MedWire News – Oncology – MRI useful for detecting tumors in men with rising PSA, negative biopsies

MedWire News: Magnetic resonance imaging (MRI) may be useful for detecting potentially missed prostate tumors in men with rising prostate-specific antigen (PSA) levels but negative biopsies, suggest review findings.

Nathan Lawrentschuk (University of Toronto, Ontario, Canada) and colleagues add that men wishing to initiate or remain on active surveillance (AS) may benefit from MRI by having any large cancers identified before embarking on treatment, or by having biopsies directed to zones of concern rather than standard follow-up areas of the prostate.

via MedWire News – Oncology – MRI useful for detecting tumors in men with rising PSA, negative biopsies.

I am not a user of routine MRIs in the treatment or diagnosing of prostate cancer, but these are two ways I have used MRIs.

I have seen patients with rising PSAs have MRIs that lead to tumor detection.  this is usually when the tumors are anterior (in the front part) of the prostate.  These areas are not usually biopsied.

I also obtain prostate MRIs in some of my active surveillance patients.

UroToday – Laparoscopic mesh herniorrhaphy: Impact on outcomes associated with radical retropubic prostatectomy

Source: Urotoday

Eighteen patients with a prior LMH underwent RRP. Five of the 18 had bilateral LMH, with unilateral LMH in the remainder. Outcomes in this group were compared with 38 patients without prior LMH. There was no difference between the groups in terms of age, preoperative PSA, prostate size, preoperative Gleason score, or body mass index, and RRP was successfully performed in all 18 LMH patients. One of 18 patients had a postoperative complication (persistent JP drainage). Compared with the control group, differences in operative time and blood loss bordered on statistical significance.

Prior LMH is not a contraindication to RRP. While resulting in slightly longer operating times and higher blood loss, our experience suggests that RRP can be safely performed in these patients.

This study from the Medical College of Wisconsin showed how radical prostatectomy can be performed safely after laparoscopic hernia surgery with mesh. My experience with robotic surgery has been similar. Robotic prostatectomy after laparoscopic hernia surgery takes a little more time, but is not too much of a problem.

The first step where the bladder is moved out of the way is more complicated and performing a pelvic lymph node dissection is more complicated as well. Patients of mine who are at risk of developing prostate cancer sometimes develop inguinal hernias. If they are considering undergoing laparoscopic hernia surgery with mesh, I am comfortable with given them the OK.

UroToday – Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair – Abstract

Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair

We found the incidence of concurrent prostate cancer with hernia to be low, but 51% of men had PSA values that suggested an increased relative risk of future development of prostate cancer. Men at increased risk of prostate cancer should be made aware of the impact that mesh might have on subsequent treatment options before mesh placement.

Many years ago it was thought that a prior laparoscopic hernia repair would be a major problem for a patient who had prostate cancer wanted a robotic prostatectomy.

Since 2003 the majority of robotic surgeons have performed robotic surgery through the abdominal cavity. With this approach, the bladder and blood vessels can safely be separated from the mesh with direct visualization.

I do not consider a prior hernia repair with mesh to be a significant concern prior to robotic surgery. The surgery should take a little longer, but removing the prostate is not a significant problem.

The only concern in patients that will undergo hernia repair is to make sure they do not have cancer at the present time. If they do and want surgery for prostate cancer, then a robotic hernia repair and robotic prostatectomy shoudl be done at the same time, avoiding 2 surgeries. I have performed over 100 of these combination hernia repairs and davinci prostatectomies.

UroToday – Nephroureteral Stent on Suction for Urethrovesical Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy

I found an abstract about a way to manage urinary ascites that can rarely happen after dvP.

Conventional measures, including catheter traction, passive drainage, and needle vented Foley catheter suction, failed. On postoperative day 6 a unilateral nephroureteral stent was placed on intermittent suction.

Placement of one nephroureteral stent on suction device immediately stopped the urinary anastomotic leakage into the peritoneal cavity.

In case of a persistent urinary leak after RALP that fails conservative management, a nephroureteral stent on suction may aid to stop the anastomotic leak.

I have seen this problem a few times in the past 5 years. The best way to manage it, in my opinion, is to place a drain laparoscopically by the surgeon if one does not exist. I found that interventional radiology does not place as large a drain or in as good a place.

While I am placing the drain laparascopically, I also perform a cystoscopy to attempt to place 5 fr ureteral catheters for urinary diversion. I think the most important thing is to push the foley in away from the bladder neck. I think foley traction on the anastamosis is what keeps the opening open.

Is the Complication Rate of Radical Cystectomy Predictive of the Complication Rate of Other Urological Procedures?

Source: UroToday

A higher hospital radical cystectomy volume appears to lead to a lower risk of complications only after other common urological oncological procedures, namely radical prostatectomy and nephrectomy, but not after nononcological urology procedures.

This abstract found that hospitals that performed radical cystectomy (removal of the bladder and surrounding tissue for bladder cancer) had less complcations for kidney and prostate cancer surgery as well.

I have been perfoming radical cystecomies my whole career and started perfoming these robotically 3 1/2 years ago. Although I thought performing the more complex surgery helpe me in other surgeries, I didnt realize that a study would show less complications for these other procedures.

The Prognostic Impact of Seminal Vesicle Involvement Found at Prostatectomy and the Effects of Adjuvant Radiation

Source: Urotoday

Patients with seminal vesicle positive disease who received adjuvant radiation compared to observation realized an improvement in 10-year biochemical failure-free survival from 12% to 36% (p = 0.001), in 10-year overall survival from 51% to 71% (p = 0.08) and in metastasis-free survival from 47% to 66% (p = 0.09), respectively.

Although seminal vesicle involvement is a negative prognostic factor, long-term control is possible especially if patients are given adjuvant radiation therapy. This therapy appears to be effective in patients with seminal vesicle involvement.

This one study showed an advantage of giving patients radiation if they had cancer in the seminal vesicles at the time of radical prostatectomy. Many factors need to be addressed in determining if radiation is necessary after surgery.

Robotic prostatectomy findings in patients with a single microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy

A Single Microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy-Can We Predict Adverse Pathological Outcomes?
Source: Urotoday

While a microfocus of Gleason score 6 prostate cancer on biopsy is commonly considered low risk disease, there was a greater than 1/5  risk of pathological upgrading and/or up staging. Patients with Gleason score 6 microfocal prostate cancer should be counseled that they may harbor more aggressive disease, especially when pretreatment clinical risk factors are present, such as advanced age or high clinical prostate specific antigen density.

The team at the University of Chicago looked at patients with only 1 small focus of cancer that was the lower grade (6) on biopsy. Overall 42 patients (22%) had adverse pathological outcomes, including upgrading in 35 [higher gleason score] (18%) and upstaging [cancer outside the prostate] in 16 (8%). I performed a similar study almost 2 years ago that also found the amount and type of cancer is underestimated on biopsy.

MedWire News – Prostate Cancer – Endocrine and radiotherapy ‘standard care’ for locally advanced prostate cancer

Source Medwire News

Adding local radiotherapy to endocrine treatment halves the 10-year prostate cancer-specific mortality in patients with locally advanced or high-risk local prostate cancer compared with endocrine treatment alone, researchers report.
“In the light of these data, endocrine treatment plus radiotherapy should be the new standard,” Anders Widmark (Umeå University, Sweden) and team write in The Lancet.

This study looked at 875 patients with locally advanced prostate cancer (T3; 78%; PSA<70; N0; M0) without evidence of distant spread. These men were from multiple centers in Norway, Sweden, and Denmark. In this set of patients, adding radiation helped men live longer compared to hormonal therapy alone.

The only difference in my practice, and in many centers in the US is that we sometimes perform surgery for these patients as well. The other difference is that these patients were given continuous endocrine treatment using flutamide, which is not as effective as other hormonal therapy regimens that we usually use (gonadotropin-releasing hormone (GnRH) agonists).

Dr Moyad on Vitamin E- Do not take over 400 IU daily

Source: Dr. Moyad on December 2008 Newsletter

“It is now 100% official, high-doses (400 IU or more per day) of vitamin E supplements should not be taken by anyone, especially men trying to prevent, those diagnosed, or even treated for prostate cancer (in other words all men on planet earth)!!!”

Dr. Moyad is in my opinion, the most respected and knowledgeable authority on nutritional support and supplements for prostate cancer. He comments on how the use of high dose Vitamin E is not only beneficial, but likely harmful.

Impact of Accessory Pudendal Arteries on Potency Following Robot-Assisted Prostatectomy

Source: UroToday from 2008 Wold Congress of Endourology

  • After multivariate analysis there was no significance with sacrificing an APA and time of potency recovery. There was no correlation with sacrificing an APA and postoperative quality of erections (94% vs 90% p=0.30) or mean IIEF-5 (22.4 vs 20.7 p=0.11).
  • As one of the few reports regarding anomalous venous anatomy during robotic prostatectomy, this study found no correlation between APAs and preoperative potency. Additionally the authors found no correlation between sacrificing APAs and 24-month potency return. The authors concluded that they found no effect on the time to return of potency, quality of erections or mean IIEF-5 scores at 24 months.

This is the first study that I have seen that addresses return of sexual function in men with accessory pudendal arteries. This is an extra artery that brings blood to the genital area that travels very close to the prostate and through the DVC (vein that brings blood back from the penis).

I usually try saving these arteries and usually I am successful, but it is good to know it may not be a big deal to transect it if necessary.

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