Prior Transurethral Resection Of Prostate Research Articles

Late Urinary Toxicity After Extreme or Moderate Hypofractionated Prostate Radiation Therapy in Patients With Prior Transurethral Resection of Prostate

PurposeTo study the late urinary toxicity in patients with prostate cancer with prior transurethral resection of prostate (TURP) and treated with hypofractionated prostate radiotherapy. MethodsPatients diagnosed with prostate cancer, with a prior TURP, and treated with moderate or extreme hypofractionated intensity modulated radiotherapy (MHRT or SBRT), were included in this study. Severity and duration of urinary symptoms observed during serial follow up after at least three months from radiotherapy were graded per CTCAE v5.0 using information from prospectively maintained institutional database. Impact of hypofractionation and other potential contributory factors on cumulative grade 2+ late urinary toxicity was analysed with univariable and multivariable binary logistic regression. ResultsTotal 203 eligible patients were included (MHRT=114, 64-68Gy/25#; SBRT=89, 35-37.5Gy/5#). Median time from TURP to radiotherapy was 10 months (IQR 7-16), similar for MHRT and SBRT. Overall, mean cavity volume was 1.17cc (IQR 0.5-1.35), while in MHRT and SBRT groups was 1.03 cc (IQR 0.4-1.15) and 1.27 cc (IQR 0.5-1.4), respectively. At a median follow up of 37 months, cumulative grade 3 and grade 2 late urinary toxicity was 8.4% (n=17) and 23.2% (n=47) respectively. Grade 3 symptoms were observed at median 29 months (IQR 19-62) after radiotherapy completion, lasting for a median duration of 8 months (IQR 2-14). Hematuria (6.4%) and urinary obstruction (3.4%) were the chief grade 3 symptoms. Multivariable analysis for age, diabetes, pelvic radiotherapy, fraction size, prostate volume, TURP to radiotherapy duration, and TURP cavity volume showed no significant association with late grade 2+ urinary toxicity. Conclusion: In this large cohort of patients with prior TURP and treated with hypofractionated prostate radiotherapy, incidence of severe late urinary adverse effects was <10%, mainly hematuria or urinary obstruction. Most of these were temporary, and no significant contributory factors were identified for late urinary morbidity after TURP and radiotherapy.

Late Urinary Toxicity and QoL with Curative Radiotherapy for High-Risk Prostate Cancer: Dose-Effect Relations in the POP-RT Randomized Phase III Trial

Whole pelvic radiotherapy (WPRT) showed better biochemical failure-free survival and metastasis-free survival than prostate-only radiotherapy (PORT) in the phase III randomized POP-RT trial for high and very high-risk prostate cancer, albeit with higher RTOG grade 2 late urinary toxicity. We report updated long term, symptom-wise comparison and dose-effect relations from this trial. Late urinary toxicity, and cumulative severity of each symptom over the follow-up period was graded using CTCAE v5.0. Grade 2+ toxicities were compared between the trial arms by chi square test. Bladder dosimetry in 5-Gy increments (V5, V10, V15...V65 Gy, V68 Gy) from the trial database of approved radiotherapy plans, was compared for each urinary symptom and overall late gr2+ toxicity by student t-test. Observed differences in dosimetric parameters were tested using multivariable logistic regression analysis, including age at diagnosis, known diabetes, tumor stage, trial arm, and prior transurethral resection of prostate (TURP). Urinary QOL scores were compared between arms using generalised linear mixed model. Combined late symptom-wise toxicity and dose-volume data were available for analysis for 193/224 patients. At a median follow-up of 75 months, cumulative CTCAE gr2+ late urinary toxicity remained higher with WPRT than PORT, though not statistically significant (36.5% vs 26.8%, p = 0.15). Grade 3 toxicity was low and similar in both arms. Symptom-wise cumulative rates showed no significant difference between arms (Table 1). Dosimetric comparison showed significantly higher bladder V5-V15 in patients with gr2+ toxicity over those with <gr2 urinary toxicity. On symptom-wise analysis, V5-V40 range was significantly higher for presence of dysuria, hematuria, and urgency. No significant differences were observed over higher dose range for any urinary symptom. On multivariable analysis, no significant association was identifiable between bladder dosimetry and urinary symptoms. Urinary QOL scores was similar between both the arms for all the symptoms. Compared to prostate-only radiotherapy, whole pelvic radiotherapy resulted similar Grade 3 urinary toxicity of about 5% with about 10% higher cumulative grade 2+ urinary toxicity over long term follow up. This difference was not reflected in patient-reported QOL. WPRT particularly increased urgency and hematuria. Larger bladder volume being irradiated with 5Gy to 15Gy dose range could contribute to increase in urinary symptoms.

The Fraction Size Sensitivity of Late Genitourinary Toxicity: Analysis of Alpha/Beta (α/β) Ratios in the CHHiP Trial

Moderately hypofractionated external beam intensity modulated radiation therapy (RT) for prostate cancer is now standard-of-care. Normal tissue toxicity responses to fraction size alteration are nonlinear: the linear-quadratic model is a widely used framework accounting for this, through the α/β ratio. Few α/β ratio estimates exist for human late genitourinary endpoints; here we provide estimates derived from a hypofractionation trial. The CHHiP trial randomized 3216 men with localized prostate cancer 1:1:1 between conventionally fractionated intensity modulated RT (74 Gy/37 fractions (Fr)) and 2 moderately hypofractionated regimens (60 Gy/20 Fr and 57 Gy/19 Fr). RT plan and suitable follow-up assessment was available for 2206 men. Three prospectively assessed clinician-reported toxicity scales were amalgamated for common genitourinary endpoints: dysuria, hematuria, incontinence, reduced flow/stricture, and urine frequency. Per endpoint, only patients with baseline zero toxicity were included. Three models for endpoint grade ≥1 (G1+) and G2+ toxicity were fitted: Lyman Kutcher-Burman (LKB) without equivalent dose in 2 Gy/Fr (EQD2) correction [LKB-NoEQD2]; LKB with EQD2-correction [LKB-EQD2]; LKB-EQD2 with dose-modifying-factor (DMF) inclusion [LKB-EQD2-DMF]. DMFs were age, diabetes, hypertension, pelvic surgery, prior transurethral resection of prostate (TURP), overall treatment time and acute genitourinary toxicity (G2+). Bootstrapping generated 95% confidence intervals and unbiased performance estimates. Models were compared by likelihood ratio test. The LKB-EQD2 model significantly improved performance over LKB-NoEQD2 for just 3 endpoints: dysuria G1+ (α/β=2.0 Gy; 95% confidence interval [CI], 1.2-3.2 Gy), hematuria G1+ (α/β=0.9 Gy; 95% CI, 0.1-2.2 Gy) and hematuria G2+ (α/β=0.6 Gy; 95% CI, 0.1-1.7 Gy). For these 3 endpoints, further incorporation of 2 DMFs improved on LKB-EQD2: acute genitourinary toxicity and prior TURP (hematuria G1+ only), but α/β ratio estimates remained stable. Inclusion of EQD2-correction significantly improved model fitting for dysuria and hematuria endpoints, where fitted α/β ratio estimates were low: 0.6 to 2 Gy. This suggests therapeutic gain for clinician-reported GU toxicity, through hypofractionation, might be lower than expected by typical late α/β ratio assumptions of 3 to 5 Gy.

Robot-Assisted Radical Prostatectomy After Prior Transurethral Resection of Prostate: An Analysis of Perioperative, Functional, Pathologic, and Oncologic Outcomes.

Background: We performed a retrospective comparison of surgical, oncologic, and functional outcomes after robot-assisted radical prostatectomy between patients who have undergone prior transurethral resection of prostate (TURP) to TURP-naive patients. Methods: Past robotic prostatectomy hospital data were scrutinized to form two matched groups of patients: those who have undergone prior TURP and TURP-naive patients. The perioperative and pathologic data along with functional and oncologic outcomes for a period of 3 years were compared between groups. Results: Compared with TURP-naive patients, prior TURP patients experienced longer robot-assisted laparoscopic prostatectomy times (p < 0.001), increased incidence of bladder neck reconstruction (p = 0.03), greater blood loss (p = 0.0001), and lesser nerve sparing (p < 0.01). Complication rates (p = 0.3), positive surgical margin (p = 0.4), extracapsular disease (p = 0.3), or seminal vesicle invasion (p = 0.1) were comparable between groups. Continence (p = 0.5) and potency (p = 0.1) at 1 year were not different between groups. Biochemical recurrence rates were not different at 3 years (p = 0.9). Diabetes slowed recovery of continence in patients with prior TURP compared with TURP-naive patients until 6 months after surgery. Conclusion: Although prior TURP makes subsequent robotic prostatectomy more technically demanding, it can be safely performed by experienced surgeons without compromising long-term functional or oncologic outcomes.

Does prior transurethral resection of prostate have a negative impact on the outcome of holmium laser enucleation of prostate? Results from a prospective comparative study.

ObjectivesTo prospectively evaluate safety and efficacy of holmium laser enucleation of prostate (HoLEP) for surgical treatment of recurrent symptoms due to prostatomegaly after prior transurethral resection of prostate (TURP).Materials and Methods:We prospectively evaluated 43 patients with a history of TURP who underwent HoLEP (study group). Patients in chronological order who underwent HoLEP without prior TURP were included in the control group. We hypothesized that prior TURP would increase technical difficulties, thereby leading to a reduction in procedure efficiency by 25%. Patients’ demographic, intraoperative, and postoperative data were compared, and statistical analysis was performed.Results:Demographic data in both groups were comparable. The average interval between past TURP and HoLEP was 4.22 years. There was no difficulty in identifying the dissection plane in the study group and the difference in the procedure efficiency between the study and the control groups were statistically insignificant (0.75 ± 0.31 g/min-study group vs. 0.69 ± 0.36 g/min-control group; P = 0.665). The intraoperative parameters and postoperative outcomes were comparable in both groups.Conclusions:Prior TURP does not negatively impact the outcome of HoLEP in treating symptomatic recurrence for enlarged prostate after initial TURP.

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.

Moderately Hypofractionated Radiotherapy and Androgen Deprivation Therapy for High-risk Localised Prostate Cancer: Predictors of Long-term Biochemical Control and Toxicity

AimsThere is a paucity of long-term data on outcomes of high-risk prostatic adenocarcinoma after moderately hypofractionated radiotherapy with elective nodal treatment and long-term androgen deprivation therapy (ADT). We report long-term control and toxicity outcomes and analyse the predictors of failure and toxicity. Materials and methodsThe records of 120 consecutive high-risk prostate cancer patients treated in a single institution between February 2012 and December 2016 were retrospectively analysed. A moderately hypofractionted radiotherapy (HypoRT) regimen of 60 Gy in 20 fractions over 4 weeks with simultaneous elective pelvic irradiation to 44 Gy in 20 fractions with intensity-modulated radiotherapy was used, together with long-term ADT with either orchiectomy or medical castration for a total duration of 2–3 years. We analysed biochemical control, metastasis-free survival and late toxicities and their predictive factors using survival analysis. ResultsPatients had locally advanced cancers (cT3 77.5%, median pretreatment prostate-specific antigen 30 ng/ml, Gleason score 8–10 in 45.8%). The median follow-up time was 70 months. The 3- and 5-year probability of freedom from biochemical progression was 93% and 80%, respectively. The 5-year probability of freedom from local relapse/intra-pelvic nodal relapse/distant metastases as the site of first failure was 96%/97%/86%, respectively. Gleason score 8–10 and medical ADT for 2–3 years (as opposed to orchidectomy) were independent risk factors for distant metastases. A total of 18 grade 2 and above late gastrointestinal toxicity events and a total of 23 grade 2 and above late genitourinary toxicity events were documented. Patients who underwent a transurethral resection of prostate prior to radiotherapy had worse urological toxicity. ConclusionsHypoRT with elective nodal treatment results in excellent pelvic control. Distant metastases are the primary mode of failure. Risk of metastases is associated with Gleason score and the duration of ADT. Late urinary toxicities are more common in those with prior transurethral resection of prostate.

Safety of Prostate Stereotactic Body Radiation Therapy after Transurethral Resection of Prostate (TURP): A Propensity Score Matched Pair Analysis

PurposeTo determine the genitourinary (GU) toxicity outcomes in prostate cancer patients treated with stereotactic body radiation therapy (SBRT) who have undergone a prior transurethral resection of prostate (TURP) and compare it to a similar non-TURP cohort. Materials and MethodsFifty prostate cancer patients who had undergone a single TURP, had a good baseline urinary function, and had been subsequently treated with SBRT were chosen from a prospectively maintained database. These were propensity score matched to a similar non-TURP cohort treated during the same period. Matching was done for diabetes mellitus and volume of radiation therapy. Acute GU and late GU toxicity were scored using the Radiation Therapy Oncology Group (RTOG) criteria. Stricture and incontinence were scored using Common Terminology for Common Adverse Events version 4.0. ResultsMedian follow-up for the entire cohort was 26 months (non-TURP vs TURP, 30 months vs 22 months, P = .34). The median duration between TURP and start of SBRT was 10 months. There was no significant difference between non-TURP versus TURP cohort in terms of RTOG acute GU toxicities grade ≥2 (8% vs 6%, P = .45), RTOG late GU toxicities grade ≥2 (8% vs 12%, P = .10), stricture rates (4% vs 6%, P = .64), and incontinence rates (0% vs 4%, P = .15). The median duration of time to late toxicity was 16 months vs 10 months (P = .12) in non-TURP and TURP cohort, respectively. ConclusionsAlthough modestly increased as compared with non-TURP patients, GU toxicities remains low with SBRT in post-TURP patients. SBRT can be safely performed in carefully selected post-TURP prostate cancer patients.

Early Results of Extreme Hypofractionation Using Stereotactic Body Radiation Therapy for High-risk, Very High-risk and Node-positive Prostate Cancer

AimsStereotactic body radiotherapy (SBRT) in low- and intermediate-risk prostate cancer has shown encouraging results. However, its use in high-risk patients is limited due to lack of data regarding adequate radiotherapy dose, need for pelvic nodal treatment and androgen deprivation therapy. Herein we report our experience of SBRT in this subgroup. Materials and methodsAnalysis of a prospectively maintained database of 68 consecutive patients of the National Comprehensive Cancer Network (NCCN) high-risk, very high-risk and node-positive adenocarcinoma prostate treated with SBRT was undertaken. All patients were treated with rotational intensity-modulated radiotherapy with daily image guidance. The dose delivered to the prostate and gross node was 35–37.5 Gy in 5 alternate day fractions. Node-positive patients received 25 Gy to pelvic nodal regions until the common iliac nodes. Treatment was delivered in 7–10 days. All patients received long-term androgen deprivation therapy (79% medical and 21% surgical). ResultsMost patients (65%) had a Gleason score ≥ 8. The median prostate-specific antigen was 42. Twenty patients were high risk (30%), 11 (16%) very high risk and 37 (54%) node positive. No acute Radiation Therapy Oncology Group grade ≥ 3 genitourinary or gastrointestinal toxicity was noted. Acute grade 2 genitourinary and gastrointestinal toxicity were 12% and 3%, respectively. Late grade 3 genitourinary and gastrointestinal toxicity was 3% and 0%, respectively. There was no increase in acute or late gastrointestinal toxicity with prophylactic pelvic nodal radiotherapy. Prior transurethral resection of prostate (n = 11) did not increase toxicity. At a median follow-up of 18 months, 97% patients were alive and 94% were biochemically controlled. ConclusionSBRT is safe in the treatment of high-risk, very high-risk and node-positive prostate cancer, even with prophylactic pelvic radiotherapy or prior transurethral resection of prostate. Longer follow-up is required to determine efficacy.

Perioperative and functional outcomes in patients underwent robotic-assisted radical prostatectomy following a prior transurethral resection of prostate

Perioperative and functional outcomes in patients underwent robotic-assisted radical prostatectomy following a prior transurethral resection of prostate

Selective indication for check cystogram before catheter removal following robot assisted radical prostatectomy.

Introduction:With the improvement in anastomotic technique, it is rare to find anastomotic site leak after robot-assisted radical prostatectomy (RARP). It may not always be necessary to do regular check cystogram before catheter removal. We evaluated our 230 consecutive RARP patients and their cystograms to determine the indications for selective use of cystogram before catheter removal.Materials and Methods:We reviewed our prospectively collected RARP database of 230 consecutive patients. Cystography was performed at low pressure by gravity instillation of diluted contrast through the catheter. Patients were observed under fluoroscopy in lateral oblique position for any contrast leak at the site of anastomosis. All patients were followed for a minimum of 6 months, and the longest follow-up was 5 years.Results:A total of 207 patients (90%) underwent catheter removal on postoperative day 7. Nine patients (3.9%) had extravasation on initial cystogram. Two patients with leak had a history of transurethral resection of prostate (TURP) and seven other had bladder neck reconstruction for wide bladder neck. Three patients with minimal leak did not require catheter replacement. In rest of the 6 patient with leak, continued catheter drainage was done. No significant difference in the intraoperative variables, blood loss, duration of drain, length of hospital stay, and continence outcomes was noted between the patients with leak compared to rest of the patients. None of the patient needed any procedure/intervention related to the surgery and none developed bladder neck stenosis.Conclusion:In usual circumstances, catheter removal can be done safely on a postoperative day 7 without routine cystography. Selective use of check cystogram can be done in the case where bladder neck reconstruction is performed or those had a prior TURP and a wide bladder neck.

Urethral strictures and the cancer survivor.

Urethral stricture disease is poorly understood in prostate cancer survivors who have undergone radiation or ablative treatments. We review the cause and incidence of urethral strictures (excluding bladder neck contracture) in this setting, as well as risk factors and treatment options. Stricture rates differ for various modalities of radiation therapy, with the highest rate in high-dose-rate brachytherapy. Risk factors include higher dose of radiation delivered to prostate apex, radiation delivered per treatment, and prior transurethral resection of prostate. Cryoablation and high-intensity focused ultrasound of the prostate also carry high risk of urethral stricture formation, particularly in the salvage setting. Dilation or direct vision incision of the urethra can be utilized as a temporizing technique, with frequent recurrence. Urethral stenting is also an option; however, this is associated with a high rate of incontinence. Urethroplasty has durable outcomes for radiation-induced strictures, with a preference for excision and primary anastomosis because of the bulbomembranous location and relatively short length of these strictures. Salvage radical prostatectomy has been described in a small series as treatment for posterior urethral strictures and bladder neck contractures resulting from ablative therapies. Prostate cancer survivors treated with radiation or ablative therapies are at risk for urethral stricture formation. Urethroplasty is a feasible and durable treatment option and should be considered in the appropriate patient.

Stereotactic body radiation therapy (SBRT) following procedures for benign prostatic hyperplasia (BPH): A report on early toxicity.

165 Background: When treating patients with prostate cancer, hypofractionation with SBRT takes advantage of radiobiologically favorable factors as compared to conventional fractionation. However, this may increase the risk of urinary toxicity, especially in patients with prior procedures for BPH. Herein, we report early urinary toxicity following SBRT in patients with a history of procedures for BPH. Methods: Thirty three patients treated with SBRT for localized prostate cancer from February 2009 to October 2011 at Georgetown University Hospital with history of a prior procedure for BPH were included in this retrospective analysis. Treatment was delivered using the CyberKnife with doses of 35 Gy-36.25 Gy in 5 fractions. Toxicities were scored using the CTCAE v.3. Cystoscopy findings were retrospectively reviewed. Patient-reported urinary symptoms were assessed using the American Urological Association Symptom Score (AUA). Results: The median age was 70 years (range, 64 - 84). The median follow-up time was 18.7 months (range 9.2 – 38.9). Grade 2 or 3 urinary toxicity occurred in 9 patients and there were no grade 4 or 5 toxicities. Hematuria occurred in 12 patients. The median time to onset of hematuria from SBRT was 6 months (range 1 – 30). Grade 1 hematuria occurred in 7 patients, grade 2 in 4 patients and 1 patient experienced grade 3. Cystoscopy was performed in 9 of these patients at a median time of 9 months (range 3-27). Eight had hyperemia or evidence of bleeding from the prostatic urethra and 5 of these patients also had evidence of bleeding from the bladder neck/wall. All patients except one, who died from other causes, are still being followed and hematuria has resolved in 9 of the 12 patients. The median baseline AUA symptom score of 7 increased to 11 at 1 month, however decreased to a median score of 6 at 3 months. The median AUA symptom score increased to 9 at 1 year. Conclusions: A history of prior transurethral resection of prostate may predispose patients to increased urinary toxicity and hematuria following prostate SBRT. Stricter urethra/bladder neck dosimetric criteria or alternative fractionation regimens may be required to decrease urinary toxicity in these patients.

Efecto en el sangrado perioperatorio durante la resección transuretral de la próstata tras un mes de tratamiento con dutasteride

Objective Evaluate the effect of dutasteride in perioperative bleeding during Transurethral Resection of Prostate (TURP). Materials and Methods Forty consecutive patients with criteria for TURP were included. Finasteride/dutasteride use, renal impairment, prostate <30 cc, age <50 were excluded. Patients were divided in 2 groups. Group 1: 24 consecutive patients treated with dutasteride 0.5 mg/day/30-days prior TURP. Group 2: 16 without treatment. Prostatic volume, difference in hemoglobin pre/post TURP, duration and amount of resected tissue were recorded. Surgeon was blinded. Statistical analysis: Multiple linear regression, Mann-Whitney and student t-tests were used. Results In group 1, 33%(8) improved their lower urinary tract symptoms and skipped TURP. Mean Hemoglobin loss difference between groups was 0.11 gr/dl (CI 95% −0.55; 0.77, p=0.88). There was no statistical difference among variables. No positive or negative predictive values in the linear regression model. Conclusion Dutasteride did not significantly impact the studied variables in these non randomized and small sample size settings.

Effect of one month treatment with dutasteride on transurethral resection of the prostate

ObjectiveEvaluate the effect of dutasteride in perioperative bleeding during Transurethral Resection of Prostate (TURP). Materials and MethodsForty consecutive patients with criteria for TURP were included. Finasteride/dutasteride use, renal impairment, prostate <30cc, age <50 were excluded. Patients were divided in 2 groups. Group 1: 24 consecutive patients treated with dutasteride 0.5mg/day/30-days prior TURP. Group 2: 16 without treatment. Prostatic volume, difference in hemoglobin pre/post TURP, duration and amount of resected tissue were recorded. Surgeon was blinded. Statistical analysis: Multiple linear regression, Mann-Whitney and student t-tests were used. ResultsIn group 1, 33%(8) improved their lower urinary tract symptoms and skipped TURP. Mean Hemoglobin loss difference between groups was 0.11gr/dl (CI 95% −0.55; 0.77, p=0.88). There was no statistical difference among variables. No positive or negative predictive values in the linear regression model. ConclusionDutasteride did not significantly impact the studied variables in these non randomized and small sample size settings.

UP-1.069: Outcomes of Robotic Radical Prostatectomy in Men with Prior Transurethral Resection of Prostate

UP-1.069: Outcomes of Robotic Radical Prostatectomy in Men with Prior Transurethral Resection of Prostate

Urethral stricture following high dose rate brachytherapy for prostate cancer

Purpose To evaluate the incidence, timing, nature and outcome of urethral strictures following high dose rate brachytherapy (HDRB) for prostate carcinoma. Methods and materials Data from 474 patients with clinically localised prostate cancer treated with HDRB were analysed. Ninety percent received HDRB as a boost to external beam radiotherapy (HDRBB) and the remainder as monotherapy (HDRBM). Urethral strictures were graded according to the Common Terminology Criteria for Adverse Events v3.0. Results At a median follow-up of 41 months, 38 patients (8%) were diagnosed with a urethral stricture (6-year actuarial risk 12%). Stricture location was bulbo-membranous (BM) urethra in 92.1%. The overall actuarial rate of grade 2 or more BM urethral stricture was estimated at 10.8% (95% CI 7.0–14.9%), with a median time to diagnosis of 22 months (range 10–68 months). All strictures were initially managed with either dilatation ( n = 15) or optical urethrotomy ( n = 20). Second line therapy was required in 17 cases (49%), third line in three cases (9%) and 1 patient open urethroplasty (grade 3 toxicity). Predictive factors on multivariate analysis were prior trans-urethral resection of prostate (hazard ratio (HR) 2.81, 95% CI 1.15–6.85, p = 0.023); hypertension (HR 2.83, 95% CI 1.37–5.85, p = 0.005); and dose per fraction used in HDR (HR for 1 Gy increase per fraction 1.33, 95% CI 1.08–1.64, p = 0.008). Conclusions BM urethral strictures are the most common late grade 2 or more urinary toxicity following HDR brachytherapy for prostate cancer. Most are manageable with minimally invasive procedures. Both clinical and dosimetric factors appear to influence the risk of stricture formation.

Does Transurethral Resection of Prostate (TURP) Affect Outcome in Patients Who Subsequently Develop Prostate Cancer?

Pretreatment prostate specific antigen (PSA) is a strong predictor of prostate cancer outcome after radiotherapy and is a key parameter in pretreatment risk assessment. Because PSA is secreted from both benign and malignant tissue, a prior transurethral resection of prostate (TURP) may lower pretreatment PSA levels out of proportion to the extent of cancer. The purpose of this study was to determine whether a history of TURP is associated with increased biochemical failure (BF) after definitive radiotherapy for prostate cancer. From April 1989 to October 2001, 1135 men with low to intermediate risk T1c-2NX/0M0 (2002 AJCC) prostate cancer with a pretreatment PSA less than 20 ng/mL received three-dimensional conformal radiotherapy (median dose, 76 Gy) without androgen deprivation. The median pretreatment PSA was 7.4 ng/mL (range, 0.4 to 19.9). There were 126 men with a prior history of TURP. The Cox proportional hazards model was used for univariate and multivariate analyses for BF (nadir + 2 ng/mL definition). On multivariable analysis, Gleason score (GS), PSA, and T-stage were significant predictors of BF in a model containing TURP and dose. A history of TURP was not a significant independent predictor of BF on subgroup analysis. There was a trend toward significance for the subgroup of GS less than 7 (P = 0.12). A history of prior TURP does not affect outcome after RT for prostate cancer in low to intermediate risk patients.

Prognostic factors for late urinary toxicity grade 2-3 after conformal radiation therapy on patients with prostate cancer

Identify prognostic factors associated to late urinary toxicity in patients with prostate cancer submitted to radical conformal radiotherapy (3DCRT). From July 1997 to January 2002, 285 patients with localized prostate cancer were consecutively treated with 3DCRT and retrospectively analyzed. Thirty seven (13%) patients were submitted to transurethral prostate resection previously to 3DCRT. The median dose delivered to the prostate was 7920 cGy (7020-8460). Patient and treatment characteristics were analyzed and correlated to late urinary toxicity grade 2-3, especially whether certain radiation doses applied to certain bladder volumes, when visualized through computerized tomography (CT) planning, correlated with the observed actuarial incidences of late urinary complications, using bladder volume as a continuous variable. On a median follow-up of 53.6 months (3.6-95.3), the 5-year actuarial free from late urinary toxicity grade 2-3 survival was 91.1%. Seven and fifteen patients presented late urinary toxicity grades 2 and 3, respectively. Prior transurethral resection of prostate and radiation dose over 70 Gy on 30% of initial bladder volume were independent prognostic factors for late urinary toxicity grade 2-3. This study suggests that restricting radiation doses to 70 Gy or less on 30% of bladder volume, visualized through CT planning, may reduce late urinary complications. It furthermore suggests that patients with prior transurethral resection of prostate may indicate a group of patients with a greater risk for late urinary toxicity grade 2-3 after 3DCRT.

Lung Masses in a 70-Year-Old Man

A 70-year-old man presented with progressive mild dyspnea on exertion, cough, and low-grade fevers. He had a long history of atrial fibrillation, recurrent despite multiple cardioversions, and antiarrhythmics, and was currently rate controlled with amiodarone, 200 mg po tid. He also had a history of coronary artery disease documented by coronary angiography, asthma, and prior transurethral resection of prostate for benign prostatic hyperplasia. He was a lifelong nonsmoker with no occupational exposures.