Journal of Clinical Urology

We aim to identify predictors of successful trial without catheter after an episode of acute urinary retention and to evaluate how serum prostate specific antigen (PSA) and C-reactive protein (CRP) levels behave during an acute urinary retention episode and also whether the PSA level is a useful indicator of undetected prostate cancer.

335 patients presented to our institution in acute urinary retention from June 2006 to December 2007. After excluding females, patients with known prostate cancer, clot retention due to haematuria and catheter-related problems, 100 patients were entered into this prospective audit. On admission we documented serum PSA and CRP levels, residual urine volumes, urinary tract infection (UTI), digital rectal examination (DRE) and history of urinary tract surgery. The outcome of subsequent trial without catheter (TWOC) was documented. Where indicated, repeat serum PSA and CRP levels, transrectal ultrasound and prostate biopsies were obtained. Parametric and non-parametric tests were used for statistical analysis.

Median residual volume on catheterization was 750 mL. Successful TWOC was more likely in smaller sized prostates (Kendall tau-b, p = 0.004) and in benign feeling prostates (Fisher Exact Test, p = 0.004). TWOC failure was significantly higher in patients diagnosed with new prostate cancer (Fisher Exact Test, p = 0.032). Higher initial PSA levels, higher residual volumes and larger prostate size on DRE also resulted in higher TWOC failure rates. However these correlations were not statistically significant. UTI was confirmed in 13 of 100 patients on admission. Presence of UTI on admission had no influence on CRP or PSA levels, residual volumes or outcome of TWOC following treatment of UTI. Nine patients were diagnosed with prostate cancer of whom six had clinically significant cancer. On admission median serum PSA level was 7.0 ng/L (range 0.08–4624 ng/L) and median serum CRP level 21 mmol/L (range normal to 247 mmol/L). Serum PSA levels positively correlated with consecutive diagnosis of new prostate cancer. However when using 4 ng/L as the upper limit for normal PSA levels, sensitivity for detecting prostate cancer was 89%, specificity only 43% and positive predictive value 18%. Patients with a new diagnosis of prostate cancer had a high TWOC failure rate with eight of nine patients requiring re-catheterization. Neither PSA nor CRP levels were correlated with residual volumes, presence of UTI or prediction of TWOC outcome.

Successful TWOC is more likely in smaller sized and benign feeling prostates. Neither PSA nor CRP levels help to predict TWOC outcome. Residual urinary volumes might be of little value in predicting TWOC outcome. Patients should therefore be given the ‘benefit of the doubt’ and offered TWOC regardless of large residual volumes. Patients presenting in AUR are at risk of harboring clinically significant prostate cancer. A high level of suspicion should remain especially in those with failed TWOC and normal DRE. Serum PSA is an unreliable marker to detect prostate cancer in this patient group. We therefore do not recommend opportunistic PSA screening during an AUR episode. CRP was not a good marker for prostatic infarction or inflammation.

To determine prostate cancer detection rates in a haematuria clinic and provide an insight into the usefulness of PSA testing in the haematuria clinic.

The records of all male patients (n = 749) seen in the haematuria clinic over a 2-year period were analysed.

Of the 749 men, 511 (68%) had a PSA measured. In total, 28 cases of prostate cancer were diagnosed (3.7% of total). In the 50–69 age group, 263 out of 350 men (75%) had a PSA test. 11 cancers were diagnosed in this group (which was 3.1% of all patients or 4.2% of those screened in this age group).

Our screening rates were slightly lower than those in the ProtecT, ERSPC and PLCO studies. Our overall cancer detection rate of 3.1% (for the 50–69 year olds) is comparable to those from ERSPC (8.2%), ProtecT (2.2%) and PLCO (1.4%). The data would suggest that there is not an excess of prostate cancer in patients with haematuria. PSA testing should be accompanied by a full and frank discussion about the benefits and risks of PSA screening which is not always practical in the haematuria clinic.

Information in the British National Formulary (BNF) is obtained from a wide range of sources. BNF contains three guidelines directly pertinent to urological practice. We set out to determine urologists' adherence to these guidelines.

A standard questionnaire was sent to each urological unit in the UK (n = 191). The three guidelines relate to:

Prevention of endocarditis in patients undergoing urological interventions.

111 (58%) completed questionnaires were returned. Adherence rate was 28%, 34% and 17% respectively for each of the above guidelines. The adherence rate was 50%, 50% and 14% by specialist registrars in contrast to 22%, 27% and 16% by consultants. Adherence decreased as the number of years of experience in urology increased, from 36.3% at 5 years to 26.3% at 20 years.

The overall adherence of urologists to BNF guidelines is low (26.3%), with adherence being higher for registrars. The longer a urologist had been in urology, the lower the adherence. In the current era of evidence-based practice, we recommend that these guidelines are revisited, perhaps by the British Association of Urological Surgeons or National Institute for Clinical Excellence.

Operative notes are traditionally handwritten and are essential for providing optimal postoperative care and planning the future management of patients. This study compares handwritten to computerised operative notes using a common standard.

One hundred handwritten urological operative notes were compared to 97 urological database printed notes using the Royal College of Surgeons' of England (RCSEng) guidelines for Good Surgical Practice.

There was an overall improvement in the quality of documentation, excluding the recording of tissue removed and the presence of a signature. The recording of parameters in the printed operative database notes was greater than 95% in 16 out of 18 parameters assessed.

We strongly recommend the use of an operative database to raise the standard of operative notes in order to improve patient care and to provide a robust medico-legal record.

The launch of Choose and Book has enabled patients to choose from at least four providers of healthcare to reduce long waiting times for elective surgery. We aimed to investigate what factors patients consider when deciding on their choice of hospital and to establish what weight patients placed on each of these factors when making their choice.

Patients attending general urology outpatient clinics during a 3-month period were invited to complete a questionnaire grading these factors in level of importance to them.

Hospital cleanliness was the most important factor when choosing a hospital, followed by hospital reputation.

Cleanliness and hygiene standards within a hospital are increasingly important to patients with the rise in hospital acquired infections, heightened by a high level of media interest in hospital hygiene. The behaviour of patients in choosing where and when and by whom they want their health care will clearly have an impact on waiting times, although the true impact of this is as yet difficult to establish. With respect to urology, this may affect the choice of hospital as well as the treating urology consultant. For patients to make these choices they will need more information about their options and General Practitioners will need to provide appropriate guidance.