Characterizing and Quantifying Material Fatigue of the Artificial Urinary Sphincter Pressure Regulating Balloon.

OBJECTIVE: To characterize and quantify changes in elastic properties and in vivo pressure characteristics of pressure regulating balloons (PRB) over time, we conducted an analysis of the mechanical characteristics of the PRB after removal from patients for revision surgery. METHODS: Pressure and elasticity characteristics of new and used 61-70 cm H2O PRBs were analyzed. Pressure-volume curves were generated using commercially available urodynamics equipment. PRB pressures were measured at a standard fill volume (23 cc). Elastance was calculated by the slope of the tangent line at the inflection point of the pressure-volume curve. Tests were repeated 5 times per PRB and intraclass correlations were used to gauge test-retest reliability. Regression models were used for continuous variables based on data distribution. RESULTS: Twenty-seven used PRBs were analyzed after excluding 3 for alternative pressure ratings and 2 for occult pinpoint leaks. Time from artificial urinary sphincter placement to removal ranged from 0.02-17.6 years (median 8.4, interquartile range (IQR) 5.7-10.0). The mean pressure of all extracted PRBs: 58.8 cm H=O (± 7.4), 17 (62.9%) below the standard operating range. Each year of use in-vivo was associated with 1.09 cm H2O pressure loss on linear regression (P <.01 CI -1.52 to -0.65). PRB pressures were not significantly different according to indication for removal (1-way analysis of variance (ANOVA) P = .11). Loss of elastance was non-linear, decreasing by 1.9% per year on Poisson regression (P <.01, CI -0.03 to -0.01). When accounting for PRB age, PRB pressure was independently associated with detrusor overactivity. CONCLUSION: In PRBs tested for pressure-volume characteristics, increasing PRB age was associated with decreased pressure and elasticity.

Urethral Stricture Formation After Artificial Urinary Sphincter Cuff Erosion Is Uncommon in the Absence of Pelvic Radiation.

PURPOSE: Reported rates of urethral stricture development after artificial urinary sphincter erosion are highly variable. We hypothesized that the risk of stricture is commensurate with the degree of erosion. MATERIALS AND METHODS: We reviewed our prospectively maintained quality improvement database for all patients with artificial urinary sphincter erosion from 2011 to 2022. The incidence of postoperative stricture development was compared to the severity of erosion using a graded scale: 1, <25% circumference; 2, 25%-50% circumference; 3, >50% and <100% circumference; and 4, 100% circumference. From 862 artificial urinary sphincter surgeries, 102 erosion cases were identified, and 63 with documented erosion severity were included for analysis. Additional analysis was performed on 28 cases without documented erosion severity for validation. RESULTS: Within the main cohort, urethral stricture developed in 22 (34.9%) patients. The incidence of stricture did not vary by grade of erosion (P = .73) and was not significantly higher in men with grade 4 erosion vs lower-grade erosions (32.7% vs 50.0%, P = .34). Radiation exposure was associated with a 41.1% higher incidence of stricture (P < .01) and nearly every stricture occurred in the setting of prior radiation (21 of 22; 95.5%). In the validation group, 10 (35.7%) developed stricture, mostly in the setting of radiation (8 of 10; 80%). Overall, 29 of 32 (90.6%) cases of stricture involved a history of radiation. CONCLUSIONS: Artificial urinary sphincter erosion does not lead to urethral stricture formation in most cases and is not associated with degree of erosion. Those who develop strictures nearly always have a history of pelvic radiation.

Bladder Neck Contractures Stabilize After Placement of the Artificial Urinary Sphincter.

PURPOSE: For male cancer survivors, the combination of stress urinary incontinence and recurrent bladder neck contracture presents a management dilemma with poor consensus. Our objective was to assess the impact of artificial urinary sphincter placement on bladder neck contracture recurrence among prostate cancer survivors with stress urinary incontinence and bladder neck contracture. MATERIALS AND METHODS: Men electing artificial urinary sphincter placement at our institution undergo synchronous bladder neck contracture treatment if indicated. An institutional database was queried for men with stress urinary incontinence and ≥1 intervention for bladder neck contracture. Records were divided according to whether an artificial urinary sphincter was ever placed. The impact of artificial urinary sphincter placement on bladder neck contracture recurrence was assessed using a multivariable conditional survival analysis, with survival defined as the recurrence-free interval following bladder neck contracture intervention. The proportional hazards assumption was assessed on the basis of Schoenfeld residuals. RESULTS: The analytic cohort consisted of 118 in the artificial urinary sphincter group and 88 in the non-artificial urinary sphincter group. Patients in both groups underwent a median of 2 (range 1-8) bladder neck contracture interventions over the entire course of their care, encompassing 445 total bladder neck contracture interventions. The artificial urinary sphincter group was on average 2.6 years younger (P = .02) and had a higher pack-year smoking history (P < .01). The presence of an artificial urinary sphincter was associated with a 61% lower bladder neck contracture re-intervention rate (HR 0.39, P < .01, CI 0.30-0.50) at any time when accounting for number of prior bladder neck contracture interventions and bladder neck contracture risk factors. CONCLUSIONS: Artificial urinary sphincter placement is associated with a lower rate of bladder neck contracture re-intervention. Artificial urinary sphincter placement should not be delayed or avoided due to the presence of bladder neck contracture.

Artificial Urinary Sphincter Cuff Downsizing Improves Continence and Patient Satisfaction in Cases of Sub-cuff Atrophy.

PURPOSE: The management of artificial urinary sphincter sub-cuff atrophy remains controversial, and clinical outcomes are underreported. We intend to examine the impact of cuff downsizing in cases of isolated sub-cuff atrophy. MATERIALS AND METHODS: We reviewed our prospectively collected, institutionally approved quality improvement database for this study from 2011 to 2022. Institutional Review Board approval was obtained for the analysis. Sub-cuff atrophy in patients with post-prostatectomy incontinence was diagnosed with a clinical presentation of recurrent urinary leakage, serial pelvic films, cystoscopy, and patient evaluation. Outcomes were assessed with pad use, subjective measures, and American Urological Association Symptom Score scores. RESULTS: During the study interval, 871 encounters for artificial urinary sphincter placement were identified, 229 for revision or replacement, of which cuff downsizing for isolated cases of sub-cuff atrophy occurred in 34. Downsizing took place after a median of 6.5 years after initial artificial urinary sphincter placement. Of the patients, 97% reported subjective improvement and 93% experienced a decrease in daily incontinence pad use, with a mean±SD decrease of 2.2±1.45 pads (P < .01). American Urological Association Symptom Score bother scores decreased from pre-downsizing values by a mean±SD of 1.5±1.4 (P = .01). After a median follow-up of 1.8 years after downsizing, 24 (70.6%) of downsized cuffs remained in place, 2 (5.9%) were further downsized, 2 (5.9%) required replacement for mechanical failure, 4 (11.8%) underwent removal for erosion, and 2 (5.9%) underwent replacement for a herniated pressure regulating balloon. CONCLUSIONS: When diagnosed using objective criteria, cuff downsizing improves continence and patient satisfaction in cases of sub-cuff atrophy.

Indications and Outcomes for Intermittent Catheterization following Bulbar AUS Cuff Placement.

OBJECTIVE: To evaluate the functional and surgical impact of CIC protocols in men with a bulbar AUS in place. Stress urinary incontinence (SUI) and poor bladder emptying are both sequelae of prostate cancer treatment, though there is sparse data to guide concomitant management. The safety of intermittent catheterization (CIC) in men with an artificial urinary sphincter (AUS) at the bulbar urethra remains unclear. METHODS: We performed a retrospective review of all bulbar urethral AUS procedures at our institution. Inclusion criteria were patients with a history of prostate cancer treatment, AUS placement for SUI, and a history of CIC before and/or after AUS placement. All eligible cases were retrospectively reviewed. Surgical and continence outcomes were analyzed. RESULTS: A total of 57 patients were identified with a history of CIC and AUS placement under the care of two surgeons. Eighteen continued to perform CIC or first initiated CIC after AUS placement and 39 discontinued CIC prior to AUS placement. The incidence of erosion was no different amongst patients who continued or discontinued CIC after AUS placement (17.9% vs 22.2%, P = .79). There was no difference in future AUS removal or replacement (56.4% vs 44.4%, P = .41). Both groups experienced improvement in urinary incontinence after placement of an AUS. CONCLUSION: Bulbar AUS placement in the setting of continuous intermittent catheterization can be considered in patients who are not surgical candidates for definitive treatment of their outlet obstruction.

Resection of Pubic Symphysis and Cystectomy Significantly Improves Short-Term Patient-Reported Physical Functioning Among Patients With Pubovesical Fistula and Pubic Bone Osteomyelitis.

OBJECTIVE: To investigate the impact of extirpative surgery for pubic bone osteomyelitis with pubovesical fistula on prostate cancer survivors' physical and mental health. MATERIALS AND METHODS: The Short Form 12 (SF-12) is a validated instrument for assessing health-related quality of life (HRQOL). We reviewed a prospectively maintained database of patients treated with extirpative surgery for pubovesical fistula from 2017-2021 who completed the SF-12. Wilcoxon signed-rank and McNemar's tests were used to analyze changes in SF-12 following surgery. Narcotic prescriptions in the year before and after surgery were assessed as an additional measure of pain burden. RESULTS: Eighteen patients were included. Four had pre-operative SF-12s, 3 had post-operative SF-12s, and 11 had both. Median age was 76.5 years (IQR 71.75-80.00). All patients had previous radiation for prostate cancer. Compared to global pre-operative scores, post-operative physical composite scores (PCS) significantly increased (29.95 ± 8.59 vs 42.48 ± 7.18; P <.001), but mental composite scores (MCS) were similar (45.35 ± 9.98 vs 52.21 ± 8.23). When comparing individual, paired pre-operative and post-operative scores there was a significant improvement in PCS (30.56 ± 9.87 vs 45.45 ± 8.56; P = .005), but not MCS (47.49 ± 6.92 vs 51.60 ± 8.88). Median morphine milligram equivalent significantly decreased in the year post-surgery compared to the year prior (103.1, 33.0-250.9 vs 34.25, 0.0-105.9; P = .0008). CONCLUSION: For prostate cancer survivors with pubovesical fistula and pubic bone osteomyelitis, urinary diversion with pubic bone resection improves physical functioning and decreases narcotic prescriptions without untoward effects on mental health.

Patient-Reported and Physiologic Outcomes Following Pelvic Exenteration for Non-Repairable Radiated Rectourethral Fistula.

OBJECTIVE: To investigate the impact of pelvic exenteration (PelvEX) on patient-reported pain, distress, and quality of life along with physiologic indicators of health in cancer survivors with radiated, non-repairable rectourethral fistula (RUF). MATERIALS AND METHODS: We reviewed a prospectively maintained quality improvement database of RUF patients at our institution from 2012 to 2020. Patients with radiated, non-repairable RUF who underwent PelvEX and had follow up to 1 year were included. Pain and distress scores were collected preoperatively and at 1-year follow up. Number of narcotic prescriptions in the 3 months before surgery and the year after surgery were abstracted. Short Form 12 surveys were administered in the postoperative period. Serum albumin, creatinine, carbon dioxide, hematocrit, and glucose were abstracted from electronic health records. Statistical analysis was performed using Wilcoxon signed-rank and Mann-Whitney tests. RESULTS: Eleven patients met inclusion criteria. Patient-reported pain significantly decreased at 1 year follow-up compared to preoperative scores (median pre: 4 vs 1 year post: 0, P = .0312). Patient-reported distress significantly decreased pre- versus post-PelvEX (median pre: 5 vs post: 0, P = .0156). At the time of postoperative pain and distress surveys, 9 (82.8%) patients did not have narcotic prescriptions. Postoperative Short Form 12 scores were similar to an age-matched United States population (mental: P = .3125; physical: P = .1484). Serum-based indicators of health were not different in the pre- versus postoperative period (all P >.05). CONCLUSION: PelvEX may be a valuable treatment option to decrease patient-reported pain and distress without compromising quality of life or physiologic health in patients with radiated, non-repairable RUF.

Buccal Reharvest for Urethroplasty After Graft Site Closure is Safe and Does Not Affect Long-Term Oral Health.

OBJECTIVE: To understand the effects of reharvest on safety and long-term oral health in patients requiring buccal mucosa reharvest from a previously harvested and closed site for management of recurrent urethral stricture disease. METHODS: We conducted an IRB approved retrospective chart review from 2014 to 2019 of all patients who underwent buccal graft urethroplasty at our referral based academic medical center. Surgical data was collected, and the validated Oral Health Impact Profile (OHIP-14) survey was administered to each patient. Descriptive statistics were performed and compared between patients who underwent a buccal graft reharvest and patients who underwent standard first time buccal harvest. Buccal graft beds were closed on both initial and reharvest. RESULTS: Four patients underwent a total of 5 ipsilateral buccal graft reharvests and 6 patients underwent first time buccal harvest. Median length of follow-up for all patients was 6 months (1-35 mo) and the median length of all grafts was 6 cm (5-6 cm) with no difference in the reharvest and first-time cohorts. For patients that underwent buccal reharvest, their median post-operative OHIP-14 score was 0 (0-9 pts) out of a possible 56 points. This compared to a median postoperative OHIP-14 score of 0 (0-10 pts) for patients who underwent first time buccal harvests with oral complications limited to one post-operative hematoma in the first-time cohort. CONCLUSION: Buccal grafts can safely be reharvested from a previous site with minimal concern for long-term oral health outcomes.

Do commonly used prostate medications alter prostate MRI and fusion biopsy performance?

AIMS: To determine whether phosphodiesterase inhibitors (PDEi) or α-antagonists (AA) were associated with differences in region of interest (ROI) characteristics or prostate cancer detection on fusion biopsy (FB). MATERIALS AND METHODS: Records from 847 consecutive patients undergoing FB at three separate institutions over a period of 2 years were retrospectively reviewed. Associations between medication use, Prostate Imaging Reporting & Data System (PIRADS) scores, and ROI locations were assessed with ordinal logistic regression. Associations with lesion size and International Society of Urologic Pathology (ISUP) grade group (GG) on biopsy were tested using multivariate regression. RESULTS: Medication use included PDEi in 14.2% and AA in 23.0%. PDEi use was associated with 19.3% smaller lesion diameter (-2.8 mm; CI from -4.8 to -0.7; p < 0.01) and lower PIRADS scores on MRI (OR 0.60; CI 0.40 - 1.00; p = 0.05). AA use was associated with higher PIRADS scores (OR 1.43; CI 0.97 - 2.11; p = 0.06), fewer positive fusion-directed biopsy cores (-28.6%, CI from -57.9 to 0.01%, p = 0.05), and downgrading on final pathology (-19%; CI from -40 to 2%; p = 0.06). CONCLUSION: For PIRADS scores ≥ 3, PDEi use is associated with smaller ROI and lower PIRADS scores, while AA use is associated with higher PIRADS scores. Neither medication was associated with differences in biopsy GG. Prospective studies are needed to investigate the discordance between multi-parametric magnetic resonance imaging (mpMRI) results and oncologic outcomes associated with PDEi and AA use.

Complaint of Testicular Discomfort in Patient with Esophageal Adenocarcinoma.

We report a case of esophageal cancer with solitary metastasis to the testicle in a 71-year-old man. The tumor was picked up on physical exam following new onset complaints of pain and swelling. While most testicular masses in older men are due to lymphoma, this case highlights the need to consider metastatic disease as a source of new symptoms in patients with a recent cancer diagnosis.

Initial Experience of Magnetic Resonance Imaging Fusion Biopsy in the Community Setting.

INTRODUCTION: Magnetic resonance imaging fusion biopsy is diagnostically superior to transrectal ultrasound guided biopsy for detecting clinically significant prostate cancer. Fusion biopsy has an expanding role at major academic centers. However, the reproducibility of outcomes in the community setting is unknown. Our goal was to determine if there are significant differences in the yield of clinically significant prostate cancer upon implementation of fusion biopsy in the community setting. METHODS: We compared biopsy results from the first consecutive 175 patients undergoing fusion biopsy at an academic setting to the first 175 patients undergoing fusion biopsy at a community practice. Patients treated at an academic setting were matched to nonacademic setting treated patients using Mahalonobis distance matching. A treatment effects model was used to evaluate the effect of practice setting on the rate of clinically significant prostate cancer detection. RESULTS: The matching model resulted in 160 community based patients matched to 150 academic based patients. Balance was verified by reduction in standardized differences and variances ratios between samples. Standard errors and the 95% CI were calculated from 3,000 bootstrap samples. Practice setting had no significant effect on clinically significant prostate cancer detection, clinically significant prostate cancer detection by fusion biopsy, upgrading by fusion cores, upgrading by template cores, clinically significant prostate cancer missed by template cores or clinically significant prostate cancer missed by fusion cores. CONCLUSIONS: A sample-matched analysis of the first consecutive patients enrolled in fusion biopsy at an academic versus a community setting indicates that practice setting did not have a significant effect on the overall detection of clinically significant prostate cancer. This lends support to the use of fusion biopsy outside of academic centers.

The effect of botulinum toxin on ureteral inflammation.

PURPOSE: The impact of onabotulinum toxin type A (BoNT-A) on bladder afferent nerve pathways and chemosensory functions is an active area of investigation. There may be a role for BoNT-A in disorders of the ureter; however, no histologic studies have assessed the effects of BoNT-A on ureteral tissue. Our objective was to develop an animal model of ureteral inflammation and determine the impact of ureteral BoNT-A instillation on known mechanisms of inflammation. METHODS: The safety and feasibility of a novel animal model of ureteral inflammation was assessed. Through open cystotomy, the effect of ureteral BoNT-A instillation on inflammation was determined through H&E, masson's trichrome, Ki-67 stain, and prostaglandin E (PGE) synthase expression, a known marker of pain and inflammation in ureteral tissue. Urothelial microstructure was assessed using electron microscopy and standard histologic techniques. RESULTS: All experiments were carried to completion, and no systemic signs of botulinum toxicity were seen. BoNT-A exposure was associated with a decrease in PGE synthase expression in a dose-dependent fashion. BoNT-A exposure was not found to impact collagen deposition or cell proliferation. Disruption of tight junctions between urothelial cells was observed under conditions of inflammation. CONCLUSION: We describe the feasibility of a novel in vivo model of ureteral inflammation and report the first histologic study of the effects of BoNT-A on the ureter. Preliminary findings show that BoNT-A attenuates ureteral PGE synthase expression under conditions of inflammation. The application of BoNT-A may provide anti-inflammatory and analgesic effects in the context of ureteral disorders.

Penile Melanoma In Situ: Long Term Follow Up.

Penile melanoma in situ is extremely rare. Various treatments have been reported with good success, however follow up is generally limited to 1 year or less. The optimal treatment regimen, pattern of disease progression and utility of sentinel lymph node biopsy are not established. We provide the longest reported follow up for penile malignant melanoma in-situ, highlighting a long-term pattern of recurrence and a route of progression which does not follow more reliable patterns of lymphatic spread known to penile squamous cell carcinoma. A cautious approach should be taken for organ-sparing approaches along with proper patient counseling and close, long-term follow-up.

Evaluation of the Use of Remodelable Pericardial Bolsters during Cystectomy and Diversion to Prevent Enterocutaneous Fistulas.

INTRODUCTION: Enterocutaneous fistula is one of the most serious and potentially devastating complications after radical cystectomy, a complex operation with a significant morbidity rate. In this analysis we examined the potential benefit of biomaterial buttressing of staple lines in reducing the incidence of enterocutaneous fistula in patients undergoing cystectomy. METHODS: We retrospectively reviewed 398 patients undergoing cystectomy for bladder cancer during an approximately 11-year period at the University of Colorado Hospital, and compared the frequency of enterocutaneous fistula before and after the implementation of biomaterial buttressing for bowel anastomosis. RESULTS: In total, 301 surgical cases preceded biomaterial buttressing and 97 received buttressing with bovine pericardial strips. Seven cases (2.3%) of enterocutaneous fistula occurred without adjunctive reinforcement whereas zero cases were identified in the period using buttressing with bovine pericardial strips. Thus buttressing was associated with a nonsignificant reduction in the odds of enterocutaneous fistula (OR 0.20; 95% CI 0.01, 3.56; p=0.20). Although risk factor adjustment was prohibited by the low frequency of events, none of the cases of enterocutaneous fistula had received prior radiation therapy. Incidentally, the odds of postoperative functional bowel obstruction were significantly decreased after the implementation of buttressing (OR 0.28; 95% CI 0.08, 0.93; p=0.03). CONCLUSIONS: The absolute reduction in the incidence of enterocutaneous fistula and significantly decreased odds of functional bowel obstruction in this cohort warrant future investigation to confirm the benefit of bovine pericardial strip buttresses for bowel anastomoses in cystectomy.

Prospective Outcome Analysis of the Safety and Efficacy of Partial and Complete Cryoablation in Organ-confined Prostate Cancer.

OBJECTIVE: To determine the rate of complications and change in International Prostate Symptom Score and Sexual Health Inventory for Men scores following cryotherapy treatment of low- and intermediate-risk prostate cancer. The secondary end points were the change in prostate-specific antigen post cryotherapy and biopsy-proven recurrence. MATERIALS AND METHODS: Enrollment occurred from 2007 to 2015 to assess long-term complications of cryotherapy. A prostate biopsy was performed at 1 year or in the event of biochemical failure. Subjects were staged and graded by standard 12- to 14-core transrectal ultrasound (TRUS) biopsy. A subset of subjects underwent additional 3-dimensional mapping biopsy if the cancer was suspected to be downgraded. Analyses of functional outcomes were stratified into focal and nonfocal treatments. RESULTS: The study consisted of 393 men with low- and intermediate-risk prostate cancer, aged 44-89 years. Patient IPSS scores improved significantly in the nonfocal treatment strata at all time points and after 1 year in the focal strata with a median drop at 1 year of 4 points (P <.001). No significant difference was detected for a change in preprocedural SHIM score in either treatment strata after 2 years (P >.7). Eighty-two patients (20.9%) had a rise in prostate-specific antigen resulting in biochemical failure. Seventy patients had detected recurrence for an overall recurrence rate of 20.4% in 343 patients. A total of 109 patients (27.7%) reported urinary retention and urgency post cryotherapy, with 15.3% requiring catheterization for up to 3 weeks. Thirty-seven patients (9.4%) experienced urethral meatal stricture, and 36 patients (9.2%) reported unresolved new-onset erectile dysfunction. CONCLUSION: Complication rates, most significantly erectile dysfunction, are decreased in this study compared with those previously reported in the literature for cryotherapy for prostate cancer.

Initial Experience of Targeted Focal Interstitial Laser Ablation of Prostate Cancer with MRI Guidance.

INTRODUCTION: To develop and evaluate a technique of 3.0 Tesla magnetic resonance (MR) guided laser ablation based on 3-dimentional mapping biopsy (3DMB) for low risk prostate cancer. MATERIALS AND METHODS: The study was approved by the institutional review board and was the Health Insurance Portability and Accountability Act compliant. The prospective study was performed on seven 3DMB proven low risk prostate cancer patients. In the first phase of the procedure the patient's prostate was aligned to a position concordant with prior 3DMB using the transperineal grid and fiduciary golden marker coordinates. In the second phase ablation was performed using MR thermometry to determine the ablation endpoint and lesion coverage. Immediately after treatment dynamic contrast-enhanced MR imaging was done. Prostate-specific antigen testing was performed 3 and 12 months after the treatment and compared by ANOVA test. A follow up biopsy was done one year following ablation. RESULTS: The entire procedure took less than 2 hours and all patients tolerated the procedure well. There was a significant difference in prostate-specific antigen value before and 3 months after the treatment (p = 0.005). Four out of 6 patients had positive follow up biopsy for cancer. CONCLUSION: This study verifies the feasibility and safety of treating low risk prostate cancer with laser therapy guided by 3.0T MR imaging based on 3DMB.

The Prognostic Value of Previous Irradiation on Survival of Bladder Cancer Patients.

Background: Radiation exposure is an established risk factor for bladder cancer, however consensus is lacking on the survival characteristics of bladder cancer patients with a history of radiation therapy (RT). Confounding patient comorbidities and baseline characteristics hinders prior attempts at developing such a consensus. Objective: To compare the survival characteristics of patients with suspected radiation-induced second primary cancer (RISPC) of the bladder to those with de novo bladder cancer, taking into account the patient comorbidities and baseline characteristics predictive of survival. Methods: Retrospective analysis of patients with muscle-invasive (≥T2a) or BCG-refractory stage Tis-T1 urothelial bladder cancer. Patients were excluded if prior RT exposure was used as treatment for bladder cancer or if cause of death was due to post-operative complications. A digit matching propensity score algorithm was used to match patients with prior radiation treatment to those without prior treatment. Cox regression analysis for time until death was performed following creation of the propensity score matched sample. Results: 29 patients with history of RT were matched with two controls each, resulting in a dataset of 87 observations in the event model. Results from the Cox model indicate a significantly increased hazard ratio for death at 2.22 (p = 0.047, 95% CI: 1.015-4.860) given a history of prior radiation therapy. Conclusions: In a small cohort, bladder cancer patients who underwent cystectomy had a significantly higher risk of death in the face of prior pelvic RT. This effect was found to be independent of surgical complications, numerous established patient characteristics and comorbidities traditionally predictive of survival.

Targeted focal therapy for the management of organ confined prostate cancer.

PURPOSE: Patients currently diagnosed with low risk prostate cancer are often overtreated and experience complications, resulting in detriment to quality of life. Targeted focal therapy is a minimally invasive procedure designed to ablate tumor foci while minimizing collateral damage to maintain quality of life. MATERIALS AND METHODS: This institutional review board approved, prospective study was done to assess the safety and efficacy of targeted focal therapy using cryotherapy in men 40 to 85 years old diagnosed with low risk, organ confined prostate cancer at our institution between 2006 and 2009. Low risk, organ confined prostate cancer was defined as Gleason score 7 or less (3 + 4) on transrectal ultrasound biopsy, tumor burden 50% or less and prostate specific antigen less than 10 ng/dl. Patients were evaluated for eligibility after undergoing 3-dimensional mapping biopsy. Median followup was 28 months (IQR 26-31). RESULTS: A total of 62 men with low risk disease met study inclusion criteria. At 1 year biopsy was negative in 50 of 62 patients (81%). All 12 men who tested positive on repeat biopsy had a Gleason score of 3 + 3 = 6 with 1 or 2 positive cores. The median prostate specific antigen change was a 3.0 ng/dl decrease (p <0.01). The median American Urological Association symptom score change was a 1.5-point decrease (p <0.01). No significant change was observed in Sexual Health Inventory for Men score (p = 0.6). No urinary incontinence episodes and no severe side effects were noted. CONCLUSIONS: Targeted focal therapy in carefully selected patients provides a feasible, practical option for treating low risk prostate cancer with minimal impact on quality of life.

The accuracy of prostate cancer localization diagnosed on transrectal ultrasound-guided biopsy compared to 3-dimensional transperineal approach.

Background. Prostate cancer is often understaged following 12-core transrectal ultrasound- (TRUS-) guided biopsies. Our goal is to understand where cancers are typically missed by this method. Methods. Transperineal 3-dimensional mapping biopsy (3DMB) provides a more accurate depiction of disease status than transrectal ultrasound- (TRUS-) guided biopsy. We compared 3DMB findings in men with prior TRUS-guided biopsies to determine grade and location of missed cancer. Results were evaluated for 161 men with low-risk organ confined prostate cancer. Results. The number of cancer-positive biopsy zones per patient with TRUS was 1.38 ± 1.21 compared to 3.33 ± 4.06 with 3DMB, with most newly discovered cancers originating from the middle lobe and apex. Approximately half of all newly discovered cancerous zones resulted from anterior 3DMB sampling. Gleason upgrade was recognized in 56 patients using 3DMB. When both biopsy methods found positive cores in a given zone, Gleason upgrades occurred most frequently in the middle left and right zones. TRUS cancer-positive zones not confirmed by 3DMB were most often the basal zones. Conclusion. Most cancer upgrades and cancers missed from TRUS biopsy originated in the middle left zone of the prostate, specifically in anterior regions. Anterior sampling may lead to more accurate diagnosis and appropriate followup.