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.

Is it time for anatomists to enter the OT? Their role in clinical anatomy education of residents: A pre-trial survey research among surgeons.

OBJECTIVE: This study aimed to assess the perceived need among surgical residents to revisit their anatomical knowledge and evaluate their attitude towards integrating clinical anatomists into surgical residency program curriculum. BACKGROUND: While medical students learn human anatomy during undergraduate years, the practical application of clinically oriented anatomy becomes vital in surgical specialties. However, this aspect has not been adequately addressed in Indian surgical residency programs. METHODS: An 11-item questionnaire, including closed-ended and Likert-scale questions, was administered to 153 surgical residents. Consent was obtained, and responses were collected via Google Forms. RESULTS: Half of the respondents (50%) felt confident in their self-directed anatomy learning, but 87% believed integrating clinical anatomists would enhance their surgical expertise. Additionally, 88% saw value in revisiting cadaveric dissection. Third-year residents showed a significantly higher inclination towards cadaveric dissection. Deficiencies in the curriculum and time constraints were identified as major barriers. CONCLUSION: The study highlights a perceived need among surgical residents to augment their anatomical knowledge, advocating for the integration of clinical anatomists and cadaveric dissection into training. A collaborative approach, emphasizing both horizontal and vertical integration of anatomy, is recommended to enhance surgical education and practice. (Tab. 4, Fig. 1, Ref. 25).

Gynaecological organ involvement in females undergoing radical cystectomy: a multicentre study.

OBJECTIVE: To report the incidence of malignancy in gynaecological organs removed during radical cystectomy (RC). PATIENTS AND METHODS: A retrospective multicentre study of 1600 RCs at three high-volume institutions between January 2009 and March 2022 was performed. Pathological findings in gynaecological organs in female RC specimens were reviewed. Multivariable logistic regression analyses were used to identify predictors of malignant gynaecological organ involvement (GOI) at time of RC. RESULTS: Overall, 302 females with a median (interquartile range) age of 68 (61-75) years underwent RC for clinical (c)Ta-T4 bladder cancer. In all, 56 patients (18.5%) received neoadjuvant chemotherapy. Malignant GOI was seen in 20 patients (6.6%); the most common single sites of GOI were the uterus (five patients) and vaginal wall (four), followed by cervix (one), and ovaries (one). Nine patients had involvement of more than one gynaecological organ. No females had a primary gynaecological malignancy detected incidentally at RC. Patients with GOI were more likely to have cT3/T4 stage (P < 0.001), preoperative hydronephrosis (P = 0.004), lymphovascular invasion (P = 0.002), and squamous cell carcinoma (P = 0.005) than those without GOI. On multivariable analysis, cT4 stage was an independent predictor of malignant GOI (odds ratio 88.3, 95% confidence interval 10.1-1214; P < 0.001). CONCLUSION: To our knowledge, we present the largest multi-institutional study examining malignant GOI in females with bladder cancer undergoing RC. The rate of GOI at the time of RC is low and associated with higher clinical stage. In the absence of clinical or radiological evidence of sexual organ involvement, our results do not support their routine removal at the time of RC.

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.

Self-removal of catheter after robot-assisted radical prostatectomy: a feasibility study.

Self-removal of urinary catheter as an option after robot-assisted radical prostatectomy (RARP) has never been explored in literature. We report the feasibility and outcome of the first study of this novel concept in our hospital. We conducted a prospective audit of self-TWOC (trial without catheter) in men who underwent consecutive RARP in our centre between April 2022 and September 2022. Men who had self-TWOC filled a questionnaire about the outcomes of self-TWOC. Carbon footprint and carbon offset for each hospital TWOC avoided were calculated. Of the 129 who underwent self-TWOC, 112 filled the questionnaire and were hence included in the final analysis. Self-TWOC was successful in all the 112 (100%) men in the study. 99.1% of men were satisfied with self-TWOC at home. We managed to avoid 79.6 ± 36.72 km of travel and 77 min of travel time for every self-TWOC. This also saved 85£/patient on clinic expenses and fuel cost savings of 9.87-15.99£ per patient depending on car engine size/type. The carbon footprint calculated was 20 kg CO2 assuming average engine sized diesel/petrol cars and 10 kg CO2 for an average UK petrol hybrid car. The calculated carbon offset per patient for diesel/petrol cars: 0.32£, petrol hybrid: 0.16£. Self-TWOC for 80-160 patients will save the carbon emissions equivalent to that of a passenger on a London-New York Trans-Atlantic flight. Self-TWOC is safe, affordable and is sustainable to the environment. Widespread acceptance of this practice change will be a small, but steady step towards greener health systems across the world.

Urinary Bladder Diverticulum: A Single-Center Experience in the Management of Refractory Lower Urinary Symptoms Using a Robotic Platform.

Introduction Urinary bladder diverticulum (UBD) is commonly seen in urological practice and, in most cases, does not need treatment specifically directed towards it. However, it can give rise to symptoms that are not distinct from this finding. This makes the evaluation and management of this complex patient group challenging. We present our experience with robotic bladder diverticulectomy (RBD) for acquired bladder diverticulum to assess the outcomes and safety of this procedure when patient symptoms have failed to respond to either medical or surgical treatment directed at other associated contributing factors. Methods We retrospectively collected data on all patients who underwent RBD for persistent lower urinary tract symptoms (LUTS) at Royal Surrey County Hospital, Guildford, between 2016 and 2021, including baseline characteristics, urodynamic findings, intraoperative and postoperative outcomes, and a six-month follow-up. Patients who were diagnosed with cancer in the diverticulum, associated pathology that may contribute to their symptoms, or who had concomitant procedures at the time of RBD were excluded from this study. Results We had six patients who underwent RBD; the median age and body mass index (BMI) were 63.8 years (range 48-73) and 27.1 kg/m2 (range 24-32), respectively. The most common presenting symptoms were refractory LUTS and recurrent urinary tract infections (UTIs). The urodynamic evaluation revealed varying findings like bladder outlet obstruction (BOO), poor compliance, and equivocal readings in these patients. All patients reported incomplete bladder emptying and double voiding, with half practicing clean intermittent self-catheterization (CISC). Diverticulum size averaged 9.4 cm (range 8.5-12). The median operative time and blood loss were 166 mins (range 150-180) and 75 mls (range 50-100), respectively. The average length of stay was 1.6 days (range 1-3). Three patients developed UTIs within a month after surgery, requiring a course of oral antibiotics. Post-void residual (PVR) measured an average of 32.6 mls (range 0-161) postoperatively compared to a preoperative average of 249 mls (range 125-400), showing a two-tailed p-value of 0.016. The International Prostate Symptom Score (IPSS) score for these patients showed an average of 27.83 (range 24-31) preoperatively compared to the postoperative average of eight (range 7-12), showing a two-tailed p-value of 0.0001. Final histology showed no malignancy, and all patients reported symptom improvement, with none requiring CISC after surgery. Conclusion RBD is a safe and effective procedure in carefully selected patients with refractory LUTS and UTIs showing good postoperative and functional outcomes. The presence of a large diverticulum can have a complex effect on bladder dynamics. In the era of robotic surgery and enhanced recovery, discussion about diverticulectomy should be encouraged after proper evaluation and counseling for patients who have failed to improve with other measures of treatment for their symptoms.

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.

Minimally invasive pelvic exenteration for gynaecological malignancy: A single-centre case series and review of the literature.

For those with certain recurrent gynaecological cancers where primary management such as chemo-radiotherapy has failed, or in cases of recurrence following primary surgery, pelvic exenteration (PE) is considered the only curative option. Whilst initially considered a morbid procedure, improved surgical techniques, advancing technology, and nuanced reconstructive options have facilitated more radical resections and improved morbidity and mortality. Open PE remains the gold standard approach, however, minimally invasive techniques for PE may lessen morbidity whilst achieving the same oncological outcomes. The objective of this study was to assess the feasibility and safety of minimally invasive PE with a laparoscopic or robot-assisted approach. We also performed a review of the literature on robot-assisted PE which has not been widely reported for cases of recurrent gynaecological malignancy. Between 2015 and 2021six minimally invasive PE were performed. All patients underwent extensive multi-disciplinary assessment and counselling pre-operatively. Patient characteristics, treatment indication, perioperative data, short-term complications, and histological outcomes were recorded. There were two anterior exenterations, three posterior exenterations and one total exenteration performed. The primary cancer stage varied from stage 1a-3b. Five out of six patients had pre-operative chemo-radiotherapy. The average operative time (including surgical docking) was 600 min. Mean blood loss was 400 mL and the average length of stay was eight days. Enhanced recovery practices were used where possible. There were no intraoperative complications and one major post-operative complicationwhich was breakdown of an inferior gluteal artery perforator flap perineal reconstruction. All patients had negative margins at post-operative histopathology. All patients are alive and recurrence free at follow-up, but long-term outcome data is needed. This initial case series suggest that minimally invasive pelvic exenterationcan feasibly be performed in place of open pelvic exenteration. Furthermore, our findings suggest this may be a safe alternative as we report similar findings to the existing literature, however no firm conclusions can be drawn at such an early stage. Long term follow-up data and a larger cohort study will be needed to establish non-inferiority to open PE.

Robot-assisted salvage seminal vesicle excision for isolated recurrence after low-dose-rate prostate brachytherapy.

OBJECTIVES: To report clinical and functional outcomes for patients who have undergone salvage robot-assisted seminal vesicle excision (RA-SVE) for the focal treatment of isolated seminal vesical (SV) recurrence after treatment for prostate cancer by low-dose-rate brachytherapy. PATIENTS AND METHODS: Patients with rising prostate-specific antigen (PSA) after low-dose-rate prostate brachytherapy (LDR-PB) underwent multi-parametric magnetic resonance imaging (mp-MRI) of the prostate and 11 C-Choline or 68 Ga-prostate-specific membrane antigen (68 Ga-PSMA) positron emission tomography/computed tomography (PET/CT) scan, followed by targeted transperineal biopsy of the prostate and SVs. Isolated SV recurrence were identified in 17 (0.38%) LDR-PB patients. These 17 patients were offered RA-SVE. RESULTS: The median total operative time was 90 min and blood loss 50 mL with no postoperative transfusions required. The median hospital stay was 1 day. No intra- or postoperative complications were documented. Continence status was unaffected, no patient required urinary pads. Postoperative pathology confirmed SV invasion in all specimens. Surgical margins were positive in seven (41%) patients. All patients had at least one positive imaging study, although three (18%) mp-MRI and five (29%) PET/CT assessments were negative. One (6%) pre-SVE biopsy was also negative but with positive imaging. Salvage SVE failure, defined as three consecutive PSA rises or the need for further treatment, occurred in six patients of whom three had a positive margin. Overall failure-free survival rates were 86%, 67%, and 53% at 1, 2, and 3 years after SVE, respectively. CONCLUSIONS: Salvage RA-SVE appears to be a safe focal treatment, with very low morbidity, for patients with localised SV recurrence after LDR-PB. It permits deferral of androgen deprivation therapy in selected patients. Bilateral SVE is mandatory. This surgical option should be considered in patients with isolated prostate cancer recurrence to the SV.

Radicular Cyst Involving Deciduous Maxillary Incisor along with Bilateral Supernumerary Teeth: A Case Report.

Radicular cyst involving the deciduous dentition is rare. Most of the cases reported it with primary molar teeth with apical infection. But very rare literature is available regarding radicular cysts associated with primary incisors. Case report: A case of 9-year-old boy, who had bilaterally impacted supernumerary teeth, had developed a radicular cyst associated with a previously traumatized and intruded right upper primary lateral incisor is reported. Supernumerary teeth and intruded primary lateral incisor were removed along with enucleation of a radicular cyst. Conclusion: The importance of correct diagnosis and management of radicular cyst in pediatric patients is important as most of the radicular cysts of primary teeth go undiagnosed, which can affect the developing succedaneous tooth bud. How to cite this article: Bhosale AN, Desai S, Patil S, et al. Radicular Cyst Involving Deciduous Maxillary Incisor along with Bilateral Supernumerary Teeth: A Case Report. Int J Clin Pediatr Dent 2022;15(2):218-221.

The impact of COVID-19 on surgical volume and surgical training at a high-volume pelvic oncology centre.

INTRODUCTION: The coronavirus (COVID-19) pandemic has overwhelmed most health services. As a result, many surgeries have been deferred and diagnoses delayed. The aim of this study was to assess the effect of the COVID-19 pandemic at a high-volume pelvic oncology centre. METHODS: A retrospective review was performed of clinical activity from 2017 to 2020. We compared caseload for index procedures 2017-2019 (period 1) versus 2020 (period 2) to see the effect of the COVID pandemic. We then compared the activity during the first lockdown (March 23rd) to the rest of the year when we increased our theatre access by utilising a 'clean' site. RESULTS: The average annual number of robotic assisted radical cystectomy (RARC) and robotic assisted radical prostatectomy (RARP) performed during period 1 was 82 and 352 respectively. This reduced to 68 (17.1% reduction) and 262 (25.6% reduction) during period 2. The number of patients who underwent prostate brachytherapy decreased from 308 to 243 (21% reduction). The number of prostate biopsies decreased from 420 to 234 (44.3% reduction). The number of radical orchidectomies decreased from 18 to 11 (39% reduction). The mean number of RARC and RARP per month during period 2 was 5.5 and 22. This decreased to 4 and 9 per month during the first national lockdown but was maintained thereafter despite two further lockdowns. CONCLUSION: There has been a substantial decrease in urological oncology caseload during the COVID pandemic. The use of alternate pathways such as 'clean' sites can ensure continuity of care for cancer surgery and training needs.

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.

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.

Cone Beam Computed Tomography Heralding New Vistas in Appropriate Diagnosis and Efficient Management of Incidentally Found Impacted Mesiodens.

As dentistry continues to go "digital," the field has seen a phenomenal increase in the use of digital imaging in dental practice. Complex impacted mesiodens present potential treatment complications and sometimes possible patient morbidity. Objectives of diagnostic imaging are to aid in diagnosis, decision making, and enhance treatment outcomes. As cases become more complex, sophisticated multiplane imaging methods allowing for a three-dimensional view are more likely to meet these objectives as opposed to traditional two-dimensional radiography. The clinical report elucidates with the help of an illustrative patient how cone beam computed tomography imaging can assist the surgeon during surgical treatment planning, risk assessment, and treatment outcomes of impacted mesiodens.

Non-IgA mesangioproliferative glomerulonephritis: a benign entity?

BACKGROUND: Non-IgA mesangioproliferative glomerulonephritis is a well recognized but less studied entity. The clinical manifestations, treatment response and long-term outcome have not been clearly defined. METHODS: This single-centre study included patients with biopsy-proven non-IgA mesangioproliferative glomerulonephritis who had been on regular follow-up for >3 years. Their clinical features at presentation, response to therapy and long-term renal outcome are addressed in this study. RESULTS: Nephrotic syndrome developed in 51 of 57 patients (89.4%). The majority of them--34 of 51(80%)--were steroid sensitive and had either infrequent or no relapse. However, steroid-dependent nephrotic syndrome occurred in eight patients (15.6%), while steroid resistance occurred in nine patients (17.6 %). Thirteen patients developed chronic kidney disease (CKD) with three progressing to end-stage renal disease, three to CKD Stage 4 and seven to CKD Stage 3. CONCLUSIONS: Non-IgA mesangioproliferative glomerulonephritis is a disease, which is not benign, and is associated with significant treatment-related morbidity.