Keith Kowalczyk

Partial Nephrectomy After Previous Radio Frequency Ablation: The National Cancer Institute Experience

PURPOSE Development of new renal tumors or recurrence after radio frequency ablation not amendable for repeat ablation presents a difficult therapeutic dilemma. We report on the outcomes of partial nephrectomy on kidneys previously treated with radio frequency ablation. MATERIALS AND METHODS We performed a chart review of 13 patients who underwent 16 attempted partial nephrectomies following radio frequency ablation. Hospital records and operative reports were reviewed for demographic data, perioperative data and outcomes. The outcomes of the present series were compared to historical controls of published studies in similar patient populations. RESULTS No cases were converted to radical nephrectomy. Median time from radio frequency ablation to surgery was 2.75 years (range 1 to 7.1). A median of 7 tumors (range 2 to 40) were removed with a median estimated blood loss of 1,500 ml (range 500 to 3,500) and a median operative time of 7.8 hours (range 5 to 10.7). Operative notes commented on the presence of severe fibrosis in the operative field in 12 of 16 cases (75%). There was a modest but statistically significant decrease in renal function. Partial nephrectomy after radio frequency ablation had a higher reoperation rate compared to other series of primary or repeat partial nephrectomies but had the lowest rate of vascular or visceral injuries. CONCLUSIONS Partial nephrectomy on kidneys previously treated with radio frequency ablation is a technically challenging but feasible procedure. Residual or metachronous disease after radio frequency ablation may be salvaged with partial nephrectomy with a modest decrease in renal function. A trend toward a higher chance of reoperation and urine leak after partial nephrectomy after radio frequency ablation may be useful information for the planning and discussion of treatment decisions.

Anatomic and technical considerations for optimizing recovery of urinary function during robotic-assisted radical prostatectomy.

Purpose of reviewThe advent of robotic-assisted radical prostatectomy purported fewer complications including postprostatectomy incontinence (PPI). PPI is associated with worse quality of life. We evaluate recently reported robot-assisted radical prostatectomy surgical techniques aimed at limiting PPI, describe their anatomic basis and summarize their outcomes. Recent findingsRARP techniques to reduce PPI include bladder neck preservation, bladder neck reconstruction, urethral length preservation, periurethral suspension stitch, posterior reconstruction, combined anterior and posterior reconstruction, preservation of the endopelvic fascia, complete anterior preservation, selective suturing of dorsal venous complex and nerve sparing approach. Outcomes of reconstructive techniques seem to be conflicting, whereas outcomes of techniques aiming to preserve the native urinary continence system seem to hasten urinary function recovery. However, few of these techniques have been shown to affect long-term urinary continence. SummarySurgical techniques preserving the natural urinary continence mechanism appear to improve short-term urinary continence, whereas techniques reconstructing pelvic anatomy have mixed results. The search for the ideal technique to minimize PPI remains hampered by the lack of prospective multi-institutional studies and the long-term follow up. Although reconstructive techniques are safe with few drawbacks, meticulous surgical technique and preservation of the natural continence mechanism should remain the mainstay of PPI prevention.

948 OPTIMAL TIMING OF EARLY VERSUS DELAYED ADJUVANT RADIOTHERAPY FOLLOWING RADICAL PROSTATECTOMY FOR LOCALLY ADVANCED PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: Although post-prostatectomy adjuvant radiation therapy (ART) has shown survival benefits for pT3 disease, optimal ART timing remains unknown as randomized controlled trials have used arbitrary cut-points based on study design. Using a population-based approach, we characterize outcomes of early vs. delayed ART as well as the optimal timing of ART following radical prostatectomy (RP) for locally advanced disease. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data from 1995-2007, we identified 1056 men with pT3N0 disease receiving early ( 4 months post-RP, n 464) vs. delayed (4-12 months post-RP, n 592) ART following RP. Baseline demographic and tumor characteristics were recorded and compared. Propensity-score methods were used to compare overall mortality, prostate cancer-specific mortality (PCSM), bone-related events (defined as bone metastasis and/or pathologic fracture), and salvage hormonal therapy utilization ( 12 months following initiation of ART). Additionally, we used the maximal statistic approach to determine time cut-points with most significant ART benefit. RESULTS: Early vs. delayed ART was associated with improved PCSM (0.71 vs. 2.05 events per 100 person-years, p 0.024) for T3b disease and fewer bone-related events for T3a disease with negative margins (T3aNM, 0.92 vs. 2.50 events per 100 person-years, p 0.008). Administering ART 11 months post-RP for T3aNM (HR 15.6, p 0.022) and 6 months post-RP for T3b (HR 2.74, p 0.015) was associated with worse PCSM. Delaying ART 5 months for T3aNM (HR 2.52, p 0.005) and 7 months for T3a disease with positive margins (HR 2.26, p 0.007) was associated with increased bone-related events. CONCLUSIONS: Initiating ART 6 months post-RP for T3b disease and 11 months post-RP for T3aNM disease is associated with improved PCSM. Early ART for T3a, regardless of margin status, is also associated with fewer bone-related events. Our populationbased findings complement randomized trials designed with fixed ART timing, and aids providers and patients considering ART.

Stereotactic body radiation therapy (SBRT) following procedures for benign prostatic hyperplasia (BPH): A report on early toxicity.

165 Background: When treating patients with prostate cancer, hypofractionation with SBRT takes advantage of radiobiologically favorable factors as compared to conventional fractionation. However, this may increase the risk of urinary toxicity, especially in patients with prior procedures for BPH. Herein, we report early urinary toxicity following SBRT in patients with a history of procedures for BPH. METHODS Thirty three patients treated with SBRT for localized prostate cancer from February 2009 to October 2011 at Georgetown University Hospital with history of a prior procedure for BPH were included in this retrospective analysis. Treatment was delivered using the CyberKnife with doses of 35 Gy-36.25 Gy in 5 fractions. Toxicities were scored using the CTCAE v.3. Cystoscopy findings were retrospectively reviewed. Patient-reported urinary symptoms were assessed using the American Urological Association Symptom Score (AUA). RESULTS The median age was 70 years (range, 64 - 84). The median follow-up time was 18.7 months (range 9.2 - 38.9). Grade 2 or 3 urinary toxicity occurred in 9 patients and there were no grade 4 or 5 toxicities. Hematuria occurred in 12 patients. The median time to onset of hematuria from SBRT was 6 months (range 1 - 30). Grade 1 hematuria occurred in 7 patients, grade 2 in 4 patients and 1 patient experienced grade 3. Cystoscopy was performed in 9 of these patients at a median time of 9 months (range 3-27). Eight had hyperemia or evidence of bleeding from the prostatic urethra and 5 of these patients also had evidence of bleeding from the bladder neck/wall. All patients except one, who died from other causes, are still being followed and hematuria has resolved in 9 of the 12 patients. The median baseline AUA symptom score of 7 increased to 11 at 1 month, however decreased to a median score of 6 at 3 months. The median AUA symptom score increased to 9 at 1 year. CONCLUSIONS A history of prior transurethral resection of prostate may predispose patients to increased urinary toxicity and hematuria following prostate SBRT. Stricter urethra/bladder neck dosimetric criteria or alternative fractionation regimens may be required to decrease urinary toxicity in these patients.