Download Imaging After Radical Prostatectomy: Controversies of Urinary Incontinence

1
Luis Ramos
Harvard Medical School BIDMC Department of Radiology Class of 2011
Index Case Relevant Anatomy
Basic Facts of Prostate Cancer
Menu of Radiologic Tests for the Evaluation and Diagnosis
 Role of Radical Prostatectomy
 Discussion of Urinary Incontinence
 Conclusion
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CC: Elevated PSA
HPI: Mr. SR is a 67 year old male s/p standard radical prostatectomy, s/p salvage radiotherapy one yr later that presents with a rising PSA from 2.4 to 3.7. Pt has been complaining of urinary incontinence, as he wears 4 diapers a day. ROS: Not significant for bone pain, back pain, dysuria, urinary frequency
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PMH:
 HTN
 Hypercholesterolemia
 Leiomyoma in Gastric esophageal junction
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Allergies: Penicillin
MEDS: Allegra, Hctz, Simvastatin, Detrol, Aleve
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FH: Sister died of ovarian cancer, mother died of unknown metastatic cancer
According
to McNeal’s model
Proximal Lissosphincter
Bladder musculature
Prostate
Distal Lissosphincter
Rhabdosphincter
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Most common neoplasm among men  Incidence: 119 per 100,000  2nd most common cause of death due to cancer 
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95% of tumors are adenomcarcinomas
Primarily arises from peripheral (transition zone)
Increased risk:
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Genetic African American Dietary (High fats)
Environmental Hormonal 
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Controversies
Traditional screening guidelines
 PSA levels >10 ng/mL for men age >40 OR
 Digital rectal exam: Palpable rock hard nodule
 If any of these found they were sent for TRUS‐guided biopsy
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Unfortunately, PSA levels never correlated with a reduction in cancer mortality and potentially led to overdiagnosis and overtreatment of otherwise benign tumors
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New American Urologic Association guidelines as of 2009 included the following changes:
 1. PSA testing offered to well‐
informed patients age>40 with
a life expectancy >10 years
 2a. Routine bone scan is not required
 2b. However, bone scans are indicated for the detection of mets following initial treatment of disease
 3. CT or MRI may be considered for staging when PSA <20 ng/mL
15yr
Recurren
ce
Survival
Staging
Findings
Treatment
T1a
Non-palpable tumor; low grade cancer <5% of prostate
Observation
T1b
High grade tumor; >5% prostate involved
Radical Prostatectomy/ External Beam Radiation/
Brachytherapy
T2a
1 lobe or less
Radical Prostatectomy/ External Beam Radiation/
Brachytherapy
60-70%
T2b
More than 1 lobe
Radical Prostatectomy/ External Beam Radiation/
Brachytherapy
20-60%
T3a
Unilateral Extraprostatic Extension
Radical Prostatectomy/ External Beam Radiation/
Brachytherapy
0-10%
T3b
Bilateral Extraprostatic Extension
Hormonal Therapy (Orchioectomy OR
LHRH/Antiandrogen) + external beam radiation
0-10%
T3c
Seminal Vesicle Invasion
Hormonal Therapy (Orchioectomy OR
LHRH/Antiandrogen) + external beam radiation
0-10%
T4a
Invades Bladder Neck or Rectum
Hormonal Therapy (Orchioectomy OR
LHRH/Antiandrogen) + external beam radiation
100%
70-80%
85%
0-10%
T4b
Invades Levator muscle
Hormonal Therapy (Orchioectomy OR
LHRH/Antiandrogen) when symptomatic; irradiation for
isolated bone pain+ external beam radiation
0-10%
M+
Pelvic lymph node or distant metastases
Hormonal Therapy (Orchioectomy OR
LHRH/Antiandrogen) + external beam radiation
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Trans‐rectal Ultrasonography
 Doppler TRUS
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Endorectal MRI
Axial CT
Bone Scan
Antibody Imaging
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http://www.upmccancercenters.com/cancer/prostate/b
iopsyultrasound.html
Borlev et al: Most common diagnostic modality2
 Primary role is for tissue diagnosis: 12 core needle biospy
 Hypoechoic lesions (traditionally)
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 Only 20% of hypoechoic lesions prove to be cancer on biopsy
No t recommended for screening
 Patient Prep: Fleet enema 4 hrs prior to exam
 Antibiotic (Cephalexin) if biopsy
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Indications:  Elevated PSA or PSA velocity
 Previous biopsies showing intraepithelial neoplasia (PIN) or small acinar proliferation (ASAP)
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Contraindications:
 Elderly or frail men
 Massively elevated PSA with 
abnormal DRE
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Turkbey et al
 Drawbacks:
▪ Low sensitivity and specifcity
▪ Small foci are often not visible3
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1. Hypoechoic lesion in the peripheral zone with ill‐
defined borders
2. Assymetrical peripheral zone 3. Inhomogenity or focal capsular bulge 4. Pericapsular irregularity
High grade malignancies: Heterogeneous
Well‐differenianted
lesions: Hypoechoic
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http://www.upmccancercenters.com/cancer/prostate/b
iopsyultrasound.html
Example 1
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http://www.upmccancercenters.com/cancer/prostate/b
iopsyultrasound.html
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Example 2 : http://emedicine.medscape.com/article/457757‐overview
Calcifications
Right lobe
Left Lobe
Hypoechoic
lesion
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Hypoechoic lesions near the peripheral zone11
 Chronic or Acute Prostatitis
 Benign Prostate Hypertrophy (although it would more likely appear in the periurethral zone)
 Prostate carcinoma including adenocarcinoma
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Endorectal coil 
Accuracy ranges from 51% to 92%
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T2 weighted image is the test of choice
 Medical device used to obtain high quality images in the organs of the pelvis  improves cancer detection and staging
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Indications:
 Staging of known prostate cancer
 Guidance for radiation implant placement 
Contraindications:
 Incompatible devices
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Prep
 NPO 6 hrs prior
 IM Glucagon to decrease intestinal motility
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Limited availability of MRI Obese pts may not fit
Sensitivity to motion limits uncooperative pts
Insensitive to subtle calcifications or small bony fragments 
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T2 weighted image is the test of choice
Peripheral zone
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 Prostatitis
 Infarcts
 Stromal BPH
 Low intensity signal in cancer
 High intensity signal in normal 
Central zone
 Low signal intensity normally
 Cancer is difficult to find in this area
DDx of Low intensity in central zone
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Staging Factors: Direct Extension through12:
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Tumor capsule (T3a)
Periprostatic fat (T3b)
Neurovascular bundles (T3b)
Seminal Vescicles (T3c)
Metastasis to pelvic lymph nodes (M+)
Bladder
Prostate cancer
located in the
Periurethral zone
Urethra
Prostate
4 T2 coronal
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Purpose is to exclude lymph node mestastases in high risk patients
If adenopathy is detected, then CT‐guided biosy is encouraged
Sensitivity is low and varied (30‐40%)
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Indications:
 Previously detected negative bone scan
 Stage T3 cancers
 PSA >20 ng/mL
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Drawbacks:
 Poor soft tissue resolution
 Not widely used
 Not used routine for follow up
 Ionizing radiation
 Overall not helpful
5. http://emedicine.medscape.com/article/379996-media
Given his radiologic findings in Endorectal
MRI, it was omnious for recurrence  Staging T3c
 Given that he is s/p radical prostatectomy and s/p brachytherapy, Hormonal Therapy would probably be warranted at this time
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Nerve‐sparing dissection of the apical neck bladder with lymph node dissection
 Goals:
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 complete removal of the prostate gland along with surrounding tissue
 Tumor margins as negative as possible
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Modalities
 Open approach
 Laparoscopy
 Robotic‐Assisted 
Indications:
 cT1b and cT27
▪ T1: Non‐palpable tumor , high grade tumor >5% involved
▪ T2: Tumor involving 1 lobe or less
 cT3: controversy6
▪ Unilateral extraprostatic
extension7
▪ Usually involves radiotherapy, Hill 2007 would argue in certain cases it is clinically warranted
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Loughlin et al
Urinary Incontinence
 Incidence: up to 69%8
 Emotionally disturbing
 Severe morbidity  Up to 90% gain function within 24 months depending on which study 
Patient Age
 Older men have thinner rhabdomyosphincter
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Higher BMI Pre‐OP ED Preo‐OP voiding dysnfunction
Gleason score Prior TURP
Debates in the Urology community over what is the exact etiology of urinary incontinence after radical prostatectomy
 Exact Pathophysiology is debated
 Surgical techniques is also debated
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Pathophysiology
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▪
▪
▪
Rhabdosphincter vs Lissosphincter
according to Koraitim10
Rhabdosphincter is skeletal muscle that surrounds urethra
Not involved in maintaining continence
Fatigues easily
Lissosphincter is smooth muscle that wraps around urethra
Involved in maintaining continence
Tonically contracted
Puboprostatic Ligament sparing surgery
 Steiner et al 13
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 Advocates in order to optimize 
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urethral length and leave the anterior support of the urethra 
Poore et al14
 Rapid return to continence in the puboprostatic ligament sparing group (34 vs 57 wks in the control group
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Deliveliotis et al15
 Found no difference in the puboprostatic ligament sparing group, bladder neck preservation or having both procedures in the length of continence recovery
Seminal vescicle
sparing
Hauri et al16
 Pelvic nerve transverses rhabdosphincter and supplies smooth muscle (lissosphincter)
 Reports continence rates of 95% after 6 months in the seminal vescicle
spare group versus 85% in controls
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Given the relapse of Mr. RS does it really matter to discuss urinary incontinence?
If we approach as a life of quality issue
 Should a different surgical approach have been taken?
 Should puboprostatic ligament sparing and seminal vescicle sparing techniques have been implemented?
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More fundamentally
 What might be the relative effectiveness between radical prostatectomy, brachytherapy and external beam radiation? Which approach should be attempted first? Second?
Prostate Cancer is a very common neoplasm among men, 2nd deadliest Work up involves changes in PSA or palpable hard rock nodule in the prostate
 This is followed by TRUS that guides biopsy
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 Hypoechoic lesion in the peripheral zone suggests cancer
 Hypoechoic lesion in the transition zone suggests BPH
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If carcinoma is present, Endorectal MRI is used for staging and surgical planning
 T2 hypointense signal in the peripheral zone suggests carcinoma
If contraindications, CT may be used Depending on TNM staging (T1b‐T3a) one may opt for radical prostatectomy, brachytherapy and external beam radiation
 Radical prostatectomy has side effects that include urinary incontinence
 Causes of urinary incontinence are debated in the literature
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 Factors: Age, BMI, pre‐op function, s/p TURP
 Koraitim proposes lissosphincter model as a way to maintain continence
 Different surgical techniques
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Olga Brook, MD
Gillian Lieberman, MD
Maria Levantakis
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1. http://www.turbosquid.com/FullPreview/Index.cfm/ID/233868
2. Prostate cancer: diagnosis and staging Nigel Borley, Mark R. Feneley
http://www.ultrasound‐images.com/prostate.htm
4. Incremental Value of Multiplanar
Cross‐Referencing for Prostate
Cancer Staging with Endorectal MRI
3. Imaging techniques for prostate cancer: implications for focal therapy. Baris Turkbey, Peter A. Pinto and Peter L. Choyke
5. http://emedicine.medscape.com/article/379996‐media
6. Radical prostatectomy for clinical T3 disease: expanding indications while optimizing cancer control and quality of life
Jennifer R Hill, Samson W Fine, Jingbo Zhang and James A Eastham
7. CURRENT Diagnosis & Treatment: Surgery > Chapter 38. Urology > Tumors of the Genitourinary Tract > Carcinoma of the Prostate > Clinical Findings > Symptoms and Signs >
8. Wei JT, Dunn RL, Marcovich R et al: Prospective assessment of patient reported urinary continenceradical
prostatectomy. J Urol 2000; 164:744.
9. Post‐Prostatectomy Urinary Incontinence: A Confluence
of 3 Factors Kevin R. Loughlin* and Michaella M. Prasad†
10. The Male Urethral Sphincter Complex Revisited: An Anatomical Concept and its Physiological Correlate Mamdouh M. Koraitim
11. Hypoechoic Rim of Chronically Inflamed Prostate, as Seen at TRUS: Histopathologic Findings Hak Jong Lee, MD,1 Ghee Young Choe, MD,2 Chang Gyu Seong, MD,3 and Seung Hyup Kim, MD4 
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12. CURRENT Diagnosis & Treatment: Surgery > Chapter 38. Urology > Tumors of the Genitourinary Tract > Carcinoma of the Prostate > Clinical Findings > Symptoms and Signs >
13. Steiner MS: The puboprostatic ligament and the
male urethral suspensory mechanism: an anatomic
study. Urology 1994; 44: 530.
14. Poore RE, McCullough DL and Jarow JP: Puboprostatic ligament sparing improves urinary continence
after radical retropubic prostatectomy. Urology 1998; 51: 67.
15. Deliveliotis C, Protogerou V, Alargof E et al:Radical prostatectomy: bladder neck preservation and puboprostatic
ligament sparing— effects on continence and positive margins. Urology 2002;60: 855.
16. John H and Hauri D: Seminal vesicle‐sparing radical prostatectomy: a novel concept to restore early urinary continence. Urology 2000; 55: 820.