Surgery (RMH) - Research Publications
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ItemStrategies for success: a multi-institutional study on robot-assisted partial nephrectomy for complex renal lesions(WILEY, 2018-05)OBJECTIVE: To describe our technique, illustrated with images and videos, of robot-assisted partial nephrectomy (RAPN) for challenging renal tumours. PATIENTS AND METHODS: A study of 249 patients who underwent RAPN in multiple institutions was performed. Patients were identified using prospective RAPN databases. Complex renal lesion were defined as those with a RENAL nephrometry score ≥10. Data were analysed and differences among groups examined. RESULTS: A total of 31 (12.4%) RAPNs were performed for complex renal tumours. The median (interquartile range [IQR]) patient age was 57 (50.5-70.5) years and 21 patients (67.7%) were men. The median (IQR) American Society of Anesthesiologists score was 2 (2-3). The median (IQR) operating time was 200 (50-265) min, warm ischaemia time was 23 (18.5-29) min, and estimated blood loss was 200 (50-265) mL. There were no intra-operative complications. Two patients (6.4%) had postoperative complications. One patient (3.2%) had a positive surgical margin. The median (IQR) length of stay was 3.5 (3-5) days and the median (IQR) follow-up was 12.5 (7-24) months. There were no recurrences. RAPN resulted in statistically significant changes in renal function 3 months after RAPN compared with preoperative renal function (P < 0.001). CONCLUSION: Our results showed that RAPN was a safe approach for selected patients with complex renal tumours and may facilitate tumour resection and renorrhaphy for challenging cases, offering a minimally invasive surgical option for patients who may otherwise require open surgery.
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ItemQuality of handwritten surgical operative notes from surgical trainees: a noteworthy issue(WILEY, 2019-03)BACKGROUND: Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico-legal ramifications. Further, well-documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met. METHOD: We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors and surgical trainees in a tertiary teaching hospital over a month period both in 2014 and 2015. Individual operative notes were assessed for quality based on parameters described by the Royal College of Surgeons of England guidelines. RESULTS: Based on the Royal College of Surgeons of England guidelines, a significant proportion of analysed surgical operative notes were incomplete, with information pertaining to the time of surgery, name of anaesthetist and deep vein thrombosis prophylaxis in particular being recorded less than 50% of the time (22.42, 36.36 and 43.03%, respectively).Overall, 80% compliance was achieved in 14/20 standards and 100% compliance was attained in only one standard. CONCLUSIONS: The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.
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ItemSurvival outcomes in elderly men undergoing radical prostatectomy in Australia(WILEY, 2018-03)BACKGROUND: To investigate the outcomes of patients older than 75 years of age in Victoria undergoing radical prostatectomy for prostate cancer. METHODS: Data on all men undergoing radical prostatectomy in Victoria between 1 January 2004 and 31 December 2014 were obtained from the Victorian Cancer Registry. Tumour characteristics including Gleason grade, stage of disease and cause of death were obtained. Statistical analysis was performed using chi-squared test, Cox proportional hazards method and Kaplan-Meier analysis. RESULTS: A total of 14 686 men underwent radical prostatectomy during the defined period, with a median follow-up of 58 months. Of these, 332 were men over the age of 75. All parameters are comparisons between patients >75 years of age and men <75 years of age. Men >75 years had a higher proportion of Gleason grade ≥8 disease (16.6% versus 11.4%, P < 0.001) but had similar stage of disease. Men >75 years had lower rates of 5- and 10-year overall survival (67.3% versus 96.3% and 27.7% versus 89.1%) and lower rates of 5- and 10-year prostate cancer-specific survival (96.2% versus 99.3% and 94.3% versus 97.4%), respectively. Age was an independent risk factor for prostate cancer specific and overall mortality on multivariate analysis (hazard ratio 1.49, 95% confidence interval 1.32-1.68; P < 0.001 and hazard ratio 4.26, 95% confidence interval 2.15-8.42; P < 0.001), when adjusted for stage and grade. CONCLUSION: Older men undergoing radical prostatectomy in Victoria had higher-grade disease but similar stage. Age was an independent risk factor for worse prostate cancer-specific and overall survival.
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ItemChanging face of robot-assisted radical prostatectomy in Melbourne over 12 years(WILEY, 2018-03)BACKGROUND: This study aims to characterize the trends in disease presentation for robot-assisted radical prostatectomy (RARP) over a 12-year period in Melbourne, Australia. METHODS: All patients undergoing an RARP between 2004 and October 2016 while under the care of six high-volume surgeons were included in this study. Data were collected prospectively regarding patient demographics and clinical details of their cancer. RESULTS: Over the 12-year time span of the study, 3075 men underwent an RARP with a median age of 63.01 years. Temporal analysis demonstrated that the median age of patients undergoing prostatectomy advanced with time with the median age in 2016 being 65.51 years compared with 61.0 years in 2004 (P < 0.001). There was also a significant trend to increased D'Amico risk groups over time with the percentage procedures for high-risk patients increasing from 12.6% to 28.10% from 2004 to 2016 (P < 0.001). Upgrade rates between biopsy and pathological Gleason grade scoring significantly trended down over the period of the study (P < 0.001). There was also a shift to increased pathological stage over the 12 years with 22.1% of men having T3 disease in 2004 compared with 49.8% in 2016. CONCLUSION: Our analysis demonstrates increasing treatment of older men with higher risk tumours, consistent with international trends. While this largely reflects a shift in case selection, further work is needed to assess whether the stage shift may relate partially to a decline in screening and increased presentation of higher risk disease.
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ItemTrends in the surgical treatment of benign prostatic hyperplasia in a tertiary hospital(WILEY, 2018-01)BACKGROUND: To assess current treatment trends and perioperative outcomes of transurethral resection of the prostate (TURP) and photoselective vaporization of the prostate (PVP) in a tertiary institution. METHODS: We prospectively collected a database of all patients undergoing TURP and PVP for benign prostatic hyperplasia (BPH) at a tertiary hospital between January 2011 and December 2013. Patient characteristics such as length of stay, readmission, anticoagulation status, American Society of Anesthesiologists (ASA) score and need for blood transfusion were recorded and analysed. RESULTS: In total, 560 cases were included: 204 (36.4%) underwent TURP and 356 (63.6%) PVP. Patients undergoing PVP had higher ASA scores (P < 0.001) and were more frequently on continuing anticoagulant therapy (P < 0.001). With regards to non-aspirin/asasantin coagulation therapy, 61 (17.1%) patients underwent PVP with their anticoagulants continued while no patients who received TURP continued anticoagulation. Blood transfusion percentages were similar at 1.0% for TURP and 1.7% for PVP but readmission proportions were higher after PVP (32 patients, 9.0%) compared to TURP (10 patients, 4.9%). These differences were attenuated when excluding patients continuing anticoagulation during the procedure. CONCLUSION: At our institution, the use of PVP has been increasing on a year-by-year basis. The results of the current study demonstrated that PVP is safe in patients with increased anaesthetic risk or on active anticoagulation when compared to traditional TURP. While this makes PVP an attractive alternative to TURP in high-risk anticoagulated patients, these patients may have complex post-discharge issues that should be addressed during the informed consent process.
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ItemUrology trial success - get urologists involved early(WILEY, 2019-11)
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ItemProstate-specific membrane antigen-positron emission tomography/computed tomography (PSMA-PET/CT)-guided stereotactic ablative body radiotherapy for oligometastatic prostate cancer: a single-institution experience and review of the published literature(WILEY, 2019-11)OBJECTIVES: To report the outcomes of stereotactic ablative body radiotherapy (SABR) in men with oligometastatic prostate cancer (PCa) diagnosed on prostate-specific membrane antigen (PSMA)-positron emission tomography/computed tomography (PET/CT), based on a single-institution experience and the published literature. PATIENTS AND METHODS: This was a retrospective cohort study of the first 20 consecutive men with oligometastatic PCa, treated with SABR in a single institution, who had biochemical recurrence after previous curative treatment (surgery/radiotherapy), had no evidence of local recurrence, were not on palliative androgen deprivation therapy (ADT), and had PSMA-PET/CT-confirmed oligometastatic disease (≤3 lesions). These men were treated with SABR to a dose of 30 Gy in three fractions for bone metastases, and 35-40 Gy in five fractions for nodal metastases. The outcomes of interest were: PSA response; local progression-free survival (LPFS); distant progression-free survival (DPFS); and ADT-free survival (ADTFS). A literature review was performed to identify published studies reporting on outcomes of PSMA-PET/CT-guided SABR. RESULTS: In our institutional cohort, 12 men (60%) had a decline in PSA post-SABR. One man had local progression 9.6 months post-SABR, with 12-month LPFS of 93%. Ten men had distant progression outside of their SABR treatment field, confirmed on PSMA-PET/CT, with 12-month DPFS of 62%, of whom four were treated with palliative ADT, two received prostate bed radiotherapy for prostate bed progression (confirmed on magnetic resonance imaging), and four received a further course of SABR (of whom one had further progression and was treated with palliative ADT). At last follow-up, six men (one with local progression and five with distant progression) had received palliative ADT. The 12-month ADTFS was 70%. Men with longer intervals between local curative treatment and SABR had better DPFS (P = 0.03) and ADTFS (P = 0.005). Four additional studies reporting on PSMA-PET/CT-guided SABR for oligometastatic PCa were identified and included in the review, giving a total of 346 patients. PSA decline was reported in 60-70% of men post-SABR. The 2-year LPFS, DPFS and ADTFS rates were 76-100%, 27-52%, and 58-62%, respectively. CONCLUSION: Our results showed that PSMA-PET/CT could have an important role in identifying men with true oligometastatic PCa who would benefit the most from metastases-directed therapy with SABR.
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ItemNational Speakers(WILEY, 2019-07)
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ItemFactors associated with spontaneous stone passage in a contemporary cohort of patients presenting with acute ureteric colic: results from the Multi-centre cohort study evaluating the role of Inflammatory Markers In patients presenting with acute ureteric Colic (MIMIC) study(WILEY, 2019-09)OBJECTIVES: To assess the relationship of white blood cell count (WBC) and other routinely collected inflammatory and clinical markers including stone size, stone position, and medical expulsive therapy use (MET), with spontaneous stone passage (SSP) in a large contemporary cohort of patients with acute ureteric colic, as there are conflicting data on the role of WBC and other inflammatory markers in SSP in patients with acute ureteric colic. PATIENTS AND METHODS: Multicentre retrospective cohort study coordinated by the British Urology Researchers in Surgical Training (BURST) Research Collaborative at 71 secondary care hospitals across four countries (UK, Republic of Ireland, Australia, and New Zealand). In all, 4170 patients presented with acute ureteric colic and a computed tomography confirmed single ureteric stone. Our primary outcome measure was SSP, as defined by the absence of need for intervention to assist stone passage (SP). Multivariable mixed effects logistic regression was used to explore the relationship between key patient factors and SSP. RESULTS: In all, 2518 patients were discharged with conservative management and had further follow-up with a SSP rate of 74% (n = 1874/2518). Sepsis after discharge with conservative management was reported in 0.6% (n = 16/2518). On multivariable analysis neither WBC, neutrophils count, nor C-reactive protein (CRP) predicted SSP, with an adjusted odds ratio (OR) of 0.97 (95% confidence interval [CI] 0.91-1.04, P = 0.38), 1.06 (95% CI 0.99-1.13, P = 0.1) and 1.00 (95% CI 0.99-1.00, P = 0.17), respectively. MET also did not predict SSP (adjusted OR 1.11, 95% CI 0.76-1.61). However, stone size and stone position were significant predictors. SSP for stones <5 mm was 89% (95% CI 87-90) compared to 49% (95% CI 44-53) for stones ≥5-7 mm, and 29% (95% CI 23-36) for stones >7 mm. For stones in the upper ureter the SSP rate was 52% (95% CI 48-56), middle ureter was 70% (95% CI 64-76), and lower ureter was 83% (95% CI 81-85). CONCLUSION: In contrast to the previously published literature, we found that in patients with acute ureteric colic who are discharged with initial conservative management neither WBC, neutrophil count, nor CRP, helps determine the likelihood of SSP. We also found no overall benefit from the use of MET. Stone size and position are important predictors and our present findings represent the most comprehensive SP rates for each millimetre increase in stone size from a large contemporary cohort adjusting for key potential confounders. We anticipate that these data will aid clinicians managing patients with acute ureteric colic and help guide management decisions and the need for intervention.