Prospective trial of regional (hockey-stick) prostate cryoablation: oncologic and quality of life outcomes

Focal Minimally Invasive Treatment in Localized Prostate Cancer: Comprehensive Review of Different Possible Strategies

BACKGROUND

Focal therapy is a promising, minimally invasive method for the treatment of patients with localized prostate cancer. According to the existing literature, there is growing evidence for positive functional outcomes and oncological effectiveness. The aim of this review is to evaluate the technical efficacy of three minimally invasive techniques (cryoablation, electroporation, and microwave ablation) and their impact on quality of life in patients with prostate cancer.

METHODS

Studies between January 2020 and July 2023 were selected using PubMed, Embase, and The Cochrane Library and analyzed following PRISMA guidelines; they have not been registered.

RESULTS

Twenty-three studies investigating three different sources of energy to deliver focal therapy were found. Thirteen studies evaluated the performance of the cryoablation therapy, seven studies of the irreversible electroporation, and three studies of microwave ablation option. The majority of studies were retrospective cohort studies. Cryoablation showed excellent oncological outcomes for low-grade prostate cancer, whether performed on the lesion, on the hemigland, or on the entire gland, with the best results obtained for patients with intermediate risk. Irreversible electroporation showed promising oncological outcomes with no significant changes in functional outcomes. Microwave ablation showed great early functional outcomes.

CONCLUSIONS

The oncological effectiveness of minimally invasive treatment in comparison to standard of care is still under investigation, despite encouraging results in terms of functional outcomes improvement and adverse events reduction. More comprehensive research is needed to fully understand the function of minimally invasive treatment in patients with localized PCa.

The Added Value of Systematic Sampling in In-Bore Magnetic Resonance Imaging-Guided Prostate Biopsy

We sought to quantify the additive value of systematic biopsy (SB) using in-bore magnetic resonance (MR)-guided prostate biopsy (IBMRGpB) by retrospectively reviewing the records of 189 patients who underwent IBMRGpB for suspected prostate cancer or as part of the surveillance protocol for previously diagnosed prostate cancer. The endpoints included clinically significant and non-clinically significant cancer diagnosis. SB detected clinically significant disease in 67 (35.5%) patients. Five (2.65%) patients whose targeted biopsies indicated benign or non-clinically significant disease had clinically significant disease based on SB. SB from the lobe contralateral to the lesion detected clinically significant disease in 15 (12%) patients. The size of the prostate was larger and the percentage of lesions located in the peripheral zone of the prostate was higher in patients with SB-detected clinically significant disease. The location of the main lesion in the peripheral zone of the prostate was a predictor for clinically significant disease in the multivariate analysis (OR = 8.26, p = 0.04), a finding supported by a subgroup analysis of biopsy-naïve patients (OR = 10.52, p = 0.034). The addition of SB during IBMRGpB increased the diagnosis of clinically significant as well as non-clinically significant prostate cancer. The location of the main lesion in the peripheral zone emerged as a positive predictive factor for clinically significant disease based on SB. These findings may enhance patient-tailored management.

Focal cryotherapy for prostate cancer: a contemporary literature review

Objective

To perform a comprehensive review of the contemporary literature regarding both functional and oncologic outcomes after primary focal cryotherapy for prostate cancer (PCa), providing these results as a foundation for discussing recent developments in the realm of focal therapy.

Background

Traditional treatments for PCa are often associated with debilitating functional side effects for patients. Due to advances in imaging and biopsy strategies, focal ablative therapies recently have garnered much interest and offer an alternative primary treatment for PCa patients with localized disease. Focal cryoablation utilizes heat extraction from tissues to generate an iceball and cause tissue destruction while sparing uninvolved prostatic regions. Optimized patient selection and postoperative management continue to be areas of interest and study as the field continues to develop.

Methods

A search was performed of the PubMed and Embase databases to identify articles pertaining to primary focal PCa cryoablation since our group's last comprehensive review in 2016.

Conclusions

Primary focal cryoablation for PCa offers optimized functional outcomes and a favorable adverse event profile. True evaluation of oncologic outcomes is hampered by lack of long-term follow-up and highly variable clinical endpoints across these studies. Nonetheless, outcomes appear adequate in the short- to medium-term time frame. Utilization of focal cryoablation is expected to grow with continued refinement of patient selection and management options in cases of treatment failure.

Focal Therapy for Prostate Cancer: The Impact on Sexual Function

Focal therapy (FT) has emerged as a potential treatment for localized prostate cancer (PCa) with encouraging functional outcomes. According to the compelling evidence based on meta-analyses and recent trials, erectile function (EF) is mostly retained at 6 and 12 months after FT when compared to baseline. These findings are consistent across different energy sources reported to date. However, overall, quality of life, including impotence, was not the endpoint for most studies. Additionally, impotency has not been consistently reported in most of the recent literature. Furthermore, confounding factors such as baseline potency and usage of phosphodiesterase 5 inhibitors (PDE5-I) were also frequently undisclosed. Long-term functional outcomes are awaited. To fully comprehend how FT affects EF, more extensive long-term randomized clinical trials using EF as a primary outcome are needed.

Detailing Sexual Outcomes After Focal Therapy for Localised Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

Focal therapy has emerged as a promising option to treat well-selected men with localised prostate cancer while preserving healthy prostate tissue and key structures, such as the urethral sphincter and neurovascular bundles. However, how this tissue preservation may translate into improved outcomes, particularly into improved sexual outcomes, is still an active research field.

OBJECTIVE

We conducted a systematic review and meta-analysis of the literature to summarise the existing evidence, in order to provide patients with updated data on what to expect after treatment and help identify gaps in current knowledge that may warrant future research.

EVIDENCE ACQUISITION

A systematic literature search was conducted on Medline, EMBASE, Scopus, and Web of Science. The search strategy was defined using the "litsearchr" function in R based on a preliminary "naïve" search using the following terms on Medline: (("focal therapy" OR "focal treatment") AND ("prostate cancer") AND ("sexual function" OR "erectile function")). A total of 42 studies, comprising 3117 patients treated and 2352 with available sexual outcomes, were included in the qualitative data synthesis and 26 in a random-effect meta-analysis.

EVIDENCE SYNTHESIS

The five-item International Index of Erectile Function (IIEF-5) was the most frequently used questionnaire (30/42 studies), with completion rates ranging from 24% to 100% at 18-24 mo. A decrease was noted at 3 mo (IIEF-5 decrease estimate -3.70 [95% confidence interval -4.43, -2.96]), with improvements at 6 mo (-2.18 [-2.91, -1.46]) and 12 mo (-2.14 [-2.96, -1.32]). Studies in which patients had an altered baseline sexual function were more likely to report a significant and durable postoperative decrease in erectile function scores. The patient-reported outcome questionnaires used were not designed for a diverse population. Functional outcomes were not the primary endpoint and have not been reported consistently in most studies considered.

CONCLUSIONS

Focal therapy led to changes in erectile function in most cases under the significance threshold of the patient-reported outcome questionnaires used. However, patients should be counselled according to their baseline erectile function. More research is warranted to detail aspects other than erectile function, such as ejaculation or orgasm. The early postoperative period appears key to study sexual changes after focal therapy, while only a moderate decrease is expected at 12 mo.

PATIENT SUMMARY

We reviewed the published literature detailing the sexual consequences of focal therapy for localised prostate cancer using patient-reported outcome questionnaires. Patients were likely to describe a significant decrease in their erectile function at 3 mo, with improvements noted at 6 and 12 mo. The results obtained may not be reproducible in a more diverse population, and further research is warranted to better study aspects other than erectile function, such as ejaculation or orgasm.