[The long journey from palpation to biopsy : The history of diagnosing prostate cancer]. / Der lange Weg von der Palpation zur Biopsie : Zur Geschichte der Prostatakarzinomdiagnostik.

Though it is thousands of years old, prostate cancer (PCa) has only been known for 200 years. Until about 50 years ago, the diagnosis could only be made by digital rectal examination. Although the first prostate biopsies were already implemented in the beginning of the last century, it only obtained importance with the introduction of prostate-specific antigen (PSA) testing in the early screening for PCa and the pathologist, thus, became an essential partner for the urologist. In more recent years, specific MRI has significantly increased the accuracy of prostate biopsies. Thus, the question arises whether this technique is going to be so meaningful one day that prostate biopsy and the associated pretherapeutic histology are going to be redundant.

[Focal therapy of prostate cancer]. / Fokale Therapie des Prostatakarzinoms.

The target of focal therapy (FT) in prostate cancer (PC) is partial treatment of the prostate aiming at preserving surrounding anatomical structures. The intention is to minimize typical side effects of radical treatment options combined with local tumor control. Numerous established and new technologies are used. Results of published studies showed a good safety profile, few side effects and good preservation of functional results. Oncologic long-term data are lacking so far. Photodynamic therapy (PDT) is the only technology that has been studied in a published prospective randomized trial. The FT is challenged by the multifocality of PC; therefore, the quality of prostate biopsy, histopathological assessment as well as imaging are of paramount importance. Multiparametric magnetic resonance imaging (MRI) has gained increasing importance. The FT is experimental and should only be offered within clinical trials.

Why we should not routinely apply irreversible electroporation as an alternative curative treatment modality for localized prostate cancer at this stage.

Irreversible electroporation (IRE), a new tissue ablation procedure available since 2007, could meet the requirements for ideal focal therapy of prostate cancer with its postulated features, especially the absence of a thermal ablation effect. Thus far, there is not enough evidence of its effectiveness or adverse effects to justify its use as a definitive treatment option for localized prostate cancer. Moreover, neither optimal nor individual treatment parameters nor uniform endpoints have been defined thus far. No advantages over established treatment procedures have as yet been demonstrated. Nevertheless, IRE is now being increasingly applied for primary prostate cancer therapy outside clinical trials, not least through active advertising in the lay press. This review reflects the previous relevant literature on IRE of the prostate or prostate cancer and shows why we should not adopt IRE as a routine treatment modality at this stage.

[MRI/TRUS fusion-guided prostate biopsy : Value in the context of focal therapy]. / MRT/TRUS-fusionierte Biopsiesysteme : Stellenwert bei der fokalen Therapie des Prostatakarzinoms.

BACKGROUND: Several systems for MRI/TRUS fusion-guided biopsy of the prostate are commercially available. Many studies have shown superiority of fusion systems for tumor detection and diagnostic quality compared to random biopsy. The benefit of fusion systems in focal therapy of prostate cancer (PC) is less clear. OBJECTIVES: Critical considerations of fusion systems for planning and monitoring of focal therapy of PC were investigated. MATERIALS AND METHODS: A systematic literature review of available fusion systems for the period 2013-5/2016 was performed. A checklist of technical details, suitability for special anatomic situations and suitability for focal therapy was established by the German working group for focal therapy (Arbeitskreis fokale und Mikrotherapie). RESULTS: Eight fusion systems were considered (Artemis™, BioJet, BiopSee®, iSR´obot™ Mona Lisa, Hitachi HI-RVS, UroNav and Urostation®). Differences were found for biopsy mode (transrectal, perineal, both), fusion mode (elastic or rigid), navigation (image-based, electromagnetic sensor-based or mechanical sensor-based) and space requirements. DISCUSSION: Several consensus groups recommend fusion systems for focal therapy. Useful features are "needle tracking" and compatibility between fusion system and treatment device (available for Artemis™, BiopSee® and Urostation® with Focal One®; BiopSee®, Hitachi HI-RVS with NanoKnife®; BioJet, BiopSee® with cryoablation, brachytherapy). CONCLUSIONS: There are a few studies for treatment planning. However, studies on treatment monitoring after focal therapy are missing.

[Focal therapy for small renal masses : Observation, ablation or surgery]. / Fokale Therapie von kleinen Nierentumoren : Beobachtung, Ablation oder Operation.

BACKGROUND: The rising incidence of renal cell carcinoma, its more frequent early detection (stage T1a) and the increasing prevalence of chronic renal failure with higher morbidity and shorter life expectancy underscore the need for multimodal focal nephron-sparing therapy. DISCUSSION: During the past decade, the gold standard shifted from radical to partial nephrectomy. Depending on the surgeon's experience, the patient's constitution and the tumor's location, the intervention can be performed laparoscopically with the corresponding advantages of lower invasiveness. A treatment alternative can be advantageous for selected patients with high morbidity and/or an increased risk of complications associated with anesthesia or surgery. Corresponding risk stratification necessitates previous confirmation of the small renal mass (cT1a) by histological examination of biopsy samples. Active surveillance represents a controlled delay in the initiation of treatment. RESULTS: Percutaneous radiofrequency ablation (RFA) and laparoscopic cryoablation are currently the most common treatment alternatives, although there are limitations particularly for renal tumors located centrally near the hilum. More recent ablation procedures such as high intensity focused ultrasound (HIFU), irreversible electroporation, microwave ablation, percutaneous stereotactic ablative radiotherapy and high-dose brachytherapy have high potential in some cases but are currently regarded as experimental for the treatment of renal cell carcinoma.

Standardization of definitions in focal therapy of prostate cancer: report from a Delphi consensus project.

PURPOSE: To reach standardized terminology in focal therapy (FT) for prostate cancer (PCa). METHODS: A four-stage modified Delphi consensus project was undertaken among a panel of international experts in the field of FT for PCa. Data on terminology in FT was collected from the panel by three rounds of online questionnaires. During a face-to-face meeting on June 21, 2015, attended by 38 experts, all data from the online rounds were reviewed and recommendations for definitions were formulated. RESULTS: Consensus was attained on 23 of 27 topics; Targeted FT was defined as a lesion-based treatment strategy, treating all identified significant cancer foci; FT was generically defined as an anatomy-based (zonal) treatment strategy. Treatment failure due to the ablative energy inadequately destroying treated tissue is defined as ablation failure. In targeting failure the energy is not adequately applied to the tumor spatially and selection failure occurs when a patient was wrongfully selected for FT. No definition of biochemical recurrence can be recommended based on the current data. Important definitions for outcome measures are potency (minimum IIEF-5 score of 21), incontinence (new need for pads or leakage) and deterioration in urinary function (increase in IPSS >5 points). No agreement on the best quality of life tool was established, but UCLA-EPIC and EORTC-QLQ-30 were most commonly supported by the experts. A complete overview of statements is presented in the text. CONCLUSION: Focal therapy is an emerging field of PCa therapeutics. Standardization of definitions helps to create comparable research results and facilitate clear communication in clinical practice.

[Irreversible electroporation. Current value for focal treatment of prostate cancer]. / Irreversible Elektroporation. Aktueller Stellenwert in der fokalen Therapie des Prostatakarzinoms.

BACKGROUND: Irreversible electroporation (IRE), a new tissue ablation procedure available since 2007, could meet the requirements for ideal focal therapy (FT) with its postulated features, especially the absence of a thermal ablative effect. Thus far, there is no adequate tumor-entity-specific proof of its effectiveness, and its clinical application has hitherto been confined to very small patient cohorts. This also holds true for prostate cancer (PCA). Nevertheless, it is now being increasingly applied outside clinical trials-to a certain extent due to active advertising in the lay press. AIM OF THE STUDY: In this study, current discrepancies between the clinical application and study situation and the approval and market implementation of the procedure are described. The media portrayal of IRE is discussed from different perspectives, particularly with reference to the FT of PCA. This is followed by a final clinical assessment of IRE using the NanoKnife® system. DISCUSSION: Strict requirements govern new drug approvals. According to the German Drug Act (AMG), evidence of additional benefit over existing therapy must be provided through comparative clinical trials. For medicotechnical treatment procedures, on the other hand, such trial-based proof is not required according to the Medical Devices Act (MPG). The use of IRE even outside clinical trials has been actively promoted since the NanoKnife® system was put on the market. This has led to an increase in the number of uncontrolled IRE treatments of PCA in the last 2 years. The patients have to cover the high treatment costs themselves in these cases. If articles in the lay press advertise the procedure with promising but unverified contents, false hopes are raised in those concerned. This is disastrous if it delays the use of truly effective treatment options. CONCLUSION: IRE basically still has high potential for the treatment of malignancies; however, whether it can really be used for FT remains unclear due to the lack of data. This also holds true for the treatment of PCA. Only carefully conducted scientific research studies can clarify the unresolved issues regarding IRE of PCA. The urgently needed development of universally valid treatment standards for IRE is unnecessarily hampered by the flow commercially driven patients.

[Cancer control in focus insights and future perspectives for the focal treatment of prostate cancer]. / Krebskontrolle im Fokus - Einblicke und Ausblicke rund um die fokale Therapie des Prostatakrebses.

Faced with the dilemma of choosing between the extremes of standard whole gland therapy and active surveillance, those affected by prostate cancer have recently been on the lookout for less invasive alternatives. Particularly the question of whether it would be possible in low risk cancer to treat only the tumour itself while sparing the organ has long been considered. This article discusses the pros and cons of focal treatment and elucidates the latest innovative technologies. High overtreatment rates in low-risk patients submitted to standard therapy and considerable technological advances in diagnosis (particularly multiparametric MRI) and therapy are regarded by the authors as key arguments for abandoning complete tumour eradication with its side effects in favour of sufficient local cancer control by focal treatment with better preserved quality of life in suitable cases.

[Focal therapy for prostate cancer in Germany - 2014 status]. / Fokale Therapie des Prostatakarzinoms in Deutschland - Status 2014.

BACKGROUND: In localized low-risk prostate cancer (PCa), there is a therapeutic dilemma between possible overtreatment by one of the standard therapies and potentially insufficient cancer control by active surveillance (AS). Focal therapy (FT) provides an alternative therapeutic option as it aims to preserve the organ and to eliminate the cancer focus at the same time. METHODS: In this article the current state of FT for localized low-risk prostate carcinoma in Germany is described. In addition, criteria that should be used to select patients for FT are proposed. RESULTS: Currently, the effectiveness of FT is under evaluation by two multicenter, prospective studies in Germany: TOOKAD and HEMI. However, localized low-risk prostate carcinoma remains a diagnostic challenge: Multiparametric MRI as well as histopathological second opinion are considered mandatory in addition to transrectal biospy. CONCLUSION: The oncological outcome of both the TOOKAD and HEMI study will be crucial for any form of FT for prostate carcinoma in Germany in the future. However, there is a remarkably high acceptance of FT among patients.

[Focal prostate cancer therapy: capabilities, limitations and prospects]. / Fokale Therapie des Prostatakarzinoms: Möglichkeiten, Limitierungen und Ausblick.

INTRODUCTION: Patients with low-risk prostate cancer (PCa) face the difficult decision between a potential overtreatment by one of the standard therapies and active surveillance (AS) with the potential insecurity regarding cancer control. A focal therapy (FT) implies a treatment of the tumor within the prostate only. METHODS: This review evaluates the current literature and expert opinion of different therapies suited for FT as well as concepts for prostate imaging, biopsy and histopathological evaluation. RESULTS: Currently there is a lack of multicenter, randomized, prospective data on the effectiveness of FT. Nonetheless, the published data indicate a sufficient tumor control with a favorable side effect profile. There are still flaws in the diagnostics with regard to tumor detection and histological evaluation. Multicenter studies are currently recruiting worldwide which will provide new data with a higher level of evidence. CONCLUSION: At present, the effectiveness of FT should not be compared directly to standard radical therapies and FT should only be performed within studies. In cases of cancer progression after FT a salvage treatment should still be possible.

Laparoscopic radical prostatectomy with the Heilbronn technique: an analysis of the first 180 cases.

PURPOSE: In 1998 Guillonneau and Vallancien introduced laparoscopic radical prostatectomy with primary access to the seminal vesicle. In 1999 we developed a different laparoscopic technique similar to the classic retropubic radical prostatectomy. We focus on early results and the learning curve of the procedure in the first 180 patients. MATERIALS AND METHODS: A transperitoneal approach is used with immediate access to Retzius' space. After the dorsal vein complex is endoscopically sutured, the urethra is incised and distal pedicles of the prostate with or without the neurovascular bundle transected. The apex is then pulled ventrally followed with incision at the bladder neck, and transvesical access to vas deferens and seminal vesicle. After completing the posterior wall of the urethrovesical anastomosis with 5 interrupted endoscopic sutures, the Foley catheter is placed, bladder neck closed and specimen extracted via the umbilical incision. From March 1999 to December 2000 we have performed 180 procedures, including 3 for stage pT1 tumor, 88 pT2, 82 pT3 and 7 pT4. Mean preoperative PSA was 13.3 ng./ml. (range 1.4 to 148), mean specimen weight 37.4 gm. (10 to 125) and median Gleason score 6 (3 to 9). For evaluation of the learning curve a separate analysis of 3 groups with 60 patients in each was done. Differences between groups 1 (first 60 patients) and 3 (last 60) were analyzed for statistically significant differences. RESULTS: Mean operating time was 271 minutes (range 150 to 500) and transfusion rate 31%. The reintervention rate was 4.4% and complication rate 18.8%. Of the patients 92% did not require any analgesia on postoperative day 2. Positive margins were found in 16% of the patients. The rate of positive margins in pT2 tumors was 2.3%, pT3a 15% and pT3b 34%. After a median followup of 12 months (range 3 to 23) in 9 (5%) patients a prostate specific antigen relapse was observed. The anastomosis was tight after removal of the catheter in 83% of patients, with a median time of 7 days (range 5 to 30). An anastomotic stricture had to be treated with laser incision in 3.3% of patients. On discharge from the hospital 33% of patients were continent, after 6 months 74% and after 12 months 97%. Analysis of the learning curve revealed significant differences in operating time (324 versus 265 minutes), conversion rate to open surgery (8.1% versus 1.7%), complication rate (23.3% versus 11.7%) and rate of prolonged catheterization (31.6% versus 10%, respectively), whereas the percentage of positive margins and continence rates showed no influence. CONCLUSIONS: Laparoscopic radical prostatectomy requires significant laparoscopic expertise with an ongoing learning curve. Morbidity is low, oncological control similar to results of open surgery and functional results are promising. The procedure should be performed only at dedicated centers with adequate training and expertise.

Heilbronn laparoscopic radical prostatectomy. Technique and results after 100 cases.

INTRODUCTION: In 1999, Guillonneau and Vallancien presented a refined approach of a descending laparoscopic radical prostatectomy which based mainly on the primary access to the seminal vesicles and an improved suturing and knotting technique. Based on our own experience reconstructive laparoscopy as well as with open retropubic radical prostatectomy we have used a combined ascending/descending technique similar to open surgery. In this paper we want to describe our approach and to present the initial results with the Heilbronn technique. MATERIALS AND METHODS: A transperitoneal approach is used with a W-shaped arrangement of the trocars (13-mm umbilical port, 2 x 10 mm medial, 2 x 5 mm lateral ports). After the exposure of the Retzius' space and control of the dorsal vein complex the urethra is incised and the distal pedicles of the prostate (+/- the neurovascular bundle) are transsected. We now pull the apex ventrally and start with the incision at the bladder neck followed by a transvesical access to both vasa deferentia and seminal vesicles. The gland is entrapped in the Extraction Bag. After accomplishing the posterior wall of the urethrovesical anastomosis with five interrupted sutures, the foley catheter is placed into the bladder and the bladder neck is closed. Now the prostate is extracted via the umbilical incision. From March 1999 to June 2000, we have performed 100 cases (48 pT2-, 47 pT3- and 5 pT4 tumors). The mean preoperative PSA was 26.8 (1.4-75.5) ng/ml. Two tumors were grade 1, 72 grade 2 and 26 grade 3. Median Gleason score was 6 (3-9). All specimen were inked and examined according to the Stanford protocol. Postoperative continence was evaluated using a questionnaire monitored by a colleague who was involved in surgery. RESULTS: We had 5 conversions (rectal injury, difficult dissection, adhesion, 2x bleeding at the dorsal vein complex). The mean operating time was 278 (180-500) min., the transfusion rate 31%. One patient required reintervention due to bleeding from the right obturator fossa. 95% of the patients did not require any analgesia on the second postoperative day. Positive margins were found in 17% of the patients, of which 12 had a PSA nadir to a value of less than 0.1 ng/ml within 3 weeks after surgery. In 82 patients, the anastomosis was tight after removal of the catheter, median catheter time was 8 (6-30) days. 4% developed a stricture at the anastomotic site which could be treated by laser incision. On discharge 33% were continent, after 6 months 81%, whereas only 2 patients still suffer from grade II stress incontinence at 9 months. CONCLUSIONS: Laparoscopic radical prostatectomy is feasible but requires laparoscopic expertise. Its learning curve is still ongoing. Morbidity is low, oncological control is similar to results of open surgery, functional results are promising.

Telesurgical laparoscopic radical prostatectomy. Initial experience.

INTRODUCTION: Telepresence surgery offers theoretically to overcome two main problems of laparoscopic surgery, i.e. the limitation to only four degrees of freedom and the lack of stereovision. Since 1998, telesurgical minimally invasive procedures have been performed with the da Vinci system mainly for cardiac bypass surgery. Clinical experience in urology is still very limited. We want to present our initial experience using the device for robot-assisted laparoscopic radical prostatectomy. MATERIAL AND METHODS: The Intuitive surgical system consists of two main components: the surgeon's viewing and control console with 3D imaging and the surgical arm unit that positions and maneuvers detachable surgical instruments. These instruments introduced via two 8-mm trocars allow movements in all 6 degrees of freedom due to the EndoWrist technology. The surgeon performs the procedure seated at the console holding specially designed instruments. Highly specialized computer software and mechanics transfer the surgeon's hand movements exactly to the microsurgical movements of the manipulators at the operative site. We have used a semilunar-shaped 5-trocar arrangement with the robot's arms at the lateral trocars and two assistant trocars medially. A sixth trocar was used in the right suprapubic area for retraction of the gland. The left assistant used different instruments such as bipolar forceps, Ultracision, Endoclip, whereas the right assistant mainly used the suction-irrigation device. Except the first case, the Intuitive System was attached after exposure of Retzius' space. RESULTS: We have treated 6 patients (2 pT2, 4 pT3, median Gleason score 6). The OR time averaged 315 (242-480) min including pelvic lymph node dissection. No intraoperative complications occurred, 1 patient required transfusions. There were no positive margins, median catheter time was 5 days. 3 patients were completely continent after 1 month. CONCLUSION: Telerobotic laparoscopic surgery offers several advantages over all presently available techniques, such as all six degrees of freedom, dexterity enhancement, tremor filtering, and stereovision. There is a learning curve with the device, mainly because of the magnification, the 3D image and the lack of tactile feedback. However, only after a short period of time, the experienced surgeon is able to get familiar with the device. However, there are still concerns with respect to the high investment and running costs of the device as well as regarding the necessity of further developments of instruments for urological procedures.