Daniel Moon

Sepsis and 'superbugs': should we favour the transperineal over the transrectal approach for prostate biopsy?

To determine the rate of hospital re‐admission for sepsis after transperineal (TP) biopsy using both local data and worldwide literature, as there is growing interest in TP biopsy as an alternative to transrectal ultrasonography (TRUS)‐guided biopsy for patients undergoing repeat prostate biopsy.

Outcomes of artificial urinary sphincter implantation in the irradiated patient

To present the outcomes of men undergoing artificial urinary sphincter (AUS) implantation. To determine the impact a history of radiation therapy has on the outcomes of prosthetic surgery for stress urinary incontinence.

Re: Marco Borghesi, Hashim Ahmed, Robert Nam, et al. Complications after systematic, random, and image-guided prostate biopsy.

CONTEXT Prostate biopsy (PB) represents the gold standard method to confirm the presence of cancer. In addition to traditional random or systematic approaches, a magnetic resonance imaging (MRI)-guided technique has been introduced recently. OBJECTIVE To perform a systematic review of complications after transrectal ultrasound (TRUS)-guided, transperineal, and MRI-guided PB. EVIDENCE ACQUISITION We performed a systematic literature search of Web of Science, Embase, and Scopus databases up to October 2015, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Complications and mortality following random, systematic, and image-guided PBs were reviewed. Eighty-five references were included. EVIDENCE SYNTHESIS The most frequent complication after PB was minor and self-limiting bleeding (hematuria and hematospermia), regardless of the biopsy approach. Occurrence of rectal bleeding was comparable for traditional TRUS-guided and image-guided PBs. Almost 25% of patients experienced lower urinary tract symptoms, but only a few had urinary retention, with higher rates after a transperineal approach. Temporary erectile dysfunction was not negligible, with a return to baseline after 1-6 mo. The incidence of infective complications is increasing, with higher rates among men with medical comorbidities and older age. Transperineal and in-bore MRI-targeted biopsy may reduce the risk of severe infectious complications. Mortality after PB is uncommon, regardless of biopsy technique. CONCLUSIONS Complications after PB are frequent but often self-limiting. The incidence of hospitalization due to severe infections is continuously increasing. The patients general health status, risk factors, and likelihood of antimicrobial resistance should be carefully appraised before scheduling a PB. PATIENT SUMMARY We reviewed the variety and incidence of complications after prostate biopsy. Even if frequent, complications seldom represent a problem for the patient. The most troublesome complications are infections. To minimize this risk, the patients medical condition should be carefully evaluated before biopsy.

Laparoscopic Radical Prostatectomy : Reducing the Learning Curve

OBJECTIVES To review the operative results of a single surgeon after a laparoscopic radical prostatectomy (LRP) fellowship to assess whether the LRP learning curve can be abbreviated. METHODS We undertook a prospective study of 50 men who underwent LRP performed by a recently graduated LRP fellowship-trained surgeon. The patient details, operative data, complications, and post-operative followup were collected over the initial 12-month period. RESULTS The median age was 63 years (range, 47 to 72 years) and median follow-up of 6 months (range, 1 to 12 months). The majority of patients had a preoperative clinical stage T1c (30 = 60%) with a median PSA of 6.4 ng/mL. The median operative time was 225 minutes (range, 160 to 360 minutes) and median blood loss was 400 mL. There were three major complications: 1 anastamotic revision and 2 bladder neck contractures. The positive surgical margin rate for pT2 disease was 5% and for pT3 disease was 20%. Continence rates were 87% at 12 months (no pad use); unilateral (14%) and bilateral nerve sparing (34%) yielded early return of potency in 37.5% of men. No conversions, no rectal injuries, and no deaths occurred in the series. CONCLUSIONS The learning curve that has been observed in other series is not seen with regard to operative time or complication rates. Crucially, it is not seen in a positive surgical margin rate. A dedicated fellowship in laparoscopic radical prostatectomy abbreviates the extensive learning curve for this most technically challenging procedure.

PADUA and R.E.N.A.L. nephrometry scores correlate with perioperative outcomes of robot-assisted partial nephrectomy: analysis of the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database.

To evaluate and compare the correlations between Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) and R.E.N.A.L. [Radius (tumour size as maximal diameter), Exophytic/endophytic properties of the tumour, Nearness of tumour deepest portion to the collecting system or sinus, Anterior (a)/posterior (p) descriptor and the Location relative to the polar line] nephrometry scores and perioperative outcomes and postoperative complications in a multicentre, international series of patients undergoing robot‐assisted partial nephrectomy (RAPN) for masses suspicious for renal cell carcinoma (RCC).

Transperineal biopsy prostate cancer detection in first biopsy and repeat biopsy after negative transrectal ultrasound-guided biopsy: the Victorian Transperineal Biopsy Collaboration experience.

To present the Victorian Transperineal Biopsy Collaboration (VTBC) experience in patients with no prior prostate cancer diagnosis, assessing the cancer detection rate, pathological outcomes and anatomical distribution of cancer within the prostate.

Perioperative, functional and oncological outcomes after open and minimally invasive prostate cancer surgery: experience from Australasia.

•  To systematically review the current literature concerning perioperative, functional and oncological outcomes reported after open and minimally invasive prostate cancer surgery specifically from institutions within Australasia.

Patterns-of-care and health economic analysis of robot-assisted radical prostatectomy in the Australian public health system

To compare patterns of care and peri‐operative outcomes of robot‐assisted radical prostatectomy (RARP) with other surgical approaches, and to create an economic model to assess the viability of RARP in the public case‐mix funding system.

Patients with medical risk factors for chronic kidney disease are at increased risk of renal impairment despite the use of nephron-sparing surgery

To determine whether patients with normal preoperative renal function, but who possess medical risk factors for chronic kidney disease (CKD), experience poorer renal function after partial nephrectomy (PN) for renal cell carcinoma (RCC) compared with those without risk factors.

Extraprostatic Extension into Periprostatic Fat is a More Important Determinant of Prostate Cancer Recurrence than an Invasive Phenotype

PURPOSE Although micrometastasis development correlates closely with the depth of invasion of many tumor types, it is unclear whether invasion into but not through the prostatic pseudocapsule has a negative impact on prognosis, similar to extraprostatic extension. We defined the impact of pseudocapsular invasion on the risk of post-prostatectomy biochemical recurrence. MATERIALS AND METHODS Patients with pT2-3a prostate cancer were identified from a prospectively recorded database. Those with pT2 disease were categorized according to pseudocapsular invasion presence or absence. The impact of pseudocapsular invasion on biochemical recurrence was determined by univariable and multivariable Cox regression analysis. RESULTS In a cohort of 1,338 patients we identified 595 with organ confined cancer positive for pseudocapsular invasion. Compared to tumors without evidence of invasion, pseudocapsular invasion was positively associated with higher Gleason grade and tumor volume (1.2 vs 1.9 cc, each p<0.001). On univariable analysis there was no difference in biochemical recurrence-free survival between patients with vs without pseudocapsular invasion, although those with extraprostatic extension had significantly lower biochemical recurrence-free survival (p<0.001). This was confirmed on multivariable analysis, which revealed that extraprostatic extension was a significant independent predictor of biochemical recurrence (HR 1.53, p=0.018). The presence of pseudocapsular invasion had no effect (HR 0.81, p=0.33). CONCLUSIONS Pseudocapsular invasion is not a pathological feature associated with an adverse outcome after prostatectomy. Thus, the depth of tumor invasion is not a continuum of risk and access to periprostatic adipose tissue is a more important determinant of disease behavior than an invasive phenotype.