Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5209_Библиотеки_им_академика_М_И_Перельмана.pdf
32 Robotic High-Intensity Focused Ultrasound oftheProstate
Table 32.4 Robotic HIFU complication rates
Clavien-Dindo
References
Beerlage etal. (1991)
[18]
El Fegoun etal. (2011)
[19]
van Velthoven etal.
(2014) [20]
van Velthoven etal.
(2016) [21]
Feijoo etal. (2016) [22] II: 12
Albisinni etal. (2017)
[23]
Rischmann etal. (2017)
[24]
Garcia-Barreras etal.
(2018) [25]
Ganzer etal. (2018) [26] I: 27.5
Rosenhammer etal.
(2019) [30]
Abreu etal. (2020) [6] I: 8
Nahar etal. (2020) [31] I: 26.9
Tourinho-Barbosa etal.
(2020) [32]
UTI urinary tract infection, NR not reported
grade (%)
NR NR NR NR 0
NR 0 8.3 16.7 NR
I & II: 19.3
IIIb: 3.4
I & II: 36
III: 4
IIIb: 3
I: 12.7
II: 1.8
I: 50.5
II: 32.4
IIIa: 9.9
IIIb: 2.7
I: 1.7
II: 13.1
IIIa: 0.8
IIIb: 0.8
II: 21.6
III: 2
I: 14.3
III: 4.8
II: 5
II: 25
III: 10.4
II: 20.1
IIIa: 2.2
IIIb: 0.3
IVa: 0.3
Urethral stricture
rate (%)
3.4 3.4 10.3 0
4 8 6 0
0 9 6 0
0 7 1 0
0.9 7.2 16.2 0
NR 9.7 3.4 NR
2 9.8 17.6 0
NR 14.3 0 0
0 7 5 0
NR 7.7 38.5 0
1.3 12 9.1 0.3
Urinary retention
rate (%)
UTI rate
(%)
401
Recto-urethral
stula (%)
Patients’ Report Quality ofLife
Robotic HIFU is generally well-received by
patients, exhibiting low regret rates. For example,
a multicenter prospective study evaluating patient
satisfaction and regret rates following focal therapy for PCa reported that 89% of patients who
underwent HIFU (mechanical or robotic) felt it
was the correct decision, while only 7% expressed
regret, and 86% would opt for the same treatment
if faced with the decision again [34]. In contrast,
regret rates for radical prostatectomy, externalbeam radiotherapy, and brachytherapy vary signicantly, ranging from 5% to 31%, 9.2% to
24%, and 0% to 24%, respectively [35]. Factors
such as postoperative impotence, elevated IPSS,
and detection of cancer in follow-up biopsies
were identied as independent predictors of
treatment regret in patients post-HIFU.
Conclusions
Robotic HIFU emerges as a viable, fully automated, and less invasive alternative for nonmetastatic prostate cancer treatment, offering a
balance of effective medium-term cancer control
with favorable safety and functional outcomes.
402
L. S. Ramacciotti et al.
Continence, erectile, bowel function, and quality
of life are well-preserved, while high-grade complications are low.
References
1. Golan R, Bernstein AN, McClure TD, Sedrakyan A,
Patel NA, Parekh DJ, etal. Partial gland treatment
of prostate cancer using high-intensity focused ultrasound in the primary and salvage settings: a systematic review. J Urol. 2017;198(5):1000–9.
2. Valerio M, Cerantola Y, Eggener SE, Lepor H,
Polascik TJ, Villers A, et al. New and established
technology in focal ablation of the prostate: a systematic review. Eur Urol. 2017;71(1):17–34.
3. Hopstaken JS, Bomers JGR, Sedelaar MJP, Valerio
M, Fütterer JJ, Rovers MM.An updated systematic
review on focal therapy inlocalized prostate cancer:
what has changed over the past 5 years? Eur Urol.
2022;81(1):5–33.
4. Abreu AL, Kaneko M, Cacciamani GE, Lebastchi
AH.Focal therapy for prostate cancer: getting ready
for prime time. Eur Urol. 2022;81(1):34–6.
5. Ehdaie B, Tempany CM, Holland F, Sjoberg DD,
Kibel AS, Trinh QD, etal. MRI-guided focused ultrasound focal therapy for patients with intermediaterisk prostate cancer: a phase 2b, multicentre study.
Lancet Oncol. 2022;23(7):910–8.
6. Abreu AL, Peretsman S, Iwata A, Shakir A, Iwata
T, Brooks J, et al. High intensity focused ultrasound hemigland ablation for prostate cancer: initial outcomes of a United States series. J Urol.
2020;204(4):741–7.
7. Chin JL, Billia M, Relle J, Roethke MC, Popeneciu IV,
Kuru TH, etal. Magnetic resonance imaging-guided
transurethral ultrasound ablation of prostate tissue in
patients with localized prostate cancer: a prospective
phase 1 clinical trial. Eur Urol. 2016;70(3):447–55.
8. Shehata IA. Treatment with high intensity focused
ultrasound: secrets revealed. Eur J Radiol.
2012;81(3):534–41.
9. Elhelf IAS, Albahar H, Shah U, Oto A, Cressman E,
Almekkawy M. High intensity focused ultrasound:
the fundamentals, clinical applications and research
trends. Diagn Interv Imaging. 2018;99(6):349–59.
10. Van Leenders GJ, Beerlage HP, Ruijter ET, de la
Rosette JJ, van de Kaa CA.Histopathological changes
associated with high intensity focused ultrasound
(HIFU) treatment for localised adenocarcinoma of the
prostate. J Clin Pathol. 2000;53(5):391–4.
11. Napoli A, Aleri G, Scipione R, Leonardi A, Fierro
D, Panebianco V, etal. High-intensity focused ultrasound for prostate cancer. Expert Rev Med Devices.
2020;17(5):427–33.
12. Checcucci E, De Luca S, Piramide F, Garrou D,
Mosca A, Galla A, et al. The real-time intraoperative guidance of the new HIFU Focal-One® platform
allows to minimize the perioperative adverse events
in salvage setting. J Ultrasound. 2022;25(2):225–32.
13. Huber PM, Afzal N, Arya M, Boxler S, Dudderidge
T, Emberton M, etal. An exploratory study of dose
escalation vs standard focal high-intensity focused
ultrasound for treating nonmetastatic prostate cancer.
J Endourol. 2020;34(6):641–6.
14. Shoji S, Uchida T, Nakamoto M, Kim H, de Castro
Abreu AL, Leslie S, et al. Prostate swelling and
shift during high intensity focused ultrasound:
implication for targeted focal therapy. J Urol.
2013;190(4):1224–32.
15. Ashra AN, Nassiri N, Gill IS, Gulati M, Park D,
de Castro Abreu AL. Contrast-enhanced transrectal
ultrasound in focal therapy for prostate cancer. Curr
Urol Rep. 2018;19(10):87.
16. de Castro Abreu AL, Ashra AN, Gill IS, Oishi M,
Winter MW, Park D, et al. Contrast-enhanced transrectal ultrasound for follow-up after focal HIFU
ablation for prostate cancer. J Ultrasound Med.
2019;38(3):811–9.
17. Bacchetta F, Martins M, Regusci S, Jichlinski P,
Meuwly JY, Lucca I, etal. The utility of intraoperative
contrast-enhanced ultrasound in detecting residual
disease after focal HIFU for localized prostate cancer.
Urol Oncol. 2020;38(11):846.
18. Beerlage HP, Thüroff S, Debruyne FM, Chaussy C,
de la Rosette JJ. Transrectal high-intensity focused
ultrasound using the Ablatherm device in the treatment of localized prostate carcinoma. Urology.
1999;54(2):273–7.
19. El Fegoun AB, Barret E, Prapotnich D, Soon S,
Cathelineau X, Rozet F, etal. Focal therapy with highintensity focused ultrasound for prostate cancer in the
elderly. A feasibility study with 10 years follow-up.
Int Braz J Urol. 2011;37(2):213–9; discussion 20–2.
20. Van Velthoven R, Aoun F, Limani K, Narahari K,
Lemort M, Peltier A. Primary zonal high intensity
focused ultrasound for prostate cancer: results of
a prospective phase IIa feasibility study. Prostate
Cancer. 2014;2014:756189.
21. van Velthoven R, Aoun F, Marcelis Q, Albisinni
S, Zanaty M, Lemort M, et al. A prospective clinical trial of HIFU hemiablation for clinically localized prostate cancer. Prostate Cancer Prostatic Dis.
2016;19(1):79–83.
22. Feijoo ER, Sivaraman A, Barret E, Sanchez-Salas R,
Galiano M, Rozet F, etal. Focal high-intensity focused
ultrasound targeted hemiablation for unilateral prostate cancer: a prospective evaluation of oncologic and
functional outcomes. Eur Urol. 2016;69(2):214–20.
23. Albisinni S, Aoun F, Bellucci S, Biaou I, Limani K,
Hawaux E, etal. Comparing high-intensity focal ultrasound hemiablation to robotic radical prostatectomy
in the management of unilateral prostate cancer: a
matched-pair analysis. J Endourol. 2017;31(1):14–9.
24. Rischmann P, Gelet A, Riche B, Villers A, Pasticier G,
Bondil P, etal. Focal high intensity focused ultrasound
of unilateral localized prostate cancer: a prospective
32 Robotic High-Intensity Focused Ultrasound oftheProstate
403
multicentric hemiablation study of 111 patients. Eur
Urol. 2017;71(2):267–73.
25. Garcia-Barreras S, Sanchez-Salas R, Sivaraman A,
Barret E, Secin F, Nunes-Silva I, etal. Comparative
analysis of partial gland ablation and radical prostatectomy to treat low and intermediate risk prostate
cancer: oncologic and functional outcomes. J Urol.
2018;199(1):140–6.
26. Ganzer R, Hadaschik B, Pahernik S, Koch D,
Baumunk D, Kuru T, et al. Prospective multicenter
phase II study on focal therapy (hemiablation) of
the prostate with high intensity focused ultrasound. J
Urol. 2018;199(4):983–9.
27. Annoot A, Olivier J, Valtille P, Deken V, Leroy X,
Puech P, etal. Extra-target low-risk prostate cancer:
implications for focal high-intensity focused ultrasound of clinically signicant prostate cancer. World J
Urol. 2019;37(2):261–8.
28. Glybochko PV, Amosov AV, Krupinov GE, Petrovskii
NV, Lumpov IS. Hemiablation of localized prostate
cancer by high-intensity focused ultrasound: a series
of 35 cases. Oncology. 2019;97(1):44–8.
29. Mortezavi A, Krauter J, Gu A, Sonderer J, Bruhin J,
Reeve KA, etal. Extensive histological sampling following focal therapy of clinically signicant prostate
cancer with high intensity focused ultrasound. J Urol.
2019;202(4):717–24.
30. Rosenhammer B, Niessen C, Rotzinger L, Reiss J,
Schnabel MJ, Burger M, etal. Oncological outcome
and value of postoperative magnetic resonance imaging after focal high-intensity focused ultrasound therapy for prostate cancer. Urol Int. 2019;103(3):270–8.
31. Nahar B, Bhat A, Reis IM, Soodana-Prakash N,
Becerra MF, Lopategui D, et al. Prospective evaluation of focal high intensity focused ultrasound for
localized prostate cancer. J Urol. 2020;204(3):483–9.
32. Tourinho-Barbosa RR, Sanchez-Salas R, Claros
OR, Collura-Merlier S, Bakavicius A, Carneiro
A, et al. Focal therapy for localized prostate cancer with either high intensity focused ultrasound or
cryoablation: a single institution experience. J Urol.
2020;203(2):320–30.
33. Abramowitz MC, Li T, Buyyounouski MK, Ross
E, Uzzo RG, Pollack A, et al. The phoenix denition of biochemical failure predicts for overall
survival in patients with prostate cancer. Cancer.
2008;112(1):55–60.
34. Ghorei A, Kaneko M, Peretsman S, Iwata A, Brooks
J, Shakir A, et al. Patient-reported satisfaction and
regret following focal therapy for prostate cancer: a
prospective multicenter evaluation. Eur Urol Open
Sci. 2023;50:10–6.
35. Christie DR, Sharpley CF, Bitsika V.Why do patients
regret their prostate cancer treatment? A systematic
review of regret after treatment for localized prostate
cancer. Psychooncology. 2015;24(9):1002–11.
Transrectal Laser Focal Therapy
ofProstate Cancer
JohnF.Feller, BernadetteM.Greenwood,
AaronHarman, andAraKaramanian
33
Introduction andBackground
Prostate cancer is the most common noncutaneous malignancy in men, affecting approximately
1in 8 men during their lifetime. It is also the second leading cause of cancer death in American
men, accounting for 11% [1]. Since the FDA
approved the use of prostate-specic antigen
(PSA) for prostate cancer screening in 1994,
most prostate cancer has been diagnosed at an
early stage when it is still conned to the gland.
Approximately three-quarters of all prostate cancer patients have low- or intermediate-risk disease [2]. Many of these cancers are indolent and
J. F. Feller (*)
Department of Radiology, Loma Linda University
School of Medicine, Loma Linda, CA, USA
HALO Precision Diagnostics, Indian Wells, CA, USA
e-mail: john@halodx.com
B. M. Greenwood
Department of Radiologie and Nuclear Medicine,
Radboud University Medical Center, Nijmegen,
Gelderland, The Netherlands
HALO Precision Diagnostics, Indian Wells, CA, USA
A. Harman · A. Karamanian
HALO Precision Diagnostics, Indian Wells, CA, USA
are unlikely to pose a threat to the patient’s health
or life.
While active surveillance and watchful waiting have been used to decrease the morbidities
associated with whole gland therapies, there are
risks even with this line of management. Several
studies have shown associated psychological
morbidities as well as a signicant decrease in
sexual function [3, 4]. In addition, there is a risk
of disease progression and subsequent death by
delaying treatment. A prospective randomized
control trial of 347 patients who underwent a
radical prostatectomy and 348 patients on watchful waiting found a 6.1% greater cancer-specic
survival at 15 years for the radical prostatectomy
group [5].
Image-guided focal therapies have emerged as
a way to treat localized prostate cancer while
minimizing side effects. Transrectal ultrasound
was the rst imaging modality used to guide therapies and is still used with HIFU, cryoablation,
and irreversible electroporation. With the advent
of multiparametric magnetic resonance imaging
(mpMRI), it is now possible to not only visualize
the target lesion [6] and small anatomic structures such as the cavernosal nerve bundles and
ejaculatory ducts but also monitor the ablative
heat in near-real time [7]. However, most ablative
modalities are not MRI-compatible, and most of
those that are do not allow for real-time ther-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
T. J. Polascik et al. (eds.), Imaging and Focal Therapy of Early Prostate Cancer,
https://doi.org/10.1007/978-3-031-66754-1_33
405
406
J. F. Feller et al.
mometry due to susceptibility artifacts due to ferrous metal.
One of the newer focal therapies for the treatment of prostate cancer is laser focal therapy
(LFT) [8], which has a distinct advantage over
other modalities. The laser beroptics used in
LFT do not contain any ferromagnetic materials,
which would prevent the use of real-time MRI
thermometry. Therefore, the ablative heat can be
monitored, decreased or increased, and turned off
to control and customize an ablation zone. This is
starkly different from the typical way that thermal ablations are performed in other parts of the
body, in which the power and time used to create
the ablation for the target tumor are taken directly
from the user manual with little to no adjustment
during the ablation. Precise monitoring with realtime adjustment is critical when ablating next to
delicate anatomical structures such as the cavernosal nerves, which are located immediately
adjacent to the prostate posterolaterally, and the
external urethral sphincter, which is located
immediately inferior to the prostate, continuous
with the isthmus of the prostate. In this fraught
anatomical landscape, one millimeter can mean
the difference between normal function and
disability.
Another advantage of LFT in prostate cancer
ablation is its razor-thin margin. The zone of
transition between the zone of coagulative necrosis and the untreated tissue is only 0.5–2.5mm
wide [9], allowing for thorough ablations of subcapsular lesions while leaving adjacent extraprostatic anatomical structures intact. This is
very important because approximately 70% of
localized prostate cancers arise in the peripheral
zone [10], and peripheral zone cancers frequently
about the capsule.
Despite its strengths, there are a few barriers
that are preventing the widespread adoption of
transrectal LFT.Many interventional radiologists
have limited access to procedural MRI scanners.
In the United States, LFT is considered investigational by Medicare or private insurance and,
therefore, not widely covered. There are certain
notable exceptions; for example, government
employees of the state of Georgia do have coverage. This means that almost all patients currently
have to pay out of pocket, a cost-prohibitive
expense for most men. Unfortunately, there is a
nancial disincentive for urologists (who do not
perform this procedure) to refer patients to interventional radiologists for LFT. In our practice,
most patients are self-referred after doing their
research on the Internet.
Indications
The American Urological Association/American
Society for Therapeutic Radiology and Oncology
guidelines of 2022 recommend prostate ablation
only in patients with intermediate-risk cancer
[11], an opinion shared by 100% of respondents
in the Delphi consensus project on focal laser
ablation of 2019 [12]. In reality, an elderly patient
with small volume high-grade disease who wants
to maintain his genitourinary function may be a
good candidate as long as he understands the
risks of recurrence and progression. On the other
hand, patients with low-grade disease but a
PI-RADS 4 or 5 lesion on mpMRI may also be
good candidates, as it has been shown that these
patients are at a higher risk of progression on
active surveillance [13]. Although 73% of survey
respondents in the Delphi consensus project felt
that LFT is only appropriate when performed as
part of a clinical trial, or observational/registry
study, in reality, the procedure is performed outside of clinical trials at several institutions.
Contraindications
MRI-guided transrectal LFT is contraindicated
in patients with an uncorrectable coagulopathy,
patients without a rectum, and patients with
MRI-incompatible implanted devices. It can be
33 Transrectal Laser Focal Therapy ofProstate Cancer
407
performed in patients with stage T3 or T4 prostate cancer (i.e., extracapsular extension or invasion of adjacent structures) or oligometastatic
disease for tumor burden reduction. Prior radiation or focal therapy are not contraindications
[14]. Hip arthroplasties or prior Urolift procedures are also not contraindications to treatment
but can degrade imaging and introduce artifacts
during thermometry. Some groups have used
PSA or PSA density cutoffs as exclusion criteria
for clinical trials [15]; however, these are not
absolute contraindications as long as the patient
understands the risks of recurrence and metastasis after a thorough discussion. While discordance between the location of lesions on mpMRI
and biopsy has been used as an exclusion criterion in clinical trials [16–18], we do not consider it a contraindication, addressing such cases
with ablation of all sites considered positive on
both mpMRI and biopsy. While MRI-occult
cancers cannot be directly targeted with imaging, they can be treated with regional ablations
based on the pathology report.
Preprocedure Workup
Rigorous patient selection is extremely important. When a patient reaches out to us for consultation, we review all relevant clinical
information, including the patient’s age, functional status, medical comorbidities, PSA,
pathology report, mpMRI, and, if available,
somatic genetic testing, nuclear bone scan, or
PSMA scan. If the patient has a PSA greater
than 20 ng/mL, we require a PSMA scan to
demonstrate no metastatic disease, and we still
counsel that there is a high risk of recurrence
and metastasis after treatment. We ask him to
complete an International Prostate Symptom
Score (IPSS) survey and Sexual Health
Inventory for Men (SHIM) questionnaire prior
to the ablation and again at every post-procedure follow-up to assess for any treatmentrelated changes [19].
Subsequently, we have a thorough phone conversation with the patient explaining the nature of
the procedure, the risks, benets, and alternatives
(i.e., other focal therapies, radical prostatectomy,
radiation, or active surveillance). The discussion
of risks is tailored to the specic patient. For
example, a patient with prostate cancer adjacent
to the ejaculatory ducts will be appraised of the
high risk of developing dry ejaculation.
Most, if not all, of the men who seek us out
for treatment do so because of a desire to preserve their quality of life. However, each
patient has a unique set of priorities and preferences. For example, a patient may not be sexually active and may not prioritize erectile
function or the ability to ejaculate but has a
strong desire to maintain urinary continence
and asks that we ablate as aggressively as necessary adjacent to the nerve bundles to achieve
local control as long as it does not damage the
external urethral sphincter. Alternatively, a
patient may ask us to do our best to preserve
every aspect of his genitourinary function,
including fertility, even if it means potentially
leaving residual cancer. If patients report bothersome lower urinary tract symptoms (LUTS),
we can also ablate the periurethral transitional
zone, which has been shown to be safe and
effective for reducing LUTS [20, 21]
(Fig. 33.1). For this reason, we may perform
two drastically different ablations in patients
with identical lesions but different priorities
and preferences.
408
J. F. Feller et al.
a
d
Fig. 33.1 61-year-old man with GG2 prostate cancer
presents with increasing PSA and worsening lower urinary tract symptoms (IPSS 20). Axial T2-weighted image
(a) demonstrates a hypointense lesion and axial ADC
image (b) demonstrates a lesion with restricted diffusion
in the left posterolateral midgland peripheral zone
(arrows). Axial oblique T2-weighted image from laser
focal therapy (c) shows the laser cannula within the lesion.
Axial oblique MR-thermometry (d) shows the heat
spreading from the active tip of the laser ber (arrow).
b
e
c
f
Axial T1-weighted image (e) acquired after administration of gadolinium demonstrates the ablation zone covering both the lesion and the transitional zone (arrows). The
PSA dropped from 1.9 to 0.2, and was 0.4 at our last
evaluation 4 years later. The patient’s lower urinary tract
symptoms signicantly improved with a reported IPSS of
5 at our last evaluation four years later. Erectile function
was not negatively affected. Axial T2-weighted image
from 4 years later (f) demonstrates post-ablation change
without evidence of recurrent disease
Technique
This section describes the materials and methods
with which MRI-guided transrectal LFT is performed at our institution. Patients taking 5-alphareductase inhibitors or androgen deprivation
therapy are instructed to discontinue use one
month prior to the procedure, as these can make
the prostate hard and difcult to penetrate. We
instruct our patients to be on a liquid diet starting
at noon the day before the procedure and eat nothing for six hours before the procedure. Patients
take saline enemas the night before and the morning of the procedure to fully evacuate the rectum.
We administer IV ceftriaxone the day prior to the
procedure, just before the procedure, and the day
after the procedure, and PO Bactrim for 10 days
starting the day before the procedure.
A three-way 16 French Foley catheter is inserted
prior to the procedure to allow for cooled urethral
saline protection (CUSP or CBI, continuous bladder irrigation) during ablations. Patients are positioned prone in the 3 T MRI scanner (Magnetom
Skyra, Siemens, Munich, Germany). Our partner
facility uses a 1.5 T scanner with high-performance
gradients and has excellent results. It is important
to use cushions, pillows, a foam headrest, and other
MRI-compatible positioning devices to avoid
patient motion or discomfort. Conscious sedation
with intravenous fentanyl and midazolam is administered. Continuous assessments with pulse oximetry, sphygmomanometry, and capnography are
used to titrate sedation. A betadine swab may be
used to clean the anterior surface of the rectum. A
transrectal needle guide is lubricated with 2% lidocaine jelly and inserted into the rectum (Fig.33.2a).
An InVivo DynaTRIM device (Invivo, Gainesville,
FL) is used to hold the transrectal needle guide in
place and make directional adjustments throughout
the procedure (Fig.33.2b, c).
33 Transrectal Laser Focal Therapy ofProstate Cancer
409
Fig. 33.2 Needle guide
(a) and DynaTRIM
device (b, c). The four
knobs on the DynaTRIM
device allow ne
adjustments in eight
directions
a
b
c
Fig. 33.3 DynaLOC software used for targeting
DynaLOC software is used to perform the initial targeting (Fig. 33.3). However, subsequent
needle placements are performed freehand. A
22-G needle is used to administer 1% lidocaine
for both local anesthesia within the prostate and
perform a periprostatic block. If necessary, lidocaine is also used to perform hydrodissection to
create space between the prostatic capsule and
410
J. F. Feller et al.
adjacent structures such as the rectum and cavernosal neurovascular bundles (Fig. 33.4). A 5.6
French plastic cooling cannula is guided into the
prostate under MRI guidance, and the laser ber
is inserted once cannula positioning is
conrmed.
Ablations are performed using a 980nm laser
(Visualase™ by Medtronic, Inc., a Minnesota,
U.S.A. company) with 15-W diode laser energy.
The system is on a consolidated mobile cart with
the laser, a computer, a dual monitor vertical display, and a water pump (Fig. 33.5). Real-time
biplane MR thermometry is performed to monitor the ablation zone. A peristaltic pump is used
to circulate room-temperature normal saline
through the Visualase cooling cannula during
ablations to avoid charring the tissue adjacent to
a
b
the applicator surface. Once the ablative heat
reaches the desired diameter, the laser ber is
retracted through the cannula in small, stepwise
increments (Fig. 33.6), creating a cylindrical
ablation zone. The laser is then turned off, and
the cooling cannula is repositioned to a different
part of the prostate. Overlapping ablations are
repeated until the tumor and a surrounding margin of tissue are adequately covered. For subcapsular lesions, the heat is extended to and slightly
through the adjacent capsule without pursuing
any larger margin in that direction. Axial and
sagittal postablation T1 scans with gadoterate
meglumine gadolinium contrast are performed
to assess the ablation zone. If necessary, one or
more additional ablations are then performed to
extend the margin. We use gadoterate meglu-
c
d
Fig. 33.4 64-year-old man with diffuse right-sided GG1
and right posterolateral apical GG2 prostate cancer. Axial
T2-weighted image (a) demonstrates the GG2 lesion in
the right posterolateral peripheral zone (red arrow) in
close proximity to the right neurovascular bundle (blue).
Sagittal T2-weighted image (b) demonstrates normal
apposition of the prostate to the rectum. Intraprocedural
sagittal oblique T2-weighted image (c) demonstrates the
laser cannula within the prostate after hydrodissection
was performed to protect the neurovascular bundle and
e
rectum. Note the separation between the prostate and rectum (arrow) measuring 7mm. Post-ablation post-contrast
T1-weighted axial image (d) demonstrates the ablation
zone covering the target lesion and the rest of the right
side of the prostate, immediately adjacent to the neurovascular bundle and rectum. Axial T2-weighted image (e) 6
months later demonstrates post-ablation change without
evidence of residual disease. The PSA dropped from 7.6
to a nadir of 0.76. The patient did not suffer rectal damage
and reported no adverse effects to his erectile function
33 Transrectal Laser Focal Therapy ofProstate Cancer
411
mine contrast because of its macrocyclic structure, excellent stability, and extremely low rate
of releasing free gadolinium.
Fig. 33.5 Visualase ablation system with two computer
screens allowing biplane monitoring
Periprocedure andFollow-up Care
Patients are observed in recovery for approximately 60 min before being released. We
exchange the three-way foley catheter used for
cooling the urethra for a dual-balloon Duette
catheter, which our patients report is more comfortable and may decrease the risk of urinary tract
infections. If hematuria is seen, we will place an
18-French catheter rather than a 14-French catheter to decrease the risk of a clot clogging the
catheter. The prescribed catheter dwell time
depends on the size of the ablation zone and can
range from one to 14 days.
The following day, we have the patient return
to the ofce. We ask for a relevant review of systems, take a set of vital signs, present the ablation
images to the patient, review activity instructions,
review the follow-up schedule, and answer any
questions. Suppose the ablation zone is adjacent
to one or both neurovascular bundles. In that
case, we give the patient a two-month supply of
tadalal 5mg to be taken daily to promote blood
ow and healing in case of thermal injury to the
nerves.
Specic follow-up protocols vary by practice.
At our institution, we check PSAs every 6
months indenitely. mpMRI is also a very
important part of post-ablation follow-up, and
we request them at 6 months, 12 months, and
yearly after that. In our experience, it is normal
to see the postablation PSA either oscillate
slightly in a tight range or slowly increase over
Fig. 33.6 Visualase 5.6
French cannula with
980nm laser ber. The
indicator light (arrows)
demonstrates the
location of the active tip
which emits the laser
energy. During the
ablation, the laser ber
is retracted through the
cannula in small,
stepwise increments,
creating a cylindrical
ablation zone