Cryosurgical Ablation Research Articles

Intraoperative margin assessment with near real time pathology during partial gland ablation of prostate cancer: A feasibility study

BackgroundIn-field or in-margin recurrence after partial gland cryosurgical ablation (PGCA) of prostate cancer (PCa) remains a limitation of the paradigm. Stimulated Raman histology (SRH) is a novel microscopic technique allowing real time, label-free, high-resolution microscopic images of unprocessed, un-sectioned tissue which can be interpreted by humans or artificial intelligence (AI). We evaluated surgical team and AI interpretation of SRH for real-time pathologic feedback in the planning and treatment of PCa with PGCA. MethodsAbout 12 participants underwent prostate mapping biopsies during PGCA of their PCa between January and June 2022. Prostate biopsies were immediately scanned in a SRH microscope at 20 microns depth using 2 Raman shifts to create SRH images which were interpreted by the surgical team intraoperatively to guide PGCA, and retrospectively assessed by AI. The cores were then processed, hematoxylin and eosin stained as per normal pathologic protocols and used for ground truth pathologic assessment. ResultsSurgical team interpretation of SRH intraoperatively revealed 98.1% accuracy, 100% sensitivity, 97.3% specificity for identification of PCa, while AI showed a 97.9% accuracy, 100% sensitivity and 97.5% specificity for identification of clinically significant PCa. 3 participants’ PGCA treatments were modified after SRH visualized PCa adjacent to an expected MRI predicted tumor margin or at an untreated cryosurgical margin. ConclusionSRH allows for accurate rapid identification of PCa in PB by a surgical team interpretation or AI. PCa tumor mapping and margin assessment during PGCA appears to be feasible and accurate. Further studies evaluating impact on clinical outcomes are warranted.

Adverse Events Associated With ClariFix Posterior Nasal Nerve Cryoablation: A MAUDE Database Analysis.

Posterior nasal nerve (PNN) cryoablation is a novel surgical technique used to address chronic rhinitis. The purpose of this study is to review the medical device reports (MDRs) submitted to the Food and Drug Administration's (FDA) Manufacturer and User Device Facility Experience (MAUDE) database to identify adverse events related to the use of ClariFix, a device designed for office-based cryosurgical ablation of the PNN. A total of 12 adverse events associated with ClariFix from January 2017 to August 2020 were identified and analyzed. The most common adverse events associated with ClariFix PNN cryoablation include epistaxis and nasal swelling. Further studies are needed to clarify whether PNN cryoablation is associated with epistaxis in certain populations.

Evaluation of In-Office Cryoablation of Posterior Nasal Nerves for the Treatment of Rhinitis.

BackgroundChronic rhinitis is a common condition generally treated with medical therapies. However, 10–22% of patients are refractory to medical therapies. A cryotherapy handheld device targeting the postganglionic nerve fibers of the posterior nasal nerve (PNN) now serves as an additional option for therapy. This study evaluates the efficacy of the cryosurgical ablation device of the PNN in the clinic setting.MethodsThis was a prospective single-arm trial of 24 adult patients at seven locations within a large health maintenance organization. Patients with chronic rhinitis that failed medical therapy were offered an in-office cryoablation of PNN. Patients completed the Total Nasal Symptom Score (TNSS) questionnaire consisting of 5 items reported based on the previous 12 hours and 2 weeks at the following time points: pre-treatment, 30 days, 90 days and 1 year post-treatment.ResultsFollowing cryoablation of the PNN, the TNSS 12-hour symptom score improved from 6.92 (±2.9) to 3.17 (±2.4, P < 0.001) at 30 days, 2.92 (±1.4, P < 0.001) at 90 days and 3.08 (±2.6, P < 0.001) at 1 year post treatment. Similar results were noted for the 2 weeks scores improving from 7.75 (±3.1) to 3.79 (±2.1, P < 0.001) at 30 days, 3.88 (±1.9, P < 0.001) at 90 days and 3.76 (±2.1, P < 0.001) at 1 year post-treatment. 64.7% of respondents stated the procedure decreased or eliminated nasal sprays.ConclusionsOur independent evaluation of cryoablation of the PNN shows improvement in nasal symptoms over a 1 year period and is consistent with other published data.

Cryosurgical ablation for treatment of common warts on the nasal vestibule.

Common warts rarely occur on the nasal vestibule. It should be treated more carefully than other skin lesions because scar contracture results in the narrowing of the external naris, causing nasal obstruction and reducing the patient's quality of life. In this report, we introduce our method for common warts on the nasal vestibule using handheld cryoablation devise. We performed a series of four cryosurgical ablation procedures to treat common warts on the nasal vestibule. All the procedures employed a reusable handheld cryoablation device (CRY-AC®, Brymill Cryogenic Systems, Ellington, CT). All patients were successfully treated for four to six sessions without any adverse event. Cryotherapy for common warts on nasal vestibular is easily performed in an office setting under no anesthesia without bleeding. We believe this easy and safe procedure is suitable as the first line therapy for common wart on nasal vestibular.

Minor surgery in general practice in Ireland- a report of workload and safety

BackgroundThe provision of minor surgical services is an established part of the task profile of general practitioners (GPs) in many countries in Europe and elsewhere. This study aimed to collect data on the clinical process and outcomes for specified minor surgical procedures undertaken in Irish general practice by GPs experienced in minor surgery in order to document the scope and safety of minor surgery being undertaken.MethodsOver a six-month period, 24 GPs in 20 practices recorded data on a pre-determined list of procedures undertaken in adults (aged 18 and older); procedures for ingrown toenails were also recorded for those aged 12–18 years. Clinical data were rendered fully anonymous by the participating GPs, entered onto the Excel database template and returned to the project team monthly.ResultsOn average, each practice undertook 212 procedures in a six-month period. The four most frequent procedures include two relatively non-invasive procedures (cryosurgical ablation of skin lesions and aspiration and/or injection of joints) and two more invasive procedures (full thickness excision of skin lesion and shave, punch or incisional biopsy). Overall, 83.8% of relevant specimens were submitted for histology. Combining benign and malignant cases, there was an overall 87% clinical and histological concordance; 85% of malignancies were suspected clinically. A complication was recorded in 0.9% after 1 month.ConclusionsIrish GPs with experience in minor surgery can provide a range of surgical services in the community safely.

Cryosurgical Ablation Of Bladder Cancer: Development Of A Novel Cryosurgical Platform

Cryosurgical Ablation Of Bladder Cancer: Development Of A Novel Cryosurgical Platform

Comprehensive Evaluation of Focal Therapy Complications in Prostate Cancer: A Standardized Methodology.

Purpose: Today, up to one-third of newly diagnosed prostate cancer (PCa) cases may be suitable for focal treatment. The lack of data about the toxicity profiles of lesion-targeting therapies, however, has made it difficult to compare treatment modalities. The aim of the present study was to evaluate comprehensively the incidence, severity, and timing of onset of complications for PCa patients undergoing focal high-intensity focused ultrasound (HIFU) and focal cryosurgical ablation of the prostate (CSAP). Materials and Methods: A total of 336 patients were included who underwent focal HIFU or focal CSAP as a primary treatment for PCa between January 2009 and December 2017. Mean follow-up was 11 months (standard deviation: 3.0). All complications were captured and graded according to severity, and classified by timing of onset. Univariate and multivariate analysis was performed to identify predictors of the most common side effects. Results: There were 98 complications in 79/210 patients (38%) undergoing focal HIFU and 34 complications in 27/126 patients (21%) undergoing focal CSAP. In terms of severity, 95% of the complications of focal HIFU and 91% of the complications of focal CSAP were minor. Most complications presented in the early postoperative period. On multivariate analysis, subtotal HIFU was associated with acute urinary retention (AUR), while a smaller prostate size and longer catheterization time with dysuria. In CSAP patients, longer catheterization time was associated with AUR and urethral sloughing. The main limitation is the nonrandomized and retrospective nature. Conclusions: Focal HIFU and focal CSAP provide a tolerable toxicity, with primarily minor complications presenting in the early postoperative period.

Combined carbon dioxide laser and cryosurgical ablation of rostral nasal septum squamous cell carcinoma in 10 dogs.

Squamous cell carcinoma (SCC) is the most commonly reported neoplasm of the nasal planum and treatment is focused on localized disease. Rostral maxillectomy and/or nasal planectomy are considered standard of care for excision of nasal planum SCC; however, the cosmetic outcome of these procedures can be deemed unacceptable by many pet owners. The study aim was to evaluate the efficacy of combination carbon dioxide (CO2 ) laser surgery and cryosurgery as a palliative treatment modality in dogs with nasal SCCs. Ten client-owned dogs with nasal SCC were included: seven neutered males, two spayed females and one intact male, with a median age of 12.5years (range 9-15years). Tumour CO2 laser ablation was followed by cryosurgical ablation of the visible tumour, adjacent and subjacent tissue. Three rapid freeze-slow thaw cycles were performed. Eight of 10 dogs were Labrador retrievers. The ages ranged from 9 to 14years. Overall median survival time was 260days with two dogs still alive at the time of writing. Combined CO2 laser and cryosurgical ablation was practical, cost-effective and provided an excellent aesthetic outcome in dogs with SCCs restricted to the nasal septum, while providing acceptable palliation of local disease.

Cryosurgical ablation in the gastrointestinal tract: Development of a novel cryosurgical platform

Cryosurgical ablation in the gastrointestinal tract: Development of a novel cryosurgical platform

New Developments in Interventional Oncology: Liver Metastases From Colorectal Cancer.

Colorectal cancer is the third leading cause of cancer death in the United States. Although hepatic excision is the first-line treatment for colorectal liver metastasis (CRLM), few patients are candidates. Locoregional therapy (LRT) encompasses minimally invasive techniques practiced by interventional radiology. These include ablative treatments (radiofrequency ablation, microwave ablation, and cryosurgical ablation) and transcatheter intra-arterial therapy (hepatic arterial infusion chemotherapy, transarterial "bland" embolization, transarterial chemoembolization, and radioembolization with yttrium 90). The National Comprehensive Cancer Network recommends LRT for unresectable CRLM refractory to chemotherapy. The following is a review of LRT in CRLM, including salient features, advantages, limitations, current roles, and future considerations.

The feasibility and safety of repeat cryosurgical ablation of localized prostate cancer

BackgroundThe aim of the study was to assess the morbidity and efficacy of repeat cryoablation (CA) in the treatment of localized prostate cancer.MethodsTwenty-seven patients with median age of 71 years (range 48–80) who underwent repeat CA between April 2003 and April 2011 at a single institution were included. The median initial prostate-specific antigens (PSA) and Gleason values were 6.2 ng/ml (range 4–23.6) and 7 (range 6–9), respectively. Twenty-four patients underwent two CA treatments, and three patients underwent three CA treatments. Pre- and perioperative parameters and oncological and functional outcomes were evaluated.ResultsNo intraoperative complications occurred. After the first CA, PSA was undetectable in 10 patients, and the median nadir PSA value was 0.65 ng/ml (range 0.1–4.9). After the second CA, 4 patients had undetectable PSA, and the median nadir PSA value was 1.25 ng/ml (range 0.2–7.9). For patients who underwent a third CA treatment, no patients had undetectable PSA, and the subsequent median nadir PSA value was 1.6 ng/ml (range 0.4–4.5). Two patients had incontinence (1 pad per day) following repeat CA. One patient had urinary retention after the third CA treatment, and one had urethral stricture. The mean hospitalization and follow-up periods were 1 day (range 0–2) and 51.5 months (range 11–96), respectively.ConclusionsRepeat CA successfully reduced PSA levels, and complications were modest. We conclude that repeat CA is a feasible, safe, and effective treatment option for localized prostate cancer.

Малоинвазивные методы в лечении больных раком предстательной железы

The incidence of prostate cancer has increased in recent decades. Radical prostatectomy and radiotherapy are the standard methods of radical treatment of patients with prostate cancer. The complications and reduced quality of life of patients often develop after radical treatment. These facts were the basis for the search and implementation of new minimally invasive treatments. Effective treatment of patients and reduce the number of complications there are goals of minimally invasive treatments. Information about modern methods of minimally invasive treatment of patients with prostate cancer, such as cryosurgical ablation, high-intensity focused ultrasound therapy is presented in this article. Furthermore, mechanisms of action, the process of treatment, oncological efficacy and possible complications are described. The article includes information on the experimental methods, such as interstitial thermotherapy and photodynamic therapy. International studies of use of these methods are given. In addition, the method electrochemical lysis is shown in this article, the results of clinical practice in patients with prostate cancer. Key words Prostate cancer, minimally invasive treatments, electrochemical lysis

Focal Treatment Alternatives in Prostate Cancer

Yard. Doc. Dr. Mert Ali Karadag, Kafk as Universitesi Tip Fakultesi, Uroloji Anabilim Dali, Kars, Turkiye, Tel. 532 558 43 24 Email. karadagmert@yahoo.com Gelis Tarihi: 13.03.2014 • Kabul Tarihi: 03.02.2015 ABSTRACT The destiny of prostate cancer patients has been dramatically changed since the introduction of prostate specifi c antigen (PSA) into clinical use in late 1980s. Currently more men are diagnosed with localized, small, less aggressive and non-lethal prostatic carcinoma. Besides radical prostatectomy, cryosurgical ablation of the prostate, brachytherapy and high-intensity focused ultrasound have been accepted as alternative treatment options in clinically localized prostatic carcinoma. In this review, we aimed to evaluate the success and complication rates of alternative focal treatment options as the primary outcome. The secondary outcome of this review was to defi ne the candidate patients eligible for these procedures. We searched the Medline using specifi ed expressions including “focal treatment alternatives of prostatic carcinoma”, “high-intensity focused ultrasound and cryosurgery of prostatic carcinoma” and “radiofrequency ablation of prostatic carcinoma”. A total of 1173 papers related to the focal treatment options were analyzed and only 45 of them related to the subject were included. There wasn’t a controlled trial dealing with the topic. American Urologic Association guidelines have accepted cryosurgical ablation of the prostate as a therapeutic option; however the high-intensity focused ultrasound is still considered as an experimental treatment option, although it has been developed as a minimally invasive procedure with reduced morbidity and potentially with the same therapeutic effi cacy in comparison with the surgical or non surgical options. For patients meeting the variable criteria for regular follow up visits without intervention but experiencing anxiety with the feeling of losing active treatment options, focal therapies may be ideal alternatives. However, focal therapy options should be spared for patients with low to moderate risks. The radiologic and clinical stages should be below T2b and T2a, respectively. In addition, all candidates should be informed that the alternatives are considered as experimental and they may need an alternative treatment option in time. Focal therapy alternatives may be more realistic treatment options in the near future; however, well designed multicenter prospective randomized trials are required to provide evidence based data.

A17 Session 5: General Urology : Role of focal therapy prostate cancer

New forms of thermal ablation have emerged over the past few decades to eradicate solid organ cancers. Much of this is due to the propagation of companies and technologies aimed at providing minimally invasive procedures that can be performed in an out-patient setting. In addition, we have learned more about the biology of some of these cancers, and research has demonstrated that the low metastatic rate for many of these indolent tumors make them amenable to ablation. At the end of the last century the introduction of third generation, gas-driven cryotherapy based on the Joule–Thompson effect has completely revolutionized the technique of cryosurgical ablation of the prostate. Recent improvements have allowed a simpler and quicker freeze–thaw process inside the prostate gland that has significantly shortened the operative time. Secondly, the use of ultra thin 17-gauge needles has become a truly minimally invasive procedure with direct transperineal skin penetration and precise insertion of the cryoprobes into the prostate through a conventional brachytherapy-type grid template. Despite these advances, whole-gland prostate cancer treatments can damage intimate anatomical structures (bladder, erectile nerves, rhabdosphincter and rectum) that contribute to a high quality of life. While the incidence of such damage has decreased as techniques to deliver both radiation and surgical extirpation have improved, morbidity remain significant in both frequency and personal impact. The role of organ-preserving therapy—most commonly termed “focal therapy”—has been suggested as a way to eliminate small-volume prostate cancer. The hypothetical premise of focal therapy is that while clinically insignificant smaller tumors may coexist elsewhere in the prostate gland, a dominant tumor drives the biology of the disease; thus, destroying the dominant tumor may alter the natural history of the disease for the individual patient. If focal therapy can destroy the dominant tumor in a way that limits collateral damage to urinary, bowel, and erectile functions associated with other prostate cancer therapies, this form of management may be desirable for well-selected patients who may be willing to accept potential oncological concessions in order to limit these risks. The concept of focal therapy for prostate cancer follows the same treatment paradigm used for almost all other solid tumors, where careful study has revealed that functional outcomes are improved by minimizing the excised or destroyed tissue with no resulting loss of oncologic efficacy. The use of focal therapy to treat kidney and bladder malignancies is well established in the literature. The focus of this lecture will discuss the clinical outcomes of focal therapy in the management of prostate cancer and selecting the proper patients for the procedure. In addition, post-operative management of these patients will be discussed, including functional as well as oncological outcomes.

Commentary on: “Focal cryosurgical ablation of the prostate: A single institute’s perspective”

The morbidity of whole gland treatment for prostate cancer is significant. Given the low risk of prostate cancer specific mortality for most men diagnosed with prostate cancer, alternative therapies such as sub-total or hemi-ablation of the prostate and focal ablation of prostate tumors are being investigated. The developing role of imaging for prostate tumors will dramatically change and likely improve the treatment morbidity for low risk prostate tumors. Commentary on: http://www.biomedcentral.com/1471-2490/13/2.

Cryosurgery for colorectal liver metastases.

Cryosurgical ablation is mainly reserved for treatment of unresectable lesions for patients with colorectal liver metastases, including multiple tumors in the liver, tumors located at anatomical position that does not permit liver resection, patients with high risk for resection and patients who refuse liver resection. The techniques of cryosurgery include open cryosurgery, laparoscopic cryosurgery, and percutaneous cryoablation. Long-term follow-up study showed that cryosurgery is a safe and important option for a wide range of unresectable colorectal hepatic metastases and provides the potential for long-term survival.

Clinical outcome, proteome kinetics and angiogenic factors in serum after thermoablation of colorectal liver metastases

BackgroundThermoablation is used to treat patients with unresectable colorectal liver metastases (CRLM). We analyze clinical outcome, proteome kinetics and angiogenic markers in patients treated by cryosurgical ablation (CSA) or radiofrequency ablation (RFA).Methods205 patients underwent CSA (n = 20), RFA (n = 22), partial hepatectomy (PH, n = 134) or were found truly unresectable (n = 29). Clinical outcome, proteome transitions and angiogenic response in serum were analyzed at various time points after ablation.ResultMedian overall survival in CSA patients (17.6 months) was worse (p < 0.0001) when compared to RFA treated patients (51.7 months) and patients after PH (43.4 months). The complication rate was higher in the CSA group (50%) as compared to the RFA group (22%). Proteomics analyses showed consistently more changes in serum protein abundance with CSA compared to RFA. In the first four days after ablation a pro-angiogenic serum response occurred.ConclusionsRFA of CRLM is superior to CSA with a median survival which equals survival in patients after PH. Proteomics analyses suggests a more aggravated serum response to CSA compared to RFA. Thermoablation is associated with changes in serum levels of angiogenic factors favouring a pro-angiogenic environment, but without differences between RFA and CSA.

5. Whole gland cryosurgical ablation of prostate cancer

Introduction and background: Prostate cancer may be a lethal disease causing significant suffering, usually for men of older age. Unfortunately, our understanding is limited when it comes to growth rate and the time when metastases develop. Radical treatment may be effective in properly selected patients, but side effects are significant and contemporary treatment demands big resources. In spite of overtreatment, failure rates are high and there is great need of salvage treatment. Cryosurgical ablation (CSA) is a minimally invasive treatment option which may be offered as day-surgery and is a preferred modality for focal treatment of prostate cancer. The aim of this presentation is to provide an overview of contemporary evidence for CSA as primary and salvage treatment in prostate cancer, and to discuss how the technique of CSA may be improved. Materials and methods: A Medline/Pubmed search using Scopus and Science direct for articles published in the English language was undertaken. The following search terms were used: Prostate cancer, primary treatment, salvage radiation treatment or therapy, salvage brachytherapy, salvage prostatectomy, salvage cryoablation or cryotherapy, salvage HIFU (high intensity focused ultrasound), and permutations of these procedures. Papers were selected for scrutiny based on their pertinence, the study size and overall contribution to the field. Results: Salvage CSA. Primary treatment fails in up to 40% of patients after radical prostatectomy (RP) and up to 67% after external beam radiation (EBRT). 10 year data after salvage CSA show biochemical disease free survival between 40–60%, incontinence rates 3–13%, rectal fistula rate of 1–2% and need of TURP in 3%. Published results depend heavily on patient selection. Unfortunately, most patients with radiation failure are not offered salvage treatment but are given ADT which might increase the risk of cardiovascular events. Primary CSA. 10 year results of primary CSA are similar to EBRT and RP in terms of evidence for progression. A positive biopsy rate of 7.7% at 36 months was found in a RCT of CSA versus EBRT, and a 10 year negative biopsy rate of 77% was found in a prospective case series. The incontinence rate is 0.9% but erectile dysfunction is still high with 64% reported in a recent series. The need for TURP after CSA is about 1% and the risk of rectal fistula is almost negligible. Discussion: CSA may kill prostate cancer in primary and salvage settings. The procedure is technically demanding as there is a delicate balance between freezing hard enough for cell death and not causing damage to surrounding structures. The challenge is to achieve killing conditions in all regions of the prostate. A cryosensitizer which gives killing potential to ice near the freezing point should be aimed at. Vitamin D-3 is an interesting alternative for further studies. The importance of slow thawing also needs further exploration as there seems to be differences in practice between US and European colleagues.

Salvage treatment in prostate cancer: a clinical approach

Radiotherapy is the main salvage option after primary radical prostatectomy. Radical prostatectomy, cryosurgical ablation and high-intensity focused ultrasound are the main salvage options after primary radiotherapy. After primary radiotherapy, long-term oncological outcome of salvage radical prostatectomy and salvage cryosurgical ablation is fairly comparable with the results of primary radical prostatectomy and primary cryosurgical ablation. Side effects of salvage radical prostatectomy in elite centers are acceptable and side effects of salvage cryosurgical ablation in tertiary centers are almost the same as after primary cryosurgical ablation. Good long-term data after salvage high-intensity focused ultrasound are lacking and the risk of side effects is considerable. After primary radical prostatectomy, there is a high level of evidence for oncological benefit of salvage radiotherapy. Careful patient selection is important for all salvage modalities.

An unsung Canadian hero!

This issue is chock-a-bloc with interesting articles, and has something for everyone. We have 2 new CUA guidelines. The guideline on the medical management of patients with urolithiasis, first authored by Ryan Paterson, is an excellent overview of a complex subject. I have often wondered how aggressively to investigate stone formers, and this guideline provides clear direction. There are also very useful suggestions for dietary advice. Required reading for all of us who manage patients with urolilthiasis. The second guideline, by Fred Saad and Sebastian Hotte on the management of castrate resistant prostate cancer, is a lovely summary of a rapidly changing field. Many new pathway specific non-cytotoxic drugs are in the pipeline, and will have an increasing role in the management of castrate-resistant disease. It behoves urologists to be familiar with these drugs and the principles of management of these patients. We present 2 papers which are quite unusual in their subject matter. Early in my career, I observed what seemed to be a Canadian syndrome of frequent presentation of excellent studies at urology conferences, but infrequent subsequent publication of that data. Geoffrey Gotto, Andrew McNeilly and colleagues compare the publication record of CUA members during two 2-year periods in the mid 90s and mid-2000s. Thirty percent of CUA members published during the more recent period, an impressive figure. The quality of publications has also improved, with a greater proportion of RCTs and clinical trials. Canadians published more than twice the number of RCTs in 2003–4 as they did 10 years prior. We believe that the initiation of the CJU, and now the CUAJ, contributed significantly to an increase in the number of articles published by Canadian urologists – this is confirmed by this study. In 2003–4, the CJU published more articles from Canadians than any other journal except the Journal of Urology. To quote their concluding line: “CUA members should be proud of their academic productivity.” Indeed. Two articles address the management of small renal masses. Ross Mason, Ricardo Rendon and colleagues report that peripheral renal masses are 3.5 times more likely to be benign than central masses. This is very useful information, and should drive decision-making about renal biopsy and conservative management of small masses. Venu Chalasani, Joe Chin and colleagues report the results of cryosurgical ablation in 19 patients not candidates for partial nephrectomy. Four of 19 patients had a recurrence; 16% at 4 years. This is higher than in other series, and may reflect the longer follow-up in this series. Cryo clearly is effective in many patients, but the local recurrence rate appears to be higher than with surgical resection. Perhaps the most interesting article in this journal for medical history buffs is an article about a little known figure, Abraham Groves, who practiced in Fergus Ontario from 1871 to 1930, a career spanning 60 years. Dr. Groves, who had very little surgical training, performed over 20 000 operations. More importantly, in spite of working in isolation in a rural environment, he was a pioneer in many areas, including aseptic surgery, cystolithotomy and suprapubic prostatectomy. He published 36 papers. The article makes for fascinating reading about an extraordinary Canadian surgeon who used observation, logic and an innovative spirit to improve the care of his patients. An unsung Canadian hero!