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Objectives To examine available data relating to the surgical management of stress urinary incontinence (SUI) in Australia before, during and after a well-publicized Senate Inquiry into transvaginal mesh use and to consider outcomes in the context of global guideline changes. Patients and methods The annual number of surgical procedures for the management of SUI by procedure type and age group for the years 2008/2009-2017/2018 was obtained from the Australian Government Department of Human Services database using Medicare Benefits Schedule item numbers. The data extracted were limited to women aged 25 years and older. These data were used to calculate age-specific and age-standardized rates, so as to accurately analyse trends in the usage of different procedures. Hospital Episode Statistics for mid-urethral sling (MUS) insertions were obtained for England's National Health Service from the Health and Social Care Information Centre for the years 2008/2009-2016/2017. These data were also used to calculate annual age-standardized rates for comparison purposes. Results Rates declined for most SUI procedures over time (MUS, colposuspension, fascial slings) except for urethral bulking agents. The absolute number of MUSs implanted in 2008/2009 was 5729, which decreased to 3127 in the 2017/2018 financial year. Over the decade, the annual rate for MUS implantation per 100 000 population halved from 78 to 36. Over this same period, the rate of usage of bulking agents doubled, although represented a low volume of procedures (overall numbers increased from 304 to 698, representing an increase from four to eight procedures per 100 000 population). The age-specific peak rate for MUS and Burch colposuspension changed over the decade from 55-64 years to 65-74 years, suggesting that women are deferring surgical treatment until later in life. Over the last decade, the total number of surgical procedures performed in Australia to treat SUI has decreased markedly from 6812 to 4279. This represents a decrease in the annual rate per 100 000 population from 93 to 49. Conclusions There are clear changes evident for SUI management in the past decade in Australia, including an overall decline in operative numbers, which correlate with international advisory notifications and local investigations. The results of the Australian Senate inquiry, including removal of single-incision mini-slings, greater availability of patient resources, and greater regulation of SUI procedures, will probably have ongoing effects. Surgeons need to ensure that sufficient training and patient education continue in order to maintain appropriate access to treatment of SUI in the future.

Introduction and Objectives: Renal cell carcinoma (RCC) accounts for 2–3% of all cancers. With increasing use of Computer Tomography, a large proportion are detected earlier and amenable to focal therapies such as Radiofrequency Ablation (RFA). Our institution is unable to offer image‐guided percutaneous ablation (PA) through the public service due to lack of Interventional Radiology (IR) resources. Currently, patients with a small renal mass (SRM) are either actively observed, undergo radical nephrectomy (RN), partial nephrectomy (PN) or referred to another tertiary institution for focal therapy. Recent studies have demonstrated no difference in long‐term efficacy between RN, PN and PA treatment of SRMs in selected patients; but with significantly higher rates of morbidity in the surgical treatment groups. Our Urology Multidisciplinary Team (MDT) is supported by an interventional radiologist with Uroradiology specialisation who provides PA for our patients through a private facility and we assessed the cost‐effectiveness of our institution outsourcing PA . The aim of the study was to compare the costs associated with performing nephrectomies (RN, PN) in a public hospital with the costs of performing minimally invasive PA in a private hospital; and to assess the financial impact on the public system of the different treatment options for SRMs. Methods: The cost of performing PA at a large tertiary private hospital for patients with a SRM (

INTRODUCTION AND OBJECTIVE:Renal colic is a common urological problem with a lifetime incidence of approximately 8-19% in males and 3-5% in females. The MIMIC Study was a 4171 patient cohort study ...

Smoking remains a common habit among the general population. Despite the well-established risks of smoking, relatively few studies have been undertaken to assess the understanding of these risks among the general population. We intended to assess the understanding of smoking as a risk factor for various conditions in a urology outpatient cohort to assess the level of knowledge as well as particular strengths and weaknesses they possess. A four-page questionnaire was distributed among urology outpatients over a 5 month period. The questionnaire captured information regarding the knowledge of smoking as a risk factor for various urological and non-urological conditions. Results were collated and stratified according to patient’s cancer history as well as smoking status. A total of 112 participants were included in our analytical sample. Our study demonstrated a deficiency in knowledge regarding smoking and urological conditions. When ranked by level of knowledge, four of the bottom five conditions were urological in nature. Furthermore, we found that patients with a personal cancer history demonstrated generally poorer knowledge of smoking as a risk factor compared to patients without a cancer history. Conversely, smokers themselves demonstrated a greater understanding of risks compared to non-smokers. Our study suggests there is much work to be done in the education of patients on the risks of smoking from a urological point of view. We believe more initiative needs to be taken by the specialists treating such patients to achieve an improved level of knowledge.

Introduction Strengthening The Reporting Of Cohort Studies in Surgery (STROCSS) guidelines were developed in 2017 in order to improve the reporting quality of observational studies in surgery and updated in 2019. In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, we aimed to update STROCSS 2019 guidelines. Methods A STROCSS 2021 steering group was formed to come up with proposals to update STROCSS 2019 guidelines. An expert panel of researchers assessed these proposals and judged whether they should become part of STROCSS 2021 guidelines or not, through a Delphi consensus exercise. Results 42 people (89%) completed the DELPHI survey and hence participated in the development of STROCSS 2021 guidelines. All items received a score between 7 and 9 by greater than 70% of the participants, indicating a high level of agreement among the DELPHI group members with the proposed changes to all the items. Conclusion We present updated STROCSS 2021 guidelines to ensure ongoing good reporting quality among observational studies in surgery., Highlights • In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, STROCSS 2019 guidelines were updated through a DELPHI consensus exercise. • 42 people participated in the development of STROCSS 2021 guidelines and there was a high level of agreement among the DELPHI group members with the proposed changes to all the items. • Updated STROCSS 2021 guideline is presented.

BACKGROUND Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico-legal ramifications. Further, well-documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met. METHOD We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors and surgical trainees in a tertiary teaching hospital over a month period both in 2014 and 2015. Individual operative notes were assessed for quality based on parameters described by the Royal College of Surgeons of England guidelines. RESULTS Based on the Royal College of Surgeons of England guidelines, a significant proportion of analysed surgical operative notes were incomplete, with information pertaining to the time of surgery, name of anaesthetist and deep vein thrombosis prophylaxis in particular being recorded less than 50% of the time (22.42, 36.36 and 43.03%, respectively).Overall, 80% compliance was achieved in 14/20 standards and 100% compliance was attained in only one standard. CONCLUSIONS The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.

Background Aeromonas hydrophila (AH) is a rare gram-negative anaerobic bacterium that is usually found in freshwater and contaminated soils. AH may behave in a pathogenic manner and a majority of the literature reports clinical manifestations of significant infection – typically in the immunocompromised. However, recent genomic typing of the bacterium has led to the discovery of a less virulent but antibiotic resistant strain which may be responsible for colonisation rather than infection. Case report We present an example of successful graft uptake in the presence of heavy graft site growth of Aeromonas hydrophila . Discussion Contemporary literature is yet to make the distinction between colonisation and infection of this bacterium, with clinicians relying solely on the presence of infective stigmata and serum analysis. However, this is a critically important distinction when ascertaining the likelihood of success of wound healing.

Multiparametric magnetic resonance imaging (mpMRI) has added to the armamentarium for the diagnosis and surveillance for organ-confined prostate cancer. Atypical small acinar proliferation and high-grade prostatic intraepithelial neoplasia (HGPIN) are premalignant prostatic lesions. The management of such lesions remains contentious, and the addition of mpMRI introduces further uncertainty, given its ability to pick up indolent lesions and its use in targeted biopsy. We aimed to perform a comprehensive review of current evidence regarding atypical small acinar proliferation, high-grade prostatic intraepithelial neoplasia, and mpMRI to ascertain a consensus for a current management algorithm.

Laparoscopic lens fogging (LLF) hampers vision and impedes operative efficiency. Attempts to reduce LLF have led to the development of various anti-fogging fluids and warming devices. Limited literature exists directly comparing these techniques. We constructed a model peritoneum to simulate LLF and to compare the efficacy of various anti-fogging techniques. Intraperitoneal space was simulated using a suction bag suspended within an 8 L container of water. LLF was induced by varying the temperature and humidity within the model peritoneum. Various anti-fogging techniques were assessed including scope warmers, FREDTM, ResoclearTM, chlorhexidine, betadine and immersion in heated saline. These products were trialled with and without the use of a disposable scope warmer. Vision scores were evaluated by the same investigator for all tests and rated according to a predetermined scale. Fogging was assessed for each product or technique 30 times and a mean vision rating was recorded. All products tested imparted some benefit, but FREDTM performed better than all other techniques. Betadine and ResoclearTM performed no better than the use of a scope warmer alone. Immersion in saline prior to insertion resulted in decreased vision ratings. The robotic scope did not result in LLF within the model. In standard laparoscopes, the most superior preventative measure was FREDTM utilised on a pre-warmed scope. Despite improvements in LLF with other products FREDTM was better than all other techniques. The robotic laparoscope performed superiorly regarding LLF compared to standard laparoscope.

Background: Contemporary recommendations regarding the duration of follow-up after radical prostatectomy (RP) are highly heterogeneous. Protocol-based follow-up schemes have been implemented to facilitate the expeditious identification of patients with recurrence. The aim of this study is to assess the reliability and comfort of general practitioners (GPs) in follow-up of RP. Methods: Following institutional ethical approval, we performed a retrospective review in patients undergoing follow-up after RP between January 2004 and December 2010. Patient factors, disease variables, and follow-up prostate specific antigen (PSA) compliance was collected. “Noncompliant” follow-up care was defined as: patients that had not received a PSA for a 14 month period within 5 years of prostatectomy. Patient and disease-based risk factors for noncompliant follow-up were assessed. GPs were also surveyed in their follow-up practice of RP patients, to assess their familiarity in caring for these patients. Results: In total, 65 cases were identified that met the inclusion criteria. At 60 months of follow-up, 66% (43/65) of patients had a compliant follow-up regime. For patients with noncompliant follow-up at 60 months, median time of compliance did not differ significantly when assessing preoperative PSA, Gleason sum, extraprostatic extension, or surgical margin status. Of the GPs surveyed, 68% of GPs felt comfortable in follow-up of RP patients. Some 62% of GPs would expect the PSA to be < 0.1 and 25% of GPs would measure the PSA annually. Conclusion: Our study identified that follow-up by GPs after RP is insufficient. Accordingly, there is a requirement for formal educational programs if primary care is to take a greater role in follow-up of these patients.

Purpose Localised prostate cancer diagnosis and management is increasingly complex due to its heterogeneous progression and prognostic subgroups. Pitfalls in current screening and diagnosis have prompted the search for accurate and invasive molecular and genetic biomarkers for prostate cancer. Such tools may be able to distinguish clinically significant cancers from less aggressive variants to assist with prostate cancer risk stratification and guide decisions and healthcare algorithms. We aimed to provide a comprehensive review of the current prostate cancer biomarkers available and in development. Methods MEDLINE and EMBASE databases searches were conducted to identify articles pertaining to the use of novel biomarkers for prostate cancer. Results A growing number of novel biomarkers are currently under investigation. Such markers include urinary biomarkers, serology-based markers or pathological tissue assessments of molecular and genetic markers. While limited clinical data is present for analysis, early results appear promising. Specifically, a combination of serum and urinary biomarkers (Serum PSA + Urinary PCA3 + Urinary TMPRSS2-ERG fusion) appears to provide superior sensitivity and specificity profiles compared to traditional diagnostic approaches (AUC 0.88). Conclusion The accurate diagnosis and risk stratification of prostate cancer is critical to ensure appropriate intervention. The development of non-invasive biomarkers can add to the information provided by current screening practices and allows for individualised risk stratification of patients. The use of these biomarkers appears to increase the sensitivity and specificity of diagnosis of prostate cancer. Further studies are necessary to define the appropriate use and time points of each biomarker and their effect on the management algorithm of prostate cancer.

Item does not contain fulltext Trainee-led collaboratives offer exciting new perspectives and approaches to urological research. They provide a central network of expertise in methodology, mentoring, and knowledge of research processes that allows the conduct of large multicentre studies that can recruit quickly. This provides the consultant workforce of tomorrow with the skills required to deliver practice-changing clinical studies in urology.

Purpose of review Up to 70% of prostate biopsies are negative in men with suspected prostate cancer. Because of inherent limitations in biopsy strategies, a significant proportion of cancers are missed on initial biopsy. Following negative biopsy, men frequently exhibit persistently elevated prostate-specific antigen - raising concerns for missed diagnosis. We highlight the recent updates in the management of negative prostate biopsy. Recent findings Advances in noninvasive diagnostics are available and assist clinicians in further substratifying risk of prostate cancer. Despite limited data, urinary prostate cancer antigen 3 and transmembrane protease serine 2 appear to have a promising predictive value for patients suspected of prostate cancer. The advent of multiparametricMRI allows the visualization of intermediate and high-grade prostate cancer, particularly in the troublesome anterior prostate. This modality may further provide the potential for magnetic resonance-guided targeted biopsies. Current data suggest that in the presence of suspicious radiological findings, magnetic resonance-guided biopsies have superior sensitivity profiles compared with traditional rebiopsy approaches. In the absence of multiparametricMRI or suspicious findings, traditional saturation biopsies are sufficient. Summary The management of negative biopsies is evolving rapidly with emerging diagnostics to stratify risk of prostate cancer in men with previous negative biopsies. An increasing body of information supports the use of magnetic resonance-guided biopsies.

True metastatic ureteric lesions are exceptionally rare when sourced from any primary tumour. Primary prostatic cancer metastasis to the ureter is understandably even more atypical with very few cases reported in current literature. True intramural ureteric metastatic disease deposited from prostate cancer is an even rarer occurrence. We present a case of a man in his mid-60s with left-sided hydronephrosis in the setting of biochemical recurrence of Gleason 9 prostate cancer. Initially misdiagnosed as obstruction secondary to mass effect from a large trigonal lesion, subsequent investigation revealed solid intramural metastatic deposit of prostate primary tumour in the distal ureter. We detail current hypotheses regarding the subsequent pathophysiology of the disease and its common clinical presentations. Our case highlights that prostatic metastasis should be considered as a differential in coexisting prostate cancer and ureteric obstruction despite its low incidence.

Objective To describe our technique using photoselective vaporization of the bladder (PVB) for the management of hemorrhagic cystitis and initial results of the procedure in 12 patients. Materials and Methods An audit of theater records of a single surgeon was performed to identify patients who had undergone PVB for the management of radiation cystitis. Rigid cystoscopy was performed. Ureteric catheters were placed and active bleeding sites were targeted to optimize vision. Ablation was commenced using the vaporize function. When lasering around delicate structures, the coagulation function was used. Ureteric catheters remained in situ for 24 hours. An 18Fr Foley catheter was placed. When urine output was clear, continuous bladder irrigation was ceased. Both ureteric catheters and the Foley catheter were removed before the 24-hour mark. Results Twelve patients were identified. Eight patients had previously required blood transfusion secondary to bladder hemorrhage. Nine patients were successfully treated and 2 patients saw improvement in hematuria but required a repeat procedure at 3 weeks postoperatively. Four patients underwent hyperbaric oxygenation as consolidative therapy. One patient was unsuccessfully treated and underwent cystectomy. There were no mortalities. No patients sustained bladder perforation or damage to surrounding structures. Conclusion Radiation cystitis can be life threatening and remains a challenge for the urologist with traditional intravesical treatments, such as aluminum or formalin, having variable results. We present an alternate technique using PVB to ablate the bladder mucosa, with good results. Consolidation with hyperbaric oxygen therapy may be considered. Our study is limited by the small sample size, and the presence of bilateral ureteric catheters leaving the bladder free from urine may impact immediate postoperative outcomes. These initial results are promising; however, further prospective evaluation with a larger cohort and pre- and postoperative cystograms would enable better evaluation of this technique as a definitive management option for hemorrhagic cystitis.

Three-dimensional (3D) printing was invented in 1983 but has only just begun to influence medicine and surgery. Conversion of digital images into physical models demonstrates promise to revolutionize multiple domains of surgery. In the field of uro-oncology, researchers and clinicians have recognized the potential of this technology and are working towards making it an integral part of urological practice. We review current literature regarding 3D printing and other 3D technology in the field of urology. A comprehensive assessment of contemporary literature was performed according to a modified PRISMA analysis for the purposes of this narrative review article. Medical databases that were searched included: Web of Science, EMBASE and Cochrane databases. Articles assessed were limited only to English-language peer-reviewed articles published between 1980 and 2017. The search terms used were “3D”, “3-dimensional”, “printing”, “printing technology”, “urology”, “surgery”. Acceptable articles were reviewed and incorporated for their merit and relevance with preference given for articles with high impact, original research and recent advances. Thirty-five publications were included in final analysis and discussion. The area of 3D printing in Urology shows promising results, but further research is required and cost reduction must occur before clinicians fully embrace its use. As costs continue to decline and diversity of materials continues to expand, research and clinical utilization will increase. Recent advances have demonstrated the potential of this technology in the realms of education and surgical optimization. The generation of personalized organs using 3D printing scaffolding remains the ‘holy grail’ of this technology.

Bilateral obstructing ureteric calculi is a rare cause of acute renal failure. Although urolithiasis in later pregnancy is not uncommon, the development of bilateral obstruction secondary to ureteric calculi in the first trimester is rare and poses difficulty to diagnosis and management. Symptoms of diseases and physiological changes associated with pregnancy can obscure diagnosis of urolithiasis and obstructive uropathy. Advances in minimally invasive endourology afford intervention with reduced risk to fetal health. We present the second case of acute renal failure caused by bilateral obstructing ureteric calculi in a pregnant patient and discuss current management algorithms for this group.

The prevalence of benign prostatic hypertrophy (BPH) causing bothersome lower urinary tract symptoms increases with our ageing population. Treatment of BPH traditionally begins with medical therapy and surgical intervention is then considered for those whose symptoms progress despite treatment. Minimally invasive surgical therapies have been developed as an intermediary in the treatment of BPH with the aim of decreasing the invasiveness of interventions. These therapies also aim to reduce morbidity and dysfunction related to invasive surgical procedures. Multiple treatment options exist in this group including mechanical and thermo-ablative strategies. Emerging therapies utilizing differing technologies range from the established to the experimental. We review the current literature related to these minimally invasive therapies and the evidence of their effectiveness in treating BPH. The role of minimally invasive surgical therapies in the treatment of BPH is still yet to be strongly defined. Given the experimental nature of many of the modalities, further study is required prior to their recommendation as alternatives to invasive surgical therapy. More mature evidence is required for the analysis of durability of effect of these therapies to make robust conclusions of their effectiveness.

We describe a simple technique in which current and freely available technology can be utilised by surgeons while operating the Da Vinci Si/Xi Surgical Robotic systems. This technique allows for a parallel intraoperative display within the surgical console of any desired subject material from a standard computer, utilising commercially available cabling. The ability to view 3D reconstructed images, patient radiology and patient results within the console whilst operating, has the potential to increase operative efficiency, reduce error and aid in adequate resection of tissues. The ease with which our technique is achieved, the benefits of its use and the low cost associated with its implementation support our suggestion that all robotic surgeons incorporate this into their regular operative setup.

In penile cancer, the optimal diagnostics and management of metastatic lymph nodes are not clear. Advances in minimally invasive staging, including dynamic sentinel lymph node biopsy, have widened the diagnostic repertoire of the urologist. We aimed to provide an objective update of the recent trends in the management of penile squamous cell carcinoma, and inguinal and pelvic lymph node metastases.We systematically reviewed several medical databases, including the Web of Science® (with MEDLINE®), Embase® and Cochrane databases, according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines. The search terms used were penile cancer, lymph node, sentinel node, minimally invasive, surgery and outcomes, alone and in combination. Articles pertaining to the management of lymph nodes in penile cancer were reviewed, including original research, reviews and clinical guidelines published between 1980 and 2016.Accurate and minimally invasive lymph node staging is of the utmost importance in the surgical management of penile squamous cell carcinoma. In patients with clinically node negative disease, a growing body of evidence supports the use of sentinel lymph node biopsies. Dynamic sentinel lymph node biopsy exposes the patient to minimal risk, and results in superior sensitivity and specificity profiles compared to alternate nodal staging techniques. In the presence of locoregional disease, improvements in inguinal or pelvic lymphadenectomy have reduced morbidity and improved oncologic outcomes. A multimodal approach of chemotherapy and surgery has demonstrated a survival benefit for patients with advanced disease.Recent developments in lymph node management have occurred in penile cancer, such as minimally invasive lymph node diagnosis and intervention strategies. These advances have been met with a degree of controversy in the contemporary literature. Current data suggest that dynamic sentinel lymph node biopsy provides excellent sensitivity and specificity for detecting lymph node metastases. More robust long-term data on multicenter patient cohorts are required to determine the optimal management of lymph nodes in penile cancer.

Radiological imaging remains the cornerstone of follow-up of patients with urolithiasis. Plain abdominal X-ray (XRKUB) of these patients is largely becoming obsolete in favor of noncontrast computed tomography of the abdomen and pelvis (CTKUB), which offers superior sensitivity and specificity. Contentiousness exists, however, related to the radiation doses associated with CT. Calcium oxalate remains the most common stone composition across most populations. These calculi are radiopaque and thus follow-up with XRKUB may be appropriate in some settings, avoiding the higher radiation doses associated with standard protocol CT. With the emergence of low-dose CT, however, and the modest accuracy of XRKUB, the ongoing role for XRKUB in the management of urolithiasis is debatable. In this study, we assessed the proportion of pure calcium urolithiasis visible on XRKUB to assess the utility of XRKUB for follow-up of pure calcium urolithiasis. Hospital laboratory databases were analysed to identify patients who had undergone urological intervention and extraction of urolithiasis composed of pure calcium salts, who had undergone CTKUB and XRKUB during the same episode for diagnosis of the calculus. One hundred five calculi were included and the imaging for each patient analyzed. 79/105 calculi (75%) identified on CT were visible on XRKUB. The median calculus visible on XRKUB was 7.0 mm (interquartile range [IQR] 5.0-10.0 mm), the median calculus not seen was 4.25 mm (IQR 3.5-7.0 mm) as measured on CT (p 0.01). XRKUB accuracy varied according to calculus position within the renal tract. Calculi were most often visible in the renal pelvis and proximal ureter (86%), 50% of mid-ureteral and 72% of distal ureteral calculi were visible (p = 0.01). Until low-dose CT protocols become widely adopted, XRKUB still has a limited role in the management of pure calcium urolithiasis in selected patients. Due to its modest accuracy in many settings, this role is limited mainly to larger proximal urolithiasis.

Introduction Urologists, like any specialists within their field, consistently strive for the highest standards of clinical and research practice. Dissemination of clinical outcomes, basic research and ideas, both locally and internationally, through publications helps achieve this goal. The USANZ, recognising this, moved its official publication from the bi-nationally based ANZ Journal of Surgery (ANZJS) to the BJU International (BJUI) in 2009 [1]. This move consolidated an affiliation which started in 2005, when the BJUI became the journal used for publishing abstracts of the USANZ National Scientific Meeting [2]. The BJU International Australia and New Zealand Supplement was created as a platform for publications from USANZ members and trainees, with the first edition published in 2011 [3]. To date, there have been six editions of this supplement, which almost solely publishes the work of Australian and New Zealand authors, promoting their international exposure.