Evaluation of Outcomes Following Focal Ablative Therapy for Treatment of Localized Clinically Significant Prostate Cancer in Patients >70 Years: A Multi-institute, Multi-energy 15-Year Experience.

PURPOSE: In older patients who do not wish to undergo watchful waiting, focal therapy could be an alternative to the more morbid radical treatment. We evaluated the role of focal therapy in patients 70 years and older as an alternative management modality. MATERIALS AND METHODS: A total of 649 patients across 11 UK sites receiving focal high-intensity focused ultrasound or cryotherapy between June 2006 and July 2020 reported within the UK-based HEAT (HIFU Evaluation and Assessment of Treatment) and ICE (International Cryotherapy Evaluation) registries were evaluated. Primary outcome was failure-free survival, defined by need for more than 1 focal reablation, progression to radical treatment, development of metastases, need for systemic treatment, or prostate cancer-specific death. This was compared to the failure-free survival in patients undergoing radical treatment via a propensity score weighted analysis. RESULTS: Median age was 74 years (IQR: 72, 77) and median follow-up 24 months (IQR: 12, 41). Sixty percent had intermediate-risk disease and 35% high-risk disease. A total of 113 patients (17%) required further treatment. Sixteen had radical treatment and 44 required systemic treatment. Failure-free survival was 82% (95% CI: 76%-87%) at 5 years. Comparing patients who had radical therapy to those who had focal therapy, 5-year failure-free survival was 96% (95% CI: 93%-100%) and 82% (95% CI: 75%-91%) respectively (P < .001). Ninety-three percent of those in the radical treatment arm had received radiotherapy as their primary treatment with its associated use of androgen deprivation therapy, thereby leading to potential overestimation of treatment success in the radical treatment arm, especially given the similar metastases-free and overall survival rates seen. CONCLUSIONS: We propose focal therapy to be an effective management option for the older or comorbid patient who is unsuitable for or not willing to undergo radical treatment.

The rapid assessment for prostate imaging and diagnosis (RAPID) prostate cancer diagnostic pathway.

OBJECTIVE: To report outcomes within the Rapid Assessment for Prostate Imaging and Diagnosis (RAPID) diagnostic pathway, introduced to reduce patient and healthcare burdens and standardize delivery of pre-biopsy multiparametric magnetic resonance imaging (MRI) and transperineal biopsy. PATIENTS AND METHODS: A total of 2130 patients from three centres who completed the RAPID pathway (3 April 2017 to 31 March 2020) were consecutively entered as a prospective registry. These patients were also compared to a pre-RAPID cohort of 2435 patients. Patients on the RAPID pathway with an MRI score 4 or 5 and those with PSA density ≥0.12 and an MRI score 3 were advised to undergo a biopsy. Primary outcomes were rates of biopsy and cancer detection. Secondary outcomes included comparison of transperineal biopsy techniques, patient acceptability and changes in time to diagnosis before and after the introduction of RAPID. RESULTS: The median patient age and PSA level were 66 years and 6.6 ng/mL, respectively. Biopsy could be omitted in 43% of patients (920/2130). A further 7.9% of patients (168/2130) declined a recommendation for biopsy. The percentage of biopsies avoided among sites varied (45% vs 36% vs 51%; P < 0.001). In all, 30% (221/742) had a local anaesthetic (grid and stepper) transperineal biopsy. Clinically significant cancer detection (any Gleason score ≥3 + 4) was 26% (560/2130) and detection of Gleason score 3 + 3 alone constituted 5.8% (124/2130); detection of Gleason score 3 + 3 did not significantly vary among sites (P = 0.7). Among participants who received a transperineal targeted biopsy, there was no difference in cancer detection rates among local anaesthetic, sedation and general anaesthetic groups. In the 2435 patients from the pre-RAPID cohor, time to diagnosis was 32.1 days (95% confidence interval [CI] 29.3-34.9) compared to 15.9 days (95% CI 12.9-34.9) in the RAPID group. A total of 141 consecutive patient satisfaction surveys indicated a high satisfaction rate with the pathway; 50% indicated a preference for having all tests on a single day. CONCLUSIONS: The RAPID prostate cancer diagnostic pathway allows 43% of men to avoid a biopsy while preserving good detection of clinically significant cancers and low detection of insignificant cancers, although there were some centre-level variations.

Multiparametric ultrasound versus multiparametric MRI to diagnose prostate cancer (CADMUS): a prospective, multicentre, paired-cohort, confirmatory study.

BACKGROUND: Multiparametric MRI of the prostate followed by targeted biopsy is recommended for patients at risk of prostate cancer. However, multiparametric ultrasound is more readily available than multiparametric MRI. Data from paired-cohort validation studies and randomised, controlled trials support the use of multiparametric MRI, whereas the evidence for individual ultrasound methods and multiparametric ultrasound is only derived from case series. We aimed to establish the overall agreement between multiparametric ultrasound and multiparametric MRI to diagnose clinically significant prostate cancer. METHODS: We conducted a prospective, multicentre, paired-cohort, confirmatory study in seven hospitals in the UK. Patients at risk of prostate cancer, aged 18 years or older, with an elevated prostate-specific antigen concentration or abnormal findings on digital rectal examination underwent both multiparametric ultrasound and multiparametric MRI. Multiparametric ultrasound consisted of B-mode, colour Doppler, real-time elastography, and contrast-enhanced ultrasound. Multiparametric MRI included high-resolution T2-weighted images, diffusion-weighted imaging (dedicated high B 1400 s/mm2 or 2000 s/mm2 and apparent diffusion coefficient map), and dynamic contrast-enhanced axial T1-weighted images. Patients with positive findings on multiparametric ultrasound or multiparametric MRI underwent targeted biopsies but were masked to their test results. If both tests yielded positive findings, the order of targeting at biopsy was randomly assigned (1:1) using stratified (according to centre only) block randomisation with randomly varying block sizes. The co-primary endpoints were the proportion of positive lesions on, and agreement between, multiparametric MRI and multiparametric ultrasound in identifying suspicious lesions (Likert score of ≥3), and detection of clinically significant cancer (defined as a Gleason score of ≥4 + 3 in any area or a maximum cancer core length of ≥6 mm of any grade [PROMIS definition 1]) in those patients who underwent a biopsy. Adverse events were defined according to Good Clinical Practice and trial regulatory guidelines. The trial is registered on ISRCTN, 38541912, and ClinicalTrials.gov, NCT02712684, with recruitment and follow-up completed. FINDINGS: Between March 15, 2016, and Nov 7, 2019, 370 eligible patients were enrolled; 306 patients completed both multiparametric ultrasound and multiparametric MRI and 257 underwent a prostate biopsy. Multiparametric ultrasound was positive in 272 (89% [95% CI 85-92]) of 306 patients and multiparametric MRI was positive in 238 patients (78% [73-82]; difference 11·1% [95% CI 5·1-17·1]). Positive test agreement was 73·2% (95% CI 67·9-78·1; κ=0·06 [95% CI -0·56 to 0·17]). Any cancer was detected in 133 (52% [95% CI 45·5-58]) of 257 patients, with 83 (32% [26-38]) of 257 being clinically significant by PROMIS definition 1. Each test alone would result in multiparametric ultrasound detecting PROMIS definition 1 cancer in 66 (26% [95% CI 21-32]) of 257 patients who had biopsies and multiparametric MRI detecting it in 77 (30% [24-36]; difference -4·3% [95% CI -8·3% to -0·3]). Combining both tests detected 83 (32% [95% CI 27-38]) of 257 clinically significant cancers as per PROMIS definition 1; of these 83 cancers, six (7% [95% CI 3-15]) were detected exclusively with multiparametric ultrasound, and 17 (20% [12-31]) were exclusively detected by multiparametric MRI (agreement 91·1% [95% CI 86·9-94·2]; κ=0·78 [95% CI 0·69-0·86]). No serious adverse events were related to trial activity. INTERPRETATION: Multiparametric ultrasound detected 4·3% fewer clinically significant prostate cancers than multiparametric MRI, but it would lead to 11·1% more patients being referred for a biopsy. Multiparametric ultrasound could be an alternative to multiparametric MRI as a first test for patients at risk of prostate cancer, particularly if multiparametric MRI cannot be carried out. Both imaging tests missed clinically significant cancers detected by the other, so the use of both would increase the detection of clinically significant prostate cancers compared with using each test alone. FUNDING: The Jon Moulton Charity Trust, Prostate Cancer UK, and UCLH Charity and Barts Charity.

Prostate cancer in transgender women: what does a urologist need to know?

OBJECTIVE: To review of the existing literature, current guidelines and standard of practice related to prostate cancer in transgender women, as the transgender population share many of the same healthcare needs as their cisgender counterparts, but may have additional specialist needs. MATERIALS AND METHODS: We performed a non-systematic review of the literature, current guidelines and standard of practice related to prostate cancer in transgender women. RESULTS: Our search revealed 10 case reports of prostate cancer in transgender women, four specialist opinion papers, six cohort studies, and four systematic reviews. The information in these publications were assimilated to produce a review of prostate cancer in transgender women. CONCLUSION: The risk of prostate cancer in transgender women who are not on gender-affirming hormone therapy (GAHT) or who have not had gender-affirming surgery (GAS) and gender non-conforming individuals (who may never commence GAHT or have GAS) is the same as that in the cis male population. In these patients, healthcare professionals need to be able to discuss screening, diagnostic and treatment options considering future wishes for gender-affirming treatment. Prostate cancer incidence in transgender women on GAHT or following GAS is lower than age-matched cis-male counterparts, but diagnosis and treatment is more nuanced. The present review discusses the existing literature about development and incidence of prostate cancer in this population, and makes recommendations about screening, the usefulness of diagnostic tools e.g. prostate-specific antigen and magnetic resonance imaging, and considerations when formulating treatment. Potential directions for future research are discussed, which will hopefully lead to development of robust evidence-based guidelines for the diagnosis and management of prostate cancer in transgender women.

A Comparison of Prostate Cancer Detection between Visual Estimation (Cognitive Registration) and Image Fusion (Software Registration) Targeted Transperineal Prostate Biopsy.

PURPOSE: We compared clinically significant prostate cancer detection by visual estimation and image fusion targeted transperineal prostate biopsy. MATERIALS AND METHODS: This multicenter study included patients with multiparametric magnetic resonance imaging lesions undergoing visual estimation or image fusion targeted transperineal biopsy (April 2017-March 2020). Propensity score matching was performed using demographics (age and ethnicity), clinical features (prostate specific antigen, prostate volume, prostate specific antigen density and digital rectal examination), multiparametric magnetic resonance imaging variables (number of lesions, PI-RADS® score, index lesion diameter, whether the lesion was diffuse and radiological T stage) and biopsy factors (number of cores, operator experience and anesthetic type). Matched groups were compared overall and by operator grade, PI-RADS score, lesion multiplicity, prostate volume and anesthetic type using targeted-only and targeted plus systematic histology. Multiple clinically significant prostate cancer thresholds were evaluated (primary: Gleason ≥3+4). RESULTS: A total of 1,071 patients with a median age of 67.3 years (IQR 61.3-72.4), median prostate specific antigen of 7.5 ng/ml (IQR 5.3-11.2) and 1,430 total lesions underwent targeted-only biopsies (visual estimation: 372 patients, 494 lesions; image fusion: 699 patients, 936 lesions). A total of 770 patients with a median age of 67.4 years (IQR 61-72.1), median prostate specific antigen of 7.1 ng/ml (IQR 5.2-10.6) and 919 total lesions underwent targeted plus systematic biopsies (visual estimation: 271 patients, 322 lesions; image fusion: 499 patients, 597 lesions). Matched comparisons demonstrated no overall difference in clinically significant prostate cancer detection between visual estimation and image fusion (primary: targeted-only 54% vs 57.4%, p=0.302; targeted plus systematic 51.2% vs 58.2%, p=0.123). Senior urologists had significantly higher detection rates using image fusion (primary: targeted-only 45.4% vs 63.7%, p=0.001; targeted plus systematic 39.4% vs 64.5%, p <0.001). CONCLUSIONS: We found no overall difference in clinically significant prostate cancer detection, although image fusion may be superior in experienced hands.

Likert vs PI-RADS v2: a comparison of two radiological scoring systems for detection of clinically significant prostate cancer.

OBJECTIVE: To compare the clinical validity and utility of Likert assessment and the Prostate Imaging Reporting and Data System (PI-RADS) v2 in the detection of clinically significant and insignificant prostate cancer. PATIENTS AND METHODS: A total of 489 pre-biopsy multiparametric magnetic resonance imaging (mpMRI) scans in consecutive patients were subject to prospective paired reporting using both Likert and PI-RADS v2 by expert uro-radiologists. Patients were offered biopsy for any Likert or PI-RADS score ≥4 or a score of 3 with PSA density ≥0.12 ng/mL/mL. Utility was evaluated in terms of proportion biopsied, and proportion of clinically significant and insignificant cancer detected (both overall and on a 'per score' basis). In those patients biopsied, the overall accuracy of each system was assessed by calculating total and partial area under the receiver-operating characteristic (ROC) curves. The primary threshold of significance was Gleason ≥3 + 4. Secondary thresholds of Gleason ≥4 + 3, Ahmed/UCL1 (Gleason ≥4 + 3 or maximum cancer core length [CCL] ≥6 or total CCL≥6) and Ahmed/UCL2 (Gleason ≥3 + 4 or maximum CCL ≥4 or total CCL ≥6) were also used. RESULTS: The median (interquartile range [IQR]) age was 66 (60-72) years and the median (IQR) prostate-specific antigen level was 7 (5-10) ng/mL. A similar proportion of men met the biopsy threshold and underwent biopsy in both groups (83.8% [Likert] vs 84.8% [PI-RADS v2]; P = 0.704). The Likert system predicted more clinically significant cancers than PI-RADS across all disease thresholds. Rates of insignificant cancers were comparable in each group. ROC analysis of biopsied patients showed that, although both scoring systems performed well as predictors of significant cancer, Likert scoring was superior to PI-RADS v2, exhibiting higher total and partial areas under the ROC curve. CONCLUSIONS: Both scoring systems demonstrated good diagnostic performance, with similar rates of decision to biopsy. Overall, Likert was superior by all definitions of clinically significant prostate cancer. It has the advantages of being flexible, intuitive and allowing inclusion of clinical data. However, its use should only be considered once radiologists have developed sufficient experience in reporting prostate mpMRI.

Severe depression and anxiety in women with overactive bladder.

AIM: Depression and anxiety are prevalent psychiatric conditions and are associated with overactive bladder. The objective of this study was to determine prevalence and severity of anxiety and depression associated with overactive bladder (OAB) in women. METHODS: 274 women with clinical diagnosis of OAB were recruited from 2012 to 2015. They were submitted to the International Consultation on Incontinence Questionnaire-Overactive Bladder (ICIQ-OAB), the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI). RESULTS: Severe or moderate depression was present in 59.8% of women and severe or moderate anxiety was identified in 62.4%. Higher scores of depression and anxiety were associated with higher scores of ICIQ-OAB (P = 0.0031 and 0.0049). Women with severe depression had higher nocturia score than those with mild depression (P = 0.0046). Also, women with severe depression had higher urgency incontinence score than those with minimal depression (P = 0.0261). Patients with severe anxiety had higher nocturia score than those with minimal anxiety (P = 0.0118) and women with moderate anxiety had higher urgency incontinence score than with minimal anxiety (P = 0.0300). CONCLUSIONS: Moderate or severe depression and anxiety are prevalent in women with OAB. There is a correlation between intensity of OAB symptoms with depression and anxiety. Anxiety and depression levels are mainly related with urgency incontinence and nocturia.

Clinical and ultrasonographic evaluation of the pelvic floor in primiparous women: a cross-sectional study.

INTRODUCTION AND HYPOTHESIS: We used clinical examination and transperineal 3D/4D ultrasound (US) to evaluate pelvic floor muscles (PFM) after different delivery modes. METHODS: Women were surveyed using validated questionnaires. PFM were evaluated and classified according to the Modified Oxford Scale following 3D/4D transperineal US. For statistical analysis, Kruskal-Wallis, Mann-Whitney, chi-square, and Fisher exact tests were used. RESULTS: Fifty-three women were evaluated: 32 with previous vaginal delivery (VD) and 21 with cesarean section (CS) (8 nonelective and 13 elective). No significant difference among groups was observed regarding urinary incontinence (UI) after delivery (p = 0.39), loss of muscle strength referred by the patient (p = 0.48), or evaluated through digital examination (p = 0.87). No patient with elective CS had avulsion, with difference between VD and elective CS (p = 0.008). US evaluation identified no differences in bladder-neck elevation (p = 0.69) or descent (p = 0.65) , and no difference in genital hiatus size (p = 0.35), levator ani thickness (p = 0.35 -0.44), or presence of major or minor levator ani avulsion (p = 0.10). CONCLUSIONS: We evaluated primiparous women within 12 to 24 months of delivery and found that VD was associated with PFM avulsion. There was no difference among VD and nonelective or elective CS in symptomatology or other anatomic alterations evaluated through 3D/4D transperineal US.

Weaknesses in the continuity of care for preterm infants discharged from the neonatal unit.

OBJECTIVE: To identify weaknesses in the continuity of care for preterm infants discharged from a neonatal unit, based on the perspective of professionals in the family health strategy. METHOD: Qualitative research, carried out with 16 professionals from four health regions in a capital city in the center-west of Brazil. Data collection took place from October to December 2020, through semi-structured, individual, and in-person interviews. Data underwent content analysis, supported by the concept of continuity of care. RESULTS: The analysis consisted of three categories: Challenges for care in the unit and referral to specialized services; weak interactions between the preterm baby's family and health professionals; Information: essential aspect for the connection between health professionals and the family of the preterm newborn. CONCLUSION: Health services are shown to be fragile in terms of the dimensions of continuity of care, contributing to the discontinuity of care for preterm children.

Focal therapy versus radical prostatectomy and external beam radiotherapy as primary treatment options for non-metastatic prostate cancer: results of a cost-effectiveness analysis.

AIMS: Focal therapy treats individual areas of tumour in non-metastatic prostate cancer in patients unsuitable for active surveillance. The aim of this work was to evaluate the cost-effectiveness of focal therapy versus prostatectomy and external beam radiotherapy (EBRT). MATERIALS AND METHODS: A Markov cohort health state transition model with four health states (stable disease, local recurrence, metastatic disease and death) was created, evaluating costs and utilities over a 10-year time horizon for patients diagnosed with non-metastatic prostate cancer. National Health Service (NHS) for England perspective was used, based on direct healthcare costs. Clinical transition probabilities were derived from prostate cancer registries in patients undergoing radical prostatectomy, EBRT and focal therapy using cryotherapy (Boston Scientific) or high-intensity focused ultrasound (HIFU) (Sonablate). Propensity score matching was used to ensure that at-risk populations were comparable. Variables included age, prostate-specific antigen (PSA), International Society of Urological Pathology (ISUP) grade group, maximum cancer core length (mm), T-stage and year of treatment. RESULTS: Focal therapy was associated with a lower overall cost and higher quality-adjusted life year (QALY) gains than either prostatectomy or EBRT, dominating both treatment strategies. Positive incremental net monetary benefit (NMB) values confirm focal therapy as cost-effective versus the alternatives at a willingness to pay (WTP) threshold of £30,000/QALY. One-way deterministic sensitivity analyses revealed consistent results. LIMITATIONS: Data used to calculate the transition probabilities were derived from a limited number of hospitals meaning that other potential treatment options were excluded. Limited data were available on later outcomes and none on quality of life data, therefore, literature-based estimates were used. CONCLUSIONS: Cost-effectiveness modelling demonstrates use of focal therapy (cryotherapy or HIFU) is associated with greater QALY gains at a lower overall cost than either radical prostatectomy or EBRT, representing good value for money in the NHS.

Focal therapy can be used for the primary treatment of individual areas of cancer in those patients with prostate cancer whose disease has not spread (localized or non-metastatic prostate cancer) and whose disease is unsuitable for active monitoring. Focal therapy in these patients results in similar control of the cancer to more invasive therapies, such as surgical removal of the prostate and radiotherapy, with the benefit of fewer sexual, urinary and rectal side effects. This work considered whether using focal therapy (either freezing the cancer cells using cryotherapy or using high-intensity focused ultrasound [HIFU] to destroy cancer cells) was good value for money in the National Health Service (NHS) compared with surgery or radiotherapy. An economic model was developed which considered the relative impact of treatment with focal therapies, surgery or radiotherapy within the NHS in England. Previously collected information from people undergoing treatment for their prostate cancer, together with published literature and clinical opinion, was used within the model to predict the treatment pathway, costs incurred and the results of treatment in terms of patient benefits (effectiveness and quality of life). The model showed that focal therapy using either cryotherapy or HIFU was associated with a lower overall cost and higher patient benefit than either surgery or radiotherapy, indicating that focal therapy represents good value for money in the NHS.

Predicting the Need for Biopsy to Detect Clinically Significant Prostate Cancer in Patients with a Magnetic Resonance Imaging-detected Prostate Imaging Reporting and Data System/Likert ≥3 Lesion: Development and Multinational External Validation of the Imperial Rapid Access to Prostate Imaging and Diagnosis Risk Score.

BACKGROUND: Although multiparametric magnetic resonance imaging (MRI) has high sensitivity, its lower specificity leads to a high prevalence of false-positive lesions requiring biopsy. OBJECTIVE: To develop and externally validate a scoring system for MRI-detected Prostate Imaging Reporting and Data System (PIRADS)/Likert ≥3 lesions containing clinically significant prostate cancer (csPCa). DESIGN, SETTING, AND PARTICIPANTS: The multicentre Rapid Access to Prostate Imaging and Diagnosis (RAPID) pathway included 1189 patients referred to urology due to elevated age-specific prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE); April 27, 2017 to October 25, 2019. INTERVENTION: Visual-registration or image-fusion targeted and systematic transperineal biopsies for an MRI score of ≥4 or 3 + PSA density ≥0.12 ng/ml/ml. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Fourteen variables were used in multivariable logistic regression for Gleason ≥3 + 4 (primary) and Gleason ≥4 + 3, and PROMIS definition 1 (any ≥4 + 3 or ≥6 mm any grade; secondary). Nomograms were created and a decision curve analysis (DCA) was performed. Models with varying complexity were externally validated in 2374 patients from six international cohorts. RESULTS AND LIMITATIONS: The five-item Imperial RAPID risk score used age, PSA density, prior negative biopsy, prostate volume, and highest MRI score (corrected c-index for Gleason ≥3 + 4 of 0.82 and 0.80-0.86 externally). Incorporating family history, DRE, and Black ethnicity within the eight-item Imperial RAPID risk score provided similar outcomes. The DCA showed similar superiority of all models, with net benefit differences increasing in higher threshold probabilities. At 20%, 30%, and 40% of predicted Gleason ≥3 + 4 prostate cancer, the RAPID risk score was able to reduce, respectively, 11%, 21%, and 31% of biopsies against 1.8%, 6.2%, and 14% of missed csPCa (or 9.6%, 17%, and 26% of foregone biopsies, respectively). CONCLUSIONS: The Imperial RAPID risk score provides a standardised tool for the prediction of csPCa in patients with an MRI-detected PIRADS/Likert ≥3 lesion and can support the decision for prostate biopsy. PATIENT SUMMARY: In this multinational study, we developed a scoring system incorporating clinical and magnetic resonance imaging characteristics to predict which patients have prostate cancer requiring treatment and which patients can safely forego an invasive prostate biopsy. This model was validated in several other countries.

Cancer Control Outcomes Following Focal Therapy Using High-intensity Focused Ultrasound in 1379 Men with Nonmetastatic Prostate Cancer: A Multi-institute 15-year Experience.

BACKGROUND: Focal therapy aims to treat areas of cancer to confer oncological control whilst reducing treatment-related functional detriment. OBJECTIVE: To report oncological outcomes and adverse events following focal high-intensity focused ultrasound (HIFU) for treating nonmetastatic prostate cancer. DESIGN, SETTING, AND PARTICIPANTS: An analysis of 1379 patients with ≥6 mo of follow-up prospectively recorded in the HIFU Evaluation and Assessment of Treatment (HEAT) registry from 13 UK centres (2005-2020) was conducted. Five or more years of follow-up was available for 325 (24%) patients. Focal HIFU therapy used a transrectal ultrasound-guided device (Sonablate; Sonacare Inc., Charlotte, NC, USA). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Failure-free survival (FFS) was primarily defined as avoidance of no evidence of disease to require salvage whole-gland or systemic treatment, or metastases or prostate cancer-specific mortality. Differences in FFS between D'Amico risk groups were determined using a log-rank analysis. Adverse events were reported using Clavien-Dindo classification. RESULTS AND LIMITATIONS: The median (interquartile range) age was 66 (60-71) yr and prostate-specific antigen was 6.9 (4.9-9.4) ng/ml with D'Amico intermediate risk in 65% (896/1379) and high risk in 28% (386/1379). The overall median follow-up was 32 (17-58) mo; for those with ≥5 yr of follow-up, it was 82 (72-94). A total of 252 patients had repeat focal treatment due to residual or recurrent cancer; overall 92 patients required salvage whole-gland treatment. Kaplan-Meier 7-yr FFS was 69% (64-74%). Seven-year FFS in intermediate- and high-risk cancers was 68% (95% confidence interval [CI] 62-75%) and 65% (95% CI 56-74%; p = 0.3). Clavien-Dindo >2 adverse events occurred in 0.5% (7/1379). The median 10-yr follow-up is lacking. CONCLUSIONS: Focal HIFU in carefully selected patients with clinically significant prostate cancer, with six and three of ten patients having, respectively, intermediate- and high-risk cancer, has good cancer control in the medium term. PATIENT SUMMARY: Focal high-intensity focused ultrasound treatment to areas of prostate with cancer can provide an alternative to treating the whole prostate. This treatment modality has good medium-term cancer control over 7 yr, although 10-yr data are not yet available.

Paternal age and assisted reproductive technology: problem solver or trouble maker?

In our society, the number of couples with advanced reproductive age seeking fertility treatment is increasing steadily. While the negative effect of female age on assisted reproductive technology (ART) outcomes is well established, the impact of paternal age needs to be clarified. We reviewed the current literature to determine whether advanced paternal age affects the results of ART and the health of resulting offspring. We found that the published literature is overall supportive of a positive association between advanced paternal age (>40 years) and semen quality deterioration. However, the existing evidence does not corroborate nor discard the influence of advanced paternal age on ART outcomes. Similarly, the effect of paternal age on the health of ART offspring remains equivocal, although data from naturally-conceived children clearly indicates that advanced paternal age increases the frequency of genetic, neurodevelopmental, and psychiatric diseases in the progeny. Noteworthy, the current literature is limited and subjected to bias due to the impact of maternal age as a critical confounder. Health care providers should discuss with concerned couples the available options to counteract the possible negative influence of advanced paternal age on ART outcomes and health of resulting offspring. These include identification and treatment of underlying conditions with potential negative long-term effects on fertility, sperm freezing at a young age, and use of antioxidant supplements for men at risk of excessive oxidative stress. Aged male partner from couples undergoing ART, in particular men of 50 years and older, should consider use of preimplantation genetic testing as a means to detect embryo abnormalities and select euploid embryos for transfer to the uterine cavity.

Weaknesses in the continuity of care for preterm infants discharged from the neonatal unit / Debilidades en la continuidad de la atención a los recién nacidos prematuros egresados de la unidad neonatal / Fragilidades para a continuidade do cuidado ao pré-termo egressoda unidade neonatal

ABSTRACT Objective: To identify weaknesses in the continuity of care for preterm infants discharged from a neonatal unit, based on the perspective of professionals in the family health strategy. Method: Qualitative research, carried out with 16 professionals from four health regions in a capital city in the center-west of Brazil. Data collection took place from October to December 2020, through semi-structured, individual, and in-person interviews. Data underwent content analysis, supported by the concept of continuity of care. Results: The analysis consisted of three categories: Challenges for care in the unit and referral to specialized services; weak interactions between the preterm baby's family and health professionals; Information: essential aspect for the connection between health professionals and the family of the preterm newborn. Conclusion: Health services are shown to be fragile in terms of the dimensions of continuity of care, contributing to the discontinuity of care for preterm children.

RESUMEN Objetivo: Identificar debilidades en la continuidad de la atención al recién nacido prematuro egresado de una unidad neonatal, desde la perspectiva de los profesionales de la estrategia de salud de la familia. Método: Investigación cualitativa, realizada con 16 profesionales de cuatro regiones sanitarias de una capital del centro-oeste de Brasil. La recolección de datos se realizó de octubre a diciembre de 2020, mediante entrevistas semiestructuradas, individuales y presenciales. Los datos fueron sometidos a análisis de contenido, sustentado en el concepto de continuidad de la atención. Resultados: Tres categorías comprendieron el análisis: Desafíos para la atención en la unidad y derivación a servicios especializados; Interacciones débiles entre la familia del bebé prematuro y los profesionales de la salud; Información: aspecto esencial para la vinculación entre los profesionales de la salud y la familia del recién nacido prematuro. Conclusión: Los servicios de salud son frágiles en términos de continuidad de la atención, lo que contribuye a la discontinuidad de la atención a los niños nacidos prematuros.

RESUMO Objetivo: Identificar as fragilidades para a continuidade do cuidado ao pré-termo egresso de unidade neonatal, a partir da perspectiva de profissionais da estratégia saúde da família. Método: Pesquisa qualitativa, realizada junto a 16 profissionais de quatro regionais de saúde de uma capital do centro-oeste do Brasil. A coleta dos dados ocorreu nos meses de outubro a dezembro de 2020, por meio de entrevistas semiestruturadas, individuais e presenciais. Os dados foram submetidos à analise de conteúdo, sustentada pelo conceito da continuidade do cuidado. Resultados: Três categorias compuseram a análise: Desafios para o atendimento na unidade e para o encaminhamento aos serviços especializados; Interações frágeis entre família do pré-termo e profissionais de saúde; Informação: aspecto essencial para a conexão entre profissionais de saúde e família do recém-nascido pré-termo. Conclusão: Os serviços de saúde mostram-se frágeis quanto às dimensões da continuidade do cuidado colaborando para a descontinuidade da atenção à criança nascida pré-termo.

Fatores perinatais associados ao desconforto respiratório do recém-nascido / Factores perinatales asociados con malestar respiratorio en el recién nacido / Perinatal factors associated with respiratory discomfort in the newborn

Objetivo: Analisar a prevalência e fatores perinatais associados ao desconforto respiratório em neonatosinternados em uma Unidade de Terapia Intensiva Neonatal em Cuiabá, Mato Grosso. Método: Estudo transversal, analítico, retrospectivo, com coleta dos dados entre os meses de outubro e dezembro de 2019, em 844 prontuários de recém-nascidos internados entre 2014 e 2018. Utilizou-se a Regressão de Poisson, considerando significância de 0,05 (p<0,05). Resultados: do total de neonatos, 49,05% foram diagnosticados com desconforto respiratório. A prevalência da doença foi 60% maior entre os pré-termos, 36% maior entre os que apresentaram histórico de uso materno de esteroide antenatal e 25% maior entre os de baixo peso ao nascer. Observou-se, ainda, que a prevalência do uso de capacete de oxigênio, pressão positiva contínua nas vias aéreas e dieta parenteral foi 91%, 89% e 18% maior entre os neonatos com a doença. No entanto, o uso de fórmulas e leite materno em neonatos com desconforto respiratório foi 85% e 62% menor do que os neonatos que não apresentavam tal condição. Conclusão: Indica-se maior atenção da equipe de saúde e gestores, uma vez que o conhecimento desses fatores poderá auxiliá-los no planejamento de ações para consolidação da rede de atenção perinatal, com reestruturação e qualificação dos processos assistenciais no pré-natal, parto e nascimento(AU)

Objective: To analyze the prevalence of perinatal factors associated with respiratory distress in neonates admitted to a Neonatal Intensive Care Unit in Cuiabá, Mato Grosso. Method: A cross-sectional, analytical, retrospective study, with data collection between the months of October and December 2019, in 844 medical records of newborns hospitalized between 2014 and 2018. Poisson Regression was used, considering a significance of 0.05 (p <0.05). Results: Of the total number of neonates, 49.05% were diagnosed with respiratory distress. The prevalence of the disease was 60% higher among premature infants, 36% higher among those who had a history of maternal use of antenatalsteroids, and 25% higher among those with low weight. It was also observed that the prevalence of use of an oxygen helmet, the continuous positive airway pressure and the parenteral diet was 91%, 89% and 18% higher among neonates with the disease, respectively. However, the use of formulas and breast milk in infants with discomfort was 85% and 62% lower than that of infants who did not have this condition. Conclusion: Greater attention by the health team and managers is necessary as knowledge of these factors may assist them in planning actions to consolidate the perinatal network, with restructuring and qualification of care processes in prenatal aid, delivery and birth.(AU)

Objetivo: Analizar el predominio y losfactores perinatales asociados a la dificultad respiratoria en neonatosingresados en una Unidad de Cuidados Intensivos Neonatales de Cuiabá, Mato Grosso. Método: Estudio transversal, analítico y retrospectivo, con recolección de datos entre los meses de octubre a diciembre de 2019, en 844 historias clínicas de recién nacidos hospitalizados entre 2014 y 2018. Se utilizó Regresión de Poisson, considerando una significancia de 0.05 (p <0,05). Resultados: Del total de neonatos, el 49,05% fueron diagnosticados de dificultad respiratoria. El predominio de la enfermedad fue un 60% más alto entre los bebés prematuros, un 36% más alto entre los que tenían antecedentes de uso materno de esteroides prenatales y un 25% más alto entre los que tenían bajo peso. También se observó que el predominio del casco de oxígeno, presión positiva continua en las vías respiratorias y dieta parenteral fue 91%, 89% y 18% mayor entre los recién nacidos con la enfermedad. Sin embargo, el uso de fórmulas y leche materna en lactantes con malestar fue 85% y 62% menor que el de lactantes que no padecían esta afección. Conclusión: Se indica una mayor atención por parte del equipo de salud y los gestores, ya que el conocimiento de estos factores puede ayudarlos a planificar acciones para consolidar la red perinatal, con reestructuración y calificación de los procesos de atención en el prenatal, parto y nacimiento.(AU)