Patients' Emotional Talk During Surveillance Cystoscopy for Non-muscle Invasive Bladder Cancer: Opportunities for Improving Communication.

OBJECTIVE: To examine the emotional communication that takes place between patients and health care providers during surveillance cystoscopy for non-muscle invasive bladder cancer (NMIBC). METHODS: Participants were 57 patients with a diagnosis of NMIBC attending for surveillance cystoscopy and 10 health care professionals (HCPs). Cystoscopy procedures were audio-recorded and transcribed verbatim. Two approaches to analysis of transcriptions were undertaken: (1) a template analysis and (2) Verona Coding Definitions of Emotional Sequences. RESULTS: Communication during cystoscopy generally comprised of "social/small talk," "results of the cystoscopy," and "providing instructions to the patient." Emotional talk was present in 41/57 consultations, with 129 emotional cues and concerns expressed by patients. Typically patients used hints to their emotions rather than stating explicit concerns. The majority (86%) of HCPs responses to the patient did not explicitly mention the patient's emotional concern or cue. Urology trainees were less likely than other HCPs to provide space for patients to explore their emotional concerns (t = -1.78, P <.05). CONCLUSION: Emotional communication was expressed by the majority of patients during cystoscopy. While all HCPs responded to patients' emotional communication, there were a number of missed opportunities to "pick-up" on patients' emotional cues and improve communication. Urologists need to be aware of the nuances of patients' emotional communication. Learning to identify and respond appropriately to emotional cues may improve communication with patients.

Transcriptomic changes during stage progression of mycosis fungoides.

BACKGROUND: Mycosis fungoides (MF) is the most common cutaneous T-cell lymphoma, which in the early patch/plaque stages runs an indolent course. However, ~25% of patients with MF develop skin tumours, a hallmark of progression to the advanced stage, which is associated with high mortality. The mechanisms involved in stage progression are poorly elucidated. OBJECTIVES: We sought to address the hypothesis of MF cell trafficking between skin lesions by comparing transcriptomic profiles of skin samples in different clinical stages of MF. METHODS: We performed whole-transcriptome and whole-exome sequencing of malignant MF cells from skin biopsies obtained by laser-capture microdissection. We compared three types of MF lesions: early-stage plaques (ESP, n = 12) as well as plaques and tumours from patients in late-stage disease [late-stage plaques (LSP, n = 10) and tumours (TMR, n = 15)]. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were used to determine pathway changes specific for different lesions which were linked to the recurrent somatic mutations overrepresented in MF tumours. RESULTS: The key upregulated pathways during stage progression were those related to cell proliferation and survival (MEK/ERK, Akt-mTOR), T helper cell (Th)2/Th9 signalling [interleukin (IL)4, STAT3, STAT5, STAT6], meiomitosis (CT45A1, CT45A3, STAG3, GTSF1, REC8) and DNA repair (PARP1, MYCN, OGG1). Principal coordinate clustering of the transcriptome revealed extensive gene expression differences between early (ESP) and advanced-stage lesions (LSP and TMR). LSP and TMR showed remarkable similarities at the level of the transcriptome, which we interpreted as evidence of cell percolation between lesions via haematogenous self-seeding. CONCLUSIONS: Stage progression in MF is associated with Th2/Th9 polarization of malignant cells, activation of proliferation, survival, as well as increased genomic instability. Global transcriptomic changes in multiple lesions may be caused by haematogenous cell percolation between discrete skin lesions.

A pilot study of autologous rectus fascial wrap at the time of artificial urinary sphincter placement in patients at risk of cuff erosion.

PURPOSE: Cuff erosion is one of the dreaded complications of artificial urinary sphincter (AUS) implantation. Patients with a history of pelvic irradiation are at increased risk of erosion. To reduce the risk of erosion we describe a novel technique and report the results in our initial series of patients. MATERIALS AND METHODS: A prospective analysis of patients treated with AUS and rectus fascial wrap was performed. Inclusion criteria were severe urinary incontinence (UI) and previous pelvic radiation therapy (RTX). Primary outcomes were erosion rate, complications and continence rate. Secondary outcomes were patient satisfaction. RESULTS: Twenty-three patients were analysed. The median age was 70 years. Nine (39%) had previous surgery; 6/9 had an Advance sling, 2/9 had a Virtue sling, and 1/9 had an AUS which had eroded. Median pad use was five pads/day IQR, (4-6). Median pad weight was 630 ml, 6 cm of fascia was harvested in every case, but cuff size varied. Complications occurred in 6/23 (26%): two patients with Clavien 1 and four patients with Clavien 3B (urinary retention requiring suprapubic catheter). In all cases, the retention resolved. One patient presented at 3 months post-op with erosion (4.3% erosion rate). Median follow-up was 32 months, IQR (24-37). Excluding the patient with erosion, 17/22 (77.3%) of patients achieved complete continence, while 5/22 (22.7%) achieved social continence. CONCLUSION: The autologous fascial wrap technique is efficient and easy to harvest, with comparable clinical outcomes to other techniques. The medium-term results have been encouraging, but longer-term follow up is needed.

Modifications to Botulinum toxin A delivery in the management of detrusor overactivity recalcitrant to initial injections: a review.

PURPOSE: One quarter of patients will not respond to initial intra-detrusor Botulinum toxin A (BTX) injections for detrusor overactivity. Alternative treatment options include long-term catheterization, sacral neuromodulation, urinary diversion or bladder augmentation. Some of these procedures are invasive. This review explores modifications to BTX delivery that can improve outcome. METHODS: A search of Medline, Embase and Cochrane Library to December 2017 was performed according to Preferred Reporting Items for Systematic Review and Metaanalysis (PRISMA) guidelines. Search criteria included, dose escalation, increasing injection site number, trigone injection, switching preparation and alternative methods of BTX delivery. RESULTS: Several modifications to BTX delivery may improve response. There is moderate evidence that increasing the dose from 100 U to 200 U results in statistically better symptom control. Trigone-including injections were associated with significantly improved patient-reported symptom scores, as well as superior results in urodynamic outcomes without risking urinary retention and vesico-ureteric reflux. Switching from onabotulinum (OTA) or abobotulinum (ATA) or vice versa may also improve response in over 50% of patients as shown in limited studies. Increasing the number of injection sites is not beneficial. Indeed, decreasing the number of injections to as low as three sites does not result in decreased clinical outcomes. Injection-free delivery is associated with lower efficacy compared to conventional intradetrusor injections. CONCLUSION: Before contemplating alternative treatments, practitioners can try to improve on BTX delivery. Firstly, the dose can be increased to 200 U; the trigone included in the injection sites and switching brands may also be helpful.

RIRS in the elderly: Is it feasible and safe?

BACKGROUND: The aim of this study was to compare the safety and efficacy of RIRS in men ≥65 years to those <65 years. MATERIALS AND METHODS: Patients who underwent RIRS were prospectively collected from March 2013 to March 2014 in 5 European centers. Perioperative outcomes and complications in elderly men were compared with men <65 years. Univariable and multivariable analyses were performed for factors predicting overall complications. The groups were compared using Mann-Whitney U test. Categorical variables were compared using chi-squared test and the Yates correction or the Fisher's exact test. RESULTS: A total of 399 patients with renal stones were included, 308 (77.19%) were aged <65 years, 91 (22.8%) were aged ≥65 years. Elderly patients were more likely to have higher ASA scores (35.7% vs 92.3%; p < 001), Charlson Comorbidity Index (1.8 vs. 5.2, p < 0.001), hyperlipidemia (10.06% vs. 30.76%; p = 0,0005) and coronary heart disease (5.51% vs. 17.58; p = 0.005) compared to younger cohort. Perioperative outcomes (stone free rate, operative time and re-intervention rate) did not show differences between the two groups (p > 0.05). Surgical and medical complication rates were similar between the cohorts (14.28% vs 9.89%; p = 0.38). Multivariate analysis did not identify any predictive factors of complications among the two groups (p > 0.05). CONCLUSIONS: In this study, elderly RIRS patients had comparable short term efficacy and perioperative complications to younger patients, despite a higher prevalence of comorbidity. Age itself should not be considered as a risk factor for the development of complications in patients undergoing RIRS for renal stone.

Is confirmation of ureteric stent placement in laparoscopic pyeloplasty necessary?

PURPOSE: Placement of an antegrade double-J (JJ) ureteric stent is an important component of pyeloplasty. Correct siting of distal end of the stent in the bladder is essential for ease of removal. To date, no studies have compared methods for confirming stent position. This study aims to address that void in the literature. METHODS: Eligible patients underwent laparoscopic pyeloplasty with antegrade stent placement at our institution from 2007 to 2015 inclusive. Methods to verify distal stent position of rigid cystoscopy, artificial bladder filling or no confirmation were compared. Effectiveness was determined by the proportion of malpositioned stents detected intra-operatively compared to the total found malpositioned, both intra-operatively and during follow-up. RESULTS: A total of 75 patients underwent laparoscopic pyeloplasty. Forty-six (61.3%) patients had distal stent position assessed intra-operatively, comprising 27 by cystoscopy and 19 by artificial bladder filling, while for 29 (38.7%) patients no verification method was used. Cystoscopy, artificial bladder filling and no confirmation detected intra-operatively 2, 1 and 0 malpositioned stents, from malpositioned stent totals of 2, 2 and 1, respectively. CONCLUSION: Malposition of JJ ureteric stent is uncommon, and omitting intra-operative position verification appears reasonable in select cases. Artificial bladder filling can help detect malpositioned JJ stents without repositioning the patient for cystoscopy. However, our results suggest both may be unreliable. If stent malposition is suspected, certainty is desired or extended operative duration is less critical, then the surgeon should proceed with cystoscopy.

The Effect of Obesity and Increased Waist Circumference on the Outcome of Laparoscopic Nephrectomy.

Introduction. The prevalence of obesity is increasing worldwide. Obesity can be determined by body mass index (BMI); however waist circumference (WC) is a better measure of central obesity. This study evaluates the outcome of laparoscopic nephrectomy on patients with an abnormal WC. Methods. A WC of >88 cm for women and >102 cm for men was defined as obese. Data collected included age, gender, American Society of Anaesthesiologists (ASA) score, renal function, anaesthetic duration, surgery duration, blood loss, complications, and duration of hospital stay. Results. 144 patients were assessed; 73 (50.7%) of the patients had abnormal WC for their gender. There was no difference between the groups for conversion to open surgery, number of ports used, blood loss, and complications. Abnormal WC was associated with a longer median anaesthetic duration, 233 min, IQR (215-265) versus 204 min, IQR (190-210), p = 0.0022, and operative duration, 178 min, IQR (160-190) versus 137 min, IQR (128-162), p < 0.0001. Patients with an abnormal WC also had a longer inpatient stay, p = 0.0436. Conclusion. Laparoscopic nephrectomy is safe in obese patients. However, obese patients should be informed that their obesity prolongs the anaesthetic duration and duration of the surgery and is associated with a prolonged recovery.

The surgical experience influences the safety of retrograde intrarenal surgery for kidney stones: a propensity score analysis.

The aim of this study is to evaluate if surgical experience could influence the outcomes of retrograde intrarenal surgery (RIRS) in terms of stone clearance and complication rate. Patients from five institutions were included in this study. Patients were divided into two groups. Group 1: patients treated by three surgeons in the early phase of learning curve (surgical experience <100 procedures); Group 2: cases operated by two surgeons with great endourological experience (>400 procedures). Patients and stone characteristics, outcome and complications were analyzed. Multivariable regression model was used. Differences between groups were estimated using propensity scores to adjust for the bias inherent to the different characteristics. 381 RIRS were analyzed (Group 1: 150 RIRS; Group 2: 231 RIRS). Clinical data and stone parameters were comparable. The SFR was 70 % in Group 1 and 77.9 % in Group 2 (p = 0.082). Operative time was significantly shorter in the Group 2 (76.3 vs. 53.1 min, p = 0.001). The overall complication rate was significantly lower in Group 2 (20.7 vs. 8.7, p = 0.001). At unadjusted analysis, a non-significant difference was found between centers on SFR (OR 1.51 95 % CI 0.95-2.41). Conversely, a significant difference was found on overall complications (OR 0.36 95 %CI 0.20-0.67) with lower overall complication in Group 2. This study shows that surgeon experience influences the outcomes of RIRS mainly in terms of safety. Further studies will be needed to assess the exact number of procedures necessary to obtain a plateau in the rate of complications and success.

Radiographer Delivered Fluoroscopy Reduces Radiation Exposure During Endoscopic Urological Procedures.

INTRODUCTION: The 1999 Ionising Radiation Regulations recommend that medical professionals using ionising radiation should aim to keep exposure as 'low as reasonably practicable'. Urologists regularly use fluoroscopy during endoscopic surgical procedures. In some institutions, this is delivered by a radiographer whereas in others, it is delivered by the urological surgeon. OBJECTIVES: To determine if radiographer-delivered fluoroscopy can reduce the exposure to ionising radiation during urological procedures. METHODS: An analysis of 395 consecutive patients, who underwent endoscopic urological procedures requiring fluoroscopy, was performed simultaneously across two institutions, over a 4 month period. 321 patients were matched and included in the analysis. RESULTS: Radiographer delivered fluoroscopy was associated with reduced ionising radiation exposure for retrograde pyelography procedures ED 0.09626 vs. 1.323 mSev, p= 0.0003, and endoscopic stone surgeries ED 0.3066 Vs. 0.5416 mSev, p=0.0039, but not for ureterorenoscopic stone surgeries 0.4880 vs. 0.2213 mSev, p=0.8292. CONCLUSION: Radiographer delivered fluoroscopy could reduce the patient's exposure to ionising radiation for some urological procedures.

Management of recalcitrant urethral strictures with self-dilatation balloon catheter.

INTRODUCTION: Urethral strictures constitute a significant clinical problem that often requires long-term management. OBJECTIVE: To report the long-term outcomes of adjuvant home self-urethral dilatation of recurrent urethral strictures using a balloon catheter. MATERIALS AND METHODS: Male patients (N = 11), performing self-dilatation with a balloon catheter (minimum 24 months) were assessed by patient-reported outcome measures (PROMs) health questionnaire specific for post treatment assessment of men with urethral stricture disease. RESULTS: Median duration of balloon catheter use is 46.5 months, IQR (24-150). Patients performed self-balloon dilatation on average 1.4 times a week, median 1, IQR (1-2) to maintain the patency of their urethra. The mean PROMs LUTS score of the patients was 2.45, median 2, IQR (1-4). The median and mean Peeling score was 2 IQR (1-2). 100 % patient reported that they either very satisfied or satisfied with the overall outcome and QoL. CONCLUSIONS: Our initial experience of outpatient self-dilatation with a balloon dilatation is encouraging and is an acceptable inexpensive and simple treatment for patient maintains urethral patency and potentially decreases stricture recurrence.

Paraoesophageal hernia: an overview.

Paraoesophageal hernias are a rare but clinically important type of hiatus hernia. Gastric volvulus and perforation may ensue. Investigation and management is determined by patient presentation. This review summarizes current research regarding paraoesophageal hernias.

Torsion of monofilament and polyfilament sutures under tension decreases suture strength and increases risk of suture fracture.

BACKGROUND: A continuous running suture is the preferential method for abdominal closure. In this technique the suture is secured with an initial knot and successive tissue bites are taken. At each tissue bite, the needle is rotated through the tissue; in doing so, the suture can twist around the knot which acts as an anchor. OBJECTIVE: To determine the effect of axial torsional forces on sutures used in abdominal closure. METHODS: The effect of axial twisting on polydioxanone (PDS*II), polyglactin (Vicryl), polypropylene (Prolene) and nylon (Ethilon) sutures was investigated using a uniaxial testing device. RESULTS: The maximum tensile force withstood for untwisted sutures was determined: polydioxanone failed at a tensile force of 116.4±0.84 N, polyglactin failed at 113.9±2.4 N, polypropylene failed at 71.1±1.5 N and nylon failed at 61.8±0.5 N. Twisting decreased the maximum tensile force of all sutures; one complete twist per 10 mm (i.e., 15 twists) decreased the tensile strength of polydioxanone by 21%, polyglactin by 23%, polypropylene by 16% and nylon by 13%, p<0.001. Excessive twisting caused a nonlinear decrease in suture strength, with one twist per 75 mm (i.e., 20 twists) of polydioxanone decreasing strength by 39%, P<0.001. CONCLUSION: The effect of excessive twisting on the mechanical properties of sutures is a previously unrecognised phenomenon. Surgeons should be aware that this can result in a decrease in suture strength and reduce the elasticity of the material, and therefore need to adapt their practice to reduce the torsional force placed on sutures.

Observation of B --> K(+/-) pi(0) and B --> (K)0 pi(0), and evidence for B --> pi(+)pi(-).

We have studied charmless hadronic decays of B mesons into two-body final states with kaons and pions and observe three new processes with the following branching fractions: beta(B-->pi(+)pi(-)) = (4.3(+1. 6)(-1.4)+/-0.5)x10(-6), beta(B-->K(0)pi(0)) = (14.6(+5.9+2.4)(-5.1-3. 3))x10(-6), and beta(B-->K(+)/-pi(0)) = (11.6(+3.0+1.4)(-2.7-1.3))x10(-6). We also update our previous measurements for the decays B-->K(+)/-pi(-/+) and B+/--->K(0)pi(+/-).

Two-body B meson decays to eta and eta('): observation of B --> eta K*.

In a sample of 19 x 10(6) produced B mesons, we have observed the decays B-->eta K(*) and improved our previous measurements of B-->eta'K. The branching fractions we measure for these decay modes are B(B+-->eta K(*+)) = (26.4(+9.6)(-8.2)+/-3.3)x10(-6), B(B(0)-->eta K(*0)) = (13.8(+5.5)(-4.6)+/-1.6)x10(-6), B(B(+)-->eta'K(+) = (80(+10)(-9)+/-7)x10(-6), and B(B(0)-->eta'K0) = (89(+18)(-16)+/-9)x10(-6). We have searched with comparable sensitivity for related decays and report upper limits for these branching fractions.

Measurement of charge asymmetries in charmless hadronic B meson decays.

We search for CP-violating charge asymmetries (alpha(CP)) in the B meson decays to K(+/-)pi(-/+), K(+/-)pi(0), K(0)(S)pi(+/-), K(+/-)eta('), and omega pi(+/-). Using 9.66 million upsilon(4S) decays collected with the CLEO detector, the statistical precision on alpha(CP) is in the range of +/-0.12 to +/-0.25 depending on decay mode. While CP-violating asymmetries of up to +/-0.5 are possible within the standard model, the measured asymmetries are consistent with zero in all five decay modes studied.

Aftercataracts.

A Soemmering ring cataract with opacified lens capsule is presented as a representative case report of aftercataract occurring secondary to perforating trauma of the anterior lens capsule. The various types and causes of aftercataracts are discussed as well as their management.

Relation of symptoms to accommodative infacility of school-aged children.

Conventional optometric wisdom holds that accommodative infacility may result in asthenopic symptoms, yet the literature contains little support for this belief. We determined whether failure to achieve 8 cycles per minute of binocular accommodative facility or 11 cycles per minute of monocular accommodative facility tends to be associated with symptoms. Sixty subjects were given questionnaires to determine whether they were symptomatic. Monocular and binocular accommodative rock using plus and minus 2 D lenses was performed. Statistical analysis indicates that symptomatic subjects performed significantly poorer than asymptomatic subjects on both monocular and binocular facility tests. Patients presenting with asthenopic symptoms should therefore be tested for accommodative infacility.