Faculty Bibliography

The challenge to the urology community is to reduce the risks of screening and treatment by reducing the number of men undergoing unnecessary biopsy and whole-gland curative treatment of low-risk disease. There is compelling evidence that focal ablation of prostate cancer is truly minimally invasive and offers major functional advantages over whole-gland treatment.

Purpose of Review: The widely acknowledged limitations of the standard prostate cancer (PCa) diagnostic paradigm have provided an impetus to explore novel imaging modalities to diagnose, localize, and risk stratify PCa. As the body of literature focused on HistoScanningTM(HS) grows, there is need for a comprehensive review of the clinical efficacy of this technology. Recent Findings: Eighteen original, English language articles were found to adequately study the use of HistoScanningTM for prostate cancer diagnosis in the clinical setting. The articles were found by conducting a bibliographic search of PubMed in April 2017 in addition to utilizing references. The studies are divided into four groups based on study design. Study methods and quantitative data are summarized for each of the relevant articles. The results are synthesized to evaluate the utility of HistoScanningTM for the purpose of diagnosing PCa. Summary: Despite the promise of early pilot studies, there is a lack of consistent results across a number of further investigations of HistoScanningTM. This becomes increasingly evident as study size increases. As various other modern diagnostic modalities continue to develop, the future of HistoScanningTM, both alone and in conjunction with these technologies, remains unclear.

OBJECTIVE: To provide a multi-institutional analysis of clinical factors predicting unplanned hospital readmission after major inpatient urologic surgery. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a risk-adjusted data collection mechanism for analyzing clinical outcomes data including 30-day perioperative readmissions and complications. We identified 23,108 patients who underwent major inpatient urologic surgery from 2011 to 2012. Readmission rates were determined and stratified by procedure type. Multiple logistic regression was used to determine independent risk factors for 30-day unplanned hospital readmissions. RESULTS: Of 23,108 total patients undergoing urologic surgery, 1329 patients (5.8%) had unplanned readmissions. Upper tract reconstruction and urinary diversion without cystectomy (21/102) and cystectomy (291/1,662) had the highest rates of readmission of all procedures analyzed. Readmitted patients had a 64.2% (853/1329) and 64.4% (855/1329 patients) rate of major and minor complications, respectively, compared to 6.7% (1459/21779) and 15.9% (3462/21779) for patients not readmitted (p<0.02). Organ space infection (OR 15.23), pulmonary embolism (OR 12.14), deep venous thrombosis (OR 10.96), and return to the operating room (OR 8.46) were the most substantial predictors of readmission. Laparoscopic/robotic procedures had significantly lower readmission rates compared to open procedures for prostatectomy, partial nephrectomy, and nephrectomy (p<0.01). CONCLUSIONS: Readmission after inpatient urological surgery occurs at a rate of 5.8%, with cystectomy and urinary diversion demonstrating the highest rates. Major and minor postoperative complications were the most substantial predictors of readmission. These results may guide risk reduction initiatives to prevent readmissions after major urologic surgery.

PURPOSE OF REVIEW: The widely acknowledged limitations of the standard prostate cancer (PCa) diagnostic paradigm have provided an impetus to explore novel imaging modalities to diagnose, localize, and risk stratify PCa. As the body of literature focused on HistoScanning(HS) grows, there is need for a comprehensive review of the clinical efficacy of this technology. RECENT FINDINGS: Eighteen original, English language articles were found to adequately study the use of HistoScanning for prostate cancer diagnosis in the clinical setting. The articles were found by conducting a bibliographic search of PubMed in April 2017 in addition to utilizing references. The studies are divided into four groups based on study design. Study methods and quantitative data are summarized for each of the relevant articles. The results are synthesized to evaluate the utility of HistoScanning for the purpose of diagnosing PCa. Despite the promise of early pilot studies, there is a lack of consistent results across a number of further investigations of HistoScanning. This becomes increasingly evident as study size increases. As various other modern diagnostic modalities continue to develop, the future of HistoScanning, both alone and in conjunction with these technologies, remains unclear.

The primary goal of a focal therapy treatment paradigm is to achieve cancer control through targeted tissue destruction while simultaneously limiting deleterious effects on peri-prostatic structures. Focal therapy approaches are employed in several oncologic treatment protocols, and have been shown to provide equivalent cancer control for malignancies such as breast cancer and renal cell carcinoma. Efforts to develop a focal therapy approach for prostate cancer have been challenged by several concepts including the multifocal nature of the disease and limited capability of prostate ultrasound and systematic biopsy to reliably localize the site(s) and aggressiveness of disease. Multi-parametric MRI (mpMRI) of the prostate has significantly improved disease localization, spatial demarcation and risk stratification of cancer detected within the prostate. The accuracy of this imaging modality has further enabled the urologist to improve biopsy approaches using targeted biopsy via MRI-ultrasound fusion. From this foundation, an improved delineation of the location of disease has become possible, providing a critical foundation to the development of a focal therapy strategy. This chapter reviews the accuracy of mpMRI for detection of "aggressive" disease, the accuracy of mpMRI in determining the tumor volume, and the ability of mpMRI to accurately identify the index lesion. While mpMRI provides a critical, first step in developing a strategy for focal therapy, considerable questions remain regarding the relationship between MR identified tumor volume and pathologic tumor volume, the accuracy and utility of mpMRI for treatment surveillance and the optimal role and timing of follow-up mpMRI.

OBJECTIVES: To evaluate the cancer detection rates (CDR) for men undergoing 12 core systematic prostate biopsy with negative prebiopsy mpMRI (NegMR). MATERIALS & METHODS: Clinical data from consecutive men undergoing prostate biopsy with prebiopsy 3T mpMRI from December 2011 to August 2014 were reviewed from an IRB approved prospective database. Prebiopsy mpMRI was read by a single radiologist and men with NegMR prior to biopsy were identified for this analysis. Clinical features, CDR, and NPV rates were summarized. RESULTS: Seventy five men underwent SPB with a NegMRI during the study period. For the entire cohort, men with no prior biopsy, men with prior negative biopsy, and men enrolled in active surveillance protocols, overall CDR was 18.7%, 13.8%, 8.0% and 38.1%, respectively, and detection of Gleason sum >/= 7 (GS>/=7) cancer was 1.3%, 0%, 4.0% and 0%, respectively. The NPV for all cancers was 81.3%, 86.2%, 92.0%, and 61.9%, and for GS>/=7 cancer was 98.7%, 100%, 96.0% and 100%, respectively. CONCLUSIONS: Negative prebiopsy mpMRI confers an overall NPV of 82% on 12 core biopsy for all cancer and 98% for GS>/=7. Based upon biopsy indication, these findings assist in prebiopsy risk stratification for detection of high risk disease and may provide guidance in the decision to pursue biopsy

BACKGROUND: Increasing evidence supports the use of magnetic resonance imaging (MRI)-ultrasound fusion-targeted prostate biopsy (MRF-TB) to improve the detection of clinically significant prostate cancer (PCa) while limiting detection of indolent disease compared to systematic 12-core biopsy (SB). OBJECTIVE: To compare MRF-TB and SB results and investigate the relationship between biopsy outcomes and prebiopsy MRI. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of a prospectively acquired cohort of men presenting for prostate biopsy over a 26-mo period. A total of 601 of 803 consecutively eligible men were included. INTERVENTIONS: All men were offered prebiopsy MRI and assigned a maximum MRI suspicion score (mSS). Men with an MRI abnormality underwent combined MRF-TB and SB. OUTCOMES: Detection rates for all PCa and high-grade PCa (Gleason score [GS] >/=7) were compared using the McNemar test. RESULTS AND LIMITATIONS: MRF-TB detected fewer GS 6 PCas (75 vs 121; p<0.001) and more GS >/=7 PCas (158 vs 117; p<0.001) than SB. Higher mSS was associated with higher detection of GS >/=7 PCa (p<0.001) but was not correlated with detection of GS 6 PCa. Prediction of GS >/=7 disease by mSS varied according to biopsy history. Compared to SB, MRF-TB identified more GS >/=7 PCas in men with no prior biopsy (88 vs 72; p=0.012), in men with a prior negative biopsy (28 vs 16; p=0.010), and in men with a prior cancer diagnosis (42 vs 29; p=0.043). MRF-TB detected fewer GS 6 PCas in men with no prior biopsy (32 vs 60; p<0.001) and men with prior cancer (30 vs 46; p=0.034). Limitations include the retrospective design and the potential for selection bias given a referral population. CONCLUSIONS: MRF-TB detects more high-grade PCas than SB while limiting detection of GS 6 PCa in men presenting for prostate biopsy. These findings suggest that prebiopsy multiparametric MRI and MRF-TB should be considered for all men undergoing prostate biopsy. In addition, mSS in conjunction with biopsy indications may ultimately help in identifying men at low risk of high-grade cancer for whom prostate biopsy may not be warranted. PATIENT SUMMARY: We examined how magnetic resonance imaging (MRI)-targeted prostate biopsy compares to traditional systematic biopsy in detecting prostate cancer among men with suspicion of prostate cancer. We found that MRI-targeted biopsy detected more high-grade cancers than systematic biopsy, and that MRI performed before biopsy can predict the risk of high-grade cancer.

INTRODUCTION: There is increasing interest in using imaging in the detection and localization of prostate cancer (PCa). Both multiparametric magnetic resonance imaging (mpMRI) and HistoScanning (HS) have been independently evaluated in the detection and localization of PCa. We undertook a prospective, blinded comparison of mpMRI and HS for cancer localization among men undergoing radical prostatectomy. METHODS: Following approval by the institutional review board, men scheduled to undergo radical prostatectomy, who had previously undergone mpMRI at our institution, were offered inclusion in the study. Those consenting underwent preoperative HS following induction of anesthesia; mpMRI, HS, and surgical step-section pathology were independently read by a single radiologist, urologist, and pathologist, respectively, in a blinded fashion. Disease maps created by each independent reader were compared and evaluated for concordance by a 5 persons committee consisting of 2 urologists, 2 pathologists, and 1 radiologist. Logistic regression for correlated data was used to assess and compare mpMRI and HS in terms of diagnostic accuracy for cancer detection. Generalized estimating equations based on binary logistic regression were used to model concordance between reader opinion and the reference standard assessment of the same lesion site or region as a function of imaging modality. RESULTS: Data from 31/35 men enrolled in the trial were deemed to be evaluable. On evaluation of cancer localization, HS identified cancer in 36/78 (46.2%) regions of interest, as compared with 41/78 (52.6%) on mpMRI (P = 0.3968). The overall accuracy, positive predictive value, negative predictive value, and specificity for detection of disease within a region of interest were significantly better with mpMRI as compared with HS. HS detected 36/84 (42.9%) cancer foci as compared with 42/84 (50%) detected by mpMRI (P = 0.3678). Among tumors with Gleason score>6, mpMRI detected 19/22 (86.4%) whereas HS detected only 11/22 (50%, P = 0.0078). Similarly, among tumors>10mm in maximal diameter, mpMRI detected 28/34 (82.4%) whereas HS detected only 19/34 (55.9%, P = 0.0352). CONCLUSION: In our institution, the diagnostic accuracy of HS was inferior to that of mpMRI in PCa for PCa detection and localization. Although our study warrants validation from larger cohorts, it would suggest that the HS protocol requires further refinement before clinical implementation.