Prostatic Capsule Research Articles

Can tumor contact length predict extracapsular extension, lymph node involvement, and biochemical recurrence?

e17016Background: Prostate cancer (PC) is the cancer most commonly diagnosed in men and the second leading cause of death. Multiparametric magnetic resonance imaging (mpMRI) is the benchmark imagin...

Contrast enhanced ultrasound (CEUS) with MRI image fusion for monitoring focal therapy of prostate cancer with high intensity focused ultrasound (HIFU)1.

Reduced acceptance of radical prostatectomy in patients with low risk or intermediate risk prostate cancer has significantly changed treatment strategies in prostate cancer (PCa) during the last years. Focal therapy of the prostate with high intensity focused ultrasound (HIFU) is an organ-preserving treatment for prostate cancer with less impairment of health-related quality of life. Follow-up after HIFU therapy by imaging modalities remains a major problem as eg. MRI performs poorly. Contrast enhanced ultrasound (CEUS) allows to monitor the vascular architecture of organs non-invasively. However, only limited data are available using CEUS to define successful and complete HIFU treatment of the prostate. In this study, we aimed to evaluate short-term image findings using CEUS and image fusion before and after HIFU treatment. Prospective single arm study in patients with uni- or bilateral, low or intermediate risk prostate cancer or recurrent cancer after radiotherapy treated with HIFU at our institution between October 2016 and November 2017. HIFU hemiablation or whole gland treatment was performed using the Focal One® device. PCa was diagnosed either by multiparametric magnetic resonance imaging (mpMRI) followed by MRI fusion based targeted biopsy combined with 12 core transrectal ultrasound (TRUS) guided biopsy or 12 core random biopsy only. Monitoring of the target region before, immediately and 24 hours after the ablation was done by CEUS in combination with image fusion using an axial T2-weighted MRI sequence. 6 consecutive patients with Gleason score (GS) 6, 5 patients with GS 7a prostate cancer and one patient with biochemical recurrence after radiotherapy were included in the study. Three patients underwent whole gland treatment due to histological proven bilateral PCa or recurrent PCa after radiotherapy. Hemiablation was performed in 9 patients with unilateral tumor and no PIRADS 4 or 5 lesion in the contralateral lobe. Median patient age was 69.8 years and median PSA (prostate-specific antigen) level was 8.4 ng/ml. CEUS showed markedly reduced microbubbles in the ablated area, the prostate capsule still showed signs of perfusion. The study is limited by the short follow up and small number of patients. CEUS examination showed a reduction of microcirculation in the treated area immediately after the treatment and 24 hours later. The combination of CEUS and image fusion seems to be helpful for detecting the PCa target lesion and monitor the success of HIFU ablation treatment. Evidence for image findings after HIFU-therapy are rare. Further studies on this topic are needed.

Endorectal MR imaging of prostate cancer: Evaluation of tumor capsular contact length as a sign of extracapsular extension

ObjectiveTo evaluate the length of contact between dominant tumor foci and the prostatic capsule as a sign of extracapsular extension at endorectal multiparametric MR imaging. Materials and methodsWe retrospectively identified 101 patients over a three-year interval who underwent endorectal multiparametric prostate MR imaging prior to radical prostatectomy for prostate cancer. Two readers identified the presence of dominant tumor focus (largest lesion with PI-RADS version 2 score of 4 or 5), and measured the length of tumor capsular contact and likelihood of extracapsular extension by standard criteria (1–5 Likert scale). Results were analyzed using histopathological review as reference standard. ResultsExtracapsular extension was found at histopathological review in 27 patients. Reader 1 (2) identified dominant tumor in 79 (73) patients, with mean tumor capsular contact length of 18.2 (14.0) mm. The area under the receiver operating characteristic curve for identification of extracapsular extension by tumor capsular contact length was 0.76 for reader 1 and 0.77 for reader 2, with optimal discrimination at values of 18 mm and 21 mm, respectively. In the subset of patients without obvious extracapsular extension by standard criteria (Likert scores 1–3), corresponding values were 0.74 and 0.66 with optimal thresholds of 24 and 21 mm. ConclusionLength of contact between the dominant tumor focus and the capsule is a moderately useful sign of extracapsular extension at endorectal multiparametric prostate MR imaging, including the subset of patients without obvious extracapsular extension by standard criteria, with optimal discrimination at threshold values of 18 to 24 mm.

PD42-02 LOWERING POSITIVE MARGIN RATES AT RADICAL PROSTATECTOMY BY COLOR CODING OF BIOPSY SPECIMENS TO PERMIT INDIVIDUALIZED PRESERVATION OF THE NEUROVASCULAR BUNDLES: IS IT FEASIBLE? A PILOT INVESTIGATION.

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VI1 Apr 2018PD42-02 LOWERING POSITIVE MARGIN RATES AT RADICAL PROSTATECTOMY BY COLOR CODING OF BIOPSY SPECIMENS TO PERMIT INDIVIDUALIZED PRESERVATION OF THE NEUROVASCULAR BUNDLES: IS IT FEASIBLE? A PILOT INVESTIGATION. Wei Phin Tan, Patrick Whelan, Ritu Ghai, Shahid Ekbal, and Leslie Deane Wei Phin TanWei Phin Tan More articles by this author , Patrick WhelanPatrick Whelan More articles by this author , Ritu GhaiRitu Ghai More articles by this author , Shahid EkbalShahid Ekbal More articles by this author , and Leslie DeaneLeslie Deane More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1955AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The ability of mpMRI to distinguish extracapsular extension from organ-confined disease when a lesion in is contact with the capsule remains poor and has very limited sensitivity. We aim to evaluate whether color-coding of core biopsy specimens aid in preservation of the neurovascular bundles on radical prostatectomy, from an oncological perspective. METHODS MRI guided transrectal ultrasound and biopsy of the prostate was performed in 51 consecutive patients suspected of being high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor (figure 1). RESULTS Of the 51 patients undergoing prostate biopsy, 30 (58.8 %) were found to have cancer of the prostate. This was Grade Group 1 in 13.7 %, 2 in 25.5 %, 3 in 7.8 %, 4 in 7.8 % and 5 in 3.9 % of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. 4 patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic extension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy. Color coding the specimen does not alter the cellular architecture, nor does it affect the integrity of DNA/RNA material, thus having no potential for impacting genomic assessment of the tissue for further clinical risk analysis and stratification. CONCLUSIONS Color-coding of prostate biopsy core specimens assists in tailoring the approach to preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modification of the prostate biopsy protocol is valuable in larger groups of patients. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e814 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Wei Phin Tan More articles by this author Patrick Whelan More articles by this author Ritu Ghai More articles by this author Shahid Ekbal More articles by this author Leslie Deane More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Image Quality and Geometric Distortion of Modern Diffusion-Weighted Imaging Sequences in Magnetic Resonance Imaging of the Prostate.

The aim of this study was to compare qualitative and quantitative image quality and geometric distortion of 4 magnetic resonance diffusion-weighted imaging (DWI) sequences of the prostate using comparable imaging parameters and similar acquisition times. Axial T2-weighted turbo spin echo images and axial DWI echo-planar imaging (EPI) sequences, including single-shot spin-echo (ss-EPI), readout-segmented multishot (rs-EPI), selective excitation-reduced field of view (sTX-EPI), and prototype single-shot technique applying slice-specific shimming (iShim-EPI) sequences, were acquired at 3 T in 10 healthy volunteers (mean age, 26.1 ± 3.8 years; body mass index, 23.2 ± 3.0 kg/m). Two radiologists, blinded to the type of DWI, independently rated DWIs on a 5-point Likert scale regarding subjective image quality features (resolution, demarcation of prostate capsule, zonal anatomy). Interreader agreement was assessed using the intraclass correlation coefficient. Signal-to-noise ratio (SNR) and apparent diffusion coefficient (ADC) values were assessed separately in the peripheral and transitional zone. For the analysis of geometric distortion, the diameter of the prostate from left to right and from anterior to posterior was measured at the level of the verumontanum on b-1000 DWIs and on T2-weighted turbo spin echo images. Differences were compared using the Wilcoxon rank sum test for qualitative parameters, analysis of variance, and Friedman test for quantitative parameters. A P value of less than 0.05 was considered significant, with correction for multiple comparisons. Interreader agreement was good to excellent (intraclass correlation coefficient, 0.71-0.79) for all qualitative features. Subjective image quality regarding "resolution" was significantly better for ss-EPI than rs-EPI (mean Likert score, 4.25 vs 3.8; P = 0.031) and sTX-EPI (4.25 vs 3.3; P = 0.046) and for iShim-EPI as compared with rs-EPI (4.4 vs 3.8; P = 0.031) and sTX-EPI (4.4 vs 3.3; P = 0.047). There was no significant difference regarding capsule demarcation and zonal anatomy. Signal-to-noise ratio was significantly higher in iShim-EPI than sTX-EPI (SNR ± standard deviation [SD], 28.13 ± 8.21 vs 14.96 ± 2.4; P = 0.015). The ADC values were lower for the peripheral zone in the sTX-EPI than in the ss-EPI (ADC ± SD, 1002.94 ± 83.51 vs 1165.05 ± 115.64; P = 0.013) and the rs-EPI (1002.94 ± 83.51 vs 1244.40 ± 89.95; P = 0.0012) and in the transitional zone in the sTX-EPI compared with the rs-EPI (874.50 ± 200.72 vs 1261.47 ± 179.23; P = 0.0021). There were no statistically significant differences in geometric distortion between all DWI sequences. Single-shot spin-echo EPI and iShim-EPI showed a tendency toward superior image quality and SNR compared with rs-EPI and sTX-EPI with no significant differences in geometric distortion.

V01-12 ROBOTIC REPAIR OF IATROGENIC PROSTATOSYMPHYSEAL FISTULA FOLLOWING PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE

You have accessJournal of UrologyReconstruction - Lower Urinary Tract1 Apr 2018V01-12 ROBOTIC REPAIR OF IATROGENIC PROSTATOSYMPHYSEAL FISTULA FOLLOWING PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE Andrew Sun, Scott Lundy, Kenneth Angermeier, and Amr Fergany Andrew SunAndrew Sun More articles by this author , Scott LundyScott Lundy More articles by this author , Kenneth AngermeierKenneth Angermeier More articles by this author , and Amr FerganyAmr Fergany More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.303AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prostatosymphyseal fistula (PSF) is a rare but serious complication following bladder outlet procedures such as transurethral resection of the prostate (TURP) or photoselective vaporization of the prostate (PVP). To date, 9 cases of iatrogenic PSF have been reported, all treated either conservatively with prolonged urinary diversion or with aggressive surgical management (radical prostatectomy or open fistula repair). Here we demonstrate feasibility of a minimally-invasive robotic-assisted fistula repair with perivesical fat flap coverage. METHODS A 73 year old man presented with pelvic and musculoskeletal pain two months after undergoing PVP for obstructive voiding symptoms, and imaging and cystoscopy revealed a large PSF. The patient was counseled on the management options and elected to proceed with robotic surgical repair. The patient was positioned in low lithotomy and transperitoneal access was obtained with a Veress needle. Port placement was performed in the standard w configuration used in robotic prostatectomy. The bladder was dissected free from the anterior abdominal wall, with progressively more inflamed and fibrotic tissue encountered as the dissection was carried towards the pubic symphysis. The endopelvic fascia was incised bilaterally, and the fistula tract was carefully dissected off the pubis and necrotic areas cauterized. The urethra was then mobilized around the fistula tract to identify healthy tissue for anastomotic repair. A relaxing v incision was made in the anterior prostatic capsule to allow for a wide anastomosis to the distal urethral defect. Two running 3-0 V lock sutures were used to complete the anastomosis over a new Foley catheter. A perivesical tissue flap was then mobilized to provide interposition for the repair and secured over the anastomosis with a V-lock suture. A JP drain was placed. RESULTS Operative time was 115 minutes. Estimated blood loss was 50 mls. Total hospital stay was 2 days. A cystogram at 4 weeks post-op demonstrated no leak and the foley catheter was removed. At 7 weeks follow up he was doing well with complete resolution of his pelvic and musculoskeletal pain. He was able to void with minimal complaint, good stream, and a post-void residual of 25cc. CONCLUSIONS PSF following PVP can be successfully repaired using a robotic-assisted prostate-sparing approach. This offers an attractive alternative to more radical surgical options and may potentially spare the patient from urinary and potency complications associated with radical prostatectomy. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e87 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Andrew Sun More articles by this author Scott Lundy More articles by this author Kenneth Angermeier More articles by this author Amr Fergany More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Hormones concentration in the blood of dogs with implant of the Suprelorin 4.7 mg

This article describes the results of the study of the prostate gland of dogs and changes in the level of sex hormones when treated with Suprelorin 4.7 mg implanted subcutaneously in the shoulder region. Suprelorin is an innovative drug that limits the production of testosterone. His action can be compared with the results of castration, but the owners of the animal provide their dog and, in fact, themselves, with the lack of stress and various problems associated with surgical intervention. Suprelorin is a non-steroidal, peptide contraceptive in the form of an implant. The active ingredient is deslorelin (an agonist GnRH), which inhibits the reproductive function at the level of the hypothalamic-pituitary axis for at least 6 months. Deslorrelin is a synthetic analogue of GnRH less susceptible to decomposition, seven times more potent than endogenous GnRH, more stable, and also with a higher sensitivity to GnRH receptors. GnRH plays a key role in controlling the reproductive system of females and males. And in the case of long-term prescribing of small doses of deslorelin, inhibition of functioning of the pituitary gonadal axis occurs. The central place in which the blocking of the synthesis and / or allocation of follicle stimulating (FSH) and luteinizing hormones (LH) in the dogs, which was introduced implant. In this case, there are no side effects of steroid. When conducting diagnostic measures with the help of an ultrasound machine, the tasks facing the specialist are: to determine the shape, size and echostructure of the prostate gland, its contours and capsules. According to the results of the ultrasound, experimental groups of animals and control were formed. The criterion for the formation of experimental groups was the increase the size of the prostate and structural changes (increasing or decreasing echogenicity, hypo-and anechoic inclusion in the parenchyma) in it. In the examination of dogs by ultrasound, it was found that the animals in the control group of the prostate were normal, and in animals of the experimental group were found structural changes in it, in particular, increase the size of the gland, increase echogenicity and heterogeneity of the structure of the parenchyma, anechoic inclusions of various sizes. While assessing the level of hormones in dogs, there was a significant decrease in testosterone levels in the experimental group, as well as an increase in the level of estradiol, luteinizing hormone, thyroid stimulating hormone, and T3 total in blood serum of dogs in experimental groups. The level of hormones was monitored weekly and reflected its changes on the schedule. Libido of all animals under the action of the implant significantly decreased. Behavior became calmer. Appetite improved and activity was normal. The sexual function of the treated dogs was completely restored a year later.

Accuracy in local staging of prostate cancer by adding a three-dimensional T2-weighted sequence with radial reconstructions in magnetic resonance imaging.

BackgroundThe evidence supporting the use of magnetic resonance imaging (MRI) in prostate cancer detection has been established, but its accuracy in local staging is questioned.PurposeTo investigate the additional value of multi-planar radial reconstructions of a three-dimensional (3D) T2-weighted (T2W) MRI sequence, intercepting the prostate capsule perpendicularly, for improving local staging of prostate cancer.Material and MethodsPreoperative, bi-parametric prostate MRI examinations in 94 patients operated between June 2014 and January 2015 where retrospectively reviewed by two experienced abdominal radiologists. Each patient was presented in two separate sets including diffusion-weighted imaging, without and with the 3D T2W set that included radial reconstructions. Each set was read at least two months apart. Extraprostatic tumor extension (EPE) was assessed according to a 5-point grading scale. Sensitivity and specificity for EPE was calculated and presented as receiver operating characteristics (ROC) with area under the curve (AUC), using histology from whole-mount prostate specimen as gold standard. Inter-rater agreement was calculated for the two different reading modes using Cohen’s kappa.ResultsThe AUC for detection of EPE for Readers 1 and 2 in the two-dimensional (2D) set was 0.70 and 0.68, respectively, and for the 2D + 3D set 0.62 and 0.65, respectively. Inter-rater agreement (Reader 1 vs. Reader 2) on EPE using Cohen’s kappa for the 2D and 2D + 3D set, respectively, was 0.42 and 0.17 (i.e. moderate and poor agreement, respectively).ConclusionThe addition of 3D T2W MRI with radial reconstructions did not improve local staging in prostate cancer.

Lowering positive margin rates at radical prostatectomy by color coding of biopsy specimens to permit individualized preservation of the neurovascular bundles: is it feasible? a pilot investigation.

ABSTRACTObjective:To evaluate whether color-coding of prostate core biopsy specimens aids in preservation of the neurovascular bundles from an oncological perspective.Materials and Methods:MRI guided transrectal ultrasound and biopsy of the prostate were performed in 51 consecutive patients suspected of being at high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor.Results:Of the 51 patients undergoing prostate biopsy, 30 (58.8%) were found to have cancer of the prostate: grade group 1 in 13.7%, 2 in 25.5%, 3 in 7.8%, 4 in 7.8% and 5 in 3.9% of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. Five patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic extension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy.Conclusion:Color-coding of prostate biopsy core specimens may assist in tailoring the approach for preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modification of the prostate biopsy protocol is valuable in larger groups of patients.

Radical prostatectomy performed via robotic, transperitoneal and extraperitoneoscopic approaches: functional and early oncological outcomes

IntroductionOncological remission along with high postoperative functionality [continence and erectile function (EF)] are the main aspects of prostate cancer (PCa) treatment. The aim of this study was to compare functional and oncological treatment results achieved after a nerve-sparing radical prostatectomy (RP) via transperitoneal (TPRP), extraperitoneal (EPRP) and robot-assisted (RARP) approach.Material and methodsFrom March 2015 to March 2016, 507 RP were performed at the Institute for Urology and Reproductive Health (Moscow, Russia). A total of 264 patients with localized (cТ1а–2с) prostate cancer [prostate-specific antigen (PSA) <20 ng/ml, Gleason score ≤7], intact prostate capsule (according to MRI), International Index of Erectile Function (IIEF-5) ≥19 and a life expectancy >10 years were included into the retrospective study. All the surgeries were performed by a single surgeon. The outcomes were evaluated after urethral catheter removal and 3–6–12 months after RP.ResultsNerve preservation (NP) was performed for 153 patients without significant distinctions in time (р = 0.064) and blood loss (р = 0.073). The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-SF) score was lower for NP: 9.23 ±6.59 and 3.86 ±5.38 after 3 and 12 months respectively compared with continence after RP without nerve preservation (NP): 14.27 ±5.1 vs. 6.15 ±4.76 (р <0.001). Continent was 52.2% vs. 83.3% vs. 81.8% in TPRP, RARP and EPRP groups; р <0.001. IIEF-5 scores were 14.67 ±9.4, 4.2 ±4.26 and 4.0 ±2.07 after RARP, TPRP and EPRP respectively (р = 0.002). After 12 months the PSA: TPRP = 0.11 ±0.19, RARP = 0.03 ±0.05 and EPRP = 0.53 ±1.87 ng/ml (р <0.001). Outcomes depend on surgical approach and was better in the RARP-group (AUC = 0.768 ±0.034 (CI 95% 0,701–0.834; р <0.001).ConclusionsWe suggest RARP with NP as a method of choice for treatment of prostate cancer in patients interested in preservation of EF and quality of life in general.

Trans-rectal Ultrasound-Guided Autologous Blood Injection in the Interprostatorectal Space Prior to Percutaneous MRI-Guided Cryoablation of the Prostate.

To report a novel technique of ultrasound-guided injection of autologous blood in the interprostatorectal space, in an attempt to facilitate ablative prostatic procedures by widening durably the space between the rectum and the prostate. Between April and November 2016, four consecutive patients underwent the haemoprotection injection technique. For each patient, we recorded the time to perform the technique, the amount of injected blood, the achieved distances between the rectum and the prostate post-injection at fixed defined points (apex, middle, and base of prostate at the midline, left, and right sides of the gland), the extension of the ice ball outside the prostate capsule at those fixed points, and whether any residual blood was present on 1-month follow-up MRI. Mean time to perform haemoprotection injection was 54min, with an average blood volume of 103cc. Mean distance achieved at the apex, middle, and base of the prostate, respectively, was 12, 13, and 16mm in the midline; 8, 10, and 13mm on the left side; and 9, 10, and 13mm on the right side. The mean extension distance of the ice ball beyond the capsule was 4, 6, and 6mm in the midline; 4, 5, and 6mm on the left side; and 1, 3, and 3mm on the right side. No residual blood was present on 1-month follow-up MRI in all patients. No rectal fistula occurred. Haemoprotection may create a safe and effective virtual space between the prostate and rectum.

Prostate shapes on pre-treatment MRI between prostate cancer patients who do and do not undergo biochemical recurrence are different: Preliminary Findings

Early identification of PCa patients at risk for biochemical recurrence (BCR) post-therapy will potentially complement definitive therapy with either neo- or adjuvant therapy to improve prognosis. BCR post definitive therapy is often associated with disease progression that might cause a bulge in the prostate gland. In this work we explored if an atlas-based comparison approach reveals shape differences in the prostate capsule as observed on pre-treatment T2-weighted MRI between prostate cancer patients who do (BCR+) and do not (BCR−) have BCR following definitive therapy. A single center IRB approved study included 874 patients. Complete image datasets, clinically localized PCa, availability of Gleason score, data available for post-treatment PSA and follow-up for at least 3 years in patients without BCR were the inclusion criteria to select 77 patients out of the 874 patients. Further controlling for Gleason score, stage, age and to maintain equal number of cases for the BCR+ and BCR− categories, the total number of cases was reduced to 50. Manually segmented prostate capsules were aligned to a BCR− template for statistical comparison between the BCR+ and BCR− groups. Statistically significant shape difference between the two groups was observed towards the lateral and the posterior sides of prostate.

The Hybrid Method Can Cover the External Prostatic Region Compared With the Conventional Method in Patients Who Undergo Prostate Low-Dose-Rate Brachytherapy

The advantage of low-dose rate (LDR) brachytherapy is the potential ability to cover the external prostatic region with a curative radiation dose. Most external prostatic extension (EPE) is observed (90%) within 5 mm from prostatic capsule. The loose seed which is implanted around prostate often migrates to vessel and lung, while the stranded seed rarely migrates. We hypothesize that the hybrid method (using loose seed in combination of stranded seed) can irradiate with a wide margin (5 mm from prostate capsule) compared with the conventional method (using loose seed alone).A randomized control trial (trial number: UMIN 000012780) was conducted to compare dose evaluation parameters between the conventional method and the hybrid method. Between 2004 and July 2016, a total of 220 patients who underwent LDR-brachytherapy were enrolled. Patients were randomized and allocated to two groups (conventional method vs, hybrid method). We compared dose evaluation (post-dosimetric) parameters (%D90, V100, V150, %UD30, R100) calculated at 1 month after seed implant by CT scan between the two groups, and also compared post-dosimetric parameters using the planning target volume (PTV) with prostate+5mm margin. In the conventional method group, 42 patients received seed implant alone and 68 patients received seed implant in combination with external beam radiation therapy (EBRT), while 43 patients received seed implant alone and 67 in combination with EBRT in the hybrid method group. Regarding dose evaluation parameters, prostate dose (%D90, V100, V150), and urethral dose (%UD30), were not significantly different between 2 groups, while V100 (+5 mm margin) and %D90 (+5 mm margin) were significantly higher in the hybrid method group compared with the conventional method group (P<0.001) (Table 1). The present randomized control trial shows that the hybrid method of LDR-brachytherapy can achieve a higher coverage of peri-prostatic region under keeping a low urethral and rectal dose compared with the conventional method.Abstract 1086; Table 1Comparison of dose evaluation parameters between conventional method and hybrid method%D90 (%)V100 (%)V150 (%)%UD30 (%)R100 (mL)V100 (+5mm margin) (%)%D90 (+5mm margin) (%)Conventional116.896.658.8129.80.0977.279.2Hybrid119.097.259.0131.40.1580.583.4P-value0.0910.0570.7810.4050.0080.001>0.001> Open table in a new tab

Лазерная энуклеация гиперплазии простаты (HOLEP и THULEP): сравнительный анализ эффективности при лечении рецидивов гиперплазии простаты

The estimated recurrence rate of benign prostatic hyperplasia (BPH) after transurethral resection of the prostate is about 5 to 15%. Laser enucleation of the prostate results in a much lower recurrence rate (not exceeding 1-1.5%). At the same time, laser enucleation of the prostate is still not widely used for recurrent prostatic hyperplasia since it believed to be technically difficult in cases. To describe the distinctive features of thulium and holmium laser enucleations of the prostate in the management of recurrent BPH and show that the technical difficulties are not an obstacle to the wide application of this technique. This was a retrospective study comprising 676 patients aged 54 to 87 years with clinically pronounced infravesical obstruction due to prostatic hyperplasia (IPSS>20, Qmax<10). All patients were divided into four groups. Groups 1 (n=489) and 3 (n=153) underwent holmium (HoLEP) and thulium (ThuLEP) laser enucleations of the prostate, respectively. Groups 2 (n=23) and 4 (n=11) included patients with BPH recurrence after HoLEP (group 2) and ThuLEP (group 4). All patients underwent diagnostic evaluation at baseline and at 6 months after surgery. The mean ThuLEP operating time was shorter than that of HoLEP (p=0.02). The mean duration of repeat and primary ThuLEP and HoLEP did not differ statistically significantly (p>0.05). There was no difference in the length of hospitalization and catheterization between the four groups (p>0.05). At six months after surgery, a statistically significant improvement in I-PSS, Qmax, QoL, and RUV was observed in all groups compared with preoperative values (p>0.05)). We found that the technical difficulties of the re-operation, such as the difficult separation of adenomatous tissue from the prostate capsule, the multinodular nature of the adenoma, increased tissue density are easy to overcome and do not confer a significant complexity. In turn, better completeness of resection, low complication and recurrence rates and the possibility of surgery, even in elderly patients with multiple comorbidities - these features allow us to conclude that laser enucleation of the prostate is not only an effective treatment for infravesical obstruction due to benign prostatic hyperplasia, but is also a method of choice in the treatment of patients with recurrent BPH.

Computerized Planning of Prostate Cryosurgery and Shape Considerations.

The current study aims to explore possible relationships between various prostate shapes and the difficulty in creating a computer-based plan for cryosurgery. This research effort is a part of an ongoing study to develop computational means in order to improve cryosurgery training and education. This study uses a computerized planner—a key building block of a recently developed prototype for cryosurgery training. The quality of planning is measured by the overall defect volume, a proprietary concept which refers to undercooled areas internal to the target region and overcooled areas external to it. Results of this study numerically confirm that the overall defect volume decreases with an increasing number of cryoprobes, regardless of the geometry of the prostate. However, the number of cryoprobes required to achieve the smallest possible defect may be unrealistically high (<30). Results of this study also demonstrate that the optimal cryoprobe layout is associated with a smaller defect for symmetric prostate geometries and, independently, for prostate models that better resemble a sphere. Furthermore, a smaller defect is typically achieved when the urethra passes through the center of the prostate model. This study proposes to create a cryoprobe convex hull for the purpose of initial planning, which is a subdomain similar in shape to the prostate but at a reduced size. Parametric studies indicate that a cryoprobe convex hull contracted by 7 to 9 mm in all directions from the prostate capsule serves as a quasi-optimal initial condition for planning, that is, a preselected number of cryoprobes placed in the cryoprobe convex hull yields favorable results for optimization. The cryoprobe convex hull could accelerate computer-based planning, while also being adopted as a concept for traditional cryosurgery training, when computerized means are absent.

Periprostatic innervation: New issues based on segmental analysis of 10 human cadaver pelvic blocs.

The exact paths of periprostatic nerves have been under debate over the last decades. In the present study, the topographic distribution of nerves around the prostate and their relative distances from the prostatic capsule were analyzed in male cadaver visceral blocs. The pelvic organs from ten fresh male cadavers were removed and serial sectioned en bloc for histological investigation. The macroslices was divided into four sectors. Each sector was centrally covered with a raster dividing each sector in three subsectors numbered clockwise. The prostatic capsule was identified, and distances of 2.5 and 5 mm from the prostate were demarked with lines. We quantified the number of nerve fibers present in each subsector of each slide and recorded their position relative to the prostatic capsule. In general, the topographic analysis revealed that the majority of nerves were identified in sectors 4 through 9, corresponding to the posterolateral and posterior surfaces of the prostate gland. At the prostate base, the majority of nerves were found at the posterolateral and posterior surfaces of the gland. Within the mid-region of the prostate, the same topographic distribution pattern was observed, but the nerve fibers were closer to the prostatic capsule. At the apical region, the percentage of nerve fibers identified in the anterior region was higher, despite their major concetration in the posterior surface. The nerves identified at the apex were mainly located up to 2.5 mm from the prostate. This proximity to the prostate was specifically observed in the anterolateral and anterior sectors. In the craniocaudal sense, the percentage of nerves identified between 2.5 and 5 mm from the prostatic capsule remained constant. A significant number of nerve fibers were present in the anterior and anterolateral positions, especially at the apex. The anterior nerves were closer to the prostate. This proximity suggests that the anterior nerves may participate in local physiology and that the cavernous nerves are probably formed by the posterior nerve fibers. It is likely that the safe distance of 2.5 mm from all surfaces of the prostate may be related to cavernous fiber preservation.

Natural Orifice Transluminal Endoscopic Partial Prostatectomy: A Real-time Image-guided Focal Extirpative Feasibility Study

To assess the feasibility of focal endoscopic excision of prostate cancer (PCa) under guidance of real-time magnetic resonance imaging (MRI) or magnetic ultrasound fusion (MUF). Using a cadaveric model, multifocal PCa was simulated using 2 MRI-compatible fiducial markers. These were inserted transrectally and used to generate regions of interests (ROIs) on a 1.5-T surface-coil MRI. The first marker was placed in the right mid-peripheral zone (ROI 1), and the second marker was placed in the left seminal vesicle as a referent lesion for subsequent imaging. MRI of the specimen was then obtained. The radiologist created ROIs using fusion biopsy system at each marker. Two additional incidental ROIs were identified in the left transitional zone (ROI 2-suspicious for benign prostatic hyperplasia nodule) and in the right anterior peripheral zone (ROI 3-suspicious for PCa). Holmium laser enucleation of the transitional zone of the prostate was performed to gain access to the peripheral zone lesions. MUF was used during endoscopic laser excision to convey targeting accuracy. The cadaver was then reimaged to determine the adequacy of resection and examined for histopathologic correlation. Real-time MUF imaging identified the target lesions consistently at the locations designated as ROIs. Complete endoscopic resection of ROIs was possible. Repeated MUF imaging and the postprocedure MRI confirmed the completeness of resection. Pathologic examination demonstrated complete excision, intact neurovascular bundles, and posterior prostatic capsule. This approach may represent a new minimally invasive frontier for focal surgical resection of PCa, making histopathologic margin status determination possible.

Computer extracted shape features of prostate capsule from MRI to predict biochemical recurrence of prostate cancer post-treatment.

e16579 Background: Pre-treatment identification of biochemical recurrence (BCR) from MRI may enable the use of aggressive neo-adjuvant therapies for prostate cancer patients to improve prognosis. BCR is often associated with aggressive cancer growth and/or extra prostatic extension resulting in an irregular bulge and focal capsular retraction. This may induce differences in the shape of the prostate capsule between BCR positive (BCR+) and BCR negative (BCR-) patients as observed on MRI. In this work, we show that computer extracted shape features of the prostate capsule on MRI can identify patients that are at a risk of BCR post-treatment Methods: In a single centre IRB approved study, from a registry of 874 patients, availability of complete image datasets (T1w, T2w and ADC map); no treatment for PCa before MRI; presence of clinically localised PCa; availability of Gleason score; and data available for post-treatment PSA and follow-up for at least 3 years in patients without BCR were used as inclusion criteria to select 80 patients. The prostate capsule was manually segmented on T2w MRI by an experienced radiologist. Two atlases A+ and A- were created for BCR+ and BCR- patients respectively with similar Gleason score (6 to 9), similar numbers in each cohort (25 each) and similar tumor stage (T2 to T3). A t-test based analysis corrected for multiple comparison revealed statistically significant prostate shape differences between A+ and A- in surface of interest (SOI). Curvature features (magnitude and surface normal orientations) were extracted from SOI of the two cohorts. A random forest classifier was trained using the 50 training images (from A+ and A-) and validated using a hold-out validation set of 30 patients. Results: The inter-quartile range, variance, skewness and kurtosis of curvature magnitude and normal orientations were found to be predictive of BCR. The RF classifier trained using these features could predict BCR with an accuracy of 78% and an AUC of 0.71 in the validation set. Conclusions: Curvature magnitude and orientation features of the prostate capsule from the SOI may be predictive of BCR. In future a multi centre independent datasets will be used to validate the findings.

A combination of computer extracted measurements of prostate capsule shape and tumor texture on MRI to predict biochemical recurrence post treatment.

e16554 Background: Prostate cancer (PCa) biochemical recurrence (BCR) occurs in a significant proportion of men after treatment and is associated with increased mortality. Identifying PCa patients at risk of BCR following definitive therapy may help identify patients who might benefit from adjuvant therapy. Multi-parametric MRI (mpMRI) is being increasingly used in pre-treatment staging and risk stratification of PCa. In this work, we sought to explore whether a combination of computer extracted features relating to prostate capsule shape and tumor texture from pre-treatment mpMRI is predictive of BCR post treatment. Methods: This single center and retrospective study included 80 men with PCa who underwent pre-treatment 3T mpMRI and were followed for &gt; 3 years post treatment. These men were grouped into a training set D1 (N = 50, 25 each of BCR+ and BCR-) and an independent validation set D2 (N = 30, 10 BCR+ and 20 BCR-). The prostate capsule and cancer region of interest (ROI) were annotated on mpMRI by a single experienced radiologist. Shape features (curvature and orientation) were extracted from a surface of interest where statistically significant differences were observed between BCR+ and BCR- patients in the training set. Radiomic features for capturing tumor textural patterns (including 1st and 2nd order statistics, Gabor and Haralick) were extracted from within the radiologist annotated cancer ROIs. Features from D1 were used to train random forest classifiers, one each with shape (Cs) and radiomic (CR) features. A fused Bayesian classifier (CR+S) was created by integrating decisions from both Cs and CR. Results: The classifiers Cs, CR and CR+S were evaluated on independent validation set D2, resulting in area under the curve (AUCs) of 0.71, 0.81 and 0.84 respectively. Cs added value in patients who had extra prostatic spread of PCa, but suffered from mpMRI intensity artefacts that affected performance of CR. Conclusions: Integrating prostate capsule shape and tumor radiomic features from pre-treatment mpMRI enabled prediction of PCa BCR after treatment. Multi-site validation is needed to establish the robustness of the approach.

Prostate cancer: 'The prostate' in patients with metastatic prostate cancer: to treat or not to treat?

Advances in understanding of prostate cancer biology and improved treatment options have changed management of metastatic prostate cancer. Escape of the malignancy from the prostatic capsule no longer means that treatment is focused on limiting systemic spread, and data suggest that local treatment of the prostate is beneficial, even in men whose tumour has spread.