Serious complications and recurrences after retropubic vs transobturator midurethral sling procedures for 2682 patients in the VIGI-MESH register.

BACKGROUND: Midurethral slings are the gold standard for treating stress urinary incontinence, but their complications may raise concerns. Complications may differ by the approach used to place them. OBJECTIVE: This study aimed to compare serious complications and reoperations for recurrence after midurethral sling procedures when using the retropubic vs the transobturator route for female stress urinary incontinence. STUDY DESIGN: This analysis was of patients included in the French, multicenter VIGI-MESH register since February 2017 who received a midurethral sling for female stress urinary incontinence either by the retropubic or the transobturator route and excluded patients with single-incision slings. Follow-up continued until October 2021. Serious complications (Clavien-Dindo classification ≥ grade III) attributable to the midurethral sling and reoperations for recurrence were compared using Cox proportional hazard models including any associated surgery (hysterectomy or prolapse) and a frailty term to consider the center effect. Baseline differences were balanced by propensity score weighting. Analyses using the propensity score and Cox models were adjusted for baseline differences, center effect, and associated surgery. RESULTS: A total of 1830 participants received a retropubic sling and 852 received a transobturator sling in 27 French centers that were placed by 167 surgeons. The cumulative 2-year estimate of serious complications was 5.8% (95% confidence interval, 4.8-7.0) in the retropubic group and 2.9% (95% confidence interval, 1.9-4.3) in the transobturator group, that is, after adjustment, half of the retropubic group was affected (adjusted hazard ratio, 0.41; 95% confidence interval, 0.3-0.6). The cumulative 2-year estimate of reoperation for recurrence of stress urinary incontinence was 2.7% (95% confidence interval, 2.0-3.6) in the retropubic group and 2.8% (95% confidence interval, 1.7-4.2) in the transobturator group with risk for revision for recurrence being higher in the transobturator group after adjustment (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-2.9); this surplus risk disappeared after exclusion of the patients with a previous surgery for stress urinary incontinence. CONCLUSION: The transobturator route for midurethral sling placement is associated with a lower risk for serious complications but a higher risk for surgical reoperation for recurrence than the retropubic route. Despite the large number of surgeons involved, these risks were low. The data are therefore reassuring.

Technical feasibility of robot-assisted laparoscopic radical prostatectomy in renal transplant recipients: Results of a series of 12 consecutive cases.

INTRODUCTION: We evaluate the technical feasibility of robotic prostatectomy in renal transplant recipients. METHODS: We retrospectively analyzed preoperative and perioperative settings, as well as functional and oncologic results of 12 patients operated on between 2009 and 2013. Prostatectomy was performed via a transperitoneal approach without any changing in the ports position. The average age was 61.92 ± 2.98 years. The period between transplant and the diagnosis of adenocarcinoma was 79.7 months. The mean PSA was 7.34 ng/mL (range: 4.9-11). RESULTS: The operative time was 241.3 ± 35.6 minutes with only one conversion and one transfusion. The intervention was difficult due to adhesions on the side of the graft in 50% of cases. There was a case of obstructive acute renal failure resulting from a hematoma of the Retzius treated by percutaneous nephrostomy at D20. There was a majority of pT2c (72.7%), including 3 positive margins (27.3%) and 2 biochemical relapses treated with radiotherapy and hormonotherapy, respectively. The end point prostate-specific antigen was undetectable. There was no significant difference between preoperative and J7 creatinine (p = 0. 22). CONCLUSIONS: Robotic prostatectomy in renal transplant recipients is a safe technique with no serious effects on the allograft.

The accuracy of different biopsy strategies for the detection of clinically important prostate cancer: a computer simulation.

PURPOSE: The true accuracy of different biopsy strategies for detecting clinically significant prostate cancer is unknown, given the positive evaluation bias required for verification by radical prostatectomy. To evaluate how well different biopsy strategies perform at detecting clinically significant prostate cancer we used computer simulation in cystoprostatectomy cases with cancer. MATERIALS AND METHODS: A computer simulation study was performed on prostates acquired at radical cystoprostatectomy. A total of 346 prostates were processed and examined for prostate cancer using 3 mm whole mount slices. The 96 prostates that contained cancer were digitally reconstructed. Biopsy simulations incorporating various degrees of random localization error were performed using the reconstructed 3-dimensional prostate computer model. Each biopsy strategy was simulated 500 times. Two definitions of clinically significant prostate cancer were used to define the reference standard, including definition 1--Gleason score 7 or greater, and/or lesion volume 0.5 ml or greater and definition 2--Gleason score 7 or greater, and/or lesion volume 0.2 ml or greater. RESULTS: A total of 215 prostate cancer foci were present. The ROC AUC to detect and rule out definition 1 prostate cancer was 0.69, 0.75, 0.82 and 0.91 for 12-core transrectal ultrasound biopsy with a random localization error of 15 and 10 mm, 14-core transrectal ultrasound biopsy and template prostate mapping using a 5 mm sampling frame, respectively. CONCLUSIONS: To our knowledge our biopsy simulation study is the first to evaluate the performance of different sampling strategies to detect clinically important prostate cancer in a population that better reflects the demographics of a screened cohort. Compared to other strategies standard transrectal ultrasound biopsy performs poorly for detecting clinically important cancer. Marginal improvement can be achieved using additional cores placed anterior but the performance attained by template prostate mapping is optimal.

A biopsy simulation study to assess the accuracy of several transrectal ultrasonography (TRUS)-biopsy strategies compared with template prostate mapping biopsies in patients who have undergone radical prostatectomy.

UNLABELLED: What's known on the subject? and What does the study add? Transrectal ultrasonography (TRUS)-guided biopsies can miss prostate cancer and misclassify risk in a diagnostic setting; the exact extent to which it does so in a repeat biopsy strategy in men with low-intermediate risk prostate cancer is unknown. A simulation study of different biopsy strategies showed that repeat 12-core TRUS biopsy performs poorly. Adding anterior sampling improves on this but the highest accuracy is achieved using transperineal template prostate mapping using a 5 mm sampling frame. OBJECTIVE: To determine the effectiveness of two sampling strategies; repeat transrectal ultrasonography (TRUS)-biopsy and transperineal template prostate mapping (TPM) to detect and exclude lesions of ≥0.2 mL or ≥0.5 mL using computer simulation on reconstructed three-dimensional (3-D) computer models of radical whole-mount specimens. PATIENTS AND METHODS: Computer simulation on reconstructed 3-D computer models of radical whole-mount specimens was used to evaluate the performance characteristics of repeat TRUS-biopsy and TPM to detect and exclude lesions of ≥0.2 mL or ≥0.5 mL. In all, 107 consecutive cases were analysed (1999-2001) with simulations repeated 500 times for each biopsy strategy. TPM and five different TRUS-biopsy strategies were simulated; the latter involved a standard 12-core sampling and incorporated variable amounts of error, as well as the addition of anterior cores. Sensitivity, specificity, negative and positive predictive values for detection of lesions with a volume of ≥0.2 mL or ≥0.5 mL were calculated. RESULTS: The mean (SD) age and PSA concentration were 61 (6.4) years and 8.5 (5.9) ng/mL, respectively.In all, 53% (57/107) had low-intermediate risk disease. In all, 665 foci were reconstructed; there were 149 foci ≥0.2 mL and 97 ≥ 0.5 mL in the full cohort and 68 ≥ 0.2 mL and 43 ≥ 0.5 mL in the low-intermediate risk group. Overall, TPM accuracy (area under the receiver operating curve, AUC) was ≈0.90 compared with AUC 0.70-0.80 for TRUS-biopsy. In addition, at best, TRUS-biopsy missed 30-40% of lesions of ≥0.2 mL and ≥0.5 mL whilst TPM missed 5% of such lesions. CONCLUSION: TPM under simulation conditions appears the most effective re-classification strategy, although augmented TRUS-biopsy techniques are better than standard TRUS-biopsy.

Characterizing clinically significant prostate cancer using template prostate mapping biopsy.

PURPOSE: Definitions of prostate cancer risk are limited since accurate attribution of the cancer grade and burden is not possible due to the random and systematic errors associated with transrectal ultrasound guided biopsy. Transperineal prostate mapping biopsy may have a role in accurate risk stratification. We defined the transperineal prostate mapping biopsy characteristics of clinically significant disease. MATERIALS AND METHODS: A 3-dimensional model of each gland and individual cancer was reconstructed using 107 radical whole mount specimens. We performed 500 transperineal prostate mapping simulations per case by varying needle targeting errors to calculate sensitivity, specificity, and negative and positive predictive value to detect lesions 0.2 ml or greater, or 0.5 ml or greater. Definitions of clinically significant cancer based on a combination of Gleason grade and cancer burden (cancer core length) were derived. RESULTS: Mean±SD patient age was 61±6.4 years (range 44 to 74) and mean prostate specific antigen was 9.7±5.9 ng/ml (range 0.8 to 36.2). We reconstructed 665 foci. The total cancer core length from all positive biopsies for a particular lesion that detected more than 95% of lesions 0.5 ml or greater and 0.2 ml or greater was 10 mm or greater and 6 mm or greater, respectively. The maximum cancer core length that detected more than 95% of lesions 0.5 ml or greater and 0.2 ml or greater was 6 mm or greater and 4 mm or greater, respectively. We combined these cancer burden thresholds with dominant and nondominant Gleason pattern 4 to derive 2 definitions of clinically significant disease. CONCLUSIONS: Transperineal prostate mapping may provide an effective method to risk stratify men with localized prostate cancer. The definitions that we present require prospective validation.

Focal therapy for prostate cancer: a potential strategy to address the problem of overtreatment.

Focal therapy for localized prostate cancer involves destroying the cancer focus in order to offer patients the potential of combining cancer control with minimal side-effects. Current standard of care involves either active surveillance or radical therapy. Neither of these is ideal. Active surveillance carries a risk of under- treatment, with psychological morbidity as a result of anxiety and is associated with side-effects due to repeated biopsies, although radical therapy is the gold standard for curative treatment. With the proportion of unifocal or unilateral disease among men with low-risk disease rising, a focal approach could avoid both under and over-treatment. With the advent of improved accuracy for cancer localization provided by multiparametric MRI and new biopsy strategies such as transperineal mapping biopsies, ablative modalities such as cryotherapy, high intensity focused ultrasound, photodynamic therapy and radio-interstitial tumour ablation make focal treatments a real possibility.

Terapia focal en cáncer de próstata: Una estrategia potencial para solucionar el problema del sobretratamiento / Focal therapy for prostate cancer: a potential strategy to address the problem of overtreatment

La terapia focal pretende destruir el foco tumoral con un margen de tejido circundante para ofrecer a los pacientes el potencial de combinar control oncológico y mínimos efectos colaterales. El tratamiento estándar actual incluye vigilancia activa o tratamiento radical. Ninguna de estas opciones es ideal. La vigilancia activa conlleva el riesgo de infratratamiento, morbilidad psicológica como resultado de la ansiedad, y no está libre de efectos colaterales debido a las biopsias repetidas. Aunque el tratamiento radical es el patrón oro del tratamiento curativo, conlleva riesgos de sobretratamiento con sus numerosos efectos colaterales. Con el aumento de la proporción de cánceres unifocales o unilaterales entre varones de bajo riesgo, un abordaje focal podría evitar tanto el infra como el sobretratamiento. Con la mejora de la precisión de la localización del cáncer proporcionada por la resonancia magnética nuclear multiparamétrica y las nuevas estrategias de biopsia como los mapas biópsicos transperineales, las terapias ablativas como crioterapia, ultrasonidos focalizados de alta intensidad (HIFU), terapia fotodinámica y ablación radiointersticial de tumores hacen del tratamiento focal una posibilidad real(AU)

Focal therapy involves destroying the cancer focus and the tissue surrounding the cancer in order to offer patients the potential of combining cancer control with minimal side-effects. Current standard of care involve either surveillance or radical therapy. Neither of these is ideal. Active surveillance carries risk of under-treatment, psychological morbidity as a result of anxiety and is not without side-effects due to repeated biopsies., Although radical therapy is the gold standard for curative treatment it carries risks of over-treatment with its numerous side-effects. With the proportion of unifocal or unilateral disease among men with low-risk disease rising, a focal approach could avoid both under and over-treatment. With the advent of improved accuracy for cancer localization provided by multi-parametric MRI and new biopsy strategies such as transperineal mapping biopsies, ablative modalities such as cryotherapy, high intensity focused ultrasound, photodynamic therapy and radio-interstitial tumour ablation make a focal treatments a real possibility(AU)

Focal therapy for prostate cancer: fact or fiction?

Prostate cancer is the commonest male cancer diagnosed in men in the UK, and the treatment of organ confined prostate cancer is a subject of much debate. Focal therapy for prostate cancer intends to treat the cancer within the prostate, whilst sparing the majority of the benign prostate tissue. In addition, the intention is to avoid treatment effects in the surrounding structures, the damage of which leads to the side effects commonly associated with radical whole gland therapies. This relies on accurate localization of the prostate cancer by biopsy and imaging followed by treatment using a modality capable of delivery to a focal area within the prostate. Focal therapy lies between the current extremes of radical whole gland treatment and active surveillance. There have been many articles reviewing the concept of focal therapy for organ confined prostate cancer, but with a paucity of data available for analysis. This is being addressed with an increase in the published data on focal therapy, using a number of different modalities. In this review, we address the question of whether the data currently published does in fact support the further development of the focal therapy approach, or whether it is a concept best relegated to the realms of fiction.

Conceptual basis for focal therapy in prostate cancer.

The proportion of men with low- to intermediate-risk prostate cancer is rising with the increasing use of formal and informal prostate-specific antigen screening. The risk-to-benefit ratio of radical therapy is large with many men suffering genitourinary side effects compared with the small degree of cancer control that they derive from surgery or radiotherapy. On the other hand, the current alternative, active surveillance, carries risk of progression as well as some psychological and healthcare burdens. Focal treatment may be an acceptable alternative: in aiming to destroy only the areas of prostate cancer, focal therapy could deliver cancer control while at the same time avoid damage to surrounding structures. This may reduce incontinence, impotence, and rectal toxicity. Improvements in localization of cancer such as template transperineal prostate-mapping biopsies as well as state-of-the-art imaging such as multiparametric MRI and novel ultrasound-based tissue characterization tools have made the delivery of focal therapy possible. Minimally invasive ablative technologies such as cryotherapy, high-intensity focused ultrasound, photodynamic therapy, photothermal therapy, or radiofrequency interstitial tumor ablation can precisely treat to within a few millimeters. Early studies evaluating focal therapy have found a lower side-effect profile with acceptable short- to medium-term cancer control rates. If these promising results are confirmed in future prospective trials, focal therapy could start to challenge the current standard of care.

Focal therapy in prostate cancer: determinants of success and failure.

Focal therapy is emerging as a potential challenge to the standard of care for localized prostate cancer. Short-term quality-of-life outcomes such as genitourinary side effects, anxiety levels, and global measures of quality of life using validated questionnaires are vital although proof-of-concept trials and retrospective case series have already established lower toxicity from focal therapy in some detail. Defining what outcomes will be measured and what defines a successful focal treatment in the medium and long term is problematic. Measuring long-term efficacy or effectiveness within a randomized trial is somewhat straightforward since hard endpoints are measured such as presence or absence of metastatic disease and/or death. However, owing to the long natural history of localized prostate cancer detected in the modern prostate-specific antigen screening era, with these events usually occurring a minimum of 10 years after therapy makes such a long-term trial large, costly, and probably unfeasible now. This article discusses the optimal determinants of success or failure for focal therapy that require careful consideration within multicenter trials evaluating medium-term oncological efficacy.