Peter Stapleton

Background/Objectives: To evaluate the surgical and functional outcomes of robot-assisted simple prostatectomy (RASP) for men with bothersome lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH), aiding informed clinical decision-making. Methods: We conducted a prospective study of 69 patients undergoing RASP for BPH-related LUTS or acute urinary retention (AUR). Three high-volume robotic urologists from a single center, utilising a modified Millins technique, performed the RASP procedures. Pre-operative data included demographics (age, prostate-specific antigen (PSA), prostate volume), LUTS measures (International Prostate Symptom Score (IPSS), quality-of-life (QOL), flow rates, pad use), and intraoperative parameters (operative time, blood loss, histology, hospital stay). Postoperative outcomes were collected at 6–8 weeks and included symptom scores, flow rates, pad use, and patient satisfaction. Data were analysed using descriptive statistics and multivariate linear logistic regression; significance was set at 95% confidence. Results: Median patient age was 74 years (interquartile range (IQR) 72–77) with a median prostate volume of 143 cc (IQR 123–195) and preoperative IPSS of 19 (IQR 15.0–23.0). Median console time was 60 min (IQR 50.0–65.0), estimated blood loss was 350.0 mL (IQR 200–500), and specimen weight was 105.5 g (IQR 67.25–132.5). Median hospital stay was 1.0 day; all patients passed their trial of void (TOV) postoperatively, with an IPSS improvement of 78.9% (12 points), QOL improvement of 75% (3 points), maximum flow rate (Qmax) increase of 16.3 mL/s and an overall patient satisfaction of 10 out of 10 (extremely satisfied), independent of specimen size, operative duration, or pad usage. Conclusions: RASP appears to be a safe and effective surgical option for men with high-volume BPH and bothersome LUTS, offering substantial symptom improvement and excellent patient satisfaction. Its advantages may extend to patients with very large prostates or concurrent bladder pathology. However, findings are limited by our modest sample size and short follow-up. Larger prospective and comparative trials are warranted to better define the role of RASP in the treatment algorithm for BPH.

Background/Objectives: To determine long-term patient-reported outcomes for patients undergoing hyperbaric oxygen therapy (HBO2) following external beam radiotherapy. Methods: A retrospective cohort study of all consecutive patients who underwent HBO2 for radiation cystitis in South Australia from September 2017 to March 2023 was performed. Patient-reported symptom severity, anxiety, healthcare use and transfusion requirements pre- and post-treatment were collected through telephone interview. Readmission data and procedural data was collected through both telephone interview and a state-wide electronic medical record. Jamovi was used to perform paired sample t-tests for statistical analysis. Results: There were 89 patients who underwent HBO2 for radiation cystitis with 54 completing the questionnaire. There were 85% of patients alive at the time of follow-up, with 61% of the total cohort and 74% of survivors completing the questionnaire. For those completing the questionnaire, 96% were male with all of them having prostate cancer. Median age was 74 (interquartile range [IQR] 69–78). The mean reduction in patients’ perceived symptom severity after HBO2 on a scale out of 10 was 7.9 to 2 with a difference of 5.9 (95% confidence interval [CI] 5.1–6.7, p < 0.001) and the mean reduction in perceived anxiety was 6.9 to 2.1 with a difference of 4.7 (95% CI 3.6–5.8 p < 0.001). Patients reported a reduction in family doctor visits from 2.7 to 0.76 with a mean reduction of 2 (95% CI 0.8 to 3.2, p = 0.003), emergency department presentations from 3.3 to 0.57 with a mean reduction of 2.7 (95% CI 1.4–4.1, p ≤ 0.001) and blood transfusions from 0.67 to 0.31 with a mean reduction of 0.34 (95% CI −0.44 to 1.1, p = 0.017). Ongoing haematuria was reported in 21 of the 54 patients (39%). Further treatment was required for 20 patients (25%). No patients reported any severe or ongoing adverse effects from HBO2 via the questionnaire. Conclusions: HBO2 is a safe option for recurrent haematuria due to radiation cystitis with high patient satisfaction and reduction in patient-perceived symptom severity, anxiety and healthcare utilisation. Level of evidence: 4.

Objectives: To evaluate the oncological safety of testosterone replacement therapy (TRT) in hypogonadal patients with prostate cancer, as testosterone deficiency (TD) rises in prevalence with age and in prostate cancer may be treatment‐related, whilst contributing to poor health outcomes.Patients and Methods: Following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines, Medline, EMBASE, PubMed, and Scopus were searched. Studies were included assessing progression and biochemical recurrence in men with prostate cancer and TD receiving TRT.Results: Searches yielded 4067 studies, of which 19 were included: five in active surveillance, 10 post‐radical prostatectomy (RP), six post‐radiotherapy. Pooled meta‐analysis was not valid due to insufficient number of comparative studies and significant clinical and methodological heterogeneity. Progression rates on active surveillance ranged from 0% to 32% and did not differ significantly to non‐exposed controls on retrospective comparison at follow‐up as long as 70 months. Biochemical recurrence rates in TRT‐exposed cohorts were low post‐definitive treatment ranging from 0% to 7% post‐RP to 0–6% post‐radiotherapy (± androgen deprivation therapy) with up to 60 months of follow‐up. Overall certainty of TRT oncological safety is limited by lack of long‐term, prospective, controlled comparative data and lack of assessment of survival outcomes.Conclusions: Retrospective evidence supports cautious use of TRT in low–intermediate‐risk disease on active surveillance and favourable localised disease post‐RP or post‐radiotherapy with appropriate prostate‐specific antigen responses. Diligent patient selection and monitoring are required until randomised controlled trial data are available to inform safe management of TD in prostate cancer.

Background/Objectives: Pelvic lymph node dissection during radical cystectomy has been established to be important for staging and therapeutic purposes. However, there is uncertainty regarding the optimal extent of nodal dissection. This study aimed to assess the impact of an extended pelvic lymphadenectomy template compared to a standard template in patients with bladder cancer undergoing radical cystectomy. Methods: We performed a systematic review and meta-analysis of randomised studies comparing extended pelvic lymph node dissection to standard pelvic lymph node dissection in patients undergoing radical cystectomy. A search of multiple databases was performed up to October 2024. The standard template was defined as including at least the obturator and internal and external iliac nodes. An extended template was defined as a standard template plus the removal of proximal nodal packets. The primary outcomes were overall survival and major Clavien–Dindo complications. Results: Two studies encompassing a total of 933 participants met the eligibility criteria. There was no observed improvement in overall survival with extended lymph node dissection compared to limited dissection [HR 0.95, 95%CI 0.66–1.4]. In addition, extended lymph node dissection was associated with an increased risk of grade ≥3 Clavien–Dindo complications compared to limited nodal dissection [RR 1.2, 95%CI 1.02–1.37]. There was also an increased risk of lymphoceles requiring intervention with extended lymphadenectomy. Conclusions: Extended pelvic lymphadenectomy does not improve oncological outcomes and is associated with increased morbidity compared to a standard template in bladder cancer patients undergoing radical cystectomy.

Background/Objectives: Late toxicity following radiotherapy is common and compromises patient quality of life. However, the impact of toxicity on patient-reported outcome measures (PROMs) five years after prostate external beam radiotherapy (EBRT) is poorly characterised. We describe PROMs using the Expanded Prostate Cancer Index Composite (EPIC-26) five years post-EBRT compared against radical prostatectomy (RP). Methods: A prospective cohort of patients with localised prostate cancer treated from 2000 to 2020 captured by a state-level cancer registry was analysed. Multivariable mixed-effects linear modelling was performed to compare differences between EPIC-26 domains over time between ERBT and RP patients. The percentage of patients recording a decline in EPIC-26 domains compared with baseline which exceeded the minimal clinically important difference (MCID) was calculated and compared between groups. Additionally, subgroup analysis was performed on patients treated using contemporary techniques. Results: There were 1720 patients (EBRT n = 1441 vs. RP n = 279) with evaluable EPIC-26 PROMS. Patients in the EBRT group had a higher median age (74 vs. 66, p < 0.001) and National comprehensive Cancer Network (NCCN) high-risk disease (61% vs. 24%, p < 0.001). Bowel domain scores were worse after EBRT compared to RP (beta −0.46, 95% CI −1.20–−0.28, p < 0.001), with a greater proportion of patients reporting a change in symptoms that exceeded the MICD at 12 months (22 vs. 11%, p = 0.009). Moderate/big bowel bother scores were significantly higher in the EBRT cohort at baseline and all follow-up periods compared to RP (beta −8.27, 95% CI −10.21–−6.34, p < 0.001). Pad use (i.e., ≥1) per day was significantly lower amongst the EBRT group (beta 16.56, 95% CI 14.35–18.76, p < 0.001). Despite contemporary techniques, EBRT was associated with worse bowel domain scores at 12 (75 vs. 80, p < 0.05) and 60 months (75 vs. 80, p < 0.05) compared to RP; however, EBRT was associated with less pad use at 12 (4% vs. 34%, p < 0.001), 24 (10% vs. 33%, p < 0.001) and 60 months (13% vs. 33%, p = 0.15) than RP. Conclusions: There are significant differences in PROMs after local curative treatment for prostate cancer which persist to five years post-treatment, despite contemporary techniques. Understanding the associated toxicity patterns helps inform shared decision-making during pre-treatment counselling.

Introduction: Prostate biopsy results form the mainstay of patient care. However, there is often significant discordance between the biopsied histology and the ‘true’ histology shown on a radical prostatectomy (RP). Discordance in pathology can lead to the mismanagement of patients, potentially missing clinically significant cancer and delaying treatment. There have been many advancements to improve the concordance of pathology and more accurately counsel patients; most notably, the induction of pre-biopsy mpMRIs has become a gold standard to aid in triaging and identifying clinically significant cancers, and also to facilitate ‘targeted’ biopsies. Although there have been multiple reviews on MRI-targeted biopsies, upgrading remains an ongoing phenomenon. Aim: To assess the rates of prostate cancer upgrading and the clinical implication of upgrading on NCCN stratification. Methods: We conducted a retrospective audit of 2994 men with non-metastatic prostate cancer diagnosed between 2010 and 2019 who progressed to a radical prostatectomy within 1 year of diagnosis without alternative cancer treatment from the multi-institutional South Australia Prostate Cancer Clinical Outcomes Collaborative registry. The study compared the histological grading between the biopsies and radical prostatectomies of men with prostate cancer and the varying rates of upgrading and downgrading for patients with and without a pre-biopsy MRI. Data were also obtain on suspected confounding variables; age, PSA, time to RP, T-stage at diagnosis and RP, number of cores, number of positive cores, prostate size, tumour volume and procedure type. The results were assessed through cross tabulation and uni- and multi-variate logistic regression while adjusting for confounders. Results: Upgrading occurred in (926) 30.9% of patients and downgrading in (458) 15.3% of patients. In total, 71% (410/579) of grade group 1 and 24.9% (289/1159) of grade group 2 were upgraded following a radical prostatectomy. By contrast, 33.4% (373/1118) of patients without prebiopsy MRI were upgraded at RP compared to 29.5% (553/1876) of the patients who received a pre-biopsy MRI. When analysed on a uni-variate level, the inclusion of a pre-biopsy MRI demonstrated a statically significant decrease in upgrading of the patient’s pathology and NCCN risk stratification (p = 0.026, OR 0.83, CI 0.71–0.98) (p = 0.049, OR 0.82, CI 0.64–1.01). However, when adjusted for confounders, the use of an MRI did not maintain a statistically significance. Conclusions: When considering the multiple variables associated with tumour upgrading, a pre-biopsy MRI did not show a statistically significant impact. However, upgrading of Gleason Grade Group following a prostatectomy is an ongoing phenomenon which can carry significant treatment implications and should remain a consideration with patients and clinicians when making decisions around treatment pathways. More research is still required to understand and improve biopsy grading to prevent further upgrading from affecting treatment choices.

Aim: To assess the efficacy and safety of aspiration and sclerotherapy for the management of hydroceles in an ambulatory regional setting. Methods: A retrospective analysis was performed on all men who underwent aspiration and sclerotherapy for the management of symptomatic hydroceles at a single regional Australian centre from 1 January 2006 to 31 December 2023. All procedures were carried out in an ambulant setting under local anaesthetic and sodium tetradecyl sulphate (STD) as the sclerosing agent. Results: 291 men were included in the study with a median follow-up of 99 days. Resolution of hydrocele both clinically and symptomatically post initial aspiration and sclerotherapy was 58.8% (171/291). The average time to recurrence for men who failed initial management was 167 days (IQR 28–112 days). Following initial aspiration and sclerotherapy, 67.7% (63/93) of men with recurrence chose to have a repeat aspiration and sclerotherapy of these men, and 68.3% (43/63) had resolution of their hydroceles. Hence, after two aspiration and sclerotherapy interventions, 73.5% (214/291) of men had clinical and symptomatic resolution of their hydroceles. The median age of participants was 62.3 years (IQR 52.1–70.8). The median initial aspirated volume was 150 mL (IQR 100–250 mL), and the injected volume was 10 mL (IQR 8–10 mL). Notably, the median aspirated volume decreased for men with a recurrence to 100 mL (IQR 63.8–143.8 mL), and an injected volume of 0 ml (IQR 0–4.8 mL). The overall complication rate was 3.4% (10/291), of which all but one was managed conservatively. Conclusion: Aspiration and sclerotherapy with STD represent a minimally invasive, safe and effective treatment for hydroceles that can be utilized in the regional and ambulatory settings under local anaesthetic, potentially reducing wait times for interventions and improving patient flow for public hospital waitlists.