Robotic-assisted magnetic resonance imaging ultrasound fusion results in higher significant cancer detection compared to cognitive prostate targeting in biopsy naive men.

BACKGROUND: To determine differences in cancer detection rates (CDRs) of regions of interest (ROI) on magnetic resonance imaging (MRI) with robotic-assisted (RA) targeted biopsies (RA-TB) compared to cognitive targeted biopsies (C-TB). METHODS: In a two-centre, retrospective outcome study, a total of 92 consecutive men who had a pre-biopsy MRI, were biopsy naïve and had a transperineal (TP) prostate biopsy between 9/2015 and 7/2017 were included. The primary analysis consists of 39 men who had C-TB and 53 men who had RA-TB. Outcomes from targeted biopsies were reported as CDR for clinically significant prostate cancer (csPC) and for any cancer. RESULTS: Targeted csCDR was higher in RA-TB vs. C-TB (32.1% vs. 10.3%, P=0.014). Targeted CDR of any cancer with Prostate Imaging Reporting and Data System (PI-RADS) 3-5 ROIs was also significantly higher in RA-TB compared to C-TB (47.2% vs. 12.8%, P=0.001). On multivariable analysis significant factors which affected the CDR for csPC was prostate volume only [odds ratio (OR) 1.04, 95% confidence interval (CI): 1.01-1.07]. For any cancer, the CDR was related to prostate volume (OR 1.03, 95% CI: 1.01-1.06) and RA-TB (OR 5.97, 95% CI: 1.69-21.07). RA biopsy results in less acute urinary retention (1.9% vs. 12.8%, P=0.03), less prolonged haematuria (7.5% vs. 38.5%, P<0.01) and shortened biopsy times (24 vs. 32 min, P<0.001). CONCLUSIONS: RA targeted biopsy results in higher CDR for clinically significant cancers and any cancer. It also suffers lower complications compared to cognitive directed TP biopsy. The ease of use and standardisation of the robotic procedure may reduce the learning curve and increase biopsy accuracy.

Safety, efficacy and predictors of local recurrence after percutaneous radiofrequency ablation of biopsy-proven renal cell carcinoma.

PURPOSE: To evaluate the safety and efficacy of percutaneous radiofrequency ablation (RFA) for localised renal cell carcinoma (RCC) and examine potential associations between age, gender, tumour size, location, chronic kidney disease, comorbidities, learning curve and local recurrence. METHODS: We retrospectively analysed survival outcomes for patients with biopsy-proven RCC treated by RFA at Westmead Hospital. Complication data were gathered from all patients that underwent renal RFA. 3 and 5 year local recurrence-free (RFS), disease-free (DFS) and overall survival (OS) outcomes were reported. Univariate and multivariate analysis was used to examine each potential predictor. RESULTS: A total of 168 patients were eligible for the study. Forty-eight patients with biopsy-proven RCC had minimum 3-year follow-up. Our complication rate was 1.2 % (2/168) and local recurrence rate 10.4 % (5/48). Five-year RFS, DFS and OS were 86.8, 82.3 and 92.6 % on a median 4.1-year follow-up (IQR 3.4-4.9). None of the patient or tumour-specific characteristics were associated with RFS. CONCLUSION: Radiofrequency ablation performed at our centre was a safe and effective procedure with low complication rates and durable RFS. Tumour characteristics, comorbidities and learning curve were not associated with local recurrence.

Percutaneous radiofrequency ablation of small renal tumors using CT-guidance: a review and its current role.

PURPOSE: To provide key evidence-based strategies to improve outcomes of radiofrequency ablation and limit recurrences of small renal tumors. MATERIALS AND METHODS: The literature was searched via OvidSP MEDLINE from 1997 to current using MeSH terms. All levels of evidence and types of reports were reviewed. RESULTS: We comprehensively reviewed technical issues, mechanisms, imaging criteria, ablative success, enhancement within one month, contraindications, oncological efficacy, morbidity rates, and follow-up strategies. CONCLUSION: The technique is safe and effective. Tumors < 2.5 cm are statistically most likely to remain disease-free. Anterior tumors are contraindicated. Strict follow-up is needed to detect failures, most of which occur within 3 months and can be easily salvaged with repeat radiofrequency ablation. Homogeneous enhancement within 1 month is not necessarily a failure, and tends to disappear after 4 to 6 weeks. Multi-disciplinary meetings must occur to discuss each case prior to treatment.

Renal cell carcinoma: stage, grade and histology migration over the last 15 years in a large Australian surgical series.

OBJECTIVE: • To verify whether migration towards earlier-stage renal cell carcinoma (RCC), which has been observed in the USA over the last decade, also applies to Australia. PATIENTS AND METHODS: • Between January 1993 and December 2007, 547 nephrectomies performed in public and private hospitals in western Sydney were analysed from a retrospectively collected database. • Data were divided into three consecutive time groups. • Tumour-node-metastasis (TNM) stage as well as patient demographics, size, grade and histology of tumours and proportion of benign tumours were also assessed. RESULTS: • In all, 499 nephrectomies were performed for RCC. The median age was 62 years, with a male:female ratio of 1.9 : 1. Similarly sized tumours were identified in each time group [group 1 (1993-1997), 54.8 mm; group 2 (1998-2002), 52.0 mm; group 3 (2003-2007), 52.2 mm, P= 0.6]. • Pathological stage II disease decreased from 18.1 to 11.1%, but stage III disease showed an increase from 13.9 to 21.5% over that time period (P= 0.02). • The proportion of stage I and stage IV disease has remained relatively the same. There has been a statistically significant upward histological migration for the papillary subtype from 1.3 to 10.2% (P= 0.01). • There has also been an increasing representation of Fuhrman grade III tumours over time, from 17.6 to 30.8%, and a decreasing proportion of Fuhrman grade I tumours from 16.2 to 7.1% (P= 0.03). • There was a decrease in the incidence of benign tumours originally thought to be malignant on preoperative investigations, from 10% in group 1 to 4% in group 3 (P= 0.03). CONCLUSION: • The recent US phenomenon of migration towards earlier-stage, smaller RCCs as well as increased representation of benign tumours was not observed in the present study. The results of the present study, however, show an upward histological migration for papillary RCCs and an increasing representation of more aggressive Fuhrman grade III tumours.

Multidetector spiral CT renal angiography in the diagnosis of giant renal artery aneurysms.

A case of giant renal artery aneurysm in a 63-year-old man is presented. Renal artery aneurysms are rare (incidence of <1%) and this case is one of the largest giant renal artery aneurysms recorded in the literature. This case also demonstrates the value of multidetector spiral CT renal angiography (CTA) in the diagnosis, planning and treatment of renal aneurysms.

Multidetector spiral CT renal angiography in the diagnosis of renal artery fibromuscular dysplasia.

OBJECTIVE: The aim of this study was to evaluate the role and detection rate of multidetector spiral CT renal angiography (CTA) as compared with conventional angiography (CA), the commonly accepted gold standard, in the diagnosis of renal artery fibromuscular dysplasia (FMD). In addition, the role of CTA reconstructions (multiplanar reformatted images (MPR), maximum intensity projections (MIP) and shaded-surface display (SSD)) in the detection of FMD was also evaluated. MATERIALS AND METHODS: CTA results were retrospectively reviewed in 21 hypertensive patients with CA-proven FMD. Clinical indications for referral included resistant hypertension (requiring greater than three antihypertensive medications), labile hypertension, hypertension in combination with renal impairment and the presence of abdominal bruits in the context of systemic hypertension. In some cases, these clinical indications were supplemented by positive results in other tests, including plasma renin assay, captopril scintigraphy and/or Doppler ultrasound. The findings of CA in these 21 patients were compared to CTA. RESULTS: Mean patient age was 62.33+14.32 years (range 24-85 years). CTA identified all 42 main renal arteries (100%) and all 10 accessory renal arteries (100%) visualized on CA. In the diagnosis of FMD, CTA detected all 40 (100%) lesions detected by CA. No single CTA reconstruction technique was able to detect all lesions noted on corresponding CA, however, upon review of all CTA reconstructions (MPR, MIP and SSD) in each case, every lesion was correctly identified by CTA. CONCLUSION: Our experience suggests that CTA is a non-invasive, reliable and accurate method for the diagnosis of renal artery fibromuscular dysplasia. Moreover, in our experience CTA has many advantages as a diagnostic screening tool over CA, including accessibility, speed, lower complication profile, versatility and cost-effectiveness. CTA shows great potential as a guiding tool for directing subsequent procedures such as CA+balloon angioplasty.

Renal tumors: technical success and early clinical experience with radiofrequency ablation of 18 tumors.

PURPOSE: To evaluate the feasibility, safety, and technical efficacy of image-guided radiofrequency ablation (RFA) for the treatment of small peripheral renal tumors and to report our early results with this treatment modality. METHODS: Twenty-two RFA sessions for 18 tumors were performed in 11 patients with renal tumors. Indications included coexistent morbidity, high surgical or anesthetic risk, solitary kidney, and hereditary predisposition to renal cell carcinoma. Ten patients had CT-guided percutaneous RFA performed on an outpatient basis. One patient had open intraoperative ultrasound-guided RFA. Technical success was defined as elimination of areas that enhanced at imaging within the entire tumor. With the exception of one patient with renal insufficiency who required gadolinium-enhanced MRI, the remaining patients underwent contrast-enhanced CT for post-treatment follow-up assessment. Follow-up was performed after 2-4 weeks and then at 3, 6, 12 months, and every 12 months thereafter. RESULTS: Fourteen (78%) of 18 tumors were successfully ablated with one session. Three of the remaining four tumors required two sessions for successful ablation. One tumor will require a third session for areas of persistent enhancement. Mean patient age was 72.82 +/- 10.43 years. Mean tumor size was 1.95 +/- 0.79 cm. Mean follow-up time was 10.91 months. All procedures were performed without any major complications. CONCLUSIONS: Our early experience with percutaneous image-guided radiofrequency ablation demonstrates it to be a feasible, safe, noninvasive, and effective treatment of small peripheral renal tumors.

Helical CT in the diagnosis of acute lower gastrointestinal haemorrhage.

INTRODUCTION: A pilot study to evaluate helical computer tomography (CT) as a diagnostic tool for acute lower gastrointestinal tract (GIT) bleeding. CT was compared to conventional angiography (CA) and colonoscopy for the diagnosis and detection of bleeding site in suspected cases of acute lower GIT bleeding. METHODS: Seven patients presenting with acute lower GIT bleeding, between June and November 2002, underwent CT examinations. All of these seven patients underwent CA following CT. Emergency colonoscopies were performed on five patients investigated with both CT and CA. Median delay from the most recent episode of hematochezia to CT was two and a half hours, to CA was 3h, and to colonoscopy was 4h. None of the patients underwent nuclear medicine (NM) bleeding studies. RESULTS: Haemoglobin drop in all patients was greater than 15 g/L in the first 24h of presentation. The mean age was 68.86 years (range, 49-83 years). Comparing CT and CA, there were four concordant and three discordant results. Both modalities had concordant findings of two active bleeding sites, one non-bleeding rectal tumour, and one negative case result. In three patients, the source of bleeding was found on CT whereas CA was negative. Emergency colonoscopies performed in all of these three patients confirmed blood in the colon/ileum. CONCLUSION: Early experience suggests that CT is a safe, convenient and accurate diagnostic tool for acute lower GIT haemorrhage. It raises questions regarding the sensitivity of CA. A new management algorithm for acute lower GIT haemorrhage using CT as the pre-CA screening tool is being proposed based on the preliminary findings. Positive CT will allow directed therapeutic angiography, while negative CT will triage patients into alternative management pathways.