A 12-year follow-up of ANNA/C-TRUS image-targeted biopsies in patients suspicious for prostate cancer.

PURPOSE: PSA screening has been rehabilitated. PSA is not specific and can be elevated by benign reasons. Additionally, a subgroup of patients with prostate hyperplasia may harbor prostate cancer (PCa). During monitoring, the clinician aims to detect significant tumors in time, submitting patients to minimal psychological and physical burden, especially in men with high serum PSA and repeat biopsies. We aimed to determine long-term outcomes with respect to ANNA/C-TRUS ability to detect PCa with six targeted biopsies. METHODS: A subset of 71 patients were enrolled. During monitoring, they were subjected to primary, secondary, or even multiple prostate biopsies when needed. Protocol monitoring included PSA measurements, digital rectal examination (DRE) and imaging. RESULTS: The median follow-up was 12 years. Forty-one patients had a history of negative systematic random biopsies (1-3 sessions). Their age ranges 62-85 years, PSA 0.5-47.3 ng/ml, and the median prostate volume 11-255 cc. During monitoring, 15 patients were diagnosed with PCa. Only two harbored aggressive tumors. The median time to diagnosis was 6 years. All PCa patients are free from biochemical relapse. From the remaining 56 patients, 11 did not have any biopsies, 12 had one, 13 had two, and 20 had three or more biopsy sessions. CONCLUSIONS: ANNA/C-TRUS is a useful method monitoring patients with a risk of PCa. 50-75% of the usually performed biopsy cores could be spared and, after 12 years, 97% of the patients were either without evidence of a PCa or were diagnosed with a good prognosis tumor.

Internal Fusion: exact correlation of transrectal ultrasound images of the prostate by detailed landmarks over time for targeted biopsies or follow-up.

PURPOSE: Innovative imaging modalities are applied for diagnosing and follow-up of prostate cancer (PCa). To perform authentic targeted biopsies and evaluate prostate changes, it is essential to reliably identify and hit targets in their true anatomical location over time. A newly described image correlation method (Internal Fusion) allows precise correlation of serial transrectal ultrasound (TRUS) images in vitro and vivo. Identifiable morphologic structures such as prostatic calcifications define internal anchor points (Internal Landmarks) to facilitate exact correlation. METHODS: After verification of Internal Fusion in vitro, 83 patients were included from January to August 2017 with at least one prior series of 5-mm spaced TRUS images stored as computed tomographic (US-CT) online data set. Two experienced operators collected new images in correlation with each cross-section of the previous examinations based on Internal Landmarks. RESULTS: Of the 83 patients, fifty (60%) had prior negative biopsies. Fourteen (17%) wished US-CT targeted biopsies and PCa were detected in 7/14 patients (50%). Overall, accurate imaging correlations were attained in 369/397 slices (93%). In initial and repeat biopsy, 31/31 and 35/35 images could be correlated detecting PCa in 5/8 (63%) and 2/6 patients (33%). The longest observation of prostate changes over time (Trend Monitoring) with accurate image correlation was 8 years and 6 months. CONCLUSIONS: Internal Fusion by Internal Landmarks ensures exact correlation in long-term follow-up. It is possible to precisely monitor trends in prostate tissue changes. In case of PCa suspicion, biopsies could be targeted with high accuracy by Internal Fusion, even over time.

[Digitalization in urology-challenge and opportunity]. / Digitalisierung in der Urologie ­ Herausforderung und Chance.

Digitalization is changing medicine. In Germany these changes are not highly accepted yet. Medical pathways should be supported and become safer by digital transformation. Furthermore, artificial intelligence (AI) applications are increasingly used in medicine. Only time will tell whether these will decrease the workload and make patient treatment easier, while increasing precision and individualization.. Urology must accept the upcoming new challenges. This can best be done by participating in the development.

Increasing the dose of vardenafil on a daily basis does not improve erectile function after unilateral nerve-sparing radical prostatectomy.

INTRODUCTION: Several treatment regimens for rehabilitation of erectile function (EF) after nerve-sparing radical prostatectomy (nsRP) are currently discussed. The optimal and most cost-effective therapy is still not found yet. AIM: To evaluate the effect of vardenafil, a PDE5 inhibitor, dose escalation on recovery of EF after unilateral nsRP. METHODS: Thirty-six sexually active patients received a unilateral nsRP. All patients completed an International Index of Erectile Function-5 items (IIEF-5) questionnaire concerning EF preoperatively. Group 1 (N = 12 patients) received vardenafil 5 mg/day vs. group 2 (N = 12) who received vardenafil 10 mg/day at night beginning the day of catheter removal. A control of 12 patients underwent follow-up without PDE5 inhibitors. MAIN OUTCOME MEASURE: The IIEF-5 was the primary end point. IIEF-5 questionnaires were completed at baseline, 3, 6, and 12 months after nsRP. RESULTS: In group 1 (5 mg/day vardenafil) the IIEF-5 score decreased from a preoperative 22.4 mean score to 4.2 at 3 months, 8.9 at 6 months, and 13.4 mean score at 12 months after nsRP vs. preoperative 22.8, 4.1 at 3 months, 7.9 at 6 months, and 12.8 mean score at 12 months in group 2 (10 mg/day vardenafil). In the control group the preoperative IIEF-5 mean score of 21.9 decreased to 3.8 at 3 months, 6.1 at 6 months, and 8.9 at 12 months. Statistical evaluation showed significant difference in IIEF-5 score and time to recovery of EF between groups 1 and 3 and between groups 2 and 3 (P < 0.01). No statistical differences were found between groups 1 and 2. CONCLUSIONS: Daily low-dose vardenafil lead to significant improvement of recovery of EF. In this study doubling the dosage did not improve the recovery of EF further.

Laparoscopic adrenalectomy in urological centres - the experience of the German Laparoscopic Working Group.

OBJECTIVE: To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain. PATIENTS AND METHODS: The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed. RESULTS: The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively. CONCLUSION: LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.

Prostate cancer diagnostics: innovative imaging in case of multiple negative biopsies.

OBJECTIVE: According to international guidelines, a primary set of TRUS-guided systematic biopsy should consist of 10-12 tissue samples. If a clinical suspicion of a prostate carcinoma persists, a secondary biopsy session should also involve 10-12 samples. However, if there still is a clinical suspicion of prostate cancer is there a role for innovative imaging guided biopsies? MATERIALS AND METHODS: The available innovative imaging techniques range from MRI, Doppler techniques with and without contrast agents, a renaissance of elastography to computer-assisted evaluation of TRUS signal information. RESULT: All of these methods attempt to make more specific statements on the imaged tissue. Before routine clinical use, a review of the literature is recommended to be able to differentiate between the different methods. Sophisticated modern MRI techniques allow for excellent high-resolution prostate imaging. However, MRI guided biopsies so far are not routine practice and are not recommended in urological guidelines. A literature review reflects differences in stage of development, biopsy performance and clinical validity of the different imaging modalities. Elastography, contrast imaging and C-TRUS/ANNA guided biopsies have been investigated in clinical trails suggesting possible benefits over additional systematic random biopsies alone. Because of the differences in design and clinical maturity of the innovative imaging methods, it is essential to be able to inform the patients about individual evidence-based performance prior to its clinical utilization. CONCLUSION: The ideal time for innovative imaging techniques seems to be in patients with multiple series of negative systematic biopsies possibly leading to a more specific PCa detection. However, patients often ask for a qualitative diagnostic approach right from the beginning. This should only be performed after educating the patient on the experimental and 'non-guideline-conform' character of such a proceeding.

Computerized transrectal ultrasound of the prostate in a multicenter setup (C-TRUS-MS): detection of cancer after multiple negative systematic random and in primary biopsies.

OBJECTIVE: To improve prostate cancer diagnostic imaging, a computer-based analysis of the transrectal ultrasound signal (C-TRUS) was developed. Until recently, the C-TRUS existed only as a stand-alone device. Now, C-TRUS was developed into a network-compatible module (C-TRUS-MS). This new technology allows users to transmit C-TRUS images from any internet platform to C-TRUS-MS investigation. After analysis, the cancer-suspicious marked images are then retransmitted via internet. Targeted biopsies can then be taken at the urologists' office remotely. MATERIALS AND METHODS: This prospective study investigates whether the rates of prostate cancer detection with C-TRUS-MS "multicenter online" are comparable with those achieved by the stand-alone unit. In addition to patients with a history of multiple systematic random biopsies, a group of patients who had not undergone systematic random biopsies were analyzed. RESULTS: A total of 1,545 digital images (2-23 per patient, median 6) from 57 urologists were transmitted to the analysis center. After analysis, the color-coded images were sent back electronically and utilized for a maximum of six targeted biopsies. C-TRUS-MS was able to detect prostate cancer in 91 patients. In addition, we evaluated 75 patients without any previous random biopsies. In this group, C-TRUS-MS was able to detect prostate cancer in 31 out of 75 patients (41%). CONCLUSION: The results indicate that C-TRUS-MS "online" achieves similar results as the stand-alone system, independent of the user even with little experience in the method. Furthermore, C-TRUS-MS for the first time is able to detect carcinomas in patients without prior biopsies in a high number by taking only six targeted biopsies.

Can transrectal prostate ultrasound compete with multiparametric MRI in the detection of clinically significant prostate cancer?

We consider the current and future role of transrectal ultrasound imaging in the diagnosis of prostate cancer, with a particular focus on the pre-biopsy localization and targeting role that multiparametric MRI (mpMRI) has come to occupy for some men in recent years. We draw a distinction between transrectal ultrasound (TRUS) used only as a means of distributing zonal biopsies with its employment as a means for identifying and targeting sonographically abnormal lesions. The role of AI in lesion identification and targeting will be reviewed. Comparisons of cost and availability, frequency of contraindications and diagnostic accuracy between these two imaging modalities will be drawn.

Innovative endoscopic enucleations of the prostate - Xie's Prostate Enucleations.

In the past 2 decades, endoscopic enucleation of the prostate has become a safe and effective surgical treatment for benign prostatic hyperplasia (BPH), with comparable outcomes to traditional surgeries. Transurethral vapor enucleation and resection of the prostate (TVERP), transurethral vapor enucleation of the prostate (TVEP), and ultrasound-navigated TVEP (US-TVEP) are new, innovative endoscopic enucleation procedures. These procedures are named Xie's Prostate Enucleations (Xie's Procedures for short). Current clinical data indicate that Xie's Procedures are safe and effective treatment options for patients with BPH, especially for patients with larger prostates. Further prospective, randomized clinical trials compared with traditional transurethral resection of prostate (TURP) are still needed.

Ensuring Consistent European-Wide Urological Care by the Use of Evidence-Based Clinical Practice Guidelines: Can We Do Better.

The European Association of Urology (EAU) annually updates 21 clinical practice guidelines in which summaries of the evidence base and best practice recommendations are made. The methodology applied to achieve this and integrate stakeholder opinion is continuously improving. However, there is evidence to suggest wide variation in clinical practice indicating that many patients receive suboptimal and heterogeneous care. Studies from certain countries suggest that 2 out of 5 patients do not receive care according to the current scientific evidence, and in 1 out of 4 cases the care provided is potentially harmful. Clearly, the harmonisation of care in alignment with evidence-based best practice recommendations is something to strive for. Development of robust methods to disseminate and implement guideline recommendations and measure their impact is an objective the EAU is committed to improving. An important strategy for achieving harmonisation in urological care across Europe is to ensure the availability of high-quality clinical practice guidelines and to actively promote their implementation by clinicians and healthcare providers.

GEC/ESTRO-EAU recommendations on temporary brachytherapy using stepping sources for localised prostate cancer.

BACKGROUND AND PURPOSE: The aim of this paper is to present the GEC/ESTRO-EAU recommendations for template and transrectal ultrasound (TRUS) guided transperineal temporary interstitial prostate brachytherapy using a high dose rate iridium-192 stepping source and a remote afterloading technique. Experts in prostate brachytherapy developed these recommendations on behalf of the GEC/ESTRO and of the EAU. The paper has been approved by both GEC/ESTRO steering committee members and EAU committee members. PATIENTS AND METHODS: Interstitial brachytherapy (BT) to organ confined prostate cancer can be applied as a boost treatment in combination with external beam radiation therapy (EBRT) using a proper number of BT fractions in curative intent. Temporary transperineal BT alone or in combination with EBRT are feasible as a palliative/salvage treatment modality because of local recurrence, however, without large clinical experience. The use of temporary BT as a monotherapy is subject of ongoing clinical research. RESULTS: Recommendations for pre-treatment investigations, patient selection, equipment and facilities, the clinical team, the implant procedure (treatment planning and needle implantation) dose and fractionation, reporting, management of side effects and follow-up are given. CONCLUSIONS: These recommendations are intended to be technically and advisory in nature, but the ultimate responsibility for the medical decision rests with the treating physician. Although, this paper represents the consensus of an interdisciplinary group of experts, TRUS and template guided temporary transperineal interstitial implants in prostate cancer are a constantly evolving field and the recommendations are subject to modifications as new data become available.

EAU standardised medical terminology for urologic imaging: a taxonomic approach.

BACKGROUND: The terminology and abbreviations used in urologic imaging have generally been adopted on an ad hoc basis by different speciality groups; however, there is a need for shared nomenclature to facilitate clinical communication and collaborative research. OBJECTIVE: This work reviews the current nomenclature for urologic imaging used in clinical practice and proposes a taxonomy and terminology for urologic imaging studies. DESIGN, SETTING, AND PARTICIPANTS: A list of terms used in urologic imaging were compiled from guidelines published by the European Association of Urology and the American Urological Association and from the American College of Radiology Appropriateness Criteria. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Terms searched were grouped into broad categories based on technology, and imaging terms were further stratified based on the anatomic extent, contrast or phases, technique or modifiers, and combinations or fusions. Terms that had a high degree of utilisation were classified as accepted. RESULTS AND LIMITATIONS: We propose a new taxonomy to define a more useful and acceptable nomenclature model acceptable to all health professionals involved in urology. The major advantage of a taxonomic approach to the classification of urologic imaging studies is that it provides a flexible framework for classifying the modifications of current imaging modalities and allows the incorporation of new imaging modalities. The adoption of this hierarchical classification model ranging from the most general to the most detailed descriptions should facilitate hierarchical searches of the medical literature using both general and specific terms. This work is limited in its scope, as it is not currently all-inclusive. This will hopefully be addressed by future modification as others embrace the concept and work towards uniformity in nomenclature. CONCLUSIONS: This paper provides a noncomprehensive list of the most widely used terms across different specialties. This list can be used as the basis for further discussion, development, and enhancement. PATIENT SUMMARY: In this paper we describe a classification system for urologic imaging terms with the aim of aiding health professionals and ensuring that the terms used are more consistent.

Long-term outcome after elective irradiation of the pelvic lymphatics and local dose escalation using high-dose-rate brachytherapy for locally advanced prostate cancer.

PURPOSE: To report the 8-year outcome of local dose escalation using high-dose-rate conformal brachytherapy combined with elective irradiation of the pelvic lymphatics for localized prostate cancer. METHODS AND MATERIALS: One hundred forty-four consecutively treated men (1986-1992) were recorded prospectively. Twenty-nine (20.14%) patients had T1b-2a tumors, and 115 (79.86%) patients had T2b-3 tumors according to, respectively, American Joint Committee on Cancer/Union Internationale Contre le Cancer 1992. All patients had a negative nodal status, proven by CT or MRI. The mean initial PSA value was 25.61 ng/mL (Initial value for 41.66% of patients was <10 ng/mL, for 21.52% was 10-20 ng/mL, and for 32.63% was >20 ng/mL). The total dose applied by external beam radiotherapy was 50 Gy in the pelvis and 40 Gy in the prostate. The high-dose-rate brachytherapy was delivered in two fractions, which were incorporated into the external beam treatment (after 20-Gy and 40-Gy external beam radiotherapy dose). The dose per fraction was 15 Gy for the PTV1 (peripheral prostate zone) and 9 Gy for the PTV2 (entire prostatic gland). Any patient free of clinical or biochemical evidence of disease was termed bNED. Actuarial rates of outcome were calculated by Kaplan-Meier and compared using the log-rank. Cox regression models were used to establish prognostic factors of the various measures of outcome. RESULTS: The median follow-up was 8 years (range 60-171 months). The overall survival rate was 71.5%, and the disease-free survival rate was 82.6%. The bNED survival rate was 72.9%. Freedom from local recurrence for T3 stage was 91.3%, whereas for G3 lesions it was 88.23%. Freedom from distant recurrence for T3 stage was 82.6% and for G3 lesions 70.59%. Univariate survival analyses revealed that low stage (T1-2), low grade (G1-2), no hormonal therapy, initial PSA value less than 40 ng/mL, and PSA normalization <1.0 ng/mL after irradiation were associated with long survival. In multivariate analyses, initial PSA value, PSA kinetics after radiation therapy, and no adjuvant hormonal treatment were independent prognostic factors. Grade 3 late radiation toxicity (according to RTOG/EORTC scoring scheme) was 2.3% for the genitourinary system in terms of cystitis and 4.10% for the gastrointestinal system in terms of proctitis. Grades 4 and 5 genitourinary/gastrointestinal morbidity was not observed. A history of transurethral resection of the prostate with a median interval of less than 6 months from radiotherapy was associated with a high risk of genitourinary toxicity. CONCLUSION: The 8-year results confirm the feasibility and effectiveness of combined elective irradiation of the pelvic lymphatics and local dose escalation using high-dose-rate brachytherapy for cure of localized and especially high-risk prostate cancer.

Expression of human beta-defensins 1 and 2 in kidneys with chronic bacterial infection.

BACKGROUND: Constitutive expression and localization of antimicrobial human beta-defensin-1 (HBD-1) in human kidneys as a potential mechanism of antimicrobial defense has been previously reported. Inducible expression of human beta-defensin-2 (HBD-2) has been described in various epithelial organs but not for the urogenital tract. METHODS: We investigated the gene- and protein expression of HBD-1 and HBD-2 by reverse transcriptase-polymerase chain reaction, and immunohistochemistry in 15 normal human kidney samples and 15 renal tissues with chronic bacterial infection. Additionally, cell culture experiments were performed to study HBD gene expression by real-time RT-PCR in response to inflammatory cytokines TNFalpha and IL-1beta as well as lipopolysaccharide from Gram-negative bacteria. RESULTS: Constitutive HBD-1 gene- and protein expression was detected in normal renal tissue and kidneys with chronic infection. As a novel finding, inducible HBD-2 gene- and protein expression was demonstrated in tubulus epithelia with chronic infection but not in normal renal tissue. In pyelonephritic kidneys HBD-1 and HBD-2 expression showed a similar pattern of localization in distal tubules, loops of Henle and in collecting ducts of the kidney. Furthermore, real-time RT-PCR of kidney derived cell lines stimulated with inflammatory agents TNF-alpha, IL-1beta and LPS revealed a strong increase in relative HBD-2 transcription level and also a slight increase in relative HBD-1 transcription level. CONCLUSIONS: Upregulated HBD-2 expression in renal tubulus epithelium indicates a role of a wider range of human defensins for antimicrobial host defense in the urogenital tract than previously recognized.