Redefining bladder neck dose in low-dose-rate prostate brachytherapy-Can we improve urinary toxicity without impacting disease control?

BACKGROUND: We sought to assess the impact of bladder neck dose (BND) on patient reported urinary toxicity, and feasibility of relative urethral sparing technique in prostate brachytherapy (PB). METHODS AND MATERIALS: We retrospectively identified bladder neck as a point dose on post-implant CT scans in patients treated with 131Cs PB. Urinary symptoms were assessed through EPIC questionnaires. Patient cohorts were identified based on mean BND as a percentage of prescription dose with toxicity assessment at each time point. RESULTS: In our cohort of 542 patients, BND was associated with clinically significant acute urinary symptoms and chronic symptoms, as patients receiving >70% of the prescription dose had significantly worse overall EPIC scores than patients receiving ≤70% of prescription dose. There was no difference in bDFS between patients receiving BND ≤70% (96% bDFS) and >70% (94% bDFS) at a median follow up of 57 months. CONCLUSIONS: BND has a significant impact on both acute and chronic urinary symptoms, with reduced symptoms reported with BND <70% of prescription dose. With a median follow up of 4.7 years, excellent bDFS has thus far been achieved with relative urethral and bladder neck sparing. Utilizing this constraint should improve urinary symptoms without impacting disease control.

Cs-131 prostate brachytherapy boost and effect of hydrogel rectal spacer on long-term patient-reported rectal bleeding and bowel quality of life.

PURPOSE: This study evaluates long-term patient-reported bowel quality of life (QOL), rectal bleeding, and bleeding bother in patients with prostate cancer treated with external beam radiation therapy (EBRT) and Cesium-131 LDR brachytherapy (LDR-BT) boost with and without hydrogel rectal spacer. METHODS AND MATERIALS: This is a retrospective analysis of prostate cancer patients treated between 2007 and 2022 with 45 Gy EBRT followed by 85 Gy Cs-131 LDR-BT boost with or without hydrogel rectal spacer. Expanded Prostate Cancer Index Composite (EPIC) QOL questionnaires pre-treatment and at each follow-up were collected. Patient-reported rectal bleeding occurring more than "rarely" and bother from rectal bleeding occurring more than a "very small problem" were deemed clinically significant. Fisher's exact test was used to test the association of rectal spacer use and the incidence of clinically significant rectal bleeding and bleeding bother. Paired samples t-test was used to analyze mean bowel scores at each time point. RESULTS: Three hundred and forty-one patients were included in the analysis. The rectal spacer was used in 108 patients. Overall median follow-up was 48 months (IQR, 24-72), with a median follow-up of 24 months (IQR, 12-37.5) for the hydrogel group and 60 months (IQR, 36-84) for the non-hydrogel group. EPIC questionnaire response rates at median follow-up were 33% and 37% for the hydrogel and non-hydrogel groups, respectively. A clinically significant decrease in mean bowel domain scores was seen in the bowel bother domain at 6 and 12 months for patients who did not receive a rectal spacer. At the last follow-up of 60 months, the prevalence of clinically significant rectal bleeding and bleeding bother were 2.2% and 2.2%, respectively. The cumulative incidence of clinically significant long-term rectal bleeding was 2.8% and 18.9% in the hydrogel group and non-hydrogel group, respectively (Fisher's exact test, p < 0.0001). The cumulative incidence of clinically significant long-term bowel bother was 4.6% and 19.7% in the hydrogel group and non-hydrogel group, respectively (Fisher's exact test, p < 0.001). CONCLUSIONS: Use of hydrogel rectal spacer with EBRT and Cs-131 LDR-BT boost was significantly associated with a lower incidence of patient-reported rectal bleeding and bother from rectal bleeding, and better long-term bowel QOL. Cumulative incidence was 2.8% (hydrogel group) versus 18.9% (non-hydrogel group) and 4.6% (hydrogel group) versus 19.7% (non-hydrogel group) for clinically significant long-term rectal bleeding and long-term bleeding bother, respectively.

Effect of short-term corticosteroid usage on acute urinary toxicity following Cs-131 prostate brachytherapy.

PURPOSE: To evaluate short-term patient reported urinary quality of life scores in patients with prostate cancer treated at our institution with and without perioperative prednisone following Cesium-131 (131Cs) prostate LDR brachytherapy. METHODS AND MATERIALS: We started routinely using a perioperative 7-day course of prednisone at a dose of 5 mg per day, beginning 1 day prior to 131Cs prostate LDR brachytherapy from 2013 with goal of improving acute urinary symptomatology. One hundred consecutive patients treated with prednisone were selected, with comparison to 100 consecutive patients who were not treated with prednisone. We analyzed for differences in mean change with standard deviation (SD) in EPIC and AUA scores at 0.5-1 month and 3 months with or without prednisone by Mann-Whitney U Test. Binary logistic regression was performed to assess for impact of prednisone on postoperative urinary catheter use. RESULTS: Pretreatment EPIC and AUA scores were available in 197 patients. Less reduction in EPIC US score was noted at 0.5-1.0 month in the group who received prednisone with mean change of -22.9 (SD 15.4) when compared to the group who did not receive prednisone with mean change of -31.7 (SD 19.3), p < 0.01, with significance lost at 3 months. There was no significant difference in acute urinary retention requiring postoperative urinary catheter placement with perioperative prednisone (OR 1.13, p = 0.71). CONCLUSIONS: A short course of perioperative low-dose prednisone was associated with less severe worsening in urinary symptoms by the EPIC questionnaire at the 0.5-1.0-month timepoint suggesting some improvement in acute urinary quality of life, although differences did not remain statistically significant at 3 months.

Treatment of intermediate-risk prostate cancer with Cs-131: Long-term results from a single institution.

PURPOSE: To evaluate our institutional outcomes utilizing Cs-131 prostate brachytherapy (PB) for the intermediate-risk (IR) group of prostate cancer patients. METHODS AND MATERIALS: We reviewed a prospectively collected database of men treated with Cs-131 PB between 2006 and 2019. Patients with less than 24-months follow-up were excluded. Patients were classified as IR if they had one of the following factors: Gleason Score 7, prostate specific antigen >10 but <20 ng/mL, or T2b-c on clinical exam. We defined unfavorable-IR (UIR) as having either Grade Group 3, >1 IR factors, or ≥50% positive core biopsies. The Kaplan-Meier method was used to estimate actuarial event-time probabilities for biochemical freedom from disease (BFD). RESULTS: A total of 335 patients with a median follow-up of 70.1 months (IQR 48.3-106.3 months) were identified. Androgen deprivation therapy (ADT) was used in 7.2% of patients. Favorable-IR (FIR) patients were commonly treated with PB alone (91.8%). FIR patients who underwent PB alone had a 5-year BFD of 98.1%. UIR patients were commonly treated with external beam radiotherapy plus PB (61.2%). These patients had 5-year BFD of 91.1%. The 5-year BFD for UIR patients treated without ADT was 90.9%, whereas it was 95.0% among UIR patients treated with ADT (log-rank p = 0.83). CONCLUSIONS: FIR patients have excellent outcomes when treated with PB alone. External beam radiotherapy plus PB is a reasonable treatment approach for UIR patients. Future studies may elucidate which IR patients would benefit from treatment intensification.

Intraprostatic calcification and biochemical recurrence in men treated with cesium-131 prostate brachytherapy.

PURPOSE: Baseline intraprostatic calcification (IC) has been shown to be associated with a higher rate of biochemical recurrence (BCR) in men treated with iodine-125 prostate brachytherapy (PB). We evaluated this association in a cohort of men treated with cesium-131 PB. METHODS AND MATERIALS: We retrospectively reviewed the charts of all low- and intermediate-risk prostate cancer patients treated with cesium-131 PB +/- external beam radiotherapy (EBRT) at our institution from 2/2011 to 7/2018. Patients with < 24 months of follow up or those who received androgen deprivation therapy were excluded. Baseline IC status (defined as one or more ICs ≥ 5 mm) was determined on post-PB CT scans. Cox analysis was used to assess predictors of BCR and Kaplan-Meier survival curves were calculated. RESULTS: Two hundred and sixteen low- and intermediate-risk prostate cancer patients treated with cesium-131 PB +/- EBRT were included. Median follow up was 56.9 months (range 24.1-111.4). Overall, 76 (35.2%) patients had baseline IC and 140 (64.8%) did not. Baseline disease characteristics did not differ significantly between groups. On univariate Cox analysis, only risk group (p = 0.047) and initial PSA (p = 0.016) were significant predictors of BCR, whereas baseline IC was not (p = 0.11). The 5-year BCR-free survival in patients with versus without baseline IC was 97.7% versus 93.8% (p = 0.405), respectively. CONCLUSIONS: In a cohort of low- and intermediate-risk prostate cancer patients treated with cesium-131 PB, the rate of BCR in men with baseline IC was low and baseline IC was not associated with a higher risk of BCR.

Acute patient-reported bowel quality of life and rectal bleeding with the combination of prostate external beam radiation, low-dose-rate brachytherapy boost, and SpaceOAR.

PURPOSE: This study evaluates acute patient-reported bowel quality of life (QOL) and rectal bleeding in prostate cancer patients treated with combination external beam radiation (EBRT), low-dose-rate brachytherapy (LDR-BT), and SpaceOAR. MATERIALS AND METHODS: A retrospective review of prostate cancer patients treated with EBRT (45 Gy), cesium-131 LDR-BT (85 Gy), and SpaceOAR was conducted. Patient-reported acute (≤3 months after LDR-BT) bowel QOL and rectal bleeding was analyzed from Expanded Prostate Cancer Index Composite (EPIC) questionnaires. Five-point changes in mean bowel QOL scores were considered clinically significant. Clinically significant rectal bleeding was bleeding occurring more than "rarely" ("about half the time," "usually," or "always"), and clinically significant bleeding bother was considering bleeding a "small, moderate, or big problem." Outcomes were analyzed using descriptive statistics and paired t-tests. RESULTS: 69 patients were identified. Bowel summary, function, and bother scores clinically and significantly decreased 2 weeks after LDR-BT (79.9 ± 15.6, 80.5 ± 15.4, and 79.4 ± 18.1, respectively) compared with pre-EBRT scores (92.3 ± 9.1, 93.3 ± 9.0, and 92.6 ± 11.9, respectively) and pre-LDR-BT scores (91.1 ± 11.0, 91.6 ± 9.8, and 90.6 ± 13.3, respectively), but returned to clinical and statistical baseline pre-EBRT values at 3 months (88.7 ± 12.4, 88.8 ± 11.1, and 88.7 ± 14.5, respectively). The 3-month cumulative incidence of clinically significant rectal bleeding and bleeding bother was 4.35% and 2.90%, respectively. CONCLUSIONS: With combination EBRT, LDR-BT, and SpaceOAR, bowel QOL returned to the baseline 3 months after LDR-BT. Clinically significant rectal bleeding was <5%. Further followup will confirm if low acute rectal toxicity translates to reduced late toxicity.

Cesium-131 prostate brachytherapy: A single institutional long-term experience.

AIMS: To report on the PSA outcomes in men undergoing prostate seed implant (PSI) with Cesium-131 at a single institution. MATERIALS AND METHODS: All patients who underwent prostate brachytherapy with Cesium-131 (131Cs) at our institution and had the potential for at least 24 months of follow up were included in this study. Results are reported for the by NCCN risk group (low, low/high-intermediate, and high), as well as by treatment received (monotherapy, combination external beam radiation + PSI, or trimodal therapy with androgen deprivation). The Phoenix definition (absolute nadir plus 2 ng/mL) was used to define biochemical freedom from disease (BFD). RESULTS: Eight hundred and six men have undergone prostate brachytherapy with Cesium-131 at our institution, and 669 men were included in analysis. Median follow up was 60.0 months (range: 0-144 months). According to NCCN risk categories, 29.9% were low-, 55.6% intermediate-, and 14.5% high-risk. Using the Phoenix criteria, 5/10-year BFD was 97.1/95.3% for patients in the low-risk category, 94.0/90.1% for patients in the intermediate-risk category, and 86.2/56.6% for patients in the high-risk category. PSA ≤0.2 ng/dL at 4 years was predictive of 10 year biochemical control: 96.3% vs 70.4%, p < 0.001. CONCLUSIONS: The present study demonstrates that prostate brachytherapy with 131Cs achieves excellent long-term biochemical control.

Long-Term Patient-Reported Rectal Bleeding and Bowel-Related Quality of Life After Cs-131 Prostate Brachytherapy.

PURPOSE: There is limited long-term data on outcome and side effects of Cs-131 prostate brachytherapy and minimal patient-reported data on rectal bleeding with any isotope. We aimed to describe the incidence, prevalence, and predictors of late patient-reported rectal bleeding after Cs-131 brachytherapy. METHODS AND MATERIALS: We reviewed a prospectively collected database of 620 men treated with Cs-131 prostate brachytherapy. Of 620 patients, 390 (62.9%) received brachytherapy as monotherapy; the remainder received combination therapy with external beam radiation therapy (EBRT). Patients were administered Expanded Prostate Cancer Index Composite questionnaires preoperatively and postoperatively at each follow-up visit. The primary outcome was late rectal bleeding, defined as rectal bleeding reported at the 6-month follow-up or later. Clinically significant rectal bleeding was defined as occurring more than "rarely," and clinically significant bother from rectal bleeding was defined as considering bleeding more than a "very small problem." Univariate and multivariate Cox regression were performed to identify factors predictive for rectal bleeding. RESULTS: With a median follow-up time of 48 months, the cumulative incidence of clinically significant late rectal bleeding was 12.4%, with 15.2% reporting clinically significant bother from bleeding. At the time of last follow-up, the prevalence of clinically significant rectal bleeding and bother were 4.0% and 4.7%, respectively. On univariate analysis, acute clinically significant rectal bleeding, defined as occurring within the first 6 months (P = .001) and combination therapy with EBRT (P = .001) predicted for clinically significant late rectal bleeding. On multivariate analysis, both EBRT (P = .001; hazard ratio, 2.50; 95% confidence interval, 1.58-3.94) and acute rectal bleeding (P < .001; hazard ratio, 3.11; 95% confidence interval, 1.75-5.53) remained significant predictors for late rectal bleeding. CONCLUSIONS: Prostate brachytherapy with Cs-131 is well tolerated in the long term. Although the incidence of clinically significant patient-reported late rectal bleeding was 12.4%, the prevalence at last follow-up was only 4.0%, suggesting that this problem tends to resolve.

Characterizing Clinically Meaningful Changes in Lower Urinary Tract Symptoms Using the American Urological Association Symptom Index.

OBJECTIVE: To correlate patients' perception of changes in their lower urinary tract symptoms with changes in their American Urological Association Symptom Index (AUA-SI) scores with the goal of improving the ability of patients and clinicians to assess the clinical meaningfulness of changes in the AUA-SI score. MATERIALS AND METHODS: Men were asked to complete an AUA-SI survey and answer a symmetrical response framework question to evaluate their global perception of change in lower urinary tract symptoms at each interval, namely, "Are your urinary symptoms much better, slightly better, the same, slightly worse, or much worse compared to your prior visit?" Median changes and interquartile ranges (IQRs) in the AUA-SI scores were compared with the global evaluation response for the entire cohort. Additionally, outcomes were stratified by baseline AUA-SI severity classification (mild, moderate, or severe). RESULTS: The median changes and IQRs in AUA-SI scores of patients rating themselves as much better, slightly better, the same, slightly worse, and much worse compared with their symptoms at the time of their last AUA-SI were -2 (IQR -6 to 0), -1 (IQR -5 to 1), 0 (IQR -2 to 2), 5 (IQR 0-9), and 11 (IQR 5-18), respectively. There was a significant difference in AUA-SI score change between each rating category (P <.001). CONCLUSION: These results demonstrate that the patients require only a small decrease in their AUA-SI scores to report they are slightly better or much better, whereas a larger increase in their AUA-SI scores is required for patients to report their symptoms are slightly worse or much worse.

Long-Term Quality of Life in Prostate Cancer Patients Treated With Cesium-131.

PURPOSE: To evaluate long-term patient-reported quality of life (QOL) scores in men with prostate cancer treated at our institution with 131Cs prostate brachytherapy. METHODS AND MATERIALS: Patients treated more than 4 years ago with 131Cs (n=290) were asked to fill out an Expanded Prostate Cancer Index Composite (EPIC) QOL questionnaire and American Urological Association Symptom Score (AUASS) survey, before treatment and at each follow-up appointment. We compared patients' EPIC and AUA scores at baseline with scores at a last follow-up of at least 4 years after treatment using the Wilcoxon signed-rank test. RESULTS: At a median last follow-up of 5.5 years after treatment with 131Cs prostate brachytherapy there were no clinically significant changes in the EPIC or AUA scores from baseline. There was statistical worsening in the EPIC urinary incontinence subscore. Subset analyses revealed improved QOL outcomes in patients who received external beam radiation therapy or α-blocker therapy, whereas androgen deprivation therapy was not associated with differences in QOL change. CONCLUSIONS: Our results demonstrate minimal long-term changes in urinary or bowel patient-reported QOL with 131Cs prostate brachytherapy. These findings suggest that patients treated with this isotope are able to recover and then maintain their baseline QOL in the long term.

Ureteral obstruction following partial nephrectomy: can it be caused by fibrin glue?

Fibrin sealants are widely used during partial nephrectomy, however reports regarding the potential complications associated with their use are limited. We present the case of a 67-year-old male who developed delayed ureteral obstruction without hydronephrosis following partial nephrectomy in a solitary kidney. We hypothesize that the obstruction and absence of hydronephrosis were caused by extrinsic compression and subsequent inflammation due to the fibrin glue. Our report underscores the importance of a high index of suspicion for obstruction when acute kidney injury occurs following partial nephrectomy when fibrin glue is used, even in the absence of collecting system dilatation.

Simultaneous cuff revision and placement of an AdVance male sling for persistent post-prostatectomy urinary incontinence initially managed with AMS 800 artificial urinary sphincter.

Placement of an artificial urinary sphincter (AUS) remains the gold standard for treatment of stress urinary incontinence after radical prostatectomy. Persistent or recurrent incontinence after AUS placement can occur. Options then include cuff revision or placement of a retrourethral transobturator sling (RTS), among other alternatives. This report describes simultaneous cuff revision and placement of a RTS for management of refractory stress urinary incontinence after radical prostatectomy. This approach obviates the need for additional procedures if one approach fails. This is especially valuable for patients averse to operative intervention and those at high risk for general anesthesia.

Prostate-specific antigen spikes with ¹³¹Cs brachytherapy. Is there a difference with other radioisotopes?

PURPOSE: There is a suggestion that a dose-rate effect exists for the prostate-specific antigen (PSA) spike after brachytherapy. ¹³¹Cs is a newer radioisotope with a half-life of 9.7 days that is being used for prostate brachytherapy. There is no published data on the PSA spike with this radioisotope and the goal of this study was to quantify PSA spikes with ¹³¹Cs and compare it with published data for other isotopes. METHODS AND MATERIALS: We have been maintaining a prospective database for all patients treated with ¹³¹Cs prostate brachytherapy at our institution. We selected patients for whom followup PSA was available for at least 24 months. The PSA spike was defined as an increase of 0.2 ng/mL, followed by a decline to prespike level. RESULTS: One hundred twenty-three patients had monotherapy, whereas 32 had external beam radiation therapy followed by a brachytherapy boost. Median followup was 36 months and mean numbers of PSAs obtained were 7. Forty-six (29.7%) patients had a PSA spike. The mean time and duration for the PSA spike were 12.5 and 8.8 months, respectively. The mean magnitude of increase and mean PSA value at increase were 0.63 and 1.56 ng/mL, respectively. CONCLUSIONS: The incidence of a PSA spike in our series is consistent with reported numbers for other radioisotopes. The occurrence of the spike at 12.5 months appears to be at the early end of the spectrum reported for (125)I, but the duration and magnitude are similar to other radioisotopes.

Predictors of urinary morbidity in Cs-131 prostate brachytherapy implants.

PURPOSE: Cesium-131 is a newer radioisotope being used in prostate brachytherapy (PB). This study was conducted to determine the predictors of urinary morbidity with Cs-131 PB. METHODS AND MATERIALS: A cohort of 159 patients underwent PB with Cs-131 at our institution and were followed by using Expanded Prostate Cancer Index Composite (EPIC) surveys to determine urinary morbidity over time. EPIC scores were obtained preoperatively and postoperatively at 2 and 4 weeks, and 3 and 6 months. Different factors were evaluated to determine their individual effect on urinary morbidity, including patient characteristics, disease characteristics, treatment, and dosimetry. Multivariate analysis of covariance was carried out to identify baseline determinants affecting urinary morbidity. Factors contributing to the need for postoperative catheterization were also studied and reported. RESULTS: At 2 weeks, patient age, dose to 90% of the organ (D90), bladder neck maximum dose (D(max)), and external beam radiation therapy (EBRT) predicted for worse function. At 4 weeks, age and EBRT continued to predict for worse function. At the 3-month mark, better preoperative urinary function, preoperative alpha blockers, bladder neck D(max), and EBRT predicted for worse urinary morbidity. At 6 months, better preoperative urinary function, preoperative alpha blockers, bladder neck D(max), and EBRT were predictive of increased urinary problems. High bladder neck D(max) and poor preoperative urinary function predicted for the need for catheterization. CONCLUSIONS: The use of EBRT plus Cs-131 PB predicts for worse urinary toxicity at all time points studied. Patients should be cautioned about this. Age was a consistent predictor of worsened morbidity immediately following Cs-131 PB, while bladder D(max) was the only consistent dosimetric predictor. Paradoxically, patients with better preoperative urinary function had worse urinary morbidity at 3 and 6 months, consistent with recently published literature.

Acute bowel morbidity after prostate brachytherapy with cesium-131.

PURPOSE: The present study evaluates the severity and time to resolution of bowel symptoms in men undergoing prostate brachytherapy (PB) with cesium-131 ((131)Cs). METHODS AND MATERIALS: A longitudinal, prospective study of patients who had undergone PB with (131)Cs at a single institution was performed. All patients were asked to complete the Expanded Prostate Cancer Index Composite preoperatively and at 2 weeks and 1, 3, and 6 months postoperatively. Outcomes were analyzed using descriptive statistics and Student's t test. RESULTS: The first 142 patients to have undergone PB with (131)Cs at our institution were included in the study. The mean Expanded Prostate Cancer Index Composite bowel summary score at baseline was 90.1±11.0 compared with 71.5±22.8 (p=0.000), 70.1±20.7, 87.1±13.8 (p=0.01), and 90.7±9.2 (p=0.70) at 2 weeks and 1, 3, and 6 months postoperatively, respectively. CONCLUSIONS: In men undergoing PB as monotherapy with (131)Cs, bowel symptoms returned to baseline by 3 months after the procedure. For patients undergoing PB with (131)Cs as part of combination therapy, bowel symptoms return to their post-external beam radiotherapy, pre-PB baseline by 3 months after the procedure.

Changes in lower urinary tract symptoms after prostate brachytherapy.

PURPOSE: To further define the bothersome lower urinary tract symptoms that occur after prostate brachytherapy (PB) by evaluating patient's responses to the individual questions of the urinary portion of the Expanded Prostate Cancer Index Composite (EPIC) survey and the AUA symptoms score in men undergoing PB. MATERIAL AND METHODS: A longitudinal, prospective study of 170 patients who have undergone PB at a single institution was performed. All patients were asked to complete the EPIC survey pre-operatively and at 2 weeks, 4 weeks, 3 months, and 6 months post-operatively. Starting with the 75(th) patient in the cohort, patients were also asked to complete the AUA symptom score. RESULTS: The pattern of changes for each question is similar for both the EPIC survey and the AUA symptom score, with a marked worsening of symptoms at 2 and 4 weeks and an improvement to baseline by 3 to 6 months. Hematuria questions had the quickest and dysuria questions had the longest return to baseline. The dysuria questions had the greatest change and the incontinence questions had the smallest change in magnitude. Obstructive symptoms had a greater magnitude of change when compared to irritative symptoms, but the irritative symptoms took longer to return to baseline. CONCLUSIONS: The present study adds to the fund of knowledge regarding the bothersome lower urinary tract symptoms which occur after PB by analyzing the individual questions of both the urinary portion of the EPIC survey and the AUA symptom score.

Cesium 131 versus iodine 125 implants for prostate cancer: evaluation of early PSA response.

INTRODUCTION: Given the shorter half-life of cesium-131 (Cs-131) compared to iodine-125 (I-125), we hypothesized that initial PSA outcomes may differ. We compare initial PSA outcomes in men undergoing Cs-131 prostate brachytherapy to men treated with I-125. PATIENTS AND METHODS: The first post-treatment PSA (obtained 3-6 months after the procedure) was compared in patients undergoing I-125 prostate brachytherapy to that of patients undergoing Cs-131 prostate brachytherapy at the same institution. Comparisons included the total cohort as well as low and intermediate risk patients. RESULTS: Mean pre-treatment PSA was 6.9 ng/mL in the I-125 cohort, and 6.9 ng/mL in the Cs-131 cohort. Mean initial post-treatment PSA was 0.9 ng/mL (range < 0.1-4.6) in the I-125 cohort and 1.2 ng/mL (range < 0.1-23.5) in the Cs-131 patients. For low risk patients, mean pre-treatment PSA was 5.8 ng/mL in the I-125 cohort, and 5.1 ng/mL in the Cs-131 cohort. Initial mean post-treatment PSA for low risk patients was 1.2 ng/mL (range < 0.1-4.6) in the I-125 group and 1.0 ng/mL (range < 0.1-2.9) in the Cs-131 patients (p = 0.37). For intermediate risk patients, mean pre-treatment PSA was 7.3 ng/mL in the I-125 cohort, and 7.3 ng/mL in the Cs-131 cohort. Mean initial post-treatment PSA in intermediate risk patients was 1.5 ng/mL (range < 0.1-2.9) in the I-125 group and 1.2 ng/mL (range < 0.1-4.6) in the Cs-131 patients (p = 0.52). CONCLUSIONS: Given the shorter half-life of Cs-131 compared to I-125, we hypothesized that initial post-brachytherapy PSA levels were similar between men receiving treatment with Cs-131 and I-125. The aim of the present study is not to predict long term outcome after Cs-131 prostate brachytherapy, but rather to simply compare initial PSA outcomes in men undergoing prostate brachytherapy with I-125 to Cs-131. Long term data are needed to document cancer control achieved with Cs-131.

Acute lower urinary tract symptoms after prostate brachytherapy with cesium-131.

OBJECTIVES: To evaluate the severity and interval to resolution of the acute lower urinary tract symptoms in men undergoing prostate brachytherapy (PB) with cesium-131 ((131)Cs). METHODS: A longitudinal, prospective study of patients who had undergone PB with (131)Cs at our institution and had a minimum of 6 months of follow-up was performed. Urinary symptoms were assessed using the Expanded Prostate Cancer Index Composite. Patients were asked to complete a survey preoperatively and at 2 weeks and 1, 3, and 6 months postoperatively. RESULTS: The first 152 patients who underwent PB with (131)Cs at our institution were included in the present study. The mean Expanded Prostate Cancer Index Composite urinary summary score decreased significantly from baseline (86.4) at 2 weeks (59.2) and 1 month (62.2) after PB. These scores returned to the clinical baseline by 3 months (79.6) and to the statistical baseline by 6 months (84.0) after PB. The urinary subscales (function, bother, incontinence, irritative/obstructive) followed the same course in returning to the clinical and statistical baseline values. Similar patterns were seen when patients were stratified by PB as monotherapy. For patients undergoing combination therapy, the mean Expanded Prostate Cancer Index Composite scores returned to the clinical and statistical baseline values by 3 months after their procedure. CONCLUSIONS: In patients undergoing PB with (131)Cs, the postprocedure lower urinary tract symptoms generally returned to the clinical baseline by 3 months and the statistical baseline value by 6 months after PB.

Cost comparison between watchful waiting with active surveillance and active treatment of clinically localized prostate cancer.

OBJECTIVES: In part because of concern regarding overtreatment in men with prostate cancer, watchful waiting with active surveillance (WWAS) has been increasingly used in men diagnosed with low-risk prostate cancer. The present study investigates the difference in costs between men with low-risk prostate cancer treated with up-front radical prostatectomy (RP) versus WWAS. METHODS: A cost model was constructed using data from centers that have published their results in men who were followed up with WWAS compared with the actual costs of up-front RP calculated from a high volume center. Two WWAS arms of 15-year duration were created in which the follow-up protocol and conversion rate to active treatment were varied. RESULTS: The cost of up-front RP including costs of surgery, complications, and follow up for 15 years was $15 235 per person. Costs of WWAS were estimated using annual conversion rates from WWAS to RP of both 5% and 7%. Costs per person in the WWAS arms ranged from $6558 to $11 992 in the scenarios created which represent a 43%-78.7% reduction in costs when compared with men undergoing up-front RP. CONCLUSIONS: Watchful waiting with active surveillance is being increasingly used in hopes of decreasing the potential overtreatment of prostate cancer in men with low-risk disease. The present study suggests that WWAS is likely to markedly decrease costs when compared with active treatment with RP.