American Urological Association Score Research Articles

Defining the "Cutoff" on the Urethral Caliber in Diagnosing a Female Urethral Stricture.

Introduction The rarity in detecting female urethral stricture (FUS) backed by the inconsistency regarding the cutoff on the caliber to direct any treatment for its increase poses a challenge to its existence. Therefore, the present study was conducted to determine the caliber of the urethra that clearly identifies aFUS. Materials and method In this prospective observational study conducted between November 2015 and July 2017, women with obstructive lower urinary tract symptoms (LUTS) and a history of relief on at least a single urethral dilatation were included if the American Urological Association (AUA) score was more than seven and the maximum flow rate (Qmax) was less than 20 mL/sec. Of the 71 women recruited, 10 women had recognizable external causes: caruncle (five), mucosal prolapse (three), and meatal stenosis (two). The remaining 61 underwent voiding cystourethrogram (VCUG) and urodynamics followed by urethrocystoscopy, if the findings suggested a stricture. A definitive diagnosis was sought in those without stricture disease. We categorized all patients as either having a "true" stricture or an alternate etiology. Categorical variables were presented in number and percentage (%) and continuous variables as mean ± standard deviation (SD). Results The mean dilatationranged between one and six; the mean AUA score, ~17.82 ± 3.59; mean Qmax, ~10.21 ± 3.39 mL/sec; and the mean post-void residue (PVR), 106.65 ± 51 mL. A total of 29 patients were diagnosed to have stricture (dense = 17; flimsy = 12). None of the patients in this group had a urethral caliber of more than 14 French (Fr). Other etiologies were dysfunctional voiding (17), underactive bladder (seven), cystocele (four), and primary bladder neck obstruction (PBNO) (four). Conclusion Women with voiding LUTS should be screened for FUS only if the urethral caliber is ≤14 Fr.

Preoperative Bladder Scanning Can Predict Postoperative Urinary Retention Following Total Joint Arthroplasty.

As total joint arthroplasty (TJA) moves to the outpatient setting, it is becoming clear that postoperative urinary retention (POUR) is a potential impediment to same-day discharge. Although risk factors for POUR have been widely studied, the lack of their clinical utility warrants investigation of specific preoperative factors that can assist in surgical planning and patient optimization. The purpose of the current study was to determine whether preoperative symptom surveys and bladder scanning are useful tools in identifying POUR risk. We performed a prospective analysis of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) at a high-volume orthopaedic hospital between December 1, 2020, and September 30, 2021. A total of 507 patients (324 female and 183 male) undergoing TJA completed the American Urological Association (AUA) symptom index preoperatively and then again at 14 and 64 days postoperatively. Post-void bladder scans were obtained in the immediate preoperative setting. POUR was defined as a bladder volume of >500 mL that required catheterization. Chi-square and quintile analysis were used to compare bladder scanning volumes, and Student t tests were used to compare AUA scores. The rate of POUR was 37% (66 female and 34 male) and 23% (37 female and 19 male) in the TKA and THA groups, respectively. Increasing post-void residual volume (PVRV) measured on preoperative bladder scanning was found to be predictive of POUR. Among the TKA cohort, younger age and lower body mass index were also associated with increased catheterization, although age was not statistically significant. The AUA symptom survey was not found to correlate with POUR in either population. There was a predictable and exponential increase in the rate of catheterization as preoperative PVRV increased from 50 to 200 mL. The AUA symptom score showed no utility in predicting POUR in our study population. We propose that preoperative bladder ultrasonography become standard practice in TJA, especially among patients scheduled for same-day discharge. Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Acute toxicity outcomes from salvage high-dose-rate brachytherapy for locally recurrent prostate cancer after prior radiotherapy.

Isolated intra-prostatic recurrence of prostate adenocarcinoma after definitive radiotherapy presents a challenging clinical scenario. Salvage options require specialized expertise and pose risks of harm. This study aimed to present the acute toxicity results from using salvage high-dose-rate brachytherapy (sHDR-BT) as treatment in locally recurrent prostate cancer cases. Seventeen consecutive patients treated with sHDR-BT between 2019 and 2022 were evaluated retrospectively. Eligible patients had to have received curative intent prostate radiotherapy previously, and showed evidence of new biochemical failure. Evaluation with American Urological Association (AUA) and Common Terminology Criteria for Adverse Events (CTCAE) symptom assessments were performed for each case. The median (inter-quartile range) age prior to salvage treatment was 68 (66-74) years. The median post-sHDR-BT follow-up time was 20 (13-24) months. At baseline prior to sHDR-BT, 8 (47%) patients had significant lower urinary tract symptoms. The median AUA score prior to sHDR-BT was 7 (3-18). Three (18%) patients reported irregular bowel function and 2 (12%) reported hematochezia prior to sHDR-BT. One-month post-treatment, the median AUA score was 13 (8-21, p = 0.21). Using CTCAE scoring, there were no cases of grade 2+ bowel or rectal toxicity, and no cases of grade 3+ urinary toxicity. Reported grade 2 urinary toxicities included 10 (59%) cases of bladder spasms, 2 (12%) cases of incontinence, 1 (6%) urinary obstruction, and 4 (24%) reports of urinary urgency. All these adverse events were temporary. This study adds to the existing literature by demonstrating that the acute toxicity profile of sHDR-BT is acceptable even without intra-operative magnetic resonance (MR) guidance or image registration. Further study is ongoing to determine long-term efficacy and toxicity of treatment.

Preliminary Analysis of a Phase II Trial of Stereotactic Body Radiation Therapy for Prostate Cancer With High-Risk Features After Radical Prostatectomy

PurposeThere are limited data regarding using stereotactic body radiation therapy (SBRT) in the postprostatectomy setting. Here, we present a preliminary analysis of a prospective phase II trial that aimed to evaluate the safety and efficacy of postprostatectomy SBRT for adjuvant or early salvage therapy. Materials and MethodsBetween May 2018 and May 2020, 41 patients fulfilled inclusion criteria and were stratified into 3 groups: group I (adjuvant), prostate-specific antigen (PSA) < 0.2 ng/mL with high-risk features including positive surgical margins, seminal vesicle invasion, or extracapsular extension; group II (salvage), with PSA ≥ 0.2 ng/mL but < 2 ng/mL; or group III (oligometastatic), with PSA ≥ 0.2 ng/mL but < 2 ng/mL and up to 3 sites of nodal or bone metastases. Androgen deprivation therapy was not offered to group I. Androgen deprivation therapy was offered for 6 months for group II and 18 months for group III patients. SBRT dose to the prostate bed was 30 to 32 Gy in 5 fractions. Baseline-adjusted physician reported toxicities (Common Terminology Criteria for Adverse Events), patient reported quality-of-life (Expanded Prostate Index Composite, Patient-Reported Outcome Measurement Information System), and American Urologic Association scores were evaluated for all patients. ResultsThe median follow-up was 23 months (range, 10-37). SBRT was adjuvant in 8 (20%) patients, salvage in 28 (68%), and salvage with the presence of oligometastases in 5 (12%) patients. Urinary, bowel, and sexual quality of life domains remained high after SBRT. Patients tolerated SBRT with no grade 3 or higher (3+) gastrointestinal or genitourinary toxicities. The baseline adjusted acute and late toxicity grade 2 genitourinary (urinary incontinence) rate was 2.4% (1/41) and 12.2% (5/41). At 2 years, clinical disease control was 95%, and biochemical control was 73%. Among the 2 clinical failures, 1 was a regional node and the other a bone metastasis. Oligometastatic sites were salvaged successfully with SBRT. There were no in-target failures. ConclusionsPostprostatectomy SBRT was very well tolerated in this prospective cohort, with no significant effect on quality of life metrics postirradiation, while providing excellent clinical disease control.

Post-operative Urinary Dysfunction Following Shoulder Surgery: Rates and Risk Factors.

Post-operative urinary retention (POUR) and dysfunction are recognized complications following orthopaedic surgery. Recent literature has focused on urinary retention and its associated complications following hip and knee reconstruction and lower extremity surgery. There is a paucity of literature focusing on POUR and shoulder surgery. The purpose of this study is to describe the rates of urinary dysfunction in patients undergoing shoulder surgery as well as the associated risk factors. This was a single institution, prospective cohort study. Eligibility criteria included patients older than 50 years of age undergoing open or arthroscopic shoulder surgery. The primary outcome was the American Urological Association (AUA) symptom score (7 questions total scored 0-5, total 35 points max) administered before and after surgery. Higher scores reflect worse urinary dysfunction. Intra-operative data such as type of surgery, type of anesthesia, use of anticholinergics, peripheral nerve block, length of case, and amount of intravenous fluids were collected. Of 194 patients, the mean age was 61.4 years (Standard Deviation (S.D.) = 13.0)) and the average BMI was 29.2 (S.D. = 5.6). The sample was 35.6% female. Overall, 46.4% reported worse AUA scores post-operatively within the first 3 to 5 days, including 4.1% of which were clinically defined as "moderately worse" (>5 point worse) or "much worse" (>11 points worse). Worse preoperative AUA scores correlated with worse postop AUA score on linear regression analysis (r=0.883, P<0.0001). Males with a history of BPH showed a statistically significant positive association with worsening urinary dysfunction postoperatively (P=0.039). Four patients (2.1%) required postoperative catheterization. A significantly higher percentage of patients with preoperative AUA scores of ≥11 experienced worsening of urinary function post-operatively (P=0.04). Worsening of urinary function following shoulder surgery is common. The AUA score may be used to identify at-risk patients and to track changes in urinary function post-operatively. Men with a diagnosis of BPH are at particularly high risk. Further investigation is needed to elucidate the impact of urinary dysfunction on patient outcomes, satisfaction, and cost as well as the role of prophylactic medications.

Clinical Outcomes of Prostate SBRT Using Non-Adaptive MR-Guided Radiotherapy (MRgRT)

<h3>Purpose/Objective(s)</h3> Stereotactic body radiation therapy (SBRT) is widely used for localized prostate cancer and implementation of MR-guided radiotherapy (MRgRT) has the advantage of smaller target margins and improved sparing of organs at risk. Here we evaluate outcomes and time required to treat using non-adaptive MRgRT for prostate SBRT at our institution. <h3>Materials/Methods</h3> From 9/2019 to 10/2021, 77 consecutive patients were treated with MRgRT prostate SBRT. Patients included low (4%), favorable intermediate (40%), unfavorable intermediate (49%) and high risk (7%). Short-term ADT was used in 32% of patients. Our clinical pathway allowed maximum prostate gland volume of 60cc. Target volumes included prostate gland and proximal seminal vesicles with an isotropic 3mm margin. Treatment was prescribed to 36.25 Gy in 5 fractions every other day with urethral sparing to maximum dose of 35 Gy. SpaceOAR gel was used in 17% of patients Time on the Linac was recorded as beam on time (BOT) plus total treatment time (TTT) including gating. Analyzed outcomes included PSA response and patient reported outcomes scored by the American Urological Association (AUA) questionnaire and toxicity per CTCAE v5. Repeated-measure analysis and Bonferroni correction were used to test changes in PSA and toxicity. <h3>Results</h3> Median follow up was 9.5 months (range 1.1 – 23.1). Median pre-treatment PSA was 6.5 (range 2.2 – 19.6) and median AUA score was 6 (1 – 25) with a median prostate size of 32.6 cc (range 17 – 70). At first follow up, median change in PSA was -5.23 ng/mL (Delta range +0.02– -19.3ng/ml) with a median AUA of 10 (range 1 – 26). At second follow up, median change in PSA was -6.33 ng/mL (range +1.48– -19.31ng/mL) and median AUA of 7 (range 0 – 33). At third follow up, median change in PSA was -6.09ng/mL (range -1.84 – -14.9ng/mL) and median AUA was 6.5 (1 – 25). There was a significant decrease in PSA between pre-treatment and first through fourth follow up (p=0.003). The greatest difference was between pretreatment PSA and PSA at 4^thfollow-up (decrease in PSA by 5.9 ng/ml, p<.001). Toxicity as measured by CTCAE v5 decreased from 53% at first follow up to 23% at second follow up and 1% at third follow up. Common toxicities included grade 2 urethritis, tenesmus and one grade 3 proctitis. No grade ≥4 toxicity was seen. Our MR-Linac underwent an upgrade in 11/2020 allowing for faster treatment times. For patients treated prior to the upgrade, mean BOT was 4.89 min with a TTT of 12.50 min whereas for those treated after mean BOT was 4.52 min with a TTT of 10.68 min. <h3>Conclusion</h3> A benefit of MRgRT is the potential for treatment adaptation, however it comes at the cost of increased resource utilization and reduced clinical efficiency. Our experience with non-adaptive MRgRT prostate SBRT maintains clinical efficiency as well as efficacy. Taken together these results suggest a non-adaptive approach may allow more patients to access an effective and safe treatment, while also maximizing resource utilization.

Long-term Follow-up and Success Rate of Ventral Inlay Buccal Mucosal Graft Urethroplasty for Female Urethral Stricture Disease

ObjectiveTo determine the long-term success of ventral inlay buccal-mucosal graft urethroplasty (Vi-BMGU) for female urethral strictures (FUS). Materials and MethodsWe performed a retrospective analysis of prospectively maintained data on patients who underwent Vi-BMGU between May 2016 and January 2020 with a minimum follow-up of 2 years. The primary outcome was the long-term success after 2 to 5 years of surgery. Patients were followed with American Urological Association (AUA) symptom score, uroflowmetry, and post-void residual (PVR) urine measurement. Failure (recurrence) was defined by an increase in the AUA symptoms score by 3 on subsequent follow-up visits and maximum flow rate (Qmax) <12 cc/s and inability to calibrate with an 18 Fr catheter. ResultsTwenty-one patients were included. The Median follow-up was 42 months (range: 24-64 months). The AUA symptom scores, Qmax, and PVR, improved in all except 3 patients. The median AUA score fell from 27 (range 18-34) at diagnosis to 9 (range 6-24), at the last follow-up. Similarly, the median PVR values decreased from 138 ml (34-290) to 24 ml (19-360) and the mean Qmax improved from 7.7 ± 2.2 ml/s to 22.6 ± 5 ml/s. None experienced urinary incontinence. There were 2 failures, 1 at 6 months and the other at 24 months. The overall success rate was 90.5 %. Success rates on life table analysis were 95%, 85%, 85%, 85%, and 85% after 1, 2, 3, 4 and 5 years respectively. ConclusionThe 95% success at 1 year and 85% sustained success at 2 to 5 years of follow-up establishes the long-term success of Vi-BMGU.

Trial without Catheter in Acute Retention of Urine secondary to Prostatomegaly

Introduction: Acute Retention of Urine is one of the main presentations for Benign Prostatic hyperplasia. Trial without catheter is an ambulatory care protocol. The greater morbidity and mortality associated with emergency surgery, and the potential morbidity associated with prolonged catheterization have led to the increasing use of a trial without catheter. Trial without catheter involves catheter removal allowing patients to void successfully so that surgery can be performed at a later stage. Use of an alpha (1)-blocker before a Trial without catheter has demonstrated that it increases its success. Aims: Identifying the success and failure of Trial without Catheter in patients with Benign Prostatic Hyperplasia and evaluating factors influencing them. Methods: A total of 60 patients who presented with acute urinary retention were enrolled in this study at Nepalgunj Medical College which was conducted between February 2021 and August 2021. All the patients underwent Foley Catheterization. Tablet Alfuzosin 10mg one tablet at night and requested follow-up after a week. Trial without Catheter conducted and the amount of urine measured after removal of the Foley catheter. Results: The study evaluated various factors predicting success of Trail without Catheter. Age group of 61-70years had higher success. Patients with moderate American Urological Association score had higher success rates than the rest. About 10 (6%) patients had a Quality of Life of less than four. The prostate volume ranging from 30-39ml had higher success rates. Patients with Grade III Intravesical Prostatic Protrusion had fewer chances of successful Trial without Catheter. Duration of Lower Urinary Tract Symptoms less than six months was favorable for the success of Trial without Catheter. Thirty five (58.3%) patients voided more than 200ml during Trial without Catheter. Conclusion: Trial without catheter should be opted for selective patients having Benign Prostatic Hyperplasia presenting with Acute Urinary Retention.

Ten-year treatment complication outcomes of radical prostatectomy vs external beam radiation vs brachytherapy for 1503 patients with intermediate risk prostate cancer

To compare 10-year late complications of radical prostatectomy (RP) versus external-beam-radiation-therapy (EBRT) versus brachytherapy (BT). Retrospective analysis was performed on 1503 intermediate-risk-prostate-cancer patients treated from 2004 to 2007, using univariate comparisons. Eight hundred and nineteen underwent RP, 574 EBRT, and 110 BT. RP urinary and rectal complications were graded severe if patients required ≥3 pads/diapers per day, chronic condom catheter or penile clamp, daily clean-intermittent-catheterization, sling, artificial-urinary-sphincter, or rectal fistula. Complications for EBRT/BT were severe if graded 3/4 on the Radiation-Therapy-Oncology-Group scale for late effects. The prevalence of erectile-dysfunction-devices (EDD) of injections, pumps and/or penile implants were compared. Median follow-up for RP versus EBRT versus BT were 10.0, 9.6, and 9.8 years. Median age were 62.1, 70.8, 65.3, p < 0.0001. The 10-year prevalence of severe urinary complications for RP versus EBRT versus BT were 10.1%, 12.5%, 4.6%, p = 0.03, and were less for RP <64 years, p = 0.03, and lower Charlson score, p = 0.05. Pretreatment American-Urological-Association (AUA) score existed for 7.3%, 11.5%, 97.3% of RP versus EBRT versus BT, p < 0.0001, and the 10-year prevalence of EDD were 24.3%, 6.6%, 8.2%, respectively, p< 0.0001. Severe rectal complications were slightly higher for EBRT, p = 0.06. BT had lower prevalence of severe urinary complications, possibly by using AUA score to avoid patients with obstructive uropathy. Urinary complications may be reduced by limiting RP to younger, healthier patients, and by avoiding EBRT/BT with obstructive symptoms. RP had higher prevalence of EDD, despite having younger, healthier patients.

Predisposing factors of persistent storage symptoms after holmium laser enucleation of the prostate in patients with benign prostatic hyperplasia and their correlations to the symptom recovery period

Bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms (LUTS) in older men. Although medical treatments can reduce BPH-related LUTS and even prevent invasive treatments, at least one in five men who complain of LUTS due to BPH will eventually need surgery. Of LUTS, storage symptoms persist in 20 to 40% of patients even after the obstruction is resolved. The present study aims to investigate the predisposing factors of the persistent storage symptoms after HoLEP in patients with BPH and their correlations to the recovery time of the symptoms. A total of 127 patients with complaints of storage symptoms and who underwent transurethral HoLEP surgery at Pusan National University Hospital from May 2014 to June 2017 were included in this study. Urodynamic studies were performed in all patients, and BOO was confirmed by urodynamic studies before HoLEP. All patients were asked to complete the IPSS (also known as the American Urological Association score) and the Overactive Bladder Symptom Score (OABSS) questionnaire to evaluate LUTS on the day before HoLEP and 3 months after HoLEP. Patients were divided into group I, which included patients with persistent storage symptoms after HoLEP, and group II, which included patients without storage symptoms after HoLEP. Of a total of 127 patients, 68 were included in group I, and the remaining 59 were included in group II. In the univariable analysis, group I showed statistically significantly older mean age, higher mean peak detrusor pressure during filling cystometry, and lower mean MCC than group II. Multivariate analysis of these three variables showed that only mean age and mean peak detrusor pressure during filling cystometry had statistically significant differences. In group I, 12 patients had storage symptoms until 12 months after surgery. When comparing these patients with the remaining 56 patients, only mean age showed statistically significant differences. Old age and high peak detrusor pressure during filling cystometry were the predictors of persistent storage symptoms after HoLEP. Furthermore, older patients were unlikely to recover storage symptoms until 12 months after operation.

Risk of urinary morbidity associated with photoselective vaporization of the prostate (PVP) in prostate cancer patients undergoing a combined radiotherapy regimen consisting of dynamic adaptive radiotherapy (DART) and brachytherapy boost.

231 Background: Recent studies have shown PVPs to be associated with diminished perioperative and postoperative complications compared to transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH). This is the first study to evaluate the timing of PVP intervention and post-treatment morbidity related to a combined regimen of DART and Pd-103 brachytherapy for treatment of prostate cancer. Methods: Between 12/05 and 04/20, 51 consecutive patients underwent Greenlight Laser (GLL) or Olympus Plasma Button (OPB) PVP after DART (median dose: 45 Gy) and before Pd-103 brachytherapy (median dose: 90 Gy). 27 patients received GLL PVP and 24 patients received OPB PVP. Peripheral seed loading designs were utilized to achieve optimal urethral sparing. The time from DART to PVP ranged from 1 to 81 days (median: 18 days). For 12 patients, the interval between DART and PVP was ≤7 days. The time from PVP to seed implant ranged from 0 to 55 days (median: 18 days). For 13 patients, the interval between PVP and implant was ≤7 days. American Urological Association (AUA) symptom scores were compiled prior to PVP and on the last post-brachytherapy follow-up. Post-implant follow-up ranged from 6 months to 15 years (median: 6.4 years). Results: No patient experienced post-implant urinary retention or incontinence. Morbidity was limited to RTOG grade 1-2 symptoms, with the exception of one patient who experienced protracted dysuria, which was identified to be secondary to a pre-existing prostate anomaly (steep urethral curvature). Only that patient required dilation for urethral stricture. AUA scores improved or remained the same in 43 of 51 patients. Only 1 patient of the remaining 8 experienced an increase in AUA &gt; 8 points. Conclusions: In our experience, there have been remarkably few adverse urinary sequelae following Pd-103 implantation in patients with prior PVP and DART. In contrast to TURPs, PVPs are safe even with short intervals between DART and brachytherapy. Based upon these results, pre-implant PVP is preferred, rather than PVPs or TURPs in the post-implant setting.

Biochemical Control and Toxicity Outcomes of Stereotactic Body Radiation Therapy Versus Low-Dose-Rate Brachytherapy in the Treatment of Low- and Intermediate-Risk Prostate Cancer

Low-dose-rate (LDR) brachytherapy and stereotactic body radiation therapy (SBRT) have both shown acceptable outcomes in the treatment of low- and intermediate-risk prostate cancer. Minimal data have been published directly comparing rates of biochemical control and toxicity with these 2 modalities. We hypothesize that LDR and SBRT will provide similar rates of biochemical control. All low- and intermediate-risk patients with prostate cancer treated definitively with SBRT or LDR between 2010 and 2018 were captured. Phoenix definition was used for biochemical failure. Independent t tests were used to compare baseline characteristics, and repeated measure analysis of variance test was used to compare American Urologic Association (AUA) and the Expanded Prostate Cancer Index Composite (EPIC) scores between treatment arms over time. Biochemical control was estimated using the Kaplan-Meier method. Differences in acute and late toxicity were assessed via Pearson χ2. In the study, 219 and 118 patients were treated with LDR and SBRT. Median follow-up was 4.3 years (interquartile range, 3.1-6.1). All patients treated with LDR received 125.0 Gy in a single fraction. SBRT consisted of 42.5 Gy in 5 fractions. Five-year biochemical control for LDR versus SBRT was 91.6% versus 97.6% (P = .108). LDR patients had a larger increase in mean AUA scores at 1 month (17.2 vs 10.3, P < .001) and 3 months posttreatment (14.0 vs 9.7, P < .001), and in mean EPIC scores at 1 month (15.7 vs 13.8, P < .001). There was no significant difference between LDR and SBRT in late grade 3 genitourinary toxicity (0.9% vs 2.5%, P = .238); however, LDR had lower rates of late grade 3 gastrointestinal toxicity (0.0% vs 2.5%, P = .018). Our data show similar biochemical control and genitourinary toxicity rates at 5 years for both SBRT and LDR, with slightly higher gastrointestinal toxicity with SBRT and higher AUA and EPIC scores with LDR.

Implementation of high-dose-rate brachytherapy for prostatic carcinoma in an unshielded operating room facility

PurposeThe purpose of the study was to describe our approach towards safe delivery of single-fraction high-dose-rate (HDR) brachytherapy (BT) boost in patients with prostate cancer in the setting of an unshielded operating room (OR). Methods and MaterialsA total of 95 patients received 15 Gy HDR BT boost. The procedure involved transrectal ultrasound–based catheter insertion and planning in the OR, after which the patient was moved to a shielded treatment room for radiation. This required three vital components: (1) an OR table capable of transporting the patient in lithotomy position, (2) robust motion management checks to ensure reproducibility of prostate and catheter positions in the treatment room before radiation delivery, (3) remote monitoring of patient vitals while under anesthesia, during the radiation. Initial viability of this approach was confirmed by assessing acute toxicities using the Common Terminology Criteria for Adverse Events v4.0 and American Urologic Association symptom scores. ResultsWe found good stability in prostate and catheter position, with less than 1 mm shifts in each direction due to patient transfer. The median baseline American Urologic Association score was 7 (3–11), which increased to 12 (7–17) at 4 weeks and 9 (5–14) at 3 months (p = 0.003). Common Terminology Criteria for Adverse Events ≥ grade 2 genitourinary and gastrointestinal toxicities were experienced by 7% and 0% patients, respectively, at 3 months posttreatment completion. ConclusionsSingle-fraction HDR prostate BT can be delivered safely in an unshielded OR facility with a distant shielded treatment room using rigorous motion management checks and supplementary procedural equipment.

Salvage Brachytherapy for Recurrent Prostate Cancer after Definitive Radiation Treatment and Factors That May Impact Outcomes

Salvage low-dose-rate (LDR) brachytherapy is a potential treatment option for patients with locally recurrent prostate cancer following primary radiation therapy. Here we report our single institution outcomes and toxicity when utilizing LDR brachytherapy in the salvage setting. Nineteen patients with biopsy-proven locally recurrent prostate cancer underwent salvage LDR brachytherapy under transrectal ultrasound guidance utilizing 103 Pd to 120 Gy from August 2010 through February 2018. Prostate-specific antigen (PSA) failure was determined utilizing the Phoenix (nadir+2) definition. Toxicity was graded using Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 and patient reported questionnaires including the Expanded Prostate Cancer Index Composite (EPIC) and American Urological Association (AUA). Median follow-up was 41 months. The 4- and 5- year PSA relapse-free survival (RFS) following salvage treatment were 78.9% and 68.4%, respectively. Androgen deprivation therapy was utilized in conjunction with salvage treatment in 7 patients (37%). On univariate analysis, 5- year PSA relapse was associated with both patients who experienced early failures after initial definitive treatment (p=.012), or if the patient had received stereotactic body radiation treatment (SBRT) (p=.005) prior to salvage treatment. Of the four patients who were treated following a biopsy-proven recurrence after initial SBRT treatment, two patients (50%) experienced PSA failure at a median of 9 months after their salvage treatment. AUA and EPIC scores showed a significant increase at one-month follow-up after salvage brachytherapy (p = .023) and returned to baseline within six months. Three patients (16%) experienced Grade 3 acute or late urinary toxicity, five patients experienced Grade 2 acute urinary toxicity, and one patient experienced Grade 2 acute rectal toxicity. Post-implant dosimetry did not predict for toxicity. There were no Grade 4 or 5 toxicities. LDR brachytherapy is a viable treatment option in the salvage setting with minimal morbidity. While longer follow-up is needed, early failures from initial radiation treatment and prior SBRT may portend for worse outcomes following salvage LDR brachytherapy.

Clinical Evaluation of Homoeopathic Medicines in Benign Prostatic Hyperplasia

Background Symptomatic benign prostatic hyperplasia (BPH) is a common condition in elderly men and has a significant impact on their daily lives. Surgical procedures are currently used for the conventional treatment for BPH; but they have been associated with clinically significant adverse effects in patients. Objectives The main purpose of this article is to evaluate the role of homoeopathic medicines for the treatment of BPH. Materials and Methods Clinically diagnosed 30 subjects of BPH were given homoeopathy treatment and followed up for a period of 1 year. Homoeopathic medicines were prescribed to the subjects according to the principles of homoeopathy. Effects of homoeopathic medicines were analysed periodically by American Urological Association score (AUA score) and ultrasonography. Results Marked amelioration of symptoms and reduction in size of prostate gland in BPH subjects were observed after homoeopathic treatment when analysed by AUA score and ultrasonography. There was marked reduction in various symptoms of BPH like nocturia, straining, incomplete sensation after urination, interrupted flow of urination with dribbling of urine and urgency significantly from 21.60 ± 4.64 units to 12.23 ± 3.68, that is, ∼57% reduction in symptoms of obstruction of bladder problem. The reduction was statistically significant (p = 0.001). However, transabdominal pelvic ultrasonic scan did not show statistically significant results. Conclusion Homoeopathic medicines can prove to be an alternative treatment of BPH.

Ten year treatment complication outcomes of radical prostatectomy versus external beam radiation therapy versus brachytherapy for 1,503 patients with intermediate risk prostate cancer.

e16599 Background: To compare 10 year treatment complication outcomes of radical prostatectomy(RP) vs external beam radiation therapy(EBRT) vs brachytherapy(BT) for patients with intermediate risk prostate cancer(IRPC). Methods: A retrospective analysis was performed on 1,503 IRPC patients who underwent treatment from 2004 to 2007, using univariate comparisons. 819 underwent RP, 574 underwent EBRT, and 110 underwent BT using iodine-125. Urinary and rectal complications for RP were graded as severe if patients required ≥ 3 pads/diapers per day, required chronic use of condom catheter or penile clamp, daily self-catheterization, placement of sling or artificial urinary sphincter, or developed rectal fistula/incontinence. Complications for EBRT and BT were graded as severe if they were classified as grade 3 or 4 on the Radiation Therapy Oncology Group grading system for late effects. For erectile dysfunction, the prevalence of patients requiring injections, pumps or penile implants were calculated after a minimum of 1 year of follow up. Results: Median follow up was 10.0 years for RP, 9.6 for EBRT, and 9.8 for BT. Neoadjuvant androgen deprivation therapy was given in 0.6% for RP patients vs 58.9% of EBRT vs 12.7% of BT, p &lt; 0.0001. Median age for RP vs EBRT vs BT was 62.1, 70.8, 65.3, p &lt; 0.0001. The 10-year prevalence of severe urinary complications for RP vs EBRT vs BT was 10.1%, 12.5%, 4.6%, p = 0.04. The percentage of patients having a pre-treatment American Urological Association(AUA) urinary score for RP vs EBRT vs BT was 7.3%, 11.5%, 97.3%, p &lt; 0.0001. The 10-year prevalence of severe rectal complications for RP vs EBRT vs BT was 0.5%, 1.6%, 0.0%, p = 0.06. The 10-year prevalence of erectile dysfunction devices for RP vs EBRT vs BT was 24.3%, 6.6%, 8.2%, p &lt; 0.0001. Conclusions: After 10 years of follow-up, BT had the lowest rate of severe urinary complications, which may due to using the AUA score to avoid implanting those who had significant baseline obstructive voiding symptoms. EBRT had a higher rate of severe rectal complications. RP had the highest probability of undergoing treatment using erectile dysfunction devices, despite having younger patients.

Ten year treatment complication outcomes of radical prostatectomy versus external beam radiation therapy versus brachytherapy for 1,503 patients with intermediate risk prostate cancer.

67 Background: To compare 10 year treatment complication outcomes of radical prostatectomy(RP) vs external beam radiation therapy(EBRT) vs brachytherapy(BT) for patients with intermediate risk prostate cancer(IRPC). Methods: A retrospective analysis was performed on 1,503 IRPC patients who underwent treatment from 2004 to 2007, using univariate comparisons. 819 underwent RP, 574 underwent EBRT, and 110 underwent BT using iodine-125. Urinary and rectal complications for RP were graded as severe if patients required ≥ 3 pads/diapers per day, required chronic use of condom catheter or penile clamp, daily self-catheterization, placement of sling or artificial urinary sphincter, or developed rectal fistula/incontinence. Complications for EBRT and BT were graded as severe if they were classified as grade 3 or 4 on the Radiation Therapy Oncology Group grading system for late effects. For erectile dysfunction, the prevalence of patients requiring injections, pumps or penile implants were calculated after a minimum of 1 year of follow up. Results: Median follow up was 10.0 years for RP, 9.6 for EBRT, and 9.8 for BT. Neoadjuvant androgen deprivation therapy was given in 0.6% for RP patients vs 58.9% of EBRT vs 12.7% of BT, p &lt; 0.0001. Median age for RP vs EBRT vs BT was 62.1, 70.8, 65.3, p &lt; 0.0001. The 10-year prevalence of severe urinary complications for RP vs EBRT vs BT was 10.1%, 12.5%, 4.6%, p = 0.04. The percentage of patients having a pre-treatment American Urological Association(AUA) urinary score for RP vs EBRT vs BT was 7.3%, 11.5%, 97.3%, p &lt; 0.0001. The 10-year prevalence of severe rectal complications for RP vs EBRT vs BT was 0.5%, 1.6%, 0.0%, p = 0.06. The 10-year prevalence of erectile dysfunction devices for RP vs EBRT vs BT was 24.3%, 6.6%, 8.2%, p &lt; 0.0001. Conclusions: After 10 years of follow-up, BT had the lowest rate of severe urinary complications, which may due to using the AUA score to avoid implanting those who had significant baseline obstructive voiding symptoms. EBRT had a higher rate of severe rectal complications. RP had the highest probability of undergoing treatment using erectile dysfunction devices, despite having younger patients.

Outcomes of a Dose-Escalated Stereotactic Body Radiation Phase 1 Trial for Patients With Low- and Intermediate-Risk Prostate Cancer

This study presents a prospective phase 1, institutional review board-approved dose-escalated stereotactic body radiation therapy trial for prostate cancer (CaP) to assess the impact of dose level on quality of life, toxicity, and clinical outcomes. From 2011 to 2016, 26 patients with low- and intermediate-risk CaP received 40, 45, and 50Gy in 5 fractions to the prostate in cohorts of 9, 10, and 7 patients. Self-reported quality of life was prospectively measured from the Expanded Prostate Cancer Index Composite and American Urological Association. Common Terminology Criteria for Adverse Events (version 4.03) data were collected to observe acute and late toxicities. The Phoenix definition was used to calculate outcome. No patients received androgen deprivation therapy. Median follow-up was 67.2months (range, 71-230months). There was an increase in Expanded Prostate Cancer Index Composite and American Urological Association scores followed by a return to baseline over 2years for all cohorts. There were no grade 3 or higher toxicities or significant differences in toxicity between treatment arms. The prostate-specific antigen (PSA) nadir was significantly lower in the 45-Gy and 50-Gy cohorts when compared with the 40-Gy cohort (P<.05). Two biochemical failures were observed in the 40-Gy arm after 43 and 62months, resulting in a freedom from biochemical failure rate of 92%. PSA survival was 100%, and actuarial overall survival was 96%. PSA nadir was 0.6, 0.1, and 0.1ng/mL, in the 40-Gy, 45-Gy, and 50-Gy cohorts, respectively. This prospective, phase 1 dose-escalation study of stereotactic body radiation therapy for CaP identified acceptable genitourinary and gastrointestinal toxicity for each dose level of 40, 45, and 50Gy. Although there was no difference in biochemical failure between the groups, we showed that higher doses of 45 and 50Gy are associated with improved PSA nadir. The results of this study will be used to develop a larger prospective study to confirm the findings.

Prospective Safety and Patient-Reported Quality-of-Life Outcome for Prostate Cancer Treated with Image-Guided Compact Pencil-Beam Proton Unit

To evaluate toxicity and patient-reported quality-of-life outcome for prostate cancer treated with a modern single-gantry pencil-beam scanning (PBS) proton unit. Men with localized prostate cancer treated consecutively at one institution with a single-gantry compact pencil-beam scanning (PBS) proton unit between 09/2014 – 07/2017 were identified from an institutional review board-approved registry protocol. Patients’ quality-of-life (QOL) questionnaires were prospectively collected at baseline and subsequent follow-ups. Patient characteristics and tumor histology were obtained by medical chart review. Patients without any follow-up or missing baseline assessment were excluded. Urinary symptoms and erectile dysfunction (ED) were assessed by the American Urological Association (AUA) Symptom Index and the Sexual Health Inventory For Men (SHIM) Score, respectively. Genitourinary (GU) and gastrointestinal (GI) toxicities were evaluated by physician according to Common Terminology Criteria for Adverse Events (CTCAE v.4.0) and collected at each follow up. Data was analyzed using two-tail Fisher’s exact test comparing each time point to their baseline. A total of 113 patients were prospectively enrolled. Median age was 68.4 (47.6-89.8). Median baseline PSA was 5.9 ng/mL. Median Gleason score was 7. NCCN Risk grouping for low-, intermediate-, and high-risk were 15.0%, 57.4%, and 32.7%, respectively. For those initially presenting with moderate-severe urinary symptoms (42.0%), more (45.8%-66.7%) reported mild urinary symptoms and most (87.5%-100%) had stable/improved AUA scores during the first year. The most common urinary complaints at baseline were increased frequency and urgency, and these symptoms improved after treatment at follow-up. Forty percent (40.3%) reported no/mild ED at baseline. This trended down slightly after treatment but remained stable at follow-ups (28%-32%). The percentage of men requiring ED medication was not different at follow-up (32.0%-43.2%) compared to baseline (43.4%). The rate of impotence refractory to medication at follow-up was low and similar to that at baseline (3%-6%). Acute grade 2 GU and GI toxicities were 6.6% and 0.8% at the end of treatment. There were one grade 3 urinary incontinence GU toxicity at 3 months and one grade 3 rectal bleeding GI toxicity at 1 year. Proton therapy with image-guidance using modern compact PBS for prostate cancer is safe. It may improve urinary symptoms with minimal impact on sexual QOL in patients with localized prostate cancer. Long-term follow up is needed to confirm these favorable results.

Nerve‐sparing in salvage robot‐assisted prostatectomy: surgical technique, oncological and functional outcomes at a single high‐volume institution

To show the feasibility, oncological and functional outcomes of neurovascular bundle (NVB) preservation during salvage robot-assisted radical prostatectomy (RARP). In the present institutional review board-approved retrospective analysis, between January 2008 and March 2016, 80 patients underwent salvage RARP, performed by a single surgeon (V.P), because of local recurrence after primary treatment. These patients were categorized into two groups depending on the degree of nerve-sparing (NS) performed: a good-NS group (≥50% of NVB preservation) and a poor-NS group (<50% of NVB preservation). A standard transperitoneal six-port technique, using the DaVinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), was performed, and either an anterograde or a retrograde approach was used for NVB preservation. Validated questionnaires were used preoperatively (Sexual Health Inventory for Men [SHIM] and American Urological Association scores). Potency after salvage RARP was defined as the ability to achieve a successful erection with penetration >50% of the time, while full continence after salvage RARPwas defined as 0 pads used. The Kaplan-Meier method was used for survival and predictive estimations, and regression models were used to identify the predictors of potency, continence and biochemical failure (BCF). The potency rate at 12months was higher in the good-NS group (25.6% vs 4.3%; P = 0.036) regardless of previous SHIM score, and good NS tended to be predictive of potency after salvage RARP (P = 0.065). The full continence rate at 12months and BCF rate were similar in the two groups, and non-radiation primary treatment was the only predictor of continence at 12months after salvage RARP (P = 0.033). Our data support the feasibility and safety of NVB preservation for salvage RARP conducted in select patients in a high-volume institution and the subsequent better recovery of adequate erections for intercourse.