Robotic-Assisted Bladder Diverticulectomy: Indications, Technique and Outcomes - a Case Series.

PURPOSE: This case series describes the experience and outcomes of multiple Australian surgeons performing robotic-assisted bladder diverticulectomy (RABD), highlighting the procedural effectiveness and safety, for both benign and malignant indications for diverticulectomy. METHODS: Outcomes were analysed from Thirteen experienced Australian urologists who performed RABD between 2016 and 2023. Retrospective analysis was performed on prospectively collected data which included patient demographics, diverticulum characteristics, surgical approaches, and post-operative outcomes. Surgical techniques included the extravesical and intravesical approaches, with the focus on maintaining oncological principles in cases of malignancy. RESULTS: A total of 28 patients underwent RABD, with the majority being male and a mean age of 63.9 years. All surgeons utilised a four port transperitoneal approach and opted for the extravesical dissection of the diverticular neck, one case utilised both extravesical and a trans-diverticular approach. Functional outcomes demonstrated symptomatic resolution in patients with non-malignant diverticula, while oncological outcomes indicated clear margins in 90% of malignant cases. The average length of the procedure was 106 minutes, with minimal blood loss and a mean hospital stay of 2.67 days. Early complications occurred in 14% with the majority Clavien-Dindo grade II . CONCLUSION: Robotic bladder diverticulectomy, predominantly via the transperitoneal extravesical approach, has emerged as a safe, effective, and reliable surgical intervention for both malignant and non-malignant bladder diverticula. The consistent surgical approach and excellent outcomes demonstrated in this case series reinforce the procedure's potential as a safe option, even in the setting of malignancy within a diverticulum.

Rare case of acute renal failure secondary to Erdheim-Chester disease.

In this report we describe the clinical journey of a 62-year-old male that presented with acute kidney injury secondary to Erdheim-Chester disease, a non-Langerhans variant of histiocytosis rarely encountered by urological surgeons. ECD can uncommonly cause acute renal failure and management includes decompression of the collecting system. A multi-disciplinary approach is required to facilitate adequate investigation to determine the specific ECD subtype and most appropriate treatment options, particularly as the available targeted therapies have only recently been utilised.

Lost and forgotten: A case of intravesical migration of an intrauterine device.

In this report we explore the clinical journey of a female patient that presented with a history of failed contraception and more recently recurrent urinary tract infection (UTI). Renal tract ultrasound was done to investigate the cause of UTI and a bladder calculus was seen. During cystolithotripsy an intrauterine device (IUD) was seen embedded in the calculus. The risk factors for intravesical migration of an IUD are discussed.

Music during flexible cystoscopy for pain and anxiety - a patient-blinded randomised control trial.

OBJECTIVES: To assess the role of music in reducing the pain and anxiety associated with flexible cystoscopy using a blinded trial design. PATIENTS AND METHODS: A patient-blinded randomised control trial of music during flexible cystoscopy was performed comparing the pain, measured by visual analogue scale (VAS), anxiety, measured by the State-Trait Anxiety Inventory (STAI), and vital signs of 109 patients across two public hospitals in New South Wales, Australia. The purpose and hypothesis of the study was concealed from patients until after results had been collected. RESULTS: There were no statistically significant differences detected between the No Music and Music groups in VAS pain score (mean [SD] 2.04 [1.94] vs 2.10 [1.90], P = 0.86), change in STAI anxiety score (mean [SD] 4.87 [9.87] vs 6.8 [11.07], P = 0.33) or post-procedural vital signs (mean [SD] heart rate 74 [14] vs 72 [13] beats/min, P = 0.66; systolic blood pressure 144 [20] vs 141 [19] mmHg, P = 0.47) between the two groups. CONCLUSION: Music does not appear to decrease perceived pain or anxiety when used during flexible cystoscopy. These findings may differ from the literature due to several factors, most significantly blinding of participants, but also potentially due to the ethnic composition of the study population or lack of choice of music.

Necrotising granulomatous mass of the foreskin with inguinal lymphadenopathy: a rare presentation of syphilis.

We report the case of a 24-year-old man who presented with a 5-week history of painful right inguinal lymphadenopathy, weight loss and non-ulcerative foreskin mass. The patient's symptoms progressed despite initial antibiotic therapy. The foreskin mass was clinically suspicious for squamous cell carcinoma; however, histopathology of both the foreskin mass and inguinal lymph node showed necrotising granulomatous inflammation. Extensive immunohistochemistry testing was inconclusive and could not identify a causative microorganism. Ultimately, serology was positive for Treponema pallidum and he was treated with intramuscular benzathine penicillin. This is an unusual case, which highlights the importance of extensive investigation for differential diagnoses of penile mass and exemplifies the resurgence of syphilis in developed countries.

High negative predictive value of 68Ga PSMA PET-CT for local lymph node metastases in high risk primary prostate cancer with histopathological correlation.

BACKGROUND: Current guidelines highlight the importance of accurate staging in the management and prognostication of high risk primary prostate cancer. Conventional radiologic imaging techniques are insufficient to reliably detect lymph node metastases in prostate cancer. Despite promising results, there is limited published data on the diagnostic accuracy of PSMA PET-CT to assess local nodal metastases prior to radical prostatectomy. This study aims to assess the diagnostic efficacy of 68Ga PSMA PET-CT in local lymph node staging of high risk primary prostate cancer when compared to histopathological findings following radical prostatectomy with pelvic lymph node dissection. METHODS: We retrospectively analysed consecutive patients with high risk primary prostate cancer referred by urologists for primary staging PSMA PET-CT using a 68Ga-labeled PSMA ligand, Glu-NH-CO-NHLys-(Ahx)-[HBEDD-CC], from October 2015 to October 2017. The scans of patients who underwent radical prostatectomy with pelvic lymph node dissection were interpreted by the consensus reading of two experienced nuclear medicine physicians blinded to clinical and histopathological data. The contemporaneous records of the referring urologists were retrospectively reviewed for noteworthy unexpected PET findings that altered their personal preference for surgical management. RESULTS: Seventy-one patients were recruited and analysed. PSMA PET-CT showed findings compatible with local disease in 47 patients (66.2%), lymph node metastases in 10 patients (14.1%) and distant metastases in 14 patients (19.7%). Twenty-eight patients (twenty-seven of whom had local disease only) underwent surgery yielding 214 lymph nodes, all of which were negative on histopathological analysis. On a node-based analysis, 213 of 214 lymph nodes were accurately identified as negative for disease with a negative predictive value of 100%. 11 patients had unexpected PET findings contemporaneously documented by urologists to alter their preference for surgical management. CONCLUSIONS: PSMA PET-CT appears to have a high negative predictive value for local lymph node metastases in high risk primary prostate cancer when compared to histopathological findings following radical prostatectomy with pelvic lymph node dissection.

A standardized analysis of the current surgical and non-surgical treatment selection process for men with localized prostate cancer.

Robot-assisted radical prostatectomy to treat localized prostate cancer has increased in popularity, although other options exist, including radiotherapy and active surveillance. The decision about choosing the right treatment has become pertinent for many patients. This literature review aimed to assess the current state-of-the-art regarding decisional aids and the associated decisional outcomes for the purpose of designing a method for both patients and doctors to use to make the best treatment decision for the patient. A literature search was conducted via MEDLINE, Embase, and Web of Science databases using the keywords "prostate" and "cancer" and "impact" and "decisio*" and "treatment." Articles were included that focused on treatment outcomes, decision-making processes, and the use of decisional aids for localized prostate cancer. Articles that investigated prostate cancer in general or prostate cancer screening were excluded, as were articles that were not written in English. Altogether, 13 articles were finally critically reviewed for this study. Results were conflicting regarding the relations between patient factors, use of decisional aids, and decisional outcomes. There was a large gap in the literature regarding the optimal decision-making process for men with localized prostate cancer. The role of currently available decisional aids is limited to helping patients make the right decisions. There is a need to develop a novel decisional aid in which patient-physician discussion-involving evaluation of a spectrum of patient-, doctor-, and treatment-related factors-is included.

A Case Report of Priapism With Unusual Presentation and Clinical Course.

This is a case report on a patient with an unusual presentation and clinical course of priapism. It further discusses treatment options with reflection on current literatures and guidelines. 48 year old patient presented with a history of more than 50 episodes of priapism, each lasting for five minutes. Patient had history of brain tumor that was resected and had since been in remission. On examination and further biochemistry assessment revealed conflicting clinical findings, making it difficult to ascertain the type of priapism in this case. The patient, however, recovered from the acute attacks of priapism after 24 hours of conservative management and no obvious cause had been identified on post-discharge follow-up. Priapism, despite being rare, is a medical emergency. This case report reflected upon the limitations of treatment guidelines and the lack of level one evidence to support treatment decisions.