Bruce Montgomery

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

Study Type – Diagnostic (exploratory cohort)

The issue of prophylactic antibiotics prior to flexible cystoscopy

Objective: The aim of this study was to determine whether single–dose parenteral antibacterial therapy significantly alters the rate of infection in patients undergoing flexible cystourethroscopy. Patients and Methods: 162 patients were studied prospectively having either received parenteral antibacterial chemoprophylaxis prior to flexible cystourethroscopy or not. Pre– and postprocedure mid stream samples of urine (MSSU) were obtained to objectively evaluate the presence of infection. Results: Gentamicin prophylaxis reduced the rate of post–cystoscopy–positive MSSUs from 21 to 5%. Conclusion: The surprisingly high rate of infection after flexible cystoscopy was significantly reduced by a single dose of gentamicin.

Are prostatic biopsies necessary in men aged ≥80 years?

To examine whether prostatic biopsies are necessary in all men aged ≥80 years, as men found to have prostate cancer are frequently treated with a ‘watch and wait’ policy or with hormonal withdrawal alone, and biopsies are associated with a small but significant complication rate.

Urinary retention following transperineal template prostate biopsy – study of risk factors

Background: As greater numbers of transperineal template prostate biopsies (TTPBs) are being performed, we have noticed that a considerable number of patients experience urinary retention post-procedure. We wanted to quantify this, and to examine factors that might predict which patients will experience retention. Patients and methods: Data analysis was performed on a prospectively maintained database on 93 consecutive patients undergoing template prostate biopsy over a 12-month period. Results: Mean patient age was 66 years (range 46–79). Mean prostate-specific antigen (PSA) was 8.34 ng/ml (1–31), mean transrectal ultrasonography (TRUS) volume 51 cc (10–133) and mean number of cores 52 (11–84). Twenty-five patients had muscle relaxant as part of their anaesthetic (27%). Fifteen patients had haematuria immediately post-procedure (16%). Twenty-six procedures were performed by a urology trainee (28%). Sixteen patients experienced retention post-template biopsy (17%). Their mean age was 67 years, mean PSA 8.9 ng/ml, mean TRUS volume 68 cc and mean number of cores 58. Of the retention group, 10 patients had muscle relaxant (63%), one patient had haematuria (6%) and four procedures were performed by a trainee (25%). Factors that significantly correlated with retention were TRUS volume (r = 0.36, p = 0.0004) and the use of muscle relaxant (r = 0.37, p = 0.0003). Age, PSA, number of cores taken, haematuria post-biopsy, and intra-operative furosemide, paracetamol, diclofenac, morphine and dexamethasone were not correlated with retention (p > 0.05). Conclusion: Patients with higher TRUS volumes are at increased risk of retention post-TTPB and should be counselled accordingly. Due to anti-muscarinic effects, muscle relaxants should not be used.

The Acidification Response of Normal Subjects to Ammonium Chloride Using a 3-Day Loading Test

The acidification response to NH4 Cl loading (0·1 g/kg bw/day) was tested in 16 normal healthy subjects in the basal fasting state on Day 4, the subjects having taken the salt daily for the 3 previous days. The response was measured in terms of blood pH and in urine, creatinine, phosphate, pH, titratable acidity, ammonium, net acidity and creatinine clearance. To minimise inter-subject variation the urine values were adjusted to a standard body surface area of 1·73 m2. A normal range for the blood pH of the mean value ±2 SD, encompassed the observed range of values. However, to fit the observed range of acid-base values in urine into the 2 SD range required a logarithmic transformation of the data. Statistical analysis confirmed a significant correlation between blood [H+] net acid secretion, urine titratable acidity and ammonium. Urine net acid secretion was positively correlated with urinary phosphate, titratable acidity and ammonium.

Improving the documentation of flexible cystoscopy notes: Case for introduction of electronic patient records?

Introduction/Objective: Good surgical practice dictates that comprehensive and legible records are maintained by surgeons of all their interactions with patients. Flexible cystoscopy (FC) notes should be no exception to this standard. Currently at our institution, for every cystoscopy, FC operators document the same information in two different locations: handwritten in patient notes and electronic discharge letter. Methods: A closed-loop audit of FC notes at our institution was undertaken and data were collected prospectively using patients’ notes. Notes were scrutinised against the Royal College of Surgeons (RCS)/British Association of Urological Surgeons (BAUS) standards. The first period was 13–17 October 2015, and the second period was 20–31 May 2016. A total of 73 patients were included (43+30). Results: The first cycle highlighted several areas requiring improvement. Eight of 15 parameters fell short of the 100% target compliance: time (5.9%), responsible consultant (32.4%), operator (50%), postoperative instructions (82.4%), indication for FC (85.3%), date (88.2%), procedure name (91.2%) and signature (97%). Subsequently, a new electronic FC proforma was designed using the RCS/BAUS criteria for data to be documented. A successive re-audit using identical criteria established 100% compliance in all fields. Conclusion: Adopting the new proforma significantly improved the quality of FC documentation. Subsequently, new online software incorporating our proforma was introduced as part of electronic patient records, allowing for data to be easily accessed and read. We discuss the relevance of this in the context of existing literature. Level of evidence: Not applicable for this multicentre audit.

Transperineal drainage of a prostatic abscess using a template biopsy grid for guidance: Point of technique

63-year old man with a history of BPH attended &E. He was feeling generally unwell and suffering rom rigors. He had been diagnosed in the comunity with a UTI six days earlier and treated ith antibiotics. On examination, he was in sepic shock. There were no findings per abdomen, nd DRE revealed a small, non-tender prostate. He ailed to improve with aggressive fluid resuscition nd broad-spectrum antibiotics and was admitted o the intensive care unit (ICU) with urosepsis. CT chest, abdomen and pelvis did not reveal ny abnormality. Urine culture from the community rew an E. coli, which was resistant to ampicillin nd trimethoprim. Blood cultures taken on admision to hospital also grew an E. coli, with the

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.

CAN PROSTATE CANCER TARGETS BE ACHIEVED

At the time of prostate biopsy, the needle is usually targeted at the areas most likely to contain tumour, rather than a specific lesion. This ‘best guess’ technique is inevitably going to lead to sampling errors. Reports [1–5] show that 10–40% of prostate cancers are detected at a second biopsy session, depending on the number of prostate cores taken and the sites sampled. The European Prostate Cancer Prevention Study took octant biopsies in 1051 men with a PSA level of 4–10 ng/mL [1]; cancer was detected in 22% of men at the first biopsy session. In all men with benign biopsies further biopsies were taken at 6–8week intervals. The cancer detection rate was 10% in the second, 5% in the third and 4% in the fourth biopsy session. Radical prostatectomy was undertaken in 86% of men with cancer. Interestingly, in men diagnosed at the second biopsy session there was no significant difference in pathological stage, Gleason score or preoperative PSA level compared to those diagnosed on the first biopsy session. In this large study 12% of men would be diagnosed outside a 31-day target. However, the Government builds in a 5% ‘missed target’ rate to take into account ‘complex clinical pathways’. Gilmour Frew, National Manager for Urology and Lung Workstreams, Cancer Services Collaborative ‘Improvement Partnership’ of the NHS Modernization Agency, states ‘where cancer is diagnosed in two-week rule (TWR) referrals outside the 31-day rule the breach will be regarded as a clinical exception and will be accounted for in the 5% allowed for in the 62 day Cancer Waiting Times Target’.