Patient-reported functional outcomes and oncological control after primary focal cryotherapy for clinically significant prostate cancer: A Phase II mandatory biopsy-monitored study.

INTRODUCTION: We report herein the impact of focal therapy (FT) on multi-domain functional outcomes in a Phase II prospective clinical trial (NCT04138914) in focal cryotherapy for clinically significant prostate cancer (csPCa). METHODS: The primary outcome was the detection of a ≥5 point deterioration in any of the four main expanded prostate index composite (EPIC) functional domains. Pretreatment multiparametric magnetic resonance imaging (mpMRI) and transperineal targeted and systematic saturation biopsy were used to select patients with prostate-specific antigen (PSA)≤20 ng/mL, Gleason grade group (GG) ≤4, mpMRI lesion volume ≤ 3 mL (for a single lesion) or ≤1.5 mL (where two lesions were present). Focal cryotherapy was performed with a minimum 5 mm margin around each target lesion. EPIC scores were obtained at baseline and posttreatment at 1, 3, 6, and 12 months. Mandatory repeat mpMRI and prostate biopsy were performed at 12 months to determine the infield and outfield recurrence. RESULTS: Twenty-eight patients were recruited. The mean age was 68 years, with PSA of 7.3 ng/mL and PSA density of 0.19 ng/mL2 . No Clavien-Dindo ≥3 complications occurred. Transient worsening of EPIC urinary (mean diff 16.0, p < 0.001, 95% confidence interval [CI]: 8.8-23.6) and sexual function scores (mean diff 11.0, p:0.005, 95% CI: 4.0-17.7) were observed at 1-month posttreatment, with recovery by Month 3. A subgroup who had ablation extending to the neurovascular bundle had a trend to delayed recovery of sexual function to Month 6. At 12-month repeat mpMRI and biopsy, 22 patients (78.6%) had no detectable csPCa. Of the six patients (21.4%) who had csPCa recurrences, four were GG2, one GG3, and one GG4. Four patients underwent repeat FT, one underwent radical prostatectomy, while the remaining one patient with low-volume GG2 cancer opted for active surveillance. CONCLUSION: FT using cryotherapy was associated with a transient deterioration of urinary and sexual function with resolution at 3 months posttreatment and with reasonable early efficacy in well-selected csPCa patients.

Intensive sampling of the umbra and penumbra improves clinically significant prostate cancer detection and reduces risk of grade group upgrading at radical prostatectomy.

PURPOSE: Our objective is to evaluate the clinically significant prostate cancer detection rate of overlapping and perilesional systematic biopsy cores and its impact on grade group (GG) concordance at prostatectomy. MATERIALS AND METHODS: Biopsy maps of those undergoing MRI-targeted (TB) and systematic biopsy (SB) were reviewed to reclassify systematic cores. Perilesional (PL) cores were defined as adjacent cores within 10 mm of the target lesion ("penumbra") whilst overlap (OL) cores were defined as cores within the ROI itself ("umbra"). All other cores were designated as distant cores (DC). The incremental csPCa detection rate (GG ≥ 2) and the rate of GG upgrading on prostatectomy as OL, PL and DC sequentially added to TB were determined. RESULTS: Out of the 398 patients included, the median number of OL and PL cores was 5 (IQR 4-7) and 5 (IQR 3-6) respectively. OL cores detected more csPCa than PL cores (31 vs 16%, p < 0.001). OL and PL cores improved the csPCa detection rate of TB from 34 to 39% (p < 0.001) and 37% (p = 0.001) respectively. TB+OL+PL had greater csPCa detection compared to just TB+OL (41 vs 39%, p = 0.016) and TB+PL (41 vs 37%, p < 0.001). Of the 104 patients who underwent prostatectomy, GG upgrading rate for TB+OL+PL was lower compared to TB (21 vs 36%, p < 0.001) and was not significantly different compared to TB+OL+PL+DC (21 vs 19%, p = 0.500). CONCLUSION: A biopsy strategy incorporating both intensive sampling of the umbra and penumbra improved csPCa detection and reduced risk of GG upgrading at prostatectomy.

Incorporating artificial intelligence in urology: Supervised machine learning algorithms demonstrate comparative advantage over nomograms in predicting biochemical recurrence after prostatectomy.

OBJECTIVE: After radical prostatectomy (RP), one-third of patients will experience biochemical recurrence (BCR), which is associated with subsequent metastasis and cancer-specific mortality. We employed machine learning (ML) algorithms to predict BCR after RP, and compare them with traditional regression models and nomograms. METHODS: Utilizing a prospective Uro-oncology registry, 18 clinicopathological parameters of 1130 consecutive patients who underwent RP (2009-2018) were recorded, yielding over 20,000 data points for analysis. The data set was split into a 70:30 ratio for training and validation. Three ML models: Naïve Bayes (NB), random forest (RF), and support vector machine (SVM) were studied, and compared with traditional regression models and nomograms (Kattan, CAPSURE, John Hopkins [JHH]) to predict BCR at 1, 3, and 5 years. RESULTS: Over a median follow-up of 70.0 months, 176 (15.6%) developed BCR, at a median time of 16.0 months (interquartile range [IQR]: 11.0-26.0). Multivariate analyses demonstrated strongest association of BCR with prostate-specific antigen (PSA) (p: 0.015), positive surgical margins (p < 0.001), extraprostatic extension (p: 0.002), seminal vesicle invasion (p: 0.004), and grade group (p < 0.001). The 3 ML models demonstrated good prediction of BCR at 1, 3, and 5 years, with the area under curves (AUC) of NB at 0.894, 0.876, and 0.894, RF at 0.846, 0.875, and 0.888, and SVM at 0.835, 0.850, and 0.855, respectively. All models demonstrated (1) robust accuracy (>0.82), (2) good calibration with minimal overfitting, (3) longitudinal consistency across the three time points, and (4) inter-model validity. The ML models were comparable to traditional regression analyses (AUC: 0.797, 0.848, and 0.862) and outperformed the three nomograms: Kattan (AUC: 0.815, 0.798, and 0.799), JHH (AUC: 0.820, 0.757, and 0.750) and CAPSURE nomograms (AUC: 0.706, 0.720, and 0.749) (p < 0.001). CONCLUSION: Supervised ML algorithms can deliver accurate performances and outperform nomograms in predicting BCR after RP. This may facilitate tailored care provisions by identifying high-risk patients who will benefit from multimodal therapy.

Multiparametric MRI-ultrasonography software fusion prostate biopsy: initial results using a stereotactic robotic-assisted transperineal prostate biopsy platform comparing systematic vs targeted biopsy.

OBJECTIVE: To compare the detection rates of prostate cancer between systematic biopsy and targeted biopsy using a stereotactic robot-assisted transperineal prostate platform. MATERIALS AND METHODS: We identified consecutive patients with suspicious lesion(s) on multiparametric magnetic resonance imaging (mpMRI), who underwent both systematic and MRI-transrectal ultrasonography (US) fusion targeted biopsy using our proprietary transperineal robot-assisted prostate biopsy platform between January 2015 and January 2019 at our institution, for retrospective analysis. Comparative analysis was performed between systematic and targeted biopsy using McNemar's test, and the cohort was further stratified by prior biopsy status and Prostate Imaging Reporting and Data System (PI-RADS) v2.0 score. International Society of Urological Pathology (ISUP) grade group (GG) ≥2 cancers (previously known as Gleason grade ≥7) were considered to be clinically significant. RESULTS: A total of 500 patients were included in our final analysis, of whom 67 (13%) were patients with low-risk cancer on active surveillance. Of the 433 patients without prior diagnosis of cancer, 288 (67%) were biopsy-naïve. A total of 248 (57%) were diagnosed with prostate cancer, with 199 (46%) having clinically significant prostate cancer (ISUP GG ≥2). There were no statistically significant differences in the overall prostate cancer and clinically significant prostate cancer detection rate between systematic and targeted biopsy (51% vs 49% and 40% vs 38% respectively; P = 0.306 and P = 0.609). Of the 248 prostate cancers detected, 75% (187/248) were detected on both systematic and targeted biopsy, 14% (35/248) were detected on systematic biopsy alone and 11% (26/248) were detected on targeted biopsy alone. Of the 199 clinically significant cancers detected, 69% (138/199) were detected on both systematic and targeted biopsy, 17% (33/199) on systematic biopsy alone and 14% (28/199) on targeted biopsy alone. There were no statistically significant differences in the detection rate between systematic and targeted biopsy for both overall and clinically significant prostate cancer, even when the cohort was stratified by prior biopsy status and PI-RADS score. Targeted biopsy has greater sampling efficiency compared to systematic biopsy for both overall and clinically significant prostate cancer (23.2% vs 9.8%, P < 0.001 and 14.8% vs 5.6%, P < 0.001). CONCLUSIONS: Using our robot-assisted transperineal prostate platform, combined MRI-US targeted biopsy with concurrent systematic prostate systematic biopsy probably represents the optimal method for the detection of clinically significant prostate cancer.

Reducing the number of systematic biopsy cores in the era of MRI targeted biopsy-implications on clinically-significant prostate cancer detection and relevance to focal therapy planning.

BACKGROUND: The optimal number of systematic biopsy cores in the era of multi-parametric MRI targeted biopsy remains unclear, especially on its impact of focal therapy planning. Our objective is to investigate the impact of reducing the number of systematic cores on prostate cancer detection in the era of MRI-US fusion targeted biopsy and as well as its relevance in template planning for focal therapy. MATERIALS AND METHODS: A retrospective analysis of 398 consecutive men who underwent both systematic saturation (~24 cores) and MRI-US fusion targeted biopsy was performed. Four reduced-core systematic biopsy strategies (two-thirds, half, one-third and one-quarter systematic cores) were modelled and the detection rates of clinically-significant prostate cancer (csPCa defined as grade group ≥2) were compared to that of a full systematic biopsy using McNemar's test. Focal therapy treatment plans were made based on positive cores on combined (targeted and systematic) biopsy and the various reduced-cores strategies to compare the proportion who had a change in treatment plan. RESULTS: csPCa was detected in 42% (168/398) of this patient cohort. Non-targeted systematic saturation biopsy had a 21% (83/398) csPCa detection rate. Our four strategies reduced the mean number of non-targeted systematic cores from 21.8 to 14.5, 10.9, 7.3 and 5.4 cores and their csPCa detection rates were significantly decreased to 16%, 13%, 9% and 8% respectively (all p < 0.05). Compared to the reduced-core strategies, a full systematic saturation biopsy resulted in change to the focal therapy treatment plan in 12% (2/3 cores), 19% (1/2 cores), 24% (1/3 cores) and 29% (1/4 cores) of the time (p = 0.0434). CONCLUSIONS: Reducing the number of systematic biopsies when performing an MRI-targeted biopsy leads to reduced detection of csPCa and alter the treatment plans for focal therapy, possibly limiting its oncological efficacy.

Serum testosterone levels and testosterone 'bounce' phenomenon predict response to novel anti-androgen therapies in castration-resistant prostate cancer.

BACKGROUND: The relevance of continuous testosterone (TT) monitoring in castration-resistant prostate cancer (CRPC) remains in question. OBJECTIVE: To determine if TT levels before and during novel anti-androgen therapies (NAAT), and the TT 'bounce' phenomenon may predict treatment response in CRPC. MATERIALS AND METHODS: From 2014 through 2018, we identified 92 CRPC patients treated with either Abiraterone or Enzalutamide from a prospectively maintained cancer registry. The TT levels measured before and during NAAT were correlated with the oncological outcomes, determined by PSA response (% change), PSA progression-free survival (PFS) and overall survival (OS). RESULTS AND LIMITATIONS: At CRPC, 58 (63.0%) and 34 (37.0%) patients opted for Abiraterone and Enzalutamide respectively. Median TT levels at CRPC status before and during NAAT were 10.37 ng/dl and 20.46 ng/dl respectively. PSA response was superior in patients with a higher TT before NAAT (P:0.048, median difference: 18.22%, 95% CI 0.70 - 40.37) and longer time to CRPC (P: 0.041, median difference: 15.31%, 95% CI 1.84 -34.84), with a trend towards lower TT during NAAT (P: 0.062). Over a follow up of 33.0 months, 65 patients (70.7%) developed PSA progression. PSA PFS was longer in patients with higher TT before NAAT (16.3 vs. 10.8 months; P: 0.023), lower TT during NAAT (17.0 vs. 9.1 months; P: 0.001), and longer time to CRPC (13.4 vs. 8.0 months; P: 0.032). Importantly, better OS was observed in lower TT during NAAT (45.0 vs. 33.0 months; P:0.029) and longer time to CRPC (43.0 vs. 31.0 months; P: 0.025). The TT 'bounce' phenomenon was observed in 28 patients (33.3%), and was associated with a poorer PSA response (P: 0.029, median difference: 18.90%, 95% CI 3.83 - 41.45), shorter PSA PFS (8.6 vs 15.2 months, P: 0.002) and shorter OS (29.0 vs. 45.0 months, P: 0.012). CONCLUSION: In CRPC patients, TT behaviors before and during NAAT, and the 'bounce' phenomenon continue to predict treatment response and could guide clinical decisions.

Two Weeks Too Long: Optimal Duration for Ureteral Prestenting and Its Physiologic Effects on the Ureter in a Yorkshire-Landrace Pig Model.

INTRODUCTION: Prestenting of the ureter is commonly performed to allow for passive dilation and better access to the urinary system during subsequent procedures. There is no level 1 evidence on the duration of prestenting and EAU guidelines suggest a 1-2 weeks duration. MATERIALS AND METHODS: Our primary aim is to investigate the optimal duration required for prestenting in a porcine model. Our secondary aim is to compare the ureteral wall compliance between the stented and the unstented ureters. METHODS: Three female pigs between 40 and 50 kg were used. We modified a human protocol for performing intravenous pyelograms in our study to obtain ureteral measurements on days 0, 5, 7, and 14. Unilateral stenting on days 0, 5, and 7 was performed. On day 14, bilateral nephroureterectomy was performed, and ureteral compliance was measured in the stent and unstented ureter. RESULTS: There were significant ureteral dilation between days 0 and 5 for all three pigs (p1 = 0.001, p2 ≤ 0.001 and p3 = 0.01). The rate of dilation appears to plateau after day 5 (p1 = 0.416, p2 = 0.344, and p3 = 0.774). Ureteral compliance in the stented ureter is better than in a nonstent ureter (p1 = 1.44 vs 0.13, p2 = 0.8 vs 0.04, p3 = 0.62 vs 0.2). An unexpected observation was the ureteral dilation and increased tortuosity in the unstented ureter in two of the three pigs (p1 = 0.152, p2 = 0.007). CONCLUSION: Our results suggest that optimal prestenting may be achieved in 5 days in a porcine model. It can potentially form the basis to start randomized human trials.

Non-invasive evaluation of lower urinary tract symptoms (LUTS) in men.

Lower urinary tract symptoms (LUTS) are common in males over the age of 40 years old and are likely to increase with an aging population. Currently urodynamic studies are the gold standard to determine the aetiology of voiding dysfunction and LUTS. However, due to its invasive nature, a great number of non-invasive ultrasound based investigations have been developed to assess patients with symptomatic LUTS. The clinical application of non-invasive tests could potentially stratify patients who would require more invasive investigations and allow more precise patient directed treatment. A PubMed literature review was performed and we will discuss the non-invasive investigations that have been developed thus far, focusing on bladder wall and detrusor wall thickness (BWT & DWT), ultrasound estimated bladder weight (UEBW) and intravesical prostatic protrusion (IPP).

Intramuscular gentamicin improves the efficacy of ciprofloxacin as an antibiotic prophylaxis for transrectal prostate biopsy.

INTRODUCTION: Infection-related complications after transrectal ultrasound guided prostatic biopsy (TRPB) could be life threatening. Our centre observed sepsis after TRPB despite prophylactic oral ciprofloxacin. We reviewed all cases of post-TRPB sepsis with their bacteriology and evaluated if the addition of intramuscular (I/M) gentamicin to standard prophylaxis before TRPB could reduce its incidence. MATERIALS AND METHODS: In a single urological centre, we performed an interventional study that compared a prospective group with retrospective control. The latter is known as the "cipro-only" group included consecutive patients who underwent TRPB between 1 September 2003 and 31 August 2004. The addition of I/M gentamicin 80 mg half an hour before TRPB started on 1 September 2004. All subsequent patients who underwent TRPB until 31 August 2005 were included in the "cipro+genta" group. Patients who did not receive the studied antibiotics were excluded. RESULTS: There were 374 patients in the "cipro+genta" group and 367 patients in the "cipro-only" group with comparable profiles. There were 12 cases of post-TRPB sepsis in the "cipro-only" group and 5 cases in the "cipro+genta" group. Ciprofloxacin-resistant Escherichia coli (E. coli) was the only pathogen isolated in both groups. In the "cipro-only" group, 9 patients had positive blood cultures and 8 were sensitive to gentamicin. In the "cipro+genta" group, the only positive E. coli was gentamicin-resistant. One patient in the "cipro+genta" group was admitted to the intensive care unit with septicaemia. CONCLUSION: The addition of I/M gentamicin to oral ciprofloxacin is a safe and effective prophylactic antibiotic regime in reducing the incidence of post-TRPB sepsis.

Bipolar transurethral resection of prostate: a new reference standard?

PURPOSE OF REVIEW: Transurethral resection of prostate is the gold standard for the surgical management of benign prostate hyperplasia. Bipolar devices allow transurethral resection of prostate with saline irrigation, which lessens water intoxication and negates the need for diathermy pad and unwanted stimulation of the obturator nerves and cardiac devices. Several randomized clinical trials compare the various bipolar devices with conventional monopolar ones. For this review, we search all peer-reviewed published literature databases and present the evidence from them to substantiate its advantages and disadvantages. RECENT FINDINGS: Of the various types of bipolar devices, Gyrus has the longest clinical experience. Bipolar transurethral resection of prostate overcomes the shortcomings of bipolar transurethral prostate vaporization, which includes the absence of histology, postop irritative urinary symptoms and nondurable clinical outcomes. With bipolar transurethral resection of prostate, there is lesser bleeding which leads to shorter resection time and lower fluid absorption. This also enables shorter cathterization time and hospital stay. Transurethral resection syndrome has not been observed. SUMMARY: Bipolar transurethral resection of prostate has demonstrated similar clinical efficacy as monopolar transurethral resection of prostate with shorter catheterization and hospital stay. It eliminates the occurrence of transurethral resection syndrome and minimizes bleeding risk. Long term outcomes from these randomized clinical trials will determine the durability of its clinical efficacy and incidence of urethral strictures.

Rare cause of intestinal obstruction after laparoscopic radical nephrectomy: internal herniation via a mesenteric defect.

A 43-year-old man had painless macroscopic hematuria and was diagnosed with a 9-cm renal carcinoma in the lower pole of the left kidney. He underwent laparoscopic transperitoneal left radical nephrectomy (LRN) with an uneventful recovery. Eleven days later, he developed intestinal obstruction (IO). Abdominal computed tomography scan showed dilated small bowels occupying the left renal fossa. Laparotomy revealed closed-loop small bowel obstruction resulting from internal intestinal herniation via a 5-cm mesenteric defect. It was repaired after the herniated bowels were reduced. This case illustrates a rare cause of IO after LRN, in which mesenteric defect is necessary.

A prospective randomized study comparing monopolar and bipolar transurethral resection of prostate using transurethral resection in saline (TURIS) system.

OBJECTIVES: To compare transurethral resection of prostate (TURP) using monopolar and bipolar transurethral resection in saline (TURIS) system. MATERIALS AND METHODS: A prospectively randomized study was conducted between January 2004 and January 2005. Patient demographics and indications for surgery were recorded. The safety end points studied were occurrence of complications and decline in postoperative serum sodium (Na(+)) and hemoglobin (Hb) levels. Efficacy end points were resection time, weight of resected prostate tissue, and improvement in International Prostate Symptoms Score (IPSS) and maximum flow rate (Q(max)) in patients' uroflow over 12 mo. RESULTS: One hundred consecutive patients were randomized and completed the study, with 52 patients in the monopolar TURP group and 48 in the TURIS group. At baseline, the two groups were comparable; they had at least 12 mo of follow-up. Mean resection time and mean weight of resected prostate tissue were comparable for both groups. Declines in the mean postoperative serum Na(+) for TURIS and monopolar TURP groups were 3.2 and 10.7 mmol/l, respectively (p<0.01). However, there was no statistical difference in the decline in postoperative Hb between the two groups. There were two cases of clinically significant transurethral resection syndrome in the monopolar group. Urethral strictures were observed in three cases of TURIS and one patient in the monopolar group. The IPSS and Q(max) improvements were comparable between the two groups at 12 mo of follow-up. CONCLUSIONS: Bipolar TURP using the TURIS system is clinically comparable to monopolar TURP at 1 yr with an improved safety profile.