[Palliative surgery for metastatic prostate cancer]

Androgen deprivation in combination with novel hormonal agents, docetaxel, or in combination with abiraterone/prednisone plus docetaxel or darolutamid plus docetaxel represent the standard therapeutic approach in metastatic hormone-sensitive prostate cancer (mHSPC). Patients with low-risk prostate cancer also benefit from additional radiation therapy or radical prostatectomy in terms of progression-free and overall survival. Despite favorable response rates, basically all patients will develop castration resistant prostate cancer (CRPC) within 2.5 to 4 years. In addition to systemic chemotherapy, second-line hormonal treatment of systemic application of radionuclides such as radium223 or 177Lu-PSMA represent salvage management options. However, nowadays about 50-65% of patients will develop symptoms due to local progression of prostate cancer which is the result of improved oncological outcomes with significantly prolonged survival times due to the new medical treatment options. Management of such symptomatic local progression will become more important in upcoming years so that all uro-oncologists need to be aware of the various surgical management options. Complications of the lower urogenital tract such as recurrent gross hematuria ± bladder clotting and with the necessity for red blood cell transfusions, subvesical obstruction and acute urinary retention, rectourethral or rectovesical fistulas might be managed by palliative surgery such as palliative transurethral resection of the prostate (TURP), radical cystectomy, radical cystoprostatectomy with urinary diversion, and pelvic exenteration. Symptomatic or asymptomatic obstruction of the upper urinary tract might be managed by endoluminal or percutaneous urinary diversion, ureteral reimplantation, ileal ureter replacement, or implantation of the Detour® system (Coloplast GmbH, Hamburg, Germany).

Management of gastro-intestinal emergencies in patients with ileal conduit ureteral diversion

Radical cystectomy with urinary deviation is performed increasingly in France. Ileal conduit ureteral diversion (ICUD), described by Bricker and widely used after this type of radical resection, leads to substantial anatomic modifications that are potential danger zones during subsequent gastro-intestinal or urinary tract operations. Injury to the urinary diversion apparatus can lead to disastrous complications in these patients who are often elderly and frail. General surgeons are most often called upon to re-operate these patients, either for an ICUD-related gastro-intestinal complication, or for an unrelated abdominal emergency that arises later (bowel obstruction, infection, cancer). During such operations, certain anatomic structures are particularly exposed to injury that may be irreversible, particularly, the mesentery of the ileal conduit and the left ureter. Approaching the right lower quadrant, the dissection of the ileo-ileal anastomosis or of the left mesocolon are the procedures or maneuvers that pose the most risk. A number of simple but effective preventive measures are available and must be known, such as to operate the patient with an urologist or to insert ureteral stents before surgery. Preoperative contrast-enhanced computed tomography with late phase urinary imaging is essential to assess the anatomic modifications and anticipate the operative procedural steps. Finally, one should not hesitate to disinsert the stoma and proceed with retrograde dissection, thus facilitating the identification of the ileal conduit, the mesentery and the ureters.

Hyperchloremic Metabolic Acidosis with Hyperglycemic Hyperosmolar Syndrome after Robot-Assisted Radical Cystoprostatectomy with Ileal Conduit Urinary Diversion: A Case Report

Hyperchloremic metabolic acidosis can be a problem in urinary diversion using the ileum. A 73-year-old Japanese male was hospitalized in emergency due to anorexia and malaise 3 weeks after being discharged from the hospital after getting robot-assisted radical cystoprostatectomy and intracorporeal ileal conduit urinary diversion. The blood analysis revealed metabolic acidosis, elevated chloride ions, and marked hyperglycemia: he was diagnosed with hyperchloremic metabolic acidosis and hyperglycemic hyperosmolar syndrome. We started administering insulin and large amounts of fluid replacement; besides, we inserted a large-diameter open tip catheter into the ileal conduit in hopes of inhibiting urine reabsorption in the intestinal mucosa. His general condition gradually improved, and he was discharged 10 days after his hospitalization.

[Pelvic exenteration in patients with locally advanced, symptomatic castration-resistant prostate cancer]

GOAL

The retrospective evaluation of clinical outcomes after palliative pelvic exenteration (PPE) in patients with subvesical and supravesical complications due to symptomatic locally advanced castration-resistant prostate cancer (CRPC).

PATIENTS AND METHODS

In all, 84 patients with locally advanced and symptomatic CRPC underwent radical cystoprostatectomy (n = 71, 83.3%) or anterior and posterior exenteration (n = 13, 16.7%). Local staging was done via pelvic MRI (magnetic resonance imaging), cystoscopy, and rectoscopy. Systemic staging was performed by computed tomography of the thorax, abdomen pelvis, and skeletal scintigraphy. Perioperative complications were evaluated using the Clavien-Dindo classification. The primary study objective was symptom-free survival defined as absence of lower or upper urinary tract symptoms and absence of endoluminal or percutaneous intervention.

RESULTS

After a median follow-up of 43.5 (3-139) months, symptom-free survival at 1 and 3 years was 95.2% and 86.7%, respectively. In all, 86.7% of patients remained symptom-free for their remaining lifetime with respect to local symptoms. Overall survival at 1 and 3 years was 92.9% and 54.7%, respectively. Clavien-Dindo grade 2, 3, and 4 complications occurred in 19 (22.6%), 7 (8.3%), and 3 (3.6%) patients, respectively.

CONCLUSION

With adequate patient selection, PPE is possible with a low complication rate and results in significant symptom relief in the lower or upper genitourinary tract in about 90% of patients, of whom more than 80% remain symptom-free for the remainder of their lives. Prerequisites for favorable surgical outcomes are patient selection, an interdisciplinary approach, and appropriate surgical expertise.

Spontaneous rupture of continent cutaneous urinary diversion after 25 years

Spontaneous rupture of a continent cutaneous urinary diversion is uncommon and diagnosis of this situation requires a high degree of suspicion. In this paper we present a 66-year-old man with continent cutaneous pouch after radical cystoprostatectomy that presented with spontaneous perforation 25 years after surgery. Spontaneous pouch perforation in our case after 25 years emphasizes the need for long follow-up in patients with continent diversion.

ERG and PTEN status of isolated high-grade PIN occurring in cystoprostatectomy specimens without invasive prostatic adenocarcinoma

High-grade prostatic intraepithelial neoplasia (HGPIN) is widely believed to represent a precursor to invasive prostatic adenocarcinoma. However, recent molecular studies have suggested that retrograde spread of invasive adenocarcinoma into pre-existing prostatic ducts can morphologically mimic HGPIN. Thus, previous molecular studies characterizing morphologically identified HGPIN occurring in radical prostatectomies or needle biopsies with concurrent invasive carcinoma may be partially confounded by intraductal spread of invasive tumor. To assess ERG and PTEN status in HGPIN foci likely to represent true precursor lesions in the prostate, we studied isolated HGPIN occurring without associated invasive adenocarcinoma in cystoprostatectomies performed at Johns Hopkins between 2009 and 2014. Of 344 cystoprostatectomies, 33% (115/344) contained invasive prostatic adenocarcinoma in the partially submitted prostate (10 blocks/case on average) and were excluded from the study. Of the remaining cases without sampled cancer, 32% (73/229) showed 133 separate foci of HGPIN and were immunostained for ERG and PTEN using genetically validated protocols. Of foci of HGPIN with evaluable staining, 7% (8/107) were positive for ERG. PTEN loss was not seen in any HGPIN lesion (0/88). Because these isolated HGPIN foci at cystoprostatectomy are unlikely to represent retrograde spread of invasive tumor, our study suggests that ERG rearrangement, but not PTEN loss, is present in a minority of potential neoplastic precursor lesions in the prostate.