Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted and Systematic Prostate Biopsy to Prevent Infectious Complications: The PREVENT Randomized Trial.

BACKGROUND AND OBJECTIVE: The transrectal biopsy approach is traditionally used to detect prostate cancer. An alternative transperineal approach is historically performed under general anesthesia, but recent advances enable transperineal biopsy to be performed under local anesthesia. We sought to compare infectious complications of transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis. METHODS: We assigned biopsy-naïve participants to undergo transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis (rectal culture screening for fluoroquinolone-resistant bacteria and antibiotic targeting to culture and sensitivity results) through a multicenter, randomized trial. The primary outcome was post-biopsy infection captured by a prospective medical review and patient report on a 7-d survey. The secondary outcomes included cancer detection, noninfectious complications, and a numerical rating scale (0-10) for biopsy-related pain and discomfort during and 7-d after biopsy. KEY FINDINGS AND LIMITATIONS: A total of 658 participants were randomized, with zero transperineal versus four (1.4%) transrectal biopsy infections (difference -1.4%; 95% confidence interval [CI] -3.2%, 0.3%; p = 0.059). The rates of other complications were very low and similar. Importantly, detection of clinically significant cancer was similar (53% transperineal vs 50% transrectal, adjusted difference 2.0%; 95% CI -6.0, 10). Participants in the transperineal arm experienced worse periprocedural pain (0.6 adjusted difference [0-10 scale], 95% CI 0.2, 0.9), but the effect was small and resolved by 7-d. CONCLUSIONS AND CLINICAL IMPLICATIONS: Office-based transperineal biopsy is tolerable, does not compromise cancer detection, and did not result in infectious complications. Transrectal biopsy with targeted prophylaxis achieved similar infection rates, but requires rectal cultures and careful attention to antibiotic selection and administration. Consideration of these factors and antibiotic stewardship should guide clinical decision-making. PATIENT SUMMARY: In this multicenter randomized trial, we compare prostate biopsy infectious complications for the transperineal versus transrectal approach. The absence of infectious complications with transperineal biopsy without the use of preventative antibiotics is noteworthy, but not significantly different from transrectal biopsy with targeted antibiotic prophylaxis.

Patient reported treatment burden and attitudes towards in-home intravesical therapy among patients with bladder cancer.

PURPOSE: To quantify patient reported treatment burden while receiving intravesical therapy for bladder cancer and to survey patient perspectives on in-home intravesical therapy. MATERIALS AND METHODS: We conducted a cross-sectional survey of the Bladder Cancer Advocacy Network Patient Survey Network. Survey questions were developed by investigators, then iteratively revised by clinician and patient advocates. Eligible participants had to have received at least 1 dose of intravesical therapy delivered in an ambulatory setting. RESULTS: Two hundred thirty-three patients responded to the survey with median age of 70 years (range 33-88 years). Two-thirds of respondents (66%, 151/232) had received greater than 12 bladder instillations. A travel time of >30 minutes to an intravesical treatment facility was reported by 55% (126/231) of respondents. Fifty-six percent (128/232) brought caregivers to their appointments, and 36% (82/230) missed work to receive treatment. Sixty-one respondents (26%) felt the process of receiving bladder instillations adversely affected their ability to perform regular daily activities. Among those surveyed, 72% (168/232) reported openness to receiving in-home intravesical instillations and 54% (122/228) answered that in-home instillations would make the treatment process less disruptive to their lives. CONCLUSIONS: Bladder cancer patients reported considerable travel distances, time requirements, and need for caregiver support when receiving intravesical therapy. Nearly three-quarters of survey respondents reported openness to receiving intravesical instillations in their home, with many identifying potential benefits for home over clinic-based therapy.

Incidental detection of pheochromocytoma during workup for symptomatic aortic stenosis: A case report and management discussion.

Pheochromocytoma patients with high levels of circulating catecholamines are at risk of cardiovascular complications related to hypertensive emergencies and subsequent organ damage. A patient with concomitant aortic stenosis and pheochromocytoma has compounded risk of cardiovascular complications, especially during surgery, which complicates medical decision-making. We report a patient with Turner syndrome and congenital heart defects (CHDs) who was incidentally discovered to have a pheochromocytoma during workup of symptomatic severe bioprosthetic aortic stenosis. Management included laparoscopic adrenalectomy followed by Transcatheter Aortic Valve Replacement (TAVR). We describe considerations for multidisciplinary management in this complex clinical case.

Protocol of a multicentre randomised controlled trial assessing transperineal prostate biopsy to reduce infectiouscomplications.

INTRODUCTION: Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer. METHODS AND ANALYSIS: We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer. ETHICS AND DISSEMINATION: The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER: NCT04815876.

Pathological and Clinical Outcomes in a Large Surveillance and Intervention Cohort of Radiographically Cystic Renal Masses.

PURPOSE: We evaluated oncologic risks in a large cohort of patients with radiographic cystic renal masses who underwent active surveillance or intervention. MATERIALS AND METHODS: A single-institutional database of 4,340 kidney lesions managed with either active surveillance or intervention between 2000-2020 was queried for radiographically cystic renal masses. Association of radiographic tumor characteristics and high-grade pathology was evaluated. RESULTS: We identified 387 radiographically confirmed cystic lesions in 367 patients. Of these, 247 were resected (n=240) or ablated (n=7; n=247, 203 immediate vs 44 delayed intervention). Pathologically, 23% (n=56) demonstrated high-grade pathology. Cystic features were explicitly described by pathology in only 18% (n=33) of all lesions and in 7% (n=4) of high-grade lesions. Of the intervention cohort, African American race, male gender, and Bosniak score were associated with high-grade pathology (P < .05). On active surveillance (n=184), Bosniak IV lesions demonstrated faster growth rates than IIF and III lesions (2.7 vs 0.6 and 0.5 mm/y, P ≤ .001); however, growth rates were not associated with high-grade pathology (P = .5). No difference in cancer-specific survival was identified when comparing intervention vs active surveillance at 5 years (99% vs 100%, P = .2). No difference in recurrence was observed between immediate intervention vs delayed intervention (P > .9). CONCLUSIONS: A disconnect between "cystic" designation on imaging and pathology exists for renal lesions. Over 80% of radiographic Bosniak cystic lesions are not described as "cystic" on pathology reports. More than 1 in 5 resected cystic renal lesions demonstrated high-grade disease. Despite this finding, judiciously managed active surveillance ± delayed intervention is a safe and effective management option for most radiographic cystic renal masses.

Adjuvant Therapy for High-Risk Localized Renal Cell Carcinoma: Current Landscape and Future Direction.

Locally and regionally advanced renal cell carcinoma (RCC) can recur at high rates even after visually complete resection of primary disease. Both targeted therapies and immunotherapies represent potential agents that might help reduce recurrence of RCC in these patients. This paper reviews the current body of evidence defining their potential impact and examines the large Phase III randomized clinical trials that have been performed to assess the safety and efficacy of these systemic therapies in the adjuvant setting. Given that the findings from these trials have been predominantly negative, this paper also explores the role of other potential adjuvant agents, including single and combination agent targeted therapies and immunotherapies, whose use is currently limited to metastatic RCC. Finally, the use of radiation therapy and the use of advanced imaging modalities in RCC are also considered.

Resolution of manic symptoms following unilateral adrenalectomy in patient with primary bilateral macronodular adrenal hyperplasia.

Primary bilateral macronodular adrenal hyperplasia (PBMAH) is often associated with symptoms of cortisol excess, which may include neuropsychological symptoms. We report a patient with PBMAH who presented with manic symptoms that resolved following unilateral adrenalectomy.

How many cores are enough? Optimizing the transperineal prostate biopsy template.

INTRODUCTION AND OBJECTIVE: Most urologists use a 10-12 core template during transrectal ultrasound guided prostate biopsy (TRUS-B). A similar consensus template does not exist for transperineal prostate biopsy (TP-B) including the optimal number and location of biopsy cores. We examined our institutional cohort to develop an optimal systematic template for TP-B. METHODS: We prospectively monitored our first 200 consecutive free-hand TP-B. These included men who were biopsy naïve (n = 117), had elevated PSA with prior negative biopsy (n = 18), and men on active surveillance (n = 65). All men underwent a 20 core TP-B with each core placed in a separate specimen container. This allowed the 20-core TP-B to be easily broken down as though fewer cores had been taken in each patient. Ten, 12, and 16 core templates were designed a priori and compared within each patient to the 20 core template. The highest Grade Group (GG) at pathologic analysis was assigned to each biopsy. Primary outcome was detection of clinically significant prostate cancer, defined as ≥GG2. Secondary outcome was detection of GG1 prostate cancer. We performed sub-group analyses of biopsy naïve men and biopsy naïve men stratified by PSA density (<0.15 vs. ≥0.15 ng/mL/cc). An historic institutional cohort of 10-12 core TRUS-B (n = 170) was used to compare prostate cancer detection between techniques. P value of ≤0.05 was considered statistically significant. RESULTS: Clinically significant cancers were detected in 98 men (49%) using a 20 core TP-B technique. Had we sampled fewer cores we would have identified clinically significant cancers in 93 (47%, 16 core), 91 (46%, 12 core), and 82 (41%, 10 core) men. More clinically significant cancers were detected by the 20 core template compared to the 10 core template for both the whole cohort (49% vs. 41%, P = 0.02) and the biopsy naïve subset (48% vs. 40%, P = 0.05). Additional cores did not result in an increased detection of GG1 cancers (20-core: 35% vs. 10-core: 44%, P = 0.09). Less than one quarter of biopsy naïve men with a PSA density <0.15 were found to have clinically significant cancers. More clinically significant cancers were detected in the 12-core TP-B cohort compared to the 12-core TRUS-B series (46% vs. 38%, P < 0.001). CONCLUSIONS: A 20 core TP-B systematic biopsy template detected a greater number of clinically significant prostate cancers compared to a 10 core TP template. Cancer detection was similar for 12, 16, and 20 core templates. Higher core numbers did not result in greater detection of GG1 tumors reflecting increased detection of concomitant ≥GG2 with greater sampling. We propose a minimum 12 core systematic biopsy template for men undergoing TP-B.

Metastatic serous endometrial carcinoma to the ureter.

Metastatic endometrial carcinoma involving the renal parenchyma has been reported. However, ureteral metastasis is exceedingly rare. Here we describe what we believe to be the first case report of metastatic endometrial serous carcinoma to the ureteral and renal pelvic urothelium. The patient is a 68 year old female diagnosed with endometrial serous carcinoma three years prior to presentation who was found to have metastatic disease within the right ureter and retroperitoneal lymph nodes. Following a complete response in the lymph nodes to chemotherapy, she was treated with robot-assisted right nephroureterectomy for residual, isolated PET-avid right ureteral metastasis.

Open versus minimally invasive surgery for suspected adrenocortical carcinoma.

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. Although laparoscopy has been widely adopted for management of benign adrenal tumors, minimally invasive surgery for ACC remains controversial. Retrospective analyses, frequently with fewer than one hundred participants, comprise the majority of the literature. High-quality data regarding the optimal surgical approach for ACC are lacking due to the rarity of the disease and the fact that determination of tumor type (e.g., adenoma or carcinoma) is determined after adrenalectomy, since adrenal tumors are generally not biopsied. While the benefits of minimally invasive surgery including lower intra-operative blood loss and decreased hospital length-of-stay have been consistently demonstrated, clinical equipoise for long-term survival and recurrence outcomes between open and minimally invasive adrenalectomy (MIA) remains. This review examines retrospective studies that directly compare patients with ACC who underwent either open or laparoscopic adrenalectomy, and considers these findings in the context of current guideline recommendations for surgical management of ACC.

Complete response of penile mycosis fungoides with systemic brentuximab therapy.

Mycosis fungoides with penile involvement is extremely rare. Previous reports have shown successful treatment with imiquimod or a combination of beam radiation and chemotherapy. We present a patient with mycosis fungoides and penile involvement. The penile lesions were initially treated with topical imiquimod; however, he developed worsening glandular lesions and discharge. Therefore the treatment was discontinued. Subsequent treatment with brentuximab (anti-CD30) targeted therapy resulted in complete resolution of the penile lesions. To our knowledge, this represents the first case of a complete penile mycosis fungoides response to brentuximab therapy. Brentuximab may be considered for refractory penile mycoses fungoides.

The role of lymphadenectomy at the time of radical nephroureterectomy for upper tract urothelial carcinoma.

The role of lymphadenectomy (LND) at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) is controversial. The National Comprehensive Cancer Network guidelines recommend performing a template-based LND for high-risk primary tumors while the European guidelines state that it is not feasible to determine indication or extent of LND at the time of surgery for UTUC. Herein, we review the anatomic rationale for template-based LND, examine when a LND should be considered, and discuss the impact of LND on staging and survival outcomes.

Cancer Prevention and Screening for Older Adults: Part 1. Lung, Colorectal, Bladder, and Kidney Cancer.

The incidence of most cancers increases with age. Cancer is the second most common cause of death in older adults after cardiovascular disease. Many common cancers in older adults can be prevented from occurring or can be identified at an early stage and treated effectively. The prevention and identification of cancer in its early stages, in an attempt to reduce discomfort and disability associated with advanced cancer and cancer treatment, is also a priority. Overscreening for cancer in older adults can lead to unnecessary diagnostic testing and unnecessary treatment. Both older adults and their healthcare providers need guidance on the appropriate use of cancer prevention and screening interventions. This first of a two-part review addresses special considerations regarding cancer prevention for adults aged 65 and older. Screening decisions and the impact of limited life expectancy and an older adult's ability to tolerate cancer treatment are also addressed. Guidance is provided regarding the prevention and early identification of lung, colorectal, bladder, and kidney cancer in older adults. The prevention of breast, prostate, and female urogenital cancers are addressed in Part 2. J Am Geriatr Soc 68:2399-2406, 2020.

Cancer Prevention and Screening for Older Adults: Part 2. Interventions to Prevent and Screen for Breast, Prostate, Cervical, Ovarian, and Endometrial Cancer.

The incidence of most cancers increase with age. Cancer is the second most common cause of death in older adults after cardiovascular disease. Many common cancers in older adults can be prevented from occurring or can be identified at an early stage and treated effectively. Although cancer is feared primarily because of premature mortality, for many older adults, preventing and identifying cancer in its early stages, in an attempt to reduce discomfort and disability associated with advanced cancer and cancer treatment, is also a priority. Overscreening for cancer in older adults can lead to unnecessary diagnostic testing and unnecessary treatment. Both older adults and their healthcare providers need guidance on the appropriate use of cancer prevention and screening interventions. This is the second part of a two-part clinical review on cancer prevention and screening for adults aged 65 and older. Guidance is provided regarding the prevention and early identification of breast, prostate, cervical, ovarian, and endometrial cancer. The prevention of lung, colorectal, bladder, and kidney cancer is addressed in Part 1.

Isolated DHEAS production by an adrenal neoplasm: Clinical, biochemical and pathologic characteristics.

Androgen-secreting adrenal neoplasms have a low incidence, usually secrete multiple hormones, and may present with hirsutism, acne, and alopecia. We report an exceedingly rare case of a purely dehydroepiandrosterone-sulfate (DHEA-S) secreting adrenal neoplasm found incidentally on cross sectional imaging. The clinical, biochemical, and pathologic findings of this neoplasm are described.

Case report: Adenosquamous carcinoma of the prostate with greater than 20 month response to multimodal therapy.

Adenosquamous carcinoma is an extremely rare and lethal subtype of prostate cancer affecting an estimated 0.03 per million men annually. It has been associated with prior hormone therapy for prostate adenocarcinoma. We present a case of de novo adenosquamous carcinoma of the prostate treated with a multimodal approach including surgery, androgen-deprivation therapy, chemotherapy, and radiation.