Single session of high-intensity focused ultrasound therapy for the management of organ-confined prostate cancer: A single-institute experience

ObjectiveThe aim of this study was to evaluate the therapeutic response and complications of high-intensity focused ultrasound for patients with localized prostate cancer.Materials and MethodsWe evaluated the clinical outcomes of 29 patients who received high-intensity focused ultrasound as first-line treatment for localized prostate cancer at our hospital from October 2010 to March 2016. Biochemical recurrence was defined, according to the Stuttgart definition of biochemical failure, as the prostate-specific antigen nadir plus 1.2 ng/mL. Prostate-specific antigen levels and complications were recorded during regular follow-up.ResultsThe mean follow-up period was 24.6 months. Six patients experienced biochemical recurrence (20.68%). Disease progression was noted in six patients (20.68%), and salvage therapy was performed in these patients. The 24.6-month cancer-specific survival rate was 100%. No severe complications were reported.ConclusionHigh-intensity focused ultrasound is an alternative therapy for patients with localized prostate cancer. In combination with preceding transurethral resection of the prostate, this treatment shows promise in disease control with a low complication rate in short-term follow-up.     

机器人经腹腔镜行前列腺根治性切除术60例的初步结果

目的评价机器人经腹腔镜行前列腺根治性切除术的可行性和效果。方法利用da Vinci机器人外科手术系统对60例局限性前列腺癌患者施行机器人经腹腔镜行前列腺根治性切除术。患者年龄53～75岁，平均63．7岁；Gleason评分5～9，平均6；术前前列腺特异性抗原(PSA)5．5～38．3ng／ml，平均9．4ng／ml。结果术前机器人准备时间平均28(10～90)min，手术平均时间200(95～330)min。术中平均失血量355(50—1200)ml，输血7例(12％)。术后平均1d恢复正常饮食。术后平均导尿管留置时间7d，平均住院时间3d。1例发生吻合口漏尿者紧急手术探查和重新吻合，1例因膀胱颈挛缩行经尿道膀胱颈切开，1例因严重尿路感染行静脉输入抗生素。30例术前有性生活的患者术后6个月内自动恢复或经PDE5抑制剂或PGEl药物治疗后恢复性功能。术后3个月随访38例，完全控尿21例(55％)，轻度尿失禁9例(24％)，中度尿失禁8例(21％)。随访至术后6个月24例，完全控尿17例(71％)，轻度尿失禁4例(17％)，中度尿失禁3例(12％)。结论机器人经腹腔镜前列腺根治性切除术术中失血少、术后患者疼痛小、恢复快、住院时间短，使盆腔内难以进行的腹腔镜手术变得简单、方便，更加灵巧和准确。     

Oncological outcomes of pathologically organ-confined,lymph node-positive prostate cancer after radical prostatectomy

BackgroundThe aim of this study was to investigate the impact of lymph-node involvement on oncological outcomes in patients with pathologically organ-confined prostate cancer (pT2 CaP) after radical prostatectomy (RP).MethodsWe retrospectively analyzed 9,631 pT2 CaP patients who underwent RP at a single institution between 1998 and 2018. Kaplan-Meier plots and Cox regression models (CRMs) assessed biochemical recurrence (BCR)-free survival and metastasis-free survival (MFS) according to N-stage. In subgroup analyses of N1 patients, Kaplan-Meier plots and CRMs were stratified according to adjuvant treatment.ResultsOf 9,631 pT2 staged patients, 241 (2.5%) harbored lymph-node metastases after RP (pN1). The median follow-up was 60.8 months. No pT2 N1-staged patient died due to CaP. The 5-year BCR-free survival rates were 54.7 vs. 88.4% in pT2 N1 vs. pT2 N0 patients, respectively (P < 0.001). The 5-year MFS rates were 92.5 vs. 98.9% in pT2 N1 vs. pT2 N0 patients, respectively (P < 0.001). Within pT2 N1 patients, presence of ≥3 positive lymph nodes was an independent risk factor for BCR (hazard ratio [HR] 3.4, P < 0.001) and for metastatic progression (HR 1.7, P = 0.04). Finally, 3-year BCR-free survival was improved in pT2 N1 patients treated with adjuvant radiation therapy (87.1% vs. 63.7% for patients who received other treatment options [P < 0.001]).ConclusionPatients with pathologically organ-confined but lymph node-positive CaP exhibited favorable oncological outcomes after RP. Presence of ≥3 positive LNs predicted higher rates of BCR and metastatic progression. In consequence, in pT2 N1 patients treated with RP with ≥3 positive LNs, adjuvant treatment may be considered.9     

Single tertiary cancer center experience on the management of pT3b prostate cancer after robotic-assisted laparoscopic prostatectomy

BackgroundPathological involvement of the seminal vesicle poses a treatment dilemma following robotic prostatectomy. Margin status plays an important role in deciding further management. A wide range of treatment options are available, including active monitoring, adjuvant radiotherapy, salvage radiotherapy, and occasionally androgen deprivation therapy. Patients undergoing postoperative radiotherapy tend to have higher risk of urinary and bowel morbidities. The recent RADICALS-RT concluded that adjuvant radiotherapy did not have any benefit compared with salvage radiotherapy. We aim to audit the incidence, margin status, and management of T3b cancer cases at our center.Materials and methodsA retrospective analysis was conducted of all patients diagnosed with pathological T3b (pT3b) prostate cancer following robotic-assisted laparoscopic prostatectomy from January 2012 to July 2020. Preoperative parameters analyzed included prostate-specific antigen (PSA), T stage, and age. A chi-square test and 2-tailed t test were used to determine the relationship between categorical and continuous variables, respectively. Kaplan-Meier survival curves were generated to assess overall survival in patients with pT3b prostate cancer and used to compare unadjusted progression-free survival among those who underwent adjuvant and salvage radiotherapy.ResultsA total of 83 (5%) of 1665 patients who underwent robotic prostatectomy were diagnosed with pT3b prostate cancer between January 2012 and July 2020. Among these, 36 patients (44%) did not receive any radiotherapy during follow-up, compared with 26 patients (31%) who received adjuvant radiotherapy and 21 (25%) who received salvage radiotherapy. The median age of our cohort was 64 (SD, 6.4) years. Mean PSA at presentation was 12.7 μg/L. Positive margins were seen in 36 patients (43%); however, there was no statistically significant difference between treatment groups (p = 0.49). The median overall survival was 96%. There was no significant difference between the adjuvant and salvage groups in terms of biochemical progression-free survival (p = 0.66). Five-year biochemical progression-free survival was 94% for those in the adjuvant radiotherapy group and 97% for those in the salvage radiotherapy group.ConclusionsOur audit corroborates with the recently concluded RADICALS-RT study, although we had fewer patients with positive margins. Radiotherapy can be avoided in patients with T3b prostate cancer, even if margin is positive, until there is definitive evidence of PSA recurrence. In keeping with the conclusion of RADICALS-RT, salvage radiotherapy may be preferable to adjuvant radiotherapy.     

The impact of cancer treatment on quality of life outcomes for patients with localized prostate cancer

PURPOSE: We evaluated the impact of localized prostate cancer treatment on general, cancer specific and symptom domains of quality of life for up to 5 years after diagnosis. MATERIALS AND METHODS: A total of 842 men from the Health Professionals Followup Study, diagnosed between 1993 and 1998, were included in cross-sectional analyses of quality of life associated with prostate cancer treatment. A subset of 146 men diagnosed after 1995 were followed prospectively. Quality of life was assessed with the Medical Outcomes Study Short-Form 36 Health Status Survey, Cancer Rehabilitation Evaluation System Short Form and University of California Los Angeles Prostate Cancer Index by mailed questionnaires. Primary treatment modality was taken from medical records and patient self-report. RESULTS: Significant treatment differences were observed in all quality of life measures, with the largest occurring in sexual, urinary and bowel symptoms. Bowel function was significantly worse in patients who received external radiation and brachytherapy compared with prostatectomy (p <0.05). Although they had better or equivalent urinary and sexual function (p <0.05), patients treated with external radiation, hormones or watchful waiting had lower generic quality of life scores in multiple domains compared with those who underwent prostatectomy. Patients who had brachytherapy had similar generic quality of life outcomes compared with prostatectomy in all domains. CONCLUSIONS: Our findings suggest that important differences in quality of life go beyond known physical symptoms associated with various prostate cancer treatment options, many of which involve making a trade-off. It is important for patients with prostate cancer and health care providers to consider these differences while making treatment decisions.     

Functional outcomes and complications following radiation therapy for prostate cancer: a critical analysis of the literature

Context

Prostate cancer (PCa) patients have many options within the realms of surgery or radiation therapy (RT). Technical advancements in RT planning and delivery have yielded different approaches, such as external beam, brachytherapy, and newer approaches such as image-guided tomotherapy or volumetric-modulated arc therapy. The selection of the optimal RT treatment for the individual is still a point of discussion, and the debate centres on two important outcomes—namely, cancer control and reduction of side-effects.

Objective

To critically review and summarise the available literature on functional outcomes and rectal sequelae following RT for PCa treatment.

Evidence acquisition

A review of the literature published between 1999 and 2010 was performed using Medline and Scopus search. Relevant reports were identified using the terms prostate cancer, radiotherapy, functional outcomes, external beam radiation, brachytherapy, IMRT, quality of life, and tomotherapy and were critically reviewed and summarised.

Evidence synthesis

Related to nonuniform definition of their assessed functional end points and uneven standards of reporting, only a minority of series retrieved could be selected for analyses. Moreover, patterns of patient selection for different types of RT, inherent differences in the RT modalities, and the presence or absence of hormonal treatment also limit the ability to synthesise results from different publications or perform meta-analyses across the different treatment types. Nonetheless, several studies agree that recent technical improvements in the field of RT planning and delivery enable the administration of higher doses with equal or less toxicity. Regardless of the type of RT, the most frequently considered functional end points in the published analyses are gastrointestinal (GI) complications and rectal bleeding. Established risk factors for acute or late toxicities after RT include advanced age, larger rectal volume, a history of prior abdominal surgery, the concomitant use of androgen deprivation, preexisting diabetes mellitus, haemorrhoids, and inflammatory bowel disease (IBD). Similarly, mild acute irritative urinary symptoms are reported in several studies, whereas total urinary incontinence and other severe urinary symptoms are rare. Pretreatment genitourinary complaints, prior transurethral resection of the prostate (TURP), and the presence of acute genitourinary toxicity are suggested as contributing to long-term urinary morbidity. Erectile dysfunction (ED) is not an immediate side-effect of RT, and the occurrence of spontaneous erections before treatment is the best predictor for preserving erections sufficient for intercourse. In addition, the use of magnetic resonance imaging (MRI) permits a reduction in the dose delivered to vascular structures critical for erectile function.

Conclusions

In the future, further improvement in RT planning and delivery will decrease side-effects and permit administration of higher doses. Related to the anatomy of the prostate, these higher doses may favour rectal sparing while not readily sparing the urethra and bladder neck. As a consequence, there may be a future shift from dose-limiting long-term rectal morbidity towards long-term urinary morbidity. In the absence of prospective randomised trials comparing different types of surgical and RT-based treatments in PCa, the introduction of validated tools for reporting functional and clinical outcomes is crucial for evaluating and identifying each individual's best treatment choice.     

Salvage radical prostatectomy as management of locally recurrent prostate cancer: outcomes and complications

Purpose

Management of prostate cancer following radiation therapy remains challenging, especially for younger men or those with life expectancy greater than 10 years. We outline the efficacy, safety and adequacy of radical prostatectomy for the treatment of radiorecurrent localized prostate cancer.

Methods

A systematic review was performed in September 2012 searching MEDLINE articles from 1980 to 2012 on salvage radical prostatectomy. We excluded unpublished data and non-English-language articles.

Results

The ideal candidate for salvage radical prostatectomy (SRP) has a life expectancy greater than 10 years, a PSA < 10 ng/ml and whose initial clinical staging was T1 or T2. A prostate biopsy and imaging studies to rule out metastatic disease should be performed prior to SRP. Salvage RP has a high complication rate, but this appears to be decreasing over time. Urinary continence rates range from 36 to 81 %, whereas erectile function following SRP was generally poor with less than 30 % of men regaining adequate erectile function. Men with good erectile function prior to SRP fared better than those with pre-operative erectile dysfunction. Biochemical recurrence-free probability at 5 years ranged from 37 to 55 % and the estimated cancer-specific survival at 10 years ranged from 70 to 83 %. Minimally invasive SRP is feasible and early outcomes suggest that this approach is not inferior to open surgery.

Conclusion

SRP offers a potentially curative option with proven long-term disease-free survival in appropriately selected patients. Given the morbidity of this procedure, judicious patient selection and referral to providers experienced with salvage surgery may optimize patient outcomes.     

Single staff cystectomy in a low-volume center: Oncological outcomes and complications

IntroductionRadical cystectomy (RC) with bilateral pelvic lymph node dissection (PLND) is a complex surgical procedure, associated with substantial perioperative complications. Previous studies suggested reserving it to high-volume centers in order to improve oncological and perioperative outcomes. However, only limited data exist regarding low-volume centers with highly experienced surgeons. We aimed to assess oncological and perioperative outcomes after RC performed by experienced surgeons in the low-volume center of Luzerner Kantonsspital, Lucerne, CH.MethodsWe retrospectively analyzed the data of 158 patients who underwent RC and PLND performed between 2009 and 2019 at a single low-volume center by three experienced surgeons, each having performed at least 50 RCs. Complications were graded according to the 2004 modified Clavien-Dindo grading system.ResultsA total of 110 patients (70%) received an incontinent urinary diversion (ileal conduit or ureterocutaneostomy) and 48 patients (30%) received a continent urinary diversion (ileal orthotopic neobladder, ureterosigmoidostomy, or Mitrofanoff pouch). Median operating time was 419 minutes (interquartile range [IQR] 346–461). Overall, at RC specimen, 71.5% of patients had urothelial carcinoma, 12.6% squamous, 3.1% sarcomatoid, 1.2% glandular, and 0.6% small cell carcinoma. Median number of lymph nodes removed was 23 (IQR 16–29.5). Positive margins were found in eight patients (5.1%). Overall five-year survival rate was 52.4%. The complication rate was 56.3%: 143 complications were found in 89 patients, 36 (22.8%) with Clavien ≥3. The 30-day mortality rate was 2.5%.ConclusionsRC could be safely performed in a low-volume center by experienced surgeons with comparable outcomes to high-volume centers.     

Ductal prostate cancer: contemporary management and outcomes

OBJECTIVES: To evaluate contemporary management and outcomes of ductal prostate cancer (PCA). MATERIALS AND METHODS: We reviewed all patients with ductal PCA and at least 6 months of follow-up seen at UTMB from 1990 to 2005, which comprised 17 patients (mean age: 67.7 years, range 55-87). At time of diagnosis, 11 patients had localized disease (Group 1) and 6 patients had distant metastasis (Group 2). RESULTS: Treatment of Group 1 patients included radiation and endocrine treatment for at least 2 years (n = 7), radiation alone (n = 2), and radical surgery (n = 2). At a mean follow-up of 3.6 years (r = 1-12 years) 8 patients (67.7%) remained free of recurrence, 1 patient had biochemical recurrence alone, 1 patient had recurrence in the anterior urethra, and the other had progression with metastasis to the brain and subsequent death. In addition to metastasis to regional/distant lymph nodes and bone in Group 2, metastatic sites included brain (n = 1), peritoneum (n = 1), and lung (n = 1). Mean follow-up was 2.3 years (r = 8 months to 4 years). All patients received androgen deprivation. One patient had progression of disease despite lack of biochemical recurrence and is alive at 2.5 years. One patient died from other causes while the 4 remaining patients are in remission at last follow-up. CONCLUSIONS: Contemporary management of localized ductal PCA with radiation and endocrine therapy yields adequate disease-free survival. Metastatic sites include brain, lung, peritoneum, and anterior urethra, and most patients respond well to endocrine treatment.     

Supportive care, pain management, and quality of life in advanced prostate cancer.

Despite achievements in the area of providing care for patients with advanced prostate cancer, ample work remains. Additional research is needed regarding the control of pain from bone metastases and the management of fatigue and urinary symptoms. Investigators have only begun to explore the area of quality of life research in patients with prostate cancer. Other issues not addressed in this article that are significant to the care of these patients include caregiver burden and end-of-life care. These areas significantly affect quality of life. The supportive care, pain management, and quality of life issues discussed herein present many challenges to health care providers. Close attention to what patients tell us about their care will make the challenge more attainable and the caregiving more satisfying.     

Optimizing outcomes and quality of life in the hormonal treatment of prostate cancer

We review the effectiveness of androgen-deprivation therapy (ADT) in the management of prostate cancer, and the effect that this treatment has on a patient's quality of life (QoL), based on discussions held at a European symposium on the management of prostate cancer. The overall QoL is reduced in asymptomatic men, and there are known decreases in cognitive function, self-esteem, libido and sexual function. Hot flashes are also a frequent problem. Prolonged ADT can lead to osteoporosis and subsequently fractures. Various effective methods exist to manage and minimize these side-effects; some are specific to the side-effect, whereas other more general methods include lifestyle changes, specific drugs and added hormonal manipulations. Intermittent ADT for patients taking luteinizing hormone-releasing hormone agonists offers a promising method to reduce adverse effects, and possibly increases the time to androgen independence. Initial studies indicate that prostate-specific antigen-based progression with intermittent ADT is similar to that seen with continuous ADT, but there is a reduction in side-effects, leading to an improvement in QoL.     

Multidisciplinary management of bone complications in prostate cancer and optimizing outcomes of bisphosphonate therapy

Prostate cancer is the second most common cancer diagnosed in men worldwide and, although advances in treatment options have extended the overall survival of these patients, bone health issues remain a challenge throughout the continuum of care. Patients with prostate cancer are at high risk of skeletal complications from bone metastases and bone loss induced by cancer treatments, such as androgen-deprivation therapy. The preservation of skeletal health might require the cooperation of urologists, oncologists, pain specialists, and other physicians specializing in the treatment of prostate cancer. Complications resulting from bone loss and bone metastases can result in increased risk of fracture and death. Implementation of a multidisciplinary approach for the management of bone health can, therefore, provide clinically meaningful benefits to patients with skeletal complications. The early diagnosis and treatment of bone loss and bone metastases with bisphosphonates are critical for the maintenance of skeletal wellness and prevention of bone complications in patients with prostate cancer.