Amr Emara

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.

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.

Background: Prostate cancer (PCa) is the most common cancer in men in the UK. Patients with intermediate-risk, clinically localised disease are offered radical treatments such as surgery or radiotherapy, which can result in severe side effects. A number of alternative partial ablation (PA) technologies that may reduce treatment burden are available; however the comparative effectiveness of these techniques has never been evaluated in a randomised controlled trial (RCT). Objectives: To assess the feasibility of a RCT of PA using high-intensity focused ultrasound (HIFU) versus radical prostatectomy (RP) for intermediate-risk PCa and to test and optimise methods of data capture. Design: We carried out a prospective, multicentre, open-label feasibility study to inform the design and conduct of a future RCT, involving a QuinteT Recruitment Intervention (QRI) to understand barriers to participation. Setting: Five NHS hospitals in England. Participants: Men with unilateral, intermediate-risk, clinically localised PCa. Interventions: Radical prostatectomy compared with HIFU. Primary outcome measure: The randomisation of 80 men. Secondary outcome measures: Findings of the QRI and assessment of data capture methods. Results: Eighty-seven patients consented to participate by 31 March 2017 and 82 men were randomised by 4 May 2017 (41 men to the RP arm and 41 to the HIFU arm). The QRI was conducted in two iterative phases: phase I identified a number of barriers to recruitment, including organisational challenges, lack of recruiter equipoise and difficulties communicating with patients about the study, and phase II comprised the development and delivery of tailored strategies to optimise recruitment, including group training, individual feedback and ‘tips’ documents. At the time of data extraction, on 10 October 2017, treatment data were available for 71 patients. Patient characteristics were similar at baseline and the rate of return of all clinical case report forms (CRFs) was 95%; the return rate of the patient-reported outcome measures (PROMs) questionnaire pack was 90.5%. Centres with specific long-standing expertise in offering HIFU as a routine NHS treatment option had lower recruitment rates (Basingstoke and Southampton) – with University College Hospital failing to enrol any participants – than centres offering HIFU in the trial context only. Conclusions: Randomisation of men to a RCT comparing PA with radical treatments of the prostate is feasible. The QRI provided insights into the complexities of recruiting to this surgical trial and has highlighted a number of key lessons that are likely to be important if the study progresses to a main trial. A full RCT comparing clinical effectiveness, cost-effectiveness and quality-of-life outcomes between radical treatments and PA is now warranted. Future work: Men recruited to the feasibility study will be followed up for 36 months in accordance with the protocol. We will design a full RCT, taking into account the lessons learnt from this study. CRFs will be streamlined, and the length and frequency of PROMs and resource use diaries will be reviewed to reduce the burden on patients and research nurses and to optimise data completeness. Trial registration: Current Controlled Trials ISRCTN99760303. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 52. See the NIHR Journals Library website for further project information.

Background and Purpose: The current first-line recommended modality for nephrectomy is by the laparoscopic approach. This is one of the most frequent laparoscopic interventions conducted in urology. From a skills acquisition and delivery perspective in minimally invasive urologic surgery, there is a paucity of objective scoring systems for advanced laparoscopic urologic procedures. We developed a system of direct observation with structured criteria to evaluate the surgical conduction of laparoscopic nephrectomy (LN). We tested the application and preliminary validity of the scoring system. Methods: Sixty cases of prerecorded LN performed in four teaching hospitals were each analyzed by four mentors. Each mentor scored each case based on a 100-point scoring systemthat comprised 20 key steps for LN (each step ranging 0 to 5). Steps included port placement and safety checks in addition to the actual case. In addition, a negative marking system based on a 50-point index scoring system was deployed such that technically unsound techniques were penalized. The sum of the two resulted in the final score. The final scores independently submitted for each recorded case were analyzed and compared. The system was then used to predict the experience of a surgeon for 10 pilot cases. The cases included a mix of five fellows and five experienced laparoscopic urologic surgeons. The cases were blinded to the independent assessors. A further 20 cases involving 10 cases performed by a trainee who sufficiently completed training (as deemed by the recent award of a certificate of specialist training in urology) vs one who is not ready were reviewed. Results: There was no significant difference in the scores submitted by each of the four mentors for each of the cases observed. There was a strong correlation between overall score and seniority/experience of the performing surgeon of each case; ie, it was able to predict whether an experienced surgeon or laparoscopic fellow performed the case. It was able to predict accurately between a trainee who sufficiently completed training vs one who is “not ready.” Conclusion: The scoring system was a reliable tool for assessing the performance of LN and accurately predicts the level of experience of the surgeon. This system could be a useful supplementary tool for assessing the baseline skill and progress of trainees.

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Prostate BXT is an established treatment option for low and intermediate risk localized prostate cancer. Long‐term studies have confirmed similar oncological outcomes for low risk disease compared with radical prostatectomy and external beam radiotherapy. This study reports long‐term toxicity for a large cohort of patients who had been followed‐up after LDR BXT for up to 10 years, with a minimum follow‐up of 5 years. Long‐term toxicity results are very encouraging and provide useful date to help clinicians and patients make informed treatment choices. OBJECTIVE: To report on the long‐term toxicity outcome for patients with prostate cancer treated by low‐dose rate (LDR) brachytherapy (BXT). PATIENTS AND METHODS: The study population comprised a cohort of men treated in our centre between March 1999 and April 2004 with LDR BXT for prostate cancer who had at least 5 years of follow‐up post‐implant. Patients who had died or experienced biochemical failure were excluded. We contacted eligible patients and asked them to complete a questionnaire to assess current urinary, erectile and bowel function. Urinary and erectile function was compared pre‐ and post‐treatment and outcomes were assessed by treatment modality. RESULTS: Of the 226 LDR BXT‐treated patients with >5 years of follow‐up, 174 (77.0%) responded to the questionnaire. The mean International Prostate Symptom Score (IPSS) increased from 6.70 pre‐BXT to 7.91 at follow‐up ( P = 0.003). Of the patients with mild symptoms pre‐BXT (IPSS, 0–7), 64.2% retained mild symptoms at follow‐up, 31.2% developed moderate symptoms (IPSS, 8–9) and 4.6% reported severe symptoms (IPSS, 20–35). A good or acceptable quality of life (QoL) secondary to urinary symptoms (IPSS QoL, 0–4) was reported by 98.0% of respondents. Of those patients potent (International Index of Erectile Function‐5 ≥11) pre‐BXT, 62.9% remained potent at follow‐up. There were no differences in the proportion of patients who were potent when analyzed by the number of years post‐implant. At follow‐up, 51.7% and 45.4% of patients, respectively, had normal or mild bowel symptoms as indicated by the European Organisation for the Research and Treatment of Cancer questionnaire (QLQ‐C30/PR25 scores, 4–8). Moderate bowel symptoms (QLQ‐C30/PR25 scores, 9–12) were reported by 2.9% of respondents; none reported severe symptoms. CONCLUSION: The present study shows low morbidity after LDR BXT over the long‐term for a large cohort of patients.