Myeloid Sarcoma of the Bladder in a Patient with Chronic myelomonocytic Leukaemia

BackgroundMyeloid sarcoma is a rare extramedullary tumour of immature granulocytes, most commonly involving the skin, bone, lymph nodes, and soft tissue. It is usually associated with a diagnosis of relapsed or de novo acute myeloid leukaemia, acute lymphoblastic transformation of a myelodysplastic/myeloproliferative neoplasm, or can occur as isolated myeloid sarcoma.Case reportA 66-year-old female with a 7-year history of stable chronic myelomonocytic leukaemia presents with urgency, frequency, dysuria symptoms, and without new constitutional symptoms. She is found to have atypical, multifocal lesions on the right posterolateral wall of the bladder with associated hydronephrosis. Pathology reveals the diagnosis as myeloid sarcoma; surprisingly, bone marrow evaluation does not show evidence of acute leukaemic transformation.ConclusionsMyeloid sarcoma occurring in patients with chronic myelomonocytic leukaemia is extremely rare, and there are no cases reported in the English literature of these patients developing lesions in the bladder. The urological manifestations of an underlying haematological malignancy are best managed with a combination of systemic chemotherapy and allogeneic stem cell transplant, and in this case, the only surgical intervention required was ureteric stenting and tissue biopsy. Although rare, it is essential to consider alternative diagnoses when confronted with an atypical bladder tumour; failure to do so may result in patient harm by exposure to unnecessary intervention and delay to potentially curative treatment.

West Midlands Endourology Meeting Abstracts

West Midlands Endourology Meeting Abstracts

The Impact of Remote Urology Outpatient Clinics during the COVID-19 Pandemic

Introduction: The coronavirus (COVID-19) pandemic of 2020 had a major impact on NHS services. From the 23rd of March 2020, the Urology Department in Basingstoke initiated telephone-led consultation clinicsinstead of face-to-face outpatient appointments, in accordance with U.K. guidance.Objectives: To evaluate patient experience and satisfaction following the introduction of remote (telephone) consultations during the COVID-19 pandemic.Patients and methods: The first 200 remote patient appointments between the 30th of March 2020 and the 16th of April 2020 were sent a postal questionnaire (19 questions relating to their experience and level of satisfaction with the interaction). Telephone consultations were conducted by 6 consultants, 3 registrars, and 2 specialist nurses. The patients were not prewarned to expect a questionnaire after the remote ap-pointment. The associated cost saving resulting from a switch from face-to-face appointments to remote telephone appointments was also calculated.Results: 100 out of the 200 patients responded within 1 month (response rate 50%). A total of 44% of the patients were new referrals, while 56% were follow-ups. Overall, the feedback was positive regarding the telephone consultation, with 88% rating the care received as excellent or very good. In addition, 90% would recommend a telephone consultation to family and friends. However, 35% would prefer in the future to have another telephone consultation rather than face-to-face consultation, with 46% preferring a face-to-face appointment in the future and 19% unsure. For new patients, the proportion wishing to have a face-to-face appointment, in the end, was unsurprisingly higher than it was for those undergoing a follow-up (39% vs. 7 %). In these 2 weeks, the cost reduction to the NHS from shifting from face-to-face consultation to telephone consultation was estimated to be £6500.Conclusions: Telephone urology clinics are a satisfactory alternative to face-to-face appointments for many of our patients now and beyond the COVID-19 pandemic. They are efficient, cost-effective, and feasible to undertake urological consultation and can be implemented successfully in selected patients. The feedback from this questionnaire would suggest that priority should be given to face-to-face appointments for new patients and for complex follow-up appointments. Telephone follow-up appointments, however, are a good approach for the majority of patients.

Day Case GreenLight Laser Photoselective Vaporisation of the Prostate (GL-PVP)

Background and ObjectiveIn recent years, GreenLight laser photoselective vaporisation of the prostate (GL-PVP) has emerged as the primary ablative surgical treatment option for symptomatic bladder outlet obstruction (BOO) secondary to benign prostatic enlargement (BPE). Unlike the reference procedure, monopolar-transurethral resection of the prostate (M-TURP), GL-PVP can be performed as a day case. As waiting list pressures continue to burden health boards across the UK, exacerbated by the COVID-19 pandemic, enhanced access to day case surgery to optimise patient flow is now of paramount importance. We evaluated the safety and feasibility of day case GL-PVP at our high-volume UK centre and identified predictors of a postoperative overnight stay. Material and MethodsWe performed a retrospective observational cohort study of all patients who underwent primary GL-PVP at a single institution between October 2016 and June 2021. All procedures were performed utilising the 180W GreenLight XPS™ laser therapy system. Various clinical, operative and functional data were collated, and outcomes were compared between patients who underwent day case surgery and those admitted overnight postoperatively. ResultsIn all, 538 patients underwent GL-PVP during the study period. Median patient age was 72 (interquartile range (IQR) 66–77), and median prostate volume was 62.5cc (IQR 45–90). Five hundred nineteen patients (96.5%) were discharged within 23 hours of admission, and 366 patients (68.0%) were managed as a true day case. Operative and functional outcomes were comparable between patients managed as a day case and those admitted overnight. There was higher patient-reported satisfaction and a lower rate of early hospital readmission in the day-case group. On univariate logistic regression analysis, patients aged ≥80 years (Odds Ratio 2.64 [95% Confidence Interval 1.65– 4.24], p = < 0.001), those with American Society of Anaesthesiologists (ASA) physical status classification score ≥3 (OR 1.92 [95% CI 1.33–2.78], p = < 0.001), those with prostate volume ≥80cc (OR 1.62 [95% CI 1.00–2.61], p = 0.05) and those in whom the operation time ≥60 minutes (OR 1.66 [95% CI 1.10–2.52], p = 0.02) were more likely to be admitted overnight following GL-PVP. On multivariate logistic regression analysis, age ≥80 (OR 2.64 [95% CI 1.47–4.73], p = 0.001) and ASA score ≥3 (OR 2.03 [95% CI 1.28–3.22], p = 0.003) remained predictive variables of an overnight stay. ConclusionFrom our observations of a large cohort of patients over a study period of almost five years, day case GL-PVP is a feasible concept and does not appear to compromise perioperative outcomes. With appropriate service redesign and optimisation of postoperative patient pathways, day case GL-PVP can be established in other centres and may have a role in alleviating waiting list pressures.

Should National Institute for Clinical Excellence (NICE) Guidelines Remove Urine Cytology as a Suggested Adjunct in Suspected Bladder Cancer (haematuria) Investigations?

BackgroundDespite National Institute for Clinical Excellence (NICE) guidelines suggesting the use of urine cytology (UC) for the diagnosis of bladder cancer, its use is variable. Reasons for this include sub-optimal sensitivity, financial cost, availability of alternative tests, and uncertainty over interpretation of results. Anecdotally, however, suspicious or malignant UC when other investigations are normal, occasionally leads to a cancer diagnosis. Therefore, we retrospectively assessed a cohort of our haematuria patients to determine the value of UC in cancer diagnosis and the clinical significance of atypical UC (graded as C3). Patients and methodsWe identified 3018 patients with haematuria referred on the suspected cancer pathway (“two-week wait”) in 2015. We retrospectively analysed clinical, demographic, and follow-up/outcome data in a random cohort of 500 cases. ResultsMedian follow up was 58 months. Urological malignancy was diagnosed in 61/500 patients; all were identified by cystoscopy or imaging, i.e., irrespective of UC result. No cases of atypical UC re-presented with a ‘missed’ cancer diagnosis within the five-year follow-up period. However, suspicious and malignant cytology was associated with high-grade/aggressive tumours and subsequent tumour recurrence. ConclusionUrine cytology did not identify any cancers that were not already found by imaging or cystoscopy. Atypical UC in the presence of negative haematuria investigations does not appear to be associated with malignancy, and therefore should not alter patient management nor prompt further investigation. Suspicious and malignant UC was associated with higher risk cancers and could therefore be used to prioritise waiting lists for transurethral resection of bladder tumour (TURBT), however, it is unclear whether this might benefit patient outcomes. We conclude therefore that UC has no role in haematuria investigations.

Uncovering Silent Fungal Infections complicating Obstructive Uropathy due to Renal Papillary Necrosis in Diabetic patients – A step towards preventing Recurrent Obstructive Uropathy.

Introduction and Objectives: Renal papillary necrosis is one of the common causes of obstructive uropa-thy in diabetic patients. During removal of necrosed renal papilla, many patients were observed to have fluffy necrotic material in the ureter, and renal pelvis, and a few among them present again with recurrent episodes of obstructive uropathy and sepsis following DJ stent removal. Our study aimed to identify thesignificance of this fluffy necrotic material and its evaluation by histopathological examination (HPE). Materials and Methods: This is a prospective observational study done in our institute by compiling data of 56 patients admitted with obstructive uropathy secondary to renal papillary necrosis who underwent a protocol-based treatment from 2016 to 2019. All these patients underwent initial DJ stenting followed by check flexible ureteroscopy or nephroscopy after 6 weeks. The white, necrotic fluffy material collected during initial DJ stenting or with subsequent flexible ureteronephroscopy was sent for HPE. All these patients were followed up for 1-3 years. Results: Out of 56 patients, 15 patients had fluffy necrotic material in the bladder on initial cystoscopy, of which 1 patient was diagnosed with aspergillosis and 1 patient with candida infection on HPE. During check flexible ureteroscopy (FU), 19 patients had minimal burden of fluffy necrotic material in renal pelvis, of which one patient was diagnosed with aspergillosis, one with candida (same patient diagnosed on cystoscopy), and one patient with both aspergillus and candida colonies on HPE. 5 patients had the significant burden of fluffy necrotic material in the renal pelvis, requiring removal via percutaneous nephroscopic access. Among these 5 patients, 2 were diagnosed with aspergillosis and 1 with candida infection on HPE. A total of 32 patients had single papilla, and 24 had multiple papillae in the pelvicalyceal system. 5 out of 7 patients with positive fungal pathology had negative fungal cultures. Compared to our historical data of 4% mortality and 22% recurrent obstructive uropathy in the 3 years preceding the adoption of this protocol, with the present protocol, no patient developed recurrent pyelonephritis during follow-up of 1–3 years after DJ stent removal following complete evacuation of necrotic material and appropriate antifungal treatment. Conclusion: This study highlights the need for check ureterorenoscopy and removal of all necrotic papillae and debris to establish a microbiological and histopathological diagnosis along with proper antifungal treatment to prevent episodes of recurrent pyelonephritis and obstructive uropathy.

Evolution of Percutaneous Renal Access

Introduction: Nephrostomy insertion is a vital part of modern-day urology used to manage obstructedrenal tract or gain percutaneous renal access.Method: We carried out a PubMed literature search on the history of the development of nephrostomies. Results: The first percutaneous nephrostomy was performed in 1864 on a child who died in 5 years. Nephroscopy was then described and performed in 1941 during an open surgery with subsequent advancement to percutaneous nephrolithotomy in 1976 and antegrade stent insertion in 1978.Conclusion: Clinical need and innovation have led to percutaneous renal access and subsequent stone treatment modality.

The Implementation of a Risk Stratification Tool for the Haematuria Clinic to Optimise the Management of Patients with High-Risk Bladder Cancer in the COVID-19 Era

Introduction: Elective waiting lists have become more stretched because of the COVID-19 pandemic and patients have evidently been waiting longer for treatment. Patients with high-risk bladder cancer require timely treatment and there is strong evidence to suggest that delay in treatment contributes to a risk of disease progression, metastases and death. Studies have shown that bladder tumour appearances at flexible cystoscopy (FC) can accurately predict high-risk disease on histopathology following transurethral resec-tion. An opportunity for service improvement resulted in a review of the practice followed by the authors and the development of a risk stratification tool for the haematuria clinic which aimed to prioritise thepathway of those with high-risk disease.Materials and methods: A risk stratification tool was developed for patients with newly diagnosed bladder tumours at the haematuria clinic. A tumour assessment carried out at FC is used to predict patients with high-risk disease, thus allowing those patients to be prioritised over those with low-risk disease on the waiting list. It also includes a reminder to request staging investigations for those with suspected high-risk disease. A closed loop audit was carried to review the following: the quality of tumour risk assessment at the haematuria clinic; time from FC to transurethral resection of bladder tumour (TURBT); concordance between tumour assessment at FC and histopathology after TURBT; efficiency of arranging early staging investigations for those with suspected high-risk bladder cancer; time from FC to staging CT scan. Results: A risk assessment was carried out for 93% of patients in the second cycle compared with 40% in the first cycle. Concordance was noted in 83% of those with confirmed high-risk non-muscle invasive bladder cancer (NMIBC) and 83% of muscle invasive bladder cancer (MIBC) in the first cycle, and in 100% of patients with high-risk NMIBC and MIBC in the second cycle. The interval from FC to TURBT decreased from 27 days in the first cycle to 21 days in the second cycle in those with high-risk NMIBC, and from 27 to 13 days in those with MIBC. Time from FC to staging CT for patients with high-risk bladder cancer was 6 days in the first cycle and 3 days in the second cycle if the request was made from the haematuria clinic. If the CT scan was requested later, the interval increased to 39 days in the first cycle and 22 days in the second cycle.Conclusion: There is a high degree of concordance between tumour risk assessment at FC and final pathol-ogy following TURBT which is supported by several series. Performing risk assessment and requesting staging investigations at the haematuria clinic for patients with newly diagnosed high-risk bladder cancer can minimise delays in their treatment pathway and improve patient outcomes.

Initial Results of Laser Ureteroscopy Treatment for Lithiasis of the Upper Urinary Tract at Aristide Le Dantec Hospital in Dakar (Senegal)

Background: In Africa, lithogenesis was initially considered rare and it was mostly caused by infections. Recent studies suggest that obesity, change in dietary habits (milk, dairy products) and hot climate can contribute to an increase of the condition in the region. Over the past decades, the management of upper urinary tract urolithiasis has evolved significantly with minimally invasive techniques. The challenge for sub-Saharan countries is related with the acquisition and the training for minimally invasive treatment. In fact, open surgery has less indications in the management of urolithiasis. The aim of this study is to evaluate the preliminary results of ureteroscopic laser treatment for upper urinary tract lithiasis in our hospital. Methods: This was a prospective, descriptive study realized between June 2016 and December 2018. The patients included were those who had ureteroscopic laser treatment for upper urinary tract lithiasis. The treatment was performed under general anesthesia by two surgeons. The studied parameters were: age, sex, patient medical history, comorbidities, renal function, cytobacteriological examination of urine, characteristics of lithiasis, intra and postoperative complications (using the Clavien–Dindo classification), ureteroscopic laser failures (frequency and causes). Success of treatment was defined by: the absence of a residual fragment at the renal and ureteral level or of a residual fragment <4 mm at the renal level on the control imaging. Data analysis was done with IBM SPSS Statistic 23 software. Statistical significance was considered when P < 0.05. Results: This study involved 43 patients. The mean age was 40.84 years ± 15.33 years. The age group between 30 and 39 years was predominant. The sex ratio was 1.26. Nephritic colic was the circumstance of discovery in 93.02%. The Uro-CT scan performed in all our patients, revealed kidney stones in 16.3% and ureteral stones in 83.7%. The right side was the most involved in 55.8%. The mean size of the stones was 12.2 mm ± 4.89 at the renal level and 12.05 mm ± 5.54 at the ureteral level. The semi-rigid ureteroscope was used in 88.37% and the flexible ureteroscope in 11.63%. The lithiasis was visualized in 74.4% of cases. Laser fragmentation was performed in 69.77% of cases. A J stent was placed after 72.1% of cases. Pelvic ureteral stripping and pelvic ureteral aspiration were realized in one case each. Acute pyelonephritis (ANP) was observed in 25.6% of patients. There were 75% fragment free at postoperative control. Any factors associated with treatment failure were not found.

Is Flexible Cystoscopy Necessary in the Investigation of Non-visible Haematuria?

Background: Historic evidence suggests up to 16% (approximately) of non-visible haematuria (NVH) referrals result in Urological cancer diagnosis. The majority are bladder cancers, for which flexible cystoscopy is regarded the “gold standard” diagnostic procedure. Recent changes to suspected cancer referral guidelines, public information campaigns and reduced smoking prevalence may have changed this percentage. We retrospectively calculated cancer detection rates from NVH referrals to assess whether flexible cystoscopy,an invasive and morbid procedure, remains necessary.Patients and methods: All patients referred to our University teaching hospital on a suspected (“two-week”) cancer pathway with NVH over a 16-week period were included. Clinical and demographic data were collected for a series of 200 patients (96 male, age range 27–92, median 68).Results: Only eight patients had urological malignancy found (two renal and six bladder cancers). Both renal, and four bladder cancers, were identified on imaging prior to flexible cystoscopy. Only two bladder cancers were therefore detected by cystoscopy; one low-risk non-muscle invasive (patient has already been discharged) and one in a patient that was unfit for treatment (died of heart failure). Only seven (3.5%) of the patients were offered the option of not undergoing flexible cystoscopy.Conclusion: Our analyses suggest that flexible cystoscopy is rarely of benefit in patients with NVH. We suggest that patients should be given an accurate risk of bladder cancer diagnosis during the consent process. We advocate that flexible cystoscopy can be avoided for the majority of NVH referrals, particularly in patients without strong risk factors for urothelial cell carcinoma. Avoidance of flexible cystoscopy would reduce patient risks from procedural morbidity, reduce risks of acquiring coronavirus from hospital attendance, and there could be huge reductions in financial and service delivery demands in an overstretched secondary-care service.