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Kimura K, Yamamoto T, Tsuchiya J, Yoshida S, Yanai S, Onishi I, Fujii Y, Tateishi U. A diagnostic approach of various urethral diseases using multimodal imaging findings: comprehensive overview. Abdom Radiol (NY) 2024:10.1007/s00261-024-04435-0. [PMID: 38896251 DOI: 10.1007/s00261-024-04435-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 06/21/2024]
Abstract
In clinical practice, urethral diseases are not as frequent as conditions affecting other components of the urinary system. Radiological imaging tests, such as retrograde urethrography, CT, MRI, and PET/CT, along with patient history, are crucial for accurately assessing relatively rare urethral lesions. This article aimed to provide a comprehensive overview of urethral lesions, from traumatic changes to neoplasms, and discuss the multimodal imaging findings of various urethral lesions that radiologists should know. To this end, the normal imaging anatomy of the urethra and a step-by-step approach that can be used in clinical practice have been presented to help in the systematic understanding of urethral lesions.
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Affiliation(s)
- Koichiro Kimura
- Department of Diagnostic Radiology, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan.
| | - Tatsuya Yamamoto
- Department of Diagnostic Imaging, Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - Junichi Tsuchiya
- Department of Diagnostic Radiology, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan
| | - Soichiro Yoshida
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shuichi Yanai
- Department of Radiology, Fraternity Memorial Hospital, Tokyo, Japan
| | - Iichiro Onishi
- Department of Pathology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ukihide Tateishi
- Department of Diagnostic Radiology, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan
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2
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Takekawa K, Horiguchi A, Ojima K, Shinchi M, Hirano Y, Furukawa Y, Ito K, Azuma R. Urosymphyseal fistula development following treatment for radiation-induced urethral stenosis in three patients with prostate cancer. IJU Case Rep 2024; 7:123-126. [PMID: 38440698 PMCID: PMC10909145 DOI: 10.1002/iju5.12683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/01/2023] [Indexed: 03/06/2024] Open
Abstract
Introduction Urosymphyseal fistula is a rare and devastating complication that develops after radiation therapy for prostate cancer and is often triggered by the treatment of radiation-induced urethral stenosis. Here, we report our experience with urosymphyseal fistulas in three patients with prostate cancer. Case presentation Three patients with prostate cancer developed urethral stenosis after radiotherapy. The management of urethral stenosis was suprapubic tube placement in case 1, direct vision internal urethrotomy in case 2, and excision with primary anastomosis in case 3. All patients presented with severe suprapubic or thigh pain or both. Urosymphyseal fistulas were detected on magnetic resonance imaging. Conservative treatment was unsuccessful, and all patients required debridement of the necrotic pubic symphysis and simple cystectomy. In cases 1 and 2, ileal conduit urinary diversion was performed. Conclusion Urologists need to be aware that urosymphyseal fistulas can occur in irradiated patients with prostate cancer, especially after urethral stenosis treatment.
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Affiliation(s)
- Kazuki Takekawa
- Department of UrologyNational Defense Medical CollegeTokorozawaSaitamaJapan
| | - Akio Horiguchi
- Department of UrologyNational Defense Medical CollegeTokorozawaSaitamaJapan
| | - Kenichiro Ojima
- Department of UrologyNational Defense Medical CollegeTokorozawaSaitamaJapan
| | - Masayuki Shinchi
- Department of UrologyNational Defense Medical CollegeTokorozawaSaitamaJapan
| | - Yusuke Hirano
- Department of UrologyNational Defense Medical CollegeTokorozawaSaitamaJapan
| | - Yoshiyuki Furukawa
- Department of UrologyNational Defense Medical CollegeTokorozawaSaitamaJapan
| | - Keiichi Ito
- Department of UrologyNational Defense Medical CollegeTokorozawaSaitamaJapan
| | - Ryuichi Azuma
- Department of Plastic SurgeryNational Defense Medical CollegeTokorozawaSaitamaJapan
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3
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Dirk K, Rourke KF. Health-related Quality of Life in Patients With Urethral Stenosis After Radiation Treatment for Prostate Cancer. Urology 2024; 185:109-115. [PMID: 38160763 DOI: 10.1016/j.urology.2023.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To evaluate patient-reported quality of life (PRQoL) in patients presenting with membranous urethral stenosis after prostate radiotherapy. Urethral stenosis is an under-reported complication after prostate radiotherapy with a particular deficiency in PRQoL. METHODS Patients presenting with urethral stenosis after radiotherapy were retrospectively reviewed from 2004 to 2022. PRQoL was assessed via patient survey using the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP). RESULTS Two hundred thirty patients were identified at a mean age of 67.7years and mean time to stricture diagnosis of 63.6months' postradiotherapy. Of 87 patients completing the survey, 29.9% recalled being aware of urethral stenosis as a potential complication and 51.7% had documentation of urethral stenosis as a potential complication. 33.5% of patients underwent urethroplasty, 59.6% repeat endoscopic treatment and 6.1% an indwelling catheter. 64.4% of patients reported urinary dysfunction as a "moderate" or "big" problem, 66.7% reported frequent or total incontinence, 64.4% required daily pad use and 50.6% reported incontinence as either a "moderate" or "big" problem. 85.0% reported poor or absent orgasmic dysfunction and 88.5% reported erections insufficient for sexual activity. Additionally, 47.1% of patients reported rectal pain and 31.0% reported dysuria. Depressive symptoms and fatigue were reported by 41.4% and 60.9% of patients respectively. CONCLUSION Urethral stenosis after radiotherapy is a clinically complex entity with a broad scope of associated symptoms including high rates of patient-reported incontinence, voiding dysfunction, sexual dysfunction, pain, bowel dysfunction and depression. This multifocal nature combined with often insidious presentation and patient unawareness creates a uniquely challenging condition to treat.
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Affiliation(s)
- Kennedy Dirk
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
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Fernandez AM, Jones CP, Patel HV, Ghaffar U, Hakam N, Li KD, Nabavizadeh B, Breyer BN. Real-World Complications of the SpaceOAR Hydrogel Spacer: A Review of the Manufacturer and User Facility Device Experience Database. Urology 2024; 183:157-162. [PMID: 37774851 DOI: 10.1016/j.urology.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE To characterize adverse events related to use of the perirectal spacing agent SpaceOAR, we examined the Manufacturer and User Facility Device Experience (MAUDE) database. METHODS The MAUDE database was queried for "SpaceOAR" and "Augmenix" from June 2015 (when SpaceOAR was approved by the Food and Drug Administration) to October 2022. Reports were reviewed for adverse events (AEs), operative procedures performed because of the AE, and changes to the radiation plan. AEs were categorized using Common Terminology Criteria for Adverse Events (CTCAE), version 5.0. RESULTS Six hundred fifty-four reports were reviewed. Eighty-four were excluded and 4 reports reviewed 2 separate cases of SpaceOAR administration. Five hundred seventy-four cases were ultimately included. Three deaths were reported (0.5% of all AEs). One point six percent of cases represented CTCAE grade 4 injuries (life-threatening consequences; urgent intervention indicated), 15.9% grade 3 (severe but not immediately life-threatening; hospitalization), 24.2% grade 2 (moderate; local/noninvasive intervention), and 57% of events were CTCAE grade 1 (mild; asymptomatic or mild symptoms). Bowel diversion occurred in 29 cases (9%). CONCLUSION Both asymptomatic (n = 311) and debilitating (n = 12) complications of SpaceOAR hydrogel use were identified. Death, gel embolization, anaphylaxis, rectal ulcerations, and infections requiring bowel or urinary diversions were among the complications reviewed. Providers should consider these potential complications before perirectal spacer administration and during patient counseling.
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Affiliation(s)
- Adrian M Fernandez
- Department of Urology, University of California San Francisco, San Francisco, CA.
| | - Charles P Jones
- Department of Urology, University of California San Francisco, San Francisco, CA
| | - Hiren V Patel
- Department of Urology, University of California San Francisco, San Francisco, CA
| | - Umar Ghaffar
- Department of Urology, University of California San Francisco, San Francisco, CA
| | - Nizar Hakam
- Department of Urology, University of California San Francisco, San Francisco, CA
| | - Kevin D Li
- Department of Urology, University of California San Francisco, San Francisco, CA
| | - Behnam Nabavizadeh
- Department of Urology, University of California San Francisco, San Francisco, CA
| | - Benjamin N Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA.
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Lonergan PE, Baskin A, Greenberg SA, Mohamad O, Washington SL, Zhao S, Cowan JE, Broering JM, Nguyen HG, Cooperberg MR, Breyer BN, Carroll PR. The Long-term Incidence and Quality of Life Outcomes Associated With Treatment-Related Toxicities of External Beam Radiotherapy for Prostate Cancer. Urology 2023; 178:114-119. [PMID: 37244430 DOI: 10.1016/j.urology.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To assess the long-term incidence of treatment-related toxicities and quality of life (QOL) outcomes associated with toxicity after external beam radiotherapy (EBRT) for prostate cancer. METHODS We identified all men who had EBRT between 1994 and 2017 from Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), a longitudinal, nationwide prostate cancer registry. CaPSURE was queried for patient-reported and International Classification of Diseases-9/10 and Current Procedural Terminology codes. The Medical Outcomes Studies Short Form 36 and the University of California, Los Angeles Prostate Cancer Index were used to provide measures of general health, sexual, urinary, and bowel function. Repeated measures mixed models were used to determine QOL change after onset of toxicity. RESULTS From a total of 15,332, 1744 (11.4%) men had EBRT. The median follow-up was 7.9years (interquartile range [IQR] 4.3-12.7). The median time to onset of any toxicity including urinary pad usage in 265 (15.4% at 8years) men was 4.3years (IQR 1.8-8.0). The most frequent toxicity was hemorrhagic cystitis (104, 5.9% at 8years) after a median of 3.7years (1.3-7.8), gastrointestinal (48, 2.7% at 8years) after a median of 4.2years (IQR 1.3-7.8), followed by urethral stricture (47, 2.4% at 8years) after a median of 3.7years (IQR 1.9-9.1). Repeated measures mixed models found that onset of hemorrhagic cystitis was associated with change in general health over time. CONCLUSION EBRT for prostate cancer is associated with distinct treatment-related toxicities which can occur many years after treatment and can affect QOL. These results may help men understand the long-term implications of treatment decisions.
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Affiliation(s)
- Peter E Lonergan
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA; Department of Urology, St. James's Hospital, Dublin, Ireland; Department of Surgery, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Avi Baskin
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Scott A Greenberg
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Osama Mohamad
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA; Department of Radiation Oncology, University of California, San Francisco, San Francisco, CA
| | - Samuel L Washington
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA; Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Shoujun Zhao
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Janet E Cowan
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Jeanette M Broering
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Hao G Nguyen
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Matthew R Cooperberg
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA; Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Benjamin N Breyer
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA; Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Peter R Carroll
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
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6
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Barnard J, Liaw A, Gelman J. Long-term follow-up suggests high satisfaction rates for bulbomembranous radiation-induced urethral stenoses treated with anastomotic urethroplasty. World J Urol 2023; 41:1905-1912. [PMID: 37314572 PMCID: PMC10352169 DOI: 10.1007/s00345-023-04429-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/18/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE To analyze patients who underwent anastomotic urethroplasty for radiationinduced bulbomembranous urethral stricture/stenosis (RIS) due to prostate cancer treatment with up to 19 years of follow-up and assess long-term patient reported outcomes (PROMs). Long-term follow-up with the inclusion of urethroplasty specific PROMs is lacking in the available research. METHODS Patients who underwent anastomotic urethroplasty for RIS were identified from 2002 to 2020. Inclusion criteria included completion of 4-month post-operative cystoscopy and PROMs including IPSS, SHIM, MSHQ-EF, 6Q-LUTS, and global satisfaction queries at 4 months. PROMs were assessed annually thereafter, and cystoscopy was performed for adverse change in PROMs or worsening uroflow/PVR parameters. PROMs were compared at pre-op, post-op, and most recent follow-up. RESULTS 23 patients met inclusion criteria. Short-term anatomic success was 95.7%. At a mean follow-up of 73.1 months (9.1-228.9), one late recurrence occurred for an overall success of 91.3%. Significant and sustained objective improvement was identified in voiding scores, quality of life, and urethroplasty specific PROMs. Satisfaction was 91.3% despite sexual side effects, and 95.7% of patients stated they would have surgery again knowing their outcome at a mean of over 6 years' follow up. CONCLUSIONS RIS are challenging problems, but durable symptomatic relief is achievable in well-selected patients. Patients with bulbomembranous RIS should be appropriately counseled regarding the risk of urinary incontinence and sexual side effects after anastomotic urethroplasty. However, long-term success is high, and overall QoL will have sustained subjective improvement in most cases.
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Affiliation(s)
- John Barnard
- West Virginia University School of Medicine, Morgantown, WV, USA.
| | - Aron Liaw
- University of California-Irvine, Irvine, CA, USA
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7
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Sterling J, Rahman SN, Varghese A, Angulo JC, Nikolavsky D. Complications after Prostate Cancer Treatment: Pathophysiology and Repair of Post-Radiation Urethral Stricture Disease. J Clin Med 2023; 12:3950. [PMID: 37373644 DOI: 10.3390/jcm12123950] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Radiation therapy (RT) in the management of pelvic cancers remains a clinical challenge to urologists given the sequelae of urethral stricture disease secondary to fibrosis and vascular insults. The objective of this review is to understand the physiology of radiation-induced stricture disease and to educate urologists in clinical practice regarding future prospective options clinicians have to deal with this condition. The management of post-radiation urethral stricture consists of conservative, endoscopic, and primary reconstructive options. Endoscopic approaches remain an option, but with limited long-term success. Despite concerns with graft take, reconstructive options such as urethroplasties in this population with buccal grafts have shown long-term success rates ranging from 70 to 100%. Robotic reconstruction is augmenting previous options with faster recovery times. Radiation-induced stricture disease is challenging with multiple interventions available, but with successful outcomes demonstrated in various cohorts including urethroplasties with buccal grafts and robotic reconstruction.
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Affiliation(s)
- Joshua Sterling
- Yale School of Medicine, 20 York Street, New Haven, CT 06511, USA
| | - Syed N Rahman
- Yale School of Medicine, 20 York Street, New Haven, CT 06511, USA
| | - Ajin Varghese
- New York College of Osteopathic Medicine, 8000 Old Westbury, Glen Head, NY 11545, USA
| | - Javier C Angulo
- Faculty of Biomedical Sciences, Universidad Europea, 28905 Madrid, Spain
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David R, Buckby A, Kahokehr AA, Lee J, Watson DI, Leung J, O'Callaghan ME. Long term genitourinary toxicity following curative intent intensity-modulated radiotherapy for prostate cancer: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis 2023; 26:8-15. [PMID: 35260794 PMCID: PMC10023565 DOI: 10.1038/s41391-022-00520-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/10/2022] [Accepted: 02/16/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Recent studies have shown that radiation-induced pelvic toxicity often requires urological consultation. However, the 10-year incidence of genitourinary toxicity following intensity-modulated radiotherapy (IMRT) amongst patients with localised prostate cancer remains unclear. Hence, we conducted a systematic review and meta-analysis to determine the incidence of late genitourinary toxicity relying on Radiation Therapy Oncology Group (RTOG) and Common Terminology Criteria for Adverse Events (CTCAE) grade as well as the incidence of specific genitourinary toxicity. Secondary objectives involved quantifing the number of studies reporting 120-month follow-up endpoints, time to event analysis, predictive factors or economic evaluation. METHODS Articles published from January 2008 to December 2021 describing prospective studies were systematically searched in MEDLINE, EMBASE and Cochrane (PROSPERO protocol CRD42019133320). Quality assessment was performed by use of the Cochrane Risk of Bias 2 Tool for RCTs and the Newcastle Ottowa Scale for non-RCTs. Meta-analysis was performed on the 60-month incidence of RTOG and CTCAE Grade ≥2 genitourinary toxicity, haematuria, urinary retention and urinary incontinence. RESULTS We screened 4721 studies and six studies met our inclusion criteria. All included studies involved normofractionation, three included a hypofractionation comparator arm and none involved nodal irradiation. The pooled 60-month cumulative incidence of RTOG and CTCAE Grade ≥2 genitourinary toxicity were 17% (95% CI: 5-20%, n = 678) and 33% (95% CI: 27-38%, n = 153), respectively. The pooled 60-month cumulative incidence of Haematuria was 5% (95% CI: -4-14%, n = 48), Urinary incontinence 12% (95% CI: 6-18%, n = 194), Urinary retention 24% (95% CI: 9-40%, n = 10). One study reported time to event analyses, one reported predictive factors, no studies reported economic analysis or 120-month toxicity. There was considerable heterogeneity amongst the studies. CONCLUSION There are few high-quality studies reporting 60-month toxicity rates after IMRT. Conservative estimates of 60-month toxicity rates are high and there is need for longer follow-up and consistent toxicity reporting standards.
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Affiliation(s)
- Rowan David
- College of Medicine and Public Health, Bedford Park, Flinders University, Bedford, SA, Australia.
- Department of Urology, SA Health, Flinders Medical Centre, Bedford, SA, Australia.
| | - Alex Buckby
- Department of Urology, SA Health, Flinders Medical Centre, Bedford, SA, Australia
| | - Arman A Kahokehr
- College of Medicine and Public Health, Bedford Park, Flinders University, Bedford, SA, Australia
- Discipline of Medicine, Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, SA, Australia
| | - Jason Lee
- College of Medicine and Public Health, Bedford Park, Flinders University, Bedford, SA, Australia
- Department of Urology, SA Health, Flinders Medical Centre, Bedford, SA, Australia
| | - David I Watson
- College of Medicine and Public Health, Bedford Park, Flinders University, Bedford, SA, Australia
| | - John Leung
- College of Medicine and Public Health, Bedford Park, Flinders University, Bedford, SA, Australia
- GenesisCare, Adelaide, SA, Australia
| | - Michael E O'Callaghan
- College of Medicine and Public Health, Bedford Park, Flinders University, Bedford, SA, Australia
- Department of Urology, SA Health, Flinders Medical Centre, Bedford, SA, Australia
- Discipline of Medicine, Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, SA, Australia
- South Australian Prostate Cancer Clinical Outcomes Collaborative, Adelaide, SA, Australia
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Prostate cancer risk, screening and management in patients with germline BRCA1/2 mutations. Nat Rev Urol 2023; 20:205-216. [PMID: 36600087 DOI: 10.1038/s41585-022-00680-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 01/05/2023]
Abstract
Mutations in the BRCA1 and BRCA2 tumour suppressor genes are associated with prostate cancer risk; however, optimal screening protocols for individuals with these mutations have been a subject of debate. Several prospective studies of prostate cancer incidence and screening among BRCA1/2 mutation carriers have indicated at least a twofold to fourfold increase in prostate cancer risk among carriers of BRCA2 mutations compared with the general population. Moreover, BRCA2 mutations are associated with more aggressive, high-grade disease characteristics at diagnosis, more aggressive clinical behaviour and greater prostate cancer-specific mortality. The risk for BRCA1 mutations seems to be attenuated compared with BRCA2. Prostate-specific antigen (PSA) measurement or prostate magnetic resonance imaging (MRI) alone is an imperfect indicator of clinically significant prostate cancer; therefore, BRCA1/2 mutation carriers might benefit from refined risk stratification strategies. However, the long-term impact of prostate cancer screening is unknown, and the optimal management of BRCA1/2 carriers with prostate cancer has not been defined. Whether timely localized therapy can improve overall survival in the screened population is uncertain. Long-term results of prospective studies are awaited to confirm the optimal screening strategies and benefits of prostate cancer screening among BRCA1/2 mutation carriers, and whether these approaches ultimately have a positive impact on survival and quality of life in these patients.
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Citrin DE, Schott E, Salerno K, Ning H, Pinto PA, Wood BJ, Lindenberg L, Mena E, Turkbey B. Successful Stereotactic Body Radiation Therapy for Postbrachytherapy Prostate Recurrence and Penile Bulb Metastasis. Adv Radiat Oncol 2022; 7:100860. [PMID: 35647400 PMCID: PMC9133405 DOI: 10.1016/j.adro.2021.100860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/08/2021] [Indexed: 12/01/2022] Open
Affiliation(s)
- Deborah E. Citrin
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Erica Schott
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Kilian Salerno
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Holly Ning
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Peter A. Pinto
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | | | - Liza Lindenberg
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Esther Mena
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Baris Turkbey
- Molecular Imaging Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
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11
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MR Imaging in Real Time Guiding of Therapies in Prostate Cancer. Life (Basel) 2022; 12:life12020302. [PMID: 35207589 PMCID: PMC8878909 DOI: 10.3390/life12020302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/31/2022] [Accepted: 02/11/2022] [Indexed: 11/22/2022] Open
Abstract
Magnetic resonance imaging (MRI)-guided therapy for prostate cancer (PCa) aims to reduce the treatment-associated comorbidity of existing radical treatment, including radical prostatectomy and radiotherapy. Although active surveillance has been used as a conservative method to reduce overtreatment, there is a growing demand for less morbidity and personalized (focal) treatment. The development of multiparametric MRI was of real importance in improving the detection, localization and staging of PCa. Moreover, MRI has been useful for lesion targeting within the prostate, as it is used in the guidance of prostate biopsies, by means of cognitive registration, MRI-ultrasound fusion guidance or direct in-bore MRI-guidance. With regard to PCa therapies, MRI is used for precise probe placement into the lesion and to accurately monitor the treatment in real-time. Moreover, advances in MR-compatible thermal ablation allow for noninvasive real-time temperature mapping during treatment. In this review, we present an overview of the current status of MRI-guided therapies in PCa, focusing on cryoablation, focal laser ablation, high intensity focused ultrasound and transurethral ultrasound ablation. We explain the important role of MRI in the evaluation of the completeness of the ablation and during follow-up. Finally, we will discuss the challenges and future development inherent to these new technologies.
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12
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Faithfull S, Cockle-Hearne J, Lemanska A, Otter S, Skene SS. Randomised controlled trial to investigate the effectiveness of the symptom management after radiotherapy (SMaRT) group intervention to ameliorate lower urinary tract symptoms in men treated for prostate cancer. Support Care Cancer 2021; 30:3165-3176. [PMID: 34932140 PMCID: PMC8857109 DOI: 10.1007/s00520-021-06749-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/07/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE To evaluate the effectiveness of the symptom management after radiotherapy (SMaRT) group intervention to improve urinary symptoms in men with prostate cancer. METHODS The randomised controlled trial (RCT) recruited men from one radiotherapy centre in the UK after curative radiotherapy or brachytherapy and with moderate to severe urinary symptoms defined as scores ≥ 8 on the International Prostate Symptom Score (IPSS) questionnaire. Sixty-three men were randomised either; to SMaRT, a 10-week symptom-management intervention including group support, education, pelvic floor muscle exercises, or a care-as-usual group. The primary outcome was the IPSS at 6 months from baseline assessment. Secondary outcomes were IPSS at 3 months, and International Continence Society Male Short Form (ICS), European Organisation for Research and Treatment of Cancer Quality of Life prostate scale (EORTC QLQ-PR25), EORTC QLQ-30 and Self-Efficacy for Symptom Control Inventory (SESCI) at 3 and 6 months from baseline. Analysis of covariance (ANCOVA) was used to analyse the effect of the intervention. RESULTS SMaRT group intervention did not improve urinary symptoms as measured by IPSS at 6-months. The adjusted difference was - 2.5 [95%CI - 5.0 to 0.0], p = 0.054. Significant differences were detected at 3 months in ICS voiding symptoms (- 1.1 [- 2.0 to - 0.2], p = 0.017), ICS urinary incontinence (- 1.0 [- 1.8 to - 0.1], p = 0.029) and SESCI managing symptoms domain (13.5 [2.5 to 24.4], p = 0.017). No differences were observed at 6 months. CONCLUSIONS SMaRT group intervention provided short-term benefit in urinary voiding and continence and helped men manage symptoms but was not effective long term.
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Affiliation(s)
- Sara Faithfull
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, Surrey, UK.
| | - Jane Cockle-Hearne
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, Surrey, UK
| | - Agnieszka Lemanska
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, Surrey, UK
| | - Sophie Otter
- Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX, Surrey, UK
| | - Simon S Skene
- Surrey Clinical Trials Unit, University of Surrey, Egerton Road, Guildford, GU2 7XP, UK
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13
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Hoeh B, Müller SC, Kluth LA, Wenzel M. Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review. Front Surg 2021; 8:688394. [PMID: 34434956 PMCID: PMC8381645 DOI: 10.3389/fsurg.2021.688394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/09/2021] [Indexed: 12/24/2022] Open
Abstract
The purpose of this narrative review is to discuss and highlight recently published studies regarding the surgical management of patients suffering from prostate cancer treatment complications. Focus will be put on the recalcitrant and more complex cases which might lead to urinary diversion as a definite, last resort treatment. It is in the nature of every treatment, that complications will occur and be bothersome for both patients and physicians. A small percentage of patients following prostate cancer treatment (radical prostatectomy, radiation therapy, or other focal therapies) will suffer side effects and thus, will experience a loss of quality of life. These side effects can persist for months and even years. Often, conservative management strategies fail resulting in recalcitrant recurrences. Prostate cancer patients with "end-stage bladder," "devastated outlet," or a history of multiple failed interventions, are fortunately rare, but can be highly challenging for both patients and Urologists. In a state of multiple previous surgical procedures and an immense psychological strain for the patient, urinary diversion can offer a definite, last resort surgical solution for this small group of patients. Ideally, they should be transferred to centers with experience in this field and a careful patient selection is needed. As these cases are highly complex, a multidisciplinary approach is often necessary in order to guarantee an improvement of quality of life.
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Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
| | - Stefan C Müller
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, QC, Canada
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14
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Lumen N, Campos-Juanatey F, Greenwell T, Martins FE, Osman NI, Riechardt S, Waterloos M, Barratt R, Chan G, Esperto F, Ploumidis A, Verla W, Dimitropoulos K. European Association of Urology Guidelines on Urethral Stricture Disease (Part 1): Management of Male Urethral Stricture Disease. Eur Urol 2021; 80:190-200. [PMID: 34059397 DOI: 10.1016/j.eururo.2021.05.022] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/15/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of male urethral stricture disease. EVIDENCE ACQUISITION The panel performed a literature review on these topics covering a time frame between 2008 and 2018, and used predefined inclusion and exclusion criteria for the literature to be selected. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on a review of the available literature and after panel discussion. EVIDENCE SYNTHESIS Management of male urethral strictures has extensively been described in literature. Nevertheless, few well-designed studies providing high level of evidence are available. In well-resourced countries, iatrogenic injury to the urethra is one of the most common causes of strictures. Asymptomatic strictures do not always need active treatment. Endoluminal treatments can be used for short, nonobliterative strictures at the bulbar and posterior urethra as first-line treatment. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques, and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates. CONCLUSIONS Management of male urethral strictures is complex, and a multitude of techniques are available. Selection of the appropriate technique is crucial, and these guidelines provide relevant recommendations. PATIENT SUMMARY Injury to the urethra by medical interventions is one of the most common reasons of male urethral stricture disease in well-resourced countries. Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. These guidelines, developed based on an extensive literature review, aim to guide physicians in the selection of the appropriate technique(s) to treat a specific type of urethral stricture.
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Affiliation(s)
- Nicolaas Lumen
- Division of Urology, Gent University Hospital, Gent, Belgium.
| | | | - Tamsin Greenwell
- Department of Urology, University College London Hospital, London, UK
| | - Francisco E Martins
- Department of Urology, Santa Maria University Hospital, University of Lisbon, Lisbon, Portugal
| | - Nadir I Osman
- Department of Urology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Silke Riechardt
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marjan Waterloos
- Division of Urology, Gent University Hospital, Gent, Belgium; Division of Urology, AZ Maria Middelares, Gent, Belgium
| | - Rachel Barratt
- Department of Urology, University College London Hospital, London, UK
| | - Garson Chan
- Division of Urology, University of Saskatchewan, Saskatoon, Canada
| | - Francesco Esperto
- Department of Urology, Campus Biomedico University of Rome, Rome, Italy
| | | | - Wesley Verla
- Division of Urology, Gent University Hospital, Gent, Belgium
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15
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Management of Lower Urinary Tract Symptoms after Prostate Radiation. Curr Urol Rep 2021; 22:37. [PMID: 34041611 DOI: 10.1007/s11934-021-01048-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW To present urologists with guidance on how to approach and manage lower urinary tract symptoms (LUTS) in patients who have undergone radiation therapy (RT) for prostate cancer. RECENT FINDINGS There are few studies that specifically examine treatment approaches for LUTS in patients who have undergone prostate cancer RT. LUTS after prostate RT are unique when compared to de novo LUTS. Understanding these distinctions is important for urologists' practice as well as patients' quality of life. Discussion of the risks and management of post-RT LUTS should be included in the shared decision-making process when counseling patients on various treatment options for prostate cancer. Further studies evaluating treatments for storage and voiding symptoms after RT are needed to help guide future care.
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16
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Waterloos M, Martins F, Verla W, Kluth LA, Lumen N. Current Management of Membranous Urethral Strictures Due to Radiation. Front Surg 2021; 8:635060. [PMID: 33748181 PMCID: PMC7969877 DOI: 10.3389/fsurg.2021.635060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/01/2021] [Indexed: 11/13/2022] Open
Abstract
Radiotherapy is a frequently used treatment for prostate cancer. It does not only causes the intended damage to cancer cells, but also affects healthy surrounding tissue. As a result radiation-induced urethral strictures occur in 2.2% of prostate cancer patients. Management of urethral strictures is challenging due to the presence of poor vascularized tissue for reconstruction and the proximity of the sphincter, which can impair the functional outcome. This review provides a literature overview of risk factors, diagnostics and management of radiation-induced urethral strictures.
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Affiliation(s)
- Marjan Waterloos
- Department of Urology, AZ Maria Middelares Ghent, Ghent, Belgium
- Department of Urology, University Hospital Ghent, Ghent, Belgium
| | - Francisco Martins
- Department of Urology, University of Lisbon School of Medicine, Lisbon, Portugal
| | - Wesley Verla
- Department of Urology, University Hospital Ghent, Ghent, Belgium
| | - Luis Alex Kluth
- Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Nicolaas Lumen
- Department of Urology, University Hospital Ghent, Ghent, Belgium
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17
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Sapienza LG, Ning MS, Carvalho EDF, Spratt D, Calsavara VF, McLaughlin PW, Gomes MJL, Baiocchi G, Abu-Isa E. Efficacy and Incontinence Rates After Urethroplasty for Radiation-induced Urethral Stenosis: A Systematic Review and Meta-analysis. Urology 2021; 152:109-116. [PMID: 33631205 DOI: 10.1016/j.urology.2021.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/30/2020] [Accepted: 02/05/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To estimate the efficacy of urethroplasty and rates of de novo stress urinary incontinence (SUI) in the specific setting of radiation-induced urethral stenosis. METHODS A systematic search of databases (PubMed and EMBASE) was performed between 1980-2019 (CRD42020144845). Inclusion criteria were: (1) prior pelvic radiotherapy; (2) surgical urethroplasty; (3) rates of successful treatment and/or SUI development and (4) total case number provided. The pooled summary of stenosis resolution rate and SUI were calculated using the random-effects model weighted by the inverse variance. Accessory analyses were performed by reconstructive technique and type of RT. RESULTS Ninety-six studies were identified, of which 8 retrospective studies met inclusion criteria, comprising 256 patients. The proportion of cases treated with external beam RT (EBRT), brachytherapy (BT), or combination (EBRT+BT) were 52%, 33%, and 15%, respectively, of studies that specified modality. Most strictures involved the bulbomembranous region (n = 212; 83%). Sixty-one percent of cases (n = 157) entailed primary anastomosis, while the remainder underwent augmentation reconstruction (graft or flap). The mean follow-up time after urethroplasty varied from 10 to 50.5 months. The pooled stenosis resolution rate was 80% (95% CI: 74%-86%). There were no significant associations between stenosis resolution rate and reconstructive technique (rho=0.20, P = .74) or RT modality (rho=-0.31, P = .53). Fifty-three cases developed subsequent SUI, with a pooled complication rate of 19% (95% CI: 10%-31%). CONCLUSIONS Urethroplasty after radiation-induced urethral stenosis is effective for 80% of cases, independent of prior RT modality or urethroplasty technique; however, 1 out of every 5 patients develops SUI post-procedure.
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Affiliation(s)
| | - Matthew Stephen Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Daniel Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | | | - Maria Jose Leite Gomes
- Department of Radiation Oncology, Hospital Federal dos Servidores do Estado (HFSE-RJ), Rio de Janeiro, RJ, Brazil
| | - Glauco Baiocchi
- Department of Gynecologic Oncology, A.C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Eyad Abu-Isa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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18
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Voelzke BB, Leddy LS, Myers JB, Breyer BN, Alsikafi NF, Broghammer JA, Elliott SP, Vanni AJ, Erickson BA, Buckley JC, Zhao LC, Wright T, Rourke KF. Multi-institutional Outcomes and Associations After Excision and Primary Anastomosis for Radiotherapy-associated Bulbomembranous Urethral Stenoses Following Prostate Cancer Treatment. Urology 2021; 152:117-122. [PMID: 33556448 DOI: 10.1016/j.urology.2020.11.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the outcomes of excision and primary anastomosis (EPA) for radiation-associated bulbomembranous stenoses using a multi-institutional analysis. The treatment of radiation-associated urethral stenosis is typically complex owing to the adverse impact of radiation on adjacent tissue. METHODS An IRB-approved multi-institutional retrospective review was performed on patients who underwent EPA for bulbomembranous urethral stenosis following prostate radiotherapy. Preoperative patient demographics, operative technique, and postoperative outcomes were abstracted from 1/2007-6/2018. Success was defined as voiding per urethra without the need for endoscopic treatment and a minimum follow-up of 12 months. RESULTS One hundred and thirty-seven patients from 10 centers met study criteria with a mean age of 69.3 years (50-86), stenosis length of 2.3 cm (1-5) and an 86.9% (119/137) success rate at a mean follow-up 32.3 months (12-118). Univariate Cox regression analysis identified increasing patient age (P = .02), stricture length (P <.0001) and combined modality radiotherapy (P = .004) as factors associated with stricture recurrence while body mass index (P = .79), diabetes (P = .93), smoking (P = .62), failed endoscopic treatment (P = .08) and gracilis muscle use (P = .25) were not. On multivariate analysis, increasing patient age (H.R.1.09, 95%CI 1.01-1.16; P = .02) and stenosis length (H.R.2.62, 95%CI 1.49-4.60; P = .001) remained associated with recurrence. Subsequent artificial urinary sphincter was performed in 30 men (21.9%), of which 25 required a transcorporal cuff and 5 developed cuff erosion. CONCLUSIONS EPA for radiation-associated urethral stenosis effectively provides unobstructed instrumentation-free voiding. However, increasing stenosis length and age are independently associated with surgical failure. Patients should be counseled that further surgery for incontinence may be necessary.
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Affiliation(s)
- B B Voelzke
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - L S Leddy
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - J B Myers
- Division of Urology, University of Utah, Salt Lake City, UT
| | - B N Breyer
- Department of Urology, University of California-San Francisco Medical Center, San Francisco, CA
| | | | - J A Broghammer
- Department of Urology, University of Kansas Medical Center, Kansas City, KS
| | - S P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - A J Vanni
- Department of Urology, Lahey Clinic, Burlington, MA
| | - B A Erickson
- Department of Urology, University of Iowa, Iowa City, IA
| | - J C Buckley
- Department of Urology, University of California-San Diego, San Diego, CA
| | - L C Zhao
- Department of Urology, New York University Langone Health, New York City, NY
| | - T Wright
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | - K F Rourke
- Division of Urology, University of Alberta, Edmonton, AB, Canada.
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19
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Lower Urinary Tract Symptoms in Prostate Cancer Patients Treated With Radiation Therapy: Past and Present. Int Neurourol J 2021; 25:119-127. [PMID: 33504132 PMCID: PMC8255820 DOI: 10.5213/inj.2040202.101] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/05/2020] [Indexed: 12/16/2022] Open
Abstract
The incidence of prostate cancer (PCa) is increasing concomitantly with population aging. Accordingly, interest in radiation therapy (RT) and the frequency of RT are also increasing. The types of RT can be broadly divided into external beam RT (EBRT), brachytherapy (BT), and combination therapy (EBRT+BT). Lower urinary tract symptoms (LUTS) after RT for the treatment of PCa are common; however, there are few reviews on the relationship between RT and LUTS. Herein, we review the causes and incidence of LUTS, as well as the evaluation and treatment options. Because of the reported risks of RT, patients undergoing RT should be counseled regarding the challenges of treatment and informed that they may have higher failure rates than nonirradiated patients. Moreover, thorough evaluation and treatment strategies are needed to support treatment recommendations. With a review of the existing literature, this narrative article provides an overview to aid urologists in treating patients presenting with complications associated with RT for the treatment of PCa. Further research is required to provide evidence of the effectiveness and feasibility of the management approach to the care of patients with LUTS after RT for the treatment of PCa.
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20
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Bosch R, McCloskey K, Bahl A, Arlandis S, Ockrim J, Weiss J, Greenwell T. Can radiation-induced lower urinary tract disease be ameliorated in patients treated for pelvic organ cancer: ICI-RS 2019? Neurourol Urodyn 2020; 39 Suppl 3:S148-S155. [PMID: 32662556 PMCID: PMC7496485 DOI: 10.1002/nau.24380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/18/2020] [Indexed: 12/15/2022]
Abstract
Aims This article reviews the clinical outcomes and basic science related to negative effects of radiotherapy (RT) on the lower urinary tract (LUT) when used to treat pelvic malignancies. Methods The topic was discussed at the 2019 meeting of the International Consultation on Incontinence―Research Society during a “think tank” session and is summarized in the present article. Results RT is associated with adverse effects on the LUT, which may occur during treatment or which can develop over decades posttreatment. Here, we summarize the incidence and extent of clinical symptoms associated with several modes of delivery of RT. RT impact on normal tissues including urethra, bladder, and ureters is discussed, and the underlying biology is examined. We discuss innovative in vivo methodologies to mimic RT in the laboratory and their potential use in the elucidation of mechanisms underlying radiation‐associated pathophysiology. Finally, emerging questions that need to be addressed through further research are proposed. Conclusions We conclude that RT‐induced negative effects on the LUT represent a significant clinical problem. Although this has been reduced with improved methods of delivery to spare normal tissue, we need to (a) discover better approaches to protect normal tissue and (b) develop effective treatments to reverse radiation damage.
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Affiliation(s)
- Ruud Bosch
- Department of Urologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karen McCloskey
- Centre for Cancer Research and Cell Biology, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Amit Bahl
- Bristol Cancer Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Salvador Arlandis
- Functional and Reconstructive Urology Section, Hospital Universitari Politècnic La Fe, Valencia, Spain
| | - Jeremy Ockrim
- Female, Functional and Restorative Urology Unit, University College London Hospitals, London, UK
| | - Jeffrey Weiss
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Tamsin Greenwell
- Female, Functional and Restorative Urology Unit, University College London Hospitals, London, UK
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21
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Significant Management Variability of Urethral stricture Disease in United States: Data from the AUA Quality (AQUA) Registry. Urology 2020; 146:265-270. [DOI: 10.1016/j.urology.2020.07.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/26/2020] [Accepted: 07/29/2020] [Indexed: 01/26/2023]
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Narang K, Kadian M, Venkatesan K, Mishra S, Bisht S, Gupta D, Banerjee S, Kataria T. Phase I/II Study of Extreme Hypofractionated Stereotactic Body Radiation Therapy Boost to Prostate for Locally Advanced, Node-Positive and Oligometastatic Cancer. Cureus 2020; 12:e11751. [PMID: 33403181 PMCID: PMC7773303 DOI: 10.7759/cureus.11751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Introduction: Stereotactic body radiation therapy (SBRT) is increasingly being utilized to deliver escalated radiation doses for improving outcomes in various malignancies. We analyzed our cohort of locally advanced, node-positive, and bone oligometastatic prostate cancer patients, that were treated with a combination of pelvic RT using conventional fractionation (CF) and SBRT boost to prostate using extreme hypofractionation (EH), along with hormone therapy (HT). Materials and Methods: Outcomes of 44 prospectively treated patients were analyzed. Volumetric modulated arc therapy (VMAT) was utilized to deliver a dose of 45 Gy to pelvic nodal region, 50 Gy to prostate, and 54-56 Gy to gross nodes in 25 fractions. EH boost 18 Gy in three fractions was delivered to the prostate using CyberKnife (Accuray, Sunnyvale, CA, USA) SBRT. Bone oligometastasis, if any, were treated to a dose of 16 Gy in two fractions, delivered on weekends. Serum prostate-specific antigen (PSA), multi-parametric magnetic resonance imaging (MRI) of pelvis, and prostate-specific membrane antigen-positron emission tomography (PSMA-PET) were used for response assessment during follow-up. HT was given as per standard guidelines. Results: There were 33 (75%) locally advanced, nine (20.5%) node-positive, and two (4.5%) oligometastatic cases. At a median follow-up of 63.5 months, the five-year progression-free survival (PFS) was 88.2%, biochemical PFS (bPFS) was 91.4% and overall survival (OS) was 96.9%. Grade III or greater acute genitourinary and gastrointestinal toxicity was 2.3% each, and late toxicity was 4.5% and 0%, respectively. Conclusion: Excellent five-year outcomes can be attained even for locally advanced, node-positive and bone oligometastatic prostate cancer, by means of dose-escalation using EH-SBRT boost to the prostate.
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Affiliation(s)
- Kushal Narang
- Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurugram, IND
| | - Mohit Kadian
- Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurugram, IND
| | - K Venkatesan
- Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurugram, IND
| | - Saumyaranjan Mishra
- Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurugram, IND
| | - Shyam Bisht
- Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurugram, IND
| | - Deepak Gupta
- Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurugram, IND
| | - Susovan Banerjee
- Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurugram, IND
| | - Tejinder Kataria
- Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurugram, IND
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23
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Policastro CG, Simhan J, Martins FE, Lumen N, Venkatesan K, Angulo JC, Gupta S, Rusilko P, Ramírez Pérez EA, Redger K, Flynn BJ, Hughes M, Blakely S, Nikolavsky D. A multi-institutional critical assessment of dorsal onlay urethroplasty for post-radiation urethral stenosis. World J Urol 2020; 39:2669-2675. [PMID: 32944804 DOI: 10.1007/s00345-020-03446-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 09/05/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To critically evaluate a multi-institutional patient cohort undergoing Dorsal-Onlay Buccal Mucosal Graft Urethroplasty (D-BMGU) for recurrent post-radiation posterior urethral stenosis. METHODS Retrospective multi-institutional review of patients with posterior urethral stenosis from 10 institutions between 2010-2019 was performed. Patients with at least 1-year follow-up were assessed. Patient demographics, stenosis characteristics, peri-operative outcomes, and post-operative clinical and patient-reported outcomes were analyzed. The primary outcomes were stenosis recurrence and de-novo stress urinary incontinence (SUI). Secondary outcomes were changes in voiding, sexual function, and patient-reported satisfaction. RESULTS Seventy-nine men with post-radiation urethral stenosis treated with D-BMGU met inclusion criteria. Median age and stenosis length were 72 years, (IQR 66-75), and 3.0 cm (IQR 2.5-4 cm), respectively. Radiation modalities included: 36 (45.6%) external beam radiotherapy (EBRT), 13 (16.5%) brachytherapy (BT), 10 (12.7%) combination EBRT/BT, and 20 (25.3%) EBRT/radical prostatectomy. At a median follow-up of 21 months (IQR 13-40), 14 patients (17.7%) had stenosis recurrence. Among 37 preoperatively-continent patients, 3 men (8.1%) developed de-novo SUI following dorsal onlay urethroplasty. Of 29 patients with preoperative SUI all but one remained incontinent post-operatively (96.6%). Following repair, patients experienced significant improvement in PVR (92.5 to 26 cc, p = 0.001) and Uroflow (4.6 to 15.9 cc/s, p = 0.001), and high overall satisfaction, with 91.9% reporting a GRA of + 2 or better). CONCLUSION Dorsal onlay buccal mucosa graft urethroplasty is a safe and feasible technique in patients with post-radiation posterior urethral stenosis. This non-transecting approach may confer low rates of de-novo SUI. Further research is needed to compare this technique with excisional urethroplasty.
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Affiliation(s)
- Connor G Policastro
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA
| | - Jay Simhan
- Einstein Medical Center/Fox Chase Cancer Center, Philadelphia, PA, USA
| | | | | | - Krishnan Venkatesan
- Georgetown University, Washington, DC, USA.,MedStar Washington Hospital Center, Washington, DC, USA
| | - Javier C Angulo
- Departemento Clinico, Universidad Europea de Madrid, Hospital Universitario de Getafe, Madrid, Spain
| | | | | | | | | | | | - Michael Hughes
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA
| | - Stephen Blakely
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA
| | - Dmitriy Nikolavsky
- Department of Urology, SUNY Upstate Medical University, 750 E Adams St, CWB 2nd Floor, Syracuse, NY, 13210, USA.
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Development and Validation of A Male Anterior Urethral Stricture Classification System. Urology 2020; 143:241-247. [DOI: 10.1016/j.urology.2020.03.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 01/20/2023]
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Doiron RC, Witten J, Rourke KF. The scope, presentation, and management of genitourinary complications in patients presenting with high-grade urethral complications after radiotherapy for prostate cancer. Can Urol Assoc J 2020; 15:E6-E10. [PMID: 32701436 DOI: 10.5489/cuaj.6599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The scope of complications arising after radiotherapy (RT) treatment for prostate cancer is under-recognized and not well-described. The objective of this study is to describe the presentation, scope, and management of genitourinary (GU) complications in patients referred for high-grade urethral complications or sphincter weakness incontinence after prostate RT. METHODS A retrospective review was performed of patients referred to a reconstructive urologist for management of grade 4 urethral complications and sphincter weakness incontinence after prostate RT from December 2004 to December 2015. Patients' signs, symptoms, complications, and treatments are described. RESULTS A total of 120 patients were identified, with a mean age of 67.8 years; 55.8% (n=67) received external beam radiotherapy (EBRT), 38.3% (n=46) brachytherapy (BT), and 5.8% (n=7) combination RT. The mean time to first complication after RT was 57.7 months (1-219) and number of complications per patient was 5.1±2.2. The most common associated complications were urethral stenosis (n=106, 88.3%), sphincter weakness urinary incontinence (n=55, 45.8%), radiation cystitis (n=61, 50.8%), refractory storage lower urinary tract symptoms (n=106, 88.3%), GU pain (n=28, 23.3%), and prostate necrosis/abscess (n=17, 14.2%). Patients required a mean of 7.4±4.4 treatments over a 33-month period, including urethral dilation/urethrotomy (n= 93, 77.5%), urethroplasty (n=53, 44.2%), transurethral resection (n=52, 43.3%), cystolithopaxy (n=14, 11.7%), artificial urinary sphincter (n=8, 6.7%), and urinary diversion (n=8, 6.7%). Patients with RT combined with other modalities had more complications (6.2 vs. 4.2, p=0.001), higher rates of incontinence (93.8% vs. 29.5%, p=0.001), necrosis (31.3% vs. 8.0%, p=0.003), erectile dysfunction (84.4% vs. 51.1%, p=0.001), and hematuria (59.4% vs. 36.4%, p=0.04). CONCLUSIONS Urethral complications related to prostate RT are seldom an isolated problem and require a substantial amount of urological resources and interventions.
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Affiliation(s)
- R Christopher Doiron
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jon Witten
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
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Vetterlein MW, Kluth LA, Zumstein V, Meyer CP, Ludwig TA, Soave A, Riechardt S, Engel O, Dahlem R, Fisch M, Rosenbaum CM. Buccal mucosal graft urethroplasty for radiation-induced urethral strictures: an evaluation using the extended Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM). World J Urol 2020; 38:2863-2872. [PMID: 32067075 PMCID: PMC7644515 DOI: 10.1007/s00345-020-03102-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/21/2020] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES To evaluate objective treatment success and subjective patient-reported outcomes in patients with radiation-induced urethral strictures undergoing single-stage urethroplasty. PATIENTS AND METHODS Monocentric study of patients who underwent single-stage ventral onlay buccal mucosal graft urethroplasty for a radiation-induced stricture between January 2009 and December 2016. Patients were characterized by descriptive analyses. Kaplan-Meier estimates were employed to plot recurrence-free survival. Recurrence was defined as any subsequent urethral instrumentation (dilation, urethrotomy, urethroplasty). Patient-reported functional outcomes were evaluated using the validated German extension of the Urethral Stricture Surgery Patient-Reported Outcome Measure (USS PROM). RESULTS Overall, 47 patients were available for final analyses. Median age was 70 (IQR 65-74). Except for two, all patients had undergone pelvic radiation therapy for prostate cancer. Predominant modality was external beam radiation therapy in 70% of patients. Stricture recurrence rate was 33% at a median follow-up of 44 months (IQR 28-68). In 37 patients with available USS PROM data, mean six-item LUTS score was 7.2 (SD 4.3). Mean ICIQ sum score was 9.8 (SD 5.4). Overall, 53% of patients reported daily leaking and of all, 26% patients underwent subsequent artificial urinary sphincter implantation. Mean IIEF-EF score was 4.4 (SD 7.1), indicating severe erectile dysfunction. In 38 patients with data regarding the generic health status and treatment satisfaction, mean EQ-5D index score and EQ VAS score was 0.91 (SD 0.15) and 65 (SD 21), respectively. Overall, 71% of patients were satisfied with the outcome. CONCLUSION The success rate and functional outcome after BMGU for radiation-induced strictures were reasonable. However, compared to existing long-term data on non-irradiated patients, the outcome is impaired and patients should be counseled accordingly.
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Affiliation(s)
- Malte W Vetterlein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Luis A Kluth
- Department of Urology, University Medical Center Frankfurt, Frankfurt (Main), Germany
| | - Valentin Zumstein
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Urology, Cantonal Medical Center St. Gallen, St. Gallen, Switzerland
| | - Christian P Meyer
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tim A Ludwig
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Armin Soave
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Silke Riechardt
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Oliver Engel
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Roland Dahlem
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Clemens M Rosenbaum
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Department of Urology, Asklepios Medical Center Barmbek, Hamburg, Germany
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Long-term outcomes of anastomotic urethroplasty for radiation-induced strictures. World J Urol 2019; 38:3055-3060. [DOI: 10.1007/s00345-019-03028-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 11/18/2019] [Indexed: 01/10/2023] Open
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28
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Chao M, Bolton D, Lim Joon D, Chan Y, Lawrentschuk N, Ho H, Spencer S, Wasiak J, Guerrieri M, Ow D, Troy A, Pham T, Sengupta S, Tan A, McMillan K, Koufogiannis G, Foroudi F, Ng M, Khoo V. High dose rate brachytherapy boost for prostate cancer: Biochemical control and the impact of transurethral resection of the prostate and hydrogel spacer insertion on toxicity outcomes. J Med Imaging Radiat Oncol 2019; 63:415-421. [DOI: 10.1111/1754-9485.12882] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 03/05/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Michael Chao
- The Austin Hospital Heidelberg Australia
- Ringwood Private Hospital Melbourne Victoria Australia
- University of Melbourne Melbourne Victoria Australia
| | - Damien Bolton
- The Austin Hospital Heidelberg Australia
- Ringwood Private Hospital Melbourne Victoria Australia
- University of Melbourne Melbourne Victoria Australia
| | | | - Yee Chan
- The Austin Hospital Heidelberg Australia
- Ringwood Private Hospital Melbourne Victoria Australia
| | - Nathan Lawrentschuk
- The Austin Hospital Heidelberg Australia
- University of Melbourne Melbourne Victoria Australia
| | - Huong Ho
- Genesis Cancer Care Victoria Ringwood Australia
| | | | - Jason Wasiak
- The Austin Hospital Heidelberg Australia
- University of Melbourne Melbourne Victoria Australia
| | | | - Darren Ow
- The Austin Hospital Heidelberg Australia
| | - Andrew Troy
- The Austin Hospital Heidelberg Australia
- Ringwood Private Hospital Melbourne Victoria Australia
| | - Trung Pham
- The Valley Private Hospital Melbourne Victoria Australia
| | | | - Alwin Tan
- The Bays Hospital Mornington Victoria Australia
| | - Kevin McMillan
- Ringwood Private Hospital Melbourne Victoria Australia
- The Box Hill Hospital Melbourne Victoria Australia
| | | | - Farshad Foroudi
- The Austin Hospital Heidelberg Australia
- University of Melbourne Melbourne Victoria Australia
| | - Michael Ng
- Ringwood Private Hospital Melbourne Victoria Australia
| | - Vincent Khoo
- The Austin Hospital Heidelberg Australia
- University of Melbourne Melbourne Victoria Australia
- Monash University Melbourne Victoria Australia
- Royal Marsden Hospital London UK
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Guimond E, Lavallée MC, Foster W, Vigneault É, Guay K, Martin AG. Impact of a dominant intraprostatic lesion (DIL) boost defined by sextant biopsy in permanent I-125 prostate implants on biochemical disease free survival (bDFS) and toxicity outcomes. Radiother Oncol 2019; 133:62-67. [PMID: 30935583 DOI: 10.1016/j.radonc.2018.12.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/22/2018] [Accepted: 12/30/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND PURPOSE To compare bDFS and toxicity outcomes in a population of intermediate risk prostate cancer patients treated using I-125 LDR brachytherapy with or without DIL boost based on multiple core biopsy maps. MATERIALS AND METHODS Between January 2005 and December 2013, all our intermediate risk prostate cancer patients treated with LDR I-125 brachytherapy were reviewed. All patients were given 144 Gy to the prostate. A pathologic DIL distribution (defined by sextant biopsy) was contoured prospectively prior to planning, to be covered by the 150% isodose line. Of the 165 patients treated, 55 received a DIL boost. Patients completed prospectively the IPSS questionnaire, a sexual and bowel function questionnaire. Gastro-intestinal toxicities were graded according to CTCAE v4.03. A patient was considered to have erectile dysfunction if he was unable to achieve erection to perform intercourse. BDFS was determined according to the Phoenix consensus definitions. RESULTS The median follow-up was 78 months. The estimated 7-year bDFS rate was 96% (95% CI, 74-99%) in the DIL group versus 89% (95% CI, 79-94%) in the control group (p = 0.188). There was no difference between groups in urinary, gastro-intestinal or sexual toxicities up to 5 years of follow-up. There was no difference in urinary obstruction with catheterization between DIL versus control groups (3,6 vs 2,8 %, p = 1.00). Only 1 patient in the DIL group had ≥grade 3 toxicity (TURP) and none in the control group. CONCLUSIONS Boost to DIL defined by sextant biopsy with permanent seed prostate implant shows a trend toward improvement of biochemical control in intermediate risk prostate cancer patient without increasing toxicity.
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Affiliation(s)
- Elizabeth Guimond
- Centre Hospitalier Universitaire de Québec - Université Laval, Canada; Laval University, Québec, Canada.
| | | | - William Foster
- Centre Hospitalier Universitaire de Québec - Université Laval, Canada; Laval University, Québec, Canada.
| | - Éric Vigneault
- Centre Hospitalier Universitaire de Québec - Université Laval, Canada; Laval University, Québec, Canada.
| | | | - André-Guy Martin
- Centre Hospitalier Universitaire de Québec - Université Laval, Canada; Laval University, Québec, Canada.
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Matta R, Chapple CR, Fisch M, Heidenreich A, Herschorn S, Kodama RT, Koontz BF, Murphy DG, Nguyen PL, Nam RK. Pelvic Complications After Prostate Cancer Radiation Therapy and Their Management: An International Collaborative Narrative Review. Eur Urol 2018; 75:464-476. [PMID: 30573316 DOI: 10.1016/j.eururo.2018.12.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/04/2018] [Indexed: 02/06/2023]
Abstract
CONTEXT Radiotherapy used for treating localized prostate cancer is effective at prolonging cancer-specific and overall survival. Still, acute and late pelvic toxicities are a concern, with gastrointestinal (GI) and genitourinary (GU) sequelae being most common as well as other pelvic complications. OBJECTIVE To present a critical review of the literature regarding the incidence and risk factors of pelvic toxicity following primary radiotherapy for prostate cancer and to provide a narrative review regarding its management. EVIDENCE ACQUISITION A collaborative narrative review of the literature from 2010 to present was conducted. EVIDENCE SYNTHESIS Regardless of the modality used, the incidence of acute high-grade pelvic toxicity is low following conventionally fractionated external beam radiotherapy (EBRT). After moderate hypofractionation, the crude cumulative incidences for late grade 3 or higher (G3+) GI and GU complications are as high as 6% and 7%, respectively. After extreme hypofractionation, the 5-yr incidences of G2+ GU and GI toxicities are 3-9% and 0-4%, respectively. Following brachytherapy monotherapy, crude rates of late G3+ GU toxicity range from 6% to 8%, while late GI toxicity is rare. With combination therapy (EBRT and brachytherapy), the cumulative incidence of late GU toxicity is high, between 18% and 31%; however, the prevalence is lower at 4-14%. Whole pelvic radiotherapy remains a controversial treatment option as there is increased G3+ GI toxicity compared with prostate-only treatment, with no overall survival benefit. Proton beam therapy appears to have similar toxicity to photon therapies currently in use. With respect to specific complications, urinary obstruction and urethral stricture are the most common severe urinary toxicities. Rectal and urinary bleeding can be recurrent long-term toxicities. The risk of hip fracture is also increased following prostate radiotherapy. The literature is mixed on the risk of in-field secondary pelvic malignancies following prostate radiotherapy. Urinary and GI fistulas are rare complications. Management of these toxicities may require invasive treatment and reconstructive surgery for refractory and severe symptoms. CONCLUSIONS There has been progress in the delivery of radiotherapy, enabling the administration of higher doses with minimal tradeoff in terms of slightly increased or equal toxicity. There is a need to focus future improvements in radiotherapy on sparing critical structures to reduce GU and GI morbidities. While complications such as fistulae, bone toxicity, and secondary malignancy are rare, there is a need for higher-quality studies assessing these outcomes and their management. PATIENT SUMMARY In this report, we review the literature regarding pelvic complications following modern primary prostate cancer radiotherapy and their management. Modern radiotherapy technologies have enabled the administration of higher doses with minimal increases in toxicity. Overall, high-grade long-term toxicity following prostate radiotherapy is uncommon. Management of late high-grade pelvic toxicities can be challenging, with patients often requiring invasive therapies for refractory cases.
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Affiliation(s)
- Rano Matta
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Heidenreich
- Department of Urology, Uro-Oncology, Robot-Assisted and Reconstructive Surgery, University of Cologne, Cologne, Germany
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ronald T Kodama
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke Prostate and Urologic Cancers Center, Duke University Medical Center, Durham, NC, USA
| | - Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Robert K Nam
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada.
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31
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Lobo N, Kulkarni M, Hughes S, Nair R, Khan MS, Thurairaja R. Urologic Complications Following Pelvic Radiotherapy. Urology 2018; 122:1-9. [DOI: 10.1016/j.urology.2018.07.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/17/2018] [Accepted: 07/07/2018] [Indexed: 11/28/2022]
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