Giles Hellawell

Technique of Laparoscopic-Endoscopic Single-Site Surgery Radical Nephrectomy

BACKGROUND Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. OBJECTIVE To assess the feasibility of LESS radical nephrectomy (LESS-RN). DESIGN, SETTING, AND PARTICIPANTS Ten patients with body mass index (BMI) < or = 30 underwent LESS-RN for renal tumour by two experienced laparoscopists. SURGICAL PROCEDURE TriPort (Olympus Winter & Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 30 degrees camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed. MEASUREMENTS Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. RESULTS AND LIMITATIONS Ten cases were successfully accomplished (two right-sided tumours and eight left-sided tumours; tumour diameter ranges: 4-8 cm). The mean patient age was 63.5 yr (22-77 yr), and median BMI was 23.56 (18.2-26.6). The mean operative time was 146.4 min (120-180 min), and the mean blood loss was 202 ml (50-900 ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pT3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted. CONCLUSIONS LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN.

Laparoendoscopic Single-Site Surgery: Early Experience with Tumor Nephrectomy

BACKGROUND AND PURPOSE Laparoendoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. We performed LESS for renal tumor nephrectomy in eight patients to assess feasibility and perioperative outcome. PATIENTS AND METHODS Eight patients with a body mass index (BMI) <or=30 underwent single-port nephrectomy for renal tumor by an experienced laparoscopic surgeon. Tri-Ports were used through a transumbilical incision in all cases. A flexible grasper and a 5-mm 30-degree high-definition camera were used in addition to standard laparoscopic equipment. Patient demographics; operative details, including procedure duration, blood loss, and complications; and final pathology results were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. RESULTS All LESS nephrectomy operations were successfully accomplished without the need to convert to conventional laparoscopy. The median patient age was 60.75 years (range 22-76 years) and median BMI was 22.95 (range 18.2-26.1). The median operative duration was 141 minutes (range 120-180 min), and the median blood loss was 103 mL (range 50-150 mL). Histologic evaluation confirmed complete excision of an intact specimen. All cases revealed organ-confined T(1) renal-cell carcinoma (two right-sided and six left-sided, tumor diameter range 4-8 cm). A tumor with an adjacent simple renal cyst was excised in one patient. No intraoperative or postoperative complications occurred. CONCLUSIONS LESS was a feasible and safe approach in a selected group of patients (low BMI and stage tumor). LESS nephrectomy was made possible with the use of multi-instrument port and flexible instruments. The oncologic outcome was not compromised. Further evaluation of LESS surgery needs prospective, randomized studies.

Predictive value of pretreatment inflammation-based prognostic scores (neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio) for invasive bladder carcinoma

Purpose Inflammation-based prognostic scores including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) are associated with oncologic outcomes in diverse malignancies. We evaluated the predictive value of pretreatment prognostic scores in differentiating nonmuscle invasive (NMIBC) and muscle invasive bladder cancer (MIBC). Materials and Methods Consecutive transurethral resection of bladder tumour (TURBT) cases from January 2011 to December 2013 were analysed retrospectively. Patient demographics, tumour characteristics and prognostic scores results were recorded. Receiver operating characteristics curves were used to determine prognostic score cutoffs. Univariate and multivariate binomial logistic regression analysis was performed to evaluate the association between variables and MIBC. Results A total of 226 patients were included, with 175 and 51 having NMIBC (stages Ta and T1) and MIBC (stage T2+) groups, respectively. Median age was 75 years and 174 patients were male. The NLR cutoff was 3.89 and had the greatest area under the curve (AUC) of 0.710, followed by LMR (cutoff<1.7; AUC, 0.650) and PLR (cutoff>218; AUC, 0.642). Full blood count samples were taken a median of 12 days prior to TURBT surgery. Multivariate logistic regression analysis identified tumour grade G3 (odds ration [OR], 32.848; 95% confidence interval [CI], 9.818-109.902; p=0.000), tumour size≥3 cm (OR, 3.353; 95% CI, 1.347-8.345; p=0.009) and NLR≥3.89 (OR, 8.244; 95% CI, 2.488-27.316; p=0.001) as independent predictors of MIBC. Conclusions NLR may provide a simple, cost-effective and easily measured marker for MIBC. It can be performed at the time of diagnostic flexible cystoscopy, thereby assisting in the planning of further treatment.

Probiotics, dendritic cells and bladder cancer

Whats known on the subject? and What does the study add?

Hemostasis during nerve-sparing endoscopic extraperitoneal radical prostatectomy.

The incidence of bleeding during laparoscopic radical prostatectomy has been reported to range between 1% and 7.6%. Postoperative bleeding complications have been encountered in 0.7% of endoscopic extraperitoneal radical prostatectomy cases and require endoscopic or open re-intervention. Thus, bleeding complications represent a significant factor of intra- and postoperative morbidity. We review our experience with endoscopic extraperitoneal radical prostatectomy, and we propose methods to prevent and manage intraoperative bleeding complications. In addition, special technical considerations regarding the nerve-sparing procedures are presented.

Baseline Multiparametric MRI for Selection of Prostate Cancer Patients Suitable for Active Surveillance: Which Features Matter?

Introduction Increasing evidence has supported the use of multiparametric magnetic resonance imaging (mpMRI) for the detection of prostate cancer. However, its role in selecting patients clinically suitable for active surveillance (AS) is still in development. We aimed to find relevant mpMRI features that might be helpful for refinement of the selection of low‐risk prostate cancer patients for AS. We also evaluated the interobserver variability in reporting prostate mpMRI features. Patients and Methods From 2008 to 2012, 135 patients were selected for AS using Epstein criteria. Baseline mpMRI studies were performed within 3 months of recruitment and reviewed by 2 radiologists who were unaware of the patients’ outcomes. The radiologists recorded the mpMRI features using the Prostate Imaging Reporting and Data System (PI‐RADS) guidelines. The overall likelihood of the presence of significant prostate cancer was also determined using the Likert and PI‐RADS, version 2 (v2), scores. Univariate and multivariate analyses, receiver operating characteristic curves, and Kaplan‐Meier survival curves were calculated for the mpMRI features with respect to patient withdrawal from the AS program and failure‐free survival (FFS). The interobserver agreement was also evaluated. Results At a median follow‐up time of 31 months (range, 6‐80 months), 84 patients (62.2%) were participating in the AS program. In 2 multivariate models, the variables significantly associated with outcomes for both readers were the index lesion size (hazard ratio [HR], 2.34 and 3.13, respectively) and overall PI‐RADS, v2, score (HR, 2.51 and 3.21, respectively). The interobserver agreement was higher for the overall Likert and PI‐RADS, v2, scores. Conclusion Overall, the PI‐RADS, v2, score and index lesion size were strongly associated with FFS. Overall, the Likert and PI‐RADS, v2, scoring systems have been confirmed to be useful, although further improvements are needed. Micro‐Abstract Multiparametric magnetic resonance imaging is gaining importance to characterise localised prostate cancers. Our study supports available evidence in literature regarding its utility in the selection of patients clinically suitable for active surveillance. Index lesion size and overall summary score are among the features more strongly associated to the clinical outcome.

Does urinary cytology have a role in haematuria investigations

To determine the diagnostic accuracy of urinary cytology to diagnose bladder cancer and upper tract urothelial cancer (UTUC) as well as the outcome of patients with a positive urine cytology and normal haematuria investigations in patients in a multicentre prospective observational study of patients investigated for haematuria.

Prostatic Biopsy Undergrading: The Feasibility of Secondary Laparoscopic Pelvic Lymphadenectomy

Objectives: Prostate biopsy grade is a key factor when deciding whether to perform pelvic lymph node dissection (PLND) at laparoscopic radical prostatectomy. In common with many laparoscopic radical prostatectomy centers, we perform PLND in patients found to have intermediate and high-risk prostate cancer based upon preoperative PSA, prostate biopsy and imaging. We assessed the feasibility of performing a secondary laparoscopic PLND 6 weeks postoperatively in the presence of postoperative upgrading in patients who did not have PLND. Methods: A prospective study recording the pathological results and operative outcomes prospectively over a 10-month period during which 24 patients underwent a secondary PLND. All patients had a preoperative PSA level <10 ng/ml and biopsy Gleason score of ≤6 (3 + 3) and the prostatectomy specimen was subsequently found to have a Gleason score of ≧7 (4 + 3) or increased stage. Results: During the 10-month period, 377 prostatectomies were carried out in our department in which 54 (18.3%) had an upgrading in the prostatectomy specimen. 24 patients (mean age 60 and mean PSA 6.7 ng/ml) agreed to a secondary PLND. No lymph nodes metastases were observed. One patient who was sexually potent following a nerve-sparing prostatectomy was impotent after the secondary PLND. Conclusions: Upgrading of prostate Gleason score is seen in up to a third of cases in many large published series that is reflected in our experience. A laparoscopic secondary lymphadenectomy is feasible with low morbidity and yields valuable pathological clinical staging for subsequent surveillance and therapy for these high-risk patients.

ENDING THE ‘LEARNING CURVE’

All the patients in this survey were satisfied with their procedure, which is consistent with the values cited elsewhere [4]. Kortmann et al. [5] suggested that most of the patients found urodynamic studies less bothersome than they had expected, which might explain the high level of acceptance to have urodynamic studies repeated, in that patients might have expected far worse and were hence pleasantly surprised. This highlights the issue of preprocedure counselling, and previous studies have reported a correlation between pain scores and pre-procedure anxiety levels [6].

IS IT TIME TO MISS THE TARGET FOR PROSTATE CANCER

The global emphasis on improving health outcomes has led to the creation in many countries of chronological targets in the patient pathway. In the UK, time periods for urgent cancer referrals have been adopted and these have been modifi ed, more recently, to create strict timelines for completion of treatment. The Department of Health now has a 2-month target from referral to treatment for all cancers, referred to as the ‘ 62-day target ’. Patients enter this pathway via the referring primary care practitioner who adheres to the guidelines that dictate the criteria for an urgent cancer referral. The timescale for initial review and subsequent treatment applies uniformly to all cancers (except basal cell carcinoma). The creation of fi nancial penalties that apply when a patient ‘ breaches ’ the targets has ensured the timelines are adhered to.