Risk of secondary malignancy following radiation therapy for prostate cancer.

We investigated whether prostate cancer patients treated with external beam radiation therapy (EBRT) have a higher cumulative incidence of secondary cancer compared with patients treated with radical prostatectomy (RP). We used state-wide linked data from South Australia to follow men with prostate cancer diagnosed from 2002 to 2019. The cumulative incidence of overall and site-specific secondary cancers between 5 and 15 years after treatment was estimated. Fine-Gray competing risk analyses were performed with additional sensitivity analyses to test different scenarios. A total of 7625 patients were included (54% underwent RP and 46% EBRT). Characteristics of the two groups differed significantly, with the EBRT group being older (71 vs. 64 years), having higher comorbidity burden and being more likely to die during follow-up than the RP group. Fifteen-year cumulative incidence for all secondary cancers was 27.4% and 22.3% in EBRT and RP groups, respectively. In the adjusted models, patients in the EBRT group had a significantly higher risk of genitourinary (adjusted subhazard ratio (aSHR), 2.29; 95%CI 1.16-4.51) and lung (aSHR, 1.93; 95%CI 1.05-3.56) cancers compared with patients in the RP group. However, there was no statistically significant difference between the two groups for risk of any secondary cancer, gastro-intestinal, skin or haematologic cancers. No statistically significant differences in overall risk of secondary cancer were observed in any of the sensitivity analyses and patterns for risk at specific cancer sites were relatively consistent across different age restriction and latency/time-lag scenarios. In conclusion, the increased risk of genitourinary and lung cancers among men undergoing EBRT may relate partly to treatment effects and partly to unmeasured residual confounding.

PCNL in neurogenic bladder: A challenging population for both clinical management and analysis.

Objectives: To review the management of patients with neurogenic bladder undergoing percutaneous nephrolithotomy (PCNL) at our institution with the aim of assessing peri-operative morbidity. Subjects/patients and methods: We conducted a retrospective review of all neurogenic bladder patients who underwent PCNL at our hospital in the last decade with the aim of assessing peri-operative morbidity. Results: A total of 298 PCNL were performed during the study period of which 58 were in patients with a neurogenic bladder or urinary diversion, 33 of which were in SCI patients. Preoperative demographic and stone characteristics, intraoperative data and postoperative length of stay and complications are summarised in table form. Conclusion: PCNL remains an acceptably safe and efficacious treatment for upper tract stone disease in patients with neurogenic bladders and will continue to have a valuable role where SCI prevents alternative approaches such as ureteroscopy.

Long term genitourinary toxicity following curative intent intensity-modulated radiotherapy for prostate cancer: a systematic review and meta-analysis.

BACKGROUND: Recent studies have shown that radiation-induced pelvic toxicity often requires urological consultation. However, the 10-year incidence of genitourinary toxicity following intensity-modulated radiotherapy (IMRT) amongst patients with localised prostate cancer remains unclear. Hence, we conducted a systematic review and meta-analysis to determine the incidence of late genitourinary toxicity relying on Radiation Therapy Oncology Group (RTOG) and Common Terminology Criteria for Adverse Events (CTCAE) grade as well as the incidence of specific genitourinary toxicity. Secondary objectives involved quantifing the number of studies reporting 120-month follow-up endpoints, time to event analysis, predictive factors or economic evaluation. METHODS: Articles published from January 2008 to December 2021 describing prospective studies were systematically searched in MEDLINE, EMBASE and Cochrane (PROSPERO protocol CRD42019133320). Quality assessment was performed by use of the Cochrane Risk of Bias 2 Tool for RCTs and the Newcastle Ottowa Scale for non-RCTs. Meta-analysis was performed on the 60-month incidence of RTOG and CTCAE Grade ≥2 genitourinary toxicity, haematuria, urinary retention and urinary incontinence. RESULTS: We screened 4721 studies and six studies met our inclusion criteria. All included studies involved normofractionation, three included a hypofractionation comparator arm and none involved nodal irradiation. The pooled 60-month cumulative incidence of RTOG and CTCAE Grade ≥2 genitourinary toxicity were 17% (95% CI: 5-20%, n = 678) and 33% (95% CI: 27-38%, n = 153), respectively. The pooled 60-month cumulative incidence of Haematuria was 5% (95% CI: -4-14%, n = 48), Urinary incontinence 12% (95% CI: 6-18%, n = 194), Urinary retention 24% (95% CI: 9-40%, n = 10). One study reported time to event analyses, one reported predictive factors, no studies reported economic analysis or 120-month toxicity. There was considerable heterogeneity amongst the studies. CONCLUSION: There are few high-quality studies reporting 60-month toxicity rates after IMRT. Conservative estimates of 60-month toxicity rates are high and there is need for longer follow-up and consistent toxicity reporting standards.

Predicting post-radiation genitourinary hospital admissions in patients with localised prostate cancer.

PURPOSE: The risk of treatment-related toxicity is important for patients with localised prostate cancer to consider when deciding between treatment options. We developed a model to predict hospitalisation for radiation-induced genitourinary toxicity based on patient characteristics. METHODS: The prospective South Australian Prostate Cancer Clinical Outcomes registry was used to identify men with localised prostate cancer who underwent curative intent external beam radiotherapy (EBRT) between 1998 and 2019. Multivariable Cox proportional regression was performed. Model discrimination, calibration, internal validation and utility were assessed using C-statistics and area under ROC, calibration plots, bootstrapping, and decision curve analysis, respectively. RESULTS: There were 3,243 patients treated with EBRT included, of which 644 (20%) patients had a treated-related admission. In multivariable analysis, diabetes (HR 1.35, 95% CI 1.13-1.60, p < 0.001), smoking (HR 1.78, 95% CI 1.40-2.12, p < 0.001), and bladder outlet obstruction (BOO) without transurethral resection of prostate (TURP) (HR 7.49, 95% CI 6.18-9.08 p < 0.001) followed by BOO with TURP (HR 4.96, 95% CI 4.10-5.99 p < 0.001) were strong independent predictors of hospitalisation (censor-adjusted c-statistic = 0.80). The model was well-calibrated (AUC = 0.76). The global proportional hazards were met. In internal validation through bootstrapping, the model was reasonably discriminate at five (AUC 0.75) years after radiotherapy. CONCLUSIONS: This is the first study to develop a predictive model for genitourinary toxicity requiring hospitalisation amongst men with prostate cancer treated with EBRT. Patients with localised prostate cancer and concurrent BOO may benefit from TURP before EBRT.

Incidence of genitourinary complications following radiation therapy for localised prostate cancer.

PURPOSE: Studies of genitourinary toxicity following radiotherapy for prostate cancer are mainly from high volume single institutions and the incidence and burden of treatment remain uncertain. Hence we determine the cumulative incidence of treatment-related genitourinary toxicity in patients with localised prostate cancer treated with primary external beam radiotherapy (EBRT) at a state population level. METHODS: We analysed data from a prospective population-based cohort, including hospital admission and cancer registry data, for men with localised prostate cancer who underwent primary EBRT without nodal irradiation between 1998 and 2019 in South Australia. The 10-year cumulative incidence of genitourinary toxicity requiring hospitalisation or procedures was determined. Clinical predictors of toxicity and the volume of admissions, non-operative, minor operative and major operative procedures were determined. RESULTS: All the included patients (n = 3350) had EBRT, with a median (IQR) of 74 Gy (70-78) in 37 fractions (35-39). The 10-year cumulative incidence of was 28.4% (95% CI 26.3-30.6) with a total of 2545 hospital admissions, including 1040 (41%) emergency and 1893 (74%) readmissions. The 10-year cumulative incidence of patients in this cohort requiring a urological operative procedure was 18% (95% CI 16.1-19.9), with a total of 106 (4.2%) non-operative, 1044 (41%) minor operative and 57 (2.2%) major operative urological procedures. CONCLUSIONS: Genitourinary toxicity after radiotherapy for prostate cancer is common. Although there continue to be advancements in radiotherapy techniques, patients and physicians should be aware of the risk of late toxicity when considering EBRT.

A prospective case series of Fournier's gangrene at a tertiary centre involving adjacent organs.

BACKGROUND: Recent studies of patients with Fournier's gangrene (FG) highlight the importance of early surgical intervention in improving mortality rates. We prospectively determined subgroups of patients with FG at high risk of severe local morbidity. METHODS: We prospectively evaluated all patients diagnosed with FG at a tertiary hospital (1 January 2018 to 1 January 2021). Data were collated on demographics, comorbidity, infection source, treatment and clinical outcomes. RESULTS: We identified 14 consecutive male patients with a median (interquartile range) age of 57 (50-64) years. Most common risk factors were diabetes (n = 10, 71%) and obesity (n = 10, 71%). Median (range) HbA1c was 11.20 (7.5-15.3), and body mass index of 41.25 (23.7-70.0). Seven patients had adjacent organ involvement (AOI), involving the corporal bodies (57%) and testes (43%). The most common suspected source was dermatological (50%), followed by genitourinary (29%) and gastrointestinal (GI) (21%). Median (interquartile range) hospital length of stay (LOS) was 32 (8.5-30.75) days. Patients with AOI were more likely to have a suspected GI source, need mechanical ventilation (p = 0.023), a significantly longer LOS (p = 0.015) and time to wound closure (p = 0.04). Patients with suspected dermatological origin of infection, had a significantly lower rate of AOI (p = 0.029), mechanical ventilation (p = 0.029) and a shorter LOS (p = 0.035). CONCLUSION: In our prospective series, FG is associated with a high rate of AOI and suspected non-dermatological origin of infection, which confers significant perioperative morbidity including the need for mechanical ventilation, LOS and longer time from initial debridement to wound closure.

Surgical Locker room Environment: Understanding the Hazards (SLEUTH) study.

BACKGROUND: Anecdotal evidence reveals that medical equipment are easily found in hospital changing rooms. Access to potentially lethal drugs and intravenous access equipment may put vulnerable medical staff at risk. The aims are to quantify the burden of medical equipment found in this environment, calculate the associated cost burden and to raise clinician awareness about a potential health hazard. METHODS: We prospectively collected data on the medical paraphernalia found in surgical changing rooms from one private and two public hospitals in South Australia over 2 months. We systematically searched open surgical lockers, benches and floors in male and female lockers rooms. Item costs were calculated from Imprest and the Pharmacy Department. RESULTS: During the study period, we found a total of 537 items. There were 280 sharps, including 185 scalpels found in one open locker. There were 78 items of intravenous paraphernalia, 38 surgical tapes, 70 bandages and 73 miscellaneous items. In addition, there were six medications found including 3 × 5 mL vials of 1% lignocaine, one vial of lignocaine with adrenaline, one ketorolac suppository and 5 mL fentanyl. There were 529 (98.5%) items within their date of expiry. The total cost of the items was 2358 Australian dollars (AUD), with an estimated annual cost of 14 148 AUD over the three sites and 424 400 AUD over South Australia. CONCLUSION: The burden of available medical supplies found in the theatre changing room is high and worrisome. Strategies for appropriate disposal and safe storage of medical equipment are required.

Does urethral length affect continence outcomes following robot assisted laparoscopic radical prostatectomy (RALP)?

BACKGROUND: Post-operative urinary incontinence is a significant concern for patients choosing to undergo a radical prostatectomy (RP) for treatment of prostate cancer. The aim of our study was to determine the effect of pre-operative MUL on 12 month continence outcomes in men having robot-assisted laparoscopic prostatectomy (RALP). METHODS: We use the South Australian Prostate Cancer Clinical Outcomes Collaborative (SA-PCCOC) database, to identify 602 patients who had undergone RALP by a high volume surgeon. Only patients who received an assessment and education by a specialist pelvic floor physiotherapist, had completed EPIC questionnaires before treatment and did not have radiotherapy treatment within 12 months of surgery were included. MUL measurements were taken from pre-operative magnetic resonance imaging (MRI) scans. The short-form version of the Expanded Prostate Cancer Index Composite (EPIC-26) was used to measure continence outcomes. Continence was defined as 100/100 in the EPIC-26 Urinary Continence domain score. RESULTS: The observed median MUL in this study was 14.6 mm. There was no association between MUL and baseline continence. MUL was associated with continence at 12 months post RALP (OR 1.13, 95% CI 1.03-1.21, p = 0.0098). In men who were continent before surgery, MUL was associated with return to continence at 12 months after RALP (OR 1.15, 1.05-1.28, p = 0.006). MUL was also associated with change in continence after surgery (ß = 1.22, p = 0.002). CONCLUSIONS: MUL had no effect on baseline continence but had a positive and significant association with continence outcomes over 12 months post RALP.

Penile gangrene due to calciphylaxis: a multidisciplinary approach to a complex clinical challenge.

Penile calciphylaxis is a rare but clinically challenging condition to manage. While multiple treatment options have been proposed, the underlying evidence is anecdotal, and the overall prognosis remains extremely poor. We describe the case of a patient who underwent urgent debridement of a suspected gangrenous penile tip, who was intraoperatively found to have penile calciphylaxis. The necrosis progressed and the patient had a glans amputation. A non-healing wound developed, requiring reconstruction with two skin grafts using foreskin by the plastic and reconstructive surgical unit. The patient was commenced on sodium thiosulfate and his wound had completely healed 2 months following his last operation. We review the literature to determine the biochemical features, management options and outcomes in patients with penile calciphylaxis.

Gall bladder torsion: a disease of the elderly.

We describe the case of a gall bladder torsion in an elderly female patient, which was discovered during laparoscopic exploration for presumed acute cholecystitis. The rising incidence of this relatively uncommon process can be attributed to increasing life expectancy. Gall bladder torsion typically manifests in septuagenarians and octogenarians of the female gender, as seen in the presented case. It is thought that local mesenteric redundancy predisposes to the development of mechanical organoaxial torsion along the gall bladder's longitudinal axis involving the cystic duct and artery. Clinicians must have a high index of suspicion for gall bladder torsion, as a mimicker of acute cholecystitis, in the described patient demographic. Preoperative diagnosis is challenging with the vast majority of reported cases being diagnosed intraoperatively, and only five cases preoperatively. Prompt surgical intervention results in an overall mortality rate of approximately 5%, while a delay in diagnosis can lead to catastrophic patient outcomes.

Jim Peters--sportsman, soldier, surgeon.

Jim Peters, a country boy who excelled academically and in the sporting arena was a Victorian urological pioneer. His passion for teaching and belief in the development of Australasian urology resulted in the establishment of two of Melbourne's earliest Urology Units (which are now major academic University departments), the creation of a formal urological training program and the promotion of Australian urology within the International urological community.