The Predictive Ability of Pre-Operative Magnetic Resonance Imaging to Detect Pathological Outcomes in Prostate Cancer

Aims Accurate preoperative knowledge of tumour stage is important in preoperative planning at radical prostatectomy (RP). The aim of this study was to assess the predictive ability of multiparametric MRI for detecting pathological outcomes. Methods A retrospective review was performed of all patients who underwent RP over a 4 year period. Results Preoperative MRI was reported as showing T3 or T4 disease in 26(17.9%) out of 145 patients undergoing RP. Of these, 10(6.9%) had ECE (extra-capsular extension) and 1(0.7%) had SVI (seminal vesicle invasion) on final histology. The sensitivity and specificity of MRI for detecting ECE were 27.3% and 87.6%, respectively. The sensitivity and specificity of MRI for detecting SVI were 11.1% and 97.8%, respectively. The positive predictive values for determining ECE and SVI were 45.5% and 25%, respectively and negative predictive values were 75.9% and 94.4%. Conclusion MRI has good specificity but poor and heterogeneous sensitivity for predicting T3 disease in RP specimen.

Aetiology, epidemiology and management strategies for blunt scrotal trauma.

OBJECTIVES: To describe our experience of all patients presenting to a tertiary referral centre over a 3 year time period with blunt scrotal trauma and to describe a methodical approach for managing this group of patients. METHODS: A retrospective analysis was performed on all patients presenting to the Emergency Department (ED) of a level 1 trauma centre with blunt scrotal trauma from 2010 to 2013 inclusive. Inclusion criteria included a recent history of blunt scrotal trauma with associated pain and/or swelling of the affected testis on clinical examination. RESULTS: Twenty-seven male patients with a median age of 19 (range 8-65) years were included and all but 1 patient underwent scrotal ultrasonography upon presentation. Sixteen patients (59%) presented with scrotal trauma secondary to a sports related injury. Fifteen patients were managed conservatively and of the 12 who underwent urgent exploration 9 had a testicular rupture, including 1 who had an emergency orchidectomy due to a completely shattered testis. Four patients had >30% of the testis replaced by necrotic tissue/haematoma; of which 2 ultimately underwent orchidectomy and insertion of testicular prosthesis. CONCLUSION: Our findings demonstrate that the necessity for scrotal protection in sports that predispose to scrotal trauma should be reviewed. We also demonstrate the importance of scrotal ultrasonography for determining an appropriate management strategy (i.e., conservative versus surgical treatment) in this young patient cohort.

Characteristics of modern Gleason 9/10 prostate adenocarcinoma: a single tertiary centre experience within the Republic of Ireland.

INTRODUCTION: The 2005 international society of urological pathology consensus statement on Gleason grading in prostate cancer revised Gleason scoring in clinical practice. The potential for grade migration with this refinement poses difficulties in interpreting historical series. We report the characteristics of a recent cohort of consecutive Gleason score 9 or 10 prostate cancers in our institution. The purpose of this study was to define the clinicopathologic variables and staging information for this high-risk population, and to identify whether traditional prostate staging techniques are adequate for this subcohort of men. MATERIALS AND METHODS: A computational review of our pathology database was performed. Between May 2010 and September 2012, 1,295 consecutive biopsies were undertaken, 168 of which were high-grade tumours (12.97 %). This group were divided into two cohorts of which 84 (12.05 %) had a highest reported Gleason score of 9 (N = 79) or 10 (N = 5) and 84 were reported as Gleason 8. All biopsies were double-reported by pathologists with a special interest in uropathology. RESULTS: Men diagnosed with a Gleason pattern 5 tumour were statistically far more likely to have advanced disease on direct rectal examination of the prostate compared with Gleason sum 8 tumours (p < 0.001) and a positive first-degree family history of prostate cancer (p < 0.001). Overall, Gleason sum 9/10 prostate cancers were also found to be statistically more aggressive than Gleason sum 8 tumours on TRUS core biopsy analysis with significantly higher levels of perineural invasion (p < 0.0001) and extracapsular extension (p = 0.001) as well as a higher levels of tumour found within the core biopsy sample. Those men diagnosed with Gleason pattern 5 prostate cancer also had radiological indicators of increased tumour aggressiveness compared with Gleason sum 8 cancer with respect to bone (p = 0.0002) and visceral (p = 0.044) metastases at presentation. CONCLUSIONS: This series of Gleason score 9/10 prostate cancers serves to highlight the large disease burden, adverse pathologic features, and locally advanced nature of this aggressive subtype, which has previously been under-described in the literature, and differs from historical series in having a large high-grade cohort demonstrating high rates of metastatic disease. A history of prostate cancer amongst first-degree relatives was particularly prevalent in this population raising the issue of screening in a high-risk population. The high incidence of visceral metastatic disease at presentation supports upfront staging with CT thorax, abdomen, and pelvis in patients with Gleason 9 or 10 prostate cancers.

Radical prostatectomy outcome when performed with PSA above 20 ng/ml.

Many centres currently do not offer radical prostatectomy (RP) to men with high-risk localised prostate cancer due to concerns regarding poor outcome, despite evidence to the contrary. We identified 18 men undergoing RP with serum PSA >20 ng/ml (high-risk by National Comprehensive Cancer Network definition) and minimum follow-up of 12 years (mean 13.5). Mean preoperative PSA was 37.0 ng/ml (Range 21.1-94.0). Prostatectomy pathology reported extracapsular disease in 16 (88.9%), positive surgical margins in 15 (83%) and positive pelvic lymph nodes in 5 (27.8%). Overall and cancer-specific survival at 5 and 10-years was 83.3%, 88.2%, 72% and 76.5% respectively. With complete follow-up 11 (61.1%) are alive, and 5 (27.8%) avoided any adjuvant therapy. Complete continence (defined as no involuntary urine leakage and no use of pads) was achieved in 60%, with partial continence in the remainder. We conclude that surgery for this aggressive variant of localised prostate cancer can result in satisfactory outcome.

Can pre-assessment of patients with LUTS result in early discharge from urology clinic?

Waiting times for appointments for urological out-patients in Ireland and the U.K. can be excessively long. Nurse-led Lower Urinary Tract symptom (LUTs) pre-assessment clinics have been introduced to streamline patient care pathways. We examined whether a nurse-led pre-assessment LUTS clinic could result in the rapid assessment and discharge of patients following their first out-patient visit. A pilot study was undertaken whereby patients referred with LUTS were sent for pre-assessment prior to their out-patients appointment. 214 consecutive patients underwent pre-assessment. Of these, 39 (18%) patients were discharged following their first out-patient visit and 27 (13%) patients were discharged after a second attendance. A further 35 (16%) patients continued to attend but underwent no further investigations or treatment, and possibly should have been discharged earlier. Overall 46% of pre-assessed patients could have been discharged early from the urology clinic. In conclusion a nurse-led pre-assessment LUTS clinic could result in the rapid assessment and discharge of patients following their first out-patient visit.

Should patients with symptomatic BPH have a trial of medical therapy by their general practitioner prior to referral for urological assessment?

The British Association of Urological Surgeons (BAUS) has recently recommended guidelines for the management of Lower Urinary Tract Sypmtoms by GPs outlining the indications for urological referral. We wished to assess the prescription of medical therapy by GPs in the referrals to our LUTS pre-assessment clinic. 115 consecutive patients were reviewed prospectively, over a three month period. Each patient was assessed for International Prostatic Symptom Score (IPSS) and Bother Score, uroflowometry with post void residual and whether medical therapy had been commenced (D-Blocker or 5-D-Reductase inhibitor). The majority of patients (75%) were classified with moderate symptoms. Only 10% of those with moderate symptoms and 5% of those with severe symptoms were commenced on medical therapy by their GP as recommended by the BAUS guidelines. Only 30 patients (26%) had completed an IPSS form with their GP. The majority of patients referred to our service for assessment of LUTS have at least moderate symptom severity and are not prescribed medical therapy by their GP. Further primary care education with greater emphasis on the BAUS LUTS algorithm prior to referral to an urologist should be encouraged.

Ireland's contribution to urology and nephrology research in the new millennium: a bibliometric analysis.

INTRODUCTION: Bibliometrics is the statistical analysis of written publications. Bibliometric analyses have been performed across a range of biomedical disciplines. The aim of this study was to provide a comprehensive qualitative and quantitative analysis of Irish urology and nephrology research and to analyse how this compares internationally. METHODS: We performed a retrospective bibliometric analysis of the top 20 ranking journals in the field of "Urology and Nephrology" based on their 5 years impact factor, as obtained from the ISI Journal Citation Report database over the 15-year study period, 2000-2015. Utilising the Pubmed database, a search phrase was constructed using country of affiliation, year of publication and journal title. The abstracts of the Irish publications identified were analysed for their institution of origin, article theme and content. RESULTS: A total of 67,740 article abstracts were analysed over the 15 years study period. As anticipated, the USA accounted for the largest number of publications by a country [28,206 (41.64 % of all articles)]. Ireland contributed 347 articles in total (0.51 % of all articles); however, ranking according to population per million was 13th worldwide. Ireland's contribution to urology and nephrology research was highest in the BJUI-British Journal of Urology International [76 articles (21.90 % of Irish total)]. CONCLUSION: We believe this study to be the largest bibliometric analysis in the field of urology and nephrology internationally. This study provides a novel overview of the current Irish urology- and nephrology-related research, and examines how our results compare within the international community.

Adaptation of the animal welfare assessment grid (AWAG) for monitoring animal welfare in zoological collections.

Animal welfare monitoring is an essential part of zoo management and a legal requirement in many countries. Historically, a variety of welfare audits have been proposed to assist zoo managers. Unfortunately, there are a number of issues with these assessments, including lack of species information, validated tests and the overall complexity of these audits which make them difficult to implement in practice. The animal welfare assessment grid (AWAG) has previously been proposed as an animal welfare monitoring tool for animals used in research programmes. This computer-based system was successfully adapted for use in a zoo setting with two taxonomic groups: primates and birds. This tool is simple to use and provides continuous monitoring based on cumulative lifetime assessment. It is suggested as an alternative, practical method for welfare monitoring in zoos.

Testicular vasculitis mimicking a testicular neoplasm.

Vasculitis of the testis generally presents as a manifestation of systemic vasculitis which is well documented. In isolation, it has only been described on few occasions previously, and hitherto it has been in the young. It often mimics a neoplasm of the testis resulting in radical orchidectomy, only for it to be diagnosed when the specimen is examined under the microscope. In our case, an elderly man presented to us with a presumed testicular neoplasm, however, despite strong clinical and radiological suspicion a testicular vasculitis in isolation was revealed. Following our experience, we performed a literature review and examined all of the cases of testicular vasculitis reported so far and present our findings. We report the general clinical presentation, methods of investigation and subsequent management. This is the first time it has been described in the elderly population.

Right heart thrombus: recognition, diagnosis and management.

The clinical, echocardiographic, hemodynamic, angiographic and pathologic features of five patients who had right heart thrombus are presented and their management is discussed. Two modes of presentation were recognized. In four patients, right heart thrombus complicated peripheral venous thrombosis and was associated with major pulmonary thromboembolism and right heart obstruction. In the fifth, it complicated myocarditis with heart failure and appeared to cause right heart obstruction. Two-dimensional echocardiography was diagnostic of right heart thrombus in four patients and showed evidence of right heart dysfunction in those with major pulmonary thromboembolism. The diagnosis was confirmed at surgery in three patients and at autopsy in one. Three patients successfully underwent surgical removal of the thrombus followed by anticoagulation. One patient was treated successfully with anticoagulation alone. The only death occurred in the patient with myocarditis.

Attitudes among junior doctors towards improving the transurethral catheterisation process.

OBJECTIVES: To evaluate the subjective opinions of junior doctors on their adequacy of training and confidence levels for performing transurethral catheterisation (TUC) and to investigate their subjective interest in a 'safety mechanism' that would eliminate the potential for urethral trauma during TUC. METHODS: An anonymous online survey was emailed to all interns that had a documented email address on the Royal College of Surgeons Ireland registry (2012-2013). The survey consisted of eight questions pertaining to TUC of male patients. RESULTS: The survey was delivered to 252 email addresses and the response rate was 52% (130/252). The vast majority (99%; n = 128) of interns felt confident inserting a transurethral catheter independently and 73% (n = 95) subjectively received appropriate training for catheterising male patients. The incidence of trauma after mistakenly inflating the catheter's anchoring balloon in the urethra was 3% (n = 4). The majority (90%; n = 116) of respondents were interested in a safety mechanism for preventing urethral trauma and 71% (n = 92) felt that a safety mechanism for urethral trauma prevention should be compulsory for all transurethral catheterisation among male patients. CONCLUSION: Despite pre-emptive training programmes, it appears that iatrogenic urethral trauma secondary to TUC remains a persistent morbidity in healthcare settings. Designing a safer transurethral catheter may be necessary to eliminate the risk of unnecessary urethral trauma in patients.

The prevalence of infective endocarditis after aortic valve replacement.

Replacement valve endocarditis occurred in 3.7% of 2443 patients who underwent primary or redo aortic valve replacements at The Prince Charles Hospital between December 31, 1969 and January 1, 1992, based on a cross-sectional follow-up in 1992 which was 98.8% complete. Because some patients had re-replacements during the study period, a total of 2686 operations were considered for analysis. A variety of replacement devices were used, including 571 allografts (21%), 1152 xenografts (43%), and 880 mechanical valves (36%). Insertion of an allograft valve resulted in a constant risk of endocarditis which, by multivariable hazard function analysis, negated the effect of any early-phase factors (p < 0.0001). With other replacement devices, the risk of infection peaked early after operation (9 weeks) and then gave way to a constant risk. Compared with the risk associated with allograft valves, constant risk was higher when the replacement device was a Carpentier-Edwards xenograft (n = 1021, p = 0.02) and lower when a St. Jude Medical mechanical valve was used (n = 505, p = 0.05). In nonallograft recipients, the presence of active preoperative endocarditis (p < 0.0001) or a concomitant synthetic synthetic aortic root replacement (p = 0.0006) increased the magnitude of the early peaking risk. Regardless of replacement device, constant risk was increased in patients with renal dysfunction (p = 0.01), in younger patients 0.04). When preoperative endocarditis was caused by Staphylococcus aureus, culture-positive postoperative wound infection was associated with increased risk of replacement valve infection (p < 0.001) and when it occurred, the same organism was usually responsible (86%). Identification of patients at increased risk for replacement valve infection may lead to reduced morbidity through strategies such as selective use of replacement devices and antimicrobial prophylaxis.

A comparison of aortic valve replacement with viable cryopreserved and fresh allograft valves, with a note on chromosomal studies.

We examined the long-term clinical function and fate of allograft aortic valves, preserved by two differing methods, for aortic valve replacement: (1) fresh allografts stored at 4 degrees C refrigeration (group I) and (2) viable allografts cryopreserved in liquid nitrogen at -196 degrees C (group II). A total of 316 aortic valve replacement operations were performed, 124 in group I (December 1969 to May 1975) and 192 in group II (June 1975 to December 1986). Concomitant surgical procedures (eg, coronary artery bypass grafting and mitral valve replacement) were necessary in 120 operations. The overall immediate 30 day mortality was 6.0% (confident limits 4.6% to 7.7%), and the survival rates were 83% at 4 years and 60% at 15 years. Endocarditis and technical factors concerning reoperation showed no difference between the two groups according to parametric estimates and hazard function analyses. However, there was a marked difference in reoperation for valve degeneration: 23 patients in group I and 0 patients in group II. The freedom from reoperation for valve degeneration at 10 years was 89% for group I and 100% for group II, and at 15 years it was 59% for group I. The hazard function for group I reflected the late rising risk of degeneration. The freedom from thromboembolism of both groups (aortic valve replacement with or without bypass grafting) was 97% at 10 years and 96% at 15 years. Group II explanted valves (operation for technical malalignment reasons) has consistently shown evidence of persisting viability on tissue culture, on metabolic studies, and on histologic appearances. Chromosomal studies have shown the donor origin of these cells. The superior results with the cryopreserved valve is considered to be due to persisting viability, which appears to be the key to durability.

Rifampicin antibiotic impregnation of the St. Jude Medical mechanical valve sewing ring: a weapon against endocarditis.

The Dacron sewing ring material of the St. Jude Medical mechanical heart valve (St. Jude Medical, Inc., St. Paul, Minn.) was passively impregnated with rifampicin (60 mg/ml) both in its unsealed state and after sealing by the methods of preclotting in blood, autoclaving in blood, and autoclaving in 20% albumin. Antistaphylococcal activity in the Dacron material was assessed immediately after rifampicin impregnation and at regular periods up to 5 days after implantation into the goat aorta. When the Dacron material had been sealed by autoclaving in blood and autoclaving in 20% albumin significant retention of antistaphylococcal activity was found after 5 days in vivo. Best results were obtained with the use of autoclaved blood (p < 0.05). We also compared these results with those obtained from impregnating commercially available gelatin-sealed (Gelseal) and collagen-sealed (Hemashield) Dacron material with rifampicin. Although antistaphylococcal activity was equivalent immediately after rifampicin impregnation, after 4 days in vivo the activity was negligible in Gelseal material (p < 0.05) and could not be demonstrated in Hemashield material. Rifampicin impregnation of the intact St. Jude Medical mechanical valve sewing ring may have an application in the prevention of prosthetic valve endocarditis and a clinical protocol is suggested.

An analysis of valve re-replacement after aortic valve replacement with biologic devices.

Biologic valve re-replacement was examined in a series of 1343 patients who underwent aortic valve replacement at The Prince Charles Hospital, Brisbane, with a cryopreserved or 4 degrees C stored allograft valve or a xenograft valve. A parametric model approach was used to simultaneously model the competing risks of death without re-replacement and re-replacement before death. One hundred eleven patients underwent a first re-replacement for a variety of reasons (69 patients with xenograft valves, 28 patients with 4 degrees C stored allograft valves, and 14 patients with cryopreserved allograft valves). By multivariable analysis younger age at operation was associated with xenograft, 4 degrees C stored allograft, and cryopreserved allograft valve re-replacement. However, this effect was examined in the context of longer survival of younger patients, which increases their exposure to the risk of re-replacement as compared with that in older patients whose decreased survival reduced their probability of requiring valve re-replacement. In patients older than 60 years at the time of aortic valve replacement, the probability of re-replacement (for any reason) before death was similar for xenografts and cryopreserved allograft valves but higher for 4 degrees C stored valves. However, in patients younger than 60 years, the probability of re-replacement at any time during the remainder of the life of the patient was lower with the cryopreserved allograft valve compared with the xenograft valve and 4 degrees C stored allografts.

Human aortic valve allografts elicit a donor-specific immune response.

OBJECTIVE: The nature and magnitude of the immunologic response to implantation of human cryopreserved aortic valve allografts was investigated. METHODS: Twenty aortic valve allograft recipients were investigated for donor-specific antibody and T-cell-mediated responses with serial flow cytometric and microlymphocytotoxic crossmatch assays and one-way mixed lymphocyte cultures. RESULTS: Donor-specific immunoglobulin G antibodies to class I and II human leukocyte antigens were first detected in the serum of all aortic valve allograft recipients at 30 days after implantation and persisted in substantial amounts in all but one of the recipients at day 365. Recipient T-cell alloreactivity toward donor lymphocytes was significantly increased at day 30 compared with levels before and 10 days after operation. CONCLUSIONS: Cryopreserved aortic valve allografts elicit a substantial allogeneic response in recipients. This alloreactivity may contribute to the observed morphologic changes in aortic valve allografts and eventual long-term deterioration of allograft function.

An analysis of risk factors for death and mode-specific death after aortic valve replacement with allograft, xenograft, and mechanical valves.

From September 1967 to January 1990, a total of 2100 patients underwent 2366 aortic valve replacements with a variety of allograft, xenograft, and mechanical valves. Concomitant procedures were performed in 764 patients. Actuarial survival at 12 years was 59.6% (70% confidence limits 57.8% to 61.4%). Hazard function for death was highest immediately after operation, falling to merge with a slowly rising phase of risk at approximately 3 months. Actuarial freedom from sudden death at 12 years was 88.0% (70% confidence limits 86.7% to 89.3%). The shape of the hazard function for sudden death was similar to that for death. Actuarial freedom from death with cardiac failure at 12 years was 87.9% (70% confidence limits 86.5% to 89.2%). The shape of the hazard function for death with cardiac failure was also similar to that for death. Risk factor analysis revealed the important deleterious impact on long-term survival resulting from impaired left ventricular structure and function because of aortic valve disease. No current-era valve used in this study (allograft, xenograft, or mechanical) was a risk factor for death. Both aortic wall disease and endocarditis necessitating aortic valve replacement substantially decreased long-term patient survival. Aortic valve replacement is advisable much earlier in the natural history of aortic valve disease before secondary left ventricular damage occurs.

Aortic valve infection. Risk factors for death and recurrent endocarditis after aortic valve replacement.

Patients (n = 195) undergoing aortic valve replacement (n = 209) for native or prosthetic valve endocarditis were studied to determine risk factors for death and recurrent endocarditis and also to determine the valve type least likely to be associated with recurrent endocarditis. Ten-year survival was 60%, the highest risk of dying occurring within the first 3 postoperative months. Risk factors for death in this early phase included increased urea concentration, higher New York Heart Association functional class, prosthetic valve endocarditis, infection status (lower in patients with healed endocarditis), longer duration of cardiopulmonary bypass, and nonuse of an allograft valve. In the late phase (beyond 3 months), risk factors included age at operation and Staphylococcus aureus infection (only in New York Heart Association functional class V). Ten years after aortic valve replacement, 79% of valves were free of recurrent endocarditis. The highest risk of recurrence was in the first 4 months. Longer duration of cardiopulmonary bypass was a weak risk factor for recurrent endocarditis in the early phase, and in the late phase risk factors were S. aureus infection (only in New York Heart Association functional classes III, IV, and V) and the use of now discontinued biologic valves. Allograft aortic valve replacement was shown to be associated with a low and constant risk of recurrent endocarditis, whereas other valve types were associated with a high early risk. The allograft valve should be the preferred replacement device for aortic root infection.

Composite stentless xenograft for aortic valve replacement: clinical evaluation of function.

At The Prince Charles Hospital, 55 patients have received the composite porcine aortic xenograft (model 300, Cryolife-O'Brien valve; Cryolife International, Atlanta, GA; formerly the Bravo Cardiovascular Inc valve) for aortic valve replacement since December 1992. Associated procedures were required in 50% of patients (coronary artery bypass grafting in 25 patients). Hospital and "late" mortality have been 0%. Follow-up has been 100% complete. The median patient age was 74 years (range, 59 to 88 years). One permanent intraoperative cerebrovascular accident and two early thromboembolic events (both associated with acute atrial fibrillation) have constituted the only three morbid events. Serial echocardiography at 1 week, 6 months, and 1 year has shown a mean gradient of 9 mm Hg. A small number of patients have a "trivial" degree of valve incompetence. No progression of either gradient or incompetence is evident. The clinical state of 54 of these patients is most satisfactory. However, long-term surveillance is necessary to determine the 8- to 10-year durability of this stentless xenograft.

The Cryolife-O'Brien composite aortic stentless xenograft: surgical technique of implantation.

The Cryolife-O'Brien (Cryolife International, Atlanta, GA; formerly the Bravo Cardiovascular Inc valve) stentless porcine aortic xenograft (model 300) is a composite valve of three noncoronary leaflets, symmetric in configuration with a broad coaptive leaflet surface. Because the valve has only a superior aortic wall cuff, a single continuous suture line of 3/0 Prolene provides a rapid, safe implantation. The ideal recipients are elderly patients, who benefit from a short cardiopulmonary bypass period and whose degenerative calcific valves are generally symmetric. The step-by-step technique of implantation is outlined, as are the principles of maintaining symmetry during implantation. The stentless valve has been used for aortic valve replacement in 55 elderly patients, with no deaths and minimal morbidity.