British Association of Urological Surgeons (BAUS) consensus document: Management of female voiding dysfunction.

OBJECTIVES: To report the British Association of Urological Surgeon's (BAUS) guidance on the assessment and management of female voiding dysfunction. METHODS: A contemporary literature search was conducted to identify the evidence base. The BAUS Section of Female, Neurological and Urodynamic Urology (FNUU) Executive Committee formed a guideline development group to draw up and review the recommendations. Where there was no supporting evidence, expert opinion of the BAUS FNUU executive committee, FNUU Section and BAUS members, including urology consultants working in units throughout the UK, was used. RESULTS: Female patients with voiding dysfunction can present with mixed urinary symptoms or urinary retention in both elective and emergency settings. Voiding dysfunction is caused by a wide range of conditions which can be categorized into bladder outlet obstruction (attributable to functional or anatomical causes) or detrusor underactivity. Guidance on the assessment, investigation and treatment of women with voiding dysfunction and urinary retention, in the absence of a known underlying neurological condition, is provided. CONCLUSION: Wa have produced a BAUS approved consensus on the management pathway for female voiding dysfunction with the aim to optimize assessment and treatment pathways for patients.

Bladder leiomyoma masquerading as a ureterocele.

We present a unique case of bladder leiomyoma that was mistakenly diagnosed as a ureterocele. The delay in diagnosis meant ongoing significant voiding lower urinary tract symptoms, which could have been avoided. This was eventually successfully treated by transurethral resection. Leiomyoma is the most common benign bladder mass and should be considered in the differential diagnosis when a smooth mass with normal overlying mucosa is seen on cystoscopy or a homogeneous, low density bladder mass is seen on cross-sectional imaging. Despite the benign nature of the lesion, leiomyoma can convey significant morbidity to the patient.

British Association of Urological Surgeons (BAUS) consensus document: management of bladder and ureteric injury.

Injuries to the bladder and ureter are uncommon but usually require prompt urological management. Due to their infrequent nature, Urologists maybe unfamiliar with managing these acute problems and may not work in specialist centres with readily available expertise in open and abdominal surgery. We aim to provide advice in the form of a consensus statement led by the Female, Neurological and Urodynamic Urology (FNUU) Section of the British Association of Urological Surgeons (BAUS), in consultation with BAUS members and consultants working in units throughout the UK, to create a comprehensive management pathway and a series of statements to aid clinicians.

British Association of Urological Surgeons (BAUS) and Nurses (BAUN) consensus document: management of the complications of long-term indwelling catheters.

OBJECTIVE: To look at best evidence and expert opinion to provide advice in the form of a consensus statement lead by Female, Neurological and Urodynamic Urology (FNUU) section of the British Association of Urological Surgeons (BAUS) in conjunction with the British Association of Urological Nurses (BAUN). METHODS: Initially a literature search was performed with incorporation of aspects of the existing guidance and further informed by UK best practice by core members of the group. The document then underwent reviews by the FNUU Executive Committee members, the BAUN executive committee, a separate experienced urologist and presented at the BAUS annual meeting 2020 to ensure wider feedback was incorporated in the document. RESULTS: Complications of long-term indwelling catheters include catheter-associated urinary tract infections (CAUTI), purple urine bag syndrome, catheter blockages, bladder spasms (causing pain and urinary leakage), loss of bladder capacity, urethral erosion ("catheter hypospadias")/dilatation of bladder outlet and chronic inflammation (metaplasia and cancer risk). CONCLUSIONS: We have provided a list of recommendations and a troubleshooting table to help with the management of the complications of long term catheters.

The meaning of words - closing the gap in understanding between doctors and patients in 21st century consent.

'When I use a word' Humpty Dumpty said, in a rather scornful tone, 'it means just what I choose it to mean, neither more nor less'. 'The question is' said Alice 'whether you can make words mean so many different things'. Through the Looking-Glass, Lewis Carroll, 1872.

British Association of Urological Surgeons suprapubic catheter practice guidelines - revised.

AIMS: To report the updated and revised British Association of Urological Surgeons (BAUS) guideline on indications, safe insertion and subsequent care of suprapubic catheters (SPCs). METHODS: The existing BAUS guideline on the insertion of SPCs was reviewed and has been updated in light of both activity and outcome data published since the original guideline was written. A systematic review of all new data from 2010 onwards was carried out. This updated guideline is largely evidence-based but, where evidence was lacking, is based on the consensus of expert opinion from members of the BAUS Section of Female, Neurological and Urodynamic Urology. RESULTS: Suprapubic catheterization is widely used and generally considered a safe procedure. There is, however, a small risk of serious complications including bowel injury. The BAUS has produced an updated consensus statement on SPC use with the aim of minimizing risks and establishing best practice. Areas for future research and development are also highlighted. This review has been commissioned and approved by the BAUS and the Section of Female, Neurological and Urodynamic Urology. CONCLUSIONS: While SPC insertion is generally regarded as a safe procedure, the risk of serious morbidity and death must always be considered and outlined to patients. These revised guidelines should assist in minimizing the morbidity associated with SPC usage.

Micro-organisms attached to the lumens and balloons of indwelling urinary catheters and correlation with symptoms, antibiotic use and catheter specimen of urine results.

To determine micro-organisms attached to removed urethral catheters and relate this to patient-specific information. Indwelling urethral catheters were collected from patients at a UK teaching hospital. The balloon and lumen were sonicated, and micro-organisms were enumerated. Catheter specimen urine results were retrospectively reviewed. Escherichia coli and Enterococcus faecalis were the most common isolates from 61 catheters. 19.7% of patients received antibiotics and 25 % of those had a multi-drug-resistant (MDR) organism in the lumen. Only 2.04% of catheters from patients not receiving antibiotics had a MDR organism. All lumens were colonized irrespective of antibiotic use. Symptom presentation did not correlate with numbers of colonizing organisms or species. Despite heavy colonization, only 8/61 patients were symptomatic. Indwelling urinary catheters in place for ≥10 days were universally colonized and there was no correlation with symptom presentation. Symptom presentation remains the most important factor for defining catheter-associated urinary tract infection.

A tolerability and patient acceptability pilot study of a novel antimicrobial urinary catheter for long-term use.

AIMS: We have developed a novel antimicrobial urinary catheter (AUC) impregnated with rifampicin, triclosan, and sparfloxacin and demonstrated that it has long-term (∼84 days) protection against bacterial colonization in vitro. This study aimed to assess the safety and patient acceptability of this device in long-term catheter users. METHODS: Adults who use long term (>28 days) indwelling urinary catheters with capacity to consent were invited to receive the AUC at their next catheter change. The primary outcome measure was adverse events (AE) attributable to antimicrobial impregnation of the catheter. Secondary outcome measures included severity of related AEs, patient acceptability, early removal of the trial catheter, and degree of microbial colonization of trial catheters. Except for the last, outcomes were assessed by telephone interviews. Original and trial catheters were collected, and the lumens and balloons were separated and analyzed for microbiological colonization. RESULTS: Thirty participants were recruited. Eighty four AEs were reported, and only one was rated as "probably" related to antimicrobial impregnation. The AE was mild and resolved within 48 h. A total of 82.14% of participants rated the catheter as no different or better than their usual catheter. Two participants chose to remove the AUC early due to it feeling shorter. There were significantly fewer bacterial isolates attached to the balloons of trial catheters compared to the matched original catheters. CONCLUSIONS: The AUC has an advantageous safety profile and was acceptable to the majority of participants. Information gained from this trial will support a larger randomized controlled study of efficacy.

Isolated Red Patches Seen During Endoscopic Surveillance of Bladder Cancer: Incidence of Malignancy and When Should We Biopsy?

OBJECTIVE: To establish whether the regular biopsy of red patches (RPs) seen during endoscopic surveillance for bladder cancer is worthwhile and determine a suitable time frame for repeat biopsy of prior histologically benign persistent RPs in patients on endoscopic surveillance for bladder cancer. PATIENTS AND METHODS: Four thousand eight hundred five flexible cystoscopy (FC) reports over a 12-month period were retrospectively reviewed at a United Kingdom tertiary teaching hospital and those undergoing cystoscopic surveillance for bladder cancer and found to have solitary RPs at FC were included in the study. A proportion of these cases had biopsies taken for histopathologic analysis. RESULTS: Two hundred forty-one FC performed on 183 patients on endoscopic surveillance for bladder cancer had RPs and 120 (49.8%) of them had previous intravesical Bacillus Calmette-Guerin therapy. Eighty-five patients (35.3%) underwent biopsy of the RP. Malignancy was found in 20 biopsies (23.5%), of which, 11 out of 20 (55%) were carcinoma in-situ. Sixteen of these recurrences were biopsied previously, of which 11 (68.8%) were benign at last biopsy, 6 of which were in the last 12 months. The remaining four recurrences had no previous biopsy. No cases of malignancy were identified in patients with low-risk bladder cancer. CONCLUSION: We recommend the biopsy of all RPs found during endoscopic surveillance of patients with intermediate-/high-risk bladder cancer due to the significant incidence of malignant recurrence identified, particularly if no biopsy has been performed within the previous 12 months. This is independent of previous biopsy histology.

KI67 and DLX2 predict increased risk of metastasis formation in prostate cancer-a targeted molecular approach.

BACKGROUND: There remains a need to identify and validate biomarkers for predicting prostate cancer (CaP) outcomes using robust and routinely available pathology techniques to identify men at most risk of premature death due to prostate cancer. Previous immunohistochemical studies suggest the proliferation marker Ki67 might be a predictor of survival, independently of PSA and Gleason score. We performed a validation study of Ki67 as a marker of survival and disease progression and compared its performance against another candidate biomarker, DLX2, selected using artificial neural network analysis. METHODS: A tissue microarray (TMA) was constructed from transurethral resected prostatectomy histology samples (n=192). Artificial neural network analysis was used to identify candidate markers conferring increased risk of death and metastasis in a public cDNA array. Immunohistochemical analysis of the TMA was carried out and univariate and multivariate tests performed to explore the association of tumour protein levels of Ki67 and DLX2 with time to death and metastasis. RESULTS: Univariate analysis demonstrated Ki67 as predictive of CaP-specific survival (DSS; P=0.022), and both Ki67 (P=0.025) and DLX2 (P=0.001) as predictive of future metastases. Multivariate analysis demonstrated Ki67 as independent of PSA, Gleason score and D'Amico risk category for DSS (HR=2.436, P=0.029) and both Ki67 (HR=3.296, P=0.023) and DLX2 (HR=3.051, P=0.003) as independent for future metastases. CONCLUSIONS: High Ki67 expression is only present in 6.8% of CaP patients and is predictive of reduced survival and increased risk of metastasis, independent of PSA, Gleason score and D'Amico risk category. DLX2 is a novel marker of increased metastasis risk found in 73% patients and 8.2% showed co-expression with a high Ki67 score. Two cancer cell proliferation markers, Ki67 and DLX2, may be able to inform clinical decision-making when identifying patients for active surveillance.

Biomaterial modification of urinary catheters with antimicrobials to give long-term broadspectrum antibiofilm activity.

Catheter-associated urinary tract infection (CAUTI) is the commonest hospital-acquired infection, accounting for over 100,000 hospital admissions within the USA annually. Biomaterials and processes intended to reduce the risk of bacterial colonization of the catheters for long-term users have not been successful, mainly because of the need for long duration of activity in flow conditions. Here we report the results of impregnation of urinary catheters with a combination of rifampicin, sparfloxacin and triclosan. In flow experiments, the antimicrobial catheters were able to prevent colonization by common uropathogens Proteus mirabilis, Staphylococcus aureus and Escherichia coli for 7 to 12weeks in vitro compared with 1-3days for other, commercially available antimicrobial catheters currently used clinically. Resistance development was minimized by careful choice of antimicrobial combinations. Drug release profiles and distribution in the polymer, and surface analysis were also carried out and the process had no deleterious effect on the mechanical performance of the catheter or its balloon. The antimicrobial catheter therefore offers for the first time a means of reducing infection and its complications in long-term urinary catheter users.

Very high residual volumes should not prevent transurethral resection of the prostate being offered to men presenting with urinary retention.

OBJECTIVE: The aim of this study was to identify factors at presentation that can help to predict outcomes and guide subsequent management decisions in patients with acute on chronic retention. MATERIAL AND METHODS: The medical notes of 187 consecutive patients presenting with urinary retention at two teaching hospitals between 2008 and 2009 were reviewed. All patients were followed up for a minimum of 3 years. All patients were catheterized at presentation. The majority then underwent one or more of trial without catheter (TWOC), transurethral resection of the prostate (TURP) (both considered successful if the patient voided with a subsequent postvoid residual volume of <200 ml on three successive occasions) or long-term catheterization. Patient factors such as age, associated acute kidney injury (AKI), performance status, residual volume, prior lower urinary tract symptoms (LUTS), treatment of LUTS, diagnosis of diabetes and neuropathy were recorded. RESULTS: Increasing age (p = 0.002) and increasing residual volume (p = 0.046) were associated with a significant increase in the failure of TWOC. The rate of AKI increased significantly with residual volume (p < 0.0001). As residual volume increased so did the likelihood that a patient would undergo TURP (p = 0.0009). Age did not appear to influence the outcome of TURP (p = 0.17). Increasing residual volume did not significantly reduce the likelihood of successful TURP (p = 0.068). CONCLUSIONS: High residual volumes should not preclude TURP. There is a clear correlation between AKI and residual volume. Increasing age and residual volume both reduce the likelihood of successful TWOC.

Botulinum toxin type A for the treatment of non-neurogenic overactive bladder: does using onabotulinumtoxinA (Botox(®) ) or abobotulinumtoxinA (Dysport(®) ) make a difference?

OBJECTIVE: To compare the clinical effects of two different commercially available botulinum toxin type A products, onabotulinumtoxinA (Botox(®) ; Allergan Inc., Irvine, CA, USA) and abobotulinumtoxinA (Dysport(®) ; Ipsen Ltd, Slough, UK), on non-neurogenic overactive bladder (OAB). PATIENTS AND METHODS: We included 207 patients, who underwent treatment with botulinum toxin type A for non-neurogenic OAB from January 2009 to June 2012 at our institution, in a prospective database that recorded details of their presentation, treatment and outcomes. In December 2009, our institution switched from using onabotulinumtoxinA to using abobotulinumtoxinA. RESULTS: Results from the onabotulinumtoxinA cohort (n = 101) and the abobotulinumtoxinA cohort (n = 106) were compared. Similar reductions in daytime frequency, nocturia and incontinence episodes were observed after treatment, with no difference in duration of effect. The abobotulinumtoxinA cohort had almost twice the rate of symptomatic urinary retention (23 vs 42%) requiring intermittent self-catheterisation (ISC). CONCLUSIONS: AbobotulinumtoxinA use was complicated by a significantly higher risk of requiring ISC. The study suggests that these two toxins are not interchangeable at the doses used.

The Incidence of Concussion in a Professional Australian Rugby League Team, 1998-2012.

Background. Rugby league is a physically demanding team sport and the National Rugby League is the highest-level competition of rugby league in Australia. Frequent tackles and collisions between players result in a high incidence of injury to players. Concussion injuries have been the source of much debate, with reporting varying greatly depending on the definition used. Method. Injury records of 239 players from one professional National Rugby League were analysed during a continuous period of 15 years, with particular interest in the incidence and recurrence of concussions and the change in incidence over time. Result. A total of 191 concussions were recorded, affecting 90 players. The incidence of concussion injuries was found to be 28.33 per 1000 player match hours, with an increase over time (P = 0.0217). Multiple concussions were recorded for 51 players. Conclusion. A statistically significant increase in the incidence of concussion injuries was found, without a concurrent increase in the number of head injuries or total injuries. New rules which mandate removal of players from the field may be beneficial for protection of players on the long term, although they risk being counterproductive, if they make players less likely to report their symptoms during matches.

A case for one-stage revision in infected total knee arthroplasty?

Infection in total knee replacement is a rare but devastating complication. The current literature tends to support a two-stage revision as definitive treatment of established deep infection. Despite the fact that single stage revision is a well recognised treatment for the infected hip replacement, it has not gained the same level of support in the knee. This article reviews the literature of two-stage and single stage revision and reports the senior author's experience with the latter.

Gangrenous cystitis in a 42-year-old male.

Gangrenous cystitis is now an extremely rare condition since the widespread use of antibiotics. The authors report a case of gangrenous cystitis in a previously fit and normal 42-year-old male who presented in acute urinary retention. He underwent a partial cystectomy during an exploratory laparotomy for clinical deterioration and peritonitis. Diagnosis of this rare disease is challenged by its low incidence and lack of characteristic pathognomic features, resulting in delayed diagnosis and increased morbidity and mortality. The authors review the literature to date on the aetiology, presentation, diagnosis and management of gangrenous cystitis and emphasise the importance of early and aggressive surgical management.

Perioperative and intraoperative maneuvers to optimize surgical outcomes in skull base surgery.

There are many approaches to obtaining a workable endoscopic surgical field in sinus surgery. With extended sinus and transdural endoscopic surgery, a more rigid approach must be taken. There are 3 main factors that invariably lead to poor surgical outcomes in endoscopic sinus and skull base surgery: bleeding, inadequate access, and unidentified anatomic anomalies. Bleeding is arguably the most common reason for incomplete resection. An understanding of microvascular and macrovascular bleeding allows a more structured approach to improve the surgical field in extended endoscopic surgery. The endoscopic surgeon should always be comfortable in performing the same procedure as an open operation. However, converting or abandoning an endoscopic procedure should rarely occur because much of this decision making should take place preoperatively. Along with poor hemostasis, inadequate access is an important cause of poor outcome. Evaluation of the anatomy involved by pathology but also the anatomy that must be removed to allow adequate exposure is important. This article reviews the current techniques used to ensure optimal surgical conditions and outcomes.

Neuroapplication of amplatzer vascular plug for therapeutic sacrifice of major craniocerebral arteries: an initial clinical experience.

INTRODUCTION: Clinical use of the Amplatzer vascular plug in the cardiopulmonary and peripheral vasculatures has been described extensively in the literature. We present our initial experience in adapting this device for therapeutic sacrifice of major craniocerebral arteries. MATERIALS AND METHODS: Between July 2007 and November 2008, 8 patients (mean age 59.1 years; range 18 to 82 years) underwent therapeutic occlusion of major craniocerebral arteries using the device, for direct caroticocavernous fistula (1 patient), symptomatic unruptured giant cavernous internal carotid aneurysms (2 patients), and preoperative embolisation before surgical resections of skull base tumours that had encroached upon the internal carotid or vertebral artery (5 patients). The plugs were used alone or in conjunction with detachable platinum coils. The applications of the device, as well as the angiographic and clinical results of the procedures were evaluated. RESULTS: Applications of the plugs were straightforward and successful in all cases, with hermetic occlusions of all target arteries. When used without additional coils, several plugs were deployed in tandem to achieve complete occlusion of the artery. No migration of the device was seen. No patient developed untoward neurological deficits following the procedures, and the 3- and/or 6-month follow-up showed stable results. CONCLUSION: The Amplatzer vascular plug could be a valuable addition to the neurointerventional armamentarium, particularly in therapeutic occlusion of major craniocerebral arteries. Rigidity of the delivery system limits its current use to vessels below the skull base. The potential risk of distal thromboembolism also requires further evaluation.

Successful treatment of six cases of indirect carotid-cavernous fistula with ethylene vinyl alcohol copolymer (Onyx) transvenous embolization.

BACKGROUND: Endovascular transvenous treatments have become the mainstay in the management of indirect carotid-cavernous fistulas (CCFs). However, the standard coil techniques are associated with a substantial failure and complication rate. The ethylene vinyl alcohol copolymer (Onyx) Liquid Embolization System has advantages over coils, including the ability to penetrate and occlude vessels of small caliber or with difficult access. METHODS: This was a review of 5 consecutive patients with indirect type D CCFs who underwent 6 procedures using the Onyx system alone at the Prince of Wales Hospital, Sydney, between December 2005 and May 2007. The cavernous sinus was catheterized with MTI Echelon-10 or Rebar-14 microcatheters via the femoral vein using an inferior petrosal approach to the cavernous sinus in 5 procedures and directly via the superior ophthalmic vein in 1 procedure. RESULTS: All 5 patients had complete closure of the fistulas as seen on imaging and full reversal of ophthalmic manifestations without lingering complications and with substantially shorter procedure times than with conventional approaches. CONCLUSIONS: The Onyx system is a safe and useful method of closing indirect CCFs transvenously. This is the first series report of the use of the Onyx system alone in the treatment of these vascular abnormalities.