Comparing outcomes of transperineal to transrectal prostate biopsies performed under local anaesthesia.

Objectives: To compare and review the outcomes of transperineal (TP) prostate biopsies with transrectal (TR) biopsies performed under local anaesthesia (LA). A review of the relevant published literature is presented. Patients and methods: We prospectively analysed 212 consecutive patients who underwent TP prostate biopsy using the PrecisionPoint™ access system under LA, at our institution from October 2018 to March 2020. We compared the morbidity and cancer detection rates using this approach with our historical cohort of 178 patients who underwent the TR biopsy method under LA. Results: The mean age of the TP biopsy group was 69 years, and median prostate specific antigen (PSA) was 13.17 ng/ml. Mean prostate volume was 45.1 ml with a median of 12 cores taken per patient. Patient demographics were similar to our TR biopsy cohort, with mean age of 68 years, median PSA of 10.76, mean prostate volume of 49.6 ml and a median of 12 cores taken per patient. The TP biopsy group had 0% sepsis rate compared with 2.2% in the TR group. Haematuria in the TP versus transrectal ultrasonography (TRUS) cohort was 0.9% versus 1.7%, respectively. The TP biopsy-naïve group had a cancer detection rate of 63.5% (127 of 200 patients), of which 84% were ≥Grade Group 2 (GG2). The TR biopsy-naïve group had cancer detection rate of 50% (86 of 172 patients), of which 87.2% was ≥GG2. Conclusion: TP prostate biopsy had less urinary infectious and septic complications compared with the TR approach. Our data suggest at least comparable diagnostic accuracy between both biopsy approaches.

Transitioning to robotic partial nephrectomy with a team-based proctorship achieves the desired improved outcomes over open and laparoscopic partial nephrectomy.

Proctoring may facilitate a safe transition to robotic-assisted partial nephrectomy (RAPN) for centres performing open (OPN) and laparoscopic partial nephrectomies (LPN). This study compared the 5-year outcomes of RAPN, initiated with a team-based proctorship, with OPN and LPN. Following an observation course at the proctor's institution and a 3-surgeon performance of proctored RAPN in August 2014, a review of 90 RAPN, 29 LPN and 43 OPN consecutively performed by the same team from 2013 to 2019 at National University Hospital, Singapore was conducted. Peri-operative data, functional and oncological outcomes were compared amongst the three groups. Most cases were performed robotically after 2015 with comparable baseline characteristics in all groups. Median RENAL Nephrometry Score was not significantly different between RAPN (8 [IQR 6, 9]) and OPN (9 [IQR 7, 10]) (P = 0.12) but was significantly lower for LPN (7 [IQR 5, 8]) compared to RAPN (P = 0.002). RAPN achieved the lowest blood loss (226 ml vs.348 ml and 263 ml for OPN and LPN respectively, P = 0.02), transfusion rate (3% vs.21% and 17% respectively, P = 0.003) and median length of stay after surgery (4 vs.6 and 5 days respectively, P = 0.001). Complication rates, warm ischemic times were similar between the three approaches with no differences in 1-year and long-term renal function. The rate of positive surgical margin was 8%, 8% and 3% for RAPN, LPN and OPN, respectively (P = 0.76), with a single recurrence in each arm. Despite modest hospital volume, a team-based proctorship facilitated the transition to the Da Vinci robotic platform to perform partial nephrectomies of equivalent complexities as open surgery, achieving improved perioperative outcomes, while maintaining oncological and kidney functional results.

Implementation of a Ureteric Colic Telemedicine Service: A Mixed Methods Quality Improvement Study.

OBJECTIVE: To assess the effectiveness of a telemedicine service for ureteric colic patients in reducing the number of unnecessary face-to-face consultations and shortening waiting time for appointments. METHODS: A telemedicine workflow was implemented as a quality improvement study using the Plan-Do-Study-Act method. All patients presenting with ureteric colic without high-risk features of fever, severe pain, and hydronephrosis, were recruited, and face-to-face appointments to review scan results were replaced with phone consultations. Data were prospectively collected over 3 years (January 2017 to December 2019). Patient outcomes including the reduction in face-to-face review visits, time to review, reattendance and intervention rates, were tracked in an interrupted time-series analysis, and qualitative feedback was obtained from patients and clinicians. RESULTS: Around 53.2% of patients presenting with ureteric colic were recruited into the telemedicine workflow. A total of 465 patients (46.2%) had normal scan results and 250 patients (24.9%) did not attend their scan appointments, hence reducing the number of face-to-face consultations by 71.1%. A total of 230 patients (22.9%) required subsequent follow-up with urology, while 61 patients (6.1%) were referred to other specialties. Mean (SD) time to review was 30.0 (6.2) days, 6-month intervention rate was 3.4% (n = 34) and unplanned reattendance rate was 3.2% (n = 32). Around 93.1% of patients reported satisfaction with the service. CONCLUSION: The ureteric colic telemedicine service successfully and sustainably reduced the number of face-to-face consultations and time to review without compromising on patient safety. The availability of this telemedicine service has become even more important in helping us provide care to patients with ureteric colic in the current COVID-19 pandemic.

A Multicentre Evaluation of the Role of the Prostate Health Index (PHI) in Regions with Differing Prevalence of Prostate Cancer: Adjustment of PHI Reference Ranges is Needed for European and Asian Settings.

Asians have a lower incidence of prostate cancer (PC). We compared the performance of the Prostate Health Index (PHI) for 2488 men in different ethnic groups (1688 Asian and 800 European men from 9 sites) with PSA 2-20ng/ml and PHI test and transrectal ultrasound-guided biopsy results available. Of these, 1652 men had PSA 2-10ng/ml and a normal digital rectal examination and underwent initial biopsy. The proportions of PC (Gleason ≥6) and higher-grade PC (HGPC, Gleason ≥7) across different PHI ranges were compared. The performance of PSA and PHI was compared using the area under the receiver operating characteristic curve (AUC) and decision curve analyses (DCA). Among Asian men, HGPC would be diagnosed in 1.0%, 1.9%, 13%, and 30% of men using PHI thresholds of <25, 25-35, 35-55, and >55, respectively. At 90% sensitivity for HGPC (PHI >30), 56% of biopsies and 33% of Gleason 6 PC diagnoses could have been avoided. Among European men, HGPC would be diagnosed in 4.1%, 4.3%, 30%, and 34% of men using PHI thresholds of <25, 25-35, 35-55, and >55, respectively. At 90% sensitivity for HGPC (PHI >40), 40% of biopsies and 31% of Gleason 6 PC diagnoses could have been avoided. AUC and DCA confirmed the benefit of PHI over PSA. The benefit of PHI was also seen at repeat biopsy (n=397) and for PSA 10-20ng/ml (n=439). PHI is effective in cancer risk stratification for both European and Asian men. However, population-specific PHI reference ranges should be used. PATIENT SUMMARY: The Prostate Health Index (PHI) blood test helps to identify individuals at higher risk of prostate cancer among Asian and European men, and could significantly reduce unnecessary biopsies and overdiagnosis of prostate cancer. Different PHI reference ranges should be used for different ethnic groups.

Robotic kidney autotransplantation in a porcine model: a procedure-specific training platform for the simulation of robotic intracorporeal vascular anastomosis.

Robotic-assisted kidney transplantation (RKT) with the Da Vinci (Intuitive, USA) platform has been recently developed to improve outcomes by decreasing surgical site complications and morbidity, especially in obese patients. This potential paradigm shift in the surgical technique of kidney transplantation is performed in only a few centers. For wider adoption of this high stake complex operation, we aimed to develop a procedure-specific simulation platform in a porcine model for the training of robotic intracorporeal vascular anastomosis and evaluating vascular anastomoses patency. This paper describes the requirements and steps developed for the above training purpose. Over a series of four animal ethics' approved experiments, the technique of robotic-assisted laparoscopic autotransplantation of the kidney was developed in Amsterdam live pigs (60-70 kg). The surgery was based around the vascular anastomosis technique described by Menon et al. This non-survival porcine training model is targeted at transplant surgeons with robotic surgery experience. Under general anesthesia, each pig was placed in lateral decubitus position with the placement of one robotic camera port, two robotic 8 mm ports and one assistant port. Robotic docking over the pig posteriorly was performed. The training platform involved the following procedural steps. First, ipsilateral iliac vessel dissection was performed. Second, robotic-assisted laparoscopic donor nephrectomy was performed with in situ perfusion of the kidney with cold Hartmann's solution prior to complete division of the hilar vessels, ureter and kidney mobilization. Thirdly, the kidney was either kept in situ for orthotopic autotransplantation or mobilized to the pelvis and orientated for the vascular anastomosis, which was performed end to end or end to side after vessel loop clamping of the iliac vessels, respectively, using 6/0 Gore-Tex sutures. Following autotransplantation and release of vessel loops, perfusion of the graft was assessed using intraoperative indocyanine green imaging and monitoring urine output after unclamping. This training platform demonstrates adequate face and content validity. With practice, arterial anastomotic time could be improved, showing its construct validity. This porcine training model can be useful in providing training for robotic intracorporeal vascular anastomosis and may facilitate confident translation into a transplant human recipient.

Postoperative risk of chronic kidney disease in radical nephrectomy and donor nephrectomy patients: a comparison and analysis of predictive factors.

INTRODUCTION: To compare baseline renal function and identify predictive factors in patients undergoing radical nephrectomy (RN) or donor nephrectomy (DN) and their risk of subsequent chronic kidney disease (CKD) after surgery. MATERIALS AND METHODS: A retrospective review of patients with no baseline CKD undergoing RN (n = 88) and DN (n = 58) from 2000 to 2008 was performed. Baseline and postoperative renal function (eGFR) was determined using the Modification of Diet in Renal Disease (MDRD) formula. CKD was defined as eGFR < 60 mL/min/1.73 m2 according to the National Kidney Foundation guidelines. RESULTS: Before surgery, patients undergoing RN and DN had a mean eGFR (+/- SD) of 83.5 +/- 17.4 and 92.9 +/- 17.0 mL/min/1.73 m2 respectively (p = 0.002). Patients with RN had significantly greater morbidities including hypertension (47.7%), diabetes (14.8%) and ischemic heart disease (12.5%) than DN (5.2%, 0% and 1.7% respectively) (all p < 0.05). Median follow up was 3.5 years. The relative hazard of developing CKD post RN compared with DN was 1.91 (95% CI 1.01 to 3.61, p = 0.040). The median time to CKD was 77 months (range 2-107) for RN and 100 months (range 11-105) for DN. Age, gender, comorbidities, radical nephrectomy and baseline kidney function were individual risk factors for CKD post nephrectomy. However, preoperative eGFR was the only independent prognostic factor on multi-variable analysis. CONCLUSIONS: Patients undergoing RN are distinctly different from kidney donors in terms of age, renal function and comorbidities. RN is not an independent predictive factor for CKD but the lower baseline renal function in RN patients significantly accelerates renal senescence in the uninephrectomy state.

Necrotizing fasciitis after laparoscopic colonic surgery: case report and review of the literature.

A 67-year-old woman, with a past medical history of diabetes mellitus and hypertension, underwent an elective laparoscopic anterior resection for sigmoid colon adenocarcinoma. She was readmitted on the tenth postoperative day with complaints of abdominal pain and a foul smelling discharge from her abdominal wound. She was later diagnosed with necrotizing fasciitis (NF) over the extraction wound. To our knowledge there has only been one other case of NF after laparoscopic colonic surgery reported in the literature. We reviewed the literature on NF after laparoscopic surgery, and discussed the clinical diagnosis; diagnostic adjuncts such as magnetic resonance imaging, bedside exploration under local anesthesia, frozen section of deep incisional biopsies, and laboratory tests; and management principles of NF. Although there is a low incidence of wound infections associated with laparoscopic colonic surgery, necrotizing infections although rare, are a very real possibility.