Prior male sling does not affect outcomes of artificial urinary sphincter

OBJECTIVE

To investigate the outcomes of artificial urinary sphincter (AUS) placement in patients with post-prostatectomy urinary incontinence (PPUI) with or without a prior male sling.

PATIENTS AND METHODS

We performed a retrospective chart review of patients who underwent AUS for PPUI from 2007 to 2022. The primary endpoint was to determine the proportion of patients who achieved social continence, defined as self-reported use of 0-1 pad/day. The secondary endpoints were device failure rates and device failure-free survival.

RESULTS

The analysis included 210 patients, with 30 (14.3%) having had prior slings and 180 (85.7%) without prior slings. After AUS insertion, 80.0% of patients with prior slings and 76.7% of those without prior slings achieved continence (0-1 pad/day). There were six (20.0%) and 53 (29.4%) device failures in patients with and without prior slings, respectively. The median device failure-free survival was not reached in patients with prior slings and was 8.9 years in patients without prior slings (P = 0.048). Limitations include retrospective nature and small sample size.

CONCLUSIONS

The efficacy and safety of AUS in patients with prior slings are similar to those without. Prior sling is associated with a longer device failure-free survival. AUS remains a viable option in patients who have persistent PPI after prior slings.

Bilateral Cavernosal Artery Ligation to Treat Ischemic Priapism Following Inflatable Penile Prosthesis Implantation

OBJECTIVE

To describe the first known case of recurrent acute priapism after penile prosthesis implantation.

MATERIALS AND METHODS

A 60-year-old gentleman with a history of recurrent ischemic priapism without hemoglobinopathy presented with refractory erectile dysfunction and underwent uncomplicated penile prosthesis placement. His course was complicated by early acute ischemic priapism confirmed via ultrasound. Due to his pain, attempts to relieve the priapism using ultrasound-guided phenylephrine injections were attempted but were unsuccessful.

RESULTS

He subsequently underwent exploration with confirmation of distal ischemic priapism followed by brisk bright red blood from the proximal corpora upon device externalization. A perineal exploration was performed and the bilateral cavernosal arteries were suture ligated with immediate relief. The device was reimplanted and the patient recovered uneventfully.

CONCLUSION

We report the first known case of ischemic priapism following inflatable penile prosthesis implantation. The details of this case challenge the dogma that priapism is a binary event and instead supports an imbalance between unopposed cavernosal artery inflow possibly due to vascular calcifications and compromised venous outflow due to the presence of the device. Prosthetic urologists should be aware of this rare phenomenon and consider all available approaches on an individualized case-by-case basis.

Extensive dystrophic calcification of eroded artificial urinary sphincter cuff—a rare cause of urethral obstruction—a case report

Background

Case Description

Conclusions

The effect of the timing of biochemical failure after external beam radiotherapy or low-dose-rate brachytherapy for definitive prostate cancer treatment

28

Background: To assess the effect of the timing of biochemical failure (bF) after definitive radiotherapy with external beam (EBRT) or low dose-rate brachytherapy (LDR) on clinical failure (cF) and prostate cancer-specific mortality (PCSM). Methods: From 1996 to 2009, 4478 patients were treated and by 2010, 456 patients were noted to have a bF. They were categorized as early (< 5 years post-therapy) or late (≥ 5 years post-therapy) failures. Factors thought to influence cF and PCSM were scored. Cox regression was used to assess the timing of bF on cF and Fine and Gray regression was used to assess the timing of bF on PCSM. Results: There were 330 (72.4 %) patients categorized as early and 126 (27.6 %) as late failures. The median PSA follow-up post-radiotherapy for the early bF group is 82 months vs. 155 months for the late bF group, and the median PSA follow-up post-bF is 54 months for the early bF group vs. 69 months for the late bF group. The early failures were more likely to be high-risk (p = 0.0080), have a higher Gleason score (p = 0.0008), and use ADT (p = 0.0325). The five-year rate of cF post early bF is 61% vs 43% post late bF (p <0.0001). The five-year rate of PCSM post early bF is 27% vs 9% post late bF (p <0.0001). The multivariable analyses assessing the cF and PCSM are shown in Table. Conclusions: Early bF is associated with higher rates of cF and PCSM. Patients treated with LDR have a lower risk of PCSM. [Table: see text]

The importance of the need for better systemic therapy in the definitive treatment of high-risk prostate cancer regardless of whether the initial treatment modality was external beam radiation, I-125 brachytherapy, or radical prostatectomy

65

Background: While androgen deprivation therapy (ADT) is a common form of systemic therapy for treating high-risk prostate cancer (HRCaP), distant metastases development remains the predominate form of failure. We present a description of the sites of failure after treatment of HRCaP with External Beam Radiation (EBRT), I-125 Brachytherapy (PB), or Radical Prostatectomy (RP). This is accompanied by an analysis of prostate cancer-specific mortality (PCSM) after clinical failure. Methods: The study includes 2186 patients with HRCaP according to NCCN guidelines (684 EBRT, 409 PB, and 1093 RP). The association of PCSM with clinical and pathologic variables was assessed with Fine and Gray regression with non-PCSM mortality treated as a competing event. Results: The median f/u is 52 months. Overall, there were 323 clinical failures (sites of first failures: 287 distant (DM), 34 local (LF), 2 DM + LF). The median time to the diagnosis of DM was 44 months. ADT was used in 93% of EBRT, 53% of PB and 19% of RP patients. Further details regarding the development of DM is shown in Table 1. The type of initial treatment was not associated with PCSM after DM (Table 1). The only factor significantly associated with PCSM was Gleason Score (p = 0.0372). Conclusions: DM is the primary mode of failure after definitive treatment of HRCaP. The type of initial definitive treatment did not affect PCSM after DM. The cure rates of all forms of definitive treatment of HRCaP would benefit from better systemic therapy. [Table: see text]

Penile-sparing modalities in the management of low-stage penile cancer

Penile-sparing modalities are gaining widespread adoption for the management of low-stage penile cancer due to an increasing demonstration of sound oncologic, cosmetic, sexual, psychosocial, and quality of life outcomes. This review aims to provide a comprehensive overview of the respective treatment options in the armamentarium of the practicing urologist in dealing with this rare but problematic condition.

The effect of androgen deprivation therapy on prostate cancer-specific mortality in high-risk prostate cancer: Patients treated with low dose-rate brachytherapy without supplementary external beam radiotherapy

e550

Background: Androgen deprivation therapy (ADT) is a mainstay accompaniment of external beam radiotherapy (EBRT) for treating high-risk prostate cancer (HPCaP). Both low dose-rate brachytherapy (LDR) as the sole method of radiotherapy and the need for ADT in conjunction with it are relatively unexplored with HRCaP. We present an inception cohort study of HRCaP patients treated with LDR alone with or without ADT. Methods: The study includes 515 patients with HRCaP according to NCCN guidelines. They were treated with I-125 LDR alone to a dose of 144 Gy with lateral, superior, and inferior margins of at least 5 mm (medin D90 = 149.39 Gy). The association of prostate cancer-specific mortality (PCSM) with pre-treatment variables was assessed with Fine and Gray regression with non-PCSM mortality treated as a competing event. PCSM rates were calculated using the cumulative incidence method. Results: The median age is 70 years. The median f/u is 48.9 months. Fifty-four percent were Gleason 7, 28% were Gleason 8, and 11% were Gleason 9. Fifty-three percent received ADT for a median duration of 6 months (range = 1-32 months). At 5 years, the PCSM rate was 1.2 % for LDR and 4.2% for LDR + ADT, and at 10 years, the PCSM rate for LDR was 3.3% and 4.2% for LDR + ADT (p = 0.34). Table 1 shows the association of pre-treatment factors with PCSM. Conclusions: ADT does not affect PCSM for HRCaP patients. Further studies should be done to explore if ADT is necessary with LDR for HRCaP. [Table: see text]

Comparisons of outcomes for patients with high-risk prostate cancer treated with brachytherapy, external beam radiation, or radical prostatectomy

63

Background: There is no consensus on how to best treat patients (pts) with high-risk prostate cancer. Methods: The outcomes for 2,736 high-risk prostate cancer pts treated with radical prostatectomy (RP), external beam radiotherapy (RT), and I-125 brachytherapy (BT) at a single institution from 1996 to 2012 were reviewed. The majority of RT pts were treated prior to 2002 because of our preference for RP and BT over time. High-risk was defined per the NCCN criteria. The outcomes assessed were biochemical failure (bF), clinical failure (cF), and prostate cancer mortality (PCM). Results: The distribution by treatment was RP 54%, RT 27%, and BT 19%. The median follow up for all pts was 4.6 years (y) (range 0.1-19.5): 3.8 y (0.1-18.7) for RP, 7.7 y (0.1-19.4) for RT, and 4.1 y (0.1-16.8) for BT pts. No patient received RT+BT, and 44% received androgen deprivation therapy (ADT). On multivariable analysis (see table) RP pts were at higher risk for bF vs. RT; BT pts and RT pts were at higher risk for cF vs. RP; and RT pts were at higher risk for PCM vs. RP. All multivariable analyses were adjusted for clinical stage, biopsy Gleason score, pre-treatment PSA, and duration of ADT. Conclusions: RP is associated with worse bF but better cF and PCM. There is no difference between BT and RT for bF, cF, or PCM while BT and RP had similar PCM. These outcomes may be a result of selection bias or differences in follow up time among the three treatment arms so no demonstration of modality superiority is possible. [Table: see text]

Public Restroom Habits in Patients After Artificial Urinary Sphincter Implantation

OBJECTIVE

To investigate public restroom habits with secondary outcomes evaluating health-related quality of life (HRQoL) outcomes in our patients who underwent artificial urinary sphincter (AUS) implantation after prostatectomy. Postprostatectomy incontinence is a significant burden on patients' emotional health and ability to perform activities of daily living.

METHODS

Between June 2012 and January 2014, we identified 50 men who had undergone AUS placement for postprostatectomy incontinence. All 50 men completed baseline Expanded Prostate Cancer Index Composite-Urinary Domain (EPIC-UD) and Urogenital Distress Inventory Short Form (UDI-6) questionnaires preoperatively. We evaluated patients' subjective postoperative continence status using the UDI-6 and EPIC-UD scales via a telephone-administered questionnaire.

RESULTS

Thirty-one of 50 patients (62%) were contacted and agreed to participate in the study. The pad score decreased significantly from 3 (median = 3 pads per day [ppd]; interquartile range [IQR] = 2) during minimal activity before surgery to 1 (median = 1.0 ppd; IQR = 0.5) after surgery (P <.001), and from 5 pads (median =5 ppd; IQR = 5) during strenuous activity to 1 pad (median = 1 ppd; IQR = 2; P <.001). QoL analysis pre- and post-AUS revealed a score increase of 16.5 points (P <.007) in EPIC-UD and an increase of 23.93 (P <.022) in UDI-6. Men reporting lower ppd before AUS placement were more likely to report higher public restroom urinal use (R = 0.366; P <.043) and increased public restroom comfort level (R = 0.342; P <.060) as compared with men with higher preoperative ppd usage.

CONCLUSION

EPIC-UD and UDI-6 scores improved significantly and demonstrated high levels of correlation to self-reported ppd; however, both failed to show any correlation to patients' comfort level with public restrooms. The single predictor of patients' comfort was self-reported ppd with minimal activity.

Impact of timing of biochemical failure on the eventual development of clinical failure after definitive treatment with brachytherapy or external beam radiotherapy for prostate cancer

53

Background: Late treatment failure is often considered to be a rare event. We will assess the influence of the timing of biochemical failure (bF) after definitive brachytherapy (BT) or external beam radiotherapy (EBRT) for prostate cancer on its frequency and association with clinical failure (cF). Methods: Patients with prostate cancer treated between 1996 and 2009 with at least 5 years of follow-up (N= 2,293; 1,060 EBRT, 1,233 BT) were studied in the context of an IRB-approved inception cohort study. Those with a bF were reviewed to determine the timing of bF [< 5 years after treatment (bF<5) vs. > 5 years after treatment (bF>5)] and occurrence of cF post-bF. The bF definition used was the nadir + 2.0 ng/mL version. Results: Of the total patient population, 477 (21%) were noted to have bF- 244 (11%) bF<5 vs. 233 (10%) bF>5. The median follow-up after bF for the bF< 5 group is 41 months while in the bF> 5 group it is 22 months. In the BT group, 94 (8%) failed < 5 years and 87 (7%) failed > 5 years. In the EBRT group, 150 (14%) failed < 5 years and 146 (14%) failed > 5 years. The median PSA value (ng/mL) at the time of bF for all patients, EBRT, and BT in the bF<5 group was 3.70, 3.65, and 3.80, respectively (p=not significant). The median PSA value (ng/mL) at the time of bF for all patients, EBRT, and BT in the bF>5 group was 3.01, 3.01, and 3.04, respectively (p=not significant). Overall, 53.3% of patients in the bF<5 group developed cF while 27% of patients in the bF>5 group developed a cF. The actuarial five year rate of cF for the bF <5 group was 50% vs. 38% for the bF>5 group (p= 0.028). The detection of bF and cF was closely linked to PSA testing frequency ( p < 0.0001). Conclusions: The risk of bF does not appear to decrease >5 years post treatment. Late bF (i.e. >5 years after treatment) may still result in eventual cF. While cF is less common after bF > 5 years post definitive therapy, it still affects 27% of those with bF and is strongly associated with PSA testing frequency. The lower rate of cF after 5 years may relate to the shorter follow-up time for this group.

Continence outcomes after treatment of recalcitrant postprostatectomy bladder neck contracture and review of the literature

OBJECTIVE

To present our experience with 2-stage management for recalcitrant refractory bladder neck contracture (BNC) after radical prostatectomy.

METHODS

A 15-year retrospective medical record review was performed for patients referred for BNC using current procedural terminology code or by International Classification of Diseases-Ninth Revision code for bladder neck incision (BNI). Treatment consisted of deep cold-knife BNI, followed by cystoscopy at 3-4 months. If stable and healed, an artificial urethral sphincter (AUS) or male sling was placed depending on continence level. Recurrent BNC at 3 months was treated with a second BNI.

RESULTS

Sixty-three patients were referred with median (range) age of 66 (41-82) years, body mass index 30.1 (21.9-64.8) kg/m(2), and follow-up of 11 (1-144) months. Seventeen (27%) underwent adjuvant radiation therapy. Of the 46 who had successful management of the BNC, 91.3% were satisfied with level of continence after BNI alone or with a single additional operation. Of the 33 who underwent AUS or sling, only 2 failures occurred: 1 ultimately required cystectomy after multiple urethral erosions, and 1 with mild incontinence was satisfied with a secondary sling procedure. Four patients progressed to permanent urinary diversion. Together, either BNI (n = 4) or the secondary incontinence procedure (n = 1) was not successful in a total of 5 patients and required permanent urinary diversion. Nine had concurrent severe membranous strictures with no coaptation of the external urethral sphincter and were treated with direct vision internal urethrotomy and AUS and were continent.

CONCLUSION

This represents the largest known experience with BNC after radical prostatectomy. Patients can be managed with cold-knife incision, followed by AUS or sling, with 66% achieving continence.

Outcomes after photoselective vaporization of the prostate and transurethral resection of the prostate in patients who develop prostatic obstruction after radiation therapy

OBJECTIVE

To compare the need for repeat treatment or urinary diversion in patients undergoing transurethral resection of the prostate (TURP) compared with photoselective vaporization of the prostate (PVP) after brachytherapy or external beam radiation therapy (EBRT).

METHODS

The prostate cancer database of Cleveland Clinic includes 3600 patients who have undergone prostate brachytherapy and 2500 patients who have undergone EBRT. We cross-referenced these patients with the electronic medical record to identify patients who required PVP or TURP after radiation. The primary outcome was the need for any further intervention after PVP or TURP, including bladder neck incision, repeat TURP, or permanent supravesicular diversion.

RESULTS

Sixty of the 3600 patients (1.7%) required prostate reduction surgery after brachytherapy. Of these 60 patients, 19 of 40 (47.5%) who underwent TURP required further intervention, and 10 of 20 patients (50%) who underwent PVP required subsequent intervention. Twenty-eight of the 2500 patients (1.1%) required prostate reduction surgery after EBRT. Of these 28 patients, 5 of 18 patients (27.8%) who underwent TURP required further intervention, and 5 of 10 patients (50%) who underwent PVP required subsequent intervention. Following either type of radiation there was not a significant difference in the need for further treatment based on the type of surgery (P >.999 for brachytherapy; P = .412 for EBRT). The median time between radiation and prostate reduction surgery is 20.2 months (range, 14.6-27.6) after brachytherapy and 53.3 months (range, 27.5-53.3) after EBRT (P = .0005).

CONCLUSION

This study suggests that PVP and TURP are comparable in treating prostatic obstruction after brachytherapy or EBRT. However, obstruction after brachytherapy occurs earlier compared with after EBRT.

Photoselective vaporization of the prostate compared to transurethral resection of the prostate in patients who develop prostatic obstruction following brachytherapy

187

Background: Patients who undergo brachytherapy are at risk of developing prostatic obstruction, and a subset of these patients requires prostate reduction surgery. These patients pose a challenge to urologists who seek to determine the appropriate form of intervention given the reduced healing capacity of irradiated tissue. Given our observation that certain patients suffer recalcitrant prostatic obstruction following photoselective vaporization of the prostate (PVP), we evaluated outcomes after TURP compared to PVP for patients who experienced bladder outlet obstruction after brachytherapy. Methods: Cleveland Clinic’s prostate cancer database includes 3,600 patients who have undergone prostate brachytherapy since 1996. We cross-referenced these patients with the EMR to identify patients who required prostate reduction surgery following brachytherapy. We reviewed operative notes for these patients to identify the type of intervention completed, and we used the EMR to identify post-PVP/TURP complications requiring intervention. Clinical and demographic characteristics were obtained from the prospective database. Results: Sixty of the 3,600 patients developed urinary retention requiring prostate reduction surgery. The average age of these patients was 69 and the average prostate size was 52 grams. Forty patients underwent TURP and 20 patients were treated with PVP. Of the TURP patients, 19/40 (47.5%) required subsequent TURP, dilation, incision or permanent diversion, including 9 patients (22.5%) who required at least 2 further procedures. Of the PVP-treated patients, 10/20 (50%) required subsequent instrumentation including 4 (20%) who underwent at least 2 procedures. Conclusions: Half of the patients who require prostate reduction surgery for urinary retention following brachytherapy may require further procedures regardless of whether TURP or PVP is performed. Neither procedure confers less morbidity. [Table: see text]

Variations in treatment modality use for the definitive management of prostate cancer in the United States

174

Background: No prospective, randomized comparative efficacy trial exists to guide treatment of definitively managed prostate cancer patients. Despite this, treatment selection varies nationally and we attempt to assess these patterns of use. Methods: The SEER database was queried to identify cases of prostate cancer diagnosed between 1998-2008. The modalities identified were brachytherapy (brachy), combination of brachytherapy and external beam radiation (CombRT), external beam radiotherapy (EBRT), radical prostatectomy and external beam radiotherapy (RP+RT), and radical prostatectomy (RP). The number of cases by year, patient age and SEER region was computed. Results: There were 361,135 men in this analysis: 12.4% brachy, 6.8% CombRT, 27.5% EBRT, 3.1% RP+RT, and 50.3% RP. As expected, treatment modality varied by age with younger men more likely to receive RP and older man more likely to receive EBRT or brachy. There was some variation in choice of treatment modality over time: 6.6% for brachy; 4.2% for CombRT; 1.9% for EBRT; 2.0% for RP+RT; and 7.8% for RP. The variation in treatment modality by region was surprisingly wide (table): 14.4% for brachy; 25.5% for CombRT; 28.5% for EBRT; 3.8% for RP+RT; and 26.8% for RP. Conclusions: Choice of prostate cancer treatment modality varies by age, year of treatment, and most notably geographical region. Surprisingly the changes in reimbursement rates over the study period seem to have had minimal impact on choice of treatment modality. The regional variation implies that affiliations among healthcare providers significantly impact treatment. [Table: see text]

Long-term toxicity and associated cost of initial treatment and subsequent toxicity-related intervention for patients treated with prostatectomy, external beam radiotherapy, or brachytherapy: A SEER/Medicare database study

4

Background: Treatment-related toxicity for prostate cancer (CaP) is rarely reported more than 5 years after therapy. We examined the SEER-Medicare linked database with the potential of having 16 years of follow-up data on toxicity requiring procedural intervention.

Methods: The SEER-Medicare database was queried for CaP patients treated with prostatectomy (RP), external beam radiotherapy (EBRT), or brachytherapy (PI) between 1991-2007. We identified procedural billing codes associated with toxicity-related treatments. We obtained information on the Medicare reimbursement rates for the initial treatment and any toxicity-related interventions. We then computed the cost per patient-year within each treatment modality over time.

Results: A total of 137,427 patients who were 65 years or older at the time of CaP diagnosis and who had CaP as their only cancer diagnosis were retrieved from the SEER/Medicare database: 59,559 (43.3%) treated with RP, 60,806 (44.2%) treated with EBRT, and 17,062 (12.4%) treated with PI. No patient received combined therapy. The median follow-up is 71 months. Overall, 10,585 (7.3%) patients experienced a toxicity requiring intervention. Within treatment modalities, the percentages receiving toxicity-related intervention were: RP 6.9%, EBRT 8.8%, and PI 3.7%. The gastrointestinal (GI) and genitourinary (GU) toxicity comparisons are listed in the table. Dilation of a urethral stricture was the most common GU toxicity (3.6% of all patients) while cauterization of rectal bleeding was the most common GI toxicity (0.8% of all patients).

Conclusions: The long-term toxicity and cost per patient-year of the major prostate cancer treatment modalities differ. EBRT is the most toxic and most costly.

[Table: see text]

Comparing long-term toxicity between external beam radiotherapy modalities: A SEER/Medicare database study

118

Background: The use of intensity modulated radiotherapy (IMRT) for the treatment of prostate cancer (CaP) has been widely promoted due to the hypothesized benefit of low late toxicity.

Methods: The SEER-Medicare database was queried for CaP patients treated with external beam radiotherapy (EBRT), 1991-2007. CPT billing codes were used to identify patients treated with IMRT or standard EBRT (sEBRT), which was comprised of conformal radiotherapy or a four-field technique. Patients without a treatment billing code were excluded from the analysis. Information on dose is unavailable. CPT codes were also used to identify procedures associated with gastrointestinal (GI) or genitourinary (GU) toxicity related treatments. Cumulative incidence rates for GI and GU toxicity were calculated with death treated as a competing event.

Results: A total of 137,427 patients who were 65 years or older at the time of CaP diagnosis and who had CaP as their only cancer diagnosis were retrieved from the SEER-Medicare database: 60,806 were treated with EBRT and a treatment billing code was identified for 35,388 patients. No patient received combined therapy. Seventeen percent of patients received IMRT. The median follow-up for patients receiving IMRT is 40 months (mo) (range 2-157) vs 77 mo (range 0-203) for patients receiving sEBRT. Overall, 3,699 (10%) patients experienced a toxicity requiring an intervention. The five year rate of GI The gastrointestinal (GI) and genitourinary (GU) toxicity comparisons are listed in the table. For both endpoints, rate of toxicity at five years was higher for the IMRT group. The most common GU toxicity for both groups was dilation of a urethral stricture (3.8% of all sEBRT patients vs 3.4 of all IMRT patients). Cauterization of rectal bleeding was the most common GI toxicity (2.4% of all sEBRT patients vs 1.6 of all IMRT patients).

Conclusions: While the rates of GI toxicity between IMRT and sEBRT are comparable, of concern is the higher rate of GU toxicity for the IMRT patients despite this group having a shorter follow up than the sEBRT group.

[Table: see text]

Long-term (potential 10-year follow-up) toxicity after treatment for prostate cancer with either external beam radiation therapy, interstitial brachytherapy, or radical prostatectomy

65

Background: To examine gastrointestinal (GI) and genitourinary (GU) toxicity profiles of patients treated in 1999 with external beam radiotherapy (RT), prostate interstitial brachytherapy (PI) or radical prostatectomy (RP).

Methods: The records of 483 patients treated in 1999 were retrospectively reviewed to evaluate toxicity profiles, with 24% of the patients treated with PI, 40% with RP, and 36% with RT. Late GI and GU morbidity profiles were specifically examined and both were graded according to the RTOG acute and late morbidity scoring criteria. Other factors examined were patient age, BMI, smoking history, and medical comorbidities including presence of diabetes mellitus (DM), peripheral vascular disease, and connective tissue disease. Due to the low event rate for late GU and GI toxicities, a competing risk regression (CRR) analysis was done with death as the competing event.

Results: See Table. Median follow-up time was 8.6 years (range 0.2-11.5). On CRR univariate analysis the presence of DM was associated with GU toxicity grade ≥2 (p=0.043, HR 2.35, 95% CI=1.03-5.39). DM remained significant on multivariate analysis (p=0.034, HR 2.44, 95% CI= 1.07-5.59). Since there were no events in the RP group, only the PI and RT patients were included in the CRR analysis for late GI toxicity Grade <=2. On univariate analysis, RT and DM were significantly associated with late GI toxicity. On multivariable analysis, both variables remained significant (RT: p=0.038, HR=4.71, 95%CI=1.09-20.3; DM: p=0.008, HR=3.81, 95%CI=1.42-10.2).

Conclusions: Late effects occur with all three treatment modalities. The presence of DM at the time of treatment was significantly associated with worse late GI and GU toxicity. RT was significantly associated with worse late GI toxicity compared to PI and RP.

[Table: see text]

No significant financial relationships to disclose.

PSA bounce and biochemical failure after brachytherapy for prostate cancer: a study of 820 patients with a minimum of 3 years of follow-up

PURPOSE

To determine clinical or dosimetric factors associated with a prostate-specific antigen (PSA) bounce, as well as an association between a PSA bounce and biochemical relapse-free survival (bRFS), in patients treated with iodine-125 brachytherapy.

METHODS AND MATERIALS

A variety of clinical and treatment factors were examined in 820 patients who had a minimum of 3 years of PSA follow-up with T1-T2cN0M0 prostate cancer. Four different PSA threshold values were used for defining a PSA bounce: a PSA rise of ≥ 0.2, ≥ 0.4, ≥ 0.6, and ≥ 0.8 ng/mL.

RESULTS

A PSA bounce of ≥ 0.2, ≥ 0.4, ≥ 0.6, and ≥ 0.8 ng/mL was noted in 247 patients (30.1%), 161 (19.6%), 105 (12.8%), and 78 (9.5%), respectively. The median time to the first PSA rise was 17.4, 16.25, 16.23, and 15.71 months, respectively, vs. 34.35 months for a biochemical failure (p < 0.0001). A PSA rise of ≥ 0.2 ng/mL was the only definition for which there was a significant difference in bRFS between bounce and non-bounce patients. The 5-year bRFS rate of patients having a PSA bounce of ≥0.2 was 97.7% vs. 91% for those who did not have a PSA bounce (p = 0.0011). On univariate analysis for biochemical failure, age, risk group, and PSAs per year had a statistically significant correlation with PSA bounce of ≥ 0.2 ng/mL. On multivariate analysis, age and PSAs per year remained statistically significant (p < 0.0001 and p = 0.0456, respectively).

CONCLUSIONS

A bounce definition of a rise ≥ 0.2 ng/mL is a reliable definition among several other definitions. The time to first PSA rise is the most valuable factor for distinguishing between a bounce and biochemical failure.