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Benign Prostatic Hyperplasia and Prostate Cancer Laser Ablation

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Image-guided Laser Ablation

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Abstract

Treatment of symptoms of the lower urinary tract due to benign prostatic obstruction (LUTS/BPH) in men with transperineal laser ablation (TPLA) may offer advantages in terms of functional outcome and safety compared to current standard therapies. Because the technique is relatively new, the indications and outcomes for this treatment are being investigated. However, it is already applied outside of clinical trials. The results of the feasibility study are excellent in terms of both clinical and safety improvements. No significant procedural, periprocedural, and distant complications have been reported so far. In particular, severe complications such as incontinence, erectile dysfunction, retrograde ejaculation, and urethral stenosis have not yet been reported. It is necessary to acquire clinical information from these treatments to plan future research.

Prostate cancer (PCa) is the second cause of cancer-related deaths for men. The standard surgical treatment is radical prostatectomy. Possible side effects of this treatment are incontinence and erectile dysfunction. These side effects are especially undesired in patients with only a small focus of PCa. A focal treatment without these side effects is desirable and must be researched. Focal laser ablation (FLA) is an investigated technique for local treatment. So far the single fiber setup of most systems requires fiber replacement. This leads to longer treatment duration and thus higher costs. The EchoLaser system is a laser ablation system with four laser sources. This provides a larger treatment area, without the need for fiber replacement. This makes the system ideal for FLA of prostate cancer, especially since it can be applied under local anesthesia.

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Author information

Authors and Affiliations

  1. Department of Diagnostic Imaging and Interventional Radiology, Regina Apostolorum Hospital, Albano Laziale, Rome, Italy

    Claudio Maurizio Pacella

  2. Division of Interventional Radiology, European Institute of Oncology, IRCCS, Milan, Italy

    Giovanni Mauri

  3. Department of Diagnostic Imaging and Interventional Radiology, Tor Vergata University, Rome, Italy

    Guglielmo Manenti & Tommaso Perretta

  4. Department of Diagnostic and Interventional Radiology, Pesenti-Fenaroli Hospital-ASST Bergamoest, Alzano Lombardo, Italy

    Gianluigi Patelli

Authors
  1. Claudio Maurizio Pacella
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  2. Giovanni Mauri
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  3. Guglielmo Manenti
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  4. Tommaso Perretta
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  5. Gianluigi Patelli
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Editor information

Editors and Affiliations

  1. Department of Interventional Radiology, Ospedale Regina Apostolorum, Albano Laziale, Rome, Italy

    Claudio Maurizio Pacella

  2. Department of Ultrasound, Zhejiang University, Hangzhou, China

    Tian'an Jiang

  3. Division of Interventional Radiology, European Institute of Oncology, IRCCS, Milan, Italy

    Giovanni Mauri

Appendix: Pre- and Postoperative Imaging Diagnostic Techniques

Appendix: Pre- and Postoperative Imaging Diagnostic Techniques

13.1.1 Multiparametric Magnetic Resonance Imaging for Prostate Cancer

Magnetic resonance imaging (MRI) is a scanning method that makes use of a strong magnetic field, radio waves, and dedicated computer software to show detailed images of organs and tissues in the body. The employment of different pulse sequences, or parameters, during the MRI examination helps in highlighting specific differences between healthy and unhealthy tissue. When two or more parameters are used, it goes under the name of multiparametric MRI (mpMRI).

Prostate multiparametric MRI documents gland anatomy and any pathologic process within and around it. Four parameters are routinely used in prostate cancer detection, each highlighting different tissue features. T2-weighted sequence (T2 MRI) yields a multiplanar (3D) map of prostate zone anatomy; a suspicious-looking area is referred to as a region of interest (ROI). Diffusion-weighted imaging (DWI MRI) shows movement of water molecules within a given tissue; cancer cells restrict the motion more than normal cells do, which shows up in DWI MRI.

Dynamic contrast-enhanced imaging (DCE MRI) reveals pathologic blood flow. Prostate cancer develops its own blood vessels, which look abnormal. When injected, the contrast agent is quickly taken up by those aberrant vessels, then washes out, and is later excreted in urine. As well, the pace of the uptake/washout yields additional information about the nature of the neoplasm.

Spectroscopy (MRI-S) may be added as a fourth parameter. When prostate cancer is present, its survival is maintained through certain chemical processes (metabolism) that are distinct from normal cell metabolism. MRI-S gives metabolic information useful in confirming prostate cancer [87, 88].

Multiparametric MRI of the prostate is the imaging of choice for men with rising or abnormally high PSA, a previous negative biopsy with recent increase in prostate-specific antigen (PSA) levels, or the presence of additional findings warranting its use in non-biopsied patients. This exam is also used as active surveillance in patients with proven cancer that do not require therapy at the time.

Prostate mpMRI can rule in or out a biopsy in people already treated for cancer, as mpMRI can confirm therapy success and monitor for disease recurrence outside the treatment area. Malignancy risk assessment of a prostatic lesion detected with magnetic resonance imaging is made using an image-based risk reporting system called Prostate Imaging Reporting and Data System (PI-RADS™v.2) (American college of radiology. MR prostate imaging reporting and data system version 2.0 [internet] Available from: Http://www.Acr.Org/quality-safety/resources/pirads/ [cited 2015 jun 16]). PIRADS v.2 allows for data obtained from the aforementioned MRI parameters to be collected jointly in a unique score; after all imaging sequences are evaluated and a score is given for each, those are combined resulting in a final outcome between 1 and 5 for the suspected lesion.

13.1.2 Prostate Biopsy Techniques

Currently, there are three different MRI-guided biopsy techniques available: MRI-ultrasound fusion, MRI-MRI fusion (“in-bore” biopsy), and cognitive fusion.

The MRI-US fusion biopsy enables the operator to merge the images obtained from the prostatic mpMRI where the index lesion was identified, performed beforehand, and then stored on the device, with real-time US imaging by means of a special 3D software. As the US probe is advanced via a transrectal approach, the fusion software shifts the MRI image accordingly, guiding needle positioning; this allows for better visualization of the lesion and higher procedural accuracy, as many trials have shown [89, 90]. Additionally, needle location in the 3D space can be tracked and recorded for future reference. As a new application of the technique, the MRI-US fusion may gain interest as a guidance tool for selective focal ablation of prostate cancer.

In MRI-MRI fusion (“in-bore” biopsy) the procedure is performed directly in the MRI suite as real-time imaging is obtained during biopsy execution.

The cognitive fusion is an easy-to-use technique simply based on the review, by the biopsy operator, of a previously acquired MRI to help guiding needle positioning under TRUS guidance.

Overall, high-resolution mpMRI of the prostate safely provides all the information needed in order to take the best next step decision in the setting of a neoplastic lesion. Furthermore, it is used to guide precision focal treatments such as focal laser ablation [91].

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Pacella, C.M., Mauri, G., Manenti, G., Perretta, T., Patelli, G. (2020). Benign Prostatic Hyperplasia and Prostate Cancer Laser Ablation. In: Pacella, C., Jiang, T., Mauri, G. (eds) Image-guided Laser Ablation. Springer, Cham. https://doi.org/10.1007/978-3-030-21748-8_13

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