Additional elastography-targeted biopsy improves the agreement between biopsy Gleason grade and Gleason grade at radical prostatectomy

Purpose

To assess whether real-time elastography-targeted biopsy (RTE-bx) may help to correctly assign Gleason grade at radical prostatectomy (RP) and to compare discriminant properties of systematic biopsy alone (sbx) versus combination with RTE-bx (comb-bx) to distinguish between postoperatively favorable (Gleason 3 + 3, pT2, Nx/0) and postoperatively unfavorable (Gleason ≥4 + 4) prostate cancer (PCa) at RP.

Patients and methods

Overall, 259 patients diagnosed with PCa at systematic biopsy in combination with RTE-bx underwent RP between 2008 and 2011. Gleason Score derived from sbx versus comb-bx was compared to the gold-standard RP, and discriminant properties were assessed. Specificity gains were examined for sbx versus comb-bx when the endpoint consisted of postoperatively favorable PCa at RP. Sensitivity gains were examined, when analyses focused on postoperatively unfavorable PCa.

Results

Comb-bx resulted in higher correct overall Gleason assignment (68.3 vs. 56.7 %, p = 0.008) than sbx. Similarly, lower rates of undergrading (21.2 vs. 36.3 %, p < 0.001) were recorded. Specificity gains with comb-bx were 10 % (92 vs. 82 %, p = 0.004) for postoperatively favorable PCa. Comb-bx resulted in 31 % sensitivity gains relative to sbx (94 vs. 63 %, p = 0.03), when postoperatively unfavorable PCa was the endpoint.

Conclusion

The agreement between biopsy and pathology Gleason Score was significantly higher for comb-bx than sbx. Additionally, comb-bx reduced the rate of false positives in the diagnosis of favorable PCa. Rates of correctly classified unfavorable PCa at RP were also higher for comb-bx. Those data indicate that comb-bx is useful in clinical practice.

     

Apparent diffusion coefficient value is a strong predictor of unsuspected aggressiveness of prostate cancer before radical prostatectomy

Purpose

To evaluate the use of multiparametric MRI (mp MRI) parameters in order to predict prostate cancer aggressiveness as defined by pathological Gleason score or molecular markers in a cohort of patients defined with a Gleason score of 6 at biopsy.

Methods

Sixty-seven men treated by radical prostatectomy (RP) for a low grade (Gleason 6) on biopsy and mp MRI before biopsy were selected. The cycle cell proliferation (CCP) score assessed by the Prolaris test and Ki-67/PTEN expression assessed by immunohistochemistry were quantified on the RP specimens.

Results

49.25 % of the cancers were undergraded on biopsy compared to the RP specimens. Apparent diffusion coefficient (ADC) < 0.80 × 10^?3 mm²/s (P value 0.003), Likert score >4 (P value 0.003) and PSA density >0.15 ng/ml/cc (P value 0.035) were significantly associated with a higher RP Gleason score. Regarding molecular markers of aggressiveness, ADC < 0.80 × 10^?3 mm²/s and Likert score >4 were also significantly associated with a positive staining for Ki-67 (P value 0.039 and 0.01, respectively). No association was found between any analyzed MRI or clinical parameter and the CCP score.

Conclusion

Decreasing ADC value is a stronger indicator of aggressive prostate cancer as defined by molecular markers or postsurgical histology than biopsy characteristics.

     

Multiparametric ultrasound-targeted biopsy compares favorably to multiparametric MRI-transrectal ultrasound fusion-targeted biopsy on initial biopsy of men at risk for prostate cancer

Purpose

The purpose this study is to evaluate the efficacy of multiparametric ultrasound-targeted biopsies in patients undergoing initial biopsy of the prostate for the suspicion of prostate cancer.

Materials and methods

A total of 167 patients who are biopsy naïve underwent multiparametric ultrasound-targeted biopsy of the prostate. All patients had a transrectal ultrasound which included gray-scale evaluation and color Doppler evaluation. 12-core biopsies were performed on all patients, based on sextant anatomy; however, all cores were directed toward visually abnormal areas of the prostate as identified by multiparametric ultrasound, when such areas were present.

Results

Of 167 patients undergoing biopsy, a total of 111 (66.5%) were positive for cancer. Of these, 78 (70.3%) had a Gleason grade ≥ 7 and 33 (29.7%) had a Gleason grade ≤ 6. Of those undergoing radical prostatectomy 29 of 38 (76.3%) had biopsy Gleason grade ≥ 7, while nine of 38 (23.7%) had a Gleason grade ≤ 6. Only four of 38 (10.5%) patients who had final pathologic staging underwent surgical therapy for disease of low-malignant potential (Gleason ≤ 6).

Conclusion

On initial biopsy for prostate cancer, multiparametric ultrasound-targeted biopsy compares favorably to the published performance of multiparametric MRI-TRUS fusion-targeted biopsy in terms of positive biopsy rate and the detection of disease of low-malignant potential.

     

Clinical impact of prostate biopsy undergrading in an academic and community setting

Purpose

To evaluate whether the rate of Gleason score (GS) upgrade on final pathology, the rate of positive surgical margins (PSM) and the rate of biochemical recurrence (BCR) after radical prostatectomy (RP) were different if prostate biopsy (PB) was graded by community pathologists (CP) as compared to specialized uro-pathologists (UP).

Methods

A consecutive series of patients undergoing RP in our institution between 2005 and 2013 were retrospectively reviewed. Any GS higher or lower in RP specimen as compared to PB GS was defined as GS upgrade or downgrade, respectively. Additionally, stratification for the new ISUP 2014 grading system was performed. Predictors of GS upgrade and PSMs and prognostic parameters for BCR were assessed by stepwise logistic regression models and by multivariable Cox regression analyses, respectively.

Results

A total of 786 patients were available for analysis, and median follow-up was 36 months (1–101 months). A GS upgrade was found in 345 patients (43.9 %) and a GS downgrade in 91 patients (11.6 %). Discordance between PB GS and RP GS was significantly more frequent when grading had been performed by a CP (50.5 % upgrade, 9.0 % downgrade) than by a UP (33.1 % upgrade, 15.7 % downgrade, p < 0.001). CP evaluation was an independent predictor for GS upgrade (odds ratio [OR] 1.91, p < 0.001) and for PSMs (OR 1.69, p = 0.003), as well as an independent predictor of BCR (hazard ratio [HR] 1.65, p = 0.028).

Conclusions

Pathologic evaluation of PBs by a dedicated UP should be recommended to reduce the rate of biopsy undergrading, PSM and BCR after RP.

     

Postoperative upgrading of prostate cancer in men ≥75 years: a propensity score-matched analysis

Purpose

Gleason score upgrading should be considered when indicating surgery in prostate cancer (PCa) patients. In elderly patients, definitive treatment of low-risk PCa must be weighed with the risks of overtreatment. Our aim was to evaluate rates of Gleason score upgrading in patients ≥75 years undergoing radical prostatectomy (RP) for localized PCa and to identify predictors associated with upgrading.

Methods

3296 patients undergoing RP were retrospectively evaluated and categorized into age groups: <70 years (n = 2971) vs. ≥75 years (n = 325). We analyzed prostate-specific antigen (PSA), biopsy counts, Gleason score, pathologic T- and N-stage, and surgical margin. Propensity score matching was performed to compare rates of up- and downgrading on surgical specimen using the new five-tier pathologic grading system. Logistic regression was used to identify independent predictors of upgrading.

Results

Preoperatively, patients ≥75 years had higher PSA (8.8 vs. 7.3 ng/mL) and lower proportion of grade group 1 (Gleason score 6) at biopsy (29.2 vs. 47.9%; both p < 0.001) compared to patients <70 years. At RP, patients ≥75 years were more likely to have extraprostatic disease (50 vs. 30%) and lower rates of grade group 1 (14.1 vs. 34.8%; both p < 0.001). Postoperative downgrading was similar (15.1 vs. 19.5%). However, patients ≥75 years had higher rates of postoperative upgrading (46.6 vs. 27.9%; p < 0.001). Age ≥75 years, higher PSA levels at RP, and an increased number of positive biopsy cores were associated with upgrading.

Conclusions

Patients ≥75 years not only demonstrated higher rates of advanced disease but more frequent upgrading on RP specimen. Age ≥75 years, higher PSA levels at RP, and an increased number of positive biopsy cores were predictive for upgrading. The increased risk of upgrading should be taken into consideration when discussing optimal treatment for this specific cohort.

     

Are 10-, 10–12-, or &gt; 12-mm prostate biopsy core quality control cutoffs reasonable?

Purpose

To explore the role of prostate biopsy core length on prediction of index tumor clinical significance and localization on radical prostatectomy (RP) and time to recurrence, hypothesizing 10-, 10–12-, or > 12-mm minimum core as potential biopsy quality control.

Methods

Assessed 2424 prostate biopsy cores and corresponding RP of 202 patients submitted to the first set of 12 cores prostate biopsy between 2010 and 2015. Analyzed biopsy core length, age, prostate volume (PV), free and total PSA ratio, PSA density, RP index tumor clinical significance, extension, localization, surgical margins, and cancer control. Prostate biopsy confronted to surgical specimens defined Gleason grade-grouping system (1–5) agreement.

Results

Median age was 63.7 years, PSA 10.1 ng/dl, PSA density 28%, and mean follow-up 5 years. Recurrence was identified in 64 (31.7%) patients and predicted by PSA > 10 at time of diagnosis (p = 0.008), seminal vesicle invasion (p = 0.0019), core tumor percentage (p = 0.033), and tumor localization predominantly in the prostate base (p = 0017). The mean core length was longer in index tumor positive cores (p = 0.043) and in tumors classified as clinically insignificant (p = 0.011), without impact on tumor localization (basal vs apical p = 0.592; left vs. right p = 0.320). Biopsy core length categories (≤ 10, 10–12 and > 12 mm) did not significantly impact Gleason grade-grouping agreement or time to recurrence (p > 0.05). Core length was not significantly different in all Gleason grade-groupings 1–5 (p = 0.312).

Conclusion

Prostate biopsy core length impacts tumor characterization; however, 10 mm minimum core length and even 10–12- and > 12-mm categories failed as a biopsy quality control in our data.

     

Positive trends in paediatric renal biopsy service provision in the UK: a national survey and re-audit of paediatric renal biopsy practice

Background

Paediatric renal biopsy standards introduced in the UK in 2010 were intended to reduce variation and improve practice. A concurrent national drive was aimed at building robust paediatric nephrology networks to ensure services cater for the needs of the family and minimise time away from home. We aimed to identify current national practice since these changes on behalf of the British Association for Paediatric Nephrology.

Methods

All UK paediatric nephrology centres were invited to complete a survey of their biopsy practice, including advance preparation. From 1 January to 30 June 2012, a national prospective audit of renal biopsies was undertaken at participating centres comparing practice with the British Association for Paediatric Nephrology (BAPN) standards and audit results from 2005.

Results

Survey results from 11 centres demonstrated increased use of pre-procedure information leaflets (63.6 % vs 45.5 %, P?=?0.39) and play preparation (90.9 % vs 9.1 %, P?=?0.0001). Audit of 331 biopsies showed a move towards day-case procedures (49.5 % vs 32.9 %, P?=?0.17) and reduced major complications (4.5 % vs 10.4 %, P?=?0.002). Biopsies with 18-gauge needles had significantly higher mean pass rates (3.2 vs 2.3, P?=?0.0008) and major complications (15.3 % vs 3.3 %, P?=?0.0015) compared with 16-gauge needles.

Conclusions

Percutaneous renal biopsy remains a safe procedure in children, thus improving family-centered service provision in the UK.

     

Targeted transperineal biopsy of the prostate has limited additional benefit over background cores for larger MRI-identified tumors

Purpose

To compare histological outcomes in patients undergoing MRI–transrectal ultrasound fusion transperineal (MTTP) prostate biopsy and determine the incremental benefit of targeted cores.

Methods

Seventy-six consecutive patients with 89 MRI-identified targets underwent MTTP biopsy. Separate targeted biopsies and background cores were obtained according to a standardized protocol. Target biopsies were considered of added diagnostic value if these cores showed a higher Gleason grade than non-targeted cores taken from the same sector (Group 1, n = 41). Conversely, where background cores demonstrated an equal or higher Gleason grade, target cores were considered to be non-beneficial (Group 2, n = 48).

Results

There was no significant difference in age, PSA, prostate volume, time-to-biopsy, and number of cores obtained between the groups. A greater proportion of target cores were positive for cancer (158/228; 69.3 %) compared to background (344/1881; 18.38 %). The median target volume was 0.54 cm³ for Group 1 (range 0.09–2.79 cm³) and 1.65 cm³ for Group 2 (0.3–9.07 cm³), p < 0.001. The targets in Group 1 had statistically lower diameters for short and long axes, even after correction for gland size. The highest area under the receiver operating characteristic curve was demonstrated when a lesion cutoff value of 1.0 cm in short axis was applied, resulting in a sensitivity of 83.3 % and a specificity of 82.9 %.

Conclusions

When a combined systematic and targeted transperineal prostate biopsy is performed, there is limited benefit in acquiring additional cores from larger-volume targets with a short axis diameter >1.0 cm.

     

Atypical small acinar proliferation at index prostate biopsy: rethinking the re-biopsy paradigm

Purpose

Guidelines for atypical small acinar proliferation (ASAP) diagnosed on prostate biopsy recommend repeat biopsy within 3–6 months after diagnosis. We sought to discern the rate of detecting clinically significant prostate cancer on repeat biopsy and predictors associated with progression.

Materials and methods

We performed a retrospective chart review of patients who underwent prostate biopsy at our institution from January 1, 2008, to December 31, 2015. Gleason grade group (GGG) system and D’Amico stratification were used to report pathology and risk stratification, respectively. Logistic and linear regression analyses were performed.

Results

A total of 593 patients underwent transrectal ultrasound-guided prostate biopsy, of which 27 (4.6%) had the diagnosis of ASAP. Of these, 11 (41%) had a repeat biopsy. Median time from diagnosis to repeat biopsy was 147 days (IQR 83.5–247.0). Distribution across the GGG system on repeat biopsy was as follows: 7 (63.6%) benign, 3 (27.3%) GG1, and 1 (9.1%) GG2. ASAP was not associated with subsequent diagnosis of clinically significant prostate cancer (OR 0.46, 95% CI 0.064–3.247, P = 0.432). There was no association between ASAP and high cancer risk (ASAP: β = ? 0.12; P = 0.204).

Conclusions

Patients diagnosed with ASAP managed according to guideline recommendations are more likely diagnosed with benign pathology and indolent prostate cancer on repeat biopsy. These findings support prior studies suggesting refinement of guidelines in regard to the appropriateness and timeliness of repeat biopsy among patients diagnosed with ASAP.

     

Real-time cancer diagnosis during prostate biopsy: ex vivo evaluation of full-field optical coherence tomography (FFOCT) imaging on biopsy cores

Objectives

To evaluate the diagnostic accuracy (Acc) of full-field optical coherence tomography (FFOCT) for cancer detection on prostate biopsy.

Materials and methods

Thirty-eight consecutive patients with elevated PSA and/or suspicious digital rectal examination were prospectively included. For each patient, 1–10 cores were randomly selected and imaged with FFOCT immediately after sampling. The images obtained were de-identified and analyzed by three pathologists blinded to the results of pathological evaluation. The overall average Acc was measured, as well as sensitivity (Se), specificity (Sp), positive and negative predictive values (PPV and NPV). The Acc learning curve was assessed by multivariate logistic regression, and inter-reader concordance was assessed by Kappa index.

Results

One hundred and nineteen cores were imaged. Of them, 40 (33.6 %) were involved with cancer. The overall average Acc of FFOCT for cancer detection was of 70.6 %. Se, Sp, PPV, and NPV were of 63, 74, 55.5, and 80 %, respectively. A substantial agreement was observed among pathologists (κ = 0.6, p < 0.001). On multivariate analysis, Acc was associated with the number of previously interpreted cases, with a predicted Acc of 82 % at the end of learning curve. The overall average accuracy for high Gleason score (>3 + 3) determination was of 72 %, although results were limited by the small amount of cases.

Conclusions

FFOCT of prostate biopsy cores may provide a diagnostic accuracy greater than 80 %, with a good reliability and a high NPV.

Take home message

“Full-field optical coherence tomography is a novel imaging modality that could have a potential value in real-time diagnosis of prostate cancer during prostate biopsy procedures.”

     

The detection of significant prostate cancer is correlated with the Prostate Imaging Reporting and Data System (PI-RADS) in MRI/transrectal ultrasound fusion biopsy

Purpose

To evaluate the performance of real-time MRI/ultrasound (MRI/US) fusion-guided targeted biopsy (TB) in men with primary and repeat biopsies and correlate the prostate cancer detection rate (CDR) with the PI-RADS score.

Methods

Analysis included 408 consecutive men with primary and prior negative biopsies who underwent TB and 10-core random biopsy (RB) between January 2012 and January 2015. TB was performed with a real-time MRI/US fusion platform with sensor-based registration. Clinically significant PCa was defined as Gleason score (GS) ≥7 or GS 6 with maximal cancer core length ≥4 mm for TB and according to Epstein criteria for RB.

Results

The overall CDR was 56 % (227/408). The CDR for primary biopsy was 74 % (60/81) and 57 % (67/117), 49 % (62/126), 45 % (38/84) for patients with 1, 2 and ≥3 prior negative biopsies. CDRs correlated with PI-RADS 2/3/4/5 were 16 % (5/32), 26 % (29/113), 62 % (94/152) and 89 % (99/111), respectively. The rates of significant tumors in relation to PI-RADS 2/3/4/5 were 60 % (3/5), 66 % (19/29), 74 % (70/94), 95 % (94/99). In 139 (61 %) cases with radical prostatectomy (RP), the rates of ≥pT3 tumors in correlation with PI-RADS 4 and 5 were 20 % (11/56) and 49 % (32/65). PI-RADS constituted the strongest predictor of significant PCa detection (p < 0.007).

Conclusions

Real-time MRI/US fusion-guided TB combined with RB improved PCa detection in patients with primary and repeat biopsies. The CDR was strongly correlated with a rising PI-RADS score, values of 4 and 5 increasing the detection of clinically significant tumors and leading to a higher histological stage after RP.

     

Impact of surgeon-defined capsular incision during radical prostatectomy on biochemical recurrence rates

Purpose

To determine the impact of intraoperative surgeon-defined incision of the prostatic capsule (CapI) on cancer recurrence and to give an overview of the different definitions of CapI. CapI during radical prostatectomy (RP) occurs in a non-negligible number of patients; still, its impact on biochemical recurrence (BCR) remains controversial as definition of CapI differs in literature.

Methods

We analyzed the data of 3253 consecutive RP between 2009 and 2011. Occurrence and side of intraoperative CapI was documented by the surgeon. Factors influencing CapI were addressed using logistic regressions. The impact of CapI on BCR was analyzed using Cox regressions including traditional prognosticators.

Results

Median follow-up was 36.2 months. Unilateral (bilateral) CapI occurred in 22.2 % (12.1 %) of patients. CapI was reported more often following open RP (p < 0.0001) and nerve-sparing procedure (p = 0.0004). Three-year BCR-free survival was 78.8, 79.9 and 82.1 % (p = 0.13) for patients with no, unilateral and bilateral CapI. In multivariate analysis, pT-stage (p < 0.0001), Gleason grade (p < 0.0005) and nodal status (p < 0.0005) were significantly associated with BCR. However, CapI had no independent impact on BCR (unilateral vs. no CapI, p = 0.55, bilateral vs. no CapI, p = 0.32).

Conclusions

Intraoperative CapI occurs in a relevant number of RP and is more frequent during nerve-sparing procedure and open RP. However, there seems to be no impact of CapI and its extent on the incidence of early BCR.

     

Relationship between non-suspicious MRI and insignificant prostate cancer: results from a monocentric study

Objectives

To assess whether non-suspicious multiparametric magnetic-resonance imaging (mpMRI) was associated with no cancer or indolent prostate cancer (PCa) in subsequent biopsies.

Patients and methods

Retrospective analyses of a prospective database were conducted between 2009 and 2013. It included men with an abnormal digital rectal examination and/or prostate-specific antigen levels <20 ng/mL and a non-suspicious multiparametric MRI (Likert score <3). Participants underwent a systematic 12-extended-core biopsy ultrasound protocol (STD). Indolent PCa was defined as a single core with a Gleason score of 6 (3 + 3) and a cancer-core length of ≤4 mm.

Results

Seventy-eight patients with a negative MRI were included in the study; median patient age was 62 years (IQR 50–74). Median PSA level was 7.15 ng/mL, with a median PSA density of 0.15. The digital rectal examination was abnormal in eight cases. From MRI, 53 patients were Likert 2, 25 patients were Likert 1, and median prostate volume was 56.5 mL. From biopsies, no cancer was found in 92.3 % (n = 72). PCa was histologically confirmed in six patients (7.7 %): five cases were indolent (as defined above); only one patient had a cancer core of 5 mm long, with a Gleason score of 6 (3 + 3). All six patients were within the low-risk group according to the D’Amico classification.

Conclusion

Men with non-suspicious mpMRI are likely to have no or indolent PCa in subsequent biopsies.

     

Predictors for the detection of prostate cancer and clinically significant prostate cancer using TRUS-guided biopsy in patients with negative initial biopsy results

Purpose

We aimed to determine the predictors for the detection of prostate cancer and clinically significant prostate cancer in the setting of repeat prostate biopsy using trans-rectal ultrasonography-guided biopsy.

Methods

A total of 636 patients who underwent repeat prostate biopsy were included. The patients were divided into two groups according to the repeat biopsy results (with vs. without prostate cancer). A multivariable analysis was performed to assess the predictors for the detection of prostate cancer and clinically significant prostate cancer.

Results

Prostate cancer was detected in 98 patients (15.4%). Although there was no difference in the prostate-specific antigen velocity, the prostate-specific antigen density was higher in the patients with prostate cancer at the initial (0.14 vs. 0.17 ng/mL/cc, p = 0.049) and repeat biopsies (0.17 vs. 0.26 ng/mL/cc, p < 0.001). The proportions of the patients who met the active surveillance criteria were as follows: 22.4% (Johns Hopkins), 30.6% (University of Toronto), 32.7% (University of California at San Francisco), 30.6% (Prostate Cancer Research International Active Surveillance), 27.6% (Memorial Sloan Kettering Cancer Center), and 13.3% (University of Miami). In the multivariable analysis, age, hypoechoic lesion on trans-rectal ultrasonography, and prostate-specific antigen density at the repeat biopsy were the significant predictors for prostate cancer and clinically significant prostate cancer.

Conclusions

Trans-rectal ultrasonography before repeat prostate biopsy and the prostate-specific antigen density are useful for selecting patients with a high probability for prostate cancer if repeat trans-rectal ultrasonography-guided biopsy is considered. In addition, these are also helpful for detecting clinically significant prostate cancer.

     

High preoperative neutrophil–lymphocyte ratio predicts biochemical recurrence in patients with localized prostate cancer after radical prostatectomy

Purpose

To investigate the association between preoperative neutrophil–lymphocyte ratio (NLR) and oncological outcomes in patients with localized prostate cancer (PCa) after radical prostatectomy (RP).

Methods

We retrospectively reviewed the records of 1367 patients who underwent RP between November 2003 and April 2012. Patients who underwent a concurrent biopsy/procedure in other organs, had evidence of acute infection, or had systemic inflammatory disease were excluded. We divided the patients by NLR level and analyzed their perioperative outcomes. To determine NLR significance, we performed a multivariate logistic regression analysis of the pathological adverse outcomes and a Cox proportional hazard analysis of the biochemical recurrence (BCR), which was defined as a prostate-specific antigen level ≥0.2 ng/mL on two consecutive tests.

Results

Among the 1367 patients, 158 (11.6 %) in the high-NLR (≥2.5) group had a higher biopsy Gleason score (p < 0.001), pathological Gleason score (p < 0.001), and pathological stage (p < 0.001) than patients in the low-NLR (<2.5) group (n = 1209, 88.4 %). Multivariate analysis revealed that high NLR was significantly correlated with adverse pathological outcomes of higher pathological stage (HR 1.688; 95 % CI 1.142–2.497; p = 0.009) and extracapsular extension (HR 1.698; 95 % CI 1.146–2.516; p = 0.008). Kaplan–Meier analysis showed significantly worse BCR-free survival (p < 0.001) in patients with a high NLR. A high NLR was a significant predictor of BCR after RP (HR 1.358; 95 % CI 1.008–1.829; p = 0.044).

Conclusions

High NLR was significantly related to unfavorable clinicopathological outcomes and worse BCR-free survival. Further studies are needed to clarify the correlation between NLR and PCa.

     

Survival outcomes of locally advanced prostate cancer in patients aged &lt; 50 years after local therapy in the contemporary US population

Purpose

To assess survival outcomes of locally advanced prostate cancer (LAPC) in patients aged <?50 years after local therapy (LT), as compared to that in the older patients (≥?50 years). Moreover, effectiveness of postoperative radiation therapy (PRT) after radical prostatectomy (RP) was also assessed in patients aged <?50 years.

Methods

Within the Surveillance, Epidemiology, and End results database (2004–2014), non-metastatic cT3–4 LAPC patients treated with LT (RP, RT or RP+RT) were identified. After propensity score matching (PSM), cancer-specific mortality (CSM), overall survival (OS), and other-cause mortality (OCM) rates were assessed. Multivariable competing risk regression (MVA CRR) model was also used in our analysis.

Results

1507 younger (<?50 years) and 34833 older (≥?50 years) LAPC patients treated with LT were identified. Younger patients with LAPC had overall more aggressive disease features than their older counterparts. After PSM, younger patients yielded higher cumulative CSM rates than the older patients (P?=?0.046). However, OS and cumulative OCM rates were significantly higher (P?=?0.038 and P?<?0.0001, respectively) in the older cohort. In the MVA CRR model, younger patients yielded higher CSM (P?=?0.02). Specifically, younger patients resulted in higher CSM in Gleason score 8–10, cT3b/4 stage, cN1 stage, and patients treated with RP. No statistically significant differences were found in patients treated with RP versus RP+PRT in all parameters.

Conclusions

LAPC patients aged <?50 years yielded higher CSM after LT, specifically after RP, compared with the older counterparts (≥?50 years). No significant differences were observed in RP versus RP+PRT regarding survival outcomes in our analysis.

     

Laparoscopic nephrectomy for polycystic kidney: comparison of the transperitoneal and retroperitoneal approaches

Purpose

To evaluate and compare perioperative outcomes in patients undergoing either transperitoneal (TP) or retroperitoneal (RP) laparoscopic nephrectomy for autosomal dominant polycystic kidney disease (ADPKD).

Methods

All patients with ADPKD who underwent unilateral laparoscopic nephrectomy between 2000 and 2012 in two academic departments were retrospectively included. The perioperative parameters were compared between the TP and RP groups.

Results

A total of 82 patients were included, 43 patients in the TP group and 39 in the RP group. The patients’ characteristics were similar between TP set and RP set, except for the time from dialysis onset to nephrectomy (p = 0.02). Complication rates (25.6 vs 33.3 %, p = 0.44), transfusion rates (11.6 vs 20.5 %, p = 0.27) and conversion to open surgery (4.6 vs 7.7 %, p = 0.56) were similar between the TP and RP groups, respectively. Operative time was shorter for TP procedures (171.6 vs 210.5 min, p = 0.002), but there was no difference between the two approaches after 20 surgeries (p = 0.06). Patients in TP group had a shorter length of hospital stay (5.3 ± 1.9 vs 7.2 ± 2.5 days, p = 0.002). However, there was a trend towards shorter return of bowel function in the RP group (2.1 ± 0.9 vs 2.4 ± 0.8 days, p = 0.09).

Conclusion

TP and RP laparoscopic nephrectomies provide good outcomes in patients with ADPKD. The choice of a TP route could decrease the length of hospital stay and the operative time during the beginning of the learning curve period.

     

Topical rectal antiseptic at time of prostate biopsy: how a resident patient safety project has evolved into institutional practice

Purpose

To report outcomes 5 years after a resident quality initiative incorporated topical rectal antiseptic into our ultrasound-guided prostate needle biopsy (TRUS PNB) protocol.

Methods

A chart review was conducted on 1007 men who underwent TRUS PNB between 2010 and 2017. Comparison groups include those who received a topical rectal antiseptic (N?=?437) compared to those who did not (N?=?570). Povidone-iodine (N?=?303) or 4% chlorhexidine solution without alcohol (N?=?134) were topical agents. Outcomes of interest included post-biopsy infection (urinary tract infection and/or sepsis), hospital admission, and need for ICU monitoring.

Results

Median age and PSA of men included in this study were 64 years and 12 ng/mL. Almost 90% of patients were Caucasian, 13% had diabetes, 3% were on immunosuppression, 32% had at least one prior biopsy, 14% received antibiotics, and 7% were hospitalized in the past 6 months. 22 patients (2.2%) developed a post-biopsy infection with a significant reduction in the group receiving topical rectal antiseptic (0.8 vs. 3.3%, p?=?0.01). Post-biopsy UTI rates (p?=?0.04) and hospital admission (p?=?0.03) were also lower in the topical antiseptic group with trends to reduction in sepsis and need for ICU monitoring.

Conclusions

What started as a resident quality safety project 5 years ago has demonstrated a reduction in infections and hospital admissions following TRUS PNB. Our institutional practice now routinely uses povidone-iodine or chlorhexidine as an adjunct to oral quinolones for TRUS PNB perioperative prophylaxis.

     

Time between diagnosis and surgical treatment on pathological and clinical outcomes in prostate cancer: does it matter?

Introduction

Prostate cancer (PC) most of the time presents with an indolent course. Thus, delays in treatment due to any causes might not affect long-term survival and may not affect cancer cure rates.

Purpose

In this study, we evaluated the effect of delay-time between PC diagnosis and radical prostatectomy regarding oncological outcomes: Gleason score upgrade on surgical specimen, pathologic extracapsular extension (ECE) on surgical specimen, and postoperative biochemical recurrence (BCR) on follow-up.

Methods

We evaluated PC patients who underwent radical prostatectomy (RP) regarding clinical and pathological findings and theirs respective interval between diagnosis and surgical treatment measured in days and months. We used univariate and multivariate logistic regression to evaluate the impact of interval-time.

Results

A total of 908 PC patients underwent RP between 2006 and 2014. Mean age was 61.5 years, the mean time-to-surgery was 191 days (>?6 months) and 187 (20.5%) patients had BCR, with a mean follow-up of 44 months. According to our analysis, no statistically significant maximum cut-off time interval between diagnostic biopsy and surgery could be established (p?=?0.215). Regardless of interval-time:?≤?6 months (56.5%), 6–12 months (38.5%), and?>?12 months (5.1%) after biopsy, we found no time interval correlated with poor oncological outcomes. This study has several limitations. It was retrospective and had a mean follow-up of 4 years. Additional follow-up is necessary to determine whether these findings will be maintained over time.

Conclusions

We showed that the time between diagnosis and surgical treatment did not affect the oncological outcomes in our study.

     

Bone matrix mineralization is preserved during early perimenopausal stage in healthy women: a paired biopsy study

Summary

Bone matrix mineralization based on quantitative backscatter electron imaging remained unchanged during the first year of menopause in paired transiliac biopsy samples from healthy women. This suggests that the reported early perimenopausal reductions in bone mineral density are caused by factors other than decreases in the degree of mineralization.

Introduction

It is unknown whether perimenopausal loss of bone mass is associated with a drop in bone matrix mineralization.

Methods

For this purpose, we measured the bone mineralization density distribution (BMDD) by quantitative backscatter electron imaging (qBEI) in n?=?17 paired transiliac bone biopsy samples at premenopausal baseline and 12 months after last menses (obtained at average ages of 49?±?2 and 55?±?2 years, respectively) in healthy women. For interpretation of BMDD outcomes, previously measured bone mineral density (BMD) and biochemical and histomorphometric markers of bone turnover were revisited for the present biopsy cohort.

Results

Menopause significantly decreased BMD at the lumbar spine (?4.5 %) and femoral neck (?3.8 %), increased the fasting urinary hydroxyproline/creatinine ratio (+60 %, all p?<?0.01) and histomorphometric bone formation rate (+25 %, p?<?0.05), but affected neither cancellous nor cortical BMDD variables (paired comparison p?>?0.05). Mean calcium concentrations of cancellous (Cn.CaMean) and cortical bone (Ct.CaMean) were within normal range (p?>?0.05 compared to established reference data). Ct.CaMean was significantly correlated with Cn.CaMean before (R?=?0.81, p?<?0.001) and after menopause (R?=?0.80, p?<?0.001) and to cortical porosity of mineralized tissue (Ct.Po.) after menopause (R?=??0.57, p?=?0.02).

Conclusions

Surprisingly, the BMDD was found not affected by the changes in bone turnover rates in this cohort. This suggests that the substantial increase in bone formation rates took place shortly before the second biopsy, and the bone mineralization changes lag behind. We conclude that during the first year after the last menses, the degree of bone matrix mineralization is preserved and does not contribute to the observed reductions in BMD.