Urethral midlobe embolism after focal ablation of Gleason 7 prostate cancer


Abstract

This is the case of a 56-year-old man who experienced urinary intermittence, frequency, urgent urination and dysuria 5 months after undergoing focal laser ablation (FLA) for cancer of the Gleason prostate (PC) 3 + 4 = 7. The cystoscopy revealed an obstruction of the bladder with a foreign body and the patient felt immediate relief after its removal. The final pathology confirmed the diagnosis of the foreign body as a piece of necrotic prostate tissue from the midlobe. To our knowledge, this is the first case of intermittent urethral obstruction by a desquamated prostatic midlobe after ALF. FLA is an emerging therapy for inferior or intermediate quality PC, and this case highlights the need for continued evaluation of the long-term results of this procedure.

Background

Focal laser ablation (FLA) is an emerging technology for the management of low or intermediate risk small prostate cancers (PC). Although the gold standard therapies for the management of CP are active surveillance, radical prostatectomy and / or radiotherapy, several contemporary studies have shown the benefit of FLA in reducing urinary and erectile adverse effects (AEs). while respecting oncological principles. .1 FLA uses MRI imaging guidance and temperature monitoring with a laser platform to achieve precise and consistent ablation of prostate tissue.2 In this case report, we describe a patient who presented to our clinic with intermittent obstructive urinary tract symptoms 5 months after his FLA for Gleason 3 + 4 = 7 PC.

Case presentation

We present a 56-year-old male with an elevated prostate specific antigen (PSA) of 6.2 who was found to have Gleason 6 PC on routine biopsy. About 6 months later, MRI identified a Prostate Image-Reporting and Data System (PI-RADS) 4 lesion in the area of ​​transition from the right base to the mid-gland, and the targeted biopsy passed the stage. from her cancer to Gleason 3 + 4 = 7 (Figure 1). After seeing many doctors, he suffered an uncomplicated FLA of his prostate.

Five months after the procedure, he presented to the clinic with urinary urgency, frequency, dysuria, and a complaint of sudden cessation of urine flow halfway through. Her American Urological Association (AUA) symptom score was 22 for tamsulosin. Cystoscopy revealed a foreign body (FB) with the appearance of partially calcified tissue, measuring approximately 1 cm, in the bladder. Close inspection of the MRI before and after treatment of the patient showed loss of a midlobe of the prostate after treatment, with a nodular FB in the bladder (Figure 2A and 2B). The FB was removed endoscopically under anesthesia in several pieces using cold-cut biopsy forceps. The patient experienced immediate improvement in his urinary tract problems. The final pathology showed a small detached fragment of granulation tissue mixed with stone fragments. He had immediate symptom resolution and his postoperative AUA symptom score was 6. Seven months after the FLA procedure, he had a PSA of 1.6.

Discussion

Over the past decade, there has been an increase in new techniques for managing localized CP. FLA, cryoablation (CA) and focal therapy, using high intensity focused ultrasound (HIFU),3 all offer minimally invasive and organ-preserving options for these low- or intermediate-grade unifocal cancers. Specifically, FLA embodies many advantages of a minimally invasive procedure for the treatment of localized PC, as it has minimal impact on quality of life and reasonable oncologic control with few AEs.4 Due to the novelty of the procedure, some rare complications related to FLA may appear over time.

Long-term results from focal therapies such as HIFU and cryotherapy have been reported. One such systematic review and meta-analysis of HIFU revealed that after whole gland HIFU, the incidence rates of urinary obstruction, retention, and infection were 15%, 11%, and 7%, respectively. The incidence rates of urinary obstruction, retention, and infection after partial gland HIFU were 2%, 9%, and 11%, respectively.5.6 The differences in complication rates between whole and partial prostate gland removal reflect the need for continued analysis of treatment options for localized PC. A study of cryosurgical ablation (CSA) in patients with low-grade PC found that the most common AE 1 year after CSA was urinary tract obstruction, sometimes requiring removal of necrotic prostate tissue and calcifications.7 Although FB obstruction of bladder complications have been reported after HIFU and CSA, they have not been addressed or studied in FLA.

An FB embolism of the midlobe of the bladder is an extraordinarily unusual complication after ablative treatment of the prostate. Presumably, FLA caused necrosis of the base of the midlobe by destruction of the proximal blood supply, resulting in amputation of the midlobe. This FB embolized intermittently in the prostatic urethra / bladder neck, causing sudden cessation of urine flow accompanied by irritative voiding symptoms. We cannot find any other example of a similar complication related to prostate ablative therapies in the searchable literature.

Given the special nature of this complication and the likely increased use of prostate disease ablation procedures in future care, endoscopic evaluation with cystoscopy may be an earlier step in the management of morbidity. urine after these treatments. Urethral desquamation after HIFU and CA is a more common cause of urethral obstruction, and cystoscopy can be both diagnostic and therapeutic. Testing for a urinary tract infection would be the best clinical practice, but medical management would not have helped this patient. We do not believe that patients with protruding midlobes should be refused ablative treatments for prostate disease, but perhaps a higher index of suspicion would be prudent if patients experience urinary problems after treatment. .

It also raises the question of whether FLA would be a reasonable treatment for benign prostatic hyperplasia. The defect on his post-treatment MRI was similar to a defect related to the transurethral resection of the prostate and, compared to what he felt before the ALF, the patient had a noticeable improvement in his benign hyperplasia symptomatology. prostate.

To our knowledge, this is the first case of prostate tissue obstructing the bladder following prostate FLA. This case highlights the need for a long-term evaluation of outcomes and complications following emerging focal therapies, particularly laser ablation.

Financial disclosure: PM: Astellas (investigator), Dendreon (investigator)

The references

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Oto A, Sethi I, Karczmar G, et al. MRI-guided focal laser ablation for prostate cancer: phase I trial. Radiology. 2013; 267 (3): 932-940. doi: 10.1148 / radiol.13121652

Eggener S, Salomon G, Scardino PT, De la Rosette J, Polascik TJ, Brewster S. Focal therapy for prostate cancer: possibilities and limitations. Eur Urol. 2010; 58 (1): 57-64. doi: 10.1016 / j.eururo.2010.03.034

Lepor H, Llukani E, Sperling D, Fütterer JJ. Complications, early recovery and functional results and oncological control after focal laser ablation of prostate cancer. Eur Urol. 2015; 68 (6): 924-926. doi: 10.1016 / j.eururo.2015.04.029

Hostiou T, Gelet A, Chapelon JY, et al. High-intensity focused recovery ultrasound for locally recurrent prostate cancer after low-dose brachytherapy: oncologic and functional findings. Int BJU. 2019; 124 (5): 746-757. doi: 10.1111 / bju.14838

He Y, Tan P, He M, et al. Primary treatment of prostate cancer by high-intensity focused ultrasound: a systematic review and meta-analysis. Medicine (Baltimore). 2020; 99 (41): e22610. doi: 10.1097 / MD.0000000000022610

Bjerklund Johansen TE. Crioterapia prostática como tratamiento primario en pacientes con cáncer de próstata [Cryosurgical ablation as primary treatment in prostate cancer patients]. Actas Urol Esp. 2007; 31 (6): 651-659. Spanish. doi: 10.1016 / s0210-4806 (07) 73702-6


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