Publications by authors named "Prasad Patki"

24 Publications

  • Page 1 of 1

Perioperative impact of body mass index on upper urinary tract and renal robot-assisted surgery: a single high-volume centre experience.

J Robot Surg 2021 Jul 27. Epub 2021 Jul 27.

Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, Hampstead, London, UK.

To assess the impact of body mass index (BMI) on peri-operative outcomes of kidney and upper tract robot-assisted surgery. Medical audit of patients who underwent robot-assisted kidney and upper tract cancer surgery at a single institution between 2017 and 2019, categorized on BMI into obese patients with a BMI ≥ 30 kg/m and a control group with BMI < 25 kg/m. Patient and tumour characteristics, surgery time, intraoperative blood loss, intraoperative adverse events (AE) according to the European Association of Urology Intraoperative Adverse Incidents Classification (EAUiaiC), conversion- to-open/radical rate as well as 30-day postoperative AE according to Clavien-Dindo (CD) and length of inpatient stay were analyzed. 366 patients were identified, 141 with a BMI < 25 (normal-weight) and 225 BMI ≥ 30 (obesity). There were no significant differences between the groups in terms of age, gender, comorbidities, tumour size, TNM stage and type of surgery. Obese patients had a higher estimated blood loss (198.05 ml), surgery time (171.75 min), intraoperative AE (all grades) (14.67%, 95% CI (0.10-0.19) as well as adherent perinephric fat (APF) (14.22%, 95% CI (0.09-0.19)) in contrast to the control group (86.85 ml, 148.29 min, 7.04% and 2.12%, respectively). Hospital stay, major intraoperative AE (≥ 3) and major postoperative AE (CD > 2) distributed equally between groups. Robotic kidney and upper tract surgery in obese patients showed an increase in surgery time and blood loss potentially related to APF. However, obesity was not associated with conversion to open surgery or radical nephrectomy in nephron-sparing procedures, length of stay, major intraoperative AE or postoperative complications.
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http://dx.doi.org/10.1007/s11701-021-01285-6DOI Listing
July 2021

Growth and renal function dynamics of renal oncocytomas on active surveillance.

BJU Int 2021 May 28. Epub 2021 May 28.

Division of Surgery and Interventional Science, University College London.

Objectives: To study the natural history of renal oncocytomas and address indications for intervention by determining how growth associates with renal function over time, the reasons for surgery and ablation, and disease-specific survival.

Patients And Methods: Retrospective cohort of consecutive patients with renal oncocytoma on active surveillance reviewed at the Specialist Centre for Kidney Cancer at Royal Free London NHS Foundation Trust (2012 to 2019). Comparison between groups was tested using the Mann-Whitney U and the Chi-square tests. A mixed-effects model with a random intercept for patient was used to study the longitudinal association between tumour size and estimated glomerular filtration rate (eGFR).

Results: Longitudinal data from 98 patients with 101 lesions was analysed. Most patients were male (68.3%), median age was 69 years (IQR 13). The median follow-up was 29 months (IQR 26). Most lesions were small renal masses, 24% measured over 4 cm. Over half (64.4%) grew at a median rate of 2 mm per year (IQR 4). No association was observed between tumour size and eGFR over time (p=0.871). Nine lesions (8.9%) were subsequently treated. Two deaths were reported, neither were related to the diagnosis of renal oncocytoma.

Conclusion: Natural history data from the largest active surveillance cohort of renal oncocytomas to date show that renal function does not seem to be negatively impacted by growing oncocytomas, and confirms clinical outcomes are excellent after a median follow up of over 2 years. Active surveillance should be considered the gold standard management of renal oncocytomas up to 7cm.
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http://dx.doi.org/10.1111/bju.15499DOI Listing
May 2021

The European Association of Urology COVID Intermediate-priority Group is Poorly Predictive of Pathological High Risk Among Patients with Renal Tumours.

Eur Urol 2021 Aug 20;80(2):265-267. Epub 2021 May 20.

UCL Medical School, University College London, London, UK; Specialist Centre For Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK. Electronic address:

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http://dx.doi.org/10.1016/j.eururo.2021.05.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136273PMC
August 2021

Impact of the first surge of the COVID-19 pandemic on a tertiary referral centre for kidney cancer.

BJU Int 2021 May 8. Epub 2021 May 8.

Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK.

Objective: To analyse the impact of the COVID-19 pandemic on a centralized specialist kidney cancer care pathway.

Materials And Methods: We conducted a retrospective analysis of patient and pathway characteristics including prioritization strategies at the Specialist Centre for Kidney Cancer located at the Royal Free London NHS Foundation Trust (RFH) before and during the surge of COVID-19.

Results: On 18 March 2020 all elective surgery was halted at RFH to redeploy resources and staff for the COVID-19 surge. Prioritizing of patients according to European Association of Urology guidance was introduced. Clinics and the specialist multidisciplinary team (SMDT) meetings were maintained with physical distancing, kidney surgery was moved to a COVID-protected site, and infection prevention measurements were enforced. During the 7 weeks of lockdown (23 March to 10 May 2020), 234 cases were discussed at the SMDT meetings, 53% compared to the 446 cases discussed in the 7 weeks pre-lockdown. The reduction in referrals was more pronounced for small and asymptomatic renal masses. Of 62 low-priority cancer patients, 27 (43.5%) were deferred. Only one (4%) COVID-19 infection occurred postoperatively, and the patient made a full recovery. No increase in clinical or pathological upstaging could be detected in patients who underwent deferred surgery compared to pre-COVID practice.

Conclusion: The first surge of the COVID-19 pandemic severely impacted diagnosis, referral and treatment of kidney cancer at a tertiary referral centre. With a policy of prioritization and COVID-protected pathways, capacity for time-sensitive oncological interventions was maintained and no immediate clinical harm was observed.
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http://dx.doi.org/10.1111/bju.15441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8239749PMC
May 2021

Pattern, timing and predictors of recurrence after surgical resection of chromophobe renal cell carcinoma.

World J Urol 2021 Apr 13. Epub 2021 Apr 13.

Division of Surgery and Interventional Science, University College London, London, UK.

Purpose: Currently there are no specific guidelines for the post-operative follow-up of chromophobe renal cell carcinoma (chRCC). We aimed to evaluate the pattern, location and timing of recurrence after surgery for non-metastatic chRCC and establish predictors of recurrence and cancer-specific death.

Methods: Retrospective analysis of consecutive surgically treated non-metastatic chRCC cases from the Royal Free London NHS Foundation Trust (UK, 2015-2019) and the international collaborative database RECUR (15 institutes, 2006-2011). Kaplan-Meier curves were plotted. The association between variables of interest and outcomes were analysed using univariate and multivariate Cox proportional hazards regression models with shared frailty for data source.

Results: 295 patients were identified. Median follow-up was 58 months. The five and ten-year recurrence-free survival rates were 94.3% and 89.2%. Seventeen patients (5.7%) developed recurrent disease, 13 (76.5%) with distant metastases. 54% of metastatic disease diagnoses involved a single organ, most commonly the bone. Early recurrence (< 24 months) was observed in 8 cases, all staged ≥ pT2b. 30 deaths occurred, of which 11 were attributed to chRCC. Sarcomatoid differentiation was rare (n = 4) but associated with recurrence and cancer-specific death on univariate analysis. On multivariate analysis, UICC/AJCC T-stage ≥ pT2b, presence of coagulative necrosis, and positive surgical margins were predictors of recurrence and cancer-specific death.

Conclusion: Recurrence and death after surgically resected chRCC are rare. For completely excised lesions ≤ pT2a without coagulative necrosis or sarcomatoid features, prognosis is excellent. These patients should be reassured and follow-up intensity curtailed.
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http://dx.doi.org/10.1007/s00345-021-03683-9DOI Listing
April 2021

The Fate of Ureteral Memokath Stent(s) in a High-Volume Referral Center: An Independent Long-Term Outcomes Review.

J Endourol 2021 02 23;35(2):180-186. Epub 2020 Sep 23.

Department of Urology, Royal London Hospital, Bart's Health NHS Trust, London, United Kingdom.

To independently assess upper urinary tract Memokath (MMK-051) stent outcomes in a national tertiary referral center. Two researchers, completely independent to the treating team, reviewed electronic MMK-051 stent(s) patient management records. Outcomes included time to first complication, complication(s)-severity, MMK-051 stent lifespan and change incidence, salvage therapy, further surgical intervention, and mortality. One hundred patients received 162 MMK-051 stent(s) (59% with malignant and 63% with distal ureteral obstruction [UO]) with only three lost to follow-up (FU). At 5-year mean FU, only 25 patients had complication-free original MMK-051 stents (14 alive, 11 dead). Of the remaining 75 patients, 22 had other stents, 12 had major surgery (e.g., nephrectomy), 3 became dialysis dependent, and 14 stabilized without ureteral stenting after original MMK-051 removal. Malignant obstruction patients had greater original MMK-051 stent longevity ( < 0.02), but also 20 of the 21 deaths (95%). The 72% mean 5-year stent complication rate included migration (46%), blockage (34%), nonfunctioning kidney (8%), urosepsis needing intravenous antibiotics (8%), and others (6%), including one postoperative death, one ureteral injury, and two with intractable pain. Median time to first complication was 12.5 months. MMK-051 stents had optimal utility in managing malignant UO and in those unfit for corrective surgery. Longer independently assessed mean 5-year outcomes review revealed much higher complication rates (72%) than previously reported. Future international metallic ureteral stent guidelines should encourage clinicians to adopt patient-centered multidisciplinary assessment and selection, with counseling plus goal-setting, and harmonized long-term protocol-based reporting, for optimized future patient safety and outcomes.
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http://dx.doi.org/10.1089/end.2020.0542DOI Listing
February 2021

Safety and feasibility of early single-dose mitomycin C bladder instillation after robot-assisted radical nephroureterectomy.

BJU Int 2020 12 9;126(6):739-744. Epub 2020 Aug 9.

Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK.

Objectives: To assess the safety and feasibility of early single-dose mitomycin C (MMC) bladder instillation after robot-assisted radical nephroureterectomy (RARNU) at a tertiary kidney cancer centre. RARNU with bladder cuff excision and subsequent MMC bladder instillation to reduce recurrence risk is the 'gold standard' for high-risk upper urinary tract urothelial carcinoma (UUTUC). We adapted a RARNU technique with precise distal ureteric dissection, bladder cuff excision and watertight bladder closure.

Patients And Methods: We retrospectively reviewed all patients undergoing RARNU for UUTUC at our centre performed as a standardised transperitoneal procedure comprising of: bladder cuff excision, two-layer watertight closure and intraoperative bladder leak test; without re-docking/re-positioning of the robotic surgical system. Patient demographics, the timing of MMC instillation, adverse events (surgical and potentially MMC-related) and length of stay (LOS) were assessed according to the Clavien-Dindo classification.

Results: A total of 69 patients underwent a RARNU with instillation of MMC. The median (interquartile range [IQR]) age was 70 (62-78) years. The median (IQR) day of MMC instillation was 2 (1-3) days and the median (IQR) LOS was 2 (2-4) days, with urethral catheter removal on day of discharge in all cases. Only Grade I Clavien-Dindo complications occurred in seven patients (10%); five had ileus, one a wound infection and one a self-limiting delirium, all managed conservatively. No adverse events potentially related to MMC instillation were noted within 30 days postoperatively.

Conclusion: The use of intravesical MMC instillation given in the immediate postoperative period appears feasible and safe in patients undergoing RARNU with intraoperative confirmation of a water-tight closure ensuring early catheter-free discharge, with no significant adverse events. The potential reduction in intravesical recurrence in patients receiving early MMC needs to be assessed with longitudinal follow-up studies.
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http://dx.doi.org/10.1111/bju.15162DOI Listing
December 2020

Guideline adherence for the surgical treatment of T1 renal tumours correlates with hospital volume: an analysis from the British Association of Urological Surgeons Nephrectomy Audit.

BJU Int 2020 01 18;125(1):73-81. Epub 2019 Aug 18.

Netherlands Cancer Institute, Amsterdam, The Netherlands.

Objective: To assess European Association of Urology guideline adherence on the surgical management of patients with T1 renal tumours and the effects of centralisation of care.

Patients And Methods: Retrospective data from all kidney tumours that underwent radical nephrectomy (RN) or partial nephrectomy (PN) in the period 2012-2016 from the British Association of Urological Surgeons Nephrectomy Audit were retrieved and analysed. We assessed total surgical hospital volume (HV; RN and PN performed) per centre, PN rates, complication rates, and completeness of data. Descriptive analyses were performed, and confidence intervals were used to illustrate the association between hospital volume and proportion of PN. Chi- squared and Cochran-Armitage trend tests were used to evaluate differences and trends.

Results: In total, 13 045 surgically treated T1 tumours were included in the analyses. Over time, there was an increase in PN use (39.7% in 2012 to 44.9% in 2016). Registration of the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) complexity score was included in March 2016 and documented in 39% of cases. Missing information on postoperative complications appeared constant over the years (8.5-9%).  A clear association was found between annual HV and the proportion of T1 tumours treated with PN rather than RN (from 18.1% in centres performing <25 cases/year [lowest volume] to 61.8% in centres performing ≥100 cases/year [high volume]), which persisted after adjustment for PADUA complexity. Overall and major (Clavien-Dindo grade ≥III) complication rate decreased with increasing HV (from 12.2% and 2.9% in low-volume centres to 10.7% and 2.2% in high-volume centres, respectively), for all patients including those treated with PN.

Conclusion: Closer guideline adherence was exhibited by higher surgical volume centres. Treatment of T1 tumours using PN increased with increasing HV, and was accompanied by an inverse association of HV with complication rate. These results support the centralisation of kidney cancer specialist cancer surgical services to improve patient outcomes.
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http://dx.doi.org/10.1111/bju.14862DOI Listing
January 2020

Protocol for a feasibility study of a cohort embedded randomised controlled trial comparing phron paring reatment (NEST) for small renal masses.

BMJ Open 2019 06 11;9(6):e030965. Epub 2019 Jun 11.

Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London, London, UK.

Introduction: Small renal masses (SRMs; ≤4 cm) account for two-thirds of new diagnoses of kidney cancer, the majority of which are incidental findings. The natural history of the SRM seems largely indolent. There is an increasing concern regarding surgical overtreatment and the associated health burden in terms of morbidity and economy. Observational data support the safety and efficacy of percutaneous cryoablation but there is an unmet need for high-quality evidence on non-surgical management options and a head-to-head comparison with standard of care is lacking. Historical interventional trial recruitment difficulties demand novel study conduct approaches. We aim to assess if a novel trial design, the cohort embedded randomised controlled trial (RCT), will enable carrying out such a comparison.

Methods And Analysis: Single-centre prospective cohort study of adults diagnosed with SRM (n=200) with an open label embedded interventional RCT comparing nephron sparing interventions. Cohort participants will be managed at patient and clinicians' discretion and agree with longitudinal clinical data and biological sample collection, with invitation for trial interventions and participation in comparator control groups. Cohort participants with biopsy-proven renal cell carcinoma eligible for both percutaneous cryoablation and partial nephrectomy will be randomly selected (1:1) and invited to consider percutaneous cryoablation (n=25). The comparator group will be robotic partial nephrectomy (n=25). The primary outcome of this feasibility study is participant recruitment. Qualitative research techniques will assess barriers and recruitment improvement opportunities. Secondary outcomes are participant trial retention, health-related quality of life, treatment complications, blood transfusion rate, intensive care unit admission and renal replacement requirement rates, length of hospital stay, time to return to pre-treatment activities, number of work days lost, and health technologies costs.

Ethics And Dissemination: Ethical approval has been granted (UK HRA REC 19/EM/0004). Study outputs will be presented and published.

Trial Registration: ISRCTN18156881; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2019-030965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6577353PMC
June 2019

Contemporary surgical management of renal oncocytoma: a nation's outcome.

BJU Int 2018 06 2;121(6):893-899. Epub 2018 Mar 2.

Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK.

Objective: To report on the contemporary UK experience of surgical management of renal oncocytomas.

Patients And Methods: Descriptive analysis of practice and postoperative outcomes of patients with a final histological diagnosis of oncocytoma included in The British Association of Urological Surgeons (BAUS) nephrectomy registry from 01/01/2013 to 31/12/2016. Short-term outcomes were assessed over a follow-up of 60 days.

Results: Over 4 years, 32 130 renal surgical cases were recorded in the UK, of which 1202 were oncocytomas (3.7%). Most patients were male (756; 62.9%), the median (interquartile range [IQR]) age was 66.8 (13) years. The median (IQR; range) lesion size was 4.1 (3; 1-25) cm, 43.5% were ≤4 cm and 30.3% were 4-7 cm lesions. In all, 35 patients (2.9%) had preoperative renal tumour biopsy. Most patients had minimally invasive surgery, either radical nephrectomy (683 patients; 56.8%), partial nephrectomy (483; 40.2%) or other procedures (36; 3%). One in five patients (243 patients; 20.2%) had in-hospital complications: 48 were Clavien-Dindo classification grade ≥III (4% of the total cohort), including three deaths. Two additional deaths occurred within 60 days of surgery. The analysis is limited by the study's observational nature, not capturing lesions on surveillance or ablated after biopsy, possible underreporting, short follow-up, and lack of central histology review.

Conclusion: We report on the largest surgical series of renal oncocytomas. In the UK, the complication rate associated with surgical removal of a renal oncocytoma was not negligible. Centralisation of specialist services and increased utilisation of biopsy may inform management, reduce overtreatment, and change patient outcomes for this benign tumour.
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http://dx.doi.org/10.1111/bju.14159DOI Listing
June 2018

Succinate Dehydrogenase B (SDHB)-Associated Bladder Paragangliomas.

Clin Genitourin Cancer 2017 02 23;15(1):e131-e136. Epub 2016 Jun 23.

Department of Endocrinology, St Bartholomew's Hospital, West Smithfield, London, UK.

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http://dx.doi.org/10.1016/j.clgc.2016.06.006DOI Listing
February 2017

Robot-assisted partial nephrectomy: a comparison of the transperitoneal and retroperitoneal approaches.

J Endourol 2013 Jul 2;27(7):869-74. Epub 2013 May 2.

Department of Surgery and Cancer, Imperial College, London, United Kingdom.

Purpose: To present the oncologic and functional outcomes of robot-assisted partial nephrectomy (RAPN) and analyze retroperitoneal and transperitoneal approaches.

Patients And Methods: RAPN was performed on 103 patients; 44 patients underwent a retroperitoneal and 59 a transperitoneal approach. Demographic, operative, and postoperative data was collected and retrospectively analyzed on all patients.

Results: Overall average warm ischemic time was 20.4 (0-48) minutes, total operative time was 175.3 (85-330) minutes, and estimated blood loss was 258.1 (20-3100) mL. When retroperitoneal and transperitoneal approaches were compared, there was no significant difference in warm ischemic time but a significant reduction in both estimated blood loss and total operative time in the retroperitoneal group.

Conclusion: Our series would suggest that if performed by a surgeon familiar with a laparoscopic retroperitoneal approach to renal surgery, retroperitoneal RAPN is at least equivalent to the more common transperitoneal approach in the outcomes assessed.
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http://dx.doi.org/10.1089/end.2013.0023DOI Listing
July 2013

Unrecognized bladder perforation with mid-urethral slings.

BJU Int 2010 Nov;106(10):1514-8

Department of Urology, Lister Hospital Stevenage, Stevenage, UK.

Objective: To present a series of women with late presentation of mid-urethral synthetic slings perforating the bladder and their management, this is rare but can lead to significant morbidity with medico-legal consequences.

Patients And Methods: We retrospectively reviewed the case notes of nine women with urinary symptoms referred to our unit for further investigation after synthetic mid-urethral sling placement.

Results: The women presented between 8 weeks and 18 months after initial sling placement. Eight patients underwent a tension-free vaginal tape insertion via the retropubic route and one patient had an 'outside-in' obturator sling with the I-Stop device (CL Medical, Lyon, France). The frequencies of presenting symptoms were: dysuria in six; recurrent urinary tract infection in four; frequency and urgency in four and pelvic pain in two. Seven of the nine women developed bladder calculi on the exposed sling material, all of which were visible on plain X-ray. In six women, perforations were present at more than one site; in three urethral perforation had occurred together with an anterolateral bladder injury and in the remaining three there was bilateral bladder perforation. Initial management included cystoscopy and cystolithopaxy followed by transurethral resection (TUR) of the visible prolene mesh into the detrusor muscle. One woman required two TURs to clear all the mesh. Two women required further open surgery to remove all of the remaining mesh, both for ongoing pelvic pain that resolved after revision surgery. All the women had resolution of symptoms but all had recurrent stress urinary incontinence after tape division/excision. We used a novel technique to remove intraurethral mesh using a nasal speculum urethrally and excising the tape under direct vision, where resection proved impossible due to poor endoscopic views, with significant risk of sphincter injury.

Conclusions: The possibility of unrecognized tape perforation or erosion must be considered in women with persistent urinary symptoms, infection or pain after any form of mid-urethral sling procedure. Bladder stones almost invariably develop if the exposed mesh has been present for >3 months. Most patients can be managed with endoscopic resection to remove all intravesical tape. Cystoscopy should remain a mandatory procedure together with any form of mid-urethral sling placement but does not prevent unrecognized perforations in inexperienced hands.
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http://dx.doi.org/10.1111/j.1464-410X.2010.09378.xDOI Listing
November 2010

Patients' perspective of botulinum toxin-A as a long-term treatment option for neurogenic detrusor overactivity secondary to spinal cord injury.

BJU Int 2009 Jul 10;104(2):216-20. Epub 2009 Feb 10.

Department of Neuro-urology and Spinal Research Centre, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.

Objective: To evaluate patients' perspective on whether they would consider botulinum toxin-A (BTX-A) injections as a long-term treatment option for managing their neurogenic detrusor overactivity (NDO) secondary to spinal cord injury (SCI).

Patients And Methods: In all, 72 patients with SCI and urodynamically confirmed NDO refractory to anticholinergics, who have had at least one or more injections with BTX-A were invited to participate in a 5-min telephone questionnaire covering various aspects of their treatment. Questions about patient satisfaction were rated on a scale from 1 to 10 (1, not satisfied; to 10, very satisfied).

Results: Of the 72 patients surveyed, 48 (67%) were still actively undergoing repeat BTX-A injections. The mean patient satisfaction score was 6.2. Of the 48 patients, 43 (90%) replied that they would consider continuing with BTX-A injections as a long-term treatment option. Only seven (15%) of patients still having BTX-A injections would consider an alternative permanent surgical option in the next 5 years. Of those patients considering a one-off permanent surgical solution, younger patients were likely to consider this at a later interval than those in an older group (Spearman's correlation coefficient, -0.52, 95% confidence interval -0.78 to -0.10, P = 0.02). The annual new patient recruitment rate was high (mean 14.4) and the annual withdrawal rate was low (mean 4.8).

Conclusion: With high satisfaction and low annual withdrawal rates, there are increasingly many patients on BTX-A. Most consider continuing BTX-A injections in the long term, increasing the future demand for this service. There is an urgent need for further research into optimizing the current delivery of an intradetrusor BTX-A injection service for patients with NDO.
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http://dx.doi.org/10.1111/j.1464-410X.2009.08368.xDOI Listing
July 2009

Dynamic biochemical information recovery in spontaneous human seminal fluid reactions via 1H NMR kinetic statistical total correlation spectroscopy.

Anal Chem 2009 Jan;81(1):288-95

Department of Biomolecular Medicine, Division of Surgery, Oncology, Reproductive Biology and Anaesthetics (SORA), Faculty of Medicine, Imperial College London, South Kensington, SW7 2AZ, United Kingdom.

Human seminal fluid (HSF) is a complex mixture of reacting glandular metabolite and protein secretions that provides critical support functions in fertilization. We have employed 600-MHz (1)H NMR spectroscopy to compare and contrast the temporal biochemical and biophysical changes in HSF from infertile men with spinal cord injury compared to age-matched controls. We have developed new approaches to data analysis and visualization to facilitate the interpretation of the results, including the first application of the recently published K-STOCSY concept to a biofluid, enhancing the extraction of information on biochemically related metabolites and assignment of resonances from the major seminal protein, semenogelin. Principal components analysis was also applied to evaluate the extent to which macromolecules influence the overall variation in the metabolic data set. The K-STOCSY concept was utilized further to determine the relationships between reaction rates and metabolite levels, revealing that choline, N-acetylglucosamine, and uridine are associated with higher peptidase activity. The novel approach adopted here has the potential to capture dynamic information in any complex mixture of reacting chemicals including other biofluids or cell extracts.
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http://dx.doi.org/10.1021/ac801993mDOI Listing
January 2009

Seminal oligouridinosis: low uridine secretion as a biomarker for infertility in spinal neurotrauma.

Clin Chem 2008 Dec 2;54(12):2063-6. Epub 2008 Oct 2.

Department of Biomolecular Medicine, SORA Division, Faculty of Medicine, Imperial College London, London, UK.

Background: Compromised sexual health is a major rehabilitative barrier for men with lower-spinal cord injury (SCI). Although studies have revealed decreased sperm motility, the quantitative biochemical changes that underlie the infertility mechanism remain poorly understood.

Methods: We employed a nontargeted approach combining 800 MHz hydrogen nuclear magnetic resonance ((1)H NMR) spectroscopy and ultra-performance liquid chromatography-mass spectrometry (UPLC-MS) with pattern recognition methods to analyze seminal fluid metabolite profiles in 10 men with and 8 without SCI above thoracic vertebra 10 (T10).

Results: The metabolic phenotype for SCI could be predicted from the (1)H NMR data. The median concentration of uridine in fertile controls was 1.55 mmol/L (range 1.0-5.0 mmol/L), but was undetectable by both NMR and MS in all but 2 individuals from the SCI group, one who later fathered a child without assisted fertility techniques.

Conclusions: We hypothesize that uridine is likely to be an essential precursor to metabolites required for capacitation and is a potential marker for the prognosis of post-SCI functional fertility recovery. We derived the term "seminal oligouridinosis" to describe this newly identified condition.
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http://dx.doi.org/10.1373/clinchem.2008.112219DOI Listing
December 2008

Effects of spinal cord injury on semen parameters.

J Spinal Cord Med 2008 ;31(1):27-32

Neurourology Department, London Spinal Cord Injury Centre, Royal National Orthopaedic Hospital, Middlesex, UK.

Objective/background: Neurogenic reproductive dysfunction in men with spinal cord injury (SCI) is common and the result of a combination of impotence, ejaculatory failure, and abnormal semen characteristics. It is well established that the semen quality of men with SCI is poor and that changes are seen as early as 2 weeks after injury. The distinguishing characters of poor quality are abnormal sperm motility and viability. In the majority of the men with SCI, the sperm count is not abnormal. We elaborate on the effects of the SCI on semen parameters that may contribute to poor motility and poor viability.

Methods: Review.

Design: PubMed and MEDLINE databases were searched using the following key words: spinal cord injuries, fertility, sexual dysfunction, and spermatogenesis. All literature was reviewed by the team of authors according to the various stages of sperm development and transport in the male reproductive cycle.

Findings: The cause of asthenozoospermia appears to be multifactorial.

Conclusion: Current literature does not support the preeminence of a single factor relating to neurogenic reproductive dysfunction in men with SCI. After SCI, there is ample evidence of disturbance of sperm production, maturation and storage, and transport due to an abnormal neuroendocrine milieu. Semen quality seems to be primarily affected by changes to the seminal plasma constituents, type of bladder management, and the neurogenic impairment to the ejaculatory function. Further focused and structured studies are required.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2435039PMC
http://dx.doi.org/10.1080/10790268.2008.11753977DOI Listing
August 2008

An effective day case treatment combination for refractory neuropathic mixed incontinence.

Int Braz J Urol 2008 Jan-Feb;34(1):63-71; discussion 71-2

Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK.

Objective: Women with drug refractory neurogenic mixed incontinence (NMI) have limited minimally invasive treatment options and require reconstructive surgery. We examined efficacy of a combination of day case intradetrusor (ID) botulinum toxin (BTX-A) bladder injections and transobturator (TOT) or tension free vaginal tape (TVT).

Materials And Methods: Eleven women who are pharmacotherapy intolerant or who have drug refractory NMI were treated. Two opted for open surgery and the remaining 9 received 1000 units of Dysport diluted in 30 mL saline cystoscopically at 30 ID sites followed by TOT in 6 or TVT in 3 as a day case combination treatment. Patient demographics, pre and post treatment videocystometrogram (VCMG), pad test and International Committee on Incontinence Questionnaire (ICIQ) scores were recorded. At 6 weeks (repeat ICIQ, pad test and patient satisfaction), at 3 and 12 months (VCMG) and 'current' (ICIQ and patient satisfaction) was recorded.

Results: The mean age was 56.7 years (range 41 to 78) with a mean follow up of 19.1 months (range 7 to 33). All women were continent at 3 and 12 months. Quality of life (ICIQ scores) improved at 6 weeks (p > 0.001) and remained stable up to the last follow up (p > 0.001). Eight women have stopped using pads. At 3 months, there was significant improvement in MDP (p > 0.014) and MCC (p = 0.002). Anticholinergics were discontinued in 7 with global high satisfaction with the treatment BTX-A injections were repeated in 4 (mean 13.5 months).

Conclusion: Anticholinergic refractory women with NMI can be effectively treated as a day case with combination of ID BTX-A injections and TVT or TOT.
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http://dx.doi.org/10.1590/s1677-55382008000100010DOI Listing
April 2009

Botulinum toxin-type A in the treatment of drug-resistant neurogenic detrusor overactivity secondary to traumatic spinal cord injury.

BJU Int 2006 Jul;98(1):77-82

Department of Neurourology Spinal Injuries Unit, RNOH, Stanmore, UK.

Objective: To assess, in a prospective study, whether botulinum toxin-type A (BTX-A) injected into the detrusor muscle, can be used as a day-case treatment for drug-resistant neurogenic detrusor overactivity (NDO) in patients with spinal cord injury (SCI).

Patients And Methods: BTX-A (Dysport, Ipsen, Luxembourg; 1000 units) was injected cystoscopically into the detrusor muscle of 37 patients with drug-resistant NDO and SCI, as a day-case procedure. The maximum cystometric capacity (MCC), maximum detrusor pressure (MDP), NDO, continence, and anticholinergic requirement were used as outcome variables. The International Consultation on Incontinence questionnaire (ICIQ) was used to assess the patient's quality of life before and after the BTX-A injection.

Results: The mean follow-up was 7 months. The MCC increased from a mean of 259 to 522 mL, and the MDP decreased from a mean of 54 to 24 cmH2O. Incontinence and NDO were abolished in 82% and 76% patients, respectively. In all, 86% of the patients were able to stop or reduce anticholinergics, with a similar proportion of patients scoring favourably on the ICIQ. The mean duration of improvement was 9 months.

Conclusions: Injection with BTX-A is an effective day-case treatment that bridges the gap between oral and invasive surgical treatment of drug-resistant NDO in patients with SCI.
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http://dx.doi.org/10.1111/j.1464-410X.2006.06192.xDOI Listing
July 2006

Lower urinary tract dysfunction in ambulatory patients with incomplete spinal cord injury.

J Urol 2006 May;175(5):1784-7; discussion 1787

Spinal Injuries Unit, Department of Neuro-urology, Royal National Orthopaedic Hospital, Stanmore, United Kingdom.

Purpose: We evaluated urinary tract dysfunction in individuals with spinal injury who remained able to ambulate. We observed changes with time in urological management.

Materials And Methods: All patients attending outpatient clinics with traumatic, incomplete (American Spinal Injury Association grades D and E) spinal cord injury during a 2-year period were identified. All patients had their hospital notes reviewed retrospectively and salient urological data extracted.

Results: A total of 43 men and 21 women were identified during this period. Mean age was 46 years (range 18 to 70). Mean followup was 7 years (range 1 to 18). At the time of inpatient discharge 40 of the 64 patients (62.5%) could void spontaneously, 20 required CSIC and 4 had a suprapubic catheter. In 19 of these 40 patients (47.5%) who had been initially assessed as having a bladder that was safe to void spontaneously the condition deteriorated, such that CSIC was required. Conversely 5 of 20 patients (25%) who initially required CSIC improved, such that it became redundant. At last followup 68.7% of the patients had abnormal urodynamics and 24 of the 64 (37.5%) required a change in urological management despite no appreciably detectable neurological change.

Conclusions: Despite relatively near total neurological recovery patients with incomplete SCI have neuropathic bladder unless proved otherwise. Salient deterioration in bladder dysfunction is not uncommon. Regular urological monitoring and appropriate treatment changes are required in the long term.
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http://dx.doi.org/10.1016/S0022-5347(05)00979-1DOI Listing
May 2006

Variation in urological practice amongst spinal injuries units in the UK and Eire.

Neurourol Urodyn 2004 ;23(3):252-6; discussion 257

Department of Neuro-Urology, Spinal Injuries Unit, Stanmore, Middlesex, United Kingdom.

Aims: To investigate variations in common urological practice between the Spinal Injuries Units (SIU) of UK and Eire.

Methods: In December 2002, each of the 12 SIU in the UK and Eire were sent a questionnaire addressing basic practice relating to urological outpatient follow-up, management of urinary tract infection, upper tract surveillance, and urodynamic studies.

Results: Regarding frequency of urological review, two units only saw patients when specifically required. One unit reviewed patients every 6 months and six centres reviewed patients annually. The remaining three units had a patient-specific follow-up protocol. Regarding urinary tract infection, only five units had a unified departmental management protocol. Four units advocated antibiotic prophylaxis for recurrent UTI. Only one unit would routinely treat asymptomatic UTI in individuals using catheters. The range of recommended duration of treatment for symptomatic UTI was 3-14 days (mean 6.3). All units performed routine upper tract screening, ranging from annually to every 3 years. Six units did not perform routine urodynamic studies; in other units the range of frequency of urodynamics was from annually to every 3 years.

Conclusions: The variation in urological practice amongst SIU in the UK and Eire is considerable. This finding supports the need for an increase in the level of collaboration and research.
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http://dx.doi.org/10.1002/nau.20005DOI Listing
June 2004
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