Clinical Study Urodynamic Evaluation after High-Intensity ...downloads.hindawi.com/journals/pc/2014/462153.pdf · Urodynamic Evaluation after High-Intensity Focused Ultrasound for

Clinical StudyUrodynamic Evaluation after High-Intensity Focused Ultrasoundfor Patients with Prostate Cancer

Luigi Mearini Elisabetta Nunzi Silvia Giovannozzi Luca LepriCarolina Lolli and Antonella Giannantoni

Department of Urology and Andrology University of Perugia SantrsquoAndrea delle Fratte 06100 Perugia Italy

Correspondence should be addressed to Luigi Mearini luigimearinitinit

Received 22 January 2014 Revised 10 April 2014 Accepted 24 April 2014 Published 15 May 2014

Academic Editor Katsuto Shinohara

Copyright copy 2014 Luigi Mearini et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

This prospective study assesses the impact of high-intensity focused ultrasound (HIFU) on lower urinary tract by comparingpre- and postoperative symptoms and urodynamic changes Thirty consecutive patients with clinically organ-confined prostatecancer underwent urodynamic study before HIFU and then at 3ndash6 months after surgery Continence status and symptoms wereanalyzed by means of International Prostate Symptoms Score IPSS and International Index Erectile Function IIEF5 As a resultthere were a significant improvement in bladder outlet maximum flow at uroflowmetry and reduction in postvoid residual PVRat 6-month follow-up and a concomitant significant reduction of detrusor pressure at opening and at maximum flow De novooveractive bladder and impaired bladder compliance were detected in 10 of patients at 3 months with progressive improvementat longer follow-up Baseline prostate volume and length of the procedure were predictors of 6-month IPSS score and continencestatus In conclusion followingHIFUdetrusor overactivity decreased bladder compliance and urge incontinence represent de novodysfunction due to prostate and bladder neck injury during surgery However urodynamic study shows a progressive improvementin all storage and voiding patterns at 6-month follow-up Patients with high prostate volume and long procedure length sufferedfrom irritative symptoms even at long term

1 Introduction

The European Association of Urology and the AmericanUrological Association recommend radical prostatectomy(RP) or external-beam radiotherapy (EBRT) as the standardtreatment options for patients with localized prostate cancer[1]

Despite the recent developments in surgical techniqueswith the introduction of robot-assisted RP [2] and newradiotherapy devices [3] urinary incontinence and erectiledysfunction continue to be the most devastating complica-tions following radical treatment Active surveillance sparescontinence and potency in cases of low-risk prostate cancerhowever some patients have radical treatments as a result ofdisease progression or psychological distress [4]Thus amin-imally invasive (albeit investigational) therapy such as high-intensity focused ultrasound (HIFU) offers the possibility ofa cure with reduced side effects for selected patients

InHIFU ultrasound beams emitted from a high-poweredtransducer target a precise tissue volume sparing the sur-rounding tissue Because HIFU is a minimally invasiveprocedure and comparable to a curative therapy we expectedto find a high curative efficacy and low incidence of incon-tinence and impotence as well as small effects on the lowerurinary tract (LUT)

Perioperative and long-term side effects following HIFUhave been extensively described the most common includeurinary retention urinary tract infections incontinence anderectile dysfunction

In particular the rates of urinary retention ranged fromlt1 to 20 [5] Acute urinary retention is an expected effectof thermal injury edema and swelling of the prostate [6]with the prostate volume increasing up to 30 from baselineA transurethral resection of prostate (TURP) prior to HIFUand the insertion of a catheter or suprapubic tube are thesimplest ways to prevent or to treat acute urinary retention[7]

Hindawi Publishing CorporationProstate CancerVolume 2014 Article ID 462153 7 pageshttpdxdoiorg1011552014462153

2 Prostate Cancer

Sloughing the elimination of necrotic tissue is anotherLUT problem During sloughing patients complain ofdysuria with urgency as well as irritative or obstructivesymptoms or both A preoperative TURP or symptomatictreatment using drugs is usually sufficient

Another frequent complication is bladder outlet obstruc-tion (BOO) as a result of bladder neck urethral or both typesof stenosis BOO occurs in 36 to 245 of all cases [8]and this complication is usually managed by dilation Onlya few cases require surgical procedures such as transurethralincision or TURP

To date no study has analyzed LUT function usingurodynamics before and after primaryHIFU to treat localizedprostate cancer

Moreover the common occurrence of side effects in theLUT is correlated with different ablative technologies anddifferent prostate gland approaches

The current prospective study investigated the clinicaland urodynamic patterns of patients treated with HIFU

2 Materials and Methods

21 Demographics Thirty consecutive patients with clinicallylocalized prostate cancer (cT1c-cT2c) undergoingHIFUwereprospectively enrolled in this study which was conductedin accordance with the Declaration of Helsinki (1964) andapproved by internal review board

The inclusion criteria for HIFU were a histological diag-nosis of prostate cancer a PSA lt 15 ngmL and stage T1c-T2N0M0 (N and M statuses were assessed using a CT scan andbone scintigraphy)

The exclusion criteria were a prostate volume greaterthan 50 cc (two treatments scheduled) the presence of amedian lobe intraprostatic calcification of more than 1 cmor concomitant anal stricture

No patients underwent TURP prior to HIFU or receivedneoadjuvant hormone therapy

All patients were informed of the scientific nature of theinvestigation and they provided written informed consent

22 Surgical Technique The HIFU technique adhered to theprotocol described by Illing et al [9 10] in a previous paper[11]

This study used the Sonablate 500 (Focus Surgery Indi-anapolis IN USA) HIFU device

The HIFU probe has two focal lengths with a focuslength at 40 cm and 30 cm which limited the treatable glandvolume

HIFUwas performedwithout a preoperative TURP for allincluded cases At the end of the procedure a percutaneouscystostomy was inserted into patients to reduce the incidenceof postoperative stenosis [12]

Follow-up assessments were scheduled at 1 3 and 6months and then every 6 months afterwards These eval-uations included an accurate objective examination usingdigital rectal examination (DRE) a transrectal ultrasoundscan (TRUS) at 3 and 6 months and urodynamics

PSA levels were tested at 1 3 and 6months and then every6 months afterwards A prostate biopsy was performed at 6months to obtain at least 8 samples depending on residualprostate volume

23 Clinical and Urodynamic Evaluations Clinical and uro-dynamic evaluations were performed 3ndash7 days before surgery(ie the baseline evaluation) and at 3ndash6months after surgery

A 1-month follow-up assessment was used to evaluate anyLUT dysfunctions

The clinical evaluation consisted of the patientrsquos medicalhistory a physical examination and the administration ofthe International Prostate Symptoms Score (IPSS) and theInternational Index of Erectile Function (IIEF-5)

A score of ge7 on the IPSS indicates moderate-to-severesymptoms whereas a score of le16 on the IIEF5 indicatesmoderate-to-severe erectile dysfunction

To assess continence status we recorded the number ofdaily pads (0-1 versusgt1) and daily episodes of urgency aswellas episodes of urgency and stress incontinence in a voidingdiary

Uroflowmetry with the detection of maximum flow(119876max) and postvoid residual (PVR) volume was scheduledfor all participants the urodynamic evaluation was per-formed in patients without urinary tract infections via urineculture

The urodynamic assessment was performed accordingto International Continence Society Standards [13] whichinvolved water cystometry with 37∘C normal saline solutionat a filling rate of 50mLmin This is a medium filling usedin clinical practice and in experimental studies reserving alower filling rate for neurogenic disorder A 6F double-lumenNelaton transurethral catheter was used for infusion andrecording intravesical pressure and a 16-channel intrarectalballoon catheter was used to record abdominal pressure

Cystometry detrusor overactivity (DO) and bladdercompliance (BC) defined as normal (gt20mLcmH

2O)

impaired (10ndash20mLcmH2O) or poor (lt10mLcmH

2O)

were recorded119876max detrusor pressure at opening (119875detOpen) detru-

sor pressure at maximum flow (119875det119876max) and PVR wererecorded

BOOand detrusor contractility were assessed on pressureflow studies using Schaferrsquos nomogram Grades 0-1 bladderoutlet conditions were considered unobstructed Grade 2is an equivocal score and Grades 3ndash6 were consideredobstructedThe nomogram was also used to classify detrusorstrength as normal weak or very weak Voiding by strainingor detrusor contraction was also recorded

At the end of the study we measured the Valsalva leakpoint pressure (VLPP) Specifically after filling the bladderto 150ndash200mL the catheter was removed and the Valsalvamanoeuvers were repeated to measure abdominal pressureThe VLPP is defined as the lowest abdominal pressure thatinduces visible stress incontinence and it assesses intrinsicsphincter deficiency (ISD)

Prostate Cancer 3

24 Data Analyses Data analyses were performed using testsfor repeated nonparametric data (ie the Friedman andCochran 119876 tests) The Bonferroni correction was appliedto the Wilcoxon and McNamara tests for multiple post hoccomparisons The 1205942 test was applied for trend data

Correlations among variables were tested using Spear-manrsquos rho correlation coefficient

Multivariate logistic regression models that incorporatedthe baseline parameters were fit to predict outcomes Thegoodness of fit of these models (ie internal calibration) waschecked using theHosmer-Lemeshow test Odds ratios (ORs)with 95 confidence intervals were also calculated

Data are reported as the mean plusmn standard deviation Thelevel of significance was set at 119875 lt 005 All data analyseswere performed using SPSS version 1011 forWindows (SPSSChicago IL USA)

3 Results

31 Demographics The mean age of the patients was 736 plusmn31 yrs (median = 740 yrs range = 67ndash79 yrs) the mean PSAvalue was 63plusmn 30 ngmL (median = 64 ngmL range = 24ndash143 ngmL)

The mean prostate volume at baseline was 402 plusmn 156mL(median = 385mL range = 160ndash520mL)

Eleven participants (366) were classified as clinicalstage T1c and the remaining participants were categorized asT2 A total of 21 participants had Gleason scores of le6 (70)whereas 9 patients had scores of ge7

The mean treatment length was 11371015840plusmn 3881015840 (median= 10651015840 range = 491015840ndash2401015840) the mean time to spontaneousvoiding was 132 plusmn 15 days (median = 128 days range = 12ndash16 days)

The mean PSA nadir was 023 plusmn 055 ngmL (median =003 ngmL range = 000ndash266 ngmL) which was reached ina median of 21 months (range = 1ndash3 months) At 6 monthsthe mean PSA was 047 plusmn 086 ngmL (median = 018 ngmLrange = 000ndash450 ngmL) The 6-month positive prostatebiopsy rate was 166 after one treatment

32 Urinary Symptoms and Baseline Questionnaires Table 1presents the survey and continence status data

The mean IPSS was 92 plusmn 59 (median = 95 range = 0ndash20) Seventeen patients (566) showed moderate-to-severelower urinary tract symptoms

Twelve patients (40) complained of preoperative abnor-mal sexual function with a mean IIEF-5 score of 6 plusmn 77However only 584 of these patients showed an IIEF-5 scorele16

Six patients complained of urgency and urge inconti-nence but none used pads or collecting devices

33 Urodynamic Measures at Baseline The mean 119876max was138plusmn53mLs (median = 130mLs range = 5ndash23mLs) andthe mean PVR was 318 plusmn 653mL (median = 0mL range =0ndash210mL)

Table 2 and Figure 1(a) show the urodynamic andSchaferrsquos nomogram results respectively

DOwas detected in 16 patients (534) impaired or poorBC was detected in 9 patients (30) and impaired detrusorcontractility was detected in 13 patients (434) BOO wasfound in 7 patients (234)

The mean 119875detOpen was 410 plusmn 289 cmH2O (median =

285 cmH2O range = 16ndash136 cmH

2O) and themean119875det119876max

was 407 plusmn 243 cmH2O (median = 325 cmH

2O range = 6ndash

110 cmH2O) which corresponds to a mean 119876max of 139 plusmn

44mLs (median = 130mLs range = 5ndash22mLs) and amean PVR of 337 plusmn 712mL (median = 304mL range = 0ndash190mL)

Schaferrsquos nomogram in Figure 1(a) shows impaired detru-sor contractility with BOO in 2 patients (66) and BOOplusstrong detrusor contractility in 3 patients (10)

The VLPP was positive in only one patient at an abdomi-nal pressure of 65 cmH

2O

34 Three- and Six-Month Follow-Up Evaluations

341 Urinary Symptoms and Questionnaires Table 1 showsthe questionnaires and continence status follow-up data

The mean IPSS was 92 plusmn 59 and 85 plusmn 45 at 3 and 6months respectively and no difference emerged comparedwith baseline (119875 = 0576) Likewise no differences emergedat 3 or 6 months among patients with mild-to-moderate LUTsymptoms

Of the patients who reported preoperative normal sexualfunction 10 (833) continued to report that they had noproblems at the follow-up assessment However according totheir IIEF-5 scores 70 of these patients showed impairedsexual functionThe differences at follow-up were not signif-icant (119875 = 0432)

No patients showed a de novo stress incontinence statuswhereas 267 and 167 of patients suffered from urgeincontinence at 3 and 6 months respectively (119875 = 0341)A significant increase in de novo urge incontinence wasobserved at 3 months compared with baseline (119875 = 004)

35 Urodynamic Study The free uroflowmetry showedmean119876max scores of 150 plusmn 67mLs (median = 140mLs range =11ndash19mLs) and 169 plusmn 68mLs (median = 158mLs range= 11ndash23mLs) at 3 and 6 months respectively (119875 = 004) themean PVR was 305 plusmn 543mL (median = 0mL range = 0ndash180mL) and 211 plusmn 334mL (median = 100mL range = 0ndash40mL) at 3 and 6 months respectively (119875 = 006)

Three patients required urethral dilation at an earlypostoperative follow-up

Table 2 and Figures 1(b)ndash1(c) show the urodynamic andSchaferrsquos nomogram results at follow-up respectively

De novo DO was detected in 3 patients (10) at the 3-month follow-up evaluation A slight deterioration of BCwasobserved at 3 months At the 6-month follow-up assessmentonly 264 of patients showed an impaired BC The meanmaximum bladder capacity remained unchanged

Detrusor contractility showed progressive (although notsignificant) improvement over time

BOO was found in 3 patients (10) at 3 months and1 patient (34) at 6 months (119875 = 004) These scores

4 Prostate Cancer

Table 1 Subjective data relative to International Prostate Symptoms Score IPSS International Index Erectile Function 5 IIEF continencestatus and urgency

Baseline 3 months 6 months119875

Number of pts Mean Number of pts Mean Number of pts MeanIPSS

30 100 92 30 100 92 30 100 85 0576Normal 13 434 13 434 17 566Mild-moderate 17 566 17 566 13 434

IIEFPotent 12 10 10 0432Normal 5 416 3 300 3 30Poor 7 584 7 700 7 70

ContinenceComplete 24 80 22 733 25 833 0341Urge 6 20 8 267lowast 5 167Stress 0 0 0 0 0 0

Urgency 20 666 24 80lowast 17 566lowast 004lowastlowast

119875 lt 005

Table 2 Data relative to urodynamic studies Main patterns of storage and voiding phases

Baseline 3 months 6 months119875

Number of pts Mean Number of pts Mean Number of pts MeanDetrusor

Normal 14 466 11 367 14 466 0184Overactive 16 534 19 633 16 534

Bladder compliance (mLcmH2O)Normal 21 700 18 600 22 733Impaired 8 266 12 400 7 233 0876Poor 1 34 0 0 1 34

Voiding desire (mL)First 30 996 30 942 30 981 0837Strong 30 2552 30 2551 30 2509 0955

Max capacity (mL) 30 3281 30 3111 30 3232 0389Bladder outlet

Normal 23 766 27 90 29 966lowast 004lowast

Obstructed 7 234 3 10 1 34lowast

119875detOpen (cmH2O) 30 410 30 303lowast 30 302lowast 001lowast

119875det119876max(cmH2O) 30 407 30 331lowast 30 388lowast 001lowast

Detrusor contractilityNormal 17 566 23 767 23 767 0174Weak 10 334 7 233 7 233Strong 3 10 0 0 0 0

VoidingWithout straining 15 50 17 566 16 534 0189With straining 15 50 13 434 14 466

Volume at uroflowmetry 30 2925 30 1690lowast 30 2470 003lowast

Qmax (mLs) 30 139 164lowast 169lowast 002lowast

PVR (mL) 30 318 140 100lowast 005lowast

VLPP (cmH2O) 0 1 37 0lowast

119875 lt 005

Prostate Cancer 5

30Flow

0

0

N+

Nminus

W+

Wminus

VW

0 I II III ST

IV

V

VI

150

Pdet

(a)

30

Flow

00 150

N+

Nminus

W+

Wminus

VW

0 I II III ST

IV

V

VI

Pdet

(b)

30

Flow

0

0 150

N+

Nminus

W+

Wminus

VW

0 I II III ST

IV

V

VI

Pdet

(c)

Figure 1 (a) Detrusor pressure at maximumdetrusor pressure (119875detmax) andmaximumflow rate (119876max) as assessed by the Schafer nomogrambefore HIFU (b) Detrusor pressure at maximum detrusor pressure (119875detmax) and maximum flow rate (119876max) as assessed by the Schafernomogram 3 months after HIFU (c) Detrusor pressure at maximum detrusor pressure (119875detmax) and maximum flow rate (119876max) as assessedby the Schafer nomogram 6 months after HIFU

corresponded to mean 119875detOpen scores of 303 cmH2O and

302 cmH2O and mean 119875det119876max scores of 331 cmH

2O and

388 cmH2O at 3 and 6 months respectively (119875s = 001)

Mean 119876max progressively increased from 3 to 6 months(119875 = 002)

Schaferrsquos nomograms (Figures 1(b)ndash1(c)) associated withthe 3- and 6-month follow-up assessments revealed that nopatients had impaired detrusor contractility associated withBOO or BOO associated with strong detrusor contractility

The VLPP was positive for two patients (abdominalpressures of 37 and 65 cmH

2O) at 3 months and one patient

(abdominal pressure = 73 cmH2O) at 6 months

The 6-month IPSS score was positively correlated with119875detOpen (rho = 0361 119875 = 005) but negatively correlated with119876max (rho = minus0657 119875 lt 001)

The multivariate analysis revealed that only prostatevolume (119875 = 002) and procedural length (119875 = 004)predicted the 6-month IPSS score

The 6-month IIEF-5 score was positively correlated withthe baseline IIEF-5 score (rho = 0569 119875 lt 001) but nega-tively correlated with age (rho = minus0457 119875 = 001) howeverno correlations were found with regard to prostate volume

and procedural length A multivariate analysis revealed thatonly the baseline IIEF-5 score significantly predicted the 6-month IIEF-5 score (119875 = 001)

Six-month continence status was positively correlatedwith a strong voiding desire (rho = 0382 119875 = 003) andurgency (rho = 0373 119875 = 004) at urodynamic evaluationA multivariate analysis revealed that prostate volume (119875 =004) and procedural length (119875 = 002) predicted urgeincontinence119875detOpen was positively correlated with 119875det119876max (rho =

0789 119875 lt 001) and obstructed voiding (rho = 0384119875 = 003) but negatively correlated with 119876max (rho = minus0535119875 lt 001) however no correlations were found with regardto age prostate volume or procedural length 119875det119876max wasnegatively correlated with 119876max (rho = minus0455 119875 = 001) butnot with other variables

4 Discussion

To our knowledge present study is the first reporting theresults of a prospective investigation on urinary symptoms

6 Prostate Cancer

and urodynamic findings among patients with prostate can-cer treated using HIFU Our results demonstrate that thisprocedure is safe with regard to LUT function

HIFU has been investigated since 1987 with regard to theprostate gland In 1993 Madersbacher et al [14] presentedthe results of a Phase II study on the safety and efficacyof tissue ablation using HIFU among 36 patients withsymptomatically benign prostatic hyperplasia (BPH) Theseauthors demonstrated that HIFU reduced urinary symptomsand increased urinary flow Later the same group studied the3- to 6-month urodynamic changes induced by HIFU amongpatients with BPH The use of HIFU for BPH relieving wasan interesting technique but characterized by the treatment ofvarious amounts of prostatic tissue surrounding the urethraIn case of prostate cancer and in whole-gland therapyurodynamic impact upon lower urinary tract is variablyreported Moreover the functional outcomes after HIFU areinfluenced by the use of different devices different surgicalapproaches and follow-ups

Many centers perform a TURP immediately prior toHIFU a few weeks before HIFU or immediately afterHIFU [15] These approaches reduce the risk of prolongedurinary retention [16] and permit the treatment of high-volume prostates [17ndash19] Although helpful the addition ofTURP partially reduces the mini-invasivity of the proceduremoreover TURP requires an adjunctive anaesthesia

Interestingly other experiences emphasize the fact thatthe rates of long-term BOO and urethral stenosis do notdecrease when TURP is conducted in conjunction withHIFU For example Ganzer et al [20] showed that theincidence of postoperative BOO was 283 furthermore169 of patients reported stress incontinence that requiredsurgery for 07 of all patients Other studies showed that theincidence of postoperative BOO was similar after comparingHIFU alone with HIFU + TURP before (219 versus 179resp) and after HIFU + contemporary TURP (343) [21]

The primary advantages of HIFU alone are reducinginvasivity and costs furthermore HIFU alonemight alleviateLUT symptoms The major disadvantages of HIFU alone arethe impossibility of treating high-volume prostate glandsmoreover a higher incidence of early postoperative LUTsymptoms is observed

Neoadjuvant antiandrogen therapy is a valid alternativeto TURP to reduce prostate volume [12 19] Evaluating theefficacy of this approach is beyond the scope of current studybut it is a valid alternative when prostate volume limits theuse of HIFU

HIFU affects LUT in the early postoperative period Ourstudy confirmed that a high proportion of patients (267)presented urgency and urge incontinence however thesesymptoms were also observed in 20 of patients beforesurgery suggesting that they can be attributed to surgicaldamage to the bladder neck and prostatic urethra in a smallpercentage of patients The presence of urine edema anddebris in the proximal urethra activates afferent circuits fromthe prostate to the bladder inducing involuntary detrusorcontractions [22] At 6-month follow-up assessment whensloughing and edemawere resolved these symptoms reducedin most patients The urodynamic study of storage phase

showed a correspondence with increased DO and impairedBC at 3 months showing improvement at 6-month follow-up

Not all HIFU candidates presented preoperative LUTsymptoms suggestive of BOO According to the IPSS only566 of our patients had mild-to-moderate symptoms The119876max at free uroflowmetry was gt15mLs in 40 of patientsThe pressureflow study showed that 766 of patients hadnormal bladder outlet

Based on the pressureflow study and Schaferrsquos nomo-gram (Figures 1(b)ndash1(c)) most patients with preopera-tive BOO will have unobstructed flows The 119875detOpen and119875det119876max significantly decreased at follow-up correspond-ing to increased 119876max and reduced PVR However despitethe improvements in pressure and flow the 6-month IPSSrevealed that a discrete proportion of patients continuedto suffer from mild-to-moderate symptoms mostly relatedto irritation Based on the multivariate analysis showingthat prostate volume and procedure length predicted the6-month IPSS we hypothesize that patients with high-volume prostates require more time to relieve edema anddebris passage and resolution of irritative and obstructivesymptoms Note that three patients with high IPSSs requiredurethral dilation This finding matches that of other studiesdemonstrating that high power and the overlap of treatedareas (eg for high-volume prostates) produce higher ratesof postoperative complications [23]

All typesdegrees of urinary incontinence have beenreported in 1ndash343 of patients following HIFU [5] It isunclear whether an association exists among stress inconti-nence HIFU and TURP however previous experience hasshown that the rate of urinary incontinence is significantlylower among patients receiving TURP + HIFU comparedwith those receiving HIFU alone [24] In our experience(present and previous one [11]) no patients experienced iso-lated stress urinary incontinence except those who received asecond HIFU session The VLPP was low in only one patientat 3-month follow-up De novo urge incontinence developedin 67 of patients at 3 months

The present study has several limitations It is a single-arm study without any comparison with a group of patientstreated with HIFU + TURP furthermore only a smallnumber of patients were included and the follow-up wasshort

5 Conclusions

Lower urinary tract function following HIFU for prostatecancer should be adequately assessed by symptomsrsquo analysisand urodynamic studies

In the long term preoperatively impaired bladder outletsearly postoperative detrusor overactivity decreased blad-der compliance and patient-reported urgency and urgeincontinence leave the place to a progressive increasing inbladder compliance improved bladder outlet a significantlyincreasing maximum flow rate and reduced PVR

The current urodynamic study confirmed previous datathereby demonstrating that HIFU alone can be deliveredsafely

Prostate Cancer 7

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

References

[1] A Heidenreich P J Bastian J Bellmunt et al Guidelines onProstate Cancer European Urology Guidelines 2013

[2] V Ficarra M Borghesi N Suardi et al ldquoLong-term evaluationof survival continence and potency (SCP) outcomes afterrobot-assisted radical prostatectomy (RARP)rdquo BJU Interna-tional vol 112 no 3 pp 338ndash345 2013

[3] L Budaus M Bolla A Bossi et al ldquoFunctional outcomes andcomplications following radiation therapy for prostate cancer acritical analysis of the literaturerdquo European Urology vol 61 no1 pp 112ndash127 2012

[4] R C N van den Bergh I J Korfage and C H BangmaldquoPsychological aspects of active surveillancerdquo Current Opinionin Urology vol 22 no 3 pp 237ndash242 2012

[5] E R Cordeiro X Cathelineau S Thuroff M MarbergerS Crouzet and J J de la Rosette ldquoHigh-intensity focusedultrasound (HIFU) for definitive treatment of prostate cancerrdquoBJU International vol 110 pp 1228ndash1242 2012

[6] S Shoji T Uchida M Nakamoto et al ldquoProstatic swelling andshift during high-intensity focused ultrasound implication fortargeted focal therapyrdquo The Journal of Urology vol 190 no 4pp 1224ndash1232 2013

[7] C Chaussy and SThuroff ldquoThe status of high-intensity focusedultrasound in the treatment of localized prostate cancer and theimpact of a combined resectionrdquo Current Urology Reports vol4 no 3 pp 248ndash252 2003

[8] A Blana S Rogenhofer R Ganzer et al ldquoEight yearsrsquo experi-ence with high-intensity focused ultrasonography for treatmentof localized prostate cancerrdquo Urology vol 72 no 6 pp 1329ndash1333 2008

[9] R O Illing T A Leslie J E Kennedy J G Calleary C WOgden and M Emberton ldquoVisually directed high-intensityfocused ultrasound for organ-confined prostate cancer a pro-posed standard for the conduct of therapyrdquo BJU Internationalvol 98 no 6 pp 1187ndash1192 2006

[10] T A Leslie R O Illing J E Kennedy et al Conduct ofHIFU therapy for low tomoderate risk organ confined prostatecancer with the Sonablate-500 Systemmdashresults of consensusmeeting FromUKHIFUwebsite httpwwwukhifucompdfsConsensusofOpinionauthorchangepdf

[11] L Mearini L DrsquoUrso D Collura et al ldquoVisually directed tran-srectal high intensity focused ultrasound for the treatment ofprostate cancer a preliminary report on the Italian experiencerdquoThe Journal of Urology vol 181 no 1 pp 105ndash111 2009

[12] T Dudderidge E Zacharakis J Calleary et al ldquoFactors affect-ing the need for endoscopic intervention for debris or strictureafter HIFU for prostate cancerrdquo Urology vol 70 no 3 p 1142007

[13] W Schafer P Abrams L Liao et al ldquoGood urodynamicpractices uroflowmetry filling cystometry and pressure-flowstudiesrdquo Neurourology and Urodynamics vol 21 no 3 pp 261ndash274 2002

[14] S Madersbacher C Kratzik N Szabo M Susani L Vingersand M Marberger ldquoTissue ablation in benign prostatic hyper-plasia with high-intensity focused ultrasoundrdquo European Urol-ogy vol 23 no 1 pp 39ndash43 1993

[15] M Sumitomo J Asakuma A Sato K Ito K Nagakura andT Asano ldquoTransurethral resection of the prostate immediatelyafter high-intensity focused ultrasound treatment for prostatecancerrdquo International Journal of Urology vol 17 no 11 pp 924ndash930 2010

[16] T Ripert M-D Azemar J Menard et al ldquoTransrectal high-intensity focused ultrasound (HIFU) treatment of localizedprostate cancer review of technical incidents and morbidityafter 5 years of userdquo Prostate Cancer and Prostatic Diseases vol13 no 2 pp 132ndash137 2010

[17] H Azzouz and J J M C H de la Rosette ldquoHIFU localtreatment of prostate cancerrdquo EAU-EBU Update Series vol 4no 2 pp 62ndash70 2006

[18] G Vallancien D Prapotnich X Cathelineau H Baumertand F Rozet ldquoTransrectal focused ultrasound combined withtransurethral resection of the prostate for the treatment oflocalized prostate cancer feasibility studyrdquo The Journal ofUrology vol 171 no 6 I pp 2265ndash2267 2004

[19] D Pfeiffer J Berger and A J Gross ldquoSingle application of high-intensity focused ultrasound as a first-line therapy for clinicallylocalized prostate cancer 5-year outcomesrdquo BJU Internationalvol 110 pp 1702ndash1707 2012

[20] R Ganzer H M Fritsche A Brandtner et al ldquoFourteen-yearoncological and functional outcomes of high-intensity focusedultrasound in localized prostate cancerrdquo BJU International vol112 no 3 pp 322ndash329 2013

[21] C Netsch D Pfeiffer and A J Gross ldquoDevelopment of bladderoutlet obstruction after a single treatment of prostate cancerwith high-intensity focused ultrasound experience with 226patientsrdquo Journal of Endourology vol 24 no 9 pp 1399ndash14032010

[22] S Y Jung M O Fraser H Ozawa et al ldquoUrethral afferentnerve activity affects the micturition reflex implication forthe relationship between stress incontinence and detrusorinstabilityrdquo The Journal of Urology vol 162 no 1 pp 204ndash2121999

[23] K Komura T Inamoto P C Black et al ldquoClinically significanturethral stricture andor subclinical urethral stricture afterhigh-intensity focused ultrasound correlates with disease-freesurvival in patients with localized prostate cancerrdquo UrologiaInternationalis vol 87 no 3 pp 276ndash281 2011

[24] C Chaussy and SThuroff ldquoThe status of high-intensity focusedultrasound in the treatment of localized prostate cancer and theimpact of a combined resectionrdquo Current Urology Reports vol4 no 3 pp 248ndash252 2003

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OphthalmologyJournal of

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Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom