Does instillation of lidocaine gel following flexible cystoscopy decrease the severity of post procedure symptoms? A randomised controlled trial assessing the efficacy of lidocaine gel post flexible cystoscopy.

OBJECTIVE: To assess whether instillation of lidocaine gel both before and after flexible cystoscopy is more effective at reducing post procedural symptoms than instillation of lidocaine gel pre flexible cystoscopy alone. We hypothesise that inadequate urethral dwell time and dilution of lidocaine gel by the irrigation fluid during flexible cystoscopy limits its anaesthetic efficacy. Only one other study has attempted to reduce bothersome urinary symptoms through an intervention after flexible cystoscopy. METHODS: This was a randomised controlled trial in which patients were randomised 1:1 to receive lidocaine gel pre and post flexible cystoscopy (treatment) or lidocaine gel pre flexible cystoscopy only (control). Patient-reported outcome measures were used to assess symptoms and quality of life prior to cystoscopy, on day 2 and day 7 post cystoscopy. RESULT: Fifty patients were divided equally between the treatment and control groups. There were no significant differences in baseline characteristics between the groups (p = 1.000). An overall symptoms variable was measured, though no significant difference was found in the distribution of responses between the groups at baseline, 2 or 7 days after the flexible cystoscopy (p = 0.423, 0.651,0.735). In the treatment group, 1 patient (4.0%) presented to a doctor for review following flexible cystoscopy, and 4 patients (16.0%) presented in the control group (p = 0.349). CONCLUSION: Initial study results suggest that post-operative lidocaine does not significantly limit the exacerbation of urinary symptoms following flexible cystoscopy; however, our results are not powered to detect a small difference. We do not recommend a change in practice based on our results.

Evaluation of endoscopic laser excision of polypropylene mesh/sutures following anti-incontinence procedures.

PURPOSE: We reviewed our experience with and outcome of the largest series to our knowledge of patients who underwent endoscopic laser excision of eroded polypropylene mesh or sutures as a complication of previous anti-incontinence procedures. MATERIALS AND METHODS: A total of 12 female patients underwent endoscopic laser excision of suture/mesh erosions at 1 center during a 10-year period. Primary outcome variables were the requirement of additional endoscopic or open surgery to remove mesh/sutures. Secondary outcome variables were persistence of urinary symptoms, postoperative complications, continence status and requirement of additional anti-incontinence procedures. RESULTS: The mean interval from previous surgery to erosion was 59 months (range 7 to 144) and the duration of presenting symptoms ranged from 3 to 84 months (mean 19). Ten patients underwent endoscopic excision of the mesh/suture with the holmium:YAG laser and 2 underwent excision with the thulium laser. Mean operative duration was 19 minutes (range 10 to 25) and followup was 65.5 months (range 6 to 134). Postoperatively 6 patients remain asymptomatic and 2 required a rectus fascial sling for recurrent stress urinary incontinence. Four patients underwent a second endoscopic excision due to minor persistence of erosion. Only 1 patient ultimately required open cystotomy to remove the eroded biomaterial. No intraoperative complications were recorded and all patients are currently asymptomatic. CONCLUSIONS: Endoscopic laser excision is an acceptable first line approach for the management of eroded biomaterials due to its high long-term success rate and minimally invasive nature.

Time to audit.

INTRODUCTION: Public and political pressures are increasing on doctors and in particular surgeons to demonstrate competence assurance. While surgical audit is an integral part of surgical practice, its implementation and delivery at a national level in Ireland is poorly developed. Limits to successful audit systems relate to lack of funding and administrative support. In Wexford General Hospital, we have a comprehensive audit system which is based on the Lothian Surgical Audit system. MATERIALS AND METHODS: We wished to analyse the amount of time required by the Consultant, NCHDs and clerical staff on one surgical team to run a successful audit system. Data were collected over a calendar month. This included time spent coding and typing endoscopy procedures, coding and typing operative procedures, and typing and signing discharge letters. RESULTS: The total amount of time spent to run the audit system for one Consultant surgeon for one calendar month was 5,168 min or 86.1 h. Greater than 50% of this time related to work performed by administrative staff. Only the intern and administrative staff spent more than 5% of their working week attending to work related to the audit. CONCLUSIONS: An integrated comprehensive audit system requires a very little time input by Consultant surgeons. Greater than 90% of the workload in running the audit was performed by the junior house doctors and administrative staff. The main financial implications for national audit implementation would relate to software and administrative staff recruitment. Implementation of the European Working Time Directive in Ireland may limit the time available for NCHD's to participate in clinical audit.

Antibiotic prophylaxis for transrectal ultrasound biopsy of the prostate in Ireland.

INTRODUCTION: Prostate cancer is the most common solid cancer affecting men in Ireland. Transrectal ultrasound (TRUS) biopsies of the prostate are routinely performed to diagnose prostate cancer. They are, in general, a safe procedure but are associated with a significant risk of infective complications ranging from fever, urinary tract infection to severe urosepsis. At present, there are no recommended national guidelines on the use of antibiotic prophylaxis to minimise the risk of infective complications post-TRUS biopsy. AIM: To review the antibiotic prophylaxis for TRUS biopsy used in Irish hospitals. METHOD: We used a standard telephone questionnaire to establish what antibiotic protocol is in use in each hospital. RESULTS: 40 hospitals were contacted, of which 29 perform TRUS biopsies. In the majority of hospitals, TRUS biopsies are carried out in the radiology department. All hospitals administer antibiotic prophylaxis but there is wide variation in the protocols used. There are five different antibiotics prescribed, ciprofloxacin being the most common. Treatment protocols vary from 1 to 10 days antibiotic cover post procedure. CONCLUSION: There is a lack of standardisation of antibiotic prophylaxis in Irish hospitals. There is a need for guidelines to clarify the most appropriate antibiotic, route of administration and duration of treatment.

Carbonic anhydrase IX expression in prostate cancer.

Tumour hypoxia is associated with over 70% of solid tumours including prostate and colorectal cancer. Hypoxia promotes tumour progression and resistance to treatment. Carbonic anhydrase IX (CA IX) is an endogenous marker of hypoxia. It is expressed in lung and renal cell carcinomas and is associated with a poor prognosis. CA IX has an important role in maintaining pH levels in the highly metabolically active cancer cell. The expression of CA IX in prostate cancer has not previously been investigated. Immunohistochemistry was used to examine CA IX expression in 59 patients, using tissue microarrays (TMAs) and full sections of BPH, surrounding stroma and prostate adenocarcinoma. Cores reviewed included 189 BPH, 130 Gleason grade 3, 93 Gleason grade 4, 40 Gleason grade 5. CA IX expression in colorectal cancer and HIF 1alpha in prostate cancer acted as positive controls. There was only occasional cell staining for CA IX expression. Although prostate cancer is a hypoxic tumour it does not express CA IX. This implies it relies on alternative pathways for maintaining pH balance in cancer. These studies would indicate that CA IX is not a suitable marker of hypoxia in prostate cancer.