Single setting 3D MRI-US guided frozen section and focal cryoablation of the index lesion: proof of principle and initial series

==inizio abstract==

In this video we first report reliability of frozen section for the diagnosis of prostate cancer combined with a real time 3D focal cryoablation of the index lesion.
NaviGo system provided a real time 3D monitoring of the index lesion, while focal cryoablation is performed using the Endocare CryoCS. V-probes are used to tailor the ice ball size to the treatment area. Systematic prostate biopsy is performed to confirm absence of cancer outside the index lesion. Complications, functional and early oncologic outcomes are reported.
This initial report includes 3 patients with a clinical suspicious of prostate cancer based on PSA and a single MRI lesion with a PIRADS score 4 or 5. All patients denied consent to any radical treatment.
Prostate cancer diagnosis was histologically confirmed in all 3 patients by frozen sections. Postoperative course was uneventful and all patients were discharged on first postoperative day.
Mean PSA values decreased from 12.51 (baseline) to 1.72 ng/mL at 3-mo evaluation. Three-mo postoperative MRI images showed complete ablation of the index lesion in all patients.
Urinary continence and erectile function were preserved in all patients.
Achieving diagnosis and focal treatment of prostate cancer index lesion in a single session is a further step towards a minimally invasive and patient tailored approach.

==fine abstract==

The diagnostic and staging performance of mpMRI/US guided fusion prostate biopsy: prospective analysis on 41 consecutive whole mount radical prostatectomy specimens

==inizio objective==

The ultimate assessment of MRI/US diagnostic and staging performance requires a meticulous comparison of biopsy and whole mount radical prostatectomy specimens. In this study we assessed the diagnostic and staging performance of mpMRI/US fusion prostate biopsy comparing core biopsy findings with whole mount radical prostatectomy specimens in 41 consecutive patients treated in a single centre series.

==fine objective==

==inizio methodsresults==

Baseline, clinical and pathologic data of 41 consecutive patients with prostate cancer diagnosis at mp-MRI/US guided “fusion” biopsy who underwent minimally invasive radical prostatectomy and whole mount sections of pathologic specimens were prospectively collected.
All fusion biopsies were performed using the UroStation™ (Koelis, France) with an end-fire 3D TRUS transducer.
Diagnostic performance of MRI-US fusion biopsy was evaluated at different levels: 1. core biopsy correspondence with pathologic findings of whole mount sections; 2. Correct identification of the index lesion; 3. Gleason score upgrading at final pathology; 4. presence of extraprostatic extension and of nodal involvement.

==fine methodsresults==

==inizio results==

Out of 107 cases with positive fusion US/MRI guided prostate biopsy performed, fifty-nine patients underwent minimally invasive radical prostatectomy. Forty-one specimens were analyzed using whole mount sections. Clinical and pathologic data of this cohort are reported into Table 1.
Out of 41 patients, 25 (60.1%) had a clinically significant PCa not identified by MRI/US guided fusion biopsy. At a per core analysis 150/701 (21.4%) cores were positive for GS>6 out of the suspicious ROI at MRI.
The mean ratio of tumor foci/suspicious ROI was 0.56 ± 0.27.
The index lesion was correctly identified by mpMRI-US fusion biopsy in 63.4% (26/41) of the patients.
Gleason score of fusion US-MRI guided prostate biopsy was upgraded at final pathologic report in 9 (21.9%) cases.
The staging accuracy in predicting tumor side, extraprostatic extension and nodal involvement was 75.6% (31/41), 70.3 % (29/41) and 90.2% (37/41), respectively.

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

mpMRI and Fusion US/MRI guided prostate biopsy provided a reliable diagnostic and staging performance for patients receiving a surgical treament. Systematic core biopsy seems still to have a clinical role in detecting clinically significant PCa otherwise missed by MRI.

==fine conclusion==

==inizio reference==

-Multiparametric Magnetic Resonance Imaging (MRI) and MRI-Transrectal Ultrasound Fusion Biopsy for Index Tumor Detection: Correlation with Radical Prostatectomy Specimen.
Radtke JP, Schwab C, Wolf MB, Freitag MT, Alt CD, Kesch C, Popeneciu IV, Huettenbrink C, Gasch C, Klein T, Bonekamp D, Duensing S, Roth W, Schueler S, Stock C, Schlemmer HP, Roethke M, Hohenfellner M, Hadaschik BA.
Eur Urol. 2016 Nov;70(5):846-853. doi: 10.1016/j.eururo.2015.12.052.

==fine reference==

Diagnostic performance of multiparametric MRI in prostate cancer: per core analysis of three prospective ultrasound/MRI fusion biopsy datasets

==inizio objective==

The fusion of multiparametric (Mp) magnetic resonance imaging (MRI) with real time 3D ultrasound during prostate biopsy is gaining popularity. The aim of this study was to evaluate the diagnostic performance of Mp-MRI using a per-core analysis of patients who underwent prostate “fusion” biopsy.

==fine objective==

==inizio methodsresults==

Baseline, clinical and pathological data of 498 consecutive patients who underwent Mp-MRI/ultrasound “fusion” biopsy of prostate were prospectively collected in three centres between October 2013 and October 2016. The UroStation™ (Koelis, France) and ultrasound system with an end-fire 3D TRUS transducer were used for the imaging fusion process.
Diagnostic accuracy of Mp-MRI was evaluated in the whole cohort and in those patients with Gleason score >6, separately. Sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and accuracy (Ac) of Mp-MRI were assessed on the base of a per core analysis of histologic findings.

==fine methodsresults==

==inizio results==

Demographic data are reported into Table 1.
Out of 498 patients, 286 had a PCa diagnosis (57.4%); 162 of them (32.5%) were Gleason score ≥7. Overall, 9360 cores were taken: Se, Sp, PPV, NPV and Ac of Mp-MRI in the whole cohort were 46.5%, 81.7%, 36.6%, 87% and 75.2%, respectively. When restricting the analysis to Gleason scores >6, Se, Sp, PPV, NPV and Ac were 45.9%, 79.8%, 25.1%, 90.9% and 75.4%, respectively. In a per patient analysis, the detection rate of PI-RADS scores 3,4 and 5 were 24%, 68% and 93.6%, respectively, while for Gleason score PCa>6 the detection rate of PIRADS 3, 4 and 5 were 6%, 35.2% and 73.4%, respectively. In a per core analysis, the PPV of PI-RADS scores 3,4 and 5 were 8.5%, 37.8% and 73.2%, respectively, while the PPV of PI-RADS scores for Gleason score PCa>6 were 5.1%, 21.2% and 62.2%, respectively (Table 2).

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

This study confirmed high PCa detection rates with Mp-MRI-ultrasound fusion biopsy. A meticulous analysis of 9360 biopsy cores taken showed a poor sensitivity and PPV of Mp-MRI, especially for Gleason score >6 PCa. Despite the poor discrimination of PI-RADS scores of 3 and 4, PIRADS scores 5 correctly identified PCa lesions with Gleason scores >6.

==fine conclusion==

==inizio reference==

– Multiparametric Magnetic Resonance Imaging (MRI) and MRI-Transrectal Ultrasound Fusion Biopsy for Index Tumor Detection: Correlation with Radical Prostatectomy Specimen.
Radtke JP, Schwab C, Wolf MB, Freitag MT, Alt CD, Kesch C, Popeneciu IV, Huettenbrink C, Gasch C, Klein T, Bonekamp D, Duensing S, Roth W, Schueler S, Stock C, Schlemmer HP, Roethke M, Hohenfellner M, Hadaschik BA.
Eur Urol. 2016 Nov;70(5):846-853. doi: 10.1016/j.eururo.2015.12.052.

==fine reference==

A new technique for reconstruction of the bladder neck during Radical Prostatectomy

==inizio abstract==

The technique used for the bladder neck reconstruction during robotic assisted radical prostatectomy (RALP), can influence the continence rate. In this video we present a new technique we have adopted for the reconstruction of the bladder neck: this procedure belongs from gastrointestinal surgery and it is used to close bowel anastomosis according to the technique described by Gambee or O’ Conell. This technique consists in a single-layer through-and-through anastomosis: the suture goes from serous to mucosal surface, back into the mucosa on the same side of the incision, out into the middle of the cut surface to be approximated, across the incision into the wound edge opposite, down into gut lumen, back through the mucosa and through the wall to the serous surface and a tie with the tail of the suture across the incision. This technique allows to create a bladder neck more similar to the native one if compared with the anterior tennis racket technique and may lead to improved functional outcomes. An improved and more accurate reconstruction of the bladder neck may lead to more favourable functional outcome, this particular technique has never been utilized before to reconstruct the bladder neck. Urologists should consider to adopt it to increase the early continence rate. 


==fine abstract==

STRATEGICAL IMPLICATIONS OF THE INTRODUCTION OF AN ALTERNATIVE TREATMENT MODALITY (HIGH INTENSITY FOCUS ULTRASOUND) IN A PROSTATE CANCER UNIT IN THE CONTEXT OF MULTIDISCIPLINARY TEAM

==inizio objective==

The critical evaluation of a new modality of treatment which employs a new technology has to be considered in the context of “Health Technology Assessment” (HTA). This analysis lead to documents whose utility is essential both for National Health System and the stakeholders, i.e. subjects who are interested in the technology itslef and who can judge it from different point of view, varying from costs to clinical references. We considered the introduction of an alternative treatment modality, i.e. High Intensity Focused Ultrasound (HIFU) in the context of the Prostate Cancer Unit (PCU) in Our centre.
PCU is a multi-disciplinary team (MDT) constituted by an Urologist, a Medical Oncologist and a Radiation Oncologist, who manage almost 100 case of prostate cancer (PCa) per year, according to the position paper of European School of Oncology. The capacity of offering to the patients the ordinary therapies and also alternatives, due to clinical experience of the Centre, plays a fundamental role for the correct management of PCa. The aim of the present study was to contextualize the results of the analysis among the strategies of MTD, also evaluating the social impact.

==fine objective==

==inizio methodsresults==

We analyzed the patients affected by prostate cancer, who were all evaluated by MTD in 2015.
For the purpose of the study, we considered only low risk patients, according to Epstein’s criteria. The available therapeutic alternatives in Our Centre were: radical prostatectomy (open or robotic) (RRP), radiation therapy (RT), active surveillance (AS) and HIFU.
We compared our experience with those reported in literature, searching for the key words: “multidisciplinary team”, “ prostate cancer “ and “High Intensity Focused Ultrasound”.

==fine methodsresults==

==inizio results==

In our Centre 360 patients with PCa were evaluated by PCU in 2015.
During the same year we executed 500 prostate biopsy, among these 146 pts were affected by low risk Pca
The partion of patients according to chosen treatment modality is described in table 1.

==fine results==

==inizio discussions==

SEE RESULTS AND TABLE 1

==fine discussions==

==inizio conclusion==

Different treatment modalities may be offered to the patients after the diagnosis of PCa; obviously, every alternative may have both physical and psychological side-effects, all significantly impact on the quality of life. The management of the patient in the context of MDT may change, especially regarding therapy itself; this is due to the fact the decisions of the MTD are applicable and reproducible, according to the internal guide-lines followed by all the members. Our MTD follows data literature, especially regarding the orientation towards AS and RT. Additionally, patients tend to chose RT during the PCU visits.
There are no available data about the impact of MTD on survival, or about a correlation between the MTD and a improvement of the outcome of the patients. Nevertheless, a clear idea about the overall survival of the single treatment modality may lead to a more simple choose by the patients. In this context, we could not have certainties, because of the too recent follow up as well as the recent introduction of PCU in Our Center.

==fine conclusion==

==inizio reference==

1. Pillay B, Wootten AC, Crowe H, Corcoran N, Tran B, Bowden P, Crowe J, Costello AJ. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Cancer Treat Rev 2016; 42:56-72.

2. Valdagni R.. Multidisciplinary Team Meetings in Cancer Care: We Could and Should do Better Than This. Clin Oncol (R Coll Radiol) 2016;28(12):799-800

3. Ramsay CR, Adewuyi TE, Gray J, Hislop J, Shirley MD, Jayakody S, MacLennan G, Fraser C, MacLennan S, Brazzelli M, N’Dow J, Pickard R, Robertson C, Rothnie K, Rushton SP, Vale L, Lam TB. Ablative therapy for people with localised prostate cancer: a systematic review and economic evaluation. Health Technol Assess 2015 19(49):1-490.

==fine reference==

Robot assisted nerve sparing radical prostatectomy using near infrared fluorescence technology and Indocyanine Green: initial experience

==inizio objective==

The use of Indocyanine green (ICG) with near infrared (IR) fluorescence is a consolidated technology to visualize edge lesions in laparoscopic robot-assisted nephron sparing surgery and is actually used in robotic assisted partial nephrectomy. Instead, we propose the use of the ICG with near IR fluorescence during laparoscopic robot assisted radical prostatectomy (RARP), to identify and improve the preservation of neurovascular bundle and the hemostasis.

==fine objective==

==inizio methodsresults==

From April, 2015 to February, 2016, 62 patients underwent to RARP in our Urology Unit. In 26 of these, in the attempt to have a better visualization of neurovascular bundles, we used to inject ICG during the procedure, as described below. After the bladder neck incision and seminal vescicles dissection, we injected 1,25ml of ICG. Then we proceeded to bilateral pedicles resection only after the visualization of arterious vessels location, through IR technology. Just after the visualization with IR technology, the dissection was performed by non electrified scissors and Hem-o-lok Ligation System, with non IR visualization. Subsequently we evaluated post operative continence, defined by the suspension of pads within six months from RARP.

==fine methodsresults==

==inizio results==

Starting from 10 seconds after the injection of ICG we visualized the arterial structure using near IR fluorescence technology, and progressively we could obtain an optimal highlighting of neurovascular bundles.
This procedure is useful to easily dissect lateral pedicles and control arterial flow and hemostasis, specially for those of us that started robotic surgery only few months ago. We easily identified prostatic arteries and neurovascular bundles using near IR fluorescence technology in all patients (100%). Then, we performed the dissection alternating IR (picture) and non IR view for each patient .
There wasn’t any increase in the operative time compared to RARP without ICG injection performed by the same surgeons. Complications related to injection of ICG did not occurred. In the follow up 24 patients (92.3 %) were continent and two patients (7,7%) were still using pad after six months from surgery.

==fine results==

==inizio discussions==

We use IR green technology to perform meticulous nerve sparing RARP. This expedient helps to improve nerve sparing technique and hemostasis. It let us also to minimize the risk to damage neurovascular bundles, both for experienced robotic surgeon, and for urologists that are just approaching the robotic technology, obtaining a high continence rate within six months after surgery.

==fine discussions==

==inizio conclusion==

In our experience the application of ICG with near IR fluorescence during RARP could be useful in preserving the neurovascular bundle without any complication.

==fine conclusion==

==inizio reference==

==fine reference==

Does RALP learning curve impact on patients’ outcomes?

==inizio objective==

RALP learning curve is associated with long operating times, inferior operatory and post-operatory outcomes and an increased number of complications.
We report the initial results of 80 RALP procedures performed in our Institute , with the introduction of a new surgeon laparoscopically trained that followed a modular structured program.
The aim of this study is to evaluate if our approach to training would yield a safer outcomes for patients undergoing the procedure during the learning curve.

==fine objective==

==inizio methodsresults==

From 06.2015 to 06.2016 a new surgeon began a training program in RALP. He was open and laparoscopically trained . RARP procedure was splitted into steps: opening peritoneum and bladder takedown ( 5 cases) , endopelvic fascia and bladder neck (12 cases), seminal vesicle/vas deferens (15 cases), pedicle/nerve sparing and apex (12 cases), posterior dissection and posterior bladder neck transection ( 15 cases), anastomosis with reconstruction as described by Porpiglia (10 cases), lymphadenectomy ( according to guidelines)( 11 cases) . In all procedure the training surgeon performed a single step of RALP under supervision of an experienced preceptor. Consolle time and perioperative variables were compared to 80 surgeon-only cases.

==fine methodsresults==

==inizio results==

The median surgical time was not significantly different between the two cohort of patients (160 min vs 150 min; p NS) . The median estimated blood loss was 200 ml. There was no difference in positive margins , length of stay , catheter days , readmission . There were 2 complications Clavien II(anemia that required blood transfusion) and 6 Clavien IIIa (5 drainage for lymphocele and 1 urinary leakage), no conversions nor transfusions. The median hospital stay was 3 days. The median catheterization time was 7 days. The biochemical recurrence-free survival rate (PSA < 0.01 ng/ml) was 94 % over an average follow-up of 6 months. The continence rates were (no pad) 70 % within 3 months and 90 % within 6 months with no difference between the two group. ==fine results== ==inizio discussions== The introduction of a new surgeon in robotic team and the impact of learning curve on oncological, functional and perioperative outcomes is actually object of debate; as confirmed by the raising of studies focused on modality of teaching RALP. Like most of studies reported in literature, we splitted RALP in steps but in our clinical practice the training surgeon performed just one step in each procedure, even if he had already completed the learning curve of other steps, with the aim of not impact on surgical time and focus attention in the step in-training. Similarly to our study, Schommer [1] et al splitted the procedure in steps and they examined perioperative outcomes of resident involvement during various steps of robot-assisted radical prostatectomy (RARP) concluding that supervised resident console involvement did not affect perioperative outcomes, although, it prolongs surgical time, with the bladder takedown step having the most effect. Wang et al [2] reported that a new surgeon joining a high-volume robotic prostatectomy program with an established robotic team and mentorship can progress through the learning curve without compromising overall outcomes of the practice. Lovegrove et al [3] developed and validated a modular training and assessment pathway via Healthcare Failure Mode and Effect Analysis (HFMEA) for trainees undertaking RARP and evaluate learning curves for procedural steps. The RARP Assessment Score based on HFMEA methodology identified critical steps for focused RARP training and assessed surgeons. They reported the experience necessary to reach a level of competence in technical skills to protect patients: 16 cases for anterior bladder neck transection , 18 cases for posterior bladder neck transection , 9 cases for posterior dissection , 15 cases for dissection of prostatic pedicle and seminal vesicles and 17 cases for anastomosis . In our experience the learning curve of the new surgeon was shorter, this may be caused by his previous large experience in open surgery , laparoscopy and table surgeon in about 300 RALP. This hypothesis may be confirmed by Ku et al [4] ; indeed they reported that previous large-volume experience of laparoscopic radical may shorten the learning curve for RARP in terms of oncological outcome as well as , previous experience with laparoscopy may improve the functional outcomes of RARP. As far as surgical team experience overall is concerned, an experienced surgical team, in general, and the surgeon assistant in particular are believed to play a critical role in the operation's safety and success; anyway as Abu- Ghanem [5] showed, the assistant's seniority has no influence on perioperative course following RALP. Consequently, given a highly experienced primary surgeon, a less experienced assistant can be safely incorporated into this procedure. Obviously, whenever disposable, a dual-console system may improve intraoperative and perioperative outcomes , representing a safe and more efficient modality for robotic surgical education as compared to a single-console system , as reported by Morgan et al [6]. ==fine discussions== ==inizio conclusion== The implementation of a training program in which the trained surgeon is involved in at least one portion of RARP allowed us to overcome the initial learning curve with no difference in perioperatory outcomes, oncological and functional results . ==fine conclusion== ==inizio reference== 1. Schommer E, Tonkovich K, Li 2, Thiel DD. “ Impact of Resident Involvement on Robot-Assisted Radical Prostatectomy Outcomes”. J Endourol. 2016 Oct;30(10):1126-1131. 2. Wang L, Diaz M, Stricker H, Peabody JO, Menon M, Rogers CG. “Adding a newly trained surgeon into a high-volume robotic prostatectomy group: are outcomes compromised?” J Robot Surg. 2016 Jun 27. 3. Lovegrove C, Novara G, Mottrie A, Guru KA, Brown M, Challacombe B, Popert R, Raza J, Van der Poel H, Peabody J, Dasgupta P, Ahmed K. “Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment”. Eur Urol. 2016 Mar;69(3):526-35. 4. Ku JY, Ha HK.”Learning curve of robot-assisted laparoscopic radical prostatectomy for a single experienced surgeon: comparison with simultaneous laparoscopic radical prostatectomy”. World J Mens Health. 2015 Apr;33(1):30-5 5. Abu-Ghanem Y, Erlich T, Ramon J, Dotan Z, Zilberman DE. “Robot assisted laparoscopic radical prostatectomy: assistant's seniority has no influence on perioperative course”. J Robot Surg. 2016 Nov 9. 6. Morgan MS1, Shakir NA, Garcia-Gil M, Ozayar A, Gahan JC, Friedlander JI, Roehrborn CG, Cadeddu JA. “ Single- versus dual-console robot-assisted radical prostatectomy: impact on intraoperative and postoperative outcomes in a teaching institution” . World J Urol. 2015 Jun;33(6):781-6. ==fine reference==

ECONOMICAL IMPLICATIONS OF THE INTRODUCTION OF AN ALTERNATIVE TREATMENT MODALITY FOR PROSTATE CANCER (HIGH INTENSITY FOCUS ULTRASOUND) IN A MULTIDISCIPLINARY TEAM

==inizio objective==

The critical evaluation of a new modality of treatment which employs a new technology has to be considered in the context of “Health Technology Assessment” (HTA). This analysis lead to documents whose utility is essential both for National Health System and the stakeholders, i.e. subjects who are interested in the technology and who can judge it according different point of view, varying from costs to clinical references. We analyzed the economic impact of the introduction of an alternative treatment modality, i.e. High Intensity Focused Ultrasound (HIFU) in the context of the Prostate Cancer Unit (PCU) in Our centre.
The PCU is a multidisciplinary team (MDT), constituted by an Urologist, a Medical Oncologist and a Radiation Oncologist, who manage almost 100 case of prostate cancer (PCa) per year, according to the position paper of European School of Oncology. The capacity of offering to the patients both the common and the alternative treatment modalities, related to clinical experience of the Centre, plays a fundamental role for the correct management of patients with PCa.

==fine objective==

==inizio methodsresults==

We retrospectively analyzed all the patients affected by Pca and evaluated by PCU during 2015. We selected low risk patients, according to Epstein’s criteria.
Thus, we calculated and compared the costs of the four treatment modalities available in Our Centre for these pts: active surveillance according to PRIAS (AS) , radical prostatectomy (open –RRP- or robotic –RARP-), radiation therapy [3D-conformational (3D-CRT), Imaging Modulated Radiation Therapy (IMRT), Volumetric Modulated Arc Therapy (VMAT), with or without markers] and HIFU.
We also reviewed the literature searching for the following key words: “prostate cancer”, “active surveillance”, “prostatectomy”, “ radiation therapy” , “HIFU” and “costs”.

==fine methodsresults==

==inizio results==

In our Centre 360 patients with PCa were evaluated by PCU in 2015.
During the same year we executed 500 prostate biopsy, among these, 146 pts were affected by low risk PCa.
The partition of patients, according to chosen treatment modality, is described in table 1.
Table 2 evidences the costs of every treatment modality.

==fine results==

==inizio discussions==

See results

==fine discussions==

==inizio conclusion==

RT represents the most frequent treatment modality for low risk PCa in Our Centre. The costs are intermediate between AS (considering the whole time of 7 years) and the robotic surgery (8000 €, 8300 € e 12000 €, respectively). According to both literature and clinical experience of other centers, the RARP showed the highest costs. The literature review about HIFU did not evidence any study about the efficacy; consequently we focuses on costs only, which are inferior to other treatments, including RRP.

==fine conclusion==

==inizio reference==

1. Pillay B, Wootten AC, Crowe H, Corcoran N, Tran B, Bowden P, Crowe J, Costello AJ. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Cancer Treat Rev 2016; 42:56-72.
2. Valdagni R.. Multidisciplinary Team Meetings in Cancer Care: We Could and Should do Better Than This. Clin Oncol (R Coll Radiol) 2016;28(12):799-800

3. Ramsay CR, Adewuyi TE, Gray J, Hislop J, Shirley MD, Jayakody S, MacLennan G, Fraser C, MacLennan S, Brazzelli M, N’Dow J, Pickard R, Robertson C, Rothnie K, Rushton SP, Vale L, Lam TB. Ablative therapy for people with localised prostate cancer: a systematic review and economic evaluation. Health Technol Assess 2015 19(49):1-490.

==fine reference==

SALVAGE HIGH INTENSITY FOCUS ULTRASOUND (HIFU) FOLLOWING PRIMARY HIFU FOR PROSTATE CANCER HAS TO BE CONSIDERED AS AN ALTERNATIVE TREATMENT FOR RECURRENCE

==inizio objective==

Recurrent disease following primary high intensity focus ultrasound (HIFU) for localized prostate cancer (PCa)  is possible but nothing about this field is described in literature. Theoretical therapeutic options may include salvage prostatectomy, salvage radio-therapy,  hormonal therapy, observation and salvage HIFU.

==fine objective==

==inizio methodsresults==

We report our experience with three patients with PCa treated with HIFU and retreated with HIFU because of local recurrence. We also reviewed the literature, searching for the key words: “Prostate Cancer Recurrence”, “Focal Therapy”, “High Intensity Focus Ultrasound” and “Salvage Therapy”.

==fine methodsresults==

==inizio results==

Case 1. 69 year-old man, treated with trans-urethral resection of prostate (TURP) and HIFU because of prostate adenocarcinoma (ADK) Gleason 3 + 3, PSA 3.07 ng/mL. There were no short- or long term complications. PSA progressively increased during years after the procedure, until it reaches 5.94 ng/mL. He executed a Coline PET-CT with evidence of captation in the right lobe. A multi- parametric Magnetic Resonance Imaging documented a lesion with diameters pf 15 X 9 X 13 mm, in right median paramedian zone, with PI-RADS 5. Thus, the patient executed HIFU only in the right lobe. There were no short- or long term complications. The man described only mild urgency. The last PSA was 0.47 ng/mL, 20 months after the salvage HIFU.
Case 2. 64 year-old man, treated with trans-urethral resection of prostate (TURP) and HIFU because prostate ADK Gleason 3 + 3, PSA 2.98 ng/mL. Additionally, the pathological report after TURP evidenced a prostate ADK Gleason 3 + 3 in the transitional zone, in < 5% of the specimens. There were no short- or long term complications. Six years after the first HIFU the patient executed a prostate biopsy, with a PSA of 0,57 ng/mL. The pathological report documented a single core with prostate ADK Gleason 3 + 3, located in a different zone of the prostate comparing with the first biopsy. There were no short- or long term complications. The last PSA was 0.93 ng/mL, 26 months after the salvage HIFU. Case 3. 60 year-old man, treated with HIFU because prostate ADK Gleason 3 + 3, PSA of 6,4 ng/mL. The man reported significant pain during micturion and recurrent prostatitis; thus he used the sovrapubic catheter during 2 moths after the procedure. 48 months after HIFU,PSA was 1,28 ng/mL. Thus, the patient executed a second biopsy, with diagnosis of prostate ADK Gleason 4 + 4 in the left lobe. He executed salvage HIFU, describing urgency during the following months. 12 months after the second HIFU PSA was 4,05 ng/mL. Thus he underwent Imaging Modulated RadioTherapy with a total dose of 70 Gy. The last PSA was 2,38, with a colice CT-PET without recurrence. He is still in follow-up, still reporting urgency. No androgenic blockade was administered in all the cases. ==fine results== ==inizio discussions== SEE RESULTS ==fine discussions== ==inizio conclusion== Salvage HIFU is a feasible and therapeutic option for PCa recurrence after primary HIFU, with no or mild complications. It should be considered for patients who refuse surgery or radiotherapy, or for who with contraindications for androgenic blockade. More trials are necessary to confirm these preliminary data. ==fine conclusion== ==inizio reference== NONE ==fine reference==

Urinary continence outcomes after peri-urethral suspension according to Patel during Robot Assisted Laparoscopic Radical Prostatectomy (RALP). Results from a case-control study

==inizio objective==

Technical variations of RALP have been proposed by different authors to improve urinary continence with conflicting results, due to the persistence of multiple adjunctive factors such as bladder neck sparing and the patient or disease characteristics. The aim of the present study was to determine the effects of peri-urethral suspension according to Patel on a cohort of consecutive patients who underwent RALP for clinically localized prostate cancer.

==fine objective==

==inizio methodsresults==

Two-hundred and thirty patients who previously underwent RALP were recalled by telephone and subsequently investigated by PSA testing , ultrasound post-voiding residual urine measurement and specifically designed questionnaire to investigate their quality of life and the effects of surgery on urinary continence. 174 of them responded to the telephone recall and were eligible for the study while 56 were considered as drop out (2 deceased for unrelated diseases, 51 refused to respond the questionnaire). 81 out 174 received PUS with polyglecaprone 3-0 suture prior of Van Velthoven vesico-urethral anastomosis ( Group 1) while 93 out 174 received a standard vesico-urethral polyglecaprone 3-0 suture according to Van Velthoven (Group 2). Statistical analysis was performed by Fisher Exact test.

==fine methodsresults==

==inizio results==

Patients presented comparable preoperative characteristics in both groups except for prostate volume, which had a median value greater than 40 cc in 95.3% of Group 1 in comparison to 80.8% in the Group 2 (p<0.001). Pathological analysis demonstrated comparable distribution of progression risk in both groups but a significantly higher number of T3 patients in the control group ( 13.3% vs. 25.6%) (p=0.02). Positive surgical margin rate was comparable between the two groups. Sixty-nine percent of patients in the Group 1 were immediately and totally continent after the urethral catheter removal as well as after a median follow up of 23±17.4 months (period 2011-2016) while only 48.3% in the Group 2 were continent with a median follow up of 30±22.1 months (period 2009-2016). Socially acceptable continence (no pads or a single safety pad a day) was found in 92.58% of the Group 1 and 79.56 of the Group 2 patients respectively (p=0.003). Severe incontinence was found in 4.9% and 15% of the Group 1 and 2 respectively. ==fine results== ==inizio discussions== ==fine discussions== ==inizio conclusion== Periurethral suspension according to Patel during RALP resulted in a statistically significant shorter interval to continence recovery and higher continence rate at a median 23 months follow up time. ==fine conclusion== ==inizio reference== ==fine reference==