Robotic RPLND for stage IIA/B nonseminoma: the Princess Margaret Experience

PURPOSE

Retroperitoneal lymph node dissection (RPLND) is a treatment option for men in a primary and post-chemotherapy setting. The aim of this review was to explore the published data looking at feasibility, safety and outcomes of robotic RPLND for CSI/II NSGCT but we will in particular highlight how we have approached adoption of robotic RPLND at the Princess Margaret.

METHODS

A review and summary of the published data to date was performed regarding the role of robotic RPLND for stage IIA/B nonseminoma.

RESULTS

Published series of robotic RPLND to date have proven feasibility and safety in experienced centres. Less blood loss, shorter length of stay and decreased morbidity are promising findings. Our data from Princess Margaret strengthen the argument of oncologic efficacy as we operated only on patients with known retroperitoneal disease (Stage at RPLND was IIA (n = 15, 55.6%), IIB (n = 9, 33.3%), IIC (n = 1, 3.7%) and III (n = 2, 7.4%)), did not use adjuvant chemotherapy and found a relapse rate (11%) similar to open RPLND.

CONCLUSIONS

The debate is ongoing regarding the role of robotic RPLND- the excellent oncological outcomes achieved by an open RPLND are the minimum starting point for robotic RPLND. Until such time that robotic RPLND is proven to be gold standard it should be performed in experienced centres by high volume RPLND surgeons and in the setting of a protocol.

The Management of Incidental Prostate Cancer Following TURP

Aims The aim of this study was to assess the incidence, management and outcomes of incidentally diagnosed prostate cancer following TURP. Methods A retrospective review was performed using the histopathological departments’ database of all patients who underwent a TURP across two university teaching hospitals over a ten year period. Results During the study period, a total of 826 patients underwent a TURP. 72 (10.3%) had an incidental diagnosis of CaP following TURP. 46 (63.9%) were managed expectantly while 26 (36.1%) underwent active treatment. Overall mortality was 29.2% (n=21) while cancer specific mortality was 6.9% (n=5). All these patients were in the hormonal treatment sub-group. Conclusion Our study demonstrates an expectant approach is favourable in low risk disease. Curative treatment does need to be considered for younger patients with a long life expectancy or patients with higher risk disease.

The Predictive Ability of Pre-Operative Magnetic Resonance Imaging to Detect Pathological Outcomes in Prostate Cancer

Aims Accurate preoperative knowledge of tumour stage is important in preoperative planning at radical prostatectomy (RP). The aim of this study was to assess the predictive ability of multiparametric MRI for detecting pathological outcomes. Methods A retrospective review was performed of all patients who underwent RP over a 4 year period. Results Preoperative MRI was reported as showing T3 or T4 disease in 26(17.9%) out of 145 patients undergoing RP. Of these, 10(6.9%) had ECE (extra-capsular extension) and 1(0.7%) had SVI (seminal vesicle invasion) on final histology. The sensitivity and specificity of MRI for detecting ECE were 27.3% and 87.6%, respectively. The sensitivity and specificity of MRI for detecting SVI were 11.1% and 97.8%, respectively. The positive predictive values for determining ECE and SVI were 45.5% and 25%, respectively and negative predictive values were 75.9% and 94.4%. Conclusion MRI has good specificity but poor and heterogeneous sensitivity for predicting T3 disease in RP specimen.

Iatrogenic Bowel Injury at Exchange of Supra-Pubic Catheter

Suprapubic catheter insertion and exchange is a common urological procedure, but it is not without risks and complications. While bowel perforation is a recognised complication at suprapubic catheter insertion, it is not commonly reported at suprapubic catheter exchange. We report our experience of recognition, diagnosis and subsequent successful management of the most important complication related to suprapubic catheters.

Is The Consent Process Appropriate - The Interns’ Perspective?

Aims Consent is an integral component to any medical procedure involving a competent patient, a communicating doctor, and transfer of information about the procedure. The aim of this study was to assess interns’ experience of the consent process. Methods An online questionnaire was distributed to interns in Ireland questioning their role in the consent process within six months of starting as an intern. Results One hundred and seventy-one interns (89.1%) had consented a patient for a procedure during their first intern rotation. One hundred and forty-three (83.6%) reported their supervisors did not explain the procedure to the intern prior to consent. One hundred and fifty-eight (92.4%) respondents consented for a procedure which they had not witnessed before. Sixty (35.1%) of interns reported that they have obtained signed consent without fully discussing the procedure and the associated risks. Conclusion The most junior members of a team are independently consenting patients on a regular basis without the appropriate level of knowledge.

An assessment of professionalism on students' Facebook profiles

INTRODUCTION

With the advent of social media, healthcare professionals not only need to be conscious of professionalism in their face-to-face interactions but also in the electronic environment. The aim of this study was to assess the level of online professionalism on Facebook profiles available for public viewing of students from a dental school.

MATERIALS AND METHODS

A search was performed via a new Facebook account of all students in the University Dental School (dental hygiene, dental nursing, dental science and dental technology). Profiles were categorised as 'private' or 'public'. Demographic details and photographs/comments of unprofessional behaviour were recorded for each individual Facebook profile. Each profile was subsequently scored with regard to professionalism based on a previously published score.

RESULTS

There are a total of 287 students in the dental school. Of these, 62% (n = 177) had a Facebook account. Three per cent (n = 6) had a public account (fully accessible) whilst 97% (n = 171) had a private account (limited access); 36% (n = 63) of students mentioned the dental school/hospital on their profile; 34% (n = 60) had questionable content on their profile whilst 3% (n = 6) had definite violations of professionalism on their profile; and 25% (n = 44) had unprofessional photographs on their profile. Of those with unprofessional content, 52% (n = 23) of these had a documented affiliation with the dental school also visible on their profile.

CONCLUSION

There was a concerning level of unprofessional content visible on students' Facebook profiles. Students need to be fully aware of their professional responsibility in the setting of social media.

An Analysis of Gender Diversity in Urology in the UK and Ireland

Traditionally, surgery and certain surgical sub-specialities in particular have been predominantly male orientated. In recent years, there has been an increased proportion of female medical graduates which will ultimately have an effect on speciality choices. The aim of this study was to assess the gender diversity among urologists in the UK and Ireland. The total number and gender breakdown of consultant urologists and trainees in the UK and Ireland was obtained from the British Association of Urological Surgeons (BAUS) and the Irish Society of Urology (ISU) membership offices. The total number and gender breakdown of medical school entrants and graduates in 2015 was obtained from the six medical schools in the Republic of Ireland. There are a total of 1,012 consultant urologists in the UK and Ireland. In the UK, 141 (14.6%) are female compared to four (8.2%) in Ireland, p= 0.531. There was a significant increase in the number of females between consultant urologists and trainees in both the UK (p=0.0001) and Ireland (p=0.015). In recent years, there has been a significant change in the percentage of female trainees in the UK and Ireland (22.8% (n=75) in 2011 vs 31.7% (n=93) in 2014, p=0.019. Between the six medical schools in Ireland, there were significantly more female entrants (n=726, 56.5%) than female graduates (n=521, 51.2%) in 2015, p=0.013.There has been a significant shift in gender diversity in urology in the UK and Ireland. Efforts to increase diversity should be pursued to attract further trainees to urology.

Post-Chemotherapy Retroperitoneal Lymph Node Dissection in Patients with Non-Seminomatous Germ Cell Tumour (NSGCT)

Diabetic retinopathy is a significant complication of diabetes, and the most common cause of blindness in people under the age of 65. The National Diabetic Retinal Screening Programme (Diabetic RetinaScreen) was established to detect sight threatening retinopathies. The purpose of this cross-sectional study is to determine the barriers to the uptake of Diabetic RetinaScreen, to investigate discrepancies in attendance, if any, between patients whose diabetes care is delivered in a large tertiary referral hospital out-patient setting or in general practice, and to evaluate general practitioner's satisfaction with the service. Older age (OR 1.023, 95% CI 1.001 to 1.046) and complications of diabetes, excluding ocular complications, (OR 2.741, 95% CI 1.158 to 6.489) were associated with increased attendance at Diabetic RetinaScreen. Online referral is now available and the preferred method of referral. Efforts to encourage younger patients who do not yet have complications of diabetes may be beneficial.

The effect of social media (#SoMe) on journal impact factor and parental awareness in paediatric urology

BACKGROUND

Social media (SoMe) comprises a number of internet-based applications that have the capability to disseminate multimodal media and allow for unprecedented inter-user connectivity. The role of Twitter has been studied in conferences and education; moreover, there is increasing evidence that patients are more likely to use social media for their own health education.

OBJECTIVE

The aim of this study was to assess the impact of social media platforms on the impact factor of both urological and paediatric journals that publish on paediatric urology, and to assess parental awareness of social media in paediatric urology.

STUDY DESIGN

A filtered Journal of Citation Reports (JCR) search was performed for the period 2012-16 for journals that published articles on paediatric urology. Journals were ranked according to impact factor, and each individual journal website was accessed to assess for the presence of social media. Parents in paediatric urology clinics and non-paediatric urology patients also filled out a questionnaire to assess for awareness and attitudes to social media. All statistical analysis was performed using Prism 6 software (Prism 6, GraphPad Software, California, USA).

RESULTS

Overall, there were 50 urological journals and 39 paediatric journals with a mean impact factor of 2.303 and 1.766, respectively. There was an overall average increase in impact factor across all urological journals between 2012 and 16. The presence of a Twitter feed was statistically significant for a rise in impact factor over the 4 years (P = 0.017). The cohort of parents was statistically more likely to have completed post-secondary education, to have and access to a social media profile, use it for health education, and use it to access journal/physician/hospital social media accounts.

DISCUSSION

This study examined, for the first time, the role of social media in paediatric urology, and demonstrated that SoMe use is associated with a positive influence in impact factor, but also a parental appetite for it. Limitations included a non-externally validated questionnaire. There may also have been bias in larger journals that generate and maintain social media platforms such as Twitter, which may then in turn have an influence on impact factor.

CONCLUSIONS

Social media use within paediatric urology was associated with a higher impact factor, which remained significant after 4 years of analysis. Parents were more likely to use a wide variety of social media to search for conditions and physicians/healthcare providers; therefore, journals and institutions need to embrace and endorse SoMe as a potential source of important clinical information.

Multidisciplinary emergent removal of a metal penoscrotal constriction device

Strangulation of the genital organs is a rare presentation to the emergency department which requires urgent intervention to avoid long term complications. Penoscrotal constriction devices are either used for autoerotic stimulus or to increase sexual performance by maintaining an erection for a longer period. We report a case of a man who presented with penile strangulation following the application of a titanium penoscrotal constriction ring during sexual intercourse seven hours previously. The Fire Brigade department attended with an electric operated angle grinder to facilitate removal of the ring as standard medical equipment (orthopaedic saws, bolt and bone cutters) were insufficient. Fully functional recovery was achieved.

Ireland's contribution to urology and nephrology research in the new millennium: a bibliometric analysis

INTRODUCTION

Bibliometrics is the statistical analysis of written publications. Bibliometric analyses have been performed across a range of biomedical disciplines. The aim of this study was to provide a comprehensive qualitative and quantitative analysis of Irish urology and nephrology research and to analyse how this compares internationally.

METHODS

We performed a retrospective bibliometric analysis of the top 20 ranking journals in the field of "Urology and Nephrology" based on their 5 years impact factor, as obtained from the ISI Journal Citation Report database over the 15-year study period, 2000-2015. Utilising the Pubmed database, a search phrase was constructed using country of affiliation, year of publication and journal title. The abstracts of the Irish publications identified were analysed for their institution of origin, article theme and content.

RESULTS

A total of 67,740 article abstracts were analysed over the 15 years study period. As anticipated, the USA accounted for the largest number of publications by a country [28,206 (41.64 % of all articles)]. Ireland contributed 347 articles in total (0.51 % of all articles); however, ranking according to population per million was 13th worldwide. Ireland's contribution to urology and nephrology research was highest in the BJUI-British Journal of Urology International [76 articles (21.90 % of Irish total)].

CONCLUSION

We believe this study to be the largest bibliometric analysis in the field of urology and nephrology internationally. This study provides a novel overview of the current Irish urology- and nephrology-related research, and examines how our results compare within the international community.

Efficacy of vacuum erectile devices (VEDs) after radical prostatectomy: the initial Irish experience of a dedicated VED clinic

Controversy exists regarding optimal penile rehabilitation program following radical prostatectomy (RP). Vacuum erectile devices (VEDs) have become an important component of penile rehabilitation protocols. The aim of this study was to assess the efficacy and patient satisfaction of a dedicated VED clinic. A voluntary telephone questionnaire was performed of all patients who attended a VED clinic to date in two university teaching hospitals. Patient demographics, histopathological characteristics and functional status (International Index of Erectile Function (IIEF) scores) were obtained from a retrospective review of a prospectively maintained database. Sixty-five men attended the dedicated VED clinic in the two university teaching hospitals. Forty-men (76.3%) men purchased a VED following the dedicated clinic. There was significant differences noted between the mean preoperative and the 3-month postoperative IIEF scores (22.08±3.16 vs 11.3±3.08, P=0.0001) and between the 3-month postoperative IIEF score and the post-VED use IIEF score (11.3±3.08 vs 16.74±2.62, P=0.0001). Despite VED use, there was a significant reduction in erectile function from presurgery status (22.08±3.16 vs 16.74±2.62, P=0.0001). All patients reported that the dedicated VED was helpful and would recommend it to other patients. Our study demonstrates that, despite a reduction in erectile function after RP, successful erections are attainable with a VED. There is potential and need for the development of a standard penile rehabilitation program and treatment of ED after RP internationally.

Incidental findings detected on emergency abdominal CT scans: a 1-year review

INTRODUCTION

In recent years, there has been a substantial rise in the use of computed tomography (CT) in the emergency medicine setting. Accordingly, with increased CT usage there has been an upsurge in incidental pathology detection.

METHODS

A retrospective review of all emergency CT abdominal scans performed at a university teaching hospital was examined. The frequency of incidental findings, their clinical significance and workload effect for the radiology department was assessed.

RESULTS

1155 patients had an emergency abdominal CT scan of which 700 had incidental findings detected. Of the incidental findings, 143 were deemed indeterminate requiring urgent investigations. Twenty-four occult neoplasms were confirmed subsequently. Additionally, 259 patients were recommended for additional diagnostics. The cumulative effect of the initial emergency abdominal CT was 15,015 relative value units (RVU). Subsequent imaging of incidental findings resulted in another 1674 RVU workload for radiology.

CONCLUSION

Incidental findings cause considerable debate and concern over which patients require significant follow-up, investigations, and/or surveillance. This exerts significant pressures on sub-specialties for their expert input, with increased workload and implications on healthcare service provision.

Conversion rates of abstracts to publications from the Irish Society of Urology Annual Meeting (2005–2011) – Questioning the scientific value of national urological meetings for smaller European nations

Background:

Large annual scientific meetings such as the American Urological Association (AUA) and the European Association of Urology (EUA) have abstract conversion rates into publication of 37%−48%. There are no data on the conversion rates from national meetings of smaller European countries. Our objective was to present the conversion rates and manuscript characteristics of the Irish Society of Urology (ISU) annual meeting over a seven-year period (2005–2011), and to demonstrate the value, viability and sustainability of such a meeting as a model for other small national research programmes.

Methods:

All abstracts presented at the ISU annual meeting between 2005 and 2011 were identified. The subsequent publication rate following the meetings was established for the corresponding studies based on a Medline scan. A range of characteristics associated with subsequent publication were analysed using the logistic regression of the dichotomous variable of publications vs. non-publication of each factor.

Results:

Overall, 46% of the 322 abstracts presented at the ISU meeting were followed by publication into Medline-indexed journals with a mean impact factor of 2.6. A total of 74% abstracts were published within two years. Oral presentations were more likely to be published than posters ( p < 0.0001), and prospective clinical research was more likely to be published in a journal with a higher impact factor than retrospective analyses ( p = 0.033); the mean time to publication was 16.7 months.

Conclusions:

Almost half the abstracts presented at the ISU were subsequently published in peer-reviewed journals, the majority within two years. This compares favourably with larger urological meetings, and provides an incentive to other smaller countries within Europe to continue with national research programmes.

Paediatric urology training: what does the future hold?

BACKGROUND

Paediatric urology training is not a mandatory part of higher surgical training in urology in Ireland. It is predicted there will be a shortfall of surgeons trained in paediatric surgery in the coming years leading to a reliance on specialist paediatric surgical centres.

AIM

The aim of this study was to assess the attitudes of urological trainees regarding the current state of paediatric urology training and to address the potential future changes to training structures.

METHODS

A voluntary anonymous internet-based survey was emailed to all urological trainees. Parameters assessed included sex, level of training, attitudes towards paediatric urology training and levels of competence regarding core paediatric urological procedures.

RESULTS

69.2 % (n = 18) responded to the survey. 94.4 % (n = 17) would favour mandatory paediatric training-of these, 52.9 % (n = 9) would favour this in a dedicated paediatric hospital with a paediatric urologist. 66.7 % (n = 12) would like to provide a paediatric urology service as a consultant. 55.6 % (n = 10) felt they were competent to perform circumcision or scrotal exploration independently and manage all associated complications. No trainee felt themselves to be competent to perform orchidopexy independently and manage all complications.

CONCLUSION

Our study demonstrates a promising desire to provide paediatric services in the future. A greater emphasis on structured paediatric urology training is required to maintain the standard currently offered by adult urologists.

The use of smartphone applications by urology trainees

OBJECTIVE

Mobile phone technology is continuously advancing- the smartphone allows users instant access to information via the internet. Downloadable applications (apps) are becoming widespread across medical specialities. The aim of this study was to assess the use of smartphone apps among urology trainees in Ireland.

METHODS

An anonymous electronic survey was distributed via Survey Monkey(®) to all urology trainees in Ireland assessing their ownership and use of smartphones and downloadable apps. A search of urology apps was performed using the Apple App Store and the Android Market.

RESULTS

36 (81.8%) of trainees responded with 100% ownership of smartphones. 28 (77%) report downloading apps with 11 (30.6%) reporting paying for them. The mean number of apps downloaded was 4 (Range 1-12). 16 (44.4%) trainees think apps for smartphones are very useful in clinical practice, 14 (42.4%) think they are useful. A total of 126 urology apps were available. 76 (60.3%) were designed for physicians, 46 (36.5%) for patients, 2 (1.6%) for students and 2 (1.6%) for urological nurses.

CONCLUSION

There are an ever increasing number of urology apps available. Urology trainees are using smartphones as an educational and reference tool and find them a useful aide in clinical practice.

Two hit hypothesis: an unusual complication following supra-pubic catheter insertion

Osteomyelitis is an inflammation of the bone caused by an infection. Though bone is normally resistant to bacterial infection, events including trauma, presence of foreign bodies including prosthesis can act as a nidus for infection. Osteomyelitis is a rare but recognised complication of radiotherapy. Osteomyelitis of the pubis has scarcely been reported as a complication following urological procedures- prostatectomy, sling surgery and catheterisation. We report a rare complication of a gentleman post radiotherapy presenting with delayed osteomyelitis of the pubis following supra-pubic catheterisation.

Paediatric orchidopexy: a need for dedicated paediatric surgical training among urologists?

BACKGROUND

Undescended testis (UDT) is one of the most common congenital abnormalities with a prevalence of about 1% at the age of 1 year. UDT is associated with an increased risk of testicular tumours and infertility.

AIMS

The aim of this study was to assess who is carrying out paediatric orchidopexy in Ireland.

METHODS

A survey was distributed via Survey Monkey to all Consultant Paediatric Surgeons and Urologists in Ireland.

RESULTS

Twenty-seven (64.3%) urologists and five (71.4%) paediatric surgeons responded to our online survey. Of the urologists, 100% reported formal training in paediatric orchidopexy. Eight (29.6%) underwent a dedicated paediatric fellowship. 13 (48.1%) currently perform paediatric orchidopexy. Nine (33%) think it should be carried out by a urologist, whereas eight (29.6%) think it should be carried out by paediatric surgeon. The mean age at which urologists think an orchidopexy for UDT should be performed by was 18 months (range 1-4 years). Approximately 400 orchidopexies are performed per year by the surveyed urologists. Of the paediatric surgeons, three (60%) feel it should be carried out by a paediatric surgeon whereas two (40%) feel it does not matter. All paediatric surgeons feel it should be performed by 1 year of age. Approximately 700 orchidopexies are performed per year by the surveyed paediatric surgeons.

CONCLUSION

UDT is a concerning condition which requires intervention at an early stage. Dedicated training in core paediatric procedures is required to continue to meet this need for the future to prevent delayed orchidopexy and resultant increased risk of testicular tumours.

Congenital-infantile fibrosarcoma of the foot--avoidance of amputation

Congenital-infantile fibrosarcoma is a rare entity with a five year survival rate of over 90%. Surgery is still the most common treatment modality with amputation often necessary. There have been reports supporting the use of neoadjuvant chemotherapy to debulk the tumour in an effort to facilitate limb sparing surgery. We report a case of a newborn who presented with a life threatening haemorrhage from a fibrosarcoma of the foot, successfully treated with Vincristine, Actinomycin and Cyclophosphamide (VAC) chemotherapy alone.

Time to surgical review: an assessment of the traditional model of emergency surgical care

BACKGROUND

The traditional model for emergency surgical care consists of an on-call team providing service to the emergency department, while simultaneously balancing the demands of elective work. Various newer models, such as the "surgeon of the week" aim to reduce the conflict between elective and emergency duties. Despite the recent focus on newer models, there remains no data on the effectiveness of the traditional model. We aim to assess the efficacy of the traditional model in a large regional hospital.

METHODS

A retrospective study between July 2009 and March 2010 was performed. Primarily, we assessed the initial time to surgical consultation after emergency department referral. Secondarily, we evaluated the impact of time periods, days of week, and case-mix etiology on this consultation time.

RESULTS

The overall median time to surgical consultation after emergency department referral was 30 min (N = 860, P = 0.709). However, the median time to consultation was 60, 30, and 20 min for daytime, evening and night time, respectively (*P < 0.001). Trauma cases had a median time of 15 min, vascular had 45 min, neoplasm had 120 min, while other categories (upper and lower gastroenterology, and skin related) were 30 min (*P = 0.025).

DISCUSSION

Newer models of acute surgical care have desirable outcomes in consultation times. However, regional and economical implications have a substantial impact on which model is feasible at local levels. We demonstrated that the traditional model still remains effective in a large sized tertiary referral unit.

DOCSS: doctors on-call smartphone study

INTRODUCTION

Smartphones have revolutionised our demands for constant access to information. The usage of smartphones in the clinical setting is becoming widespread. The aim of our study was to assess smartphone ownership and usage across a cohort of interns.

METHODS

A voluntary novel questionnaire was distributed to interns in two university hospitals. Details regarding smartphone ownership and usage were assessed. Likert scales were utilised for analysis.

RESULTS

Sixty-one (74.4 %) interns responded to the survey. Sixty (98.4 %) owned a smartphone with iPhone(®) being the most popular (76.7 %). Fifty-five (91.6 %) interns have downloaded medical applications ('apps'), while 29 (52.3 %) reported paying for them. Regarding smartphone use on-call, 30 (50 %) interns agreed it aids diagnoses, 26 (43 %) agree it helped in interpreting laboratory values, 31 (51.7 %) agreed it helped in dosing of medication and 33 (55 %) agreed it was of assistance in medical emergency protocols. Forty-two (70 %), 42 (70 %) and 46 (76.7 %) interns agreed or strongly agreed smartphones have a positive influence on them in terms of levels of stress, confidence and level of knowledge, respectively.

CONCLUSION

Smartphone usage is widespread among our intern cohort. The introduction of hospital applications with local guidelines would be welcomed; however, this may require informed patient consent regarding their use.

Incidentalology: A developing urological sub-specialty

OBJECTIVE

To identify the incidence and features of significant incidental findings discussed at our departmental multidisciplinary team meeting (MDM). The improved quality of radiological imaging has resulted in increased rates of incidental findings. Although some may be trivial, many have clinical significance and early diagnosis and treatment may be beneficial.

METHODS

A retrospective analysis was performed of all cases discussed at the MDM between January 2012 and February 2013. Cases were divided into two groups--Group 1 consisted of patients whose initial imaging was performed for a urological presentation which resulted in a synchronous finding; Group 2 consisted of patients who were referred with a synchronous urological finding for discussion following investigation of an initial benign urological condition or a non-urological condition.

RESULTS

696 patients were discussed at 53 MDMs. 109 (15.7%) patients had incidental findings. 61 (56%) of these were in Group 1. 16 (26.2%) were synchronous malignant diagnoses, 25 (41%) were benign and 20 (32.8%) were indeterminate. 48 (44%) patients in Group 2 - 40 (83.3%) were renal in origin and 30 (75%) of these proceeded to surgery. The median tumour size was 3.2 cm (Range: 1.2 cm-10 cm). One patient had radio-frequency ablation. Two were referred for palliative care. Seven patients are under ongoing surveillance--the median size of these lesions is 3.6 cm (Range: 2.1 cm-8.3 cm).

CONCLUSION

A substantial workload is generated from the investigation of incidental findings discussed at MDM--these now represent the majority of the caseload for renal cancer surgery.

Peri-operative management in urinary diversion surgery: A time for change?

INTRODUCTION

Bowel preparation was established as part of the pre-operative course for patients undergoing ileal conduit formation since the late 1970's. Rationales for its use include reduction in infection and wound complications, technically easier anastomosis and earlier return to bowel function. However, recent reports have challenged this practice. Traditionally antibiotics were also administered for several days prior to surgery with the assumption that bacterial load was reduced. Modification of antibiotic protocols resulted from evidence-based findings. Furthermore, publications emphasizing the benefit of Enhanced Recovery Protocols/Programmes (ERP) have become contemporary.

METHODS

An online multiple-choice questionnaire (via Monkey Survey) was administered to all consultant urologists in Ireland. This national cross-sectional study evaluated the use of bowel preparation and antibiotic prophylaxis prior to urinary diversion. In addition, we also assessed consultant urologists' awareness of ERP and their views on the introduction and implementation of such a national program.

RESULTS

Of the 41 consultant urologists surveyed, 80.4% (n = 33) responded. 63.6% routinely used bowel preparation. Klean Prep was the most commonly used bowel preparation. 80.9% of urologists admit their patient's one-day pre-operatively for bowel preparation, with 87.8% using antibiotic prophylaxis at anesthesia induction, and 18.1% continuing the antibiotics for 24-48 h post-operatively. Although 74% of consultants are aware of ERP, only 66.6% are in favor of their national implementation.

CONCLUSION

The majority of Irish urologists use bowel preparation prior to ileal conduit formation. Substantial recent evidence has emerged showing no difference in infective complications or anastomotic leakage when bowel preparation was not used. National guidelines would be beneficial regarding the use of bowel preparation, antibiotic prophylaxis and ERP for urinary diversion surgery.

Long-term follow up for colon cancer in a minimally invasive, colorectal unit

Our aim was to assess the long-term survival advantage associated with the laparoscopic approach for colon cancer resection in an Irish minimally invasive unit. Between January 2005 and December 2006, 154 patients underwent resection for colon cancer. 108 underwent a laparoscopic resection, with a conversion rate of 11%. The overall 5 year survival was 71.4%. The overall 5 year survival rate for laparoscopic resections was 80.6% where as the overall survival for open resection was 50%. Laparoscopic surgery had a significant 5 year overall survival advantage compared to open in both non metastatic disease (Stage I and II) (92.2% vs. 69.6%, p = 0.0288) and metastatic disease (Stage III and IV), (68.4% vs. 30.4%, p = 0.0026). Laparoscopic surgery in a dedicated minimally invasive unit with verifiable low conversion rates is feasible and in our experience associated with a long-term survival advantage for colon cancer.

Double trouble--ureteric obstruction due to bilateral urothelial carcinoma

Upper tract urothelial carcinoma (UTUC) represents -5% of all urothelial carcinomas. Synchronous bilateral tumors are extremely rare with only 19 reports in the literature. Haematuria is the main presenting complaint. We report a case of synchronous bilateral tumors of the ureters in a gentleman with frank haematuria treated with staged aggressive resection.

The cost utility of a multi-disciplinary foot protection clinic (MDFPC) in an Irish hospital setting

BACKGROUND

Foot ulceration which may result in lower limb amputation is one of the most feared complications among patients with diabetes and the prevention of both ulceration and amputation is a major challenge facing the health service. Many studies have proposed dedicated diabetic foot teams as the future of diabetic foot care.

AIMS

We aimed to quantify the cost benefit and sustainability of a multi-disciplinary foot protection clinic (MDFPC) in an Irish university hospital setting.

METHODS

A dedicated bi-weekly consultant-led MDFPC including Vascular Surgery, Endocrinology, Orthopaedic Surgery, Podiatry, Orthotics and Tissue Viability was established in June 2008.

RESULTS

Between 2006 and 2010, a total of 221 lower limb procedures (major/minor amputations and debridement) were performed. The number of major amputations decreased from 12 during the control period (2 years before the clinic) to 7 in the study period (2 years after the clinic). After costing all activity associated with the clinic, there was an overall saving of €114,063 per year associated with the introduction of the MDFPC.

CONCLUSION

This is the first study in an Irish context, and one of few international studies, to demonstrate that an aggressive-coordinated approach to diabetic foot care is both cost effective and clinically efficient in reducing the burden of foot-related complications in a diabetic population.