Michael Esposito

Relief of Benign Prostatic Hyperplasia-related Bladder Outlet Obstruction after Transarterial Polyvinyl Alcohol Prostate Embolization

JVIR 2000; 11:767–770 THE standard management of benign prostatic hyperplasia (BPH) is based on overall patient health and the severity of symptoms. Voiding difficulties attributable to BPH can be quantified with the International Prostatic Symptom Score, a questionnaire consisting of seven symptom categories, with a range of increasingly severe symptom scores from 0 through 35. The score is based on the severity of each of the following obstructive urinary symptoms: hesitancy, decreased urinary stream, intermittency, sensation of incomplete emptying, nocturia, frequency, and urgency. The questionnaire responses are graded, with each of the seven symptom categories contributing a maximum of 5 points, for a total possible score of 35. Symptoms can be ranked as mild (score, 0–7), moderate (score, 8–19), and severe (score, 20–35) (1). Prostatectomy constitutes the traditional management of gross hematuria and/or severe voiding difficulties secondary to BPH. This can be accomplished by transurethral or open surgical means. Various medications, specifically 5-alpha reductase inhibitors and selective -blockers, can decrease the severity of voiding symptoms secondary to BPH. Symptomatic BPH typically occurs in the sixth and seventh decades; it is this older age group that tends to be affected with comorbid cardiovascular disease. Surgical intervention in this age group is considered to be of high risk. We present a case of persistent hematuria and severe urinary obstructive symptoms secondary to BPH, which failed to respond to multiple attempts at conventional therapy. The patient’s condition was successfully managed with superselective transarterial polyvinyl alcohol (PVA) embolization. CASE HISTORY

Prospective study of quality of life of patients receiving treatment for prostate cancer.

Background: No research was found that compared quality of life (QOL) outcomes of prostate cancer patients receiving intensity-modulated radiation therapies with prostate cancer patients receiving radical prostatectomy. Objectives: To (a) describe differences in QOL before and after three types of treatment for prostate cancer: radical prostatectomy, intensity-modulated radiation therapy + seed implantation (permanent brachytherapy), or intensity-modulated radiation therapy + high dose rate radiotherapy (temporary brachytherapy); and (b) investigate demographic, physical, and psychosocial variables that impact QOL of men with prostate cancer. Methods: Data were collected on three occasions: baseline (prior to treatment), 1 month, and 3 months after beginning treatment. Measures included biographic data, physiological, and psychological measures. Analysis of variance and hierarchical regression were used to examine patterns, describe differences, and identify predictors of QOL in the three treatment groups. QOL was conceptualized as a multidimensional construct that included physical, psychological, social, and functional well-being and prostate cancer concerns. Results: Groups differed significantly in bowel and urinary symptom scores and prostate cancer concerns at baseline, and in urinary and depressive symptoms at 3 months. There were no significant group differences at 1 month. Discussion: Significant differences were found in QOL as measured with the Functional Assessment of Cancer Treatment-Prostate after treatment with radical prostatectomy, intensity-modulated radiation therapy + seed implantation, or intensity-modulated radiation therapy + high dose rate radiotherapy. Findings may provide healthcare providers with knowledge about treatment sequelae for prostate cancer, enable healthcare providers to educate patients about QOL outcomes of treatment for prostate cancer, and enable patients to make more informed treatment decisions.

Corrigendum: Incorrect Spelling of Author's Name: US Preventive Services Task Force prostate-specific antigen screening guidelines result in higher Gleason score diagnoses

[This corrects the article on p. 423 in vol. 58.].

V8-11 THE USE OF A NOVEL CURVED-TIP SUCTION DEVICE IN LAPAROSCOPIC AND ROBOTIC UROLOGIC SURGERY

INTRODUCTION AND OBJECTIVES: Despite primary treatment of prostate cancer with surgery or external radiation therapy, 2040% of patients relapse within 5 years and 25-35% progress to metastatic disease. Salvage lymph node dissection has been proposed in patients with biochemical recurrence from prostate cancer and nodal involvement only, although the optimal template remains a question of debate. Herein we describe the technique of robotic high-extended salvage retroperitoneal and pelvic lymphadenectomy (sRPLND+PLND) for “node-only” recurrent prostate cancer. METHODS: Twenty patients underwent robotic sRPLND+PLND for “node-only” recurrent prostate cancer after definitive primary treatment as identified by carbon-11 acetate PET/CT. Our anatomic template extends from bilateral renal artery and vein cranially up to Cloquets node caudally, completely excising lymphatic-fatty tissue from aorto-caval and iliac vascular trees. Meticulous node-mapping assessed nodes at 4 prospectively-assigned anatomic zones. RESULTS: Median age at salvage RPLND was 64 (45-76), median BMI was 26.4 kg/m2 (21.4 41.2), previous primary treatment was radical prostatectomy in 17 patients (85%) and external radiation therapy in 4 patients (15%), median time from primary treatment was 32 months (4-160) and median PSA at sRPLND+PLND was 2.1 ng/dl (0.28 38.17). Median operative time was 5 hours (3.5-5.8), blood loss was 100 ml (50-300), and hospital stay was 1 day (1-3). No patient had intra-operative complication, open conversion or blood transfusion. Four patients had Clavien II post-operative complications: flank/scrotal ecchymosis in 1 patient (5%), chylous ascites in 2 patients (10%) and neuropraxia/foot drop in 1 patient (5%). Final histology confirmed positive nodes in 16 patients (20%). Mean and median (range) number of nodes excised per patient was 89 and 80 (41-132) respectively. Mean and median (range) number of positive nodes was 21 and 6 (0-109) respectively. At 2 months post-operatively median (range) PSA was 0.76 ng/mL (<0.01-2 ng/mL). CONCLUSIONS: Herein we describe the detailed technique of robotic high-extended salvage RPLND+PLND for “node-only” recurrent prostate cancer and present the initial experience. Robotic sRPLND+PLND duplicates open surgery, with superior nodal counts and decreased morbidity compared to the published literature. Longer follow-up is necessary to assess oncologic outcomes.

US Preventive Services Task Force prostate-specific antigen screening guidelines result in higher Gleason score diagnoses

Purpose To evaluate the impact that the 2012 US Preventive Services Task Force (USPSTF) prostate-specific antigen (PSA) screening guidelines have had on the diagnosis of prostate cancer, we compared the incidence and distribution of new cases diagnosed in 2011-before the USPSTF PSA screening recommendations versus 2014 at which time the guidelines were widely adopted. Materials and Methods We identified all prostate biopsies performed by a large urology group practice utilizing a centralized pathology lab. We examined total biopsies performed, percentage of positive biopsies, and for those with positive biopsies examined for differences in patient age, PSA, and Gleason score. Results A total of 4,178 biopsies were identified – 2,513 in 2011 and 1,665 in 2014. The percentage of positive biopsies was 27% in 2011 versus 34% in 2014 (p<0.0001). Among patients with positive biopsies, we found statistically significant differences between the 2 cohorts in the median ages and Gleason scores. Patients were about 1 year younger in 2014 compared to 2011 (t-test; p=0.043). High Gleason scores (8–10) were diagnosed in 19% of the 2014 positive biopsies versus 9% in the 2011 positive biopsies (chi square; p<0.0001). Conclusions After the widespread implementation of the 2011 USPTF PSA screening guidelines, 34% fewer biopsies were performed with a 29% increase in positive biopsy rates. We found a significantly higher incidence of high grade disease in 2014 compared with 2011. The percentage of patients with positive biopsies having Gleason scores 8–10 more than doubled in 2014. The higher incidence of these more aggressive cancers must be part of the discussion regarding PSA screening.