Perioperative management of direct oral anticoagulants in patients undergoing radical prostatectomy: results of a prospective assessment.

INTRODUCTION AND OBJECTIVES: In the perioperative setting, temporary interruption of direct oral anticoagulants (DOACs) is recommended. However, the safety of these recommendations is based on non-urological surgical experiences. Our objective was to verify the safety of these recommendations in patients undergoing radical prostatectomy (RP). MATERIALS AND METHODS: Patients regularly receiving a DOAC and scheduled for RP at our institution were prospectively assessed. DOAC intake was usually stopped 48 h before surgery without any preoperative bridging therapy. Postoperatively, patients received risk-adapted low-molecular weight heparin (LMWH). On the third day after unremarkable RP, DOAC intake was restarted and the administration of LMWH was stopped. We assessed perioperative outcomes and 30-day morbidity. RESULTS: Thirty-two consecutive patients receiving DOAC underwent RP at our institution between 12/2017 and 07/2018. Time of surgery (median, 177 min) and intraoperative blood loss (median, 500 mL) were unremarkable. DOACs were restarted on the third postoperative day in 30 patients (94%). No patient had a significant hemoglobin level reduction after DOAC restart. Overall, 28% of patients experienced complications within 30 days after surgery. Most of which were minor (Clavien ≤ 2), three patients (9%), however, had Clavien ≥ 3 complications. CONCLUSION: Our report is the first to prospectively assess current guideline recommendations regarding DOAC restarting after major urological surgery. RP can safely be performed, if DOACs are correctly paused before surgery. Moreover, in case of an uneventful postoperative clinical course, DOACs can be safely restarted on the third postoperative day. A 9% Clavien ≥ 3 30-day morbidity warrants attention and should be further explored in future studies.

Additional elastography-targeted biopsy improves the agreement between biopsy Gleason grade and Gleason grade at radical prostatectomy.

PURPOSE: To assess whether real-time elastography-targeted biopsy (RTE-bx) may help to correctly assign Gleason grade at radical prostatectomy (RP) and to compare discriminant properties of systematic biopsy alone (sbx) versus combination with RTE-bx (comb-bx) to distinguish between postoperatively favorable (Gleason 3 + 3, pT2, Nx/0) and postoperatively unfavorable (Gleason ≥4 + 4) prostate cancer (PCa) at RP. PATIENTS AND METHODS: Overall, 259 patients diagnosed with PCa at systematic biopsy in combination with RTE-bx underwent RP between 2008 and 2011. Gleason Score derived from sbx versus comb-bx was compared to the gold-standard RP, and discriminant properties were assessed. Specificity gains were examined for sbx versus comb-bx when the endpoint consisted of postoperatively favorable PCa at RP. Sensitivity gains were examined, when analyses focused on postoperatively unfavorable PCa. RESULTS: Comb-bx resulted in higher correct overall Gleason assignment (68.3 vs. 56.7 %, p = 0.008) than sbx. Similarly, lower rates of undergrading (21.2 vs. 36.3 %, p < 0.001) were recorded. Specificity gains with comb-bx were 10 % (92 vs. 82 %, p = 0.004) for postoperatively favorable PCa. Comb-bx resulted in 31 % sensitivity gains relative to sbx (94 vs. 63 %, p = 0.03), when postoperatively unfavorable PCa was the endpoint. CONCLUSION: The agreement between biopsy and pathology Gleason Score was significantly higher for comb-bx than sbx. Additionally, comb-bx reduced the rate of false positives in the diagnosis of favorable PCa. Rates of correctly classified unfavorable PCa at RP were also higher for comb-bx. Those data indicate that comb-bx is useful in clinical practice.

Incremental detection rate of prostate cancer by real-time elastography targeted biopsies in combination with a conventional 10-core biopsy in 1024 consecutive patients.

OBJECTIVE: To quantify the incremental detection rate (DR) of a targeted biopsy in addition to a randomized 10-core biopsy. PATIENTS AND METHODS: This retrospective study analysed 1024 patients who consecutively underwent a four-core real-time elastography (RTE) targeted biopsies in addition to a randomized 10-core transrectal ultrasonography (TRUS)-guided biopsy in a primary or rebiopsy setting. The overall DR, the DR of a 10-core randomized, RTE targeted biopsy and the incremental DR were calculated. RESULTS: Overall, randomized and RTE targeted biopsy DRs (for the combination, the 10-core and the four-core RTE biopsy scheme) were 46.2% (n = 473), 39.1% (n = 400) and 29.0% (n = 297), respectively. Four-core RTE targeted biopsies detected an additional 73 patients not detected by the 10-core randomized biopsies (increase in the overall DR of 7.1%). This represented a relative increase in DR of 18.3%. The incremental DR was better in rebiopsy patients (24.8%) than in patients having their first biopsy (14.7%). Within all patients diagnosed by RTE targeted biopsy only, 34 patients harboured significant Gleason 4 or 5 prostate cancer (PCa), diagnosed by four-core RTE biopsy only. Moreover, PCa with a Gleason grade of 4 or 5 was detected by four-core RTE biopsies in 30 patients, who showed low-grade PCa ≤ Gleason 3 only in the systematic 10-core biopsy. CONCLUSIONS: Real-time elastography targeted biopsy seems to be an appropriate method for increasing the DR of PCa. Nevertheless, RTE targeted biopsies missed a high proportion of patients with PCa and should therefore be considered as an addition to randomized biopsies.

Accuracy of HistoScanning™ for the prediction of a negative surgical margin in patients undergoing radical prostatectomy.

OBJECTIVE: To assess the accuracy of HistoScanning™ (HS) as a visualization tool for preoperative treatment planning for nerve-sparing (NS) radical prostatectomy (RP). PATIENTS AND METHODS: A retrospective study was carried out on 80 patients with prostate cancer undergoing RP from October 2009 to December 2009. All patients underwent a HS procedure 1 day before surgery. Frozen sections (FSs) were performed on each latero-posterior side of the prostate to assess for the presence of cancer. On the HS analysis, the region corresponding to that removed at FS was assessed for suspicious lesions. The size of suspicious lesions within this volume was compared with the FS histopathological analysis. RESULTS: HS results corresponded to a 93% probability of having a negative surgical margin in the FSs. The presence of a HS volume ≥0.2 mL in a specific side was associated with a 3.7 times increased risk of a positive surgical margin at FS. CONCLUSIONS: HS has the potential to assist in the planning of NSRP. Larger, multicentre studies need to be performed for validation of these encouraging results.