HOW I DO IT

• Urethral bulking with native tissue during artificial urinary sphincter surgery          

  Rabinowitz J. Matthew, Liu L. James, Levy A. Jason, DuComb William, Burnett L. Arthur The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA  

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  The artificial urinary sphincter (AUS) is the “gold standard” surgical treatment for severe stress urinary incontinence.  However, a subset of patients with frail urethras may require technical adjuncts to ensure optimal cuff function.  Our objective is to provide a detailed tutorial of our institution’s method for performing urethral bulking with native tissue in patients with frail urethras during AUS surgery. We have found that urethral bulking with native tissue provides a cost-efficient and durable technique for improved AUS cuff coaptation.  Our experience demonstrates adequate short and intermediate term efficacy with limited complications.  These techniques equip surgeons with an alternative surgical approach for appropriate patients receiving AUS surgery who have been previously exposed to pelvic radiation and/or significant surgical morbidity resulting in frail urethral tissue.

  Keywords: prostate cancer, artificial urinary sphincter, urinary stress incontinence, urethral disease,

  Apr 2023 (Vol. 30, Issue 2 , Page 11516)
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• How I Do It: Transperineal prostate biopsy using local anesthetic in an outpatient setting

  Ordones Vasconcelos Flávio, Vermeulen Lodewikus, Bressington Morgan, Menon Abilash, Burns Timothy, Muller Loretta, Fraundorfer Mark, Gilling J. Peter Urology Department, Tauranga Public Hospital, Tauranga, Bay of Plenty, New Zealand // Division of Urology, São Paulo State University, UNESP, Botucatu, São Paulo, Brazil // Honorary Senior Lecturer, University of Auckland, Auckland, New Zealand

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  Transperineal prostate biopsy (TPPB) is proven to be an effective diagnostic tool for prostate cancer detection. It allows satisfactory sampling of apical and anterior areas which is not well achieved with the transrectal route, without the associated risks of urinary tract infection or sepsis. The main objective of this paper is to describe the technique utilized in our institution to perform transperineal prostate biopsy under local anesthetic in the outpatient clinic setting.

  Keywords: prostate cancer, transperineal, prostate biopsy, local anesthetic,

  Feb 2023 (Vol. 30, Issue 1 , Page 11453)
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• Using darolutamide in advanced prostate cancer: How I Do It

  Hamilton Joelle, MD Urology Centers of Alabama, Homewood, Alabama, USA

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  Darolutamide is a nonsteroidal androgen inhibitor FDA approved for the treatment of castration-resistant non-metastatic prostate cancer (nmCRPC). After decades of offering androgen deprivation therapy (ADT) alone or first-generation androgen receptor blockers for patients whose PSA was rising despite castrate levels of testosterone, there are now three different treatment options to add to ADT. These include apalutamide approved in February 2018, enzalutamide FDA approved in June 2018, and darolutamide approved July 2019. Each of these androgen receptor pathway blockers, when added to ADT or surgical orchiectomy, prolongs metastasis-free-survival (MFS) and median survival (MS). This paper focuses on the use of the newest approved agent in this class, darololutmide.

  Keywords: prostate cancer, castrate-resistant, non-metastatic disease, antiandrogen, darolutamide,

  Jun 2021 (Vol. 28, Issue 3 , Page 10673)
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• How I Do It -MRI-ultrasound fusion prostate biopsy using the Fusion MR and Fusion Bx systems

  Perlis Nathan, Lawendy Bishoy, Barkin Jack, MD University of Toronto, Department of Surgery, Toronto, Ontario, Canada

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  There is increasing evidence to support the use of multiparametric magnetic resonance imaging (MRI) in men at risk for clinically significant prostate cancer to help identify lesions and inform biopsy. Randomized, level 1 evidence demonstrates that men who are managed with MRI and MRI-ultrasound fusion targeted biopsy (MRF-TB) have more clinically significant prostate cancer and less clinically insignificant prostate cancer detected and avoid biopsy altogether more often than men who undergo systematic, whole-gland prostate biopsy (SPB). Furthermore, strategies that incorporate MRF-TB have lower rates of upgrading on radical prostatectomy compared to SPB. However, generalizing this data to wider practice is challenging because there is a learning curve for interpreting MRI and performing MRF-TB, and some of the fusion technologies are better than others. We describe our group's early experience with the Fusion MR and Fusion Bx systems (Focal Healthcare, Toronto, ON, Canada). These products are designed with elastic fusion technology that is user-friendly, intuitive and accurate. The Fusion MR contouring system is straightforward and allows for contouring with several MRI sequences simultaneously. The Fusion Bx biopsy system has a semi-robotic arm that accounts for prostate deformation and patient movement and allows for freehand-like access, which is a seamless transition from SPB for clinicians. There were 68 lesions targeted in the first 51 patients. The overall cancer detection rate was 22%/61%/83% for PI-RADS 3/4/5, respectively. The Gleason grade group 2 prostate cancer or higher rate was 6%/47%/75% for PI-RADS 3/4/5, respectively. There were no major complications in this cohort of patients. Limitations of this study include small number of patients and lack of formal follow up to rule out sepsis. Overall, the Fusion MR and Fusion Bx systems are accurate, straightforward and safe to use for MRF-TB. Early experience does not show any significant learning curve.

  Keywords: prostate cancer, multiparametric magnetic resonance imaging, systematic prostate biopsy, MRI-ultrasound fusion-targeted biopsy, Gleason grade group,

  Apr 2020 (Vol. 27, Issue 2 , Page 10185)
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• How I do it: Apalutamide use in non-metastatic castrate resistant prostate cancer

  Moul W. Judd, MD Division of Urology, Department of Surgery and Duke Cancer Institute, Durham, North Carolina, USA

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  Urologists have been using oral nonsteroidal antiandrogens (AA) for 30 years as a component of combined androgen blockade. In February 2018, a new third generation AA, apalutamide, became available for the first time for non-metastatic (M0) castrate resistant prostate cancer (CRPC). Apalutamide was found to delay the presence of metastases (metastases free survival-MFS) by approximately 2 years versus placebo in M0 CRPC. While overall survival benefit has yet to be established, the MFS benefit is clinically meaningful and urology practices should be equipped to manage patients using this new oral agent. Since the majority of patients remain under urologic care when this disease stage develops and because the drug is straightforward to administer, urology practices are ideal to identify and treat. The objective of this brief article is to discuss the typical patient profile for use of apalutamide and to review the pros and cons of use and common side effects and management.

  Keywords: prostate cancer, apalutamide, castrate-resistant, non-metastatic disease, antiandrogen,

  Jun 2019 (Vol. 26, Issue 3 , Page 9782)
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