Urinary Continence Recovery after Radical Prostatectomy-Anatomic/Reconstructive and Nerve Sparing Techniques to Improve Outcomes

In an editorial board moderated debate format, two experts in prostate cancer surgery are challenged with presenting the key strategies in radical prostatectomy that improve urinary functional outcomes. Dr Bernardo Rocco was tasked with arguing the facts that support the anatomic preservation and reconstruction steps that improve continence. Drs. Christian Pavlovich and Sasha Druskin were tasked with arguing the facts supporting neurovascular bundle and high anterior release surgical planes that improve continence. Associate Editor John Davis moderates the debate, and outlines the current status of validated patient questionnaires that can be used to evaluate urinary continence, and recent work that allows measuring what constitutes a "clinically significant" difference that either or both of these surgical techniques could influence. A review of raw data from a publication from Dr. Pavlovich's team demonstrates how clinically relevant differences in patient reported outcomes can be correlated to technique. A visual atlas is presented from both presenting teams, and Dr. Davis demonstrates further reproducibility of technique. This article is protected by copyright. All rights reserved

Original Articles PERCUTANEOUS RADIO FREQUENCY ABLATION OF SMALL RENAL TUMORS: INITIAL RESULTS

ABSTRACT Purpose: Thermal tissue ablation with radio frequency energy is an experimental treatment of renal tumor. We report early results of an ongoing trial of percutaneous radio frequency ablation for small renal tumors. Materials and Methods: Patients with percutaneously accessible renal tumors were evaluated for radio frequency ablation. Tumors were solid on computerized tomography (CT), 3 cm. or less in diameter and enlarging during at least 1 year. Ablation was performed at the Interventional Radiology suite under ultrasound and/or CT guidance. A 50 W., 460 kHz. electrosurgical generator delivered radio frequency energy via a percutaneously placed 15 gauge coaxial probe. At least 2, 10 to 12-minute ablation cycles were applied to each lesion. Patients were observed overnight before discharge from hospital and reevaluated 2 months later. Results Conclusions: Percutaneous radio frequency ablation of small renal tumor is well tolerated and minimally invasive. It will remain experimental until procedural and imaging parameters that correlate with tumor destruction are validated

Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation of Prostate Cancer

Purpose: Magnetic resonance imaging-guided transurethral ultrasound ablation uses directional thermal ultrasound under magnetic resonance imaging thermometry feedback control for prostatic ablation. We report 12-month outcomes from a prospective multicenter trial (TACT). Materials and methods: A total of 115 men with favorable to intermediate risk prostate cancer across 13 centers were treated with whole gland ablation sparing the urethra and apical sphincter. The co-primary 12-month endpoints were safety and efficacy. Results: In all, 72 (63%) had grade group 2 and 77 (67%) had NCCN® intermediate risk disease. Median treatment delivery time was 51 minutes with 98% (IQR 95-99) thermal coverage of target volume and spatial ablation precision of ±1.4 mm on magnetic resonance imaging thermometry. Grade 3 adverse events occurred in 9 (8%) men. The primary endpoint (U.S. Food and Drug Administration mandated) of prostate specific antigen reduction ≥75% was achieved in 110 of 115 (96%) with median prostate specific antigen reduction of 95% and nadir of 0.34 ng/ml. Median prostate volume decreased from 37 to 3 cc. Among 68 men with pretreatment grade group 2 disease, 52 (79%) were free of grade group 2 disease on 12-month biopsy. Of 111 men with 12-month biopsy data, 72 (65%) had no evidence of cancer. Erections (International Index of Erectile Function question 2 score 2 or greater) were maintained/regained in 69 of 92 (75%). Multivariate predictors of persistent grade group 2 at 12 months included intraprostatic calcifications at screening, suboptimal magnetic resonance imaging thermal coverage of target volume and a PI-RADS™ 3 or greater lesion at 12-month magnetic resonance imaging (p <0.05). Conclusions: The TACT study of magnetic resonance imaging-guided transurethral ultrasound whole gland ablation in men with localized prostate cancer demonstrated effective tissue ablation and prostate specific antigen reduction with low rates of toxicity and residual disease

Molecular biomarkers in the context of focal therapy for prostate cancer: Recommendations of a delphi consensus from the focal therapy society

BACKGROUND: Focal therapy (FT) for prostate cancer (PCa) is promising. However, long-term oncological results are awaited and there is no consensus on follow-up strategies. Molecular biomarkers (MB) may be useful in selecting, treating and following up men undergoing FT, though there is limited evidence in this field to guide practice. We aimed to conduct a consensus meeting, endorsed by the Focal Therapy Society, amongst a large group of experts, to understand the potential utility of MB in FT for localized PCa. METHODS: A 38-item questionnaire was built following a literature search. The authors then performed three rounds of a Delphi Consensus using DelphiManager, using the GRADE grid scoring system, followed by a face-to-face expert meeting. Three areas of interest were identified and covered concerning MB for FT, 1) the current/present role; 2) the potential/future role; 3) the recommended features for future studies. Consensus was defined using a 70% agreement threshold. RESULTS: Of 95 invited experts, 42 (44.2%) completed the three Delphi rounds. Twenty-four items reached a consensus and they were then approved at the meeting involving (N.=15) experts. Fourteen items reached a consensus on uncertainty, or they did not reach a consensus. They were re-discussed, resulting in a consensus (N.=3), a consensus on a partial agreement (N.=1), and a consensus on uncertainty (N.=10). A final list of statements were derived from the approved and discussed items, with the addition of three generated statements, to provide guidance regarding MB in the context of FT for localized PCa. Research efforts in this field should be considered a priority. CONCLUSIONS: The present study detailed an initial consensus on the use of MB in FT for PCa. This is until evidence becomes available on the subject

Protocol of a Multicentre Randomised Controlled Trial Assessing Transperineal Prostate Biopsy to Reduce Infectiouscomplications

Introduction Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer. Methods and analysis We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/ discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer. Ethics and dissemination The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals. Trial registration number NCT04815876

Role of genetic testing for inherited prostate cancer risk: Philadelphia prostate cancer consensus conference 2017

Purpose: Guidelines are limited for genetic testing for prostate cancer (PCA). The goal of this conference was to develop an expert consensus-dri

Comparing Micro-Ultrasound to mpMRI in Detecting Clinically Significant Prostate Cancer

Objectives: To compare the performance of micro-ultrasound (mUS) with multi-parametric magnetic resonance imaging (mpMRI) in detecting clinically significant prostate cancer. Materials and Methods: Retrospective data from consecutive patients with any indication for prostate biopsy in 2 academic institutions were included. The operator, blinded to mpMRI, would first scan the prostate and annotate any mUS lesions. All mUS lesions were biopsied. Any mpMRI lesions that did not correspond to mUS lesion upon unblinding were additionally biopsied. Grade group (GG) ≥ 2 was considered clinically significant cancer. The Jeffreys interval method was used to compare performance of mUS with mpMRI with the non-inferiority limit set at −5%. Results: Imaging and biopsy were performed in 82 patients with 153 lesions. mUS had similar sensitivity to mpMRI (per-lesion analysis: 78.4% versus 72.5%), but lower specificity, positive predictive value, negative predictive value, and area under the curve. Micro-ultrasound found GG ≥ 2 in 13% of cases missed by mpMRI, while mpMRI found GG ≥ 2 in 11% of cases missed by mUS. The difference 0.020 (95% CI −0.070 to 0.110) was not statistically significant (P = 0.33). Conclusion: The sensitivity of mUS in detecting GG ≥ 2 disease was similar to that of mpMRI, but the specificity was lower. Further evaluation with a larger sample size and experienced operators is warranted

Easy, reproducible extraperitoneal pelvic access for robot - assisted radical prostatectomy

ABSTRACT Robot - assisted radical prostatectomy is commonly performed transperitoneally (tRARP), although the extraperitoneal (eRARP) approach is a safe and effective alternative that may be preferred in certain situations. We developed a novel method of direct access into the space of Retzius with a visual obturator port (Visiport™) for laparoscopic or robotic prostatectomy. We present an instructional video of extraperitoneal pelvic access for eRARP with both internal and external camera views. The patient is first placed in lithotomy and 15° Trendelenburg position. The camera is inserted infraumbilically and angled caudally. The pre-peritoneal space is accessed through the anterior rectus fascia using a Visiport™ (Covidien, $60 www.esutures.com), and the working space is developed with a kidney - shaped balloon OMSPDBS2™ (Covidien,$ 49 www.esutures.com). After the space is insufflated, subsequent trocars are angled in extraperitoneally under direct vision. The average time from incision to final port placement after a learning curve of about 50 cases is 8 minutes (IQR 7-10). We have performed over 1.000 cases using this technique and eRARP has become our procedure of choice. Our last 500 + cases were performed robotically. Approximately 10% of the time peritoneotomies were noted, but rarely did these require conversion to tRARP. There have been no bowel or other abdominal organ injuries, major vascular or other complications in any of these cases

Hidden Renal Artery Pseudoaneurysm: The Need for Repeat Angiographic Intervention in a Symptomatic Patient

Renal artery pseudoaneurysm (RAP) is a well-known and life-threatening complication of partial nephrectomies. Angioembolization is the preferred intervention, allowing for visualization, diagnosis, and treatment in 96% of cases. We report a case of a pseudoaneurysm that was difficult to diagnose even with optimal technique, requiring repeat imaging and additional angiographic intervention. Our case shows that RAP after partial nephrectomies may be difficult to diagnose even with high suspicion and appropriate technique. Repeat angiography may be required. Urologists and interventional radiologists together must keep RAP high on the differential even after a negative angiogram to adequately diagnose and treat symptomatic patients