Factors associated with pathological up-staging in MRI cT3a prostate cancer - a retrospective study from a high-volume centre.

INTRODUCTION: Multiparametric MRI (mpMRI) parameters of pT3a prostate cancer have not been examined in large cohort studies. Therefore, we aimed to identify factors associated with up-staging of mpMRI cT3a in post-operative histopathological confirmation. METHODS: Retrospective analysis of a prospectively maintained database of a single UK cancer centre. Only cT3a cases who underwent robotic-assisted radical prostatectomy (RARP) were included (N = 383). MRI and specimen histopathology was reviewed independently by expert uro-radiologists and uro-histopathologists, respectively. Factors included age, BMI, prostate-specific antigen (PSA) level, biopsy international society of urological pathology (ISUP) grade, Prostate Imaging Reporting & Data System (PI-RADS®) score, tumour size, tumour coverage of gland (%), gland weight and surgical margins were analysed as predictors of pT3a prostate cancer. RESULTS: N = 383. Mean age 66 years (58-71), mean BMI 27.1 kg/m2 (25.0-30.0). 314 (82.0%) cases down- unchanged or down-staged, and 69 (18.0%) cases upstaged. PSA level (P = 0.002), PI-RADS score (P < 0.001) and ISUP grade (P < 0.001) are positively associated with upstage categories. ISUP grade ≥3 (OR 5.45, CI 1.88, 9.29, P < 0.002), PI-RADS score ≥4 (OR 3.92, CI 1.88-9.29, P < 0.001) and tumour coverage (OR 1.06, CI 1.05-1.08, P < 0.001) significantly positively associated with upstaging disease, with concurrent decreased probability of downstaging (OR 0.55, 0.14, 0.44, respectively, P < 0.05). Tumour coverage was positively correlated with increasing positive surgical margins (P < 0.05). Capsular contact > 15 mm was very unlikely to be upstaged (OR 0.36, CI 0.21-0.62, P < 0.001), aligning with published results past the widely accepted significant level for extracapsular disease on MRI. CONCLUSION: The study has identified PSA level, ISUP, PI-RADS score, tumour volume and percentage coverage are key predictive factors in cT3a upstaging. This study uniquely shows tumour coverage percentage as a predictor of cT3a upstaging on mpMRI. ISUP is the strongest predictor, followed by PI-RADS score and tumour coverage of gland. Multi-institutional studies are needed to confirm our findings.

Newer therapies and surgical management of ketamine-induced uropathy: A review.

BACKGROUND AND AIMS: Ketamine use as a recreational drug is becoming more popular nowadays. Ketamine-induced uropathy (KIU) is a late finding observed with long-term use of ketamine. A systematic review of Ketamine-Induced Uropathy was performed to emphasise its key clinical manifestations, mechanism of action and establish an effective treatment pathway. METHODS AND RESULTS: A literature search was conducted in MEDLINE via Pubmed and Cochrane using the keywords ketamine and bladder, ketamine and uropathy, and ketamine and epidemiology. The search strategy was limited to articles published from 2000 to 2023. Both animal and human studies were included. A total of 101 papers were reviewed based on topic relevance from the title and abstracts available. While ketamine is a controlled drug in the United Kingdom (UK) and other countries, 283 ketamine-related deaths have been reported in the UK. There is no definite pathogenesis but multiple potential mechanisms that cause KIU and its related symptoms. KIU involves chronic inflammation of the bladder, ureteral wall thickening, hydronephrosis and finally, chronic renal failure. A multidisciplinary approach is paramount when managing these patients to break the vicious cycle. The mainstay of medical and surgical treatment pathways is continued abstinence to prevent symptom relapse. This review included the pathophysiology, novel medical treatments and surgical management of KIU. CONCLUSION: KIU is a rare but significantly disabling condition often seen among ketamine abusers. With the rising trend in drug addiction, KIU is expected to be more common. Unfortunately, it is a late complication in chronic ketamine abusers and is only partially reversible even with abstinence. This review discusses this rare entity's newer medical treatments and surgical options.

Assessment of routine same-day discharge surgery for robot-assisted radical prostatectomy.

INTRODUCTION: It is important for robotic surgery to be cost-effective, especially by reducing the length of stay (LOS). Therefore, we developed a protocol for day-case robot-assisted radical prostatectomy (RARP). This study aimed to validate this as a safe practice of care and to assess the potential benefits to the hospital and patient. METHODS: In this single-centre study, all patients booked for RARP between April 2022 and October 2022 were screened for suitability for day case. All tumour types were included. Exclusion criteria were a history of complex abdominal surgeries, salvage prostatectomy, body mass index (BMI) > 35 and patient living alone or > 150 km away from the hospital. All day-case RARPs were performed as a morning case with a protocol for review throughout the day with evening discharge if mobilising independently and eating/drinking well. The primary outcome of the study was success rate of discharge home on day of surgery (DOS) with secondary outcomes of readmissions and complications. A patient questionnaire was completed at home including both visual analogue scale (VAS) for pain and satisfaction rating. RESULTS: Forty-five patients underwent day-case RARP over a 6-month period with minimum of 30 days of follow-up. 41/45 (91%) had successful DOS discharge home. The four admissions overnight were due to dizziness, low oxygen saturation, intraoperative complications and a diagnosis of COVID-19. There were no readmissions and no 30-day complications. The most common issues at home were catheter discomfort and constipation with low mean VAS pain score and low nausea reported. The overall patient satisfaction rating was very high at 4.8/5, and 97% said they would recommend to a family member. The cost saving for the hospital was 400 pounds per patient. CONCLUSION: Day-case procedure is a viable, safe and efficient pathway for appropriately selected and counselled patients undergoing RARP.

Functional and oncological outcomes of robot-assisted radical prostatectomy in obese men: a matched-pair analysis.

Robot-assisted radical prostatectomy (RARP) in men with body mass index (BMI) ≥ 35 kg/m2 is considered technically challenging. We conducted a retrospective matched-pair analysis to compare the oncological and functional outcomes of RARP in men with BMI ≥ 35 kg/m2. We interrogated our prospectively maintained RARP database and identified 1273 men who underwent RARP from January 2018 till June 2021. Among them, 43 had BMI ≥ 35 kg/m2, and 1230 had BMI < 35 kg/m2. A 1:1 genetic matching was performed between these two groups for PSA, Gleason grades, clinical stage, D'Amico risk stratification, and nerve-spare extent. Continence rates and biochemical rates on 1-year follow-up were analysed. We performed statistical analysis using SPSS, and Paired tests were done using Wilcoxon sign rank-sum test. p < 0.05 was considered statistically significant. The two groups were comparable in almost all parameters except for age. Console time (p = 0.20) and estimated blood loss (p > 0.90) were not significantly different. There was no blood transfusion, open conversion or (Clavien-Dindo grade ≥ 3) intra/postoperative complication in either of the two groups. The two groups did not have any difference in biochemical recurrence rates (BCR) on 1-year follow-up (p > 0.90). Men with BMI ≥ 35 achieved continence rates equivalent to men with BMI < 35 within 1 year. On logistic regression analysis, age (p < 0.001) and extent of nerve sparing (p = 0.026) emerged as significant factors influencing continence recovery. RARP is safe in men with BMI ≥ 35 kg/m2. The 1-year continence and oncological outcomes are similar to matched men with BMI < 35 kg/m2 undergoing RARP.

Robotic-assisted bladder diverticulectomy: point of technique to identify the diverticulum.

We aim to outline our technique of performing a robotic-assisted bladder diverticulectomy at our institution and report our surgical outcomes. We report the cases of three robotic-assisted bladder diverticulectomies, performed at the Royal Surrey County Hospital during the period of January 2014 to December 2015. Patient was positioned in low dorsal lithotomy position. A 6Fr double-J stent was prophylactically inserted at the start of the procedure. Foley catheter was placed over guide wire into the diverticulum and balloon inflated on the diverticulum neck. We used a transperitoneal extravesical approach to mobilise the distended bladder diverticulum, dissected en bloc and transected at the diverticulum neck in all cases. The bladder was closed in two layers with absorbable sutures. The procedures were uneventful, without post-operative complications and minimal blood loss. The median length of stay was 3 days and all three patients reported a significant improvement in all symptoms with non-significant post-void residuals. Robotic-assisted bladder diverticulectomy is a safe and effective procedure that results in both symptom relief and minimal post-void residuals.

Atypical Carcinoid Neuroendocrine Tumor of the Ureter: A Case Report and Literature Review.

Neuroendocrine tumors (NETs) of the ureter are rare, with less than 40 cases described in the literature. A majority of tumors described are poorly differentiated tumors with a poor prognosis. We present the case of a moderately differentiated atypical carcinoid NET of the ureter with a good postoperative outcome. A literature review was also performed to identify similar cases to compare their management and postoperative outcomes.

Robotic assisted radical prostatectomy for localised prostate cancer in thalidomide generation.

Thalidomide was used in the late 1950s and early 1960s as a sedative for morning sickness in pregnant women. It resulted in thousands of babies being born with various congenital anomalies, such as phocomelia. Subsequently, the drug was banned for this indication. Most of the survivors have become thalidomide adults and now they are in their fifties. We report the first case of a robot-assisted radical prostatectomy in a 54-year-old male with prostate cancer and phocomelia as a result of thalidomide embryopathy. He presented with a PSA of 3.3 and was diagnosed with Gleason 3 + 4 prostate cancer. An extra peritoneal approach was chosen due to his body habitus and to avoid extreme Trendelenburg tilt. Side docking with the da Vinci robot was employed and the prostatectomy was carried out in the standard extra peritoneal fashion. At 6 months' follow-up his PSA is unrecordable and he is voiding well with minimal urinary incontinence, requiring 1 pad/day. We aim to outline our approach and highlight the technical modifications in this rare physically disabling condition.