Surgery (Austin & Northern Health) - Research Publications

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    Vesico-urethral anastomosis sampling: a forgotten tool for guiding salvage radiation after radical prostatectomy
    Timm, B ; Farag, M ; Liodakis, P ; Angus, D ; Joon, DL ; Bolton, D (WILEY, 2021-05-01)
    OBJECTIVE: To review the utility of vesicourethral anastomosis (VUA)-directed biopsy in the setting of biochemical recurrence (BCR) after radical prostatectomy (RP) for prostate cancer (PCa) in patients who have undergone evaluation by gallium-68 prostate-specific membrane antigen positron emission tomography with computed tomography (68 Ga-PSMA PET/CT). METHODS: We completed a retrospective review of a prospectively maintained dataset from January 2015 to August 2020. Patient demographics were recorded for those who experienced BCR, as defined by a rise in prostate-specific antigen (PSA) level to above 0.2 ng/mL, who had a 68 Ga-PSMA PET/CT that did not demonstrate recurrence within the prostate bed, and who subsequently underwent a transperineal ultrasonography (TPUS)-guided biopsy directed at the VUA. Histological reporting of the biopsies was undertaken in order to determine whether the benefits of salvage radiation therapy (SRT) could be justified by the presence of cancer cells. RESULTS: Eighteen patients who had a 68 Ga-PSMA PET/CT and underwent VUA-directed biopsy were identified as having BCR. 68 Ga-PSMA PET/CT scans demonstrated avidity at the VUA in none of the patients, although two out of 18 patients showed avidity in the seminal vesicles and two out of 18 patients showed avidity within regional lymph nodes. Histology from the TPUS-guided, VUA-directed biopsies demonstrated no prostatic tissue in six out of 18 and presence of prostatic tissue in 12 out of 18 of patients, respectively. In 7 out of 18 cases, there was histological evidence of recurrent PCa at the VUA in the absence of a positive 68 Ga-PSMA PET/CT scan. CONCLUSION: This study highlights the potential value of VUA-directed biopsy. We are reminded that a negative 68 Ga-PSMA PET/CT does not exclude local recurrence and that the addition of a VUA-directed biopsy may aid in the decision-making process for patients with BCR following RP, especially when 68 Ga-PSMA PET/CT is locally negative. When the result of both 68 Ga-PSMA PET/CT and VUA-directed biopsy are negative, it should encourage clinicians to share decision-making in regard to undertaking SRT vs continuing BCR surveillance. This may delay the possible side effects associated with SRT, despite its excellent PSA failure-free survival rate.
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    Original Article Impact of delay from transperineal biopsy to radical prostatectomy upon objective measures of cancer control
    Qu, LG ; Jack, G ; Perera, M ; Evans, M ; Evans, S ; Bolton, D ; Papa, N (ELSEVIER SINGAPORE PTE LTD, 2022-04-01)
    Objective: Treatment delays in prostate cancer have been characterised, although not explicitly in men undergoing transperineal prostate biopsies. We aimed to determine if delays to radical prostatectomy correlate with adverse outcomes using a contemporary population-based cohort of men diagnosed by transperineal biopsies. Methods: This study analysed men with prostate cancer of the International Society for Urological Pathology grade group ≥2, diagnosed by transperineal prostate biopsies who underwent prostatectomy, using the prospectively data from 1 January 2014 to 30 June 2018 Prostate Cancer Outcomes Registry-Victoria. Data were analysed according to stratified demographic and disease characteristics. Time intervals from biopsy (28, 60, 90, 120, and 270 days) were compared using odds ratios and regression analyses for proportion of upgrading, early biochemical recurrence, pT3 disease at prostatectomy, and positive surgical margins. Results: In total, 2008 men were analysed. There were 306 (16.7%) men with upgrading, 151 (8.4%) with biochemical recurrence, 1068 (54.1%) with pT3 disease, and 464 (23.1%) with positive surgical margins (percentages excluded patients with missing data). All adverse outcomes studied were significantly associated with higher prostate-specific antigen and grade at diagnosis. Delays of 120-270 days did not adversely alter the incidence of Gleason upgrading, pT3, or recurrence. Delays (most frequent 60-89 days, 28%) were associated with positive surgical margins but not monotonically. Regression modelling demonstrated no increased likelihood of most adverse outcomes for up to 270 days. Conclusion: Men with prostate cancer of grade group ≥2 diagnosed through transperineal biopsy may wait up to 270 days for a prostatectomy without a greater likelihood of upgrading, pT3 disease, positive surgical margins, or biochemical recurrence.
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    Age-Related Mental Health Consequences of COVID-19: A Global Perspective
    de la Rosette, J ; Laguna, P ; Zeng, G ; Coloby, P ; Momesso, A ; Azhar, RA ; Chłosta, P ; Heesakkers, J ; Crişan, N ; Ruiz, L ; Bolton, D ; Gómez, R ; Klotz, L ; Kulkarni, S ; Tanguay, S ; Gravas, S (Societe Internationale dUrologie, 2021-01-18)
    Purpose: The Société Internationale d’Urologie (SIU) conducted a survey to determine whether the pandemic has harmed the mental health of practicing urologists worldwide. Methods: Members of the Executive Board of the SIU designed a self-selected survey consisting of multiple-choice questions about the safety and mental health of urologists during the COVID-19 pandemic. The survey was disseminated by email to SIU members worldwide. Results: A total of 3448 SIU members from 109 countries responded to the survey, which sought to determine the extent of mental health symptoms, including depression, anxiety, insomnia, and distress—experienced during the COVID-19 pandemic. Overall, 21% of urologists who responded reported that their mental health was very challenged, with 58% indicating increased stress levels, and 15% indicating greatly increased stress levels. Older urologists were less likely to report any of the negative mental health symptom queried (ie, delirium [rs = −0.06, P = 0.001], psychosis [rs = −0.04, P = 0.019], anxiety [rs = −0.09, P < 0.001], depression [rs = −0.08, P <.001], distress [rs = −0.07, P < 0.001]), except insomnia (P > 0.20). Furthermore, 29% of urologists indicated they were afraid to go to work, while 53% reported being afraid to go home to their families after work. Conclusion: In this worldwide survey of practicing urologists, more than half of the participants reported an increase in insomnia, distress, and other psychological symptoms as they managed patients during the COVID-19 pandemic, although half of respondents did not experience any mental health symptoms. Institutions should provide psychological coping resources to all health care staff, not only for the front-line workers during the pandemic.
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    Clash of the calculators: External validation of prostate cancer risk calculators in men undergoing mpMRI and transperineal biopsy.
    Wei, G ; Kelly, BD ; Timm, B ; Perera, M ; Lundon, DJ ; Jack, G ; Bolton, DM (Wiley, 2021-05)
    Objective: To compare the accuracy of the European Randomized Study of Screening for Prostate Cancer (ERSPC) RC, MRI-ERSPC-RC, and Prostate Biopsy Collaborative Group (PBCG) RC in patients undergoing transperineal prostate biopsy. Patients and methods: We identified 392 patients who underwent mpMRI before transperineal prostate biopsy across multiple public and private institutions between January 2017 and August 2019. The estimated probabilities of detecting PCa and significant PCa were calculated using the MRI-ERSPC-RC, ERSPC-RC, and PBCG-RC. Receiver operating characteristic (ROC) curves for each calculator were generated and the area underneath the curve (AUC) was compared. Calibration and clinical utility were assessed with calibration plots and decision curve analysis, respectively. Results: PCa was detected in 285 patients (72.7%) with significant PCa found in 200 patients (51.1%). ROC curve analysis found the MRI-ERSPC-RC outperformed the ERSPC-RC and PBCG-RC. For the prediction of PCa, the AUC was 0.756, 0.696, and 0.675 for the MRI-ERSPC-RC, ERSPC-RC, and PBCG-RC, respectively. The AUC for the prediction of significant PCa was 0.803, 0.745, and 0.746 for the MRI-ERSPC-RC, ERSPC-RC, and PBCG-RC, respectively. Conclusions: Our study validated the ERSPC-RC, MRI-ERSPC-RC, and PBCG-RC in a cohort undergoing transperineal prostate biopsy with the MRI-ERSPC-RC performing the best. These RCs may enable improved shared decision making and help to guide patient selection for biopsy.
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    Cribriform pattern disease over-represented in pelvic lymph node metastases identified on 68GA PSMA-PET/CT.
    Bolton, D ; Hong, A ; Papa, N ; Perera, M ; Kelly, B ; Duncan, C ; Clouston, D ; Lawrentschuk, N (Wiley, 2022-09)
    Objectives: To determine whether any specific histologic subtype of prostate cancer was preferentially represented in pelvic lymph node metastases identified on 68GA-PSMA-PET/CT. Subjects and Methods: A consecutive series of 66 men with biochemical recurrent prostate cancer was evaluated with 68GA-PSMA-PET/CT. Where disease was confined to pelvic lymph nodes, patients were offered salvage extended pelvic lymph node dissection. Twenty patients ultimately proceeded to extended bilateral template pelvic lymph node dissection. Lymph node positivity and the histologic subtype of apparent cancer were assessed, as was PSA response to this intervention. Results: Mean PSA at time of PSMA scanning for patients undergoing lymphadenectomy was 2.49 (n = 20, range 0.21-12.0). In 16 of 20 patients, there was evidence of metastatic cribriform pattern prostate cancer in excised nodes (100% cribriform pattern in 11/16). Only four of 20 patients had no evidence of this histologic subtype of disease. PSA response was not related to the presence or proportional amount of cribriform pattern disease identified. Conclusions: Cribriform pattern adenocarcinoma appears to be the histologic subtype preferentially identified in pelvic lymph nodes on 68GA-PSMA-PET/CT. The use of PSMA-PET may be particularly valuable in staging of primary or biochemically recurrent prostate cancer in patients with cribriform pattern disease detected on initial biopsy or radical prostatectomy. Further research is required to further confirm the observed association.
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    3D printed patient-specific prostate cancer models to guide nerve-sparing robot-assisted radical prostatectomy: a systematic review
    Coles-Black, J ; Ong, S ; Teh, J ; Kearns, P ; Ischia, J ; Bolton, D ; Lawrentschuk, N (SPRINGERNATURE, 2022-03-29)
    Precise knowledge of each patient's index cancer and surrounding anatomy is required for nerve-sparing robot-assisted radical prostatectomy (NS-RARP). Complementary to this, 3D printing has proven its utility in improving the visualisation of complex anatomy. This is the first systematic review to critically assess the potential of 3D printed patient-specific prostate cancer models in improving visualisation and the practice of NS-RARP. A literature search of PubMed and OVID Medline databases was performed using the terms "3D Printing", "Robot Assisted Radical Prostatectomy" and related index terms as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eight articles were included; six were identified via database searches, to which a further two articles were located via a snowballing approach. Eight papers were identified for review. There were five prospective single centre studies, one case series, one technical report and one letter to the editor. Of these articles, five publications (62.5%) reported on the utility of 3D printed models for NS-RARP planning. Two publications (25%) utilised 3D printed prostate models for simulation and training, and two publications (25%) used the models for patient engagement. Despite the nascency of the field, 3D printed models are emerging in the uro-oncological literature as a useful tool in visualising complex anatomy. This has proven useful in NS-RARP for preoperative planning, simulation and patient engagement. However, best practice guidelines, the future regulatory landscape, and health economic considerations need to be addressed before this synergy of new technologies is ready for the mainstream.
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    The impact of health-policy-driven subsidisation of prostate magnetic resonance imaging on transperineal prostate biopsy practice and outcomes.
    Wei, G ; Reeves, F ; Perera, M ; Kelly, BD ; Esler, S ; Bolton, D ; Jack, G (Wiley, 2022-07)
    Background: From 1 July 2018, the Australian Medicare Benefits Schedule (MBS) introduced rebates for multi-parametric magnetic resonance imaging (mpMRI) for the workup for prostate cancer (PCa). We aimed to determine if subsidisation of mpMRI prior to transperineal biopsy altered our institution's prostate biopsy practice patterns and outcomes. Methods: All patients who underwent transperineal prostate biopsy at an Australian tertiary institution from 1 January 2017 to 1 January 2020 were identified. Patients with known PCa were excluded. Patients were stratified into two groups: a pre-subsidisation cohort comprising patients biopsied prior to the introduction of mpMRI subsidisation on 1 July 2018 and a post-subsidisation cohort comprising patients biopsied after 1 July 2018. Histopathological results were compared with further stratification based on mpMRI results. Clinically significant cancer was defined as ISUP Grade Group ≥ 2. Results: Six hundred and fifty men fulfilled the inclusion criteria. Three hundred and sixty-one patients were in the pre-subsidisation cohort and 289 in the post-subsidisation cohort. Of the patients in the pre-subsidisation group, 36.3% underwent a pre-biopsy mpMRI compared with 77.5% in the post-subsidisation group. Of the patients in the pre-subsidisation group, 59.6% had positive biopsies (p = 0.024) compared with 68.2% in the post-subsidisation group. The rate of clinically significant PCa was lower in the pre-subsidisation group (39.1%) compared with the post-subsidisation (49.5%, p = 0.008). The negative predictive value of mpMRI for clinically significant PCa was 86.5%. Conclusion: Our institution experienced a reduction of negative prostate biopsies and an increase in clinically significant PCa within transperineal biopsy specimens after the Australian healthcare system introduced financial subsidisation of mpMRI.
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    Spindle cell tumours of the ureter: Operation or observation?
    Chinni, V ; El-Khoury, HJ ; du Plessis, J ; Bolton, D (ELSEVIER SCIENCE INC, 2022-07-01)
    We describe a rare case of inflammatory spindle cell tumour of the ureter in a patient who presented with renal colic and macroscopic haematuria. Pyeloscopy revealed a partially obstructing mass at the proximal right ureter which confirmed a myofibroblastic tumour on biopsy. Radical nephrectomy was performed which confirmed a spindle cell tumour of the ureter confined to the resection margins. Follow-up imaging in 12 months did not illustrate recurrence or metastasis. The decision to perform a nephrectomy was due to the limited experience with this tumour. Reports illustrate that this tumour is unlikely to metastasize, and thus be managed conservatively.
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    Ureteric orifice obstruction by catheter balloon Post-TURP: A rare cause of obstructive uropathy
    Qin, KR ; Gibson, L ; Manning, TG ; Sethi, K ; Bolton, D (ELSEVIER SCIENCE INC, 2022-01-01)
    A 50-year-old male underwent small volume TURP for median lobe prostatic hypertrophy. Post-procedure, a 3-way urethral catheter was placed. He subsequently developed flank pain, anuria and creatinine rise. CT demonstrated bilateral obstructive uropathy. In the absence of obstructing lesions, it was suspected that the catheter balloon may have caused obstruction of bilateral ureteric orifices. Balloon deflation (from 30 to 10 mL) and catheter repositioning resulted in rapid resolution of pain and resumption of urine output. Urologists should consider the catheter balloon as a cause of obstructive uropathy, especially after procedures where normal trigonal anatomy is disrupted.
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    Cystic papillary adenoma of the seminal vesicle.
    Heijkoop, B ; Bolton, D ; Katz, D ; Ryan, A ; Epstein, J ; Appu, S (Springer Science and Business Media LLC, 2021-04-15)
    BACKGROUND: Primary Seminal Vesicle (SV) tumours are a rare entity, with most SV masses representing invasion of the SV by malignancy originating in an adjacent organ, most often the prostate. Previously reported primary SV epithelial tumours have included adenocarcinoma and cystadenoma, with limited prior reports of inracystic papillary structures. CASE PRESENTATION: A 35-year-old male presented with azoospermia, intermittent macroscopic haematuria, and mild right iliac fossa and groin pain. A papillary appearing seminal vesicle mass was found on imaging and seminal vesicoscopy. The mass was robotically excised with diagnosis of benign cystic papillary adenoma made. CONCLUSION: In this manuscript we describe a rare case of a benign cystic papillary adenoma of the seminal vesicle, a unique histological entity differentiated from cystadenoma of the Seminal Vesicle by its papillary component.