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Introduction: Current research on prostate cancer is heavily focused on early detection and new treatments. There is a lack of research on the overall morbidity prostate cancer survivors face and the amount of healthcare treatment they receive toward the end of their lives. Identifying these care needs will allow appropriate healthcare modeling, resource allocation and service re-design to ensure higher quality care toward the end of life. The aim of this study is to quantify and analyze the use of healthcare services by patients dying with but not necessarily of prostate cancer. Methods: All patients who died with a diagnosis of prostate cancer during a 2-year period at a single hospital were included. Data on outpatient attendances, elective and emergency admissions and palliative care involvement in the 12 months prior to death were collected. Results: A total of 77 patients were included and of these, 60 (78.0%) had 545 scheduled appointments with 473 (86.8%) attendances. More non-attendances occurred in the last 6 months of life; 56 vs 16, p < 0.001. Nurse led clinics doubled in the last 6 months of life, 117 vs 66. There were 173 admissions from 63 (81.8%) patients resulting in 1816 days inpatient stay. This averaged to 2.7 admissions per patient for 10.5 days per episode. 32 (41.6%) patients were seen by palliative care resulting in 192 visits in total. 78 (40.6%) were inpatient and 114 (59.4%) were community reviews. Conclusions: In the last year of life, prostate cancer patients use a considerable amount of healthcare resources. Understanding this clinical and economical burden is important for healthcare remodeling to provide better quality care that is cost effective.

In nephroureterectomy (NU), a crucial surgical step is excision of the bladder cuff. A urinary catheter is placed postoperatively and a cystogram prior to catheter removal is often performed to rule out a urine leak from the urinary bladder. We investigated the necessity of cystogram after bladder cuff excision prior to removal of the urinary catheter. A systematic review (SR) was also performed to investigate the incidence of urinary leak on cystography after NU bladder cuff excision. The primary outcomes were postoperative clinical complications including sepsis, fistula, voiding issues after catheter removal and/or any radiological abnormality indicating persistent leak from the bladder. A retrospective study was performed in a centre where cystograms are not routinely performed prior to catheter removal in NU patients. Patients were followed up clinically, radiologically and cystoscopically. A SR of 402 patients demonstrated that the incidence of urine leak from the bladder is 0.003% among patients after catheter removal after NU. In total, 67 patients were included and no clinical, radiological or cystographic evidence of a persistent urinary leak was noted at follow-up due to omission of cystogram. Based on this systematic review, it may be possible to safely omit routine cystography prior to removal of urinary catheter after bladder cuff excision in patients undergoing NU.

Objectives: The aim of this article is to summarise core quality improvement (QI) methodologies and concepts to assist urology teams in conducting well-designed improvement projects. Materials and Methods: We provide an introduction to the methodological foundations of QI, including the model for improvement, plan-do-study-act, lean and six sigma and present some useful QI tools such as process modelling and pareto charts with examples of how they might be applied to urological care. We also introduce the concept of measurement for QI and describe how this differs from the more traditional measurement approaches used in research. Results: The key to successful QI work undoubtedly lies in the careful planning and appropriate selection of the available QI tools and methods, alongside pragmatic approaches to measurement that yield enough data to spot meaningful variation in outcomes. Conclusions: To support these core methods, QI leadership and stakeholder engagement will be critical to embedding QI into urological care and ensuring that improvements can be sustained once QI projects come to an end. Level of evidence: Not applicable.

Introduction & Aims: There is a current drive nationally to improve the management of acute ureteric colic. Management targets set by the British Association of Urological Surgeons (BAUS) include a 4-week target for the time from diagnosis-to-definitive management, or to clinic review in patients managed expectantly. The motivation to review our acute stone service stemmed from concerns that we did not have the capacity to consistently offer primary definitive treatment or timely clinic review to patients. We aimed to restructure our service using Plan-Do-Study-Act (PDSA) cycles to achieve the BAUS targets. Method: All patients diagnosed with a ureteric stone between March and September 2017 were reviewed as a baseline. Our strategy for improvement involved implementing an emergency stone clinic (ESC) model. This was developed through collaboration between the key stakeholders and centred on a weekly consultant-led specialist clinic designed to review and make early management decisions for all patients referred with a ureteric stone meeting pre-agreed criteria. Post-intervention data were collected between June 2018 and January 2019. To assess whether we were able to meet these targets during the COVID-19 pandemic, data were also collected between January 2020 and October 2020. Results: Time from CT diagnosis to clinic review reduced from 77 to 9 days. Patients seen within 4 weeks of diagnosis improved from 2.9% to 90.5%. Of those requiring a procedure, the percentage receiving a primary intervention increased to 72.1%. Emergency stent insertion was reduced from 69% to 27.9%. The rate of patient re-presentation to A&E reduced from 3.0 to 1.6 episodes/month. The percentage receiving their definitive procedure within 4 weeks improved from 26.2% to 51.2% in the first post-intervention cycle and remained at 54.5% during the pandemic period. Conclusions: Implementing the ESC model led to substantial improvements in patient care and significant progress towards achieving the BAUS management targets while reducing the burden on our Emergency Department. Level of evidence: Not applicable

Various fields have used gaze behaviour to evaluate task proficiency. This may also apply to surgery for the assessment of technical skill, but has not previously been explored in live surgery. The aim was to assess differences in gaze behaviour between expert and junior surgeons during open inguinal hernia repair. Gaze behaviour of expert and junior surgeons (defined by operative experience) performing the operation was recorded using eye-tracking glasses (SMI Eye Tracking Glasses 2.0, SensoMotoric Instruments, Germany). Primary endpoints were fixation frequency (steady eye gaze rate) and dwell time (fixation and saccades duration) and were analysed for designated areas of interest in the subject’s visual field. Secondary endpoints were maximum pupil size, pupil rate of change (change frequency in pupil size) and pupil entropy (predictability of pupil change). NASA TLX scale measured perceived workload. Recorded metrics were compared between groups for the entire procedure and for comparable procedural segments. Twenty-five cases were recorded, with 13 operations analysed, from 9 surgeons giving 630 min of data, recorded at 30 Hz. Experts demonstrated higher fixation frequency (median[IQR] 1.86 [0.3] vs 0.96 [0.3]; P = 0.006) and dwell time on the operative site during application of mesh (792 [159] vs 469 [109] s; P = 0.028), closure of the external oblique (1.79 [0.2] vs 1.20 [0.6]; P = 0.003) (625 [154] vs 448 [147] s; P = 0.032) and dwelled more on the sterile field during cutting of mesh (716 [173] vs 268 [297] s; P = 0.019). NASA TLX scores indicated experts found the procedure less mentally demanding than juniors (3 [2] vs 12 [5.2]; P = 0.038). No subjects reported problems with wearing of the device, or obstruction of view. Use of portable eye-tracking technology in open surgery is feasible, without impinging surgical performance. Differences in gaze behaviour during open inguinal hernia repair can be seen between expert and junior surgeons and may have uses for assessment of surgical skill.

In contrast to the ingestion of coin batteries, the ingestion of cylindrical batteries is an uncommon medical presentation. Owing to their larger size, cylindrical battery ingestion can lead to serious complications including intestinal haemorrhage, bowel obstruction, bowel perforation, peritonitis and even death. We discuss the case of a 17-year-old girl who presented after swallowing three cylindrical batteries. Her medical history included depression and previous battery ingestion that required surgical removal. During this presentation however, these ingested batteries were removed endoscopically at oesophagogastroduodenoscopy and ileocolonoscopy. The patient was subsequently discharged without complication. This paper discusses the complications and management of cylindrical battery ingestion.

Background The development of quantitative objective tools is critical to the assessment of surgeon skill. Eye tracking is a novel tool, which has been proposed may provide suitable metrics for this task. The aim of this study was to review current evidence for the use of eye tracking in training and assessment. Methods A systematic literature review was conducted in line with PRISMA guidelines. A search of EMBASE, OVID MEDLINE, Maternity and Infant Care, PsycINFO, and Transport databases was conducted, till March 2013. Studies describing the use of eye tracking in the execution, training or assessment of a task, or for skill acquisition were included in the review. Results Initial search results returned 12,051 results. Twenty-four studies were included in the final qualitative synthesis. Sixteen studies were based on eye tracking in assessment and eight studies were on eye tacking in training. These demonstrated feasibility and validity in the use of eye tracking metrics and gaze tracking to differentiate between subjects of varying skill levels. Several training methods using gaze training and pattern recognition were also described. Conclusions Current literature demonstrates the ability of eye tracking to provide reliable quantitative data as an objective assessment tool, with potential applications to surgical training to improve performance. Eye tracking remains a promising area of research with the possibility of future implementation into surgical skill assessment.