Surgery (Austin & Northern Health) - Research Publications

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    Salmonella Oranienburg haemorrhagic cystitis in an immunocompetent young male.
    Teh, J ; Quinlan, M ; Bolton, D (Microbiology Society, 2017-08)
    Introduction. Non-typhoidal salmonella (NTS) bacteriuria is extremely rare. Haemorrhagic cystitis is defined by urinary symptoms including haematuria, frequency, urgency and dysuria. Reports of haemorrhagic cystitis caused by NTS are exceptionally uncommon, especially in immunocompetent, young, male patients. Case presentation. A 27-year-old male with no past medical history presented to the Emergency Department with a 24 h history of visible haematuria having returned five days earlier from a five month trip across South America. He also reported one week of suprapubic pain with associated dysuria, frequency, difficulty voiding and fevers. A non-contrast abdominal and pelvic CT scan showed a grossly thick-walled bladder with marked peri-vesical stranding, strongly suggestive of cystitis, with an unremarkable appearance of the remainder of the urinary tract. Urine culture at presentation subsequently grew Salmonella Oranienburg. The patient reported total symptomatic relief following just one week of oral antibiotics with no recurrence to date. Conclusion. NTS urinary tract infection (UTI), especially in healthy young people, is very rare. In such cases, the existence of underlying diseases must be considered, especially diabetes mellitus, urological abnormalities and immunosuppression. However, a diagnosis of NTS UTI should also be among the differentials in those presenting with acute urinary symptoms preceded by gastrointestinal upset, especially following travel in underdeveloped countries. Antibiotic therapy is invariably indicated and close follow-up is warranted due to the risk of several potentially serious complications.
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    Novel Use of Ex Vivo Uretero-Pyeloscopy in Autotransplantation: A Systematic Review and Case Report.
    Tnay, T ; Elmer, S ; Bolton, DM ; Lawrentschuk, N (Mary Ann Liebert Inc, 2015)
    BACKGROUND: Autotransplant has been practiced for decades but is regaining popularity in the nephron-sparing era. Initially for benign disease, autotransplantation has a select role in malignant processes that warrants new techniques and ideas to ensure patient safety. We review the use of ex vivo uretero-pyeloscopy and frozen section to ensure kidneys may be utilized in a patient with suspected malignancy. CASE PRESENTATION: A systematic review (PRISMA standard) of ex vivo uretreo-pyeloscopy was undertaken. We then present the case of a 37-year-old Caucasian female who was suspected of having ureteral obstructing malignancy; she had previous treatment of the bladder with bacillus Calmette-Guerin (BCG) for recurrent urothelial malignancy. The lesion biopsies and cytology were suspicious but inconclusive, indicating nephroureterectomy was a likely course of management. RESULTS: On reviewing the literature, we found that the use of ex vivo uretero-pyeloscopy has been described for urolithiasis to remove stones before transplantation but not specifically to exclude malignancy. Ultimately, in this case, the patient underwent a renal autotransplantation for obstruction that was caused by a granuloma on the background of the previous BCG treatment. Intraoperatively, ex vivo uretero-pyeloscopy and frozen section were crucial in guiding this case by allowing for appropriate identification and resection of the ureteral lesion. In addition, the preservation of ureteral length allowed for autotransplantation, which remains effective at follow-up. CONCLUSION: Ex vivo urteroscopy has been used effectively in donor kidneys to treat urolithiasis with minimal complications. We believe that this is the first documented case of ex vivo uretero-pyeloscopy being used effectively in renal autotransplantation to exclude urothelial malignancy.
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    Strategies for success: a multi-institutional study on robot-assisted partial nephrectomy for complex renal lesions
    Hennessey, DB ; Wei, G ; Moon, D ; Kinnear, N ; Bolton, DM ; Lawrentschuk, N ; Chan, YK (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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    Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue
    Nzenza, TC ; Manning, T ; Ngweso, S ; Perera, M ; Sengupta, S ; Bolton, D ; Lawrentschuk, N (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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    Intraductal carcinoma of the prostate can evade androgen deprivation, with emergence of castrate-tolerant cells
    Porter, LH ; Hashimoto, K ; Lawrence, MG ; Pezaro, C ; Clouston, D ; Wang, H ; Papargiris, M ; Thorne, H ; Li, J ; Ryan, A ; Norden, S ; Moon, D ; Bolton, DM ; Sengupta, S ; Frydenberg, M ; Murphy, DG ; Risbridger, GP ; Taylor, RA (WILEY, 2018-06)
    OBJECTIVE: To determine the relevance of intraductal carcinoma of the prostate (IDC-P) in advanced prostate cancer by first examining whether IDC-P was originally present in patients who later developed advanced prostate cancer and then using patient-derived xenografts (PDXs) to investigate the response of IDC-P to androgen deprivation therapy (ADT). MATERIALS AND METHODS: We conducted a retrospective pathology review of IDC-P in primary prostate biopsy or surgery specimens from 38 men who subsequently developed advanced prostate cancer. Overall survival was calculated using the Kaplan-Meier method. To demonstrate the response of IDC-P to ADT, we established PDXs from seven patients with familial and/or high-risk sporadic prostate cancer. After castration and testosterone restoration of host mice, we measured the volume and proliferation of IDC-P within PDX grafts. RESULTS: We found that IDC-P was a prominent feature in the primary prostate specimens, present in 63% of specimens and often co-existing with poorly differentiated adenocarcinoma. Overall survival was similar in patients with or without IDC-P. In the PDXs from all seven patients, IDC-P was identified and present at a similar volume to adenocarcinoma. Residual IDC-P lesions persisted after host castration and, similar to castrate-tolerant adenocarcinoma, testosterone restoration led to tumour regeneration. CONCLUSION: The study showed that IDC-P is prevalent in aggressive prostate cancer and contains cells that can withstand androgen deprivation. Thus, IDC-P appears functionally relevant in advanced prostate cancer. The presence of IDC-P may be a trigger to develop innovative clinical management plans.
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    Distress and unmet needs during treatment and quality of life in early cancer survivorship: A longitudinal study of haematological cancer patients
    Oberoi, DV ; White, VM ; Seymour, JF ; Prince, HM ; Harrison, S ; Jefford, M ; Winship, I ; Hill, DJ ; Bolton, D ; Millar, J ; Doo, NW ; Kay, A ; Giles, G (WILEY, 2017-11)
    OBJECTIVE: To examine the influence of anxiety, depression and unmet supportive care needs on future quality of life (QoL) in multiple myeloma (MM) and diffuse large B-cell lymphoma (DLBCL) patients. METHODS: Multiple myeloma and DLBCL patients recruited through the population-based Victorian Cancer Registry. Data were collected through two telephone interviews: (T1) on average 7 months postdiagnosis, (T2) average 8 months later. QoL was examined at T2 using the Functional Assessment of Cancer Therapy (FACT-G) scale. The Hospital Anxiety and Depression Scale measured anxiety and depression, and the Supportive Care Needs Survey measured unmet needs at T1. Multivariate linear regression examined associations between QoL subscales (physical, emotional, social and functional well-being and overall QoL) and T1 anxiety, depression and unmet needs. RESULTS: Except physical well-being, all other QoL subscales and overall QoL were significantly associated with T1 anxiety. All QoL subscales and overall QoL were significantly associated with T1 depression. Only patient care needs were associated with physical and social well-being and overall QoL. CONCLUSION: Anxiety, depression and patient care unmet needs during treatment are associated with diminished physical and emotional well-being in the following months. Psychological distress and unmet supportive care needs experienced during treatment should be addressed to maximise future QoL.
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    Implementation rates of uro-oncology multidisciplinary meeting decisions
    Kinnear, N ; Smith, R ; Hennessey, DB ; Bolton, D ; Sengupta, S (WILEY, 2017-11)
    OBJECTIVES: To assess implementation rates of the consensus plans made at the uro-oncology multidisciplinary meeting (MDM) of an Australian tertiary centre, and analyse obstacles to implementation. METHODS: A retrospective review was performed of all patients discussed at the uro-oncology MDM at our institution between 1 January and 30 June 2015. Rates of referral for MDM discussion after a new histological diagnosis of malignancy, categorised by tumour type, were assessed. Patient records were interrogated to confirm MDM plan implementation, with the outcomes examined being completion of MDM plan within 3 months and factors preventing implementation. RESULTS: During the enrolment period, from 291 uro-oncological procedures, 240 yielded malignant histology of which 160 (67%) were discussed at the MDM. Overall, 202 patients, including 32 females, were discussed at the uro-oncology MDM. MDM consensus plans were implemented in 184 (91.1%) patients. Reasons for deviation from the MDM plan included delay in care, patient deterioration or comorbidities, patient preference, consultant decision, loss to follow-up, and change in patient scenario due to additional new information. CONCLUSION: The MDM is increasingly important in the care of uro-oncology patients, with about two-thirds of new diagnoses currently captured. There appear to be few barriers to the implementation of consensus plans, with nearly all patients undergoing the recommended management.
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    Trends in the surgical management of stage 1 renal cell carcinoma: findings from a population-based study
    White, V ; Marco, DJT ; Bolton, D ; Davis, ID ; Jefford, M ; Hill, D ; Prince, HM ; Millar, JL ; Winship, IM ; Coory, M ; Giles, GG (WILEY, 2017-11)
    OBJECTIVES: To determine whether the use of nephron-sparing surgery (NSS) for treatment of stage 1 renal cell carcinoma (RCC) changed between 2009 and the end of 2013 in Australia. PATIENTS AND METHODS: All adult cases of RCC diagnosed in 2009, 2012 and 2013 were identified through the population-based Victorian Cancer Registry. For each identified patient, trained data-abstractors attended treating hospitals or clinician rooms to extract tumour and treatment data through medical record review. Multivariable logistic regression analyses were carried out to examine the significance of change in use of NSS over time, after adjusting for potential confounders. RESULTS: A total of 1 836 patients with RCC were identified. Of these, the proportion of cases with stage 1 tumours was 64% in 2009, 66% in 2012 and 69% in 2013. For T1a tumours, the proportion of patients residing in metropolitan areas receiving NSS increased from 43% in 2009 to 58% in 2012 (P < 0.05), and 69% in 2013 (P < 0.05). For patients residing in non-metropolitan areas, the proportion receiving NSS increased from 27% in 2009 to 49% in 2012, and 61% in 2013 (P < 0.01). Univariable logistic regression showed patients with moderate (odds ratio [OR] 0.57, 95% confidence interval [CI] 0.35-0.94) or severe comorbidities (OR 0.58, 95% CI 0.33-0.99), residing in non-metropolitan areas (OR 0.65, 95% CI 0.47-0.90), were less likely to be treated by NSS, while those attending high-volume hospitals (≥30 cases/year: OR 1.79, 95% CI 1.21-2.65) and those with higher socio-economic status (OR 1.45, 95% CI 1.02-2.07) were more likely to be treated by NSS. In multivariable analyses, patients with T1a tumours in 2012 (OR 2.00, 95% CI 1.34-2.97) and 2013 (OR 3.15, 95% CI 2.13-4.68) were more likely to be treated by NSS than those in 2009. For T1b tumours, use of NSS increased from 8% in 2009 to 20% in 2013 (P < 0.05). CONCLUSION: This population-based study of the management of T1 renal tumours in Australia found that the use of NSS increased over the period 2009 to 2013. Between 2009 and 2013 clinical practice for the treatment of small renal tumours in Australia has increasingly conformed to international guidelines.
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    Transperineal prostate biopsy - tips for analgesia
    McGrath, S ; Christidis, D ; Clarebrough, E ; Ingle, R ; Perera, M ; Bolton, D ; Lawrentschuk, N (WILEY, 2017-08)
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    Trends in the surgical treatment of benign prostatic hyperplasia in a tertiary hospital
    Ow, D ; Papa, N ; Perera, M ; Liodakis, P ; Sengupta, S ; Clarke, S ; Bolton, DM ; Lawrentschuk, N (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.