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Objective: To assess the efficacy and safety of combined High-Intensity Focused Ultrasound (HIFU) and Holmium Laser Enucleation of the Prostate (HoLEP) in treating patients with both localized prostate cancer (PCa) and prostate > 60 g., Methods: All patients who underwent HIFU for treatment of localized PCa were prospectively enrolled in our study. We reviewed records of patients undergoing procedures from January 2016 to January 2023. For patients with prostate sizes > 60 g, HoLEP was offered before HIFU to prevent worsened urinary symptoms post-treatment. Oncological outcomes-prostatic-specific (PSA) kinetics, recurrence rates, treatment failure - and functional results-Sexual Health Inventory for Men (SHIM), International Prostate Symptoms Score (IPSS), and urinary complications were compared between patients undergoing combined HoLEP and HIFU with those underwent HIFU-monotherapy., Results: Among 100 patients, 74 underwent HIFU-monotherapy and 26 underwent the combined HoLEP and HIFU. The majority had intermediate-risk PCa (67%). Pathologic assessment of HoLEP specimens showed no tumor evidence in 57% of cases. In comparison to the HIFU-only group, the combined group exhibited significantly lower PSA metrics across various intervals, however, no differences were found regarding overall and infield recurrences and treatment failure rates. While the combined treatment initially resulted in higher incontinence rates and shorter catheterization durations (P < 0.001), no significant difference in IPSS was observed during subsequent follow-ups., Conclusion: HoLEP and HIFU can be safely combined for the treatment of PCa in patients with >60 g prostate volume without compromising early oncological outcomes thereby expanding the therapeutic scope of HIFU in treating patients with localized PCa and large adenomas., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: High-intensity focused ultrasound (HIFU) is regarded as a promising alternative treatment option for localized prostate cancer (PCa) as it has been proposed to offer similar oncologic control to the standard of care, but with significantly reduced treatment-related side effects. This systematic literature review assesses the available evidence of whole-gland HIFU as primary treatment for localized PCa., Methods: MEDLINE (PubMed) was searched for studies investigating oncological and functional outcomes following whole-gland HIFU as primary treatment for localized PCa. Our primary outcomes for the review were biochemical disease-free survival rates (BDFS), overall and PCa-specific survival rates as well as negative biopsy rates. Our secondary outcomes were functional results and complications of the treatment., Results: A total of 375 articles were identified, of which 35 were included in the present review. All 35 articles were prospective or retrospective case series. Mean/median duration of follow-up across studies was 10.9 to 94 months, and 6618 patients were included in the review. The BDFS rate varied greatly across studies from 21.7% to 89.2% during follow-up. The 10-year PCa-specific survival rate following HIFU was 90%, 99%, and 100% in 3 studies. Negative biopsy rates post-HIFU ranged from 20% to 92.7% across studies. Common side effects to HIFU included urinary incontinence (grade 1: 0%-22.7%), erectile dysfunction (11.6%-77.1%), urinary tract infections (1.5%-47.9%), and bladder outlet obstruction mainly as urethral strictures (7%-41.2%)., Conclusion: Great variation in oncological and functional outcomes was seen across studies. More prospective trials are needed before whole-gland HIFU can be considered as a treatment option for localized PCa., Competing Interests: Disclosure The authors have stated that they have no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study is to describe the anatomical and functional changes observed in multiparametric magnetic resonance imaging (mpMRI) during follow-up after focal therapy (FT) for localized prostate cancer (PCa)., Materials and Methods: In this prospective study, we analyzed pre- and postoperatively acquired mpMRI of 10 patients after FT (7 days; 3, 6, 9, 12 months). 7/10 (70%) patients underwent vascular-targeted photodynamic therapy (VTP). 3/10 (30%) patients underwent high-intensity focused ultrasound (HIFU). MpMR image analysis was performed using a semi-automatic software for segmentation of the prostate gland (PG) and tumor zones. Signal intensities (SI) of T2-weighted (T2w), T1-weighted (T1w),diffusion-weighted (DWI) and dynamic contrast-enhanced (DCE) images as well as volumes of the prostate gland (PGV) and tumor volumes (TV) were evaluated at each time point., Results: The results showed a significant increase of PGV 7 days after FT (p = 0.042) and a significant reduction of PGV between 7 days and 6, 9 and 12 months after FT (p < 0.001). The TV increased significantly 7 days after FT (p < 0.001) and decreased significantly between 7 days and 12 months after FT (p < 0.001). There was a significant increase in SI of the ADC in the ablation zone after 6, 9 and 12 months after FT (p < 0.001). 1/9 patients (11%) had recurrent tumor on rebiopsy characterized as a a small focal lesion on mpMRI with strong diffusion restriction (low SI on ADC map and high SI on b-value DWI)., Conclusion: MpMRI is able to represent morphologic changes of the ablated zone after FT and might be helpful to detect recurrent tumor., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Food and Drug Administration must make decisions about emerging high intensity focused ultrasound (HIFU) devices that may lack relevant clinical oncologic data but present with known side effects. This study aims to capture patients' perspective by quantifying their preferences regarding the available benefit and important side effects associated with HIFU for localized prostate cancer., Materials and Methods: Preferences for HIFU outcomes were examined using a discrete choice experiment survey. Participants were asked to choose a preferred treatment option in 9 choice questions. Each included a pair of hypothetical treatment profiles that have similar attributes/outcomes with varying levels. Outcomes included prostate biopsy outcome and treatment-related risks of erectile dysfunction (ED) and urinary incontinence (UI). We calculated the maximum risk of side effect patients were willing to tolerate in exchange for increased benefit. Preferences were further explored via clinical and demographic data., Results: About 223 subjects with a mean age of 64.8 years completed the survey. Respondents were willing to accept a 1.51%-point increase in new ED risk for a 1%-point increase in favorable biopsy outcome. They were also willing to accept a 0.93%-point increase in new UI risk for a 1%-point increase in biopsy outcome. Subjects who perceived their cancer to be more aggressive had higher risk tolerance for UI. Younger men were willing to tolerate less ED risk than older men. Respondents with greater than college level of education had a lower risk tolerance for ED or UI., Conclusions: Results may inform development and regulatory evaluation for future HIFU ablation devices by providing supplemental information from the patient perspective., Competing Interests: Disclosure The authors have no conflict of interest to declare., (Published by Elsevier Inc.)

For patients diagnosed with localized prostate cancer, there are multiple treatment options available. The traditional treatment modalities include radical prostatectomy and radiotherapy. Nevertheless, focal therapy, including high-intensity focused ultrasound (HIFU) and cryotherapy, has emerged as a less-invasive method in this setting. Some patients undergoing primary radiation therapy experience recurrence, but there is currently no consensus on the optimal approach for salvage treatment in such cases. The lack of robust data and randomized controlled trials comparing different whole-gland and focal salvage therapies presents a challenge in determining the ideal treatment strategy. This narrative review examines the prospective and retrospective data available on salvage HIFU following radiation therapy. Based on the literature, salvage HIFU for radio-recurrent prostate cancer has promising oncological outcomes, with an overall 5-year survival rate of around 85%, as well as incontinence rates of about 30% based on the patient's risk group, follow-up times, definitions used, and other aspects of the study. Salvage HIFU for prostate cancer proves to be an effective treatment modality for select patients with biochemical recurrence following radiotherapy.

Purpose: This is an external validation of several biochemical recurrence definitions based on prostate specific antigen criteria (PSA). The purpose is to predict the need of additional treatment and failure after focal therapy using high intensity focused ultrasound (HIFU) for localized prostate cancer (PCa)., Materials and Methods: A total of 343 consecutive patients who underwent HIFU with Ablatherm® and Focal One® devices between June 2001 and November 2020 were identified. Treatment failure was defined as clinically significant PCa on postoperative biopsy, the need for salvage radical or systematic treatment, metastasis, or PCa-related death. The biochemical recurrence definitions tested were PSA nadir, time to PSA nadir, percentage of PSA reduction, Huber et al. criteria defined as PSA nadir + 1 ng/mL at 12 months or PSA nadir + 1.5 ng/mL at 24-36 months. Multivariable Cox regression analysis and decision-curve analysis were used to validate and compare criteria. Kaplan-Meier analysis was used to assess criteria associated with the highest accuracy., Results: One hundred seventy-eight patients met the inclusion criteria and were analyzed. Overall, 61 (34%) and 41 (23%) patients had an additional treatment and failure with a median follow-up of 52 months. At multivariable analysis, model including Huber et al. criteria exhibited the highest Harrell's C-index for the prediction of the need of additional treatment (hazard ratio [HR]: 10, p < 0.001, c-index: 84%) and treatment failure (HR: 9.1, p < 0.001, c-index: 82%) as well as higher net benefit. The 60-months need of additional treatment and treatment failure-free survival were 89% and 98% compared to 26% and 49%, respectively, when stratified according to Huber et al. criteria (Log-rank test, p < 0.001). Similar results were found after excluding patient with non-clinically significant PCa at initial biopsy., Conclusions: We report an external validation of biochemical recurrence definitions predicting the need of additional treatment and failure after focal therapy using HIFU for localized PCa. Huber et al. criteria were identified as the most accurate and could be used to guide clinicians toward further evaluation and salvage treatments., (© 2023 Wiley Periodicals LLC.)

Purpose: We reported preliminary outcomes of high-intensity focused ultrasound (HIFU) [Sonablate ® ] in the combination of transurethral resection of the prostate for localized prostate cancer in Taiwan., Methods: Seventy-seven patients using Sonablate ® HIFU for localized prostate cancer were enrolled in this study from April 2021 to December 2022. Prostate-specific antigen biochemical recurrence, International Index of Erectile Function (IIEF)-5 scores, International Prostate Symptom Score (IPSS), quality of life (QoL) scores, and postoperative complications were recorded during follow-up., Results: Overall, 19.5% of patients were low-risk, 36.4% were intermediate-risk, and 44.1% were high-risk according to the D'Amico risk classification. The median follow-up was 12.09 ± 5.85 months, and the biochemical-free survival rates for the low-, intermediate-, and high-risk groups were 100% (15/15), 96.4% (27/28), and 79.4% (27/34), respectively. Four patients (5.2%) received salvage radiotherapy and all maintained biochemical-free survival. The mean IPSS and QoL scores before versus after HIFU were 10.4 versus 6.8 (p = 0.003) and 3.2 versus 3.0 (p = 0.096), respectively. There was no statistically significant change in preoperative and postoperative IIEF scores (20.6 vs. 19; p = 0.062) in patients who had an IIEF score of >15 at baseline and received nerve-sparing procedures (subtotal ablation)., Conclusions: The results of Sonablate ® HIFU in Taiwan indicated adequate short-term cancer control, excellent potency, and continence preservation. HIFU can achieve improvement of IPSS with low complication rates., (© 2023. Society of Surgical Oncology.)

Introduction: In recent years, improved diagnosis of prostate cancer has allowed the development of focal therapy, in order to reduce the morbidity of treatments. Our study assesses the medium-term oncological and functional results of FocalOne® HIFU treatment in localized prostate cancer., Methods: This is a retrospective, multicentre study including patients with low- or intermediate-risk localized prostate cancer treated with Focal one HIFU between November 2014 and December 2019. The primary endpoint was the retreatment rate and subgroup analyses were performed to identify predictive factors of retreatment., Results: One hundred and thirty-seven patients were included with a median follow-up of 25.5 months. Seventy percent of patients had clinical stage T2, 64% had an ISUP score of 2 or 3 on initial biopsies and 38% were treated with hemi-ablation. Follow-up biopsies were performed in 76.6% of patients during follow-up with 21.8% having clinically significant cancers. The retreatment rate at 24 months was 37.2%, with positive biopsies being the primary criterion for retreatment. Patients with a PSA>8ng/mL had a significantly higher retreatment rate. Finally, morbidity remained acceptable with 5.8% of patients requiring reoperation for complications and 21% for de novo erectile dysfunction., Conclusion: Our results are in agreement with those of the literature, seeming to indicate a lower morbidity of the focal treatment by HIFU compared to the radical treatments while offering an acceptable oncological control. Prospective randomized trials are ongoing., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background: Focal therapy aims to treat areas of cancer to confer oncological control whilst reducing treatment-related functional detriment., Objective: To report oncological outcomes and adverse events following focal high-intensity focused ultrasound (HIFU) for treating nonmetastatic prostate cancer., Design, Setting, and Participants: An analysis of 1379 patients with ≥6 mo of follow-up prospectively recorded in the HIFU Evaluation and Assessment of Treatment (HEAT) registry from 13 UK centres (2005-2020) was conducted. Five or more years of follow-up was available for 325 (24%) patients. Focal HIFU therapy used a transrectal ultrasound-guided device (Sonablate; Sonacare Inc., Charlotte, NC, USA)., Outcome Measurements and Statistical Analysis: Failure-free survival (FFS) was primarily defined as avoidance of no evidence of disease to require salvage whole-gland or systemic treatment, or metastases or prostate cancer-specific mortality. Differences in FFS between D'Amico risk groups were determined using a log-rank analysis. Adverse events were reported using Clavien-Dindo classification., Results and Limitations: The median (interquartile range) age was 66 (60-71) yr and prostate-specific antigen was 6.9 (4.9-9.4) ng/ml with D'Amico intermediate risk in 65% (896/1379) and high risk in 28% (386/1379). The overall median follow-up was 32 (17-58) mo; for those with ≥5 yr of follow-up, it was 82 (72-94). A total of 252 patients had repeat focal treatment due to residual or recurrent cancer; overall 92 patients required salvage whole-gland treatment. Kaplan-Meier 7-yr FFS was 69% (64-74%). Seven-year FFS in intermediate- and high-risk cancers was 68% (95% confidence interval [CI] 62-75%) and 65% (95% CI 56-74%; p = 0.3). Clavien-Dindo >2 adverse events occurred in 0.5% (7/1379). The median 10-yr follow-up is lacking., Conclusions: Focal HIFU in carefully selected patients with clinically significant prostate cancer, with six and three of ten patients having, respectively, intermediate- and high-risk cancer, has good cancer control in the medium term., Patient Summary: Focal high-intensity focused ultrasound treatment to areas of prostate with cancer can provide an alternative to treating the whole prostate. This treatment modality has good medium-term cancer control over 7 yr, although 10-yr data are not yet available., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: Prostate cancer (PCa) is the second most common oncologic disease among men. Radical treatment with curative intent provides good oncological results for PCa survivors, although definitive therapy is associated with significant number of serious side-effects. In modern-era of medicine tissue-sparing techniques, such as focal HIFU, have been proposed for PCa patients in order to provide cancer control equivalent to the standard-of-care procedures while reducing morbidities and complications. The aim of this systematic review was to summarise the available evidence about focal HIFU therapy as a primary treatment for localized PCa., Material and Methods: We conducted a comprehensive literature review of focal HIFU therapy in the MEDLINE database (PROSPERO: CRD42021235581). Articles published in the English language between 2010 and 2020 with more than 50 patients were included., Results: Clinically significant in-field recurrence and out-of-field progression were detected to 22% and 29% PCa patients, respectively. Higher ISUP grade group, more positive cores at biopsy and bilateral disease were identified as the main risk factors for disease recurrence. The most common strategy for recurrence management was definitive therapy. Six months after focal HIFU therapy 98% of patients were totally continent and 80% of patients retained sufficient erections for sexual intercourse. The majority of complications presented in the early postoperative period and were classified as low-grade., Conclusions: This review highlights that focal HIFU therapy appears to be a safe procedure, while short-term cancer control rate is encouraging. Though, second-line treatment or active surveillance seems to be necessary in a significant number of patients., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Purpose: Extraintestinal pathogenic Escherichia coli (ExPEC) are a leading cause of invasive infections in adults. The study aimed to evaluate the incidence of microbiologically confirmed invasive ExPEC disease in patients undergoing transrectal ultrasound-guided prostate needle biopsy (TRUS-PNB), O-serotype distribution and antibiotic resistance profiles of associated E. coli isolates., Materials and Methods: Adult men (≥18 years) undergoing TRUS-PNB were enrolled. The TRUS-PNB procedure was performed according to local standard of care, including preferences of prophylactic antibiotics. Clinical and microbiological data were collected., Results: Of the 4,951 patients (mean age 66.9 years) enrolled 4,935 (99.7%) underwent TRUS-PNB (95.1% received prophylactic antibiotics); 98.9% completed the study. Overall incidence of invasive ExPEC disease was 0.67% (33/4,935 patients; 95% CI 0.46-0.94); highest incidence was in the U.S. (0.97%, 14/1,446; 95% CI 0.53-1.62). Prevalence of the 10 selected O-serotypes O1, O2, O4, O6, O8, O15, O16, O18, O25 and O75 was 52.0% (95% CI 31.3-72.2). E. coli isolates showed highest resistance rates to levofloxacin and ciprofloxacin (76%; 95% CI 54.8-90.6 for both). Among fluoroquinolone-resistant ExPEC isolates, prevalence of the 10 selected O-serotypes was 60%., Conclusions: This study provides an estimate of microbiologically confirmed invasive ExPEC disease incidence following TRUS-PNB. Information on E. coli O-serotype distribution and associated antibiotic resistance profiles from invasive ExPEC disease cases in the first 30 days following TRUS-PNB may help guiding antibiotic use and inform development of a prophylactic ExPEC vaccine.

Background: High-intensity focused ultrasound (HIFU) is a novel therapy for prostate cancer. Owing to a lack of long-term data, HIFU is recommended for use only in the context of research., Objective: To examine the trend for HIFU use nationally and rates of strictures and fistulae., Design, Setting, and Participants: Patients undergoing HIFU for prostate cancer between April 2007 and March 2018 were studied in an English national database (Hospital Episode Statistics). Data on complications were included for patients with a minimum of 1-yr follow-up. Analysis of complications was controlled for other interventions., Outcome Measures and Statistical Analysis: Descriptive analyses of HIFU rates and the incidence of strictures and fistulae were carried out. Cox and logistic regression models were built for urethral stricture incidence., Results and Limitations: A total of 2320 HIFU treatments among 1990 patients were identified. The median age was 67yr (interquartile range 61-72). Some 1742 patients met the criteria for follow-up analysis. The highest-volume centre performed 1513 HIFU procedures, followed by 194 at the second highest. The number of HIFU procedures increased annually, rising from 196 to 283 per year. There were 208 patients (11.9%) who went on to have radiotherapy and 102 (5.9%) radical prostatectomy after HIFU. Following HIFU, stricture developed in 133/1290 patients (10.3%) and urinary fistula in 16/1240 (1.3%) before any further intervention. More recent years for HIFU were associated with a lower likelihood of stricture formation (2016/2017 vs 2007/2008: hazard ratio 0.30, 95% confidence interval 0.11-0.79; p=0.015). Limitations include the lack of staging information and unknown rates of HIFU outside of publicly funded health care., Conclusions: HIFU is performed at a large number of low-volume centres and complication rates do not differ from those for established therapies., Patient Summary: This report highlights the trend for provision of high-intensity focused ultrasound treatment for prostate cancer in England. The results suggest that the rate of urethral structural complications may not be lower than that for established prostate cancer treatments., (Copyright © 2019. Published by Elsevier B.V.)

High-intensity focused ultrasound (HIFU), a noninvasive ablation therapy that has been widely used clinically in ablation of solid tumors, induces immune sensitization. We therefore in this study investigated whether HIFU treatment could enhance the efficacy of a herpes simplex virus 2 (HSV-2) vaccine. First, we observed that in HSV-2-positive cervical intraepithelial neoplasia (CIN) II patients, HIFU treatment induced significantly higher anti-HSV-2 neutralization response than surgical removal. Next, we tested the efficacy of HIFU-treated, UV-inactivated HSV-2-infected cells as a proof-of-concept vaccine in mice. Our data showed that HIFU-treated formulation significantly enhanced HSV-2 antibody titers and neutralization titers, compared to UV-, microwave (MW)-, or freeze-thaw (FT)-treated formulations. HIFU treatment also promoted the Th1/2 cell-mediated response. A long-term full protection was observed in mice that received the HIFU-treated formulation, and no weight loss was detected. Our findings indicate that the novel application of HIFU in vaccine production may represent a rational way to improve vaccine efficacy. IMPORTANCE High-intensity focused ultrasound (HIFU) is mainly used in tumor ablation and tumor vaccinology study. It has been shown to induce immune sensitization and enhance tumor responsiveness to other therapies. Our study has shown enhanced anti-HSV-2 response in HIFU-treated CIN II patients. Furthermore, in a murine model, we have demonstrated that HIFU-treated HSV-2 vaccine induced long-term protective immunity against lethal challenge. Our findings indicate that the novel application of HIFU in vaccine production may represent a rational way to improve vaccine efficacy., (Copyright © 2020 Xiao et al.)

Objective: To prospectively compare the interobserver variability of combined transrectal ultrasound (TRUS)/computed tomography (CT)- vs. CT only- vs. magnetic resonance imaging (MRI) only-based contouring of the high-risk clinical target volume (CTV HR ) in image-guided adaptive brachytherapy (IGABT) for locally advanced cervical cancer (LACC)., Methods: Five patients with LACC (FIGO stages IIb-IVa) treated with radiochemotherapy and IGABT were included. CT, TRUS, and T2-weighted MRI images were performed after brachytherapy applicator insertion. 3D-TRUS image acquisition was performed with a customized ultrasound stepper device and software. Automatic applicator reconstruction using optical tracking was performed in the TRUS dataset and TRUS and CT images were fused with rigid image registration with the applicator as reference structure. The CTV HR (based on the GEC-ESTRO recommendations) was contoured by five investigators on the three modalities (CTV HR &#95;CT, CTV HR &#95;TRUS-CT, and CTV HR &#95;MRI). A consensus reference CTV HR &#95;MRI (MRIref) was defined for each patient. Descriptive statistics and overlap measures were calculated using RTslicer (SlicerRT Community and Percutaneous Surgery Laboratory, Queen's University, Canada), comparing contours of every observer with one another and with the MRIref., Results: The interobserver coefficient of variation was 0.18 ± 0.05 for CT, 0.10 ± 0.04 for TRUS-CT, and 0.07 ± 0.03 for MRI. Interobserver concordance in relation to the MRIref expressed by the generalized conformity index was 0.75 ± 0.04 for MRI, 0.51 ± 0.10 for TRUS-CT, and 0.48 ± 0.06 for CT. The mean CTV HR &#95;CT volume of all observers was 71% larger than the MRIref volume, whereas the mean CTV HR &#95;TRUS-CT volume was 15% larger., Conclusion: Hybrid TRUS-CT as an imaging modality for contouring the CTV HR in IGABT for LACC is feasible and reproducible among multiple observers. TRUS-CT substantially reduces overestimation of the CTV HR volume of CT alone while maintaining similar interobserver variability.

Transrectal ultrasound (TRUS)-guided systematic biopsy, the current gold standard for the detection of prostate cancer, suffers from low sensitivity for clinically significant cancer. The use of diagnostic multiparametric MRI has increased the relevance of targeted biopsy techniques such as MRI-TRUS fusion biopsy and direct (in-bore) MRI-guided biopsy, which have higher detection rate for clinically significant cancer. Although primarily used in patients who remain at high clinical suspicion for prostate cancer despite a negative systematic biopsy, with the increasing use of upfront diagnostic MRI, these biopsies are expected to replace routine systematic biopsies. This pictorial essay aims to enhance our understanding of the concepts of these biopsy techniques so that they can be performed safely and provide maximum diagnostic yield., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2020 The Korean Society of Radiology.)

Introduction: Modification of antibiotic prophylaxis prior to transrectal ultrasound-guided prostate biopsy (TRUSPB) based on pre-procedure rectal culture results is effective for prevention of infection from fluoroquinolone (FQ)-resistant and extended-spectrum beta-lactamase (ESBL) Escherichia coli strains. This has several implications for service delivery and cost. Our aim was to audit sepsis rates after introduction of ESBL screening and to identify risk factors for FQ resistance in ESBL strains and factors for sepsis risk., Methods: This was a prospective cohort study from 2013 to 2016. TRUSPB patients underwent pre-procedure rectal swabs. ESBL-positive patients received amikacin in addition to ciprofloxacin prophylaxis. Patients filled a formal risk assessment questionnaire prior to biopsy., Results: Sepsis rate after introduction of targeted prophylaxis reduced from 3.1% (2009-2012) to 1.4% (2013-2016). Of 38 ESBL patients, n = 5 (13%) developed severe post-TRUSPB sepsis. Among the FQ-resistant ESBL producers, the sepsis rate was 24%. Predictive factor for FQ resistance in ESBL producers included-antibiotic use in the last 3 months (OR 15). The logistic regression analysis did not identify any significant factor for post-TRUSPB sepsis in ESBL-positive patients once they had received additional prophylaxis., Conclusion: In the face of rising TRUSPB sepsis and higher sepsis rates with ESBL carriers despite additional prophylaxis, introduction of a targeted antibiotic prophylaxis prior to TRUSPB sepsis prostate biopsies based on rectal swabs or urine cultures may reduce sepsis rates or clinicians may find themselves leaning towards increasingly performing transperineal biopsies with lower sepsis rates supporting the 'trexit' initiative.

An increase or 'upgrade' in Gleason Score (GS) in prostate cancer following Transrectal Ultrasound (TRUS) guided biopsies remains a significant challenge to overcome. to evaluate whether MRI has the potential to narrow the discrepancy of histopathological grades between biopsy and radical prostatectomy, three hundred and thirty men treated consecutively by laparoscopic radical prostatectomy (LRP) between July 2014 and January 2019 with localized prostate cancer were included in this study. Independent radiologists and pathologists assessed the MRI and histopathology of the biopsies and prostatectomy specimens respectively. A multivariate model was constructed using logistic regression analysis to assess the ability of MRI to predict upgrading in biopsy GS in a nomogram. A decision-analysis curve was constructed assessing impact of nomogram using different thresholds for probabilities of upgrading. PIRADS scores were obtained from MRI scans in all the included cases. In a multivariate analysis, the PIRADS v2.0 score significantly improved prediction ability of MRI scans for upgrading of biopsy GS (p = 0.001, 95% CI [0.06-0.034]), which improved the C-index of predictive nomogram significantly (0.90 vs. 0.64, p < 0.05). PIRADS v2.0 score was an independent predictor of postoperative GS upgrading and this should be taken into consideration while offering treatment options to men with localized prostate cancer.

To explore the shape characteristics of ablation lesions created via laser ablation (LA), radiofrequency ablation (RFA) and microwave ablation (MWA) in canine prostates and the clinical significance of these characteristics, six adult male beagles were randomly assigned to the LA, RFA, and MWA groups. These ablations were performed with common parameters applied in clinical practice (LA, 3 W/1200 J; RFA and MWA, 30 W/120 s). One ablation lesion was created in each lobe of the prostate via the ablation technique, resulting in a total of twelve ablation lesions. Transrectal ultrasound (TRUS) was used as guidance during puncture and to monitor changes in the ablation lesions. Finally, the ablation efficacy was assessed using transrectal contrast-enhanced ultrasonography (CEUS), and the transverse diameter (TRD), anteroposterior diameter (APD) and longitudinal diameter (LD) of each ablation lesion were measured. The volume (V) and the ratio (R) value were calculated. R reflects the shape characteristic of the ablation lesion (the R value close to 1.0 indicates a more spherical shape). The R values of the ablation lesions were 0.89 ± 0.02, 0.72 ± 0.01, and 0.65 ± 0.03 for RFA, MWA and LA, respectively, and they were significantly different (P = 0.027). The volumes of the ablation lesions were 2.17 ± 0.10 ml, 1.51 ± 0.20 ml, and 0.79 ± 0.07 ml for MWA, LA and RFA, respectively, and they were also significantly different (P = 0.001). The three abovementioned thermal ablation techniques with common parameters in clinical practice can be used for ablation in the prostate. The shapes and volumes of the ablation lesions of the three techniques were varied: The RFA-created lesions had the lowest volumes and were more spherical in shape, demonstrating that RFA could be used for the treatment of relatively small lesions or tumours adjacent to vital organs. The MWA lesions had the largest size with a spherical shape, which could be advantageous for the ablation of tumours with relatively large sizes. The sizes of the ablation lesions created via LA were between those of RFA and MWA but presented more oval in shape, suggesting that this method is highly appropriate for the ablation of benign prostatic hyperplasia (BPH)., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To investigate focal therapy using High Intensity Focused Ultrasound (HIFU) for the treatment of localized prostate cancer (CaP), we analyzed the safety and complications of this procedure., Methods: Patients (pts) eligible for this multicenter prospective cohort study suffered from low to intermediate risk localized CaP with no prior treatment. After tumor identification on multiparametric MRI and in prostate biopsy, the lesions were treated with HIFU observing a safety margin of 8 to 10 mm. Adverse events (AE) after 30 and 90 days, as well as the required interventions were assessed and stratified for treatment localizations., Results: Of the 98 men included in the study in two European centers, 35 (35.7%) experienced AEs in the first 30 days after HIFU intervention with Clavien-Dindo grade ≤ II: 15 pts (15.3%) had a postoperative urinary tract infection and 26 pts (26.5%) a urinary retention. Four pts (4.1%) underwent subsequent intervention (Clavien-Dindo grade IIIa/b). The number of late postoperative complications occurring between 30 and 90 days after intervention was low (2.0%). The highest complication rate was associated with tumors located at the anterior base (50.0%). The inclusion of the urethra in the ablation zone led to AEs in 20 out of 41 cases (48.8%) and represented a significant risk factor for complications within 30 days (odds ratio = 2.53; 95% confidence interval: 1.08-5.96; P = 0.033)., Conclusions: Focal therapy of CaP lesions with a robotic HIFU-probe is safe and renders an acceptable rate of minor early AEs. The inclusion of the urethra in the ablation zone leads to an increase in early complications and should be avoided whenever possible., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: To determine the efficacy and safety of a periprostatic nerve block combined with perineum subcutaneous anaesthesia and intrarectal lidocaine gel for transrectal ultrasound-guided transperineal prostate biopsy (TPBx) through a prospective randomised controlled trial., Methods: In total, 216 patients from May 2018 to November 2018 were randomly assigned to the experimental group and the control group at a ratio of 1:1. The experimental group received a periprostatic nerve block combined with subcutaneous perineal anaesthesia and intrarectal lidocaine gel. The control group received total intravenous anaesthesia. A visual analogue scale (VAS) score (0-10) was used to evaluate pain at different stages. The operative time, duration of hospitalisation, intraoperative vital signs, perioperative complications and clinicopathological features were recorded., Results: The overall detection rate of prostate cancer was 40.74%, and the median Gleason score was 8 for all patients diagnosed with prostate cancer. No significant differences in terms of detection rates, Gleason scores and ISUP/WHO Grade Groups were found between the two groups (P > 0.05). The experimental group had no pain or just met the criteria for mild pain during the biopsy, which was significantly alleviated after the biopsy, and had a shorter operation time compared with that of the control group (P < 0.05). Compared with the control group, the experimental group had more stable haemodynamics and respiratory status and fewer surgical complications (P < 0.05)., Conclusions: In multiple aspects, a periprostatic nerve block combined with subcutaneous perineal anaesthesia and intrarectal lidocaine gel is a safer and more efficient approach to local anaesthesia for TPBx that can almost replace total intravenous anaesthesia and is worthwhile applying in the clinical setting.

Objectives: To estimate the impact of peri-prostatic fat (PPF) measurements using preoperative magnetic resonance imaging on the prediction of prostate cancer (PCa) with transrectal ultrasound-guided biopsy., Patients and Methods: We performed a retrospective 2-center study on 660 consecutive patients receiving transrectal ultrasound-guided biopsy-biopsy from June 2016 to October 2018. Pathologic and immunohistochemical characteristics were collected. PPF measurements including PPF area (PPFA) and PPFA to prostate area (PA) ratio (PPFA/PA) were assessed by preoperative staging magnetic resonance imaging. Clinical variables were correlated with Gleason score by using Spearman (ρ) correlation coefficients. Multivariable analysis was performed to identify independent predictors of PCa. The diagnostic performance was estimated using ROC curves., Results: The Gleason score was significantly correlated with age (ρ = 0.114, P = 0.035), prostate-specific antigen (PSA) (ρ = 0.482, P < 0.001), PIRADS scoring (ρ = 0.403, P < 0.001) and PPFA/PA (ρ = 0.238, P < 0.001). Multivariate analysis revealed that PPFA/PA, age, digital rectal examination, family history of PCa, PSA, and PIRADS scoring were independently predictive of PCa. The ROC AUC to detect PCa or clinically significant PCa (CS-PCa; Gleason Score 3 + 4 or greater) improved with the addition of PPFA/PA (PCa: 0.93 vs. 0.89; CS-PCa: 0.92 vs. 0.90)., Conclusion: PPFA/PA is an independent predictor for PCa along with age, digital rectal examination, family history of PCa, PSA, and PIRADS scoring. PPF measurements especially PPFA/PA may help detect PCa or CS-PCa, thus helping improve PCa risk stratification and screening to avoid unnecessary biopsies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Context: Recent studies suggested that magnetic resonance imaging (MRI) followed by targeted biopsy ("MRI-stratified pathway") detects more clinically significant prostate cancers (csPCa) than the systematic transrectal ultrasound-guided prostate biopsy (TRUS-Bx) pathway, but controversy persists. Several randomized clinical trials (RCTs) were recently published, enabling generation of higher-level evidence to evaluate this hypothesis., Objective: To perform a systematic review and meta-analysis of RCTs comparing the detection rates of csPCa in the MRI-stratified pathway and the systematic TRUS-Bx pathway in patients with a suspicion of prostate cancer (PCa)., Evidence Acquisition: PubMed, EMBASE, and Cochrane databases were searched up to March 18, 2019. RCTs reporting csPCa detection rates of both pathways in patients with a clinical suspicion of prostate cancer were included. Relative csPCa detection rates of the MRI-stratified pathway were pooled using random-effect model. Study quality was assessed using the Cochrane risk of bias tool for randomized trials. A comparison of detection rates of clinically insignificant PCa (cisPCa) and any PCa was also performed., Evidence Synthesis: Nine RCTs (2908 patients) were included. The MRI-stratified pathway detected more csPCa than the TRUS-Bx pathway (relative detection rate 1.45 [95% confidence interval {CI} 1.09-1.92] for all patients, and 1.42 [95% CI 1.02-1.97] and 1.60 [95% CI 1.01-2.54] for biopsy-naïve and prior negative biopsy patients, respectively). Detection rates were not significantly different between pathways for cisPCa (0.89 [95% CI 0.49-1.62]), but higher in the MRI-stratified pathway for the detection of any PCa (1.39 [95% CI 1.05-1.84])., Conclusions: The MRI-stratified pathway detected more csPCa than the systematic TRUS-guided biopsy pathway in men with a clinical suspicion of PCa, for both biopsy-naïve patients and those with prior negative biopsy. The detection rate of any PCa was higher in the MRI-stratified pathway, but not significantly different from that of cisPCa., Patient Summary: Our meta-analysis of clinical trials shows that the magnetic resonance imaging-stratified pathway detects more clinically significant prostate cancers than the transrectal ultrasound-guided prostate biopsy pathway in men with a suspicion of prostate cancer., (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To report the oncological and functional outcomes of salvage hemiablation high-intensity focused ultrasound (HIFU) in patients with unilateral radio-recurrent prostate cancer., Patients and Methods: Patients with biochemical recurrence (BCR) after primary radiation therapy and evidence of unilateral organ confined recurrence based on a complete match between mpMRI and MRI targeted biopsies were included. Patients with distant metastasis were excluded. Patients were followed with serial serum PSA determinations. BCR were defined using the Phoenix criteria. Complications were graded according to the Clavien score. IIEF-5 questionnaire was used to assess erectile dysfunction. Urinary incontinence was reported using physician reported rates., Results: A total of 10 consecutive patients (median age: 71 years, IQR: 69-76) were prospectively enrolled. The median pre-treatment PSA and post-treatment PSA nadir were 3.1ng/mL (IQR: 1.54-8.59) and 1.52ng/mL (IQR: 0.76-2.2), respectively. At a median follow-up of 41.5 (IQR: 18-58) months, 50% of patients experience BCR. BCR free-survival rates at 24 and 36 months were 75% (CI95%: 31-93) and 60% (CI95%: 20-85), respectively. Urinary in continence grade II occurred in two patients and the remaining patients were pad-free. One patient developed de novo erectile dysfunction requiring PDE5I. The erectile function scores decreased from a mean of 10.1 to 8.7., Conclusion: Hemiablation HIFU is an alternative to whole gland therapy in patients with unilateral radio- recurrent prostate cancer, which offers limited urinary and rectal morbidity, and preserves functional outcomes., Level of Evidence: 3., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Objective: To study the feasibility of transvesical prostate resection and its effect on urethral stricture., Materials and Methods: We included 99 patients with symptomatic bladder outlet obstruction who underwent transvesical resection of prostate (TVRP; n = 48) and transurethral (TURP; n = 51) prostatectomy. We examined all the patients by means of digital rectal examination, transrectal ultrasound, and evaluated them by international prostate symptom score, quality of life score, uroflowmetric assessment and PSA level, and established definitive diagnosis. We followed up the patients in first month, third month, and the first year of the operation and monitored once a year in the following years., Results: In this study, totally 99 symptomatic bladder outlet obstruction patients were included (TVRP = 48 and TURP = 51). Mean age of the patients were 66.5 ± 8.2vs 68 ± 9.8years for our patients with TVRP and TURP, respectively. Two groups displayed similar values in terms of improvements in the Qmax and PVR, and there were no statistically significant differences in between. We obtained similar values for resection time and weight of resected prostate tissue in both groups. Urethral stricture was not observed in TVRP group. In TURP group however, stricture was observed in 4 (7.8%) patients in bulbar urethra in sixth month at average. And there was also a concomitant urethral meatal stricture in one of these patients. When the 2 groups were compared, the rate of urethral stricture was statistically significantly higher in the TURP group (P = .001)., Conclusion: Resection of prostate without using urethra significantly reduces the incidence of urethral stricture due to mucosal damage., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: To assess factors that can predict active surveillance (AS) failure on serial transrectal ultrasound guided biopsies in patients with low-risk prostate cancer., Methods: We evaluated the records of 144 consecutive patients enrolled in AS between 2007 and 2014 at a single academic institution. Low risk inclusion criteria included PSA < 10 ng/ml, cT1c or cT2a, Grade Group (GG) 1, < 3 positive cores, and < 50% tumor in a single core with the majority having a PSA density of < 0.15. AS reclassification was defined as progression to GG ≥2, 3 or more cores, or core tumor volume ≥ 50%. Univariate and multivariate Cox proportional hazards regression analysis was used to determine predictors of reclassification and a match-pair analysis performed on a control group of patients choosing surgery., Results: Inclusion criteria were met by 130 men with a median follow-up of 52 months. The reclassification or AS failure rate was 38.5%, with the majority 41/50 (82%) finding GG ≥ 2 cancer. Most patients had unilateral disease on diagnostic biopsy (94.6%), but 40.7% had bilateral cancer detected during follow-up. Men with bilateral detected tumor were more likely to ultimately fail AS than patients with unilateral tumors (HR 4.089; P < 0.0001) and failed earlier with a reclassification-free survival of 32 vs 119 months respectively. In a matched-pair analysis using a population of 211 concurrent patients that chose radical prostatectomy rather than AS, 76% of patients with unilateral cancer on biopsy had bilateral cancer on final pathology., Conclusions: The finding of bilateral prostate cancer on biopsy is associated with earlier AS reclassification. Finding bilateral disease may not represent disease progression, but rather enhanced detection of more extensive disease highlighting the importance of confirmatory biopsy.

Background: To overcome the limitations regarding two dimensional (2D) greyscale (GS) transrectal ultrasound (TRUS)-guided biopsy in prostate cancer (PCa) detection and tissue packaging in biopsy processing, there is an ongoing focus on new imaging and pathology techniques. A three-dimensional (3D) model of the prostate with biopsy needle guidance can be generate by the Navigo™ workstation (UC-care, Israel). The SmartBX™ system (UC-care, Israel) provides a prostate biopsy core preembedding method. The aim of this study was to compare cancer detection rates between the 3D TRUS-guidance and preembedding method with conventional 2D GS TRUS-guidance among patients undergoing prostate biopsies., Methods: We retrospectively analyzed the records of all patients who underwent prostate biopsies for PCa detection at our institution from 2007 to 2016. The cohort was divided into a 2D GS TRUS-guidance cohort (from 2007 to 2013, n = 1149) and a 3D GS TRUS-guidance with preembedding cohort (from 2013 to 2016, n = 469). Effect of 3D GS TRUS-guidance with preembedding on detection rate of PCa and clinically significant PCa (Gleason score ≥ 7 or > 2 biopsy cores with a Gleason score 6) was compared to 2D GS TRUS-guidance using regression models., Results: Detection rate of PCa and clinically significant PCa was 39.0 and 24.9% in the 3D GS TRUS cohort compared to 33.5 and 19.0% in the 2D GS TRUS cohort, respectively. On multivariate regression analysis the use of 3D GS TRUS-guidance with preembedding was associated with a significant increase in detection rate of PCa (aOR = 1.33; 95% CI: 1.03-1.72) and clinically significant PCa (aOR = 1.47; 95% CI: 1.09-1.98)., Conclusion: Our results suggest that 3D GS TRUS-guidance with biopsy core preembedding improves PCa and clinically significant PCa detection compared to 2D GS TRUS-guidance. Additional studies are needed to justify the application of these systems in clinical practice.

Objective: The aim of this study was to evaluate the value of computed tomography (CT) in determining total prostate volume (TPV), as an alternative to transrectal ultrasonography (TRUS) when TRUS is not available., Methods: The patient cohort included patients who underwent both CT and TRUS within a 3-month interval from January 2012 to December 2013 at a single institution. In all, 67 non-contrast and 217 contrast-enhanced CT images were reviewed twice by 3 independent observers 2 months after the initial evaluation. Prostate length and width were measured on axial images and height was measured on sagittal images. To compare differences between CT and TRUS in TPV estimation, the CT/TRUS ratio of TPV was calculated and a Bland-Altman plot was constructed. Inter- and intraobserver variabilities and the effect of contrast enhancement were also evaluated statistically., Results: The mean (± SD) age of patients was 64.5 ±10.8 years and the mean time interval between CT and TRUS was 16.3 ± 22.6 days. The mean TRUS-measured TPV was 44.7 ± 24.9 mL and the mean CT/TRUS TPV ratio was 0.80 ± 0.20, indicating that TPV estimated by CT is 20% lower than that determined by TRUS, regardless of contrast enhancement (P > .05). The mean difference in TPV between TRUS and CT was 11.3 ± 14.3 mL, with differences of 1.7, 9.9, and 32.9 mL for prostate volumes of ≤30, >30-60, and >60 mL, respectively. Interobserver variability was excellent (r > 0.9), whereas intraobserver variability was very good (r > 0.7)., Conclusion: CT is a reliable method for prostate volume measurement and is well correlated with TRUS. Although CT estimates of TPV are 20% lower than those obtained using TRUS, CT can be used as an alternative to TRUS when TRUS is not available., (© 2018 John Wiley & Sons Australia, Ltd.)

Background: Prostate HistoScanning (PHS) is a tissue characterization system used to enhance prostate cancer (PCa) detection via transrectal ultrasound imaging., Objective: To assess the impact of supplementing systematic transrectal biopsy with up to three PHS true targeting (TT) guided biopsies on the PCa detection rate and preclinical patient assessment., Design, Setting, and Participants: This was a prospective study involving a cohort of 611 consecutive patients referred for transrectal prostate biopsy following suspicion of PCa. PHS-TT guided cores were obtained from up to three PHS lesions of ≥0.5cm 3 per prostate and only one core per single PHS lesion. Histological outcomes from a systematic extended 12-core biopsy (Bx) scheme and additional PHS-TT guided cores were compared., Outcome Measurements and Statistical Analysis: Comparison of PHS results and histopathology was performed per sextant. The χ 2 and Mann-Whitney test were used to assess differences. Statistical significance was set at p<0.05., Results and Limitations: PHS showed lesions of ≥0.5cm 3 in 312 out of the 611 patients recruited. In this group, Bx detected PCa in 59% (185/312) and PHS-TT in 87% (270/312; p<0.001). The detection rate was 25% (944/3744 cores) for Bx and 68% (387/573 cores) for PHS-TT (p<0.001). Preclinical assessment was significantly better when using PHS-TT: Bx found 18.6% (58/312) and 8.3% (26/312), while PHS-TT found 42.3% (132/312) and 20.8% (65/312) of Gleason 7 and 8 cases, respectively (p<0.001). PHS-TT attributed Gleason score 6 to fewer patients (23.4%, 73/312) than Bx did (32.4%, 101/312; p=0.0021)., Conclusions: Patients with a suspicion of PCa may benefit from addition of a few PHS-TT cores to the standard Bx workflow., Patient Summary: Targeted biopsies of the prostate are proving to be equivalent to or better than standard systematic random sampling in many studies. Our study results support supplementing the standard schematic transrectal ultrasound-guided biopsy with a few guided cores harvested using the ultrasound-based prostate HistoScanning true targeting approach in cases for which multiparametric magnetic resonance imaging is not available., (Copyright © 2017 European Association of Urology. All rights reserved.)

Objective: To analyse the functional and oncologic outcomes at one year of focal therapy with HIFU compared with total prostatectomy in patients with localised prostate cancer (PCa)., Patients and Methods: Retrospective and monocentric study from 2008 to 2014 comparing 2 cohorts of patients with localised PCa (T1/T2 clinical stage, Gleason score≤3+4=7 and PSA<15ng/mL), one treated by focal therapy (HIFU-F group), one by robot-assisted total prostatectomy (RATP group). Primary outcome was a trifecta defined as: absence of urinary incontinence, erectile function with sexual relations without treatment, negative PSA with negative surgical margins (RATP group) or negative biopsy cores (HIFU-F group)., Results: The 53 patients included in the "HIFU-F" group and the 66 patients in the "RATP" group were similar in terms of preoperative PSA, D'Amico risk group, erectile function but were different in terms of age, prostatic volume, length of cancer, Gleason score. Complication rate was not different. In multivariate analyse with propensity score, "HIFU-F" group achieved a better trifecta score than "RATP" group (OR=8,3, p=0,005)., Conclusion: In case of low or intermediate risk localised PCa, "HIFU-F" group had better functional outcomes than initial learning curse "RATP" group, at one year. A long-term evaluation by a common endpoint is necessary to judge the oncological equivalence of both techniques., Level of Evidence: 3., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background: Clinically significant nonmetastatic prostate cancer (PCa) is currently treated using whole-gland therapy. This approach is effective but can have urinary, sexual, and rectal side effects., Objective: To report on 5-yr PCa control following focal high-intensity focused ultrasound (HIFU) therapy to treat individual areas of cancer within the prostate., Design, Setting, and Participants: This was a prospective study of 625 consecutive patients with nonmetastatic clinically significant PCa undergoing focal HIFU therapy (Sonablate) in secondary care centres between January 1, 2006 and December 31, 2015. A minimum of 6-mo follow-up was available for599 patients. Intermediate- or high-risk PCa was found in 505 patients (84%)., Intervention: Disease was localised using multiparametric magnetic resonance imaging (mpMRI) combined with targeted and systematic biopsies, or transperineal mapping biopsies. Areas of significant disease were treated. Follow-up included prostate-specific antigen (PSA) measurement, mpMRI, and biopsies., Outcome Measurements and Statistical Analysis: The primary endpoint, failure-free survival (FFS), was defined as freedom from radical or systemic therapy, metastases, and cancer-specific mortality., Results and Limitations: The median follow-up was 56 mo (interquartile range [IQR] 35-70). The median age was 65 yr (IQR 61-71) and median preoperative PSA was 7.2 ng/ml (IQR 5.2-10.0). FFS was 99% (95% confidence interval [CI] 98-100%) at 1 yr, 92% (95% CI 90-95%) at 3 yr, and 88% (95% 85-91%) at 5 yr. For the whole patient cohort, metastasis-free, cancer-specific, and overall survival at 5 yr was 98% (95% CI 97-99%), 100%, and 99% (95% CI 97-100%), respectively. Among patients who returned validated questionnaires, 241/247 (98%) achieved complete pad-free urinary continence and none required more than 1 pad/d. Limitations include the lack of long-term follow-up., Conclusions: Focal therapy for select patients with clinically significant nonmetastatic prostate cancer is effective in the medium term and has a low probability of side effects., Patient Summary: In this multicentre study of 625 patients undergoing focal therapy using high-intensity focused ultrasound (HIFU), failure-free survival, metastasis-free survival, cancer-specific survival, and overall survival were 88%, 98%, 100%, and 99%, respectively. Urinary incontinence (any pad use) was 2%. Focal HIFU therapy for patients with clinically significant prostate cancer that has not spread has a low probability of side effects and is effective at 5 yr., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Focal therapy for prostate cancer (PCa) remains experimental. Aim of the current study is to review available evidence and perform a pooled analysis exploring oncologic and functional results of high intensity focus ultrasound (HIFU) focal therapy for the treatment of unilateral PCa., Methods: The National Library of Medicine Database was searched for relevant articles. A wide search was performed, including the combination of following words: "HIFU," "prostate," "cancer," and "focal." Overall, 167 articles were reviewed. Of these, seven articles were identified and eligible for the pooled analysis. Data on HIFU hemiablation or focal prostate ablation, oncologic and functional results were pooled from these seven studies that included 366 men with unilateral PCa., Results: In the 366 analyzed cases, mean age was 67 years (95% confidence interval 66-69), and mean preoperative prostate-specific antigen was 6.4 ng/cc (5.5-7.4). Three studies included PCa up to Gleason 7 (3 + 4), three studies did include also Gleason 7 (4 + 3), whereas one study had no limitation in terms of Gleason score. Regarding early complications, low-grade Clavien-Dindo I-II were reported in 26% (16-37), whereas high-grade Clavien-Dindo ≥III were found in 3.8% (0-8.6). Analyzing oncologic outcomes mean follow-up was 26 months (23-31): at one year after HIFU, negative biopsy rate for clinically significant PCa was 87% (79-96), whereas salvage treatment-free survival rate was 92% (85-98). Regarding functional outcomes, reported potency rates were 74% (64-84), and continence 96% (91-100), although definitions of potency and continence were not homogenous across studies., Conclusions: This pooled analysis of the results of focal HIFU treatment of PCa shows promising oncologic and functional outcomes. Well-selected patients may be candidates for such a conservative partial treatment of the gland. Well-designed trials are awaited to compare HIFU focal treatment with current standard of care.

Background: Prostate cancer (PCa) is the most common cancer in men in the UK. Patients with intermediate-risk, clinically localised disease are offered radical treatments such as surgery or radiotherapy, which can result in severe side effects. A number of alternative partial ablation (PA) technologies that may reduce treatment burden are available; however the comparative effectiveness of these techniques has never been evaluated in a randomised controlled trial (RCT)., Objectives: To assess the feasibility of a RCT of PA using high-intensity focused ultrasound (HIFU) versus radical prostatectomy (RP) for intermediate-risk PCa and to test and optimise methods of data capture., Design: We carried out a prospective, multicentre, open-label feasibility study to inform the design and conduct of a future RCT, involving a QuinteT Recruitment Intervention (QRI) to understand barriers to participation., Setting: Five NHS hospitals in England., Participants: Men with unilateral, intermediate-risk, clinically localised PCa., Interventions: Radical prostatectomy compared with HIFU., Primary Outcome Measure: The randomisation of 80 men., Secondary Outcome Measures: Findings of the QRI and assessment of data capture methods., Results: Eighty-seven patients consented to participate by 31 March 2017 and 82 men were randomised by 4 May 2017 (41 men to the RP arm and 41 to the HIFU arm). The QRI was conducted in two iterative phases: phase I identified a number of barriers to recruitment, including organisational challenges, lack of recruiter equipoise and difficulties communicating with patients about the study, and phase II comprised the development and delivery of tailored strategies to optimise recruitment, including group training, individual feedback and 'tips' documents. At the time of data extraction, on 10 October 2017, treatment data were available for 71 patients. Patient characteristics were similar at baseline and the rate of return of all clinical case report forms (CRFs) was 95%; the return rate of the patient-reported outcome measures (PROMs) questionnaire pack was 90.5%. Centres with specific long-standing expertise in offering HIFU as a routine NHS treatment option had lower recruitment rates (Basingstoke and Southampton) - with University College Hospital failing to enrol any participants - than centres offering HIFU in the trial context only., Conclusions: Randomisation of men to a RCT comparing PA with radical treatments of the prostate is feasible. The QRI provided insights into the complexities of recruiting to this surgical trial and has highlighted a number of key lessons that are likely to be important if the study progresses to a main trial. A full RCT comparing clinical effectiveness, cost-effectiveness and quality-of-life outcomes between radical treatments and PA is now warranted., Future Work: Men recruited to the feasibility study will be followed up for 36 months in accordance with the protocol. We will design a full RCT, taking into account the lessons learnt from this study. CRFs will be streamlined, and the length and frequency of PROMs and resource use diaries will be reviewed to reduce the burden on patients and research nurses and to optimise data completeness., Trial Registration: Current Controlled Trials ISRCTN99760303., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 22, No. 52. See the NIHR Journals Library website for further project information., Competing Interests: Ray Fitzpatrick is a member of the Health Technology Assessment Priority Research Advisory Methods Group. Richard Hindley has received payments for lecturing and proctoring for SonaCare Medical (Charlotte, NC, USA; high-intensity focused ultrasound treatment). Hashim U Ahmed reports grants and personal fees from SonaCare Medical and grants from Trod Medical (Heverlee, Belgium) and Sophiris Bio Inc. (La Jolla, CA, USA) outside the submitted work.

Objectives: Magnetic resonance imaging/transrectal ultrasound (MRI/TRUS) fusion-guided focal high intensity focused ultrasound (HIFU) therapy of the prostate has recently been developed as a selective HIFU-therapy technique to enable targeted ablation of prostate cancer. Here we report a series of patients treated with focal HIFU therapy, discuss its potential pitfalls, and address controversies concerning the indications., Materials and Methods: This single-center prospective study reports outcomes of patients treated from September 2014 to March 2016. Follow-up was a minimum of 12 months. MRI/TRUS-fusion-guided HIFU was performed under general anesthesia using the Focal One® device (EDAP, France). A control biopsy at 12 months was taken using the MRI/TRUS-fusion biopsy platform Artemis™ (Eigen, California) combining targeted and systematic cores. Prostate-specific antigen (PSA) changes from baseline, patient-reported outcome measures, and complications using the Clavien-Dindo classification system are also reported., Results: Twenty-four patients (PSA < 10 ng/ml, n = 17 Gleason 3+3, n = 7 Gleason 3+4) with either unifocal or bifocal prostate imaging reporting and data system (PI-RADS) 3-5 lesions (n = 19) or without a PI-RADS lesion (n = 5) were treated. Nineteen patients underwent focal HIFU, five patients zonal HIFU. Of the 20 patients that had biopsies at 12 months, 8 patients had a positive biopsy within the ablation zone (overall cancer free rate: 60%). Using different definitions of clinically significant cancer, the cancer-free rate for the ablation zone varies between 75% and 95%. Four of the eight patients (all persistent Gleason 3+4 or upgrading to 4+3) underwent a radical whole gland salvage therapy. Patient-reported outcome measures showed no significant decrease in urinary continence (expanded prostate cancer index composite -26 urinary incontinence: P = 0.080), but there was a reduction in potency (International index of erectile function in preoperatively potent patients: median decrease of 2 points to a median of 19 points at 12 months; 95% confidence interval: 15.79-22.21; P = 0.044). Only one complication > grade II occurred., Conclusions: Targeted MRI/TRUS fusion-guided focal HIFU allows local tumor ablation, but is not free from limitations. The procedure has good functional outcomes and a quick recovery. Multicenter trials with more patients are required to determine the procedure´s role in the prostate cancer therapy algorithm., (Copyright © 2018. Published by Elsevier Inc.)

Purpose of Review: Contrast-enhanced transrectal ultrasound (CeTRUS) is an emerging imaging technique in prostate cancer (PCa) diagnosis and treatment. We review the utility and implications of CeTRUS in PCa focal therapy (FT)., Recent Findings: CeTRUS utilizes intravenous injection of ultrasound-enhancing agents followed by high-resolution ultrasound to evaluate tissue microvasculature and differentiate between benign tissue and PCa, with the latter demonstrating increased enhancement. The potential utility of CeTRUS in FT for PCa extends to pre-, intra- and post-operative settings. CeTRUS may detect PCa, facilitate targeted biopsy and aid surgical planning prior to FT. During FT, the treated area can be visualized as a well-demarcated non-enhancing zone and continuous real-time assessment allows immediate re-treatment if necessary. Following FT, the changes on CeTRUS are immediate and consistent, thus facilitating repeat imaging for comparison during follow-up. Areas suspicious for recurrence may be detected and target-biopsied. Enhancement can be quantified using time-intensity curves allowing objective assessment and comparison. Based on encouraging early outcomes, CeTRUS may become an alternative imaging modality in prostate cancer FT. Further study with larger cohorts and longer follow-up are needed.

Introduction: Prostate cancer is one of the most common types of cancer in men. The gold standard for the detection of prostate cancer is ultrasound guided transrectal prostate biopsy. The detectability of cancer using this method is from 30 to 50%. As a result, many men undergo multiple repeat biopsies for suspected prostate cancer. The European Association of Urology does not give any recommendations on this matter. A revolutionary new method in the diagnosis of prostate cancer is a targeted prostate biopsy using a fusion of multiparametric magnetic resonance imaging (MRI) and ultrasound., Materials and Methods: At the R.M. Fronstein Clinic of Urology, 55 patients with suspected prostate cancer from September 2017 to January 2018 underwent fusion prostate biopsy. Of them, 21 patients had negative primary biopsies. Two patients had verified prostate cancer. 32 patients did not undergo primary biopsies., Results: The findings of the study suggest that using MRI-ultrasound fusion for guidance of targeted prostate biopsy improves the quality of the histological material, allows patients to avoid unnecessary biopsy, reduces the number of punctures, thereby offering higher diagnostic performance in detecting prostate cancer. MRI-ultrasound fusion targeted biopsy has a high sensitivity in detecting clinically significant cancer and low for clinically insignificant cancers., Conclusion: The technique affords accurate detection of the location and extent of pathological lesions in the prostate thus allowing focal therapy for prostate cancer.

Aims and Objectives: To assess the effects of three different bowel preparation methods on the incidence of infectious complications in patients who underwent transrectal ultrasonography-guided prostate biopsy., Background: The standard bowel preparation protocol for prostate biopsy has not been established., Design: A retrospective study in a single centre., Methods: From January 2013-December 2015, the clinical records of 1,130 patients who underwent prostate biopsy were, respectively, reviewed. All the patients received metronidazole prophylaxis before biopsy. The patients were divided into three groups according to the bowel preparation methods: patients in Group A (n = 402) received only soapy enema; patients in Group B (n = 413) received polyethylene glycol; while patients in Group C (n = 315) received polyethylene glycol plus povidone-iodine enema. Infectious complications were classified as fever (>37.5°C), urinary tract infection and sepsis. The postoperative adverse events were also observed., Results: The overall postbiopsy infectious complications were observed in 48 (4.25%) patients of all the cases, including 23 (5.72%) cases in Group A, 20 (4.84%) cases in Group B and five patients (1.59%) in Group C. There was significant difference among the groups (p = .018). In detail, these infectious complications included 22 (1.95%) cases of fever and 26 (2.30%) cases of urinary tract infection. No sepsis was observed among the total patients. The incidence of adverse events was 14.43% (58/402) occurred in Group A, 25.91% (107/413) in Group B and 26.67% (84/315) in Group C. The difference was statistically significant., Conclusions: Our study confirmed that combined preparation regimens of polyethylene glycol with povidone-iodine enema could significantly reduce the postbiopsy infection rate. Conventional soapy enema is associated with less adverse events., Relevance to Clinical Practice: Findings of this study provide useful evidence-based information for healthcare professionals. The application of combined preparation regimens of polyethylene glycol with povidone-iodine enema resulted in better improvement in the prevention of postbiopsy infection., (© 2017 John Wiley & Sons Ltd.)

Purpose: We aimed to investigate the efficiency and cancer detection of magnetic resonance imaging (MRI) / ultrasonography (US) fusion-guided prostate biopsy in a cohort of biopsy-naive men compared with standard-of-care systematic extended sextant transrectal ultrasonography (TRUS)-guided biopsy., Methods: From 2014 to 2016, 72 biopsy-naive men referred for initial prostate cancer evaluation who underwent MRI of the prostate were prospectively evaluated. Retrospective review was performed on 69 patients with lesions suspicious for malignancy who underwent MRI/US fusion-guided biopsy in addition to systematic extended sextant biopsy. Biometric, imaging, and pathology data from both the MRI-targeted biopsies and systematic biopsies were analyzed and compared., Results: There were no significant differences in overall prostate cancer detection when comparing MRI-targeted biopsies to standard systematic biopsies (P = 0.39). Furthermore, there were no significant differences in the distribution of severity of cancers based on grade groups in cases with cancer detection (P = 0.68). However, significantly fewer needle cores were taken during the MRI/US fusion-guided biopsy compared with systematic biopsy (63% less cores sampled, P < 0.001) CONCLUSION: In biopsy-naive men, MRI/US fusion-guided prostate biopsy offers equal prostate cancer detection compared with systematic TRUS-guided biopsy with significantly fewer tissue cores using the targeted technique. This approach can potentially reduce morbidity in the future if used instead of systematic biopsy without sacrificing the ability to detect prostate cancer, particularly in cases with higher grade disease.

Purpose: We evaluated focal therapy with high intensity focused ultrasound hemiablation in a prospective trial., Materials and Methods: We performed a prospective, multicenter, single arm study in patients with unilateral low/intermediate risk prostate cancer who were treated from April 2013 through March 2016 in Germany in AUO (Arbeitsgemeinschaft Urologische Onkologie) Study Protocol AP 68/11. Unilateral prostate cancer was assessed by transrectal ultrasound guided biopsy and multiparametric magnetic resonance imaging. Hemiablation was done using the Ablatherm® or the Focal One® device. The oncologic outcome was assessed by the salvage treatment rate, multiparametric magnetic resonance imaging and rebiopsy at 12 months. Functional outcome, quality of life, anxiety and depression were measured by validated questionnaires at baseline and every 3 months., Results: Of the 54 recruited patients 51 completed 12-month or greater visits. Mean ± SD followup was 17.4 ± 4.5 months. Mean prostate specific antigen decreased from 6.2 ± 2.0 to 2.9 ± 1.9 ng/ml at 12 months (p <0.001). Biopsy at 12 months was positive for any prostate cancer and for clinically significant prostate cancer in 13 (26.5%) and 4 (8.2%) of the 49 patients, respectively. Posttreatment multiparametric magnetic resonance imaging had limited 25% sensitivity for clinically significant prostate cancer. Ten patients (19.6%) underwent salvage treatment. Potency was maintained in 21 of the 30 men who were potent preoperatively. There was no increase in incontinence. Quality of life, anxiety and depression did not change postoperatively. The study was limited by a short followup and the lack of a control arm., Conclusions: Focal therapy hemiablation is safe with little alteration of functional outcome. The oncologic outcome is acceptable on short-term followup. Followup multiparametric magnetic resonance imaging performed poorly and should not replace repeat biopsy. Focal therapy has no impact on posttreatment anxiety and depression., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Imaging can benefit clinicians in evaluating men with infertility or sexual dysfunction by giving an overview of a patient's overall clinical condition before undertaking an invasive procedure. An understanding of the limitations and advantages of image modalities used in clinical practice will ensure that clinicians can optimize patient care with imaging when necessary. PATIENT SUMMARY: The objective of this article was to review the current literature on imaging modalities used for the diagnosis and management of male infertility and sexual dysfunction. An understanding of the advantages and limitations of these imaging modalities will ensure that clinicians can optimize patient care with imaging when necessary., (Copyright © 2018. Published by Elsevier B.V.)

Purpose: Patient selection for focal salvage remains difficult. Therefore, we developed and internally validated prediction models for biochemical failure (BF) and a composite endpoint (CE) following focal salvage high intensity focused ultrasound (HIFU) for radiorecurrent prostate cancer., Materials and Methods: A prospective HIFU registry identified 150 cases (November 2006-August 2015). Recurrence was assessed with multiparametric magnetic resonance imaging (MRI) combined with template prostate mapping biopsies, targeted biopsies, or systematic transrectal ultrasound-guided biopsies. Metastatic disease was ruled out with a positron emission tomography-computed tomography and a bone scan. Focal salvage HIFU consisted of quadrant-ablation, hemi-ablation, or index-lesion ablation. Cox-regression was used for BF (Phoenix-definition) and CE (BF/MRI+/biopsies+/local or systemic treatment/metastases+/prostate cancer specific mortality+). Internal validation was performed using bootstrap resampling (500 datasets) after which C-statistic and hazard ratios were adjusted. Models were calibrated and risk scores created., Results: Median follow-up was 35 months (interquartile range: 22-52). Median biochemical disease-free survival (DFS) was 33 months (95% CI: 23-45). Median CE-free survival was 24 months (95% CI: 21-35). After multivariable analysis, DFS interval after primary radiotherapy, presalvage prostate-specific antigen (PSA), PSA-doubling time, prostatic volume, and T-stage (both MRI based) predicted BF. For the CE, PSA-doubling time was not predictive but additionally, primary Gleason score was. The adjusted C-statistics were 0.68 and 0.64 for BF and CE, respectively. Calibration was accurate until 48 months. The risk scores showed 3 groups, with biochemical DFS of 60%, 35%, and 7% and CE-free survival of 40%, 24%, and 0% at 4 years., Conclusion: Our model, once externally validated, could allow for better selection of patients for focal salvage HIFU., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the ability of contrast-enhanced transrectal ultrasound (CETRUS) scanning for prostate cancer detection in different area, compared with conventional transrectal ultrasound (TRUS)., Methods: 228 patients underwent TRUS-guided prostate biopsy after examinations of TRUS and CETRUS scanning. Cancer detection between CETRUS and TRUS were compared by patient and by site in different areas (right, left; base, mid-gland, apex). The receiver operating characteristic (ROC) curve was plotted to evaluate the diagnostic performance of CETRUS., Results: 89 patients were malignant and 48 patients were significant cancer. Compared with TRUS, CETRUS could increase the detection rates of overall and significant cancer (P = 0.008; P = 0.031). CETRUS had higher sensitivity, specificity (except right lobe), accuracy, positive predictive value (PPV) and negative predictive value (NPV) in total, right and left lobe (P < 0.05). The sensitivity were greater for CETRUS in all areas except left base and right apex (P < 0.05). The accuracy were greater for CETRUS in all areas except left mid-gland and right apex (P < 0.05). ROC analysis showed CETRUS totally got the AUC of 0.816. The AUC was higher in left lobe than right lobe (0.837 vs. 0.793). It was most accurate at the base (0.833), then mid-gland (0.826), and lowest in apex (0.772)., Conclusions: CETRUS had a significant advantage over conventional TRUS for prostate cancer detection in different areas. CETRUS much more easily missed the cancer in apex, we must focus more on apex and may add other imaging modalities to improve the visualization and detection of prostate cancer.

Purpose To report the safety profile and 2-year functional outcomes of in-bore magnetic resonance (MR)-guided focused ultrasound on single cancer foci in men with prostate cancer. Materials and Methods Ethics approval was obtained from the centralized institutional review board for this prospective single-arm study, and patients provided informed consent. Patients with untreated low-volume low-grade prostate cancer (clinical stage T2a or lower; Gleason score, 3+3; index tumor ≤10 mm 3 ) underwent MR-guided focused ultrasound between July 2011 and February 2013. All patients underwent robotic transperineal mapping biopsy and multiparametric MR imaging. Only those with a maximum of two lesions smaller than 10 mm at mapping biopsy were included. Target areas were sonicated with real-time MR thermometry monitoring, excluding critical areas from the beam path. Serum prostate-specific antigen (PSA) and Expanded Prostate Index Composite (EPIC) scores were obtained at baseline and at 1, 3, 6, 12, 18, and 24 months and were plotted to observe their trend. Mean EPIC subdomain score changes at each serial time point were compared with the baseline score by using paired t tests (level of significance, P < .007). Repeat transperineal biopsy was performed at 6 and 24 months. Results Fourteen men (mean age, 62.8 years; median PSA level, 8.3 ng/mL) underwent treatment, with 12 men completing 2-year follow-up. A median reduction of PSA level by 2.9 ng/mL was observed at 6 months. Seven men had Clavien-Dindo grade 1-2 complications. There was a slight insignificant deterioration of EPIC urinary symptom score (mean increase of 7.8 points compared with baseline, P = .012) noted at 1 month, but it returned to baseline by 3 months. There was a trend to deterioration in sexual function score (mean decrease, 4.4 points; P = .04 [not significant]) that normalized at 3 months. There was no significant change in EPIC subdomain scores from baseline over the 24 months. At 6-month template biopsy, one man had cancer with a Gleason score greater than 6; at 24 months, three men had cancer with a Gleason score greater than 6. Conclusion MR-guided focused ultrasound is technically feasible for focal prostate ablation and appears to have a favorable early safety and functional profile. Further clinical trials are necessary to establish oncologic efficacy. © RSNA, 2017 Online supplemental material is available for this article.

Purpose: Advances in prostate imaging, biopsy and ablative technologies have been accompanied by growing enthusiasm for partial gland ablation, particularly using high-intensity focused ultrasound, to treat prostate cancer. Preserving noncancerous prostate tissue and minimizing damage to the neurovascular bundles and external urethral sphincter may improve functional outcomes., Materials and Methods: A systematic review was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using a combination of MeSH® terms, free text search and examination of relevant bibliographies using MEDLINE® and Embase® from the inception of each database through October 10, 2016. We excluded studies describing exclusively whole gland ablation, case reports and series where treatment was followed by immediate resection., Results: A total of 13 studies that enrolled 543 patients were included. Of the studies 11 were performed in the primary setting and 2 in the salvage setting. Median followup ranged from 6 months to 10.6 years. Rates of posttreatment erectile dysfunction and urinary incontinence ranged from 0% to 48% and 0% to 50%, respectively, with definitions varying by study. Overall there were 254 reported complications. Marked heterogeneity between studies limited the ability to pool results regarding functional and oncologic outcomes. A total of 76 patients (14%) subsequently received further oncologic treatment., Conclusions: Early evidence suggests that partial gland ablation is a safe treatment option for men with localized disease. Longer term data are needed to evaluate oncologic efficacy and functional outcomes, and will aid in identifying the optimal candidates for therapy. Standardization of outcomes definitions will allow for better comparison between studies and among treatment modalities., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Since the patient wanted both his lower urinary tract symptoms and his prostate cancer to be treated together, he decided to undergo robot-assisted radical prostatectomy., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

In magnetic resonance (MR)-targeted, 3-D transrectal ultrasound (TRUS)-guided biopsy, prostate motion during the procedure increases the needle targeting error and limits the ability to accurately sample MR-suspicious tumor volumes. The robustness of the 2-D-3-D registration methods for prostate motion compensation is impacted by local optima in the search space. In this paper, we analyzed the prostate motion characteristics and investigated methods to incorporate such knowledge into the registration optimization framework to improve robustness against local optima. Rigid motion of the prostate was analyzed adopting a mixture-of-Gaussian (MoG) model using 3-D TRUS images acquired at bilateral sextant probe positions with a mechanically assisted biopsy system. The learned motion characteristics were incorporated into Powell's direction set method by devising multiple initial search positions and initial search directions. Experiments were performed on data sets acquired during clinical biopsy procedures, and registration error was evaluated using target registration error (TRE) and converged image similarity metric values after optimization. After incorporating the learned initialization positions and directions in Powell's method, 2-D-3-D registration to compensate for motion during prostate biopsy was performed with rms ± std TRE of 2.33 ± 1.09 mm with ~3 s mean execution time per registration. This was an improvement over 3.12 ± 1.70 mm observed in Powell's standard approach. For the data acquired under clinical protocols, the converged image similarity metric value improved in ≥8% of the registrations whereas it degraded only ≤1% of the registrations. The reported improvements in optimization indicate useful advancements in robustness to ensure smooth clinical integration of a registration solution for motion compensation that facilitates accurate sampling of the smallest clinically significant tumors.

Background: Transrectal prostate biopsy has limited diagnostic accuracy. Prostate Imaging Compared to Transperineal Ultrasound-guided biopsy for significant prostate cancer Risk Evaluation (PICTURE) was a paired-cohort confirmatory study designed to assess diagnostic accuracy of multiparametric magnetic resonance imaging (mpMRI) in men requiring a repeat biopsy., Methods: All underwent 3 T mpMRI and transperineal template prostate mapping biopsies (TTPM biopsies). Multiparametric MRI was reported using Likert scores and radiologists were blinded to initial biopsies. Men were blinded to mpMRI results. Clinically significant prostate cancer was defined as Gleason ⩾4+3 and/or cancer core length ⩾6 mm., Results: Two hundred and forty-nine had both tests with mean (s.d.) age was 62 (7) years, median (IQR) PSA 6.8 ng ml (4.98-9.50), median (IQR) number of previous biopsies 1 (1-2) and mean (s.d.) gland size 37 ml (15.5). On TTPM biopsies, 103 (41%) had clinically significant prostate cancer. Two hundred and fourteen (86%) had a positive prostate mpMRI using Likert score ⩾3; sensitivity was 97.1% (95% confidence interval (CI): 92-99), specificity 21.9% (15.5-29.5), negative predictive value (NPV) 91.4% (76.9-98.1) and positive predictive value (PPV) 46.7% (35.2-47.8). One hundred and twenty-nine (51.8%) had a positive mpMRI using Likert score ⩾4; sensitivity was 80.6% (71.6-87.7), specificity 68.5% (60.3-75.9), NPV 83.3% (75.4-89.5) and PPV 64.3% (55.4-72.6)., Conclusions: In men advised to have a repeat prostate biopsy, prostate mpMRI could be used to safely avoid a repeat biopsy with high sensitivity for clinically significant cancers. However, such a strategy can miss some significant cancers and overdiagnose insignificant cancers depending on the mpMRI score threshold used to define which men should be biopsied.

Over the past 25 years, the average life expectancy for men has increased almost 4 years, and the age of prostate cancer detection has decreased an average of 10 years with diagnosis increasingly made at early-stage disease where curative therapy is possible. These changing trends in the age and extent of malignancy at diagnosis have revealed limitations in conventional curative therapies for prostate cancer, including a significant risk of aggressive cancer recurrence, and the risk of long-term genitourinary morbidity and its detrimental impact on patient's quality of life (QOL). Greater awareness of the shortcomings in radical prostatectomy, external radiotherapy, and brachytherapy has prompted the search for alternative curative therapies that offer comparable rates of cancer control and less treatment-related morbidity to better preserve QOL. High-intensity focused ultrasound (HIFU) possesses characteristics that make it an attractive curative therapy option. HIFU is a noninvasive approach that uses precisely delivered ultrasound energy to achieve tumor cell necrosis without radiation or surgical excision. In current urologic oncology, HIFU is used clinically in the treatment of prostate cancer and is under experimental investigation for therapeutic use in multiple malignancies. Clinical research on HIFU therapy for localized prostate cancer began in the 1990s, and there have now been ∼65,000 prostate cancer patients treated with HIFU, predominantly with the Ablatherm (EDAP TMS, Lyon, France) device. Neoadjuvant transurethral resection of the prostate has been combined with HIFU since 2000 to reduce prostate size, facilitate tissue destruction, and to minimize side effects. Advances in imaging technologies are expected to further improve the already superior efficacy and morbidity outcomes, and ongoing investigation of HIFU as a focal therapy in salvage and palliative indications is serving to expand the role of HIFU as a highly versatile noninvasive therapy for prostate cancer.

Objectives: Our aim was to assess whether magnetic resonance imaging (MRI) features predict recurrence-free survival (RFS) after prostate cancer high-intensity focused ultrasound (HIFU) ablation., Methods: We retrospectively selected 81 patients who underwent (i) whole-gland HIFU ablation between 2007 and 2011 as first-line therapy or salvage treatment after radiotherapy or brachytherapy, and (ii) pre- and postoperative MRI. On preoperative imaging, two senior (R1, R2) and one junior (R3) readers assessed the number of sectors invaded by the lesion with the highest Likert score (dominant lesion) using a 27-sector diagram. On postoperative imaging, readers assessed destruction of the dominant lesion using a three-level score. Multivariate analysis included the number of sectors invaded by the dominant lesion, its Likert and destruction scores, the pre-HIFU prostate-specific antigen (PSA) level, Gleason score, and the clinical setting (primary/salvage)., Results: The most significant predictor was the number of prostate sectors invaded by the dominant lesion for R2 and R3 (p≤0.001) and the destruction score of the dominant lesion for R1 (p = 0.011). The pre-HIFU PSA level was an independent predictor for R2 (p = 0.014), but with only marginal significance for R1 (p = 0.059) and R3 (p = 0.053)., Conclusion: The dominant lesion's size and destruction assessed by MRI provide independent prognostic information compared with usual predictors., Key Points: • The size of the MR-dominant lesion significantly influences post-HIFU recurrence-free survival. • The destruction score of the MR-dominant lesion predicts post-HIFU recurrence-free survival. • Patients with a completely devascularized MR-dominant lesion show better recurrence-free survival • Pre- and post-HIFU MRI provide prognostic information independent of usual predictors.