A randomised trial of robotic and open prostatectomy in men with localised prostate cancer

Background: Prostate cancer is the most common male cancer in the Western world however there is ongoing debate about the optimal treatment strategy for localised disease. While surgery remains the most commonly received treatment for localised disease in Australia more recently a robotic approach has emerged as an alternative to open and laparoscopic surgery. However, high level data is not yet available to support this as a superior approach or to guide treatment decision making between the alternatives. This paper presents the design of a randomised trial of Robotic and Open Prostatectomy for men newly diagnosed with localised prostate cancer that seeks to answer this question.Methods/design: 200 men per treatment arm (400 men in total) are being recruited after diagnosis and before treatment through a major public hospital outpatient clinic and randomised to 1) Robotic Prostatectomy or 2) Open Prostatectomy. All robotic prostatectomies are being performed by one surgeon and all open prostatectomies are being performed by one other surgeon. Outcomes are being measured pre-operatively and at 6 weeks and 3, 6, 12 and 24 months post-surgery. Oncological outcomes are being related to positive surgical margins, biochemical recurrence +/- the need for further treatment. Non-oncological outcome measures include: pain, physical and mental functioning, fatigue, summary (preference-based utility scores) and domain-specific QoL (urinary incontinence, bowel function and erectile function), cancer specific distress, psychological distress, decision-related distress and time to return to usual activities. Cost modelling of each approach, as well as full economic appraisal, is also being undertaken.Discussion: The study will provide recommendations about the relative benefits of Robotic and Open Prostatectomy to support informed patient decision making about treatment for localised prostate cancer; and to assist in treatment services planning for this patient group.Trial registration: ACTRN12611000661976

Crossed renal ectopia and aorto-occlusive disease: a management strategy

We present a rare case of a patient with aortoiliac occlusive disease on the background of type A crossed renal ectopia, for whom open surgical intervention was required. Aortic exposure in patients with concomitant crossed renal ectopia can present technical challenges to the vascular surgeon. The knowledge of variations in the ectopic renal blood supply is of paramount importance when performing surgery to treat this condition and affects the choice of surgical exposure. We present and discuss the operative details of our patient and outline an approach to this subset of patients

Alpha-fetoprotein-producing Carcinoma of the Renal Pelvis Exhibiting Hepatoid and Urothelial Differentiation

Neoplasms commonly associated with alpha-fetoprotein (AFP) production are hepatocellular carcinomas and some germ cell tumors, typically yolk sac tumor. Rare tumors of visceral origin may also be associated with AFP production and those exhibiting a distinctive morphology are now known as hepatoid adenocarcinomas. To date, eight such tumors have been reported from the bladder and a further four from the renal pelvis. We report a unique case of a mixed hepatoid adenocarcinoma and urothelial carcinoma of the renal pelvis and ureter, in which both components were found to express AFP. An 84-year-old woman with a serum AFP level of 701 ng/ml was found to have advanced high-grade renal pelvi-calyceal and ureteral urothelial carcinoma exhibiting focal hepatoid adenocarcinoma differentiation. Both components displayed strong immunostaining for AFP. The patient was treated by radical nephro-uretectomy and postoperatively the serum AFP level declined to normal at a rate commensurate with its biological half-life. The presence of AFP expression in both the urothelial and hepatoid components of the tumor suggest that the molecular pathway changes associated with AFP production precede the hepatoid differentiation of tumor cells

Review and update of benign prostatic hyperplasia in general practice

Background: Benign prostatic hyperplasia (BPH) is the most common benign tumour in men. Although men with BPH often need medical or surgical management from a urologist at some point throughout the timeline of their disease, most men are initially assessed and managed by a general practitioner (GP) in the primary healthcare setting. Objectives: The aim of this article is to highlight the principles of the pathogenesis, presentation, assessment and management of BPH in a primary care setting. Discussion: Between 2009 and 2011, BPH was managed by GPs at approximately 228,000 general practice visits per annum in Australia. Several changes in pharmaceutical agents and surgical intervention have occurred over the past decade. As a result, it is imperative that GPs remain up to date with assessment and management of BPH, are aware of new therapies and understand when to refer to a urologist

Improved specificity with 68Ga PSMA PET/CT to detect clinically significant lesions “invisible” on multiparametric MRI of the prostate: a single institution comparative analysis with radical prostatectomy histology

Purpose: Positron emission tomography (PET) for prostate-specific membrane antigen (PSMA) represents a promising method for prostate cancer diagnosis and staging. Comparisons of PSMA-based tumour characterisation to multiparametric MRI (mpMRI) are limited, hence this study sought to compare the diagnostic accuracy of Ga-PSMA PET/CT to mpMRI against radical prostatectomy (RP) whole gland histopathology. Methods: A retrospective cohort study of consecutive patients who underwent pre-operative mpMRI and Ga-PSMA PET/CT followed by a RP was performed. Standard clinical parameters were collected. “Per patient” and “per lesion” analyses for image-based detection according to RP histopathology were described using sensitivity, specificity and other measures of diagnostic accuracy. Results: Fifty-eight patients (median age 65.5\ua0years, median PSA 7.35\ua0ng/mL) underwent RP, resulting in a high-risk cohort (≥pT3 69%). Sensitivities for identification of index lesion, bilateral and multifocal disease were 90%, 21%, 19% for mpMRI and 93%, 42%, 34% for Ga-PSMA PET/CT. Histology analyses revealed 88 cancer foci of Gleason grades 3 + 3 (4%), 3 + 4 (64%), 4 + 3 (19%), 4 + 4 (3%) and ≥ 4 + 5 (10%), of which Ga-PSMA PET/CT correctly detected more foci (78%, AUC 0.817) than mpMRI (69%, AUC 0.729). Conclusions: Ga-PSMA PET/CT may better reflect RP histopathology compared to mpMRI when considering multifocal and bilateral disease. These findings may influence surgical planning, targeted biopsy and focal therapy strategies and require further research

A regeneration proof of the central Llmit theorem for uniformly ergodic Markov chains

Central limit theorems for functionals of general state space Markov chains are of crucial importance in sensible implementation of Markov chain Monte Carlo algorithms as well as of vital theoretical interest. Different approaches to proving this type of results under diverse assumptions led to a large variety of CLT versions. However due to the recent development of the regeneration theory of Markov chains, many classical CLTs can be reproved using this intuitive probabilistic approach, avoiding technicalities of original proofs. In this paper we provide a characterization of CLTs for ergodic Markov chains via regeneration and then use the result to solve the open problem posed in [Roberts & Rosenthal 2005]. We then discuss the difference between one-step and multiple-step small set condition

Improved detection and reduced biopsies: the effect of a multiparametric magnetic resonance imaging-based triage prostate cancer pathway in a public teaching hospital

Purpose: Multiparametric magnetic resonance imaging (mpMRI) improves clinically significant prostate cancer (csPCa) detection by facilitating targeted biopsy (cognitive, fusion technology, or in-gantry MRI guidance) and reducing negative biopsies. This study sought to describe the feasibility of introducing an mpMRI-based triage pathway, including diagnostic performance, applicability to training, and cost analysis. Methods: An observational retrospective cohort study of consecutive patients attending a large public tertiary referral training hospital who underwent mpMRI for suspicion of prostate cancer was considered. Standard clinical, MRI-related, histopathological, and financial parameters were collected for analysis of biopsy avoidance, diagnostic accuracy of biopsy approach, and operator (consultant and resident/registrar) and logistical (including financial) feasibility. Results: 653 men underwent mpMRI, of which 344 underwent prostate biopsy resulting in a 47% biopsy avoidance rate. Overall, 240 (69.8%) patients were diagnosed with PCa, of which 208 (60.5%) were clinically significant, with higher rates of csPCa observed for higher PIRADS scores. In patients who underwent both systematic and targeted biopsy (stTPB), targeted cores detected csPCa in 12.7% and 16.6% in more men than systematic cores in PIRADS 5 and 4, respectively, whereas systematic cores detected csPCa in 5% and 3.2% of patients, where targeted cores did not. A high standard of performance was maintained across the study period and the approach was shown to be cost effective. Conclusions: Introdution of an mpMRI-based triage system into a large public tertiary teaching hospital is feasible, cost effective and leads to high rates of prostate cancer diagnosis while reducing unnecessary biopsies and detection of insignificant PCa