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There is emerging but limited data assessing single-port (SP) robot-assisted surgery as an alternative to multi-port (MP) platforms. We compared perioperative outcomes between SP and MP robot-assisted approaches for excision of high and low complexity renal masses. Retrospective chart review was performed for patients undergoing robot-assisted partial or radical nephrectomy using the SP surgical system (n = 23) at our institution between November 2019 and November 2021. Renal masses were categorized as high complexity (7+) or low complexity (4–6) using the R.E.N.A.L. nephrometry scoring system. Adjusting for baseline characteristics, patients were matched using a prospectively maintained MP database in a 2:1 (MP:SP) ratio. For high complexity tumors (n = 12), SP surgery was associated with a significantly longer operative time compared to MP (248.4 vs 188.1 min, p = 0.02) but a significantly shorter length of stay (1.9 vs 2.8 days, p = 0.02). For low complexity tumors (n = 11), operative time (177.7 vs 161.4 min, p = 0.53), estimated blood loss (69.6.0 vs 142.0 mL, p = 0.62), and length of stay (1.6 vs 1.8 days, p = 0.528) were comparable between SP and MP approaches. Increasing nephrometry score was associated with a greater relative increase in operative time for SP compared to MP renal surgery (p = 0.07) using best of fit linear modeling. SP robot-assisted partial and radical nephrectomy is safe and feasible for low complexity renal masses. For high complexity renal masses, the SP system is associated with a significantly longer operative time compared to the MP technique. Careful consideration should be given when selecting patients for SP robot-assisted kidney surgery.

Introduction: With increased demands on surgeon productivity and outcomes, residency robotics training increasingly relies on simulations. The objective of this study is to assess the validity and ...

INTRODUCTION AND OBJECTIVE:Urinary incontinence(UI) and erectile dysfunction (ED) are common complications of radical prostatectomy(RP) with devastating impact on quality of life(QoL). Baseline cha...

Purpose: Today, up to one-third of newly diagnosed prostate cancer (PCa) cases may be suitable for focal treatment. The lack of data about the toxicity profiles of lesion-targeting therapies, however, has made it difficult to compare treatment modalities. The aim of the present study was to evaluate comprehensively the incidence, severity, and timing of onset of complications for PCa patients undergoing focal high-intensity focused ultrasound (HIFU) and focal cryosurgical ablation of the prostate (CSAP). Materials and Methods: A total of 336 patients were included who underwent focal HIFU or focal CSAP as a primary treatment for PCa between January 2009 and December 2017. Mean follow-up was 11 months (standard deviation: 3.0). All complications were captured and graded according to severity, and classified by timing of onset. Univariate and multivariate analysis was performed to identify predictors of the most common side effects. Results: There were 98 complications in 79/210 patients (38%) undergoing focal HIFU and 34 complications in 27/126 patients (21%) undergoing focal CSAP. In terms of severity, 95% of the complications of focal HIFU and 91% of the complications of focal CSAP were minor. Most complications presented in the early postoperative period. On multivariate analysis, subtotal HIFU was associated with acute urinary retention (AUR), while a smaller prostate size and longer catheterization time with dysuria. In CSAP patients, longer catheterization time was associated with AUR and urethral sloughing. The main limitation is the nonrandomized and retrospective nature. Conclusions: Focal HIFU and focal CSAP provide a tolerable toxicity, with primarily minor complications presenting in the early postoperative period.

The significance of upstaging of cT1 renal tumors to pT3a is not clear. We evaluate the incidence of upstaging, identify predictors and analyze oncological outcomes of these patients versus those who did not upstage. We also compared the oncological outcomes of cT1 upstaging to pT3a with de novo pT3a renal tumors.From a database of 1021 renal tumors with complete available follow-up data, 517 patients had cT1. Patients upstaging to pT3a were compared to those who did not. Baseline clinical, perioperative, histopathologic features and oncological outcomes were analysed.Out of 517 cT1 patients, 105 (20.3%) upstaged to pT3a and 412 (79.7%) did not. Proportion of patients in each group undergoing partial and radical nephrectomy, postoperative tumor size, histology, margin status and lymph node involvement were similar. Among upstaged, 9 patients (8.6%) developed first recurrence as compared to only 3 (0.7%) in those not upstaging (P 0.001). The median time to recurrence (57 vs. 107 months; P 0.001) was lesser in de novo pT3a renal tumors.Pathological upstaging from cT1 to pT3a and necrosis on histopathology were associated with recurrence. Advanced age, smoking, necrosis on histopathology, clear cell histology and higher Fuhrman grades contributed to pathological upstaging of cT1 tumors. De novo pT3a RCC had worse survival when compared to cT1 patients upstaging to pT3a RCC.

Whether focal therapy (FT) jeopardizes subsequent prostate cancer (PCa) salvage treatments, when needed, remains a major concern and is largely unknown. To describe and report safety, oncological and functional outcomes of salvage treatments following PCa recurrence and/or persistence after FT. A systematic review on salvage treatments for PCa recurrence/persistence after FT was carried out according to the PRISMA guidelines using an ‘a priori protocol’. A comprehensive literature review was also performed to investigate options to treat FT PCa recurrence/persistence that have not yet been reported after FT. Four retrospective series were included (n = 67 men); overall quality of the studies was low. Salvage treatments yielded 32.8% (n = 22 of 67) biochemical recurrence rate (BCR) after a 7–62-months mean follow-up. No cancer-related deaths occurred. Patients experienced acceptable complications (n = 12 patients; n = 8 Clavien 3) and rare severe incontinence (4.5% using > 2 pads/day). Erectile function (EF) was rarely assessed (62.8% no information available), being overall poor. Other salvage options have been reported following whole-gland ablation and include: (1) re-do ablation yielding worst BCR and EF but similar complications and continence compared to first line ablation; (2) salvage radiotherapy yielding 16.6–38.8% BCR and acceptable toxicity profile with urinary and EF being poorly assessed. Current evidence is weak and limited to a few retrospective series. Oncological control is acceptable although it seems lower compared to a primary treatment setting. Functional outcomes are comparable to primary treatment with the exception of EF; overall, suggesting FT has little impact on subsequent salvage treatments. Future studies are needed to confirm the current findings.

Background Focal therapy (FT) for localized prostate cancer (PCa) treatment is raising interest. New technological mpMRI-US guided FT devices have never been compared with the previous generation of ultrasound-only guided devices. Materials and Methods We retrospectively analyzed prospectively recorded data of men undergoing FT for localized low- or intermediate-risk PCa with US- (Ablatherm®-2009 to 2014) or mpMRI-US (Focal One®-from 2014) guided HIFU. Follow-up visits and data were collected using internationally validated questionnaires at 1, 2, 3, 6 and 12 months. Results We included n=88 US-guided FT HIFU and n=52 mpMRI-US guided FT HIFU respectively. No major baseline differences were present except higher rates of Gleason 3+4 for the mpMRI-US group. No major differences were present in hospital stay (p=0.1), catheterization time (p=0.5) and complications (p=0.2) although these tended to be lower in the mpMRI-US group (6.8% versus 13.2% US FT group). At 3 months mpMRI-US guided HIFU had significantly lower urine leak (5.1% vs. 15.9%, p=0.04) and a lower drop in IIEF scores (2 vs. 4.2, p=0.07). Of those undergoing 12-months control biopsy in the mpMRI-US-guided HIFU group, 26% had residual cancer in the treated lobe. Conclusion HIFU FT guided by MRI-US fusion may allow improved functional outcomes and fewer complications compared to US- guided HIFU FT alone. Further analysis is needed to confirm benefits of mpMRI implementation at a longer follow-up and on a larger cohort of patients.

OBJECTIVE: Irreversible electroporation (IRE) uses microsecond long electric pulses to kill cells through membrane permeabilization, without affecting surrounding extracellular structures. We evaluated whether IRE can be used to induce urinary obstruction for a rat model of renal scarring. MATERIALS AND METHODS: Intra-surgical IRE (2000 V/cm, 90 pulses, 100 μs) with caliper electrodes was performed in the right proximal ureter in male rats (n = 24) which were euthanized at 2, 5, or 10 days post-treatment, following contrast-enhanced magnetic resonance imaging (ceMRI). Complete urinary tract (bilateral kidneys, ureter and bladder) was extracted, and scored on a five-point scale for renal dilation, ureteral dilation and hydronephrosis. Whole kidney sections underwent immunohistochemistry to quantify levels of macrophages (CD68), activated fibroblasts (α-Smooth Muscle Actin [α-SMA]), collagen (Masson’s Trichrome) and Hematoxylin and Eosin. Change in renal pelvis diameter and the number of glomeruli in the treated and contralateral urinary tract was also computed. RESULTS: Intrasurgical IRE performed with non-invasive caliper electrodes resulted in immediate loss of peristalsis in the treated ureteral segment, and cell death in the ureteral muscularis along with urothelial sloughing. Dilation of the ureter was observed on gross anatomic evaluation and histopathology. Magnetic resonance imaging indicated partial stricture and urinary obstruction in IRE treated urinary tract, without evidence of urinoma, leakage or fistula formation. Enlargement of the kidney with progressive renal dilation and hydronephrosis was evident between Day 2 and Day 10 post-treatment. Obstructed kidney demonstrated scarring with elevated levels of tissue collagen, macrophages and α-Smooth Muscle Actin positive fibroblasts. There was a steady decrease in the number of glomeruli in the obstructed kidney, while glomeruli numbers in the contralateral kidney remained unchanged through the 10-day observation period. CONCLUSION: IRE provides a safe and reproducible technique to induce partial ureteral obstruction and renal fibrosis in rat model without the need for ligation or its associated complications.

Purpose: Ultrasound-magnetic resonance imaging (US-MRI) fusion biopsy (FB) improves the detection of clinically significant prostate cancer (PCa). We aimed to compare the Gleason upgrading (GU) rates and the concordance of the Gleason scores in the biopsy versus final pathology after surgery in patients who underwent transrectal ultrasound (TRUS) systematic random biopsies (SRB) versus US-MRI FB for PCa. Materials and Methods: A retrospective analysis of data that were collected prospectively from January 2011 to June 2016 from patients who underwent prostate biopsy and subsequent radical prostatectomy. The study cohort was divided into two groups: US-MRI FB (Group A) and TRUS SRB (Group B). US-MRI FB was performed in patients with a previous MRI with a focal lesion with a Likert score ≥3; otherwise, a TRUS SRB was performed. Results: In total, 73 men underwent US-MRI FB, and 89 underwent TRUS SRB. The GU rate was higher in Group B (31.5% vs. 16.4%; p=0.027). According to the Gleason grade pattern, GU was higher in Group B than in Group A (40.4% vs. 23.3%; p=0.020). Analyses of the Gleason grading patterns showed that Gleason scores 3+4 presented less GU in Group A (24.1% vs. 52.6%; p=0.043). The Bland-Altman plot analysis showed a higher bias in Group B than in Group A (-0.27 [-1.40 to 0.86] vs. −0.01 [-1.42 to 1.39]). In the multivariable logistic regression analysis, the only independent predictor of GU was the use of TRUS SRB (2.64 [1.11 – 6.28]; p=0.024). Conclusions: US-MRI FB appears to be related to a decrease in GU rate and an increase in concordance between biopsy and final pathology compared to TRUS SRB, suggesting that performing US-MRI FB leads to greater accuracy of diagnosis and better treatment decisions.

Purpose To describe the salvage radical prostatectomy (sRP) experience in patients presenting with recurrent, clinically localized prostate cancer after multiple failed local treatments. Materials and methods Among the 251 sRP performed during 2000-2016, 11 patients had failed multiple local therapies. We describe baseline clinical characteristics at primary cancer diagnosis and prior to sRP, surgical information, complications and oncological outcomes. Results The mean±standard deviation age at sRP was 65±5 years and the median (interquartile range) serum prostate-specific antigen (PSA) level was 2 (1.3) ng/mL. The most common first and subsequent treatments were radiotherapy and cryotherapy, respectively, with median time of 24 months from the last local treatment. The median operative time was 180 minutes and median estimated blood loss was 750 mL. Five (45.5%) patients underwent additional procedures during sRP for pre-operative morbidity from prior treatments (rectourethral fistula, urethral stricture, incontinence). Post-operative complications requiring invasive intervention occurred in 7 (63.6%) patients. Over a median follow-up of 29 (12-96) months, 10 of the 11 men (90.9%) achieved an undetectable PSA in after sRP. Three of these men with an initially undetectable PSA level experienced biochemical recurrence; the remaining 7 are without evidence of disease. Overall, no local recurrence or systemic metastasis was identified at last follow-up. Conclusions sRP is technically feasible and offers durable cancer control in patients with recurrent prostate cancer despite having undergone multiple prior attempts at cure. These patients experience higher rates of post-operative complications and such patients must be appropriately counseled regarding the potential risks and benefits.

Background Salvage partial gland ablation (sPGA) has been proposed to treat some localized radiorecurrent prostate cancer. The role of prostate biopsy and magnetic resonance imaging (MRI) characteristics to identify patients eligible for sPGA is unknown. Objective To evaluate the ability of MRI and prostate biopsy characteristics to identify an index lesion suitable for sPGA and validate this selection using detailed tumor maps created from whole-mount slides from salvage radical prostatectomy (sRP) specimens. Design, setting, and participants Men who underwent sRP for recurrent prostate cancer following primary radiotherapy with external beam radiotherapy (EBRT) and/or brachytherapy between 2000 and 2014 at a single high-volume cancer center were eligible. Those with tumor maps, MRI and biopsy data were included in analysis. Outcome measurements and statistical analysis Primary outcome was the ability of clinicopathologic and imaging criteria to identify patients who may be eligible for sPGA based on detailed tumor map from whole-mount sRP slides. Results and limitations Of 216 men who underwent sRP following whole gland radiotherapy, tumor maps, MRI, and biopsy data were available for 77. Of these, 15 (19%) were determined to be eligible for sPGA based on biopsy-proven unilateral disease in contiguous sextant segments, a dominant lesion on MRI concordant with biopsy location or no focal region of interest, and no imaging evidence of extraprostatic disease. Review of tumor maps identified 6 additional men who would have met criteria for sPGA, resulting in sensitivity of 71% (95% C.I. 48%–89%) and specificity of 100% (lower bound of 95% C.I. 94%). None of the 15 men who met the criteria for sPGA on clinical data were identified incorrectly on tumor maps to require full gland surgery (upper bound of 95% C.I. 22%). Median tumor volume of the index lesion was 0.4 cc and recurrent cancer was noted in the apex, mid-gland, and base in 81%, 100%, and 29% of men. Conclusions In men with recurrent prostate cancer after radiotherapy, biopsy findings and MRI can be used to select index lesions potentially amenable for sPGA and can guide patient evaluation for inclusion in clinical trials of sPGA following radiation failure. Larger, prospective studies are required to evaluate both the role of MRI and clinical criteria in guiding focal salvage therapy and the effectiveness of this modality for radiorecurrent prostate cancer.

BACKGROUND: Whole-gland extirpation or irradiation is considered the gold standard for curative oncological treatment for localized prostate cancer, but is often associated with sexual and urinary impairment that adversely affects quality of life. This has led to increased interest in developing therapies with effective cancer control but less morbidity. We aimed to provide details of physician consensus on patient selection for prostate focal therapy (FT) in the era of contemporary prostate cancer management. METHODS: We undertook a four-stage Delphi consensus project among a panel of 47 international experts in prostate FT. Data on three main domains (role of biopsy/imaging, disease and patient factors) were collected in three iterative rounds of online questionnaires and feedback. Consensus was defined as agreement in >= 80% of physicians. Finally, an in-person meeting was attended by a core group of 16 experts to review the data and formulate the consensus statement. RESULTS: Consensus was obtained in 16 of 18 subdomains. Multiparametric magnetic resonance imaging (mpMRI) is a standard imaging tool for patient selection for FT. In the presence of an mpMRI-suspicious lesion, histological confirmation is necessary prior to FT. In addition, systematic biopsy remains necessary to assess mpMRI-negative areas. However, adequate criteria for systematic biopsy remains indeterminate. FT can be recommended in D'Amico low-/intermediate-risk cancer including Gleason 4+3. Gleason 3+4 cancer, where localized, discrete and of favorable size represents the ideal case for FT. Tumor foci

The literature on focal therapy is currently insufficient to recommend it as first-line treatment. We need information from both randomised controlled trials and prospective registries for every available energy. That said, important research is under way in this field, and the door should be kept open to an approach that has the potential to offer adequate cancer control with lower morbidity and better post-treatment quality of life in properly selected patients.

Resumen Introduccion Se debaten los resultados oncologicos de la prostatectomia radical (PR) en pacientes que progresan en vigilancia activa (VA). Comparamos los resultados de los pacientes elegibles para VA sometidos a PR inmediatamente despues del diagnostico con aquellos que lo hacian despues de un retraso o progresion de la enfermedad en VA. Metodos Entre 2000 y 2014, 961 pacientes fueron elegibles para VA segun los criterios de la EAU. Se comparo la PR a los 6 meses del diagnostico (PRI) o mas alla (PRT), PR sin VA (PRTa) y pacientes en VA que progresan a PR (PRTb). Se registro PSA inicial, caracteristicas clinicas y de biopsia. Los resultados oncologicos incluyeron patologia adversa (PA) en la muestra de PR y recurrencia bioquimica (RBQ). Se realizo un analisis de pares emparejados entre los pacientes con PRTb y GS7 sometidos a PR inmediata (GS7PRI). Resultados PRI, PRT, PRTa y PRTb tuvieron 820 (85%), 141 (15%), 118 (12,24%) y 23 (2,7%) pacientes respectivamente. PRI, PRTa y PRTb se sometieron a PR a una mediana de 3, 9 y 19 meses despues del diagnostico, respectivamente. Las caracteristicas basales fueron comparables. PRT vs. PRI tuvieron una mediana de tiempo mas temprana (31 vs. 43 meses; p Conclusiones Los pacientes que progresaron en VA tuvieron los peores resultados oncologicos. PR para progresion de GS7 y par coincidente de pacientes con GS7 tuvieron resultados similares. Peores resultados oncologicos en los progresores de VA no pueden explicarse por una mera demora en PR.

Resumen Introduccion La importancia de la sobrestadificacion de tumores renales cT1 a pT3a no esta clara. Evaluamos la incidencia de la sobrestadificacion, identificamos factores predictivos y analizamos los resultados oncologicos de estos pacientes frente a aquellos que no sobrestadificaron. Tambien comparamos los resultados oncologicos de la sobrestadificacion de cT1 a pT3a con tumores renales pT3a de novo. Metodos De una base de datos de 1.021 tumores renales con datos de seguimiento completos disponibles, 517 pacientes tenian cT1. Los pacientes que sobrestadificaron a pT3a se compararon con aquellos que no lo hicieron. Se analizaron los resultados de las caracteristicas clinicas, perioperatorias, histopatologicas y oncologicas iniciales. Resultados De 517 pacientes con cT1, 105 (20,3%) sobrestadificaron a pT3a y 412 (79,7%) no lo hicieron. La proporcion de pacientes en cada grupo tratados mediante nefrectomia parcial y radical, el tamano del tumor postoperatorio, la histologia, el estado de los margenes, y la afectacion de ganglios linfaticos fueron similares. Entre los que sobrestadificaron, 9 pacientes (8,6%) desarrollaron la primera recurrencia en comparacion con solo 3 (0,7%) en aquellos que no sobrestadificaron (p Conclusiones La sobrestadificacion patologica de cT1 a pT3a y la necrosis en la histopatologia se asociaron con la recurrencia. La edad avanzada, el tabaquismo, la necrosis en la histopatologia, la histologia de celulas claras y grados mas altos de Fuhrman contribuyeron a la sobrestadificacion patologica de los tumores cT1. El CCR pT3a de novo tuvo una supervivencia peor cuando se comparo con los pacientes con cT1 que sobrestadificaron a CCR pT3a.

Objective We report our initial experience in the treatment of prostate cancer (PCa) with high-intensity focused ultrasound (HIFU) using the Focal-One ® device. Material and methods Retrospective review of the prospectively populated database. Between June 2014 and 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-One ® device under general anesthesia. Oncological follow-up: PSA measurement and control biopsy with mpMRI according to protocol. Questionnaire-based functional outcome assessment was done. Complications were reported using Clavien classification. Results The median PSA was 7.79 ng/ml (IQR: 6.32–9.16), with a median prostate volume of 38 cc (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. Conclusions Focal-One ® HIFU treatment appears to be a safe procedure with few complications. Functional outcomes proved no urinary incontinence and sexual function were maintained in 83%.

Introduction: In the era of minimally-invasive surgery, urinary incontinence (UI) after radical prostatectomy (RP) still represents a troublesome issue for a considerable rate of patients. Factors associated with the risk of post-RP UI, need to be carefully assessed throughout the overall clinical management process thus including the pre-operative, intra-operative and post-operative setting.Areas covered: This review analyses current published evidences regarding clinical and surgical aspects associated with urinary continence (UC) recovery after RP. A careful evaluation of patient's clinical characteristics should be carried out before surgery in order to properly counsel the patients regarding the risk of UI. In the last two decades, the advent of robotic surgery has led to an overall improvement of functional outcomes after RP, thanks to the development of different surgical strategies based on either the preservation' or the reconstruction' of the anatomical elements responsible for urinary continence.Finally, several therapeutic strategies including either a conservative approach, or pharmacological and surgical treatments, should be carefully considered for the post-operative management of UI.Expert commentary: A comprehensive pre-operative patient's clinical assessment, along with a proper and well-conducted surgical procedure and an effective post-operative care management are essential element to achieve a high probability of UC recovery.

To describe a new technique for superficial implantation of the I-Stop TOMS transobturator sling and present the clinical outcomes on patients treated for mild to moderate urinary incontinence after radical prostatectomy.We evaluated the four-arm sub urethral sling I-Stop TOMS performed in our institution between March 2012 and March 2015 using a superficial implantation technique. After a small incision, the perineal aponeurosis was incised but no muscle dissection was performed. Inclusion criteria for sling procedure used in the study was mild (1-2 pads/day) to moderate (3-5 pads/day) postprostatectomy incontinence and at least 12 months after radical prostatectomy. Improvement was defined as the patient having 50% reduction in the number of pads and success as patient either not wearing pads or using one security pad. The primary objective was to evaluate the proportion of patients achieving continence after the modified sling implantation technique at 12 months after surgery. Fifty-two patients underwent our new technique and 34 had completed 12 months follow-up. The procedure was successful for 28 patients (82.4%). There was an improvement in 25 patients (73.5%). Pad use at 12 months had decreased significantly compared with baseline (mean 0.7 vs 2.2, P .00001). The complications were rare and the procedure was well tolerated as shown by median visual analogic scale of 1.5 (interquartile range, 2 to 1).This novel approach for insertion of the transobturator I-Stop TOMS male sling is a quick, simple, and well-tolerated procedure with low complication rate, allowing a significant improvement in postprostatectomy incontinence.

Introduction: The aim of the study was to identify the appropriate level of Charlson comorbidity index (CCI) in older patients (>70 years) with high-risk prostate cancer (PCa) to achieve survival benefit following radical prostatectomy (RP). Methods: We retrospectively analyzed 1008 older patients (>70 years) who underwent RP with pelvic lymph node dissection for high-risk prostate cancer (preoperative prostate-specific antigen >20 ng/mL or clinical stage ≥T2c or Gleason ≥8) from 14 tertiary institutions between 1988 and 2014. The study population was further grouped into CCIÂ

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 3mm (IQR: 2–10mm), and total cancer length was 6.5mm (IQR: 2–24mm). 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.

To evaluate the transition from laparoscopic (LPN) to robotic partial nephrectomy (RPN) in our institution using ‘trifecta’ outcomes as surrogate marker of efficacy. We identified 347 patients (LPN = 303, RPN = 44) in our prospectively maintained PN database between 2000 and 2014. The patients were chronologically divided into G1—first 151 LPN cases, G2—subsequent 152 LPN cases and G3—all RPN patients. Trifecta outcomes were defined as warm ischemia time (WIT) ≤25 min, no positive surgical margin (PSM) and complications ≤Clavien 2. Multivariable logistic model was used to analyze the predictors of the trifecta outcomes. The tumor complexity significantly increased from G1 to G3. We achieved lower WIT and less high-grade complication (Clavien ≥ 3) from G1 to G2, and the trend continued even with transition to RPN. PSM was consistently low throughout the transition. Renal functional outcomes always showed a significant positive trend, and with RPN, we achieved improved recovery of renal function (44 vs 57 vs 82 %, p

Personalizing focal ablation energy for prostate cancer on the basis of cancer location is a novel concept. We propose the use of high-intensity focused ultrasound, cryotherapy, and brachytherapy for posterior, anterior, and apical tumors, respectively, to improve the overall outcome. This concept needs to be verified in prospective studies.

Introduction Oncological outcomes of radical prostatectomy (RP) in patients progressing on active surveillance (AS) are debated. We compared outcomes of AS eligible patients undergoing RP immediately after diagnosis with those doing so after delay or disease progression on AS. Methods Between 2000 and 2014, 961 patients were AS eligible as per EAU criteria. RP within 6 months of diagnosis (IRP) or beyond (DRP), RP without AS (DRPa) and AS patients progressing to RP (DRPb) were compared. Baseline PSA, clinical and biopsy characteristics were noted. Oncological outcomes included adverse pathology in RP specimen and biochemical recurrence (BCR). Matched pair analysis was done between DRPb and GS7 patients undergoing immediate RP (GS7IRP). Results IRP, DRP, DRPa and DRPb had 820 (85%), 141 (15%), 118 (12.24%) and 23 (2.7%) patients respectively. IRP, DRPa and DRPb underwent RP at a median of 3, 9 and 19 months after diagnosis respectively. Baseline characteristics were comparable. DRP vs. IRP had earlier median time (31 vs. 43 months; p p = 0.045). DRPb showed higher BCR (19 vs. 5%; p = 0.021) with earlier median time to BCR, compared to IRP and DRPa ( p = 0.038). There was no difference in adverse pathology and BCR rates, but time to BCR was significantly lesser in DRPb (49 vs. 6 months; p Conclusions Patients progressing on AS had worst oncological outcomes. RP for GS7 progression and matched pair of GS7 patients had similar outcomes. Worse oncological outcomes in AS progressors cannot be explained by a mere delay in RP.

Purpose To verify the quality of pelvic lymph node dissection (PLND) performed at radical prostatectomy (RP) and its impact on nodal recurrence in patients undergoing salvage lymph node dissection (sLND). Materials and methods Retrospective review of 48 patients who underwent sLND for presumed nodal recurrence, to describe the PLND characteristics at RP and correlate the anatomical sites and number of suspicious nodes reported in radiological imaging and final pathology of sLND. Results Overall, at RP, 8 (16.7%) did not undergo PLND, 32 (66.7%) and 8 (16.7%) received a "limited" (between external iliac vein and obturator nerve) and an "extended" (external iliac, hypogastric, and obturator) dissection, respectively. Median nodes removed during limited and extended dissection were 2 and 24, respectively. At sLND, the mean age was 61.3 years and median prostate specific antigen (PSA) was 1.07 ng/mL. Median nodes removed at sLND were 17 with a median of 2 positive nodes. Recurrent nodes were identified within the template of an extended PLND in 62.5%, 50.0% and 12.5% patients, respectively, following prior no, limited and extended dissection at RP. Recurrence outside the expected lymphatic drainage pathway was noted in 37.5% patients with prior extended dissection at RP. There was a correlation between imaging and pathology specimen in 83% for node location and 58.3% for number of anatomical sites involved. Conclusions In prostate cancer patients undergoing sLND, most had inadequate PLND at the original RP. Pattern of nodal recurrence may be influenced by the prior dissection and pre sLND imaging appears to underestimate the nodal recurrence.

We analyzed the oncologic and functional outcomes of partial gland ablation compared with robot-assisted radical prostatectomy in patients with low and intermediate risk prostate cancer.A total of 1,883 patients underwent robot-assisted radical prostatectomy and 373 underwent partial gland ablation from July 2009 to September 2015. We selected 1,458 of these participants for analysis, including 1,222 and 236 treated with robot-assisted radical prostatectomy and partial gland ablation, respectively. Patients had a Gleason score of 3 + 3 or 3 + 4, clinical stage T2b or less, prostate specific antigen 15 ng/dl or less, unilateral disease and life expectancy greater than 10 years. Propensity score matching analysis (1:2) was applied in the overall robot-assisted radical prostatectomy sample, which selected 472 patients for comparison. For partial gland ablation 188 men underwent high intensity focused ultrasound and 48 underwent cryotherapy. Oncologic outcomes were analyzed in terms of the need for salvage treatment. Partial gland ablation failure was defined as any positive control biopsy after treatment. Functional outcomes were assessed by validated questionnaires.Matching was successful across the 2 groups, although men treated with partial gland ablation were older (p0.001). Mean followup in the partial gland ablation group was 38.44 months. Partial gland ablation failure was observed in 68 men (28.8%), including 53 (28.1%) treated with high intensity focused ultrasound and 15 (31.2%) treated with cryotherapy. Partial gland ablation was associated with a higher risk of salvage treatment (HR 6.06, p0.001). Complications were comparable between the groups (p = 0.06). Robot-assisted radical prostatectomy was associated with less continence recovery and a lower potency rate 3, 6 and 12 months after surgery (p0.001).In select patients with organ confined prostate cancer partial gland ablation offered good oncologic control with fewer adverse effects that required additional treatments. Potency and continence appeared to be better preserved after partial gland ablation.

Background According to the novel prostate cancer (PCa) grade grouping, men with Gleason score 8 should be included in the grade group 4 regardless of primary and secondary scores. We aimed at evaluating the effect of Gleason patterns on the risk of recurrence in men with grade group 4 PCa. Patients and methods Overall, 1,089 patients treated with radical prostatectomy with grade group 4 PCa at final pathology were identified. Biochemical recurrence (BCR) was defined as 2 consecutive prostate-specific antigen values≥0.2 ng/ml and rising. Clinical recurrence (CR) was defined as positive imaging after BCR. Kaplan-Meier analyses assessed time to BCR and CR. Multivariable Cox regression analyses assessed the impact of Gleason patterns on the risk of BCR and CR. Results Overall, 295 (27.1%), 651 (59.8%), and 143 (13.1%) patients had pathologic Gleason pattern 3+5, 4+4, and 5+3. Overall, 435 (39.9%) patients had positive margins and 439 (30.2%), 300 (27.5%), 350 (32.1%), and 216 (19.8%) had pT2, pT3a, pT3b/4, and pN1 disease. Median follow-up was 83 months. Overall, 536 and 221 patients experienced BCR and CR. The 10-year BCR- and CR-free survival rates were 42.9% and 67.5% vs. 38.3% and 59.7% vs. 40.6% and 50.4% for patients with pathologic Gleason pattern 3+5 vs. 4+4 vs. 5+3, respectively (all P≤0.005). In multivariable analyses, patients with Gleason pattern 3+5 were at lower risk of BCR compared to those with 4+4 (P = 0.002). Men with Gleason pattern 3+5 were at lower risk of CR compared to those with 4+4 and 5+3 (all P≤ 0.01). Conclusions Patients with a primary Gleason score 3 are at reduced risk of recurrence as compared to their counterparts with 4 or 5. Primary and secondary Gleason scores should be considered to stratify the risk of recurrence after surgery in patients with grade group 4 PCa.

The process of defining an “ideal patient” for focal therapy (FT) has been a dynamic process in accordance with the growing understanding and limitations of FT. The focus of FT has shifted from being an alternative for active surveillance (AS) to an acceptable middle ground therapeutic option between AS and radical treatment (surgery/radiation). The aim of this chapter is to present a brief review of factors that influence the patient selection for FT and also review the recent international consensus panel recommendations.

There is an emerging shift in the management of localized prostate cancer (PCa) from whole-gland treatment to “partial gland ablation” strategies or “focal therapy.” The dynamics in the treatment landscape of PCa is attributed to the epidemiological changes in the disease, improved understanding of the cancer biology, technological advances in prostate imaging, and novel approaches such as targeted biopsies. As focal therapy is being gradually integrated into routine clinical use, it is highly essential to incorporate the application of patient-reported outcome measures (PROMs) into focal therapy practice. Routine use of PROMs can improve patient-physician communications, aid in better decision-making, and serve as a tool for outcome measurement, performance assessment, and benchmarking. Though most of the published literature on focal therapy for prostate cancer has used validated questionnaires to measure the functional outcomes, the reporting is heterogeneous and not standardized specifically for focal therapy. Well-organized multidisciplinary working group and qualitative research interviews will help in building treatment-specific PROM tools for validation and subsequent clinical application. Researchers should be encouraged to develop PROM instruments specific for focal therapy, and incorporation of such tools into clinical practice will allow robust comparative studies essential to physicians and patients.

Prostate cancer is characterized by a low mortality—incidence ratio partially due to the diagnosis of localized and low-risk disease. Focal therapy for prostate cancer has evolved in order to address the need for treatment of localized disease without exposing patients to the morbidities associated with radical therapy such as incontinence and erectile dysfunction and thus allowing them to maintain a good quality of life. In women, similarly to prostate cancer, the overdiagnosis of breast cancer due to improved imaging has induced the progression of surgical techniques from radical mastectomy to a more focal approach with individualized breast conservative strategies. In the following chapter, we will be reviewing the evolution of focal therapy in breast and prostate cancer and will examine what were the factors that drove this evolution in time.

of biopsy. One or more SR were found in 168 men (83.6%). They were PIRADS 2 in 20 men (11.9%), PIRADS 3 in 61 (36.3%) and PIRADS 45 in 87 (51.8%). Under local anaesthesia and antibiotic prophylaxis, two cores of the most suspicious areas were obtained by CF-TRUSGB, and thereafter a 12TRUSGB was performed. End points were detection rates of PCa and high grade PCa (HGPCa: Gleason>6). Efficiency was calculated as the number of cores needed to detect one PCa and one HGPCa. RESULTS: PCa was diagnosed in 53 of 168 men (31.5%), 44 of them (83.0%) by 12TRUSGB and 38 (71.7%) by CF-TRUSGB, p1⁄40.047. HGPCa was present in 39 men (73.6%), 31 (79.5%) in 12TRUSGB specimens and 33 (86.4%) in CF-TRUSFB ones, p1⁄40.024. 12TRUSGB missed 9 PCa (17.0%), being 8 of them HGPCa (88.9%), and CF-TRUSGB missed 15 PCa (28.3%), being 4 of them HGPCa (26.7%), p1⁄40.026. 12TRUSGB needed 53.5 cores to detect one men with PCa and 75.9 to detect one HGPCa, however CF-TRUSGB needed 12.3 and 14.1 respectively, p1⁄40.001. CONCLUSIONS: We conclude that CF-TRUSGB, in men scheduled for repeat PB, helps us to improve the detection of HGPCa and is more efficient to detect PCa and HGPCa. However, we can not avoid the performance of 12TRUSGB since 15 PCa were missed by CF-TRUSGB.