Intraoperative ultrasonography with a surgeon-manipulated microtransducer during robotic radical prostatectomy

Direct comparison of low-dose-rate brachytherapy versus radical prostatectomy using the surgical definition of biochemical recurrence for patients with intermediate-risk prostate cancer

Background

We compared the oncological outcomes of patients who received seed brachytherapy (SEED-BT) with those who received radical prostatectomy (RP) for intermediate-risk prostate cancer.

Methods

Candidates were patients treated with either SEED-BT (n = 933) or RP (n = 334). One-to-one propensity score matching was performed to adjust the patients’ backgrounds. We compared the biochemical recurrence (BCR)-free rate using the Phoenix definition (prostate-specific antigen [PSA] nadir plus 2 ng/mL) for SEED-BT and the surgical definition (PSA cut-off value of 0.2 ng/mL) for RP. We also directly compared the BCR-free rates using the same PSA cut-off value of 0.2 ng/mL for both SEED-BT and RP.

Results

In the propensity score-matched analysis with 214 pairs, the median follow-up treatment was 96 months (range 1–158 months). Fifty-three patients (24.7%) were treated with combined SEED-BT and external-beam radiotherapy. Forty-three patients (20.0%) received salvage radiotherapy after RP. Comparing the BCR-free rate using the above definitions for SEED-BT and RP showed that SEED-BT yielded a significantly better 8-year BCR-free rate than did RP (87.4% vs. 74.3%, hazard ratio [HR] 0.420, 95% confidence interval [CI] 0.273–0.647). Comparing the 8-year BCR-free rate using the surgical definition for both treatments showed no significant difference between the two treatments (76.7% vs. 74.3%, HR 0.913, 95% CI 0.621–1.341). SEED-BT had a significantly better 8-year salvage hormonal therapy-free rate than did RP (92.0% vs. 85.6%, HR 0.528, 95% CI 0.296–0.942, P = 0.030). The 8-year metastasis-free survival rates (98.5% vs. 99.0%, HR 1.382, 95% CI 0.313–6.083, P = 0.668) and overall survival rates (91.9% vs. 94.6%, HR 1.353, 95% CI 0.690–2.650) did not significantly differ between the treatments.

Conclusions

The BCR-free rates did not significantly differ between patients treated with SEED-BT and those treated with RP for intermediate-risk prostate cancer even when they were directly compared using the surgical definition for BCR. SEED-BT and RP can be adequately compared for oncological outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-022-02046-x.

Development and future prospective of treatment for localized prostate cancer with high-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) was experimentally used for focal therapy for anti-cancer effects in prostate cancer (PC). Focal therapy is a diagnosis-based investigational treatment option for localized PC that cures clinically significant PC (csPC) while preserving the anatomical structures related to urinary and sexual function based on its spread observed using multi-parametric magnetic resonance imaging (mpMRI). The European Association of Urology indicated that the current status of focal therapy for localized PC was an investigational modality and encouraged prospective recording of outcomes and recruitment of suitable patients in 2018. During the last few years, large-population multi- and single-center prospective studies have investigated focal therapy as a treatment strategy for localized PC. In a multicenter prospective study with 5-year follow-up, failure-free survival, which was defined as avoidance of local salvage therapy (surgery or radiotherapy), systemic therapy, metastases, and prostate cancer-specific death, was 88%. In the previous studies, there was no significant influence on urinary function before and at 3 months after the treatment, although transient impairment was reported 1 month after the treatment. Pad- and leak-free continence was preserved in 80-100% of the patients after treatment. Erectile function was significantly impaired in the initial 3 months after treatment compared to the pretreatment values, but it improved 6 months after the focal therapy in the previous reports. Paired comparison studies and cohort studies with long-term follow-up will contribute to verifying this treatment's clinical outcomes for patients with localized PC.

The evolution of image guidance in robotic-assisted laparoscopic prostatectomy (RALP): a glimpse into the future

OBJECTIVES

To describe the innovative intraoperative technologies emerging to aid surgeons during minimally invasive robotic-assisted laparoscopic prostatectomy.

METHODS

We searched multiple electronic databases reporting on intraoperative imaging and navigation technologies, robotic surgery in combination with 3D modeling and 3D printing used during laparoscopic or robotic-assisted laparoscopic prostatectomy. Additional searches were conducted for articles that considered the role of artificial intelligence and machine learning and their application to robotic surgery. We excluded studies using intraoperative navigation technologies during open radical prostatectomy and studies considering technology to visualize lymph nodes. Intraoperative imaging using either transrectal ultrasonography or augmented reality was associated with a potential decrease in positive surgical margins rates. Improvements in detecting capsular involvement may be seen with augmented reality. The benefit, feasibility and applications of other imaging modalities such as 3D-printed models and optical imaging are discussed.

CONCLUSION

The application of image-guided surgery and robotics has led to the development of promising new intraoperative imaging technologies such as augmented reality, fluorescence imaging, optical coherence tomography, confocal laser endomicroscopy and 3D printing. Currently challenges regarding tissue deformation and automatic tracking of prostate movements remain and there is a paucity in the literature supporting the use of these technologies. Urologic surgeons are encouraged to improve and test these advanced technologies in the clinical arena, preferably with comparative, randomized, trials.