JELEU Vol 2(Special Issue 1):e1-e6; March 26, 2019.This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License.

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West Midlands Endourology Meeting

ABSTRACTS

March 29, 2019

“It’s my absolute pleasure as editor in chief of The Journal ofEndoluminal Endourology to announce this special edition of thejournal. The West Midlands Endourology Meeting is a prestigiousevent, with excellent academic content and it is our pleasure topublish the seven best abstracts in this special edition.”

Wasim Mahmalji, MBBS,BSc, MSc, MRCS, FRCS

DOI: 10.22374/jeleu.v2iSpecial Is.43

West Midlands Endourology Meeting: Abstracts

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JELEU Vol 2(Special Issue 1):e1-e6; March 26, 2019.This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License

Outcome of Flexible UreterorenoscopicLasertripsy in the Treatment ofStaghorn Stones

IntroductionPercutaneous nephrolithotomy(PCNL) is a well-established treatment for staghorn stones. Withimprovement in technology and techniques offlexible ureterorenoscopic lasertripsy (FURS), it isincreasingly used to primarily treat large stonesincluding staghorn stones.

Materials and MethodsAll patients with partial and complete staghornstones treated by FURS by a single endourologistwere included. Outcome measures comparedincluded duration of procedure, length of stay,retreatment rate, complications and clinical successrates.

ResultsOut of 18 staghorns, 6 complete and 12 partialstaghorn stone had FURS treatment.Comparatively, the Complete staghorn group wereolder (mean 73.6 vs. 69.6 years), had largermaximum stone size (mean 48.3mm vs. 26.4mm),lower pre-op stenting (0% vs 8.3%) with similar BMI(mean 31.7 vs. 30.5), ASA scores (mean 2.5 vs.2.3), similar recurrent UTI incidence (66.7% vs61.5%) and Hounsfield unit (mean 845 vs. 817HU).MAP stone composition was found 50% of completestaghorn vs 16.7% of partial staghorn group.

Complete staghorn group took longer totaloperatively to clinical success (mean 189 mins vs.85.9 mins), lower primary procedure success(66.7% vs. 83.3%), higher number of repeatprocedure (mean 1.67 vs 1.27); with similar hospitalstay (mean 1.16d vs. 1.25d). The complete stone-free rate after 6 months was lower in CompleteStaghorn group (83.3% vs 91.7%); where 1 patientof each group had small remnant staghorn aspectinaccessible to laser. There were no complicationson the Complete Staghorn group and one patientwith Partial staghorn developed postop fever(Clavien 2) settled with antibiotics.

ConclusionFURS is efficacious and safe for primary treatmentof staghorn.

Emergency Primary Ureteroscopy –

Emergency Primary Ureteroscopy - Importance in Present NHS Practice

M Ahmed, S Ndirika, Jenny Bo and Mr A.DhanasekaranSandwell and West Birmingham NHS Trust

ObjectivesEmergency primary ureteroscopy is defined aspatients undergoing ureteroscopy when presentedwith acute ureteric colic instead of double J stentingand/or delayed elective ureteroscopy. In this study,we analysed the outcomes of emergency primaryureteroscopy (URS) versus emergency stentinsertion for acute ureteric colic patients at Sandwelland West Birmingham NHS Trust (SWBH).

Materials and MethodsA retrospective review of all ureteroscopy and stentinsertion surgeries performed at SWBH from June2018 to December 2018. In total 105 surgeries wereidentified: 33 cases were excluded due to the non-stone indications and 72 consecutive casesidentified in emergency URS, emergency stent anddelayed elective URS groups. Data on patientdemographics, stone and procedure details werecollected and analysed.

ResultsIn total 105 cases were identified from theatrecodes when searched for emergency, ureteroscopy,laser fragmentation and ureteric stent.Reterospectively, 24 consecutive cases identified ineach of the groups: emergency URS versusemergency double J stenting versus electivedelayed URS. Overall, men were 3 times morelikely to need stone treatment. Stones were ofsimilar size across the groups (7-8mm) with 78%stone clearance in emergency URS versus 88% inelective setting and 33% versus 67% proximalureteric stones noted in the respective groups. Inemergency URS, 30% complication noted (4 grade1 ureteric injuries, 1 stent symptom, 1 orchitis). Allcases were stented followed by removal in 3-4weeks. In the elective setting, 6 were pre-stented,62.5% stented post-op and complications werelower or poorly documented. 17/24 had primaryURS and 25% needed flexible URS. For patientsundergoing emergency stent insertion all neededfurther procedures (1PCNL, 22URS, 1 awaitingURS), 13% complication and an average waitingtime of 8 weeks to definitive treatment. Overall,lower inpatient stay and the absence of additionaladmission in the emergency URS group implygreater financial savings to the overstretched NHS.Full economic details will be presented.

patients with impacted stones and patientspresenting with forneceal rupture emergencyprimary ureteroscopy was performed. UrologyGIRFT (Getting It Right First Time) programmepublished in July 2018 also stressed in therecommendations 9, 10 and 11. We made changes

in on-call consultant’s job plan as per GIRFTrecommendations. We don’t have access to inhouse ESWL in our trust. Provision of emergencyureteroscopy requires the availability of expertiseand longer emergency theatre slots. In thispresentation, we discuss ways by which we tackledthese challenges. We compared our results withHES data presented in GIRFT publication asdemonstrated in the following table.

Mussammet Ahmed and Vincent KooAlexandra Hospital Redditch, WestMidlands

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West Midlands Endourology Meeting: Abstracts

excluding underlying pathology, patients wait forextended periods for outpatient clinics and treatment,often with significant symptoms and reduced quality oflife. The introduction of our nurse-led service hasmoved focus of BPS management toward patient-centred treatment and empowerment, i.e. from ‘patientat hospital’ cystistat® to ‘patient at home’ hyacyst®.

ConclusionOur results show that emergency URS is safelyfeasible with the added benefit of offering earlierstone clearance, less pressure on the electiveoperating waiting list and greater financial savingsfor the NHS. These findings are also reflected inUrology GRIFT recommendations.

An Innovative Patient-CentredApproach in the Management of PainfulBladder Syndrome Improves Outcomesand Quality of Life

MO Kitchen1,2, K Willard1,3, H Thursby1,2,W Asaad1, M Taylor1,3, T Harrison1,3, MBould1,3, L Gommersall1,2

1Department of Urology, UniversityHospitals of North Midlands NHS Trust,UK.2Institute for Science and Technology inMedicine, Keele University, UK.3Nurse-led Urology Ambulatory Unit, RoyalStoke Hospital, UK

IntroductionBladder pain syndrome (BPS) symptoms can bedifficult to manage. Subsequent to investigations

Patients and MethodsWe assessed 30 patients with bladder pain syndromesymptoms from our caseload, performing self-catheterisation with self-administration of hyacyst® (athome). Patients completed standardised quality of lifequestionnaires prior to, during, and followingestablishment on treatment; these were compared to self-reported outcomes from 16 patients receiving intravesicalcystistat® (in hospital).

ResultsMedian follow-up was 13.8 months. 25/30 patients weresuccessfully established on as required self-administrationhyacyst®, compared to 9/16 that continued on nurse-administered cystistat® (Quality of life/acceptability wasbetter in the hyacyst® group). Mean frequency ofadministration was 6.8 weeks for hyacyst® and 4.2 weeksfor in-hospital cystistat®. Cost per treatment averaged£70 for hyacyst® and £350 for cystistat®. Treatment waittimes were 3.4 months for first cystistat® and 0.7 monthsfor self-catheterisation teaching and hyacyst® (p<0.05).Approximately 150 patient hospital visits were ‘saved’ byestablishing patients on hyacyst® (per year).

ConclusionPreliminary data suggest that self-administered hyacyst®is well tolerated, cheaper than standard cystistat®, hassignificantly shorter waiting times, and patient-reportedoutcomes are better. These data also suggest that self-administered treatment reduces clinician and nurse-ledclinic visits, freeing slots and reducing wait times for otherservices such as Mitomycin/BCG.

Introducing Mini and Supine PCNL in anestablished PCNL Centre – WhatDifference Has It Made?

Shehab KhashabaCity and Sandwell HopsitalAimMini PCNL is now established as a less invasivemethod of PCNL due to the lesser dimension of thepuncture tract. Supine PCNL is proved to beadvantageous due to the possibility of simultaneous

West Midlands Endourology Meeting: Abstracts

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retrograde access and better positioning for airway access. Mini and Supine PCNL technique was introduced in the Sandwell and West Birmingham Hospitals Trust in 2017. Standard PCNL is performed in this trust for more than 15 years. We studied the difference in clinical outcomes due to the introduction of Mini and Supine PCNL on the management of renal stone disease.

MethodsPatient details from 344 urological procedurescarried out between 2015 to 2019 at SWBH NHSTrust were accessed. The operation notes,laboratory results and radiology images of theidentified patients were reviewed. Of these,retrospectively a total of 100 PCNL procedureswere identified: 70 standard PCNL and 30 miniPCNL. Data were collected regarding the access tostone, completeness of stone clearance,postoperative events like the need for bloodtransfusion, pain tolerability, length of hospital stayand long-term outcome.

Data were analysed to determine average patientage, sex, renal function, stone size and STONEscore for both standard and mini PCNL. Surgicaloutcomes are compared to determine whether theintroduction of the Mini and Supine PCNLprocedure has advantages over standard PCNL.

ResultsCollected data were assessed using SPSSsoftware. Gender and age distribution werecomparable in both groups. Average stone size wassmaller in the Mini PCNL group. Stone clearancewas found to be better in Mini PCNL group.However, smaller stone size is a confoundingfactor. Mini PCNL patients stayed less than 24hours in the hospital and most of the patients didnot require nephrostomy tubes. Blood transfusionrates are less in Mini PCNL possibly due to thesmaller diameter of tracts. We will present full datawith charts in the presentation.

ConclusionThe Introduction of Mini and Supine PCNL resultedin better patient outcome by decreasing the hospitalstay, less need for blood transfusion and intra-operative comfortable positioning of the patient.

Is Hypothermic Lignocaine Is BetterThan Normothermic Lignocaine forFlexible Cystoscopy procedures?Prospective Single Blinded RandomizedStudy

Mr Syed Ehsanullah and Mr ADhanasekaranSandwell and West Birmingham NHS Trust

AimWe use normothermic lignocaine gel (Instillagel®Anaesthetic Antiseptic Lubricant) routinely for localanaesthesia flexible cystoscopy procedures. In thepast few years, many minimally invasive procedureswere introduced for Benign Prostatic Enlargement. Ofthese UroLift and Rezum are suitable to beperformed under local anaesthesia. Using rigidcystoscopy under local anaesthesia is challengingand requires experience. Various modifications madeto improve patient comfort in these procedures. Ofwhich using hypothermic Lignocaine gel from thefridge at approximately 4* C is useful. We did aRandomized Single Blinded Study to compare patientcomfort with hypothermic and normothermiclignocaine in flexible cystoscopy procedures.

Materials and MethodsLignocaine gel we used is Instillagel® AnaestheticAntiseptic Lubricant. Lidocaine in a gel made withHydroxyethylcellulose, Propylene Glycol and PurifiedWater. The gel comes in disposable syringes eachcontaining either 6ml or 11 mL. We used 11 mLsyringes. We discussed with a statistician to calculatethe number of patients required to enrol to get 80%power for the study outcome. We randomized 50patients in two arms and used the visual analoguescore to estimate patient comfort.

Results and DiscussionThere are some historical studies showing heatinglignocaine reduces pain during intradermal injection.Few studies showed that alkalinised local anaestheticmixture works better. No studies were available oncold lignocaine gel on cystoscopy procedures. In ourstudy we found the patients in hypothermiclignocaine arm tolerated the procedure well. Fullstatistics details are presented. The disadvantages of

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JELEU Vol 2(Special Issue 1):e1-e6; March 26, 2019.This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License

West Midlands Endourology Meeting: Abstracts

this study were (1) we enrolled only flexiblecystoscopy patients, (2) if we enrolled a largernumber of patient's it may show a better statisticaldifference, and (3) discomfort from flexiblecystoscopy can't be compared with rigidcystoscopy.

The reason why hypothermic lignocaine from thefridge at 4°C is better is due to the pK absorptionvalue. The lignocaine gels were kept in the fridgeovernight. Further reasons why hypothermiclignocaine is efficient in mucosal anaesthesia needsfurther studies.

IntroductionCommon risk factors for Uric acid stones are age,high BMI, hyperuricemia, hyperuricosuria and acidicurinary pH. Little is known about the correlation ofuric acid stones with different patient characteristicsof various ethnic backgrounds. We aim to analysedifferences in patient characteristics in uric acidstones.

MethodsStone analysis data from 446 patients wereanalysed retrospectively. Patients with Uric acidstones were identified and their age, BMI, serumuric acid level and urine pH was compared amongstdifferent patient populations using SPSS (MannWhitney test).Results

Calcium oxalate was the commonest stone(n=301,67.5%) followed by uric acid (n=42, 9.4%).Comparison of different patient characteristics in theuric acid group is shown in the table.There was statistically significant difference in Ageand a trend towards lower BMI, higher uric acidlevel and lower pH and these didn’t reach statisticalsignificance.

Upper Tract TCC: Audit of Diagnostic ofDiagnostic Pathway.Nathan Ingamells, William Taylor andKesavapillai SubramonianQueen Elizabeth Hospital Birmingham

IntroductionUpper tract urothelial carcinoma (UTUC) accountsfor only 5% of urothelial cancer. BAUS audit datashowed that on average six nephroureterectomiesare performed per unit annually. UTUC is difficultto diagnose and has a sinister clinicalcourse. We audited our patients to understand howto improve our diagnostic pathway.

Material and MethodsSixty-one patients diagnosed with UTUC haddefinitive surgery over a ten-year period. Forty-eight were included in our analysis. Forty-two hadprior ureteroscopy and 6 patients proceeded tonephroureterectomy based on the CT andcytology alone. At ureteroscopy 34 patients had abiopsy. 8 patients had ureteroscopy but biopsywasn’t possible, of these 75% were performed bynon-endourologists. Thirty of 34 biopsies weresufficient for diagnosis of UTUC.

Registrars took 75% of the insufficient biopsies.Twenty-eight patients had selective uretericcytology, of which 11 were diagnostic for TCC.25patients were referred via the two-week waitpathway. Median wait for haematuriaappointment, ureteroscopy and definitive surgerywere 21, 94 and 108 days respectively. Only onepatient who had T3 disease on CT met the 62-daytarget.

ConclusionsUreteroscopy can be very challenging in thiscohort and we recommend that this be carriedout by an endourologist following a strictprotocol. Selective ureteric cytology can beuseful and should be taken. Theatre slots shouldbe kept for these patients so that there isminimal waiting time delay. Initial MDTdiscussion prior to ureteroscopy shouldrecommend progression straight to definitivesurgery if histology is diagnostic to avoid furtherMDT delays.

Racial Disparities in Uric Acid Stones:Single Centre Cohort StudyManzoor Ahmad, Mohamed Iqbal andK.SubramonianQueen Elizabeth Hospital Birmingham

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ConclusionOur study shows that Asians suffer from uric acid stone ata younger age and have relatively lower BMI and higheruric acid levels. This correlates with epidemiologicalstudies of Gout from Southeast Asia suggesting thatpathogenesis of Gout and Uric acid stones in Asianpopulation is different to Caucasian population. Largersample size is needed to confirm this along with metabolicscreening and genetic evaluation for confirming thepathogenesis.

West Midlands Endourology Meeting: Abstracts