Biochemical control and toxicity for favorable- and intermediate-risk patients using real-time intraoperative inverse optimization prostate seed implant: Less is more!

PURPOSE: To report the biochemical control rate and clinical outcomes with real-time inverse planning (inverse optimization prostate seed implant [IO-PSI]) for favorable-risk (FR) and intermediate-risk (IR) prostate adenocarcinoma in a community practice setting. This analysis is an extended followup of our initial report, with favorable early biochemical control rate (biochemical nonevidence of disease) of 97% at 4 years. METHODS AND MATERIALS: Three hundred fifty-seven evaluable patients with FR and IR prostate cancer underwent real-time IO-PSI (iodine-125/145 Gy or palladium-103/120 Gy) between 2001 and 2013. RESULTS: With a median followup of 54 months (range, 24-110 months), the absolute biochemical failure free survival of disease was 96%. The 8-year actuarial probability of prostate-specific antigen failure-free survival for FR and IR cohorts was 92.4% and 87%, respectively. Late genitourinary and gastrointestinal toxicity remained low. Late Grade 2 and Grade 3 genitourinary toxicity was 19% and 1%, respectively. Late Grade 2 and 3 rectal bleeding rates were 1% and 0%, respectively. No difference in biochemical control was observed with preimplant short course androgen deprivation or between Gleason score 3 + 4 vs. 4 + 3 patients. No dosimetric parameter was predictive of biochemical failure. Patients with FR had a significantly decreased risk of failure (hazard ratio = 0.26; 95% confidence interval = 0.09-0.78; p = 0.02) compared with those with IR. Patients with a prostate-specific antigen nadir >0.4 ng/mL had an increased risk of failure (hazard ratio = 1.37; 95% confidence interval = 1.27-1.47; p < 0.0001). CONCLUSIONS: Our initial biochemical and clinical outcomes using real-time IO-PSI persisted with extended followup and support our original hypothesis for use of a reduced number of sources, needles, and total activity, suggesting that with IO, less is more.

Nephron-sparing surgery.

This retrospective study examines partial nephrectomies performed over a period of approximately three years to confirm the feasibility of the procedure for suspected renal cell carcinoma. The surgeries were done primarily at a 1000-bed, university-affiliated hospital by members of a private urologic surgery practice. We examined whether recent advances in diagnosis and surgical therapy increased the viability of partial nephrectomy as an alternative to radical nephrectomy in certain carefully selected patients. Patients underwent preoperative evaluation to confirm suitability for partial nephrectomy. Surgeons used an extraperitoneal approach and mobilized the kidney after incising Gerota's fascia. Nearly one-third of the procedures involved renal cooling. Because three masses turned out to be benign cysts, and one tumor was an oncocytoma, four patients with benign disease were spared unnecessary radical nephrectomy. With an average follow-up of 32 months, all patients remain free of disease and are not dependent on dialysis. Our findings are consistent with those of national studies that show partial nephrectomy does not compromise disease-free survival in properly selected patients. The success of nephron-sparing surgery in this sample opens the door for exploration of more advanced, less invasive techniques for management of renal cell carcinoma.

Scrotal recurrence of paratesticular rhabdomyosarcoma in a previously undescended testicle 5 years after orchiectomy.

A case of scrotal recurrence of a paratesticular rhabdomyosarcoma 5 years after orchiectomy and chemotherapy is described. To our knowledge local recurrences have been reported previously only in the inguinal region. The patient had a history of orchiopexy, which may have contributed to the scrotal recurrence.

Use of the appendix in urologic reconstructive operation.

Advances in genitourinary operation have allowed use of an appendicovesicostomy in patients requiring chronic catheterization for bladder emptying. Recent discussions of the appropriateness of incidental appendectomy have ignored the potential usefulness of the appendix as a catheterizable stoma. We present our experience with the Mitrofanoff principle to illustrate the advantages of an appendicovesicostomy and make a plea against incidental appendectomy in certain patient groups.

Prepubertal vasal injury: its effect on postpubertal vas deferens.

At this institution, via clinical observation at laparoscopy, a phenomenon was noted in humans that was associated with injury to the prepubertal vas deferens. There were 4 cases that presented with apparent atrophy of the abdominal pelvic portion of the vas deferens following injury to the vas in the prepubertal period. A study was undertaken to see if this phenomenon could be duplicated in an animal model. Prepubertal Sprague-Dawley rats were selected and divided into several groups ranging from sham surgery to unilateral partial vasectomy. These groups allowed for observations following different modes of trauma as well as creation of a control population. Additionally, an adult group was studied to evaluate the effects of vas injury in the adult rat. In the adult group, following trauma to the vas, no changes in the abdominal pelvic portion of the vas were noted. In the prepubertal group, with ligation and with segmental excision (partial vasectomy), striking diminution in outer diameter and wall thickness of the distal vas deferens was noted. This study indicates that the rat prepubertal vas serves as a good model for study of the human vas deferens. Further studies are underway which seek to elicit the mechanism of the observed injury.

Acute bilateral testicular torsion in the adolescent.

A case of acute bilateral testicular torsion in the adolescent is reported. This case reaffirms the need to perform bilateral scrotal exploration in cases of suspected torsion. Although it represents an extreme rarity, delay in exploration may have resulted in bilateral orchiectomy. The case also appears to be another example of intermittent testicular pain as a harbinger of impending torsion in a patient with the bell clapper deformity. Perhaps a more aggressive approach should be taken to explore patients surgically who present with intermittent scrotal pain.