The pattern of prostate cancer local recurrence after radiation and salvage cryoablation.

OBJECTIVE: We assessed the pattern of local recurrence after salvage cryoablation of the prostate, and the impact of local recurrence on intermediate-term outcome. METHODS: One hundred twenty-two patients who underwent salvage cryoablation were studied after a mean follow-up of 56 months. Serial prostate biopsy was carried out after cryoablation. The histopathology of prostate biopsies before and after cryoablation were compared. The prognostic value of post-cryoablation biopsy was assessed with the Cox regression method. RESULTS: 23.1% of patients had a positive biopsy for prostate cancer following salvage cryoablation. Most cancer recurrences occurred in the apex (51.5%), base (21.2%) and seminal vesicles (18.2%). The presence of cancer at the base of the prostate was found to be a prognostic factor for eventual biochemical failure. Overall 5-year biochemical disease-free survival (bDFS) was 28%, however patients with cancer at the base of the prostate had a 5-year bDFS of 0%. CONCLUSION: Cancer recurrences occurred in areas where aggressive freezing was avoided as it might result in serious problems (e.g., urethro-rectal fistula and incontinence). Post-cryoablation biopsies and the location of persistent disease are of prognostic value.

Disease-free survival following salvage cryotherapy for biopsy-proven radio-recurrent prostate cancer.

BACKGROUND: The optimum treatment of prostate cancer recurrence following radiation therapy (RT) remains controversial due to the lack of long-term data. OBJECTIVE: Our aim was to review the survival of patients who underwent salvage cryotherapy to the prostate gland for biopsy-proven recurrent prostate cancer and establish prognostic indicators. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was performed on all patients undergoing salvage cryotherapy at an academic urology unit for biopsy-proven locally recurrent prostate cancer after RT from 1995 to 2004. Patients' preoperative, perioperative, and postoperative data were reviewed and recorded. INTERVENTION: Two freeze-thaw cycles of transperineal cryotherapy were performed under transrectal ultrasound guidance by a single surgeon. MEASUREMENTS: The primary outcome was survival. Secondary outcomes were disease-free survival (DFS), metastasis-free survival, and progression to androgen-deprivation therapy. RESULTS AND LIMITATIONS: Of 187 patients, 176 had records available for follow-up (follow-up rate: 94%). Mean follow-up was 7.46 yr (range: 1-14 yr). Fifty-two patients were followed for >10 yr. DFS at 10 yr was 39%. Risk factors for recurrence were presalvage prostate-specific antigen (PSA), preradiation, and presalvage Gleason score. A PSA nadir >1.0 ng/dl was highly predictive of early recurrence. CONCLUSIONS: Salvage cryotherapy led to an acceptable 10-yr DFS. Presalvage PSA and Gleason score were the best predictors of disease recurrence. A PSA nadir >1 ng/dl following cryotherapy indicated a poor prognosis, and recurrence of disease was universal in these patients.

Salvage cryoablation of the prostate: followup and analysis of predictive factors for outcome.

PURPOSE: We assessed the efficacy of cryoablation of the prostate with an emphasis on finding predictive factors that lead to improved outcome. MATERIALS AND METHODS: A total of 187 patients with locally recurrent prostate cancer after radiotherapy underwent salvage cryoablation of the prostate, and were studied after a mean followup of 39 months. Survival analysis was performed with the Kaplan-Meier method. Several variables were tested for predictive value using the Cox regression model including serum prostate specific antigen before radiotherapy, serum prostate specific antigen at cryoablation, clinical stage before radiotherapy, Gleason score before radiotherapy, Gleason score at cryoablation, number of positive biopsy cores and use of neoadjuvant hormonal therapy before cryoablation. RESULTS: Serum prostate specific antigen at cryoablation was a predictive factor for biochemical recurrence on univariate and multivariate analysis (p <0.001). Patients with pre-cryoablation prostate specific antigen less than 4 ng/ml had a 5 and 8-year biochemical recurrence-free survival of 56% and 37%, respectively. In contrast, patients with pre-cryoablation prostate specific antigen 10 ng/ml or greater had a 5 and 8-year biochemical recurrence-free survival of only 1% and 7%, respectively. Patients with pre-cryoablation prostate specific antigen from 4 to 9.99 ng/ml had intermediate survival outcomes. Of the patients 32% were started on hormonal therapy for disease progression at a mean of 31 months postoperatively. Overall 5 and 8-year survival was 97% and 92%, respectively. CONCLUSIONS: Salvage cryoablation is a viable treatment option for patients with prostate cancer in whom radiation therapy has failed. Salvage cryoablation should be performed when serum prostate specific antigen is still relatively low because in these patients the procedure may potentially be curative. Even when cryoablation fails to eradicate the disease in some patients, it allows hormonal therapy to be deferred for a significant period of time in that cohort.

Urodynamic studies in the evaluation of young men presenting with lower urinary tract symptoms.

AIM: To evaluate the usefulness of urodynamic study in young men with lower urinary tract symptoms (LUTS). METHODS: We reviewed the charts of 50 men with LUTS aged 50 years and below. Those with neurological diseases, urethral trauma or strictures were excluded. All underwent multichannel urodynamic studies (UDS). The pre- and post-UDS diagnoses and treatment modalities were compared. RESULTS: Mean age was 38.1 years (17-49). The main pre-UDS diagnoses included prostatitis in seven (14%), overactive bladder in seventeen (34%) and benign prostatic hyperplasia in nine (18%). Pre-UDS management ranged from anticholingeric agents for thirteen (26%), alpha-adrenergic antagonists for nine (18%), antibiotics for six (12%). Abnormal UDS were noted in 36 (72%), including detrusor overactivity in 9 (18%), detrusor underactivity/acontractility in 5 (10%) and bladder outlet obstruction in 21 (42%). Fourteen (28%) had primary bladder neck dysfunction and five (10%) had benign prostatic hyperplasia. Post-UDS management included anticholingeric agents for ten (26%), alpha-adrenergic antagonists for seventeen (34%), catheterization for four (10%), behavioral therapy for three (6%), surgery for three (6%). None were prescribed antibiotics. Following UDS, the diagnosis had to be updated in 40 (80%) and concomitant change in management was required in 34 (68%). CONCLUSION: Young men presenting with LUTS have different underlying etiologies. Clinical diagnosis and treatment are often empiric and inaccurate. Urodynamic study is useful in the evaluation of this group of patients as it aids in arriving at an accurate diagnosis and guides treatment therapy.