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Background Renal stone disease is common and can cause emergency presentation with acute pain due to ureteric colic. International guidelines have stated the need for a multicentre randomised controlled trial (RCT) to determine whether a non-invasive outpatient (shockwave lithotripsy [SWL]) or surgical (ureteroscopy [URS]) intervention should be the first-line treatment for those needing active intervention. This has implications for shaping clinical pathways. Objective To report a pragmatic multicentre non-inferiority RCT comparing SWL with URS. Design, setting, and participants This trial tested for non-inferiority of up to two sessions of SWL compared with URS as initial treatment for ureteric stones requiring intervention. Outcome measurements and statistical analysis The primary outcome was whether further intervention was required to clear the stone, and secondary outcomes included quality of life assessment, severity of pain, and serious complications; these were based on questionnaires at baseline, 8 wk, and 6 mo. We included patients over 16 yr with a single ureteric stone clinically deemed to require intervention. Intention-to-treat and per-protocol analyses were planned. Results and limitations The study recruited between July 1, 2013 and June 30, 2017. We recruited 613 participants from a total of 1291 eligible patients, randomising 306 to SWL and 307 to URS. Sixty-seven patients (22.1%) in the SWL arm needed further treatment compared with 31 patients (10.3%) in the URS arm. The absolute risk difference was 11.7% (95% confidence interval 5.6%, 17.8%) in favour of URS, which was inside the 20% threshold we set for demonstrating noninferiority of SWL. Conclusions This RCT was designed to test whether SWL is non-inferior to URS and confirmed this; although SWL is an outpatient noninvasive treatment with potential advantages both for patients and for reducing the use of inpatient health care resources, the trial showed a benefit in overall clinical outcomes with URS compared with SWL, reflecting contemporary practice. The Therapeutic Interventions for Stones of the Ureter (TISU) study provides new evidence to help guide the choice of modality for this common health condition. Patient summary We present the largest trial comparing ureteroscopy versus extracorporeal shockwave lithotripsy for ureteric stones. While ureteroscopy had marginally improved outcome in terms of stone clearance, as expected, shockwave lithotripsy had better results in terms of health care costs. These results should enable patients and health care providers to optimise treatment pathways for this common urological condition.

Objectives: To assess the cost‐effectiveness, resource use implications, quality‐adjusted life‐years (QALYs) and cost per QALY of care pathways starting with either extracorporeal shockwave lithotripsy (SWL) or with ureteroscopic retrieval (ureteroscopy [URS]) for the management of ureteric stones. Patients and Methods: Data on quality of life and resource use for 613 patients, collected prospectively in the Therapeutic Interventions for Stones of the Ureter (TISU) randomized controlled trial (ISRCTN 92289221), were used to assess the cost‐effectiveness of two care pathways, SWL and URS. A health provider (UK National Health Service) perspective was adopted to estimate the costs of the interventions and subsequent resource use. Quality‐of‐life data were calculated using a generic instrument, the EuroQol EQ‐5D‐3L. Results are expressed as incremental cost‐effectiveness ratios and cost‐effectiveness acceptability curves. Results: The mean QALY difference (SWL vs URS) was −0.021 (95% confidence interval [CI] −0.033 to −0.010) and the mean cost difference was −£809 (95% CI −£1061 to −£551). The QALY difference translated into approximately 10 more healthy days over the 6‐month period for the patients on the URS care pathway. The probabaility that SWL is cost‐effective is 79% at a society's willingness to pay (WTP) threshold for 1 QALY of £30,000 and 98% at a WTP threshold of £20,000. Conclusion: The SWL pathway results in lower QALYs than URS but costs less. The incremental cost per QALY is £39 118 cost saving per QALY lost, with a 79% probability that SWL would be considered cost‐effective at a WTP threshold for 1 QALY of £30 000 and 98% at a WTP threshold of £20 000. Decision‐makers need to determine if costs saved justify the loss in QALYs.

Objectives: With an increasing number of patients undergoing ureteroscopic surgery worldwide for stone disease, and the concomitant pressures on health care resources, we aimed to review global patterns for ureteric stenting following ureteroscopy. With a centralized electronic database, a longitudinal cohort study was designed to help define the indications for stenting, type of drainage, and methods of stent removal. Methods: This multicenter study was conducted prospectively, with centralized data acquisition by uCARE (research arm of the Société Internationale d'Urologie), and registered at ClinicalTrials.gov (NCT03567421). Along with baseline demographic data, details were entered for stone imaging characteristics, intraoperative information, including urine culture, and exit strategy for stent removal. An independent audit was undertaken to sample the accuracy of data entered across the sites. Results: In total, 2544 patients were included from 50 centers in 15 countries. There were 1969 patients with ureteric stones, and 942 with renal stones. While 41% ureteric stones were distal (median length 10mm), 52% renal stones were in the lower pole (median diameter 11 mm). The majority of patients (68.8%) were given antibiotics at induction; 20.6% were “pre-stented” before the ureteroscopy, and a high percentage were stented following ureteroscopy (91%). The majority of the stents (85.1%) were polyurethane, mean duration of stent after surgery was 27 days, and 80% of stent removals were undertaken in the operating room. Conclusion: This is one of the largest prospective global cohort studies, reflecting widespread usage of stenting, despite emerging evidence to the contrary. Stent removals may also be modified with time, as the pressure on health care resources mounts.

ObjectiveThe WHO declared SARS-CoV-2 a pandemic on 11th March 2020 prompting a rapid change to surgical practice. This study focuses on how the management of ureteric colic has adapted in a major tertiary referral unit during the peak of the pandemic so that lessons be can be learned in case a second wave occurs. Materials and MethodsWe compared admission rates and treatment patterns against national and European guidelines in 20 weeks, divided into pre- and peri-pandemic. ResultsA total of 72 patients were admitted during the study period. 64% (46/72) were admitted pre-pandemic. 22% (10/46) of these were septic (5 stented, 5 nephrostomized) while 20% (9/46) were managed conservatively. 59% (27/46) of pre-pandemic admissions were suitable for active treatment, of which 48% (13/27) received definitive treatment (11 ureteroscopy (URS), 2 shockwave lithotripsy (SWL)) all within 48 hours of admis-sion. 52% (14/27) had temporising procedures (11 stented, 3 nephrostomized) and underwent definitive treatment within 63 days.Of the total patients, 36% (26/72) were admitted peri-pandemic. 23% (6/26) were septic (1 stent, 5 nephrostomized), while 31% (8/26) were managed conservatively. 46% (12/26) were suitable for active treatment. 75% (9/12) received definitive treatment (4 URS, 5 SWL) of which 33% (4/12) within 48 hours and the remaining treated and stone free within 12 days. 25% (3/12) had temporising procedures (2 stented, 1 nephrostomized), with the definitive treatment provided within 17 days. ConclusionUreteric colic admissions were reduced by almost half during the pandemic. There has been increased primary treatment with a reduction in temporising procedures and time to receiving definitive treatment. In the ‘new normal,’ lessons learned must be carried forward to maintain high rates of definitive treatments.

Objectives To perform a systematic review to identify the clinical, fiscal and environmental evidence on the use of urological telehealth and/or virtual clinic (VC) strategies, and to highlight research gaps in this rapidly evolving field. Methods Our PROSPERO-registered (CRD42019151946) systematic search of Embase, Medline and the Cochrane Review Database was performed to identify original research articles pertaining to adult urology telehealth or VC strategies. Risk-of-bias (RoB) assessment was performed according to the Cochrane 2.0 RoB tool or the Joanna Briggs Institute Checklist for non-randomized studies. Results A total of 5813 participants were included from 18 original articles (two randomized controlled trials [RCTs], 10 prospective studies, six retrospective studies). Urology sub-specialities comprised: uro-oncology (n = 6); general urology (n = 8); endo-urology (n = 2); and lower urinary tract symptoms and/or incontinence (n = 2). Across all sub-specialties, prospective studies using VCs reported a primary median (interquartile range [IQR]) VC discharge rate of 16.6 (14.7-29.8)% and a primary median (IQR) face-to-face (FTF) clinic referral rate of 32.4 (15.5-53.3)%. Direct cost analysis demonstrated median (IQR) annual cost savings of £56 232 (£46 260-£61 116). Grade II and IIIb complications were reported in two acute ureteric colic studies, with rates of 0.20% (3/1534) and 0.13% (2/1534), respectively. The annual carbon footprint avoided ranged from 0.7 to 4.35 metric tonnes of CO2 emissions, depending on the mode of transport used. Patient satisfaction was inconsistently reported, and assessments lacked prospective evaluation using validated questionnaires. Conclusion Urology VCs are a promising new platform which can offer clinical, financial and environmental benefits to support an increasing urological referral burden. Further prospective evidence is required across urological sub-specialties to confirm equivalency and safety against traditional FTF assessment.

INTRODUCTION AND OBJECTIVE:Preservation of sexual function whilst alleviating bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is a major attraction fo...

Introduction Minimally invasive surgical treatments (MISTs) of benign prostatic hyperplasia (BPH) have evolved to offer men daycase care with preservation of urinary continence and sexual function. This systematic review evaluates trends in minimally invasive BPH surgery over the last decade Method Systematic review (PRISMA) of Embase/MEDLINE databases (2010-2020). MISTs included Rezum, Urolift, Prostatic Artery Embolisation (PAE), Temporary Implantable Nitinol Device (TIND), Intraprostatic Injection, Transurethral Microwave Therapy (TUMT) and Transurethral Needle Ablation (TUNA). Primary outcome: urinary functional change (International Prostate Symptom Score (IPSS)/maximum flow (Qmax)). Secondary outcomes: sexual functional change (International Index of Erectile Function-5 (IIEF-5)), technical failures and complications. Results 74 studies were included (total: 8,917 patients). Primary: all interventions offered improvement in IPSS and Qmax (intervention (no. studies): range IPSS change, range Qmax change, range months follow-up; Rezum (4): -46.7% to -62.7%, +17.6% to + 55.6%, 6-48; Urolift (11): -35.2% to -64.2%, +16.7% to + 89.6%, 1-60; PAE (36): -36.8% to -85.2%, +17.4% to + 155.2%, 3-38; TIND (2): -36.8% to -59.6%, +32.9% to + 95.9%, 12-36; Intraprostatic Injection (14): -24.3% to -62%, +8.7% to + 98.4%, 3-24; TUMT (4): -56.1% to -58.7%, +12.9% to + 60.2%, 6-60; TUNA (3): -17.6% to -63.2%, +3.9% to + 39%, 1-120). Secondary: 33 studies of all interventions bar TIND and TUMT reported IIEF-5 change; sexual function was largely preserved. Technical failures and Clavien-Dindo ≥3 complications were rare. Conclusions MISTs for BPH are efficacious and safe. Randomised comparisons with long-term urinary and sexual follow-up are needed to guide choice; until then, patients should be carefully counselled based on individual priorities and circumstances.

Background: It is hypothesised that simulation enhances progression along the initial phase of the surgical learning curve. Objective: To evaluate whether residents undergoing additional simulation, compared to conventional training, are able to achieve proficiency sooner with better patient outcomes. Design, setting, and participants: This international, multicentre, randomised controlled trial recruited 94 urology residents with experience of zero to ten procedures and no prior exposure to simulation in ureterorenoscopy, selected as an index procedure. Intervention: Participants were randomised to simulation or conventional operating room training, as is the current standard globally, and followed for 25 procedures or over 18 mo. Outcome measurements and statistical analysis: The number of procedures required to achieve proficiency, defined as achieving a score of ≥28 on the Objective Structured Assessment of Technical Skill (OSATS) scale over three consecutive operations, was measured. Surgical complications were evaluated as a key secondary outcome. This trial is registered at www.isrctn.com as ISCRTN 12260261. Results and limitations: A total of 1140 cases were performed by 65 participants, with proficiency achieved by 21 simulation and 18 conventional participants over a median of eight and nine procedures, respectively (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.72–2.75). More participants reached proficiency in the simulation arm in flexible ureterorenoscopy, requiring a lower number of procedures (HR 0.89, 95% CI 0.39–2.02). Significant differences were observed in overall comparison of OSATS scores between the groups (mean difference 1.42, 95% CI 0.91–1.92; p < 0.001), with fewer total complications (15 vs 37; p = 0.003) and ureteric injuries (3 vs 9; p < 0.001) in the simulation group. Conclusions: Although the number of procedures required to reach proficiency was similar, simulation-based training led to higher overall proficiency scores than for conventional training. Fewer procedures were required to achieve proficiency in the complex form of the index procedure, with fewer serious complications overall. Patient summary: This study investigated the effect of simulation training in junior surgeons and found that it may improve performance in real operating settings and reduce surgical complications for complex procedures.

INTRODUCTION AND OBJECTIVES:Patients with an underlying urological diagnosis colonised with multidrug-resistant organisms (MDRO) such as ESBL are predisposed to recurrent UTIs. Treatment can be pro...

Background: Renal anastomosing hemangioma (RAH) is an extremely rare benign vascular tumor first described in 2009. Making this diagnosis is fraught with challenges. Radiologically they share features consistent with renal cell carcinomas (RCCs). Their vascular nature poses risks if considering preoperative biopsy and histologically they share characteristics akin to angiosarcomas. The few reports published in the literature suggest presentation with hematuria, flank pain, and polycythemia although the majority are diagnosed at postnephrectomy histologic examination. This case represents the first metachronous RAH in the literature, and is the first RAH presenting with severe hemorrhage. Case Presentation: A 62-year-old woman of Albanian heritage presented to urology with visible hematuria and positive urine cytology. Three years before this presentation, she had undergone an elective radical right-sided nephrectomy for a suspected RCC detected on magnetic resonance imaging, which proved to be an RAH after postoperative histologic examination of the specimen. The patient was investigated with cystoscopy and ureteroscopy for this new hematuria presentation, both of which were unremarkable. Fourteen hours post ureteroscopy, the patient became severely hypotensive and developed acute kidney injury. A CT scan indicated a large left-sided renal subcapsular and retroperitoneal hematoma that was actively bleeding. The patient was hemodynamically unstable and, therefore, required an emergency open left-sided nephrectomy, rendering her anephric and dialysis dependent. Postoperative histologic examination proved that the left kidney also contained an RAH. Conclusion: The anastomosing hemangioma is an important subtype to differentiate from angiosarcoma before and after a nephrectomy. Urologists should carefully consider invasive tests in patients with previously diagnosed vascular lesions as there may be an increased risk of bleeding. Patients with a previously diagnosed anastomosing hemangioma may require surveillance of the contralateral kidney.

Objectives To assess the efficacy and safety of prostate artery embolization (PAE) for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) and to conduct an indirect comparison of PAE with transurethral resection of the prostate (TURP). Patients and methods As a joint initiative between the British Society of Interventional Radiologists, the British Association of Urological Surgeons and the National Institute for Health and Care Excellence, we conducted the UK Register of Prostate Embolization (UK-ROPE) study, which recruited 305 patients across 17 UK urological/interventional radiology centres, 216 of whom underwent PAE and 89 of whom underwent TURP. The primary outcomes were International Prostate Symptom Score (IPSS) improvement in the PAE group at 12 months post-procedure, and complication data post-PAE. We also aimed to compare IPSS score improvements between the PAE and TURP groups, using non-inferiority analysis on propensity-score-matched patient pairs. The clinical results and urological measurements were performed at clinical sites. IPSS and other questionnaire-based results were mailed by patients directly to the trial unit managing the study. All data were uploaded centrally to the UK-ROPE study database. Results The results showed that PAE was clinically effective, producing a median 10-point IPSS improvement from baseline at 12 months post-procedure. PAE did not appear to be as effective as TURP, which produced a median 15-point IPSS score improvement at 12 months post-procedure. These findings are further supported by the propensity score analysis, in which we formed 65 closely matched pairs of patients who underwent PAE and patients who underwent TURP. In terms of IPSS and quality-of-life (QoL) improvement, there was no evidence of PAE being non-inferior to TURP. Patients in the PAE group had a statistically significant improvement in maximum urinary flow rate and prostate volume reduction at 12 months post-procedure. PAE had a reoperation rate of 5% before 12 months and 15% after 12 months (20% total rate), and a low complication rate. Of 216 patients, one had sepsis, one required a blood transfusion, four had local arterial dissection and four had a groin haematoma. Two patients had non-target embolization that presented as self-limiting penile ulcers. Additional patient-reported outcomes, pain levels and return to normal activities were very encouraging for PAE. Seventy-one percent of PAE cases were performed as outpatient or day cases. In contrast, 80% of TURP cases required at least 1 night of hospital stay, and the majority required 2 nights. Conclusion Our results indicate that PAE provides a clinically and statistically significant improvement in symptoms and QoL, although some of these improvements were greater in the TURP arm. The safety profile and quicker return to normal activities may be seen as highly beneficial by patients considering PAE as an alternative treatment to TURP, with the concomitant advantages of reduced length of hospital stay and need for admission after PAE. PAE is an advanced embolization technique demanding a high level of expertise, and should be performed by experienced interventional radiologists who have been trained and proctored appropriately. The use of cone-beam computed tomography is encouraged to improve operator confidence and minimize non-target embolizations. The place of PAE in the care pathway is between that of drugs and surgery, allowing the clinician to tailor treatment to individual patients' symptoms, requirements and anatomical variation.

Objective. Diagnostic reliability of prenephroureterectomy ureteroscopy (PNU) for the detection of upper tract carcinoma in situ (CIS) remains unproven in particular and underreported in general.Methods. Patients who underwent radical nephroureterectomy (RNU) in a large multicentre retrospective study for upper tract transitional cell carcinoma (UT-TCC) between January 2002 and December 2013 were identified from our hospitals databases. PNU appearances, stage, and grade of ureteroscopic biopsy were compared with final histology results of RNU to assess the diagnostic reliability of PNU for carcinoma in situ (CIS).Results. Three hundred patients underwent RNU for UT-TCC. 106 (106/300; 35.3%) of the cohort had PNU using white light with biopsies taken in most (92/106; 86.7%). Postnephroureterectomy histology of the cohort showed CIS in 65 (65/300; 21.6%) patients. Thirty nine of patients with CIS (39/65; 60%) had prenephroureterectomy ureteroscopy biopsies. Out of ten patients with CIS on ureteroscopic biopsies, six did not show CIS on final histopathology (6/10; 60%). Moreover, grading and staging on PNU biopsies of obvious tumours showed a significant nonconcordance with final histopathology of RNU specimen(P=0.02). Overall survival was also shorter in patients with CIS compared with those without; this showed strong statistical significance(P=0.004).Conclusions. There is a high incidence of CIS in upper tract with significant underdetection and discordance rate between the histopathology of biopsy samples obtained by white light PNU and resected specimen of radical nephroureterectomy. The presence of concomitant CIS and high stage disease in the upper tract TCC carried a poor prognosis following radical nephroureterectomy.

Tumour necrosis factor receptor-associated periodic syndrome (TRAPS) is an autosomal dominant condition caused by mutations in the TNFRSF1A gene. It is characterised by recurrent episodes of myalgia, followed by prolonged fever, migratory rashes, headache, serositis, arthralgia, abdominal pain and periorbital oedema. We describe a 49-year-old man with a self-limiting episode of paraparesis who reported recurrent bouts of abdominal symptoms and headaches since childhood. He had a persistent inflammatory response with night sweats and weight loss. We diagnosed TRAPS 2 years after having identified a TNFRSF1A gene mutation. His symptoms and inflammatory response resolved dramatically with the interleukin-1 receptor antagonist anakinra.

The introduction of laparoscopic techniques in the late 1980s and early 1990s has ushered in a novel era in the surgical treatment of human diseases. Following the first laparoscopic nephrectomy done by Clayman et al . in 1991 [1], the initially noted advantages of minimally invasive urological surgery were later proved [2,3]. This soon led to the transition from novelty to the current concept of established ‘expectations’. Despite the success of conventional laparoscopic urological surgery, incisions ranging from 1 to 3 cm in length and three to five ports in number are still required. Each additional working port increases the inherent risk of bleeding, infection, concordant organ damage, hernia formation and decreased cosmetic outcome.

The case of an 81-year-old man with a known 5.2 cm abdominal aortic aneurysm (AAA) and transitional cell carcinoma of the bladder who presented to the emergency department in painful clot retention is described. Approximately 5 h after starting bladder irrigation he developed a sudden onset of severe abdominal pain radiating to his back. Urgent CT scan (AAA protocol) revealed a rupture of the lower pole calyx of his right kidney and a stable aneurysm. Bladder irrigation was stopped and the patient settled with a catheter and simple analgesia. Given his significant co-morbidities, it was felt that surgical intervention for the underlying malignancy was inappropriate and the patient was discharged home. At last outpatient review, his renal function was at its baseline and he was suffering no ill-effects from the ruptured kidney.

Introduction Retrograde ejaculation is not a recognized complication of ureteric reimplantation surgery. We describe this unusual complication in a 25-year-old man, with no other cause for his ejaculatory dysfunction. Case presentation A 25-year-old Caucasian man presented with left hydronephrosis ascribed to a megaureter. Following open reimplantation of the ureter, the patient developed retrograde ejaculation that did not respond to medical therapy. Conclusion The key result reported here is that retrograde ejaculation is a possible complication of open pelvic surgery, for which patients should receive counselling. This is relevant for both urologists and general physicians who consult relatively young men with ejaculatory difficulties.

The age of peak incidence for stone disease is 20-40 years, although stones are seen in all age groups. There is a male to female ratio of 3:2.We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions for stone removal in people with asymptomatic kidney stones? What are the effects of interventions for the removal of symptomatic renal stones? What are the effects of interventions to remove symptomatic ureteric stones? What are the effects of interventions for the management of acute renal colic? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).We found 21 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.In this systematic review we present information relating to the effectiveness and safety of the following interventions: antispasmodic drugs, extracorporeal shockwave lithotripsy, intravenous fluids, NSAIDs, opioids, oral fluids, percutaneous nephrolithotomy, and ureteroscopy.

Sacral nerve stimulation (neuromodulation) can restore bladder sensation and the ability to void in women with urinary retention due to sphincter overactivity (Fowler's syndrome). Modulation of central afferent activity is considered critical to this therapeutic effect but the neural mechanisms are poorly understood. Therefore, we undertook a functional brain imaging study to determine how neuromodulation acts on brain centers involved in the representation and control of bladder function.Eight patients with Fowler's syndrome and 8 healthy controls underwent brain imaging with positron emission tomography to identify regions of brain activity relating to the perception of bladder fullness and their modulation by sacral nerve stimulation.In healthy controls bladder fullness enhanced activity in brainstem (midbrain) and limbic cortical regions. Women with urinary retention showed no significant brainstem activity but did show enhanced limbic cortical activity when the bladder was full in the absence of neuromodulation. Neuromodulation restored a normal pattern of midbrain activity and decreased cortical activity in this group.Our study provides novel neuroimaging evidence for the existence of abnormal interaction between brainstem and cortical centers in women with urinary retention. Furthermore, we have been able to show evidence that the therapeutic effect of sacral neuromodulation is achieved through restoration of activity associated with brainstem autoregulation and attenuation of cingulate activity.