Q. How do you ensure correct site surgery, for example in patients undergoing radical inguinal orchidectomy or nephrectomy?
A. I follow the guidelines, as set out by the National Patient Safety Agency (NPSA) [5], which provides a checklist of steps taken at various times before and at the time of surgery and by various members of the operative team, as follows:
1. The operating surgeon or a member of his team should see the patient at the time of consent and prior to transfer to theatres. The patient’s identity should be confirmed, imaging and documentation reviewed and, in conjunction with the patient (prior to any anaesthetic premedications being taken), the site should be marked in indelible pen.
2. Prior to transfer to theatre the ward staff should review the documentation and inspect/ confirm the presence of the mark.
3. Once in the anaesthetic room, prior to anaesthesia, a member of the operating team should again review the relevant imaging and documentation and should re-inspect the mark made.
4. In the operating theatre, immediately prior to the start of surgery all theatre staff involved in the case should as part of the World Health Organisation (WHO) checklist confirm the patient’s identity, the procedure to be performed and the marking of the correct skin site.
The WHO Surgical Safety Checklist, incorporating the Sign In before induction of anaesthesia, the Time Out before skin incision and the Sign Out before the patient leaves the operating room incorporates steps 3 and 4 in the previous list.
There may be certain circumstances where marking may not be appropriate, such as where it may cause a delay to emergency surgery, bilateral procedures, surgery to teeth or mucus membranes and situations where the laterality of the procedure would be confirmed during surgery. If a patient was to refuse preoperative skin marking, it is recommended that this should be carefully documented in the patient’s notes. The correct site surgery checklist should still be followed to ensure that staffs are aware at each stage.
Q. What precautions do you take when inserting a prosthesis (e.g. artificial urinary sphincter, penile)?
A. In my practice, steps to reduce the risk of infection begin prior to the surgical procedure itself. The patient is advised to have Hibiscrub/chlorhexidine washes or shower for 24-48 hours and Naseptin cream. Any other focus of infection, detected pre-operatively is also treated, prior to consideration for surgery. At induction of anaesthesia, prophylactic, broad- spectrum, intravenous antibiotics to cover skin commensals are given. Shaving of the surgical site is performed in theatre prior to surgery. During the procedure itself, I ensure that there is the least number of theatre staff in the operating room as possible, and that their movement in and out of theatre is minimised. I ensure meticulous haemostasis at time of surgery. Antibiotic solutions can be applied to the prosthesis (e.g. gentamicin), once removed from the sterile packaging, as well as irrigating the wound with antibiotics prior to placement. When inserting the prosthesis fresh gloves are applied and a no-touch technique is used. Typically, I will use a small swab to handle the prosthesis. After the procedure antibiotic treatment is continued as per local policy.
Q. How would you manage a patient who begins to have difficulty breathing following scrotal injection of lignocaine, prior to vasectomy under local anaesthetic?
A. Treat this as an emergency as the patient is likely to be having an anaphylactic reaction (allergy to lignocaine). Initially assess the patient and confirm the diagnosis and request a nurse/colleague to fast bleep the ‘Arrest’ team. While waiting for the emergency team, follow advanced life support principles and check airway, breathing and circulation. Oxygenate patient and gain intravenous access. From the resuscitation trolley give 0.5 mL 1 in 1:1000 adrenaline intramuscularly. Give 200 mg intravenous hydrocortisone and 10 mg intravenous chlorpheniramine (Piriton).
Q. An alcoholic 73-year-old man presents with a prostate-specific antigen (PSA) of 120 and bony metastatic disease. He is commenced on androgen deprivation therapy. Your SpR correctly recognises that he has risk factors for osteoporosis and requests a DEXA scan, but he is not sure how it works. Can you explain?
A. Dual energy x-ray absorptiometry (DEXA) is a highly accurate and reproducible diagnostic test used to estimate bone mineral density (BMD), which relates to risks of osteoporosis and fracture. The total radiation dose is similar to that of a chest x-ray. The patient cannot wear any metal, and the scan must take place at least 24 hours after radionuclide, intravenous contrast or barium studies.
An x-ray arm emitting two distinct, low-energy beams is passed over a supine patient.
The bone area can be segmented and the difference in attenuation used to calculate estimated density of bone, fat and lean muscle.
The BMD is compared with sex-matched peak density to give WHO-defined ‘T’-score based on standard deviations from normal, used to define osteoporosis as less than -2.5; osteopenia between —1 and -2.5; normal greater than -1. The T score is used in older men and post-menopausal women.
‘Z’-scores, based on age, sex and ethnicity-matched data are utilised in children and premenopausal patients, again based on standard deviations.
NICE currently recommend assessment of osteoporosis risk using algorithms such as WHO-FRAX or QFracture tool prior to obtaining a DEXA scan.
Q. Can you describe how a CT-PET scan works and how it is carried out?
A. Static anatomical images from a CT scan are combined with the functional images of the positron emission tomography (PET) scan; the combination may have a greater diagnostic yield over either modality alone.
PET is a dynamic nuclear medicine technique. A radiolabelled analogue such as 18F-FDG (18 fluorine-fluorodeoxyglucose) is injected; the analogue and radionuclide accumulates in metabolically active tissue. On decay the radionuclide emits a positron - positively charged electron - which reacts with a local electron to produce diametrically opposite 511 keV photons. This process is known as ‘annihilation’. The photons are detected by a PET camera. The scan takes around 30 minutes.
Q. What are the indications for a PET scan in urological malignancy? What different types of scan can you describe?
A. An 18F-FDG PET is recommended in advanced seminomatous germ cell tumours of the testis, where a greater than 3 cm nodal mass persists following chemotherapy, to guide surveillance or active treatment. However, PET is not recommended in non-seminomatous germ cell tumours (NSGCTs) due to high false-negative rates (TE22 study). FDG is excreted by the kidneys and accumulates in the urinary tract, limiting its use in urological malignancy.
In prostate cancer, 11C-choline PET is recommended in cases of biochemical failure after radical radiotherapy or prostatectomy, if salvage treatment is being considered. ttere is no role for PET in primary staging. Prostate-specific membrane antigen (PSMA) is a glycoprotein that has increased expression in high-grade prostate cancer. ttere is increasing evidence that 68-Gallium labelled PSMA PET-CT may have improved sensitivity in detecting nodal metastasis over CT imaging alone in preoperative high-risk disease, and also in detecting recurrent disease following radical therapy.
PET CT may be used for assessment of nodal disease in advanced penile cancer. ttere is no recommendation for PET in the European Association of Urology (EAU) guidelines for renal, non-muscle invasive bladder, upper tract urothelial cancers. Small-scale studies have shown some use in muscle-invasive bladder cancer but this is not part of established treatment protocols.
Q. What do you know about SPECT and its use in urology?
A. A single-photon emission computed tomography (SPECT) scan uses similar principles to a bone scan; however the injected radiopharmaceutical, typically 99mTc, is utilised and detected by a gamma camera that rotates around the patient, rather than just taking anterior and posterior views. The images are reconstructed and combined with CT images which can be taken concurrently. SPECT has demonstrated some promise in differentiation of oncocytomas in recent trials.