Transrectal Ultrasound Guidance Research Articles

Color VISION for improved ultrasound visualization of brachytherapy needles.

High dose rate brachytherapy is commonly used in the treatment of prostate cancer. Treatment planning is often performed under transrectal ultrasound (US) guidance, but brachytherapy needles can be challenging to digitize due to the presence of poor US conspicuity and imaging artifacts. The plan accuracy and quality, however, are dependent on the proper visualization of the needles with millimeter accuracy. This work describes a technique for generating a color overlay of needle locations atop the grayscale US image. Prototype devices were developed to produce vibrations in the brachytherapy needles that generate a high contrast color Doppler (CD) signal that highlights the needle locations with superior contrast and reduced artifacts. Denoted by the acronym color VISION (Vibrationally Induced Shimmering for Identifying an Object's Nature), the technology has the potential to improve applicator conspicuity and facilitate automated applicator digitization. Three prototype vibrational devices with frequencies between 200-450Hz were designed in-house and evaluated with needle implants in a phantom and cadaveric male pelvis using: (1) an actuator attached to the front of a prostate needle template; (2) an actuator attached to the top of the needle template; and (3) a hand-held actuator with a stylet, inserted directly into a needle's inner lumen. Acquired images were postprocessed in MATLAB to evaluate the potential for automated digitization. All prototype devices produced localized shimmering in implanted brachytherapy needles in both the axial and sagittal planes. The template mounted actuators provided better vibrational coupling and ease of operation than the stylet prototype. The Michelson contrast, or visibility, of the shimmering CD signal was 100% compared with ≤40% for B-mode imaging of a single needle. Proof-of-principle for automated applicator digitization using only the CD signal was demonstrated. The color VISION prototype devices successfully coupled mechanical vibrations into brachytherapy needles to generate US CD shimmering and accurately highlight brachytherapy needle locations. The high contrast and natively registered signal are promising for future work to automate the needle digitization and provide a real-time visual overlay of the applicator on the B-mode US image.

Discrepancies in Gleason score between needle core biopsy and radical prostatectomy specimens with correlation between clinical and pathological staging.

The studies have shown that GS given after assessment of the entire prostate gland on the radical prostatectomy specimen may differ from GS given after examination of a small sample from needle core biopsy. We conducted this study to assess discrepancies in the Gleason score between NCB and RP specimens and to find out the correlation between the clinical stage and pathological stage. The study included 174 patients with carcinoma prostate which underwent robotic-assisted radical prostatectomy (RARP). Pre-operative Gleason score was determined on 12-core biopsy samples under trans-rectal ultrasound (TRUS) guidance. The Gleason score obtained from the radical prostatectomy specimen was compared with that of the NCB Gleason score to find out differences. The preoperative Gleason score (GS) ranges from 6 to 9 with a mean GS of 6.97 ± 1.02. The post-operative GS ranges between 6 and 10 with mean and GS of 7.5 ± 1.10. On the pre-operative assessment of biopsy specimens, 70 (43.2%) patients had a GS of 6, while 44 patients had a GS of 7 (27.1%) and 48 (29.8%) patients had a GS of more than 7. On the postoperative assessment of specimens, 31 (19.1%) patients had post-operative GS of 6, while 66 (41%) patients had GS of 7 and 74 (41.1%) patients had GS of more than 7. When pre-operative GS and post-operative GS were compared, no changes were observed in the GS of 79 patients, whereas 83 patients showed the difference in GS, with 75 patients showing up-gradation and eight patients marked as down-graded. concordance between biopsy and the pathology results directly affects the prognosis of the patient. The results of our study demonstrated the rate of discordance between Gleason scores obtained from transrectal prostate biopsy and RP surgical specimens. This rate brings into question the accuracy of the chosen treatment.

Transrectal and Transperineal Prostate Biopsy under Local Anesthesia with Transrectal Ultrasound Guidance Comprehensive Review of Techniques and Complications

Transrectal and Transperineal Prostate Biopsy under Local Anesthesia with Transrectal Ultrasound Guidance Comprehensive Review of Techniques and Complications

Automatic search for photoacoustic marker using automated transrectal ultrasound.

Real-time transrectal ultrasound (TRUS) image guidance during robot-assisted laparoscopic radical prostatectomy has the potential to enhance surgery outcomes. Whether conventional or photoacoustic TRUS is used, the robotic system and the TRUS must be registered to each other. Accurate registration can be performed using photoacoustic (PA markers). However, this requires a manual search by an assistant [IEEE Robot. Autom. Lett8, 1287 (2023).10.1109/LRA.2022.3191788]. This paper introduces the first automatic search for PA markers using a transrectal ultrasound robot. This effectively reduces the challenges associated with the da Vinci-TRUS registration. This paper investigated the performance of three search algorithms in simulation and experiment: Weighted Average (WA), Golden Section Search (GSS), and Ternary Search (TS). For validation, a surgical prostate scenario was mimicked and various ex vivo tissues were tested. As a result, the WA algorithm can achieve 0.53°±0.30° average error after 9 data acquisitions, while the TS and GSS algorithm can achieve and 0.48°±0.32° average errors after 28 data acquisitions.

2D/3D Deep Registration Along Trajectories With Spatiotemporal Context: Application to Prostate Biopsy Navigation.

The accuracy of biopsy targeting is a major issue for prostate cancer diagnosis and therapy. However, navigation to biopsy targets remains challenging due to the limitations of transrectal ultrasound (TRUS) guidance added to prostate motion issues. This article describes a rigid 2D/3D deep registration method, which provides a continuous tracking of the biopsy location w.r.t the prostate for enhanced navigation. A spatiotemporal registration network (SpT-Net) is proposed to localize the live 2D US image relatively to a previously aquired US reference volume. The temporal context relies on prior trajectory information based on previous registration results and probe tracking. Different forms of spatial context were compared through inputs (local, partial or global) or using an additional spatial penalty term. The proposed 3D CNN architecture with all combinations of spatial and temporal context was evaluated in an ablation study. For providing a realistic clinical validation, a cumulative error was computed through series of registrations along trajectories, simulating a complete clinical navigation procedure. We also proposed two dataset generation processes with increasing levels of registration complexity and clinical realism. The experiments show that a model using local spatial information combined with temporal information performs better than more complex spatiotemporal combination. The best proposed model demonstrates robust real-time 2D/3D US cumulated registration performance on trajectories. Those results respect clinical requirements, application feasibility, and they outperform similar state-of-the-art methods. Our approach seems promising for clinical prostate biopsy navigation assistance or other US image-guided procedure.

Reliable Visualization of the Treatment Effect of Transperineal Focal Laser Ablation in Prostate Cancer Patients by Magnetic Resonance Imaging and Contrast-enhanced Ultrasound Imaging

BackgroundTransperineal focal laser ablation (TPLA) treatment for prostate cancer (PCa) is an experimental focal ablative therapy modality with low morbidity. However, a dosimetry model for TPLA is lacking. ObjectiveTo determine (1) the three-dimensional (3D) histologically defined ablation zone of single- and multifiber TPLA treatment for PCa correlated with magnetic resonance imaging (MRI) and contrast-enhanced ultrasound (CEUS) and (2) a reliable imaging modality of ablation zone volumetry. Design, setting, and participantsThis was a prospective, multicenter, and interventional phase I/II pilot study with an ablate-and-resect design. TPLA was performed in 12 patients with localized prostate cancer divided over four treatment regimens to evaluate potential variation in outcomes. InterventionTPLA was performed approximately 4 wk prior to robot-assisted radical prostatectomy (RARP) in a daycare setting using local anesthesia. Outcome measurements and statistical analysisFour weeks after TPLA, ablation zone volumetry was determined on prostate MRI and CEUS by delineation and segmentation into 3D models and correlated with whole-mount RARP histology using the Pearson correlation index. Results and limitationsTwelve office-based TPLA procedures were performed successfully under continuous transrectal ultrasound guidance using local perineal anesthesia. No serious adverse events occurred. A qualitative analysis showed a clear demarcation of the ablation zone on T2-weighted MRI, dynamic contrast-enhanced MRI, and CEUS. On pathological evaluation, no remnant cancer was observed within the ablation zone. Ablation zone volumetry on CEUS and T2-weighted MRI compared with histology had a Pearson correlation index of r = 0.94 (95% confidence interval [CI] 0.74–0.99, p < 0.001) and r = 0.93 (95% CI 0.73–0.98, p < 0.001), respectively. ConclusionsCEUS and prostate MRI could reliably visualize TPLA ablative effects after minimally invasive PCa treatment with a high concordance with histopathological findings and showed no remnant cancer. Patient summaryThe treatment effects of a novel minimally invasive ablation therapy device can reliably be visualized with radiological examinations. These results will improve planning and performance of future procedures.

Hyaluronic Acid as a Tissue Spacer Between Prostate and Rectum to Aid Dissection During Radical Prostatectomy

Introduction: We demonstrate a novel method of spacer gel injection immediately before prostatectomy, displacing the prostate away from the rectum to aid later dissection. Post-pelvic radiotherapy prostatectomy is associated with more complex resection and higher surgical morbidity. Tissue adhesion between rectum and prostate caused by radiotherapy scarring increases the risk of rectal injury from 0.5% in primary prostatectomy to 6.9% during prostatectomy in an irradiated pelvis. Barrigel® is a nonanimal stabilized hyaluronic acid. It is anechoic and, therefore, identifiable when injected percutaneously into Denonvillier's space under transrectal ultrasound guidance. Patients at a high risk of rectal injury during prostatectomy may undergo on-table transperineal Denonvillier hyaluronic acid injection. Methods: The technique is demonstrated on a 72-year-old man with pT3bN0M0 prostate cancer with a history of pelvic radiotherapy and evidence of scarring of Denonvillier's fascia on preoperative MRI. The patient should be positioned in lithotomy with a transrectal probe in situ. A 20 cm 18-gauge needle is inserted into Denonvillier's fascia through the perineum. About 3 to 10 mL of Barrigel is injected under ultrasound guidance separating the rectum from the prostate. The patient can then be positioned, prepped, and draped for prostatectomy. In this demonstration, the patient underwent robot-assisted laparoscopic radical prostatectomy. Results: Barrigel is typically absorbed fully in 12 months. There was no evidence of rectal injury on leak testing and the patient had a noncomplicated postoperative course. Pathologic review confirmed clear surgical margins. Conclusions: We demonstrate a novel technique of injecting Barrigel percutaneously into Denonvillier's fascia. The dissection of the prostate from the rectum during robot-assisted laparoscopic prostatectomy was effective with no complications. No competing financial interests exist. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No funding was received. Runtime of video: 2 mins 11 secs

Multiparametric imaging guided HDR interventional radiotherapy (brachytherapy) boost in localized prostate cancer: a multidisciplinary experience.

The aim of this study was to report a monoinstitutional multidisciplinary experience about the use of multiparametric imaging to identify the areas with higher risk of relapse in localized prostate cancer, with the purpose of allowing a biologically planned target dose escalation. We performed a retrospective evaluation of patients diagnosed with prostate cancer who received treatments at our Interventional Oncology Center with interstitial interventional radiotherapy from 2014 to 2022. Inclusion criteria were histologically confirmed localized prostate cancer; and National Comprehensive Cancer Network (NCCN) risk class unfavorable intermediate or high/very high risk. The diagnostic work-up included multiparametric Magnetic resonance imaging (MRI), multiparametric Transrectal ultrasound (TRUS), Positron Emission Tomography Computed Tomography (PET-CT) with choline or PSMA (or alternatively bone scan). All patients were assessed and received one treatment with interstitial high-dose-rate interventional radiotherapy (brachytherapy) delivering external beam radiotherapy (46 Gy). All procedures were performed using transrectal ultrasound guidance under general anesthesia and the prescribed doses were 10 Gy to the whole prostate, 12 Gy to the peripheral zone and 15 Gy to the areas at risk. We report the data of 21 patients who were considered for the statistical analysis with a mean age of 62.5 years. The mean PSA nadir was 0.03 ng/ml (range 0-0.09). So far, no biochemical nor radiological recurrences have been recorded in our series. Regarding acute toxicity, the most commonly reported side effects were G1 urinary in 28.5% of patients and G2 urinary in 9.5%; all recorded acute toxicities resolved spontaneously. We present a real-life experience of biologically planned local dose escalation by interventional radiotherapy (brachytherapy) boost, followed by external beam radiotherapy in patients with intermediate unfavorable- or high/very high risk. The local control and the biochemical control rates are proved to be excellent and the toxicity profile tolerable.

Unilateral Pelvic Lymph Node Dissection in Prostate Cancer Patients Diagnosed in the Era of Magnetic Resonance Imaging-targeted Biopsy: A Study That Challenges the Dogma.

Bilateral extended pelvic lymph node dissection at the time of radical prostatectomy is the current standard of care if pelvic lymph node dissection is indicated; often, however, pelvic lymph node dissection is performed in pN0 disease. With the more accurate staging achieved with magnetic resonance imaging-targeted biopsies for prostate cancer diagnosis, the indication for bilateral extended pelvic lymph node dissection may be revised. We aimed to assess the feasibility of unilateral extended pelvic lymph node dissection in the era of modern prostate cancer imaging. We analyzed a multi-institutional data set of men with cN0 disease diagnosed by magnetic resonance imaging-targeted biopsy who underwent prostatectomy and bilateral extended pelvic lymph node dissection. The outcome of the study was lymph node invasion contralateral to the prostatic lobe with worse disease features, ie, dominant lobe. Logistic regression to predict lymph node invasion contralateral to the dominant lobe was generated and internally validated. Overall, data from 2,253 patients were considered. Lymph node invasion was documented in 302 (13%) patients; 83 (4%) patients had lymph node invasion contralateral to the dominant prostatic lobe. A model including prostate-specific antigen, maximum diameter of the index lesion, seminal vesicle invasion on magnetic resonance imaging, International Society of Urological Pathology grade in the nondominant side, and percentage of positive cores in the nondominant side achieved an area under the curve of 84% after internal validation. With a cutoff of contralateral lymph node invasion of 1%, 602 (27%) contralateral pelvic lymph node dissections would be omitted with only 1 (1.2%) lymph node invasion missed. Pelvic lymph node dissection could be omitted contralateral to the prostate lobe with worse disease features in selected patients. We propose a model that can help avoid contralateral pelvic lymph node dissection in almost one-third of cases.

A Matched-pair Analysis Comparing Systematic Prostate Biopsy by Conventional Transrectal Ultrasound-guidance Versus Software-based Predefined 3D-Guidance

To compare software-based three-dimensional-guided systematic prostate biopsy (3D-GSB) with conventional transrectal ultrasound-guided systematic biopsy (TGSB) regarding prostate cancer (PCa) detection rates (CDR). In total, 956 patients (200 TGSB patients and 756 3D-GSB patients) without prior positive biopsies and with a prostate-specific antigen value ≤20ng/ml were eligible for analysis. TGSB and 3D-GSB cases were matched in a 1:1 ratio using propensity score matching with age, prostate-specific antigen, prostate volume, previous biopsy status, and suspicious palpatory finding as confounders. 3D-GSB was conducted with the semi-robotic prostate fusion-biopsy system Artemis. For each patient in both groups, SB was conducted in a similar pattern with 12 cores. All cores in 3D-GSB were automatically planned and mapped on a 3D-model as well as on the real-time transrectal ultrasound imaging. Primary end points were the clinically significant (cs) and overall CDR. Secondary end point was the cancer-positive core rate. After matching, the csCDR was not significantly different between the 3D-GSB and the TGSB groups (33.3% vs28.8%, P=.385). Overall CDR was significantly higher for 3D-GSB compared to TGSB (55.6% vs39.9%, P=.002). 3D-GSB detected significantly more non-significant PCa than TGSB (22.2% vs11.1%, P=.004). In patients with PCa, the number of cancer-positive SB cores was significantly higher by TGSB (42% vs25%, P<.001). 3D-GSB was associated with a higher CDR than TGSB. However, no significant difference was shown in detection of csPCa between both techniques. Therefore, currently, 3D-GSB does not appear to add value to conventional TGSB.

MP15-16 SINGLE DOSE ANTIBIOTICS AT THE TIME OF TRANSPERINEAL PROSTATE BIOPSY ARE EQUIVALENT TO OUTPATIENT ANTIBIOTIC PROPHYLAXIS IN PREVENTING INFECTION

You have accessJournal of UrologyCME1 Apr 2023MP15-16 SINGLE DOSE ANTIBIOTICS AT THE TIME OF TRANSPERINEAL PROSTATE BIOPSY ARE EQUIVALENT TO OUTPATIENT ANTIBIOTIC PROPHYLAXIS IN PREVENTING INFECTION Maxwell Sandberg, Wyatt Whitman, Janmejay Hingu, Parth Thakker, Caleb Bercu, Anita Rong, Jacob Greenberg, Ronald Davis, Ashok Hemal, and Matvey Tsivian Maxwell SandbergMaxwell Sandberg More articles by this author , Wyatt WhitmanWyatt Whitman More articles by this author , Janmejay HinguJanmejay Hingu More articles by this author , Parth ThakkerParth Thakker More articles by this author , Caleb BercuCaleb Bercu More articles by this author , Anita RongAnita Rong More articles by this author , Jacob GreenbergJacob Greenberg More articles by this author , Ronald DavisRonald Davis More articles by this author , Ashok HemalAshok Hemal More articles by this author , and Matvey TsivianMatvey Tsivian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003235.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There has been a trend towards transperineal (TP) prostate biopsy over transrectal (TR) due to a reduced rate of infection. In response, there is now an ongoing debate as to the need for prophylactic antibiotics during TP biopsy. The objective of this study was to argue for the non-inferiority of single-dose antibiotics at the time of biopsy to outpatient antibiotics in preventing infection, regardless of antibiotic class chosen. METHODS: Biopsies were performed using TP technique under TR ultrasound guidance with anesthesia. All patients from 2012-present who underwent TP biopsy were identified and retrospectively chart reviewed. Infection was defined as at least one of the following: fever (≥38.3 °C) or positive urine culture (>10^5 CFU) within 72 hours post-biopsy. Patients were divided into 2 groups, those who received antibiotics at the time of biopsy along with outpatient antibiotics either before/after biopsy (group 1) and those who only received intraoperative antibiotics at the time of biopsy (group 2). Antibiotic choice and duration were at the discretion of the treating physician. Pearson’s Chi Squared was run to evaluate the difference in infection rate between the 2 groups. Fisher’s exact test evaluated the relationship between type of antibiotic and infection rate. RESULTS: A total of 767 biopsies were included in the study. Group 1 had 327 patients and group 2 had 440 patients. Infection rate post-TP biopsy was 1.97% (N=15). The infection rate for group 1 was 1.83% (N=6) and 2.05% (N=9) in group 2. No significant difference in infection rate existed between group 1 and group 2 (p=0.835). Secondary analysis was performed to evaluate infection rates based on antibiotic agent. TP biopsies with multiple antibiotics used at the same time were excluded from analysis. The type of antibiotic administered did not change infection rates within group 1 (p>0.99), group 2 (p=0.673), or between groups 1 and 2 (p>0.99). CONCLUSIONS: Based on our data, it appears that single dose antibiotics at the time of TP prostate biopsy are equivalent to outpatient antibiotic prophylaxis in preventing infection. Further, the class of antibiotic does not seem to affect infection rates. Given the overall low rate of infection, antibiotic regimens should be further evaluated for their utility. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e198 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Maxwell Sandberg More articles by this author Wyatt Whitman More articles by this author Janmejay Hingu More articles by this author Parth Thakker More articles by this author Caleb Bercu More articles by this author Anita Rong More articles by this author Jacob Greenberg More articles by this author Ronald Davis More articles by this author Ashok Hemal More articles by this author Matvey Tsivian More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparison of Single Versus Multiple Doses of Fluoroquinolone (Levofloxacin) for Prophylaxis in Prostate Biopsy

Objective: To assess the efficacy of Levofloxacin 500 mg orally for prophylaxis in transrectal prostate biopsy guided by ultrasonography compared to three dosages. Study design: A comparative study Place and Duration: this study was done in Murshid Hospital and Health Care Centre Karachi from September 2021 to September 2022 Methodology: A total of 615 patients having the typical indications for prostate biopsy performed under transrectal ultrasonography guidance (increased PSA, abnormal digital rectal examination) were included in this study. Overall 425 patients were considered qualified for participation; using Graph Pad Prism 6.0, patients were assigned to one of two groups using random assignment, 205 individuals in Group A were given one oral dosage of 500 mg of levofloxacin 60 to 120 minutes before the procedure, Likewise, 220 patients in Group B received Levofloxacin (500 mg) once per 24 hours for two days before to the procedure as well as the day of it. Results: Patients in Group A were given orally a single dose of levofloxacin 500 mg there were 205 patients in this group. These individuals were diagnosed with diabetes mellitus (DM) at a rate of 43.9%, febrile urinary tract infections at a rate of 4.3%, and sepsis at a rate of 0.97%.In this group, 65.80cc,was the average prostate volume, and 90.17% were overweight.A total of 220 patients in groupB who received orally three doses of levofloxacin 500 mg, with an average age of 67.45 years and a PSA mean of 21.26 ng/mL; 31.8% of patients had diabetes mellitus, &amp; 4.45% had a febrile urinary tract infection (FUTI). In this group, no patients had sepsis, 75.61 cc was the mean prostate volume, and 72.74% of the patients were overweight, as in Group A. Conclusion: Because of how effective it is, a single dose of levofloxacin containing 500 milligrams is an excellent option for prophylaxis in patients who are going to have a transrectal prostate biopsy. Keywords: transrectal biopsy, flroquinolone, prophylaxis

Trans-rectal ultrasound-guided hybrid intra-cavitary and interstitial brachytherapy in carcinoma cervix: A feasibility study from a tertiary cancer center in India.

To report the feasibility of performing hybrid intra-cavitary and interstitial (IC/IS) brachytherapy in patients with carcinoma cervix under trans-rectal ultrasound (TRUS) guidance. All patients who received an external beam radiotherapy (EBRT) dose of 50 Gy in 25 fractions with weekly chemotherapy, followed by a brachytherapy boost (21 Gy in 3 fractions) were prospectively included for analysis. IC/IS brachytherapy was performed using Fletcher style tandem and ovoid applicator with interstitial component under TRUS guidance. Parameters of implant quality analyzed included ability to insert tandem, ratio of needles loaded to the number of needles inserted, and incidence of uterine or organ at risk (OARs) perforation. Dosimetric parameters evaluated were dose to point A*, TRAK, D90 high-risk clinical target volume (HR-CTV), and D2cc to OARs (bladder, rectum, and sigmoid). Width and thickness of the target was compared between TRUS (TRUSw and TRUSt) and MRI (MRIw and MRIt). Twenty carcinoma cervix patients treated with IC/IS brachytherapy were included for analysis. The mean HR-CTV volume was 36 cc. The median number of needles used were 6 (range, 2-10 needles). None of the patients had uterine perforation. Two patients had bowel and bladder perforation. The mean D90 HR-CTV and D98 HR-CTV were 87.3 Gy and 82 Gy EQD2, respectively. The mean D2cc to the bladder, rectum, and sigmoid were 80 Gy, 70 Gy, and 64 Gy EQD2, respectively. The mean dose to point A* was 70.4 Gy EQD2. The mean TRAK was 0.40. The mean TRUSw (±SD) and MRIw (±SD) were 4.58 cm (±0.44) and 4.49 cm (±0.50), respectively. The mean TRUSt (±SD) and MRIt (±SD) were 2.7 cm (±0.59) and 2.62 cm (±0.59), respectively. On statistical analysis, there was a significant correlation between TRUSw and MRIw (r = 0.93), and TRUSt and MRIt (r = 0.98). TRUS-guided IC/IS brachytherapy is feasible and provides adequate coverage of the target, with acceptable doses to OARs.

Hydrogel spacer injection to the meso-sigmoid to protect the sigmoid colon in cervical cancer brachytherapy: A technical report.

The use of a hydrogel spacer inserted into recto-vaginal fossa is a valuable strategy to mitigate radiation exposure to the rectum during radiation therapy for female pelvic malignancies. However, when the sigmoid colon is in proximity to the cervix, radiation exposure to the sigmoid colon cannot be adequately mitigated with a hydrogel spacer injected into the recto-vaginal fossa. Here, we presented a case, in which a hydrogel spacer was injected into the meso-sigmoid to protect the sigmoid colon. A 73-year-old female diagnosed with T3b stage IIIC2r uterine cervical cancer (FIGO 2018) underwent high-dose-rate interstitial brachytherapy consisting of 24 Gy in 4 fractions, following concurrent chemoradiotherapy with external beam radiation therapy of 50 Gy in 25 fractions of whole pelvic radiation therapy. In the initial brachytherapy, the sigmoid colon was in close contact with the uterine cervix. In the second brachytherapy, attempts to create a space between the sigmoid colon and uterine cervix using injected artificial ascites were unsuccessful due to rapid absorption of fluid. In the third and fourth brachytherapy fractions, 5 mL of hydrogel was injected into the meso-sigmoid through a pouch of Douglas under trans-rectal ultrasonography guidance. Dose ratio of sigmoid colon D2cc and high-risk clinical target volume (HR-CTV) D90 of each brachytherapy were evaluated. Dose ratio of the sigmoid colon D2cc to HR-CTV D90 was 1.03, 0.43, 0.56, and 0.47 in each respective brachytherapy session, indicating dose escalation to HR-CTV whilst achieving acceptable sigmoid dose with hydrogel spacer injected into the meso-sigmoid. The dose ratio of the sigmoid colon to HR-CTV D90 was decreased by introducing a hydrogel spacer into the meso-sigmoid. In cases where the sigmoid colon is in proximity to the cervical tumor, this novel technique can be considered to achieve better clinical outcomes.

Safe Service Delivery of a Complex Early Pregnancy Problem: Caesarean Scar Pregnancy.

Caesarean Scar Pregnancy (CSP) is an ectopic pregnancy with implantation into the niche of the uterine scar. We aimed to describe the local management of consecutive cases of CSP to develop a standard operating procedure (SOP). Between December 2019 and June 2022, there were 19,100 maternities. Of these, 23 were CSPs in 19 patients. Median BMI was 29 (range 20.5-52), median number of Caesarean deliveries (CS) was 2 (range 1-4) and 7/23 (30%) were cigarette smokers. At diagnosis, 9/23 were live pregnancies, 3/23 were retained products of conception (RPOC), 9/23 were pregnancies of uncertain viability (PUV), and 2/23 were non-viable. In six, the initial management was expectant, surgical suction evacuation with transrectal ultrasound guidance in 16, and one had a hysterectomy. The median blood loss was 100 mL (range 50-2000 mL). Two patients (9%) required a blood transfusion. Median hospital stay was 1 day (range 0-4). At follow-up after 10 weeks, no patients had an ongoing haematoma, and one had significant RPOC electing hysterectomy. Eight women were known to have 9 subsequent pregnancies (recurrent CSP n = 4, livebirth n = 2, miscarriage n = 2, tubal ectopic n = 1). Outcomes as rated by low blood loss, short hospital stay, and rare need for further intervention were favorable. Factors associated included prompt ultrasonographic diagnosis, availability of transrectal ultrasound guided surgery, and specialist follow-up, which form the basis of the SOP.

Can Perirectal Spacing Help Reduce GI Toxicity in Patients Undergoing Post-Prostatectomy Radiotherapy?

<h3>Purpose/Objective(s)</h3> To report single institutional feasibility of recto-vesical hyaluronic acid or hydrogel spacer insertion for patients undergoing post prostatectomy radiotherapy (PPRT). <h3>Materials/Methods</h3> Spacer insertion was considered in patients referred for PPRT following an intra or interfascial radical prostatectomy who had no radiological evidence of local recurrence (based on prostate specific membrane antigen positron emission tomography). The spacer was inserted into the perirectal fat between the bladder and anterior rectal wall using a transperineal approach under transrectal ultrasound guidance. Two gold seed fiducial markers were also inserted at the level of the vesico-urethral anastomosis for image guided radiation therapy as per institutional practice. Pre and post spacer computerized tomography planning scans, together with post spacer magnetic resonance imaging scans, were acquired for dosimetric comparison. The prostate bed clinical target volume (CTV) was delineated according to Australian guidelines and the CTV was uniformly expanded by 7mm to create the planning target volume (PTV). The prescribed dose to the prostate bed was 70.2Gy in 1.8 Gy fractions using volumetric arc radiation therapy. The PTV and rectal dosimetry for the two sets of planning scans (PTV 7mm/pre spacer and PTV 7mm/post spacer) were compared. <h3>Results</h3> Sixty-one patients were recruited between 9/18 to 10/21. Fifty-eight patients successfully underwent rectal spacer insertion without postoperative complications. We did not attempt spacer insertion in 3 patients as we were unable to hydrodissect the perirectal fat plane. Only 33 patients had pre spacer planning scans available for dosimetric comparison. The distance between the bladder and rectal wall was increased from ≤1mm to a median of 11mm (9-13) at its greatest extent. The rectal volume for all patients (N=61) receiving 42.2Gy (rV60%), 49.1Gy (rV70%), 56.2 Gy (rV80%), 63.2Gy (rV90%) and 70.2Gy (rV100%)] were 28.1%, 23%, 17.9%, 12.5% and 3.8% respectively. With spacing, a statistically significant reduction was seen on all rectal volume end points from rV60% to rV100% in the 33 patients with both pre and post planning scans (see Table 1). The median follow up was 10.5 months (3-31). The risk of any grade acute GI toxicity was 28% (grade 1 26% and grade 2 2%). The risk of late GI toxicity was 7% (all grade 1 proctitis). <h3>Conclusion</h3> More than 90% of our selected PPRT patients were able to achieve recto-vesical separation, with no surgical complications, resulting in a 43.7% reduction in rV90%. The reduction in acute and late grade 2 GI toxicity is of notable significance, albeit with short follow up. Table 1 Pre and Post Spacer Rectal Dosimetry

Focal injection of a radiopaque viscous spacer before focal brachytherapy as re-irradiation for locally recurrent prostate cancer

PURPOSEClose vicinity of the target volume and a sensitive organ may prevent an effective radiotherapy/brachytherapy. A liquid hydrogel spacer cannot be placed well focally in specific small areas or fatty tissue. The purpose of this study was to report the injection technique and results of a radiopaque viscous hydrogel spacer. METHODSThe radiopaque viscous spacer was applied focally using transrectal ultrasound guidance before focal brachytherapy in re-irradiated areas in two patients. The technical feasibility of the injection between the recurrence and the rectum / bladder, the resulting distance, visibility in different imaging modalities, stability within several months, dose distribution, toxicity and tumor control up to 18 months after treatment was analyzed. RESULTSAfter hydrodissection, the needle was moved from the base towards the apex during injection of each syringe, respectively. The viscous spacer could be successfully injected focally and resulted in a planned distancing of the target volume (right lobe and seminal vesicle area) and the rectum of at least 1 cm and additional distancing to the bladder of at least 5 mm. Both brachytherapy treatments were performed without relevant toxicities. The PSA nadirs indicated a satisfactory short-term response to the treatment. CONCLUSIONSThe viscous hydrogel spacer can be injected focally at a specific prostate lobe or seminal vesicles. A viscous spacer remains stable within fatty tissue in any areas that are accessible by an ultrasound guided needle injection to create a distance between the high brachytherapy dose within the target and the organ at risk.

Painless Rectal Bleeding in a Patient With Prostate Cancer

Painless Rectal Bleeding in a Patient With Prostate Cancer

PD41-01 DETECTION OF OCCULT PROSTATE ADENOCARCINOMA USING STEREOTACTIC TRANSPERINEAL BIOPSY FOLLOWING NEGATIVE TRANSRECTAL ULTRASOUND-GUIDED BIOPSIES

You have accessJournal of UrologyCME1 May 2022PD41-01 DETECTION OF OCCULT PROSTATE ADENOCARCINOMA USING STEREOTACTIC TRANSPERINEAL BIOPSY FOLLOWING NEGATIVE TRANSRECTAL ULTRASOUND-GUIDED BIOPSIES Russell Maxwell, Roksana Tech, Manuj Agarwal, and Brian Moran Russell MaxwellRussell Maxwell More articles by this author , Roksana TechRoksana Tech More articles by this author , Manuj AgarwalManuj Agarwal More articles by this author , and Brian MoranBrian Moran More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002602.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There remains concern for prostate cancer in men who have a persistently elevated or rising serum PSA despite having a non-diagnostic transrectal ultrasound-guided biopsy (TRUS-B). Stereotactic transperineal prostate biopsy (STPB) may address this challenging clinical dilemma. Using transrectal ultrasound guidance and a transperineal template allows for comprehensive prostatic tissue sampling and lower likelihood of underestimating disease volume and grade. This study sought to determine occult prostate cancer detection rates utilizing STPB in men following negative TRUS-B. METHODS: Consecutive patients at a single institution between 2004 to 2020 who underwent STPB following a non-diagnostic TRUS-B were included. Patients who had primary STPB, non-STPB biopsy, a prior positive biopsy, or no core sampling were excluded. Well-protocolized STPB using prostate brachytherapy clinical setup and systematic comprehensive tissue sampling has been previously described in detail (Moran et al. Urology 2009). Multivariate logistic regression models were constructed to evaluate potential predictors of positive STPB. RESULTS: Out of 3756 patients, 2647 (70%) met final inclusion criteria and were analyzed (median age: 64 years, IQR: 59-69 years). Included patients had at least one prior negative TRUS-B (median 1, IQR: 1-2) before STPB and had median pre-STPB serum PSA levels of 8.1 ng/mL (IQR: 5.7-11.6 ng/mL). Median prostate size and number of cores sampled were 47 cc (IQR: 36-63 cc) and 37 (IQR: 30-44), respectively. STPB detected prostate adenocarcinoma in 956 of the 2647 patients (36%, 95% CI: 34-38%) with a median of 2 cores positive (IQR: 1-3). Of those with positive STPB, pathology findings revealed grade group 1-5 disease rates of 51%, 22%, 14%, 9%, and 4%, respectively. On multivariate analyses, older age (OR 1.79, 95% CI: 1.59-2.01, p <0.001) and higher pre-STPB PSA levels (OR 1.35, 95% CI: 1.19-1.52, p <0.001) were associated with higher odds of obtaining a positive STPB result, while large prostate size (OR 0.38, 95% CI: 0.34-0.44, p <0.001) and higher number of prior negative biopsies (OR 0.89, 95% CI: 0.82-0.97, p=0.011) were associated with lower odds. CONCLUSIONS: STPB can detect a significant number of occult and clinically significant prostate cancer in men with prior negative TRUS-B. This is the largest series to date and further supports the use of STPB to address this difficult clinical dilemma. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e689 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Russell Maxwell More articles by this author Roksana Tech More articles by this author Manuj Agarwal More articles by this author Brian Moran More articles by this author Expand All Advertisement PDF DownloadLoading ...

Rectal Perforation: A Rare Complication Following Uncomplicated Vaginal Delivery.

Rectal perforation during vaginal delivery is an uncommon event. It can cause complications including pelvic abscess and other life threatening illnesses, if not treated early. We here report a 24 years lady presented with a week long history of abdominal pain and fever associated with rectal discharge three weeks after uncomplicated vaginal delivery. Abdominal computed tomography findings suggestive of rectal perforation and revealed a huge pelvic abscess. A pigtail catheter was inserted into the pelvic abscess under transrectal ultrasound guidance and drained successfully. The patient recovered uneventfully and discharged 5 days after admission. Keywords: Pelvic abscess; rectal perforation; uncomplicated vaginal delivery.