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Objective: This article equips Canadian urologists with the latest advancements in focal therapy (FT) principles and outcomes while providing an overview of its current landscape in Canada, including challenges and future directions. Methods: We conducted a nonsystematic review of the literature on FT in urology and prostate cancer (PCa), focusing on Canadian-led studies. Articles were identified using PubMed, MEDLINE, and Google Scholar and selected based on relevance and originality. The final search was completed in April 2024. A survey was also conducted among Canadian urologists and radiologists practicing FT. It covered their experiences, access to technology, implementation challenges, and reimbursement policies. Data were collected via video calls, phone calls, or email, and responses were reported anonymously. Results: Fourteen Canadian urologists and radiologists performing FT were contacted, and 12 participated in this study. Despite the increasing adoption of FT by Canadian urologists, nationwide implementation remains limited due to financial constraints and resource shortages. This has restricted the availability of FT for Canadian men with PCa compared with their American and European counterparts. Only two provinces-Saskatchewan and Alberta-currently have billing codes for FT, forcing patients elsewhere to either join clinical trials or pay out of pocket. To close this care gap, equitable health care coverage and integration of FT into standard treatment options are essential. Conclusion: The quality of research in FT is showing promising improvements, with several clinical trials currently underway that may pave the way for broader acceptance within clinical guidelines by multiple urological societies. Although Canada has been slower to adopt FT compared with other parts of the world, Canadian urologists continue to advocate for provincial health care coverage to ensure that this innovative technology becomes accessible to Canadian patients. more...

Objectives: Multiparametric magnetic resonance imaging (mpMRI) has made dramatic inroads into the management of localized prostate cancer (PCa); however, not all suspicious lesions represent clinically significant (cs) PCa. We aimed to analyze the hypothetical effect of incorporating tumor volume ratio (TVR) into prostate biopsy (PBx) decision-making. Materials and Methods: Two hundred and fifty-two patients with suspicious lesions at mpMRI undergoing transperineal PBx under local anesthesia between 2019 and 2022 were retrospectively evaluated. TVR was calculated by dividing the tumor volume by the prostate volume. A regression model was used to assess predictors of csPCa. Descriptive statistics were applied to evaluate the effect of including TVR in PBx decision-making. Results: Overall, 119 patients (47%) were found to have csPCa. Age ( p < 0.001), prior negative PBx ( p = 0.011), and TVR ( p < 0.001) were found to be independent predictors of csPCa. Applying the TVR cutoff of 0.23, a total of 117/252 (46%) PBx would have been avoided at the cost of missing csPCa in 26 (10%) men. Conclusions: Age, previous biopsy status, and TVR were found to be independent predictors of csPCa in men with suspicious lesions at mpMRI. Implementation of TVR into PBx decision-making improves the accuracy of mpMRI. Future studies are required to validate our findings and evaluate the role of TVR in avoiding unnecessary PBx. more...

Purpose: To assess determinants of performance on the Transfer Task of the Basic Laparoscopic Urologic Surgery (BLUS(©)) skills curriculum administered at Objective Structured Clinical Examinations (OSCEs)., Methods: After obtaining Institutional Review Board approval and informed consent, urology trainees (Postgraduate Year [PGY]-3 to PGY-5) from four different training programs (A, B, C, D) were recruited for the study. Transfer Task Times (TTTs) were compared and correlated with previous laparoscopic experience, amount of endotrainer practice and scores obtained at practice sessions and other OSCE stations., Results: A total of 37 trainees were evaluated on three successive semiannual OSCEs from May 2011 to May 2012, including 16 (43.2%) trainees from program A with a dedicated laparoscopic skills training program. Compared with trainees from programs B, C, and D, trainees from program A had significantly more practice per week (0 v 45 minutes, p=0.001) and significantly lower median TTTs at OSCEs (114 [68-209] v 74 [52-189] seconds, p=0.001) despite significantly lower number of laparoscopic cases assisted within the previous 6 months (13 [0-57] v 2 [0-35], p=0.001). For program A trainees, TTTs moderately correlated with median TTTs at practice sessions (r=0.57, p=0.001) and negatively correlated with amount of practice per week (r=-0.41, p=0.003). Thus, more training resulted in faster times at OSCEs. On multivariate analysis, amount of practice per week was the only significant predictor of TTTs at OSCEs (p=0.028)., Conclusion: Performance on the transfer task of BLUS during OSCEs significantly correlated with the amount of practice rather than the number of laparoscopic cases assisted. more...

Purpose: The aim of this study was to prospectively identify predictors of radiation exposure during ureteroscopy., Patients and Methods: Eighty-five consecutive patients who presented for ureteroscopies and laser lithotripsy were considered. Fluoroscopy time (FT) was obtained from radiology reports for each patient, and clinical data were obtained from chart review. Nine patients were excluded (three unconfirmed FTs, four staghorn calculi, one ectopic kidney, and one multiple ureteral strictures). Seventy-six patients were included in the study. Univariate and multivariate linear regression were used to identify factors that determined FT., Results: The patient cohort was 65.8% male with a mean age of 52.7 years. Mean FT was 183 s, and mean surgical time was 68.4±29 minutes. Mean stone size was 10±5 mm in the greatest dimension. A large proportion of patients (50%) had renal stones, multiple stones were present in 31.6% of cases, and 22.3% of stones were radiolucent. Cases were equally distributed between surgeons A and B, and 46% of patients had preoperative stents. On multivariate analysis, increased FT was independently associated with surgeon A (104 additional seconds per case, P<0.001), longer duration of surgery (14 s per 10 minutes, P<0.001), and male patients (54 s per procedure, P=0.02). Age, stone characteristics, presence of ureteral stent, and stone-free status did not correlate with FT., Conclusions: Surgeon behavior, longer duration of surgery, and male gender were significant predictors of FT and, hence, radiation exposure during ureteroscopy. In the present study, stone characteristics were not found to be predictors of FT. more...

Background and Purpose: Percutaneous nephrolithotomy (PCNL) in the prone position is associated with a 0.1% risk of colon injury, yet there have not been any reported cases of colon injury with supine PCNL. The aim of the present study was to prospectively compare CT scans of patients performed in both supine and prone positions on bolsters., Patients and Methods: Sixteen consecutive patients (mean age 55, 12 men) with 19 renal units (3 bilateral) who presented for PCNL underwent preoperative supine (without bolsters) and prone (with bolsters) noninfused CT scans. Axial images through lower pole calices containing stones necessitating percutaneous access were then analyzed. Percutaneous access was planned based on both supine and prone CT scans. Skin-to-stone distance (cm), angle of the percutaneous tract to the anterior-posterior axis (degrees), and visceral organ-to-tract distance (cm) were measured., Results: Visceral organ-to-tract distance was significantly shorter in the prone position when compared with the supine position (2.8 cm vs 3.5 cm, P=0.04). In three renal units, visceral organ-to-tract distance in the prone position was less than 0.4 cm. Furthermore, the prone position was associated with significantly shorter skin-to-stone distance (7.6 cm vs 9.0 cm, P=0.0005) and significantly wider angles (40 degrees vs 35 degrees, P=0.02). Small sample size and simulation of the percutaneous access tract are two limitations of the present study., Conclusions: When prone PCNL is contemplated, preoperative planning CT scans that are performed in the prone position with bolsters provide better preoperative assessment of colon-to-percutaneous renal tract distance. more...

Background: The Hopkins rod-lens nephroscope has been the standard in percutaneous renal surgery. Despite its high resolution, it is bulky when an external camera and light source are attached. Therefore, new technology to make the scopes lighter and more ergonomic is needed., New Technology: The new Invisio Smith digital nephroscope is the first digital nephroscope from Gyrus ACMI. It was used for the first time in two patients with caliceal stones. The tip houses dual LED-driven light carriers and a 1-mm digital camera, which obviate the need for an external light source and camera, thus eliminating the risk of drape fires and patient burns. The Smith nephroscope is much lighter (470 g vs. 939 g) and more ergonomic when compared to the standard rod-lens nephroscope., Conclusions: The Smith digital nephroscope is much lighter, more ergonomic and safer. Long term use is needed to test its durability. more...

We report three cases of end-stage renal failure necessitating hemodialysis subsequent to BCG administration for the treatment of upper-urinary tract transitional-cell carcinoma in patients with a solitary kidney, one with normal renal function and two with chronic renal failure prior to BCG instillation. We discuss treatment-related issues with pertinent literature review. more...

Objective: To evaluate the safety and efficacy of holmium:YAG laser vaporization v transurethral electroresection (TURP) for benign prostatic hyperplasia., Patients and Methods: Thirty-six patients were randomized. Two laser procedures (60 to 80 W) were performed for one TURP. Symptom Score, peak flow rate, potency, and ejaculation status were measured at baseline and at 1, 3, 6, and 12 months., Results: The mean operative time was 75 minutes for laser and 56 minutes for TURP (P = 0.0407). With a mean laser energy delivered of 103.6 kJ, hemostasis was satisfactory during vaporization. The mean catheterization time was 1.7 and 2.1 days in the laser and TURP group, respectively. For the laser and TURP groups, the mean AUA Score improved from 20 preoperatively to 7 and from 24.1 to 5, respectively, at 12 months. The mean peak flow increased from 8.4 to 19.5 mL/sec and from 7.6 to 16.8 ml/sec, respectively, at 12 months. These results are not statistically different. No significant initial dysuria occurred. No significant difference between the groups appeared in potency or ejaculatory status during the follow-up. One patient in the laser group (Day 5) and two in the TURP group (2nd and 6th month) had to undergo a second procedure to relieve obstruction., Conclusion: Although taking slightly longer to accomplish, holmium:YAG laser vaporization of BPH provides early results very similar to those of TURP with a shorter catheterization time and no initial dysuria or pain. more...

To assess the usefulness of an experimental model of ureteropelvic junction (UPJ) obstruction designed to facilitate subsequent percutaneous surgery, a right UPJ obstruction was created in 10 pigs by an open retroperitoneal surgical approach. With the pig in the left lateral decubitus position, a 0.038-inch Terumo guidewire was inserted via a 1-cm longitudinal upper-third ureterotomy and advanced up and down so as to bridge the UPJ from the flank to the urogenital opening. A UPJ obstruction was then induced by securing two 2-0 chromic gut ties, separated by an interval of 1 cm, over the Terumo guidewire and a 6F ureteral catheter, which was removed immediately after this procedure. After closure of the ureterotomy, the kidney was anchored horizontally to the muscle wall, and the Terumo guidewire was coiled subcutaneously in the flank and fixed to the urogenital opening. Each pig developed marked hydronephrosis, diagnosed by ultrasonography, after a mean interval of 8.3 days. Retrograde ureteropyelography confirmed this pronounced dilation of the right collecting system above a tight UPJ stricture (mean length 1.17 cm). Subsequent percutaneous access to the UPJ over the Terumo guidewire in the lateral decubitus position was facilitated by the almost-horizontal plane of dilation (mean operating time 14 minutes). Pathologic examination of the UPJ revealed mild periureteral fibrosis, but the muscle layer and urothelium remained normal. We have developed a reliable and reproducible model of secondary UPJ obstruction especially designed for percutaneous surgery. This model should provide a better understanding of current endoscopic techniques such as endopyelotomy and could help to promote new treatment concepts such as percutaneous endoscopic pyeloplasty. more...

Laparoscopic suturing is still difficult and time-consuming. The aim of this study, using the porcine model, was to evaluate the feasibility, safety, and efficacy of laparoscopic fibrin glue ureteral anastomosis without stay sutures for approximating the ureteral ends. In five pigs, after bilateral cystoscopic insertion of a 7F ureteral catheter, each upper ureter was laparoscopically dissected free and transected with scissors. The ureteral ends were then approximated with two atraumatic grasping forceps, and the fibrin glue was applied over the anastomotic site using a specially designed catheter (Duplocath). After waiting 5 minutes for the sealant to adhere, the forceps were removed, and the anastomotic site was examined for any early disruption. The ureteral stents were then pulled back to the distal ureter, and retrograde ureteropyelography was accomplished bilaterally in order to assess the immediate patency of the anastomoses. The animals were sacrificed and the ureteral anastomoses surgically removed for histologic examination. The operative time after insertion of the trocars averaged 15 minutes for each anastomosis, and no early disruption was observed after withdrawal of the grasping forceps. Immediate ureteral fluoroscopic patency was achieved in all 10 ureteral anastomoses, without leakage in 8 and with minimal leakage in 2. Histologic examination revealed a mild inflammatory reaction in the serosa with no modifications of the mucosa or the muscularis. Subsequently, two pigs were subjected to the same procedure bilaterally and not sacrificed. These two animals died with enormous urinomas on postoperative days 6 and 8. In each case, the anastomotic site was completely disrupted on one side, while the other side remained grossly patent. However, histologic examination of these latter anastomoses revealed no real coaptation of the ureteral ends, while demonstrating complete eversion of the mucosa. In conclusion, fibrin glue ureteroureterostomies, although easy to accomplish, are not safe enough to be used without stay sutures in laparoscopic surgery. more...

A new technique of endosurgical pelvic lymph node dissection was performed for the staging of 10 prostate and 8 bladder cancers. The technique, involving an exclusive extraperitoneal space development with CO2 insufflation, is described in detail. Using the standard endosurgical (laparoscopic) equipment, we performed a complete bilateral ilio-obturator lymph node dissection in 15 patients (83%). In the remaining three patients, because of technical difficulties, only unilateral dissection was performed. The average operating time was 84 minutes. Morbidity was low (one instance of sepsis). Prospective assessment of CO2 homeostasis showed that arterial CO2 pressure (PaCO2) increased significantly but could be controlled by increasing minute ventilation output. Our results show that perioperative assessment of end-tidal CO2 partial pressure is necessary and sufficient for the adaptation of minute ventilation output. Two patients with prostate cancer had positive nodes. No intraoperative or postoperative morbidity related to the procedure was observed in patients submitted to radical surgery. Extraperitoneal endosurgical pelvic lymphadenectomy with CO2 insufflation is a rapid, safe, and effective method in the staging of urologic pelvic malignancies and represents an alternative to traditional open surgery as well as to conventional transperitoneal laparoscopic lymphadenectomy. more...