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To prospectively determine the value of post-MRI micro-ultrasonography (microUS) in the diagnosis of transition zone (TZ) significant prostate cancer (sPCa).Eighty-four consecutive men (66 ± 6.3 years) with a mean PSA level of 10.2 ± 7.4 ng/mL and at least one TZ-PI-RADS2 lesion were included. All patients had MRI-directed microUS and biopsy. Sensitivity and specificity of post-MRI microUS to visualize PI-RADS2 TZ lesions, the cancer detection rate of TZ-sPCa, and tumor characteristics according to their visibility on microUS were evaluated. Interreader agreement for detecting microUS+ lesions was evaluated using Cohen's kappa test.Of the 92 PI-RADS2 lesions, 71 (71/92; 77%) were visible on microUS and biopsy was performed without image fusion, which was required for the 21 invisible lesions (21/92; 22.8%). TZ-sPCa detection rate was 51.1% (47/92). Sensitivity and specificity of MRI-directed microUS were 83% (39/47; 95% CI: 69.2-92.4%) and 28.9% (13/45; 95% CI: 16.4-44.3%), on a per-lesion basis and 86.4% (38/45; 95% CI: 72.6-94.8%) and 27.5% (11/40; 95% CI: 14.6-43.9%) on a per-patient basis. Visible tumors on microUS exhibited a larger volume and a lower mean ADC value than non-visible tumors (15.8 ± 5.1 vs. 12.5 ± 3.6 mm and 0.82 ± 1.1 × 10MRI-targeted transrectal microUS is effective to detect TZ-sPCa. TRUS-MRI image fusion helps overcome limitations due to TZ tissue heterogeneity.microUS can visualize the majority of MRI-detected PI-RADS2 TZ lesions (sensitivity = 83%). Interreader agreement of MRI-directed microUS in the detection of TZ lesions appears excellent (kappa = 0.88). In 77% of PI-RADS2 TZ lesions, biopsy was performed under microUS visual control. MRI fusion system was only used to overcome limitations due to tissue heterogeneity of benign prostatic hyperplasia.

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

International audience; Robust data evaluating the association of preoperative parameters of the patients with quality of life after radical prostatectomy are lacking. We investigated whether clinical and biological preoperative characteristics of the patients were associated with impaired patient-reported quality of life (QoL) and sexual outcomes 1 year after radical prostatectomy. We evaluated patient-reported outcomes among the 1343 men participating in the AndroCan trial (NCT02235142). QoL and erectile dysfunction (ED) were assessed before and 1 year after radical prostatectomy using validated self-assessment questionnaires (Aging Male’s Symptoms [AMS] and the 5-item abridged version of the International Index of Erectile Function [IIEF5]). At baseline, 1194 patients (88.9%) accepted to participate. A total of 750 (55.8%) patients answered the 1-year postoperative questionnaires. Out of them, only 378 (50.4% of responders) provided answers that could be used for calculations. One year after prostatectomy, ED had worsened by 8.0 (95% confidence interval [CI]: 7.3–8.7; P< 0.0001) out of a maximum of 20. The global AMS score has worsened by 2.8 (95% CI: 1.7–3.8; P < 0.0001). ED scores 1 year postsurgery were positively correlated with preoperative age and percentage of fat mass, and negatively correlated with total cholesterol, dehydroepiandrosterone (DHEA), and androstenediol (D5); AMS were poorly correlated with preoperative parameters. QoL and sexual symptoms significantly worsened after radical prostatectomy. Baseline bioavailable testosterone levels were significantly correlated with smaller changes on AMS somatic subscores postprostatectomy. These findings may be used to inform patients with newly diagnosed prostate cancer.

Failure rates after first-line treatment of localized prostate cancer (PCa) treatment remain high. Improvements to patient selection and identification of at-risk patients are central to reducing mortality. We aimed to determine if cancer aggressiveness correlates with androgen levels in patients undergoing radical prostatectomy for localized PCa. We performed a prospective, multicenter cohort study between June 2013 and June 2016, involving men with localized PCa scheduled to undergo radical prostatectomy. Clinical and hormonal patient data (testosterone deficiency, defined by total testosterone (TT) levels

Objective To determine the predictors of early, intermediate and late biochemical recurrence (BR) following minimally invasive radical prostatectomy in patients with localized prostate cancer (PC). Material and methods We included 6195 patients with cT1-3N0M0 prostate cancer treated using radical laparoscopic prostatectomy (RLP) and radical robot-assisted prostatectomy at our institution between 2000 and 2016. None of the patients underwent adjuvant therapy. BR is defined as PSA levels ≥0.2 ng/dL. The time to BR is divided into terciles to identify the variables associated with early ( 36 months) recurrence. We employed logistic regression models to determine the risk factors associated with each interval. Results We identified 1148 (18.3%) patients with BR. The median time to BR was 24 months (IQR, 0.98–53.18). The multivariate analysis showed that preoperative PSA levels, lymph node invasion, positive margins and RLP are associated with early recurrence (p ≤ 0.029 for all). Laparoscopic surgery was the only predictor of intermediate recurrence (p = 0.001). The predictors of late recurrence included a pathological Gleason score ≥7, stage ≥pT3, positive margins and RLP (p ≤ 0.02 for all). Conclusions The patients with high-risk prostate cancer can develop late recurrence and require long-term follow-up. Identifying patients with higher PSA levels and lymph node invasion has an important predictive role in the first year after surgery. The association between RLP and BR warrants further assessment.

Iatrogenic recto-urinary fistulas are a disastrous complication of therapeutic interventions on the prostate. Many surgical approaches have been described to repair recto-urinary fistulas and no consensus has been reached regarding the better approach. The objective of this study is to present the results of our updated 20-year experience in the surgical management of recto-urinary fistula using a modified York Mason procedure. We proceed to a retrospective single-institution review of surgically treated patients for iatrogenic recto-urinary fistulas between 1998 and 2017 by the modified York Mason technique. Descriptive analysis of our population was performed. Continuous and categorical variables were compared using Mann–Whitney and Fischer tests, respectively. All tests were two-sided with a significance level set at p value

Background Radical prostatectomy (RP) has been used as the main primary treatment for prostate cancer (PCa) for many years with excellent oncologic results. However, approximately 20-40% of those patients has failed to RP and presented biochemical recurrence (BCR). Prostatic specific antigen (PSA) has been the pivotal tool for recurrence diagnosis, but there is no consensus about the best PSA threshold to define BCR until this moment. The natural history of BCR after surgical procedure is highly variable, but it is important to distinguish biochemical and clinical recurrence and to find the correct timing to start multimodal treatment strategy. Also, it is important to understand the role of each clinical and pathological feature of prostate cancer in BCR, progression to metastatic disease and cancer specific mortality (CSM). Review design A simple review was made in Medline for articles written in English language about biochemical recurrence after radical prostatectomy. Objective To provide an updated assessment of BCR definition, its meaning, PCa natural history after BCR and the weight of each clinical/pathological feature and risk group classifications in BCR, metastatic disease and CSM.

We intended to analyze the outcomes and predictive factors for underestimating the prostate cancer (PCa) grade group (GG) from prostate biopsies in a large monocentric cohort of patients treated by minimally invasive radical prostatectomy (RP).Using a monocentric prospectively maintained database, we included 3062 patients who underwent minimally invasive RP between 2006 and 2013. We explored clinicopathologic features and outcomes associated with a GG upgrade from biopsy to RP. Multivariate logistic regression was used to develop and validate a nomogram to predict upgrading for GG1.Biopsy GG was upgraded after RP in 51.5% of cases. Patients upgraded from GG1 to GG2 or GG3 after RP had a longer time to biochemical recurrence than those with GG2 or GG3 respectively, on both biopsy and RP, but a shorter time to biochemical recurrence than those who remained GG1 after RP (P .0001). In multivariate analyses, variables predicting upgrading for GG1 PCa were age (P = .0014), abnormal digital rectal examination (P .0001), prostate-specific antigen density (P .0001), percentage of positive cores (P .0001), and body mass index (P = .037). A nomogram was generated and validated internally.Biopsy grading system is misleading in approximately 50% of cases. Upgrading GG from biopsy to RP may have consequences on clinical outcomes. A nomogram using clinicopathologic features could aid the probability of needing to upgrade GG1 patients at their initial evaluation.

Resume Objectif Decrire les modalites specifiques de prise en charge des traitements ablatifs dans le cancer de la prostate. Materiels et methodes Une recherche bibliographique a partir de Medline ( http://www.ncbi.nlm.nih.gov ) et Embase ( http://www.embase.com ) a ete realisee et les articles ont ete selectionnes sur leur methodologie, leur langue de publication (anglais/francais) et leur pertinence. Apres selection, 61 articles ont ete analyses. Resultats Le developpement d’innovations telles les therapies ablatives dans le cancer de la prostate s’accompagne de modalites specifiques dans leur prise en charge. Il en est ainsi en amont, pendant et apres la procedure. Plus encore que pour les traitements classiques et reconnus, la decision de proposer une therapie ablative, encore en evaluation, impose une analyse et un consensus de l’ensemble de l’equipe et le consentement du patient. Les specificites du patient et les aspects medicoeconomiques doivent egalement etre consideres. La realisation de la procedure doit etre confiee a des acteurs referents qui doivent en assurer un suivi precis et evalue. Conclusion L’indication, la realisation et le suivi des therapies ablatives dans le cancer de la prostate requierent des modalites specifiques. Celles-ci doivent etre respectees afin d’optimiser les resultats et d’obtenir une evaluation precise et objective pour en definir au mieux les indications futures.

We assessed the impact of focal therapy on perioperative, oncologic and functional outcomes in men who underwent salvage robotic assisted radical prostatectomy compared to primary robotic assisted radical prostatectomy.Focal therapy was performed in patients presenting with Gleason score 3 + 3 or 3 + 4, clinical stage cT2a or less, serum prostate specific antigen 15 ng/ml or less, unilateral positive biopsy, maximum length of any positive core less than 10 mm and life expectancy greater than 10 years. Focal therapy was defined as target ablation of the index lesion plus a 1 cm safety margin in the normal ipsilateral prostatic parenchyma. The salvage group included 22 men who underwent salvage prostatectomy after focal therapy failure. The primary group was defined using matched pair 1:2 selection of 44 of 2,750 patients treated with primary prostatectomy. The primary and secondary end points were the between group differences in functional and oncologic outcomes, respectively.Complication rates were comparable (p0.05). Pad-free probability was comparable between the groups at 1 and 2 years (p = 0.8). Recovery of erectile function was significantly lower after salvage robotic assisted radical prostatectomy (p = 0.008), which also showed a significantly lower probability of cumulative biochemical recurrence-free survival compared to primary robotic assisted radical prostatectomy (56.3% vs 92.4% at 2 years, p = 0.001). Salvage prostatectomy demonstrated a significantly increased risk of biochemical recurrence (HR 4.8, 95% CI 1.67-13.76, p = 0.004). Study limitations included the retrospective nature, the lack of randomization and the short followup.Salvage robotic assisted radical prostatectomy after focal therapy failure is feasible with acceptable complication rates. However, patients assigned to primary focal therapy should be advised about a poorer prognosis in terms of oncologic control and lower erectile recovery rates in case of a future salvage surgery.

Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications.

Purpose To evaluate whether patients with prostate cancer have worse functional urinary recovery with focal brachytherapy (FBT) at the base versus the apex of the prostate. Methods and Materials The functional outcomes of patients treated with FBT at the base of the prostate were compared with those of patients treated with FBT at the apex. Urinary symptoms, continence, and erectile dysfunction were measured using the International Prostate Symptom Score (IPSS), International Continence Score (ICS), and International Index of Erectile Function (IIEF-5) questionnaires, respectively, at baseline and at 6, 12, and 24 months after treatment. Results Twenty-eight and 13 patients were treated with FBT at the apex and the base, respectively, of the prostate. A significant difference between groups was found in the IPSS score at 6 months (mean IPSS: apex 6.4 ± 4.7, base 10.6 ± 5.7; p = 0.02), but not at baseline or at 12 and 24 months after treatment. On multivariate analysis, only FBT at the base of the prostate remained an independent predictor of worsening urinary symptoms (odds ratio, 5.8; p = 0.04). Conclusions At 6 months after FBT, significantly less urinary toxicity was found in patients who underwent FBT at the apex versus the base of the prostate. Continence and sexual side effects were minimal in all patients.

Resumen La cistectomia radical y diseccion de los ganglios linfaticos regionales es el tratamiento estandar para el cancer vesical musculo invasivo localizado y no musculo-invasivo de alto riesgo, y representa uno de los principales procedimientos quirurgicos urologicos. El abordaje quirurgico abierto es todavia ampliamente adoptado, aunque en las ultimas 2 decadas se han hecho esfuerzos con el fin de evaluar si los procedimientos minimamente invasivos, ya sean laparoscopicos o asistidos por robot, podrian mostrar un beneficio en comparacion con la tecnica estandar. La cistectomia radical abierta se asocia con una alta tasa de complicaciones, pero los datos de la serie quirurgica laparoscopica y robotica no lograron demostrar una clara reduccion en las tasas de complicaciones postoperatorias en comparacion con la serie quirurgica abierta. La cistectomia radical laparocopica y robotica muestran una reduccion en la perdida de sangre, las tasas de estancia hospitalaria y de transfusion, pero un mayor tiempo operatorio, mientras que la cistectomia radical abierta se asocia tipicamente con un tiempo operatorio mas corto, pero con un ingreso mas largo en el hospital y, posiblemente, una mayor tasa complicaciones de alto grado.

Resumen Introduccion La reaccion inflamatoria local despues de una biopsia prostatica (BP) puede influir de manera negativa en los resultados globales posprostatectomia radical. No hay evidencia suficiente en la literatura respecto al impacto del numero de punciones en los resultados posquirurgicos. Objetivos Determinar el impacto del numero de punciones de la BP en las complicaciones posquirurgicas y en el estado de los margenes operatorios. Material y metodos Se registraron prospectivamente 2.054 pacientes sometidos a prostatectomia radical asistida por robot (PRAR) en nuestra institucion. Se formaron 2 grupos de pacientes, en relacion con el numero de punciones en la BP (G1 ≤ 12 punciones; G2 > 12 punciones). Se evaluo por medio del analisis multivariable (modelos de regresion logistica) el impacto del numero de punciones en las complicaciones posquirurgicas. Resultados Se incluyeron 1.042 pacientes en el grupo 1 (≤ 12 punciones) y 1.012 pacientes en el grupo 2 (> 12 punciones). La tasa de complicaciones perioperatorias se incremento a medida que aumentaba el numero de punciones. (G1 6,4 vs. G2 8,5%; p = 0,03); no obstante, las complicaciones mayores (Clavien 3-4) fueron similares (G1 1,4 vs. G2 2,2%; p = 0,16). No hubo diferencia estadisticamente significativa respecto a los margenes quirurgicos positivos en ambos grupos (G1 11,8 vs. 9,98%; p = 0,2). El analisis multivariable (regresion logistica) demostro que el grupo 2 tenia un porcentaje un 39% mayor de experimentar complicaciones post-PRAR (OR 0,645). Conclusion El mayor numero de punciones (> 12) en la BP podria estar relacionado con mayor sangrado y complicaciones posquirurgicas despues de PRAR. Una cuidadosa evaluacion preoperatoria de los pacientes que se sometieron a biopsias o protocolos de saturacion multiple es obligatoria. La aplicacion de intervalos mas largos (> 6 semanas) entre la biopsia y la cirugia puede ser recomendable para minimizar los potenciales riesgos de complicaciones quirurgicas en los pacientes que pueden beneficiarse de PRAR. Otros estudios son todavia necesarios para confirmar estos resultados.

Resumen Antecedentes La quimioterapia neoadyuvante (QN) antes de la cistectomia radical minimamente invasiva (CRMI) se considera un estandar de cuidado en el cancer vesical infiltrante o cancer vesical no musculo invasivo de alto riesgo recurrente. Objetivo Evaluar el impacto de la QN en la morbimortalidad despues de CRMI. Diseno, escenario y participantes Se evaluo prospectivamente a 135 pacientes intervenidos mediante CRMI (laparoscopica: n = 100; robotica: n = 35) entre 2007 y 2013 con ≥90 dias de seguimiento (mediana de edad: 66 anos). Las complicaciones fueron analizadas y clasificadas de acuerdo con el sistema de clasificacion de Clavien Dindo. Mediciones de resultados y analisis estadistico Se utilizaron modelos de regresion logistica para evaluar el impacto de la QN en las complicaciones postoperatorias. Se utilizaron metodos de Kaplan-Meier con la prueba de log-rank para las probabilidades de supervivencia especifica del cancer y las diferencias entre los 2 grupos (CRMI con y sin QN). Resultados y limitaciones De un total de 135 pacientes, 62 recibieron QN; 118 pacientes (87,4%) desarrollaron 179 complicaciones, principalmente infecciosas (48,0%) o gastrointestinales (21,2%) ≤90 dias despues de la cirugia; 3 pacientes fallecieron Conclusiones La QN no afecta a la morbilidad ni a la mortalidad postoperatorias. Se necesita un seguimiento mas largo para evaluar el impacto de QN en los resultados oncologicos.

Background Neoadjuvant chemotherapy (NC) before minimally invasive radical cystectomy (MIRC) is considered a standard of care in muscle-invasive bladder cancer or recurrent high-risk non–muscle-invasive bladder cancer. Objective To evaluate the impact of NC on morbidity and mortality after MIRC. Design, setting, and participants We prospectively evaluated 135 patients who underwent MIRC (laparoscopic: n = 100; robotic: n = 35) between 2007 and 2013 with ≥90 days of follow-up (median age: 66 years). Complications were analyzed and graded according to the Clavien–Dindo classification system. Outcome measurements and statistical analysis Logistic regression models were used to evaluate the impact of NC on postoperative complications. Kaplan–Meier methods with the log-rank test were used for cancer-specific survival probabilities and differences between the two groups (MIRC with and without NC). Results and limitations Sixty-two of 135 patients received NC. A total of 118 patients (87.4%) developed 179 complications, chiefly infectious (48.0%) or gastrointestinal (21.2%), ≤90 days after surgery; 3 patients died

To evaluate the ability of high-frequency (29 MHz) transrectal micro-ultrasound (microUS) as a second-look examination after biparametric MRI (bp-MRI) and to reidentify focal lesions seen on diagnostic MRI and to detect new ones A total of 118 consecutive men (mean age, 66 ± 13 [SD] years; range, 49–93 years) with a mean prostate-specific antigen level of 11 ± 19 (SD) ng/mL (range, 2–200 ng/mL) and at least one focal lesion (MRI+) with a score > 2 on bp-MRI were included. Of these, 79/118 (66.9%) were biopsy-naive and 102/118 (86.5%) had non-suspicious rectal examination. All patients had MRI-directed microUS-guided biopsy using a 29-MHz transducer. All lesions visible on micro-ultrasound (microUS+) were targeted without image fusion, which was only used for MRI+/microUS− lesions. Significant prostate cancer (sPCa) was defined by a Gleason score ≥ 7 or a maximum cancer core length > 3 mm. A total of 144 focal prostatic lesions were analyzed, including 114 (114/144, 79.2%) MRI+/microUS+ lesions, 13 MRI+/microUS− lesions (13/144, 9%), and 17 MRI−/microUS+ lesions (17/144, 11.8%). Significant PCa was detected in 70 MRI+/microUS+ lesions (70/114, 61.4%), in no MRI+/microUS− lesion (0/13, 0%), and in 4 MRI-/microUS+ lesions (4/17, 23.5%). The sensitivity and specificity of microUS on a per-patient and a per-lesion basis were 100% (95% CI, 84.9–100%) and 22.8% (95% CI, 12.5–35.8%) and 100% (95% CI, 85.1–100%) and 22.6% (95% CI, 12.3–36.2%), respectively. MicroUS, as a second-look examination, may show promise to localize targets detected on bp-MRI. • Used as a second-look examination, microUS-guided biopsies have a 100% detection rate of sCa originating in the PZ or lower third of the TZ, without microUS-MRI image fusion. • MicroUS results may provide additional information about lesions visible on MRI. • MicroUS may provide the ability to detect small PZ lesions undetected by bp-MRI.

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

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

Resumen Objetivos Reportamos nuestra experiencia inicial en el tratamiento del cancer de prostata (PCa) con ultrasonido focalizado de alta intensidad (HIFU) utilizando el dispositivo Focal-One®. Material y metodos Estudio retrospectivo de datos recogidos prospectivamente. Entre junio de 2014 y octubre de 2015, 85 pacientes recibieron tratamiento HIFU (focal/total), para PCa localizado. La localizacion preoperatoria del tumor fue realizada con resonancia magnetica multiparametrica (mpMRI) y biopsias prostaticas mediante mapeo transperineal. El tratamiento fue realizado utilizando el dispositivo Focal-One® bajo anestesia general. Seguimiento oncologico: medicion del PSA y biopsia control con mpMRI segun protocolo. Los resultados funcionales fueron evaluados mediante cuestionarios validados y las complicaciones reportadas utilizando la clasificacion Clavien. Resultados La mediana de PSA fue 7,79 ng/ml (6,32-9,16) con una mediana de volumen prostatico de 38 cc (33-49,75). El tratamiento fue focal y total en 64 y 21 pacientes respectivamente. Diez pacientes recibieron tratamiento de rescate. La tasa de complicaciones fue del 15%, todas Clavien 2. La estancia hospitalaria media fue 1,8 dias (0-7) y la sonda vesical fue retirada el dia 2 (1-6). La media de reduccion porcentual del PSA fue 54%. La mediana de seguimiento fue 3 meses (2-8). Resultados funcionales: todos los pacientes estuvieron continentes a los 3 meses y la potencia se mantuvo en el 83% de los previamente potentes. Conclusiones El tratamiento HIFU Focal-One® es un procedimiento seguro con pocas complicaciones. Los resultados funcionales no reportan casos de incontinencia y la funcion sexual se mantuvo en el 83%.

Objective We report our initial experience in the treatment of prostate cancer (PCa) with high-intensity focused ultrasound (HIFU) using the Focal-One ® device. Material and methods Retrospective review of the prospectively populated database. Between June 2014 and October 2015, 85 patients underwent HIFU (focal/whole-gland) treatment for localized PCa. Preoperative cancer localization was done with multiparametric magnetic resonance imaging (mpMRI) and transperineal mapping biopsies. Treatment was carried out using the Focal-One ® device under general anesthesia. Oncological follow-up: PSA measurement and control biopsy with mpMRI according to protocol. Questionnaire-based functional outcome assessment was done. Complications were reported using Clavien classification. Results The median PSA was 7.79 ng/ml (IQR: 6.32–9.16), with a median prostate volume of 38 cc (IQR: 33–49.75). Focal and whole-gland therapy was performed in 64 and 21 patients respectively. Ten patients received salvage HIFU. Complications were encountered in 15% of cases, all Clavien 2 graded. Mean hospital stay was 1.8 days (0–7) and bladder catheter was removed on day 2 (1–6). Mean percentage reduction of PSA was 54%. Median follow-up was 3 months (IQR: 2–8). Functional outcomes: All patients were continents at 3 months and potency was maintained in 83% of the preoperatively potent. Conclusions Focal-One ® HIFU treatment appears to be a safe procedure with few complications. Functional outcomes proved no urinary incontinence and sexual function were maintained in 83%.

Objectives To evaluate the role of transperineal template guided mapping biopsy (TTMB) in determining the management strategy in patients with low risk prostate cancer (PCa). Methods We retrospectively evaluated 169 patients who underwent TTMB at our institution from February 2008 to June 2011. Ninety eight of them harbored indolent PCa defined as: Prostate Specific Antigen

Resumen Objetivos Evaluar el papel de la biopsia de mapeo guiada por plantilla transperineal (TTMB) en la determinacion de la estrategia de manejo en pacientes con cancer de prostata (CaP) de bajo riesgo. Metodos Evaluamos retrospectivamente 169 pacientes que se sometieron a TTMB en nuestra institucion entre febrero de 2008 y junio de 2011. Noventa y ocho de ellos albergaban CaP indolente definido como: antigeno prostatico especifico Resultados TTMB detecto el cancer en 64 (65%) pacientes. La clasificacion al alza y estadidificacion al alza se observaron en el 33% (n = 21), 12% (n = 8) y 7% (n = 5), respectivamente, de los canceres detectados. Las caracteristicas de la enfermedad fueron similares a la ETR inicial en 30 (48%) pacientes y TTMB fue negativa en 34 (35%) pacientes. El volumen de la prostata fue significativamente menor en los pacientes con clasificacion al alza y/o estadificacion al alza observado en TTMB (45,4 vs 37,9; p = 0,03). Los resultados de TTMB influenciaron en el 73,5% de los pacientes clasificacion al alza y/o estadificacion al alza para recibir tratamiento radical, mientras que el 81% de los pacientes con estadio y/o grado sin modificar continuaron la vigilancia activa o terapia focal. Conclusiones En los pacientes con CaP de bajo riesgo diagnosticados por ETR, una posterior TTMB demostro clasificacion al alza y/o estadificacion al alza en aproximadamente un tercio de los pacientes, y dio lugar a un cambio final en la decision de tratamiento.

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

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

This study aims to investigate whether clinical and biological preoperative characteristics of patients who were to undergo radical prostatectomy were associated with impairment in patient-reported quality of life (QoL) and erectile dysfunction immediately before intervention. We evaluated patient-reported outcomes among 1019 patients (out of 1343) of the AndroCan study, willing to score the Aging Male Symptom (AMS) and the International Index of Erectile Function 5-item (IIEF-5) auto-questionnaires. Univariate linear regression and robust multiple regression were used to ascertain the relationship between demographic, clinical, and hormonal parameters and global AMS or IIEF-5 scores. As a result, most patients (85.1') of the Androcan cohort agreed to complete questionnaires. Significantly higher IIEF-5 global scores were found in non-Caucasian and obese patients, with larger waist circumference, metabolic syndrome, diabetes mellitus, cardiovascular disease, hypertension, high blood sugar, concomitant medications, and hypogonadism, while the AMS global score was significantly higher in patients with larger waist circumference, metabolic syndrome, high blood pressure, raised glycemia, and concomitant medication. The IIEF-5 global score was correlated to age, dehydroepiandrosterone (DHEA), fat mass percentage, and androstenediol (D5). The AMS global score was significantly correlated to DHEA, D5, and DHEA sulfate. Finally, the multivariate models showed that QoL and erectile function were significantly affected, before surgery, by symptoms and signs that are usually considered as pertaining to the metabolic syndrome, while sexual hormones are essentially correlated to erectile dysfunction.

Objectifs Evaluer et comparer l’impact de la surveillance active (SA), de la therapie focale (FT) et de la prostatectomie radicale (PR) sur les resultats psychologiques et fonctionnels chez les hommes atteints d’un cancer de la prostate de faible risque de progression (CaP). Methodes Il s’agit d’une etude longitudinale prospective comparant 3 groupes (SA, FT et RP), incluant tous les patients presentant un CaP de faible risque localise defini par : un PSA ≤ 10 ng/mL, un score de Gleason = 6 [3 + 3], un stade clinique ≤ T2a, ≤ 2 biopsies positives contenant moins de ≤ 50 % de cancer. Deux series d’autoquestionnaires ont ete realisees comme suit ; une serie (Q0) au moment de la confirmation du traitement, et une deuxieme avant le dosage de PSA a 12 mois (Q1). Chaque serie comprenait les autoquestionnaires suivants ; le Memorial Anxiety Scale for Prostate Cancer (MAX-PC), l’International Index of Erectile Function (IIEF-5), l’International Prostate Symptom Score (IPSS) ainsi que l’International Continence Society, male Incontinence Symptoms (ICSmaleIS) ( Fig. 1 ). Le critere de jugement principal etait la difference intergroupe du score MAX-PC de reference (Q0). Les criteres de jugement secondaires etaient la difference intergroupe des scores MAX-PC, IIEF-5, IPSS et ICSmaleIS a 1 an (Q1). Resultats Nous avons inclus 300 patients (n = 100 par groupe). L’âge moyen et le PSA moyen etaient comparables entre les groupes (p = 0,0827 et p = 0,0679, respectivement). Avant traitement, le score median MAX-PC etait inferieur dans le groupe SA (14,3 ± 6,6) vs (17,8 ± 10,9, p = 0,0061) ; (17,2 ± 10,3, p = 0,0338) dans les groupes therapie focale et prostatectomie radicale respectivement. A un an, les 3 groupes etaient comparables en termes d’anxiete selon le score MAX-PC. La fonction erectile evaluee par l’IIEF5 etait comparable entre les 3 groupes a l’inclusion (Q0), cependant, a Q1 nous avons note une baisse significative du score IIEF5 dans le groupe PR compare au groupe FT et SA (p Conclusion Les patients en SA avaient de meilleurs resultats fonctionnels que le groupe therapie focale et prostatectomie radicale. Sans inferiorite en termes d’anxiete a l’inclusion (Q0), cette derniere avait tendance a diminuer au fil du suivi.

BACKGROUND Prostate-specific antigen (PSA) doubling time is relying on an exponential kinetic pattern. This pattern has never been validated in the setting of intermittent androgen deprivation (IAD). Objective is to analyze the prognostic significance for PCa of recurrent patterns in PSA kinetics in patients undergoing IAD. METHODS A retrospective study was conducted on 377 patients treated with IAD. On-treatment period (ONTP) consisted of gonadotropin-releasing hormone agonist injections combined with oral androgen receptor antagonist. Off-treatment period (OFTP) began when PSA was lower than 4 ng/ml. ONTP resumed when PSA was higher than 20 ng/ml. PSA values of each OFTP were fitted with three basic patterns: exponential (PSA(t) = λ.eαt), linear (PSA(t) = a.t), and power law (PSA(t) = a.tc). Univariate and multivariate Cox regression model analyzed predictive factors for oncologic outcomes. RESULTS Only 45% of the analyzed OFTPs were exponential. Linear and power law PSA kinetics represented 7.5% and 7.7%, respectively. Remaining fraction of analyzed OFTPs (40%) exhibited complex kinetics. Exponential PSA kinetics during the first OFTP was significantly associated with worse oncologic outcome. The estimated 10-year cancer-specific survival (CSS) was 46% for exponential versus 80% for nonexponential PSA kinetics patterns. The corresponding 10-year probability of castration-resistant prostate cancer (CRPC) was 69% and 31% for the two patterns, respectively. Limitations include retrospective design and mixed indications for IAD. CONCLUSION PSA kinetic fitted with exponential pattern in approximately half of the OFTPs. First OFTP exponential PSA kinetic was associated with a shorter time to CRPC and worse CSS. Prostate 76:13–21, 2016. © 2015 Wiley Periodicals, Inc.

Resumen Contexto La cirugia robotica evoluciona rapidamente y se ha convertido en una parte esencial de la practica quirurgica en diversas partes del mundo. En el futuro la tecnologia robotica se expandira globalmente y la mayoria de los cirujanos en todo el mundo tendran acceso a robots quirurgicos. Es fundamental que nos mantengamos al dia en cuanto a los resultados de los procedimientos quirurgicos asistidos por robots, lo que permitira a todos desarrollar una opinion imparcial sobre la utilidad clinica de esta innovacion. Objetivo El objetivo de esta revision es presentar la evolucion, una evaluacion objetiva de los resultados clinicos y las perspectivas futuras de las cirugias urologicas asistidas por robot. Adquisicion de la evidencia Se llevo a cabo una revision bibliografica sistematica de los resultados clinicos de las cirugias urologicas roboticas en PubMed. Se incluyeron ensayos controlados aleatorios, estudios de cohortes y revisiones de articulos. Ademas, se realizo una busqueda detallada en el buscador de la web para obtener informacion sobre la evolucion y las tecnologias en desarrollo en robotica. Sintesis de la evidencia La evidencia actual sugiere que los resultados clinicos de las cirugias urologicas asistidas por robot son comparables a los resultados de cirugias convencionales abiertas y laparoscopicas, y se asocian con menos complicaciones. Sin embargo, no se dispone de resultados a largo plazo de todas las cirugias urologicas roboticas comunes. Son muchos los desarrollos innovadores en robotica que estaran disponibles para el uso clinico en un futuro cercano. Conclusion La cirugia urologica robotica continuara evolucionando en el futuro. Deberiamos seguir analizando criticamente si los avances en tecnologia y el mayor coste se traducen finalmente en un mejor rendimiento quirurgico global y en mejores resultados.

Context Robotic surgery is rapidly evolving and has become an essential part of surgical practice in several parts of the world. Robotic technology will expand globally and most of the surgeons around the world will have access to surgical robots in the future. It is essential that we are updated about the outcomes of robot assisted surgeries which will allow everyone to develop an unbiased opinion on the clinical utility of this innovation. Objective In this review we aim to present the evolution, objective evaluation of clinical outcomes and future perspectives of robot assisted urologic surgeries. Acquisition of evidence A systematic literature review of clinical outcomes of robotic urological surgeries was made in the PUBMED. Randomized control trials, cohort studies and review articles were included. Moreover, a detailed search in the web based search engine was made to acquire information on evolution and evolving technologies in robotics. Synthesis of evidence The present evidence suggests that the clinical outcomes of the robot assisted urologic surgeries are comparable to the conventional open surgical and laparoscopic results and are associated with fewer complications. However, long term results are not available for all the common robotic urologic surgeries. There are plenty of novel developments in robotics to be available for clinical use in the future. Conclusion Robotic urologic surgery will continue to evolve in the future. We should continue to critically analyze whether the advances in technology and the higher cost eventually translates to improved overall surgical performance and outcomes.

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

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

To evaluate predictive factors associated with detectable prostate-specific antigen (PSA) and describe clinical recurrence (CR) and cancer-specific mortality (CSM) after robot-assisted radical prostatectomy (RARP). The study included 2500 patients who were treated with RARP at a single institution between 2000 and 2016. All patients had clinically localized PCa. Patients were divided into two groups according to PSA value at 6 weeks after surgery: undetectable (n = 2271; PSA

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

Aim To assess outcomes of whole gland high-intensity focused ultrasound (HIFU) as compared with minimally-invasive radical prostatectomy (MIRP) in elderly patients. Materials & methods Patients aged ≥70 years with, cT1-cT2 disease, biopsy Gleason score (GS) 3 + 3 or 3 + 4 and preoperative PSA ≤10 ng/mL were submitted to either whole-gland HIFU or MIRP. Propensity-score matching analysis was performed to ensure the baseline equivalence of groups. Follow-up visits were routinely performed assessing PSA and urinary function according to the International Continence Score (ICS) and the International Prostatic Symptoms Score (IPSS) questionnaires. Estimated rates of salvage-treatment free survival (SFS) overall-survival (OS), cancer-specific survival (CSS) and metastasis-free survival (MTS) were assessed and compared. Results Overall, 84 (33.3%) and 168 (66.7%) patients were treated with HIFU and MIRP, respectively. MIRP was associated with a 5-yrs SFS of 93.4% compared to 74.8% for HIFU (p < 0.01). The two groups did not differ in terms of OS and MTS. No cancer-related deaths were registered. Patients treated with HIFU showed better short-term (6-mos) continence outcomes [mean-ICS: 1.7 vs. 4.8; p = 0.005] but higher IPSS mean scores at 12-mos assessment. A comparable rate of patients experiencing post-treatment Clavien-Dindo grade ≥III complications was observed within the two groups. Conclusions Whole-gland HIFU is a feasible treatment in elderly men with low-to intermediate-risk PCa and could be considered for patients either unfit for surgery, or willing a non-invasive treatment with a low morbidity burden, although a non-negligible risk of requiring subsequent treatment for recurrence should be expected.

Resume Introduction Lors de la prise en charge du cancer de prostate ou des tumeurs de vessie infiltrantes, les indications et l’etendue du curage ganglionnaire pelvien sont identiques quelle que soit la voie d’abord utilisee. Methode Nous presentons ici la technique chirurgicale pas a pas du curage ilio-obturateur par cœlioscopie robot-assistee, ainsi que ses resultats et complications eventuelles rapportes dans la litterature. Resultats La lymphadenectomie cœlioscopique robot-assistee est une technique standardisee, avec une morbidite faible. Discussion Le type et la frequence des complications sont comparables a ceux decrits par voie cœlioscopique ou par voie ouverte. Actuellement, le curage limite doit etre abandonne pour privilegier un curage interessant au minimum les regions iliaques externe, obturatrice et iliaque interne afin d’optimiser la stadification loco-regionale et d’ameliorer le pronostic des patients.