Prostate cancer risk stratification using magnetic resonance imaging-ultrasound fusion vs systematic prostate biopsy.

BACKGROUND: Image-guided approaches improve the diagnostic yield of prostate biopsy and frequently modify estimates of clinical risk. To better understand the impact of magnetic resonance imaging-ultrasound fusion targeted biopsy (MRF-TB) on risk assessment, we compared the distribution of National Comprehensive Cancer Network (NCCN) risk groupings, as calculated from MRF-TB vs systematic biopsy alone. METHODS: We performed a retrospective analysis of 713 patients who underwent MRF-TB from January 2017 to July 2021. The primary study objective was to compare the distribution of National Comprehensive Cancer Network risk groupings obtained using MRF-TB (systematic + targeted) vs systematic biopsy. RESULTS: Systematic biopsy alone classified 10% of samples as very low risk and 18.7% of samples as low risk, while MRF-TB classified 10.5% of samples as very low risk and 16.1% of samples as low risk. Among patients with benign findings, low-risk disease, and favorable/intermediate-risk disease on systematic biopsy alone, 4.6% of biopsies were reclassified as high risk or very high risk on MRF-TB. Of 207 patients choosing active surveillance, 64 (31%), 91 (44%), 42 (20.2%), and 10 (4.8%) patients were classified as having very low-risk, low-risk, and favorable/intermediate-risk and unfavorable/intermediate-risk criteria, respectively. When using systematic biopsy alone, 204 patients (28.7%) were classified as having either very low-risk and low-risk disease per NCCN guidelines, while 190 men (26.6%) received this classification when using MRF-TB. CONCLUSION: The addition of MRF-TB to systematic biopsy may change eligibility for active surveillance in only a small proportion of patients with prostate cancer. Our findings support the need for routine use of quantitative risk assessment over risk groupings to promote more nuanced decision making for localized cancer.

Ejaculatory Preserving Holmium Laser Enucleation of the Median Lobe: Preserving Sexual Function While Improving Urinary Outcomes.

OBJECTIVE: To evaluate perioperative outcomes related to sexual and urinary function in patients who underwent a holmium laser enucleation of the prostate (HoLEP) with selective laser enucleation of the median lobe. MATERIALS AND METHODS: We retrospectively reviewed the first 450 HoLEP cases by a single surgeon from April 2019 to March 2022. Fifty-five patients with intravesical-prostatic protrusion or high bladder neck without obstructing lateral lobes underwent selective enucleation of the median lobe of the prostate. Patients were asked to comment on whether they had retrograde ejaculation during their follow-up appointment. Urinary function was assessed using the American Urological Association Symptom Score and subjective evaluation of urinary incontinence. RESULTS: Median age of the cohort was 65 years (range: 44-91). Compared to preoperative, there was significant improvement in mean postoperative American Urological Association Symptom Score (22.5 vs 6.9, P < .001), mean postoperative quality of life scores (4 vs 1.2, P < .001), and mean postoperative post void residual volumes (244.1 vs 69.3 cc, P < .001). No patients reported stress urinary incontinence. Of the 55 patients who underwent selective enucleation of the median lobe, 40 were sexually active. Of those men, 35 reported normal ejaculation, 3 had retrograde ejaculation that was unchanged from pre-op, and 2 had new ejaculatory dysfunction. CONCLUSION: In this case series of selective laser enucleation of the median lobe, urinary function significantly improved in short-term follow-up with preservation of ejaculation in approximately 90% of men.