Transperineal retropubic approach in total pelvic exenteration for advanced and recurrent colorectal and anal cancer involving the penile base: technique and outcomes.

BACKGROUND: Complete pathological resection of locally advanced and recurrent anorectal cancer is considered the most important determinant of survival outcome. Involvement of the retropubic space with cancer threatening or involving the penile base poses specific challenges due to the potential for margin involvement and blood loss from the dorsal venous plexus. In the present study we evaluate a new transperineal surgical approach to excision of anterior compartment organs involved or threatened by cancer which facilitates exposure and visualisation of the bulbar urethra and the deep vein of the penis caudal to the retropubic space and penile base. METHODS: A retrospective study was performed on male patients with tumour extension into the penile base treated at our institution using the transperineal surgical approach. Descriptive data for patient demographics, radiology, operative details, postoperative histology, complications and outcomes were collated. RESULTS: Ten male patients with tumour extension into the penile base were identified. Two patients had recurrent anal cancer, 6 had locally advanced primary rectal cancer and 2 had recurrent rectal cancer. All patients had exenterative surgery with excision of the penile base utilising the transperineal approach. All patients had R0 resection. No local recurrence developed after a median follow up period of 15 months. CONCLUSIONS: The transperineal approach to the penile base and retropubic space allows for high rates of R0 resection margin status with direct visualisation of the dorsal venous plexus, thereby minimising blood loss. In our experience, this technique is the preferred approach to excision of cancers threatening and involving the penile base and also for most male patients requiring total pelvic exenteration.

Extended lateral pelvic sidewall excision (ELSiE): an approach to optimize complete resection rates in locally advanced or recurrent anorectal cancer involving the pelvic sidewall.

BACKGROUND: Complete pathological resection of locally advanced or recurrent rectal and anal cancer is regarded as one of the most important determinants of oncological outcome. Disease in the lateral pelvic sidewall has been considered a contraindication for pelvic exenteration surgery owing to the significant likelihood of incomplete resection. METHODS: We describe a novel technique (ELSiE) to resect disease involving the lateral pelvic sidewall. Patient demographics, post-operative histology, length of hospital stay and complications were collected from prospectively maintained electronic patient database. RESULTS: During 2011-2013, six patients underwent pelvic exenteration surgery with the ELSiE approach. All patients had R0 resection. Three patients required sciatic nerve excision. Four patients developed post-operative complications although no major complications occurred. CONCLUSIONS: Patients with locally advanced and recurrent cancer involving the lateral pelvic sidewall may be rendered suitable for potentially curative radical resection with a modification in the approach to the lateral pelvic sidewall. Our pilot series seems to indicate that our novel technique (ELSiE) is feasible, safe and yields high rates of complete pathological resection.

Durability and complications of photoselective vaporisation of the prostate with the 120W high performance system GreenLight™ lithium triborate laser.

INTRODUCTION: The aim of this study was to examine the durability of photoselective vaporisation of the prostate (PVP) with the 120W GreenLight HPS(®) laser (American Medical Systems, Minnetonka, MN, US), and to examine the incidence, nature and factors associated with complications from the procedure. METHODS: Clinical records of PVP patients were reviewed to compare details between patients who developed complications and those who did not. Kaplan-Meier survival curves were used to assess durability. Cox regression was used to examine associations between complications and perioperative factors. RESULTS: Successful outcomes were maintained in 84% of 117 patients at the 2-year follow-up appointment. Complication rates were low and comparable with transurethral resection of the prostate (TURP). Complications were developed by 18 patients (15.4%) over a mean follow-up duration of 20.8 months. The most common complications were residual prostate requiring another surgery (5/117, 4.3%) and urethral stricture (4/117, 3.4%). Patients with complications had significantly longer catheterisation duration. Length of hospital stay, lasing energy, pre and postoperative levels of prostate specific antigen (PSA), pre and postoperative maximum flow rate (Qmax), and age at surgery were not found to influence development of complications. CONCLUSIONS: Results from PVP with an HPS(®) laser are durable. Complications are low and compare favourably with TURP. Lasing energy, PSA, Qmax, patient age and length of stay are not associated with development of complications. However, a longer postoperative catheterisation after PVP is associated with development of complications.

High dose rate prostate brachytherapy: an overview of the rationale, experience and emerging applications in the treatment of prostate cancer.

The technological advances in real-time ultrasound image guidance for high dose rate (HDR) prostate brachytherapy places this treatment modality at the forefront of innovation in radiotherapy. This review article will explore the rationale for HDR brachytherapy as a highly conformal method of dose delivery and safe dose escalation to the prostate, in addition to the particular radiobiological advantages it has over low dose rate and external beam radiotherapy. The encouraging outcome data and favourable toxicity profile will be discussed before looking at emerging applications for the future and how this procedure will feature alongside stereotactic radiosurgery.

Laparoscopic radical prostatectomy: reducing the learning curve.

OBJECTIVES: To review the operative results of a single surgeon after a laparoscopic radical prostatectomy (LRP) fellowship to assess whether the LRP learning curve can be abbreviated. METHODS: We undertook a prospective study of 50 men who underwent LRP performed by a recently graduated LRP fellowship-trained surgeon. The patient details, operative data, complications, and post-operative followup were collected over the initial 12-month period. RESULTS: The median age was 63 years (range, 47 to 72 years) and median follow-up of 6 months (range, 1 to 12 months). The majority of patients had a preoperative clinical stage T1c (30 = 60%) with a median PSA of 6.4 ng/mL. The median operative time was 225 minutes (range, 160 to 360 minutes) and median blood loss was 400 mL. There were three major complications: 1 anastamotic revision and 2 bladder neck contractures. The positive surgical margin rate for pT2 disease was 5% and for pT3 disease was 20%. Continence rates were 87% at 12 months (no pad use); unilateral (14%) and bilateral nerve sparing (34%) yielded early return of potency in 37.5% of men. No conversions, no rectal injuries, and no deaths occurred in the series. CONCLUSIONS: The learning curve that has been observed in other series is not seen with regard to operative time or complication rates. Crucially, it is not seen in a positive surgical margin rate. A dedicated fellowship in laparoscopic radical prostatectomy abbreviates the extensive learning curve for this most technically challenging procedure.

Radiation exposure and the urologist: what are the risks?

PURPOSE: Endourology is established in urology practice with routine use of fluoroscopic guidance. Medical personnel are rarely exposed to direct radiation exposure but secondary exposure occurs via radiation scatter. There are few reports on scatter radiation exposure and the subsequent risk to medical personnel involved in urological fluoroscopic procedures. We review the risks of scatter radiation exposure to medical personnel with reference to the routine use of fluoroscopic imaging in urological practice. MATERIALS AND METHODS: We measured staff radiation exposure during a series of ureteral endourological procedures using LiF:Mg,Ti thermoluminescent dosimeters placed at the extremities of the operating surgeon, the assistant and the scrub nurse. Doses for percutaneous nephrolithotomy (PCNL) procedures were calculated by extrapolating from the ureteral procedure thermoluminescent dosimeter data. Theoretical scattered radiation dose rates were also calculated. RESULTS: The average ureteral procedure fluoroscopy time was 78 seconds with an exposure rate of 71 kV, 2.4 mA. The surgeon received the highest radiation exposure with the lower leg (11.6 +/- 2.7 microGy) and foot (6.4 +/- 1.8 microGy) receiving more radiation than the eyes (1.9 +/- 0.5 microGy) and hands (2.7 +/- 0.7 microGy). For a predicted annual caseload of 50 ureteral cases, the dose received does not exceed 0.12% of the Ionising Radiations Regulations 1999 annual dose limit for adult workers. Radiation exposure during PCNLs is higher but does not exceed 2% of the annual dose limits even if 50 PCNLs are performed annually. CONCLUSIONS: Fluoroscopic screening results in radiation exposure of medical personnel. The estimate of maximum scatter radiation exposure to the surgeon for 50 PCNL procedures a year did not exceed 10 mGy. This amount is less than 2% of permissible annual limits of equivalent dose to the extremities. Medical personnel should be aware of scatter radiation risks and minimize radiation exposure when involved in fluoroscopic screening procedures.

The European working time directive: implications for subspecialty acute care.

The requirements of the new deal for junior doctors' hours has meant that many smaller trusts are unable to provide adequate cover on-call for medical and surgical subspecialties. The care of the acute subspecialty patients has, therefore, shifted to general teams in many trusts. We assessed what impact this had upon the outcome of acute urological cases in our district general hospital by prospectively monitoring acute renal colic admissions over a 12-month period and surveyed the provision of services in other regional hospitals. The shift in care of the acute urological patient was associated with considerable morbidity for patients admitted in our hospital. The additional financial burden due to this morbidity was estimated to be 33000 pounds/annum. The implementation of the new deal must be achieved with every care to minimise the clinical and financial costs of withdrawing acute subspecialty services.

Chemosensitization of human prostate cancer using antisense agents targeting the type 1 insulin-like growth factor receptor.

OBJECTIVE: To assess the effect of the downregulation of type 1 insulin-like growth factor receptor (IGF1R) on the chemosensitivity of prostate cancer cells. IGF1R is overexpressed by prostate cancer compared with benign prostatic epithelium and IGF1R expression commonly persists in androgen-independent metastatic disease at levels comparable to those in the primary. MATERIALS AND METHODS: Human androgen-independent DU145 prostate cancer cells were transfected with IGF1R antisense oligonucleotides or antisense RNA. Transfected cultures were treated with cisplatin, mitoxantrone, paclitaxel or vehicle control, and survival measured using a clonogenic assay. RESULTS: Both antisense strategies suppressed IGF1R protein levels to 30-50% of those in control cultures. This was associated with 1.5-2-fold enhancement of sensitivity to cisplatin, mitoxantrone and paclitaxel, and an increase in cisplatin-induced apoptosis. CONCLUSION: This approach has potential for development as a clinical treatment for advanced prostate cancer and other chemoresistant tumours.

A radiation perspective for treating loin pain in pregnancy by double-pigtail stents.

OBJECTIVE: To review the risks of placing double-pigtail stents during pregnancy in women presenting with loin pain associated with hydronephrosis. PATIENTS AND METHODS: A consecutive series of women presenting with loin pain and hydronephrosis in pregnancy were treated with double-pigtail ureteric stents. A flexible cystoscope was used to identify the ureteric orifice and to pass a guidewire into the renal pelvis under fluoroscopic guidance. Stents were placed using the exchange technique over a stiff guidewire. Procedures were carried out under none or limited sedoanalgesia. Screening times and radiation dose were recorded. Data were collected for the average uterine radiation dose from a variety of radiological procedures. Previous publications were reviewed to determine the lethal, teratogenic and carcinogenic risk to the developing fetus from radiation exposure. RESULTS: Seven patients referred with symptomatic hydronephrosis during pregnancy were treated. The screening time during placement was minimized. The mean (range) uterus (i.e. fetal) dose was 0.40 (0.03-0.79) mGy. Most radiological procedures involve uterine doses of < 20 mGy, far below the 100 mGy that may result in fetal damage during periods of maximum radiosensitivity. CONCLUSION: Minimized radiation exposure from a range of uroradiological procedures in pregnant women has limited fetal risk. The use of fluoroscopy for symptomatic hydronephrosis during pregnancy allows ureteric stents to be placed safely and reliably. The average excess risk to the fetus from this procedure is 1 in 43 000 of cancer induction and 1 in 100 000 of heritable disease, i.e. very small when compared with the natural incidence. Pregnancy should not exclude the use of appropriate diagnostic radiation exposure and urologists may conduct appropriate diagnostic and therapeutic procedures, taking care to limit X-ray exposure without fear of risk to the developing fetus.

Urology and the Internet: an evaluation of internet use by urology patients and of information available on urological topics.

OBJECTIVE: To determine the use of the Internet by urological patients for obtaining information about their disease, and to conduct an evaluation of urological websites to determine the quality of information available. PATIENTS AND METHODS: Questionnaires about Internet use were completed by 180 patients attending a general urological outpatient clinic and by 143 patients attending a prostate cancer outpatient clinic. The Internet evaluation was conducted by reviewing 50 websites listed by the Hotbottrade mark search engine for two urological topics, prostate cancer and testicular cancer, and recording details such as authorship, information content, references and information scores. RESULTS: Of the patients actively seeking further information about their health, 19% of the general urological outpatient group and 24% of the prostate cancer group used the Internet to obtain this information. Most websites were either academic or biomedical (62%), provided conventional information (95%), and were not referenced (71%). The information score (range 10-100) was 44.3 for testicular cancer and 50.7 for prostate cancer; the difference in scores was not significant. CONCLUSION: The use of the Internet by patients is increasing, with > 20% of urology patients using the Internet to obtain further information about their health. Most Internet websites for urological topics provide conventional and good quality information. Urologists should be aware of the need to familiarize themselves with urological websites. Patients can then be directed to high-quality sites to allow them to educate themselves and to help them avoid misleading or unconventional websites.

Should air contrast computed tomography become the first investigation of the colon of frail or elderly patients?

OBJECTIVE: Air contrast computed tomography (ACCT) is an alternative test to barium enema or colonoscopy. We review our experience of this test as the first investigation of frail, elderly patients with lower gastrointestinal symptoms, and record the subsequent clinical course of these patients to evaluate the efficacy of the technique. PATIENTS AND METHODS: We performed 109 ACCT studies on frail patients aged 70 years or over with lower gastrointestinal symptoms. The findings were correlated with subsequent investigations and surgical findings. Patients with normal scans were followed up in out-patients or by their GP. Average follow up was 17 months. RESULTS: A good quality complete examination of the colon was achieved in 97% of patients. Of 109 examinations 34 (31%) were reported as normal, 65 (60%) as diverticular disease, nine (8%) as demonstrating a colonic malignancy and one (1%) showed a benign polyp. One sigmoid tumour was missed initially but diagnosed on a repeat ACCT study. CONCLUSION: ACCT is a reliable, well-tolerated technique in elderly frail patients.