Search

Objective: 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)., Methods: 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., Results: 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., Conclusion: This update of the French recommendations should help to improve the management of patients with PC., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Background: Hospital volume is considered to be a quality measure for outcomes after major oncological surgery. However, countrywide data are lacking for radical prostatectomy (RP)., Objective: To assess the impact of hospital volume on postoperative outcomes after RP performed using an open (ORP) versus a minimally invasive surgery (MIS, including pure and robot-assisted RP) approach., Design, Setting, and Participants: Data for patients undergoing RP in France from 2014 to 2019 were extracted from the central database of the national health care system., Outcome Measurements and Statistical Analysis: Primary endpoints were length of hospital stay (LOS), complications (measured as severity index [SI] scores), and hospital readmission rates at 30 and 90 d., Results and Limitations: The median annual hospital volume was 19 RPs (interquartile range 1-40) in the overall cohort. MIS was associated with better outcomes than ORP. Greater hospital volume was correlated with shorter LOS (p < 0.001), high SI scores (SI3: p < 0.001; SI4: p < 0.001), and 30-d (p < 0.001) and 90-d readmission rates (p < 0.001). Incidence rates for SI3 and SI4 scores, and 30-d and 90-d readmission were 12.8 %, 5.8 %, 29.8 %, and 35.4 % in very low-volume centres (<10 annual cases) compared with 8.1 %, 1.9 %, 18.1 %, and 23.9 %, respectively, in other centres (all p < 0.001). Hospital volume was an independent risk factor for all outcomes after taking into account age, lymph node dissection, year of surgery, and surgical approach (ORP vs MIS). The main limitation is the lack of post-RP oncological and functional data., Conclusions: This nationwide analysis of RP procedures shows a significant correlation between hospital volume and postoperative outcomes irrespective of the surgical approach. Very low case volume (<10 annual procedures per centre) is associated with the highest risk of complications, readmission, and prolonged LOS. Greater hospital volume is directly correlated with shorter LOS even beyond this threshold., Patient Summary: In this study we analysed the French nationwide database for removal of the prostate for prostate cancer. We found that the number of these cases that a hospital carries out per year was associated with outcomes after surgery, with better outcomes for higher annual case numbers., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objectives: To evaluate the technical feasibility, oncological and functional outcomes of nerve sparing cystoprostatectomy (NSCP) and prostate capsule-sparing cystectomy (PCSC) for the treatment of organ-confined bladder cancer at a single referral centre., Patients and Methods: From April 2001 to June 2012, 60 patients underwent PCSC and 47 were treated with NSCP. Inclusion criteria for PCSC were: fully informed consent for the well-motivated patient; negative transurethral resection of the bladder neck; normal prostatic specific antigen (PSA) level (defined as <4 ng/dL during the first year of the study, which was later lowered to 2.5 ng/dL); and normal transrectal ultrasonography, with biopsy for any suspicious nodule. Patients received a complete oncological and functional follow-up. The Kaplan-Meier method was used to depict survival outcomes after surgery., Results: After a median follow-up of 73 and 62 months for PCSC and NSCP, respectively, the 5-year cancer-specific survival was 90% for the PCSC group and 78% for the NSCP group (P = 0.055). Considering complications within 30 days after surgery, 13% and 21% patients had Clavien ≥III complications in the PCSC and NSCP groups, respectively (P = 0.2). For functional outcomes, at 3 months after surgery, 54 (90%) and 24 (51%) patients reported full recovery of daytime urinary continence in the PCSC and NSCP groups, respectively (P < 0.001); and for erectile function recovery, 32 (53%) and four (9%) patients in the PCSC group and in the NSCP group were respectively potent without any treatment (P < 0.001)., Conclusions: NSCP and PCSC are appropriate for a subset of patients with bladder cancer, with excellent oncological and functional results. These surgical procedures should be proposed to well-motivated patients., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

Introduction: The local inflammatory process after prostate biopsies can have a negative impact on functional outcomes of radical prostatectomy. There is no evidence in literature demonstrating its impact on radical prostatectomy., Objectives: To evaluate the impact of the number of TRUS core biopsies in the surgical morbidity and rate of positive margin on robot assisted radical prostatectomy (RARP)., Material and Methods: A prospectively maintained database of 2,054 RARPs in a single institution. Patients were further grouped into 2 groups based on the number of TRUS biopsy cores (G1≤12 cores; G2>12 cores). Multivariable logistic regression model was applied to analyze the impact of number of cores on complications., Results: A total number of 1,042 patients in the group 1 (≤12 cores) and 1,012 patients in the group 2 (>12 cores) were included. The rate of perioperative complications increased with higher number of biopsies (G1 6.4 vs. G2 8.5%; P=.03), but high grade complication (Clavien 3-4) were similar (G1 1.4 vs. G2 2.2%; P=.16). Positive surgical margin rates were similar in both groups (G1 11.8 vs. 9.98%; P=.2). At the multivariable logistic regression analysis shown that G2 had a 39% (OR 0.645) higher rate to experience perioperative complications during RARP., Conclusion: Higher number of TRUS biopsy cores (>12) is associated to higher blood loss and perioperative complications during RARP. Careful preoperative evaluation for those patients underwent multiple biopsies or saturation protocols is mandatory. Application of longer intervals (>6 weeks) between biopsy and surgery may be advisable to minimize potential risks of surgical complications in patients may benefit from RARP. Further studies are still necessary to confirm these results., (Copyright © 2016 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: To evaluate the role of Transperineal Template guided Mapping Biopsy (TTMB) in determining the management strategy in patients with low risk prostate cancer (PCa)., Methods: 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 Antigen<10ng/ml, Gleason score 6 or less, clinical stage T2a or less, unilateral disease and a maximum of one third positive cores at first biopsy and<50% 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., Results: 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., Conclusions: 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., (Copyright © 2016. Publicado por Elsevier España, S.L.U.)

Background: In selected patients with unilateral, organ-confined prostate cancer (PCa), hemiablation of the affected lobe might be feasible to achieve acceptable cancer control with fewer complications., Objectives: To assess the oncologic and functional outcomes of focal high-intensity focused ultrasound (HIFU) hemiablation in unilateral organ-confined PCa., Design, Setting and Patients: Single-center prospective evaluation of HIFU hemiablation for unilateral organ-confined PCa was performed from July 2009 through December 2013., Intervention: Cancer localization was done with transrectal ultrasound-guided biopsy and multiparametric magnetic resonance imaging followed by HIFU hemiablation., Outcome Measurement and Statistical Analysis: Oncologic outcomes were analyzed with control biopsies and prostate-specific antigen (PSA) measurement. Functional outcomes were assessed with validated questionnaires for genitourinary symptoms., Results and Limitations: Of 71 HIFU hemiablation patients, 67 completed the study protocol. The mean age was 70.2 yr (standard deviation: 6.8 yr), and median PSA was 6.1 ng/ml (interquartile range [IQR]: 1.6-15.5 ng/ml). Median maximum cancer-core length was 3 mm (IQR: 2-10 mm), and total cancer length was 6.5 mm (IQR: 2-24 mm). Gleason score was 6 (3+3) in 58 patients (86.6%) and 7 (3+4) in 9 patients (13.4%). Median follow-up was 12 mo (IQR: 6-50 mo), and at 12 mo, 56 of 67 patients had a negative control biopsy in the treated lobe. At 3 mo, all patients were continent, and potency was maintained in 11 of 21 preoperatively potent patients (confidence interval, 0.18-0.69). Complications included 8% Clavien-Dindo grade 2 and 2.8% grade 3 events., Conclusions: Focal HIFU hemiablation appears to achieve acceptable oncologic outcomes with low morbidity and minimal functional changes. Longer follow-up will establish future considerations., Patient Summary: This study showed that high-intensity focused ultrasound hemiablation in selected patients with unilateral organ-confined prostate cancer can be used for satisfactory cancer control with minimal effect on genitourinary functions., (Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate the feasibility of prostate histoscanning true targeting (PHS-TT) guided transrectal ultrasound (TRUS) biopsy., Methods: This is a prospective, single center, pilot study performed during February 2013-September 2013. All consecutive patients planned for prostate biopsy were included in the study, and all the procedure was performed by a single surgeon aided by the specialized true targeting software. Initially, the patients underwent PHS to map the abnormal areas within the prostate that were ≥0.2 cm(3). TRUS guided biopsies were performed targeting the abnormal areas with a specialized software. Additionally, routine bisextant biopsies were also taken. The final histopathology of the target cores was compared with the bisextant cores., Results: A total of 43 patients underwent combined 'targeted PHS guided' and 'standard 12 core systematic' biopsies. The mean volume of abnormal area detected by PHS is 4.3 cm(3). The overall cancer detection rate was 46.5 % (20/43) with systemic cores and target cores detecting cancer in 44 % (19/43) and 26 % (11/43), respectively. The mean % cancer/core length of the PHS-TT cores were significantly higher than the systematic cores (55.4 vs. 37.5 %. p < 0.05). In biopsy naïve patients, the cancer detection rate (43.7 % vs. 14.8 %. p = 0.06) and the cancer positivity of the cores (30.1 vs. 6.8 %. p < 0.01) of target cores were higher than those patients with prior biopsies., Conclusion: PHS-TT is feasible and can be an effective tool for real-time guidance of prostate biopsies.

Purpose: We evaluated the prostate cancer detection with transperineal template-guided mapping biopsy in patients with elevated prostate-specific antigen and negative magnetic resonance imaging (MRI)-guided biopsy., Materials and Methods: Totally 75 patients underwent transperineal template-guided mapping biopsy for prior negative MRI-guided (cognitive registration) biopsy during April 2013 to August 2014. Primary objective was to report clinically significant cancer detection in this cohort of patients. Significant cancer was defined using varying thresholds of MCL or Gleason grade 3+4 or greater or both. Cancers with more than 80% of positive core length anterior to the level of urethra were termed anterior zone cancer. Secondary objective was to evaluate the potential clinical and radiological predictors for significant cancer detection., Results: The mean age was 61.6 ± 6.5 years and median prostate-specific antigen was 10.4 ng/dl (7.9-18) with a mean MRI target size of 7.2mm (4-11). Transperineal template-guided mapping biopsy identified cancer in 36% (27/75) patients and 66.6% (18/27) of them were anterior zone cancers. The rates of detection of clinically significant and insignificant cancer according to the several definitions used range from 22.7% to 30.7% and 5.3% to 13.3%, respectively. Multivariate analysis did not identify any predictors for finding clinically significant and anterior cancers in this group of patients., Conclusion: Transperineal template-guided mapping biopsy appears to be an excellent biopsy protocol for downstream management following negative MRI-guided biopsy. Most of the cancers detected were predominantly anterior tumors., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To assess the accuracy of prostate histoscanning (PHS) for spatial detection and localization of prostate cancer (PCa)., Patients and Methods: Prospective, single center study from January to September 2012 was conducted. Inclusion criterion was biopsy confirmed PCa in patients scheduled for radical prostatectomy. In total, 98 patients were included in the study. Results of PHS were compared against whole-mount step sectioning by the Stanford technique. A lower limit of 0.1 cm(3) was used for PHS. A dedicated 12-sector form was used for spatial correlation. The urologist and pathologist were blinded for each other's results. Sensitivity, specificity, and receiver operating characteristic curves were calculated with a logistic regression model for covariates., Results: PHS performance for detection of PCa lesions ≥0.1 cm(3) had sensitivity of 60%, specificity of 66%, and area under the curve (AUC) of 0.63. Posterior and anterior sectors achieved sensitivity of 77%, specificity of 39%, and 28% and 84%, respectively. The model containing PHS positivity within a given sector reached sensitivity of 73.4%, specificity of 65.7%, and AUC of 0.75. In a ogistic regression model, the performance of PHS was affected by sector location, rectal distance, index, and total cancer volume (all P<0.0001) and bladder fullness (P=0.02). The best PHS accuracy was present in midposterior sectors., Conclusions: PHS has a potential for clinical practice, especially if PHS positivity within given sectors is taken into account. A trained operator is important. More studies are necessary to test different detection limits in various clinical settings, such as targeted biopsies and image guided focal therapy.

Objectives: To assess oncological (biochemical and histological recurrence) and functional (urinary and potency) outcomes in patients with unilateral low-risk organ-confined prostate cancer (PCa) treated with focal cryoablation (FC)., Patients and Methods: From January 2009 to March 2012, patients with localized PCa who refused active surveillance were assigned to a FC protocol. This was a prospective, single-arm cohort study. Inclusion criteria were: unilateral disease, clinical stage T1c to T2a, prostate-specific antigen (PSA) concentration <10 ng/mL, low volume index lesion and Gleason score ≤6 (3+3). Hemi-ablation was carried out using the Precise(TM) cryoablation system (Galil Medical, Inc., Arden Hills, MN, USA). Oncological (PSA values) and functional (International Prostate Symptom Score and International Index of Erectile Function (IIEF)-5 score) outcomes were analysed at 3-, 6- and 12-month follow-up. The primary endpoint for oncological efficacy, no cancer in ipsilateral side, was based on the 12-month mandatory biopsy., Results: A total of 48 consecutive patients with a mean age of 67 years were included. The median (interquartile range) follow-up was 13.2 (7.4-26.5) months. Follow-up prostate biopsies were negative for the treated lobe in 86% of patients. The mean PSA concentration dropped significantly at 3 months (by 55%) but did not correlate well with positive biopsy results. Urinary symptoms were unchanged. A slight decrease in the IIEF-5 score was present at 3 months, but did not differ significantly from baseline at 6-month follow-up. There were 15% grade 1 and 4% grade 2 complications (Clavien classification)., Conclusions: Focal cryoablation is a low-morbidity option in selected patients with low-risk PCa. We showed PSA concentration to be an unreliable marker for monitoring FC and recommend a protocol of mandatory biopsies for follow-up. A multicentre randomized controlled trial is necessary to confirm the low-morbidity and the biopsy-proven PCa cure rates., (© 2013 The Authors. BJU International © 2013 BJU International.)

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., (Copyright © 2013 S. Karger AG, Basel.)

Introduction: To evaluate erectile function among men who had undergone laparoscopic radical prostatectomy and received postoperative medical therapy for erectile dysfunction., Materials and Methods: We performed a prospective study in men who underwent laparoscopic radical prostatectomy between September 2003 and November 2005 at our center and who received penile rehabilitation after surgery. All patients had antegrade interfascial dissection. They received 10 mg tadalafil on the fifth postoperative day and continued to receive it every other day, regardless of erectile function. Intracavernous injection of alprostadil was initiated at 3 or 6 months depending on response to treatment with tadalafil. Follow up evaluations were done at 3, 6, 12, 18 and 24 months. Oncologic and functional outcomes and compliance were assessed. Patients filled in International Index of Erectile Function-5 (IIEF-5) questionnaires., Results: Of 1078 men who underwent laparoscopic radical prostatectomy during this time, 586 patients met inclusion criteria, complied with the study medication, and had complete data for 24 months. The patients had a median preoperative baseline IIEF-5 score of 22. A total of 150 patients (26%) underwent unilateral nerve-sparing surgery, while 436 patients (74%) had bilateral nerve-sparing surgery. At 24 months, 35% of patients who underwent unilateral nerve-sparing surgery and 68% of patients who underwent bilateral nerve-sparing surgery reported having sufficient erectile function for intercourse without using intracavernous injection of alprostadil. At 24 months after surgery, the median IIEF-5 score was 13 (1-25) for the whole cohort, 5 (1-25) for patients who had undergone unilateral nerve-sparing surgery, and 15 (1-25) for patients who had undergone bilateral nerve-sparing surgery., Conclusions: The findings suggest that adequate patient selection and postoperative medical intervention allows the preservation or recovery of erectile function after laparoscopic radical prostatectomy. Inaccurate selection of patients and postoperative assessment might explain inferior erectile function results following this surgery.

Purpose: To review the literature and present a current picture of the evolution in radical prostatectomy from the laparoscopic point of view., Materials and Methods: We conducted an extensive Medline literature search. Articles obtained regarding laparoscopic radical prostatectomy (LRP) and our experience at Institut Montsouris were used for reassessing anatomical and technical issues in radical prostatectomy., Results: LRP nuances were reassessed by surgical teams in order to verify possible weaknesses in their performance. Our basic approach was to carefully study the anatomy and pioneer open surgery descriptions in order to standardized and master a technique. The learning curve is presented in terms of an objective evaluation of outcomes for cancer control and functional results. In terms of technique-outcomes, there are several key elements in radical prostatectomy, such as dorsal vein control-apex exposure and nerve sparing with particular implications in oncological and functional results. Major variations among the surgical teams' performance and follow-up prevented objective comparisons in radical prostatectomy. The remarkable evolution of LRP needs to be supported by comprehensive results., Conclusions: Radical prostatectomy is a complex surgical operation with difficult objectives. Surgical technique should be standardized in order to allow an adequate and reliable performance in all settings, keeping in mind that cancer control remains the primary objective. Reassessing anatomy and a return to basics in surgical technique is the means to improve outcomes and overcome the difficult task of the learning curve, especially in minimally access urological surgery.

Purpose: Prostate-sparing radical cystectomy has been described in the literature and has proven to be a promising procedure owing to the continence and erectile function results without necessarily compromising the oncologic outcome in selected patients., Technique Points: A transperitoneal approach is used. Lymph node dissection is performed with frozen section, and then the ureters are ligated and biopsied. The seminal vesicles are dissected, followed by complete mobilization of the bladder. Incision of the bladder neck is performed, followed by simple prostatectomy. Finally, bowel reconstruction is carried out via a small infra-umbilical incision that also permits the extraction of the surgical specimen and the anastomosis of neobladder to the prostate capsule. A total of 25 patients have undergone this procedure, with average surgical times of 285 min and blood loss of 640 ml. The complications encountered included: one bowel incarceration, one urinary leak, one lymphocele and one port hernia. At median 9 months follow-up, no patient presented with daytime incontinence, although seven complained of nocturia. A total of 20 patients maintained their preoperative sexual potency, and four reported a postoperative decrease in their erectile function., Conclusions: Laparoscopic prostate-sparing radical cystectomy appears to be oncologically safe, reproducible and has promising functional benefits. The authors believe this procedure presents a good option in very select patients.

Background and Purpose: Prostate-sparing radical cystectomy has been described in the literature and has proven to be a promising procedure because of the continence and erectile function results which does not necessarily compromise the oncologic outcome in properly selected patients. We report our preliminary results with this technique performed laparoscopically., Patients and Methods: A total of 25 patients with an average age of 60 years have undergone this procedure. Through a transperitoneal approach, lymph-node dissection is done with frozen-section examination, and the ureters are ligated and biopsied. The seminal vesicles are dissected, followed by complete mobilization of the bladder. Next the bladder neck is incised followed by the bladder-pedicle dissection. A simple prostatectomy can be performed if required. Finally, the neobladder is reconstructed via a small infraumbilical incision that also permits extraction of the surgical specimen. The neobladder is anastomosed to the prostate capsule., Results: The average surgical time was 285 minutes and the mean blood loss 640 mL. The complications encountered (4) were: one case each of bowel incarceration, urinary leak, lymphocele, and port-site hernia. All but one of the patients are alive at 9-month follow-up, with the one patient dying of cancer progression. No patient presented with daytime incontinence, although seven reported nocturia. There were 20 patients who maintained their preoperative sexual potency, and four described a decrease in erectile function postoperatively., Conclusions: We have been performing laparoscopic prostate-sparing radical cystectomy for more than 2 years and have found it oncologically safe and reproducible with promising functional benefits. It presents a good option for properly selected patients.

Purpose: Nerve sparing radical prostatectomy may allow preservation of potency but it can increase positive surgical margins. We used intraoperative frozen section (IFS) analysis to monitor the nerve sparing procedure in laparoscopic prostatectomy., Materials and Methods: A total of 100 patients with localized prostatic carcinoma underwent bilateral intrafascial nerve sparing laparoscopic prostatectomy with IFS. A wedge of tissue was cut from base to apex in the region of the neurovascular bundles (NVBs) and analyzed on frozen section. If carcinoma was detected at the inked margin, the corresponding NVB was resected. Definitive margin status was evaluated after permanent section analysis of IFS prostatectomy specimens and eventually NVB specimens., Results: IFS analysis was positive in 24 patients, as confirmed in all by permanent section of the wedges. Three of these patients had positive margins in the prostate specimen at another site. Of the 76 tumors with negative IFSs 1 had positive margins on permanent sections of the wedges and 8 had positive margins on the prostate specimen at another site. IFS led to a decrease in the overall positive margin status from 33% to 12% and from 26.1% to 7.9% in pT2 tumors. Tumor was found on NVB resection in 8 cases (33%)., Conclusions: These results suggest that IFS analysis is a reliable method by which to monitor nerve sparing during laparoscopic prostatectomy. IFS could allow the surgeon to offer a nerve sparing procedure more frequently without compromising cancer control.