Focused UTUC pathways with a risk-stratified approach to diagnostic ureteroscopy: is it the need of the hour? A retrospective cohort analysis.

INTRODUCTION: Upper urinary tract urothelial cancer is a rare, aggressive variant of urinary tract cancer. There is often delay to diagnosis and management for this entity in view of diagnostic and staging challenges needing additional investigations and risk stratifications for improved outcomes. In this article, we share our experience in developing a dedicated diagnostic and treatment pathway for UTUC and assess its impact on time lines to radical nephroureterectomy (RNU). We also evaluate the impact of diagnostic ureteroscopy (DUR) on UTUC care pathways timelines. MATERIALS AND METHODS: A prospective database was maintained for all patients who underwent a RNU from January 2015 to August 2022 in a high-volume single tertiary care centre in the UK. In 2019, a Focused UTUC pathway (FUP) was implemented at the centre to streamline diagnostic and RNU pathways. A retrospective analysis of the database was conducted to compare time lines and diagnostic trends between the pre-FUP and FUP cohorts. Primary outcome measures were time to RNU from MDT. Secondary outcome measures were: impact of DUR on time to RNU from MDT and negative UTUC rates between DUR and non-DUR cohorts. Differences in continuous variables across categories were assessed using the independent sample t test. Categorical variables between cohorts were analysed using the chi-square (χ2). Statistical significance in this study was set as p < 0.05. RESULTS: A total of 500 patients with complete data were included in the analysis. The pre-FUP and FUP cohorts consisted of 313 patients and 187 patients, respectively. The overall cohort had a mean age (SD) of 70 years (9.3). 66% of the overall cohort were males. The median time to RNU from MDT in the FUP was significantly lower compared to the pre-FUP cohort; 62 days (IQR 59) vs. 48 days (IQR 41.5), p < 0.0001. The median time to RNU from MDT in patients who underwent a diagnostic URS in the FUP cohort was significantly lower compared to the pre-FUP cohort; 78.5 days (IQR 54.8) vs. 68 days (IQR 48), p-NS. The non-UTUC rates in the DUR and non-DUR cohorts were 6/248 (2.4%) and 14/251 (5.6%), respectively (NS). CONCLUSION: In this series, we illustrate the effectiveness of integrating a multidisciplinary approach with specialised personnel, ring-fenced clinics, efficient diagnostic assessment and optimised theatre capacity. By adopting a risk-stratified approach to diagnostic ureteroscopy, we have achieved a significant reduction in time to RNU.

Calyceal Diverticula Disease: Diagnosis and Management Options in the Era of Non-Contrast CT Scan.

INTRODUCTION: Calyceal diverticula (CD) are traditionally diagnosed by contrast studies. However, non-contrast CT is the standard imaging modality for kidney stones. Therefore, we aimed to determine if the lack of contrast imaging affected outcomes of the management of symptomatic CD with stone. MATERIALS AND METHODS: This is a retrospective study of patients diagnosed with CD with intracalyceal stone from 2000 to 2017 analyzing demographics, clinical data, and success of different treatment options. The timing of CD diagnosis is correlated to the success of the first treatment. RESULTS: Forty-eight patients were found. CD was diagnosed prior to intervention in 20 (42%) cases and intraoperatively during flexible ureteroscopy in 17 (35%) and 11 (23%) cases were diagnosed after failed intervention, mainly ESWL. We found that the success rate of treatment was highly affected by the timing and modality of diagnosis. Preoperative diagnosis of CD was associated with 69% success rate of the first intervention. In contrast, there was a 0% success rate of first treatment if CD was not diagnosed with contrast imaging. Furthermore, univariate analysis showed no significant association between sociodemographics and clinical variables and success treatment (p > 0.05). CONCLUSIONS: The delay in diagnosing CD with stone contributes significantly to the success rate and the number of treatments.

Continuous low-dose antibiotic prophylaxis for adults with repeated urinary tract infections (AnTIC): a randomised, open-label trial.

BACKGROUND: Repeated symptomatic urinary tract infections (UTIs) affect 25% of people who use clean intermittent self-catheterisation (CISC) to empty their bladder. We aimed to determine the benefits, harms, and cost-effectiveness of continuous low-dose antibiotic prophylaxis for prevention of recurrent UTIs in adult users of CISC. METHODS: In this randomised, open-label, superiority trial, we enrolled participants from 51 UK National Health Service organisations. These participants were community-dwelling (as opposed to hospital inpatient) users of CISC with recurrent UTIs. We randomly allocated participants (1:1) to receive either antibiotic prophylaxis once daily (prophylaxis group) or no prophylaxis (control group) for 12 months by use of an internet-based system with permuted blocks of variable length. Trial and laboratory staff who assessed outcomes were masked to allocation but participants were aware of their treatment group. The primary outcome was the incidence of symptomatic, antibiotic-treated UTIs over 12 months. Participants who completed at least 6 months of follow-up were assumed to provide a reliable estimate of UTI incidence and were included in the analysis of the primary outcome. Change in antimicrobial resistance of urinary and faecal bacteria was monitored as a secondary outcome. The AnTIC trial is registered at ISRCTN, number 67145101; and EudraCT, number 2013-002556-32. FINDINGS: Between Nov 25, 2013, and Jan 29, 2016, we screened 1743 adult users of CISC for eligibility, of whom 404 (23%) participants were enrolled between Nov 26, 2013, and Jan 31, 2016. Of these 404 participants, 203 (50%) were allocated to receive prophylaxis and 201 (50%) to receive no prophylaxis. 1339 participants were excluded before randomisation. The primary analysis included 181 (89%) adults allocated to the prophylaxis group and 180 (90%) adults in the no prophylaxis (control) group. 22 participants in the prophylaxis group and 21 participants in the control group were not included in the primary analysis because they were missing follow-up data before 6 months. The incidence of symptomatic antibiotic-treated UTIs over 12 months was 1·3 cases per person-year (95% CI 1·1-1·6) in the prophylaxis group and 2·6 (2·3-2·9) in the control group, giving an incidence rate ratio of 0·52 (0·44-0·61; p<0·0001), indicating a 48% reduction in UTI frequency after treatment with prophylaxis. Use of prophylaxis was well tolerated: we recorded 22 minor adverse events in the prophylaxis group related to antibiotic prophylaxis during the study, predominantly gastrointestinal disturbance (six participants), skin rash (six participants), and candidal infection (four participants). However, resistance against the antibiotics used for UTI treatment was more frequent in urinary isolates from the prophylaxis group than in those from the control group at 9-12 months of trial participation (nitrofurantoin 12 [24%] of 51 participants from the prophylaxis group vs six [9%] of 64 participants from the control group with at least one isolate; p=0·038), trimethoprim (34 [67%] of 51 vs 21 [33%] of 64; p=0·0003), and co-trimoxazole (26 [53%] of 49 vs 15 [24%] of 62; p=0·002). INTERPRETATION: Continuous antibiotic prophylaxis is effective in reducing UTI frequency in CISC users with recurrent UTIs, and it is well tolerated in these individuals. However, increased resistance of urinary bacteria is a concern that requires surveillance if prophylaxis is started. FUNDING: UK National Institute for Health Research.

Continuous low-dose antibiotic prophylaxis to prevent urinary tract infection in adults who perform clean intermittent self-catheterisation: the AnTIC RCT.

BACKGROUND: People carrying out clean intermittent self-catheterisation (CISC) to empty their bladder often suffer repeated urinary tract infections (UTIs). Continuous once-daily, low-dose antibiotic treatment (antibiotic prophylaxis) is commonly advised but knowledge of its effectiveness is lacking. OBJECTIVE: To assess the benefit, harms and cost-effectiveness of antibiotic prophylaxis to prevent UTIs in people who perform CISC. DESIGN: Parallel-group, open-label, patient-randomised 12-month trial of allocated intervention with 3-monthly follow-up. Outcome assessors were blind to allocation. SETTING: UK NHS, with recruitment of patients from 51 sites. PARTICIPANTS: Four hundred and four adults performing CISC and predicted to continue for ≥ 12 months who had suffered at least two UTIs in the previous year or had been hospitalised for a UTI in the previous year. INTERVENTIONS: A central randomisation system using random block allocation set by an independent statistician allocated participants to the experimental group [once-daily oral antibiotic prophylaxis using either 50 mg of nitrofurantoin, 100 mg of trimethoprim (Kent Pharmaceuticals, Ashford, UK) or 250 mg of cefalexin (Sandoz Ltd, Holzkirchen, Germany); n = 203] or the control group of no prophylaxis (n = 201), both for 12 months. MAIN OUTCOME MEASURES: The primary clinical outcome was relative frequency of symptomatic, antibiotic-treated UTI. Cost-effectiveness was assessed by cost per UTI avoided. The secondary measures were microbiologically proven UTI, antimicrobial resistance, health status and participants' attitudes to antibiotic use. RESULTS: The frequency of symptomatic antibiotic-treated UTI was reduced by 48% using prophylaxis [incidence rate ratio (IRR) 0.52, 95% confidence interval (CI) 0.44 to 0.61; n = 361]. Reduction in microbiologically proven UTI was similar (IRR 0.49, 95% CI 0.39 to 0.60; n = 361). Absolute reduction in UTI episodes over 12 months was from a median (interquartile range) of 2 (1-4) in the no-prophylaxis group (n = 180) to 1 (0-2) in the prophylaxis group (n = 181). The results were unchanged by adjustment for days at risk of UTI and the presence of factors giving higher risk of UTI. Development of antimicrobial resistance was seen more frequently in pathogens isolated from urine and Escherichia coli from perianal swabs in participants allocated to antibiotic prophylaxis. The use of prophylaxis incurred an extra cost of £99 to prevent one UTI (not including costs related to increased antimicrobial resistance). The emotional and practical burden of CISC and UTI influenced well-being, but health status measured over 12 months was similar between groups and did not deteriorate significantly during UTI. Participants were generally unconcerned about using antibiotics, including the possible development of antimicrobial resistance. LIMITATIONS: Lack of blinding may have led participants in each group to use different thresholds to trigger reporting and treatment-seeking for UTI. CONCLUSIONS: The results of this large randomised trial, conducted in accordance with best practice, demonstrate clear benefit for antibiotic prophylaxis in terms of reducing the frequency of UTI for people carrying out CISC. Antibiotic prophylaxis use appears safe for individuals over 12 months, but the emergence of resistant urinary pathogens may prejudice longer-term management of recurrent UTI and is a public health concern. Future work includes longer-term studies of antimicrobial resistance and studies of non-antibiotic preventative strategies. TRIAL REGISTRATION: Current Controlled Trials ISRCTN67145101 and EudraCT 2013-002556-32. FUNDING: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment Vol. 22, No. 24. See the NIHR Journals Library website for further project information.

Antibiotic treatment for intermittent bladder catheterisation with once daily prophylaxis (the AnTIC study): Study protocol for a randomised controlled trial.

BACKGROUND: Clean intermittent self-catheterisation is an important management option for people who cannot empty their bladder effectively. Recurrent urinary tract infections are common in these patients. Data from recent studies suggest that antibiotic prophylaxis may be beneficial in reducing infection risk, but the effectiveness of this intervention remains uncertain. METHODS/DESIGN: This is a 52-site, patient randomised superiority trial set in routine care comparing an experimental strategy of once daily antibiotic prophylaxis for 12 months against a control strategy of no prophylaxis in people who carry out self-catheterisation and suffer recurrent urinary tract infections. The primary outcome is number of urinary tract infections during a 12-month treatment period. Both groups will otherwise receive usual care including on demand treatment courses of antibiotics for urinary tract infection. Participants and their clinicians will not be blinded to the allocated intervention, but central trial staff managing and analysing trial data will, as far as possible, be unaware of participant allocation. The analysis will follow intention-to-treat principles. DISCUSSION: This trial was commissioned and funded by the United Kingdom National Health Service following prioritisation of the research question by the National Institute for Health and Care Excellence. TRIAL REGISTRATION: ISRCTN67145101 EUDRACT2013-002556-32. Registered on 25 October 2013.

Living with a long-term, indwelling urinary catheter: catheter users' experience.

PURPOSE: The purpose of this study was to explore the experiences of long-term catheter users within a heterogeneous population. SUBJECTS AND SETTINGS: The sample comprised 27 community-dwelling long-term catheter users. Participants included 14 female users (4 urethral, 10 suprapubic catheter) and 13 male users (6 urethral, 7 suprapubic) between 22 and 96 years of age. Interviews were conducted in participants' homes except 1, which took place in a urology outpatient department based on the participant's preference. METHODS: A qualitative research design using an interpretive description approach was used for data collection and analysis. All interviews were electronically recorded and transcribed verbatim. Interpretive description involved familiarization with the data, thematic analysis, and the development of an interpretive account. RESULTS: The impact of the catheter and daily living adjustments that catheter users made are captured within 8 themes: (1) making adjustments; (2) managing away from home; (3) nighttime adjustment; (4) catheter problems; (5) social interaction; (6) support from others; (7) unpredictability; and (8) intimacy and body image. CONCLUSIONS: Catheter users' experiences of living with a catheter are shaped by a variety of interrelated factors. Some participants were determined to overcome catheter-related problems and develop self-reliance while others adopted a more resigned approach to living with a catheter. Having a catheter enabled some participants to experience greater freedom while others led more restricted lives as a consequence of catheterization.

The management of secondary pelvi-ureteric junction obstruction - a comparison of pyeloplasty and endopyelotomy.

OBJECTIVE: To review our experience in the management of secondary pelvi-ureteric junction obstruction (PUJO) comparing endopyelotomy with pyeloplasty. PATIENTS AND METHODS: We retrospectively analysed our database of 58 patients having undergone operative management of PUJO after failed primary management, including 41 with failed pyeloplasty and 17 failed endopyelotomy. Outcomes included mercapto-acetyltriglycine (MAG3) drainage capacity, symptomatic control and need for further intervention. Success was defined as freedom from failure in all three. RESULTS: Patients undergoing secondary pyeloplasty had better outcomes than endopyelotomy for symptomatic success (87.5% vs 74%), resolution of obstruction on MAG3 renography (96% vs 74%), and no need for further intervention (96% vs 71%). Overall success was 87.5% for pyeloplasty compared with 44% after secondary endopyelotomy. CONCLUSION: Outcomes of pyelopasty for secondary PUJO were superior when compared with endopyelotomy.

A clinical evaluation of a sensor to detect blockage due to crystalline biofilm formation on indwelling urinary catheters.

OBJECTIVE: To test the performance and acceptability of an early warning sensor to predict encrustation and blockage of long-term indwelling urinary catheters. PATIENTS AND METHODS: In all, 17 long-term indwelling catheter users, 15 'blockers' and two 'non-blockers' (controls) were recruited; 11 participants were followed prospectively until catheter change, three withdrew early and three did not start. Two sensors were placed in series between the catheter and the urine bag at catheter change. The sensor nearest the bag was changed at the same time as the bag change (weekly); the sensor nearest the catheter remained in situ for the duration of the catheter's life. Bacteriology and pH determinations were performed on urine samples at each bag, sensor and catheter change. The colour of the sensors was recorded daily. On removal, each sensor and the catheter were examined for visible evidence of encrustation and blockage. Participants were asked to keep a daily diary to record colour change and any other relevant observations and to complete a psychosocial impact of assistive devices tool at the end of the study. Participants and carers/healthcare professionals (when involved in urine bag or catheter change) were asked to complete a questionnaire about the sensor. RESULTS: Urease-producing bacteria were isolated from seven of the 14 patients (including early withdrawals; P. mirabilis in four, Morganella or Providencia in three). In six of the seven patients the sensors turned blue-black; two of these were early withdrawals, two went to planned catheter change (one of these was recruited as a 'non-blocker') and three had catheter blockage. The number of days of catheterisation before blockage was 22, 23 and 25 days, and the sensor changed colour within 24-48 h after insertion. The urine mean (range) pH of the sensors that turned blue-black was 7.6 (5.5-9.0) and of the sensors that remained yellow 6.1 (5.1-7.5). The sensor was generally well-received and was positive in the psychosocial assessment. CONCLUSIONS: The sensor is a useful indicator of urine pH and of the conditions that lead to catheter blockage. It may be particularly useful for new indwelling catheter users. To be a universally acceptable predictor of catheter blockage, the time from sensor colour change to blockage needs to be reduced.

Does previous failed ESWL have a negative impact of on the outcome of ureterorenoscopy? A matched pair analysis.

This study aims to evaluate the outcome of ureteroscopy/ureterorenoscopy (URS) as a salvage procedure for stones resistant to extracorporeal shock wave lithotripsy (ESWL). Between January 2009 and January 2012, 313 patients with upper tract lithiasis were treated by URS. Among them, 87 (27.8 %) had undergone URS after prior ESWL failed to achieve stone clearance (Salvage group). These patients were matched with a group of patients who underwent URS as first-line modality (Primary group). Stone-free rates and adjuvant procedures represented the primary points for comparison. Secondary points for comparison included complications, procedure duration, total laser energy used and length of hospitalization. Matching was possible in all cases. Stone clearance rates were 73.6 and 82.8 % for the Salvage and Primary group, respectively. The difference in stone clearance rates between the two groups was not statistically significant (p = 0.186). A total of 11 patients (12.6 %) in the Primary group and 18 patients (20.7 %) in the Salvage group underwent an adjuvant procedure (p = 0.154). No statistically significant differences were noted in terms of complications, procedure duration and length of hospitalization. In the Primary group, the laser energy used for stone fragmentation was higher (p = 0.043). The rate of ureteric stenting at the end of the procedure was higher for the Salvage group (p = 0.030). Previous failed ESWL is not a predictor for unfavorable outcome of URS. Salvage URS is associated, however, with an increased need for ureteric stenting at the end of the procedure.

First experiences with the Spanner™ temporary prostatic stent for prostatic urethral obstruction.

OBJECTIVES: To assess the ease of insertion and removal of a temporary prostatic stent (the Spanner™) following the use of a prostatic urethral measuring device (the Surveyor™). PATIENTS AND METHODS: Patients with bladder outflow obstruction or urinary retention awaiting definitive surgery were fully consented. Data were collected pre- and post-insertion and patients followed-up until definitively treated. RESULTS: 16 patients had the Spanner inserted following use of the Surveyor. All insertions were uncomplicated. 14 patients were able to void satisfactorily immediately post-insertion with a mean Qmax of 15.0 ml/s and post-void residual of 51.3 ml. No symptomatic infection was reported. The stents stayed in situ for a median of 10 days. 12 stents were removed prematurely due to severe symptoms or retention. A total of 12 stents had to be removed endoscopically. CONCLUSIONS: The Spanner is easy to insert. Stent removal via the retrieval suture has been difficult necessitating the use of endoscopy in the majority of cases. Possible causes of stent failure include underestimation of the prostatic urethral length by the Surveyor leading to obstruction by apical prostatic tissue, excessive suture length between the stent and distal anchor permitting proximal migration or inadequate suture length leading to urinary incontinence. Further design modifications are suggested.

Impact of stone density on outcomes in percutaneous nephrolithotomy (PCNL): an analysis of the clinical research office of the endourological society (CROES) pcnl global study database.

OBJECTIVE: This study aimed to explore the relationship between stone density and outcomes of percutaneous nephrolithotomy (PCNL) using the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study database. MATERIAL AND METHODS: Patients undergoing PCNL treatment were assigned to a low stone density [LSD, ≤ 1000 Hounsfield units (HU)] or high stone density (HSD, > 1000 HU) group based on the radiological density of the primary renal stone. Preoperative characteristics and outcomes were compared in the two groups. RESULTS: Retreatment for residual stones was more frequent in the LSD group. The overall stone-free rate achieved was higher in the HSD group (79.3% vs 74.8%, p = 0.113). By univariate regression analysis, the probability of achieving a stone-free outcome peaked at approximately 1250 HU. Below or above this density resulted in lower treatment success, particularly at very low HU values. With increasing radiological stone density, operating time decreased to a minimum at approximately 1000 HU, then increased with further increase in stone density. Multivariate non-linear regression analysis showed a similar relationship between the probability of a stone-free outcome and stone density. Higher treatment success rates were found with low stone burden, pelvic stone location and use of pneumatic lithotripsy. CONCLUSIONS: Very low and high stone densities are associated with lower rates of treatment success and longer operating time in PCNL. Preoperative assessment of stone density may help in the selection of treatment modality for patients with renal stones.

Multi-length or 24 cm ureteric stent? A multicentre randomised comparison of stent-related symptoms using a validated questionnaire.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: One of the suggested factors for stent-related symptoms is that excess distal intravesical stent mass may cause bladder irritation. There is a lack of studies investigating this in a randomised controlled fashion using a validated questionnaire. This study compared two of the most commonly used length of stents (a 30 cm multi-length vs a 24 cm long stent) and showed no significance difference in stent-related symptoms in patients with either of these stents. OBJECTIVE: To investigate whether excessive redundant intravesical stent component contributes to the severity of stent-related symptoms in patients with a ureteric stent. We compared stent-related symptoms in patients who had either a standard 24 cm or multi-length ureteric stent. PATIENTS AND METHODS: In all, 162 patients with upper urinary tract calculi requiring ureteric stent insertion were randomised to receive either a 6 F × 24 cm Contour(TM) or multi-length 6 F × 22-30 cm Contour VL(TM) stent. Patients were requested to complete the validated Bristol Ureteric Stent Symptom Questionnaire (USSQ) at 1 and 4 weeks after stent insertion and 4 weeks after removal. The mean scores for each domain of the USSQ for both groups were compared using the Student's t-test. Any adverse events, e.g. stent migration, early removal of stent due to stent-related symptoms and failure of stent insertion, were also recorded. RESULTS: In all, 153 patients who had successful stent insertion were requested to complete the USSQ and 74% of patients returned at least the week 1 questionnaire. At 1 and 4 weeks with the stent in situ, comparison of the mean scores showed no significant difference in urinary symptoms, pain, general health, work performance, sexual dysfunction and number of days patients stayed in bed or reduced their routine activities. Three (2%) patients had their stent removed early due to stent-related symptoms and five (3%) had failed stent insertion. CONCLUSIONS: This study did not find any difference in symptoms between the 24 cm or multi-length Contour stents. However, the study was not powered to detect small differences particularly for the pain symptom domain. Stents should only be used sparingly and the stent dwell-time should be minimised.

The impact of shock wave lithotripsy on male fertility: a critical analysis of existing evidence.

We review the literature about the impact of shock wave lithotripsy (SWL) on male reproduction. Studies investigating the in vitro effect of shock waves on semen samples indicate that spermatozoa are vulnerable to SWL. According to animal studies, intratesticular bleeding is common, but pregnancy rates are not affected by shock waves. In the clinical setting, SWL causes an acute deterioration in sperm quality, but semen parameters return to baseline 3 months later. Long-term data on male fertility (ie, pregnancy rates) after SWL have yet to be reported and the significance of preexisting infertility has not been elucidated to date.

The percutaneous nephrolithotomy global study: classification of complications.

PURPOSE: This study evaluated postoperative complications of percutaneous nephrolithotomy (PCNL) and the influence of selected factors on the risk of complications using the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study database. PATIENTS AND METHODS: The CROES PCNL Global Study collected prospective data for consecutive patients who were treated with PCNL at centers around the world for 1 year. Complications were evaluated by the modified Clavien classification system. RESULTS: Of 5724 patients with Clavien scores, 1175 (20.5%) patients experienced one or more complications. The most frequent complications were fever and bleeding. Urinary leakage, hydrothorax, hematuria, urinary tract infection, pelvic perforation, and urinary fistula also occurred in ≥20 patients in each group. The majority of complications (n=634, 54.0%) were classified as Clavien grade I. Two patients died in the postoperative period. The largest absolute increases in mean Clavien score were associated with American Society of Anesthesiologists (ASA) physical status classification IV (0.75) or III (0.34), anticoagulant medication use (0.29), positive microbiologic culture from urine (0.24), and the presence of concurrent cardiovascular disease (0.15). Multivariate regression analysis revealed that operative time and ASA score were significant predictors of higher mean Clavien scores. CONCLUSION: The majority of complications after PCNL are minor. Longer operative time and higher ASA scores are associated with the risk of more severe postoperative complications in PCNL.

New ureteral stent design does not improve patient quality of life: a randomized, controlled trial.

PURPOSE: Ureteral stents result in significant morbidity in many patients. Manufacturers have altered stent design and composition to minimize symptoms. The Polaris™ stent is made of a Percuflex® combination, providing a firm proximal aspect with a softer distal aspect to minimize symptoms. In this prospective, randomized study we compared symptoms and quality of life after stent insertion to determine whether this stent is better tolerated than the InLay® stent. MATERIALS AND METHODS: Between September 2002 and September 2006 we randomized 159 patients requiring stent insertion for stone disease to receive the InLay or the Polaris ureteral stent. Patients were asked to complete the validated Ureteral Stent Symptom Questionnaire 2 weeks after stent insertion and 1 week after removal. RESULTS: A total of 98 patients completed and returned each questionnaire, including 45 with the InLay and 53 with the Polaris. There were no significant differences between the groups on any health domain assessed. In the InLay and Polaris groups 91% and 94% of patients experienced pain with the stent in situ, which decreased to 40% and 43%, respectively, after stent removal. The urinary symptom score with the stent in situ was equal in the 2 groups (32, maximum 55). Of the InLay and Polaris groups 60% and 66% of patients, respectively, would be against receiving a further stent due to symptoms (p = 0.79). CONCLUSIONS: The Polaris stent, designed with the specific aim of improving urinary symptoms and pain associated with ureteral stents, continues to have a significant detrimental effect on patient quality of life.

Relief of stent related symptoms: review of engineering and pharmacological solutions.

PURPOSE: We review the recent publications on developing engineering and pharmaceutical agents to alleviate stent related symptoms, and examine basic science studies that may support a particular approach. MATERIALS AND METHODS: Data on randomized controlled trials for relief of stent related symptoms were analyzed. Studies involving engineering and pharmacological agents to resolve stent related morbidity were assessed separately. RESULTS: A variety of physical characteristics of stents, including materials, diameter, length and shape, have been modified to reduce stent related symptoms. Numerous studies have been conducted to engineer the ideal stent without clear and definite conclusions. There are mixed results with materials and negative results with shape. Appropriate stent length appears to be important but decreased diameter has not been shown to help. A recent study using a ketorolac eluting stent showed no significant benefit. Even with the best material and length it appears that patients still have significant stent related symptoms. To relieve stent related symptoms several classes of oral medications have been proposed for off-label use based on intuition or experience. Recently prospective, randomized, placebo controlled trials have been performed, along with basic science studies regarding the pharmacology of the ureter. They showed a clear and consistent beneficial effect of alpha1-blockers in patients with indwelling ureteral stents. CONCLUSIONS: Although there have been many advances in stent composition, construction geometry and design, the ideal stent has yet to be engineered. By contrast, the oral administration of alpha-blockers has shown the greatest reduction in stent morbidity.

Audit of safety, efficacy, and cost-effectiveness of local anaesthetic cystodiathermy.

INTRODUCTION: The aim of this study was to audit our experience of cystodiathermy under local anaesthetic (LA) at the time of flexible cystoscopy for recurrent superficial bladder transitional cell carcinoma (TCC). PATIENTS AND METHODS: A total of 264 flexible cystoscopies were performed on patients with a past history of TCC. The number and site of recurrences were recorded and selected patients were offered cystodiathermy. Patient tolerability was noted. At follow-up, any recurrence was recorded. RESULTS: Eighty patients (30%) had 91 procedures showing one or more recurrences. Fifty-one of the 80 patients (64%) were treated with cystodiathermy under LA. All completed treatment. Forty-five (88%) tolerated the procedure well. Forty-seven (92%) treatments were completed within 5 min. At a median follow-up of 15 weeks, 30 (59%) treated patients had no recurrence and three (6%) had recurrence at the site of treatment. CONCLUSIONS: LA cystodiathermy is an effective and well-tolerated alternative to general anaesthetic cystodiathermy that enables treatment at the time of detection and may, thereby, reduce patient anxiety.

Strategy to control catheter encrustation with citrated drinks: a randomized crossover study.

PURPOSE: Nucleation pH is the pH at which Ca and Mg come out of urine to form crystals. If the safety margin between voiding pH and nucleation pH could be increased, it would increase the possibility of an alternative to controlling the activity of urease producing bacteria as a strategy to control catheter encrustation. MATERIALS AND METHODS: We performed a 6-week randomized crossover study in 24 patients with catheter blockage who were randomly allocated to a specific sequence of 3 consecutive available treatments, including increased fluid intake, lemon juice and potassium citrate. Each patient received all available regimens. At the end of each week 24-hour urine samples were analyzed for voiding and nucleation pH, citrate, Ca and Mg. RESULTS: Mean +/- SD nucleation pH increased from 7.45 +/- 0.60 at baseline to 7.93 +/- 0.50, 7.68 +/- 0.64 and 7.96 +/- 0.37 in the lemon juice, increased fluid intake and potassium citrate groups, respectively (p <0.0001). Mean urinary citrate increased significantly (p <0.0001), in particular due to lemon juice and potassium citrate effects. The association between treatment and Ca was weak (p = 0.12) while that of Mg was negative due to lemon (p <0.001). Average increase in the safety margin (nucleation pH minus voiding pH) beyond baseline was 0.84 (95% CI 0.63-1.04), 0.57 (95% CI 0.37-0.78) and 0.41 (95% CI 0.20-0.61) for lemon juice, increased fluid intake and potassium citrate, respectively. A strong treatment effect on the safety margin was apparent even when controlling for study design (p <0.001). CONCLUSIONS: Increased fluid intake with lemon juice may be a simple, inexpensive, effective strategy to control catheter encrustation.

Mentorship in urological laparoscopic surgery: lessons learned.

OBJECTIVE: To review the results of our experience with a mentorship programme in laparoscopic nephrectomy, set up in 1999 by the British Association of Urological Surgeons Section of Endourology. METHODS: Mentors were contacted in 2007 to submit data on the number of visits and the outcome, which included whether a urologist was able to establish an independent laparoscopic practice and sustain it. RESULTS: Four urologists acting as mentors reported a total of 164 procedures carried out in the training of 39 urologists during 148 visits. There were no conversions to open surgery and only one major complication. Overall, 29 of 39 mentored consultants were able to establish an independent laparoscopic practice and 23 continue to do so. The number of visits was associated with initial success, although this was not statistically significant. Working in a large department was associated with being able to sustain a laparoscopic practice. More experienced consultants were less likely to have initial success, but were more likely to sustain a successful practice. CONCLUSIONS: Mentorship for laparoscopic nephrectomy has been carried out safely thus far. Sustaining a laparoscopic practice requires a critical volume of cases. Future efforts should be focused on trainees rather than consultants.

A comparative study of quality of life issues relating to open versus laparoscopic nephrectomy: a prospective pragmatic study.

PURPOSE: We determined whether laparoscopic nephrectomy confers improved health related quality of life in the early postoperative period compared with open nephrectomy. MATERIALS AND METHODS: Patients undergoing open or laparoscopic nephrectomy were prospectively recruited. Patients completed the Comorbidity Symptom Scale preoperatively as well as the SF-36(R) quality of life health survey and pain visual analog scale preoperatively, and 2 days and 1 month postoperatively. RESULTS: A total of 100 patients were recruited, of whom 71 completed all questionnaires, including 38 in the laparoscopic group and 33 in the open group. In the 2 groups mean patient age was the same (56.8 years) and there was a similar sex distribution. The laparoscopic group had improved quality of life scores with significantly higher physical component scores 1 month postoperatively vs the open group (-5.7% vs -22.2%, p = 0.009). The laparoscopic group also had significantly higher mental component scores 2 days postoperatively vs the open group compared to baseline (6.0% vs -6.6%, p = 0.009). The laparoscopic group had significantly lower pain visual analog scale scores 1 month postoperatively compared to baseline. Patients with higher Comorbidity Symptom Scale scores were more likely to undergo a laparoscopic approach (p = 0.036). Despite this they had a significantly shorter hospital stay (4 vs 6 days, p <0.001). CONCLUSIONS: Quality of life benefits of laparoscopic over open nephrectomy were found in the early postoperative period despite more comorbidities in the laparoscopic group. This provides further evidence of the benefits of the laparoscopic approach over open surgery.