Optilume® drug-coated balloon dilation for the treatment of refractory post-TURP bladder neck contracture.

This case report presents the first use of Optilume® drug-coated balloon (DCB) technology for the management of post-transurethral resection of the prostate bladder neck contracture (BNC), a condition often resistant to traditional treatments. A 62-year-old male with recurrent BNC, unresponsive to multiple operative interventions, underwent treatment with the Optilume® DCB, resulting in significant symptom resolution without further invasive procedures. This novel application of DCB technology, delivering paclitaxel directly to the affected tissue, offers a promising alternative by targeting the underlying pathophysiology of BNC.

Corrigendum to "RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned" [Eur. Urol. Open Sci. 54 (2023) 33-42].

[This corrects the article DOI: 10.1016/j.euros.2023.05.007.].

Urology case report - Emergency penectomy for the transfeminine patient.

Management of gender dysphoria and healthcare for transgender and non-binary patients is a growing field in Australia and abroad. Currently, gender-affirming surgery is not offered under Australia's national public health insurance. We present an unusual case of emergency penectomy required for a 57-year-old woman assigned-male-at-birth from rural Australia after a self-inflicted chemical burn. This case report outlines the surgical challenges of partial penectomy and neo meatus formation to allow for future gender-affirming surgery and highlights the lack of infrastructure within the public healthcare system for management of gender dysphoria both in rural and metropolitan settings.

Midline extraperitoneal approach to retroperitoneal pathology - broadening the horizons.

We present an explanation of approach to open midline extraperitoneal surgery for the management of retroperitoneal pathology. Included are diagrammatic and intra-operative images to better explain the approach, as well as discussion regarding the technique.

Association between ureteric stent dwell time and urinary tract infection.

BACKGROUND: Ureteric stone obstruction commonly presents to the emergency department, with definitive management often involving ureteroscopy and laser lithotripsy. Insertion of a ureteric stent prior to staged lithotripsy is commonly performed in the public healthcare system. Foreign bodies in the urinary tract are also known to increase urinary tract infection (UTI) risk. This study aims to evaluate the association between stent dwell time and UTI prior to lithotripsy. METHODS: The medical records of all patients who were treated for ureteric stones with initial stent insertion and staged lithotripsy, from 1 January 2018 to 30 June 2019 at a single tertiary centre, by eight urologists were retrospectively reviewed. Demographic features, disease factors and urine culture data were collected and analysed. RESULTS: Of the 172 patients (median age 56.7 years) identified, one-third had a positive pre-stent urine culture. Twenty-three percent had a positive pre-lithotripsy urine culture with 38% of females compared with 15% of males having a positive culture (P = 0.001). Only 4.3% of patients had a pre-lithotripsy UTI when the stent dwell time was less than 1 month compared with 26.2% when ureteric stents were in situ for longer than 1 month (P = 0.021). The correlation between ureteric stent dwell time and pre-lithotripsy UTI was not linear. Patient comorbidities, stone size, burden and location were not statistically correlated to pre-lithotripsy UTI. CONCLUSION: In delayed two-staged surgical management of acute urolithiasis, optimal ureteric stent dwell time is less than 1 month to reduce pre-lithotripsy UTI. Female gender is an independent risk factor for pre-lithotripsy UTI.

Results of a Prospective Dose Escalation Study of Linear Accelerator-Based Virtual Brachytherapy (BOOSTER) for Prostate Cancer; Virtual HDR Brachytherapy for Prostate Cancer.

PURPOSE: To demonstrate feasibility and toxicity of linear accelerator-based stereotactic radiation therapy boost (SBRT) for prostate cancer, mimicking a high-dose-rate brachytherapy boost. METHODS AND MATERIALS: A phase 1 sequential dose escalation study of SBRT compared 20 Gy, 22 Gy, and 24 Gy to the prostate and 25 Gy, 27.5 Gy, and 30 Gy to the gross tumor volume in 2 fractions, combined with 46 Gy in 23 fractions of external beam radiation. Feasibility of dose escalation (volume receiving 125% and 150% of the dose) while meeting organ-at-risk dose constraints, grade 2 acute and late gastrointestinal and genitourinary toxicity, and freedom from biochemical failure were secondary endpoints. RESULTS: Thirty-six men with intermediate- and high-risk prostate cancer were enrolled with a median follow-up of 24 months. Sixty-four percent of patients had high-risk features. Nine men were enrolled to dose level 1, 6 to level 2, and 6 to level 3. Another 15 patients were treated at dose level 3 on the continuation study. Dose level 3 achieved superior 125% (23.75 Gy) and 150% (28.5 Gy) dose compared to dose levels 1 and 2, with minimal differences in organ-at-risk doses. Kaplan-Meier estimate of freedom from biochemical failure at 3 years was 93.3%. There were no late grade 2 or 3 gastrointestinal events. The late grade 2 genitourinary toxicity at 2 years was 19.3%. Prostate-specific membrane antigen positron emission tomography was performed at 2 years with no local recurrences. CONCLUSIONS: We have shown that a linear accelerator-based SBRT boost for prostate cancer is feasible and can achieve doses comparable to high-dose-rate boost up to the 150% isodose volumes. Rectal, bladder, and urethral doses remained low, and long-term toxicity was the same as or better than previous reports from high-dose-rate or low-dose-rate boost protocols.

Contemporary salvage post prostatectomy radiotherapy: Early implementation improves biochemical control.

INTRODUCTION: The optimal time to commence salvage radiotherapy (SRT) for a rising PSA post radical prostatectomy is not known. We wished to assess the impact of index PSA (iPSA) level prior to SRT on rates of biochemical failure (BCF) post treatment. METHODS: Patients referred to our institution for SRT for a rising PSA post surgery were accrued onto a prospective database. Baseline demographic data, tumour and treatment factors were collected including pathologic T and N stage, margin status, Gleason score (GS), lymphovascular space invasion (LVSI), use of androgen deprivation therapy (ADT) and time from surgery to salvage radiotherapy. Our endpoint was time to BCF. RESULTS: Between January 2008 and December 2013, 189 patients received SRT to a mean dose of 69.8 Gy in 34 fractions using Intensity Modulated Radiotherapy (IMRT). Median follow-up was 50 months. For patients with an iPSA of <0.2 ng/mL (n = 92), iPSA ≥ 0.2 to <1.0 ng/mL (n = 75) and ≥ 1.0 ng/mL (n = 22), rates of BCF at 5 years were 28.3%, 44.3% and 73.7% respectively. Compared to the iPSA <0.2 ng/mL group, the hazard ratios for time to BCF for an iPSA ≥ 0.2 to <1.0 ng/mL was 1.73 (P = 0.05) and >1.0 ng/mL was 3.1 (P = 0.002). Factors predicting time to BCF on univariate analysis included iPSA, GS, T stage, PSA nadir post surgery and LVSI. On multivariate analysis, GS, iPSA, use of ADT, T stage, PSA post surgery nadir and margin status remained significant. CONCLUSION: Rising iPSA levels are associated with an increasing risk of biochemical failure after adjusting for known prognostic factors and early salvage post prostatectomy radiotherapy is recommended.

A multiparametric magnetic resonance imaging-based risk model to determine the risk of significant prostate cancer prior to biopsy.

OBJECTIVE: To develop and externally validate a predictive model for detection of significant prostate cancer. PATIENTS AND METHODS: Development of the model was based on a prospective cohort including 393 men who underwent multiparametric magnetic resonance imaging (mpMRI) before biopsy. External validity of the model was then examined retrospectively in 198 men from a separate institution whom underwent mpMRI followed by biopsy for abnormal prostate-specific antigen (PSA) level or digital rectal examination (DRE). A model was developed with age, PSA level, DRE, prostate volume, previous biopsy, and Prostate Imaging Reporting and Data System (PIRADS) score, as predictors for significant prostate cancer (Gleason 7 with >5% grade 4, ≥20% cores positive or ≥7 mm of cancer in any core). Probability was studied via logistic regression. Discriminatory performance was quantified by concordance statistics and internally validated with bootstrap resampling. RESULTS: In all, 393 men had complete data and 149 (37.9%) had significant prostate cancer. While the variable model had good accuracy in predicting significant prostate cancer, area under the curve (AUC) of 0.80, the advanced model (incorporating mpMRI) had a significantly higher AUC of 0.88 (P < 0.001). The model was well calibrated in internal and external validation. Decision analysis showed that use of the advanced model in practice would improve biopsy outcome predictions. Clinical application of the model would reduce 28% of biopsies, whilst missing 2.6% significant prostate cancer. CONCLUSIONS: Individualised risk assessment of significant prostate cancer using a predictive model that incorporates mpMRI PIRADS score and clinical data allows a considerable reduction in unnecessary biopsies and reduction of the risk of over-detection of insignificant prostate cancer at the cost of a very small increase in the number of significant cancers missed.

Predictors of surgical approach for the management of renal cell carcinoma: a population-based study from New South Wales.

BACKGROUND: The simultaneous adoption of laparoscopy and partial nephrectomy (PN) has been reported to result in unintended consequences. We aim to examine the contemporary (2001-2009) trends in use of PN and laparoscopy within a population-wide database. METHODS: All renal cell carcinomas diagnosed between 2001 and 2009 in New South Wales, Australia, were identified from the Central Cancer Registry. Records of treatment were electronically linked. All patients with localized renal cell carcinoma who underwent surgical treatment were selected for this study (3771 patients). Follow-up was to the end of 2010. Multivariable logistic regression analysis was used to determine predictors of PN and laparoscopy. RESULTS: In the entire cohort, 150 (4%), 495 (13%), 1516 (40%) and 1610 (43%) received laparoscopic PN, open PN, laparoscopic radical nephrectomy (RN) and open RN, respectively. Between the years 2001 and 2009, there was a gradual increase in the use of PN except between 2005 and 2007. Between 2001 and 2009, a rapid uptake of laparoscopy was observed. Multivariable analysis demonstrated that age (OR: 0.99 (0.98-0.99)), year of surgery (OR: 1.15 (1.11-1.19)), comorbidity (OR: 1.40 (1.12-1.76)) and hospital case load >8/year (OR: 2.39 (1.49-3.81)) predicted use of PN. Year of surgery (OR: 1.19 (1.15-1.21)), comorbidity (OR: 0.70 (0.58-0.85)), non-teaching hospital (OR: 0.70 (0.53-0.93)), private hospital (OR: 1.86 (1.45-2.38)) and hospital case load > 8/year (OR: 3.36 (2.22-5.09)) predicted use of laparoscopy. CONCLUSION: The unintended decrease in PN associated with increased use of laparoscopic RN had reversed by 2009. Hospital case load predicts the use of PN and laparoscopy.

The effect of the modified Z trendelenburg position on intraocular pressure during robotic assisted laparoscopic radical prostatectomy: a randomized, controlled study.

PURPOSE: The Trendelenburg position has a dramatic effect on circulation, consequently increasing cerebral and intraocular pressure. We evaluated whether modifying the Trendelenburg position would minimize the increase in intraocular pressure. MATERIALS AND METHODS: In this prospective, randomized, controlled study we compared intraocular pressure in patients undergoing robot-assisted laparoscopic radical prostatectomy while in the Trendelenburg position or the modified Z Trendelenburg position. In group 1 intraocular pressure, blood pressure and endotracheal CO2 were measured in the patient at anesthesia induction (time 1), before positioning (time 2), and while in the Trendelenburg position (time 3) and in the modified Z Trendelenburg position (time 4). They were also measured after pneumoperitoneum (time 5), every 30 minutes (times 6 to 16), while supine at the end of pneumoperitoneum (time 17) and before awakening (time 18). We modified the Trendelenburg position by placing the head and shoulders horizontally. RESULTS: Group 1 included 29 patients in the modified Z Trendelenburg position. Group 2 included 21 patients in the Trendelenburg position. No difference was found in patient demographics or surgical outcomes. Median intraocular pressure was in the low normal range at times 1 and 2, and increased in time 3 in each group. From time 4 intraocular pressure decreased and at all time points it was significantly lower in group 1 by a mean of 4.61 mm Hg (95% CI -6.90-2.30, p <0.001). At time 17 mean intraocular pressure decreased to normal (19.6 mm Hg) in group 1 but remained in the hypertensive range (24.9 mm Hg) in group 2. At time 18 mean intraocular pressure was 17 mm Hg in each group. Blood pressure was significantly lower in group 1 with a mean reduction in systolic and diastolic pressure of 6.3 and 4.3 mm Hg, respectively. CONCLUSIONS: Our results suggest that modifying the Trendelenburg position during robot-assisted laparoscopic radical prostatectomy has a significant positive effect on patient neuro-ocular safety by lowering intraocular pressure and accelerating its recovery to the normal range without affecting the operation.

Image-guided dose-escalated intensity-modulated radiation therapy for prostate cancer: treating to doses beyond 78 Gy.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? High doses of radiotherapy correspond to higher cure rates. Most radiation centers in the UK and Australia limit prescription doses to 74-78 Gy and do not use IGRT and IMRT for all patients. The combination of IGRT and IMRT can limit the rectum and bladder to low doses allowing doses above 78 Gy to be delivered, including pelvic lymph node treatment, with low side effects. This paper provides a detailed guide of planning technique and expected toxicity to enable implementation of similar dose escalated prostate programmes in other radiotherapy centres. OBJECTIVE: To determine the short-term side-effects of dose-escalated image-guided intensity-modulated radiation therapy (IG-IMRT) for the definitive treatment of prostate cancer. PATIENTS AND METHODS: Eligible patients were treated at doses >78 Gy and with definitive intent. Patients from a prospective database with International Prostate Symptom Score (IPSS) and Common Terminology Criteria for Adverse Events, version 3.0 (CTCAE) toxicity were recorded weekly during treatment and at follow-up. RESULTS: In all, 101 patients were included, with doses ranging from 78.3 to 84 Gy (median = 79.3). The median (range) age was 71 (46-83) years; 60% received concurrent androgen deprivation and 35% had pelvic lymph node treatment. The median (range) IPSS at baseline, on treatment and at first follow-up were 7 (0-35), 15 (1-34) and 6 (0-30), respectively. The percentages of patients with grade 2 or higher toxicity during treatment, at 3 months and at 2 years were, respectively, 6.9%, 1% and 2% for gastrointestinal symptoms and 39%, 6.9% and 3% for genitourinary symptoms. There was no significant difference in gastrointestinal toxicity during treatment (P= 0.860) or at 3 months (P= 0.334) between patients with and without lymph node treatment. CONCLUSION: Doses >78 Gy delivered using daily image guidance and IMRT are well tolerated, and by 3 months short-term side-effects have normalized for the majority of patients.