Challenging Cases in Urological Surgery Cases with Expert Commentary
Edited by Karl H. Pang MBChB, BSc(Hons), MSc, PhD, FRCS(Urol), FEBU, AFHEA
Post-CCT Clinical Fellow in Andrology, Institute of Andrology, University College London Hospitals NHS Foundation Trust; Honorary Clinical Lecturer, University College London; Honorary Clinical Lecturer, Department of Oncology and Metabolism and Academic Urology Unit, University of Sheffield, UK
James W.F. Catto MBChB, PhD, FRCS(Urol)
Professor in Urological Surgery, Department of Oncology and Metabolism and Academic Urology Unit, University of Sheffield, UK; Honorary Consultant Urological Surgeon, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust European Urology Editor-in-Chief
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FOREWORD
At any national or international urology congress, the sessions delegates most enjoy are those where experts debate the management of complex cases and in so doing dissect the evidence base and show how it should be applied. This book looks to do the same, and a urologist who reads it will acquire a lot of knowledge and save an airfare, a conference registration fee and a hotel bill! It’s a new concept and I think it works. The list of subjects covered is broad ranging and very interesting; challenging in every way. The views expressed by the authors and the experts will, I am sure, generate much debate. I’m a retroperitoneal surgeon and certainly found much to debate in case 7 (renal oncocytoma), case 16 (upper urinary tract urothelial carcinoma) and case 19 (growing teratoma syndrome in testis cancer). That though I think is the point, in a challenging case there may not be a right or a wrong answer but understanding how experts reach their decisions can be a very valuable way of learning. The book should be a very good primer for board exams or the FRCS (Urol) examination. So, well done to the editors, Karl Pang and Jim Catto, on pulling it all together. The book reminded me once again of the staggering breadth of the specialty we practise and I’m looking forward to debating with specialist registrars, fellows, and consultants at Guy’s all 48 of the cases.
Tim S. O’Brien MA, DM, FRCS(Urol) Consultant Urological Surgeon Immediate past-President of BAUS
PREFACE
This is the first urological surgery book added to the Challenging Cases series. Common cases, challenges, and controversial topics are discussed in a format utilizing boxes to highlight learning points, evidence bases, and future directions. Using case examples, experts provide clinical tips and personal comments on how they manage specific presentations. Expert commentary is provided throughout each chapter with a concluding ‘Final word’ from the expert at the end of each case. This book includes a variety of cases covering most sections outlined in the Intercollegiate Surgical Curriculum for Urological Surgery including oncology, endourology, functional and female urology, neurourology, andrology, trauma, transplantation, and paediatric urology. This book is a highly valuable resource for all those interested in urological surgery, allied health professionals, trainees in the field and those sitting postgraduate urology examinations. We thank all authors and experts for their hard work and hope you enjoy reading this text.
Karl H. Pang and James W.F. Catto
Section
Christopher K. Harding
Uwais Mufti and Ased Ali
Section 2 Urinary tract stones
Jonathan
Lisa Bibby, Mostafa Sheba, Andrea Lavinio, Andrew Winterbottom, and Oliver Wiseman
Siân Allen and Daron Smith
Section
Sanjeev Pathak and Neil Oakley
Andrew Deytrikh, Georgina Reall, James Lenton, and Anthony Browning
Section
Omer Altan, Alastair Lamb, and Freddie C. Hamdy
Francesco Claps, Fabio Traunero, Nicola Pavan, and Prasanna Sooriakumaran
Adnan Ali and Noel W. Clarke
Section
Case
Samantha Conroy and Aidan P. Noon
Samantha Conroy and James W.F. Catto
Case 13 Progression of high-grade non-muscle-invasive bladder cancer
Naomi L. Neal, Richard J. Bryant, and Andrew Protheroe
Section 6 Upper urinary tract cancer
Case 14 Localized renal cancer with inferior vena cava tumour thrombus
Tobias Klatte, Antony C.P. Riddick, Grant D. Stewart, and Jose A. Karam
Case 15 Metastatic renal cancer
Joana B. Neves, Maxine G. B. Tran, and Axel Bex
Case 16 Upper urinary tract urothelial carcinoma
Richard Nobrega and Mark Sullivan
Section 7 Penile cancer Case 17 Localized penile cancer
Ian Eardley
Case 18 Advanced and metastatic penile cancer
Hussain Alnajjar and Asif Muneer
Section 8 Testicular cancer
Case 19 Growing teratoma syndrome in testis cancer 185
Jennifer Clark, Thomas A. Lee, and Vijay A.C. Ramani
Case 20 Metastatic testicular cancer: post-chemotherapy residual mass and cancer survivorship 199
Findlay MacAskill and Archie Fernando
Section 9 Functional, female, and neurourology
Case 21 Benign prostatic enlargement and acute urinary retention
Emma Papworth, Joseph Jelski, and Hashim Hashim
Case 22 Chronic retention, renal failure, and diuresis
Cherrie Ho, James Jenkins, and Marcus Drake
Case 23 Urge urinary incontinence
Pravisha Ravindra and Richard Parkinson
Case 24 Stress urinary incontinence
Rachel Barratt and Suzanne Biers
Case 25 Bladder pain syndrome/interstitial cystitis
Altaf Mangera
Case 26 Female urinary retention
Pravisha Ravindra and Nikesh Thiruchelvam
Case 27 Neurogenic bladder
Hazel Ecclestone, Rizwan Hamid, and Julian Shah
Case 28 Genitourinary prolapse
Priyanka H. Krishnaswamy and Swati Jha
Section 10 Reconstruction
Case 29 Urethral stricture disease
Jamie V. Krishnan, Nadir I. Osman, and Christopher R. Chapple
Case 30 Urethral diverticulum
Anudini Ranasinghe, Tamsin Greenwell, and Jeremy Ockrim
Case 31 Management of ketamine-induced bilateral upper urinary tract injury
Ishtiakul G. Rizvi and Mohammed Belal
Case 32 Vesicovaginal fistula
Sachin Malde and Arun Sahai
Section 11 Male infertility and sexual dysfunction
Case 33 Male factor infertility: management of the azoospermic patient 321
Matthew Young and Oliver Kayes
Case 34 Erectile dysfunction
James Tracey and Majid Shabbir
Case 35 Peyronie’s disease
Sarah Prattley and Rowland Rees
Case 36 Ejaculatory orgasmic disorders
Maria Satchi and David Ralph
Section 12 Emergency urology and trauma
Case 37 Testicular torsion controversies
Lona Vyas, Mohamed Noureldin, and Suks Minhas
Case 38 Priapism
Thomas Ellul, Nicholas Bullock, and Ayman Younis
Case 39 Renal trauma
Hack Jae Lee, Christopher Anderson, and Davendra M. Sharma
Case 40 Bladder and ureteric trauma
Guglielmo Mantica, Pieter V. Spies, and André Van der Merwe
Case 41 Penile fracture
Huw Garrod, Sacha Moore, Iqbal Shergill, and Christian Seipp
Section 13 Renal transplantation
Case 42 Renal transplantation
John M. O’Callaghan and James A. Gilbert
Section 14 Paediatric surgery
Case 43 Recurrent urinary tract infections and non-neurogenic neurogenic bladder in children 419 Martin Skott and Imran Mushtaq
Case 44 Undescended testis 425
María S. Figueroa-Díaz, Kimberly Aikins, and Imran Mushtaq
Case 45 Neurogenic bladder in children 433
Sara Lobo, Kiarash Taghavi, and Imran Mushtaq
Case 46 Haemorrhagic eschar of the glans: a case study in the myriad manifestations of urethral pathology 443 Emily Decker, Kevin Cao, and Peter Cuckow
Case 47 Vesicoureteral reflux in children
María S. Figueroa-Díaz, Alexander Cho, and Imran Mushtaq
Section 15 Urological radiology
Case 48 Acute interventional radiology procedures in urology
Yousef Shahin and Steven Kennish
ABBREVIATIONS
5-FU 5-fluorouracil
AAST American Association for the Surgery of Trauma
ABP acute bacterial prostatitis
ADT androgen deprivation therapy
AFP alpha-fetoprotein
AFS autologous fascial sling
AML angiomyolipoma
AMR antimicrobial resistance
ANH antenatal hydronephrosis
APD anterior–posterior diameter
AS active surveillance
ATLS® Advanced Trauma Life Support®
AUA American Urological Association
AUR acute urinary retention
AUS artificial urethral sphincter
BAUS British Association of Urological Surgeons
BC bladder cancer
BCD bell clapper deformity
BEP bleomycin, etoposide, and cisplatin
BMD bone mineral density
BMG buccal mucosal graft
BMI body mass index
BN bladder neck
BOO bladder outlet obstruction
BPH benign prostate hyperplasia
BPO benign prostate obstruction
BPS bladder pain syndrome
BTX botulinum toxin
BXO balanitis xerotica obliterans
CAD coronary artery disease
CAP continuous antibiotic prophylaxis
CBP chronic bacterial prostatitis
CCH collagenase Clostridium histolyticum
ccRCC clear cell renal cell carcinoma
CES cauda equina syndrome
CI confidence interval
CIS carcinoma-in situ
CISC clean intermittent self-catheterization
CIT cold ischaemic time
CKD chronic kidney disease
CP chronic prostatitis
CPPS chronic pelvic pain syndrome
CRP
C-reactive protein or cytoreductive radical prostatectomy
CT computed tomography
CTU computed tomography urogram/urography
CUR chronic urinary retention
DBD donation after brain death
DCD donation after circulatory death
DE delayed ejaculation
DM diabetes mellitus
DMSA dimercaptosuccinic acid
DOA detrusor overactivity
DRE digital rectal examination
DSD disorder of sex development
DVIU direct visual internal urethrotomy
EAU European Association of Urology
ECIRS endoscopic combined intrarenal surgery
ECOG Eastern Cooperative Oncology Group
ED Erectile dysfunction
eGFR estimated glomerular filtration rate
EORTC European Organisation for Research and Treatment of Cancer
ePLND extended pelvic lymph node dissection
EPS expressed prostatic secretions
ERAS® Enhanced Recovery After Surgery
ESWL extracorporeal shock wave lithotripsy
FDG fluorodeoxyglucose
Fr French (gauge)
FSH follicle-stimulating hormone
GCNIS germ cell neoplasia in situ
GCT germ cell tumour
GnRH gonadotropin-releasing hormone
GP general practitioner
GTS growing teratoma syndrome
hCG human chorionic gonadotropin
HGNMIBC high-grade non-muscle-invasive bladder cancer
HIV human immunodeficiency virus
HLA human leukocyte antigen
HoLEP holmium laser enucleation of the prostate
HPCR high-pressure chronic retention
HPV human papillomavirus
HR hazard ratio
HRR homologous recombination repair
HTN hypertension
IC interstitial cystitis
ICIQ International Consultation on Incontinence
Questionnaire
ICS International Continence Society
ICSI intracytoplasmic sperm injection
IFNα interferon alpha
IIEF International Index of Erectile Function
IPSS International Prostate Symptom Score
ISC intermittent self-catheterization
ISD intermittent self-dilatation
IVC inferior vena cava
KS Klinefelter syndrome
KUB kidneys, ureters, and bladder
LATP local anaesthetic transperineal
LDH lactate dehydrogenase
LH luteinizing hormone
LN lymph node
LND lymph node dissection
LPCR low-pressure chronic retention
LUTS lower urinary tract symptoms
MAG3 mercaptoacetyltriglycine
mCRPC metastatic castration-resistant prostate cancer
MCUG micturating cystourethrogram
MDT multidisciplinary team
MET medical expulsion therapy
MFI male factor infertility
MHRA Medicines and Healthcare products Regulatory Agency
MI myocardial infarction
MIBC muscle-invasive bladder cancer
MMC mitomycin C
mpMRI multiparametric magnetic resonance imaging
MRI magnetic resonance imaging
mTESE microdissection testicular sperm extraction
mTOR mammalian target of rapamycin
MUL membranous urethral length
MUT mid-urethral tape
MVAC methotrexate, vinblastine, Adriamycin® (doxorubicin), and cisplatin
NAC neoadjuvant chemotherapy
NICE National Institute for Health and Care Excellence
NIDDK National Institute of Diabetes and Digestive and Kidney Diseases
NMIBC non-muscle-invasive bladder cancer
NNNB non-neurogenic neurogenic bladder
NOA non-obstructive azoospermia
NSAID non-steroidal anti-inflammatory drug
NSGCT non-seminomatous germ cell tumour
NVB neurovascular bundle
NYHA New York Heart Association
OA obstructive azoospermia
OAB overactive bladder
OAT oligoasthenoteratospermia
onco-TESE onco-testicular sperm extraction
OR odds ratio
PCCL percutaneous nephrostomy cystolitholapaxy
PCN percutaneous nephrostomy
PCNL percutaneous nephrolithotomy
PD Peyronie’s disease
PDE5 phosphodiesterase type 5
PDE5i phosphodiesterase type 5 inhibitor
PE premature ejaculation
PET positron emission tomography
PFMT pelvic floor muscle training
PI-RADS Prostate Imaging Reporting and Data System
PLND pelvic lymph node dissection
POD post-obstructive diuresis
POP pelvic organ prolapse
PSA prostate-specific antigen
PSM positive surgical margin
PTNS percutaneous tibial nerve stimulation
PUV posterior urethral valves
qSOFA quick Sepsis-related Organ Failure Assessment
RARP robotic-assisted radical prostatectomy
RC radical cystectomy
RCC renal cell carcinoma
RCT randomized control trial
RNU radical nephroureterectomy
RPLND retroperitoneal lymph node dissection
RR risk ratio
RRT renal replacement therapy
SCC squamous cell carcinoma
SCD sickle-cell disease
SFA semen fluid analysis
SFR stone-free rate
SNM sacral neuromodulation
SNS sacral nerve stimulation
SPC suprapubic catheter
SRE skeletal-related event
SSRI selective serotonin reuptake inhibitor
SUI stress urinary incontinence
SWL shockwave lithotripsy
TA tunica albuginea
TC testicular cancer
TCC transitional cell carcinoma
TESE testicular sperm extraction
TKI tyrosine kinase inhibitor
TNM tumour, node, and metastasis
TRUS transrectal ultrasound
TS tuberous sclerosis
TUC transurethral catheter
TUCL transurethral cystolitholapaxy
TURBT transurethral resection of a bladder tumour
TURP transurethral resection of the prostate
TV tunica vaginalis
UCC urothelial cell carcinoma
UDS urodynamic studies
UDT undescended testis
UI urinary incontinence
UISS University of California Integrated Staging System
UO ureteric orifice
UPJO ureteropelvic junction obstruction
UR urinary retention
URS ureteroscopy
USS ultrasound scan
UTI urinary tract infection
UTUC upper tract urothelial carcinoma
UUI urge urinary incontinence
VCMG video cystometrography
VTT venous tumour thrombus
VUDS video urodynamic studies
VUJ vesicoureteric junction
VUR vesicoureteral reflux
VVF vesicovaginal fistula
WCC white cell count
WHO World Health Organization
EXPERTS
Ased Ali
Consultant Urological Surgeon, Department of Urology, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
Christopher Anderson
Consultant Urological Surgeon, Department of Urology, St George’s University Hospitals NHS Foundation Trust, London, UK
Mohammed Belal
Consultant Urological Surgeon, Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Axel Bex
Consultant Urological Surgeon, Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London; Honorary Associate Professor, UCL Division of Surgical and Interventional Science, UK
Suzanne Biers
Consultant Urological Surgeon, Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Anthony Browning
Consultant Urological Surgeon, Department of Urology, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
Richard J. Bryant
Associate Professor of Urological Surgery and Honorary Consultant Urological Surgeon, Nuffield Department of Surgical Sciences, Oxford Cancer Research Centre, University of Oxford; Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
James W.F. Catto
Professor of Urological Surgery and Honorary Consultant Urological Surgeon, Department of Oncology and Metabolism, University of Sheffield; Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, UK
Christopher R. Chapple
Professor and Consultant Urological Surgeon, Section of Functional and Reconstructive Urology, Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Noel W. Clarke
Consultant Urological Surgeon, Department of Urology, The Christie NHS Foundation Trust; Honorary Professor of Urological Oncology, University of Manchester, UK
Peter Cuckow
Professor of Paediatric Urological Surgery, Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
Marcus Drake
Professor of Physiological Urology, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
Ian Eardley
Consultant Urological Surgeon, Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Archie Fernando
Consultant Urological Surgeon, Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
James A. Gilbert
Consultant in Transplantation and Vascular Access Surgery, Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
Jonathan Glass
Consultant Urological Surgeon, Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Freddie C. Hamdy
Nuffield Professor of Surgery and Professor of Urology, Department of Urology, Churchill Hospital, Oxford University Hospitals NHS Trust; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
Christopher K. Harding
Consultant Urological Surgeon and Honorary Professor of Urology, Department of Urology, The Newcastle upon Tyne Hospitals NHS Foundation Trust; University of Newcastle, Newcastle, UK
Hashim Hashim
Consultant Urological Surgeon and Honorary Professor of Urology, Bristol Urological Institute, Southmead Hospital, Bristol, UK
Swati Jha
Consultant in Urogynaecology, Department of Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Jose A. Karam
Assistant Professor of Urological Surgery, Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
Oliver Kayes
Consultant Urological Surgeon and Honorary Senior Lecturer, Department of Urology, University of Leeds, Leeds, UK
Steven Kennish
Consultant Radiologist, Department of Clinical Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Andrea Lavinio
Consultant in Intensive Care, Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
James Lenton
Consultant in Interventional Radiology, Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds; Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
Altaf Mangera
Consultant Urological Surgeon, Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Suks Minhas
Professor and Consultant Urological Surgeon, Department of Urology, Imperial College Healthcare NHS Trust, London, UK
Asif Muneer
Professor and Consultant Urological Surgeon, Institute of Andrology, University College London Hospitals NHS Foundation Trust; NIHR Biomedical Research Centre University College London Hospital; Division of Surgery and Interventional Science, University College London, London, UK
Imran Mushtaq
Professor and Consultant Paediatric Urological Surgeon, Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, UK
Aidan P. Noon
Consultant Urological Surgeon, Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Neil Oakley
Consultant Urological Surgeon, Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Jeremy Ockrim
Consultant Urological Surgeon, Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
Richard Parkinson
Consultant Urological Surgeon, Department of Urology, Nottingham University Hospitals NHS Trust, Nottingham, UK
Andrew Protheroe
Associate Professor and Consultant in Medical Oncology, Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
David Ralph
Professor in Urological Surgery, Institute of Andrology, University College London Hospitals NHS Foundation Trust, London, UK
Vijay A.C. Ramani
Consultant Urological Oncological and Robotic Surgeon, Department of Urology, The Christie and Manchester University Hospitals NHS Foundation Trust, Manchester, UK
Georgina Reall
Consultant in Histopathology, Department of Histopathology, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
Rowland Rees
Consultant Urological Surgeon, Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
Arun Sahai
Consultant Urological Surgeon and Reader in Urology, Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust; King’s College London, London, UK
Christian Seipp
Consultant Urological Surgeon, The Alan De Bolla Wrexham Urology Department, Wrexham Maelor Hospital, Wrexham, UK
Majid Shabbir
Consultant Urological Surgeon and Honorary Senior Lecturer, Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Julian Shah
Consultant Urological Surgeon, King Edward VII’s Hospital and London Spinal Cord Injury Unit, Royal National Orthopaedic Hospital NHS Trust, London, UK
Davendra M. Sharma
Consultant Urological Surgeon, Department of Urology, St George’s University Hospitals NHS Foundation Trust, London, UK
Daron Smith
Consultant Endoluminal Endourologist, Endourology and Stone Unit, Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
Prasanna Sooriakumaran
Lead for Urology, Digestive Disease and Surgery Institute, Cleveland Clinic London, London, UK; Consultant Urological Surgeon, Department of Urology, University College London Hospitals NHS Foundation Trust, UK
Mark Sullivan
Consultant Urological Surgeon and Honorary Senior Lecturer, Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
Nikesh Thiruchelvam
Consultant Urological Surgeon, Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
André Van der Merwe
Professor in Urological Surgery, Division of Urology, Faculty of Medicine and Healthcare Sciences, Stellenbosch University; Tygerberg Academic Hospital, Cape Town, South Africa
Andrew Winterbottom
Consultant in Interventional Radiology, Department of Interventional Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Oliver Wiseman
Consultant Urological Surgeon, Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Ayman Younis
Consultant Urological Surgeon, Department of Urology, Swansea Bay University Health Board, Swansea, UK
CONTRIBUTORS
Kimberly Aikins
Specialist Registrar in Paediatric Surgery, Department of Paediatric Surgery and Urology, Starship Children’s Hospital, Auckland, New Zealand
Adnan Ali
Clinical Research Fellow in Urological Surgery, GenitoUrinary Cancer Research Group, Division of Cancer Sciences, The University of Manchester; FASTMAN Centre of Prostate Cancer Excellence, Manchester Cancer Research Centre; Department of Surgery, The Christie NHS Foundation Trust, Manchester, UK
Siân Allen
Consultant Urological Surgeon, Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
Hussain Alnajjar
Consultant Urological Surgeon and Andrologist, Institute of Andrology, University College London Hospitals NHS Foundation Trust, London, UK
Omer Altan
Consultant Urological Surgeon, Department of Urology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
Rachel Barratt
Post-CCT Clinical Fellow in Urology, Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
Lisa Bibby
Urology Registrar, Department of Urology, Addenbrookes Hospital, Cambridge, UK
Nicholas Bullock
Welsh Clinical Academic Track Fellow and Urology Registrar, Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, UK
Kevin Cao
Paediatric Urology Registrar, Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
Alexander Cho
Consultant Paediatric Urological Surgeon, Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
Francesco Claps
Urology Registrar, Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
Jennifer Clark
Urology Registrar, Department of Urology, The Christie NHS Foundation Trust; Manchester University Hospitals Foundation Trust, Manchester, UK
Samantha Conroy
Clinical Research Fellow, Academic Unit of Urology, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
Emily Decker
Clinical Fellow in Paediatric Urological Surgery, Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
Andrew Deytrikh
Urology Registrar, Department of Urology, Sheffield Teaching Hospitals, Sheffield, UK
Hazel Ecclestone
Consultant Urological Surgeon, London North West University Healthcare NHS Trust, London, UK
Thomas Ellul
Urology Registrar, Department of Urology, Royal Gwent University Hospital, Newport, UK
María S. Figueroa-Díaz
Consultant Paediatric Urological Surgeon, Department of Pediatric Urology, Hospital San Borja Arriarán, Santiago, Chile
Huw Garrod
Urology Registrar, Department of Urology, Royal Liverpool University Hospital, Liverpool
Tamsin Greenwell
Consultant Urological Surgeon, Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
Rizwan Hamid
Honorary Assistant Professor and Consultant Urological Surgeon, Department of Urology, University College
London Hospitals NHS Foundation Trust; Spinal Cord Injury Unit, Royal National Orthopaedic Hospital NHS Trust, London, UK
Cherrie Ho
Urology Registrar, Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
Joseph Jelski
Consultant Urological Surgeon, Department of Urology, Gloucestershire Hospitals NHS Foundation Trust, UK
James Jenkins
Urology Registrar, Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
Tobias Klatte
Consultant Urological Surgeon, Department of Urology, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK; Department of Surgery, University of Cambridge, Cambridge, UK
Jamie V. Krishnan
Urology Registrar, Section of Functional and Reconstructive Urology, Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Priyanka H. Krishnaswamy
Subspecialty Registrar in Urogynaecology, Department of Urogynaecology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
Alastair Lamb
Senior Fellow in Robotic Surgery and Honorary Consultant Urological Surgeon, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
Hack Jae Lee
Urology Registrar, Department of Urology, St George’s University Hospitals NHS Foundation Trust, London, UK
Thomas A. Lee
Urology Registrar, Department of Urology, The Christie NHS Foundation Trust and Manchester University Hospitals Foundation Trust, Manchester, UK
Sara Lobo
Paediatric Urology Senior Fellow, Department of Paediatric Urology, Great Ormond Street Hospital, London, UK
Findlay MacAskill
Urology Registrar, Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Sachin Malde
Consultant Urological Surgeon, Pelvic Floor Unit, Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Guglielmo Mantica
Consultant Urological Surgeon, Department of Urology, Policlinico San Martino Hospital, University of Genova, Genova, Italy
Sacha Moore
Academic Foundation Trainee, The Alan De Bolla Wrexham Urology Department, Wrexham Maelor Hospital, Wrexham, UK
Uwais Mufti
Post-CCT Clinical Fellow in Robotic Pelvic Urological Surgery, Department of Urology, Leeds Teaching Hospital NHS Trust, Leeds, UK
Naomi L. Neal
Consultant Urological Surgeon, Department of Urology, Hampshire Hospitals NHS Foundation Trust, UK
Joana B. Neves
Clinical Research Fellow, Division of Surgery and Interventional Science, University College London, London, UK
Richard Nobrega
Consultant Urological Surgeon, Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
Mohamed Noureldin
Clinical Fellow in Urological Surgery, Department of Urology, Imperial College Healthcare NHS Trust, London, UK
John M. O’Callaghan
Consultant Transplant Surgeon, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
Nadir I. Osman
Consultant Urological Surgeon, Section of Functional and Reconstructive Urology, Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Emma Papworth
Urology Registrar, Department of Urology, North Bristol NHS Trust, Bristol, UK
Sanjeev Pathak
Consultant Urological Surgeon, Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Nicola Pavan
Consultant Urological Surgeon, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
Sarah Prattley
Clinical Fellow in Urological Surgery, Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
Anudini Ranasinghe
Female Functional Reconstructive Fellow, Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
Pravisha Ravindra
Consultant Urological Surgeon, Department of Urology, University Hospitals of Leicester NHS Trust, Leicester, UK
Antony C.P. Riddick
Consultant Urological Surgeon and Lead Clinician for Renal Cancer, Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Ishtiakul G. Rizvi
Urology Registrar, Department of Urology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
Maria Satchi
Consultant Urological Surgeon, Department of Urology, Dartford and Gravesham NHS Trust, Kent, UK
Yousef Shahin
Academic Clinical Lecturer and Interventional Radiology Fellow, Department of Academic Unit of Radiology, University of Sheffield and Sheffield Teaching Hospitals, Sheffield, UK
Mostafa Sheba
Urology Registrar, Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Iqbal Shergill
Consultant Urological Surgeon, The Alan De Bolla
Wrexham Urology Unit, Wrexham Maelor Hospital, Wrexham, UK
Martin Skott
Peadiatric Urology, Deparment of Urology, Aarhus University Hospital, Aarhus, Denmark
Pieter V. Spies
Senior Consultant and Lecturer, Division of Urology, Department of Surgical Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
Grant D. Stewart
Professor of Surgical Oncology, Department of Surgery, University of Cambridge, Cambridge, UK
Kiarash Taghavi
Consultant Paediatric Urological Surgeon, Department of Paediatric Urology, Monash Children’s Hospital, Melbourne, Victoria, Australia
James Tracey
Clinical Fellow in Urological Surgery, Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
Maxine G. B. Tran
Professor and Consultant Urological Surgeon, Division of Surgery and Interventional Science, University College London, London, UK
Fabio Traunero
Urology Registrar, Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
Lona Vyas
Consultant Urological Surgeon with Specialist Interest in Andrology, Department of Urology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
Matthew Young
Consultant Urological Surgeon, Department of Urology, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
CURRICULUM MAP
Recurrent urinary tract infection
Prostatitis
Renal stones
Final stage topics for all trainees
Basic
Stone disease
Urinary tract
obstruction
Ureteric stones
Bladder stone management
Ureteropelvic junction obstruction Oncocytoma
Localized prostate cancer
Oligometastatic prostate cancer
Newly diagnosed metastatic prostate cancer
Nonmuscleinvasive bladder cancer
Muscle invasive bladder cancer
High grade non-muscle invasive bladder cancer
Renal cancer (inferior vena cava tumour)
Metastatic renal cancer
Upper urinary tract urothelial carcinoma
Localized penile cancer
Advanced and metastatic penile cancer
Growing teratoma syndrome in testis cancer
Metastatic testicular cancer
Benign prostatic enlargement and acute urinary retention
Assessment of children requiring urinary tract reconstruction
Assessment and management of boys requiring urethral reconstruction
Renal transplantation
Renal transplantation
SECTION 1
Urinary tract infection
Case 1 Recurrent urinary tract infection
Case 2 Prostatitis
Recurrent urinary tract infection 1
Christopher K. Harding
Expert commentary Christopher K. Harding
Case history
A 55-year-old postmenopausal woman was referred from primary care following a 3-year history of recurrent urinary tract infections (rUTIs). These episodes often presented as infective cystitis with dysuria, increased urinary frequency (including newonset nocturia), and offensive smelling cloudy urine1 and were usually without any systemic symptoms. She described these infections as occurring approximately six times per year and informed that they were previously responsive to short-course narrow-spectrum antibiotic therapy with either nitrofurantoin or trimethoprim. More recently, she had been requiring longer or multiple antibiotic courses to resolve her symptoms. She had been referred to another hospital 2 years ago with non-visible haematuria and had a full urinary tract evaluation via a renal ultrasound scan, a flexible cystoscopy, and a urine flow study which revealed no structural or functional abnormalities. Her estimated glomerular filtration rate was normal. Serial urine cultures obtained over the preceding 12–18 months had shown a variety of uropathogenic organisms but most often Escherichia coli was isolated. Over the preceding 6 months, the episodes had increased in frequency and the patient reported the feeling of having ‘an almost constant’ urinary tract infection (UTI). Her last two urine cultures had again shown evidence of E. coli exhibiting antimicrobial resistance (AMR) to nitrofurantoin and amoxycillin. She was referred to a specialist rUTI clinic for consideration of preventative treatment.
Learning point Definitions and statistics
● UTI is described as complicated or uncomplicated with the latter referring to occurrence in a structurally and functionally normal urinary tract. The vast majority of rUTIs are uncomplicated.
● Most national and international guidelines2–4 do not recommend routine investigation of women with rUTIs because the diagnostic yield is low.
● rUTI can occur due to either bacterial persistence or reinfection. Persistence is suspected if there is infection with the same bacterial species within a short time frame after clinical resolution of a previous episode.
● Most clinicians would classify rUTI as being two episodes of infection in 6 months, or three episodes in 1 year.
● The annual incidence of a single UTI is approximately 30 per 1000 women, with almost half of affected women experiencing recurrence within 12 months.
● rUTI is associated with significant morbidity, studies estimate an average of 6 days of symptoms, 2 days of restricted activity, and 1 day of time off work per episode.
