Adrenal Incidentaloma: Prevalence and Referral Patterns From Routine Practice in a Large UK University Teaching Hospital.

CONTEXT: Adrenal incidentalomas (AIs) are increasingly being identified during unrelated imaging. Unlike AI clinical management, data on referral patterns in routine practice are lacking. OBJECTIVE: This work aimed to identify factors associated with AI referral. METHODS: We linked data from imaging reports and outpatient bookings from a large UK teaching hospital. We examined (i) AI prevalence and (ii) pattern of referral to endocrinology, stratified by age, imaging modality, scan anatomical site, requesting clinical specialty, and temporal trends. Using key radiology phrases to identify scans reporting potential AI, we identified 4097 individuals from 479 945 scan reports (2015-2019). Main outcome measures included prevalence of AI and referral rates. RESULTS: Overall, AI lesions were identified in 1.2% of scans. They were more prevalent in abdomen computed tomography and magnetic resonance imaging scans (3.0% and 0.6%, respectively). Scans performed increased 7.7% year-on-year from 2015 to 2019, with a more pronounced increase in the number with AI lesions (14.7% per year).Only 394 of 4097 patients (9.6%) had a documented endocrinology referral code within 90 days, with medical (11.8%) more likely to refer than surgical (7.2%) specialties (P < .001). Despite prevalence increasing with age, older patients were less likely to be referred (P < .001). CONCLUSION: While overall AI prevalence appeared low, scan numbers are large and rising; the number with identified AI are increasing still further. The poor AI referral rates, even in centers such as ours where dedicated AI multidisciplinary team meetings and digital management systems are used, highlights the need for new streamlined, clinically effective systems and processes to appropriately manage the AI workload.

Day-case catheterless and drainless minimal-access pyeloplasty in adults: A single-center experience of 13 years.

OBJECTIVES: To analyze our practice of drainless and catheterless day-case minimal-access pyeloplasty with regard to feasibility, safety and long-term outcomes. METHODS: Patients undergoing minimal-access pyeloplasty (laparoscopic, with or without robotic assistance) in a single center between 2007 and 2020 were included in this retrospective observational study. Patient demographics and the success rate of day-case discharge along with postoperative outcomes were analyzed. RESULTS: A total of 129 patients underwent minimal-access pyeloplasty in this time period, of whom 116 met the inclusion criteria. The mean patient age was 48 years. A total of 65% of the patients (n = 75) were discharged on the same day and 88% (n = 101) were discharged within 23 h of surgery. Of the 14 patients with a hospital stay of >24 h, pain was the most common reason (60%) for delayed discharge. The overall subjective (pain-free status) and objective (unobstructed drainage) success rates were 91% and 86%, respectively. CONCLUSION: This study demonstrates that routine drains or urethral catheters are not necessary in minimal-access pyeloplasty, and their omission could facilitate early recovery and day-case discharge without compromising long-term surgical outcomes. Large randomized controlled studies are required to prospectively evaluate outcomes.

Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness.

INTRODUCTION: Adrenal incidentalomas are lesions that are incidentally identified while scanning for other conditions. While most are benign and hormonally non-functional, around 20% are malignant and/or hormonally active, requiring prompt intervention. Malignant lesions can be aggressive and life-threatening, while hormonally active tumours cause various endocrine disorders, with significant morbidity and mortality. Despite this, management of patients with adrenal incidentalomas is variable, with no robust evidence base. This project aimed to establish more effective and timely management of these patients. METHODS: We developed a web-based, electronic Adrenal Incidentaloma Management System (eAIMS), which incorporated the evidence-based and National Health Service-aligned 2016 European guidelines. The system captures key clinical, biochemical and radiological information necessary for adrenal incidentaloma patient management and generates a pre-populated outcome letter, saving clinical and administrative time while ensuring timely management plans with enhanced safety. Furthermore, we developed a prioritisation strategy, with members of the multidisciplinary team, which prioritised high-risk individuals for detailed discussion and management. Patient focus groups informed process-mapping and multidisciplinary team process re-design and patient information leaflet development. The project was partnered by University Hospital of South Manchester to maximise generalisability. RESULTS: Implementation of eAIMS, along with improvements in the prioritisation strategy, resulted in a 49% reduction in staff hands-on time, as well as a 78% reduction in the time from adrenal incidentaloma identification to multidisciplinary team decision. A health economic analysis identified a 28% reduction in costs. CONCLUSIONS: The system's in-built data validation and the automatic generation of the multidisciplinary team outcome letter improved patient safety through a reduction in transcription errors. We are currently developing the next stage of the programme to proactively identify all new adrenal incidentaloma cases.

Renal arteriovenous malformation mimicking hydronephrosis-hidden danger.

Renal arteriovenous malformations (AVMs) are rare, with an incidence of approximately 0.04%. Diagnosis is often challenging due to mimics of AVMs. We report a case of renal AVM mimicking hydronephrosis on ultrasound and unenhanced computed tomography (CT). A 24-year-old female with background of recurrent urinary tract infections (UTIs) presented to the Accident and Emergency department with 1 day history of bilateral flank pain, dysuria, rigors and pyrexia. Urine dipstick showed microscopic haematuria and blood tests showed mild neutrophilia. Dilated right renal pelvis was seen on ultrasound. Unenhanced CT of the urinary tract demonstrated right hydronephrosis with no evidence of calculi. Subsequent Uro-radiology meeting discussion concluded that renal pelvis might be pus-filled and recommended an urgent nephrostomy. However, ultrasound Doppler scan performed at the time of the planned nephrostomy demonstrated colour flow within dilated renal pelvis suggestive of an AVM. Nephrostomy was abandoned and subsequent CT angiogram confirmed a large congenital AVM. The patient was referred for embolization.Colour flow ultrasound imaging is a simple and quick technique to diagnose AVMs. However, as in our case, when colour flow Doppler imaging was not used at the initial ultrasound, the opportunity to obtain an accurate diagnosis was missed. If the subsequently planned nephrostomy had taken place, this may have led to potentially serious outcomes. We suggest that colour flow imaging should be used prior to nephrostomy insertion to differentiate hydronephrosis from vascular abnormalities.

Anastomosing Haemangioma of the Kidney Involving a Segmental Branch of the Renal Vein.

Anastomosing variant of capillary haemangioma is a rare and recently described vascular tumour with a proclivity for the genitourinary tract. Here we present the case of a 64-year-old man with incidental finding of 3.4 cm renal mass on CT who had laparoscopic nephrectomy with a good postoperative recovery. Histopathological diagnosis of anastomosing haemangioma of the kidney was made and the patient was followed up for 10 months without evidence of tumour recurrence.

An objective scoring system for laparoscopic nephrectomy.

BACKGROUND AND PURPOSE: The current first-line recommended modality for nephrectomy is by the laparoscopic approach. This is one of the most frequent laparoscopic interventions conducted in urology. From a skills acquisition and delivery perspective in minimally invasive urologic surgery, there is a paucity of objective scoring systems for advanced laparoscopic urologic procedures. We developed a system of direct observation with structured criteria to evaluate the surgical conduction of laparoscopic nephrectomy (LN). We tested the application and preliminary validity of the scoring system. METHODS: Sixty cases of prerecorded LN performed in four teaching hospitals were each analyzed by four mentors. Each mentor scored each case based on a 100-point scoring systemthat comprised 20 key steps for LN (each step ranging 0 to 5). Steps included port placement and safety checks in addition to the actual case. In addition, a negative marking system based on a 50-point index scoring system was deployed such that technically unsound techniques were penalized. The sum of the two resulted in the final score. The final scores independently submitted for each recorded case were analyzed and compared. The system was then used to predict the experience of a surgeon for 10 pilot cases. The cases included a mix of five fellows and five experienced laparoscopic urologic surgeons. The cases were blinded to the independent assessors. A further 20 cases involving 10 cases performed by a trainee who sufficiently completed training (as deemed by the recent award of a certificate of specialist training in urology) vs one who is not ready were reviewed. RESULTS: There was no significant difference in the scores submitted by each of the four mentors for each of the cases observed. There was a strong correlation between overall score and seniority/experience of the performing surgeon of each case; ie, it was able to predict whether an experienced surgeon or laparoscopic fellow performed the case. It was able to predict accurately between a trainee who sufficiently completed training vs one who is "not ready." CONCLUSION: The scoring system was a reliable tool for assessing the performance of LN and accurately predicts the level of experience of the surgeon. This system could be a useful supplementary tool for assessing the baseline skill and progress of trainees.

Routine day-case laparoscopic pyeloplasty: a paradigm shift?

PURPOSE: To determine whether day-case surgery (DS) laparoscopic pyeloplasty (LP) is feasible and safe. PATIENTS AND METHODS: Thirty-two consecutive patients, planned for DS LP between March 2006 and January 2010 at a single urologic center, were enrolled in this retrospective observational study. Every patient underwent LP after a standard pathway of care for DS. We collected demographic and medical information, including renographic data. The success rate of DS and reasons for unplanned overnight admission and readmission were collected and evaluated. RESULTS: There were 20 (62.5%) females and 12 (37.5%) males with a median age of 37 years (range 11 to 69 y). The pelviureteral junction obstruction was on the left side in 19 (59.3%) patients and on the right side in 13 (40.6%) patients. The most common symptom was loin pain (68.75%). The majority of patients were classified according to their physical status as American Society of Anesthesiologists (ASA) 1 (59.37%), ASA 2 (37.5%), and only one patient (3.1%) as ASA 3. Surgical time varied from 90 to 210 minutes (mean 148.9 min, standard deviation 34.70). Twenty-five (78.12%) patients were successfully discharged on the same day. Two (6.25%) patients were readmitted after surgery. On follow-up renography, 96.15% had improved drainage. This is a small retrospective study reporting initial experience. CONCLUSIONS: The DS LP is feasible and safe. To improve the success rate and to decrease the readmission rate, objective preoperative, intraoperative, and discharge criteria should be developed for DS and validated in randomized studies.

Day case laparoscopic nephrectomy.

PURPOSE: To report our initial experience with day case surgery (DS) laparoscopic nephrectomy (LN) and to assess its feasibility and safety. PATIENTS AND METHODS: Twenty-six consecutive patients, planned for DS LN between January 2006 and December 2009 at a single urologic center, were enrolled in this retrospective observational study. Every patient underwent LN after a standard pathway of care for DS. We collected data regarding demographic information, medical comorbidities, preoperative and postoperative symptoms, admission as well as discharge time and date. The success rate of DS and reasons for unplanned overnight admission and readmission were collected and evaluated. RESULTS: There were 12 (46.15%) women and 14 (53.84%) men with a median age of 46 years (range 11-77 y). The LN was on the left side in 15 (57.7%) patients and on the right side in 11 (42.3%) patients. Fifteen (57.7%) patients had benign diseases associated with nonfunctioning kidney and 11 (42.3%) patients had renal masses. The most common symptom was loin pain-53.3% for the patients with nonfunctioning kidneys; the majority of patients with tumors (45.6%) were asymptomatic. Twenty-two (84.61%) patients were successfully discharged the same day. Six (23.07%) patients were readmitted after surgery. CONCLUSIONS: The DS LN is feasible and safe. We believe that the results should be easily reproducible. Increasing experience may help to develop more rigorous preoperative, intraoperative, and discharge criteria to increase the success rate and to decrease the readmission rate for DS LN.

Initial treatment costs of organ-confined prostate cancer: a general perspective.

With the increasing prevalence of prostate cancer and evolving methods for the definitive treatment of OCPCa, health economic analyses will be critically important, albeit difficult to carry out. Preliminary studies point to RPP as the most cost-effective treatment for OCPCa. The quickest postoperative recovery, in experienced hands, occurs in RARP and RPP, with ORPP having a slightly, but statistically in significant, shorter hospital stay. It should be stressed that initial treatment costs are not the only important factor in healthcare costs. Readmission for early and late complications and the loss of productivity resulting from variation in time to return to work, need also to be considered. Loss of productivity may also vary in cost between different institutions and countries depending upon the proportion of patients employed. Further large-scale multicentre studies are necessary to assess this.