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Background and Objective: The most widely accepted therapeutic alternatives for men with intermediate risk prostate cancer (PCa) are mainly represented by whole gland therapies such as surgery or radiotherapy. However, these treatments can carry in some cases profound functional side effects. With the improvement of risk assessment tools and imaging modalities, in particular with the introduction of multiparametric magnetic resonance imaging of the prostate, a fine topographic characterisation of PCa lesions within the prostatic gland is now possible. This has allowed the development of gland-sparing therapies such as focal therapy (FT) as a means to provide an even more tailored approach in order to safely reduce, where feasible, the harms carried by whole gland therapies. Unfortunately, adoption of FT has been considered so far investigational due to some unsolved issues that currently hamper the use of FT as a valid alternative. Here, we aim to identify the main aspects needed to move FT forward from investigational to a valid therapeutic alternative for clinically localized PCa. Methods: The literature discussing the evolution of focal therapy in the years and its current landscape was broadly searched to identify the factors hindering FT adoption and possible solutions. Key Content and Findings: There are three broad areas hindering FT as a valid therapeutic alternative: (I) Correct patient selection; (II) harmonising the different FT technologies; (III) the lack of oncological outcomes. Conclusions: By targeting the three aforementioned weaknesses of FT, greater adoption is expected, finally making FT a valid therapeutic alternative, potentially reshaping prostate cancer treatment and functional outcomes.
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BACKGROUND: The feasibility and safety of robot-assisted radical cystectomy (RARC) may be undermined by unfavorable preoperative surgical characteristics such as previous prostate surgery (PPS). OBJECTIVE: To compare perioperative outcomes for patients undergoing RARC with versus without a history of PPS. DESIGN, SETTING, AND PARTICIPANTS: The study included 220 consecutive patients treated with RARC and pelvic lymph node dissection for bladder cancer at a single European tertiary centre. Of these, 43 had previously undergone PPS, defined as transurethral resection of the prostate/holmium laser enucleation of the prostate (n=21) or robot-assisted radical prostatectomy (n=22). SURGICAL PROCEDURE: RARC in patients with a history of PPS. MEASUREMENTS: Data on postoperative complications were collected according to the quality criteria for accurate and comprehensive reporting of surgical outcomes recommended by the European Association of Urology guidelines. Multivariable logistic, linear, and Poisson regression analyses were performed to test the effect of PPS on surgical outcomes. RESULTS AND LIMITATIONS: Overall, 43 patients (20%) were treated with RARC after PPS. Operative time (OT) was longer in the PPS group (360 vs 330min; p<0.001). Patients with PPS experienced higher rates of intraoperative complications (19% vs 6.8%) and higher rates of 30-d (67% vs 39%), and Clavien-Dindo >3 (33% vs 16%) postoperative complications (all p<0.05). Moreover, the positive surgical margin (PSM) rate after RARC was higher in the PPS group (14% vs 4%; p=0.03). On multivariable analyses, PPS at RARC independently predicted higher risk of intraoperative (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.04-6.21; p=0.01) and 30-d complications (OR 2.26, 95% CI 1.05-5.22; p=0.02), as well as longer OT (relative risk [RR] 1.03, 95% CI 1.00-1.05; p=0.02) and length of stay (RR 1.13, 95% CI 1.02-1.26; p=0.02). Lack of randomization represents the main limitation. CONCLUSIONS: RARC in patients with a history of PPS is feasible, but it is associated with a higher risk of complications and longer OT and length of stay. Moreover, higher PSM rates have been reported for these patients. Thus, measures aimed at improving surgical outcomes appear to be warranted. PATIENT SUMMARY: We investigated the effect of previous prostate surgery (PPS) on surgical outcomes after robot-assisted removal of the bladder. We found that patients with PPS have a higher risk of complications and longer hospitalization after bladder removal. These patients deserve closer evaluation before this type of bladder operation.