Surgery (RMH) - Research Publications

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    Case of the Month from Peter MacCallum Cancer Centre, Melbourne, Australia: ICG-assisted robotic Boari flap ureteric reimplantation in a case of missed ureteric injury
    Chen, K ; Lawrentschuk, N (Wiley, 2023-01)
    Itroductrion: Iatrogenic ureteric injuries are not uncommon, with reported incidences ranging from 0.5% to as high as 11.8% in some studies [1-3]. The mechanism of injury varies widely from intraluminal perforations resulting from endourology procedures to diathermy and ligation injuries in abdominopelvic operations [4, 5]. Regardless of aetiology, the management of iatrogenic ureteric injuries is challenging and requires various considerations to ensure optimal outcomes. In this BJUI Case of the Month, a patient with a missed ureteric injury following an emergency Hartmann's procedure is presented and discussed.
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    Salvage irreversible electroporation for radio-recurrent prostate cancer - the prospective FIRE trial
    Blazevski, A ; Geboers, B ; Scheltema, MJ ; Gondoputro, W ; Doan, P ; Katelaris, A ; Agrawal, S ; Baretto, D ; Matthews, J ; Haynes, A-M ; Delprado, W ; Shnier, R ; van den Bos, W ; Thompson, JE ; Lawrentschuk, N ; Stricker, PD (Wiley, 2023-06)
    OBJECTIVES: To prospectively assess the safety, functional- and oncological-outcomes of irreversible electroporation (IRE) as salvage therapy for radio-recurrent focal prostate cancer in a multicenter setting. PATIENTS AND METHODS: Men with focal recurrent PCa after external beam radiation or brachytherapy without metastatic disease on staging imaging and co-registration between mpMRI and biopsies were prospectively included in this multicenter trial. Adverse events were reported following the Clavien-Dindo classification. Validated questionnaires were used for patient-reported functional outcomes. Follow-up consisted of 3 monthly prostate specific antigen (PSA) levels, a 6-month mpMRI and standardised transperineal template mapping biopsies at 12-months. Thereafter follow-up was guided by MRI and/or PSMA-PET/CT and PSA. Local recurrence was defined as any ISUP score ≥2 on biopsies. RESULTS: 37 patients were analysed with a median (interquartile range (IQR)) follow up of 29 (22-43) months. Median age was 71 (53-83), median PSA was 3.5 ng/mL (2.7-6.1). 28 (75.5%) patients harboured intermediate risk and 9 patients (24.5%) high risk PCa. Seven patients (19%) reported self-limiting urgency, frequency, or hematuria (grade 1-2). Seven patients (19%) developed a grade 3 AE; urethral sludge requiring transurethral resection. At 12 months post treatment 93% of patients remained continent and erectile function sufficient for intercourse deteriorated from 35% to 15% (4/27). Local control was achieved in 29 patients (78%) and 27 patients (73%) were clear of local and systemic disease. Four (11%) patients had local recurrence only. Six (16%) patients developed metastatic disease with a median time to metastasis of 8 months. CONCLUSION: The FIRE trial shows that salvage IRE after failed radiation therapy for localised PCa is safe with minimal toxicity, and promising functional and oncological outcomes. Salvage IRE can offer a possible solution for notoriously difficult to manage radio recurrent prostate tumours.
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    How prostate-specific membrane antigen positron emission tomography is refining risk calculators in the primary prostate diagnostic pathway
    Ptasznik, G ; Kelly, BD ; Murphy, D ; Lawrentschuk, N ; Kasivisvanathan, V ; Page, M ; Ong, S ; Moon, D (WILEY, 2024-02)
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    Synchronous vs independent reading of prostate-specific membrane antigen positron emission tomography (PSMA-PET) and magnetic resonance imaging (MRI) to improve diagnosis of prostate cancer
    Doan, P ; Counter, W ; Papa, N ; Sheehan-Dare, G ; Ho, B ; Lee, J ; Liu, V ; Thompson, JE ; Agrawal, S ; Roberts, MJ ; Buteau, J ; Hofman, MS ; Moon, D ; Lawrentschuk, N ; Murphy, D ; Stricker, PD ; Emmett, L (Wiley, 2023-05-01)
    Objectives: To identify whether synchronous reading of multiparametric magnetic resonance imaging (mpMRI) and 68Ga-PSMA-11 positron emission tomography (PET)/computed tomography (prostate-specific membrane antigen [PSMA-PET]) images can improve diagnostic performance and certainty compared with mpMRI/PSMA-PET reported independently and synthesized, while also assessing concordance between imaging modalities and agreement with histopathology. Methods: This was a retrospective analysis of 100 patients randomly selected from the PRIMARY trial, a prospective Phase II multicentre imaging trial. Three dual-trained radiologist/nuclear medicine physicians re-reported the mpMRI and PSMA-PET both independently and synchronously for the same patients in random order, blinded to previous results. Diagnostic performance was assessed for mpMRI/PSMA-PET images read synchronously or independently and then synthesized. Agreement between imaging results and histopathology was examined. ‘Concordance’ between imaging modalities was defined as overlapping lesions. Reporting certainty was evaluated by the individual reporters for each modality. Results: International Society of Urological Pathology Grade Group ≥2 cancer was present in 60% of patients on biopsy. Synchronous reading of mpMRI/PSMA-PET increased sensitivity compared to mpMRI or PSMA-PET alone (93% vs 80% vs 88%, respectively), although specificity was not improved (63% vs 58% vs 78%, respectively). No significant difference in diagnostic performance was noted between mpMRI/PSMA-PET read synchronously and mpMRI or PSMA-PET reported independently and then synthesized. Most patients had concordant imaging (60%), while others had discordant lesions only (28%) or a mixture (concordant and discordant lesions; 12%). When mpMRI/PSMA-PET findings were concordant and positive, 95% of patients had clinically significant prostate cancer (csPCa). When PSMA-PET alone was compared to synchronous PSMA-PET/MRI reads, there was an improvement in reader certainty in 20% of scans. Conclusion: Synchronous mpMRI/PSMA-PET reading improves reader certainty and sensitivity for csPCa compared to mpMRI or PSMA-PET alone. However, synthesizing the results of independently read PSMA-PET and mpMRI reports provided similar diagnostic performance to synchronous PSMA-PET/MRI reads. This may provide greater flexibility for urologists in terms of referral patterns, reducing healthcare system costs and improving efficiencies in prostate cancer diagnosis.
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    Sustainability in urology - are we doing enough?
    Lawrentschuk, N (Wiley, 2024-02)
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    'Case of the Month' from Epworth Healthcare, Epworth, Australia: Fournier's gangrene following routine surgery
    Huang, S ; Chen, DC ; Mirabelli, AG ; Donato, R ; Pham, T ; Duong, C ; Lawrentschuk, N (WILEY, 2023-12-18)
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    The CONFIRM trial protocol: the utility of prostate-specific membrane antigen positron emission tomography/computed tomography in active surveillance for prostate cancer
    Bagguley, D ; Harewood, L ; McKenzie, D ; Ptasznik, G ; Ong, S ; Chengodu, T ; Woon, D ; Sim, K ; Sheldon, J ; Lawrentschuk, N (WILEY, 2023-10-30)
    OBJECTIVES: Primary objectives: To determine the additive value of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) in the risk stratification of men with newly diagnosed prostate cancer (PCa) who would have otherwise been deemed suitable for active surveillance (AS). Specifically, we aim to determine if PSMA PET/CT can detect a cohort of men on AS that are in fact high risk and likely to experience unfavourable outcomes should they remain on their current treatment pathway. SECONDARY OBJECTIVES: to determine the additive value of PSMA PET/CT to repeat multiparametric magnetic resonance imaging (mpMRI) of the prostate and explore whether a confirmatory biopsy may be avoided in men with a negative PSMA PET/CT and a negative repeat mpMRI of the prostate (Prostate Imaging-Reporting and Data System score of <3). Furthermore, to develop a nomogram combining clinical, imaging and biomarker data to predict the likelihood of failure on AS in men with high-risk features. Also, a blood sample will be taken to perform a Prostate Health Index test at the time of confirmatory biopsy. Furthermore, a portion of this blood will be stored at a biobank for up to 5 years if a follow-up study on molecular biomarkers and genetic assays in this cohort of men is indicated, based on the results from the CONFIRM trial. PATIENTS AND METHODS: The CONFIRM trial is a prospective, multicentre, pre-test/post-test, cohort study across Victoria, Australia, involving men with newly diagnosed low-risk PCa with high-risk features, considered suitable for AS and undergoing confirmatory biopsy. The trial's goal is to provide high-quality evidence to establish whether PSMA PET/CT has a role in risk-stratifying men deemed suitable for AS despite having high-risk feature(s). RESULTS: The CONFIRM trial will measure the proportion of men deemed unsuitable for ongoing AS based on pathological upgrading and multidisciplinary team recommendation due to PSMA PET/CT scan and PSMA-targeted confirmatory biopsy. Additionally, the positive and negative predictive values, sensitivity, and specificity of PSMA PET/CT will be calculated in isolation and combined with repeat mpMRI of the prostate. CONCLUSIONS: This trial will provide robust prospective data to determine if PSMA-PET/CT and standard of care (prostate biopsy ± repeat mpMRI) can improve diagnostic certainty in men undergoing confirmatory biopsy for low-grade PCa with high-risk features.
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    Active surveillance versus enzalutamide for low-risk prostate cancer - was it really a trial we needed?
    Williams, ISC ; Perera, S ; Murphy, DG ; Corcoran, NM ; Bolton, DM ; Lawrentschuk, N (WILEY, 2022-11)
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    Low-grade prostate cancer should still be labelled cancer Comment
    Iczkowski, KA ; Molina, M ; Egevad, L ; Bostwick, DG ; van Leenders, GJLH ; La Rosa, FG ; van der Kwast, T ; Berney, DM ; Evans, AJ ; Wheeler, TM ; Leite, KRM ; Samaratunga, H ; Srigley, J ; Varma, M ; Tsuzuki, T ; Lucia, MS ; Crawford, ED ; Harris, RG ; Stricker, P ; Lawrentschuk, N ; Woo, HH ; Fleshner, NE ; Shore, ND ; Yaxley, J ; Bratt, O ; Wiklund, P ; Roberts, M ; Cheng, L ; Delahunt, B (WILEY, 2022-12)