Abstracts of the Irish Society of Urology, 25-26 September, 2014, Killarney, Ireland.

Abstracts 17

BJUI

Irish Society of Urology Book of Abstracts Thursday 25th September 2014

Session 1: Laboratory Research and Medical Publishing Predicting biochemical recurrence following radical prostatectomy through the interaction of the insulin receptor, IGF-1 receptor and PTEN Breen KJ, Fitzgerald NM, Boyce S, O’Neill A, Fitzpatrick JM, Watson RW UCD School of Medicine and Medical Science, Conway Institute of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland

Introduction: The insulin receptor (INSR) and IGF-1 receptor (IGF-1R) have been implicated in prostate cancer progression through activation of downstream signaling mechanisms including PI3K [1]. PTEN is a negative regulator of the PI3K pathway and reduced/absent PTEN expression has been linked to lethal prostate cancer [2]. We examined the expression of the INSR, IGF-1R and PTEN in radical prostatectomy tissue of patients who developed biochemical recurrence (BCR). Methods: Tissue microarray (TMA) of 32 patients post-radical prostatectomy (16 = BCR, 16 = controls) was stained by immunohistochemistry for the INSR, IGF-1R and PTEN. The parametric independent samples t-test and nonparametric Mann Whitney U test were used to examine the statistical significance of differences in INSR, IGF1-R and PTEN expression between benign and malignant tissues, and Gleason grade. Odd ratio’s (OR) were also estimated. Results: INSR and IGF-1R expression was significantly increased in malignant compared to benign prostate tissue

(P < 0.001, P = 0.002 respectively). There was no difference between either receptors expression in patients with BCR versus non-BCR (P = 0.929, P = 0.289). There was a trend towards reduced PTEN expression in malignant tissue of BCR patients versus non-BCR patients (P = 0.0942). The trend was strongest between Gleason grade 4 disease in BCR vs non-BCR patients (P = 0.0651). When we examined the interaction of PTEN with the IGF-1R, we found patients with high IGF-1R+low PTEN were 3.5 times more likely to experience BCR versus patients with low IGF-1R+high PTEN (OR 3.5). Conclusions: Low PTEN is associated with BCR and this association is strongly modified by high IGF-1R expression. Measurement of these proteins could help to inform appropriate patient selection for adjuvant therapy and prevent BCR. References 1 Cox ME, Gleave ME, Zakikhani M et al. Insulin receptor expression by human prostate cancers. Prostate 2009; 69: 33–40 2 Haffner MC, Mosbruger T, Esopi DM et al. Tracking the clonal origin of lethal prostate cancer. J Clin Invest 2013; 123: 4918–22

© 2014 The Authors BJU International © 2014 BJU International | 114, Supplement 2, 17–41

A urine DNA methylation biomarker panel for non-invasive detection of high-risk prostate cancer Tuzova AV1, De Barra L1, O’Meachair S2, Clark J3, Cooper C3, Power R4, O’Malley K5, Manecksha RP6, Lynch T6, Perry AS1 1 Institute of Molecular Medicine, Trinity College Dublin; 2Dublin Centre for Clinical Research and Centre for Health Decision Science, School of Computer Science and Statistics, Trinity College Dublin; 3University of East Anglia; 4Department of Urology, Beaumont Hospital, Ireland; 5Department of Urology, Mater Misericordiae Hospital, D; 6 Department of Urology, St James’s Hospital, Ireland

Introduction: Opportunistic PSA testing has increased prostate cancer (PCa) incidence, resulting in significant overtreatment. Poor tumour-specificity of PSA causes unnecessary invasive biopsies, associated with substantial economic burden and trauma and anxiety to patients. Conversely, sampling bias means that needle-biopsies cannot conclusively rule-out the presence of PCa or the co-existence of more aggressive lesions. Our aim is to develop a DNA methylation panel to improve non-invasive early detection of aggressive PCa. Methods: Post-DRE first catch urines from 80 men undergoing TRUS-biopsy were used for DNA isolation and methylation analysis by quantitative methylation specific PCR. Sensitivity and specificity of the methylation panel and serum PSA were determined using logistic regression. All analyses were done blinded from TRUS-biopsy findings. Results: The patient cohort consisted of 43 biopsy-negative and 37 biopsy-positive (2 low-risk, 18 intermediate-risk and 17 17

18 Abstracts

high-risk) men. DNA methylation analysis revealed significantly higher frequencies and quantitatively higher levels in biopsy-positive men; most exemplified in the high-risk group. Urinary methylation discriminated between biopsy-positive and -negative men with an AUC of 0.82, compared with serum PSA, AUC of 0.56. Focusing specifically on high-risk PCa, the methylation panel gave an AUC of 0.87, compared with PSA, AUC of 0.54. Finally, combining methylation with PSA for non-invasive detection of high-risk PCa, produced an AUC of 0.96. Conclusion: Early indications suggest that urinary profiling of DNA hypermethylation can selectively detect high-risk PCa, with improved specificity over PSA. This “liquid biopsy” may have utility in reducing unnecessary TRUS-biopsies and serially monitoring disease progression in an active surveillance setting.

A single center validation analysis of Prostate Cancer risk loci from published GWAS: Association with PSA levels, disease aggressiveness and disease specific mortality 1,2

1,2

1,2

recurrence (BR), castration-resistant metastasis (CM), and PrCa–specific survival (DSS) using Cox proportional hazards models. Results: On univariate analysis, three SNPs were associated (P < 0.05) with BR, four with CM, and one with DSS. Applying a Bonferroni correction for SNP volume (P < 0.0008), the only significant association was between rs17632542 and PSA levels at diagnosis (P = 1.4 × 10−5). Five SNPs showed associations on multivariable analysis (P < 0.05): rs13385191 (BR/CM), rs9284813, rs4857841,rs1894292 and rs1529276 (CM), although not after correcting for multiple testing. Conclusions: We demonstrated that rs17632542 in KLK3 is associated with PSA levels at diagnosis, confirming previous reports. No significant association we seen between risk variants and disease specific endpoints. This provides further evidence that PCa risk variants are equally prone to associate with both more and less aggressive disease.

Results: There was significant correlation between PCA3 standardised to GAPDH and biopsy outcome (p = 0.036). On average men with prostate cancer had higher prostate cancer gene 3 expression (mean -4.16) than those found to be benign at biopsy (mean -6.61). Conclusion: PCA3 cannot be used in isolation as a diagnostic test, but rather may be used in conjunction with PSA and DRE to guide the decision for biopsy. Further validation of the method is required to assess its full potential.

The use of PCA3 mRNA in the diagnosis of prostate cancer

Introduction: The tumour microenvironment is host to a heterogenous population of cells including immune, fibroblasts, endothelial cells and mesenchymal stem cells (MSCs). MSCs are multipotent stromal cells capable of differentiating into various cell types such as osteocytes, adipocytes and chondrocytes. MSCs have the capacity to home to inflammatory sites including tumour sites, potentially contributing to tumour growth and progression. We hypothesize that prostate cancer (PrCa) cells re-programme MSCs, to a cancer associated fibroblasts-like phenotype to promote PrCa progression. Methods: MSCs from 2 human male donors were cultured for 48h in conditioned media from 3 PrCa cell lines of differing invasive capacity: 22Rv1, DU145 and PC3 and screened for alterations in their secretome using the MesoScale Discovery platform and Proteome Profilers. Alterations in their proliferative, migratory and invasive capacity were measured using the xCelligence real-time system. Additionally the MSCs were long-term adapted to conditioned media from PrCa cells to determine whether their secretomes induce MSC re-programming.

Sullivan JF , Stratton K , Kopp R , Manschreck C1, Scher H3, Eastham JA2, Offit KO1, Joseph V1, Lilja H1, Klein RJ1 Department of Medicine, Clinical Genetics Service,1Department of Surgery, Urology Service, 2Department of Medicine, Genitourinary Medical Oncology, 3Memorial Sloan-Kettering Cancer Center, New York, New York

Crawley S1, Hennessey DB2, Tyson M2, Subin F4, Pahuja A2,4,Wilson R1, Ryan MF3 1 Clinical Biochemistry Department, Antrim Area Hospital, Co. Antrim, 2Department of Urology, Belfast City Hospital, Belfast, 3 Pathology Department, Antrim Area Hospital, Co. Antrim, 4Department of Urology, Causeway Hospital, Coleraine

Introduction: Genome-wide association studies (GWAS) have currently identified over 75 single nucleotide polymorphsims (SNPs) associated with prostate cancer (PrCa) risk. However, susceptibility loci have not been shown to discriminate men who will develop aggressive disease. Our aim was to assess the frequency of a comprehensive selection of PrCa risk SNP’s within localised PrCa patients with respect to disease specific endpoints. Methods: We genotyped 1,355 individuals treated for PCa between 1988 and 2007 in our institution. Blood samples were prospectively collected and de-identified before genotyping and matched to clinical data with follow up to November 2013. Multivariate survival analysis was adjusted for gleason score, pathological stage and diagnosis age. We investigated associations between 60 SNPs and biochemical

Introduction: The management of patients with suspected prostate cancer is compromised by the lack of specificity of prostate specific antigen (PSA) analysis and the subjective nature of digital rectal examination (DRE). More accurate tests may better inform the Urologist which patients need invasive tests. Prostate cancer gene 3 (PCA3) is a new prostate specific gene detected in the urine after DRE. Objective: The objective of this study was to examine the utility of a newly described Roche research assay for the detection of PCA3 mRNA in urinary sediments using the Roche Lightcycler 480 system. Methods: Urine specimens were collected post DRE from 38 men. PCA3 mRNA was standardised to PSA mRNA and GAPDH. Pearson’s Correlation was used to assess the relationship between PCA3, PSA, DRE, prostate volume and biopsy outcome.

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Bone Marrow DerivedMesenchymal Stem Cell Reprogramming by Prostate Cancer Cells to Promote Prostate Cancer Progression Sarah Ridge1, Karen O’Leary1, Georgina Shaw2, Mary Murphy2, Kilian Walsh3, Garrett Durkan3, Eamonn Rogers3, Francis J Sullivan1,4, Sharon A. Glynn1 1 Prostate Cancer Institute, National University of Ireland Galway, 2REMEDI, National University of Ireland Galway, 3Dept of Urology, Galway University Hospital, 4Dept of Radiation Oncology, Galway University Hospital


Abstracts 19

Results: The secretion of angiogenic growth factors PLGF and VEGFA was elevated in MSCs cells after exposure to PrCa conditioned media for 48hr, compared to control. PrCa cell lines were found to exhibit increased rates of migration towards MSC conditioned media indicating increased chemoattractant potential. 18-day exposure of MSCs to PrCa conditioned media, led to differential re-programming when comparing AR-positive non-metastatic 22Rv1 versus AR-negative metastatic PC3 and DU145. Conclusions: Our results suggest that MSCs act as chemoattractants and angiogenic reservoirs for PrCa. Current on-going research is aimed at identifying the key mechanism involved. Human Endogenous Retrovirus K Expression Predicts a Prostate Cancer Diagnosis Ronan F. Downey1, Tiffany Wallace2, Francis J. Sullivan1,3, Feng Wang-Johanning4, Kilian Walsh5, Garrett Durkan5, Eamonn Rogers5, Radoslav Goldman6, Stefan Ambs2, Sharon A. Glynn1 1 Prostate Cancer Institute, National University of Ireland, Galway, 2Laboratory of Human Carcinogenesis, National Cancer Institute, Bethesda, MD, USA., 3Dept of Radiation Oncology, Galway University Hospital, Galway, 4 SRI International, Menlo Park, CA, USA, 5Dept of Urology, Galway University Hospital, Galway, 6 Lombardi Cancer Center, Georgetown University, Washington, DC, USA

Introduction: Retroelements account for 8% of the human genome and include the human endogenous retroviruses (HERVs). HERV-K retains open reading frames for all canonical retroviral genes (gag-pol-env). HERV-K has been implicated in the aetiology of cancers such as prostate, breast, ovarian and melanoma due to the observation of high levels of HERV-K mRNA and protein. Methods: Using qRT-PCR, we examined HERV-K gag expression in peripheral blood mononuclear cells (PBMC) from 294 cases and 135 healthy men, and type I and type II HERV-K env transcript in a subset of men. Multivariable logistic regression was used to assess the association of HERV-K mRNA transcripts with prostate cancer risk. Stratification analysis was employed to examine the effects of race, age at diagnosis and smoking status. Results: The abundance of HERV-K gag message was significantly higher in cases

than controls. Men with gag expression in the highest quartile had a more than 12-fold increased odds [OR = 12.87 (95% CI 6.3–26.25)] of being diagnosed with prostate cancer than those in the lowest quartile of gag expression. Moreover, our results showed that HERV-K expression may perform better as a disease biomarker in older than younger men (whereas the sensitivity of PSA testing decreases with age), and in men with a smoking history when compared with never smokers. Conclusion: We conclude that combining non-invasive HERV-K testing with PSA testing may improve the efficacy of prostate cancer detection specifically among older men and smokers who tend to develop a more aggressive disease. Publication rates of abstracts presented at the Irish Society of Urology Annual Meeting: Analysis and predictors of conversion to full text articles Sullivan JF, Dowling CM, Power RE Department of Urology and Renal Transplantation, Beaumont Hospital, Dublin

Introduction: Presentation of scientific research at national and international

period (2006–2010). A PubMed search was performed to identify full-text publications of the presented abstracts as of April 2014. Parameters recorded included number of authors, clinical or laboratory research, country of origin, first author status, time to publication and conversion rates per meeting section. Predictors of publication were analysed using unpaired t-tests. Results: Overall 95 of 227 abstracts (42%) presented achieved full text publication, with a trend to higher rates of conversion over more recent years. Seventy-nine percent of publications were from Irish institutions. Three-quarters of papers retained the same abstract first author. A greater percentage of laboratory research was published compared to clinical research (49% vs 39% respectively). A higher number of authors on the original meeting abstract was a significant predictor of publication (5.9 published vs 4.6 unpublished, P < 0.001). Table 1 below highlights our results. Conclusions: The conversion rate of publications from the ISU annual meeting compares favourably with other large international urology conferences. A higher number of authors was predictive of full text publication.

Table 1 Overall (mean) and yearly values for most pertinent variables. Year

Overall (mean)

2006

2007

2008

2009

2010

Overall Publication Rate Mean Time to Publication (months) Publication from Irish Centres Author No – Published (mean) Author No – Unpublished (mean) Published in International Journals

42% 24 79% 5.9 4.6 75%

43% 26 52% 5.3 4.7 61%

32% 33 92% 6.8 4.3 100%

36% 22 81% 6 4.8 87%

51% 20 74% 5.6 4.7 74%

47% 18 95% 6 4.8 55%

meetings is an important forum for the dissemination of knowledge. Reported publication rates from larger international urology meetings vary between 25 and 50% [1]. Our aim was to determine the conversion rate of abstracts presented at the Irish Society of Urology (ISU) annual meeting and to identify predictors associated with successful full text publication. Methods: We reviewed all abstracts presented at ISU meetings over a 5 year


References 1 Yoon PD, Chalasani V, Woo HH. Conversion rates of abstracts presented at the Urological Society of Australia and New Zealand (USANZ) Annual Scientific Meeting into full-text journal articles. BJU Int 2012; 110: 485–9

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20 Abstracts

Is citation index a good indicator of landmark papers in Urology?

Fig. 1 Mean citation index in each sub-speciality area.

LC McLoughlin, F O’Kelly, JA Thornhill Department of Urology, Tallaght Hospital, Dublin

Introduction: Landmark papers in urology reflect the major developments in diagnosis and management of urologic conditions. Knowledge of these is essential for practitioners of evidence based medicine, and for trainees undertaking the FRCS Urology examination. Citation index (CI) is seen as a direct measure of the quality of a scientific paper [1]. The aim of this study was to compare papers with the highest CI in each urologic sub-speciality with the landmark papers in urology. Methods: 79 of the highest impact factor journals in urology, medicine and urologic sub-specialities were identified from the Journal of Citation Reports 2012. Urology papers with the highest CI were identified from these journals using the database of the Science CI (1965–2012). 44 landmark papers in urology were then identified from textbooks, recommended reading lists for the FRCS Urology examination, and publications on landmark urology papers. High CI papers were then compared to landmark papers. Results: The top 10 cited papers in each urologic sub-speciality were identified. 31.8% (n = 14) landmark papers were among the top 10 cited papers. Urinary tract infection had the highest proportion of landmark papers in the top 10 cited articles (Table 1). Kidney cancer papers had the highest mean CI while urinary tract trauma had the lowest (Fig. 1).

Trauma Transplant Andrology Paediatric urology BPH Female, reconstructive & neuro-urology Urolithiasis Urinary tract infection Penile cancer Testes cancer Prostate cancer Bladder cancer Kidney cancer

Mean citation index

0

500

1000

1500

Conclusion: This study shows that CI alone is a poor indicator of landmark papers in Urology. This study gives a comprehensive overview of both landmark papers in urology and those with the highest CI, and may be used as an adjunct to the FRCS Urology syllabus. References 1 Baltussen A, Kindler CH. Citation classics in anesthetic journals. Anesth Analg 2004; 98: 443–51, table of contents

Table 1: Landmark papers within the top 10 cited papers Urologic sub-speciality area

Uro-oncology Kidney Bladder Prostate Testes Penile Urinary Tract Infection Urolithiasis Female, reconstructive and neuro-urology Benign prostatic hyperplasia Paediatric urology Urinary tract trauma Total

20

Landmark papers (n)

No. of landmark papers contained in top 10 cited papers

3 6 10 1 0 1 9 3 6 4 1 44

1 (33%) 1 (16.6%) 2 (20%) 0 (0%) 0 (0%) 1 (100%) 3 (33.3%) 2 (66.7% 2 (33.3%) 2 (50%) 0 (0%) 14

2000

Conversion rates of abstracts to publications from the Irish Society of Urology Annual Meeting (2005– 2011) – Questioning the scientific value of national urological meetings for smaller European Nations F O’Kelly1, S Bell1, A Galbraith1, LC McLoughlin1, DM Quinlan2, JA Thornhill1 1 Department of Urological Surgery, Tallaght Hospital, Dublin 2 Department of Urological Surgery, St. Vincent’s University Hospital, Elm park, Dublin

Introduction: Large annual scientific meetings such as the AUA and EUA have abstract conversion rates into publication of 37–48%. There is no data on the conversion rates from the national meetings of smaller European countries. Our objective was to present the conversion rates and manuscript characteristics of the Irish Society of Urology (ISU) annual meeting over a seven-year period (2005–2011), and to demonstrate the value, viability and sustainability of such a meeting as a model for other small national research programmes. Methods: All abstracts presented at the ISU annual meeting between 2005–2011 were identified. The subsequent publication rate following the meetings was established for the corresponding studies (Medline scan). A range of characteristics associated with subsequent publication were analyzed using the logistic regression of the


Abstracts 21

dichotomous variable of publications/ non-publication of each factor. Results: Overall, 46% of the 322 abstracts presented at the ISU meeting were followed by publication into Medlineindexed journals with a mean impact factor (IF) of 2.6. Seventy four percent abstracts were published within 2 years. Oral presentations were more likely to be published than posters (P < 0.0001), prospective clinical research was more likely to be published in a journal with a higher IF than retrospective analyses (P = 0.033), the mean time to publication was 16.7 months. Conclusions: Almost half the abstracts presented at the ISU were subsequently published in peer-reviewed journals, the majority within 2 years. This compares favorably with larger urological meetings, and provides an incentive to other smaller countries within Europe to continue with national research programmes. References 1 Autorino R, Quarto G, Di Lorenzo G, De Sio M, Damiano R. Are abstracts presented at the EAU meeting followed by publication in peer-reviewed journals? A critical analysis. Eur Urol 2007; 51: 833–40; discussion 840 2 Ng L, Hersey K, Fleshner N. Publication rate of abstracts presented at the annual meeting of the American Urological Association. BJU Int 2004; 94: 79–81 3 Rao AR, Beatty JD, Laniado M, Motiwala HG, Karim OMA. Publication rate of abstracts presented at the British Association of Urological Surgeons Annual Meeting. BJU Int 2006; 97: 306–9

Session 2: Prostate Cancer: Problems for both Patients and Doctors Alike External Validation of the 2007 and 2013 Updated Partin Tables in a Cohort of Irish Men KJ Breen1, S Boyce1, A Boyd Lyons1, DJ Lundon1, JM Fitzpatrick1, TB Murphy2, RW Watson1 UCD School of Medicine and Medical Science, University College Dublin, Dublin1 UCD School of Mathematical Sciences, University College Dublin, Dublin2

Introduction: Our aim was to perform the first external validation of the 2013 Partin tables and to compare the 2007 and 2013 Partin tables in a cohort of Irish men.

Methods: Prospective data collection from 795 men was performed through the Irish Prostate Cancer Research Consortium; those for whom full data was not available were excluded resulting in 414 consecutive cases available for statistical analysis. The predictive accuracy of the 2013 and 2007 Partin tables were assessed by means of receiver operating characteristic (ROC) curves and area under the curve (AUC) values to measure discriminate ability, calibration curves to measure calibration and decision curve analysis to measure clinical benefit. Results: In our cohort, the rates of organ confined (OC) disease, extracapsular extension (ECE), seminal vesicle invasion (SVI) and lymph node involvement (LNI) were 73%, 17%, 7% and 3% respectively. AUC values for OC, ECE, SVI and LNI were 0.669, 0.592, 0.695 and 0.795 respectively for the 2007 Partin tables and 0.668, 0.600, 0.688 and 0.811 respectively for the 2013 Partin tables. Conclusion: The 2013 and 2007 Partin tables cannot accurately predict OC, ECE and SVI in Irish men and should not be used for this purpose. However, the 2013 Tables can accurately predict LNI (AUC = 0.811–0.978) and represent a useful clinical tool to inform decision making regarding pelvic lymphadenectomy at radical prostatectomy. The 2013 Partin tables are superior to the 2007 tables for the prediction of LNI in an Irish population, and therefore the 2013 Tables should be preferred by clinicians.

Prostate cancer detection using a novel direct elasticity assessment device (The E-finger) DW Good1, S Hammer2, P Scanlan2, GD Stewart1, W Shu2, S Phipps1, R Rueben2, SA McNeill1 Edinburgh Urological Cancer Group, University of Edinburgh, Western General Hospital, Edinburgh, EH2 4XU, United Kingdom1 School of Engineering and Physical Sciences, Heriot Watt University, Edinburgh, United Kingdom2

Introduction: There is a need for novel biomarkers for prostate cancer in order to better differentiate significant from insignificant disease. The stiffness of prostates to detect prostate cancer has been used for hundreds of years with digital rectal examination (DRE), this however is poorly sensitive as a test. The E-finger


probe is small enough to fit on the tip of an index finger underneath a glove. Methods: We have developed a microengineered probe (5mm in diameter) capable of elasticity assessment of the prostate. We systematically assessed the prostate via DRE in vivo and ex-vivo whole specimens using the device to assess its ability to detect prostate cancer. Prostatectomy specimens were processed as normal (5mm cross-sections), shrinkage factors applied in order to correlate histology with elasticity measurements. Image analysis using Image Pro Premier was performed to calculate tumour volume, and other histological parameters. Results: To date we have performed 14 ex-vivo assessments and 4 in-vivo instrumented (i) DRE assessments. Univariate regression analysis showed that 15Hz AR &MR, 5Hz AR were significant predictors of tumour containing areas, multivariate regression also confirmed this. CART analysis revealed a cut off value of 2.4 × 107 correctly classifies 68% of cancer containing areas (p = 0.0042). Conclusion: We have shown the ability of the device to differentiate benign from malignant with 68% accuracy. These preliminary results show the potential role of elasticity in improving the subjective examination of DRE.

The use of multi-parametric MRI in the detection of prostate cancer EM Bolton1, M Quinlan1, J Costelloe1, O’Kelly F1, D Galvin1, G Lennon1, D Mulvin1, C McMahon2, D Quinlan1 Department of Urology, St. Vincent’s University Hospital, Elm Park, Dublin1 Department of Radiology, St Vincent’s University Hospital, Elm Park, Dublin2

Introduction: Although the majority of prostate cancers are diagnosed with routine trans-rectal ultrasound (TRUS) guided sectoral biopsies, there are a significant cohort of patients with persistent clinical suspicion (rising PSA, abnormal DRE) who pose an important clinical dilemma. The latest guidelines from the EAU highlight Multiparametric (MP) MRI as ‘the most accurate non-invasive method’ of identifying localised prostate cancer (CaP) and is gaining popularity as an adjunct tool in patients with prior negative TRUS biopsies and/or abnormal or increasing PSA levels.3 This study integrates prebiopsy MRI with directed TRUS-guided 21

22 Abstracts

prostate biopsies. This is the largest such study in Ireland. Methods: MP-MRI was performed in 110 patients; 92 with persistently elevated PSA despite negative TRUS biopsies, 18 with no prior biopsies. All men underwent MP, contrast-enhanced MRI without endorectal coil. Results: Median patient age was 66 years (42–81), median PSA 11.92 ng/ml and median prostate volume 68 ml. 32, 38 and 22 patients already had 1, 2 and ≥3 previous negative TRUS biopsies respectively. Targeted biopsies in 50 /110 (45%) patients showed CaP. In patients undergoing 1st biopsy, CaP was diagnosed in 11/18 (61%) and 39/92 (42.4%) in those having re-biopsy without previous cancer diagnosis. In prostates marked as highly suspicious on MRI, CaP detection was 90% (45/50). In targeted single cores from highly suspicious lesions, 38/39 (97%) biopsies were positive. Conclusion: Use of pre-biopsy MP-MRI allows a tailored approach to CaP diagnostics and should be considered in all men presenting with a clinical suspicion of CaP in spite of negative biopsy.

The presence of MRI invisible prostate cancer and importance of systematic biopsy outside the MRI lesion D Eldred-Evans, J Kinsella, I Meiers, A Polson, G Rottenberg, R Popert The Urology Centre, Guy’s and St. Thomas’ Hospitals, London, UK

Introduction: Suspicious lesions identified on multi-parametric MRI (mp-MRI) may be biopsied with a range of MRI targetedbiopsy techniques. It has been suggested that limiting biopsies to MRI suspicious areas might improve significant cancer detection whilst avoiding additional biopsies. This study assessed the performance of mp-MRI to exclude clinically significant disease (CSD) outside the MRI lesion. Methods: 163 suspicious lesions identified on mp-MRI were evaluated. MRI lesions were graded from 1 to 5 according to the European Consensus guidelines (PIRADS). MRI-US fusion targeted biopsy (M-UFTB) of the lesion was carried out using Variseed 8.0.2 software (Varian Medical Systems), followed by a systematic sampling of the remaining peripheral zone 22

by transperineal mapping sector biopsies (TPSMB). CSD was located into a prostate quadrant and defined as >4 mm max cancer length or presence of Gleason pattern 4. Results: Outside the MRI lesion, clinically significant prostate cancer was identified in 43% (70/163). This was located in the same quadrant as the lesion in 13%, an adjoining quadrant in 22% and a non-adjoining quadrant in 8%. The combination of M-UFTB and TPSB gave the highest cancer detection rate of 67% (109/163). The detection rate within the lesion significantly increased with PI-RADS score (P < 0.001, chi squared test). Conclusion: MRI ‘invisible’ cancer of clinical significance will be missed if biopsies are limited to the MRI lesion. The presence of MRI invisible cancer has implications for the planning of focal or targeted therapies. MRI-targeted biopsy techniques should incorporate a systematic biopsy protocol to avoid missing clinical significant disease.

Men’s experience of prostate biopsy in Ireland: Results from the all-Ireland PiCTure study Frances J Drummond1, Heather Kinnear2, Anna Gavin2, Eamonn O’Leary1, Garrett Durkan3,4, David Galvin5, Gordon Smyth6, Sheila Kiely4, Catherine McGarvey5, Linda Sharp1 1 National Cancer Registry Ireland, 2Northern Ireland Cancer Registry, 3University Hospital Galway, 4Mid-Western Regional Hospital Limerick, 5Mater Misericordiae Hospital, 6 Beaumont Hospital

Background: The number of men diagnosed with prostate cancer (PCa) through prostate biopsy following a raised PSA, has increased dramatically in the last two decades. How this experience affects men is unknown. Methods: Following ethical approval, men were recruited from four rapid access PCa clinics in the Republic of Ireland (RoI) and four hospitals in Northern Ireland (NI). A questionnaire was developed; content included socio-demographic and clinical factors, biopsy result, and statements describing the biopsy experience. Quality of life (QoL) was measured using EQ-5D-5L. Men received the questionnaire approximately four weeks post-biopsy. Results: Overall 334 men were recruited, 272 (81%) from RoI and 62 (19%) from

NI. 36% received a PCa diagnosis, 33% were PCa negative, 7% required further tests and 25% did not know their result. Overall 90% were ‘glad’ they had the biopsy. Men described the biopsy as necessary (90%), reassuring (83%), uncomfortable (76%), unpleasant (66%), stressful (46%) or embarrassing (34%). Descriptions varied by biopsy result (49% and 58% with and without PCa, respectively, described it as painful; 52% and 65% with and without PCa, respectively, reported it made them worry). 5% regretted having a biopsy. Mean unadjusted QoL scores were higher in men without PCa (0.930 ± 0.105) or from RoI (0.908 ± 0.136), than those with PCa (0.864 ± 0.168) or from NI (0.823 ± 0.196). Conclusion: Most men, irrespective of the result, described the biopsy as necessary or reassuring; however, a higher percentage of men without PCa, than with PCa, described it in negative terms. Men’s QoL was negatively associated with a PCa diagnosis.

Complications of TRUS Biopsy of Prostate in a Single Centre G Hann, J Morrow, J McKnight, B Duggan, A Thwaini, S Gray Department of Urology, Ulster Hospital Dundonald, Northern Ireland

Introduction: Prostate cancer incidence is rising with current lifetime risk approximately 13%. [1] TRUS-guided prostate biopsies are essential but associated with significant morbidity including bleeding and infection, ranging from simple UTI to urosepsis. A perception of rising rates of post-biopsy sepsis within our Trust led to an audit of current practices. This audit loop identifies complication rates and has mandated a change in Trust policy. Methods: Retrospective review of all TRUS prostate biopsies carried out over two twelve month periods in the SE Trust. Patients identified from TMS system via code. Re-audit involved a change in antimicrobial prophylaxis from Co-Amoxiclav to Ciprofloxacin (+/-Gentamicin). Results: A total of 224 and 294 consecutive patients were identified in the initial audit and re-audit respectively.The incidence of subjective UTI symptoms


Abstracts 23

for multiple primaries. Br J Cancer 2011; 105: 460–5 2 Hori S, Sengupta A, Joannides A, Balogun-Ojuri B, Tilley R, McLoughlin J. Changing antibiotic prophylaxis for transrectal ultrasound-guided prostate biopsies: are we putting our patients at risk? BJU Int 2010; 106: 1298–302 3 Zani EL, Clark OAC, Rodrigues Netto Jr N. Antibiotic prophylaxis for transrectal prostate biopsy. Cochrane Database Syst Rev 2011, Issue 5. Art. No.: CD006576. DOI: 10.1002/14651858.CD006576.pub2

reported was significantly reduced (14% vs 2.4%) and the number of confirmed UTIs fell from 5% to 1.4%. Confirmed bacteraemia was rare in both audit groups (1.8% and 0%). There was a significant reduction in GP and hospital attendances (8% to 1%). Patients presenting with symptomatic or confirmed UTI were more likely to require admission in the original audit. (Table 1, Fig. 1) The relative risk of infective complications following TRUS biopsy in the re-audit was 0.2, equating to a relative risk reduction of 80%. Table 1 Results summary

Histopathology (confirmed malignancy) Subjective Symptoms of Infection Confirmed UTI Confirmed Bacteraemia Hospital Attendance Confirmed UTI and Hospital Attendance

Audit: 2011–2012 (Co-Amoxiclav)

Re-audit: 2012–2013 (Cipro +/− Gent)

59% (133/224) 14% (32/224) 5% (12/224) 1.8% (4/224) 8% (18/224) 4% (9/224)

62% (182/294) 2.4% (7/294) 1.4% (4/294) None (0/294) 1% (3/294) 0.7% (2/294)

Fig. 1 Antibiotic prophylaxis comparison.

Methods: Information on all men undergoing TTP was collected prospectively. Data included demographics, PSA and previous TRUS biopsy history, procedure details, TTP histology, subsequent treatments and procedure related complications. Results: Sixty-eight TTP biopsies were performed and data analysed. All (100%) had at least one prior 12-core biopsy while 42/68 (62%) had at least 2 previous negative biopsies. In 3/68 (4.4%) a TTP was performed as part of active surveillance. Of those undergoing TTP, 33/68 (48.5%) were upgraded in comparison to initial TRUS histology. Of these 33 patients 27 (82%) had radical treatment for their prostate cancer. Complications included urinary retention (n = 1) and sepsis (n = 1). Conclusion: For patients considered high risk of prostate cancer, TTP results in a significant upgrading and potentially more accurate staging of disease compared to 12-core TRUS biopsy. The associated complication rate of TTP is low.

Percentage (%) of total patients

16 14

Co-Amoxiclav (2011-12)

12

Cipro +/‐Gent (2012‐13)

10 8

D Eldred-Evans1, G Marra1, L Vyas1, J Kinsella1, P Acher2, R Popert1 1 Urology Centre, Guy’s Hospital, London 2 Southend University Hospital, Essex

6 4 2 0

The use of transperineal sector mapping biopsy as a first-line biopsy strategy: A multiinstitutional analysis of clinical outcomes and complications

Subjective Hospital Symptoms of Attendance Infection

Confirmed UTI

Conclusion: Post-biopsy sepsis is an uncommon but serious event requiring hospital admission for parenteral antibiotics. Revising our policy on antimicrobial prophylaxis has reduced morbidity and hospital admissions among the cohort. Our experience is consistent with previous published concerns regarding antibiotic prophylaxis for TRUS guided prostate biopsies. [2,3] References 1 Sasieni PD, Shelton J, Ormiston-Smith N et al. What is the lifetime risk of developing cancer? The effect of adjusting

Confirmed Confirmed UTI Bactaeremia and Hospital Attendance

Should transperineal template biopsy become the new standard for prostate cancer diagnosis? D Moran1, C McGarvey1, T Lynch2,3, N Hegarty1,2, K O’Malley1 Mater Misericodiae Hospital1, Mater Private Hospital2, St James Hospital3

Introduction: The limitations of 12-core TRUS biopsy are well established. Its complication profile is also significant. Though trans-peritoneal template biopsy (TTP) requires additional resources, it may offer a more accurate histological diagnosis with a reduced infection rate.


Introduction: The first-line biopsy strategy for men with suspected prostate cancer has been transrectal ultrasound guided (TRUS) for over 25 years. TRUS biopsy is known to be inaccurate and misses a third of clinically significant prostate cancer leading to repeat biopsies in 30–40% of men. This study evaluates the clinical outcomes and complications of first-line transperineal biopsy in a large multi-institutional cohort. Patients and Methods: Data were collected on 402 patients who underwent primary transperineal sector mapping biopsy (TPSMB) at three participating centres over a seven year period. Men who had a previous biopsy were excluded. Primary TPSMB was a day-case procedure under general or spinal anaesthesia. TPSMB preferentially targets the peripheral zone by sectors (24 to 38 cores). 23

24 Abstracts

Cancer detection rates were calculated with clinically significant prostate cancer defined as maximum core length greater than 4mm and/or Gleason score 3+4 or greater. Results: Prostate cancer was diagnosed in 249 men (62%); this was clinically significant in 187 (75%). 43 patients (17%) had cancer located exclusively in the anterior sector and this was clinically significant in 27 (11%). Post biopsy urinary retention occurred in six patients (1.5%). Haematuria requiring overnight hospital admission occurred in four patients (1%). There was no urosepsis. Conclusions: TPSMB is a safe technique with negligible urosepsis. The high cancer detection rate, compared to similar TRUS biopsy primary cohorts that detect cancer in 40–44% of men, is likely due to a more comprehensive assessment of the anterior and apical regions of the prostate.

Active surveillance for low risk prostate cancer S Gnanappiragasam1, JC Forde1, M Moloney1, S Kiely2, K Walsh1, GC Durkan1,2 Department of Urology, University Hospital Galway1 Department of Urology, University Hospital Limerick2

Introduction: Active surveillance (AS) is a management strategy for addressing the widely acknowledged problem of overtreatment of clinically indolent prostate cancer. We present our experience with AS in the HSE West region. Methods: A total of 180 patients have been enrolled on the AS program between August 2010 and February 2014. All data was collected prospectively in a secure database. Results: Mean age of patients enrolled was 64.4 years (range 54–75). Median PSA at enrolment was 7.01ng/ml (range 2.8–14.4). The mean follow-up was 32 months (range 3–36). In total, 85% of patients had a repeat biopsy within one year with 30% having another biopsy at 3 years. Overall, 65.3% of patients remain on AS. In the remainder; 24% of patients were removed from AS for definitive treatment, 8.2% of patients are now on watchful waiting, 2.5% of patients self discharged from the program and one patient died of cardiovascular disease. The prostate cancer specific survival rate is 100%. Indications for removal from AS and referral for treatment were; upgrade of disease on 24

repeat biopsy (64%), PSA progression (26%) and 10% of patients made a decision proceed with definite treatment despite still being eligible. Regarding definitive treatment; 64.2% of patients have been for referred for external beam radiotherapy, 28.8% for brachytherapy, and 7% for surgery. Conclusion: Our findings to date support active surveillance as a valid strategy for early, localised prostate cancer.

LDR Brachytherapy in the Management of Patients wih Localized Prostate Cancer: Update of the Galway Experience in the first 536 cases, 2007–2012 Francis J. Sullivan1,2,3, Kilian Walsh1, Eamonn Rogers1, Garrett Durkan1, Paddy O’Malley2, David Bouchier Hayes2, Geraldine O’Boyle1, Anysja Zuchora1, Peter Woulfe2, Sharon Glynn3 1 Galway University Hospital, 2Galway Clinic, Prostate Cancer Institute, NUI Galway3

Introduction: Management options for localized Prostate Cancer (PC) include radical prostatectomy, as well as external beam radiotherapy [EBRT] and brachytherapy [BT]). BT can be delivered alone (monotherapy) or in combination with EBRT and/or hormone therapy. BT has been available in Ireland since 2003, but access was recently expanded to include Galway. We report an update of the results of the initial cohort of 568 men treated with LDR in Galway Hospitals over a 5 year period (2007–2012). Methods: The LDR BT was delivered by a single clinician, using real time intraoperative technique. No patient was excluded, and the experience represents all patients treated from the inception of the programme. The patients were followed, and the data stratified according to the D’Amico risk criteria, for overall survival (OS), biochemical relapse free survival (BRFS), cause specific survival (CSS), and toxicity. Results: The initial results showed an OS, BFRS rates of 100%, 97% at initial evaluation with 536 patients for evaluation (median follow up approaching 3 years and maximum follow up >5 years). Conclusion: Although still early in the follow up phase, these results support the use of LDR BT for the management of all risk groups of patients with localized PC in Ireland.

Comparing functional outcomes from open and robot-assisted radical prostatectomy by a single surgeon PE Lonergan, C Harrington, S White, E Dunne, RE Power Department of Urology, Beaumont Hospital, Dublin

Introduction: Robot-assisted radical prostatectomy (RARP) is proposed to improve functional outcomes in comparison with retropubic prostatectomy (RRP). However, few studies permit any definitive conclusions about the superiority of either technique in terms of urinary continence and potency recovery. We aimed to assess functional outcomes from both RARP and RRP performed by a single surgeon. Methods: A prospective analysis of 50 RRPs and 50 RARPs by a single surgeon was performed. Functional outcomes in the form of urinary continence (using the ISIQ-SF questionnaire) and potency (using the IIEF questionnaire) were independently assessed pre-operatively and at 3, 6 and 12 months. Results: Mean age in the RRP cohort was 60.3 years (range 48–73) with a mean PSA of 6.8ng/ml (range 1.9–20.8). Mean age in the RARP cohort was 62.2 years (range 48–71) with a mean PSA of 6.27ng/ml (range 0.8–17.6). Gleason grade and pathological stage were similar between both cohorts. The mean (± standard deviation) ICIQ score for the RRP cohort at 3, 6 and 12 months were 5.8 (±3.2), 2.7 (±3.3) and 0.7 (±2.2) respectively. Mean ICIQ score for the RARP group at the same intervals were 4.1 (±3.0), 1.1 (±2.3) and 0.1 (±0.9) respectively. At 12 months, 1 man (2%) in the RARP group was using 1 pad per day and 4 men (8%) in the RRP group were using pads. Conclusions: There is earlier urinary continence recovery in RARP, however at 12 months; there is no difference in urinary continence between either surgical approach.


Abstracts 25

The use of single photon emission computed tomography (SPECT-CT) in conjunction with isotope bone scintigraphy (IBS) to detect skeletal metastases from prostate cancer: initial Irish experience LC McLoughlin1, F O’Kelly1, C O’Brien2, M Sheikh1, J Feeney2, W Torreggiani2, JA Thornhill1 Department of Urology, Tallaght Hospital, Dublin1 Department of Radiology and Nuclear Medicine, Tallaght Hospital, Dublin2

patients were diagnosed with skeletal metastasis on SPECT-CT. The isotope uptake on IBS was due to degenerative change in 63% (n = 34); fractures in 11.1% (n = 6); inflammation in 7.4% (n = 4); and infection in 1.9% (n = 1) (Fig. 2).

35 30

Degenerative change Old fractures 20

Joint inflammation

15

Joint infection

10 5 0

Conclusion: SPECT-CT improves the diagnostic accuracy of IBS in detecting skeletal metastasis from PC and is superior to IBS in differentiating benign from malignant lesions. We recommend the use of SPECT-CT with IBS for targeted evaluation of suspicious lesions in this patient cohort. References 1 Jacobson AF, Fogelman I. Bone scanning in clinical oncology: does it have a future? Eur J Nucl Med 1998; 25: 1219–23 2 Even-Sapir E, Metser U, Mishani E, Lievshitz G, Lerman H, Leibovitch I. The

RP 13% RP + Radiotherapy 4% 2% RP + Hormonal + Radiotherapy Hormonal + Radiotherapy

6%

Hormonal therapy Radiotherapy

22%

Metastasis

25

Fig. 1 Treatment received for PC.

22%

Fig. 2 SPECT-CT findings.

40

Introduction: IBS is a standard radiological technique to detect skeletal metastases from prostate cancer (PC) [1]. The addition of SPECT-CT to IBS improves its diagnostic accuracy [2]. The aim of this study is to compare the detection of skeletal metastases by IBS alone and in combination with SPECT-CT in PC patients. Methods: 54 PC patients with suspected skeletal metastases on IBS were retrospectively recruited from 2012 to 2013. All underwent targeted evaluation with SPECT-CT. IBS and SPECT-CT images were reviewed by two consultant nuclear medicine radiologists and reported independently. The final diagnosis was made based on the CT finding corresponding to isotope uptake. Results: The mean patient age was 72.6 years (48–88 yrs). 68.5% (n = 37) men received treatment for PC; 13% (n = 7) had a radical prostatectomy (RP); 4% (n = 2) had an RP with adjuvant radiotherapy; 2% (n = 1) had an RP with adjuvant hormonal and radiotherapy; 22.2% (n = 12) had combined hormonal and radiotherapy; 22.2% (n = 12) had hormonal therapy alone; and 5.5% (n = 3) had radiotherapy alone. 31.5% (n = 17) patients were on watchful waiting (Fig. 1). 16.7% (n = 9)

31%

detection of bone metastases in patients with high-risk prostate cancer: Tc-99mMDP planar bone scintigraphy, single- and multi-field-of-view SPECT, F-18-fluoride PET, and F-18-fluoride PET/CT. J Nucl Med 2006; 47: 287–97

Watchful Waiting


Session 3: Moderated Poster Session Poster 1: Progression to clinically significant chronic kidney disease following radical nephrectomy for renal cell carcinoma Coyle D, Quinlan MR, Bolton E, D’Arcy FT, Kelly BD, Durkan G, Jaffry S, Walsh K, Rogers E Department of Urology, University Hospital Galway, Galway

Background: Radical nephrectomy (RN) is an independent risk factor for the development of chronic kidney disease (CKD) in those with renal cell carcinoma (RCC). Understanding the impact of RN on renal function over time will help to better select patients likely to benefit from nephron-sparing surgery (NSS). We aimed to examine the pattern of change in post-operative renal function in patients who underwent RN for RCC over a 3 year period at our institution, with specific reference to tumour stage. Methods: A retrospective review of histological and renal biochemical findings in patients undergoing RN for RCC over a 38 month period was undertaken. Estimated glomerular filtration rate (eGFR) 25

26 Abstracts

measurements were recorded preoperatively, at hospital discharge following RN, and at follow-up. Results: We analysed data on one hundred thirty-one patients. The median follow-up was 24 months. There was a significant increase in the proportion of patients with advanced stage CKD at follow-up with 48 (85.7%) of those with stage 2 CKD pre-operatively being re-classified as stage 3–5. Mean eGFR was significantly reduced from its pre-operative levels (76.6 mL/ min/1.73 m2) at both hospital discharge (61 mL/min/1.73 m2, P < 0.001) and follow-up (55.5 mL/min/1.73 m2, P < 0.001). Those with pT1a and pT1b tumours sustained a significantly greater decline in eGFR compared to other tumour stages. There was a weak negative correlation between tumour size and the magnitude of decline in eGFR at follow-up (R = −0.36, P < 0.001). Conclusions: Patients with pT1a and pT1b tumours sustain a disproportionate decline in renal function and may benefit the most from NSS.

Poster 2: Indeterminate small renal masses: Accuracy of diagnosis by radiologicallyguided biopsy J Costelloe, EM Bolton, M Quinlan, D Galvin, G Lennon, D Quinlan, D Mulvin. Department of Urology, St. Vincent’s University Hospital, Elm Park, Dublin

Introduction: Percutaneous biopsy of renal masses traditionally had a limited role in urological practice. Increased use of abdominal imaging has lead to a greater detection of “indeterminate” renal lesions. Increasing evidence suggests that biopsy can confirm diagnosis, subtype and grade of many primary renal cell cancers (RCC). This study investigates the histopathological accuracy of radiologically-guided percutaneous fine needle biopsy (FNB) in the evaluation of renal masses ≤4 cm. Methods: Data was retrospectively collected on 36 patients having US or CT guided biopsy. Tumour biopsy was performed with an 18 gauge needle. All patients subsequently underwent nephrectomy. Results: There were 16 males and 20 females (median age 54.3 years; range 29–74 years). Median tumour size on 26

imaging was 2.7 cm (range 1.6 cm–4 cm). The mean core number was 3.3. Of 36 patients, 30 (83.3%) were diagnosed with malignancy (21 Clear Cell RCC, 5 Papillary RCC, 2 Chromophobe RCC, 2 mucinous spindle). 5/36 (14%) were benign and 1/36 (3%) was insufficiently sampled. 16/36 (45%) patients proceeded to radical nephrectomy and 20/36 (56%) to partial nephrectomy. The accuracy of biopsy for subtype and Fuhrman nuclear grade evaluation were 32/36 (89%) and 24/36 (67%) respectively. In 2/5 patients with benign pre-op biopsy, final histology was diagnostic of benign renal tumours. Conclusions: The accuracy of FNB in identifying histological tumour type was high, but biopsy tended to underestimate Furhman grade. Image guided renal mass biopsy is safe, reliable and accurate and should be considered as a useful option for management of small indeterminate renal masses.

Poster 3: Assessing Renal Parenchymal Thickness on unenhanced computed tomography (CT) as a rapid marker for predicting renal function in patients undergoing percutaneous nephrolithotomy (PCNL) in a tertiary referral stone center (2003–2013) F O’Kelly1, RJ Flynn1, TED McDermott1, JA Thornhill1, W Torreggianni2, RP Manecksha1 1 Department of Urologic Surgery, Tallaght Hospital, Dublin 2 Department of Diagnostic and Interventional Radiology, Tallaght Hospital, Dublin

Introduction: Three-dimensional cross-sectional imaging is increasingly being recognized as an important method for assessing renal stone burden. Studies have demonstrated the role of contrastenhanced CT to assess renal perfusion, and GFR, as well as a surrogate for renal function in patients with CKD. There have been no studies assessing the role of CT in patients undergoing PCNL. This study sought to identify the relationship between renal parenchymal thickness (RPT) on CT and renal function measured by renography and eGFR in order to develop a tool for surgical decision-making and to reduce exposure to iatrogenic radiation. Methods: Patients who underwent PCNL between 2003–2013 were reviewed. Only patients with both preoperative CT and

renography were included. RPT was measured at 3 axial points (anterior, posterior and maximal width) using a mapping tool at the level of the renal pelvis using the coronal image as a reference (3 mm cuts). Correlation between RPT ratio and function was determined. Further analysis was performed using linear regression curves and Bland-Altman scatterplots, using GraphPad Prism (v6.0b). Results: 287 PCNLs were carried out on 242 patients (Mean: 49y). n = 139 patients (57.4%) were selected for further analysis. Mean parenchymal thickness was 1.76 cm affected kidneys compared with 2.1 cm controls (P = 0.03). Average renogram split function was 39% in affected kidneys. Linear regression analysis comparing renography to RPT revealed a correlation coefficient of 0.78 (P = 0.01). Conclusion: In patients who undergo PCNL, RPT from unenhanced CT is a rapid and reliable surrogate for renal function, and may obviate the need for additional renography. References 1 Hidas G et al. Estimating relative renal function from relative parenchymal volume – a feasibility study. J Endourol 2008; 22: 2527–30 2 Gupta S et al. Assessing renal parenchymal volume on unenhanced CT as a marker for predicting renal function in patients with chronic kidney disease. Acad Radiol 2012; 19: 654–60 3 Kaplon DM, Lasser MS, Sigman M, Haleblian GE, Pareek G. Renal parenchyma thickness: a rapid estimation of renal function on computed tomography. Int Braz J Urol 2009; 35: 3–8

Poster 4: Is Percutaneous nephrostomy insertion safe in hands of Urologists? Filip Subin, Binu MK Thomas, Richard Fiala, Paul Downey Urology department, Causeway Hospital, Coleraine

Introduction: Emergent percutaneous nephrostomy insertion is a potentially lifesaving procedure with a high success rate, minimal morbidity and is often used in the setting of an obstructed and infected renal collecting system. In majority of hospitals over the UK this service is provided by Interventional Radiologists


Abstracts 27

and not by Urologists. This may very often require transfer of septic patient to distant hospitals if there is no Interventional Radiologist available on site. This service has been provided in our District General Hospital by Urologists for more than four years and we analysed our success rate, morbidity and mortality associated with this procedure. Methods: Analysis of success rate of emergency USS and X-ray guided percutaneous nephrostomy insertion including 30 days post-procedure specific morbidity and mortality performed between 1.1.2010 – 31.12.2013. Results: 77 percutaneous nephrostomy insertions performed – 66 USS guided, 11 X-ray guided. Success rate was 97.4% on first attempt, 100% on second attempt. 2 nephrostomy insertions failed initially and required re-insertion within 3 days. No nephrostomy insertion specific morbidity or mortality was recorded. Conclusion: Percutaneous nephrostomy insertion is a potentially lifesaving procedure and is safe in hands of trained Urologists. This is especially useful in settings of District General Hospital with no support of Interventional Radiologists. Percutaneous nephrostomy insertion is a part of Urology training in most European countries and this might be considered also within the UK.

the other uses nurse-led recovery/ward based (CAU). Data collection was carried out over a 4month period in both units, recording times to administration and complications. BCH had 21 patients eligible, CAU had 24 patients eligible for MMC during the audit period. Results: BCH had 19/21 (90.4%) eligible patients receive MMC with a mean time to administration of 18.3 hours. 3/21 (14.3%) received MMC within 6 hours, 12/21 (57.1%) between 6 and 24 hours and 4/21 (19%) beyond 24 hours. Two patient treatments were cancelled due to prolonged bleeding. CAU had 24/24 eligible patients receive MMC with mean time to administration of 3.8 hours. 22/24 (91.7%) were within 6 hours and 2/24 (8.3%) between 6 and 24 hours. (Table 1) One complication was encountered in CAU with a leak of MMC. This was managed with topical neutralisation and no further complications encountered.

Poster 5: Mitomycin C Administration – A multicentre comparative audit of practice

Conclusion: Immediate post operative MMC administration has been demonstrated safe [2] and in our study nurse-led recovery room instillation had superior outcomes for time to administration and may lead to improved tumour recurrence outcomes. References 1 Sylvester R et al. A single immediate post-operative instillation of chemotherapy decreases risk of recurrence in patients with stage Ta T1 bladder cancer: a meta-analysis of published results of randomised controlled trials. J Urol 2004; 171: 2186–90 2 Kaasinen E et al. Factors explaining recurrence in patients undergoing chemoimmunotherapy regimens for frequently recurring superficial bladder carcinoma. Euro Urol 2002; 42: 167–74

D Curry1, G Walls1, G Rice1, D Hennessey1, H O’Kane1, C Cartwright2, R O’Kane2, P Downey2, R Fiala2, A Pahuja1,2 Belfast City Hospital, Belfast, Northern Ireland1, Causeway Hospital, Coleraine, Northern Ireland2

Introduction: A single intravesical dose of Mitomycin C (MMC) immediately post TURBT for superficial bladder tumours has been shown to reduce recurrence risk by 39% [1]. Current guidelines suggest the dose should be given within 6 hours of resection, but not more than 24 hours post operatively. Departmental practice widely varies, potentially adversely affecting outcomes. Methods: We compare practice in two units within Northern Ireland using different protocols for MMC administration. One unit uses a doctor-led ward based administration (BCH), whilst

Table 1

Total eligible Cancelled Mean time (range) 24 h


BCH

CAU

21 2 18.7 h (2.3–28.2) 3 (14.3%) 12 (57.1%) 4 (19%)

24 0 3.8 h (0.5–17.3) 22 (91.7%) 2 (8.3%) 0

Poster 6: Radiation exposure from endoscopic urological procedures is minimal is associated with a low risk of malignant potential DB Hennessey1, J Martin2, MA Tyson1, A Pahuja1,2, P Downey2, M Young1 1 Department of Urology, Craigavon Area Hospital, Portadown 2 Department of Urology, Causeway Area Hospital, Coleraine

Introduction: The Ionising Radiation (Medical Exposure) Regulations [IR(ME) R] requires that those undertaking medical exposures to establish diagnostic reference levels and to undertake appropriate reviews. Ionising radiation is commonly used in urological practice. To date there is a relative dearth of information regarding patient exposure during the urological procedures and the subsequent risk of development of a lethal malignancy due to the radiation exposure. Objectives: To determine the radiation exposure for a patient for the most commonly performed urological procedures and determine the lifetime additional risk of fatal cancer per procedure. Methods: Data was collected prospectively in two institutions on 395 patients who underwent endoscopic urological procedures over a 6 month period. Procedures were classified as cysctoscopic and retrograde, semi-rigid ureteroscopic (URS) and flexible ureterorenscopic (FURS). Data collected included procure type and difficulty, dose are product [DAP (Gy*Cm2)] and fluoroscopy time (seconds). The Effective dose (ED) was determined from the DAP by using the Monte Carlo Calculation. Results: Cystoscopic and reprography studies ED is 0.2680 IRQ (0.09177–0.8943) mSev. This increased to 0.4389 IRQ (0.09765–1.193) mSev if a JJ stent was placed. URS procedure ED is 0.2957 IRQ (0.09093–0.6006) mSev. Diagnostic URS ED is 0.1184 IRQ (0.0651–0.3255) mSEV. This increased for URS stone procedures 0.4284 IRQ (0.1736–0.6767) mSev. FURS ED is 0.4914 IRQ (0.2213–0.9198) mSev. FURS for stone ED is 0.6783 IRQ (0.3487–1.217) Conclusion: The findings of this study are reassuring. Endoscopic urological procedures appear to expose patients to relatively small radiation dose and have less than 1 in 30,000 lifetime additional risk of fatal cancer per procedure. 27

28 Abstracts

Poster 7: Radiographer delivered screening reduces radiation exposure during Endoscopic Urological procedures DB Hennessey1, J Martin2, MA Tyson1, A Pahuja1,2, P Downey2, M Young1 1 Department of Urology, Craigavon Area Hospital, Portadown 2 Department of Urology, Causeway Area Hospital, Coleraine

Introduction: The Ionising Radiation Regulations 1999 recommended that medical professionals using radiological equipment keep exposure to ionising radiations as low as reasonably practicable. Urologists regularly use radiological screening for endoscopic procedures. In some institutions, this is delivered by a radiographer whereas in other institutions it is delivered by the urological surgeon. Objectives: To determine if a radiographer can reduce the exposure to ionising radiation associated with urological procedures. Methods: An analysis of 395 consecutive patients who underwent endoscopic urological procedures requiring radiological screening in two institutions over a 4 month period was performed. 321 patients were matched in included in this analysis. Results: Radiographer delivered radiological screening was associated with reduced ionising radiation exposure for retrograde pyelographic procedures ED 0.09626 vs. 1.323 mSev, P = 0.0003, endoscopic stone surgeries ED 0.3066 vs. 0.5416 mSev, P = 0.0039, but not for ureterorenscopic stone surgeries 0.4880 vs. 0.2213 mSev, P = 0.8292. Conclusion: Radiographer delivered screening for some urological procedures can reduce the patient’s exposure to ionising radiation. Poster 8: Amount of Fluid needed for Flexible Cystoscopy Audit Wesam Elbaroni, Binu MK Thomas, Filip Subin, Paul Downey Causeway Hospital

Introduction: Amount of fluid needed for flexible cystoscopy is usually minimal. And the remaining fluids in the bag would be handled differently in different departments and practices. In some the fluid left is discarded and new bag is used. In our audit we aim to calculate how much 28

we could improve efficiency and costs if each bag was utilized efficiently. Methods 1) Measured amount of fluid left after each session between 7/2/14–7/4/14. (132 patient) 2) Calculate expenses and possible savings if different fluid and methods used. Results 1) 1L Baxter water was the type of fluid used. • Amount of fluid discarded was 112,131 ml of Baxter 1L water. • amount of fluid used was 19,869. • average lost was 849.5 and average used was 150.5. 2) In the year 2013 there were 1737 flexible cystoscopy cases done in the DPU unit. • This roughly will result in 1,475,581.5 ml discarded and costs about £ 2,136.51. • If we calculate the cost of using a new giving set for each 1737 × £1.80 = £3,126.6. Conclusion 1) Switching to 1L Saline 0.9% would only costs £0.50p. 2) From the above results we can assume that 1L bag should be enough for 4–6 patients. • That would mean 1737 patients would need 435–290 bags and would cost £217.5–130. • This is % 89.81–93.91 reduction in costs. • Different hospitals could benefit from reviewing how they handle fluids needed for flexible cystoscopy as it could improve efficiency and costs.

Poster 9: The comparative flow characteristics of different 3-way catheters,irrigation systems, and 2-way catheters relative to manufacturing specifications MA Abdelrahman1, DM Fanning1, L McLoughlin1, E Doyle1, B McMahon2, TED McDermott1, J Thornhill1 Urology Department Adelaide and Meath Hospital, Dublin1; Department of Biomedical Engineering 2, Adelaide and Meath Hospital, Dublin

Introduction: We studied flow characteristics of 3-way catheters, the irrigation systems and 2-way catheters. Methods: We studied Bard 22F, 24F, Rusch Simplastic 22F, 24F, Dover 20F,

®

®

®

22F, 24F, Rusch Golden 20F, 22F and 24F 3-way catheters, and Bard 22F, Rusch Golden 20F and Dover 20F 2-way catheters. Gravity irrigation (2-L Baxter at 120 CM) was connected to irrigation port. Maximal and average flow rates were measured for 20 seconds. Drainage was studied by blocking the irrigation channel with the fluid running on the contralateral direction. Continuous irrigation and drainage flows were measured by an artificial bladder attached to the catheter tip with 20 ml in the catheter balloon. The t test was used for statistical analysis. Results: Rusch Simplastic 22F and 24F catheters had superior irrigation (average flow 3.7 ml/s and 4.4 ml/s, 95% CI was 1.678–3.142 ml/s). The latter had average flow higher than the 95%CI (P = 0.0002). Overall average drainage flow was 11.29 ml/s (95% CI: 9.2–13.38 ml/s). The 24F Bard was superior (average flow rate 15.8 ml/s, P = 0.0006). On continuous irrigation overall average flow rate was 3.24 ml/s (95% CI was 2.385–4.094 ml/s). The 24F Rusch Simplastic and the 24F Dover had higher average flow rate (5.3 ml/s and 5.1 ml/s). The average flow rate of the former was above the upper limit of the 95%CI (P value = 0.0004). Conclusions: The 24F Bard 3-way catheter has higher drainage flow and the 24F Rusch Simplastic 3-way catheter is superior for continuous bladder irrigation. Catheter lumen size does not always correlate with flow rate.

®

Poster 10: How well does mp-MRI PiRADS scoring predict the outcome of transperineal sector prostate biopsy? Peter Acher1, Alistair Grey1, Manik Chana1, Konrad Wolfe1, Rick Popert2, Sid Liyanage1 1 Southend University Hospital NHS Foundation Trust, Southend-on-Sea, UK 2 Guy’s & St Thomas’ NHS Foundation Trust, London, UK

Introduction: This prospective cohort study aimed to determine the sensitivity and specificity of multiparametric MRI (mp-MRI) for significant prostate cancer detection with systematic transperineal sector biopsy (TPSB) as the reference standard. Methods: Two hundred and one patients had an mp-MRI (T2 and diffusionweighted images, 1.5Tesla scanner, 8-channel body coil) between July 2012


Abstracts 29

and November 2013 prior to TPSB for the following indications: prior negative transrectal biopsy with continued suspicion of cancer (103); primary biopsy (83); and active surveillance (15). A uro-radiologist, blinded to the clinical details, assigned qualitative PiRADS (Prostate Imaging Reporting and Data System) scores on a Likert scale of 1 to 5 denoting the likelihood of significant cancer with 1-highly unlikely, 3-equivocal, and 5-highly likely. Systematic TPSB was carried out as a daycase procedure under general anaesthetic and included 24 to 40 cores (depending on prostate size). Significant prostate cancer was defined as the presence of Gleason pattern 4 or cancer core length more than 5mm. Results: Mean(sd) age, PSA and prostate volumes were 65 (7) years, 11.7 (9.5) ng/ mL and 62 (37) mL respectively. Biopsies were benign, clinically significant and clinically insignificant in 124 (62%), 59 (29%) and 18 (9%) men respectively. Only two of 87 men with PiRADS score 77 years. Methods: We performed a case notes analysis on all men, aged 70–77 and >77 years, undergoing prostate biopsy during 2010. Diagnostic yield and treatment influence were recorded. Results: During the study, 76 men aged 70–77 and 31 aged >77 underwent biopsy. Despite similar PSA values (P = 0.34 Student’s t test), cancer was more common in the older cohort (24/31 vs. 40/76 P < 0.05). Radical treatment or active surveillance was offered to 30/40 and 3/24 men in the younger and older cohort respectively (P < 0.05), the oldest being 79-years-old. In the older cohort, 12 received hormone manipulation, 8 began watchful waiting and 1 patient died soon after diagnosis. In those aged >77, 13 had high-risk disease pre-biopsy, based on examination or PSA. Three patients aged >77 had increased risk stratification following biopsy, 1 proceeded to hormone manipulation and 2 to radiotherapy. Therefore, 92% (22/24) of men aged >77 would have had a similar management plan based on information available pre-biopsy. Conclusion: Our study suggests that age alone can be used to determine the appropriateness of prostate biopsy. Using increased discretion in men >77 may minimize over investigation. Poster 13: Prevalence of extended spectrum beta lactamase producing enterobacteriaceae in the urology patient population – a prospective audit JA De Marchi1, A Shah1, D Bouchier-Hayes2, WP Joyce3, P O’Malley2 Royal College of Surgeons in Ireland, Dublin1 Department of Urology, Galway Clinic2 Department of Surgery, Galway Clinic3

Introduction: Extended spectrum beta-lactamase (ESBL) producing bacteria 29

30 Abstracts

play a significant role in the urology patient where procedures such as trans-rectal ultrasound guided (TRUS) biopsies increase patient exposure to enterobateriaceae [1,2]. Few studies have examined the colonisation rate in the pre-operative healthy patient [3]. This study aims to add to identify colonisation risk factors, compare ESBL prevalence among differing patient populations, and provide a local audit of antimicrobial resistance patterns. Methods: 150 Rectal swabs were taken pre-operatively from participants and directly plated onto MacConkay and ESBL BrillianceTM plates. Grown isolates were then identified and antimicrobial susceptibilities determined. Participants were simultaneously asked to complete a questionnaire about exposure to proposed risk factors. Results: Rectal swabs from each of the three sample populations were collected (50 each). Fluroquinolone resistant enterobacteriaceae, including ESBL producers, were identified in each group (endoscopy n = 7 with 2 ESBL, TRUS biopsy n = 4 with 2 ESBL, and urology n = 8 with 3 ESBL) but with no statistically significant difference in frequency. Uni-variate analysis showed none of the proposed risk factors (History of previous prostate biopsy, recent hospital admission, recent infection, recent antibiotic use, age, race, and foreign travel) affected ESBL colonisation rate. Backwards binomial log regression (multivariate) of all independent variables again showed no significant effect. Conclusion: No significant risk factors for ESBL colonisation have been identified at this time. As such, recommendations on TRUS biopsy antibiotic prophylaxis cannot be made on individual patient characteristics and should continue to follow a protocol based on local susceptibility and resistance patterns. References 1 Minamida S, Satoh T, Tabata K et al. Prevalence of fluoroquinolone-resistant Escherichia coli before and incidence of acute bacterial prostatitis after prostate biospy. Urology 2011; 78: 1235–39 2 Duplessis C, Bavaro M, Simons M et al. Rectal cultures before transrectal ultrasound-guided prostate biospy reduce post-prostatic biospy infection rates. Urology 2012; 79: 556–63 30

3 Ozden E, Bostanci Y, Yakupoglu K et al. Incidence of acute prostatitis caused by extended-spectrum B-lactamaseproducing Escherichia coli after transrectal prostate biospy. Urology 2009; 74: 119–23 Poster 14: Repeat prostate biopsy after a finding of ASAP or high grade PIN – the experience of a tertiary referral centre for prostate cancer James C Forde, Ronan M Waldron, Garrett C Durkan Department of Urology, University Hospital Galway

Introduction: EAU guidelines recommend that atypical small acinar proliferation (ASAP) and multifocal high grade prostatic intraepithelial neoplasia (HGPIN) warrant repeat prostate biopsy as the risk of prostate cancer (PCa) is increased. Unifocal HGPIN is not considered an indication for re-biopsy. Methods: A retrospective analysis was performed of patients with ASAP or HGPIN on initial biopsy who had a repeat biopsy between May 2009 and March 2014. We also reviewed the correlation of PSA change with progression to PCa. Results: A total of 156 patients were included (33 with ASAP and 123 with HGPIN). Overall, 30.3% of patients with ASAP on initial biopsy progressed to PCa (70% Gleason 6 and 30% Gleason 7) on repeat biopsy. In patients with HGPIN, 50.4% had unifocal, while 49.6% were multifocal HGPIN initially. In unifocal HGPIN, 32.25% of patients progressed to PCa (80% Gleason 6 and 20% Gleason 7) on repeat biopsy. In multifocal HGPIN, 34.6% progressed to PCa (42.9% Gleason 6, 47.6% Gleason 7 and 9.5% Gleason 8) on repeat biopsy. PSA values did not increase in 60% of patients with ASAP, 50% with unifocal HGPIN and 42.9% with multifocal HGPIN who progressed to PCa. The mean time between initial biopsy and PCa diagnosis was 8.7, 11.3 and 9.9 months in ASAP, unifocal HGPIN and multifocal HGPIN groups respectively. Conclusion: A significant proportion of patients with unifocal HGPIN developed PCa on re-biopsy. As per EAU guidelines these patients would usually not have a repeat biopsy. PSA monitoring was not an accurate marker of progression to PCa.

Poster 15: PSA Testing: Whom, by whom and how often? O Ahmed, D Moran, P McGinn, P Daly, D Galvin, N Hegarty, K O’Malley Mater Misericodiae Hospital

Introduction: PSA testing in Ireland has risen dramatically over the last two decades. However, due to concerns in over-diagnosis and in over-treatment of prostate cancer, screening with PSA remains controversial. Current guidelines suggest that PSA testing should only be performed in well-informed men with a life expectancy of at least ten years. Despite this, PSA testing in Ireland is unregulated and some inapropiate testing may occur. We report data relating to PSA testing of >10,000 patients from our institution. Methods: Over 12 months from January 2013, patients undergoing PSA testing were identified from the clinical biochemistry and institutional database. Demograpics, clinical indication and PSA level were recorded. Results: There were 13,147 PSA tests performed on 10,716 patients during this time period. Of these, 69% were ordered by general practicioners, 6.6% by the urology service and 3% by the oncology service. Median age was 64 years (range 10–102). 31 tests were performed on female patients. A paucity of clinical data was noted for the majority of patients. PSA range levels are presented on table 1. Table 1 Percentage of patients according to PSA level PSA level (ng/ml)

% of patients

99.9

5% 38% 22% 9% 6% 12.9% 3.9% 1.60% 0.50% 1.40%

Conclusion: The vast majority of PSA testing occurs in primary care. PSA testing often occurs without a clear clinical indication. There is a vast age range of patients undergoing and some PSA testing is inappropriately performed. Some regulation may need to be introduced to reduce the level of unneccessary PSA testing in Ireland.


Abstracts 31

James C Forde1, Ophelia Blake2, Vivian E Crowley2, Thomas H Lynch1 Department of Urology, St. James’s Hospital, Dublin1 Department of Clinical Biochemistry, St. James’s Hospital, Dublin2

Introduction: In 2010, an estimated 476,076 total PSA tests were performed in Ireland, at a cost of €3.6 million [1]. The majority were ordered by general practitioners (GPs) [2]. We aimed to replicate storage conditions in GP practices and see if prolonged storage affected the total and free PSA values. Methods: Blood samples were taken from 20 male patients in four VACUETTE Serum Separator tubes (Greiner-Bio-One, Austria). Samples were stored at room temperature (22°C) for different time intervals (4, 8, 24, 48 hours) before being centrifuged and analysed. The total PSA (TPSA) and free PSA (FPSA) values were determined using the Tosoh AIA 1800 assay (Tokyo, Japan). Results: Mean TPSA values at 4, 8, 24 and 48 hours were 7.9, 8.1, 7.8 and 8.0 ug/L respectively. Values ranged from −1.26% to +2.53% compared to the initial 4-hour interval, indicating TPSA remained consistent when stored at room temperature (Fig. 1). Mean FPSA values at 4, 8, 24 and 48 hours were 2.05, 2.04, 1.83, 1.82 ug/L respectively. At 24 and 48 hours there was 10.73% and 11.22% reduction respectively in FPSA compared to the 4-hour time interval, indicating prolonged storage resulted in a reduction free PSA values (Fig. 2). After 24 hours there was an 8.8% reduction in the Free/Total PSA %.

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Fig. 2 Free PSA timeline.

5 4 Hours Free PSA value, µg/L

Poster 16: Stability and accuracy of total and free PSA values in samples stored at room temperature

4

8 Hours

3

24 Hours 48 Hours

2 1 0 4 Hours

8 Hours

24 Hours

48 Hours

Time

Conclusions: While TPSA remained stable with prolonged storage, FPSA decreased. Our recommendation is that samples taken by GPs should be used for TPSA testing only with FPSA testing limited to hospital based clinicians where storage at room temperature is of a shorter duration. References 1 Drummond FJ, Barrett E, Burns R, O’Neill C, Sharp L. The number of tPSA tests continues to rise and variation in testing practices persists: a survey of laboratory services in Ireland 2008–2010. Ir J Med Sci 2014 Sep; 183(3): 369–75. 2 Drummond FJ, Sharp L, Comber H. Major inter-laboratory variations in PSA testing practices: results from national surveys in Ireland in 2006 and 2007. Ir J Med Sci 2008 Dec; 177(4): 317–23.

Poster 17: Outcome of radical prostatectomy in a rapid access prostate clinic cohort H Ghous, JC Forde, NB Nusrat, K Walsh, GC Durkan Department of Urology, University Hospital Galway

Introduction: We assessed the outcome of radical prostatectomy (RP) performed by a single surgeon in a cohort of men attending RAPC in the west of Ireland. Methods: Between September 2010 and March 2014, patients who chose surgery were assigned to laparoscopic radical prostatectomy (LRP) or open radical prostatectomy (ORP) depending on pre-op D’Amico risk classification performed. Data were collected prospectively. Results: In total, 271 radical prostatectomies were performed. Pre-op characteristics and post-op outcomes are given in Table 1.

Fig. 1 Total PSA timeline.

15 Total PSA value, µg/L

4 Hours 8 Hours 24 Hours 48 Hours

10

5

0 4 Hours

8 Hours

24 Hours

48 Hours

Time © 2014 The Authors BJU International © 2014 BJU International | 114, Supplement 2, 17–41

31

32 Abstracts

Table 1

Number of patients Age (years) Mean (range) Pre-op PSA (ng/mL) Mean (range) Gleason grade 6–7 8–10 Operating time (minutes) Mean (range) Transfusion rate Complications Clavien-Dindo I-II Clavien-Dindo III-V Length of stay (days) Mean (Range) Pathological stage T2 T3 Overall margin status Total positive pT2 positive pT3 positive

LRP

ORP

147

124

57.7 (38–72)

60 (46–73)

6.2 (1.5–19.9) 146 (99.3%) 1 (0.7%)

7.8 (2.5–40.9)

P value

0.0025 0.0001

94 (75.8%) 30 (24.2%)

190 (130–265) 2% 19 (12.9%) 16 (10.9%) 3 (2%)

168 (110–250) 13.7% 27 (21.8%) 25 (20.2%) 2 (1.6%)

0.0001

4 (3–18)

6 (4–17)

0.0001

107 (72.8%) 40 (27.2%)

54 (43.6%) 70 (56.4%)

15.3% 9.6% 30%

Conclusions: A significant proportion of patients diagnosed with prostate cancer are over 70 years of age with majority referred for definitive treatment in the form of radiotherapy. There is a case for the age limit of the RAPC to be raised to facilitate these patients.

Poster 19: Artificial Urinary Sphincter placement after radical prostatectomy; a national perspective MJ Burke1, GJ Nason1, E Redmond1, A Aslam1, NP Kelly1, CM Akram1, SK Giri1, HD Flood1 Department of Urology, University Hospital Limerick1

23.1% 15.7% 28.6%

Introduction: Urinary incontinence is a significant complication of radical prostatectomy (RP). No published Irish data exists on the number of, or rate of, Artificial Urinary Sphincters (AUS) placed post RP. The expected rate of surgery for urinary incontinence post RP is 2.6% at 5 years [1]. Methods: American Medical Systems Inc (AMS) are the only provider of AUS in Ireland. The total number of AUS placed post RP was obtained from AMS, for the period 2009 to 2013. The overall incidence and number of RP performed in Ireland was obtained from the the National Cancer Registry of Ireland (NCRI) for the period 2008 to 2011. Results: There were a total of 14,082 cases of newly diagnosed prostate cancer and 2218 RP performed between 2008 and 2011, an overall RP rate of 15.75%. The incidence of prostate cancer has increased year on year by an average of 6.7%, from 2008 to 2011. For the same period, the total number of RP performed has increased year on year by an average of 17.7%. Between 2009 and 2013, a total of 102 AUS were inserted in Ireland, and over the same period there was an increasing rate of AUS placement (Table 1). AUS insertion rate is diluted by the arrival of the sling procedure.

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Conclusions: Careful selection of men for LRP and ORP based on pre-operative risk criteria results in optimal surgical outcomes.

Poster 18: Prostate cancer in the over 70’s – should the referral guidelines be amended? UM Haroon1, JC Forde1, T McHale2, FJ Sullivan3, GC Durkan1 Department of Urology, University Hospital Galway1 Department of Pathology, University Hospital Galway2 Department of Radiation Oncology, University Hospital Galway3

Introduction: Rapid Access Prostate Cancer (RAPC) clinics have been introduced to improve diagnostic and treatment pathways in prostate cancer (PCa) for patients under 70 years of age. We conducted an analysis of patients over 70 years of age diagnosed with PCa in our institute. Methods: A retrospective analysis of patients undergoing a TRUS biopsy in our institution during 2011 was performed. Data relating to demographics, histology, PSA readings, radiology findings and subsequent treatment pathways were recorded. 32

Results: In total, 1,229 patients underwent a TRUS biopsy of the prostate. Overall, 44% of patients were diagnosed with PCa with 36.2% of these over 70 years of age. Mean age was 75.4 years (range 71–88). Median PSA was 11.45 ng/mL (range 2.1–1,025). Gleason grade was as follows; 36% Gleason 6, 31% Gleason 7, 23% Gleason 8, 8% Gleason 9 and 2% Gleason 10. Regarding imaging, 67% patients underwent MRI, which showed T2 disease in 69.3%, T3 in 35.7%. Nuclear bone scan was performed in 68.7%, showing metastatic disease in 14.4%. Regarding treatment; 54.6% had definitive radiotherapy (79% external beam radiation therapy (EBRT), 13.2% had combined EBRT/brachytherapy and 7.8% brachytherapy alone), 25% opted for active surveillance/watchful waiting and 20.4% hormonal treatment alone. No patient over 70 had any surgical intervention.

Table 1 National figures for; Prostate cancer incidence, RP operations and AUS inserted post RP.

Prostate Cancer Incidence Number of RP operations Number of AUS inserted post RP

2008

2009

2010

2011

2012

2013

3164 437 N/A

3470 484 13

3633 579 30

3815 718 17

N/A N/A 21

N/A N/A 21

N/A, not available. © 2014 The Authors BJU International © 2014 BJU International | 114, Supplement 2, 17–41

Abstracts 33

Conclusion: With the increasing number of RP nationally, it is evident that there will be a greater requirement for post RP incontinence surgery. Further audit regarding post RP urinary incontinence surgery is required on a national level. References 1 Nam RK, Herschorn S, Loblaw DA, Liu Y, Klotz LH, Carr LK, et al. Population based study of long-term rates of surgery for urinary incontinence after radical prostatectomy for prostate cancer. J Urol 2012; 188: 502–6. eng.

Poster 20: Phase 2 trial of quadratic arm suburethral male sling NJ Kuwaijo, H Hegarty, KJ O’Malley, NJ Hegarty, PK Hegarty Mater Private Hospital, Dublin

Introduction: Management of male genuine stress incontinence has been historically with lifestyle modification, physiotherapy and insertion of artificial urinary sphincter. Transobturator suburethral slings have been used for a number of years. A second generation, quadratic sling is made up of 2 transobturator and 2 prepubic arms. The 24 month data is described herein. Methods: A prospective database included 45 consecutive men. All underwent urodynamics, flexible cystoscopy, 24 hour pad test. Nocturnal incontinence was an exclusion criterion. They filled in the ICS male incontinence and the ICIQ-UI questionnaires pre-operatively and at months 1, 3, 6 and 12 post-operatively. All cases were followed for at least 12 months. Results: 40/45 had undergone radical prostatectomy of which 10 had salvage radiotherapy and one with cryotherapy. Mean pre-operative pad number was 3/24 hours (range 1–8), mean pad weight 290g (11–1,600 g). The procedure was well tolerated, performed in day surgery or as 23 hour stay admission. Despite the challenging cohort 76% patients were rendered dry with surgery; all the remaining were all improved. 70% of those who had radiotherapy were dry. Mean post-operative pad number was 0.3 and a weight of 6g.Symptom scores improved by 73–75%. All cases cured at 3 months remained dry at 12 months follow-up.

Conclusion: Early results of the new generation sling are encouraging, with all cases either improved or cured. It would appear that salvage radiotherapy is not an contraindication to this form of surgery. Longer term results are expected, as this technique is rolled out in an international study.

Poster 21: Erectile Function Rehabilitation after Radical Prostatectomy: Practice Patterns among Irish Society of Urology members JF Sullivan1, CM Dowling1, FJ MacNamara2, JP Mulhall1, MF O’Brien2 Department of Urology, Memorial SloanKettering Cancer Center, New York, USA1 Department of Urology, Cork University Hospital, Cork2

Introduction: Despite extensive research pertaining to erectile dysfunction following radical prostatectomy (RP) there are no consensus guidelines on the best penile rehabilitation strategy [1]. Recent US and European surveys have confirmed variability in management approaches [2,3]. Our aim was to determine post RP penile rehabilitation (PR) practice patterns amongst Irish Society of Urology members. Methods: A previously published 35-question instrument assessing surgeon demographics, training and rehabilitation practices post RP was anonymously emailed to all ISU consultant members. Results: Of the 26 urologists who responded, 80% practice in the Republic of Ireland, the remainder in the UK. Years in practice ranged from 2 to 35 (mean 13). Sixty percent of respondents had undertaken speciality training in urologic oncology and 8% in sexual medicine. A large proportion (67%) declared

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