oxford handook of urology 3rd ed

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Oxford Handbook of Urology

Third edition

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Oxford Handbook of Urology 3e

Oxford Handbook of Urology

Third edition

John Reynard

Consultant Urological Surgeon

Nuffi eld Department of Surgical Sciences

Oxford University Hospitals

Oxford, UK and

Honorary Consultant Urologist to the

National Spinal Injuries Centre

Stoke Mandeville Hospital

Aylesbury, UK

Simon Brewster

Consultant Urological Surgeon

Nuffi eld Department of Surgical Sciences

Oxford University Hospitals

Great Clarendon Street, Oxford, OX2 6DP,

United Kingdom

Oxford University Press is a department of the University of Oxford

It furthers the University’s objective of excellence in research, scholarship,and education by publishing worldwide Oxford is a registered trade mark ofOxford University Press in the UK and in certain other countries

© Oxford University Press, 2013

The moral rights of the author have been asserted

First edition published 2005

Second edition published 2009

Third edition published 2013

All rights reserved No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any means,without the prior permission in writing of Oxford University Press,

or as expressly permitted by law, or under terms agreed with the appropriatereprographics rights organization Enquiries concerning reproduction

outside the scope of the above should be sent to the Rights Department,Oxford University Press, at the address above

You must not circulate this book in any other binding or cover and you mustimpose the same condition on any acquirer

British Library Cataloguing in Publication Data

Data available

ISBN 978–0–19–969613–0 (fl exicover: alk.paper)

Printed in China by

C&C Offset Printing Co Ltd

Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding

The authors would like to express their gratitude to Dr Andrew Protheroe, medical oncologist at the Churchill Hospital, Oxford, Professor Nick Watkin, urological surgeon, and Dr Hussain Alnajjar, research fellow, both

at St George’s Hospital, London, for kindly reading and commenting on parts of the manuscript They would also like to thank Mr Padraig Malone,

Mr Marcus Drake, and Mr Rowland Rees, who gave freely of their time and expertise

Detailed contents viii

Symbols and Abbreviations xix

1 General principles of management of patients 1

2 Signifi cance and preliminary investigation

8 Miscellaneous urological disease of the kidney 395

10 Upper tract obstruction, loin pain, hydronephrosis 491

11 Trauma to the urinary tract and other urological

Index 820

Contents

Detailed contents

Symbols and Abbreviations xix

Communication skills 2

Documentation and note keeping 4

Patient safety in surgical practice 6

2 Signifi cance and preliminary investigation of

Haematuria I: defi nition and types 8

Haematuria II: causes and investigation 10

Haemospermia 14

Lower urinary tract symptoms (LUTS) 16

Nocturia and nocturnal polyuria 18

Loin (fl ank) pain 20

Urinary incontinence 24

Genital symptoms 26

Abdominal examination in urological disease 28

Digital rectal examination (DRE) 30

Lumps in the groin 32

Lumps in the scrotum 34

Assessing kidney function 38

Urine examination 40

Urine cytology 42

Prostatic-specifi c antigen (PSA) 43

Radiological imaging of the urinary tract 44

Uses of plain abdominal radiography (the ‘KUB’ X-ray—kidneys, ureters, bladder) 46

Intravenous urography (IVU) 48

Other urological contrast studies 52

Computed tomography (CT) and magnetic resonance

imaging (MRI) 54

Radioisotope imaging 60

Urofl owmetry 62

Post-void residual urine volume measurement 66

Cystometry, pressure fl ow studies, and videocystometry 68

Regulation of prostate growth and development of benign

prostatic hyperplasia (BPH) 72

Pathophysiology and causes of bladder outlet obstruction

(BOO) and BPH 73

Benign prostatic obstruction (BPO): symptoms and signs 74

Diagnostic tests in men with LUTS thought to be

due to BPH 76

The management of LUTS in men: NICE 2010 Guidelines 78

Watchful waiting for uncomplicated BPH 84

Medical management of BPH: alpha blockers 86

Medical management of BPH: 5α-reductase inhibitors 88

Medical management of BPH: combination therapy 90

Medical management of BPH: alternative drug therapy 92

Minimally invasive management of BPH: surgical

alternatives to TURP 94

Invasive surgical alternatives to TURP 96

TURP and open prostatectomy 100

Acute urinary retention: defi nition, pathophysiology,

and causes 102

Acute urinary retention: initial and defi nitive management 106

Indications for and technique of urethral catheterization 108

Technique of suprapubic catheterization 110

Management of nocturia and nocturnal polyuria 116

Chronic retention 118

High-pressure chronic retention (HPCR) 120

Bladder outlet obstruction and retention in women 122

Urethral strictures and stenoses 124

Incontinence: classifi cation 128

Incontinence: causes and pathophysiology 130

Incontinence: evaluation 132

Stress and mixed urinary incontinence 136

Surgery for stress incontinence: injection therapy 138

Surgery for stress incontinence: retropubic suspension 140

Surgery for stress incontinence: suburethral tapes

and slings 142

Surgery for stress incontinence: artifi cial urinary sphincter 146

Overactive bladder: conservative and medical treatments 148

Overactive bladder: options for failed conventional therapy 150

Overactive bladder: intravesical botulinum toxin-A therapy 152

Post-prostatectomy incontinence 154

Vesicovaginal fi stula (VVF) 156

Incontinence in elderly patients 158

Management pathways for urinary incontinence 160

Initial management of urinary incontinence in women 161

Specialized management of urinary incontinence in women 162

Initial management of urinary incontinence in men 163

Specialized management of urinary incontinence in men 163

Management of urinary incontinence in frail older persons 164

Female urethral diverticulum (UD) 166

Pelvic organ prolapse (POP) 170

Urinary tract infection: defi nitions and epidemiology 176

Urinary tract infection: microbiology 178

Lower urinary tract infection: cystitis and investigation

of UTI 182

Urinary tract infection: general treatment guidelines 184

Recurrent urinary tract infection 186

Upper urinary tract infection: acute pyelonephritis 190

Pyonephrosis and perinephric abscess 192

Other forms of pyelonephritis 194

Chronic pyelonephritis 196

Septicaemia 198

Fournier’s gangrene 202

Peri-urethral abscess 204

Epididymitis and orchitis 206

Prostatitis: classifi cation and pathophysiology 208

Bacterial prostatitis 210

Chronic pelvic pain syndrome 212

Bladder pain syndrome (BPS) 214

Urological problems from ketamine misuse 218

Basic pathology and molecular biology 236

Wilms’ tumour and neuroblastoma 238

Radiological assessment of renal masses 242

Benign renal masses 244

Renal cell carcinoma: pathology, staging, and prognosis 246

Renal cell carcinoma: epidemiology and aetiology 250

Renal cell carcinoma: presentation and investigation 252

Renal cell carcinoma (localized): surgical treatment I 254

Renal cell carcinoma: surgical treatment II and non-surgical

alternatives for localized disease 256

Renal cell carcinoma: management of metastatic disease 258

Upper urinary tract transitional cell carcinoma (UUT-TCC) 260

Bladder cancer: epidemiology and aetiology 264

Bladder cancer: pathology, grading, and staging 266

Bladder cancer: clinical presentation 270

Bladder cancer: haematuria, diagnosis, and transurethral resection of bladder tumour (TURBT) 272

Bladder cancer (non-muscle invasive TCC): surgery and recurrence 276

Bladder cancer (non-muscle invasive TCC): adjuvant treatment 280

Bladder cancer (muscle-invasive): staging and surgical management

of localized (pT2/3a) disease 282

Bladder cancer (muscle-invasive): radical radiotherapy and palliative treatment 286

Bladder cancer: management of locally advanced and metastatic disease 288

Bladder cancer: urinary diversion after cystectomy 290

Prostate cancer: epidemiology and aetiology 294

Prostate cancer: incidence, prevalence, mortality, and survival 296

Prostate cancer: prevention 298

Prostate cancer: pathology of adenocarcinoma 302

Prostate cancer: grading 304

Prostate cancer: staging and imaging 306

Prostate cancer: clinical presentation 315

Prostate cancer: screening 316

Prostate cancer: prostate-specifi c antigen (PSA) 318

Prostate cancer—PSA derivatives and kinetics: free-to-total, density, velocity, and doubling time 320

Prostate cancer: counselling before PSA testing 322

Prostate cancer: other diagnostic markers 324

Prostate cancer: transrectal ultrasonography and biopsy 326

Prostate cancer: suspicious lesions 330

Prostate cancer: general considerations before treatment (modifi ed from the 2008 UK NICE Guidance) 331

Prostate cancer: watchful waiting and active surveillance 332

Prostate cancer: radical prostatectomy and pelvic

lymphadenectomy 334

Prostate cancer—radical prostatectomy: post-operative care and complications 338

Prostate cancer: oncological outcomes of radical prostatectomy 340

Prostate cancer: radical external beam radiotherapy (EBRT) 344

Prostate cancer: brachytherapy (BT) 346

Prostate cancer (minimally invasive management of localized and radio-recurrent prostate cancer): cryotherapy,

high-intensity focused ultrasound, and photodynamic therapy 348

Prostate cancer: management of locally advanced

non-metastatic disease (T3–4 N0M0) 350

Prostate cancer: management of advanced disease—hormone therapy I 352

Prostate cancer: management of advanced disease—

castrate-resistant prostate cancer (CRPC) 358

Prostate cancer: management of advanced disease—

palliative care 362

Urethral cancer 364

Penile neoplasia: benign, viral-related, and premalignant lesions 368

Penile cancer: epidemiology, risk factors, and pathology 370

Penile cancer: clinical management 374

Scrotal and paratesticular tumours 377

Testicular cancer: incidence, mortality, epidemiology,

and aetiology 378

Testicular cancer: pathology and staging 380

Testicular cancer: clinical presentation, investigation, and primary treatment 384

Testicular cancer: serum markers 386

Testicular cancer: prognostic staging system for metastatic germ cell tumours (GCT) 388

Testicular cancer: management of non-seminomatous germ

cell tumours (NSGCT) 390

Testicular cancer: management of seminoma, IGCN, and

lymphoma 392

Simple and complex renal cysts 396

Calyceal diverticulum 399

Medullary sponge kidney (MSK) 400

Acquired renal cystic disease (ARCD) 402

Autosomal dominant polycystic kidney disease (ADPKD) 404

Vesicoureteric refl ux in adults 408

Pelviureteric junction obstruction in adults 412

Anomalies of renal fusion and ascent: horseshoe kidney,

ectopic kidney 416

Anomalies of renal number and rotation: renal agenesis

and malrotation 420

Upper urinary tract duplication 422

Kidney stones: epidemiology 428

Kidney stones: types and predisposing factors 432

Kidney stones: mechanisms of formation 434

Factors predisposing to specifi c stone types 436

Evaluation of the stone former 440

Kidney stones: presentation and diagnosis 442

Kidney stone treatment options: watchful waiting and

the natural history of stones 444

Stone fragmentation techniques: extracorporeal lithotripsy (ESWL) 446

Intracorporeal techniques of stone fragmentation 450

Flexible ureteroscopy and laser treatment 454

Kidney stone treatment: percutaneous nephrolithotomy

(PCNL) 456

Kidney stones: open stone surgery 462

Kidney stones: medical therapy (dissolution therapy) 464

Ureteric stones: presentation 466

Ureteric stones: diagnostic radiological imaging 468

Ureteric stones: acute management 470

Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone 472

Ureteric stone treatment 476

Treatment options for ureteric stones 478

Prevention of calcium oxalate stone formation 482

Bladder stones 486

Management of ureteric stones in pregnancy 488

Hydronephrosis 492

Management of ureteric strictures (other than PUJO) 496

Pathophysiology of urinary tract obstruction 498

Initial resuscitation of the traumatized patient 506

Renal trauma: classifi cation, mechanism, grading 508

Renal trauma: clinical and radiological assessment 512

Renal trauma: treatment 516

Ureteric injuries: mechanisms and diagnosis 520

Ureteric injuries: management 522

Pelvic fractures: bladder and ureteric injuries 526

Malignant ureteric obstruction 546

Spinal cord and cauda equina compression 548

Male reproductive physiology 552

Aetiology and evaluation of male infertility 554

Investigation of male infertility 556

Oligozoospermia and azoospermia 560

Varicocele 562

Treatment options for male infertility 564

Physiology of erection and ejaculation 568

Erectile dysfunction: evaluation 572

Erectile dysfunction: treatment 576

Peyronie’s disease 580

Priapism 584

Retrograde ejaculation 588

Premature ejaculation 590

Other disorders of ejaculation and orgasm 592

Late-onset hypogonadism (LOH) 594

Hypogonadism and male hormone replacement therapy 596

Urethritis 600

Non-specifi c urethritis and urethral syndrome 602

Innervation of the lower urinary tract (LUT) 604

The physiology of urine storage and micturition 608

Bladder and sphincter behaviour in the patient with

neurological disease 610

The neuropathic lower urinary tract: clinical consequences

of storage and emptying problems 612

Bladder management techniques for the neuropathic patient 614

Catheters and sheaths and the neuropathic patient 622

Management of incontinence in the neuropathic patient 624

Management of recurrent urinary tract infections (UTIs)

in the neuropathic patient 628

Management of hydronephrosis in the neuropathic patient 630

Bladder dysfunction in multiple sclerosis, Parkinson’s disease, spina bifi da, after stroke, and in other neurological disease 632

Neuromodulation in neuropathic and non-neuropathic

lower urinary tract dysfunction 636

Physiological and anatomical changes in the urinary tract 640

Urinary tract infection (UTI) 642

Hydronephrosis of pregnancy 644

Embryology: urinary tract 646

Embryology: genital tract 648

Undescended testes (UDT) 650

Pelviureteric junction (PUJ) obstruction 672

Posterior urethral valves (PUV) 674

Cystic kidney disease 676

Preparation of the patient for urological surgery 698

Antibiotic prophylaxis in urological surgery 702

Complications of surgery in general: DVT and PE 706

Fluid balance and the management of shock in the surgical

patient 710

Patient safety in the urology theatre 712

Transurethral resection (TUR) syndrome 713

Catheters and drains in urological surgery 714

Sterilization of urological equipment 736

Telescopes and light sources in urological endoscopy 738

Consent: general principles 740

Cystoscopy 742

Transurethral resection of the prostate (TURP) 744

Transurethral resection of bladder tumour (TURBT) 746

Endoscopic cystolitholapaxy and (open) cystolithotomy 786

Scrotal exploration for torsion and orchidopexy 788

Electromotive drug administration (EMDA) 790

Basic physiology of bladder and urethra 794

Basic renal anatomy 796

Renal physiology: glomerular fi ltration and regulation

of renal blood fl ow 800

Renal physiology: regulation of water balance 802

Renal physiology: regulation of sodium and

potassium excretion 803

Renal physiology: acid–base balance 804

Renal replacement therapy 806

Renal transplant: recipient 808

Renal transplant: donor 810

Transplant surgery and complications 812

Index 820

 equal to or greater than

 equal to or less than

AAA abdominal aortic aneurysm

AAOS American Academy of Orthopaedic Surgeons

AAST American Association for the Surgery of Trauma

AAT androgen ablation therapy

ACCP American College of Chest Physicians

ACE angiotensin-converting enzyme

ACh acetylcholine

ACR albumin:creatinine ratio or acute cellular rejection

ACTH adrenocorticotrophic hormone

ADH antidiuretic hormone

ADT androgen deprivation therapy

ADPKD autosomal dominant polycystic kidney disease

AFP alpha-fetoprotein

AHR acute humoral rejection

AI androgen-independent

AID artifi cial insemination donor

AIDS acquired immunodefi ciency syndrome

a.m ante meridiem (before noon)

AMACR α-methylacyl CoA racemase

AML angiomyolipoma

amp ampere

AMS American Medical Systems

ANP atrial natriuretic peptide

a-NVH asymptomatic non-visible haematuria

APD automated peritoneal dialysis

APF antiproliferative factor

5AR 5α-reductase

ARCD acquired renal cystic disease

5ARI 5α-reductase inhibitor

ARPKD autosomal recessive polycystic kidney diseaseART assisted reproductive techniques

AS active surveillance

ASAP atypical small acinar proliferation

ASTRO American Society of Therapeutic Radiation OncologistsATG antithymocyte globulin

ATN acute tubular necrosis

ATP adenosine triphosphate

AUA American Urological Association

AUA-SI American Urological Association Symptom IndexAUR acute urinary retention

AUS artifi cial urinary sphincter

AVM arteriovenous malformation

BAUS British Association of Urological Surgeons

BCG bacillus Calmette–Guérin

bFGF basic fi broblastic growth factor

BHCG beta human chorionic gonadotrophin

BLI beta-lactamase inhibitor

BMSFI Brief Male Sexual Function Inventory

BNI bladder neck incision

BOO bladder outlet obstruction

BPE benign prostatic enlargement

bPFS biochemical progression-free survival

BPH benign prostatic hyperplasia

BPLND bilateral pelvic lymphadenectomy

BPO benign prostatic obstruction

BPS bladder pain syndrome

BSE bovine spongiform encephalopathy

BT brachytherapy

BTA bladder tumour antigen

BTX-A botulinum toxin-A

BUO bilateral ureteric obstruction

BXO balanitis xerotica obliterans

CAA Civil Aviation Authority

CABG coronary artery bypass graft

CAH congenital adrenal hyperplasia

CAIS complete androgen insensitivity syndrome

cAMP cyclic adenosine monophosphate

CAPD continuous ambulatory peritoneal dialysis

CBAVD complete bilateral absence of vas deferens

CCF congestive cardiac failure

CCr creatinine clearance

CEULDCT contrast-enhanced ultra-low dose computed tomography

cGMP cyclic guanosine monophosphate

CI confi dence interval

CIRF clinically insignifi cant residual fragment

CJD Creutzfeldt–Jakob disease

CISC clean intermittent self catheterization

CKD chronic kidney disease

cm centimetre

CMV cytomegalovirus

CNI calcineurin inhibitor

CNS central nervous system

COPD chronic obstructive pulmonary disease

COPUM congenital obstructive posterior urethral membrane

CP chronic prostatitis

CPB chronic painful bladder (syndrome)

CPPS chronic pelvic pain syndrome

CPRE complete primary repair of bladder exstrophy

CT computed tomography or collecting tubule

CTPA computerized tomography pulmonary angiography

CTU computed tomography urography

CT-KUB CT of the kidneys, ureters, and bladder

CVA cerebrovascular accident

Da Dalton

DCT distal convoluted tubule

DE delayed ejaculation

DESD detrusor-external sphincter dyssynergia

DEXA dual-energy X-ray absorptiometry (scan)

DGI disseminated gonococcal infection

DH detrusor hyperrefl exia

DHT dihyrotestosterone

DIC disseminated intravascular coagulation

dL decilitre

DMSA dimercapto-succinic acid (renogram)

DMSO dimethyl sulphoxide

DRE digital rectal examination

DSD detrusor sphincter dyssynergia or disorders of sex

development

DVLA Drivers Vehicle Licensing Agency

DVT deep vein thrombosis

EAU European Association of Urology

EBRT external beam radiotherapy

ECG electrocardiogram

ED erectile dysfunction

EDTA ethylene diamine tetra-acetic acid

e.g exempli gratia (for example)

EGF epidermal growth factor

eGFR estimated glomerular fi ltration rate

EHL electrohydraulic lithotripsy

ELISA enzyme-linked immunosorbant assay

EMDA electromotive drug administration

EMG electromyography

EMU early morning urine

EPLND extended pelvic lymphadenectomy

EPN emphysematous pyelonephritis

EORTC European Organization for Research and Treatment

of Cancer

EPS expressed prostatic secretions

ESBL extended spectrum B-lactamase

ESR erythrocyte sedimentation rate

ESSIC European Society for the Study of Bladder Pain

Syndrome/Interstitial Cystitis

ESWL extracorporeal shock wave therapy

FBC full blood count

FGSI Fournier’s gangrene severity index

FNA fi ne needle aspiration

FSH follicle stimulating hormone

GCT germ cell tumour

GFR glomerular fi ltration rate

GU gonococcal urethritis (or genitourinary)

GUM genitourinary medicine

HCG human chorionic gonadotrophin

HIFU high-intensity focused ultrasound

HIF hypoxia-inducible factor

HIV human immunodefi ciency virus

HLA human leucocyte antigen

HMG-CoA 3-hydroxy-3-methyl-glutaryl-CoA reductase

5-HMT 5-hydroxymethyl tolterodine

HPCR high pressure chronic retention

HoLAP holmium laser ablation of the prostateHoLEP holmium laser enucleation of the prostateHoLRP holmium laser resection of the prostateHPA Health Protection Agency

HPO42– phosphate ion

H2PO4 phosphoric acid

HPV human papilloma virus

HRO high reliability organization

HRP horseradish peroxidise

HTLA human T lymphotropic virus

Hz Hertz

IC intermittent catheterization or interstitial cystitis

ICD implantable cardioverter defi brillator

i.e id est (that is)

IFIS intraoperative fl oppy iris syndrome

ISC intermittent catheterization

ICS International Continence Society

ICSI intracytoplasmic sperm injection

ICU intensive care unit

IDC indwelling catheter

IDO idiopathic detrusor overactivity

IELT intravaginal ejaculatory latency time

IFN interferon

IGCN intratubular germ cell neoplasia

IGF insulin-like growth factor

IIEF International Index of Erectile Function

ILP interstitial laser prostatectomy

IM intramuscular

INR international normalized ratio

IPC intermittent pneumatic calf compression

IPSS International Prostate Symptom ScoreISC intermittent self-catheterization

ISD intrinsic sphincter defi ciency

ISSM International Society for Sexual Medicine

ITU intensive treatment unit

IU international unit

IUI intrauterine insemination

IVC inferior vena cava

IVP intravenous pyelography

IVU intravenous urography

KTP potassium titanyl phosphate (laser)

KUB Kidneys, ureter and bladder (X-ray)

LDUH low-dose unfractionated heparin

LFT liver function test

LHRH luteinizing hormone-releasing hormone

LMWH low molecular weight heparin

LNI lymph node invasion

LOH late-onset hypogonadism

LRP laparoscopic radical prostatectomy

LSD lysergic acid diethylamide

LUT lower urinary tract

LUTS lower urinary tract symptom

mA milliampere

μA microampere

MAB maximal androgen blockade

MAG3 mercaptoacetyl-triglycyine (renogram)

MAGPI meatal advancement and granuloplasty

MAPP Multidisciplinary Approach to Pelvic Pain

MAPS Men After Prostate Surgery (study)

MAR mixed antiglobulin reaction (test)

MCDK multicystic dysplastic kidney

mcg microgram

MCUG micturating cystourethrography

MDCTU multidetector CT urography

MIS Müllerian inhibiting substance

MIT minimally invasive treatment

mRNA messenger ribonucleic acid

MRSA meticillin-resistant staphylococcus aureus

MSMB microseminoprotein-beta

MRU magnetic resonance urography

MSK medullary sponge kidney

mSV milliSevert

MUCP maximal urethral closure pressure

MUI mixed urinary incontinence

MUSE Medicated Urethral System for Erection

MVAC methotrexate, vinblastine, adriamycin, cisplatin

NA noradrenaline

NAAT nucleic acid amplifi cation test

NaCl sodium chloride

NAION non-arteritic anterior ischaemic optic nerve neuropathy

NDO neurogenic detrusor overactivity

NGU non-gonococcal urethritis

NICE National Institute for Health and Clinical Excellence

NIDDK National Institute of Diabetes and Digestive and Kidney

Diseases

NIH National Institute of Health

NIH-CPSI National Institute of Health Chronic Prostatitis Symptom

Index

nm nanometre

NMNE non-monosymptomatic nocturnal enuresis

nmol nanomole

NMP nuclear matrix protein

NND number needed to detect

NNT number needed to treat

NSAID non-steroidal anti-infl ammatory drug

NSGCT non-seminomatous germ cell tumours

NSU non-specifi c urethritis

NVH non-visible haematuria

OAB overactive bladder

OAT oligoasthenoteratospermia

OIF onlay island fl ap

OLND obturator lymphadenectomy

OSA obstructive sleep apnoea

Pabd intra-abdominal pressure

PAOD peripheral artery occlusive disease

PaCO2 partial pressure of carbon dioxide (in arterial blood)

PaO2 partial pressure of oxygen (in arterial blood)PAG periaqueductal grey matter

PAIS Partial androgen insensitivity syndrome

PBS/IC painful bladder syndrome/interstitial cystitis

PCNL percutaneous nephrolithotomy

PCO2 carbon dioxide tension

PCR polymerase chain reaction

PCT proximal convoluted tubule

PDD photodynamic detection

PDE5 phosphodiesterase type-5

Pdet detrusor pressure

PDGF platelet-derived growth factor

PE premature ejaculation or pulmonary embolism

PEC perivascular epithelioid cell

PEP post-exposure prophylaxis

PESA percutaneous epididymal sperm aspirationPET positron emission tomography

PFMT pelvic fl oor muscle training

PFS pressure fl ow studies

PIN prostatic intraepithelial neoplasia

PLAP placental alkaline phosphatase

PLESS Proscar Long-term Effi cacy Safety Study

PMC pontine micturition center

PMNL polymorphonuclear leukocytes

PN partial nephrectomy

PNE peripheral nerve evaluation

POP pelvic organ prolapse

POPQ pelvic organ prolapse quantifi cation

PPS pentosan polysulphate sodium

PREDICT Prospective European Doxazosin and Combination Therapy

PSA prostate specifi c antigen

PTFE polytetrafl uoroethylene

PTH parathyroid hormone levels

PTN posterior tibial nerve

PTTI parenchymal transit time index

PTNS posterior tibial nerve stimulation

PUJ pelviureteric junction

PUJO pelviureteric junction obstruction

PUNLMP papillary urothelial neoplasm of low malignant potentialPUV posterior urethral valves

PVD peripheral vascular disease

Pves intravesical pressuer

PVN paraventricular nucleus

PVN peripheral vascular disease

PVP photoselective vaporization of the prostate

PVR post-void residual

QALY quality-adjusted life year

Qmax maximal fl ow rate

QoL quality of life

RBF renal blood fl ow

RCC renal cell carcinoma

RCT randomized control trial

RFA radiofrequency ablation

RI resistive index

RP radical prostatectomy

RPD renal pelvis diameter

RPF retroperitoneal fi brosis or renal plasma fl ow

RPLND retroperitoneal lymph node dissection

RPR rapid plasma regain

RT radiotherapy

RTA renal tubular acidosis

RTK receptor tyrosine kinase

SARS sacral anterior root stimulator

SC subcutaneous

SCC squamous cell carcinoma

SCI spinal cord injury

SCr serum creatinine

SEM standard error of the mean

SHBG sex hormone binding globulin

SHIM Sexual Health Inventory for Men

SHO senior house offi cer

SIRS systemic infl ammatory response syndrome

SLE systemic lupus erythematosus

SNAP synaptosomal associated protein

SNM sacral nerve modulation

SNS sacral nerve stimulation

s-NVH symptomatic non-visible haematuria

SOP standard operating procedures

SpR specialist registrar

SRE skeletal-related events

SSRI serotonin reuptake inhibitor

ssRNA single-stranded ribonucleic acid

STD sexually transmitted disease

STI sexually transmitted infection

SUI stress urinary incontinence

TAL thick ascending limb (of Loop of Henle)

TB tuberculosis

TBW total body water

TCC transitional cell carcinoma

TEAP transurethral ethanol ablation of the prostateTEDs thromboembolic deterrent stockings

TENS transcutaneous electrical nerve stimulation

TESA testicular exploration and sperm aspiration

TESE testicular exploration and sperm extractionTET tubal embryo transfer

TGF transforming growth factor

TIN testicular intratubular neoplasia (synonymous with IGCN)TIP tubularized incised plate

TNF tumour necrosis factor

TNM tumour, node, metastasis

TOV trial of void

TPIF transverse preputial island fl ap

TRUS transrectal ultrasonography

TSE testicular self-examination

TUIP transurethral incision in the prostate

TULIP transuretheral ultrasound-guided laser-induced

prostatectomy

TUMT transurethal microwave thermotherapy

TUNA transurethal radiofrequency needle ablation

TUR transurethral resection

TURBT transurethral resection of bladder tumour

TURED transurethral resection of the ejaculatory ducts

TURP transurethral resection of prostate

TURS transurethral resection syndrome

TUU transureteroureterostomy

TUVP transurethral electrovaporization of the prostate

TUVRP transurethral vaporization resection of the prostate

tvl total vaginal length

TVT tension-free vaginal tape

TVTO tension-free vaginal tape obturator route

TWOC trial without catheter

U (international) unit

UD urethral diverticulum

U & E urea and electrolytes

UI urinary incontinence

ULDCT ultra-low dose computed tomography

UPJO ureteropelvic junction obstruction

USA United States (of America)

UTI urinary tract infection

UUI urge urinary incontinence

UUO unilateral ureteric obstruction

UUT-TCC upper urinary tract transitional cell carcinoma

VB3 post-prostatic massage urine

vCJD variant Creutzfeldt–Jakob disease

VCUG voiding cystourethrography

VEGF vascular endothelial growth factorVEGFR vascular endothelial growth factor receptor

VH visible haematuria

VHL von Hippel–Lindau

VLAP visual laser ablation of the prostate

VQ ventilation/perfusion (scan)VRE vancomycin-resistant enterococci

VTE venous thromboembolism

VUJ vesicoureteric junction

VUJO vesicoureteric junction obstructionVUR vesicoureteric refl ux

VURD vesicoureteric refl ux with renal dysplasiaVVF vesicovaginal fi stula

W watt

WBC white blood cell

WCC white cell count

WHO World Health Organization

Documentation and note keeping 4

Patient safety in surgical practice 6

Communication skills

Communication is the imparting of knowledge and understanding Good communication is crucial for the surgeon in his or her daily interaction with patients The nature of any interaction between surgeon and patient will depend very much on the context of the ‘interview’, whether you know the patient already, and on the quantity and type of information that needs to be imparted As a general rule, the basis of good communication requires the following:

Introduction

•

Give your name, explain who you are, greet the patient/relative ately (e.g handshake), check you are talking to the correct person.Establish the purpose of the interview

Pick up on and respond to cues

What you think should be the patient’s main concerns may not be Try to

fi nd out exactly what the patient is worried about

Chunks and checks

•

Give information in small quantities and check that this has been stood A good way of doing this is to ask the patient to explain what they think you have said

Don’t express your personal views or beliefs

Alternate control of the interview between the patient and

•

yourself

Allow the patient to take the lead where appropriate

Signpost changes in direction

•

State clearly when you move onto a new subject

Avoid the use of jargon

•

Use language the patient will understand, rather than medical terminology

3Body language.

•

Use body language that shows the patient that you are interested in their problem and that you understand what they are going through Respect cultural differences; in some cultures, eye contact is regarded as a sign of aggression

Summarize and indicate the next steps

•

Summarize what you understand to be the patient’s problem and what the next steps are going to be

Documentation and note keeping

The Royal College of Surgeons’ guidelines state that each clinical history sheet should include the patient’s name, date of birth, and record number Each entry should be timed, dated, and signed, and your name and position (e.g SHO for ‘senior house offi cer’ or SPR for ‘specialist registrar’) should

be clearly written in capital letters below each entry You should also ument which other medical staff were present with you on ward rounds

doc-or when seeing a patient (e.g ‘ward round—SPR (Mr X)/SHO/HO’).Contemporaneous note keeping is an important part of good clini-cal practice Medical notes document the patient’s problems, the inves-tigations they have undergone, the diagnosis, and the treatment and its outcome The notes also provide a channel of communication between doctors and nurses on the ward and between different medical teams

In order for this communication to be effective and safe, medical notes must be clearly written They will also be scrutinized in cases of complaint and litigation Failure to keep accurate, meaningful notes which are timed, dated, and signed, with your name written in capital letters below, exposes you to the potential for criticism in such cases The standard of note keep-ing is seen as an indirect measure of the standard of care you have given your patients Sloppy notes can be construed as evidence of sloppy care, quite apart from the fact that such notes do not allow you to provide evi-dence of your actions! Unfortunately, the defence of not having suffi cient time to write the notes is not an adequate one, and the courts will regard absence of documentation of your actions as indicating that you did not

do what you said you did

Do not write anything that might later be construed as a personal ment about a patient or colleague (e.g do not comment on an individual’s character or manner) Do not make jokes in the patient’s notes Such comments are unlikely to be helpful and may cause you embarrassment in the future when you are asked to interpret them

com-Try to make the notes relevant to the situation so, e.g in a patient with suspected bleeding, a record of blood pressure and pulse rate is important, but a record of a detailed neurological history and examination

is less relevant (unless, e.g a neurological basis for the patient’s problem

is suspected)

The results of investigations should be clearly documented in the notes, preferably in red ink, with a note of the time and date when the investiga-tion was performed

Avoid the use of abbreviations In particular, always write LEFT or RIGHT in capital letters, rather than Lt/Rt or L/R A handwritten L can sometimes be mistaken for an R and vice versa

Operation notes

We include the following information on operation notes:

Patient name, number, and date of birth

fl owtrons, heparin, etc.)

Type, time of administration, and doses of antibiotic prophylaxis

Patient safety in surgical practice

The aviation, nuclear, and petrochemical industries are termed ‘high ability organizations’ (HROs) because they have adopted a variety of core safety principles that have enabled them to achieve safety success, despite

reli-‘operating’ in high-risk environments Surgeons can learn much from HROs and can adopt some of these safety principles in surgical practice in order

to improve safety in the non-technical aspects of care

Foremost amongst the safety principles of HROs are:

Team working

•

Use of standard operating procedures (SOPs):

carried out according to a set of rules and in a way that is standardized across the organization

Cross-checking:

• members of the team check that a procedure, drug,

or action has been done or administered by ‘verbalizing’ that action to another team member This is most familiar when aircraft cabin crew are asked by the pilot to check that the doors of the plane are locked shut (‘doors to cross-check’) and crew members cross to the opposite door to confi rm this has been done In surgical practice, an example

of cross-checking could be ‘antibiotic given?’, confi rmed by a specifi c reply such as ‘240mg IV gentamicin given’

Regular audit and feedback of audit data:

good and bad) are collected regularly and crucially, team members are notifi ed (e.g in audit meetings) of where they are performing well or badly

Establishment of variable hierarchies:

Haematuria I: defi nition and types 8

Haematuria II: causes and investigation 10

Haemospermia 14

Lower urinary tract symptoms (LUTS) 16

Nocturia and nocturnal polyuria 18

Loin (fl ank) pain 20

Urinary incontinence 24

Genital symptoms 26

Abdominal examination in urological disease 28

Digital rectal examination (DRE) 30

Lumps in the groin 32

Lumps in the scrotum 34