Mohammed Baghdadi

Optimal Settings for the Noncontact Holmium:YAG Stone Fragmentation Popcorn Technique

Purpose: The purpose of this study was to evaluate the popcorn technique using a wide range of holmium laser settings and fiber sizes in a systematic in vitro assessment. Materials and Methods: Evaluations were done with 4 artificial stones in a collection tube. A fixed ureteroscope was inserted through a ureteral access sheath to provide constant irrigation flow and the laser was placed 1 mm from the bottom. Combinations of 0.5 to 1.5 J, 10 to 20 and 40 Hz, and long and short pulses were tested for 2 and 4 minutes. We used 273 and 365 &mgr;m laser fibers. All tests were repeated 3 times. The stones were weighed before and after the experiments to evaluate the setting efficiency. Significant predictors of a highly efficient technique were assessed. Results: A total of 144 tests were performed. Mean starting weight of the stones was 0.23 gm, which was consistent among the groups. After the experiment the median weight difference was 0.07 gm (range 0.01 to 0.24). When designating a 50% reduction in stone volume as the threshold indicating high efficiency, the significant predictors of an efficient popcorn technique were a long pulse (OR 2.7, 95% CI 1.05–7.15), a longer duration (OR 11.4, 95% CI 3.88–33.29), a small (273 &mgr;m) laser fiber (OR 0.23, 95% CI 0.08–0.70) and higher power (W) (OR 1.14, 95% CI 1.09–1.20). Conclusions: Higher energy, a longer pulse, frequencies higher than 10 Hz, a longer duration and a smaller laser fiber predict a popcorn technique that is more efficient at reducing stone volume.

PD72-09 EARLY OUTCOMES OF FOCAL BRACHYTHERAPY FOR LOCALIZED PROSTATE CANCER: COMPARISON WITH WHOLE GLAND BRACHYTHERAPY.

radical prostatectomy (RP) but does not include multiparametric pelvic MRI (mpMRI). Here, we evaluate the utility of mpMRI in predicting sXRT failure after RP. METHODS: Men undergoing RP at Mayo Clinic from 20032015 who had biochemical recurrence and received sXRT were included in a retrospective chart review. Men who underwent prostate cancer treatment prior to RP, received adjuvant XRT, or who were hormone refractory at sXRT were excluded. Patients with mpMRI within 12 months of sXRT were retained. mpMRI lesions were grouped according to location: vesicourethral, seminal vesical (SV) bed / prostate fossa, pelvic nodes, pelvic bones. If no lesion was present, the mpMRI was categorized as negative. Standard descriptive statistics and multivariable cox regression analyses were performed to assess the impact of mpMRI on PSA recurrence after sXRT. Models were adjusted for the variables in the Stephenson Nomogram: PSA at RP, PSA prior to sXRT, PSA doubling time, hormone therapy with sXRT, sXRT dosage, extracapsular extension, SV invasion, pathologic Gleason score, margin status, and pN stage. RESULTS: Overall, 473 men had mpMRI prior to sXRT (median PSA at sXRT 0.45ng/ml). Of these, 56.9% (204) had an indeterminate or suspicious lesion on MRI: 25.6% (124) vesicourethral, 27.8% (135) SV bed / prostatic fossa, 7.0% (34) pelvic node, and 0.6% (3) pelvic bone. Median PSA with a visible lesion on mpMRI was 0.45ng/ml. At a median follow up of 42 months after sXRT, 29.3% (142) had PSA recurrence and 14.0% (68) had distant metastasis. Patients without a mpMRI lesion or with a suspicious nodal/bone lesion had higher rates of PSA recurrence at 4 years compared to those with vesicourethral/SV/prostate fossa lesions alone: 39.5% vs 21.9% (p<0.001), Figure 1. On multivariable analysis, patients without a mpMRI lesion or a suspicious nodal/bone lesion were significantly more likely to have PSA recurrence (HR 2.41, 95% CI 1.52-3.83, p<0.001) after adjusting for variables in the Stephenson Nomogram. CONCLUSIONS: Pre-sXRT mpMRI is a valuable tool in risk stratifying men undergoing sXRT. The median PSA with a visible lesion on mpMRI was 0.45ng/ml, supporting the use of mpMRI in the early sXRT setting.

PD56-06 NEW FRONTIERS AHEAD FOCAL THERAPY POSTOPERATIVE FOLLOW-UP: WHAT IS THE REAL ROLE OF MRI IN THIS SETTING?

INTRODUCTION AND OBJECTIVES: Several studies have demonstrated the risk of upgrade from prostate biopsy (PBx) to radical prostatectomy (RP) pathology to be as high as 40%. The objective of the current study is twofold: to evaluate the prostate cancer upgrading on RP in a cohort of patients who underwent MRI-TRUS fusion biopsy (FBx) prior to RP and to determine if saturation of index tumor (IT) during PBx decreases this risk of upgrading. METHODS: Clinical and pathologic data from a prospectively maintained single institution database was analyzed for patients who underwent both FBx and standard 12-core biopsy (Sbx) followed by RP (2010-16). Index tumor was defined as the tumor with the largest diameter on T2W MRI. Patients were considered to have a saturated index tumor (SIT) if they had a fusion target (consisting of one axial and one sagittal biopsy) taken for every 6mm of IT diameter, and were considered to have a nonsaturated index tumor (NSIT) if they had only one target assigned regardless of the size of IT. Gleason 6, Gleason 7 and Gleason 8 or above were defined as low, intermediate and high risk respectively. Gleason Upgrade was defined as a higher Gleason score on RP specimen compared to PBx. Risk category upgrade was defined as higher risk category on RP specimen. Chi square and McNemar0s test were used to compare rates of upgrade. RESULTS: 206 patients (91 with SIT and 115 with NSIT) were included in the study with median age and PSA of 61.5 (IQR 9.3) yrs and 7.38 (IQR 8) ng/ml respectively. Median number of biopsy cores per index tumor was 4 in the SIT group and 2 in the NSIT group (p<0.001) . For the entire cohort, highest Gleason score from combined Fbx/Sbx was upgraded on final pathology in 36 (17.5%) patients vs 95 (46.1%) patients when compared to Sbx only (p1⁄40.001). Risk category upgrade from combined Fbx/Sbx vs Sbx only was found in 26 (12.6%) vs 83 (40.3%), p<0.0001. Patients with SIT had lower Gleason upgrade (12.1% vs 21.7% , p 1⁄40.07) and significantly lower risk category upgrade (6 (6.6%) and 20 (17.4%), p1⁄40.02) compared to patients with NSIT. CONCLUSIONS: Ensuring that high risk cancer is not missed on biopsy is crucial to treatment planning in patients with prostate cancer. Our results demonstrate that the addition of mpMRI-TRUS Fbx significantly decreases the risk of upgrade on RP pathology, proving the efficacy of Fbx in accurately characterizing PCa preoperatively. Saturation of the index tumor further decreases the risk of upgrade on final pathology by extensive sampling and minimizing the impact of tumor heterogeneity.

PD56-07 CAN FOCAL THERAPY IMPACT ON PERIOPERATIVE, ONCOLOGICAL AND FUNCTION OUTCOMES IN MEN UNDERWENT FOCAL THERAPY SALVAGE ROBOTIC-ASSISTED RADICAL PROSTATECTOMY? A RETROSPECTIVE MATCHED-PAIR COMPARATIVE STUDY

INTRODUCTION AND OBJECTIVES: Salvage surgery is an option for recurrent prostate cancer(PCa) after focal therapy(FT). This is the first study to assess the impact of FT on surgical outcomes comparing salvage robotic-assisted radical prostatectomy(S-RARP) versus primary-RARP(P-RARP). We aimed to compare the impact of FT on perioperative, oncological and functional outcomes in men underwent S-RARP versus P-RARP. METHODS: Prospective data of 2775 men underwent RARP for localized PCa from 2000 to 2016 were reviewed. Twenty-five men underwent S-RARP after FT failure(S-RARP group). Total 2750 underwent RARP as primary treatment. Matched-pair 1:2 selection of 44 out of 2750 patients by age, IPSS and IIEF5 defined P-RARP group. Primary endpoint was between-groups differences on functional outcomes. Secondary endpoint was oncological data. p<0.05 was significant. RESULTS: Surgical time, transfusion and complication rates were comparable(p 0.05). Rates of continence probability[49.5%(SE 0.13) versus 62.4%(SE 0.08), p1⁄40.8 and 73%(SE 0.14) versus 76.5%(SE 0.07), p1⁄40.8, at 1 and 2 years, respectively] and the chance for achieving continence[HR 1.062, 95%CI 0.54-2.08, p1⁄40.861] were comparable between-groups. Potency recovery was significant lower on S-RARP at 1 year follow-up[3 2 versus 9.22 6.55, p1⁄40.008]. S-RARP showed significant lower rates of cumulative BCR-free survival probability[67.6%(SE 0.12) versus 95.1%(SE 0.03), p1⁄40.001 and 56,3%(SE 0.15) versus 92,4%(SE 0.04), p1⁄40.001, at 1 and 2 years, respectively]. S-RARP presented significant increased risk of BCR[HR 4.8, 95%CI 1.67-13.76, p1⁄40.004]. Upstaging was an independent predictor factor for BCR on S-RARP[HR 14.65, 95%CI 1.46-146.37, p1⁄40.022]. CONCLUSIONS: Salvage-RARP following FT failure is feasible and safe with acceptable complications rates. Patients assigned to FT should be previously advised about lower erectile recovery rates in case of a salvage surgery. Urologists may be warned about the risk of undertreatment in patients presenting failure along FT follow-up. Source of Funding: None

PD51-09 CONDITIONAL PROBABILITY OF BIOCHEMICAL RECURRENCE-FREE SURVIVAL AND CANCER-SPECIFIC MORTALITY AFTER RADICAL PROSTATECTOMY AT LONG TERM FOLLOW-UP

INTRODUCTION AND OBJECTIVES: Data on the oncologic outcomes of high-risk prostate cancer (HRPCa) patients at 20 years after radical prostatectomy (RP) are lacking. The aim of our investigation was to evaluate the long-term patterns of biochemical (BCR), clinical recurrence (CR), cancer specific mortality (CSM) and othercause mortality (OCM) in a multi-institutional database of surgicallytreated HRPCa patients. METHODS: We evaluated 2280 patients with HRPCa treated with RP and pelvic lymph node dissection at 3 tertiary care centers between 1986 and 2015. High-risk prostate cancer was defined according to D’Amico criteria. We estimated BCR and CR rates using the Kaplan-Meier method. The CSM and OCM rates were obtained using competing risk analyses. BCR, CR, and CSM were assessed after 20 years from surgery. Cox regression analyses assessed predictors of long-term oncological outcomes. RESULTS: Median follow-up was 210 months. Median age was 66 years. The 20-year overall BCR-free survival and CR-free survival rates were 36.7% and 76.3%. Overall, 1050 experienced BCR. The latest BCR was registered at 237 months after RP. Out of 1230 patients who experienced BCR, 394 (37.5%) developed CF, while 656 (62.5%) were CF-free at last follow-up. The latest CF was registered at 244 months from RP. Overall, 394 and 172 patients experienced OCM and CSM. The competing risk 20 years CSM and OCM rates were 12.4 and 30.8%. Overall, 74 patients (3.5%) had a follow up 20 years. Of those, 7 (9.2%) and 1 (1.3%) experienced CSM and OCM. The 25-year competing-risks OCM and CSM-free survival rates were 77.9 and 98.5%. Age at RP (HR1⁄40.97), pathological Gleason score 6 (HR1⁄43.73), time to BCR (HR1⁄41.01) and number of nodes removed (HR1⁄41.06) were predictors of being free from overall mortality at 20year follow up (all p 0.04). Among patients with a follow-up 20 years (n1⁄474), 39 (51.3%) experienced BCR at a median follow-up of 214 months. No patient developed BCR after 20 years from RP. Moreover, 12 (33.3%) developed CF within 20 years (median follow-up 231 months), while only 1 (1.5%) developed CF after 20 years from RP. CONCLUSIONS: Among HRPCa patients, CSM may still occur even after 20 years from RP. Therefore, long monitoring and follow-up should be prolonged even after this time point. Moreover, time to BCR was a strong predictor of reaching a long follow-up after surgery and should be considered as a main criterion to further stratify patients according to their risk of CF and mortality over time.