Journal of Clinical Urology

The COVID-19 pandemic has led to a long waiting list for elective surgery and increasing bed pressures from acute admissions. This led to widespread cancellations on the day of surgery even for cancer procedures. To address this, all inpatient stay robotic-assisted radical prostatectomy (RARP) cases were managed via our day surgery unit as a 23-hour stay. We report the safety and feasibility of our initial implementation.

A standard operating procedure for admission via the day surgery unit, including a modified enhanced recovery pathway, for patients undergoing RARP with or without pelvic lymph node dissection (PLND) was devised. All pre-operative variables were collected, and all perioperative outcomes analysed. Primary outcomes were number of on the day cancellations, discharge failure as 23-hour stay and 30-day readmissions.

Between November 2021 and June 2022, 135 patients underwent RARP with or without PLND via the day surgery unit. Mean patient age was 65 (46–76) years. Mean operative time and estimated blood loss were 153 (67–281) minutes and 197 (50–700) mL, respectively. Concomitant lymph node dissection was performed in 32.7% of cases. No patient required blood transfusion or conversion to open. We had 3 (2.2%) discharge failures, all of which were due to clinical reasons. Our 30-day hospital readmission rate was 3.7%, while another 5.2% attended emergency department and were discharged without admission.

Short (23-hour)-stay RARP is safe and feasible and reduces pressure on inpatient beds but requires a multidisciplinary approach and engagement from all stakeholders.

2

The objective of this study is to assess the diagnostic accuracy of CHOKAI, STONE, and STONE plus scores in detecting ureteral stones larger than 5 mm.

This comparative diagnostic accuracy study was performed in a tertiary care emergency department (ED) and included consecutive patients who presented to the ED with flank pain over a 1-year period. The performance of these scoring scales in detecting ureteral stones measuring >5 mm was determined by area under the receiver operating characteristics (AUROC) comparison.

Ureteral stones were detected in 270 (70.3%) of 384 patients included in the study. While 146 patients (54.1%) had ureteral stones measuring <5 mm, 124 patients (54.1%) had stones measuring 5 mm or more in size. The performance of the CHOKAI score in predicting ureteral stones was superior to that of the STONE PLUS score; STONE PLUS score was also superior to STONE score (p < 0.001). Analysis of the diagnostic value of CHOKAI score and STONE PLUS scores in predicting >5-mm stones showed no statistically significant difference (p = 0.59).

CHOKAI and STONE PLUS scores are useful in predicting >5-mm ureteral stones and have similar diagnostic utility to each other. STONE score does not provide accurate diagnostic information about ureteral stones larger than 5 mm.

Level 2b

Orthotopic neobladder (ONB) reconstruction following radical cystectomy for bladder cancer is a viable alternative to the formation of an ileal conduit. Although robotic surgery is gaining popularity, neobladder reconstruction is still most commonly done extra-corporeally (eONB) with a lower midline-laparotomy rather than intra-corporeal ONB (iONB) reconstruction. The novelty of a robotic approach has made several centres apprehensive to adopt this. This systematic review aims to compare functional outcomes as well as perioperative outcomes and common complications of robotic-assisted radical cystectomy with iONB versus eONB reconstruction.

A search of the literature from 2011 to 2021 was performed through PubMed, EMBASE, Medline and Scopus to identify articles comparing eONB formation with iONB formation. Urodynamic (UDS) outcomes (bladder volume, flow rate, post-voiding residual volume, continence rates and rate of clean intermittent catheterization (CIC) use) and perioperative outcomes (estimated blood loss, length of stay and operative time) were extracted as endpoints of interest. This review was registered with PROSPERO on 19 October 2022 (CRD42022366667).

Our searches identified 84 abstracts, of which 4 articles with 410 patients were eligible. Our results showed patients undergoing iONB had a higher bladder capacity and continence rate and achieved full continence much sooner than eONBs. iONBs, however, seemed to be left with higher residual volumes and a higher percentage of patients who needed CIC to void.

Both perioperative outcomes and complications favoured the iONB technique; however, eONB seemed to give better functional outcomes.

Not applicable

The objective of the study was to determine the efficacy of glycosaminoglycans in bladder instillation compared with placebo or other forms of prophylaxis in women with recurrent urinary tract infections (UTIs).

A search strategy was performed in the Cochrane central register, Embase, and Medline until October 2020, along with manual searches and reference-list checking. Randomised and nonrandomized studies in women with recurrent UTIs who received hyaluronic acid (HA) or HA plus chondroitin sulfate (CS) were included. A random-effects model was applied to the pooled results. The risk of bias was evaluated using the Cochrane RoB 2 bias tool for clinical trials and MINORS for nonrandomized studies. The quality of the evidence was evaluated by the GRADE method.

One randomised study and eight nonrandomized studies were included. All evaluated HA or HA plus CS. HA or HA plus CS decreased the average UTI patient-years (mean difference (MD) = −2.62; 95% confidence interval (CI) = −4.00 to −1.23), increased the time to recurrence (MD = 145.70; 95% CI = 61.57 to 229.83), and improved symptoms and quality of life as evaluated through the total pelvic pain and urgency/frequency score (MD = −6.08; 95% CI = −7.68 to −4.48) and the visual analog scale (MD = −4.79; 95% CI = −5.55 to −4.03). There was high heterogeneity in the results, a high risk of bias in the one randomised study, and a low quality of evidence according to GRADE. The number of included studies was low.

The application of HA or HA plus CS in intravesical instillation is associated with fewer UTI recurrences and improved symptoms and quality of life. The quality of the evidence provided by the studies is limited, so more studies of higher quality are needed to yield definitive conclusions.

Not applicable

Rates of prostate cancer (PC) vary considerably between ethnic groups worldwide, and migratory studies have demonstrated the importance of both inherent and environmental influences. Healthcare systems also differ significantly worldwide, and comparisons of PC data between the United Kingdom and America have previously shown contradictory conclusions among ethnic groups. The South Asian population (SA) is the most predominant UK ethnic minority group.

To systematically explore and critically analyse the available UK-based evidence regarding PC among SA men. Specifically, to review research that assesses the following factors: PC incidence, disease characteristics, treatment and survival outcomes.

The existing evidence suggests that UK SA men have a lower PC incidence and younger age at diagnosis, in comparison with White men in the United Kingdom. Contrasting evidence is presented in studies that separately analyse men originating from India, Pakistan and Bangladesh. There is insufficient and contradictory evidence regarding whether SA men show altered PC disease characteristics or have differential survival rates. The evidence is limited regarding PC treatment; however, this indicates that SA men are less frequently treated surgically compared to White men

Further high-quality research is required focusing on accurate ethnicity allocation, analysis of separate SA origin countries, socio-economic adjustment, subgroup analysis of treatment in low-risk PC and identifying the support needs of SA minorities with PC. This will help to ensure that ethnic minorities with PC are appropriately diagnosed, counselled and treated

3

The availability of surgical videos has changed the nature of learning outside the operating room. Within urology, there are limited reports on the use of surgical videos during training. This study sought to characterise both the preferred platforms and the utilization patterns of videos among a contemporary cohort of urology trainees.

An anonymous survey was distributed by the Society of Academic Urologists to trainees in September 2021. Data prospectively collected included respondent demographics, video platforms utilized, perceived educational value, satisfaction, and overall time spent using videos for case preparation.

In total, 169 urology residents and fellows completed the survey (23.6%). Nearly all (96.4%) respondents reported utilizing videos to prepare for cases, with 95.1% reporting videos as helpful for this purpose. YouTube (81.4%) and American Urological Association (AUA) University (16.3%) were the most common sources for video content. Video ‘narration’ was the most valued feature. When stratified by trainee level, 91.5% of senior residents/fellows reported using YouTube, compared with 56.6% of junior residents (p < 0.005). Overall, approximately 4 out of 5 trainees ultimately recommend YouTube as a video resource, compared with 57% recommending AUA University (p < 0.05).

Most urology trainees report surgical videos as a crucial component of their training, preferring to access videos directly from the YouTube website. As the quality of videos from YouTube varies, finding ways to share quality educational content should remain a priority for the medical education community moving forward.

Not applicable

To calculate the re-admission rate with haematuria within 30 days of elective transurethral resection of bladder tumour (TURBT), and identify factors associated with this.

This was a multicentre, retrospective audit, identifying all adult patients over the age of 16 who underwent elective TURBT between 1 September and 30 November 2019. Data were collected from medical records and operation notes on patient demographics, intra-operative factors and post-operative management. Primary outcome measure was the proportion of patients emergently re-admitted with haematuria. Secondary outcome measures were the re-operation rate for haematuria, and the rate of new acute thrombotic event (TE). Fisher’s exact test was used to calculate p values within subgroups for re-admission rates.

443 patients from 12 hospitals were included. Median age was 75 years (17–99). 15 patients (3.4%) were re-admitted with haematuria. Subgroup analysis demonstrated higher rate of re-admission for pre-existing antithrombotic agents (ATAs) (2.0% vs. 6.1%, p = 0.046), increased for non-Aspirin ATAs (10.5%, p = 0.0015). 52% of non-Aspirin ATAs were restarted within 48 hours of surgery; post-operative plan for restarting was not documented in 22.1%. One patient (0.23%) developed acute TE (pulmonary embolus).

Pre-existing use of non-Aspirin ATAs is associated with increased risk of post-TURBT haematuria, with variable practice in post-operative recommencement.

Level 3

The UK medical workforce is in crisis. The number of surgeons in National Health Service (NHS) practice has decreased, partly because newly qualified doctors withdraw from the workforce, and partly because of the early retirement of experienced surgeons. The reasons for urological trainee loss are largely known, but stress factors influencing the retirement of consultants before state pension age (SPA) are not.

An online survey of the consultant membership of the British Association of Urological Surgeons was carried out over a 12-week period starting in September 2020. Information was sought regarding stresses at work and home, together with factors affecting retirement decisions. Data analysis was performed if > 90% of questions were complete.

Overall, 36.5% of 1374 invitees completed the survey. Workplace-based issues were the main causes of stress: on-call, an unsupportive working environment, complaint handling and poor relations with hospital managers were predominant factors which were exacerbated by punitive taxation. Experienced urologists ameliorated these factors by reducing their contracted activity, increasing part-time working and, ultimately, retiring before SPA.

Workplace-based factors are associated with stress reported by consultant urologists. Alleviation of stressor factors, especially those related to on-call activity, should be explored to reduce the erosion of the senior workforce.

Not applicable

The learning curve for Retzius-sparing robotic radical prostatectomy is not fully understood.

This study attempts to identify the learning curve across the first 130 cases of a single surgeon.

All Retzius-sparing robotic radical prostatectomy cases performed by a single surgeon at a high-volume tertiary hospital between April 2019 and July 2022 were included.

Outcome measures included positive surgical margin rate, complication rates and unplanned readmission to hospital, postoperative urinary continence, erectile function and prostate-specific antigen (PSA) measurement. Cases were divided chronologically into three groups and differences between groups assessed.

A total of 130 Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) cases were identified. Differences were found between groups in several areas. Positive surgical margin rate fell between Group 1 (30.2%) and Group 3 (9.1%). Safety, postoperative continence, erectile function and PSA remained stable. Median patient age increased between Group 1 (59 years) and Group 3 (66.5 years) (p = 0.04). Proportion of patients with stage >T2 increased between Group 1 (27.9%) and Group 2 (41.9%) (p = 0.036). Median console time increased between Group 1 (120 minutes) and Group 2 (150 minutes) (p = 0.01). Median gland weight increased between Group 1 (28 g) and Group 3 (35.5 g) (p < 0.001).

The positive surgical margin rate improved over the learning curve, despite the complexity of cases increasing, reflected in older patients, larger prostates and higher stage disease. Safety and functional outcomes are excellent throughout. The learning curve might be facilitated by careful case selection favouring smaller prostates with less advanced disease.

We analysed the learning curve for Retzius-sparing robotic radical prostatectomy. Across the first 130 cases, positive surgical margin rate fell; safety and continence remained excellent. Selection of smaller and less advanced cases may facilitate learning.

III

The main aim of this study is to characterise the humanistic burden of bladder pain syndrome (BPS) on patients within the United Kingdom and to estimate the key healthcare resource usage and cost of treating these patients.

An online survey was administered through two charities. Respondents were asked questions on BPS diagnosis, socio-demographics and health-related quality of life using the O’Leary-Sant Interstitial Cystitis Symptom Index (ICSI) and Problem Index (ICPI), the Pelvic Pain and Urinary/Frequency (PUF) and the EQ-5D questionnaires. Healthcare resource and therapy use, for the previous 6 months, were recorded and used to calculate economic burden.

A total of 252 patients completed the survey. Mean ICSI ICPI scores were 12.6 and 11.0, respectively, indicating severe symptoms. Mean PUF score was 21.2, indicating poor health status and a high number of BPS-related symptoms and problems. Mean EQ-5D utility score was 0.541. In the previous 6 months, 172 (68%) saw their general practitioner (GP) and 80 (32%) a primary care nurse, and 165 (65%) had one or more outpatient visits, due to their BPS.

This survey adds to our current understanding of BPS in the United Kingdom, highlighting that patients with BPS have poor health-related quality of life and incur high resource use.

Not applicable