Oncological and functional outcome after partial prostate HIFU ablation with Focal-One®: a prospective single-center study.

BACKGROUND: We aimed to evaluate oncological and functional outcomes of index lesion HIFU ablation with Focal-One®. MATERIALS AND METHODS: We prospectively assessed treatment-naïve men with localized prostate cancer between 2017 and 2019. Inclusion criteria were stage cT ≤ 2, ≥5 years of life expectancy, grade group ≤3. Multiparametric magnetic resonance was performed before ablation. Patients with a prostate volume of ≥80 ml underwent debulking. Treatment failure was defined as a histologically confirmed tumor that required salvage treatment or androgen deprivation therapy. RESULTS: One hundred and eighty nine patients were enrolled. Data are presented as median and Interquartile Range (IQR). Median age was 70(11) years. Median baseline PSA was 5.8(3) ng/ml. Fourteen (7.4%) patients had prostate debulking before ablation. 104 (55%) patients underwent targeted ablation, 45 (23.8%) extended targeted ablation, 31 (16.4%) hemiablation, and 9 (4.8%) extended hemiablation. Median targeted ablated volume was 14(9) ml. Ninety-three complications occurred in 63/189 (33.3%) patients within 90 days. There were 77/93 (82.8%) minor (Clavien grade 1-2) and 16/93 (17.2%) major complications (Clavien grade 3a). Thirty-nine patients suffered from genito-urinary infections (Clavien grade 2). Fifteen patients required transurethral resection of the prostate/urethrotomy for recurrent urinary retention (Clavien grade 3a). One patient developed a recto-urethral fistula (Clavien grade 3a) and two long-lasting urinary incontinence. Median PSA nadir was 2.2(2.9) ng/ml. At a median follow-up of 29(15) months, 21/177 (11.9%) patients were treatment failures, 26 on monitoring, and 26 had a further ablation. Multivariable logistic regression found that failure patients had higher PSA (7.8 vs 5.7 ng/ml,p0.001) and double PSA nadir (4.8 vs 2.0 ng/ml, p < 0.001). Higher PSA nadir correlated with a 74% higher probability of failure (OR 1.74 95% CI 1.40-2.16). Cancer in the anterior stroma increased the odds of failure of three folds (OR 3.36 95% CI 1.18-9.53). Two mixed effect models (one for IPSS and one for IEEF-15) were estimated and they showed that time reaches the statistical significance coefficient only for the IEEF-15, meaning that subsequent evaluations of the indicators were significantly lower at each time point. CONCLUSIONS: Index lesion HIFU ablation demonstrated satisfactory early oncological outcome but anteriorly located tumors had inadequate ablation. Urinary function was well preserved. Sexual function slightly decreased during follow-up.

Iatrogenic foreign body in urinary bladder: Holmium laser vs. Ceramic, and the winner is

ABSTRACT Introduction Urological surgery is estimated to be the third most common cause of iatrogenic-retained foreign bodies 1. Presentation A 76-year old man was undergoing a transurethral resection of bladder tumor with a 26-Ch continuous flow resectoscope (Karl Storz, Germany). Before starting resection, a detachment of resectoscope sheath tip was noted. The ceramic tip was free-floating in the bladder lumen, and it would not fit within the sheath, making direct extraction using the loop impossible. An attempt was made to break it with a stone punch, but it was unsuccessful due to impossibility of closing it in the branches. Therefore, we decided to fragment the tip with holmium laser (RevoLix®, LISA Laser products, Germany), using an 800-micron, front-firing fiber. Laser device was settled at with 2.5 J energy and 5 Hz frequency. Ceramic appeared very hard, but it was difficult to carry on breaking with this setting because of tip retropulsion. Then, laser setting was switched to lower energy and higher frequency (1 J and 13 Hz). This setting guaranteed the same power of 13 W, but with minimal retropulsion. Results Tip was fragmented against the posterior bladder wall in seven pieces, which were retrieved trough the outer sheath. A total 5.62 kJ were used to fragment it. At the end, superficial lesions of the posterior bladder wall were highlighted. Surgical time was 55 minutes. Patient was discharged home next day without problems. Conclusions Holmium laser fragmentation is a safe and effective approach to remove foreign bodies from the bladder.

A structured framework for optimizing high-intensity focused ultrasound ablative treatment in localized prostate cancer.

High-intensity focused ultrasound (HIFU) treatment has recently been pursued to reduce radical treatment-related morbidity in low-to-intermediate-risk localized prostate cancer (PCa), especially in older men. The aim of this study was to develop a dedicated framework for HIFU therapy. All clinical data, such as risk categories, magnetic resonance with functional parametric imaging, and histopathology, are essential for driving proper HIFU treatment. All needed data can be added to the framework to localize areas that need to be treated. Once PCa areas have been featured, quantified, and located, planning can be adapted to drive accurate HIFU treatment. Our planning framework may be useful for all ablative therapies in order to standardize treatment for both clinical and scientific purposes.

Iatrogenic foreign body in urinary bladder: Holmium laser vs. Ceramic, and the winner is .

INTRODUCTION: Urological surgery is estimated to be the third most common cause of iatrogenic-retained foreign bodies (1). PRESENTATION: A 76-year old man was undergoing a transurethral resection of bladder tumor with a 26-Ch continuous flow resectoscope (Karl Storz, Germany). Before starting resection, a detachment of resectoscope sheath tip was noted. The ceramic tip was free-floating in the bladder lumen, and it would not fit within the sheath, making direct extraction using the loop impossible. An attempt was made to break it with a stone punch, but it was unsuccessful due to impossibility of closing it in the branches. Therefore, we decided to fragment the tip with holmium laser (RevoLix®, LISA Laser products, Germany), using an 800-micron, front-firing fiber. Laser device was settled at with 2.5 J energy and 5 Hz frequency. Ceramic appeared very hard, but it was difficult to carry on breaking with this setting because of tip retropulsion. Then, laser setting was switched to lower energy and higher frequency (1 J and 13 Hz). This setting guaranteed the same power of 13 W, but with minimal retropulsion. RESULTS: Tip was fragmented against the posterior bladder wall in seven pieces, which were retrieved trough the outer sheath. A total 5.62 kJ were used to fragment it. At the end, superficial lesions of the posterior bladder wall were highlighted. Surgical time was 55 minutes. Patient was discharged home next day without problems. CONCLUSIONS: Holmium laser fragmentation is a safe and effective approach to remove foreign bodies from the bladder.

Is complete anatomical endoscopic laser enucleation of the prostate always necessary? Yes, it is!

INTRODUCTION: Thulium laser enucleation of the prostate is gaining popularity due to its short learning curve and low postoperative morbidity. The aim of Thulium laser enucleation of the prostate is the complete endoscopic enucleation of the adenoma. We report an unusual case of bladder outlet obstruction developed 6 weeks after Thulium laser enucleation of the prostate. CASE DESCRIPTION: A 74-year-old man complained of severe voiding phase symptoms lasting 2 weeks, starting 6 weeks after Thulium laser enucleation of the prostate. He underwent a transrectal ultrasound, which showed a wide prostatic fossa. A cystoscopy revealed that the prostatic fossa was filled with whitish tissue arising from two tiny residual adenomas. The obstructing tissue was resected with the aid of Thulium laser and the histopathology report showed necrotic prostatic glands. CONCLUSION: Partially enucleated and left inside adenoma may become necrotic and cause bladder outlet obstruction several weeks after Thulium laser enucleation of the prostate. Transrectal ultrasound control at the end of enucleation may help reduce this complication.

Radical cystectomy in frail octogenarians in thoracic continuous spinal anesthesia and analgesia: a pilot study.

BACKGROUND: Radical cystectomy (RC) is the gold standard therapy in nonmetastatic muscle-invasive bladder cancer and is usually performed under general anesthesia (GA). GA is high risk in most older patients due to comorbidities. Continuous spinal anesthesia (CSA) may be an alternative solution to reduce postoperative morbidity in elderly. The aim of this study was to assess the feasibility, morbidity, and mortality of RC performed under CSA in octogenarian patients. METHODS: We retrospectively reviewed data of five frail patients aged ⩾80 who underwent RC in CSA. CSA was achieved starting with 2.5 mg hyperbaric bupivacaine plus 25 µg fentanyl. Postoperative analgesia was achieved through the intrathecal catheter, using continuous delivery of levo-bupivacaine 60 mg plus fentanyl 75 µg in 72 hours. RESULTS: Surgery was completed in all cases in CSA. No patients required postoperative intensive care unit admission. Complications were Clavien I for four in three patients, Clavien II for seven in five patients, and Clavien IIIb for one patient. Postoperative consumption of painkillers was negligible. Oral feeding resumed within 3 days in all cases. The mean postoperative stay was 9.6 days. All patients were alive at 3 months of follow up. CONCLUSIONS: Management of muscle-invasive bladder cancer (MIBC) in older patients is becoming an important issue due to the continuous aging of the population. Age should not preclude RC, but careful management is mandatory because perioperative morbidity and mortality are increased in the elderly. Our preliminary results show that CSA and analgesia is a feasible option as an additional way to reduce morbidity and mortality in frail octogenarians who require RC.

Oncological safety and quality of life in men undergoing simultaneous transurethral resection of bladder tumor and prostate: results from a randomized controlled trial.

PURPOSE: To assess oncological safety and quality of life (QL) of men undergoing simultaneous transurethral resection of bladder tumor (TURBT) and transurethral resection of the prostate (TURP) for symptomatic benign prostatic hyperplasia (BPH). METHODS: Ninety-five men with a new diagnosis of bladder cancer (BC) and symptomatic BPH were randomized to receive TURBT + tamsulosin (Group 1) or TURBT + TURP (Group 2). Inclusion criteria were age ≤ 75 years, first diagnosis of BC up to 4 cm, and prostate volume ≤ 80 ml. All patients were evaluated preoperatively with digital rectal examination, PSA, maximal urine flow rate (Qmax), and International Prostate Symptom Score (IPSS). IPSS and Qmax were repeated at 1-year follow-up. QL was evaluated at 1 year using a modified version of the self-report bladder cancer subscale of the Functional Assessment of Cancer Therapy. RESULTS: Eighty-five men completed the study (43 in Group 1 and 42 in Group 2). Adjuvant instillation therapy was given to 26 patients in Group 1 and to 27 in Group 2. Average time to the first recurrence was 16.64 months in Group 1 and 17.7 in Group 2. Total recurrences were 27 in Group 1 and 22 in Group 2. Bladder neck/prostatic urethra recurrences were 9 in Group 1 vs. 8 in Group 2. QL, IPSS, and Qmax 12 months after surgery were better in Group 2. CONCLUSION: Concomitant TURBT and TURP appear to be oncologically safe procedures in terms of total and prostatic urethra recurrence, and improve QL in men with BC who require surgery for symptomatic BPH.