Search

BACKGROUND Non-muscle invasive bladder cancer (NMIBC) accounts for 75% of bladder cancers. It is common and costly. Cost and detriment to patient outcomes and quality of life are driven by high recurrence rates and the need for regular invasive surveillance with frequent repeat treatments. There is evidence that the quality of the initial surgical procedure (Transurethral resection of bladder tumour (TURBT)) and timely administration of postoperative bladder chemotherapy significantly reduces cancer recurrence rates and improves outcomes such as cancer progression and mortality. There is some survey-based evidence that TURBT practice varies significantly across surgeons and sites1. There is evidence from clinical trials that NMIBC recurrence rate varies significantly between sites and that this cannot be accounted for by differences in patient, tumour, or adjuvant treatment factors, suggesting that how the surgery is performed may be a reason for the variation. OBJECTIVE This study primarily aims to determine if feedback of and education about surgical quality indicators can improve performance, and secondarily if this can reduce cancer recurrence rates. METHODS This study is an observational, international, multi-centre study with an embedded cluster randomised trial of audit, feedback, and education. Sites will be included if they perform TURBT for NMIBC. RESULTS The study has 4 co-primary outcomes which are 4 TURBT quality indicators: a surgical performance factor; an adjuvant treatment factor; and two documentation factors. A key secondary outcome is the early cancer recurrence rate. CONCLUSIONS Local and/or national ethical and institutional approvals or exemptions will be obtained at each participating site. The study results will be published in peer-reviewed journals and presented at national and international scientific congresses. CLINICALTRIAL The study is registered with clinicaltrials.org (NCT05154084).

To produce a best practice consensus guideline for the conduct of scrotal exploration for suspected testicular torsion using formal consensus methodology.A panel of 16 expert urologists, representing adult, paediatric, general, and andrological urology used the RAND/UCLA Appropriateness Consensus Methodology to score a 184 statement pre-meeting questionnaire on the conduct of scrotal exploration for suspected testicular torsion. The collated responses were presented at a face-to-face online meeting and each item was rescored anonymously after a group discussion, facilitated by an independent chair with expertise in consensus methodology. Items were scored for agreement and consensus and the items scored with consensus were used to derive a set of best practice guidelines.Statements scored as with consensus increased from Round 1 (122/184, 66.3%) to Round 2 (149/200, 74.5%). Recommendations were generated in ten categories: consent, assessment under anaesthetic, initial incision, intraoperative decision making, fixation, medical photography, closure, operation note, logistics and follow-up after scrotal exploration. Our statements assume that the decision to operate has already been made. Key recommendations in the consent process included the discussion of the possibility of orchidectomy and the possibility of subsequent infection of the affected testis or wound requiring antibiotic therapy. If after the examination under anaesthesia, the index of suspicion of testicular torsion is lower than previously thought, then the surgeon should still proceed to scrotal exploration as planned. A flow chart guiding decision making dependent on intraoperative findings has been designed. If no torsion is present on exploration and the bell clapper deformity is absent, the testis should not be fixed. When fixing a testis using sutures, 3 or 4-point is acceptable and non-absorbable sutures are preferred.We have produced consensus recommendations to inform best practice in the conduct of scrotal exploration for suspected testicular torsion.

Aim: A contemporary evaluation of current urological practices, and assessment of the prevalence of urinary tract cancers, in patients referred to secondary care with suspected urinary tract cancer; to allow recommendation in cancer diagnosis pathways that may improve patient experience, minimize invasive and unnecessary investigations, reduce waste of resources and optimize use of the most appropriate tests. Patients: Any patient referred with visible, nonvisible haematuria or nonhaematuria for suspected urothelial cancer, excluding those with previous urological cancer or those who are unable to undergo a cystoscopy. Outcomes: Prevalence of urological cancers in patients referred for suspected urothelial cancer as confirmed on flexible cystoscopy, imaging and/or further cytopathological evaluation. Sensitivity, specificity, positive and negative predictive value of different imaging modalities in the diagnosis of different urothelial cancers. Identification of patient factors associated with different types of urothelial cancer. Costeffectiveness of different diagnostic strategies for diagnosis of bladder and upper tract cancer. Study design: Prospective multicentre observational cohort study carried out in UK, European and non-European International Urological Secondary care centres. Methods Patient data will be collected from secondary care centres that evaluate patients with suspected urinary tract cancer and have the ability for cystoscopy to be carried out. Participating collaborators will need to have access to cystoscopy, and will complete a summary sheet of the normal practice currently used at their site for investigation of suspected urothelial cancer. A set data collection period will be allocated, in which time data for consecutive patients seen by the participating collaborators will be collected. All requested data can be collected from the routine assessment of the patients that meet the inclusion criteria. Patients will be followed up until the final diagnostic outcome is reached.

Background: Patient factors associated with urinary tract cancer can be used to risk stratify patients referred with haematuria, prioritising those with a higher risk of cancer for prompt investigation. Objective: To develop a prediction model for urinary tract cancer in patients referred with haematuria. Design, setting, and participants: A prospective observational study was conducted in 10 282 patients from 110 hospitals across 26 countries, aged ≥16 yr and referred to secondary care with haematuria. Patients with a known or previous urological malignancy were excluded. Outcome measurements and statistical analysis: The primary outcomes were the presence or absence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC], and renal cancer). Mixed-effect multivariable logistic regression was performed with site and country as random effects and clinically important patient-level candidate predictors, chosen a priori, as fixed effects. Predictors were selected primarily using clinical reasoning, in addition to backward stepwise selection. Calibration and discrimination were calculated, and bootstrap validation was performed to calculate optimism. Results and limitations: The unadjusted prevalence was 17.2% (n = 1763) for bladder cancer, 1.20% (n = 123) for UTUC, and 1.00% (n = 103) for renal cancer. The final model included predictors of increased risk (visible haematuria, age, smoking history, male sex, and family history) and reduced risk (previous haematuria investigations, urinary tract infection, dysuria/suprapubic pain, anticoagulation, catheter use, and previous pelvic radiotherapy). The area under the receiver operating characteristic curve of the final model was 0.86 (95% confidence interval 0.85-0.87). The model is limited to patients without previous urological malignancy. Conclusions: This cancer prediction model is the first to consider established and novel urinary tract cancer diagnostic markers. It can be used in secondary care for risk stratifying patients and aid the clinician's decision-making process in prioritising patients for investigation. Patient summary: We have developed a tool that uses a person's characteristics to determine the risk of cancer if that person develops blood in the urine (haematuria). This can be used to help prioritise patients for further investigation.

INTRODUCTION AND OBJECTIVE:The percentage of medical schools mandating urology rotations in the USA has decreased from 99% in 1956 to 17% in 2009, whereas 65% of medical school directors stated in ...

Ureteric injuries from blunt trauma are rare in adults requiring prompt diagnosis and management. To our knowledge this is the second case report of a complete transection of the ureter due to blunt injury at the pelvi-ureteric junction in an adult. Following a high-speed road traffic collision, a 26-year-old female with bilateral duplex kidneys was admitted with complete transection of the lower moiety of her right collecting system confirmed on computed tomography Urogram. This was repaired successfully with a minimally invasive laparoscopic technique in keeping with European Association of Urology guidelines. A 3-month follow-up MAG 3 renogram indicated adequate drainage from the right kidney with no evidence of obstruction. This successful outcome demonstrates a laparoscopic repair is achievable and favourable, improving post-operative recovery and reduction of inpatient length of stay. We recommend that a laparoscopic approach should be attempted unless laparotomy is indicated for other injuries.

Background: Haematuria often requires investigation with an imaging test and flexible cystoscopy to rule out urinary tract cancers. With a reduction in diagnostic services due to the COVID-19 pandemic there is a risk of compromise in the care of patients referred with haematuria. We aimed to provide a pragmatic strategy that optimises the use of scarce resources by reducing patient visits to hospital and allocating the appropriate diagnostic tests according to risk of bladder cancer. Methods: The IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of newly suspected urinary tract cancer. Patients underwent cystoscopy, imaging tests, urine cytology and transurethral resection of bladder tumour (TURBT), where indicated. We developed strategies using combinations of imaging and cytology as triage tests to flexible cystoscopy. These strategies aimed to maximise cancer detection within a pragmatic pathway in a resource-limited environment. Findings: 8112 patients (74 4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70 7%) patients had visible haematuria (VH) and 2375 (29 3%) had non-visible haematuria (NVH). Amongst all patients, 1474 (18 2%) had bladder cancer;1333 (23 2%) in VH group and 141 (5 94%) in NVH group. Diagnostic test performance was used to determine optimal age cut-offs for each proposed strategy. We recommended proceeding directly to TURBT for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients (threshold of 60-years-old with VH, or 70-years-old with NVH) to capture high risk bladder cancer. Interpretation: We suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

Introduction Non-muscle invasive bladder cancer (NMIBC) is one of the most expensive cancers to treat, driven by high recurrence rates and disease progression. Mortality rates in the UK for all bladder cancers have remained relatively stable over the past decade. NMIBC can be curatively treated with transurethral resection of the bladder tumour (TURBT). Despite international evidence-based guidelines on the TURBT procedure and postoperative single instillation of mitomycin-C, TURBT quality continues to vary widely. RESECT will be the first ever international study of TURBT surgery evaluating the achievement of TURBT quality indicators globally and assessing if audit and performance feedback can improve surgical outcomes. Methods RESECT is a prospective, multicentre international observational cohort study. Collaborators at each site will collect data using REDCap about local TURBT practice, early recurrence rates and the experience of local TURBT surgeons. The primary outcome is the rate of achievement of key TURBT quality indicators. Advertisement for the study launched in 2020. Results As of October 1st, 2020, 524 collaborators have registered to participate. Collaborators represent 334 centres from 54 countries, with the highest number of centres from the United Kingdom (133), Spain (17), and India (16). 50.8% are trainees, 30.3% consultants, and 17.2% medical students. Based on current registrations, patient recruitment will far exceed initial projections and considerably improve statistical power. Conclusion RESECT has attracted many collaborators internationally from consultants and trainees at all stages. RESECT has significant potential to positively impact TURBT practice, health economics and ultimately improve outcomes for patients with NMIBC globally.

INTRODUCTION AND OBJECTIVE:The aim of this study was to determine the prevalence of urinary tract cancer (UTC) in secondary care. Secondary aims were to explore reasons for differences in prevalenc...

Objective: The Consultant Outcomes Publication has made it mandatory to submit surgeon-level data on radical cystectomy (RC) practice in England. The current analysis describes contemporary surgical practice and compares this by surgeon and centre case volume. Materials and methods: Between 1 January 2014 and 31 December 2015, data on 3742 RCs performed by 161 surgeons over 84 centres were recorded on the British Association of Urological Surgeons audit and data platform. Centre case volumes were grouped as high (> 60), medium (30–60) and low (< 30), while surgeon case volumes were grouped as high (> 30), medium (8–30) and low (< 8). All data averages were for the combined 2-year period. Results: The median number of RCs performed was 16/surgeon and 31/centre; 45.4% of cases were performed for muscle-invasive transitional cell carcinoma (TCC). The commonest performed urinary diversion was ileal conduit (85.2%), followed by orthotopic bladder substitution (5.7%). Open radical cystectomy (ORC) was performed in 67.8%, robotically-assisted cystectomy (RARC) in 20.6% and laparoscopic cystectomy (LRC) in 9.1% of cases. RARC was more likely to be performed by high-volume surgeons and centres. The majority of patients underwent a lymph node dissection (LND), with rates varying from 79.5% to 90.3%. Reported rates of high-grade complication were generally low across all groups, suggesting under-reporting. There was a trend towards higher reported transfusion rates as centre volumes decreased. The median length of stay (LOS) was 7–9 days for minimally invasive approaches compared to open surgery, which was 11–12 days. Mortality rates were low across all groups. Conclusions: Compliance with the data registry is high. ORC remains the most common approach. High-case volume surgeons and centres more commonly offer RARC. The majority of patients undergo LND. There is a trend towards higher reported rates of transfusion as centre volume decreases. LOS is shorter in RARC and LRC in comparison to ORC, but is otherwise similar across centres and surgeons. Level of evidence: 2b

OBJECTIVES To describe contemporary radical prostatectomy (RP) practice using the British Association of Urological Surgeons (BAUS) data and audit project and to observe differences in practice in relation to surgeon or centre case-volume. PATIENTS AND METHODS Data on 13 920 RP procedures performed by 179 surgeons across 86 centres were recorded on the BAUS data and audit platform between 1 January 2014 and 31 December 2015. This equates to ~95% of total RPs performed over this period when compared to Hospital Episode Statistics (HES) data. Centre case-volumes were categorised as 'high' (>200), 'medium' (100-200) and 'low' ( 100) and 'low' (

INTRODUCTION AND OBJECTIVES:The IDENTIFY study aims to determine contemporary urinary tract cancer rates and diagnostic test performance in patients referred to secondary care with suspected urothe...

Objectifs L’objectif de notre etude (IDENTIFY) etait de determiner le taux de cancer des voies urinaires de maniere contemporaine ainsi que les performances des tests diagnostiques chez des patients ayant une suspicion de cancer urothelial. Methodes Etude prospective, internationale et multicentrique aupres de patients adresses pour cystoscopie en consultation d’urologie. Les donnees demographiques, cliniques et des tests diagnostiques ont ete recoltees. Les taux de prevalence ont ete calcules pour chaque sous-type de cancer urologique de meme que la performance des tests diagnostiques. Resultats Plus de 11 060 patients consultant pour cystoscopie ont ete inclus dans 128 hopitaux de 30 pays (decembre 2017–decembre 2018). Au total, 65 % presentait une hematurie macroscopique (HMa), 29 % une hematurie microscopique (Hmi) et 6 % aucune hematurie (AH). La prevalence du cancer de la vessie (CV) etait de 17,7 % globalement ; de 18,1 %, 3,7 % et 26,6 % pour les groupes HMa, Hmi et AH respectivement. On retrouvait une HMa dans 81,5 % des cancers de vessie. La prevalence des tumeurs de la voie excretrice superieure (TVES) etait de 1 %, du carcinome a cellules renales de 0,9 % et le cancer de la prostate de 1,2 %. La prevalence du CV et des TVES culminait entre 70 et 79 ans et etait plus elevee chez les hommes. Les variables associees de maniere significative aux CV comprenaient le type d’hematurie, l’âge, les antecedents de tabagisme, l’anticoagulation, les signes fonctionnels urinaire de la phase de remplissage et plus d’un episode d’HMa (25,5 %) contre un seul episode (17,9 %). Les performances diagnostiques de l’echographie et de l’uroscanner sont presentees dans le Tableau 1 . Conclusion En cas d’hematurie macroscopique, une tumeur de vessie est identifiee dans pres d’une cystoscopie sur 5. L’echographie et l’uroscanner ont des performances similaires pour diagnostiquer un cancer de vessie. Ces nouvelles donnees permettront une approche personnalisee des bilans d’hematurie ainsi que le developpement de modeles predictifs afin optimiser la detection du cancer urothelial.

Squamous cell carcinoma (SCC) arising from a suprapubic cystostomy tract is a rare complication of long-term suprapubic catheterization (SPC). A 53-year-old man with paraplegia secondary to spina bifida presented with a painful granulomatous lesion around his SPC site that was being treated with silver nitrate cauterization in the community. Consequently, he developed a sacral pressure sore due to reduced mobility from the pain. He also had increasing difficulties with defaecation secondary to his spina bifida. His sacral pressure sore was secondary to a cryptoglandular fistula with coccygeal osteomylelitis. Post-operative pathology revealed infiltrative SCC involving full thickness of the specimen from skin to the bladder wall with clear surgical margins. We describe the first case requiring a simultaneous suprapubic tract SCC excision and colostomy formation. We recommend early investigation of lesions arising from a long-term suprapubic tract especially in patients with spinal cord injuries or congenital defects.