Multiparametric magnetic resonance imaging for prostate cancer-a comparative study including radical prostatectomy specimens.

PURPOSE: To evaluate the diagnostic and staging ability of multiparametric MRI (mpMRI) compared to radical prostatectomy (RP) specimens after dissemination of this technology to several centres. mpMRI is an evolving technique aiming to improve upon the diagnostic sensitivity of prostate biopsy for the diagnosis of prostate cancer. Differences in interpretation, expertise and application of mpMRI are responsible for the range of reported results. METHODS: This retrospective clinical study was conducted with consecutive patients through an electronic database of tertiary hospitals and adjacent private urology practices in Australia. Patients having undergone RP were assessed for the presence of a pre-operative mpMRI performed between 2013 and 2015 which was evaluated against the reference standard of the RP whole-mount specimen. MRI reports were evaluated using the Prostate Imaging Reporting and Data System (PI-RADS). RESULTS: In our cohort of 152 patients, the sensitivity and specificity of mpMRI (PI-RADS ≥ 4) for prostate cancer (Gleason ≥ 4 + 3) detection were 83 and 47%, respectively. For the identification of extraprostatic disease, the sensitivity and specificity were 29 and 94%, respectively. CONCLUSION: These results represent a 'real-world' approach to mpMRI and appear comparable to other single-centre studies. MRI staging information should be interpreted in context with other risk factors for extraprostatic disease. mpMRI has a useful role as an adjunct for prostate cancer diagnosis and directing management towards improving patient outcomes.

The current use of active surveillance in an Australian cohort of men: a pattern of care analysis from the Victorian Prostate Cancer Registry.

OBJECTIVES: To ascertain the treatment trends and patterns of care, for men with prostate cancer on active surveillance (AS) in Victoria, Australia. PATIENTS AND METHODS: De-identified data was obtained for 6424 men from the Victorian Prostate Cancer Registry. Men included in this study were diagnosed with prostate cancer from 2008 to August 2012 with ≥ 12-months of follow-up. Patients were stratified using the National Comprehensive Cancer Network (NCCN) risk grouping system and those who were not actively treated were identified. Data was acquired to describe the trends and uptake of AS according to public vs private hospital sector, and regional vs metropolitan regions. RESULTS: In all, 1603/6424 (24.9%) men received no treatment with curative intent at 12-months follow-up. This cohort included patients in whom the chosen management plan was recorded as AS (980/1603, 61.1%), watchful waiting (341/1603, 21.3%), or no management plan (282/1603, 17.6%). From this, 980/6424(15.3%) of the patients were recorded as being on AS across all NCCN categories at 12 months after diagnosis. This included 653/1816 (35.9%) of very low- and low-risk men, and 251/2820 (8.9%) of intermediate-risk men. Of our patients on AS, 169/980 (17.2%) progressed onto active treatment after 12 months. This active treatment included radical prostatectomy in 116 (68.6%), 32 (18.9%) undergoing external beam radiation therapy, 12 (7.1%) undergoingt brachytherapy and nine (5.3%) undergoing androgen-deprivation therapy. Overall, 629/979 (64.2%) of the AS patients were notified from a private hospital, with 350/979 (35.7%) of the patients notified from a public hospital (one patient unclassified). Of these, 202/652 (30.9%) of the AS patients with very low-/low-risk disease were managed in the public sector, vs 450/652 (69%) of very low-/low-risk AS patients being managed in the private sector. In our cohort, patients with very low- and low-risk disease, managed in a private hospital, were more likely to be on AS (P = 0.005). AS patients in the private sector were also a median of 2.8 years younger (median 65.6 vs 68.4 years, P < 0.001); had a lower median PSA level (5.3 vs 6.7 ng/mL, P < 0.001); and had lower biopsy Gleason score and clinical staging. There was no significant difference in the uptake of AS demographically, in our cohort of men between metropolitan and regional areas. CONCLUSION: In this contemporary registry-based population, AS is being used in a significant proportion of patients. The proportion of men progressing to intervention is lower than that reported in the current literature. Patients are more likely to be on AS if they are managed in a private hospital, with no differences in the uptake of AS, from metropolitan to regional areas.

Transperineal biopsy prostate cancer detection in first biopsy and repeat biopsy after negative transrectal ultrasound-guided biopsy: the Victorian Transperineal Biopsy Collaboration experience.

OBJECTIVES: To present the Victorian Transperineal Biopsy Collaboration (VTBC) experience in patients with no prior prostate cancer diagnosis, assessing the cancer detection rate, pathological outcomes and anatomical distribution of cancer within the prostate. PATIENTS AND METHODS: VTBC was established through partnership between urologists performing transperineal biopsies of the prostate (TPB) at three institutions in Melbourne. Consecutive patients who had TPB, as first biopsy or repeat biopsy after previous negative transrectal ultrasound-guided (TRUS) biopsy, between September 2009 and September 2013 in the VTBC database were included. Data for each patient were collected prospectively (except for TPB before 2011 in one institution), based on the minimum dataset published by the Ginsburg Study Group. Univariate and multivariate analyses were used to identify factors predictive of cancer detection on TPB. RESULTS: In all, 160 patients were included in the study, of whom 57 had TPB as first biopsy and 103 had TPB as repeat biopsy after previous negative TRUS biopsies. The median patient age at TPB was 63 years, with the repeat-biopsy patients having a higher median serum PSA level (5.8 ng/mL for first biopsy and 9.6 ng/mL for repeat biopsy) and larger prostate volumes (40 mL for first biopsy, and 51 mL for repeat biopsy). Prostate cancer was detected in 53% of first-biopsy patients and 36% of repeat-biopsy patients, of which 87% and 81%, respectively, were clinically significant cancers, defined as a Gleason score of ≥7, or more than three positive cores of Gleason 6. Of the cancers detected in repeat biopsies, 75% involved the anterior region (based on the Ginsburg Study Group's recommended biopsy map), while 25% were confined exclusively within the anterior region; a lower proportion of only 5% of cancers detected in first biopsies were confined exclusively within the anterior region. Age, serum PSA level and prostate volume were predictive of cancer detection in repeat biopsies, while only age was predictive in first biopsies. CONCLUSIONS: TPB is an alternative approach to TRUS biopsy of the prostate, offering a high rate of detection of clinically significant prostate cancer. It provides excellent sampling of the anterior region of the prostate, which is often under-sampled using the TRUS approach, and should be considered as an option for all men in whom a prostate biopsy is indicated.

Sepsis and 'superbugs': should we favour the transperineal over the transrectal approach for prostate biopsy?

OBJECTIVE: To determine the rate of hospital re-admission for sepsis after transperineal (TP) biopsy using both local data and worldwide literature, as there is growing interest in TP biopsy as an alternative to transrectal ultrasonography (TRUS)-guided biopsy for patients undergoing repeat prostate biopsy. PATIENTS AND METHODS: Pooled prospective databases on TP biopsy from multiple centres in Melbourne were queried for rates of re-admission for infection. A literature review of PubMed and Embase was also conducted using the search terms: 'prostate biopsy, fever, infection, sepsis, septicaemia and complications'. RESULTS: In all, 245 TP biopsies were performed (111 at Alfred Health, 92 at Epworth Healthcare, 38 at Peter MacCallum Cancer Centre, and four at other institutions). The rate of hospital re-admission for infection was zero. The literature review showed that the rate of sepsis after TRUS biopsy appears to be rising with increasing rates of multi-resistant bacteria found in rectal flora, and is as high as 5%. However, the rate of sepsis from published series of TP biopsy approached zero. CONCLUSIONS: Both local and international data suggest a negligible rate of sepsis with TP biopsy. This compares to a concerning rise in the rate of sepsis after TRUS biopsy due to the increasing prevalence of multi-resistant bacteria in rectal flora. Although TRUS biopsy is convenient, cheap and quick to perform, we think that TP biopsy should now be offered as an option, not only to patients undergoing repeat prostate biopsy, but to all patients in whom a prostate biopsy is indicated.

Algorithm for selecting men for pelvic lymph node dissection (PLND) during radical prostatectomy based on clinical risk factors in an Australian population.

OBJECTIVE: To define selection criteria for pelvic lymph node dissection (PLND) based on a contemporary Australian cohort of men with clinically localised prostate cancer undergoing radical prostatectomy (RP) with PLND, as stage migration of prostate cancer has led to re-evaluation of the role of PLND at the time of RP. PATIENTS AND METHODS: In all, 200 consecutive men treated by one surgeon between 2000 and 2005 with open RP and PLND. The clinical and pathological data were extracted by retrospective chart review. Associations between clinical predictors and LN positivity were assessed by logistic regression analysis. RESULTS: Overall, there were LN metastases were in 10 (5%) men. The LN positivity rate was significantly associated with biopsy Gleason score, preoperative prostate-specific antigen (PSA) concentration and percentage of positive cores (PPC), with respective odds ratios (OR) (95% confidence interval [CI]) of 3.70 (1.98-6.92), 1.11 (1.04-1.19) and 1.04 (1.01-1.06) Trend toward significant association with clinical stage (OR 1.75, 95% CI 0.97-3.13) On multivariate analysis, PSA concentration and biopsy Gleason score were significant predictors of LN disease. All 10 men with LN metastases came from a high-risk group of 96, identifiable by having at least one of the following: stage ≥ cT2b, biopsy Gleason score ≥ 4+3, PSA concentration of ≥ 10 ng/mL or PPC of ≥ 38%. CONCLUSIONS: The risk of LN metastases depends upon well-defined clinical risk factors of stage, biopsy Gleason score, PSA concentration and PPC. The present data suggests a simple risk-stratification method, using these risk factors, of identifying men to have PLND at the time of RP.

Draping and associated equipment for indwelling catheter manipulation by hospital staff: an assessment of attitudes and adequacy.

OBJECTIVE: To address the usability and safety aspects of current equipment for indwelling urinary catheter (IDC) manipulation, by assessing the attitudes of doctors and nurses to infection control, occupational health and environmental waste, and the perceived adequacy of available catheter packs, particularly drapes, when performing such manipulations. SUBJECTS AND METHODS: A self-administered survey instrument was created using an online database and completed by doctors and nurses. The survey covered basic demographics and experience with IDC, attitudes to infection control, occupational health and safety, and the environment, as well as adequacy of current equipment in containing spillage of urine and/or blood. RESULTS: In all, 87 doctors and 228 nurses completed 315 of 350 (90%) surveys. Doctors and nurses were concerned about infection control, occupational health and safety issues, and environmental waste. Incidents involving spillage of urine and/or blood often go unreported. There were no differences between nurses and doctors having specialist training in urology or experience (P > 0.05). The second major finding is that available catheter packs, particularly drapes, when manipulating IDCs, are inadequate and spillage is likely. These findings were more pronounced in doctors and those with urology training (P < 0.05). CONCLUSION: The attitudes of health professionals involved with IDC manipulations are consistent with other fields, as is the under-reporting of episodes of contamination by bodily fluids. The current equipment, particularly drapes, are inadequate for containing urine and blood, leading to infection control, occupational health, environmental and cost implications.

Active surveillance for prostate cancer: a narrative review of clinical guidelines.

In the past decade active surveillance (AS) of men with localized prostate cancer has become an increasingly popular management option, and a range of clinical guidelines have been published on this topic. Existing guidelines regarding AS for prostate cancer vary widely, but predominantly state that the most suitable patients for AS are those with pretreatment clinical stage T1c or T2 tumours, serum PSA levels <10 ng/ml, biopsy Gleason scores of 6 or less, a maximum of one or two tumour-positive biopsy core samples and/or a maximum of 50% of cancer per core sample. Following initiation of an AS programme, most guidelines recommend serial serum PSA measurements, digital rectal examinations and surveillance biopsies to check for and identify pathological indications of tumour progression. Definitions of disease reclassification and progression differ among guidelines and multiple criteria for initiation of definitive treatment are proposed. The variety of descriptions of criteria for clinically insignificant prostate cancer indicates a lack of consensus on optimal AS and intervention thresholds. A single set of guidelines are needed in order to reduce variations in clinical practice and to optimize clinical decision-making. To enable truly evidence-based guidelines, further research that combines existing evidence, while also gathering information from more long-term studies is needed.

Current role of multiparametric magnetic resonance imaging in the management of prostate cancer.

The purpose of this review was to evaluate the current role of multiparametric magnetic resonance imaging (mp-MRI) in the management of prostate cancer (PC). The diagnosis of PC remains controversial owing to overdetection of indolent disease, which leads to overtreatment and subsequent patient harm. mp-MRI has the potential to equilibrate the imbalance between detection and treatment. The limitation of the data for analysis with this new technology is problematic, however. This issue has been compounded by a paradigm shift in clinical practice aimed at utilizing this modality, which has been rolled out in an ad hoc fashion often with commercial motivation. Despite a growing body of literature, pertinent clinical questions remain. For example, can mp-MRI be calibrated to reliably detect biologically significant disease? As with any new technology, objective evaluation of the clinical applications of mp-MRI is essential. The focus of this review was on the evaluation of mp-MRI of the prostate with respect to clinical utility.

Magnetic resonance imaging for prostate cancer: Comparative studies including radical prostatectomy specimens and template transperineal biopsy.

PURPOSE: Multiparametric magnetic resonance imaging (mpMRI) is an emerging technique aiming to improve upon the diagnostic sensitivity of prostate biopsy. Because of variance in interpretation and application of techniques, results may vary. There is likely a learning curve to establish consistent reporting of mpMRI. This study aims to review current literature supporting the diagnostic utility of mpMRI when compared with radical prostatectomy (RP) and template transperineal biopsy (TTPB) specimens. METHODS: MEDLINE and PubMed database searches were conducted identifying relevant literature related to comparison of mpMRI with RP or TTPB histology. RESULTS: Data suggest that compared with RP and TTPB specimens, the sensitivity of mpMRI for prostate cancer (PCa) detection is 80-90% and the specificity for suspicious lesions is between 50% and 90%. CONCLUSIONS: mpMRI has an increasing role for PCa diagnosis, staging, and directing management toward improving patient outcomes. Its sensitivity and specificity when compared with RP and TTPB specimens are less than what some expect, possibly reflecting a learning curve for the technique of mpMRI.

Advances in ureteroscopy.

Ureteroscopy (URS) is a procedure which has been constantly evolving since the development of first generation devices 40 years ago. Progress towards smaller and more sophisticated equipment has been particularly rapid in the last decade. We review the significant steps that have been made toward improving outcomes and limiting morbidity with this procedure which is central to the management of urolithiasis and other upper urinary tract pathology.

Predictors of positive surgical margins at open and robot-assisted laparoscopic radical prostatectomy: a single surgeon series.

Robot-assisted laparoscopic radical prostatectomy (RALRP), increasingly used to treat localized prostate cancer, has advantages over open radical prostatectomy (ORP) in terms of reduced bleeding and quicker convalescence. However, debate continues over whether RALRP provides superior or at least equivalent surgical outcomes. This study compares positive surgical margins (+SM), as a surrogate for long-term cancer control, at RALRP and ORP performed by a single experienced surgeon during the process of taking up RALRP. 400 consecutive patients undergoing surgery for prostate cancer under a single surgeon (DW) between November 1999 and July 2009 were studied. Prior to July 2005, all patients underwent ORP; after this date, most patients were treated by RALRP. Data were collected by retrospective chart review and analysed independently of the treating surgeon. +SM were defined as the presence of cancer at an inked surface. Overall, 23 (11.5%) of 200 patients undergoing RALRP had +SM, compared to 40 (20.0%) of 200 patients undergoing ORP (P < 0.05). On univariate logistic regression analysis, in addition to surgical approach (odds ratio [OR] = 1.92), patient age (OR = 1.05), pathologic stage (OR = 3.93) and specimen Gleason (GS) score (OR = 1.86) were significant predictors of +SM. On multivariate analysis, surgical approach, p-stage and specimen GS remained significant predictors of +SM. RALRP is associated with lower rates of +SM compared to ORP, even after adjusting for other known risk factors. Of note, the RALRP in this study were part of the surgeon's learning curve.