The treatment landscape of nonmetastatic castrate resistant prostate cancer: A contemporary perspective.

OBJECTIVES: The incidence of nonmetastatic castrate resistant prostate cancer (nmCRPC) is not well defined in contemporary practice. The aim of this study is to describe the incidence and patterns of treatment of nmCRPC over the last 6 years at a single high-volume Australian health institution. SUBJECTS AND METHODS: All men newly diagnosed with prostate cancer at Western Health, Melbourne from January 2016 to December 2021 were included in the study. Those diagnosed with nonmetastatic prostate cancer and treated with medical or surgical castration for biochemical failure post attempted curative therapy were retrospectively reviewed for signs of castration resistance using prostate specific antigen (PSA) and testosterone biochemical markers up until October 2022. RESULTS: From January 2016 to December 2021, 822 patients were diagnosed with prostate cancer, 590 had localized disease, 373 underwent definitive locoregional therapy, and 31 went on to have biochemical recurrence and were commenced on androgen deprivation therapy. Twenty-five patients had undetectable PSA levels and were classified as having nonmetastatic castrate sensitive prostate cancer (nmCSPC), whilst the remaining 6 patients experienced a rising PSA and were thus classified as nmCRPC. The incidence rate of nmCRPC was 228 cases per 100,000 person-years. The median age at the time of prostate biopsy was 74 years (interquartile range [IQR] 64-79) in the nmCRPC group and 62 years (IQR 57-69) in the nmCSPC group. The median prebiopsy PSA (ng/ml) in the nmCRPC and nmCSPC groups were 27.5 (IQR 19.9-50.4), and 16.5 (IQR 9.0-26.0), respectively. The median duration from prostate cancer diagnosis to onset of nmCRPC was 24 months (IQR 17-29) and the median PSA doubling time was 3.4 months (IQR 2.2-5.7). CONCLUSIONS: Thus, nmCRPC is an uncommon disease. Further population-based studies are required to better understand the incidence of nmCRPC.

Implementation of the enhanced recovery after surgery protocol for radical cystectomy patients: A single centre experience.

PURPOSE: The enhanced recovery after surgery (ERAS) protocol for radical cystectomy aims to facilitate postoperative recovery and hasten a return to normal daily activities. This study aims to report on the perioperative outcomes of implementation of an ERAS protocol at a single Australian institution. MATERIALS AND METHODS: We identified 73 patients with pT1-T4 bladder cancer who underwent open radical cystectomy at Western Health, Victoria between June 2016 and August 2021. A retrospective analysis of a prospectively maintained database was performed. Perioperative outcomes included length of hospital stay, nasogastric tube requirement and duration of postoperative ileus. RESULTS: The median age was 74 years (interquartile range [IQR] 66-78) for the ERAS group and 70 years (IQR 65-78) for the pre-ERAS group patients. All patients in each group underwent ileal conduit formation. The median length of hospital stay was 7.0 days (IQR 7.0-9.3) for the ERAS group and 12.0 days (IQR 8.0-16.0) for the pre-ERAS group (p=0.003). Within the ERAS group, 25.0% had a postoperative ileus, and 25.0% had a nasogastric tube inserted, compared with 64.9% (p=0.001) and 45.9% (p=0.063) respectively within pre-ERAS group. The median bowel function recovery time, defined as duration from surgery to first bowel action, was 5.0 days (IQR 4.0-7.0) in the ERAS group and 7.5 days (IQR 5.0-8.5) in the pre-ERAS group (p=0.016). CONCLUSIONS: Implementation of an ERAS protocol is associated with a reduction in hospital length of stay, postoperative ileus and bowel function recovery time.

Development and implementation of an enhanced recovery after surgery protocol for renal transplantation.

BACKGROUND: Successful implementation of enhanced recovery after surgery (ERAS) in kidney transplantation requires multidisciplinary consultation, education and attention to protocol. This study discusses the process implementation pathway of the ERAS protocol and its outcome. METHODS: A standardized ERAS protocol was designed for the renal transplant recipient and implemented in July 2017. Data collected prospectively of recipients transplanted from July 2017 to December 2018 were compared to prospectively collected data of recipients who were transplanted prior to ERAS implementation from January 2016 to July 2017 from our renal database. The parameters of interest included length of stay, incidence of delayed graft function and readmission rate. RESULTS: There was no difference in the demographics and the incidence of delayed graft function across both groups, although subgroup analysis suggested a significantly lower incidence of delayed graft function with kidneys donated after circulatory death in the cohort that were managed by the ERAS protocol. The median length of stay for patients on the ERAS protocol was 5 days (range 3-16 days). This was 2 days shorter than the median length of stay for patients not on the ERAS protocol (7 days; range 5-14, P < 0.001). This statistically significant difference in length of stay was consistent across all donor subgroups (living donor, donor after cardiac death and donation after brainstem death). Seventy-nine percent of the patients on the ERAS protocol were discharged on post-operative day 4. CONCLUSION: An ERAS protocol for renal transplant patients is feasible. Our data show that successful implementation of ERAS in kidney transplantation is possible and results in significant cost savings due to shorter length of stay.

Laparoscopic-assisted Ex Vivo Reconstruction of Renal Artery Aneurysm with Internal Iliac Artery and Auto-transplantation.

Renal artery aneurysms (RAA) represent a complex and an often incidentally found disease commonly treated with endovascular approaches. In cases where in situ approaches are unsuitable, laparoscopic-assisted ex vivo repairs offer significant advantages during and post-surgery. We present a case of a female patient who presented with a long-standing right-sided flank pain. She was diagnosed with bilateral asymptomatic RAAs positioned well into the hilum, therefore making in situ repair infeasible. A laparoscopic-assisted ex vivo repair of the renal artery was performed using a graft from the internal iliac artery, which is a novel approach.

Role of inflammatory markers as predictors of laparotomy in patients presenting with acute abdomen.

BACKGROUND: There is a need for an ideal indicator of surgery in patients presenting with acute abdomen. Several markers have been analysed, but the search still continues as none have proven effective. This study aimed to analyse and compare the predictive value of plasma procalcitonin (PCT) strip test in patients presenting with acute abdomen and identify a useful cut-off value to differentiate patients that would benefit with surgery from those that require conservative management. METHODS: A prospective study was conducted in the department of general surgery from June 2012 to June 2013. Plasma PCT was estimated by the semi-quantitative strip test. The levels of plasma PCT and other routinely used markers of inflammation were analysed and compared. RESULTS: Of the total of 58 patients, 44 patients (76%) were men with a mean age of 45 years. Forty patients required emergency surgical intervention. A plasma PCT value of >0.5 ng/mL at admission was 80% sensitive and 100% specific for predicting need for antibiotics in patients with acute abdomen that were managed conservatively. The mean plasma PCT value in the patients undergoing surgery (5.0-10.0 ng/mL) was significantly more than in those managed conservatively (0.5-2.0 ng/mL). Using receiver operating characteristic (ROC) curves a cut-off for plasma PCT of >5.0 ng/mL was 75% sensitive and 100% specific for considering surgical intervention in patients presenting with acute abdomen. CONCLUSIONS: Plasma PCT (value >5 ng/mL) could be used as an adjunct to clinical examination to predict requirement of surgery in patients presenting with acute abdomen.