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Background: Considering that most men benefit diagnostically from increased sampling of index lesions, limiting systematic biopsy (SBx) to the region around the index lesion could potentially minimize overdetection while maintaining the detection of clinically significant prostate cancer (csPCa). Objective: To evaluate the diagnostic performance of a hypothetical magnetic resonance imaging (MRI)-directed targeted-plus-perilesional biopsy approach. Design setting and participants: This single-center, retrospective analysis of prospectively generated data included all biopsy-naïve men with unilateral MRI-positive lesions (Prostate Imaging Reporting and Data System category ≥3), undergoing both MRI-directed targeted biopsies and SBx. Grade group 2-5 cancers were considered csPCa. Outcome measurements and statistical analysis: The diagnostic performance of a targeted-plus-perilesional biopsy approach was compared with that of a targeted-plus-systematic biopsy approach. The primary outcome was the detection of csPCa. Secondary outcomes included the detection of clinically insignificant prostate cancer (ciPCa) and the number of total biopsy cores. Results and limitations: A total of 235 men were included in the analysis; csPCa and ciPCa were detected, respectively, in 95 (40.4%) and 86 (36.6%) of these 235 men. A targeted-plus-perilesional biopsy approach would have detected 92/95 (96.8%; 95% confidence interval [CI] 91.0-99.3%) csPCa cases. At the same time, detection of systematically found ciPCa would be reduced by 11/86 (12.8%; 95% CI 6.6-21.7%). If a targeted-plus-perilesional biopsy approach would have been performed, the number of biopsy cores per patient would have been reduced significantly (a mean difference of 5.2; 95% CI 4.9-5.6, p < 0.001). Conclusions: An MRI-directed targeted-plus-perilesional biopsy approach detected almost all csPCa cases, while limiting overdiagnosis and reducing the number of biopsy cores. Prospective clinical trials are needed to substantiate the withholding of nonperilesional SBx in men with unilateral lesion(s) on MRI. Patient summary: Limiting systematic biopsies to the proximity of the suspicious area on magnetic resonance imaging helps detect an equivalent number of aggressive cancers and fewer indolent cancers. These findings may help patients and physicians choose the best biopsy approach.
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PURPOSE: Catheter-related bladder discomfort occurs in up to 63% of patients following robot-assisted radical prostatectomy. The optimal intraoperative anesthesia regime to prevent patients from catheter-related bladder discomfort is unknown. MATERIALS AND METHODS: A prospective cohort analysis was conducted. Patients with biopsy-proven prostate cancer selected for robot-assisted radical prostatectomy were included between January 2017 and April 2020 from a high volume prostate cancer center. Eight different treatment regimens were compared, ie a combination of general anesthesia and a transversus abdominis plane block with either an additional dose of clonidine or an additional dose of ketamine, or perivesical infiltrations (with 20 ml ropivacaine), or periurethral infiltrations (with ropivacaine); or a dorsal penile nerve block (with 20 ml ropivacaine). Multiple logistic regression and linear mixed models were used to analyze differences in catheter-related bladder discomfort and pain (0-10) at the postoperative recovery unit between the treatment protocols. RESULTS: Of the 391 patients included, those with a combination transversus abdominis plane block, perivesical and periurethral block with ropivacaine had the lowest incidence of catheter-related bladder discomfort, clinically relevant and statistically significantly lower compared to our baseline protocol (transversus abdominis plane block only), ie 36% vs 70%, p=0.001. Overall, patients who were treated with periurethral and/or perivesical infiltrations reported a statistically significantly lower incidence of catheter-related bladder discomfort compared to patients who did not receive this local infiltration (46.5% vs 60.7%, p=0.001). CONCLUSIONS: Perivesical and periurethral injections with ropivacaine have the potential to reduce the incidence of early postoperative catheter-related bladder discomfort by up to 49%. Further randomized studies are necessary to determine the optimal treatment regime to prevent early postoperative catheter-related bladder discomfort.
