A comparison of operative and margin outcomes from surgeon learning curves in robot assisted radical prostatectomy in a changing referral practice.

Introduction The aim of this study was to explore the impact of increasing proportions of high risk referrals on surgical margin outcomes of a surgeon's learning curve in robotic prostatectomy. Methods All patients in this study underwent robot assisted radical prostatectomy (RARP) performed by three different consultant urological surgeons. Data collected included preoperative clinical stage, Gleason score and prostate specific antigen levels, which were used to risk stratify patients according to National Institute for Health and Care Excellence criteria. Oncological clearance was assessed by overall and stage specific positive margin status. Comparisons were made between each surgeon for the first and second 50 consecutive cases. Results For the three surgeons, there was a progressive increase in the proportion of high risk cases referred accompanied by a corresponding decline in low risk disease (p<0.001). Postoperative pathology also showed an upward trend in pT3 cases across the three eras. There was no statistical difference in overall positive margin rates between the surgeons. The overall rates were 12%, 20% and 23% for the first 50 cases, and 32%, 36% and 21% for the second 50 cases for the three surgeons respectively. Conclusions Our series demonstrates an upward trend in the risk profile of men referred for robotic prostatectomy over a nine-year period. Despite this, there was minimal impact on pathological and surgical outcomes among our surgeons, who were at the initial stages of their RARP learning curve. Our results suggest that there is no requirement for an active case selection bias against patients with high risk disease for surgeons newly embarking on their RARP learning experience.

Caustic ingestion injury of the upper aerodigestive tract in adults.

Adult ingestion of caustic substances is an unusual but serious surgical problem, with injuries likely to be more extensive than those in the corresponding paediatric population. After initial stabilisation and airway management, clinicians are presented with a complex multisystemic problem, frequently requiring a multidisciplinary approach involving several surgical disciplines and associated therapies. A new multidisciplinary team was convened to discuss complex ingestion injury in adults and established techniques were used to bring forward a proposed treatment algorithm. An algorithm may potentially improve clinical efficacy and risk in the management of these complex patients.

Mature ganglioneuroma of the adrenal gland as a new rare cause of visible haematuria: A case report & literature review.

INTRODUCTION: Ganglioneuromas are benign tumours of the sympathetic ganglia and the adrenal glands medulla. We describe a case of a fit and well 18 year old Caucasian male patient who initially presented to primary care with intermittent episodes of painless frank haematuria as well as some non-specific right-sided loin pain. PRESENTATION OF CASE: In this 18 year old man, initial ultrasound investigations at a 'one stop haematuria' clinic revealed the presence of an echogenic solid mass of 120×110×90mm around the upper pole of the right kidney. A CT scan of the abdomen proved inconclusive to further determine the aetiology of the mass. Following a local multidisciplinary meeting (MDT) an MRI of the abdomen was undertaken which confirmed the presence of a large right adrenal mass. A biopsy was taken to determine the histology of the mass confirming a mature ganglioneuroma. The patient subsequently underwent surgery within 6 weeks of having presented to his general practitioner. CONCLUSION AND DISCUSSION: The surgery was uncomplicated and excision of the mass was made via a thoraco-abdominal approach. The patient recovered well post operatively and was discharged home within 8 days with outpatient follow-ups organised.

Pulmonary infection with Nocardia caviae in a patient with diabetes mellitus and liver cirrhosis.

The first reported case of pulmonary infection with Nocardia caviae in Britain occurred in a 67 year old woman, in whom diabetes mellitus and liver cirrhosis probably contributed to impaired cell mediated immunity. She was successfully treated with gentamicin 60 mg eight hourly and sulphadimidine 500 mg six hourly for six months and then with sulphadimidine 2 g/day for a further three months. When Nocardia caviae is isolated from the sputum of a patient with chronic respiratory infection and fever, effective treatment should be started promptly.