Search

Background: Transperineal biopsy (TPB) of the prostate has been increasingly utilized as it has reduced infection risks. Traditionally however, it is performed under general anaesthesia, thus it carries a differing set of risks. Recently, new studies have performed TPB under local anaesthesia with success. In the present study, we explored our experience of performing TPB under local anaesthesia in an Australian cohort., Methods: In this prospective study based at a metropolitan outpatient clinic, patients were provided with TPB under local anaesthesia. We assessed prostate cancer detection rates, complication rates and patient tolerability. Pain tolerability was assess using patient reported pain score on the visual analogue scale. Follow up data was collected at days 7 and 30 post-biopsy via telephone interview., Results: A total of 48 patients were enrolled in this study between June 2020 and March 2021. Median age was 65.5 years and median PSA was 6.95 ng/mL. Clinically significant prostate cancer was detected in 58% of patients. During the procedure, pain scores were rated the highest during infiltration of local anaesthetic agent with a median score of 5. By the conclusion of the procedure, median pain score was 1. Vast majority of patients (85.4%) would opt for a repeat TPB under local anaesthesia should the need for prostate biopsy arise again. Two of our patients experienced infectious complications, and one experienced urinary retention., Conclusion: Our data is in line with currently available data and confirms that TPB under local anaesthesia can be achieved in a safe and tolerable manner., (© 2022 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: To evaluate the role of in-bore MRI-guided biopsy (IB-MRGB) in the diagnosis of clinically significant prostate cancer (csPCa)., Methods: In this tertiary single centre study, a total of 125 consecutive patients receiving IB-MRGB over a three-year period were evaluated, including 73 patients who had prior biopsies and 52 biopsy-naïve patients. We assessed cancer detection rate of patients according to the degree of suspicion based on mpMRI findings. Histopathological data were reviewed by experienced uropathologists., Results: The mpMRI was suspicious for PCa (PI-RADS 4/5) in 77% (96/125) and equivocal (PI-RADS 3) in 23% (29/125). The detection rate for csPCa was 54.2% (52/96) and 20.7% (6/29) for suspicious lesions (PI-RADS 4/5) and equivocal lesions (PI-RADS 3), respectively. In subgroup analysis, patients with previous negative biopsy, overall positive biopsy rate and csPCa detection rate were 48.3% (19/35) and 34.5% (13/35), respectively. In patients on AS, 36/44 (81.8%) and 21/44 (47.8%) had PCa and csPCa respectively. In biopsy-naïve patients 34/52 (65.4%) and 27/52 (51.92%) had PCa and csPCa respectively. Of the patients on AS, 18/44 (41.6%) upgraded from ISUP 1 to ISUP 2 PCa, and 4/44 (9.1%) upgraded from ISUP 1 to ISUP 3 PCa on IB-MRGB. A total of 14 Clavien-Dindo≤2 complications occurred in 14 patients (11.2%) that were directly related to the biopsy. No Clavien-Dindo≥3 complications occurred., Conclusion: MRI-targeted biopsy is suitable for assessment of csPCa. Given the favourable complications profile, its use may be considered in both the initial biopsy and re-biopsy settings., (© 2022 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: The aim of this study was to describe our initial Australian single surgeon experience with robotic-assisted radical cystectomy (RARC) and intracorporeal urinary diversion (ICUD) and to compare the outcomes with open radical cystectomy (ORC)., Methods: Between January 2014 and June 2016, consecutive patients diagnosed with muscle invasive and high-risk non-muscle invasive bladder cancer undergoing radical cystectomy were included. Treatment modalities included either RARC with ICUD or ORC. ICUD consisted of either intracorporeal ileal conduit or orthotopic neobladder formation. Prospectively collected perioperative and oncological outcomes were analysed., Results: Twenty-six RARC and 13 ORC were performed. Median operating times were 362 and 240 min for RARC and ORC, respectively (P < 0.001). Estimated blood loss for RARC was 300 mL compared with 500 mL for ORC (P = 0.01). Post-operative haemoglobin drop was less in the RARC cohort (20% versus 24%, P = 0.03). There was no statistical difference in overall 90-day complication rates (81% versus 62%, P = 0.25) and 90-day major complication rates (19% versus 23%, P = 0.67) between the RARC and ORC groups, respectively. Positive surgical margins for RARC were 4% and 8% for ORC (P = 1.0)., Conclusion: Early results demonstrate that the safe introduction of RARC with ICUD in Australia is potentially feasible without compromising perioperative and oncological outcomes. Future randomized trial with larger numbers will be required for further analysis in the Australian setting., (© 2018 Royal Australasian College of Surgeons.)

Background: Radical cystectomy (RC) remains a morbid procedure. The use of Enhanced Recovery After Surgery (ERAS) pathways has proven to reduce care time and post-operative complications after colorectal surgery. There is a high potential for reducing morbidity associated with RC by utilizing ERAS in this setting. The purpose of this review is to examine the current evidence for ERAS in preoperative, intra-operative and post-operative setting of care for RC patients and to propose ERAS evidence-based protocol for patients undergoing RC in the Australian and New Zealand environment., Preoperative: Patient's medical optimization, avoidance of oral mechanical bowel preparation and emphasis on preoperative administration of high-energy carbohydrate drinks from colorectal literature has led to inclusion of these strategies in the preoperative considerations of ERAS in RC., Intra-Operative: Epidural analgesia has an integral role in reducing surgical stress response, improving analgesia and expediting functional recovery and should be included in ERAS RC protocols. Of relevance is 72 h maximum length of its duration. With regard to minimally invasive approach to RC, despite encouraging results from high-volume centres, high-level evidence in this field are lacking (ongoing clinical trials). Standardized anaesthetic protocols with particular emphasis on perioperative fluid management are essential components of ERAS protocols., Post-Operative: Avoidance of routine nasogastric tube placement, early mobilization and multifaceted approach to optimization of gut function and elimination of post-operative ileus are the cornerstones of post-operative care in the setting of ERAS in RC patients., (© 2015 Royal Australasian College of Surgeons.)

Background: Injection of local anaesthetic agents around the prostatic nerve bundles during transrectal ultrasonography (TRUS) biopsy of the prostate has shown to reduce the pain associated with the procedure. It has been shown that some of the discomfort associated with the procedure is secondary to spasm of the anal sphincter. Topical diltiazem can relax the anal sphincter. Our aim was to evaluate the use of topical diltiazem cream as an adjunct to periprostatic nerve block in reducing pain associated with TRUS-guided prostatic biopsy., Method: Between September 2009 and September 2010, 114 patients were enrolled in the trial (from two centres). Patients undergoing TRUS biopsy of prostate were randomized into diltiazem and placebo groups. Patients were asked to fill out a questionnaire at the end of the procedure. The questionnaire enquired about discomfort associated with various parts of the procedure using a 10-cm visual analogue scale (VAS)., Results: For discomfort due to the presence of the probe, pain during the biopsy and overall pain prior to leaving the department, mean VAS was higher for the placebo group, but the difference was not statistically significant., Conclusion: Diltiazem cream has a better side effect profile than glyceryl trinitrate cream and is better tolerated. Although we have demonstrated trends favouring diltiazem use as an adjunct to local anaesthetic in TRUS biopsy of the prostate, this did not reach a statistically significant level. The pain scores associated with TRUS biopsy in our cohort were lower than those in the published literature. This phenomenon might have contributed to the results observed in this trial., (© 2013 Royal Australasian College of Surgeons.)

Background: To retrospectively determine key demographic and clinical features of 35 patients with Xanthogranulomatous pyelonephritis (XGP) in a New Zealand setting and to compare it with the existing literature., Methods: A retrospective review of patients having a confirmed diagnosis of XGP on histopathology examination was performed. Key clinical and demographic features were analysed and compared with the published literature., Results: XGP was diagnosed in 35 patients over a 12-year (2001-2013) period in Auckland Public Hospital. Ninety-one percent of the patients were female. The population had significantly higher numbers of Maori and Pacific Island patients compared with the general population (74%). Staghorn calculi were the most common cause (51.4%) with obstructing ureteric calculi as the next most common (22.9%) cause. Twenty percent of cases were not thought to be XGP prior to nephrectomy (suspicious renal mass). Thirteen (38%) patients suffered serious complications post-operatively (Clavien 3-5)., Conclusion: XGP is a rare chronic inflammatory condition that appears to be overrepresented by Maori and Pacific islanders in our cohort when compared with the overall patient pool. Surgical treatment is associated with significant morbidity but remains the only definitive option. Obesity and other conditions associated with metabolic syndrome may coexist at the time of presentation and may be contributing factors to the development of XGP and poor outcomes associated with it., (© 2014 Royal Australasian College of Surgeons.)

Background: To assess the outcomes of patients undergoing percutaneous renal artery embolization (PRAE) prior to radical nephrectomy., Methods: We performed retrospective chart review of patients undergoing PRAE in Auckland Public Hospital from January 2004 to December 2011. PRAE was performed under epidural anaesthesia and within 24 h of nephrectomy. We compared our perioperative outcomes with the published literature., Results: Forty-two patients were identified in this series. Patients had predominantly more advanced stage disease with 30 (71%) being T3 or higher (TNM staging). Median operation time was 192 min (range 84-428). 45.2% of patients experienced complications from the surgery. There were no complications associated with PRAE., Conclusions: PRAE prior to nephrectomy is a safe procedure. There is no convincing evidence in the literature that the benefits outweigh the risks. All published studies are non-randomized and subject to selection bias, so the true role of PRAE has not yet been determined and routine use is probably not justified., (© 2014 Royal Australasian College of Surgeons.)