The association between patient and disease characteristics, and the risk of disease progression in patients with prostate cancer on active surveillance.

PURPOSE: The objective of this study was to identify and assess patient and disease characteristics associated with an increased risk of disease progression in men with prostate cancer on active surveillance. METHODS: We studied patients with low-risk (ISUP GG1) or favorable intermediate-risk (ISUP GG2) PCa. All patients had at least one repeat biopsy. Disease progression was the primary outcome of this study, based on pathological upgrading. Univariate and multivariate Cox proportional hazard analyses were used to evaluate the association between covariates and disease progression. RESULTS: In total, 240 men were included, of whom 198 (82.5%) were diagnosed with low-risk PCa and 42 (17.5%) with favorable intermediate-risk PCa. Disease progression was observed in 42.9% (103/240) of men. Index lesion > 10 mm (HR = 2.85; 95% CI 1.74-4.68; p < 0.001), MRI (m)T-stage 2b/2c (HR = 2.52; 95% CI 1.16-5.50; p = 0.02), highest PI-RADS score of 5 (HR 3.05; 95% CI 1.48-6.28; p = 0.002) and a higher PSA level (HR 1.06; 95% CI 1.01-1.11; p = 0.014) at baseline were associated with disease progression on univariate analysis. Multivariate analysis showed no significant baseline predictors of disease progression. CONCLUSION: In AS patients with low-risk or favorable intermediate-risk PCa, diameter of index lesion, MRI (m)T-stage, height of the PI-RADS score and the PSA level at baseline are significant predictors of disease progression to first repeat biopsy.

External validation of the Rotterdam prostate cancer risk calculator within a high-risk Dutch clinical cohort.

PURPOSE: This study aims to externally validate the Rotterdam Prostate Cancer Risk Calculator (RPCRC)-3/4 and RPCRC-MRI within a Dutch clinical cohort. METHODS: Men subjected to prostate biopsies, between 2018 and 2021, due to a clinical suspicion of prostate cancer (PCa) were retrospectively included. The performance of the RPCRC-3/4 and RPCRC-MRI was analyzed in terms of discrimination, calibration and net benefit. In addition, the need for recalibration and adjustment of risk thresholds for referral was investigated. Clinically significant (cs) PCa was defined as Gleason score ≥ 3 + 4. RESULTS: A total of 1575 men were included in the analysis. PCa was diagnosed in 63.2% (996/1575) of men and csPCa in 41.7% (656/1575) of men. Use of the RPCRC-3/4 could have prevented 37.3% (587/1575) of all MRIs within this cohort, thereby missing 18.3% (120/656) of csPCa diagnoses. After recalibration and adjustment of risk thresholds to 20% for PCa and 10% for csPCa, use of the recalibrated RPCRC-3/4 could have prevented 15.1% (238/1575) of all MRIs, resulting in 5.3% (35/656) of csPCa diagnoses being missed. The performance of the RPCRC-MRI was good; use of this risk calculator could have prevented 10.7% (169/1575) of all biopsies, resulting in 1.2% (8/656) of csPCa diagnoses being missed. CONCLUSION: The RPCRC-3/4 underestimates the probability of having csPCa within this Dutch clinical cohort, resulting in significant numbers of csPCa diagnoses being missed. For optimal performance of a risk calculator in a specific cohort, evaluation of its performance within the population under study is essential.

An Magnetic Resonance Imaging-directed Targeted-plus-perilesional Biopsy Approach for Prostate Cancer Diagnosis: "Less Is More".

Background: Considering that most men benefit diagnostically from increased sampling of index lesions, limiting systematic biopsy (SBx) to the region around the index lesion could potentially minimize overdetection while maintaining the detection of clinically significant prostate cancer (csPCa). Objective: To evaluate the diagnostic performance of a hypothetical magnetic resonance imaging (MRI)-directed targeted-plus-perilesional biopsy approach. Design setting and participants: This single-center, retrospective analysis of prospectively generated data included all biopsy-naïve men with unilateral MRI-positive lesions (Prostate Imaging Reporting and Data System category ≥3), undergoing both MRI-directed targeted biopsies and SBx. Grade group 2-5 cancers were considered csPCa. Outcome measurements and statistical analysis: The diagnostic performance of a targeted-plus-perilesional biopsy approach was compared with that of a targeted-plus-systematic biopsy approach. The primary outcome was the detection of csPCa. Secondary outcomes included the detection of clinically insignificant prostate cancer (ciPCa) and the number of total biopsy cores. Results and limitations: A total of 235 men were included in the analysis; csPCa and ciPCa were detected, respectively, in 95 (40.4%) and 86 (36.6%) of these 235 men. A targeted-plus-perilesional biopsy approach would have detected 92/95 (96.8%; 95% confidence interval [CI] 91.0-99.3%) csPCa cases. At the same time, detection of systematically found ciPCa would be reduced by 11/86 (12.8%; 95% CI 6.6-21.7%). If a targeted-plus-perilesional biopsy approach would have been performed, the number of biopsy cores per patient would have been reduced significantly (a mean difference of 5.2; 95% CI 4.9-5.6, p < 0.001). Conclusions: An MRI-directed targeted-plus-perilesional biopsy approach detected almost all csPCa cases, while limiting overdiagnosis and reducing the number of biopsy cores. Prospective clinical trials are needed to substantiate the withholding of nonperilesional SBx in men with unilateral lesion(s) on MRI. Patient summary: Limiting systematic biopsies to the proximity of the suspicious area on magnetic resonance imaging helps detect an equivalent number of aggressive cancers and fewer indolent cancers. These findings may help patients and physicians choose the best biopsy approach.

Coping styles in patients with hypospadias.

OBJECTIVE: The objective of this study is to investigate the coping styles used by patients with hypospadias. Long-term hypospadias studies generally show satisfying outcomes, but some report a lower quality of life (QoL) or poorer psychosocial adjustment, particularly in patients with proximal hypospadias. A lower QoL or psychosocial adjustment was found to be associated with passive coping styles in other pediatric patient populations. Hypothetically, patients with hypospadias also develop different coping styles due to medical experiences in childhood, leading to the lower QoL outcomes on the long term. However, coping styles of patients with hypospadias have never been analyzed. PATIENTS AND METHODS: Adult men with hypospadias repair in childhood were recruited (n = 55; aged 19.9 [IQR 19.2-22.1]). Coping styles were determined with the Utrecht Coping List (UCL) and results compared with a reference group of male students (n = 55, age 20-30 years, no medical history). Sub analysis of coping styles of the hypospadias groups was done based on three items: severity of hypospadias, time of last hypospadias surgery and occurrence of postoperative complications. RESULTS: Compared to the reference groups, patients with hypospadias had higher scores on Avoidance (P < 0.05), particularly patients who had ≥1 postoperative complication or proximal hypospadias. Patients with proximal hypospadias also had lower scores on Seeking Social Support compared to the reference group (P < 0.05). Within the hypospadias group, coping style scores did not differ based on severity of hypospadias, timing of surgery or postoperative complications. CONCLUSION: Patients with hypospadias, particularly those with proximal hypospadias or a postoperative complication, more often use an avoiding coping style compared to a reference population. Attention to coping styles during the follow-up of patients with hypospadias might help to improve the QoL in these patients.

Proximal hypospadias treated with a transverse preputial island tube: long-term functional, sexual, and cosmetic outcomes.

OBJECTIVE: To study long-term urinary and sexual function, and cosmetic outcomes in adult patients who underwent single-stage transverse preputial island tube (TPIT) for proximal hypospadias repair in childhood. Long-term data on outcomes of patients with proximal hypospadias with severe coexisting curvature and insufficient urethral plate are scarce, but are necessary to decide which repair technique is most beneficial. PATIENTS, SUBJECTS AND METHODS: Patients with proximal hypospadias operated with TPIT (TPIT Group) were compared to patients with distal hypospadias repair (Distal Group) and to a control group of male medical students (Control Group). Participants completed the International Prostate Symptom Score, the International Index of Erectile Function (IIEF-15), additional non-validated questions, and performed uroflowmetry. Cosmesis was assessed in the patients with hypospadias using the Pediatric Penile Perception Score (PPPS); stretched penile length was also measured. RESULTS: Of the 121 eligible patients with hypospadias, 54 with either TPIT or distal hypospadias repairs participated. The TPIT Group comprised 12 patients (median age of 20.0 years) and the Distal Group comprised 42 patients (median age of 19.6 years). The complication rates were similar, at 8 of the 12 patients in the TPIT Group vs 26/42 (62%) in the Distal Group (P = 0.76). Urinary outcomes were similar in the TPIT, Distal, and the Control (comprised of 148 medical students with a median age of 21.0 years) groups. The TPIT Group had a lower maximum urinary flow rate compared to the Control Group, at 24.1 vs 28.6 mL/s (P < 0.05). IIEF-15 scores were similar in the TPIT, Distal and Control groups, except for 'Orgasmic Function' (7.5 vs 10.0 vs 10.0, respectively; P < 0.01). Although the TPIT Group had a smaller penile length compared to the Distal Group (10.1 vs 12.9 cm, P < 0.01), PPPS outcomes were similar. CONCLUSION: In these TPIT patients, long-term urinary, sexual and cosmetic outcomes were similar to those in patients with distal hypospadias repairs and controls.

Long-term follow-up after transurethral treatment of infravesical obstruction in boys.

OBJECTIVE: To study whether boys who underwent transurethral treatment of (mild) infravesical obstruction during childhood have lower urinary tract symptoms and complications at young adult age. MATERIALS AND METHODS: Young adult men who underwent transurethral treatment for infravesical obstruction as a child were contacted. The following measurements were done: International Prostate Symptom Score (IPSS), International Consultation on Incontinence Modular Questionnaire on Urinary Incontinence, frequency volume chart uroflowmetry, and postvoid residual. A group of 151 male students who completed IPSS and underwent uroflowmetry was used as reference group to compare with patients. RESULTS: Of 135 traceable patients, 87 men (median age 21.9 years; interquartile range [IQR] 19.6-25.6) returned the questionnaires, and 71 underwent uroflowmetry. Median age at initial treatment was 7.9 years (IQR 1.0-10.8). Compared with men in the reference group, patients had similar IPSS and quality of life scores; median IPSS was 3, and IPSS-quality of life 1 (IQR 0.0-1.0). Urgency incontinence and postmicturition incontinence were reported in 2.4% and 8.5%, respectively. Frequency volume charts (n = 29) showed normal frequency and voided volumes. Uroflowmetry results were comparable with the reference group, although 16 (22.5%) patients voided volumes >600 mL. One patient had urethral stricturing, and one a significant postvoid residual. CONCLUSION: Young adult men treated for (mild) urethral obstruction in childhood have few micturition symptoms and good uroflowmetry results, not different from a reference group. Some patients, however, report incontinence, and this group deserves close attention. Late complications were rare.

Urinary, sexual, and cosmetic results after puberty in hypospadias repair: current results and trends.

PURPOSE OF REVIEW: To give an overview of the recently published long-term outcomes of hypospadias surgery performed at childhood, of patients who have had multiple previous repairs, and results of surgery done to treat late complications following hypospadias repair. RECENT FINDINGS: Urethral function after hypospadias repair is good, but cosmesis based on the patients' opinion, on the long term, was disappointing. Also erectile function was reported to be good, although persisting curvature and ejaculation disorders were mentioned, more evidently in patients with proximal hypospadias. Long-term results using buccal mucosa repairs in hypospadias cripples are good, but the use of tissue expanders may be a good alternative. Late complications of hypospadias repair, such as urethral strictures, are difficult to treat, and have a high failure rate compared to urethroplasty for other reasons. SUMMARY: Functional results of hypospadias repair are generally satisfactory in the long term, although improvement must be pursued. Most adult men with a history of hypospadias present themselves with urinary tract symptoms. Cosmesis judged by patients remains rather poor in the long run and better techniques should be found. Preferably, assessment of long-term results should be done by validated test methods for better comparison.

Anticonvulsants for tinnitus.

BACKGROUND: Tinnitus is the perception of sound or noise in the absence of an external or internal acoustic stimulation. It is a common and potentially distressing symptom for which no adequate therapy exists. OBJECTIVES: To assess the effectiveness of anticonvulsants in patients with chronic tinnitus. SEARCH STRATEGY: We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, CENTRAL (2010, Issue 2), MEDLINE, EMBASE, bibliographies and additional sources for published and unpublished trials. The date of the most recent search was 26 May 2010. SELECTION CRITERIA: We selected randomised controlled trials in patients with chronic tinnitus comparing orally administered anticonvulsants with placebo. The primary outcome was improvement in tinnitus measured with validated questionnaires. Secondary outcomes were improvement in tinnitus measured with self-assessment scores, improvement in global well-being or accompanying symptoms, and adverse drug effects. DATA COLLECTION AND ANALYSIS: Three authors assessed risk of bias and extracted data independently. MAIN RESULTS: Seven trials (453 patients) were included in this review. These studies investigated four different anticonvulsants: gabapentin, carbamazepine, lamotrigine and flunarizine. The risk of bias of most studies was 'high' or 'unclear'. Three studies included a validated questionnaire (primary outcome). None of them showed a significant positive effect of anticonvulsants. One study showed a significant negative effect of gabapentin compared to placebo with an increase in Tinnitus Questionnaire (TQ) score of 18.4 points (standardised mean difference (SMD) 0.82, 95% confidence interval (CI) 0.07 to 1.58). A second study showed a positive, non-significant effect of gabapentin with a difference compared to placebo of 2.4 points on the Tinnitus Handicap Inventory (THI) (SMD -0.11, 95% CI -0.48 to 0.25). When the data from these two studies are pooled no effect of gabapentin is found (SMD 0.07, 95% CI -0.26 to 0.40). A third study reported no differences on the THI after treatment with gabapentin compared to placebo (exact numbers could not be extracted from the article).A meta-analysis of 'any positive effect' (yes versus no) based on a self-assessment score (secondary outcome) showed a small favourable effect of anticonvulsants (RD 14%, 95% CI 6% to 22%). A meta-analysis of 'near or total eradication of tinnitus annoyance' showed no effect of anticonvulsants (risk difference (RD) 4%, 95% CI -2% to 11%). Side effects of the anticonvulsants used were experienced by 18% of patients. AUTHORS' CONCLUSIONS: Current evidence regarding the effectiveness of anticonvulsants in patients with tinnitus has significant risk of bias. There is no evidence from studies performed so far to show that anticonvulsants have a large positive effect in the treatment of tinnitus but a small effect (of doubtful clinical significance) has been demonstrated.

Long-term followup of hypospadias: functional and cosmetic results.

PURPOSE: We assessed long-term results after hypospadias surgery with respect to urinary and sexual function, cosmetic appearance and intimate relationships. MATERIALS AND METHODS: We contacted 116 patients who are now adults and who underwent surgery between 1987 and 1992. Participation included mailed questionnaires containing the International Prostate Symptom Score, International Index of Erectile Function and the Dutch Survey of Intimate Relations (Nederlandse Relatie Vragenlijst) as well as uroflowmetry and cosmesis assessment using the Pediatric Penile Perception Score. A control group of 151 male students completed the International Prostate Symptom Score and International Index of Erectile Function, and underwent uroflowmetry. RESULTS: A total of 91 patients (78%) were traceable, 57% returned the questionnaires and 27% visited the clinic. Hypospadias was distal, mid shaft and proximal in 47, 8 and 11 patients, respectively. International Prostate Symptom Score was greater than 7 in 9 of 64 patients (14%) compared to 10 of 151 controls (7%). Patients with distal hypospadias complained more about micturition. Patients with proximal hypospadias had lower maximum urine flow than other patients and controls. For sexuality the total International Index of Erectile Function did not differ between patients and controls. Patients with proximal hypospadias reported less satisfaction with penile length and objectively penile length was less than the average of all patients (10.8 vs 12.1 cm). Cosmetic outcome was considered satisfactory. Outcomes in the 33 patients who returned the Dutch Survey of Intimate Relations correctly were above average, especially for sexuality and independence. CONCLUSIONS: Patients with distal hypospadias have a higher International Prostate Symptom Score and patients with proximal hypospadias have lower maximum urine flow than controls. Sexual function and cosmesis are rated good. The quality of intimate relationships is above average.