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. 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.

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4. 2008 AUA Annual Meeting
03 DL Prostate Ultrasound
5/17/2008 10:30 a.m.- 1:30 p.m.
Disclosures
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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
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A special AUA value for your patients:
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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. 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. 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. 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. 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. 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. 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. 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. *
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. 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. transverse Gleason 7
sagittal
left side
Transverse bladder sagittal
Ductal Ectasia vs. SV Cyst Mullerian Duct Cyst

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. 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. EJ duct cyst ? Cause or result of obstruction
1213037

18. • Obstructed Right
SV Ductal ectasia or dilatation may be
• Absent Left SV related to ejaculatory duct obstruction
• EJ ducts not found
3371043

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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