Achieving Benchmarks for National Quality Indicators Reduces Recurrence and Progression in Non-muscle-invasive Bladder Cancer.

BACKGROUND: Noncompliance with evidence-based interventions and guidelines contributes to significant and variable recurrence and progression in patients with non-muscle-invasive bladder cancer (NMIBC). The implementation of a quality performance indicator (QPI) programme in Scotland's National Health Service (NHS) aimed to improve cancer outcomes and reduce nationwide variance. OBJECTIVE: To evaluate the effect of hospitals achieving benchmarks for two specific QPIs on time to recurrence and progression in NMIBC. DESIGN, SETTING, AND PARTICIPANTS: QPIs for bladder cancer (BC) were enforced nationally in April 2014. NHS health boards collected prospective data on all new BC patients. Prospectively recorded surveillance data were pooled from 12 collaborating centres. INTERVENTION: QPIs of interest were (1) hospitals achieving detrusor muscle (DM) sampling target at initial transurethral resection of bladder tumour (TURBT) and (2) use of single instillation of mitomycin C after TURBT (SI-MMC). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary and secondary endpoints were time to recurrence and progression, respectively. Kaplan-Meier and Cox multivariable regression analyses were performed. KEY FINDINGS AND LIMITATIONS: Between April 1, 2014 and March 31, 2017, we diagnosed 3899 patients with new BC, of which 2688 were NMIBC . With a median follow up of 60.3 mo, hospitals achieving the DM sampling target had a 5.4% lower recurrence rate at 5 yr than hospitals not achieving this target (442/1136 [38.9%] vs 677/1528 [44.3%], 95% confidence interval [CI] = 1.6-9.2, p = 0.005). SI-MMC was associated with a 20.4% lower recurrence rate (634/1791 [35.4%] vs 469/840 [55.8%], 95% CI = 16.4-24.5, p < 0.001). On Cox multivariable regression, meeting the DM target and SI-MMC were associated with significant improvement in recurrence (hazard ratio [HR] 0.81, 95% CI = 0.73-0.91, p = 0.0002 and HR 0.66, 95% CI = 0.59-0.74, p < 0.004, respectively) as well as progression-free survival (HR 0.62, 95% CI = 0.45-0.84, p = 0.002 and HR 0.65, 95% CI = 0.49-0.87, p = 0.004, respectively). We did not have a national multicentre pre-QPI control. CONCLUSIONS: Within a national QPI programme, meeting targets for sampling DM and SI-MMC in the real world were independently associated with delays to recurrence and progression in NMIBC patients. PATIENT SUMMARY: Following the first 3 yr of implementing a novel quality performance indicator programme in Scotland, we evaluated compliance and outcomes in non-muscle-invasive bladder cancer. In 2688 patients followed up for 5 yr, we found that achieving targets for sampling detrusor muscle and the single instillation of mitomycin C during and after transurethral resection of bladder tumour, respectively, were associated with delays in cancer recurrence and progression.

A rare diagnosis: Acute bilateral vasitis mimicking incarcerated bilateral inguinal hernia.

Inflammation of the vas deferens or what known as acute vasitis is an under-reported condition that usually presents with scrotal or inguinal pain and swelling which can be misdiagnosed and treated as many other conditions. Here, we present one of the first cases to be reported in the literature with bilateral manifestation. A 28-year-old male patient presented complaining of bilateral testicular and inguinal pain associated with inguinal swelling for 3 days. Initially, the patient was being evaluated as a case of incarcerated bilateral inguinal hernia, but with the aid of radiological imaging, the patient was diagnosed correctly and the unnecessary surgical intervention was prevented.

An Unusual Cause of Recurrent Visible Hematuria; Posterior Urethral Hemangioma: A Case Report and Review of Literature.

Urinary tract hemangiomas are uncommon entity to urologists, despite their benign nature and course; they can cause significant patient's hemodynamic instability or distress if not recognized and managed properly. Here, we present a case of urethral hemangioma with its treatment, follow-up course and review of literature of similar cases. Introduction: Bloody urine or urethral bleeding can be the initial presentation of a number of different medical and surgical conditions, some of which are benign and others are malignant, when encountered, they are alarming and must be evaluated thoroughly. As a cause, urethral hematomas are faced rarely, among all urinary tract sites; they are the second least common(1). Due to their paucity in clinical practice, there is no agreed approach on their management and each case has to be individualized. In the literature, different assessment and treatment methods were tried with satisfactory outcomes in each one. Here we report a case with detailed, concise explanation of such pathology and a comprehensive comparison in light of previous literature. Keywords: Urethral hemangioma, urethral bleeding, benign urinary tract tumors.

Segmental Testicular Infarction: A Case Report.

Segmental testicular infarction is an uncommon condition; it is idiopathic in most cases and the pathophysiology behind it is unclear. Patients usually present with a sudden onset of testicular pain, which mimics conditions such as testicular torsion and epididymo-orchitis in clinical presentation and can sometimes be mistaken for a testicular tumor on ultrasound, which can mislead some urologists to opt for an unnecessary surgical treatment. However, with proper assessment and reassuring tests, surgical treatment can be avoided, and successful conservative management can be achieved.

Enhanced Quality and Effectiveness of Transurethral Resection of Bladder Tumour in Non-muscle-invasive Bladder Cancer: A Multicentre Real-world Experience from Scotland's Quality Performance Indicators Programme.

BACKGROUND: Clinical outcomes from non-muscle-invasive bladder cancer (NMIBC) are partly determined by the quality of initial interventions. To improve and standardise treatment for cancer, Scotland implemented a national Quality Performance Indicator (QPI) programme for bladder cancer (BC). OBJECTIVE: To evaluate compliance with specific quality indicators (QIs) related to transurethral resection of bladder tumour (TURBT) and to understand clinical outcomes from NMIBC following the introduction of the QPI programme. DESIGN, SETTING, AND PARTICIPANTS: Within a robust governance framework, 12 mandatory evidence-based QPIs were implemented nationally in April 2014. We report prospectively collected data for all new BC patients (between April 2014 and March 2017). We include follow-up data for 2689 patients. INTERVENTION: The TURBT-related QPIs were (1) using a bladder diagram, (2) single post-TURBT instillation of mitomycin C (SPI-MMC), (3) detrusor muscle (DM) in the specimen, and (4) early re-TURBT in high-risk NMIBC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We measured compliance with these QPIs and (1) recurrence rate at first follow-up cystoscopy (RRFFC), (2) rates of residual cancer, and (3) pT2 cancer at re-TURBT. Associations between QPI compliance, tumour features, and outcomes were assessed with multivariable logistic regression models. RESULTS AND LIMITATIONS: Among 4246 new BC patients, SPI-MMC was used in 67% (2029/3023) NMIBC patients. In 1860 NMIBC patients undergoing TURBT, RRFFC, rate of residual cancer, and rate of pT2 at re-TURBT were 13% (116/888), 33% (212/653), and 2.9% (19/653), respectively. SPI-MMC was associated with lower RRFFC, independent of all variables including hospital volume and surgeon. Presence of DM in the specimen halved the likelihood of residual disease in pT1 cancers. The main limitation is the lack of a pre-QPI introduction cohort for comparison. CONCLUSIONS: The implementation of a QI programme in Scotland appears to facilitate high-quality TURBT, which in a real-world setting is associated with low early recurrence/residual cancer and accurate pathological staging. PATIENT SUMMARY: Following the first 3 yr of implementing a novel Quality Performance Indicator (QPI) programme in Scotland, we assessed compliance and outcomes in non-muscle-invasive bladder cancer. Evaluating over 4000 new bladder cancer patients, we found that the QPI programme was associated with low recurrence and accurate staging following the initial transurethral resection of bladder tumour.

Case report of a rare urinary bladder tumor variant (carcinosarcoma).

Carcinosarcoma of the bladder is a rare and aggressive variant of bladder tumor. The causes are not clear for this bladder tumor variant. Early diagnosis with immediate surgical resection is the most accepted management as reported so far in the literature, but the optimal management is unknown to date. Here, we report a case of a 62-year-old woman with bladder carcinosarcoma who presented with macroscopic hematuria.

Acute right epididymo-orchitis complicated by pampiniform plexus thrombosis.

Acute scrotum considered to be a common and one of the urological top emergency cases. However, acute testicular pain due to testicular vein thrombosis is rare especially if this thrombosis considered to be a complication of an infection, and not due to varicocele or malignancy-related conditions. A rare case of right epididymo-orchitis case complicated by right pampiniform plexus thrombosis, which resolved spontaneously with no anticoagulant management., Testicular vein thrombosis considered to be a rare differential diagnoses of acute scrotum presentation. With a limited number of reported cases, it requires more evaluation to develop a proper medical approach.

Verification and diagnostic evaluation of the RealStar® Middle East respiratory syndrome coronavirus (N gene) reverse transcription-PCR kit 1.0.

Aim: We report the diagnostic evaluation of a confirmatory reverse transcription-PCR (RT-PCR) kit targeting the Middle East respiratory syndrome coronavirus (MERS-CoV) N gene. Material & methods: 33 patient samples from two collections sites in Riyadh, Saudi Arabia, which were pre-characterized via real-time RT-PCR targeting MERS-CoV orf1a and upE, and were tested using the MERS-CoV N gene, as a confirmatory assay. This diagnostic procedure follows a two-step diagnostics scheme, recommended by the WHO. Results: 18/33 samples tested positive, 11/33 tested negative for MERS-CoV RNA and 2/33 showed uncertain results. Conclusion: The results suggest, that the RealStar® MERS-CoV (N gene) RT-PCR kit 1.0 can be considered a suitable and reliable confirmatory assay in combination with the RealStar MERS-CoV RT-PCR kit 1.0 according to the diagnostic scheme recommended by WHO.

Analgesia for patients undergoing shockwave lithotripsy for urinary stones – a systematic review and meta-analysis

ABSTRACT Background Shock wave lithotripsy (SWL) is the first line treatment modality for a significant proportion of patients with upper urinary tracts stones. Simple analgesics, opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are all suitable agents but the relative efficacy and tolerability of these agents is uncertain. Objectives To determine the efficacy of the different types of analgesics used for the control of pain during SWL for urinary stones. Materials and Methods We searched the Cochrane Renal Group’s Specialised Register, MEDLINE, EMBASE and also hand-searched reference lists of relevant articles (Figure-1). Randomised controlled trials (RCT’s) comparing the use of any opioid, simple analgesic or NSAID during SWL were included. These were compared with themselves, each-other or placebo. We included any route or form of administration (bolus, PCA). We excluded agents that were used for their sedative qualities. Data were extracted and assessed for quality independently by three reviewers. Meta-analyses have been performed where possible. When not possible, descriptive analyses of variables were performed. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals. Results Overall, we included 9 RCTs (539 participants from 6 countries). Trial agents included 7 types of NSAIDs, 1 simple analgesic and 4 types of opioids. There were no significant differences in clinical efficacy or tolerability between a simple analgesic (paracetamol) and an NSAID (lornoxicam). When comparing the same simple analgesic with an opioid (tramadol), both agents provided safe and effective analgesia for the purpose of SWL with no significant differences. There were no significant differences in pain scores between NSAIDs or opioids in three studies. Adequate analgesia could be achieved more often for opioids than for NSAIDs (RR 0.358; 95% CI 043 to 0.77, P=0.0002) but consumed doses of rescue analgesia were similar between NSAIDs and opioids in two studies (P=0.58, >0.05). In terms of tolerability, there is no difference in post-operative nausea and vomiting (PONV) between the groups (RR 0.72, 95% CI 0.24 to 2.17, P=0.55). One study compared outcomes between two types of NSAIDs (diclofenac versus dexketoprofen). There were no significant differences in any of our pre-defined outcomes measures. Conclusion Simple analgesics, NSAIDs and opioids can all reduce the pain associated with shock wave lithotripsy to a level where the procedure is tolerated. Whilst there are no compelling differences in safety or efficacy of simple analgesics and NSAIDs, analgesia is described as adequate more often for opioids than NSAIDs.

Analgesia for patients undergoing shockwave lithotripsy for urinary stones - a systematic review and meta-analysis.

BACKGROUND: Shock wave lithotripsy (SWL) is the first line treatment modality for a significant proportion of patients with upper urinary tracts stones. Simple analgesics, opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are all suitable agents but the relative efficacy and tolerability of these agents is uncertain. OBJECTIVES: To determine the efficacy of the different types of analgesics used for the control of pain during SWL for urinary stones. MATERIALS AND METHODS: We searched the Cochrane Renal Group's Specialised Register, MEDLINE, EMBASE and also hand-searched reference lists of relevant articles (Figure-1). Randomised controlled trials (RCT's) comparing the use of any opioid, simple analgesic or NSAID during SWL were included. These were compared with themselves, each-other or placebo. We included any route or form of administration (bolus, PCA). We excluded agents that were used for their sedative qualities. Data were extracted and assessed for quality independently by three reviewers. Meta-analyses have been performed where possible. When not possible, descriptive analyses of variables were performed. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals. RESULTS: Overall, we included 9 RCTs (539 participants from 6 countries). Trial agents included 7 types of NSAIDs, 1 simple analgesic and 4 types of opioids. There were no significant differences in clinical efficacy or tolerability between a simple analgesic (paracetamol) and an NSAID (lornoxicam). When comparing the same simple analgesic with an opioid (tramadol), both agents provided safe and effective analgesia for the purpose of SWL with no significant differences. There were no significant differences in pain scores between NSAIDs or opioids in three studies. Adequate analgesia could be achieved more often for opioids than for NSAIDs (RR 0.358; 95% CI 043 to 0.77, P=0.0002) but consumed doses of rescue analgesia were similar between NSAIDs and opioids in two studies (P=0.58, >0.05). In terms of tolerability, there is no difference in post-operative nausea and vomiting (PONV) between the groups (RR 0.72, 95% CI 0.24 to 2.17, P=0.55). One study compared outcomes between two types of NSAIDs (diclofenac versus dexketoprofen). There were no significant differences in any of our pre-defined outcomes measures. CONCLUSION: Simple analgesics, NSAIDs and opioids can all reduce the pain associated with shock wave lithotripsy to a level where the procedure is tolerated. Whilst there are no compelling differences in safety or efficacy of simple analgesics and NSAIDs, analgesia is described as adequate more often for opioids than NSAIDs.

Acute viral respiratory infections among children in MERS-endemic Riyadh, Saudi Arabia, 2012-2013.

The emergence of the Middle East Respiratory Syndrome (MERS) in Saudi Arabia has intensified focus on Acute Respiratory Infections [ARIs]. This study sought to identify respiratory viruses (RVs) associated with ARIs in children presenting at a tertiary hospital. Children (aged ≤13) presenting with ARI between January 2012 and December 2013 tested for 15 RVs using the SeeplexR RV15 kit were retrospectively included. Epidemiological data was retrieved from patient records. Of the 2235 children tested, 61.5% were ≤1 year with a male: female ratio of 3:2. Viruses were detected in 1364 (61.02%) children, 233 (10.4%) having dual infections: these viruses include respiratory syncytial virus (RSV) (24%), human rhinovirus (hRV) (19.7%), adenovirus (5.7%), influenza virus (5.3%), and parainfluenzavirus-3 (4.6%). Children, aged 9-11 months, were most infected (60.9%). Lower respiratory tract infections (55.4%) were significantly more than upper respiratory tract infection (45.3%) (P < 0.001). Seasonal variation of RV was directly and inversely proportional to relative humidity and temperature, respectively, for non MERS coronaviruses (NL63, 229E, and OC43). The study confirms community-acquired RV associated with ARI in children and suggests modulating roles for abiotic factors in RV epidemiology. However, community-based studies are needed to elucidate how these factors locally influence RV epidemiology. J. Med. Virol. 89:195-201, 2017. © 2016 Wiley Periodicals, Inc.

Laparoscopic nephrectomy - Pfannenstiel or expanded port site specimen extraction: a systematic review and meta-analysis.

INTRODUCTION: To anaylse the current evidence regarding the safety, feasibility and advantages of intact specimen extraction via various extraction sites after conventional laparoscopic nephrectomy (LN). MATERIAL AND METHODS: A comprehensive literature search was performed identifying studies evaluating outcomes from Pfannenstiel (PFN) versus extended port site (EPS) extraction sites, after conventional laparoscopic nephrectomy/nephroureterectomy (LRN/LNU) and donor nephrectomy (LDN). Outcome measures included procedure duration, incision length, duration of inpatient stay, analgesic requirements, complications and warm ischemia time (for donor nephrectomy cases). RESULTS: This systematic review of five comparative studies found no significant difference in morbidity, wound length, wound complications or opioid consumption across all studies. Inpatient stay (p = 0.03) and estimated blood loss (p = 0.03) were significantly less in favour of a PFN extraction site. When comparing radical nephrectomy cases alone, the PFN group had a shorter procedure time (NS), less estimated blood loss (p = 0.04), shorter inpatient stay (p <0.05), significantly less morphine use (p <0.006) and fewer wound complications. CONCLUSIONS: This review demonstrates the viability of retrieving a nephrectomy specimen/graft through a PFN incision in relation to the benefits of cosmesis and reduced pain. As reported in several trials, morbidity is not significantly increased and key outcome measures, such as duration of inpatient stay, pain scores, complications, analgesic requirements and time taken to return to normal activities, remain non-inferior. This study is limited by the small number of generally low quality studies available for analysis. Further well-constructed randomised controlled trials are needed to shed more light on this subject area.

Intracranial metastasis of adenocarcinoma of the prostate presenting with symptoms of spinal cord compression.

Spinal cord compression is a not uncommon complication of metastatic prostate cancer. Intracranial metastasis of prostatic adenocarcinoma is however unusual. We report a case of a 67-year-old man with metastatic prostate carcinoma, who presented with a 3-day history of lower limb weakness and collapse. Neurological assessment demonstrated increased tone and reduced power in both legs. As he had typical signs and symptoms of spinal cord compression, an MRI of the spine was performed; this demonstrated no evidence of cord compression. A subsequent CT of the brain demonstrated an extensive parafalcine metastasis. This revealed an extensive enhancing mass extending bilaterally along almost the entire length of the falx cerebri, measuring up to 3 cm in width and associated with marked white matter oedema in the adjacent brain bilaterally. Unfortunately, this man succumbed to his illness a few days later. The imaging findings are presented and highlight the importance of brain imaging in patients presenting with suspected cord compression due to prostatic metastatic disease when MR of the spine shows no evidence of cord compression.

Characterisation of MRSA strains isolated from patients in a hospital in Riyadh, Kingdom of Saudi Arabia.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is spreading worldwide and poses a serious public health problem, being present in hospital settings and communities. However, from the Middle East and the Arabian Peninsula few molecular typing data on MRSA strains are currently available. In order to obtain data on the population structure of MRSA in Riyadh, Saudi Arabia, 107 clinical and environmental MRSA isolates were genotyped using a microarray-based assay. RESULTS: Five major MRSA strains from four clonal complexes were identified CC8/ST239-III (20.75%), PVL-positive as well as -negative CC22-IV (18.87% and 9.43%, respectively), PVL-positive CC30-IV (12.26%) and PVL-positive CC80-IV (17.92%). Minor strains, which accounted for less than 3% each, included CC1-IV/SCCfus, PVL-positive CC1/ST772-V, PVL-positive as well as- negative CC5-IV, CC5-IV/SCCfus, CC5-V, CC6-IV, CC45-IV, PVL-negative CC80-IV, PVL-positive CC88-IV, CC97-V and a CC9/ST834-MRSA strain. CONCLUSIONS: Typing of MRSA strains from Riyadh revealed a high diversity of clonal complexes. The prevalence of the genes encoding the Panton-Valentine leukocidin was surprisingly high (54.21%), and a significant rate of resistance markers was detected also in strains considered as community-associated.