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Resumen El aumento de la incidencia del cancer de prostata (CaP) en los ultimos anos se ha producido principalmente a expensas de los CaP de bajo riesgo evolutivo. El concepto de vigilancia activa de estos CaP con bajo riesgo de progresion surgio paulatinamente al mismo tiempo que el concepto de sobretratamiento. La vigilancia activa es un tratamiento curativo destinado a preservar la calidad de vida del paciente, remitiendo el tratamiento radical a una posible progresion, sin perder las posibilidades de curacion. La vigilancia activa se basa en un estricto protocolo de seguimiento del paciente, que permite detectar a tiempo una posible progresion de la enfermedad hacia un estadio desfavorable, posibilitando la propuesta de un tratamiento activo diferido, sin riesgo oncologico para el paciente. Actualmente, se dispone de los resultados oncologicos a largo plazo de la vigilancia activa gracias a grandes series prospectivas. Estos resultados han confirmado su seguridad carcinologica, bajo reserva de un porcentaje acumulado de tratamiento diferido que oscila entre el 20-50% a los 5 anos. Desde hace varios anos, la vigilancia activa se ha integrado en las recomendaciones de las sociedades cientificas (CC-AFU [Comite de Cancerologie de l’Association Francaise d’Urologie], EAU [European Association of Urology]) como tratamiento de referencia para los CaP de bajo riesgo y, recientemente, como opcion en pacientes seleccionados con un cancer de riesgo intermedio. Los criterios de inclusion varian de un estudio a otro, en particular en terminos de volumen tumoral en las biopsias. El criterio consensuado es la presencia de un cancer del grupo ISUP (International Society of Urological Pathology) 1. La realizacion sistematica de una resonancia magnetica previa a las biopsias, seguida de biopsias dirigidas en caso de lesion, ha permitido reducir el riesgo de reclasificacion y de tratamiento diferido, mejorando asi la seguridad oncologica de los pacientes elegibles. Los biomarcadores, aparte de la densidad del antigeno prostatico especifico, no han mostrado tener un gran interes.

The objective of the French Urology Association Cancer Committee is to propose an update of the recommendations for the diagnosis and management of prostate cancer (PC).A systematic review of the literature from 2020 to 2022 was conducted by the CCAFU on the diagnosis and therapeutic management of localised PC, while evaluating the references and their levels of evidence.The recommendations specify the genetics, epidemiology and means of diagnosing prostate cancer, as well as the notions of screening and early detection. MRI, the gold standard imaging examination for localised cancer, is recommended before prostate biopsies are performed. The transperineal approach reduces the risks of infection. The therapeutic methods are described and recommended according to the clinical context. Active surveillance is the gold standard of treatment for tumours with a low risk for progression. Early salvage radiotherapy is recommended in case of biochemical recurrence after radical prostatectomy. Imaging, particularly molecular imaging, helps to guide the decision-making in the event of biochemical recurrence after local treatment, but should not delay early salvage radiotherapy in the event of biological recurrence after radical prostatectomy.This update of the French recommendations should help to improve the management of patients with PC.

The objective of the French Urology Association Cancer Committee is to propose an update of the recommendations for the management of prostate cancer.A systematic review of the literature from 2020 to 2022 was conducted by the CCAFU on the elements of therapeutic management of metastatic and castration-resistant prostate cancer (PC), while evaluating the references and their levels of evidence.Androgen deprivation therapy (ADT) remains the standard treatment for metastatic prostate cancer. ADT intensification is now a standard of care in the management of metastatic prostate cancer. This intensification is discussed in relation to the patient and the characteristics of the disease. For all metastatic hormone-sensitive PC (synchronous and metachronous), the overall survival benefit associated with good tolerability makes the combination of ADT and novel hormonal agents (NHA) a standard. For patients with high-volume/high-risk de novo metastatic disease, treatment with docetaxel in addition to ADT + NHA can be discussed for eligible patients. In patients with castration-resistant prostate cancer (CRPC), the contribution of new therapies that have become available in recent years, as well as the advent of precision medicine, help to improve the control of tumour progression and survival, and highlight the value of testing for alterations in DNA repair genes within the tumour tissue or constitutionally.This update of the French recommendations should help to improve the management of patients with prostate cancer.

Resumen El cancer de prostata (CaP) es el cancer mas comun en los varones y la tercera causa de muerte por cancer. Sin embargo, su enfoque diagnostico ha cambiado en los ultimos anos, con un impacto epidemiologico evidente (menor numero de biopsias, reduccion de la mortalidad). Existe la controversia sobre la deteccion del CaP por el antigeno prostatico especifico (PSA), con una mejor comprension de la estrategia de deteccion precoz (enfoque individualizado, no de salud publica) y la confirmacion a largo plazo de la reduccion de la mortalidad especifica por CaP gracias a esta estrategia. Esta estrategia se basa en los antecedentes familiares, la prueba de PSA y el tacto rectal. Se han desarrollado numerosos marcadores moleculares, tanto en sangre como en orina, para superar las limitaciones de la prueba de PSA, sin traduccion clinica por el momento. Los adelantos corresponden mas bien al campo de las pruebas de imagen. La resonancia magnetica (RM) previa a la biopsia se recomienda ahora porque, combinada con las biopsias dirigidas, mejora la deteccion de los CaP clinicamente significativos. El lugar de las biopsias sistematicas, efectuadas esencialmente por via transrectal, sigue siendo importante debido a las limitaciones aun presentes de la RM (disponibilidad, experiencia del radiologo, falsos negativos).

For patients with cT1 renal lesions, Partial Nephrectomy (PN) is the gold standard treatment. However, 20% of small renal masses are benign, situation in which the PN is an overtreatment. The percutaneous Renal Tumor Biopsy (RTB) may lower the risk of overtreatment as there is a 90% concordance rate on histotype between the RTB and the final pathology. It has been suggested that the RTB could increase the difficulty of the PN and increase the risk of surgical complications.To compare surgical outcomes and complications of PN with or without previous RTB.monocentric retrospective review of patients who underwent laparoscopic or robotic-assisted PN between January 2012 and December 2019.perioperative complications were recorded using Clavien-Dindo classification, peroperative data included operative time, clamping time and blood loss, and histological outcomes of RTB and PN.In total, 163 patients were included in our study. There were significantly less benign lesions in PN with prior RTB: 7% (4/56) vs. 20% (22/107) without prior RTB (P=0.03). There were no significant differences regarding Clavien-Dindo2 perioperative complications with respectively 7% (4/56) vs. 10% (11/107) (P=0.57). Same goes for peroperative data such as duration of surgery (P=0.81), warm ischemia (P=0.07) and blood loss (P=0.13).RTB does not increase the risk of surgical complications of PN and may reduce the risk of small renal masses overtreatment.

Isolated local relapse after prostate cancer radiotherapy corresponds to 40% of biochemical failure. The management of these relapses is not well defined. Several strategies are available including surgery, high-intensity focused ultrasounds (HIFU), cryotherapy and reirradiation. Radical prostatectomy is the historical approach; biochemical control is obtained in 50 to 80% at 5 year. However, morbidity is higher after irradiation than as a first line treatment. Some limited series of HIFU and cryotherapy have been published with interesting results, but again the risk of urinary and rectal toxicity is high. However, new generation technologies could decrease the complication rate. Reirradiation could be performed with brachytherapy and more recently with stereotactic radiation therapy. The results of salvage low-dose-rate brachytherapy have been reported in some series with a 5-year biochemical control rate of 34 to 88%. High-dose rate brachytherapy seems to be better tolerated, but the number of patients treated and reported is too low to draw firm conclusions. This is the same for stereotactic radiation therapy salvage treatment. A prospective trial of salvage brachytherapy (CAPRICUR) is now open in France and inclusion in this trial is recommended.

To determine the predictors of early, intermediate and late biochemical recurrence (BR) following minimally invasive radical prostatectomy in patients with localised prostate cancer (PC).We included 6195 patients with cT1-3N0M0 prostate cancer treated using radical laparoscopic prostatectomy (RLP) and radical robot-assisted prostatectomy at our institution between 2000 and 2016. None of the patients underwent adjuvant therapy. BR is defined as PSA levels ≥0.2 ng/dL. The time to BR is divided into terciles to identify the variables associated with early (12 months), intermediate (12-36 months) and late (36 months) recurrence. We employed logistic regression models to determine the risk factors associated with each interval.We identified 1148 (18.3%) patients with BR. The median time to BR was 24 months (IQR, 0.98-53.18). The multivariate analysis showed that preoperative PSA levels, lymph node invasion, positive margins and RLP are associated with early recurrence (P≤.029 for all). Laparoscopic surgery was the only predictor of intermediate recurrence (P=.001). The predictors of late recurrence included a pathological Gleason score ≥7, stage ≥pT3, positive margins and RLP (P≤.02 for all).The patients with high-risk prostate cancer can develop late recurrence and require long-term follow-up. Identifying patients with higher PSA levels and lymph node invasion has an important predictive role in the first year after surgery. The association between RLP and BR warrants further assessment.

Objectives: To review the current literature about prostate-sparing radical cystectomy (PSRC) and its potential for management of a selected population of patients with bladder cancer. Materials and Methods: The PubMed, EMBASE and Scopus databases were searched for the key words ‘prostate', ‘sparing' and ‘cystectomy' between 1984 and 2012. Articles in English, French and German were considered relevant for review. Institutional experience with this procedure was also included. Results: PSRC remains a controversial procedure for the treatment of patients harboring bladder carcinoma, mainly due to insufficient knowledge of clear indications and/or contraindications. Experience with PSRC is still limited to very few referral centers and there is a lack of large series with long-term outcomes. The potential for excellent functional outcomes must be carefully balanced against inconsistent oncological results. Conclusions: PSRC may become an option for carefully selected and extensively informed patients. Suggestions for possible indications and contraindications are presented.

Focal therapy has settled as an alternative to radical treatment in selected cases of localized prostate cancer. The selection of patients who are candidates for focal therapy is based on imaging diagnosis relying on multiparametric MRI and image fusion techniques. Thanks to the oncological results and safety profiles of initial series, various energy sources have been developed over the last years. The availability of multiple types of energy sources for focal therapy, commits us to evaluate what type of energy would be the optimal depending on patient's profile and type of lesion. A unique energy for focal therapy would be ideal, but facing the research of the various types of energy we must identify which one is recommended for each lesion. With the experience of our center in different approaches of focal therapy we propose the "A LA CARTE" MODEL based on localization of the lesion. We present the criteria the "a la carte" model is based on, supported by the published evidence on the use of different ablative therapies for the treatment of localized prostate cancer. Lesion localization, technical characteristics of each type of energy, patient's profile and secondary effects must be considered in every choice of focal therapy.

Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications.

Certains patients apres une prostatectomie totale sont a risque de rechute. Cette rechute peut etre due a la presence de micrometastases au moment du diagnostic. Les resultats d’essais therapeutiques randomises prospectifs conduits chez des patients a haut risque de rechute ont montre que l’utilisation de la radiotherapie postoperatoire adjuvante permettait d’ameliorer la survie sans progression et la survie sans metastase et le controle local. Les patients qui n’ont pas recu de radiotherapie adjuvante mais qui rechutent secondairement sont candidats a une irradiation de rattrapage. L’hormonotherapie se discute egalement dans cette indication. Les resultats encourageants de la chimiotherapie moderne en phase avancee de la maladie permettent de tester cette attitude therapeutique a une phase plus precoce a la rechute biologique actuellement. Cet article se propose de faire le point des criteres de decision de l’utilisation de ces traitements pour la prise en charge de ces patients a haut risque et des essais en cours en situation adjuvante ou de rattrapage.

The aging of the population has resulted in an increase in the number of elderly patients with prostate cancer. Among the curative treatment options in the elderly subject, external radiotherapy is the most frequently chosen option. Combined treatment including radiotherapy and hormone therapy should be preferred to hormonal therapy alone, including in elderly patients, whenever life expectancy surpasses 4-5 years. The indications for this radiotherapy should be defined in an attempt to prevent excessive or insufficient treatment, to adapt the treatment modalities to the patient's age by assessing its potential toxicity, and to discuss the possible alternatives. In cases of localized prostate cancer in men who are aging well, a standard treatment should be proposed, preferring radiotherapy possibly associated with hormone therapy in cases with negative prognostic factors. Patients with a reversible health problems can also receive standard treatment, notably in cases with aggressive prognostic factors.

We report our initial experience in the treatment of prostate cancer (PCa) with high-intensity focused ultrasound (HIFU) using the Focal-OneRetrospective review of the prospectively populated database. Between June 2014 to October 2015, 85 patients underwent HIFU (focal/whole-gland) treatment for localized PCa. Preoperative cancer localization was done with multiparametric magnetic resonance imaging (mpMRI) and transperineal mapping biopsies. Treatment was carried out using the Focal-OneThe median PSA was 7.79ng/ml (IQR 6.32-9.16), with a median prostate volume of 38cc (IQR: 33-49.75). Focal and whole-gland therapy was performed in 64 and 21 patients respectively. Ten patients received salvage HIFU. Complications were encountered in 15% of cases, all Clavien 2 graded. Mean hospital stay was 1.8 days (0-7) and bladder catheter was removed on day 2 (1-6). Mean percentage reduction of PSA was 54%. Median follow-up was 3 months (IQR: 2-8). Functional outcomes: All patients were continents at 3 months and potency was maintained in 83% of the preoperatively potent.Focal-One

To evaluate the role of Transperineal Template guided Mapping Biopsy (TTMB) in determining the management strategy in patients with low risk prostate cancer (PCa).We retroscpectively evaluated 169 patients who underwent TTMB at our institution from February 2008 to June 2011. Ninety eight of them harbored indolent PCa defined as: Prostate Specific Antigen10ng/ml, Gleason score 6 or less, clinical stage T2a or less, unilateral disease and a maximum of one third positive cores at first biopsy and50% of the core involved. TTMB results were analyzed for Gleason score upgrading and upstaging as compared to initial TransRectal UltraSound (TRUS) biopsies and its influence on the change in the treatment decisions.TTMB detected cancer in 64 (65%) patients. The upgrade, upstage and both were noted in 33% (n=21), 12% (n=8) and 7% (n=5) respectively of the detected cancers. The disease characteristics was similar to initial TRUS in 30 (48%) patients and TTMB was negative in 34 (35%) patients. Prostate volume was significantly smaller in patients with upgrade and/or upstage noted at TTMB (45.4 vs 37.9; P=.03). TTMB results influenced 73.5% of upgraded and/or upstaged patients to receive radical treatment while 81% of the patients with unmodified stage and/or grade continued active surveillance or focal therapy.In patients with low risk PCa diagnosed by TRUS, subsequent TTMB demonstrated cancer upgrade and/or upstage in about one-third of the patients and resulted in eventual change in treatment decision.

Resume L'anastomose uretrovesicale est le dernier temps operatoire de la prostatectomie radicale. Quelle que soit la voie d'abord, la prostatectomie radicale est une intervention difficile. Les temps de dissection sont similaires par voie ouverte et par voie laparoscopique. L'anastomose uretrovesicale laparoscopique requiert une gestuelle particuliere. Cette gestuelle doit etre maitrisee par le chirurgien realisant une prostatectomie radicale laparoscopique. Cette technique est codifiee et reproductible. Elle peut etre assimilee sur pelvitrainer avant de commencer a realiser cette intervention par voie laparoscopique. Cet article rapporte les points clefs necessaires a la realisation de l'anastomose uretrovesicale par voie laparoscopique, ainsi que les differentes variations techniques.

La prostatectomie radicale est le traitement de reference du cancer de prostate localise. Le developpement de la laparoscopie en urologie, d’abord pour la nephrectomie puis pour la prostatectomie, est le signe d’une evolution naturelle vers une chirurgie moins invasive. Les principaux avantages sont evidemment la diminution de la morbidite (diminution du saignement, rapidite de recuperation...) associee a une amelioration de la qualite de la vision. Avec 6 ans de recul, les resultats oncologiques sont comparables a ceux de la chirurgie ouverte et les resultats fonctionnels sont tres encourageants. Un suivi a long terme est indispensable, particulierement sur le plan carcinologique.

The objective of this manuscript is to provide an evidence-based analysis of the current status and future perspectives of robotic laparoendoscopic single-site surgery (R-LESS). A PubMed search has been performed for all relevant urological literature regarding natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). All clinical and investigative reports for robotic LESS and NOTES procedures in the urological literature have been considered. A significant number of clinical urological procedures have been successfully completed utilizing R-LESS procedures. The available experience is limited to referral centers, where the case volume is sufficient to help overcome the challenges and learning curve of LESS surgery. The robotic interface remains the best fit for LESS procedures but its mode of use continues to evolve in attempts to improve surgical technique. We stand today at the dawn of R-LESS surgery, but this approach may well become the standard of care in the near future. Further technological development is needed to allow widespread adoption of the technique.

The primary goal of robotic-assisted radical prostatectomy (RALP) is to completely remove the cancer and cure the patient of their carcinoma. Secondary goals of definitive therapy for prostate cancer include both the preservation of preoperative continence and potency. The apical dissection is one of the most crucial steps in the RALP. The dissection of the apex is the one part of this procedure in which the oncological outcome as well as the functional outcomes are in jeopardy if done inaccurately or incorrectly. The surgeon must clearly identify the apex of the prostate to avoid inadvertently entering the prostate and creating a positive surgical margin. The nerves are located in close proximity to the urethra and may be injured if not identified. Post-operative continence is also dependent on an accurate apical dissection. The rhabdosphincter should be clearly identified and a maximum functional urethral length should be maintained to prevent damage to these structures and to avoid postoperative incontinence. If the surgeon does not perform a meticulous dissection the “trifecta” of longterm cancer control, along with recovery of continence and sexual function will not be achieved [1].