1 Testicular prosthesis experience in Glasgow: a retrospective study looking at the changing trends between paediatric and adult populations Musaab Yassin1 , Aza Mohammed3, Gregor Walker2, David Hendry3. 1 Department of Urology, Southern General Hospital 2 Department of Paediatric Surgery, Royal Hospital for Sick Children (Yorkhill) 3 Department of Urology, Gartnavel General Hospital Aim of the Study: To assess the practice of testicular prosthesis insertion related to orchidectomy in one geographical region and to identify the difference in the rates of insertion among different age groups. Methods: Males who underwent orchidectomy between 1989 and 2009 were identified from data collected from Scottish Morbidity Records, ISD Scotland. Patients were classified into six age groups. Prosthesis insertion and the relation to original operation was analysed according to different age groups. Main results: A total of 3366 patients underwent orchidectomy in twenty years. Commonest indications for orchidectomy differed between age groups (UDT in 55% of <12 yrs, trauma/torsion in 52% of 13-15yrs, UDT in 36.7% of 16-20 yrs, and malignancy in the older patients). The total number of patients who had a testicular prosthesis was 532 patients, of which 410 patients (12.2%) having had a prosthesis inserted following orchidectomy. The remaining 122 had a prosthesis inserted without prior orchidectomy. The rate of prosthesis insertion differed among different age groups (0.6 % in < 13 years, 8.1% in 13 – 15 years, 19.7% in 16 – 20 years, 32.3% in 21 – 30 years, 23.5% in 31 – 40 years, 15.8% in 40 + years in the patients who had orchidectomy before). In patients that opted for a prosthesis, 32% of < 16 year old males had the prosthesis inserted at the same time as their orchidectomy operation, compared to 83% of the 16+ males. The odds ratio for having a prosthesis inserted at a later date for the under 16’s was 10.11 (5.08, 20.15, p < 0.0001). Conclusion: There is a discrepancy in the timing of testicular prosthesis insertion in different age groups with younger males being more likely to have a prosthesis inserted at a later date than their orchidectomy. This may be related to patient size and pubertal status but paediatric surgeons should be mindful of the possibility of concurrent prosthesis insertion at the time of initial scrotal exploration. 1 2 RISING INFECTION RATE WITH CONTEMPORARY PROSTATE BIOPSY DY GUO, S LIU, L CHAN and A LALAK Introduction UTI and sepsis are the commonest post-procedural complications for transrectal ultrasound guided needle biopsy of the prostate (TRUSP). We prospectively evaluated the incidence of infective complications and correlated with changes in our biopsy protocol over the past 15 years. Materials and Methods Between1995 to 2009, all TRUSP in Concord hospital (NSW, Australia) were performed or supervised by a single urologist. A complication questionnaire was collected prospectively following each procedure. Missing information was obtained retrospectively by searching medical records. The data were grouped and analysed according to the number of cores and type of prophylactic antibiotic regimens. Results 4629 men underwent TRUSP during the studied period, 217 (4.7%) reported post-procedural fever and 132 (2.9%) had infection requiring hospitalisation. Sextant biopsies were routinely carried out from 1995 to 1997 and were associated with an infection rate of 1.5% (12 of 820). Between 1998 and 2004, eight core biopsies became the standard of practice and the infection rate was 2.8% (62 of 2240). Since 2005, a minimum of twelve cores were routinely taken and an infection rate of 3.7% (58 of 1569) was observed. This was statistically significant (p = 0.002). Between 1995 and 1999, both trimethoprim and quinolones were used for prophylaxis. Infection rate of the period was 2.2% (33 of 1510), trimethoprim was associated with a higher infection rate (3.0% versus 1.4%, p<0.05). Conclusion The overall infection rate was 2.9% in our study. Higher number of cores appeared to increase post-procedural infection. Quinolones were more superior when compared to trimethoprim. 2 3 Active surveillance for prostate cancer Willder JM1, Qayyum T1, Clark RN2, Edwards J1, Underwood MA3 1. Institute of Cancer, College of Medical, Veterinary and Life Sciences, University of Glasgow, McGregor Building, Western Infirmary, Glasgow, G11 6NT, UK. 2. Department of Urology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, UK. 3. Department of Urology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK. Abstract Introduction Active surveillance (AS) patients are suitable for radical treatment if biochemical or pathological progression is demonstrated. Methods Urology consultants in GGCHB were questioned on their management of AS patients. Follow up of AS patients was then examined with regards to the proSTART protocol. Results All responding consultants stated they used PSA and repeat biopsy routinely. 32.3% indicated which protocol they used for repeat biopsy: 50% proSTART, 10% with rising PSA, 10% “as per protocol”, 10% alternative regime. 14.8% of 115 AS patients were diagnosed by TUR (no TRUS). 47.8% had 3 monthly PSA checked in first 2 years and 90.9% had 6 monthly PSA checked thereafter. 28.6% had repeat biopsy at 1 year and 25% at 4 years post diagnosis. Conclusion For AS patients to undergo radical treatment for prostate cancer there must be clear evidence of disease progression. AS follow up is poor, despite clinicians believing they are offering appropriate care. 3 4 Radical Treatment For Bladder Cancer In Tayside: Non-random Comparison of Surgery Versus Radiotherapy Tait C, Sweeney C, Byrne D, Nabi G Department of Urology, Ninewells Hospital & Medical School, Dundee Aim: To assess the outcomes of radical cystectomy versus radiotherapy in patients treated in Tayside over the past ten years. Patients: 125 patients treated with radical cystectomy and 163 with radical radiotherapy between 1998 and 2010 were reviewed retrospectively. Data concerning age, sex, comorbidity, stage and grade, treatment and mortality outcomes was retrieved. Results: The mean age of radiotherapy patients was 72 years, and cystectomy patients 68. Radiotherapy patients had more comorbidity, with average Charlson comorbidity index 5.72 vs 4.73. Deceased cystectomy patients with Charlson score of 5 or less had an average survival of 33 months compared to 17 months in radiotherapy patients. Highest comorbidity patients survived longer when treated with radiotherapy. Kaplan-Meier analysis for follow-up showed no significant differences (Wilcoxon test-p Value 0. 5=605). Conclusions: There are no statistically significant differences in patient survival following radical treatment between radiotherapy and cystectomy. The radical radiotherapy cohort had higher comorbidities 4 5 Is the presence or absence of tumour necrosis a significant predictor of survival in Bladder Cancer? Qayyum T1, McArdle PA2, Hilmy M2, Going JJ3, Orange C4, Seywright M4, Underwood MA2, McMillan DC5, Edwards JE1 1. Institute of Cancer, College of MVLS, University of Glasgow, Western Infirmary, Glasgow 2. Department of Urology, Royal Infirmary, Glasgow 3. University Department of Pathology, Royal Infirmary, Glasgow 4. Department of Pathology, Western Infirmary, Glasgow 5. School of Medicine, College of MVLS, University of Glasgow, Royal Infirmary, Glasgow Introduction Currently when bladder cancer pathology is assessed, the absence or presence of tumour necrosis is not always reported. The aim of this study was to determine whether a quantitative assessment of necrosis would provide additional prognostic information. Study Design We studied the pathological features and cancer specific survival of 47 patients with bladder cancer. A grading system depending on extent of necrosis was compared to the presence or absence of necrosis. Results A simple assessment of presence or absence and quantitative assessment of necrosis was associated with cancer specific survival (p=0.02). On multivariate analysis, using a quantitative assessment of necrosis was retained as a significant independent factor for cancer specific survival (HR 2.93, 95% CI 1.17-7.35, p=0.022) Conclusion A quantitative assessment of tumour necrosis assessment was shown to be an independent predictor of cancer specific survival in bladder cancer. 5 6 Circumcision under local anaesthetic; patient experience, consultant beliefs. Mustafa Hilmy, Ian Dunn Department of Urology, Monklands Hospital, Monkscourt Avenue, Airdrie ML6 0JS Introduction: Circumcision remains a general anaesthetic (GA) procedure in many centres. Local anaesthetic (LA) circumcision has advantages in terms of cost and flexibility. We assessed patient experience of anaesthesia for circumcision, as well as practice and attitudes among consultant urologists. Methods: Adult patients undergoing circumcision were invited to complete a questionnaire before discharge. Subjective scores (scale 1-10) concerning pre-operative anxiety, pain experienced during administration of the anaesthetic, or the procedure itself, were recorded. Patients were asked if they would recommend the same anaesthetic. A separate questionnaire, concerning anaesthesia for circumcision, was sent to all consultant urologists in Scotland. Results: 42 (34 LA, 8GA) patients completed the questionnaire (under five surgeons). Fourteen (42%) in the LA group experienced some discomfort during the anaesthetic (mean score 3.6, range 2-8). Seven of these (and one other patient) also reported pain during the procedure (mean score 3.8, range 2-7). All 42 patients were happy with their choice of anaesthetic and would recommend the same anaesthetic option to a friend. 26/49 consultants completed the questionnaire. Two thirds (65%) do not routinely offer LA circumcision. Reasons for this include a belief that patients want GA, and that LA circumcision is associated with significant patient discomfort. More than half of this group would consider offering more patients LA circumcision if shown evidence of equivalence in patient satisfaction. Conclusion: Despite reservations by consultant urologists, LA circumcision is acceptable to patients. Pre-operative counselling should prepare the patient for minor discomfort during anaesthetic administration. Clean intermittent self catheterization in men with chronic urinary retention due to benign prostate enlargement 6 7 Sarfraz Ahmad, I. El-Mokadem, O. Aboumarzouk, C. Sweeney, A. Robertson, C. Goodman, G. Nabi Department of Urology, Ninewells Hospital and Medical School, Dundee Background and objectives Transurethral resection of prostate is the commonest surgical treatment offered to men with chronic urinary retention, especially in high pressure chronic urinary retention, albeit at no or little long-term outcome reports. The study evaluated clean intermittent self catheterization (CISC) as an alternate option to surgical therapy. Methods Men presenting with chronic urinary retention (including high pressure chronic retention) were recruited into a prospective study. The inclusion criteria were: patient’s choice and ability to carry out CISC. The follow-up protocol carried out in a dedicated nurse led clinic entailed satisfaction with CISC, renal function and/or imaging of upper tract and any complications reported by patients. Results 59 patients were identified according to inclusion criteria. Mean follow up was 4.7 years (0.5-13 years). Based on serum creatinine at presentation, participants were divided into two groups: group A consisted of chronic retention with renal failure (n =11) and group B had men with chronic retention and normal renal profile (n = 48). None of the participants had deterioration in renal function in group B. Only one patient in group A developed worsening of renal function. None of the participants discontinued CISC due to dissatisfaction or complications. Conclusions CISC is well tolerated with low complication rate in men with chronic urinary retention. Renal function are preserved on long-term, however patients with high pressure retention need a close monitoring. 7 8 Diagnostic performance and inter-observer variation of CT in complex renal cystic masses Ismail el-Mokadem, Matthew Budak, Sarfraz Ahmad, Omar Aboumarzouk, Christopher Goodman, Ghulam Nabi Ninewells Hospital, Dundee, NHS Tayside OBJECTIVE: To assess diagnostic accuracy and inter-observer variability of CT in the diagnosis of complex renal cystic masses (Bosniak II and more) MATERIALS AND METHODS: Eighty five cystic renal masses were reported independently by two radiologists (first radiologist observed and reported prior to multidisciplinary meeting and the second during the meeting). The cystic masses were categorized by each reviewer according to the Bosniak classification for complex renal cystic renal masses. Both the individual and the pooled results for both radiologists were analyzed. Inter-observer agreement and discordance in classifying lesions as Bosniak categories II, IIF, III or IV were assessed. RESULTS: Both readers agreed on the Bosniak classification in 74%, or 63 of the 85 lesions (42 for II or IIF, 15 for III and 6 for IV). Assessment of inter-observer variability by kappa analysis yielded scores of 0.58 (95% CI 0.44 to 0.73) for the Bosniak. 8.5% (n=7) were upgraded from II to IIF (n=4) or from IIF to III (n=3). 11% (n=10) were downgraded form IIF to II (n=7) or from III to IIF (n=3) by the second reader. CONCLUSION: In spite of a good inter-observers agreement, there is a lack of precision (low kappa score) in categorisation of complex renal cystic masses especially Bosniak IIF cysts and this may present as a difficulty in making recommendations for surgery versus surveillance. 8 9 Pictorial review of image guide suprapubic catheterisation P Jacob, B P Rai, C Badrakumar, S Borgaonker, A Todd-Raigmore hospital, Inverness Aim To review the effectiveness of imaging guided SPC insertion. Description Suprapubic catheter insertion is a common method of bladder drainage in contemporary urological practice. Although generally considered a safe procedure, the risk of bowel injury is estimated at up to 2.5%, with a mortality of 1.8% 1. Recently published BAUS guidelines have recommended that ultrasound may be helpful to identify bowel loops 2. The objectives of ultrasound guidance for SPC insertion are to assess bladder filling, identify interposed bowel at risk from injury and guide the needle puncture at the optimum site. Aguilera PA et al performed real time USS guided SPC insertions in 17 patients with AUR (acute urinary retention) with no complications 3. Evidence from central venous catheter insertions is that ultrasound guidance not only reduces the complication rate but improves first time success rate and as a result reduces infection rates4.The NPSA guidelines suggest the use of image guidance as one of the measures for avoiding complications related to SPC insertion 5 CT guided SPC insertion is an alternative technique reserved for patients with complex anatomy, possibly due to previous surgery. Conclusion Imaging guided SPC insertion has the potential to reduce the incidence of bowel injury and other SPC related complications. Radiologists play a key role in image guided SPC insertion, particularly in complex cases. It could be performed as a combined procedure with the Urologists, till they are trained adequately to be able to perform the procedure independently. The technique necessitates some training for most operators and will pose training, equipment and logistical issues for medical institutions. Logistics will vary considerably between various centres and the above issues could be addressed on an individual basis. 9 10 Prevalence of papillary renal cell carcinoma (pRCC) in patients with complex cystic renal lesions (Bosniak ≥IIF): 10 years single centre experience. Ismail El-Mokadem, Matthew Budak, Chris Goodman, Ghulam Nabi Department of Urology, Ninewells Hospital, Dundee Background and objectives: Relative hypovacularity of papillary RCC (pRCC) can be mistaken for renal cyst or on contrary pseudo-enhancement of renal cysts can mimic pRCC. We hypothesised that incidence of pRCC is different in patients with radiologically complex cystic renal masses as compared to the reported incidence of 10-15% Patients and methods Retrospective electronic records of 434 patients who were reported as “renal cyst” or “complex renal cyst” or “Bosniak cyst” between January 2000 and December 2010 by the radiology department were retrieved. Simple cysts reports were excluded from further analysis. The records of 128 patients with complex cystic renal masses (Bosniak ≥IIF) were further analysed for further follow up imaging, requirement for surgery and incidence of pRCC in the histopathology. The incidence rate was compared with the overall incidence of pRCC from the same institution and the reported from the literature. Results Thirty three patients (25.7%, 33/128) underwent surgical excision of omplex cystic renal lesions either for Bosniak III or IV (16/53) or for progression of Bosniak IIF (7/75) on follow up imaging during the study period. The final histopathology showed RCC in 26 specimens, benign cysts in 6 and 1 was reported as Transitional cell carcinoma. Of those with renal cell carcinoma, incidence of pRCC was 34.6% (9/26). This was significantly higher than the overall incidence of pRCC reported from the same institution and in the reported literature. Conclusion A higher incidence of pRCC was seen in patients with complex cystic renal masses in this study. Our observation should help in changing the follow up radiological observation of complex renal cysts particularly with relative hypovascularity of the pRCC. 10 11 HER2 overcomes PTEN-loss induced Cellular Senescence to cause Aggressive Prostate Cancer I. Ahmad, R. Patel, J. Edwards, O.J. Sansom, H.Y. Leung The Beatson Institute for Cancer Research, Garscube Estate, Switchback Road, Glasgow, G61 1BD Background: Prostate cancer (CaP) is the commonest cancer amongst adult men in the western world. Given patients are often elderly and are likely to die with, rather than from CaP, it is important to delineate key pathways which confer poor prognosis and predict potential therapy. Methods: We utilised a both human tissue microarrays (TMA) with cores from benign and CaP (n=239) as well as transgenic mice driven by the prostate specific Probasin Cre. Results: In this study we demonstrated the cooperation between PTEN loss and HER2 activation in accelerating prostate carcinogenesis, both in the human and mouse. Neither mutation in isolation lead to changes in survival in human CaP, but on a PTEN null background HER2 or HER3 overexpression resulted in a statistically significant reduction in patient survival. Similarly in the mouse, presence of both mutations synergised to lead to rapidly proliferating tumours with an aggressive phenotype, overcoming the well-documented PTEN loss-induced cell senescence phenotype (PICS). Treatment with a MEK inhibitor appeared to negate the effects of activated HER2, returning the tumours to their PICS phenotype. Conclusion: Taken together, this suggests that stratification of CaP patients for HER2/3 and PTEN status could identify a group of poorly performing patients that may then be responsive to inhibition of activated MAPK signalling pathways, returning these advanced tumours to a senescent state. 11 12 Bladder cancer diagnosis using a novel dual pulse Raman spectroscopy probe and portable system: A feasibility study Sarfraz Ahmad, G. P. Singh, S. Lane, T. Brown, G. Nabi Department of Urology, Ninewells Hospital and Medical School, Dundee Background and objectives Accurate cystoscopic diagnosis of bladder cancer, in particular, post adjuvant intravesical treatment remains a challenge. Raman spectroscopy, with high chemical specificity has potential to provide fingerprint of the tissues. We describe development of a novel probe and its application in the diagnosis of bladder cancer in a feasibility study. Material and methods A prototype clinical Raman instrument including a compact diode laser, spectrograph, CCD detector and a computer mounted on a portable cart suitable for clinical use within an operating room was designed. A novel optical fibre based portable near infrared (785 nm excitation) Raman spectroscopy was used to acquire data from TURBT tissue specimen (freshly resected bladder tumour and normal tissue of size about 2-3 mm).The acquisition time for each spectrum was 5 s. The Raman spectra were correlated with histopathology. Results 20 (10 normal and 10 cancer) fresh urinary fresh bladder specimen (at TURBT) were scanned ex-vivo prior to histopathology analyses. Raman spectra clearly showed the biochemical difference between tumour and normal tissue with significantly high sensitivity and specificity and were distinctive for normal and cancer tissue in all the patients. Conclusions The feasibility study showed successful translation of Raman spectroscopy technology in the diagnosis of bladder cancer. Raman spectra obtained using novel probe are distinctive for between bladder cancer and normal mucosa. 12 13 Retrospective and prospective audit of ileal conduit, continent diversion and orthotopic neobladder at WGH, Edinburgh, to assess surgical and QOL outcomes J Jones, D Clark, LH Stewart, A Alhasso Western General Hospital, Edinburgh Background Ileal conduit remains the most common urinary diversion, but continent diversions and orthotopic neobladder allow patients to remain continent. Here we assess the outcomes of continent diversions at our own institution compared to the published literature and to patients undergoing ileal conduit at our institution. Materials & Methods 34 patients have undergone urinary diversions between 2007 and 2011 at our institution. Patients were followed up with regards to clinical outcomes and complications/reintervention rates. Results 12 ileal conduits, 7 orthotopic neobladders and 15 continent diversions were performed. All patients remain within follow up. Of the ileal conduits, there were no re-interventions or major complications. Of the orthotopic neobladders, one patient is awaiting conversion to ileal conduit, although none have undergone further re-intervention. Of the continent diversions, 1 patient developed pouchitis and 2 patients have required ureteric reimplantation. Conclusions Continent diversions are associated with higher rates of re-intervention when compared to ileal conduits at our institution. Outcomes of continent diversions with regards to surgical outcomes and quality of life are comparable to other published literature. Follow up of Urological cancer patients; the results of a regional survey. R Clark1, K Qureshi1, T Kane2 13 14 1. Department of Urology, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, UK. 2. MCN Manager, West of Scotland Cancer Network Background: Current follow up regimes for urological cancers show significant variation between individual clinicians. Our aim was to establish current reported follow up regimes and compare those to existing guidelines and evidence. Methods: We sent out an online survey to 92 clinicians in the West of Scotland (42 people responded – 45.6%) to determine follow up practices and performed a literature review of the evidence available to guide us. Results: There are significant differences in the follow up regimes for prostate, renal and bladder cancer in our region with varied practices seen across all aspects including frequency of outpatient visits, use of imaging, length of follow up and the use of shared care with GPs and clinical nurse specialists. Conclusion: The evidence base proving benefit of specific follow up regimes is weak with most recommendations based on consensus view rather than randomised studies. Regional guidelines would act as a useful guide for clinicians to help rationalise follow up regimes and potentially optimise use of resources. 14 15 Teenage schistosomiasis - A real public health issue in Scotland! O Blach, B P Rai, S Bramwell , Raigmore Hospital, Inverness Introduction Every year Scottish schools send students to Malawi under the patronage of the Scotland Malawi Partnership. 22.8% of Scotland’s new cases of schistosomiasis are from fresh water exposure at Malawi. Case History A 17-year-old male was referred by general practitioner with frank haematuria. As a part of his school cultural exchange programme he recently travelled to Malawi. The boy along with other students swam at the fresh water lakes in Malawi. Cystoscopy showed diffuse erythematous patches with little white blobs. Subsequent serology was positive for schistosomiasis. The school, infectious diseases department and public health authorities were notified. Discussion The case highlights lack of awareness among schools to risk of schistosomiasis by fresh water lakes exposure in Malawi. Scottish schools should adopt policies forbidding activities involving such exposure. Public and primary health care services should be educated about schistosomiasis risks associated with travel to schistosomiasis endemic countries. 15 16 The management of T1a Renal Cancer A Hartley1, M Hair2, M Aitchison3 1: Department of Urology Ayr Hospital & University of Edinburgh, 2: University of the West of Scotland, 3: Department of Urology Gartnavel General Hospital, Glasgow Background: Historical treatment for T1a renal tumours was radical nephrectomy. Recently, nephron sparing techniques have been developed and seven different management options now exist. This study compares current management of T1a renal tumours in the UK, Europe and the USA, reviews the evidence for each option and proposes two trials to compare treatment options. Methods: Data was obtained from UK and American cancer registries, published literature and a questionnaire sent to all practicing UK Urology Consultants. Two trials were designed using appropriate statistical tests. Results: Radical surgery is more commonly the treatment of choice in America compared to partial nephrectomy or ablative therapy in the UK. Active surveillance is rarely used in America but has become popular in the UK and Europe. Long-term follow-up data for ablative techniques and active surveillance is lacking. Conclusion: Lack of evidence for newer techniques could account for variation in practice. This study proposes two trials that could provide this missing data. 16 17 Activation of the Wnt Signalling Pathway synergises with either PI3K or MAPK activation to lead to Urothelial Cell Carcinomas (UCC) with differing treatment requirements I. Ahmad, H.Y. Leung, O.J. Sansom The Beatson Institute for Cancer Research, Glasgow, Scotland. G611BD Background: Although deregulation of the Wnt signalling pathway has been implicated in urothelial cell carcinoma (UCC), the functional significance is unknown. Methods: We utilised both human tissue microarrays (TMA) with cores from benign urothelium and UCC (n=80) as well as transgenic mice driven by the bladder-specific Uroplakin-Cre. Results: In our TMA we were able to establish a significant correlation between Wnt activation and activation of either the PI3K or MAPK signalling pathways in the UCC samples. These Wnt/PI3K and Wnt/MAPK tumours clustered to mutually exclusive groups. To test its functional importance, we targeted expression of an activated form of β-catenin to the urothelium of transgenic mice using Cre-Lox technology (UroIICRE+β-catenin exon3/+ ). Expression of this activated form of β-catenin led to the formation of localised hyperproliferative lesions by 3 months, which did not progress to malignancy. These lesions were characterised by a marked increase of the Pten tumour suppressor protein. Thus, we next combined the UroIICRE+β-catenin fl/fl exon3/+ activate either PI3K (Pten ) or MAPK (H-Ras mice with transgenic mice engineered to Q61L ) pathways within the murine urothelium. We were able to elicit rapid aggressive metastatic UCC in these models. The UroIICRE+βexon3/+ catenin Pten (demonstrated exon3/+ catenin fl/fl by H-Ras tumours had increased pAKT signalling and were dependent on mTOR regression Q61L with Rapamycin) signalling, whilst the UroIICRE+β- tumours, although phenotypically similar, demonstrated dependency on MAPK signalling (as demonstrated by regression with MEK inhibition, but not Rapamycin). Conclusion: We demonstrate PI3K and MAPK pathway activation synergises with Wnt signalling to drive UCC in vivo leading to tumours with differing molecular and treatment profiles. 17 18 The Urology One Stop Clinic Asim Naseer Qureshi, Ian Mitchell Department of Urology, Victoria Hospital, Kirkcaldy Introduction Our aim of this study was to provide effective service for patients, minimise queues, and provide quicker diagnosis and to bring members of multidisciplinary team to one place. Methods 200 patients were selected in this study randomly to see case mix, diagnosis, suspected cancer, follows up, discharge. Discussion Patients often wait weeks to be seen for straightforward problems. Specialists see more and more patients in even shorter period of times leading to poor quality consultations and potentially clinical error. Conclusion One stop urology clinics are tailored to patients needs. Correspondence is generated in real time and given to GPs electronically. These clinics are maximally effective and are efficient. One stop clinics offer the best chance of minimizing low-value followup visits or “diagnostic churn”. We propose that new referrals should only be ever being seen in clinics where all tools necessary for diagnosis can be provided. 18 19 The Superiority of Transperineal Template Mapping Biopsy of the Prostate Gland over the Transrectal Saturation Approach Sarah Housley, Stuart McCracken, Jose Dominguez-Escrig, Krishna Narahari, Damian Greene, Sunderland Royal Hospital (SRH) INTRODUCTION: Recent interest in focal treatment of prostate cancer has further highlighted the need for accurate detection of prostate cancer and in response SRH introduced transperineal template mapping biopsy (TTMB). In this study we aim to compare transrectal saturation and TTMB in men attending for repeat prostate biopsy. METHODS: The study included 100 consecutive patients who required repeat biopsy based on rising PSA despite previous negative biopsy. The first 50 patients underwent transrectal saturation biopsies and the second 50 patients underwent TTMB RESULTS: Prostate cancer was detected in 46% of the 50 TTMB performed, compared with 22% for transrectal saturation biopsy. Of the TTMB biopsies positive for cancer, 43% (10/23) were unilateral and therefore suitable for focal hemi-cryotherapy. TTMB had a complication rate of 12% compared with a complication rate of 22% for the transrectal saturation biopsy group. CONCLUSIONS: TTMB has a similar morbidity to transrectal saturation technique. Our study demonstrates that cancer detection rate is higher in patients who undergo TTMB. Despite the requirement for general anaesthesia and a potential increased urinary retention rate, novel transperineal mapping schemes allow for more accurate sampling of the entire gland. 19 20 A study of emergency supra-pubic catheter insertion in the West of Scotland: Is more training needed? A Hartley1, R Clark2, M Fraser3 1: Department of Urology, Ayr Hospital 2: Department of Urology, Gartnavel General Hospital, Glasgow 3: Department of Urology, Southern General Hospital, Glasgow Background: The National Patient Saftey Agency (NPSA) commissioned guidelines for the insertion of suprapubic catheters in 2009. These were designed to increase patient safety and reduce the number of adverse events. Methods: All emergency suprapubic catheter insertions performed by Urologisits in the West of Scotland over a six month period were documented and procedure was compared to NPSA guidelines. Results: Twenty-four patients underwent an emergency suprapubic catheter insertion but absolute adherence to NPSA guidelines was only achieved in four cases. One patient underwent a significant complication which may have been avoided if guidelines had been followed. Conclusion: We highlight the need for compliance with current guidelines and have identified areas in which further training could be useful. We propose a workshop for all core surgical trainees on the insertion of these catheters and the associated use of ultrasound. 20 21 Are we selecting active surveillance patients appropriately for prostate cancer? Willder JM1, Qayyum T1, Edwards J1, Underwood MA2 1. Institute of Cancer, College of Medical, Veterinary and Life Sciences, University of Glasgow, McGregor Building, Western Infirmary, Glasgow, G11 6NT, UK. 2. Department of Urology, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK. Abstract Introduction Active surveillance (AS) patients are selected according to strict criteria outlined by the National Institute for Health and Clinical Excellence (NICE). Methods The allocation of patients to AS was objectively examined with regards to NICE guidelines for low risk patients. Results Only 10% (n=11) of 110 patients on AS fulfilled all the selection criteria as outlined by NICE. 83.6% (n=92/110) were pathological stage T1c. Of those who had a TRUS at diagnosis 27.2% (n=25/92) had 10 or more cores taken. 76.4% (n=84/110) were Gleason grade 3+3. 63% (n=58/92) of patients who had a TRUS at diagnosis had cancer in <50% of the total number of biopsy cores. 71.8% (n=79/110) had PSA <10ng/ml. Conclusion This review demonstrates the poor adherence to NICE guidelines in the allocation of patients to active surveillance, thus jeopardising patients’ opportunity for curative treatment. 21 22 Pregabalin for Chronic Prostatitis and Chronic Pelvic Pain Syndrome Omar M Aboumarzouk, Ismail el-Mokadem, Sarfraz Ahmad, Gulam Nabi, Paul Halliday Department of Urology, Ninewells Hospital and Medical School, Dundee Introduction and Objectives: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a condition that is as equally detrimental to the quality of life of patients as angina, diabetes, or Crohn's. Resent evidence suggests that it may have a neuropathic origin and therefore medications such as pregabalin might have a role in the controlling of symptoms. The primary objective is to compare pregabalin to other modalities of pain relief to alleviate patients symptoms of CP/CPPS. The secondary objectives are to assess the safety and effectives of pregabalin to improve various individual symptom aspects of CP/CPPS. Methods: Search methods Various databases will be search for pregabalin treatment of Class III prostatitis: CP/CPPS for study inclusion. Selection criteria Randomised controlled trials comparing pregabalin to a placebo or other types of analgesics for the management of patients with CP/CPPS . Patients with known causes of pain/discomfort with be excluded. Data collection and analysis Only one randomised trial was included. The trial compared pregabalin to a placebo for patients who suffer from CP/CPPS. The results of this study was analysed and discussed. Results: There were a total of 324 patients included. There were 218 patients randomised to receive pregabalin, while 106 patients received a placebo. Pregabalin was not superior to a placebo in improving patient overall symptoms score, assessed by improvement in the NIH-CPSI score (P=0.07). Pregabalin was also as good as a placebo in controlling individual domains of the NIH-CPSI score, such as pain, urinary symptoms, and quality of life (P=0.07, 0.34, and 0.16). Fifty-nine percent of the patients developed side effects, with neurologic symptoms significantly higher in the pregabalin group compared to the placebo group (P=0.01) and more pain in the placebo group (P=0.003). Conclusion: There is no evidence to suggest pregabalin is an effect analgesic for patients with CP/CPPS. However further research is required on neuropathic analgesics for CP/CPPS symptom control. 22 23 Is Urine Cytology a relevant investigation for Urological Malignancies? Said Mishriki, Ross Vint, Bhaskar Somani, Thomas Lam Aberdeen Royal Infirmary Introduction and Objectives: Most current guidelines for asymptomatic haematuria investigation recommend mandatory urine cytology. However evidence for its continued use is weak. ValiThe aim of this study is to gauge the value of urine cytology as routine investigation for haematuria. Material and Methods: 2778 patients from January 1999 to date. Urine cytology was routinely submitted at one stop haematuria clinic. Results: The sensitivity and specificity of urine cytology were 45% and 88% respectively. 2 cytology samples diagnosed cancer where all other investigations did not. The first was a primary carcinoma in-situ of the bladder in which the cystoscopy showed inflammation and should have been biopsied. The second was an upper tract tumour that was not diagnosed until bilateral ureteroscopy was performed. Conclusion: This prospective analysis shows that omitting routine urine cytology is not detrimental in investigating patients with haematuria and is cost effective as official NHS estimate its cost at £92 each. Its use should be limited until after other initial investigations are clear. 23 24 Dipstick Haematuria: Prospective Outcomes of 974 patients SF Mishriki, B Somani, R Vint, T Lam Aberdeen Royal Infirmary Introduction and Objectives: Dipstick haematuria in adults is a common finding with a prevalence of up to 20% contributing to about 6% of urology referrals. This study assesses the incidence of urologic malignancy, need for investigations and the outcome of dipstick haematuria. Methods: 974 patients with dipstick haematuria attended between January 1999 and April 2007. Results: No pathology was identified in 859 (88.2%). Malignancy was found in 47 (4.8%) patients. The rest had benign pathology. No malignancy was identified in patients with recurrent or persistent non-visible haematuria. Conclusion: The study suggests that almost 90% of patients with non-visible haematuria will not have any underlying pathology. Benign and malignant diseases were found in 6.9% and 4.8% of patients respectively. The study also suggests that for patients who have completed investigations and who subsequently develop recurrent or persistent non-visible haematuria, a repeat of the full set of urological investigations is unnecessary. Can symptom score and prostate size predict failure of medical treatment of LUTS/BPH? Prospective 17-year follow-up study J Graham, BK Somani, Lam T, SF Mishriki Aberdeen Royal Infirmary 24 25 Introduction and Objectives: Lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPH) can be treated with lifestyle modification, medical treatment (MT) or surgery. Very few long-term studies report on the predictors for failure of MT. Methods and Materials: 178 patients with LUTS secondary to BPH between 1993 and 1994, were evaluated and prospectively followed up. Treatment decision was based on subjective symptoms, flows and residual volumes. All patients were initially managed medically for their symptoms. Protocol-based assessment was performed using AUA symptom score, bother scoreQoL score and prostate size at baseline. At 17 years, MT failures (defined as requiring TURP) were compared to those on continued MT. Results: Fifty patients (28%) underwent TURP within the 17 year follow-up period, of which over two-thirds (n=36) were within the first 3 years. AUA Bother QoL Long Term Medical Treatment (n=128) Failed Medical Treatment (TURP) (n=50) Comparison Baseline 12 years p value Baseline 12 years p value p value 13+/-7.5 8+/-8.24 0.01 18.5+/-6.4 4+/-4.8 <0.001 0.003 (1-34) (0-34) (5-31) (0-17) 10+/-7.3 6+/-6.7 14+/-7.2 3+/-3.5 <0.001 0.002 (0-31) (0-26) (1-30) (0-12) 5+/-4.2 2+/-4.1 7+/-3.5 1+/-2.9 <0.001 0.088 (0-17) (0-14) (2-14) (0-10) <0.001 <0.001 Conclusion: Patients with worse AUA and bother scores failed MT and needed TURP. For both groups symptom scores were improved at 12 years compared with baseline. In this study prostate size only was not a predictor of failure. 25
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