Low-dose-rate brachytherapy and long-term treatment outcomes in patients younger than 60 years of age.

Purpose: Low-dose-rate (LDR) brachytherapy in young men remains controversial amongst urologists due to their concerns regarding long-term biochemical control and treatment-related toxicities. The purpose of this study was to evaluate the treatment outcomes of men under 60 years of age who underwent LDR brachytherapy with iodine-125 (125I) for clinically localized low- to intermediate-risk prostate cancer. Material and methods: All consecutive patients with clinically localized prostate cancer treated at our institution from 2003 to 2016 with 125I monotherapy were included in the study. Prescription dose was 145.0 Gy modified peripheral loading (MPD). All patients were assessed for biochemical progression-free survival using Phoenix definition (nadir +2 ng/ml), clinical progression-free survival, overall survival (OS), and any associated treatment toxicity. Results: A total of 161 patients were included, with a median follow-up of 6.8 years (range, 3-14.54 years). Median age at implant was 57 years (range, 53-59 years). Mean prostate specific antigen (PSA) level at diagnosis was 4.43 ng/ml (SD = 2.29). Majority of men had low-risk prostate cancer (70.2%). Biochemical progression-free survival at 8 years was 94% for the entire cohort. Median PSA at 4 years was 0.169 (IQR, 0.096-0.360), with 45% of patients having a PSA greater than 0.2. OS was 96.9%, with 5 deaths reported but only one was secondary to prostate cancer. Late grade > 2 genitourinary toxicities were reported in 18 patients (11.2%). Three patients (1.9%) developed secondary cancers, all considered unrelated to their LDR brachytherapy. Conclusions: With excellent long-term treatment outcomes and minimal associated toxicities, our results showed that LDR brachytherapy can be an effective treatment of choice in younger men.

Patterns of chemotherapy use in muscle-invasive bladder cancer in a tertiary centre.

Objectives: Although neoadjuvant chemotherapy (NAC) has been demonstrated to have significant benefits to survival in patients with muscle-invasive bladder cancer (MIBC), the current utilization of NAC in Australia is unknown. The aim of this study was to evaluate the patterns of neoadjuvant and adjuvant chemotherapy (AC) use in patients undergoing cystectomy for MIBC at a large tertiary institution in Australia. Methods: A retrospective study was conducted using data of patients who underwent a radical cystectomy (RC) at a high-volume centre for MIBC between 2011 and 2021. Results: Of 69 patients who had a cystectomy for ≥ pT2 bladder cancer, 73.9% were eligible for NAC. However, of those eligible, only five patients received NAC (9.8%). Of the total patients who were eligible for AC, only 44.4% received postoperative chemotherapy. Common reasons for the lack of uptake were due to patients being unfit or declining treatment. There was no difference in progression-free survival or overall survival in those who received NAC and AC. Conclusions: The majority of patients undergoing RC for MIBC received AC compared to NAC, reflecting the real-world challenge of NAC uptake. This highlights the need for ongoing improvements in selection and usage of NAC and less reliance of AC utilization post RC.

Hyaluronic acid rectal spacer in EBRT: Usability, safety and symmetry related to user experience.

OBJECTIVES: To report on the usability, safety, symmetry, and effectiveness of hyaluronic acid (HA) injected between the prostate and the rectum for patients undergoing treatment for prostate cancer with external beam radiotherapy (EBRT), and present a novel definition of rectal spacer symmetry that is reproducible and independent of patient anatomy. PATIENTS AND METHODS: 102 consecutive patients with clinical stage of T1c-3b prostate cancer underwent general anaesthesia for fiducial marker insertion and injection of HA into the perirectal space before EBRT. HA safety, symmetry, separation, and usability based on user experience were assessed. RESULTS: HA insertion was completed with a 100% success rate independent of user experience, rated as 'easy' or 'very easy' in all cases. There were no postoperative complications reported. The mean (SD) recto-prostatic separation for all patients at the base, midgland and apex were 12 (±2) mm, 11 (±2) mm, and 9 (±1) mm respectively. The mean sagittal length of the implant was 43 (±5) mm. The implant was rated as symmetrical in 98% of cases. The mean rV70Gy was 1.6% (IQR 0.8-3.3%) for patients receiving 78-80Gy. The mean rV53Gy was 2.8% (IQR 1.2-4.8%) for patients receiving 60-62Gy. The median prostate size was 43.5 cc (IQR 32-57). CONCLUSION: Injection of HA was able to achieve highly symmetrical recto-prostatic separation, with new users able to produce excellent separation, particularly at the apex, achieving similar dosimetry outcomes as competent and experienced users. HA is safe, easy to use, and significantly reduced mean rV70Gy and rV53Gy compared to non-spacer patients.

Primary Prostatic Carcinoma With De Novo Diffuse Neuroendocrine Differentiation.

The 2016 World Health Organization classification of prostate cancer with neuroendocrine (NE) differentiation includes NE cells in usual prostate cancer, adenocarcinoma with Paneth cell-like NE differentiation, well-differentiated NE tumor (carcinoid), small cell NE carcinoma, and large cell NE carcinoma. In this article, we report a rare case of primary prostatic carcinoma with de novo diffuse NE differentiation presenting with bilateral hydronephrosis in a 79-year-old man. This case did not fit into any of the existing classifications. The clinical, radiological, morphological, and immunohistochemical findings and response to androgen deprivation therapy (ADT) are presented. The proposed pathogenesis of NE differentiation via transdifferentiation from conventional prostatic adenocarcinoma whereby genomic alterations, coupled with ADT can induce lineage plasticity resulting in NE differentiation is described.

Impact of hydrogel and hyaluronic acid rectal spacer on rectal dosimetry and toxicity in low-dose-rate prostate brachytherapy: a multi-institutional analysis of patients' outcomes.

PURPOSE: To report on rectal dosimetry and toxicity outcomes in men with prostate cancer (PCa) treated with iodine-125 low-dose-rate brachytherapy (LDR-BT) with or without polyethylene glycol hydrogel (HS) or hyaluronic acid (HA) rectal spacer (RS) insertion. MATERIAL AND METHODS: Seventy consecutive men treated with LDR-BT between December 2017 and July 2019 were included in this study, including twenty-eight (40%) men who had RS insertion according to the preference of referring urologist, compared to a group of forty-two men (60%) without RS. Descriptive statistics were used to compare RS safety, dosimetric effects on organs at risk (rectum and urethra), and gastrointestinal (GI) and genitourinary toxicities (GU) (assessed using the CTCAE v.4) between the two groups of patients. RESULTS: The median prostate-rectal separation with RS at mid prostate was 10 mm (IQR, 8-11.5 mm). The median follow-up was 23.5 months. There were no post-operative complications for RS insertion. There was significantly reduced rectal dosimetry in RS-group vs. non-RS group; the median RV100 was 0.0 cc (IQR, 0.0-0.0 cc) vs. 0.4 cc (IQR, 0.1-1.1 cc) (p < 0.001), respectively. The mean rectal D1cc and D2cc were 52.4% vs. 84.2% (p < 0.001) and 45.7% vs. 70.0% (p < 0.001) for RS and non-RS group, respectively. There were no statistically significant differences in the mean urethral D20, D5, and D1. There were significantly less grade 1 acute and late GI toxicities in RS-group when compared to non-RS group (0% vs. 24%, p = 0.004 for acute GI toxicity; 4% vs. 33%, p = 0.003 for late GI toxicity). There were no reported acute or late grade 2 or above GI toxicities. CONCLUSIONS: Insertion of RS in men treated with LDR-BT is safe and resulted in a significant reduction in rectal dosimetry. The reduction in rectal dosimetry with RS insertion translates into significantly reduced acute and late GI toxicities.

Non-surgical urologic management of neurogenic bladder after spinal cord injury.

PURPOSE: To review the available data on non-surgical management for neurogenic bladder in patients with spinal cord injury (SCI). Before the introduction of urinary catheters and antibiotics, neurogenic bladder was one of the main culprits for death in those patients with SCI. Currently, the management of neurogenic bladder is focused in improving quality of life and preserving renal function. METHODS: A literature review was performed and therapeutic management for neurogenic bladder was divided in six sections: (1) intermittent bladder catheterization; (2) indwelling catheters; (3) condom catheter drainage; (4) reflex voiding and bladder expression with Valsalva or Credé; (5) oral drug therapy of the spinal cord injured bladder; and (6) botulinum neurotoxin (BoNT). RESULTS: Intermittent catheterization is recommended as the preferable method for management of neurogenic bladder in patients with SCI based on limited high-quality data. However, this may not be feasible or available to all and other alternative options include condom catheter drainage or indwelling catheters such as urethral catheters or suprapubic tube, reflex voiding, and bladder expression with Valsalva or Credé. Non-invasive medical therapies are the key to improve incontinence, urodynamic parameters, and quality of life in this population. Botulinum neurotoxin has revolutionized the management of neurogenic bladder in the last two decades decreasing the need for reconstruction or diversion. CONCLUSION: The Joint SIU-ICUD (Société Internationale d'Urologie) (International Consultation on Urological Diseases) International Consultation reviewed the available presented data and provided specific conclusions and recommendations for each non-surgical urologic method to address neurogenic bladder after SCI.

Clinicopathological characteristics and management of prostate cancer in the human immunodeficiency virus (HIV)-positive population: experience in an Australian major HIV centre.

OBJECTIVES: To characterise clinicopathological characteristics of prostate cancer among human immunodeficiency virus (HIV)-positive men and to evaluate the current practice patterns in the management of prostate cancer in these men. PATIENTS AND METHODS: We retrospectively reviewed all patients with HIV in the State-wide HIV referral centre in Victoria, who were diagnosed with prostate cancer from 2000 onwards. In all, 12 patients were identified, and the medical records were reviewed to collect data on HIV parameters at the time of prostate cancer diagnosis, as well as prostate cancer clinicopathological characteristics, treatment details and outcomes. RESULTS: At the time of prostate cancer diagnosis, eight patients had undetectable viral load, and the median cluster of differentiation 4 (CD4) count was 485 cells/µL. The average age at diagnosis of prostate cancer was 63 years and the median prostate-specific antigen (PSA) level of 11.1 ng/mL. Four patients had Gleason 6 prostate cancer, four Gleason 7, one Gleason 8 and three Gleason 9. Seven of the 12 patients had a positive family history for prostate cancer. Of the patients with clinically localised prostate cancer (10), most were treated with radiotherapy (RT): one permanent seed brachytherapy (BT), five external beam RT (EBRT), two open radical prostatectomies (RP), one active surveillance (AS), and one on watchful waiting (WW). For the two patients with metastatic disease, one had androgen-deprivation therapy and EBRT, while the other had a combination of EBRT and chemo-hormonal therapy with doxetacel. All patients were followed for a median of 46 months, with three deaths reported, none of which was a prostate cancer-specific death. CONCLUSIONS: This is the first Australasian series on prostate cancer management in a HIV population. With the prolonged survival among HIV-positive men in the highly active anti-retroviral therapy era, PSA testing should be offered to this group of patients, especially those with a positive family history. HIV-positive men should also be offered all treatment options in the same manner as men in the general population.

Evaluation of Crestal Bone Loss Around Implants Placed at Equicrestal and Subcrestal Levels Before Loading: A Prospective Clinical Study.

INTRODUCTION: Depth of placement of implant shoulder in relation to the crestal bone positively influence bone remodelling and preservation but the role of placement depth on bone loss before loading is not very clear. AIM: To assess the effect of placement depth alone on the crestal bone loss around implant placed at subcrestal and equicrestal level before prosthetic loading. MATERIALS AND METHODS: Patients reporting to the Department of Prosthodontics with the complaint of missing teeth were enrolled in the study after analysing inclusion and exclusion criteria. A total of 24 implants were planned to be placed into two groups as Group E (n=12) and Group S (n=12). Follow up radiographs after implant placement and after six months were analysed for the amount of bone loss. RESULTS: On six months follow up crestal bone levels of Group E were apical to Group S. Bone loss comparison between groups after six months follow up, revealed almost same mean bone loss. CONCLUSION: The implants placed at subcrestal and equicrestal level did not show difference in crestal bone loss before prosthetic loading.

Repeated radiological radiation exposure in patients undergoing surgery for urinary tract stone disease in Victoria, Australia.

UNLABELLED: What's known on the subject? and What does the study add? Radiation exposure is a cause of cancer. Increasing use of CT scans has increased patient exposure to ionizing radiation which may increase long-term risk of cancer. Not all scans performed may be medically necessary. Up to 30% of patients presenting with renal/ureteric colic have been estimated to receive too much radiation. At least 30% of patients attending for stone surgery have exceeded the recommended annual radiation dosage. Many Australian radiology providers do not routinely record CT radiation dose. Radiation dose varies widely between individual patients and between radiology providers. Image intensifiers may be an additional significant source of radiation exposure. Implementing guidelines and informing patients of their cumulative radiation exposure should reduce exposure and risk. SUMMARY: At least 44% of a group of patients undergoing stone operations have been exposed to high levels of radiation, mostly from repeated CT scans, over a short period with possible increased risk of developing cancer. We suggest ways in which that risk can be reduced. OBJECTIVE: • To assess radiation exposure in patients attending for surgery for urinary tract stones. PATIENTS AND METHODS: • Fifty-eight consecutive patients attending for stone surgery were asked to provide their radiological imaging over the preceding year. • Radiation dosage was recorded where available. Individual radiology providers were contacted to provide additional data. RESULTS: • The median number of radiological investigations was six (range 2-15). • Patients had attended 12 different providers on 22 sites. Only three providers routinely recorded computed tomography (CT) radiation dose. • Up to 26 patients (44%) were subjected to at least 50 mGy radiation in the course of their treatment with at least eight (13.8%) receiving over 100 mGy from CT scans alone. • CT and image intensifier radiation dose varied considerably between providers even for the same patients. CONCLUSIONS: • Many patients with urinary tract stones are subjected to relatively high doses of radiation in the course of their investigation and treatment. This may have later malignant consequences. • Many providers in Australia are not recording radiation dose and patients seem to have many unnecessary scans. • Suggestions on improved management are made which could significantly reduce radiation exposure.