Prior Transurethral Resection Of The Prostate Research Articles

Effect of Prior Transurethral Prostate Resection (TURP) or Laser Enucleation (ThuLEP) on Radiotherapy-Induced Toxicity and Quality of Life in Prostate Cancer Patients Undergoing Definitive Radiotherapy.

In our study, the post-radiotherapy quality of life of prostate cancer patients who previously underwent transurethral resection of the prostate (TURP) is compared to those who had thulium laser enucleation of the prostate (ThuLEP) and those who had no prior surgery. It also aims to identify and assess risk factors affecting therapy tolerance in this patient group. We analyzed 132 patients with localized prostate cancer treated with definitive radiotherapy (RT), including 23 who had prior TURP and 19 who previously underwent ThuLEP. A total of 62% of patients underwent irradiation within 12 months after surgery. We included only patients treated with radiotherapy using the IMRT technique. Changes in patient-reported urinary toxicity were evaluated using the International Prostate Syndrome Score (IPSS) and the quality of life index of the World Health Organization (QoL/WHO-PSS) over a three-year post-radiotherapy period. Patients with prior TURP experienced significant deterioration in QoL and IPSS immediately after irradiation (p < 0.001), whereas those without previous surgery showed both less significant differences in IPSS and QoL scores. In conclusion, patients with previous TURP/ThuLEP differ from those without previous surgery in urinary quality of life and acute and chronic urinary symptom profiles after RT. The surgical technique (ThuLEP vs. TURP) and the time interval to irradiation are crucial factors affecting RT tolerance in acute and late settings. The previously operated patient group reported a significantly longer period of increased symptom burden.

Does previous transurethral resection of the prostate affect the outcomes in robotic assisted radical prostatectomy?

Transurethral resection of the prostate (TURP) is one of the surgical options for treating enlarged prostates with lower urinary symptoms (LUTS). In this older group of patients, concomitant prostate cancer is not uncommon. However, the fibrosis and distortion of the prostate anatomy by prior TURP can potentially hinder surgical efficacy at robotic-assisted radical prostatectomy (RARP). We aim to evaluate functional, and oncologic outcomes of RARP in patients with and without previous TURP. 231 men with previous TURP underwent RARP (TURP group). These men were propensity score matched using clinicopathological characteristics to men without previous TURP who underwent RARP (Control group). Perioperative and postoperative variables were analysed for significant differences in outcomes between groups. Variables analysed included estimated blood loss (EBL), operative time, catheter time, hospitalization time, postoperative complications, positive surgical margins (PSM) rates, cancer status, biochemical recurrence (BCR), potency, and continence rates. Patients in the TURP group showed no statistically significant differences in operative safety measures including median EBL, operative time, catheter time, hospitalization time or postoperative complications. No significant difference between the groups in terms of potency rates and continence rates. Furthermore, there were no statistically significant differences in oncological outcomes, including PSM rates (15% vs 18%, P = 0.3) and BCR. In RARP after TURP there is often noticeable distortion of the surgical anatomy. For an experienced team the procedure is safe and provides similar oncologic control and functional outcomes to RARP in patients without previous TURP.

Varnishing prostate cancer acinar (adenocarcinoma of the prostate gland pt0) in prostate biopsy specimen which subsequently becomes diagnosed as no prostate cancer or pt0 prostate cancer in a prostatectomy specimen: review and update

Taking into consideration the increased undertaking of screening tests for serum prostate-specific antigen (PSA), it would be envisaged that the diagnosis of prostate cancer at an early clinical stage and small tumour-size had been appreciably increased over recent years and as a consequence, the volume of tumour within radical prostatectomy (RP) specimens had decreased in size. Pathological stage pT0 is referred to as no evidence of residual tumour within a radical prostatectomy (RP) specimen from a patient in whom biopsy-proven prostate carcinoma had been histologically confirmed as a diagnosis. This entity was given a terminology of the "vanishing cancer phenomenon" by Goldstein and associates. The pT0 stage of prostate cancer had been noted ensuing hormone therapy or prior transurethral resection of the prostate (TURP) for benign prostatic hyperplasia before the undertaking of RP. Even though much research had addressed these two scenarios of pT0 stage prostate cancer, patients that manifest with pT0 status in cases other than the aforementioned two scenarios occur on very rare occasions which had been iterated to be in between 0.2% and 0.8% of all prostate cancer patients). Only few studies had examined such patients. The clinical significance of pT0 staging has remained not to be clear. Nevertheless, many reports had documented that that pT0 stage patients do portend a highly satisfactory clinical outcome. pT0 at RP is extremely rare. Although most pT0 patients had tended to have low serum PSA levels, low clinical stage, low biopsy Gleasson Score (GS), and only one positive biopsy core, those with more aggressive characteristics could still harbour pT0 at RP. In order to prevent the undertaking of unnecessary treatment of such clinically insignificant cancers, it would be important to ascertain preoperative clinical and pathologic characteristics which might help the Urologists and oncologist to pre-operatively ascertain patients with a high probability of pT0 staging upon RP specimens. The ensuing article has discussed general overview aspects as well as miscellaneous narrations and discussions from some case reports, case series and studies related to the varnishing prostate cancer in order to provide recent educative material on the varnishing prostate cancer to all readers.

Surgical Outcomes for Elderly Patients Undergoing Transurethral Resection of the Prostate for Chronic Urinary Retention and Proposal of a Management Algorithm.

Introduction: Chronic urinary retention (CUR) is a major problem in elderly patients and leads to high levels of morbidity. CUR can be treated surgically with transurethral resection of the prostate (TURP), but surgery is frequently avoided in elderly patients due to increased perioperative risks and the presence of detrusor underactivity, which can lead to surgical failure. We report on contemporary outcomes for catheterized elderly patients undergoing TURP from a high-volume university teaching hospital. Patients and Methods: Catheterized patients 80 years of age and older undergoing TURP for CUR at a university teaching hospital between 2012 and 2020 (9 years) were eligible. Those with neurogenic bladder, urethral stricture, or prior TURP were excluded. Surgical success was defined as being catheter free at 3- and 12-month follow-up. Statistical analysis was performed using the Chi-squared test for grouped data and logistic regression modeling for continuous data. Results: A total of 147 patients were included and underwent TURP. Of these, 118 (80.3%) were completely catheter free or using intermittent self-catheterization at initial 3-month follow-up. One hundred seventeen (79.6%) remained catheter free at 1-year follow-up. Postvoid residual >1500 mL before TURP (p = 0.017); age ≥90 (p = 0.0067); and World Health Organization performance status ≥3 (p < 0.00001) were all identified as independent risk factors for surgical failure. A selected subset of patients excluding these risk factors showed overall catheter-free rates of 88.8% at 3-month follow-up. Early and late complications were noted in 6.8% and 2.7% of patients. Conclusion: Our contemporary series demonstrate high rates of successful postoperative voiding for selected elderly patients after TURP, with catheter-free rates at 12 months of 88.8%. Overall complication rate was 9.5%, which may be justified given the alternative morbidity of long-term catheterization. TURP remains an efficacious and cost-effective treatment for selected elderly patients who are catheterized for CUR.

Robot-Assisted Simple Prostatectomy: A Comparison of Primary Simple Prostatectomy vs Salvage Simple Prostatectomy in Treatment of Lower Urinary Tract Symptoms.

Purpose: Simple prostatectomy is indicated in patients with enlarged glands (>80 g) who present with lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia. Salvage robotic simple prostatectomy (SSP) is defined as simple prostatectomy after failed transurethral procedure. The aim of this study is to evaluate the efficacy of primary robotic simple prostatectomy (PSP) vs SSP in ameliorating LUTS. Materials and Methods: We retrospectively reviewed 124 patients who underwent RSP between 2013 and 2021. Indications for surgery were enlarged prostate, bothersome LUTS, or symptoms refractory to medical management and/or previous prostate surgery. PSP and SSP preoperative, perioperative, and postoperative variables were recorded. The severity of LUTS was assessed using the International Prostate Symptoms Score (IPSS). Two-tailed t-tests were performed to compare primary vs salvage RSP cohorts at a p-value of 0.05. Results: Of 124 patients who underwent RSP, 98 were primary and 26 were in the salvage setting with 19 patients undergoing prior transurethral resection of the prostate, 3 status post-transurethral microwave therapy, 1 status post-transurethral needle ablation of the prostate, and 3 status post-UroLIFT. Mean length of stay following RSP was 1.87 (days). At mean follow-up of ∼12 months, no patient required reoperation for LUTS. Preoperative IPSS for primary and salvage RSP was 18.56 and 16.25, respectively (p = 0.36), and postoperative IPSS for primary and salvage RSP was 5.33 and 8.00, respectively (p = 0.38). Conclusion: Regardless of primary or salvage indication, RSP remains a highly efficient and durable procedure for improvement in LUTS. RSP performed in the salvage setting greatly improved urinary function outcomes in patients after failure of previous transurethral procedures.

Impact of previous transurethral resection of prostate on robot-assisted radical prostatectomy: a matched cohort analysis.

We aimed to compare surgical, oncological, and functional outcomes of robot-assisted radical prostatectomy (RARP) in prostate cancer patients with and without prior history of transurethral resection of the prostate (TURP), using a matched cohort analysis. In an IRB-approved protocol, all patients who underwent RARP at our institution between April 2005 and July 2018 with at least 1-year follow-up were included. Among these, patients who had undergone a previous TURP (Group A) were compared with those without TURP (Group B) using the Survival, Continence, and Potency outcomes reporting system. Using propensity score matching for age, PSA and Gleason score, the two cohorts were further subdivided in a 1:2 ratio into Group C (prior TURP from Group A) and Group D (without prior TURP from Group B). Similar comparisons were made between Group C and D. Patients in Group A (n = 40) had lower PSA (p = 0.031) and were more likely to have Gleason grade 1 disease (p = 0.035) than patients in Group B (n = 143). In the propensity-matched group analysis, patients of Group C (n = 38) had higher operative time and blood loss than Group D (n = 76) patients. Group C patients also had lower continence at 3, 6, and 12months after surgery. However, oncological and potency outcomes were similar in both the groups. We concluded that previous TURP is a predictor for surgical and continence outcomes following RARP. Even though these patients have a potentially lower stage or grade of disease, they are less likely to achieve social continence than men who have not had a previous TURP. This information would be important in counseling them for treatment options.

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.

Clinical predictors of severe late urinary toxicity after curative intensity-modulated radiation therapy for localized prostate cancer.

Intractable late urinary toxicity is a serious complication after radiotherapy for patients with localized prostate cancer (LPC). We assessed clinical factors correlated with severe late urinary toxicity in LPC treated with curative image-guided intensity-modulated radiation therapy (IMRT). A total of 452 patients with LPC treated with IMRT between 2002 and 2016 were retrospectively analyzed. Among them, 432 patients received androgen deprivation therapy (ADT). The median total irradiated doses were 80 (range, 76-80) Gy. Each daily dose was 2 Gy per fraction. The median follow-up was 83 (range, 4-210) months. Late urinary toxicity was scored according to the National Cancer Institute Common Terminology Criteria for Adverse Events, Version 4.03. Grade 3 late urinary toxicity was observed in 27 patients. No cases with grade ≥ 4 late urinary toxicity were observed. The 5-, 10-, and 12.5-year grade 3 late urinary toxicity-free survival rates were 97%, 91.8% and 88.1%, respectively. Age, risk classification, total irradiated dose, ADT duration, antithrombotic therapy (AT), cardiovascular disease, hypertension (HT), diabetes mellitus (DM), dyslipidemia (DL), prior transurethral resection of the prostate (TURP) and prior high-intensity focused ultrasound (HIFU) were investigated for correlations with grade 3 late urinary toxicity. In univariate analysis, AT and prior HIFU and no other studied factors, were correlated with grade 3 late urinary toxicity. AT and prior HIFU appear to be predictive of grade 3 late urinary toxicity. Patients with LPC with these relevant clinical factors should be carefully followed up by sharing detailed information with the urology department.

Abstract No. 452 Prostatic artery embolization for inpatient and emergent hematuria: a single-system experience

Prostatic artery embolization (PAE) is typically an elective outpatient procedure performed for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). However, PAE is also performed for hematuria, including in inpatient or emergent settings. This report aims to elucidate the causes of hematuria in this population. PAE cases from June 2014 until August 2020 at two hospitals in a tertiary academic health system were queried (n = 216). Patients were included in this study if they underwent inpatient or emergent PAE for hematuria as the primary indication. For all consecutive patients meeting these inclusion criteria, demographic, baseline, procedural, and follow-up data were collected. Of the 216 patients queried, 10 (4.6%) received PAE with hematuria as the primary indication. The patients studied had a mean age of 73.0 years (SD = 11.1). No patients reported any other urinary symptoms (frequency, urgency, straining, incomplete emptying, nocturia, etc). Seven of the 10 patients’ procedures were a technical success defined as stasis. Of these 10 patients, 6 had bleeding secondary to prior transurethral resection of the prostate (TURP). Of those post-TURP patients, 3 were performed acutely for hematuria (3, 6, and 11 days) and 3 for chronic hematuria (2 months, 12 months, and 14 months). Of these 6 patients, 3 were never documented as re-presenting with hematuria. Two presented to the emergency department within 30 days for recurrent gross hematuria, and one reported chronic hematuria for one month following discharge. Two other patients presented with hematuria secondary to other procedures, robotic prostatectomy and TURBT. One was due to hemorrhage of the prostate secondary to metastatic adenocarcinoma of the prostate presenting with hypotension and anemia. One patient presented with hematuria secondary to invasive large B-cell lymphoma and treatment with heparin. In this patient, the right prostatic artery could not be visualized and so bilateral PAE could not be achieved. Preliminary single system experience showed that post-TURP hematuria was the most common cause of reason for pursuing emergent PAE. More research is needed to determine the prevalence of recurrence of hematuria in these patients.

The impact of transition from conventional robot-assisted radical prostatectomy to retzius sparing robot-assisted radical prostatectomy: A retrospective multivariate analysis.

Introduction:To assess the outcomes of Retzius sparing robotic-assisted radical prostatectomy (RS-RARP) in comparison with the conventional RARP.Materials and Methods:A retrospective analysis of 320 cases of RARP, performed from 2014 April to 2019 April, was performed. The predictor variables included age, body mass index, clinical stage, prostate-specific antigen, Gleason score category in biopsy, D'Amico risk category, presence of the median lobe, prior transurethral resection of the prostate, and the ability to perform the RS-RARP. The outcome variables included console time, blood loss, blood transfusion, nerve sparing, bladder neck sparing, positive surgical margins (PSM), number and the site of PSMs, extracapsular invasion, seminal vesicle involvement, complications, continence, erectile function, biochemical recurrence, and adjuvant treatment. Regression analysis was performed using the linear regression for the continuous variables and binary logistic regression for the categorical variables with two levels.Results:Three hundred and twenty patients underwent radical prostatectomy from 2014 April to 2019 April. We started the RS-RARP program in December 2016. Twenty-three patients who did not meet the inclusion criteria were excluded and a total of 297 patients were studied. Multivariate analysis demonstrated that RS-RARP was a strong positive independent predictor for continence recovery at 3 months, 6 months, and 12 months. RS-RARP was an independent predictor of reduced console time and increased probability of bladder neck sparing. RS-RARP was also independently associated with increased PSM in the posterolateral, anterolateral, and the apical regions.Conclusion:RS-RARP has better continence rates up to 12 months compared with the conventional approach, but is associated with increased PSM at certain locations.

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.

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.

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.

V07-06 PROSTATO-NEOVAGINAL FISTULA REPAIR IN A PATIENT WITH PRIOR TRANSURETHRAL RESECTION OF THE PROSTATE

You have accessJournal of UrologyLower-Tract Reconstruction II: ED/Infertility & Transgender Surgery (V07)1 Apr 2020V07-06 PROSTATO-NEOVAGINAL FISTULA REPAIR IN A PATIENT WITH PRIOR TRANSURETHRAL RESECTION OF THE PROSTATE Rebecca Sager*, Daniela Kaefer, Natasha Ginzburg, and Dmitriy Nikolavsky Rebecca Sager*Rebecca Sager* More articles by this author , Daniela KaeferDaniela Kaefer More articles by this author , Natasha GinzburgNatasha Ginzburg More articles by this author , and Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000897.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vaginoplasties for gender affirmation are becoming increasingly common and are reported to carry a risk of serious urological complications such as urethro-neovaginal fistulae. Our objective was to demonstrate a technique for repair of prostatic urethro-neovaginal fistula in a transgender female with prior transurethral resection of the prostate (TURP). METHODS: A 65-year-old transgender female presented with a complaint of severe incontinence and was diagnosed with a prostato-neovaginal fistula. She had undergone TURP for symptomatic benign prostatic hyperplasia (BPH) prior to penile inversion vaginoplasty at another institution. Following vaginoplasty, she had severe incontinence of urine after the initial vaginal packing removal. Cystoscopy and vaginoscopy identified fistulae from the urethra, just proximal to the verumontanum, to the neovagina. The options for repair were considered ensuring that the neovagina remained patent. Surgical technique: The urethra was dissected laterally away from neovagina, and the prostatic and membranous urethral plate was incised dorsally. An Asopa-type dorsal inlay urethroplasty with buccal mucosa graft was performed. The lateral urethral edges were rotated ventrally, approximated and the adjacent tissue flaps were brought over in layers to cover ventral urethral anastomosis. A 16 French urethral catheter and vaginal packing were left in place at the conclusion of the case. Patient was followed with imaging, cystoscopy and questionnaires. RESULTS: Voiding cystourethrogram was performed 3 weeks post-operatively with no evidence of fistula. On follow up visits at 4- and 8-months patient reported no recurrent incontinence, no difficulty with vaginal dilations or penetrative vaginal intercourse. Cystoscopy and pelvic exam at the 8-months follow-up demonstrated no evidence of fistula or stricture and no stress incontinence with cough or Valsalva. CONCLUSIONS: Surgical treatment of BPH by TURP prior to gender affirmation surgery in transgender female patients may lead to complicated fistulae in a setting of incompetent bladder neck. The close proximity of the neovaginal dissection to a thinned prostate capsule and external sphincter may predispose this group of patients to fistula formation and incontinence. Traditional interposition flaps such as gracilis could create significant bulk compromising the neovaginal space. Asopa-type urethroplasty with dorsal inlay of buccal mucosa graft and ventral urethral closure can be used for a novel application in repair of complex prostato-neovaginal fistula. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e644-e645 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rebecca Sager* More articles by this author Daniela Kaefer More articles by this author Natasha Ginzburg More articles by this author Dmitriy Nikolavsky More articles by this author Expand All Advertisement PDF downloadLoading ...

Abstract No. 689 Prostate artery embolization in patients with prior transurethral resection of the prostate: a feasibility study

This study examines the feasibility of prostate artery embolization (PAE) as a treatment for benign prostatic hyperplasia (BPH) with refractory lower urinary tract symptoms (LUTS) after transurethral resection of the prostate (TURP). The feasibility of PAE to treat refractory BPH-associated LUTS in patients with prior TURP has not been established. PAE cases from April 2015 through June 2019 at two hospitals in a tertiary academic health system were queried (n = 159). Patients were included if they underwent elective PAE and had at least one prior TURP (n = 10). Patients undergoing emergent PAE for hematuria were excluded. Demographic, baseline, procedural, and follow-up data were collected where available for consecutive patients meeting the inclusion criteria. Technical success was defined as bilateral stasis. Patients studied had a mean age of 72.5 years (SD = 5.7) and ellipsoid prostate volumes of 131.1 cm3 (range, 54-196 cm3). The median time between most recent TURP and PAE was 7 years (range, 1-15 years). 7 patients had 1 prior TURP, 2 had 2, and 1 had 3. Mean baseline International Prostate Symptom Score (IPSS) was 20.2 (SD = 9.6) and mean Quality of Life score (QOL) was 4.4 (SD = 1.6). Procedures had a mean fluoroscopy time of 37.5 minutes, radiation dose of 647583.2 mGycm2, and contrast volume of 142 mL. Technical success was achieved in 8 of 10 patients. In the other 2 patients, unilateral stasis was achieved. One failure was unilateral due to excessive fluoroscopy time and one was due to inability to visualize the left prostatic artery. After an average of 70.8 days (SD = 88) post-PAE, mean IPSS reduction was 4.9 (n = 7, SD = 5.0, P = 0.03) and mean QOL reduction was 0.5 (n = 6, SD = 0.5, P = 0.04). Post-PAE adverse events included urethral irritation (n = 1), pain (n = 1), and incomplete emptying with a need for self-catheterization (n = 1). While more research is required to fully assess efficacy and safety, preliminary results in a group of 10 patients indicate feasibility of PAE as a promising treatment option in patients with BPH-associated refractory LUTS post-TURP.

Prior Transurethral Resection Of The Prostate Does Not Predict For Grade 2+ Urinary Toxicity in Men Receiving Modest Dosing SBRT for Prostate Cancer

Prior Transurethral Resection Of The Prostate Does Not Predict For Grade 2+ Urinary Toxicity in Men Receiving Modest Dosing SBRT for Prostate Cancer

High dose rate brachytherapy boost for prostate cancer: Biochemical control and the impact of transurethral resection of the prostate and hydrogel spacer insertion on toxicity outcomes.

To examine the long-term outcomes of high dose rate brachytherapy boost (HDR-BT) combined with external beam radiotherapy (EBRT) for intermediate and high-risk prostate cancer patients. Data from 95 patients who underwent combined EBRT (50.4Gy) and HDR-BT to the prostate between 2010 and 2017 were retrospectively analysed. Biochemical progression free survival (bPFS), local recurrence free survival (LRFS), metastatic free survival (MFS) and overall survival (OS) were estimated using Kaplan-Meier method. Regression analysis was conducted to identify important predictors of outcomes. A total of 24 patients received an initial HDR-BT dose of 18Gy in three fractions, with the remaining 71 patients receiving 16Gy in two fractions as per departmental protocol changes. Most patients (88%) received androgen deprivation therapy. A transurethral resection of the prostate (TURP) was performed in 14 patients and hydrogel spacers (HS) were used in 30 patients. Median follow-up was 58months. The 5-year bPFS, LRFS, MFS and OS were 92%, 100%, 92% and 88%. Univariate regression revealed no statistical association between patient characteristics and time to relapse (all P>0.1). Late > grade 2 genitourinary (GU) toxicity was 6.3%. The use of HS or prior TURP had no impact on late GU toxicity. Late Grade 1 gastrointestinal (GI) toxicity was 5.3%. The combined HDR-BT with EBRT resulted in excellent bPFS. The cumulative risk of late GU and GI toxicity was low and can be further improved with preventative strategies such as a pre-emptive TURP and/or HS insertion.

Patient and Dosimetric Predictors of Genitourinary and Bowel Quality of Life After Prostate SBRT: Secondary Analysis of a Multi-institutional Trial

Stereotactic body radiation therapy (SBRT) is an emerging option for localized prostate cancer. However, there are no standard dosimetric guidelines, and normal tissue tolerances for extreme hypofractionation are not well defined. We analyzed dosimetric correlations with patient-reported urinary and bowel quality of life (QOL) on a prospective trial. Patients with low- or intermediate-risk prostate cancer from 18 institutions were enrolled on a phase 2 trial from 2007 to 2012 and treated using robotic SBRT to 38Gy in 4 fractions on consecutive days. No androgen deprivation was used. Patients received simulation with Foley catheter for urethral delineation. The clinical target volume was prostate (low-risk patients) or prostate plus 1cm of proximal seminal vesicles (intermediate-risk patients). Multiple dosimetric measures for urethra, bladder, and rectum were prospectively recorded. QOL using the Expanded Prostate Cancer Index Composite was assessed before and after treatment at protocol-specific time points. Linear regression was used to assess factors associated with QOL at 1month and 2years. A total of 259 patients were enrolled. QOL data were available for 98%, 96%, and 84% at baseline, 1month, and 2years, respectively. Median age was 69years. Prior transurethral resection of the prostate and clinical target volume size were associated with 2-year urinary incontinence. There was a trend toward worse 2-year obstruction/irritation in older patients on multivariable analysis. Bladder and urethral doses were not associated with either 1-month or 2-year urinary QOL. In contrast, rectum maximum dose was associated with both 1-month and 2-year bowel QOL. At 2years, the proportion with moderate or big overall bowel problems (as defined by Expanded Prostate Cancer Index Composite-26) was significantly higher in patients with rectum maximum dose greater than versus less than the median 37.4Gy (11% vs 2%, Fisher's exact test P=.008). These results provide novel data that contribute to a better understanding of patient and dosimetric factors associated with adverse QOL effects from prostate SBRT.

A single institution analysis of low-dose-rate brachytherapy: 5-year reported survival and late toxicity outcomes.

PurposeTo report the 5-year biochemical relapse-free survival (BRFS), overall survival (OS), and long-term toxicity outcomes of patients treated with low-dose-rate (LDR) brachytherapy as monotherapy for low- to intermediate-risk prostate cancer.Material and methodsBetween 2004 and 2011, 371 patients were treated with LDR brachytherapy as monotherapy. Of these, 102 patients (27%) underwent transurethral resection of the prostate (TURP) prior to implantation. Follow-up was performed every 3 months for 12 months, then every 6 months over 4 years and included prostate specific antigen evaluation. The biochemical relapse-free survival (BRFS) was defined according to the Phoenix criteria. Acute and late toxicities were documented using the Common Terminology Criteria for Adverse Events version 4.0. The BRFS and OS estimates were calculated using Kaplan-Meier plots. Univariate and multivariate analyses were performed to evaluate outcomes by pre-treatment clinical prognostic factors and radiation dosimetry.ResultsThe median follow-up of all patients was 5.45 years. The 5-year BRFS and OS rates were 95% and 96%, respectively. The BRFS rates for patients with Gleason score (GS) > 7 and GS ≤ 6 were 96% and 91% respectively (p = 0.06). On univariate analysis, T1 and T2 staging, risk-group classification, and prostate volumes had no impact on survival at 5 years (p > 0.1). Late grade 2 and 3 genitourinary (GU) toxicities were observed in 10% and 5% of patients respectively. Additionally, patients with prior TURP had a greater incidence of late grade 2 or 3 urinary retention (p = 0.001). There were 14 deaths in total; however, none were attributed to prostate cancer.ConclusionsLDR brachytherapy is an effective treatment option in low- to intermediate-risk prostate cancer patients. We observed low biochemical relapse rates and minimal GU toxicities several years after treatment in patients with or without TURP. However, a small risk of urinary retention was observed in some patients.