[Multiparametric MRI and MRI-TRUS fusion biopsy in patients with prior negative prostate biopsy]. / Wertigkeit der multiparametrischen MRT und der MRT-TRUS-Fusionsbiopsie bei primär negativ biopsierten Patienten.

BACKGROUND: Multiparametric MRI (mpMRI) plays an increasingly important role in prostate cancer (PCa) diagnostics and is recommended in men with previously negative TRUS biopsy. The optimal biopsy method after mpMRI is under discussion. OBJECTIVE: Prospective, PIRADS- and START-conform analysis of the relevance of mpMRI and MRI-TRUS fusion biopsy in patients with prior negative TRUS biopsy and comparison of the detection rates of fusion-targeted biopsies (tB) and systematic transperineal saturation biopsies (sB). MATERIALS AND METHODS: Between 10/2012 and 09/2015, 287 patients with prior negative TRUS biopsy underwent mpMRI and software-assisted, rigid MRI-TRUS fusion biopsy. In addition to and strictly separated from sB (median cores n = 24), tB (median cores per patient n = 4, per lesion n = 3) were performed in case of suspicious MRI lesions (PIRADS ≥ 2). Both biopsy methods were compared by using McNemar's test. RESULTS: Of the 287 patients, 148 (52 %) had positive biopsies. Of these, 108/287 (38 %) had significant PCa (Gleason Score [GS] = 3 + 3 and PSA ≥ 10 ng/ml or GS ≥ 3 + 4) and again 43/287 (15 %) had a GS ≥ 4 + 3 PCa. sB failed to diagnose 8/148 PCa (5.4 %) and 6/108 significant PCa (5.5 %), whereas tB failed to diagnose 48 (32.4 %) PCa (p < 0.0001) and 22 (20.4 %) significant PCa (p = 0.0046). Of the PCa missed by tB, 11  had a GS ≥ 3 + 4 and 5 of these a GS = 4 + 3. On a per patient basis, MRI failed to detect 5 significant PCa, whereby 17 of the significant PCa were missed by fusion-targeted cores alone. CONCLUSIONS: In men with unsuspicious MRI (PIRADS < 3), there is a 11 % risk of significant PCa. In case of suspicious MRI lesions, the combination of both biopsy approaches offers maximum tumor detection.

Further reduction of disqualification rates by additional MRI-targeted biopsy with transperineal saturation biopsy compared with standard 12-core systematic biopsies for the selection of prostate cancer patients for active surveillance.

BACKGROUND: Active surveillance (AS) is commonly based on standard 10-12-core prostate biopsies, which misclassify ~50% of cases compared with radical prostatectomy. We assessed the value of multiparametric magnetic resonance imaging (mpMRI)-targeted transperineal fusion-biopsies in men under AS. METHODS: In all, 149 low-risk prostate cancer (PC) patients were included in AS between 2010 and 2015. Forty-five patients were initially diagnosed by combined 24-core systematic transperineal saturation biopsy (SB) and MRI/transurethral ultrasound (TRUS)-fusion targeted lesion biopsy (TB). A total of 104 patients first underwent 12-core TRUS-biopsy. All patients were followed-up by combined SB and TB for restratification after 1 and 2 years. All mpMRI examinations were analyzed using PIRADS. AS was performed according to PRIAS-criteria and a NIH-nomogram for AS-disqualification was investigated. AS-disqualification rates for men initially diagnosed by standard or fusion biopsy were compared using Kaplan-Meier estimates and log-rank tests. Differences in detection rates of the SB and TB components were evaluated with a paired-sample analysis. Regression analyses were performed to predict AS-disqualification. RESULTS: A total of, 48.1% of patients diagnosed by 12-core TRUS-biopsy were disqualified from AS based on the MRI/TRUS-fusion biopsy results. In the initial fusion-biopsy cohort, upgrading occurred significantly less frequently during 2-year follow-up (20%, P<0.001). TBs alone were significantly superior compared with SBs alone to detect Gleason-score-upgrading. NPV for Gleason-upgrading was 93.5% for PIRADS⩽2. PSA level, PSA density, NIH-nomogram, initial PIRADS score (P<0.001 each) and PIRADS-progression on consecutive MRI (P=0.007) were significant predictors of AS-disqualification. CONCLUSIONS: Standard TRUS-biopsies lead to significant underestimation of PC under AS. MRI/TRUS-fusion biopsies, and especially the TB component allow more reliable risk classification, leading to a significantly decreased chance of subsequent AS-disqualification. Cancer detection with mpMRI alone is not yet sensitive enough to omit SB on follow-up after initial 12-core TRUS-biopsy. After MRI/TRUS-fusion biopsy confirmed AS, it may be appropriate to biopsy only those men with suspected progression on MRI.

[Urinary diversion in elderly patients]. / Harnableitung beim älteren Patienten.

BACKGROUND: Bladder cancer represents one of the ten most prevalent cancers worldwide. More than 400,000 people worldwide are newly diagnosed every year. Within 2 years after diagnosis, 80% of patients with muscle invasive bladder cancer without treatment die. METHODS: The aggressive local surgical approach with a cystectomy is the therapy of choice. The median age of patients with de novo bladder cancer is 70 years. Thus bladder cancer is a cancer of the elderly. For demographical reasons, the number of eldery patients undergoing radical cystectomy will rise in the next few years. The type of urinary diversion is a major factor influencing perioperative morbidity and quality of life in these patients. Incontinent urinary diversions are preferentially used in daily practice. CONCLUSIONS: There are only a few contraindications for orthotopic neobladder; however, age alone is not a contraindication. Patient selection and a nerve sparing approach are crucial in men and women to achieve excellent functional results with orthotopic neobladder in elderly patients.

Improved detection of anterior fibromuscular stroma and transition zone prostate cancer using biparametric and multiparametric MRI with MRI-targeted biopsy and MRI-US fusion guidance.

BACKGROUND: The objective of this study was to analyze the potential of prostate magnetic resonance imaging (MRI) and MRI/transrectal ultrasound-fusion biopsies to detect and to characterize significant prostate cancer (sPC) in the anterior fibromuscular stroma (AFMS) and in the transition zone (TZ) of the prostate and to assess the accuracy of multiparametric MRI (mpMRI) and biparametric MRI (bpMRI) (T2w and diffusion-weighted imaging (DWI)). METHODS: Seven hundred and fifty-five consecutive patients underwent prebiopsy 3 T mpMRI and transperineal biopsy between October 2012 and September 2014. MRI images were analyzed using PIRADS (Prostate Imaging-Reporting and Data System). All patients had systematic biopsies (SBs, median n=24) as reference test and targeted biopsies (TBs) with rigid software registration in case of MRI-suspicious lesions. Detection rates of SBs and TBs were assessed for all PC and sPC patients defined by Gleason score (GS)⩾3+4 and GS⩾4+3. For PC, which were not concordantly detected by TBs and SBs, prostatectomy specimens were assessed. We further compared bpMRI with mpMRI. RESULTS: One hundred and ninety-one patients harbored 194 lesions in AFMS and TZ on mpMRI. Patient-based analysis detected no difference in the detection of all PC for SBs vs TBs in the overall cohort, but in the repeat-biopsy population TBs performed significantly better compared with SBs (P=0.004 for GS⩾3+4 and P=0.022 for GS⩾4+3, respectively). Nine GS⩾4+3 sPCs were overlooked by SBs, whereas TBs missed two sPC in men undergoing primary biopsy. The combination of SBs and TBs provided optimal local staging. Non-inferiority analysis showed no relevant difference of bpMRI to mpMRI in sPC detection. CONCLUSIONS: MRI-targeted biopsies detected significantly more anteriorly located sPC compared with SBs in the repeat-biopsy setting. The more cost-efficient bpMRI was statistically not inferior to mpMRI in sPC detection in TZ/AFMS.