Giles Rottenberg

Role of fluorodeoxyglucose positron emission tomography (FDG PET)-computed tomography (CT) in the staging of bladder cancer

To determine whether to use 18F‐fluorodeoxyglucose positron emission tomography (FDG PET) scans in the preoperative staging of bladder cancer (BC).

Definitions of terms, processes and a minimum dataset for transperineal prostate biopsies: a standardization approach of the Ginsburg Study Group for Enhanced Prostate Diagnostics.

To define terms and processes and agree on a minimum dataset in relation to transperineal prostate biopsy procedures and enhanced prostate diagnostics. To identify the need for further evaluation and establish a collaborative research practice.

Incidental renal stones in potential live kidney donors: prevalence, assessment and donation, including role of ex vivo ureteroscopy

Previously, donors with asymptomatic stones found incidentally on CT were not considered ideal donor candidates because of the presumed risk of morbidity to both the donor and recipient. Increasingly, studies show that these risks are low. This study aims to evaluate the long‐term safety of using ex vivo ureteroscopy to remove the stones from the donor kidney on the bench before donation. Outcomes so far suggest that this technique can safely render a kidney stone‐free before transplantation. This has led to 20 more transplants in our institution than would otherwise be possible.

Low-grade phyllodes tumor of the seminal vesicle treated with laparoscopic excision.

Background A 43-year-old man presented with a 2-year history of hematospermia and dull ache in the left testis. On physical examination he had left epididymal tenderness and a normal digital rectal examination.Investigations Transrectal ultrasonography and MRI.Diagnosis Low-grade phyllodes tumor of the left seminal vesicle.Management Laparoscopic excision of the left seminal vesicle.

Can the Presence of Crystalluria Predict Stone Formation in Patients with Cystinuria

OBJECTIVES To determine the feasibility of crystalluria as a biomarker for stone disease in patients with cystinuria. PATIENTS AND METHODS All patients attending a multidisciplinary cystinuria clinic provided early morning urine (EMU) and clinic urine (CU) samples for crystal measurement over a 2-year period (August 1, 2010, to July 31, 2012). Association between presence of crystals, presence of stone(s), and new stone growth (NSG) was determined using the chi-square test. Crystal numbers in EMU and CU were compared in patients with stones/NSG and no stones/stable disease using the Mann-Whitney U test. RESULTS There was a statistically significant difference between the presence of crystalluria and presence of stones for CU (chi-square test = 5.86, df = 1, p = 0.02) but not EMU (chi-square test = 1.92, df = 1, p = 0.17) and between the presence of crystalluria and NSG for CU (chi-square test = 8.10, df = 1, p = 0.004) but not EMU (chi-square test = 1.32, df = 1, p = 0.25). Patients with stones and NSG have higher levels of crystalluria in CU than patients with no stones or stable disease (stones, median = 41, interquartile range [IQR] = 600 vs median = 0, IQR = 21, p = 0.01; NSG, median = 49, IQR = 525 vs median = 0, IQR = 40, p = 0.01). CONCLUSION The presence of crystalluria in CU samples is associated with the presence of stones. Crystalluria is comparable to ultrasound and may serve as a useful adjunct to predict whether a patient with cystinuria has stones, which could guide the frequency of clinic review and imaging.

The successful, sustainable elimination of a waiting list for urology outpatients.

Not all studies have shown an advantage to preservation and reconstruction of the periurethral tissue planes. Joshi et al . [8] reported on 107 patients undergoing RARP, where alternate patients underwent posterior reconstruction of the median fibrous raphe while the others had a standard vesico-urethral anastomosis without reconstruction. In this parallel group trial, no difference was noted in the continence rate at 3 and 6 months. Menon et al . [9] conducted the only randomized controlled trial examining continence in 116 consecutive patients undergoing RARP. 57 patients were randomized to a single urethro-vesical anastomosis (without periprostatic reconstruction) and 59 to double-layer anastomosis (with periprostatic tissue reconstruction). They found that early urinary continence rates were high in both groups, and there was no improvement in continence rates with posterior reconstruction. The urine leak rates, however, were lower in those undergoing posterior reconstruction before vesico-urethral anastomosis.

A prospective study of the utility of a routine ‘loopogram’ at three months for the early detection of anastomotic stricture post-cystectomy and conduit urinary diversion

Objective: The objective of this study is to evaluate the utility of routine loopogram follow-up three months after cystectomy and urinary diversion in the early detection of benign ureteroileal anastomotic stricture (UAS). Materials and methods: A loopogram was incorporated into our standard follow-up three months after cystectomy and conduit urinary diversion in August 2010–December 2015. Data were maintained prospectively in a database. Results: A total of 250 patients (181 male; 69 female); median age of 70 years (range: 38–83) underwent cystectomy and conduit urinary diversion during this period. Of these, 167 (66.8%) had a routine loopogram at three months. Seven of 167 were confirmed to have a benign UAS. Twenty-three of 250 (9.2%) had an early loopogram prior to the planned three-month study in response to symptoms. Nine of 23 were diagnosed with benign UAS. Sixty of 250 (24%) did not have a routine loopogram for a variety of reasons. Five patients with normal three-month loopograms developed late strictures after a median time of 22 months (range 5–38). In total 21/250 (8.4%) patients developed UAS. Stricture rates for the open, robotic and laparoscopic modalities were 8/129 (6.2%), 12/111 (10.8%) and 1/10 (10%) respectively. Five of seven of patients with early, asymptomatic UAS diagnosed on routine loopogram received treatment; four of five had improvement in renal function. Conclusion: Overall stricture rate in this series was 8.4%. The majority of UAS occur early and are more likely to be symptomatic. A policy of routine loopogram benefitted only 4/250 (1.6%) patients. We advocate the use of loopograms in cases with a high index of suspicion rather than for routine screening. Level of evidence: Not applicable for this multicentre audit.

Ex vivo study of prostate cancer localization using rolling mechanical imaging towards minimally invasive surgery

Rolling mechanical imaging (RMI) is a novel technique towards the detection and quantification of malignant tissue in locations that are inaccessible to palpation during robotic minimally invasive surgery (MIS); the approach is shown to achieve results of higher precision than is possible using the human hand. Using a passive robotic manipulator, a lightweight and force sensitive wheeled probe is driven across the surface of tissue samples to collect continuous measurements of wheel-tissue dynamics. A color-coded map is then generated to visualize the stiffness distribution within the internal tissue structure. Having developed the RMI device in-house, we aim to compare the accuracy of this technique to commonly used methods of localizing prostate cancer in current practice: digital rectal exam (DRE), magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) biopsy. Final histology is the gold standard used for comparison. A total of 126 sites from 21 robotic-assisted radical prostatectomy specimens were examined. Analysis was performed for sensitivity, specificity, accuracy, and predictive value across all patient risk profiles (defined by PSA, Gleason score and pathological score). Of all techniques, pre-operative biopsy had the highest sensitivity (76.2%) and accuracy (64.3%) in the localization of tumor in the final specimen. However, RMI had a higher sensitivity (44.4%) and accuracy (57.9%) than both DRE (38.1% and 52.4%, respectively) and MRI (33.3% and 57.9%, respectively). These findings suggest a role for RMI towards MIS, where haptic feedback is lacking. While our approach has focused on urological tumors, RMI has potential applicability to other extirpative oncological procedures and to diagnostics (e.g., breast cancer screening).

The Staging of Prostate Cancer

The key role of staging in prostate cancer is to accurately determine the extent of the disease in order to place the man into a specific staging group and hence tailor the most appropriate treatments for each individual patient. Prostate cancer staging is at the present time a rapidly evolving field with many novel techniques in development. Initial clinical evaluation is performed by digital rectal examination combined with transrectal ultrasound. Traditionally, the evaluation of the primary tumor in terms of extracapsular extension and the regional/pelvic lymph nodes has been by body-array coil MRI cross-sectional imaging. Distant metastases are imaged by CT/MRI or radio nucleotide scanning corroborated by plain x-rays if required.

Definitions of terms, processes and a minimum dataset for transperineal prostate biopsies: a standardization approach of the Ginsburg Study Group for Enhanced Prostate Diagnostics: A standardization approach for transperineal prostate biopsies

To define terms and processes and agree on a minimum dataset in relation to transperineal prostate biopsy procedures and enhanced prostate diagnostics. To identify the need for further evaluation and establish a collaborative research practice.