Prostate Ultrasound
                                                       Saturday, May 17, 2008
                        ...
Prostate Ultrasound
                                                            Saturday, May 17, 2008
                   ...
Meeting Disclaimer
Regarding materials and information received, written or otherwise, during the 2008 American Urological...
2008 AUA Annual Meeting


03 DL Prostate Ultrasound

5/17/2008                                                            ...
Principles of Transrectal Ultrasound
                                                              Normal and Abnormal Ana...
Reflection and Refraction                                           Principle of Image Generation

                       ...
3 mHz


                7 mHz

                                                                              8
           ...
The boundaries between different tissues in
                Transducer                 Image                 the body can ...
Monitor

 Many comparable urology specific devices are
 available
                                                        ...
Kidney, right long
Active Frequency                            Gain                   Frame
probe         Magnification   ...
G
                                             A
   RENAL CYST                                I
                          ...
*




      Essential elements                                   Medicare guidelines:
       •   Patient identification (N...
2006 Medicare Fees for Office
                      Summary                                                  US
          ...
transverse   Gleason 7
                                                       sagittal
                                   ...
Contour Changes in Prostate Cancer


                                                • Focal bulge
                       ...
Post-Prostatectomy




  • Smooth anastamosis
  • Post-op changes in
                                               transv...
EJ duct cyst ? Cause or result of obstruction




1213037
• Obstructed Right
  SV                        Ductal ectasia or dilatation may be
• Absent Left SV            related to ...
Ultrasound Findings of BPH




      • Increased inner gland: bi-lobed
      • Increased Doppler flow




Fleet or other e...
Rectal wall is a good absorptive surface
10cc of 2% lidocaine gel intrarectally instilled 10
min before the procedure has ...
Staging by TRUS is very unreliable and does                                                                               ...
Saturation Prostate Biopsies - Technique
         Why perform a saturation biopsy?
              Who is a Candidate?      ...
Patient preparation                         Preparation of the
                                              introducers
 ...
Patient Selection for I-125 Seed Implant
1.       Cancer Issues:
              • Disease confined to prostate
            ...
Identification of Urethra on TRUS with Foley catheter

 General/spinal anesthesia, patient supine.
 Needle guide template ...
Planning for permanent prostate
                                                                                          ...
Extended Core Biopsy Techniques
                                                                                      Why ...
Left lateral decubitus    Planning CT
position
Prostate imaged and
measured
3 mL of 1% lidocaine
injected bilaterally
3 ma...
Anterior                 Cube-cut
                                                                view                    ...
Prostate Brachytherapy using Transrectal Ultrasound




                                                                  ...
Prostate Post-Implant
       Analysis
                                                                                    ...
Cryotherapy – Tissue Injury                                The Cryoablation Procedure
Putative mechanisms include:        ...
Thermocouple and
                                                       ultrasound feedback is
                           ...
Focal Cryotherapy – Early Results                                                                  Efficacy of cryosurgery...
Focal Cryotherapy – Early Results                                                              Efficacy of cryosurgery in ...
Transrectal Prostate Ultrasound and Prostate Biopsy Report


Name________________________________ MR# _____________       ...
OFFICE OF EDUCATION
                                                  Improving Practice and Patient Care Through Affordab...
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Eco prostatica

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Eco prostatica

  1. 1. Prostate Ultrasound Saturday, May 17, 2008 10:30 a.m. – 1:30 p.m. COURSES 03 DL FACULTY Yair Lotan, M.D. Course Director Edouard J. Trabulsi, M.D. John F. Ward, M.D. American Urological Association Education and Research, Inc. 2008 Annual Meeting, Orlando, FL May 17-22, 2008 RE-ENTRY PASS Sponsored by: The American Urological Association Education and Research, Inc.
  2. 2. Prostate Ultrasound Saturday, May 17, 2008 10:30 a.m. – 1:30 p.m. COURSES 03 DL FACULTY Yair Lotan, M.D. Course Director Edouard J. Trabulsi, M.D. John F. Ward, M.D. American Urological Association Education and Research Inc. 2008 Annual Meeting, Orlando, FL May 17-22, 2008 Sponsored by: The American Urological Association Education and Research, Inc.
  3. 3. Meeting Disclaimer Regarding materials and information received, written or otherwise, during the 2008 American Urological Association Education and Research, Inc. Annual Meeting Instructional/Postgraduate MC/EC and Dry Lab Courses sponsored by the Office of Education: The scientific views, statements, and recommendations expressed in the written materials and during the meeting represent those of the authors and speakers and do not necessarily represent the views of the American Urological Association Education and Research, Inc.® Reproduction Permission Reproduction of all Instructional/Postgraduate, MC/EC and Dry Lab Courses is prohibited without written permission from individual authors and the American Urological Association Education and Research, Inc. These materials have been written and produced as a supplement to continuing medical education activities pursued during the Instructional/Postgraduate, MC/EC and Dry Lab Courses and are intended for use in that context only. Use of this material as an educational tool or singular resource/authority on the subject/s outside the context of the meeting is not intended. Accreditation The American Urological Association Education and Research, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) for physicians. The American Urological Association Education and Research, Inc. takes responsibility for the content, quality, and scientific integrity of the CME activity. CME Credit The American Urological Association Education and Research, Inc. designates each Instructional Course educational activity for a maximum of 1.5 AMA PRA Category 1 credits™; each Postgraduate Course for a maximum of 3.25 AMA PRA Category 1 credits™; each MC Course for a maximum of 1.0 AMA PRA Category 1 credits™; each EC Course for a maximum of 2.0 AMA PRA Category 1 credits™; each MC Plus Course for a maximum of 2.0 AMA PRA Category 1 credits™; and each Dry Lab Course for a maximum of 2.5 AMA PRA Category 1 credits™. Physicians should only claim credits commensurate with the extent of their participation in the activity. Disclosure Policy Statement As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Urological Association Education and Research, Inc., must insure balance, independence, objectivity and scientific rigor in all its sponsored activities. All faculty participating in an educational activity provided by the American Urological Association Education and Research, Inc. are required to disclose to the audience any relevant financial relationships with any commercial interest to the provider. The intent of this disclosure is not to prevent a faculty with relevant financial relationships from serving as faculty, but rather to provide members of the audience with information on which they can make their own judgments. The American Urological Association Education and Research, Inc. must resolve any conflicts of interest prior to the commencement of the educational activity. It remains for the audience to determine if the faculty’s relationships may influence the educational content with regard to exposition or conclusion. When unlabeled or unapproved uses are discussed, these are also indicated. Evidence-based Content As a provider of continuing medical education accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the American Urological Association Education and Research, Inc. to review and certify that the content contained in this CME activity is evidence-based, valid, fair and balanced, scientifically rigorous, and free of commercial bias.
  4. 4. 2008 AUA Annual Meeting 03 DL Prostate Ultrasound 5/17/2008 10:30 a.m.- 1:30 p.m. Disclosures According to the American Urological Association’s Disclosure Policy, speakers involved in continuing medical education activities are required to report all relevant financial relationships with any commercial interest to the provider by completing an AUA Disclosure Form. All information from this form is provided to meeting participants so that they may make their own judgments about a speaker’s presentation. Well in advance of the CME activity, all disclosure information is reviewed by a peer group for identification of conflicts of interest, which are resolved in a variety of ways. The American Urological Association does not view the existence of relevant financial relationships as necessarily implying bias, conflict of interest, or decreasing the value of the presentation. Each faculty member presenting lectures in the Annual Meeting Instructional or Postgraduate, MC or EC and Dry Lab Courses has submitted a copy of his or her Disclosure online to the AUA. These copies are on file in the AUA Office of Education. This course has been planned to be well balanced, objective, and scientifically rigorous. Information and opinions offered by the speakers represent their viewpoints. Conclusions drawn by the audience members should be derived from careful consideration of all available scientific information. The following faculty members(s) declare a relationship with the commercial interests as listed below, related directly or indirectly to this CME activity. Participants may form their own judgments about the presentations in light of full disclosure of the facts. Faculty Disclosure Yair Lotan, M.D. Course Director Nothing to disclose Edouard J. Trabulsi, M.D. Intuitive Surgical: Meeting Participant or Lecturer John F. Ward, M.D. Nothing to disclose Disclosure of Off-Label Uses The audience is advised that this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. Please consult the prescribing information for full disclosure of approved uses. Faculty and speakers are required to disclose unlabeled or unapproved use of drugs or devices before their presentation or discussion during this activity. A special AUA value for your patients: www.UrologyHealth.org is a joint AUA/AFUD patient education web site that provides accurate and unbiased information on urologic disease and conditions. It also provides information for patients and others wishing to locate urologists in their local areas. This site does not provide medical advice. The content and illustrations are for informational purposes only. This information is not intended to substitute for a consultation with a urologist. It is offered to educate the patient, and their families, in order for them to get the most out of office visits and consultations.
  5. 5. Principles of Transrectal Ultrasound Normal and Abnormal Anatomic Findings Yair Lotan, M.D. Louis L. Pisters, M.D. Edouard J. Assistant Professor Professor of Urology Trabulsi, M.D. Prostate Biopsy Techniques and Practical of Urology Assistant Points MD Anderson Cancer Center Houston, Professor of Practical Applications; The University of Urology Texas Fiducial Placement Texas Southwestern Medical Center at Thomas Brachytherapy Jefferson Cryotherapy Dallas University Ultrasound waves are mechanical waves The transducer has a dual function as a sender and receiver Like other mechanical waves, ultrasound waves need a Reflected mechanical sound waves are received by the medium to be transmitted transducer and converted back into electrical energy The most commonly used transducers range from 3.5 The electrical energy is converted into a picture on the MHz to 10 MHz depending on the application screen The scan head acts as receiver > 99% of the time Attenuation refers to the weakening of ultrasound Pulse duration or waves as they travel through the body pulse “ON” time Attenuation is due to the following interactions: reflection Listen time or Li t ti interference i t f pulse “OFF” time absorption (conversion to heat) TIME scattering divergence Total cycle time or pulse repetition period
  6. 6. Reflection and Refraction Principle of Image Generation Prostate Incident (transaxial view) wave Θi R Θr Reflected R M di Medium 1 wave R R R R Θ Transmitted t and refracted T Medium 2 wave Axial Resolution Axial resolution refers to the ability to Lateral resolution refers to identify (as separate) the ability to identify (as two objects in the separate) objects which are direction of the equidistant from the transducer but spaced apart traveling sound wave Lateral resolution is a function of the focused Depends on the width of the sound wave frequency of sound beam waves The more focused the beam, the better the lateral Higher frequency= resolution (i.e. even closely better axial resolution spaced objects can be differentiated) Most transducers have a: Transducer focal point (producing the Image best lateral resolution) focal range (producing Direction of scan Focal adequate resolution) Focal Range Point A narrow focal range limits the ability to image large Point Image of organs targets point targets Ultrasound beam
  7. 7. 3 mHz 7 mHz 8 10 mHz 6 4 2 0 2 4 6 8 10 12 14 16 Transducer Maximum Range in cm Reverberation 1 Edging artifact 2 Axial distortion (refraction artifact) 3 Propagation velocity artifact P i l i if 4 Image Transducer Refracted beam ....... .. Correct Image of location Target target of target Edging.avi
  8. 8. The boundaries between different tissues in Transducer Image the body can be seen because of impedance differences. the difference i i If th diff in impedance i l d is large, Low velocity significant amount of ultrasound energy will be reflected back and not through- transmitted (loss of energy and penetration) Distorted linear structure Linear Structure If the difference in impedance is very large, all Density Impedance ultrasound energy will be reflected, and no through-transmission will occur (shadowing Air & other gases 1.2 0.0004 behind the object with high or low impedance, Water & other clear liquids 1000 1.48 loss of any imaging capability) Avg of soft tissues 1060 1.63 Muscle 1080 1.70 In general, the relatively small difference in impedance between soft tissues allows tissue Liver 1060 1.64 differentiation Fat tissue 952 1.38 Bone & other calcified 1912 7.8 objects Description of Ultrasound Images The appearance of tissue in the body is a consequence of: the tissue composition the various mechanisms of attenuation h i h i f i the impedance difference between the target tissue and the surrounding tissues
  9. 9. Monitor Many comparable urology specific devices are available Keyboard End- or sidefire probes with 5 – 8.5 MHz Transducer Bay frequency q y Printer (Thermal) Higher frequency – better resolution Transducer Differences end- vs sidefire: Plugs Slightly different volume measurements Different aim of needle into prostate Mostly preference of physician No convincing evidence of different cancer yield Wheel for portability 1. Gain 2. Time-gain compensation “ To produce a good quality image.” 3. Frequency 4. Focal zone 5. Depth / size 6. Cine function Kidney, right long Labeled 1. Sufficient and uniform brightness Kidney - Adequate size 2. Sharp and in focus 3. Adequate size Uniform Appropriate focal zones tissue 4. Oriented and labeled for documentation echogenicity Orientation & identification
  10. 10. Kidney, right long Active Frequency Gain Frame probe Magnification Dynamic rate range TGC Curve Focal zones Depth of field (16 cm) Definition: A control mechanism for varying the Focal zones sensitivity of the transducer to out of position returning ultrasound waves. Side and site not labeled
  11. 11. G A RENAL CYST I N Excessive Gain Insufficient Gain Gain default with orientation change Definition: A control to allow variation in the size or depth of a displayed image. Physics: Physics: Appropriate depth depends on the purpose of the Selecting some portion of the available exam. data from an ultrasound examination for display. Decreasing depth may, in some cases, make interpretation of data more difficult.
  12. 12. * Essential elements Medicare guidelines: • Patient identification (Name/DOB) Technical quality of ultrasound exam must: • Date of procedure Be in keeping with accepted national standards • Indication for procedure Not typically require a follow-up test Be performed and interpreted by qualified individuals • Type of p yp procedure • Providers (ordering / performing) Medical necessity, images, findings, interpretation and report must be documented in the medical record • Equipment used* • Findings • Images Ultrasound examinations: Abdominal and retroperitoneal U-15A-R1 (contractor determination number U-15 (L18363) Trailblazer Health Enterprises) http://www.trailblazerhealth.com/lmrp.asp?ID=2270&Imrptype=parta Effective: 4/21/05 Disinfection of Probes Levels of disinfection • Separate report (Medicare guidelines) • Low level: non-critical items; will come in contact with • Patient Identification: Patient ID/DOB, ordering skin physician, performing provider, date • Intermediate: some critical items and non-critical items • High level: semicritical items; come into contact with • Indication for procedure mucous membrane or nonintact skin • Equipment used: Machine, probe used • Critical: will enter tissue or vascular system or blood will flow through them • Type of examination Consult manufacturer regarding specific • Description of findings / comparison with previous recommendations studies • Diagnosis / Impression • Signature of performing provider
  13. 13. 2006 Medicare Fees for Office Summary US Procedure CPT National Consistent technique TRUS 76872 Documentation of findings TRUS guidance 76942 $463.07 • Summary Prostate biopsy 55700 • Images Scrotal 76870 $90.44 $90 44 Patient safety and equipment maintenance RP complete 76770 $112.15 • Disinfection of probes Renal 76775 $83.21 Pelvic complete 76856 $92.97 Bladder 76857 $82.85 PVR 51798 $15.19 Note: Videotapes available from AUA Office of Education 4.4% from 2005 *Reference: http://auacodingtoday.com Base and apex Lateral gland margin Urethra Neurovascular Ejaculatory j y bundle ducts Symmetry Seminal vesicles Seminal vesicles Confirm a Biopsy lesion Biopsy TRANSVERSE VIEW LONGITUDINAL VIEW ZONAL ANATOMY AND CALCIFICATIONS ANATOMICAL LANDMARKS Bladder Transition Zone Transition Zone Urethra Peripheral Zone Calcifications Ejac. duct Verumontanum Sem. Ves. Peripheral Zone
  14. 14. transverse Gleason 7 sagittal left side Transverse bladder sagittal Ductal Ectasia vs. SV Cyst Mullerian Duct Cyst
  15. 15. Contour Changes in Prostate Cancer • Focal bulge – capsular bulge • Irregular margin – capsular invasion • Loss of periprostatic fat Sagittal midline Transverse AdenoCa in Left mid Gray Scale: echogenic cancer Transverse apex transverse Gleason 9 with sagittal Transverse Intraductal cancer capsular sagittal mid-gland Gleason pattern 3 invasion Transverse Sagittal
  16. 16. Post-Prostatectomy • Smooth anastamosis • Post-op changes in transverse sagittal bladder neck Post-radical prostatectomy Gleason 7 lesion, left mid-gland Gleason 7-9 diffusely Prostatitis Doppler of Prostate Cancer Gleason 7, Left base Gleason 6, Right base
  17. 17. EJ duct cyst ? Cause or result of obstruction 1213037
  18. 18. • Obstructed Right SV Ductal ectasia or dilatation may be • Absent Left SV related to ejaculatory duct obstruction • EJ ducts not found 3371043
  19. 19. Ultrasound Findings of BPH • Increased inner gland: bi-lobed • Increased Doppler flow Fleet or other enema is recommended (no or Randomized, placebo controlled studies have limited evidence) clearly demonstrated the efficacy and cost- Lateral decubitus position is preferred (to effectiveness of various schemes of antibiotic avoid interference from air bubbles rising to prophylaxis prior to TRUS guided biopsies top of water balloon etc) f b ll ) Antibiotic prophylasis should be part of the Antibiotic prophylaxis is recommended (strong state of the art of TRUS guided biopsy evidence) Periprostatic infiltration with 1 or 2% lidocaine is recommended for pain control and comfort management (strong evidence)
  20. 20. Rectal wall is a good absorptive surface 10cc of 2% lidocaine gel intrarectally instilled 10 min before the procedure has been shown to reduce pain and discomfort I Inferior hypogastric plexus at the tip of the seminal vesicles can be infiltrated with 10 ml of 1% aqueous lidocaine Use long spinal needle, pass through needle guide (A) Infiltration of plane between rectal wall and prostate, of TRUS probe, infiltrate under direct visual control demonstrating development of hydrodissection space into nerve bundles (shaded area). (B) Infiltration of nerve plexus of prostate adjacent to seminal vesicle. (C) Infiltration of apical region Wait 5-10 min for effect to take place, then proceed of prostate at genitourinary diaphragm with TRUS biopsies 5 5 20 25 Central Hyper Transition Iso Peripheral Hypo 70 75
  21. 21. Staging by TRUS is very unreliable and does Well / moderate not provide information useful for clinical decision making Poorly differentiated Similarly, staging by CT and MRI is too unreliable as a basis for clinical decision making Biopsies guided into the seminal vesicle may give information regarding their involvement The grade found by TRUS biopsy may or may not be representative for the cancer Author/ 2nd bx. 3rd bx. Source Population + / total % + / total % Keetch et al Screening J Urol 151: 1571, 94 Yearly f/u 88/427 19 16/203 8 Roehrborn et al Clinic 28/123 23 2/22 9 An increase in the number of cores leads in Urology 47: 347, 96 Ukiruma et al Select Clinic general to an increase in the cancer detection 17 rate 33/193 14/54 26 Urology 50: 66, 97 Select Fleshner et al Clinic 39/130 30 — — J Urol 158: 505, 97 Rietberger et al Select Screening/ For the same number of cores, strategies with a g J Urol 160: 2121, 98 EORTC 49/442 11 — — higher detection rate Letran et al Clinic J Urol 160: 426, 98 PSA 2-15 ng/ml 15/51 29 — — Use more laterally directed biopsies of the PZ Borboroglu et al J Urol 163:158. 00 Clinic Select 17/57 30 — — Emphasize base and apex more than mid-gland Djavan et al PSA 4-10 ng/ml 83/820 10 — — biopsies J Urol 163: 1144, 00 All had 2nd TRUS Gerard et al Clinic Use TZ biopsies in larger glands Urology 55: 553, 00 Select 1637/6380 25.7 — — Slawin et al Clinic J urol 165: 1554, 01 Select 27/111 24.3 — — Stewart et al Clinic J Uruol 166:86, 01 Select 77/224 34 — — Increasing Prostate Cancer Detection Rates with Extended Extended Core Biopsy Techniques Core Biopsy Protocols A. B. C. Study No. of Cores Cancer Detection Rate Eskew, 1997 6 23% 13 40% Naughton, 2000 6 26% 12 27% A1 Sextant, Hodge, S t t H d 10 C Core, Presti, 2000 P ti 12 C Core, (Double (D bl Presti, 2000 6 33% 1989 Sextant) 8 39% 10 40% D. E. Babaian, 2000 6 20% 11 30% De la Taille, 2003 6 22% x x 12 28% 18 30% x T2 biopsy 21 31% 13 Core, Eskew, 1997 11 Core, Babaian, 2001
  22. 22. Saturation Prostate Biopsies - Technique Why perform a saturation biopsy? Who is a Candidate? • Position • To diagnose cancer. •Dorsal lithotomy position (perineal) (patients with abnormal or rising PSA or worrisome DRE •Lateral (transrectal) who have already undergone one or more negative extended biopsies) • General anesthesia • To determine extent of cancer in patients with a positive • Grid (synchronize to TRUS image) extended biopsy. (patients considering observation or focal cryotherapy) • Biopsy at grid coordinates • To assess local control in patients treated with initial radiation or cryotherapy. • Pull back according to length of (patients with rising PSAs after radiation or cryotherapy) prostate and length of biopsy needle. (18 gauge needle / 18mm biopsy core) Cancer Detection on Repeat Biopsy Saturation Biopsies - Complications Sextant*† Saturation Biopsy‡§ • Bleeding 1 prior biopsy 10-17% 36% – Perineal pressure reduces risk of 2 prior bi i biopsies i 5-14% 5 14% 31% perineal bruising / hematoma – Hematuria 3+ prior biopsies 4-12% 14-36% – Hematospermia • Infection * Data adapted from Roehl et al (2002). † Data adapted from Djavan et al (2001a). ‡ Data adapted from Stewart et al (2001). • 2% risk § Data adapted from Fleshner and Klotz (2002). Saturation Biopsy - Conclusions Gold markers 1. SB’s can improve cancer detection in patients 99.95% ASTM B562-95 (1999) with a prior negative extended biopsy. Pre-cut 2. SB’s can be used to localize cancer and 5.0 x 1.1 mm determine cancer extent in patients Sterilized considering observation or local cryotherapy Packaged 3. SB’s are very useful in the evaluation of Sets of three patients with rising PSAs after initial radiation therapy or cryotherapy.
  23. 23. Patient preparation Preparation of the introducers Similar to that for prostate biopsy Three Bard 18 Gauge Prophylactic antibiotic by 20 cm long Cleansing enema brachytherapy seed Anticoagulation medications are held strand i l d implant needles Bone wax applied to the distal end Gold marker loaded using stylet Left lateral decubitus Planning CT position Prostate imaged and measured 3 mL of 1% lidocaine injected bilaterally 3 markers placed at the apex and left and right base Portal Images
  24. 24. Patient Selection for I-125 Seed Implant 1. Cancer Issues: • Disease confined to prostate • Stage: T1, T2A, early T2B • Grade: Gleason 2-6/10 • PSA: < 10 ng/ml 2. 2 Prostate Issues: important for morbidity A. Relative contraindications: • Volume > 70 cc • Very large TURP defect • Marked obstruction symptoms (IPSS score >15) B. Ideal patient: • Gland < 50 cc • Intact prostate • Peak urinary flow rate > 10 cc/sec Hexagonal Magazine Head Seeds are stacked parallel on top of each other. Cartridg MICK 200-TP Needle Receptor e Needle ReceptorRelease Button
  25. 25. Identification of Urethra on TRUS with Foley catheter General/spinal anesthesia, patient supine. Needle guide template mounted against the perineum, hollow needles inserted through the template into prostate. Needle position checked with ultrasound/fluoroscopy and reinserted and/or template repositioned, etc. Foley Cystoscopy performed at completion of implant, during catheter same anesthesia. Post-implant CT for dosimetry and implant evaluation. Sagital Transverse Planning for permanent prostate implant Software Template superimposed on prostate Pre-implant plan Anterior Cube-cut for view view 160 Gy (16,000 rads) I-125 dose coverage g Prostate contour Urethra 160 Gy isodose line Seed/needle utilized on current image (red), adjacent image (blue) Rectum Planning for permanent prostate implant Reduction of Pubic Arch Interference Evaluation of pubic arch interference (PAI/PAO) Pre - LHRH Monotherapy Post - LHRH Monotherapy Axial view with 3-D image of prostate (red) showing pubic arch (yellow) interference
  26. 26. Planning for permanent prostate Operating room setup implant 3-D image of prostate (red), urethra urethra (green) and prescribed dose for Iodine-125 implant base apex (160 Gy = 16, 000 rads) Wallner, K. Brachytherapy made complicated Prostate Brachytherapy using Transrectal Ultrasound Needle Transrectal ultrasound axial images Axial CT image pubic symphysis urethral marker rectal marker Prostate rectal marker urethral marker Lateral scout view AP scout view Increasing Prostate Cancer Detection Rates with Extended Core Biopsy Protocols Study No. of Cores Cancer Detection An increase in the number of cores leads in Rate general to an increase in the cancer detection Eskew, 1997 6 23% rate 13 40% Naughton, 2000 6 26% For the same number of cores, strategies with a g 12 27% higher detection rate Presti, 2000 6 33% 8 39% Use more laterally directed biopsies of the PZ 10 40% Emphasize base and apex more than mid-gland Babaian, 2000 6 20% biopsies 11 30% De la Taille, 2003 6 22% Use TZ biopsies in larger glands 12 28% 18 30% 21 31%
  27. 27. Extended Core Biopsy Techniques Why perform a saturation biopsy? A. B. C. Who is a Candidate? • To diagnose cancer. (patients with abnormal or rising PSA or worrisome DRE who have already undergone one or more negative A1 Sextant, Hodge, S t t H d 10 C Core, Presti, 2000 P ti 12 C Core, (Double (D bl extended biopsies) 1989 Sextant) • To determine extent of cancer in patients with a positive D. E. extended biopsy. (patients considering observation or focal cryotherapy) x x • To assess local control in patients treated with initial radiation or cryotherapy. x T2 biopsy (patients with rising PSAs after radiation or cryotherapy) 13 Core, Eskew, 1997 11 Core, Babaian, 2001 Saturation Prostate Biopsies - Technique Cancer Detection on Repeat Biopsy • Position Sextant*† Saturation •Dorsal lithotomy position (perineal) Biopsy‡§ •Lateral (transrectal) 1 prior biopsy 10-17% 36% • General anesthesia 2 prior biopsies 5-14% 31% • Grid (synchronize to TRUS image) • Biopsy at grid coordinates 3+ prior biopsies 4-12% 14-36% • Pull back according to length of * Data adapted from Roehl et al (2002). prostate and length of biopsy needle. † Data adapted from Djavan et al (2001a). ‡ Data adapted from Stewart et al (2001). (18 gauge needle / 18mm biopsy core) § Data adapted from Fleshner and Klotz (2002). Patient preparation Preparation of the introducers Similar to that for prostate biopsy Three Bard 18 Gauge Prophylactic antibiotic by 20 cm long Cleansing enema brachytherapy seed Anticoagulation medications are held strand i l d implant needles Bone wax applied to the distal end Gold marker loaded using stylet
  28. 28. Left lateral decubitus Planning CT position Prostate imaged and measured 3 mL of 1% lidocaine injected bilaterally 3 markers placed at the apex and left and right base Portal Images
  29. 29. Anterior Cube-cut view view Planning for permanent prostate implant Reduction of Pubic Arch Interference Evaluation of pubic arch interference (PAI/PAO) Pre - LHRH Monotherapy Post - LHRH Monotherapy Axial view with 3-D image of prostate (red) showing pubic arch (yellow) interference Planning for permanent prostate Operating room setup implant 3-D image of prostate (red), urethra urethra (green) and prescribed dose for Iodine-125 implant base apex (160 Gy = 16, 000 rads) Wallner, K. Brachytherapy made complicated
  30. 30. Prostate Brachytherapy using Transrectal Ultrasound Needle Transrectal ultrasound axial images Axial CT image pubic symphysis urethral marker rectal marker Prostate rectal marker urethral marker Lateral scout view AP scout view Prostate Post-Implant Permanent prostate implant Analysis CT image Anterior view Lateral view of prostate after Foley catheter p permanent implant p Foley catheter Pubic symphysis Foley balloon Foley balloon of Pd-103 seeds Urethra with Iodine125 seeds urethral marker Iodine125 seeds 155 156
  31. 31. Prostate Post-Implant Analysis Prostate contour Prostate 70 Gy isodose line 150 Gy isodose line Pd-103 3-D image of prostate, Seed Identification 150 Gy isodose surface and and I-125 seeds Isodose Coverage Urethra 157 Permanent Prostate Implant Percent of Radioactivity Remaining after Time 100% 90% 80% The half-life of I-125 is 60.5 days, Pd-103 is 17 days. 70% 60% After 10 half-lives (605 days for I-125, 170 days for Pd-103), less than 1/1000 Pd 103), 50% (or less than 0.1%) of the original 40% activity remains. 30% 20% 10% Days I-125 0 9 19 30 44 60 80 105 121 140 201 261 605 Days Pd-103 0 2.5 5.4 8.7 12.4 17 22.4 29.4 34 39.4 56.4 73.4 170 Primary Cryotherapy: Who is a Candidate? • T1C – T3 disease, any grade • Small T3’s in which ice will encompass tumor • Alternate to radiation therapy • Probably not as effective as surgery, especially in younger patients. • Advantage in: 1. Obese patients 2. Cardiac disease 3. Inflammatory Bowel Disease
  32. 32. Cryotherapy – Tissue Injury The Cryoablation Procedure Putative mechanisms include: • 3rd generation probes with Argon/Helium 1. Osmotic changes as a result of extracellular H2o transformation into ice. • Software with grid – improved probe 2. Shearing forces exerted on cell membrane by positioning extracellular ice crystals. 3. Intracellular freezing. • Thermocouples 4. Tissue ischemia (destruction of blood vessels). • Current procedure vastly different 5. Immune responses. from 1990’s 1. Imaging the prostate with Ultrasound Individual patient anatomy can be entered 2. Treatment planning into a computer-based treatment planning system. 3. 3 Placement of cryoprobes This computer system 4. Placement of thermocouples helps optimize positioning of the cryotherapy probes 5. Placement of urethral warming catheter and thermocouple positions. 6. Freezing Cryoprobes and thermocouples are placed transperineally through a grid or by manual id b l guidance. They are guided into place with ultrasound.
  33. 33. Thermocouple and ultrasound feedback is used to monitor p g progress. Probes Placed before Freeze Started in the Freezing Anterior Freezing is complete once critical temperatures are reached. Sagittal Image of Posterior Ice Ice Stopped at Denonvillier’s Start Fascia Efficacy of Primary Cryotherapy PSA – Recurrence Ref. N Crygen Median Nadir Low Free Survival Medium High When Definition Neg ADT Primary Cryotherapy – Complications (%) F/U PSA Biopsie (%) (months) undetect s able (%) (%) N Erectile Fistula Incontinence Sloughing / TURP Prepeli 65 A 35 83% 3 Yrs ASTRO 7/8 68 Dysfunction ca, (88) 2005 Han, 122 A 12 75% 1 Yr PSA >0.5 37 Han, 2003 122 87 0 4.3 5.8 2003 ng/ml Ellis, 2006 , 75 82 0 5.5 6.7 Donnell 76 N 50 75% 50 PSA >1.0 63/73 34 y, 2002 Mos ng/ml (86) Long, 2001 975 93 0.5 7.5 13 Bahn, 590 A/N 68 92% 89% 89% 7 Yrs ASTRO 514/590 91 Bahn, 2001 590 95 0.1 4.3 5.5 2002 (87) Long, 975 A/N 24 76% 71% 61% 5 Yrs PSA >1.0 33 2001 (82) De La 35 A 8.3 22 (63) 70% 9 Mos PSA 100 Taille, increase 2000 0.2 above nadir Koppie, 176 N 31 88 (49) 56% 3 Yrs Nadir >0.5 103/167 28 1999 or PSA (61) increase of 0.2 Technical Modifications to Improve Technical Modifications to Improve Potency Potency Focal Cryotherapy – partial (less than whole- Nerve – Warming Cryotherapy gland) treatment designed to spare one (or – Use of helium probe in region of the neurovascular both) NVB’s bundle to actively warm during treatment. – May treat entire ipsilateral side including ipsilateral NVB. – May limit treatment to region/location of positive biopsy.
  34. 34. Focal Cryotherapy – Early Results Efficacy of cryosurgery in controlling recurrent prostate cancer after failure of Study N Follow- PSA Results Positive Potency (%) up Post- radiation therapy Treatment Biopsy (%) Ref. No. of Median FU Undetectable PSA Negative Patients pts (months) PSA <0.5 FU receiving Onik, 2002 9 36 Stable 0/6 (0%) 7/9 (77%) biopsies ADT (<0.05 ng/ml) ng/ml n Bahn, 31 70 26/28 (93%) 1/25 (4%) (%) n (%) n (%) 13/27 (48%) ( ) 2006 (by Astro) No treatment Miller 33 16.8 NA 3 (33) 26 (79) 16 (48) 11/27 (41%) Pisters 150 17 47 (31) 63 (42) 116 (77) 40 (27) With oral drugs Chin 106 43 NA 114 (97) 91 (86) 71 (67) 24/27 (89%) De la Taille 43 21.9 NA 26 (60) NA 43 (100) With or without drugs Han 18 20 NA 13 (72) NA 0 Management of Cryotherapy Complications of Salvage Cryotherapy Complications Generation Author N Incontinence Obstruction Rectal Sloughing Fistula Injury • Incontinence:- if mild, pads - if severe, artificial sphincter 3rd Ghafar 38 8% 0 0 0 0 3rd Han 29 7% N/A 0 N/A 0 • Obstruction – CIC 2nd Pisters 150 73% 44% 1% N/A 1% (TUR can cause incontinence) 2nd Chin 118 20% 8.5% 3.3% 5.1% 3.3% • Sloughing: - place catheter, or TUR 2nd Miller 33 9% 4% 0 N/A 0 • Fistula: - colostomy Cryotherapy - Conclusions • Minimally invasive. • Fewer complications with 3rd generation equipment, ultra- thin probes, and thermocouples. • High potency rates with focal cryo (approx. 80-90%) – longer follow-up needed. • Acceptable alternative to radiation therapy. • Most appropriate for older patients or those refusing surgery.
  35. 35. Focal Cryotherapy – Early Results Efficacy of cryosurgery in controlling recurrent prostate cancer after failure of Study N Follow- PSA Results Positive Potency (%) up Post- radiation therapy Treatment Biopsy (%) Ref. No. of Median FU Undetectable PSA Negative Patients pts (months) PSA <0.5 FU receiving Onik, 2002 9 36 Stable 0/6 (0%) 7/9 (77%) biopsies ADT (<0.05 ng/ml) ng/ml n Bahn, 31 70 26/28 (93%) 1/25 (4%) (%) n (%) n (%) 13/27 (48%) ( ) 2006 (by Astro) No treatment Miller 33 16.8 NA 3 (33) 26 (79) 16 (48) 11/27 (41%) Pisters 150 17 47 (31) 63 (42) 116 (77) 40 (27) With oral drugs Chin 106 43 NA 114 (97) 91 (86) 71 (67) 24/27 (89%) De la Taille 43 21.9 NA 26 (60) NA 43 (100) With or without drugs Han 18 20 NA 13 (72) NA 0 Management of Cryotherapy Complications of Salvage Cryotherapy Complications Generati Author N Incontinen Obstruction Rectal Sloughin Fistula on ce Injury g • Incontinence:- if mild, pads - if severe, artificial sphincter 3rd Ghafar 38 8% 0 0 0 0 3rd Han 29 7% N/A 0 N/A 0 • Obstruction – CIC 2nd Pisters 150 73% 44% 1% N/A 1% (TUR can cause incontinence) 2nd Chin 118 20% 8.5% 3.3% 5.1% 3.3% • Sloughing: - place catheter, or TUR 2nd Miller 33 9% 4% 0 N/A 0 • Fistula: - colostomy Cryotherapy - Conclusions • Minimally invasive. • Fewer complications with 3rd generation equipment, ultra- thin probes, and thermocouples. • High potency rates with focal cryo (approx. 80-90%) – longer follow-up needed. • Acceptable alternative to radiation therapy. • Most appropriate for older patients or those refusing surgery.
  36. 36. Transrectal Prostate Ultrasound and Prostate Biopsy Report Name________________________________ MR# _____________ Date_________ DIAGNOSIS: □ Elevated PSA □ Abnormal Exam Current PSA__________ PROCEDURES: □ Echography of Prostate □ US Guidance for needle biopsy □ Transrectal needle biopsy of prostate SURGEON: ___________________________ Signature: __________________________ TRANSRECTAL ULTRASOUND: □ PSA density: ________ ng/cc □ Prostate measurements: Height_____ mm; Width ______ mm; Length ______ mm □ Prostate volume: ________ cc □ No hypoechogenic areas suggestive of cancer are seen. □ Hypoechogenic areas exist which could represent areas of malignancy. These are seen in the following locations: ___________________________________ □ Hyperdense echos are seen suggestive of calculi in the capsule. □ Seminal vesicles: □ normal □ other ______________________________________ □ Prostate median lobe: □ absent □ present, size: ________________________________ □ Bladder exam: □ normal □ abnormal _________________________________________ □ Documentation images were taken. OPERATIVE DESCRIPTION: Informed consent was obtained and signed. The patient was placed in the left lateral decubitus position. The 7.0 mHz biplanar transrectal ultrasound probe was placed in the rectum. Imaging in transverse and longitudinal views was done with the findings as indicated. (Example only – each urologist should formulate his/her own operative description.) ULTRASONIC GUIDED PROSTATE BIOPSY: □ Prostate anesthetic block was performed using 1% Xylocaine. □ Biopsies of abnormal appearing areas were performed. □ Biopsies were taken from the base, mid-gland and apex bilaterally as indicated. □ Total number of biopsies taken: __________. □ Documentation images were taken. OPERATIVE DESCRIPTION: Multiple biopsies of the prostate via needle were obtained using ultrasonic guidance into the rectum. Post operative instructions were given to the patient in detail per post op instruction sheet. Patient will be contacted with the biopsy result when available. (Example only – each urologist should formulate his/her own operative description.)
  37. 37. OFFICE OF EDUCATION Improving Practice and Patient Care Through Affordable Quality Urological Education AUA EDUCATIONAL PRODUCTS 2008 AUA Courses Subject-Oriented Seminars Surgical Learning Center Courses ∗ AUA Annual Review Course ∗ Hand-assisted Laparoscopy: Nephrectomy, June 5-8—Dallas, TX Nephroutererectomy & Partial Nephrectomy Course Directors: Daniel A. Shoskes, MD & Allen F. Morey, MD June 7-8—Houston, TX ∗ Basic Sciences for Urology Residents Course Director: R. Ernest Sosa, MD June 13-18—Charlottesville, VA ∗ Introductory Urodynamics Course Director: William Steers, MD August 1-3—Reno, NV ∗ 2008 Summer Research Conference Course Director: Timothy Boone, MD August 7-9— Baltimore, MD ∗ Hands-on Ultrasound Course Director: Arthur L. Burnett, MD October 25-26—Dallas, TX ∗ Cutting Edge Topics in Urology Course Director: Pat F. Fulgham, MD October 3-5—Scottsdale, AZ ∗ Mentored Laparoscopy Course Director: Gopal Badlani, MD November 8-9—Houston, TX ∗ Female Urology & Advanced Urodynamics Course Director: Stephen Y. Nakada, MD October 16-18—New Orleans, LA ∗ Hand-assisted Laparoscopy: Nephrectomy, Course Director: Victor Nitti, MD Nephroutererectomy & Partial Nephrectomy ∗ 4th International Congress on the History of Urology December 6-7—Houston, TX November 7-9—Baltimore, MD Course Director: R. Ernest Sosa, MD Rainer Engel, MD ∗ AUA Coding Seminars ∗ Female Sexual Dysfunction – Move to the Forefront December 12-13—Washington, DC July 12— Las Vegas, NV Course Director: Irwin Goldstein, MD August 9— Washington, DC September 20—Tampa, FL Other AUA Educational Products New Products! Monographs/DVDs/Webinars ∗Prostate Cancer Webinar Series ∗Annual Meeting Webcasts ∗Basic Ultrasound DVD ∗Update Series ∗Urolithiasis DVD (not for CME) ∗Self Assessment Study Program—Print, CD, and Internet For more information: ∗Practice Management Webinar Series (not for CME) Email CME@AUAnet.org or call 1-866-Ring-AUA ∗Advanced Laparoscopy Surgical DVD Visit the AUA Product Store in the Registration Area

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