The economic implications of unsuspected findings from CT urography performed for haematuria

OBJECTIVES

We set out to determine the prevalence of unsuspected findings from CT urography (CTU) performed for haematuria and to evaluate the economic implications associated with the subsequent management of these findings.

METHODS

We analysed the results of 778 consecutive CTU scans performed in a haematuria clinic between 2008 and 2010. We excluded cases where diagnosis of an abnormality had been made prior to CTU. Costs incurred during the follow-up of unsuspected findings were calculated following guidance set out in the NHS Costing Manual 2009/10.

RESULTS

778 CTU scans were performed for patients attending a haematuria clinic from 2008 to 2010. 455 men and 323 women underwent CTU scan; they had a median age of 62 years. 56% of scans were found to have unexpected extra-urinary findings (587 abnormalities in 439 scans). Common findings included diverticular disease (138, 17.7%), adrenal masses [85, 10.9%; 40 (5.1%) of which were indeterminate], lung abnormalities (67, 8.6%), gall bladders containing calculi (44, 5.7%), adnexal cysts (25, 7.7% of women) and aortic aneurysms (18, 2.3%). These findings led to a total of 136 outpatient appointments, 88 radiological investigations and 11 procedures (4 of which were major). The overall cost incurred was £47,366, or £60 per patient.

CONCLUSION

CTU is associated with a high rate of unsuspected findings. There is an economic implication to performing CT scanning in this setting, in which further unanticipated investigation and treatment cost is approximately £60 per patient.

Percutaneous sperm retrieval in secondary azoospermia

INTRODUCTION

Males presenting for assisted reproduction after vasectomy have a high chance of normal spermatogenesis and of successful surgical sperm retrieval. We aimed to evaluate simple percutaneous methods of retrieving sperm for intracytoplasmic sperm injection in males with secondary azoospermia due to previous vasectomy.

PATIENTS AND METHODS

We analyzed a series of post-vasectomy males who presented for sperm retrieval between 1999 and 2005 and who were not being considered for vasal reconstruction as their primary method of re-establishing their fertility.

RESULTS

All 132 men had sperm retrieved successfully, 97% with percutaneous methods. In seventy-five percent of the couples intracytoplasmic sperm injection was done, with a total number of 184 cycles being performed. The clinical pregnancy and live birth rates were 25 and 24%, respectively. There were no significant scrotal haematomas, and only 2 patients had postoperative pain after percutaneous sperm retrieval that required analgesia for more than 2 days.

CONCLUSION

We have shown that percutaneous sperm retrieval, where normal spermatogenesis is assumed, is successful in all men following vasectomy. Percutaneous methods of retrieving epididymal or testicular sperm are inexpensive, simple and could replace open techniques in men who are not considering vasal reconstruction following vasectomy.

Ultrasound guided location and resection of a suburothelial cavernous haemangioma of the bladder

Complete endoscopic resection of bladder tumours can be difficult. This is particularly true when there is normal overlying mucosa, as in a cavernous haemangioma. We describe a case where intraoperative ultrasound was used to guide successful endoscopic resection.

Outpatient follow up appointments; are we using the resources effectively?

OBJECTIVE

British Association of Urological Surgeons (BAUS) guidelines and government initiatives have put pressure on the effective use of outpatient resources. Follow up appointments need to be carefully managed to ensure efficient use of available resources. The aim of this study was to audit outpatient follow up service with particular attention to the appropriateness of the appointments made.

METHODS

All patients attending a general urology clinic were assessed by a form completed for each individual appointment. The source of the appointment and the time interval was recorded and each follow up appointment was judged to be either appropriate or inappropriate by the person giving the consultation. For those deemed to be inappropriate, justification was sought and the notes independently reviewed by a different clinician to verify this categorisation.

RESULTS

Of 164 appointments made, 143 patients attended for follow up. A total of 131 appointments were considered to be appropriate (92%) with only 12 deemed by the consulting clinician to be inappropriate (8%). The commonest cause for an inappropriate appointment was failure to appreciate that follow up had already been arranged for a different date. There was no correlation between the source of the referral and an inappropriate referral.

CONCLUSION

This audit suggests an effective use of the outpatient follow up resource with respect to the appropriateness and timing of follow up consultations. Other areas of resource management such as default rates should be investigated in an attempt to improve the efficiency of a service.

Abnormal TGFbeta levels in the amniotic fluid of Down syndrome pregnancies

PROBLEM

The status of cytokines in amniotic fluid (AF) from chromosomally abnormal pregnancy is largely undefined. TGFbeta plays a key role in fetal growth and differentiation and is responsible for the immunoregulatory activity of AF in normal pregnancy, but its status in Down syndrome (DS) pregnancies is unknown. In addition we investigated the IL-2 status of AF from DS pregnancies.

METHOD OF STUDY

Midtrimester AF from chromosomally normal (n = 25) and abnormal pregnancies with DS (n = 15) were assayed for bioactive and latent TGFbeta levels using the mink lung epithelial cell growth inhibition bioassay and for IL-2 activity by the CTLL-2 cell proliferation bioassay and by ELISA.

RESULTS

Levels of bioactive TGFbeta (mean 4.6+/-0.6 U/mL) were significantly increased in DS AF compared with the normal samples (mean 2.8+/-0.3 U/mL, P<0.003) but latent TGFbeta levels did not differ between DS and normal groups. In addition DS AFs showed reduced IL-2 like bioactivity compared with normal samples (P = 0.0006) but IL-2 immunoactivity was undetectable in DS and normal AFs by ELISA.

CONCLUSIONS

DS AFs display increased TGFbeta activity and lacked IL-2 immunoactivity. The reduced ability of DS AFs to stimulate CTLL-2 cell proliferation is unrelated to the IL-2 status of AF. Altered TGFbeta levels may prove useful as an additional biochemical index for the detection of DS pregnancies.

Human amniotic fluid lacks interleukin-2 and interleukin-15 but can interact with the beta-chain of the interleukin-2 receptor

The present study investigated whether an explanation for the conflicting reports on the interleukin-2 (IL-2) status of amniotic fluid is due to the presence of IL-15 which shares biological activities with IL-2 and utilizes the IL-2 receptor beta-chain. Amniotic fluids from 45 normally progressing pregnancies between 14 and 16 weeks after the last menstrual period were assayed for IL-2 and IL-15 by bioassay and enzyme-linked immunosorbent assay (ELISA). The ability of amniotic fluids to induce cytotoxic T lymphoblastoid line-2 (CTLL-2) cell proliferation was demonstrated to be dependent upon bioassay culture conditions. In serum-free medium each amniotic fluid stimulated CTLL-2 proliferation with a mean level of IL-2-like bioactivity of 14.7 +/- 2.3 ng/ml but amniotic fluids failed to induce CTLL-2 proliferation in serum-supplemented medium. Treatment with neutralizing anti-IL-2 or anti-IL-15 antibodies failed to inhibit amniotic fluid-induced CTLL cell proliferation in serum-free medium, indicating a lack of IL-2 and IL-15 bioactivity. In contrast, treatment with anti-IL-2 receptor beta-chain antibody significantly reduced amniotic fluid-induced proliferation. The lack of IL-2 and IL-15 activity in amniotic fluids was confirmed using ELISA. Although high levels of IL-15 immunoactivity were detected in all samples, specificity controls showed a lack of specific IL-15 immunoactivity in amniotic fluid. Pretreatment of amniotic fluids with 100-500 ng/ml mouse immunoglobulin G abrogated IL-15 immunoactivity, indicating that amniotic fluid contains molecules binding to Fc regions of immunoglobulins and responsible for false ELISA positivity. These studies unequivocally show that amniotic fluid lacks IL-2 and IL-15 but can stimulate CTLL-2 cell proliferation via the IL-2 receptor beta-chain. The absence of IL-2 and IL-15 in normal mid-trimester amniotic fluid suggests that the cytokine profile of human pregnancy appears to be associated with a bias against type 1 cytokines within the feto-placental unit.