Focal therapy with high-intensity focused ultrasound for prostate cancer in the elderly. A feasibility study with 10 years follow-up.

PURPOSE: To evaluate the long-term efficacy of prostate cancer control and complication rates, in the elderly, after focal therapy with high-intensity focused ultrasound (HIFU). MATERIALS AND METHODS: Between June 1997 and March 2000, patients with localized prostate cancer were included into a focal therapy protocol. Inclusion criteria were: PSA ≤ 10 ng/mL, ≤ 3 positive biopsies with only 1 lobe involved, clinical stage ≤ T2a, Gleason score ≤ 7 (3+4), negative CT scan and bone scan. Hemi-ablation of the prostate was performed with the Ablatherm® device. Survival, complication rates and urinary continence were evaluated. Control biopsies were performed at 1 year. Treatment failure was defined as a positive biopsy or need for salvage therapy. RESULTS: Twelve patients with a mean age 70 years were included. Median follow-up was 10 years. Control prostate biopsies were negative in 11/12 (91%) patients. Overall survival was 83% (10/12) and cancer specific survival was 100% at 10 years. Two patients died from other causes. Recurrence free survival was 90% (95% CI; 0.71-1) at 5 years, and 38% (95% CI; 0.04-0.73) at 10 years. Five patients had salvage therapy with repeat HIFU (n = 1) or hormonal therapy (n = 4) and all salvage patients were alive at 10 years. No patients developed lymph node or bone metastasis. No patients suffered from urinary incontinence. International Prostate Symptom Score was stable at 1 year. Complications included two urinary tract infections and one episode of acute urinary retention. CONCLUSIONS: Hemi-prostate ablation with HIFU can be safely performed in selected elderly patients with adequate long-term cancer control and low complication rates. Results from larger prospective studies using improved imaging techniques and extensive biopsy protocols are awaited.

Focal therapy with high-intensity focused ultrasound for prostate cancer in the elderly: a feasibility study with 10 years follow-up

PURPOSE: To evaluate the long-term efficacy of prostate cancer control and complication rates, in the elderly, after focal therapy with high-intensity focused ultrasound (HIFU). MATERIALS AND METHODS: Between June 1997 and March 2000, patients with localized prostate cancer were included into a focal therapy protocol. Inclusion criteria were: PSA < 10 ng/mL, < 3 positive biopsies with only 1 lobe involved, clinical stage < T2a, Gleason score < 7 (3+4), negative CT scan and bone scan. Hemi-ablation of the prostate was performed with the Ablatherm(R) device. Survival, complication rates and urinary continence were evaluated. Control biopsies were performed at 1 year. Treatment failure was defined as a positive biopsy or need for salvage therapy. RESULTS: Twelve patients with a mean age 70 years were included. Median follow-up was 10 years. Control prostate biopsies were negative in 11/12 (91 percent) patients. Overall survival was 83 percent (10/12) and cancer specific survival was 100 percent at 10 years. Two patients died from other causes. Recurrence free survival was 90 percent (95 percent CI; 0.71-1) at 5 years, and 38 percent (95 percent CI; 0.04-0.73) at 10 years. Five patients had salvage therapy with repeat HIFU (n = 1) or hormonal therapy (n = 4) and all salvage patients were alive at 10 years. No patients developed lymph node or bone metastasis. No patients suffered from urinary incontinence. International Prostate Symptom Score was stable at 1 year. Complications included two urinary tract infections and one episode of acute urinary retention. CONCLUSIONS: Hemi-prostate ablation with HIFU can be safely performed in selected elderly patients with adequate long-term cancer control and low complication rates. Results from larger prospective studies using improved imaging techniques and extensive biopsy protocols are awaited.

Laparoscopic versus open simple prostatectomy: an evaluation of morbidity.

PURPOSE: To evaluate the morbidity between laparoscopic simple prostatectomy (LSP) and open simple prostatectomy (OSP) in the management of benign prostatic hyperplasia. PATIENTS AND METHODS: From January 2003 through January 2008, 280 consecutive patients underwent adenomectomy either by an extraperitoneal laparoscopic transcapsular "Millin" approach (96 patients, 34.3%) or open transvesical approach (184 patients, 65.7%). Medical therapy had failed in all patients. Perioperative and outcome data were recorded and compared. RESULTS: There was no significant difference in patient age, prostate size, uroflow rate, mean International Prostate Symptom Score, operative blood loss, or total time of continuous bladder irrigation between the two groups. Mean operative time was significantly longer in the laparoscopy group, 95.1 +/- 32.9 minutes, v the open group at 54.7 +/- 19.7 minutes (P < 0.0001). Total catheter time was significantly shorter in the laparoscopy group (5.2 +/- 2.6 v 6.4 +/- 2.9 days; P < 0.001) as was length of hospital stay (6.3 +/- 1.9 v 7.7 +/- 2.4 days; P < 0.0001). The most common complication between the two groups was hemorrhage, occurring in 27 (28.1%) patients in the laparoscopy group and 54 patients (29.3%) in the open group. Of the 19 urinary tract infections observed between the two groups, 18 occurred in the open group as well as all 9 cases of urinary sepsis. CONCLUSIONS: LSP offers advantages over OSP in terms of shorter catheter time, shorter hospital length of stay, and fewer urinary tract infections.

Oncological evaluation of prostate sparing cystectomy: the Montsouris long-term results.

PURPOSE: Prostate sparing cystectomy provides an alternative therapeutic option in highly selected patients with invasive bladder cancer who wish to avoid the significant functional side effects of traditional surgery. Concern exists regarding the oncological safety of this technique especially with regard to the presence of prostatic urothelial cancer and incidental prostate adenocarcinoma. We present the long-term oncological outcomes of a large series of patients treated at a single institution. MATERIALS AND METHODS: Between October 1992 and June 2004 a total of 117 patients were selected for prostate sparing cystectomy after meeting the inclusion criteria. RESULTS: Nine patients underwent radical cystoprostatectomy after prostate urothelial carcinoma was diagnosed intraoperatively. Long-term oncological results (2 years minimum followup [mean 55 months]) are presented here for the remaining patients. The rate of local and distant recurrence was 4.7% and 34%, respectively, at 20 months. Overall survival at 5 years in our study was 67%, and 5-year disease-free survival rates were 77% for pT2 N0 or less, 44% for pT3 N0 or greater and 22% for pN+ disease. Of 6 patients found to have prostate adenocarcinoma in transurethral prostate resection specimens 1 was treated with high intensity focused ultrasound and 5 were followed with active surveillance, 2 of whom later died of bladder cancer. CONCLUSIONS: We report oncological data on the largest prospective cohort of patients, with the longest followup, treated by prostate sparing cystectomy to date. Outcomes are comparable with the largest published series of cystoprosatectomies. With appropriate screening the risk of a clinically significant prostate cancer appears to be low. For certain selected patients this technique represents a valuable additional option for treatment.

Access related complications during percutaneous nephrolithotomy: urology versus radiology at a single academic institution.

PURPOSE: A recent survey revealed that only 11% of urologists performing percutaneous nephrolithotomy routinely obtained percutaneous access themselves. Reasons for this trend may include lack of training, comfort level and perceived need for radiological involvement. In this study we evaluated percutaneous access for percutaneous nephrolithotomy obtained by interventional radiologists or a urologist at a single academic institution, and compared access trends and complications. MATERIALS AND METHODS: Two cohorts of patients who had undergone percutaneous nephrolithotomy between 1999 and 2003 were reviewed. Percutaneous access was performed by a group of interventional radiologists (group 1) or a urologist (group 2). An access difficulty score was calculated using patient, stone and procedural variables. Primary outcome measures of percutaneous access complications such as bleeding, failure of access, pneumothorax or other organ injury were compared between groups. Secondary outcome measures of stone-free rates were also compared. RESULTS: In groups 1 and 2, 54 and 49 patients were identified with a total number of tracts of 54 and 60, respectively. Both groups had similar rates of supracostal access. Mean access difficulty scores were similar between groups. Access related complications were significantly higher in the radiology access group (15 vs 5). Stone-free rates were significantly better in the urology access group (86% vs 61%). CONCLUSIONS: Despite similar access difficulty between groups, access related complications were less and stone-free rates were improved during urologist acquired percutaneous access. Urologists instructed in percutaneous access may be able to provide improved stone-free rates during percutaneous nephrolithotomy while minimizing access related complications.