Iqbal S. Shergill

The role of transperineal template biopsies of the prostate in the diagnosis of prostate cancer: a review.

The incidence of prostate cancer has shown a significant increase, highlighting the importance of early diagnosis. Current practice considers histological diagnosis a necessity in the majority of the cases. The limitations of transrectal biopsies led to the development of the promising transperineal prostatic biopsies. The latter offers a safer approach by avoiding the rectum, utilizing brachytherapy template grid to detect anterior zone disease and provides accurate prostatic mapping by systematically sampling the whole gland. It also helps to direct biopsies based on images obtained from previous prostate scanning and identify those eligible for focal therapy to direct focal treatment accurately. The current literature provides enough reassurance that transperineal template biopsies are effective, efficient and superior to the traditional and inaccurate transrectal biopsies. The absence of consensus on the technical aspect of template biopsies is a drawback, yet it highlights the need to develop robust guidelines to standardize the procedure.

The resonance® metallic ureteric stent in the treatment of chronic ureteric obstruction: a safety and efficacy analysis from a contemporary clinical series

BackgroundWe evaluate the efficacy and safety of metallic ureteric stenting using the Cook Resonance® stent in the treatment of chronic ureteric obstruction of benign and malignant aetiology. Published experience of using this stent in this context is limited. We add to the body of literature on this topic.MethodsAll patients who had a Resonance® metallic stent inserted between April 2009 and November 2014 in our institution were identified from a prospectively maintained stent-database. Primary outcome was relief of ureteric obstruction, defined by successful clinical and radiological treatment of hydronephrosis/hydroureter. Secondary outcome measures included operative time, radiological exposure, total stent dwell time (defined as the cumulative time in months for which a Resonance® metallic stent was in situ), and early and late complications.ResultsTwenty-one patients underwent 52 stent insertion episodes (SIE). Median age was 58xa0years (range 39–90). Stent insertion resulted in successful treatment of hydronephrosis/hydroureter in 96% (2 SIE resulted in failure to relieve ureteric obstruction). Median operative time was 21xa0min (range 12–90) Median radiation exposure was 815.3xa0cGy/cm2 (range 192.9–5366.3). Median stent dwell time was 19.5xa0months (range 6–52) in non-malignant and 12xa0months (range 2–48) in malignant ureteric obstruction. One stent migrated proximally during insertion and had to be retrieved using an antegrade approach. 5 patients re-admitted with haematuria: all resolved without intervention or blood transfusion. 3 episodes of post-operative urinary infection were recorded; all were successfully treated with oral antibiotics.ConclusionMetallic ureteric stenting using the Resonance® stent is safe and effective for treating ureteric obstruction from both malignant and benign causes. The success rate in our series is 96%.

A pilot study evaluating changes to haematological and biochemical tests after Flexible Ureterorenoscopy for the treatment of kidney stones

Background Currently there is limited research documenting the changes in blood parameters, following Flexible Ureterorenoscopy. This study aims to determine whether there are any changes in haematology and biochemistry parameters, following Flexible Ureterorenoscopy for the treatment of kidney stones. Methods 40 consecutive patients aged between 27–87 years (median 49 years) undergoing Flexible Ureterorenoscopy for the treatment of kidney stones were recruited (26 male, 14 female). Blood samples were collected from each patient at four time points: baseline (pre-operatively) followed by 30 minutes, 120 minutes and 240 minutes post-operatively. On these samples, routine haematological and biochemistry tests were carried out. In addition to the assessment of clinical parameters prospectively from the medical notes. Results There was a significant decrease observed following Flexible Ureterorenoscopy in the following parameters: lymphocytes (p = 0.007), eosinophils (p = 0.001), basophils (p = 0.001), haemoglobin (p = 0.002), red blood cells (p = 0.001), platelet count (p = 0.001), fibrinogen concentration (p = 0.001), von Willebrand factor (p = 0.046), C reactive protein (p = 0.01), total protein (p = 0.001), albumin (p = 0.001), globulin (p = 0.001) and alkaline phosphatase (p = 0.001). In addition, there was a significant increase observed in the following parameters: white blood cells (p = 0.001), neutrophils (p = 0.001), activated partial thromboplastin time (p = 0.001), total bilirubin (p = 0.012), creatinine (p = 0.008), sodium (p = 0.002) and potassium (p = 0.001). Limiting factors for this study were the sample size, and restriction on the recruitment time points. Conclusions Significant changes were noted to occur in haematology and biochemistry parameters following Flexible Ureterorenoscopy. Some of the data presented in this study may represent the ‘normal’ post-operative response following FURS, as no major complications occurred, in the majority of our patients. This data on the ‘normal response’ will need to be validated but may ultimately aid clinicians in distinguishing patients at risk of complications, if reproduced in larger multi-centre studies.

Urolift–minimally invasive surgical BPH management

ABSTRACT Introduction: An ideal treatment option for symptomatic Benign Prostatic Hyperplasia (BPH) should relieve lower urinary tract symptoms (LUTS) and restore Quality of Life (QoL). Currently available medical therapies and surgical options for symptomatic BPH have side effects that adversely affects quality of life. Prostatic urethral lift (PUL) is a novel endourology procedure that promises to relieve LUTS without the aforementioned side effects. Areas covered: We diligently reviewed all the published literature on PUL, till July 2016 using standard search criteria. Expert commentary: There is good quality evidence to establish the efficiency of PUL in treating symptomatic BPH without adversely affecting the QoL. Based on the current literature, PUL can be considered as an option for those symptomatic BPH patients with small or medium size prostates (< 80 ml) without median lobe enlargement, who failed on medical therapy or are intolerant to it and wish to preserve their sexual function.

Low power HOLEP after failed urolift: A case report using 50 Watt laser

Benign prostatic hyperplasia (BPH) affects millions of men worldwide. The UroLift device was recently introduced as a means to perform prostatic urethral lift procedure for lateral lobe hypertrophy in patients with obstructive voiding symptoms, who would like to avoid sexual and ejaculatory dysfunction.1 Crucially, Urolift has been associated with a failure rate of 7% at 2 years and 14% at 4 years,2 and with the increasing popularity of the Urolift procedure, urologists should be prepared to perform secondary procedures in cases of Urolift failure. Whilst high power 100W HOLEP has been performed,3 in this case report, we describe the first use of low power HOLEP using 50 Watt Laser in a case of failed Urolift implantation.

Multiparametric MRI to improve detection of prostate cancer compared with transrectal ultrasound-guided prostate biopsy alone : the PROMIS study

BACKGROUNDnMen with suspected prostate cancer usually undergo transrectal ultrasound (TRUS)-guided prostate biopsy. TRUS-guided biopsy can cause side effects and has relatively poor diagnostic accuracy. Multiparametric magnetic resonance imaging (mpMRI) used as a triage test might allow men to avoid unnecessary TRUS-guided biopsy and improve diagnostic accuracy.nnnOBJECTIVESnTo (1) assess the ability of mpMRI to identify men who can safely avoid unnecessary biopsy, (2) assess the ability of the mpMRI-based pathway to improve the rate of detection of clinically significant (CS) cancer compared with TRUS-guided biopsy and (3) estimate the cost-effectiveness of a mpMRI-based diagnostic pathway.nnnDESIGNnA validating paired-cohort study and an economic evaluation using a decision-analytic model.nnnSETTINGnEleven NHS hospitals in England.nnnPARTICIPANTSnMen at risk of prostate cancer undergoing a first prostate biopsy.nnnINTERVENTIONSnParticipants underwent three tests: (1) mpMRI (the index test), (2) TRUS-guided biopsy (the current standard) and (3) template prostate mapping (TPM) biopsy (the reference test).nnnMAIN OUTCOME MEASURESnDiagnostic accuracy of mpMRI, TRUS-guided biopsy and TPM-biopsy measured by sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) using primary and secondary definitions of CS cancer. The percentage of negative magnetic resonance imaging (MRI) scans was used to identify men who might be able to avoid biopsy.nnnRESULTSnDiagnostic study - a total of 740 men were registered and 576 underwent all three tests. According to TPM-biopsy, the prevalence of any cancer was 71% [95% confidence interval (CI) 67% to 75%]. The prevalence of CS cancer according to the primary definition (a Gleason score of ≥u20094u2009+u20093 and/or cancer core length of ≥u20096u2009mm) was 40% (95% CI 36% to 44%). For CS cancer, TRUS-guided biopsy showed a sensitivity of 48% (95% CI 42% to 55%), specificity of 96% (95% CI 94% to 98%), PPV of 90% (95% CI 83% to 94%) and NPV of 74% (95% CI 69% to 78%). The sensitivity of mpMRI was 93% (95% CI 88% to 96%), specificity was 41% (95% CI 36% to 46%), PPV was 51% (95% CI 46% to 56%) and NPV was 89% (95% CI 83% to 94%). A negative mpMRI scan was recorded for 158 men (27%). Of these, 17 were found to have CS cancer on TPM-biopsy. Economic evaluation - the most cost-effective strategy involved testing all men with mpMRI, followed by MRI-guided TRUS-guided biopsy in those patients with suspected CS cancer, followed by rebiopsy if CS cancer was not detected. This strategy is cost-effective at the TRUS-guided biopsy definition 2 (any Gleason pattern of ≥u20094 and/or cancer core length of ≥u20094u2009mm), mpMRI definition 2 (lesion volume of ≥u20090.2u2009ml and/or Gleason score of ≥u20093u2009+u20094) and cut-off point 2 (likely to be benign) and detects 95% (95% CI 92% to 98%) of CS cancers. The main drivers of cost-effectiveness were the unit costs of tests, the improvement in sensitivity of MRI-guided TRUS-guided biopsy compared with blind TRUS-guided biopsy and the longer-term costs and outcomes of men with cancer.nnnLIMITATIONSnThe PROstate Magnetic resonance Imaging Study (PROMIS) was carried out in a selected group and excluded men with a prostate volume of >u2009100u2009ml, who are less likely to have cancer. The limitations in the economic modelling arise from the limited evidence on the long-term outcomes of men with prostate cancer and on the sensitivity of MRI-targeted repeat biopsy.nnnCONCLUSIONSnIncorporating mpMRI into the diagnostic pathway as an initial test prior to prostate biopsy may (1) reduce the proportion of men having unnecessary biopsies, (2) improve the detection of CS prostate cancer and (3) increase the cost-effectiveness of the prostate cancer diagnostic and therapeutic pathway. The PROMIS data set will be used for future research; this is likely to include modelling prognostic factors for CS cancer, optimising MRI scan sequencing and biomarker or translational research analyses using the blood and urine samples collected. Better-quality evidence on long-term outcomes in prostate cancer under the various management strategies is required to better assess cost-effectiveness. The value-of-information analysis should be developed further to assess new research to commission.nnnTRIAL REGISTRATIONnCurrent Controlled Trials ISRCTN16082556 and NCT01292291.nnnFUNDINGnThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 39. See the NIHR Journals Library website for further project information. This project was also supported and partially funded by the NIHR Biomedical Research Centre at University College London (UCL) Hospitals NHS Foundation Trust and UCL and by The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research Biomedical Research Centre and was co-ordinated by the Medical Research Councils Clinical Trials Unit at UCL (grant code MC_UU_12023/28). It was sponsored by UCL. Funding for the additional collection of blood and urine samples for translational research was provided by Prostate Cancer UK.

The first use of Resonance® metallic ureteric stent in a case of obstructed transplant kidney

INTRODUCTIONnTo date, double JJ stent is the mainstay ureteric stent used in a transplant kidney. We herein report the first use of Resonance(®) metallic ureteric stent to manage ureteric obstruction in a transplant kidney.nnnPRESENTATION OF CASEnA 45-year-old lady underwent an uneventful living related donor renal transplantation. Due to post-operative pelvi-ureteric obstruction and recurrent obstruction following multiple distal stent migration and expulsion necessitated frequent nephrostomy insertion and antegrade stenting, she underwent challenging but successful retrograde insertion of a 12 centimetres long and size 6.0 French Cook Resonance(®) metallic ureteric stent which was performed under general anaesthesia.nnnDISCUSSIONnMetallic ureteric stents are a fairly recent introduction to modern urology and they have been successfully used in the management of benign and malignant obstruction of ureter.nnnCONCLUSIONnThis is the first case of therapeutic metallic ureteric stent insertion in a transplant kidney.

Prostate Cancer Emergencies

Urological emergencies of prostate cancer are increasingly becoming more common and may present to emergency departments, general physicians, and urologists. Importantly, they may result in pain and discomfort (urinary retention and skeletal fractures), loss of function (neurological complication or priapism), or in rare cases death (bone fractures, infected obstructed kidneys, and sepsis). Hence, it is mandatory to have a full understanding of the clinical presentation of these emergencies, and in addition, appreciation of rapid diagnosis and expeditious treatment is mandatory. This chapter reviews the presentation, diagnosis, and clinical treatment of acute emergencies related to prostate cancer and the complications of treatments.

Nanotechnology and the Implications for Penile Cancer

Nanotechnology refers to the creation of functional material devices and systems through the control of matter on an atomic or molecular scale – the nanometer scale (1 nm = 1 × 10−9 m). It is at this size that the majority of biologic molecules inside living cells operate.