Mathias Winkler

Characteristics of incidental prostatic adenocarcinoma in contemporary radical cystoprostatectomy specimens

To investigate the relationship between prostate‐specific antigen (PSA) level and tumour volume for incidental adenocarcinoma of the prostate found in cystoprostatectomy (CP) specimens, and to analyse the incidence of clinically significant prostate cancers in CP specimens and the biochemical recurrence of incidental prostate cancers on short‐term follow up.

MAPPED study design: A 6 month randomised controlled study to evaluate the effect of dutasteride on prostate cancer volume using magnetic resonance imaging

OBJECTIVEnTo evaluate the percentage change in volume of prostate cancer, as assessed by T2-weighted MRI, following exposure to dutasteride (Avodart) 0.5mg daily for six months.nnnPATIENTS AND METHODSnMRI in Primary Prostate cancer after Exposure to Dutasteride (MAPPED) is a double-blind, placebo-controlled trial, supported by GlaxoSmithKline (GSK). Men with prostate cancer suitable for active surveillance (low-intermediate risk prostate cancer on biopsy), and a visible lesion on T2-weighted MRI of at least 0.2 cc, were eligible for consideration. Forty-two men were randomised to 6 months of daily dutasteride 0.5mg or placebo. Multi-parametric MRI (mpMRI) scans were performed at baseline, 3 and 6 months. The percentage changes in cancer volume over time will be compared between the dutasteride and placebo groups. Planned analyses will examine the association between tumour volume and characteristics (perfusion and contrast washout) as seen on mpMRI, HistoScan ultrasound and biopsy histopathology in both groups.nnnDISCUSSIONnMAPPED is the first randomised controlled trial to use mpMRI to look at the effect of dutasteride on the volume of prostate cancer. If dutasteride is shown to reduce the volume of prostate cancer, it might be considered as an adjunct for men on active surveillance. Analysis of the placebo arm will allow us to comment on the short-term natural variability of the MR appearance in men who are not receiving any treatment.nnnCONCLUSIONnMAPPED will evaluate the short-term effect of dutasteride on prostate cancer volume, as assessed by mpMRI, in men undergoing active surveillance for low or intermediate risk prostate cancer. The study completed recruitment in January 2012.

Repeat retroperitoneal lymph-node dissection after chemotherapy for metastatic testicular germ cell tumour.

To examine the operative findings, histopathology and clinical outcome of patients undergoing repeat retroperitoneal lymph node dissection (RPLND) after initial chemotherapy and RPLND (PC‐RPLND) for metastatic testicular germ cell tumour (GCT), as a small proportion relapse or have residual disease after incomplete resection in the lung, retrocrural or pelvic nodes, and retroperitoneum.

Lymphoepithelioma-like carcinoma of the urinary bladder: A case report and review of systemic treatment options.

Lymphoepithelioma-like carcinoma (LELC) of the urinary bladder is a rare variant, which can occur in a pure form or in conjunction with transitional cell carcinoma. Owing to the scarcity of reported cases, the optimum treatment is yet to be defined, although the benefits of chemotherapy are increasingly recognised. We present a case of a 64-year-old man with pure LELC, treated with trans-urethral resection of the bladder tumor (TURBT) and primary gemcitabine and platinum-based chemotherapy. He remained free of disease at six-month follow-up cystoscopy. The case adds to the growing evidence for the efficacy of chemotherapy, coupled with TUR, as part of a bladder-preserving treatment option for LELC.

Retroperitoneal lymph node dissection after chemotherapy in patients with elevated tumour markers: indications, histopathology and outcome

To evaluate the factors affecting outcome and the pathological findings in patients who had retroperitoneal lymph node dissection (pcRPLND) after chemotherapy with elevated tumour markers, as such patients have an unfavourable prognosis, with further salvage chemotherapy being the usual treatment of choice.

Erectile dysfunction following radical prostatectomy: A review

Radical prostatectomy remains the gold-standard treatment for localised prostate cancer. Despite the widespread introduction of nerve-sparing techniques, post-operative erectile dysfunction (ED) is still a significant source of morbidity. There are multiple approaches to prevent and treat ED. Recent refinements to surgical technique attempt to minimise disruption to the prostatic neural and arterial supply. A greater understanding of the factors affecting ED has also enabled the first multi-variate risk stratification model, thereby potentially improving awareness of pre-operative risk. Numerous on-demand treatments are available, including phosphodiesterase type 5 inhibitors, intracavernous/transurethral alprostadil, vacuum erection devices and combination therapy with multiple agents. As our understanding of the aetiology improves, attempts to manipulate the molecular mechanisms underpinning ED are also being investigated. In addition, early pharmacological rehabilitation is used to preserve cavernosal smooth muscle function until intra-operative neurapraxia resolves, although the optimum regimen is yet to be defined. Currently, much work is ongoing to improve our understanding and treatment of post-prostatectomy ED. We review the current status and recent advances in this field.

Prostate cancer detection using quantitative T2 and T2-weighted imaging: The effects of 5-alpha-reductase inhibitors in men on active surveillance: Quantitative T2 and Dutasteride in PCa

T2‐weighted imaging (T2‐WI) information has been used in a qualitative manner in the assessment of prostate cancer. Quantitative derivatives (T2 relaxation time) can be generated from T2‐WI. These outputs may be useful in helping to discriminate clinically significant prostate cancer from background signal.

Upper Urinary Tract (Kidney, Ureter and Adrenal Gland)

Whilst the patient is supine, following induction of anaesthesia, a urinary catheter is inserted. The patient is now rotated to the lateral position and the urinary bag is placed either at the top or bottom end of the bed for access by the anaesthetist. The legs are separated and protected with either pillows or a specially designed foam or rubber device between them as seen in the inset, in order to relieve any weight on pressure points, while the legs are slightly flexed at the knees. All other bony points, including shoulders and hips, are protected by the rubber or foam mat that is positioned on the operating table. The head and neck are supported with either pillows or a rubber head ring in order to maintain them in a neutral position. Depending on the softness of the table mattress, an axillary rubber roll may be required (not illustrated in these images) to prevent brachial plexus injury.

Urinary Bladder and Prostate

New operating procedures that spare the important neural structures of the urogenital tract have led to improved functional results in terms of bladder function, urinary continence and erectile potency. Well-described examples are nerve-sparing radical prostatectomy [1–3] and cystectomy (continence, potency) [3, 4], ureteric antireflux surgery (bladder function) [5], extended radical hysterectomy with total mesometrial resection (bladder function) [6] and rectal resection (continence, bladder function, potency) [7].

Laparoscopic pelvic lymphadenectomy (PLA) in prostate cancer staging and impact on radiotherapy fields

Introduction: Staging PLA in high risk prostate ancer may help to determine suitability for radical reatment or whole pelvis radiation. Additionally, ong-term androgen deprivation therapy may be voided. We assess the role and safety of PLA. Methods: Patients with high-risk prostate caner were selected prospectively. Indications for PLA ncluded a risk of nodal metastases >30% (Roach ormula, clinical T3 or radiological N1 disease on RI). Standard template lymphadenectomy was erformed. Results: 36 patients underwent staging PLA. o statistically significant difference in Gleason core, T stage, presenting PSA, or number of nodes esected, was seen for node positive disease. Mean SA was 44.5 ng/ml. 95% of patients were discharged within 24 h, with o intra-operative complications. The mean numer of nodes removed was 14 (SD ± 4). 30% (10/36) xperienced early complications which resolved lymphocoele formation 13%, lymphoedema 8%, crotal oedema 3%, and obturator nerve paraestheia 5%). One patient developed a small pulmonary mbolus and was anti-coagulated. Node positivity as observed in 30% of patients with PLA comared to 19% detected on MRI. Overall, 70% of cases ere node negative and did not undergo whole elvic radiotherapy, which would have been stanard treatment. PLA upstaged MR from N0 to N1 in 261