Evaluation of functional and oncological outcomes of localized prostate cancer after different minimally invasive therapeutic methods: A single center experience

OBJECTIVES

To study the functional and oncological results of minimally invasive treatment methods: cryoablation, brachytherapy, and high-intensity focused ultrasound (HIFU) therapy of localized prostate cancer in a single hospital.

METHODS

One hundred sixty patients with localized prostate cancer were treated with minimally invasive methods (53, 52, 55 patients with cryoablation, brachytherapy and HIFU therapy, respectively). Prostate-specific antigen and evaluation of post-procedure biopsies were used as an assessment. The review of functional indicators and quality of life was made with International Index of Erectile Function (IIEF-5), International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), quality of life (QoL) questionnaires.

RESULTS

Patients after cryoablation showed worse results of oncological control according to positive repeat biopsies, best indicators were observed after brachytherapy. When considering the IPSS results, there were statistically significantly worse scores in the brachytherapy group in the early postoperative period, these differences do not reach statistical significance in the late period in the brachytherapy and cryoablation groups. Patients in the cryoablation group showed worse indicators of IIEF-5; in the early postoperative period; in the late follow-up period, the indicators of erectile function in patients in the cryoablation group did not statistically significantly differ from those in patients after brachytherapy. Patients after HIFU therapy showed fewer cases of de novo erectile dysfunction during the follow-up period of 3 years, higher average IIEF-5 scores, lower IPSS scores and better QoL results.

CONCLUSION

The recurrence of prostate cancer was statistically significantly higher in the International Society of Urological Pathology (ISUP) 3 grade group. HIFU therapy had better urination indicators compared to other groups, that can be associated with the laser enucleation of prostatic hyperplasia. The advantage was noted in patients after HIFU therapy when comparing the parameters to the IIEF-5 thus, HIFU treatment had a better impact on patients' QoL with localized prostate cancer.

[Puncture access with a new atraumatic needle MG for mini-percutaneous nephrolithotomy]

INTRODUCTION

An important aspect of the prevention of complications in percutaneous nephrolithotomy (PCNL) is to reduce the likelihood of injury to the adjacent structures and perirenal tissues.

AIM

To determine the efficiency and safety of renal puncture during mini-PCNL with a new atraumatic needle MG.

MATERIALS AND METHODS

A total of 67 patients who underwent mini-percutaneous nephrolithotomy at the Institute of Urology and Human Reproductive Health of Sechenov University were included in the prospective study. For the purpose of homogeneity of the groups, those with staghorn nephrolithiasis, nephrostomy, a history of prior kidney surgery (including PCNL), renal and collecting system anomalies, acute pyelonephritis, and blood clotting disorders were not included. The main group consisted of 34 (50.7%) patients who underwent atraumatic kidney puncture with a new needle MG (MIT, Russia), while in the control group there were 33 (49.3%) patients, who underwent standard puncture with Chiba or Troakar needles (Coloplast A/S, Denmark). The outer diameter of all needles was 18 G.

RESULTS

In patients with a standard access, a hemoglobin decrease in the early postoperative period was more pronounced (p=0.024). The incidence of complications according to the Clavien-Dindo classification did not differ significantly (p=0.351), however, a JJ stent was placed in two patients from the control group due to impaired urine flow and the development of urinoma.

CONCLUSION

Together with a similar stone-free rate, atraumatic needle allows to reduce a hemoglobin drop, as well as less development of severe complications.

[Prospective comparison of cognitive and mpMR/US fusion biopsy for prostate cancer detection]

INTRODUCTION

According to the recommendations of the European Association of Urology the presence of a suspicious lesion on MRI is an indication for both primary and secondary MR-targeted biopsies. At the same time, the Russian Society of Urologists recommends to perform mpMR/US fusion biopsy only in patients with a prior negative biopsy. In clinical practice, mpMR/US fusion and cognitive biopsies are the most frequently performed. However, when comparing them, contradictory data on detection of clinically significant prostate cancer is obtained.

OBJECTIVE

to compare the detection rate of clinically significant prostate cancer performing cognitive and mpMR/US fusion biopsies.

MATERIALS AND METHODS

Inclusion criteria: PSA >2 ng/mL and/or a positive DRE, and/or a suspicious lesion on TRUS, and PI-RADSv2.1 lesion more or equal 3. At first, "unblinded" urologist performed a transperineal mpMR/ultrasound fusion and saturation biopsy. Then "blinded" urologist obtained transrectal cognitive biopsy Clinically significant cancer was defined as ISUP more or equal 2.

RESULTS

We enrolled 96 patients. Median age was 63 years, prostate volume - 47 cm3 and PSA - 6.82 ng/mL. MpMR/US fusion and cognitive biopsies were comparable in regard to the detection rate of clinically significant (32.3% vs 25.0%; p=0.264), clinically insignificant cancer (25.0% and 26.0%; p=0.869) and overall detection rate (57.3% and 51%;p=0.385). Both biopsies missed clinically significant cancer with equal frequency (5.2%; p=0.839). Histological efficacy also was comparable. The number of positive cores between mpMR/US fusion and cognitive biopsy was equal (34.1% and 31.1% respectively; p= 0.415). At the same time, no statistically significant difference was found with respect to maximum cancer core length (53.1% vs 47.7%, respectively; p=0.293).

CONCLUSION

The results suggest that both cognitive and mpMR/US fusion biopsies are equally accurate diagnostic methods for clinically significant prostate cancer detection, thus their wider introduction into clinical practice is necessary.

[Predictors for locoregional recurrence after radical prostatectomy]

An analysis of domestic and foreign literature on the predictors of prostate cancer recurrence are presented in the article. A deep analysis of both pathological and histological risk factors for progression was provided, as well as of laboratory and clinical predictors.

[Retrograde intrarenal surgery using a 1.94 m superpulsed thulium fiber laser]

INTRODUCTION

surgical treatment of urinary stone disease plays an important role in urological practice. Stone fragmentation can be performed using various lithotripters, from which Holmium fiber laser (Ho: YAG) has currently taken the main place. According to the current literature, a superpulsed thulium fiber laser with a wavelength of 1.94 m and a maximum power output of 40 W showed in vitro higher efficiency compared to Ho: YAG, while having the same safety profile. The use of a thulium fiber laser with a pulse energy of 0.025-6 J and a high repetition rate (up to 1600 Hz) allows to most effectively perform stone dusting during retrograde intrarenal surgery (RIRS).

AIM

to improve the performance of RIRS using the 1.94m superpulsed thulium fiber laser.

MATERIALS AND METHODS

a total of 152 patients with renal stones who were treated during the period from February 2018 to July 2019 were included in the study. The analysis of the laser settings, their effect on retropulsion and visibility when performing RIRS using a superpulsed thulium fiber laser with a wavelength of 1.94 m and a maximum power output of 40 W, a peak power of 500 W, as well as an assessment of the stone-free rate the first postoperative day and 3 months after the procedure was done.

RESULTS

The most frequently used settings were as following: 0.5 J, 30 Hz, 15 W (No. 1), 0.15 J, 200 Hz, 30 W (No. 2), 0.8 J, 31.25 Hz, 25 W (No. 3), 0.8 J, 37.5 Hz, 30 W (No. 4). The statistical analysis of the influence of the settings on the quality of endoscopic imaging and retropulsion was carried out. In addition, the features of each settings were analyzed. The stone-free rate on the first postoperative day was evaluated using low-dose CT.

CONCLUSION

A superpulsed thulium fiber laser with a wavelength of 1.94 m and a maximum power of 500 W has shown high efficiency in clinical practice when performing RIRS, since it allows to have good endoscopic imaging, minimal retropulsion, and to perform stone dusting, which had a positive effect on the stone-free rate. Optimization of the settings of thulium fiber lithotripsy may improve the results of surgical treatment of urinary stone disease.

[Flexible ureteroscopy for lower pole renal stones: novel superpulse thulium (TM) fiber laser lithotripsy]

INTRODUCTION

The SuperPulse Thulium (Tm) fiber laser (wavelength of 1.94 m) has been recently introduced as a directed-energy source for urology. Preclinical studies have shown a significant potential of the SuperPulse Tm fiber laser (SP TFL) for lithotripsy. However, clinical reports of using SP TFL to treat urolithiasis are still few and limited. Of special interest are challenging cases, e.g., lower pole stones, when extreme deflection of the instrument is required.

OBJECTIVE

To evaluate the effectiveness of the SuperPulse Tm fiber laser in the management of lower pole small calyceal stones during flexible ureteroscopy (F-URS).

METHOD

s. The SuperPulse Tm fiber laser device (Urolase 2, IRE Polus, Fryazino, Russia) has been cleared for clinical use by the Ministry of Health of Russian Federation. Study protocol has been approved by the Ethical Review Committee. Between January 2018 and February 2019, 130 patients with kidney stones have undergone Thulium fiber laser lithotripsy during F-URS. We retrospectively analyzed 15 of this patients with a single radiopaque lower pole calculus that were included in the present study. Stone size, stone density, lithotripsy time (from the first to last footswitch press) and "lasering" (laser emission) time were measured. The SP TFL was used for stone disintegration with different settings in dusting and fragmentation modes (0.1 - 4J, 7-300Hz, 6-40W) via a fiber with a 200-m core diameter. Low dose CT scanning was performed on POD 90 to assess SFR.

RESULTS

Stone size ranged from 4 to 17 mm and stone density varied from 350 to 1459 HU. The average lithotripsy time was 12 min (3-30 min). The average "lasering" time was 1.3 min (0.4-2.5 min) and the mean hospital stay was 1.1+/-0.3 days. In all cases we reached the lower pole stone containing calyx with a laser fiber. The complication rates were evaluated by using the Clavien-Dindo grading system and did not exceed GII (6.6%). SFR on POD 90 was achieved in 86.6% of cases.

CONCLUSIONS

F-URS with SuperPulse Tm fiber laser is safe and effective option in the management of lower pole small calyceal stones. The possibility of using small laser fibers gives better instrument deflection which make possible to reach lower pole calyceal stones even with acute lower pole infundibulopelvic angle (IPA).

[Clinical case of delayed diagnosis of tuberous sclerosis]

A clinical case of successful drug treatment of multiple renal angiomyolipomas in patient with tuberous sclerosis is presented, which suggests potential role of medical treatment of benign kidney tumors.

[Minimally invasive techniques of localized prostate cancer]

Currently, prostate cancer (PCa) is one of the most important problem of modern medicine, including economical issue. The detection of PCa compared to any other cancers progressively increases with age. Currently, PCa is the most commonly diagnosed solid tumor. Radical prostatectomy and radiation therapy are considered standard of treatment for PCa. However, while excellent long-term oncologic results can be achieved, these methods are often associated with significant complication rate, which negatively affects the quality of life of patients. Technological advancement and their implementation in medicine have increased treatment opportunities in oncourology. The purpose of this literature review is to study alternative treatment methods of localized PCa and compare their efficiency with conventional therapy.

[Multi-parametric MRI/US fusion guided biopsy for the diagnosis of prostate cancer. ur experience]

INTRODUCTION

Prostate cancer is one of the most common types of cancer in men. The gold standard for the detection of prostate cancer is ultrasound guided transrectal prostate biopsy. The detectability of cancer using this method is from 30 to 50%. As a result, many men undergo multiple repeat biopsies for suspected prostate cancer. The European Association of Urology does not give any recommendations on this matter. A revolutionary new method in the diagnosis of prostate cancer is a targeted prostate biopsy using a fusion of multiparametric magnetic resonance imaging (MRI) and ultrasound.

MATERIALS AND METHODS

At the R.M. Fronstein Clinic of Urology, 55 patients with suspected prostate cancer from September 2017 to January 2018 underwent fusion prostate biopsy. Of them, 21 patients had negative primary biopsies. Two patients had verified prostate cancer. 32 patients did not undergo primary biopsies.

RESULTS

The findings of the study suggest that using MRI-ultrasound fusion for guidance of targeted prostate biopsy improves the quality of the histological material, allows patients to avoid unnecessary biopsy, reduces the number of punctures, thereby offering higher diagnostic performance in detecting prostate cancer. MRI-ultrasound fusion targeted biopsy has a high sensitivity in detecting clinically significant cancer and low for clinically insignificant cancers.

CONCLUSION

The technique affords accurate detection of the location and extent of pathological lesions in the prostate thus allowing focal therapy for prostate cancer.

[Erectile dysfunction associated with radical prostatectomy: appropriateness and methods to preserve potency]

RELEVANCE

Erectile dysfunction (ED) associated with radical prostatectomy (RP) affects 25-75% of patients and has a significant negative impact on their quality of life AIM: To analyze the maintenance of erectile function after RP depending on the type of endoscopic access and nerve-sparing.

MATERIALS AND METHODS

This retrospective study comprised 231 patients with localized prostate cancer, who underwent surgery between February 2015 and February 2016. Surgery was performed using one of three approaches: laparoscopic, extraperitoneoscopic or robot-assisted. Nerve-sparing surgery was chosen were based on the Briganti nomogram (low risk of extraprostatic extension), Partins table, and taking into account the patients desire to maintain EF. EF and the quality of life were evaluated using the International Index of Erectile Function (IIEF-5) questionnaire and the QoL (Quality of Life) scale.

RESULTS

Nerve-sparing RP was performed in 153 patients. Nerve-sparing RP did not differ significantly from non-nerve sparing RP with regard to operative time (p=0.064) and blood loss (p=0.073). According to the pathomorphological study, the prostatic capsule was intact, and surgical margins were negative in all cases. The incidence of significant ED and complete loss of erectile function was greater in patients after non-nerve sparing RP compared with nerve sparing RP [(5.0 (0-10.0) vs. 6.5 (0.8-19,0) points according to the IIEF-5 scale, p=0.271)]; 96.2% versus 72.2% (p<0.001). Nerve-sparing RP had a statistically significant better effect on the quality of life: 1.63+/-1.16 points against 1.88+/-1.02 points (p=0.035).

CONCLUSION

The best outcomes were observed in patients undergoing robot-assisted RP. Nerve-sparing RP resulted in a lower rate of ED. This advantage without compromising the completeness of resection allows us to consider nerve-sparing RP as an appropriate and validated modality of preventing erectile dysfunction in properly selected patients.

[Ultrasound-guided percutaneous cryoablation of renal tumors]

INTRODUCTION

Surgery remains the gold-standard curative treatment for localized (T1) renal carcinoma. However, recent medical-technological advances have led to the development of new minimally invasive treatment options, one of which is percutaneous cryoablation.

AIM

To assess the effectiveness and safety of ultrasound-guided percutaneous cryoablation of renal tumors.

MATERIALS AND METHODS

The study comprised 12 patients aged 52 to 76 years who underwent ultrasound-guided percutaneous cryoablation of renal tumors from 2015 to 2017. In 11 patients, the size of the renal mass was 3.0 cm (T1a), in 1 patient 4.5 cm (T1b). A Doppler ultrasound, contrast-enhanced MSCT and computer 3D modeling were performed in all patients pre-operatively and 6 months after surgery to assess the tumors size and extent and the spatial location of the tumor internal surface to the pelvicalyceal system. In all patients, the tumors were located along the posterior or lateral surface of the kidney, in the lower or middle segment and without sinus invasion. We used a 3rd generation Galil Medicals SeedNet Gold Cryotherapy System and IceSeed and IceRod cryoprobes. Intraoperatively, immediately before cryoablation, the tumor was biopsied. In all patients the diagnosis of renal cell carcinoma was confirmed morphologically.

RESULTS

Mean duration of cryoablation was 60 minutes. Endotracheal, spinal, local and intravenous anesthesia was used in 1, 6, 5 and 1 patients, respectively. Doppler ultrasound at 6 months after surgery showed that in 11 patients (T1a) the tumor size decreased on average by 8 mm, with no blood flow in the tumors. MSCT with 3D modeling also revealed a decrease in tumor size and total absence of contrast agent accumulation, or accumulation gradient not exceeding 10 HU (initially it was about 200 HU). In the patient with T1b stage renal carcinoma, MSCT showed a decrease in tumor size from 4.5 to 3.7 cm, however, there was a mass up to 1.5 cm with a high gradient of contrast agent accumulation. The patient underwent kidney resection. No intra- and postoperative complications were observed.

CONCLUSION

The accumulated experience allows to confirm the effectiveness and safety of ultrasound-guided percutaneous cryoablation and to consider it a method of choice for patients with stage T1a renal carcinoma located along the posterior or lateral surface of the kidney in the lower or middle segment, without sinus invasion.

[Irreversible electroporation to treat prostate cancer (Nanoknife)]

Modern medicine tends to use minimally invasive treatments. Selected patients with prostate cancer may be treated using irreversible electroporation that involves the application of a NanoKnife device. The procedure directs short electrical pulses that open microscopic pores in the cells in the treatment area and effectively destroy cancer cells. This literature review outlines the history of irreversible electroporation, its use in surgery for treating cancers of the pancreas, liver, lung, kidney and brain. This technique is relatively new and is not yet applied in routine urologic practice, but has been increasingly used in Europe and North America and, no doubt, will find an appropriate utilization in Russia.

[The potential of endovideosurgical technologies for simultaneous ipsilateral presentation of a kidney tumor and kidney stone]

AIM

To determine the treatment strategy in patients with kidney tumors co-occurring with ipsilateral kidney stones.

MATERIALS AND METHODS

During the period from 2006 to 2015, a combination of kidney tumor and urolithiasis was detected in 159 (11.5%) patients. Of these, 61 patients had indications for surgical treatment for both diseases at the time of hospitalization. The article analyzes the surgical treatment results of 14 patients with ipsilateral combination of kidney stone and kidney tumors and shows the potential of endovideosurgical technologies in managing this category of patients.

RESULTS

The surgical treatment for stones was initially conducted in 3 (21.4%) patients, 4 (28.6%) patients underwent the kidney tumor surgery at the first stage, and the remaining 7 (50.0%) patients underwent one-stage surgery for both diseases. Despite the co-occurrence of two pathologies in one kidney, only 2 patients (14.3%) underwent an organ-removing operation.

DISCUSSION

Combined minimally invasive organ-sparing surgery for unilateral combination of the kidney stone and kidney tumor is the most preferable treatment option, allowing the patient to get rid of both the tumor and the kidney stone within one anesthesia session. One-stage laparoscopic kidney resection with pyelolithotomy or calycolithoextraction allows preventing possible complications associated with the postoperative stone migration and eliminates the need for repeat surgery.

[Focal laser thermocoagulation for localized prostate cancer]

Focal therapy involving destruction of prostate specific region containing a clinically meaningful tumor is a new treatment for prostate cancer. Despite the absence of long-term results of applying this method of treatment, there are prerequisites that allow to consider focal therapy as a method with a lower risk of side effects typical of conventional treatment. Focal laser thermocoagulation is a developing technique with a number of advantages, the most important of which is the ability to perform the treatment under the real-time magnetic resonance imaging control. This review describes the principles of laser thermocoagulation, and presents the data of already published clinical studies, as well as the eligibility criteria for focal laser thermocoagulation of prostate cancer. The prospects of development of the method are discussed.

[Cryoablation in urology]

Modern science opens up new potentials for the effective treatment of complex diseases using minimally invasive techniques. One of the obvious achievements of recent years is cryoablation - technology of local freezing of tissues, allowing to create a precision zone of tumor cell death in renal cancer and prostate cancer. The literature review presents historical information, highlighting the main stages in the development of cryosurgery since the XIX century. The analysis of domestic and foreign literature has shown that in urological practice cryoablation has been widely used. Based on the literature data, indications, contraindications and complications of cryoablation in renal cancer and prostate cancer, as well as long-term results of treatment are discussed. Cryoablation has been used actively abroad; in the Russia, method is developing, but without a doubt, will be actively introduced in medical practice.

[Modern technologies in diagnosis and treatment of patients with late stages of hydronephrosis]

To evaluate the role of modern ultrasonic, x-ray and radionuclide methods in staging hydronephrosis; that of stimulators of stem cells of the bone marrow in combined therapy of patients with late hydronephrosis, we examined and treated 18 patients with late-stage hydro- and ureterohydronephrosis. All the patients were operated. Preoperative preparation included drainage of the upper urinary tract and stimulation of bone marrow stem cells. Organ-saving surgery was conducted with a satisfactory functional result in 14 of 18 patients. Modern methods of investigation provide an objective assessment of structural-functional condition of the kidneys and upper urinary tract in patients with late hydro- and ureterohydronephrosis, may evidence for possible reversibility of registered uro- and hemodynamic alterations. Preoperative use of stimulators of bone marrow stem cells promotes activation of repair processes in renal parenchyma which is essential for efficacy of a further reconstructive operation.