Frequency and predictors of recurrence of bladder tumour on first check cystoscopy - a tertiary care hospital experience

Abstract OBJECTIVE: To determine the frequency and predictors of non-muscle invasive bladder tumour recurrence on first-check cystoscopy after transurethral resection of bladder tumour. METHODS: This cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from April to November 2014, and comprised patients with a suspected newly-diagnosed urothelial cancer. Patients with non-muscle invasive disease with complete resection of all visible lesions along with deep biopsy from the tumour base were included. Patients received standard adjuvant intravesical therapy according to their risk stratification and underwent a white-light check cystoscopy at 3 months to look for tumour recurrence. Association between clinico-pathological variables and recurrence at first cystoscopy was determined. SPSS 20 was used for data analysis. RESULTS: The mean age of 84 patients at presentation was 63.3±12.5 years (range: 36-89 years). There were 75(89%) men and 9(11%) women. On initial transurethral resection, the size of tumour was less than 3cm in 32(38%) participants and equal to or above 3cm in 52(62%). Single tumour was found in 51(61%) subjects and multiple tumours in 33(39%). None of the resected tumours was primary carcinoma in situ and 35(42%) tumours were of high grade. The overall recurrence rate at first cystoscopy was 28(33.3%). Larger tumour, higher grade and tumour multifocality were factors associated with recurrence at check cystoscopy (p\u3c0.05 each). Patients\\u27 age, gender, smoking status and tumour stage did not correlate with early recurrence (p\u3e0.05 each). CONCLUSIONS: The number, size and grade of the tumour strongly correlated with recurrence at check cystoscopy

Renal Cell Carcinoma of pelvic kidney with atypical nodal metastasis: A diagnostic challenge

Ectopic pelvic kidney is a known congenital anomaly; however, the presence of renal cell carcinoma (RCC) in an ectopic kidney is rare with the evidence available in the form of a few case reports only. In this case report, we present a case of metastatic RCC in the pelvic kidney which became a diagnostic challenge because of atypical contrast-enhanced computed tomographic (CT) characteristics and unusual pattern of lymph node involvement including cervical lymph node in the absence of visceral metastasis. Because of its unusual location and uncertain vascular anatomy, ectopic kidney poses a surgical challenge. Owing to the rarity of this condition, optimal surgical approach, metastatic potential, routes of metastasis, and effectiveness of systemic agents in pelvic RCC compared to RCC in a normally located kidney, are largely unknown. Key Words: Renal cell carcinoma, Pelvic kidney, Lymph node metastasis

Attrition in surgical residency programmes: Causes and effects

Objective: To determine the rate and trend of attrition from a surgical residency programme and to identify the reasons for attrition.Methods: A questionnaire-based survey was conducted at a university hospital. Separate questionnaires were designed for residents and programme directors (PDs). The residents who left the training voluntarily from one of the five surgical residency programmes (i.e., general surgery, orthopaedics, neurosurgery, otorhinolaryngology and urology) during the academic years 2005-2011 were identified from a departmental database. The residents who did not respond after three attempts at contact, or those who refused to participate, were excluded.Results: During the last 6years, 106 residents were recruited; 84 (78%) were men, of whom 34.5% left the programme voluntarily. Of 22 women, half (54%) left the programme voluntarily (P=0.07). The overall 6-year attrition rate was 39%. The reasons identified for attrition, in descending order, were personal reasons, attitude of senior residents or faculty, and change of specialty. None of the residents cited an excess workload as a reason for their leaving the programme. About 40% rejoined the same specialty after leaving, while 35% chose a different specialty (80% chose a different surgical subspecialty and 20% chose medicine). There was a significant discrepancy in the perspective of residents and PDs about the reasons for attrition.Conclusion: Attrition among surgical residents, in particular woman residents, is high. Personal reasons and interpersonal relations were the most commonly cited reasons. Programme managers and residents have significantly different perspectives, again an indication of a communication gap

Functional and clinical outcome of ileal (Studer) neo-bladder reconstruction: Single centre experience from Pakistan

Objective: To determine the medium and long-term outcome of orthotopic continent urinary diversion with ileal (Studer) neo-bladder following radical cystectomy. Study Design: Case series. Place and Duration of Study: Department of Surgery, The Aga Khan University Hospital, Karachi, from January 1998 to September 2010. Methodology: Thirty eight patients underwent radical cystectomy for invasive bladder tumor with ileal neo-bladder (Studer type) reconstruction. Peri-operative and late complications, functional outcome of neo-bladder, urinary continence, metabolic and upper urinary tract status and overall survival were evaluated in all patients. Results: A total of 29 patients (23 males and 6 females) with mean age of 59 ± 12 years were included for the final analysis. The mean duration of surgery (both radical cystectomy and urinary diversion) was 520 ± 70 minutes. Perioperative complication rate was 24% (n=7) with surgical site infection in 4 patients, sepsis in 1 patient and 2 had ureteroileal leak. At 6 months follow-up, 22 patients were fully continent while 7 patients had minimal stress / nocturnal incontinence. The continence rate was 93% (n=27) at one year follow-up. The mean capacity of neo-bladder at 6 months was 384 ± 66 mLs. The late complication rate was 17% (n=5). Three patients developed anastomotic stricture requiring transurethral incision of neo bladder neck, one formed stone in neo-bladder and one developed incision hernia. All patients had preserved renal functions on follow-up. The survival rate was 80% (n=23) at a median follow-up of 66.4 ± 36 months. Two patients developed local recurrence and four developed distant metastasis. Conclusion: Studer ileal neo-bladder is a safe and effective option for urinary diversion in select patients with good oncological and functional outcomes comparable to contemporary literature, even in a low volume center

Predictors of lymph node involvement in bladder cancer treated with radical cystectomy

Objective: To identify the clinical variables associated with prevalence of lymph node metastasis in patients with bladder cancer treated by radical cystectomy and lymphadenectomy for primary bladder cancer. Methods: Review of records of Ninety-five patients who underwent radical cystectomy and pelvic lymph node (LN) dissection during the period of 1995-2008 from a prospectively maintained database. Eighteen patients were excluded due to lack of data on the nodal status, leaving 77 evaluable patients. Associations between LN metastasis and age, gender, duration of disease, number of transurethral resection (TUR) prior to cystectomy, pathological grade and tumour stage was analyzed. Data was analyzed using the SPSS software, version 15. Statistical tests applied were independent sample t test or the Mann Whitney U test, the chi-square test and the Fischer exact test. Results: The median age of the patients was 58 years in lymph node negative group and 63 years in lymph node positive group. There were 87% males and 13% females. LN metastasis was detected in 19 (25%) patients. Mean duration of disease in LN negative patients was 537 +/- 997 days compared to 509 +/- 708 days in LN positive patients. Mean number of TUR were same in both the groups, pathological grade was not found significantly different in both groups, where as primary tumour stage was found to be significantly (p \u3c 0.05) higher in LN positive patients. Conclusions: Higher primary tumour stage at radical cystectomy is associated with higher prevalence of lymph node metastasis

Prospective evaluation of outcome of percutaneous nephrolithotomy using the ‘STONE’ nephrolithometry score: a single-centre experience

Abstract OBJECTIVE: To assess the prediction of stone clearance and complications of percutaneous nephrolithotomy (PCNL) using the \u27STONE\u27 nephrolithometry score, assessing stone size, tract length (skin-to-stone distance), degree of obstruction, number of calyces involved and stone essence (density). PATIENTS AND METHODS: This was a prospective study of patients undergoing single-tract PCNL while prone, conducted at a university hospital. All patients had non-contrast-enhanced computed tomography within 3 weeks of the procedure. Only patients with a unilateral procedure and radio-opaque stones were included. The five variables of the STONE nephrolithometry score were calculated before the procedure. The stone-free rates were assessed with a plain abdominal film at 4 weeks and complications were graded using the modified Clavien system. RESULTS: In all, 107 patients were included in the final analysis. Overall, 80% of patients were rendered stone-free. Among the individual variables, a larger stone (P = 0.002) and the involvement of multiple calyces (P = 0.04) were associated with residual stones, while tract length (skin-to-stone distance), stone density and presence of hydronephrosis were not. Patients who were rendered stone-free had a statistically significant lower overall STONE score than those with residual stones, at 7.24 vs. 8.14 (P = 0.02). The score also correlated with operative duration, which was significantly longer with a higher STONE score (P = 0.03). The complication rate was 18% and most complications were Clavien grade 2, with bleeding requiring a blood transfusion (11 patients) being the commonest. There were no deaths within 30 days of surgery, but there was no correlation between the STONE score and complications. CONCLUSION: The STONE nephrolithometry score is a simple and easy to apply system for predicting complexity in stone clearance with PCNL

An assessment of the impact of flow disruptions on mental workload and performance of surgeons during percutaneous nephrolithotomy

Objective: The aim of this study was to assess the impact of intraoperative disruptions on surgeons’ workload and performance during percutaneous nephrolithotomy (PCNL).Materials and methods: A structured and standardized tool was used to identify disruptions and interferences that occurred during 33 PCNL procedures. The surgical steps during PCNL were divided into four phases: ureteric catheter placement (phase I), puncture and tract dilation (phase II), intra-calyceal navigation and stone fragmentation (phase III), and tube placement (phase IV). Surgeons’ workload was evaluated using a validated tool: Surgery Task Load Index (SURG-TLX), and correlated with the mean observed intraoperative disruptions. All operating team members evaluated the teamwork immediately after the procedure. Statistical analysis was performed using SPSS Statistics version 22 (IBM, Armonk, NY).Results: A total of 1,897 disturbances were observed, with an average of 57.48 ± 16.36 disruptions per case. The largest number of disruptions occurred during phase III of PCNL (32.06 ± 14.12). The most common cause of the disruption was people entering or exiting the operating room (OR) (29.1 ± 10.03/case), followed by the ringing of phones or pagers (6.42 ± 2.4). The mean observed intraoperative disruptions were significantly associated with the operating surgeon’s mental workload, and it had a significant impact on all domains of surgeons’ mental workload as measured by SURG-TLX. Compared to other team members, surgeons’ assistants experienced an inferior sense of teamwork (r=-0.433; p=0.012).Conclusion: Significant intraoperative disruptions were observed during PCNL. They were observed to directly correlate with the surgeon\u27s workload and had a detrimental effect on teamwork. Improving OR dynamics by reducing unnecessary disruptions would help establish an efficient and smooth surgical work environment for safe surgical care

Training the resident in percutaneous nephrolithotomy

Objective: From the trainers\u27 perspective percutaneous nephrolithotomy (PCNL) is one of the most challenging endourological procedures. In this review we examine the problems arising when training residents in PCNL, and how to facilitate this process. Methods: The recommendations are derived from discussions and consensus during the First European Urolithiasis Society (EULIS) meeting held in London in September 2011. In addition, we searched Medline for articles identified using the keywords \u27training\u27, \u27percutaneous surgery\u27, \u27renal calculi\u27, \u27PCNL\u27, \u27virtual reality\u27 and \u27simulators\u27. We also assessed the effect of modern technology, including the availability of virtual reality models vs. operating room training, and how international organisations like EULIS and European Urological Association can help. Results: The difficulty of training residents in PCNL is partly due to the complexity of obtaining a safe access to the kidney for lithotripsy. The most common way of obtaining access is guided by imaging only, and usually only fluoroscopic imaging is available. This has the potential for injuring structures from the skin to the renal capsule. Minor vascular injuries are relatively common, although most are self-limiting. Visceral injuries that are particularly important are pleural and less commonly colonic injuries, but they are more complex and often require additional procedures. Conclusions: Teaching the skills is more challenging than performing PCNL. In most urological training programmes it is difficult to incorporate teaching and training skills when performing PCNL. To train an academic stone doctor, proficiency in the safe conduct of PCNL is mandatory