Abstract: BACKGROUND: The management of carcinoma in situ (CIS) of the penis is controversial, with relatively high local recurrence rates after minimally invasive therapies.
OBJECTIVE: Report the surgical technique and outcome of partial glans resurfacing (PGR) and total glans resurfacing (TGR) as primary treatment modalities for CIS of the glans penis.
DESIGN, SETTING, AND PARTICIPANTS: Between 2001 to 2010, 25 patients with biopsy-proven CIS underwent TGR (n=10) or PGR (n=15), defined as <50% of the glans requiring resurfacing. All patients were surveyed clinically every 3 mo for 2 yr and every 6 mo thereafter.
SURGICAL PROCEDURE: Excision of the glans epithelium and subepithelium of either the entire glans or the locally affected area, with a macroscopic clear margin. The penis was then reconstructed using a split skin graft.
MEASUREMENTS: Positive surgical margin (PSM) rates and rates of recurrence and progression were collated. Complications, cosmesis, and patient satisfaction were evaluated.
RESULTS AND LIMITATIONS: Mean follow-up was 29 mo (range: 2-120 mo). There were no postoperative complications, and 24 of 25 patients (96%) had complete graft take with excellent cosmesis. Overall, 12 of 25 patients (48%) had PSMs. Only 7 of 25 (28%) required further surgery, 2 of 25 (8%) for extensive CIS at the margin and 5 of 25 (20%) for unexpected invasive disease. Additional surgery consisted of further resurfacing in 4 of 25 cases (16%) or glansectomy in 3 of 25 cases (12%). Those undergoing further surgery had no further compromise to their oncologic outcome. The overall local recurrence rate was 4%. There were no cases of progression.
CONCLUSIONS: Glans resurfacing is a safe and effective primary treatment for CIS. The procedure maintains a functional penis without compromising oncologic control, while ensuring that definitive histopathlogy is obtained. Glans resurfacing has a low risk of recurrence and progression. Patients need to be warned that approximately 28% will require further surgery for PSM or understaging of their primary disease, although the need for further surgery does not compromise oncologic control.
Abstract: OBJECTIVE To report on the high rectal fistula rate associated with salvage high-intensity focused ultrasound (HIFU) after the failure of combined brachytherapy and external beam radiotherapy (EBRT) for prostate cancer; salvage ablative therapy for prostate cancer is indicated when there is local recurrence after RT, brachytherapy or their combination. PATIENTS AND METHODS We retrospectively reviewed all men with prostate cancer treated with HIFU between 1 March 2005 and 31 May 2007, and identified five men treated after the failure of both brachytherapy and EBRT for localized prostate cancer. RESULTS Three of the five men had iodine-seed implantation brachytherapy combined with EBRT as primary treatment, one had high-dose rate brachytherapy combined with EBRT and one had salvage iodine-seed brachytherapy for failed EBRT. Three of the five patients developed a recto-urethral fistula after HIFU. CONCLUSIONS The high rate of recto-urethral fistula formation in this group might reflect an impaired blood supply or HIFU-associated near-field heating of the rectal wall. Tissue viability and healing might affect this group regardless of the salvage method. Careful patient selection and avoidance of rectal diagnostic biopsies might minimize the risk. Emerging ablative therapies regarded as less invasive than traditional therapies must be used with caution.
Abstract: Background:The use of minimally invasive ablative therapies in localised prostate cancer offer potential for a middle ground between active surveillance and radical therapy.Methods:An analysis of men with organ-confined prostate cancer treated with transrectal whole-gland HIFU (Sonablate 500) between 1 February 2005 and 15 May 2007 was carried out in two centres. Outcome data (side-effects using validated patient questionnaires, biochemical, histology) were evaluated.Results:A total of 172 men were treated under general anaesthetic as day-case procedures with 78% discharged a mean 5 h after treatment. Mean follow-up was 346 days (range 135-759 days). Urethral stricture was significantly lower in those with suprapubic catheter compared with urethral catheters (19.4 vs 40.4%, P=0.005). Antibiotics were given to 23.8% of patients for presumed urinary tract infection and the rate of epididymitis was 7.6%. Potency was maintained in 70% by 12 months, whereas mild stress urinary incontinence (no pads) was reported in 7.0% (12 out of 172) with a further 0.6% (1 out of 172) requiring pads. There was no rectal toxicity and no recto-urethral fistulae. In all, 78.3% achieved a PSA nadir </=0.5 mug ml(-1) at 12 months, with 57.8% achieving </=0.2 mug ml(-1). Then, 8 out of 13 were retreated with HIFU, one had salvage external beam radiotherapy and four chose active surveillance for small-volume low-risk disease. Overall, there was no evidence of disease (PSA <0.5 mug ml(-1) or negative biopsy if nadir not achieved) after one HIFU session in 92.4% (159 out of 172) of patients.Conclusion:HIFU is a minimally invasive, day-case ablative technique that can achieve good biochemical outcomes in the short term with minimal urinary incontinence and acceptable levels of erectile dysfunction. Long-term outcome needs further evaluation and the inception of an international registry for cases treated using HIFU will significantly aid this health technology assessment
Abstract: OBJECTIVES: To investigate the use of minimally invasive high-intensity focused ultrasound (HIFU) as a salvage therapy in men with localized prostate cancer recurrence following external beam radiotherapy (EBRT). PATIENTS AND METHODS: A review of 31 cases treated using the Sonablate 500 HIFU device, between 1 February 2005 and 15 May 2007, was carried out. All men had presumed organ-confined, histologically confirmed recurrent prostate adenocarcinoma following EBRT. RESULTS: The mean (range) age was 65 (57-80) years with a mean preoperative PSA level of 7.73 (0.20-20) ng/mL. The patients were followed for a mean (range) of 7.4 (3-24) months. Side-effects included stricture or intervention for necrotic tissue in 11 of the 31 patients (36%), urinary tract infection or dysuria syndrome in eight (26%), and urinary incontinence in two (7%). Recto-urethral fistula occurred in two men, although one was due to patient movement due to inadequate anaesthesia, so the 'true' rate is 3%. Half of the patients had PSA levels of <0.2 ng/mL at the last follow-up. Three patients had metastatic disease whilst another two had only local, histologically confirmed, failure. A further four patients had evidence of biochemical failure only. Overall, 71% had no evidence of disease following salvage HIFU. CONCLUSIONS: Salvage HIFU is a minimally invasive daycase procedure that can achieve low PSA nadirs and good cancer control in the short term, with comparable morbidity to other forms of salvage treatment. The issue of accurate staging at the time of recurrence is still problematic, as a proportion of these men will harbour microscopic metastases undetected by conventional staging investigations.
Abstract: ABSTRACT: BACKGROUND: We report a case of metachronous solitary metastasis of renal cell carcinoma to the contralateral adrenal gland treated by laparoscopic transperitoneal adrenalectomy. CASE PRESENTATION: A 58-year-old man presented to our institution for regular follow up, 2 years after a right radical nephrectomy with preservation of the ipsilateral adrenal gland, for a primary renal cell carcinoma. The patient remained asymptomatic but an abdominal computed tomography scan on follow up revealed a 6.5 x 4 cm2 mass in the left adrenal gland. A positron emission tomography scan was also performed to rule out other possible metastases, and a magnetic resonance imaging scan was used for accurate localization and determination of resectability of the adrenal tumour. A bone scan, metabolic screen, liver and renal function tests were all within normal limits. A laparoscopic transperitoneal adrenalectomy was then performed. The postoperative period was uneventful, and the patient was discharged on postoperative day two. The patient remains in satisfactory condition and no recurrence or adrenal insufficiency has been observed during 12 months follow up. CONCLUSION: Metachronous contra lateral adrenal metastases from primary renal cell carcinoma are very rare but should always be suspected in any nephrectomised patient presenting with an adrenal tumour. Regular follow up in these patients accompanied with computed tomography imaging may help the surgeon to detect early lesions. Laparoscopic transperitoneal adrenalectomy is feasible, safe and effective, with minimal trauma to the patient.
Abstract: OBJECTIVE: The aim of our study was to demonstrate our experience regarding the surgical treatment of complications after foreign body ingestion. SUBJECT AND METHODS: From 1997 to 2005, we treated 16 adult patients (mean age 44.8 years, range 21-77), who presented with complications after foreign body ingestion. RESULTS: The complications treated were perforation-peritonitis: n = 7 (44%), intra-abdominal abscess formation: n = 5 (31%), upper gastrointestinal bleeding: n = 3 (19%) and inflammatory mass formation: n = 1 (6%) patient. The diagnosis was made intra-operatively in 13 (81.3%) of the cases. The commonest anatomical position of the perforation was the large bowel, in 7 (43%) of the cases. Bony food parts were the commonest foreign bodies accidentally swallowed, in 9 (56%) patients. The median hospital stay was 7 days (2-18), while no death occurred in the postoperative period among the patients of the study. The postoperative morbidity rate was 22.2%. CONCLUSIONS: The most common complication after foreign body ingestion was the perforation of the gastrointestinal tract. The risk of perforation was higher when sharp foreign bodies were ingested. The pre-operative diagnosis was difficult, and it was usually achieved intra-operatively. (c) 2008 S. Karger AG, Basel
Abstract: Scrotal lymphedema (scrotal elephantiasis) is uncommon outside of filariasis endemic regions. We present a case of a 65-year-old with idiopathic lymphedema of the scrotum and functional impairment of the penis. The patient underwent surgical excision of the edematous subcutaneous tissues and plastic reconstruction of his penis and scrotum. Three years later, the patient showed no signs of local recurrence, had complete restoration of urinary and sexual function and was extremely satisfied with the result. Surgical management was an effective strategy in the management of scrotal lymphedema in this case.
Abstract: We report an unusual case of a patient with strangulated Meckel diverticulum in a femoral hernia. A 65-year-old woman presented with a nonradiating, constant pain in the right groin with associated nausea and anorexia. Physical examination revealed a tender, irreducible lump in the right groin area. At operation, a hernia sac containing a strangulated Meckel diverticulum was clearly recognized going through the femoral ring. A diverticulectomy was performed, and the femoral ring was closed with a polypropylene plug. No recurrence has been observed during the 3 year follow-up. Strangulated Meckel diverticulum in a femoral hernia remains a challenging diagnosis due to its extremely rare occurrence. Surgical exploration provides definite diagnosis of this rare condition.
Abstract: BACKGROUND: The aim of this experimental study was to investigate whether insulin-like growth factor I (IGF-I) can protect the colonic healing from the adverse effects of intraperitoneal administration of 5-fluorouracil (5-FU). MATERIALS AND METHODS: Eighty male Wistar rats were randomized into four groups of 20 rats each. Immediately after anastomoses were performed, rats in the control group were injected with 1 mL/100 gr of intraperitoneal saline solution, which was repeated daily until killed. Rats in the 5-FU and IGF-I +5-FU groups received 5-FU in a dose of 20 mg/kg body weight intraperitoneally, from the day of operation until killed. Rats in the IGF-I and IGF-I +5-FU groups received IGF-I in a dose of 2 mg/kg body weight intraperitoneally, immediately after the colonic anastomosis was performed and on 2nd, 4th, and 6th postoperative day. Rats were sacrificed on the 7th postoperative day. RESULTS: The dehiscence rate in the 5-FU group was 30% and it was significantly higher compared with the control and the IGF-I group (P = 0.020 for both comparisons). However, in the IGF-I +5-FU group, the dehiscence rate decreased to 10%. The administration of IGF-I resulted in a significant rise of bursting pressure in the IGF-I +5-FU group compared with the 5-FU group (P < 0.001). There was no statistical difference in bursting pressure between the IGF-I +5-FU and control groups (P = 1.000). The hydroxyproline levels were higher in the IGF-I and the IGF-I +5-FU groups as a result of the stimulating act of IGF-I. CONCLUSION: IGF-I, when given intraperitoneally, seems to mediate some of the adverse effects of 5-FU on the colonic healing in rats.
Abstract: The aim of this experimental study was to investigate the contribution of insulin-like growth factor I (IGF)-I in the colonic healing process when injected intraperitoneally after colon resection. Forty male Wistar rats were used. Rats in the control group were injected with 3 mL of a solution of 0.9% NaCl intraperitoneally after the operation and on postoperative day 2, 4, and 6. Rats in the IGF-I group received recombinant human IGF-I in a dose of 2 mg/kg body weight intraperitoneally, immediately after the colonic anastomosis was performed and on postoperative day 2, 4, and 6. All rats were killed on postoperative day 7. The hydroxyproline tissue content was significantly higher in the IGF-1 group than in the control group. The bursting pressures were also significantly higher in IGF-1 group than in the control group. The weight change between the groups differed significantly; in the control group the average weight decreased about 5% postoperatively, while in the IGF-1 group the average weight increased about 6%. The average inflammatory cell infiltration score was significantly higher in the control group. Neoagiogenesis did not differ significantly between the two groups. The fibroblast activity differed significantly between the two groups, as the control group had significantly less fibroblasts compared to the IGF-1 group. In conclusion, IGF-I when given intraperitoneally stimulates the healing of colonic anastomoses in the rats. Further studies are required in order to determine whether this effect is dose related.
Abstract: BACKGROUND: The aim of this study is to report the outcome after surgical treatment of 32 patients with ampullary cancers from 1990 to 1999. METHODS: Twenty-one of them underwent pancreaticoduodenectomy and 9 local excision of the ampullary lesion. The remaining 2 patients underwent palliative surgery. RESULTS: When the final histological diagnosis was compared with the preoperative histological finding on biopsy, accurate diagnosis was preoperatively established in 24 patients. The hospital morbidity was 18.8% as 9 complications occurred in 6 patients. Following local excision of the ampullary cancer, the survival rate at 3 and 5 years was 77.7% and 33.3% respectively. Among the patients that underwent Whipple's procedure, the 3-year survival rate was 76.2% and the 5-year survival rate 62%. CONCLUSION: In this series, local resection was a safe option in patients with significant co-morbidity or small ampullary tumors less than 2 cm in size, and was associated with satisfactory long-term survival rates.
Abstract: BACKGROUND: Metastases from hepatocellular carcinoma (HCC) can be found in the lung and adrenal gland. We report case of a patient who presented with adrenal metastasis as the first clinical manifestation of HCC. CASE PRESENTATION: A patient was referred for surgical treatment for a tumor in retro-peritoneal space. The computerized tomography (CT) scan revealed a mass originating from the left adrenal gland. The patient underwent left adrenalectomy and the exploration of abdominal cavity did not reveal any other palpable lesions. Histologically, the resected lesion was a poorly differentiated metastatic tumor from HCC. Seven months later patient was readmitted complaining of cachexia, icterus, and significant weight loss. CT scan revealed hyperdense lesions of the liver. CONCLUSION: HCC may have atypical presentations like in present case. Fine needle aspiration/tru-cut biopsy might be useful in the investigation of an accidentally discovered adrenal mass regardless of the size and can lead to the detection of a primary tumor.
Abstract: BACKGROUND: Spigelian hernia is a rare partial abdominal wall defect in the transversus abdominus aponeurosis or Spigelian fascia. We here report the case of a patient with incarcerated greater omentum in a Spigelian hernia. CASE REPORT: The patient presented with a six-hour history of nausea, constant abdominal pain, and a palpable mass in the left lower quadrant. Abdominal computed tomography revealed that omentum was strangulated in a Spigelian hernia that was successfully treated by plug and mesh repair. No recurrence has been observed during three-year follow-up. CONCLUSIONS: In our case, plug and mesh repair was a safe and effective method of repairing an incarcerated Spigelian hernia with durability through three years of follow-up.
Abstract: Introduction and Objectives
The diagnosis of prostate cancer (PCa) relies on transrectal ultrasound-guided biopsies. Recently, there has been much debate about the role of extended sampling and saturation biopsies for accurate diagnosis. Once diagnosed, men with low-intermediate risk PCa have to choose between active surveillance and radical treatment. This requires accurate risk stratification with pathological factors on biopsy playing a vital role (Gleason grade and cancer burden such as percentage number of cores positive). Equally, recent debate has centred on the role of focal therapy in PCa. Template transperineal prostate mapping biopsies may have a role in accurate diagnosis, risk stratification and localising foci of cancer.
Materials and Methods
62 men with a diagnosis of localised PCa underwent prostate mapping under general anaesthesia using a 5-mm brachytherapy grid on a stepper guided by transrectal ultrasound, between 4th July 2006 and 25th September 2007. The procedure was carried in men with either unilateral prostate cancer or low volume bilateral disease in whom determination of laterality and risk was required.
Results
Mean age 61 years (range 40-75). Mean PSA 7.1ng/ml (range 0.85-43). 2 men had one episode of urinary retention, All men have mild-moderate perineal ecchymoses, dysuria and initial self-resolving haematuria. All men had prophylactic intravenous antibiotics with no reported infections. Mean number of biopsies taken at TRUS and prostate mapping was 10.1 (range 6-24) and 31.4 (range 16-54), respectively. TRUS biopsy demonstrated 46 men with Gleason 3+3 (74.2%); 8 Gleason 3+4 (12.9%); 2 Gleason 4+3 (3.2%); 1 had Gleason 4+4 (1.6%); and 5 with low volume cancer in which grading was not possible (8.1%). After prostate mapping 19 had 3+3 (30.6%); 35 had 3+4 (56.5%); 1 had 3+5 (1.6%) and 6 (9.7%) were found to have no cancer. Overall, 26 (41.9%) were upgraded from Gleason 6 to 7; one upgraded from 6 (1.6%) to Gleason 8; and 2 (3.2%) were downgraded from Gleason 4+3 to 3+4. Mean number of cores positive on TRUS and prostate mapping was 1.6 (range 1-6) and 6.5 (range 0-21), respectively (t-test, p<0.001). The percentage positive cores was 18.2% (range 5%-50%) and 20.6% (range 0%-63.6%), respectively (p=0.34). Of the 57 men with unilateral cancer on TRUS, 23 (40.4%) were confirmed unilateral on prostate mapping, but 33 (57.9%) had bilateral disease.
Conclusion
Accurate representation of Gleason grade and disease burden in men with localised PCa is essential to determine the optimal management strategy. Prostate mapping offers precise risk determination with low morbidity. A significant number of men have a change in their risk stratification after prostate mapping with 75% either upgraded or found to have a greater burden of disease. Equally important, 13% were either downgraded or shown to have no significant cancer. These outcomes have implications for deciding on suitability for active surveillance versus radical therapy. Furthermore, with current research focused on the role of focal therapy in prostate cancer, accurate localisation of disease and determination of unilateral status is best served by prostate mapping.
Abstract: Objectives
High intensity focused ultrasound (HIFU) has been proposed as a form of salvage treatment for men who have failed primary curative therapy of organ confined prostate cancer (PCa). Visually-directed HIFU allows the operator to alter the treatment power based on real-time ultrasonic changes in the target tissue. This minimises the risk of damage to surrounding structures and optimises energy deposition.
Materials & Methods
Thirty-two patients with biochemical and histologically-confirmed recurrence, presumed to be organ-confined following staging with MRI and bonescan, were treated over a 20-month period using the Sonablate®-500 device (Focus Surgery, IN, USA). Our cohort included 13 post external beam radiotherapy, 4 post radical prostatectomy, 2 after low-dose-brachytherapy, 3 following a combination of brachytherapy and external beam radiotherapy and 10 following failed photodynamic therapy or cryosurgery. All received a single HIFU treatment. PSA kinetics were evaluated as a surrogate of short-term oncological efficacy and correlated to degree of tissue destruction demonstrated on gadolinium contrast enhanced MRIs.
Results
Mean age was 67 years (range 57-78 years). The mean pre-HIFU PSA was 7.39ng/ml (range 0.20-28.56ng/ml). At 3-months follow-up, mean PSA was 2.07ng/ml (range <0.05-13ng/ml). Specifically, six (19%) had unrecordable PSA levels (<0.05ng/ml), ten (31%) had a PSA level ≤0.2ng/ml, eight (25%) had PSA between 0.2ng/ml and 1ng/ml and eight (25%) had PSA >1ng/ml. The level of PSA nadir correlated well with degree of residual tissue at MRI.
Conclusions
Trans-rectal visually-directed HIFU is able to significantly lower the PSA in a large proportion of men who have failed previous curative interventional therapy for presumed organ-confined PCa. In this small cohort, 50% of men were able to achieve the robust target PSA nadir of ≤0.2ng/ml which has previously been shown to be associated with good clinical outcome. These results therefore support the continued evaluation of HIFU as a salvage treatment in localized recurrence of PCa.
Abstract: Introduction: Prostate cancer kills one man every hour in the United Kingdom. High Intensity Focussed Ultrasound (HIFU) is a new minimally invasive treatment of localised prostate cancer which is claimed to significantly reduce the post operative length of hospital stay compared to the standard of care (radical prostatectomy). The treatment consists of aiming high frequency (4MHz) ultrasound energy into the prostate cancer from a rectal probe effecting discrete necrosis of malignant prostate tissue. In our institution HIFU is performed using a Sonoblate 500 HIFU device which offers imaging and adjustment of energy level for each ultrasonic pulse therefore enabling real time adjustments to treatment. The energy can be delivered with 2mm precision reducing the risk of morbidity such as impotence and incontinence. There is a risk of rectal injury and fistula formation therefore the patient needs to be immobile during treatment. Previous published literature describes performing the procedure under regional anaesthesia (RA). We present our data using HIFU under general anaesthetic (GA) as a Day Surgery procedure in our institution over a 9 month period. Results: Data was collected prospectively on 77 patients undergoing HIFU over a 9 month period. The mean age was 64 years (range 47 – 78). 26 patients were ASA 1, 48 were ASA 2 and 3 patients were ASA 3. The average length of the operative procedure was 203 minutes (~3.5 hrs) and the average length of total hospital stay was 299 minutes (~5 hrs). 7 patients were admitted to hospital overnight. 3 of these were admitted for surgical reasons including peri-operative urethral dilatation and post-operative haematuria. 2 patients were admitted following slow recovery from anaesthesia as a result of the procedure being performed in the afternoon. 2 patients were admitted for nausea and vomiting post operatively. No patients were admitted because of post operative pain. Patients returned to a trial without (suprapubic) catheter clinic (TWOC) 2 weeks after the HIFU.Conclusion: HIFU performed as described above offers men an alternative form of therapy for their prostate cancer. HIFU reduces the post operative hospital bed stay from an average of 5 bed nights to 5 hours when compared with the standard treatment of radical prostatectomy. General anaesthesia ensures patient immobility and yet enables same day discharge without the associated risks and side effects of regional anaesthesia. Post operative pain has not been a problem with HIFU for prostate cancer. The procedure is best performed in the morning to allow adequate time to achieve discharge criteria. HIFU is therefore ideally suited to Day Surgery.
Abstract: Objectives
Magnetic resonance imaging is increasingly used in prostate cancer (PCa) to not only determine extracapsular disease but also to localise disease within the gland. The newer modalities of MR spectroscopy, dynamic contrast enhancement (DCE) and diffusion have added to this precision significantly. We evaluated the role of T2-weighted and DCE MRI prior to first biopsy in men with either abnormal digital rectal examination (DRE) or raised PSA (≥4.0ng/ml).
Materials & Methods
A retrospective analysis of 30 patients with elevated PSA or abnormal DRE, between January 2005 and December 2006 who underwent T2-weighted and DCE-MRI prior to transrectal ultrasound guided (TRUS) biopsies was carried out. T2- weighted and gadolinium enhanced T1-spin echo MRI sequences were obtained using a specific prostate imaging protocol. All images were examined by an experienced uro-radiologist prior to biopsy for the presence or absence of PCa on the left and right side of the gland. TRUS biopsies were examined by an experienced uro-oncology histopathologist. The sensitivity, specificity and negative predictive value of combined T2W and DCE MRI in detection of PCa was determined.
Results
The mean age was 63.6 years (range 49–83 years). PCa was detected in 17 of 30 patients on biopsy. Number of cores taken ranged from 8-12 dependent on size of prostate. 8 patients had Gleason 3+3 disease, 4 had Gleason 3+4 disease, 3 had Gleason 4+3 disease and 1 had Gleason 4+4 disease. Cancer was confidently detected in 12 of 30 patients on MRI. The mean size of lesion detected on MRI was 9.7mm (range 5-15mm for discrete lesions; 5 patients had diffuse disease). The sensitivity, specificity and negative predictive value for the detection of prostate cancer were 72%, 67.9% and 67.9%, respectively.
Conclusion
We recognise the reference standard used is not the gold standard of whole-mount histology, but our approach is a pragmatic one in this group of men, most of whom will not have cancer. Of those diagnosed with PCa many will not have surgery for their disease and therefore whole-mount histology will not be available. Our study shows that combining DCE-MRI with T2W-MRI prior to biopsy is a useful tool to predict the presence or absence of PCa. The addition of spectroscopy and diffusion to T2W and DCE (multi-modality MRI) may further increase accuracy.
Abstract: Objectives
High intensity focused ultrasound (HIFU) has been used for the primary treatment of organ-confined prostate cancer (PCa). Visually-directed HIFU has been proposed as a standard for the conduct of therapy for the Sonablate®500 device allowing the user to adapt energy deposition based on immediate feedback from real-time ultrasound changes. This study aimed to evaluate the outcomes in a cohort who had primary HIFU treatment using PSA nadir as a surrogate for oncological effectiveness.
Table 1.
MP-18.15 Risk Category PSA Nadir ng/ml <0.05 >0.05-≤0.2 0.2-≤1 >1 Total
Low n 23 5 12 3 43
% 64 11 28 7 100%
Intermediate n 20 16 11 5 52
% 39 30 21 10 100%
High n 5 9 6 2 22
% 22 41 22 15 100%
Materials & Methods
Between February 2005 and December 2006, 117 men with presumed organ-confined disease treated with HIFU were included. All were treated under general anaesthetic in a single session. Patients were stratified using D’Amico’s risk categories. The percentage of men achieving a PSA nadir ≤0.2ng/mL or unrecordable (<0.05ng/ml) in each risk group was analysed. 43 men were included in the low-risk group, 52 men in the intermediate-risk group and 22 men in the high-risk group.
Results
Mean age was 64 years (range 47-80 years) whilst mean follow-up was 453 days (range 69-744 days). 12 had hormonal therapy for 3 months prior to HIFU as cytoreduction to allow full gland coverage. In the low-intermediate group, 67% (64/95) achieved a PSA nadir of ≤0.2ng/ml and two-thirds of these were unrecordable. Overall, when including the high-risk category this did not change the achievement of this robust PSA level with 67% (78/117) achieved a PSA nadir of ≤0.2ng/mL and almost two-thirds of this group achieved unrecordable levels (<0.05ng/mL). We analysed the determinants of a low PSA nadir (≤0.2ng/mL) by evaluating the effect of prostate size, operator experience (early versus late in the learning curve), degree of calcification, disease stage and grade and other risk parameters on biopsy (50% core involvement, 50% of cores involved with PCa) and level of PSA at diagnosis in a predictive logistic regression model.
Conclusions
Visually-directed HIFU in men with localised PCa can achieve the accepted robust PSA nadir of 0.2ng/ml at 3 months post-treatment whilst most of this group achieve unrecordable levels. This data demonstrates the efficacy of this treatment modality in terms of PSA kinetics. Further analysis will attempt to correlate PSA kinetics with long-term clinical outcome.
Abstract: Introduction
Complications from HIFU mainly relate to passage of necrotic debris and stricture formation. We present a prospective series of 136 patients treated with HIFU for primary or radiorecurrent prostate cancer and identify risk factors for the need for endoscopic intervention.
Methods
Visually directed HIFU was performed using the Sonablate®500 device. Grade and stage distribution is shown in Table 1. Mean pre-treatment PSA was 7.29ng/ml. Patients had a median age of 64. Primary HIFU was delivered to 120 patients, 34 of which received androgen deprivation therapy (ADT) preoperatively for size reduction. Salvage HIFU after radiotherapy was delivered to 15 patients, 6 of whom had prior ADT. Perioperatively, 97 patients were managed with a urethral catheter (UC). Subsequently suprapubic catheters (SPC) were preferred (37 patients). Median follow-up 431 days (range 69-744). Patients with obstructive lower urinary tract symptoms were initially managed with cystoscopic washout of debris and or urethral dilatation. If this failed a bladder neck incision was performed.
Table 1.
POS-03.114 Gleason score n MRI stage n Cystoscopic interventions required
2 1 T1 41 n Primary Salvage
4 1 T2 59 1 22 2
5 2 T3 20 2 7 2
6 68 n/k 16 3 2 0
7 50 4 2 1
8 7 total 33/120 27.5% 5/15 33.3%
9 4
n/k 3 Total 38/136 (27.9%)
Results
Mean catheterisation time was 12.8 and 16 days for UC and SPC patients respectively. Trial without catheter failure occurred in 18 patients (18.8%) with UC compared to 5 SPC patients (12.5%). In total, 38 patients (27.9%) required one or more interventions for debris or stricture formation (Table 1). UC patients required more interventions than SPC patients[31/91 (34%) vs 6/37 (16.2%)]. In those having primary HIFU, ADT reduced the intervention rate from 25/86 (29%) to 8/34 (23.5%). Salvage HIFU patients had a more marked reduction from 71.4% to 0%. There was no significant difference in prostate size between the hormone naive and treated groups (29cc vs 26cc).
Abstract: Introduction: High intensity focused ultrasound (HIFU) has been proposed as a form of salvage treatment for men who have failed primary radiation therapy for prostate cancer. Methods: Thirty-three men were treated over 15 months using the Sonablate-500 device (Focus Surgery, IN, USA). All had biopsy confirmed prostate cancer recurrence following external beam radiotherapy and rising PSA. None were taking androgen deprivation therapy. Men received a single treatment session of HIFU only. Results: The mean PSA before HIFU therapy was 7.73 ng/ml for the whole group (n = 33). In the men who have had at least 3 months follow up (n = 26) the mean PSA was 8.80 ng/ml. Three months after treatment seven men (n = 7) had unrecordable PSA levels, fourteen men (n = 14) had a PSA level less than 0.2 ng/ml, and twelvemen (n = 12) had a PSA level of greater than 0.2 ng/ml. Conclusions: Trans-rectal HIFU is able to significantly lower the PSA in a proportion
of men who have previously undergone external beam radiation therapy for presumed organ confined prostate cancer. In
this small cohort, 53.8% of men were able to achieve a PSA nadir of <0.2 ng/ml which has previously been shown to be associated with a good outcome.
Abstract: Objectives
Salvage therapy is indicated when men treated with radiotherapy, brachytherapy, or a combination of these for presumed localized prostate cancer (PCa) have biochemical and histologically proven recurrence. Prostatectomy, cryosurgery and recently HIFU have been applied in the salvage setting. Reports on the toxicity of salvage cryosurgery have been scarce. We have previously reported on successful results using visually-directed HIFU in primary PCa. However, we report on the high risk of developing rectal injury from salvage-HIFU after combination of seed brachytherapy and external beam radiotherapy.
Materials and Methods
A retrospective analysis of 25 patients treated with HIFU using the Sonablate®-500 device (Focus Surgery, IN, USA), following failed primary treatment identified 2 men who had previously undergone iodine seed brachytherapy alone (BT), 13 who had external beam radiation (EBRT) alone, and 10 with combined BT and EBRT.
Results
Within a mean 264 days follow-up (range 76-714 days) 4 patients developed recto-urethral fistulae after 4 to 8 months. 3 had been treated with a combination of EBRT and BT and 1 had EBRT alone.
Table 1.
MP-08.20 EBRT BT EBRT + BT
Number of patients treated 13 2 10
Number of fistulae 1 0 3
% developing fistulae 8% 0% 30%
Conclusions
Recto-urethral fistula formation is a catastrophic complication often requiring major reconstructive surgery. The high rate of recto-vesical fistula formation in patients treated with a combination of EBRT and BT may reflect impaired blood supply prior to HIFU treatment. Such tissue viability effects are likely to affect men regardless of modality of salvage and certainly similar problems seem to arise in cryosurgery. Evaluating biochemical signs of recurrence with transperineal biopsy and MRI rather than transrectal biopsy as well as modifying treatment protocols so that targeted high energy is delivered to recurrent areas with lower energy in the rest of the gland may be of value.
