Unrecognised paraganglioma of the urinary bladder precipitating hypertensive crisis.

Bladder paragangliomas (bPGLs) account for only 0.06% of all bladder tumours, most commonly presenting with post-micturition syncope and hypertensive crisis. Silent paragangliomas are very rare, and failure to recognise them in the perioperative setting can precipitate a hypertensive crisis in the absence of sufficient alpha-blockade. Here, we describe a case of unrecognised bPGL in a woman with pre-existing hypertension and a single prior episode of haematuria thought to be related to urothelial carcinoma. She was found to have a low-grade non-invasive papillary urothelial carcinoma (potentially the cause of her haematuria) and an unrelated vascular-appearing tumour causing hypertensive crisis and broad complex tachycardia on resection. This was confirmed to be a bPGL on histology for which she underwent definitive management with a partial cystectomy following blood pressure management.

Jackstones in the renal pelvis: A rare calculus.

Jackstones are a rare subtype of calculi, characterised by radiating spicules. We describe a case of multiple jackstones in the urinary upper tract. A 53-year-old man was referred for evaluation of left flank pain. Imaging revealed a left pelvic-ureteric junction obstruction and several left renal calculi. A left supine percutaneous nephrolithotomy was performed and two jackstone calculi were extracted. The presence of multiple jackstones in the renal pelvis should prompt for evaluation for obstruction and complete stone clearance should be achieved to avoid recurrence.

Obstructed kidney secondary to a benign renal fibroepithelial polyp: A rare and interesting case.

Renal fibroepithelial polyp (FEP) is a very rare tumour and we describe a case causing acute ureteric obstruction. A 56 year old lady presented with presumed pyelonephritis and left hydronephrosis, without calculi. She was transferred to a tertiary hospital urology service where after an unsuccessful retrograde attempt at stent insertion, a nephrostomy was inserted. Subsequently, the patient underwent a ureteropyeloscopy and excision of a FEP arising from the renal pelvis. Renal FEP is a very rare cause of obstruction and was successfully managed endoscopically.

The modified International Society of Urological Pathology system improves concordance between biopsy and prostatectomy tumour grade.

OBJECTIVES: To assess the concordance between biopsy and radical prostatectomy (RP) specimens using the 2005 Gleason score (GS) and the International Society of Urological Pathology (ISUP) 2014/World Health Organization 2016 modified system, accounting for the introduction of transperineal biopsy and pre-biopsy multiparametric magnetic resonance imaging (mpMRI). PATIENTS AND METHODS: Between 2002 and 2019, we identified 2431 patients with paired biopsy and RP histopathology from a prospectively recorded and maintained prostate cancer database. Biopsy specimens were graded according to the 2005 GS or ISUP 2014 modified system, according to the year of diagnosis. Multivariable logistic regression analysis was conducted to retrospectively assess the impact of prostate-specific antigen (PSA), PSA density, age, pre-biopsy mpMRI, and biopsy method, on the rate of upgraded disease. The kappa coefficient was used to establish the degree of change in concordance between groups. RESULTS: Overall, 24% of patients had upgraded disease and 8% of patients had downgraded disease when using the modified ISUP 2014 criteria. Agreement in the updated ISUP 2014 cohort was 68%, compared with 55% in the 2005 GS group, which was validated by a kappa coefficient that was good (k = 0.5 ± 0.4) and poor (k = 0.3 ± 0.1), respectively. In multivariable models, a change in grading system independently improved overall disease concordance (P = 0.02), and there were no other co-segregated patient or pathological factors such as PSA, total number of cores, maximum cancer length, biopsy route or the use of mpMRI that impacted this finding. CONCLUSION: The 2014 ISUP modifed system improves overall concordance between biopsy and surgical specimens, and thus allows more accurate prognostication and management in high-grade disease, independent of more extensive prostate sampling and the use of mpMRI.

Primary basal cell carcinoma of the prostate with concurrent adenocarcinoma.

INTRODUCTION: Prostatic basal cell carcinoma is an extremely rare tumor, exhibiting various histopathological features and clinical spectrums of disease. CASE PRESENTATION: A 69-year-old male presented to our department with 2 years of voiding difficulty and intermittent macroscopic hematuria. With a presumed diagnosis of benign prostatic hyperplasia, he underwent a transurethral resection of the prostate. Pathological examination revealed atypical basaloid cells forming solid nests. Robot-assisted radical prostatectomy was subsequently performed, confirming a diagnosis of basal cell carcinoma with coexisting acinar adenocarcinoma. CONCLUSION: Although more cases of basal cell carcinoma are indolent than aggressive, there is no reliable method of differentiation between these presentations. Thus, we recommend radical surgery and 6-monthly disease surveillance until more is discovered about this very rare malignancy.

Extended-spectrum ß-lactamase in the rectal flora of patients undergoing transrectal prostate biopsy: a study of the prevalence in a major metropolitan hospital.

OBJECTIVES: To determine the prevalence of extended-spectrum ß-lactamase (ESBL) in patients undergoing transrectal prostate biopsy, to assess the incidence of postoperative sepsis, to correlate the development of sepsis with the presence of preoperative ESBL on rectal swabs, and to assess the adequacy of prophylactic antibiotic guidelines in the context of local ESBL prevalence. METHODS: Patients undergoing transrectal ultrasonography (TRUS)-guided biopsy at the Royal Melbourne Hospital between January 2012 and July 2016 had rectal swabs taken immediately prior to TRUS with specific cultures to identify the presence of ESBL. Patients were given a prophylactic antibiotic, 500 mg oral ciprofloxacin, 1 h before the TRUS procedure. Data were collected prospectively, with retrospective review of all readmitted patient files and audit data to ensure complete capture of events. RESULTS: A total of 387 TRUS-guided biopsy procedures were performed. Rectal swabs were correctly collected in 352 patients (91%). The median patient age was 65 years. In all, 25 (7%) ESBL-positive swabs were identified. Most ESBL were Escherichia coli. Half (50%) of ESBL were resistant to ciprofloxacin and all were sensitive to meropenem. A small increase in ESBL prevalence over time was not significant (R2 = 0.35). Four patients (1.1%) were readmitted with sepsis; ESBL Pseudomonas had previously grown in one patient, but sepsis was attributable to non-ESBL E. coli. In one of the readmitted patients ESBL E. coli was present, but this patient did not have ESBL preoperatively. There were no deaths or high-dependency/intensive care unit admissions. CONCLUSIONS: This study represents the largest Australian series to investigate ESBL prevalence, and reveals a rate lower than that of many other nations. Our sepsis rate is lower than many international series, perhaps because of our low ESBL rate and strict antibiotic prophylaxis. Preoperative swab results did not predict postoperative sepsis, and the process was therefore not useful for guiding antibiotic therapy. In this patient population, TRUS biopsy, with ciprofloxacin prophylaxis, remains a safe option for diagnostic prostate biopsy.

Urolithiasis - Ten things every general practitioner should know.

BACKGROUND: Upper urinary tract stones are a common problem in Australia, with an incidence of 0.13% per year, and a lifetime prevalence of up to 15% in males and 8% in females. Many of these patients first present to general practitioners (GPs), so a thorough understanding of the diagnosis, treatment and prevention of stone disease is an important part of any GP's arsenal. OBJECTIVE: In this article, we present evidence-based guidelines regarding urolithiasis, from diagnosis, through to conservative and operative management, and prevention, as a reference for GPs and other primary care physicians. DISCUSSION: The majority of urolithiasis cases can be conservatively managed. However, prior to conservative management, adequate imaging must be obtained and emergent conditions must be excluded. Conservative management should not be initiated without a plan in the event the management fails, and adequate analgesia and medical expulsive therapy should be prescribed. Should surgery be necessary, the majority of operations can be performed as minimally invasive day procedures.

Impact of Brassica and Lucerne Finishing Feeds and Intramuscular Fat on Lamb Eating Quality and Flavor. A Cross-Cultural Study Using Chinese and Non-Chinese Australian Consumers.

Use of forage brassicas (Brassica napus) and lucerne (alfalfa; Medicago sativa) as ruminant feeds has been linked to unacceptable flavors in sheepmeat. Lambs from low and high intramuscular fat sires were allocated to one of four finishing feeds-perennial ryegrass (Lolium perenne), lucerne, and two brassica forages-for a 6 week period. Grilled loins (Longissimus thoracis et lumborum) were subjected to chemical and sensory analysis by a trained panel and also evaluated by non-Chinese and Chinese background Australian consumers. Consumer liking was similar for both groups, and liking was highest for the brassica- and lucerne-finished lamb, especially from high intramuscular fat sires. No evidence of a distinctive lucerne- or brassica-induced flavor taint was measured by the trained panel or gas chromatography-mass spectrometry-olfactometry. The diets influenced the composition of lipids and branched-chain fatty acids in the subcutaneous fat, and the concentration of total branched-chain fatty acids was positively correlated with flavor and overall liking. Significantly higher levels of key aroma volatiles were measured in the higher fat samples.

Trends in penile cancer: a comparative study between Australia, England and Wales, and the US.

PURPOSE: To investigate and compare the trends in incidence and mortality of penile cancer between Australia, England and Wales, and the US, and provide hypotheses for these trends. METHODS: Cancer registry data from 1982 to 2005 inclusive were obtained from Australia, England and Wales, and the United States. From these data, age-specific, -standardised and mortality:incidence ratios were calculated, and compared. RESULTS: The overall incidence of penile cancer in England and Wales (1.44 per 100,000 man-years) was higher than in Australia (0.80 per 100,000), and the US (0.66 per 100,000). Incidence of penile cancer in all three countries has remained relatively stable over time. Similarly, although the mortality rates were also higher in England and Wales (0.37 per 100,000 man-years) compared to Australia (0.18 per 100,000) and the US (0.15 per 100,000), the mortality/incidence ratios were similar for all three countries. CONCLUSIONS: Penile cancer incidence is low, affecting mainly older men. Rates differ between the three countries, being twice as common in England and Wales as in the other studied regions. Circumcision rates have a potential influence on these rates but are not the sole explanation for the variation.

Calculus-related ureteral intussusception: A case report and literature review.

INTRODUCTION: Ureteral intussusception is a rarely reported condition, primarily as a complication of ureteric tumours. Fewer than 30 case reports have been made. This case represents the first reported case, to our knowledge, of ureteral intussusception caused by a ureteric calculus. PRESENTATION OF CASE: We present the case of a 70 year old man with a history of conservatively managed renal calculi, in whom obstructive ureterolithiasis was incidentally detected. Retrograde pyelography and ureteroscopy revealed intussusception of the ureter around a calculus. Extensive biopsies revealed no evidence of tumour, and the intussusception resolved following stone clearance. DISCUSSION: Literature review of previously reported cases of ureteral intussusception revealed 26 cases, of which 22 were secondary to tumour and 4 were secondary to surgical procedures. We propose a mechanism by which calculus-related ureteral intussusception may occur, and suggest treatment for this condition. CONCLUSION: Calculus-related ureteral intussusception is a rare condition, of which this represents the only case report. Management of the condition should involve excluding the presence of tumour, and then clearing the stone, avoiding the use of a basket for retrieval of fragments.

Expression and functional role of negative signalling regulators in tumour development and progression.

Alterations in intracellular signalling pathways such as the mitogen-activated protein kinases (MAPKs) are key common mechanisms of tumour development and progression. As such, there has been intense research into developing drugs that can inhibit or attenuate intracellular signalling. In recent years, there has been increasing recognition that the cell already has innate negative regulatory proteins that achieve this in normal homeostasis. These regulators provide a feedback inhibitory mechanism that controls the intensity and duration of activated signalling by exogenous stimuli. Members of this group include Raf kinase inhibitor protein 1, the MAPK phosphatases, the SPROUTY and SPRED families and similar expression to FGF. A number of studies have now demonstrated significant alterations in expression of negative regulators in malignant tissue in different cancer types. In functional studies, manipulated expression of these regulators has been shown to significantly influence tumour cell behaviour and phenotype. Here, we summarise the evidence for the functional expression of negative signalling regulators in tumour growth and progression and discuss their potential role as cancer biomarkers and targets for novel drug therapy.