Rectal preparation significantly improves prostate imaging quality: Assessment of the PI-QUAL score with visual grading characteristics.

PURPOSE: To investigate the effects of a rectal preparation regimen, that consisted of a rectal cleansing enema and an endorectal gel filling protocol, on prostate imaging quality (PI-QUAL). METHODS: Multiparametric MRI (mpMRI) was performed in 150 consecutive patients divided into two groups of 75 patients. One group received a rectal preparation with a cleansing enema and endorectal gel filling (median age 65.3 years, median PSA level 6 ng/ml). The other patient group did not receive such a preparation (median age 64 years, median PSA level 6 ng/ml). Two uroradiologists independently rated general image quality and lesion visibility on diffusion-weighted imaging (DWI), T2-weighted (T2w), and dynamic contrast-enhanced (DCE) images using a five-point ordinal scale. In addition, two uroradiologists assigned PI-QUAL scores, using the dedicated scoring sheet. Data sets were compared using visual grading characteristics (VGC) and receiver operating characteristics (ROC)/ area under the curve (AUC) analysis. RESULTS: VGC revealed significantly better general image quality for DWI (AUC R1 0.708 (0.628-0.779 CI, p < 0.001; AUC R2 0.687 (0.606-0.760 CI, p < 0.001) and lesion visibility for both readers (AUC R1 0.729 (0.607-0.831 CI, p < 0.001); AUC R2 0.714 (0.590-0.818CI, p < 0.001) in the preparation group. For T2w imaging, rectal preparation resulted in significantly better lesion visibility for both readers (R1 0.663 (0.537-0.774 CI, p = 0.014; R2 0.663 (0.537-0.774 CI, p = 0.014)). Averaged PI-QUAL scores were significantly improved with rectal preparation (AUC R3/R4 0.667, CI 0.581-0.754, p < 0.001). CONCLUSION: Rectal preparation significantly improved prostate imaging quality (PI-QUAL) and lesion visibility. Hence, a rectal preparation regimen consisting of a rectal cleansing enema and an endorectal gel filling could be considered.

An update on systemic therapy for penile cancer.

PURPOSE OF REVIEW: Whereas substantial advances have been made in systemic tumour therapy in the past decade, the prognosis of advanced squamous cell carcinoma (SCC) of the penis remains disproportionally poor. In this review, we aimed to present an update on systemic therapy of penile SCC highlighting the most recent data and future perspectives. RECENT FINDINGS: Lymph node metastases play a key role in treating and assessing the prognosis of patients with penile SCC. Data show longer overall survival with the use of adjuvant chemotherapy in patients with pelvic lymph node metastases and recent analyses lead to the development of a nomogramm predicting overall survival in connection with the use of perioperative chemotherapy. There are two pathways in the pathogenesis of penile cancer, including human papilloma virus related and unrelated, leading to many possible novel therapeutic targets. Other targeted therapies have been evaluated, which show promising results with the use of tyrosine kinase inhibitors. SUMMARY: Chemotherapy has shown moderate activity in advanced stages of the disease, however, the ideal timing of chemotherapy in patients with lymph node metastases is not entirely clear. Potential targets for future therapies exist, and are already being tested in other malignancies. Owing to the rarity of this condition, a robust evidence is lacking and it is of great importance to pursue further research to unveil several aspects of this disease, particularly in patients with recurrence, lymph node metastases or metastatic disease.

Role of lasers in urology.

Laser technology has long been a standard treatment for many diseases. In particular, laser treatment is considered the standard of care in various urological diseases. While originally primarily restricted to stone treatment, lasers have since evolved to play an important role even in the treatment of malignant diseases. In this review, we take a closer look at the history of lasers in urology and some implications for treatments today.

Focal therapy of prostate cancer.

PURPOSE OF REVIEW: The aim of this study was to summarize the latest evidence, as well as the rationale behind using focal therapy for the treatment of prostate cancer. With patients becoming more educated, knowledge of the available evidence is key when discussing treatment. RECENT FINDINGS: In older works, the natural history of prostate cancer has been described as being multifocal, driven by one index lesion. This represents the key argument for most experts, why focal therapy is feasible in prostate cancer. Most modalities have similar results. For high-intensity focussed ultrasound (HIFU), a pooled data analysis with a median follow-up of 2.2 years showed a negative biopsy rate of 77% with a salvage therapy free rate of 92%. A matched pair analysis comparing irreversible electroporation with robot-assisted radical prostatectomy showed a better side effect profile for focal therapy in evenly matched groups, yet with worse disease-free survival. Interestingly, the better outcomes concerning continence and erectile function did not translate into better patient-reported outcomes. SUMMARY: Focal therapy modalities are generally well tolerated and show good results in terms of continence and potency. Long-term follow-up is not available, and inclusion criteria for trials are not yet uniform. Newer technologies, such as photodynamic therapy, are being developed, as well as improvements to older techniques, such as HIFU.

[Palliative surgery for metastatic urothelial cancer]. / Palliative Chirurgie beim metastasierten Urothelkarzinom.

Palliative surgery is performed in order to relieve symptoms as well as to increase survival in selected tumour entities. For urothelial cancer, its role is limited and clinical data are limited, too. Yet with better responses being achieved to systemic therapy, more and more surgical procedures are being carried out in the form of individualised treatment concepts and are then published as case series. For patients with low metastatic load, or if the tumour is restricted to lymph nodes inside and outside the pelvis, as well as for singular pulmonary metastasis, there seems to be a survival benefit in select cases. Calculation of risks and benefits is difficult and, for now, should be reconsidered for every individual patient. Therefore, prospective trials are difficult to perform and should not be expected to exist in the future. This review aims to summarise the most important publications on this topic.

Prostate biopsy: guidelines and evidence.

PURPOSE OF REVIEW: To summarize the highest level evidence that was acquired within the last years, with regard to diagnosis of prostate cancer. With many secondary diagnostic tools becoming available, and not being mentioned in the guidelines, this review is meant to assist clinical decision-making in initial biopsy and rebiopsy settings. RECENT FINDINGS: The PROMIS Trial delivered level 1b evidence about the diagnostic accuracy of prostate multiparametric MRI (mpMRI) as a triage tool for prostate biopsy. MRI-ultrasound-fusions-targeted biopsy has been evaluated and compared with the standard of care, and has been found to have a higher cancer detection rate. The different approaches to MRI-guided biopsies do not show significant differences. Urine biomarkers analysing RNA as well as genetic assays of biopsy specimen have also shown to be helpful in the decision to (re-)biopsy a patient, especially in combination with MRI. SUMMARY: Patients and doctors alike have been trying to avoid prostate biopsies, the risks, and the side effects of potential overtreatment. Imaging and other biomarkers are used to increase diagnostic accuracy, yielding more precise information to act on. None of these secondary diagnostic tools are perfect, yet they can, and should be used if one stays aware of their limitations.

Validation of lymphovascular invasion is an independent prognostic factor for biochemical recurrence after radical prostatectomy.

OBJECTIVE: To validate the impact of lymphovascular invasion (LVI) on biochemical recurrence (BCR) in patients treated with radical prostatectomy (RP) in a large multiinstitutional cohort. MATERIAL AND METHODS: Retrospective data from 6,678 patients treated with a RP and bilateral lymphadenectomy for prostate cancer (PC) from 8 centers were collected. The primary endpoint was BCR. RESULTS: Overall, 767 patients (11.5%) had LVI. Patients with LVI had significantly higher Gleason scores (P = 0.01). After a median follow-up of 28 months (interquartile range: 21-44), patients with LVI had a 1.66 fold increased risk of BCR (P<0.001). The 1-, 2- and 5-year biochemical recurrence-free survival probabilities for LVI vs. no LVI were 94% vs. 97%, 91% vs. 94%, and 76% vs. 84%, respectively. On multivariable analysis that adjusted for the effects of established prognostic factors, LVI was an independent predictor of BCR (hazard ratio = 1.42, P<0.001). Adding LVI to a multivariable base model increased the discrimination by a small but significant margin (+0.2%, P = 0.0005). In subgroup analyses, LVI remained an independent predictor for BCR in patients with worse pathological features. CONCLUSIONS: About 10% of patients with localized PC have LVI on their RP specimen. We confirm that LVI is associated with features of biologic aggressive PC such as high Gleason grade and BCR after RP. Adverse further studies with strict definitions of LVI and longer follow-up periods are needed to determine the prognostic and predictive utility of LVI in the management of PC.