Comparing outcomes of transperineal to transrectal prostate biopsies performed under local anaesthesia.

Objectives: To compare and review the outcomes of transperineal (TP) prostate biopsies with transrectal (TR) biopsies performed under local anaesthesia (LA). A review of the relevant published literature is presented. Patients and methods: We prospectively analysed 212 consecutive patients who underwent TP prostate biopsy using the PrecisionPoint™ access system under LA, at our institution from October 2018 to March 2020. We compared the morbidity and cancer detection rates using this approach with our historical cohort of 178 patients who underwent the TR biopsy method under LA. Results: The mean age of the TP biopsy group was 69 years, and median prostate specific antigen (PSA) was 13.17 ng/ml. Mean prostate volume was 45.1 ml with a median of 12 cores taken per patient. Patient demographics were similar to our TR biopsy cohort, with mean age of 68 years, median PSA of 10.76, mean prostate volume of 49.6 ml and a median of 12 cores taken per patient. The TP biopsy group had 0% sepsis rate compared with 2.2% in the TR group. Haematuria in the TP versus transrectal ultrasonography (TRUS) cohort was 0.9% versus 1.7%, respectively. The TP biopsy-naïve group had a cancer detection rate of 63.5% (127 of 200 patients), of which 84% were ≥Grade Group 2 (GG2). The TR biopsy-naïve group had cancer detection rate of 50% (86 of 172 patients), of which 87.2% was ≥GG2. Conclusion: TP prostate biopsy had less urinary infectious and septic complications compared with the TR approach. Our data suggest at least comparable diagnostic accuracy between both biopsy approaches.

Transitioning to robotic partial nephrectomy with a team-based proctorship achieves the desired improved outcomes over open and laparoscopic partial nephrectomy.

Proctoring may facilitate a safe transition to robotic-assisted partial nephrectomy (RAPN) for centres performing open (OPN) and laparoscopic partial nephrectomies (LPN). This study compared the 5-year outcomes of RAPN, initiated with a team-based proctorship, with OPN and LPN. Following an observation course at the proctor's institution and a 3-surgeon performance of proctored RAPN in August 2014, a review of 90 RAPN, 29 LPN and 43 OPN consecutively performed by the same team from 2013 to 2019 at National University Hospital, Singapore was conducted. Peri-operative data, functional and oncological outcomes were compared amongst the three groups. Most cases were performed robotically after 2015 with comparable baseline characteristics in all groups. Median RENAL Nephrometry Score was not significantly different between RAPN (8 [IQR 6, 9]) and OPN (9 [IQR 7, 10]) (P = 0.12) but was significantly lower for LPN (7 [IQR 5, 8]) compared to RAPN (P = 0.002). RAPN achieved the lowest blood loss (226 ml vs.348 ml and 263 ml for OPN and LPN respectively, P = 0.02), transfusion rate (3% vs.21% and 17% respectively, P = 0.003) and median length of stay after surgery (4 vs.6 and 5 days respectively, P = 0.001). Complication rates, warm ischemic times were similar between the three approaches with no differences in 1-year and long-term renal function. The rate of positive surgical margin was 8%, 8% and 3% for RAPN, LPN and OPN, respectively (P = 0.76), with a single recurrence in each arm. Despite modest hospital volume, a team-based proctorship facilitated the transition to the Da Vinci robotic platform to perform partial nephrectomies of equivalent complexities as open surgery, achieving improved perioperative outcomes, while maintaining oncological and kidney functional results.

Implementation of a Ureteric Colic Telemedicine Service: A Mixed Methods Quality Improvement Study.

OBJECTIVE: To assess the effectiveness of a telemedicine service for ureteric colic patients in reducing the number of unnecessary face-to-face consultations and shortening waiting time for appointments. METHODS: A telemedicine workflow was implemented as a quality improvement study using the Plan-Do-Study-Act method. All patients presenting with ureteric colic without high-risk features of fever, severe pain, and hydronephrosis, were recruited, and face-to-face appointments to review scan results were replaced with phone consultations. Data were prospectively collected over 3 years (January 2017 to December 2019). Patient outcomes including the reduction in face-to-face review visits, time to review, reattendance and intervention rates, were tracked in an interrupted time-series analysis, and qualitative feedback was obtained from patients and clinicians. RESULTS: Around 53.2% of patients presenting with ureteric colic were recruited into the telemedicine workflow. A total of 465 patients (46.2%) had normal scan results and 250 patients (24.9%) did not attend their scan appointments, hence reducing the number of face-to-face consultations by 71.1%. A total of 230 patients (22.9%) required subsequent follow-up with urology, while 61 patients (6.1%) were referred to other specialties. Mean (SD) time to review was 30.0 (6.2) days, 6-month intervention rate was 3.4% (n = 34) and unplanned reattendance rate was 3.2% (n = 32). Around 93.1% of patients reported satisfaction with the service. CONCLUSION: The ureteric colic telemedicine service successfully and sustainably reduced the number of face-to-face consultations and time to review without compromising on patient safety. The availability of this telemedicine service has become even more important in helping us provide care to patients with ureteric colic in the current COVID-19 pandemic.

A Multicentre Evaluation of the Role of the Prostate Health Index (PHI) in Regions with Differing Prevalence of Prostate Cancer: Adjustment of PHI Reference Ranges is Needed for European and Asian Settings.

Asians have a lower incidence of prostate cancer (PC). We compared the performance of the Prostate Health Index (PHI) for 2488 men in different ethnic groups (1688 Asian and 800 European men from 9 sites) with PSA 2-20ng/ml and PHI test and transrectal ultrasound-guided biopsy results available. Of these, 1652 men had PSA 2-10ng/ml and a normal digital rectal examination and underwent initial biopsy. The proportions of PC (Gleason ≥6) and higher-grade PC (HGPC, Gleason ≥7) across different PHI ranges were compared. The performance of PSA and PHI was compared using the area under the receiver operating characteristic curve (AUC) and decision curve analyses (DCA). Among Asian men, HGPC would be diagnosed in 1.0%, 1.9%, 13%, and 30% of men using PHI thresholds of <25, 25-35, 35-55, and >55, respectively. At 90% sensitivity for HGPC (PHI >30), 56% of biopsies and 33% of Gleason 6 PC diagnoses could have been avoided. Among European men, HGPC would be diagnosed in 4.1%, 4.3%, 30%, and 34% of men using PHI thresholds of <25, 25-35, 35-55, and >55, respectively. At 90% sensitivity for HGPC (PHI >40), 40% of biopsies and 31% of Gleason 6 PC diagnoses could have been avoided. AUC and DCA confirmed the benefit of PHI over PSA. The benefit of PHI was also seen at repeat biopsy (n=397) and for PSA 10-20ng/ml (n=439). PHI is effective in cancer risk stratification for both European and Asian men. However, population-specific PHI reference ranges should be used. PATIENT SUMMARY: The Prostate Health Index (PHI) blood test helps to identify individuals at higher risk of prostate cancer among Asian and European men, and could significantly reduce unnecessary biopsies and overdiagnosis of prostate cancer. Different PHI reference ranges should be used for different ethnic groups.

Robotic kidney autotransplantation in a porcine model: a procedure-specific training platform for the simulation of robotic intracorporeal vascular anastomosis.

Robotic-assisted kidney transplantation (RKT) with the Da Vinci (Intuitive, USA) platform has been recently developed to improve outcomes by decreasing surgical site complications and morbidity, especially in obese patients. This potential paradigm shift in the surgical technique of kidney transplantation is performed in only a few centers. For wider adoption of this high stake complex operation, we aimed to develop a procedure-specific simulation platform in a porcine model for the training of robotic intracorporeal vascular anastomosis and evaluating vascular anastomoses patency. This paper describes the requirements and steps developed for the above training purpose. Over a series of four animal ethics' approved experiments, the technique of robotic-assisted laparoscopic autotransplantation of the kidney was developed in Amsterdam live pigs (60-70 kg). The surgery was based around the vascular anastomosis technique described by Menon et al. This non-survival porcine training model is targeted at transplant surgeons with robotic surgery experience. Under general anesthesia, each pig was placed in lateral decubitus position with the placement of one robotic camera port, two robotic 8 mm ports and one assistant port. Robotic docking over the pig posteriorly was performed. The training platform involved the following procedural steps. First, ipsilateral iliac vessel dissection was performed. Second, robotic-assisted laparoscopic donor nephrectomy was performed with in situ perfusion of the kidney with cold Hartmann's solution prior to complete division of the hilar vessels, ureter and kidney mobilization. Thirdly, the kidney was either kept in situ for orthotopic autotransplantation or mobilized to the pelvis and orientated for the vascular anastomosis, which was performed end to end or end to side after vessel loop clamping of the iliac vessels, respectively, using 6/0 Gore-Tex sutures. Following autotransplantation and release of vessel loops, perfusion of the graft was assessed using intraoperative indocyanine green imaging and monitoring urine output after unclamping. This training platform demonstrates adequate face and content validity. With practice, arterial anastomotic time could be improved, showing its construct validity. This porcine training model can be useful in providing training for robotic intracorporeal vascular anastomosis and may facilitate confident translation into a transplant human recipient.

Prospective validation of %p2PSA and the Prostate Health Index, in prostate cancer detection in initial prostate biopsies of Asian men, with total PSA 4-10 ng ml-1.

Despite its widespread use for prostate cancer screening, low specificity makes PSA a suboptimal biomarker, especially in the diagnostic "gray zone" of 4-10 ng ml-1 . False-positives lead to unnecessary biopsies with attendant morbidities. This is the first prospective validation study of %p2PSA and the Prostate Health Index (PHI) in Asian men presenting with a total PSA between 4.0 and 10 ng ml-1 . We studied 157 Asian men between 50 and 75 years old, with normal per rectal prostate examinations, undergoing their first prostate biopsy, using a standardized biopsy protocol, for PSA levels of 4-10 ng ml-1 . Thirty (19.1%) were found to have prostate cancer on biopsy. Statistically significant differences between patients with and without prostate cancer were found for total PSA, p2PSA, %p2PSA, and PHI. The areas under the curve of the receiver operating characteristic curve for total PSA, %fPSA, %p2PSA, and PHI were 0.479, 0.420, 0.695, and 0.794, respectively. PHI predicts prostatic biopsies results best. At a sensitivity of 90%, the specificity (95% CI) of PHI was 58.3%, more than triple the specificity of total PSA at 17.3%, potentially avoiding 77 (49%) unnecessary biopsies. Similar to studies in mainly Caucasian populations, we have prospectively shown that %p2PSA and PHI greatly outperform total and free to total PSA ratio, in the detection of prostate cancer at first biopsy. Higher PHI levels also correspond to increasing the risk of detecting GS ≥7 cancers. We have validated the use of PHI to aid decision-making regarding prostate biopsies in Asian men with serum PSA between 4 and 10 ng ml-1 .

Preoperative Renal Volume: A Surrogate Measure for Radical Nephrectomy-Induced Chronic Kidney Disease.

OBJECTIVES: Surgically induced chronic kidney disease (CKD) has been found to have less impact on survival as well as function when compared to medical causes for CKD. The aim of this study is to evaluate whether preoperative remaining kidney volume correlates with renal function after nephrectomy, which represents an individual's renal reserve before surgically induced CKD. METHODS: A retrospective review of 75 consecutive patients (29.3% females) who underwent radical nephrectomy (RN) (2000-2010) was performed. Normal side kidney parenchyma, excluding renal vessels and central sinus fat, was manually outlined in each transverse slice of CT image and multiplied by slice thickness to calculate volume. Estimated glomerular filtration rate (eGFR) was determined using the Modification of Diet in Renal Disease equation. CKD is defined as eGFR < 60 mL/min/1.73 m(2). RESULTS: Mean preoperative normal kidney parenchymal volume (mean age 55 [SD 13] years) is 150.7 (SD 36.4) mL. Over median follow-up of 36 months postsurgery, progression to CKD occurred in 42.6% (n = 32) of patients. On multivariable analysis, preoperative eGFR and preoperative renal volume <144 mL are independent predictors for postoperative CKD. On Kaplan-Meier analysis, median time to reach CKD postnephrectomy is 12.7 (range 0.03-43.66) months for renal volume <144 mL but not achieved if renal volume is >144 mL. CONCLUSIONS: Normal kidney parenchymal volume and preoperative eGFR are independent predictive factors for postoperative CKD after RN and may represent renal reserve for both surgically and medically induced CKD, respectively. Preoperative remaining kidney volume may be an adjunct representation of renal reserve postsurgery and predict later renal function decline due to perioperative loss of nephrons.

Postoperative risk of chronic kidney disease in radical nephrectomy and donor nephrectomy patients: a comparison and analysis of predictive factors.

INTRODUCTION: To compare baseline renal function and identify predictive factors in patients undergoing radical nephrectomy (RN) or donor nephrectomy (DN) and their risk of subsequent chronic kidney disease (CKD) after surgery. MATERIALS AND METHODS: A retrospective review of patients with no baseline CKD undergoing RN (n = 88) and DN (n = 58) from 2000 to 2008 was performed. Baseline and postoperative renal function (eGFR) was determined using the Modification of Diet in Renal Disease (MDRD) formula. CKD was defined as eGFR < 60 mL/min/1.73 m2 according to the National Kidney Foundation guidelines. RESULTS: Before surgery, patients undergoing RN and DN had a mean eGFR (+/- SD) of 83.5 +/- 17.4 and 92.9 +/- 17.0 mL/min/1.73 m2 respectively (p = 0.002). Patients with RN had significantly greater morbidities including hypertension (47.7%), diabetes (14.8%) and ischemic heart disease (12.5%) than DN (5.2%, 0% and 1.7% respectively) (all p < 0.05). Median follow up was 3.5 years. The relative hazard of developing CKD post RN compared with DN was 1.91 (95% CI 1.01 to 3.61, p = 0.040). The median time to CKD was 77 months (range 2-107) for RN and 100 months (range 11-105) for DN. Age, gender, comorbidities, radical nephrectomy and baseline kidney function were individual risk factors for CKD post nephrectomy. However, preoperative eGFR was the only independent prognostic factor on multi-variable analysis. CONCLUSIONS: Patients undergoing RN are distinctly different from kidney donors in terms of age, renal function and comorbidities. RN is not an independent predictive factor for CKD but the lower baseline renal function in RN patients significantly accelerates renal senescence in the uninephrectomy state.

Impact of Kidney Disease Outcomes Quality Initiative guidelines on the prevalence of chronic kidney disease after living donor nephrectomy.

PURPOSE: We evaluated the prevalence of chronic kidney disease stage 3 or worse based on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines after living kidney donation at a single institution. MATERIALS AND METHODS: The collected data of 86 consecutive patients who underwent uneventful donor nephrectomy between 1987 and 2008 were evaluated retrospectively. Estimated glomerular filtration rate was determined using the Modification of Diet in Renal Disease from serum creatinine levels collected before and after surgery in kidney donor followup clinics. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 ml/minute/1.73 m(2) according to the Kidney Disease Outcomes Quality Initiative guidelines. Cox regression analyses were then used to determine the impact of predictors on the development of chronic kidney disease. RESULTS: All donors (mean age 41.2, SD 9.9 years) had a mean preoperative estimated glomerular filtration rate of 88.7 ml/min/1.73 m(2) (SD 16.3). Median followup was 6.4 years (range 0.9 to 21.0). Progression to stage 3 or worse chronic kidney disease was seen in 24.4% (95% CI 15.2-33.7) of patients. There were 2 patient deaths secondary to cancer and none required dialysis. Multivariable analysis showed that preoperative estimated glomerular filtration rate less than 82 ml/minute/1.73 m(2) was an independent risk factor for post-donation chronic kidney disease. For every 1 ml/minute/1.73 m(2) increase in baseline estimated glomerular filtration rate, the hazard of postoperative chronic kidney disease was reduced by 7% (HR 0.93, 95% CI 0.89-0.97, p = 0.001). CONCLUSIONS: Kidney Disease Outcomes Quality Initiative stage 3 chronic kidney disease or worse occurs in 24.4% of kidney donors. Long-term prospective studies and closer followup of donors are needed to identify its implications, given the associated risk of cardiovascular diseases with chronic kidney disease in the general population.

Treatment of a patient with post-TURP hemorrhage using bilateral SAPE.

BACKGROUND: A 74-year-old man developed severe, life-threatening bleeding refractory to endoscopic fulguration from a prostatic capsular perforation while undergoing transurethral resection of prostate (TURP) for complicated benign prostatic hyperplasia. At the time of the procedure the patient had several comorbidities, including hypertension and associated nephropathy, and erectile dysfunction. INVESTIGATIONS: CT angiography and pelvic arteriography. DIAGNOSIS: Post-TURP arterial hemorrhage refractory to conventional methods of hemostasis, complicated by TURP syndrome and disseminated intravascular coagulopathy. MANAGEMENT: Bilateral selective arterial prostatic embolization, after endoscopic hemostasis and continuous catheter balloon traction failed to stop the hemorrhage.

A case of adult acute idiopathic scrotal edema.

BACKGROUND: A 40-year-old man presented to a hospital emergency department with acute-onset, bilateral, painless swelling of the scrotum, which had developed progressively over the previous 12 h. He was physically well with no remarkable medical history, and was not taking any medication. He had no history of allergies or trauma (including insect bites to the genitalia), no urinary symptoms, and was not sexually active. INVESTIGATIONS: Physical examination, assessment of erythrocyte sedimentation rate, white blood cell count, renal function panel, urine microscopic analysis, urine cultures, transillumination, and scrotal ultrasonography. DIAGNOSIS: Acute idiopathic scrotal edema. MANAGEMENT: The patient received expectant management and treatment with an NSAID to relieve his inflammation. He was discharged from hospital and his symptoms resolved within 72 h of onset of treatment.

Necrotizing fasciitis after laparoscopic colonic surgery: case report and review of the literature.

A 67-year-old woman, with a past medical history of diabetes mellitus and hypertension, underwent an elective laparoscopic anterior resection for sigmoid colon adenocarcinoma. She was readmitted on the tenth postoperative day with complaints of abdominal pain and a foul smelling discharge from her abdominal wound. She was later diagnosed with necrotizing fasciitis (NF) over the extraction wound. To our knowledge there has only been one other case of NF after laparoscopic colonic surgery reported in the literature. We reviewed the literature on NF after laparoscopic surgery, and discussed the clinical diagnosis; diagnostic adjuncts such as magnetic resonance imaging, bedside exploration under local anesthesia, frozen section of deep incisional biopsies, and laboratory tests; and management principles of NF. Although there is a low incidence of wound infections associated with laparoscopic colonic surgery, necrotizing infections although rare, are a very real possibility.

Health-related quality of life in thyroid cancer survivors.

OBJECTIVE: The study objective was to study the impact of the diagnosis, treatment, and follow-up of differentiated thyroid cancer (DTC) on the quality of life and related issues in an urban multi-ethnic Asian population. DESIGN: A self-administered questionnaire containing the Short Form 36 Health Survey (SF-36) and assessing sociodemographic, disease, and treatment-related status was mailed to patients with DTC. MAIN OUTCOMES: One hundred fifty-two (52.4%) of 290 patients answered the questionnaire. There was a statistically significant decrease in SF-36 scores between thyroid cancer survivors and the general population in all domains except for social functioning (SF). Physical functioning (PF) was worse in those survivors who were aged 50 years or older. Mental health (MH) scores were better in those who had more than 12 years of formal education. Being employed had a positive influence on role physical (RP) and role emotional (RE) scores. Being of Malay/Indian ethnicity strongly correlated with lower scores in bodily pain (BP), SF, RE and MH domains. CONCLUSION: Although most patients with well-differentiated thyroid cancer have near normal life expectancy, our study has shown that there is a significant decrease in their quality of life, especially in the elderly and poorer educated. Returning to work should be encouraged to improve the quality of life in DTC survivors.

Accuracy of fine needle aspiration cytology and frozen section histopathology for lesions of the major salivary glands.

INTRODUCTION: Identifying malignancy either preoperatively or intraoperatively can have a significant impact on the management of salivary gland tumours. We review our experience with fine needle aspiration cytology (FNAC) and frozen section (FS) for salivary gland lesions. We analyse the accuracy of both modalities and their influence on management. MATERIALS AND METHODS: Retrospective review of 114 patients who underwent salivary gland surgery, 91 with intraoperative FS and 68 with preoperative FNAC. Both sets of results were compared against each other and the final histopathological diagnosis. RESULTS: The accuracy of FS was 92.3%, with a sensitivity and specificity of 62.5% and 100%. Histologic concordance was 92.4% for benign lesions, and 100% for malignant tumours. The accuracy of FNAC was 89.7%, with a sensitivity and specificity of 100%. The non-diagnostic rate was 10.3%. Histologic concordance for FNAC was inferior to that for FS, with only 64.2% of benign lesions and 50% of malignant tumours correctly identified. FNAC did not alter the management of benign disease even when a correct diagnosis was obtained. CONCLUSION: Our results suggest that FNAC and FS are complementary in usefulness for malignant tumours. However, FNAC does not influence the management of benign lesions and routine FNAC for every patient may not be cost-effective.