An unusual delayed rectal metastasis from prostate cancer masquerading as primary rectal cancer.

INTRODUCTION AND IMPORTANCE: Rectal metastasis of prostate cancer origin is exceedingly rare. Its clinical presentation, endoscopic morphology, and histopathology are similar to primary rectal cancer. Misdiagnosis may lead to inappropriate treatment. CASE PRESENTATION: We report a case of a gentleman in his 80's with a history of treated prostate cancer T3aN0M0 with radical prostatectomy sixteen years ago. He presented with one-year complaints of altered bowel habits and weight loss. Physical and rectal examination was unremarkable. Colonoscopy manifested some inflammatory changes in the rectum. The pelvis magnetic resonance imaging (MRI) showed an abnormal posterior rectal wall thickening 2 cm above the anal canal. Biopsy confirmed poorly differentiated adenocarcinoma of prostate origin. The staging workup was negative for other distant metastasis. After a multidisciplinary decision, the patient was started on androgen deprivation therapy and given palliative radiotherapy to the rectum. Six weeks later, the patient was stable with mild radiation proctitis. CLINICAL DISCUSSION: Management of rectal metastasis varies depending on the patient's choice, the extent of metastatic burden, symptoms, age, life expectancy, quality of life and comorbidities. While surgery remains the standard of care, other option including radiotherapy, hormonal therapy and chemotherapy has been documented in the literature with survival of few weeks to 2 years. CONCLUSION: Delayed rectal metastasis of prostate cancer after radical prostatectomy is a rare entity. Its clinical presentation and endoscopic and histopathological findings of rectal metastasis are similar to primary colorectal cancer, making diagnosis more demanding.

Establishing a national high fidelity cadaveric emergency urology simulation course to increase trainee preparedness for independent on-call practice: a prospective observational study.

BACKGROUND: Whilst competence in the management of a wide range of urological emergencies is a requirement for certification in urology, many conditions are uncommon and exposure during training may be limited. This prospective observational study sought to evaluate the feasibility and effectiveness of a standardised cadaveric emergency urology simulation course aimed at improving operative confidence and competence prior to independent on-call practice in the United Kingdom. METHODS: A two-day cadaveric emergency urology simulation course supported by the British Association of Urological Surgeons (BAUS) was implemented at two pilot centres. All delegates that undertook one of the initial series of courses were invited to complete online pre- and post-course questionnaires relating to prior operative experience, documented competence and perceived confidence in being able to perform specific emergency procedures independently. Primary outcome was a self-reported 'confidence score' selected from a linear numeric scale ranging from 1 (not at all confident to perform a given procedure independently) to 10 (fully confident). Statistical analysis was undertaken using SPSS Statistics for Mac Version 25 and the paired student's t-test used to compare mean pre- and post-course scores. RESULTS: One hundred and four delegates undertook the course during the study period. Of these, 85 (81.7%) completed the pre-course survey and 67 (64.4%) completed the post-course survey, with 61 (58.7%) completing both. The greatest proportion of respondents were Speciality Trainees in Urology of ST5 level or higher (equivalent of Resident/Fellows with 4 or more years of surgical training; n = 31, 36.5%). Delegates reported variable pre-course exposure, with most experience reported in loin approach to the kidney (median 10) and least in exploration and packing of a transurethral resection cavity and emergency nephrectomy (median 0). Following course completion, a statistically significant increase in confidence score was observed for each procedure, with the greatest increases seen for shunt for priapism (4.87 to 8.80, p < 0.001), ureteric reimplantation (3.52 to 7.33, p < 0.001) and primary ureteric anastomosis (3.90 to 7.49, p < 0.001). CONCLUSIONS: A standardised high fidelity cadaveric simulation course is feasible and significantly improves the confidence of trainees in performing a wide range of emergency procedures to which exposure is currently limited.

Evaluation of diffusion weighted imaging in the context of multi-parametric MRI of the prostate in the assessment of suspected low volume prostatic carcinoma.

Data from a multi-parametric MRI study of patients with possible early-stage prostate cancer was assessed with a view to creating a more efficient clinical protocol. Based on a correlation analysis suggesting that diffusion-weighted imaging (DWI) scores are more strongly correlated with overall PIRADS scores than other modalities such as dynamic contrast enhanced imaging or spectroscopy, we investigate the combination of T2-weighted imaging (T2w) and DWI as a potential diagnostic tool for prostate cancer detection, staging and guided biopsies. Quantification of the noise floor in the DWI images and careful fitting of the data suggests that the mono-exponential model provides a very good fit to the data and there is no evidence of non-Gaussian diffusion for b-values up to 1000s/mm2. This precludes the use of kurtosis or other non-Gaussian measures as a biomarker for prostate cancer in our case. However, the ADC scores for healthy and probably malignant regions are significantly lower for the latter in all 20 but one patient. The results suggest that a simplified mp-MRI protocol combining T2w and DWI may be a good compromise for a cost and time efficient, early-stage prostate cancer diagnostic programme, combining robust MR biomarkers for prostate cancer that can be reliably quantified and appear well-suited for general clinical practice.

Should We Use Antibiotic Prophylaxis for Flexible Cystoscopy? A Systematic Review and Meta-Analysis.

INTRODUCTION: The role of antibiotic prophylaxis for routine flexible cystoscopy (FC) is not clear due to the varying practices of individual clinicians. There are no formal guidelines, and this may be due to a lack of formal summary of the data. METHODS: A systematic review was conducted in April 2014 including all randomised control trials on prophylactic antibiotic use for FC. The main outcome measures were confirmed bacteriuria on mid-stream urine (MSU), asymptomatic bacteriuria and symptomatic bacteriuria. A meta-analysis was conducted with difference between groups expressed as an odds ratio (OR) and control group risk. RESULTS: 5,107 patients were included, 2,173 in placebo and 2,934 in the antibiotic group. The OR for all three outcomes favoured the antibiotic group; the risk of developing symptomatic bacteriuria was 0.06 times more likely in the control group (OR 0.34), 0.054 (OR 0.40) for developing asymptomatic bacteriuria and 0.109 for confirming bacteriuria on MSU (OR 0.36). The number needed to treat (NNT) was 15 (13-19) for MSU positive bacteriuria; 32 (27-42) for symptomatic bacteriuria and 26 (23-33) for asymptomatic bacteriuria. CONCLUSIONS: Antibiotic prophylaxis did confer a reduction in cases of symptomatic and asymptomatic bacteriuria but the NNT were high. Therefore, the authors cannot advocate the use of antibiotic prophylaxis for routine FC procedures.

A role for STEAP2 in prostate cancer progression.

Prostate adenocarcinoma is the second most frequent cancer worldwide and is one of the leading causes of male cancer-related deaths. However, it varies greatly in its behaviour, from indolent non-progressive disease to metastatic cancers with high associated mortality. The aim of this study was to identify predictive biomarkers for patients with localised prostate tumours most likely to progress to aggressive disease, to facilitate future tailored clinical treatment and identify novel therapeutic targets. The expression of 602 genes was profiled using oligoarrays, across three prostate cancer cell lines: CA-HPV-10, LNCaP and PC3, qualitatively identifying several potential prognostic biomarkers. Of particular interest was six transmembrane epithelial antigen of the prostate (STEAP) 1 and STEAP 2 which was subsequently analysed further in prostate cancer tissue samples following optimisation of an RNA extraction method from laser captured cells isolated from formalin-fixed paraffin-embedded biopsy samples. Quantitative analysis of STEAP1 and 2 gene expression were statistically significantly associated with the metastatic cell lines DU145 and PC3 as compared to the normal prostate epithelial cell line, PNT2. This expression pattern was also mirrored at the protein level in the cells. Furthermore, STEAP2 up-regulation was observed within a small patient cohort and was associated with those that had locally advanced disease. Subsequent mechanistic studies in the PNT2 cell line demonstrated that an over-expression of STEAP2 resulted in these normal prostate cells gaining an ability to migrate and invade, suggesting that STEAP2 expression may be a crucial molecule in driving the invasive ability of prostate cancer cells.

Putative prognostic epithelial-to-mesenchymal transition biomarkers for aggressive prostate cancer.

Prostate cancer is the second most frequently diagnosed cancer worldwide and is the sixth leading cause of cancer deaths in men, yet it varies greatly in its aggressiveness. Currently, it is not possible to adequately differentiate between patients whose tumors will remain indolent and those patients whose disease will progress, resulting in unnecessary aggressive treatment. Consequently, there is an urgent need to identify markers of prostate cancer progression, invasiveness and metastasis to more accurately predict prognosis. The aim of this study was to assess the ability of key epithelial-to-mesenchymal transition molecules in identifying prostate cancer patients who are likely to develop aggressive tumors. Using 215 archival patient tissue samples, immunohistochemistry was applied to examine the expression and sub-cellular localization of E-Cadherin, Snail, Slug, Twist, Vimentin, BMP-2 and BMP-7. Of the seven markers assessed, a significantly increased expression of Snail protein was observed within the nucleus of prostate cancer cells and was strongly associated with increasing Gleason score and clinical stage. In addition, loss of E-Cadherin expression at the cellular membrane of prostate cancer cells was also significantly associated with increasing Gleason score, clinical stage, and additionally, a reduction in survival.