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ABSTRACT: What's known on the subject? and What does the study add? Transurethral resection of the prostate (TURP) remains the dominant and definitive treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS-BPH), but the widespread use of medical therapies (particularly monotherapies) for rapid symptom improvement has meant that the most common indication for TURP has shifted to moderate-severe medical therapy refractory LUTS to, coupled with abnormal objective parameters, or when complications arise. Patients undergoing TURP as part of contemporary randomised controlled trials are not older but have a larger preoperative prostate volume and reduced major morbidity compared with large cohort studies from successive past eras. Delayed surgery because of prolonged medical monotherapy may explain a higher reported failure to void rate, possibly because of negative impact on detrusor function from unrelieved obstruction. This study examined contemporary TURP for significant changes, specifically regarding prostate size, operative parameters, and outcomes, compared with two preceding decades. Electronic databases PubMed, EMBASE & Cochrane collaboration were searched for English literature on prospective randomized controlled trials, published between 1997 and 2007 using keywords "transurethral resection" and "prostate". Monopolar TURP (M-TURP) cohort data of each study were selectively pooled for analysis, weighting studies according to patient numbers. Where possible, pooled post-operative outcomes data were compared with two large cohort landmark studies of successive preceding decades. A total of 3470 patients from 67 studies were included. Mean patient age (67 years) was unchanged, while mean pre-operative prostate volume of 47.6 g was greater than previously reported. Mean resected prostate tissue (25.8 g) with a resection time of 38.5 minutes suggested improved resection efficiency. A statistically significantly reduced transfusion rate and increased urinary tract infection (UTI) rate were reported. Hospital stay (3.6 days) and initial catheterisation duration (2.5 days) were similar, but post-operative urinary retention rate was slightly higher (6.8%). Contemporary RCTs of M-TURP showed larger prostate volume, and reduced major morbidity, compared with large cohort studies from successive past eras. The higher reported failure to void rate, may possibly reflect worse detrusor function at time of TURP. Delaying surgery by prolonged medical monotherapy may compound this. Trials methodology in this area requires quality improvement and standardisation in future.
BJU International 04/2012; · 2.84 Impact Factor
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ABSTRACT: Adult renal rhabdomyosarcoma is a rare subtype of renal sarcoma. We present a case of a renal mass treated with radical nephrectomy that subsequently was shown to be renal rhabdomyosarcoma. We discuss the clinical presentation, imaging findings, and histology for this case and review the available literature.
Case reports in oncological medicine. 01/2012; 2012:460749.
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ABSTRACT: A 72-year-old man presented with painless frank haematuria. Investigations included intravenous urogram and abdominal/pelvic CT which revealed a marked focal thickening of the wall of the inferior aspect of the left renal pelvis extending into the lower pole calyx and into the pelviureteric junction resulting in left hydronephrosis. Urine cytology demonstrated clusters of malignant keratinised squamous cells and schistosome ova. He underwent left laparoscopic radical nephroureterectomy and histology revealed moderately differentiated keratinising squamous cell carcinoma in the renal pelvis.
Case reports in oncological medicine. 01/2012; 2012:352401.
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ABSTRACT: Bladder lymphomas are rarely primary tumours and more commonly associated with systemic lymphoma, either as nonlocalised bladder lymphoma or as secondary bladder lymphoma. Primary bladder lymphomas (PBL) tend to be low-grade mucosa-associated lymphoid tissue (MALT) type, contrasting with diffuse large cell or follicular centre cell types more commonly seen in secondary bladder lymphoma. Bladder involvement by systemic lymphoma infers poor prognosis and patients often have no localising symptoms (typically a postmortem diagnosis). Other treatments are preferred over surgery for all bladder lymphomas, except where diagnosis is uncertain or for relief of irritative bladder symptoms. We describe a unique case of systemic high-grade B-cell lymphoma with simultaneous cutaneous renal and bladder lesions at presentation.
Case reports in oncological medicine. 01/2012; 2012:480826.
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ABSTRACT: • To explore whether risk-adjusted funnel plots are a useful adjunct to analyse volume-outcome data and to further facilitate our understanding of institutional performance data by combining funnel-plot methodology with an incremental statistical modelling approach.
• Risk-adjusted funnel plots were generated for mortality and re-intervention rates after elective radical cystectomy using administrative data from NHS Hospital Trusts between 2000/01 and 2006/07. Trusts were divided into volume tertiles based on their average annual cystectomy rate. • A funnel plot was produced for each of the following four incremental statistical models: model one (no adjustment), model two (adjusted for patient case mix variables), model three (case mix and 'clustering' of patients) and model four (additional adjustment for institutional structural and process-of-care variables).
• In the final complex model (model four), no Trusts had abnormally high mortality or re-intervention rates. • Comparison of the funnel plots showed the importance of adjusting for certain confounding factors, such as the surgeon, at the institutional level, before they could be labelled as having truly outlying performance.
• Risk-adjusted funnel plots have a useful role to play as a component of a methodological framework for investigating the volume-outcome relationship at the institutional level. They can act as a complementary method of validating data by displaying disaggregated outcomes at provider level and account for unmeasured confounders, so reducing the opportunity for spurious labelling of outliers.
BJU International 09/2011; 108(6):844-50. · 2.84 Impact Factor
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ABSTRACT: •To evaluate the volume-outcome relationship for radical cystectomy in England using outcomes other than mortality.
•Patients undergoing an elective radical cystectomy were extracted from administrative hospital data for financial years 2000/1 to 2006/7. •Institutional and surgeon volume was assessed against postoperative re-intervention, postoperative complications and emergency readmission within 28 days, using a set of models accounting for patient case-mix, the 'clustered' nature of the data and structural and process of care measures.
•In the final model, the odds of re-intervention within 14 and 30 days of operation for medium-volume institutions compared to low-volume institutions were found to be 63% (odds ratio, OR, 1.63; 95% CI 1.15-2.32; P= 0.01) and 52% (OR, 1.52; 95% CI, 1.13-2.04; P= 0.01) higher, respectively. •In the summary of adjusted probabilities, low-volume institutions appeared to have a lower re-intervention rate than both medium- and high-volume institutions. •By contrast, high-volume surgeons were associated with a reduced odds (OR, 0.68; 95% CI, 0.51-0.91; P= 0.01) of early re-intervention (within 14 days) compared to low-volume surgeons. •This surgeon volume-outcome effect became apparent only after adjusting for the influence of the institution and structural and process of care confounders. •There was no statistically significant relationship between volume and complication or readmission rates.
•Radical cystectomy measures of re-intervention rates can be used as outcome measures to discern differences across institutional or surgeon volume providers when the institutional and surgeon volume are co-examined and adjustment for structural and process of care confounders is performed. •The finding of a lower risk of re-intervention in low-volume institutions needs to be explored further.
BJU International 02/2011; 108(8 Pt 2):E258-65. · 2.84 Impact Factor
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ABSTRACT: To investigate the relation between volume and mortality after adjustment for case mix for radical cystectomy in the English healthcare setting using improved statistical methodology, taking into account the institutional and surgeon volume effects and institutional structural and process of care factors.
Retrospective analysis of hospital episode statistics using multilevel modelling.
English hospitals carrying out radical cystectomy in the seven financial years 2000/1 to 2006/7.
Patients with a primary diagnosis of cancer undergoing an inpatient elective cystectomy.
Mortality within 30 days of cystectomy.
Compared with low volume institutions, medium volume ones had a significantly higher odds of in-hospital and total mortality: odds ratio 1.72 (95% confidence interval 1.00 to 2.98, P=0.05) and 1.82 (1.08 to 3.06, P=0.02). This was only seen in the final model, which included adjustment for structural and processes of care factors. The surgeon volume-mortality relation showed weak evidence of reduced odds of in-hospital mortality (by 35%) for the high volume surgeons, although this did not reach statistical significance at the 5% level.
The relation between case volume and mortality after radical cystectomy for bladder cancer became evident only after adjustment for structural and process of care factors, including staffing levels of nurses and junior doctors, in addition to case mix. At least for this relatively uncommon procedure, adjusting for these confounders when examining the volume-outcome relation is critical before considering centralisation of care to a few specialist institutions. Outcomes other than mortality, such as functional morbidity and disease recurrence may ultimately influence towards centralising care.
BMJ (Clinical research ed.). 01/2010; 340:c1128.
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ABSTRACT: In recent years, much attention has been paid to the assessment of the quality of health care. This focus has been driven mainly by a desire to improve health care and decrease inequalities within health care systems. As well as addressing key areas such as structure, process, and outcome, which are normally taken from the provider's viewpoint, it is also necessary to address the patient's perspective. Patient-reported outcomes are an increasingly popular method of assessing the patient's experience within the health care system. Along with well-known patient reported outcomes such as health-related quality of life and current health state, patient satisfaction can provide an ultimate end point to health care quality. It is thus an essential part of quality assessment. The concept of patient satisfaction and its measurement, however, has often been overlooked by researchers. Therefore, current measures of satisfaction may not be adequate to assess quality of health care. This article aims to provide an overview of the concept of patient satisfaction. It also discusses current methods of patient-reported outcome assessment and suggests methodology to create new instruments to measure patient satisfaction.
Surgery 10/2009; 146(3):435-43. · 3.10 Impact Factor
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ABSTRACT: To investigate compliance with Improving Outcomes Guidance (IOG) for radical pelvic surgery in England, and explore the pattern of service provision for radical cystectomy (RC) and radical prostatectomy (RP) before and after the introduction of IOG.
For the period 2000/01-2006/07, all admissions for RC and RP were extracted from Hospital Episode Statistics (HES). At the institutional level, the numbers of RC and RP cases were combined to assess adherence to IOG. The IOG catchment populations for each institution were calculated by linking HES data to census ward population data. The pattern of service provision for RC and RP was independently assessed by assigning institutions into low-, medium- and high-volume groups of roughly equal volumes a priori, based on the ascending order of annual RC or RP rate, respectively. For RC it was also possible to explore the between-institution referral activity for RC by identifying the 'final endoscopic bladder procedure' that occurred immediately before the RC for each patient. This gave an indication of where the diagnosis and decision for RC had been made.
The percentage of institutions achieving the recommended IOG minimal case volume of 50 per year increased significantly between 2000/01 and 2006/07 (36% in odds per year, P < 0.001; odds ratio 1.36, 95% confidence interval 1.24-1.50), although absolute numbers remained relatively low (34% in 2006/07). Only one institution had a catchment population greater than the recommended 1 million. The total number of institutions performing RC decreased significantly over the years (P = 0.03), whereas for RP the decrease was not significant (P = 0.6). The decrease reflected a decline in the number of low-volume institutions, both for RC and RP, although this decline was not more than expected by chance. There had been a significant increase in the percentage of patients referred to another provider for their RC, from 5.5% in 2000/01 to 19.6% in 2006/07 (28% rise in odds per year, P < 0.001: odds ratio 1.28, 95% confidence interval 1.23-1.33).
There was evidence of centralization of radical pelvic urological surgery, although it is only relatively recently that this seems to have taken place with any certainty. The absolute numbers of providers achieving the IOG minimum caseload standard was relatively low. What impact this has had, if any, on the quality of patient care is yet to be fully determined.
BJU International 06/2009; 104(10):1446-51. · 2.84 Impact Factor
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ABSTRACT: It has been acknowledged that standardised training programmes are needed to improve laparoscopic training of urologic trainees. Previous studies have suggested that simulator-based laparoscopic training can improve performance during real laparoscopic procedures.
To determine if there are performance differences for the completion of a simulated laparoscopic suturing task among urology residents based on their postgraduate year of training (PGY).
Using a validated scoring checklist, two independent observers objectively scored the completion of a standardised laparoscopic suturing task in a bench-top laparoscopic box trainer. PGY and previous exposure to laparoscopic surgery and laparoscopic simulated training was obtained from self-administered questionnaires. Data acquisition was undertaken at the European Urological Residents Education Programme (EUREP) 2007, run by the European School of Urology, and included a pan-European cohort of 201 urology residents.
Reliability among those rating the suturing tasks was excellent (Cronbach's α=0.83). Each resident was scored for the suturing task. Residents were categorised into three groups based on their PGY status (junior [n=8]; intermediate [n=37]; senior [n=156]). The Kruskal-Wallis test was used to measure trend across the PGY; the Mann-Whitney U test was used to determine variation among categorised PGY groups.
Laparoscopic suturing skill was significantly different across PGY levels (p=0.032), and between junior residents and both intermediate and senior residents (p=0.008 and p=0.012, respectively). There was no significant difference between intermediate and senior residents (p=0.697). Only 12% of participants rated their existing volume of laparoscopic operative cases as sufficient, while 55% of participants had no regular opportunities, and 32% of participants had not performed laparoscopic procedures as primary surgeon. Most residents (96%) reported the use of laparoscopic simulators to be beneficial in training, although current European training programmes appear to provide <50% of residents with the opportunity to train with them.
A discernable relationship existed between the score obtained for a laparoscopic suturing task and year of resident training. Modular simulator training as part of a formal training programme may help to overcome some of the shortfall in residents' exposure to laparoscopic procedures as primary surgeon.
European urology 11/2008; 56(5):865-72. · 7.67 Impact Factor
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ABSTRACT: To assess systematically the quality of evidence for the volume-outcome relationship in uro-oncology, and thus facilitate the formulating of health policy within this speciality, as 'Implementation of Improving Outcome Guidance' has led to centralization of uro-oncology based on published studies that have supported a 'higher volume-better outcome' relationship, but improved awareness of methodological drawbacks in health service research has questioned the strength of this proposed volume-outcome relationship.
We systematically searched previous relevant reports and extracted all articles from 1980 onwards assessing the volume-outcome relationship for cystectomy, prostatectomy and nephrectomy at the institution and/or surgeon level. Studies were assessed for their methodological quality using a previously validated rating system. Where possible, meta-analytical methods were used to calculate overall differences in outcome measures between low and high volume healthcare providers.
In all, 22 studies were included in the final analysis; 19 of these were published in the last 5 years. Only four studies appropriately explored the effect of both the institution and surgeon volume on outcome measures. Mortality and length of stay were the most frequently measured outcomes. The median total quality scores within each of the operation types were 8.5, 9 and 8 for cystectomy, prostatectomy and nephrectomy, respectively (possible maximum score 18). Random-effects modelling showed a higher risk of mortality in low-volume institutions than in higher-volume institutions for both cystectomy and nephrectomy (odds ratio 1.88, 95% confidence interval 1.54-2.29, and 1.28, 1.10-1.49, respectively).
The methodological quality of volume-outcome research as applied to cystectomy, prostatectomy and nephrectomy is only modest at best. Accepting several limitations, pooled analysis confirms a higher-volume, lower-mortality relationship for cystectomy and nephrectomy. Future research should focus on the development of a quality framework with a validated scoring system for the bench-marking of data to improve validity and facilitate rational policy-making within the speciality of uro-oncology.
BJU International 11/2008; 103(3):341-9. · 2.84 Impact Factor
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ABSTRACT: A 57-year-old man presented with a 4-week history of intermittent, painless frank hematuria. There were no other symptoms. He had no previous urologic history, is a nonsmoker, and works as a manual laborer.
Physical examination, ultrasound of the urinary tract, and intravenous urography were all unremarkable. Urine microscopy confirmed more than 5 red blood cells per high-power field, but no malignant cells were seen on cytologic assessment. Flexible cystoscopy revealed a 3 cm, partially solid, solitary lesion on the right lateral wall of the bladder. The tumor was completely resected under general anesthesia.
Histologically, the tumor was described as a G3 pT1 transitional cell carcinoma of the bladder.
Following the resection of a solitary recurrence 6 weeks after the initial tumor resection, the patient underwent a standard course of intravesical bacillus Calmette-Guérin therapy. Despite this, another tumor was identified 3 months later. Histologically, this tumor was described as a lymphoepithelioma-like carcinoma, of at least grade G3pT1. The patient underwent radical cystoprostatectomy with ileal conduit formation; no adjuvant systemic chemotherapy was given in light of complete tumor resection. The patient is under continuing, close clinical and radiologic observation and remains free of disease recurrence, 36 months postoperatively.
Nature Clinical Practice Urology 04/2007; 4(3):167-71. · 4.07 Impact Factor
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Journal of the Royal Society of Medicine 04/2007; 100(3):122-4. · 1.41 Impact Factor
