The psychological impact of adverse events on urology trainees.

INTRODUCTION: Adverse events (AE) are an inevitable reality in healthcare, with an incidence of 7.5-14.1% worldwide. AEs are recognised to cause psychological and emotional distress in healthcare workers, with surgeons being particularly susceptible. We report the first data on the emotional impact in relation to adverse events in surgeons in the Republic of Ireland (ROI). METHODS: We distributed a web-based survey to all urology trainees in the ROI. The questionnaire focused on trainees' personal account of AEs, their emotional response, perceived contributing factors and perceived benefit of support systems. The primary care PTSD screen (PC-PTSD-V) assessed for PTSD. RESULTS: A total of 16 responses were received from 12 (75%) registrars and 4 (25%) SHOs. Of the AEs reported, 12 (75%) were ≥ Clavien-Dindo 3b. Contributing factors identified included lapse of judgement (n = 6, 37.5%), risk of procedure (n = 7, 43%), lack of experience (n = 4, 25%). Anxiety (n = 8, 50%), guilt (n = 7, 44%) and sleep problems (n = 4, 25%) were the most reported emotional responses. Physical symptoms were reported in 2 (12%) trainees. A PC-PTSD-V score ≥ 3 was reported in 2 (12%) trainees. Most trainees (n = 13, 81%) reported talking to someone following the event with most (n = 12, 93%) talking to a consultant or NCHD colleague. Most respondents (n = 14, 87%) agreed that their training could better prepare them for the personal impact of AEs. CONCLUSION: Surgical trainees report negative psychological and emotional responses that are consistent with second victim symptoms. Those surveyed felt that their training could better prepare them for the personal impact of such events.

Strategies to maximise patient comfort during extracorporeal shockwave lithotripsy - A randomised controlled trial.

BACKGROUND/PURPOSE OF STUDY: We aim to assess if distraction techniques improve patient comfort tolerability of SWL. METHODS: We carried out a prospective randomised controlled trial of SWL-naïve patients attending for treatment. Patients were randomised into three groups and offered oral analgesia as standard of care. Group 1 (n = 19) received stress balls to squeeze during treatment. Group 2 (n = 19) listened to music during treatment. Group 3 (n = 17) received standard of care only. All patients completed a validated health anxiety inventory score prior to treatment. All patients completed a validated pain questionnaire and visual analogue scale (VAS) after treatment. Primary outcomes were completion of SWL treatment and pain score results. RESULTS: 55 patients attending for SWL were randomised. There was no difference in stone size or position, presence of a stent, height or weight between the groups. VAS scores were lower in controls compared to Group 1 (1.93 vs 3.69, p = 0.08). On subgroup analysis of non-anxious patients, pain questionnaire scores were lower in controls compared to Group 1 (2.58 vs 4.77, p = 0.06). VAS scores were lower in patients who received optional analgesia alone than in patients who received stress balls alone (1.92 vs 4.07, p = 0.05). Across all subgroups, pain scores were lower in the control group compared to the distraction groups, but did not achieve significance. CONCLUSIONS: In conclusion, distraction techniques should not replace standard of care for analgesia during SWL. This study was registered with clinicaltrials.gov (identifier NCT03379922).

Outcomes from the Introduction of a Combined Urology Outpatient Clinic.

BACKGROUND: A combined urology clinic staffed by four consultants and four non-consultant hospital doctors (NCHDs) was introduced in our institution in October 2015. This clinic is supported by a pre-clinic radiology meeting and a synchronous urology clinical nurse specialist (CNS) clinic with protected uroflow/trial of void slots. Herein, we report on the outcomes of this clinic in comparison with the standard format of urology outpatient review. METHODS: We carried out a retrospective review of clinic attendances from May to July 2016. We recorded the number of new and return attendances, which team members had reviewed the patient and patient outcomes. We also calculated the waiting times for new patients to be reviewed in the outpatient clinic. RESULTS: The combined urology clinic reviewed an average of 12 new and 46 return patients per clinic. The standard urology clinic reviewed an average of 8 new and 23 return patients per clinic. 54% of patients were seen by a consultant in the combined urology clinic, and 20% of patients were seen by a consultant in the standard urology clinic. The rate of patient discharge for new patients was 14.8% in the combined clinic compared to 5.9% in the standard clinic. Overall patient outcomes are outlined in the table. The waiting time for review of new patients in the combined clinic was reduced by 39% from 144 days to 89 days over a one-year period. CONCLUSIONS: The introduction of a combined urology outpatient clinic with the support of pre-clinic radiology meeting and synchronous urology CNS clinic facilitates patient discharge.

Acute urinary retention and constipation precipitated by herpes zoster infection.

A 76-year-old man presented to the emergency department complaining of acute urinary retention (AUR) and severe constipation. His recent medical history included 4 days of treatment in the community for gluteal herpes zoster with famciclovir. A transurethral catheter was passed and the patient completed a full course of famciclovir with resolution of constipation. The patient's catheter was successfully removed 3 weeks after his presentation. We report on the clinical presentation and management of an unusual case of AUR and constipation caused by a zoster viral infection of the S2-S4 dermatome.

Prophylactic intravesical chemotherapy decreases bladder tumor recurrence after nephroureterectomy for primary upper tract urothelial carcinoma: A systematic review and meta-analysis.

PURPOSE: A high incidence of bladder tumor (BT) occurs after radical nephroureterectomy (NU) for primary upper tract urothelial carcinoma (UTUC). Although some studies have shown that prophylactic intravesical chemotherapy could prevent BT recurrence, it has not become standard practice at this stage. The purpose of this study was to evaluate the effect of intravesical instillation chemotherapy in preventing BT recurrence in patients with primary UTUC after nephroureterectomy. METHODS: A comprehensive literature search was performed in July 2014 using the Medline, Embase, and Cochrane Library databases, as well as the China National Knowledge Infrastructure and Wanfang Data. All clinical trials compared the effect of prophylactic intravesical chemotherapy after radical NU for primary UTUC. Analysis was performed using the Stata 12.0 SE software. RESULTS: Eight trials were analyzed with a total of 979 patients including 521 patients receiving intravesical chemotherapy instillation and 458 without instillation. The BT incidence rate was 125 out of 521 patients (24.0%) with intravesical instillation chemotherapy after NU, and 169 out of 458 patients (36.9%) without intravesical chemotherapy after NU. Compared with those who didn't receive instillation, the pooled odds ratio (OR) of BT recurrence was 0.45 (95% confidence interval/CI 0.34-0.61, p<0.0001) in instillation patients. In the sub-analyses, the OR of single instillation was similar to repeated instillations (0.48 and 0.42). The OR of beginning the first instillation within 24 hrs, 48 hrs and 2 weeks was 0.34, 0.48 and 0.46, respectively. CONCLUSIONS: This systematic review demonstrates that prophylactic intravesical instillation chemotherapy can prevent BT recurrence in primary UTUC patients after NU. It also suggests that single instillation may have a similar effect to repeated instillations. The first instillation beginning within 24 hrs seems to show lower BT recurrence than at 48 hrs or 2 weeks. However, given that some limitations exist, well-designed randomized controlled trials are needed to further evaluate these results.

A review of expression profiling of circulating microRNAs in men with prostate cancer.

MicroRNAs (miRNAs) are small non-coding RNAs that are involved in gene regulation and expression. These molecules have been implicated in the pathogenesis of several malignancies. MiRNAs have the potential to be both a tissue- and blood-based biomarker for cancer diagnosis, classification, prognosis and response to treatment. The levels of dysregulated miRNAs in the circulation of individuals make miRNAs an ideal biomarker for the detection of prostate cancer. The present study provides a comprehensive review of the expression profiling of miRNAs in the circulation of men with prostate cancer. Further research is necessary to identify if circulating miRNAs have the potential to be a biomarker for prostate cancer in clinical practice.

Laparoendoscopic single-site radical prostatectomy: technique and initial outcomes.

BACKGROUND: Laparoendoscopic single-site surgery radical prostatectomy (LESS-RP) is a challenging urological procedure and needs to be further evaluated. This study was undertaken to illustrate the safety and initial results of pure LESS-RP with conventional available instruments. METHODS: A prospective clinical database was established in September 2010 to assess the outcome following the introduction of LESS-RP at our institution. By June 2012, six procedures had been performed. The mean patient age was 74.7 (74.0 - 76.0) years. The mean body mass index (BMI) was 23.8 (19.5 - 32.2) kg/m(2). The LESS-RP was preformed through an extra-peritoneal approach using single port access with QudaPort, 0° lens 5 mm flexible tip video-laparoscope and available conventional laparoscopic instruments. Parameters assessed were operative time, estimated blood loss, intra-operative complications, drainage time, postoperative pain score (visual analogue pain scale (VAPS), 0 - 10), pathological results, and postoperative prostate specific antigen (PSA) levels. RESULTS: LESS-RP was completed for all six cases without additional trocar placement or conversion to standard laparoscopic or open radical prostatectomy. The mean operative times were 252.5 (190.0 - 305.0) minutes, estimated blood loss was 300 (100 - 500 ml). There was no documentable intraoperative complication. The mean wound-drainage time was 5.2 (2.0 - 7.0) days, and the first postoperative day VAPS was 0.8 (0 - 3.0). Final pathological staging was pT2aN0M0 in four cases and pT2cN0M0 in two cases. Surgical margins were negative for all cases. The one-month post-operative PSA was less than 0.02 ng/ml in each case. All patients were continent without pad usage at 1 year postoperatively. CONCLUSION: The technique of pure LESS-RP is feasible and early outcomes are acceptable.

Use of a robot for high-throughput crystallization of membrane proteins in lipidic mesophases.

Structure-function studies of membrane proteins greatly benefit from having available high-resolution 3-D structures of the type provided through macromolecular X-ray crystallography (MX). An essential ingredient of MX is a steady supply of ideally diffraction-quality crystals. The in meso or lipidic cubic phase (LCP) method for crystallizing membrane proteins is one of several methods available for crystallizing membrane proteins. It makes use of a bicontinuous mesophase in which to grow crystals. As a method, it has had some spectacular successes of late and has attracted much attention with many research groups now interested in using it. One of the challenges associated with the method is that the hosting mesophase is extremely viscous and sticky, reminiscent of a thick toothpaste. Thus, dispensing it manually in a reproducible manner in small volumes into crystallization wells requires skill, patience and a steady hand. A protocol for doing just that was developed in the Membrane Structural & Functional Biology (MS&FB) Group(1-3). JoVE video articles describing the method are available(1,4). The manual approach for setting up in meso trials has distinct advantages with specialty applications, such as crystal optimization and derivatization. It does however suffer from being a low throughput method. Here, we demonstrate a protocol for performing in meso crystallization trials robotically. A robot offers the advantages of speed, accuracy, precision, miniaturization and being able to work continuously for extended periods under what could be regarded as hostile conditions such as in the dark, in a reducing atmosphere or at low or high temperatures. An in meso robot, when used properly, can greatly improve the productivity of membrane protein structure and function research by facilitating crystallization which is one of the slow steps in the overall structure determination pipeline. In this video article, we demonstrate the use of three commercially available robots that can dispense the viscous and sticky mesophase integral to in meso crystallogenesis. The first robot was developed in the MS&FB Group(5,6). The other two have recently become available and are included here for completeness. An overview of the protocol covered in this article is presented in Figure 1. All manipulations were performed at room temperature (~20 °C) under ambient conditions.

Harvesting and cryo-cooling crystals of membrane proteins grown in lipidic mesophases for structure determination by macromolecular crystallography.

An important route to understanding how proteins function at a mechanistic level is to have the structure of the target protein available, ideally at atomic resolution. Presently, there is only one way to capture such information as applied to integral membrane proteins (Figure 1), and the complexes they form, and that method is macromolecular X-ray crystallography (MX). To do MX diffraction quality crystals are needed which, in the case of membrane proteins, do not form readily. A method for crystallizing membrane proteins that involves the use of lipidic mesophases, specifically the cubic and sponge phases(1-5), has gained considerable attention of late due to the successes it has had in the G protein-coupled receptor field(6-21) (www.mpdb.tcd.ie). However, the method, henceforth referred to as the in meso or lipidic cubic phase method, comes with its own technical challenges. These arise, in part, due to the generally viscous and sticky nature of the lipidic mesophase in which the crystals, which are often micro-crystals, grow. Manipulating crystals becomes difficult as a result and particularly so during harvesting(22,23). Problems arise too at the step that precedes harvesting which requires that the glass sandwich plates in which the crystals grow (Figure 2)(24,25) are opened to expose the mesophase bolus, and the crystals therein, for harvesting, cryo-cooling and eventual X-ray diffraction data collection. The cubic and sponge mesophase variants (Figure 3) from which crystals must be harvested have profoundly different rheologies(4,26). The cubic phase is viscous and sticky akin to a thick toothpaste. By contrast, the sponge phase is more fluid with a distinct tendency to flow. Accordingly, different approaches for opening crystallization wells containing crystals growing in the cubic and the sponge phase are called for as indeed different methods are required for harvesting crystals from the two mesophase types. Protocols for doing just that have been refined and implemented in the Membrane Structural and Functional Biology (MS&FB) Group, and are described in detail in this JoVE article (Figure 4). Examples are given of situations where crystals are successfully harvested and cryo-cooled. We also provide examples of cases where problems arise that lead to the irretrievable loss of crystals and describe how these problems can be avoided. In this article the Viewer is provided with step-by-step instructions for opening glass sandwich crystallization wells, for harvesting and for cryo-cooling crystals of membrane proteins growing in cubic and in sponge phases.

Embryonal rhabdomyosarcoma of the testis.

Rhabdomyosarcoma (RMS), arising from mesenchymal cells, is the most common soft tissue tumour in children and accounts for up to half of all sarcomas. We present the case of a 33-year-old male presented to the urology department of the University College Hospital Galway (Ireland) in March 2009 with a 2-month history of a left scrotal swelling, increasing in size.

Photoselective vaporization of the prostate with the potassium-titanyl-phosphate laser in men with prostates of >100 mL.

OBJECTIVES: To assess the efficacy of photoselective vaporization of the prostate (PVP) in men with prostates of >100 mL and causing bladder outlet obstruction (BOO), using the high-power 80 W potassium-titanyl-phosphate laser (GreenLight PV, Laserscope, San Jose, CA, USA), which offers rapid tissue ablation with minimal bleeding. PATIENTS AND METHODS: We assessed 54 consecutive patients with prostates of >100 mL (mean 135, SD 42, range 100-300) who had PVP between May 2003 and August 2005. Evaluations before PVP included urine flowmetry, the International Prostate Symptom Score (IPSS), a quality-of life (QoL) score, prostate-specific antigen (PSA) level, and prostate volume measured by transrectal ultrasonography (TRUS). RESULTS: The mean (SD, range) duration of PVP was 81.6 (22.9, 39-150) min, the mean energy used for PVP was 278 (60, 176-443) kJ and the mean duration of catheterization after PVP was 23.0 (17.1, 0-72) h. The mean (sd) maximum urinary flow rate improved from 8.0 (3.1) to 18.2 (8.1), 18.5 (9.2), 17.9 (7.8) and 19.3 (9.8) mL/s at 3, 6, 12 and 24 months, respectively. The IPSS and QoL scores showed similar improvements, and there was a statistically significant reduction in PSA level and prostate volume after PVP. There was no major complication and no patient had transurethral resection syndrome or a blood transfusion. CONCLUSIONS: The 80 W KTP laser PVP offers rapid tissue ablation in patients with BOO caused by a large prostate. The short- and medium-term outcomes show that this technique can be a viable alternative to open prostatectomy.

An assessment of the use of a continent catheterizable stoma in female tetraplegics.

OBJECTIVES: To evaluate the success of a continent catheterizable stoma in females with cervical spinal cord injury which resulted in neurogenic bladder dysfunction, the management of which may require clean intermittent catheterization despite altered hand function. PATIENTS AND METHODS: Six female tetraplegic patients with a lesion at C7 or above (age range 12-22 years) had a continent catheterizable abdominal stoma formed as part of their bladder management. As an objective measure of effectiveness, the time to complete catheterization was assessed before and after surgery. A quality-of-life survey at a mean (range) of 44 (6-90) months was also evaluated. RESULTS: All six patients can catheterize while in their wheelchair. The mean (range) time required for catheterization decreased from 27 (10-40) to 7.8 (1-15) min after surgery. All six reported a significant improvement in continence, body image, independence, convenience, time saving and satisfaction. CONCLUSION: Constructing a continent catheterizable stoma is a valuable option in selected tetraplegic patients.

Urethral atrophy after artificial urinary sphincter placement: is cuff downsizing effective?

PURPOSE: We reviewed the outcome of cuff downsizing with an artificial urinary sphincter for treating recurrent incontinence due to urethral atrophy. MATERIALS AND METHODS: We analyzed the records of 17 patients in a 7-year period in whom clinical, radiological and urodynamic evidence of urethral atrophy was treated with cuff downsizing. Cuff downsizing was accomplished by removing the existing cuff and replacing it with a 4 cm. cuff within the established false capsule. Incontinence and satisfaction parameters before and after the procedure were assessed by a validated questionnaire. RESULTS: Mean patient age was 70 years (range 62 to 79). Average time to urethral atrophy was 31 months (range 5 to 96) after primary sphincter implantation. Mean followup after downsizing was 22 months (range 1 to 64). Cuff downsizing caused a mean decrease of 3.9 to 0.5 pads daily. The number of severe leakage episodes decreased from a mean of 5.4 to 2.1 The mean SEAPI (stress leakage, emptying, anatomy, protection, inhibition) score decreased from 8.2 to 2.4. Patient satisfaction increased from 15% to 80% after cuff downsizing. In 1 patient an infected cuff required complete removal of the device. CONCLUSIONS: Patient satisfaction and continence parameters improved after cuff downsizing. We believe that this technique is a simple and effective method of restoring continence after urethral atrophy.