To analyze the feasibility of intraoperative radiotherapy (IORT) in patients with high-risk prostate cancer and candidates for radical prostatectomy.
A total of 38 patients with locally advanced ...prostate cancer were enrolled. No patients had evidence of lymph node or distant metastases, probability of organ-confined disease >25%, or risk of lymph node involvement >15% according to the Memorial Sloan-Kettering Cancer Center Nomogram. The IORT was delivered after exposure of the prostate by a dedicated linear accelerator with beveled collimators using electrons of 9 to 12 MeV to a total dose of 10-12 Gy. Rectal dose was measured in vivo by radiochromic films placed on a rectal probe. Adminstration of IORT was followed by completion of radical prostatectomy and regional lymph node dissection. All cases with extracapsular extension and/or positive margins were scheduled for postoperative radiotherapy. Patients with pT3 to pT4 disease or positive nodes received adjuvant hormonal therapy.
Mean dose detected by radiochromic films was 3.9 Gy (range, 0.4-8.9 Gy) to the anterior rectal wall. The IORT procedure lasted 31 min on average (range, 15-45 min). No major intra- or postoperative complications occurred. Minor complications were observed in 10/33 (30%) of cases. Of the 27/31 patients who completed the postoperative external beam radiotherapy, 3/27 experienced Grade 2 rectal toxicity and 1/27 experienced Grade 2 urinary toxicity.
Use of IORT during radical prostatectomy is feasible and allows safe delivery of postoperative external beam radiotherapy to the tumor bed without relevant acute rectal toxicity.
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GEOZS, IJS, NUK, OILJ, UL, UM, UPUK
OBJECTIVE
To review our experience with laparoscopic adrenalectomy (LA), to evaluate the effectiveness and safety of this procedure in patients with adrenal malignancy.
PATIENTS AND METHODS
The study ...included patients who underwent LA from 1995 to 2002, with histologically identified adrenocortical cancer (ACC) or metastasis. Indications for LA were adrenal masses with no radiological evidence of involvement of the surrounding structures, or solitary metastasis with well‐controlled primary cancer. The variables evaluated were: size of the lesion, operative duration, estimated blood loss, intraoperative complications, local, port‐site and intra‐abdominal recurrence, distant metastasis, and survival time.
RESULTS
Fourteen malignant adrenal lesions in 205 LAs (7%) were confirmed with histological diagnoses that showed a primary ACC in six and metastasis in another seven (in one there was bilateral metastasis). The mean (sd) size of the malignant lesions was 5.9 (2.8) cm. The 12 unilateral procedures required a mean operative duration of 164 (47) min; the bilateral procedure lasted 215 min. There was one conversion to open surgery caused by local infiltration, whereas there were no intraoperative complications. The mean follow‐up was 30 months, during which three patients died, one from endoperitoneal and trocar port‐site seeding.
CONCLUSION
When the malignancy is confined to the adrenal gland, LA seems to be a feasible option if the principles of oncological surgery are respected. Nevertheless, further investigations are required to evaluate the appropriateness of this operation.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Intraoperative electron beam radiotherapy (IOERT) for prostate cancer (PC) is a radiotherapeutic technique, giving high doses of radiation during radical prostatectomy (RP). This paper presents the ...published treatment approaches for intraoperative radiotherapy analyzing functional outcome, morbidity, and oncological outcome in patients with clinical intermediate-high-risk prostate cancer. A systematic review of the literature was performed, searching PubMed and Web of Science. A “free text” protocol using the term intraoperative radiotherapy and prostate cancer was applied. Ten records were retrieved and analyzed including more than 150 prostate cancer patients treated with IOERT. IOERT represents a feasible technique with acceptable surgical time and minimal toxicity. A greater number of cases and longer follow-up time are needed in order to assess the long-term side effects and oncological outcome.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
We characterize the consequences of androgen deprivation therapy on body composition in elderly men.
Using a dual energy x-ray absorptiometry instrument, we determined the changes in bone mineral ...density, bone mineral content, fat body mass and lean body mass in 35 patients with prostate cancer without bone metastases who received luteinizing hormone releasing hormone analogue for 12 months.
At baseline conditions 46% of cases were classified as osteopenic and 14% as osteoporotic at the lumbar spine and 40% were osteopenic and 4% osteoporotic at the hip. Androgen deprivation significantly decreased bone mineral density either at the lumbar spine (mean gm./cm.
2 SD 1.00 0.194, 0.986 0.172 and 0.977 0.182 at baseline, and 6 and 12 months, respectively, p <0.002) or the hip (0.929 0.136, 0.926 0.144 and 0.923 0.138, p <0.03). A more than 2% decrease in bone mineral density was found at the lumbar spine in 19 men (54.3%) and at the hip in 15 (42.9%). Bone mineral content paralleled the bone mineral density pattern. Lean body mass decreased (mean gm. SD 50,287 6,656, 49,296 6,554 and 49,327 6,345, p <0.003), whereas fat body mass consistently increased (18,115 6,209, 20,724 6,029 and 21,604 5,923 p <0.001).
Serial bone densitometry evaluation during androgen deprivation therapy may allow the detection of patients with prostate cancer at risk for osteoporotic fractures, that is those with osteopenia or osteoporosis at baseline and fast bone loss. The change in body composition may predispose patients to accidental falls, thus increasing the risk of bone fracture.
Increasing evidences indicate that despite the osteoblastic nature of metastatic bone lesions due to prostate cancer osteolysis is a regular feature and may cause skeletal morbidity. This observation ...provides the rationale for the use of bisphosphonates for managing bone metastatic prostate cancer.
We reviewed the literature on the mechanisms by which prostate cancer affects bone cell function and disrupts physiological bone turnover. We also summarized the clinical results of bisphosphonate for treating bone pain in patients with prostate cancer.
Metastatic prostate cancer in bone interferes with physiological bone remodeling by abnormal release of the hormones and paracrine factors physiologically involved in the modulation of osteoblastic and osteoclastic activity. Tumor induced bone formation and resorption develop within the same metastasis but excessive new bone is deposited away from bone resorption sites and does not contribute to bone strength. The increase in bone resorption may also be a generalized phenomenon that is most likely due to iatrogenic osteoporosis or related to hyperparathyroidism in response to the increased calcium demand. The bone resorption index in patients with bone metastatic prostate cancer correlates with bone pain and is an independent predictor of adverse skeletal events. However, small clinical studies of the efficacy of bisphosphonates for controlling bone pain in patients with prostate cancer show contradictory results.
Improved understanding of the pathophysiology of prostate cancer induced metabolic bone disease implies that bisphosphonates may have a role in the treatment of this disorder. This issue is being addressed by large-scale ongoing randomized studies.
To analyze, in a consecutive study, the perioperative, postoperative, and functional results of the transperitoneal and extraperitoneal approaches for laparoscopic radical prostatectomy.
A total of ...160 patients underwent radical prostatectomy and were subdivided into two groups. Group 1 underwent the transperitoneal approach and group 2, the extraperitoneal approach. The preoperative parameters, age, prostate-specific antigen level, biopsy Gleason score, American Society of Anesthesiologists class, body mass index, and clinical stage, were considered. The perioperative parameters evaluated were the operative time, blood loss, blood transfusion, hospital stay, catheterization time, complications, histopathologic findings, TNM stage, Gleason score, prostate and tumor volumes, and functional results.
The patients in both groups had comparable preoperative data. No differences were observed between the two groups in the intraoperative data, except for the mean operative time (179 ± 54.6 for group 1 versus 133.7 ± 27 minutes for group 2). Also, no differences were observed between the two groups in terms of the postoperative data. The proportion of complications was 21.25% in group 1 and 22.5% in group 2. We recorded symptomatic lymphocele requiring treatment with a drain or reoperation in 8 patients (10%) in group 2 and 0% in group 1 (
P <0.001) of all the patients who underwent lymphadenectomy. The rate of positive surgical margins was 25% for group 1 and 21.25% for group 2 (
P = NS). For those with Stage pT2, the positive margin rate was 7.3% and 10% for groups 1 and 2, respectively. The recovery of continence at 3 months was faster in group 2 (75% of patients versus 50.9% in group 1;
P <0.01).
The extraperitoneal approach required less operative time and enabled faster recovery of continence and the transperitoneal approach prevented the formation of lymphocele.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
In the last few years laparoscopic surgery has become the gold standard for the treatment of several urological diseases such as renal cancer and ureteropelvic junction obstruction (UPJO). A ...transmesenteric approach for left laparoscopic pyeloplasty has been recently described in order to avoid bowel manipulation and the potentially related complications. The aim of the present study is to describe the surgical technique and the advantages of the transmesenteric approach for laparoscopic pyeloplasty, pyelolithotomy, and simple nephrectomy in our experience.
From December 2007 to May 2010, 12 laparoscopic procedures for left renal diseases were performed using a transmesenteric approach. The indications were left UPJO in 9 cases, left pelvic-ureteral stones in 2 cases, and left end-stage kidney disease in one case.
No conversions or intraoperative complications were observed. No blood transfusions were required. Resumption of oral intake and canalization occurred in all cases within 48 hours of the procedure. All patients had an uneventful postoperative course.
The laparoscopic transmesenteric approach represents an interesting and advantageous technical improvement of minimally invasive surgery for the treatment of left renal diseases.
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