History Of Transurethral Resection Of The Prostate Research Articles

Extreme hypofractionated stereotactic radiotherapy for localized prostate Cancer: Efficacy and late urinary toxicity according to transurethral resection of the prostate history

Background and purposeExtreme hypofractionated stereotactic body radiotherapy (SBRT) is a therapeutic alternative for localized low- or intermediate-risk prostate cancer. Despite the availability of several studies, the toxicity profile of SBRT has not been comprehensively described. This real-world evidence study assessed the efficacy and toxicities associated with this regimen, and potential prognosis factors for genitourinary toxicities. Materials and methodsThis retrospective study included 141 consecutive patients with localized prostatic adenocarcinoma treated with CyberKnife™ SBRT, as primary irradiation, at the Oscar Lambret Center between 2010 and 2020. The prescribed dose was 36.25 Gy in 5 fractions. Acute and late toxicities were graded according to the CTCAE (version 5.0). Biochemical recurrence-free survival (bRFS) and overall survival (OS) were estimated using the Kaplan–Meier method. The cumulative incidence of biochemical recurrence (cBR) was estimated using the Kalbfleisch–Prentice method. ResultsAmong the included patients, 13.5 % had a history of transurethral resection of the prostate (TURP). The median follow-up was 48 months. At 5 years, bRFS, cBR, and OS were 72 % (95 %CI: 61–81), 7 % (95 %CI: 3–14), and 82 % (95 %CI: 73–89), respectively. Twenty-nine patients experienced at least one late toxicity of grade ≥ 2; genitourinary (N = 29), including 3 cases of chronic hematuria, and/or gastrointestinal (N = 1). The cumulative incidence of late urinary toxicity of grade ≥ 2 was 20.6 % at 5 years (95 %CI: 13.9–28.1). Multivariate analysis revealed that a history of TURP was significantly associated with late urinary toxicity of grade ≥ 2, after adjusting for clinical target volume (Odds Ratio = 3.06; 95%CI: 1.05–8.86; P = 0.04). ConclusionExtreme hypofractionated SBRT is effective for localized prostate cancer with a low risk of late toxicity. A history of TURP is associated with a higher risk of late urinary toxicity. These findings may contribute to the optimal management of patients treated with this regimen, particularly those with a history of TURP.

Safety of transurethral resection of large prostate.

Benign prostatic hyperplasia is a common benign disease occurs in older men. Some patients can be treated medically but eventually, most of them will need a surgical intervention, and the most commonly applied procedure is transurethral resection of the prostate (TURP). The objective of this study is to assess the feasibility and safety of performing transurethral resection of large prostate (80 g and more). Out of 153 patients reviewed 48 cases included in this study. The main data collected from patients' files and patient interview. The criteria of exclusion were prostate size <80 g and previous history of TURP. The collected data were analyzed by the Statistical Package for the Social Sciences (SPSS). The main results showed that 93.7% of patients did not experience major bleeding postoperatively, neither major drop in hemoglobin level. Moreover, the patient's distribution according to the presence of TUR syndrome was only 2.1% with mild symptoms. No patient had an episode of retention during the hospital stay or in the follow-up. Surgeon experience, systematic resection approach, and strict time of resection are important factors to assure the safety of TURP in large prostate. In cases of huge prostate size >100 g, staged TURP can be offered safely or if patients' obstructive symptoms do not resolve after the first procedure.

Surgical Treatments of Benign Prostatic Hyperplasia and Prostate Cancer Stereotactic Radiotherapy: Impact on Long-Term Genitourinary Toxicity

AimsAlthough the results on acute and late toxicity of ultrahypofractionation are encouraging, data on safety in prostate cancer patients with a medical history of transurethral resection of the prostate (TURP) or adenomectomy remain scarce, especially in cases of repeated procedures. The aim of the present study was to report on long-term toxicities after stereotactic body radiotherapy (SBRT) of prostate cancer patients with previous surgical treatment of benign prostatic hyperplasia. Materials and methodsAmong 150 patients treated with SBRT (median dose 36.25 Gy in five fractions) realised from 2014 to 2019 in a single-centre institution, data of 24 men with a history of TURP (n = 19) or adenomectomy (n = 5) were analysed. Repeated TURP was carried out in three patients, with a median time between surgery and SBRT of 54 months. Genitourinary toxicity was assessed using the Common Terminology Criteria for Adverse Events v4.0 grading scale. ResultsWith a median follow-up of 45 months, 10 of 24 (42%) patients experienced at least one episode of transient haematuria. One patient (4%) with three previous TURP presented a grade 3 acute non-infective cystitis. Late grade 2 and 3 genitourinary toxicities were observed in eight (33%) and four patients (17%) (two treated with adenomectomy, one with multiple TURP and one with a 140 cm3 prostate size), respectively, with no grade ≥4 adverse events. A complete recovery of grade 3 genitourinary toxicities was observed for all patients after hyperbaric oxygen therapy. ConclusionProstate SBRT is feasible and well-tolerated in patients with a medical history of surgical treatments of benign hyperplasia. Patients with prior adenomectomy or multiple TURP are at higher risk of developing severe genitourinary toxicity and should be carefully evaluated before SBRT treatments.

Does prior transurethral resection of prostate affect the functional and oncological outcomes of robot-assisted radical prostatectomy? A matched-pair analysis.

Robot-assisted radical prostatectomy (RARP) is challenging in men with prior history of transurethral resection of the prostate (TURP). Few studies analyze this peculiar group of patients, and hence we sought to investigate the outcome of RARP in post-TURP men. We interrogated our prospectively maintained database containing 643 patients who underwent RARP from January 2012 to December 2020. We matched 36 men with prior history of TURP consecutively to 72 men without prior TURP. The groups were matched for age, body mass index (BMI), Charlson comorbidity index (CCI), serum PSA, International Society of Urological Pathology (ISUP) grade groups and clinical stage. Men with prior history of stricture surgeries, pelvic radiation, ablative laser procedures, Urolift and Rezum were excluded from the study. Fisher's Exact test/Chi-square was used for the comparison of categorical variables. Mann-Whitney test (Independent group/Unpaired data) and Wilcoxon sign rank test (for paired data) were employed to analyze continuous variables. The complication rates, median day of drain removal and length of hospital stay were similar between the groups. The TURP group required bladder neck reconstruction twice as often as the non-TURP group (58.3% versus 29.1%, p = 0.0035) and a longer duration of postoperative catheterization (10 versus 8days, p = 0.0005). The rate of positive surgical margins was higher in the TURP group (30.5% versus 25%, p = 0.5414), albeit statistically insignificant. Biochemical recurrence (BCR) at one year (48.8% versus 60%, p = 0.0644) and zero pad/one safety-pad continence rates at one, three, six and twelve months were also not significantly different (14.3%, 35.4%, 59.2%, 81.6% for non TURP group versus 9.1%, 28.6%, 53.6%, 76.0% for TURP group). On multivariate analysis, prior TURP was not associated with a higher risk of BCR, margin positivity or incontinence. The oncological and functional outcomes of RARP post-TURP are comparable to men without prior TURP.

High-Dose Rate (HDR) Brachytherapy is a Safe and Effective Treatment for Prostate Cancer Patients With Prior Transurethral Resection of the Prostate (TURP)

To evaluate the clinical and patient-reported outcomes and toxicities in prostate cancer patients undergoing HDR brachytherapy after TURP.Data was prospectively collected for patients undergoing HDR brachytherapy from October 1991 to March 2016. Patients were classified according to NCCN risk criteria. Implants were performed under ultrasound-guidance with CT based planning. Goal dosimetric constraints included V100 Prostate > 95%, D1cc Urethra < 105%, D1cc Bladder < 75%, and D1cc Rectum < 75%. Multivariate cox analysis (MVA) was performed and adjusted for age, T stage, Gleason score, initial PSA, and androgen deprivation therapy (ADT) use. Sexual health inventory for men (SHIM) score, International Prostate Symptom Score (IPSS), and CTCAE v5.0 graded toxicity were recorded.2266 patients underwent HDR brachytherapy. 228 underwent a prior TURP. The median follow-up was 61.1 months (range 3 - 257.4 mos). The median time from TURP to HDR was 52.5 months (range 0.17 - 392 mos). A total of 641, 431, 617, and 577 patients were low-, favorable intermediate-, unfavorable intermediate-, and high-risk, respectively, of which 41, 49, 53, and 85 patients with TURP were low-, favorable intermediate-, unfavorable intermediate-, and high-risk, respectively. Patients with a prior history of TURP were more advanced in age and had a higher incidence of high-risk disease (P < 0.001). Of the patients with history of prior TURP, 49 (22%) and 54 (24%) patients experienced Gr 1 and 2 GU toxicity. 8 patients (3.5%) experienced grade 3 GU toxicity with a median time to occurrence of 16 mo (0.2 - 57.7 mo), and 3 of the Grade 3 toxicities resolved. No grade ≥4 GU toxicity and significant differences in toxicity were observed between the cohorts (P = 0.108). Patient-reported SHIM scores were found to not be statistically significant between prior TURP and non-TURP patients, with average decreases in SHIM no greater than 5 points at all time points in the TURP cohort. No significant differences were observed in biochemical free survival, distant metastases free survival, and prostate cancer specific survival at 4 and 8 years between patients who did and did not receive a prior TURP (8-yr BCFS 84.7% (95% CI: 78.2%-91.8%) vs. 89.1% (95% CI: 87.3-91.0%), respectively; P = 0.16). The TURP cohort was found to have lower overall survival (8-yr OS 72.0% (95% CI 64.8%-79.9%) vs. 81.9% (95% CI: 80.0% - 84.1%) respectively; P = 0.041), and may be attributed to the older age of the TURP cohort (P < 0.001).HDR brachytherapy is a safe and effective treatment modality with low toxicity for prostate cancer patients after a prior TURP.

Genitourinary Toxicity In Prostate Cancer Patients With History Of Transurethral Resection Of The Prostate Undergoing High Dose Rate Brachytherapy With A Novel Urethral-Sparing Technique

Prior transurethral resection of the prostate (TURP) is traditionally considered a contraindication to high dose rate prostate brachytherapy (HDR-B) due to increased risk of urinary morbidity and poor dose distribution in the prostate. We previously described a novel technique using a modified triple-lumen catheter to visualize and spare the TURP defect during CT-based HDR-B. We now report genitourinary (GU) toxicity in our institutional experience with this urethral-sparing technique. Prostate cancer patients with >3 months follow-up who underwent HDR-B using a modified triple-lumen catheter to visualize the TURP defect were included. Patient demographics, disease characteristics, dosimetry, and clinical outcomes were retrospectively reviewed. Toxicity was graded using NCI CTCAE v5.0 and classified as acute (≤90 days after HDR-B) or late (>90 days). Thirty-three patients met inclusion criteria. Median age was 76 years (IQR 74-80) and median follow up was 17.0 months (range 3.3-64.8). Thirty patients had 1 previous TURP and 3 patients had 2. Median time from most recent TURP to HDR-B was 49.0 months (IQR 6.1-125.8). Twenty-nine patients had newly diagnosed prostate cancer: 9 intermediate risk, 17 high risk, and 3 regional risk disease per NCCN. Among these, 1 patient received HDR-B monotherapy (27 Gy/2 fractions) and 28 received HDR-B boost (15 Gy/1 fraction) combined with external beam radiotherapy (EBRT). Four patients underwent salvage HDR-B for local recurrence 3-12 years after definitive radiotherapy: 1 received EBRT, 1 LDR-B and 2 HDR-B monotherapy. Among these, 2 patients received whole gland monotherapy (15 Gy/1 fraction, 36 Gy/6 fractions), 1 received partial gland monotherapy (27 Gy/2 fractions), and 1 received whole gland boost (18 Gy/3 fractions) combined with EBRT. Twenty-seven (82%) patients did not experience acute G2 or higher GU toxicity. Five (15%) patients experienced G2 toxicity (4 with retention or hematuria requiring temporary catheter placement and 1 with urinary frequency). One patient had G3 hematuria requiring procedural intervention 2 months after HDR-B. Only 2 of 29 newly diagnosed patients experienced acute G2 or higher GU toxicity, compared to 4 of 4 patients receiving salvage HDR-B re-irradiation. Twenty-seven (82%) patients did not experience late G2 or higher GU toxicity. Three (9%) patients experienced G2 hematuria (2 with clot retention requiring catheter placement and 1 requiring hyperbaric oxygen therapy) and 4 (12%) experienced G2 urinary incontinence. Two (6%) patients had late G3 toxicity (hematuria and retention) requiring procedural intervention. HDR-B in prostate cancer patients with a history of TURP has an acceptably low risk of G2 or higher GU toxicity when the urethral defect is adequately spared during CT-based planning. Acute G2 or higher GU toxicity occurred primarily in patients receiving salvage HDR-B re-irradiation and did not predict late G2 or higher GU toxicity.

Outcomes of High-Dose Rate (HDR) Brachytherapy in Intermediate- to High-Risk Prostate Cancer Patients with Prior Transurethral Resection of the Prostate (TURP)

The purpose of this study was to evaluate the effect of prior TURP on genitourinary toxicity, sexual function, and biochemical-failure free survival (bFFS) in patients receiving HDR brachytherapy at a large volume academic center. Data was prospectively collected for patients undergoing HDR brachytherapy from August 2010 to December 2016. Patients were classified according to NCCN risk criteria. Patients with favorable intermediate-risk disease underwent HDR monotherapy alone and patients with unfavorable intermediate- to high- risk disease underwent a combination of IMRT and HDR brachytherapy boost. Implants were performed under ultrasound-guidance with CT based planning. Goal dosimetric constraints included V100 Prostate >95% and D1cc Urethra <105%. Univariate log rank test was used for treatment categorization to compare biochemical-failure free survival (bFFS). Multivariate cox analysis (MVA) was performed and adjusted for age, T stage, Gleason score, initial PSA, and androgen deprivation therapy (ADT) use. Sexual health inventory for men (SHIM) score, International Prostate Symptom Score (IPSS), and CTCAE v5.0 graded toxicity were recorded. 248 patients underwent HDR brachytherapy and were included in the analysis. 31 patients had prior TURP. The median follow-up was 47 months (range 3 – 83 months) and the median age was 71 (range 57 – 83). A total of 146 and 102 patients were intermediate- and high-risk, respectively, of which and 12 and 19 patients with TURP were intermediate- and high-risk, respectively. Median time from TURP to HDR was 18 months (range 3 – 146). 14 (45%) and 7(23%) patients with a history of TURP experienced Gr 1 and 2 GU toxicity. There were no patients that experienced Gr ≥3 GU toxicity. Patient reported GU and sexual function quality of life outcomes were not found to be statistically significant between prior TURP and non-TURP patients. One patient with a prior TURP experienced a biochemical recurrence. No significant difference was observed in biochemical-failure free survival between patients who did and did not receive a prior TURP (96±4% vs. 86±4%, respectively; p = 0.36). HDR brachytherapy is a safe and effective treatment for patients diagnosed with prostate cancer who received prior TURP.

Urinary Morbidity in Men Treated With Stereotactic Body Radiation Therapy (SBRT) for Localized Prostate Cancer Following Transurethral Resection of the Prostate (TURP).

Background: Clinical data suggest that stereotactic body radiation therapy (SBRT) provides similar clinical outcomes as other radiation modalities for prostate cancer. However, data reporting on the safety of SBRT after TURP is limited. Herein, we report our experience using SBRT to deliver hypofractionated radiotherapy in patients with a history of TURP including physician-reported toxicities and patient-reported quality of life.Methods: Forty-seven patients treated with SBRT from 2007 to 2016 at Georgetown University Hospital for localized prostate carcinoma with a history of prior TURP were included in this retrospective analysis. Treatment was delivered using the CyberKnife® (Accuray Incorporated, Sunnyvale, CA) with doses of 35 Gy or 36.25 Gy in 5 fractions without prostatic urethral sparing. Toxicities were recorded and scored using the CTCAE v.4. Cystoscopy findings were retrospectively reviewed. Urinary quality of life data was assessed using the International Prostate Symptom Scoring (IPSS) and Expanded Prostate Cancer Index Composite 26 (EPIC-26). A Wilcoxon signed-rank sum test was used to determine if there was a statistically significant increase or decrease in IPSS or EPIC scores between timepoints. Minimally important differences were calculated by obtaining half the standard deviation at time of start of treatment.Results: Forty-seven patients at a median age of 72 years (range 63–84) received SBRT. The mean follow-up was 4.7 years (range 2–10 years). Late Grade 2 and grade 3 urinary toxicity occurred in 23 (48.9%) and 3 (6.4%) men, respectively. There were no Grade 4 or 5 toxicities. Approximately 51% of patients experienced hematuria following treatment. Mean time to hematuria was 10.5 months. Twenty-five cystoscopies were performed during follow-up and the most common finding was hyperemia, varices of the bladder neck/TURP defect, and/or necrotic tissue in the TURP defect. Baseline urinary QOL composite scores were low, but they did not clinically significantly decline in the first 2 years following treatment.Conclusions: In patients with prior TURP, prostate SBRT was well-tolerated. GU toxicity rates were comparable to similar patients treated with conventionally fractionated radiation therapy. Urinary quality of life was poor at baseline, but did not worsen clinically over time. Stricter dosimetric criteria could potentially improve the rate of high-grade late toxicity, but may increase the risk of peri-urethral recurrence.

The Management of Patients Diagnosed with Incidental Prostate Cancer: Narrative Review.

5–14% of patients underwent surgery for benign prostate hyperplasia harboring prostate cancer (PCa) focus. The best management of incidental prostate cancer (iPCa) has been debated. The decision “treatment or no treatment” should be determined by predictors which accurately foretell PCa progression after transurethral resection of the prostate (TURP). The purpose of this study is to review the available data that can be useful in daily clinical judgment. Transrectal ultrasound prostate biopsy (TRUSBx) did not provide further Gleason score (GS) data in most patients diagnosed with iPCa. TRUSBX may be useful before active surveillance, but not in all following radical prostatectomy. The decision “treatment or no treatment” should be dependent on the expected chance of having residual cancer and clinical progression. Prostate-specific antigen (PSA) levels before and after TURP are good predictors of residual cancer after TURP. Pathological report of T0 is most likely seen in patients with low PSA density after TURP and indistinguishable lesion on multiparametric magnetic resonance imaging. The decision “treatment vs no treatment” is judged by life expectancy, tumor characteristic in the pathology report of TURP sample and PSA level following TURP. Active surveillance should be contemplated in patients with iPCa who have both prostate-specific antigen density ≤0.08 after TURP and indistinguishable cancer lesion on multiparametric magnetic resonance imaging. Patients who do not meet the criteria for active surveillance are candidates for radical prostatectomy or radiotherapy (RT). Radical prostatectomy could be peacefully done after TURP with somewhat greater morbidity. RT in patients who had a history of TURP could be safely done and is associated with acceptable quality of life.

Transurethral resection of the prostate is an independent risk factor for biochemical recurrence after radical prostatectomy for prostate cancer.

Biochemical recurrence (BCR) is important for measuring the oncological outcomes of patients who undergo radical prostatectomy (RP). Whether transurethral resection of the prostate (TURP) has negative postoperative effects on oncological outcomes remains controversial. The primary aim of our retrospective study was to determine whether a history of TURP could affect the postoperative BCR rate. We retrospectively reviewed patients with prostate cancer (PCa) who had undergone RP between January 2009 and October 2017. Clinical data on age, prostate volume, serum prostate-specific antigen levels (PSA), biopsy Gleason score (GS), metastasis stage (TNM), D'Amico classification, and American Society of Anesthesiologists (ASA) classification were collected. Statistical analyses including Cox proportional hazard models and sensitivity analyses which included propensity score matching, were performed, and the inverse-probability-of-treatment-weighted estimator and standardized mortality ratio-weighted estimator were determined. We included 1083 patients, of which 118 had a history of TURP. Before matching, the non-TURP group differed from the TURP group with respect to GS (P = 0.047), prostate volume (mean: 45.19 vs 36.00 ml, P < 0.001), and PSA level (mean: 29.41 vs 15.11 ng ml−1, P = 0.001). After adjusting for age, PSA level, T stage, N stage, M stage, and GS, the TURP group showed higher risk of BCR (hazard ratio [HR]: 2.27, 95% confidence interval [CI]: 1.13–3.94, P = 0.004). After matching (ratio 1:4), patients who underwent TURP were still more likely to develop BCR according to the adjusted propensity score (HR: 2.00, 95% CI: 1.05–3.79, P = 0.034). Among patients with PCa, those with a history of TURP were more likely to develop BCR after RP.

Radical prostatectomy after previous TUR-P: Oncological, surgical, and functional outcomes

ObjectivesTo examine oncological, surgical, and functional outcomes of radical prostatectomy (RP) in patients with history of transurethral resection of the prostate (TUR-P). Materials and methodsRetrospective analysis of 18,681 RP-patients including 470 patients with previous TUR-P at a single institution (2002–2015). Kaplan-Meier as well as multivariable Cox and logistic regression analyses compared surgical, oncological, and functional outcomes between TUR-P and non-TUR-P patients after propensity score matching (nearest neighbor in a 1:3 fashion). ResultsAfter propensity score adjustment, pathological and surgical results were similar between both groups. Specifically, rates of positive surgical margins and nerve-sparing (NS) procedure did not differ between groups (positive surgical margins: 18.5% vs. 17.2%, P = 0.7; nerve-sparing: 89.4% vs. 91.6%, P = 0.5). In addition, there was no difference in mean operating room time (185 vs. 184 minutes, P = 0.6), blood loss (710 vs. 666 ml, P = 0.1), and catheterization time (12 days, P = 0.3). In multivariable analyses, TUR-P patients did not exhibit higher risk of biochemical recurrence, metastatic progression, or mortality (all P > 0.05). However, TUR-P patients exhibited higher risk for urinary incontinence at third month (OR: 1.47; 95% confidence interval [CI] 1.01–2.12, P = 0.04) and first year (OR: 2.06; 95% CI 1.23–3.42, P = 0.006) and worse 1-year erectile function recovery (OR: 0.48; 95% CI 0.27–0.86, P = 0.02). ConclusionsThis large series of TUR-P RP patients demonstrated that RP could be safely performed in patients with history of TUR-P without compromising oncological results. However, functional outcomes were worse for patients with previous TUR-P.

Efficacy and safety of 120-W GreenLight High-Performance System laser photo vaporization of the prostate: 3-year results with specific considerations

Purpose:High-Performance System (HPS) laser photo vaporization of the prostate (PVP) is a widely used procedure nowadays. The safety and efficacy of the procedure has been affirmed in general patients with benign prostatic hyperplasia (BPH), but data on the safety and efficacy in specific situations, such as in patients with a large prostate, patients taking anticoagulant or 5-alpha reductase inhibitor (5-ARI) medication, and patients with a history of acute urinary retention (AUR) or previous transurethral resection of the prostate (TURP), is lacking. We investigated the safety and efficacy of HPS laser PVP in these unique patient groups.Methods:The study was conducted from March 2009 to February 2012 among patients for lower urinary tract symptoms. Patients in whom BPH was diagnosed and who were treated with 120-W HPS GreenLight PVP were selected. Patients were divided into groups of prostate size above and below 80, anticoagulant medication, 5-ARI medication, AUR history, and TURP history on the basis of the preoperative history and physical examination.Results:A total of 533 patients observable for a follow-up period of more than 6 months were enrolled as the study population. The patients’ mean preoperative prostate size was 51.0±32.7 mL and their mean prostate-specific antigen was 4.5±27.9 ng/mL. The average operating time was 24.5±12.2 minutes and the average applied energy during surgery was 152,184±89,495 J. Postoperative objective and subjective parameters in all groups were significantly improved compared with preoperative values.Conclusions:Laser resection of the prostate is safe and effective. The results of HPS laser PVP were not influenced by prostate size, the use of anticoagulants, the intake of 5-ARI for BPH management, a history of AUR, a history of TURP, or other factors. Thus, this study was able to reconfirm the efficacy and safety of laser resection of the prostate.

Can high-dose-rate brachytherapy prevent the major genitourinary complication better than external beam radiation alone for patients with previous transurethral resection of prostate?

To compare the grade 3 genitourinary toxicity and oncological outcome for localized prostate cancer between high-dose-rate (HDR) brachytherapy and external beam radiation therapy (EBRT) alone in patients with previously undergone Transurethral resection of the prostate (TURP). From November 1998 to November 2008, 78 patients with a history of TURP underwent radiation therapy for localized prostate cancer. Of these, 59 were enrolled in this study. In this study, 34 patients underwent HDR brachytherapy and 25 patients underwent EBRT alone. Grade 3 genitourinary complication was observed in 8.8 % of HDR brachytherapy group and 44 % in EBRT alone group. Five-year urinary incontinence rate was 2.9 % in HDR brachytherapy and 24 % in EBRT alone group. The results showed that significant higher incidence of grade 3 genitourinary complication (p = 0.003) and urinary incontinence was the most significant (p = 0.023) in the EBRT alone group. Five-year biochemical survival rate was 82.4 % in HDR brachytherapy group and 72.0 % in EBRT alone group (p = 0.396). In patients with prostate cancer who have previously undergone TURP, we observed that HDR brachytherapy was able to control prostate cancer with fewer GU morbidities and oncological outcomes that were similar to those associated with traditional EBRT alone. Moreover, HDR brachytherapy led to a decrease in major GU toxicity and also preserved the sphincter function more than that in TURP patients who underwent EBRT alone.

Surgical, Oncologic, and Short-Term Functional Outcomes in Patients Undergoing Robot-Assisted Prostatectomy After Previous Transurethral Resection of the Prostate

The objective of this study was to assess the surgical, oncologic, and short-term functional outcomes of patients with a history of transurethral resection of the prostate (TURP) who underwent robot-assisted laparoscopic prostatectomy (RALP). The records of 2000 men who underwent RALP from February 2006 to April 2010 were retrospectively reviewed. A total of 80 men had undergone TURP before RALP. A match-paired analysis was performed using our database to identify 80 additional men without a history of TURP with equivalent clinicopathologic characteristics to serve as a control group (non-TURP group). The parameters compared included patient preoperative clinicopathologic characteristics, intraopeoperative characteristics, postoperative oncologic characteristics, minor and major postoperative complications, continence, and potency. The mean time between TURP and RALP was 3.6 months (3-6 months). Regarding preoperative characteristics, a statistical difference was only observed regarding preoperative patient potency in the TURP vs non-TURP group. Regarding intraopeoperative characteristics, a statistical difference was observed regarding the need for bladder neck reconstruction and skin-to-skin operative time. Regarding postoperative pathologic characteristics, the positive surgical margin rate was not significant when the two groups were compared. The continence and potency rates in 12 months were similar (87.5%/91.25%) and (70.3%/86.5%) for both patient cohorts. Although the procedure is technically more demanding, exhibits a prolonged operative time and time interval before continence and potency returns, it can be safely performed without compromising functional results as well as the radical nature of cancer surgery.

External Beam Radiation Therapy After Transurethral Resection of the Prostate: A Report on Acute and Late Genitourinary Toxicity

To describe genitourinary (GU) toxicity in men with a history of transurethral resection of the prostate (TURP) treated with external beam radiation therapy (EBRT) for prostate cancer. Seventy-one men with a history of TURP were treated with EBRT for prostate cancer. The median time from TURP to EBRT was 15 months. The median EBRT dose was 70 Gy, and 21 men (30%) received androgen deprivation therapy (ADT). Acute GU toxicity and late GU toxicity were scored by Radiation Therapy Oncology Group criteria and compared with a cohort of 538 men without prior TURP. The median follow-up for men with TURP and men without TURP was 40 months and 50 months, respectively (p = 0.7605). The rate of acute Grade 2 GU toxicity or higher was 41%, and was increased with a history of more than 1 TURP (73% vs. 31%, p = 0.0036). The 4-year rate of freedom from late Grade 3 GU toxicity or higher was 84%, and was decreased with ADT (45% vs. 95% without ADT, p = 0.0024). By last follow-up, maximal GU toxicity tended to resolve (p < 0.0001) and there was no worsening of urinary symptom scores (p = 0.6911). Compared to men without a prior TURP, TURP patients had a lower rate of freedom from late Grade 3 toxicity or higher (84% vs. 96%, p = 0.0483). Multivariate analysis suggested a higher rate of late Grade 3 toxicity or higher with TURP (risk ratio, 2.87; p = 0.0612) and EBRT dose of 74 Gy or greater (risk ratio, 2.26; p = 0.0521). Men treated for prostate cancer with EBRT after TURP have a higher risk of severe GU toxicity; however, the overall incidence is low, and toxicity tends not to persist.

Patients with prior TURP undergoing robot-assisted laparoscopic radical prostatectomy have higher positive surgical margin rates.

With the incidence of robot-assisted radical prostatectomy (RALP) increasing, questions regarding the significance of margin status have arisen. Patients with a history of a prior transurethral resection of the prostate (TURP) may have a higher incidence of positive margins because of the prior surgery. We examined our IRB-approved database to determine whether patients who had undergone a prior TURP had higher rates of positive margins than patients who had no history of TURP. Between July 2003 and March 2007, six urologic surgeons in our medical group (City of Hope medical group) performed RALP on 2,041 patients. Consent to enter the database was obtained from 1,768 patients. Of these, 51 had undergone prior TURP. Patients with a history of TURP before undergoing RALP had positive margin rates of 35.3% (18 of 51) compared with 17.6% (18 of 102) of patients without a history of TURP (P=0.015). The location of the positive margins was statistically more prevalent at the bladder neck in TURP patients (13.7 vs. 2.0%) than in non-TURP patients (Fisher's exact P value=0.004). These two groups were statistically similar with regard to other variables examined including race, BMI, preoperative PSA, Gleason score, and pathologic stage. Patients who underwent RALP following TURP were found to have a higher positive margin rate. The positive margins were more likely to be located at the bladder neck in TURP versus non-TURP patients.

Does prior transurethral resection of prostate compromise brachytherapy quality: A dosimetric analysis

To evaluate, in a retrospective review, prostate brachytherapy dosimetry outcomes relative to the transurethral resection of the prostate (TURP) cavity size to address the theoretical concern that an intraprostatic cavity may hinder adequate radioactive source placement. A total of 73 patients who underwent prostate brachytherapy as part of their treatment of localized prostate cancer had a history of a prior TURP. Of these 73 patients, 37 underwent (125)I implantation, 19 (103)Pd implantation, and 17 partial (103)Pd implantation. The dose was calculated using the dose to 90% of the prostate gland (D(90)) from the 1-month post-implant dosimetric analysis. The doses were normalized relative to 100% of the prescription dose. Archived transrectal ultrasound images were used to determine the maximal length and width of the visible residual TURP cavities. The prolate spheroid or symmetric egg shape was used to calculate each residual cavity volume. The derived volume of the TURP cavity was divided by the measured ultrasound volume of the prostate at brachytherapy, creating a percentage of volume measurement for each prostate. All p values, unless otherwise specified, were generated by comparing patients without a visible TURP defect with the subgroups of patients with a visible defect using the Student t test. A visible residual TURP defect was noted on the operative transrectal ultrasound images of 55 (75%) of the 73 patients with a history of TURP before brachytherapy. The 18 patients without a visible TURP defect had a median D(90) of 96% and were used for subsequent statistical comparison. Thirty-six patients with a TURP defect <10% of the entire prostate volume had a median D(90) of 109% (p = 0.02). Thirteen patients with a TURP defect between 10% and 20% of the prostate volume had a median D(90) of 112% (p = 0.03). Six patients with a TURP defect >20% of the prostate volume had a D(90) of 89% (p = 0.43). A visible residual TURP cavity that is assumed to have a prolate spheroid shape and occupy >/=10% of a prostate volume did not appear to be a statistically significant hindrance to proper dosimetric outcome.

Long-term urinary toxicity after 3-dimensional conformal radiotherapy for prostate cancer in patients with prior history of transurethral resection

Purpose: To report on the long-term urinary morbidity among prostate cancer patients with a prior history of a transurethral resection of the prostate (TURP) treated with high-dose 3-dimensional conformal radiotherapy (3D-CRT). Methods and Materials: Between 1988 and 1997, 1100 patients with clinically localized prostate cancer were treated with 3D-CRT. Of these, 120 patients (8%) were identified as having had a prior TURP and are the subjects of this analysis. The median age was 71 years (range: 49–83 years). The clinical stages of the patients were T1c: 33 (28%); T2a: 38 (32%); T2b: 15 (13%); and T3: 34 (27%). Neoadjuvant androgen ablation therapy was given to 39 (33%). The median radiation dose prescribed to the planning target volume was 75.6 Gy (range: 64.8–81 Gy). The median elapsed time from TURP to initiation of 3D-CRT was 69 months (range: 4–360 months). The median follow-up time was 51 months (range: 18–109 months). Results: Five patients of the 120 with a prior history of TURP (4%) developed a urethral stricture after 3D-CRT which was corrected with dilatation. The 5-year actuarial likelihood of ≥ Grade 2 late urinary toxicities was 9%. No Grade 4 urinary toxicities were observed in this group of patients. Among 110 patients who were completely continent of urine prior to 3D-CRT, 10 (9%) developed stress incontinence requiring 1 pad daily for protection or experienced occasional leakage (not requiring pad protection). The 5-year incidence of ≥ Grade 1 stress incontinence was 18% in patients who developed acute ≥ Grade 2 GU symptoms during the course of 3D-CRT compared to 7% for patients who experienced Grade 1 or no acute urinary symptoms ( p = 0.05). The radiation dose (≥75.6 Gy vs. <75.6 Gy), the number of prior TURP procedures, or the volume of resected tissue at the time of TURP had no significant impact on the long-term urinary morbidity outcome. A multivariate analysis demonstrated that the presence of Grade 2 acute urinary symptoms was the only predictor of ≥ Grade 1 stress incontinence after 3D-CRT in this group of patients. Conclusions: Despite prior TURP, the incidence of ≥ Grade 3 urinary toxicities is low. Nevertheless, especially among patients with a prior history of TURP who experience Grade 2 acute urinary symptoms during radiation treatment, a higher risk of stress incontinence is observed.

The effect of prior transurethral resection of the prostate on post radiation urethral strictures and bladder neck contractures

Patients treated for prostate cancer from 1975–1982 were reviewed to assess if pre-irradiation transurethral resection of the prostate (TURP) predisposed to the formation of post treatment urethral strictures or bladder neck contractures. A total of 368 patients were treated with external beam irradiation delivered by a linear accelerator or 125I interstitial implants. Of the 253 patients treated by external beam, 138 patients had a history of at least one TURP before treatment. Implants were performed in 115 patients and 57 had a history of TURP before treatment. A total of 40 patients from both groups developed post treatment complications of urethral strictures or bladder neck contractures. Three patients developed both complications. An analysis of the 40 patients revealed that 29 (72.5%) patients had a TURP performed within a median time of 33 days prior to their initiation of radiation therapy. Of 195 patients in the prior TURP group, 29 (15%) developed one or both complications. Only 11 (6%) of the 173 patients in the non-TURP group developed one or both complications. This comparison was statistically significant with a p value of .025. Various factors analyzed including the treatment regimen, histologic grade, stage of disease, and volume of prostatic tissue removed at surgery did not show any positive correlation. Multiple TURP's were evaluated for greater distribution to the incidence of post treatment complications. The prior TURP group of 195 patients contained 60 with a history of at least two TURPS before radiation therapy. Eleven (18.3%) developed one or both complications. Of the 135 patients in the single TURP group, 18 (13.3%) developed complications. This was not statistically significant. Therefore, we concluded that the initial TURP with its mechanical description of mucosa and resultant scarring is a predisposing risk for development of urethral strictures or bladder neck contractures. Review of the literature concerning time sequence for healing of the urethra shows 4–6 weeks to be an appropriate interval between surgery and radiation.