Perception, career choice and self-efficacy of UK medical students and junior doctors in urology.

INTRODUCTION: There is a growing concern about the reduced clinical exposure to urology at undergraduate level in the United Kingdom. As a consequence, the competencies of junior doctors are considered inadequate. The views of these doctors in training towards urology remain under reported. METHODS: A modified Delphi method was employed to construct a questionnaire. Given the rise of social media as a platform for scientific discussion, participants were recruited via a social networking site. Outcomes assessed included career preference, exposure to urology, perceived male dominance, and confidence at core procedures. RESULTS: In total, 412 and 66 responses were collected from medical students and junior doctors, respectively. Overall, 41% of participants felt that they had received a good level of clinical exposure to urology as part of their training and 15% were considering a career in this speciality. Female students were significantly less likely to consider urology as a career option (p < 0.01). Of these, 37% of the students felt confident at male catheterization and 46% of students regarded urology as a male-dominated speciality. CONCLUSIONS: Urology is perceived as male dominated and is the least likely surgical speciality to be pursued as a career option according to our survey. Increased exposure to urology at the undergraduate level and dedicated workshops for core urological procedures are needed to address these challenges.

Robot-assisted laparoscopic total extraperitoneal hernia repair during prostatectomy: technique and initial experience.

INTRODUCTION: To describe the technique of total extraperitoneal inguinal hernia repair performed during Robot-assisted Endoscopic Extraperitoneal Radical Prostatectomy (R-EERPE) and to present the initial outcomes. MATERIAL AND METHODS: 12 patients underwent inguinal hernia repair during 120 R-EERPEs performed between July 2011 and March 2012. All patients had a clinically palpable inguinal hernia preoperatively. The hernia was repaired using a Total Extraperitoneal Patch (TEP) at the end of the procedure. RESULTS: Sac dissection and mesh placement was simpler compared to conventional laparoscopy due to improved, magnified, 3-D vision along with 7° of movement, and better control of mesh placement. The median operating time was 185 minutes, with on average, an additional 12 minutes incurred per hernia repair. The median blood loss for the procedures was 250 ml, and the mean pathological prostate weight was 55 gm. No additional blood loss was noted and there were no postoperative complications. None of the patients had a recurrence at 12 months. We await long-term follow-up data. CONCLUSIONS: Robot-assisted TEP is feasible and should be considered in patients with hernia at the time of R-EERPE.

Evaluating the learning curve of experienced laparoscopic surgeons in robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE: Radical prostatectomy is the gold standard surgical treatment for organ-confined prostate cancer. There is no consensus on the impact of previous laparoscopic experience on the learning curve of robot-assisted laparoscopic prostatectomy (RALP). We compared the perioperative complications and early patient outcomes from our initial 100 cases of RALP with laparoscopic prostatectomy (LRP) cases performed well beyond the learning curve. PATIENTS AND METHODS: Between July 2011 and January 2012, 110 RALP were performed by one of two surgeons, each with previous experience of more than 1000 LRP. The cases were pair matched from among the last 208 patients who had undergone LRP by the same surgeons at the same time. The clinical parameters, operative details, postoperative complications, and short-term outcomes from these patients, collected prospectively, were compared between the two groups. RESULTS: The prostate-specific antigen (PSA) level and age of the two groups was similar. The operative time (128.4 vs 153.9 min; P=0.01) and blood loss (200 vs 254 mL; P=0.01) was significantly less for the LRP group, but the duration of catheterization was similar (5.89 vs 6.2 days). The complication rate was low. No procedures needed conversions, and no patient had a visceral injury or blood transfusion. Twenty-three patients in the LRP group and 33 patients in the RALP group had extraprostatic disease, and the positive margin rate was 14% and 19% for these respective groups. At 3 months, PSA level was undetectable in 94% of LRP and 92% RALP patients, while 56% and 65% (P=0.062) patients in these groups were using 0 to 2 pads per day. CONCLUSIONS: The initial results of the outcome of RALP are at least at par with those of LRP and with those of previously published RALP series. This suggests the lack of a steep learning curve for experienced laparoscopic surgeons in performing RALP.

Shockwave lithotripsy: arterial aneurysms and vascular complications.

BACKGROUND AND PURPOSE: The application of shockwave lithotripsy (SWL) in patients with arterial aneurysm remains controversial, and several case reports exist in the world literature that describe both safe use and rupture. In addition, other vascular complications have been reported. The potential for hemorrhage is affected by coagulation status and antiplatelet therapy, yet little evidence exists on their interaction with SWL. We aim to review the vascular complications after SWL. METHODS: A review of the world literature was performed in accordance with methodology that is defined by the Cochrane Collaboration. An Internet bibliographic search on MEDLINE was performed during May and June 2010, with additional hand-searching of references. The search terms lithotripsy, aneurysm, abdominal aortic aneurysm, pseudoaneurysm, hemorrhage, hematoma, coagulation, aspirin, clopidogrel, and warfarin were used. RESULTS: In reported cases, there have been 18 patients with abdominal aortic aneurysm (AAA) who have undergone SWL. Both safe and uncomplicated treatment have been reported as well as rupture of AAA. Other vascular complications after SWL have included pseudoaneurysm, venous thrombosis, arterial stenosis, and arteriovenous fistulation. Patients with hemorrhagic risk factors can undergo SWL after correction of coagulopathy. Experimental work on animal models and human tissue has evaluated the effects of SWL on the vasculature. CONCLUSION: There is currently no high-level evidence to suggest that SWL in the presence of arterial aneurysm is unsafe. Experimental work on ex vivo human tissue does not suggest that SWL is causative to aneurysm rupture. With the availability of CT imaging in modern clinical practice, aneurysms of the arterial tree should be identified as part of the investigation of urinary tract calculi. SWL can be safely performed in patients with AAA, but monitoring postprocedure is mandatory, along with access to emergency vascular surgery support; importantly, any onset of new pain or symptoms should be aggressively investigated by radiologic imaging in the first instance.

Routine use of magnetic resonance imaging in the management of T(1c) carcinoma of the prostate: is it necessary?

PURPOSE: To assess the role and implications of MRI in the management of patients with stage T(1c) prostate cancer. PATIENTS AND METHODS: Data were collected from our oncology database, where all new prostate cancers are recorded, for a period of 3 years ending December 2005. A total of 915 patients were found to have prostate cancer. Of the 204 patients with stage T(1c) disease, 144 were considered eligible for radical treatment and underwent cross-sectional imaging in the form of an MRI scan. Gleason grade, clinical stage, cross-sectional imaging results, and subsequent treatment were recorded. The results were analyzed to see whether the MRI findings altered the modality of treatment offered to the patient. RESULTS: Of the 144 patients, 137 had scans that showed no extracapsular invasion, while five scans were equivocal. All five patients had further investigation, either by CT scanning or targeted biopsies, which confirmed the cancer to be localized. In the remaining two cases, the MRI findings upstaged T(1c) disease to T(3) disease, as there was evidence of extracapsular involvement. The imaging result therefore affected treatment choice in only two patients in that radical surgery was not offered because of the scan findings. CONCLUSIONS: The role of MRI in the management of clinical stage T(1c) prostate cancer is limited, as it altered the management of only 1.3% of our patients. The cost v the value of this study should be discussed with the patient before MRI is prescribed.

Stuttering priapism after ingestion of alfuzosin.

A patient who presented with priapism after ingestion of alfuzosin is described. He presented with recurrent priapism, which was relieved temporarily after physical exercise. It did not subside with pharmacologic management and was managed surgically using Winter's procedure. It remained quiescent for a short period, only to reappear later. After additional conservative management, he was well enough to be discharged. At 12 months of follow-up, he was well, had no penile fibrosis, was able to have unaided intercourse, and had moderately bothersome lower urinary tract symptoms. This case illustrates that no therapeutic drug is without side effects and emphasizes the need to warn patients appropriately.

Testicular metastasis from gastric carcinoma.

Secondary neoplasms of the testis have been reported with an incidence of 0.02% to 2.5% on autopsy. Other than leukemias and lymphomas, the most common sites from which metastases occur are the lung and prostate gland. We report the case of a 58-year-old patient, recently diagnosed with gastric carcinoma, who presented with swelling and discomfort of the left testis. An ultrasound scan of the scrotum suggested a malignant mass. Orchiectomy was performed, and the subsequent pathologic examination revealed the mass to be a gastric carcinoma metastasis that appeared to mimic a testicular primary clinically.