The Effect of Androgen Deprivation Therapy Before Salvage Whole-gland Cryoablation After Primary Radiation Failure in Prostate Cancer Treatment.

OBJECTIVE: To define the effects of androgen deprivation therapy (ADT) used prior to salvage cryoablation (SC) for the treatment of recurrent localized prostate cancer after radiation. METHODS: Patients from the Cryo On-Line Database registry undergoing SC after radiation failure were divided according to whether they had previously received or not received ADT. Baseline characteristics including demographics and presalvage cancer risk were compared. Biochemical progression-free survival (bPFS) as defined by the Phoenix criteria was compared between the 2 groups as a whole and also in D'Amico risk-stratified subgroups. In addition, postsurgical complications such as urinary fistula, retention, incontinence, and erectile dysfunction were compared. RESULTS: Two groups consisting of 254 and 486 patients with and without pre-SC ADT were analyzed. The patients who received ADT were younger (P = .003) and had higher presalvage D'Amico risks (P <.001). The 5-year bPFS was 63.8% and 39.3% for the hormone-naïve and the pre-SC ADT patients, respectively (P <.001). On subgroup analysis, the difference in 5-year bPFS was significant only for patients with a high D'Amico cancer risk (54.3% vs 30.5%; P = .013). On multivariate analysis, presalvage prostate-specific antigen (hazard ratio [HR], 1.7), Gleason score ≥ 8 (HR, 2.5), and use of pre-SC ADT (HR, 1.7) correlated with biochemical recurrence. Additionally, patients receiving pre-SC ADT experienced less urinary retention (P = .001) and incontinence (P = .008) but were more likely to be impotent (P = .010). CONCLUSION: Patients receiving ADT before SC, especially those with high-risk prostate cancer, had worse 5-year bPFS. Added caution is needed when selecting patients having previously received ADT for salvage cryotherapy.

Hybrid transureteral nephrectomy in a survival porcine model.

BACKGROUND AND OBJECTIVES: Natural-orifice approaches for nephrectomy have included access via the stomach, vagina, bladder, and rectum. Recently, the feasibility of using the ureter as a natural orifice for natural-orifice transluminal endoscopic surgery nephrectomy has been demonstrated in a nonsurvival porcine model. The purpose of this study was to assess the outcomes of transureteral laparoscopic natural-orifice transluminal endoscopic surgery nephrectomy in a survival porcine model. METHODS: Three pigs underwent hybrid transureteral natural-orifice transluminal endoscopic surgery nephrectomy. An experimental balloon/dilating sheath was inserted over a wire to dilate the urethra, ureteral orifice, and ureter. Through a bariatric 12-mm laparoscopic port, the ureter was opened medially and the hilar dissection was performed. Next, 2 needlescopic ports were placed transabdominally to facilitate hilar transection. The kidney was morcellated using a bipolar sealing device and extracted via the ureter using the housing of a bariatric stapling device. The ureteral orifice was closed with a laparoscopic suturing device. The bladder was drained by a catheter for 10 to 14 days postoperatively. Pigs were euthanized on postoperative day 21. RESULTS: All surgical procedures were successfully completed, with no intraoperative complications. One pig had an episode of postoperative clot retention that resolved with catheter irrigation. Each pig was healthy and eating a normal diet prior to euthanasia. CONCLUSIONS: This study demonstrates the feasibility of a hybrid transureteral approach to nephrectomy in a survival porcine model. This technique avoids the intentional violation of a second organ system and the risk for peritoneal contamination. Improved instrumentation is needed prior to implementation in the human population.

A prospective analysis of robotic tip cover accessory failure.

BACKGROUND AND PURPOSE: The robotic monopolar scissors tip cover accessory (TCA) is an insulation device that prevents current leak from surfaces on the instrument other than the scissors tip. Reports of insulation failure and patient injury have been made but not systematically studied. We investigate the incidence of TCA failure and potential mechanisms that lead to malfunction. MATERIALS AND METHODS: Eighty TCAs (40 first and 40 second generation) were collected after a single urologic or gynecologic surgery at a single academic institution. Each TCA was inspected for damage under a microscope. Current leak was measured in an electrolysis solution, and electrical arcing was tested in a porcine kidney model. Log-rank and Friedman two-way analysis of variance by ranks compared failure at different angulations and power settings. Chi-square analysis compared failure between first and second generation TCAs (f-TCAs and s-TCAs). RESULTS: Visible insulation defects were detected in 39% of f-TCAs (size range <0.5-2.75 mm). Electrical arcing was observed in 33% of f-TCAs. Arcing increased with greater wrist angulation (P=0.014) and higher power settings (P=0.048). Minor damage was observed in 25% of s-TCAs. No electrical arcing was observed in any of the s-TCAs despite angulation and power strain. s-TCAs demonstrated significantly less failure than f-TCAs (P<0.001). CONCLUSION: In this study, 33% of f-TCAs demonstrated insulation failure after a single surgical use. f-TCA failure increased with greater wrist angulation and electrical power. The improved design of s-TCAs demonstrated no current leak or arcing on ex-vivo testing and appears to have significantly decreased failure potential. Centers still using the f-TCA should transition to the s-TCA and be vigilant in reporting device failures to prevent unnecessary patient morbidity.

In automated fluoroscopy settings, does shielding affect radiation exposure to surrounding unshielded tissues?

BACKGROUND AND PURPOSE: Automatic brightness control (ABC), a function of modern fluoroscopy machines, adjusts radiation intensity in real time to enhance image quality. While shielding reduces radiation exposure to protected areas, it is unknown how much radiation adjacent unshielded areas receive when using ABC settings. Our purpose was to assess radiation dosage to shielded and unshielded tissue when using fluoroscopic ABC mode compared with fixed exposure settings. MATERIALS AND METHODS: In a simulated ureteroscopy, thermoluminescent dosimeters (TLDs) were placed at three sites in a female human cadaver, including the right renal hilum, right distal ureter adjacent to the uterus, and directly over the uterus. The cadaver received 60 seconds of radiation exposure using a C-arm fluoroscopy system under ABC and fixed settings (1.38 mAs, 66 kVp) with and without uterine shielding. Radiation dosage absorbed by the TLDs was compared using two-way analysis of variance and least-squares confidence intervals. RESULTS: Shielding significantly reduced radiation dose to the uterus by 62% and 82% (P<0.05 for both) in ABC and fixed settings, respectively. Shielding of the uterus in ABC, however, resulted in an approximately twofold increase in radiation dosage to the ureter and ipsilateral kidney (P<0.05 for both) and a decrease in image quality. Using fixed settings, shielding of the uterus did not increase radiation dose to the ipsilateral ureter and kidney. CONCLUSION: There is a significant increase in radiation dosage to surrounding tissues when shielding is used with ABC mode during fluoroscopy. Radiation can be reduced and image quality improved by using fixed settings when shielding is indicated.

Prostate specific antigen levels and prostate cancer detection rates in patients with end stage renal disease.

PURPOSE: Patients with end stage renal disease plus prostate cancer are ineligible to receive a renal transplant at most centers until an acceptable cancer-free period is demonstrated. To our knowledge previously established prostate specific antigen reference ranges have not been validated in patients with end stage renal disease. We determined age stratified 95th percentile prostate specific antigen reference ranges and the prostate cancer detection rate at specific prostate specific antigen intervals for patients with end stage renal disease. MATERIALS AND METHODS: We retrospectively reviewed the records of 775 male patients with end stage renal disease on the waiting list for a renal transplant who had undergone a serum prostate specific antigen test. Prostate specific antigen was stratified by age at the time of the blood test and 95th percentile reference ranges were calculated for each decade. A total of 80 patients underwent prostate biopsy for increased prostate specific antigen and/or abnormal digital rectal examination. The cancer detection rate was calculated for specific prostate specific antigen reference ranges. RESULTS: The age specific 95th percentile prostate specific antigen references ranges were 0 to 4.0 ng/ml for ages 40 to 49 in 137 patients, 0 to 5.3 ng/ml for ages 50 to 59 in 257, 0 to 10.5 ng/ml for ages 60 to 69 in 265 and 0 to 16.6 ng/ml for ages 70 to 79 years in 69. The cancer detection rate was 44%, 38% and 67% for prostate specific antigen 2.5 to 4.0, 4 to 10 and greater than 10 ng/ml, respectively. CONCLUSIONS: In our study population of patients with end stage renal disease age stratified prostate specific antigen was higher than in the general population. The cancer detection rate was increased in our patients with end stage renal disease compared to that in patients with normal renal function at specific prostate specific antigen intervals. Lower prostate specific antigen cutoffs may be appropriate to recommend prostate biopsy in patients with end stage renal disease.