Robotic-assisted radical prostatectomy-impact of a mentorship program on oncological outcomes during the learning curve.

BACKGROUND AND AIMS: The learning curve for robotic-assisted radical prostatectomy (RARP) is estimated to be about 50-200 cases. This study will evaluate the benefit of a mentorship programme after completing a mini-fellowship in RARP by an experienced surgeon who previously trained in open and laparoscopic surgery. METHODS: Our study was a retrospective comparative analysis of RARP performed by a single consultant urologist. A retrospective chart review of the first 120 cases was performed. The 120 patients were divided into three groups of 40 cases. For the first 40 cases, an appropriately qualified mentor was present. The peri-operative and oncological outcomes were compared between the three groups. RESULTS: Operative times significantly decreased with experience (250 min vs 234 min vs 225 min, p < 0.05). Complication rates, estimated blood loss, and length of stay were similar between all groups. There was a higher rate of positive margins in the final group (20% vs 17.5% vs 32.5%, p < 0.5). There was a greater number of pT3 tumours in group 3 (42%, n = 17) compared to groups 1 and 2 (20%, n = 8, and 22.5%, n = 9) which may account for the higher rate of positive margins in this group. CONCLUSION: In the transition of an experienced laparoscopic surgeon to robotic surgery, we showed that there is a benefit of a mentorship programme after a mini-fellowship in reducing the impact of the learning curve on patient outcomes. Ongoing mentorship may be of benefit in cases where a high volume of tumour is suspected and should be avoided in the early part of the learning curve to maximise oncological outcomes.

Spermatic vein embolization as a treatment for symptomatic varicocele.

INTRODUCTION: Varicocele is a relatively common condition in men that causes pain in approximately 10% of cases. There have been few studies to date assessing the improvements in both pain and quality of life parameters associated with spermatic vein embolization (SVE) as a treatment for patients with symptomatic varicocele, so we aimed to assess this. METHODS: A review was carried out of consecutive SVE procedures performed at our institution from 2013-2019. Only patients with painful varicocele were included after other causes of testicular pain were excluded. The technique employed was a combination of distal coil embolization of the spermatic vein with 4-6 mm coils at the level of the inguinal canal, as well as sclerotherapy to prevent reflux of sclerosant. Furthermore, a prospective validated Pain Impact Questionnaire-6 (PIQ-6) was performed to assess for improvement in quality of life. A matched pair Student two-tailed t-test was used to compare mean scores pre- and post-treatment, with 95% confidence intervals presented as T scores and their associated p-values. RESULTS: Over six years, 62 SVE procedures were performed for symptomatic varicocele. Success rate was 95%, with a median followup of nine months. Two patients had a failed procedure on two occasions requiring subsequent surgical ligation. There was one clinically significant recurrence. All components of PIQ-6 score showed a statistically significant reduction post-SVE, most noticeably pain severity and impact on leisure activities. CONCLUSIONS: SVE is a safe, effective, and well-tolerated treatment for symptomatic varicocele, improving pain and quality of life.

Prostate cancer detection with magnetic resonance imaging (MRI)/ cognitive fusion biopsy: Comparing standard and targeted prostate biopsy with final prostatectomy histology.

INTRODUCTION: The use of multiparametric magnetic resonance imaging (MRI) with targeted biopsies of the prostate improves the diagnosis of clinically significant prostate cancer. Recent studies have shown that targeted prostate biopsies also more accurately predict final histopathology after radical prostatectomy (RP). There are three broad techniques for performing MRI-targeted prostate biopsy: cognitive MRI/ultrasound (US) fusion, software MRI/US fusion, and in-bore MRI-guided. Current practices recommend that a standard systematic 12-core prostate biopsy be performed, as well as targeted biopsies in patients with positive MRI findings. This study aimed to evaluate the accuracy of histological grading of cognitive MRI/US fusion prostate biopsy by comparing the histology from the targeted biopsy specimens (TB), standard systematic specimens (SB), and the combination of both (CB) specimens with the final histological grade from subsequent prostatectomy. METHODS: A retrospective, single-center review of 115 patients who underwent standard systematic and cognitive MRI/US-targeted biopsy of the prostate before undergoing a RP between 2016 and 2019 was performed. MRI findings, biopsy, final histology International Society of Urological Pathology (ISUP) grades, and patient demographics were collected. Cochran's Q test and McNemar test were used to compare the differences in upgrading, downgrading, and concordance between each biopsy group. RESULTS: The concordance between SB, TB, and CB biopsy were 28.7%, 49.6%, and 50.4%, respectively. There was no significant difference in concordance between TB and CB. Patients were more likely to be downgraded on the final histology when comparing CB with TB alone (26.1% vs. 16.5%, p<0.05). In cases where an ISUP grade 1 cancer was diagnosed on TB (n=24), there was a 62.5% chance that the final histology would be upgraded. In the same sample, when combined with a SB, the risk of upgrading on final histology was reduced to 37.5%. CONCLUSIONS: Although grading concordance between TB and CB were similar, the concomitant use of a SB significantly reduced the rate of upgrading in the final RP histopathology. CB may result in better decision-making regarding treatment options and also have implications for intraoperative planning.

Ipsilateral robot assisted laparoscopic side to side ureteroureterostomy in a duplex collecting system - A video case report with 1 year follow up.

A 26-year-old male presented with an obstructing calculus in the mid superior-moiety ureter in a duplicated urinary collecting-system. A sequela of the obstruction resulted in a symptomatic stricture in a functional superior-moiety ureter, unresponsive to endoscopic interventions. An ipsilateral robot-assisted laparoscopic side-to-side ureteroureterostomy was performed thus bypassing the stricture in the superior-moiety ureter. Follow up endoscopic visualisation showed a healthy, patent anastomosis. This video presentation shows appropriate positioning, operative technique and follow up for a robot assisted side-to-side ureteroureterostomy. Our minimally invasive novel method is a feasible and safe treatment of a duplex collecting system with a symptomatic ectopic ureter.

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.

The sentinel stent? A systematic review of the role of prophylactic ureteric stenting prior to colorectal resections.

PURPOSE: 'Prophylactic' ureteric stents potentially reduce rates, and facilitate intraoperative recognition, of iatrogenic ureteric injury (IUI) during colorectal resections. A lack of consensus surrounds the risk-benefit equation of this practice, and we aimed to assess the evidence base. METHODS: A systematic review was performed according to PRISMA guidelines. MEDLINE, Scopus, EMBASE and Cochrane databases were searched using terms 'ureteric/ureteral/JJ/Double J stent' or 'ureteric/ureteral catheter' and 'colorectal/prophylactic/resection/diverticular disease/diverticulitis/iatrogenic injury'. Primary outcomes were rates of ureteric injuries and their intraoperative identification. Secondary outcomes included stent complication rates. RESULTS: We identified 987 publications; 22 papers met the inclusion criteria. No randomised controlled trials were found. The total number of patients pooled for evaluation was 869,603 (102,370 with ureteric stents/catheters, 767,233 controls). The most frequent indications for prophylactic stents were diverticular disease (45.38%), neoplasia (33.45%) and inflammatory bowel disease (9.37%). Pooled results saw IUI in 1521/102,370 (1.49%) with, and in 1333/767,233 (0.17%) without, prophylactic ureteric stents. Intraoperative recognition of IUIs occurred in 10/16 injuries (62.5%) with prophylactic stents, versus 9/17 (52.94%) without stents (p = 0.579). The most serious complications of prophylactic stent use were ureteric injury (2/1716, 0.12%) and transient ureteric obstruction following stent removal (13/666, 1.95%). CONCLUSIONS: Placement of prophylactic ureteric stents has a low complication rate. There is insufficient evidence to conclude that stents decrease ureteric injury or increase intraoperative detection of IUIs. Apparently higher rates of IUI in stented patients likely reflect use in higher risk resections. A prospective registry with harmonised data collection points and stratification of intraoperative risk is needed.

Neoadjuvant Platinum-Based Chemotherapy is an Independent Predictor for Preoperative Thromboembolic Events in Bladder Cancer Patients Undergoing Radical Cystectomy.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) confers a significant survival benefit in patients with muscle invasive bladder cancer. Platinum-based chemotherapy increases the risk of thromboembolic events (TEE). We determined the effect of cisplatin-based NAC on the incidence of preoperative TEEs in radical cystectomy patients. MATERIALS AND METHODS: A retrospective matched case-control study was performed on 55 patients undergoing radical cystectomy for muscle invasive bladder cancer. Group 1 (n = 20) included patients that received NAC prior to radical cystectomy and Group 2 (n = 35) included patients that underwent radical cystectomy without NAC. Logistic regression analyses tested potential predictors for TEEs in both groups (age, American Society of Anesthesiologists grade, use of NAC, histological subtype, pathological stage). RESULTS: In total, 6 patients of 55 developed a TEE. Five patients of 20 (25%) treated with NAC prior to radical cystectomy developed TEEs, while 1 of 35 (2.9%) treated with radical cystectomy alone developed a TEE. On univariate and multivariate regression analysis, NAC prior to radical cystectomy was an independent predictor for TEE prior to radical cystectomy (p = 0.033 and p = 0.043, respectively). The effect of perioperative anticoagulation on operative blood loss and postoperative hemoglobin level was not statistically significant between both groups (p = 0.22 and p = 0.08, respectively). CONCLUSION: Neoadjuvant cisplatin-based chemotherapy is a significant predictor for preoperative TEE in patients undergoing radical cystectomy.

Identification and Cost of Disposable Endourological Devices for Nephrolithiasis: A Cross-Sectional Study Among Urological Trainees.

INTRODUCTION: Knowledge on health economics among urology trainees is not formally assessed. The cost of commonly utilised endourological devices may not be considered by trainees. AIM: The present study was conducted with the aim to assess whether urology trainees were knowledgeable on identification and cost of commonly used disposable devices in the management of nephrolithiasis. MATERIALS AND METHODS: Forty urology trainees in Ireland were invited to complete a visual online questionnaire on the identification of 10 frequently utilised disposable endourological devices. In addition, trainees were requested to estimate the cost of 12 disposable endourological devices. Responses were stratified according to trainee grade and urological subspecialty of interest. Data are presented as a mean ± standard deviation. RESULTS: The response rate was 70% (28/40). Endourology was the subspecialty of interest in 21% (n= 6). No trainee correctly identified all 10 endourological devices and the mean test score was 5.32 ± 2.28. No trainee accurately estimated the cost for all 12 devices assessed. The cost of endourological devices was underestimated by €67.13 ± €60.76 per device. A total of 54% (n=15) of trainees underestimated the total cost of disposable devices used during standard flexible ureterorenoscopy, laser lithotripsy and JJ stent insertion by €303.66 ± €113.83. CONCLUSION: Our findings indicate deficiencies in trainee knowledge on endourological devices and their associated costs. Incorporating a health economics module into postgraduate urology training may familiarise trainees with healthcare expenditure within their departments.

Comparative effectiveness of adrenal sparing radical nephrectomy and non-adrenal sparing radical nephrectomy in clear cell renal cell carcinoma: Observational study of survival outcomes.

INTRODUCTION: We compare the survival outcomes of patients with clear cell renal cell carcinoma (RCC) treated with adrenal sparing radical nephrectomy (ASRN) and non-adrenal sparing radical nephrectomy (NASRN). METHODS: We conducted an observational study based on a composite patient population from two university teaching hospitals who underwent RN for RCC between January 2000 and December 2012. Only patients with pathologically confirmed RCC were included. We excluded patients undergoing cytoreductive nephrectomy, with loco-regional lymph node involvement. In total, 579 patients (ASRN = 380 and NASRN = 199) met our study criteria. Patients were categorized by risk groups (all stage, early stage and locally advanced RCC). Overall survival (OS) and cancer-specific survival (CSS) were analyzed for risk groups. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression. RESULTS: The median follow-up was 41 months (range: 12-157). There were significant benefits in OS (ASRN 79.5% vs. NASRN 63.3%; p = 0.001) and CSS (84.3% vs. 74.9%; p = 0.001), with any differences favouring ASRN in all stage. On multivariate analysis, there was a trend towards worse OS (hazard ratio [HR] 1.759, 95% confidence interval [CI] 0.943-2.309, p = 0.089) and CSS (HR 1.797, 95% CI 0.967-3.337, p = 0.064) in patients with NASRN (although not statistically significant). Of these patients, only 11 (1.9%) had adrenal involvement. CONCLUSIONS: The inherent limitations in our study include the impracticality of conducting a prospective randomized trial in this scenario. Our observational study with a 13-year follow-up suggests ASRN leads to better survival than NASRN. ASRN should be considered the gold standard in treating patients with RCC, unless it is contraindicated.

Renal Trauma: The Rugby Factor.

INTRODUCTION: Renal trauma accounts for 5% of all trauma cases. Rare mechanisms of injuries including sports participation are increasingly common. Rugby-related trauma poses a conundrum for physicians and players due to the absence of clear guidelines and a paucity of evidence. Our series highlights traumatic rugby-related renal injuries in our institution, and emphasize the need for international guidelines on management. METHODS: A retrospective review of all abdominal traumas between January 2006 and April 2013, specifically assessing for renal related trauma that were secondary to rugby injuries was performed. All patients' demographics, computerized tomography results, hematological and biochemical results and subsequent management were recorded. RESULTS: Five male patients presented with rugby-related injuries. Mean age was 21 years old. All patients were hemodynamically stable and managed conservatively in acute setting. One patient was detected to have an unknown pre-existing atrophic kidney that had been subsequently injured, and was booked for an elective nephrectomy an 8-week interval. CONCLUSION: Rugby-related trauma has generated essential attention. This paper serves to highlight this type of injury and the need for defined guidelines on role of imaging and international consensus on timing of return to contact sport, in both professional and amateur settings.

Clinico-pathological analysis of renal cell carcinoma demonstrates decreasing tumour grade over a 17-year period.

INTRODUCTION: Renal cell carcinoma (RCC) represents about 3% of adult malignancies in Ireland. Worldwide there is a reported increasing incidence and recent studies report a stage migration towards smaller tumours. We assess the clinico-pathological features and survival of patients with RCC in a surgically treated cohort. METHODS: A retrospective analysis of all nephrectomies carried out between 1995 and 2012 was carried out in an Irish tertiary referral university hospital. Data recorded included patient demographics, size of tumour, tumour-node-metastasis (TNM) classification, operative details and final pathology. The data were divided into 3 equal consecutive time periods for comparison purposes: Group 1 (1995-2000), Group 2 (2001-2006) and Group 3 (2007-2012). Survival data were verified with the National Cancer Registry of Ireland. RESULTS: In total, 507 patients underwent nephrectomies in the study period. The median tumour size was 5.8 cm (range: 1.2-20 cm) and there was no statistical reduction in size observed over time (p = 0.477). A total of 142 (28%) RCCs were classified as pT1a, 111 (21.9%) were pT1b, 67 (13.2%) were pT2, 103 (20.3%) were pT3a, 75 (14.8%) were pT3b and 9 (1.8%) were pT4. There was no statistical T-stage migration observed (p = 0.213). There was a significant grade reduction over time (p = 0.017). There was significant differences noted in overall survival between the T-stages (p < 0.001), nuclear grades (p < 0.001) and histological subtypes (p = 0.022). CONCLUSION: There was a rising incidence in the number of nephrectomies over the study period. Despite previous reports, a stage migration was not evident; however, a grade reduction was apparent in this Irish surgical series. We can demonstrate that tumour stage, nuclear grade and histological subtype are significant prognosticators of relative survival in RCC.

Sexual function outcomes following fracture of the penis.

INTRODUCTION: Fracture of the penis is a rare urological emergency which occurs as a result of abrupt trauma to an erect penis. There is paucity of data regarding long-term sexual function or erectile potency following fracture of the penis. The aim of this study is to objectively assess the overall sexual function following fracture of the penis. METHODS: A retrospective analysis of 21 penile fractures was performed. A voluntary telephone questionnaire was performed to assess long term outcomes using three validated questionnaires-the Erection Hardness Grading Scale, the International Index of Erectile Function (IIEF-5) and the Brief Male Sexual Function inventory (BMSFI). RESULTS: The mean age was 33.1 years (range: 19-63). The median follow up was 46 months (range: 3-144). All fractures were a result of sexual misadventure and all were surgically repaired. There were two concomitant urethral injuries. Seventeen patients were contactable. Fourteen patients demonstrated no evidence of erectile dysfunction (ED) (IIEF-5>22), 1 patient reported symptoms of mild ED (IIEF-5, 17-21) and one patient reported mild to moderate ED (IIEF-5, 12-16). No patients reported insufficient erection for penetration (EHGS: 1 or 2). Regarding the overall BMSFI, 13 (83%) patients were mostly satisfied or very satisfied with their sex life within the previous month. CONCLUSION: In a small surgical series of men with penile fracture managed within a short time frame from presentation, we demonstrate erectile potency is maintained. Long-term overall sexual satisfaction is promising.

Can delayed time to referral to a tertiary level urologist with an abnormal PSA level affect subsequent Gleason grade in the opportunistically screened population?

PURPOSE: There is growing conflict in the literature describing the effect of delayed treatment on outcomes following radical prostatectomy. There is also evidence to suggest progression of low-risk prostate cancer to develop higher grades and volumes of prostate cancer during active surveillance. It is unknown as to what affect a delay in referral of those men with abnormal screened-PSA levels have on subsequent Gleason grade. METHODS: We identified 350 men through our rapid access prostate clinic who underwent TRUS biopsy for abnormal age-related PSA and/or abnormal clinical examination. Clinicopathological findings were compared for those with positive versus negative TRUS biopsies, and for those with initial delays in referral (<12 months, 12-18 months, and >18 months). We used ANOVA and Student's t-tests amongst other statistical tools to examine significance of clinical findings. RESULTS: Of the 350 men who underwent TRUS biopsy, those with a delay in referral of 12 months or more were significantly associated with higher PSA titers, clinically palpable disease and likelihood of diagnosis with prostate cancer. A delay of 18 months or more led to a significantly higher risk of being diagnosed with a leading grade 4 prostate cancer, which was further supported using PSA velocity as a diagnostic tool (change >0.4 ng/ml/year). CONCLUSION: We recommend that repeated asymptomatic abnormal age-related PSA readings and/or abnormal clinical examination in the screened population be referred without delay to a urologist for further assessment, enrolment into an active surveillance program or definitive subsequent treatment.

Can we avoid surgery in elderly patients with renal masses by using the Charlson comorbidity index?

OBJECTIVE To determine the safety of surveillance for localized contrast-enhancing renal masses in elderly patients whose comorbidities precluded invasive management; to provide an insight into the natural history of small enhancing renal masses; and to aid the clinician in identifying those patients who are most suitable for a non-interventional approach. PATIENTS AND METHODS We conducted a retrospective chart review of 26 consecutive patients (16 men and 10 women), who were followed for > or =1 year, with localized solid enhancing renal masses between 1998 and 2006. These patients were unfit or unwilling to undergo radical or partial nephrectomy. None had their tumours surgically removed. Study variables included age, presentation, tumour size, growth rate, Charlson comorbidity index (CMI) and available pathological data. RESULTS The mean (range) patient age was 78.14 (63-89) year, with a mean follow-up of 28.1 (12-72) months. The mean tumour size was 4.25 (2.5-8.7) cm at diagnosis. The tumour growth rate was 0.44 cm/year; among smaller masses (T1a) it was 0.15 cm/year, vs 0.64 cm/year in the larger masses (T1b and T2). The mean CMI was 2.96. There were 11 deaths overall; 10 patients died from unrelated illnesses. One death was directly attributable to metastatic renal cancer; this patient had an initial tumour diameter of 5.4 cm and a CMI of 6. All patients who died had a CMI of > or =3. CONCLUSIONS Elderly patients with small renal tumours (T1a) and comorbidity scores of > or =3 were more likely to die as a result of their comorbidities rather than the renal tumour. Surveillance of small renal masses appears to be a safe alternative in elderly patients who are poor surgical candidates, where the overall growth rate appears to be slow.

Squamous cell carcinoma of the renal pelvis after curative retroperitoneal radiotherapy for seminoma.

We report the case of a 71-year-old male who presented with squamous cell carcinoma of the renal pelvis in a solitary functioning kidney, 34 years after orchidectomy and adjuvant retroperitoneal radiotherapy for stage II seminoma. This rare second malignancy occurred in the radiation treatment field. Second malignancies are an uncommon but serious sequela of radiotherapy, with potential for significant health problems in patients with complete remission of primary disease. To our knowledge, this is the first report of squamous cell carcinoma of the renal pelvis occurring after radiation treatment.

Cell death mechanisms associated with G2 radiosensitivity in patients with prostate cancer and benign prostatic hyperplasia.

Cells respond to genotoxic insults such as ionizing radiation by halting in the G2 phase of the cell cycle. Delayed cell death (mitotic death) can occur when the cell is released from G2, and specific spindle defects form endopolyploid cells (endoreduplication/tetraploidy). Enhanced G2 chromosomal radiosensitivity has been observed in many cancers and genomic instability syndromes, and it is manifested by radiation-induced chromatid aberrations observed in lymphocytes of patients. Here we compare the G2 chromosomal radiosensitivity in prostate patients with benign prostatic hyperplasia (BPH) or prostate cancer with disease-free controls. We also investigated whether there is a correlation between G2 chromosomal radiosensitivity and aneuploidy (tetraploidy and endoreduplication), which are indicative of mitotic cell death. The G2 assay was carried out on all human blood samples. Metaphase analysis was conducted on the harvested chromosomes by counting the number of aberrations and the mitotic errors (endoreduplication/tetraploidy) separately per 100 metaphases. A total of 1/14 of the controls were radiosensitive in G2 compared to 6/15 of the BPH patients and 15/17 of the prostate cancer patients. Radiation-induced mitotic inhibition was assessed to determine the efficacy of G2 checkpoint control in the prostate patients. There was no significant correlation of G2 radiosensitivity scores and mitotic inhibition in BPH patients (P = 0.057), in contrast to prostate cancer patients, who showed a small but significant positive correlation (P = 0.029). Furthermore, there was no significant correlation between G2 radiosensitivity scores of BPH patients and endoreduplication/ tetraploidy (P = 0.136), which contrasted with an extremely significant correlation observed in prostate cancer patients (P < 0.0001). In conclusion, cells from prostate cancer patients show increased sensitivity to the induction of G2 aberrations from ionizing radiation exposure but paradoxically show reduced mitotic indices and aneuploidy as a function of aberration frequency.

Management of gestational nephrolithiasis in the presence of a bicornuate uterus and pelvic kidney.

A 39-year-old para 0(+1) woman with known nephrolithiasis within a left-sided pelvic kidney presented with left-sided renal colic at 7 weeks gestation. She had a previous miscarriage due to a bicornuate uterus. Ultrasound and magnetic resonance urography confirmed an incomplete obstruction of the left upper renal tract which was relieved by percutaneous nephrostomy. She presented again at 14 weeks with renal colic and minimal output. An ultrasound confirmed recurrent hydronephrosis and a nephrostogram showed that the catheter had retracted almost completely from the collecting system. This was considered to be due to the upward pressure of the enlarging uterus on the catheter, which had been fixed externally to the skin. This problem was obviated by not securing the replacement nephrostomy tube to the skin. She developed pre-eclamptic toxaemia and gave birth at 35 weeks gestation by caesarean section. The calculus was later dissolved using extra-corporeal shockwave lithotripsy.

Thromboprophylaxis for radical prostatectomy: a comparative analysis of present practice between the USA, the UK, and Ireland.

BACKGROUND: A clinical dilemma exists in the management of patients undergoing radical prostatectomy (RP) whereby measures taken to reduce the risk of thrombotic events may adversely affect efforts to limit blood loss. No consensus exists in the literature on the ideal management of thromboprophylaxis in these patients. Our aim is to examine and compare current thromboprophylactic policy and practice between the centres involved in performing RP. METHODS: A questionnaire was forwarded to all urology residency programmes in Ireland, the United Kingdom, and the United States, regarding their current practice with respect to thromboprophylaxis in RP. Completed questionnaire were returned by fax and the data entered into a computer database. RESULTS: An overall response rate of 60% was achieved. The questionnaires demonstrated a significant difference in clinical practice between Urologists in the United States and the United Kingdom. Just 24% of American Urologists use pharmacological thromboprophylaxis in contrast to 100% of British Urologists. There was no difference in the use of non-pharmacological thromboprophylaxis. Pharmacological thromboprophylaxis is mainly administered by units, mostly in the United Kingdom, doing fewer radical prostatectomies. CONCLUSIONS: While there have been studies advocating the use of pharmacological thromboprophylaxis in patients undergoing major pelvic surgery, there is no consensus on it is use in urological practice. This study has demonstrated significant differences in the management of thromboprophylaxis between the USA and the UK/Ireland. Units performing the largest number of radical prostatectomies, mostly in the USA, do not use pharmacological thromboprophylaxis and most do not use compression boots.

Can prostate biopsies predict suitability for nerve-sparing radical prostatectomy?

OBJECTIVE: The process for selecting patients suitable for nerve-sparing radical prostatectomy (NSRP) has been the source of much debate. In this study we analysed the use of prostate biopsies as the principal selection tool. MATERIAL AND METHODS: Patients undergoing radical retropubic prostatectomy (n = 133) were retrospectively categorized as having "unilateral" (biopsy demonstrated malignancy confined to one side of the gland) or "bilateral" carcinoma. The accuracy and reliability of this categorization were determined by correlation with the final histopathology of the resected radical prostatectomy specimen. RESULTS: Prostate biopsy suggested "unilateral" carcinoma in 30/58 (52%) and 45/75 (60%) patients diagnosed using transrectal ultrasound-guided (TRUS) and transperineal digital-guided (TP) routes, respectively. Subsequent analysis of the resected specimen, however, revealed "bilateral" malignancy in 50 patients (86%) in the TRUS group and in 63 (84%) in the TP group. Furthermore, positive surgical margins were identified on the "benign" side (by preoperative biopsy) in 6 (20%) patients in the TRUS subgroup whose biopsy had suggested "unilateral" carcinoma, and in 12 (27%) of the comparative TP subgroup. CONCLUSIONS: Biopsy-suggested "unilateral" carcinoma was associated with both a high incidence of "bilateral" disease on final histology following radical prostatectomy and an alarming incidence (24%) of positive surgical margins on the "benign" side where NSRP might be advocated.