Ergonomic use of the fourth arm to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP).

OBJECTIVE: To demonstrate an ergonomic fourth arm technique to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Balloon of a Foley catheter inflated in the bulbar urethra. Fourth arm cranial traction via suture in the tip of the catheter. DVC oversewn under direct vision. RESULTS: Oversew of DVC with minimal patient-side surgical assistance. About a 50% reduction in apical positive margin rate. CONCLUSION: A useful, ergonomic method of oversewing the DVC during RALP.

Dermatological manifestation of metastatic prostate cancer.

A 59-year-old man presented to the urology department with increased urinary urgency, frequency, poor urinary flow and unintentional weight loss. He had a 25-year history of idiopathic urticaria episodes which had increased in frequency over the previous 2 months. On investigation, he was found to have a raised prostate-specific antigen level. He was investigated further with a multiparametric MRI, a local anaesthetic transperineal prostate biopsy, a CT scan of chest/abdomen/pelvis with contrast and a nuclear medicine bone scan. He was diagnosed with metastatic adenocarcinoma of the prostate and commenced on a luteinising hormone-releasing hormone antagonist and referred to oncology for further treatment. Since starting treatment, he has experienced no further episodes of urticaria.

A Multicentre Analysis of the Detection of Clinically Significant Prostate Cancer Following Transperineal Image-fusion Targeted and Nontargeted Systematic Prostate Biopsy in Men at Risk.

BACKGROUND: Prostate biopsy guided by magnetic resonance imaging (MRI) is increasingly used to obtain tissue from men with suspected prostate cancer (PC). OBJECTIVE: To report a multicentre series of image-fusion transperineal prostate biopsies and compare the diagnostic yield of clinically significant PC (csPC) between targeted and nontargeted biopsies. DESIGN, SETTING, AND PARTICIPANTS: The study included 640 consecutive patients with elevated prostate specific antigen (PSA) presenting for first biopsy or following a previous negative transrectal biopsy under the care of 13 urologists in 11 centres in the UK (April 2014-June 2017). INTERVENTION: Multiparametric MRI was carried out in 61 approved prostate MRI centres with transperineal targeted alone (n=283) or targeted plus nontargeted (n=357) transperineal rigid image-fusion targeted biopsy (MIM-Symphony-DX). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Rates of csPC and insignificant cancer detection in targeted and nontargeted biopsies were measured using a number of thresholds to define clinical significance. The primary definition was Gleason≥4+3 or any grade ≥6mm. RESULTS AND LIMITATIONS: The mean age, median PSA, and median prostate volume for the cohort were 63.8yr (standard deviation [SD] 8.4), 6.3 ng/ml (SD 5.8), and 42.0cm3 (SD 24.7), respectively. Overall, 276/640 men (43.1%) were diagnosed with csPC. csPC was detected from targeted biopsies alone in 263/640 cases (41.1%). Of the 357 men who underwent nontargeted biopsies, three (0.8%) had csPC exclusively in nontargeted cores, with no evidence of cancer in targeted cores. Overall, 32/357 (9.0%) had csPC in nontargeted biopsies regardless of the targeted biopsy findings. Clinically insignificant disease in nontargeted biopsies was detected in 93/357 men (26.1%). Our findings were consistent across all other thresholds of clinical significance. Limitations include the lack of nontargeted biopsies in all men. CONCLUSIONS: In this large multicentre series, nontargeted prostate biopsy cores had a low yield of csPC and a high yield of clinically insignificant PC. An image-fusion targeted-biopsy-only approach maintains high detection for csPC and low detection of clinically insignificant cancers. PATIENT SUMMARY: In this report, we found that following prostate multiparametric magnetic resonance imaging and targeted transperineal biopsies of suspicious areas, the clinical value of performing additional extensive unguided biopsies of nonsuspicious areas is limited and can often find insignificant cancers that do not need treatment.

The discovery of prostate-specific antigen.

The discovery of prostate-specific antigen (PSA) was beset with controversy; as PSA is present in prostatic tissue and semen, it was independently discovered and given different names, thus adding to the controversy. In this review we document the early research in this field to describe the chronology of the discovery of PSA. Using a comprehensive Medline search of the historical aspects of PSA, all relevant papers were reviewed; communication with the scientists involved in the discovery of PSA was an invaluable contribution. In 1960, Flocks was the first to experiment with antigens in the prostate and 10 years later Ablin reported the presence of precipitation antigens in the prostate. In 1971, Hara characterized a unique protein in the semen fluid, gamma-seminoprotein. Li and Beling, in 1973, isolated a protein, E1, from human semen in an attempt to find a novel method to achieve fertility control. In 1978, Sensabaugh identified semen-specific protein p30, but proved that it was similar to E1 protein, and that prostate was the source. In 1979, Wang purified a tissue-specific antigen from the prostate ('prostate antigen'). PSA was first measured quantitatively in the blood by Papsidero in 1980, and Stamey carried out the initial work on the clinical use of PSA as a marker of prostate cancer. Thus the discovery of PSA is interesting and surrounded by controversy. Although the credit for purifying PSA goes to Wang, other eminent scientists published research on this antigen. The initial work on PSA in semen was to asses its properties as a forensic marker for rape victims, but soon its potential as a marker for prostate cancer became evident.

Trans-rectal ultrasound guided biopsy of the prostate: nationwide diversity in practice and training in the United Kingdom.

INTRODUCTION: TRUS-guided needle biopsy of the prostate is the standard technique in the diagnosis of prostate cancer. However the practice is highly variable across the United Kingdom. We survey the standard approaches to TRUS biopsy of prostate, highlighting the nationwide diversity of practice and training. METHODS: One hundred and eighty questionnaires were sent out to specialist registrars, investigating the number of prostate biopsy cores taken, the use of prophylactic antibiotics, rectal preparation and local analgesia in TRUS biopsy of the prostate. One hundred and fourteen trainees (63%) returned the questionnaires. Twenty-three percent reported sextant biopsy as standard, 36% taking eight-core and 26% taking 10 or more cores. There is no standard regime for antibiotic prophylaxis. Eighteen percent also reported rectal preparation as routine. Thirty-eight percent of the patients receive local anaesthesia prior to the biopsy. Overall, 42% of the TRUS biopsies are carried out by urologists, 29% by radiologists and 21% by both. Six percents have nurse practitioners' involvement. Fifty-six percent of trainees are involve in the TRUS biopsy, 68% do not think they received enough training to carry out the procedure. CONCLUSIONS: TRUS-guided needle biopsy of the prostate is the standard technique in the diagnosis of prostate cancer. Our survey highlights nationwide diversity in practice in the UK with respect of the number of cores taken, antibiotic prophylaxis and local anaesthesia utilisation. This raised the issue of standardising the practice. More urologists are also actively taking part in this procedure, making the structured training increasingly important.

Robotic assisted laparoscopic partial nephrectomy using contrast-enhanced ultrasound scan to map renal blood flow.

OBJECTIVE: The paper describes novel real-time 'in situ mapping' and 'sequential occlusion angiography' to facilitate selective ischaemia robotic partial nephrectomy (RPN) using intraoperative contrast enhanced ultrasound scan (CEUS). MATERIALS AND METHODS: Data were collected and assessed for 60 patients (61 tumours) between 2009 and 2013. 31 (50.8%) tumours underwent 'Global Ischaemia', 27 (44.3%) underwent 'Selective Ischaemia' and 3 (4.9%) were removed 'Off Clamp Zero Ischaemia'. Demographics, operative variables, complications, renal pathology and outcomes were assessed. RESULTS: Median PADUA score was 9 (range 7-10). The mean warm ischaemia time in selective ischaemia was less and statistically significant than in global ischaemia (17.1 and 21.4, respectively). Mean operative time was 163 min. Postoperative complications (n = 10) included three (5%) Clavien grade 3 or above. Malignancy was demonstrated in 47 (77%) with negative margin in 43 (91.5%) and positive margin in four (8.5%). Long-term decrease in eGFR post selective ischaemia robotic partial nephrectomy was less compared with global ischaemia (four and eight, respectively) but not statistically significant. CONCLUSIONS: This technique is safe, feasible and cost-effective with comparable perioperative outcomes. The technical aspects elucidate the role of intraoperative CEUS to facilitate and ascertain selective ischaemia. Further work is required to demonstrate long-term oncological outcomes. © 2016 The Authors. The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons, Ltd.

Safety and detailed patterns of morbidity of transrectal ultrasound guided needle biopsy of prostate in a urologist-led unit.

OBJECTIVE: We prospectively evaluate the safety, morbidity and characteristics of complications for transrectal ultrasound guided needle biopsy of prostate carried out solely by urologists in a single unit. This will help to counsel patient prior to the biopsy. PATIENTS AND METHODS: One hundred consecutive patients were recruited to complete questionnaires prospectively, 2 weeks and 3 months after TRUS and prostate biopsy. Haematospermia, haematuria and rectal bleeding characteristics were evaluated. Pain, analgesia requirement, infection and urinary retention rates were also assessed. RESULTS: Ninety-two patients (92%) returned questionnaires 2 weeks and 63 patients (63%) three months after the biopsy. At 2 weeks questionnaire, 58 patients (63%) experienced haematuria and 9 patients (10%) for more than 1 week. Eighty-five percent of the 58 patients who had haematuria described it as mild and intermittent. Twenty-three (25%) patients experienced a rectal bleed and none for more than four days. Only 1 patient experienced clots with the rectal bleeding. Twelve (13%) patients had difficulty passing urine but the symptoms resolved by day four. Acute urinary retention did not occur. Thirty-five (38%) patients had some degree of discomfort and only one patient had pain for more than three days. Twenty-five (27%) patients took analgesia between 1 and 8 days (Mean 3 days). Two patients had a urinary tract infection despite prophylactic antibiotics. At three months, 4 patients (6%) had experienced secondary haematuria 3 weeks after the biopsy. Two patients experienced more rectal bleeding 2 weeks after the biopsy and 1 patient had residual discomfort 2 weeks after the procedure. Thirteen patients (21%) had haematospermia between day 6 and 56 (Mean 21 days). CONCLUSIONS: Transrectal ultrasound guided biopsy of the prostate is generally well tolerated with minor pain and morbidity in our urologist-led service. Our data will assist counselling of patients prior to the procedure.

Penis: an unusual site for pilonidal sinus.

Pilonidal sinus affects different regions of the body, gluteal cleft being the most common. This condition affecting the penis is extremely rare with only a few case reports around the world. It is prone for complications like infection, actinomycosis, abscess formation, erectile dysfunction and phimosis amongst others. We present a case of Pilonidal sinus of the penis where a pre-operative diagnosis was made and appropriate treatment in the form of circumcision prevented complications.

Zero ischaemia partial nephrectomy: a call for standardized nomenclature and functional outcomes.

Nephron-sparing surgery for the removal of small renal masses delivers equivalent oncological outcomes and better functional outcomes compared with those associated with radical nephrectomy. All contemporary partial nephrectomy techniques including open, laparoscopic and robotic approaches involve the use of hilar clamping in order to facilitate haemostasis, and to enable accurate tumour excision and parenchymal reconstruction. Zero ischaemia was subsequently introduced as a technique to eliminate the renal ischaemia induced by hilar clamping. Following the introduction of zero ischaemia techniques, researchers have arbitrarily applied this term to techniques ranging from no use of clamping to selective clamping of renal arteries and/or veins, or their branches. Substantial variations exist in the way that zero ischaemia and other renal preservation techniques are described in the literature. Similarly, further diversity exists in the measurement and reporting of functional outcomes after surgery. The introduction of standard and reproducible classifications or guidelines will ensure consistency and uniformity. Establishing consensus on the terminology used to describe techniques and functional outcomes will not only facilitate improved communication and surgical practice, but will also enable critical appraisal of surgical techniques.

Role of intra-operative contrast-enhanced ultrasound (CEUS) in robotic-assisted nephron-sparing surgery.

This review examines studies of intra-operative contrast-enhanced ultrasound (CEUS) and its emerging role and advantages in robotic-assisted nephron-sparing surgery. Contrast-enhanced ultrasound is a technology that combines the use of second-generation contrast agents consisting of microbubbles with existent ultrasound techniques. Until now, this novel technology has aided surgeons with procedures involving the liver. However, with recent advances in the CEUS technique and the introduction of robotics in nephron-sparing surgery, CEUS has proven to be efficacious in answering several clinical questions with respect to the kidneys. In addition, the introduction of the microbubble-based contrast agents has increased the image quality and signal uptake by the ultrasound probe. This has led to better, enhanced scanning of the macro and microvasculature of the kidneys, making CEUS a powerful diagnostic modality. This imaging method is capable of further lowering the learning curve and warm ischemia time (WIT) during robotic-assisted nephron-sparing surgery, with its increased level of capillary perfusion and imaging. CEUS has the potential to increase the sensitivity and specificity of intra-operative images, and can significantly improve the outcome of robotic-assisted nephron-sparing surgery by increasing the precision and diagnostic insight of the surgeon. The purpose of this article is to review the practical and potential uses of CEUS as an intra-operative imaging technique during robotic-assisted nephron-sparing surgery.

Nephroureterectomy for emphysematous pyelonephritis: An aggressive approach is sometimes necessary. A case report and literature review.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a life-threatening urological emergency. A high index of suspicion is required for diagnosis as such patients may present to physicians with typical features of pyelonephritis. PRESENTATION OF CASE: A 67 year old lady presented atypically to the Emergency Department with symptoms of renal colic. The diagnosis of emphysematous pyelonephritis was established on prompt CT scanning. She did not respond to conservative management. Due to acute, critical deterioration, she underwent a radical right nephroureterectomy. The resected kidney involved a long segment of necrotic, gangrenous ureter. The patient had a smooth post-operative recovery and was successfully discharged. She remains well on follow-up after one year. DISCUSSION: Early radiological diagnosis is imperative for risk stratification of EPN. Current evidence recommends percutaneous catheter drainage with interval nephrectomy as the gold standard treatment. We review the literature for pathophysiology and clinical prognostic factors. This case adds onto the limited evidence base on ureteric involvement in EPN, suggesting a revision of EPN classification. CONCLUSION: Further research on ureteric involvement and treatment outcomes in EPN is required. Even in the current era of minimally invasive surgery and renal preservation therapies, early open nephrectomy still has a role in the management of EPN.

A unique extra-anatomic urinary diversion!

The ureter is often involved in pelvic malignancy, leading to obstruction, hydronephrosis, and deterioration of renal function. Decompression is provided either by retrograde stenting or by nephrostomy followed by antegrade stent insertion. We present an interesting case where an iatrogenic accident during antegrade stenting led to the placement of the lower end of the stent in the rectal stump. Although this led to a favorable outcome, in that it provided internal continent drainage, it cannot be recommended for emulation. However, it does show that a physician should not only have conventional wisdom but also a good measure of innovation and pragmatism.

Occlusion angiography using intraoperative contrast-enhanced ultrasound scan (CEUS): a novel technique demonstrating segmental renal blood supply to assist zero-ischaemia robot-assisted partial nephrectomy.

BACKGROUND: Recent innovations in technology and operative techniques have enabled safe performance of robot-assisted zero-ischaemia partial nephrectomy (PN), thus preventing the deleterious effect of warm ischaemia time. OBJECTIVE: To describe a novel technique of occlusion angiography using intraoperative contrast-enhanced ultrasound scan (CEUS) for zero-ischaemia robot-assisted PN (RAPN). DESIGN, SETTING, AND PARTICIPANTS: We used a prospective cohort evaluation of five patients who had imaging suspicious of renal cell carcinoma (RCC) treated at a single centre. SURGICAL PROCEDURE: We used computed tomography with three-dimensional reconstruction to identify renal arterial anatomy and its relationship to the tumour. Then, RAPN was performed with selective clamping and demonstration of a nonperfused segment of kidney (occlusion angiography) using intraoperative CEUS. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We prospectively collected data on baseline, perioperative, and postoperative parameters. RESULTS AND LIMITATIONS: We describe the effects seen on ultrasound contrast administration. Contrast flare is seen in the segment of the kidney that is perfused. When selective clamping is performed, a watershed (line of demarcation) between the perfused and nonperfused segments of the kidney is clearly seen, allowing excision of the tumour in a relatively avascular plane and ensuring an adequate oncologic margin, when feasible. The mean age was 68.2 yr of age (range: 36-85), and the mean tumour size was 29.6mm (range: 20-42). The mean intraparenchymal extension of the tumour was 22.6mm (range: 12-30). Three tumours were located on the right kidney and two on the left. The mean blood loss was 420ml (range: 200-1000). The histology revealed clear cell RCC in two patients, oncocytoma in two patients, and type 1 papillary RCC in one patient. All the surgical specimens had negative surgical margins. The mean decrease in glomerular filtration rate was 8.4ml (range: 0-24). The mean follow-up was 6.4 mo (range: 5-8), with no evidence of recurrence in any patient. The only limitation in adopting this technique is the need for an intraoperative ultrasound probe with a CEUS mode. However, most specialists who perform minimally invasive surgery for small renal tumours believe that intraoperative ultrasound scan imaging is essential to achieving adequate resection margins. CONCLUSIONS: Intraoperative CEUS can be a useful adjunct in determining whether zero-ischaemia RAPN is feasible by delineating the area of nonperfusion. This technique has several advantages over the currently available techniques, such as indigo carmine green and Doppler probes.

Cutaneous myiasis of Cordylobia anthropophaga.

We report on a case of glans penis cutaneous myiasis with Cordylobia anthropophaga acquired from Somalia. The mode of transmission and preventative measures are discussed.

Disappearing drain--disaster averted and lesson learnt!

The use of postoperative drains date back to Hippocrates. We report an iatrogenic case of migrated drain into the retroperitoneum. A novel technique using a rigid cystoscope for retrieval is described that prevented another laparotomy.