Prior Pelvic Radiation Research Articles

Local Radiotherapy or Chemotherapy for Oligo-recurrent Cervical Cancer in Patients With Prior Pelvic Irradiation.

The aim of this study was to compare the clinical outcomes of patients treated by local radiotherapy or chemotherapy for oligo-recurrent cervical cancer with prior pelvic irradiation. Forty-one patients who had received pelvic irradiation for cervical cancer developed oligo-recurrent (≤5 lesions) relapses and underwent local radiotherapy (n=22) or systemic chemotherapy (n=19). Overall survival (OS), local recurrence-free survival (LRFS) and distant-free survival (DFS) were estimated, and risk factors were identified. The median follow-up was 24.1 months. The group of local radiotherapy showed a significantly superior LRFS, but inferior DFS. There was no significant difference in OS. Multivariate analysis revealed that FIGO stage at initial diagnosis was associated with OS. For patients with early FIGO stages (IB-IIB), local radiotherapy provided a tendency toward longer OS than chemotherapy. Out-field oligo-recurrence in patients with initial early FIGO stages may be an indication of salvage radiotherapy.

Outcomes after definitive re-irradiation with 3D brachytherapy with or without external beam radiation therapy for vaginal recurrence of endometrial cancer

BackgroundLimited outcome data exists on salvage re-irradiation for vaginal relapse of previously-irradiated endometrial cancer. We report our 10-year experience with management of vaginal recurrence using definitive intent re-irradiation brachytherapy with or without EBRT. MethodsA retrospective review was performed on 22 patients treated with definitive-intent re-irradiation brachytherapy ± EBRT for vaginal recurrence of endometrial cancer. The cumulative rectosigmoid and bladder D2cc (EQD2) were limited to <75 Gy and <90 Gy, respectively. Kaplan-Meier and Cox proportional hazards modeling were used to estimate survival. Severe (grade 3 or higher) radiation-related toxicities, defined according to CTCAE v4, were recorded. ResultsPrior radiation therapy consisted of vaginal brachytherapy (54.5%), pelvic EBRT (22.7%), or combination pelvic EBRT and brachytherapy (22.7%). Median re-irradiation interval was 26.6 months. Salvage re-irradiation consisted of EBRT with brachytherapy in 50.0% and brachytherapy alone in 50.0%. Median HR-CTV D90 (EQD2) was 64.5 Gy (IQR: 49.6–75.8). Median cumulative D2cc for bladder, rectum, and sigmoid were 72.1 Gy (range: 30.3–81.8), 70.6 Gy (range: 32.0–80.5), and 52.7 Gy (range: 29.6–75.3), respectively. At a median follow-up of 27.6 months, 3-year local control, regional control, disease-free survival, and overall survival rates were 65.8%, 76.6%, 40.8%, and 68.1%, respectively. There were no grade ≥ 3 acute or late rectosigmoid or bladder toxicities. ConclusionRe-irradiation with 3D conformal brachytherapy for vaginal recurrence is feasible and safe as long as cumulative dose to surrounding normal organs is limited, and offers a chance to potentially salvage 40% of patients presenting with vaginal recurrence in the setting of prior pelvic radiation.

Autologous rectus fascia sling for treatment of stress urinary incontinence in women: A review of the literature.

Stress urinary incontinence (SUI) is common in the adult females. Surgical treatment options include synthetic mid-urethral sling (MUS), autologous sling, bulking agents, and Burch colposuspension. The autologous pubovaginal sling (PVS) has re-emerged in response to complications of synthetic MUSs and FDA communications regarding the use of vaginal mesh. This resulted in patients' fear related to vaginal mesh and drop in number of patients seeking surgical treatment of SUI. PVS has re-emerged as an option for treatment of primary SUI. The aim of this review is to familiarize, disseminate information, and share tips for the practicing female pelvic surgeons related to the practice of the autologous fascia sling. We reviewed the literature related to the autologous sling. We used the following data bases and search engines: GoPubMed (Transinsight), Cochrane reviews (Wiley Interscience), google scholar (google), and Scopus (Elsevier). Because it is the most commonly investigated and utilized, we focused on the autologous rectus fascia sling. We also focused on the retropubic sling approach because the literature on transobturator rectus fascia sling is sparse. Out of 307 articles related to the subject found, 22 articles were included and the rest were excluded. ARFS is a valid primary method of treatment for female SUI. Also, it is used in particular indications such as patients with intrinsic sphincter deficiency (ISD), prior pelvic irradiation, failed and/or complicated synthetic MUS, and violated urethral lumen.

Current management of radiation cystitis: a review and practical guide to clinical management

Haemorrhage is a frequent complication of radiation cystitis leading to emergency presentations in patients with prior pelvic radiation therapy. Standard initial patient management strategies involve resuscitation, bladder washout with clot evacuation and continuous bladder irrigation. Beyond this, definitive surgical treatment is associated with significant morbidity and mortality. Alternative less invasive management options for non-emergent haemorrhagic cystitis include systemic medical therapies, hyperbaric oxygen (HBO), intravesical therapies and laser ablation. However, evidence to support and compare treatment for haemorrhagic radiation cystitis is limited. Herein, a literature search pertaining to the current management of haemorrhagic cystitis was conducted. In total, 23 studies were included in this review with 2 studies reviewing systemic therapy, 7 studies evaluating HBO therapy, 10 studies investigating a variety of intravesical therapies and the remaining 4 were relating to ablative therapies. Across these studies, the patient groups were heterogenous with small numbers and variable follow up periods. With evaluation of existing literature, this narrative review also provides a stepwise clinical algorithm to aid the urologist in treating patients presenting with complications associated with radiation cystitis.

A Rare Case of Bevacizumab and Radiation-Induced Ischemic Bowel Injury

Ischemic colitis is a poorly documented side effect of the combination of palliative radiation and targeted therapy with Bevacizumab, a recombinant and humanized monoclonal antibody against the vascular endothelial growth factor receptor.1 We present a case of acute onset of ischemic colitis in a patient with prior pelvic irradiation undergoing treatment of metastatic rectal adenocarcinoma with Bevacizumab. A 68 y/o male with microsatellite stable, KRAS-mutated Stage IVB Rectal Adenocarcinoma status post 3 months of fluorouracil, oxaliplatin, folinic acid, abdominal perineal resection with ileo-colonic anastomosis with end colostomy, and palliative radiation to pelvis and spine presented with abdominal pain and bright red blood in his ostomy bag. Hemoglobin was 5.6 g/dL on admission, with appropriate response after transfusion. Recent endoscopy showed monlial esophagitis and non-bleeding erosive gastropathy. Colonoscopy 1 year prior showed multiple benign polyps. He underwent colonoscopy via colostomy, which was remarkable for both a continuous area of non-bleeding ulcerated mucosa and a segmental area of severely friable mucosa within the distal colon, neither with stigmata of recent bleeding. Histopathology demonstrated severely active colitis with ulceration. Colorectal surgery recommended no acute surgical intervention given his poor prognosis. Conventional therapy for treatment of metastatic colorectal cancer includes a fluoropyrimidine-based therapy with or without the use of targeted therapy and/or palliative radiation. Bevacizumab inhibits tumor neovascularization, which has proven beneficial when treating solid tumors by restricting tumor growth and metastatic ability.1 Radiation amplifies this effect by free radical formation, which promotes cell death. Results of a retrospective study looking at 33 patients undergoing therapy with Bevacizumab and prior radiation showed a 9% incidence of severe bowel complications, including acute ischemic colitis and bowel perforation.2 Ischemic colitis, a rare and minimally reported risk of therapy with Bevacizumab and radiation, should be considered in patients presenting with sudden onset of abdominal pain and hematochezia.1487_A Figure 1. Previously normal appearing descending colon1487_B Figure 2. Friability with absence of bleeding in distal colon1487_C Figure 3. Ulceration of distal colon

Treatment of primary rectal adenocarcinoma after prior pelvic radiation: The role of hyperfractionated accelerated reirradiation

PurposePrevious studies have reported that hyperfractionated accelerated reirradiation can be used as part of multimodality treatment of locally recurrent rectal cancer with acceptable toxicity and promising outcomes. The purpose of this study was to evaluate the outcomes and toxicity of hyperfractionated accelerated reirradiation for patients with primary rectal adenocarcinoma and a history of prior pelvic radiation for other primary malignancies. Methods and materialsWe identified 10 patients with a prior history of pelvic radiation for other primary malignancies who were treated with hyperfractionated accelerated reirradiation for primary rectal adenocarcinoma. Radiation therapy was administered with 1.5 Gy twice daily fractions to a total dose of 39 Gy to 45Gy. ResultsThe median follow-up time was 3.2 years (range, 0.6-9.0 years). Seven of 10 patients received surgery after reirradiation. The 3-year freedom-from-local-progression rate was 62% for all patients and 80% for patients who underwent surgery. The 3-year overall survival rate was 100%, with 3 deaths occurring at 4.7, 6.5, and 9.0 years after reirradiation. One patient had an acute Grade 3 toxicity of diarrhea, and 1 patient experienced a late Grade 3 toxicity of sacral insufficiency fracture. ConclusionsHyperfractionated accelerated reirradiation was well tolerated with promising rates of freedom from local progression and overall survival in patients with primary rectal cancer with a history of prior pelvic radiation therapy. This approach, along with concurrent chemotherapy and surgery, appears to be a viable treatment strategy for this patient population.

Multiparametric MRI reporting using Prostate Imaging Reporting and Data System version 2.0 (PI-RADSv2) retains clinical efficacy in a predominantly post-biopsy patient population

ObjectiveTo evaluate the efficacy of multiparametric magnetic resonance imaging (mp-MRI) using Prostate Imaging Reporting and Data System version 2.0 (PI-RADSv2) definitions in detecting organ-confined prostate cancer. MethodsAll patients who underwent radical prostatectomy between January 1, 2014 and December 30, 2014 were identified. All underwent mp-MRI within 180 days before surgery. Those with prior pelvic irradiation or androgen deprivation therapy were excluded. Fully embedded, whole-mount histopathology was centrally reviewed and correlated with imaging for tumour location, Gleason score (GS) and stage. ResultsThere were 39 patients included, of which 35 (90%) had mp-MRI done post-biopsy. A total of 93 cancer foci were identified on whole-mount pathology, of which mp-MRI detected 63 (68%). Of those detected by mp-MRI, 14 were PI-RADS 3 (n = 6 for GS 6, n = 8 for GS 7, no GS ≥ 8) and 49 were PI-RADS 4–5 (n = 7 for GS 6, n = 33 for GS 7, and n = 9 for GS ≥ 8). There were 30 (32%) cancer foci missed by mp-MRI (n = 15 for GS 6, n = 13 for GS 7 and n = 2 for GS ≥ 8). A lesion classified as PI-RADS 4–5 predicted a higher grade cancer on pathology as compared to PI-RADS 3 (for GS 7 lesions, odds ratio [OR] = 3.53, 95% CI: 0.93–13.45, p = 0.064). The mp-MRI size detection limit was 20 mm2 and 100 mm2 for 50% and 75% probability of cancer, respectively. In associating with radiological and pathologic stage, the weighted Kappa value was 0.69 (p < 0.0001). The sensitivity and positive predictive values for this study were 68% (95% CI: 57%–77%) and 78% (95% CI: 67%–86%), respectively. ConclusionIn this predominantly post-biopsy cohort, mp-MRI using PI-RADSv2 reporting has a reasonably high diagnostic accuracy in detecting clinically significant prostate cancer.

Impact of prior pelvic bone marrow irradiation on toxicity of oxaliplatin-based chemotherapy in rectal cancer.

e15706Background: Radiotherapy is used in the neoadjuvant setting in majority of rectal cancer patients in order to improve local control in patients with threatened resection margin. Preoperative ...

PD33-05 INITIAL EXPERIENCE OF INJECTION OF DEHYDRATED HUMAN AMNION/CHORION ON OUTCOMES OF URETHROTOMY FOR RECURRENT URETHRAL STRICTURES

You have accessJournal of UrologyStem Cell Research: Stem Cell Research I1 Apr 2018PD33-05 INITIAL EXPERIENCE OF INJECTION OF DEHYDRATED HUMAN AMNION/CHORION ON OUTCOMES OF URETHROTOMY FOR RECURRENT URETHRAL STRICTURES Joseph Pariser, Maha Husainat, Omar Soto-Aviles, and Richard Santucci Joseph PariserJoseph Pariser More articles by this author , Maha HusainatMaha Husainat More articles by this author , Omar Soto-AvilesOmar Soto-Aviles More articles by this author , and Richard SantucciRichard Santucci More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1560AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recurrent urethral strictures can be managed endoscopically, but success rates approach 0% after 3 or more procedures. Scar modulation has the potential to be a therapeutic target for these patients. Amniofix (MiMedex, Marietta, GA) is a dehydrated human amnion/chorion membrane (dHACM) allograft designed to reduce scar tissue formation and promote healing, with a robust supportive literature in other body systems. We report the first clinical experience of adjuvant injectable dHACM placed at the time of urethrotomy in a population with otherwise high expected failure rates with urethrotomy alone. METHODS Between July 2016 and December 2016, a select group of patients with urethral stricture underwent urethrotomy and injection of dHACM into the incised scar tissue. Baseline demographics were collected. Patients were followed postoperative by symptoms, uroflowmetry (UF) and post-void residual (PVR) at least every 4 months. Successful treatment consisted of lack of additional procedures or self-catheterization for the treated stricture. RESULTS Twelve patients with median age 73 years were treated. Seven patients (58%) had prior pelvic radiation, and five patients (42%) had prior urethroplasty. The mean number of endoscopic procedures prior to injection was 2.5 (range 0-7). Successful treatment for the individual stricture was seen in 8 patients (67%) over the observation period. However, 2 of these patients developed other strictures requiring surgical intervention, one at the fossa navicularis and one in the prostatic urethra. There were no adverse effects noted from treatment. Median followup was 299 days (IQR 226-317). CONCLUSIONS Despite a heavily pretreated patient population including prior endoscopic treatments, radiation and/or urethroplasty, strictures treated with urethrotomy and adjuvant dHACM injection had a higher rate of success than expected with urethrotomy alone. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e652 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Joseph Pariser More articles by this author Maha Husainat More articles by this author Omar Soto-Aviles More articles by this author Richard Santucci More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Postoperative Outcomes After Radical Cystectomy in Patients With Prior Pelvic Radiation

To compare complication rates, perioperative outcomes, and survival after radical cystectomy (RC) in patients with prior abdominal or pelvic radiation therapy (RT) vs those without an RT history. We retrospectively reviewed patients undergoing RC for urothelial carcinoma between January 2008 and January 2016. Patients were stratified by receipt of RT, and differences in complications (any, minor, and major) at 30 and 90 days, as well as estimated blood loss, length of surgery, length of hospital stay, and pathologic stage, were compared. Recurrence-free, cancer-specific, and overall survival were compared using the Kaplan-Meier method and log-rank test. We identified 518 patients who underwent RC between 2008 and 2016. Of these patients, 55 (11%) had a history of RT. There were no significant differences in complication rates (66% vs 69%, P= .80) between patients who did not and patients who did have a history of RT. Similarly, there were no differences in any perioperative or pathologic outcome by receipt of prior RT (all P>.05). Meanwhile, at a median follow-up of 26 (interquartile range 13-46) months among patients alive at last follow-up, no differences in survival were observed by prior RT (P= .08). Among patients with a history of prior abdominal or pelvic RT treated at a tertiary referral center, there was no difference in complication rates, perioperative, or pathologic outcomes. Importantly, no differences in survival were noted by prior RT receipt. Therefore, our data support the use of RC, when indicated, in patients with a prior history of abdominal or pelvic RT.

Clinical and molecular characterization of urothelial cancer developing after pelvic radiation.

518 Background: The development of urothelial cancer (UC) after pelvic radiotherapy (RT) is an increasingly recognized phenomenon. Numerous studies show a relationship between ionizing radiation and urothelial dysplasia and DNA damage. It is not known if UC that develops after pelvic RT is associated with a distinct molecular signature, which could have treatment implications for this subset of UC. Methods: The University of North Carolina (UNC) Genitourinary Oncology Database was queried for cases of UC between 01/2012 and 06/2016 in patients with prior pelvic RT. Demographics, clinical stage, and details of prior RT were collected. Patients with available archival FFPE tumor tissue underwent next generation targeted exome sequencing per the UNCSeq pipeline. Somatic mutations and copy number alterations were analyzed. Total mutation burden (TMB) (mutations per total Megabase region of 30X coverage, mut/Mb) and insertion-to-deletion (indel) ratio was calculated. Wilcoxon rank sum was used to compare TMB and indel ratio of RT-associated cases with all cases of UC sequenced at UNC. Results: 38 patients with UC developing after prior pelvic RT were identified. 68% had muscle-invasive UC. Median age was 76. Prior RT was for the purpose of prostate cancer treatment in all patients. 26% had received external beam radiotherapy, 29% brachytherapy, and 16% both (29% unknown). Median time from RT to diagnosis of UC was 8 years. Ten patients with muscle-invasive UC had tumors available for sequencing. The most commonly identified somatic alterations were TP53 in 60%, RB1 40%, CREBBP 30%, ELF3 30%, HLA-DRB1 30%, KDM6A 30%, and MLL2 30%, including co-occurrence of TP53 and RB1 mutations in 30% of patients. The median TMB was 12.1 mut/Mb, significantly lower than the median TMB of 25.6 mut/Mb in all cases of UC sequenced at UNC (p = 0.006). The indel ratio was not different between the two groups (p = 0.11). Conclusions: UC that develops after pelvic RT is a frequent entity that occurs years after RT. Tumors of patients who received prior RT had a lower overall TMB than other UC tumors, suggesting that RT-induced UC may be a different entity than carcinogen-induced UC. Further studies should expand our analysis to confirm these findings.

Association of RAS mutations with race in metastatic colorectal cancer: CALGB/SWOG 80405 (ALLIANCE).

638 Background: Colorectal cancer (CRC) is a heterogeneous disease with distinct molecular subtypes in part based on RAS mutational status. It is plausible that RAS mutations are differentially distributed between CC and AA and may contribute to poor outcomes in AAs with CRC. Methods: We did a retrospective analysis of CALGB/SWOG 80405 trial patients. We divided the entire cohort into 2 groups: a) Common RAS: mutation in KRAS exon 2, codon 12 or 13; b) Extended RAS: any NRAS mutations or mutation in KRAS except those listed above. We then analyzed these two subgroups for association between RAS mutations and race (3 categories: Caucasian, AA, Others) using chi-square test for univariate analyses and logistic regression for multivariate analysis. We also analyzed the effect of extended RAS testing on prognosis of metastatic CRC by estimating the overall survival (OS) using Kaplan-Meier method and 95% confidence interval (CI). Cox proportional-hazard model was used for multivariate analyses. Results: There were 1729 CRC patients in common RAS group of which 357 (20.6%) had mutations present. Extended RAS group had 621 patients of which 95 (15.5%) had mutations present. There was no significant difference in the rate of common RAS mutations between CC and AA (20.5% vs. 24%, p=0.22). However, extended RAS mutations were significantly more in AA as compared to CC (25% vs. 14%, p=0.02). Multivariate analysis adjusted for age, gender, prior adjuvant chemotherapy and pelvic radiation confirmed higher odds of extended RAS mutation in AA compared to CC (adjusted OR 1.12; 95% CI 1.01-1.23; p=0.02). The median OS in patients with an extended RAS mutation was shorter as compared to those without extended RAS mutation (25.3 vs. 31.9 months; HR 1.26; 95% CI 0.99-1.62; p=0.05). Multivariate analyses adjusted for age, gender, race, prior adjuvant chemotherapy and pelvic radiation showed a trend towards longer OS in patients without extended RAS mutation as compared those with extended RAS mutation (adjusted HR= 1.24, 95% CI, 0.97-0.1.58, p=0.08). Conclusions: Extended RAS mutations are significantly more common in AA as compared to CC. Additionally, presence of extended RAS mutation may confer a poor prognosis in CRC patients.

Efficacy of combination chemotherapy using irinotecan and nedaplatin for patients with recurrent and refractory endometrial carcinomas: preliminary analysis and literature review

We aimed to retrospectively evaluate the efficacy and toxicity of an irinotecan hydrochloride (CPT) and nedaplatin (N) combination therapy for recurrent and refractory endometrial carcinoma, administered based on UGT1A1 genotype. Between 2009 and 2017, 21 patients who received CPT-N therapy for recurrent endometrial carcinoma as second- or third-line chemotherapy at our hospital were identified. The CPT-N regimen included 40-70mg/m2 of CPT-11 on days 1, 8, and 15, and 50mg/m2 of nedaplatin on day 1, q4 weeks. The median patient age was 63years. The number of prior chemotherapeutic regimens ranged from 1 to 2. Two patients had prior pelvic irradiation. The response rate [ratio of complete remission (CR) to partial remission (PR)] of CPT-N therapy was 3 of 21 (14.3%), and clinical benefit rate (CBR) [the combined percentages of CR, PR, and stable disease (SD)] was 9 of 21 (42.8%). Toxicities included grade 3 neutropenia [4 (19.0%) cases], grade 3 febrile neutropenia [2 (9.5%) cases], and grade 3 diarrhea [3 (14.3%) cases]; all resolved with conservative treatment. Patients with a wild-type UGT1A1 status received higher doses of CPT-11 (p = 0.048) and had similar RR and CBR compared to those with a UGT1A1*6 and *28 status. There were no significant differences in frequencies of hematological or non-hematological toxicities, regardless of UGT1A1 status. The CPT-N regimen for recurrent and refractory endometrial carcinoma had tolerable side effects and significant efficacy. This regimen is a viable treatment option for endometrial carcinoma.

Whole-Gland Prostate Cancer Cryoablation with Magnetic Resonance Imaging Guidance: One-Year Follow-Up

Patients who develop prostate cancer after prior abdominal perineal resection are poor surgical candidates, and have limited treatment options. Therefore, our goal is to present results from a single institutional experience of four patients who underwent whole gland MRI-guided cryoablation with a history complicated by prior abdominoperineal resection. Four MRI-guided cryoablative treatments (mean age 64, range 59-69 years) for primary and locally recurrent prostate adenocarcinoma were retrospectively reviewed in patients with prior abdominal perineal resection for colorectal cancer (3) and juvenile polyposis (1). Average prostate volume prior to ablation was 23 cc, with an average PSA of 5.6 ng/mL. For each gland, 7-10 cryoprobes were placed approximately 0.5 cm apart in the prostate gland under MRI guidance by a transperineal approach with 3-4 freeze-thaw cycles performed. Each patient had follow up imaging and PSA measurements out to 12 months post ablation. All four patient's PSA dropped below 0.1 ng/mL at 3-6 month post-ablation and remained at these levels at 12 months. Three of the 4 patients had PSA measurements to 33 months post-ablation, with no evidence of recurrence. No patient developed urinary incontinence due to the whole gland cryoablation. With all four patients in our study having undetectable PSAs 12 months post ablation, and with no patient developing urinary incontinence due to the cryoablation, MRI-guided cryoablation appears to be a promising treatment option in patients who are poor surgical candidates due to prior pelvic surgery and/or radiation.

Rate of Symptomatic Lymphocele Formation After Extraperitoneal vs Transperitoneal Robot-Assisted Radical Prostatectomy and Bilateral Pelvic Lymphadenectomy.

With the peritoneum acting as a natural surface for lymphatic reabsorption, transperitoneal robot-assisted radical prostatectomy (tRARP) is thought to be associated with a lower incidence of symptomatic lymphoceles (SLs) compared with its extraperitoneal counterpart (eRARP) when bilateral pelvic lymph node dissection (BPLND) is performed. In this study, we aim to determine if there is a difference in SL formation and characteristics between the two approaches. We retrospectively reviewed the records of patients who underwent eRARP or tRARP and BPLND by a single surgeon at a tertiary care academic center from July 1, 2003, to May 31, 2016. Patients with a history of prior pelvic radiotherapy, concomitant inguinal hernia repair, RARP without BPLND, or nonadenocarcinoma of the prostate were excluded. The resulting eRARP and tRARP groups were propensity matched for age, body mass index (BMI), American Association of Anesthesiologists (ASA) score, D'Amico risk classification, and pathological lymph node (LN) count. A total of 3183 RARPs were performed during this time period. After applying exclusion criteria and propensity score matching, 671 patients remained in each group. No statistically significant differences were noted between the groups with regard to age, BMI, ASA, pre-RARP prostate-specific antigen, D'Amico risk classification, biopsy and pathological Gleason sum score, pathological T stage, or margin status. The tRARP group had a higher clinical T stage (p = 0.0015), length of stay (LOS; p = 0.005), pathological N stage (4.92% vs 1.36%, p = 0.0002), and high total LN count (7.22 ± 5.54 vs 5.78 ± 4.18 LNs, p < 0.0001). The eRARP group had higher operating room times (197.4 ± 48.96 minutes vs 192.2 ± 44.12 minutes, p = 0.04) and estimated blood loss (218.4 ± 152.0 mL vs 179.9 ± 119.4 mL, p < 0.0001). No differences were noted in the frequency of SL formation [eRARP: 19/671 (2.83%) vs tRARP: 10/671 (1.49%), p = 0.09] or any clinical characteristics of the SL. Logistic regression analysis showed no effect of LN count (p = 0.071), pathological N stage (p = 0.111), or both combined (p = 0.085) on SL formation. In this cohort, the rate and clinical characteristics of SL were similar among patients treated with eRARP or tRARP and BPLND. The low event rate of SL in each group and trends favoring higher SL with LN yield and pN1 disease in the tRAPR group may deem the study underpowered to make definitive conclusions.

Phase I/II trial of dose-reduced capecitabine in elderly patients with advanced colorectal cancer.

Combination chemotherapy is associated with improved outcomes in trials of selected fit patients with advanced colorectal cancer (acrc). For older or less-fit patients, combination chemotherapy is associated with greater toxicity and less benefit. Capecitabine monotherapy is a reasonable option for those patients, but the optimal dose remains controversial. A multicentre phase i/ii trial of reduced-dose capecitabine (2000 mg/m2, days 1-14 every 21 days) was conducted in 221 patients representing one or more of the following subsets: age greater than 65 years (n = 167), Eastern Cooperative Oncology Group (ecog) performance status of 1 or greater (n = 139), elevated lactate dehydrogenase (ldh) (n = 105), or prior pelvic radiation (n = 54). Based on phase i results, patients with prior pelvic radiation received capecitabine 750 mg/m2 twice daily. The goal was to ascertain efficacy in a design that was unlikely to cause high levels of toxicity. Median age in the patient cohort was 72 years. A median of 5 and a mean of 8 capecitabine cycles were given (range: 0-50 cycles). Grade 3 or 4 toxicity occurred in 25% of patients during the first 3 cycles (8.1% hand-foot syndrome, 7.7% diarrhea). The response rate was 13.6%, with a 69.7% disease control rate. Median progression-free survival (pfs) was 5.6 months. Post progression, 56 patients received further capecitabine monotherapy (median of 4 additional cycles). Median overall survival duration for the patients was 14.3 months. Median survival was significantly higher for those who, at baseline, had an ecog performance status of 0 (compared with 1 or more) and normal ldh (compared with elevated ldh). Toxicity is less with dose-reduced capecitabine than with historical full-dose capecitabine, with only a small trade-off in efficacy, seen as a lower objective response rate. The improved tolerability could lead to an increased number of cycles of therapy, and pfs appears to be consistently higher at the lower dose. Those observations should, in the absence of a head-to-head clinical trial, be viewed as compelling evidence that 1000 mg/m2, or even 750 mg/m2, twice daily is an appropriate dose in elderly or frail patients with acrc.

Standard fractionation external beam radiotherapy with and without intraoperative radiotherapy for locally recurrent rectal cancer: the role of local therapy in patients with a high competing risk of death from distant disease.

We sought to evaluate the effectiveness and safety of utilizing radiotherapy (RT) with standard fractionation, with or without intraoperative RT (IORT), to treat locally recurrent rectal cancer (LRRC). Retrospective review of 25 patients with LRRC treated with standard fractionation RT from 2005 to 2011. 15 patients (60%) had prior pelvic RT and 10 (40%) had synchronous metastases. The median equivalent dose in 2-Gy fractions was 30 and 49.6 Gy in patients with and without prior RT, respectively. 23 patients (92%) received concurrent chemotherapy and 16 (64%) underwent surgical resection. Eight patients (33.3%, four with and four without prior RT) received IORT. A competing risks model was developed to estimate the cumulative incidence of local failure with death treated as a competing event. Median follow-up was 36.9 months after the date of local recurrence. 3-year rates of overall survival (OS), local control (LC) and death with LC were 51.6%, 73.3% and 69.2%, respectively. On multivariable analysis, surgical resection was significantly predictive of improved OS (p < 0.05). If surgical resection were removed from the multivariable model, given the collinearity between IORT delivery and surgical resection, then IORT also became a significant predictor of OS (p < 0.05). Systemic disease at the time of local recurrence was not associated with either LC or OS. No patient had grade ≥3 acute or late toxicity. RT with standard fractionation is safe and effective in the treatment of patients with LRRC, even in patients with significant risk of systemic disease and/or history of prior RT. Advances in knowledge: The utility of RT with standard fractionation, generally with chemotherapy, in the treatment of LRRC is demonstrated. In this high-risk cohort of patients with a 40% incidence of synchronous metastatic disease, surgical resection of the recurrence was the major predictor of OS, though a benefit to IORT was also suggested. No patients had grade ≥3 acute or late toxicity, though 40% had undergone prior RT, underscoring the tolerability of standard fractionation RT in this setting.

The Risk of Recurrent Urinary Incontinence Requiring Surgery After Suburethral Sling Removal for Mesh Complications

We sought to examine the risk of recurrent stress urinary incontinence (SUI) after suburethral sling mesh removal or excision. We conducted a retrospective cohort study of patients who were continent before removal or excision of synthetic midurethral slings; this cohort of 278 subjects was much larger than seen in previous such studies. Patients with preoperative incontinence, additional vaginal mesh placements, prior mesh revision/excision, existing SUI, and prior pelvic radiation or fistula were excluded. Only patients with follow-up detailing continence status within 1 year of mesh removal were examined. Of 278 patients, 117 (70 retropubic and 47 transobturator) midurethral sling removals met inclusion criteria. Demographic data were comparable between groups. Presenting symptoms were also similar, with similar extrusion rates. Chronic pain was the reason for mesh removal in 80% of cases. In 1 year of follow-up, 38.6% (27/70) retropubic and 34.0% (16/47) transobturator sling removals had SUI requiring an anti-incontinence procedure. Total sling mesh removal was performed in 51.4% of retropubic vaginal mesh and 51.1% of transobturator mesh cases. In this continent population with sling complications, approximately 1/3 developed significant SUI within 1 year of mesh removal requiring anti-incontinence surgery, regardless of the amount or type of mesh removed. Total mesh removal did not increase SUI risk.

MP46-07 MULTICENTER ANALYSIS OF ARTIFICIAL URINARY SPHINCTER OUTCOMES IN PATIENTS AFTER BOTH RADICAL PROSTATECTOMY AND ANASTOMOTIC URETHROPLASTY

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Male Incontinence: Therapy1 Apr 2017MP46-07 MULTICENTER ANALYSIS OF ARTIFICIAL URINARY SPHINCTER OUTCOMES IN PATIENTS AFTER BOTH RADICAL PROSTATECTOMY AND ANASTOMOTIC URETHROPLASTY Jonathan Wingate, Jeremy Myers, Gregory Murphy, Nejd Alsikafi, Bradley Erickson, Benjamin Breyer, and Bryan Voelzke Jonathan WingateJonathan Wingate More articles by this author , Jeremy MyersJeremy Myers More articles by this author , Gregory MurphyGregory Murphy More articles by this author , Nejd AlsikafiNejd Alsikafi More articles by this author , Bradley EricksonBradley Erickson More articles by this author , Benjamin BreyerBenjamin Breyer More articles by this author , and Bryan VoelzkeBryan Voelzke More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1446AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We sought to assess artificial urinary sphincter (AUS) outcomes in a subset of patients who have had a history of radical prostatectomy and anastomotic urethroplasty in order to describe outcomes after having two prior urethral transecting surgeries. Our null hypothesis is that multiple transections of the urethra do not increase the possibility of urethral erosion following artificial urinary sphincter placement. METHODS We performed a retrospective review from five participating centers in the Trauma and Urologic Reconstruction Network of Surgeons. The study period included February 2010 - January 2016. Of the 445 incontinence procedures in our prospective database, there were 35 patients who underwent an AUS and had both a radical prostatectomy and anastomotic urethroplasty. Patients were excluded if they did not have a minimum of 6 months of follow up after AUS placement. Twenty-two patients met inclusion criteria. The surgeon independently determined choice of transcorporal or standard cuff technique. RESULTS Median age was 67.5 years. Mean follow up time was 32.2 months (IQR 16.6 - 44.6 months). Twelve patients had a history of prior pelvic radiation for prostate cancer. Of the 22 patients, twenty patients had transcorporal cuff placement. There were 7 complications - 2 erosions, 3 hematomas, 1 infection, and 1 pump migration. Of these complications, four required additional surgery - the two erosions underwent AUS removal, one hematoma required exploration, and the patient with pump migration had his pump location adjusted. The overall AUS in situ rate in our cohort was 90.9% (20/22). History of prior radiation was not associated with AUS complications (p = 0.23). CONCLUSIONS AUS implantation can be performed in patients after two urethral transecting surgeries with an in situ rate of 90.9% at medium term follow up. Surgeons appear to prefer transcorporal placement in these scenarios. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e621 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Jonathan Wingate More articles by this author Jeremy Myers More articles by this author Gregory Murphy More articles by this author Nejd Alsikafi More articles by this author Bradley Erickson More articles by this author Benjamin Breyer More articles by this author Bryan Voelzke More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Extraperitoneal vs Transperitoneal Robot-Assisted Radical Prostatectomy in the Setting of Prior Abdominal or Pelvic Surgery

During robot-assisted radical prostatectomy (RARP), the prostate may be approached extraperiteoneally (extraperitoneal robot-assisted radical prostatectomy [eRARP]) or transperitoneally (transperitoneal robot-assisted radical prostatectomy [tRARP]). The former avoids the abdominal cavity, which might be of benefit in patients who have had prior abdominal or pelvic surgery (PAPS). Our objective was to compare the outcomes of patients with PAPS undergoing either technique. A retrospective review of patients treated with RARP from July 1, 2003 to December 31, 2014 with a minimum follow-up of 3 months was undertaken. Of 2927 patients, 620 were identified as having undergone RARP (without concomitant unrelated procedures) and PAPS (excluding patients with prior inguinal hernia repair with mesh or unclear surgical histories) for prostate adenocarcinoma without prior pelvic radiotherapy. Of these, 340 patients underwent eRARP and 280 patients underwent tRARP. Patients in the eRARP group were younger (61.04 years vs 62.32, p = 0.02), had a higher body mass index (29.65 vs 28.98, p = 0.09), lower American Society of Anesthesiologists scores (p = 0.03), and lower D'Amico risk classification disease (p < 0.0001). The two groups had similar rates of 1, 2, and >2 PAPS. On univariate analysis, the eRARP group had lower operative time (188.96 minutes vs 197.92 minutes, p = 0.003), extensive lysis of adhesions (0.9% vs 14.3%, p < 0.0001), length of hospital stay (LOS) (1.13 days ±0.45 vs 1.33 day ±1.08, p = 0.003), and higher estimated blood loss (210.74 mL vs 190.79 mL, p = 0.06). The eRARP group had a lower rate of gastrointestinal complications (0% vs 3.21%, p = 0.0007), a trend toward lower early post-operative complications (8.53% vs 12.86%, p = 0.08), and lower overall complications (9.41% vs 15%, p = 0.03). In regression analysis with model selection, only LOS was lower in the eRARP group (p = 0.02). Both methods are safe in patients with prior abdominal surgeries. A lower incidence of gastrointestinal complications and a shorter length of stay were noted in the extraperitoneal cohort.