UroLift

[thaddeus]

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Some of my Urologists approached me recently about the idea of implanting the UroLift system prior to prostate EBRT for patients with pretreatment obstructive symptoms, with the idea that the metal components of the implants could serve as fiducials for IRGT in lieu of standard gold fiducial placement. Of course I said "what an excellent idea, my gracious Referral Overlords", but in thinking about it there seems to be at least a theoretical concern that scatter from the metal could cause increased urethral dose since the metal component is right against the wall of the urethra. Anyone have any experience with this? The only literature I could find was a rigorous series of 7 patients; not enough to hang your hat on:

UroLift in Place of Fiducial Markers for Patients With Benign Prostatic Hyperplasia Undergoing External Beam Radiation Therapy. - PubMed - NCBI

UroLift | BPH Treatment | Enlarged Prostate Surgery

 

[seper]

Interesting. I guess your concern is "electron backscatter", like with metal dental work during oral cavity irradiation? I've never decided if that problem was real or made up.

 

[thaddeus]

yea that's my concern. Obviously not an issue with fiducials placed in the prostate parenchyma, but potentially one if right on the urethral wall. I've definitely seen mucosal reaction adjacent to dental work before, so I think its a real phenomenon.

 

[evilbooyaa]

Backscatter is like a 1-2% difference from discussions I've had with my physicists and data they showed me. You can be conservative with a 5% increase. You're going to be limited in the small angle in terms of passing through that area.

If your tumor isn't right along the urethra and you're still really concerned, you could limit that interface to 95-97% of the prescription dose and I imagine you'd be fine.

 

[thaddeus]

Thanks, that's reassuring.

 

[Haybrant]

does anyone have experience with TURP prior to prostate RT; they aren't doing this urolift procedure around here. I have a guy with a 110 cc prostate with very significant median lobe pushing into the bladder, his urgency is like 5/5. Apparently a poor surgical candidate due to comorbidities per urology. He has low intermediate disease (gleason is 3+4 in 3 cores and PSA is 7). How long do you wait after TURP to start RT? Anything additional to consent about? Thank you

 

[OTN]

does anyone have experience with TURP prior to prostate RT; they aren't doing this urolift procedure around here. I have a guy with a 110 cc prostate with very significant median lobe pushing into the bladder, his urgency is like 5/5. Apparently a poor surgical candidate due to comorbidities per urology. He has low intermediate disease (gleason is 3+4 in 3 cores and PSA is 7). How long do you wait after TURP to start RT? Anything additional to consent about? Thank you

I've done it before- usually wait at least 3 weeks and make sure any post-procedural inflammation prior to initiation of RT.

EDIT: My patients who underwent TURP prior to RT did well.

 

[Chartreuse Wombat]

does anyone have experience with TURP prior to prostate RT; they aren't doing this urolift procedure around here. I have a guy with a 110 cc prostate with very significant median lobe pushing into the bladder, his urgency is like 5/5. Apparently a poor surgical candidate due to comorbidities per urology. He has low intermediate disease (gleason is 3+4 in 3 cores and PSA is 7). How long do you wait after TURP to start RT? Anything additional to consent about? Thank you

I trained three decades ago but the classical teaching then was 12 weeks after TURP. Of course this is based on nothing but following TURP you have an open wound that needs to heal primarily. There is likely an increased risk of incontinence with XRT following TURP but the risk is lower than TURP following XRT.
Old paper at link
Urinary incontinence following external-beam radiotherapy for clinically localized prostate cancer. - PubMed - NCBI

 

[nkmiami]

I have always given pts 2-3 months, based on residency, but never knew the actual rational.

 

[thaddeus]

does anyone have experience with TURP prior to prostate RT; they aren't doing this urolift procedure around here. I have a guy with a 110 cc prostate with very significant median lobe pushing into the bladder, his urgency is like 5/5. Apparently a poor surgical candidate due to comorbidities per urology. He has low intermediate disease (gleason is 3+4 in 3 cores and PSA is 7). How long do you wait after TURP to start RT? Anything additional to consent about? Thank you

How about waiting until he has disease progression?? Low volume, Gleason 3+4 disease is totally fair game for active surveillance. And with that volume he'll have some nontrivial side effects from RT, regardless of the TURP.

 

[Haybrant]

How about waiting until he has disease progression?? Low volume, Gleason 3+4 disease is totally fair game for active surveillance. And with that volume he'll have some nontrivial side effects from RT, regardless of the TURP.

Everything is considered and offered. You only control so much of the narrative for a patient.

 

[cpants]

does anyone have experience with TURP prior to prostate RT; they aren't doing this urolift procedure around here. I have a guy with a 110 cc prostate with very significant median lobe pushing into the bladder, his urgency is like 5/5. Apparently a poor surgical candidate due to comorbidities per urology. He has low intermediate disease (gleason is 3+4 in 3 cores and PSA is 7). How long do you wait after TURP to start RT? Anything additional to consent about? Thank you

Your guy wouldn't be a candidate for urolift anyway. Need to have prostate <80gm with no substantial median lobe component. The urolift pulls the lateral lobes of the prostate to the side and doesn't treat the median lobe at all.

Think urolift could be a good option in lieu of fiducials because the procedure is very minimally invasive and would treat the patient's BPH symptoms. I leave the physics to you guys, but obviously wouldn't want to increase risks of stricture or BNC by upping urethral dose.

I'd much rather TURP before than after for healing reasons. In a guy with a big prostate and bad obstructive symptoms I'd lean toward RP anyway.

 

[DoctwoB]

Your guy wouldn't be a candidate for urolift anyway. Need to have prostate <80gm with no substantial median lobe component. The urolift pulls the lateral lobes of the prostate to the side and doesn't treat the median lobe at all.

Think urolift could be a good option in lieu of fiducials because the procedure is very minimally invasive and would treat the patient's BPH symptoms. I leave the physics to you guys, but obviously wouldn't want to increase risks of stricture or BNC by upping urethral dose.

I'd much rather TURP before than after for healing reasons. In a guy with a big prostate and bad obstructive symptoms I'd lean toward RP anyway.

You can treat median lobes with urolift as shown by results of medlift study which was a late breaking abstract at AUA https://www.jurology.com/article/S0022-5347(18)42754-1/fulltext.

It requires a different technique though of rolling the median lobe back into the prostatic urethra before firing the implant and pinning it there. Unclear what the learning curve is like. So it is feasible, but if someone is really median lobe predominant would still likely favor TUR or rezum.

Ironic that the Uro forum is so dead this is where this discussion occurs.

 

[Haybrant]

Any updates on urolift from anyone? Were you able to align to the metal component of this instead of fiducials? Did you actually cool down the plan at all? Just got a referral for a patient that has it, appreciate the feedback

 

[thaddeus]

I've treated a couple guys with Urolift now; haven't seen any toxicity in excess of what I would expect (of course anecdotal with n=2). They're reasonable to use for fiducial alignment, but the clips are closer together than you usually get with well-placed fiducials, so any rotational correction is limited. Wouldn't want to use them for SBRT (prob shouldn't SBRT someone who needs Urolift anyway), but were totally fine for IMRT.