Research (Articles)
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The ‘Emergency Stone Clinic’ – improving patient care: A collaborative, hospital-based quality improvement projectIntroduction & 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.
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Improving the Quality of Transurethral Resection of Bladder Tumour (TURBT) Operative Notes Following the European Association of Urology Guidelines: A Completed Audit Loop Study.Background The European Association of Urology (EAU) recommends that the operative steps and documentation necessary for successful and appropriate management of bladder cancer include identifying factors necessary to assign disease risk stratification, clinical stage, adequacy of resection and the presence of complications and immediate intravesical chemotherapy administration. Aim To assess and improve the adequacy of current transurethral resection of bladder tumour (TURBT) documentation at a district general hospital in the UK against the EAU 2022 guidelines. Methods Operative notes over a one-year period were assessed for the inclusion of key steps to achieve a comprehensive TURBT as outlined by EAU guidelines. Outcomes included documentation on the details of the operative findings and intervention as well as the perioperative assessment. A standardised template for TURBT procedures was created and surgical staff received training on its usage. The audit was subsequently repeated after six months to assess for improvements. Results TURBT documentation of 78 cases in the first cycle was compared to 37 cases from the second cycle. Significant improvements in the documentation of tumour size (46% to 89%; p<0.05), tumour description (59% to 89%; p <0.05), depth of resection (36% to 89%; p<0.05), administration of chemotherapy (21% to 46%; p<0.05) and assessment for perforation (22% to 68%; p=0.001) were demonstrated. Improvements in pre-operative and post-operative examination rates under anaesthesia also achieved statistical significance (47% & 14% respectively to 89%; p<0.05). There was an increase in the documentation of completeness of resection but this did not achieve statistical significance (59% to 68%; p=0.42). Conclusion The operative note template led to the improvement in the documentation, improving the risk stratification of bladder cancer in patients undergoing TURBT. The use of procedure-specific operative note templates should be adopted for all commonly performed procedures to improve the completeness of documentation
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Hypothermic lidocaine compared with normothermic lidocaine during cystoscopy as assessment for prostatic urethral lift–UroLift. A prospective single-blinded randomized studyIntroduction: Outpatient cystoscopy is a common procedure performed in urology practice. Rigid cystoscopy, however, even with the use of local anesthetic has been reported to cause mild-to-moderate pain in 76% of men. In our practice, minimally invasive treatment options for several disorders, such as the UroLift System (Teleflex, Pleasanton, CA, USA) or Rezu-m (Boston Scientific, Marlborough, MA, USA) for benign prostatic hyperplasia, have led to increasing numbers of procedures being performed as day surgeries under local anesthetic, but these involve rigid cystoscopes. Finding ways to improve the intraoperative experience of patients could increase the number of suitable patients opting to be treated this way. Lidocaine provides local anesthesia by preventing the transmembrane flow of sodium ions in nerve cells. Before taking effect, however, stimulation of nociceptors during administration can cause notable pain. This effect is reported to have been lessened by the addition of an alkalizing agent, such as sodium bicarbonate, or warming the gel to body temperature. Li et al investigated the use of alkalinized lidocaine gel for use during rigid cystoscopy. Patients who were administered lidocaine gel containing sodium bicarbonate reported substantially reduced visual analog scale (VAS) scores compared with those who received non-alkalinized lidocaine gel (mean 1.3 ± 0.9 versus 5.28 ± 1.99). However, this approach is not well assessed in men undergoing cystoscopy. Warming of lidocaine before injection also reduced intraprocedural pain, but the findings are not consistent, and whether the same effect is seen during intraurethral instillation is less clear. Flexible cystoscopy is generally well tolerated. Some studies suggest that anesthesia is unnecessary, although a meta-analysis of studies involving 411 men found that pain was likely to be reduced using lidocaine gel. Given the better tolerance of flexible cystoscopy, we used this approach to perform a proof-of-concept randomized study to investigate whether cooling of lidocaine gel alters pain levels during administration and cystoscopy procedures compared with room temperature lidocaine.
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Sporadic Renal Angiomyolipoma: Can We Adopt a Uniform Management Protocol?Renal angiomyolipomas (AMLs), formerly known as PEComas (tumors showing perivascular epithelioid cell differentiation) are common benign renal masses composed of a varying ratio of fat, blood vessels, and smooth muscles. They are largely asymptomatic and diagnosed incidentally on imaging. The adipose tissue content is the factor that gives AMLs their characteristic appearance on imaging and makes them easily identifiable. However, the fat-poor or fat-invisible varieties, which are difficult to differentiate radiologically from renal cell carcinomas (RCCs), present a diagnostic challenge. It is thus essential to establish the diagnosis and identify the atypical and hereditary cases as they require more intense surveillance and management due to their potential for malignant transformation. Multiple management options are available, ranging from conservative approach to embolization and to the more radical option of nephrectomy. While the indications for intervention are relatively clear and aimed at a rather small cohort, the protocol for follow-up of the remainder of the cohort forming the majority of cases is not well established. The surveillance and discharge policies therefore vary between institutions and even between individual practitioners. We have reviewed the literature to establish an optimum management pathway focusing on the typical AMLs.