Prostate cancer screening with prostate-specific antigen: A guide to the guidelines

AbstractBackgroundProstate cancer remains the most common non-skin cancer malignancy in men. Prostate-specific antigen (PSA) is recognized as a biomarker for the diagnosis, monitoring, and risk prediction of prostate cancer. Its use in the setting of prostate cancer screening has been controversial due to the risk of over diagnosis and over treatment.ObjectiveWithin Australia, there are inconsistent recommendations surrounding the use of PSA screening in clinical practice. In light of the 2016 PSA-screening guidelines by the major Australian health authorities, the current review aims to highlight the controversies and objectively outline the current recommendations within Australia.DiscussionHealth-care authorities across Australia have issued conflicting guidelines for prostate cancer screening culminating in confusion amongst health care practitioners and members of the public alike. A general consensus is held by other countries across the globe but differences amongst the specific details in how to best employ a PSA screening program still exist

Severe Irritant Contact Dermatitis Causing Skin Ulceration Secondary to a Testosterone Patch

Testosterone replacement has undergone somewhat of a revolution in the past decade with the introduction of topical administration techniques, including patches and gels, as well as an increasing interest in the treatment of older men with low testosterone levels for what is now termed andropause. Increasingly, testosterone replacement therapy is being individually tailored. Side effects to skin patches have been reported with irritant contact dermatitis being the most common. However, ulceration has previously not been reported. Herein, we present a case that highlights testosterone transdermal therapies, their potential side effects and management strategies, and broadens our knowledge as we approach an era where these types of treatments are likely to be more common

An Investigation of the Basic Physics of Irrigation in Urology and the Role of Automated Pump Irrigation in Cystoscopy

Objective. To investigate the effects of height, external pressure, and bladder fullness on the flow rate in continuous, non-continuous cystoscopy and the automated irrigation fluid pumping system (AIFPS). Materials. Each experiment had two 2-litre 0.9% saline bags connected to a continuous, non-continuous cystoscope or AIFPS via irrigation tubing. Other equipment included height-adjustable drip poles, uroflowmetry devices, and model bladders. Methods. In Experiment 1, saline bags were elevated to measure the increment in flow rate. In Experiment 2, saline bags were placed under external pressures to evaluate the effect on flow rate. In Experiment 3, flow rate changes in response to variable bladder fullness were measured. Results. Elevating saline bags caused an increase in flow rates, however the increment slowed down beyond a height of 80 cm. Increase in external pressure on saline bags elevated flow rates, but inconsistently. A fuller bladder led to a decrease in flow rates. In all experiments, the AIFPS posted consistent flow rates. Conclusions. Traditional irrigation systems were susceptible to changes in height of irrigation solution, external pressure application, and bladder fullness thus creating inconsistent flow rates. The AIFPS produced consistent flow rates and was not affected by any of the factors investigated in the study

The Role of Lymph Node Fine-Needle Aspiration in Penile Cancer in the Sentinel Node Era

Penile squamous cell carcinoma (SCC) is an uncommon condition in Western countries. Inguinal lymph nodes dissection can be curative in 20%–60% of node positive patients. However, there is a high complication rates from the dissection, thus accurate diagnosis of inguinal lymph nodes metastasis is required. Current non invasive methods to detect lymph nodes metastasis are unreliable. Dynamic Sentinel Node Biopsy (DNSB), ultrasonography (US), and fine needle aspiration (FNA) cytology were proposed to in an attempt to detect sentinel lymph node (SLN). Despite the initial high rate of false negative results, recent DSNB showed improved survival compared to wait and see policy as well as reduced mortality compared to prophylactic inguinal lymphadenectomy. In addition, the US guided FNA shown 100% of specificity in detecting clinically occult lymph nodes metastasis. We proposed an algorithm for management of lymph nodes in penile cancer and suggest that FNA with US guidance should be performed in all high risk patients and that therapeutic dissection should be performed if findings are positive

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

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

Critical appraisal of meta-analyses: an introductory guide for the practicing surgeon

Meta-analyses are an essential tool of clinical research. Meta-analyses of individual randomized controlled trials frequently constitute the highest possible level of scientific evidence for a given research question and allow surgeons to rapidly gain a comprehensive understanding of an important clinical issue. Moreover, meta-analyses often serve as cornerstones for evidence-based surgery, treatment guidelines, and knowledge transfer. Given the importance of meta-analyses to the medical (and surgical) knowledge base, it is of cardinal importance that surgeons have a basic grasp of the principles that guide a high-quality meta-analysis, and be able to weigh objectively the advantages and potential pitfalls of this clinical research tool. Unfortunately, surgeons are often ill-prepared to successfully conduct, critically appraise, and correctly interpret meta-analyses. The objective of this educational review is to provide surgeons with a brief introductory overview of the knowledge and skills required for understanding and critically appraising surgical meta-analyses as well as assessing their implications for their own surgical practice

Realistic Anatomical Prostate Models for Surgical Skills Workshops Using Ballistic Gelatin for Nerve-Sparing Radical Prostatectomy and Fruit for Simple Prostatectomy

PURPOSE: Understanding of prostate anatomy has evolved as techniques have been refined and improved for radical prostatectomy (RP), particularly regarding the importance of the neurovascular bundles for erectile function. The objectives of this study were to develop inexpensive and simple but anatomically accurate prostate models not involving human or animal elements to teach the terminology and practical aspects of nerve-sparing RP and simple prostatectomy (SP). MATERIALS AND METHODS: The RP model used a Foley catheter with ballistics gelatin in the balloon and mesh fabric (neurovascular bundles) and balloons (prostatic fascial layers) on either side for the practice of inter- and intrafascial techniques. The SP model required only a ripe clementine, for which the skin represented compressed normal prostate, the pulp represented benign tissue, and the pith mimicked fibrous adhesions. A modification with a balloon through the fruit center acted as a "urethra." RESULTS: Both models were easily created and successfully represented the principles of anatomical nerve-sparing RP and SP. Both models were tested in workshops by urologists and residents of differing levels with positive feedback. CONCLUSIONS: Low-fidelity models for prostate anatomy demonstration and surgical practice are feasible. They are inexpensive and simple to construct. Importantly, these models can be used for education on the practical aspects of nerve-sparing RP and SP. The models will require further validation as educational and competency tools, but as we move to an era in which human donors and animal experiments become less ethical and more difficult to complete, so too will low-fidelity models become more attractive

Evaluating the diagnostic role of in-bore magnetic resonance imaging guided prostate biopsy: a single-centre study.

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

Survival outcomes of younger men (< 55 years) undergoing radical prostatectomy

Background: The aim of the paper is to investigate the outcomes of patients younger than 55 years in Victoria, Australia undergoing radical prostatectomy (RP) for prostate cancer. Materials and methods: Data on all men undergoing RP in Victoria between January 1, 2004 and December 31, 2014 were obtained from the Victorian Cancer Registry. Tumor characteristics including Gleason grade, stage of disease (based on final pathology specimen), and cause of death were also obtained. Statistical analysis was performed using Chi-square test, Cox proportional hazards method, and Kaplan-Meier analysis. Results: A total of 14,686 men underwent RP during the defined period. Of these men 109 were aged 35–44 years and 1,998 were aged 45–54 years. Men aged 35–44 years and 45–54 years were compared against men aged 55–74 years. The majority of men between the ages of 35 years and 44 years, and 45 years and 54 years had higher rates of Gleason ≤ 7 disease compared with men aged between 55 years and 74 years (92.7% vs. 86.8% vs. 79.3%; P < 0.01) and ≤ T2 disease (82.6% vs. 75.6% vs. 49.9%; P < 0.01) but similar median prostate-specific antigen values. On a multivariate analysis adjusting for Gleason score, T stage, and prostate-specific antigen, men aged 45–54 years and 55–64 years had 67% and 46% increase in overall survival, respectively, compared to men aged 65–74 years; but these differences were not seen in the 35–44 year age group. There were no differences in prostate cancer specific deaths between the groups. The 5- and 10-year overall survival outcomes were both higher for men aged 45–54 years compared to mean aged 55–74 years (97.9% vs. 95.9% and 94.9% vs. 85.3). Conclusion: Men aged 45–54 years undergoing RP had better overall survival compared to men aged 55–74 years, but these effects were not seen in men aged 35–44 years. There were no differences in prostate cancer specific survival in these groups