Faculty Bibliography

PURPOSE/OBJECTIVE:We aim to evaluate the current beliefs and practice patterns of urologists in regard to use of cryosurgery for management of PCa. METHODS:An anonymous 13-point survey was designed and sent out to members of the Society of Urologic Oncology (SUO), Endourological Society (ES) and American College of Cryosurgery (ACC). Descriptive statistics and univariate analyses were used to determine variables associated with the use of cryosurgery. RESULTS:Of the 206 responses received [81 (39.2 %) SUO; 106 (51.5 %) ES; 19 (9.2 %) ACC], 83 (40.3 %) performed cryosurgery. The majority of respondents who utilize cryosurgery do so in unilateral (80.3 %) and bilateral (77.6 %) intermediate-risk PCa. Also, users of this technology indicated significant use in primary treatment (>72 %), salvage treatment (>83 %), in patients who prefer cryosurgery (89.9 %) have a life expectancy ≥10 years (65.8 %) and poor erections (74.7 %). The main reason for not utilizing cryosurgery was the lack of technical expertise (56.7 %). A urologist in a non-academic practice setting was 3.2 times more likely to perform cryosurgery compared to a urologist in an academic setting, p = 0.0001. CONCLUSION/CONCLUSIONS:Cryosurgery is increasingly being accepted among urologists. However, the need for large-scale studies as well as randomized clinical trials to further delineate the benefits of cryosurgery and convince the non-users and institutions cannot be overemphasized.

INTRODUCTION:Salvage treatment options for recurrent unilateral prostate cancer (PCa) after primary radiation are limited and associated with severe complications and poor quality of life measures. Salvage focal cryotherapy (SFC) has shown success in biochemical recurrence (BCR) free survival. We aim to determine if SFC can delay use of androgen deprivation therapy (ADT) in recurrent PCa with low morbidity. METHODS:A retrospective review of patients who underwent SFC at our institution from 2007 to 2015 was performed. Patients with <2 follow-up prostate-specific antigen (PSA) values, metastatic disease, and a history of radical prostatectomy were excluded. Age at treatment, prior treatment history, PSA nadir, complications, BCR status (nadir +2 ng/ml), and follow-up data were obtained/analysed. ADT was commenced if patient experienced BCR and had a PSA doubling time <6 months or positive confirmatory biopsy or positive imaging. Cox regression and survival analysis were used to assess confounding and time to BCR respectively. RESULTS:A total of 65 patients were included and followed for a median of 26.6 (8.0-99.0) months. Thirty-one (47.7%) patients did not experience BCR. An even higher number of patients (52/65, 80.0%) are yet to receive ADT. Of those who experienced BCR [median time to BCR, 17.1 [interquartile range (IQR):11.4-23.3] months], 22/34 (64.7%) are currently carefully monitored without ADT. Survival analysis showed a biochemical recurrence-free survival of 48.1 at 1- and 3-year follow up. No patient died/experienced major complications. CONCLUSIONS:SFC may be used to delay the use of ADT. Further assessment of our findings with high-powered studies and longer follow-up is required.

BACKGROUND:The Phoenix definition (PD) and Stuttgart definition (SD) designed to determine biochemical recurrence (BCR) in patients with postradiotherapy and high-intensity focused ultrasound organ-confined prostate cancer are being applied to follow patients after cryosurgery. We sought to identify predictors of BCR using the PD and SD criteria in patients who underwent primary focal cryosurgery (PFC). MATERIALS AND METHODS:We performed a retrospective review of patients who underwent PFC (hemiablation) at 2 referral centers from 2000 to 2014. Patients were followed up with serial prostate-specific antigen (PSA). PSA levels, pre- and post-PFC biopsy, Gleason scores, number of positive cores, and BCR (PD = [PSA nadir+2ng/ml]; SD = [PSA nadir+1.2ng/ml]) were recorded. Patients who experienced BCR were biopsied, monitored carefully or treated at the discretion of the treating urologist. Cox regression and survival analyses were performed to assess time to BCR using PD and SD. RESULTS:A total of 163 patients were included with a median follow-up of 36.6 (interquartile range: 18.9-56.4) months. In all, 64 (39.5%) and 98 (60.5%) experienced BCR based on PD and SD, respectively. On multivariable Cox regression, the number of positive pre-PFC biopsy cores was an independent predictor of both PD (hazard ratio [HR] = 1.4, P = 0.001) and SD (HR = 1.3, P = 0.006) BCRs. Post-PFC PSA nadir was an independent predictor of BCR using the PD (HR = 2.2, P = 0.024) but not SD (HR = 1.4, P = 0.181). Survival analysis demonstrated a 3-year BCR-free survival rate of 56% and 36% for PD and SD, respectively. Of those biopsied after BCR, 14/26 (53.8%) using the PD and 18/35 (51.4%) using the SD were found to have residual/recurrent cancer. Of those with prostate cancer on post-PFC biopsy, 57.1% of those with BCR by the PD and 66.7% of those with BCR by the SD were found to have a Gleason score ≥7. CONCLUSION:Both the PD and the SD may be used to determine BCR in post-PFC patients. However, the ideal definition of BCR after PFC remains to be elucidated.