Organiser: Prof Bhaskar Somani
Co-organisers: Miss Amelia Pietropaolo, Mr Richard Lockyer, Mr Rowland Rees, Mr Ed Chedgy, Dr Adi Bhatnagar, Victoria Jahrreiss, Naill Kelly
Abstract 1
Is ureteroscopy and laser stone fragmentation safe and effective in Octogenarians? A systematic review of current literature
Daksh Bhatnagar, Carlotta Nedbal, Bhaskar K Somani
University Hospital Southampton NHS Foundation Trust, Southampton, England, UK
Background: With the ageing of our patient population, and the increasing incidence of kidney stone disease (KSD) in the elderly, ureteroscopy and laser stone fragmentation (URSL) is becoming more common. In this review of current literature, we aim to assess safety and efficacy of URSL as a primary treatment for KSD in the octogenarians.
Materials and methods: A systematic review of literature according to the PRISMA guidelines was performed, using the relevant search terms. Original articles were screened and included. A systematic review of the studies is provided, with emphasis on outcomes of URS in the octogenarians, defined as greater than 80 years of age.
Results: 12 studies (1239 patients) were included in the analysis. URS performed in the elderly population showed good safety and efficacy, with stone-free rates (SFR) (73-100%) comparable to the general population. URS-specific complication rates (3.7-41%) seem to be slightly higher compared to other age groups but mostly with Clavien < 3 complications, with postoperative events mostly related to anaesthesia and pre-existing medical conditions. The overall complication rate was still low, with a slightly prolonged hospital stay. Predictors for SFR were age, severe comorbidities, and stone burden.
Conclusion: URS for stone treatment in the elderly population is safe and effective, with comparable surgical outcomes to that of the general population. As comorbidities play an important role in the fitness for surgery and overall survival, the benefit and risks of active stone treatment should be carefully balanced.
Abstract 2
Holmium Laser Enucleation of the Prostate. Outcome Comparison Between Patients with Indwelling Catheter, ISC and Catheter-Free
Sadeesh Kodikarage, Yih Chyn Phan, Mohamed Ismail
Portsmouth Hospitals University NHS Trust, Portsmouth, England, UK
Introduction: To compare operative outcome and postoperative complications in 3 groups of patients i.e. patients with long-term catheter (LTC), patients who perform intermittent self-catheterisation (ISC), and patients who are catheter-free underwent holmium laser enucleation of the prostate (HoLEP).
Material and Methods: A retrospective study of 171 patients who underwent HoLEP between January 2020 to January 2022 were analysed. Age, length of stay, prostate volume (PV), resected prostate weight (PW), pre and post operative flowmetry data, postvoid residual (PVR), histological analysis, and complication rates were compared between the 3 groups of patients. Predictive factors for the development of urethral stricture (US) and urinary incontinence (UI) were analysed using Pearson bivariate and multiple linear regression analysis.
Results: The mean age of patients was 72 years old. 88% were performed as day surgery. A total of 60, 78, and 33 patients were catheter-free, performing ISC and had LTC. Mean PS was 118ml (25-360) with a mean Qmax and PVR were 7ml/sec and 638ml respectively. Mean resected PW was 92g (10-322). Postoperative mean Qmax and PVR were 21ml/sec and 65ml respectively. Postoperative US and UI rates were 5.8% and 3.5% respectively. Prostate cancer was detected in 10% of the patients. PV and resected PW were the only 2 factors that predicted the development of postoperative US. There were no significant predicting factors for UI.
Conclusion: HoLEP procedure is a safe surgery with a low postoperative complication rate. PV which likely reflects the length of operating time especially at the early learning curve can predict the development of postoperative US.
Abstract 3
What did we learn about prostate cancer management during COVID-19?
Joel M Bowen, Zephanai Braithwaite, Eleanor van der Zanden, James Hicks, Paul Carter, Debashis Sarkar
St Richard’s Hospital, Chichester, England, UK
Introduction: The rapid rise of the COVID-19 pandemic in 2020 placed huge pressure upon healthcare. Decisions were made regarding reallocation of resources and some conditions were prioritised over others. Given the high prevalence and relatively slow progression of prostate cancer, focus shifted away from investigating and following up this disease. Our aim is to assess the impact of the pandemic upon patient outcomes at our centre.
Patients and Methods: We performed a retrospective study of 150 patients referred for prostate cancer investigation during 2017-2019, whose follow up was delayed by more than a year due to COVID-19. Patient follow up was reviewed with regards to changes in PSA trend, MRI changes and biopsy results.
Results: Of our patients, 100 of 150 (67%) had prostate cancer diagnosed. The median age was 72 (range 51-93). Of these, 72% displayed a rise in PSA, with a median rise of 4.25ng/ml from referral to latest PSA (after COVID). 78% of patients with rising PSA underwent MRI and half of these had repeat MRI. Disease progression was visualised in only 8 (5%) patients, 6 of whom had a subsequent biopsy. One patient was found to have Gleason 6 disease, 3 showed Gleason 7 (2%) and 2 had Gleason 8 (1%) disease.
There was no mortality recorded from this subgroup, with one patient progressing to radical surgery and three to radiotherapy/adjuvant hormones. The only two patients who progressed to non-curative management had high grade (Gleason 8) disease.
Conclusions: Very few patients showed disease progression despite reduced surveillance. Change of outcome was seen in very few high grade cancers and thus we recommend reducing frequency of PSA monitoring for ISUP Group 1-3 patients, with early discharge to primary care. This will reduce a significant burden on urological care. We need a national consensus regarding PSA follow up.
Abstract 4
The Trends And Outcomes of URS Across a Decade; Shift towards Day-care Surgery
Aizaz Khalid, Francessca New, Dan Magrill
University Hospital Sussex NHS Foundation Trust, England, UK
Background: About 1 in 7 people will require a hospital-based intervention for urolithiasis in their lifetime, this incidence is increasing. This translates into a major disease burden on healthcare resources. Ureteroscopy (URS) is a mainstay of management for urolithiasis. Traditionally this has been done as an overnight stay but more recently we are moving towards day case procedures in many surgical interventions. We audited our local URS cases over 3 different periods in the last decade to analyze the trends and outcomes of URS.
Methods: This is a retrospective study. Patient data collected using hospital information management systems from 3 different periods. First, a 12 month period from 2014-2015. Second a 12 month period in 2021. Third, a 9 month period in 2023.
Results: A total of 220 patients were operated on across these 3 periods. Mean age of 57 years(17-84). 147 were males while 73 were females with a male female ratio of 2:1. Only rigid URS was used in 32% of the case in the 1st period. This increased to 37% in the second period but decreased to 21.3% in the third period. Flexible URS only was used in 21%, 55% and 13% respectively in the 3 periods while both the techniques were combined in 2%, 3.3% and 36% respectively. In 2014-2015 only 19% of the patients were discharged on the same day, this number increased to 85% in 2021 and peaked at 95% in 2023. The re-admission rate was 11%, 10% and 10% in the 3 periods respectively. The stone free rate increased from 43% in 2014-2015 to 67% and 60% in 2021 and 2023 respectively. The rate of leaving a stent post op went up from 28% to 33% to 56% across the 3 periods.
Conclusion: Across the 3 periods that were audited, the number of day cases increased from 19% to 95% which represents a very significant change, and it did not increase the re-admission rates. This was also accompanied with an increase in the stone free rate. This demonstrates the non-inferiority of day case procedures to inpatient procedures with the obvious benefit of conservation of healthcare resources
Abstract 5
β-endorphin inhibits the proliferation of and the TNF-α induced pro-inflammatory cytokine release from PC3, LNCaP and benign prostate cell lines in vitro: Support for exercise based strategies in prostate cancer management
Prapussara Sirikhansaeng1, Omar Abdelwahab1, Muhammadbakhoree Yusuh1, Laurie Lau2, Brian R. Birch3, Bashir A. Lwaleed1
1Faculty of Environmental and Life Sciences, University of Southampton, Southampton, England, UK, 2Faculty of Medicine, University of Southampton, Southampton, England, UK, 3University Hospital Southampton NHS Foundation Trust, Department of Urology, Southampton, England, UK
Introduction and Objectives: β-Endorphin, an agonist of µ-opioid receptors, is released from the anterior pituitary into the peripheral circulation in response to a variety of stresses and numerous studies have documented increases in peripheral blood levels of β-endorphin in response to exercise. Furthermore, β-endorphins may have therapeutic value in cancer prevention and general health improvement by inhibiting the inflammatory response of bovine endometrial epithelial and stromal cells via the β-opioid receptor. Moreover, endorphins may inhibit tumours cells and prevent metastatic transformation by decreasing body stress, maintaining an active immune system, and balancing the levels of pro-inflammatory and anti-inflammatory cytokines such as IL-1β, IL-8 and IL-12. The PI3K-Akt pathway is one of the most frequently over-activated intracellular pathways, which has become a vital tumour-related pathway by regulating cell life processes including apoptosis and proliferation. In this study, we explored the effects of β-endorphin on the proliferation of the PC3, LNCap and benign prostate cell lines and TNF-α induced expression of the cytokines IL-1β, IL-6 and IL-8 via intracellular signalling events in the prostate PCa PC3 and LNCaP cell lines.
Materials & Methods: PC3, LNCaP and benign prostate cells were treated with β-endorphin (10-60 pg/ml) for 24, 48, and 72-hour incubation periods and an MTT assay used to explore cytotoxicity. In addition, an ELISA assay was used to assess the release of the pro-inflammatory cytokines IL-6, IL-8 and IL-1β by PC3 and LNCaP cells upon their incubation with TNF-α (10 ng/ml) for 24 hours with or without pre-incubation with β-endorphin. Finally, the associated intracellular signalling events were assessed using a specific Proteome Profiler Human Phospho-Kinase Array Kit.
Results: Interestingly, various concentrations of β-endorphin showed a significant cytotoxic effect on PC3 and LNCaP cells, which was maximal at 30-40 pg/mL concentration but no effect on the benign cell line (Figure 1). Moreover, 24-hour incubation with TNF-α induced significant release of the cytokines IL-1β, IL-6 and IL-8 by PC3 and LNCaP cells, which was significantly inhibited by pre-incubation with 30 pg/mL of β-endorphin (Shown for IL-1β in Figure 2). Furthermore, upon 2 hours of incubation, TNF-α induced significant elevation in the phosphorylation levels of the protein kinases GSK-3α/β (S21/S9), Src (Y419), WNK1 (T60), Akt 1/2/3 (Ser473), p53 (S15), PRAS40 (T246) and WNK1 (T60) (shown for PC3 cells and Akt 1/2/3 in Figure 3).
Figure 1.
Effect of various concentrations of β-endorphin treatments for 24, 48, and 72 hours on the viability of PC3. LNCaP and benign cells Data are expressed as means ± SEM. ns = P > 0.05, * = P < 0.05, ** = P < 0.01, *** = P < 0.001 and **** = P < 0.0001 compared to control cultures.
Figure 2.
The effect of β-endorphin pre-incubation on the release of the cytokine IL-1β, by PC3 and LNCaP cells upon 24-hour treatment with TNF-α. Data are expressed as means ± SEM. ns = P > 0.05 and **** = P < 0.0001 compared to control cultures.
Figure 3.
The levels of the phosphorylated protein kinases in the PC3 cells lysates following β-endorphin 30 pg/mL, TNF-α 10 ng/mL, β-endorphin 30 pg/mL+TNF-α 10 ng/mL treatment. The PC3 cells were activated with TNF-α (10 ng/mL) with or without β-endorphin. Data are expressed as means ± SEM. * = P < 0.05, ** = P < 0.01 and *** = P < .001 compared to TNF-α.
Conclusions:
1. β-endorphin demonstrated a significant effect in preventing TNF-α induced tissue inflammation through suppression of the pro-inflammatory cytokine release by PC3 and LNCaP cells.
2. This was accompanied by modulation of TNF-α intracellular signalling events in PC3 and LNCaP cells with reduction in cell growth seen in both cell lines.
3. The results provide supporting evidence for the role of exercise based strategies (which increase β-endorphin levels) in the management of PCa patients.
Abstract 6
Should patients with PI-RADS 3 lesions on MRI have an immediate biopsy?
Gemma Scrimgeour, Ferys Warren, Kevin Turner, Joshua Phillips
Department of Urology, Royal Bournemouth Hospital, University Hospitals Dorset, England, UK
Introduction: The detection of clinically significant prostate cancer (csPCa), defined as Gleason score ⩾3+4, in biopsies of patients with Prostate Imaging-Reporting and Data System 3 (PI-RADS 3) lesions on magnetic resonance imaging (MRI) is well-documented. It is still unclear whether this group should proceed to immediate biopsy. We sought to analyse outcomes for these patients.
Materials & Methods: A retrospective analysis of all consecutive male patients at a single institution who had had an MRI scan of their pelvis/prostate for raised PSA from the 1st January 2018 was undertaken. Patients whose MRIs showed lesions of PI-RADS 3 (using PI-RADS v2.0) with five years of follow-up data available were identified. Data collection included patient demographics, presenting PSA, PSA density (PSAD), DRE findings, management (including biopsy results if performed) and outcome at five years.
Results: A total of 100 patients were included for analysis. Mean age was 65 years (range 44-81). Mean PSA was 6.9 (range 0.5-25.5), with a mean PSAD of 0.13 (range 0.01-0.43).
Sixty patients (60%) had up-front biopsies (88% TRUS, 12% template). Of the patients who were biopsied, 27 (45%) had histologically confirmed PCa, and over half of these (27% of the total biopsied group) had csPCa with Gleason score ⩾3+4.
Of the 40 that were not biopsied at presentation, 38 had no other features of concern such as suspicious DRE or raised PSAD. Two of these patients subsequently met the criteria for biopsy after a median of 24 months, both of which were benign. One patient with adverse features at presentation (raised PSAD and suspicious DRE) persistently refused a biopsy and was subsequently treated for ISUP Grade Group 2 disease with brachytherapy 18 months later. Another patient had a raised PSAD but normal DRE and commenced active surveillance for Grade Group 1 disease after biopsy 20 months later.
After five years’ follow-up, five patients in the non-biopsy group had died of unrelated causes, one was ⩾80 and three were out of area. The majority remain under community PSA monitoring, although only 69% had a repeat PSA within the last year.
Conclusion: The detection of csPCa in patients with PI-RADS 3 lesions was comparable with other studies. In our experience, in the absence of adverse features, it is safe not to biopsy these patients. Only two patients (5%) were subsequently diagnosed with csPCa, both of whom met the threshold for biopsy at presentation. Concerningly, community PSA monitoring is haphazard, but may be improved with clear recommendations for the frequency/duration of monitoring and re-referral thresholds.
Abstract 7
Life expectancy in patients undergoing renal tract decompression for extramural ureteric obstruction is lower than those managed conservatively. Such patients require thorough counselling regarding their options and palliative care should be strongly considered
Tom Pugh, Amit Mevcha
Urology Department, Royal Bournemouth Hospital (RBH), Bournemouth, England, UK
Introduction: Renal tract decompression is often performed for individuals with extramural malignant ureteric obstruction (MUO), aiming to prolong life or facilitate further treatment. However, anecdotal evidence suggests these individuals have poor outcomes relating to survival, improvement in renal function and rates of further treatment.
Patients: Patients who were referred to the RBH in 2019/20 for MUO were included, regardless of primary malignancy or degree of renal impairment.
Methods: Data were analysed from 37 patients referred. Patients were stratified based on primary malignancy and reason for referral (AKI vs hydronephrosis). 26/37 patients underwent intervention with 11/37 managed conservatively. Survival, renal function, hyperkalaemia and further treatment data were compared in relation to primary malignancy.
Results: Median life expectancy was lower in the intervention group vs control (99 vs 175 days) with worse outcomes in non-urological cancers. Individuals referred with hydronephrosis alone had better outcomes than those with normokalaemic renal failure (hyperkalaemia showed increased survival vs normokalaemia). 50% of patients undergoing intervention did not survive for > 100 days, with only 27% of those in the intervention group proceeding to further treatment.
Conclusions: Our data show that those undergoing intervention for MUO have worse outcomes than those managed conservatively (especially in non-urological primaries), with only a minority receiving further treatment. Renal failure is a predictor of worse outcomes. This demonstrates that MUO is a sign of end stage disease and, given the anecdotal relative positives of a death from progressive renal failure, palliative care rather than intervention should be strongly considered in these patients.
Abstract 8
Outcomes of holmium-laser enucleation of the prostate (HoLEP) are comparable between consultants and registrars at an early stage in their training experience and appear similar regardless of the stage at which the surgeon was trained, suggesting that registrar level training in HoLEP is safe and effective
Tom Pugh1, Phoebe Carter2, Max Johnston2, Tommy Johnston1, James Manners1, James Brewin2
1Urology Department, Royal Bournemouth Hospital, Bournemouth, England, UK, 2Urology Department, Salisbury District Hospital, Sailsbury, England, UK
Introduction: Holmium laser enucleation of the prostate (HoLEP) is rapidly becoming the intervention of choice for BPH and is considered superior to TURP (in terms of flow, durability and reduced complication rates), particularly in larger prostate volumes (>80cc).
Training in HoLEP, unlike TURP, is not yet ubiquitous in Urological training programmes. We sought to demonstrate that those who learn HoLEP at registrar level have similar outcomes to those who learn at consultant level in terms of complication rates, stress incontinence and length of stay (LOS).
Patients and Methods: Consecutive patients undergoing HoLEP by two mentorship trained consultant surgeons and one registrar trainee were compared to a control group of cases performed by an experienced HoLEP surgeon. Specimen weight, LOS, stress incontinence outcomes and complication rate data was collected retrospectively for 30 HoLEP cases by each surgeon. All patients underwent follow up at 3-6 months post-operatively. Data was then analysed vs control cases to assess for any differences in outcomes.
Results: Specimen weight was greater (p < 0.001) in the control group but was similar between learners. There was no difference between rates of stress urinary incontinence (p = 0.22) or complications (p = 0.39) between all groups.
Conclusions: Our data shows comparable outcomes, regardless of the stage at which the surgeon trained in HoLEP, demonstrating learning as a registrar is safe and effective. This, along with the increased use of HoLEP as a technique for bladder outflow obstruction surgery suggests that training in HoLEP should become commonplace at registrar level.
Abstract 9
Assessing the Diagnostic Accuracy of the TWIST Score for Testicular Torsion: Exploring Opportunities for Improvement
Ali Mohamed, Mohamed Ibrahim, Zeina Othman, Samer Jallad, Luke Forster
Wexham Park Hospital, Frimley Health NHS Foundation Trust, Berkshire, England, UK
Objective: The study aimed to validate the Testicular Workup for Ischaemia and Suspected Torsion (TWIST) score as a diagnostic tool for testicular torsion (TT) and assess its correlation with surgical outcomes.
Methods: A retrospective analysis was conducted on acute scrotum cases in a busy hospital emergency department. TWIST scores were calculated retrospectively based on history and examination and compared with surgical outcomes. Exclusion criteria included patients with a history of trauma. Patients were divided into two groups: low-risk group (TWIST score < 3) and high-risk group (TWIST scores ⩾ 3).
Results: Out of 56 patients, only 2 cases (3.6%) had TWIST scores used as a diagnostic aid prior to exploration, and these scores accurately predicted testicular torsion. Among the remaining 54 patients, 19 cases (35.2%) were diagnosed with testicular torsion, while 35 cases (64.8%) had negative explorations, indicating alternative conditions such as torsion of hydatid cyst of Morgagni, epididymitis, orchitis, or a normal-looking testicle.
Retrospective analysis of TWIST scores and data showed a statistically significant correlation between the TWIST score and detection of testicular torsion [Table 1].
Table 1.
analysis of the data.
| Low Risk Group | High Risk Group | ||
|---|---|---|---|
| Testicular Torsion | 2 | 17 | 19 |
| No Testicular Torsion | 20 | 15 | 35 |
| 22 | 32 | 54 |
The Fisher exact test statistic value is 0.0012. The result is significant at p < .05.
Analyzing the data found to be statistically significant of value of 0.0012, where the result is significant at P < 0.05.
Conclusion: Our findings demonstrate a strong correlation between the TWIST score and surgical outcome in diagnosing testicular torsion. The TWIST score can serve as a valuable tool in reducing the rate of unnecessary testicular explorations by aiding in the accurate diagnosis of TT. A large number of specially prospective studies are required to objectively determine the correlation.
Abstract 10
Litigation claims in Urology in the National Health Service (NHS): an analysis of the trends, costs and causes over a 17-year period
Abhinav Tiwari1, Jenni Lane1, Bhaskar K Somani1,2
1Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, England, UK, 2Faculty of Medicine, Southampton General Hospital, University of Southampton, Southampton, England, UK
Introduction: Surgical specialities account for significant litigation claims and costs due to their invasive nature. This study aimed to analyse the litigation trends and the reasons for claims within the specialty of urology, within the National Health Service (NHS), over a 17-year period.
Materials and Methods: Data was requested from NHS Resolutions under the Freedom of Information Act 2000. This included the total number of claims in urology, the number of these that were successful (settled or closed), and the costs in damages paid out, per financial year between 2006-2023. A breakdown of the successful claims by their primary cause was also collected. These were coded into the categories non-operative, intra-operative, post-operative, and ‘other’.
Results: 4124 litigation claims were made between 2006-2023. 60.9% (2511/4124) of these claims were successful. £145 million was paid out in damages. The number of successful claims increased 2.9-fold from the start to end of this period, and the costs in damages paid out increased 10-fold. Regarding primary causes for the successful claims (Figure 1), failure or delay of treatment (20.9%, 525/2511), failure or delay of diagnosis (14.5%, 364/2511), and intra-operative problems (9.1%, 229/2511) accounted for the highest proportion. Overall, non-operative causes for successful claims accounted for 79.4% (1993/2511), intra-operative for 17.6% (441/2511), and post-operative for 0.7% (17/2511).
Figure 1.
The top 8 reasons for successful litigation claims in urology between 2006 and 2023.
Conclusions: The number of successful urological litigation claims and their associated costs is rising. The majority are due to non-operative causes, which may be partially explained by NHS waiting lists alongside the effects of the COVID-19 pandemic.
Abstract 11
Trends of ‘Artificial Intelligence, Machine Learning, Virtual Reality and Radiomics in Urolithiasis’ over the last 30 years (1994–2023) as published in the literature (PubMed): a Comprehensive review
Carlotta Nedbal1,2, Clara Cerrato2, Victoria Jahrreiss2,3, Amelia Pietropaolo2, Andrea Benedetto Galosi1, Daniele Castellani1, Bhaskar Kumar Somani2
1Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Le Marche, Ancona, Italy, 2Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, England, UK, 3Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
Purpose: To analyze the bibliometric publication trend on the application of “Artificial Intelligence (AI) and its subsets in Urolithiasis” in a 30-years period. We analysed the publication trend including clinical, surgical and training applications in endourology.
Materials and Methods: We performed a comprehensive review of the literature from 1994 to 2023 for all published papers on “AI, Machine Learning, Virtual reality and Radiomics” in “Urolithiasis” with papers in all languages included in the final review and divided in: A-Non-surgical, B-Surgical and C-Training papers. Three time periods of publication were labelled as: Period1 (1994-2003), Period2 (2004-2013), Period3 (2014-2023).
Results: Over a 30-year time, 343 papers have been published. Groups A, B and C included 129, 163 and 51 papers respectively, with an overall increase from Period1 to Period2 of 123% (p = 0.009) and to Period3 of 453% (p = 0.003). This increase from Period2 to Period3 for groups A, B and C was 476% (p = 0.019), 616% (0.001) and 185% (p < 0.001) respectively (Fig.1).
Figure 1.
Trend of publications in different fields (non-surgical, surgical and training settings).
Group-A papers included rise in papers on “stone characteristics” (+2100%; p=0.011), “renal function” (p = 0.002), “stone diagnosis” (+192%), “prediction of stone passage” (+400%) and “quality of life” (+1000%). Group-B papers included rise in papers in “URS”(+2650%,p = 0.008), “PCNL” (+600%, p=0.001) and “SWL” (+650%,p=0.018) (fig.2). Analysing Group-B, “Targeting” (+453%, p < 0.001), “Outcomes” (+850%, p=0.013) and “Technological Innovation” (p = 0.0311) had rising trends. Group-C papers included rise in papers in “PCNL” (+300%, p=0.039), followed by a positive trend of “URS” (+188%, p=0.003).
Figure 2.
Trend of publications on training in two different surgical techniques (URS and PCNL) with corresponding linear trend lines.
Conclusion: Publications on artificial intelligence and its subset areas for urolithiasis have increased exponentially over the last 3 decades – and especially over the last decade – in surgical and non-surgical clinical areas as well as in training. While applications related to new technology has fuelled this, PCNL particularly seems to garner most interest. Future AI related growth in the field of endourology and urolithiasis is likely to improve training and patient centered decision making and clinical outcomes.
Abstract 12
Comparison of ureteoroscopy and laser stone fragmentation (URSL) between Holmium:YAG laser with MOSES vs Non- MOSES technology: A prospective single-centre propensity score-matched analysis using similar laser settings
Victoria Jahrreiss1, Francesco Ripa2, Clara Cerrato3, Carlotta Nedbal3, Amelia Pietropaolo3, Bhaskar K Somani3
1Medical University of Vienna, Department of Urology, Vienna, Austria, 2University College London Hospitals, Department of Stones and Endourology, London, UK, 3University Hospital Southampton, Department of Urology, Southampton, UK
Introduction & Objectives: In-vitro studies have shown that the holmium MOSES technology can lead to an increase in efficacy of lithotripsy and a reduction of retropulsion, but clinical evidence comparing it to Non-MOSES technology is still scarce. We compared ureteoroscopy and laser stone fragmentation (URSL) with Holmium:YAG laser with MOSES vs Non-MOSES technologies.
Materials & Methods: Patient data and outcomes were prospectively collected and analyzed regarding patient demographics, stone parameters and clinical outcomes. Patients undergoing URSL with standard high power holmium laser (100W) without MOSES technology (group-1) were compared to 60W holmium laser with MOSES (group-2) using the same clinical laser settings (0.4-1J, 20-40Hz) with dusting and pop-dusting technique. The independent t-test, Mann–Whitney-U test and Chi-squared test were used, with a p-value of < 0.05 as significant. Given the different size of the cohorts, we performed a propensity score 1:1 matched analysis.
Results: A total of 206 patients (1:1 matched) with a male:female ratio of 94:112 and a median age of 56 (range: 39-68) years were analyzed. Group 1 and 2 were matched for ureteric stones (27.7% and 22.3%, p = 0.42), pre-stenting (37% and 35%, p = 0.66), mean number of stones (1.76 ± 1.3) and (1.82 ± 1.4, p=0.73) and ureteral access sheath use (37% and 35%, p=0.77) respectively. While there was no significant statistical difference in clinical outcomes, the stone size was slightly larger in group 2, 14.8mm ±10.8 vs 11.7 mm± 8.0, for a lower operative time 42.7 min± 30.6 vs 48.5 min± 25, lower perioperative complication rates 3.9% vs 4.9% and a higher stone free rate 90.3% vs 87.4%.
Conclusions: While the use of MOSES technology was slightly beneficial for treatment of stones in terms of clinical outcomes, this was not statistically significant. As this debate continues, there is a need for high quality randomized studies to show if there is a true difference in these outcomes.
Table 1.
| Males | 94 | |||
| Females | 112 | |||
| Age (median) | 56 | (39-68) | ||
| HP 100W (n = 103) | Moses 60W (n = 103) | p-value | ||
| Previous endoscopic procedures | 34 (33%) | 27 (26.2%) | 0,29 | |
| Recurrent UTI | 18 (17.5%) | 17 (16.5%) | 0,85 | |
| BMI | 30.3 ± 9.9 | 28.5 ± 6.2 | 0,006 | |
| Pre-operative stent | 39 (37.9%) | 36 (35%) | 0,66 | |
| Stones number | 1.76 ± 1.3 | 1.82 ± 1.4 | 0,73 | |
| Total stone length | 11.7 ± 8.0 | 14.8 ± 10.8 | 0,14 | |
| Stone location | ||||
| VUJ | 4 | 3 | 0,7 | |
| Distal ureter | 10 | 8 | 0,62 | |
| Mid ureter | 2 | 8 | 0,05 | |
| Proximal ureter | 12 | 7 | 0,23 | |
| PUJ | 4 | 2 | 0,41 | |
| Lower pole | 22 | 33 | 0,08 | |
| Mid pole | 12 | 9 | 0,49 | |
| Upper pole | 9 | 12 | 0,49 | |
| Renal pelvis | 28 | 21 | 0,25 | |
| Overall | 103 | 103 | ||
| Operative time | 48.5 ± 25 | 42.7 ± 30.6 | 0,13 | |
| Ureteral access sheath | 38 (36.9%) | 36 (35%) | 0,77 | |
| Post-operative stent | 60 (58.3%) | 64 (62.1%) | 0,57 | |
| Complications | 5 (4.9%) | 4 (3.9%) | 0,73 | |
| Sepsis 2 | Sepsis 3 | |||
| Haematuria 1 | UTI 1 | |||
| Anaesthetic reaction 1 | ||||
| Renal abscess 1 | ||||
| Stone-free | 90 (87.4%) | 93 (90.3%) | 0,51 | |
Abstract 13
SIMply for Surgeons. Facilitating access to surgical simulation training across the south central region
Katie Eyre, Johanna Thomas, Mei Nortley, Lucia Derriman, Ariel Ong and Liz Kostov
Thames Valley Deanery Education Leaders in Training Programme, England, UK
Introduction: In the past decade, operative training time has reduced across all surgical specialities. Surgical simulation is taking an increasingly important role in skill acquisition. We aimed to improve trainee access to and engagement with surgical simulation across the south central region.
Method: A literature review identified the evidence supporting surgical simulation training. A questionnaire to all levels of surgical trainee, trainers and education leaders in Thames Valley assessed current access to simulation training, its benefits and barriers to usage. Directors of medical education, training bodies and industry were consulted to evaluate gaps in provision and potential stake holders in ongoing provision.
Results: 48 responded to the questionnaire. 94% (43/48) found simulation beneficial for skill enhancement and acquisition. The barriers most impacting access to simulation were lack of dedicated time (70%; 34/48) knowledge of available courses (62%; 30/48), and inadequate supervision (46%; 22/48). Free text responses demonstrated the strength of feeling regarding time for operative training and desire to engage with a wider breadth of simulation.
Outcome: To address the barriers to accessing simulation a pan-specialty website was developed, SIMply for Surgeons, which brings together local and national courses in one location, both specialty specific and generic. The website facilitates finding appropriate courses for trainees to enhance their operative training and enable them to plan best use of time and funding. Through enabling access to existing courses this prevents duplication and saves money through effective use of resources. Building a team of interested ‘specialty champions’ will ensure that the website content remains contemporary and able to effectively support trainees in skill acquisition. Presentation of our work to the regional urological community will ensure increased engagement with and use of this invaluable website to support surgical training in south central.
Abstract 14
Management of stress urinary incontinence in female patients with spinal cord injury in the post-mesh era
Elizabeth Brewin, Melissa Davies, Katie Eyre
Department of Urology, Salisbury NHS Foundation Trust, Duke of Cornwall Spinal Treatment Centre, Sailsbury, England, UK
Aim: Stress urinary incontinence (SUI) is common in the female population, including those with spinal cord injury (SCI). Since July 2018 there has been a high vigilance pause on the use of transvaginal mesh. We report the outcomes of non-mesh SUI surgery in female SCI patients in our centre, and compare this to our historical cohort of mid-urethral tape (mesh) surgery.
Methods: A retrospective cohort study design identified SCI patients undergoing colposuspension or autologous fascial sling (AFS) between 2018 and 2023. Inclusion criteria were urodynamically proven stress urinary incontinence and follow up ⩾12 months. The primary outcome measures were success rate of SUI surgery defined by pad use and ICIQ scores within 12 months post operatively. Secondary measures included complication rate, and patient satisfaction. Comparison was made with our historical mesh cohort (2005 – 2015).
Results: 14 patients (mean age; 53years) were identified (11 with upper motor neuron lesions, 3 lower motor neuron lesions); 7 underwent AFS and 7 colposuspension. 38 SCI patients who had mesh-based procedures were available for comparison. The median (IQR) daily pad use pre-operatively in the non-mesh group was 3 (2.25-4.0), and 1 (0.25-1.75) at first review post-operatively (p = 0.004), and ICIQ scores improved from 18 (16-20) to 4 (3-9) (p = 0.002). 5 patients developed complications (1 wound infection, 1 wound haematoma and 3 de novo urinary urgency). As a marker of satisfaction, 73% (8/11) of those responding to the question would recommend this procedure to a friend with the same problem. There was no difference in cure rates between the non-mesh and mesh groups: at 12 months 43% (6/14) reported their incontinence as cured and 36% (5/14) as significantly improved. In comparison to mesh-based procedures where 53% (20/38) were cured and 16% (6/38) significantly improved (p = 0.31).
Conclusion: Colposuspension and AFS are effective in treating SUI in female SCI patients. When compared with mesh-based procedures, colposuspension and AFS represent reliable alternatives in the post-mesh era.
Abstract 15
Does the use of Tamsulosin affect the risk of acute urinary retention following trans-perineal prostate biopsy?
Tomas Austin, Joshuah Hill, Sean Pellow, Lucy Hobson, Sally Deverill, Matt Crockett, Dominic Hodgson
Queen Alexandra Hospital Portsmouth, Portsmouth, England, UK
Introduction: Trans-perineal biopsy for prostate cancer diagnosis is a very common local anaesthetic, outpatient procedure, and focus is increasingly given to the potential complications of this procedure including the development of urinary retention. There is uncertainty as to whether the use of Tamsulosin can reduce this risk.
Patients and Methods: A retrospective audit of 762 biopsies was performed, assessing the post procedure incidence of urinary retention post procedure. Tamsulosin was given routinely to all patients, unless they were already taking it, until June 2023. Our practice changed after we had reviewed outcomes and documented a low incidence of retention within four weeks of biopsy, such that from June 2023 we ceased to prescribe Tamsulosin. We reassessed outcomes to see if this had impacted on retention rates.
Results: A total of 595 procedures were performed before June 2023. 39 (6.6%) patients were excluded from further analysis as Tamsulosin use was contraindicated. 145 (24.4%) patients were already taking Tamsulosin prior to the biopsy and a further 411 (69.1%) were prescribed it at the time of the procedure; Eight of these patients (1.4%) developed acute urinary retention. Those who were already taking Tamsulosin had a retention rate of 1.0% (6 patients) and those who were given Tamsulosin had a retention rate of 0.3% (2 patients). After our change in practice, of 167 men undergoing procedures only one (0.6%) went into retention (5 patients had contraindications).
Conclusion: Tamsulosin does not seem to decrease the risk of retention following local anaesthetic trans-perineal prostate biopsy and routine use of this is not necessary.
Abstract 16
Regional disparities in BOO surgical management in 2023: a pilot study
Edward Armstrong, Richard Menzies-Wilson, Ben Turney
Oxford University Hospitals, Oxford, England, UK
Introduction: Surgical management of bladder outlet obstruction (BOO) is a cornerstone of urological practice. Geographical disparities are well recognised as a cause of health inequality. This pilot study aimed to quantify differences in BOO surgical volume between NHS regions.
Methods: Data on the number of BOO surgical procedures performed in 2023, stratified by region, was obtained using NHS Hospital Episode Statistics. Population data was obtained from the Office of National Statistics mid-2022 population estimates. Data on tamsulosin and finasteride prescribing was obtained from Open Prescribing. Surgical and prescribing volume was calculated per 100,000 males over the age of 50 for each NHS region.
Results: There was considerable disparity in total BOO surgical volume, ranging from 338 procedures/ year/ 100,000 males over the age of 50 (Midlands) to 780 (London). Transurethral resection of prostate (TURP) remained the highest volume procedure across all regions and had the lowest relative regional variability (coefficient of variation 0.22). The greatest variation was seen in laser prostatectomy volume (coefficient of variation 0.8), where Midlands, North West and South West had substantially lower volume than other regions (Figure 1). There did not appear to be any correlation between surgical volume and tamsulosin/ finasteride prescribing rates.
Figure 1.
BOO procedures/ year/ 100,000 males over the age of 50 by region BNI, Bladder neck incision; TURP, Transurethral resection of prostate
Conclusions: These results show considerable disparity in laser prostatectomy volume across NHS regions which may suggest a disparity in access for patients.
Abstract 17
Assessment of telephone clinics effectiveness and convenience compared to face-to-face clinics
Mohammed Dallash, Mohamed Ibrahim, Nisha Pindoria, Mostafa Shendy, Jeetesh Bhardwa, Jas Kalsi
Wexham Park Hospital, Frimley Health NHS Foundation Trust, Berkshire, England, UK
Introduction: Owing to Covid-19 pandemic and how it changed the healthcare landscape; a new approach was implemented to manage the growing patients’ number in outpatient clinics while being wary of spreading infection risk. Hence the introduction of telephone clinics, which has been running since the first lockdown.
Aim: Assessing effectiveness of telephone clinic through completion of online survey for clinicians and non-clinicians to improve efficacy.
Method: Anonymised online survey with 14 questions to clinicians in surgical departments and 11 questions to non-clinical staff. We had 34 and 11 responses respectively.
Results: 44.1% of clinicians disagreed with telephone clinics being more efficient than face-to-face clinics while 35.3% agreed. Additionally, 61.8% of clinicians had no access to adequate facilities to run telephone clinics. Logistically, 47.1% preferred face-to-face clinics. Furthermore, 79.4% favoured running telephone and face-to-face clinics concurrently. Non-clinical staff had stronger views as 81.8% said telephone clinics are less efficient and 72.7% have received negative feedback from patients.
Conclusion: While telephone clinics were safer to conduct and helped minimise the outpatient clinics backlog; it lacks the sometimes-essential physical examination, personal touch and holistic approach of medicine that patients expect.
Abstract 18
Complications associated with Holmium Laser Enucleation of the Prostate (HoLEP) procedures conducted at a single centre by a single surgeon between 2020-2023
Erfan Masiha, Tsz Man Li, Bob Yang, Sunil Kumar
Department of Urology, Royal Berkshire Hospital, Reading, England, UK
Introduction And Objective: Holmium Laser Enucleation of the Prostate (HoLEP) has emerged as the preferred surgical approach for addressing bladder outflow obstruction (BOO) resulting from prostatic enlargement, particularly in cases where the size exceeds 80cc. However, the procedure has a reputation for complexity and a demanding learning curve. This study analyses patient outcomes and complications associated with HoLEP procedures conducted at a single centre by an experienced surgeon between 2020- 2023.
Methods: A retrospective analysis was carried out using our electronic patient record (EPR) system for patients who had undergone HoLEP between December 2020-July 2023. This included review of clinical documentation, imaging, laboratory results and operative notes.
Results: 114 patients were identified. These patients had a mean age of 71y (R = 53-89y), mean body mass Index (BMI) of 29.6 (R = 20-40), mean PSA of 7.7 ng/ml (R = 0.2-31.7ng/ml) and mean prostate volume of 117 ml (R = 24-250ml). Operative details demonstrated: Mean enucleation time of 97 min (R = 20-150 min), mean morcellation time of 30 min (R = 5-120min), mean energy use 229Kj (R = 70-440Kj), mean tissue resection of 64.8g. Of note is that 12(10.4%) patients demonstrated malignancy on histology.
Post-operative recovery and complications: Mean post-operative stay was 1.2 days (0-8 days), with 15% as day case procedures. 10(8.7%) patients went into acute urinary retention having failed day-1 post operative Trial without catheter (TWOC). No patients needed blood transfusions or return to theatre and 1 ICU admission (hyponatremia). 10(8.7%) patients complained of stress incontinence at follow-up. 5(4.3%) patients developed urethral strictures
| Pre-op | Post-op | |
|---|---|---|
| Average Qmax (ml/s) | 6.2 | 16.8 |
| Catheter status | 54(47%) | 4(3.5%) |
Conclusions: Our study underscores HoLEP as a safe and highly effective surgical treatment for BOO. The results in this study, which analysed data from a single centre over a four-year period, reveals favourable patient outcomes, improved Qmax, good catheter free rates and relatively low complication rates. Our data compares favourably to that of Montorsi et al. from EAU (European Association of Urology) 2023 meeting.
Footnotes
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