Painless jaundice and unexplained weight loss is an exceedingly rare presentation for renal cell ... more Painless jaundice and unexplained weight loss is an exceedingly rare presentation for renal cell carcinoma (RCC). Such a presentation is more typical of a hepatocellular pathology. Stauffer syndrome is a paraneoplastic syndrome seen in RCC and is characterized by deranged hepatic enzymes and in association with fever, fatigue and weight loss. These symptoms typically resolve following nephrectomy. The predominant picture of this syndrome is that of an anicteric patient. Here we report the case of a 48 year old man who presented with a 3 week history of painless jaundice, malaise, anorexia and unintentional weight loss of 10 kilograms. Imaging revealed a solid right renal mass measuring 11 cm × 11 cm × 14 cm. There were also findings consistent with the presence of an inferior vena cava thrombosis and multiple pulmonary lesions. Biopsy confirmed the pulmonary lesions as metastatic clear cell renal carcinoma. Following multi-disciplinary discussion, cytoreductive nephrectomy was recommended to the patient, however multiple paraneoplastic syndromes subsequently developed and the patient experienced hypertension, severe coagulopathy and hypercalcaemia. Subsequently, the patient opted for supportive and palliative care. The patient died 2 weeks after initial presentation. Paraneoplastic syndromes associated with RCC are often underdiagnosed due to their variety and often non-specific nature. Paraneoplastic syndromes may lead to patient presentation, where they often suggest advanced or metastatic disease, and those caring for such patients should remain vigilant as further syndromes may complicate patient care.
A 79-year-old gentleman presented to the Emergency Department (ED) with catheter-related issues o... more A 79-year-old gentleman presented to the Emergency Department (ED) with catheter-related issues on a background of a long-term catheter for previous urinary retention, Hartmann’s procedure for colorectal cancer, and brachytherapy for prostate cancer. A 3-way silicone catheter was placed by ED staff and bladder irrigation commenced. The urine draining following catheterisation was found to be dark and thick, and irrigation fluid was noted to be draining per rectum. CT imaging was performed and demonstrated the catheter tip extending through the posterior wall of the urethra and into the rectum. The patient was admitted under the urology team, and urinary diversion was achieved with a suprapubic catheter. Subsequent imaging demonstrated a periprostatic abscess, which was initially managed with antimicrobial therapy, followed by attempted image-guided drainage. Repeat imaging following a 6-week course of antibiotics failed to show an improvement in the collection. During his inpatient ...
Introduction Circumcision is one of the most commonly performed surgical procedures in male child... more Introduction Circumcision is one of the most commonly performed surgical procedures in male children. A range of surgical techniques exist for this commonly performed procedure. The aim of this study is to assess the safety, functional outcome and cosmetic appearance of a sutureless circumcision technique. Methods Over a 9-year period, 502 consecutive primary sutureless circumcisions were performed by a single surgeon. All 502 cases were entered prospectively into a database including all relevant clinical details and a review was performed. The technique used to perform the sutureless circumcision is a modification of the standard sleeve technique with the use of a bipolar diathermy and the application of 2-octyl cyanoacrylate (2-OCA) to approximate the tissue edges. Results All boys in this study were pre-pubescent and the ages ranged from 6 months to 12 years (mean age 3.5 years). All patients had this procedure performed as a day case and under general anaesthetic. Complications included: haemorrhage (2.2%), haematoma (1.4%), wound infection (4%), allergic reaction (0.2%) and wound dehiscence (0.8%). Only 9 (1.8%) parents or patients were dissatisfied with the cosmetic appearance. Conclusion The use of 2-OCA as a tissue adhesive for sutureless circumcisions is an alternative to the standard suture technique. The use of this tissue adhesive, 2-OCA, results in comparable complication rates to the standard circumcision technique and results in excellent post-operative cosmetic satisfaction.
The aim of this study is to assess the cost effectiveness of the 120W HPS photoselective vaporiza... more The aim of this study is to assess the cost effectiveness of the 120W HPS photoselective vaporization of the prostate (PVP) in comparison with transurethral resection of the prostate (TURP). Methods: 60 PVP procedures performed over a 3 year period (Feb 2009-July 2011) were compared with 60 TURP procedures performed during the same time period. The focus of the paper was primarily on the potential cost saving with the PVP procedure due to a shorter inpatient hospital stay. Results: Of the 120 procedures performed, 60 were PVPs while 60 were TURPs. 15 (25%) PVPs were performed as a day-case procedure, while 45 (75%) were performed as an in-patient procedure. The median length of stay for a PVP in our institution is 4 days (range 0-29 days). The median length of stay for TURP is 7 days (range 3-26 days). In our institution, the mean cost of a TURP is V11,200, the mean cost of a PVP is V7,300 while the day case PVP costs V2,800. Conclusions: This study highlights the potential savings to public hospitals with a shorter in-patient hospital stay for patients undergoing the PVP procedure.
Background: The Saolta University Healthcare Group consists of seven hospitals covering a populat... more Background: The Saolta University Healthcare Group consists of seven hospitals covering a population of approximately 709,000. Galway University Hospital is the only tertiary referral centre for acute urological emergencies within the group. Previously, there was no dedicated emergency surgery pathway for urological cases and these were added to a congested, shared emergency list. Research has demonstrated that an increased time to definitive surgical intervention for urinary tract calculi leads to increased mortality. Problem areas were identified in the emergency surgical pathway and a multidisciplinary team was established to identify solutions. Recommendations
Background. A combined urology clinic staffed by four consultants and four non‐consultant hospita... more Background. A combined urology clinic staffed by four consultants and four non‐consultant hospital doctors (NCHDs) was introduced in our institution in October 2015. This clinic is supported by a pre‐clinic radiology meeting and a synchronous urology clinical nurse specialist (CNS) clinic with protected uroflow/trial of void slots. Herein, we report on the outcomes of this clinic in comparison with the standard format of urology outpatient review. Methods. We carried out a retrospective review of clinic attendances from May to July 2016. We recorded the number of new and return attendances, which team members had reviewed the patient and patient outcomes. We also calculated the waiting times for new patients to be reviewed in the outpatient clinic. Results. The combined urology clinic reviewed an average of 12 new and 46 return patients per clinic. The standard urology clinic reviewed an average of 8 new and 23 return patients per clinic. 54% of patients were seen by a consultant in...
A 48 year old female self presented accompanied by her husband to our Urology service on Valentin... more A 48 year old female self presented accompanied by her husband to our Urology service on Valentine's day with a history of accidental insertion of foreign body in the urethra instead of vagina as part of consensual sexual act. She complained of dysuria and suprapubic fullness. There was accompanying single episode of haematuria. Her past medical history included overactive bladder for which she was on antimuscarinics. On initial examination vital signs were within normal range. Examination of the cardiovascular and respiratory systems was unremarkable. Examination of the abdomen revealed suprapubic tenderness. Pelvic examination was unremarkable. Baseline blood investigations included a full blood count, renal profile, coagulation screen, urine analysis and Xray pelvis. All bloods were with in normal range. Her urine analysis showed microscopic haematuria without any evidence of active infection. Xray pelvis revealed a large foreign body in the bladder Fig. 1.
Conclusion: Patients under 80 years of age were discharged sooner when treated on the ERAS pathwa... more Conclusion: Patients under 80 years of age were discharged sooner when treated on the ERAS pathway regardless of whether their right hemicolectomy was open or laparoscopic. However, patients over the age of 80 had a shorter hospital stay when not put on the ERAS pathway.
Background:Primary soft tissue sarcomas contribute to only 2% of all malignancies arising from th... more Background:Primary soft tissue sarcomas contribute to only 2% of all malignancies arising from the male genitourinary tract. Leiomyosarcoma (LMS) is a malignant soft tissue neoplasm which originates from the mesenchyme and has a characteristic smooth muscle differentiation. Usually, it presents as a painless, firm, slow growing unilateral scrotal mass. Investigations include imaging, tumour markers and histopathology. Case Presentation:A 65 year old gentleman known Diabetic and Beta-thalassemic trait was referred to Urology OPD at Letterkenny University Hospital. His presenting complaint was left groin lump which appeared one year ago and was growing larger in size gradually. According to the patient his lump was slightly painful(localized) initially, that later became painless. He did not report any testicular trauma/infection or UTI. There was no significant history of malignancies running through his family. Clinical examination revealed soft and lax abdomen, normal testes. There...
Creation of a vesicovaginal fistula (VVF) is a complication seen in a variety of patients from pr... more Creation of a vesicovaginal fistula (VVF) is a complication seen in a variety of patients from prolonged labour and elective hysterectomies to advanced gynaecological malignancies. Causing distressing symptoms such as a loss of continence and vulval excoriation, conventional teaching has always advocated an open surgical approach as described by Sims in 1852. This however may not be feasible in cases of advanced malignancy or attractive to the post-operative patient. In this article the case of a 46-year-old lady with a VVF following elective hysterectomy is discussed. She was successfully managed with endoscopic closure of her fistula with fibrin glue.
Creation of a vesicovaginal fistula (VVF) is a complication seen in a variety of patients from pr... more Creation of a vesicovaginal fistula (VVF) is a complication seen in a variety of patients from prolonged labour and elective hysterectomies to advanced gynaecological malignancies. Causing distressing symptoms such as a loss of continence and vulval excoriation, conventional teaching has always advocated an open surgical approach as described by Sims in 1852. This however may not be feasible in cases of advanced malignancy or attractive to the post-operative patient. In this article the case of a 46-year-old lady with a VVF following elective hysterectomy is discussed. She was successfully managed with endoscopic closure of her fistula with fibrin glue.
Painless jaundice and unexplained weight loss is an exceedingly rare presentation for renal cell ... more Painless jaundice and unexplained weight loss is an exceedingly rare presentation for renal cell carcinoma (RCC). Such a presentation is more typical of a hepatocellular pathology. Stauffer syndrome is a paraneoplastic syndrome seen in RCC and is characterized by deranged hepatic enzymes and in association with fever, fatigue and weight loss. These symptoms typically resolve following nephrectomy. The predominant picture of this syndrome is that of an anicteric patient. Here we report the case of a 48 year old man who presented with a 3 week history of painless jaundice, malaise, anorexia and unintentional weight loss of 10 kilograms. Imaging revealed a solid right renal mass measuring 11 cm × 11 cm × 14 cm. There were also findings consistent with the presence of an inferior vena cava thrombosis and multiple pulmonary lesions. Biopsy confirmed the pulmonary lesions as metastatic clear cell renal carcinoma. Following multi-disciplinary discussion, cytoreductive nephrectomy was recommended to the patient, however multiple paraneoplastic syndromes subsequently developed and the patient experienced hypertension, severe coagulopathy and hypercalcaemia. Subsequently, the patient opted for supportive and palliative care. The patient died 2 weeks after initial presentation. Paraneoplastic syndromes associated with RCC are often underdiagnosed due to their variety and often non-specific nature. Paraneoplastic syndromes may lead to patient presentation, where they often suggest advanced or metastatic disease, and those caring for such patients should remain vigilant as further syndromes may complicate patient care.
A 79-year-old gentleman presented to the Emergency Department (ED) with catheter-related issues o... more A 79-year-old gentleman presented to the Emergency Department (ED) with catheter-related issues on a background of a long-term catheter for previous urinary retention, Hartmann’s procedure for colorectal cancer, and brachytherapy for prostate cancer. A 3-way silicone catheter was placed by ED staff and bladder irrigation commenced. The urine draining following catheterisation was found to be dark and thick, and irrigation fluid was noted to be draining per rectum. CT imaging was performed and demonstrated the catheter tip extending through the posterior wall of the urethra and into the rectum. The patient was admitted under the urology team, and urinary diversion was achieved with a suprapubic catheter. Subsequent imaging demonstrated a periprostatic abscess, which was initially managed with antimicrobial therapy, followed by attempted image-guided drainage. Repeat imaging following a 6-week course of antibiotics failed to show an improvement in the collection. During his inpatient ...
Introduction Circumcision is one of the most commonly performed surgical procedures in male child... more Introduction Circumcision is one of the most commonly performed surgical procedures in male children. A range of surgical techniques exist for this commonly performed procedure. The aim of this study is to assess the safety, functional outcome and cosmetic appearance of a sutureless circumcision technique. Methods Over a 9-year period, 502 consecutive primary sutureless circumcisions were performed by a single surgeon. All 502 cases were entered prospectively into a database including all relevant clinical details and a review was performed. The technique used to perform the sutureless circumcision is a modification of the standard sleeve technique with the use of a bipolar diathermy and the application of 2-octyl cyanoacrylate (2-OCA) to approximate the tissue edges. Results All boys in this study were pre-pubescent and the ages ranged from 6 months to 12 years (mean age 3.5 years). All patients had this procedure performed as a day case and under general anaesthetic. Complications included: haemorrhage (2.2%), haematoma (1.4%), wound infection (4%), allergic reaction (0.2%) and wound dehiscence (0.8%). Only 9 (1.8%) parents or patients were dissatisfied with the cosmetic appearance. Conclusion The use of 2-OCA as a tissue adhesive for sutureless circumcisions is an alternative to the standard suture technique. The use of this tissue adhesive, 2-OCA, results in comparable complication rates to the standard circumcision technique and results in excellent post-operative cosmetic satisfaction.
The aim of this study is to assess the cost effectiveness of the 120W HPS photoselective vaporiza... more The aim of this study is to assess the cost effectiveness of the 120W HPS photoselective vaporization of the prostate (PVP) in comparison with transurethral resection of the prostate (TURP). Methods: 60 PVP procedures performed over a 3 year period (Feb 2009-July 2011) were compared with 60 TURP procedures performed during the same time period. The focus of the paper was primarily on the potential cost saving with the PVP procedure due to a shorter inpatient hospital stay. Results: Of the 120 procedures performed, 60 were PVPs while 60 were TURPs. 15 (25%) PVPs were performed as a day-case procedure, while 45 (75%) were performed as an in-patient procedure. The median length of stay for a PVP in our institution is 4 days (range 0-29 days). The median length of stay for TURP is 7 days (range 3-26 days). In our institution, the mean cost of a TURP is V11,200, the mean cost of a PVP is V7,300 while the day case PVP costs V2,800. Conclusions: This study highlights the potential savings to public hospitals with a shorter in-patient hospital stay for patients undergoing the PVP procedure.
Background: The Saolta University Healthcare Group consists of seven hospitals covering a populat... more Background: The Saolta University Healthcare Group consists of seven hospitals covering a population of approximately 709,000. Galway University Hospital is the only tertiary referral centre for acute urological emergencies within the group. Previously, there was no dedicated emergency surgery pathway for urological cases and these were added to a congested, shared emergency list. Research has demonstrated that an increased time to definitive surgical intervention for urinary tract calculi leads to increased mortality. Problem areas were identified in the emergency surgical pathway and a multidisciplinary team was established to identify solutions. Recommendations
Background. A combined urology clinic staffed by four consultants and four non‐consultant hospita... more Background. A combined urology clinic staffed by four consultants and four non‐consultant hospital doctors (NCHDs) was introduced in our institution in October 2015. This clinic is supported by a pre‐clinic radiology meeting and a synchronous urology clinical nurse specialist (CNS) clinic with protected uroflow/trial of void slots. Herein, we report on the outcomes of this clinic in comparison with the standard format of urology outpatient review. Methods. We carried out a retrospective review of clinic attendances from May to July 2016. We recorded the number of new and return attendances, which team members had reviewed the patient and patient outcomes. We also calculated the waiting times for new patients to be reviewed in the outpatient clinic. Results. The combined urology clinic reviewed an average of 12 new and 46 return patients per clinic. The standard urology clinic reviewed an average of 8 new and 23 return patients per clinic. 54% of patients were seen by a consultant in...
A 48 year old female self presented accompanied by her husband to our Urology service on Valentin... more A 48 year old female self presented accompanied by her husband to our Urology service on Valentine's day with a history of accidental insertion of foreign body in the urethra instead of vagina as part of consensual sexual act. She complained of dysuria and suprapubic fullness. There was accompanying single episode of haematuria. Her past medical history included overactive bladder for which she was on antimuscarinics. On initial examination vital signs were within normal range. Examination of the cardiovascular and respiratory systems was unremarkable. Examination of the abdomen revealed suprapubic tenderness. Pelvic examination was unremarkable. Baseline blood investigations included a full blood count, renal profile, coagulation screen, urine analysis and Xray pelvis. All bloods were with in normal range. Her urine analysis showed microscopic haematuria without any evidence of active infection. Xray pelvis revealed a large foreign body in the bladder Fig. 1.
Conclusion: Patients under 80 years of age were discharged sooner when treated on the ERAS pathwa... more Conclusion: Patients under 80 years of age were discharged sooner when treated on the ERAS pathway regardless of whether their right hemicolectomy was open or laparoscopic. However, patients over the age of 80 had a shorter hospital stay when not put on the ERAS pathway.
Background:Primary soft tissue sarcomas contribute to only 2% of all malignancies arising from th... more Background:Primary soft tissue sarcomas contribute to only 2% of all malignancies arising from the male genitourinary tract. Leiomyosarcoma (LMS) is a malignant soft tissue neoplasm which originates from the mesenchyme and has a characteristic smooth muscle differentiation. Usually, it presents as a painless, firm, slow growing unilateral scrotal mass. Investigations include imaging, tumour markers and histopathology. Case Presentation:A 65 year old gentleman known Diabetic and Beta-thalassemic trait was referred to Urology OPD at Letterkenny University Hospital. His presenting complaint was left groin lump which appeared one year ago and was growing larger in size gradually. According to the patient his lump was slightly painful(localized) initially, that later became painless. He did not report any testicular trauma/infection or UTI. There was no significant history of malignancies running through his family. Clinical examination revealed soft and lax abdomen, normal testes. There...
Creation of a vesicovaginal fistula (VVF) is a complication seen in a variety of patients from pr... more Creation of a vesicovaginal fistula (VVF) is a complication seen in a variety of patients from prolonged labour and elective hysterectomies to advanced gynaecological malignancies. Causing distressing symptoms such as a loss of continence and vulval excoriation, conventional teaching has always advocated an open surgical approach as described by Sims in 1852. This however may not be feasible in cases of advanced malignancy or attractive to the post-operative patient. In this article the case of a 46-year-old lady with a VVF following elective hysterectomy is discussed. She was successfully managed with endoscopic closure of her fistula with fibrin glue.
Creation of a vesicovaginal fistula (VVF) is a complication seen in a variety of patients from pr... more Creation of a vesicovaginal fistula (VVF) is a complication seen in a variety of patients from prolonged labour and elective hysterectomies to advanced gynaecological malignancies. Causing distressing symptoms such as a loss of continence and vulval excoriation, conventional teaching has always advocated an open surgical approach as described by Sims in 1852. This however may not be feasible in cases of advanced malignancy or attractive to the post-operative patient. In this article the case of a 46-year-old lady with a VVF following elective hysterectomy is discussed. She was successfully managed with endoscopic closure of her fistula with fibrin glue.
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