Post-MRI transrectal micro-ultrasonography of transition zone PI-RADS > 2 lesions for biopsy guidance.

OBJECTIVE: To prospectively determine the value of post-MRI micro-ultrasonography (microUS) in the diagnosis of transition zone (TZ) significant prostate cancer (sPCa). PATIENTS AND METHODS: Eighty-four consecutive men (66 ± 6.3 years) with a mean PSA level of 10.2 ± 7.4 ng/mL and at least one TZ-PI-RADS > 2 lesion were included. All patients had MRI-directed microUS and biopsy. Sensitivity and specificity of post-MRI microUS to visualize PI-RADS > 2 TZ lesions, the cancer detection rate of TZ-sPCa, and tumor characteristics according to their visibility on microUS were evaluated. Interreader agreement for detecting microUS+ lesions was evaluated using Cohen's kappa test. RESULTS: Of the 92 PI-RADS > 2 lesions, 71 (71/92; 77%) were visible on microUS and biopsy was performed without image fusion, which was required for the 21 invisible lesions (21/92; 22.8%). TZ-sPCa detection rate was 51.1% (47/92). Sensitivity and specificity of MRI-directed microUS were 83% (39/47; 95% CI: 69.2-92.4%) and 28.9% (13/45; 95% CI: 16.4-44.3%), on a per-lesion basis and 86.4% (38/45; 95% CI: 72.6-94.8%) and 27.5% (11/40; 95% CI: 14.6-43.9%) on a per-patient basis. Visible tumors on microUS exhibited a larger volume and a lower mean ADC value than non-visible tumors (15.8 ± 5.1 vs. 12.5 ± 3.6 mm and 0.82 ± 1.1 × 103 vs. 0.9 ± 1.4 × 10-3 mm2/s) (p = 0.02). Non-visible tumors showed a heterogeneous non-specific echotexture or were masked by the shadowing caused by corpora amylacea. Interreader agreement was almost perfect (kappa = 0.88; 95% CI: 0.79-0.95). The main limitation is the single-center feature of the study. CONCLUSION: MRI-targeted transrectal microUS is effective to detect TZ-sPCa. TRUS-MRI image fusion helps overcome limitations due to TZ tissue heterogeneity. KEY POINTS: microUS can visualize the majority of MRI-detected PI-RADS > 2 TZ lesions (sensitivity = 83%). Interreader agreement of MRI-directed microUS in the detection of TZ lesions appears excellent (kappa = 0.88). In 77% of PI-RADS > 2 TZ lesions, biopsy was performed under microUS visual control. MRI fusion system was only used to overcome limitations due to tissue heterogeneity of benign prostatic hyperplasia.

MRI-directed high-frequency (29MhZ) TRUS-guided biopsies: initial results of a single-center study.

OBJECTIVES: To evaluate the ability of high-frequency (29 MHz) transrectal micro-ultrasound (microUS) as a second-look examination after biparametric MRI (bp-MRI) and to reidentify focal lesions seen on diagnostic MRI and to detect new ones METHODS: A total of 118 consecutive men (mean age, 66 ± 13 [SD] years; range, 49-93 years) with a mean prostate-specific antigen level of 11 ± 19 (SD) ng/mL (range, 2-200 ng/mL) and at least one focal lesion (MRI+) with a score > 2 on bp-MRI were included. Of these, 79/118 (66.9%) were biopsy-naïve and 102/118 (86.5%) had non-suspicious rectal examination. All patients had MRI-directed microUS-guided biopsy using a 29-MHz transducer. All lesions visible on micro-ultrasound (microUS+) were targeted without image fusion, which was only used for MRI+/microUS- lesions. Significant prostate cancer (sPCa) was defined by a Gleason score ≥ 7 or a maximum cancer core length > 3 mm. RESULTS: A total of 144 focal prostatic lesions were analyzed, including 114 (114/144, 79.2%) MRI+/microUS+ lesions, 13 MRI+/microUS- lesions (13/144, 9%), and 17 MRI-/microUS+ lesions (17/144, 11.8%). Significant PCa was detected in 70 MRI+/microUS+ lesions (70/114, 61.4%), in no MRI+/microUS- lesion (0/13, 0%), and in 4 MRI-/microUS+ lesions (4/17, 23.5%). The sensitivity and specificity of microUS on a per-patient and a per-lesion basis were 100% (95% CI, 84.9-100%) and 22.8% (95% CI, 12.5-35.8%) and 100% (95% CI, 85.1-100%) and 22.6% (95% CI, 12.3-36.2%), respectively. CONCLUSION: MicroUS, as a second-look examination, may show promise to localize targets detected on bp-MRI. KEY POINTS: • Used as a second-look examination, microUS-guided biopsies have a 100% detection rate of sCa originating in the PZ or lower third of the TZ, without microUS-MRI image fusion. • MicroUS results may provide additional information about lesions visible on MRI. • MicroUS may provide the ability to detect small PZ lesions undetected by bp-MRI.

Comparative Analysis of Partial Gland Ablation and Radical Prostatectomy to Treat Low and Intermediate Risk Prostate Cancer: Oncologic and Functional Outcomes.

PURPOSE: We analyzed the oncologic and functional outcomes of partial gland ablation compared with robot-assisted radical prostatectomy in patients with low and intermediate risk prostate cancer. MATERIALS AND METHODS: A total of 1,883 patients underwent robot-assisted radical prostatectomy and 373 underwent partial gland ablation from July 2009 to September 2015. We selected 1,458 of these participants for analysis, including 1,222 and 236 treated with robot-assisted radical prostatectomy and partial gland ablation, respectively. Patients had a Gleason score of 3 + 3 or 3 + 4, clinical stage T2b or less, prostate specific antigen 15 ng/dl or less, unilateral disease and life expectancy greater than 10 years. Propensity score matching analysis (1:2) was applied in the overall robot-assisted radical prostatectomy sample, which selected 472 patients for comparison. For partial gland ablation 188 men underwent high intensity focused ultrasound and 48 underwent cryotherapy. Oncologic outcomes were analyzed in terms of the need for salvage treatment. Partial gland ablation failure was defined as any positive control biopsy after treatment. Functional outcomes were assessed by validated questionnaires. RESULTS: Matching was successful across the 2 groups, although men treated with partial gland ablation were older (p <0.001). Mean followup in the partial gland ablation group was 38.44 months. Partial gland ablation failure was observed in 68 men (28.8%), including 53 (28.1%) treated with high intensity focused ultrasound and 15 (31.2%) treated with cryotherapy. Partial gland ablation was associated with a higher risk of salvage treatment (HR 6.06, p <0.001). Complications were comparable between the groups (p = 0.06). Robot-assisted radical prostatectomy was associated with less continence recovery and a lower potency rate 3, 6 and 12 months after surgery (p <0.001). CONCLUSIONS: In select patients with organ confined prostate cancer partial gland ablation offered good oncologic control with fewer adverse effects that required additional treatments. Potency and continence appeared to be better preserved after partial gland ablation.

Modified York Mason technique for repair of iatrogenic recto-urinary fistula: 20 years of the Montsouris experience.

PURPOSE: Iatrogenic recto-urinary fistulas are a disastrous complication of therapeutic interventions on the prostate. Many surgical approaches have been described to repair recto-urinary fistulas and no consensus has been reached regarding the better approach. The objective of this study is to present the results of our updated 20-year experience in the surgical management of recto-urinary fistula using a modified York Mason procedure. METHODS: We proceed to a retrospective single-institution review of surgically treated patients for iatrogenic recto-urinary fistulas between 1998 and 2017 by the modified York Mason technique. Descriptive analysis of our population was performed. Continuous and categorical variables were compared using Mann-Whitney and Fischer tests, respectively. All tests were two-sided with a significance level set at p value < 0.05. RESULTS: We included 30 consecutive patients treated for iatrogenic recto-urinary fistula. The median follow-up was 76 months (2-195). The median size of the fistula was 5 mm (2-20). Successful healing of the recto-urinary fistula was observed in 80, 97, and 100% of patients after 1, 2, or 3 York Mason procedure. During the study period, no one single case of acquired urinary incontinence or durable fecal incontinence has been observed. CONCLUSIONS: Our modified York Mason technique is a reliable and effective procedure with a 100% success rate for the repair of small iatrogenic recto-urinary fistulas in non-irradiated patients. It has a very low morbidity rate, and no case of postoperative urine or fecal incontinence has been observed.

Biochemical recurrence after radical prostatectomy: what does it mean?

BACKGROUND: Radical prostatectomy (RP) has been used as the main primary treatment for prostate cancer (PCa) for many years with excellent oncologic results. However, approximately 20-40% of those patients has failed to RP and presented biochemical recurrence (BCR). Prostatic specific antigen (PSA) has been the pivotal tool for recurrence diagnosis, but there is no consensus about the best PSA threshold to define BCR until this moment. The natural history of BCR after surgical procedure is highly variable, but it is important to distinguish biochemical and clinical recurrence and to find the correct timing to start multimodal treatment strategy. Also, it is important to understand the role of each clinical and pathological feature of prostate cancer in BCR, progression to metastatic disease and cancer specific mortality (CSM). Review design: A simple review was made in Medline for articles written in English language about biochemical recurrence after radical prostatectomy. OBJECTIVE: To provide an updated assessment of BCR definition, its meaning, PCa natural history after BCR and the weight of each clinical/pathological feature and risk group classifications in BCR, metastatic disease and CSM.

Effect of Prior Focal Therapy on Perioperative, Oncologic and Functional Outcomes of Salvage Robotic Assisted Radical Prostatectomy.

PURPOSE: We assessed the impact of focal therapy on perioperative, oncologic and functional outcomes in men who underwent salvage robotic assisted radical prostatectomy compared to primary robotic assisted radical prostatectomy. MATERIALS AND METHODS: Focal therapy was performed in patients presenting with Gleason score 3 + 3 or 3 + 4, clinical stage cT2a or less, serum prostate specific antigen 15 ng/ml or less, unilateral positive biopsy, maximum length of any positive core less than 10 mm and life expectancy greater than 10 years. Focal therapy was defined as target ablation of the index lesion plus a 1 cm safety margin in the normal ipsilateral prostatic parenchyma. The salvage group included 22 men who underwent salvage prostatectomy after focal therapy failure. The primary group was defined using matched pair 1:2 selection of 44 of 2,750 patients treated with primary prostatectomy. The primary and secondary end points were the between group differences in functional and oncologic outcomes, respectively. RESULTS: Complication rates were comparable (p >0.05). Pad-free probability was comparable between the groups at 1 and 2 years (p = 0.8). Recovery of erectile function was significantly lower after salvage robotic assisted radical prostatectomy (p = 0.008), which also showed a significantly lower probability of cumulative biochemical recurrence-free survival compared to primary robotic assisted radical prostatectomy (56.3% vs 92.4% at 2 years, p = 0.001). Salvage prostatectomy demonstrated a significantly increased risk of biochemical recurrence (HR 4.8, 95% CI 1.67-13.76, p = 0.004). Study limitations included the retrospective nature, the lack of randomization and the short followup. CONCLUSIONS: Salvage robotic assisted radical prostatectomy after focal therapy failure is feasible with acceptable complication rates. However, patients assigned to primary focal therapy should be advised about a poorer prognosis in terms of oncologic control and lower erectile recovery rates in case of a future salvage surgery.

Surgical method influences specimen margins and biochemical recurrence during radical prostatectomy for high-risk prostate cancer: a systematic review and meta-analysis.

PURPOSE: To perform a meta-analysis comparing the rates of positive surgical margins (PSM) and biochemical recurrence (BCR) between open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP) in patients with high-risk prostate cancer. METHODS: A systematic review was performed on Pubmed, Embase and Scopus databases in August 2016, according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. References retrieved were evaluated using the Newcastle-Ottawa scale and the Black and Down's tool for quality assessment. RESULTS: Nine retrospective cohorts comparing ORP and RARP were selected and included in the meta-analysis. All studies reported the PSMs. Patients treated with RARP presented less risk of PSMs (risk difference -0.04, p 0.02) than those treated with ORP. Five articles reported hazard ratios for BCR-free survival. Patients treated with RARP had less risk of BCR (HR 0.72, 95% CI 0.58-0.89) than those treated with ORP. Reports for PSM assessment were considered of adequate quality, while the studies retrieved for BCR assessment were considered limited because of the heterogeneity of their results. CONCLUSION: Patients with high-risk prostate cancer treated with RARP have less risk of having PSM and BCR when compared to those treated with ORP. A strong conclusion is precluded due to the observational nature of the studies retrieved for our analysis.

Focal cryotherapy: step by step technique description.

INTRODUCTION AND OBJECTIVE: Focal cryotherapy emerged as an efficient option to treat favorable and localized prostate cancer (PCa). The purpose of this video is to describe the procedure step by step. MATERIALS AND METHODS: We present the case of a 68 year-old man with localized PCa in the anterior aspect of the prostate. RESULTS: The procedure is performed under general anesthesia, with the patient in lithotomy position. Briefly, the equipament utilized includes the cryotherapy console coupled with an ultrasound system, argon and helium gas bottles, cryoprobes, temperature probes and an urethral warming catheter. The procedure starts with a real-time trans-rectal prostate ultrasound, which is used to outline the prostate, the urethra and the rectal wall. The cryoprobes are pretested and placed in to the prostate through the perineum, following a grid template, along with the temperature sensors under ultrasound guidance. A cystoscopy confirms the right positioning of the needles and the urethral warming catheter is installed. Thereafter, the freeze sequence with argon gas is started, achieving extremely low temperatures (-40ºC) to induce tumor cell lysis. Sequentially, the thawing cycle is performed using helium gas. This process is repeated one time. Results among several series showed a biochemical disease-free survival between 71-93% at 9-70 month- follow-up, incontinence rates between 0-3.6% and erectile dysfunction between 0-42% (1-5). CONCLUSIONS: Focal cryotherapy is a feasible procedure to treat anterior PCa that may offer minimal morbidity, allowing good cancer control and better functional outcomes when compared to whole-gland treatment.

First off-time treatment prostate-specific antigen kinetics predicts survival in intermittent androgen deprivation for prostate cancer.

BACKGROUND: Prostate-specific antigen (PSA) doubling time is relying on an exponential kinetic pattern. This pattern has never been validated in the setting of intermittent androgen deprivation (IAD). Objective is to analyze the prognostic significance for PCa of recurrent patterns in PSA kinetics in patients undergoing IAD. METHODS: A retrospective study was conducted on 377 patients treated with IAD. On-treatment period (ONTP) consisted of gonadotropin-releasing hormone agonist injections combined with oral androgen receptor antagonist. Off-treatment period (OFTP) began when PSA was lower than 4 ng/ml. ONTP resumed when PSA was higher than 20 ng/ml. PSA values of each OFTP were fitted with three basic patterns: exponential (PSA(t) = λ.e(αt)), linear (PSA(t) = a.t), and power law (PSA(t) = a.t(c)). Univariate and multivariate Cox regression model analyzed predictive factors for oncologic outcomes. RESULTS: Only 45% of the analyzed OFTPs were exponential. Linear and power law PSA kinetics represented 7.5% and 7.7%, respectively. Remaining fraction of analyzed OFTPs (40%) exhibited complex kinetics. Exponential PSA kinetics during the first OFTP was significantly associated with worse oncologic outcome. The estimated 10-year cancer-specific survival (CSS) was 46% for exponential versus 80% for nonexponential PSA kinetics patterns. The corresponding 10-year probability of castration-resistant prostate cancer (CRPC) was 69% and 31% for the two patterns, respectively. Limitations include retrospective design and mixed indications for IAD. CONCLUSION: PSA kinetic fitted with exponential pattern in approximately half of the OFTPs. First OFTP exponential PSA kinetic was associated with a shorter time to CRPC and worse CSS.

A nomogram predicting the cancer-specific mortality in patients eligible for radical cystectomy evaluating clinical data and neoadjuvant cisplatinum-based chemotherapy.

PURPOSE: Despite the increasing number of studies confirming the importance of neoadjuvant chemotherapy (NC) in patients before radical cystectomy (RC) for bladder cancer (BCa), NC remains underused. The aim of our study was to develop a nomogram predicting the cancer-specific mortality (CSM) of patients who underwent RC for transitional BCa, evaluating the available clinical information and the NC. MATERIALS AND METHODS: We identified 423 patients who underwent RC and pelvic lymph node dissection, treated or not with NC, in two European high-volume centers between 2007 and 2013. Chi-square and Student's t tests were used to evaluate differences between groups. Kaplan-Meier curves were used to assess time to cancer-specific (CSS) and overall survival (OS). Uni- (UVA) and multivariable (MVA) Cox regression analyses were developed to address predictors of CSS and OS. A nomogram based on the Cox regression coefficient was developed to show the impact of NC on CSM. RESULTS: Mean follow-up was 20.3 months. Our population had mainly pT2 disease (77.1%), and 19.4% had preoperative cisplatinum-based NC. NC showed better CSS at UVA (p = 0.014) and MVA (odds ratio: 0.44; p = 0.043). Overall, the 3-year OS and the CSS rate were 69.3 and 79%, respectively. The nomogram developed to predict the 36-month CSM showed predictive accuracy of 67%. CONCLUSIONS: We developed the first nomogram predicting the 36-month CSM rate in patients with high-risk BCa according to the clinical data. Moreover, we demonstrate that preoperative cisplatinum-based chemotherapy is associated with better CSS.

Prostate histoscanning true targeting guided prostate biopsy: initial clinical experience.

OBJECTIVE: To evaluate the feasibility of prostate histoscanning true targeting (PHS-TT) guided transrectal ultrasound (TRUS) biopsy. METHODS: This is a prospective, single center, pilot study performed during February 2013-September 2013. All consecutive patients planned for prostate biopsy were included in the study, and all the procedure was performed by a single surgeon aided by the specialized true targeting software. Initially, the patients underwent PHS to map the abnormal areas within the prostate that were ≥0.2 cm(3). TRUS guided biopsies were performed targeting the abnormal areas with a specialized software. Additionally, routine bisextant biopsies were also taken. The final histopathology of the target cores was compared with the bisextant cores. RESULTS: A total of 43 patients underwent combined 'targeted PHS guided' and 'standard 12 core systematic' biopsies. The mean volume of abnormal area detected by PHS is 4.3 cm(3). The overall cancer detection rate was 46.5 % (20/43) with systemic cores and target cores detecting cancer in 44 % (19/43) and 26 % (11/43), respectively. The mean % cancer/core length of the PHS-TT cores were significantly higher than the systematic cores (55.4 vs. 37.5 %. p < 0.05). In biopsy naïve patients, the cancer detection rate (43.7 % vs. 14.8 %. p = 0.06) and the cancer positivity of the cores (30.1 vs. 6.8 %. p < 0.01) of target cores were higher than those patients with prior biopsies. CONCLUSION: PHS-TT is feasible and can be an effective tool for real-time guidance of prostate biopsies.

Evolution from laparoscopic to robotic nephron sparing surgery: a high-volume laparoscopic center experience on achieving 'trifecta' outcomes.

OBJECTIVE: To evaluate the transition from laparoscopic (LPN) to robotic partial nephrectomy (RPN) in our institution using 'trifecta' outcomes as surrogate marker of efficacy. PATIENTS AND METHODS: We identified 347 patients (LPN = 303, RPN = 44) in our prospectively maintained PN database between 2000 and 2014. The patients were chronologically divided into G1-first 151 LPN cases, G2-subsequent 152 LPN cases and G3-all RPN patients. Trifecta outcomes were defined as warm ischemia time (WIT) ≤25 min, no positive surgical margin (PSM) and complications ≤Clavien 2. Multivariable logistic model was used to analyze the predictors of the trifecta outcomes. RESULTS: The tumor complexity significantly increased from G1 to G3. We achieved lower WIT and less high-grade complication (Clavien ≥ 3) from G1 to G2, and the trend continued even with transition to RPN. PSM was consistently low throughout the transition. Renal functional outcomes always showed a significant positive trend, and with RPN, we achieved improved recovery of renal function (44 vs 57 vs 82 %, p < 0.05). The overall 'trifecta' rates increased significantly from G1 to G2 and reached 81.8 % in RPN (48 vs 75.6 vs 81 %, p < 0.01). Multivariate analysis has shown that the use of robot has significant effect on achieving overall trifecta. The limitations of the study are being retrospective and non-randomized, and the trifecta definitions were not externally validated. CONCLUSIONS: Our transition to RPN was essentially a continuation of our previous LPN experience as we continue to achieve higher 'trifecta' rates inspite of increasing tumor complexity.

Transperineal template-guided mapping biopsy of the prostate.

Accurate diagnosis of prostate cancer has eluded clinicians for decades. With our current understanding of prostate cancer, urologists should devise and confidently present the available treatment options ­ active surveillance/radical treatment/focal therapy to these patients. The diagnostic modalities used for prostate cancer have the dual problem of false negativity and overdiagnosis. Various modifications in the prostate biopsy techniques have increased the accuracy of cancer detection, but we are still far from an ideal diagnostic technique. Transperineal template-guided mapping biopsy of the prostate is an exhaustive biopsy technique that has been improvised over the past decade, and has shown superior results to other available modalities. We have carried out a PubMed search on the available experiences on this diagnostic modality, and along with our own experiences, we present a brief review on transperineal template-guided mapping biopsy of the prostate.

Positive surgical margins after minimally invasive radical prostatectomy in patients with pT2 and pT3a disease could be considered pathological upstaging.

OBJECTIVE: To assess the prognostic significance of positive surgical margins (PSMs) after minimally invasive radical prostatectomy (MIRP) in interaction with other established prognosis factors. PATIENTS AND METHODS: We retrospectively analysed data prospectively collected between 1998 and 2010 for 4628 consecutive patients who underwent MIRP for clinically localized prostate cancer. The impact of PSM on biochemical recurrence (BCR), defined as prostate-specific antigen (PSA) >0.2 ng/mL, was evaluated using multivariable Cox proportional hazards regression. Estimates of BCR-free survival were generated using the Kaplan-Meier method and compared among groups using the log-rank test. RESULTS: The median follow-up was 55 months. On multivariable analysis, PSM was an independent prognostic factor for BCR (adjusted hazard ratio: 2.14 for PSMs vs negative surgical margins (NSMs); 95% confidence interval [CI]: 1.86-2.45; P < 0.001). Other independent predictors for BCR were preoperative PSA, date of surgery, pT stage, Gleason score and lymph node involvement (all P < 0.001). The 5-year BCR-free probability was 80.6% (95% CI: 79-82.2) for NSMs vs 51% (95% CI: 47-55) for PSMs (log-rank P < 0.001). Patients with pT2 and pT3a PSMs had a similar prognosis to those with pT3a and pT3b NSMs, respectively (log-rank P ≥ 0.05). CONCLUSION: A PSM after MIRP is associated with 2.14-fold increased risk of BCR. In patients with pT2 and pT3a disease, a PSM could be considered a pathological upstaging.

Focal cryoablation: a treatment option for unilateral low-risk prostate cancer.

OBJECTIVES: To assess oncological (biochemical and histological recurrence) and functional (urinary and potency) outcomes in patients with unilateral low-risk organ-confined prostate cancer (PCa) treated with focal cryoablation (FC). PATIENTS AND METHODS: From January 2009 to March 2012, patients with localized PCa who refused active surveillance were assigned to a FC protocol. This was a prospective, single-arm cohort study. Inclusion criteria were: unilateral disease, clinical stage T1c to T2a, prostate-specific antigen (PSA) concentration <10 ng/mL, low volume index lesion and Gleason score ≤6 (3+3). Hemi-ablation was carried out using the Precise(TM) cryoablation system (Galil Medical, Inc., Arden Hills, MN, USA). Oncological (PSA values) and functional (International Prostate Symptom Score and International Index of Erectile Function (IIEF)-5 score) outcomes were analysed at 3-, 6- and 12-month follow-up. The primary endpoint for oncological efficacy, no cancer in ipsilateral side, was based on the 12-month mandatory biopsy. RESULTS: A total of 48 consecutive patients with a mean age of 67 years were included. The median (interquartile range) follow-up was 13.2 (7.4-26.5) months. Follow-up prostate biopsies were negative for the treated lobe in 86% of patients. The mean PSA concentration dropped significantly at 3 months (by 55%) but did not correlate well with positive biopsy results. Urinary symptoms were unchanged. A slight decrease in the IIEF-5 score was present at 3 months, but did not differ significantly from baseline at 6-month follow-up. There were 15% grade 1 and 4% grade 2 complications (Clavien classification). CONCLUSIONS: Focal cryoablation is a low-morbidity option in selected patients with low-risk PCa. We showed PSA concentration to be an unreliable marker for monitoring FC and recommend a protocol of mandatory biopsies for follow-up. A multicentre randomized controlled trial is necessary to confirm the low-morbidity and the biopsy-proven PCa cure rates.

Oncologic outcomes after minimally invasive radical prostatectomy in patients with seminal vesicle invasion (pT3b) without adjuvant therapy.

PURPOSE: To evaluate the long-term outcomes of patients with prostate cancer who have pathological pT3b N0-Nx, with postoperative PSA < 0.1 ng/ml and no systematic adjuvant treatment. MATERIALS AND METHODS: Using a monocentric prospectively maintained database, we identified among 2,142 men who underwent minimally invasive radical prostatectomy, 104 pT3b N0-Nx patients, with postoperative PSA < 0.1 ng/ml and at least 5 years of follow-up. Patients were considered for salvage treatment at biochemical recurrence (PSA ≥ 0.2 ng/ml). RESULTS: The median time of follow-up was 83.5 months (interquartile range [IQR]: 69-99). Overall, 102 patients (98 %) had T2 clinical stage or less. Specimen Gleason score was 7 in 71 patients (68 %) and <7 in 15 (14 %). Thirty-eight patients (37 %) were upgraded for Gleason score after radical prostatectomy. The overall 5-year probability of freedom from biochemical recurrence for the entire cohort was 55.8 % (95 % CI 45.8-65.8) and 73.3 % for patients who had specimen Gleason score <7 (p = 0.005). In univariate analysis, specimen Gleason score and surgical margin status were significant predictors for biochemical failure after radical prostatectomy (p = 0.05 and 0.007, respectively). In multivariate analysis, only specimen Gleason score >7 was significantly associated with biochemical failure (p = 0.009). CONCLUSION: SVI is an adverse prognostic factor, but it is not associated with a uniformly poor prognosis. Specimen Gleason score and surgical margin status are significant predictors of recurrence after radical prostatectomy in patients with prostate cancer and SVI.

How to diagnose and treat focal therapy failure and recurrence?

PURPOSE OF REVIEW: Focal therapy presents an alternative option for disease-targeted therapy while preserving erectile and urinary function without compromising oncological outcome. Such treatment, which preserves normal prostate parenchyma, presents a clinical challenge to the urologist, as typical disease surveillance parameters are not as reliable in post-ablation follow-up. We propose an integrated approach to post-ablation surveillance to identify treatment failure as well as recurrence. RECENT FINDINGS: Post-ablation prostate-specific antigen kinetics, imaging based on multiparametric MRI and control biopsies are the tools currently used to follow patients after focal therapy. Good treatment response is indicated by a negative control biopsy, absence of persistent lesion on post-treatment imaging and a reduction in prostate-specific antigen of at least 50%. SUMMARY: When histological evidence of therapeutic failure or recurrence is present, different options of management may be proposed to the patient including active surveillance, focal salvage therapy or radical salvage treatment, depending on the characteristics of the lesion found. A recommended post-ablation surveillance protocol is presented as well as a discussion of management strategies based on the data currently available.

Renal biopsies for small renal masses. For whom, when and how.

Objective of this manuscript is to provide an evidence-based analysis of the current status and future perspectives in kidney biopsies in small renal masses (BSRM). A PubMed search has been performed for all relevant urological literature regarding BSRM. A literature research of English, French and Spanish languages was performed using the Pubmed database from 2000 to February 2012 using the terms renal mass biopsy and renal tumor biopsy. Manuscripts providing a highest level of evidence were selected for the review.Clinical experience from author's Institutions is also reflected in the manuscript. Considerable technical advances have been made in imaging over the last decade. The latter allow for a comprehensive sharp diagnosis of small renal masses (SRM). Therapeutic decision for SRM's is supported by objective knowledge of histological features and renal biopsy represents an accurate and safe option to particularize treatment in renal incidentalomas. Furthermore, renal biopsies are incorporated in the application and follow-up of patients undergoing ablative therapies. An important number of clinical reports have been published in the subject but there is lack of technical standardization. The available experience is limited to referral centers and there are still up to 30% of biopsies that fail to provide clear diagnosis. Renal biopsies have significantly improved in its diagnostic accuracy and it is indicated when tissue diagnosis can change the therapeutic approach of SRM's. Meantime, the role of renal biopsies keeps on growing and limitations of the procedure are less when compared to the benefits it provides.

Evaluation of erectile function after laparoscopic radical prostatectomy in a single center.

INTRODUCTION: To evaluate erectile function among men who had undergone laparoscopic radical prostatectomy and received postoperative medical therapy for erectile dysfunction. MATERIALS AND METHODS: We performed a prospective study in men who underwent laparoscopic radical prostatectomy between September 2003 and November 2005 at our center and who received penile rehabilitation after surgery. All patients had antegrade interfascial dissection. They received 10 mg tadalafil on the fifth postoperative day and continued to receive it every other day, regardless of erectile function. Intracavernous injection of alprostadil was initiated at 3 or 6 months depending on response to treatment with tadalafil. Follow up evaluations were done at 3, 6, 12, 18 and 24 months. Oncologic and functional outcomes and compliance were assessed. Patients filled in International Index of Erectile Function-5 (IIEF-5) questionnaires. RESULTS: Of 1078 men who underwent laparoscopic radical prostatectomy during this time, 586 patients met inclusion criteria, complied with the study medication, and had complete data for 24 months. The patients had a median preoperative baseline IIEF-5 score of 22. A total of 150 patients (26%) underwent unilateral nerve-sparing surgery, while 436 patients (74%) had bilateral nerve-sparing surgery. At 24 months, 35% of patients who underwent unilateral nerve-sparing surgery and 68% of patients who underwent bilateral nerve-sparing surgery reported having sufficient erectile function for intercourse without using intracavernous injection of alprostadil. At 24 months after surgery, the median IIEF-5 score was 13 (1-25) for the whole cohort, 5 (1-25) for patients who had undergone unilateral nerve-sparing surgery, and 15 (1-25) for patients who had undergone bilateral nerve-sparing surgery. CONCLUSIONS: The findings suggest that adequate patient selection and postoperative medical intervention allows the preservation or recovery of erectile function after laparoscopic radical prostatectomy. Inaccurate selection of patients and postoperative assessment might explain inferior erectile function results following this surgery.

Comparison of the rate, location and size of positive surgical margins after laparoscopic and robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: • To review and compare the rate, location and size of positive surgical margins (PSMs) after pure laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP). PATIENTS AND METHODS: • The study comprised 200 patients who underwent RALP and 200 patients who underwent LRP up to January 2008. • We compared patient age, body mass index, preoperative prostate-specific antigen (PSA), preoperative stage and grade, prostate size, pathological stage and grade and neurovascular bundle preservation, as well as PSM rate, size and location. • Continuous and categorical data were compared using Student's t-test and Pearson's chi-squared test. • Multivariate regression analyses were used to identify preoperative and intraoperative predictors of PSMs. RESULTS: • Although the PSM rate was similar between the two groups (LRP: 12% vs RALP: 13.5%; P = 0.76), location and size were not. PSMs after LRP were mostly at the apex (58.3%; P = 0.038), while most PSMs after RALP were posterolateral ([PL] 48%; P = 0.046). • In addition, the median margin size after RALP was significantly smaller than after LRP (RALP: 2 mm vs LRP: 3.5 mm; P = 0.041). • In univariate and multivariate analyses, tumour-node-metastasis (TNM) stage and preoperative PSA were the only independent preoperative predictors of PSMs (P = 0.044 and P = 0.01, respectively). CONCLUSION: • The PSM risk is dependent on TNM stage and preoperative PSA and not the surgical technique, when comparing LRP with RALP.