Salvage high-intensity focused ultrasound (S-HIFU) for recurrence after primary radiotherapy of prostate cancer.

OBJECTIVES: To evaluate functional and oncological outcomes of salvage high-intensity focal ultrasound (S-HIFU) after external beam radiotherapy (EBRT) failure in prostate cancer (PCa) patients. METHODS: This single-center study included patients who underwent S-HIFU for local recurrence after EBRT between 2006 and 2023. Cancer-specific survival, metastasis-free survival and progression-free survival were illustrated using Kaplan-Meier curves. Disease progression was defined by one of the following criteria: increase of 2ng/mL or more above the PSA nadir, positive post-S-HIFU biopsy or initiation of androgen deprivation therapy (ADT). Multivariable Cox proportional hazards model was used to identify predictors of disease progression after S-HIFU. RESULTS: A total of 52 S-HIFU sessions for 48 patients were performed. Median time between EBRT and S-HIFU was 6.5 years. Median PSA before S-HIFU was 3.2ng/mL and median PSA nadir after S-HIFU was 0.58ng/mL. A total of 39 (81.3%) complications was recorded, including 3 (6.3%) high grade complications according to the Clavien-Dindo classification. After a median follow-up period of 6 years, 14 (29.2%) patients developed metastatic disease. Eighteen (37.5%) patients had no recurrence, whereas 30 (62.5%) patients received ADT for disease progression. The estimated 5-yr cancer-specific survival (CSS), metastasis-free survival (MFS) and progression-free survival rates (PFSR) were 100%, 79.9% (95% CI 67-92) and 41.2% (95% CI 74-96), respectively. The estimated 10-yr CSS, MFS and PFSR were 80% (95% CI 45-100), 50.7% (95% CI 19.4-82.1) and 14% (95% CI 10.8-45), respectively. The hazard of progression increased with the intermediate (HR 3.8; 95% CI 0.99 to 15; p=0.049) and high pre-EBRT d'Amico-s risk group (HR 4.1; 95% CI 0.98 to 16.2; p=0.050). Also, the time between EBRT and S-HIFU was significantly associated with risk of progression (HR 0.61; 95% CI 0.43 to 0.86; p=0.004). No significant difference linked to the disease progression (DP) risk was found between focal vs whole-gland treatment (p=0.70). CONCLUSION: Physicians should consider HIFU as a local salvage treatment after failed EBRT, thus avoiding or delaying palliative androgen deprivation therapy. Further studies are needed to improve patient selection for this therapy.

Modified holmium laser enucleation for benign prostatic obstruction to preserve sexual and ejaculatory function.

INTRODUCTION: To report ejaculatory and urinary results in patients who underwent holmium laser enucleation of the prostate (HoLEP) with selective laser enucleation of the median lobe (MLHoLEP). METHODS: Patients with lower urinary tract symptoms (LUTS)/benign prostatic obstruction (BPO) who underwent MLHoLEP to preserve ejaculatory function in a single center were retrospectively identified. Urinary function was assessed using International Prostate Score Symptom (IPSS), IPSS-Quality of Life index (IPSS-QoL), peak urinary flow (Qmax) and postvoid residual (PVR). Erectile function was assessed using International Index of Erectile Function (IIEF-5). In patients with preoperative antegrade ejaculation, retrograde ejaculation was routinely screened at each follow-up visit. Sexual and urinary functions at 3 and 12 months were compared with baseline values. RESULTS: A total of 55 patients met our inclusion criteria. A significant improvement in the IPSS, IPSS-QoL, PVR and Qmax was found at 3 and 12 months, compared with baseline (all P<0.05). Eight patients (14.5%) required surgical reintervention due to persistant LUTS/BPO. No significant changes in the erectile function were found at 3 (P=0.3) and 12 months (P>0.9). In patients with preoperative antegrade ejaculation (n=32), only four cases of de novo retrograde ejaculation were recorded postoperatively. CONCLUSION: MLHoLEP represents a new alternative for men with LUTS/BPO who wish to preserve their ejaculatory function. Patients should be aware that improvement in urinary function may be inferior to the traditional technique, with a higher reintervention rate due to persistent LUTS. LEVEL OF EVIDENCE: Grade 4.

Thulium Fiber Versus Holmium:Yttrium-aluminum-garnet Laser for Endoscopic Enucleation of the Prostate: A Systematic Review and Meta-analysis.

BACKGROUND AND OBJECTIVE: Thulium fiber laser (TFL) emerged as a competitor of holmium:yttrium-aluminum-garnet (Ho:YAG) laser for anatomic enucleation of the prostate (AEEP) in men with lower urinary tract symptoms (LUTS) related to benign prostatic obstruction (BPO). The aim was to compare the surgical outcomes of Ho:YAG and TFL for AEEP. METHODS: A literature search was conducted to identify reports published from inception until January 2024. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The coprimary outcomes were the postoperative International Prostate Symptom Score (IPSS), IPSS-Quality of Life (IPSS-QoL), and peak urinary flow (Qmax). KEY FINDINGS AND LIMITATIONS: Five studies met our inclusion criteria, and data from 1287 and 1555 patients who underwent AEEP with Ho:YAG (holmium laser enucleation of the prostate [HoLEP]) and TFL (thulium fiber laser enucleation of the prostate [ThuFLEP]), respectively, were reviewed. ThuFLEP was associated with a better IPSS at 3 mo even if the difference was not clinically significant (mean difference [MD] 0.59, 95% confidence interval [CI]: 0.29-0.88; p < 0.001). No difference was found for IPSS at 6-12 mo (p = 0.9), and IPSS-QoL at 3 mo (p = 0.9) and 6-12 mo (p = 0.2). HoLEP was associated with a better Qmax at 3 mo (MD 1.41 ml/s, 95% CI: 0.51-2.30; p = 0.002) and ThuFLEP at 6-12 mo (MD -2.61 ml/s, 95% CI: -4.68 to 0.59; p = 0.01), but the differences were not clinically significant. No difference was found in the major (p = 0.3) and overall (p = 0.3) complication rates. HoLEP was associated with shorter enucleation (MD -11.86, 95% CI: -22.36 to 1.36; p = 0.03) but not total operative time (p = 0.5). CONCLUSIONS AND CLINICAL IMPLICATIONS: The present review provides the most updated evidence on the impact of Ho:YAG and TFL in AEEP, demonstrating that these two energy sources are effective in relieving bothersome LUTS in men with BPO. PATIENT SUMMARY: Thulium fiber laser is a new energy source that can be used safely for performing endoscopic enucleation of the prostate in men with bothersome symptoms associated with benign prostatic enlargement.

Is There an Impact of Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted Biopsy in Clinically Significant Prostate Cancer Detection Rate? A Systematic Review and Meta-analysis.

CONTEXT: It is unclear whether a magnetic resonance imaging (MRI)-targeted transperineal (TP) biopsy can improve the detection of clinically significant prostate cancer (csPCa). OBJECTIVE: To compare the MRI-targeted TP and transrectal (TR) approaches for csPCa detection. EVIDENCE ACQUISITION: A literature search was conducted using the PubMed/Medline, Embase, and Web of Science databases to identify reports published until February 2023. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The primary outcome was the detection of csPCa (Gleason grade group ≥2). Sensitivity analyses were performed to investigate csPCa detection rates according to tumor location, Prostate Imaging Reporting and Data System (PI-RADS) score, and type of fusion (cognitive or software based). EVIDENCE SYNTHESIS: Eleven studies met our inclusion criteria, and data from 3522 and 5140 patients who underwent, respectively, TR and TP MRI-targeted biopsies were reviewed. No statistically significant difference in the detection of csPCa was observed between the TR and TP approaches (odds ratio [OR] 1.11, 95% confidence interval [CI] 0.98-1.25; p = 0.1). When stratifying patients according to lesion location, the TP approach was associated with higher csPCa detection in case of anterior (OR 2.17, 95% CI 1.46-3.22; p < 0.001) and apical (OR 1.86, 95% CI 1.14-3.03; p = 0.01) lesions. In the subgroup analysis based on PI-RADS score, the TP approach was associated with higher csPCa detection (OR 1.57, 95% CI 1.07-2.29; p = 0.02) in PI-RADS 4 lesions. Conversely, no difference was found in PI-RADS 3 and 5 lesions (p > 0.05). The main limitation was the retrospective design of most included studies. CONCLUSIONS: No significant association was found between the prostate biopsy approach and csPCa detection rate when we considered all biopsy indications. The TP approach provides a detection advantage in anterior and apical tumors, arguing for a preferred use of the TP approach in these lesion locations. PATIENT SUMMARY: The transperineal magnetic resonance imaging-targeted prostate biopsy approach appears to be more effective only for selected lesions. No clear benefit was seen for the transperineal approach in the overall population.

[Management of testicular torsion by a general surgeon isolated in Africa]. / Prise en charge de la torsion du testicule par un chirurgien généraliste isolé en Afrique.

The onset of sudden and intense scrotal pain exposes to several problems when it occurs in a young man in Africa. Among the possible etiologies, testicular torsion is the surgical emergency to rule out, because beyond 6 hours of evolution the functional prognosis of the testicle is concerned. The septic evolution towards a purulent melting, in case of exceeded torsion, is also possible. Of slightly lower incidence than in Western countries, lack of awareness of this pathology by local health actors, the precariousness or health isolation of certain populations in certain under-medicalized regions, contribute to diagnostic and therapeutic delays. This often leads to a pejorative development, loss of the testicle being directly correlated with the delay in treatment. Testicular torsion has thus been identified as one of the main causes of male infertility in Africa. However, clinical diagnosis and surgical treatment require few resources and remain accessible in an environment with low resources or in precarious conditions. Indeed, despite the contribution of ultrasound in certain situations, the clinical picture is at the center of the diagnosis and therapeutic decision making. At the slightest doubt, surgical exploration is necessary. The multi-tunic anatomy of the testicle facilitates its surgical fixation in the event of conservation, ideally by triangulation of single-strand non-absorbable thread. Simultaneous fixation of the contralateral testicle is currently the subject of debate in the literature. In Africa, the benefit/risk balance, taking into account in particular the difficulty of subsequent access to care, justifies, from our point of view, performing contralateral orchidopexy at the same time. Depending on the appearance of the testicle and, to a lesser extent, the duration of the evolution of the symptoms, orchidectomy may be necessary. This article describes the clinical picture of spermatic cord torsion and the orchidopexy technique.

Lymph Node Dissection During Radical Nephro-Ureterectomy for Upper Tract Urothelial Carcinoma: A Review.

Although lymphonodal dissection is well-accepted for muscle-invasive bladder cancer management, its role is still debated during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). The aim of this study was to summarize the current knowledge concerning the indication, anatomical template, prognostic, and therapeutic roles of lymph node dissection (LND) performed at the time of RNU. Quality control markers, such as the number of lymph nodes (LN) removed, lymph node density, and safety of the different surgical approaches, were assessed. We performed a narrative review using the PubMed and ClinicalTrials.gov databases. We identified and analyzed articles based on the practice and the role of lymph node dissection for non-metastatic UTUC. There are no clear guidelines regarding the indication of LND for UTUC, but aggressive tumors may beneficiate from lymphadenectomy since lymph node invasion is a clear independent poor prognostic factor, allowing for adjuvant treatments. It seems that an extended lymphadenectomy may provide therapeutic advantages as a higher number of nodes removed may be related to the removal of undetected LNs micrometastases and a subsequent improvement in recurrence rate and cancer-specific survival. Clear anatomical templates are thus needed based on the location and the laterality of the primary tumor.