Routine Ertapenem Prophylaxis for Transrectal Ultrasound Guided Prostate Biopsy does Not Select for Carbapenem Resistant Organisms: A Prospective Cohort Study.

PURPOSE: Sepsis after transrectal ultrasound guided prostate biopsy is an increasing problem in this era of rising antibiotic resistance. Although ertapenem prophylaxis has proved effective at our institution to reduce this, it has raised local and regional antimicrobial stewardship concerns. We investigated the possible selective effect of single dose ertapenem prophylaxis on fecal colonization with carbapenem resistant Enterobacteriaceae. MATERIALS AND METHODS: Patients underwent a rectal swab prior to receiving prebiopsy ertapenem prophylaxis. A second swab was obtained at followup 4 to 6 weeks later. Swabs were screened for carbapenem resistant Enterobacteriaceae using an enhanced CDC (Centers for Disease Control) method. Prebiopsy swabs were also screened for extended spectrum ß-lactamase producing and ciprofloxacin resistant Enterobacteriaceae. Patients were monitored for post-biopsy sepsis. RESULTS: A total of 326 patients were enrolled in the study. At baseline 6.4% and 9.0% of patients had colonization with extended spectrum ß-lactamase producing and ciprofloxacin resistant Enterobacteriaceae, respectively. Carbapenem resistant Enterobacteriaceae were not detected at baseline or followup in any patients. Colonization with nonfermentative organisms with intrinsic ertapenem resistance was detected in 29.4% of patients at baseline and followup (p = 1.0). Three cases (0.9%, 95% CI 0.2-2.8) of probable post-biopsy sepsis were identified during the study period. None was bacteremic or required intensive care unit admission. CONCLUSIONS: Single dose ertapenem prophylaxis did not appear to have a significant selective effect on fecal colonization with carbapenem resistant Enterobacteriaceae or other ertapenem resistant gram-negative organisms in this outpatient group. It is highly effective prophylaxis for transrectal ultrasound guided prostate biopsy. In the right setting ertapenem may represent a useful prophylactic option to prevent post-transrectal ultrasound guided prostate biopsy sepsis.

Does waiting after peri-prostatic nerve block reduce pain during transrectal ultrasound-guided prostate biopsy? A randomized controlled trial.

BACKGROUND: To determine if a short, clinically sufficient and manageable time delay after peri-prostatic nerve block (PNB) reduces pain during transrectal ultrasound (TRUS)-guided prostate biopsy. METHODS: This was a prospective, randomized controlled trial. All patients who underwent TRUS-guided prostate biopsy between February and June 2014 were randomized into waiting or control groups. All biopsies were performed by senior registrars with the same PNB technique. Patients in the waiting group waited 5 min after PNB prior to biopsies. Those in the control group did not. Patients were then asked to complete a questionnaire regarding pain associated with different parts of the procedure and their degree of anxiety using a 10-cm, validated visual analogue scale. Mann-Whitney U tests were performed on the pain and anxiety scores and analysis of variance was conducted using the Statistical Package for the Social Sciences software. RESULTS: A total of 92 patients were randomized to 39 in the waiting group and 53 in the control group. Mean overall pain scores were 2.85 and 2.66 (P = 0.626) for the waiting and control groups, respectively. The mean pain scores from probe insertion, biopsy, before leaving the department and mean anxiety scores were similar between the two groups and did not reach statistical significance. Analysis of variance showed that irrespective of group and age, increasing anxiety is associated with an increase in overall pain score (P < 0.0005). CONCLUSION: Waiting 5 min after PNB did not reduce pain in men undergoing TRUS-guided prostate biopsy.

Surgical waiting time for radical cystectomy: a New Zealand experience.

BACKGROUND: The New Zealand Ministry of Health (MOH) has issued recommendations under the new 'Faster Cancer Treatment Programme' specifically mandating that 'treatment begin within 31 days of a decision being made to have that treatment'. In preparation to plan compliance with these targets and identify delays, the wait-times for radical cystectomy (RC) for bladder cancer at our institution were reviewed. METHODS: Patient data were collected for all patients who underwent radical cystectomy in Wellington Hospital from 2006 to 2013. Three interval periods for RC were defined and reviewed. The cause of delay was assessed. We looked at survival based upon delay periods. RESULTS: There were 43 RC during the study period. The median time from recommendation to RC was 29 days (range 2-97). Seventeen (40%) were outside this time period due to requirement for further medical investigation (n = 7), patient-related factors (n = 3), other speciality input needed (n = 3), scheduling factors (n = 2) and unknown factors (n = 2). CONCLUSION: The median wait-time to RC was 29 days in our institution, within the MOH period. A significant proportion (40%) of patients had a delay of >31 days commonly due to patient factors such as co-morbidities needing additional investigations. A delay of >31 days did not confer a worse survival outcome in this cohort.

Do ethnic patterns in cryptorchidism reflect those found in testicular cancer?

PURPOSE: There are established variations in testicular cancer incidence between ethnic groups within countries. It is currently unclear whether the occurrence of cryptorchidism-a known risk factor for testicular cancer-follows similar patterns. In New Zealand Maori have unusually high rates of testicular cancer compared to individuals of European ancestry. We hypothesized that ethnic trends in the incidence of cryptorchidism would reflect those for testicular cancer in this setting. MATERIALS AND METHODS: We followed 318,441 eligible male neonates born in New Zealand between 2000 and 2010 for the incidence of orchiopexy confirmed cryptorchidism and the incidence of known risk factors for cryptorchidism (low birth weight, short gestation, small size for gestational age) using routine maternity, hospitalization and mortality records. Logistic regression was used to calculate odds ratios for the presence of known risk factors for cryptorchidism by ethnic group. Poisson regression was used to calculate relative risk of cryptorchidism by ethnicity, adjusted for risk factors. RESULTS: Ethnic patterns of cryptorchidism incidence in New Zealand closely mirrored those previously observed for testicular cancer. Maori had higher rates of cryptorchidism than all other ethnic groups (adjusted RR 1.2 [95% CI 1.11-1.3]), with Pacific (0.89 [0.8-0.99]) and Asian groups (0.68 [0.59-0.79]) having the lowest rates (European/other, referent). CONCLUSIONS: Since the principal risk factors for cryptorchidism are present in utero, the results of the current study strengthen the likelihood that the ethnic patterning of testicular cancer is at least partly due to prenatal risk factors.

Unstaged cancer in a population-based registry: prevalence, predictors and patient prognosis.

PURPOSE: Information on cancer stage at diagnosis is critical for population studies investigating cancer care and outcomes. Few studies have examined the factors which impact (1) staging or (2) outcomes for patients who are registered as having unknown stage. This study investigated (1) the prevalence of unknown stage at diagnosis on the New Zealand Cancer Registry (NZCR); (2) explored factors which predict unknown stage; (3) described receipt of surgery and (4) survival outcomes for patients with unknown stage. METHODS: Patients diagnosed with the most prevalent 18 cancers between 2006 and 2008 (N=41,489) were identified from the NZCR, with additional data obtained from mortality and hospitalisation databases. Logistic and Cox regression were used to investigate predictors of unknown stage and patient outcomes. RESULTS: (1) Three distinct groups of cancers were found based on proportion of patients with unknown stage (low=up to 33% unknown stage; moderate=33-64%; high=65%+). (2) Increasing age was a significant predictor of unknown stage (adjusted odds ratios [ORs]: 1.18-1.24 per 5-year increase across groups). Patients with substantive comorbidity were more likely to have unknown stage but only for those cancers with a low (OR=2.65 [2.28-3.09]) or moderate (OR=1.17 [1.03-1.33]) proportion of patients with unknown stage. (3) Patients with unknown stage were significantly less likely to have received definitive surgery than those with local or regional disease across investigated cancers. (4) Patients with unknown stage had 28-day and 1-year survival which was intermediate between regional and distant disease. DISCUSSION: We found that stage completeness differs widely by cancer site. In many cases, the proportion of unknown stage on a population-based register can be explained by patient, service and/or cancer related factors.

Salvage prostatectomy post-definitive radiation therapy: The Vancouver experience.

INTRODUCTION: Prostate cancer recurrence following primary radiation is common. If the recurrence remains localized to the prostate gland, surgical removal may result in long-term local control or cure. Despite the well-established oncological outcomes, salvage prostatectomy is infrequently performed or reported. We present our experience with salvage prostatectomy at a Canadian centre. METHODS: We identified all patients undergoing salvage prostatectomy at the Vancouver General Hospital between 1995 and 2010 from a prospectively recorded and maintained prostate cancer database. Details regarding initial presentation, delivery of radiotherapy, clinical features at the time of recurrence, as well as oncological and functional outcomes, were collected. Information regarding postoperative morbidity was collected prospectively and confirmed by retrospective chart review. RESULTS: Over a 15-year period, salvage prostatectomy was successfully completed in 21 patients. With a median follow-up period of 68 months (range: 2-122), 9 (43%) patients experienced a biochemical recurrence, with most failing within the first 2 years of surgery. There were 3 deaths in the cohort, all from prostate cancer, giving a prostate cancer specific and overall survival of 86%. The main postoperative morbidity was bladder neck contracture, occurring in 40%. One patient each developed a recto-urethral fistula and osteitis pubis. Physician-recorded data regarding continence was available in 13 (62%). Of these 13 patients, 10 (85%) men were recorded as dry or using 1 pad per day. CONCLUSIONS: This is the first Canadian centre to report that salvage prostatectomy can be performed with favourable oncological and functional outcomes.