Current process and outcomes of the surgical management of LUTS due to benign prostatic enlargement: how consistent are we? - results from the multi-institutional audit of surgical management of BPE (AuSuM BPE) in the United Kingdom.

OBJECTIVE: In view of changing landscape of surgical treatment for LUTS secondary to BPE, this audit was undertaken to assess key aspects of the processes and outcomes of the current interventional treatments for BPE, across different units in the UK. MATERIALS AND METHOD: A multi-institutional snapshot audit was conducted for patients undergoing interventions for LUTS/BPE over 8-week period. Using Delphi process two-part proforma was designed to capture data. RESULTS: 529 patients were included across 20 NHS trusts in England and Wales. Median age was 73 years. Indications for surgery were acute retention (47%) and LUTS (45%). 80% of patients had prior medical therapy. TURP formed the commonest procedure. 27% patients had <23 hour hospital stay. Immediate (21%) and delayed (18%) complications were Clavien-Dindo <2 category. High proportion of patients reported residual symptoms. Type and indication of surgery were significant predictor of complications, length of stay and failure of TWOC outcomes, on multivariate analyses. There were variations in departmental processes, 50% centres used PROMs. CONCLUSION: Monopolar TURP still remains the commonest intervention for BPE. Most departments are adopting newer technologies. The audit identified opportunities for development of consistent, effective and patient centric practices as well as need for large-scale focused studies.

The use of artificial intelligence and deep learning reconstruction in urological computed tomography: Dose reduction at ghost level.

Objective: The objective of the study is to demonstrate that with the use of artificial intelligence (AI) in computed tomography (CT), radiation doses of CT kidney-ureter-bladder (KUB) and CT urogram (CTU) can be reduced to less than that of X-ray KUB and CT KUB, respectively, while maintaining the good image quality. Materials and Methods: We reviewed all CT KUBs (n = 121) performed in September 2019 and all CTUs (n = 74) performed in December 2019 at our institution. The dose length product (DLP) of all CT KUBs and each individual phase of CTU were recorded. DLP of each scan done with new scanner (Canon Aquilion One Genesis with AiCE [CAOG]) which uses AI and deep learning reconstruction (DLR) were compared against traditional non-AI scanner (GE OPTIMA 660 [GEO-660]). We also compared DLPs of both scanners against the United Kingdom, National Diagnostic Reference Levels (NDRL) for CT. Results: One hundred and twenty-one patient's CT KUBs and 74 patient's CTUs were reviewed. For CT KUB group, the mean DLP of 81/121 scans done using AI/DLR scanner (CAOG) was 77.8 mGy cm (1.16 mSv), while the mean DLP of 40/121 CT KUB done with GEO-660 was 317.1 mGy cm (4.75 mSv). For CTU group, the mean DLP for 46/74 scans done using AI/DLR scanner (CAOG) was 401.9 mGy cm (6 mSv), compared to mean DLP of 1352.6 mGy cm (20.2 mSv) from GEO-660. Conclusion: We propose that CT scanners using AI/DLR method have the potential of reducing radiation doses of CT KUB and CTU to such an extent that it heralds the extinction of plain film XR KUB for follow-up of urinary tract stones. To the best of our knowledge, this is the first study comparing CT KUB and CTU doses from new scanners utilizing AI/DLR technology with traditional scanners using hybrid iterative reconstruction technology. Moreover, we have shown that this technology can markedly reduce the cumulative radiation burden in all urological patients undergoing CT examinations, whether this is CT KUB or CTU.

Not such a small diagnosis: small cell carcinoma of the prostate.

Small cell carcinoma (SCC) is an aggressive malignancy most commonly described in the lung. We present a case of a 61-year-old male who presented with a neck swelling and was subsequently found to have metastatic SCC of the prostate. Clinicians should be aware that it metastasizes early. Unlike conventional prostate adenocarcinoma, it is not a prostate-specific antigen (PSA) secreting tumor hence serum levels do not correlate with disease severity, and a low PSA reading may give false reassurance. In the future, further studies on genomic typing and novel targeted therapies may achieve better clinical outcomes for patients with this aggressive type of prostate cancer.

Bad expression influences time to androgen escape in prostate cancer.

OBJECTIVE: To assess the role of selected downstream Bcl-2 family members (Bad, Bax, Bcl-2 and Bcl-xL) in the development of androgen-independent prostate cancer (AIPC), as androgen-deprivation therapy is the treatment of choice in advanced prostate cancer, yet patients generally relapse and progress to an AI state within 18-24 months. PATIENTS, MATERIALS AND METHODS: The patient cohort was established by retrospectively selecting patients with prostate cancer who had an initial response to androgen-deprivation therapy, but subsequently relapsed with AIPC. In all, 58 patients with prostate cancer were included with matched androgen-dependent (AD) and AI prostate tumours available for immunohistochemical analysis; two independent observers using a weighted-histoscore method scored the staining. Changes in Bad, Bax, Bcl-2 and Bcl-xL expression during transition to AIPC were evaluated and then correlated to known clinical variables. RESULTS: High Bad expression in AD tumours was associated with an increased time to biochemical relapse (P = 0.007) and a trend towards improved overall survival (P = 0.053). There were also trends towards a decrease in Bad (P = 0.068) and Bax (P = 0.055) expression with progression to AIPC. There were no significant results for Bcl-2 or Bcl-xL. CONCLUSION: There is evidence to suggest that Bad expression levels at diagnosis influence time to biochemical relapse and overall survival, and that levels of pro-apoptotic proteins Bad and Bax fall during AIPC development. Bad might therefore represent a possible positive prognostic marker and potential therapeutic target for AIPC in the future.

The relationship between angiogenesis and cyclooxygenase-2 expression in prostate cancer.

OBJECTIVE: To test the hypothesis that angiogenesis in prostate cancer is associated with tumour invasion and metastasis, and that this is mediated through increased cyclooxygenase-2 (COX-2) expression. PATIENTS AND METHODS: Angiogenesis was assessed in 105 patients with either prostate cancer (79) or benign prostatic hyperplasia (BPH, 26) and these data correlated with levels of COX-2 expression in the same dataset. The mean microvessel density (MVD) was analysed as a marker of angiogenesis, using the endothelial antigen CD34 stained by immunohistochemistry. RESULTS: There was no difference in MVD in progressive tumour stages compared with BPH. There was a negative correlation between MVD and COX-2 expression, but the effect of increased COX-2 expression on MVD was not marked. CONCLUSION: These data suggest that COX-2 drives tumour spread in prostate cancer by means other than the promotion of angiogenesis.

The role of c-Jun and c-Fos expression in androgen-independent prostate cancer.

Molecular mechanisms underlying the development of androgen-insensitive prostate cancer (AIPC) are poorly understood. However, there is growing evidence that different molecular profiles may result in the development of AIPC. Cell line studies demonstrate that c-Jun and c-Fos, via formation of the transcription factor activated protein 1 (AP-1), activate androgen-regulated genes independent of androgens and that c-Jun alone acts as an androgen receptor co-factor. The aim of this study was to investigate whether increased levels of c-Jun and phosphorylated c-Jun are associated with the development of AIPC using clinical material. Material from a cohort of 51 patients with paired tumours, obtained before and after the development of AIPC, and with full clinical biochemical follow-up, was retrieved from the archives. Tumour c-Jun, activated c-Jun, c-Fos, and pan protein kinase C (PKC) protein expression were analysed by immunohistochemistry and protein expression was scored by two independent observers using a weighted histoscore. No evidence was found to suggest that c-Jun acting as an androgen receptor co-factor influences the development of AIPC. However, it was observed that patients with high expression levels of phosphorylated c-Jun had a significantly shorter survival from relapse compared with patients with low phosphorylated c-Jun protein expression (p = 0.023), suggesting that increased AP-1 levels may promote AIPC tumour growth. Whilst PKC did not appear to activate c-Jun in vivo, increased PKC expression in AIPC tumours was also associated with decreased patient survival from time of relapse (p = 0.014). In conclusion, the data support the hypothesis that activation of c-Jun plays a role in the development of AIPC via AP-1 formation in some patients. However, PKC appears to promote the development of AIPC independently of c-Jun activation via an as yet unexplained mechanism.