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OBJECTIVE: To examine the emotional communication that takes place between patients and health care providers during surveillance cystoscopy for non-muscle invasive bladder cancer (NMIBC). METHODS: Participants were 57 patients with a diagnosis of NMIBC attending for surveillance cystoscopy and 10 health care professionals (HCPs). Cystoscopy procedures were audio-recorded and transcribed verbatim. Two approaches to analysis of transcriptions were undertaken: (1) a template analysis and (2) Verona Coding Definitions of Emotional Sequences. RESULTS: Communication during cystoscopy generally comprised of "social/small talk," "results of the cystoscopy," and "providing instructions to the patient." Emotional talk was present in 41/57 consultations, with 129 emotional cues and concerns expressed by patients. Typically patients used hints to their emotions rather than stating explicit concerns. The majority (86%) of HCPs responses to the patient did not explicitly mention the patient's emotional concern or cue. Urology trainees were less likely than other HCPs to provide space for patients to explore their emotional concerns (t = -1.78, P <.05). CONCLUSION: Emotional communication was expressed by the majority of patients during cystoscopy. While all HCPs responded to patients' emotional communication, there were a number of missed opportunities to "pick-up" on patients' emotional cues and improve communication. Urologists need to be aware of the nuances of patients' emotional communication. Learning to identify and respond appropriately to emotional cues may improve communication with patients.

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PURPOSE: Cuff erosion is one of the dreaded complications of artificial urinary sphincter (AUS) implantation. Patients with a history of pelvic irradiation are at increased risk of erosion. To reduce the risk of erosion we describe a novel technique and report the results in our initial series of patients. MATERIALS AND METHODS: A prospective analysis of patients treated with AUS and rectus fascial wrap was performed. Inclusion criteria were severe urinary incontinence (UI) and previous pelvic radiation therapy (RTX). Primary outcomes were erosion rate, complications and continence rate. Secondary outcomes were patient satisfaction. RESULTS: Twenty-three patients were analysed. The median age was 70 years. Nine (39%) had previous surgery; 6/9 had an Advance sling, 2/9 had a Virtue sling, and 1/9 had an AUS which had eroded. Median pad use was five pads/day IQR, (4-6). Median pad weight was 630 ml, 6 cm of fascia was harvested in every case, but cuff size varied. Complications occurred in 6/23 (26%): two patients with Clavien 1 and four patients with Clavien 3B (urinary retention requiring suprapubic catheter). In all cases, the retention resolved. One patient presented at 3 months post-op with erosion (4.3% erosion rate). Median follow-up was 32 months, IQR (24-37). Excluding the patient with erosion, 17/22 (77.3%) of patients achieved complete continence, while 5/22 (22.7%) achieved social continence. CONCLUSION: The autologous fascial wrap technique is efficient and easy to harvest, with comparable clinical outcomes to other techniques. The medium-term results have been encouraging, but longer-term follow up is needed.

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PURPOSE: One quarter of patients will not respond to initial intra-detrusor Botulinum toxin A (BTX) injections for detrusor overactivity. Alternative treatment options include long-term catheterization, sacral neuromodulation, urinary diversion or bladder augmentation. Some of these procedures are invasive. This review explores modifications to BTX delivery that can improve outcome. METHODS: A search of Medline, Embase and Cochrane Library to December 2017 was performed according to Preferred Reporting Items for Systematic Review and Metaanalysis (PRISMA) guidelines. Search criteria included, dose escalation, increasing injection site number, trigone injection, switching preparation and alternative methods of BTX delivery. RESULTS: Several modifications to BTX delivery may improve response. There is moderate evidence that increasing the dose from 100 U to 200 U results in statistically better symptom control. Trigone-including injections were associated with significantly improved patient-reported symptom scores, as well as superior results in urodynamic outcomes without risking urinary retention and vesico-ureteric reflux. Switching from onabotulinum (OTA) or abobotulinum (ATA) or vice versa may also improve response in over 50% of patients as shown in limited studies. Increasing the number of injection sites is not beneficial. Indeed, decreasing the number of injections to as low as three sites does not result in decreased clinical outcomes. Injection-free delivery is associated with lower efficacy compared to conventional intradetrusor injections. CONCLUSION: Before contemplating alternative treatments, practitioners can try to improve on BTX delivery. Firstly, the dose can be increased to 200 U; the trigone included in the injection sites and switching brands may also be helpful.

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PURPOSE: Placement of an antegrade double-J (JJ) ureteric stent is an important component of pyeloplasty. Correct siting of distal end of the stent in the bladder is essential for ease of removal. To date, no studies have compared methods for confirming stent position. This study aims to address that void in the literature. METHODS: Eligible patients underwent laparoscopic pyeloplasty with antegrade stent placement at our institution from 2007 to 2015 inclusive. Methods to verify distal stent position of rigid cystoscopy, artificial bladder filling or no confirmation were compared. Effectiveness was determined by the proportion of malpositioned stents detected intra-operatively compared to the total found malpositioned, both intra-operatively and during follow-up. RESULTS: A total of 75 patients underwent laparoscopic pyeloplasty. Forty-six (61.3%) patients had distal stent position assessed intra-operatively, comprising 27 by cystoscopy and 19 by artificial bladder filling, while for 29 (38.7%) patients no verification method was used. Cystoscopy, artificial bladder filling and no confirmation detected intra-operatively 2, 1 and 0 malpositioned stents, from malpositioned stent totals of 2, 2 and 1, respectively. CONCLUSION: Malposition of JJ ureteric stent is uncommon, and omitting intra-operative position verification appears reasonable in select cases. Artificial bladder filling can help detect malpositioned JJ stents without repositioning the patient for cystoscopy. However, our results suggest both may be unreliable. If stent malposition is suspected, certainty is desired or extended operative duration is less critical, then the surgeon should proceed with cystoscopy.

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Introduction. The prevalence of obesity is increasing worldwide. Obesity can be determined by body mass index (BMI); however waist circumference (WC) is a better measure of central obesity. This study evaluates the outcome of laparoscopic nephrectomy on patients with an abnormal WC. Methods. A WC of >88 cm for women and >102 cm for men was defined as obese. Data collected included age, gender, American Society of Anaesthesiologists (ASA) score, renal function, anaesthetic duration, surgery duration, blood loss, complications, and duration of hospital stay. Results. 144 patients were assessed; 73 (50.7%) of the patients had abnormal WC for their gender. There was no difference between the groups for conversion to open surgery, number of ports used, blood loss, and complications. Abnormal WC was associated with a longer median anaesthetic duration, 233 min, IQR (215-265) versus 204 min, IQR (190-210), p = 0.0022, and operative duration, 178 min, IQR (160-190) versus 137 min, IQR (128-162), p < 0.0001. Patients with an abnormal WC also had a longer inpatient stay, p = 0.0436. Conclusion. Laparoscopic nephrectomy is safe in obese patients. However, obese patients should be informed that their obesity prolongs the anaesthetic duration and duration of the surgery and is associated with a prolonged recovery.

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INTRODUCTION: The 1999 Ionising Radiation Regulations recommend that medical professionals using ionising radiation should aim to keep exposure as 'low as reasonably practicable'. Urologists regularly use fluoroscopy during endoscopic surgical procedures. In some institutions, this is delivered by a radiographer whereas in others, it is delivered by the urological surgeon. OBJECTIVES: To determine if radiographer-delivered fluoroscopy can reduce the exposure to ionising radiation during urological procedures. METHODS: An analysis of 395 consecutive patients, who underwent endoscopic urological procedures requiring fluoroscopy, was performed simultaneously across two institutions, over a 4 month period. 321 patients were matched and included in the analysis. RESULTS: Radiographer delivered fluoroscopy was associated with reduced ionising radiation exposure for retrograde pyelography procedures ED 0.09626 vs. 1.323 mSev, p= 0.0003, and endoscopic stone surgeries ED 0.3066 Vs. 0.5416 mSev, p=0.0039, but not for ureterorenoscopic stone surgeries 0.4880 vs. 0.2213 mSev, p=0.8292. CONCLUSION: Radiographer delivered fluoroscopy could reduce the patient's exposure to ionising radiation for some urological procedures.

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INTRODUCTION: Urethral strictures constitute a significant clinical problem that often requires long-term management. OBJECTIVE: To report the long-term outcomes of adjuvant home self-urethral dilatation of recurrent urethral strictures using a balloon catheter. MATERIALS AND METHODS: Male patients (N = 11), performing self-dilatation with a balloon catheter (minimum 24 months) were assessed by patient-reported outcome measures (PROMs) health questionnaire specific for post treatment assessment of men with urethral stricture disease. RESULTS: Median duration of balloon catheter use is 46.5 months, IQR (24-150). Patients performed self-balloon dilatation on average 1.4 times a week, median 1, IQR (1-2) to maintain the patency of their urethra. The mean PROMs LUTS score of the patients was 2.45, median 2, IQR (1-4). The median and mean Peeling score was 2 IQR (1-2). 100 % patient reported that they either very satisfied or satisfied with the overall outcome and QoL. CONCLUSIONS: Our initial experience of outpatient self-dilatation with a balloon dilatation is encouraging and is an acceptable inexpensive and simple treatment for patient maintains urethral patency and potentially decreases stricture recurrence.

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BACKGROUND: A continuous running suture is the preferential method for abdominal closure. In this technique the suture is secured with an initial knot and successive tissue bites are taken. At each tissue bite, the needle is rotated through the tissue; in doing so, the suture can twist around the knot which acts as an anchor. OBJECTIVE: To determine the effect of axial torsional forces on sutures used in abdominal closure. METHODS: The effect of axial twisting on polydioxanone (PDS*II), polyglactin (Vicryl), polypropylene (Prolene) and nylon (Ethilon) sutures was investigated using a uniaxial testing device. RESULTS: The maximum tensile force withstood for untwisted sutures was determined: polydioxanone failed at a tensile force of 116.4±0.84 N, polyglactin failed at 113.9±2.4 N, polypropylene failed at 71.1±1.5 N and nylon failed at 61.8±0.5 N. Twisting decreased the maximum tensile force of all sutures; one complete twist per 10 mm (i.e., 15 twists) decreased the tensile strength of polydioxanone by 21%, polyglactin by 23%, polypropylene by 16% and nylon by 13%, p<0.001. Excessive twisting caused a nonlinear decrease in suture strength, with one twist per 75 mm (i.e., 20 twists) of polydioxanone decreasing strength by 39%, P<0.001. CONCLUSION: The effect of excessive twisting on the mechanical properties of sutures is a previously unrecognised phenomenon. Surgeons should be aware that this can result in a decrease in suture strength and reduce the elasticity of the material, and therefore need to adapt their practice to reduce the torsional force placed on sutures.

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