Prostate cancer (PCa) management poses challenges due to treatment-related morbidities associated with conventional therapies. Focal therapy (FT) is emerging as a promising alternative for intermediate-risk PCa, aiming to selectively target localized cancerous lesions while preserving healthy tissue. This review explores emerging FT modalities for PCa treatment, focusing on transrectal MRI-guided focused ultrasound surgery (MRgFUS), transurethral ultrasound ablation (TULSA), focal laser ablation (FLA), and histotripsy. A comprehensive literature search was conducted to identify studies and clinical trials related to FT. Relevant articles were selected and data were synthesized to provide insights into the efficacy and feasibility of MRgFUS, TULSA, FLA, and histotripsy for FT. MRgFUS utilizes transrectal high-intensity focused ultrasound under MRI guidance to selectively ablate cancerous tissue, demonstrating positive outcomes in oncologic control and preservation of urinary and sexual function. TULSA employs transurethral delivery of high-intensity ultrasound energy under MRI guidance, showing promising results for whole gland treatment. FLA benefits from precise ablation, indicating effectiveness in tumor destruction while preserving quality-of-life. Histotripsy, a mechanical ablation method, exhibits promise by inducing tissue fractionation through bubble activity, offering advantages such as tissue selectivity and real-time treatment monitoring. Emerging FT modalities present promising alternatives for the management of localized PCa, offering personalized treatment. Further research and clinical trials are warranted to establish the long-term efficacy of these techniques in PCa management.

Focal Laser ablation (FLA), or interstitial Laser thermotherapy, is a promising minimally invasive approach for the treatment of localized prostate cancer and benign prostatic hyperplasia. This technique is gaining popularity among patients due to its ability to preserve pre-treatment quality of life. The examination is performed under magnetic resonance imaging (in bore) or ultrasound guidance, via a percutaneous transrectal or transperineal route. Under transperineal ultrasound guidance, FLA can use up to four Laser fibers to create confluent zones of tissue ablation, enabling treatment of larger prostate- or tumor volumes. Primary indications for FLA include intermediate-risk localized prostate cancer and benign prostatic hyperplasia refractory to medical treatment due to ineffectiveness or side effects. The intervention is typically performed under light sedation or under locoregional anesthesia. FLA lasts approximately 10 min, with a total intervention time of < 60 min on an outpatient basis. Patients are often discharged with either a suprapubic or bladder catheter to prevent urinary retention, especially if the ablated area is close to the urethra. Minor complications are rare and limited to transient voiding dysfunction, urinary tract infection, or hematuria. Major complications, such as rectoprostatic fistula, are avoided by rectoprostatic hydrodissection. FLA is an effective, well-tolerated option in the minimally invasive treatment of prostate disease, offering rapid treatment times, low complication rates, and preservation of quality of life for appropriately selected patients. However, variability in recurrence rates following FLA for prostate cancer highlights the need for further investigation into optimal patient selection for this treatment.

Objective: To evaluate transperineal laser ablation (TPLA) with Echolaser® (Echolaser® TPLA, Elesta S.p.A., Calenzano, Italy) as a treatment for benign prostatic hyperplasia (BPH) and prostate cancer (PCa) using the Delphi consensus method. Methods: Italian and international experts on BPH and PCa participated in a collaborative consensus project. During two rounds, they expressed their opinions on Echolaser® TPLA for the treatment of BPH and PCa answering online questionnaires on indications, methodology, and potential complications of this technology. Level of agreement or disagreement to reach consensus was set at 75%. If the consensus was not achieved, questions were modified after each round. A final round was performed during an online meeting, in which results were discussed and finalized. Results: Thirty-two out of forty invited experts participated and consensus was reached on all topics. Agreement was achieved on recommending Echolaser® TPLA as a treatment of BPH in patients with ample range of prostate volume, from <40 mL (80%) to >80 mL (80%), comorbidities (100%), antiplatelet or anticoagulant treatment (96%), indwelling catheter (77%), and strong will of preserving ejaculatory function (100%). Majority of respondents agreed that Echolaser® TPLA is a potential option for the treatment of localized PCa (78%) and recommended it for low-risk PCa (90%). During the final round, experts concluded that it can be used for intermediate-risk PCa and it should be proposed as an effective alternative to radical prostatectomy for patients with strong will of avoiding urinary incontinence and sexual dysfunction. Almost all participants agreed that the transperineal approach of this organ-sparing technique is safer than transrectal and transurethral approaches typical of other techniques (97% of agreement among experts). Pre-procedural assessment, technical aspects, post-procedural catheterization, pharmacological therapy, and expected outcomes were discussed, leading to statements and recommendations. Conclusion: Echolaser® TPLA is a safe and effective procedure that treats BPH and localized PCa with satisfactory functional and sexual outcomes.

Background and objective: Prostate multiparametric magnetic resonance imaging (MRI) shows high sensitivity for International Society of Urological Pathology grade group (GG) >2 cancers. Many artificial intelligence algorithms have shown promising results in diagnosing clinically significant prostate cancer on MRI. To assess a region-of-interest- based machine-learning algorithm aimed at characterising GG >2 prostate cancer on multiparametric MRI. Methods: The lesions targeted at biopsy in the MRI-FIRST dataset were retrospectively delineated and assessed using a previously developed algorithm. The Prostate Imaging- Reporting and Data System version 2 (PI-RADSv2) score assigned prospectively before biopsy and the algorithm score calculated retrospectively in the regions of interest were compared for diagnosing GG >2 cancer, using the areas under the curve (AUCs), and sensitivities and specificities calculated with predefined thresholds (PIRADSv2 scores >3 and >4; algorithm scores yielding 90% sensitivity in the training database). Ten predefined biopsy strategies were assessed retrospectively. Key findings and limitations: After excluding 19 patients, we analysed 232 patients imaged on 16 different scanners; 85 had GG >2 cancer at biopsy. At patient level, AUCs of the algorithm and PI-RADSv2 were 77% (95% confidence interval [CI]: 70-82) and 80% (CI: 74-85; p = 0.36), respectively. The algorithm's sensitivity and specificity were 86% (CI: 76-93) and 65% (CI: 54-73), respectively. PI-RADSv2 sensitivities and specificities were 95% (CI: 89-100) and 38% (CI: 26-47), and 89% (CI: 79-96) and 47% (CI: 35-57) for thresholds of >3 and >4, respectively. Using the PI-RADSv2 score to trigger a biopsy would have avoided 26-34% of biopsies while missing 5-11% of GG >2 cancers. Combining prostate-specific antigen density, the PI-RADSv2 and algorithm's scores would have avoided 44-47% of biopsies while missing 6-9% of GG >2 cancers. Limitations include the retrospective nature of the study and a lack of PI-RADS version 2.1 assessment. Conclusions and clinical implications: The algorithm provided robust results in the multicentre multiscanner MRI-FIRST database and could help select patients for biopsy. Patient summary: An artificial intelligence-based algorithm aimed at diagnosing aggressive cancers on prostate magnetic resonance imaging showed results similar to expert human assessment in a prospectively acquired multicentre test database. (c) 2024 The Author(s). Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY license.

To prospectively determine the value of post-MRI micro-ultrasonography (microUS) in the diagnosis of transition zone (TZ) significant prostate cancer (sPCa). Eighty-four consecutive men (66 ± 6.3 years) with a mean PSA level of 10.2 ± 7.4 ng/mL and at least one TZ-PI-RADS > 2 lesion were included. All patients had MRI-directed microUS and biopsy. Sensitivity and specificity of post-MRI microUS to visualize PI-RADS > 2 TZ lesions, the cancer detection rate of TZ-sPCa, and tumor characteristics according to their visibility on microUS were evaluated. Interreader agreement for detecting microUS+ lesions was evaluated using Cohen’s kappa test. Of the 92 PI-RADS > 2 lesions, 71 (71/92; 77

Longtemps négligées au profit de la voie transrectale, les biopsies de prostate par voie transpérinéale connaissent depuis peu un regain d’intérêt. De plus en plus pratiquées en raison du risque infectieux significativement inférieur à celui de la voie transrectale, elles sont associées à des performances diagnostiques similaires après une courbe d’apprentissage. Cet article rapporte les principales étapes, les indications et les précautions nécessaires pour réaliser ces biopsies encore trop peu pratiquées.

L’IRM de la prostate localise avec précision le cancer de la zone transition (ZT) diagnostiqué ensuite par des biopsies ciblées avec fusion d’images ou des biopsies guidées par IRM, avec les limites d’utilisation propres à chaque technique. La résolution spatiale élevée de la micro-échographie, qui utilise une sonde de très haute fréquence (29 MHz) pourrait pallier les inconvénients des deux techniques pour guider les prélèvements. Une IRM biparamétrique a été réalisée avant biopsie chez 61 patients consécutifs présentant une lésion de score PI-RADS > 2 dans la ZT. L’examen, réalisé à 1,5 T avec une antenne pelvienne de 60 éléments (Aera 64, Siemens Healthineers), comportait une séquence T2-3D et une séquence de diffusion avec trois valeurs de b acquises (b50, 500, 1000 s/mm2) et trois calculées (b2000, 4000, 6000 s/mm2). Une fusion d’images était disponible, mais non activée d’emblée, pour évaluer la fiabilité de la micro-échographie sans fusion dans la détection des cancers significatifs (sCaP) de la ZT visibles à l’IRM (présence de grade de Gleason 4 et/ou longueur maximale de cancer [LMCa] > 3 mm sur une carotte). L’âge moyen, le taux moyen de PSA et le volume prostatique étaient respectivement de 65 ± 9,8 [SD]ans (extrêmes : 50–80), de 10,6 ± [SD]8,5 ng/mL (extrêmes : 2–55) et de 57 ± 30[SD]mL (extrêmes : 25–160). L’IRM montrait 64 lésions focales PI-RADS 3, 4, 5 dans respectivement 21 (21/64,33 %), 27 (27/64,42 %) et 16 (16/64,25 %) d’entre elles. La micro-échographie a visualisé 52 lésions (52/64, 81 %), sans fusion d’images pour 42 (42/52,81 %), après activation de la fusion d’images pour 10 d’entre elles (10/52,19 %) et manquait 12 lésions (12/64, 19 %). Le taux de détection global des sCaP était de 48,3 % (31/64) et de 0,9 % (2/21), 59 % (16/27), 81 % (13/16), en cas de PI-RADS respectivement 3, 4, 5. Sur les 43 lésions PI-RADS 4 et 5, la lésion était visualisée 30 fois (30/43,70 %) par micro-échographie sans fusion, 7 fois (7/43,16 %) après fusion et restait 6 fois non détectable (6/43,14 %). La micro-échographie peut visualiser la majorité des lésions PI-RADS > 2 de la ZT. Les lésions PI-RADS 3 sont en grande majorité des lésions bénignes. La micro-échographie pourrait être réservée aux lésions PI-RADS 4 et 5, mais la fusion d’images reste nécessaire pour réaliser la biopsie des lésions non visualisées.

Objective: To compare the mean apparent diffusion coefficient (ADCmean) and glandular density of Gleason score (GS) 3 + 3 transition zone prostate cancers (TZ-PCa) with those of the peripheral zone (PZ-PCa). Material & methods: Seventy-nine men (mean age: 65 +/- 6 [SD] years; range: 52-81 years) with 37 TZ-PCa (37/ 79; 53 %) and 42 PZ-PCa (42/79; 47 %) had prostate MRI before radical prostatectomy. Glandular cell density was semi-quantitatively evaluated in all tumors. ADCmean and glandular cell density of GS3 + 3 TZ-PCa were compared to those of PZ-PCa. ADCmean was correlated to GS in each zone. Results: ADCmean of GS 3 + 3 tumors was significantly lower in the TZ (728 x 10(-6) +/- 52 [SD] mm(2)/s; range: 670 1060mm(2)/s) than in the PZ (865 x 10(-6) +/- 121 [SD] mm(2)/s; range: 670-1120mm(2)/s) (p = 0.0007), related to a significantly higher glandular density involving more than 50 % of the tumor in 58 % (7/12) of patients in GS3 + 3 TZ-PCa versus 7.6 % (1/13) in PZ-PCa (p = 0.03). ADCmean of GS3 + 3 TZ-PCa was not significantly different from that of GS 3 + 4 (p = 0.14) or GS>3 + 4 Ca (p = 0.9), whatever the zone of origin. In the PZ, ADCmean of GS 3 + 3-PCa was higher than that of Gleason>3 + 4 PZ-PCa (p = 0.02) and similar to that of GS 3 + 4 PZ-PCa (p = 0.24). Correlation between ADCmean and GS was weak for TZ-PCa (rho = 0.32; p = 0.04) and moderate for PZ-PCa (rho = 0.45; p = 0.003). Conclusion: ADCmean of GS 3 + 3 TZ-PCa is significantly lower than that of GS 3 + 3 PZ-PCa, related to a unique dense histological pattern and reaches that of higher-grade PCa, whatever the zone of origin.

High-quality evidence shows that MRI in biopsy-naive men can reduce the number of men who need prostate biopsy and can reduce the number of diagnoses of clinically insignificant cancers that are unlikely to cause harm. In men with prior negative biopsy results who remain under persistent suspicion, MRI improves the detection and localization of life-threatening prostate cancer with greater clinical utility than the current standard of care, systematic transrectal US-guided biopsy. Systematic analyses show that MRI-directed biopsy increases the effectiveness of the prostate cancer diagnosis pathway. The incorporation of MRI-directed pathways into clinical care guidelines in prostate cancer detection has begun. The widespread adoption of the Prostate Imaging Reporting and Data System (PI-RADS) for multiparametric MRI data acquisition, interpretation, and reporting has promoted these changes in practice. The PI-RADS MRI-directed biopsy pathway enables the delivery of key diagnostic benefits to men suspected of having cancer based on clinical suspicion. Herein, the PI-RADS Steering Committee discusses how the MRI pathway should be incorporated into routine clinical practice and the challenges in delivering the positive health impacts needed by men suspected of having clinically significant prostate cancer.

The Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) was developed with a consensus-based process using a combination of published data, and expert observations and opinions. In the short time since its release, numerous studies have validated the value of PI-RADS v2 but, as expected, have also identified a number of ambiguities and limitations, some of which have been documented in the literature with potential solutions offered. To address these issues, the PI-RADS Steering Committee, again using a consensus-based process, has recommended several modifications to PI-RADS v2, maintaining the framework of assigning scores to individual sequences and using these scores to derive an overall assessment category. This updated version, described in this article, is termed PI-RADS v2.1. It is anticipated that the adoption of these PI-RADS v2.1 modifications will improve inter-reader variability and simplify PI-RADS assessment of prostate magnetic resonance imaging even further. Research on the value and limitations on all components of PI-RADS v2.1 is strongly encouraged.

OBJECTIVE. The objective of our study was to analyze the feasibility and potential role of robotic-assisted transrectal MRI-guided biopsy for the diagnosis of prostate cancer. MATERIALS AND METHODS. A total of 57 patients (mean age, 67 ± 6 [SD] years; age range, 57-83 years; mean prostate-specific antigen level, 10.7 ± 6.1 ng/mL) with a single prostatic lesion visible on biparametric MRI (T2-weighted and DW images) underwent robotic-assisted MRI-guided transrectal biopsy. The procedure was analyzed in terms of technical success, defined by an accurate alignment of the needle guide with the lesion; occupation time of the MRI room; number of cores; cancer detection rate (CDR); and complications. RESULTS. The biparametric MRI score was 3, 4, and 5 in 11 (19%), 30 (53%), and 16 (28%) of the 57 patients, respectively. Twenty-three lesions (23/57, 40%) originated in the peripheral zone and 34 (34/57, 60%) in the transition zone. Software-based adjustments of the robot allowed the needle guide to be aligned with the target in all lesions. The number of cores was one, two, three, and four in one (2%), 36 (63%), 18 (32%), and three (5%) patients, respectively. Obtaining more than two cores had no incremental value in determining the Gleason score or the maximum cancer core length (MCCL). The overall CDR for any cancer was 67% (38/57). It was 95% (36/38) for tumors with Gleason grade of more than 3 or MCCL greater than 3 mm and 53% (20/38) for tumors with Gleason score greater than 6. No complications were observed. The median occupation time of the MRI room was 37.8 ± 9.7 minutes (range, 32-74 minutes). CONCLUSION. Robotic-assisted MRI-guided biopsy yields 100% technical success rate with a short MRI room occupation time and high CDRs using one or two cores.

Objectifs L’incorporation des donnees de l’IRM pour guider une biopsie de prostate augmente le taux de detection des cancers significatifs (sCa). La fusion d’images a des limites reconnues dans la precision du ciblage. Le guidage IRM direct est precis, mais n’est pas facilement disponible. L’echographie de tres haute frequence (micro-echographie), utilisee apres l’IRM pourrait pallier les limites des deux autres techniques. Resultats Cinquante-huit lesions situees dans zone peripherique dans 71 % des cas etaient observees a l’IRM et visibles a la micro-echographie dans 90 % des cas (52/58, 90 %). Le score PIRADS etait de 3, 4, 5, dans respectivement 19 % (10/52), 60 % (31/52) et 21 % (11/52) des cas. Le taux de detection respectif de sCa etait de 20, 68, et 91 %. Les 6 lesions visibles a l’IRM et invisibles a la micro-echographie (6/58,10 %) etaient dans la zone peripherique dans 4 cas et avaient un score PIRADS 3 dans 5 des 6 cas, sans sCa decele dans ce groupe. Treize lesions etaient visibles a la micro-echographie et invisibles a l’IRM. Le taux de detection de sCa etait de 31 %(4/13) : une extension controlaterale de la lesion index dans un cas et nodule distant dans trois cas. Conclusion Pour les lesions focales PIRADS > 2, la valeur localisatrice de la micro-echographie en fait une alternative fiable a la fusion d’images. Pour les lesions PIRADS 3 invisibles a l’echographie, l’absence de cancer significatif decele suggere de s’abstenir d’une biopsie immediate.

Analyser la faisabilité des biopsies transrectales guidées par IRM (MRGB) avec une assistance robotique pour le diagnostic du cancer de la prostate. Au total, 66 patients (âge moyen, 67 ± 33, extrêmes : 57–83), PSA : 10 ± 6 ng/mL), avec une seule lésion prostatique visible sur une IRM biparamétrique (pondérée en t2 et en imagerie de diffusion) ont eu une MRGB. Chez 36 patients, il s’agissait d’une seconde biopsie (biopsies systématiques ou fusion IRM-trus dans 30 et 6 cas, respectivement lors de la première séance). Pour les 30 patients restants, il s’agissait de la première biopsie. Le taux de réussite du prélèvement de la lésion, le taux de détection du cancer (CDR) et le temps d’occupation de la salle de IRM ont été calculés. Le score Pirads biparamétrique était respectivement de 3, 4 et 5 chez 22/66 (33,3 %), 26/66 (39,4 %) et 18/66 (27,3 %). Trente-deux lésions provenaient de la zone périphérique et 34 de la zone de transition. Le pilotage du robot par un logiciel dédié a permis d’aligner le guide de l’aiguille avec la cible dans tous les cas. Deux carottes ont été obtenus chez 60/66 patients (91 %) et 3 carottes chez 6/66 patients (9 %). Le temps d’occupation de la salle IRM a chuté de 60 à 35 minutes pour les 30 derniers patients. Le taux de détection global du cancer était de 63,6 % (42/66) et de 90,5 % (38/42) pour les tumeurs significatives (grade de Gleason 4 ou longueur maximale de cancer > 3 mm et Gleason 3 + 3). Aucune complication n’a été observée. La biopsie de prostate guidée par IRM avec assistance robotique peut être effectuée avec un temps d’occupation de la salle IRM court. Le prélèvement est possible quel que soit l’emplacement de la lésion, ne nécessitant que deux carottes dans 91 % des cas.

Purpose To measure the precision in placement of a biopsy needle in a magnetic resonance (MR) imaging-detected target with transrectal ultrasonography (US), to document the clinical relevance of precision, and to report on the precision of cognitive and software-based registrations. Materials and Methods This prospective study was approved by the institutional review board and performed between June 2013 and September 2013. Patients provided informed verbal consent. Two cores each were obtained with cognitive and fusion techniques in 88 patients with a Prostate Imaging Reporting and Data System version 1 score of at least 3. Precision was measured with Euclidian geometry by using the Digital Imaging and Communications in Medicine archives of the biopsy as the distance from the core to the center (dCC) and the distance from the core to the surface of the target modeled as a sphere. To address clustering of data from multiple cores in the same patients, analyses of precision focused on the best shot for a patient or a technique. The Welch unequal variance t test and Yates corrected χ2 test were used as appropriate. Results Mean precision was 2.5 mm (95% confidence interval: 1.8 mm, 3.3 mm). Positive cores were closer to the center than were negative cores (dCC: 1.7 mm vs 3.1 mm, respectively; P = .025). More cancers were detected with on-target than off-target cores (33 of 71 cores [46.5%] vs three of 17 cores [17.6%]; P = .03). Cores obtained with the fusion technique achieved a higher precision than did cores obtained with the cognitive technique (dCC: 2.8 mm vs 7.1 mm, respectively; P < .0001). Targeted cores demonstrated cancer in 44 patients. Fewer cancers were detected with the cognitive technique than with the fusion technique (31 of 44 patients [70.5%] vs 40 of 44 patients [90.9%]; P = .03). Conclusion A deformable MR imaging/transrectal US image registration system achieved a higher precision and depicted cancer in more patients than did the cognitive freehand technique. © RSNA, 2018.

Prostate interventional magnetic resonance imaging (MRI) is now routinely performed in many centers. Its more widespread acceptance is limited by the cost of the use of MRI largely related to the long duration time of the procedures. However, the benefit of a robotic assistance has generated a new interest, because it substantially shortens the procedure time, while improving the accuracy. MRI-guided biopsy is considered as an appealing alternative to transrectal ultrasound (TRUS)-guided fusion biopsy, given the limitations of TRUS-MRI image registration systems. MRI-guided focal treatment also benefits from robotic assistance and from the unique property of MRI, which allows the measurement of the temperature in real-time during tumor ablation. The transrectal and transperineal approaches can be used and the respective indications of each pathway will depend on several factors, including the location of the tumor and the examination time, which will condition the occupation time of the MR room, a major factor influencing the overall cost of MRI-guided procedures. This review addresses the current practice of prostate MRI-guided interventional procedures and potential future applications.

To compare inter-reader concordance and accuracy of qualitative diffusion-weighted (DW) PIRADSv2.0 score with those of quantitative DW-MRI for the diagnosis of peripheral zone prostate cancer.