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Introduction and ObjectivesWe report our experience with salvage lymph node dissection (sLND) in oligorecurrent prostate cancer (PCa) post radical prostatectomy (RP).Material and MethodsWe retrospectively analyzed data of 24 patients who underwent sLND for biochemical recurrence (BCR) post RP, from July 2012 to February 2018. sLND was performed following an extended bilateral template. Clinical and pathological characteristics of primary RP and sLND were reported. Biochemical response and initiation of additional therapy post sLND were analyzed. Survival analysis was performed using KaplanMeier curves.Results24 sLND were performed. RP specimens showed 58.3% of Gleason score 7 and 50% of locally advanced disease. Median time to BCR post RP was 24 months with a median PSA value of 1.4 ng/ml pre sLND. 75% of patients underwent imaging prior to sLND. sLND showed oligometastasis on the final pathology report in 54.2% of patients. Metastatic lymph nodes were mainly identified in the iliac artery territory (61.5%). Complete biochemical response (PSA < 0.2 ng/ml) was maintained throughout the first 12 months of follow-up in 20.83% of patients and 8.33% of patients at the end of the study (median follow-up 70 months). Survival rates free of additional therapy (ADT/RT) were 45.83% at one year and 25% at 5 years.ConclusionsWe observed a biochemical response post sLND in 20.83% of our patients, lasting throughout the first year of follow up, with survival rates free of ADT and/or RT of 45.83% at one year and 25% at 5 years.

Extended Pelvic Lymph Node Dissection (ePLND) remains the most accurate technique for the detection of occult lymph node metastases (LNMs) in prostate cancer (CaP) patients. Here we aim to examine whether free-Indocyanine Green (F-ICG) could accurately assess the pathological nodal (pN) status in CaP patients during real-time lymphangiography as a potential replacement for ePLND.219 consecutive patients undergoing F-ICG-guided PLND, ePLND and radical prostatectomy (RP) for clinical-localized CaPwere included in this prospective single-center study. The pathological outcomes of F-ICG-guided PLND were compared to confirmatory ePLND. Parameters of a binary diagnostic test for the proper classification of the pN status of patients ('per-patient' analysis) and for the probability of detecting all the metastatic LNs ('per-node' analysis) were calculated. Outcome measures were prevalence, accuracy (Acc), sensitivity (Se), negative predictive value (NPV), and likelihood ratio of a negative F-ICG-guided PLND test result [LR(-)].F-ICG-guided PLND successfully visualized LNs in all procedures with no adverse events. The overall per-patient F-ICG staging Acc was 97.7%, Se was 91.4%, with a NPV of 97.0%, and LR(-) of 8.6%. At the overall per-node level, 4,780 LNs were removed and 1,535 (32.1%) were fluorescent in vivo. F-ICG-guided PLND identified LNMs with a Se of 63.4%.This study confirms that F-ICG-guided lymphangiography correctly staged almost 98% of patients. The high per-patient NPV suggested that avoiding ePLND is safe for most patients when F-ICG stained nodes were pN0. Thus, more conservative approaches might minimise perioperative morbidity during LNMs diagnosis in selected patients.

OBJECTIVES: To evaluate whether indocyanine green guidance can improve the quality of extended pelvic lymph node dissection in patients undergoing radical prostatectomy. METHODS: A total of 214 patients underwent laparoscopic radical prostatectomy with indocyanine green-guided lymph node dissection plus extended pelvic lymph node dissection. These patients (group A) were matched 1:1 for clinical risk groups according to the National Comprehensive Cancer Network classification with patients who underwent the same procedure without fluorescence guidance (group B). Biochemical recurrence was defined as two consecutive prostate-specific antigen rises of at least 0.2 ng/mL. The Kaplan-Meier method and Cox regression models were used to identify predictors of biochemical recurrence. RESULTS: The median number of retrieved nodes was significantly higher in group A (22 vs 14, P < 0.001). The rate of lymph node metastases was higher in group A (65.9% vs 34.1%, P = 0.01). Increasing the yield of lymph node dissection was independently and negatively correlated with the biochemical recurrence risk in both overall and pN-positive patients (hazard ratio 0.97, P = 0.03; and hazard ratio 0.95, P = 0.02). The 5-year biochemical recurrence-free survival rates were (75.8% vs 65.9, P = 0.09) and (54.1% vs 24.9%, P = 0.023) for group A and group B in the overall cohort and pN-positive cohort, respectively. CONCLUSION: Indocyanine green-guided lymph node dissection plus extended pelvic lymph node dissection improves identification of lymphatic drainage, resulting in a higher number of lymph nodes and retrieved lymph node metastases, and allowing a more accurate local staging and a prolonged biochemical recurrence-free survival.

INTRODUCTION AND OBJECTIVE: Current standard imaging procedures have limited ability to predict lymph node (LN) involvement in clinically localized prostate cancer (PCa) and extended pelvic lymph node dissection (ePLND) during radical prostatectomy (RP) remains the most accurate staging procedure. However, meticulous ePLND is time-consuming and associated with an increased risk of morbidity. In order to improve these aspects, sentinel LN mapping with different guided techniques has been proposed over the years. The primary aim of this study is to evaluate the effectiveness of indocyanine green (ICG)-guided ePLND to assess regional LN status in patients who underwent RP. Secondary objective is to evaluate the potential role of a selective ICG lymph node dissection (LND) in patients with ≤ 2 LN metastasis which according to the literature are those who may more benefit from ePLND. METHODS: Data about 226 consecutive patients underwent laparoscopic RP with ICG-guided ePLND at our Department were prospectively evaluated. A solution of 25 mg ICG in 5 ml sterile water was transperineally injected. PLND started with the ICG stained nodes followed by extended template. Primary outcome measures were sensitivity (S), negative predictive value (NPV) and likelihood ratio of a negative test (LRn) of ICG-guided procedure. To our knowledge this study shows data about the largest cohort of patients underwent ICG-guided ePLND. RESULTS: Overall, median age of patients was 64.8 years with a median PSA of 6.6 ng/ml. Extracapsular disease occurred in 50.9% of patients, Gleason score ≥ 8 was reported in 11.9% cases and positive surgical margins rate was 24.3%. Median number of nodes retrieved was 22 (IQR 16-27) and median number of ICG stained per patient nodes was 6 (IQR 4-9). Overall 4939 nodes were removed and 1599 (32.4%) were fluorescent in vivo. Node-positive disease was found in 58 (25.7%), of which 53 (91.4%) had some of the metastatic LNs stained by ICG, while 5 (8.6%) were false negative. Therefore 97.8% of the sample was properly classified by ICG-guided ePNLD (S: 91.4%, NPV: 97.1% and LRn: 8.6%). Considering 209 (92.5%) patients with 0, 1 or 2 metastatic LNs, 39 (18.7%) had a node-positive disease of which 34 (87.2%) had metastatic ICG stained LNs. Again, 97.6% were properly classified by ICG approach (S: 87.2%, NPV: 97.1% and LRn: 12.8%). These 39 node-positive patients had a total of 48 metastatic LNs and all except 9 (18.8%) were fluorescent in vivo (S: 81.2%). CONCLUSIONS: ICG guidance correctly stage 97% of cases. Furthermore, its high NPV will allow to avoid ePLND as soon as an accurate intraoperative analysis is available. Among those patients in whom the LND may have a potentially curative role, ICG alone would have lost only 9 metastatic LNs. This suggest that maybe there is a place for selective LND in patients with limited LN metastatic burden.

[EN] Prostate segmentations are required for an ever-increasing number of medical applications, such as image-based lesion detection, fusion-guided biopsy and focal therapies. However, obtaining accurate segmentations is laborious, requires expertise and, even then, the inter-observer variability remains high. In this paper, a robust, accurate and generalizable model for Magnetic Resonance (MR) and three-dimensional (3D) Ultrasound (US) prostate image segmentation is proposed. It uses a densenet-resnet-based Convolutional Neural Network (CNN) combined with techniques such as deep supervision, checkpoint ensembling and Neural Resolution Enhancement. The MR prostate segmentation model was trained with five challenging and heterogeneous MR prostate datasets (and two US datasets), with segmentations from many different experts with varying segmentation criteria. The model achieves a consistently strong performance in all datasets independently (mean Dice Similarity Coefficient -DSC- above 0.91 for all datasets except for one), outperforming the inter-expert variability significantly in MR (mean DSC of 0.9099 vs. 0.8794). When evaluated on the publicly available Promise12 challenge dataset, it attains a similar performance to the best entries. In summary, the model has the potential of having a significant impact on current prostate procedures, undercutting, and even eliminating, the need of manual segmentations through improvements in terms of robustness, generalizability and output resolution, This work has been partially supported by a doctoral grant of the Spanish Ministry of Innovation and Science, with reference FPU17/01993

To evaluate the efficacy of duloxetine to treat stress urinary incontinence, 1 of the most frequent complications after radical prostatectomy. Conservative measures and surgery are well-established treatments. However, drug treatment could be an intermediate option.All patients had1 year of follow-up after radical prostatectomy to avoid interfering with the natural recovery period (established stress urinary incontinence). Continence was measured by the average daily use of pads and the International Consultation on Incontinence Questionnaire-short form. In Spain, it is necessary to proceed with off-label use formality, and all patients were informed and agreed. The initial dose of duloxetine was 30 mg once daily and was increased to 60 mg/d. Drug treatment was maintained for 9 months.From June 2006 to July 2007, 68 patients were included. The median age was 68 years (range 52-79). The median duration of duloxetine treatment was 5.56 months (range 1-18). A statistically significant decrease in the International Consultation on Incontinence Questionnaire-Urinary Incontinence-short form (from 13 to 9; P.001) and the average number of pads/d (from 2 to 1; P.001) was observed between the initial and 3-month visit. At the end of the follow-up period, 74% and 57% of the patients had a reduced International Consultation on Incontinence Questionnaire-Urinary Incontinence-short form score and a decrease in the number of pads used daily, respectively. Of the 68 patients, 32 (47%) presented with some side effects and 17 patients stopped the treatment because of adverse effects (25%).Our results suggest that duloxetine is a possible alternative treatment of postprostatectomy established stress urinary incontinence. The continence improvement results were mild and conditioned in part by the frequency of the side effects. Provided that duloxetine does not preclude later continence surgery and the benefits are observed at the first visit, we believe it can be a treatment option for selected patients.

Thanks to the higher diagnostic accuracy and safety, new imaging techniques provide future prospects in terms of patient management and follow-up in active surveillance (AS) protocols. Two of the aims of developing new imaging techniques are improving patient selection criteria and to improve follow-up with non-invasive tests. Another objective is to improve the diagnostic performance of biopsies; this would enable physicians to switch from blind systematic TRUS-guided biopsies to targeted biopsies to reduce the amount of biopsies required and reduce the diagnostic rate of clinically insignificant cancers. The notable advances of multi-parametric or functional prostatic imaging (mpMRI) have led to perceptible diagnostic improvements as it they does do not only provide information regarding size and location but also tumor aggressiveness. MRI has proven to be the most reliable non-invasive technique to be able to exclude patients with clinically significant cancer and thus gain acceptance in AS protocols during selection, confirmation and follow-up of AS patients. This chapter reviews the notable impact of multiparametric prostate MRI (mpMRI) on improving both diagnostic accuracy and follow-up. The second point describes the technical advances in the field of transrectal ultrasound imaging, aiming at improving the diagnostic accuracy of biopsies given their increased accessibility and real-time use.

High-intensity focused ultrasound (HIFU) competes with radiofrequency and cryotherapy for the treatment of small renal masses as a third option among ablative approaches. As an emerging technique, its possible percutaneous or laparoscopic application, low discomfort to the patient and the absence of complications make this technology attractive for the management of small renal masses. This manuscript will focus on the principles, basic research and clinical applications of HIFU in small renal masses, reviewing the present literature. Therapeutic results are controversial and from an clinical view, HIFU must be considered a technique under investigation at present time. Further research is needed to settle its real indications in the management of small renal masses; maybe technical improvements will certainly facilitate its use in the management of small renal masses in the near future.