Surgery (Austin & Northern Health) - 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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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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ItemProspective analysis of hydrogel spacer for patients with prostate cancer undergoing radiotherapy(WILEY, 2018-09)OBJECTIVE: To report on the dosimetric benefits and late toxicity outcomes after injection of hydrogel spacer (HS) between the prostate and rectum for patients treated with prostate radiotherapy (RT). PATIENTS AND METHODS: In all, 76 patients with a clinical stage of T1-T3a prostate cancer underwent general anaesthesia for fiducial marker insertion plus injection of the HS into the perirectal space before intensity-modulated RT (IMRT) or volumetric-modulated arc RT (VMAT). HS safety, dosimetric benefits, and the immediate- to long-term effects of gastrointestinal (GI) toxicity were assessed. RESULTS: There were no postoperative complications reported. The mean (range) prostate size was 66.0 (25.0-187.0) mm. Rectal dose volume parameters were observed and the volume of rectum receiving 70 Gy (rV70 ), 75 Gy (rV75 ) and 78 Gy (rV78 ) was 7.8%, 3.6% and 0.4%, respectively. In all, 21% of patients (16/76) developed acute Grade 1 GI toxicities, but all were resolved completely by 3 months after treatment; whilst, 3% of patients (2/76) developed late Grade 1 GI toxicities. No patients had acute or late Grade ≥2 GI toxicities. CONCLUSION: Injection of HS resulted in a reduction of irradiated rectal dose volumes along with minimal GI toxicities, irrespective of prostate size.
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ItemSingle-use disposable digital flexible ureteroscopes: an ex vivo assessment and cost analysis(WILEY, 2018-05)OBJECTIVE: To assess and measure the capability of a single-use disposable digital flexible ureteroscope, the LithoVue™ (Boston Scientific, Marlborough, MA, USA), and to assess if there is a benefit to switching to single-use scopes. PATIENTS AND METHODS: The LithoVue was compared to two commonly used reusable flexible ureteroscopes (Olympus URF-V [Olympus, Tokyo, Japan] and Karl Storz Flex-Xc [Karl Storz & Co. KG, Tuttlingen, Germany]) ex vivo. An analysis of reusable ureteroscope usage was performed to evaluate damage, durability, and maintenance costs. This was then compared to the projected costs of using single-use disposable scopes. RESULTS: Flexion, deflection and irrigation flow of the LithoVue was equivalent, if not better than the reusable flexible ureteroscopes. An analysis of 234 procedures with seven new Olympus URF-V scopes, revealed 15 scope damages. Staghorn stones and lower pole/mid-zone stones were significant risk factors for damage (P = 0.014). Once damage occurred it was likely to occur again. Total repair costs were $162 628 (Australian dollars) (£92 411 in Great British pounds), the mean cost per case was $695 (£395). Factoring in the purchase cost, cleaning and repair costs, the cumulative cost of 28 reusable flexible ureteroscopy procedures was ~$50 000 (£28 412). If the LithoVue was priced at $1 200 (£682), switching to a single-use scope would cost ~$35 000 (£19 888). CONCLUSION: The LithoVue is analogous to reusable flexible ureteroscopes in regard to standard technical metrics. Depending on its purchase cost it may also represent a cost saving for hospitals when compared to the cumulative costs of maintaining reusable scopes. Additionally, urologist may consider using the scope in cases in which reusable scope damage is anticipated.
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ItemExploring pathways towards improving patient experience of robot-assisted radical prostatectomy (RARP): assessing patient satisfaction and attitudes(WILEY, 2018-05)OBJECTIVE: To determine patient satisfaction and experience after robot-assisted radical prostatectomy (RARP) for prostate cancer, using a convergent mixed-method qualitative analysis approach. PATIENTS AND METHODS: 412 patients who underwent RARP between January 2014 and June 2016 were mailed questionnaires and invited to participate in focus groups. Qualitative data was thematically analysed using NVivo. Descriptive statistics were obtained from the questionnaire using SPSS. RESULTS: 214 patients responded (52% of sample size) of whom 97.6% were satisfied and 91.1% would likely recommend RARP. Key themes from the qualitative data highlighted the psychosocial impacts of the diagnosis and RARP process. The importance of early recovery, the benefits of pelvic floor exercises and educational resources were emphasised. CONCLUSION: Patients were overwhelmingly satisfied with RARP, largely due to relevance and timeliness of the information and support provided both before and after surgery. With an increased understanding of the factors and outcomes that are most important to patients regarding all aspects of hospital care, we can create more targeted care pathways. Key themes will help inform the implementation of an enhanced recovery after surgery (ERAS) protocol to further improve recovery and early return to function.
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ItemRadiotherapy-related complications presenting to a urology department: a more common problem than previously thought?(WILEY, 2018-05)OBJECTIVE: To quantify the burden of the side effects of radiotherapy on a tertiary referral urology department. PATIENTS AND METHODS: A prospective study of all urology admissions to a public urology department at a tertiary hospital in a 6-month period was performed. Patients admitted with complications attributable to radiotherapy were included in the study. Data obtained included patient demographics, radiotherapy details, complication type and management required. RESULTS: A total of 1198 patients were admitted; 921 (77%) were elective and 277 (23%) were emergency admissions. Thirteen out of the 921 (1.4%) elective admissions and 20 out of the 277 (7.2%) emergency admissions were attributable to radiotherapy complications. Radiotherapy complications was the fourth most common reason for emergency admission, ahead of acute urinary retention. These 33 admissions were accounted for by 21 patients. A total of 39 separate complications attributable to radiotherapy were diagnosed, with some patients having multiple complications. The median (interquartile range) time to onset of complications was 4 (1-9) years. The surgical intervention rate was 67%. The commonest procedures were washout with/without clot evacuation or diathermy in theatre (15.8%) and urethral dilatation/bladder neck incision (15.8%). Two urinary diversions and two cystoprostatectomies plus urinary diversion were performed. CONCLUSION: Radiotherapy complications are consequential and account for a substantial proportion of a tertiary urology department's emergency workload. These complications generally occur years after radiotherapy and frequently require surgical intervention.
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ItemMachine learning to support social media empowered patients in cancer care and cancer treatment decisions(PUBLIC LIBRARY SCIENCE, 2018-10-18)BACKGROUND: A primary variant of social media, online support groups (OSG) extend beyond the standard definition to incorporate a dimension of advice, support and guidance for patients. OSG are complementary, yet significant adjunct to patient journeys. Machine learning and natural language processing techniques can be applied to these large volumes of unstructured text discussions accumulated in OSG for intelligent extraction of patient-reported demographics, behaviours, decisions, treatment, side effects and expressions of emotions. New insights from the fusion and synthesis of such diverse patient-reported information, as expressed throughout the patient journey from diagnosis to treatment and recovery, can contribute towards informed decision-making on personalized healthcare delivery and the development of healthcare policy guidelines. METHODS AND FINDINGS: We have designed and developed an artificial intelligence based analytics framework using machine learning and natural language processing techniques for intelligent analysis and automated aggregation of patient information and interaction trajectories in online support groups. Alongside the social interactions aspect, patient behaviours, decisions, demographics, clinical factors, emotions, as subsequently expressed over time, are extracted and analysed. More specifically, we utilised this platform to investigate the impact of online social influences on the intimate decision scenario of selecting a treatment type, recovery after treatment, side effects and emotions expressed over time, using prostate cancer as a model. Results manifest the three major decision-making behaviours among patients, Paternalistic group, Autonomous group and Shared group. Furthermore, each group demonstrated diverse behaviours in post-decision discussions on clinical outcomes, advice and expressions of emotion during the twelve months following treatment. Over time, the transition of patients from information and emotional support seeking behaviours to providers of information and emotional support to other patients was also observed. CONCLUSIONS: Findings from this study are a rigorous indication of the expectations of social media empowered patients, their potential for individualised decision-making, clinical and emotional needs. The increasing popularity of OSG further confirms that it is timely for clinicians to consider patient voices as expressed in OSG. We have successfully demonstrated that the proposed platform can be utilised to investigate, analyse and derive actionable insights from patient-reported information on prostate cancer, in support of patient focused healthcare delivery. The platform can be extended and applied just as effectively to any other medical condition.
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ItemSurvival outcomes of younger men (< 55 years) undergoing radical prostatectomy(ELSEVIER INC, 2018-03)BACKGROUND: The aim of the paper is to investigate the outcomes of patients younger than 55 years in Victoria, Australia undergoing radical prostatectomy (RP) for prostate cancer. MATERIALS AND METHODS: Data on all men undergoing RP in Victoria between January 1, 2004 and December 31, 2014 were obtained from the Victorian Cancer Registry. Tumor characteristics including Gleason grade, stage of disease (based on final pathology specimen), and cause of death were also obtained. Statistical analysis was performed using Chi-square test, Cox proportional hazards method, and Kaplan-Meier analysis. RESULTS: A total of 14,686 men underwent RP during the defined period. Of these men 109 were aged 35-44 years and 1,998 were aged 45-54 years. Men aged 35-44 years and 45-54 years were compared against men aged 55-74 years. The majority of men between the ages of 35 years and 44 years, and 45 years and 54 years had higher rates of Gleason ≤ 7 disease compared with men aged between 55 years and 74 years (92.7% vs. 86.8% vs. 79.3%; P < 0.01) and ≤ T2 disease (82.6% vs. 75.6% vs. 49.9%; P < 0.01) but similar median prostate-specific antigen values. On a multivariate analysis adjusting for Gleason score, T stage, and prostate-specific antigen, men aged 45-54 years and 55-64 years had 67% and 46% increase in overall survival, respectively, compared to men aged 65-74 years; but these differences were not seen in the 35-44 year age group. There were no differences in prostate cancer specific deaths between the groups. The 5- and 10-year overall survival outcomes were both higher for men aged 45-54 years compared to mean aged 55-74 years (97.9% vs. 95.9% and 94.9% vs. 85.3). CONCLUSION: Men aged 45-54 years undergoing RP had better overall survival compared to men aged 55-74 years, but these effects were not seen in men aged 35-44 years. There were no differences in prostate cancer specific survival in these groups.
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ItemReporting and ideal testosterone levels in men undergoing androgen deprivation for prostate cancer-time for a rethink?(ELSEVIER INC, 2018-03)BACKGROUND: This study aims to review current laboratory reporting strategies across Australia and New Zealand with a view to propose a more useful template for reporting serum testosterone in the context of prostate cancer. MATERIALS AND METHODS: Registered pathology laboratories in Australia and New Zealand were enrolled into the current study. An electronic or a phone survey was utilized to collect data from each participating laboratory. Obtained information included assay utilized, units reported, reference intervals, lowest reported value, and lowest detectable value. To identify recommendations for testosterone testing, a systematic search was performed across Web of Science (including MEDLINE), EMBASE, and Cochrane libraries. RESULTS: Assessment of national pathology laboratories identified significant heterogeneity in the reporting methods. Reports typically used a "normal healthy male of 35 years of age" as a comparator but did not refer to optimal castrate levels, the lowest level that their assay was able to detect, nor did they include appended clinical guidelines relating to the prostate cancer patient cohort. CONCLUSIONS: Across Australia and New Zealand, various methods for testing and reporting serum testosterone exist, while international guidelines remain vague. The fashion in which serum testosterone levels are displayed should be re-evaluated to address the relevant clinical population and reflect an agreed-upon castrate threshold in patients undergoing androgen deprivation therapy.