Todd Manning

Prostate cancer biomarkers: Are we hitting the mark?

Purpose Localised prostate cancer diagnosis and management is increasingly complex due to its heterogeneous progression and prognostic subgroups. Pitfalls in current screening and diagnosis have prompted the search for accurate and invasive molecular and genetic biomarkers for prostate cancer. Such tools may be able to distinguish clinically significant cancers from less aggressive variants to assist with prostate cancer risk stratification and guide decisions and healthcare algorithms. We aimed to provide a comprehensive review of the current prostate cancer biomarkers available and in development. Methods MEDLINE and EMBASE databases searches were conducted to identify articles pertaining to the use of novel biomarkers for prostate cancer. Results A growing number of novel biomarkers are currently under investigation. Such markers include urinary biomarkers, serology-based markers or pathological tissue assessments of molecular and genetic markers. While limited clinical data is present for analysis, early results appear promising. Specifically, a combination of serum and urinary biomarkers (Serum PSA + Urinary PCA3 + Urinary TMPRSS2-ERG fusion) appears to provide superior sensitivity and specificity profiles compared to traditional diagnostic approaches (AUC 0.88). Conclusion The accurate diagnosis and risk stratification of prostate cancer is critical to ensure appropriate intervention. The development of non-invasive biomarkers can add to the information provided by current screening practices and allows for individualised risk stratification of patients. The use of these biomarkers appears to increase the sensitivity and specificity of diagnosis of prostate cancer. Further studies are necessary to define the appropriate use and time points of each biomarker and their effect on the management algorithm of prostate cancer.

Penile Cancer: Contemporary Lymph Node Management

Purpose: In penile cancer, the optimal diagnostics and management of metastatic lymph nodes are not clear. Advances in minimally invasive staging, including dynamic sentinel lymph node biopsy, have widened the diagnostic repertoire of the urologist. We aimed to provide an objective update of the recent trends in the management of penile squamous cell carcinoma, and inguinal and pelvic lymph node metastases. Materials and Methods: We systematically reviewed several medical databases, including the Web of Science® (with MEDLINE®), Embase® and Cochrane databases, according to PRISMA (Preferred Reporting Items for Systematic Review and Meta‐Analyses) guidelines. The search terms used were penile cancer, lymph node, sentinel node, minimally invasive, surgery and outcomes, alone and in combination. Articles pertaining to the management of lymph nodes in penile cancer were reviewed, including original research, reviews and clinical guidelines published between 1980 and 2016. Results: Accurate and minimally invasive lymph node staging is of the utmost importance in the surgical management of penile squamous cell carcinoma. In patients with clinically node negative disease, a growing body of evidence supports the use of sentinel lymph node biopsies. Dynamic sentinel lymph node biopsy exposes the patient to minimal risk, and results in superior sensitivity and specificity profiles compared to alternate nodal staging techniques. In the presence of locoregional disease, improvements in inguinal or pelvic lymphadenectomy have reduced morbidity and improved oncologic outcomes. A multimodal approach of chemotherapy and surgery has demonstrated a survival benefit for patients with advanced disease. Conclusions: Recent developments in lymph node management have occurred in penile cancer, such as minimally invasive lymph node diagnosis and intervention strategies. These advances have been met with a degree of controversy in the contemporary literature. Current data suggest that dynamic sentinel lymph node biopsy provides excellent sensitivity and specificity for detecting lymph node metastases. More robust long‐term data on multicenter patient cohorts are required to determine the optimal management of lymph nodes in penile cancer.

Minimally invasive surgical therapies for benign prostatic hypertrophy: The rise in minimally invasive surgical therapies

The prevalence of benign prostatic hypertrophy (BPH) causing bothersome lower urinary tract symptoms increases with our ageing population. Treatment of BPH traditionally begins with medical therapy and surgical intervention is then considered for those whose symptoms progress despite treatment. Minimally invasive surgical therapies have been developed as an intermediary in the treatment of BPH with the aim of decreasing the invasiveness of interventions. These therapies also aim to reduce morbidity and dysfunction related to invasive surgical procedures. Multiple treatment options exist in this group including mechanical and thermo-ablative strategies. Emerging therapies utilizing differing technologies range from the established to the experimental. We review the current literature related to these minimally invasive therapies and the evidence of their effectiveness in treating BPH. The role of minimally invasive surgical therapies in the treatment of BPH is still yet to be strongly defined. Given the experimental nature of many of the modalities, further study is required prior to their recommendation as alternatives to invasive surgical therapy. More mature evidence is required for the analysis of durability of effect of these therapies to make robust conclusions of their effectiveness.

Primary care follow-up of radical prostatectomy patients: A regional New Zealand experience

Background Contemporary recommendations regarding the duration of follow-up after radical prostatectomy (RP) are highly heterogeneous. Protocol-based follow-up schemes have been implemented to facilitate the expeditious identification of patients with recurrence. The aim of this study is to assess the reliability and comfort of general practitioners (GPs) in follow-up of RP. Methods Following institutional ethical approval, we performed a retrospective review in patients undergoing follow-up after RP between January 2004 and December 2010. Patient factors, disease variables, and follow-up prostate specific antigen (PSA) compliance was collected. “Noncompliant” follow-up care was defined as: patients that had not received a PSA for a 14 month period within 5 years of prostatectomy. Patient and disease-based risk factors for noncompliant follow-up were assessed. GPs were also surveyed in their follow-up practice of RP patients, to assess their familiarity in caring for these patients. Results In total, 65 cases were identified that met the inclusion criteria. At 60 months of follow-up, 66% (43/65) of patients had a compliant follow-up regime. For patients with noncompliant follow-up at 60 months, median time of compliance did not differ significantly when assessing preoperative PSA, Gleason sum, extraprostatic extension, or surgical margin status. Of the GPs surveyed, 68% of GPs felt comfortable in follow-up of RP patients. Some 62% of GPs would expect the PSA to be < 0.1 and 25% of GPs would measure the PSA annually. Conclusion Our study identified that follow-up by GPs after RP is insufficient. Accordingly, there is a requirement for formal educational programs if primary care is to take a greater role in follow-up of these patients.

Management of men with previous negative prostate biopsy.

Purpose of review Up to 70% of prostate biopsies are negative in men with suspected prostate cancer. Because of inherent limitations in biopsy strategies, a significant proportion of cancers are missed on initial biopsy. Following negative biopsy, men frequently exhibit persistently elevated prostate-specific antigen – raising concerns for missed diagnosis. We highlight the recent updates in the management of negative prostate biopsy. Recent findings Advances in noninvasive diagnostics are available and assist clinicians in further substratifying risk of prostate cancer. Despite limited data, urinary prostate cancer antigen 3 and transmembrane protease serine 2 appear to have a promising predictive value for patients suspected of prostate cancer. The advent of multiparametricMRI allows the visualization of intermediate and high-grade prostate cancer, particularly in the troublesome anterior prostate. This modality may further provide the potential for magnetic resonance-guided targeted biopsies. Current data suggest that in the presence of suspicious radiological findings, magnetic resonance-guided biopsies have superior sensitivity profiles compared with traditional rebiopsy approaches. In the absence of multiparametricMRI or suspicious findings, traditional saturation biopsies are sufficient. Summary The management of negative biopsies is evolving rapidly with emerging diagnostics to stratify risk of prostate cancer in men with previous negative biopsies. An increasing body of information supports the use of magnetic resonance-guided biopsies.

Collaboration Through Communication: The Young Urology Researchers Organisation (YURO).

Young Urology Researchers Organisation (YURO) Todd G. Manning*, Daniel Christidis*, Paul Zotov and Nathan Lawrentschuk* *Department of Surgery, Austin Health, University of Melbourne, Young Urology Researchers Organisation (YURO), Department of Surgery, Alfred Health, Department of Surgical Oncology, Peter MacCallum Cancer Centre, and Olivia Newton John Cancer Research Institute, Melbourne, Vic., Australia

Three dimensional models in uro-oncology: a future built with additive fabrication

PurposeThree-dimensional (3D) printing was invented in 1983 but has only just begun to influence medicine and surgery. Conversion of digital images into physical models demonstrates promise to revolutionize multiple domains of surgery. In the field of uro-oncology, researchers and clinicians have recognized the potential of this technology and are working towards making it an integral part of urological practice. We review current literature regarding 3D printing and other 3D technology in the field of urology.MethodA comprehensive assessment of contemporary literature was performed according to a modified PRISMA analysis for the purposes of this narrative review article. Medical databases that were searched included: Web of Science, EMBASE and Cochrane databases. Articles assessed were limited only to English-language peer-reviewed articles published between 1980 and 2017. The search terms used were “3D”, “3-dimensional”, “printing”, “printing technology”, “urology”, “surgery”. Acceptable articles were reviewed and incorporated for their merit and relevance with preference given for articles with high impact, original research and recent advances.ResultsThirty-five publications were included in final analysis and discussion.ConclusionsThe area of 3D printing in Urology shows promising results, but further research is required and cost reduction must occur before clinicians fully embrace its use. As costs continue to decline and diversity of materials continues to expand, research and clinical utilization will increase. Recent advances have demonstrated the potential of this technology in the realms of education and surgical optimization. The generation of personalized organs using 3D printing scaffolding remains the ‘holy grail’ of this technology.

“Plug and Play”: a novel technique utilising existing technology to get the most out of the robot

We describe a simple technique in which current and freely available technology can be utilised by surgeons while operating the Da Vinci Si/Xi Surgical Robotic systems. This technique allows for a parallel intraoperative display within the surgical console of any desired subject material from a standard computer, utilising commercially available cabling. The ability to view 3D reconstructed images, patient radiology and patient results within the console whilst operating, has the potential to increase operative efficiency, reduce error and aid in adequate resection of tissues. The ease with which our technique is achieved, the benefits of its use and the low cost associated with its implementation support our suggestion that all robotic surgeons incorporate this into their regular operative setup.

Contemporary Accuracy of Digital Abdominal X-Ray for Follow-Up of Pure Calcium Urolithiasis: Is There Still a Role?

Radiological imaging remains the cornerstone of follow-up of patients with urolithiasis. Plain abdominal X-ray (XRKUB) of these patients is largely becoming obsolete in favor of noncontrast computed tomography of the abdomen and pelvis (CTKUB), which offers superior sensitivity and specificity. Contentiousness exists, however, related to the radiation doses associated with CT. Calcium oxalate remains the most common stone composition across most populations. These calculi are radiopaque and thus follow-up with XRKUB may be appropriate in some settings, avoiding the higher radiation doses associated with standard protocol CT. With the emergence of low-dose CT, however, and the modest accuracy of XRKUB, the ongoing role for XRKUB in the management of urolithiasis is debatable. In this study, we assessed the proportion of pure calcium urolithiasis visible on XRKUB to assess the utility of XRKUB for follow-up of pure calcium urolithiasis. Hospital laboratory databases were analysed to identify patients who had undergone urological intervention and extraction of urolithiasis composed of pure calcium salts, who had undergone CTKUB and XRKUB during the same episode for diagnosis of the calculus. One hundred five calculi were included and the imaging for each patient analyzed. 79/105 calculi (75%) identified on CT were visible on XRKUB. The median calculus visible on XRKUB was 7.0 mm (interquartile range [IQR] 5.0-10.0 mm), the median calculus not seen was 4.25 mm (IQR 3.5-7.0 mm) as measured on CT (p < 0.01). XRKUB accuracy varied according to calculus position within the renal tract. Calculi were most often visible in the renal pelvis and proximal ureter (86%), 50% of mid-ureteral and 72% of distal ureteral calculi were visible (p = 0.01). Until low-dose CT protocols become widely adopted, XRKUB still has a limited role in the management of pure calcium urolithiasis in selected patients. Due to its modest accuracy in many settings, this role is limited mainly to larger proximal urolithiasis.

Urological Society of Australia and New Zealand's alignment with the BJU International: a collaborative success magnified by a supplement journal

Introduction Urologists, like any specialists within their field, consistently strive for the highest standards of clinical and research practice. Dissemination of clinical outcomes, basic research and ideas, both locally and internationally, through publications helps achieve this goal. The USANZ, recognising this, moved its official publication from the bi-nationally based ANZ Journal of Surgery (ANZJS) to the BJU International (BJUI) in 2009 [1]. This move consolidated an affiliation which started in 2005, when the BJUI became the journal used for publishing abstracts of the USANZ National Scientific Meeting [2]. The BJU International Australia and New Zealand Supplement was created as a platform for publications from USANZ members and trainees, with the first edition published in 2011 [3]. To date, there have been six editions of this supplement, which almost solely publishes the work of Australian and New Zealand authors, promoting their international exposure.