In vivo ureteroscopic intrarenal pressures and clinical outcomes: a multi-institutional analysis of 120 consecutive patients.

OBJECTIVES: To evaluate the pressure range generated in the human renal collecting system during ureteroscopy (URS), in a large patient sample, and to investigate a relationship between intrarenal pressure (IRP) and outcome. PATIENTS AND METHODS: A prospective multi-institutional study was conducted, with ethics board approval; February 2022-March 2023. Recruitment was of 120 consecutive consenting adult patients undergoing semi-rigid URS and/or flexible ureterorenoscopy (FURS) for urolithiasis or diagnostic purposes. Retrograde, fluoroscopy-guided insertion of a 0.036-cm (0.014″) pressure guidewire (COMET™ II, Boston Scientific, Marlborough, MA, USA) to the renal pelvis was performed. Baseline and continuous ureteroscopic IRP was recorded, alongside relevant operative variables. A 30-day follow-up was completed. Descriptive statistics were applied to IRP traces, with mean (sd) and maximum values and variance reported. Relationships between IRP and technical variables, and IRP and clinical outcome were interrogated using the chi-square test and independent samples t-test. RESULTS: A total of 430 pressure traces were analysed from 120 patient episodes. The mean (sd) baseline IRP was 16.45 (5.99) mmHg and the intraoperative IRP varied by technique. The mean (sd) IRP during semi-rigid URS with gravity irrigation was 34.93 (11.66) mmHg. FURS resulted in variable IRP values: from a mean (sd) of 26.78 (5.84) mmHg (gravity irrigation; 12/14-F ureteric access sheath [UAS]) to 87.27 (66.85) mmHg (200 mmHg pressurised-bag irrigation; 11/13-F UAS). The highest single pressure peak was 334.2 mmHg, during retrograde pyelography. Six patients (5%) developed postoperative urosepsis; these patients had significantly higher IRPs during FURS (mean [sd] 81.7 [49.52] mmHg) than controls (38.53 [22.6] mmHg; P < 0.001). CONCLUSIONS: A dynamic IRP profile is observed during human in vivo URS, with IRP frequently exceeding expected thresholds. A relationship appears to exist between elevated IRP and postoperative urosepsis.

Introduction of Rezum system technology to Ireland for treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: a pilot study on early outcomes and procedure cost analysis.

OBJECTIVE: Rezum technology uses heat from radiofrequency-generated water vapour to ablate prostate tissue. We evaluate the introduction of this thermal therapy to an Irish teaching hospital for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia. METHODS: A pilot study of men with moderate to severe lower urinary tract symptoms who underwent Rezum treatment to the prostate was performed. Perioperative efficacy was evaluated using international prostate symptom score (IPSS), quality of life score (IPSS-QOL), uroflowmetry and post-void residual (PVR) volumes. Costs were evaluated and compared against matched patients undergoing the standard of care, transurethral resection of the prostate (TURP). RESULT: Ten patients with a mean age of 70 ± 9 years who met the inclusion criteria underwent Rezum treatment. Mean PSA was 4.73 ± 4 ng/mL and mean prostate volume 72 ± 30 cc. Rezum therapy significantly improved both IPSS by 74% from mean baseline score of 20.8 ± 4 to 5.3 ± 1.49 (p < 0.001) and IPSS-QOL score by 84% from mean baseline score of 4.4 ± 0.7 to 0.6 ± 0.7 (p < 0.001) at 3 months. Maximum flow rate increase by 44% from 9.26 ± 2.5 to 13.34 ± 2.3 mL/s (p < 0.001). When compared to ten matched patients undergoing TURP in the same period, there was a significant cost saving of €1986.52 per patient for Rezum, overall up-front cost saving of €22,819 with an additional 19 bed days and 5 theatre hours spared. CONCLUSION: Rezum, a minimally invasive thermal therapy, provides significantly improved symptom relief and quality of life with a significant cost saving to the institution.

Does postal consent for flexible cystoscopy work?

BACKGROUND: Informed consent is an integral part of the process prior to any surgical procedure [1]. Flexible cystoscopy is a common day case urological procedure and it is the gold standard investigation for visible haematuria [2]. AIM: To assess if postal consent is a suitable form of gaining informed consent for flexible cystoscopy. METHODS: Patients booked for a flexible cystoscopy are initially reviewed in clinic. An information leaflet with an attached consent form is then posted to their home 2 weeks prior to their procedure. We designed a short questionnaire, to assess patient's satisfaction and understanding of the literature, given to them after the procedure. RESULTS: Sixty-seven questionnaires were completed. The mean age was 54. Sixty patients (93%) think that postal consent is of benefit to the patient. Sixty-one patients (91%) read the information sheet and felt that there was enough information regarding the procedure on it. Fifty-four patients (81%) had no difficulty understanding the consent form. Forty patients (60%) signed the form prior to arrival in the hospital. CONCLUSION: Postal consent is commonly used for gastro-intestinal endoscopy procedures. Postal consent for flexible cystoscopy is not well reported in the literature. Our study shows postal consent to be a suitable form of gaining informed consent for flexible cystoscopy.

Expect the unexpected: chronic renal abscess secondary to renal actinomycosis.

Actinomycosis is an invasive infection, which can affect numerous anatomical sites, though rarely the kidney. The rate of nephrectomy is high despite antibiotic therapy. A 51 year old presented with a Proteus mirabilis renal abscess 9 years following a similar renal abscess. The abscess persisted despite appropriate antibiotic treatment and radiological drainage. In addition to P. mirabilis, Actinomyces species was isolated on polymicrobial abscess culture after 6 weeks antibiotic therapy. Despite appropriate antibiotics, nephrectomy was required. Histology confirmed actinomycosis. Actinomycosis should be considered in chronic, destructive infections, especially if failure to respond to appropriate antimicrobials. However, Actinomyces species may be missed by routine culture techniques. Because of the polymicrobial nature of abscesses, good communication with the laboratory is essential to ensure that cultures are prolonged and the isolation of one pathogen does not hinder the isolation of others.

Contemporary trends for urological training and management of stress urinary incontinence in Ireland.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to evaluate the trends in stress urinary incontinence (SUI) surgery since the 2018 pause on use of the polypropylene (PP) mid-urethral sling (MUS) and to quantify the effect this has had on surgical training. METHODS: Two anonymous surveys were sent to all current urology trainees and to all consultant surgeons who specialise in stress urinary incontinence surgery. RESULTS: Prior to the pause, 86% (6 out of 7) of consultant urologists and 73% (11 out of 15) of consultant gynaecologists would "always"/"often" perform MUS for SUI. After that, 100% (22 out of 22) of consultants reported that they "never" perform MUS. There has been a modest increase in the use of urethral bulking agent (UBA) procedures among urologists, with 43% (3 out of 7) now "often" performing this, compared with 71% (5 out of 7) "never" performing it pre-2018. Trainee exposure to SUI surgery reduced by 75% between 2016 and 2020. Despite a ten-fold increase in UBA procedures logged by trainees, the decline in MUS has resulted in a major reduction in total SUI surgeries. Coinciding with this decrease in surgeries, there was a 56% reduction in trainees' self-assessed competence at SUI surgery. Thirteen percent of trainees are interested in specialising in Female Urology and those trainees had significantly greater exposure to SUI procedures during their training than those who did not (p = 0.0072). CONCLUSIONS: This study has identified a downward trend in SUI surgery, which is concerning for the undertreatment of females with SUI. A decline in SUI surgery training has resulted in reduced trainee confidence and interest in this subspecialty.

Comparison of synthetic mesh erosion and chronic pain rates after surgery for pelvic organ prolapse and stress urinary incontinence: a systematic review.

BACKGROUND: The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery. METHODS: A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion rates for POP and SUI surgery. Secondary outcome measurements were incidence of de novo pain and a comparison of patient demographics for both surgeries. RESULTS: Twenty-six studies on 292,606 patients (n = 9077 for POP surgery and n = 283,529 for SUI surgery) met the inclusion criteria. Median follow-up was 26.38 ± 22.17 months for POP surgery and 39.33 ± 27.68 months for SUI surgery. Overall, the POP group were older (p < 0.0001) and had a lower BMI (p < 0.0001). Mesh erosion rates were significantly greater in the POP group compared to the SUI group (4% versus 1.9%) (OR 2.13; 95% CI 1.91-2.37; p < 0.0001). The duration from surgery to onset of mesh erosion was 306.84 ± 183.98 days. There was no difference in erosion rates between abdominal and transvaginal mesh for POP. There was no difference in erosion rates between the transobturator and retropubic approach for SUI. The incidence of chronic pain was significantly greater in the POP group compared to the SUI group (6.7% versus 0.6%) (OR 11.02; 95% CI 8.15-14.9; p < 0.0001). The duration from surgery to onset of chronic pain was 325.88 ± 226.31 days. CONCLUSIONS: The risk of mesh erosion and chronic pain is significantly higher after surgery for POP compared to SUI. These significant complications occur within the first year after surgery.

Intraductal carcinoma of the prostate in an Irish prostate cancer patient cohort-an aggressive pathology and a strong familial link.

BACKGROUND: The prevalence of intraductal carcinoma of the prostate (IDC-P) is poorly studied in the Irish population. This study investigated the incidence and clinicopathologic characteristics of IDC-P in an Irish prostate cancer (PCa) patient cohort. The study also discusses the rationale for genetic counseling and screening in Irish patients with familial risk factors for IDC-P. MATERIALS AND METHODS: This study investigated patients diagnosed with IDC-P on prostate biopsy from 2012 to 2016. Primary outcome measurements were incidence, management, and clinical outcomes after follow-up in patients with IDC-P. The secondary outcome measurement was to identify a familial link for IDC-P. RESULTS: A total of 1,143 patients were diagnosed with PCa on needle biopsy, of which 30 (2.3%) had concomitant IDC-P. Mean age and prostate-specific antigen at diagnosis were 68.6 ± 10.5 years (range 53-85 years) and 9.15 ± 8.65 ng/mL (range 2.1-166 ng/mL), respectively. In total, 17 of 30 patients (57%) were diagnosed with concomitant high-grade (i.e., ≥Gleason score 8) PCa. Eight patients (27%) were treated with radical prostatectomy; of which five had biochemical recurrence (BCR) after 10.55 ± 25.9 months. Eleven patients (37%) received radical radiotherapy; of which one had BCR after 36 months. Eleven patients (37%) presented with advanced PCa and were managed with androgen deprivation therapy ± chemotherapy. A family history for PCa in first-degree relatives was found in eight patients (27%). CONCLUSIONS: IDC-P is associated with more aggressive clinicopathologic features and an increased risk of BCR after treatment. In Ireland, clinical guidelines and a genetic screening pathway are required to provide early detection and appropriate multimodal management of patients with IDC-P.

Predictors of long-term renal allograft survival after second kidney transplantation.

INTRODUCTION: Few studies investigate significant perioperative predictors for long-term renal allograft survival after second kidney transplant (SKT). We compared long-term survival following SKT with primary kidney transplant and determined predictors of renal allograft failure after SKT. METHODS: Outcomes of all primary or second kidney transplant recipients at a national kidney transplant center between 1993 and 2017 were reviewed. The primary outcomes measurements were renal allograft survival for both first and second kidney transplants. Secondary outcome measurements were incidence of delayed graft function (DGF), incidence of acute rejection (AR), and predictors for renal allograft survival in SKT recipients. RESULTS: In total, there were 392 SKTs and 2748 primary kidney transplants performed between 1993 and 2017. The 1-, 5-, and 10-year death-censored graft survival for deceased-donor recipients was 95.3%, 88.7%, and 78.2% for primary kidney transplant and 94.9%, 87.1%, and 74.9% for SKT (P = .0288). Survival of primary renal allograft <6 years (HR 0.6, P = .017), AR episodes (HR 1.6, P = .031), DGF (HR 2.0, P = .005), and HLA-DR MM (HR 1.7, P = .018) was independent predictors of long-term renal allograft failure after SKT. CONCLUSION: These findings may provide important information on long-term survival outcomes after SKT and for identifying patients at risk for long-term renal allograft failure after SKT.

Predictors of emergency department attendance following ureterorenoscopy for urolithiasis.

BACKGROUND: We sought to determine the rate of emergency department (ED) attendance for complications after ureterorenoscopy (URS) for stone disease and to identify risk factors for ED attendance after URS. METHODS: An analysis of all patients undergoing URS over 12 months at a single institution was performed. Patient demographics, preoperative and intraoperative variables associated with postoperative complications and subsequent ED attendance were collected. Logistic regression analyses were performed to determine predictors of URS complications presenting to ED. RESULTS: In total, 202 ureteroscopies were performed on 142 patients for urolithiasis. The mean age was 50.73 ± 13.93 and 66% were male. The incidence of re-presentation to ED was 14.8% (n = 30). Patients presented with postoperative pain (n = 10; 4.95%), pyrexia (n = 9; 4.46%), urinary tract infection (UTI) (n = 7, 3.47%), haematuria (n = 3, 1.49%) and urosepsis (n = 1; 0.5%). Significant risk factors for ED attendance included preoperative stent dwell time > 30 days (P = 0.004), recently treated positive preoperative urine culture (P < 0.0001), stone size ≥ 13 mm (P = 0.043), stone location mid-ureter (P = 0.036) and female gender (P = 0.005). The following factors did not predict ED attendance, stent omission, access sheath utilization and operation duration. CONCLUSION: Risk factors for ED attendance after URS include prolonged pre-stent dwell time, stone size ≥ 13 mm, treatment for a positive preoperative urine culture, mid-ureteric stone location and female gender. Urologists should be aware of these findings to decrease the risk of emergency re-presentation after elective URS surgery.

Warm Ischemia Time at Vascular Anastomosis is an Independent Predictor for Delayed Graft Function in Kidney Transplant Recipients.

OBJECTIVES: Delayed graft function after kidney transplant can affect patient and graft survival, resulting in prolonged hospital stay and need for dialysis. Ischemia times during organ procurement and reanastomosis at transplant are key factors in delayed graft function. MATERIALS AND METHODS: We analyzed all living- and deceased-donor renal transplants in Ireland over a 33-month period, with effect of warm ischemia time during anastomosis on delayed graft function being the primary outcome. We performed statistical regression analyses to account for confounding variables. Patients had identical surgical technique and immunosuppression protocols. RESULTS: Of 481 transplants during the study period, 20 patients were excluded because of paired-kidney exchange, nephron dosing transplant, or simul-taneous pancreas-kidney transplant. In the donor pool, 70% were donors after brainstem death, 3.6% were donors after cardiac death, and 26% were living donors. All living donors were direct altruistic donors and underwent stringent assessment via the ethics committee and multidisciplinary team meeting. Of living donors, 8% were not related. These were true altruistic donors who were acquaintances of the recipients and volunteered themselves for assessment. They were assessed in accordance with the declaration of Istanbul and received no compensation of any kind for donation. Of total patients, 18% had delayed graft function, defined as need for dialysis within 7 days of transplant. Warm ischemia time during anastomosis significantly affected risk of delayed graft function but not graft survival or function at 3 months. This factor did not correlate with hospital stay duration. Time on dialysis and recipient weight significantly correlated with risk of delayed graft function. CONCLUSIONS: Our findings support a role for minimizing warm ischemia time during anastomosis to reduce delayed graft function and need for dialysis in the perioperative period. However, a longer time does not appear to affect creatinine levels and therefore graft function at 3 months.

Ureteric stenting with magnetic retrieval: an alternative to traditional methods.

INTRODUCTION: Ureteric stents are frequently placed following endo-urological procedures. These stents cause significant morbidity for patients. Standard ureteric stents are removed by flexible cystoscopy. This procedure can be unpleasant for patients and requires additional resources. A newly designed magnetic stent allows removal in an outpatient setting. The aim of our study is to compare the magnetic stent and standard ureteric stents with regard to morbidity, pain on stent removal and cost-effectiveness. METHODS: This study was carried out across two sites between September 2016 and July 2017. In site A, a magnetic stent (Urotech, Black-Star®) is removed by magnetic retrieval device. Fifty consecutive patients completed the validated Ureteric Stent Symptom Questionnaire (USSQ) and visual analogue scale (VAS) at the time of stent removal. On site B, a soft polyurethane stent (Cook Universa) was removed by flexible cystoscopy. Fifty patients were identified retrospectively and completed questionnaires by post. Cost analysis was also performed. RESULTS: One hundred questionnaires were included for analysis. No significant difference in stent morbidity as assessed by the USSQ was shown between both groups. Median duration of stenting was significantly shorter in the magnetic stent group (5.5 versus 21.5 days, p < 0.001). Mean pain on stent removal was significantly less with magnetic retrieval (2.9 versus 3.9, p < 0.05). Complication rates were similar in both groups. Cost analysis showed a cost saving of €203 per patient with the magnetic stent group. CONCLUSION: Magnetic stents cause similar morbidity for patients compared with standard stents removed by flexible cystoscopy; they are associated with less pain at removal and are cost saving.

Admission of patients with acute urinary retention leads to a definitive management decision.

BACKGROUND: Acute urinary retention (AUR) is a common urologic emergency. However, its management is not standardized due to lack of clinical guidelines. AIMS: We retrospectively reviewed the treatment of all male patients admitted to our institution with AUR over 12 months. METHODS: Data was obtained from the HIPE (Hospital Inpatient Enquiry) data system, each patient's electronic discharge summary and from patient medical records. RESULTS: There were 130 AUR admissions during the period. About 74 admissions were due to benign prostatic enlargement (BPE). Of these, 45.9% (n = 34) passed their trial without catheter (TWOC). The remainder (n = 40) failed their TWOC necessitating recatheterization and consideration for transurethral resection of prostate (TURP) or re-TWOC. An indwelling urinary catheter (IDC) was inserted for 27.5% (n = 11) of patients with a failed TWOC secondary to comorbidities. This group had a mean age of 78 years (range 68-96 years). Of those who failed their TWOC, 32.5% (n = 13) had a TURP on index admission. Of the remaining 16 patients with failed TWOC, 75% (n = 12) were discharged with an IDC and readmitted for an elective TURP with a median waiting time of 55 days (range 17-138 days). 18.75% (n = 3) passed a re-TWOC and thus offset the need to have any surgical intervention and 6.25% (n = 1) proceeded to a radical retropubic prostatectomy for biopsy proven prostate adenocarcinoma. CONCLUSION: Admission of patients with acute urinary retention leads to a definitive management decision and reduced prolonged catheterization.

Long-Term Outcomes of Renal Transplant in Patients With End-Stage Renal Failure Due to Systemic Lupus Erythematosus and Granulomatosis With Polyangiitis.

OBJECTIVES: Systemic lupus erythematosus and granulomatosis with polyangiitis are systemic inflammatory conditions associated with renalfailure that can recur after renal transplant. Patients with these conditions are treated with chronic immunosuppression, potentially increasing risk of secondary malignancies. Here, we investigated long-term outcomes in renal transplant recipients with these conditions. MATERIALS AND METHODS: Transplant recipients with end-stage kidney disease due to systemic lupus erythematosus and granulomatosis with polyangiitis seen between 1982 and 2016 at a national kidney transplant center were included. Primary outcome variables were long-term allograft survival and incidence of secondary malignancy. Secondary outcome measures were incidence of delayed graft function, primary disease recurrence, and serum creatinine at follow-up. RESULTS: Ninety-eight transplant procedures (90 from deceased donors) in 92 consecutive patients (mean age 42.3 ± 14.4 y) were included: 55 with systemic lupus erythematosus and 37 with granulomatosis with polyangiitis. Follow-up duration was 110.53 ± 81.95 months (range, 1-393 mo). Overall renal allograft survival was 94.7% at 1 year, 85.4% at 5 years, and 75.4% at 10 years posttransplant. Patientswith systemic lupus erythematosus showed overall allograft survival of 91.6% at 1 year, 84.3% at 5 years, and 74.4% at 10 years. There was 1 allograft failure due to recurrence of primary disease in this group. Patients with granulomatosis with polyangiitis showed overall allograft survival of 100% at 1 year, 92.4% at 5 years, and 92.4% at 10 years. There were 21 mortalities, with 5 (23.8%) due to secondary malignancy. In total, 46 malignancies were diagnosed in 31 patients. CONCLUSIONS: We found excellent long-term renal allograft survival rates in patients with systemic lupus erythematosus and granulomatosis with polyangiitis, with secondary malignancy rates similar to those shown in recipients without autoimmune diseases. These findings provide clinicians with long-term data on transplant recipients with end-stage renal failure due to systemic inflammatory conditions.

Progressive improvement in short-, medium- and long-term graft survival in kidney transplantation patients in Ireland - a retrospective study.

It is often quoted that while short-term graft survival in kidney transplantation has improved in recent years, it has not translated into a commensurate improvement in long-term graft survival. We considered whether this was true of the entire experience of the national kidney transplant program in Ireland. A retrospective analysis of the National Kidney Transplant Service (NKTS) database was undertaken to investigate patient and graft survival for all adult first deceased donor kidney transplant recipients in Ireland, 1971-2015. Three thousand two hundred and sixty recipients were included in this study. Kaplan-Meier methods were used to estimate survival at each time period post transplant for the various eras of transplantation. Uncensored graft survival has improved over the course of the program in Ireland at various time points despite risk factors for graft failure progressively increasing over successive eras. For example the graft survival at 15 years post transplant has increased from 10% in 1971-1975 to 45% by 1996-2000. Ireland has experienced a progressive improvement in long-term graft survival following kidney transplantation. Whether these trends are attributable to biological or nonbiological factors is unclear but likely involves a combination of both.

Robotic simulation training for urological trainees: a comprehensive review on cost, merits and challenges.

Simulation in surgery is a safe and cost-effective way of training. Operating room performance is improved after simulation training. The necessary attributes of surgical simulators are acceptability and cost-effectiveness. It is also necessary for a simulator to demonstrate face, content, predictive, construct and concurrent validity. Urologists have embraced robot-assisted surgery. These procedures require steep learning curves. There are 6 VR simulators available for robot-assisted surgery; the daVinci Skills Simulator (dVSS), the Mimic dV Trainer (MdVT), the ProMIS simulator, the Simsurgery Educational Platform (SEP) simulator, the Robotic Surgical Simulator (RoSS) and the RobotiX Mentor (RM). Their efficacy is limited by the lack of comparative studies, standardisation of validation and high cost. There are a number of robotic surgery training curricula developed in recent years which successfully include simulation training. There are growing calls for these simulators to be incorporated into the urology training curriculum globally to shorten the learning curve without compromising patient safety. Surgical educators in urology should aim to develop a cost-effective, acceptable, validated simulator that can be incorporated into a standardised, validated robot-assisted surgery training curriculum for the next generation of robotic surgeons.

Incidence, Management, and Clinical Outcomes of Prostate Cancer in Kidney Transplant Recipients.

OBJECTIVES: We reviewed the incidence, management, and survival outcomes of prostate cancer among kidney transplant recipients and compared these characteristics with a national population (nonrecipients). MATERIALS AND METHODS: A retrospective study was performed on all kidney transplant recipients from a National Kidney Transplant Centre who were subsequently diagnosed with prostate cancer. Primary outcome variables included comparisons of incidence and 5-year overall survival in kidney transplant recipients versus nonrecipients after treatment of prostate cancer. Secondary outcome variables were prostate-specific antigen levels at diagnosis, Gleason grade, treatment strategy, and morbidity from treatment among kidney transplant recipients. RESULTS: Of 4048 kidney transplants performed, 3020 were male recipients (63.9%). In total, 34 kidney transplant recipients (1.1%) were diagnosed with prostate cancer 109 ± 83 months (range, 7-372 mo) after transplant. The mean age at prostate cancer diagnosis was 64 ± 7 years, median prostate-specific antigen level was 10 ng/dL (range, 2.6-771 ng/dL), and 76% (n = 26/34) were diagnosed with localized disease. The incidence of prostate cancer was 1126/100 000 in kidney transplant recipients compared with 160/100 000 nonrecipients in Ireland (P = .01). Treatment strategies included curative radiotherapy (n = 18), curative surgery (n = 2), androgen deprivation therapy (n = 8), and watchful waiting (n = 6). Overall survival rates at 1, 3, and 5 years were not significantly different between kidney transplant recipients with prostate cancer versus nonrecipients with prostate cancer (98% vs 98%, 80% vs 79%, and 77% vs 72%, respectively, P = .8). CONCLUSIONS: The incidence of prostate cancer is significantly higher among kidney transplant recipients compared with nonrecipients in the general population, with most diagnosed with localized disease. Definitive management guidelines should be developed to increase awareness and optimize treatment options in this unique patient cohort.

Perioperative Management of New Oral Anticoagulants in Urological Surgery.

New oral anticoagulants (NOACs) are increasingly replacing the use of warfarin in clinical practice. Their use has now also been extended to thromboprophylaxis in many orthopedic surgeries. This, in addition to an increasingly aging population with many complex comorbidities means that these medications will be ever more frequently encountered by urologists. Thus, a clear understanding of the mechanism of action of NOACs, their time to peak action and half-life is essential for the purpose of managing these patients perioperatively. This article demonstrates the patient and procedural variability that must be taken into account in the perioperative management of the anticoagulated patient. While the time to peak onset and half-life of NOACs can aid in determining the interval of interruption of anticoagulation, the risks of thrombosis and bleeding must be assessed before the decision to stop anticoagulation. This article takes into account the evidence available on NOACs in urological surgery in order to inform the perioperative management of these medications and to propose guidelines to aid in clinical decision making. In attempting this, we address the issue of the lack of high-level evidence surrounding NOACs in urological surgery given their relative novelty and the need for further research to better guide practice.

The transobturator suburethral sling: a safe and effective option for all degrees of post prostatectomy urinary incontinence.

INTRODUCTION: Male stress urinary incontinence (SUI) after radical prostatectomy (RP) is common. The surgical standard of care traditionally has been placement of an artificial urinary sphincter (AUS) but since its introduction the transobturator male sling has been shown to have particular unique advantages. Our aim was to assess outcomes of a consecutive series of suburethral sling insertions in men presenting with all degrees of post RP SUI. MATERIALS AND METHODS: A consecutive cohort of men undergoing AdVance sling insertion following RP were studied. Parameters assessed included pre and postoperative urinary function, 24 hour pad use, quality of life (QoL) outcomes, complications and further treatments. Degree of incontinence was categorized as mild (1-2), moderate (3-5) or severe (≥ 6) depending on daily pad use. Patients were reviewed at 1, 4 and 6 months. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used to assess symptom severity and QoL outcomes. RESULTS: Seventy-seven patients were included, mean age 68 and mean time to sling post RP 34 (8-113) months. Preoperative degree of incontinence: mild 22%, moderate 58%, severe 20%. Fourteen percent had undergone post RP radiation therapy (RT). In total 73% experienced complete resolution of symptoms post sling, 12% significant improvement, 15% no reduction in pad use. Sixty percent with severe incontinence were classified as cured (no pad or 1 dry pad for security reasons). When patients with preoperative RT were excluded, cure rate rose to 82%. On follow up survey at 30 months (mean), the ICIQ-SF score decreased from baseline 17.7 (9-21.0) to 8.0 (0-20) (p < 0.0001), CI 95% (8-12). CONCLUSIONS: Suburethral slings are effective and safe for all degrees of post RP incontinence, are associated with improved QoL parameters and with appropriate selection and counseling are a viable option for more severe degrees of post RP SUI.

Clinical Evaluation of a Safety-device to Prevent Urinary Catheter Inflation Related Injuries.

OBJECTIVE: To evaluate the feasibility of a novel "safety-valve" device for preventing catheter related urethral trauma during urethral catheterization (UC). To assess the opinions of clinicians on the performance of the safety-valve device. MATERIALS AND METHODS: A validated prototype "safety-valve" device for preventing catheter balloon inflation related urethral injuries was prospectively piloted in male patients requiring UC in a tertiary referral teaching hospital (n = 100). The device allows fluid in the catheter system to decant through an activated safety threshold pressure valve if the catheter anchoring balloon is misplaced. Users evaluated the "safety-valve" with an anonymous questionnaire. The primary outcome measurement was prevention of anchoring balloon inflation in the urethra. Secondary outcome measurement was successful inflation of urinary catheter anchoring balloon in the bladder. RESULTS: Patient age was 76 ± 12 years and American Society of Anaesthesiologists grade was 3 ± 1.4. The "safety-valve" was utilized by 34 clinicians and activated in 7% (n = 7/100) patients during attempted UC, indicating that the catheter anchoring balloon was incorrectly positioned in the patient's urethra. In these 7 cases, the catheter was successfully manipulated into the urinary bladder and inflated. 31 of 34 (91%) clinicians completed the questionnaire. Ten percent (n = 3/31) of respondents had previously inflated a urinary catheter anchoring balloon in the urethra and 100% (n = 31) felt that a safety mechanism for preventing balloon inflation in the urethra should be compulsory for all UCs. CONCLUSION: The safety-valve device piloted in this clinical study offers an effective solution for preventing catheter balloon inflation related urethral injuries.

Unusual genitourinary tract activity.

A 23-year-old woman presented to the emergency department after manually inserting foreign bodies into the urinary bladder through her urethra. A plain abdominal film of the kidneys, ureters and bladder confirmed three radio-opaque densities in the urinary bladder. She was taken to the operating room where cystourethroscopy was performed. At cystoscopy 2 'corn-on-the-cob' skewers and 1 battery were identified but were too large to be retrieved safely with a grasper through the protective sheath. The objects were grasped with a 'sponge-holding forceps' (placed alongside the cystoscope) and extracted one at a time. A psychiatric consultation was sought and the patient was diagnosed and treated for borderline personality disorder. Unusual genitourinary activity (UGUA) has been described for several centuries and is characterised by the deposition of foreign objects in the genitalia. 1 The most common incentive for UGUA is sexual stimulation, but psychiatric disorders and intoxication are also associated. 2 Management involves retrieval of foreign bodies and evaluation of psychosocial factors.