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Oxford Handbook of  Urology

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Oxford Handbook of Urology

Fourth edition

John Reynard

Consultant Urological Surgeon

Churchill Hospital, Oxford University Hospitals Oxford, UK

Simon F Brewster

Consultant Urological Surgeon

Churchill Hospital

Oxford University Hospitals Oxford, UK

Suzanne Biers

Consultant Urological Surgeon

Addenbrooke’s Hospital

Cambridge University Hospitals Cambridge, UK

Consultant Urological Surgeon

Churchill Hospital

Oxford University Hospitals Oxford, UK

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 of Oxford University Press in the UK and in certain other countries

© Oxford University Press 2019

The moral rights of the authors have been asserted

First Edition Published in 2005

Second Edition Published in 2009

Third Edition Published in 2013

Fourth Edition Published in 2019

Impression: 1

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, by licence or under terms agreed with the appropriate reprographics 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 work in any other form and you must impose this same condition on any acquirer

Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America

British Library Cataloguing in Publication Data

Data available

Library of Congress Control Number: 2018954691

ISBN 978–0–19–878348–0

Printed and bound 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 breast-feeding

Photographs and images provided courtesy of Boston Scientific (© Boston Scientific 2016—Do not copy or distribute). The content of this publication is under the sole responsibility of its authors and does not represent the opinion of BSC. Please refer to Boston Scientific product DFUs for indications, contraindications, precautions, and warnings. Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

Preface

John Reynard and I were invited to write the Oxford Handbook of Urology to bolster the already comprehensive collection of these familiar handbooks by Oxford University Press in 2003. We had been appointed as consultants in Oxford in 1998, both enthusiastic and active in teaching, research, and publication, having already produced successful urology textbooks, already proud co-authors of a book called Urology: A Handbook for Medical Students, published in 2001. So we were delighted to accept the invitation. Suzanne Biers, our talented junior trainee, joined us as co-author, initially providing a perspective first as a senior house officer, then as a specialist registrar, and ultimately as a Cambridge consultant by the third edition.

The first edition was published in 2006, the second in 2009, and the third in 2013. During this time, the book became the go-to text for urology surgical trainees studying for the Royal College of Surgeons FRCS (Urology) examination. The review of the third edition in European Urology Today, published in September 2014, by Prof P Meria (Paris) concluded: ‘This pocketbook is undoubtedly an outstanding tool for everyone and we recommend it to all urologists regardless of their level of practice’. Judging by reviews posted on Amazon.co.uk, the OHU is also popular with general practitioners, medical students, other groups of junior doctors and graduate nurses. The three editions have been translated into three languages and have, between them, sold over 18 000 hard copies and 800 digital versions internationally. The third edition was ‘Highly Commended’ in the surgical specialties category of the 2014 British Medical Association Medical Book Awards. Urology is a rapidly developing sub-speciality, both in terms of surgical technology and medical therapeutic advances, so there has been no shortage of topics to update in each edition, including this latest which we are proud to present now. For the fourth edition, we are delighted to be joined by Naomi Neal, another of our excellent senior registrars who recently passed the FRCS (Urology), to share the work and bring fresh perspectives.

We sincerely hope you enjoy the book, that it might inspire you to become a urologist or develop urology within your career, to help you to pass an examination, to develop sub-specialist interest and knowledge in urology, and most importantly, to help you confidently manage patients under your care. We welcome any feedback in order to improve on each revision and ensure it provides everything you need in a comprehensive quick-reference handbook. We wish you all the best in your future endeavours and hope you enjoy, and are inspired by, urology as much as we have been.

Simon Brewster, on behalf of the authors, October 2017

Acknowledgements

The authors would like to express their gratitude to Professor Andrew Protheroe, Medical Oncologist at the Churchill Hospital in Oxford, Professor Nick Watkin, Consultant in Andrology and Genito-urethral Reconstruction at St George’s Hospital in London, Mr Dan Wood, Consultant in Adolescent and Reconstructive Urology at University College London Hospitals, and Miss Helen Bolton, Senior Fellow in Obstetrics and Gynaecology at Addenbrooke’s Hospital in Cambridge, who all gave freely of their time and expertise.

Symbols and abbreviations

7 approximately

M website

cross-reference

i increased d decreased

l leads to

female

male

degree Celsius

plus or minus

less than

greater than

equal to or greater than

alpha

beta

κ kappa

π pi

® registered trademark

™ trademark

A&E accident and emergency

AAA abdominal aortic aneurysm

AAOS American Academy of Orthopaedic Surgeons

AAST American Association for the Surgery of Trauma

ABG arterial blood gas

4-ABP 4-aminobiphenyl

ACCP American College of Chest Physicians

ACE angiotensin-converting enzyme

ACh acetylcholine

ACR albumin:creatinine ratio; acute cellular rejection

ACTH adrenocorticotrophic hormone

ADAM Androgen Deficiency in the Aging Male (questionnaire)

ADH antidiuretic hormone

ADPKD autosomal dominant polycystic kidney disease

ADT androgen deprivation therapy

AF atrial fibrillation

AFP alpha-fetoprotein

AFS autologous fascial sling

AHR acute humoral rejection

AID artificial insemination by donor

AIDS acquired immune deficiency syndrome

AK-TEDS above-knee thromboembolic stocking

ALPP abdominal leak point pressure

AMACR alpha-methylacyl CoA racemase

AML angiomyolipoma

ANP atrial natriuretic peptide

a-NVH asymptomatic non-visible haematuria

APD automated peritoneal dialysis

APF antiproliferative factor

APTT activated partial thromboplastin time

5AR 5α-reductase

ARCD acquired renal cystic disease

5ARI 5α-reductase inhibitor

ARPKD autosomal recessive polycystic kidney disease

ART assisted reproductive techniques

AS active surveillance

ASAP atypical small acinar proliferation

ASB asymptomatic bacteriuria

ASTRO American Society of Therapeutic Radiation Oncologists

ATFP arcus tendineus fascia pelvis

ATG antithymocyte globulin

ATN acute tubular necrosis

ATP adenosine triphosphate

AUA American Urological Association

AUA-SI American Urological Association Symptom Index

AUR acute urinary retention

AUS artificial urinary sphincter

AVM arteriovenous malformation

AZF azoospermic factor

BAUS British Association of Urological Surgeons

BCG bacille Calmette–Guérin

BCR bulbocavernosus reflex; biochemical recurrence

bd bis die (twice daily)

BDFS biochemical disease-free survival

bFGF basic fibroblast growth factor

BMI body mass index

BNF British National Formulary

BNI bladder neck incision

BOO bladder outlet obstruction

BP blood pressure

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

BPSA benign prostate-specific antigen

BRFS biochemical recurrence-free survival

BSE bovine spongiform encephalopathy

BT brachytherapy

BTA bladder tumour antigen

BTX botulinum toxin

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

CAUTI catheter-associated urinary tract infection

CBAVD complete bilateral absence of the vas deferens

CD collecting duct

CEULDCT contrast-enhanced ultra-low-dose computerized tomography

CF cystic fibrosis

CFTR cystic fibrosis transmembrane conductance regulator

CFU colony-forming unit

cGMP cyclic guanosine monophosphate

Ch Charrière

chRCC chromophobe renal cell carcinoma

CI confidence interval

CIRF clinically insignificant residual fragment

CIS carcinoma in situ

CISC clean intermittent self-catheterization

CJD Creutzfeldt–Jakob disease

CKD chronic kidney disease

CKD-EPI Chronic Kidney Disease Epidemiology Collaboration

cm centimetre

cmH2O centimetre of water

CMV cytomegalovirus

CNI calcineurin inhibitor

CNS central nervous system

CO2 carbon dioxide

COPD chronic obstructive pulmonary disease

COPUM congenital obstructive posterior urethral membrane

CPA cyproterone acetate

CPPS chronic pelvic pain syndrome

CPRE complete primary repair of bladder exstrophy

cRCC clear renal cell carcinoma

CRF chronic renal failure

CRP C-reactive protein

CRPC castrate-resistant prostate cancer

CSS cancer-specific survival

CT computerized tomography; collecting tubule

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

CTPA computerized tomography pulmonary angiography

CTU computerized tomography urography

CVD cardiovascular disease

CVP central venous pressure

CXR chest X-ray

Da dalton

DCN dorsal clitoral nerve

DCT distal convoluted tubule

DE delayed ejaculation

DESD detrusor–external sphincter dyssynergia

DEXA dual-energy X-ray absorptiometry (scan)

DFS disease-free survival

DGI disseminated gonococcal infection

DH detrusor hyperreflexia

DHT dihydrotestosterone

DI diabetes insipidus

DIC disseminated intravascular coagulation

dL decilitre

DMSA dimercaptosuccinic acid (renogram)

DMSO dimethyl sulfoxide

DNA deoxyribonucleic acid

DPN dorsal penile nerve

DRE digital rectal examination

DSD detrusor sphincter dyssynergia; disorders of sex development

DSLNB dynamic sentinel lymph node biopsy

DVLA Driver and Vehicle Licensing Agency

DVT deep vein thrombosis

EAU European Association of Urology

EBC estimated bladder capacity

EBRT external beam radiotherapy

EBV Epstein–Barr virus

ECF extracellular fluid

ECG electrocardiogram

ED erectile dysfunction

EDO ejaculatory duct obstruction

EDTA ethylene diamine tetra-acetic acid

EGF epidermal growth factor

eGFR estimated glomerular filtration rate

EGFR epidermal growth factor receptor

EHL electrohydraulic lithotripsy

EIA enzyme immunoassay

ELISA enzyme-linked immunosorbent assay

EMDA electromotive drug administration

EMG electromyography

EMU early morning urine

EN2 Engrailed-2

ENT ear, nose, and throat

EPLND extended pelvic lymphadenectomy

EPN emphysematous pyelonephritis

EORTC European Organization for Research and Treatment of Cancer

EPS expressed prostatic secretions

ER extended release

ESBL extended-spectrum β-lactamase

ESR erythrocyte sedimentation rate

ESSIC European Society for the Study of Bladder Pain Syndrome/ Interstitial Cystitis

ESWL extracorporeal shock wave therapy

F French

FBC full blood count

FDA Food and Drug Administration

FDG fluoro-2-deoxy-D-glucose

FGSI Fournier’s gangrene severity index

FISH fluorescence in situ hybridization

FNA fine-needle aspiration

FSH follicle-stimulating hormone

F:T free-to-total (ratio)

5FU 5-fluorouracil

FVC frequency–volume chart

g gram

G gauge

GA general anaesthetic

GABA gamma-aminobutyric acid

GAG glycosaminoglycan

GCT germ cell tumour

GFR glomerular filtration rate

GI gastrointestinal

GIFT gamete intra-Fallopian transfer

GnRH gonadotrophin-releasing hormone

GP general practitioner

GSTP1 glutathione-S-transferase P1

GTN glyceryl trinitrate

GU gonococcal urethritis

GUM genitourinary medicine

Gy Gray

h hour

H+ hydrogen ion

HAL hexaminolevulinic acid

Hb haemoglobin

hCG human chorionic gonadotrophin

HCO3– bicarbonate

HDR high-dose rate

HDU high-dependency unit

HIF hypoxia-inducible factor

HIFU high-intensity focused ultrasound

HIV human immunodeficiency virus

HLA human leucocyte antigen

HMG human menopausal gonadotrophin

HMG-CoA 3-hydroxy-3-methyl-glutaryl coenzyme A

5-HMT 5-hydroxymethyl tolterodine

HO house officer

HoLAP holmium laser ablation of the prostate

HoLEP holmium laser enucleation of the prostate

HoLRP holmium laser resection of the prostate

HPCR high-pressure chronic retention

HPF high-power field

HPV human papillomavirus

HRO high-reliability organization

HRP horseradish peroxidase

5-HT 5-hydroxytryptamine

HTLV human T lymphotropic virus

Hz hertz

IC intermittent catheterization; interstitial cystitis

ICD implantable cardioverter–defibrillator

ICF intracellular fluid

ICS International Continence Society

ICSI intracytoplasmic sperm injection

IDO idiopathic detrusor overactivity

IELT intravaginal ejaculatory latency time

IFIS intraoperative floppy iris syndrome

IFN interferon

Ig immunoglobulin

IgA immunoglobulin A

IGCCCG International Germ Cell Cancer Collaborative Group

IGCN intratubular germ cell neoplasia

IGF insulin-like growth factor

IGFBP insulin-like growth factor binding protein

IIEF International Index of Erectile Function

IL interleukin

ILP interstitial laser prostatectomy

IM intramuscularly

IMRT intensity-modulated radiotherapy

INR international normalized ratio

IPC intermittent pneumatic calf compression

IPSS International Prostate Symptom Score

ISC intermittent self-catheterization

ISD intrinsic sphincter deficiency

ISF interstitial fluid

ISSM International Society for Sexual Medicine

ITU intensive treatment unit

IU international unit

IUI intrauterine insemination

IV intravenous

IVC inferior vena cava

IVF in vitro fertilization

IVP intravenous pyelography

IVU intravenous urography/urogram

JGA juxtaglomerular apparatus

JVP jugular venous pressure

K+ potassium

kDa kilodalton

Kf formation product

kg kilogram

KGF keratinocyte growth factor

kHz kilohertz

kJ kilojoule

kPa kilopascal

K sp solubility product

KTP potassium titanyl phosphate (laser)

KUB kidneys, ureters, and bladder

L litre

LA local anaesthetic

LDH lactate dehydrogenase

LDL low-density lipoprotein

LDR low-dose-rate

LDUH low-dose unfractionated heparin

LFT liver function test

LH luteinizing hormone

LHRH luteinizing hormone-releasing hormone

LMWH low-molecular-weight heparin

LNI lymph node invasion

LoH loop of Henle

LOH late-onset hypogonadism

LRINEC Laboratory Risk Indicator for Necrotizing Fasciitis

LRP laparoscopic radical prostatectomy

LSD lysergic acid diethylamide

LUT lower urinary tract

LUTS lower urinary tract symptom

LVI lympho-vascular invasion

m metre

μA microampere

mA milliampere

MAB maximal androgen blockade

MAG3 mercaptoacetyl-triglycyine (renogram)

MAGPI meatal advancement and granuloplasty

MAOI monoamine oxidase inhibitor

MAP mean arterial pressure

MAPP Multidisciplinary Approach to Pelvic Pain (study)

MAR mixed agglutination reaction

MBq megabecquerel

MCDK multicystic dysplastic kidney

MCUG micturating cystourethrography

MDCTU multidetector computerized tomography urography

MDP methylene diphosphonate

MDRD Modification of Diet in Renal Disease

MDT multidisciplinary team

mEq milliequivalent

MESA microsurgical epididymal sperm aspiration

MET medical expulsive therapy

MeV mega electron volt

μ

g microgram

mg milligram

mGy milligray

MHC major histocompatibility complex

MHRA Medicines and Healthcare Products Regulatory Agency

mHz millihertz

MHz megahertz

MI muscle-invasive

MIBG meta-iodo-benzyl-guanidine

min minute

MIS Müllerian inhibiting substance; minimally invasive surgery

MIT minimally invasive treatment

mIU milli international unit

μL microlitre

mL millilitre

μm micron

mm millimetre

mmHg millimetre of mercury

MMC mitomycin C

mol mole

μmol micromole

mmol millimole

MNE monosymptomatic nocturnal enuresis

mOsm milliosmole

MPA mycophenolate

mpMRI multiparametric magnetic resonance imaging

MPOA medial preoptic area

MPR multiplanar reformatting

MRCoNS meticillin-resistant coagulase-negative staphylococci

MRI magnetic resonance imaging

MRSA meticillin-resistant Staphylococcus aureus

MRU magnetic resonance urography

MS multiple sclerosis

MSK medullary sponge kidney

MSMB microseminoprotein-beta

MSU mid-stream urine

mSv millisievert

mTOR mammalian target of rapamycin

MUCP maximal urethral closure pressure

MUI mixed urinary incontinence

MUS mid-urethral sling

MUSE Medicated Urethral System for Erection (device)

MVAC methotrexate, vinblastine, adriamycin, cisplatin

Na+ sodium

NA noradrenaline

NAAT nucleic acid amplification test

NaCl sodium chloride

NAION non-arteritic anterior ischaemic optic nerve neuropathy

NBI narrow-band imaging

NDO neurogenic detrusor overactivity

NE nocturnal enuresis

ng nanogram

NGU non-gonococcal urethritis

NHS National Health Service

NICE National Institute for Health and Care 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

NMI non-muscle invasive

NMNE non-monosymptomatic nocturnal enuresis

nmol nanomole

NMP nuclear matrix protein

NND number needed to detect

NNT number needed to treat

NO nitric oxide

NOA non-obstructive azoospermia

NOAC new oral anticoagulant

NP nocturnal polyuria

NS nerve sparing; non-seminomatous

NSAID non-steroidal anti-inflammatory drug

NSGCT non-seminomatous germ cell tumour

NSU non-specific urethritis

NVH non-visible haematuria

OA obstructive azoospermia

OAB overactive bladder

OAT oligoasthenoteratospermia

od omni die (once daily)

OIF onlay island flap

OLND obturator fossa lymphadenectomy

OSA obstructive sleep apnoea

Pabd intra-abdominal pressure

PaCO2 partial pressure of carbon dioxide (in arterial blood)

PAE prostate artery embolization

PAG periaqueductal grey (matter)

PAIS partial androgen insensitivity syndrome

PAOD peripheral artery occlusive disease

PARP poly-ADP ribose polymerase

PC prostate cancer

PCA3 prostate cancer antigen 3

PCN percutaneous nephrostomy

PCNL percutaneous nephrolithotomy

PCO2 carbon dioxide tension

PCR protein:creatinine ratio; polymerase chain reaction

PCT proximal convoluted tubule

PD Parkinson’s disease

PDD photodynamic detection

PDE phosphodiesterase

PDE5 phosphodiesterase type-5

Pdet detrusor pressure

PDGF platelet-derived growth factor

PDT photodynamic therapy

PE premature ejaculation; pulmonary embolism

PEC perivascular epithelioid cell

PEDT Premature Ejaculation Diagnostic Tool

PEP post-exposure prophylaxis

PESA percutaneous epididymal sperm aspiration

PET positron emission tomography

PFMT pelvic floor muscle training

PFS pressure–flow study; progression-free survival

PG prostaglandin

PGE2 prostaglandin E2

phi Prostate Health Index

PI3 phosphoinositide 3

PIN prostatic intraepithelial neoplasia; penile intraepithelial neoplasia

PIRAD Prostate Imaging Reporting and Data (system)

PLAP placental alkaline phosphatase

PLESS Proscar Long-term Efficacy Safety Study

PMC pontine micturition centre

PMNL polymorphonuclear leucocyte

pmol picomole

PN partial nephrectomy

PNE peripheral nerve evaluation

PO per os (orally)

PO2 oxygen tension

POP pelvic organ prolapse

POPQ pelvic organ prolapse quantification

PPI post-prostatectomy incontinence

PPS pentosan polysulfate sodium

PR pulse rate

pRCC papillary renal cell carcinoma

PRP prion protein

PSA prostate-specific antigen

PSAD prostate-specific antigen density

PSADT prostate-specific antigen doubling time

PSMA prostate-specific membrane antigen

PTEN phosphatase and tensin homologue

PTFE polytetrafluoethylene

PTH parathyroid hormone

PTNS posterior (percutaneous) tibial nerve stimulation

PTTI parenchymal transit time index

PUJ pelviureteric junction

PUJO pelviureteric junction obstruction

PUNLMP papillary urothelial neoplasm of low malignant potential

PUR post-partum urinary retention

PUV posterior urethral valves

PUVA psoralen combined with vitamin A

PVA polyvinyl alcohol

PVD peripheral vascular disease

Pves intravesical pressure

PVN paraventricular nucleus

PVP photoselective vaporization of the prostate

PVR post-void residual

qds quater die sumendus (four times daily)

Qmax maximal flow rate

QoL quality of life

RARP robot-assisted radical prostatectomy

RBC red blood cell

RBF renal blood flow

RCC renal cell carcinoma

RCT randomized controlled trial

REM rapid eye movement

RFA radiofrequency ablation

RI resistive index

RNA ribonucleic acid

RNU radical nephroureterectomy

ROI region of interest

RP radical prostatectomy; retropubic tape

RPF retroperitoneal fibrosis; renal plasma flow

RPLND retroperitoneal lymph node dissection

RPR rapid plasma reagin

RR respiratory rate

RT radiotherapy

RTA renal tubular acidosis; road traffic accident

RTK receptor tyrosine kinase

rUTI recurrent urinary tract infection

s second

SARS sacral anterior root stimulator

SC subcutaneous

SCC squamous cell carcinoma

SCI spinal cord injury

SHBG sex hormone-binding globulin

SHO senior house officer

SIMS single-incision mid-urethral sling

SIRS systemic inflammatory response syndrome

SLE systemic lupus erythematosus

SNM sacral nerve modulation

SNS sacral nerve stimulation

s-NVH symptomatic non-visible haematuria

SOP standard operating procedure

SPC suprapubic catheter

SpR specialist registrar

SR sustained release

SRE skeletal-related event

SSRI selective serotonin reuptake inhibitor

STD sexually transmitted disease

STI sexually transmitted infection

STIR short TI inversion recovery

SUI stress urinary incontinence

SWL shock wave lithotripsy

T tesla

TAPD transverse anteroposterior diameter

TB tuberculosis

TBW total body water

TC testicular cancer

TCC transitional cell carcinoma

tds ter die sumendus (three times daily)

TEAP transurethral ethanol ablation of the prostate

TEDS thromboembolic deterrent stockings

TENS transcutaneous electrical nerve stimulation

TESA testicular exploration and sperm aspiration

TESE testicular exploration and sperm extraction

TET tubal embryo transfer

TGF transforming growth factor

TIN testicular intratubular neoplasia (synonymous with IGCN)

TIP tubularized incised plate

TNF tumour necrosis factor

TOT transobturator tape

TOV trial of void

TPIF transverse preputial island flap

TRUS transrectal ultrasound

TS tuberous sclerosis

TSE testicular self-examination

TUIP transurethral incision of the prostate

TULIP transurethral ultrasound-guided laser-induced prostatectomy

TUMT transurethral microwave thermotherapy of the prostate

TUNA transurethral needle ablation of the prostate

TUR transurethral resection

TURBT transurethral resection of bladder tumour

TURED transurethral resection of the ejaculatory ducts

TURP transurethral resection of the prostate

TUVP transurethral vaporization of the prostate

TUVRP transurethral vapour resection of the prostate

TVT tension-free vaginal tape

TVTO tension-free vaginal tape obturator

TWOC trial without catheter

U unit

UD urethral diverticulum

UDT undescended testis

U&E urea and electrolytes

UI urinary incontinence

UK United Kingdom

ULDCT ultra-low-dose computerized tomography

ULTRA Unrelated Live Transplant Regulatory Authority

UPJO uretero-pelvic junction obstruction

URS ureterorenoscopy

USA United States

USS ultrasound scan

UTI urinary tract infection

UUI urge urinary incontinence

UUO unilateral ureteric obstruction

UUT-TCC upper urinary tract transitional cell carcinoma

vCJD variant Creutzfeldt–Jakob disease

VCUG videocystourethrography

VEGF vascular endothelial growth factor

VEGFR vascular endothelial growth factor receptor

VH visible haematuria

VHL von Hippel–Lindau

VIP vasoactive intestinal peptide

VLAP visual laser ablation of the prostate

V/Q ventilation–perfusion

VRE vancomycin-resistant enterococci

VTE venous thromboembolism

VUJ vesicoureteric junction

VUJO vesicoureteric junction obstruction

VUR vesicoureteric reflux

VURD vesicoureteric reflux with renal dysplasia

VVF vesicovaginal fistula

W watt

WAGR Wilms’ tumour/aniridia/genitourinary anomalies/mental retardation

WBC white blood cell

WCC white cell count

WHO World Health Organization

wk week

WW watchful waiting

y year

YAG yttrium-aluminium-garnet

ZIFT zygote intra-Fallopian transfer

General principles of management of patients

Communication skills 2

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 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 appropriately (e.g. handshake); check you are talking to the correct person.

• Establish the purpose of the interview.

• explain the purpose of the interview from the patient’s perspective and yours and the desired outcome of the interview.

• Establish the patient’s baseline knowledge and understanding.

• Use open questions; let the patient talk, and confirm what they know.

• Listen actively.

• Make it clear to the patient that they have your undivided attention— that you are focusing on them. this involves appropriate body language (keep eye contact—do not look out of the window!).

• Pick up on, and respond to, cues.

• the patient/relative may offer verbal or non-verbal indications about their thoughts or feelings.

• Elicit the patient’s main concern(s).

• What you think should be the patient’s main concerns may not be. try to find out exactly what the patient is worried about.

• Chunks and checks.

• Give information in small quantities, and check that this has been understood. a good way of doing this is to ask the patient to explain what they think you have said.

• Show empathy.

• Let the patient know you understand their feelings.

• Be non-judgemental.

• Do not 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 on to a new subject.

• Avoid the use of jargon.

• Use language the patient will understand, rather than medical terminology.

• Body 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 officer’ or Spr for ‘specialist registrar’) should be clearly written in capital letters below each entry. You should also document which other medical staff were present with you on ward rounds or when seeing a patient (e.g. ‘ward round—Spr (Mr X)/Sho/ho’).

Contemporaneous note-keeping is an important part of good clinical practice. Medical notes document the patient’s problems, the investigations 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-keeping 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 evidence of your actions. Unfortunately, the defence of not having sufficient time to write the notes is not an adequate one, and the courts may 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 comment 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.

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 investigation 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.

• Date of operation.

• Surgeon, assistants.

• Patient position (e.g. supine, prone, lithotomy, Lloyd–Davies).

• type of deep vein thrombosis (DVt) prophylaxis [above-knee thromboembolic stockings (ak-teDS), Flowtrons, heparin, etc.].

• type, time of administration, and doses of antibiotic prophylaxis.

• Presence of an image intensifier, if appropriate.

• type and size of endoscopes used.

• Your signature and your name in capitals.

• Post-operative instructions and follow-up, if appropriate. if a consultant is supervising you but is not scrubbed, you must clearly state that the ‘consultant (named) was in attendance’.

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