INTRODUCTION:Radical prostatectomy (RP) practice has been transformed by active surveillance (AS) guidelines for low-risk prostate cancer and the 2014 ISUP Gleason reclassification. The aim of this study was to describe the temporal evolution of clinical and pathological characteristics of patients undergoing RP at two high-volume French centers over 18 years. MATERIAL:We retrospectively analyzed 8,358 consecutive RPs performed between January 2007 and December 2025 at Hôpital Foch and Institut Montsouris (Paris). Patients were stratified by D'Amico risk classification across three periods (2007-2012, 2013-2018, 2019-2025). RESULTS:Low-risk patients declined from 4.5% to 0.6% (P<0.001); high-risk patients increased from 9.5% to 21.7% (P<0.001). Biopsy Gleason score≤6 fell from 48.0% to 4.2% (P<0.001). Pathological stage≥pT3 rose from 30.5% to 47.3% (P<0.001) and lymph node involvement (pN1) from 1.0% to 5.4% (P<0.001). Median age increased from 62.6 to 66.2 years (P<0.001). These shifts accelerated after 2012-2014, coinciding with major AFU guideline revisions and the ISUP reclassification. CONCLUSION:This large bicentric series demonstrates a profound and sustained shift in the risk profile of patients undergoing RP over 18 years, with near-disappearance of low-risk cases and growing proportions of high-risk and pathologically advanced disease, which may reflect successful guideline-concordant AS implementation. LEVEL OF EVIDENCE:Low.

BACKGROUND AND OBJECTIVE:Androgen-deprivation therapy survival benefits after radical prostatectomy (RP) in nonmetastatic high-risk prostate cancer (PCa) patients with an undetectable prostate-specific antigen (PSA) level are unclear. The AFU-GETUG-20 study assessed the benefit of leuprorelin immediately after RP in this population. METHODS:This open-label, randomized, phase 3 trial is conducted at 37 French centers. Participants undergoing RP for nonmetastatic PCa were aged ≥18 yr, with a postoperative Gleason score of ≥7 and PSA <0.1 ng/ml. Participants were randomly assigned (1:1) to the observation or leuprorelin (45 mg subcutaneous Q6M, 24 mo) arm. The primary endpoint was metastasis-free survival in the intent-to-treat population (n = 322). The secondary objectives PSA and testosterone level evolution, PCa-specific survival, overall survival, safety, and quality of life. KEY FINDINGS AND LIMITATIONS:From 2011 to 2017, 325 patients were randomized to the observation (n = 163) or leuprorelin (n = 162) arm. The 10-yr risk of metastasis occurrence was similar between arms (hazard ratio [HR] 0.63 [95% confidence interval {CI} 0.30-1.30]; p = 0.204) with no differences in PSA rise-free survival (HR 0.74 [95% CI 0.47-1.16]; p = 0.187), overall survival (HR 1.24 [95% CI 0.56-2.76]; p = 0.596), or PCa-specific survival (HR 0.57 [95% CI 0.10-3.17]; p = 0.512). Leuprorelin-treated patients had lower testosterone level after surgery (p < 0.001), shorter time to global health degradation (p = 0.0019), fatigue (p < 0.001), pain (p < 0.001), and additional adverse events, mainly hot flashes (83.6% vs 6.2%), pain (57.2% vs. 17.1%), fatigue (45.4% vs 16.3%), and psychiatric disorders (25.0% vs 2.3%). Insufficient enrollment affected the trial power but permitted pertinent comparison. CONCLUSIONS AND CLINICAL IMPLICATIONS:Leuprorelin treatment immediately after RP in high-risk nonmetastatic PCa patients with an undetectable PSA level does not improve survival, but increases adverse events, leading to poorer quality of life compared with observation.

BACKGROUND AND OBJECTIVE:Irreversible electroporation (IRE) is an emerging non-thermal focal therapy for localized prostate cancer (PCa), offering tissue-selective ablation with functional preservation. This review aimed to delineate the 'ideal' candidate for primary IRE and provide practical guidance. METHODS:A narrative review (2014-2025) of primary IRE for localized PCa was conducted, including prospective series, multicentre registries, comparative studies, and systematic reviews. We synthesized baseline characteristics, lesion features, ablation strategy, oncologic/functional outcomes, and complications, focusing on cancer control and safety. RESULTS:The best outcomes were reported in men with magnetic resonance imaging-visible, organ-confined intermediate-risk (International Society for Urological Pathology [ISUP] 2-3) PCa, typically presenting a single dominant unilateral index lesion characterized by multiparametric MRI and biopsy. Contemporary series show in-field ablation of clinically significant cancer in ~80-90% with high functional preservation. The main limitation is out-of-field recurrence (~15-25% of failures), reflecting PCa multifocality. In-field persistence at 12 months was ~16% in the PRESERVE trial. Lesion size is a key practical constraint; current evidence and electrode geometry favour targets generally ≤20 mm. Limited comparative evidence, largely from a single study, suggests better oncologic control with hemi-gland IRE (clinically significant PCa persistence 8.6%) versus focal ablation (25%), whereas focal IRE better preserves erectile function. CONCLUSIONS AND CLINICAL IMPLICATIONS:Primary IRE appears safe and effective in selected localized PCa. The ideal candidate has unilateral MRI-visible, organ-confined ISUP 2-3 disease, prostate-specific antigen density <0.15-0.20 ng/mL/cm3, and a lesion small enough for reliable electrode coverage. Hemi-gland templates may improve oncologic reliability, whereas focal ablation maximizes functional outcomes. PATIENT SUMMARY:IRE is a focal, non-thermal treatment for localized PCa that can control the treated lesion while usually preserving urinary continence and often erectile function. Cancer can still occur elsewhere in the prostate after treatment, so follow-up is essential.

BACKGROUND AND OBJECTIVE:The VAPEUR randomized controlled trial compared Rezūm water vapor thermal therapy (WVTT) with combination pharmacotherapy (CP; alpha-blockers plus 5-alpha-reductase inhibitors) in sexually active men with symptomatic benign prostatic obstruction (BPO). METHODS:Overall, 151 men were randomized to WVTT (n = 75) or CP (n = 76). Primary endpoints changed from baseline to 1 yr in the International Prostate Symptom Score (IPSS) and Male Sexual Health Questionnaire (MSHQ) score. Secondary endpoints included surgical/medical treatment for recurring symptoms, ≥4 points IPSS worsening (ΔIPSS ≥4), and catheterization beyond 90 d post-procedure. KEY FINDINGS AND LIMITATIONS:At 1 yr, IPSS improvement was greater with WVTT than CP (mean difference -4.6 points; 97.5% confidence interval [CI] -7.6 to -1.6; p < 0.001), with mean improvements of 10.8 ± 6.8 versus 6.2 ± 7.7 points, respectively. MSHQ scores remained stable with WVTT (+1.1 ± 16.9) and CP (-5.2 ± 16.4). Superiority in preserving sexual function was not demonstrated with multiple imputation. Quality‑of‑life (QoL) improvement was greater with WVTT (-2.7 ± 1.8 vs -1.8 ± 2.0; p = 0.01). WVTT resulted in lower rates of surgical retreatment (1.3% vs 9.2%), ΔIPSS ≥4, (2.7% vs 13%) and post-90 d catheterization (0% vs 1.3%), but higher pharmacological retreatment (12% vs 1.3%; combined: hazard ratio = 0.52, CI 0.25-1.1, p = 0.08). Treatment‑related adverse events (AEs) were more frequent with WVTT (40% vs 28%; serious AEs, 12% vs 1.3%), largely procedure‑related; at 1 yr, 93% were resolved in WVTT versus 60% (25/42) in CP. CONCLUSIONS AND CLINICAL IMPLICATIONS:At 1 yr, WVTT provides superior symptom relief and greater QoL improvement versus CP, while preserving sexual function. These findings support WVTT as an effective alternative to CP.

OBJECTIVES:To evaluate outcomes of FT (HIFU or cryotherapy) in prostate cancer (PCa) patients who do not meet the ideal focal therapy candidate profile, assessing whether expanding selection criteria beyond traditional parameters is safe. MATERIALS AND METHODS:A retrospective analysis was performed on 282 patients treated with FT for ISUP 1 and 2 PCa at a single European center (2009-2020). Patients were categorized into three groups: G1 (ideal candidates: single lesion ≤12mm, favorable biopsy features), G2 (ISUP 1 with minor deviations), and G3 (ISUP 2 with multiple lesions, larger tumor size, or positive cores outside the target zone). A secondary exploratory analysis compared ISUP 2 patients fully meeting criteria versus those with one deviating feature. Multivariable regression with propensity score matching was applied. RESULTS:Overall recurrence occurred in 187 patients (66%): 77% in G1, 60% in G2, and 77% in G3. No significant differences were observed between G1 and G3 regarding infield recurrence-free survival, clinically significant infield recurrence-free survival, or outfield recurrence-free survival (all p>0.05). In the secondary analysis, lesion size ≥12mm was the only feature associated with worse infield recurrence-free survival (p=0.04) and clinically significant infield recurrence-free survival (p=0.001). Multivariate Cox regression confirmed lesion size as an independent predictor (HR: 1.21; 95% CI: 1.05-1.40; p=0.01). CONCLUSIONS:Expanding FT selection criteria to include selected ISUP 2 patients with features outside traditional parameters appears safe. These preliminary findings highlight the need for multicenter studies to validate these results.

BackgroundRadical prostatectomy remains a key curative treatment for localized prostate cancer which has undergone continuous transformation. Recent developments in robot-assisted and single-port surgery have followed the concept of minimizing morbidity while maintaining oncologic safety. Furthermore, the integration of artificial intelligence and novel diagnostic tools have transformed the modern surgical workflow. Therefore, the aim of this study is to give an overview of the evolution of surgical techniques, functional and oncological outcomes, and available surgeon-assisting concepts.MethodsWe conducted a non-structured review to summarize the evolution of radical prostatectomy techniques and recent developments in surgeon-assisting tools. Relevant English-language publications were identified through a targeted PubMed search using predefined keywords related to, laparoscopic, robot-assisted, Retzius-sparing, and single-port approaches. Key studies, systematic reviews, and meta-analyses were used and synthesized to provide a comparative overview. Furthermore, studies focusing on integration of artificial intelligence, novel diagnostic tools and targeted surgery are discussed.ResultsLaparoscopic surgery aims to reduce morbidity yet is technically demanding. Robotic-assisted approaches improve visualization and precision, leading to faster recovery and earlier continence recovery. Newer Retzius-sparing and single-port techniques show promising functional results, though evidence is still limited. Novel diagnostic tools including image overlay, targeted surgery, and fast and accurate intraoperative pathological assessment of resection margins are increasingly shaping modern radical prostatectomy.ConclusionRadical prostatectomy has evolved into a minimally invasive, technology-driven procedure with improved recovery and functional outcomes. Advances in robotics, imaging, and artificial intelligence enhance surgical precision. Ongoing innovation and long-term data will define the future of prostate surgery.

BACKGROUND:Prostate biopsy is a complex, multi-step procedure lacking standardisation across patient selection, tools, technique, and biopsy strategy, potentially influencing local treatment planning. An international consensus project was initiated to harmonise these aspects. METHODS AND ANALYSIS:A systematic review informed statement development. A modified Delphi process involving 34 international experts was conducted over three rounds. Panellists evaluated 96, 99, and 112 statements in Rounds 1-3, respectively, grouped into 36 stems. Statements were iteratively revised based on feedback and discussion. Consensus was assessed using a modified RAND appropriateness method. KEY FINDINGS AND LIMITATIONS:All experts completed the three rounds. Consensus was achieved for 29 of 36 stems (81%). Both biparametric and multiparametric magnetic resonance imaging were endorsed within the diagnostic pathway, provided imaging quality is adequate. Key elements of a targeted plus perilesional biopsy scheme were harmonised. For treatment planning, a targeted ± perilesional biopsy scheme was considered sufficient for most aspects of local treatment planning. However, additional contralateral sampling still seems necessary for specific indications, notably focal therapy candidate selection. Limitations include imbalances in specialty representation and heterogeneity in expertise across topics. CONCLUSION AND CLINICAL IMPLICATIONS:The ProBIOPSY consensus defines a contemporary, standardised framework for prostate biopsy. While targeted-based strategies are sufficient for most clinical scenarios, no single biopsy approach provides complete information for all treatment decisions, underscoring the need for indication-specific biopsy tailoring.

INTRODUCTION:Androgen deprivation therapy (ADT) remains a cornerstone of treatment for both localized and metastatic prostate cancer (PC). Relugolix, an oral gonadotrophin-releasing hormone antagonist, provides a new option for achieving rapid testosterone suppression using an oral formulation. MATERIALS AND METHODS:A comprehensive literature search was conducted in PubMed by combining the search terms "relugolix", "TAK-385", "MVT-601", "prostate cancer", and "prostatic neoplasms" and focusing on prospective and retrospective studies published in English. RESULTS:The HERO pivotal phase III trial demonstrated sustained testosterone suppression in 96.7% of patients with PC treated with relugolix versus 88.8% with leuprolide through to 48weeks (P<0.001). Relugolix achieved faster testosterone suppression and recovery post-treatment and a 54% lower risk of major adverse cardiovascular events compared with leuprolide. Data from HERO and phase II studies also support its use in combination with radiotherapy or other systemic therapies. Real-world studies performed to date have confirmed the effectiveness of relugolix, with more than 98% patients achieving castrate testosterone levels. Adherence to relugolix was generally high, and its safety profile aligned with clinical trial data. Practical considerations include, among others, treatment combination and drug-drug interactions, patient choice, and oncological outcomes. CONCLUSIONS:Clinical trials and real-world evidence support relugolix as a convenient and effective ADT option for PC. It offers rapid and sustained testosterone suppression, potential cardiovascular benefits, and an alternative to injectable therapies. Long-term adherence, the use of combination treatments and related drug-drug interactions require further investigation.

Background/Objectives: Focal therapy (FT) for prostate cancer (PCa) is an alternative to radical treatments that aims to balance cancer control and quality of life preservation in well-selected patients. Understanding its general principles and outcomes is key for its widespread adoption and proper implementation. Methods: The International Consultation on Urological Diseases nominated a committee to review the literature on FT for PCa. A comprehensive PubMed search was conducted to identify articles focused on the different aspects of FT, including patient selection, imaging techniques, treatment modalities, cancer control and safety outcomes, integration with other approaches and future perspectives. Results: FT for PCa was introduced in the 1990s with cryotherapy and high-intensity focused ultrasound (HIFU) as pioneering modalities. Though initially guided by transrectal ultrasound (TRUS) and large biopsy templates, FT implementation expanded significantly with the advent of multiparametric magnetic resonance imaging (MRI) and the validation of the index lesion concept. Appropriate patient selection is key for FT and relies on prostate-specific antigen (PSA) metrics, MRI findings and targeted biopsy information. Multiple energy sources are now available, each with specific technical characteristics. Cancer control rates vary by energy modality, tumor characteristics, and institutional experience, demonstrating comparable outcomes to radical treatments in well-selected patients. The safety profile is excellent, with high rates of urinary continence and sexual function preservation. Post-treatment surveillance integrates PSA measurements, imaging, and histological assessment. Future directions for further FT adoption include the availability of long-term data, protocol standardization and technological improvements to enhance patient selection and treatment planning and delivery. Conclusions: FT is a valuable therapeutic option for selected patients with localized PCa, demonstrating promising oncological outcomes and better functional preservation compared to radical treatments. Understanding its principles and technical aspects is essential for offering comprehensive PCa care.

For intermediate-risk prostate cancer, definitions remain inconsistent and management varies. Greater precision is urgently needed via optimal use of existing tools and integration of emerging innovations to harmonise care and improve outcomes for this most common disease category.

You have accessJournal of UrologyProstate Cancer: Localized: Ablative Therapy II (PD39)1 May 2024PD39-11 REDO FOCAL THERAPY FOR RECURRENT LOCALIZED PROSTATE CANCER: A SINGLE INSTITUTION EXPERIENCE Daniele Cignoli, Luigi Candela, Andrea Rodriguez-Serrano, David Lopez, Armando Stabile, Andrea Salonia, Alberto Briganti, Francesco Montorsi, Camille Lanz, Eric Barret, Annick Mombet, Petr Macek, Xavier Cathelineau, and Lara Rodriguez-Sanchez Daniele CignoliDaniele Cignoli , Luigi CandelaLuigi Candela , Andrea Rodriguez-SerranoAndrea Rodriguez-Serrano , David LopezDavid Lopez , Armando StabileArmando Stabile , Andrea SaloniaAndrea Salonia , Alberto BrigantiAlberto Briganti , Francesco MontorsiFrancesco Montorsi , Camille LanzCamille Lanz , Eric BarretEric Barret , Annick MombetAnnick Mombet , Petr MacekPetr Macek , Xavier CathelineauXavier Cathelineau , and Lara Rodriguez-SanchezLara Rodriguez-Sanchez View All Author Informationhttps://doi.org/10.1097/01.JU.0001008924.16121.42.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Focal therapy [FT] for localized Prostate Cancer [PCa] is associated with a not negligible rate of recurrence after treatment. With this study, we aimed to assess the safety and efficacy of redoFT [rFT]. METHODS: 48 patients treated with rFT (HIFU or cryotherapy [CRYO]) because of recurrence after a previous FT for low- and intermediate-risk PCa at one European high-volume center between 2009 and 2018, were retrospectively analyzed. The primary outcome of the study was to assess failure free-survival (FFS, defined as post rFT positive biopsy within ISUP≥2, whole gland or systemic salvage treatment, PCa metastasis and/or PCa specific death) and radical treatment free-survival (TFS, radical prostatectomy [RP], radiotherapy [RT], and/or hormone therapy [HT] after rFT). Secondly, Multivariable Cox regression analysis [MVA] was used to predict the effect of %∆PSA after rFT (defined as the ratio between PSA nadir and pre-rFT PSA) on the outcomes. Covariates were age, pre-rFT PSA and PSA density [PSAd], ISUP, mm of positive biopsy cores and treatment type. RESULTS: All 48 patients included in the analyses underwent a first FT (67% HIFU and 33% CRYO) for low- and intermediate-risk PCa (63% ISUP1 and 37% ISUP2-3) and a rFT (71% HIFU and 29% CRYO) because of recurrence. Median %∆PSA, after rFT, was 47%(IQR: 22-63). Median FU, after rFT, was 54mos (IQR:32-70). Treatment failure rate after rFT was 50% (24pts). Among recurrences, 58% (14pts) were infield to rFT location, while outfield in 42% (10pts). 58% were ISUP 2, 38% ISUP 3 and 4% ISUP 4. Median FFS was 63mos (95%CI 27-NA). Because of recurrence, 23pts (48%) underwent whole gland treatment, namely RP(8%), RT(23%), HT(4%) or a combination(13%). Median TFS was 41mos (95%CI 30-NA). PCa metastasis occurred in 2 patients and no PCa specific death were registered. At MVA, %∆PSA after rFT was an independent predictor of both FFS (HR: 0.25, 95%CI: 0.08-0.75, p=0.01) and TFS (HR: 0.20, 95%CI: 0.06-0.65, p=0.007). Overall, 9pts (19%) experienced early complications after rFT, 8(17%) were Clavien 1 and 1(2%) Clavien 2. CONCLUSIONS: With a low rate of complications, rFT seems to be a good option in case of recurrence after a previous FT as approximately half of patients who experience PCa recurrence after their initial FT treatment may be able to postpone or even avoid the need for more invasive radical therapies. Multicenter studies are warranted. Download PPT Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e817 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Daniele Cignoli More articles by this author Luigi Candela More articles by this author Andrea Rodriguez-Serrano More articles by this author David Lopez More articles by this author Armando Stabile More articles by this author Andrea Salonia More articles by this author Alberto Briganti More articles by this author Francesco Montorsi More articles by this author Camille Lanz More articles by this author Eric Barret More articles by this author Annick Mombet More articles by this author Petr Macek More articles by this author Xavier Cathelineau More articles by this author Lara Rodriguez-Sanchez More articles by this author Expand All Advertisement PDF downloadLoading ...

Advances in imaging modalities and radiotherapy (RT) technologies have enabled the development of focal RT approaches for localized prostate cancer (PCa). This systematic review aims to evaluate the oncological and toxicity outcomes of focal or partial-gland RT, while also discussing the optimal patient selection criteria and treatment planning strategies for this emerging approach. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The literature search was performed on February, 2025, on Pubmed, with the keywords “focal RT” and “definitive” and “prostate cancer”; and “focal brachytherapy (BT)” and “definitive” and “prostate cancer”. Both focal BT and partial-gland stereotactic body radiotherapy (SBRT) strategies demonstrated a minimal impact on toxicity and quality of life parameters. Only a transient increase in urinary frequency was suggested at 6–12 months following focal treatment, returning to baseline thereafter. In highly selected low-risk (LR) and intermediate-risk (IR) PCa patients with both excellent radiological-histological concordance and a limited number of positive cores, focal RT demonstrated excellent biochemical relapse-free survival and metastasis-free survival, reaching up to 97

BACKGROUND AND OBJECTIVE:Kidney-sparing treatments are salvage options for renal cell carcinoma (RCC) after local recurrence. However, there is no level 1 evidence in the literature examining the efficacy of focal therapies (FTs) and partial nephrectomy (PN) in a head-to-head, randomised comparison. METHODS:A systematic search (PROSPERO CRD420251033642) was performed. The present analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. KEY FINDINGS AND LIMITATIONS:Overall, 30 studies involving 873 patients were included in the final analysis. Patients with RCC were treated primarily with FTs (n = 376, 43%) and PN (n = 462, 53%). Of FTs, cryoablation was received by 198 (57%) RCC patients. The rates of recurrence for FTs ranged from 4% to 20%, while those for PN ranged from 3% to 19%. The intraoperative complication rates ranged from 2% to 6% for FTs and from 3% to 9% for PN. The postoperative complications rates ranged from 2% to 40% for FTs and from 8% to 40% for PN, while the major postoperative complications rates, defined as Clavien-Dindo ≥3, ranged from 2% to 9% for FTs and from 1% to 18% for PN. The rates of overall survival ranged from 82% to 100% for FTs, and from 96% to 100% for PNs. Limitations included the bias in patients' selection and the absence of time-to-event data. CONCLUSIONS AND CLINICAL IMPLICATIONS:PN achieved acceptable overall survival, recurrence, and complication profiles, demonstrating its feasibility in a salvage setting. Patient selection is mandatory to identify those best candidates for PN and FT, thereby prioritising oncological outcomes.

PURPOSE:We compare the detection rates of clinically significant prostate cancer (csPCa) between cognitively targeted micro-ultrasound-guided biopsy (MB) and MRI/ultrasound fusion-guided biopsy (PFB) in men with MRI-visible lesions. MATERIALS AND METHODS:We retrospectively analyzed 1119 men who underwent MB (n = 767) or PFB (n = 352) between 2019 and 2022. Inverse probability of treatment weighting based on a logistic regression propensity score was applied to balance baseline characteristics between groups. Weighted logistic regression models were used to compare csPCa detection in the overall cohort and in subgroups of biopsy-naïve men and those with anterior lesions. A separate multivariable logistic regression was performed in the full cohort to identify independent predictors of csPCa. Concordance between biopsy and radical prostatectomy Gleason scores was also evaluated. RESULTS:After inverse probability of treatment weighting adjustment, csPCa detection with MB was higher than with PFB in combined sampling (45% vs 34%; odds ratio, 1.61; 95% CI: 1.23-2.11; P < .01). However, no significant difference was observed between techniques for targeted biopsies alone, both in the overall cohort and among biopsy-naïve men. In patients with anterior lesions, csPCa detection rates were also similar. In the full cohort multivariable model, MB and Prostate Imaging-Reporting and Data System 5 lesions were independently associated with csPCa. Gleason upgrading at prostatectomy was more frequent in the PFB group (38% vs 17%; P = .01). CONCLUSIONS:While MB demonstrated higher csPCa detection in adjusted analyses, the benefit was not consistent across all settings. Further studies are warranted to determine whether this reflects a methodological advantage or context-dependent factors.