Re-auditing a regional lithotripsy service

Does regional audit improve practice in the management of urological cancers?

Objective:

The effect of a regional audit is underreported and uncertain. Across the North West of England we have conducted annual regional audits of urological cancer care for over 20 years.

Methods:

We reviewed the data from four complete audit cycles (prostate, testis, bladder and kidney) to ascertain the change in adherence to agreed guidelines. Adherence to guidelines was pooled across cancer types and the following domains. Preoperative investigation, planning and counselling Perioperative and intraoperative care Follow-up regimen and documentation Difference in adherence to guidelines was expressed as an absolute percentage change and statistical significance was determined using Fisher’s exact test.

Results:

Over the four complete audit cycles 3659 case notes were reviewed totalling 20,470 observations. The four separate audits generated 42 guidelines which were equally assessable between audit cycles (prostate (nine), testis (seven), bladder (18) and kidney (eight)). Overall, adherence to guidelines between the original and follow-up audit improved from 63.4% to 73.4% ( p < 0.05). Adherence improved across all cancers; however, this was not equal across all domains. Marked improvements were seen in preoperative investigation (+13%, p < 0.05), planning and counselling and follow-up and documentation (+12%, p < 0.05). A non-significant rise of 0.1% was seen in guidelines pertaining to intraoperative care ( p = 0.95).

Conclusions:

A regional audit has overseen and documented an improvement in practice in urological cancer within the region studied. Although the mechanisms leading to this are likely to be complex, we suggest that the audit process per se is likely to contribute to this improvement rather than merely document it.

Percutaneous Lithotripsy: Indications

Although percutaneous nephrolithotomy (PCNL) is more invasive than extracorporeal lithotripsy (ESWL) it still plays an important role in the treatment of renal stones and indications to PCNL are mainly the cases where ESWL gives poor outcome results. When considering the indications to treat a patient affected by a renal stone, we have to evaluate factors related to: the stone, the kidney, the patient, the instruments and finally the urologist. We believe that elective indications to PCNL are: a stone burden >2cm; staghorn and complex stones; stones in hydronephrotic kidneys or associated to UPJ obstruction; lower calyceal stones when >10 mm or in a calyx with an unfavorable anatomy; ureteral stones impacted in the UPJ with severe hydronephrosys; stones in caliceal diverticula.

Urinary tract stones--Part II: current status of treatment

The majority of renal and ureteric stones are now managed by minimally invasive techniques, for example nephrostomy, ureteral stents, extracorporeal shockwave lithotripsy or percutaneous nephrolithotomy. A multi-disciplinary approach is necessary, and this review examines the status of modern stone therapy and the contribution of the radiology department.