Testicular infarction and spontaneous scrotal rupture secondary to acute epididymo-orchitis.

Epididymo-orchitis is a common cause of acute unilateral testicular pain. Both infectious or non-infectious causes have been proposed and, rarely, testicular abscess formation and even infarction can occur as a severe complication. We present here a case of acute epididymo-orchitis leading to testicular abscess formation, infarction and spontaneous rupture through the scrotal wall despite appropriate antibiotic treatments. Orchidectomy and partial scrotectomy were performed during surgical exploration for management of the non-viable testis and associated scrotal sinus. Clinical vigilance is important to prevent this complication by close clinical follow up with ultrasonography and even early surgical decompression to prevent testicular loss.

Assessing operating theatre efficiency: a prospective cohort study to identify intervention targets to improve efficiency.

BACKGROUND: Operating theatre efficiency is critical to providing optimum healthcare and maintaining the financial success of a hospital. This study aims to assess theatre efficiency, with a focus on staff activities, theatre utilisation and case changeover. METHODS: Theatre efficiency data were collected prospectively at a single centre in metropolitan Melbourne, Australia, over two 5-week periods. Characteristics of each case and various time points were collected, corresponding to either in-theatre staff activities or patient events. RESULTS: Two hundred and ninety-nine cases were prospectively audited over a range of surgical specialties. Setting up represented 42.4% (37.28 min), operating time 40.1% (35.28 min) and finishing up time 17.5% (15.43 min). Theatres were empty (turnover time) for 17.42 min, which was 39.4% of the non-operative time between operations (44.25 min, turnaround time). Plastic surgery operations required the shortest set-up and finishing times on most of the measured metrics, with general surgery and obstetrics/gynaecology having longer times. List order made a significant difference, with efficiency improving over the list and over the day for separate am and pm lists. When a patient was not on time to theatre, efficiency in both set up and finishing up metrics was significantly worse. CONCLUSIONS: A large proportion of theatre time was being spent on non-operative tasks, making staff activities potential targets for operating theatre improvement interventions. Motivation and team familiarity were identified as the major factors behind efficiently run operating theatres, supporting the use of regular operating teams and maintenance of a highly motivated workforce.

68Ga-PSMA-PET screening and transponder-guided salvage radiotherapy to the prostate bed alone for biochemical recurrence following prostatectomy: interim outcomes of a phase II trial.

PURPOSE: To evaluate outcomes for men with biochemically recurrent prostate cancer who were selected for transponder-guided salvage radiotherapy (SRT) to the prostate bed alone by 68Ga-labelled prostate-specific membrane antigen positron emission tomography (68Ga-PSMA-PET). METHODS: This is a single-arm, prospective study of men with a prostate-specific antigen (PSA) level rising to 0.1-2.5 ng/mL following radical prostatectomy. Patients were staged with 68Ga-PSMA-PET and those with a negative finding, or a positive finding localised to the prostate bed, continued to SRT only to the prostate bed alone with real-time target-tracking using electromagnetic transponders. The primary endpoint was freedom from biochemical relapse (FFBR, PSA > 0.2 ng/mL from the post-radiotherapy nadir). Secondary endpoints were time to biochemical relapse, toxicity and patient-reported quality of life (QoL). RESULTS: Ninety-two patients (median PSA of 0.18 ng/ml, IQR 0.12-0.36), were screened with 68Ga-PSMA-PET and metastatic disease was found in 20 (21.7%) patients. Sixty-nine of 72 non-metastatic patients elected to proceed with SRT. At the interim (3-year) analysis, 32 (46.4%) patients (95% CI 34.3-58.8%) were FFBR. The median time to biochemical relapse was 16.1 months. The rate of FFBR was 82.4% for ISUP grade-group 2 patients. Rates of grade 2 or higher gastrointestinal and genitourinary toxicity were 0% and 15.2%, respectively. General health and disease-specific QoL remained stable. CONCLUSION: Pre-SRT 68Ga-PSMA-PET scans detect metastatic disease in a proportion of patients at low PSA levels but fail to improve FFBR. Transponder-guided SRT to the prostate bed alone is associated with a favourable toxicity profile and preserved QoL. TRIAL REGISTRATION NUMBER: ACTRN12615001183572, 03/11/2015, retrospectively registered.

Patterns of disease detection using [18F]DCFPyL PET/CT imaging in patients with detectable PSA post prostatectomy being considered for salvage radiotherapy: a prospective trial.

PURPOSE: Prostate-specific membrane antigen (PSMA) PET/CT is increasingly used in patients with biochemical recurrence post prostatectomy to detect local recurrence and metastatic disease at low PSA levels. The aim of this study was to assess patterns of disease detection, predictive factors and safety using [18F]DCFPyL PET/CT versus diagnostic CT in patients being considered for salvage radiotherapy with biochemical recurrence post prostatectomy. METHODS: We conducted a prospective trial recruiting 100 patients with detectable PSA post prostatectomy (PSA 0.2-2.0 ng/mL) and referred for salvage radiotherapy from August 2018 to July 2020. All patients underwent a PSMA PET/CT using the [18F]DCFPyL tracer and a diagnostic CT. The detection rates of [18F]DCFPyL PET/CT vs diagnostic CT were compared and patterns of disease are reported. Clinical patient and tumour characteristics were analysed for predictive utility. Thirty-day post-scan safety is reported. RESULTS: Of 100 patients recruited, 98 were suitable for analysis with a median PSA of 0.32 ng/mL. [18F]DCFPyL PET/CT was positive 46.4% and equivocal 5.2%, compared to 15.5% positivity for diagnostic CT. Local recurrence was detected on [18F]DCFPyL PET/CT in 28.5%, nodal disease in 27.5% and bony metastases in 6.1% of patients. Both ISUP grade group (p < 0.001) and pre-scan PSA (p = 0.029) were significant predictors of [18F]DCFPyL PET/CT positivity, and logistic regression generated probabilities combining the two showed improved prediction rates. No significant safety events were reported post [18F]DCFPyL administration. CONCLUSIONS: [18F]DCFPyL PET/CT increases detection of disease in patients with biochemical recurrence post prostatectomy compared to diagnostic CT. Patients being considered for salvage radiotherapy with a PSA >0.2 ng/mL should be considered for [18F]DCFPyL PET/CT scan. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Number: ACTRN12618001530213 ( http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375932&isReview=true ).

Ductal variant prostate carcinoma is associated with a significantly shorter metastasis-free survival.

BACKGROUND: Ductal adenocarcinoma is an uncommon prostate cancer variant. Previous studies suggest that ductal variant histology may be associated with worse clinical outcomes, but these are difficult to interpret. To address this, we performed an international, multi-institutional study to describe the characteristics of ductal adenocarcinoma, particularly focussing on the effect of presence of ductal variant cancer on metastasis-free survival. METHODS: Patients with ductal variant histology from two institutional databases who underwent radical prostatectomies were identified and compared with an independent acinar adenocarcinoma cohort. After propensity score matching, the effect of the presence of ductal adenocarcinoma on time to biochemical recurrence, initiation of salvage therapy and the development of metastatic disease was determined. Deep whole-exome sequencing was performed for selected cases (n = 8). RESULTS: A total of 202 ductal adenocarcinoma and 2037 acinar adenocarcinoma cases were analysed. Survival analysis after matching demonstrated that patients with ductal variant histology had shorter salvage-free survival (8.1 versus 22.0 months, p = 0.03) and metastasis-free survival (6.7 versus 78.6 months, p < 0.0001). Ductal variant histology was consistently associated with RB1 loss, as well as copy number gains in TAP1, SLC4A2 and EHHADH. CONCLUSIONS: The presence of any ductal variant adenocarcinoma at the time of prostatectomy portends a worse clinical outcome than pure acinar cancers, with significantly shorter times to initiation of salvage therapies and the onset of metastatic disease. These features appear to be driven by uncoupling of chromosomal duplication from cell division, resulting in widespread copy number aberration with specific gain of genes implicated in treatment resistance.

​Primary retroperitoneal pseudocyst: beware of the hoax solid enhancing adrenal mass.

​We report the case of a 55-year-old male patient with an incidental finding on CT of a 'large adrenal mass'. The mass, which was intimately related to the left adrenal, was enhancing but not metabolically active. CT showed a 40×32 mm mass adjacent to the left adrenal and medial border of the spleen, 32 Hounsfield units (HU) precontrast and 116 HU postcontrast, consistent with a solid enhancing mass. The patient had no previous history of acute pancreatitis or any history of trauma. The patient proceeded to a laparoscopic left adrenalectomy; intraoperatively, a well-circumscribed lesion was identified intimately related to the splenic artery and able to be peeled away easily from the left adrenal. The lesion was unable to be dissected from the splenic artery and consequently the splenic artery was divided in order to completely resect this lesion. Histopathology identified the lesion as a 'non-pancreatic fibrous pseudocyst', with a thick calcified wall, the absence of epithelial lining and widespread inflammatory change.

Hierarchical task analysis for identification of interrelationships between ergonomic, external disruption, and internal disruption in complex laparoscopic procedures.

BACKGROUND: Traditionally, hierarchical task analysis (HTA) in surgery examines observable disruption in a predefined set of tasks as performed, rather than examining the ergonomics requirements, which may predispose surgical teams to act erroneously. This research aims to address this gap in the literature. It develops a HTA protocol taking into consideration surgical team actions, observable external disruption, internal disruption, and ergonomic goals required for safer conducting procedures. Laparoscopic radical prostatectomy (LRP) is selected as a case. METHODS: This research involved observations inside operating rooms (ORs) of three large teaching hospitals in Australia and China. Two rounds of observations are conducted: observations for developing HTA, and observations after presenting the developed HTA among surgical teams. The traditional HTA format is expanded to include two additional columns: technical considerations and ergonomics considerations. Two groups are formed from the observed LRPs. LRPs in the first group were conducted with no regard to the specified ergonomic goals and associated ergonomic features, and the second are conducted with the surgical teams attempting to follow specified ergonomic goals and features as prescribed in HTA. Careful attempt is required to select procedures such that the total operative times for both groups are approximately equal (± 5%). RESULTS: Between March 2016 and November 2017, a total of 29 LRPs were observed, and a HTA developed. The results reveal significant reduction (43%) in the total external disruptive events and approximately 58% reduction in the internal disruptive events in LRPs conducted with HTA requirements. CONCLUSIONS: The developed HTA appears to have some utility, but needs evaluation in larger studies. It can potentially be used as a training aid, and as a checklist for evaluating surgical performance.

The role of cystectomy in elderly patients - a multicentre analysis.

INTRODUCTION: Life expectancy in developed countries is continuously increasing. Hence elderly patients are becoming more common in our clinical practice. Currently, one of the greatest challenges of medicine is balancing the life expectancy of elderly patients against aggressive treatments that carry significant risks. OBJECTIVE: To outline the complications and survival in surgical patients 80 years and over undergoing radical cystectomy for bladder cancer. PATIENTS AND METHODS: A review of a radical cystectomy in elderly recorded in four different institutional prospective databases during the period between 1991 and 2014. Clinical and pathologic features, complications and survival were evaluated. RESULTS: A total of 111 patients were available. Median (range) age 82.2 (80-89) years. Seventeen women and 94 men. Regarding the ASA score, 6 patients were ASA I, 47 patients were ASA II, 49 patients ASA III and 9 ASA IV. Prior to surgery, 48 patients had hydronephrosis. The median (range) creatinine series was 1.1 (0.71-11.1) ng/dL. In 88 cases an ileal conduit was performed, 17 a cutaneous ureterostomy diversion, 5 neobladders and 1 ureterosigmoidostomy case. The median (range) operative time was 230 (120-420) min and a total of 97 patients required blood transfusion. The median (range) hospital stay was 14 (7-126) days. The early and late complication rates were 50.4% and 32%, respectively. A total of 14 patients (12.6%) required surgical reintervention. Eight patients (7.2%) died in the immediate postoperative period. The readmission rate of the series was 27.2%. The mean follow-up of the series was 18 (0.27-134.73) months. During this period 66 patients died, 52 of them due to the tumor. Twelve month tumour progression free survival was 83.9% for ≤pT1, 70.2% for pT2 and 36% for ≥pT3, respectively. Twelve month cancer specific survival was 85.6% for ≤pT1, 75.1% for pT2 and 42.5% for ≥pT3, respectively. CONCLUSION: Radical cystectomy in elderly population is an aggressive surgical treatment with a significant complication rate, hospital readmission and perioperative mortality rate. Careful selection of patients is essential in order to minimize the complications of this surgery and balance benefits against risks in the elderly population. Tumour progression and cancer specific survival are poor for patients with ≥pT3 disease. Alternatives such as tri-modality therapy need to be considered within a multi-disciplinary approach. More data is required to determine which sub-groups of elderly patients would benefit from a complication, survival and quality of life perspective.

Spermatocytic seminoma with sarcoma: an indication for adjuvant chemotherapy in localized disease.

Spermatocytic seminoma (SCS) with sarcoma is an extremely rare testicular tumor with only 11 cases previously described in the literature. We present the 12th case of SCS with sarcoma in a 29-year-old male. SCS itself is an uncommon germ cell tumor with a relatively indolent clinical course that mostly affects males around the fifth decade of life. Sarcomatous differentiation of SCS occurs in 5% to 6% of cases and correlates with a higher possibility of metastatic disease and a poor prognosis. Clinically, this tumor manifests as a slow-growing testicular mass often with an accelerated period of secondary growth. After a concise review of the literature, we conclude that SCS with sarcoma should be treated by radical inguinal orchidectomy with strong consideration given to adjuvant chemotherapy.

Nephrectomy for a renal metastasis of undiagnosed hepatocellular carcinoma arising from an orthotopic liver transplant undertaken for cryptogenic cirrhosis.

Urological involvement of hepatocellular carcinoma (HCC) is rare; HCC arising in an orthotopic liver transplant (OLT) is exceptionally rare. Here we report the case of a 70-year-old man who was incidentally found to have metastatic HCC in the right kidney arising from his OLT undertaken for cryptogenic cirrhosis 10 years previously. Adding to the complexity of this case was the lack of an obvious liver primary HCC at the time of the radical nephrectomy, thus making the final diagnosis all but impossible. We believe this report represents the first report of HCC metastasizing to the kidney after OLT and adds to the few reports in the literature of HCC arising in transplanted livers.

Effectiveness of epidural versus alternate analgesia for pain relief after radical prostatectomy and correlation with biochemical recurrence in men with prostate cancer.

OBJECTIVES: Our objectives were to analyze the effectiveness of epidural anesthesia in patients who underwent open retropubic radical prostatectomy (RRP) at our institution over the past decade, and to examine subsequent oncologic outcomes, comparing those receiving with those not receiving epidural anesthesia. METHODS: A comprehensive database of all patients undergoing RRP from November 1996 to December 2006 was analyzed; 354 patients underwent RRP at our institution and were divided into those receiving or not receiving an epidural. An independent pain management team scoring technical success found epidural technique to be consistent. Oncological outcome was an endpoint of our study, comparing both analysis groups. We classed prostate-specific antigen (PSA) recurrence after RRP as a serum PSA ≥ 0.2 ng/mL at any stage of postoperative follow-up. Complications were recorded to 30 days using the modified Clavien system, and full statistical analyses were undertaken. RESULTS: Records were available for 239 men; we observed a decreased trend in the use of epidural for pain management, along with a decrease in average hospital stay and an overall epidural success rate of 64%. When dividing data into RRP with and without epidural, we found a median hospital stay of 7 days for patients receiving an epidural compared with 6 days for those not receiving an epidural. The differences were statistically significant (P < 0.048) and remained so after adjusting for complications (P < 0.0001). Regarding oncological outcome, PSA recurrence was further analyzed in this cohort. Percentage of recurrence was higher (14.8%) for patients receiving an epidural than for the non-epidural group (4.8%). The differences were statistically significant (P = 0.012). CONCLUSION: Epidural analgesia increased length of hospital stay and technical problems related to the epidural. Furthermore, men receiving an epidural showed an increased recurrence of PSA. In light of our findings, epidurals are probably not indicated for men undergoing RRP. However, as minimally invasive techniques are becoming more widespread, and epidural analgesia is being used less frequently, large randomized controlled trials to definitively support our hypotheses are unlikely to be undertaken.

Cystectomy in patients with spinal cord injury: indications and long-term outcomes.

PURPOSE: We evaluated indications and outcomes of cystectomy in patients with spinal cord injury in a urology unit attached to a statewide spinal cord injury service. MATERIALS AND METHODS: We performed a review of all patients with spinal cord injury in our database who underwent cystectomy between 1997 and 2008. Demographic, pathological and perioperative data were collected. Oncological outcomes were documented for those with malignant indications while patient satisfaction was recorded using the Patient Global Impression of Improvement scale for all patients. RESULTS: Of 2,569 acute spinal cord injury presentations there were 14 patients who underwent cystectomy. Mean patient age was 53 years (range 39 to 72). Of the 14 patients 9 had malignant disease and 5 had benign indications for cystectomy. Overall mean followup was 48 months (median 30.8). Cumulative survival in the malignant cohort was 66.7% with a 33.3% recurrence rate resulting in death. All survivors remained disease-free at a mean of 49 months (median 31). Mean Patient Global Impression of Improvement score was 3 (range 1-very much better to 7-very much worse). In the nonmalignant cohort mean followup was 75 months (median 77). The overall Patient Global Impression of Improvement score in this group was 2.4, suggesting overall positive patient satisfaction. CONCLUSIONS: In patients with spinal cord injury cystectomy is performed almost as often for nonmalignant as for malignant indications. Our data support a more aggressive presentation of cancer with a different pathological profile but not survival compared to normal populations. Centers treating patients with spinal cord injury should consider a lower threshold for the surgical management of bladder cancer where appropriate, especially considering that morbidity, satisfaction and outcome do not appear to be compromised in patients with spinal cord injury.

Improving informed consent for patients undergoing radical prostatectomy using multimedia techniques: a prospective randomized crossover study.

OBJECTIVE: to compare the comprehension gained by standard consent (SC) vs a unique interactive multimedia presentation (IMP), for radical prostatectomy (RP), as informed consent for RP requires that the patient understands the procedure and potential complications. PATIENTS AND METHODS: forty patients undergoing RP were prospectively randomized to SC or IMP, followed by a 26-question test on critical aspects of the surgery and its implications. The groups were crossed over and re-tested, with a subsequent statistical analysis. SC involved typical verbal interaction and consultation with physicians and nurses, whilst the IMP provided consistent and animated information on these topics, and included multiple-choice questions probing understanding of key points. Progression through the IMP only occurred with correct responses; incorrect responses prompted a review of the information before repeating the question. Telephone interviews assessed usability, overall understanding, educational level and primary language. RESULTS: the patient groups had similar demographics. The IMP group (78%) had significantly higher knowledge test scores (P < 0.001) than the SC group (57%), suggesting a better understanding of the implications of surgery. This was maintained on crossover, with the SC group scores improving by 11% compared to testing before IMP (P < 0.001). The initial IMP group scores were unchanged on crossover and repeat testing (P < 0.05). CONCLUSION: IMP provides better patient understanding than SC for RP, by ensuring that the procedure and risks have been explained consistently, and by actively testing the patient. Such tools assist in obtaining ethical and legally informed consent, thus increasing patient knowledge whilst reducing patient anxiety and potential dissatisfaction or medico-legal consequences when less than ideal outcomes occur.

Anatomic considerations for radical retropubic prostatectomy in an achondroplastic dwarf.

This is the first report of a radical retropubic prostatectomy (RRP) in an achondroplastic dwarf. We highlight the pelvic anatomy, precluding laparoscopic or robotic prostatectomy, and making open surgery extremely difficult. We review relevant literature regarding general, urological, and orthopedic abnormalities of achondroplasia (ACH) and present a clinical case. No reports of RRP in achondroplastic dwarfs exist, with only one case of an abandoned RRP due to similar pelvic anatomy in a patient with osteogenesis imperfecta. Significant lumbar lordosis found in ACH results in a short anteroposterior dimension, severely limiting access to the prostate. We present a case of a 62-year-old achondroplastic dwarf who had Gleason 3+4 disease on transrectal ultrasound-guided biopsy in four from 12 cores. Surgery was difficult due to narrow anteroposterior pelvic dimension, but achievable. Histological analysis revealed multifocal prostate cancer, with negative surgical margins and no extraprostatic extension. RRP in ACH patients, although possible, should be approached with caution due to the abnormal pelvic dimensions, and discussions regarding potential abandonment of surgery should be included during informed consent. This case highlights the preoperative use of computed tomography to assist in the surgical planning for patients with difficult pelvic anatomy.

An analysis of deaths related to urological surgery, reviewed by the State Coroner: a case for cardiac vigilance before transurethral prostatectomy.

OBJECTIVES: To ascertain the frequency of in-hospital deaths after urological surgery in a compulsory reporting setting, and to identify the contributing and potentially reversible factors involved in patients who had had transurethral resection of the prostate (TURP). METHODS: We reviewed all hospital deaths reported to the State Coroner from Coronial Services Victoria (CSV), Australia, in 2000-2002 to identify those instances associated with urological surgery. These cases were then analysed using methods developed by CSV. Resources available included medical records, police reports, government data on operative procedures and autopsy results. RESULTS: There were 20 in-hospital deaths after urological surgery identified for the 3-year period; most related to pre-existing comorbidities, predominantly ischaemic heart disease. Two episodes of hospital-acquired infection, two instances of technical complication of surgery contributing to death, and one pulmonary embolus were identified. Numerically the largest group of deaths after surgery was patients having TURP, and these deaths represented 0.05% (nine of 17 044) of all TURPs in this period. Most in this group (eight) had an acute myocardial infarction. CONCLUSION: Death after urological surgery appears to be uncommon; assessing patients for coronary artery disease before urological surgery, particularly TURP, closer cardiovascular monitoring after surgery, and rapid transfer to a coronary care unit if required, may further reduce mortality.