Comparison of the morbidity and mortality of cystectomy and ileal conduit urinary diversion for neurogenic lower urinary tract dysfunction according to the approach: Laparotomy, laparoscopy or robotic.

OBJECTIVES: To evaluate and compare the morbidity and mortality of cystectomy-ileal conduit urinary diversion in patients with neurogenic lower urinary tract dysfunction according to the surgical approach, and to evaluate predictive factors of early and late morbidity. METHODS: This was a single-center retrospective study based on 65 patients operated between May 2005 and December 2011. The surgical approach consisted of: laparotomy (n = 11), laparoscopy (n = 14) and robotic (n = 40). Evaluation of early (<30 days) and late (>30 days) morbidity and mortality was carried out according to the Clavien-Dindo classification. RESULTS: The operating time was longer (P = 0.007) and the mean time to return of bowel function was shorter (P = 0.012) in the robotic group. The early complication rate for the overall population was 41.5%: minor complications in 32.3% of cases and major complications in 9.2% of cases. A tendency towards a lower minor complication rate was observed in favor of robotic surgery (P = 0.08), with a reduction of the postoperative hemorrhagic complication rate (P = 0.03). The late complication rate for the overall population was 43.1%: minor complications in 20% and major complications in 23.1%. A lower surgical revision rate under general anesthesia was observed in favor of robotic surgery (P = 0.03). No predictive factor of early and late morbidity was identified. CONCLUSION: Robotic cystectomy-ileal conduit urinary diversion in patients with neurogenic lower urinary tract dysfunction is feasible and safe. Its morbidity in experienced hands seems to be limited and comparable with laparoscopy or open surgery.

Clinical outcomes after salvage radiotherapy without androgen deprivation therapy in patients with persistently detectable PSA after radical prostatectomy: results from a national multicentre study.

PURPOSE: To assess oncologic outcomes after salvage radiotherapy (SRT) without androgen deprivation therapy (ADT) in patients with persistently detectable PSA after radical prostatectomy (RT). METHODS: Two hundred and one patients who failed to achieve an undetectable PSA received SRT without ADT. The primary endpoint was failure to SRT that was defined by clinical progression or use of second-line ADT. Clinicopathological parameters, 6-week PSA level, PSAV and pre-SRT PSA levels were assessed using time-dependent analyses. RESULTS: Median postoperative 6-week PSA and pre-SRT PSA levels were 0.25 and 0.48 ng/mL, respectively. Median time between surgery and SRT was 7 months. Failure to SRT was reported in 42.8 % of cases with the need for second-line ADT in 26.9 % of cases. Pre-SRT PSA was strongly correlated with postoperative 6-week PSA (p < 0.001) but not with PSAV. The risk of SRT failure was increased by threefold in case of Gleason score 8-10 (p = 0.036) or pT3b cancer (p = 0.006). Risk group classification based on these prognostic factors improved SRT failure prediction. Survival curves confirmed that 5-year ADT-free survival rates were significantly influenced by PSAV (p = 0.002) and pre-SRT PSA (p = 0.030). CONCLUSIONS: In patients with persistently detectable PSA after RP and selected for local salvage treatment, SRT offers good oncologic clinical outcomes. The most powerful pathologic predictive factors of SRT failure include a pT3b stage, a Gleason score 8 or more cancer and high PSAV and pre-SRT PSA levels. Patients having a high PSAV >0.04 ng/mL/mo would be potentially better candidates for a systemic therapy due to a high SRT failure rate.

Preclinical Evaluation of Intraoperative Low-Energy Photon Radiotherapy Using Spherical Applicators in Locally Advanced Prostate Cancer.

BACKGROUND: Surgery plus adjuvant radiotherapy is standard care for locally advanced prostate cancer (stage pT3R1). Intraoperative low-energy photon radiotherapy offers several advantages over external beam radiotherapy, and several systems are now available for its delivery, using spherical applicators, which require only limited shielding. The aim of this study was to evaluate the feasibility of this technique for the prostate bed. MATERIALS AND METHODS: Applicators were assessed using MRI image data and cadaveric dissection. In cadavers, targeted tissues, defined as a urethral section, both neurovascular bundle sections, the bladder neck and the beds of the seminal vesicles, were marked with metallic surgical clips. Distances between clips and applicator were measured using CT. A dosimetric study of the application of 12 Gy at 5 mm depth was performed using CT images of prostatectomized cadavers. RESULTS: Using MRI images from 34 prostate cancer patients, we showed that the ideal applicator diameter ranges from 45 to 70 mm. Using applicators of different sizes to encompass the prostate bed in nine cadavers, we showed that the distance between target tissues and applicator was <2 mm for all target tissues except the upper extremity of the seminal vesicles (19 mm). Dosimetric study showed a good dose distribution in all target tissues in contact with the applicator, with a low probability of rectum and bladder complication. CONCLUSION: Intraoperative radiotherapy of the prostate bed is feasible, with good coverage of targeted tissues. Clinical study of safety and efficacy is now required.

Monte Carlo evaluation of the effect of inhomogeneities on dose calculation for low energy photons intra-operative radiation therapy in pelvic area.

The aim of this study was to evaluate the effect of inhomogeneities on dose calculation for low energy photons intra-operative radiation therapy (IORT) in pelvic area. A GATE Monte Carlo model of the INTRABEAM® was adapted for the study. Simulations were performed in the CT scan of a cadaver considering a homogeneous segmentation (water) and an inhomogeneous segmentation (5 tissues from ICRU44). Measurements were performed in the cadaver using EBT3 Gafchromic® films. Impact of inhomogeneities on dose calculation in cadaver was 6% for soft tissues and greater than 300% for bone tissues. EBT3 measurements showed a better agreement with calculation for inhomogeneous media. However, dose discrepancy in soft tissues led to a sub-millimeter (0.65 mm) shift in the effective point dose in depth. Except for bone tissues, the effect of inhomogeneities on dose calculation for low energy photons intra-operative radiation therapy in pelvic area was not significant for the studied anatomy.

Radical prostatectomy for high-risk prostate cancer defined by preoperative criteria: oncologic follow-up in national multicenter study in 813 patients and assessment of easy-to-use prognostic substratification.

OBJECTIVE: To estimate the effect of predictive factors for oncologic outcomes after radical prostatectomy (RP) for high-risk prostate cancer (PCa). METHODS: A total of 813 patients underwent RP for high-risk PCa in a national retrospective multi-institutional study. High-risk PCa was defined as follows: prostate-specific antigen (PSA) level>20 ng/mL, Gleason score 8-10, and/or clinical Stage T2c-T4 disease. The preoperative criteria of high-risk PCa were studied in a logistic regression model to assess the correlations with the pathologic findings in the RP specimens. The predictive factors isolated or combined in scores were assessed by Cox multivariate and Kaplan-Meier analyses in predicting PSA failure (recurrence-free survival [RFS]) and overall survival (OS). RESULTS: The median follow-up was 64 months. Organ-confined disease was reported in 36.5%. The 5-year RFS, metastasis-free survival, and OS rate was 74.1%, 96.1%, and 98.6%, respectively. Each preoperative criteria of high-risk PCa was an independent predictor of PSA failure. The PSA failure risk was increased by 1.5- and 2.8-fold in men with 2 and 3 criteria, respectively. The RFS, but not the OS, was significantly different according to the preoperative score (P<.001). The postoperative score was significantly predictive for RFS and OS (P<.001 and P<.035, respectively). The risk of PSA failure was significantly increased with an increasing postoperative score (2-4.6-fold). CONCLUSION: National data support evidence that RP can result in encouraging midterm oncologic outcomes for the management of high-risk PCa. At 5 years after surgery, 75% of patients remain disease free. Our easy-to-use risk stratification might help clinicians to better predict the clinical and PSA outcomes of high-risk patients after surgery.