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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES Programme no. 5 - Urology
RADIO 4
TX DATE: TUESDAY 26TH AUGUST 2008 2100-2130
PRESENTER: MARK PORTER
CONTRIBUTORS:
TIM O'BRIEN
JONATHAN GLASS
KAY THOMAS
PROKAR DASGUPTA
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. Today's programme is all about matters urological. Our kidneys filter around 200 litres of fluid a day, nearly all of which is absorbed back into the circulation, but around one and a half litres - that's nearly three pints - will be turned into urine and travel down the ureters to be stored in the bladder before being expelled.
Great when it all goes to plan, but like all complex systems it can, and often does, go wrong.
Later on I'll be finding out how botulinum toxin - Botox - is being used as an experimental treatment for a common form of incontinence caused by an overactive bladder.
But first a look at another frequent urological complaint - haematuria - blood in the urine. A clue to a range of underlying problems that can include kidney stones and cancer.
To find out more I went to the new urology centre at Guy's Hospital in London - a purpose built clinic which radically altered the way NHS provides outpatient services. Rather than multiple visits to a hospital for an initial consultation, tests and scans, and follow-up to discuss the results and decide on treatment - for most patients attending Guys, it all happens on the same day. In theory you can arrive at the clinic, see the consultant, have your tests, go back to discuss the results with him or her, and be booked in for whatever treatment you need, all on the same afternoon.
It's a pioneering initiative that consultant urologist Tim O'Brien is very proud of.
O'BRIEN
Here we are in our new centre - the urology centre - at Guys and we see 120 new referrals a week in the clinics and those patients have a range of problems from blood in the urine to prostate cancer to continence issues, stones - so the full range of urology. And we see those patients in three clinics.
PORTER
Now obviously other than being very new and very slick looking what's different about this clinic from the conventional clinics that you used to run here?
O'BRIEN
Well I think in essence we've tried to end all the fragmentation in time and place that used to exist in diagnosis. I think patients used to experience a very fragmented service - different places at different times - and we've tried to bring all the people and all the tools that you need for a diagnosis under one roof at one time to really give people the maximum chance of getting a diagnosis on their first visit to hospital.
PORTER
So this is a one-stop-shop, where you wouldn't really see the consultant but you'd get to have your tests done as well.
O'BRIEN
I mean one stop is a term that we use and it's a term that people understand. If it takes two stops then that's fine but it's not five stops.
PORTER
Yeah it's compare and contrast, I mean if some - if I was to refer a patient maybe with blood in their urine they might be going back and fore a couple of times, if not more than a couple of times.
O'BRIEN
Yeah I mean I think we've looked at what we previously did and it could be - the patient might have four visits to hospital - a visit to see the consultant, visit for the scan, visit for the scope, visit for urine tests, visit again to see the consultant - so it could easily be four or five visits and now three quarters of our patients just have the single visit - they get an answer the first day.
PORTER
And they get that visit pretty quickly.
O'BRIEN
They do. One of the things we wanted to do was improve the timeliness with which we give consultations and we set ourselves the challenge of seeing everybody who's referred to here within 10 days of receipt of the referral and we're doing well with that, there have been one or two weeks where we haven't quite kept up with that but I think we're very pleased with how quickly we're seeing people. We don't want to keep people - why keep people waiting?
PORTER
And the workload's presumably the same as you get to see them quickly.
O'BRIEN
Yeah I think - I mean the term that people use is do today's work today and I think that's a very good principle to try and follow, particularly when patients have potentially very serious diseases that you're diagnosing.
PORTER
And blood in the urine - particularly if it's not accompanied by any discomfort - is often the only clue to a serious underlying problem, and accounts for a significant proportion of Tim O'Brien's workload.
O'BRIEN
Fifteen percent of the patients who are referred to us at Guy's urology have blood in the urine.
PORTER
And are they patients that have noticed the blood themselves or has it been picked up on other tests?
O'BRIEN
Both really, it's a mixture, probably about one third patients who've noticed it themselves and maybe two thirds has been picked up on tests.
PORTER
Because of course the significance of that is that you can have blood in your urine without knowing it because of these little dipsticks that we're using all the time.
O'BRIEN
You can. The clinical significance of blood in the urine that you can see as a patient visible haematuria, macroscopic haematuria, is immense. I mean 25% of patients with visible macroscopic haematuria have cancer. So there are very few symptoms in medicine that correlate so closely with cancer.
PORTER
Do you think patients see it as an alarm symptom as they would perhaps if they coughed up blood - I think a lot of patients see that as a real problem?
O'BRIEN
I think some people don't and most do, I think, I think if you have blood in the urine that you see most people report that but some don't. And I think we need to improve the public's awareness of the significance of blood in the urine that the patient sees themselves.
PORTER
So these are patients who are presenting here in the clinic, they're going to get a diagnosis possibly in one day and that can be quite a significant diagnosis, how do you actually investigate them once they arrive here?
O'BRIEN
A patient will have a conversation with a urologist and often the answer will come from there but the two key investigations, looking for the two key diagnoses and ultrasound of the kidney, looking for a kidney tumour or a kidney stone and in a cystoscopy, which is a telescopic inspection of the bladder, which is looking for a bladder tumour, from our perspective, as urologists, the three really key diagnoses are kidney cancer, bladder cancer and stones.
PORTER
Going back to the history - the story that the patient gives you in the consultation - what sort of clues can you get from that that would point you in the direction of one of those?
O'BRIEN
Oh well I mean a patient who smokes 30 cigarettes a day who has blood in the urine that they can see is likely to have a bladder tumour. A patient who's had a lot of pain in the kidney area perhaps is more likely to have had a stone. But kidney tumours are slightly more difficult, they often are without other symptoms and often by the time they produce blood in the urine they're very large indeed.
PORTER
So the patient would go from your consulting room to the next investigation, let's assume that's the ultrasound test, what's actually involved in that?
O'BRIEN
Well it's a non-invasive test. A radiologist does that, some jelly is applied to the skin and then the ultrasound probe is placed on the skin and ultrasound waves, sound waves, are used to image the organ. The quality of those images now is outstanding. I remember ultrasound was introduced when I was a medical student 23 years ago and it was always - it was like a fog, it was bizarre. But actually one really does see tremendous detail now and actually we as urologists are beginning to teach ourselves how to do ultrasound. I think ultrasound will become a technique that every clinician uses.
PORTER
And consultant urologist Jonathan Glass is one of those clinicians - and since I was in a cutting edge urology centre, it seemed silly not to ask Jonathan to give my kidneys the once over.
GLASS
It's very safe, it doesn't involve any radiation and it's very quick, in fact the best bloke who gets the information from the scan is the chap doing the scan himself - or him or herself - unlike some other scans which you can get a good view on on the computer later on, in fact this scan is operator dependent, so you want to get a good - the person doing it needs to be good so they can get a good view of what's inside.
PORTER
So what we're going to do we're have a look at my right kidney.
GLASS
Right kidney.
PORTER
Which I hope is entirely normal.
GLASS
Turn yourself - left side slightly down, I'm going to put some cold jelly on your tummy, just lean over a tiny bit more. And we may want you to turn over completely on your front because I normally scan people before putting a hole in their kidney.
PORTER
Please no holes.
GLASS
Okay so we put some jelly on you, there we are. So we're now just trying to track down your kidney and there it is, hiding behind your liver on the right side. The kidney sits in a sheath which goes up and down, moves up and down every time you breathe so sometimes during this scan we may ask you to take a deep breath in and the hold your breath and that brings the kidney down so we can see it. So we have a look here - there's the lower part of your right kidney, here's the top half of the right kidney, which we're not seeing because it's hidden underneath your ribs. So if you take a few deep breaths in and out. There you go. And now deep breath in and hold your breath and that allows us to get a nice view of the top of the kidney. There's a prominent white mark there in the middle of your kidney which - stones can sometimes look like that but yours is a blood vessel, you can see there's no shadow beyond it, stones cast a shadow just like an object casting a shadow when it's in front of light and stones cast a shadow generated by the sound waves not getting through, what we call an acoustic shadow. But that looks like a pretty normal right kidney, all looks very normal.
PORTER
Perfect. Do you want a quick look at my left?
GLASS
Yeah why not.
PORTER
Sorry, do you want me to roll over a bit more?
GLASS
Bit of jelly. [Indistinct words] view of your left kidney. Again a deep breath in and out. The left kidney often lies a bit higher than the right. The liver pushes down the right kidney so the left kidney's often lying a bit higher. A slightly awkward angle. And again deep breath in and out. Deep breath in and out. And a deep breath in and then hold your breath. And again it looks absolutely fine. Not even any cysts or anything.
PORTER
Good, two perfect kidneys, thank you very much.
Ultrasound scans may be the best way of picking up the 6,500 new cases of kidney cancer that are diagnosed in the UK every year, but the more common cancer of the bladder requires a slightly different approach.
O'BRIEN
The ultrasound is a good way of looking at the bladder but it's not the definitive way of looking at the bladder and that comes with passing a fine flexible endoscope, flexible tube, into the bladder. And one gets beautiful views of the bladder and can diagnose a tumour there.
PORTER
Now to get into the bladder you're going to have to go in through the urethra, you would apply it to the outside, and in a man that would be through the middle of the penis and a woman through the entrance in the vagina.
O'BRIEN
That's uncomfortable but sometimes too uncomfortable to do in very young patients - 20 year olds - but I should think 90% of patients who need a cystoscopy can have it done under local anaesthetic, just in the clinic, with them awake.
PORTER
And the local anaesthetic would be an injection or a gel?
O'BRIEN
A jelly, a jelly with an anaesthetic agent in it. The lubrication seems to the be the key thing.
PORTER
So you're passing the scope in, are you actually looking at the inside of the bladder because bladder tumours can bleed at quite an early stage?
O'BRIEN
They can, yeah they can. And one of the catches with bladder tumours is that the bleeding's often intermittent, so you asked me earlier about whether patients report it, I think patients may wait for the second episode of bleeding and that's not a good thing to do because the bleeding may not be every day - I had one patient with a bladder tumour who bled once and then the second time he bled was four years later and he had a bladder tumour, I'm sure, for the whole of that time.
PORTER
By which time it ...
O'BRIEN
Made it more difficult yeah. So the bleeding can be intermittent.
PORTER
And that bleeding is typically painless. Indeed if the blood in your urine is associated with some form of discomfort it suggests a less sinister cause. Blood with burning and needing to go the loo more often can be due to infection, while blood with excruciating loin pains suggests kidney stones. Once experienced, never forgotten. As Jemma knows all too well.
JEMMA
The pain was really quite severe, it would make you get hot and clammy and sick and you know you'd feel really uncomfortable and restless. You try taking antibiotics but nothing would work because initially you're treating it - you've just got an infection so you start to take painkillers, that's not working, then you suffer with something called renal colic - as all the women will know if you've had a baby it's like child labour, nothing in the world can take that pain away until you've given birth to that baby or you've had some really heavy drugs like morphine or pethidine or epidural. So you're just walking, you're pacing, you can't sit down, you can't lay down, you're out of your mind with pain.
PORTER
Kay Thomas is another of the consultant urologists working at the new centre at Guy's and she has a special interest in kidney stones.
THOMAS
They are unable to keep still, sweating, clutching their side - whichever side the stone is on - possibly describing blood in their urine - haematuria.
PORTER
But they would have had - it takes a while to form a stone, so why suddenly have they developed this nasty pain?
THOMAS
Usually because it's moved down into the ureter, which is the tube that drains the kidney into the bladder, and that's quite a small tube and it's got lots of muscle in the lining of it and basically the body's trying to get rid of the stone and that's what gives them the pain.
PORTER
So it's the waves of muscular contraction trying to force the stone through.
THOMAS
Yeah.
PORTER
And does it ever manage to force the stone through?
THOMAS
Yes a lot of people pass theirs spontaneously without any help at all from us. It depends a little bit on the size of the stone and exactly where it is but up to 90% of stones, if they're small can pass on their own.
PORTER
So your management here in the hospital of a typical case of renal colic would be what?
THOMAS
In casualty they're obviously being given painkillers straightaway and then they need some form of x-ray to tell us if they do have a stone, because they might have something else going on, and in this hospital they'll have a CT scan usually, in other places, where that's not available, they'll have some dye injected and a series of x-rays taken.
PORTER
And that'll show up where the stone is and then you can make a decision about whether to leave things to nature?
THOMAS
Yes.
PORTER
And why do some people get stones and others don't or is it something that we're all prone to as we get older?
THOMAS
There is a general increase with a sort of Western diet. Men traditionally have been more prone to stones than women, although that's changing with change in diet and the difference between the sexes is equally out. Some people with certain diseases are more prone to get them - people who get infections, there are certain rarer types of metabolic disease. But often in people we don't actually know why they get a stone, it's just bad luck.
PORTER
And the actual stone itself is it akin to the sort of scale that you'd see in the bottom of a kettle?
THOMAS
Yes, most of them are composed of calcium, they're the most common and actually they're the ones that we have the least information about why they're actually forming them.
PORTER
Simon is one of the unlucky minority prone to kidney stones. After three attacks of renal colic he's come to know what to expect and how to catch the offending item.
SIMON
The expert that I am now I have a selection of tea strainers at home and the specialist, Mr Thomas, said it's going to be not pleasant but you could pass it, so she gave me another drug which widens parts of your body to ease the pressure, along with painkillers, and lots of water and every time I got up I could here my wife saying - has it come out yet? And on a Sunday afternoon I'd drunk about six litres of water and all the usual things and it just - I could feel it - it moved, I had that awful pain and then it's almost like a slot machine, just popped out, and I'm so proud of it - it's razor sharp, oval shape - and it's a nasty little thing, it looks like something from a space movie, one of these nasty alien things.
PORTER
Now we're talking about treating renal colic by leaving things to nature until you pass the stone but we're sitting here in quite a high tech suite, specifically designed for treating people with these stones. First of all, before we get on to where we are, why do some stones need help to come out?
THOMAS
If they're too large they may just stay in the kidney and they will just get bigger with time and actually stop the kidney working properly, so those need treatment. Or if they've got stuck in the tube draining the kidney, the ureter, and haven't managed to pass out on their own then those will need treatment.
PORTER
Which brings us nicely on to the machine we're sitting next to here which is a?
THOMAS
Lithotripter, which is used for breaking up stones without the use of an anaesthetic, so it's not an operation as such, it's an outpatient treatment.
PORTER
And we're sitting next to it, I mean it's what people would recognise as a fairly conventional sort of operating theatre type couch but over it is this sort of hemi-circular device with something that looks like - it looks a bit like an x-ray machine almost. But what's it actually doing?
THOMAS
Yeah the bit that you can see at the moment is the x-ray part. There are two ways in which we can find the stone, because obviously in order to treat it we need to be able to find it. So the tube you're referring to is the x-ray part and there's also underneath the bed an ultrasound machine. Lithotripters vary and some have only the x-ray part. And then also underneath the bed is actually the treatment part which produces the shockwaves that break up the stone.
PORTER
And those shockwaves are made up of what?
THOMAS
There's an electromagnetic device with in, which basically then sends shockwaves through focused on to the patient.
PORTER
And they'll be focused on the stone - will disintegrate the stone?
THOMAS
Yes.
PORTER
Without presumably damaging surrounding tissue.
THOMAS
With minimal damage to the surrounding tissues, although you have to be careful to target the stone properly and also not to give treatments too close together because - particularly if the stone's in the kidney you need to space your treatments out because there is some short term damage potentially to the kidney if you do your treatments too close together.
PORTER
So do you have more than one shockwave?
THOMAS
Yes, yeah you have up to 2,500 shockwaves in one session.
PORTER
Right, okay, and are they focused in a certain way that they meet over the stone?
THOMAS
No on this machine and most conventional lithotripters they're just going in one direction, there are some new machines that have two heads treating the stone from slightly different angles.
PORTER
And if I was lying on this and you turned the machine on and sent a shockwave through me what would I feel or hear?
THOMAS
You hear a ticking noise every time there's a shockwave and you'd feel a flicking on your skin of your back each time a shockwave passed through. And the intensity of that would increase as we increased the intensity of the shockwave.
PORTER
And presumably it's the fact that the stone is hard that means it picks up - that it responds more to the shockwaves than the surrounding soft tissues.
THOMAS
Yeah.
PORTER
So then what happens - does it literally smash it up into little bits?
THOMAS
Sometimes you can see that happening straightaway as you're doing the treatment ...
PORTER
If you're lucky.
THOMAS
... and you use the x-ray - exactly - use the x-ray throughout the treatment. Sometimes it's necessary to bring people back for an x-ray and decide whether they need more treatment.
PORTER
Is it actually painful, you were talking about them being awake here feeling it so presumably they're not having an anaesthetic?
THOMAS
They're not having anaesthetic, about two thirds of our patients manage without any painkillers at all, otherwise they're given a morphine type injection. The new lithotripters are much less painful than the older ones.
PORTER
But there is a hitch that I can see in that the stones have got to come out somewhere, so presumably all these bits of broken up debris is then travelling down the ureter between the kidney and the bladder, does that not in itself cause renal colic, that we were talking about earlier?
THOMAS
Yes it can do and it can cause haematuria as well and patients need to be aware of that. If they're unlucky and all the bits come down at the same time then they can block the urethra and get severe renal colic and sometimes need to have pieces taken out. But you need to be careful who you choose to give the lithotripter to, so you wouldn't give it to somebody with a very large stone for that reason.
PORTER
Kay Thomas talking to me in the lithotripsy department. And those larger stones that can't be broken up with shock waves have to be removed surgically.
Blood in the urine may be a red flag symptom that should never be ignored, but investigations don't always reveal a cause - sinister or otherwise. Tim O'Brien again.
O'BRIEN
That can be a challenge to reassure people in that situation and what I tend to say to people is that perhaps you ought to consider this as a urological nosebleed - a dramatic symptom but with a very gentle explanation. I mean most people know that a nosebleed, although a dramatic symptom, is not the harbinger of something serious. And I think in many situations blood in the urine is likewise but patients have to have the investigations first. So I tend to use that term - a urological nosebleed - which most people seem to understand.
PORTER
Tim O'Brien.
Problems with bladder control make up another large part of the weekly workload of the urologists at Guys and St Thomas'. Overactive bladder is a common complaint where the muscular wall starts contracting before the bladder is properly full. Meaning people like Christine have to go to the loo more often, and get there in a hurry when they do.
CHRISTINE
I had urge incontinence where I felt the bladder was getting completely filled up and I just couldn't hold it at all and literally just fell away from me. I couldn't drink because I'd have to think of the - I work in the centre of London and I thought how am I going to get to work without finding a toilet, inevitably 9 times out of 10 I didn't, but I had to wear constant double protection all the time. And then started in bed putting protection on the sheets, forget any relationships ever, there was never a relationship. It was just awful, absolutely terrible that you couldn't drink at all, I had to think everywhere I went - journeys, everywhere.
PORTER
Standard treatments for this type of problem include training exercises to teach the bladder to hold more urine before it starts contracting and drugs to relax it. But they don't work for everyone and, up until recently, the only other options were to simply live with the problem, or have surgery to try and improve the bladder's capacity.
But recent work with the muscle paralysing toxin Botox looks set to provide another option. It's not yet licensed for this use, and still under trial her in the UK, but the early results look promising. Urologist Prokar Dasgupta is another member of the Guys and St Thomas' team, and one of the UK pioneers of the Botox bladder treatment.
DASGUPTA
Well in 2002, six years ago now, I was sitting in Queen's Square with Professor Fowler and we were discussing what to do about this major problem and we had over the last 10, 15 years had a major interest in this and we were trying to treat these patients by putting various solutions into their bladder, the commonest solution being an extract of chilli peppers, called capsicum, which was very good for the patients but of course painful and didn't have a licence. Subsequently went on to a similar substance, which was derived from a cactus, again effective but in the long term didn't do much good. So while we were scratching our heads over this we noticed a paper in one of our journals - in patients who had disease of the spinal cord, specifically a spinal cord injury, whose bladders had been treated with botulinum toxin. And the results were really magical and this was a small study but all the patients needed either a general or what we call regional anaesthetic, they needed a rigid telescope put in their bladders and a needle to inject the substance. And this was a small group of patients from Switzerland. And we really were thinking as to whether we should take this further and no one had done this in the UK and whether we should try and develop a new strategy of injecting botulinum toxin in. And what we came up with, as a research protocol, was doing this under local anaesthetic, as a day case, where we put a very fine telescope into the patient's bladder, put an ultra fine needle - which you can barely see - and inject the bladder. Now six years on it has been a mega success, what we were fortunate enough to introduce to UK in 2002.
PORTER
The Botox works in the same way as it does for cosmetic treatments. It temporarily paralyses the muscles in the area where it is injected - except in this case it's the overactive muscular bladder wall, rather than the facial muscles responsible for frown lines and crow's feet. It takes a few days to work, and the effects can last anywhere between four and nine months. Christine has been involved in the early trials - which are still ongoing.
CHRISTINE
And he said we can give you Botox. Well straightaway, being as I am, bit silly sometimes, I said - I pointed to my eyes - and I said how can you put it in there and it's going to affect me down there? And he just laughed and he said no it won't affect you there and I was really, really surprised. I think Botox must be wonderful for a lot of people. When I first had the Botox, obviously you don't know what to expect, and well I was really nervous, I think I had 100 mil - 10 shots of Botox - in my bladder and it's a feeling you really can't describe, it's not painful but me being nervous I was crying at the least little thing and I think I might have said a swear word but that's how you go when something like that happens because you really don't know what to expect. But after I'd had the 10 the first time you felt a bit lifeless and then two days later it was working. It just started working - I'll never forget it, on the evening it started working I thought I want to go to the toilet, and I thought oh no, that's alright, fine, I can hold it. It lasted six months, because it was January. The aftercare in between has been absolutely excellent, you cannot fault it, but yes your life does definitely change but the after care's been excellent.
PORTER
Christine - a happy customer.
And - as Mr Dasgupta's colleague, Tim O'Brien, is quick to point out, patient feedback has played an important role in developing the new clinic at Guy's.
O'BRIEN
Patients have been at the heart of what we've done. Through the four years of development we've had a number of days where patients of certain conditions and urology patients in general have been invited up to Guy's and we've spent a whole day with them and found out what it's been like using the old services and found out from them some of the features that they'd like to see in new services.
PORTER
And what was their main complaint about the old service?
O'BRIEN
Communication was a major issue - when they rang up did they - did they get through. One of the big issues for patients is getting back into the system. Patients were very content to be managed in the community but if they had a problem they wanted easy re-access to the system ...
PORTER
And to see the same person or the same team.
O'BRIEN
Yes I think that's a very important aspect of this - having a nurse who's managed a single disease area who could be their point of contact. So we now have bladder cancer nurses, renal cancer nurses, prostate cancer nurses, incontinence nurses and the patients with those problems know those nurses and so know they can come back into the system if they need to. What was also very reassuring actually was that the patients were hugely supportive of what we were doing, this wasn't something that they felt was going to be irrelevant, I mean in large measure they backed our ideas and I remember one day the patient just said: Tim, just get on with it, just get it done.
PORTER
And since you have got it done what sort of response have you had, what's proved most popular with them?
O'BRIEN
Prompt access has proved popular but I think the most popular thing is being - having everything done at the same time. Not having the inconvenience of multiple visits to hospital spread over several weeks. That's been very, very, very well received.
PORTER
Surgeon Tim O'Brien talking to me at the new urology centre at Guy's Hospital.
Don't forget you can listen to any part of the programme again by using the Listen Again facility on the Case Notes website at bbc.co.uk/radio 4 - where you can also download the programme as a podcast.
Next week I will be travelling to Newcastle to find out more about the mysterious world of poisons.
ENDS
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