Personalised indocyanine-guided lymphadenectomy for prostate cancer: a randomised clinical trial.

OBJECTIVES: To study the safety and efficacy of a personalised indocyanine-guided pelvic lymph node dissection (PLND) against extended PLND (ePLND) during radical prostatectomy (RP). PATIENTS AND METHODS: Patients who were candidates for RP and lymphadenectomy, with intermediate- or high-risk prostate cancer (PCa) according to the National Comprehensive Cancer Network guidelines, were enrolled in this randomised clinical trial. Randomisation was made 1:1 to indocyanine green (ICG)-PLND (only ICG-stained LNs) or ePLND (obturator fossa, external, internal, and common iliac and presacral LNs). The primary endpoint was the complication rate within 3 months after RP. Secondary endpoints included: rate of major complications (Clavien-Dindo Grade III-IV), time to drainage removal, length of stay, percentage of patients classified as pN1, number of LNs removed, number of metastatic LNs, rate of patients with undetectable prostate-specific antigen (PSA), biochemical recurrence (BCR)-free survival, and rate of patients with androgen-deprivation therapy at 24 months. RESULTS: A total of 108 patients were included with a median follow-up of 16 months. In all, 54 were randomised to ICG-PLND and 54 to ePLND. The postoperative complication rate was higher in the ePLND (70%) vs the ICG-PLND group (32%) (P < 0.001). Differences between major complications in both groups were not statically significant (P = 0.7). The pN1 detection rate was higher in the ICG-PLND group (28%) vs the ePLND group (22%); however, this difference was not statistically significant (P = 0.7). The rate of undetectable PSA at 12 months was 83% in the ICG-PLND vs 76% in the ePLND group, which was not statistically significant. Additionally, there were no statistically significant differences in BCR-free survival between groups at the end of the analysis. CONCLUSIONS: Personalised ICG-guided PLND is a promising technique to stage patients with intermediate- and high-risk PCa properly. It has shown a lower complication rate than ePLND with similar oncological outcomes at short-term follow-up.

Free-indocyanine green-guided pelvic lymph node dissection during radical prostatectomy.

INTRODUCTION AND OBJECTIVES: Extended Pelvic Lymph Node Dissection (ePLND) remains the most accurate technique for the detection of occult lymph node metastases (LNMs) in prostate cancer (CaP) patients. Here we aim to examine whether free-Indocyanine Green (F-ICG) could accurately assess the pathological nodal (pN) status in CaP patients during real-time lymphangiography as a potential replacement for ePLND. MATERIALS AND METHODS: 219 consecutive patients undergoing F-ICG-guided PLND, ePLND and radical prostatectomy (RP) for clinical-localized CaPwere included in this prospective single-center study. The pathological outcomes of F-ICG-guided PLND were compared to confirmatory ePLND. Parameters of a binary diagnostic test for the proper classification of the pN status of patients ('per-patient' analysis) and for the probability of detecting all the metastatic LNs ('per-node' analysis) were calculated. Outcome measures were prevalence, accuracy (Acc), sensitivity (Se), negative predictive value (NPV), and likelihood ratio of a negative F-ICG-guided PLND test result [LR(-)]. RESULTS: F-ICG-guided PLND successfully visualized LNs in all procedures with no adverse events. The overall per-patient F-ICG staging Acc was 97.7%, Se was 91.4%, with a NPV of 97.0%, and LR(-) of 8.6%. At the overall per-node level, 4,780 LNs were removed and 1,535 (32.1%) were fluorescent in vivo. F-ICG-guided PLND identified LNMs with a Se of 63.4%. CONCLUSIONS: This study confirms that F-ICG-guided lymphangiography correctly staged almost 98% of patients. The high per-patient NPV suggested that avoiding ePLND is safe for most patients when F-ICG stained nodes were pN0. Thus, more conservative approaches might minimise perioperative morbidity during LNMs diagnosis in selected patients.

Bilateral Seminal Vesicle Invasion Is Not Associated with Worse Outcomes in Locally Advanced Prostate Carcinoma.

Background and Objectives: Patients with seminal vesicle invasion (SVI) are a highly heterogeneous group. Prognosis can be affected by many clinical and pathological characteristics. Our aim was to study whether bilateral SVI (bi-SVI) is associated with worse oncological outcomes. Materials and Methods: This is an observational retrospective study that included 146 pT3b patients treated with radical prostatectomy (RP). We compared the results between unilateral SVI (uni-SVI) and bi-SVI. The log-rank test and Kaplan-Meier curves were used to compare biochemical recurrence-free survival (BCR), metastasis-free survival (MFS), and additional treatment-free survival. Cox proportional hazard models were used to identify predictors of BCR-free survival, MFS, and additional treatment-free survival. Results: 34.93% of patients had bi-SVI. The median follow-up was 46.84 months. No significant differences were seen between the uni-SVI and bi-SVI groups. BCR-free survival at 5 years was 33.31% and 25.65% (p = 0.44) for uni-SVI and bi-SVI. MFS at 5 years was 86.03% vs. 75.63% (p = 0.1), and additional treatment-free survival was 36.85% vs. 21.93% (p = 0.09), respectively. In the multivariate analysis, PSA was related to the development of BCR [HR 1.34 (95%CI: 1.01-1.77); p = 0.03] and metastasis [HR 1.83 (95%CI: 1.13-2.98); p = 0.02]. BCR was also influenced by lymph node infiltration [HR 2.74 (95%CI: 1.41-5.32); p = 0.003]. Additional treatment was performed more frequently in patients with positive margins [HR: 3.50 (95%CI: 1.65-7.44); p = 0.001]. Conclusions: SVI invasion is an adverse pathology feature, with a widely variable prognosis. In our study, bilateral seminal vesicle invasion did not predict worse outcomes in pT3b patients despite being associated with more undifferentiated tumors.

Indocyanine green guidance improves the efficiency of extended pelvic lymph node dissection during laparoscopic radical prostatectomy.

OBJECTIVES: To evaluate whether indocyanine green guidance can improve the quality of extended pelvic lymph node dissection in patients undergoing radical prostatectomy. METHODS: A total of 214 patients underwent laparoscopic radical prostatectomy with indocyanine green-guided lymph node dissection plus extended pelvic lymph node dissection. These patients (group A) were matched 1:1 for clinical risk groups according to the National Comprehensive Cancer Network classification with patients who underwent the same procedure without fluorescence guidance (group B). Biochemical recurrence was defined as two consecutive prostate-specific antigen rises of at least 0.2 ng/mL. The Kaplan-Meier method and Cox regression models were used to identify predictors of biochemical recurrence. RESULTS: The median number of retrieved nodes was significantly higher in group A (22 vs 14, P < 0.001). The rate of lymph node metastases was higher in group A (65.9% vs 34.1%, P = 0.01). Increasing the yield of lymph node dissection was independently and negatively correlated with the biochemical recurrence risk in both overall and pN-positive patients (hazard ratio 0.97, P = 0.03; and hazard ratio 0.95, P = 0.02). The 5-year biochemical recurrence-free survival rates were (75.8% vs 65.9, P = 0.09) and (54.1% vs 24.9%, P = 0.023) for group A and group B in the overall cohort and pN-positive cohort, respectively. CONCLUSION: Indocyanine green-guided lymph node dissection plus extended pelvic lymph node dissection improves identification of lymphatic drainage, resulting in a higher number of lymph nodes and retrieved lymph node metastases, and allowing a more accurate local staging and a prolonged biochemical recurrence-free survival.

[ICG lymphography and fluorescence in pelvic lymphadenectomy for bladder and prostate cancer.] / Linfografía con ICG y fluorescencia en la linfadenectomía pélvica por cáncer vesical y prostático.

OBJECTIVE: ICG navigation in cancer surgery may help during pelvic lymphadenectomy. METHODS: We performed a systematic review combining the terms: bladder cancer or radical cystectomy and ICG, and prostate cancer or radical prostatectomy and ICG. We used the PRISMA guidelines recommendations. We describe the populations studied in each work, the pathological results, as well as the parameters specificity, sensitivity and predictive values. RESULTS: In muscle-invasive bladder cancer, 4 case series analyzed the performance of lymphography with ICG. The most accepted injection method is under endoscopic vision. Several punctures are done in the submucosa and the detrusor surrounding the scar. Sentinel nodes were found in up to 92% of patients with a technique sensitivity to find metastases of 88% in the series with largest casuistry. In prostate cancer, we collected data from 11 case series. Nine of them apply transrectal or transperineal dilution immediately before surgery. Sensitivity in the detection of all adenopathies ranged between 44% and 100%. The sensitivity of the technique to know the lymph node stage ranges between 67% and 100%. CONCLUSIONS: There is little experience of ICG-guided lymph node dissedction in bladder tumors. Endoscopic fluorophore injection allows us to find the nodes that drain the infiltrated area. However, the use of this technique is not widespread. In prostate cancer, it is a reproducible and efficient technique for staging patients with prostate cancer.

OBJETIVO: La principal aplicación del ICG en cirugía oncológica es la navegación intraoperatoria durante la linfadenectomía. Revisamos la literatura para conocer el uso de ICG durante la linfadenectomía pélvica en el cáncer de próstata y cáncer de vejiga.MATERIAL Y MÉTODO: Hacemos una revisión sistemática con los términos cáncer de vejiga o cistectomía radical, cáncer de próstata o prostatectomía radical. Utilizamos las recomendaciones de las guías PRISMA. Describimos las poblaciones a estudio en cada trabajo, los resultados patológicos así como los parámetros sensibilidad especificidad y valores predictivos. RESULTADOS: En tumor vesical musculo invasivo 4 series de casos analizan el rendimiento de la linfografia con ICG. El método de inyección más aceptado es la inyección de la dilución -bajo visión endoscópica- en la submucosa y en el detrusor, peri tumoral o pericicatrical. Se encontraron ganglios centinela hasta en el 92% de los pacientes con una sensibilidad de la técnica para encontrar las metástasis del 88% en la serie de mayor casuística. En cáncer de próstata recopilamos datos de 11 series. De entre ellas 9 aplican la dilución vía transrectal o transperineal inmediatamente antes de la cirugía. La sensibilidad en la detección de todas las adenopatías oscila entre el 44 y el 100%. En cuanto la sensibilidad de la técnica para conocer el estadio ganglionar oscila entre el 67% y el 100%. CONCLUSIONES: Existe poca experiencia de la linfadenectomía guiada por ICG en tumor de vejiga. La inyección endoscópica del fluoróforo permite encontrar los ganglios que drenan el área infiltrada, sin embargo no se populariza el uso de esta técnica. El cáncer de próstata es una técnica reproducible y eficiente para estadiar a los pacientes con cáncer de próstata.

Linfografía con ICG y fluorescencia en la linfadenectomía pélvica por cáncer vesical y prostático / ICG lymphography and fluorescence in pelvic lymphadenectomy for bladder and prostate cancer

Objetivo: La principal aplicación del ICG en cirugía oncológica es la navegación intraoperatoria durante la linfadenectomía. Revisamos la literatura para conocer el uso de ICG durante la linfadenectomía pélvica en el cáncer de próstata y cáncer de vejiga. Material y método: Hacemos una revisión sistemática con los términos cáncer de vejiga o cistectomía radical, cáncer de próstata o prostatectomía radical. Utilizamos las recomendaciones de las guías PRISMA. Describimos las poblaciones a estudio en cada trabajo, los resultados patológicos así como los parámetros sensibilidad especificidad y valores predictivos. Resultados: En tumor vesical musculo invasivo 4 series de casos analizan el rendimiento de la linfografia con ICG. El método de inyección más aceptado es la inyección de la dilución -bajo visión endoscópica- en la submucosa y en el detrusor, peri tumoral o pericicatrical. Se encontraron ganglios centinela hasta en el 92% de los pacientes con una sensibilidad de la técnica para encontrar las metástasis del 88% en la serie de mayor casuística. En cáncer de próstata recopilamos datos de 11 series. De entre ellas 9 aplican la dilución vía transrectal o transperineal inmediatamente antes de la cirugía. La sensibilidad en la detección de todas las adenopatías oscila entre el 44 y el 100%. En cuanto la sensibilidad de la técnica para conocer el estadio ganglionar oscila entre el 67% y el 100%. Conclusiones: Existe poca experiencia de la linfadenectomía guiada por ICG en tumor de vejiga. La inyección endoscópica del fluoróforo permite encontrar los ganglios que drenan el área infiltrada, sin embargo no se populariza el uso de esta técnica. El cáncer de próstata es una técnica reproducible y eficiente para estudiar a los pacientes con cáncer de próstata

Objective: ICG navigation in cancer surgery may help during pelvic lymphadenectomy. Methods: We performed a systematic review combining the terms: bladder cancer or radical cystectomy and ICG, and prostate cancer or radical prostatectomyand ICG. We used the PRISMA guidelines recommendations. We describe the populations studied in each work, the pathological results, as well as the parameters specificity, sensitivity and predictive values. Results: In muscle-invasive bladder cancer, 4 case series analyzed the performance of lymphography with ICG. The most accepted injection method is under endoscopic vision. Several punctures are done in the submucosa and the detrusor surrounding the scar. Sentinel nodes were found in up to 92% of patients with a technique sensitivity to find metastases of 88% in the series with largest casuistry. In prostate cancer, we collected data from 11 case series. Nine of them apply transrectal or transperineal dilution immediately before surgery. Sensitivity in the detection of all adenopathies ranged between 44% and 100%. The sensitivity of the technique to know the lymph node stage ranges between 67% and 100%. Conclusions: There is little experience of ICG-guided lymph node dissedction in bladder tumors. Endoscopic fluorophore injection allows us to find the nodes that drain the infiltrated area. However, the use of this technique is not widespread. In prostate cancer, it is a reproducible and efficient technique for staging patients with prostate cancer

Long-term functional outcome and complications of male suburethral slings in the management of post-prostatectomy incontinence: A prospective five-year follow-up study.

OBJECTIVES: Suburethral male slings are an alternative option for mild stress urinary incontinence. Our purpose is to evaluate the long-term functional outcomes, efficacy and worsening continence of male suburethral slings. MATERIAL AND METHODS: The functional outcomes of realignment/anatomical slings were evaluated with AdVance ®, and the outcomes of compressive slings were evaluated with InVance®. We considered 55 patients fulfilling 5 years of complete follow-up. We included patients with a 24-hour pad weight test <400 grams. Night-continent patients who also had positive "repositioning tests" were considered for AdVance®, whereas patients without sphincter contraction or previous pelvic radiotherapy were considered for InVance®. RESULTS: Between February 2006 and September 2010, 24 AdVance® and 31 InVance® slings were implanted. The median follow-up times from sling insertion were 75 months in the AdVance® group (range: 64-97) and 86 months in the InVance® group (range: 61-108). At three months of follow-up, 43 of 55 patients were considered to be cured (pad-free) (78.1%), 79.1% in the AdVance® group and 77.4% in the InVance® group. Postoperatively, 16.6% of patients with AdVance® and 22.5% of patients with InVance® presented "de novo" urgency. At 5 years of follow-up, we observed 10 cases of some deterioration of continence, 3 patients in the AdVance® group and 7 in the InVance® group (15.8% and 29.1% of the initially cured, respectively). To date, there have been no reports of urethral sling erosion. CONCLUSIONS: Male slings are safe and effective. Although we observed an increase in "de novo" urgency, in our experience, slings seemed to maintain their efficacy during long-term follow-up, and the risks of urethral erosion are low.

OBJETIVOS: Los cabestrillos suburetrales masculinos son una opción alternativa para la incontinencia urinaria de esfuerzo leve. El objetivo del trabajo es evaluar los resultados funcionales a largo plazo, la eficacia y el empeoramiento de la continencia en los cabestrillos suburetrales masculinos. METODOS: Se evaluaron los resultados funcionales de los cabestrillos de realineamiento/anatómicos con Ad- Vance® y compresivos con InVance®. Se incluyeron 55 pacientes que cumplían con los 5 años de seguimiento completo. Incluimos pacientes con un peso en el test de la compresa de 24 h menor de 400 gramos. Los pacientes con continencia nocturna que tenían también positivas las pruebas de reposicionamiento se consideraron para AdVance®, mientras que los pacientes sin contracción esfinteriana o con radioterapia pélvica previa fueron considerados para InVance®. RESULTADOS: Entre febrero 2006 y septiembre 2010 se implantaron 24 cabestrillos AdVance® y 31 InVance ®. La mediana de seguimiento fue de 75 meses desde la inserción del cabestrillo en el grupo de AdVance® (rango 64-97) y 86 meses en el grupo de InVance® (rango: 61-108). A los tres meses de seguimiento, 43 de los 55 pacientes fueron considerados curados (sin compresa) (78,1%), 79,1% en el grupo de AdVance® y 77,4% en el de InVance®. En el postoperatorio, el 16,6% de los pacientes con AdVance® y el 22,5% de los InVance® presentaron urgencia "de novo". A los 5 años de seguimiento, observamos 10 casos con algún deterioro de la continencia, 3 pacientes en el grupo de AdVance® y 7 en el de InVance® (15,8% y 29,1% de los pacientes inicialmente curados, respectivamente). Hasta la fecha, no se han presentado casos de erosión del cabestrillo. CONCLUSIONES: Los cabestrillos masculinos son seguros y eficaces. Aunque observamos un incremento de la urgencia "de novo", en nuestra experiencia, los cabestrillos parecen mantener su eficacia durante el seguimiento a largo plazo, y los riesgos de erosión uretral son bajos.

Magnetic resonance imaging as an assessment tool following intervention with an AdVance XP suburethral sling for postprostatectomy urinary incontinence.

AIMS: The aim of this study was to compare magnetic resonance imaging (MRI) parameters in patients with mild incontinence after radical prostatectomy, who had undergone treatment with a suburethral sling. The objective was to compare patients who had been successfully treated with unsuccessful patients. METHODS: This observational cohort study at a single institution evaluated consecutive patients treated with an AdVance XP sling. MRI was performed using a 1.5 Tesla system. Preoperative urodynamic assessment and flexible cystoscopy were performed. The qualitative analysis was based on sling indentation (complete vs incomplete). The quantitative analysis comprised the following three parameters: the sling-pubis distance, the thickness of the proximal urethral bulb, and the sling backward distance (SBD), defined as the distance between the prolongation of a line through the major axis of the pubis (the line-segment joining the vertices of the pubis) and the sling indentation. The primary outcome was pad count at 3 months; cure as zero pads. A logistic univariate regression model was employed to assess the potential predictors of successful outcomes. An adjusted multivariate logistic regression model using the significant univariate factors was developed. RESULTS: Of the 83 patients enrolled, the univariate analysis revealed a relationship between failure and adverse urodynamics and between success and sling indentation, thickness of the proximal bulb and SBD. Only the association with SBD persisted in the multivariate analysis. CONCLUSIONS: MRI revealed a strong relationship between proper positioning of the sling (small SBD) and continence outcome. These data have important implications for a second surgery following initial sling failure.

Long-term functional outcome and complications of male suburethral slings in the management of post-prostatectomy incontinence: a prospective five-year follow-up study / Resultados funcionales a largo plazo y complicaciones de los cabestrillos suburetrales masculinos en el manejo de la incontinencia postprostatectomía: estudio prospectivo con seguimiento a cinco años

Objectives: Suburethral male slings are an alternative option for mild stress urinary incontinence. Our purpose is to evaluate the long-term functional outcomes, efficacy and worsening continence of male suburethral slings. Material and methods: The functional outcomes of realignment/anatomical slings were evaluated with AdVance(R), and the outcomes of compressive slings were evaluated with InVance(R). We considered 55 patients fulfilling 5 years of complete follow-up. We included patients with a 24-hour pad weight test < 400 grams. Night-continent patients who also had positive "reposi-tioning tests" were considered for AdVance(R), whereas patients without sphincter contraction or previous pelvic radiotherapy were considered for InVance(R). RESULTS: Between February 2006 and September 2010, 24 AdVance(R) and 31 InVance(R) slings were implanted. The median follow-up times from sling insertion were 75 months in the AdVance(R) group (range: 64-97) and 86 months in the InVance(R) group (range: 61-108). At three months of follow-up, 43 of 55 patients were considered to be cured (pad-free) (78.1%), 79.1% in the AdVance(R) group and 77.4% in the InVance(R) group. Postoperatively, 16.6% of patients with AdVance(R) and 22.5% of patients with InVance(R) presented "de novo" urgency. At 5 years of follow-up, we observed 10 cases of some deterioration of continence, 3 patients in the AdVance(R) group and 7 in the InVance(R) group (15.8% and 29.1% of the initially cured, respectively). To date, there have been no reports of urethral sling erosion. Conclusions: Male slings are safe and effective. Although we observed an increase in "de novo" urgency, in our experience, slings seemed to maintain their efficacy during long-term follow-up, and the risks of urethral erosion are low

Objetivos: Los cabestrillos suburetrales masculinos son una opción alternativa para la incontinencia urinaria de esfuerzo leve. El objetivo del trabajo es evaluar los resultados funcionales a largo plazo, la eficacia y el empeoramiento de la continencia en los cabestrillos suburetrales masculinos. Metodos: Se evaluaron los resultados funcionales de los cabestrillos de realineamiento/anatómicos con Ad- Vance(R) y compresivos con InVance(R). Se incluyeron 55 pacientes que cumplían con los 5 años de seguimiento completo. Incluimos pacientes con un peso en el test de la compresa de 24 h menor de 400 gramos. Los pacientes con continencia nocturna que tenían también positivas las pruebas de reposicionamiento se consideraron para AdVance(R), mientras que los pacientes sin contracción esfinteriana o con radioterapia pélvica previa fueron considerados para InVance(R). Resultados: Entre febrero 2006 y septiembre 2010 se implantaron 24 cabestrillos AdVance(R) y 31 InVance(R). La mediana de seguimiento fue de 75 meses desde la inserción del cabestrillo en el grupo de AdVance(R) (rango 64-97) y 86 meses en el grupo de InVance(R) (rango: 61-108). A los tres meses de seguimiento, 43 de los 55 pacientes fueron considerados curados (sin compresa) (78,1%), 79,1% en el grupo de AdVance(R) y 77,4% en el de InVance(R). En el postoperatorio, el 16,6% de los pacientes con AdVance(R) y el 22,5% de los InVance(R) presentaron urgencia "de novo". A los 5 años de seguimiento, observamos 10 casos con algún deterioro de la continencia, 3 pacientes en el grupo de AdVance(R) y 7 en el de InVance(R) (15,8% y 29,1% de los pacientes inicialmente curados, respectivamente). Hasta la fecha, no se han presentado casos de erosión del cabestrillo. Conclusiones: Los cabestrillos masculinos son seguros y eficaces. Aunque observamos un incremento de la urgencia "de novo", en nuestra experiencia, los cabestrillos parecen mantener su eficacia durante el seguimiento a largo plazo, y los riesgos de erosión uretral son bajos

The management of active surveillance in prostate cancer: validation of the Canary Prostate Active Surveillance Study risk calculator with the Spanish Urological Association Registry.

The follow up of patients on active surveillance requires to repeat prostate biopsies. Predictive models that identify patients at low risk of progression or reclassification are essential to reduce the number of unnecessary biopsies. The aim of this study is to validate the Prostate Active Surveillance Study risk calculator (PASS-RC) in the multicentric Spanish Urological Association Registry of patients on active surveillance (AS), from common clinical practice. RESULTS: We find significant differences in age, PSA and clinical stage between our validation cohort and the PASS-RC generation cohort (p < .0001), with a reclassification rate of 10-22% on the follow-up Bx, no cancer was found in 43% of the first follow-up Bx. The calibration curve shows underestimation of real appearance of reclassification. The AUC is 0.65 (C.I.95%: 0.60-0.71). PDF and CUC do not suggest a specific cut-off point of clinical use. METHODS: We select 498 patients on AS with a minimum of one follow-up biopsy (Bx) from the 1,024 males registered by 36 Spanish centers recruiting patients on the Spanish Urological Association Registry on AS. PASS-RC external validation is carried by means of calibration curve and area under de ROC-curve (AUC), identifying cut-offs of clinical utility by probability density functions (PDF) and clinical utility curves (CUC). CONCLUSIONS: In our first external validation of the PASS-RC we have obtained a moderate discrimination ability, although we cannot recommend cut-off points of clinical use. We suggest the exploration of new biomarkers and/or morpho-functional parameters from multiparametric magnetic resonance image, to improve those necessary tools on AS.

Prospective follow-up study of artificial urinary sphincter placement preserving the bulbospongiosus muscle.

AIMS: Artificial urinary sphincter (AUS) AMS-800® is an effective treatment for male stress urinary incontinence. The aim of the study was to assess the long-term effectiveness and complications of artificial urinary sphincter placement preserving the bulbospongiosus muscle. METHODS: From April 2004 to March 2014, all consecutive male patients with urinary incontinence who underwent an AUS prosthesis insertion were prospectively evaluated. Surgical technique consisted of a perineal incision for cuff placement around the bulbous urethra preserving the bulbospongiosus muscle. Cure rate was defined as no pad use. RESULTS: A total of 82 consecutive patients (median age 68 years, range: 54-78) were prospectively evaluated (median follow-up 46 months, range: 12-135). Bulbospongiosus muscles were preserved intact in all cases with no intraoperative complications. Postoperative complications were reported in 14 patients (1 urethral erosion). The overall cure rate (dry rate) was 76.8% and the median ICIQ-UI score improved from 18 (range: 8-21) to 4 (range: 0-17) (P < 0.001). Artificial urinary sphincter survival rate was 95.5% (95%CI 89.4-100%) at 24 months and 62.6% (95%CI 45.5-79.6%) at 60 months. The mechanical failure rate was 6.3% (median 46.1 months, range: 22.2-100.9) and urethral atrophy and/or inadequate compression rate was 9.5% (median 58.6 months, range: 39-101.4 months). CONCLUSIONS: Our study suggests that placement of AUS preserving the bulbospongiosus muscle is technically easy and efficient, reports excellent continence rates and lower urethral erosion rates, and could delay the onset of urethral atrophy compared to other surgical procedures used for sphincter placement.

An update on imaging techniques to optimize active surveillance in prostate cancer.

Thanks to the higher diagnostic accuracy and safety, new imaging techniques provide future prospects in terms of patient management and follow-up in active surveillance (AS) protocols. Two of the aims of developing new imaging techniques are improving patient selection criteria and to improve follow-up with non-invasive tests. Another objective is to improve the diagnostic performance of biopsies; this would enable physicians to switch from blind systematic TRUS-guided biopsies to targeted biopsies to reduce the amount of biopsies required and reduce the diagnostic rate of clinically insignificant cancers. The notable advances of multi-parametric or functional prostatic imaging (mpMRI) have led to perceptible diagnostic improvements as it they does do not only provide information regarding size and location but also tumor aggressiveness. MRI has proven to be the most reliable non-invasive technique to be able to exclude patients with clinically significant cancer and thus gain acceptance in AS protocols during selection, confirmation and follow-up of AS patients. This chapter reviews the notable impact of multiparametric prostate MRI (mpMRI) on improving both diagnostic accuracy and follow-up. The second point describes the technical advances in the field of transrectal ultrasound imaging, aiming at improving the diagnostic accuracy of biopsies given their increased accessibility and real-time use.

Actualización en las técnicas de imagen para optimizar la vigilancia activa en cáncer de próstata / An update on imaging techniques to optimize active surveillance in prostate cancer

Las nuevas técnicas de imagen, gracias a su mayor precisión diagnóstica y seguridad, tienen un gran potencial en el manejo de los pacientes considerados para vigilancia activa (VA).Entre los objetivos de las técnicas de imagen se encuentran mejorar los criterios de selección de los pacientes y optimizar el seguimiento mediante pruebas no invasivas. Asimismo, pretenden mejorar el rendimiento diagnóstico de la biopsia pasando de la biopsia ecodirigida sistemática "a ciegas" a la biopsia dirigida focalizada, con la finalidad de poder reducir el número de biopsias y permitiendo disminuir el diagnóstico de cánceres clínicamente insignificantes. Los notables avances en la RM multiparamétrica o funcional de próstata (RMmp) han permitido una mejora en el diagnóstico, ya que no sólo aporta información de la localización y el tamaño, sino también sobre la agresividad tumoral. La RMmp ha demostrado ser la técnica no invasiva más fiable para poder excluir a aquellos pacientes con cáncer clínicamente significativo, obteniendo así cada vez más protagonismo en los protocolos de VA tanto en los periodos de selección como durante su confirmación y el seguimiento. Este capítulo pretende detallar el notable impacto que está teniendo la incorporación de la RMmp en mejorar el diagnóstico y facilitar el seguimiento de estos pacientes. En segundo lugar se detallan los avances técnicos en el campo de la ecografía transrectal en su intento de mejorar el rendimiento diagnóstico de la biopsia, gracias a su mayor accesibildad y su realización en tiempo real

Thanks to the higher diagnostic accuracy and safety, new imaging techniques provide future prospects in terms of patient management and follow-up in active surveillance (AS) protocols. Two of the aims of developing new imaging techniques are improving patient selection criteria and to improve follow-up with non-invasive tests. Another objective is to improve the diagnostic performance of biopsies; this would enable physicians to switch from blind systematic TRUS-guided biopsies to targeted biopsies to reduce the amount of biopsies required and reduce the diagnostic rate of clinically insignificant cancers. The notable advances of multi-parametric or functional prostatic imaging (mpMRI) have led to perceptible diagnostic improvements as it they does do not only provide information regarding size and location but also tumor aggressiveness. MRI has proven to be the most reliable non-invasive technique to be able to exclude patients with clinically significant cancer and thus gain acceptance in AS protocols during selection, confirmation and follow-up of AS patients. This chapter reviews the notable impact of multiparametric prostate MRI (mpMRI) on improving both diagnostic accuracy and follow-up. The second point describes the technical advances in the field of transrectal ultrasound imaging, aiming at improving the diagnostic accuracy of biopsies given their increased accessibility and real- time use

Abordaje conservador de la incontinencia post-prostatectomía radical / Conservative management of post-radical prostatectomy incontinence

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AdVance/AdVance XP transobturator male slings: preoperative degree of incontinence as predictor of surgical outcome.

OBJECTIVE: To evaluate the efficacy of the AdVance transobturator male sling in the treatment of male stress urinary incontinence and to identify the preoperative predictors of a successful outcome. MATERIALS AND METHODS: All patients were considered for sling placement 1 year after radical prostatectomy or transurethral resection of the prostate. The degree of incontinence was assessed using the 24-hour pad weight test. A preoperative urodynamic assessment and cystoscopy were performed in all cases. Patients without sphincter contractions during the "repositioning test" were excluded. Since September 2010, we have implanted the AdVance XP transobturator sling. Cure was defined as no pad use. RESULTS: From February 2008 to June 2011, 61 patients underwent transobturator sling (34 AdVance and 27 AdVance XP) insertion. In 26 cases, the sling was anchored with bioabsorbable sutures, and in 35 cases, it was not fixed. Of the 61 patients, 7 had a history of anastomotic stricture and 3 of radiotherapy. Preoperatively, median 24-hour pad weight was 200 g (range 25-1848). Finally, 26 patients had detrusor overactivity or low bladder compliance. The median follow-up was 26 months (range 12-53). The overall cure rate was 80% (49 of 61). Deterioration of continence was observed during follow-up in 2 patients. The preoperative variables (age, body mass index, 24-hour pad weight, International Consultation on Incontinence Questionnaire-Short Form, adverse urodynamics, sling fixation, AdVance XP) and their association with the surgical outcome were analyzed. The preoperative 24-hour pad weight correlated inversely with the outcome (odds ratio 0.996), with a 0.4% decrease in cure rate for each 1-g increase in the preoperative 24-hour pad weight. The complications included perineal hematoma in 2, acute urinary retention in 9, perineal numbness in 5, and de novo storage symptoms (urgency) in 5 patients. CONCLUSION: The results of our study have shown that the AdVance and AdVance XP male slings are safe and efficient in patients with mild postprostatectomy stress incontinence. The severity of incontinence was the only predictor of a successful outcome.

Importance of previous transurethral resection of the prostate before eerpe.short-term functional outcomes in a single surgeon series.

OBJECTIVES: Laparoscopic Radical Prostatectomy (LRP) is technically a very demanding procedure and potentially even more challenging in patients with previous transurethral resection (TURP). This study evaluates the impact of previous TURP on the short-term functional outcome of patients undergoing extraperitoneal LRP. METHODS: Retrospective analysis of a prospectively collected database, comprising a single-surgeon cohort of 155 consecutive LRP cases, 19 of which had previous history of TURP. Demographics, clinical and functional outcomes were evaluated and compared among patients with and without previous TURP. Multivariate analysis was performed to identify potential variables independently associated with continence outcomes. Incontinence was defined as the need of more than 1 pad/day. Potency was defined as the ability for sexual intercourse with or without the use of phosphodiesterase inhibitors. RESULTS: Demographic and clinical variables were comparable among the two study groups. Neurovascular bundle preservation was possible in 26% and 37% of patients with and without previous TURP, respectively. No major complications were recorded and the incidence of minor complications was comparable. Overall continence rate at 3 months was 82,58%, for the entire cohort. Subset analysis demonstrated a 3-month continence rate of 73.7% vs. 83.8% (p>0.05) in patients with and without TURP, respectively. Multivariate analysis demonstrated age, BMI and ASA were variables independently associated with continence outcomes. In the cohort of patients with previous TURP, 2 out of 7 undergoing preservation recovered erections, with a mean follow up of 15.5 months, comparable to the 30% achieved in patients without TURP and nerve sparing procedure. CONCLUSIONS: Laparoscopic Radical Prostatectomy in patients with previous TURP is feasible, with complication rates and short-term functional outcomes comparable to those in patients without previous resection.

Relevancia de la resección transuretral de próstata en los resultados funcionales de la prostatectomía radical laparoscópica / Importance of previous transurethral resection of the prostate before eerpe. short-term functional outcomes in a single surgeon series

OBJETIVO: La dificultad del tratamiento quirúrgico del Cáncer de próstata (caP) se acentúa en los pacientes con antecedentes de resección transuretral de próstata (RTU). En este estudio valoraremos la influencia de la RTU en los resultados funcionales a corto plazo de la prostatectomía radical laparoscópica extraperitoneal. MÉTODO: Revisión retrospectiva de una base de datos de cumplimentación prospectiva de una serie de pacientes intervenidos por un solo cirujano de manera consecutiva. Se compararon las características demográficas, clínicas y patológicas de los pacientes con y sin RTU previa, para posteriormente realizar un estudio multivariante mediante regresión logística para comprobar qué variables se asociaban de manera independiente y significativa a la incontinencia según el criterio (>1 compresa/día). Se consideró potentes a aquellos pacientes capaces de penetrar con o sin la ayuda de inhibidores de la 5 fosfodiesterasa. Se dispuso de la evaluación funcional de 155 pacientes, 19 de los cuales tenían antecedentes de RTU previa. RESULTADOS: Los subgrupos no diferían en las variables relevantes para el estudio. La conservación de haces neurovasculares se realizó en un 37% de los pacientes sin RTU previa y en un 26% del grupo contrario. No se objetivaron complicaciones mayores, la frecuencia de complicaciones menores no difería. La tasa de continencia de la serie global, evaluada en los 3 primeros meses, era del 82,58%. En el subgrupo de pacientes sin antecedentes de RTU previa era del 83,8% mientras que en el subgrupo de pacientes con RTU previa era del 73,7%, p>0,05. En el análisis multivariante, se asociaron de manera independiente y significativa a la continencia la edad, el IMC y el ASA. Tampoco se observaron diferencias significativas en la proporción de pacientes que recuperaron la erección en uno y otro grupo (28 vs 30%). CONCLUSIONES: Los resultados funcionales a corto plazo son aceptables y comparables a los de los pacientes sin resección previa (AU)

OBJECTIVES: Laparoscopic Radical Prostatectomy (LRP) is technically a very demanding procedure and potentially even more challenging in patients with previous trans-urethral resection (TURP). This study evaluates the impact of previous TURP on the short-term functional outcome of patients undergoing extraperitoneal LRP. METHODS: Retrospective analysis of a prospectively collected database, comprising a single-surgeon cohort of 155 consecutive LRP cases, 19 of which had previous history of TURP. Demographics, clinical and functional outcomes were evaluated and compared among patients with and without previous TURP. Multivariate analysis was performed to identify potential variables independently associated with continence outcomes. Incontinence was defined as the need of more than 1 pad/day. Potency was defined as the ability for sexual intercourse with or without the use of phosphodiesterase inhibitors. RESULTS: Demographic and clinical variables were comparable among the two study groups. Neurovascular bundle preservation was possible in 26% and 37% of patients with and without previous TURP, respectively. No major complications were recorded and the incidence of minor complications was comparable. Overall continence rate at 3 months was 82,58%, for the entire cohort. Subset analysis demonstrated a 3-month continence rate of 73.7% vs. 83.8% (p>0.05) in patients with and without TURP, respectively. Multivariate analysis demonstrated age, BMI and ASA were variables independently associated with continence outcomes. In the cohort of patients with previous TURP, 2 out of 7 undergoing preservation recovered erections, with a mean follow up of 15.5 months, comparable to the 30% achieved in patients without TURP and nerve sparing procedure. CONCLUSIONS: Laparoscopic Radical Prostatectomy in patients with previous TURP is feasible, with complication rates and short-term functional outcomes comparable to those in patients without previous resection (AU)

Postprostatectomy established stress urinary incontinence treated with duloxetine.

OBJECTIVES: To evaluate the efficacy of duloxetine to treat stress urinary incontinence, 1 of the most frequent complications after radical prostatectomy. Conservative measures and surgery are well-established treatments. However, drug treatment could be an intermediate option. METHODS: All patients had >1 year of follow-up after radical prostatectomy to avoid interfering with the natural recovery period (established stress urinary incontinence). Continence was measured by the average daily use of pads and the International Consultation on Incontinence Questionnaire-short form. In Spain, it is necessary to proceed with off-label use formality, and all patients were informed and agreed. The initial dose of duloxetine was 30 mg once daily and was increased to 60 mg/d. Drug treatment was maintained for 9 months. RESULTS: From June 2006 to July 2007, 68 patients were included. The median age was 68 years (range 52-79). The median duration of duloxetine treatment was 5.56 months (range 1-18). A statistically significant decrease in the International Consultation on Incontinence Questionnaire-Urinary Incontinence-short form (from 13 to 9; P < .001) and the average number of pads/d (from 2 to 1; P < .001) was observed between the initial and 3-month visit. At the end of the follow-up period, 74% and 57% of the patients had a reduced International Consultation on Incontinence Questionnaire-Urinary Incontinence-short form score and a decrease in the number of pads used daily, respectively. Of the 68 patients, 32 (47%) presented with some side effects and 17 patients stopped the treatment because of adverse effects (25%). CONCLUSIONS: Our results suggest that duloxetine is a possible alternative treatment of postprostatectomy established stress urinary incontinence. The continence improvement results were mild and conditioned in part by the frequency of the side effects. Provided that duloxetine does not preclude later continence surgery and the benefits are observed at the first visit, we believe it can be a treatment option for selected patients.

High-intensity focused ultrasound in small renal masses.

High-intensity focused ultrasound (HIFU) competes with radiofrequency and cryotherapy for the treatment of small renal masses as a third option among ablative approaches. As an emerging technique, its possible percutaneous or laparoscopic application, low discomfort to the patient and the absence of complications make this technology attractive for the management of small renal masses. This manuscript will focus on the principles, basic research and clinical applications of HIFU in small renal masses, reviewing the present literature. Therapeutic results are controversial and from an clinical view, HIFU must be considered a technique under investigation at present time. Further research is needed to settle its real indications in the management of small renal masses; maybe technical improvements will certainly facilitate its use in the management of small renal masses in the near future.