Benefit and harm of lymphadenectomy in intermediate risk prostate cancer: comparison of five nomograms.

BACKGROUND: Pelvic lymph node dissection (PLND) is recommended method for detecting prostate cancer (PCa) nodal metastases although associated with serious complications. In this study, we aimed to assess benefit/harm of routine PLND in intermediate risk PCa patients and to compare diagnostic yield of five different nomograms in predicting lymph node invasion (LNI). METHODS: Retrospective analysis of consecutive PCa patients with intermediate risk of biochemical recurrence who underwent open radical prostatectomy (RP) with bilateral PLND between January 2017 and December 2019 at our institution. Partin, 2012-Briganti, 2018-Briganti, Cagiannos and Memorial Sloan Kettering Cancer Center (MSKCC) values were calculated. To compare accuracy, sensitivity, specificity, and area under receiver-operating curve (AUC) were calculated and then optimal cutoff values were estimated, analyses repeated and compared. To assess benefit and harm of PLND, relative risk (RR) and number need to treat (NNT) with LNI and complications set as outcome were calculated. RESULTS: Total 309 subjects. Average age 62.2 years, average PSA 7.2 ng/mL; 18 (5.8%) had LNI; 88 (28.5%) suffered Clavien-Dindo grade 3-5 complication. AUC for predicting LNI: 0.729 for 2012-Briganti, 0.660 for MSKCC, 0.521 for 2018-Briganti, 0.486 for Cagiannos, and 0.424 for Partin. None of pairwise AUC comparisons based on default and newly established cutoff values were statistically significant. Lowest NNT was for Partin and Cagiannos with default cutoff (≥ 5%). Risks of serious complications between higher/lower than cutoff values were non-significant across nomograms. CONCLUSIONS: 2012-Briganti nomogram outperforms, although not significantly, MSKCC, 2018-Briganti, Cagiannos, and Partin nomograms in classifying LNI in intermediate risk PCa patients. Routine PLND in these patients should be avoided, due to high rate and severity of complications.

Can a Simple Geriatric Assessment Predict the Outcome of TURP?

PURPOSE: To determine the impact of a simple preoperative geriatric assessment on the outcome in older patients with recurrent urinary retention who underwent desobstructive surgery. PATIENTS AND METHODS: Patients aged 75 years or older with recurrent urinary retention referred for TURP entered this prospective, multicentre study. Several demographic, intra- and postoperative parameters were assessed. Preoperative geriatric assessment was performed by the 7-item Canadian Study of Health and Ageing (CSHA) frailty scale (1: very fit, 7: severely frail; completion takes less than a minute). The main outcome parameters were successful voiding rates at discharge and 3 months postoperatively. RESULTS: A total of 54 patients were recruited; 42 (77.8%) patients had a CSHA index of 1-3 and were considered as "fit", the remaining 12 (22.2%) formed the "frail" group (CSHA index 4-7). Age was identical in both cohorts (79.5 ± 3.7 vs. 79.7 ± 3.3 years); differences were demonstrable for the American Society of Anesthesiologists (ASA) score (p = 0.001), the number of daily medications (>4: 32 vs. 75%, p = 0.02), falls within the past 6 months (12 vs. 33%), and the necessity of home/nursing care (5 vs. 42%, p = 0.004). Intra- and perioperative complications, duration of postoperative catheterization, and length of hospitalization were identical in both cohorts. The success rate at discharge was 80.6% in fit and 75.0% in frail patients; the respective values at 3 months were 95.2 and 83.3%. CONCLUSIONS: A simple 1-min geriatric assessment tool can predict - to a certain extent - the outcome of desobstructive surgery in older patients with recurrent urinary retention. Fit patients achieve an excellent outcome while frail patients might benefit from a more in-depth urodynamic/geriatric evaluation.

Use of Urinary Collection Devices in Community and Nursing Homes in Istria County.

INTRODUCTION: This study is aimed at assessing the use of various types of urinary catheters, appropriateness of catheter placement and factors associated with antibiotic use in a population of chronically catheterized patients in Istria County. MATERIALS AND METHODS: This cross-sectional study, conducted between March and June 2017 in Istria County, Croatia, was initiated through a network of general family medicine offices. Data were collected from general practitioners (GPs) and from medical managers in nursing homes. Participants were asked to review medical records of their patients and to complete a 10-item questionnaire designed to retrieve information on patients with urinary catheter. RESULTS: All GPs in the county were surveyed. We identified 309 patients with urinary catheter: 216 men (70%) and 93 women (30%). The overall prevalence of individuals with urinary catheters was 0.18%: 4.7% in nursing home population and 0.1% among non-institutionalized adult population. Most common indication for catheterization was chronic urinary retention (52%). One hundred eighty-six patients (60.4%) reported antibiotic usage in the previous 3 months for treating urinary infection. CONCLUSIONS: In Istria County, the prevalence of indwelling urinary catheters is highest in males, especially among patients in nursing homes. There is a need for focused education among GPs regarding urinary catheter maintenance and antibiotic prescription for suspected urinary tract infections.

Increasing prostate-specific antigen levels differently influence prostate cancer detection rates of two different 12-core prostate biopsy schemes.

OBJECTIVE: To compare two 12-core transrectal ultrasound-guided prostate biopsy schemes in respect to cancer detection rates. METHODS: Retrospective, single-center analysis of consecutive patients (n = 897) who underwent prostate biopsy (S1) with all 12 cores from far lateral areas (n = 269) or prostate biopsy (S2) with 6 cores from parasagittal and 6 from far lateral areas (n = 628). RESULTS: Crude cancer detection rates with S1 and S2 were similar (39.0 and 38.9% for the first biopsy and 29.4 and 31.3% for repeated biopsies, respectively). Abnormal digital rectal exam, lower prostate volume and higher prostate-specific antigen (PSA) levels were independently associated with higher odds of cancer detection. Regarding first biopsies (n = 747), there was significant interaction between biopsy scheme and PSA (p < 0.001). Overall, the adjusted odds of cancer detection were higher with S1 (S1/S2 odds ratio = 2.54, 95% CI: 1.12-5.74), but the S1-S2 relationship was conditional on PSA: odds ratios progressively increased with increasing PSA from 0.64 (95% CI: 0.40-1.02) at PSA 5 ng/ml to 39.1 (95% CI: 2.71-566) at 75 ng/ml. CONCLUSION: Higher PSA levels increase the probability of cancer detection with 12-core prostate biopsies, but relative efficiency of different procedures appeared conditional on the PSA level. Data suggest that PSA levels should be considered in the choice of prostate biopsy sampling scheme.

Systematic biopsy should not be omitted in the era of combined magnetic resonance imaging/ultrasound fusion-guided biopsies of the prostate.

PURPOSE: To evaluate prostate cancer detection rates with classical trans-rectal ultrasound-guided systematic 10-core biopsies (SB), targeted biopsies (TB) guided by magnetic resonance (MR)/US fusion imaging and their combination in biopsy-naïve and patients with previously negative prostate biopsies. We compared pathology results after radical prostatectomy with biopsy findings. METHODS: Consecutive patients with prostate imaging-reporting and data system lesions grade ≥ 3 submitted to MRI/US-guided TB and subsequent standard 10-core SB between December 2015 and June 2019 were analyzed. RESULTS: Detection rate (TB- or SB-positive) in 563 included patients (192 naïve, 371 with previous biopsies) was 56.7% (67.7% for the first, 50.9% for repeated biopsies). With TB (disregarding SB), the rates were 41.4%, 52.1% and 35.8%, respectively. With SB (disregarding TB), the rates were 49.1%, 63.0% and 41.8%, respectively. Eventually, 118 patients underwent surgery and clinically significant cancer was found in 111 (94.1%) specimens. Of those, 23 (20.7%) would have been missed had we relied upon a negative TB and 14 (12.6%) would have been missed had we relied upon a negative SB, disregarding a positive finding on the alternative biopsy template. CONCLUSION: SB should not be omitted since TB and SB combination have higher detection rate of clinically relevant prostate cancer than either procedure alone.

Prostate Biopsy in the Left Lateral Decubitus Position is Less Painful than Prostate Biopsy in the Lithotomy Position: A Randomized Controlled Trial.

PURPOSE: The primary objective was to assess whether transrectal ultrasound (TRUS)-guided prostate biopsy in the left lateral decubitus (LLD) position differed from the procedure in the lithotomy position regarding patients' pain perception. The secondary objective was to assess the analgesic effect of intrarectal 2% lidocaine gel in this setting. MATERIALS AND METHODS: This single-center, open-label trial enrolled 148 men undergoing prostate biopsy. Then men were randomly assigned to group 1 (LLD position, no lidocaine, n=50, "test"), group 2 (lithotomy position+lidocaine, n=50, "positive control"), and group 3 (lithotomy position, no lidocaine, n=48, "negative control"). Twelve-core samples were taken in each biopsy set. Pain was assessed by using a 10-point visual analogue scale (VAS). RESULTS: Across the groups, patients were comparable regarding age, prostate-specific antigen levels, prostate volume, digital rectal examination findings, and pathohistological diagnosis. VAS scores were lower in group 1 (median, 2.95) than in group 2 (median, 4.95; p<0.001) or group 3 (median, 4.60; p<0.001). The difference between group 2 and group 3 was insignificant (p=0.268). The adjusted mean differences (with adjustment for the above covariates) were as follows: group 1 vs. group 2, -1.43 (95% confidence interval [CI]: -2.25 to -0.60; p<0.001); group 1 vs. group 3, -1.22 (95% CI: -2.04 to -0.41; p=0.001); group 2 vs. group 3, 0.20 (95% CI, -0.63 to 1.04; p=0.836); and group 1 vs. groups 2 and 3, -1.33 (95% CI, -1.92 to -0.73; p<0.001). The procedure was comparably well tolerated across the groups. CONCLUSIONS: Pain perception during prostate biopsy was lower in the LLD position than in the lithotomy position. Intrarectal 2% lidocaine gel does not seem to affect pain perception.

Prostate specific antigen density can help avoid unnecessary prostate biopsies at prostate specific antigen range of 4-10 ng/ml.

Elevated level of prostatic specific antigen (PSA) is an established parameter to help determine the need to perform prostate biopsy. The aim of the present study was to determine whether PSA density (PSAD) could better predict pathologic finding of 12-core prostate biopsy in men with PSA 4-10 ng/mL than PSA alone. Transrectal ultrasound guided biopsy was performed in 125 men with PSA within this range. The rate of cancer detection was 24%. Study results showed a significant difference in PSAD between the two patient groups with negative and positive biopsy findings (P=0.002), while difference in the measured PSA levels was not significant (P=0.091). Study results suggested that PSAD could serve as an additional parameter in predicting negative outcome of prostate biopsy, with a cut-off value of 0.15 ng/mL/mL within PSA range of 4-10 ng/mL (sensitivity 86.7% and negative predictive value 91.5%).