R. Van Velthoven

Postoperative Radiotherapy After Radical Prostatectomy: A Randomised Controlled Trial (EORTC Trial 22911)

Summary Background Local failure after prostatectomy can arise in patients with cancer extending beyond the capsule. We dida randomised controlled trial to compare radical prostatectomy followed by immediate external irradiation withprostatectomy alone for patients with positive surgical margin or pT3 prostate cancer. Methods After undergoing radical retropubic prostatectomy, 503 patients were randomly assigned to a wait-and-seepolicy, and 502 to immediate postoperative radiotherapy (60 Gy conventional irradiation delivered over 6 weeks).Eligible patients had pN0M0 tumours and one or more pathological risk factors: capsule perforation, positivesurgical margins, invasion of seminal vesicles. Our revised primary endpoint was biochemical progression-freesurvival. Analysis was by intention to treat. Findings The median age was 65 years (IQR 61–69). After a median follow-up of 5 years, biochemical progression-free survival was significantly improved in the irradiated group (74·0%, 98% CI 68·7–79·3

A review of currently available vessel sealing systems

Laparoscopic surgery is rapidly expanding among urologists as a minimally invasive treatment with surgical procedures becoming increasingly challenging. Accurate haemostatis is of utmost importance in laparoscopy, as bleeding can rapidly impair the working environment conditions. We subsequently reviewed the different haemostatic tools used in laparoscopy with the focus on ultrasonic dissectors and electrothermal bipolar vessel sealer (EBVS). Briefly, there is a wide variety of haemostatic tools currently available in laparoscopy, all with their inherent advantages and limitations. The comparison of ultrasonic dissectors and EBVS shows that both systems are very attractive with similar physical properties concerning thermal spread and bursting pressure of vessels sealed. It has to be noted, however, that EBVS can handle vessels of up to 7 mm. In conclusion, haemostatic tools constitute a rapidly evolving domain with devices being developed which cause less thermal spread, while being more precise and faster. This evolution should finally allow more complex laparoscopic surgical procedures.

A prospective clinical trial of HIFU hemiablation for clinically localized prostate cancer

Background:Focal therapy is an emerging mini-invasive treatment modality for localized prostate cancer aimed to reduce the morbidity associated with radical therapy while maintaining optimal cancer control. We report the mid-term oncological and functional results of primary hemiablation high-intensity focused ultrasound (HIFU) in a prospective cohort of patients.Methods:Over 8 years, hemiablation HIFU was primarily performed in 50 selected patients with biopsy-proven clinically localized unilateral, low–intermediate risk prostate cancer in complete concordance with the prostate cancer lesions identified by magnetic resonance imaging with precise loci matching on multimodal approach. Post-treatment follow-up included regular serial PSA measurements. Biochemical recurrence was reported using Stuttgart and Phoenix criteria. The latter was used as a threshold to offer whole-gland biopsies.Results:Complete follow-up was available for all patients and the median follow-up was 39.5 months (range: 6–94). Mean nadir PSA value was 1.6 ng ml−1, which represents 72% reduction compared with initial PSA pre-treatment value (P<0.001). Median time to achieve PSA nadir was 3 months. Biochemical recurrence, according to Phoenix and Stuttgart definition, occurred in 28 and 36% of patients, respectively. The 5-year actuarial metastases-free survival, cancer-specific survival and overall survival rates were 93, 100 and 87%, respectively. Out of the eight patients undergoing biopsy, six patients had a positive biopsy for cancer occurring in the untreated contralateral (n=3) or treated ipsilateral lobe (n=1) or bilaterally (n=2). A Clavien–Dindo grade 3b complication occurred in two patients. Complete continence (no pads) and erection sufficient for intercourse were documented in 94 or 80% of patients, respectively.Conclusion:Hemiablation HIFU therapy, delivered with intention to treat, for carefully selected patients affords mid-term promising functional and oncological outcomes. The effectiveness of this technique should be now compared with whole-gland radical therapy.

Utilization of multiparametric prostate magnetic resonance imaging in clinical practice and focal therapy: report from a Delphi consensus project

PurposeTo codify the use of multiparametric magnetic resonance imaging (mpMRI) for the interrogation of prostate neoplasia (PCa) in clinical practice and focal therapy (FT).MethodsAn international collaborative consensus project was undertaken using the Delphi method among experts in the field of PCa. An online questionnaire was presented in three consecutive rounds and modified each round based on the comments provided by the experts. Subsequently, a face-to-face meeting was held to discuss and finalize the consensus results.ResultsmpMRI should be performed in patients with prior negative biopsies if clinical suspicion remains, but not instead of the PSA test, nor as a stand-alone diagnostic tool or mpMRI-targeted biopsies only. It is not recommended to use a 1.5 Tesla MRI scanner without an endorectal or pelvic phased-array coil. mpMRI should be performed following standard biopsy-based PCa diagnosis in both the planning and follow-up of FT. If a lesion is seen, MRI-TRUS fusion biopsies should be performed for FT planning. Systematic biopsies are still required for FT planning in biopsy-naïve patients and for patients with residual PCa after FT. Standard repeat biopsies should be taken during the follow-up of FT. The final decision to perform FT should be based on histopathology. However, these consensus statements may differ for expert centers versus non-expert centers.ConclusionsThe mpMRI is an important tool for characterizing and targeting PCa in clinical practice and FT. Standardization of acquisition and reading should be the main priority to guarantee consistent mpMRI quality throughout the urological community.

Tolerability and safety of flutamide in monotherapy, with orchiectomy or with LHRH-a in advanced prostate cancer patients : A Belgian Multicenter Study of 905 patients

OBJECTIVE In a multicenter study, 905 patients with newly diagnosed advanced prostate cancer treated with flutamide were followed for safety and side effects. METHODS Flutamide was administered in monotherapy (75 patients (8%)) or as part of total androgen blockade (TAB groups): the latter group had orchiectomy (196 patients (22%)) or an LHRH (634 patients (70%)). RESULTS The incidence of gastrointestinal complaints such as loss of appetite, vomiting/nausea and diarrhea (+/- 15%) was similar in the TAB and the monotherapy groups. Eighteen patients (2%) were withdrawn because of severe diarrhea. Hot flushes was the most frequently reported adverse event in TAB groups (40% of patients), leading to withdrawal in 4 patients (0.4%). Breast tenderness occurred most frequently in the monotherapy group (49%) and was reported as severe in 7% of the patients. Only 0.8% of the patients were withdrawn because of liver function changes. No unexpected potentially dangerous adverse events were reported. CONCLUSION Flutamide alone or in combination therapy appears to be safe and well tolerated.

Operative strategy in laparoscopic nephrectomy

Nephrectomy is a debilitating procedure because of the trauma to the abdominal wall. Laparoscopy could be a solution in this matter. Four patients underwent laparoscopic nephrectomy. In 3 patients with renal cancer, the transperitoneal route was used in order to obtain quicker access to the hilus. In the fourth patient with benign disease, a retroperitoneal route was chosen. There was no morbidity or mortality. Mean hospital stay was 5 days. Laparoscopic nephrectomy is safe and effective. Larger series are needed for evaluation of the long-term results in the treatment or renal cancer.

Learning curve of positive margin rate in laparoscopic radical prostatectomy

estimate -2.99, 95%CI -3.45,-2.53) but more anastomotic strictures (OR 1.40, 95%CI 1.04,1.87) and higher rates of salvage therapy (OR 3.67, 95%CI 2.81,4.81). Patients of high-volume MIRP experienced fewer anastomotic strictures (OR 0.93, 95%CI 0.87,0.99) and less salvage therapy (OR 0.92, 95%CI 0.88,0.98). CONCLUSIONS: Men undergoing MIRP vs. open radical prostatectomy have lower risk for perioperative complications and shorter lengths of stay, but are at higher risk for salvage therapy and anastomotic strictures. However, risk for these unfavorable outcomes decreases with increasing MIRP surgical volume.