OBJECTIVE To assess the correlation between high-resolution microultrasound (microUS) and multi- parametric magnetic resonance imaging (MP-MRI) in clinically significant prostate cancer (csPCa) lesion identification. METHODS We reviewed our prospectively maintained database of 267 consecutive patients who underwent MP-MRI and transperineal microUS-guided biopsy between February 2021 and April 2023. The Prostate Risk Identification using MicroUS (PRI-MUS) protocol was utilized to risk stratify prostate lesions, with PRI-MUS 3-5 defined as positive. MRI lesions were classified according to the Prostate Imaging Reporting and Data System (PI-RADS) version 2.1. Clinicopathologic outcomes were analyzed. Spearman correlation testing was computed to assess the relationship between PRI-MUS and PI-RADS. RESULTS A total of 161 patients met inclusion criteria. Mean +/- standard deviation age was 65.6 +/- 1.5 years and prostate-specific antigen was 7.6 +/- 0.6 ng/mL. Ninety-two patients were found to have PIRADS 3-5 lesions. Spearman correlation analysis revealed a moderate positive correlation between PRI-MUS and PI-RADS (r = 0.40, P < .001). MicroUS-targeted cores detected higher grade disease than systematic and MRI-targeted cores in 8/161 (5.0%) patients. CsPCa would have been missed in 4/161 (2.5%) patients without microUStargeted sampling. CONCLUSION MicroUS/PRI-MUS demonstrates moderate positive correlation with MP-MRI/PI-RADS and offers improved csPCa detection compared to MRI-targeted biopsy alone. MicroUS may be useful in conjunction with MP-MRI or as an alternative imaging modality in MRI-ineligible patients. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

OBJECTIVE To present the patient -reported quality of life (QoL) outcomes from a prospective, randomized controlled trial comparing the use of pelvic floor muscle training (PFMT) and duloxetine after robot -assisted radical prostatectomy (RARP). METHODS We identified 213 men with organ -confined disease having post-RARP urinary incontinence who were randomly assigned to received PFMT, duloxetine, combined PFMT-duloxetine and pelvic floor muscle home exercises. Urinary symptoms burden was measured by marked clinical important difference improvement (MCID) defined by using the International Prostate Symptom Score (IPSS) difference of - 8 points ( Delta IPSS <=- 8). QoL was assessed according to Visual Analog Scale (VAS), King's Health Questionnaire (KQH), and International Index of Erectile Function (IIEF-5). Multivariable regression analyses aimed to predict MCID, burden of urinary symptoms (IPSS >= 8), and patients reporting to be satisfied (IPSS QoL <= 2) or comfortable (VAS <= 1) post-RARP. RESULTS Moderate to severe urinary symptoms decreased from 48% preoperatively to 40%, 34%, and 23% at 3, 6, and 12 months post-RARP. After surgery, MCID improvement was observed in 19% of patients, and deterioration in 3.3%. Large prostate was the only factor associated to MCID (OR 1.03 [95%CI 1.01-1.05], P = .005). At 6 months, patients reached the same degree of preoperative satisfaction. Neurovascular bundle preservation was the only predictor of being comfortable regarding urinary symptoms postoperatively (OR 12.8 [CI95% 1.47-111.7], P = .02 at 3 months) and was also associated to higher median postoperative IIEF-5. CONCLUSION Despite urinary incontinence following RARP, patients with larger prostates experience a reduction of lower urinary tract symptoms within a year, which subsequently elevates QoL. Furthermore, nerve -sparing surgery augments erectile function and urinary outcomes, shaping postoperative QoL. UROLOGY 185: 73-79, 2024. (c) 2024 Elsevier Inc. All rights reserved.

INTRODUCTION:We studied patient-reported functional outcomes, safety, and oncologic efficacy of focal irreversible electroporation as a primary treatment for intermediate-risk prostate cancer. METHODS:Between February 2015 and April 2017, 20 consecutive patients elected irreversible electroporation and underwent 22 treatments. All underwent MRI-targeted and systematic transrectal biopsies. Eligibility criteria were grade group 2/3 prostate cancer in a maximum of 2 adjacent sextant prostate sectors in 1 hemigland without extraprostatic extension on MRI. Ablation was performed with a 5-mm cancer margin. Any grade group 1 cancer outside mapped index lesion was untreated. Outcome measures were based on the Prostate Quality of Life Survey, Male Sexual Health Questionnaire, and MRI-targeted and systematic biopsies at 3 and 12 months. RESULTS:Nineteen patients completed irreversible electroporation. One had electrocardiographic changes, and irreversible electroporation was aborted. No deterioration was detected in urinary or sexual domains (-0.2, 95% CI -1.4, 0.9, P = .7, and -1.9, 95% CI -10.1, 6.4, P = .6, respectively) or health-related quality of life (-0.2, 95% CI -1.4, 1.0, P = .7) at 6 months post ablation. Ejaculation volume decreased at 12 months (-1.5 points, 95% CI -2.4, -0.5, P = .003). At 12 months of follow-up, 14/19 patients (74%, 95% CI 49%, 91%) had no clinically significant cancer anywhere in the prostate. Radical treatment-free survival was 79% at 2 years (95% CI 53%, 92%) and 73% at 4 years (95% CI 47%, 88%). CONCLUSIONS:Our data show promising oncologic and functional outcomes following focal irreversible electroporation treatment for carefully selected patients with intermediate-risk prostate cancer. Further research should compare irreversible electroporation with active surveillance.

Objective:To determine whether adjuvant transforming growth factor-β (TGF-β) inhibition with pirfenidone (PFD) can mitigate ureteral wall scarring and related complications in a rat model of upper urinary tract ablation with irreversible electroporation (IRE). Methods:Transmural ablation of the ureter was performed with IRE in 24 rats. Post-IRE, animals were randomly assigned to receive PFD or no drug, followed by euthanasia at 2-, 5-, or 10-days. The complete urinary tract was extracted, and the dimensions of kidney and ureter were measured. Immunohistochemistry was performed to quantify collagen deposition, α-smooth muscle actin (α-SMA) (myofibroblasts in ureter and kidney) and TGF-β (ureter only). Results:Enlargement of the kidney and ureteral dilatation were apparent during gross necropsy of rats from both cohorts. The changes in anatomical measurements were significantly reduced in rats receiving PFD at Day 5 and 10 (p = 0.02 and 0.04, respectively). Collagen levels in the ureters gradually increased in rats from both cohorts at Day 2 and 5, but started to reduce by Day 10 in rats receiving PFD when compared with no treatment (p = 0.04). Myofibroblast levels and TGF-β staining in the ureters was lower in rats receiving PFD on Day 5 and 10, respectively (p < 0.01). Collagen levels and myofibroblast staining of the kidneys from rats receiving PFD was significantly lower than control on Days 5 and 10. Conclusion:Adjuvant PFD can reduce myofibroblast activity and ureteral fibrosis at the site of IRE ablation, enabling safe soft tissue ablation adjacent or involving the upper urinary tract.

CONTEXT:Whole-gland ablation is a feasible and effective minimally invasive treatment for localized prostate cancer (PCa). Previous systematic reviews supported evidence for favorable functional outcomes, but oncological outcomes were inconclusive owing to limited follow-up. OBJECTIVE:To evaluate the real-world data on the mid- to long-term oncological and functional outcomes of whole-gland cryoablation and high-intensity focused ultrasound (HIFU) in patients with clinically localized PCa, and to provide expert recommendations and commentary on these findings. EVIDENCE ACQUISITION:We performed a systematic review of PubMed, Embase, and Cochrane Library publications through February 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. As endpoints, baseline clinical characteristics, and oncological and functional outcomes were assessed. To estimate the pooled prevalence of oncological, functional, and toxicity outcomes, and to quantify and explain the heterogeneity, random-effect meta-analyses and meta-regression analyses were performed. EVIDENCE SYNTHESIS:Twenty-nine studies were identified, including 14 on cryoablation and 15 on HIFU with a median follow-up of 72 mo. Most of the studies were retrospective (n = 23), with IDEAL (idea, development, exploration, assessment, and long-term study) stage 2b (n = 20) being most common. Biochemical recurrence-free survival, cancer-specific survival, overall survival, recurrence-free survival, and metastasis-free survival rates at 10 yr were 58%, 96%, 63%, 71-79%, and 84%, respectively. Erectile function was preserved in 37% of cases, and overall pad-free continence was achieved in 96% of cases, with a 1-yr rate of 97.4-98.8%. The rates of stricture, urinary retention, urinary tract infection, rectourethral fistula, and sepsis were observed to be 11%, 9.5%, 8%, 0.7%, and 0.8%, respectively. CONCLUSIONS:The mid- to long-term real-world data, and the safety profiles of cryoablation and HIFU are sound to support and be offered as primary treatment for appropriate patients with localized PCa. When compared with other existing treatment modalities for PCa, these ablative therapies provide nearly equivalent intermediate- to long-term oncological and toxicity outcomes, as well as excellent pad-free continence rates in the primary setting. This real-world clinical evidence provides long-term oncological and functional outcomes that enhance shared decision-making when balancing risks and expected outcomes that reflect patient preferences and values. PATIENT SUMMARY:Cryoablation and high-intensity focused ultrasound are minimally invasive treatments available to selectively treat localized prostate cancer, considering their nearly comparable intermediate- to long term cancer control and preservation of urinary continence to other radical treatments in the primary setting. However, a well-informed decision should be made based on one's values and preferences.

You have accessJournal of UrologyCME1 Apr 2023MP09-09 CORRELATION BETWEEN PROSTATE MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING AND HIGH-RESOLUTION MICRO-ULTRASOUND Nicholas Pickersgill, M. Hassan Alkazemi, Joel Vetter, Adam Ostergar, Nimrod Barashi, Grant Henning, and Arjun Sivaraman Nicholas PickersgillNicholas Pickersgill More articles by this author , M. Hassan AlkazemiM. Hassan Alkazemi More articles by this author , Joel VetterJoel Vetter More articles by this author , Adam OstergarAdam Ostergar More articles by this author , Nimrod BarashiNimrod Barashi More articles by this author , Grant HenningGrant Henning More articles by this author , and Arjun SivaramanArjun Sivaraman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003224.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostate multiparametric magnetic resonance imaging (pMRI) has emerged as a valuable tool in the diagnostic pathway for prostate cancer. The recent introduction of high-resolution micro-ultrasound (microUS) guided prostate biopsy aims to further improve the detection of clinically significant prostate cancer (CSCaP). The correlation between these two imaging modalities is poorly understood. We investigated correlation in lesion identification between microUS and pMRI. METHODS: We reviewed our prospectively maintained database of 200 consecutive patients who underwent transperineal microUS-guided biopsy with the ExactVu™platform (Exact Imaging, Markham, Canada) between February 2021 and April 2022. The Prostate Risk Identification using MicroUS (PRI-MUS) protocol was utilized to risk stratify prostate lesions, with PRI-MUS 3-5 defined as positive. pMRI lesions were classified according to PI-RADS version 2. Clinicopathologic outcomes were analyzed. Spearman correlation testing was computed to assess the relationship between PRI-MUS and PI-RADS. Patients with sufficient data for analysis were included. RESULTS: A total of 159 patients met inclusion criteria. Of these, 117 were biopsy-naïve, 19 had a prior negative biopsy and 20 were on active surveillance. Mean±standard deviation (SD) age was 66.6±7.7 years and PSA was 10.1±4.4 ng/mL. A total of 112 patients underwent multiparametric magnetic resonance imaging (mpMRI) prior to biopsy, of which 56 were found to have PIRADS 3-5 lesions. There was a weak positive correlation between PRI-MUS and PI-RADS (r=0.23, p=0.013) (Figure 1). CONCLUSIONS: This preliminary comparison between PRI-MUS and PI-RADS scoring demonstrates a weak positive correlation between the two modalities. This may be attributable to a significant number of patients with negative pMRI who were found to have PRI-MUS 3-5 lesions. Given the rising utilization of micro-US-guided prostate biopsy and widespread use of pMRI, further prospective studies are needed to compare their ability to detect clinically significant prostate cancer. Source of Funding: Midwest Stone Institute © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e107 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicholas Pickersgill More articles by this author M. Hassan Alkazemi More articles by this author Joel Vetter More articles by this author Adam Ostergar More articles by this author Nimrod Barashi More articles by this author Grant Henning More articles by this author Arjun Sivaraman More articles by this author Expand All Advertisement PDF downloadLoading ...

BACKGROUND:Urinary incontinence (UI) can negatively impact quality of life (QoL) after robot-assisted radical prostatectomy (RARP). Pelvic floor muscle training (PFMT) and duloxetine are used to manage post-RARP UI, but their efficacy remains uncertain. We aimed to investigate the efficacy of PFMT and duloxetine in promoting urinary continence recovery (UCR) after RARP. METHODS:A randomized controlled trial involving patients with urine leakage after RARP from May 2015 to February 2018. Patients were randomized into 1 of 4 arms: (1) PFMT-biofeedback, (2) duloxetine, (3) combined PFMT-biofeedback and duloxetine, (4) control arm. PFMT consisted of pelvic muscle exercises conducted with electromyographic feedback weekly, for 3 months. Oral duloxetine was administered at bedtime for 3 months. The primary outcome was prevalence of continence at 6 months, defined as using ≤1 security pad. Urinary symptoms and QoL were assessed by using a visual analogue scale, and validated questionnaires. RESULTS:From the 240 patients included in the trial, 89% of patients completed 1 year of follow-up. Treatment compliance was observed in 88% (92/105) of patients receiving duloxetine, and in 97% (104/107) of patients scheduled to PFMT-biofeedback sessions. In the control group 96% of patients had achieved continence at 6 months, compared with 90% (p = 0.3) in the PMFT-biofeedback, 73% (p = 0.008) in the duloxetine, and 69% (p = 0.003) in the combined treatment arm. At 6 months, QoL was classified as uncomfortable or worse in 17% of patients in the control group, compared with 44% (p = 0.01), 45% (p = 0.008), and 34% (p = 0.07), respectively. Complete preservation of neurovascular bundles (NVB) (OR: 2.95; p = 0.048) was the only perioperative intervention found to improve early UCR. CONCLUSIONS:PFMT-biofeedback and duloxetine demonstrated limited impact in improving UCR after RP. Diligent NVB preservation, along with preoperative patient and disease characteristics, are the primary determinants for early UCR.

Abstract Objective We aim to create a new score to predict postoperative overall survival in patients with nonmetastatic T3aN0 renal cell carcinoma. Methods We reviewed the clinical data of adult patients who underwent radical nephrectomy for renal cell carcinoma between December 2007 and January 2022 in a single tertiary oncological institution. Clinical characteristics, clinical‐pathological staging and histopathological characteristics were analysed. Survival analyses were determined using the Kaplan–Meier curve. A nomogram was established using Cox proportional hazard regression to identify the prognostic factors affecting the overall survival. The area under the curve, calibration curves and decision curve analysis were used to evaluate prognostic efficacy. Results We analyzed 362 patients classified as pT3aN0M0 stage with a median follow‐up of 40 months. According to Cox univariate and multivariate analyses, weight loss greater than 5% in 6 months before surgery, stage V chronic kidney disease after radical nephrectomy, sarcomatoid pattern, and coagulative tumor necrosis were identified as predictors of overall survival. We developed a score and performed internal and external validation. The time‐dependent receiver operating characteristic curve, area under the curve value and calibration curve analysis showed good prediction ability of the score. The nomogram can effectively predict and stratify overall survival after radical nephrectomy in patients with pT3aN0M0 renal cell carcinoma. Conclusion Patients with pT3aN0MO renal cell carcinoma exhibited different characteristics, and those with unfavourable characteristics deserve greater attention during follow‐up. This nomogram provides an accurate prediction of overall survival after radical nephrectomy.

There is emerging but limited data assessing single-port (SP) robot-assisted surgery as an alternative to multi-port (MP) platforms. We compared perioperative outcomes between SP and MP robot-assisted approaches for excision of high and low complexity renal masses. Retrospective chart review was performed for patients undergoing robot-assisted partial or radical nephrectomy using the SP surgical system ( n = 23) at our institution between November 2019 and November 2021. Renal masses were categorized as high complexity (7+) or low complexity (4–6) using the R.E.N.A.L. nephrometry scoring system. Adjusting for baseline characteristics, patients were matched using a prospectively maintained MP database in a 2:1 (MP:SP) ratio. For high complexity tumors ( n = 12), SP surgery was associated with a significantly longer operative time compared to MP (248.4 vs 188.1 min, p = 0.02) but a significantly shorter length of stay (1.9 vs 2.8 days, p = 0.02). For low complexity tumors ( n = 11), operative time (177.7 vs 161.4 min, p = 0.53), estimated blood loss (69.6.0 vs 142.0 mL, p = 0.62), and length of stay (1.6 vs 1.8 days, p = 0.528) were comparable between SP and MP approaches. Increasing nephrometry score was associated with a greater relative increase in operative time for SP compared to MP renal surgery ( p = 0.07) using best of fit linear modeling. SP robot-assisted partial and radical nephrectomy is safe and feasible for low complexity renal masses. For high complexity renal masses, the SP system is associated with a significantly longer operative time compared to the MP technique. Careful consideration should be given when selecting patients for SP robot-assisted kidney surgery.

You have accessJournal of UrologyLate-breaking Abstract II - Malignant1 Sep 2021LBA02-08 THE IMPROVE TRIAL: SURGICAL TECHNIQUE REMAINS THE MOST IMPORTANT FACTOR ASSOCIATED WITH RECOVERY OF URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY Rafael Sanchez-Salas, Arjun Sivaraman, Rafael Tourinho-Barbosa, Caio Pasquali, Luigi Candela, Giancarlo Marra, Lara Rodriguez-Sanchez, Nathalie Cathala, Annick Mombet, Chahrazad Bey Boumezrag, Petr Macek, and Xavier Cathelineau Rafael Sanchez-SalasRafael Sanchez-Salas , Arjun SivaramanArjun Sivaraman , Rafael Tourinho-BarbosaRafael Tourinho-Barbosa , Caio PasqualiCaio Pasquali , Luigi CandelaLuigi Candela , Giancarlo MarraGiancarlo Marra , Lara Rodriguez-SanchezLara Rodriguez-Sanchez , Nathalie CathalaNathalie Cathala , Annick MombetAnnick Mombet , Chahrazad Bey BoumezragChahrazad Bey Boumezrag , Petr MacekPetr Macek , and Xavier CathelineauXavier Cathelineau View All Author Informationhttps://doi.org/10.1097/JU.0000000000002149.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Post-radical prostatectomy (RP) urinary incontinence (UI) is not uncommon. Both pelvic floor muscle training (PFMT) and duloxetine have been shown to be effective in improving post-RP UI in retrospective series. We aim to assess the efficacy of PFMT and duloxetine in urinary continence recovery (UCR) after robot-assisted RP (RARP). METHODS: We conducted a prospective, randomized controlled trial (NCT02367404) involving patients who experienced UI after RARP. Patients were randomized to 1 of 4 arms: (1) PMFT-biofeedback (BFB) only, (2) duloxetine only, (3) combined PMFT-BFB and duloxetine, and (4) control group. The PMFT program consisted of pelvic muscle contraction exercises conducted with electromyographic feedback weekly, for 3 months. Patients in duloxetine arms were instructed to take oral duloxetine 60 mg at bedtime for 3 months. The primary end point was continence rate at 6 months, defined as no leakage of urine during 3 consecutive days on the 24-hour pad test. Urinary symptoms and quality of life (QoL) were assessed by using a visual analog scale, the International Prostate Symptom Score questionnaire, and the King’s Health Questionnaire. RESULTS: A total of 240 patients (60 in each arm) were included in the trial between 2015 and 2018. Overall, 89% of patients completed 1 year of follow-up. From the patients allocated to receive treatment, 58% (69 of 120) had properly taken duloxetine and 38% (46 of 120) performed at least 10 sessions of PMFT. In the control group 53% of patients have achieved continence at 6 months, compared with 35% (p=0.07) in the PMFT-BFB arm, 39% (p=0.2) in the duloxetine arm, and 27% (p=0.009) in the combined treatment arm, without difference in time to UCR. Moderate to severe urinary symptoms were less frequent in the control group (11%) compared with treatment arms: 27% (p=0.03), 30% (p=0.01), 24% (p=0.07), respectively. At 6 months, QoL was qualified as uncomfortable or worse in 17% of patients in the control group, compared with 44% (p=0.02), 45% (p=0.01), and 38% (p=0.06) in treatment arms, respectively. After accounting for other variables, neurovascular bundle preservation was the only factor found to be associated with UCR (OR 3.5 [IQR 1.2-10.3]; p=0.02). CONCLUSIONS: PMFT-BFB and duloxetine do not improve UCR after RP, and may have negative impact on QOL; therefore, they should not be routinely recommended to patients who have undergone RP. Neurovascular bundle preservation was the only factor found to be associated with RUC. Source of Funding: This research received no specific grant from any source of funding © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1178-e1178 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rafael Sanchez-Salas More articles by this author Arjun Sivaraman More articles by this author Rafael Tourinho-Barbosa More articles by this author Caio Pasquali More articles by this author Luigi Candela More articles by this author Giancarlo Marra More articles by this author Lara Rodriguez-Sanchez More articles by this author Nathalie Cathala More articles by this author Annick Mombet More articles by this author Chahrazad Bey Boumezrag More articles by this author Petr Macek More articles by this author Xavier Cathelineau More articles by this author Expand All Advertisement Loading ...

105 Background: Our objective was to evaluate the impact of MRI and systematic biopsy characteristics to identify the index lesion for salvage partial gland ablation using tumor maps from whole mount slides of salvage radical prostatectomy (sRP) specimen. Methods: We identified 225 patients who underwent sRP between 2000 and 2014 and a tumor map was created from whole-mount slides in 77 patients. Among these patients, we selected men with a priori pre-treatment criteria considered eligible for PGA, including, biopsy proven unilateral disease concordant with a region of interest (ROI) on MRI, and excluding men with imaging suspicious for extra-capsular extension (ECE), seminal vesicle Invasion (SVI) or lymph node involvement (LNI). We describe the correlation between pre-treatment clinical characteristics and final radical prostatectomy whole mount specimen to select men eligible for PGA defined as hemi-gland ablation. Results: Among 77 patients with a tumor map of entirely-submitted and whole-mounted specimens, 15 patients were determined to be eligible for partial gland ablation based on pre-treatment clinical characteristics. The mean age was 60 years and median time from primary RT was 48 months. The median (IQR) tumor volume of the index lesion was 0.3 (0.4) cc. The location of the index lesion was determined to be the apex, mid-gland and base in 77%, 100% and 15% of patients, respectively. The median distance of the index tumor to the urethra was 0.5 (0.2) cm. The index tumor was confined to one lobe and concordant to the biopsy pathology and MRI data in all 15 patients (100%). There was no ECE, LNI or SVI identified in the sRP specimens. To account for those patients who did not have a tumor map of the whole-mount specimen, a sensitivity analysis was performed and determined that the clinical characteristics of the 77 patients with tumor maps were comparable to the entire 225 sRP cohort. Conclusions: Clinical characteristics guided by biopsy findings and MRI data can be used to select men for PGA with recurrent localized prostate cancer after radiation therapy and based on tumor maps from sRP specimen, we propose that salvage hemi-gland ablation including periurethral tissue is feasible.

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III (MP50)1 Sep 2021MP50-07 SURGICAL TECHNIQUE IS THE MAJOR DETERMINANT OF QUALITY OF LIFE FOR PATIENTS RECOVERING CONTINENCE POST-RADICAL PROSTATECTOMY Rafael Tourinho-Barbosa, Arjun Sivaraman, Caio Pasquali, Giancarlo Marra, Luigi Candela, Lara Rodriguez-Sanchez, Nathalie Cathala, Annick Mombet, Petr Macek, Rafael Sanchez-Salas, and Xavier Cathelineau Rafael Tourinho-BarbosaRafael Tourinho-Barbosa , Arjun SivaramanArjun Sivaraman , Caio PasqualiCaio Pasquali , Giancarlo MarraGiancarlo Marra , Luigi CandelaLuigi Candela , Lara Rodriguez-SanchezLara Rodriguez-Sanchez , Nathalie CathalaNathalie Cathala , Annick MombetAnnick Mombet , Petr MacekPetr Macek , Rafael Sanchez-SalasRafael Sanchez-Salas , and Xavier CathelineauXavier Cathelineau View All Author Informationhttps://doi.org/10.1097/JU.0000000000002076.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary incontinence(UI) and erectile dysfunction (ED) are common complications of radical prostatectomy(RP) with devastating impact on quality of life(QoL). Baseline characteristics of the patient and disease, surgical technique and postoperative rehabilitation have the potential to affect QoL. To present the patient reported QoL outcomes from a prospective, randomized controlled trial comparing the use of Pelvic Floor Muscle Training (PMFT) and Duloxetine in the recovery of UI post-RP. METHODS: A total of 240 men with organ-confined disease having incontinence after catheter removal post-RARP were included and randomized into one of four arms – PMFT only, Duloxetine only, combined PMFT-duloxetine and no treatment. 213 (88.8%) out of these patients completed the 12-mo follow-up. Continence was defined as no leakage on a 3-day 24-h pad test. QoL tested in relation to incontinence according to Visual Analog Scale (VAS) and King’s Health Questionnaire (KQH), urinary symptoms measured by International Prostate Symptom Score (IPSS) and erectile function measured by International Index of Erectile Function (IIEF-5) were assessed pre-operatively and at 1, 3, 6 and 12months post-RARP. Age, obesity, prostate volume, prostate-specific antigen (PSA), Gleason score, neurovascular bundle preservation (NVB-P) uni or bilateral, and rehabilitation programs were assessed to affect QoL. RESULTS: Recovery of continence was found in 1.3%(3/239), 23%(43/187) and 64.4%(132/205) of patients at 1, 3 and 12months, respectively. Improvement in QoL, UI and ED from first visit to last follow-up was observed in all self-reported outcomes. NVB-P uni or bliateral was the single feature associated to early recovery of continence (at 3months, p=0.03) and better QoL starting from first month post-RP in both VAS (p=0.01) and KHQ (p=0.005). There was no superiority between uni or bilateral NVB-P. Continence recovery was not improved by rehabilitation programs, and was slightly worse at 6months in PMFT and Duloxetine arms (35% and 39%, respectively) compared to the control arm 53%, p=0.06. Only poorer preoperative erectile function and larger prostate were associated to ED at 12months post-RP. CONCLUSIONS: NVB-P (uni or bilateral) provides early recovery of erectile function and urinary incontinence and impacts QoL of patients post-RARP. Rehabilitation programs such as PMFT and Duloxetine have shown no benefit in QoL post-RP. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e888-e888 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rafael Tourinho-Barbosa More articles by this author Arjun Sivaraman More articles by this author Caio Pasquali More articles by this author Giancarlo Marra More articles by this author Luigi Candela More articles by this author Lara Rodriguez-Sanchez More articles by this author Nathalie Cathala More articles by this author Annick Mombet More articles by this author Petr Macek More articles by this author Rafael Sanchez-Salas More articles by this author Xavier Cathelineau More articles by this author Expand All Advertisement PDF downloadLoading ...

Introduction: With increased demands on surgeon productivity and outcomes, residency robotics training increasingly relies on simulations. The objective of this study is to assess the validity and effectiveness of an ex vivo porcine training model as a useful tool to improve surgical skill and confidence with robot-assisted partial nephrectomy (RAPN) among urology residents. Methods: A 2.5 cm circular area of ex vivo porcine kidneys was marked as the area of the tumor. Tumor excision and renorrhaphy was performed by trainees using a da Vinci Si robot. All residents ranging from postgraduate year (PGY) 2 to 5 participated in four training sessions during the 2017 to 2018 academic year. Each session was videorecorded and scored using the global evaluative assessment of robotic skills (GEARS) by faculty members. Results: Twelve residents completed the program. Initial mean GEARS score was 16.7 and improved by +1.4 with each subsequent session (p = 0.008). Initial mean excision, renorrhaphy, and total times were 8.2, 13.9, and 22.1 minutes, which improved by 1.6, 2.0, and 3.6 minutes, respectively (all p < 0.001). Residents' confidence at performing RAPN and robotic surgery increased after completing the courses (p = 0.012 and p < 0.001, respectively). Overall, residents rated that this program has greatly contributed to their skill (4/5) and confidence (4.1/5) in robotic surgery. Conclusions: An ex vivo porcine simulation model for RAPN and robotic surgery provides measurable improvement in GEARS score and reduction in procedural time, although significant differences for all PGY levels need to be confirmed with larger study participation. Adoption of this simulation in a urology residency curriculum may improve residents' skill and confidence in robotic surgery.

Irreversible electroporation (IRE) uses microsecond-long electric pulses to kill cells through membrane permeabilization, without affecting surrounding extracellular structures. We evaluated whether IRE can be used to induce urinary obstruction for a rat model of renal scarring. Intrasurgical IRE (2000 V/cm, 90 pulses, 100 μs) with caliper electrodes was performed in the right proximal ureter in male rats (n = 24) which were euthanized at 2, 5, or 10 days post-treatment, following contrast-enhanced magnetic resonance imaging. Complete urinary tract (bilateral kidneys, ureter and bladder) was extracted, and scored on a five-point scale for renal dilation, ureteral dilation and hydronephrosis. Whole kidney sections underwent immunohistochemistry to quantify levels of macrophages (CD68), activated fibroblasts [α-smooth muscle actin (α-SMA)], collagen (Masson’s Trichrome) and Hematoxylin and Eosin. Change in renal pelvis diameter and the number of glomeruli in the treated and contralateral urinary tract was also computed. Intrasurgical IRE performed with non-invasive caliper electrodes resulted in immediate loss of peristalsis in the treated ureteral segment, and cell death in the ureteral muscularis along with urothelial sloughing. Dilation of the ureter was observed on gross anatomic evaluation and histopathology. Magnetic resonance imaging indicated partial stricture and urinary obstruction in IRE-treated urinary tract, without evidence of urinoma, leakage or fistula formation. Enlargement of the kidney with progressive renal dilation and hydronephrosis was evident between Day 2 and Day 10 post-treatment. Obstructed kidney demonstrated scarring with elevated levels of tissue collagen, macrophages and α-SMA-positive fibroblasts. There was a steady decrease in the number of glomeruli in the obstructed kidney, while glomeruli numbers in the contralateral kidney remained unchanged through the 10-day observation period. IRE provides a safe and reproducible technique to induce partial ureteral obstruction and renal fibrosis in rat model without the need for ligation or its associated complications.

ABSTRACT Background Focal therapy (FT) for localized prostate cancer (PCa) treatment is raising interest. New technological mpMRI-US guided FT devices have never been compared with the previous generation of ultrasound-only guided devices. Materials and Methods We retrospectively analyzed prospectively recorded data of men undergoing FT for localized low- or intermediate-risk PCa with US- (Ablatherm®-2009 to 2014) or mpMRI-US (Focal One®-from 2014) guided HIFU. Follow-up visits and data were collected using internationally validated questionnaires at 1, 2, 3, 6 and 12 months. Results We included n=88 US-guided FT HIFU and n=52 mpMRI-US guided FT HIFU respectively. No major baseline differences were present except higher rates of Gleason 3+4 for the mpMRI-US group. No major differences were present in hospital stay (p=0.1), catheterization time (p=0.5) and complications (p=0.2) although these tended to be lower in the mpMRI-US group (6.8% versus 13.2% US FT group). At 3 months mpMRI-US guided HIFU had significantly lower urine leak (5.1% vs. 15.9%, p=0.04) and a lower drop in IIEF scores (2 vs. 4.2, p=0.07). Of those undergoing 12-months control biopsy in the mpMRI-US-guided HIFU group, 26% had residual cancer in the treated lobe. Conclusion HIFU FT guided by MRI-US fusion may allow improved functional outcomes and fewer complications compared to US- guided HIFU FT alone. Further analysis is needed to confirm benefits of mpMRI implementation at a longer follow-up and on a larger cohort of patients.

Whether focal therapy (FT) jeopardizes subsequent prostate cancer (PCa) salvage treatments, when needed, remains a major concern and is largely unknown. To describe and report safety, oncological and functional outcomes of salvage treatments following PCa recurrence and/or persistence after FT. A systematic review on salvage treatments for PCa recurrence/persistence after FT was carried out according to the PRISMA guidelines using an ‘a priori protocol’. A comprehensive literature review was also performed to investigate options to treat FT PCa recurrence/persistence that have not yet been reported after FT. Four retrospective series were included (n = 67 men); overall quality of the studies was low. Salvage treatments yielded 32.8% (n = 22 of 67) biochemical recurrence rate (BCR) after a 7–62-months mean follow-up. No cancer-related deaths occurred. Patients experienced acceptable complications (n = 12 patients; n = 8 Clavien 3) and rare severe incontinence (4.5% using > 2 pads/day). Erectile function (EF) was rarely assessed (62.8% no information available), being overall poor. Other salvage options have been reported following whole-gland ablation and include: (1) re-do ablation yielding worst BCR and EF but similar complications and continence compared to first line ablation; (2) salvage radiotherapy yielding 16.6–38.8% BCR and acceptable toxicity profile with urinary and EF being poorly assessed. Current evidence is weak and limited to a few retrospective series. Oncological control is acceptable although it seems lower compared to a primary treatment setting. Functional outcomes are comparable to primary treatment with the exception of EF; overall, suggesting FT has little impact on subsequent salvage treatments. Future studies are needed to confirm the current findings.