Benjamin Ayres

The role of transperineal template prostate biopsies in restaging men with prostate cancer managed by active surveillance

Study Type – Diagnostic (exploratory cohort)

Penile lesion in end-stage renal failure — cancer or otherwise?: Calcific uremic arteriolopathy presenting with a penile lesion

Calcific uremic arteriolopathy or calciphylaxis is a rare condition that can present with clinical features similar to penile cancer. It is a diagnosis to consider in patients with end-stage renal failure (ESRF) presenting with a penile lesion. We describe one such case, where a patient with ESRF presented with a solid, tender penile mass and underwent surgery for presumed penile cancer. Histopathological analysis however confirmed a diagnosis of calcific uremic arteriolopathy, without evidence of malignancy. The clinical diagnosis of calcific uremic arteriolopathy relies on a high index of suspicion, and lesion biopsy is controversial due to a high risk of poor wound healing and sepsis. New treatment options are encouraging, and have been reported, albeit in small numbers. Delayed diagnosis can adversely affect both quality of life and prognosis in a condition with an extremely high mortality rate.

Glans resurfacing for precancerous and superficially invasive carcinomas of the glans penis: Pathological specimen handling and reporting

Glans resurfacing is a recently described technique in the management of precancerous lesions and superficial invasive tumours of the glans penis as well as cases of indolent persistent lichen sclerosus. The technique is complex and is usually only practiced in specialist centres with combined urological and plastic surgical expertise. Cosmetic and functional results are better than in more extensive penile surgery, such as glansectomy, for such cases, cancer cure and control is comparable. Knowledge of the technique used and the spectrum of disease are vital for appropriate specimen handling and pathological reporting of these complex cases to aid further management and avoid over reporting of positive margins.

Comparative outcomes of open and robotic-assisted radical cystectomy in an enhanced recovery programme era

Aim: The aim of this study was to determine the added value of robotic surgery for radical cystectomy in the context of an established enhanced recovery programme (ERP). Background: We have previously reported on ERP in open radical cystectomy (ORC) and shown that it is safe and not associated with an increase in complications or readmissions. Further, it is associated with reductions in ICU stay, length of hospital stay and duration of postoperative ileus. The recent introduction of robotic-assisted radical cystectomy (RARC), with its perceived benefit of minimal invasiveness, has led to the question of whether patients who have their radical cystectomy in the environment of ERP would experience an added benefit if the surgery were performed robotically. We implemented the ERP for all patients undergoing radical cystectomy in 2008. In 2010 we started to offer RARC as the first line treatment for all bladder cancer patients with an indication for bladder extirpation. In this study we compare the perioperative results of the last 50 RARC patients with the last 50 ORC. The same ERP protocol was implemented in all patients. Patients and methods: We used our prospectively kept electronic database to identify the last 50 ORC and 50 RARC patients (we excluded the first 10 RARC in our series to reduce learning curve effect). We compared preoperative (age, sex, comorbidity), intraoperative (diversion type, fluid loss, blood transfusion, conversion and number of lymph node dissections (LND)) and post-operative (length of stay LOS, nodal yield and pathological T stage) variables. We also reported on the 30 day complications according to Clavien–Dindo classification. Results: The two groups did not differ significantly in their preoperative variables, number of LND performed and pathological T and N stage. Patients in the RARC arm were more likely to have continent diversion and had significantly less intraoperative fluid loss. LOS and lymph nodal yield was no worse in the RARC cohort in comparison to the ORC patients. The RARC patients had significantly lower transfusion rates and overall 30-day complication rates. Conclusions: We have shown that robotic surgery offers an added value to patients undergoing radical cystectomy for bladder cancer in addition to the benefits gained from enrolling in an ERP. This is likely due to the minimally invasive nature of robotic surgery, and thus an attenuation of its physiological insult, which is the cornerstone of ERP theory.

Is the role of intravesical bacillus Calmette-Guérin in non-muscle-invasive bladder cancer changing?

Intravesical BCG is recommended as adjuvant therapy for intermediate-risk and high-risk non-muscle-invasive bladder cancer (NMIBC) in guidelines from the European Association of Urology (EAU), the AUA, the BAUS working in association with the British Uro-oncology Group and the National Comprehensive Cancer Network [1–4]. Meta-analyses show Level 1a evidence that BCG reduces recurrence and progression rates, in a disease where the 5-year probability of recurrence is up to 62% (intermediate-risk NMIBC) and 78% (high-risk NMIBC), and the 5-year probability of progression is up to 6% and 45%, respectively [5]. Despite this evidence, there are still questions over the use of intravesical BCG. Is maintenance therapy required? What is the optimal dose and schedule? Is BCG superior to intravesical chemotherapy in intermediate-risk NMIBC? Will BCG be challenged by device-assisted chemotherapy? In addition, a reduction in disease progression is not universally reported. In this article we explore the data surrounding intravesical BCG and will discuss the areas that remain under debate.

The role of hexylaminolaevulinate in the diagnosis and follow-up of non-muscle-invasive bladder cancer

Barnet and Chase Farm Hospitals NHS Trust, Herts, *Frimley Park Hospital, Camberley, Surrey, † University Hospitals of Leicester NHS Trust, Department of Urology, Clinical Sciences Unit, Leicester General Hospital, †† Renal and Urology Services, Haemodialysis Unit, Leicester General Hospital, Leicester, ‡ Basingstoke and North Hampshire Hospital, Basingstoke, § University College London, Division of Surgery and Interventional Science, London, and ¶ University Hospitals Bristol NHS Foundation Trust, Bristol, UK

Is immediate postoperative intravesical chemotherapy beneficial in non‐muscle‐ invasive bladder cancer?

Immediate instillation of intravesical chemotherapy after transurethral resection of bladder tumour (TURBT) of non-muscleinvasive bladder cancer (NMIBC) is widely used in the UK. The practice is supported by level 1a evidence from meta-analyses [1,2] and is recommended by the major international urological societies, including the European Association of Urology (EAU), the AUA and the BAUS working in association with the British Uro-oncology Group [2–4]. However, recent publications have questioned this view [5–7]. In this article we summarize the evidence for giving immediate postoperative intravesical chemotherapy and will review the arguments for and against its use.

What is the role of template prostate biopsies in the assessment of men on active surveillance

ions 6 of whom were sexually active, one patient aving fathered a child. onclusions: Penile preserving surgery with glanectomy and skin grafting is a successful technique ith minimal complications for local control of enile carcinoma arising on the glans. Local conrol can be achieved even in the presence of odal metastasis. Careful follow-up to exclude local ecurrence is required. Reasonable sexual function an be achieved in a proportion of patients.

Is Electromotive Mitomycin C an Alternative Treatment for Frail Patients with High-Risk Non-Muscle Invasive Bladder Cancer Who Have Failed Intravesical BCG?

Results: Total of 67 patients had pathological T3a disease. Biochemical recurrence was defined as PSA ≥ 0.2. 32 (48%) patients had biochemical recurrence. These patients had salvage treatment at PSA relapse rather than adjuvant. 18 out of 32 patients received radiotherapy before their PSA reached 2 and 1 patient had subcapsular orchidectomy. Overall 3 out of 37 patients had progressive disease (1 lymph node, 2 bone metastases) requiring hormonal treatment. Hence in our study 96% had progression free survival and 100% disease specific survival. 5year biochemical recurrence free survival was 67%. The overall survival was 94%. Conclusions: Surgery alone can be sufficient for pT3a prostate cancer in selected cases. Salvage radiotherapy offers additional advantage to the patients without compromising oncological outcome. Hence, we may offer surgery as a first line of multimodality therapy to all suspected pT3a patients over radiotherapy ± hormones.