Contemporary patterns of local ablative therapies for prostate cancer at United States cancer centers: results from a national registry.

PURPOSE: To describe the national-level patterns of care for local ablative therapy among men with PCa and identify patient- and hospital-level factors associated with the receipt of these techniques. METHODS: We retrospectively interrogated the National Cancer Database (NCDB) for men with clinically localized PCa between 2010 and 2017. The main outcome was receipt of local tumor ablation with either cryo- or laser-ablation, and "other method of local tumor destruction including high-intensity focused ultrasound (HIFU)". Patient level, hospital level, and demographic variables were collected. Mixed effect logistic regression models were fitted to identify separately patient- and hospital-level predictors of receipt of local ablative therapy. RESULTS: Overall, 11,278 patients received ablative therapy, of whom 78.8% had cryotherapy, 15.6% had laser, and 5.7% had another method including HIFU. At the patient level, men with intermediate-risk PCa were more likely to be treated with local ablative therapy (OR 1.05; 95% CI 1.00-1.11; p = 0.05), as were men with Charlson Comorbidity Index > 1 (OR 1.36; 95% CI 1.29-1.43; p < 0.01), men between 71 and 80 years (OR 3.70; 95% CI 3.43-3.99; p < 0.01), men with Medicare insurance (OR 1.38; 95% 1.31-1.46; p < 0.01), and an income < $47,999 (OR 1.16; 95% CI 1.06-1.21; p < 0.01). At the hospital-level, local ablative therapy was less likely to be performed in academic/research facilities (OR 0.45; 95% CI 0.32-0.64; p < 0.01). CONCLUSIONS: Local ablative therapy for PCa treatment is more commonly offered among older and comorbid patients. Future studies should investigate the uptake of these technologies in non-hospital-based settings and in light of recent changes in insurance coverage.

Dual-Energy Computed Tomography for Stone Type Assessment: A Pilot Study of Dual-Energy Computed Tomography with Five Indices.

Purpose: To assess the efficacy of dual-energy CT (DECT) in predicting the composition of urinary stones with a single index (dual energy ratio [DER]) and five indices. Methods: Patients undergoing DECT before active urolithiasis treatment were prospectively enrolled in the study. Predictions of stone composition were made based on discriminant analysis with a single index (DER) and five indices (stone density at 80 and 135 kV, Zeff [the effective atomic number of the absorbent material] of the stone, DER, dual-energy index [DEI] and dual-energy difference [DED]). After extraction, stone composition was evaluated by means of physicochemical analyses (X-ray phase analysis, electron microscopy, wet chemistry techniques, and infrared spectroscopy). Results: A total of 91 patients were included. For calcium oxalate monohydrate (COM) stones, the sensitivity, specificity, and overall accuracy of DECT with one index (DER) were 83.3%, 89.8%, and 86.8%, respectively; for calcium oxalate dihydrate (COD) and calcium phosphate stones-88.2%, 92.9%, and 91.2%, respectively; for uric acid stones-0%, 98.8% and 97.8%, respectively; for struvite stones-60%, 95.3%, and 93.4%, respectively. Discriminant analysis with five indices yielded the following sensitivity, specificity, and overall accuracy: 95.2%, 89.8%, and 92.3% for COM stones, 85.3%, 96.4%, and 92.3% for COD stones, and 100% in all three categories for both uric acid and struvite stones. Conclusions: DECT is a promising tool for stone composition assessment. It allowed for evaluation of chemical composition of all stone types with specificity and accuracy ranging from 85% to 100%. Five DECT indices have shown much better diagnostic accuracy compared to a single DECT index.

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.

Accuracy of multiparametric MR imaging with PI-RADS V2 assessment in detecting infiltration of the neurovascular bundles prior to prostatectomy.

OBJECTIVES: To evaluate the accuracy of assessment of neurovascular bundle (NVB) infiltration using multiparametric magnetic resonance imaging (mpMRI) and PI-RADS V2 prior to prostatectomy. METHODS: The ethics committee approved this retrospective study with waiver of informed consent. N=198 consecutive patients with biopsy proved cancer underwent standardized mpMRI at 3T prior to surgery. NVB infiltration was assessed for each side (a total of 396). Maximum PI-RADS V2 scores were determined for the posterolateral areas adjacent to the NVBs. Imaging results were correlated with postoperative pathology and standard descriptive statistics were calculated. RESULTS: Overall T-staging sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of mpMRI were 64.4%, 89.2%, 82.4%, 76.2% and 78.3%, respectively. In 396 cases NVB infiltration was predicted with 75.3%, 94.0%, 80.2%, 92.1 % and 89.4 % sensitivity, specificity, PPV, NPV and accuracy, respectively. Analyses of 396 NVB and their adjacent PI-RADS V2 scores with pathology revealed significantly more NVB-infiltrations in suspect scores of 5 and 4 vs. uncertain scores of 3-1 (81/264 vs. 16/132, p=0.0001). Considering scores higher than 3 as a criterion of infiltration demonstrated moderate sensitivity and poor specificity (83.5% and 38.8%, respectively). Interobserver agreement of a second reading of a random sample was good (κ=0.64) for NVB infiltrations and moderate (κ=0.59) for PI-RADS V2. CONCLUSIONS: Assessment of infiltration of the neurovascular bundles using mpMRI has valuable diagnostic performance, yet PI-RADS V2 Scores demonstrate limited eligibility. Combined findings offer crucial information for the planning of prostatectomy.

Shear wave elastography for localization of prostate cancer lesions and assessment of elasticity thresholds: implications for targeted biopsies and active surveillance protocols.

PURPOSE: Shear wave elastography allows the detection of cancer by using focused ultrasound pulses for locally deforming tissue. The differences in tissue elasticity and stiffness have been used increasingly in breast cancer imaging and help detect potential tumor lesions in the prostate. In this study we localized prostate cancer lesions using shear wave elastography before radical prostatectomy and assessed the examiner independent elasticity threshold for cancer foci detection. MATERIALS AND METHODS: Shear wave elastography scanning of the whole prostate was performed before radical prostatectomy in 60 consecutive patients with high, intermediate and low risk disease. Localization of suspected lesions and density threshold (kPa) were recorded in up to 12 areas and resulted in 703 different fields. Shear wave elastography findings were correlated with final pathology. Initially 381 areas were used to establish shear wave elastography cutoffs (development cohort 32 patients). Subsequently these cutoffs were validated in 322 areas (validation cohort 28 patients). RESULTS: Using shear wave elastography significant differences were recorded for the elasticity of benign tissue vs prostate cancer nodules at 42 kPa (range 29 to 71.3) vs 88 kPa (range 54 to 132) (all p <0.001). Median cancer lesion diameter was 26 mm (range 18 to 41). Applying the most informative cutoff of 50 kPa to the validation cohort resulted in 80.9% and 69.1% sensitivity and specificity, respectively, and 74.2% accuracy for detecting cancer nodules based on final pathological finding. The corresponding positive and negative predictive values were 67.1% and 82.2%, respectively. CONCLUSIONS: Shear wave elastography allows the identification of cancer foci based on shear wave elastography differences. Moreover, reliable cutoffs for this approach can be established, allowing examiner independent localization of prostate cancer foci.

Assessment of rates of lymph nodes and lymph node metastases in periprostatic fat pads in a consecutive cohort treated with retropubic radical prostatectomy.

OBJECTIVE: To determine the rates of lymph nodes and lymph node metastases in periprostatic fat pads yielded during exposure of the anterior surface of the dorsal vein complex, puboprostatic ligaments, and endopelvic fascia during radical prostatectomy. METHODS: Histopathologic examination was performed in 356 patients who underwent radical prostatectomy between July 2010 and September 2010 at a single institution. Separate histologic work-up of the periprostatic fat pads addressed the presence of lymph nodes and possible metastatic invasion of lymph nodes within this area. Descriptive analyses and multivariable analyses to predict the presence of lymph node metastases within these fat pads were performed. RESULTS: Lymph nodes within periprostatic fat pads were detected in 19 (5.5%) patients. Among these patients, tumor infiltration was found in 4 (1.2%). Three of these 4 patients harbored lymph node metastases without any other lymph node metastasis during standard lymphadenectomy. No relationship was detected between the total number of lymph nodes removed and the detection of lymph nodes within periprostatic fat pads (P = .6). CONCLUSION: Our analysis demonstrates that periprostatic fat pads harbor lymph nodes. No relationship between the presence of lymph node metastases in periprostatic fat pads and the presence of lymph node metastases in other areas was found. Similarly, no relationship exists between the presence of lymph nodes in this area and the total number of lymph nodes yielded in other lymphatic fields. Therefore, for guaranteeing precise lymph node staging, implementing routinely pathologic work-up of periprostatic fat pads yielded during radical prostatectomy should be considered.

Risk assessment of metastatic recurrence in patients with prostate cancer by using the Cancer of the Prostate Risk Assessment score: results from 2937 European patients.

UNLABELLED: Study Type--Prognosis (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Different tools allow the individual estimation of the various endpoints in patients with prostate cancer. The Cancer of the Prostate Risk Assessment (CAPRA) score is an easy to calculate prediction tool, based on a large population based database. However, little is known about the performance of this prediction tool in European patients. The data obtained in the present study demonstrate differences in tumour characteristics between European patients and the initial development cohort from the USA. However, the concordance index of the CAPRA scores for predicting biochemical recurrence and metastatic recurrence was 76.2 and 78.5, respectively, in European patients. Therefore, the CAPRA score also allows reliable prediction of the examined endpoints in European patients. OBJECTIVES: • To assess the ability of the Cancer of the Prostate Risk Assessment Score (CAPRA) score for predicting biochemical recurrence (BCR) and metastatic recurrence (MR) by using a large cohort of European patients with prostate cancer. • The CAPRA score was initially developed using patients treated in community-based hospitals in the USA and allows a prediction of the risk of different clinical endpoints, without incorporating the surgical margin status. PATIENTS AND METHODS: • BCR and metastatic recurrence rates were studied in 2937 patients who underwent radical prostatectomy in a tertiary referral centre after a mean (median, range) follow-up of 49 (56, 12-220) months. • The association between the examined endpoints, individual CAPRA scores and pathological features was analyzed by using Kaplan-Meier, proportional hazard and logistic regressions analyses. • Graphical representation assessed the calibration of the CAPRA score for predicting both endpoints. RESULTS: • Compared to the initial development cohort, worse tumour characteristics and a lower overall positive surgical margin rate (17.2% vs 32.4%) were detected in the European cohort. • Overall, 530 (18.4%) and 58 (1.9%) of patients developed BCR and MR. Increasing CAPRA scores were related to less favourable pathological characteristics and higher BCR and metastatic recurrence rates. • For example, the 5-year BCR and metastatic recurrence rates were markedly different at the extremes of 0-1 vs ≥ 8 (9.2% vs 70.8% and 0.7% vs 16.4%, respectively). • The concordance index for the prediction of BCR and metastatic recurrence was 76.2 and 78.5, respectively. CONCLUSIONS: • Despite differences between the present cohort and the initial development cohort with respect to clinical features and the outcomes achieved, the data obtained in the present study shows the generalizability of the CAPRA score. • Specifically, the data allow the precise identification of those European patients who are at high risk for BCR and MR.

Importance of baseline potency rate assessment of men diagnosed with clinically localized prostate cancer prior to radical prostatectomy.

INTRODUCTION: Erectile dysfunction (ED) is a common, and multifactorial medical problem with significant impact on quality of life. Knowledge about baseline potency is highly important in men undergoing treatment for prostate cancer (PCa) as it might influence judgments about impact of treatment and thereby treatment decisions. AIMS: To analyze the baseline potency rate of men with clinically localized PCa prior to radical prostatectomy (RP). Furthermore, it was of interest to identify comorbid factors of preoperative ED. MAIN OUTCOME MEASURE: Prevalence of preoperative ED and association between comorbidities and ED in men prior to RP in bi- and multivariable logistic regression analyses. METHODS: Retrospective analysis of a large single center cohort of 1,330 evaluable PCa patients who were preoperatively assessed with the abridged 5-item version of the International Index of Erectile Function (IIEF) also described as Sexual Health Inventory for Men. Baseline potency and comorbidity rates, and their distribution were described. The risk of baseline ED associated with age, body mass index (BMI), the presence of hyperlipoproteinemia (HLP), non-insulin-dependent diabetes mellitus (NIDDM), hypertension, and depression were analyzed in bi- and multivariable logistic regression analyses. RESULTS: Using the IIEF-5 cutoff value of 21, 48% demonstrated some degree of ED. Severe, moderate, mild to moderate, mild, and no ED was observed in 9.2, 4.0, 10.2, 24.7, and 52% respectively. In univariable analyses, ED significantly increased according to increasing age, BMI, presence of HLP, hypertension, NIDDM, and depression (P