Brachytherapy Template Research Articles

Development and clinical implementation of simple needle attachment post placement interstitial template (SNAPP-IT) enabling a shorter, more direct needle path while preserving tumor visualization

Purpose: Historical gynecologic interstitial brachytherapy templates block direct tumor visualization during needle placement, presenting an opportunity for clinical innovation to develop a novel interstitial template allowing direct tumor visualization during needle insertion. Methods: We designed and implemented a novel interstitial template, Simple Needle Attachment Post Placement Interstitial Template (SNAPP-IT), that allowed direct visualization of the target vaginal tumor during interstitial needle placement while maintaining the ability to individually secure needles to the template, allow a vaginal cylinder, suture holes for securing to the perineum, MRI compatibility and sterilizable for repeat use. Procedure outcomes including procedure time, needle path lengths, and plan dosimetry were prospectively captured in a patient database. Results: Forty gynecologic interstitial brachytherapy cases were recorded (20 SNAPP-IT, 20 traditional templates). Needle insertion depth was reduced using the SNAPP-IT in comparison with traditional interstitial templates (11.8cm vs 3.6cm, p<0.0001). The average CTV volume was 25.6 cc for SNAPP-IT and 20.7 cc for traditional; both methods averaged a similar number of needles (15.8, 15.6). Dosimetric constraints were similarly met in both treatment groups. Procedures performed using the SNAPP-IT were shorter compared with those performed with traditional interstitial devices (83.4 minutes vs 100.7 minutes) and there were no post-operative infections in the SNAPP-IT group. Conclusion: Implementation of a novel gynecologic interstitial brachytherapy template (SNAPP-IT) reduced procedure times, allowed direct tumor visualization, and decreased needle insertion depth. SNAPP-IT provides a useful alternative approach for vaginal interstitial brachytherapy, may increase brachytherapist efficiency with complex procedures and potentially expands access to interstitial brachytherapy.

High-Dose-Rate Brachytherapy as an Organ-Sparing Treatment for Early Penile Cancer.

Low-dose-rate brachytherapy is an effective organ-sparing treatment for patients with early-stage penile cancer. However, only limited data are available on the role of high-dose-rate brachytherapy (HDR-BT) in this clinical setting. Between 2002 and 2020, 31 patients with early penile cancer were treated at our center with interstitial HDR BT at a dose of 18 × 3 Gy twice daily. A breast brachytherapy template was used for the fixation of stainless hollow needles. The median follow-up was 117.5 months (range, 5-210). Eight patients (25.8%) developed a recurrence; of these, seven were salvaged by partial amputation. Six patients died of internal comorbidities or a second cancer. The probability of local control at 5 and 10 years was 80.7% (95% CI: 63.7-97.7%) and 68.3% (95% CI: 44.0-92.6%), respectively. Cause-specific survival was 100%. Only one case of radiation-induced necrosis was observed. The probability of penile sparing at 5 and 10 years was 80.6% (95% CI: 63.45-97.7%) and 62.1% (95% CI: 34.8-89.4%), respectively. These results show that HDR-BT for penile cancer can achieve results comparable to LDR-BT with organ sparing. Despite the relatively large patient cohort-the second largest reported to date in this clinical setting-prospective data from larger samples are needed to confirm the role of HDR-BT in penile cancer.

High-Dose Rate Brachyther-apy in the Treatment of Early Stages of Penile Carcinoma.

Interstitial low dose rate brachyther-apy is established organ spar-ing treatment of T1-&#8202;T2penile carcinoma. Experience with high-dose rate brachyther-apy is limited in this indication. Twenty-six patients with early penile carcinoma were treated by high-dose rate brachyther-apy at dose 18×3Gy per fraction twice daily between 2002-&#8202;2018at the Department of Oncology and Radiother-apy, University Hospital in Hradec Kralove. Breast interstitial brachyther-apy template was used for fixation and precise geometry reconstruction of stainless hollow needles. Median follow up was 85months (range 7-&#8202;200months). Acute reaction usually consisted of grade 2mucositis that dissolved dur-ing 8weeks after the treatment. Local recurrence occurred in 6patients, 5of them were successfully treated with partial amputation. One patient had anodal recurrence successfully salvaged by lymphadenectomy. One patient developed necrosis of the glans requir-ing partial amputation. Currently, there are 24patients alive without signs of dis-ease. One patient died of cardiac comorbidity, one died of duplicate lung cancer. Nineteen patients have apreserved penis (73%), 18of them sexually active before treatment report satisfactory intercourse. Hyperfractionated interstitial high-dose rate brachyther-apy with 18×3Gy per fraction twice daily is apromis-ing method in selected patients with penile carcinoma and deserves further evaluation in alarger prospective study. Key words penile neoplasms-&#8202; conservative treatment-&#8202; brachyther-apy This work was supported by programm Progres Q40. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 8. 1. 2019 Accepted: 15. 1. 2019.

The role of a template-assisted cognitive transperineal prostate biopsy technique in patients with benign transrectal prostate biopsies: a preliminary experience.

IntroductionUrologists are commonly facing the dilemma of elevating prostate-specific antigen (PSA) levels despite a series of negative prostate biopsy results. Although fusion biopsies are being used increasingly, they are not available in many centers. We evaluated the prostate cancer detection rate using transperineal magnetic resonance imaging (MRI) template-guided cognitive biopsy.Material and methodsTwenty-two patients with a suspicious lesion on MRI were enrolled into this study and underwent a repeated biopsy. All procedures were done under anesthesia and with antibiotic prophylaxis. Brachytherapy template was applied in each case.ResultsThe median age, PSA and prostate volume were 67 years, 9.2 ng/ml, and 65 ml, respectively. The average number of biopsy cores was 24. Nine patients (41%) were diagnosed with prostate cancer. The grade distribution was Gleason score 7 for 5 patients, and Gleason score 6 for 4 patients. No major complications occurred.ConclusionsTransperineal MRI template-guided cognitive prostate biopsy appears to be a safe procedure, which helps to detect significant cancer. The biopsy-associated adverse events are negligible.

Transperineal template-guided saturation biopsy aimed at sampling one core for each milliliter of prostate volume: 103 cases requiring repeat prostate biopsy

BackgroundWe evaluated the cancer detection rate of prostate cancer using transperineal template-guided saturation biopsy aimed at sampling one core for each milliliter of prostate volume for patients requiring repeated prostate biopsies.MethodsIn total, 103 consecutive patients with repeated prostate biopsies were enrolled in this retrospective study. The number of biopsy cores was defined by prostate volume. In principle, one biopsy core covered 1 mL of prostate volume. We used a prostate brachytherapy template with a 5-mm grid and adopted a transperineal needle biopsy.ResultsThe median age, prostate-specific antigen level, and prostate volume were 69 (range, 37–83) years, 9.2 (range, 1.9–107) ng/mL, and 34.7 (range, 18–76.7) mL, respectively. The median number of biopsy cores was 37 (range, 18–75 cores). Fifty-three patients (51.5%) were diagnosed with prostate cancer. The Gleason score was 6, 7, and 8–10 in 24.5, 64.2 and 11.3% patients, respectively. Forty-two patients (79.2%) were diagnosed with clinically significant PCa. Acute urinary retention was detected in 2 patients (1.9%).ConclusionsTransperineal template-guided saturation biopsy with one core per milliliter of prostate volume helped achieve a high cancer detection rate and high significant cancer detection rate with acceptable biopsy-associated adverse events.

MP38-06 ZERO HOSPITAL ADMISSIONS FOR INFECTION AFTER 1359 TRANSPERINEAL PROSTATE BIOPSIES

You have accessJournal of UrologyProstate Cancer: Detection & Screening IV1 Apr 2017MP38-06 ZERO HOSPITAL ADMISSIONS FOR INFECTION AFTER 1359 TRANSPERINEAL PROSTATE BIOPSIES Lana Pepdjonovic, Sean Huang, Anthony Dat, Sarah Mann, Mark Frydenberg, Daniel Moon, Ross Snow, Uri Hanegbi, Adam Landau, and Jeremy Grummet Lana PepdjonovicLana Pepdjonovic More articles by this author , Sean HuangSean Huang More articles by this author , Anthony DatAnthony Dat More articles by this author , Sarah MannSarah Mann More articles by this author , Mark FrydenbergMark Frydenberg More articles by this author , Daniel MoonDaniel Moon More articles by this author , Ross SnowRoss Snow More articles by this author , Uri HanegbiUri Hanegbi More articles by this author , Adam LandauAdam Landau More articles by this author , and Jeremy GrummetJeremy Grummet More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1159AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Transrectal biopsy is plagued by an increasing rate of serious infection, despite use of recommended fluoroquinolone antibiotics. Transperineal biopsy (TPB), on the other hand, has been associated with an exceedingly low rate of serious infection. The aim of this study was to determine the rate of hospital admissions for infection after transperineal biopsy of prostate. METHODS Patients underwent transperineal biopsy of the prostate (TPB) between May 2012 and October 2016 by a private group urology practice, at multiple hospitals across Melbourne. A standard brachytherapy template grid was used, taking a number of samples from left and right prostate posterior, mid and anterior regions. Some patients had extra core biopsies taken from target areas suspicious of cancer identified on prior MRI. Data collected from these patients were entered into an ethics approved prospective database including prophylactic antibiotics used and post operative complications. RESULTS 1359 consecutive patients underwent TPB. Initially patients were treated with quinolone prophylaxis and then later patients received cephazolin only. 1030 (75.8%) had single dose IV cephazolin, 388 (28.6%) had an oral quinolone with IV cephazolin, 107 (7.9%) had IV ceftriaxone and 2 (0.1%) had IV clindamycin, 2 (0.1%) had IV meropenem and 1 (0.1%) had IV vancomycin prophylaxis. Routine practice shifted from use of quinolones to cephazolin during the study period. 25 (1.8%) patients developed acute urinary retention and 1 patient was treated in the community with oral antibiotics for prostatitis. No patients were readmitted to hospital with infection. CONCLUSIONS Sepsis post TPB is an exceedingly rare complication, with a 0% rate in this large prospective multicentre cohort. It is safe to use single dose cephazolin only as antibiotic prophylaxis prior to TPB, negating the need for quinolones. This study supports the current Australian Therapeutic Guidelines recommendation for TPB prophylaxis. Whether any antibiotic prophylaxis is needed at all for TPB is the subject of a future study. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e486 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Lana Pepdjonovic More articles by this author Sean Huang More articles by this author Anthony Dat More articles by this author Sarah Mann More articles by this author Mark Frydenberg More articles by this author Daniel Moon More articles by this author Ross Snow More articles by this author Uri Hanegbi More articles by this author Adam Landau More articles by this author Jeremy Grummet More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Real-time electromagnetic seed drop detection for permanent implants brachytherapy: Technology overview and performance assessment.

To describe the principles and report on the performance of a novel real-time electromagnetic (EM) seed drop detection technology for permanent implants brachytherapy procedures. A novel EM hollow needle prototype was recently developed by Philips. It possesses standard 3D tracking capability as well as a seed drop detection mechanism, both performed from a single custom built EM sensor. The detection mechanism is based on the magnetic permeability changes in the sensor as the seeds pass through. Drop position estimates are generated by the tracking information at the dropping instants. Three validation experiments were carried out in this study. First, the robustness of the detection mechanism was tested in free air with four different seed types. Detection waveforms were measured and commented. The accuracy of the seed drop position estimates was then evaluated using both 2D and 3D experiments. The procedures consisted of dropping seeds in phantoms, recording the drop position estimates, and finally registering the resulting spatial distributions on reference ones obtained by accurate modalities. Seeds were dropped on a specially designed plastic support adapted to brachytherapy template dimensions for 2D experiments, and true seed positions (reference distribution) were obtained by optical detection. In 3D experiments, seeds were dropped in edible gelatin and reference distributions were obtained by localizing the implants from CT scans of the phantoms. All four seed types were correctly detected by the needle prototype. In total, 250 seeds were dropped on the plastic support, and 96 were dropped in gelatin phantoms. The detection rate was 100% in both cases. The minimum, maximum, and average drop position errors were, respectively, 0.1(+1.6/ - 0.1), 2.9(+1.4/ - 1.5), and 0.9(+1.4/ - 0.7) mm for 2D, and 0.1(+1.0/ - 0.1), 2.1(+1.1/ - 0.8), and 0.6(+1.2/ - 0.5) mm for 3D experiments. The hollow needle prototype combines both EM tracking and automatic seed drop detection in a compact and convenient form. The EM detection mechanism is robust, and the seed drop position estimates appear sufficiently accurate for potential integration of the technology to current brachytherapy treatment planning systems. In that context, it would serve as a valuable tool for rapid dosimetry validation in real-time treatment delivery.

Predictors of prostate cancer in ultrasound-guided transperineal saturation biopsy in Turkish men with multiple prior negative biopsies.

Transperineal prostate biopsy (STPB) is associated with an improved cancer detection rate and an increase in anterior and apical prostate cancers compared to standard transrectal biopsy. A total of 48 men with at least two sets of prior prostate biopsies underwent transrectal ultrasound-guided STPB. Prostate rebiopsy indications were serum prostate-specific antigen (PSA) levels greater than 2.5 ng/mL and/or abnormal digital rectal examination and/or presence of high-grade prostatic intraepithelial neoplasia (HGPIN; ≥2 cores) or atypical small acinar proliferation (ASAP) at previous biopsies. The procedure was performed at dorsal lithotomy position under general anesthesia using a perineal 0.5 cm brachytherapy template attached to the transrectal ultrasound probe. Specimens from each zone were sent separately for pathological examination. Mean PSA level at STPB was 15.9 ng/mL (range 4.03 to 59.57). An average of 54.5 cores was obtained. Prostate adenocarcinoma was detected in 15 of 48 (31%) patients. Mean percentage of malignant cores was 11.9%. Multivariate logistic regression analysis revealed that age and presence of ASAP or HGPIN at previous biopsies were independent predictors of prostate cancer (p&lt;0.05). No major complications, including sepsis and severe urinary or rectal bleeding, were observed in any of the patients. Five patients (10%) developed acute urinary retention after the procedure requiring urethral catheterization. Considerable number of patients with negative multiple biopsies were diagnosed with prostate cancer. STPB is a well-tolerated procedure with minimal morbidity, which can be considered for the diagnosis of prostate cancer in patients with previous negative biopsies.

Prostate biopsies using both gray scale and 3D color flow power doppler ultrasound (3DCFPDU).

103 Background: Historically, prostate cancer (CAP) is identified through random biopsies. Experts usually recommend 10-12 core transrectal ultrasound guided biopsies (TRUS). This often leads to sampling errors with missed diagnosis, delayed and repeated biopsies, understaging and finding indolent CAP leading to over treatment. Advances in 3DCFPD imaging suggest that selective biopsies may be superior to standard TRUS biopsies. Methods: 192 consecutive patients were biopsied (Feb. 2012 – July 2014) in the dorso-lithotomy position with local anesthesia. Median number of biopsies per patient = 8; total number of cores = 1,520. Only 3 patients had not been previously biopsied (median previous biopsies = 2). We studied tumor detection rate using combined gray scale and 3DCFPD with direct sampling of specific regions using the transperineal brachytherapy template guided method as a simple outpatient procedure. Inclusion criteria were abnormal DRE, PSA kinetics 0.75ng/mg/yr, PSA &gt;10 and % free PSA &lt;17. PSA density 0.27. Cores were stratified into 4 risk groups: 1) hypoechoic lesion (72 patients, 648 cores); 2) hypervascular lesion (26 patients, 182 cores); 3) hypoechogenic with hypervascular pulsatile vessels synchronous and coinciding with normal cardiac pulse (32 patients, 256 cores); and 4) hypoechogenic with hypervascular non-pulsatile vessels suggesting independent vascular flow consistent with neoplasm (62 patients, 434 cores). Isoechoic regions were not biopsied. Subgroups were analyzed using chi-square, student t-test, and logistic regression. Results: The diagnostic yield associated with Group 4 was statistically significantly higher compared to: 1.) 20% biopsy positive (p &lt;0.5); 2.) 19% biopsy positive (p &lt;0.3); 3.) 55% biopsy positive (p &lt;0.1); 4.) 97% biopsy positive (p &lt;0.1). Only Group 4 revealed a greater number of Gleason 7-10 CAP (p &lt;0.1). Conclusions: Transperineal template guided biopsies with gray scale and 3DCFPD are highly effective and cost effective. This may lead to reducing the number of prostate biopsies performed, better staging and allowing for enhanced detection of serious CAP by targeting the most suspicious lesions. Additional research should study the diagnostic gain with 3DCFPD.

Novel Robotic Assisted Polyglactin 910 Mesh Sling Application (RSSA) for Prevention of Small Bowel Radiation Exposure during Syed-Nesblett Brachytherapy Template (SNBT) Insertion: A Pilot Study

Novel Robotic Assisted Polyglactin 910 Mesh Sling Application (RSSA) for Prevention of Small Bowel Radiation Exposure during Syed-Nesblett Brachytherapy Template (SNBT) Insertion: A Pilot Study

2223 MEN CONSIDERING ACTIVE SURVEILLANCE FOR LOW VOLUME PROSTATE CANCER FOUND AT TRUSB DEMONSTRATE LARGER VOLUMES OF DISEASE THAN EXPECTED AT ADAPTED TRANSPERINEAL GUIDED TEMPLATE BIOPSY (ATSB)

INTRODUCTION AND OBJECTIVES: With increasing sensitivity of detection a significant proportion of men are diagnosed with minimal volume prostate cancer (MVPCa). The false negative rate associated with TRUSB is well documented; logic extends this unreliability to PCa volume prediction. To address this aTSB has been offered to all patients considering active surveillance with MVPCa, suitable for radical treatment who presented to one regional tumour network meeting from a non-screened population of 1 million over 4 years. METHODS: 46 patients who were found to have MVPCa at TRUSB underwent aTSB within 12 months of TRUSB. MVPCa was defined by 5% Gleason 7, 25% Gleason 6 and in all cases involving no more than 2cores at TRUSB. aTSB was performed using a brachytherapy template and implant probe, avoiding the periurethral area at the base. RESULTS: Median age was 64yrs(range 49-79), median PSA 8.1ng/ml(0.44-35), median prostate volume measured at aTSB 37cc(16-74) and PSAD 0.22(0.02-0.73), Median time from last TRUSB 106days(55-321). 9 had PSAD 0.15. Mean of 26 cores(15-37) was taken, resulting in mean of 0.7cores/cc(0.4-0.9). Upgrading occurred in 30/46 patients following aTSB(65%), with Gleason scores rising to 7,8,or 9 and mean aggregate cancer core length recorded at 13mm(0.4-121.3). The number of positive cores was 3 in 54%, median 4(1-13). aTSB was negative in 5 patients, two with a PSAD 0.15, one with an initially positive TRUS then subsequent negative result, all had a tiny focus of PCa at TRUSB and all but 1 had a benign MRI. 17 (37%), initially considering AS after TRUSB, subsequently selected radical treatments following aTSB. PSA, PSAD or %Free PSA did not provide reliable cut-off points for prediction of upstaging. CONCLUSIONS: This study confirms that TRUSB is not reliable in its prediction of mVPCa. In those considering active surveillance an aTSB is advocated. The aTSB result provides a more accurate estimate of cancer volume and distribution, informing on suitability for active surveillance or the most appropriate radical treatment.

Automated intraoperative calibration for prostate cancer brachytherapy

Prostate cancer brachytherapy relies on an accurate spatial registration between the implant needles and the TRUS image, called "calibration". The authors propose a new device and a fast, automatic method to calibrate the brachytherapy system in the operating room, with instant error feedback. A device was CAD-designed and precision-engineered, which mechanically couples a calibration phantom with an exact replica of the standard brachytherapy template. From real-time TRUS images acquired from the calibration device and processed by the calibration system, the coordinate transformation between the brachytherapy template and the TRUS images was computed automatically. The system instantly generated a report of the target reconstruction accuracy based on the current calibration outcome. Four types of validation tests were conducted. First, 50 independent, real-time calibration trials yielded an average of 0.57 ± 0.13 mm line reconstruction error (LRE) relative to ground truth. Second, the averaged LRE was 0.37 ± 0.25 mm relative to ground truth in tests with six different commercial TRUS scanners operating at similar imaging settings. Furthermore, testing with five different commercial stepper systems yielded an average of 0.29 ± 0.16 mm LRE relative to ground truth. Finally, the system achieved an average of 0.56 ± 0.27 mm target registration error (TRE) relative to ground truth in needle insertion tests through the template in a water tank. The proposed automatic, intraoperative calibration system for prostate cancer brachytherapy has achieved high accuracy, precision, and robustness.

851 EARLY DEVELOPMENT OF A MULTIPLEX GIANT MAGNETORESISTIVE NANOSENSOR TO DETECT URINARY MARKERS TO DISCRIMINATE BETWEEN HIGH AND LOW GRADE PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: Transperineal mapping template prostate biopsy (TMTPB) has emerged as a diagnostic option for men with a history of negative transrectal guided prostate biopsies. Reported advantages include more precise sampling of the entire prostate gland including the anterior and apical regions. We sought to determine the detection rate and distribution of prostate cancer (PCa) in a group of men with previous negative TRUS biopsy. METHODS: Forty one patients with a history of 1 or more previous negative biopsies underwent TMTPB for primary indication of elevated PSA, elevated PSA velocity, and/or abnormal DRE. Using a transperineal approach, the prostate was systematically biopsied in 26 unique regions guided by a brachytherapy template. Prostate size determined total number of cores. Clinical and biopsy parameters were evaluated as predictors for presence and location of PCa. RESULTS: The overall PCa detection rate was 53.7% (22 of 41). Significant PCa (Gleason score 7) was noted in 14 of 41 (34.1%) patients including 4/41 (9.8%) with high grade PCa (Gleason score 8). There was an average of 4.32 cores positive (S.D. 3.54). 79.8% of positive cores were in the anterior zones vs. only 22.2% were in the posterior zones (p 0.0001). However, the 13 positive cores for Gleason 8 or 9 cancers were evenly distributed: anterior in 7 cores, posterior in 5 cores and periurethral in 1 core. Men had a mean of 2.78 (S.D. 1.46) prior biopsies prior to TMTPB and the number of prior biopsies was not associated with detection. On multivariate analysis for predictors of presence of cancer, only prostate volume was significant (p 0.03). Complications were limited in 8 patients (19.5%): urinary retention (3), hematuria (4) and atrial fibrillation with rapid ventricular rate (1) requiring admission. CONCLUSIONS: TMTPB has a high rate of cancer detection, especially in the anterior zones, even in the setting of multiple previous negative biopsies. A majority of the detected cancers were clinically significant based on Gleason score. Therefore, TMTPB should be considered in any high risk patient with previous negative biopsies.

1634 TRANSPERINEAL MAPPING TEMPLATE PROSTATE BIOPSY ADDRESSES UNDER SAMPLING FOR MEN CONSIDERING ACTIVE SURVEILLANCE

You have accessJournal of UrologyProstate Cancer: Localized1 Apr 20111634 TRANSPERINEAL MAPPING TEMPLATE PROSTATE BIOPSY ADDRESSES UNDER SAMPLING FOR MEN CONSIDERING ACTIVE SURVEILLANCE Michael Rowley, Chang He, Rabia Siddiqui, Stephanie Meyers, John Wei, David Wood, and Priya Kunju Michael RowleyMichael Rowley Ann Arbor, MI More articles by this author , Chang HeChang He Ann Arbor, MI More articles by this author , Rabia SiddiquiRabia Siddiqui Ann Arbor, MI More articles by this author , Stephanie MeyersStephanie Meyers Ann Arbor, MI More articles by this author , John WeiJohn Wei Ann Arbor, MI More articles by this author , David WoodDavid Wood Ann Arbor, MI More articles by this author , and Priya KunjuPriya Kunju Ann Arbor, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1743AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Appropriate patient selection for active surveillance (AS) is crucial given the goal to select for a low risk population. We present our institutional experience with transperineal mapping template prostate biopsy (TMTPB) as an entrance criteria for AS and its effect on management. METHODS 78 patients underwent TMTPB as an entrance criteria for AS. Pathologic institutional AS criteria in men ≤ 70 years include Gleason (Gl) score < 7, ≤ 1/3 of all cores involved and ≤ 50% of any individual core involved. Inclusion criteria for men > 70 years include Gl 6 or 3+4 = 7 disease with no restriction on number or percent of cores positive. Using a transperineal approach, the prostate was systematically biopsied in 26 unique regions guided by a brachytherapy template. Prostate size determined total number of cores. Clinical and biopsy parameters were evaluated as predictors for whether entrance TMTPB changed the decision to go on to definitive therapy. RESULTS A mean of 62.8 cores were taken on TMTPB. 61 of 78 (78.2%) TMTPBs were positive for cancer. Highest Gl in patients were as follows: 34 of 78 (43.6%) Gl 6, 20 (25.6%) Gl 3+4, 4 (5.1%) Gl 4+3, and 3 (3.8%) Gl 8 or 9. Gl score was upgraded on TMTPB in 11 of 41 (26.8%) cases where the previous biopsy was available for pathologic review. Only 50 of 78 (64.1%) patients met institutional criteria for AS following TMTPB. Of the 28 cases that did not meet institutional criteria, 26 (92.9%) cases were because of Gl score and 2 (7.1%) cases were because the greatest % positive core was > 50%. 20 of 78 (25.6%) patients switched from AS to definitive therapy based on the result of the TMTPB. These patients had a higher PSA (p=0.02), higher PSA density (0.01) and higher greatest % positive core (p=0.0006) on previous biopsy. Predictors for change in management on multivariate regression included PSA density (p=0.03). Complications were limited in 10 patients (12.8%): urinary retention (5) and hematuria (5). CONCLUSIONS TMTPB leads to a change in management strategy from AS to definitive therapy in a significant percentage of patients. A significant proportion of biopsies lead to an upgrading of Gleason score. Therefore, patients contemplating AS should undergo a TMTPB for more accurate risk assessment and staging. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e655-e656 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Rowley Ann Arbor, MI More articles by this author Chang He Ann Arbor, MI More articles by this author Rabia Siddiqui Ann Arbor, MI More articles by this author Stephanie Meyers Ann Arbor, MI More articles by this author John Wei Ann Arbor, MI More articles by this author David Wood Ann Arbor, MI More articles by this author Priya Kunju Ann Arbor, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

COMBINED ANESTHESIA WITH PERIANAL-INTRARECTAL LIDOCAINE-PRILOCAINE CREAM AND PERIPROSTATIC NERVE BLOCK DURING TRANSRECTAL ULTRASOUND-GUIDED PROSTATE BIOPSY: A RANDOMIZED CONTROLLED TRIAL

Review the literature concerning transperineal transrectal ultrasound (TRUS)-guided prostate biopsy (PBx), providing an update on the topic.The literature review was performed using PubMed through a free text search strategy. The authors reviewed the abstracts of the retrieved records to select the relevant papers.The search retrieved 196 records; 68 were relevant to the issue. No high-level evidence recommends a particular kind of preparation/prophylaxis for transperineal PBx. It can be performed with a brachytherapy template under general or spinal anesthesia, or with a local periprostatic nerve block through a single-access fan technique. In the former case, up to 50 cores are obtained; in the latter, 12–26 cores. Prostate cancer detection rates range from 24% to 51%, with figures of 27–49% in patients undergoing their first PBx for a prostate-specific antigen level of 4–10 ng/ml. Such percentages are directly related to the number of cores obtained. In repeat biopsy and in prostates > 50 cc, the number of cores should be increased, paying particular attention in sampling the anterior zone. Among the studies comparing transrectal and transperineal PBx, only two demonstrated differences in detection rates in favor of the transperineal approach. Major complications are rare, with fever occurring in 0–5.2% and hospitalization in 0–1.4% of cases.Transperineal TRUS-guided PBx is a safe procedure, with high detection rates and wide applications both in first and in repeat sampling. Although having a strong rationale, the transperineal approach has so far not resulted in higher detection rates than transrectal biopsies.

Extensive transperineal template biopsies of prostate: Modified technique and results

Objectives To describe the modified technique and results of extensive transperineal template prostate biopsies in men with a high risk of prostate cancer in whom repeated transrectal biopsies are not diagnostic. Methods Men who had a rising prostate-specific antigen (PSA) level and had at least two sets of benign octant biopsies or two or more prior biopsies containing high-grade prostatic intraepithelial neoplasia or atypical small acinar proliferation were included. A biplanar transrectal ultrasound probe was attached to a brachytherapy stepping unit and a standard 0.5-cm brachytherapy template was positioned over the perineum. In the transverse image, the prostate was divided into right and left and anterior, middle, and posterior regions, and three to five transperineal biopsy cores were taken in each of the six regions through the template. Results Sixty men underwent extensive transperineal template biopsies. Their mean age was 64 years (SD 6.4), the median PSA level was 12.9 ng/mL (range 4.6 to 35.7), and the median prostate volume was 54 cm 3 (range 34 to 199). Cancer was detected in 23 men (38%), of whom 17 (74%) had Gleason grade 6, 5 (21%) Gleason grade 7, and 1 (4%) Gleason grade 9 disease. Cancer was identified in the anterior region of the prostate alone in 12 men (60%). One man required overnight admission for hematuria and two developed urinary retention; no cases of sepsis developed. Conclusions In men with a clinical suspicion of prostate cancer, but benign or equivocal prostate biopsies, extensive transperineal template biopsy of the prostate is a useful diagnostic tool. It allows sampling of the whole prostate in a systematic and safe fashion.

Re-biopsy of the Prostate Using a Stereotactic Transperineal Technique

In this study we investigated the detection rate and morbidity of stereotactic transperineal prostate re-biopsy with 3-dimensional mapping for diagnosis of nonpalpable isoechoic occult prostate malignancy. A total of 180 consecutive patients with continued increasing total prostate specific antigen and at least 1 prior benign transrectal prostate biopsy underwent stereotactic transperineal prostate biopsy at a single outpatient institution between April 2004 and March 2006. Similar to a prostate brachytherapy procedure, patients were placed in the dorsal lithotomy position. With the patient under general anesthesia, and using transrectal ultrasound, a perineal brachytherapy template and stabilizing device, the prostate was positioned on the implant grid. It was equally divided into 8 sections (octants) according to x and y coordinates on the mid gland axial image. The midplanes of axial and sagittal prostate gland images for each patient determined the x, y and z coordinates that would occupy each octant. Tissue cores were initially obtained from the apical octants, followed by identical x and y coordinates of the basilar octants. Specimens from each specific octant were placed in 1 of 8 specimen jars and pathological review was reported accordingly. Stereotactic transperineal prostate biopsy yielded positive biopsies identifying adenocarcinoma in 68 of 180 (38%) patients. Acute urinary retention developed in 18 of 180 (10%) patients requiring an indwelling urinary catheter upon discharge home. In all patients estimated blood loss was less than 5 cc and median pain score was 1 of 10. Stereotactic transperineal prostate biopsy is extremely well tolerated and useful for diagnosis of nonpalpable isoechoic occult prostate malignancy. Additionally, stereotactic transperineal prostate biopsy provides comprehensive tissue sampling with accurate 3-dimensional mapping of malignancy in this select group of patients.

Updated Results of a Phase I Trial of Motexafin Lutetium-Mediated Interstitial Photodynamic Therapy in Patients with Locally Recurrent Prostate Cancer

Locally recurrent prostate cancer after treatment with radiation therapy is a clinical problem with few acceptable treatments. One potential treatment, photodynamic therapy (PDT), is a modality that uses laser light, drug photosensitizer, and oxygen to kill tumor cells through direct cellular cytotoxicity and/or through destruction of tumor vasculature. A Phase I trial of interstitial PDT with the photosensitizer Motexafin lutetium was initiated in men with locally recurrent prostate cancer. In this ongoing trial, the primary objective is to determine the maximally tolerated dose of Motexafin lutetium-mediated PDT. Other objectives include evaluation of Motexafin lutetium uptake from prostate tissue using a spectrofluorometric assay and evaluation of optical properties in the human prostate. Fifteen men with biopsy-proven locally recurrent prostate cancer and no evidence of distant metastatic disease have been enrolled and 14 have been treated. Treatment plans were developed using transrectal ultrasound images. The PDT dose was escalated by increasing the Motexafin lutetium dose, increasing the 732 ran light dose, and decreasing the drug-light interval. Motexafin lutetium doses ranged from 0.5 to 2 mg/kg administered IV 24, 6, or 3 hr prior to 732 ran light delivery. The light dose, measured in real time with in situ spherical detectors was 25-100 J/cm2. Light was delivered via optical fibers inserted through a transperineal brachytherapy template in the operating room. Optical property measurements were made before and after light therapy. Prostate biopsies were obtained before and after light delivery for spectrofluorometric measurements of photosensitizer uptake. Fourteen patients have completed protocol treatment on eight dose levels without dose-limiting toxicity. Grade I genitourinary symptoms that are PDT related have been observed. One patient had Grade II urinary urgency that was urinary catheter related. No rectal or other gastrointestinal PDT-related tox-icities have been observed to date. Measurements of Motexafin lutetium demonstrated the presence of photosensitizer in prostate tissue from all patients. Optical property measurements demonstrated substantial heterogeneity in the optical properties of the human prostate gland which supports the use of individualized treatment planning for prostate PDT.

Treatment of Organ Confined Prostate Cancer with Third Generation Cryosurgery: Preliminary Multicenter Experience

Cryosurgical ablation of the prostate is 1 approach to the treatment of localized prostate cancer. Third generation cryosurgery uses gas driven probes that allow for a decrease in probe diameter to 17 gauge (1.5 mm). The safety, morbidity and preliminary prostate specific antigen (PSA) results of 122 cases are reported. A total of 106 patients have undergone percutaneous cryosurgery using a brachytherapy template with at least 12 months of PSA followup. Immediate and delayed morbidities were evaluated. PSA results at 3 and 12 months were recorded, and failure was defined as the inability to reach a nadir of 0.4 ng/ml or less. Complications in patients undergoing primary cryosurgery included tissue sloughing (5%), incontinence (pads, 3%), urge incontinence/no pads (5%), transient urinary retention (3.3%) and rectal discomfort (2.6%). There were no cases of fistulas or infections. Postoperative impotence was 87% in previously potent patients. For patients who underwent salvage cryosurgery there were no fistulas reported and 2 (11%) patients required pads after salvage cryosurgery. A total of 96 (81%) patients achieved a PSA nadir of 0.4 ng/ml or less at 3 months of followup, while 79 of 106 (75%) remained free from biochemical recurrence at 12 months. A total of 42 (78%) low risk patients (Gleason score 7 or less and PSA 10 or less) remained with a PSA of 0.4 ng/ml or less at 12 months of followup, compared to 37 (71%) high risk patients. All patients were discharged within 24 hours. After a followup of 1 year 3rd generation cryosurgery appears to be well tolerated and minimally invasive. The use of ultrathin needles through a brachytherapy template allows for a simple percutaneous procedure and a relatively short learning curve. A prospective multicenter trial is ongoing to determine the long-term efficacy of this technique.

Prostate cryoablation using direct transperineal placement of ultrathin probes through a 17-gauge brachytherapy template—technique and preliminary results

Objectives. To describe a new surgical approach to third-generation cryoablation of the prostate and present our preliminary results. Methods. The technique is detailed and demonstrated in a Web-based video- clip tutorial. Ninety-two men underwent prostate cryoablation (71 primary ablations, 19 salvage procedures, and 2 repeated cryoablations), using direct transperineal placement of ultrathin probes through a 17-gauge brachytherapy template. Results. No fistulous or major complications were observed. Eight patients (8.3%) had minor complications. In 36 patients, the follow-up period was long enough to permit nadir prostate-specific antigen (PSA) evaluation. In 31 (86%), the nadir PSA was 0.5 ng/mL or less. In 5 patients, the nadir PSA was greater than 0.5 ng/mL. The workup revealed systemic failure in 3 patients and inadequate eradication of the prostate gland in 2 patients. In 18 (86%) of 21 androgen-ablation-naive patients, the nadir PSA was 0.5 ng/mL or less. Nine (43%) had an undetectable nadir PSA and 3 had a nadir PSA of greater than 0.5 ng/mL. Conclusions. A modified, less-invasive approach to cryoablation of the prostate is presented. The preliminary results do not show an increased rate of complications compared with other published series. The clinical outcome data are preliminary. Longer follow-up data are required to draw conclusions concerning efficacy.