Marios Hadjipavlou

Partial vs radical nephrectomy for T1 renal tumours: an analysis from the British Association of Urological Surgeons Nephrectomy Audit

To analyse and compare data from the British Association of Urological Surgeons Nephrectomy Audit for perioperative outcomes of partial (PN) and radical nephrectomy (RN) for T1 renal tumours.

Surgical ablation for atrial fibrillation

This paper reviews the history of surgical procedures developed for eradication of atrial fibrillation (AF) during cardiac surgery for structural heart disease, and in patients with AF without other indication for cardiac surgery. Current evidence indicates that, despite their proven efficacy, the Cox-Maze procedure and its modifications require cardiopulmonary bypass and cannot be easily justified in the case of AF without other indication for cardiac surgery. In patients undergoing cardiac surgery for mitral valve disease, concomitant ablation techniques using modifications of the Maze and alternative energy sources appear to be safe and effective in treating AF, especially in non-rheumatic disease. Minimally invasive epicardial ablation has been recently developed and can be performed on a beating heart through small access incision ports. Various techniques combining pulmonary vein isolation, ganglionated plexi ablation, and left atrial lines have been tried. Initial results are promising but further clinical experience is required to establish ideal lesion sets, appropriate energy sources, and the benefit-risk ratio of such an approach in patients without other indication for cardiac surgery. The role of surgical ablation in the current management of AF is under investigation.

Urolithiasis following urinary diversion

Urolithiasis is a well-known occurrence after cystectomy and urinary diversion. With high incidence and recurrence rates of urolithiasis, complex anatomy and associated morbidities, these patients remain a management challenge for urologists. The purpose of this review is to examine the literature and consider the risk factors for stone formation in this group of patients and reflect on the reported outcomes with the range of available treatment options.

Three-dimensional analysis of vulnerable segments in the left anterior descending artery

ObjectivesAnalysis of conventional angiograms has suggested that specific anatomic parameters of particular segments of a coronary artery render them prone to vulnerable plaque development, plaque rupture, and consequent thrombosis. This study aimed at performing a three-dimensional analysis of recanalized left anterior descending (LAD) coronary arteries in patients who had suffered an anterior ST-elevation myocardial infarction (STEMI). MethodsCoronary angiograms of 76 consecutive patients with an anterior STEMI and a recanalized LAD were reconstructed in the three-dimensional space, and compared with angiograms of 76 patients with stable coronary artery disease (SCAD) and significant LAD stenosis. ResultsIn both groups the majority of lesions occurred between 20 and 40 mm (P=0.745), but the number of lesions beyond 60 mm from the ostium was significantly higher in SCAD compared with STEMI (P=0.045). Culprit lesions were statistically significantly longer in patients with STEMI compared with SCAD (18.3±7.5 vs. 12.7±6.2 mm, P<0.001). Cut-off point analysis indicated a lesion length of ≥12.5 mm as discriminating threshold between SCAD and STEMI (sensitivity 79% and specificity 63%). Bifurcation branches on the culprit lesion were seen in 79% of the patients with STEMI and 58% of those with SCAD (P=0.026). Lesion angulation was significantly sharper in STEMI compared with SCAD patients in diastole (155±15 vs. 160±14 degrees, P=0.037). Multiple logistic regression model including these parameters had a high discriminating ability with c-statistic 0.78 (95% confidence intervals: 0.71–0.86), sensitivity 72.4%, and specificity 75%. ConclusionSpecific anatomic characteristics of LAD segments predispose to development of plaque rupture and thrombosis.

Active surveillance for low-risk prostate cancer

Overtreatment of prostate cancer has become evident as studies comparing radical prostatectomy vs watchful waiting have shown that radical treatment benefits only a proportion of patients. Active surveillance was introduced as a management option for prostate cancer at low-risk of progression with the aim to closely observe for disease progression or change of tumour characteristics and offer active treatment if and when necessary. Active surveillance has been reserved for patients with Gleason 6 localised disease and low PSA; however, selection criteria may be widened as intermediate-term outcomes demonstrate excellent safety, efficacy and patient acceptance.

Radiation Exposure during Ureterorenoscopy and Laser Lithotripsy: An Analysis of Stone Characteristics

Introduction and Objectives: Stone formers often have a chronic exposure to significant quantities of ionising radiation from radiological investigations and interventions. Predicting radiation exposure would allow the clinician to quantify expected cumulative radiation and find strategies to minimise exposure. We evaluated radiation exposure during ureteroscopy and laser lithotripsy (URS + LL) for a single stone episode and correlated the results to stone characteristics. Method: Data was collected retrospectively for all patients undergoing URS + LL in our institution over a 1 year period. Patients with multiple stones, staghorn stones or incomplete stone clearance were excluded to simplify the analysis. Patient characteristics, fluoroscopy data and stone characteristics were recorded. Results: We included 302 consecutive patients in the study. The majority of stones were located in the renal calyces/pelvis (54%) with the rest located in the upper (18%), middle (13%) and lower ureter (15%). Mean stone diameter was 9.9 mm (range 4–30 mm). Mean radiation exposure time during URS + LL was 44 s (range 12–119 s) with a mean total radiation exposure of 7.5 milligray (mGy; range 1.2–29.7 mGy). Renal stones were associated with 27% higher radiation exposure compared to ureteral stones (8.3 vs. 6.7 mGy; p = 0.02). There was a positive correlation between stone diameter and radiation exposure (Spearman’s correlation coefficient ρ = 0.28; p < 0.001). Stones with diameter greater than 10 mm were associated with 37% higher radiation exposure compared to smaller stones (9.1 vs. 6.6 mGy; p < 0.001). Conclusion: There is a direct correlation between stone burden, as well as location, and radiation exposure during URS + LL. Clinicians should consider strategies to reduce total radiation exposure in recurrent stone formers at risk of high radiation exposure by limiting screening time, using pulsed rather than continuous fluoroscopy, management with primary URS + LL, or using ultrasound guidance.

Spontaneous rupture of a renal artery pseudoaneurysm with no precipitating risk factor

Renal artery pseudoaneurysm is a rare complication following renal interventional procedures or, although it may be spontaneous as described in this case. Clinicians should have a low threshold for early computer tomography (CT) imaging in cases of diagnostic uncertainty.

PD43-07 RECTAL SWAB CULTURES AND TARGETED PROPHYLACTIC ANTIMICROBIAL REGIMES DO NOT REDUCE THE RISK OF SEPSIS FOLLOWING TRANSRECTAL PROSTATE BIOPSY

key radiological, surgical and patient factors are that influence detection of clinically significant cancer by MRI-TB. Knowledge of these factors will help optimise the conduct of this diagnostic strategy. METHODS: 604 men with clinical suspicion of prostate cancer underwent multiparametric MRI (scored on a 1-5 Likert scale) followed by cognitively registered transperineal MRI-TB at a single centre in a 30-month period. Multi-parametric MRI included T2-weighted, diffusionweighted and dynamic-contrast enhanced sequences reported by an expert uro-radiologist. Factors influencing detection of clinically significant cancer by MRI-TB were investigated with a multivariate logistic regression using STATA. Multiple imputation was carried out to account for missing data. RESULTS: In the 604 men, mean age was 65 and median was PSA 7.1. Significant cancer was detected in 390 men (65%). The multivariate analysis adjusting for key confounders showed that factors significantly associated with clinically significant cancer detection included MRI-Likert score (p<0.0001), MRI coil strength (p1⁄40.0013), prior biopsy status (biopsy naive, previous negative biopsy, previous positive biopsy, p1⁄40.0016) and PSA (p1⁄40.0135). Factors not associated with detection of significant cancer included anaesthetic (general versus local,p1⁄40.1274), abnormal digital rectal examination (p1⁄40.0918), surgeon (p1⁄40.1724) and location of tumour (anterior vs posterior, p1⁄40.5825; basal vs apical, p1⁄40.9204). CONCLUSIONS: Key factors that influence the odds of detection of clinically significant cancer have been identified. This study validates the MRI-Likert score as one of the strongest predictors of clinically significant cancer detection. It highlights the importance of presenting PSA and MRI coil strength. Notably, this data also highlights that digital rectal exam finding is not very reliable, consistent with previous studies. Of particular importance, this data supports the feasibility of a local anaesthetic-only approach for transperineal targeted biopsy which has major healthcare delivery and health resource use benefits.

History and Evolution of LESS

From very humble beginnings, roughly a century ago, laparoscopic surgery has now become the standard of care for many surgical procedures. Its application in various surgical specialities has helped patients tremendously by replacing traditional open surgical procedures with laparoscopic techniques that have the added benefit of better cosmesis, significantly improved operative and post-operative outcomes without compromising on oncological outcomes. Within the field of urology, laparoscopy has evolved significantly from initially being a diagnostic tool to now providing the means for performing complex extirpative and reconstructive procedures intra-corporally. Rapid advancements made in technology, the incorporation of robotics and the development of laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) have now made truly ‘scarless’ surgery achievable.

PD44-08 ABNORMAL DIGITAL RECTAL EXAMINATION (DRE) OF THE PROSTATE INCREASES THE LIKELIHOOD OF FUTURE HIGH GRADE PROSTATE CANCER DIAGNOSIS IN PATIENTS WITH INITIAL BENIGN PROSTATE BIOPSY

METHODS: During the past year, men referred for prostate biopsy at a single institution were offered MiPS as an alternative to proceedingdirectly to abiopsy.Patient characteristics,PSA,PCA3,T2:ERG, and biopsy pathology were analyzed to see how MiPS and HG MiPS affected the decision for prostate biopsy and pathology at biopsy. Oneway ANOVA was used to compare PCA3, T2:ERG and risk levels. RESULTS: 121 men (21.5% with prior biopsy) underwent MiPS testingwith amean ageof 64 years,medianPSAof 7 ng/ml, PCA3score of 22, T2:ERG score of 2. Based on MiPS, the average predicted risk for detection of any and high grade cancer were 42.4% and 26.6%, respectively. Men who then chose to have a biopsy (n1⁄458/47.9%) had higher MiPS (54.1% vs 31.6%, p<0.05) and HG MiPS scores (35.3% vs 18.5%, p<0.05) than those who did not. Among those biopsied, MiPS, HG MiPS, PCA3, T2:ERG were higher in those with high grade cancer found on biopsy but only T2:ERG was significantly higher (178.2 vs 44.5, p<0.05). CONCLUSIONS: The combination of PSA, PCA3 and T2:ERG as a test panel for prostate cancer reduced the use of prostate biopsy in half. T2:ERGwasstrongly associatedwithdetection of highgradecancer. These findings support theuseofMiPS forassessingprostate cancer risk.