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Robin S, Jolicoeur M, Palumbo S, Zilli T, Crehange G, De Hertogh O, Derashodian T, Sargos P, Salembier C, Supiot S, Udrescu C, Chapet O. Prostate Bed Delineation Guidelines for Postoperative Radiation Therapy: On Behalf Of The Francophone Group of Urological Radiation Therapy. Int J Radiat Oncol Biol Phys 2021; 109:1243-1253. [PMID: 33186618 DOI: 10.1016/j.ijrobp.2020.11.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/14/2020] [Accepted: 11/02/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE Prostate bed (PB) irradiation is considered the standard postoperative treatment after radical prostatectomy (RP) for tumors with high-risk features or persistent prostate-specific antigen, or for salvage treatment in case of biological relapse. Four consensus guidelines have been published to standardize practices and reduce the interobserver variability in PB delineation but with discordant recommendations. To improve the reproducibility in the PB delineation, the Francophone Group of Urological Radiotherapy (Groupe Francophone de Radiothérapie Urologique [GFRU]) worked to propose a new and more reproducible consensus guideline for PB clinical target volume (CTV) definition. METHODS AND MATERIALS A 4-step procedure was used. First, a group of 10 GFRU prostate experts evaluated the 4 existing delineation guidelines for postoperative radiation therapy (European Organization for Research and Treatment of Cancer; the Faculty of Radiation Oncology Genito-Urinary Group; the Radiation Therapy Oncology Group; and the Princess Margaret Hospital) to identify divergent issues. Second, data sets of 50 magnetic resonance imaging studies (25 after RP and 25 with an intact prostate gland) were analyzed to identify the relevant anatomic boundaries of the PB. Third, a literature review of surgical, anatomic, histologic, and imaging data was performed to identify the relevant PB boundaries. Fourth, a final consensus on PB CTV definition was reached among experts. RESULTS Definitive limits of the PB CTV delineation were defined using easily visible landmarks on computed tomography scans (CT). The purpose was to ensure a better reproducibility of PB definition for any radiation oncologist even without experience in postoperative radiation therapy. CONCLUSIONS New recommendations for PB delineation based on simple anatomic boundaries and available as a CT image atlas are proposed by the GFRU. Improvement in uniformity in PB CTV definition and treatment homogeneity in the context of clinical trials are expected.
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Affiliation(s)
- Sophie Robin
- Radiation Oncology Department, Center Hospitalier Lyon Sud, Pierre Benite, France
| | - Marjory Jolicoeur
- Radiation Oncology Department, Charles LeMoyne Hospital, CISSS Montérégie-center, Montréal, Canada
| | - Samuel Palumbo
- Radiation Oncology Department, CHU UCL Namur - Sainte Elisabeth, Namur, Belgium
| | - Thomas Zilli
- Radiation Oncology Department, Geneva University Hospital, Geneva, Switzerland and Faculty of Medicine, Geneva, Switzerland
| | - Gilles Crehange
- Radiation Oncology Department, Institut Curie, Saint-Cloud, France
| | - Olivier De Hertogh
- Radiation Oncology Department, CHR Verviers East Belgium, Verviers, Belgium
| | - Talar Derashodian
- Radiation Oncology Department, Charles LeMoyne Hospital, CISSS Montérégie-center, Montréal, Canada
| | - Paul Sargos
- Radiation Oncology Department, Jewish General Hospital, McGill, Montreal, Canada
| | - Carl Salembier
- Department of Radiotherapy, Europe Hospitals Brussels, Belgium
| | - Stéphane Supiot
- Radiation Oncology Department, Institut de Cancérologie de l'Ouest, Nantes Saint-Herblain, France; CRCINA CNRS Inserm, University of Nantes and Angers, Nantes, France
| | - Corina Udrescu
- Radiation Oncology Department, Center Hospitalier Lyon Sud, Pierre Benite, France
| | - Olivier Chapet
- Radiation Oncology Department, Center Hospitalier Lyon Sud, Pierre Benite, France.
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Questioning the Status Quo: Should Gleason Grade Group 1 Prostate Cancer be Considered a "Negative Core" in Pre-Radical Prostatectomy Risk Nomograms? An International Multicenter Analysis. Urology 2019; 137:102-107. [PMID: 31705947 DOI: 10.1016/j.urology.2019.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/06/2019] [Accepted: 10/21/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the impact of excluding Gleason Grade Group 1 (GG1) prostate cancer (CaP) cores from current pre-radical prostatectomy (RP) nomograms. METHODS Multi-institutional retrospective chart review was performed on all RP patients with prostate biopsy between 2008 and 2018. Patients were individually assessed using the Memorial Sloan Kettering Cancer Center (MSKCC) and Briganti nomograms using the following iterations: (1) Original [ORIG] - all available core data and (2) Selective [SEL] - GG1 cores considered negative. Nomogram outcomes - lymph node invasion (LNI), extracapsular extension (ECE), organ-confined disease (OCD), seminal vesicle invasion (SVI), were compared across iterations and stratified based on biopsy GG. Clinically significant impact on management (CSIM) was defined as change in LNI risk above or below 2% or 5% (Δ2/Δ5). Nomogram outcomes were validated with RP pathology. RESULTS 7718 men met inclusion criteria. In men with GG2 who also had GG1 cores, SEL better predicted LNI (MSKCC - ORIG 4.97% vs SEL 3.50%; Briganti - ORIG 4.81% vs SEL 2.49%, RP outcome 2.46%), OCD (MSKCC - ORIG 40.91% vs SEL 48.44%, RP outcome: 68.46%) and ECE (MSKCC - ORIG 57.87% vs SEL 50.38%, RP outcome: 30.41%), but not SVI (MSKCC - ORIG 5.42% vs SEL 3.34%, RP outcome: 5.62%). This was also consistent in patients with GG3-5 disease. The greatest CSIM was on GG1-2 CaP; Δ2 and Δ5 in GG1 patients was 26.3%-31.0% and 1.5%-5.2%, respectively, and Δ2 and Δ5 in GG2 patients was 3.4%-22.2% and 12.3%-13.6%, respectively. CONCLUSION Excluding GG1 CaP cores from pre-RP nomograms better predicts final RP pathologic outcomes. More importantly, this may better reflect extent of true cancer burden.
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Reply by Authors. J Urol 2017; 198:606-607. [DOI: 10.1016/j.juro.2017.03.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Qi X, Gao XS, Asaumi J, Zhang M, Li HZ, Ma MW, Zhao B, Li FY, Wang D. Optimal contouring of seminal vesicle for definitive radiotherapy of localized prostate cancer: comparison between EORTC prostate cancer radiotherapy guideline, RTOG0815 protocol and actual anatomy. Radiat Oncol 2014; 9:288. [PMID: 25526901 PMCID: PMC4299806 DOI: 10.1186/s13014-014-0288-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 12/04/2014] [Indexed: 11/10/2022] Open
Abstract
Background Intermediate- to-high-risk prostate cancer can locally invade seminal vesicle (SV). It is recommended that anatomic proximal 1-cm to 2-cm SV be included in the clinical target volume (CTV) for definitive radiotherapy based on pathology studies. However, it remains unclear whether the pathology indicated SV extent is included into the CTV defined by current guidelines. The purpose of this study is to compare the volume of proximal SV included in CTV defined by EORTC prostate cancer radiotherapy guideline and RTOG0815 protocol with the actual anatomic volume. Methods Radiotherapy planning CT images from 114 patients with intermediate- (36.8%) or high-risk (63.2%) prostate cancer were reconstructed with 1-mm-thick sections. The starting and ending points of SV and the cross sections of SV at 1-cm and 2-cm from the starting point were determined using 3D-view. Maximum (D1H, D2H) and minimum (D1L, D2L) vertical distance from these cross sections to the starting point were measured. Then, CTV of proximal SV defined by actual anatomy, EORTC guideline and RTOG0815 protocol were contoured and compared (paired t test). Results Median length of D1H, D1L, D2H and D2L was 10.8 mm, 2.1 mm, 17.6 mm and 8.8 mm (95th percentile: 13.5mm, 5.0mm, 21.5mm and 13.5mm, respectively). For intermediate-risk patients, the proximal 1-cm SV CTV defined by EORTC guideline and RTOG0815 protocol inadequately included the anatomic proximal 1-cm SV in 62.3% (71/114) and 71.0% (81/114) cases, respectively. While for high-risk patients, the proximal 2-cm SV CTV defined by EORTC guideline inadequately included the anatomic proximal 2-cm SV in 17.5% (20/114) cases. Conclusions SV involvement indicated by pathology studies was not completely included in the CTV defined by current guidelines. Delineation of proximal 1.4 cm and 2.2 cm SV in axial plane may be adequate to include the anatomic proximal 1-cm and 2-cm SV. However, part of SV may be over-contoured.
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Affiliation(s)
- Xin Qi
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China.
| | - Xian-Shu Gao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China.
| | - Junichi Asaumi
- Department of Oral and Maxillofacial Radiology, Field of Tumor Biology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Min Zhang
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China.
| | - Hong-Zhen Li
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China.
| | - Ming-Wei Ma
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China.
| | - Bo Zhao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China.
| | - Fei-Yu Li
- Department of Radiology, Peking University First Hospital, Beijing, China.
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, USA.
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Khalifa J, Commandeur F, Bachaud JM, de Crevoisier R. Radiothérapie conformationnelle prostatique : quelles marges ? Cancer Radiother 2013; 17:461-9. [DOI: 10.1016/j.canrad.2013.06.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 06/07/2013] [Indexed: 11/24/2022]
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Dosimetric implications of residual seminal vesicle motion in fiducial-guided intensity-modulated radiotherapy for prostate cancer. Med Dosim 2012; 37:240-4. [DOI: 10.1016/j.meddos.2011.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 09/06/2011] [Indexed: 11/23/2022]
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Reis LO, Zani EL, Billis A, Prudente A, Denardi F, Ferreira U. The triple clinicopathologic features to seminal vesicle-sparing radical prostatectomy. J Endourol 2011; 24:1535-9. [PMID: 20804433 DOI: 10.1089/end.2009.0655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE With the widespread early detection programs for prostate cancer, there has been a downward stage migration and a marked decrease in the percentage of men with seminal vesicle invasion (SVI) compared with previous data. We evaluated clinicopathologic findings that are associated with SVI to select patients for potential seminal vesicle-sparing surgery. PATIENTS AND METHODS We reviewed our radical prostatectomy database from 1997 to 2006 to evaluate the incidence and clinical correlates of SVI. Variables analyzed included serum prostate-specific antigen (PSA) level, clinical stage, percentage of positive cores with cancer, Gleason score on biopsy, age, prostate weight, and urethral and vesical surgical margins. Statistical analysis included univariate and multivariate logistic regressions. RESULTS Of 267 patients, 32 (12%) had SVI. Preoperative PSA level, biopsy Gleason score, and percentage of positive cores were highly predictive of SVI on multivariate analysis. SVI was present in only 1/98 patients (1.02 %) with biopsy Gleason score ≤6, 0/23 patients (0%) with serum PSA level <4 ng/mL, and only 1 patient with ≤12.8% of positive cores on biopsy. In all cases of distal SVI, there was proximal involvement. CONCLUSION Serum PSA level, Gleason score, and percentage of positive cores on biopsy are statistically significant predictors of SVI on multivariate analysis. Seminal vesiculectomy does not benefit almost 99% of patients with biopsy Gleason score ≤6, PSA level <4 ng/mL, and with <12% cores with cancer. In cases of seminal vesicle-sparing surgery, frozen section of the proximal portion may be of adjunct usefulness for the triple.
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Affiliation(s)
- Leonardo Oliveira Reis
- Department of Surgery (Urology), School of Medicine, University of Campinas (UNICAMP), Campinas, Sao Paolo, Brazil.
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Soloway MS. Reply to Roberto Mario Scarpa and Cecilia Maria Cracco’s Letter to the Editor re: Alan M. Nieder, Mark S. Soloway. It’s Not a Radical Prostatectomy, It’s a Total Prostatectomy. Eur Urol 2008;54:715–6. Eur Urol 2010. [DOI: 10.1016/j.eururo.2010.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gofrit ON, Zorn KC, Shikanov SA, Zagaja GP, Shalhav AL. Is seminal vesiculectomy necessary in all patients with biopsy Gleason score 6? J Endourol 2009; 23:709-13. [PMID: 19335331 DOI: 10.1089/end.2008.0577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Radiotherapists are excluding the seminal vesicles (SVs) from their target volume in cases of low-risk prostate cancer. However, these glands are routinely removed in every radical prostatectomy. Dissection of the SVs can damage the pelvic plexus, compromise trigonal, bladder neck, and cavernosal innervation, and contribute to delayed gain of continence and erectile function. In this study we evaluated the oncological benefit of routine removal of the SVs in currently operated patients. MATERIALS AND METHODS A total of 1003 patients (mean age, 59.7 years) with prostate cancer underwent robot-assisted radical prostatectomy between February 2003 and July 2007. RESULTS Seminal vesicle invasion (SVI) was found in 46 of the operated patients (4.6%). Biopsy Gleason score (BGS), preoperative serum PSA, clinical tumor stage, percent of positive cores, and maximal percentage of cancer in a core had all a significant impact on the risk of SVI. Only 4/634 patients (0.6%) with BGS < or =6 suffered from SVI, as opposed to 42/369 (11.4%) with higher Gleason scores. CONCLUSIONS Seminal vesiculectomy does not benefit more than 99% of the patients with BGS < or =6. Considering the potential neural and vascular damage associated with seminal vesiculectomy, we suggest that routine removal of these glands during radical prostatectomy in these cases is not necessary.
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Affiliation(s)
- Ofer N Gofrit
- Section of Urology, Department of Surgery, University of Chicago Hospitals, Chicago, Illinois 60637, USA.
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Evaluating the relationships between rectal normal tissue complication probability and the portion of seminal vesicles included in the clinical target volume in intensity-modulated radiotherapy for prostate cancer. Int J Radiat Oncol Biol Phys 2009; 73:334-40. [PMID: 19147014 DOI: 10.1016/j.ijrobp.2008.09.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 09/11/2008] [Accepted: 09/23/2008] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare dose-volume consequences of the inclusion of various portions of the seminal vesicles (SVs) in the clinical target volume (CTV) in intensity-modulated radiotherapy (IMRT) for patients with prostate cancer. METHODS AND MATERIALS For 10 patients with prostate cancer, three matched IMRT plans were generated, including 1 cm, 2 cm, or the entire SVs (SV1, SV2, or SVtotal, respectively) in the CTV. Prescription dose (79.2 Gy) and IMRT planning were according to the high-dose arm of the Radiation Therapy Oncology Group (RTOG) 0126 protocol. We compared plans for percentage of rectal volume receiving minimum doses of 60-80 Gy and for rectal normal tissue complication probability (NTCP[R]). RESULTS There was a detectable increase in rectal dose in SV2 and SVtotal compared with SV1. The magnitude of difference between plans was modest in the high-dose range. In 2 patients, there was underdosing of the planning target volume (PTV) because of constraints on rectal dose in the SVtotal plans. All other plans were compliant with RTOG 0126 protocol requirements. Mean NTCP increased from 14% to 17% and 18% for SV1, SV2, and SV total, respectively. The NTCP correlated with the size of PTV-rectum volume overlap (Pearson's r = 0.86; p < 0.0001), but not with SV volume. CONCLUSIONS Doubling (1 to 2 cm) or comprehensively increasing (1 cm to full SVs) SV volume included in the CTV for patients with prostate IMRT is achievable in the majority of cases without exceeding RTOG dose-volume limits or underdosing the PTV and results in only a moderate increase in NTCP.
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Robot-assisted laparoscopic radical prostatectomy: an athermal anterior approach to the seminal vesicle dissection. J Robot Surg 2008; 2:223-6. [PMID: 27637791 DOI: 10.1007/s11701-008-0117-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 10/22/2008] [Indexed: 10/21/2022]
Abstract
The seminal vesicles, particularly the lateral aspect and tips, are among the closest structures to the cavernous nerves and pelvic plexus. Given this proximity it is essential that the seminal vesicle dissection be performed in an athermal and atraumatic fashion during robot-assisted laparoscopic prostatectomy (RALP). Traditionally the seminal vesicle dissection during RALP is performed by dividing the vas deferens and following it proximally to locate the tip of the seminal vesicle. Here we describe a modification to the traditional anterior approach to seminal vesicle dissection. Our modification allows the dissection to be performed athermally and efficiently with use of minimal traction. The dissection proceeds medially between the two terminal vas deferens to identify the medial surface of one of the seminal vesicles. This medial surface is avascular and can be developed easily along the length of the vesicle using blunt dissection. Once its tip is identified it is elevated with the fourth arm medially between the two vas deferens. The ipsilateral vas can then be clipped and divided below the level of the elevated seminal vesicle. The vascular supply to the seminal vesicle is then simply identified entering the lateral aspect of its tip. A hemolock clip is placed directly beneath the tip of the seminal vesicle to control its vasculature. The remainder of the dissection can be performed with sharp dissection. Using this technique the seminal vesicle can be excised entirely with minimal traction and no thermal energy. By elevating the tip medially away from the location of the pelvic plexus and cavernous nerves, inadvertent damage to these neural structures is avoided when placing the hemolock clips.
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What CTV-to-PTV Margins Should Be Applied for Prostate Irradiation? Four-Dimensional Quantitative Assessment Using Model-Based Deformable Image Registration Techniques. Int J Radiat Oncol Biol Phys 2008; 72:1416-25. [DOI: 10.1016/j.ijrobp.2008.03.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Revised: 03/03/2008] [Accepted: 03/03/2008] [Indexed: 11/23/2022]
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Klein EA. A new nomogram for predicting seminal vesicle invasion at radical prostatectomy. NATURE CLINICAL PRACTICE. UROLOGY 2007; 4:594-5. [PMID: 17895877 DOI: 10.1038/ncpuro0937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2007] [Accepted: 08/24/2007] [Indexed: 05/17/2023]
Affiliation(s)
- Eric A Klein
- Section of Urologic Oncology, Glickman Urological Institute, Cleveland, OH, USA.
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Yoshida K, Kuroda S, Yoshida M, Fujita Y, Sakai M, Nohara T, Kawashima A, Takahashi T, Tohda A, Oka T, Yamazaki H, Kuriyama K. New implant technique for separation of the seminal vesicle and rectal mucosa for high-dose-rate prostate brachytherapy. Brachytherapy 2007; 6:180-6. [PMID: 17606414 DOI: 10.1016/j.brachy.2007.02.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2006] [Revised: 01/10/2007] [Accepted: 02/13/2007] [Indexed: 11/26/2022]
Abstract
PURPOSE For safer treatment of seminal vesicles (SVs), we initiated a new technique using an anchor applicator for high-dose-rate interstitial brachytherapy (HDR-ISBT) of prostate cancer. METHODS AND MATERIALS Between January 2004 and March 2005, 23 intermediate- to high-risk patients were treated with HDR-ISBT as monotherapy. Transrectal ultrasonography guided implantation of the treatment applicator in and around the prostate gland and proximal SV. We used an "anchor" applicator to prevent posterior displacement of the SV. After insertion of the anchor applicator, the actual treatment applicator was implanted at the best position for optimal SV coverage. SV coverage was analyzed using a dose-volume histogram. RESULTS Implantation of the applicator on the posterior side of the SV was successful for 43 of 46 SVs (93%). The median percentage of the SVs receiving the prescribed dose was 41% (range 11-86%). Only one case of acute Grade 2 toxicity (3%) was seen. CONCLUSIONS Our anchor applicator technique for HDR-ISBT can separate the SV from the rectum. This is the first report of dose-volume histogram analysis of the SV for HDR-ISBT.
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Affiliation(s)
- Ken Yoshida
- Department of Radiology, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka-city, Osaka 540-0006, Japan.
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Bayman NA, Wylie JP. When should the seminal vesicles be included in the target volume in prostate radiotherapy? Clin Oncol (R Coll Radiol) 2007; 19:302-7. [PMID: 17448647 DOI: 10.1016/j.clon.2007.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Revised: 02/17/2007] [Accepted: 03/07/2007] [Indexed: 10/23/2022]
Abstract
External beam radiotherapy to the prostate and seminal vesicles as a radical treatment for prostate cancer can result in a significant dose being delivered to the rectum. This can be reduced if the target volume includes the prostate only. Using a Medline search, published studies are reviewed to show that the risk of seminal vesicle involvement can be accurately predicted using readily available pre-treatment parameters. We recommend when to exclude the seminal vesicles from a target volume, and the proportion of seminal vesicles that should be included in a target volume in higher risk patients.
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Affiliation(s)
- N A Bayman
- Department of Clinical Oncology, Christie Hospital, Wilmslow Road, Manchester M20 4BX, UK.
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Baccala A, Reuther AM, Bianco FJ, Scardino PT, Kattan MW, Klein EA. Complete Resection of Seminal Vesicles at Radical Prostatectomy Results in Substantial Long-Term Disease-Free Survival: Multi-institutional Study of 6740 Patients. Urology 2007; 69:536-40. [PMID: 17382160 DOI: 10.1016/j.urology.2006.12.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Revised: 09/19/2006] [Accepted: 12/12/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To estimate the disease-specific survival of patients with complete removal of the seminal vesicles (SVs) at radical prostatectomy and to develop a nomogram for the prediction of SV invasion (SVI). METHODS An analysis of 6740 patients from three institutions was performed. The primary outcome was biochemical failure analyzed according to the presence or absence of SVI using the Kaplan-Meier method and Cox proportional hazards model. The variables analyzed included age, biopsy Gleason score, clinical T stage, margin status, extracapsular extension, SVI, surgical Gleason score, initial prostate-specific antigen level, and institution. Logistic regression analysis was used to determine the preoperative factors predicting for SVI and create the model for the nomogram. RESULTS Of the 6740 patients, 566 (8.4%) had positive SVs. The median follow-up was 33.4 months (range 1 to 239). The 5 and 10-year biochemical relapse-free survival rate was 38.0% and 25.6%, respectively, for patients with positive SVs and 85.7% and 77.2%, respectively, for patients with negative SVs (P <0.0001). In the multivariate model, all variables, except for biopsy Gleason score and T stage, were significant predictors of biochemical failure (P <0.05), and all variables, except for age, were predictors of SVI. The nomogram achieved an area under the curve of 0.80. CONCLUSIONS These results have demonstrated that a substantial number of patients with SVI are disease free at 5 and 10 years after complete excision without adjuvant therapy. These findings suggest the therapeutic efficacy of complete SV excision and can identify those with a nomogram-predicted increased risk of SVI who might benefit from complete excision.
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Affiliation(s)
- Angelo Baccala
- Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44122, USA.
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Gallina A, Chun FKH, Briganti A, Shariat SF, Montorsi F, Salonia A, Erbersdobler A, Rigatti P, Valiquette L, Huland H, Graefen M, Karakiewicz PI. Development and split-sample validation of a nomogram predicting the probability of seminal vesicle invasion at radical prostatectomy. Eur Urol 2007; 52:98-105. [PMID: 17267098 DOI: 10.1016/j.eururo.2007.01.060] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Accepted: 01/05/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Seminal vesicle preservation may have a beneficial impact on erectile and urinary function after radical prostatectomy (RP). We hypothesized that contemporary patients, at very low risk of seminal vesicle invasion (SVI), can be highly accurately identified with an equally contemporary SVI nomogram. MATERIALS AND METHODS A nomogram predicting SVI was developed in a cohort study of 666 men diagnosed with 10 or more biopsy cores and treated with RP. Biopsy Gleason sum, prostate-specific antigen, clinical stage, and percentage of positive cores represented predictors in multivariable logistic regression models and formed the basis for the nomogram. The regression coefficient-based nomogram was then externally validated in a split-sample cohort of 230 patients. This cohort also served for a head-to-head comparison of external validity of the novel nomogram with two existing tools, namely Partin's SVI predictions and Koh's SVI nomogram. RESULTS Split-sample validation of the novel SVI nomogram demonstrated 79.2% accuracy versus 75.6% for Partin versus 77.7% for Koh. Our nomogram cutoff of 3% or less had 96.2% negative predictive value for identifying men at very low risk of SVI. This cutoff could have safely allowed omitting the removal of seminal vesicles in 45.2% of RP candidates, if incorrect classification of 1.7% of patients was judged acceptable. CONCLUSIONS The potential benefits of SV preservation can be safely accomplished in virtually 50% of contemporary men subjected to RP, if our tool's predictions are applied.
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Affiliation(s)
- Andrea Gallina
- Cancer Prognostics and Health Outcomes Unit, University of Montreal, Montreal, Quebec, Canada
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Guzzo TJ, Vira M, Wang Y, Tomaszewski J, D'amico A, Wein AJ, Malkowicz SB. Preoperative parameters, including percent positive biopsy, in predicting seminal vesicle involvement in patients with prostate cancer. J Urol 2006; 175:518-21; discussion 521-2. [PMID: 16406985 DOI: 10.1016/s0022-5347(05)00235-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2005] [Indexed: 11/22/2022]
Abstract
PURPOSE Complete dissection of the SVs during RP can contribute to increased morbidity including erectile dysfunction and incontinence. Therefore we evaluated the clinical parameters associated with a positive SV finding on final pathology and identified those patients with a minimal risk of SV involvement for potential SV sparing surgery. MATERIALS AND METHODS We retrospectively reviewed our RP database from 1991 to 1999 to evaluate the incidence and clinical correlates of SV invasion. Variables studied included preoperative total serum PSA, percent positive biopsy cores, DRE and biopsy Gleason score. Statistical analysis included univariate, multivariate regression analysis and ROC curves. RESULTS Of our 1,056 patients 79 (7.4%) had SV involvement. Of the 356 patients with less than 17% positive biopsies, only 2 (0.5%) had SV involvement on final pathology. Preoperative PSA, biopsy Gleason score and percent positive biopsies were all highly predictive of SV invasion on multivariate analysis. Percent positive biopsy was found to be the single best predictor of seminal vesicle invasion (p <0.0001). CONCLUSIONS In our series percent positive biopsy was the single best predictor of SV invasion at the time of RP. An analysis of preoperative parameters including percent positive biopsy, biopsy Gleason score and preoperative PSA may define a subset of patients in which prospective studies could be used to determine the value and safety of SV sparing surgery.
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Affiliation(s)
- Thomas J Guzzo
- Department of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Sella T, Schwartz LH, Hricak H. Retained Seminal Vesicles After Radical Prostatectomy: Frequency, MRI Characteristics, and Clinical Relevance. AJR Am J Roentgenol 2006; 186:539-46. [PMID: 16423965 DOI: 10.2214/ajr.04.1770] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Changes after radical prostatectomy (RP) may present potential pitfalls in the interpretation of pelvic MRI studies in post-RP patients. One such change is retained seminal vesicles (SVs). The purpose of this study was to characterize the MRI features and evaluate the frequency of retained SV remnants in patients after RP. CONCLUSION Retained SV remnants are a common finding after RP. Most are fibrotic distal tips. Recognition of SV remnants may prevent their misinterpretation as local recurrences.
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Affiliation(s)
- Tamar Sella
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Room C-278, New York, NY 10021, USA
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21
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Abstract
PURPOSE In the age of minimally invasive surgery there has been renewed interest in the perineal approach for the surgical treatment of prostate cancer. We reviewed recent publications regarding radical perineal prostatectomy (RPP) in an effort to define its role in the current management of localized prostate malignancy. At the same time we reviewed the relevant perineal anatomy and surgical approach necessary to perform this operation. MATERIALS AND METHODS We performed a review of the literature with respect to RPP and included our own extensive experience with this operation, emphasizing patient selection, the current role of pelvic lymph node dissection, surgical anatomy, oncological outcomes and complications. RESULTS RPP is an effective treatment for localized adenocarcinoma of the prostate with oncological outcomes similar to those of the retropubic technique. In comparison to RRP, patients undergoing RPP have less postoperative discomfort, more rapid return of bowel function, more rapid return to work and a decreased transfusion rate. In addition, RRP is now often performed with cavernous nerve sparing. Prostate specific antigen screening has made the rate of lymph node metastasis low enough to omit lymphadenectomy in many cases. CONCLUSIONS There is still a role for RPP in the treatment of localized prostate cancer. Erectile dysfunction after nerve sparing and incontinence rates are similar to those of RRP. In addition, it is less morbid then RRP without being as technically challenging as laparoscopic radical prostatectomy.
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Affiliation(s)
- Daniel M Janoff
- Divisions of Urology, Oregon Health and Sciences University, Portland, Oregon, USA
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Meraney AM, Haese A, Palisaar J, Graefen M, Steuber T, Huland H, Klein EA. Surgical management of prostate cancer: Advances based on a rational approach to the data. Eur J Cancer 2005; 41:888-907. [PMID: 15808956 DOI: 10.1016/j.ejca.2005.02.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2005] [Revised: 02/08/2005] [Accepted: 02/08/2005] [Indexed: 11/18/2022]
Abstract
The management of localised prostate cancer has undergone important changes in the past two decades, with major improvements in surgical technique, a greater emphasis on structured assessment of quality of life, and a greater attempt to tailor treatment to biological risk. Disease diagnosis is predicated on identification of demographic risk factors, serum levels of prostate-specific antigen and its derivatives, and extended biopsy techniques. Surgical removal of the prostate may be accomplished by open or minimally invasive techniques and in experienced hands results in good functional outcomes a high rate of cure for those with organ confined disease. Radical prostatectomy is also appropriate in selected patients with locally advanced disease and after failed radiation therapy.
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Affiliation(s)
- Anoop M Meraney
- Glickman Urological Institute A-100, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Rabah DM, Schellhammer PF, Diaz JI, Tuerk I, Soderdahl DW, Fabrizio MD. Laparoscopic radical prostatectomy: is intact organ removal attainable? Study of margin status. J Endourol 2005; 18:731-4. [PMID: 15659892 DOI: 10.1089/end.2004.18.731] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To determine the initial oncologic results (pathology) of specimens removed by laparoscopic radical prostatectomy (LRP) by examining the surgical margins. PATIENTS AND METHODS The 70 consecutive LRP procedures performed for clinically localized prostate cancer at Eastern Virginia Medical School from April 2001 to November 2002 were reviewed for preoperative and important intraoperative variables. The initial histopathology report and a prospective review by a single genitourinary pathologist for margin status as well parenchymal exposure of benign glands were assessed. Postoperative prostate specific antigen (PSA) levels were noted. RESULTS The clinical stage distribution was as follows: T1c = 59, T2a = 10, and T2b = 1. The preoperative median PSA value was 6.96 ng/mL. The mean operative time was 307 minutes. The mean estimated blood loss was 298 mL. The prospective pathologic review results were as follows: 1 pT0 (1.4%), 60 pT2 (85.7%), and 9 pT3 (12.8%). The overall positive surgical-margin rate was 15.7%. Of those patients with pT2 disease; 8 specimens (13.3%) had a positive margin, whereas 33% of patients with pT3 disease had a positive surgical margin. Parenchymal exposure of benign glands on the inked surface was recognized in 8 patients (13.3%). Data from PSA assays 1 month postoperatively were available in 69 patients. Serum PSA was undetectable (< or =0.1 ng/mL) in 67 men (97%). CONCLUSION An LRP can offer surgical margins comparable to those of open procedures series reported in the literature. Long-term progression and survival outcome data are necessary before this procedure should be offered as a replacement for open prostatectomy.
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Affiliation(s)
- Danny M Rabah
- Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Dall'Oglio MF, Sant'Anna AC, Antunes AA, Nesrallah LJ, Leite KR, Srougi M. Analysis of risk factors of involvement of seminal vesicles in patients with prostate cancer undergoing radical prostatectomy. Int Braz J Urol 2004; 30:472-8. [PMID: 15663804 DOI: 10.1590/s1677-55382004000600004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2004] [Accepted: 10/27/2004] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To determine through preoperative serum PSA level, Gleason score on biopsy and percentage of fragments affected by tumor on biopsy, the probability of involvement of the seminal vesicles. MATERIALS AND METHODS During the period between March 1991 to December 2002, we selected 899 patients undergoing radical prostatectomy for treatment of localized prostate adenocarcinoma. The analyzed preoperative variables were PSA, percentage of positive fragments and Gleason score on the biopsy. Pre-operative PSA was divided in scales from 0 to 4.0 ng/mL, 4.1 to 10 ng/mL, 10.1 to 20 ng/mL and > 20 ng/mL, Gleason score was categorized in scales from 2 to 6. 7 and 8 to 10, and the percentage of affected fragments was divided in 0 to 25%, 25.1% to 50%, 50.1% to 75%, and 75.1% to 100%. All these variables were correlated with the involvement of seminal vesicles in the surgical specimen. RESULTS Of the 899 patients under study, approximately 11% (95% CI, [9% - 13%]) had involvement of seminal vesicles. On the multivariate analysis, when PSA was < or = 4, the Gleason score was 2 to 6, and less than 25% of fragments were involved on the biopsy, only 3.6%, 7.6% and 6.2% of patients respectively, had involvement of seminal vesicles. On the multivariate analysis, we observed that PSA, Gleason score and the percentage of involved fragments were independent prognostic factors for invasion of seminal vesicles. CONCLUSION The preoperative variables used in the present study allow the identification of men with minimal risk (lower than 5%) if involvement of seminal vesicles.
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Affiliation(s)
- Marcos F Dall'Oglio
- Division of Urology, Paulista School of Medicine, Federal University of São Paulo, UNIFESP, Syrian Lebanese Hospital, São Paulo, SP, Brazil.
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Zlotta AR, Roumeguère T, Ravery V, Hoffmann P, Montorsi F, Türkeri L, Dobrovrits M, Scattoni V, Ekane S, Bollens R, Vanden Bossche M, Djavan B, Boccon-Gibod L, Schulman CC. Is seminal vesicle ablation mandatory for all patients undergoing radical prostatectomy? A multivariate analysis on 1283 patients. Eur Urol 2004; 46:42-9. [PMID: 15183546 DOI: 10.1016/j.eururo.2004.03.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2004] [Indexed: 11/25/2022]
Abstract
OBJECTIVE With a shift in prostate cancer stage and a majority of patients operated nowadays with PSA levels <10 ng/ml, rates of seminal vesicle (SV) invasion found on radical prostatectomy specimens have decreased as compared to historical data. Since SV-sparing surgery may possibly have an influence on post-operative erectile dysfunction and urinary recovery, we tried to determine which patients could be safely spared SV excision during radical prostatectomy. MATERIAL AND METHODS We used preoperative data from 1283 patients operated by radical retropubic prostatectomy--777 with serum PSA <10.0 ng/ml--to predict SV invasion on final pathological examination. Variables analyzed included age, digital rectal examination, serum PSA, biopsy Gleason score and percentage of biopsy cores invaded by prostate cancer. Statistical analysis included univariate, multivariate logistic regression analysis and receiver operating characteristic (ROC) curves. RESULTS Out of 1283 patients, 137 (10.6%) had SV involvement, 41/777 (5.2%) with PSA <10.0 ng/ml, 16.1% in the 10-20 ng/ml range and 26.2% when PSA was >20 ng/ml. Percentage of biopsies affected by prostate cancer and biopsy Gleason score were significant predictors of SV invasion in multivariate analysis, both in the entire population and in the subset of patients with PSA <10.0 ng/ml (p < 0.0001). Probability graphs created for patients with PSA <10 ng/ml indicate a risk of seminal invasion <5% when Gleason score on biopsy is <7 or when the percentage of biopsies affected by cancer is <50%. CONCLUSIONS Resection of SV might not be "oncologically" necessary in all patients undergoing RP when PSA levels are below 10 ng/ml except when biopsy Gleason score is > or =7 or when more than 50% of prostate biopsy cores show cancer involvement. SV-sparing surgery could be prospectively compared to standard retropubic prostatectomy in selected individuals analyzing potential benefits on erectile function and urinary continence.
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Affiliation(s)
- Alexandre R Zlotta
- Department of Urology, Erasme Hospital, University Clinics of Brussels, 808 route de Lennik, B-1070 Brussels, Belgium.
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26
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Koh H, Kattan MW, Scardino PT, Suyama K, Maru N, Slawin K, Wheeler TM, Ohori M. A nomogram to predict seminal vesicle invasion by the extent and location of cancer in systematic biopsy results. J Urol 2003; 170:1203-8. [PMID: 14501725 DOI: 10.1097/01.ju.0000085074.62960.7b] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We determined whether systematic biopsy results increases the accuracy of standard clinical information in predicting seminal vesicle invasion (SVI). MATERIALS AND METHODS We analyzed a retrospective cohort of 763 patients with clinical stages T1c-T3 prostate cancer who were diagnosed by systematic biopsy and treated with radical prostatectomy. We recorded the location of each biopsy core and measured the length of cancer and total length of each core. Using logistic regression analysis we constructed and internally validated a nomogram to predict SVI. RESULTS A total of 60 patients (7.9%) had SVI. Cancer was present in a biopsy core from the base in 437 patients, of whom 12.8% had SVI compared with only 1.2% of the 326 without cancer at the base. None of the 275 patients with prostate specific antigen (PSA) 10 ng/ml or less and no cancer at the base had SVI. On multivariate analysis serum PSA (p <0.0005), primary Gleason grade (p = 0.028) and percent cancer at the base (p <0.005) were the only significant predictors of SVI. The predictive accuracy of a standard model that included only stage, grade and PSA was maximally enhanced by including the percent cancer at the base (p = 0.0013). A nomogram that incorporated this variable produced probabilities of SVI that differed from the standard model by +/- 10% in 68% of the cases. CONCLUSIONS The presence and amount of cancer in systematic needle biopsy cores from the base of the prostate strongly predicts the presence of SVI. Systematic biopsy results enhance the accuracy of nomograms to predict SVI.
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Affiliation(s)
- Hideshige Koh
- Department of Urology, Memorial Sloan-Kettering Cancer Institute, New York, New York, USA
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27
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Gillitzer R, Thüroff JW. Technical advances in radical retropubic prostatectomy techniques for avoiding complications. Part I: apical dissection. BJU Int 2003; 92:172-7. [PMID: 12823368 DOI: 10.1046/j.1464-410x.2003.04282.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Radical retropubic prostatectomy is currently the most widely used surgical treatment for localized prostate cancer. This once cumbersome procedure has developed technically over the last 20 years, reducing dramatically the associated complications and morbidity, e.g. blood loss, incontinence and impotence. Currently the operation is safe and is the best choice for eradicating localized disease, with little loss in quality of life. However, differences in reported outcomes indicate that there is still a need for standardization and continued efforts for surgical excellence. This review focuses on the crucial steps of the procedure, in two parts: the first covers apical dissection and the second the steps related to vesico-urethral anastomosis and the nerve-sparing procedure. This evaluation of the technical modifications aims to offer a choice, to vary the procedure according to the individual situation and thus improve the results. Current trends in surgical technique are also presented.
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Affiliation(s)
- R Gillitzer
- Department of Urology, Johannes Gutenberg University, Mainz, Germany.
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Sofer M, Savoie M, Kim SS, Civantos F, Soloway MS. Biochemical and pathological predictors of the recurrence of prostatic adenocarcinoma with seminal vesicle invasion. J Urol 2003; 169:153-6. [PMID: 12478125 DOI: 10.1016/s0022-5347(05)64057-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE We assessed biochemical and pathological factors as predictors of recurrence in men with seminal vesicle invasion. MATERIALS AND METHODS A consecutive series of 812 men who underwent radical retropubic prostatectomy between 1992 and 2000 included 106 (13%) with seminal vesicle invasion. Disease recurrence was defined as prostate specific antigen (PSA) 0.4 ng./ml. or greater. Patients with less than 12 months of followup, salvage radical retropubic prostatectomy, lymph node metastases and adjuvant therapy were excluded from study. Data on the remaining 66 cases were analyzed using the chi-square test, bivariate logistic regression, Kaplan-Meier analyses and Cox proportional regression. Variables included demographics, recurrence, time from surgery to recurrence, positive margins, capsular invasion, extracapsular extension, Gleason score (2 to 6, 7 and 8 to 10), and dichotomized values of preoperative PSA (10 or less versus 10 ng./ml.) and tumor volume (20% or less versus greater than 20%). RESULTS Mean patient age was 62 years (range 48 to 74). At an average followup of 47.7 months (range 13 to 109) 53% of the patients were free of biochemical recurrence. Mean time to recurrence was 18.6 months (range 1.7 to 51.6). Univariate analyses revealed a statistical significant increased risk of recurrence in patients with PSA greater than 10 ng./ml. (p <0.0001), capsular invasion (p = 0.01) and age (p = 0.036). When adjusting for potential covariates, Cox proportional regression analysis indicated that higher PSA (hazard ratio 7.33, 95% CI 2.57 to 20.95), larger tumor volume (hazard ratio 5.64, 95% CI 1.97 to 16.19) and higher age (hazard ratio 1.13, 95% CI 1.04 to 1.22) were significantly associated with shorter time to recurrence. CONCLUSIONS PSA greater than 10 ng./ml., tumor volume greater than 20% and age are significant predictors of recurrence after radical retropubic prostatectomy in patients with prostate cancer and seminal vesicle invasion. Hopefully future randomized trials may show a survival benefit of adjuvant therapy in patients at high risk.
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Affiliation(s)
- Mario Sofer
- Departments of Urology and Pathology, University of Miami, Miami, Florida, USA
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29
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Biochemical And Pathological Predictors Of The Recurrence Of Prostatic Adenocarcinoma With Seminal Vesicle Invasion. J Urol 2003. [DOI: 10.1097/00005392-200301000-00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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30
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Kestin L, Goldstein N, Vicini F, Yan D, Korman H, Martinez A. Treatment of prostate cancer with radiotherapy: should the entire seminal vesicles be included in the clinical target volume? Int J Radiat Oncol Biol Phys 2002; 54:686-97. [PMID: 12377319 DOI: 10.1016/s0360-3016(02)03011-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE When treating high-risk prostate cancer with radiation therapy, inclusion of the seminal vesicles (SVs) within the clinical target volume (CTV) can dramatically increase the volume of radiated normal tissues and hinder dose escalation. Because cancer may involve only the proximal portion of the frequently lengthy SVs, we performed a complete pathology review of prostatectomy specimens to determine the appropriate length of SV to include within the CTV when SV treatment is indicated. METHODS AND MATERIALS A detailed pathologic analysis was performed for 344 radical prostatectomy specimens (1987-2000). All slides from each case were reviewed by a single pathologist (N.S.G.). Factors recorded for each case included length of each SV (cm), length of cancer involvement in each SV (cm) measured from the prostate-SV junction, and percentage of SV length involved. RESULTS Fifty-one patients (15%) demonstrated SV involvement in 81 SVs (21 unilateral, 30 bilateral SV involvement). The median SV length was 3.5 cm (range: 0.7-8.5 cm). Factors associated with SV involvement included the pretreatment PSA level, biopsy Gleason score, and clinical T classification. The commonly used risk group stratification was very effective at predicting SV positivity. Only 1% of low-risk patients (PSA <10 ng/mL, Gleason <or=6, and clinical stage <or=T2a) demonstrated SV involvement vs. 27% of high-risk patients. Patients with only one high-risk feature still demonstrated a 15% risk of SV involvement, whereas 58% of patients with all three high-risk features had positive SVs. The median length of SV involvement was 1.0 cm (90th percentile: 2.0 cm, range: 0.2-3.8 cm). A median of 25% of each SV was involved with adenocarcinoma (90th percentile: 54%, range: 4%-75%). For the 81 positive SVs, no factor was associated with a greater length or percentage of SV involvement. In the entire population, 7% had SV involvement beyond 1.0 cm. There was an approximate 1% risk of SV involvement beyond 2.0 cm or 60% of the SV. In addition, this risk was less than 4% for all subgroups, including high-risk patients. CONCLUSIONS A portion of the SV should be included in the CTV only for higher-risk patients (PSA >or=10 ng/mL, biopsy Gleason >or=7, or clinical T stage >or=T2b). When treating the SV for prostate cancer, only the proximal 2.0-2.5 cm (approximately 60%) of the SV should be included within the CTV.
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Affiliation(s)
- Larry Kestin
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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31
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Gillitzer R, Thüroff JW. Relative advantages and disadvantages of radical perineal prostatectomy versus radical retropubic prostatectomy. Crit Rev Oncol Hematol 2002; 43:167-90. [PMID: 12191739 DOI: 10.1016/s1040-8428(02)00016-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
In recent years prostate cancer has become the predominant malignancy in men. With the introduction of prostate specific antigen (PSA) the disease can be diagnosed at an early stage, at which surgical therapy can be curative. In the past century, the retropubic and the perineal routes were established as alternatives of surgical access to the gland for clinically localized prostate cancer. The selection of the operative route is mostly decided individually on the basis of surgical training and experience. The revived interest in perineal radical prostatectomy is explained by the fact that this technique has been associated with low morbidity. The differences of both surgical approaches of radical prostatectomy are elucidated and compared regarding tumor control and short and long term complication rates. Taking these results into consideration, specific advantages and disadvantages of radical perineal prostatectomy are emphasized.
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Affiliation(s)
- R Gillitzer
- Department of Urology, Johannes-Gutenberg University, Langenbeckstrasse 1, Mainz, Germany.
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32
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John H, Hauri D. RE: NERVE AND SEMINAL SPARING RADICAL CYSTECTOMY WITH ORTHOTOPIC URINARY DIVERSION FOR SELECT PATIENTS WITH SUPERFICIAL BLADDER CANCER: AN INNOVATIVE SURGICAL APPROACH. J Urol 2001. [DOI: 10.1016/s0022-5347(05)65791-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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RE: NERVE AND SEMINAL SPARING RADICAL CYSTECTOMY WITH ORTHOTOPIC URINARY DIVERSION FOR SELECT PATIENTS WITH SUPERFICIAL BLADDER CANCER: AN INNOVATIVE SURGICAL APPROACH. J Urol 2001. [DOI: 10.1097/00005392-200110000-00052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stock RG, Lo YC, Gaildon M, Stone NN. Does prostate brachytherapy treat the seminal vesicles? A dose-volume histogram analysis of seminal vesicles in patients undergoing combined PD-103 prostate implantation and external beam irradiation. Int J Radiat Oncol Biol Phys 1999; 45:385-9. [PMID: 10487560 DOI: 10.1016/s0360-3016(99)00209-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Combined brachytherapy of the prostate and external beam irradiation (EBRT) of the prostate and seminal vesicles (SV) is becoming a popular treatment for high-risk prostate cancer. Dose-volume histogram (DVH) analysis of the SV in patients undergoing this treatment was performed to determine the dose distribution to the SV and the adequacy of this treatment in patients with potential SV involvement. METHODS AND MATERIALS Twenty-five consecutive patients were treated with a Pd-103 implant of the prostate alone and 45 Gy of EBRT to the prostate and SV. Attempts were not made to implant the SV but seeds were routinely placed at the junction of the prostate and SV. All patients underwent CT-based postimplant dosimetric analysis 1 month after implantation. As part of this analysis, DVH were generated for the prostate and total SV volume (SVT). In addition, the SV was divided into 6-mm-thick volumes identified as SV1, SV2, SV3, SV4, and SV5 starting from the junction of the prostate and SV and extending distally. DVH were also generated for these structures. Delivered dose was defined as the D90 (dose delivered to 90% of the organ on DVH). RESULTS The median volumes in cc of the prostate, SVT, SV1, SV2, SV3, SV4, and SV5 were 34.33, 9.75, 2.7, 3.48, 2.92, 3.18, and 1.96 respectively. The SVT contained from 0-9 seeds (median 2). There was little dose delivered to the SVT and SV volumes from the implanted prostate. The median D90 values for the prostate, SVT, SV1, SV2, SV3, SV4, and SV5 were 8615 cGy, 675 cGy, 3100 cGy, 1329 cGy, 553 cGy, 246 cGy, and 67 cGy, respectively. The dose delivered to the prostate covered small percentages of SV. The percents of SV volumes covered by the prostate D90 were 11, 35, 3.3, 0, 0, and 0 for SVT, SV1, SV2, SV3, SV4, and SV5, respectively. CONCLUSIONS DVH analysis of the SV reveals that dose generated from an implanted prostate contributes little to the SV. Those patients at high risk for SV involvement may be undertreated with combined EBRT to prophylactic doses and prostate implantation.
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Affiliation(s)
- R G Stock
- Department of Radiation Oncology, Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
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35
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van Bokhorst-de van der Schueren MAE, van Leeuwen PAM, Kuik DJ, Klop WMC, Sauerwein HP, Snow GB, Quak JJ. The impact of nutritional status on the prognoses of patients with advanced head and neck cancer. Cancer 1999. [DOI: 10.1002/(sici)1097-0142(19990801)86:3<519::aid-cncr22>3.0.co;2-s] [Citation(s) in RCA: 213] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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36
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Theodorescu D, Lippert MC, Broder SR, Boyd JC. Early prostate-specific antigen failure following radical perineal versus retropubic prostatectomy: the importance of seminal vesicle excision. Urology 1998; 51:277-82. [PMID: 9495711 DOI: 10.1016/s0090-4295(97)00495-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Because of renewed interest in the radical perineal prostatectomy, we chose to evaluate factors influencing differences in biochemical failure as measured by prostate-specific antigen (PSA) between radical perineal and the radical retropubic prostatectomies. METHODS We undertook a retrospective review of 87 men with clinically localized prostate cancer who underwent radical retropubic (64%) or radical perineal (36%) prostatectomy, noting age, race, preoperative PSA, Gleason score, clinical stage, capsular penetration, surgical approach, and completeness of seminal vesicle (SV) excision. The two groups were comparable with respect to tumor factors such as preoperative PSA, Gleason score, clinical stage, and capsular penetration. Time to postoperative PSA failure (0.2 ng/mL or greater) was evaluated with univariate and multivariate analysis of multiple contributing factors. RESULTS Twenty-eight percent of patients had a PSA level rising to 0.2 ng/mL or greater in the follow-up period. Patients who underwent perineal prostatectomy had a higher PSA failure rate (45%) than those treated by the retropubic approach (18%) and patients with incomplete SV excision had a higher failure rate (69%) than patients with bilateral SV excision (20%). When time to PSA failure was examined by multivariate analysis, completeness of SV excision, clinical stage, and Gleason score had a statistically significant impact on this outcome. In perineal prostatectomy patients, bilateral SV excision had a significantly longer time to PSA failure than in patients with incomplete excision. There was no significant difference in time to PSA failure between patients who underwent radical retropubic prostatectomy and the patients who underwent perineal prostatectomy with bilateral SV excision. CONCLUSIONS Incomplete excision of SVs during a radical perineal prostatectomy contributes to an earlier postoperative biochemical recurrence as measured by a rising PSA, and may explain the higher disease recurrence rate for radical perineal prostatectomies as opposed to radical retropubic prostatectomies in this study.
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Affiliation(s)
- D Theodorescu
- Department of Urology, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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Affiliation(s)
- J V Jepsen
- Department of Surgery, University of Wisconsin Hospital, Madison 53792, USA
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