Richard Graham Hindley

The combination of an appendix tumour requiring cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) with the management of a renal cell cancer is rare but problematic. Acute kidney injury (AKI) is one of the major complications after CRS and HIPEC with concern that combining CRS and HIPEC with nephrectomy may further increase the risk of AKI. There is little published on this combined approach of CRS and HIPEC with nephrectomy for patients with disseminated appendiceal tumours. We report on eight patients who had CRS and HIPEC for an appendiceal tumour with synchronous nephrectomy. We performed a retrospective review of patients undergoing CRS and HIPEC for appendiceal malignancy and synchronous nephrectomy for renal cell carcinoma between 2014 and 2025. Patient demographics, operative details, pathology, postoperative morbidity and mortality were evaluated. A total of eight patients (M: F 4:4) with a median age of 65 were included, of which 5/8 (62.5%) presented with abdominal pain. Concerning the primary appendiceal pathology, CRS included right hemicolectomy or extended right hemicolectomy in 5/8 (67%). Regarding the renal pathology, 7/8 (87.5%) had either right or left nephrectomy and 1 (12.5%) had right partial nephrectomy. The mean operation time was 453.75 minutes (365–588). The mean blood loss was 1053 ml (420–2000). Mean Peritoneal Cancer Index was 13 (0–39). Complete cytoreduction was achieved in 5/8 (62.5%). Appendix tumour pathology was low grade appendiceal mucinous neoplasm in 5/8, goblet cell adenocarcinoma in 2/8 and high grade appendiceal mucinous neoplasm in 1. Pathology of the renal tumour was clear cell carcinoma in 4/8, papillary renal cell carcinoma in 3 and 1 patient with transitional cell carcinoma. Postoperative intensive care unit stay was a mean of 1 day (1–3). Median postoperative stay was 15 days (8–47). The mean drop in glomerular filtration rate was 10 ml/min/1.73 m².There was no postoperative acute renal failure nor Clavien-Dindo Grade III-V complication with no post-operative mortality. Patients with synchronous appendiceal tumours and renal cell carcinoma have good immediate outcomes after combined CRS and HIPEC with nephrectomy with no measurable increase in risk of acute renal failure in this series.

Background: Benign prostatic hyperplasia (BPH) is a complex condition that affects ~3.2 million men in the UK. As men often face multiple treatment options, discussion and consideration of their priorities and preferences is necessary; however, research indicates this is not always adopted in practice. Objectives: To evaluate decisional interventions currently available for men with symptomatic BPH, distinct from those designed for prostate cancer. Methods: Eight databases (PubMed, Web of Science, EBSCO, Science Direct, Scopus, Google, Cochrane Library, Centre for Reviews and Dissemination) were searched retrieving a total of 1979 results, of which 13 international studies discussing 10 decision aids (DAs) were included. Studies were eligible that targeted adult males experiencing urological symptoms and discussed any DA designed to promote shared decision making within secondary healthcare. Results: Narrative synthesis found most DAs focused on treatment information provision; however, risk information was not always equally presented. Most DAs lacked strong theoretical links to existing theories on behaviour change, risk communication, and decision making, and sustained implementation within clinical practice. The most effective aids went beyond information provision, to also elicit and integrate patient preferences and values, by adopting multiple behaviour change techniques (BCTs). Risk of bias indicated medium risk with limited information or justification on data collection and analysis methods. Conclusion: Current DAs relevant to BPH lack clear focus on individual patient needs required for delivering patient‐centred care. Greater transparency and explicit links to behavioural theory and BCTs related to desired future outcomes, expectations, and values are required to effectively create and implement effective interventions into urological practice.

Focal therapy treats individual areas of tumour in non-metastatic prostate cancer in patients unsuitable for active surveillance. The aim of this work was to evaluate the cost-effectiveness of focal therapy versus prostatectomy and external beam radiotherapy (EBRT). A Markov cohort health state transition model with four health states (stable disease, local recurrence, metastatic disease and death) was created, evaluating costs and utilities over a 10-year time horizon for patients diagnosed with non-metastatic prostate cancer. National Health Service (NHS) for England perspective was used, based on direct healthcare costs. Clinical transition probabilities were derived from prostate cancer registries in patients undergoing radical prostatectomy, EBRT and focal therapy using cryotherapy (Boston Scientific) or high-intensity focused ultrasound (HIFU) (Sonablate). Propensity score matching was used to ensure at-risk populations were comparable. Variables included age, prostate-specific antigen (PSA), International Society of Urological Pathology (ISUP) grade group, maximum cancer core length (mm), T-stage and year of treatment. Focal therapy was associated with a lower overall cost and higher quality adjusted life year (QALY) gains than either prostatectomy or EBRT, dominating both treatment strategies. Positive incremental net monetary benefit (NMB) values confirm focal therapy as cost effective versus the alternatives at a willingness to pay (WTP) threshold of £30,000/QALY. One-way deterministic sensitivity analyses revealed consistent results. Data used to calculate the transition probabilities were derived from a limited number of hospitals meaning that other potential treatment options were excluded. Limited data were available on later outcomes and none on quality of life data, therefore, literature-based estimates were used. Cost-effectiveness modelling demonstrates use of focal therapy (cryotherapy or HIFU) is associated with greater QALY gains at a lower overall cost than either radical prostatectomy or EBRT, representing good value for money in the NHS.

In this analysis, there was an incremental relationship between prostate cancer burden and the likelihood of a positive MRI signal. Background The effects of regional histopathologic changes on prostate MRI scans have not been accurately quantified in men with an elevated prostate-specific antigen (PSA) level and no previous bi...

Objective To compare cancer control rates of standard compared to dose escalation focal high-intensity focused ultrasound (HIFU) of prostate cancer. Materials and methods A prospectively maintained HIFU (Sonablate® 500) database identified 598 patients were identified who underwent focal HIFU (Sonablate® 500) (March/2007-November/2016). Follow-up occurred with 3-monthly clinic visits and PSA testing in the first year. Thereafter, PSA was measured 6-monthly. mpMRI with biopsy was used for MRI-suspicion of recurrence. Treatments were delivered in a quadrant or hemiablation fashion depending on the gland volume as well as tumour volume and location. Prior to mid-2015, standard focal-HIFU was used (two HIFU blocks); after this date some urologists conducted dose escalation focal-HIFU (3 overlapping HIFU blocks). Propensity matching was used to ensure two matched groups leading to 162 cases for this analysis. Treatment failure was defined by any secondary treatment (systemic therapy, cryotherapy, radiotherapy, prostatectomy, or further HIFU), metastasis from prostate cancer without further treatment, tumour recurrence with Gleason score >/=7 (>/=3+4) on prostate biopsy without further treatment, or prostate cancer-related mortality. Complications and side-effects were also compared. Results Median age was 64.5 years (IQR 60-73.5) in the standard focal-HIFU group and 64.5 years (IQR 60-69) in the dose-escalation group. Median prostate volume was 37ml (IQR 17-103) in standard group and 47.5ml (IQR 19-121) in the dose-escalation group. As tumour volume on mpMRI and Gleason score were major matching criteria these were identical with 0.43ml (IQR 0.05-2.5) and Gleason 3+3=6 in 1/32 (3%), 3+4=7 in 27/32 (84%), and 4+3=7 in 4/32 (13%). Recurrence in treated areas were found in 10/32 (31%) when standard treatment zones were applied, and in 6/32 (19%) of dose-escalation focal-HIFU (p=0.007). Conclusion This exploratory study shows that dose escalation focal-HIFU may achieve higher rates of disease control compared to standard focal-HIFU. Further prospective comparative studies are needed.