Urology clinical outcomes

Clinical outcomes are measurable changes in health, function or quality of life that result from our care. Constant review of our clinical outcomes establishes standards against which to continuously improve all aspects of our practice.

About the Urology Service

The Urology department at Great Ormond Street Hospital (GOSH) provides a national and international specialist service to treat children with simple and complex urological conditions. GOSH is one of two services in the UK specialising in the management of children with epispadias and bladder exstrophy.

Clinical outcome measures

Where available and comparable, we reference peer-reviewed papers to indicate expected results relative to other national and international centres.

1. Non-elective readmission rate within 30 days of discharge

Complications resulting from surgery can occasionally cause patients to be readmitted to hospital. The rate of readmissions is a standard hospital outcome that is monitored to reduce complications and improve care. The table below shows the number of patients discharged from urology who have a non-elective (emergency) readmission within 30 days of discharge (excludes day cases). 

Numerator: number of inpatient discharges under urology that have a subsequent non-elective readmission (to any specialty) within 30 days of discharge from GOSH.

Denominator: number of all inpatient discharges from GOSH under urology. Day cases are excluded.

Table 1 1 Non-elective re-admission rate within 30 days to any specialty after a procedure under urology

Year

Patients requiring non-elective readmission within 30 days

Total number of all inpatients discharged under Urology

Percentage of readmissions within 30 days

2015/16

10

919

1.1%

2016/17

19

947

2.0%

2017/18

20

863

2.3%

Total

49

2,729

1.8%

2. Pyeloplasty surgery

A pyeloplasty is an operation to remove a blockage in one of the ureters, part of the urinary system. Urine flows from the kidneys down through the ureters to the bladder. If the ureter is blocked, the kidney could become swollen and damaged. The blockage can either be removed using laparoscopic (keyhole) surgery or open surgery. For a small number of patients, revision surgery may be needed. Our rates of revision surgery are broadly similar to those published in peer-reviewed journals.

2.1. Pyeloplasty revisions

The table below shows the number of patients who had revision surgery (subsequent pyeloplasty, nephrectomy) within one year of the primary (original) surgery. Numbers are shown separately for laparoscopic and open surgery. Laparoscopic (keyhole) surgery is a less invasive technique than open surgery.

Numerator: number of revision surgeries within one year of primary pyeloplasty procedure at GOSH.

Denominator: number of primary pyeloplasty procedures at GOSH.

Table 2.1 Pyeloplasty procedure

Open or laparoscopic pyeloplasty

Years

Number of revision surgeries within one year of primary pyeloplasty

Total number of primary pyeloplasties

Percentage of revision surgeries within one year of primary pyeloplasty

Open

2012/13 – 2013/14

3

107

2.8%

2014/15 – 2015/16

4

65

6.2%

2016/17 – 2017/18

1

44

2.3%

Total

8

216

3.7%

Laparoscopic

2012/13 – 2013/14

1

33

3.0%

2014/15 – 2015/16

2

44

4.5%

2016/17 – 2017/18

4

40

10.0%

Total

7

117

6.0%

The revision rate for laparoscopic pyeloplasty procedures is expected to be higher than the revision rate for open pyeloplasty because it is more difficult to perform. We use the laparoscopic approach when clinically appropriate because of its benefits to the patient, including faster recovery, less pain, shorter length of hospital stay, and less scarring.

2.2 Pyeloplasty complications

One of the goals of an operation is to surgically correct the problem or improve function without causing problems associated with invasive procedures to the body. A small number of patients experience complications from surgery, such as infection, bleeding or leak of urine. To help reduce surgical complications and the potential effects on outcome and patient experience we monitor the rates of complications. The table below shows the number of patients experiencing complications. Current research shows the rate of complications following pyeloplasty is expected to be around 2.4% overall. However, the rate of complications is expected to be higher for children with additional co-existing health conditions (co-morbidity). A significant proportion of the patients we treat at GOSH have co-morbidities and other complexities that impact outcome.

Numerator: number of pyeloplasty procedures with one (or more) of the following: infection, bleeding, leak.

Denominator: number of all pyeloplasty procedures at GOSH.

Table 2.2 Pyeloplasty post-operative complications rate

Years

Patients having complications

Total number of primary pyeloplasty

Percentage of patients having complications

2012/13 – 2013/14

5

140

3.6%

2014/15 – 2015/16

9

109

8.3%

2016/17 – 2017/18

2

84

2.4%

Total

16

333

4.8%

3. Hypospadias

Hypospadias is a congenital (present at birth) problem affecting a boy's penis. About one in every 300 boys has hypospadias. We do not know what causes hypospadias and it can be associated with other conditions, such as inguinal hernia or undescended testicles.

The appearance of the penis is the most obvious sign of hypospadias but also, urine will not pass through the tip of the penis. The aim of the operation is to straighten the penis, move the hole through which urine passes (meatus) to the tip of the penis and to remove excess foreskin to reduce risk of infection after surgery.

Usually, the surgeon is able to make these corrections in one operation. But if the hypospadias is severe, the surgeon may decide to correct it in two stages, in separate operations to improve outcome. For a small number of patients, revision surgery is sometimes needed. Based on current research, the rate of revision for two-stage hypospadias surgery, which usually treats the more severe ‘proximal’ hypospadias, is expected to be between 10-30%.

3.1 Two-stage revisions

The table below shows the number of primary (first) two-stage hypospadias repairs performed at GOSH, with a subsequent revision procedure (urethral fistula repair, meatotomy, meatoplasty, meatal dilation, re-do hypospadias repair) within five years.

Numerator: number of primary two-stage hypospadias repairs with a subsequent revision procedure within five years.

Denominator: number of primary two-stage hypospadias repair procedures.

Table 3.1 Hypospadias two-stage revisions

Years

Number of revision surgeries within five years of primary two-stage hypospadias repairs

Total number of primary two-stage hypospadias repairs

Percentage of revision surgeries within five years of primary two-stage hypospadias repairs

2012/13 – 2013/14

4

48

8.3%

2014/15 – 2015/16

7

70

10.0%

2016/17 – 2017/18 8 58 13.8%

Total

19

176

10.8%

4. Bladder exstrophy

Bladder exstrophy is a congenital condition that occurs when the skin over the lower abdominal wall (bottom part of the tummy) does not form properly. The bladder is open and exposed on the outside of the abdomen. Bladder exstrophy occurs in one in every 40,000 births, affecting two to three times more boys than girls. As well as the bladder being exposed, babies with bladder exstrophy may also have related problems affecting their urinary system, including the neck of the bladder, and pelvic bones. These related problems vary in severity and do not affect every baby.

Bladder exstrophy is treated in a series of operations over the first few years of life. The overall aim of treatment is to prevent kidney damage, improve the child’s urinary system and genital function and reduce differences in appearance. For a small number of patients, revision surgery is sometimes needed.

4.1. Primary closure revisions

The table below shows the number of revision surgeries (re-do bladder exstrophy closure) within two years of primary (original) bladder exstrophy closure procedure. This is the first of the series of procedures, which brings the bladder inside the abdomen. Our rate of primary closure revisions is comparable to that published in peer-reviewed journals.

Numerator: number of revision surgeries within two years of primary bladder exstrophy closure procedure at GOSH.

Denominator: number of primary bladder exstrophy primary closure procedures at GOSH.

Table 4.1 Primary closure revisions

Years

Number of revision surgeries within two years of primary bladder exstrophy closure

Total number of primary bladder exstrophy closures

Percentage of revision surgeries within two years of primary bladder exstrophy closure

2012/13 – 2013/14

0

22

0.0%

2014/15 – 2015/16

2

20

10.0%

2016/17 – 2017/18

2

23

8.7%

Total

4

65

6.2%

4.2 Primary bladder neck revisions

The table below shows the number of revision surgeries (re-do bladder neck reconstruction) within two years of primary (original) bladder neck reconstruction procedure. This procedure aims to achieve urinary continence in the child.

Numerator: number of revision surgeries within two-years of primary bladder neck reconstruction procedure at GOSH.

Denominator: number of primary bladder neck reconstruction procedures at GOSH.

Table 4.2 Primary bladder neck revisions

Years

Number of revision surgeries within two-years of primary bladder neck reconstruction

Total number of primary bladder neck reconstructions

Percentage of revision surgeries within two-years of primary bladder neck reconstruction

2012/13 – 2013/14

1

77

1.3%

2014/15 – 2015/16

2

71

2.8%

2016/17 – 2017/18

0

60

0.0%

Total

3

208

1.4%

5. Kidney stones

Kidney (or renal) stones are clusters of tiny crystals that can form in the kidneys. Most clusters are too small to cause any problems and pass out of the body in the urine. Sometimes, the clusters can clump together to form bigger clusters, which may eventually become big enough to block the filtering units in the kidney. Sometimes, they pass out of the kidney down the ureter and out in the urine without causing any problems, but if they are big they may block the ureter or lodge in the bladder.

Some stones that are stuck in the ureter can be removed using an endoscope, a tube containing a small camera, a light and a laser device to break up the stone. Most other stones are removed using a keyhole-type surgery.

5.1. Unscheduled return to theatre within seven days after a kidney stones procedure

Due to the complexity of some operations or related to complications during surgery, a small number of patients may need further surgery that was unplanned. To help reduce this occurrence and its potential effects on outcome and patient experience, we monitor the rate of patients who return to theatre soon after a procedure. The table below shows the number of patients who have an unscheduled return to theatre within seven days of previous scheduled procedure to treat kidney stones.

Numerator: number of unscheduled theatres cases within seven days of previous scheduled kidney stones procedure.

Denominator: number of scheduled kidney stones procedures.

Table 5.1 Unscheduled return to theatre within seven days under any specialty after a scheduled kidney stones procedure

Years

Patients returning unscheduled to theatre within 7 days

Total number of scheduled kidney stones procedures

Percentage of patients returning unscheduled to theatre within 7 days

2012/13 – 2013/14

11

144

7.6%

2014/15 – 2015/16

3

143

2.1%

2016/17 – 2017/18

8

161

5.0%

Total

22

448

4.9%

This information was published in December 2018 and will be updated in December 2019.

References

Ahn J J et al. Early versus delayed closure of bladder exstrophy: A National Surgical Quality Improvement Program pediatric analysis, Journal of Pediatric Urology, 2018, 14:27e.1-27e.5

Chan Y Y et al. Outcomes after pediatric open, laparoscopic, and robotic pyeloplasty at academic institutions, Journal of Pediatric Urology, 2017, 12:49.e1-49.e6

Keays MA and S Dave. Current hypospadias management: Diagnosis, surgical management, and long-term patient-centred outcomes, Can Urol Assoc J., 2017, 11(1-2Suppl1)

Pfistermuller K L, et al. Meta-analysis of complication rates of the tubularized incised plate (TIP) repair, Journal of Pediatric Urology, 2015, 11:54-59

Pippi Salle, J.L. et al. Proximal hypospadias: A persistent challenge. Single institution outcome analysis of three surgical techniques over a 10-year period, Journal of Pediatric Urology, 2016, Volume 12, Issue 1 , 28.e1 - 28.e7

Thomas J C, et al. Management of the failed pyeloplasty: A contemporary review, Journal of Urology, 2005, 174: 2363–2366