Transperineal laser ablation of the prostate as a treatment for benign prostatic hyperplasia and prostate cancer: The results of a Delphi consensus project.

Objective: To evaluate transperineal laser ablation (TPLA) with Echolaser® (Echolaser® TPLA, Elesta S.p.A., Calenzano, Italy) as a treatment for benign prostatic hyperplasia (BPH) and prostate cancer (PCa) using the Delphi consensus method. Methods: Italian and international experts on BPH and PCa participated in a collaborative consensus project. During two rounds, they expressed their opinions on Echolaser® TPLA for the treatment of BPH and PCa answering online questionnaires on indications, methodology, and potential complications of this technology. Level of agreement or disagreement to reach consensus was set at 75%. If the consensus was not achieved, questions were modified after each round. A final round was performed during an online meeting, in which results were discussed and finalized. Results: Thirty-two out of forty invited experts participated and consensus was reached on all topics. Agreement was achieved on recommending Echolaser® TPLA as a treatment of BPH in patients with ample range of prostate volume, from <40 mL (80%) to >80 mL (80%), comorbidities (100%), antiplatelet or anticoagulant treatment (96%), indwelling catheter (77%), and strong will of preserving ejaculatory function (100%). Majority of respondents agreed that Echolaser® TPLA is a potential option for the treatment of localized PCa (78%) and recommended it for low-risk PCa (90%). During the final round, experts concluded that it can be used for intermediate-risk PCa and it should be proposed as an effective alternative to radical prostatectomy for patients with strong will of avoiding urinary incontinence and sexual dysfunction. Almost all participants agreed that the transperineal approach of this organ-sparing technique is safer than transrectal and transurethral approaches typical of other techniques (97% of agreement among experts). Pre-procedural assessment, technical aspects, post-procedural catheterization, pharmacological therapy, and expected outcomes were discussed, leading to statements and recommendations. Conclusion: Echolaser® TPLA is a safe and effective procedure that treats BPH and localized PCa with satisfactory functional and sexual outcomes.

Experience after 12 cases with the adjustable transobturator male sling for postprostatectomy stress urinary incontinence.

OBJECTIVES: The aim of the study was the prospective evaluation of the efficacy of the adjustable transobturator male system (ArgusT®) for the treatment of postprostatectomy stress urinary incontinence (PPI). METHODS: Twelve consecutive patients were treated with ArgusT system for PPI. All patients were comprehensively evaluated preoperatively and after 3 and 6 months regarding daily pad use, residual urine, Incontinence Quality of Life Scale (I-QoL) score and International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) score. Cure rate was defined as no pad use or one pad (used for security reasons). RESULTS: At 3 and 6 months, we achieved a cure rate of 91%. The mean number of pads per day decreased from 4 ± 1.3 to 0.7 ± 0.9 and 0.5 ± 0.9 after 3 and 6 months, respectively (p<0.001). Only one patient showed no significant improvement. Compared with baseline, the mean ICIQ-SF score dropped from 17.3 ± 2.8 to 2.7 ± 3.8 and 2.4 ± 3.8, at 3 and 6 months, respectively (p<0.001). The mean I-QoL score also improved significantly from 53.1 ± 20.3 to 99.5 ± 11 and 96.8 ± 12.5 after 3 and 6 months, respectively (p<0.001). Postoperative acute urinary retention was seen in one patient. CONCLUSIONS: In our early experience, the ArgusT system offers effective, safe and minimally invasive treatment option for PPI.

The percentage of core involved by cancer is the best predictor of insignificant prostate cancer, according to an updated definition (tumor volume up to 2.5 cm3): analysis of a cohort of 210 consecutive patients with low-risk disease.

OBJECTIVE: To find out which factors could predict the diagnosis of insignificant prostate cancer (ins-PCa) according to a recently updated definition (overall tumor volume up to 2.5 cm(3); final Gleason score ≤6; organ-confined disease) on a prostatic biopsy specimen. METHODS: This was a retrospective analysis of 210 patients undergoing radical prostatectomy for a cT1c prostate neoplasm with a biopsy specimen Gleason score of ≤6. A logistic regression model was used to assess the differences in the distribution of some possibly predictive factors between the ins-PCa patients, according to the updated definition, and the remaining patients. RESULTS: By applying an updated definition of ins-PCa, the prevalence of this condition increased from 13.3% to 49.5% (104 of 210 patients). The univariate analysis showed a statistically different distribution of the following factors: prostate-specific antigen density, prostate volume, number of cancer-involved cores, and maximum percentage of core involvement by cancer. At the multivariable analysis, the maximum percentage of involvement of the core retained its relevance (27.0% in ins-PCa patients and 43.8% in the remaining patients; hazard ratio, 0.972; P = .046), and a 20% cutoff was detected. CONCLUSION: In a cohort of patients with PCa cT1c and a biopsy specimen Gleason score of ≤6, the ins-PCa rate, according to the updated definition, is close to 50%, and the percentage of cancer involvement of the core is the single factor that best predicts this diagnosis.

[Radiotherapy in case of locally advanced prostate cancer: long-term follow-up in 223 patients]. / La neoplasia prostatica localmente avanzata sottoposta a radioterapia: follow-up a lungo termine in 223 pazienti

AIM OF THE STUDY: To evaluate the long-term follow-up in patients undergoing external beam radiotherapy for locally advanced prostate cancer. PATIENTS AND METHODS: From November 1999 to January 2007, 223 patients with a histologic diagnosis (204 transperineal needle biopsies; 19 trans-urethral prostatic resections) of locally advanced prostate cancer underwent external beam radiotherapy; of these patients, 151 were T3a (extracapsular extension) and 72 were T3b (involvement of seminal vesicles); the extracapsular extension was demonstrated using pelvic RMN or transrectal ultrasound, while the presence of distant and lymph node metastases was excluded using TC total body or bone scan. PSA value at diagnosis was 29.1 ng/mL (0.4-379 ng/mL). Radiotherapy was used on prostate and seminal vesicles in 201 patients (141 T3a; 60 T3b) while in 22 patients (10 T3a; 12 T3b) it was extended to the pelvis. Biochemical recurrence was defined using ASTRO definition (three consecutive PSA rises after PSA nadir); no patients underwent control prostate needle biopsy for problems of interpretation related to postactinic tissue changes. All complications were recorded and analyzed using Radiation Morbidity Scoring Criteria (RTOG). RESULTS: At a mean 55-month follow-up, of the 223 patients treated, 26 have escaped controls, 168 are alive (141 disease-free; 27 with recurrent disease) and 29 died; of this group, 11 patients died from clinical progression, while in the others the cause was not related to the prostatic problem; only one patient died from iatrogenic problems. Hormone treatment was conducted in different ways (neoadjuvant, adjuvant, concurrent to radiotherapy or in association) considering patients' characteristics. Most common complications involved rectum and bladder.
 CONCLUSIONS: Radiotherapy is a viable and safe method in the treatment of locally advanced prostate cancer; however, it is essential the role of hormone therapy.

[Insignificant prostate cancer: charateristics and predictive factors]. / Carcinoma prostatico insignificante: caratteristiche e fattori predittivi.

INTRODUCTION: The widespread screening for PSA has contributed to the increased incidence of prostate cancer (PCa), mostly identifying disease at earlier stages. Many of these patients will probably not require treatment because of the indolent course of the disease. The European Randomized Study of Screening for Prostate Cancer (ERSPC) has showed that 1410 men needed to be screened and 48 prostatectomies performed to prevent death. The aim of this study was to evaluate predictive factors of insignificant PCa in our experience. MATERIALS AND METHODS: We analyzed various preoperative clinical and biopsy findings of 225 consecutive patients who underwent prostatectomy from October 2007 to June 2010. The indication for biopsy was placed in presence of an abnormal rectal examination and/or suspected transrectal ultrasound and/or PSA >4 ng/ml. We consider insignificant a tumor with a volume ≤5% of the entire gland with a Gleason score ≤ 6, with no grades 4 or 5 and organ confined. RESULTS: The prevalence of potentially insignificant PCa in our experience was 12%. The preoperative findings of patients with insignificant PCa were significantly more favorable than the remaining cases with PCa not insignificant. Multivariate analysis did not reveal any independent predictors. CONCLUSIONS: In our experience, in a population not screened for PCa, we have not identified any factors that can predict with certainty the insignificant nature of a tumor and, therefore, useful to start a patient on an active surveillance program.

[High-intensity focused ultrasound (HIFU): our experience in the treatment of prostate cancer relapsing after radiotherapy]. / Ultrasuoni focalizzati ad alta intensità (HIFU): la nostra esperienza nel trattamento del carcinoma prostatico recidivo a radioterapia.

The aim of the study is to evaluate the safety and efficacy of high-intensity focused ultrasound (HIFU) treatment in patients with local prostate cancer recurrence after radiotherapy. From February 2009 to June 2010, 14 patients with prostate cancer recurrence after radiotherapy were selected for HIFU treatment; all patients had a positive TRUS-guided biopsy and the absence of distant metastases was confirmed by computer tomography, PET choline or bone scintigraphy. We classified all patients in 3 groups using D'Amico's classification: 4 patients high risk (PSA >20 ng/ml - 8≤ Gleason Score≤ 10 - clinical stage≥T2c), 8 patients intermediate risk (10 PSAnadir+1.2ng/ml) or after adjuvant therapy introduction. All complications were recorded. Of the 14 patients selected, 12 patients underwent HIFU treatments; 2 patients were excluded because of rectal strictures induced by radiotherapy. At a mean 13 months' follow-up, biochemical success rate was obtained in 1 of the high risk patients and in 5 of the low and intermediate risk patients; 1 man died for a disease not correlated with prostate cancer recurrence. Complications included urinary tract infection, acute urinary retentions, urethral strictures and light stress incontinence. In our experience salvage HIFU is a safe treatment option for local relapse after radiotherapy; its efficacy depends on a careful patient selection.

[Which factors allow to anticipate the diagnosis of prostate cancer in pin patients? A study on 546 patients]. / Quali fattori permettono di prevedere la diagnosi di carcinoma prostatico nei pazienti con PIN? Studio su 546 pazienti.

AIM OF THE STUDY: To analyze which factors allow to assess the risk of finding a prostate cancer (PCa) at repeated biopsies in patients with diagnosis of prostatic intraepithelial neoplasia (PIN). PATIENTS AND METHODS: At our institute all patients with a diagnosis of PIN undergo a 6-monthly control biopsy until the achievement of a benign histology or up to a maximum of 4 consecutive biopsies. For this study a retrospective review of clinical and bioptic data of patients with a diagnosis of isolated PIN (i.e. without associated atypical small acinar proliferation or small cancer foci) was carried out. The correlation between these features and the probability to find PCa at the first re-biopsy or at a further re-biopsy was independently analyzed. RESULTS: The data of 546 patients subjected to a median number of 3 biopsies, (mean: 10.8 and 12.9 cores at initial biopsy and at first re-biopsy, respectively), and with a mean "bioptic" follow-up time of 14.8 months, were analyzed. PCa was found in 174 cases (31.8%): for 116 of them it took place at the first re-biopsy, with a mean latency of 7.8 months from PIN diagnosis, whereas for 58 at a further re-biopsy, with a mean latency of 21.6 months. The risk of diagnosing PCa at the first re-biopsy was statistically correlated with the PSA value--for which a cut-off value of 7 ng/mL was identified--and with an anomalous rectal prostatic examination at the time of the initial biopsy. Differently, the risk of diagnosing PCa after the first re-biopsy correlated with the number of cores positive for PIN at the initial biopsy--for which a cut-off of 4 was identified--and to the ratio between these and the total number of cores, defined as PIN density--for which a cut-off of 50% was determined. DISCUSSION AND CONCLUSIONS. It is possible to suggest a tailored protocol of controls in patients with a diagnosis of PIN on the basis of the data available at the initial biopsy: a) high PSA value and/or an anomalous prostatic rectal examination: the diagnosis of PCa is probably just unacknowledged by the initial sampling and it is advisable to carry out an early re-biopsy; b) number of cores with PIN equal to or higher than 4 and/or PIN density equal to or higher than 50%: a true transition from PIN to PCa is likely to happen with time and it is advisable to carry out a delayed re-biopsy; c) no risk factors: just clinical and PSA monitoring to establish the indication to re-biopsy.