2024 Focal Therapy Society and Society of Urologic Robotic Surgeons Joint Meeting
Long-term Oncological and Functional Outcomes of Cryoablation of Small Renal Masses; 20-year Follow-up Results of a Single Institutional Experience
*Mahdi Mottaghi, Sriram Deivasigamani, Thomas J Polascik
Presented By: Mahdi Mottaghi, M.D.
Background: Cryoablation of the small renal mass (SRM) is a less invasive nephron-sparing treatment option and an alternative to partial nephrectomy (PN). Herein, we aim to present our institutional experience on the long-term functional and oncological outcomes of renal cryoablation of SRMs.
Methods: We conducted an IRB-approved retrospective database update of 129 consecutive patients who underwent cryoablation of a SRM (<4cm) from October 2001 to December 2011 at Duke University Hospital. Technical failure was considered as persistent enhancement on CT, requiring further ablative or surgical intervention. Disease progression was defined as the presence of local recurrence, metastasis, or need for systemic therapy. IBM SPSS software version 26.0 was used for Cox Regression analysis.
Result: The mean age was 65.52±11.37 years. The mean overall and radiologic follow-up was 9.9±5.6 (median 11) and 7.4±5.6 (median 6.1) years, respectively. Polar location on the preoperative CT was upper, central, and lower in 45 (36%), 52 (41%), and 29 (23%), respectively. Biopsy data were available for 85 cases (66%), with 61 cases (72%) diagnosed as renal cell carcinoma. Eleven (8.5%) cases experienced local failure that was managed with repeat ablation (7 cases), partial nephrectomy (1), and watchful waiting (4). Most cryoablations (78% of 129) were conducted without any reportable adverse events. Regarding functional outcomes, although creatinine increased (Wilcoxon test; p<0.001) and eGFR (Paired t-test; p<0.001) declined significantly at 1-year post-ablation, the mean change was only 11% and 8.1% from the baseline, respectively. For cases with biopsy-proven RCC, the mean OS and MFS were 46.2% and 95.1% in 15-year follow-up, respectively. In the multivariate analysis, only age was a weak independent predictor of overall survival (HR: 1.07; p=0.02). Both RFS and PFS were 86.1%, and CSS was 96.5% at 15-year follow-up. Ten cases experienced recurrence and were managed with repeat ablation (7/12), PN (2/12), and radical nephrectomy (1/12).
Conclusion: Renal cryoablation is an effective modality for oncological control and preservation of renal function in the management of SRMs.
Funding: None.
Micro-ultrasound for Index Lesion Detection and Intraoperative Cryoablation of Prostate Cancer: A Pictorial Essay
*Lucas A Arney, BS, Randall G Bissette, BS, Ethan T Nethery, MS, Mia P Edelson, BS, Daniel B Rukstalis, MD
Presented By: Lucas Allen Arney, BS
Introduction and Objective: Prostate cancer treatment relies heavily on imaging for index lesion (IL) identification and biopsy for subsequent risk stratification. Initially performed without imaging guidance, cryoablation was less efficacious due to significant post-operative complications. Technological advancements in multiparametric magnetic resonance imaging (mpMRI) have greatly improved cryotherapy precision, revitalizing cryoablation as a viable alternative therapy for clinically significant prostate cancer (csPC). However, this mpMRI technology is both expensive and requires a second patient visit for fusion overlay.
Methods: The introduction of high-frequency, high-resolution ultrasound poses an inexpensive alternative with real-time imaging capabilities for both the initial biopsy and subsequent intraoperative treatment of csPC. Recent literature shows comparable detection and concordance rates between micro-ultrasound (mUS) and mpMRI, continuing to highlight the non-inferiority of mUS for IL identification and prostate cancer diagnosis.
Results: This pictorial essay offers sonographic illustrations with descriptive insight into the utilization of mUS from biopsy to intraoperative cryoablation of csPC. Improved visualization allows identification of important anatomical structures that can be avoided throughout “freeze-ball” expansion, thereby mitigating complications.
Conclusions: High-frequency mUS offers a resolution that is 300% better than that of standard ultrasound. As a cost-effective alternative to multiparametric MRI (mpMRI), it eliminates the need for contrast and provides real-time imaging, thereby obviating the necessity of a second fusion-overlay appointment and potentially reducing the time to therapeutic intervention.
Funding: None.
Performance of an AI-assisted prostate segmentation module for MRI-guided transurethral ultrasound (TULSA) treatment planning: multi-reader multi-case study
*Laurence Klotz, MD, Sandeep Arora, MD, Pejman Ghanouni, MD, Aytek Oto, MD, Adnaan Moin, MD, Ara Karamanian, MD, Preston Sprenkle, MD, Christian Pavlovich, MD, Ben Leung, MSc, Cameron Wright, Edward Steiner, Robert Princenthal, MD, Steve Raman, MD
Presented By: Laurence H. Klotz, MD
Introduction and Objective: In performing TULSA, the physician manually outlines the intended treatment zone on up to axial T2w images before ablation begins. This contouring task is repetitive, time-consuming, and subject to intra- and inter-reader variability. Here we present the validation of a deep learning model for automatic segmentation of the prostate to improve efficiency and provide the user with a smoother, more consistent treatment plan.
Methods: The prostate segmentation model uses a SEResNet34 model architecture trained on a mix of open-source T2w prostate MRI and TULSA clinical trial data. This study included 51 axial T2w datasets from past TULSA cases (16 different institutions, 1.5T and 3T, 3 different MRI vendors). 5 experienced radiologists manually segmented each prostate twice (with and without AI-assistance) in 2 different sessions separated by a 4-week washout period. DICE scores of both segmentations (with and without AI-assistance) were compared to a reference standard (combined using the STAPLE algorithm[1] from contours by 3 independent radiologists). 3 urologists repeated the protocol.
Results: When used by experienced radiologists, the accuracy of prostate segmentation with AI-assistance was found to be non-inferior to manual segmentation with a margin of -5% (DICE scores 0.927±0.021 vs 0.928±0.020, p = 0.56). In addition, segmentation time improvement with AI-assistance exceeded the pre-defined threshold of 20% faster than manual segmentation (average 30% time saved: 2.5±1.4 vs 3.6±1.4 min, p<0.0005). Among urologists, DICE scores with vs. without AI-assistance were 0.919±0.023 vs. 0.909±0.037, with segmentation times of 3.6±2.5 vs 5.3±3.3 min.
Conclusion: For experienced radiologists, AI-assisted prostate segmentation was validated to be as accurate as manual segmentation with a time savings benefit. Urologists had greater benefits in segmentation accuracy and speed from AI assistance compared to radiologists.
Disclosures: BL and CW are employees of Profound Medical. SA, PG, AK, AM, AO, PS, LK, CP, ES, RP, and SR were compensated by Profound Medical for their time performing the segmentation task.
Funding: Funded by Profound Medical.
Incidence of ideal candidates for focal therapy in the MRI-era
Introduction: Ideal candidates for focal therapy (FT) have MRI-visible ISUP grade group 2-3 disease that is localized or unilateral; the lesion should also be preferably anterior, to allow for optimal nerve preservation at therapy. MRI has allowed for improved identification of patients who might be suitable for FT. Transperineal (TP) prostate biopsies provide positional information of prostate cancer, including anterior or posterior location. Here, we describe the frequency of optimal FT candidates among a large cohort of men with proven prostate cancer identified from MRI-guided targeted and systematic TP biopsy.
Methods: We queried the Northwestern data warehouse for men with newly diagnosed prostate cancer who had an MRI and a TP biopsy prior to diagnosis from January 2018-June 2024. We included and excluded candidates with disease optimal for FT using modified FALCON consensus guidelines. We included patients with MRI-visible (PI-RADS 3-5; unifocal or multifocal) unilateral-dominant, intermediate-risk disease. Unilateral-dominant disease was defined as intermediate risk on one side and low-risk disease or less on the contralateral side. Anterior or posterior cancer was defined by the position of cancer identified by MRI-guided targeted biopsy or systematic biopsy.
Results: We identified 1013 men diagnosed with prostate cancer on TP biopsy after MRI, of which 602 men had unfavorable-intermediate or favorable-intermediate prostate cancer. Of these 602 men, 97 (16.1%) had an MRI-visible unilateral cancer at biopsy, and 136 (22.6%) had MRI-visible unilateral-dominant cancer. Of these men with MRI-visible unilateral-dominant cancer, anterior-only disease was found in 35 men, comprising 3.5% of total cohort.
Conclusion: FT candidates comprise a significant minority of patients with intermediate risk disease. Ideal candidates with anterior-only lesions comprise an even smaller number.
Funding: None.
MRI Visibility of Prostate Cancer is a Predictor of Adverse Pathology in Radical Prostatectomy Specimens
Lorenzo Storino Ramacciotti, MD, *Masatomo Kaneko, MD, PhD, Francesco Cei, MD, Delara Jadvar, MD, Manju Aron, MD, Vinay Duddalwar, MD, Giovanni E Cacciamani, MD, Hooman Djaladat, MD, Mihir M Desai, MD, Monish Aron, MD, Inderbir Gill, MD, Andre Luis Abreu, MD
Presented By: Masatomo Kaneko, MD, PhD
Introduction and Objectives: To compare rates of adverse pathologic findings among men with visible versus invisible prostate cancer (PCa) on magnetic resonance imaging (MRI) who underwent radical prostatectomy (RP).
Methods: Consecutive patients who underwent RP as primary treatment for prostate cancer (PCa) which had multiparametric MRI (T2W, DWI, ADC, DCE) followed by prostate biopsy, between October 2011 and January 2024, were identified from a prospective database (IRB #HS-13-00663). Exclusion criteria were: I) previous PCa treatment; II) prior prostate surgery; III) salvage and simple prostatectomies. All patients underwent mpMRI within 6 months of the biopsy. MRI visible lesions were defined as Prostate Imaging Reporting & Data System (PIRADS) 3-5; invisible as PIRADS 1-2. The primary endpoint was adverse pathologic findings at RP, defined as Grade Group (GG) ≥4 or ≥pT3 stage or positive lymph node (pN1). Logistic regression analyses were performed. Statistical significance if p<0.05.
Results: A total of 568 patients met inclusion criteria (Visible = 495; Invisible= 73). The median age (67 vs 65Y, p=0.09), family history of PCa (29% vs 28%, p=0.9), and prostate volume (44 vs 51cc, p=0.3) were similar between visible and invisble groups, respectively. PSA (6.7 vs 6.0mm, p=0.008), suspicion on digital rectal examination [DRE] (34% vs 22%, p=0.04), and the rate of baseline GG≥4 (26% vs 12%, p=0.03) were higher for the PIRADS 3-5 group. The rate of adverse pathologic fidings was significantly higher for the PIRADS 3-5 group (54% vs 26%, p<.001), significantly increasing per PIRADS score (Figure). On multivariable logistic regression, suspicious DRE, MRI lesion size, a ≥GG3 baseline biopsy, and MRI visibility were indenpedent predictors for adverse pathology on RP specimens, with MRI visibility having the largest effect (odds ratio, 15.14; 95% CI, 3.53-106.1; p<.001).
Conclusions: Prostate Cancer visibility on MRI is strongly correlated with adverse pathology on radical prostatectomy specimens, even after adjusting for baseline biopsy findings.
Funding: None.
Global Delphi Consensus on Best Clinical Practices for Transperineal Prostate Biopsy
Lorenzo Storino Ramacciotti, MD, Masatomo Kaneko, MD, PhD, Giovanni E Cacciamani, MD, David Strauss, MD, Soroush Rais-Bahrami, MD, James Wysock, MD, Alessandro Tafuri, MD, Thomas J Polascik, MD, Inderbir S Gill, MD, *Andre Luis Abreu, MD
Presented By: Andre Luis Abreu, MD
Introduction: To develop a modified Delphi consensus to serve as guidance for best clinical practices for transperineal (TP) prostate biopsy (PBx).
Materials & Methods: A comprehensive screening of the current and past 5 years American Urological Association (AUA), European Association of Urology (EAU), and National Comprehensive Cancer Network (NCCN) guidelines in prostate cancer was carried out to identify inconsistencies and lack of recommendations regarding TP PBx. Statements were then formulated by members of the steering committee. International stakeholders were identified through a literature search on Scopus, focusing on authors with publications on TP PBx from 2019 to 2023. Additional stakeholders were recruited through snowball sampling. Statements were rated on a Likert scale from 1 (strongly agree) to 5 (strongly disagree), and consensus was defined a priori as ≥75% agreement (scores 1 “Strongly Agree” and 2 “Agree”) per statement. A three-round web-based Delphi survey was subsequently conducted.
Results: A total of 108 international stakeholders were invited and 77 (100%), 75 (97%), and 71 (92%) completed the first, second, and third rounds. Most respondents were Urologists (88%) followed by interventional radiology (6%). Among them, 60% reported performing over 200 PBx annually, with 85% performing over 100. Most respondents had their practices in North America (44%), followed by Europe (36%), Latin America (12%), and Asia (8%). Consensus was achieved in 44 out of the 66 statements (Table 1).
Conclusions: The current Delphi consensus addresses several unmet needs concerning guidance for best clinical practices in transperineal prostate biopsy while well-designed clinical trials are awaited.
Funding: None.
Prostate Cancer Index Lesion Reclassification Using A Novel Lightweight Machine Learning Model for Biparametric MRI
*Masatomo Kaneko, MD, PhD, Giovanni E. Cacciamani, MD, Vasileios Magoulianitis, MS, Jiaxin Yang, MS, Jintang Xue, MS, Jinyuan Liu, MS, Yijing Yang, MS, PhD, Passant Mohamed, MD, Darryl H. Hwang, MD, Karanvir Gill, MS, BA, Lorenzo Storino Ramaciotti, MD, Manju Aron, MD, Vinay Duddalwar, MD, Suzanne L. Palmer, MD, C. -C. Jay Kuo, MS, PhD, Chrysostomos L. Nikias, MS, PhD, Inderbir S. Gill, MD, Andre Luis Abreu, MD
Presented By: Masatomo Kaneko, MD, PhD
Introduction and Objective: To develop a novel lightweight machine learning model to reclassify the index region of interest (ROI) into positive or negative for clinically significant prostate cancer (CSPCa; ISUP Grade Group ≥2).
Methods: Men who underwent 3T biparametric MRI (bpMRI) followed by MRI-informed target biopsy (TB) were identified (IRB# HS-13-00663). bpMRI scans were performed either in our institution or elsewhere according to Prostate Imaging-Reporting and Data System (PIRADS) v2 or v2.1 standards. The ROI (PIRADS 3-5 lesions) were manually segmented on T2-weighted, diffusion-weighted, and apparent diffusion coefficient, and were labeled according to CSPCa detection on TB. Index ROI was defined as the highest PIRADS and largest volume lesion. The lightweight, explainable, and transparent machine learning framework, Green Learning (GL), was designed, and physically defined imaging features were selected for the feature extraction process. The classification performance for CSPCa on index ROI was analyzed by receiver operating characteristic (ROC) and logistic regression on the validation set. The optimal cutoff was determined by Youden’s index. Statistically significant if p<0.05.
Results: A total of 527 patients were included. The GL was trained on randomly selected 419 bpMRI and validated on unseen 108 bpMRI. Using a GL probability cutoff of 0.5, the area under the ROC curve (AUC), accuracy, sensitivity, and specificity were: 0.85, 71%, 61%, and 94%, respectively. Using a tuned probability cutoff of 0.332 for a subgroup with PIRADS 3 ROI, 53% (23/43) of patients with PIRADS 3 could safely avoid unnecessary TB without missing any CSPCa. The GL probability score, PSA density ≥0.15, and PIRADS score were independent predictors of the CSPCa on TB. Integration of the predictors improved the GL AUC to 0.93 (Figure).
Conclusions: The Green Learning, a novel lightweight machine learning model, reclassifies PIRADS ROI into positive or negative for CSPCa with excellent discriminant performance. It may safely reduce target biopsies. Combined with clinical predictors, the Green Learning detects CSPCa noninvasively.
Funding: None.
A new frontier in prostate tumor detection: the role of robot-assisted fusion prostate biopsy
*Gabriele Bignante, David O. Katz, Francesco Lasorsa, Angelo Orsini, William A. Langbo, Daniel F. Roadman, Riccardo Autorino, Srinivas Vourganti
Presented By: Gabriele Bignante, MD
Introduction: In today's era of precision medicine, while the potential of robotic surgery in urology is well recognized, the promise of robot-assisted prostate biopsies (RA-PBx) remains largely unexplored. This study aims to assess the feasibility and safety of RA-PBx.
Methods: This retrospective study analyzes the characteristics patients who underwent a transperineal RA-PBx using the second generation of the Mona Lisa fusion biopsy system at RUSH University from July 2023 to July 2024.
Results: The study included 44 patients with a median age of 64.50 years (IQR 58.75-60.00) and a median index-Prostate Specific Antigen (PSA) of 8.35 ng/mL (IQR 5.57-10.97). Among them, 22 patients were biopsy-naïve, 15 had previously negative PBx and 7 were biopsied within an active surveillance setting.
Pre-operative magnetic resonance imaging indicated suspicious areas in 37 patients.
Targeted biopsies (TB) diagnosed prostate cancer (PCa) in 21 patients. Additionally, PCa was identified in 5 patients with initially negative TB through randomized core biopsies. Among these 5, 4 had low grade PCa with less than 20% core involvement, and 1 had Gleason 7 (3 + 4) tumors with 30% core involvement.
The median procedure time per patient was 31 minutes, including 3 minutes for ultrasound prostate scanning, 5 minutes for prostate modeling on the ultrasound scan, 7 minutes for biopsy planning, and 16 minutes for biopsy execution.
No intraoperative complications were record, but 1 postoperative case of acute urinary retention associated with a urinary tract infection were observed. This Claviend-Dindo Grade 2 complication was successfully treated with catheterization and antibiotic therapy.
Post-biopsy, 13 patients with ISUP 1 or 2 tumors began or continued active surveillance, while 20 underwent active treatment. Specifically, 8 patients received radical prostatectomy, 4 underwent radiotherapy and 8 received high-intensity focused ultrasound.
Conclusions: These preliminary data demonstrate the effectiveness and safety of the Mona Lisa robotic system for prostate biopsies, with a high detection rate for clinically significant prostate cancer and no major technical issues. Further studies are required to compare it with other biopsy platforms to establish its role in prostate cancer diagnostics.
Funding: Dr Vourganti: Biobot Surgical (training grant). The other authors have nothing to disclose.
THE IMPACT OF THE SMARTBX™ SYSTEM ON PROSTATE CANCER DETECTION
*Hridhay Sheth, MS-2, Christian Manganti, M.D., Jatinder Kumar, M.D.
Presented By: Hridhay Sheth
Introduction and Objective: The gold standard for Prostate cancer (PCa) diagnosis is the Transrectal Ultrasonography-guided prostate biopsy (TRUS). The quality of biopsy tissue, crucial for accurate diagnosis, depends on factors like core length and preservation. Standard tissue collection methods drop each core directly into a formalin vial, which often fails to maintain the tissue's location and orientation. SmartBx™ is a novel device designed to maintain maximal length and integrity of prostate biopsy tissue, preserving the in-needle configuration and orientation. This study compared the PCa detection rate using the SmartBx™ system versus the standard method and examined the concordance between biopsy Gleason scores and those from radical prostatectomy (RP) specimens for both cohorts.
Methods: The experimental group included 171 patients who underwent SmartBx™ biopsies at University Hospital from 2022 to 2024. The control group comprised patients whose biopsies underwent traditional handling practices from 2019 to 2021. Data were retrospectively collected using Cerner Powerchart. Detection rates and Gleason score concordance were analyzed using T-tests, Chi-Square tests, and the κ-coefficient.
Results: While biopsy lengths were similar between groups, the SmartBx™ group showed a higher rate of positive cores (25.21% vs. 22.53%, p = 0.01), which translated into a significantly higher detection rate for Gleason 7b cancers (31.90% vs. 18.92%, p < 0.001) and a lower rate for Gleason 6 and 9-10 cancers. According to figure 1, the SmartBx™ cohort had a significantly higher match rate of Gleason score at biopsy to Gleason score at radical prostatectomy, with 65.8% (25/38) compared to 44.2% (34/77) in the control cohort (p = 0.014). Gleason score concordance was higher in the SmartBx™ group (65.8% vs. 44.2%, p = 0.014, κ = 0.441).
Discussion and Conclusion: The SmartBx™ system improved cancer detection per core and shows promise in reducing over-diagnosis of low-risk prostate cancer while enhancing detection of intermediate-risk cancers. It also demonstrated greater Gleason score matching at RP, suggesting more precise biopsies. Although the κ-coefficient showed no significant difference in overall agreement, SmartBx™ has the potential to enhance PCa diagnosis, warranting further study.
Funding: None.
Deep Learning-Driven Data Structuring: Transforming Pathology Reports with RegEx and BERT
*Ravleen Kaur, Alessandro Marquis, Matthew Nemshin, Michael J Schwartz, Ardeshir R Rastinehad
Presented By: Ravleen Kaur, M.S DS, B.S CS
Introduction: The inherent complexity and variability of biopsy reports, including variables from targeted and systematic sampling, presents a significant challenge in extracting structured clinical data. Traditional manual methods are labor-intensive and error-prone, leading to discrepancies in crucial data vital for patient treatment decisions. We engineered a system which combines RegEx with natural language processing models to refine and validate the extract. We preliminarily focused our analyses on patients who underwent focal therapy (FT), where the accuracy of pathological data is essential for research purposes.
Methods: 142 plain text reports of patients undergoing FT were extracted. Each report was paired with corresponding manual data entries, which, after manual annotation, served as the ground truth. We structured >40 key clinical data points, focusing on metrics such as Gleason grades, laterality, prognostic percentages, amongst others. First, we used RegEx to define patterns, engineering a process that converted narrative data into analyzable information (Figure 1). Next, to enhance accuracy and handle missed contextual cues, a refinement with BERT was developed, particularly in cases where text deviated slightly or where contextual understanding was necessary.
Results: Leveraging RegEx effectively structured the reports, achieving an initial accuracy of 88%. After integrating the BERT model, overall accuracy increased to 95%, with BERT correcting 85% of discrepancies between the RegEx output and manually entered data. When combining both systems, it demonstrated a precision of 94% and a recall of 93%, resulting in a 93.5% F1-score. This combined approach significantly improved data consistency and streamlined the data entry process, ultimately reducing manual workload and enhancing overall efficiency.
Conclusion: The integration of RegEx with deep learning models such as BERT underscores the increasing role of AI in enhancing clinical data management. In the context of FT, where precision and timely data are critical, this system offers a scalable and efficient solution that not only improves the reliability of clinical datasets, but significantly reduces manual errors and the time required for reading reports and performing manual data entry.
Funding: None.
Treating out-of-protocol prostate cancer patients with Irreversible electroporation
*Bernardino Miñana Lopez, Head Urology Department, Guillermo Andres Boville, Urology Department Consultant, Guillermo barbas Bernardos, Urology Department Consultant, Xabier Ancizu Marckert, Urology Department Consultant, Marcos Torres roca, Urology Department Consultant
Presented By: Bernardino Minana Lopez, MD, PhD
Introduction: One advantage of ablation techniques commonly used in Focal Therapy (FT) of prostate cancer (PCa) is that they allow treating patients outside of standard protocols of FT. Usually, these are challenging cases on which previous experience is lacking. Treatments are decided into a multidisciplinary oncology meeting (MDM), and need for specific protocol with Informed Consent approved by the local IRB.
The widespread use of PSMA PET Scans, multiparametric Magnetic Resonance (mpMRI) and MRI-Ultrasound fusion biopsy systems leads to an increasing number of such cases.
Irreversible Electroporation (IRE) is an ablation technique based on the emission of high-voltage electric pulses that causes opening of membrane cell pores inducing a necrosis by apoptosis, thus it is not based on any thermal effect. This, along with its precise and reliable ablation, confers this technique unique opportunities to treat these cases.
Our objective is to classify them into clinically consistent groups, present some representative cases from our experience and discuss technical aspects, pros and cons.
Methods: In our experience with 104 patients treated with IRE since 2018, 10 patients (9,6%) undergone out-of- protocol treatments. All of them have been treated with minimal adverse effects and short-term promising oncological outcomes. We have classified them into four groups:
1. First treatment in patients unfit for whole gland treatments.
These are, mainly, patients with high-risk tumors in which PSMA PET scan and transperineal biopsy showed tumor located only in the prostate.
2. First salvage treatment after primary radiotherapy.
We include in this group locally advanced only PCa recurrences and those with N+ disease.
3. Second salvage PCa after previous radical prostatectomy and first salvage radiotherapy.
Patients with biopsy-proven local recurrence after prostatectomy and a first salvage radiotherapy that refuse watchful waiting and hormone therapy.
4. Metastatic patients
Includes highly-selected oligometastatic (hormone-sensitive and castration resistant) patients with PSMA PET scan showing tumor located in the prostate.
Conclusions: The widespread use of PSMA PET scans, mpMRI and US-MRI fusion biopsy systems leads to an increasing number of patients demanding out-of-protocol treatments on which previous experience is lacking. This can only be offered after consensus in MDM and IRB-approved protocols. Thespecific characteristics of IRE provide the opportunity to treat these patients safely.
Funding: CUN Prostate Center.
Focal therapy of index lesion with irreversible electroporation. Oncological and functional results at a median follow-up of 48 months
*Bernardino Miñana Lopez, Head Urology Department, Guillermo Andres Boville, Consultant Urology Department, Guillermo Barbas Bernardos, Consultant Urology Department, Xabier Ancizu Marckert, Consultant Urology Department, Marcos Torres Roca, Consultant Urology Department
Presented By: Bernardino Minana Lopez, MD, PhD
Introduction and objectives: Focal therapy (FT) is considered a promising investigational approach for some patients with prostate cancer (PCa). Patient selection relies on the information provided by a multiparametric MRI (mpMRI) and a combination of transperineal systematic and targeted biopsies using MRI-ultrasound fusion systems. Irreversible electroporation (IRE) is based on the emission of electrical pulses that allows an accurate ablation within a predefined targeted area, avoiding thermal damage. We analyze our experience with FT using IRE targeting the index lesion in PCa.
Materials and Methods: Prospective study, single arm, interventional, IDEAL stage 2a-b, approved by local IRB. Inclusion criteria: PCa ISUP grade 1-2 (and 3 in selected patients) and a visible index lesion on mpMRI. All patients undergone systematic and targeted transperineal biopsy using MRI-ultrasound fusion system (Koelis).
All procedures were performed under general anesthesia and the urethral catheter was removed after 24 hours.
Oncological follow-up was based on mpMRI (at 4-6 weeks after treatment and then annually) and PSA at 1, 3,6,12 and every 6 mo. A control biopsy per protocol was pre-planned at 12 months in the first 30 patients. A per case biopsy was carried out when increasing PSA or a suspicious lesion on MRI was detected. Functional outcomes (IIEF 15 Q1-5, EPIC urinary, continence domain) were evaluated at 1, 3,6,12 and then yearly. Only patients with a minimum follow-up of 6 months were included.
Results: From Feb 2018 to Jun 2024, 70 patients met the inclusion criteria with a median follow-up of 48 months. Patient characteristics, procedure-related information and both oncological and functional outcomes are shown on next table.
Salvage treatments included: 7 active surveillance (AS), 12 radical prostatectomy and 5 external beam radiotherapy. Excluding patients on AS, tumor control after salvage therapy was achieved in 69 out of 70 remaining patients (98,5%). One patient has a biochemical recurrence after prostatectomy. No patients received hormone therapy or developed metastasis.
Conclusions: FT using IRE is a safe and effective procedure which does not preclude other salvage therapies. Most failures occur in the non-treated volume.
Funding: None.
Ultrasound- guided focal Laser Ablation in Patients with Localized Prostata Cancer- Oncological outcome after 6 months follow up in the Pro- FLA trail
*Simon Blaschke, Alexander Fehr, Melis Gür, Christian Samtleben, Frank Fischbach, Martin Schostak
Presented By: Simon Blaschke
Introduction and Objective: The fundamental idea of focal therapy is to specifically treat a small and locally confined tumor while sparing the remaining organ from therapy. The aim is to achieve oncological control whilst minimizing treatment-related side effects.
Focal laser ablation (FLA) is based on thermal destruction of tumor tissue. A new approach is navigating the laser fiber into the tumor lesion transperineally by MR/US fusion.
To determine the clinical safety and feasibility of transperineal ultrasound guided FLA of prostate cancer, we designed the Pro-FLA trial. It is designed as an interventional, prospective, single-center, non-randomized, non-controlled pilot study.
Here, we present the results of the confirmatory biopsies after six months.
Methods: CLS TRANBERG System is a CE-certified laser with a power of 8W. The laser emits at 1064m. The penetration depth in tissue is 7mm. The extent of tissue damage is dependent on time and temperature.
FLA is performed under MR/US fusion imaging: The mpMRI data are fused with the real-time US data to navigate the laser probe into the tumor lesion transperineally.
Temperature is monitored during the procedure at 10mm distance to the probe.
Correspondence of suspicious mpMRI findings and positive biopsies.
Maximum size of lesion 20mm.
The table shows the initial findings and the results after 6 months:
Conclusions: The Pro- FLA trail shows that FLA of prostate cancer is feasible and safe with encouraging results in terms of oncological control. The procedure is applicable safly and was well tolerated. FLA could potentially become another component in the toolbox of focal therapy in prostate cancer.
Funding: None.
Functional Outcomes of Single-Session Holmium Laser Enucleation of Prostate and High-Intensity Focused Ultrasound in Management of Prostate Cancer Patients with enlarged Prostate: Results from a Pilot Study
*Jessica Delgado, University of Miami, Anish Bhatia, University of Miami, Joao G Porto, University of Miami, Adele Raymo, University of Miami, Ruben Blachman Braun, University of Miami, Aravindh Rathinam, University of Miami, Archan Khandekar, University of Miami, Robert Marcovich, University of Miami, Dipen J Parekh, University of Miami, Bruno Nahar, University of Miami, Hemendra N Shah, University of Miami
Presented By: Jessica Delgado, MD
Introduction and Objective: In patients with prostate cancer (PCa), focal therapy with High-Intensity Focused Ultrasound (HIFU) combined with benign prostatic hyperplasia (BPH) surgery has been used to improve immediate post-operative voiding symptoms. HoLEP is a size-independent procedure and we aimed to evaluate the functional outcomes of patients undergoing simultaneous HoLEP + HIFU and compare them to those who underwent HoLEP for bladder outlet obstruction secondary to BPH.
Methods: We performed retrospective review of patients who underwent HoLEP + HIFU or HoLEP between June 2017 and May 2024. HoLEP procedures were performed using the “En-bloc” technique at 60 W energy settings. HIFU was performed with Ablatherm HIFU or Focal One device immediately following HoLEP. Nearest neighbor method with age, prostate size and coagulation status was used to propensity match HoLEP + HIFU patients with HoLEP only patients in a 1:2 ratio. Demographic, perioperative, functional characteristics, and complications of patients undergoing the combined procedure for Pca were compared with patients undergoing HoLEP for BPH. Statistical analysis was performed with Rstudio v4.1.3.
Results: A total of 99 patients were analyzed of which 33 patients underwent combined HIFU with HoLEP. Patients who underwent HoLEP and HIFU had a higher rate of postoperative acute urinary retention (AUR) (p=0.016) and delayed recovery of transient urinary continence. Postoperative UTI, urethral stricture, bladder neck stenosis, and continence rate were similar between the groups. Baseline International Prostate Symptom Score (IPSS) was higher in the HoLEP group. However, at 3, 6- and 12-months follow-up, the patients who underwent HoLEP + HIFU had similar IPSS and Qmax.
Conclusion: Patients who underwent HoLEP + HIFU had a higher rate postoperative urine retention and delayed recovery from transient urinary incontinence. The addition of HIFU to HoLEP does not seem to influence the rate of UTI, urethral stricture, or bladder neck stenosis, or improvement in voiding parameters up to 1 year followup.
Funding: None.
CAPTAIN: A Randomized Controlled Trial of MRI-Guided Transurethral Ultrasound Ablation of the Prostate versus Radical Prostatectomy
*Laurence Klotz, Sunnybrook HSC, Xiaosong Meng, UT Southwestern Medical Center, Yair Lotan, UT Southwestern Medical Center, Naveen Kella, UT Health Science Center, Preston Sprenkle, Yale School of Medicine, Christian Pavlovich, Johns Hopkins, Arvin George, Johns Hopkins, Kiarash Michel, Comprehensive Urology, Daniel N Costa, UT Southwestern Medical Centre, Michael Koch, Indiana U School of Medicine, Geoffrey Sonn, Stanford Medicine, Lance Mynderse, Mayo Clinic Rochester, Mikael Anttinen, Turku University Hospital, Joseph Chin, London Health Sciences Centre, Brant Inman, London Health Sciences Centre, Rahul Mehan, East Valley Urology Center, Pooya Banapour, Genesis Healthcare Partners, Ali-Reza Sharif-Afshar, San Fernando Valley Urological, David Woodrum, Mayo Clinic Rochester, Pejman Ghanouni, Stanford Medicine, Katarzyna Macura, Johns Hopkins, Robert Princenthal, Radnet Rolling Oaks Radiology, Martin Cohen, Radnet Rolling Oaks Radiology, Robert Staruch, Profound Medical, Gina M Clarke, Profound Medical
Presented By: Laurence H. Klotz, MD
Introduction: Radical prostatectomy (RP) and radiation therapy (RT) offer favorable long-term survival for men with localized prostate cancer (PCa) but carry significant risk of functional impairment. Emerging ablative treatment modalities appear to reduce such risks. There has been no successful randomized controlled trial of RP or RT versus ablation for clinically significant cancer. Accrual has been hampered by lack of equipoise and patient resistance to randomization. The CAPTAIN randomized controlled trial (NCT05027477) is designed to generate high level evidence comparing MRI-guided transurethral ultrasound ablation of the prostate (TULSA) with RP. CAPTAIN is statistically powered to test whether TULSA is superior to RP for safety and non-inferior for efficacy. Here, we describe the design of the trial in progress along with our strategies to enhance equipoise and recruitment.
Materials and Methods: The CAPTAIN trial is a multi-center, open-label study with an enrollment target of 201 patients. The study population consists of men with localized, NCCN intermediate-risk disease, excluding ISUP Grade Group 1. To enhance recruitment, the study incorporates a 2:1 allocation to TULSA:RP. Crossover is not permitted. Ablation target is subtotal to whole-gland. Patients may receive one repeat TULSA, if indicated, before primary efficacy is evaluated. The primary safety endpoint is preservation of erectile potency (IIEF Q2≥2) and pad-free continence (EPIC Q5) at 1 year post-treatment. The primary efficacy endpoint is freedom from additional intervention for PCa, metastatic disease, or PCa-specific death at 3 years post-treatment. For primary efficacy, a non-inferiority margin of 10% is applied. Follow-up includes post-TULSA MRI and biopsy, and survival, PSA and quality of life questionnaires for both arms for 10 years post-treatment. The first patient was enrolled in January 2022, and 19 active sites were initiated in a staggered manner to August 2024 when accrual reached >70%. Successful strategies for recruitment in the CAPTAIN trial included creating streamlined processes to flag potentially eligible and interested patients, engaging Urologists who were not co-investigators to support the trial with referrals, and recruiting from those eligible patients who were proceeding to radical prostatectomy, rather than patients who had expressed a strong interest in focal or energy-based therapy.
Funding: Profound Medical.
Targeted MRI/US Fusion and Standard TRUS Prostate Biopsy: 870 Patients - Relationship Between PIRADS Score and Prostate Cancer Detection Rate: A Single Urologist’s Experience
*Ali Kasraeian, Madison Crosby, Miguel Alcantara, Kaitlyn Mola Alcantara, Joshua Yellin, Adam Brochert, Jamie Cesaretti, Ahmad Kasraeian
Presented By: Ali Kasraeian
Introduction & Objective: Multi-parametric MRI (mpMRI) and targeted MRI/Ultrasound fusion prostate biopsy (tMRI/US FPB) are important tools in the diagnosis of prostate cancer (PCa). We report our experience with a total of 870 patients. Specifically, we report the relationship between PIRADS score and overall positive biopsy rate as well as detection rate of Gleason (G) 7 or higher PCa in men.
Methods: Data was prospectively collected and analyzed on 870 men undergoing tMRI/US FPB and TRUS standard biopsy between January 2017 and September 2022. In all patients, mpMRI was interpreted by a single radiologist using the PIRADS scoring system. 3D rendering of regions of interest was performed prior to tMRI/US FPB performed by a single urologist using the Invivo UroNav System. Concurrent standard 14 core biopsy (14Bx) was performed in all cases. Data was Prospectively collected and analyzed.
Results: Prostate biopsy was performed on 870 men between January 2017 and September 2022 of whom 63% (548/870) were diagnosed with PCa. In our analysis, of the men diagnosed, 63% were diagnosed with G7 or higher disease. Among PIRADS 3 Fusion biopsies, the positive rate for PCa was 68% with 46% being G7 or higher disease (15%, G8-9 PCa). Additionally, among PIRADS 4 Fusion biopsies, the positive rate for PCa was 95%, with 93% being Gleason 7 or higher disease (38%, G8-9 PCa). Lastly, among PIRADS 5 Fusion prostate biopsies, 93% were positive for a PCa with all but one being a G7 PCa or higher (87%), and 67% being G8-9 PCa.
The overall positive rate for MRI-US Fusion prostate biopsies was found to be 76% (310/409). G7 or higher disease was found in 53% of those men (with 20% being G8-9 PCa). The TRUS standard prostate biopsy positive rate was 52% (238/461) with 18% being G7 or higher disease (3.7%, G8-9 PCa).
Conclusions: tMRI/US FPB is an important technology that increases the diagnostic yield of prostate biopsy when combined with 14Bx. In our series, the increased positive biopsy rate with combined tMRI/US FPB-14Bx was statistically significant when compared to 14Bx alone. In addition, tMRI/US FPB-14Bx found more Gleason 7 or higher PCa. Lastly, PIRADS 4 and 5 lesions on mpMRI were associated with higher rate of both overall and Gleason > 7 PCA detection.
Source of Funding: None.
Robot Assisted Focal Ablation (RAFA) Using Cryotherapy for Prostate Cancer
*Louis S. Liou
Presented By: Louis S. Liou, MD, PhD
Mona Lisa (Biobot) has been developed for precise localization of transperineal biopsies utilizing fusion software and arm tracking technology in 3D space. Cryoablation for prostate cancer has been utilized for many years with either a free hand or grid placed needle approach. Then technology of the Mona Lisa robotic arm has been combined with cryoablation to show feasibility and explore precise placement of needles in the ablation procedure.
A single surgeon’s experience was retrospectively reviewed. 9 patients consented to the addition of the Mona Lisa to the standard focal cryoablation surgery. 8 total patients were treated completely. We documented the intra operative technique, time, and short-term post-operative follow up of 1 to 3 months.
The patients average age was 67 (range 62-72) with 6 cases being focal ablation, one whole gland, one salvage, and one aborted. Average needles placed was 5 (3-8) while average time of procedure was 113 min (76-170 min). Patients in NCCN categories were - 4 Favorable Intermediate, 2 Unfavorable Intermediate, 2 High risk, 1 Low risk.
Robot assisted cryoablation with the Mona Lisa was performed in various clinical scenarios and was able to be completed in all the cases but one. There were challenges with adaption of the unit to ablation from biopsy. Multiple changes in the workflow and technology were implemented to improve the process. The PSA kinetics, IPSS, IIEF were all consistent with what was usually expected without robot assistance. PSA decrease by up to 50% while urinary function worsened after the first month but then returned to baseline at 3 months. Erectile function did not change appreciably.
Although the Mona Lisa was developed for the transperineal prostate biopsy, we have shown the feasibility in using the system for MRI fusion guided placement of cryoprobes. Short term outcomes have shown no major differences in PSA kinetics, urinary and erectile function from the standard cryoablation procedure. Time of procedure did decrease with experience and the number of needles. More refinements of the system will optimize robotically assisted focal ablation (RAFA).
Funding: None.
Use of Biochemical and Imaging Criteria for Selecting Patients for Prostate Biopsy in Recurrence Risk Assessment Post-HIFU Therapy
*Tarek Ajami, Adam Williams, Joao Porto, Archan Khandekar, Ankur Malpani, Chad R. Ritch, Mark Gonzalgo, Sanoj Punnen, Dipen J. Parekh, Bruno Nahar
Presented By: Tarek Ajami, MD
Introduction: Despite the growing adoption of HIFU treatment for localized prostate cancer, standardized criteria for evaluating treatment success and predicting recurrence remain undefined. Herein, we analyze the predictive value of noninvasive tools such as PSA dynamics and MRI to determine recurrence after HIFU.
Materials: From our HIFU therapy registry, we selected patients treated primarily for localized prostate cancer with at least one year of follow-up between January 2016 and January 2023. Trimestral PSA, MRI in the first year, and a mandatory control biopsy were analyzed. Clinically significant recurrence was defined as the presence of GG 2 or greater on control prostate biopsy. Different PSA criteria were analyzed, including %PSA drop, PSA nadir, PSA nadir+1 (Huber criteria), PSA arithmetic velocity, and linear regression. Determinants for recurrence were based on either PSA or MRI criteria (PIRADS>3). Sensitivity, specificity, PPV, NPV, and % of unnecessary biopsies were estimated based on single or combined criteria.
Results: 92 patients who had at least 12 months of follow-up were included in the study. Among those, 82(90%) had at least one MRI, and 71(77%) underwent a surveillance biopsy. A total of 17(18%) patients had clinically significant prostate cancer recurrence. Patients with clinically significant recurrence post-HIFU had higher PSA velocity in the first year (p<0.001) and a higher risk of PSA above nadir+1 at 12 months (p=0.001). Static PSA measurement and % of PSA drop were not associated with recurrence.
Based on different recurrence prediction models (table 1), PSA criteria (A) show higher sensitivity,while MRI criteria (B) provided greater specificity. The specificity of MRI is improved when used after a PSA triage (C). Follow-up based on a combination of PSA parameters (PSA below nadir+1) and MRI criteria had higher sensitivity (88%) and negative predictive value (96%) in detecting post-treatment recurrence.
Conclusions: Post-HIFU recurrence surveillance through dynamic PSA monitoring, rather than relying on static PSA levels or comparisons to baseline, shows better predictive value. Implementing 'for cause' surveillance biopsies guided by dynamic PSA changes along with multiparametric MRI appears to enhance the detection of recurrences without missing a significant number of cases.
Funding: None.
Evaluation of Cambridge Prognostic and CAPRA Groups on outcomes following primary focal HIFU
*Deepika T Reddy, Resident, Mariana Bertoncelli Tanaka, Philipp Huber, Derek Lomas, Arnas Rakauskas, Stephanie Guillaumier, Tim Dudderidge, Richard Hindley, Amr Emara, Mohamed Noureldin, Jaspal Virdi, Caroline Moore, Manit Arya, Mathias Winkler, Mark Emberton, Taimur T Shah, Hashim U Ahmed, Raj Nigam, Massimo Valerio, Naveed Afzal, Henry Lewi, Clement Orcyzk, Chris Ogden, Iqbal Shergill, Raj Persad
Presented By: Deepika Reddy, MD, PhD
Introduction: Previous studies on focal HIFU for localized prostate cancer reported no significant differences in outcomes between D’Amico intermediate and high-risk disease. Since then, the Cambridge Prognostic Group(CPG) has been developed and adopted by NICE and CAPRA by AUA. These systems aim to provide greater nuance to understanding which patients may better benefit from treatment versus active surveillance but have yet to be reported in the context of focal therapy.
Methods: We re-evaluated 1379 patients treated with focal HIFU for localized prostate cancer within the UK-based HEAT registry. Kaplan-Meier estimates of failure free survival (FFS) defined as avoidance of salvage radical treatment, third focal treatment, systemic therapy, diagnosis of metastases or prostate cancer specific death, log-rank analysis determined if significant differences in outcomes were observed according to CPG and CAPRA score. Secondary outcomes included metastases-free survival (MFS) and overall survival (OS) per CPG and CAPRA score. Median (IQR) time to events was reported. 8 patients were diagnosed with CPG and were excluded from analysis.
Results: 211 (15.4%), 651 (47.7%), 320 (23.4%), and 176 (12.9%) patients were diagnosed with CPG 1-4 respectively, of whom 20/211 (9.5%), 62/651 (9.5%), 46/320 (14.4%), and 28/176 (15.3%) reported treatment failure. Median (IQR) time to failure was 44 (26-66), 47 (29-69), 39 (27-57), and 39 (22-51) months for CPG 1-4, and 43 (26-63), 42 (27-62) and 28 (18-49) months for CAPRA low, intermediate and high-risk disease respectively. 7-year FFS (95%CI) was 77% (51-85%), 72% (38-79%), 54% (73-67%), 63% (73-75%) for CPG 1-4 respectively, p=0.0001. 7-year MFS (95% CI) was 100% (100-100%) in all CPG groups, p=0.1116. 7-year OS (95%CI) was 99% (0.5-100%), 97% (1-99%), 99% (0.8-100%), and 95% (27-98%) for CPG 1-4 respectively, p=0.1226.
7-year FFS (95% CI) per CAPRA score 1-3 was 80% (4-86%), 61% (4-68%), 68% (7-80%) respectively, p=0.0002, 7-year MFS (95% CI) 100% (100-100%) in all groups p=0.08, and 7-year OS (95% CI) was 99% (1-100%), 97% (1-99%), and 87% (85-96%), p=0.057 respectively.
Conclusions: Current international consensuses allow for intermediate- and some high-risk patients to be offered focal therapy. Our results support the use of focal HIFU in patients with intermediate and some high-risk disease per CPG and CAPRA score systems. Patients with higher risk disease appear to experience higher rates of treatment failure at earlier timepoints than those with lower risk disease.
Funding: None.
Comparative Healthcare Research Outcomes of Novel Surgery in prostate cancer (IP4-CHRONOS): A randomised controlled trial assessing feasibility of randomisation for focal therapy in localised prostate cancer
*Deepika T Reddy, Resident, Tim Dudderidge, Manit Arya, Consuelo Nohpal De La Rosa, Francesca Fiorentino, Edward Bass, Emma Cullen, Emily Day, Toby Prevost, Natalia Klimowska-Nassar, Sasikaran Thiagarajah, Mark Emberton, Stuart McCracken, John Staffurth, Sarbjinder Sandu, Richard Hindley, Nimalan Arumainayagam, Naeem Soomro, Vincent Khoo, Mathias Winkler, Taimur T Shah, Hashim U Ahmed
Presented By: Deepika Reddy, MD, PhD
Introduction: Randomised comparative data is lacking for focal therapy of localised prostate cancer. Imperial Prostate-4 CHRONOS(IP4-CHRONOS) (ISRCTN 17796885) was designed as a parallel RCT to incorporate patient and physician equipoise to maximise acceptance to randomisation.
Methods: IP4-CHRONOS-A randomised between focal therapy (HIFU or cryoablation) and radical therapy(radiotherapy, low-dose-rate brachytherapy or prostatectomy). IP4-CHRONOS-B randomised between focal therapy alone or with neoadjuvant medication(daily 5mg finasteride or 50mg bicalutamide over 3 months). Rates of randomisation and compliance with allocated arm. Secondarily, genito-urinary function was measured using validated questionnaires at baseline and 3-months, and 12-months for IP4-CHRONOS-B.
Results: In IP4-CHRONOS-A, 7 sites over 24-months(Dec 2019-Nov 2021) approached 207 patients, with 36 randomised. Patients randomised to focal therapy were all compliant(18/18), 5/18(28%) declined radical therapy following randomisation.
IP4-CHRONOS-B randomised 64 patients over 14-months across 6 sites(Dec-2019-Feb-2021) from 143 patients. All patients received and were compliant with treatment allocation.
Median(IQR) IIEF-15 erectile function score improved from 9(2-18) to 12(2-15) following focal therapy in IP4-CHRONOS-A compared to a decrease from 5(1-13) to 1(1-3) following radical therapy. In IP4-CHRONOS-B scores at baseline, 3 months and 12 months were 15(4-29), 14(3-20), and 16(5-23) in those having focal therapy alone. Focal with finasteride were 22(15-29), 14(4-26), and 23(19-29) and focal with bicalutamide 15(5-28), 5(3-11), 1(1-16).
In IP4-CHRONOS-A, after radical therapy an additional 11(11/36, 8%) patients required at least one urinary incontinence pad per day, one patient required pads after focal. In IP4-CHRONOS-B, 3 patients reported a pad used per day prior to treatment. At 3- and 12- months, 2 and 1 patients respectively required a pad per day following focal alone and focal with bicalutamide. Following focal and finasteride 3 patients used a pad per day at 3-months, none were used by 12-months.
Conclusions: Randomising between focal and radical therapy is not feasible with 3 in 10 being non-compliant to radical therapy after randomisation. A multi-arm, multi-stage RCT investigating the role of neoadjuvant agents to potentially improve existing cancer control rates with focal therapy is feasible.
Funding: Prostate Cancer UK funded the pilot trial.
Survival Outcomes and Recurrence Patterns Following Focal HIFU Treatment for Localized Prostate Cancer: Insights on Patient Selection and Lessons Learned
*Tarek Ajami, Adam Williams, Nachiketh Soodana Prakash, Archan Khandekar, Ankur Malpani, Chad R. Ritch, Mark Gonzalgo, Sanoj Punnen, Dipen J. Parekh, Bruno Nahar
Presented By: Tarek Ajami, MD
1. Introduction: While focal therapy has been increasingly adopted as a treatment alternative to whole gland treatment for localized prostate cancer, there remains a significant need for data on survival outcomes. In this manuscript, we evaluate oncologic outcomes, including recurrence patterns and survival outcomes, in a prospective cohort of patients. Furthermore, we provide a detailed discussion of the lessons learned from our findings and propose strategies to enhance patient selection for HIFU treatment.
2. Materials: Between 2016 and 2023, 113 patients underwent focal HIFU treatment for prostate cancer. Follow-up included PSA every 3 months and prostate MRI. As per the study protocol, a control biopsy was performed at 6 or 12 months. Recurrence was categorized based on location (infield or outfield) and Gleason grade group (clinically significant vs. non-clinically significant recurrence). Kaplan-Meier curves were utilized to analyze survival outcomes, recurrence rates, and the need for retreatment.
3. Results: Of the 113 patients, 92 (81%) had follow-up with PSA for at least 12 months. The median follow-up was 29 months. The overall local recurrence rate was 37%. Clinically significant recurrences were detected in 16 (17%) patients, with 11 (68%) being infield and 5 (32%) outfield only. Non-clinically significant recurrences were observed in 18 (19%) patients. 2 patients progressed to N1 disease. Clinically significant recurrence-free survival (CS-RFS) outcomes were notably poorer in patients with high and unfavorable intermediate NCCN risk groups compared to those with favorable intermediate-risk groups (40% and 53% vs 85% CS-RFS at 3 years, Log-rank p of 0.003 and 0.05, respectively). Kaplan-Meier estimates for retreatment-free survival were 95%, 84%, 71% and 60% at 12, 24, 36 and 60 months, respectively. 16 (17%) patients underwent salvage local treatment.
4. Conclusions: Focal therapy is a promising alternative for localized prostate cancer in well-selected patients. However, those with high-risk or unfavorable intermediate-risk prostate cancer are more likely to experience treatment failure. Physicians should discuss these risks with their patients when considering offering FT.
Funding: None.
Focal Cryoablation for Low- to Intermediate-Risk Prostate Cancer using the UroNav/DynaCAD Advanced Annotation Platform Software: Medium-Term Oncological Outcomes
*Alessandro Marquis, Kenneth Solosky, Orellana Kerli, Cynthia Knauer, Alexandre Armache, Ravleen Kaur, Matthew Nemshin, Scott Thompson, Samuel W. Coons, Michael J. Schwartz, Ardeshir R. Rastinehad
Presented By: Alessandro Marquis
Introduction: Focal cryoablation (FC) for prostate cancer (PCa) is designed to treat only cancerous regions, sparing healthy tissue. Accurate targeting of MRI-visible lesions is critical for successful treatment. We evaluated the oncological outcomes of FC using the UroNav Advanced Annotation Platform (AAP) (v4.x)/DynaCAD Urology (v5.x) research systems (Investigational Device).
Methods: Men diagnosed with ≤2 MRI-positive lesion(s) with GG≤3 PCa confirmed with MR-US fusion-guided [FB] and systematic [SB] biopsy were enrolled in this prospective trial. MRI-negative GG1 (<6 mm core length) in a single SB core was allowed. All men underwent FC using the UroNav AAP. This software allows for accurate, MR-US fusion treatment planning of the cryoprobes placement to achieve complete coverage of the MRI-visible lesion and its surrounding margin. FC follow-up protocol included a mandatory 1-year post-FC MRI and biopsy (FB+SB). Thereafter men were followed up with periodic PSA, a 6–18-month MRI, and for-cause biopsy when necessary. Clinically significant (cs) PCa was defined as GG≥2 or MRI-visible GG1. Out-of-field failure (OFF) was defined as the presence of new GG≥1 PCa in SB that were negative before the FC.
Results: Between Dec 2020-Jul 2024, 69 men underwent FC. To date, 44 men were followed for ≥1 year. Before FC, 5 (11%) men had GG1 while 39 (89%) GG2-3 PCa. At the 1-year control biopsy, in-field failure (IFF) was observed in 3 (7%) men, all GG≥2. OFF was detected in 16 (36%) men, 4 (9%) GG≥2. Two (4%) men had a new MRI lesion positive for PCa, one GG2 and one GG1. One-year post-FC MRI sensitivity, specificity, PPV, NPP and accuracy in detecting IFF were 33%, 95%, 33%, 95%, and 91%, respectively. At a median (range) follow-up of 23 (12-43) months, 2 (4%) men underwent salvage radical prostatectomy, 4 (9%) second/salvage FC (3 for OFF and 1 for IFF), 11 (25%) were put under active surveillance and 27 (61%) were PCa-free. Salvage radical treatment-free survival (FS) was 95.5%, salvage-treatment-FS 86.4%, PCa-FS 72.7% and csPCa-FS 100%. Mean PSA-density values significantly decreased compared to baseline, confirming a biochemical response (pre-FC 0.164 vs 1-year post-FC 0.055, p<0.01).
Conclusions: The UroNav AAP/DynaCAD Urology systems have shown precision in assisting FC of localized low- to intermediate-risk PCa, yielding minimal recurrences in the treated areas. Careful patient selection and rigorous post-FC monitoring are essential for securing the best PCa control outcomes.
Funding: Philips Healthcare funded this research project.
Artificial intelligence prostate segmentation integrated in treatment planning for MRI-guided transurethral ultrasound ablation (TULSA): Initial real-world experience
*Stephen Scionti, HALO Scionti Prostate Center, Mark Hong, Integrative Urology, Joseph Busch, Busch Center, Daniel Costa, UT Southwestern, David Woodrum, Mayo Clinic, Ram Pathak, Mayo Clinic, David Sella, Mayo Clinic, James Cochran, Texas Prostate, Naveen Kella, The Urology Place, Martin Cohen, RadNet Inc, Adnaan Moin, WellSpan York Hospital, Jessica Lee, Yale New Haven Hospital, Steven Sukin, Texas Urology Specialists, Kelly Stratton, Oklahoma University HSC, Alexander Cole, Mass General Brigham, Cameron Wright, Profound Medical, Robert Staruch, Profound Medical, Robert Princenthal, RadNet Inc, Edward Steiner, WellSpan York Hospital, Steven Raman, David Geffen School Med, UCLA
Presented By: Stephen Michael Scionti, MD
MRI-guided TULSA is an in-bore procedure for ablation of benign and malignant prostate tissue. Manual intraoperative segmentation of the target volume (typically whole gland less selective tissue sparing) can be repetitive and time consuming with significant intra- and inter-operator variability. To reduce time, mental burden, and variability of TULSA planning, an FDA-cleared deep learning model was integrated in the treatment software for automated prostate segmentation. The AI model was validated in a multireader multicase study against a reference standard of 3 expert radiologists. Here we describe initial real-world experience using AI-assisted contouring in routine TULSA.
Survey data was gathered from 35 TULSA procedures performed by 18 physicians (9 radiologists, 9 urologists) across the first 15 US institutions where AI-assisted contouring was used. Treatment indications included localized prostate cancer (63%), combined treatment of prostate cancer and BPH (29%), and salvage treatment after prior radiation (3%) or ablation (6%). Treatment plans included whole gland (57%), subtotal (20%), and focal (23%). System logs for 11 cases were used to determine the fraction of AI-generated prostate segmentation modified by the physician.
In 31 cases with treatment naive prostates, the quality/accuracy of segmentation was rated excellent (corrections required on <10% of gland) in 21/31 (68%) cases, acceptable (10-30% corrections) in 9/31 (29%), and neutral (30-50% corrections) in 1/31 (3%). In 4 salvage cases, the accuracy of segmentation as neutral (30-50% corrections). In 31/31 primary cancer cases but only 2/4 salvage cases, physicians agreed that automated contouring decreased time and effort to define a treatment plan while maintaining accuracy. In 35/35 cases, physicians agreed that it decreased the burden of the repetitive task. In 13/15 (87%) cases by urologists, they agreed that the tool improved their accuracy in smoothly delineating the prostate boundary (13% no change), compared to 10/20 (50%) radiologist cases (50% no change). Final ablation plans were unchanged from AI segmentation in 55% of the gland (average), with physicians adjusting the plan by ≥ 5 mm in 7% of the gland.
In the initial US multi-center experience using AI-based prostate segmentation in routine TULSA procedures, physician surveys indicated that automatic segmentations had sufficient accuracy to decrease the time and effort associated with defining a treatment plan.
Funding: RS and CW are paid employees of Profound Medical. SS, DC, NK, AM, RP, ES, SR have consulting agreements with Profound Medical.
MR-US Fusion Focal IRE for Intermediate-Risk Prostate Cancer: A Single Center Experience
*Alessandro Marquis, Cynthia Knauer, Sharon Choi, Michael J. Schwartz, Ardeshir R. Rastinehad
Presented By: Alessandro Marquis
Introduction: Focal IRE (FI) for prostate cancer (PCa) is designed to treat only cancerous regions, sparing healthy tissue. Accurate targeting of MRI-visible lesions is critical for successful treatment. We evaluated oncological and functional outcomes and complications of FI using the UroNav/DynaCAD Urology system.
Methods: Men diagnosed with a single GG2 PCa MRI-positive lesion confirmed with MR-US fusion-guided [FB] and systematic [SB] biopsy were enrolled in this prospective trial. Small (<6mm) MRI-negative GG1 in a single SB core was allowed. The UroNav system enables accurate, MR-US fusion treatment planning of the IRE probes placement to achieve proper coverage of the MRI-visible lesion and its margin. FI follow-up protocol included a mandatory 3- and 12-m MRI and a 12-m biopsy (FB+SB). Clinically significant (cs) PCa was defined as GG≥2 or MRI-visible GG1. Out-of-field failure (OFF) was defined as new GG≥1 PCa in systematic cores. Functional outcomes were assessed pre-FI and at 1, 3, 6, 9 and 12 months with IPSS, IIEF-15 and EPIC-26 questionnaires while complications with the CTCAE v 5.0.
Results: Between Jul 2022-Jul 2023, 12 patients underwent FI. At the 12-m control biopsy, in-field failure was observed in 1 (8%) man (GG2). OFF was detected in 3 (25%) men (1 GG2 and 2 GG1) while 2 (17%) men had a new GG1 MRI lesion. At a median (range) follow-up was 19 (12-22) months, 1 (8%) man underwent salvage radical prostatectomy, 4 (33%) were put under active surveillance (1 with GG2) and 7 (58%) were PCa-free. Mean±SD PSA-D values significantly decreased compared to baseline (pre-FI 0.15±0.10 vs 3-m post-FI 0.05±0.04 vs 12-m post-FI 0.05±0.03, p<0.01). Urinary and sexual functions worsened within the first month to gradually recover to the baseline at 12-m (Fig 1). Mild hematuria (92%) and hematospermia (58%) were the most common complications. We also reported 1 UTI, 1 scrotal swelling and 1 transitory acute urinary retention. No CTCAE grade 3 complications were collected.
Conclusions: The UroNav/DynaCAD system-based MR-US fusion FI has shown precision in the treatment of localized PCa, yielding minimal recurrences in the treated areas and maintaining a strong safety profile.
Funding: None.
THE USE OF HIGH FREQUENCY AND POWER LASER AT AN UNUSUAL DELAYED HEM-O-LOK CLIP COMPLICATION FOLLOWING LAPAROSCOPIC RADICAL PROSTATECTOMY
Bianca F. B. Pacheco, Taline N. Rodrigues, Rafael P. Mullin, Carlos A. R. Carvalhal, Bruno N. de Lana, Marcio M. Almeida, Sandro R. Gomes
Hospital Central da Aeronáutica
Presented By: Bianca Ferreira Barros Pacheco
Introduction: The Hem-o-Lok clip (HOLC) has been routinely used in laparoscopic radical prostatectomy (LRP) for hemostatic control of the vascular pedicles, protectingt the neurovascular bundle. Migration of the clips to the anastomotic junction or inside the bladder has been reported, causing lower urinary symptoms. An intravesical foreign body generates persistent chronic inflammation that can lead to stone formation. Usually, bladder stones greater than 2 cm are submitted to cystolithotomy. However, with a high frequency and energy laser, it is possible to have a quick and effective treatment for bigger stones.
Material and Methods: A 79-year-old male patient consulted with a story of urge incontinence and recurrent low urinary tract infections since 2023, treated with multiples classes of antibiotics. He had a previous diagnosis of prostate adenocarcinoma Gleason 7(4 + 3), and was submitted to a LRP in 2018. A urinary tract ultrasonography was performed and indicated the presence of a 3 cm bladder stone. Thereafter, a urethrocystoscopy confirmed the intravesical stone and excluded the possibility of urethral stenosis or intravesical injuries.
Results: Based on the large intravesical calculi diagnosis, the patient was managed with the 70W Holmium:Yag laser, in order to fragment with a better efficiency. Our goal was to reduce intraoperative time and the use of intravesical irrigation. Throughout the fragmentation a hemostatic clip inside the stone was identified. (FIG.1)
Conclusions: The HOLC intravesical migration after a laparoscopic radical prostatectomy led to a large stone formation. Nonetheless, it was only possible to identify its existence and to comprehend the origin of the patient symptoms with the use of a high power laser.
Funding: N/A.
IN-FIELD RECURRENCE AND OUT-OF-FIELD PROGRESSION RATES FOLLOWING FOCAL THERAPY FOR LOCALIZED PROSTATE CANCER
Christopher Edwards, MD, Michael West, MD, Ariel Schulman, MD, David Silver, MD
Maimonides Medical Center, Dept of Urology
Presented By: Christopher Edwards, MD
Our institution was an early adopter of focal therapy for localized prostate cancer in the United States. We began with high-intensity focused ultrasound (HIFU) and have since expanded to offer irreversible electroporation (IRE). We offered focal therapy to patients who would not undergo standard treatment. These patients are treated under a prospective IRB-approved registry to track outcomes. Our objective was to assess the oncologic outcomes in patients undergoing focal therapy for localized prostate cancer at our institution, a large community hospital.
Our focal therapy registry was reviewed for demographic and oncologic characteristics. We included patients who underwent treatment from June 2019 to June 2024. Post-treatment biopsy results were assessed to determine in-field recurrence and out-of-field progression rates. Post-treatment biopsy results were designated as positive if they harbored clinically significant disease (Gleason Grade Group ≥ 2). Age, BMI, baseline PSA, prostate size, grade group, and whether treatment occurred within the first 30 cases were tested against in-field recurrence rates. Chi-square and T-test were used to test for statistical significance between the above variables and in-field recurrence as appropriate.
84 distinct patients with prostate adenocarcinoma underwent either 74 HIFU or 22 IRE treatments. Of the 96 total cases, 60 (62.5%) proceeded with post-treatment biopsy, 43 following HIFU and 17 following IRE. Following HIFU, 12 (27.9%) biopsies had in-field positivity, while 9 (20.9%) demonstrated out-of-field progression. Following IRE, 1 (5.9%) biopsy demonstrated in-field recurrence, while 1 (5.9%) was positive for out-of-field progression. Higher baseline PSA (13.0 vs. 6.9 ng/mL in those with in-field recurrence vs. those without in-field recurrence, respectively) was determined to be statistically significant (p=0.004, table 1).
The use of HIFU and IRE for focal therapy for prostate cancer in the community hospital setting demonstrated acceptable oncologic outcomes. Within our cohort, a higher baseline PSA was associated with higher in-field recurrence rates.
Funding: N/A.
THE DIFFERENT ETIOLOGIES AND SUBSEQUENT MANAGEMENT OF PATIENTS WITH ABORTED RADICAL PROSTATECTOMY
Carter Mikesell, Nicolas Soputro, Roxana Ramos-Carpinteyro, Adriana Pedraza, Jaya Chavali, Jihad Kaouk
Glickman Urological and Kidney Institute, Cleveland Clinic
Presented By: Carter Mikesell, MD
Introduction: Radical prostatectomy (RP) has long been the mainstay treatment for localized clinically significant prostate cancer. Despite best efforts in preoperative evaluations and optimizations, RP may still fail to be completed due to surgical and/or medical issues that arise at the time of the procedure. The aim of this present study was to describe the different etiologies of aborted RP (aRP) and their subsequent management.
Methods: A retrospective review was performed on the IRB-approved database to identify all patients whose RP were aborted following induction of anesthesia. Perioperative clinicodemographic and follow-up parameters were collected. Statistical analysis was performed with descriptive statistics as presented.
Results: Of the 44 aRP procedures, 11 were secondary to anesthesia concerns and 34 were due to surgical challenges. Most of the anesthesia concerns (64%) were related to respiratory compromise due to the Trendelenburg positioning for Transperitoneal Multi-Port Robotic RP (MP-RARP). Half of the surgical indications for aRP pertained to hostile abdomen in patients with previous history of abdominal surgery. One patient was noted to have both anesthesia and surgical reasons for aRP, with the first being ventilation issues during MP-RARP that prompted the conversion to open RP. The procedure was subsequently aborted following an intraoperative finding of a deep and narrow pelvis. Surgery was reattempted in 25 patients (56.8%) with 84% done robotically, while 18 (40.9%) were managed with radiation with or without androgen deprivation therapy and one (2.3%) elected for active surveillance. At a median follow-up of 35 months, biochemical recurrence and metastatic disease were identified in four and two cases, respectively.
Conclusions: Despite the rarity, aRP remains an important risk to consider in patients undergoing RP. Nevertheless, redo surgery following aRP can be completed successfully and should be considered as one of the main alternatives in accordance with the surgical plans initially agreed on by the patient.
Funding: N/A.
SIMPLE PROSTATECTOMY FOLLOWED BY RADIATION THERAPY FOR PROSTATE CANCER: A NOVEL TREATMENT PATHWAY/PROOF OF CONCEPT
Brian Calio1, Rafael Tua Caraccia1, Daniel Segal2, Joshua Kim3, Neil Desai2, Jeffrey Gahan1, Tara Morgan1
1Duke University Hospital,2University of Texas Southwestern Medical Center, 3Duke University School of Medicine
Presented By: Brian Patrick Calio, M.D.
Introduction: Radical prostatectomy has long been the treatment of choice for men with clinically significant prostate cancer (PCa) in men with concurrent significant lower urinary tract symptoms (LUTS). For men that meet this description with marked prostatomegaly, we present a multi-institutional proof of concept study describing an alternative pathway of robotic simple prostatectomy (RASP) followed by external beam radiation therapy (EBRT) for the treatment of clinically significant prostate cancer.
Methods: A retrospective study was performed of 17 patients with PCa who underwent RASP followed by EBRT at two institutions (Duke University Hospital, NC; University of Texas Southwestern, TX) from 2015-2023. Demographic, perioperative and post-radiation treatment functional outcomes are reported.
Results: There were no postoperative or post-EBRT complications reported for any of the 17 patients who underwent RASP followed by EBRT during median followup time of 12 months. Median time from RASP to start of EBRT was 292 days. Median prostate size was 135 grams (IQR 110- 165). 13 (76.5%) patients received a pre-EBRT rectal spacer. Median IPSS score preoperatively improved at 90 days post RASP (13 vs 2; IQR 9-15), and this benefit was sustained post-EBRT with a median IPSS at 3 vs 12 months post EBRT (4 vs 0; IQR 0-5). There was no statistically significant difference between postoperative IPSS and post-EBRT IPSS at 3 (p=0.677) or 12 (p=0.627) months. In all 14 patients with PSA data, none had recurrence during the study period.
Conclusion: A subset of patients with clinically significant prostate cancer have marked prostatomegaly and LUTS. We report an alternative treatment approach for patients unwilling to undergo radical prostatectomy. We found robotic simple prostatectomy followed by definitive radiation to be feasible and safe.
Funding: N/A.
ROBOTIC-ASSISTED ENERGY DEVICE MALFUNCTIONS AND COMPLICATIONS: A REVIEW OF ADVERSE EVENTS USING A NATIONAL REGISTRY
Christopher Edwards, MD1, Henry Blair, BS2, Gina Demeo, MD1, Elie Kaplan-Marans, MD1, Ariel Schulman, MD1
1Maimonides Medical Center, Dept of Urology, 2Downstate College of Medicine
Presented By: Christopher Edwards, MD
Robotic-assisted surgery (RAS) has become a mainstay in operating rooms, allowing for enhanced precision while minimizing incisions and recovery. Developing specialized energy devices, including the Synchro-Seal (SS) and Vessel Sealer Extend (VSE), has maximized robotic advantages. Our objective was to describe malfunctions and adverse events (AEs) associated with these robotic energy instruments, namely the SS and VSE.
The Manufacturer and User Facility Device Experience (MAUDE) database was assessed for reports using SS or VSE in RAS from January 2014 to July 2024. Only reports involving these devices being used in urologic surgical cases were included. AEs were categorized using a previously described externally validated classification system developed for the MAUDE database, which defines severity as follows: level 1 (mild)—resolution without harm; level 2 (moderate)—patient harm requiring minor intervention; level 3 (severe)—patient harm requiring major intervention; and level 4 (life-threatening or death). Reports were analyzed to determine the frequency of device malfunctions.
66 cases, 36 SS and 30 VSE, were reported with a device malfunction during a urologic RAS. Complications unrelated to device malfunctions were removed, including 4 SS and 2 VSE. The frequency of device malfunctions and their clinical outcomes are displayed in Table 1. The number and severity of AEs related to the SS were as follows: 16 (50%) mild; 16 (50%) moderate; 0 severe; 0 life-threatening/death. In comparison, those related to the VSE included 19 (67.9%) mild, 5 (17.9%) moderate, 2 (7.1%) severe, and 2 (7.1%) life-threatening/death. Notable complications related to the SS included 2 unexpected minor bleeding, while the VSE complications included 1 hemorrhage, 1 conversion to open surgery, 1 nerve injury, and 1 bowel perforation leading to patient death.
Most AEs reported to the national registry demonstrated the malfunctions of the SS and VSE devices did not lead to significant patient harm. However, there were a select number of substantial complications, including unexpected bleeding, conversion to open surgery, nerve damage, and patient death. Continuous monitoring and refinement of these devices are essential to ensure patient safety and improve outcomes in urologic RAS. Further directions include evaluating the entirety of the MAUDE database for AE case reports using the SS and VSE regardless of surgical subspecialty.
Funding: N/A.
Implementation and Utility of the da Vinci Single Port (SP®) in Pediatric Urology
*Lucas A Arney, BS, Randall G Bissette, BS, Jordan M Smith, MD, Christopher E Bayne, MD
Presented By: Lucas Allen Arney, BS
Introduction and Objective: The da Vinci Single Port (SP®) Robotic Surgical System, designed to perform complex procedures through a single 2.5 cm incision, offers a promising alternative for urological procedures, including nephroureterectomy, pyeloplasty, and appendicovesicostomy. This review aims to evaluate the implementation and utility of the SP system in pediatric urology, focusing on its feasibility, advantages, and outcomes compared to the traditional multi-port (MP) robotic system.
Methods: A saturation review of the literature was conducted on the use of the SP system in pediatric urology. The fundamental metrics analyzed included operative times, hospital stay duration, postoperative pain and complications, cosmetic outcomes, and the learning curve associated with the adoption of this technology. This review also considers technical challenges and adaptations required for the successful implementation of the SP system in pediatric patients.
Results: The SP system has been successfully utilized in a variety of pediatric urological procedures, including nephroureterectomy, pyeloplasty, and appendicovesicostomy. Reports have shown mixed operative times but similar hospital stay durations, and postoperative outcomes between SP and MP robotic surgery. The learning curve for surgeons transitioning from MP to SP systems in a pediatric population appears manageable, though a smaller abdominal circumference in pediatric patients seems to be a notable hurdle in adopting the technology. This review did not consider the initial and ongoing cost of the SP to a hospital system as it is assumed the SP will be primarily purchased and utilized by adult services.
Conclusions: The da Vinci SP robotic system emerges not as a replacement but as a complementary option to pediatric urological robotic surgery. There may be some unique advantages to the SP over MP in specific scenarios. Cosmetic outcomes appear similar but need additional research. Future research should focus on patient-centered outcomes to fully understand the benefits of the SP and optimize its use in pediatric patients.
Funding: None.
A Simplified Approach to Robotic Assisted Radical Cystectomy
Sami Wilder, MD, Adi Chandrasekaran, Sara Perkins, MD, Ryan Timar, MD, Johar Raza, MD
Vattikuti Urology Institute, Henry Ford Health
Presented By: Sam Wilder, MD, MA
We present a case of robotic intracorporeal reverse 7 ileal conduit diversion in the setting of radical cystectomy for bladder cancer with concomitant distal left ureterectomy.
Funding: N/A.
Robotic Inguinal Lymph Node Dissection. Surgical Technique: Tips and Tricks
Laura K Fumero1, Luis G Medina1, Samer Jaber2, Alvaro Gonzalo-Balbas3, Federico Eskenazi1, Jan Rudzinski1, Austin Leonard1, Rene Sotelo1
1The Catherine and Joseph Aresty Department of Urology of the Keck School of Medicine. University of Southern California. CA, USA, 2Department Urology, Hospital Británico Montevideo, Uruguay., 3Hospital Universitario Fundación Alcorcon, España
Presented By: Luis Medina, MD
Based on retrospective research and our team's clinical experience, we present the inguinal lymph node dissection technique, identifying anatomical landmarks, comparing different approaches, and offering helpful recommendations and observations throughout the procedure.
Funding: N/A.
Single Port Transvesical Vesicouterine Fistula Repair
David Ambinder, MD1, Daniel Bassily, MD1, Max Drescher, MD2, Mubashir Billah, MD2, Mutahar Ahmed, MD2
1Westchester Medical Center, 2Hackensack University Medical Center
Presented By: David Ambinder, MD, BS
Single port transvesical repair of a vesicouterine fistula (Youssef syndrome) with a complete transvesical approach illustrating the feasbility and effectiveness of this technique.
Funding: None.
Contralateral Single Port Robotic Kidney Autotransplantation for Management of Nutcracker Syndrome
Nicolas Soputro, MD, Carter Mikesell, MD, Adriana Pedraza, MD, MSc, Mohamed Eltemamy, MD, Jihad Kaouk, MD
Cleveland Clinic
Presented By: Nicolas Adrianto Soputro, MD
This video described a novel technique of robotic kidney autotransplantation using the purpose-built Single Port robotic platform as a minimally-invasive surgical management option for a patient with concomitant Nutcracker and May Thurner Syndrome.
Funding: N/A.
Step-by-Step Technique for Single-Port Robot-Assisted Radical Cystectomy with Pelvic Lymph Node Dissection
Nicolas Soputro, MD, Carter Mikesell, MD, Adriana Pedraza, MD, Mohamed Eltemamy, MD, Jihad Kaouk, MD
Cleveland Clinic
Presented By: Nicolas Adrianto Soputro, MD
This video sought to describe a step-by-step technique for robot-assisted radical cystectomy (RARC) with pelvic lymph node dissection (PLND) performed using the novel, purpose-built Single Port (SP) robotic platform. In this video, we described two cases of SP-RARC with PLND that were completed successfully in both males and females for the management of high-grade urothelial carcinoma of the bladder.
Funding: N/A.
Single-Port Robot-Assisted Extraperitoneal Left Partial Nephrectomy and Cystolithotomy
J. Ryan Russell, Department of Urology1, David Ambinder, Department of Urology2, M. Shabil Billah, Department of Urology1, Mutahar Ahmed, Department of Urology1
1Hackensack University Medical Center, 2Hackensack Meridian School of Medicine
Presented By: J. Ryan Russell, MD
This video describes and extraperitoneal single port robotic approach to an upper pole anterior tumor in a patient with very adherent retroperitoneal fat. The patient also has a 2.5 cm bladder stone. The robot was repositioned after the partial nephrectomy to also do a cystolithotomy in the extraperitoneal space.
Funding: N/A.
A Novel Approach to Robotic-Assisted Partial Nephrectomies: the Off-Clamp and Suture-less Technique
1University of Florida, Department of Urology, 2University of Florida
Presented By: Trisha Nguyen, MD
In this case series, we describe an off-clamp, suture-less technique for robotic-assisted partial nephrectomies and investigate the peri-operative outcomes of patients associated with this nephron-sparing approach.
Funding: N/A.
Single Port Retroperitoneal Right Radical Nephrectomy
David Ambinder1, Ryan Russell2, Sarah Brink2, Mubashir Billah2, Mutahar Ahmed2
1NYMC, 2HUMC
Presented By: David Ambinder, MD, BS
Description describing the feasability of performing single port radical nephrectomy in select patients.
Funding: N/A.
Arterial Bleeding After Hilar Mass Resection
Daniel Sidhom
Indiana University
Presented By: Daniel Sidhom, DO, MS
This video illustrates a renorrhaphy technique that is suitable for large defects near the renal hilum. The video also shows management of arterial bleeding from the resection site, which was encountered after unclamping the renal vessels.
Funding: N/A.
Approaches to robotic nephropexy
Banna Hussain1, Craig Rogers1, Ryan Nelson2
1Henry Ford Health, 2Michigan Urology Institue
Presented By: Banna Hussain, DO, MPH
This video describes two cases of nephroptosis and two approaches to robotically treat these patients. The first approach discussed will be the standard multiport transperitoneal approach. The second approach discussed will be the retroperitoneal single port approach. Benefits and outcomes of each will be addressed in this video.
Funding: N/A.
Intra-operative CO2 Gas Embolism in a Single Port Retroperitoneal Robot-Assisted Laparoscopic Partial Nephrectomy with the AirSeal® iFS Insufflator
Michael Massari, MD, Shay Rajavel, Medical Student, Li-Ming Su, MD, Padraic O’Malley, MD
University of Florida
Presented By: Shay Rajavel
We present a case of symptomatic gas embolism during a single port robot-assisted laparoscopic partial nephrectomy with bubbling from the resection bed as an early indicator of this intraoperative complication.
Funding: N/A.
Single-port Transvesical Radical Prostatectomy with Endopelvic Fascial and Dorsal Venous Complex Sparing: Step-By-Step Illustrative Technique
Yeonsoo Lee, Ian Das, Neal Jumar, Alex Rochwald, Raymond Pak, Ram Pathak
Mayo Clinic Florida
Presented By: Yeonsoo Sara Lee
We will describe the surgical technique and report early outcomes of the transvesical (TV) approach to single-port (SP) robot-assisted prostatectomy. Primary outcomes include time until post-operative urinary continence, rate of biochemical recurrence, and erectile function.
Funding: N/A.
A novel approach: Precision Prostatectomy
Wooju Jeong, Banna Hussain, Craig Rogers
Presented By: Banna Hussain, DO, MPH
This video describes a precision prostatectomy technique and discusses the indications, benefits and outcomes of this procedure.
Funding: N/A.
Evaluating the Utility of DVC Ligation During RALP Using AI
Charles Klose, Satvik Kuravi, Alan Perry, Raymond Pak, Andrew Zganjar, Evan Mackenzie Gibbs, Timothy Lyon, Ram Pathak
Presented By: Charles Klose, MD
We provide retrospective data and film review of DVC ligation techniques compared to a omitted DVC ligation technique for patient centered outcomes.
Funding: N/A.
Single-Port Transvesical Radical Prostatectomy after Previous BPH Procedures
Carter Mikesell, Jaya Chavali, Adriana Pedraza, Nicolas Soputro, Roxana Ramos-Carpinteyro, Jihad Kaouk
Glickman Urological and Kidney Institute, Cleveland Clinic
Presented By: Carter Mikesell, MD
We aim to demonstrate our technique, as well as tips and tricks, for Single-Port Transvesical Robotic-assisted Radical Prostatectomy in patients with history of prior prostate interventions; including previous transurethral resection of the prostate (TURP), prostatic urethral lift (PUL), and photovaporization of the prostate (PVP).
Funding: N/A.
3D ULTRASOUND-GUIDED ABLATION OF ANTERIOR PROSTATE CANCER TUMORS USING IRREVERSIBLE ELECTROPORATION AND CRYOTHERAPY
Alireza Ghoreifi1, Niranjan Nayar2, Erika L. Wood3, Amir H. Lebastchi3
1Duke University, 2Koelis, 3University of Southern California
Presented By: Amir H. Lebastchi, MD
Focal therapy modalities have shown effectiveness in the treatment of localized prostate cancer; however, each modality presents specific technical limitations, particularly when treating anterior lesions. Herein, we present step-by-step fusion-guided treatment techniques for anterior prostate cancer lesions, using irreversible electroporation and focal cryotherapy.
