Dose Distribution of High Dose-Rate and Low Dose-Rate Prostate Brachytherapy at Different Intervals-Impact of a Hydrogel Spacer and Prostate Volume.

The study aimed to compare the dose distribution in permanent low-dose-rate brachytherapy (LDR-BT) and high-dose-rate brachytherapy (HDR-BT), specifically focusing on the impact of a spacer and prostate volume. The relative dose distribution of 102 LDR-BT patients (prescription dose 145 Gy) at different intervals was compared with the dose distribution of 105 HDR-BT patients (232 HDR-BT fractions with prescription doses of 9 Gy, n = 151, or 11.5 Gy, n = 81). A hydrogel spacer (10 mL) was only injected before HDR-BT. For the analysis of dose coverage outside the prostate, a 5 mm margin was added to the prostate volume (PV+). Prostate V100 and D90 of HDR-BT and LDR-BT at different intervals were comparable. HDR-BT was characterized by a considerably more homogenous dose distribution and lower doses to the urethra. The minimum dose in 90% of PV+ was higher for larger prostates. As a consequence of the hydrogel spacer in HDR-BT patients, the intraoperative dose at the rectum was considerably lower, especially in smaller prostates. However, prostate volume dose coverage was not improved. The dosimetric results well explain clinical differences between these techniques reported in the literature review, specifically comparable tumor control, higher acute urinary toxicity rates in LDR-BT in comparison to HDR-BT, decreased rectal toxicity after spacer placement, and improved tumor control after HDR-BT in larger prostate volumes.

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

PURPOSE: Close 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. METHODS: The 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. RESULTS: After 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. CONCLUSIONS: The 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.

Permanent interstitial brachytherapy for prostate cancer implementing neoadjuvant prostatic artery embolization.

PURPOSE: Indication for permanent interstitial brachytherapy (PIB) can be limited by prostate volume, commonly decreased using neoadjuvant hormonal therapy. Volume changes and initial clinical results focusing on patients treated with prostatic artery embolization (PAE) were evaluated in this study. METHODS AND MATERIALS: A group of 102 consecutive patients were treated with permanent interstitial brachytherapy (PIB), 13 patients received a neoadjuvant PAE (median 12 weeks before PIB) in case of large prostate volume >60 cm³, and moderate to severe urinary problems. RESULTS: Patients after PAE were treated with significantly larger prostate volumes (52 ± 11 cm³ vs. 39 ± 11 cm³; p < 0.01; 66 ± 17 cm³ before PAE), but larger volume reductions to 44 ± 10 cm³ versus 35 ± 10 cm³ was found at day 30 (p < 0.05). International Prostate Symptom Score (IPSS) decreased significantly from 13 ± 5 before PAE to 7 ± 4 after PAE; p < 0.01. Initial PSA and first PSA after PIB were similar for patients with versus without PAE (5.9 ± 2.9 ng/mL vs. 6.2 ± 2.8 ng/mL and 1.5 ± 0.8 ng/mL vs. 1.9 ± 1.5 ng/mL). However, PSA 12 months after PIB was significantly lower after PAE (0.4 ± 0.3 ng/mL vs. 0.8 ± 0.6 ng/mL; p = 0.03). Four patients without prior PAE needed an intervention after urinary retention - transurethral resection of the prostate (TURP) in three cases and PAE in a single case. Urinary incontinence resulted in two cases after TURP. CONCLUSIONS: PAE could be successfully applied to decrease prostate volume and reduce urinary symptoms before PIB or as a treatment for urinary retention after PIB. A significantly lower PSA is promising for improved long-term cancer control.

Impact of preoperative biofeedback on incontinence in cancer patients undergoing radical prostatectomy.

OBJECTIVE: Post-radical prostatectomy incontinence is mainly attributable to iatrogenic verify the importance of preoperative biofeedback (BFB) in an attempt to identify a strategy to improve postoperative urinary incontinence. MATERIALS AND METHODS: Ninety candidates (median age 68 years: range 49-75) for radical retropubic prostatectomy were evaluated. Forty-five patients underwent preoperative pelvic floor training (PFT) and BFB, whereas the remaining 45 (control group) had preoperative PFT only. Patients started PFT exercises two weeks before surgery and continued during the immediate postoperative period, after catheter removal (6-7 days after surgery), and thereafter at home. No adjuvant therapy was administered and all 90 patients were assessed at follow up visits timed 1, 3 and 6 months post surgery. RESULTS: Patients who were completely dry and without use of pads were defined as continent. At the 1-month follow-up, 6.6% (3/45) of both the PFT+BFB group and the PFT only arm were continent. After 3 months, the continence rate had increased to 33.3% (15/45) and 26.6% (12/45), respectively, and at 6-month follow-up, this percentage had further risen to 71.1% (32/45) in the former group and 66.6% (30/45) in the latter group. No significant differences were observed between the two arms during follow-up, but there was a statistically significant correlation between follow-up time and continence improvement in each group. CONCLUSIONS: Preoperative BFB associated with PFT does not significantly influence urinary continence recovery after radical prostatectomy.

Health-related quality-of-life following modified ureterosigmoidostomy (Mainz Pouch II) as continent urinary diversion.

INTRODUCTION AND OBJECTIVES: The purpose of this study was to estimate the health-related quality of life (HRQoL) following modified ureterosigmoidostomy (Mainz Pouch II) urinary diversion. MATERIALS AND METHODS: Between March 1995 and February 2003 the procedure was performed in 83 patients (67 male and 16 female, median age 62 years, range 2-78 years) at the Departments of Urology in Bonn, Germany, and Pesaro, Italy. Patients were asked during follow-up to complete a validated, cancer-specific quality of life questionnaire, namely the EORTC QLQ C-30 Version 3. Forty-one patients (29 male, 12 female) completed the QLQ C-30. Twenty-eight patients were dead at the time of the study and 14 patients were lost to follow-up. A non-validated questionnaire was answered by 31 patients (75%) of the Bonn series to determine specific urinary diversion items. Mean follow-up time was 24.4 months (6 to 84 months). RESULTS: No statistically significant differences (p < 0.05) in functional and symptom scales or global health status were detected between males and females. All scales but diarrhea showed good results and the outcome was comparable to health-related quality of life in a reference population of Germany. Continence rate was 100% at daytime; all but one patient had to get up for urination at night. About one third of the patients have to urinate more than six times during the day and more than three times during the night. Sixty-three percent of the patients in the Bonn series were able to distinguish between stool and urine. CONCLUSION: The Mainz Pouch II serves as a satisfying continent urinary diversion for both sexes in selected patients in terms of quality of life. Patients seem to adapt to their "individual" form of urinary diversion. In terms of continence modified ureterosigmoidostomy can lead to daytime continence rate of 100%. The relatively high voiding frequency during night-time was not felt to be disturbing by the patients and demonstrates the adaptability of the patients.

Transurethral resection versus minimally invasive treatments of benign prostatic hyperplasia: results of treatments. Our experience.

OBJECTIVE: In this non-randomized prospective study the results of standard TURP (Transurethral Resection of the Prostate) versus other minimally invasive treatments were compared. MATERIALS AND METHODS: Among all the patients treated at our Institution for bladder outlet obstruction due to BPH (Benign Prostatic Hyperplasia) from January 1995 to June 1998, 212 patients have been evaluated; 90 patients underwent to TURP, 13 patients to TVP (Transurethral ElectroVaporization), 24 patients to TUNA (TransUrethral Needle Ablation), 71 patients to ILC (Interstitial Laser Coagulation), and 13 patients to WIT (Water-Induced Thermotherapy). RESULTS: TURP achieves the highest decrease of prostate volume (48.8%), the best increase of maximum flow rate (75.3%) and the highest decrease of residual volume (89.8%) in comparison to other methods; these results are substantially stable 24 months after treatment; on the other hand, after WIT a reduction of prostatic volume of 5.2%, an increase of maximum flow rate of 16.7% and a decrease of residual volume of 25.2% can be observed. The relief of bladder outlet obstruction is indicated by the decrease of detrusor pressure at maximum flow rate in comparison to baseline values; it decreases of 27.5% for WIT, of 34.8% for TUNA, of 38.3% for ILC, of 48.4% for TUR, and of 53.3% for T.P The recorded results are substantially stable 24 months after treatment. A marked decrease of IPSS and QL score can be observed for all the procedures after 6 months, ranging from 40.2% for WIT to 76.7% for TUNA; however, these parameters undergo to a slight worsening 24 months after treatment for TURP, TVP and TUNA, while remain substantially stable for ILC and WIT. CONCLUSION: From the analysis of our results, it appears that TURP is still the golden standard treatment for BPH; TURP remains the most effective and definitive way of treatment, but it could be less attractive from the patients' perspective, especially after minimally invasive treatments with good tolerability have become available. It is therefore evident that the choice of each method should be performed in consideration of patients' general performance status, of symptoms and of indications and contraindications of each method.

Production of serum-free and total prostate-specific antigen due to prostatic intraepithelial neoplasia.

OBJECTIVE: High serum total prostate-specific antigen (PSA) levels have proven to be predictive of concurrent cancer but the role of prostatic intraepithelial neoplasia (PIN) in the production of total (t) and free (f) PSA is still the subject of research. In this study we wanted to discover whether variations in serum fPSA and tPSA levels are caused by PIN. MATERIAL AND METHODS: We reviewed the medical records of 87 patients: in 32 of them the diagnosis of isolated PIN was made from surgical samples (simple prostatectomy, n = 19; radical cystectomy, n = 13); in 30 patients a diagnosis of benign prostatic hyperplasia (BPH) without PIN or prostatic carcinoma was made after simple prostatectomy (n = 20) or radical cystectomy (n = 10); and in 25 patients a clinically significant prostatic cancer was diagnosed and these patients underwent radical prostatectomy. All patients underwent a standard preoperative evaluation, including serum fPSA and tPSA determinations and PSA density. RESULTS: The frequency of isolated PIN in simple prostatectomy specimens was 6.3%. The mean f/t PSA ratios were 17.66% in the 32 patients with PIN, 19.2% in the 8 patients with low-grade PIN, 17.6% in the 24 patients with high-grade PIN, 24.2% in patients with BPH and 13% in patients who underwent radical prostatectomy. CONCLUSIONS: We believe that to make a definitive diagnosis of isolated PIN without carcinoma, study of the whole prostate gland is necessary, in order to definitively exclude the presence of concurrent neoplastic foci. Our data show that PIN does not contribute to tPSA levels and density; however, it may be responsible for a slight reduction in the f/t PSA ratio, with a significant reduction in cases with high-grade PIN (17.6%) compared to those with BPH (24.2%).