Journal of Clinical Urology

Before death occurs from advanced prostate cancer, all patients pass through a ‘hormone resistant’ phase of the disease (HRPC). A large proportion of patients with advanced prostate cancer on hormonal therapy are managed in the Urology Outpatient Department, albeit with multidisciplinary input into their care. Chemotherapy for HRPC has now been shown to increase survival and quality of life and many novel agents are now undergoing Phase I and Phase II trials. The timely and appropriate referral of patients for chemotherapy, however, is essential in order to optimise patients' care and use chemotherapy wisely. This article addresses many of these practical issues.

Testicular ultrasound is a non-invasive and accurate investigation for testicular abnormalities. However, the majority of testicular problems are amenable to diagnosis by clinical examination alone. Testicular USS requests and reports generated over an 18-month period (03/2006 to 09/2007) at Nottingham City Hospital were examined to determine the indication for the test and the ultrasound findings. 2475 scans were performed: 576 were requested by urologists; 1899 by GPs and other hospital specialists. The most common findings were a completely normal scan (825) and epididymal cyst (637). In the majority of cases, the ultrasound scan was not necessary to make a diagnosis and added nothing to the findings at clinical examination. Correlations of ultrasound findings with the clinical reason for the test are presented in order to suggest suitable indications for this investigation. The total cost of testicular scans performed was around £200,000. It is estimated that at least £130,000 per year could be saved in a single hospital by avoiding unnecessary testicular scans. However, where the clinical findings are equivocal, ultrasound remains an excellent diagnostic tool.

Conventional, paper-based, urological referral has been challenged by the computer-based, choose and book (C&B) system. To determine the efficiency of this new system, we audited the appropriateness of these bookings, the percentage that required re-direction, the reasons for doing so and the ‘did not attend’ (DNA) rate.

1147 electronic bookings were made to different urological clinics between June 2006 and August 2007. The patient's age, date and type of clinic originally booked to, via C&B, and finally re-directed to was collected from our C&B record, PAS and Medisec. 1952 referrals via all modes were identified between April and November, 2006 and data on patient demographics, type of referral and whether attended or DNA was recorded.

Nearly a quarter of C&B appointments were re-directed, due to referrals being made to an inappropriate clinic, inappropriate consultant, inappropriate speciality, to the wrong hospital. Additionally, 32.3% were inappropriately prioritised, 7% being given inappropriate urgency and 25.3% not enough priority. DNA rate (18.9%) was higher for bookings made via C&B when compared to bookings made via standard paper-based GP referrals (15.3%).

Although C&B facilitates patients to make their choice of appointments, nearly a quarter of our patients had arrangements made inappropriate to their needs. This meant consultants still had to screen referrals and increased workload on ancillary staff. Despite being offered a choice, DNA rate was high in referrals via C&B. Refinement of C&B pathways may reduce this inefficiency but the inflexibility of this system makes it an inefficient way of referring urological cases.

The European Working Time Directive (EWTD) poses challenges for out of hours management of the acute urological patient. With the introduction of the “Hospital at Night” team or cross specialty cover, there may be limited onsite urological experience out of hours. One of the commonest urological emergencies is acute stone colic. For the on call team to provide a safe and quality service, the BAUS Section of Endourology has produced guidelines for the emergency management of urolithiasis.