Local anaesthetic transperineal (LATP) prostate biopsy using a probe-mounted transperineal access system: a multicentre prospective outcome analysis.

OBJECTIVES: To assess the feasibility of local anaesthetic transperineal (LATP) technique using a single-freehand transperineal (TP) access device, and report initial prostate cancer (PCa) detection, infection rates, and tolerability. PATIENTS AND METHODS: Observational study of a multicentre prospective cohort, including all consecutive cases. LATP was performed in three settings: (i) first biopsy in suspected PCa, (ii) confirmatory biopsies for active surveillance, and (iii) repeat biopsy in suspected PCa. All patients received pre-procedure antibiotics according to local hospital guidelines. Local anaesthesia was achieved by perineal skin infiltration and periprostatic nerve block without sedation. Ginsburg protocol principles were followed for systematic biopsies including cognitive magnetic resonance imaging-targeted biopsies when needed using the PrecisionPoint™ TP access device. Procedure-related complications and oncological outcomes were prospectively and consecutively collected. A validated questionnaire was used in a subset of centres to collect data on patient-reported outcome measures (PROMs). RESULTS: Some 1218 patients underwent LATP biopsies at 10 centres: 55%, 24%, and 21% for each of the three settings, respectively. Any grade PCa was diagnosed in 816 patients (67%), of which 634 (52% of total) had clinically significant disease. Two cases of sepsis were documented (0.16%) and urinary retention was observed in 19 patients (1.6%). PROMs were distributed to 419 patients, with a 56% response rate (n = 234). In these men, pain during the biopsy was described as either 'not at all' or 'a little' painful by 64% of patients. Haematuria was the most common reported symptom (77%). When exploring attitude to re-biopsy, 48% said it would be 'not a problem' and in contrast 8.1% would consider it a 'major problem'. Most of the patients (81%) described the biopsy as a 'minor or moderate procedure tolerable under local anaesthesia', while 5.6% perceived it as a 'major procedure that requires general anaesthesia'. CONCLUSION: Our data suggest that LATP biopsy using a TP access system mounted to the ultrasound probe achieves excellent PCa detection, with a very low sepsis rate, and is safe and well tolerated. We believe a randomised controlled trial comparing LATP with transrectal ultrasound-guided biopsy (TRUS) to investigate the relative trade-offs between each biopsy technique would be helpful.

Training in minimally invasive surgery in urology: European Association of Urology/International Consultation of Urological Diseases consultation.

OBJECTIVES: To describe the progress being made in training for minimally invasive surgery (MIS) in urology. METHODS: A group of experts in the field provided input to agree on recommendations for MIS training. A literature search was carried out to identify studies on MIS training, both in general and specifically for urological procedures. RESULTS: The literature search showed the rapidly developing options for e-learning, box and virtual training, and suggested that box training is a relatively cheap and effective means of improving laparoscopic skills. Development of non-technical skills is an integral part of surgical skills training and should be included in training curricula. The application of modular training in surgical procedures showed more rapid skills acquisition. Training curricula for MIS in urology are being developed in both the USA and Europe. CONCLUSION: Training in MIS has shifted from 'see-one-do-one-teach-one' to a structured learning, from e-learning to skills laboratory and modular training settings.

Online and social media presence of Australian and New Zealand urologists.

OBJECTIVE: To assess the online and social media presence of all practising Australian and New Zealand urologists. SUBJECTS AND METHODS: In July 2014, all active members of the Urological Society of Australia and New Zealand (USANZ) were identified. A comprehensive search of Google and each social media platform (Facebook, Twitter, LinkedIn and YouTube) was undertaken for each urologist to identify any private websites or social media profiles. RESULTS: Of the 435 urologists currently practising in Australia and New Zealand, 305 (70.1%) have an easily identifiable social media account. LinkedIn (51.3%) is the most commonly used form of social media followed by Twitter (33.3%) and private Facebook (30.1%) accounts. About half (49.8%) have a private business website. The average number of social media accounts per urologist is 1.42 and 16 urologists (3.7%) have an account with all searched social media platforms. Over half of those with a Twitter account (55.9%) follow a dedicated urology journal club and have a median (range) number of 'followers' of 12 (1-2 862). Social media users had a median (range) of 2 (0-8 717) 'tweets' on Twitter, 2 (1-45) LinkedIn posts and 1 (1-14) YouTube video. CONCLUSION: This study represents a unique dataset not relying on selection or recall bias but using data freely available to patients and colleagues to gauge social media presence of urologists. Most Australian and New Zealand urologists have a readily identifiable online and social media presence, with widespread and consistent use across both countries.

Radical treatment of localised prostate cancer in the elderly.

Elderly men are more likely to be diagnosed with aggressive cancer, but are often inappropriately denied curative treatment. Biological rather than chronological age should be used to decide if a patient will profit from radical treatment. Therefore, every man aged >70 years should undergo a health assessment using a validated tool before making treatment decisions. Fit elderly men with intermediate- or high-risk disease should be offered standard curative local treatment in keeping with guidelines for younger men. Vulnerable and frail elderly men warrant geriatric intervention before treatment. In the case of vulnerable patients, this intervention may render them suitable for standard care. When considering radical prostatectomy outcomes a 'bifecta' of oncological control and continence is appropriate, as erectile dysfunction (although prevalent) has a much smaller impact on quality of life than in younger patients. Radiotherapy is an alternative to radical prostatectomy in men with a life expectancy of <10 years. Primary androgen-deprivation therapy is not associated with improved survival in localised prostate cancer and should only be used for symptom palliation. Further elderly-specific research is needed to guide prostate cancer care.

Recent advances in treatment for Benign Prostatic Hyperplasia.

Clinical benign prostatic hyperplasia (BPH), often identified as a worsening ability of a male to pass urine, is a significant problem for men in our society. In 2015, the use of personalised medicine is tailoring treatment to individual patient needs and to genetic characteristics. Technological advances in surgical treatment are changing the way BPH is treated and are resulting in less morbidity. The future of BPH treatments is exciting, and a number of novel techniques are currently under clinical trial.

A Valsalva leak-point pressure of >100 cmH2O is associated with greater success in AdVance™ sling placement for the treatment of post-prostatectomy urinary incontinence.

OBJECTIVES: To determine if there is a Valsalva leak-point pressure (VLPP) threshold that predicts for retro-urethral transobturator sling (RTS) success in men with post-prostatectomy urinary incontinence (UI). PATIENTS AND METHODS: The preoperative urodynamic parameters of all patients undergoing RTS (AdVance™) sling surgery over the last 5 years were analysed and compared with the postoperative outcomes. The sling was defined as having been successful if the patient no longer had to wear pads or merely used a pad to provide a sense of security. RESULTS: In all, 46 men with a mean (range) age of 65 (45-83) years, underwent AdVance™ sling surgery. 10 men had undergone holmium laser enucleation of the prostate, one a transurethral resection of the prostate and 35 radical prostatectomy. 11 men had a VLPP of ≤100 cmH2O. Of these 11 men, three had no, or minimal, improvement in their leakage and all three required a secondary procedure (artificial urinary sphincter, AUS). In the 35 men with a VLPP of >100 cmH2O there were three failures. One of these was successfully salvaged with a repeat sling, another with an AUS and one with ProACT™ balloons. The hazard ratio (HR) for failure with a VLPP of ≤100 cmH20 compared with a VLPP of >100 cmH2O was 4 (95% confidence interval 0.68-23.7). CONCLUSION: A VLPP of >100 cmH2O has a high degree of predictability for success for AdVance™ sling placement for men with post-prostatectomy UI.

PSA screening in New Zealand: total population results and general practitioners' current attitudes and practices.

AIMS: Prostate cancer is the second most common cancer among men in New Zealand. Prostate-specific antigen (PSA) as a screening tool for prostate cancer remains controversial. The aim was to determine the rate of PSA screening in New Zealand and to survey general practitioners' utility of PSA and their attitudes towards PSA screening. METHOD: A questionnaire was sent to 1000 general practitioners (GPs). In addition, a non-identifiable prospective audit of all registered New Zealand GPs' laboratory PSA tests was accessed for 2011. RESULTS: Of the 931,923 males older than 40 years, 267,037 had a PSA test performed (28.3%). This percentage peaked in the 65-75 age group (45%). 263 GP questionnaires were completed. 79% of all GPs would initiate discussion of PSA testing. The most common method of testing was at a time of another health need or check-up. CONCLUSION: The incidence of yearly PSA testing in the New Zealand male population over the age of 40 is 28%. GPs provide appropriate information for men to make an informed decision about PSA screening. There is an increasing population of GPs who will not initiate any discussion of PSA testing in their male patients.

In 2013, holmium laser enucleation of the prostate (HoLEP) may be the new 'gold standard'.

In this review article, we assess why holmium laser enucleation of the prostate (HoLEP) has become an important treatment modality for benign prostatic hypertrophy (BPH). Meta-analysis comparing HoLEP with both open prostatectomy (OP) and transurethral resection of prostate (TURP) shows TURP to be as effective with less morbidity. More recently, HoLEP has long-term durability data confirming a very low reoperation rate. This article investigates how previous hurdles to the widespread uptake of HoLEP have been overcome. Recent literature shows that the learning curve is actually similar to many other current urological procedures, and that the efficiency of HoLEP is equal to that of other surgical procedures. HoLEP is also beneficial in the growing population of men on anticoagulation who require treatment for BPH. Finally, HoLEP is the only laser treatment for BPH with level 1 evidence and endorsement in both the American Urological Association (AUA) and European Association of Urology (EAU) guidelines.

Workload in a provincial New Zealand vascular surgery service.

AIM: There is increasing evidence that centralising complex surgical procedures improves mortality rates. The focus on mortality as the primary outcome measure overlooks every other aspect of a local surgical service that could be lost by centralisation. The aim of this audit was to assess the total vascular service provided in a provincial vascular surgical unit METHOD: This was a 12-month prospective audit of the vascular surgical service in Taranaki. All outpatient and inpatient vascular consultations and procedures carried out by a surgeon or interventional radiologist were identified. RESULTS: There were 181 inpatient admissions of which 121 (67%) were elective and 60 (33%) acute. There were 41 (29%) non-operative admissions, while 140 (71%) required an operation as an inpatient. There were 967 total bed days for vascular patients with an average stay of 5 days (4-6 95% CI). There were 588 vascular outpatient consultations for 396 patients. There were 201 (34%) new patient visits and 387 (66%) follow up appointments. CONCLUSION: Although the number of operations performed per population per year in Taranaki over the audit period was consistent with other reports, the number of major vascular cases did not meet suggested annual thresholds for minimising mortality. Despite this there was no evidence of increased mortality in any group. There was a large amount of non operative work which is not considered when focus is exclusively on mortality.