Iatrogenic injury of the urinary tract during salvage procedures for pelvic sepsis:Experience of a national referral centre

Aim: This study aimed to determine the incidence, consequences and outcomes of iatrogenic urinary tract injury (IUI) during salvage surgery for pelvic sepsis.Method: Patients who underwent salvage surgery for pelvic sepsis after prior low anterior resection or Hartmann's procedure for rectal cancer were prospectively maintained in a database between 2010 and 2020 and reviewed retrospectively. The primary endpoint was the incidence of IUI. Secondary endpoints were timing of diagnosis (intra- vs. postoperative), reinterventions related to the IUI and healing of IUI. Results: In total 126 consecutive patients were included, and IUI occurred in 13 patients (10%). A ureteric injury occurred in eight patients, bladder injury in four patients and a urethral injury in one patient. All patients with an IUI had radiotherapy as neoadjuvant treatment. The IUI was diagnosed postoperatively in 63% (n = 8/13) with a median duration between surgery and diagnosis of the IUI of 10 days (IQR: 6–15). The median number of reinterventions was five (range 1–31) in the group with a postoperative diagnosis and one (range 0–1) in the group with an intraoperative diagnosis. Four patients required a surgical reintervention, all concerning injuries diagnosed postoperatively. At the end of follow-up, 85% of patients (n = 11/13) had a healed IUI. Conclusion: Iatrogenic urinary tract injury is not uncommon in salvage procedures for pelvic sepsis, even in an experienced tertiary referral centre. Most injuries were diagnosed postoperatively which affects the severity of these complications, emphasising the need to improve intraoperative diagnostic modalities.</p

Iatrogenic injury of the urinary tract during salvage procedures for pelvic sepsis:Experience of a national referral centre

Aim: This study aimed to determine the incidence, consequences and outcomes of iatrogenic urinary tract injury (IUI) during salvage surgery for pelvic sepsis.Method: Patients who underwent salvage surgery for pelvic sepsis after prior low anterior resection or Hartmann's procedure for rectal cancer were prospectively maintained in a database between 2010 and 2020 and reviewed retrospectively. The primary endpoint was the incidence of IUI. Secondary endpoints were timing of diagnosis (intra- vs. postoperative), reinterventions related to the IUI and healing of IUI. Results: In total 126 consecutive patients were included, and IUI occurred in 13 patients (10%). A ureteric injury occurred in eight patients, bladder injury in four patients and a urethral injury in one patient. All patients with an IUI had radiotherapy as neoadjuvant treatment. The IUI was diagnosed postoperatively in 63% (n = 8/13) with a median duration between surgery and diagnosis of the IUI of 10 days (IQR: 6–15). The median number of reinterventions was five (range 1–31) in the group with a postoperative diagnosis and one (range 0–1) in the group with an intraoperative diagnosis. Four patients required a surgical reintervention, all concerning injuries diagnosed postoperatively. At the end of follow-up, 85% of patients (n = 11/13) had a healed IUI. Conclusion: Iatrogenic urinary tract injury is not uncommon in salvage procedures for pelvic sepsis, even in an experienced tertiary referral centre. Most injuries were diagnosed postoperatively which affects the severity of these complications, emphasising the need to improve intraoperative diagnostic modalities.</p

Three-dimensional greyscale transrectal ultrasound-guidance and biopsy core preembedding for detection of prostate cancer:Dutch clinical cohort study

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 &gt; 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.</p

Clinical Validation of Multiparametric Ultrasound for Detecting Clinically Significant Prostate Cancer Using Computer-Aided Diagnosis: A Direct Comparison with the Magnetic Resonance Imaging Pathway

We present the protocol for a study testing the hypothesis that a computer-aided diagnosis (CAD) system for three-dimensional multiparametric ultrasound (3D mpUS) is noninferior to magnetic resonance imaging (MRI) in guiding prostate biopsies for detection of clinically significant prostate cancer (csPCa). The prospective study has a fully paired design for assessment of diagnostic accuracy and is registered on ClinicalTrials.gov as NCT06281769. A total of 438 biopsy-naïve men scheduled for prostate MRI evaluation because of an abnormal digital rectal examination and/or elevated serum prostate-specific antigen will be included. All patients will undergo both MRI (multiparametric or biparametric) and 3D mpUS with CAD (PCaVision). Suspicious lesions will be independently identified using each imaging technique. MRI targeted biopsy (TBx) and/or PCaVision TBx will be performed if suspicious lesions are identified on imaging. When both PCaVision and MRI identify lesions in an individual patient, the TBx order for this patient will be randomized. Three TBx samples per lesion will be taken for a maximum of two lesions per modality. The primary objective is the detection rate for csPCa (International Society of Urological Pathology grade group [GG] ≥2) with the PCaVision versus the MRI TBx pathway. The noninferiority margin for the absolute difference in detection rates is set at a difference of 5%. Secondary outcomes are the proportion of men in whom TBx could have been safely omitted in each pathway. Additional diagnostic accuracy analyses will be performed for different definitions of PCa (GG ≥3; GG ≥2 with cribriform growth and/or intraductal carcinoma; and GG 1). The frequency of insufficient image quality for the two pathways will also be assessed. Lastly, we will determine the diagnostic performance for csPCa detection at various 3D mpUS image quality thresholds for PCaVision

Reliable Visualization of the Treatment Effect of Transperineal Focal Laser Ablation in Prostate Cancer Patients by Magnetic Resonance Imaging and Contrast-enhanced Ultrasound Imaging

Background: Transperineal focal laser ablation (TPLA) treatment for prostate cancer (PCa) is an experimental focal ablative therapy modality with low morbidity. However, a dosimetry model for TPLA is lacking. Objective: To determine (1) the three-dimensional (3D) histologically defined ablation zone of single- and multifiber TPLA treatment for PCa correlated with magnetic resonance imaging (MRI) and contrast-enhanced ultrasound (CEUS) and (2) a reliable imaging modality of ablation zone volumetry. Design, setting, and participants: This was a prospective, multicenter, and interventional phase I/II pilot study with an ablate-and-resect design. TPLA was performed in 12 patients with localized prostate cancer divided over four treatment regimens to evaluate potential variation in outcomes. Intervention: TPLA was performed approximately 4 wk prior to robot-assisted radical prostatectomy (RARP) in a daycare setting using local anesthesia. Outcome measurements and statistical analysis: Four weeks after TPLA, ablation zone volumetry was determined on prostate MRI and CEUS by delineation and segmentation into 3D models and correlated with whole-mount RARP histology using the Pearson correlation index. Results and limitations: Twelve office-based TPLA procedures were performed successfully under continuous transrectal ultrasound guidance using local perineal anesthesia. No serious adverse events occurred. A qualitative analysis showed a clear demarcation of the ablation zone on T2-weighted MRI, dynamic contrast-enhanced MRI, and CEUS. On pathological evaluation, no remnant cancer was observed within the ablation zone. Ablation zone volumetry on CEUS and T2-weighted MRI compared with histology had a Pearson correlation index of r = 0.94 (95% confidence interval [CI] 0.74–0.99, p < 0.001) and r = 0.93 (95% CI 0.73–0.98, p < 0.001), respectively. Conclusions: CEUS and prostate MRI could reliably visualize TPLA ablative effects after minimally invasive PCa treatment with a high concordance with histopathological findings and showed no remnant cancer. Patient summary: The treatment effects of a novel minimally invasive ablation therapy device can reliably be visualized with radiological examinations. These results will improve planning and performance of future procedures

Differences in Trial and Real-world Populations in the Dutch Castration-resistant Prostate Cancer Registry

__Background:__ Trials in castration-resistant prostate cancer (CRPC) treatment have shown improved outcomes, including survival. However, as trial populations are selected, results may not be representative for the real-world population. The aim of this study was to assess the differences between patients treated in a clinical trial versus standard care during the course of CRPC in a real-world CRPC population. __Design, setting, and participants:__ Castration-resistant Prostate Cancer Registry is a population-based, observational, retrospective registry. CRPC patients from 20 hospitals in the Netherlands have been included from 2010 to 2013. __Outcome measurements and statistical analysis:__ Baseline characteristics, systemic treatment, and overall survival were the main outcomes. Descriptive statistics, multivariate Cox regression, and multiple imputations with the Monte Carlo Markov Chain method were used. __Results and limitations:__ In total, 1524 patients were enrolled of which 203 patients had participated in trials at any time. The median follow-up period was 23 mo. Patients in the trial group were significantly younger and had less comorbidities. Docetaxel treatment was more freque

Alternative therapies for localized prostate cancer.

Prostate cancer is the leading malignancy in men; an increase in detected localized prostate cancers is expected in the years to come. Radical prostatectomy, although effective, is associated with a considerable morbidity. The aim of minimal invasive alternative treatment options should be equal efficacy, but a decrease in side effects. Cryosurgical ablation of the prostate, brachytherapy, high-intensity focused ultrasound, and radiofrequency interstitial tumor ablation were evaluated after a literature review from a MEDLINE search (1966-2002). When compared with treatments in the 1960s and 1970s, increased safety is observed in all of the alternative treatments available today. Sophisticated technology, including the latest ultrasonography devices for exact planning and monitoring of treatment, contributes largely to this safety. Five-year results of cryosurgical ablation of the prostate show a prostate-specific antigen lower than 1 ng/mL in 60% of the cases; in the third generation, there are no long-term data available on cryosurgical ablation of the prostate. Recent outcome data of brachytherapy come close to results of radical prostatectomy series. Brachytherapy is the only true alternative at this point in time. High-intensity focused ultrasound and radiofrequency interstitial tumor ablation are promising new technologies that have proven to be able to induce extensive necrosis; however, follow-up is too short to determine their definite places in the treatment of prostate cancer

Fluoroscopy-use during ureterorenoscopy: are urologists concerned about radiation exposure? A nationwide survey in Belgium and The Netherlands

Introduction: To evaluate the use and awareness of radiation during URS among Belgian and Dutch urologists. Material and methods: An online questionnaire was send to all members of the Belgian and Dutch Association of Urology. Results: 170 urologists finished the complete questionnaire. 10% of the respondents are not familiar with the ALARA-principle. 29% starts with a KUB and 48% makes an XRPG at the beginning of the procedure. 85% uses fluoroscopy to place a wire or ureteral access sheet, 18% during stone treatment, 59% to screen for missed stones or calyces, 90% to place a JJ-stent or ureter-catheter and 23% to check for extravasation. 82% do not document radiation data. 51% does not wear a dosimeter during fluoroscopy. Almost all wear a lead apron during fluoroscopy, 47% uses additional thyroid shields and only 4% uses lead glasses. 88% intentionally reduces fluoroscopy time, 75% reduces the exposed area with a diaphragm, 72% brings the radiation source close to the patient and 44% uses pulsed fluoroscopy. Conclusion: There is a wide variety in the use and awareness of radiation during URS. To further reduce radiation and its negative effect for patients and medical staff, awareness about radiation safety should increase among urologists