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Uro Flash 2012 › Uro Flash Vol-1, No-9, 2012

Latest procedures in prostatic surgery An update on continuing progress

Introduction

Although drug treatment is the mainstay of treatment for symptomatic benign prostatic hyperplasia (BPH), a patient subpopulation would require invasive interventions that include transurethral resection of the prostate (TURP), and several minimally invasive surgical options; and, together, surgery and/or radiotherapy may inevitable be required in different stages of prostatic cancer. In addition, though TURP remains the gold standard for men with prostates sized 30g-80g, open prostatectomy had been the more direct option for men with glands larger than 80g-100g.1Zorn KC, Liberman D. GreenLight 180W XPS photovaporization of the prostate: how I do it. Can J Urol. 2011;18(5):5918-26.  

Whilst for individual patients, choice of treatment depends on disease severity, co-morbidity, patient preferences, and the comparative efficacy and adverse effects of the available therapies, nonetheless, a careful patient selection, and optimizing the risk-benefit ratio is essential for successful outcome, seeing the fact that even though effective in alleviating symptoms, TURP carries a higher risk of morbidity and complications than medical therapy or minimally invasive techniques.2O’Leary MP. Treatment and pharmacologic management of BPH in the context of common comorbidities. Am J Manag Care. 2006;12(5 Suppl):S129-40.  ,3Montorsi F Moncada I. Safety and Tolerability of Treatment for BPH. European Urology Supplements 2006; 5(20): 1004-1012.   Also, open surgery has its own associated complications, and has largely been replaced by novel minimally invasive options.

Recent approaches: A rise of machines in urology

The concern related to surgery and TURP, and the continuing effort to have more sophisticated and organpreserving techniques4Lindner U, Lawrentschuk N, Schatloff O, et al. Evolution from active surveillance to focal therapy in the management of prostate cancer. Future Oncol. 2011;7(6):775-87.  , have led to rise of multitude of novel technologies over the past few years, together with continuing enhancement of the existing and welldocumented procedures; the hope is to provide the patients’ technologies with tailored high-end results relating to patient needs and satisfaction and quality of life.

More recent approaches [e.g., microwave therapy, transurethral needle ablation, and a range of laser procedures (Holmium, Diode, Thulium and 532nm- Greenlight)] have promising efficacy and safety. In fact, different transurethral prostatic laser systems are available, for instance 18 Holmium enucleation of the prostate (HoLEP), photoselective vaporization of the prostate (PVP) and thulium laser enucleation, and generally all are safer in terms of perioperative bleeding.5Bachmann A, Woo HH, Wyler S. Laser prostatectomy of lower urinary tract symptoms due to benign prostate enlargement: a critical review of evidence. Curr Opin Urol. 2012;22(1):22-33.   Together, treatment trends in robotic surgery and radiation strongly favor newer technologies.6Kapoor DA, Zimberg SH, Ohrin LM, et al. Utilization trends in prostate cancer therapy. J Urol. 2011;186(3):860-4.  

Transurethral microwave thermotherapy

With significant innovation in other less invasive alternative treatments to TURP for BPH in recent years, BPH treatment guidelines now recommend minimally invasive therapy be considered as a treatment option alongside TURP and medical management. Recent clinical studies of transurethral microwave thermotherapy (TUMT), a minimal invasive technique, have provided significant evidence regarding safety, efficacy, and durability, and it has now become a minimally invasive office-based alternative to both standard TURP and medical therapy in the treatment of bladder outlet obstruction and LUTS due to BPH. In fact, TUMT treatment has improved with the advent of later generation devices.7Djavan B, Kazzazi A, Bostanci Y. Revival of thermotherapy for benign prostatic hyperplasia. Curr Opin Urol. 2012;22(1):16-21.   This well tolerated, effective, and durable therapy for the treatment of BPH has definitively found its place as one of the alternatives to TURP. Further, seeing that anestheisafree outpatient capability, lack of sexual side-effects, and avoidance of actual surgery are attractive to patient and clinician alike, TUMT deserves reconsideration in clinical practices as a suitable treatment alternative to TURP and medical therapy.

Prostiva RF therapy (Transurethral needle ablation – TUNA)

Following the latest guidelines, management of LUTS/BPH includes not only conventional prostatic surgery, but also the minimally invasive treatment of symptoms, with great attention given to improvement in the quality of life. One such minimally invasive procedure for BPH is the Prostiva RF Therapy (Transurethral needle ablation).

Prostiva RF Therapy is indicated in the treatment of BPH< 50 g with no median lobe and with PSA inside normal limits.8Tamai A, Aloisi A, Fabrello M. Prostiva RF therapy (transurethral needle ablation): evaluation of results from 127 patients. Urologia. 2011;78(3):166-70.   The procedure employs low-level radio frequency energy delivered from a generator. One hundred and twenty patients (mean age: 64 years) were treated with Prostiva RF Therapy, and IPSS score, quality of life and Index of Erectile Dysfunction (IIEF5) were compared between

baseline and last follow-up. Mean follow-up was 27 months ± 24. At baseline, the mean prostate size was 36.62±16 g, and at enrollment, 70/120 patients (58%) were under pharmacological treatment for BPH. While 102 patients were treated under spinal anesthesia, 18 were treated under local anesthesia. The total average time of the procedure was 28 minutes, and average number of ablations was 5. Uroflowmetry showed a significant improvement in 67% of patients, and 63% reported overall satisfaction with IPSS and quality of life improvement. 25% patients needed further therapies (15% pharmacological, 10% TURP). While there were no serious complications, 12% needed prolonged catheterization (max 7 days), 6% experienced transient irritation (max 2 weeks), 5 patients experienced transitory ejaculation disorders, and 1 patient anejaculation. There were no significant differences in IIEF5 either before or after the procedure. Thus, Prostiva therapy was effective in 66% of treated patients. The procedure was easy, safe and feasible to be carried out under local anesthesia.

Lasers – augmenting focal therapy for prostate

Laser therapy has seen significant application in urology over the past few years. Photoselective vaporization of the prostate (PVP), a minimal invasive endoscopic treatment of BPH obstruction, initially launched as a 60W prototype, was ultimately introduced to the urology community as a 80W system, and had been the predominant device used in clinical trials. This 1st generation used an Nd:YAG laser beam passed through a potassium-titanyl-phosphate (KTP) crystal, halving the wavelength (to 532nm), doubling the laser’s frequency, and resulting in a green light, thereby destroying and removing urethral obstruction attributable to BPH.1 The procedure indeed became a popular alternative to TURP with its main advantage, over TURP, being the minimal bleeding that allows a short urethral catheterization and hospital stay; it is, therefore, useful in patients with bleeding disorders.9Bruyere F. Photoselective vaporization of the prostate. Prog Urol. 2011;21(11):808-10.  ,1 Bruyère F. The relationship between photoselective vaporization of the prostate and sexual function. Curr Urol Rep. 2011;12(4):261-4    Outcomes demonstrated a reduced frequency and severity of clinical complications; however it was limited to smaller prostate sizes.

Subsequent evolution of lasers

Later, the 120W lithium triborate laser (LBO), also known as the GreenLight HPS (High Performance System) laser was introduced that utilizes a diode pumped Nd:YAG laser light emitted through an LBO instead of a KTP crystal, resulting in a higher-powered 532 nm wavelength green light laser while still using the same 70-degree deflecting, side firing, silica fiber delivery system.1Zorn KC, Liberman D. GreenLight 180W XPS photovaporization of the prostate: how I do it. Can J Urol. 2011;18(5):5918-26.   The HPS offered an 88% more collimated beam and smaller spot size, thereby resulting in much higher irradiance or power density in its two predecessors (60W and 80W) with a beam divergence of 8 vs. 15 degrees. The upgrade primarily aimed at reduced lasing time and improved clinical outcomes while demonstrating the same degree of safety for patients. Yet, the limitations of the 120W system included treatment of large prostates > 80g-100g and increased cost related to fiber devitrification and fracture.

In 2011, the 180W-Greenlight XPS system was introduced, not only with increased power setting to vaporize tissue quicker but significant fiber-design changes. The modifications with internal cooling, metal-tip cap protection and FiberLife (temperature sensing feedback) better preserved the integrity of the fiber generally producing a 1-fiber per case expectation. Initial personal experience with XPS has provided comparable outcomes related to morbidity, but with an opportunity to perform a more complete and rapid procedure.

High intensity focused ultrasound (HIFU)

Potentially curative salvage options for radio-recurrent prostate cancer include prostatectomy, brachytherapy, HIFU, and cryotherapy.11Finley DS, Belldegrun AS. Salvage cryotherapy for radiation-recurrent prostate cancer: outcomes and complications. Curr Urol Rep. 2011;12(3):209-15.   HIFU, a non-invasive technique, uses focused ultrasound waves to ablate tissue, and is associated with a moderate rate of complications and failure.12Elterman DS, Barkin J, Radomski SB, et al. Results of high intensity focused ultrasound treatment of prostate cancer: early Canadian experience at a single center. Can J Urol. 2011;18(6):6037-42.   In effect, it is an interesting therapy for patients

with a history of colorectal disease for whom regular treatment was challenging or non feasible. Mitach et al reported the functional and oncological outcomes of HIFU for prostate cancer in patients with a history of severe colorectal disease.13Mitach A, Crouzet S, Poissonier L, et al. HIFU for prostate cancer in patients with a history of severe colorectal disease. Prog Urol. 2011;21(9):619-24.   Fourteen patients (mean age, 65.8 ± 6.1 years.) with a history of severe colorectal disease (cancer, lymphoma, inflammatory bowel diseases [IBD]) were treated with HIFU as a primary care option for localized prostate cancer. Mean time between colorectal disease treatment and HIFU was 10.6 ± 6.8 years. The mean PSA before HIFU was 12.1 ng/mL (4.5-55), and mean prostate volume before HIFU was 22.1 ± 11.7 mL. The number of HIFU sessions per patient was 1.35. The mean nadir PSA was 0.61 ± 0.82 ng/mL. Systematic control biopsies were found to be negative in seven patients (50%). Mean follow-up was 22 months with a 35.7% complication rate (3 erectile dysfunctions, 2 urinary stress incontinences); though, no recto-urethral fistula occurred.

Attractivity of robotic HIFU is based largely on the non-invasive, extremely precise nature of this high-tech robotic therapy as well as its clean, radiation free, surgical, but nevertheless, bloodless character. Today, HIFU is used clinically as a therapeutic tool for the treatment of prostate cancer.14Chaussy CG, Thüroff S. Transrectal high-intensity focused ultrasound for local treatment of prostate cancer: current role. Arch Esp Urol. 2011;64(6):493-506.   Transrectal treatment of localized prostate cancer with HIFU is meanwhile an actively used therapy for the disease in many urological departments worldwide. Since 2000 HIFU is mostly used in combination with TURP in order to reduce prostate gland size, to facilitate effective tissue destruction, and to avoid side effects. Further palliative and salvage indications as well as focal therapy of prostate cancer are under investigation to extend the spectrum of HIFU indications for non-invasive prostate cancer therapy.

Cryosurgery/cryoablation

Modern third-generation prostate cryosurgery is safe, and most of the complications and postoperative events are transient; however, erectile function has marked deterioration.15Caso JR, Tsivian M, Mouraviev V, et al. Complications and postoperative events after cryosurgery for prostate cancer. BJU Int. 2012;109(6):840-5.   Lian et al presented early results of using third-generation cryotherapy as primary treatment for localized prostate cancer.16Lian H, Guo H, Gan W, et al. Cryosurgery as primary treatment for localized prostate cancer. Int Urol Nephrol. 2011;43(4):1089-94.   A total of 102 patients underwent primary cryosurgery for clinically localized prostate cancer – a dual freeze-thaw cycle using third-generation cryotechnology with ultrathin 17-gauge cryoneedles.

The PSA level for all patients at the last follow-up visit was < 0.5 ng/ml in 94 patients (92.2%) and ≥ 0.5 ng/ml in 8 (7.8%). One patient (1.0%) had recurrent prostate cancer confirmed by prostate biopsy and was treated with salvage cryotherapy; and 7 other patients (6.9%) had an elevated PSA level after cryotherapy despite negative post-treatment biopsies and a metastatic evaluation. While 1 patient was incontinent preoperatively, of the remaining 101 patients, 4 patients (4.0%) developed mild incontinence requiring 1 to 2 pads per day.

Urethral sloughing occurred in 5/102 patients (4.9%) and 1 of these patients (1.0%) required transurethral resection of sloughing. Though the rates of erectile dysfunction were 64.1%, no urethral strictures, rectourethral fistulas, urinary retention, or chronic pelvic pain was reported. The median inpatient stay after cryoablation was 3.2 days. In conclusion, early results suggest that cryotherapy offers a safe and effective alternative for the primary treatment of localized prostate cancer. Additional studies with longer follow-up are necessary to establish the sustained efficacy of this procedure; yet, data from the COLD (Cryo On-Line Data) Registry17Dhar N, Ward JF, Cher ML, et al. Primary full-gland prostate cryoablation in older men (> age of 75 years): results from 860 patients tracked with the COLD Registry. BJU Int. 2011;108(4):508-12.   shows whole gland cryoablation in older men (age >75 years) maintains oncological efficacy similar to that of younger men without increased morbidity.

Prostatectomy

There has been a rapid and widespread adoption of minimally invasive procedures for the treatment of prostate and bladder cancers in the last decade.18H akimi AA, Ghavamian R. Feasibility of minimally invasive lymphadenectomy in bladder and prostate cancer surgery. Urol Clin North Am. 2011;38(4):407-18, v.   The contemporary surgical approaches include laparoscopic radical prostatectomy and robot-assisted laparoscopic radical prostatectomy, and are now considered standard modalities of treatment in urology centres of excellence world-wide.19H eer R, Raymond I, Jackson MJ, et al. A critical systematic review of recent clinical trials comparing open retropubic, laparoscopic and robot-assisted laparoscopic radical prostatectomy. Rev Recent Clin Trials. 2011;6(3):241-9.  

Laparoscopic Madigan prostatectomy – a modification

Quan et al modified the Madigan prostatectomy to make it suitable for laparoscopically enucleating hyperplastic glands larger than 100 g. Extraperitoneal laparoscopic prostatectomy with maintenance of the intact urethra were performed on 16 patients with BPH and glands larger than 100 mg.20Quan C, Chang W, Chen J, et al. Laparoscopic Madigan prostatectomy. J Endourol. 2011;25(12):1879-82.  

To make the procedure suitable for laparoscopic use, two major modifications were made:

  1. Open the prostate capsule near the bladder neck without sutures along the opening
  2. Identify the bladder neck mucosa before recognizing the urethra.

All patients were evaluated preoperatively and postoperatively, and data were compared with those from open surgeries. Results showed that all laparoscopic procedures were successful with the total operative time of 111.8±28.6 minutes, which had no significant difference compared with open surgeries. However, estimated blood loss of laparoscopic procedures was significantly lower than that of open surgery, and, also the catheterization time and hospital stay time was significantly shorter than open surgery. The improvement of the IPSS, maximum flow rate, and quality-of-life score were not different between the comparing groups. The authors, thus, reported that laparoscopic Madigan prostatectomy is a safe and feasible approach for large glands (BPH). Its advantages include shorter learning curve, reduced blood loss, less retroejaculation rate, shorter catheterization time, and shorter hospital stay.

Robotic-assisted laparoscopic prostatectomy

Robotic-assisted laparoscopic prostatectomy has consolidated the position of surgical treatment for localized prostate cancer, and in a few years, it is expected to spread rapidly worldwide. However, surgical anatomy has trailed the advance in surgical techniques of robotic-assisted laparoscopic prostatectomy, and recent literature sometimes refutes the established consensus on pelvic anatomy, for the state-of-the-art technique. In effect, surgical anatomy should always be developing and changing with advances in surgical approaches.21Takenaka A, Tewari AK. Anatomical basis for carrying out a state-of-the-art radical prostatectomy. Int J Urol. 2012;19(1):7-19.  

Gupta et al critically analyzed and compared surgical, oncological and functional outcomes of robot-assisted radical prostatectomy (RARP) in patients with and without previous TURP.22Gupta NP, Singh P, Nayyar R. Outcomes of robot-assisted radical prostatectomy in men with previous transurethral resection of prostate. BJU Int. 2011;108(9):1501-5.   The study included 158 cases of RARP for clinically localized prostate cancer, including 26 cases that had undergone previous TURP (Group A). The investigators compared surgical, oncological and functional (short- and intermediate-term) outcomes of Group A with 132 cases without previous TURP (Group B). Results showed that post TURP patients reportedly had significantly greater blood loss (494 vs. 324 mL) and a need for bladder neck reconstruction (26.7% vs. 9.7%) compared to the non-TURP group. Together, surgical time (189 vs. 166 min), conversion rate, margin positivity rate and biochemical recurrence rate were also higher. Incontinence rates were higher both at 6 (14% vs. 11.8%) and 12 (25% vs. 8%) months follow-up. The authors, thus, concluded that RARP is feasible but challenging after TURP. The method entails a longer operating time, greater operative difficulty and compromised oncological or continence outcomes. Accordingly, these cases should be handled by an experienced robotic surgeon with the appropriate expertise.

Comparison of intra-operative outcomes using the new and old generation da Vinci® robot for robot assisted laparoscopic prostatectomy

Shah et al reviewed and compared intra-operative outcomes for robotic prostatectomy procedures performed on two generations of the da Vinci robotic surgery platform by reviewing 100 consecutive robotic prostatectomy cases, and comparing intra-operative outcomes for procedures randomly performed on either the da Vinci S robot or first-generation standard robot.23Shah K, Abaza R. Comparison of intraoperative outcomes using the new and old generation da Vinci® robot for robot-assisted laparoscopic prostatectomy. BJU Int. 2011;108(10):1642-5.   Together, the authors reviewed and compared baseline demographic data and intra-operative variables potentially impacting outcomes between the two groups. Results showed that mean total operative time was 191 min using the standard da Vinci robot (range 132-266) vs. 169 min with S robot (range 98-230), representing a mean difference of 22 min (P = 0.002). The difference was statistically significant despite no difference in mean patient BMI of 30.6 (range 19-51) for standard vs. 29.3 (range 21-37) for S (P = 0.31), no difference in mean prostate size of 54.6 g (range 26-101) for standard vs. 57.3 g (range 32-151) for S (P = 0.55), and no difference in frequency of nerve-sparing (P = 0.99). Also, there was no difference in the portions of procedures performed by residents, which in some cases was none and some the entire procedure, but the standard was more often used for the surgeon’s first case of the day (P = 0.006). Moreover, there was no difference in blood loss (P = 0.08), positive margins (P = 0.87), or mean number of lymph nodes removed (10.7 vs. 10.6). The authors, thus, concluded that both generations of da Vinci robotic technology are equally effective, but the S robot appears to allow shorter procedure times.

Future perspectives in Robotic surgery

In its current form, robotic surgery has established itself as a viable treatment option for several indications and indeed the gold standard for a few indications owing to the improved technology built into the robotics system.24Wedmid, A., Llukani, E. and Lee, D. I. (2011), Future perspectives in robotic surgery. BJU International, 2011;108: 1028-1036.   In effect, robotics of the current day have advanced significantly from early computer-aided design/manufacturing systems to modern master-slave robotic systems that replicate the surgeon’s exact movements onto robotic instruments in the patient. The penetration of the technology into practice is evident by the fact that globally more than 300000 robotic procedures were completed in 2010, including about 98000 robotassisted radical prostatectomies. Additional broadening applications of robotics for urological procedures are being investigated in both adult and pediatric urology.

With enhanced technologies, the use of the current robotic system continues to be further refined; for instance, increasing experience has optimized port placement reducing arm collisions to allow for more expedient surgery, and improved 3-D camera magnification provides improved intra-operative identification of structures.

Effectively, robotics has probably improved the learning curve of laparoscopic surgery while still maintaining its patient recovery advantages and outcomes. It may, thus, be envisaged that the future of robotic surgery will take this current platform forward by improving haptic (touch) feedback, improving vision beyond even the magnified eye, improving robot accessibility with a reduction of entry ports and miniaturizing the slave robot.

Role of MRI in minimally invasive focal ablative therapy for prostate

MRI, in combination with biopsy, will impact patient selection for focal ablation by helping to localize clinically significant tumor foci. Also, some ablation procedures may be performed using real-time MRI guidance. Additionally, MRI may be used for assessment of extent of necrosis shortly after therapy and for long-term surveillance for recurrent tumor.25Rosenkrantz AB, Scionti SM, Mendrinos S, et al. Role of MRI in minimally invasive focal ablative therapy for prostate cancer. AJR Am J Roentgenol. 2011;197(1):W90-6.  

3.0T MR-guided laser ablation of a prostate cancer recurrence in the postsurgical prostate bed

Biochemical recurrence of prostate cancer after definitive therapy with radical prostatectomy occurs in 25%-30% of cases. Woodrum et al recently presented the first known case of MRI-guided ablation using laser interstitial thermal therapy (LITT) for locally recurrent prostate cancer after radical prostatectomy.26Woodrum DA, Mynderse LA, Gorny KR, et al. 3.0T MR-guided laser ablation of a prostate cancer recurrence in the postsurgical prostate bed. J Vasc Interv Radiol. 2011;22(7):929-34.   Using 3.0T MR guidance, two laser applicators were placed via a transperineal approach, and laser ablation was performed using MR thermometry to determine the ablation endpoint and lesion coverage. Dynamic contrast-enhanced MR imaging after the procedure showed no definitive abnormal enhancement. The patient had no change in continence or potency after the procedure.

Conclusion

Even though the increasing use of medical therapy as a first line treatment for BPH has resulted in a dramatic decrease in TURPs which, in turn, has been associated with an apparent increase in risk of poor pre- and postoperative outcomes, many patients would require invasive interventions.27Izard J, Nickel JC. Impact of medical therapy on transurethral resection of the prostate: two decades of change. BJU Int. 2011;108(1):89-93.   This further highlights the importance of effective patient selection to have optimal outcomes, and a comparison of procedures may assist physicians and patients in selecting treatment for subgroup of men with prostate pathology.28Grimm P, Billiet I, Bostwick D, et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJU Int. 2012;109 Suppl 1:22-9.  

In an effort to decrease the invasiveness and deleterious impact on quality of life associated with prostate surgery, minimally invasive techniques, for instance lasers, have been applied to this disease. Presently, the roboticassisted laparoscopic radical prostatectomy has become the most commonly performed surgical treatment modality for adenocarcinoma of the prostate.29Duty B, Roy O, Micali S, et al. The application of natural orifice surgery for adenocarcinoma of the prostate. Urologic Oncology: Seminars and Original Investigations 2011;29(3):330-333.   Together, a technical improvement in TURP would also provide a lower complication rate with excellent long-term efficacy combined with reduced complications.30Ilbey AIT YO, Tugcu V, et al. Transurethral Resection of the Prostate With Monopolar Resectoscope: Single-surgeon Experience and Long-term Results of After 3589 Procedures. Urology 2011;78(5):1151-1155.  

References

  1. Zorn KC, Liberman D. GreenLight 180W XPS photovaporization of the prostate: how I do it. Can J Urol. 2011;18(5):5918-26.
  2. O’Leary MP. Treatment and pharmacologic management of BPH in the context of common comorbidities. Am J Manag Care. 2006;12(5 Suppl):S129-40.
  3. Montorsi F Moncada I. Safety and Tolerability of Treatment for BPH. European Urology Supplements 2006; 5(20): 1004-1012.
  4. Lindner U, Lawrentschuk N, Schatloff O, et al. Evolution from active surveillance to focal therapy in the management of prostate cancer. Future Oncol. 2011;7(6):775-87.
  5. Bachmann A, Woo HH, Wyler S. Laser prostatectomy of lower urinary tract symptoms due to benign prostate enlargement: a critical review of evidence. Curr Opin Urol. 2012;22(1):22-33.
  6. Kapoor DA, Zimberg SH, Ohrin LM, et al. Utilization trends in prostate cancer therapy. J Urol. 2011;186(3):860-4.
  7. Djavan B, Kazzazi A, Bostanci Y. Revival of thermotherapy for benign prostatic hyperplasia. Curr Opin Urol. 2012;22(1):16-21.
  8. Tamai A, Aloisi A, Fabrello M. Prostiva RF therapy (transurethral needle ablation): evaluation of results from 127 patients. Urologia. 2011;78(3):166-70.
  9. Bruyere F. Photoselective vaporization of the prostate. Prog Urol. 2011;21(11):808-10.
  10. Bruyère F. The relationship between photoselective vaporization of the prostate and sexual function. Curr Urol Rep. 2011;12(4):261-4.
  11. Finley DS, Belldegrun AS. Salvage cryotherapy for radiation-recurrent prostate cancer: outcomes and complications. Curr Urol Rep. 2011;12(3):209-15.
  12. Elterman DS, Barkin J, Radomski SB, et al. Results of high intensity focused ultrasound treatment of prostate cancer: early Canadian experience at a single center. Can J Urol. 2011;18(6):6037-42.
  13. Mitach A, Crouzet S, Poissonier L, et al. HIFU for prostate cancer in patients with a history of severe colorectal disease. Prog Urol. 2011;21(9):619-24.
  14. Chaussy CG, Thüroff S. Transrectal high-intensity focused ultrasound for local treatment of prostate cancer: current role. Arch Esp Urol. 2011;64(6):493-506.
  15. Caso JR, Tsivian M, Mouraviev V, et al. Complications and postoperative events after cryosurgery for prostate cancer. BJU Int. 2012;109(6):840-5.
  16. Lian H, Guo H, Gan W, et al. Cryosurgery as primary treatment for localized prostate cancer. Int Urol Nephrol. 2011;43(4):1089-94.
  17. Dhar N, Ward JF, Cher ML, et al. Primary full-gland prostate cryoablation in older men (> age of 75 years): results from 860 patients tracked with the COLD Registry. BJU Int. 2011;108(4):508-12.
  18. H akimi AA, Ghavamian R. Feasibility of minimally invasive lymphadenectomy in bladder and prostate cancer surgery. Urol Clin North Am. 2011;38(4):407-18, v.
  19. H eer R, Raymond I, Jackson MJ, et al. A critical systematic review of recent clinical trials comparing open retropubic, laparoscopic and robot-assisted laparoscopic radical prostatectomy. Rev Recent Clin Trials. 2011;6(3):241-9.
  20. Quan C, Chang W, Chen J, et al. Laparoscopic Madigan prostatectomy. J Endourol. 2011;25(12):1879-82.
  21. Takenaka A, Tewari AK. Anatomical basis for carrying out a state-of-the-art radical prostatectomy. Int J Urol. 2012;19(1):7-19.
  22. Gupta NP, Singh P, Nayyar R. Outcomes of robot-assisted radical prostatectomy in men with previous transurethral resection of prostate. BJU Int. 2011;108(9):1501-5.
  23. Shah K, Abaza R. Comparison of intraoperative outcomes using the new and old generation da Vinci® robot for robot-assisted laparoscopic prostatectomy. BJU Int. 2011;108(10):1642-5.
  24. Wedmid, A., Llukani, E. and Lee, D. I. (2011), Future perspectives in robotic surgery. BJU International, 2011;108: 1028-1036.
  25. Rosenkrantz AB, Scionti SM, Mendrinos S, et al. Role of MRI in minimally invasive focal ablative therapy for prostate cancer. AJR Am J Roentgenol. 2011;197(1):W90-6.
  26. Woodrum DA, Mynderse LA, Gorny KR, et al. 3.0T MR-guided laser ablation of a prostate cancer recurrence in the postsurgical prostate bed. J Vasc Interv Radiol. 2011;22(7):929-34.
  27. Izard J, Nickel JC. Impact of medical therapy on transurethral resection of the prostate: two decades of change. BJU Int. 2011;108(1):89-93.
  28. Grimm P, Billiet I, Bostwick D, et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJU Int. 2012;109 Suppl 1:22-9.
  29. Duty B, Roy O, Micali S, et al. The application of natural orifice surgery for adenocarcinoma of the prostate. Urologic Oncology: Seminars and Original Investigations 2011;29(3):330-333.
  30. Ilbey AIT YO, Tugcu V, et al. Transurethral Resection of the Prostate With Monopolar Resectoscope: Single-surgeon Experience and Long-term Results of After 3589 Procedures. Urology 2011;78(5):1151-1155.
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