MP-18.15: Visually-directed primary HIFU for treating localised prostate cancer: determinants of PSA kinetics

MODERATED POSTER SESSIONS

Table 1. MP-18.13 Operation open retropubic laparoscopic robotic open retropubic laparoscopic robotic open retropubic laparoscopic robotic

Domain quality of life quality of life quality of life urinary function urinary function urinary function sexual function sexual function sexual function

Median 5.0 5.0 5.5 6.0

Mean 5.18 4.74 5.27 5.34

SD 0.73 1.36 1.23 1.22

P-value

5.0

4.61

1.96

0.025

6.0

5.83

1.05

2.0 1.0 2.5

2.42 1.70 2.85

1.60 1.26 2.03

Materials & Methods: Fifty consecutive patients operated in Sophiahemmet (open retropubic prostatectomy), Akademiska Sjukhuset in Uppsala (laparoscopic prostatectomy) and Karolinska Sjukhuset (robotic prostatectomy) until 1.5.2005 by experienced urological surgeons (SB, MH) were sent a detailed questionnaire. The questionnaire had three domains assessing quality of life, urinary function and sexual function with a VAS scale (range 1-7) and with multiple choice questions (mcq:s). Statistic significance of VAS scale results was assessed by Kruskal-Wallace test and multiple choice question results by Fischer’s exact test. Results: 72% of patients filled and returned the questionnaire. The VAS scale results of the three domains are shown in the table: Mcq:s for occurrence of stress urinary incontinence showed “no” answers in 56.8%, 37.8% and 70.6% in open, laparoscopic and robotically operated patients, respectively (p:0.024). Mcq:s for the need of protective pads showed usage of ⬍1 pad/day in 83.8%, 54.0% and 73.5% in open, laparoscopic and robotically operated patients, respectively (p:0.110). IIEF5 sum for the open, laparoscopic and robotic patient was 8.19(⫾7.71), 5.57(⫾7.60) and 7.37(⫾7.61), respectively (p:0.101). Conclusion: While endoscopic prostatectomy has been shown to result in a lower postoperative morbidity, it shows similar long term quality of life outcomes as open retropubic prostatectomy. A comparison of operative techniques showed differences in the urinary and sexual function domains with the highest scores in the robotically operated patients and the lowest in the laparoscopic group. Similar scores were seen between open and robotically operated patients. The difference between the patients operated laparoscopically vs. robotically is likely to be

0.180

0.032

due to the longer learning curve of the laparoscopic operation technique. MP-18.14 Seed migration rate to the chest following permanent prostate brachytherapy is markedly reduced with the use of seeds in vicryl suture material Davis B, Goulet C, Furutani K, Mynderse L, Wilson T Mayo Clinic, Rochester, MN, USA Objective: Seed migration to the chest is known to occur following permanent prostate brachytherapy (PPB) and has been associated with an adverse coronary event in one report. Rates of seed migration from loose seeds (LS), mixed loose and stranded seeds (MS), and stranded seeds implanted in an absorbable vicryl suture (VS) (Rapid STRAND™) are compared. Materials & Methods: Between 5/98 and 1/07, 700 patients underwent PPB at our institution. A total of 556 consecutive patients who had a follow-up diagnostic chest x-ray are the study population. PPB under ultrasound and fluoroscopic guidance was performed with: 1) Mick applicator with placement of individual LS, 386 pts; 2) mixed Mick application of LS and placement of VS, 39 pts; or 3) exclusive placement of VS, 131 pts. The mean number of seeds implanted was 116 (49 –214), 103 (71–157), and 83 (56

–116)(p⬍0.001) in the first 495 patients, respectively. Mean time to chest x-ray following PPB was ⬍ 150 days in all cases. The number of seeds migrating to the chest was recorded and correlated with the type of seed implant. Results: Seed migration rates to the chest between the LS, MS, and VS groups is 0.75% (338/44,960 seeds), 0.12% (5/4,032 seeds), and 0.009% (1/10,884 seeds) respectively. The percentage of patients in each group who had a seed migrate to the chest is 46.4%, 10.3%, and 0.8%, and the mean number of seeds to migrate to the chest per implant is 0.9, 0.13, and 0.008 respectively. Overall, the rates of seed migration between these 3 groups are statistically significant by Poisson regression modeling (p ⬍ 0.0001). Pairwise comparisons of these 3 groups show the rate of seed migration in the LS group is significantly higher than the MS (p ⬍ 0.0005) and VS groups (p ⬍ 0.0001). Conclusions: Seed migration is substantially reduced with the use of seeds in vicryl suture material. A markedly lower rate of seed migration to the chest is observed when implants are performed using 100% seeds in vicryl suture material suggesting that further reduction in the migration rate is possible beyond those reported in studies using MS implants. MP-18.15 Visually-directed primary HIFU for treating localised prostate cancer: determinants of PSA kinetics Zacharakis E2, Ahmed HU1, Ishaq A1, Scott R1, Illing R2, Shaw G1, Calleary J1, Allen C2, Emberton M1 1 The Institute of Urology and Nephrology, Division of Surgical and Interventional Sciences, University College London, UK; 2The Department of Academic Radiology, University College Hospitals NHS Foundation Trust, UK Objectives: High intensity focused ultrasound (HIFU) has been used for the primary treatment of organ-confined prostate cancer (PCa). Visually-directed HIFU has been proposed as a standard for the con-

Table 1. MP-18.15 Risk Category Low Intermediate High

UROLOGY 70 (Supplment 3A), September 2007

PSA Nadir ng/ml n % n % n %

<0.05 23 64 20 39 5 22

>0.05-<0.2 5 11 16 30 9 41

0.2-<1 12 28 11 21 6 22

>1 3 7 5 10 2 15

Total 43 100% 52 100% 22 100%

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MODERATED POSTER SESSIONS

duct of therapy for the Sonablate®500 device allowing the user to adapt energy deposition based on immediate feedback from real-time ultrasound changes. This study aimed to evaluate the outcomes in a cohort who had primary HIFU treatment using PSA nadir as a surrogate for oncological effectiveness. Materials & Methods: Between February 2005 and December 2006, 117 men with presumed organ-confined disease treated with HIFU were included. All were treated under general anaesthetic in a single session. Patients were stratified using D’Amico’s risk categories. The percentage of men achieving a PSA nadir ⱕ0.2ng/mL or unrecordable (⬍0.05ng/ml) in each risk group was analysed. 43 men were included in the low-risk group, 52 men in the intermediate-risk group and 22 men in the high-risk group. Results: Mean age was 64 years (range 47-80 years) whilst mean follow-up was 453 days (range 69-744 days). 12 had hormonal therapy for 3 months prior to HIFU as cytoreduction to allow full gland coverage. In the low-intermediate group, 67% (64/95) achieved a PSA nadir of ⱕ0.2ng/ml and two-thirds of these were unrecordable. Overall, when including the high-risk category this did not change the achievement of this robust PSA level with 67% (78/117) achieved a PSA nadir of ⱕ0.2ng/mL and almost two-thirds of this group achieved unrecordable levels (⬍0.05ng/mL). We analysed the determinants of a low PSA nadir (ⱕ0.2ng/mL) by evaluating the effect of prostate size, operator experience (early versus late in the learning curve), degree of calcification, disease stage and grade and other risk parameters on biopsy (50% core involvement, 50% of cores involved with PCa) and level of PSA at diagnosis in a predictive logistic regression model. Conclusions: Visually-directed HIFU in men with localised PCa can achieve the accepted robust PSA nadir of 0.2ng/ml at 3 months post-treatment whilst most of this group achieve unrecordable levels. This data demonstrates the efficacy of this treatment modality in terms of PSA kinetics. Further analysis will attempt to correlate PSA kinetics with long-term clinical outcome.

MP-18.16 Modified transverse Pfannenstiel and vertical minilaparotomy incisions provide excellent exposure, minimal perioperative pain, and excellent

140

cosmesis in patients undergoing radical retropubic prostatectomy Kava BR, Soloway C, Manoharan M, Soloway MS University Of Miami/Miller School of Medicine, Miami, FL, USA

hospital. They both provide highly satisfactory cosmetic results for the patient.

Objectives: A modified transverse Pfannenstiel incision and a vertical minilaparotomy incision have been proposed as alternatives to the traditional midline incision that is used in patients undergoing a radical retropubic prostatectomy (RRP). A detailed assessment of: the technical aspects of these incisions, postoperative pain and analgesic requirements, mean hospital stay and convalescence, as well as individual patient’s attitudes to these incisions was undertaken. Materials & Methods: Consecutive patients undergoing RRP at one center were offered participation in this IRB- approved, randomized, prospective study. Patients were randomized to undergo RRP using either: a 7cm modified transverse Pfannenstiel incision (Group 1) or a 7cm vertical minilaparotomy incision (Group 2). All patients completed a demographics questionnaire and the UCLA-Prostate Cancer Index. Estimated blood loss (EBL), time of surgery, and the technical difficulty of surgery as perceived by the attending surgeon were compared. Postoperative pain scores were compared using a visual analog scale and analgesic requirements were compared using morphine equivalents. The Patient and Observer Scar Assessment Scale (POSAS), was used to assess the cosmetic outcome that was perceived by both the patient and the physician following surgery. Results: Sixty patients were randomized. Each group was balanced with respect to: age, body mass index, ethnicity, education, work status, and overall health. Mean operative time, EBL, postoperative pain score, analgesic use, and technical difficulty were not significantly different between the two incisions. No patient required transfusion, there were no wound complications and the POSAS indicated high levels of cosmetic success with both incisions. 98% of patients reported that the incision did not alter their appearance, and 96% noted that it did not change their life. Conclusions: A modified transverse Pfannenstiel incison and a vertical minilaparotomy incision offer alternatives to the standard midline longitudinal radical prostatectomy incision. Both incisions are: safe, associated with little postoperative pain, allow for early convalescence and a short postoperative length of stay in the

MP-18.17 Retrospective analysis of the distance between neurovascular bundle and prostate cancer foci in radical prostatectomy specimen - clinical implication of nerve-sparing surgery Shiina H, Urakami S, Inoue S, Hiraoka T, Sumura M, Igawa M Shimane University, Izumo, Japan Introduction: The indications for the usage of the nerve sparing modification of radical prostatectomy (NS-RP) technique in localized prostate cancer (PC) remain an issue of controversy. Accurate understanding of the anatomical relationship between PC foci and neurovascular bundle (NVB) is mandatory to establish the proper indications for NS-RP. The purposes of this study are to analyze the distance between NVB and PC foci (N-T distance) on the RP specimens and to identify the predictor for the N-T distance securing the preservation of ipsilateral NVB. Methods: Two hundred and forty-five PC patients who underwent radical prostatectomy (RP) through perineal or retropubic approach between June 2000 and November 2006 were used. The analysis focused on 302 PC foci (192 cases), which at least involved the postero-lateral region of the prostate. The N-T distance was measured ipsilaterally or bilaterally in the cases with unilateral NS-RP (107 cases) or bilateral non-NS-RP (85 cases). The N-T distance was separately measured in the regions of apex, middle and base, and was analyzed in its correlation with maximum diameter and Gleason score of PC foci, and preoperative PSA value. Results: The mean N-T distance was 2.98, 2.95 and 3.03 mm in the apex (216 foci), middle (195 foci) and base (80 foci), respectively. The corresponding mean N-T distance with extraprostatic extension (EPE) was 2.01, 1.95 and 1.85 mm, respectively. In the apex, the N-T distance was significantly associated with both tumor size and preoperative PSA value (p ⬍ 0.0001 and p ⬍ 0.05, respectively). Logistic regression analysis revealed that highrisk PC (PSA value ⱖ 4.0 ng/ml and tumor size ⱖ 2.0 cm) was 8.3 times more likely to have short N-T distance (⬍ 2.5 mm) compared with low-risk PC (PSA ⬍ 4.0 ng/ml and tumor size ⬍ 2.0 cm) (p⬍0.01; 95 % CI: 2.05- 33.6). In the base, tumor size was a paramount discriminator between short (⬍ 2.5 mm) and long (ⱖ 2.5 mm) N-T distance (p ⬍ 0.01); however,

UROLOGY 70 (Supplment 3A), September 2007