- Email: [email protected]
Cryoablation of the prostate
orchidectomy in the treatment of patients with advanced carcinoma of the prostate. Cancer 66: 1058-1066, 1990. 3. Furr BJ: Casodex (ICI 176,334)-A new, pure, peripherallyselective antiandrogen: preclinical studies. Horm Res 32 (suppl 1): 69-76, 1989. 4. Crawford ED, Eisenberger MA, McLeod DG, Spaulding JT, Benson R, Dorr FA, Blumenstein BA, Davis MA, and Goodman PJ: A controlled trial of leuprolide with and without flutamide in prostatic carcinoma. N Engl J Med 321: 419-424, 1989. 5. Wysowski DK, Frieman JP, Tourtelot JB, and Horton ML III: Fatal and nonfatal hepatotoxicity associated with flutamide. Ann Intern Med 118: 860-864, 1993. 6. Samson MK, Rivkin SE, Jones SE, Costanzi JJ, LoBuglio AF, Stephens RL, Gehan EA, and Cummings GD: Dose-response and dose-survival advantage for high- versus low-dose cisplatin combined with vinblastine and bleomycin in disseminated testicular cancer. A Southwest Oncology Group study. Cancer 53: 1029-1035,1984. 7. Kaisary AV, Tyrrell CJ, Peeling WB, and Griffiths K: Comparison of LHRH analogue (Zoladex) with orchiectomy in patients with metastatic prostatic carcinoma. Br J Uro167: 502-508, 1991. 8. Vogelzang NJ, Chodak GW, Soloway MS, Block NL, Schellhammer PF, Smith JA Jr, Caplan RJ, and Kennealey GT for the Zoladex Prostate Study Group: Goserelin versus orchiectomy in the treatment of advanced prostate cancer: final results of a randomized trial. Urology 46: 220-226, 1995.
Gore-Tex in Bolstering of Renal Parenchyma
FIGURE 1. Computed tomography scan of a 62-yearold male patient after 1 year of a left transverse partial nephrectomy for a solitary tumor of the upper renal segment. Core-Tex graft strips are shown as a linear radiopacity.
Closure Defects
TO THE EDITOR:
I read with great interest the article by Dr. Zincke and Dr. Ruckle on exogenous Gore-Tex material that was used to bolster the closure of parenchymal defects following parenchymal-sparing renal surgery (Urology 46: 96-98, 1995). During the last 4 years, I have used exactly the same technique in several patients with renal trauma, and benign or malignant renal conditions. The evolved experience indicates what the authors have already stated: the kidney can be reconstructed in a manner that is quick, hemostatic, watertight, and the least traumatic to the remaining renal tissue. Tying the horizontal mattress sutures over buttress material at the desired tension greatly decreases the likelihood of the sutures tearing through the parenchyma, while a more uniform tension across a broad front is applicated. GoreTex soft-tissue patch, which is made of expanded polytetrafluoroethylene, is biocompatible and a chemically inert, highly electronegative and microporous material that allows for good tissue ingrowth with infiltration of connective tissue and blood vessels and creating a thick, fibrous peel around it. The patch exerts minimal inflammatory reaction, and thus, is associated with a significant reduction in adhesion formation. The Gore-Tex patch has been used effectively in vascular surgery, and surgery of the head and neck, urogenital system, thorax, abdomen, and limbs for the reinforcement, suspension, and reconstruction of several organs with defects or under other abnormal conditions. It is of note, however, that although this exogenous material is radiolucent and after its application cannot be seen in x-ray plain films, it can be seen as a radiodense plaque on UROLOGY~ 46 (6), 1995
FIGURE 2. Computed tomography scan of a 36year-old female patient 9 months after resection of the left hydronephrotic, nonfunctional renal segment of a horseshoe kidney. Core-Tex, seen as a radiodense plaque, was positioned at the right margin of isthmus which was composed of normal renal tissue.
computed tomography scan (Figs. 1 and 2). The physicians must be aware of this radiologic feature in order to avoid any follow-up diagnostic confusion. Michael
D. Melekos, M.D. Department of LJrology University of Patras School of Medicine Greece
Cryoablation
of the Prostate
TO THE EDITOR:
The June 1995 issue of UROLOGY” has two articles concerning cryoablation of the prostate (Complications of Cryosurgical Ablation of the Prostate to Treat Localized Adenocarcinoma of the Prostate. Urology 45: 932-935, 1995) by Cox and Crawford (Salvage Radical Prostatectomy 901
After Failed Transperineal Cryotherapy: Histologic Findings from Prostate Whole-Mount Specimens Correlated with Intraoperative Transrectal Ultrasound Images. Urology 45: 936-941, 1995) by Grampsas, Miller, and Crawford. These articles are substantially different from our findings at Crittenton Hospital in Rochester Hills, Michigan.’ Among 210 patients treated by cryoablation of the prostate, urethrorectal fistula was noted in 5 patients (2.4%) and bladder outlet obstruction in 6 patients (2.9%), with 2 requiring transurethral prostatectomy (1.0%). Many patients experienced self-limited penile and scrotal edema, urgency, and hematuria. Of the 130 patients with a minimal follow-up of 6 months, total incontinence was noted in 3 patients (2.3%), stress incontinence in 8 patients (6.2%), and pelvic pain and dysuria in 2 (1.5%). Among the 27 patients who were potent prior to cryoablation by 1 year, 9 (33%) maintained potency. Serious complications occurred in our first 50 patients representing our learning curve. We agree with the University of Colorado experience that complications are higher following radiotherapy. Total urinary incontinence was noted only among patients with prior radiotherapy. Total urinary incontinence was documented in 3 of 27 patients (11%) with prior radiotherapy, and 0 of 102 patients without radiotherapy. We believe that the striking difference between our results and those published in the June issue of UROLCGYa is related to a different technical approach.* We perform cryoablation of the prostate with a urologist working in conjunction with a radiologist subspecializing in interventional ultrasonography. We believe that this team approach takes advantage of the strengths of both disciplines. The quality of the ultrasound machine used is also an important factor; most radiologists have access to superior ultrasound scanners than do urologists. We use a model EUB-515 scanner (Hitachi Medical Systems, Tarrytown, NY) with a 5.0 to 6.5 end fire probe and a 5.0 to 7.0 MHz biplane probe, with color Doppler and spectral analysis. Cryoablation is technically easier to perform on small prostate glands. Pretreatment combination hormonal therapy consisting of a luteinizing hormone-releasing hormone agonist combined with flutamide is used to downsize and in some cases downstage tumors, Typically, patients with clinical Stage A and B disease are treated for 3 months and those with clinical Stage C disease for 6 months. If the prostate is small, there will be greater freezing of periprostatic tissue with the resultant ice ball which is beneficial to patients with Stage C disease. Cryoablation is performed only if the total prostate volume is 40 cc or less. We have observed that combination hormonal therapy also increases the deposition of adipose tissue in Denonvilliers’ fascia, adding an extra margin of safety in the rectum. The geometry of the prostatic apex is an important factor in cryoprobe placement. A flat gland with a wide apex require the cryoprobes to be inserted further apart than a triangular-shaped gland with a narrow apex. In the latter instance, cryoprobe placement requires a freehand technique resulting in the cryoprobes actually crisscrossing externally, close to each other in the prostatic apex, and diverging toward the prostatic base, Positioning the cryoprobes close to each other at the mid-
902
line of the prostatic apex helps to prevent the apical ice ball from extending to the lateral margin of the prostatic fossa and external urinary sphincter. We routinely use at least five thermosensors located at the anterior fibromuscular stroma just below Santorini’s plexus, right and left lateral prostatic capsule at the level of the neurovascular bundle, the middle of the prostate at the seminal vesicle confluence, and the prostatic apex. This ensures attainment of temperatures of less than -20°C thoughout the entire prostate gland. It is impossible to make this assessment based on sonographic or Doppler findings after the ice ball has been formed. We employ a two-freeze technique; during the first freeze the prostatic base is treated. The second freeze often requires a pullback of the cryoprobes for treatment of the prostatic apex. Cracking of the prostate can be reduced by not freezing below -50°C anteriorly and by waiting for the prostate to thaw to 0°C before cryoprobe pullback or removal. Prostatic cracking results in an increased incidence of urinary retention, hematuria, and pelvic pain secondary to hematoma. In summary, we believe that results can be significantly improved if, (1) cyroablation is performed in conjunction with a radiologist specializing in interventional ultrasonography; (2) with state-of-the-art ultrasound scanners; (3) minimizing the size of the prostate by pretreatment combination hormonal therapy; (4) limiting this procedure to glands not larger than 40 cc; (5) utilize proper cryoablation probe placement accounting for the geometry of the prostate apex; (6) using thermocouples to monitor intraprostatic temperatures; (7) a two-freeze technique; (8) waiting for an adequate thawing before repositioning or removing cryoprobes; and (9) use of an adequate urethral-warming device. It is our experience that the complication rate is low after a steep learning curve. We have now treated nearly 400 patients with this technique and find the complication rate to be acceptable to our patients. Robert A. Badalament, M.D. Fred Lee, M.D. Duke K. Bahn, M.D. Gerald F. Wery, M.D. Anil Kumar, M.D. Crittenton Hospital Rochester Hills, Michigan REFERENCES
Bahn DK, Lee F, Solomon MH, Gontina H, Klionsky DL, and Lee FT Jr.: Prostate cancer: US-guided percutaneous cryoablation. Work in progress. Radiology 190: 551-556, 1.
1994.
2. Lee F, Bahn DK, McHugh TA, Onik GM, and Lee FT Jr.: US-guided percutaneous cryoablation of prostate cancer. Radiology 192: 769-776, 1994.
TO THE EDITOR:
Two articles appeared detailing the complications and failure of cryosurgery in treating adenocarcinoma of the prostate from the University of Colorado Health Sciences UROLOGYa 46 (61, 1995
Gore-Tex in Bolstering of Renal Parenchyma
FIGURE 1. Computed tomography scan of a 62-yearold male patient after 1 year of a left transverse partial nephrectomy for a solitary tumor of the upper renal segment. Core-Tex graft strips are shown as a linear radiopacity.
Closure Defects
TO THE EDITOR:
I read with great interest the article by Dr. Zincke and Dr. Ruckle on exogenous Gore-Tex material that was used to bolster the closure of parenchymal defects following parenchymal-sparing renal surgery (Urology 46: 96-98, 1995). During the last 4 years, I have used exactly the same technique in several patients with renal trauma, and benign or malignant renal conditions. The evolved experience indicates what the authors have already stated: the kidney can be reconstructed in a manner that is quick, hemostatic, watertight, and the least traumatic to the remaining renal tissue. Tying the horizontal mattress sutures over buttress material at the desired tension greatly decreases the likelihood of the sutures tearing through the parenchyma, while a more uniform tension across a broad front is applicated. GoreTex soft-tissue patch, which is made of expanded polytetrafluoroethylene, is biocompatible and a chemically inert, highly electronegative and microporous material that allows for good tissue ingrowth with infiltration of connective tissue and blood vessels and creating a thick, fibrous peel around it. The patch exerts minimal inflammatory reaction, and thus, is associated with a significant reduction in adhesion formation. The Gore-Tex patch has been used effectively in vascular surgery, and surgery of the head and neck, urogenital system, thorax, abdomen, and limbs for the reinforcement, suspension, and reconstruction of several organs with defects or under other abnormal conditions. It is of note, however, that although this exogenous material is radiolucent and after its application cannot be seen in x-ray plain films, it can be seen as a radiodense plaque on UROLOGY~ 46 (6), 1995
FIGURE 2. Computed tomography scan of a 36year-old female patient 9 months after resection of the left hydronephrotic, nonfunctional renal segment of a horseshoe kidney. Core-Tex, seen as a radiodense plaque, was positioned at the right margin of isthmus which was composed of normal renal tissue.
computed tomography scan (Figs. 1 and 2). The physicians must be aware of this radiologic feature in order to avoid any follow-up diagnostic confusion. Michael
D. Melekos, M.D. Department of LJrology University of Patras School of Medicine Greece
Cryoablation
of the Prostate
TO THE EDITOR:
The June 1995 issue of UROLOGY” has two articles concerning cryoablation of the prostate (Complications of Cryosurgical Ablation of the Prostate to Treat Localized Adenocarcinoma of the Prostate. Urology 45: 932-935, 1995) by Cox and Crawford (Salvage Radical Prostatectomy 901
After Failed Transperineal Cryotherapy: Histologic Findings from Prostate Whole-Mount Specimens Correlated with Intraoperative Transrectal Ultrasound Images. Urology 45: 936-941, 1995) by Grampsas, Miller, and Crawford. These articles are substantially different from our findings at Crittenton Hospital in Rochester Hills, Michigan.’ Among 210 patients treated by cryoablation of the prostate, urethrorectal fistula was noted in 5 patients (2.4%) and bladder outlet obstruction in 6 patients (2.9%), with 2 requiring transurethral prostatectomy (1.0%). Many patients experienced self-limited penile and scrotal edema, urgency, and hematuria. Of the 130 patients with a minimal follow-up of 6 months, total incontinence was noted in 3 patients (2.3%), stress incontinence in 8 patients (6.2%), and pelvic pain and dysuria in 2 (1.5%). Among the 27 patients who were potent prior to cryoablation by 1 year, 9 (33%) maintained potency. Serious complications occurred in our first 50 patients representing our learning curve. We agree with the University of Colorado experience that complications are higher following radiotherapy. Total urinary incontinence was noted only among patients with prior radiotherapy. Total urinary incontinence was documented in 3 of 27 patients (11%) with prior radiotherapy, and 0 of 102 patients without radiotherapy. We believe that the striking difference between our results and those published in the June issue of UROLCGYa is related to a different technical approach.* We perform cryoablation of the prostate with a urologist working in conjunction with a radiologist subspecializing in interventional ultrasonography. We believe that this team approach takes advantage of the strengths of both disciplines. The quality of the ultrasound machine used is also an important factor; most radiologists have access to superior ultrasound scanners than do urologists. We use a model EUB-515 scanner (Hitachi Medical Systems, Tarrytown, NY) with a 5.0 to 6.5 end fire probe and a 5.0 to 7.0 MHz biplane probe, with color Doppler and spectral analysis. Cryoablation is technically easier to perform on small prostate glands. Pretreatment combination hormonal therapy consisting of a luteinizing hormone-releasing hormone agonist combined with flutamide is used to downsize and in some cases downstage tumors, Typically, patients with clinical Stage A and B disease are treated for 3 months and those with clinical Stage C disease for 6 months. If the prostate is small, there will be greater freezing of periprostatic tissue with the resultant ice ball which is beneficial to patients with Stage C disease. Cryoablation is performed only if the total prostate volume is 40 cc or less. We have observed that combination hormonal therapy also increases the deposition of adipose tissue in Denonvilliers’ fascia, adding an extra margin of safety in the rectum. The geometry of the prostatic apex is an important factor in cryoprobe placement. A flat gland with a wide apex require the cryoprobes to be inserted further apart than a triangular-shaped gland with a narrow apex. In the latter instance, cryoprobe placement requires a freehand technique resulting in the cryoprobes actually crisscrossing externally, close to each other in the prostatic apex, and diverging toward the prostatic base, Positioning the cryoprobes close to each other at the mid-
902
line of the prostatic apex helps to prevent the apical ice ball from extending to the lateral margin of the prostatic fossa and external urinary sphincter. We routinely use at least five thermosensors located at the anterior fibromuscular stroma just below Santorini’s plexus, right and left lateral prostatic capsule at the level of the neurovascular bundle, the middle of the prostate at the seminal vesicle confluence, and the prostatic apex. This ensures attainment of temperatures of less than -20°C thoughout the entire prostate gland. It is impossible to make this assessment based on sonographic or Doppler findings after the ice ball has been formed. We employ a two-freeze technique; during the first freeze the prostatic base is treated. The second freeze often requires a pullback of the cryoprobes for treatment of the prostatic apex. Cracking of the prostate can be reduced by not freezing below -50°C anteriorly and by waiting for the prostate to thaw to 0°C before cryoprobe pullback or removal. Prostatic cracking results in an increased incidence of urinary retention, hematuria, and pelvic pain secondary to hematoma. In summary, we believe that results can be significantly improved if, (1) cyroablation is performed in conjunction with a radiologist specializing in interventional ultrasonography; (2) with state-of-the-art ultrasound scanners; (3) minimizing the size of the prostate by pretreatment combination hormonal therapy; (4) limiting this procedure to glands not larger than 40 cc; (5) utilize proper cryoablation probe placement accounting for the geometry of the prostate apex; (6) using thermocouples to monitor intraprostatic temperatures; (7) a two-freeze technique; (8) waiting for an adequate thawing before repositioning or removing cryoprobes; and (9) use of an adequate urethral-warming device. It is our experience that the complication rate is low after a steep learning curve. We have now treated nearly 400 patients with this technique and find the complication rate to be acceptable to our patients. Robert A. Badalament, M.D. Fred Lee, M.D. Duke K. Bahn, M.D. Gerald F. Wery, M.D. Anil Kumar, M.D. Crittenton Hospital Rochester Hills, Michigan REFERENCES
Bahn DK, Lee F, Solomon MH, Gontina H, Klionsky DL, and Lee FT Jr.: Prostate cancer: US-guided percutaneous cryoablation. Work in progress. Radiology 190: 551-556, 1.
1994.
2. Lee F, Bahn DK, McHugh TA, Onik GM, and Lee FT Jr.: US-guided percutaneous cryoablation of prostate cancer. Radiology 192: 769-776, 1994.
TO THE EDITOR:
Two articles appeared detailing the complications and failure of cryosurgery in treating adenocarcinoma of the prostate from the University of Colorado Health Sciences UROLOGYa 46 (61, 1995