Oncological and functional outcome after partial prostate HIFU ablation with Focal-One®: a prospective single-center study.

BACKGROUND: We aimed to evaluate oncological and functional outcomes of index lesion HIFU ablation with Focal-One®. MATERIALS AND METHODS: We prospectively assessed treatment-naïve men with localized prostate cancer between 2017 and 2019. Inclusion criteria were stage cT ≤ 2, ≥5 years of life expectancy, grade group ≤3. Multiparametric magnetic resonance was performed before ablation. Patients with a prostate volume of ≥80 ml underwent debulking. Treatment failure was defined as a histologically confirmed tumor that required salvage treatment or androgen deprivation therapy. RESULTS: One hundred and eighty nine patients were enrolled. Data are presented as median and Interquartile Range (IQR). Median age was 70(11) years. Median baseline PSA was 5.8(3) ng/ml. Fourteen (7.4%) patients had prostate debulking before ablation. 104 (55%) patients underwent targeted ablation, 45 (23.8%) extended targeted ablation, 31 (16.4%) hemiablation, and 9 (4.8%) extended hemiablation. Median targeted ablated volume was 14(9) ml. Ninety-three complications occurred in 63/189 (33.3%) patients within 90 days. There were 77/93 (82.8%) minor (Clavien grade 1-2) and 16/93 (17.2%) major complications (Clavien grade 3a). Thirty-nine patients suffered from genito-urinary infections (Clavien grade 2). Fifteen patients required transurethral resection of the prostate/urethrotomy for recurrent urinary retention (Clavien grade 3a). One patient developed a recto-urethral fistula (Clavien grade 3a) and two long-lasting urinary incontinence. Median PSA nadir was 2.2(2.9) ng/ml. At a median follow-up of 29(15) months, 21/177 (11.9%) patients were treatment failures, 26 on monitoring, and 26 had a further ablation. Multivariable logistic regression found that failure patients had higher PSA (7.8 vs 5.7 ng/ml,p0.001) and double PSA nadir (4.8 vs 2.0 ng/ml, p < 0.001). Higher PSA nadir correlated with a 74% higher probability of failure (OR 1.74 95% CI 1.40-2.16). Cancer in the anterior stroma increased the odds of failure of three folds (OR 3.36 95% CI 1.18-9.53). Two mixed effect models (one for IPSS and one for IEEF-15) were estimated and they showed that time reaches the statistical significance coefficient only for the IEEF-15, meaning that subsequent evaluations of the indicators were significantly lower at each time point. CONCLUSIONS: Index lesion HIFU ablation demonstrated satisfactory early oncological outcome but anteriorly located tumors had inadequate ablation. Urinary function was well preserved. Sexual function slightly decreased during follow-up.

Thulium Laser Vapoenucleation of the Prostate (ThuVEP) in Men at High Cardiovascular Risk and on Antithrombotic Therapy: A Single-Center Experience.

Bleeding is the most common complication of transurethral resection of the prostate and simple open prostatectomy, especially in men on antiplatelet/anticoagulant therapy. The present study aimed to evaluate the safety and effectiveness of thulium laser vapoenucleation of the prostate (ThuVEP) for benign prostatic hyperplasia in patients on chronic antithrombotic medications. Between January 2015 and December 2019, 88 men underwent the procedure under antithrombotic agents in our center. The mean age was 74.7 ± 6.1 years. Median prostate volume was 66.5 mL. Patients on oral anticoagulants were bridged to low-molecular-weight heparin (n = 35). Aspirin (n = 39), clopidogrel (n = 10), and ticlopidine (n = 4) were maintained. Of the patients, 69.3% had an American Society of Anesthesiologists score ≥ 3. Blood loss at 24 h was comparable in all groups. Median catheterization length and postoperative stays were 2 and 3 days respectively. Acute cardiovascular events occurred in 2 patients (2.3%). Of the patients, 4 required prolonged bladder irrigation, 2 required blood transfusions, 1 required a cystoscopy for bleeding control, and 1 required a suprapubic cystostomy for blood clot evacuation. No patients died within 30 days of being discharged. Late complications occurred in 3 (3.8%) patients (1 optical urethrotomy and 1 bladder neck incision for stenosis; 1 acute myocardial infarction). All follow-up visits (1, 6, and 12-month) showed a significant improvement in all urinary parameters compared to baseline. ThuVEP appears to be a feasible surgical option in high-risk patients on antithrombotic regimens, with acceptable postoperative morbidity, good functional outcome, and low incidence of medium-term reoperation rate.

A Bladder Stone 28 Years After Burch Colposuspension.

An 86-year-old lady was referred for a 3-cm bladder stone 28 years after Burch colposuspension. Cystoscopy showed a stone over a nonabsorbable suture, eroding from the right anterolateral bladder wall. The patient underwent a transurethral holmium laser lithotripsy and thulium laser removal of the eroded bladder wall. A high index of suspicion of suture erosion should always be present in case of de novo symptoms in women who underwent colposuspension, even in the long-term period.

Medical management of urolithiasis in the Middle Ages: Thesaurus Pauperum of Pope John XXI.

BACKGROUND/OBJECTIVE: This paper will present a brief description of medicine in the Middle Ages, and more comprehensive analysis of the medical management of urolithiasis in Thesaurus Pauperum, the main text of Pedro Hispano. METHOD: An in-depth reading of the Italian translation of Thesaurus Pauperum, and a review of the literature of the life of Pedro Rebuli Guiliani, known as Pedro Hispano, was performed. RESULT: Pedro Hispano was born in Portugal around 1205. He studied philosophy, theology and medicine in Paris. He was named professor of medicine at the University of Siena in 1247 and was elected Pope, as John XXI, in 1276. His primary medical book was Thesaurus Pauperum ('Treasure of the Poor'), a prescription handbook for common diseases, directed not only to physicians but also to ordinary people. We focused on the description of medical management of urolithiasis in Thesaurus Pauperum. CONCLUSION: This text is interesting not so much on account of the pharmacopoeia used, but instead, because it is, probably, one of the first medical text reporting therapeutics close to the modern evidence-based medicine.

Are Outcomes of Thulium Laser Enucleation of the Prostate Different in Men Aged 75 and Over? A Propensity Score Analysis.

OBJECTIVE: To evaluate the outcomes of thulium laser enucleation of the prostate (ThuLEP) in men aged ≥75 years compared to youngers. Traditional surgery has increased and significant morbidity in older men. Lasers have been introduced as an alternative approach to overcome the morbidity of traditional surgery. MATERIAL: We retrospectively evaluated 412 men who underwent en bloc ThuLEP. Inclusion criteria were lower urinary tract symptoms refractory to medical therapy, maximum urinary flow rate (Qmax) ≤15 mL/s, International Prostate Symptom Score (IPSS) ≥8 and absolute indications for surgery. Prostate volume, prostate specific antigen, IPSS, and Qmax, antiplatelet/anticoagulant therapy, ASA score, operation time, length of catheterization, discharge day, early complications, and reoperations were gathered. Differences between groups were estimated using propensity scores, by fitting a stepwise logistic regression model with age group as the dependent variable. RESULTS: One hundred twenty-nine patients were aged ≥75 years (Group 2). Mean age was 65.6 ± 6.0 years in Group 1 and 79 ± 3.7 years in Group 2. Propensity scores retrieved 206 patients. Median operation, catheterization time, and hospital stay were similar in both groups (55 minutes, 2 and 3 days). Overall, 85.9% of men had no complications, with no differences between the groups (82.5% in Group 1 and 89.3% in Group 2). The incidence of Clavien grade III-IV complications was comparable (3.8% in Group 1, 1% in Group 2). By 1 year, there were no statistically significant differences in IPSS, Qmax, QoL, or reoperation rate between the groups. CONCLUSION: En bloc ThuLEP is a safe and effective treatment even in men aged ≥75 years old.