nephrostomy tube without balloon. Mean STONE score (9.66±1.4 vs. 9.64±1.24) and operative time (72.84±28.34 vs. 86.05±32.1 minutes) was comparable. Mean postoperative pain score at 6 hours and 24 hours postoperative was significantly lower in balloon group as compared to without balloon group. Mean Hemoglobin drop was similar in both groups (p=0.60). CONCLUSION: The use of nephrostomy tube with balloon after PCNL as this is associated with less pain and comparable hemoglobin drop as compare to nephrostomy tube without balloon.

Hounsfield units-a significant predictor of lasering time and energy in the management of upper urinary tract stones using Holmium: Yttrium-Aluminum Garnet lasers.

PURPOSE: To study the impact of stone density as assessed by Hounsfield units (HU) on total laser energy (TLE) used and total laser time (TLT) spent in complete fragmentation of upper urinary tract stones. In addition, we also studied the impact of stone composition on the laser energy and time required for fragmentation. METHODS: Thirty consecutive patients fulfilling inclusion and exclusion criteria were included in the study. Patients with renal or proximal ureteral stones with a size of 5-20 mm were included. Stone fragmentation was performed using Ho:YAG 100 W laser and TLT and TLE were correlated with the HU and stone composition. RESULTS: The mean stone diameter was 10.83 ± 3.5 mm and the mean HU was 893 ± 315. The mean TLE and TLT were 8.86 ± 3.12 kJ and 18.46 ± 6.9 min, respectively. We observed a strong positive correlation between HU and TLE (r = 0.84, p value < 0.001) and between HU and TLT (r = 0.58, p value = 0.001). However, the stone composition did not influence the lasering energy (p value = 0.36) and lasering time (p value = 0.30). Stone diameter also had significant positive correlation with TLE (r = 0.41; p = 0.02) and TLT (r = 0.54; p- 0.002). When controlling for stone size the correlation of HU with TLE (r = 0.83; p < 0.001) and TLT (r = 0.52; p = 0.004) remained significant. CONCLUSIONS: HU and stone diameter are significant predictors of TLE and TLT when using Ho:YAG laser for stone fragmentation. However, stone composition and stone location failed to show any significant effect on either of these parameters.

Flexible ureteroscopy versus miniaturized percutaneous nephrolithotomy for renal stones of 1-2 cm.

Technological advances and innovation in endourology have significantly reduced the indications of extracorporeal shockwave lithotripsy in the management of moderate-sized renal stones. In the last decade, we have witnessed a trend towards the use of finer scopes for percutaneous procedures instead of standard percutaneous nephrolithotomy (PCNL) (≥22 Fr). Miniaturized PCNL (mPCNL), i.e. miniPCNL (12-20 Fr), ultra-miniPCNL (11-13 Fr), mini-microPCNL (8 Fr), and microPCNL (<5 Fr), is increasingly being used. Concomitant developments in laser technology have provided a safe and effective stone fragmentation modality for use via flexible ureteroscopes (fURS). Technological advances in the design of fURS have improved not only the optics (fiber optic to chip-on-the-tip technology digital image) but also the ergonomics. Both the endourological techniques are extremely effective and safe, as shown in a multitude of good-quality studies. There are some differences in stone-free rate and complications. mPCNL in general has a higher stone-free rate, albeit with a slightly higher incidence of hemorrhagic complications. fURS often requires longer stenting time and longer period to achieve stone clearance, whereas mPCNL often needs ureteral catheter for only 24 hours and has a higher first day stone-free rate. fURS is a 1 day procedure compared to mPCNL, which requires patients to stay hospitalized for 2-3 days. It is therefore important to tailor the indications of these two procedures to the individual patient's needs.

Surgical Interventions for Renal Cell Carcinoma with Thrombus Extending into the Inferior Vena Cava: A Multidisciplinary Approach.

Objective: To assess surgical strategies and the impact of a multidisciplinary approach on patients undergoing inferior vena caval thrombectomy for renal cell carcinoma and to evaluate perioperative morbidity and mortality associated with these procedures. Methodology: A retrospective audit for all adults who underwent nephrectomy and inferior vena caval thrombectomy from January 2008 till November 2018 at a University hospital. Patients with incomplete records were excluded from the study. Results: During the study period, 21 patients underwent inferior vena caval thrombectomy as a completion of radical nephrectomy. Most were males (19 : 2) with a mean age of 54±11.3 years. The most common surgical approach was the 11th rib flank approach (n=8) followed by midline abdominal (n=6) and Mercedes-Benz (n=5). Eight patients had level 1, 10 patients had level 2, and three patients had level 3 tumour thrombus. The cavotomy was closed primarily in 20 patients; one required inferior vena cava (IVC) reconstruction with a pericardial patch. The proximal clamp was applied below the hepatic veins for most patients. Two patients required suprahepatic clamping before thrombectomy. There was no intraoperative mortality. Five patients (24%) developed complications: two required cardiopulmonary resuscitation due to severe hypotension and were revived; one developed acute renal failure; and one patient required a damage control laparotomy for excessive oozing. There was no thirty-day mortality. Conclusion: The IVC thrombectomy, along with radical nephrectomy for renal cell carcinoma for 1-3 level thrombus, can be performed with acceptable morbidity in a multidisciplinary team approach.

Multi-disciplinary and shared decision-making approach in the management of organ-confined prostate cancer.

Decision-making in the management of organ-confined prostate cancer is complex as it is based on multi-factorial considerations. It is complicated by a multitude of issues, which are related to the patient, treatment, disease, availability of equipment(s), expertise, and physicians. Combination of all these factors play a major role in the decision-making process and provide for an interactive decision-making preferably in the multi-disciplinary team (MDT) meeting. MDT decisions are comprehensive and are often based on all factors including patients' biological status, disease and its aggressiveness, and physician and centres' expertise. However, one important and often under rated factor is patient-related factors. There is considerable evidence that patients and physicians have different goals for treatment and physicians' understanding of their own patients' preferences is not accurate. Several patient-related key factors have been identified such as age, religious beliefs, sexual health, educational background, and cognitive impairment. We have focused on these areas and highlight some key factors that need to be taken considered whilst counselling a patient and understanding his choice of treatment, which might not always be match with the clinicians' recommendation.