[Focal HIFU vs robot-assisted total prostatectomy: Functionnal and oncologic outcomes at one year]. / Traitement focal par HIFU versus prostatectomie radicale robot-assistée pour cancer de la prostate localisé : résultats carcinologiques et fonctionnels à 1 an.

OBJECTIVE: To analyse the functional and oncologic outcomes at one year of focal therapy with HIFU compared with total prostatectomy in patients with localised prostate cancer (PCa). PATIENTS AND METHODS: Retrospective and monocentric study from 2008 to 2014 comparing 2 cohorts of patients with localised PCa (T1/T2 clinical stage, Gleason score≤3+4=7 and PSA<15ng/mL), one treated by focal therapy (HIFU-F group), one by robot-assisted total prostatectomy (RATP group). Primary outcome was a trifecta defined as: absence of urinary incontinence, erectile function with sexual relations without treatment, negative PSA with negative surgical margins (RATP group) or negative biopsy cores (HIFU-F group). RESULTS: The 53 patients included in the "HIFU-F" group and the 66 patients in the "RATP" group were similar in terms of preoperative PSA, D'Amico risk group, erectile function but were different in terms of age, prostatic volume, length of cancer, Gleason score. Complication rate was not different. In multivariate analyse with propensity score, "HIFU-F" group achieved a better trifecta score than "RATP" group (OR=8,3, p=0,005). CONCLUSION: In case of low or intermediate risk localised PCa, "HIFU-F" group had better functional outcomes than initial learning curse "RATP" group, at one year. A long-term evaluation by a common endpoint is necessary to judge the oncological equivalence of both techniques. LEVEL OF EVIDENCE: 3.

Bloqueo de nervios pudendos para proctología en régimen de CMA / No disponible

No disponible

Un mayor número de cilindros de biopsia transrectal de próstata guiada por ultrasonido se asocia con una mayor pérdida de sangre y complicaciones perioperatorias en la prostatectomía radical asistida por robot / Higher number of transrectal ultrasound guided prostate biopsy cores is associated with higher blood loss and perioperative complications in robot assisted radical prostatectomy

Introducción: La reacción inflamatoria local después de una biopsia prostática (BP) puede influir de manera negativa en los resultados globales posprostatectomía radical. No hay evidencia suficiente en la literatura respecto al impacto del número de punciones en los resultados posquirúrgicos. Objetivos: Determinar el impacto del número de punciones de la BP en las complicaciones posquirúrgicas y en el estado de los márgenes operatorios. Material y métodos: Se registraron prospectivamente 2.054 pacientes sometidos a prostatectomía radical asistida por robot (PRAR) en nuestra institución. Se formaron 2 grupos de pacientes, en relación con el número de punciones en la BP (G1≤ 12 punciones; G2 > 12 punciones). Se evaluó por medio del análisis multivariable (modelos de regresión logística) el impacto del número de punciones en las complicaciones posquirúrgicas. Resultados: Se incluyeron 1.042 pacientes en el grupo 1 (≤ 12 punciones) y 1.012 pacientes en el grupo 2 (> 12 punciones). La tasa de complicaciones perioperatorias se incrementó a medida que aumentaba el número de punciones. (G1 6,4 vs. G2 8,5%; p = 0,03); no obstante, las complicaciones mayores (Clavien 3-4) fueron similares (G1 1,4 vs. G2 2,2%; p = 0,16). No hubo diferencia estadísticamente significativa respecto a los márgenes quirúrgicos positivos en ambos grupos (G1 11,8 vs. 9,98%; p = 0,2). El análisis multivariable (regresión logística) demostró que el grupo 2 tenía un porcentaje un 39% mayor de experimentar complicaciones post-PRAR (OR 0,645). Conclusión: El mayor número de punciones (> 12) en la BP podría estar relacionado con mayor sangrado y complicaciones posquirúrgicas después de PRAR. Una cuidadosa evaluación preoperatoria de los pacientes que se sometieron a biopsias o protocolos de saturación múltiple es obligatoria. La aplicación de intervalos más largos (> 6 semanas) entre la biopsia y la cirugía puede ser recomendable para minimizar los potenciales riesgos de complicaciones quirúrgicas en los pacientes que pueden beneficiarse de PRAR. Otros estudios son todavía necesarios para confirmar estos resultados

Introduction: The local inflammatory process after prostate biopsies can have a negative impact on functional outcomes of radical prostatectomy. There is no evidence in literature demonstrating its impact on radical prostatectomy. Objectives: To evaluate the impact of the number of TRUS core biopsies in the surgical morbidity and rate of positive margin on robot assisted radical prostatectomy (RARP). Material and methods: A prospectively maintained database of 2,054 RARPs in a single institution. Patients were further grouped into 2 groups based on the number of TRUS biopsy cores (G1≤12 cores; G2>12 cores). Multivariable logistic regression model was applied to analyze the impact of number of cores on complications. Results: A total number of 1,042 patients in the group 1 (≤12 cores) and 1,012 patients in the group 2 (>12 cores) were included. The rate of perioperative complications increased with higher number of biopsies (G1 6.4 vs. G2 8.5%; P=.03), but high grade complication (Clavien 3-4) were similar (G1 1.4 vs. G2 2.2%; P=.16). Positive surgical margin rates were similar in both groups (G1 11.8 vs. 9.98%; P=.2). At the multivariable logistic regression analysis shown that G2 had a 39% (OR 0.645) higher rate to experience perioperative complications during RARP. Conclusion: Higher number of TRUS biopsy cores (>12) is associated to higher blood loss and perioperative complications during RARP. Careful preoperative evaluation for those patients underwent multiple biopsies or saturation protocols is mandatory. Application of longer intervals (>6 weeks) between biopsy and surgery may be advisable to minimize potential risks of surgical complications in patients may benefit from RARP. Further studies are still necessary to confirm these results

The effect of asymptomatic histological prostatitis on sexual function and lower urinary tract symptoms / Efecto de la prostatitis histológica asintomática sobre la función sexual y los síntomas de tracto urinario inferior

OBJECTIVE: Prostatitis affects 10-14% of men of all ages and ethnicities. More than 50% of the men experience episodes of prostatitis at one time of their lives. Patients with CP typically have longlasting genitourinary/pelvic pain and obstructive and/or irritative voiding symptoms. Sexual dysfunction and psychological symptoms are frequently added to these symptoms. We also investigated the relationship between sexual functions, and lower urinary system symptoms, and asymptomatic histological prostatitis detected on transrectal ultrasound-guided (TRUS) biopsy performed with the indication of high PSA levels. METHODS: Sixty cases compliant with the study criteria among patients who underwent prostate biopsies between September 2014 and June 2015 with the indication of higher PSA levels were included in the study. All patients were requested to complete IIEF-5 and IPSS forms one day previously. Based on histological analysis of biopsy materials, the patients were allocated into groups of BPH (simple BPH without histological prostatitis) (n:30) and histological chronic prostatitis (combination of BPH and histological prostatitis) (n:30). RESULTS: Mean age of the cases was 65.73±5.01 (range, 56-75 yrs) years. PSA levels ranged between 4-15ng/ml. A statistically significant intergroup difference was not found regarding mean age, BMIs, PSA levels, incidence rates of hypertension and coronary artery disease (p > 0.05). Prostate volumes of the HCP group were higher than those of the BPH group , with statistically significant differences (p:0.001; p < 0.01). Questionnaire forms of the patients included in the study were statistically evaluated, and mean IPSS score of the HCP group was found to be higher when compared with that of the BPH group, with statistically significant differences. (p:0.016; p < 0.05). However mean IIEF score of the BPH group was higher than that of the HCP group, with statistically significant differences (p:0.039; p < 0.05). DISCUSSION: These findings suggested the presence of a correlation between chronic inflammation and lower urinary tract symptoms (LUTS). In addition, statistically significant lower IIEF values in patients with histological chronic prostatitis relative to those without suggested negative effects of even asymptomatic inflammation on sexual functions and mechanism of erection

OBJETIVO: La prostatitis afecta al 10-14% de varones de todas las edades y etnias. Más del 50% de los hombres experimentan episodios de prostatitis alguna vez en sus vidas. Los pacientes con prostatitis crónica (PC) típicamente tienen dolor genitourinario/ pélvico y síntomas del tracto urinario inferior obstructivos y/o irritativos de larga duración. A estos síntomas se añaden frecuentemente la disfunción sexual y los síntomas psicológicos. También investigamos la relación entre la función sexual y síntomas del tracto urinario inferior y la prostatitis asintomática detectada por biopsia de próstata guiada por ecografía transrectal realizada con la indicación de niveles de PSA elevados. MÉTODOS: Incluimos en el estudio sesenta casos que cumplían con los criterios de inclusión, entre los pacientes sometidos a biopsia de próstata entre septiembre 2014 y junio 2015 con la indicación de PSA elevado. Se requería que todos los pacientes completaran el cuestionario IEEF-5 e IPSS un día antes. En base al análisis histológico de los materiales de biopsia, los pacientes fueron asignados a grupos de HBP (HBP simple sin prostatitis histológica) (n=30) y prostatitis crónica histológica (combinación de HBP y prostatitis histológica) (n=30). RESULTADOS: La edad media de los casos fue de 65,73±5,01 años (Rango 56-75 años). Los niveles de PSA oscilaron en el rango entre 4-15ng/ml. No se encontraron diferencias estadísticamente significativas en edad media, IMC, nivel de PSA, tasas de incidencia de hipertensión y enfermedad coronaria entre los grupos (p > 0,05). Los volúmenes prostáticos del grupo de PC histológica eran mayores que los del grupo de HBP, con significación estadística (p:0,001; p < 0,01). Los cuestionarios de los pacientes incluidos en el estudio fueron evaluados estadísticamente, y se encontró que la media del resultado del IPSS e el grupo de PC histológica era mayor, con significación estadística, que el del grupo de HBP (p:0,016; p < 0,05). Sin embargo, el resultado medio del IIEF en el grupo de HBP era más alto, con diferencias estadísticamente significativas, que el del grupo de PC histológica (p:0,039; p < 0,05). DISCUSIÓN: Estos hallazgos sugieren la presencia de una correlación entre la inflamación crónica y los síntomas del tracto urinario inferior. Además, unos valores menores de IIEF en pacientes con prostatitis crónica histológica en relación con los pacientes sin PC, con diferencias estadísticamente significativas, sugería efectos negativos sobre las funciones sexuales y los mecanismos de erección incluso de la inflamación asintomática

Real-time ultrasound detection of correct intravenous placement of central venous catheters after ultrasound cannulation / Comprobación ecográfica en tiempo real de la colocación intravenosa de catéteres venosos centrales tras canulación ecoguiada

No disponible

Multimodal image-guided prostate fusion biopsy based on automatic deformable registration.

PURPOSE: Transrectal ultrasound (TRUS)-guided random prostate biopsy is, in spite of its low sensitivity, the gold standard for the diagnosis of prostate cancer. The recent advent of PET imaging using a novel dedicated radiotracer, [Formula: see text]-labeled prostate-specific membrane antigen (PSMA), combined with MRI provides improved pre-interventional identification of suspicious areas. This work proposes a multimodal fusion image-guided biopsy framework that combines PET-MRI images with TRUS, using automatic segmentation and registration, and offering real-time guidance. METHODS: The prostate TRUS images are automatically segmented with a Hough transform-based random forest approach. The registration is based on the Coherent Point Drift algorithm to align surfaces elastically and to propagate the deformation field calculated from thin-plate splines to the whole gland. RESULTS: The method, which has minimal requirements and temporal overhead in the existing clinical workflow, is evaluated in terms of surface distance and landmark registration error with respect to the clinical ground truth. Evaluations on agar-gelatin phantoms and clinical data of 13 patients confirm the validity of this approach. CONCLUSION: The system is able to successfully map suspicious regions from PET/MRI to the interventional TRUS image.

Biopsia transrectal ecodirigida convencional. Papel actual, indicaciones, técnicas y limitaciones / Conventional transrectal ultrasound guided biopsy. Current role, indications, techniques and limitations

OBJETIVO: El objetivo del presente trabajo es evaluar el papel actual de la Biopsia transrectal eco-dirigida convencional de la próstata en el diagnóstico de cáncer. Para ello repasaremos sus indicaciones, las diferentes técnicas, las complicaciones que comporta y las limitaciones de esta prueba. MÉTODOS: Para cumplir nuestros objetivo hemos realizado una revisión de la literatura utilizando como herramienta el PubMed-NCBI. También se ha valorado la información y recomendaciones de las guías clínicas disponibles, con su respectivo nivel de evidencia. Por último, alguna de las apreciaciones reflejadas se basan en la experiencia personal de nuestro grupo que ha practicado más de 7000 biopsias prostáticas con diferentes protocolos y metodologías a lo largo de dos décadas de trabajo asistencial. RESULTADOS: Las biopsias prostáticas convencionales son poco precisas, poco cercanas a la realidad en cuanto a la cantidad, ubicación y gradación de tumores. No está claro el número y localización de los cilindros a tomar, existiendo demasiados esquemas, lo que las hace menos fiables y reproductibles de lo requerido. Aunque son una buena herramienta, comportan un riesgo obvio de sobre-diagnóstico de tumores clínicamente insignificantes. La falta de estandarización de los diferentes esquemas de biopsias tiene claras implicaciones pronósticas y en la toma de decisiones. Otra limitación son los escasos resultados atribuibles a las biopsias dirigidas a las lesiones visualizables por ecografía. Evidentemente, las complicaciones, el disconfort y la angustia que generan los programas de biopsias y rebiopsias convencionales constituyen una de sus limitaciones y de los motivos de rechazo por parte de los pacientes. Nos hallamos en una encricijada en la que múltiples grupos intentan demostrar la sensibilidad y reproductibilidad de dirigir mediante diferentes técnicas las biopsias hacia los hallazgos de la resonancia multiparamétrica. CONCLUSIONES: La biopsia prostática ecodirigida sigue siendo el método principal de diagnóstico del cáncer de la próstata. La información que proporciona es de gran relevancia en el estadiaje, en la evaluación pronóstica y en la toma de decisiones terapéuticas. No obstante, son patentes sus limitaciones: baja sensibilidad, el sobrediagnóstico, las complicaciones, la angustia de los pacientes, etc. Existen dos líneas de desarrollo para mejorar su eficiencia. La que busca reducir el número de biopsias y de cores persiguiendo selectivamente los hallazgos de las resonancias y la que sigue sistematizando esquemas con aumento del número de cores para conseguir el muestreo óptimo. Los avances técnicos, como la fusión de imágenes, tal vez nos permitirán en un futuro traducir los hallazgos de las resonancias en resultados clínicos contrastados y reproducibles. Debemos estandarizar en nuestros Centros las técnicas convencionales de biopsia de próstata, protocolizándolas y haciéndolas seguras para los pacientes. Hemos de revisar nuestros resultados para asegurar tasas de detección razonables, así cmo nuestras indicaciones, teniendo en cuenta la edad, la comorbilidad y la expectativa de tratamiento de los pacientes. Debemos incluir, en la medida de lo posible, otras herramientas, como la RMN multiparamétrica, para permitir racionalizar las biopsias y aumentar su eficacia

OBJECTIVES: The objective of this work is to evaluate the current role of conventional transrectal ultrasound guided biopsy of the prostate in the diagnosis of cancer. With this aim we review its indications, the various techniques, associated complications and limitations of this test. METHODS: We performed a bibliographic review through NCBI-PUBMED. We also evaluated the information and recommendations of the available clinical guidelines with their respective evidence levels. Lastly, some of the appraisals included are based on our group's personal experience that has performed more than 7000 prostate biopsies with various protocols and methodologies over two decades of health care practice. RESULTS: Conventional prostatic biopsies lack precision; they are not close to reality in terms of tumor amount, localization and grading. The number and localization of the cores to be taken is not clear; there are too many biopsy schemes, making it less reliable and reproducible than expected. Although it is a good tool, there is an obvious risk of over diagnosis of clinically non-significant tumors. The lack of standardization of the various biopsy schemes has clear prognostic and decision-making implications. Another limitation is the scarce number of results attributable to biopsies targeted at ultrasound visible lesions. Obviously, the complications, discomfort, and distress generated by conventional biopsy and repeated biopsy programs are some of their limitations and the reasons for patient rejection. We are in a crossroad where multiple groups try to demonstrate the sensitivity and reproducibility of targeting the biopsy, by means of various techniques, to the lesions found in multiparametric MRI. CONCLUSIONS: Ultrasound guided prostatic biopsy is the main diagnostic method for prostate cancer yet. The information it gives is greatly relevant for staging, prognostic evaluation and therapeutic decision-making. Nevertheless, its limitations are evident: low sensitivity overdiagnosis, complicacions, patient`s distress, etc. There are two lines of development to improve its effi- ciency. The one aiming to reduce the number of biopsies and cores by selectively targeting the findings of the MRI and the one that continues systematizing schemes with increasing number of cores to achieve the optimal sampling. Technical advances , such as image fusion, will maybe allow us in the future to translate the MRI findings into verified and reproducible clinical results. We must standardize the conventional techniques of prostate biopsy in our centers, using protocols and making them safe for patients. We must review our results to ensure reasonable detection rates, as well as our indications, considering patient's age, comorbidities and expectations about therapy. We must include, as far as possible, other tools, such as multiparametric MRI to enable biopsy rationalization and improve their efficacy

Avances en las Técnicas Ecográficas para el diagnóstico y estadiaje del cáncer de próstata. Elastografía, Ecografía doppler, Contrastes Ecográficos, Métodos de Cuantificación ecográfica y fusión con Resonancia Magnética Nuclear / Advances in ultrasound techniques for the diagnosis and staging of prostate cancer. Elastography, Doppler ultrasound, ultrasound contrast media, ultrasound quantification media and MRI fusion

OBJETIVO: La biopsia prostática transrectal sistematica eco-guiada sigue siendo el procedimiento estándar en el diagnóstico del cáncer de próstata. Diversas modalidades ecográficas asociadas han sido propuestas. Nuestro propósito es evaluar cada una de estas modalidades, y presentar su estado actual en la literatura y utilidad clínica. MÉTODO: Revisión no estructurada de la literatura sobre la utilidad actual de los diversos modos y tipos de ecografía usados durante la biopsia prostática transrectal eco-guiada en el diagnóstico de cáncer de próstata. RESULTADOS: Las cifras publicadas sobre las distintas modalidades ecográficas asociadas presentan gran heterogeneidad y resultados muy variables. Algunas nuevas técnicas muestras resultados prometedores, con alta sensibilidad y especificidad, aumentando así el rendimiento de la biopsia transrectal convencional, acercándose a la biopsia eco-dirigida como objetivo último. La elastografía y la fusión de Resonancia Magnetica Nuclear (RMN)/Ecografia parecen mostrar cifras alentadoras, especialmente la primera, dada la reciente introducción de la elastografía "shearwave" que disminuye el factor usuario-dependiente, aumentando considerablemente los índices de detección. CONCLUSIONES: La biopsia prostática sistematica eco-guiada tiene una sensibilidad aceptable en el diagnóstico del cáncer de próstata, pero su especificidad es baja . Diversas modalidades asociadas a la ecografía están disponibles con el objetivo de aumentar su rendimiento. Aunque alentadores, los resultados se han publicado en forma aislada; creemos que la combinación de estas modalidades junto con protocolos validados de visualización serán los que lograrán un procedimiento de precisión en el diagnóstico del cáncer de próstata

OBJECTIVE: Transrectal ultrasoundguided prostate biopsy remains the gold standard in the diagnosis of prostate cancer. Various Ultrasound modalities have been proposed to increase the cancer detection rate. Our purpose is to evaluate each of these methods, and to present its current literature and clinical utility. METHOD: A non structured review of the current literature was conducted over these different various ultrasound modalities used during the transrectal ultrasound-guided prostate biopsied in the diagnosis of prostate cancer. RESULTS: The data investigation of the various modalities associated sonographic features exhibits great heterogeneity and highly variable results. Some new techniques sampling present promising results with high sensitivity and specificity, thus increasing the diagnostic yield of transrectal biopsy. It seems that elastography shows encouraging figures, especially given the recent introduction of the "shearvawe" elastography that decreases the user-dependent factor. CONCLUSIONS: The ultrasound-guided prostate biopsy has an acceptable sensitivity in the diagnosis of prostate cancer, but its specificity is still low. Various modalities associated with ultrasound are available in clinical practice in order to increase cancer detection rate. Although some promising data have been published for some of the modalities, we believe the combination of these includes validated ultrasound guided biopsy protocols to accurately target and diagnose prostate cancer

Improved outcomes with advancements in high intensity focused ultrasound devices for the treatment of localized prostate cancer.

PURPOSE: We evaluated the association between long-term clinical outcomes and morbidity with high intensity focused ultrasound. MATERIALS AND METHODS: We included patients with stage T1c-T3N0M0 prostate cancer who were treated with Sonablate® (SB) devices during 1999 to 2012 and followed for more than 2 years. Risk stratification and complication rates were compared among the treatment groups (ie SB200/500 group, SB500 version 4 group and SB500 tissue change monitor group). Primary study outcomes included overall, cancer specific and biochemical disease-free survival rates determined using Kaplan-Meier analysis (Phoenix definition). Secondary outcomes included predictors of biochemical disease-free survival using Cox models. RESULTS: A total of 918 patients were included in the study. Median followup in the SB200/500, SB500 version 4 and the SB500 tissue change monitor groups was 108, 83 and 47 months, respectively. The 10-year overall and cancer specific survival rates were 89.6% and 97.4%, respectively. The 5-year biochemical disease-free survival rate in the SB200/500, SB500 version 4 and SB500 tissue change monitor group was 48.3%, 62.3% and 82.0%, respectively (p < 0.0001). The overall negative biopsy rate was 87.3%. On multivariate analysis pretreatment prostate specific antigen, Gleason score, stage, neoadjuvant androgen deprivation therapy and high intensity focused ultrasound devices were significant predictors of biochemical disease-free survival. Urethral stricture, epididymitis, urinary incontinence and rectourethral fistula were observed in 19.7%, 6.2%, 2.3% and 0.1% of cases, respectively. CONCLUSIONS: Long-term followup of patients with high intensity focused ultrasound demonstrated improved clinical outcomes due to technical, imaging and technological advancements.

Tratamiento de las arritmias cardíacas refractarias mediante bloqueo del ganglio estrellado en un paciente. Acceso por técnica clásica y ecodirigida / Treatment of a patient with refractory cardiac arrhythmias using stellate ganglion block. Access by the classical and ultrasound-guided approach

El bloqueo del ganglio estrellado es utilizado con frecuencia por anestesiólogos y otros especialistas para el tratamiento del síndromes de dolor regional complejo del miembro superior. Esta técnica interrumpe la inervación simpática cardíaca y ha sido propuesta como tratamiento de arritmias refractarias. Presentamos el caso de un paciente con arritmias refractarias a tratamiento farmacológico que fueron controladas mediante un bloqueo continuo del ganglio estrellado izquierdo. El ganglio estrellado izquierdo es clave en el manejo de las arritmias cardiacas por ser una estructura en la que se originan gran parte de las fibras simpáticas posganglionares que se encargarán de inervar preferentemente el nodo auriculoventricular, haz de His y masa ventricular, elementos fundamentales en la génesis y mantenimiento de las arritmias ventriculares (AU)

Stellate ganglion block is a technique that is often used by anesthesiologists for the treatment of complex regional pain syndromes of the upper extremity. This technique interrupts cardiac sympathetic innervation and has been proposed as treatment for refractory arrhythmias. We present the case of a patient with arrhythmias that were refractory to pharmacological treatment, and were finally treated by continuous stellate ganglion block. Left stellate ganglion is a lynchpin of cardiac arrhythmias due to being a structure where the majority of postganglion sympathetic fibers responsible for preferentially innervating the atriventricular node, bundle of His and ventricular mass are originated, fundamentals in the origin and maintenance of ventricular arrhythmias (AU)

Automatic localization of the da Vinci surgical instrument tips in 3-D transrectal ultrasound.

Robot-assisted laparoscopic radical prostatectomy (RALRP) using the da Vinci surgical system is the current state-of-the-art treatment option for clinically confined prostate cancer. Given the limited field of view of the surgical site in RALRP, several groups have proposed the integration of transrectal ultrasound (TRUS) imaging in the surgical workflow to assist with accurate resection of the prostate and the sparing of the neurovascular bundles (NVBs). We previously introduced a robotic TRUS manipulator and a method for automatically tracking da Vinci surgical instruments with the TRUS imaging plane, in order to facilitate the integration of intraoperative TRUS in RALRP. Rapid and automatic registration of the kinematic frames of the da Vinci surgical system and the robotic TRUS probe manipulator is a critical component of the instrument tracking system. In this paper, we propose a fully automatic registration technique based on automatic 3-D TRUS localization of robot instrument tips pressed against the air-tissue boundary anterior to the prostate. The detection approach uses a multiscale filtering technique to identify and localize surgical instrument tips in the TRUS volume, and could also be used to detect other surface fiducials in 3-D ultrasound. Experiments have been performed using a tissue phantom and two ex vivo tissue samples to show the feasibility of the proposed methods. Also, an initial in vivo evaluation of the system has been carried out on a live anaesthetized dog with a da Vinci Si surgical system and a target registration error (defined as the root mean square distance of corresponding points after registration) of 2.68 mm has been achieved. Results show this method's accuracy and consistency for automatic registration of TRUS images to the da Vinci surgical system.

The current role of high-intensity focused ultrasound for the management of radiation-recurrent prostate cancer.

The standard treatment options for organ-confined prostate cancer are radical prostatectomy and radiation therapy. A number of minimally invasive new technologies have also recently emerged. High-intensity focused ultrasound (HIFU) is considered to be one of the most promising alternative therapies for prostate cancer. The indications for HIFU have recently been expanded to include its use both as a primary therapy for organ-confined prostate cancer as well as for local recurrence of prostate cancer, following radiation therapy. Although experience with the use of HIFU in the salvage setting following failed radiation therapy is limited, there is evidence to support the concept that HIFU offers comparable oncological outcomes to other established salvage treatment options for radiation-recurrent prostate cancer, with potentially less side effects. HIFU should be regarded as a viable alternative, especially for low-to-intermediate-risk cases of radiation-recurrent prostate cancer.

Experimental investigation of MRgHIFU sonication with interleaved electronic and mechanical displacement of the focal point for transrectal prostate application.

High intensity focused ultrasound (HIFU) under MRI guidance may provide minimally invasive treatment for localized prostate cancer. In this study, ex vivo and in vivo experiments were performed using a prostate-dedicated endorectal phased array (16 circular elements arranged on a truncated spherical cap of radius 60 mm) and a translation-rotation mechanical actuator in order to evaluate the lesion formation and the potential interest of dual-modality (electronic and mechanical) interleaved displacement of the focus for volumetric sonication paradigms. Different sonication sequences, including elementary lesions, line scan, slice sweeping and volume sonications, were investigated with a clinical 1.5 T MR scanner. Two orthogonal planes (axial and sagittal) were simultaneously monitored using rapid MR thermometry (PRFS method) and the temperature and thermal dose maps were displayed in real time. No RF interferences were detected in MR acquisition during sonications. The shape of the thermal lesions in vivo was examined at day 5 post-treatment by MRI follow-up (T2w sequence and Gd-T1w-TFE) and postmortem histological analysis. This study suggests that electronic displacement of the focus (along the ultrasound propagation axis) interleaved with mechanical X-Z translations and rotation around B(0) can be a suitable modality to treat patient-specific sizes and shapes of a pathologic tissue. The electronic displacement of focus (achieved in less than 0.1 s) is an order of magnitude faster than the mechanical motion of the HIFU device (1 s latency). As an example, for an in vivo volumetric sonication with foci between 32 and 47 mm (7 successive line scans, 11 lines/slice, 4 foci/line) with applied powers between 17.4 and 39.1 Wac, a total duration of sonication of 408.1 s was required to ablate a volume of approximately 5.7 cm(3) (semi-chronic lesion measured at day 5), while the maximum temperature elevation reached was 30 °C. While electronic focusing is necessary to speed up the procedure, one should consider as a potential drawback the non-negligible risk for generating secondary lobes with full steering in 3D. Reference-free PRFS thermometry accurately removed the effects of B(o) dynamic perturbation in the vicinity of the moving transducer. Therefore, the dual-modality volumetric sonication paradigm represents a cost-effective technological compromise to induce the desired shape of the lesion in the prostate through the limited endorectal space, in a reasonable period of time and without side effects.

High-intensity focused ultrasound (HIFU) for definitive treatment of prostate cancer.

UNLABELLED: What's known on the subject? and What does the study add? Novel therapeutic methods have emerged in recent years as 'focal' treatment alternatives in which cancer foci can be eradicated and greatly reducing the associated side-effects of radical treatment. High-intensity focused ultrasound (HIFU) seems to result in a well fitted technology, which has proven short- to medium-term cancer control, with a low rate of complications comparable with those of established therapies. This is an up-to-date review of the available literature on HIFU as a definitive treatment of prostate cancer. It describes the technique in a comprehensive approach in terms of technical features, procedure, indications, and gives an overview of its historical background; finally, we present the future applications of HIFU and its development trend. OBJECTIVES: • To provide an up-to-date review of the available literature on high-intensity focused ultrasound (HIFU) as a definitive treatment of prostate cancer. • To present the technique in a comprehensive approach, comparing the available devices according to the existing evidence in terms of technical features, procedure, indications, and to give an overview of its historical background; and finally, to discuss future applications of HIFU and its development trend. MATERIALS AND METHODS: • A systematic literature search was conducted using MEDLINE and EMBASE via Ovid databases (January 2000 to December 2011), to identify studies on HIFU for treatment of prostate cancer. • Only English-language and human-based full manuscripts that reported on case series studies with >50 participants, patient characteristics, efficacy and safety data were included. RESULTS: • No randomised controlled trials were identified by the literature search. We identified 31 uncontrolled studies that examined the efficacy of HIFU as primary treatment and two studies that examined the efficacy of HIFU as salvage treatment. • Most treated patients had localised prostate cancer (stage T1-T2); Gleason scores of 2-10 and mean prostate specific antigen (PSA) values of 4.6-12.7 ng/mL. The mean age range of the patients was 64.1-72 years. The mean follow-up ranged from 6.4 to 76.8 months. Negative biopsy rates ranged from 35 to 95%. PSA nadirs ranged from 0.04 to 1.8 ng/mL. The 5-year disease-free survival rates ranged from 61.2 to 95%; 7- and 8-year disease free survival rates ranged from 69 to 84%. • The most common complications associated with the HIFU procedure as the primary treatment included: urinary retention (<1-20%); urinary tract infections (1.8-47.9%); stress or urinary incontinence (<1-34.3%); and erectile dysfunction (20-81.6%). • Recto-urethral fistula was reported in <2% of patients. • Treatment-related morbidity appeared to be reduced by the combination of transurethral resection (TURP) of the prostate and HIFU. CONCLUSIONS: • Novel therapeutic methods have emerged in recent years as 'focal' treatment alternatives, in which cancer foci could be eradicated by greatly reducing the associated side-effects of radical treatment. • HIFU seems to result in short- to medium-term cancer control, with a low rate of complications comparable with those of established therapies. • However, longer-term follow-up studies are needed to evaluate cancer-specific and overall survival. If available promising results on HIFU for definitive treatment of prostate cancer are confirmed in future prospective trials, focal therapy could start to challenge the current standard of care.

[Salvage high energy focalized ultrasound (HIFU) in prostate cancer after radiotherapy]. / Ultrasonidos focalizados de alta energía (HIFU) de rescate en el cáncer de próstata después de radioterapia.

OBJECTIVES: To evaluate the efficacy and safety of High Intensity Focused Ultrasound (HIFU) as salvage treatment after radical radiotherapy in prostate cancer (PC). METHODS: We reviewed the literature through databases and published articles that refer to this treatment between 2000 and 2010. We evaluated oncological results and adverse effects, compared with those published in conjunction with other therapies. RESULTS: We evaluated the different series, which include the results of the two devices currently available, all with their initial results and those that are in the process of dose adjustment. Generally, it can be said that the biggest problem of all is that initial morbidity is reduced as the surgeon gains experience with the treatment. We must stress the importance of the short series that are evaluated, especially in follow-up time and number of patients. Also, except for a recently published systematic review, no prospective studies are published. The results from different series are compared with existing literature regarding to other PC treatments. CONCLUSIONS: In spite of published results, the treatment with HIFU for prostate cancer recurrence after radiotherapy is an option that should be considered. Especially considering that, it is important to delay the development of the disease in these patients, and there are no other alternatives that have proven to be effective. Further research is needed to explore the use of HIFU in the treatment of PC. Anyway, it is essential to publish comparative prospective series and series with more patients and longer follow-up to draw definitive conclusions.

Ultrasonidos Focalizados de Alta Energía (HIFU) de Rescate en el cáncer de próstata después de Radioterapia / Salvage High energy focalized ultrasound (HIFU) in prostate cancer after radiotherapy

OBJETIVO: Evaluar la eficacia y seguridad de los Ultrasonidos de Alta Intensidad Focalizados (HIFU) como tratamiento de rescate tras radioterapia radical en el cáncer de próstata (CP). MÉTODOS: Se revisa la literatura a través de bases de datos y los artículos publicados que hacen referencia a este tratamiento entre el año 2000 y el 2010. Se han evaluado los resultados oncológicos, así como los efectos adversos, comparando con lo publicado en relación con otras terapias existentes. RESULTADOS: Se evalúan las distintas series publicadas, en las que se incluyen los resultados de los dos dispositivos disponibles en la actualidad, todas ellas con sus resultados iniciales y las que se encuentran en fase de ajuste de dosis. Se puede afirmar de forma general que el mayor problema de todas ellas resulta la morbilidad incial que se reduce según se gana en experiencia con el tratamiento. De forma generalizada, hay que resaltar la importancia de lo cortas que son las series evaluadas, sobre todo en tiempo de seguimiento y en número de pacientes. Asimismo, salvo una revisión sistemática recientemente publicada, no existe ningún estudio prospectivo con ninguno de los dos dispositivos. Todos los resultados de las distintas series publicadas son comparados con la literatura existente en relación a los distintos tratamientos del CP. CONCLUSIONES: A pesar de los resultados publicados, el tratamiento mediante HIFU en la recidiva del cáncer de próstata tras radioterapia es una opción que debe ser considerada. Sobre todo teniendo en cuenta que, en estos pacientes, es importante retrasar el desarrollo de la enfermedad y que no existen otras alternativas que hayan demostrado ser eficaces. Es necesaria una mayor investigación para explorar la utilización de HIFU en el tratamiento cel CP. En cualquier caso, es fundamental la publicación de series prospectivas comparativas y series con mayor número de pacientes y de más largo seguimiento para poder sacar conclusiones definitivas(AU)

OBJECTIVES: To evaluate the efficacy and safety of High Intensity Focused Ultrasound (HIFU) as salvage treatment after radical radiotherapy in prostate cancer (PC). METHODS: We reviewed the literature through databases and published articles that refer to this treatment between 2000 and 2010. We evaluated oncological results and adverse effects, compared with those published in conjunction with other therapies. RESULTS: We evaluated the different series, which include the results of the two devices currently available, all with their initial results and those that are in the process of dose adjustment. Generally, it can be said that the biggest problem of all is that initial morbidity is reduced as the surgeon gains experience with the treatment. We must stress the importance of the short series that are evaluated, especially in follow-up time and number of patients. Also, except for a recently published systematic review, no prospective studies are published. The results from different series are compared with existing literature regarding to other PC treatments. CONCLUSIONS: In spite of published results, the treatment with HIFU for prostate cancer recurrence after radiotherapy is an option that should be considered. Especially considering that, it is important to delay the development of the disease in these patients, and there are no other alternatives that have proven to be effective. Further research is needed to explore the use of HIFU in the treatment of PC. Anyway, it is essential to publish comparative prospective series and series with more patients and longer follow-up to draw definitive conclusions(AU)

A comparative study of the sonographic appearance and anatomy of the obturator internus in normal males.

The aim of this study was to compare the appearance of the normal male obturator internus on transrectal ultrasound with anatomical examination to advance the knowledge of the male pelvic muscles. This information may help to provide a new imaging method for observation of the normal male obturator internus and may facilitate the treatment of obturator internus abscesses and various other types of interventional therapies. Ten formalin-fixed male cadavers were dissected to examine the appearance and structure of the obturator internus and its relationship with the structures in close proximity. The obturator internus was also observed in five fresh male cadavers using transrectal ultrasound, after which the anatomy of the muscle was confirmed by dissection and its thickness measured. The visible fusiform was observed by sonography. The measurements of obturator internus thickness were 13.33 ± 0.32 mm on the right and 13.41 ± 0.26 mm on the left; in the formalin-fixed fresh cadaver, the measurements were 13.16 ± 0.21 mm on the right and 13.17 ± 0.22 mm on the left. Using transrectal ultrasound to recognize and observe the obturator internus is a new imaging method that will provide a foundation for the recognition of its abnormalities in the future.

Análisis de imagen asistido por ordenador en ecografía transrectal de próstata / Computer-aided analysis of transrectal ultrasound images of the prostate

Introducción: El método de diagnóstico de elección del cáncer de próstata (CP) es la biopsia transrectal guiada ecográficamente. Sin embargo, es frecuente no objetivar imágenes sospechosas. Los estudios de análisis de imagen pretenden identificar patrones ecográficos propios de una patología aparentemente ocultos. Materiales y método: Registramos digitalmente 288 biopsias transrectales ecoguiadas, de las que se aislaron imágenes estáticas de cada punción-biopsia para su análisis computarizado. Para ello se procedió a la extracción de características de textura mediante «mapeo simple» en escala de gris y «matrices espaciales dependientes del nivel de gris» o «matrices de coaparición», que estudian la relación de cada píxel con sus vecinos. Se desarrolló un sistema de «reconocimiento de formas» con dos métodos de clasificación: «técnica de k-vecinos» y «modelos ocultos de Markov». Finalmente realizamos una simulación del sistema con 4 ecografistas, comparando su capacidad diagnóstica en escala de gris con imágenes procesadas con nuestro sistema en 408 punciones grabadas, no en tiempo real. Resultados: La capacidad diagnóstica (curva ROC) con mapeo simple fue de 59,7 y 61,6% con clasificación mediante k-vecinos y modelos ocultos de Markov, respectivamente. Las matrices de coaparición ofrecieron un área bajo la curva ROC de 60,1 y 60,0%. El experimento virtual se llevó a cabo mediante «mapeo simple» y clasificación con «k-vecinos», otorgando una capacidad diagnóstica en cada urólogo de 63,3, 67,0, 64,3 y 63,7% frente a 61,7, 60,5, 66,2 y 60,7% conseguidas con la imagen original. Conclusiones: La utilización de nuestro método de análisis de imagen tiene una capacidad limitada, aunque estable, en la detección de áreas prostáticas cancerígenas (AU)

Introduction: Prostate cancer is usually diagnosed by transrectal ultrasound (TRUS) biopsy. Nevertheless, suspicious images are frequently not found. Imaging analysis studies aim to identify ultrasound patterns characteristic of apparently hidden conditions. Material and methods: We digitally recorded 288 TRUS ultrasound guided transrectal biopsies and extracted 3 static images from the puncture-biopsy area. The extraction of the texture characteristics were obtained by “simple mapping” on a gray scale and spatial gray level dependence matrices (SGLDM), also known as Haralick‘s co-occurrence matrices, which study the relationship of each pixel and its neighbors. A pattern recognition software system was developed with two different classification methods: nearest neighbor (k-NN) and Markov's hidden models. Finally, a virtual experiment was carried out in which four urologists compared their diagnostic accuracy for prostate cancer with our system in 408 TRUS images, not in real time. Results: The diagnostic capacity (R.O.C. curve) with the simple gray map study was 59.7% with nearest-neighbor classification and 61.6% with Markov's hidden models classification. The co-occurrence matrices showed an area under R.O.C. curve of 60.1% and 60.0% with k-NN and Markov's hidden models classification, respectively. The virtual experiment was conducted with a simple gray map study and k-NN classification. The images processed by our system showed the following diagnostic accuracy: 63.3, 67, 64.3 and 63.7% compared to 61.7, 60.5, 66.2 and 60.7% with the original image. Conclusions: Our pattern recognition system for prostate cancer TRUS images has a limited, yet stable, accuracy (AU)

Transrectal high-intensity focused ultrasound for local treatment of prostate cancer: current role.

Attractivity of robotic high intensity focused ultrasound (HIFU) is based largely on the non-invasive, extremely precise nature of this high-tech robotic therapy as well as its clean, radiation free, surgical, but nevertheless, bloodless character. Today, in urological oncology, HIFU is used clinically as a therapeutic tool for the treatment of prostate cancer. Experimentally it is investigated for therapeutic use in kidney and breast cancer. Transrectal treatment of localized prostate cancer with HIFU has been under investigation since the 1990s and it is meanwhile an actively used therapy for the disease in many urological departments worldwide. Since 2000 HIFU is mostly used in combination with transurethral resection of the prostate in order to reduce prostate gland size, to facilitate effective tissue destruction and to avoid side effects. Palliative and salvage indications as well as focal therapy of prostate cancer are under investigation to extend the spectrum of HIFU indications for non invasive prostate cancer therapy.

High intensity focused ultrasound (HIFU).

INTRODUCTION: Curative treatments for localized prostate cancer, from least invasive to most invasive, include brachytherapy, cryosurgery, three-dimensional conformal radiation therapy, external beam radiation therapy, and radical prostatectomy. A patient with localized, low risk or intermediate risk prostate cancer who is diagnosed at an early age and receives one of these treatments has only an approximately 50% chance of maintaining an undetectable prostate-specific antigen (PSA) level, good spontaneous erections, and total continence by 5 years after treatment. OBJECTIVE: This article discusses transrectal high intensity focused ultrasound (HIFU) treatment of localized prostate cancer using the Sonablate 500 (Focus Surgery, Indianapolis, IN, USA) device, which the author has adopted in favor of the Ablatherm (EDAP, TMS S. A., Lyons, France) device, the other HIFU device approved for use in Canada. METHOD: Characteristics of the ideal prostate cancer include stage T1-T2b, less than 40 cc in size, and with an anterior-posterior dimension of up to 35 mm high. The anterior zone of the prostate is treated before the posterior zone. The procedure involves 2 to 3 second bursts of ultrasound energy, followed by 3 second cooling cycles. In each treatment lesion, the physician achieves a temperature of 100 C at the focal point. The device allows for real-time visualization of tissue response following the delivery of ultrasound energy. CONCLUSION: HIFU is a minimally invasive, outpatient treatment for localized prostate cancer that provides similar short term and medium term cure rates and considerably less morbidity and side effects than other treatments. Although the effectiveness of HIFU has not yet been demonstrated in large, long term studies, this treatment option should be discussed with patients who have just been diagnosed with low risk or intermediate risk prostate cancer and desire aggressive, noninvasive, curative therapy, with potentially a lower incidence of side effects compared to conventional therapy.