To assess the feasibility of local anaesthetic transperineal (LATP) technique using a single-freehand transperineal (TP) access device, and report initial prostate cancer (PCa) detection, infection rates, and tolerability. Patients and methodsObservational study of a multicentre prospective cohort, including all consecutive cases. LATP was performed in three settings: (i) first biopsy in suspected PCa, (ii) confirmatory biopsies for active surveillance, and (iii) repeat biopsy in suspected PCa. All patients received pre-procedure antibiotics according to local hospital guidelines. Local anaesthesia was achieved by perineal skin infiltration and periprostatic nerve block without sedation. Ginsburg protocol principles were followed for systematic biopsies including cognitive magnetic resonance imaging-targeted biopsies when needed using the PrecisionPoint TM TP access device. Procedure-related complications and oncological outcomes were prospectively and consecutively collected. A validated questionnaire was used in a subset of centres to collect data on patient-reported outcome measures (PROMs). ResultsSome 1218 patients underwent LATP biopsies at 10 centres: 55%, 24%, and 21% for each of the three settings, respectively. Any grade PCa was diagnosed in 816 patients (67%), of which 634 (52% of total) had clinically significant disease. Two cases of sepsis were documented (0.16%) and urinary retention was observed in 19 patients (1.6%). PROMs were distributed to 419 patients, with a 56% response rate (n = 234). In these men, pain during the biopsy was described as either 'not at all' or 'a little' painful by 64% of patients. Haematuria was the most common reported symptom (77%). When exploring attitude to re-biopsy, 48% said it would be 'not a problem' and in contrast 8.1% would consider it a 'major problem'. Most of the patients (81%) described the biopsy as a 'minor or moderate procedure tolerable under local anaesthesia', while 5.6% perceived it as a 'major procedure that requires general anaesthesia'. ConclusionOur data suggest that LATP biopsy using a TP access system mounted to the ultrasound probe achieves excellent PCa detection, with a very low sepsis rate, and is safe and well tolerated. We believe a randomised controlled trial comparing LATP with transrectal ultrasound-guided biopsy (TRUS) to investigate the relative trade-offs between each biopsy technique would be helpful.

OBJECTIVE To prospectively determine the effect of prostate volume on lower urinary tract symptoms (LUTS) in terms of changes in the International Prostate Symptom Score (IPSS), and to determine whether prostate volume affects the retention rate after brachytherapy, as there is concern that patients with larger prostates might develop more troublesome LUTS after brachytherapy. PATIENTS AND METHODS We prospectively identified 100 consecutive patients who had brachytherapy for prostate cancer, using a real‐time three‐dimensional seed implantation technique, at one institution. At each follow‐up review the IPSS was recorded. To determine the effect of prostate volume on the IPSS after treatment the patients were divided into two groups according to prostate volume at brachytherapy (<50 and ≥50 mL). RESULTS The median patient age was 62 years, the overall median prostate volume was 42 mL and the median intraoperative D90 was 190 Gy. The pretreatment IPSS was 4 and 8 for the <50 and ≥50 mL groups, respectively, and at 3 months after brachytherapy the median IPSS increased to 18 and 20 for the two groups, respectively. Eleven patients went into acute retention of urine after brachytherapy (six in the ≥50 mL group). CONCLUSIONS This study shows that patients with prostates of ≥50 mL have an IPSS comparable with those who have prostates of <50 mL. Large prostates should not be considered an exclusion criterion when an intraoperative planning technique is used for brachytherapy.

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This case reports highlights a rare metastatic manifestation of transitional cell carcinoma of the bladder. The onset of symptoms associated with meningeal irritation should be investigated. However, there is little consensus in the treatment of leptomeningeal carcinomatosis and it should be considered a poor prognostic sign with symptomatic management. Case reportA 51-year-old woman with a history of G3 pT4 transitional carcinoma of the bladder previously treated with chemoradiotherapy, was admitted to hospital after feeling generally unwell for three days. Her recent history included deteriorating renal function associated with bilateral hydronephrosis managed with indwelling bilateral ureteric stents. No evidence of local tumour recurrence within the bladder was found at cystoscopy.Initial investigations showed an acute kidney injury with a creatinine of 822 µmol/L from a baseline of 190-200 µmol/L. She had bilateral loin tenderness. She was catheterized and placed on strict fluid balance. An urgent ultrasound scan showed bilateral hydronephrosis. She was scheduled for an urgent cystoscopy and stent change.On induction of anesthesia, the patient suffered a grand mal seizure that self-terminated after less than five minutes. The procedure went ahead and both stents were successfully replaced. Postoperatively, the patient was taken to intensive care for hemofiltration and ventilation. An immediate postoperative computed tomography (CT) scan of the head was reported as normal. Her postoperative urine output was adequate, but she was slow to wean.She was stepped down to the ward on Day 7 post-admission and she started complaining of photophobia and neck stiffness. However, there were no other focal neurological signs and a medical review felt that meningitis was unlikely.Day 10 post-admission, the patient experienced left arm weakness that resolved on its own within an hour.In view of the clinical picture, a neurology opinion was sought. Magnetic resonance imaging (MRI) scan of the brain and a lumbar puncture was recommended. The MRI report suggested that appearances are highly suspicious of a meningeal pathology, either infection or metastatic disease. MRI with contrast was organized the next day to help differentiate between the two (Fig.1). The report concluded that the images are consistent with leptomeningeal carcinomatosis with mild hydrocephalus (Fig. 2).The results of the cerebral spinal fluid analysis were inconclusive; no malignant cells were found on cytology and there was no evidence of infection or xanthochromia.The patient was started on dexamethasone 8 mg. After discussion among the local multidisciplinary team, she was referred to the palliative care team for further care. She was discharged to the local hospice and died eight days later of metastatic cancer. DiscussionBladder cancer is the ninth most common cancer diagnosis worldwide, with more than 330 000 new cases each year and more than 130 000 deaths per year.1 The most common sites for metastatic spread are lymphatics and lungs. The...