In advanced disease, prostate cancer is well known to invade locally as well as metastasise to distant locations. Metastases occur commonly in lymph nodes and bone but have also been known to involve certain visceral organs, particularly the lungs. Involvement of soft tissue by metastases is far less common, particularly in the context of cancer recurrence. We present the case of a male aged 68 years who presented with a rising prostate-specific antigen (PSA) 10 years after radical prostatectomy (RP). The PSA increased despite salvage radiotherapy and was ultimately found to be caused by a PSA secreting prostate cancer soft tissue mass in the suprapubic region. Surgical resection of the mass caused a sharp decline in the PSA to negligible levels. This case highlights the need for ongoing surveillance post-RP and the potential for prostate cancer recurrence in the soft tissue that is refractory to routine salvage radiotherapy.

PurposeTo identify the ability of multiple variables to predict prostate cancer specific mortality (PCSM) in a whole of population series of all radical prostatectomies (RP) performed in Victoria, Australia.Materials & MethodsA total of 2154 open RPs were performed in Victoria between July 1995 and December 2000. Subjects without follow up data, Gleason grade, pathological stage were excluded as were those who had pT4 disease or received neoadjuvant treatment. 1967 cases (91.3% of total) met the inclusion criteria for this study. Tumour characteristics were collated via a central registry. We used competing hazards regression models to investigate associations.ResultsAt median follow up of 10.3 years pT stage of RP (P < 0.001) and high Gleason score of the RP specimen (P < 0.001 for ≥8 [Subhazard ratio (SHR) 11.19] and 4 + 3 = 7 [SHR 7.10]) compared with Gleason score 6 disease were strong predictors of progression to PCSM. Gleason score 3 + 4 = 7 was not at this time a significant predictor of PCSM (P = 0.08, SHR 1.84). Predictors of PCSM, independent of stage and grade, included rural residency (P = 0.003), primary surgeon contributing less than 40 cases (low‐volume) to the VRPR (P = 0.025) and the involvement of a trainee surgeon in the operation (P = 0.031).ConclusionThe significant prediction of PCSM by pT cancer stage, Gleason score and primary Gleason pattern at RP in this whole of population study suggests a need to avoid understaging/grading in the process of cancer diagnosis and active surveillance protocols. Multi‐modality therapy is likely to have a greater impact on PCSM in higher stage and Gleason grade disease. Identification of increased PCSM with rural residency and with involvement of a trainee urologist, and reduction in PCSM with higher surgeon volume all suggest potential for improved PC outcomes to be achieved with changes to surgical training and service delivery.

There is evolving evidence for the so-called cancer stem cell (CSC) hypothesis, which holds that intra-tumoral heterogeneity in urologic malignancies is hierarchical and that not all cells have the ability to proliferate indefinitely and to generate metastases. This has far-reaching implications for research and the clinical management of urologic malignancies. In this review, we outline the tenets and implications of the CSC hypothesis, summarize existing evidence for CSCs in urologic malignancies, suggest research directions that may better dissect intra-tumoral heterogeneity in urologic cancers, and outline novel therapeutic modalities implied by the CSC hypothesis.

Awareness during anesthesia has been the subject of much research and commentary in recent years. In this article, we review the recent publications in the area of anesthesia awareness and attempt to answer the question: Is awareness a problem without solutions? The incidence of awareness has been reported in benchmark studies to be about 0.1%, but two recent studies in Spain and China have reported incidences of awareness of 1% and 0.4%, respectively. Recent studies have confirmed that awareness is more common in women undergoing cesarean sections (0.26%) and in children (0.5-1%). There are very few trials that provide strong evidence for awareness prevention strategies. The best current evidence from one randomized trial suggests that bispectral index monitoring identifies the presence and reduces the incidence of awareness in high-risk patients. More trials are needed and two large ongoing trials are exploring the value of monitoring end-tidal gas concentrations and maintaining adequate age-adjusted values during surgery as an alternative method to prevent awareness.

Objective: Radical prostatectomy (RP) as a first line treatment of prostate cancer was rare prior to the advent of prostate specific antigen (PSA) testing, yet little is known of its use and outcomes in a population setting. We described baseline characteristics of cases in the Victorian Radical Prostatectomy Register (VRPR), investigated possible associations between demographic characteristics and characteristics at diagnosis and at surgery and trends over time.

A 63-year-old man with a family history of prostate carcinoma underwent a transrectal ultrasoundguided biopsy of the prostate for investigation of a slowly raising prostate-specific antigen 5.0 ng/ml. The patient had recently returned from a 4-week holiday in India, where he experienced an episode of self-limiting diarrhoea. Before biopsy he was given prophylactic norfloxacin 400 mg orally twice daily, started 1 day before biopsy and continued for 1 day post biopsy with 240 mg intravenous (IV) gentamicin given during the procedure. Three days post procedure he was admitted to hospital with fevers and rigors. Gentamicin and ceftriaxone were commenced but he remained febrile. Forty-eight hours later urine culture grew a multi-resistant gram-negative rod, and the patient was started on IV imipenem. Final sensitivities reported Escherichia coli with resistance to amoxicillin, amoxicillin and clavulanic acid, norfloxacin, ciprofloxacin, gentamicin and ceftriaxone, and with sensitivity to meropenem and nitrofurantoin. The fever settled and the patient was discharged on oral nitrofurantoin for a further 2 weeks, making a complete recovery.

Introduction: Transrectal ultrasound (TRUS) guided biopsy of the prostate is the standard procedure for diagnosing prostate carcinoma. Complications range from discomfort and bleeding to asymptomatic bacteruria and sepsis. Rarely, sepsis is fatal. E. coli is the most common pathogen causing infection and although no international standard for the use of prophylactic antibiotics exists their use has decreased the incidence of infection to around 2%. Worldwide the incidence of multi‐resistant E. coli (MREC) is increasing, and we report two cases of septicaemia secondary to MREC infection postprostate biopsy.Methods: We performed a review of case records involving postprostate biopsy MREC infection. A comprehensive literature review of TRUS guided biopsy of the prostate was also performed.Results: All patients in our series had MREC cultured following TRUS guided biopsy of the prostate. All received the same prophylactic antibiotic regime (norfloxacin and gentamicin). They required admission to hospital for intravenous antibiotics and in two cases inotropic support, eventually making full recoveries. All had a history of recent travel to a developing country whilst two had self‐limiting diarrhoea and this is the first report in the English literature of MREC following prostate biopsy. Other risk factors for acquiring multi‐resistant urinary tract infections have been identified including age and previous quinolone therapy.Conclusion: Antibiotic prophylaxis for biopsy of the prostate, being predominantly quinolones, will continue to aid in reducing morbidity. However, with the prevalence of MREC increasing current regimens will not cover such organisms potentially leading to sepsis. In our cases travel to developing countries appeared to be a risk factor for being colonised with MREC. We believe through careful history risk factors for multi‐resistant urinary tract infection including travel may alert doctors to the potential risk of MREC at the time of biopsy leading to the addition of a broader spectrum antibiotic such as intravenous meropenem.