Adverse events following intravesical Bacillus Calmette-Guérin therapy in Mater Dei Hospital, Malta

Introduction: Intravesical administration of Bacillus Calmette-Guerin (BCG), following transurethral resection of bladder tumour, has been shown to reduce recurrence and progression in appropriately selected patients with non-muscle invasive bladder cancer. The aim of the study was to report the local incidence and range of adverse events experienced by patients managed with intravesical BCG. Methods: All patients who received at least one dose of intravesical BCG treatment at Mater Dei Hospital in 2014 were included in the study. A database including demographic, histological and chronological data, together with complication type, degree and treatment required was created. Patient medical files were reviewed and the patients were invited to take part in this audit via a telephone survey. Results: 55 patients satisfied inclusion criteria and were included in the study. 54 patients were documented to have had induction BCG, with maintenance BCG in 32 patients. 22 of these experienced at least 1 adverse event with BCG, whilst 33 had no complications. 1 patient had 3 adverse events, 7 patients had 2 adverse events and 14 patients had 1 complication. Most adverse events were considered to be mild or moderate in severity. Storage bladder symptoms accounted for most of these adverse events. No death as a consequence of intravesical BCG therapy was recorded. Conclusion: Intravesical BCG therapy remains one of the mainstay therapies in the management of bladder cancer. The majority of adverse effects recorded were self-limiting or easily treatable with oral analgesics or antibiotics.peer-reviewe

Outcome of Nephrectomies in Malta since 2000

Aim: To audit the oncological results and perioperative surgical outcome of nephrectomies performed in Malta since year 2000. Method: A retrospective index case list of all nephrectomies carried out by three urological surgeons at St Luke’s and Mater Dei Hospitals from 1st September 2000 to 31st March 2012 was compiled from departmental data. Clinical, radiological and histological data were compiled from the case notes and hospital intranet computerised investigation results. Clinical staging of all patients was revised using the Union Internationale Contre le Cancer TNM staging 2009. All the patients who underwent nephrectomy for clear cell renal cell carcinoma were stratified according to individual predicted prognosis based on the SSIGN score developed by the Mayo clinic. Results: Between September 2000 and March 2012, 319 nephrectomies were carried out at the Urology Unit, of these 288 were carried out for malignancy, 218 of which were clear cell renal cell carcinoma (RCC). 112 complications were recorded for the whole cohort; two patients died from perioperative complications. 80 patients passed away, 51 of these as a direct consequence of their renal cell cancer. Median duration of follow up was 42.7 months. A Cox model reveals that a SSIGN score greater than 6 significantly worsens survival rate for RCC (p<<0.001). Conclusion: Morbidity following surgery, mortality rates, and oncological results in our single centre study are acceptable when compared to larger series.peer-reviewe

The menstruating bladder, an unusual cause of haematuria

A 39 year old lady presented with flank pain and haematuria. Radiological investigations showed unilateral hydronephrosis and a serum creatinine of 102?mol/l. At cystoscopy, a soft tissue mass was found in the region of the left ureteric orifice and was causing obstruction of the ureter. A resection biopsy of this lesion was taken. A CT scan and DTPA renogram showed a non-functioning left kidney secondary to chronic obstruction by a soft tissue mass at the left vesico-ureteric junction. Histological analysis of the endoscopic resection specimen showed that the mass contained tubal-type epithelium compatible with a diagnosis of endosalpingiosis (a rare variant of Mullerianosis of the urinary tract). In view of persistent symptoms, it was decided to proceed to surgery. A hysterectomy, bilateral salpingo-oophorectomy and partial cystectomy were performed. The patient has recovered well and is currently asymptomatic. Formal histology of the resection specimen showed the presence of endometriosis.peer-reviewe

Leiomyosarcoma of the distal ureter : a case report

Leiomyosarcoma of the genitourinary tract is a rare malignancy generally having a poor prognosis, with scarce literature having been published. This case report outlines the clinical progression of a 43year old that presented with macroscopic haematuria and was subsequently diagnosed with leiomyosarcoma of the distal ureter.peer-reviewe

Local survival outcomes in metastatic renal cell carcinoma

A quarter of patients who develop renal cell carcinoma will have metastatic disease at presentation. The role of cytoreductive surgery in these patients is a topic of debate. The aim of this study was to analyse survival outcomes of patients treated in Malta who did and did not receive a nephrectomy. Data was gathered retrospectively from the Malta Cancer Registry and Mortality Data at the Department of Health Information, records of multidisciplinary team meetings held within the urology department at Mater Dei Hospital, hospital imaging and patient records. Data gathered included: patient demographics, date of diagnosis, TNM staging, tumour histology, Fuhrman grade, time to treatment and modality of treatment. Exclusions included: • Localized disease relapsing after surgery • Non-renal cell histological subtypes • Presence of metastasis at diagnosis not certain • Concomitant primary tumours 77 patients diagnosed over 5 years between 04.03.2005 and 13.2.2009 were included. The age at presentation ranged from 30 to 88 years, with a median age of 67 years. 11 were incidental findings and 47 were symptomatic. The most prevalent symptoms were abdominal pain and gross haematuria. Five-year cancer specific survival in patients who received a nephrectomy was significantly better at 65%, compared to patients who did not undergo surgery (32%) P value <0.05, CI 95%. These results where compared favourably with SEER data outcomespeer-reviewe

Retrospective review of the diagnostic pathway of suspected prostate cancer in Mater Dei Hospital

BACKGROUND: A well-established prostate cancer diagnostic pathway is used in Europe [1] to increase early diagnosis of clinically significant prostate cancers. This retrospective review was aimed to assess the efficiency and accuracy of this pathway within the department of urology at Mater Dei Hospital.METHOD: Data collected included demographic data, digital rectal examination (DRE) findings prior to magnetic resonance imaging (MRI) and prostate specific antigen (PSA) values preceding MRI. PSA doubling time and PSA velocity were calculated. The cohort was divided into three groups according to the MRI result - negative, positive or equivocal for prostate cancer. Prostate gland volume, Prostate Imaging-Reporting and Data System (PI-RADS) score, TNM stage and histology results were documented and compared.RESULTS: 41% of the cohort had a DRE suggestive of cancer. The cohort had a mean PSA value of 4.912 ng/ml, mean PSA density of 0.152 ng/ml, mean PSA velocity of 0.306 ng/ml/year and mean PSA doubling time of 64 months. The mode PIRADS count was 2. Most cancers were staged at T3a . The mean prostate size was 61.46 cubic centi-metres. 93.4% of patients with an MRI of the prostate suggestive of cancer had a prostate biopsy. 79.5% provided samples suggestive of cancer. The most common grade of cancer was Gleason 7 disease.CONCLUSION: Allowing for limitations of a retrospective review and a small cohort, this study has shown that using the European pathway for diagnosis of prostate cancer increases diagnosis of significant prostate cancer.peer-reviewe

Retrospective audit for preoperative factors and clinical outcomes in patients undergoing bladder

BACKGROUND: Five percent of urinary tract stones are found in the urinary bladder. Bladder stones are responsible for 8% of urolithiasis related mortalities. We have conducted a study and evaluated the effectiveness, safety and the outcome of transurethral cystolithotripsy using a rigid cystoscope under general anaesthesia.METHODS: A retrospective study conducted at Mater Dei Hospital in Malta, from 2004 until 2020. Information obtained from medical records, information technology hospital system and department theatre list. 201 patients were included who all underwent cystolithotripsy with or without transurethral resection of prostate (TURP) or bladder neck incision (BNI). Approval to conduct the study was obtained after fulfilling all requirements requested by the University Research Ethics Committee of Malta, as well as obtaining approval of the CEO of Mater Dei Hospital in line with applicable hospital protocols.RESULTS: The mean age was 65 years, ranging between 21 and 89. Overall, the procedure was well tolerated and there were no major peri-operative complications. The hospital stay ranged between 1 to 33 days with an average of 3 days. Follow up average was 4.3 years. The maximum period with bladder catheter was 18 days before a successful trial without catheter. The majority of patients remained catheter free in the long term with a minority still requiring conservative measures for the relief of lower urinary tract symptoms.CONCLUSIONS: Transurethral cystolithotripsy using a rigid cystoscope under general anaesthesia is a safe and effective technique for the treatment of different sizes of bladder calculi.peer-reviewe

Assessing referrals to urology outreach in cases of acute urinary retention

INTRODUCTION: Acute Urinary Retention (AUR) is the sudden and often painful inability to pass urine characterised by a palpable or percussible bladder. It constitutes 45% of all lower urinary tract consultations and is encountered in different medical specialties. A local guideline was set up to delineate the management of acute urinary retention (AUR) in July 2018. It describes the clinical features, investigations and treatment required according to the severity of the episode. The aim of this audit is to assess the demographics of patients making use of the Urology Outreach Unit (cases of AUR), and trends in investigations done, treatment chosen and outcomes on such patients.METHOD: All patients older than 16 years of age who presented with AUR between March 2018 and September 2018 were included. Data was obtained from Urology TWOC forms and corroborated with the hospital online system.RESULTS: 89 (37.6%) of the referrals were done from Accident and Emergency Department (A&E), and 86 (36.3%) were referred from Urology firms. Urinalysis and Microscopy was sent in 45.1% of cases. Renal profile (serum) was taken in 70.5% of cases. The most commonly used catheter type used was silicone (89.6%). Catheter size of 16F was used in 83.8% of the cases. The average days spent with the catheter in situ was 11.7 days. The average attempts at TWOC was 1.1 times (max of 3). 83.5% of patients were then advised to continue their medical therapy with appropriate follow up following a successful TWOC. The rest were scheduled for a repeat TWOC (13.1%), fitted with a long-term catheter (1.69%), advised regarding self-intermittent catheterisation (1.27%), or referred for TURP (0.42%).CONCLUSION: This audit shows variable compliance to clinical guidelines. An active role of the clinician in the management and treatment of AUR might improve treatment and reduce the risk of further episodes of AUR.peer-reviewe

Optimal Utilization of Donor Grafts With Extended Criteria: A Single-Center Experience in Over 1000 Liver Transplants

OBJECTIVE: Severely limited organ resources mandate maximum utilization of donor allografts for orthotopic liver transplantation (OLT). This work aimed to identify factors that impact survival outcomes for extended criteria donors (ECD) and developed an ECD scoring system to facilitate graft-recipient matching and optimize utilization of ECDs. METHODS: Retrospective analysis of over 1000 primary adult OLTs at UCLA. Extended criteria (EC) considered included donor age (>55 years), donor hospital stay (>5 days), cold ischemia time (>10 hours), and warm ischemia time (>40 minutes). One point was assigned for each extended criterion. Cox proportional hazard regression model was used for multivariate analysis. RESULTS: Of 1153 allografts considered in the study, 568 organs exhibited no extended criteria (0 score), while 429, 135 and 21 donor allografts exhibited an EC score of 1, 2 and 3, respectively. Overall 1-year patient survival rates were 88%, 82%, 77% and 48% for recipients with EC scores of 0, 1, 2 and 3 respectively (P < 0.001). Adjusting for recipient age and urgency at the time of transplantation, multivariate analysis identified an ascending mortality risk ratio of 1.4 and 1.8 compared to a score of 0 for an EC score of 1, and 2 (P < 0.01) respectively. In contrast, an EC score of 3 was associated with a mortality risk ratio of 4.5 (P < 0.001). Further, advanced recipient age linearly increased the death hazard ratio, while an urgent recipient status increased the risk ratio of death by 50%. CONCLUSIONS: Extended criteria donors can be scored using readily available parameters. Optimizing perioperative variables and matching ECD allografts to appropriately selected recipients are crucial to maintain acceptable outcomes and represent a preferable alternative to both high waiting list mortality and to a potentially futile transplant that utilizes an ECD for a critically ill recipient

Factors predicting kidney delayed graft function among recipients of simultaneous liver‐kidney transplantation: A single‐center experience

BackgroundKidney delayed graft function (kDGF) remains a challenging problem following simultaneous liver and kidney transplantation (SLKT) with a reported incidence up to 40%. Given the scarcity of renal allografts, it is crucial to minimize the development of kDGF among SLKT recipients to improve patient and graft outcomes. We sought to assess the role of preoperative recipient and donor/graft factors on developing kDGF among recipients of SLKT.MethodsA retrospective review of 194 patients who received SLKT in the period from January 2004 to March 2017 in a single center was performed to assess the effect of preoperative factors on the development of kDGF.ResultsKidney delayed graft function was observed in 95 patients (49%). Multivariate analysis revealed that donor history of hypertension, cold static preservation of kidney grafts [versus using hypothermic pulsatile machine perfusion (HPMP)], donor final creatinine, physiologic MELD, and duration of delay of kidney transplantation after liver transplantation were significant independent predictors for kDGF. kDGF is associated with worse graft function and patient and graft survival.ConclusionsKidney delayed graft function has detrimental effects on graft function and graft survival. Understanding the risks and combining careful perioperative patient management, proper recipient selection and donor matching, and graft preservation using HPMP would decrease kDGF among SLKT recipients