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17658 TRUS guided prostate biopsy and our post-procedure complications

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Xhevdet Cuni1, Isa Haxhiu1, Himije Cuni1, and Mustafa Xhani2 and Edip Bezhani2

1University Clinical Centre, Albania

2UCC Mother Teresa, Albania

Purpose

TRUS guided prostate biopsy is widely used to confirm the diagnosis of prostate cancer which is associated with benefit of this procedure in medical treatment but still is followed by significant risk of complications. The patient's biological age, potential co-morbidities (ASA Index and Charlson Comorbidity Index), and the therapeutic consequences should also be considered.

Material & method

We conducted a patients based study of 81 men who underwent TRUS guided biopsy between Jan 2012 and Oct 2012.All patients involved in this study had first or second serum PSA value > 4.0 ng/mL and/or a suspicious DRE.The pts.mean age was 70,6 ± 3.2 years.

We recommended a 12 core biopsy,under prophylactic antibiotic regimen:cipronatin 500 mg-12 h before biopsy and 3 days later. The medical registry databases were used to estimate the rates of urological complications associated with these procedure.

Results

Immediate complications were: vasovagal episodes 7.4%(6/81), hematochezia <2 days 4,93% (4/81) and hematuria >1 day 8,64%(7/81) ).Delayed complications at 3 to 7 days were dysuria 11.11% (9/81), vague pelvic discomfort 12.3% (10/81), hematospermia 18,5%(15/81), urinary retention 4,93% (4/81). The hospital admission rate was 2% (2/8) ‘cause fever >38.5°C. Out of 81 patients who underwent this procedure, 12 pts (14,8%) were diagnosed with prostate adenocarcinoma.

Conclusions

Still is a clear lack of standardization in antibiotic prophylaxis for TRUS prostate biopsy. A review of the literature confirms that different antibiotics regimens are effective in preventing infective complications associated with the procedure.

Keywords

TRUS-bP

17810 BPE and incidental carcinoma of the prostate in Kosovo

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Xhevdet Cuni1, Isa Haxhiu2, Hilmije Aliu1, Anduena Haxhiu3, Mustafa Xhani2 and Flamur Tartari2

1University Clinical Centre, Albania

2Clinic of Urology, Albania

3Faculty of Medicine, University of Prishtina, Prishtinë, Kosovo

Introduction & Objective

To determine the occurrence of incidental carcinoma of the prostate (IPCa),in a group of patients surgically treated (TURP and open adenoma enucleation) for BPE in Kosovo. Information on incidental prostate cancer in Kosova is lacking.The present investigation is first in Kosovo who was carried out to enlighten incidental prostate cancer among the operated patients diagnosed by BPE in 5 years cohort study.

Material & method

This is hospital based study conducted in cohort study Jan 2005–Dec 2010. The study comprised a retrospective analysis of 2430 patients. The preoperative variables analyzed were DRE,serum,PSA value and patient age. Preoperatively all 2430 patients involved in this study had serum PSA value < or = 4.0 ng/mL without suspicious DRE and age >50 years-old.

Results

Out of 2430 cases operated for BPE,130 (5,3%) of all patients appear to have IPCa. In all these cases the histological findings reported prostate adenocarcinomas, Gleason score 2–6 and 7–10. 103 patients were with T1a tumour and 27 patients with T1b tumour of prostate. The mean age among patients with IPCa was 73.9 ± 9.2 years, versus 69.0 ± 3.4 years among patients with BPE. The advanced age (P = 0.004) were statistically related to the findings of the surgical specimen analysis.

Conclusions

The value of 5,3 % of patients with incidental prostate cancer in Kosovo can be explained with specific lifestyle of our population.

Generally, our population in Kosovo doesn't use excessive fat calories like in western countries. Eating traditionally a balanced diet, avoiding dietary excesses is a very important preventive factor from prostate cancer.

Keywords

IPCa,2012

19658 ProPSA and the Prostate Health Index in the role of prostate cancer diagnosis. Where are they now? A review of the current literature

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Kirandeep Mankoo

Queensland University of Technology, Australia

Introduction

Currently [-2]proPSA (proPSA) and the Prostate Health Index (PHI) play a role in diagnosing prostate cancer by influencing a clinicians decision in deciding whether a patient should be subjected to a prostate biopsy. However, their clinical utility is somewhat limited due to their inability to discriminate cancer from non-cancer, as well as cancer that is aggressive versus cancer that is not. This literature review looked at proPSA and PHI, and how they are used in a clinical environment.

Method

The latest journal articles focusing on the clinical utility of proPSA and PHI where reviewed.

Results

Current studies suggest that proPSA is better at discriminating aggressive cancer versus non aggressive cancer. PHI provides an improvement on evaluating risk of prostate cancer than usage of a free/total PSA ratio on its own. According to Beckman-Coulter the use of PHI has been estimated to reduce the outcome of negative biopsies but approximately 18–19% however larger scales studies need to be conducted for this to be confirmed. Currently there is no protocol in place to evaluate patients that yield medium risk scores. Usage of these markers may result in overdiagnosis and overtreatment.

Conclusion

Although proPSA and the PHI are not very discriminatory, clinicians still rely heavily on their results. However, there is slight improvement in sensitivity and specificity of PHI when compared with total/free PSA. However the results of proPSA and PHI are still just an assessment on risk which will never be definitive. Calls for larger scale studies to assess the true benefits of PHI and proPSA still need to be met, until then proPSA and PHI must be used with caution.

22162 Usefulness of cystography after radical retropubic prostatectomy: a prospective comparison between cystography and pericatheter retrograde urethrography

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Jong Kil Nam, Tae Nam Kim, Sung Woo Park and Moon Kee Chung

Pusan National University Yangsan Hospital, Republic of Korea

Purpose

To evaluate the usefulness of cystography after radical retropubic prostatectomy and the appropriated period of indwelling catheter removal, we prospectively compared the usefulness of cystography and pericatheter RGU to assess the integrity of the anastomosis site.

Materials and Methods

Between 2009 and 2010, cystography and pericatheter RGU was performed in 113 patients who underwent radical prostatectomy on POD 3 and 7 to reveal the presence of extravasation. If anastomotic extravasation was showed by both tests on POD 7, we performed the follow-up imaging study until there was no sign of the contrast extravasation.

Results

The mean age of the study population was 66.0years (range 51–82). The number of the patients who showed no extravasation on POD 3 and 7 were 81 and 93 patients, respectively. In cases of extravasation on POD 3, 2 patients showed only on cystography, 3 patients only on pericatheter RGU and 27 patients on both images. In cases of extravasation on POD 7, 3 patients showed only on cystography, 2 patients only on pericatheter RGU and 12 patients on both images. The 244 pairs of total 259 pairs (94.2%) showed concordant results on both imaging studies. Most patients who showed no leakage on POD 3 (71.7%), but there was delayed leakage in 3 cases on POD 7.

Conclusions

Our study showed that both tests provided similar results in all patients. However, because cystography is more simplicity, and less affected by technique, we suggest that cystography is more preferable. Because of the false negative results and the potential for disruption, we currently recommend delaying catheter removal until postoperative day 7 or later.

22394 Transperineal limited sector biopsy is as accurate as transperineal template saturation biopsy in prostate cancer detection

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Ben Williamson1, Lina Maria Carmona Echevarria2, Carlo L.A. Negro2, Chiara Fiorito2, Claudia Filippini3, Diane Nurse4, Rick Popert5 and Gordon H. Muir2

1King's College London, United Kingdom

2King's College Hospital NHS Trust, United Kingdom

3Citta della Salute Hospital, The University of Turin, Italy

4Princess Royal University NHS Trust, United Kingdom

5Guy's and St Thomas’ NHS Trust, United Kingdom

Introduction

To compare and review the diagnostic yield of a new Transperineal (TP) biopsy technique (24–32 cores) with the “saturation mapping” method (one biopsy per cc of prostate).

Materials and Methods

We reviewed patients who underwent consecutive TP biopsies of the prostate in a single tertiary academic center from June 2010 until May 2011. 90 patients were included in the analysis, with equal numbers in each group. 88 had had previous TRUS biopsy.

We recorded age, PSA, DRE, indication for template biopsy, result of transrectal ultrasound-guided prostate biopsy (TRUS) and template biopsy including number of cores, % of cores involved and laterality of cancer. Results were analyzed to determine if the TP biopsies upgraded the TRUS biopsy results, gave the same result, or were negative.

Results

Age mean was 62.4 years (42–78), PSA mean was 62.88 ng/mL(42–78). DRE was benign in 55% of the patients (n = 50), T1 in 15% (n = 14) and T2 in 24% (n = 22). The mean prostate volume was 65 cc (17.5–233). 51% (n = 46) were part of an Active Surveillance (AS) protocol, 41 % (n = 37) had the test done for high PSA with previous negative biopsies. 56% of the template biopsies were negative and 43% confirmed or upgraded the TRUS biopsy result (34% of upgrade compared to the TRUS biopsy). There were no significant differences between the results from the saturation and the new template technique.

Conclusion

A simplified limited transperineal template approach gives equal efficacy to a more complex, time consuming and expensive saturation technique.

22406 Continuous versus interrupted vesico-urethral anastomosis in open retropubic radical prostatectomy: comparison of operative outcomes and complications

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Dennis Lusaya and Sigfred Ian Alpajaro

The University of Santo Tomas Hospital, Philippines

Objective

We compared the technical results, operative outcomes, and complications of a novel continuous vesico-urethral anastomotic (VUA) suture in open radical prostatectomy (ORP) compared to the interrupted vesico-urethral anastomosis.

Methods

One hundred eighteen patients diagnosed with clinically localized prostate adenocarcinoma who underwent ORP done by a single surgeon at a tertiary hospital from 2005 to 2012 were included. Sixty-eight patients had VUA with the interrupted technique, while 50 had VUA with continuous suture technique. Technical and operative outcomes (operative time, blood loss, need for blood transfusion, duration of catheterization and hospitalization) were compared by T-test. Complications between the two techniques were matched via Pearson chi square.

Results

There was significant difference in operative outcomes of interrupted compared to continuous suture VUA with regards to operative time (3.58 + .60 hours vs 3.11 + .29 hours, P-value .001 ), estimated blood loss (899.26 + 426 ml vs 470 + 209 ml, P-value .001) and need for blood transfusion (.66 + .98 units vs .17 + .38 units, P-value .004 ), and duration of catheterization (14.66 + 2.4 days vs 8.23 + 1.75 days, P-value .001). There was no significant difference in the duration of hospital stay (5.206 + 1.05 days vs 4.9 + .42 days, P-value .130). There was no significant difference in occurrence of complications (leak on cystogram, urinary retention, bladder neck contracture, pelvic infection, urinoma formation, incontinence, and erectile dysfunction) between the two groups.

Conclusions

The continuous suture VUA technique for ORP appears to be an effective and reliable technique, reducing operative time, blood loss and early catheter removal (by post operative day 8). Randomized studies are warranted to further compare outcomes of the two VUA techniques.

22842 Anxiety in men with prostate cancer treated by active surveillance

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Jake Anderson1, Lina Riciardelli2, Sue Burney3, Mark Frydenberg4, Jane Fletcher5 and Joanne Brooker5

1Deakin University, Australia

2School of Psychology, Deakin University, Australia

3Cabrini Monash Psycho-Oncology, Cabrini Institute, Cabrini Health, Australia

4Department of Surgery Monash University, Department of Urology, MMC, Australia

5Cabrini Monash Psycho-Oncology, Cabrini Institute, Cabrini Health, Melbourne, Australia

Objectives

Prostate cancer is major cause of mortality and morbidity in Australian men. One treatment for low risk prostate cancer is active surveillance (AS). Anecdotal evidence suggests that some men on AS are vulnerable to anxiety which may have an impact on health related quality of life (HRQOL) and may also impact on the men's ability to remain on AS. The objectives of this study were to describe a range of anxieties in men on AS, and which of these anxieties predicted HRQOL. Our final aim was to examine the satisfaction that these men reported in the information provided to them about AS by their treating physician.

Methods

265 men with low risk prostate cancer enrolled on an AS database from a single urologist were invited to participate in the study. Socio-demographic information was collected and patients completed the Hospital and Anxiety Depression scale (HADS), State-trait anxiety inventory- trait scale (STAT), memorial anxiety scale for prostate cancer (MAX-PC), Functional assessment of cancer therapy – prostate version 4 (FACT-P), Illness perception questionnaire-revised (IPQ-R) and Likert scale analysis questionnaire regarding information provision . All data was analysed using SPSSS version 19.

Results

104 men agreed to participate in the study. 91% of men did not demonstrate anxiety on HADS, 98% demonstrated low levels of PSA anxiety and 87% low levels of prostate cancer anxiety on MAX-PC. However 81% of men demonstrated higher levels of anxiety regarding fear of recurrence on MAX-PC. General (state/trait) anxieties and younger age were significantly associated with illness specific prostate cancer and fear of recurrence anxieties. 92% of men were satisfied with the information received from their urologist regarding prostate cancer and AS.

Conclusions

Men experience low levels of anxiety and high HRQOL on AS, but still experience some fear of recurrence. Younger age and underlying state/trait anxieties emerged as significant predictors of overall HRQOL suggesting that these men may indeed be vulnerable psychologically on AS, and consideration could be given to urologists administering a short trait anxiety screening tool to help identify these men and consider them for active therapy. High levels of patient education as seen in this study may explain the low levels of anxiety seen in men on AS, underlying the importance of the provision of detailed verbal and written information about AS.

22926 Short-term outcomes of high-intensity focused ultrasound as a first-line therapy for high-risk prostate cancer

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Hoang Duc Nguyen1, Phuc Lien Le2 and Minh Tin Pho2

1Fv Hospital, Vietnam

2University Medical Centre, Vietnam

Objective

To report cancer control results after an application of high-intensity focused ultrasonography (HIFU) in patients with high- risk prostate cancer (PCa) according to D'Amico risk classification

Patients and methods

In a retrospective single-centre study, we analysed the outcomes of 28 patients with high- risk PCa who were treated with curative intent between May 2010 and September 2011 using an Sonablate® 500 HIFU device (Focus Surgery, USA). Transurethral resection of the prostate were performed before HIFU to downsize large prostate glands. Patients were regularly followed with PSA measurement and biopsy Oncological failure was determined by the occurrence of biochemical relapse, positive biopsy and/or metastasis. Biochemical relapse was defined as a PSA nadir +1.2 ng/mL (Stuttgart definition). Kaplan-Meier analysis was performed for survival estimates

Results

The median (range) patient age was 70.7 (54–86) years. The median (range) follow-up was 25.2 (17–33) months. Two patients were lost during follow-up. At 2 years, overall and cancer-specific survival rates were 96,1% and 100%, respectively. Negative biopsy rates were 80% at 6 months and 55.5% at 12 months after HIFU. The 2-year biochemical-free survival rates were 60%

Conclusion

HIFU treatment does not provide effective oncologic outcomes in high risk patients with prostate cancer. Therefore, high-risk patients selected to undergo HIFU treatment for prostate cancer must be very carefully chosen.

23074 Are more low risk prostate cancers detected by repeated biopsy?

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Seung Il Jung, Seung Je Lee, Insang Hwang, Eu Chang Hwang, Taek Won Kang, Dong Deuk Kwon and Kwangsung Park

Department of Urology, Chonnam National University Medical School, Republic of Korea

Objective

We hypothesized that there might be a higher incidence of low-risk prostate cancer (PC) in men diagnosed at repeated biopsy. Thus, we investigated the differences in the clinicopathological results of PC after primary and repeated biopsy.

Methods

We retrospectively reviewed patients diagnosed with PC at primary and repeated biopsy from January 2004 to April 2011. Patients were stratified into primary biopsy and repeated biopsy groups. We analyzed prostate specific antigen, clinical stage, Gleason score (GS), and positive core ratio and low-risk group using the D'Amico's classification. We also investigated GS upgrade and upstaging after radical prostatectomy (RP).

Results

Among 448 primary and 37 repeated biopsy PC patients, 82 (group 1) and 25 (group 2) underwent RP. The percent of low-risk patients were not different between the groups. The positive biopsy core ratio was significantly lower in group 2 (p = 0.009). The GS upgrade and upstaging ratio was 42.7% and 47.6% in group 1, respectively (p = 0.568), and 48.0% and 52.0% in group 2, respectively (p = 0.901). In the analysis of low-risk patients, GS upgrading and upstaging were not significantly different between the groups (p = 0.615 and p = 0.959, respectively).

Conclusions

Lower positive core ratio may imply small volume of PC and possible insignificant PC in the repeated biopsy group. However, no differences were observed for the ratio of low-risk cancers, GS upgrade, or upstaging between the groups. Therefore, PC diagnosed at a repeated biopsy is not an additional indication of active surveillance.

23622 Rehabilitation of patients after treatment for prostate cancer

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Dmitry Perepechin, Igor Chernishev and Alexander Kachmazov

Scientific-Research Institute of Urology, Russian Federation

Background

Urine incontinence in male is a possible complication after surgical treatment of prostate cancer. Appearance of this pathological condition entails serious psychological problems, as well as influences upon social-economic factors of the treatment efficiency. Most frequently surgeries leading to urine incontinence are radical prostatectomy.

Aims

The improvement of the quality of life of patients with stress urine incontinence (SI) by using a synthetic male slings.

Material and Methods

Between 2009 and 2011 male sling was performed in 17 patients (age 51–80 years) with SI. 11 patients had prior radical prostatectomy, 3-brachytherapy, 4 – radiation therapy and 1 – Hi-Fu therapy. Mean procedure time was 65 (47–88 min), estimated blood loss was 32 mL. 2 patients have moderate degree incontinent and 15 – severe. At an average follow up of 14.3 months. 13 patients use no pad per day, 1 use less before operation. Thus, the effectiveness of the operation was up to 82,6%. In 3 patients sling was inefficient even after its correction.

Conclusions

The use of male sling system is an effective way for rehabilitation of patients after treatment for prostate cancer. It can be used in patients with severe degree of urinary incontinence. If necessary male sling can be adjusted under local or general anaesthesia at any time after the implantation. Male sling system is an alternative method in patients, who previously with unsatisfactory results of the carried out operations on the UI. The advantage of the sling is also a possibility of a normal urination without any additional manipulations.

23626 Data mining is a tool for prognosis of the oncological process

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Dmitry Perepechin1, Igor Chernishev1 and Valery Shevchenko2

1Scientific-Research Institute of Urology, Russian Federation

2Moscow Aviation Institute, National Research University, Russian Federation

Currently, there is increase in the incidence of prostate cancer. An important aspect is the prediction of the disease. About this pathology has accumulated a lot of data from clinical, laboratory (including molecular genetics), instrumental studies. To develop prediction algorithms for prostate cancer treatment is necessary clinical results on a completely new level – using the principles of cybernetics and higher mathematics.

Purpose

Improving the prognosis of prostate cancer through the use of intelligent technologies Data mining.

Results

Has developed a database of prostate cancer patients, including the results of the examination and treatment of 186 patients. The data obtained was a substrate for the application of cybernetic approaches processing the information. The main objective was to obtain a previously unknown, practically useful and accessible interpretation of the knowledge needed to predict. Complex approaches to work with information, technology-based Data mining, fulfills these requirements. Methodology for Data Mining methods include classification, modeling and forecasting, based on the use of decision trees, genetic algorithms, artificial neural networks, associative memory, fuzzy logic, evolutionary programming.

Important correlation and regression analysis, descriptive analysis, multivariate analysis, analysis of variance and other statistical methods. The main advantage of Data Mining is the ability to obtain additional data and knowledge that can not be obtained by visual analysis of data, the computation of simple statistical characteristics. The results are of practical value. An important feature is the availability of the interpretation, the ability to visualize the user form and a description in terms of the domain. Essentially Data Mining technology can detect patterns in medical data to create the conditions most effective treatment for the disease, which is the subject of further research.

Conclusions

Currently accumulated a large amount of medical information that can be used for predicting the course of prostate cancer. Intelligent Data mining technologies are a possible approach for such a prediction.

24150 Robotic prostatectomy: anaesthesia, challenges and complications

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Xing Hoo, Megan Allen and Jason Chou

Peter MacCallum Cancer Centre, Australia

Introduction

Robotic-assisted Laparoscopic Prostatectomy (RALP) confers several surgical benefits over open prostatectomy including less blood loss, improved margins, reduced post-operative pain, shorter hospital stay, and potentially a reduction in erectile dysfunction and incontinence. The prolonged Trendelenberg positioning, pneumoperitoneum and limited patient access are anaesthesia challenges associated with RALP.

Objective and Methods

A retrospective cohort study (n = 147) of the first two years of the RALP programme.

Aims:

  1. Describe the anaesthetic techniques used (modalities, monitoring, analgesia, ventilation strategies).
  2. Document the anaesthesia and positioning related complications.
  3. Explore patient factors related to the anaesthesia challenges, including age, body mass index (BMI), diabetes and smoking status.

Results

All patients underwent relaxant general anaesthesia and most (91%) had arterial lines. The mean Trendelenburg positioning was 24.8 ± 2.5 degrees. Hypercarbia (mean end tidal CO2 50.9 ± 7.5 mmHg) and elevated peak airway pressure (mean PAP 32 ± 3.5 cmH2O) were common findings. Postoperative pain was well controlled, with low pain scores reported in the post-anaesthesia care unit and 85% of patients were managed with oral analgesia solely. Median blood loss was 100 ml (IQR 100–200 ml) and median length of hospital stay was one day.

Complications occurred in 17% of cases, including corneal abrasion (3%), agitation (2%), neuropraxia (1.4%), facial swelling (1.4%) and regurgitation (0.7%). Complications correlated with increasing BMI {OR 1.17 (95% CI 1.03–1.30; p = 0.012)} and longer surgery time {OR 1.01 (95% CI 1.00–1.02; p = 0.002)}.

Conclusions

Generally a well tolerated procedure despite the anaesthesia challenges. A care pathway will be developed to streamline care and minimise complications.

24190 Superior functional and equivalent oncological outcomes are achieved by converting to robotic prostatectomy, however the learning curve is long

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James Thompson1, Sam Egger2, Maret Boehm3, Anne Maree Haynes3, Jayne Matthews4 and Phillip Stricker4

1St Vincents Prostate Cancer Centre & Kinghorn Cancer Centre, Australia

2Cancer Council of NSW, Australia

3Kinghorn Cancer Centre & Garvan Institute of Medical Research, Australia

4St Vincents Prostate Cancer Centre, Australia

Objective

To determine whether an experienced open surgeon can achieve superior functional and superior or equivalent oncological outcomes to ORP; if so, to determine how many cases it takes to achieve superiority and to reach the plateau point of the learning curve.

Methods

1549 consecutive men underwent RARP (864) or ORP (685) at an Australian private hospital from 2006 to 2012, by one surgeon who had performed 3,000 ORPs prior to commencing RARP. Demographic, clinico-pathologic and QOL data was collected prospectively. QOL was measured pre-operatively, then at 1.5, 3, 6, 12 and 24 months using the validated EPIC questionnaire. Multivariate linear regression modelled the difference in QOL score (RARP minus ORP) against case experience, while logistic regression modelled the PSM odds ratio against case experience, adjusting for known confounders.

Results and Limitations

1,510 men had sufficient data for inclusion in the oncological analysis and 586 consented for and had sufficient data for QOL analysis. There were no significant differences between the entire cohort and those subsets included in the PSM and QOL analysis, thus there appeared to be no selection bias in the study groups. RARP sexual function QOL scores were initially significantly lower but later eclipsed ORP after 100 cases and became significantly higher (mean difference 8.4, 95% CI 3.4–13.7), plateauing at 713 cases. RARP urinary continence QOL scores at 1–6 months eclipsed ORP after 180 cases and became significantly higher (mean difference 7.7, 95% CI 0.7–14.7), never reaching a plateau point by 8. RARP late urinary QOL scores at 12–24 months across all domains were equivalent to ORP. The odds of a PSM in the first 100 RARPs was significantly higher than ORP, declining from an OR of 4.8 at first RARP (95%CI 1.3–16.8) to 1.5 at the 100th RARP (95%CI 1.0–2.1). The odds of a PSM became lower for RARP than ORP after 526 cases, though never significantly lower (OR at 864th case = 0.9, 95%CI 0.5–1.4). Limitations include using single surgeon data and multivariate regression to adjust for confounders.

Conclusions

For an open surgeon, RARP has a long learning curve with inferior initial outcomes then eventually significantly superior urinary and sexual QOL outcomes with equivalent oncological outcomes. Switching to RARP appears beneficial for younger and high volume surgeons, however it may not be beneficial for the patients of late-career or low-volume surgeons, but fellowship training may shorten the learning curve.

24462 Post-TRUS sepsis: targeted use of prophylactic ertapenem for high-risk patients

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Giovanni Losco and Rod Studd

Wellington Regional Hospital, New Zealand

Objective

Consistent with international trends, Wellington Regional Hospital (WRH) has experienced an increasing rate of post TRUS sepsis (PTS). We prospectively trialled ertapenem prophylaxis (EP) in patients with known risk factors for PTS.

Methods

In this prospective comparative cohort study, patients were identified as low risk (LR) or high risk (HR) for PTS based on established risk factors: previous TRUS or urosepsis, immunocompromise, recent ciprofloxacin use or overseas travel. All received ciprofloxacin and amoxicillin. HR patients additionally received EP. PTS requiring hospital admission was recorded. Data was analysed using a two-tailed Fisher's exact test. A cost-effectiveness model was developed to compare routine EP with targeted use by rectal swab culture.

Results

From January to December 2011, 281 biopsies were performed: five patients developed PTS (1.8%). From January to March 2012, 52 biopsies were performed: six patients developed PTS (11.5%). EP was introduced in March 2012. To date, six of 124 patients have developed PTS (4.8%): six of 62 in the LR group (9.6%) and 0 from 62 in the HR group (p = 0.03). Of the six patients developing PTS, three grew ciprofloxacin-resistant organisms, two had no growth and one grew a ciprofloxacin-sensitive organism. Per episode cost of routine EP is $161.53 compared to $249.77 using a rectal-swab targeted protocol.

Conclusions

Ertapenem prophylaxis is effective at reducing sepsis post-prostate biopsy. The PTS rate amongst LR patients receiving standard prophylaxis remains high. EP for all patients is likely to be the least morbid and most cost-effective strategy.

24494 Incursion into periprostatic fat is a more important determinant of prostate cancer recurrence than an invasive phenotype

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Benjamin Namdarian1, Jada Kapoor2, John Pedersen3, Christopher Hovens2, Daniel Moon4, Justin Peters4, Anthony Costello4, Paul Ruljancich1 and Niall Corcoran5

1Department of Urology, Box Hill Hospital, Australia

2Department of Surgery, Royal Melbourne Hospital, Australia

3TissuPath Pty Ltd, Australia

4Department of Urology, Royal Melbourne Hospital, Australia

5Australian Prostate Cancer Centre Epworth, Australia

Objective

Although the development of metastases correlates closely with the depth of invasion in many tumour types, it is unclear if invasion into, but not through, the prostatic pseudocapsule has a negative impact on prognosis similar to extraprostatic extension (EPE). We aimed to define the impact of prostate pseudocapsular invasion (PCI) on the risk of post-prostatectomy biochemical recurrence (BCR).

Methods

Patients with pT2–3a prostate cancer were identified from a prospectively recorded database. Patients with pT2 disease were categorized according to the presence or absence of PCI, as determined by routine pathological assessment. The impact of PCI on BCR, defined as PSA>/=0.2 confirmed on a subsequent reading, was determined by univariable and multivariable Cox regression analysis.

Results

From a study cohort of 1350, we identified 595 patients with organ-confined cancer positive for PCI. Compared to tumours without evidence of PCI, the presence of PCI was positively associated with tumours of higher Gleason grade (p < 0.001) and tumour volume (1.2 vs. 1.9 cc, p < 0.001). On univariable analysis, there was no difference in BCR-free survival between patients with or without PCI, although patients with EPE had a significantly lower BCR-free survival (p < 0.001). This was confirmed on multivariable analysis, where EPE was a significant independent predictor of BCR (HR 1.49, p = 0.029), whereas the presence of PCI had no effect (HR 0.82, p = 0.33).

Conclusion

The presence of PCI is not a pathological feature associated with an adverse outcome post-prostatectomy. This indicates that depth of tumour invasion is not a continuum of risk, and access to the periprostatic adipose tissue is a more important determinant of disease behavior than the presence of an invasive phenotype.

24526 Polyethylene glycol hydrogel spacer use significantly reduces rectal radiation dose in patients undergoing high dose rate prostate brachytherapy

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David Malouf, Nadine Beydoun and Joseph Bucci

St George Hospital, Australia

Objective

Radiation proctitis is a dreaded potential treatment complication of prostate radiotherapy. The risk of chronic rectal injury following prostate brachytherapy still approaches 10%, and is strongly related to dose. We explored the use of a transperineally inserted spacer into the prostate-rectum interface to decrease rectal radiation exposure and thereby limit chronic proctitis risk in these patients.

Methods

Ten patients with intermediate to high risk prostate adenocarcinoma undergoing external beam radiotherapy (EBRT) and high dose rate brachytherapy (HDRB) boost underwent insertion of polyethylene glycol (PEG) hydrogel based spacer under TRUS guidance into the anterior perirectal fat at the time of their brachytherapy implant. Prostate-rectum separations before and after spacer insertion were compared. Post-spacer rectal dosimetry on the HDRB and EBRT plans was determined and compared to historical controls sourced from the department's brachytherapy database. Toxicities related to spacer insertion were assessed using NCI Common Terminology Criteria for Adverse Events version 4.0.

Results

Mean prostate-rectum separation was increased from 3.5 mm (±3.9) before spacer insertion to 14.1 mm (±5.9) after spacer insertion. Mean volume of rectum receiving a minimum of 70% of the HDRB prescription dose (V70) was 0.2 cc (±0.2) in spacer patients, compared to 1.5 cc (±0.8) in controls. Mean volume of rectum receiving 40 Gy (V40) during the external beam component of treatment was 13.3% (±14.2) with spacer, compared to 30% for controls. No serious adverse events were reported following spacer insertion.

Conclusions

Transperineal spacer insertion significantly reduces rectal radiation exposure in patients undergoing EBRT and HDRB boost.

24562 Long term Erectile Function (EF) and factors influencing EF preservation following permanent seed Brachytherapy (BT) for localized prostate cancer

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Wee Loon Ong1, Ben Hindson2, Catherine Beaufort2 and Jeremy Millar2

1The University of Cambridge/ Radiation Oncology, AlfredHealth, Australia

2Radiation Oncology, AlfredHealth, Australia

Objective

To evaluate erectile function (EF) and factors influencing EF preservation following brachytherapy (BT) in men with normal EF before treatment.

Methods

The cohort consisted of patients with localized prostate cancer treated with BT at the William Buckland Radiotherapy Centre. EF was assessed prior to BT and at each follow-up visit, using the International Index of EF (IIEF5). Normal EF was defined as IIEF5 score >21. Baseline medical co-morbidities and clinical characteristics of prostate cancer were collected. Radiation dose was quantified with D90 to the prostate. Probability of normal EF preservation following BT was estimated using the Kaplan-Meier method, and the log-rank test was used to compare factors influencing EF preservation. Cox regression was used for multivariate analysis.

Results

292 patients had normal EF prior to BT. The mean age of prostate cancer diagnosis was 60 and the patients were followed-up for a median of 49 months. The estimated probability of normal EF at five year was 49.1%. In Cox regression analysis, patients above age 60 had 1.4-times (95%CI = 1.1–1.9) increased risk of developing erectile dysfunction compared to those under 60, after adjusting for potential confounders. Higher Gleason grade (7 vs. <7) and higher D90 (>150 Gy vs. <150 Gy) were also associated with poorer normal EF preservation with HR of 3.2 (95%CI = 2.3–4.4) and 1.8 (95%CI = 1.3–2.4) respectively.

Conclusion

Half of the patients with normal EF before BT preserve normal EF at five-year follow-up. Increasing age at BT, higher Gleason grade and higher D90 are associated with poorer normal EF preservation following BT.

24626 Laparoscopic Radical Prostatectomy in a regional centre – Is it possible to establish a fellowship training program in a single surgeon setting during

  1. Top of page

Mark Louie-Johnsun, Serge Luke and Mohammad Haque

Gosford Private Hospital, Australia

Objectives

The steep learning curve and case load required to become proficient in Laparoscopic Radical Prostatectomy (LRP) is well recognised and is likely one of the factors contributing to the trend towards robotic assisted surgery. We assess our early LRP experience and the impact of LRP training on our results.

Methods

Data was collected prospectively from our initial 150 consecutive patients from a single surgeon series who underwent LRP for prostate cancer between September 2009 and January 2013. A modular approach to training was established with a training case defined by the completion of at least 2 of 10 steps by two trainees in their final year of training with no prior experience in LRP. Outcomes were analysed comparing training and non training cases and also comparing first 50( I), second 50(II) and final 50 patients (III).

Results

There were 51 (34%) training cases and 99 (66%) nontraining cases with the median number of steps completed by the trainee increasing from 5/10 to 8/10 (range 2–10) from Group I to III.

Overall mean age was 63 (40–76) years and mean preoperative PSA was 8.3 (1.6–41) ng/ml. There were two (1.3%) open conversions, no rectal injuries and the major complication rate was 2.7% (Clavien >3b). 75% of patients were discharged within 48 hours. At twelve months, continence rate was 92% and 52% of preoperatively potent patients were potent after either unilateral or bilateral nerve preservation.

Training cases tended to have a higher mean blood loss (616 vs 559 ml) (p = 0.39) and longer mean operative times (273 vs 227 mins) (p < 0.001) but no difference in major complication and trend to lower positive surgical margin rates for organ confined disease (pT2) being 3.6% versus 17.6% (p = 0.06).

Overall analysis from Group I to III, mean operative time decreased from 288 to 186 (110–440) minutes (p < 0.01), blood transfusion rates decreased from 6% to 0% and positive surgical margin rate for pT2 and pT3 trended down from 14% and 52% to 9% and 32% respectively.

Conclusion

Despite being in our early learning curve, LRP is a trainable minimally invasive surgical treatment option for localized prostate cancer at our institution. Our perioperative results continue to improve with experience. Continued dissemination of this skill appears appropriate despite the increasing use of robotic assisted prostatectomy.

24678 Volumetric Modulated Arc Therapy (VMAT) to the pelvic lymph nodes in prostate cancer – the first Australian experience

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Gina Hesselberg1, Gerald Fogarty2, Lauren Haydu3, Nicole Dougheney2 and Phillip Stricker4

1The University of New South Wales, Prince of Wales Hospital, Australia

2Mater Sydney Radiation Oncology, Australia

3Melanoma Institute Australia, Australia

4St Vincent's Hospital Sydney, Australia

Objective

Volumetric Modulated Arc Therapy (VMAT) efficiently delivers IMRT for prostate cancer. Pelvic lymph node (PLN) volumes, in addition to the prostatic fossa can be successfully treated. The question of whether PLNs should be treated in the intermediate and high-risk setting is controversial. This study documents the first Australian clinical experience of VMAT in the treatment of PLNs in prostate cancer with a particular focus on early biochemical efficacy and toxicity in the salvage setting following radical prostatectomy (RP).

Methods

Patients with a diagnosis of prostate carcinoma who received VMAT radiotherapy were extracted from the database at the Mater Hospital Genesis Cancer Care Centre. Patient, tumour and treatment characteristics were analysed.

Results

115 patients treated between May 2010 and December 2012 were identified. 67 patients had a diagnosis of intermediate risk prostate carcinoma and 46 a diagnosis of high risk. 46 patients underwent definitive VMAT and 65 patients had VMAT following RP. Of the latter group, 15 patients received adjuvant VMAT post RP and 50 patients underwent salvage VMAT for biochemical failure. Investigations used to aid boost radiotherapy volume delineation to PLNs or concurrent oligometastases were utilized for 13 patients. The percentages of patients experiencing acute and late grade 2 GU toxicities were 20% and 2% respectively. The percentages of patients experiencing acute and late grade 2 GI toxicities were 25% and 2% respectively. Biochemical failure following VMAT radiotherapy occurred in 7 patients.

Conclusion

VMAT enables efficacious and efficient treatment to PLN with a favourable toxicity profile in prostate cancer.

24694 How well do men report their prostate-specific antigen testing status?

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David Smith, Leighna Carmichael, David Goldsbury and Dianne O'Connell

Cancer Council NSW, Australia

Introduction

Previous research suggests that self-reported prostate-specific antigen (PSA) testing participation may not reflect actual participation. Peak organisations worldwide agree that men should be informed of the risks and benefits before proceeding with PSA testing, so unawareness of personal testing status is undesirable.

Methods

Data were collected from a random sample of men aged 50–84 years in New South Wales, Australia, using computer-assisted telephone interviews. Medicare claims data were obtained to identify whether a man had received a PSA test, and this was compared to their self-reported testing status. Logistic regression analysis assessed demographic and health-related factors potentially associated with men's correct recall of having had a recent PSA test.

Results

Of 1585 men, 918 (58%, 95% confidence interval: 56%-61%) had a record of a Medicare-reimbursed PSA test in the previous two years. Among the tested men, 61% correctly recalled having had a PSA test in this time. Of the 360 men who did not recall being tested, 27% reported that they did not have a test in this time and the other 73% did not know what a PSA test was or what it was used for. Recall of testing was poorer with longer time since testing, older age, among men with blue-collar occupations or those with no family history of prostate cancer.

Conclusions

Two in five men with a Medicare-reimbursed PSA test reported that they had not been tested. This suggests that there are deficiencies in the health care system that call for improvements in doctor-patient communication.

24702 The relationship between solar UV exposure, serum vitamin D levels and prostate specific antigen levels, in men from NSW, Australia

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David Smith1, Visalini Nair-Shalliker1,Mark Clements2, Vasi Naganathan3, Melisa Litchfield3, Louise Waite3, David Handelsman4, Markus Seibel4, Robert Cumming3 and Bruce Armstrong4

1Cancer Council NSW, Australia

2Karolinska Institutet, Sweden

3Concord Hospital and The University of Sydney, Australia

4The University of Sydney, Australia

Background

Considerable interest surrounds the association between Vitamin D and cancer risk. Recent studies have found conflicting results regarding relationships between Vitamin D and prostate cancer.

Objective

To determine the relationship between season, personal solar UV exposure (sUV), serum 25(OH)D and 1,25(OH)2D and serum PSA in men free of self-reported prostate disease and in men with self-reported prostate disease.

Method

We used questionnaire data and blood samples collected at baseline from all participants of the Concord Health and Ageing in Men Project (n = 1705). This is a cohort study that recruited men aged 70 and up from three local government areas surrounding Concord Hospital, Sydney, Australia. Data were analysed using multiple regression, adjusting for age, BMI and region of birth.

Results

There was no consistent seasonal variation in serum PSA levels in either group of men. There was, though, weak evidence of an inverse association between sUV and serum PSA levels in winter and spring. Serum levels of 25(OH)D and 1,25(OH)2D were each positively associated with sUV. There was no direct association of either of these vitamin D metabolites with serum PSA levels in men free of prostate disease, but there was a positive association between serum PSA and 1,25(OH)2D in men with prostate disease.

Conclusion

The association between PSA and sUV was only evident at low solar UV irradiance, and this effect may be independent of serum vitamin D levels.

24710 Treatment and survival outcomes for prostate cancer for Aboriginal men in New South Wales (NSW) Australia

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David Smith, Jennifer Rodger, Rajah Supramaniam, Alison Gibberd, Veronica Saunders and Dianne O'Connell

Cancer Council NSW, Australia

Background

Prostate cancer is the second most common cancer registered in NSW Aboriginal men. Aboriginal men tend to have lower cancer survival rates compared to non-Aboriginal men.

Aims

To compare prostate cancer specific survival in Aboriginal and non-Aboriginal men in NSW and to examine factors determining survival in Aboriginal men.

Methods

NSW Cancer Registry data for 35,214 men, including 259 Aboriginal men, diagnosed with prostate cancer in 2001–2007 were linked with NSW hospital inpatient episodes. Detailed clinical information was also extracted from hospital records for 91 Aboriginal men diagnosed with prostate cancer 2000–2011.

Results

Aboriginal and non-Aboriginal men had similar age and spread of disease at diagnosis. The probability of death from prostate cancer by 5 years was 53% higher for Aboriginal men (17.5%, 95% CI 12.4–23.3) than non-Aboriginal men (11.4%, 95% CI 11.0–11.8). The risk of death from prostate cancer was higher for Aboriginal compared with non-Aboriginal men after adjusting for age at diagnosis, year of diagnosis and spread of disease (hazard ratio 1.74, 95% CI 1.26–2.33). After adjusting for prostatectomy, socioeconomic disadvantage, comorbidities and residence the increased risk reduced (1.44, 95% CI = 1.04–1.94). For the Aboriginal men with more detailed treatment information 53/91 had localised disease, of whom 20/53 had prostatectomy, 15/53 radiotherapy and 18/53 active surveillance as primary treatment.

Conclusions

Aboriginal men had lower prostate-cancer specific survival compared to non-Aboriginal men. Preventing comorbidities and addressing treatment barriers associated with place of residence and socioeconomic disadvantage may increase prostate cancer survival rates for Aboriginal men.

24750 The distribution of prostate-specific antigen (PSA) profiles in healthy men aged 40–80 years in a multiethnic population

  1. Top of page

Jasmine Lim1, Nirmala Bhoo Pathy2, Selvalingam Sothilingam3, Rohan Malek4, Murali Sundram5, Badrul Hisham Bahadzor6, Sivaprakasam Sivalingam1 and Azad Hassan Abdul Razack1

1The University of Malaya, Malaysia

2Julius Center University of Malaya, Malaysia

3Tuanku Mizan Military Hospital, Malaysia

4Selayang Hospital, Malaysia

5Kuala Lumpur Hospital, Malaysia

6University Kebangsaan Malaysia Medical Center, Malaysia

Objective

To study the distribution of PSA values in a heterogeneous population across different ages in Malaysia as well as its relationship with both clinical and demographic data.

Methods

This study was conducted as part of the prostate awareness campaign involved seven general hospitals in the Klang Valley, Malaysia, inviting the participation of men above 40 years. Data on basic demography and clinical profiles were collected, using a written form (proforma) based on the input from subject interviews and clinical examination. Blood sample of each individual was collected for PSA analysis. Permission for the anonymous analysis of all human blood samples was granted from the regional research ethics committee. Statistical comparisons of continuous and categorical variables employed Pearson coefficient correlation and multiple regression as appropriate. Two-tailed P value <0.05 was termed as statistically significant.

Results

There were 1197 men participated in the study, of which most of them were Chinese (608; 50.79%), followed by Malay (420; 35.09%), Indian (148; 12.36%) and others (21; 1.75%). The average age of the subjects was 59.36 ± 8.2 years (range 23–84 years) whilst the median PSA levels of Malay, Chinese, Indian and other ethnics were 1.07 μg/L, 1.31 μg/L, 0.83 μg/L and 0.84 μg/L respectively. A significant correlations was found between the PSA levels and subjects’ age (Pearson coefficient correlation, r = 0.206, P < 0.0005). Further analysis revealed that PSA was significantly predicted from age, ethnic, BMI and prostate volume in a multiple regression model (F = 36.943, P < 0.0005, R2 = 0.139) involving 917 of the total subjects. All variables except ethnic added statistically significantly to the prediction, p < 0.05.

Conclusion

We present the profile of PSA values across different ages in a multiethnic population and its significant correlation with age, BMI and prostate volume, providing a prelude in revising the current international recommendation of PSA test to men >50 years, at least in the Asian population.

24758 Practical aspects and learning curve for laparoscopic radical prostatectomy: analysis of 300cases performed by a single surgeon

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Tae Nam Kim1 and Jong Gil Nam2

1Pusan National University Hospital, Korea

2Yangsan Pusan National University Hospital, Korea

Objective

Laparoscopic radical prostatectomy (LRP) is a technically demanding procedure with a lengthy learning curve. To secure good oncological and functional outcomes with ensuring patient safety, the procedure has to come to the proper level in some practical aspects. We assessed the learning curve at three different view of practical aspects which contained technical, oncological and functional aspect.

Methods

We retrospectively analyzed 300 consecutive patients who underwent LRP from August 2006 to October 2012. All patients underwent extraperitoneal LRP performed by a single Surgeon. The study population was divided into six groups according to the chronological order of their date of surgery.Technical aspects consisted of total operation time, vesicourethral anastomosis time, estimated blood loss, complication rate and duration of catheterization. Assessment of oncological aspects contained the positive surgical margin and biochemical recurrence (BCR) free rate. Functional aspects were appraised with the intend to success rate for neurovascular bundle (NVB) saving and the ratio of less than 1 pad per 24 h in 6 months after LRP

Results

The mean (range) age and preoperative PSA were 65.8 years (48–79) and 15.0 ng/ml (2.3–126.6). The operative and vesicourethral anastomosis time were 231.9 min (90–630) and 28.7 min (9–126). The estimated blood loss, complication rate and duration of catheterization were 255.7 ml (30–2850), 8.3% and 6.5 days (3–34), respectively. There was no conversion to open surgery. All technical parameters improved up to plateau after the first 100 cases. The positive surgical margin rate in pT2 cases was 21.7% and decreased significantly after the first 150 cases (p = 0.02). The BCR free rate in pT2 cases at a minimum follow-up of 2 years for the first 200 patients was 93.2%. The intend to success rate for NVB saving and continence rate at 6 months postoperatively were 62.3% and 82.5%, respectively. All functional parameters were up to plateau at 150 to 200 surgeries.

Conclusions

In a tertiary care academic institution, the learning curves for the three practical aspects improved significantly with increased surgical experience. The learning curve for all parameters after laparoscopic radical prostatectomy improved up to plateaus after 200 cases.

24762 Denosumab and zoledronic acid (ZA) treatment in patients with genitourinary (GU) cancers and bone metastases

  1. Top of page

Vinod Ganju1, Luis Costa2, Karim Fizazi3, Fred Saad4, Janet Brown5, Roger von Moos6, Stéphane Oudard7, Cora N Sternberg8, Kurt Miller9, Huei Wang10, Tap Maniar10 and Ada Braun10

1Frankston Private, Australia

2Hospital de Santa Maria and Instituto de Medicina Molecular, Portugal

3Institut Gustave Roussy, University of Paris Sud, France

4The University of Montreal Hospital Center, CRCHUM, Canada

5Cancer Research UK Clincal Centre, The University of Leeds, United Kingdom

6Kantonsspital Graubunden, Switzerland

7Georges Pompidou Hospital, France

8San Camillo Forlanini Hospital, Italy

9Charité Berlin, Germany

10Amgen Inc, United States

Objective

Phase III data demonstrated denosumab is superior to ZA in preventing skeletal-related events (SREs; including pathologic fracture, spinal cord compression, radiation or surgery to bone) in patients with solid tumours and metastatic bone disease.1 This post-hoc subgroup analysis compared the efficacy and safety of denosumab and ZA in patients with GU cancers enrolled in the pivotal phase 3 trials.

Methods

Patients were randomised 1:1 to receive denosumab (120 mg, SC) or ZA (4 mg, IV, adjusted for renal function) Q4W. Daily calcium and vitamin D were strongly recommended. Time to first on-study SRE, and time to first-and-subsequent SREs were evaluated using Cox proportional hazards and Anderson-Gill models, respectively. Safety was also evaluated.

Results

2128 patients (1052 denosumab; 1076 ZA) had GU cancers (prostate = 1901, renal = 155, bladder = 63, and transitional cell = 9). Denosumab significantly delayed time to first on-study SRE by 4.0 months versus ZA (20.7 vs 16.7 months, hazard ratio [HR] = 0.81, 95%CI 0.71–0.93; p = 0.004). Denosumab also significantly delayed time to first-and-subsequent SRE (Rate ratio = 0.82, 95%CI 0.72–0.93; p = 0.002). Time to disease progression and overall survival were similar between treatment groups. Adverse events (AEs) and serious AEs rates were similar (AEs: 96.9% denosumab, 96.8% ZA; serious AEs: 62.8% denosumab, 60.2% ZA). Hypocalcaemia occurred in 12.9% of denosumab patients and 6.2% of ZA patients. No significant difference was seen in incidence of positively adjudicated osteonecrosis of the jaw between the denosumab (2.2%) and ZA (1.6%) groups (P = 0.34).

Conclusions

Denosumab was superior to ZA in preventing SREs among patients with GU cancers and metastatic bone disease.

1.  Lipton et al; 2012, Eur J Cancer

24766 Continence after retropubic radical prostatectomy: achieving outcomes without a robot

  1. Top of page

Sean Chan1 and Rajan Narula2

1Townsville General Hospital, Australia

2Townsville General Hospital and Townsville Mater Private Hospital, Australia

Objective

Robot assisted radical prostatectomy (RARP) has become increasingly popular in Western Urology centres. Recent reports from large high volume centres suggest equivalent or possibly better recovery of urinary continence than the traditional open retropubic radical prostatectomy (RRP). However, RARP is not routinely available to uninsured patients in Australia and with an increased focus among health care providers on clinical efficacy and cost effectiveness, it is unlikely to be universally accessible in the near future. We present our results of urinary continence after RRP and discuss the evolution of our technique to achieve comparable outcomes.

Material

All consecutive patients that were diagnosed with a clinically localized prostate cancer and operated for RRP by a single surgeon between Oct 2007 and March 2012 and had minimum 12 months of post operative follow were included. Patients were reviewed at least 3, 6 and 12 months post operatively. Continence was defined as per recommendation of Pasadena Consensus Panel. Key elements of our operation technique are discussed

Results

Using a ‘no pad’ definition for continence, the prevalence of urinary continence of 113 patients at 8 weeks, 3 months, 6 months and 12 months post RRP was 45%, 73%, 87% and 95% respectively.

Conclusions

Urinary incontinence is one of the most important factors affecting patient quality of life after radical prostatectomy. Achieving post RRP urinary continence is multi-factorial and determined by patient factors, surgical experience and surgical technique. We believe excellent results, comparable to RARP, can be achieved by simple measures and evolution of technique.

24770 The predictive factors for neutropenia induced by docetaxel-based systemic chemotherapy in patients with castration-resistant prostate cancer

  1. Top of page

Ill Young Seo, Jea Whan Lee and Seung Chol Park

Wonkwang University Hospital, Korea

Objective

Neutropenia is a common adverse event induced by docetaxel-based systemic chemotherapy. The aim of this study is to evaluate the predictive factors for neutropenia after docetaxel-based systemic chemotherapy in Korean patients with castration-resistant prostate cancer (CRPC).

Methods

We retrospectively reviewed the medical records of men who treated with docetaxel-based systemic chemotherapy for CRPC in single institution between May 2005 and May 2012. Forty patients were enrolled in this study. The treatment consisted of 5 mg prednisolone twice daily and 75 mg/m2 docetaxel once every 3 weeks. According to the Common Terminology Criteria Adverse Events (CTCAE) v3.0, neutropenia was defined by the neutrophil count less than 1500/mm3. We evaluated the incidence and the risk factors for neutropenia in the first cycle of the chemotherapy.

Results

The mean age was 71.7 years. Nine patient of 40 patients (22.5%) developed neutropenia in the first cycle of docetaxel-based systemic chemotherapy. Four patients experienced grade 2 neutropenia, three patients experienced grade 3, and one patient experienced grade 4 neutropenia. There were significant differences in pretreatment WBC count (7270 ± 1934/mm3 vs. 5753 ± 1741/mm3), pretreatment neutrophil (4756 ± 1741/mm3 vs. 3260 ± 1385/mm3), pretreatment albumin (4.27 ± 0.43 g/dL vs. 3.88 ± 0.41 g/dL), and previous chemotherapy. Multivariate logistic analysis showed that pretreatment WBC (p = 0.042), pretreatment neutrophil (p = 0.015), and pretreatment albumin level (p = 0.017) were significant predictive factors for neutropenia.

Conclusions

Pretreatment WBC, neutrophil count, and albumin level were significant independent risk factors for neutropenia induced by docetaxel-based systemic chemotherapy in Korean patients with castration-resistant prostate cancer.

24774 Comparison of the results of standard and extended pelvic lymph node dissection in prostate cancer patients: improving of 5-year progression free survival

  1. Top of page

Boris Alekseev, Nikolay Vorobyev, Alexey Krasheninnikov, Alexey Kalpinskiy and Andrey Kaprin

Moscow Hertsen Oncology Institute, Russian Federation

Introduction and objectives

Recently it was demonstrated that extended pelvic lymph node dissection (E-PLND) could enhance diagnostic accuracy and even survival in prostate cancer (PC) patients comparing with standard (S-PLND) one, although this question is still controversial as the results of randomized studies are absent, and it is still on the debate. The aim of the study was to evaluate biochemical progression-free survival (PFS) in PC patients who had undergone radical prostatectomy (RPE) and in subject to anatomical boundaries of PLND performed.

Materials and methods

Retrospective analysis of database from 1148 patients after RPE and PLND since 1998 till 2011 in our institution was performed. In the study 680 consecutive patients with exactly established anatomical extent of PLND and known follow-up survival status were included. According to anatomical regions of PLND performed, patients were divided in to 2 gropes: S-PLND was performed in 289 (42.5%) patients; E-PLND – in 391 (57.5%). Mean PSA level was 13.6 ± 11.7 ng/ml in S-PLND group and 16.1 ± 15.6 ng/ml in E-PLND group (p < 0.001); mean percentage of positive biopsy cores was 47.8 ± 31.1% and 53.9 ± 30.7% respectively (p = 0.02). Clinical stage (p < 0.001) and biopsy Gleason score (p < 0.001) were significantly more favorable in S-PLND group of patients. In S-PLND group low risk PC was verified in 99 (34.3%) patients, intermediate risk – in 92 (31.8%) and high risk – in 98 (33.9%) patients. In E-PLND group risk distribution was the following: low – 43 (11%), intermediate – 152 (38.9%), high – 196 (50.1%), respectively (p < 0.001). Thus, aggressive tumors were observed more frequently in E-PLND group. Mean number of LN removed was 14 ± 6 (4–37); 26 ± 8 (8–61) respectively (p < 0.001); LN metastases were verified in 34 (11.7%) and in 80 (20.5%) respectively (p = 0.003). Patients with LN metastases were excluded from the further survival analysis. Biochemical recurrence was assessed as elevation of PSA > 0.2 ng/ml on three consecutive measurements.

Results

Median follow up time was 30.5 ± 28 months (3–156 months). During this period biochemical recurrences were observed in 87 (34.1%) patients in S-PLND group and in 33 (10.6%) patients in E-PLND group. Cumulative 5-year PFS rate was 56.2 ± 3.9% for patients in S-PLND group and 73.6 ± 5.5% in E-PLND group (p < 0.001). Deaths were observed in 7 (2.8%) patients in S-PLND group and in 4 (1.3%) in E-PLND group. 5-year overall survival rates were 94.4 ± 4.1% and 97.1 ± 2.9% (p > 0.05); and cancer-specific survival was 95.8 ± 4.1% and 99.2 ± 2.5% (p > 0.05) in S-PLND and E-PLND groups respectively.

Conclusions

E-PLND is more accurate for LN staging and could possess curative effect in PC patients. S-PLND is associated with worse PFS and should not be performed especially in patients with intermediate and high risk PC.

24786 Functional and oncologic outcomes of graded bladder neck preservation during robot-assisted radical prostatectomy

  1. Top of page

Reid Graves, Ziho Lee, Shailen Sehgal, Yu-Kai Su, Elton Llukani, Kelly Monahan, Alice McGill and David Lee

The University of Pennsylvania, United States

Objectives

To describe our consistent robotic bladder neck preservation (R-BNP) technique during robot-assisted radical prostatectomy, to propose the existence of different degrees of R-BNP, and to determine the effect of increasing R-BNP on postoperative urinary continence rates.

Methods

We performed a retrospective analysis of 599 patients who underwent R-BNP by a single surgeon (DIL) at our institution between January 2008 and December 2009. All patients received R-BNP that was assigned a grade between 1–4; higher grades corresponded to an increasing degree of R-BNP. After grouping patients according to the degree of R-BNP received, postoperative urinary continence and positive surgical margin rates were compared among the four groups. Continence was defined as the use of 0 pads per day, and was assessed at 3 m and 1 y postoperatively.

Results

A higher proportion of patients were continent at 3 m postoperatively who received grade 4 compared to grade 1 (p = 0.043) and grade 2 (p = 0.006); and grade 3 compared to grade 1 (p = 0.048) and grade 2 (p = 0.009) R-BNP. There was no significant difference between grade 1 and 2 (p = 0.541), and grade 3 and 4 (p = 0.898) R-BNP. At 1 y postoperatively, there was no significant difference among the four groups in continence rate (p = 0.771). There was no significant difference among the four groups in positive surgical margin rates (p = 0.946).

Conclusions

R-BNP is a graded, rather than all-or-none outcome. Using our technique, an increasing degree of R-BNP is associated with an earlier return to urinary continence, without compromising oncologic outcomes.

24842 Long-term safety and efficacy analysis of abiraterone acetate (AA) plus prednisone (P) in study COU-AA-302for metastatic castration-resistant prostate cancer

  1. Top of page

Paul de Souza1, Dana Rathkopf2, Matthew Smith3, Peter Mulders4, Paul Mainwaring5, Scott North6, Thomas Griffin7, Youn Park8, Arturo Molina7 and Charles Ryan9

1The University of Western Sydney, Australia

2Memorial Sloan-Kettering Cancer Center, United States

3Massachusetts General Hospital Cancer Center, United States

4Radboud University Medical Centre, Netherlands

5Haematology and Oncology Clinics of Australia, Australia

6Cross Cancer Institute, Canada

7Janssen Research & Development, Los Angeles, United States

8Janssen Research & Development, Raritan, United States

9The University of California-San Francisco, United States

Objective

AA, a CYP17 inhibitor, prolongs the lives of men with progressive pre- or post-chemotherapy treated mCRPC and has a favourable safety profile[1]. This post hoc analysis examines the safety and tolerability of long-term treatment (≥24 months) in patients from study COU-AA-302.

Methods

1088 patients were randomized 1:1 to AA 1000 mg + P 5 mg po BID vs placebo + P. Co-primary endpoints were radiographic progression-free survival (rPFS) and overall survival (OS). Median times with 95%CI of the end points were estimated using the Kaplan-Meier (KM) method. Post hoc analysis of adverse events (AEs) was performed at pre-specified interim analysis (IA3) (55% OS events).

Results

At a median follow-up = 27.1 mos (IA3): rPFS HR (95%CI) = 0.53 (0.45, 0.62), p < 0.0001 and OS were improved over P [0.79 (0.66, 0.96), p = 0.0151]; the latter did not reach the pre-specified efficacy boundary (p = 0.0035). All secondary endpoints favoured the AA arm1. The incidence rate of selected AEs by duration of exposure is shown below (Table). There was no clinically relevant increase in the incidence rate of AEs with longer exposure using AA+P versus P alone; although patients on treatment for ≥24 months may have had greater tolerability. The percentage of patients who came off study due to an AE was 8% (AA) versus 6% (P).

Conclusions

The updated IA3 of COU-AA-302 confirms the delay in progression and prolongation of life by AA+P with a favorable safety profile in patients treated for ≥24 months.

1.  Rathkopf et al. ASCO-GU 2013. Abstract 5.1.

 AA+PP
Grade (%)
Exposure Time, mosNAll1/23/4NAll1/23/4
Cardiac Disorders        
 <3542651540541
 12–15302531184871
 ≥2415476176990
Fatigue        
 <35421918154017161
 12–15302871184880
 ≥2415488076440
Hyperglycemia        
 <3542421540441
 12–15302320184321
 ≥2415411076413
Hypertension        
 <3542871540862
 12–15302541184322
 ≥2415421176110
Osteoporosis        
 <3542110540210
 12–15302100184220
 ≥2415433076440
Weight Gain        
 <3542210540220
 12–15302110184000
 ≥2415422076110

24850 Survival disparities between Māori and non-Māori men with non-localised prostate cancer in New Zealand

  1. Top of page

Zuzana Obertova1, Nina Scott2, Charis Brown1, Alistair Stewart3 and Ross Lawrenson1

1Waikato Clinical School, The University of Auckland, New Zealand

2Te Puna Oranga, Waikato District Health Board, New Zealand

3School of Population Health, The University of Auckland, New Zealand

Objective

To examine differences in survival rates between Māori and non-Māori men with non-localised prostate cancer in New Zealand (NZ).

Methods

Men aged 40–69 years diagnosed with prostate cancer between 1996 and 2010 were identified from the NZ Cancer Registry; the cause of death for the deceased was sourced from the Mortality Collection by data linkage. Three-year survival for men diagnosed with non-localised prostate cancer was estimated using the Kaplan-Meier method. Men still alive after 25 May 2011 were censored. Cox proportional hazard regression models were used to estimate the relative risk of dying for Māori men after adjusting for age, diagnosis years, and deprivation index.

Results

Of the 20,719 men, 2078 (10%) were recorded as having non-localised prostate cancer at diagnosis of whom 681 have died. The probability of surviving three years was significantly lower for Māori compared to non-Māori men, regardless of diagnosis years. After adjusting for age, diagnosis years and deprivation Māori men were more likely to die of any cause (HR, 2.79 [95% CI, 2.23, 3.48]) and of prostate cancer (HR, 2.95 [95% CI, 2.31, 3.77]) compared with non-Māori men.

Conclusion

Māori men with non-localised prostate cancer died more commonly than non-Māori men. The overall survival has improved during the years for both groups but the survival difference has not changed. Māori men were more likely to be diagnosed with metastatic prostate cancer, which may be in great part due to significantly lower screening rates in Māori compared to non-Māori men in NZ.

24854 What do men say about diagnostic pathways? From prostate-specific antigen (PSA) test to prostate cancer

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Zuzana Obertova, Charis Brown, Fraser Hodgson and Ross Lawrenson

Waikato Clinical School, The University of Auckland, New Zealand

Objective

To examine prostate-specific antigen (PSA) testing patterns and wait times in New Zealand men with elevated PSA test.

Methods

Men with first elevated PSA in 2010 were identified through search of laboratory data and clinical notes at 31 general practices in the Midland Cancer Network Region. Patient questionnaires were mailed to eligible men through their general practitioners (GPs). The questionnaires were designed to assess reasons for the PSA test and follow-up care, including wait times for specialist visit.

Results

Three hundred and seven men were eligible for the study, of whom 194 (63%) filled in the questionnaire. In 54% of respondents the elevated PSA test was their first PSA test ever. Almost two-thirds of men reported that the PSA test was suggested by their GP. Half of the men were referred to a specialist following the elevated PSA test. Almost half of these referred men were seen by a specialist in the private sector. Out of these men, 78% were seen within 4 weeks from referral compared to 31% seen in the public sector (F test, p < 0.0001).

Conclusion

The majority of PSA tests were suggested by GPs, who also managed half the patients with elevated PSA without referring to a specialist. In general, about 50% of men were seen by a specialist within 4 weeks from referral; with wait times for specialist visit being considerably shorter in the private sector.

These findings will be further explored in a larger quantitative study based on GP and specialist databases.

24858 Screening for prostate cancer in rural men in New Zealand

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Ross Lawrenson1, Zuzana Obertova1, Fraser Hodgso2, Nina Scott3 and Charis Brown1

1Waikato Clinical School, The University of Auckland, New Zealand

2Waikato Clinical School, University of Auckland, New Zealand

3Te Puna Oranga, Waikato District Health Board, New Zealand

Objective

To examine the differences in screening rates between rural and urban practices in the Midland Cancer Network (MCN) Region in New Zealand.

Methods

We searched computerised records of 31 general practices in the MCN Region for men aged 40+ years with a prostate-specific antigen (PSA) test in 2010. The practices were classified in three different ways in order to describe rurality: 1) main urban areas (MUA) v. rural; 2) populations size of settlements (<10,000, 10,000–29,990 and 30,000+ residents); and 3) presence/absence of main hospital.

Results

Screening rates were lower in rural areas (17.9%) compared to MUA (25.6%; χ2 P < 0.0001), and increased with increasing population size – from 12.7% in the least populated settlements to 25.6% in the most populated settlements (χ2 P < 0.0001 for all comparisons). The practices located in settlements with a main hospital showed higher screening rates (24.1%) compared to those without a main hospital (16.4%; χ2 P < 0.0001). Increased rates of men with elevated PSA were found in rural practices (2.8%) compared to practices in MUA (1.7%; Fisher P = 0.0014) as well as in practices located in the least populated settlements (3.4%) compared to those in most populated settlements (1.8%; Fisher P = 0.0071).

Conclusion

Rural men were less likely to be screened, but when they were screened they were more likely to have an elevated PSA. Whilst we recognise that screening for prostate cancer is controversial we should be examining why there are differences in the delivery of health services in rural areas.

24958 Assessment of incontinence and urinary quality of life scores as a metric of long term urinary outcomes following robotic assisted radical prostatectomy

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Thomas Ahlering, Adam Gordon, Harleen Dhaliwal, Kathyrn Osann, Blanca Morales and Douglas Skarecky

The University of California, United States

Introduction

Incontinence variably reported from 4–70% is assumed to reflect a poor urinary outcome i.e. quality of life score (QOLs). In the present study we compare urinary incontinence (use of any pads) with urinary QOL.

Methods

The study group n = 173 was selected solely because of multiple self-reported questionnaires with at least five years of follow up from 670 consecutive men undergoing RARP between 2002–2007. Validated questionnaires included: AUAsi, urinary QOL score and selected questions from EPIC.

Results

Demographically the study group statistically represents the entire cohort. Overall mean baseline QOLs improved from 1.7 (2 = mostly satisfied) to 1.2 (1 = pleased) long term p < .05. 45% presented with moderate (n = 65) or severe (n = 13) LUTS and RARP improved their average QOLs from 2.5 to 1.5 (p < .05). Also men with minimal baseline LUTS reported long term stability in QOL with no change (1.1 to 1.0). 21 (12.1%) are incontinent: 6 (29%) had QOL scores 4–6, five are 3 or mixed and 10 have QOL scores 1–2. At baseline 19 men (11%) had QOLs ≥ 4 and long term following RARP only seven men (4%) had QOLs ≥ 4.

Conclusions

On average baseline urinary QOL was 1.7 and by 1 year improved to 1.2 remaining stable through 5 years. 45% presented with moderate to severe LUTS with baseline QOL of 2.5 dropping to 1.5. Six of 21 incontinent men have QOLs of ≥4. Our data suggests the AUAsi and urinary QOL capture baseline and long term urinary outcomes more accurately than incontinence based questionnaires.

24962 A double blind, placebo controlled randomised trial (RCT) evaluating the effect of a polyphenol rich whole food supplement on PSA progression in men

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Robert Thomas1, Pat Bellamy2, Mea Holm3 and Madeleine Williams4

1Bedford and Addenbrooke's Cambridge University NHS Trust, United Kingdom

2Cranfield University, United Kingdom

3The Primrose Unit Bedford Hospital, United Kingdom

4The Primrose Research Unit, United Kingdom

Objectives

Polyphenol rich foods such as pomegranate, green tea, broccoli and turmeric have demonstrated anti-neoplastic effects in cell lines and animal models including, anti-angiogenesis, pro-apoptosis and reduced proliferation. Although, some have been investigated in small phase II studies this combination has never been evaluated within an adequately powered RCT.

Methods

203 men, aged 53–89 yrs (average 74 yrs), with histologically confirmed prostate cancer, 59% managed with primary active surveillance (AS) or 41% with watchful waiting (WW) with a progressive PSA relapse following previous radical interventions were randomised to receive a b.d. oral capsule containing a blend of pomegranate seed, green tea, broccoli and turmeric or an identical placebo for 6 months. The randomised process produced no statistical difference in gleason grade, body mass index (BMI) or treatment category. Four men withdrew after randomisation.

Results

Of the remaining 199 men, the median rise in PSA in the food supplement group (FSG) was 14.7% (95% CI 3.4–36.7%) as opposed to 78.5% in the Placebo group (PG) (95% CI 48.1–115.5%). This difference of 63.8% was significant (p = 0.0008) using an analysis of covariance. The number of men with a stable PSA (lower or the same value) at trial completion was 46% in the FSG as opposed to 14% in the PG (32% difference, chi2, p = 0.00001). There were no significant differences in PSA% change within the predetermined subgroup analysis of age, gleason grade, treatment category or BMI. There were no differences in cholesterol, blood pressure, blood sugar or c-reactive protein between the two groups. 24% men recorded events in the FSG and 34% in the PG (non significant). Mild gastro-intestinal effects were most common (17%) in the FSG but 8% of men reported improved in stool quality.

Conclusions

This study found a highly statistically significant short term favourable effect on the percentage rise in PSA in this cohort of men with prostate cancer managed with AS or WW following ingestion of this well tolerated specific blend of concentrated foods (Pomi-T). Future trials will look at the longer term clinical effects and the benefits for men receiving ADT.

24966 Radium-223(Ra-223) safety and efficacy in prostate cancer with bone metastases: phase 3 ALSYMPCA study findings stratified by age

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Oliver Sartor1, Robert Coleman2, Sten Nilsson3, Daniel Heinrich4, Karin Staudacher5, Jose Garcia-Vargas6 and Nicholas Vogelzang7

1Tulane University Cancer Center

2Weston Park Hospital, United Kingdom

3Karolinska University Hospital, Stockholm, Sweden

4Akershus University Hospital, Norway

5Algeta ASA, Norway

6Bayer HealthCare, United States

7Comprehensive Cancer Centers of Nevada, United States

Objective

Radium-223 dichloride (Ra-223), a novel alpha-emitting pharmaceutical, targets bone metastases with high-energy, short-range alpha-particles. In the phase 3 ALSYMPCA trial, Ra-223 significantly improved overall survival (OS) in castration-resistant prostate cancer (CRPC) patients with bone metastases (median OS: 14.9 vs 11.3 mo; HR = 0.695; 95% CI, 0.581–0.832; P = 0.00007) and had a highly favorable safety profile. Age group analyses of OS and safety are presented.

Methods

Eligible patients had progressive, symptomatic CRPC with ≥2 bone metastases and no known visceral metastases; were receiving best standard of care; and were post-docetaxel, or were unfit for or declined docetaxel. Patients were randomized 2:1 to 6 injections of Ra-223 (50 kBq/kg IV, n = 614) q4wk or matching placebo (n = 307). The primary endpoint was OS. An analysis of OS and safety by age quartiles (<65 y; 65–74 y; 75–84 y; ≥85 y) was performed.

Results

Ra-223 significantly prolonged median OS versus placebo in the <65 y and 65–74 y age groups. Median OS was prolonged with Ra-223 versus placebo in the 75–84 y and ≥85 y age groups, but the treatment difference was not statistically significant. The incidence of adverse events in the various age groups was similar to that of the overall population. As observed in the overall population, diarrhea, vomiting, neutropenia, and thrombocytopenia were reported more frequently with Ra-223 versus placebo across age groups.

Age group<65 years65–74 years75–84 years≥85 years
TreatmentRa-223PlaceboRa-223PlaceboRa-223PlaceboRa-223Placebo
n158732571331909398
Median OS, mo16.911.415.012.412.210.814.09.5
P value0.0020.0270.1840.804
HR (95% CI)0.567 (0.391–0.822)0.738 (0.563–0.967)0.809 (0.591–1.107)1.185 (0.309–4.553)

Conclusions

Ra-223 prolonged survival regardless of age in CRPC patients with bone metastases. Older patients (≥65 years of age) can benefit from and tolerate Ra-223 as well as younger patients.

24974 Intravesical prostatic protrusion: as a predictor of early urinary continence recovery after laparoscopic radical prostatectomy

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Hong Koo Ha

Pusan National University Hospital, Korea

Objective

We evaluate the significance of intravesical prostatic protrusion (IPP) as a predicting factor of early urinary continence recovery after laparoscopic radical prostatectomy (LRP).

Methods

Between 2002 May and 2011 September, 242 patients underwent LRP for clinically localized or locally advanced prostate cancer. The correlation between preoperative factors, such as age, prostate volume, and IPP, and urinary continence following LRP was examined. We retrospectively collect the data of incontinence status and the number of pads required per day for urinary incontinence. IPP was measured by the vertical distance from the tip of the protruding prostate to the base of the urinary bladder in the sagittal plane of preoperative magnetic resonance imaging (MRI), which reflects the maximum longitudinal length of the prostate.

Results

The urinary continence rates at postoperative month 1, 3, and 6 were 19% (n = 46), 50% (n = 121), 79.8% (n = 193) respectively. In the univariate logistic analysis, age at surgery was associated with incontinence only at 6 and 12 months after surgery (p = 0.044 and p = 0.035, respectively). The prostate volume was associated with incontinence at 3, 6, and 12 months after surgery (p < 0.05). IPP was also associated with incontinence at all period after surgery (P < 0.05). In multivariate logistic analysis, the odds ratio (OR) of IPP at each period were 1.17 (95% confidence interval [CI], 1.02 to 1.35; p = 0.024), 1.16 (95% CI, 1.07 to 1.27; p = 0.001), 1.14 (95% CI, 1.06 to 1.23; p = 0.001), and 1.14 (95% CI, 1.04 to 1.25; p = 0.007), respectively. Continence at 1, 3, 6, and 12 months postoperatively was assessed by dividing into 2 groups based on the degree of IPP. Significantly improved continence was observed in non-significant IPP at 1, 3, 6, and 12 months postoperatively (p < 0.05).

Conclusions

The results of our study have shown that incontinence rate after LRP is correlated with IPP.

24978 Predictive factors for locally advanced prostate cancer in prostate cancer patients with Gleason score 6or lower

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Hong Koo Ha

Pusan National University Hospital, Korea

Objective

In this study we investigated prostate cancer patients whose prostate biopsy showed Gleason score of 6 or lower in order to identify, among a variety of preoperative factors, the ones that can be used for the prediction of locally advanced prostate cancer.

Methods

Among 1,400 patients who underwent prostate biopsy during the period from January 2006 to March 2011, 161 prostate cancer patients who had Gleason score of 6 or lower and subsequently underwent radical prostatectomy were included in this study. We investigated patient's age, preoperative prostate-specific antigen, longest tumor length, the max. core percentage of the longest tumor (percentage of the longest tumor length in total core length), the number of positive cores found during biopsy, invasion into surrounding nerves, and body mass index at the time of diagnosis. Patients were divided into two groups – one with disease phase type pT2 or below (Group I), the other with pT3 or higher (Group II) based on the results of postoperative biopsy, and inter-group comparison and analyses were performed to investigate the associations with each factor using single variate and multivariate analyses.

Results

Out of 161 patients, 19 (11.8%) were diagnosed with pT3 by postoperative biopsy. Mean age of patients in Group I and Group II was 67.5 ± 7.2 years and 72.9 ± 6.6 years (p = 0.002), body mass index 23.3 ± 3.2 kg/m2 and 22.9 ± 2.7 kg/m2 (p = 0.585), and prostate-specific antigen level 5.6 ± 2.3 ng/ml and 6.1 ± 2.4 ng/ml, respectively (p = 0.332). The longest tumor length was 4.2 ± 3.1 mm and 6.8 ± 4.0 mm (p = 0.007), the max. core percentage of the longest tumor 33.1 ± 24.0% and 66.5 ± 41.1% (p = 0.013), respectively. The number of positive cores was 2.5 ± 1.7 and 4.0 ± 3.3 (p = 0.072), the percentage of the positive cores 28.1 ± 26.6% and 42.6 ± 28.7% (p = 0.033), respectively. Univariate analysis revealed that age, longest tumor length, the max. core percentage of the longest tumor, and the percentage of positive cores were associated with Group II (p < 0.05), while multivariate analysis revealed the association with Group II in only the max. core percentage of the longest tumor (P = 0.0020) and the percentage of positive cores (p = 0.019).

Conclusions

We believe that. even in patients whose histological examination show Gleason score of 6 or lower, disease phase may be pT3 or higher if either the max. core percentage of longest tumor or the percentage of positive cores is high. Therefore, special care should be exercised in performing prostatectomy.

25062 A multi-centre analysis of early urinary continence recovery after robotic assisted radical prostatectomy in older men

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Marnique Basto, Chinni Vidyasagar, Helen Freeborn, Declan Murphy and Daniel Moon

Peter MacCallum Cancer Centre, Australia

Objectives

The perceived greater risk of complications in men over 70, in particular urinary incontinence, is often cited as a reason to deny these men curative surgical treatment, even when an aggressive tumour is present that appears likely to progress within their lifetime.

The aim of this study is to compare the recovery of urinary continence (UC) after robotic assisted radical prostatectomy (RARP) in men greater and less than 70 years of age.

Methods

262 patients having undergone RARP by two surgeons were identified through their prospectively collected public and private databases after exclusions, 3 May 2008–14th September 2012.

Detailed demographic, staging, peri-operative and continence data was collected; Pads/day the primary outcome. Simple frequencies were the primary statistical method.

Results

10.1% of the cohort were >70 yo. In men greater than and less than 70 yo the mean age was 59.7 and 71.1 respectively. There were a greater number of D'Amico intermediate and high-risk patients in the >70 yo cohort.

At 4–6 weeks, Men > 70 yo required on average 2 pads/day (13.3% fully continent) compared to men <70 yo requiring 1 pad/day (38.4% fully continent). By 3 months and all time points thereafter, the mean pads/day and % patients fully continent showed little difference between groups.

Conclusion

At 4–6 weeks recovery of UC was worse for men >70 yo however equalised in comparison to their younger counterparts thereafter. Our experience suggests that preclusion of older, healthy, high-risk men on the grounds of poorer continence recovery may need to be revisited.

25094 Contemporary management of prostate cancer at an Australian tertiary referral centre

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Prassannah Satasivam, Sareetaa Vijayan, Mark Frydenberg and Sree Appu

Monash Health, Australia

Objectives

Active surveillance (AS) has emerged as a safe alternative to radical prostatectomy (RP) and primary radiotherapy (XRT) for the treatment of low-risk prostate cancer. This study sought to examine whether clinical practice at our institution reflected the emerging evidence.

Methods

We retrospectively reviewed 409 consecutive TRUS-guided prostate biopsies performed between May 2010 and April 2013 at Monash Health, Melbourne. Patients with positive biopsies were stratified according to the D'Amico risk classification and treatment decisions compared using Chi-square analysis. Regression analysis was applied to 62 consecutive RPs performed during the same period to identify trends in the distribution of surgeries performed for each risk category. Statistical significance was specified as p < 0.05.

Results

Patients undergoing TRUS biopsy had a mean age of 63 years and median PSA of 7.55 μg/L. Fifty percent (n = 205) had positive biopsies, of whom 84 were subsequently classified as low-, 80 as intermediate- and 41 as high-risk according to the D'Amico criteria. On multivariate analysis, age > 65 years (p < 0.001) and D'Amico classification (p < 0.001) significantly predicted the choice of treatment modality. 37% of patients undertaking AS were over 65 years, compared with 22% of patients undergoing RP and 69% of those having XRT. Surveillance was chosen by 78% of low-risk and 26% of intermediate-risk patients. XRT was chosen by 9%, 36% and 50% of low-, intermediate- and high-risk patients respectively. RP was undertaken in 11%, 32% and 13% of low-, intermediate- and high-risk patients respectively. The rate of RP for low-risk disease fell from 50% of cases in the latter half of 2010 to none in early 2013 (p = 0.009 for trend). Conversely, RP for intermediate-risk disease rose from 38% to 75% (p = 0.02).

Conclusions

Increasing acceptance of AS has led to its widespread use in younger men and a reduction in surgery performed for low-risk disease at our institution.

25110 Functioanal and early oncological results of radical perineal prostatectomy for the management of clinically locally advanced prostate cancer

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Stefanos Bolomitis, Konstantinos Andritsos, Dimitrios Tsavdaris, Konstantinos Ioannidis, Vasileios Tzelepis and Athanasios Archontakis

401 General Military Hospital of Athens, Greece

Objective

According to current literature, radical prostatectomy is the best choice for the management of organ confined prostate cancer. There is increased evidence that surgical approach has an important role to play as a therapeutic approach for clinically locally advanced prostate cancer. The aim of our study is to evaluate the oncological and functional results of radical perineal prostatectomy for the management of patients with clinically advanced prostate cancer.

Patients and methods

Between 1993 and 2012 627 patients underwent radical perineal prostatectomy,in our institution, for histologically confirmed prostate cancer. 83 out of 627 patients had clinically advanced disease. Perioperative morbidity, functional results and early oncological outcomes were examined and compared between the organ confined and clinically advanced subgroups.

Results

The mean follow-up was 37 (8–62) months. There was no statistically significant difference in the operative time, the intraoperative blood loss, the hospital stay and the duration of catheterization between the 2 groups. The rate of complications was also similar, with the exception of two rectal injuries at the locally advanced subgroup, which were repaired successfully at the same time. 17.3% of the clinically advanced patients resulted to be organ-confined (pT2). 99,8% were continent and 36,7% were potent at the locally advanced subgroup compared to 100% and 62,5% respectively at the organ confined subgroup. One patient of the first subgroup, with infiltration of the apex, had postoperative urinary incontinence, which was managed with the placement of an artificial sphincter. The cancer-specific survival rates were not significantly different between the 2 groups.

Conclusions

In cases of locally advanced prostate cancer, the removal of the tumor -combined with adjuvant therapy, when necessary- may possibly change the natural course of the disease. In addition, through the application of RPP it is possible that the number of cases with positive surgical margins may be further reduced. At the same time, there are good functional results for the patients, without complications and local symptoms, providing overall a satisfactory quality of life.

25162 Efficacy and safety of abiraterone acetate and prednisolone in Korean and Taiwanese patients with mCRPC after chemotherapy failure

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Cheol Kwak1, Choung-Soo Kim2, Tony Wu3, Hyan-Moo Lee4, Sung-Joon Hong5, Hsi-Chin Wu6, Yen-Chuan Ou7, Susan Li8, Howard Yeh8, Margaret Yu8 and Choung-Soo Kim9

1Seoul National University Hospital, Korea

2College of Medicine, University of Ulsan, Asan Medical Center, Asan Hospital, Korea

3Division of Urology, Kaohsiung Veterans General Hospital, Taiwan

4Department of Urology, Samsung Medical Center, Sungkyunkwan University School, Korea

5Department of Urology, Yonsei University College of Medicine, Korea

6Department of Urology, China Medical University Hospital, China Medical University, Taiwan

7Taichung Veterans General Hospital, Taiwan

8Janssen Research & Development, United States

9Department of Urology, College of Medicine, University of Ulsan, Asan Medical C, Korea

Objective

The primary objective of this study was to determine the proportion of patients achieving a prostate-specific antigen (PSA) decline of atleast 50% in response to abiraterone acetate+prednisolone, in Korean and Taiwanese patients with metastatic castration-resistant prostate cancer (mCRPC) following failed androgen deprivation and docetaxel-based chemotherapy.

Methods

Patients (N = 82; 52 Korean and 30 Taiwanese) with mCRPC who had failed androgen deprivation and docetaxel-based chemotherapy were treated with abiraterone acetate (1000-mg, once daily) + prednisolone (5-mg, BID). The primary endpoint was PSA response rate. Secondary endpoints included overall survival, time to PSA progression, objective radiographic response rate, serum testosterone, and dehydroepiandrosterone sulfate (DHEA-S).

Results

Among all treated patients, 35 (43%) achieved a PSA response (95% CI: 32%-54%), which is above a prespecified historical estimate of 15% for treatment with prednisone alone; thus meeting the primary objective. Total 44 patients (54%) experienced PSA progression. Median time to PSA progression was 143 days (95% CI: 112, 253), while the median overall survival was not reached. Two (4%) of 50 patients achieved partial radiographic response. The median testosterone concentration was constant (1.21 nmol/L) throughout the treatment period while median DHEA-S decreased from 0.725 μmol/L (baseline) to 0.080 μmol/L (cycle 4). The most common adverse event (AE) was bone pain (20%) and Grade 3/4 AEs of special interest were hypokalemia (7%), fluid retention and LFT abnormalities (5% each), hypertension (2%), and cardiac disorders (1%).

Conclusion

The benefit-risk ratio of abiraterone acetate+prednisolone appears favorable in the Taiwanese and Korean population with advanced mCRPC after docetaxel-based chemotherapy.

25222 Clinicopathologic features and risk stratification of concomitant prostate cancer found in specimens removed by radical cystoprostatectomy: a prospect

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Jin Soo Jung

National Cancer Center, Korea

Objectives

To describe the prevalence of incidental prostate cancer (IPC) and to quantify its risk stratification in association with other clinicopathologic features in patients undergoing radical cystoprostatectomy (CPT) for malignancy.

Methods

Consecutive 97 male patients scheduled to undergo CPT were prospectively enrolled. The CPT specimens were examined after mapping prostate specimens, where complete transverse sections of the prostate were taken from the apex to the base at 2–3 mm intervals.

Results

Of the 97 CPT patients, 83 (85.5%) had primary bladder cancer, 12 (12.4%) colorectal cancer, and two (2.1%) penile cancer. A total of 39 (40.2%) patients had concomitant ICP. Most of the IPCs (89.7%) were confined to the prostate, except for three (7.7%) cases of extracapsular extension and one (2.7%) of seminal vesicle invasion. Median tumor volume was 0.6 cm3. Of these IPCs, 23(59.0%) cases were clinically significant prostate cancer (CSPC). Among the 76(81.7%) patients having preoperative PSA, PSA of five stratified categories showed significant correlation with increased incidence of CSPC(RR 0.313, p = 0.015). Thirty four (44.7%) patients with PSA < 4.0 ng/mL had PC, including 11 (14.5%) CSPC and the other 42 (55.3%) with PSA ≥ 4 ng/mL, PC was diagnosed in 18 (42.9%) patients, including eight (19.0%) CSPC. Those 83 patients with bladder cancer with IPC had significantly higher age (68.9 vs 61.6 years) and PSA level (3.9 vs 1.13) than those with non-IPC.

Conclusions

IPC was a common finding in CPT and 59.0% of IPC was clinically significant. In addition, PSA still appeared to be a useful screening tool for detection of PC.

25226 Efficacy of early duloxetine therapy in urinary incontinence occurred after radical prostatectomy

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Ali Erhan Eren, Cabir Alan and Gökhan Baştrük

Canakkale Onsekiz Mart University Medical Faculty Department of Urology, Turkey

Aim

To evaluate the efficacy of early duloxetine therapy in stress urinary incontinence occurred after radical prostatectomy.

Material and Method

Fifty-eight patients with an age range 55–65, who had body mass index range 28–30, were selected between 112 patients operated due to prostate cancer between 2010 and 2013. The patients had radical prostatectomy were randomized into 2 groups following the removeling of urinary catheter; group1(n:28): in which the patients had pelvic outlet exercise (POE) and duloksetin therapy, group 2 (n:30): in which the patients had POE alone. ICIQ-IU-SF and IEF questionnaires were used to evaluate the continence of the patients at the beginning and during the follow-up. Number of pad used and 1-hour pad test were used in determining the degree of urinary incontinence. The treatment lasted for 10 months and called for the control in the first month with 3-month intervals. The treatment was assessed with the tests mentioned above in each controls.

Results

Mean age of the patients mean follow-up were 60.2 (55–62) and 7.8 months (2–13), respectively. 27 of the patients (96.4%) in group 1 were completely dry at the end of first year. 5 of them were dry in first 3 months. On the other hand 17 and 3 of rest of the patients in group 1 had dryness in 6th and 10th months and gave up pad usage, respectively. Only 1 patient in group 1 could not get dryness and had urethral stricture at the end of first year. 26 of the patients (86.7%) in group 2 were completely dry at the and of first year. None of these patients had dryness in the first 3 months. 12 patients of group 2 were dry in 6th months, hovewer, 6 and 8 patients in this group had dryness in 9th and 12th months in follow-up and gave up pad usage. 4 patient in group 2 could not get dryness and 1 of them had urethral stricture at the end of first year. There was a significant difference for the time to reach continence in group 1 (p:0.008). There were significant differences in number of pad usage and weight of pad in 7th months between 2 groups. However, there was no significant difference in IEF questionnaire. None of the patients did give up the drug due to side effects and medication was ended with dose reduction after 1 month of the obtainment of continence.

Conclusion

According to our results, early duloxetine therapy in stress urinary incontinence occurred after radical prostatectomy has efficacy to provide continence.

25294 Radical prostatectomy pathological features – changes over 20years in a prostate database of 11499 cases with focus on Gleason score and high grade

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Warick Delprado, Jenny Turner, Ivan Burchett, Steve Fairy and Fiona Maclean

Douglass Hanly Moir Pathology, Australia

Objective

To demonstrate changes in pathological features of prostate cancer in radical prostatectomy specimens 1991–2012.

Methods

A database maintained prospectively since 1991 of all radical prostatectomies reported at DHM contains 11499 patients. Retrospective analysis was performed of changes in stage, margin involvement and Gleason Score (GS). Biopsy score was compared to the prostatectomy score. The significance of percentage of high Gleason Grade was examined in a subset of 4224 from 2010–12.

Results

Extraprostatic extension was stable at approximately 60%; focal decreased 25% to 15%, established increased 10% to 23%. Margin involvement decreased from 60% to 23%; focal decreased from 40% to 13%, extensive decreased from 29% to 10.6%. Seminal vesicle involvement was stable around 8%. Lymph node involvement fluctuated around 2%.

There were major changes in GS; GS4 from 2.78% to 0%, GS5 from 19.51% to 0.06%, GS6 from 34% to 6.4%, GS7 from 25% to 81%, GS8 from 9% to 2.9%, GS9 from 3.6% to 9.4%. 3+4 = 7 showed a larger change than 4+3 = 7.

Preoperative biopsies showed fall in GS6 and rise in GS7; cases upgraded from GS6 to GS7 were 33% to 64%. 90% of the biopsy upgraded cases contained less than 35% grade 4, with 36% having 5% grade 4.

For 2010–12, the percentage grade 4 in GS7 correlated with pT2 stage, with linear reduction from 85.87% with <5%, to 39.9% with 90%. Percentage 4 greater than 65% matched GS8 cases, so reporting was only useful in 3+4=7. Seminal vesicle involvement increased with percentage 4.

Conclusion

In this database there were major changes in pathological features of radical prostatectomies 1991–2012. The reasons are multifactorial.

25378 Impact of a uro-oncology multi-disciplinary meeting on clinical decision making in prostate cancer

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Kenny Rao1, Kiran Manya1, Arun Azad2, Damien Bolton4, Ian Davis3 and Shomik Sengupta4

1Austin Health, Australia

2Austin-Ludwig Oncology Unit, Australia

3Austin-Ludwig Oncology Unit & Eastern Health Department of Medicine, Australia

4Austin Department of Surgery, Australia

Purpose

Multidisciplinary meetings (MDM) provide a forum in which health care professionals can bring together their expertise from various disciplines to optimise patient care. Prostate cancer patients are increasingly managed through MDMs, although there is a paucity of evidence for their impact on clinical decision-making. Our objective was to prospectively analyze the influence of a uro-oncology MDM on prostate cancer management decisions.

Methods

All GU cancers discussed at the weekly MDM at the Austin Hospital were prospectively recorded over a 3-month period. The presenting clinician was asked to state their provisional management plans prior to discussion. This was compared with the subsequent consensus decision and the MDM's influence was graded as high or low impact.

Results

Over the study period, 120 discussions about 107 patients (7 patients discussed twice, 3 patients 3 times) were recorded, which included 46 (38.3%) patients with prostate cancer. The MDM made high impact changes to the original plan in 32 (26.7%) cases overall, including 12 (26%) prostate cancer patients. The presence of metastatic disease was associated with more high impact changes (6 of 13 patients with metastatic prostate cancer), but T-stage was not. Primary cross referrals between disciplines occurred in 40 (33.3%) cases, including 12 of 46 (26%) prostate cancer, compared to 66.7% testicular cancers and 42% bladder cancers (p < 0.02).

Conclusions

The MDM alters the treating clinician's management in about a quarter of prostate cancer cases, more so with evident metastatic disease. However, MDMs also serve purposes other than decision-making, such as cross-referral, consideration for clinical trials and peer-review of clinical practice.

25462 Longitudinal, prospective patient-reported outcomes of patients following robotic surgery for localised prostate cancer

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Adam Dowrick1, Mari Botti2, Niall Corcoran3, Addie Wootten3, Justin Peters4 and Anthony Costello3

1Australian Prostate Cancer Research Centre Epworth, Australia

2Deakin University, School of Nursing, Australia

3Australian Prostate Cancer Research Centre, Australia

4Royal Melbourne Hospital, Department of Urology, Australia

Introduction and objectives

There is little longitudinally collected data available to accurately counsel patients as to the likely functional and psychosocial outcomes following robotic surgery. We aim to present longitudinal, prospectively collected data obtained at multiple time points during the first year post-surgery.

Methods

We present the data from patients operated on by two experienced robotic surgeons from a single centre. Data was obtained at baseline and at 4 weeks, 3, 6, and 12 months post-operatively.

Results

Five hundred and thirty-one patients were included. Twenty-four percent of patients were classified as low risk according to the D'Amico classification, 58% as intermediate risk, and 18% as high risk.

The mean pre-operative EPIC urinary score dropped from 90.8 to 59.7 at 4 weeks and recovered to 84.1 at 12 months.

Seventy-three percent of patients were sexually active pre-operatively and were included in the analyses of sexual function. The EPIC sexual score dropped from a mean of 67.0 pre-operatively, to a mean of 24.6 at 4 wks and recovered to a mean score of 38.8 at 12 months.

Sixty-seven percent of patients had a pre-operative SHIM score of 22 (indicating no erectile dysfunction, ED). The rate of no ED in this sample of patients had been reduced to 13.6% at 12 months.

Conclusion

There is little longitudinal, prospectively collected data to guide patients when choosing their treatment for localised prostate cancer. This data will be valuable when counselling patients with regard to their likely functional outcomes following RARP.

25562 Waiting times from diagnosis to surgery and prostate cancer survival

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David Gillatt1, Maria Theresa Redaniel2, Maria Theresa Redaniel2, Julia Wade2, Richard Martin2 and Mona Jeffreys2

1Bristol Urological Institute, Southmead Hospital, United Kingdom

2School of Social and Community Medicine, The University of Bristol, United Kingdom

Objective

Initiatives to limit waiting times from diagnosis to surgery to 31 days were implemented in the UK, primarily to ease patient anxiety and improve cancer survival. Our study aims to determine the impact of surgery waiting times have upon prostate cancer survival and variations in survival by socio-demographic factors.

Methods

Using national databases for England (cancer registries, Hospital Episode Statistics and Office of National Statistics), we identified 17,043 men with prostate cancer, aged 15 years and older, diagnosed in 1996–2009, and who had surgical resection with curative intent within 6 months of diagnosis. We used relative survival to investigate associations between waiting times and five- and ten-year survival.

Results

Five- and ten-year relative survival estimates for the total study sample were 1.04 (95% CI: 1.04 to 1.05) and 1.08 (95% CI: 1.06–1.09), respectively. There were no notable differences in survival between patients who had surgery at 0–3 and 4–6 months. Relative survival was 8–19 percentage points higher among the elderly (>65) compared to men aged 15–54 years. Those with well and moderately differentiated tumours have 5–15 percentage points higher survival than those with poor- and undifferentiated tumours.

Conclusion

The high relative survival in our cohort probably reflects adherence to selection criteria for surgery among men with localised prostate cancer. Among men treated with surgery within 6 months of diagnosis, decreasing waiting times from diagnosis to surgery had little impact on survival.

25574 Angiotensin converting enzyme (ACE) inhibitors: impact on men receiving primary radiotherapy (RT) for prostate cancer (PC)

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Weranja Ranasinghe1, Scott Williams2, Shomik Sengupta3, Mike Chang3, Arthur Shulkes3, Damien M Bolton3, Graham Baldwin3 and Oneel Patel3

1North East Health Wangaratta/Austin Hospital, Australia

2Peter MacCullum Cancer Institute, Australia

3Department of Urology, Austin Health/ University of Melbourne, Australia

Objectives

ACE inhibitors have been linked with an increase incidence of prostate, breast and lung cancer. Our objectives were to investigate the impact of ACE inhibitors on the outcomes of patients receiving RT for PC.

Methods

We conducted a medication review of a prospective cohort of 1956 men who received primary RT with or without supplemental androgen deprivation therapy (sADT) for PC at the Peter McCallum Cancer Institute, Melbourne, Australia from 2003 -07.

Results

56% of patients had concurrent sADT. 502 men had subsequent biochemical failure, 314 had initiated sADT and 125 had died of PC. Median follow up after radiotherapy was 71 months while there was a median follow up of 41 months in patients after ADT initiation. 603 men were on ACE-inhibitors. A competing risks model was developed, and after adjusting for patient age, initial tumor stage, Gleason Score and PSA, along with planned ADT usage and ACE27 co morbidity score, there were significant association between ACE-inhibitors and PC-specific mortality both from the time of RT and sADT (p = 0.035 and 0.01 respectively), with a strong increase in hazard (HR 1.58 [95%CI 1.03–2.42) and 2.02 [95%CI 1.16–2.90]). No significant association was seen with time to metastasis development, suggesting the impact of ACE inhibitors may be in the post-metastasis phase of the disease.

Conclusions

ACE inhibitors may increase the rates of PC-specific mortality in men receiving primary radiotherapy for PC. However these results need to be further validated by randomised controlled studies and mechanism needs to be further investigated.

25578 Should prostate specific antigen (PSA) screening in be used in younger men in Australia?

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Weranja Ranasinghe1, Simon P. Kim2, Nathan Lawrentschuk7, Shomik Sengupta7, Luke Hounsome3, Jim Barber4, Richard Jones5, Paul Davis6, Damien Bolton7 and Raj Persad8

1North East Health Wangaratta, Australia

2Mayo Clinic, Rochester, United States

3South West Public Health Observatory, United Kingdom

4Velindre Hospital, United Kingdom

5The University of Leeds/Leeds Teaching Hospitals Trust, United Kingdom

6Frankston Hospital, Australia

7The University of Melbourne, Austin Hospital, Australia

8University Hospitals Bristol Trust, United Kingdom

Objectives

To analyse the trends of opportunistic PSA screening in younger men in Australia and examine its effects on TRUS-BX rates and determine the nature of PCs being detected.

Methods

All men who received an opportunistic screening PSA tests and Trans-rectal ultrasound-guided biopsies (TRUS-BX) from 2001–08 in Australia were analysed using the Australian Cancer registry (Australian Institute of Health and Welfare) and Medicare databases. Victorian cancer registry was used to obtain Gleason scores.

Both age-standardised and -specific rates were calculated along with incidence of PC and correlated with Gleason scores.

Results

A total 5,174,031 PSA tests detected 128,167 PC from 2001–08. During this period, PSA testing increased by 146% (a mean of 4629 tests per 100,000 men annually), with an 80% and 59% increases in the rates TRUS-BX and incidence of PC, respectively.

The highest increases in PSA screening (upto 174%) occurred in men less than 55 yrs and 1,101 men had to be screened to detect one incident case of PC.

This also resulted in two thirds of men aged less than 55 receiving negative TRUS-BX. There was no correlation with Gleason >7 tumours in patients less than 55 years.

Conclusion

Despite the ongoing controversy on the merits of prostate cancer screening, there was an increase in PSA testing, especially in men less than 55 years leading to a modestly higher incidence of PC in Australia. However, PSA screening was associated with high rates of negative TRUS-BX and detection of low/intermediate grade PC among younger patients.

25594 The factors which affect posterior dissection of the prostate during robot assisted laparoscopic radical prostatectomy

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Seung Hyun Jeon1, Sang Hyub Lee2, Koo Han Yoo2 and Bong-Keun Choe3

1School of Medicine, Kyung Hee University, Korea

2Department of Urology, School of Medicine, Kyung Hee University, Korea

3Department of Preventive Medicine, School of Medicine, Kyung Hee University, Korea

Objective

Posterior dissection of the prostate is one of the most difficult and critical steps during performing robot assisted laparoscopic radical prostatectomy (RALP). Rectum or sometimes prostate itself may be injured if the surgeon does not pay attention during posterior dissection of the prostate. Many urologists perform radical prostatectomy 6 or 8 weeks after biopsy to stabilize the inflammatory change between prostate and rectum which might have bad influence on posterior dissection of the prostate. We aimed to find out which factors make posterior dissection of the prostate more difficult.

Methods

Between December 2008 and March 2013, 67 patients, who were diagnosed as localized prostate cancer, underwent RALP by single surgeon at KyungHee university hospital. We retrospectively reviewed medical records of these patients, such as age (years), prostate volume (mL), prostatic specific antigen (PSA), interval between biopsy and surgery, number of biopsy sites, number of times performing biopsy, the existence of median lobe and the history of transurethral resection of the prostate. And we reviewed video to calculate the time (minute) of posterior dissection of the prostate. Correlation analysis was performed to find out which factor is most related with posterior dissection of the prostate.

Results

Mean age of 67 patients was 64.48 ± 6.92 years old. And mean prostate volume and mean time of dissection was 39.49 ± 21.20 mL and 28.01 ± 14.34 minute, respectively. The correlation coefficient between time of dissection and median lobe was 0.311 (p = 0.010). The existence of median lobe had mild harmful effects on posterior dissection of the prostate. And the correlation coefficient between time of dissection and prostate volume was 0.459 (p < 0.001). We can find out that large prostate volume had a moderately negative influence on posterior dissection of the prostate. Other factors, such as age, interval between biopsy and the operation, number of biopsy site, number of times receiving biopsy and Gleason score, did not affect posterior dissection of the prostate.

Conclusions

According to our study, if urologists plan to perform RALP, surgeons do not need to wait for 6 or 8 weeks to stabilize the tissue between rectum and prostate which were injured during biopsy. However, we should keep in mind, if the volume of patient's prostate is large; it requires more attentions especially during posterior dissection of the prostate.

25654 Phase II study of neoadjuvant ‘supercastration’ in men with high risk non-metastatic prostate cancer

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Niall Corcoran

Australian Prostate Cancer Centre Epworth, Australia

Introduction

Men with high-risk prostate cancer are at increased risk of disease relapse post-prostatectomy. Previous neo-adjuvant studies demonstrate reductions in positive margin rates, but a low pT0 response rate and no improvement in biochemical recurrence-free survival. With the advent of more effective hormonal agents we wished to determine if a ‘supercastration’ combination led to an increased pT0 response rate compared to historical controls.

Methods

This is an open label non-randomised Phase II study neoadjuvant study of ‘supercastration’ in men with high-risk clinically localized prostate cancer. Treatment consists of Degarelix 240/80 mg q 1/12, Abiraterone 1000 mg OD, Bicalutamide 50 mg OD and Prednisolone 5 mg OD for 24 weeks. The primary endpoints are safety/tolerability and pT0 response rate. Secondary endpoints include correlative molecular and hormonal studies. Using an optimal 2-stage design, the trial is powered to detect a pT0 response rate of 25%, with at least one pT0 response required in the first 9 patients required to proceed to the second phase. The final anticipated sample size is 12–17.

Results

Recruitment to the first phase is complete. The combination treatment has been well tolerated, with hot flushes and fatigue being the most commonly reported side effects. Two patients with asymptomatic elevation of liver transaminases required Abiraterone dose reductions, and there have been no unexpected toxicities. Full toxicity data on the first nine patients as well as preliminary pT0 response rates will be presented.

Conclusion

This ongoing Phase II trial will offer insights into the role of neoadjuvant ‘supercastration’ in men with high-risk prostate cancer.

25670 A systematic review with meta-analysis of transrectal prostate biopsy versus transperineal prostate biopsy for detecting prostate cancer

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Matthew Winter1, Cindy Garcia1, Philip Bergersen1, Henry Woo2 and Venu Chalasani1

1Hornsby Hospital, Australia

2Sydney Adventist Hospital, Australia

Introduction

Two techniques of prostate biopsy exist: the transrectal (TR) approach and transperineal (TP) approach.

Objective

To conduct a systematic review and meta-analysis to determine if there is any difference in cancer detection between TR and TP biopsy.

Methods

Biomedical databases (Medline, Embase, and Cochrane Central Register of Controlled Trials) and conference proceedings (EAU, AUA & BAUS) were searched. Studies were included if they were randomised controlled trials comparing TR to TP prostate biopsy, with the same number of cores taken in each arm. Meta-analysis was performed with summary odds ratio (OR) and its 95% confidence interval. An OR of greater than 1 favoured increased cancer detection with TR biopsy. An OR of less than 1 favoured increased cancer detection rate with TP biopsy.

Results

Four studies were identified with data sufficient to conduct a meta-analysis available for three studies, with a total of 742 patients undergoing biopsy. No significant visual or statistical heterogeneity was noted between trials. The overall cancer detection rate of TR biopsy was 46.8% (175/374) whilst the overall cancer detection rate of TP biopsy was 41% (151/368). This difference was not statistically significant (OR 1.27 [0.76,1.72]). Subgroup analysis (PSA < 4, 4.1–10 or >10.1) also revealed no statistical significance.

Conclusion

No statistical significant difference in the cancer detection rate of TR and TP prostate biopsy was shown. A trend towards increased cancer detection was shown during TR biopsy.

25674 Comparison of perioperative results and short-term biochemical recurrence survival in RARP within 2 weeks

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Joo Yong Lee, Richilda Red Diaz, Kang Su Cho, Won Sik Ham and Young Deuk Choi

Severance Hospital, Yonsei University College of Medicine, Republic of Korea

Objectives

To evaluate whether robot-assisted radical prostatectomy (RARP) performed within 2 weeks of prostate biopsy is associated with postoperative outcomes and biochemical recurrence compared with a control group, using propensity scores.

Methods

Of the 879 patients who underwent RARP by single surgeon (YDC) between Aug 2005 and Apr 2012, 96 patients who underwent RARP within 2 weeks of prostate biopsy were analyzed. Propensity scores for an established control group were calculated for each patient using multivariable logistic regression based upon the following covariates: age, body mass index, preoperative prostate-specific antigen level, prostate volume, biopsy Gleason score, clinical tumor stage, and D'Amico risk stratification. Propensity score-matching was performed to select the most similar propensity scores among the group after 2 weeks of biopsy, in a 1:1 ratio with respect to the reference group of patients who underwent RARP within 2 weeks of biopsy.

Results

In 192 patients, the mean age was 64.60 ± 7.44 years and mean follow-up was 28.31 ± 15.89 months. There were no statistical differences in variables used in propensity score matching. Operation time (124.48 ± 25.00 vs. 118.25 ± 25.05; p = 0.084) and estimated blood loss (292.70 ± 221.33, 250.83 ± 165.20 ml; p = 0.139) were not significantly different between the two groups. In a log-rank test using the Kaplan-Meier curve, there were no statistical differences in biochemical disease recurrence between the two groups (p = 0.067, HR: 0.6324; 95% CI 0.3859–1.0364).

Conclusion

RARP within 2 weeks of prostate biopsy may be performed safely in patients for postoperative outcomes and biochemical recurrence as compared with RARP after 2 weeks of biopsy.

25678 Comparison of three nomograms on clinically insignificant prostate cancer: a validation study

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Joo Yong Lee, Richilda Red Diaz, Kang Su Cho, Won Sik Ham and Young Deuk Choi

Severance Hospital, Yonsei University College of Medicine, Republic of Korea

Objectives

Recently several nomograms for preoperative diagnosis on clinically insignificant prostate cancer (CiPCa) have been developed. We conducted to evaluate external validation of most popular three nomograms for CiPCa with our patient cohort.

Methods

264 patients underwent open and robot-assisted radical prostatectomies by a single surgeon from our prostate cancer cohort between Jan, 2011 and March, 2012 were enrolled in our validation study. Men with complete data on clinical and pathological stage, preoperative serum PSA level, total cancer volume, Gleason score (GS) on biopsy and prostatectomy specimen were recruited. Insignificant tumors were defined as tumors with a total tumor volume in each specimen of less than 0.5 mL with organ confined disease and a histologic Gleason score of less than 7. Validation was performed to be quantified with receiver operating characteristic (ROC) analysis.

Results

Histopathologic evaluation of prostatectomy specimens revealed insignificant tumor in 50 (18.94%) of 264 patients. The calculated area under the ROC curve (AUC) were 0.831 (p < 0.001), 0.819 (p < 0.001) and 0.746 (p < 0.001) using nomograms by Nakanishi et al., Chun et al. and Chung et al., respectively. The difference between areas by pairwise test among three nomograms revealed 0.0117 (Nakanish vs. Chun; p = 0.663), 0.0845 (Nakanish vs. Chung; p = 0.028), 0.0728 (Chun vs. Chung; 0 = 0.057), respectively. In multivariate logistic regression models, PSA, prostate volume and GS showed significant correlation with CiPCa. Predicted values from logistic regression models showed a significant differences as compared with previous three nomograms 0.0643 (Nakanishi; p = 0.014), 0.0760 (Chun; p = 0.007), 0.149 (Chung; p < 0.001).

Conclusion

AUC from previous three nomograms for CiPCa showed significantly lower AUC than predicted values from logistic regression models in our patient cohort. New nomogram for CiPCa in Asian is needed for the precise prediction for CiPCa.

25698 Salvage radical prostatectomy: comparing outcomes of a single surgeon series in the advent of a robotic approach

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David Gillatt and Elizabeth Waine

Bristol Urological Institute, United Kingdom

Introduction

Radical prostatectomy for biochemical recurrence of prostate cancer following radical radiotherapy is increasingly being utilized as a salvage treatment, with increasing evidence that this treatment option can provide a durable cure. With the advent of minimally invasive surgery, questions are raised about oncological outcomes of surgery in the non-salvage setting, however it has been shown that hospital stay and blood loss are improved in minimally invasive surgery but there is no difference in oncological outcomes when performed by the experienced surgeon. There are a small number of case series presented in the literature of robotically assisted minimally invasive surgery being used in the salvage setting, which have favourable outcomes when performed by high volume surgeons.

Methods

We have reviewed the outcomes of surgery in all salvage radical prostatectomy from 2001 to 2012 completed by a single surgeon in a tertiary referral centre. The Da Vinci Robotic system has been in use within our institution since 2009. We have assessed the pre-operative parameters, intra-operative and post-operative outcomes of both open and robotic surgical approaches.

Results

There were a total of 14 open and 15 robotic salvage prostatectomies during the 4 year period from May 2008 to May 2012. Median time to biochemical recurrence in all cases was 43 months (9–60 months). Three patients in each open group had high risk cancer at diagnosis, however all patients had radiological confirmation of disease stage pre-operatively. The operative time for the robotic surgery was longer than with the open approach, median time 90 vs 130 minutes. Intra-operative blood loss was less than with the open approach. There were no significant post-operative complications in either group, and node positive disease was diagnosed in 3 patients in each group, post-operative stage, grade and positive margin status were similar in both groups. Median length of hospital stay for the robotic series was 2 days (2–6 days) whilst the open cases had a median stay of 5 days (4–9).

Conclusions

Oncological outcomes have not been compromised by using minimally invasive technique in this single surgeon series, however there was a reduction in hospital stay, operative time and blood loss when the robotic assisted approach was implemented in a surgeon with a large series of open and robot assisted prostatectomy.

25702 A modular training programme reduces total console time during robotic assisted radical prostatectomy

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David Gillatt, Bax Kevin, Thurairaja Ramesh and Waine Elizabeth

Bristol Urological Institute, United Kingdom

Introduction

Training by mentorship programmes have been utilised during the infancy of robotic assisted laparoscopic prostatectomy and results have shown that operating times and oncological outcomes improve with increasing experience. Time taken to complete the surgery during these early cases has a detrimental effect upon service provision. It is also possible that operating fatigue in the setting of early cases may prevent favourable outcomes. Impact upon the patient by prolonged surgery and anaesthesia also needs to be taken into account. In order to reduce the impact upon the patient and service provision, a modular training programme should be considered.

Methods

A modular training programme was developed and this included trainees performing 10 simulated extra-corporeal urethra-vesical anastomoses. Each step had to be performed to completion and subsequently completed within 20 minutes before progressing to more complex steps. During cases iy was possible that more than one step was completed by the trainee to maximise training opportunity. The modular training steps include port placement and docking, bladder take down and dissection of peri-prostatic fat, division of endopelvic fascia and ligation of DVC, division of anterior and posterior bladder neck, dissection of SV and vasa, development of posterior plane, division of the prostatic pedicles, apical dissection and division of urethra, formation of anastomosis with placement of posterior reconstruction or Rocco suture, and finally neurovascular bundle sparing.

Results

The trainee completed the modular training within 54 cases over a 6 month period, and has completed 20 robotically assisted prostatectomies independently in the following 3 months. Median console operating time for those 20 cases was 159 minutes (100–223 mins). This compares with a median operating time of 240 minutes (180–480 mins) for the consultant trainers who underwent a mentorship programme for complete robotic assisted laparoscopic prostatectomy.

Conclusions

In providing a training robotic fellowship in a busy tertiary referral unit, the use of the modular training scheme has shown benefit, by reducing the impact upon service provision and by reducing wasted console time. In addition the time taken to complete the first 20 complete cases is significantly reduced, when compared with the trainer's initial cases.

25722 Salvaging prostate cancer after radiation failure

  1. Top of page

David Gillatt

Bristol Urological Institute, Southmead Hospital, Australia

Introduction

Biochemical and biopsy proven recurrence after “curative” treatment for localised prostate cancer is difficult to manage because of uncertainties over natural history and the high perceived morbidity of salvage therapies

Method

The Bristol protocol for assessing recurrence and progression risk for biochemical recurrence post radiation includes; PSA velocity, template biopsy of the prostate, CT, isotope bone scan and MRI.

Proven and likely localised recurrence has been managed with a variety of localised therapies including cryo, HIFU, open and robotic surgery.

Results

43 men were treated with 45 cryo therapies, 13 with HIFU (sonoblate) and 40 surgically (16 robotically).

The largest number of complications were found in the cryo group with 2 fistulae, one ureteric obstruction and 16 % incontinence. The HIFU group suffered from persistent urinary symptoms and sloughing. The lowest complication rate was in the robotic surgery group with 90 % wearing one pad or less by 6 months and one bladder neck stenosis.

Summary

The most appropriate management of curable radiorecurrent prostate cancer is unclear. Robotic surgery offers a low morbidity approach. Focal therapy may have a role in this space. Clinical trials are urgently required.

25726 End of life care for prostate cancer

  1. Top of page

David Gillatt1, Luke Hounsome2 and Julia Verne2

1Bristol Urological Institute, Southmead Hospital, United Kingdom

2South West Public Health Observatory, United Kingdom

Introduction

In the United Kingdom despite vast improvements in outcomes for prostate cancer sufferers more than 10,000 men still die each year from the disease.

Prior to death many suffer from the consequences of local and distant progression, including urinary retention, bleeding, ureteric obstruction and pain.

Method

The NHS database for England and the Cancer registry were interrogated to investigate the impact of a cancer death on the publice health system.

Episodes in hospital and mean number of days in the year before death from cancer were calculated for prostate, bladder, lung and breast cancer.

A cost analysis was performed.

Results

Prostate cancer patients in the year before death spend almost 50% more time in hospital (29.4 days mean) than those dying of breast or lung cancer (20–21.4 days). Other pelvic cancers similarly spend a disproportionate amount of time as in patients at the end of life.

The reasons for this are not entirely clear but appear related to increased need for management of lower urinary tract problems and obstructive uropathy.

Prostate cancer for the secondary care service is more costly to manage than many other common malignancies in the year before death from that disease.

Conclusion

New pathways for palliating prostate cancer may be needed to help deliver care nearer home and avoid admission to an acute surgical bed

25734 Emergency admissions for prostate cancer in the United Kingdom

  1. Top of page

David Gillatt1, Luke Hounsome2 and Julia Verne2

1Bristol Urological Institute, Southmead Hospital, United Kingdom

2South West Public Health Observatory, United Kingdom

Introduction

Emergency admissions are unpredictable and in many cases preventable. A cancer admission as an emergency may result in a higher chance of late presentation, increased morbidity and a higher risk of death

Method

The NHS Hospital Episode Statistics and National Cancer data sets were combined to investigate emergency prostate cancer admissions for a three year period

Results

Of 197,176 admissions related to prostate cancer 58,739 (29.8%) were as an emergency. This was the highest percentage of any Urological cancer.

Predictors for emergency presentation were increasing age (>70 years), and income deprivation.

The first presentation of the disease was as an emergency in 7.5%, however in numeric terms prostate cancer was the largest group to be diagnosed during an emergency presentation.

There is a longer stay in hospital for emergency versus non emergency admissions for prostate cancer (difference 8.8 days)

Summary

The number of emergency admissions for prostate cancer may reflect the inadequacy of community support for this group

The 7.5% still presenting without a diagnosis is of concern

Older men and those in lower income groups should be targeted to allow them easier and more rapid access to prostate cancer services

25742 The Bristol robotic prostatectomy programme

  1. Top of page

David Gillatt

Bristol Urological Institute, Southmead Hospital, United Kingdom

Introduction

Between 1993 and 2008 1500 open radical prostatectomies were performed by 2 surgeons, From 2008, >1000 robotically assisted prostatectomies have been performed by a surgical team on the Da Vinci system

Method

  1. A comparison of the morbidity/mortality of open versus robotic surgery
  2. Length of stay comparison
  3. Cost analysis in a public health system
  4. An analysis of training embedded within a public health system

Results

  1. There was no mortality in either group. Transfusion rates fell in the open group from >20% in early groups to 1%. Transfusion rates for latter open and robotics are similar. Rectal injury/fistula occurred in 3 open and 5 robotic cases. Bladder neck stenosis 4% overall in open, 0.2% in robotic. Continence rates thus far are similar but with more rapid recovery in the robotic group.
  2. Length of stay: 6.7 days early open, 3.2 days later open 1.4 days robotic.
  3. In the tariff based NHS a robotic service will break even only if sufficient volume of cases are performed to spread the capital and service costs – a cost analysis of our business case reveals a surpluss once 200 cases per year are performed
  4. Training: can be delivered successfully to senior feloows and colleagues trained in house when volume is delivered

Summary

A high volume robotic prostatectomy public service can be cost effective, delivered with improvements in quality and make savings

25762 TRUS biopsy in the superbug era.Prevalence and predictors of ESBL carriage in an Australian tertiary hospital

  1. Top of page

Briony Norris, Tony DeSousa, Briony Norris, Paul Anderson and James Huang

The Royal Melbourne Hospital, Australia

Objectives

Emerging antibiotic resistance places patients undergoing transrectal biopsy of the prostate (TRUSBx) at risk of severe sepsis. Our aim was to determine the prevalence of ESBL (Extended spectrum β-lactamase) carriage in patients undergoing TRUSBx in an Australian cohort. Our secondary objective was to establish risk factors that may predict ESBL carriage, to enable judicious use of broad-spectrum prophylaxis for high-risk patients.

Methods

All patients undergoing TRUSBx at The Royal Melbourne Hospital from September 2012 to April 2013 were included in this prospective study. A targeted questionnaire was used to establish risk factors for ESBL carriage pre-procedure. In concordance with current Australian antibiotic guidelines, a single dose of 500 mg oral Ciprofloxacin was given one hour prior to TRUSBx. A pre-biopsy rectal swab was performed and results correlated to questionnaire results. Post biopsy complications were documented upon review in clinic. We are reporting on our first 53 patients.

Results

Of 53 patients enrolled, we found a 3.73% incidence (n = 2) of ESBL carriage. One of these patients had an identifiable risk factor. Infectious complications were observed in 3.73% of the population however none of these patients grew an ESBL organism on the pre-biopsy swab.

Conclusion

This is the first Australian series to determine the rate of ESBL carriage amongst TRUSBx patients. The incidence of ESBL carriage in this cohort is lower than that reported in overseas series. Further patients will be recruited to determine if a questionnaire can aid in risk stratification for ESBL carriage, to allow targeted use of broad-spectrum prophylaxis.

25774 Are transrectal prostate biopsies routinely indicated in patients with incidentally diagnosed prostate cancer following TURP for benign disease

  1. Top of page

Briony Norris1, Matthew Hong2, Lui Shiong Lee3, Suntharasivam Thiruneelakandasivam3, Matthew K Hong2, Justin S Peters2, Anne Warren4, Rob Mills5, David Greenberg6, Karen Wright6 and Vincent Gnanapragasam7

1The Royal Melbourne Hospital, Australia

2Department of Surgery, The University of Melbourne, The Royal Melbourne Hospital, Australia

3Department of Urology, Addenbrookes Hospital, United Kingdom

4Department of Pathology, Addenbrookes Hospital, United Kingdom

5Department of Urology, Norfolk and Norwich University Hospital, United Kingdom

6Eastern Cancer Registration and Information Centre

7Department of Oncology, Hutchison/MRC Centre, The University of Cambridge, United Kingdom

Objective

To determine the indication of routine trans-rectal ultrasound guided biopsy of the prostate gland (TRUSBx), following incidental cancer diagnosis after trans-urethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH).

Materials and Methods

A multi-institutional search from prospectively maintained cancer registries in the UK and Australia from 2001 to 2010 identified 63 patients with incidental TURP diagnosed prostate cancer, who underwent subsequent TRUSBx or radical prostatectomy (RP). The Gleason scores from TURP were compared to those from TRUSBx or RP. Whole mount maps from RP were analysed to provide an anatomical basis for the correlation observed.

Results

Of the 63 patients identified, 22 underwent a TRUSBx. The rates of Gleason score concordance, upgrading and downgrading were 32%, 14% and 54% respectively (Spearman correlation coefficient 0.20). In 86% of TRUSBx patients, the procedure did not give additional Gleason score information. For patients who underwent RP (n = 41), the respective rates were 61%, 22% and 17% (Spearman correlation coefficient 0.15). Of 13 whole mount maps analysed, n = 6 (46%) were found with anterior/transitional zone (AZ/TZ) tumours, n = 6 (46%) with multifocal tumours, and n = 1 (8%) with a large peripheral zone (PZ) tumour extending into the TZ.

Conclusion

TURP diagnosed prostate cancers represent predominantly anterior zone tumours. A TRUSBx does not give additional Gleason score information in a majority of cases, and therefore, is not routinely indicated. It may be selectively useful prior to active surveillance, but not in all pursuing radical treatment. These findings may help reduce unnecessary TRUSBx in the population.

25778 Transperineal template biopsy of the prostate: a review of the impact at Alfred Health

  1. Top of page

Sean Huang, Fairleigh Reeves, Jessica Preece and Jeremy Grummet

Alfred Health, Australia

Introduction

TRUS biopsies are associated with high false-negatives, sepsis and other complications.

The Transperineal Biopsy (TPB), with a template grid, provides systematic sampling of the entire prostate. Reported sepsis rates of TPB are negligible.

Objective

To review the impact of TPB at our institution by assessing rates of cancer detection/grading, treatment outcomes and complications.

Method

A retrospective review of TPBs between 2009 and 2013 was performed. Variables included reason for TPB, age, PSA, previous histology, TPB histology, and management outcomes.

Results

110 patients underwent 111 TPBs at our institution. On average, 22 cores were taken from each procedure.

Disease upgrade occurred in 37.5% of active surveillance patients, 35% of patients with previous-negative TRUS, and 58.8% in patients undergoing TPB for other reasons. Of these patients, anterior and/or transition zones were involved in 66%, 79% and 80%, respectively. Involvement in anterior and/or transition zones only occurred in 40%, 37% and 10%, respectively.

77% of patients with disease-upgrading underwent treatment with curative intent.

Complications included a 6.3% rate of acute urinary retention and 2.7% of clot retention, with no episodes of urosepsis.

Conclusions

TPB at The Alfred showed a high rate of disease-upgrading, with a large proportion involving anterior and transition zones. A significant amount of patients went on to receive curative treatment.

After our analysis, patients at our institution are now prescribed perioperative Tamsulosin.

TPB is a valuable diagnostic procedure with minimal risk of developing urosepsis. We believe TBP should be offered as an option for all repeat prostate biopsies.

25786 Multiparametric MRI in prostate cancer: a retrospective comparative analysis of mpMRI with histopathological outcomes following radical prostatectomy

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Helen Nicholson1, Hodo Haxhimolla2 and Rohit Tamhane3

1Calvary Hospital, Australia

2National Capital Private Hospital, Australia

3Canberra Imaging Group, Australia

Objectives

The use of multiparametric Magnetic Resonance Imaging (mpMRI) in the detection of prostate cancer is a rapidly expanding trend as an adjunct to prostate biopsy. However, there is little information available on the ability of mpMRI to predict prognostic prostate cancer outcomes and if this translates clinically to an improvement in clear surgical margins.

Method

A single surgeon series of 143 men, aged 45–80 years (mean 63.6 years) with biopsy proven prostate cancer underwent mpMRI (Siemens 1.5 Tesla with endorectal coil) including spectroscopy, T2 and diffusion weighted imaging sequences prior to open radical prostatectomy. Histopathological outcomes were compared with preoperative mpMRI findings.

Results

Of 143 men, mean age 64 years (range 45–80 years), mean PSA 7.4 ng/mL (1.9–32) with Gleason grade 6 (24%), 7 (65%) and 8 or 9 (11%) prostate cancer, mpMRI had a sensitivity for the sentinel lesion of 95% and a positive predictive value of 79%. For Gleason 8 and 9 prostate cancer, sentinel lesion sensitivity was 100%, although mpMRI underestimated extent in 69% and bilaterality in 56%. Sensitivity and specificity respectively of secondary parameters included capsular invasion (2%, 93%), extracapsular extension (66%, 78%), seminal vesicle invasion (25%, 98%) and lymphovascular invasion (31%, 93%). Overall positive margin rates were 18% (13% T2, 36% T3). 

Conclusion

Early results are promising for the use of mpMRI as a planning tool prior to radical prostatectomy, particularly in high risk prostate cancer. As this technology continues to evolve, it may indeed have the potential to alter prostate cancer outcomes.

25798 Sepsis and superbugs: should transperineal biopsy be offered to all prospective prostate biopsy patients?

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Jeremy Grummet1, Mahesha Weerakoon2, Sean Huang1, Nathan Lawrentschuk3, Mark Frydenberg3, Daniel Moon4, Mary O'Reilly5 and Declan Murphy2

1Alfred Health, Australia

2Peter MacCallum Cancer Institute, Australia

3Epworth Healthcare, Australia

4Epworth Healthcare, Australia

5Eastern Health, Australia

Objective

There is growing interest in transperineal biopsy as an alternative to TRUS biopsy for patients undergoing repeat prostate biopsy. We sought to determine the rate of hospital re-admission for sepsis following transperineal prostate biopsy using both local data and worldwide literature.

Methods

Pooled databases on transperineal biopsy from multiple centres in Melbourne were queried for rates of re-admission for infection. A literature review of Pubmed and Embase was also conducted using the search terms “prostate biopsy, fever, infection, sepsis, and septicaemia”.

Results

A total of 245 transperineal biopsies were performed (111 at the Alfred Hospital, 78 at Epworth Richmond, 38 at Peter MacCallum Cancer Institute, 14 at Epworth Freemasons and 4 at other institutions). The rate of hospital re-admission for infection was zero.

The literature review showed that the rate of sepsis following transrectal ultrasound-guided (TRUS) biopsy appears to be rising with increasing rates of multi-resistant bacteria found in rectal flora, and is as high as 5%. Various techniques attempting to combat this were also reported with variable success. The rate of sepsis from reported series of transperineal biopsy, however, approached zero.

Conclusions

Both local and international data suggest a negligible rate of sepsis with transperineal biopsy. This compares to a concerning rise in the rate of sepsis following TRUS biopsy due to the increasing prevalence of multi-resistant bacteria in rectal flora. Although TRUS biopsy is convenient, cheap and quick to perform, we believe that transperineal biopsy should now be offered as an option, not only to patients undergoing repeat prostate biopsy, but to all patients in whom a prostate biopsy is indicated.

25802 TRUS biopsy sepsis and use of carbapenem antibiotics at a single high volume local institution

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Olivia Leahy1, Dr Mary O'Reilly2, Dr David Phillips2 and Mr Jeremy Grummet2

1Alfred Health, Australia

2Cabrini Health, Australia

Objective

TRUS biopsy sepsis can cause serious morbidity and even mortality. There is concern over literature reports of rising rates of TRUS biopsy sepsis and multi-resistant bacteria in rectal flora. We sought to determine the number of hospital admissions for sepsis following TRUS biopsy and the rate of both prophylactic and therapeutic use of carbapenem antibiotics over the last 4 years in a single institution.

Methods

The Cabrini Health Medical Records Department computer database was queried for coding of admissions under any Cabrini urologist for sepsis and prostate-related infections over 4 years from 2009 to 2012. Treating urologists and patients were de-identified. These records were then examined for whether a TRUS biopsy had been performed within 14 days prior. The rate of carbapenem use for treatment was also assessed. Over the same time period, the database was also queried for patients undergoing TRUS biopsy at Cabrini Health and matched to orders for the supply of a carbapenem for use as prophylaxis.

Results

Over the 4 years studied, there were 63 admissions for TRUS biopsy sepsis at Cabrini Health. Twenty-three admissions were of the 1,937 patients who had TRUS biopsies performed at Cabrini (rate of 1.2%) and 40 were following TRUS biopsies at other centres. Thirty-seven (58.7%) of these patients received intravenous carbapenem as part of their sepsis treatment. None of the Cabrini TRUS biopsy patients had received a carbapenem as prophylaxis. Of the 1,937 Cabrini TRUS biopsy patients, 154 (8%) were given a carbapenem as prophylaxis, with rapid increase in use over the 4 years studied (1, 21, 59, and 73).

Conclusions

This study did not show evidence of an increasing rate of TRUS biopsy sepsis at this institution. However, most patients received a carbapenem as sepsis treatment and there was a dramatic uptake in the use of carbapenems for prophylaxis over the study period. This highlights urologists’ concern over increasingly prevalent multi-resistant bacteria in rectal flora. The study also highlights the difficulty in measuring the true rate of TRUS biopsy sepsis, as these patients more often underwent their biopsy at a different institution.

25818 Descriptive epidemiology of prostate cancer in Morocco

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Hinde Hami1, Abdelhafid Ayoujil1, Faouzi Habib2, Abdelmajid Soulaymani1, Abdelrhani Mokhtari1 and Ali Quyou2

1Laboratory of Genetics and Biometry, Faculty of Sciences, Ibn Tofail University, Morocco

2Al Azhar Oncology Center, Rabat, Morocco

Objective

Prostate cancer is one of the most common types of cancer in men. It is the fifth most common cancer and the sixth leading cause of cancer death among men in Northern Africa, with an estimated 5180 new cancer cases and 4001 deaths from cancer in 2008, the most recent year for which international estimates are available (GLOBOCAN 2008). The aim of this study is to determine the frequency and the epidemiological characteristics of prostate cancer in Morocco.

Methods

This is a retrospective analysis of prostate cancer cases, diagnosed and treated at Al Azhar Oncology Center in Rabat between 1994 and 2004.

Results

There were 377 new cases diagnosed with prostate cancer at Al Azhar Oncology Center, accounting for 12.1% of all new cases of cancer in men reported during the study period. The average age at diagnosis was 66 ± 9 years. Risk of developing prostate cancer is associated with advancing age, 93% of cases were diagnosed in men aged 55 years and older, with 86% of new cancer cases occurring among those aged 55–79 years. Among all detected cases, 9.5% were diagnosed with metastatic disease and 13.5% died during the study period.

Conclusions

Prostate cancer was the leading cause of death from cancer in men. Early detection in order to improve prostate cancer outcome and survival remains the cornerstone of prostate cancer control.

25894 Nocturnal versus daytime pad free continence following robot assisted radical prostatectomy (RARP) and implications

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Thomas Ahlering, Thanh Van, Blanca Morales, Ha Lan Tran and Douglas Skarecky

The University of California, United States

Introduction

Unlike nocturia, the nocturnal urge to urinate, nighttime urinary incontinence (NC) may reflect a relevant physiologic significance following RARP. This is the first review to analyze (NC) after RARP.

Methods

We queried 222 men undergoing RARP performed by one surgeon (TA), 81.1% (180) responded to self-reported questionnaires assessing time to day (DC) and night pad free continence. A subgroup of men were given medium sized urinary pads and asked to separate them into day and night plastic bags at day 7 after catheter removal, and return them via overnight shipping. A subgroup of 20 men with prior TURP or bladder neck reconstructions were analyzed.

Results

Group 1 had no history of bladder neck trauma, n = 160, and Group 2 had prior TURP/BNR n = 20. NC is achieved much quicker than daytime, median time to NC was 7 days versus 42 day for DC. In the subgroup of 42 men returning pads, the median number of pads used and pad weight was 1.0 and 3.7 grams for nocturnal versus 2.5 pads and 19 grams per daytime (p < 0.01). Men with prior TURP/BNR has similar times to NC as non-reconstructed BN men.

Conclusions

This study demonstrates that NC is achieved much faster than DC, and not impacted by a history of prior TURP or BN repair. In contrast to intestinal neobladders where NC is very much delayed and incomplete, NC following RARP suggests a role of an autonomically intact BN controlling NC.

30590 Robotic radical prostatectomy in the Victorian public sector: initial experience of 200cases at an academic teaching centre

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Marnique Basto, Adam Landau, Emma Birch, Jeremy Goad and Daniel Moon

Declan Murphy, Peter MacCallum Cancer Centre, Australia

Objectives

Robotic-assisted radical prostatectomy (RARP) accounts for the majority of radical prostatectomies in the private sector in Victoria. RARP was introduced to the public sector in Victoria in July 2010 with the installation of a 4-arm da Vinci S HD surgical system at Peter MacCallum Cancer Centre. Herein we describe our initial experience of RARP.

Methods

A prospective database was maintained of all patients undergoing RARP under the care of 3 surgeons at Peter MacCallum Cancer Centre from 14 July 2010 to 2 April 2013. We present demographics, staging, peri-operative, and pathological outcomes.

Results

Mean age was 60.9 years (42–76) of which the majority (54.5%) were D'Amico intermediate risk. Mean operative time was 225.7 mins with the mean and median length of stay being 1.37 and 1 days respectively. Overall 82.4% of patients were discharged by day 1 and 94% by day 2. There were no transfusions or conversions to open.

By pathological stage positive surgical margin rates are pT2 10.8%, pT3 49.3%, pT4 0%. Minor complications (Clavien I–II) are 18.5% with major complications (III–IV) at 4% with no clavien V. There were 12 delayed complications >90 days including need for cystoscopy +/- dilatation (5), optical urethrotomy, (1) AUS sling insertion (2), incisional hernia repair (4).

Conclusion

Our experience of RARP in the Victorian public sector with significant trainee involvement is encouraging. Significantly length of stay, estimated blood loss and overall morbidity are low. Results compare favourably with contemporary non-robotic radical prostatectomy performed within the public sector in Victoria.

30642 Be prepared for active surveillance. What should the patient and I expect? A review of 2 year radical prostatectomy specimen in a local hospital in Hong Kong

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Marco Chan, Cheong Yu, Cheung Hing Cheng and Peggy Sau Kwan Chu

Chi Wai Man, Tuen Mun Hospital, Hong Kong

Background and Aim

Active Surveillance (AS) is an emerging option for patient with low risk prostate cancer. Recent study showed that among the 5 sets of AS protocols, the criteria of Prostate Cancer Research International: Active Surveillance (PRIAS) has the best balance between sensitivity and specificity for insignificant cancer.1 This study aims to review if the overseas experience on AS is applicable to Hong Kong before a prospective AS series could be implemented.

Method

The preoperative PSA, clinical staging, biopsy result and the prostatectomy specimen of all patients who underwent radical prostatectomy from Jan 2009 to Dec 2010 were reviewed retrospectively (n = 64). The prostatectomy specimen pathology were analyzed for those who fitted the entry criteria of PRIAS (n = 12). Organ-confined disease (OCD) is defined as ≤ pT2c. Indolent disease (ID) is defined as OCD plus Gleason Score ≤ 6 and tumor volume < 0.5 cm3. Pre-biopsy PSA, PSA velocity, PSA density, biopsy Gleason score, the percentage of positive biopsy core and the maximum percentage of cancer per core will be tested for their association with ID.

Result

Among the 64 radical prostatectomy specimen, 56 (87.5%) is pathological T2, 8 (12.5%) is T3. The overall under-grading by the biopsy Gleason Score was 33.3%. The preoperative characterics of 12 patients (18.8%) fitted the PRIAS entry criteria. All of them had the maximum biopsy core involvement <50% despite this was not required by the PRIAS. All of them had OCD, while 66.7% had ID. Only the maximum percentage of cancer per core was associated with a radical prostatectomy specimen of ID (t-test, p < 0.05).

Conclusion

The preoperative biopsy under-grading rate of our centre is comparable to the published data. One eighth of our patient is habouring ID, for which active surveillance is a good option to avoid a radical prostatectomy. For those patients fitted into the PRIAS criteria, they should understand that there will be a one third chance that the cancer is not indolent in the longterm while they can have a very good chance of cure with 100% OCD at the time of counseling, and this chance is comparable to the published overseas series. Although the PRIAS criteria do not require the maximum percentage of cancer per core, it remains an important information for patient counseling.

Reference

1)  Pathologic Prostate Cancer Characteristics in Patients Eligible for Active Surveillance: A Head-to Head Comparison of Contemporary Protocols Eur Uro 62 (2012) 462468

32182 Early return of continence using a novel tool for identification of the perineal branch of pudendal nerve during da vinci® prostatectomy

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Naveen Kella, MD1 and Randy Fagin, MD2

1The Urology and Prostate Institute, United States of America

2Texas Institute for Robotic Surgery, United States of America

Objectives

Intra-operative identification of nerve tissue using equipment that stimulates and records Evoked Electromyography (Evoked EMG) is standard of care in brain, spine, and facial surgery. It has not, to date however, been used in minimally invasive pelvic surgery because equipment currently available is not suitable and approved for use in laparoscopic procedures. The author used a new FDA approved technology developed by ProPep SurgicalTM called the ProPep Nerve Monitoring SystemTM in an effort to demonstrate an accurate, easy, and efficient means to identify the perineal branch of the pudendal nerve (PBPN) during daVinci® prostatectomy (dVP) and evaluate early return of continence.

Methods

The ProPep Nerve Monitoring System was used to identify the PBPN in real time during dVP. A low level electric current (0.5–10 milliamps) similar to that used for Nerve Identification in other surgical specialties was applied to the tissues during prostate dissection to identify the exact location of the nerve, and following completion of dissection to assess preservation of nerve integrity. Expanded Prostate Cancer Index Composite (EPIC) scores were collected prospectively and the combined score of questions 4–8 (referring to urinary recovery and bother) were correlated to the latency of the intraoperative Evoked EMG waveforms that were recorded following removal of the prostate.

Results

The ProPep Nerve Monitoring System reliably identified the otherwise invisible PBPN with an Evoked EMG waveform in 100% of the cases. This waveform correlated to known compound motor action potentials elicited from other motor nerves. At 8 weeks post-dVP only patients with a post-dissection recorded latency of 11.5 or less reported an EPIC score of 2 or less.

Conclusions

The use of the ProPep Nerve Monitoring System during dVP allowed for accurate, easy, and efficient identification of the otherwise invisible PBPN in 100% of cases. In addition, only patients whose post-dissection waveform latency was less than 11.5 were wearing 1 pad per day or less with minimal urinary bother at 8 weeks post surgery. It is the authors’ belief that use of this equipment provides real-time information that surgeons can use to avoid inadvertent injury to this important nerve during dVP and may predict early urinary control recovery.

32186 Variability in nerve location during da vinci® prostatectomy

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Ron Kuhn, MD1 and Randy Fagin, MD2

1Arkansas Urology, United States of America

2Texas Institute for Robotic Surgery, United States of America

Objectives

Preservation of nerves during daVinci prostatectomy (dVP) has been shown to be critical to preservation of urinary function. Surgeon perception, however, has been shown to be a poor predictor of nerve location during da Vinci prostatectomy (dVP). Despite this evidence, there are varying opinions on the ability for surgeons to use anatomic landmarks to accurately identify these nerves during dVP. Intra-operative identification of nerve tissue using equipment that stimulates and records Evoked Electromyography (Evoked EMG) is standard of care in brain, spine, and facial surgery and is now available for use during dVP with the recent FDA approval of the ProPep Nerve Monitoring SystemTM developed by ProPep SurgicalTM. The ProPep Nerve Monitoring SystemTM was used by a single surgeon on a series of consecutive patients undergoing dVP to document nerve location and quantify the amount of variability.

Methods

The ProPep Nerve Monitoring System was used to identify the superficial portion of the perineal branch of the pudendal nerve (PBPN) in real time during dVP. The PBPN has been shown to innervate the levator and pelvic floor muscles and to be a critical nerve in the maintenance of urinary continence. A low level electric current (0.5–10 milliamps) similar to that used for Nerve Identification in other surgical specialties was applied to the tissues during prostate dissection and the resulting waveforms allowed the surgeon to identify the exact location of the PBPN. The surgeon documented the location of the nerve relative to the prostate using a clock-face reference on both the right and left sides. The surgeon also documented the distance of the nerve from the prostate on both the right and left sides. Data was collected prospectively.

Results

The ProPep Nerve Monitoring System reliably identified the otherwise invisible PBPN with an Evoked EMG waveform in 100% of the patients. Using a clock-face reference with 12 o'clock being located at the most anterior aspect of the prostate, and 6 o'clock at the most posterior aspect the nerve on the left side was located at 7:30 50% of the time, 8:00 25% of the time, 7:00 13% of the time, and 6:30 12% of the time. On the right side, the nerve was located at 4:30 50% of the time, 4:00 25% of the time, 5:00 13% of the time, and 5:30 12% of the time. Distance of the nerve from the prostate also varied with the nerve being located 3 mm from the prostate 45% of the time, 2 mm from the prostate 18% of the time, 4 mm from the prostate 18% of the time, 8 mm from the prostate 9.5% of the time, and 1 mm from the prostate 9.5% of the time.

Conclusions

The use of the ProPep Nerve Monitoring System during dVP identified the otherwise invisible PBPN which innervates the pelvic floor in 100% of the cases. Both the nerve location relative to the prostate as well as the nerve distance from the prostate varied from case to case with the most common location occurring only 50% of the time. Given the importance of nerve preservation for urinary control recovery, the documented inability for surgeon perception to predict nerve location, and the documented variability of nerve location from case to case, the use of the ProPep Nerve Monitoring SystemTM is an effective tool for improving the accuracy of nerve identification and could improve the preservation of these nerves and the clinical outcomes achieved by patients.