Erin P. Gibbons

Validation of the Fournier's Gangrene Severity Index in a Large Contemporary Series

PURPOSE In this study we identified prognostic factors for survival and validated the accuracy of the Fourniers gangrene severity index in patients with Fourniers gangrene. MATERIALS AND METHODS We retrospectively reviewed medical records of patients diagnosed with Fourniers gangrene between 1996 and 2006. Fourniers gangrene severity index scores were assessed using a receiver operating characteristic curve. Using an outcome variable of inpatient mortality, univariate analyses were performed using the Mann-Whitney U, chi-square and Fisher exact tests. RESULTS A total of 68 patients (79.4% male, mean age 55.8 +/- 15.2 years) diagnosed with Fourniers gangrene met the criteria for review. The inpatient mortality rate was 10% (7 patients). The mean Fourniers gangrene severity index score for survivors was 5.4 +/- 3.5 vs 10.9 +/- 4.7 for nonsurvivors (p = 0.006). Isolated Fourniers gangrene severity index and individual laboratory parameters associated with mortality included heart rate (p = 0.05), respiratory rate (p = 0.02), serum creatinine (p = 0.03), serum bicarbonate (p = 0.001), serum lactate (p = 0.001) and serum calcium (p = 0.03). Although mean total body surface area was only suggestive of an association (p = 0.169), abdominal wall (p = 0.004) or lower extremity (p = 0.005) involvement was associated with increased mortality. Using a Fourniers gangrene severity index score threshold of 9 (sensitivity 71.4%, specificity 90%) there was a 96% survival rate in patients with a Fourniers gangrene severity index of less than 9 and a 46% mortality rate in those with a Fourniers gangrene severity index of 9 or greater (p = 0.001, OR 22, 95% CI 3.5-139.7). CONCLUSIONS The Fourniers gangrene severity index remains an objective and simple method to quantify the extent of metabolic aberration at presentation in patients with Fourniers gangrene. A Fourniers gangrene severity index threshold value of 9 is sensitive and specific for predicting mortality in this patient population.

Correlation between risk factors for vascular disease and the American Urological Association Symptom Score

To evaluate the correlation between risk factors for vascular disease and the American Urological Association Symptom Score (AUA‐SS), by comparing the presence of these risk factors with the degree of lower urinary tract symptoms (LUTS).

Planning based on postneedle volume with early dosimetric assessment is beneficial for Cesium-131 permanent prostate seed implantation

PURPOSE This study reports on prostate edema after prostate brachytherapy using Cesium-131 ((131)Cs) and describes our method to compensate. METHODS AND MATERIALS Thirty-one patients underwent brachytherapy using an afterloading technique. Volume measurements of the prostate were taken at various time intervals relative to the date of implant. Real-time operating room dosimetry was used for seed placement on the postneedle prostate volume. The prostate volumes at the various time points were used to determine the effect of prostate edema on dosimetry. RESULTS Increase in prostate volume occurred immediately after needle placement, as measured by both ultrasound (mean increase of 17.7% (0-75.0%) from 36.8 to 46.9 cc) and Day 0 CT (mean increase of 15.3% (0-54.8%) to 45.9 cc). Day 0 assessment of dosimetry revealed a median D(90) of 102.7% (86.7-133.4%), median V(100) of 91.8% (75.9-98.4%), median V(150) of 44.4% (23.8-81.3%), and median V(200) of 16.3% (7.8-36.9%). This edema dissipated over the next 4 weeks, with resultant changes in dosimetric parameters. By 4 weeks, prostate volume had returned to the preimplant volume (37.7 cc) with increased D(90) (118.2%), V(100) (95.6%), V(150) (63.9%), and V(200) (28.4%). CONCLUSIONS There is significant immediate edema with prostate brachytherapy. This affects the dosimetry of the implant substantially. Because of this edema, our planning for brachytherapy is done on the postneedle implant volume. Quality assurance studies should be done on the same day as the implant to avoid substantial overestimation of dosimetric parameters.

Overcoming pubic arch interference with free-hand needle placement in men undergoing prostate brachytherapy

PURPOSE The present study evaluates the postimplant dosimetry when free-hand needles were placed to overcome interference from the pubic arch. METHODS AND MATERIALS A review of all patients who underwent prostate brachytherapy at our institution from 2001 to 2006 was performed. Postimplant dosimetry in men requiring free-hand needle placement was compared with postimplant dosimetry in men not requiring free-hand needle placement. RESULTS Of the 145 patients who underwent prostate brachytherapy, 8 patients required free-hand needle placement. The mean prostate volume in the free-hand needle cohort was 46.0cc with a mean of 3.4 free-hand needles placed. In the 137 patients not requiring free-hand needle placement, the mean volume was 39.7cc. The mean D(90), V(100), V(150), and rectal V(100) for the free-hand cohort was 129.5%, 96.3%, 81.6%, and 1.45cc, respectively. The mean D(90), V(100), V(150), and rectal V(100) in men not requiring free-hand needle placement was 126.8%, 97.1%, 78.7%, and 1.03cc, respectively. CONCLUSION The present study finds that adequate postimplant dosimetry can be obtained if free-hand needles are required due to pubic arch interference.

Dosimetric outcomes in prostate brachytherapy: is downsizing the prostate with androgen deprivation necessary?

OBJECTIVES A large prostate volume has historically been a relative contraindication to prostate brachytherapy (PB) because of concerns of toxicity and potential pubic arch interference. Common practice has been to downsize large prostates with androgen deprivation therapy (ADT) before proceeding with brachytherapy. The present study compares postimplant dosimetry in patients with prostate volumes >50 cc with those with prostate volumes </=50 cc. METHODS A review of all patients who underwent PB at our institution from 2001 to 2006 was performed. Postimplant dosimetry was obtained approximately 4 weeks after brachytherapy. RESULTS One-hundred forty-five out of a total of 148 patients had available dosimetry. In the 113 patients with prostate volumes </=50 cc (mean, 35.4 cc, range, 14.2-49.7 cc); the mean D(90) (dose which covers 90% of the prostate), V(100) (volume of prostate receiving 100% of the prescribed dose), V(150) (volume of prostate receiving 150% of the prescribed dose), and V(200) (volume of prostate receiving 200% of the prescribed dose) was 128.9%, 95.6%, 73.9%, and 51.2%, respectively. In the 32 patients with prostate volumes >50 cc (mean 58.1 cc, range 50.2-86.0 cc); the mean D(90), V(100), V(150), and V(200) was 125.1%, 95.2%, 68.2%, and 41.7%, respectively. The rectal V(100) was 1.0 cc for both cohorts. There was no statistically significant difference between the cohorts with respect to postimplant dosimetry for D(90), V(100), and V(150). The V(200) for prostate volumes >50 cc was significantly lower (p<0.05). CONCLUSIONS In the present study, patients with prostate volumes >50 cc have postimplant dosimetry parameters similar to patients with prostate volumes </=50 cc for D(90), V(100), and V(150); and significantly lower values for V(200). These results suggest that patients with large prostate volumes may not need to be routinely placed on hormonal therapy; sparing patients the side effects of hormonal therapy, and sparing the health care system the costs of luteinizing hormone-releasing hormone agonist injections.

Acute bowel morbidity after prostate brachytherapy with cesium-131

PURPOSE The present study evaluates the severity and time to resolution of bowel symptoms in men undergoing prostate brachytherapy (PB) with cesium-131 ((131)Cs). METHODS AND MATERIALS A longitudinal, prospective study of patients who had undergone PB with (131)Cs at a single institution was performed. All patients were asked to complete the Expanded Prostate Cancer Index Composite preoperatively and at 2 weeks and 1, 3, and 6 months postoperatively. Outcomes were analyzed using descriptive statistics and Students t test. RESULTS The first 142 patients to have undergone PB with (131)Cs at our institution were included in the study. The mean Expanded Prostate Cancer Index Composite bowel summary score at baseline was 90.1±11.0 compared with 71.5±22.8 (p=0.000), 70.1±20.7, 87.1±13.8 (p=0.01), and 90.7±9.2 (p=0.70) at 2 weeks and 1, 3, and 6 months postoperatively, respectively. CONCLUSIONS In men undergoing PB as monotherapy with (131)Cs, bowel symptoms returned to baseline by 3 months after the procedure. For patients undergoing PB with (131)Cs as part of combination therapy, bowel symptoms return to their post-external beam radiotherapy, pre-PB baseline by 3 months after the procedure.

Prostate brachytherapy after ileal pouch-anal anastomosis reconstruction.

OBJECTIVE To determine the safety of prostate brachytherapy in patients with clinically localized prostate cancer who have undergone proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS We performed a retrospective chart review of patients with a prior history of IPAA reconstruction who underwent prostate brachytherapy at our institution. Clinical records were reviewed for demographic characteristics, postoperative dosimetry, changes in bowel function, and oncologic outcomes. Data were analyzed using descriptive statistics. RESULTS Five patients with an IPAA underwent prostate brachytherapy for clinically localized prostate cancer. Mean time from colorectal reconstruction to prostate brachytherapy was 6.3 years. Adequate dosimetry (mean D90 114.9%, mean V100 91.1%, mean R100 0.76 mL) was achieved in each patient. Bowel frequency worsened in the immediate postoperative period in all patients, but all patients returned to their baseline bowel pattern by 4 months after their procedure. Serious complications, such as J-pouch ulcers, fistulas, or fecal incontinence, did not occur in these patients. CONCLUSIONS Prostate brachytherapy is a safe treatment option in patients with clinically localized prostate cancer and a history of proctocolectomy and IPAA reconstruction.

Comparison between real-time intra-operative ultrasound-based dosimetry and CT-based dosimetry for prostate brachytherapy using cesium-131.

The purpose of this study was to evaluate the correlation between real-time intra-operative ultrasound-based dosimetry (USD) and day 0 post-implant CT dosimetry (CTD) 131 Cs permanent prostate brachytherapy. Fifty-two consecutive patients who underwent prostate brachytherapy with 131 Cs were evaluated. Real time operating room planning was performed using VariSeed 7.1 software. Post-needle placement prostate volume was used for real-time planning. Targets for dosimetry were D90 >110%, V100 >90%, V150 <50%, and V200 <20%. The CT scan for post-operative dosimetry was obtained on day 0. The mean values for USD, CTD, and the linear correlation, respectively, were, for D90: 114.0%, 105.61%, and 0.15; for V100: 95.1%, 91.6%, and 0.22; for V150: 51.5%, 46.4%, and 0.40; and for V200: 15.8%, 17.9%, and 0.42. The differences between the mean values for USD and CTD for D90 (p<0.01), V100 (p<0.01), and V150 (p<0.05) were statistically significant. For D90, 30.8% of patients had a >15% difference between USD and CTD and 51.9% of patients had a >10% difference between these values. In contrast, the USD and CTD for V100 were within 5% in 55.8% of patients and within 10% in 86.5% of patients. This study demonstrates a correlation between the mean intra-operative USD and post-implant day 0 CTD values only for V200. Significant variation in D90, V150, and V200 values existed for individual patients between USD and CTD. These results suggest that real-time intra-operative USD does not serve as a surrogate for post-operative CTD, and that post-operative CTD is still necessary.

Female Urethral Diverticula

The first clinical description of a female urethral diverticulum is credited to Dr. John Hey in 1805. In his essay “Of Collections of Pus in the Vagina,” Dr. Hey described the diagnosis and treatment of this entity, which included a transvaginal incision, and packing of the diverticular sac with lint (1). Over the next 150 yr, the medical literature offers scant references pertaining to the topic of female urethral diverticula. However, in 1956, with the advent of a new diagnostic tool in the form of positive pressure urethrography (PPU), the detection and diagnosis of female urethral diverticula demonstrated a predictable dramatic increase (2).