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Video: PCNL practice and outcomes in England

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Percutaneous nephrolithotomy in England: practice and outcomes described in the Hospital Episode Statistics database

James N. Armitage, John Withington*†, Jan van der Meulen*‡, David A. Cromwell*, Jonathan Glass†, William G. Finch§, Stuart O. Irving§ and Neil A. Burgess§

Department of Urology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, *Clinical Effectiveness Unit, The Royal College of Surgeons of England, †Department of Urology, Guy’s & St Thomas’ NHS Foundation Trust, ‡London School of Hygiene and Tropical Medicine, London, and §Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK

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OBJECTIVE

• To investigate the postoperative outcomes of percutaneous nephrolithotomy (PCNL) in English National Health Service (NHS) hospitals.

PATIENTS AND METHODS

• We extracted records from the Hospital Episode Statistics (HES) database for all patients undergoing PCNL between March 2006 and January 2011 in English NHS hospitals.

• Outcome measures were haemorrhage, infection within the index admission, and rates of emergency readmission and in-hospital mortality within 30 days of surgery.

RESULTS

• A total of 5750 index PCNL procedures were performed in 165 hospitals.

• During the index admission, haemorrhage was recorded in 81 patients (1.4%), 192 patients (3.8%) had a urinary tract infection (UTI), 95 patients (1.7%) had fever, and 41 patients (0.7%) had sepsis.

• There were 595 emergency readmissions in 518 patients (9.0%). Reasons for readmission were varied: 70 (1.2%) with UTI, 15 (0.3%) sepsis, 73 (1.3%) haematuria, 25 (0.4%) haemorrhage, and 25 (0.4%) acute urinary retention.

• There were 13 (0.2%) in-hospital deaths within 30 days of surgery.

CONCLUSIONS

• Haemorrhage and infection represent relatively common and potentially severe complications of PCNL.

• Mortality is extremely rare after PCNL (about one in 400 procedures overall) but almost one in 10 patients have an unplanned hospital readmission within 30 days of surgery.

• Complications of PCNL may be under-reported in the HES database and need to be corroborated using other data sources.

 

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Video: Orthotopic neobladder reconstruction by sigmoid colon

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Prospective comparison of quality-of-life outcomes between ileal conduit urinary diversion and orthotopic neobladder reconstruction after radical cystectomy: a statistical model

Vishwajeet Singh, Rahul Yadav, Rahul Janak Sinha and Dheeraj Kumar Gupta
Department of Urology, King George Medical University, Lucknow, Uttar Pradesh, India

 

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OBJECTIVE

• To conduct a prospective comparison of quality-of-life (QoL) outcomes in patients who underwent ileal conduit (IC) urinary diversion with those who underwent orthotopic neobladder (ONB) reconstruction after radical cystectomy for invasive bladder cancers.

PATIENTS AND METHODS

• Between January 2007 and December 2012, 227 patients underwent radical cystectomy and either IC urinary diversion or ONB (sigmoid or ileal) reconstruction.

• Contraindications for ON were impaired renal function (serum creatinine >2 mg/dL), chronic inflammatory bowel disease, previous bowel resection and tumour involvement at the bladder neck/prostatic urethra. Patients who did not have these contraindications chose to undergo either IC or ONB reconstruction, after impartial counselling.

• Baseline characteristics, including demographic profile, body mass index, comorbidities, histopathology of the cystoprostatectomy (with lymph nodes) specimen, pathological tumour stage, postoperative complications, adjuvant therapy and relapse, were recorded and compared.

• The European Organization for Research and Treatment of Cancer QoL questionnaire C30 version 3 was used to analyse QoL before surgery and 6, 12 and 18 months after surgery.

RESULTS

• Of the 227 patients, 28 patients in the IC group and 35 in the ONB group were excluded. The final analysis included 80 patients in the IC and 84 in the ONB group.

• None of the baseline characteristics were significantly different between the groups, except for age, but none of the baseline QoL variables were found to be correlated with age.

• In the preoperative phase, there were no significant differences in any of the QoL domains between the IC or the ONB groups. At 6, 12 and 18 months in the postoperative period, physical functioning (P < 0.001, P < 0.001 and P = 0.001, respectively), role functioning (P = 0.01, P = 0.01 and P = 0.003, respectively), social functioning (P = 0.01, P = 0.01 and P = 0.01, respectively) and global health status/QoL (P < 0.001, P < 0.001 and P = 0.002, respectively) were better in patients in the ONB group than in those in the IC group and the differences were significant.

• The financial burden related to bladder cancer treatment was significantly lower in the ONB group than in the IC group at 6, 12 and 18 months of follow-up (P = 0.05, P = 0.05 and P = 0.005, respectively)

CONCLUSIONS

• ONB is better than IC in terms of physical functioning, role functioning, social functioning, global health status/QoL and financial expenditure.

• ONB reconstruction provides better QoL outcomes than does IC urinary diversion.

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Video: Prostatic urethral lift for the treatment of LUTS

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Multicentre prospective crossover study of the ‘prostatic urethral lift’ for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia

Anthony L. Cantwell, William K. Bogache*, Steven F. Richardson†, Ronald F. Tutrone‡, Jack Barkin§, James E. Fagelson, Peter T. Chin†† and Henry H. Woo

‡‡Atlantic Urological Associates, Daytona Beach, FL, *Carolina Urological Research Center, Myrtle Beach, SC, †Western Urological Clinic, Salt Lake City, UT, ‡Chesapeake Urology, Baltimore, MD, USA, §University of Toronto, Toronto, ON, Canada, Urology Associates of Denver, Denver, CO, USA, ††Figtree Private Hospital, Figtree, and ‡‡Sydney Adventist Hospital Clinical School, University of Sydney, Sydney, NSW, Australia

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OBJECTIVE

• To assess the clinical effect of the ‘prostatic urethral lift’ (PUL) on lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) through a crossover design study.

PATIENTS AND METHODS

• Men aged ≥50 years with an International Prostate Symptom Score of ≥13, a maximum urinary flow rate (Qmax) of ≤12 mL/s, and a prostate of 30–80 mL were enrolled into a crossover study after completing a prospective, randomised, controlled, ‘blinded’ pivotal study in which they were control subjects receiving a sham procedure.

• Patients were followed for 1 year after crossover PUL at 19 centres in the USA, Canada and Australia. The sham procedure involved rigid cystoscopy with simulated active treatment sounds.

• PUL involved placing permanent UroLift® (NeoTract, Inc., Pleasanton, CA, USA) implants into the lateral lobes of the prostate to enlarge the urethral lumen.

• Urinary symptom relief, health-related quality of life (HRQL) impact, urinary flow parameters, sexual function, and adverse events were assessed and compared between the sham and PUL using paired statistical analysis.

RESULTS

• Symptom, flow, HRQL and sexual function assessments showed response improvements from baseline results, similar to results from other published studies, and most parameters were markedly improved after PUL vs the sham procedure in the same patients.

• Symptom, flow, and HRQL improvements were durable over the 12 months of the study.

• Adverse events associated with the procedure were typically transient and mild to moderate; one patient (2%) required re-intervention with transurethral resection of the prostate in the first year.

• There were no occurrences of de novo, sustained ejaculatory or erectile dysfunction.

CONCLUSION

• The PUL can be performed under local anaesthesia, causes minimal associated perioperative complications, allows patients to quickly return to normal activity, provides rapid and durable improvement in symptoms, and preserves sexual function.

 

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Video: Stent extraction strings after ureteroscopy

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Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trial

Kerri T. Barnes, Megan T. Bing and Chad R. Tracy

Department of Urology, University of Iowa, Iowa City, IA, USA

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OBJECTIVE

• To determine whether ureteric stent extraction strings affect stent-related quality of life (QoL) or increase complications after ureteroscopy (URS) for stone disease.

PATIENTS AND METHODS

• In all, 68 patients undergoing URS (October 2011 to May 2013) for stone disease were randomised to receive a ureteric stent with or without an extraction string.

• Patients completed the Ureteric Stent Symptom Questionnaire (USSQ) on postoperative days 1 and 6, and 6 weeks after stent removal.

• Pain was assessed at stent removal.

• Adverse events, including early stent removal, stent migration, retained stent, urinary tract infection (UTI), emergency room (ER) visits and postoperative phone calls were monitored.

RESULTS

• There was no difference in stent-related QoL as measured by the USSQ between those with and without a stent extraction string, pain at stent removal between those who pulled their stent independently vs those who underwent cystoscopy for stent removal, or in the rate of UTIs, ER visits or phone calls between groups.

• Five patients (four female, one male) removed their stent early by inadvertently pulling the string; none required replacement.

• Patients without a string had a significantly longer period with the postoperative ureteric stent (10.6 vs 6.3 days, P < 0.001).

• One patient without a stent string retained her ureteric stent for 6 months, which was removed by cystoscopy without incident.

CONCLUSION

• Ureteric stent extraction strings may offer several advantages without increasing stent-related urinary symptoms, complications, or postoperative morbidity.

 

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Video: Survival after RP for clinically localised prostate cancer

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Survival after radical prostatectomy for clinically localised prostate cancer: a population-based study

Martin Andreas Røder1, Klaus Brasso1, Ib Jarle Christensen2, Jørgen Johansen3, Niels Christian Langkilde4, Helle Hvarness1, Steen Carlsson5, Henrik Jakobsen6, Michael Borre7 and Peter Iversen1

1Copenhagen Prostate Cancer Center and Department of Urology, 2The Finsen Laboratory, Copenhagen Biotech Research and Innovation Centre (BRIC), Rigshospitalet Copenhagen University Hospital, Faculty of Health and Medical Sciences, Copenhagen, 3Department of Urology, Regional Hospital West Jutland, Holstebro, 4Department of Urology, Aalborg University Hospital, Faculty of Medicine, Aalborg, 5Department of Urology, Odense University Hospital, Faculty of Health Sciences, Odense, 6Department of Urology, Herlev Hospital, Copenhagen University Hospital, Faculty of Health and Medical Sciences, Herlev and 7Department of Urology, Skejby, Aarhus University Hospital, Department of Clinical Medicine, Aarhus, Denmark

 

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OBJECTIVES

• To describe survival and cause of death in a nationwide cohort of Danish patients with prostate cancer undergoing radical prostatectomy (RP).

• To describe risk factors associated with prostate cancer mortality.

PATIENTS AND METHODS

• Observational study of 6489 men with localised prostate cancer treated with RP at six different hospitals in Denmark between 1995 and 2011.

• Survival was described using Kaplan–Meier estimates. Causes of death were obtained from the national registry and cross-checked with patient files.

• Cumulative incidence of death, any cause and prostate cancer-specific, was described using Nelson–Aalen estimates.

• Risk for prostate cancer death was analysed in a Cox multivariate regression model using the covariates: age, cT-category, PSA level and biopsy Gleason score.

RESULTS

• The median follow-up was 4 years. During follow-up, 328 patients died, 109 (33.2%) from prostate cancer and 219 (66.8%) from other causes. Six patients (0.09%) died ≤30 days of RP.

• In multivariate analysis, cT-category was a predictor of prostate cancer death (P < 0.001). Compared with T1 disease, both cT2c (hazard ratio [HR] 2.2) and cT3 (HR 7.2) significantly increased the risk of prostate cancer death. For every doubling of PSA level the risk of prostate cancer death was increased by 34.8% (P < 0.001). Biopsy Gleason score 4 + 3 and ≥8 were associated with an increased risk of prostate cancer death compared with biopsy Gleason score ≤ 6 of 2.3 and 2.7 (P = 0.003), respectively.

• The cumulative hazard of all-cause and prostate cancer-specific mortality after 10 years was 15.4% (95% confidence interval [CI] 13.2–17.7) and 6.6% (95% CI 4.9–8.2) respectively.

CONCLUSIONS

• We present the first survival analysis of a complete, nationwide cohort of men undergoing RP for localised prostate cancer.

• The main limitation of the study was the relatively short follow-up.

• Interestingly, our national results are comparable to high-volume, single institution, single surgeon series.

 

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AUS outcomes in irradiated vs non-irradiated patients

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Outcomes of artificial urinary sphincter implantation in the irradiated patient

Niranjan J. Sathianathen, Sean M. McGuigan* and Daniel A. Moon*

Faculty of Medicine, Nursing and Health Sciences, Monash University, and *Epworth HealthCare, Melbourne, Vic., Australia

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OBJECTIVES

• To present the outcomes of men undergoing artificial urinary sphincter (AUS) implantation.

• To determine the impact a history of radiation therapy has on the outcomes of prosthetic surgery for stress urinary incontinence.

PATIENTS AND METHODS

• A cohort of 77 consecutive men undergoing AUS implantation for stress urinary incontinence after prostate cancer surgery, including 29 who had also been irradiated, were included in a prospective database and followed up for a mean period of 21.2 months.

• Continence rates and incidence of complications, revision and cuff erosion were evaluated, with results in irradiated men compared with those of men who had undergone radical prostatectomy alone.

• The effect of co-existing hypertension, diabetes mellitus and surgical approach on outcomes were also examined.

RESULTS

• Overall, the rate of social continence (0–1 pad/day) was 87% and similar in irradiated and non-irradiated men (86.2 vs 87.5%). Likewise, the incidence of infection (3.4 vs 0%), erosion (3.4 vs 2.0%) and revision surgery (10.3 vs 12.5%) were not significantly different between the groups.

• There was a far greater incidence of co-existing urethral stricture disease in irradiated patients (62.1 vs 10.4%) which often complicated management; however, AUS implantation was still feasible in these men and, in four such cases, a transcorporal cuff placement was used.

• There were poorer outcomes in patients with diabetes, and a greater re-operation rate in those men who underwent a transverse scrotal rather than perineal surgical approach, although the differences did not reach statistical significance.

CONCLUSIONS

• Previous irradiation in patients may increase the complexity of treatment because of a greater incidence of co-existing urethral stricture disease; however, these patients are still able to achieve a level of social continence similar to that of non-irradiated patients, with no discernable increase in complication rates, cuff erosion or the need for revision surgery.

• AUS implantation remains the ‘gold standard’ for management of moderate-to-severe stress urinary incontinence in both irradiated and non-irradiated patients after prostate cancer treatment.

 

 

Video: Peri-operative blood transfusion: outcomes in patients with bladder cancer

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Impact of peri-operative blood transfusion on the outcomes of patients undergoing radical cystectomy for urothelial carcinoma of the bladder

Luis A. Kluth1,3, Evanguelos Xylinas1,4, Malte Rieken1,5, Maya El Ghouayel1, Maxine Sun1, Pierre I. Karakiewicz6, Yair Lotan7, Felix K.-H. Chun3, Stephen A. Boorjian8, Richard K. Lee1, Alberto Briganti9, Morgan Rouprêt10, Margit Fisch3, Douglas S. Scherr1 and Shahrokh F. Shariat1,2,11

1Department of Urology and 2Division of Medical Oncology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA, 3Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany, 4Department of Urology, Cochin Hospital, Assistance Publique-Hopitaux de Paris, Paris Descartes University, Paris, France, 5Department of Urology, University Hospital of Basel, Basel, Switzerland, 6Department of Urology, University of Montreal, Montreal, QC, Canada, 7Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA, 8Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN, USA, 9Department of Urology, Vita-Salute University, Milan, Italy, 10Department of Urology of la Pitié-Salpétrière, Assistance Publique-Hôpitaux de Paris, University Paris VI, Faculté de Médicine Pierre et Marie Curie, Paris, France, and 11Department of Urology, Medical University of Vienna, Vienna, Austria

L.A.K. and E.X. contributed equally to this work

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OBJECTIVE

• To determine the association between peri-operative blood transfusion (PBT) and oncological outcomes in a large multi-institutional cohort of patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB).

PATIENTS AND METHODS

• We conducted a retrospective analysis of 2895 patients treated with RC for UCB.

• Univariable and multivariable Cox regression models were used to analyse the effect of PBT administration on disease recurrence, cancer-specific mortality, and any-cause mortality.

RESULTS

• Patients’ median (interquartile range [IQR]) age was 67 (60, 73) years and the median (IQR) follow-up was 36.1 (15, 84) months.

• Patients who received PBT were more likely to have advanced disease (P < 0.001), high grade tumours (P = 0.047) and nodal metastasis (P = 0.004).

• PBT was associated with a higher risk of disease recurrence (P = 0.003), cancer-specific mortality (P = 0.017), and any-cause mortality (P = 0.010) in univariable, but not multivariable, analyses (P > 0.05).

• In multivariable analyses, pathological tumour stage, pathological nodal stage, soft tissue surgical margin, lymphovascular invasion and administration of adjuvant chemotherapy were independent predictors of disease recurrence, cancer-specific mortality and any-cause mortality (all P values <0.002).

CONCLUSIONS

• Patients with UCB who underwent RC and received PBT had a greater risk of disease recurrence, cancer-specific mortality and any-cause mortality in univariable, but not multivariable, analysis.

• Although the greater need for PBT with more advanced disease is probably caused by a number of factors, including surgical and cancer-related factors, the present analysis showed that the disease characteristics rather than need for PBT led to worse outcomes.

 

Step-by-Step: Robotic kidney transplantation

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Robotic kidney transplantation with intraoperative regional hypothermia

Ronney Abaza, Khurshid R. Ghani*, Akshay Sood*, Rajesh Ahlawat†, Ramesh K. Kumar*, Wooju Jeong*, Mahendra Bhandari*, Vijay Kher† and Mani Menon*

Department of Urology, Ohio State University, Columbus, OH, *Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA, and †Kidney and Urology Institute, Medanta-The Medicity, Gurgaon, India

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OBJECTIVE

• To describe a novel and reproducible technique of robotic kidney transplantation (RKT) that requires no repositioning, and permits intraoperative regional hypothermia.

PATIENTS AND METHODS

• A GelPOINT™ (Applied Medical, Santa Ranchero, CA, USA) access port was used for delivery of ice-slush and introduction of the graft kidney. The new RKT technique using ice-slush has been performed in 39 patients.

RESULTS

• At a mean follow-up of 3 months all of the grafts functioned. There was a marked reduction in pain and analgesic requirement compared with patients undergoing open KT, with a propensity towards quicker graft recovery and lower complication rate.

CONCLUSION

• RKT has been shown to be safe and feasible in patients undergoing living-donor related KT. A prospective trial is underway to assess outcomes definitively.

 

USANZ 2014 Video Abstracts

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67th USANZ Annual Scientific Meeting, Brisbane, 16-19 March 2014

[accordion]

LUTS / BPH

[acc_item title=”Robot-assisted simple prostatectomy – initial clinical experience‘ label=’
S. LESLIE*, N. AHMADI*, K. HART*, N.N. JEFFERY*, P. SVED*, A. VASILARAS*, J. WONG*, D.R. EISINGER*, J. BOULAS* and M. ARON†
*Royal Prince Alfred Hospital, Department of Urology, Sydney, Australia; †University of Southern California, Institute of Urology, USA

[/acc_item]

Oncology

[acc_item title=”Submucosal contrast injection to facilitate image-guided delivery of external beam radiotherapy post-prostatectomy – a pilot study‘ label=’
S. SENGUPTA*,†, D.L. JOON‡, N. LAWRENTSCHUK*,† and D. BOLTON*,†
*Department of Urology, Austin health, Heidelberg, Australia ; †Austin Department of Surgery, University of Melbourne, Australia; ‡Department of Radiation oncology, Austin health, Heidelberg, Australia

)[/acc_item]

Other

[acc_item title=”LESS left simple nephrectomy‘ label=’
G. MIRMILSTEIN, A. RUTLEDGE and A. TIU
Department of Urology, Royal Newcastle Centre, Newcastle, Australia

[/acc_item]

[acc_item title=”LESS right upper pole moiety nephrectomy‘ label=’
A. RUTLEDGE, G. MIRMILSTEIN and A. TIU
Department of Urology, Royal Newcastle Centre, Newcastle, Australia

[/acc_item]

[acc_item title=”Transperineal biopsy streamlined‘ label=’
J. GRUMMET*,† , S. MANN† , H. GRUMMET† and D. MURPHY*
*Epworth Healthcare, Melbourne; †Australian Urology Associates, Melbourne

[/acc_item]

Prosthesis Urology

[acc_item title=”‘How I do it’ – the Minimally Invasive No Touch (MINT) penile implant‘ label=’
C. LOVE*,† and D. KATZ*
*Men’s Health Melbourne, Melbourne, Australia; †Bayside Urology, Melbourne, Australia

[/acc_item]

Reconstructive Urology/Transplant

[acc_item title=”Endoscopic Young-Dees incision for recurrent bladder neck stenosis after radical prostatectomy‘ label=’
V. TSE* and J. WONG†
*Concord Hospital, University of Sydney, Sydney, Australia; †Royal Prince Alfred Hospital, Sydney, Australia

[/acc_item]

Uro-oncology

[acc_item title=”Laparoscopic left partial nephrectomy in morbid obesity‘ label=’
A. RUTLEDGE , G. MIRMILSTEIN and A. TIU
Department of Urology, Royal Newcastle Centre, Newcastle, Australia

[/acc_item]

[/accordion]

 

Video: Trends in renal function after RN

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Trends in renal function after radical nephrectomy: a multicentre analysis

Jae S. Chung1, Nak H. Son2, Seok-Soo Byun6, Sang E. Lee6, Sung K. Hong6, Chang W. Jeong6, Sang C. Lee6, Dong-Wan Chae7, Won S. Choi8, Yong H. Park3, Sung H. Hong4, Yong J. Kim9 and Seok H. Kang5

1Department of Urology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, 2Department of Biostatistics, Yonsei University College of Medicine, 3Department of Urology, Seoul National University Hospital, 4Department of Urology, Seoul St. Mary’s Hospital, 5Department of Urology, Korea University Anam Hospital, Seoul, 6Departments of Urology and 7Internal Medicine, Seoul National University Bundang Hospital, Seongnam, 8Choi Won Suk Urology Clinic, Yongin, and 9Department of Urology, Chungbuk National University Hospital, Cheongju, Korea

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OBJECTIVE

• To evaluate serial changes in renal function by investigating various clinical factors after radical nephrectomy (RN).

PATIENTS AND METHODS

• The study population consisted of 2068 consecutive patients who were treated at multiple institutions by RN for renal cortical tumour without metastasis between 1999 and 2011.

• We measured the serial change in estimated glomerular filtration rate (eGFR) and clinical factors during a 60-month follow-up period.

• The changes in eGFR over time were analysed according to baseline eGFR (eGFR ≥60 and 15–59 mL/min/1.73m2) using a linear mixed model.

• The independent prognostic value of various clinical factors on the increase in eGFR was ascertained by multivariate mixed regression model.

RESULTS

• Overall, there was a subsequent restoration of renal function over the 60 months.

• The slope for the relationship between the eGFR and the time since RN was 0.082 (95% confidence interval [CI] 0.039–0.104; P < 0.001) and 0.053 (95% CI 0.006–0.100; P = 0.038) in each baseline group, indicating that each month after RN was associated with an increase in eGFR of 0.082 and 0.053 mL/min/1.73m2, respectively.

• When we analysed renal function based on various factors, postoperative eGFR of patients with diabetes mellitus, old age (≥70 years) or a preoperative eGFR of <30 mL/min/1.73 m2, was decreased or maintained at a certain level without any improvement in renal function.

• Preoperative predictors of an increase in eGFR after RN were young age, no DM, no hypertension, a preoperative eGFR of ≥30 mL/min/1.73m2 and time after surgery (≥36 months).

CONCLUSIONS

• Renal function recovered continuously during the 60-month follow-up period after RN.

• However, the trends in functional recovery change were different according to various clinical factors and such information should be discussed with patients when being counselled about their treatment for renal cell carcinoma (RCC).

 

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