'Will you be doing my operation doctor?' Patient attitudes to informed consent

BACKGROUND

As part of the consent process, it is part of a doctor's duty of care to reveal any material risk. Depending upon the level of supervision, whether the operating surgeon is a trainee may be such a risk, but in our experience this is not routinely discussed with patients pre-operatively. We set out to discover patients' attitudes to being operated on by trainee urological surgeons.

PATIENTS AND METHODS

A total of 101 completed questionnaires were received from patients (90 male, 11 female, mean age 72 years) undergoing transurethral resection of the prostate (TURP), transurethral resection of a bladder tumour (TURBT) or cystodiathermy on various aspects of their attitudes to being operated on by junior doctors as part of training.

RESULTS

The response rate was 77%. Of the respondents, 94 patients (91%) thought that junior doctors should perform surgery as part of their training. Only 11 of 73 (15%) said they would be happy for a junior doctor, competent to perform the procedure, to operate unsupervised. Of 98 patients, 80 (82%) thought they should be told if the operation was going to be performed by a junior doctor, and 85 (87%) that they should be told their name and designation.

CONCLUSIONS

For consent to be 'informed', the experience and identity of the surgeon should be made known to patients. Most patients are happy to be operated on by a junior doctor under consultant supervision, but would want to be told and know their name and status.

Renal cell carcinoma: incidental detection during routine ultrasonography in men presenting with lower urinary tract symptoms

OBJECTIVE

To compare renal cell carcinomas (RCCs) presenting incidentally in patients referred for lower urinary tract symptoms (LtJTS) with those presenting symptomatically, by stage, intervention and outcome.

PATIENTS AND METHODS

The case notes of all male patients (100) diagnosed with RCC between 1991 and 1998 were reviewed and modes of presentation recorded. The patients were divided into two groups: those who were referred with LUTS (frequency, urgency, hesitancy, poor stream, nocturia) and in whom RCC would not have been suspected and was thus detected incidentally on routine ultrasonography; and all patients in whom carcinoma might have been suspected from their symptoms but, for the purposes of this study, also included patients in whom RCC was diagnosed during ultrasonography for unrelated intra-abdominal pathology. Details of diagnostic imaging and clinical staging were similarly recorded for both groups and where surgical intervention was undertaken, histopathological data were also noted. The clinical course and long-term outcome of incidentally detected tumours was then compared with their symptomatically presenting counterparts.

RESULTS

The mean (range) follow-up for all patients was 30 (1.5-96) months; for those in the incidental group it was 31 (1-86) months and in the symptomatic patients 29 (1-96) months. Organ-confined disease was found in two-thirds of patients with incidental tumours and in 38% of those in whom the tumour may have been suspected; the difference was statistically significant (chi-squared test P<0.05). The mean (SD) size of tumours discovered incidentally and in symptomatic patients was 5.9 (1.94) cm and 9.2 (3.39) cm, respectively; this difference was also statistically significant (t-test, P<0.001). Of the 24 patients with incidentally detected tumours, 14 (58%) were alive with no recurrence, and of the 76 presenting symptomatically, 27 (35%) were alive with no recurrence at the last follow-up; disease survival curves showed a statistically better survival rate for those with organ-confined tumours.

CONCLUSION

Incidentally diagnosed RCC represents a significant proportion of those who are ultimately diagnosed with the malignancy. Opportunities which arise for appropriate screening of the upper tracts during routine urological investigations (e.g. ultrasonography of the upper tracts in patients referred for LUTS) should be endorsed, contrasting with the more traditional approach, which argues that it yields no ultimate survival advantage.

Patient satisfaction with physician assistants (PAs) in an ED fast track

The study objective was to determine patient satisfaction with physician assistants (PAs) in an emergency department (ED) fast track (FT). An additional goal was to determine if patients would be willing to wait longer to be seen primarily by an emergency physician (EP) rather than a PA. The study was conducted between March 1, 1999 and May 1, 1999 at a community hospital with an annual ED census of 48,644 patients; 18% are seen in the ED FT. All patients were seen primarily by a PA. An anonymous survey was given to patients at time of discharge. Patients rated their degree of satisfaction by placing an X on a 100 millimeter visual analogue scale. Patients also indicated if they would be willing to wait longer to be seen primarily by an EP rather than a PA. A total of 111 surveys were analyzed, for a response rate of 11%. Sixty-two patients (56%) were women and 49 men (44%), with a mean age of 28 years. Twenty-seven patients (24%) were younger than 18 years and required a legal guardian to complete the survey. The mean patient satisfaction score was 93 (95% CI: 90.27 to 95.73). Only 13 patients (12%) indicated they would be willing to wait longer to be seen primarily by an EP rather than a PA. Patients seen in an ED FT are very satisfied with the care rendered by a PA. Few patients would be willing to wait longer in such a setting to be seen primarily by an EP.

Spontaneous regression of a solitary cerebral metastases in renal carcinoma followed by meningioma development under medroxyprogesterone acetate therapy

A case of regression of a probable cerebral metastasis of a hypernephroma after nephrectomy and hormone therapy is presented. The patient subsequently developed a meningioma after therapy with medroxyprogesterone acetate. A relationship between meningioma growth and sex hormones has been documented, but little is known about the effect of hormone therapies on tumour growth.

Erectile and ejaculatory failure after transurethral prostatectomy

OBJECTIVES

To evaluate the clinical incidence of sexual dysfunction after transurethral resection of the prostate (TURP) and to identify risk factors.

SETTING

Havering Hospitals NHS Trust, Essex, UK.

PATIENTS AND METHODS

253 patients who underwent TURP were assessed using a standard proforma regarding pre- and post-operative erectile and ejaculatory functions. The patients who developed post-operative erectile failure were compared with the unaffected group.

RESULTS

126 patients completed the study; 22 were pre-operatively impotent and remained so post-operatively. Of 104 patients who were sexually active 18 developed post-operative erectile impairment. Five patients (4.8%) had total erectile failure. Only 7% of patients retained ejaculation after the operation. Significant risk factors in the patients with post-operative erectile failure, were presentation with acute retention and development of profuse primary hemorrhage.

CONCLUSION

The study reaffirmed that there is a low but significant clinical incidence (4.8%) of erectile failure after TURP which is associated with certain risk factors. Ejaculatory failure was higher in incidence but carried a lower clinical significance.

The colonic conduit: a better method of urinary diversion?

The colonic conduit urinary diversion has been assessed in a retrospective study of 47 children in order to compare the results of this operation with that of other forms of urinary diversion. The overall complication rate was 81%. The rate of stomal stenosis was 34% and that of upper tract dilatation was 36%. These results are very similar to the complication rate for the ileal conduit, which is now the most popular form of urinary diversion. It is suggested that all forms of urinary diversion have a high long-term complication rate and that other means of management should be considered more seriously.

Changes in the appearance of venography after ligation of a varicocele

Images

Penile injuries with particular reference to injury to the erectile tissue

A retrospective study of 56 patients with penile injuries showed that 28 injuries were sustained during coitus and a further 12 in other sexual practices. Four different types of injury to the erectile mechanism are described and the management of each discussed. A modified phalloplasty technique is described for patients who have sustained a complete loss of the phallus.

Colonic carcinoma at the site of ureterosigmoidostomy: what is the risk?

A case of colonic carcinoma arising 27 years after urinary diversion by ureterosigmoidostomy is reported. This late complication is now well recognized and increasing numbers of cases are being reported. The implications of this patient and the 31 previously reported cases are considered.

Abnormalities of the suspensory ligament of the penis as a cause for erectile dysfunction

Four patients are described with a defect in the suspensory ligament of the penis. In one patient this was traumatic in origin but in the other 3 aetiology appeared to be congenital. The clinical history, physical findings and treatment are summarised.

Misdiagnosis of Testicular Tumours1

One hundred cases of testicular tumour have been reviewed: 37% of cases were initially misdiagnosed mainly because of confusion between testicular tumour and epididymo-orchitis. A more aggressive surgical approach to doubtful testicular swellings is suggested.

Varicocele: a review of radiological and anatomical features in relation to surgical treatment

The patterns of venous drainage of the testis and scrotum have been evaluated in patients with varicocele by a variety of radiological procedures, including left renal venography, and at the time of operation by ascending venography and retrograde injection of contrast medium into prominent varicosities. These studies have allowed classification of the system of veins involved in the condition into several groups, including involvement of the internal spermatic vein alone, pure cremasteric varicocele, mixed internal spermatic and cremasteric varicosities in one or both systems with valvular incompetence or mere dilatation without apparent incompetence of valves. As a result, an anatomical approach to the surgical management of varicocele is suggested which attempts to place the operative treatment on a more rational basis appropriate to each case.

Parameatal urethral cysts: a review of 6 cases

6 cases of parameatal urethral cysts are reported in 3 males and 3 females. The condition is considered to be rare. The aetiology is thought to be obstruction of the para-urethral ducts possibly due to infection. The treatment of choice is complete excision.

High-pressure liquid chromatographic studies of TCC and metabolites in experimental animals and man

A reversed-phase high performance liquid chromatographic (HPLC) procedure for the analyses of 3,4,4'-trichlorocarbanilide (TCC) and its free and/or conjugated metabolic products in plasma/serum in described. A rapid, effective clean-up procedure, prior to chromatographic evaluation, involves a single-step combined protein removal and THF extraction. Detection of the TCC moiety after HPLC separation is by UV absorption at 265 nm; quantitation by peak height measurement. A detection limit of 10 ppb of TCC and/or metabolities has been demonstrated for this method. Verification of this method was by radiotracer counting of the appropriate HPLC peaks from plasma of animals adminstered 14C-TCC/TCC. The utility of this method was demonstrated in both animal pharmacological and toxicological studies and in human bathing studies.