Satisfaction and surgical outcomes in patients undergoing penile prosthesis implantation for drug-refractory erectile dysfunction: mid-term results in a single center French cohort.

INTRODUCTION: To investigate the mid-term results of penile prosthesis (PP) implantation in patients with erectile dysfunction (ED) from a "real-life" historic cohort in a French academic center. MATERIALS AND METHODS: All patients receiving an inflatable PP between 2004 and 2014 in our institution were included in this study. ED was assessed preoperatively using the IEEF-5 questionnaire. Postoperative satisfaction with the PP was assessed using the EDITS questionnaire at each follow up visit. Postoperative complications were classed according to the Clavien classification. Surgical and functional outcomes were recorded prospectively. RESULTS: Seventy-six men received a PP during the 10 year study period. Median (IQR) age was 62 (58-69) years. The main causes of ED were radical prostatectomy (n = 40; 53%) and diabetes mellitus (n = 28; 36.8%). Five patients (6.6%) had a non-functioning PP in place requiring complete substitution or a previous penile implant which had already been removed at the time of surgery. Sixty-nine (90.8%) patients received an AMS 700 CX device and seven (9.2%) a Coloplast Titan. The surgical approach was penoscrotal in 45 (59.2%) and infrapubic in 31 (40.8%). Intraoperative complications occurred in four (5%) patients, without compromising the intervention. Postoperative complications occurred in 27 (35.5%) patients: 17 (22%) were Clavien I-II and 10 (15%) Clavien III. All major complications resulted in prosthesis removal (n = 9; 11.8%) or revision (n = 1; 1.3%). Median (IQR) follow up was 43 (34-55) months. At the end of follow up, 70 (92.1%) patients had a functional implant. Fifty-four (71.1%) patients were satisfied with the device at the 6 month follow up visit and beyond. Early satisfaction (at 3 months) was reported by 44 (57.9%) patients. A previous PP was the only significant risk factor for prosthesis removal (p = 0.001). CONCLUSION: PP implantation is a safe and satisfactory treatment for ED. However, patient selection remains crucial in determining the post-surgical success of this procedure.

Stress urinary incontinence in female neurological patients: long-term functional outcomes after artificial urinary sphincter (AMS 800TM ) implantation.

AIMS: To report the long-term functional outcomes of artificial urinary sphincter (AUS) implantation in female adult neurological patients suffering from stress urinary incontinence (SUI) due to sphincter deficiency. METHODS: Female patients with neurological disease suffering from SUI due to sphincter deficiency who underwent AUS (AMS 800TM ) implantation between 1984 and 2011 were included. Continence rate defined as no need for pads and survival rates of the device without needing explantation or revision using Kaplan-Meier curves were reported. RESULTS: Overall, 26 patients, median age 49.2 years (IQR 28.5-59.7) were included. The median follow-up time was 7.5 years (IQR 3.9-23.8). At the end of follow-up period, 15 patients (57.7%) still had their primary AUS. The AUS was explanted in five women because of infection or erosion. Survival rates, without AUS explantation were 90%, 84%, 84%, and 74% at 5, 10, 15, 20 years, respectively. Survival rates without AUS revision were 75%, 51%, 51%, and 51% at 5, 10, 15, 20 years, respectively. 71.4% of patients with AUS were continent. When considering the 26 initial patients, including the patients in whom the AUS was explanted, the continence rate was 57.7%. CONCLUSIONS: For treating neurogenic sphincter deficiency in the long term, the AMS 800TM can offer a satisfying rate of continence to female patients, with a tolerable rate of explantation and revision. Neurourol. Urodynam. 36:764-769, 2017. © 2016 Wiley Periodicals, Inc.

Relationship between non-suspicious MRI and insignificant prostate cancer: results from a monocentric study.

OBJECTIVES: To assess whether non-suspicious multiparametric magnetic-resonance imaging (mpMRI) was associated with no cancer or indolent prostate cancer (PCa) in subsequent biopsies. PATIENTS AND METHODS: Retrospective analyses of a prospective database were conducted between 2009 and 2013. It included men with an abnormal digital rectal examination and/or prostate-specific antigen levels <20 ng/mL and a non-suspicious multiparametric MRI (Likert score <3). Participants underwent a systematic 12-extended-core biopsy ultrasound protocol (STD). Indolent PCa was defined as a single core with a Gleason score of 6 (3 + 3) and a cancer-core length of ≤4 mm. RESULTS: Seventy-eight patients with a negative MRI were included in the study; median patient age was 62 years (IQR 50-74). Median PSA level was 7.15 ng/mL, with a median PSA density of 0.15. The digital rectal examination was abnormal in eight cases. From MRI, 53 patients were Likert 2, 25 patients were Likert 1, and median prostate volume was 56.5 mL. From biopsies, no cancer was found in 92.3 % (n = 72). PCa was histologically confirmed in six patients (7.7 %): five cases were indolent (as defined above); only one patient had a cancer core of 5 mm long, with a Gleason score of 6 (3 + 3). All six patients were within the low-risk group according to the D'Amico classification. CONCLUSION: Men with non-suspicious mpMRI are likely to have no or indolent PCa in subsequent biopsies.

Apparent diffusion coefficient value is a strong predictor of unsuspected aggressiveness of prostate cancer before radical prostatectomy.

PURPOSE: To evaluate the use of multiparametric MRI (mp MRI) parameters in order to predict prostate cancer aggressiveness as defined by pathological Gleason score or molecular markers in a cohort of patients defined with a Gleason score of 6 at biopsy. METHODS: Sixty-seven men treated by radical prostatectomy (RP) for a low grade (Gleason 6) on biopsy and mp MRI before biopsy were selected. The cycle cell proliferation (CCP) score assessed by the Prolaris test and Ki-67/PTEN expression assessed by immunohistochemistry were quantified on the RP specimens. RESULTS: 49.25 % of the cancers were undergraded on biopsy compared to the RP specimens. Apparent diffusion coefficient (ADC) < 0.80 × 10(-3) mm(2)/s (P value 0.003), Likert score >4 (P value 0.003) and PSA density >0.15 ng/ml/cc (P value 0.035) were significantly associated with a higher RP Gleason score. Regarding molecular markers of aggressiveness, ADC < 0.80 × 10(-3) mm(2)/s and Likert score >4 were also significantly associated with a positive staining for Ki-67 (P value 0.039 and 0.01, respectively). No association was found between any analyzed MRI or clinical parameter and the CCP score. CONCLUSION: Decreasing ADC value is a stronger indicator of aggressive prostate cancer as defined by molecular markers or postsurgical histology than biopsy characteristics.

Multiparametric Magnetic Resonance Imaging Predicts Postoperative Pathology but Misses Aggressive Prostate Cancers as Assessed by Cell Cycle Progression Score.

PURPOSE: We identified prognostic biomarkers in prostate cancer by a radiogenomics strategy that integrates gene expression using the cell cycle progression score and medical images. MATERIALS AND METHODS: We obtained institutional review board approval and written informed consent from 106 men with prostate cancer, including 60% at low risk, who underwent multiparametric magnetic resonance imaging before radical prostatectomy was done and a cell cycle progression score was determined. The correlation between the results of multiparametric magnetic resonance imaging and Gleason grade or cell cycle progression score was assessed by logistic regression. RESULTS: Patients with primary Gleason grade greater than 3 had a longer median maximal tumor diameter (13 vs 10 mm) and a lower median apparent diffusion coefficient (0.745 vs 0.88×10(-3) mm2 per second, each p=0.0001) than those with primary Gleason grade 3 or less. Maximal diameter 10 mm or greater (OR 4.9, 95% CI 1.7 to 14.0, p=0.0012) and apparent diffusion coefficient 0.80×10(-3) mm2 per second or less (OR 7.5, 95% CI 3.0 to 18.7, p<0.0001) were significantly associated with primary Gleason grade greater than 3. The combined measure of maximal diameter less than 10 mm and apparent diffusion coefficient greater than 0.80×10(-3) mm2 per second identified only index lesions harboring primary Gleason grade 3. However, 7 of those lesions showed a molecular pattern of high risk lethal prostate cancer (cell cycle progression score greater than 0). CONCLUSIONS: Multiparametric magnetic resonance imaging is able to predict low and high risk Gleason scores in the tumor. However, the cell cycle progression score did not completely match the imaging result. These findings suggest that management of early stages prostate cancer could strongly benefit by performing magnetic resonance imaging targeted biopsy coupled with molecular analysis.

Hereditary-like urothelial carcinomas of the upper urinary tract benefit more from adjuvant cisplatin-based chemotherapy after radical nephroureterectomy than do sporadic tumours.

OBJECTIVE: To evaluate the impact of 'hereditary-like' status in upper tract urothelial carcinoma (UTUC) on the survival of patients who have undergone radical nephroureterectomy (RNU) and adjuvant chemotherapy. PATIENTS AND METHODS: A multicentre retrospective study was performed on all patients with high-risk UTUC who underwent RNU and adjuvant cisplatin-based chemotherapy. Using a patient risk identification tool, we distinguished tumours suspected to be hereditary from sporadic tumours and compared survival rates. RESULTS: A total of 112 patients with a median age of 67 years were included. Hereditary-like tumour status was detected in 35 patients (31.3%), while 77 patients (68.7%) had sporadic tumours. The median age was significantly younger in the hereditary-like tumour group (56.0 vs 69.8 years, P < 0.001). Overall survival (OS) after chemotherapy was significantly better in the group with hereditary-like tumours than in the group with sporadic tumours (5-year OS: 48.2 vs 32%; P = 0.008). The cancer-specific survival (CSS) rate was significantly better in the group with 'hereditary-like' tumours than in the group with sporadic tumours (5-year CSS: 58 vs 35%; P = 0.006). Although there was a trend in favour of the hereditary-like tumours, we observed no significant difference regarding progression-free survival (PFS) between the two groups (5-year PFS: 71 vs 52%; P = 0.07). CONCLUSION: Adjuvant chemotherapy after RNU improves survival outcomes in patients with hereditary-like UTUC compared with those with sporadic tumours.

Impact of the length of time between diagnosis and surgical removal of urologic neoplasms on survival.

OBJECTIVE: Our aim was to assess the effect of surgical wait time on the survival of patients with urological neoplasms, including prostate, bladder, penile, and testicular cancers and upper tract tumours (UTUC). MATERIALS AND METHODS: Current, relevant studies were identified from the literature. Keywords used for article retrieval were as follows: delay; surgery; prostate cancer; urothelial carcinoma; renal cell carcinoma; testicular cancer; bladder; renal pelvis; ureter; and survival. RESULTS: Regarding the length of surgical wait time, it does not matter in cases of incidental T1a renal cell carcinomas. In other cases of renal cell carcinomas, surgery should be considered within <1 month; it is of crucial importance in bladder cancer and should be <1 month for a TURBT in cases of non-muscle-invasive bladder cancer and <1 month for a radical cystectomy in cases of muscle-invasive bladder cancer; it is important in invasive UTUC and should be <1 month for a radical nephroureterectomy; it is not crucial in cases of low-risk prostate cancer. In any other case, radical prostatectomy should be considered within <2 months; it is important in testicular cancer and should be fewer than 10 days for an orchiectomy. CONCLUSION: Prolonged surgical wait times have an impact on the overall quality of life and anxiety of the patient. Extending the wait time beyond a given threshold can also have a negative impact on the patient's clinical outcomes, but this threshold differs between urological neoplasms.

The surgical approach can be determined from the pathological specimen obtained after open or robot-assisted laparoscopic radical prostatectomy.

PURPOSE: To assess the surgical approach using the pathological specimen obtained after open radical prostatectomy (ORP) or robot-assisted radical prostatectomy (RALRP). METHODS: A prospective study has been performed in patients who underwent either ORP or RALRP for localized prostate cancer. Two dedicated uro-pathologists, blinded to the surgeons and the operating rooms' schedules, analyzed the pathological specimens according to the Stanford protocol. Both pathologists also determined the surgical approach used based on several criteria pertaining to the pathological specimen. RESULTS: Overall, 117 patients with a median age of 63 years were included. The main characteristics (i.e., Gleason score, pTNM stage, preoperative PSA and margin) were comparable in both groups (p > 0.05). Pathologists 1 and 2 were able to significantly assess the surgical procedure from the pathological specimen provided (in 76.1 and 69.2 % of cases, respectively). Pathologist 1 had a better performance than pathologist 2 (AUC 0.75, IC 95 % [0.67-0.83] vs. AUC = 0.68 IC 95 % [0.59-0.77]) (p = 0.017). The κ index of the inter-observer agreement was satisfactory (0.76). In a univariate analysis, the criteria linked to the pathologist's assessment were as follows: macroscopic integrity of the specimen (p = 0.04), presence of periprostatic fat (p = 0.04), width of periprostatic tissue (p < 0.001) and nerve-sparing status (p < 0.001). CONCLUSION: It was possible to determine the surgical procedure from the analysis of the specimen obtained after a radical prostatectomy. In view of these data and from this perspective, one could infer that there are indeed oncological differences between the robotic and open approaches to radical prostatectomy.

Comparison of oncologic outcomes after radical prostatectomy in men diagnosed with prostate cancer with PSA levels below and above 4 ng/mL.

PURPOSE: To assess whether the PSA level (threshold 4 ng/mL) is a prognostic factor in biochemical recurrence-free survival in men with prostate cancer (PCa) with an initial PSA level <10 ng/mL who underwent robotic-assisted laparoscopic radical prostatectomy (RARLP). METHODS: We prospectively recruited data for consecutive patients treated by RARLP for PCa with an initial PSA level below 10 ng/mL between 2003 and 2011 at our institution. We divided the population into two groups: patients with a PSA level below 4 ng/mL (G1; n = 53) and patients with a PSA level between 4 and 10 ng/mL (G2; n = 371). Biochemical recurrence was defined as a single increase in PSA greater than 0.2 ng/mL after surgery. Multivariate analysis was used to assess prognostic factors of recurrence-free survival. RESULTS: Overall, 424 patients were included, and the median age was 62 (58-67) years. The median PSA was 5.8 ng/mL (4.8-7.7 ng/mL). Overall, 6 patients from G1 and 34 patients from G2 experienced a biochemical recurrence. Overall, the 5-year recurrence-free survival rate was 86.6 %. The PSA level at diagnosis (under or over 4 ng/mL) was not significantly linked to recurrence-free survival (HR = 0.59, p = 0.25). However, positive margins and a Gleason score >7 on the specimen were significantly linked to recurrence-free survival with respective hazard ratios of 4.30 (p < 0.0001) and 6.18 (p < 0.0001), respectively. CONCLUSION: A PSA level <4 ng/mL alone appears to be obsolete as a cut-off to define a population of men likely to have indolent disease.

Secondary chemoprevention of localized prostate cancer by short-term androgen deprivation to select indolent tumors suitable for active surveillance: a prospective pilot phase II study.

PURPOSE: To investigate the impact of 3-month androgen deprivation therapy (st-ADT) a secondary chemoprevention of indolent-localized prostate cancer (PCa). METHODS: A prospective phase II study enrolled men over 4 years with low-risk PCa and the following characteristics: PSA < 10 ng/mL, Gleason score of 6 (3 + 3) or less, three positive cores or less, and tumor stage T2a or less. Patients received a single sub-cutaneous injection of 22.5 mg of leuprolide acetate with Atrigel 3-month depot associated with a daily oral intake of bicalutamide 50 mg/day during 15 days around the injection. Follow-up included PSA and bioavailable testosterone blood tests every 3 months and yearly surveillance biopsies. Primary end point was the presence of PCa on biopsy at last follow-up. Secondary end points were detailed pathological features and adverse events. RESULTS: Overall, 98 men were included and 45 of them (45.9 %) had a negative biopsy after a median follow-up of 13 months [11-19.5]. Of the 53 patients with positive biopsy, 17 had pathologic progression because of upgraded Gleason score (11 patients), four or more positive cores (three patients) or both (three patients). The only significant predictive factor biopsy outcome was the number of positive cores at diagnosis. CONCLUSIONS: Secondary chemoprevention by st-ADT for localized PCa could be useful to pinpoint indolent tumors suitable for AS. Indeed, after st-ADT nearly one patient out of two had negative biopsies and 17 % had pathological progression. This is an innovative option to consider as an alternative to current AS protocols contingent upon confirmation in subsequent studies.

Prostate cancer diagnosis: multiparametric MR-targeted biopsy with cognitive and transrectal US-MR fusion guidance versus systematic biopsy--prospective multicenter study.

PURPOSE: To compare biopsy performance of two approaches for multiparametric magnetic resonance (MR)-targeted biopsy (TB) with that of extended systematic biopsy (SB) in prostate cancer (PCa) detection. MATERIALS AND METHODS: This institutional review board-approved multicenter prospective study (May 2009 to January 2011) included 95 patients with informed consent who were suspected of having PCa, with a suspicious abnormality (target) at prebiopsy MR. Patients underwent 12-core SB and four-core TB with transrectal ultrasonographic (US) guidance, with two cores aimed visually (cognitive TB [TB-COG]) and two cores aimed using transrectal US-MR fusion software (fusion-guided TB [TB-FUS]). SB and TB positivity for cancer and sampling quality (mean longest core cancer length, Gleason score) were compared. Clinically significant PCa was any 3 mm or greater core cancer length or any greater than 3 Gleason pattern for SB or any cancer length for TB. Statistical analysis included t test, paired χ(2) test, and κ statistic. Primary end point (core cancer length) was calculated (paired t test). RESULTS: Among 95 patients (median age, 65 years; mean prostate-specific antigen level, 10.05 ng/mL [10.05 µg/L]), positivity rate for PCa was 59% (n = 56) for SB and 69% (n = 66) for TB (P = .033); rate for clinically significant PCa was 52% (n = 49) for SB and 67% (n = 64) for TB (P = .0011). Cancer was diagnosed through TB in 16 patients (17%) with negative SB results. Mean longest core cancer lengths were 4.6 mm for SB and 7.3 mm for TB (P < .0001). In 12 of 51 (24%) MR imaging targets with positive SB and TB results, TB led to Gleason score upgrading. In 79 MR imaging targets, positivity for cancer was 47% (n = 37) with TB-COG and 53% (n = 42) with TB-FUS (P = .16). Neither technique was superior for Gleason score assessment. CONCLUSION: Prebiopsy MR imaging combined with transrectal US-guided TB increases biopsy performance in detecting PCa, especially clinically significant PCa. No significant difference was observed between TB-FUS and TB-COG for TB guidance.

Current role of image-guided robotic radiosurgery (Cyberknife(®) ) for prostate cancer treatment.

OBJECTIVES: To describe the most recent data from phase I and II clinical trials of stereotactic body radiation therapy (SBRT) using image-guided robotic radiosurgery, specifically the Cyberknife(®) (Accuracy Incorporated, Sunnyvale, CA, USA). To better determine thecurrent role of this type of radiosurgery in prostate cancer (PCa) management. MATERIALS AND METHODS: Current clinical trials and relevant retrospective studies were identified from the literature, clinical trial databases, websites and conference abstracts. The indications, technical aspects, efficacy and toxicity of SBRT using the Cyberknife(®) system were summarized. RESULTS: The Cyberknife(®) system is an experimental treatment mostly used for localized PCa in stage cT1/T2a-b N0 M0 with a Gleason score ≤ 7 and PSA level ≤ 20 ng/mL. Hypofractionated radiation therapy was delivered in five fractions of 7-7.25 Gy for a total dose of 35-36.25 Gy. After treatment, the median PSA levelfell from 4.9-8.3 ng/mL to 0.1-1.6 ng/mL at a median follow-up of 4-60 months. The biochemical progression-free survival rates ranged from 78.3 to 100%. Acute and late toxicities were mostly grade 1/2 rectal or urinary complications. Few grade 3 and no grade 4 toxicities occurred during follow-up; however, erectile dysfunction and testes toxicity were also reported. CONCLUSIONS: The use of the Cyberknife(®) system is limited mainly by its pretreatment and maintenance costs. Despite encouraging preliminary results, longer-term follow-up and randomized controlled phase III clinical trials are necessary before the Cyberknife(®) system becomes a standard treatment method.

Role of pelvic phased array magnetic resonance imaging in staging of prostate cancer specifically in patients diagnosed with clinically locally advanced tumours by digital rectal examination.

OBJECTIVES: To assess the value of dynamic contrast-enhanced magnetic resonance imaging (MRI) for the prediction of extracapsular extension (ECE) in patients with clinical T3 (cT3) prostate cancer (PCa) compared to digital rectal examination (DRE). MATERIALS AND METHODS: A retrospective review of data for patients treated by radical prostatectomy for cT3 PCa was performed. Patients who underwent MRI in the pre-operative work-up were included. The likelihoods of extracapsular extension (T3a) and seminal vesicle invasion (T3b) were scored on the basis of MR images. For data analysis, receiver operating characteristic (ROC) curves were generated. RESULTS: Overall, 70 consecutive patients were included. Mean age was 63.8 (range 45-75) years, and the mean PSA level was 11.3 (range 2.9-26) ng/ml. Pathological analysis of the prostatic specimens confirmed 81.4% (n = 57) had pT3 disease. According to MRI, 57 (81.4%) patients were predicted correctly to have T3 disease. The overstaging (actual pT2) by either DRE or MRI or both was 18.6, 7 or 7%, respectively. The sensitivity, specificity and positive (PPV) and negative predictive values (NPV) of MRI were 94.7, 69, 93 and 75%. The kappa index of concordance between pre-operative MRI stage and pathological stage was 0.68 (P < 0.00001). The performance of MRI for T3 staging was AUC 0.87 (95% CI, 0.77-0.97). CONCLUSIONS: Pre-prostatectomy MRI adds significant incremental value to the assessment of patients with cT3 disease. Its ability to accurately predict and characterize pathological T3 status and its superiority to standard clinical variables (e.g. DRE) confirm its usefulness in pre-operative work-up.

Genetic polymorphisms on 8q24.1 and 4p16.3 are not linked with urothelial carcinoma of the bladder in contrast to their association with aggressive upper urinary tract tumours.

PURPOSE: Bladder urothelial carcinoma (bladder-UC) displays distinct genotypic differences compared to upper tract UC (UTUC). We recently reported specific 8q24 SNP variants confer susceptibility to UTUC and aggressive disease features. Herein, we evaluate a bladder-UC cohort to see whether similar polymorphisms are linked similarly same way with disease risk and aggressiveness. METHODS: 231 bladder-UC patients and 261 benign controls were matched for gender, age, ethnicity and smoking habits. We retrospectively retrieved information on tumour stage, grade, size, multiplicity, carcinoma in situ and tumour number. DNA was extracted from paraffin-embedded primary bladder-UC samples and blood of benign controls. Genotyping of rs9642880[T] (8q24.1) and rs798766[T] (4p16.3) was performed using commercially available Taqman(®) assays and the ABI™ 7000 Sequence Detector. RESULTS: Using a case-control analysis, bladder-UC risk was increased in individuals carrying the T/T genotype of rs9642880 [OR = 1.72 (95 % CI 1.1-2.8); p = 0.028] and rs798766 [OR = 1.84 (95 % CI 0.9-2.3); p = 0.01]. When analysing parameters of bladder-UC aggressiveness, the T/T genotypes for rs9642880 and rs798766 were not found to be associated with either grade [OR = 0.89 (95 % CI 0.52-1.32; p = 0.68) and OR = 0.95 (95 % CI 0.58-1.48; p = 0.61), respectively] or pathological stage [OR = 0.79 (95 % CI 0.42-1.48; p = 0.46) and OR = 0.90 (95 % CI 0.49-1.61; p = 0.72), respectively]. SNP variability of rs9642880[T] and rs798766[T] is associated with an increased risk of bladder-UC but we did not find an association with disease aggressiveness as we did previously for UTUC. CONCLUSIONS: This is further evidence of the distinct genetic differences that exist between bladder-UC and UTUC, and it is not possible to extrapolate results of genetic studies between these two urothelial disease entities.

A direct comparison of the diagnostic accuracy of three prostate cancer nomograms designed to predict the likelihood of a positive initial transrectal biopsy.

BACKGROUND: Several tools have been developed to predict the outcome of prostate biopsies performed to diagnosis prostate cancer (PCa). However, few studies have focused on the comparative accuracy of these predictive tools. We aim to establish the predictive accuracy of three commonly used nomograms by comparing their prostate biopsy outcome predictions with actual pathological results. METHODS: From January 2008 to December 2010, 708 consecutive patients with an elevated serum PSA level and/or abnormal DRE were referred to our institution. All data were collected prospectively. All patients underwent a TRUS 12-core biopsy. Probability of a positive biopsy was predicted using three online risk calculation nomograms. The discriminative ability of the nomograms was assessed via AUC and the most accurate model was calibrated and compared to actual biopsy results. RESULTS: Of 667 patients fulfilling all three nomograms criteria, 384 (57.5%) had PCa and 283 (42.5%) did not. AUC for the PCPT-CRC, SWOP-PRI, and Montreal nomograms was 0.68 (95% CI, 0.63-0.72), 0.72 (95% CI, 0.68-0.76), and 0.79 (95% CI, 0.76-0.82), respectively. A comparison of the three models' performance showed that the Montreal model provided the greatest predictive accuracy (P = 0.03). CONCLUSIONS: External validation of three commonly used nomograms designed to predict the likelihood of a positive prostate biopsy reveals the Montreal model was more accurate than either the PCPT-CRC or SWOP-PRI models. The Montreal nomogram achieves a diagnostic accuracy of 79% and is superior to PSA alone though we await further research to define the probability (of cancer) threshold above which a prostate biopsy would be advised.

Quantitative RT-PCR analysis of PSA and prostate-specific membrane antigen mRNA to detect circulating tumor cells improves recurrence-free survival nomogram prediction after radical prostatectomy.

BACKGROUND: Circulating tumor cell (CTC) analysis is a potential new biomarker in prostate cancer. We hypothesize that quantitative detection of CTCs in patients pre- and post-radical prostatectomy (RP) using quantitative TaqMan® fluorogenic RT-PCR will improve the accuracy of the Kattan nomogram to predict the probability of recurrence-free survival (RFS) post-RP. METHODS: Ninty-two patients who underwent RP between 2004 and 2009 had venous blood samples taken pre- (Day - 1) and post-operatively (Day + 7). We performed quantitative Taqman® RT-PCR to detect circulating prostate-specific antigen (PSA) and prostate-specific membrane antigen (PSMA) mRNA. We calculated both the logarithmic ratio of Day + 7/Day - 1 for PSA (PSAr) and PSMA (PSMAr) expression (log(Day+7/Day-1) ) and the Kattan nomogram predicted probability of disease recurrence for each patient. We then analyzed how the AUC-ROC analysis for the Kattan nomogram prediction alone (K) compared to the addition of the PSAr and PSMAr in predicting 5-year RFS. RESULTS: The mean age (years), PSA (ng/ml), and follow-up (mo) was 65.1, 9.13, and 72, respectively. The AUCs for K, PSAr + K, and PSMAr + K were 0.752 (95%CI 0.620-0.860), 0.830 (95%CI 0.740-0.911), and 0.837 (95%CI 0.613-0.923), respectively (P = 0.03). The Kattan 5-year PSA RFS was 75%. The actual 5-year PSA RFS survival rate was 77%. CONCLUSIONS: Data from modern quantitative RT-PCR to detect circulating prostate-derived PSA and PSM mRNA pre- and post-RP improves the accuracy of the Kattan nomogram to predict biochemical recurrence.

Current role of diethylstilbestrol in the management of advanced prostate cancer.

What's known on the subject? and What does the study add? Diethylstilbestrol (DES) has been found to have anti-tumour properties and clinical effectiveness in prostate cancer that is resistant to the first-line hormonal therapy. This review found that low-dose DES has anti-tumour efficacy with limited cardiovascular side effects and should be considered for secondary hormone manoeuvres. The aim of this review was to describe the most recent data from contemporary clinical trials of diethylstilbestrol (DES) to better determine its current role in advanced prostate cancer treatment as new hormonal therapies emerge. Relevant clinical studies using 1 mg of DES in castrate-resistant prostate cancer (CRPC) were identified from the literature, clinical trial databases, websites and conference abstracts. The efficacy and safety outcomes were summarized. DES in CRPC produced a biological response (change in PSA level) and improved the median survival of patients when used as a second-line hormone therapy after standard androgen deprivation with bicalutamide and LHRH analogues. These findings were for low doses of DES. The 1-mg dose is associated with a reduced toxicity, including fewer thromboembolic and cardiovascular events. Low-dose DES appears to be safe and effective for CRPC before initiating chemotherapy. The cost/efficiency ratio may encourage physicians to consider DES as a therapy option before chemotherapy in non-symptomatic CRPC.

Persistently elevated prostate-specific antigen at six weeks after radical prostatectomy helps in early identification of patients who are likely to recur.

OBJECTIVE: To determine the prognostic factors of biochemical recurrence in patients who failed to achieve an undetectable prostate-specific antigen (PSA) after radical prostatectomy (RP) for prostate cancer. MATERIALS AND METHODS: We reviewed data on 240 men who underwent RP as first-line treatment and who had a PSA assay available at 6 weeks after surgery. Persistent detectable PSA was defined as a PSA level ≥ 0.1 ng/ml at 6 weeks after surgery. RESULTS: Overall, 83 men presented persistently elevated PSA after RP and 81 had a biochemical recurrence. Median follow-up was 44 months. In univariate analysis, these factors were associated with biochemical recurrence: preoperative PSA level (P < 0.0001), biopsy and pathologic Gleason score (P < 0.001), capsular involvement (P = 0.0001), positive surgical margins (P < 0.0001), pathological stage ≥ T3 (P = 0.0001), and detectable post-operative PSA ≥ 0.1 ng/ml (P = 0.0001). In a multivariate analysis, only the detectable post-operative PSA level ≥ 0.1 ng/mL (P = 0.001), positive surgical margins (P = 0.002), and pathological stage ≥ T3 (P < 0.001) were significant. The individual, five-year, PSA-free survival rate for men with post-operative PSA <0.1 ng/ml and ≥ 0.1 ng/ml were 59 and 42%, respectively (P < 0.001). CONCLUSIONS: A majority of patients who failed to achieve an undetectable PSA after surgery had a subsequent biochemical recurrence in the outcome. A systematic PSA assay 6 weeks after RP could be useful to early identify patients who are likely to recur.

Prospective comparison of short-term functional outcomes obtained after pure laparoscopic and robot-assisted laparoscopic sacrocolpopexy.

OBJECTIVE: To prospectively compare short-term functional outcomes achieved by laparoscopic or robot-assisted sacrocolpopexy for pelvic organ prolapse. MATERIALS AND METHODS: We prospectively collected clinical and operative data over 24 months for female patients who underwent either pure laparoscopic sacrocolpopexy (LSCP) or robot-assisted laparoscopic sacrocolpopexy (RALSCP). Clinical data included age, BMI and assessment of PFDI-20 score. Perioperative data included operative time and complications. Post-operative outcomes included hospital stay, length of catheterisation, pain and functional outcomes as assessed by clinical examination and PFDI-20 score assessment. RESULTS: Overall, 67 women with a median age of 65 were included: 47 in the LSCP arm and 20 in the RALSCP arm. RALSCP was superior in terms of blood loss (median 55mls vs. 280; P = 0.03) and strict operative time (median 125 min vs. 220; P < 0.0001), but this time advantage was nullified when comparing overall operating room time (215 min vs. 220). With a median follow-up of 16 months, the overall anatomic repair rate was 98.5%, and there was an improvement in overall PFDI-20 score before and after surgery (P = 0.001) but with no difference between the two surgical approaches. CONCLUSIONS: RALSCP allows for a safe and effective repair of pelvic organ prolapse in female patients. Whilst being equivalent to LSCP in terms of functional outcome, it is superior in terms of blood loss and strict operative time. These results are based on short-term assessment, and further studies of larger populations with longer follow-up and objective assessments of outcome are needed to make any definitive statement.

Low accuracy of routine ultrasound-guided systematic 12-core biopsies in prostate tumor mapping.

INTRODUCTION: To determine the accuracy of a 12-core biopsy protocol in assessing the location of prostate tumors within radical prostatectomy (RP) specimens. MATERIALS AND METHODS: A consecutive series of patients with T1c stage prostate cancer who had undergone 12 ultrasound-guided prostate biopsies prior to RP was considered. The locations of the biopsies from prostate gland mapping were compared with the locations of tumor tissues obtained after analysis of the prostate specimens. RESULTS: Overall, 78 patients (27.4%) were included. The median PSA level was 6 ng/mL. The median prostate weight was 45 g (range 22 to 102). Overall, 936 biopsies were performed in the 78 men, of which 254 biopsies were positive. The mean number of positive biopsies per patient was 3.7 (range 1 to 12). Pathologic examination of the surgical specimens revealed that 58 (74.4%) patients had pT2 disease and 20 patients (25.6%) had locally advanced disease (pT3). The biopsy protocol's sensitivity, specificity and positive predictive value for tumor location were 0.34, 0.83 and 0.84. The performance of the protocol was modest in assessing the exact tumor location (area under curve (AUC) 0.581, 95% confidence interval (CI) 0.489-0.719). CONCLUSIONS: Routine, ultrasound-guided, systematic 12-core biopsies lack precision in prostate tumor mapping.