Two-years Postradiotherapy Biopsies: Lessons from MRC RT01 Trial.

BACKGROUND: The importance of 2-yr postradiotherapy prostate biopsy status remains uncertain. OBJECTIVE: To assess the value of 2 year post treatment biopsies in a randomised trial of radiotherapy dose escalation. DESIGN, SETTING, AND PARTICIPANTS: Between 1998 and 2001, 843 men with localised prostate cancer were randomised to receive either control-64Gy or escalated-74Gy conformal radiotherapy (CFRT) in the MRC RT01 trial in combination with 3-6-mo neoadjuvant androgen deprivation therapy. Prostate biopsies were planned at 2 yr from start of CFRT in suitable men. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Prostate biopsy results and prostate-specific antigen (PSA) levels performed at 2 yr post-CFRT were evaluated with long-term biochemical progression free survival (bPFS) and overall survival. Outcome measures were timed from the 2-yr biopsy using a landmark approach. RESULTS AND LIMITATIONS: A 2-yr biopsy was performed in 312/843 patients. One hundred and seventy-seven patients were included in the per-protocol group with median follow-up of 7.8 yr from biopsy. Median PSA at biopsy was 0.5ng/ml. Sixty-four bPFS events were reported: 46/145 (32%) in patients with negative, 6/18 (33%) suspicious, and 12/14 (86%) positive biopsies. A positive biopsy was prognostic of worse bPFS, going forward, compared with negative and suspicious biopsies, hazard ratio (HR)=4.81 (95% confidence interval [CI]: 2.50-9.26, p<0.001). The estimate for survival was HR=1.58 (95% CI: 0.52-4.78, p=0.42). PSA values at 2 yr between 1.01ng/ml and 2.09ng/ml were also associated with subsequent PSA failures (HR=2.71, 95% CI: 1.98-3.71), bPFS events (HR=2.45, 95% CI: 1.81-3.32), and prostate cancer-specific survival (HR=2.87, 95% CI: 1.08-7.64) compared with PSA ≤1.0ng/ml. CONCLUSIONS: Two-year postradiotherapy prostate biopsies have limited value in patients with PSA control but both positive biopsy and higher PSA status are strongly associated with future bPFS events. A policy of selected biopsy may provide an opportunity for early salvage interventions. PATIENT SUMMARY: Routine 2-yr postradiotherapy biopsy is not recommended but can be considered in selected patients with unfavourable post-treatment prostate-specific antigen levels who are suitable for early salvage treatments.

The correlation between retrograde leak point pressure and 24-hour pad weight.

AIM: To assess the correlation between retrograde leak point pressure (RLPP) and 24-hr pad weight (24PW) in men with post-prostatectomy incontinence. METHODS: We performed RLPP and 24PW measurements on 61 patients with a history of post-prostatectomy stress urinary incontinence (SUI). We examined the relationship of RLPP and 24PW. We also reviewed the urodynamic and clinical data of these patients to explain our findings. RESULTS: The mean age was 70 years (SD ± 7.4, range: 51-87). The mean RLPP was 36.8 cmH2 O (SD ± 15.3, range: 9-76), the mean 24PW was 499 g (±677 g, range: 16.5-3,177 g). There was a good and significant negative correlation between RLPP and 24PW (r = 0.56, P < 0.01). RLPP was able to differentiate between cases of mild/moderate (<400 g) and severe (≥400 g) incontinence. Patients with RLPP <30 cmH2 O had significantly higher 24PW (mean 825 g, median 768 g) when compared with patients with RLPP >30 cmH2 O (mean 257.8 g, median 100 g, P < 0.01). CONCLUSIONS: RLPP could be used as an objective and potentially more reliable substitute to pad weight to objectify and stratify SUI in post-prostatectomy patients. Neurourol. Urodynam. 36:1119-1123, 2017. © 2016 Wiley Periodicals, Inc.

Long-term efficacy of polydimethylsiloxane (Macroplastique) injection for Mitrofanoff leakage after continent urinary diversion surgery.

OBJECTIVE: To assess the long-term efficacy of polydimethylsiloxane (Macroplastique) injection (MPI) in the treatment of Mitrofanoff leakage secondary to valve incompetence. PATIENTS AND METHODS: Between 1995 and 2012, the records of 24 consecutive patients who underwent MPI for Mitrofanoff urinary leakage after continent cutaneous urinary diversion (CCUD) surgery were examined. All patients had a valve deemed of sufficient length (>2 cm) to attempt Macroplastique coaptation. Treatment outcomes were divided into three categories based on physician assessment: success (dry), partial success (>50% reduction in incontinence pads) and failure. Success rates were assessed according to the type of reservoir and conduit channel. RESULTS: The mean (range) follow-up was 30 (6-96) months. One patient had initial difficulty catheterising, and subsequently required major revision surgery. In all, 12 patients (50%) failed the treatment and subsequently underwent operative revision to the channel. Three patients (12.5%) achieved complete success; one patient had an appendix channel through native bladder and the remaining two had Monti channels through colon. Nine patients (37.5%) had partial success; success rates were higher with appendix channels (four of six) and colonic reservoirs (six of seven) when compared with Monti channels (eight of 18, 44%) and ileal reservoirs (zero of two). Five of the nine patients with partial success eventually required further surgical revision for deteriorating continence at a mean (range) of 41 (14-96) months, whilst the other four have maintained sufficient continence with MPI alone. CONCLUSION: Macroplastique bulking cured only 12.5% patients, but leakage was substantially improved in a further 37.5% allowing major surgery to be avoided or postponed in one half of the cohort. Appendix Mitrofanoffs do better than the Monti Mitrofanoff, with channels through colonic segments generally doing better than those through ileal bladders. MPI should be considered as a less invasive alternative to avoid or delay major reconstructive surgery.

Developing a laparoscopic radical prostatectomy service: defining the learning curve.

BACKGROUND AND PURPOSE: Laparoscopic radical prostatectomy (LRP) is an established treatment for patients with prostate cancer in selected centers with appropriate expertise. We studied our single-center experience of developing a LRP service and subsequent training of two additional surgeons by the initial surgeon. We assessed the learning curve of the three surgeons with regard to perioperative outcomes and oncologic results. PATIENTS AND METHODS: Three hundred consecutive patients underwent a LRP between January 2005 and April 2011. Patients were divided into three equal groups (1-100 group 1], 101-200 [group 2], and 201-300 [group 3]). Age, American Society of Anesthesiologists score, preoperative comorbidities, and indications for LRP were comparable for all three patient groups. Perioperative and oncologic outcomes were compared across all three groups to assess the impact of the learning curve for LRP. All surgical complications were classified using the Clavien-Dindo system (CDS). RESULTS: The mean age was 61.9 years (range 46-74 y). There was a significant reduction in the mean operative time (P<0.05), mean blood loss (P<0.05), mean duration of hospital stay (P<0.05), and duration of catherization (P<0.05) between the three groups as the series progressed. The two most important factors predictive of positive surgical margins at LRP were the initial prostate-specific antigen level and tumor stage at diagnosis. The overall positive margin rate was 27.7%. For pT(2) tumors, the positive margin rate was 21%, while patients with pT(3) tumors had a positive margin of 44%. For pT(2) tumors, positive margin rates decreased with increasing experience (group 1, 27% vs group 2, 17% vs group 3, 19%). The incidence of major complications--ie, grade CDS score ≤ III--was 4.6% (14/300). CONCLUSION: LRP is a safe procedure with low morbidity. As surgeons progress through the learning curve, perioperative parameters and oncologic outcomes improve. Using a carefully mentored approach, LRP can be safely introduced as a new procedure without compromising patient outcomes.