National review of urology outpatient practice in the UK.

OBJECTIVE: To audit the current UK outpatient workload and compare this to the national standards as set out by the British Association of Urological Surgeons (BAUS) in A Quality Urological Service for Patients in the New Millennium published in October 2000. PARTICIPANTS: 520 UK (NHS) and 21 Republic of Ireland (non-NHS) consultant urologists registered with BAUS in 2000. MAIN OUTCOME MEASURES: Extent to which consultant urologists are able to comply with guidelines set out by their specialist association, the BAUS and by the Royal College of Surgeons of England. RESULTS: The questionnaire return rate was 61% (318/520; regional range 42%-75%). The median "routine" clinics/week was two (1-5) with a mean of 13 (1-40) new and 26 (7-80) follow ups. Fifteen percent (49/318) of consultants worked alone in clinic; of the remainder assistance included specialist registrar 67% (212/318), staff grade/associate specialist 32% (102/318), senior house officer 53% (172/318), and pre-registration house officer 2% (7/318). Only 21% (66/318; regional range 0%-46%) of responding consultants followed the BAUS recommendations for outpatient workload/manpower. CONCLUSIONS: A minority of consultants are able to adhere to the outpatient workload guidelines as set out by BAUS council in 2000. In addition, there appears to be significant variations within and between training regions. Development of this project into a regional audit tool may allow intraregional guideline formation governing hospital outpatient workload.

Nurse-led cystoscopy: the next step.

OBJECTIVES: To determine and compare the accuracy of flexible cystoscopy and subsequent management by a specialist urology registrar (SpR) and a specialist urology nurse (SUN). PATIENTS AND METHODS: Flexible cystoscopy was undertaken on 50 patients by both endoscopists each unaware of the results of the other's examination. The findings and management plans were independently declared and then compared. Any cystoscopic discrepancies were assessed by one consultant with the patients under a general anaesthetic. RESULTS: Tumours were found in 20% of patients; there was a consensus of the endoscopic findings and subsequent management plan between the SpR and the SUN in 94% of the patients. Any missed tumours (all surveillance) were minute and clinically insignificant. The chance-corrected proportional agreement (kappa value) between the SUN and final diagnosis and management was 0.94. CONCLUSION: A properly trained SUN can undertake both diagnostic and surveillance flexible cystoscopy, and decide upon further management to the same degree as can a urology SpR.

Suspected testicular torsion: a survey of clinical practice in North West England.

Several aspects of the management of suspected testicular torsion are controversial. A questionnaire was mailed to all 33 consultant urologists in the North West region of England to elicit their policies for routine clinical management. 29 of 33 questionnaires were returned (2 incomplete). As regards radiological investigation, 4 consultants always request ultrasound examination; the others do not favour routine imaging. When the diagnosis of testicular torsion is confirmed at operation, all consultants would perform bilateral testicular fixation, although with considerable variations in technique; most use Vicryl sutures (66%) and three-point fixation (57%). One-third would do an ipsilateral orchidopexy if there was no clear evidence of testicular torsion at operation. The variation revealed by this survey prompted an attempt to formulate a protocol for management. A review of the published work indicates that, in cases of proven testicular torsion, treatment should include bilateral fixation with delayed-absorption or non-absorbable sutures; fixation should be at three points. When torsion is not found at operation, there is no evidence of benefit from orchidopexy.

Photodynamic therapy for superficial bladder cancer under local anaesthetic.

OBJECTIVES: To evaluate the use of local anaesthesia (LA) in 5-aminolaevulinic acid (ALA) photodynamic therapy (PDT) for superficial transitional cell carcinoma (TCC) of the bladder, and to provide further toxicity and tolerability data on this new method within the context of a phase 1 trial. PATIENTS AND METHODS: ALA PDT was administered to 19 patients with recurrent superficial TCC (stage Ta/carcinoma in situ, grades 1-3) using escalating doses of ALA (3-6%) and 633 nm laser light (25-50 J/cm2) under various LA (lignocaine) protocols. Pain was assessed using a linear analogue scale from 0 to 10. The endpoints of tolerability and toxicity were assessed for the different LA, light and ALA doses, with lignocaine levels. RESULTS: ALA PDT is painful and requires some form of anaesthesia. The discomfort was immediate, associated with bladder spasm, and was a function of the ALA concentration rather than the total light dose given. Simple passive diffusion (PD) of 2% lignocaine instilled for 40 min before PDT gave adequate anaesthesia with 3% ALA (n=8; median pain score 1, range 0-2). With 6% ALA the pain was dramatically increased using PD (n=6; median pain score 8, range 5-10) and therefore the more potent LA technique of electromotive drug administration (EMDA) of 2% lignocaine was used, with excellent results (n=3; median pain score 1, range 0-2). All patients had transient bladder irritability that typically lasted 9-12 days, with no subjective/objective change in long-term bladder function. No other toxicity was reported. Serum lignocaine levels were minimal. CONCLUSION: Bladder ALA PDT is both safe and feasible under LA. At a dose of 3% ALA, the procedure was well-tolerated using PD of lignocaine. At higher doses (6% ALA) more effective anaesthesia is required and this can be obtained satisfactorily with EMDA of lignocaine. With refinement, ALA PDT may be feasible as an outpatient treatment for superficial bladder TCC.

Photodynamic therapy for superficial bladder cancer.

In photodynamic therapy, a photosensitizing drug is activated by visible light and in the presence of oxygen, results in local cell death. This evolving modality is now being used to treat and palliate a very wide variety of human solid tumors and carcinoma-in-situ lesions. With regard to bladder cancer, advances in drug development and modern light delivery techniques mean that photodynamic therapy shows promise in the treatment of superficial bladder cancer resistant to conventional treatments.

The Mitrofanoff procedure: does it last?

OBJECTIVE: To examine the long-term effectiveness of the Mitrofanoff principle and establish if the catheterizing channel is sufficiently robust for long-term use. PATIENTS AND METHODS: Ten patients who had undergone Mitrofanoff reconstruction between 1989 and 1991 (minimum follow-up 10 years) were offered reinterview by one of the authors (J.F.), which involved a structured questionnaire assessing catheterization, continence and complications. RESULTS: One patient had died; nine patients were alive and eight agreed to the structured interview. All the patients had their original stoma and all were completely continent. Four of the patients had experienced stenosis, four had had stones and four had been ill with urinary tract infection(s). CONCLUSION: Despite the complications of infection, stones and some episodic stenosis, the Mitrofanoff channel remains functional for long periods without sustaining structural damage.

Twenty-four hour access to a CD-ROM surgical database has educational and patient management benefits.

This study determined whether 24 h access to current surgical literature via a personal computer CD-ROM was of relevance to the junior surgeon managing acute surgical referrals. Over a 2 month period, a total of 53 acute surgical referrals were assessed and initially managed by a single basic surgical trainee. The Medline database was searched using Silver Platter software for current surgical literature regarding aetiology and management after the initial patient assessment. Of the 53 searches made (mean search time 7 min 22 s), 20 (38%) were judged to have produced information that increased basic surgical trainee knowledge and a further 9 (17%) changed patient management. By contrast, 24 (45%) of searches did not reveal helpful information. The availability of a surgical database that provides the trainee with abstracts of the current literature is valuable both for the educational development of the surgeon and improvement of patient care.

Bladder washout and stone formation in paediatric enterocystoplasty.

OBJECTIVE: To review the incidence of stone formation in our patients with enterocystoplasty to determine the effect of regular bladder washout. METHODS: From 1988 to 1995, a prospective cohort of 30 children underwent enteroplasty with continent diversion. Over the same period, a consecutive group of 30 children had an augmentation alone. All were instructed to wash out their bladder on a weekly basis with sterile water. The frequency of the washouts increased if there were problems with increasing mucus production. Their incidence of stone formation has been compared to a similar group of 30 children performing clean intermittent self catheterisation (CISC) on their native bladders. RESULTS: Five (17%) children with continent diversions formed bladder stones (mean time to formation 35 months, range 13-59 months) were compared with 2 (7%) of children with augmentation. No child performing CISC alone formed stones. CONCLUSIONS: A regime of regular bladder washout in children with enterocystoplasty did not significantly reduce the incidence of stone formation when compared to previously published data.

Identification of patients requiring out-patient follow-up after transurethral prostatectomy: is there a role for nurse-led screening of post-operative outcomes by telephone?

OBJECTIVE: To determine the most efficient method to follow patients after transurethral prostatectomy (TURP) such that only those patients suffering significant post-operative problems are reviewed. PATIENTS AND METHODS: The study comprised two parts: (1) a retrospective review of the case notes of 100 consecutive patients who underwent TURP under one consultant to determine whether any factors could be identified pre- or post-operatively by which those patients most likely to require clinic review could be selected and; (2) a prospective review of the succeeding 100 patients undergoing TURP, using a telephone 'screening' call made by the urological research nurse 3 months after the operation. Patients who requested follow-up and those patients with malignancy or admitted in high-pressure chronic retention were reviewed in the out-patient department. RESULTS: In the first part, 17 patients (17%) required an out-patient review for malignancy. Only nine patients (11%) with benign histology required further treatment after TURP; this subgroup could not be identified on the basis of their pre- or post-operative symptoms. In the second part, 23 patients were not reviewed by telephone; 14 had carcinoma of the prostate, eight had no telephone and one could not be contacted after seven attempts. Of the remaining 77 contacted by phone, 61 (79%) declined further clinic review and 16 (21%) requested follow-up for persistent problems. A mean of two calls was made per patient and the mean duration of each call was 6.3 min. CONCLUSIONS: Based on pre- or post-operative symptoms at the time of discharge, there is no reliable method of identifying those patients who have a poor result after TURP. Telephone screening of patients at 3 months identified successfully those patients who required an out-patient review and enabled resources to be targeted towards this difficult group of patients.

Intravesical instillation of oxybutynin hydrochloride for detrusor hyper-reflexia.

The effect of intravesical oxybutynin hydrochloride on detrusor behaviour was studied in 15 patients with urinary incontinence due to detrusor hyper-reflexia by ambulatory bladder monitoring. Twelve patients had a reduction in the frequency and amplitude of hyper-reflexic contractions and incontinence episodes following oxybutynin administration. Intravesical oxybutynin may have a role in the management of patients on intermittent self-catheterisation with detrusor hyper-reflexia who cannot tolerate the side effects of anticholinergic agents, including oxybutynin.

Prediction of recovery in antenatally diagnosed hydronephrosis.

A series of 335 children with antenatally diagnosed hydronephrosis which persisted after the postnatal period was prospectively assessed. Idiopathic hydronephrosis (85 patients) and pelviureteric junction obstruction (73 patients) were the commonest conditions. All patients with idiopathic hydronephrosis were managed conservatively; 87% have had a complete resolution of hydronephrosis and 13% have remained unaltered. No patient managed conservatively has shown a deterioration in renal function.

Neurogenic bladder dysfunction in lumbar intervertebral disc prolapse.

Lumbar disc prolapse with urinary dysfunction is an uncommon condition. The clinical, pathological and follow-up details of 30 patients are presented. Detrusor recovery is rare and most patients are left with an areflexic bladder. Female patients with lumbar disc prolapse and an areflexic detrusor who strain to empty their bladders are likely to develop genuine stress incontinence. This may be managed by the early institution of intermittent self-catheterisation, which may reduce the need for incontinence surgery.

Artificial urinary sphincter insertion in congenital neuropathic bladder.

A series of 44 patients with neuropathic bladder dysfunction due to congenital myelodysplasia underwent implantation of an artificial urinary sphincter (AUS); in 26 patients a reconstructive procedure was performed at the same time. Five patients who initially had AUS implantation alone developed detrusor hyper-reflexia and required a clam cystoplasty. Forty patients (90%) are continent, 2 are occasionally damp and 2 are wet and awaiting further surgery; 66% of patients who underwent AUS insertion and reconstruction were found to have significant residual urine and they perform intermittent self-catheterisation (ISC). In patients with a good bladder capacity and normal compliance and detrusor hyper-reflexia controlled by anticholinergic drugs, cystoplasty is not necessary at the time of AUS insertion.