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Radical treatments such as prostatectomy and radiotherapy have demonstrated success in terms of biochemical and disease-specific survival for localised prostate cancer. However, whilst the end goal of any cancer treatment is to control or cure disease it must also do so by minimising any side effects that may be experienced by the patient. Focal therapy as a concept aims to redress this established therapeutic ratio by treating areas of the prostate affected by significant disease as opposed to treating the entire gland. However, there are a number of common criticisms of focal therapy - we deem the seven sins - that require further interrogation. [ABSTRACT FROM AUTHOR]

Background Tissue preservation by means of focal therapy offers some men with clinically significant prostate cancer an alternative to standard care that appears to confer favourable genito-urinary outcomes. The precise estimates of these outcomes have so far been based on small series. Objective This analysis pools the sexual domain related patient reported outcomes from three prospective, registered studies that represent a range of inclusion criteria. Design, setting, and participants One-hundred and eighteen men with localised prostate cancer (prostate specific antigen ≤ 15 ng/ml, Gleason ≤ 4 + 3, stage ≤ T3aN0M0) treated in a tissue-preserving manner using high intensity focused ultrasound from three registered studies were included. Data on International Index of Erectile Function (IIEF-5) scores and use of phosphodiesterase-5-inhibitors were collected at baseline, and 1 mo, 3 mo, 6 mo, 9 mo, and 12 mo postoperatively. The IIEF-15 total and individual domain scores were used to assess overall sexual function. Urinary function was assessed with the International Prostate Symptom Score (IPSS), IPSS quality-of-life, and UCLA-Expanded Prostate Cancer Index Composite continence questionnaires. General health status was derived by means of the Charlson score. Multiple linear regression was used to assess whether age, grade, stage, qualitative scores (IIEF, IPSS, Expanded Prostate Cancer Index Composite, Charlson), or focal therapy type duration were associated with IIEF-5 and IIEF-15 scores at 12 mo. Results and limitations Median age was 63 yr (interquartile range [IQR] 52–70 yr). Median IIEF-erectile score at baseline was 23 (IQR 11–28). This declined significantly to 9 (IQR 3–22, p < 0.01) at 1 mo, but improved to 20 (IQR 9–29, p = 0.30) at 1 yr posttreatment. Changes in total IIEF and other IIEF domains were only significantly different from preoperative values at 1 mo and 3 mo postoperatively. In the same period, the proportion of men using phosphodiesterase-5-inhibitors was 10% preoperatively, reaching 43% and 42% at 6 mo and 9 months before declining to 37% at 1 yr. The only baseline determinants of postoperative erectile function were total IIEF and IIEF-erectile function scores ( p = 0.002). The primary limitation of our study is the relatively short follow-up of 1 yr. Conclusion Men who received a range of tissue preserving therapies from the three pertinent studies experienced small decreases in total IIEF, erectile, and individual sexual domain scores that are not significantly different to those recorded at baseline. The only determinant of erectile dysfunction after tissue preserving therapy was preoperative erectile dysfunction status. Tissue preservation confers a high probability of maintaining erectile function that appears independent of all perioperative factors with the exception of baseline status. Patient summary In this report, the largest prospectively collected and published set of patients with erectile dysfunction outcomes post–focal therapy for prostate cancer, we have found a return to baseline International Index of Erectile Function–erectile and total International Index of Erectile Function scores by 6 mo post–focal therapy which was maintained at 1 yr, with the majority of patients not on any form of medical treatment for their erectile dysfunction at that point. Focal therapy may represent a suitable alternative for men of any age or comorbidity wishing to maintain erectile function. [ABSTRACT FROM AUTHOR]

Objective: To summarize the discussion that took place at a public workshop, co-sponsored by the U.S. Food and Drug Administration, the American Urological Association, and Society of Urologic Oncology reviewing the current state of the art for partial gland ablation (PGA) for the management of patients with prostate cancer. The purpose of this workshop was to discuss potential indications, current available evidence, and designs for future trials to provide the evidence needed by patients and providers to decide how and when to use PGA.Methods: A workshop evaluating PGA for prostate cancer was held in New Orleans, Louisiana, in May 2015. Invited experts representing all stakeholders and attendees discussed the regulatory development of medical products, technology available, potential indications, and designs of trials to evaluate this modality of therapy.Results: The panel presented the current information on the technologies available to perform PGA, the potential indications, and results of prior consensus conferences. Use of magnetic resonance imaging for patient selection, guide therapy, and follow-up was discussed. Designs of trials to assess PGA outcomes were discussed.Conclusion: The general consensus was that currently available technologies are capable of selective ablation with reasonable accuracy, but that criteria for patient selection remain debatable, and long-term cancer control remains to be established in properly designed and well-performed prospective clinical trials. Concerns include the potential for excessive, unnecessary use in patients with low-risk cancer and, conversely, that current diagnostic techniques may underestimate the extent and aggressiveness of some cancers, leading to inadequate treatment. [ABSTRACT FROM AUTHOR]

Background Although localised prostate cancer is multifocal in most instances, the index lesion might be responsible for disease progression. Objective To determine the early genitourinary functional and cancer control outcomes of index lesion ablation. Design, setting, and participants This was a single-centre prospective development study in which 56 men were treated (July 2009–January 2011). The mean age was 63.9 yr (standard deviation 5.8) and median prostate-specific antigen (PSA) was 7.4 ng/ml (interquartile range [IQR] 5.6–9.5). There were seven (12.5%) low-risk, 47 (83.9%) intermediate-risk, and two (3.6%) high-risk cancers. Intervention Multiparametric magnetic resonance imaging (mpMRI) and prostate biopsies to localise disease, followed by index lesion ablation using high-intensity focused ultrasound. Outcome measurements and statistical analysis Primary outcomes were genitourinary side effects measured using validated questionnaires. Secondary outcomes included absence of clinically significant disease at 12 mo. Results and limitations The composite of leak-free, pad-free continence, and erections sufficient for penetration decreased from a baseline frequency of 40/56 (71.4%) to 33/56 (58.9%) at 12 mo. Pad-free and leak-free, pad-free continence was preserved in 48/52 (92.3%) and 46/50 (92.0%) patients, respectively. Erections sufficient for intercourse were preserved in 30/39 (76.9%) patients. The median PSA nadir decreased to 2.4 ng/ml (IQR 1.6–4.1). At 12 mo, 42/52 (80.8%) patients had histological absence of clinically significant cancer and 85.7% (48/56) had no measurable prostate cancer (biopsy and/or mpMRI). Two (3.6%) patients had clinically significant disease in untreated areas not detected at baseline. The main study limitation is the short follow-up duration. Conclusions Index lesion ablation had low rates of genitourinary side effects and acceptable short-term absence of clinically significant cancer. Comparative effectiveness trials are required to assess cancer control outcomes against radical therapy. Patient summary In this study we looked at whether it is possible to treat the largest and highest-grade tumour in men who have more than one known prostate tumour. We show that the side effects of targeted ablation were low, with acceptable rates of early cancer control. Larger studies with longer follow-up are needed. Trial registration NCT00988130 [ABSTRACT FROM AUTHOR]

ReIMAGINE represents the first efforts to define prostate cancer risk using the full spectrum of emerging diagnostics (both commercial and academic). The outputs will provide image-based data sets that will replace, or adjust, historical and flawed risk calculators. [ABSTRACT FROM AUTHOR]

Focal therapy is a novel strategy that attempts to enhance the therapeutic ratio of standard radical treatment in prostate cancer. Irreversible electroporation (IRE) has some inherent characteristics that may be ideal for focal therapy. Precise confined ablation in the treatment area obtained via nonthermal damage with potential for minimal toxicity to surrounding structures may lead to optimal treatment with improved preservation of continence and erectile function. Initial data of focal IRE of the prostate are encouraging although further assessment is awaited to confirm these findings using robust methodology. In this article, we provide a comprehensive step-by-step description of our technique to deliver focal IRE in selected men with localized prostate cancer located in a discrete area of the prostate. [ABSTRACT FROM AUTHOR]

Objective To report our experience with salvage high-intensity focused ultrasound (HIFU) in patients with local failure after brachytherapy for prostate cancer. Patients and Methods Whole-gland HIFU was administered to prospectively recruited patients with local histologic failure after brachytherapy at 2 institutions in the United Kingdom and Canada. Functional and oncologic outcomes of the procedure were analyzed. Results Nineteen patients underwent the treatment, 12 with Gleason sum 7 and 5 with Gleason sum 8 at recurrence. Thirteen men had grade-3a or -3b complications by the Clavien system; there were no grade-4 or -5 complications. The most common postoperative complication was dysuria, which was self-limited. Three men developed rectourethral fistulae. The overall continence rate was 68.4%. At a mean follow-up of 51.6 months, all men were alive. The overall biochemical recurrence-free survival rate was 66.7% and 73.3% using the “nadir prostate-specific antigen level” +1.3 ng/mL and +2 mg/ml criteria, respectively. This study is limited by the small cohort size, relatively short follow-up period, and heterogeneity of the patient population. Conclusion In this, the largest prospective series to date, we demonstrate that salvage HIFU for locally recurrent prostate cancer after failed primary brachytherapy has encouraging disease control results, albeit with a relatively high complication rate. [ABSTRACT FROM AUTHOR]

Objective To determine whether multiparametric magnetic resonance imaging (mp-MRI) has a role in reducing the uncertainty in risk stratification by transrectal ultrasound (TRUS) biopsy, using histology at transperineal template-guided prostate mapping (TPM) biopsy as the reference test. Materials and methods Overall, 194 patients underwent TRUS biopsy, who were followed up in less than 18 months by means of (a) mp-MRI with pelvic phased array using T2-weighted, diffusion-weighted and dynamic contrast-enhanced sequences and (b) TPM biopsy. Of those patients, low risk on TRUS biopsy was defined in 4 different ways—(a) definition 1: Gleason 3+3 (any cancer core length) ( n = 137), (b) definition 2: maximum cancer core length (MCCL)<50% (any Gleason score) ( n = 62), (c) definition 3: Gleason 3+3 and MCCL<50% ( n = 52), and (d) definition 4: Gleason 3+3, MCCL<50%, prostate-specific antigen level<10 ng/ml, and<50% positive cores ( n = 28). Mp-MRI was scored for the likelihood of cancer from 1 (cancer very unlikely) to 5 (cancer very likely). Binary logistic regression analysis was performed to evaluate the association between MRI scores and TPM histology. Results Median prostate-specific antigen level was 7 ng/ml (range: 0.9–29), median time between TRUS biopsy and mp-MRI was 120 days (range: 41–480), and median time between mp-MRI and TPM biopsy was 60 days (range: 1–420). A median of 48 cores (range: 20–118) were taken at TPM biopsy. Gleason score was upgraded in 62 of 137 (45%) patients at TPM biopsy. The negative predictive values of mp-MRI score 1 to 2 for predicting that cancer remained low risk (according to each definition) were 75%, 100%, 83%, and 100% for definitions 1, 2, 3, and 4, respectively. An mp-MRI score of 4 to 5 had positive predictive values for upgrade or upsize of 59%, 67%, 75%, and 69% for definitions 1, 2, 3, and 4, respectively. Conclusion The presence of an mp-MRI lesion in men with low-risk prostate cancer on TRUS biopsy confers, in most patients, a high likelihood that higher-risk disease will be present (either Gleason pattern 4 or a significant cancer burden). Conversely, if a lesion is not seen on mp-MRI, the attribution of low-risk grade or cancer burden is much more likely to be correct. Mp-MRI might therefore be used to triage men for resampling biopsies before entering active surveillance. [ABSTRACT FROM AUTHOR]

Abstract: Context: Active surveillance (AS) is an alternative to initial radical treatment of low-risk prostate cancer (PCa). Current criteria for selection and follow-up incorrectly exclude some patients eligible for AS and misclassify some who actually harbour significant disease. Better prediction of cancer behaviour at diagnosis would allow less strict monitoring and may improve acceptance of AS. Objective: To review and critically analyse the literature on the value of novel clinical tools for patient selection and monitoring on AS. Evidence acquisition: A comprehensive search of the PubMed database until July 10, 2013, was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement guidelines. Studies assessing novel markers and diagnostics for patient selection for AS and follow-up during AS were included. Studies analysing only classic clinical parameters used in current protocols (prostate-specific antigen, prostate volume, number of (positive) prostate biopsies, percentage malignant tissue, Gleason score) were excluded. This review focuses only on the AS setting and not on predicting insignificant disease in general. Evidence synthesis: Of 787 studies on AS, 30 were included in this review: 14 on magnetic resonance imaging (MRI), 5 on serum markers, 5 on urinary markers, 4 on histopathology markers, and 2 on germline genetic markers. Several of these markers improve the prediction of tumour volume, tumour grade, or time to active treatment. MRI has a high specificity for low-risk PCa; new serum markers are associated with unfavourable disease. In none of the studies was the new marker used as the primary decision tool. Long-term outcome measures such as mortality were not assessed. The definition of indolent PCa is disputable. Conclusions: Imaging and serum markers may improve future patient selection for AS and follow-up during AS. Prospective studies should aim to further evaluate the clinical utility of these new markers with respect to longer term outcomes of AS. Patient summary: We searched the literature for articles reporting new ways to safely monitor low-risk prostate cancer for patients who have not had radical treatment. We found 30 articles. The most promising tools appear to be magnetic resonance imaging scans and various new blood markers. These may be used in the future within active surveillance regimens. [Copyright &y& Elsevier]

Summary: Background: Radical whole-gland therapy can lead to significant genitourinary and rectal side-effects for men with localised prostate cancer. We report on whether selective focal ablation of unifocal and multifocal cancer lesions can reduce this treatment burden. Methods: Men aged 45–80 years were eligible for this prospective development study if they had low-risk to high-risk localised prostate cancer (prostate specific antigen [PSA] ≤15 ng/mL, Gleason score ≤4 + 3, stage ≤T2), with no previous androgen deprivation or treatment for prostate cancer, and who could safely undergo multiparametric MRI and have a general anaesthetic. Patients received focal therapy using high-intensity focused ultrasound, delivered to all known cancer lesions, with a margin of normal tissue, identified on multiparametric MRI, template prostate-mapping biopsies, or both. Primary endpoints were adverse events (serious and otherwise) and urinary symptoms and erectile function assessed using patient questionnaires. Analyses were done on a per-protocol basis. This study is registered with ClinicalTrials.gov, number NCT00561314. Findings: 42 men were recruited between June 27, 2007, and June 30, 2010; one man died from an unrelated cause (pneumonia) 3 months after treatment and was excluded from analyses. After treatment, one man was admitted to hospital for acute urinary retention, and another had stricture interventions requiring hospital admission. Nine men (22%, 95% CI 11–38) had self-resolving, mild to moderate, intermittent dysuria (median duration 5·0 days [IQR 2·5–18·5]). Urinary debris occurred in 14 men (34%, 95% CI 20–51), with a median duration of 14·5 days (IQR 6·0–16·5). Urinary tract infection was noted in seven men (17%, 95% CI 7–32). Median overall International Index of Erectile Function-15 (IIEF-15) scores were similar at baseline and at 12 months (p=0·060), as were median IIEF-15 scores for intercourse satisfaction (p=0·454), sexual desire (p=0·644), and overall satisfaction (p=0·257). Significant deteriorations between baseline and 12 months were noted for IIEF-15 erectile (p=0·042) and orgasmic function (p=0·003). Of 35 men with good baseline function, 31 (89%, 95% CI 73–97) had erections sufficient for penetration 12 months after focal therapy. Median UCLA Expanded Prostate Cancer Index Composite (EPIC) urinary incontinence scores were similar at baseline as and 12 months (p=0·045). There was an improvement in lower urinary tract symptoms, assessed by International Prostate Symptom Score (IPSS), between baseline and 12 months (p=0·026), but the IPSS-quality of life score showed no difference between baseline and 12 months (p=0·655). All 38 men with no baseline urinary incontinence were leak-free and pad-free by 9 months. All 40 men pad-free at baseline were pad-free by 3 months and maintained pad-free continence at 12 months. No significant difference was reported in median Trial Outcomes Index scores between baseline and 12 months (p=0·113) but significant improvement was shown in median Functional Assessment of Cancer Therapy (FACT)-Prostate (p=0·045) and median FACT-General scores (p=0·041). No histological evidence of cancer was identified in 30 of 39 men biopsied at 6 months (77%, 95% CI 61–89); 36 (92%, 79–98) were free of clinically significant cancer. After retreatment in four men, 39 of 41 (95%, 95% CI 83–99) had no evidence of disease on multiparametric MRI at 12 months. Interpretation: Focal therapy of individual prostate cancer lesions, whether multifocal or unifocal, leads to a low rate of genitourinary side-effects and an encouraging rate of early absence of clinically significant prostate cancer. Funding: Medical Research Council (UK), Pelican Cancer Foundation, and St Peters Trust. [Copyright &y& Elsevier]

Abstract: Background: Multiparametric magnetic resonance imaging (mpMRI) may have a role in detecting clinically significant prostate cancer in men with raised serum prostate-specific antigen levels. Variations in technique and the interpretation of images have contributed to inconsistency in its reported performance characteristics. Objective: Our aim was to make recommendations on a standardised method for the conduct, interpretation, and reporting of prostate mpMRI for prostate cancer detection and localisation. Design, setting, and participants: A consensus meeting of 16 European prostate cancer experts was held that followed the UCLA-RAND Appropriateness Method and facilitated by an independent chair. Measurement: Before the meeting, 520 items were scored for “appropriateness” by panel members, discussed face to face, and rescored. Results and limitations: Agreement was reached in 67% of 260 items related to imaging sequence parameters. T2-weighted, dynamic contrast-enhanced, and diffusion-weighted MRI were the key sequences incorporated into the minimum requirements. Consensus was also reached on 54% of 260 items related to image interpretation and reporting, including features of malignancy on individual sequences. A 5-point scale was agreed on for communicating the probability of malignancy, with a minimum of 16 prostatic regions of interest, to include a pictorial representation of suspicious foci. Limitations relate to consensus methodology. Dominant personalities are known to affect the opinions of the group and were countered by a neutral chairperson. Conclusions: Consensus was reached on a number of areas related to the conduct, interpretation, and reporting of mpMRI for the detection, localisation, and characterisation of prostate cancer. Before optimal dissemination of this technology, these outcomes will require formal validation in prospective trials. [Copyright &y& Elsevier]

Summary: Prepubertal testicular and paratesticular tumours are a rare group of tumours, distinct from postpubertal paediatric and adult tumours of this region. Tumours within this group are testicular germ-cell tumours (such as benign teratoma, epidermoid cyst and malignant yolk-sac tumours) and stromal tumours (such as juvenile granulosa-cell, leydig-cell, and sertoli-cell tumours). Paratesticular tumours can be benign (lipoma, leiomyoma, haemangioma) or malignant (rhabdomyosarcoma, melanotic neuroectodermal tumour of infancy). Because of their rarity, centralised pathology and treatment, and national collaborative clinical trials have been important in establishing the optimum management of malignant tumours in this group. We provide an up-to-date and comprehensive review of the clinical presentation, imaging, pathology, and clinical management of prepubertal paratesticular and testicular tumours. [Copyright &y& Elsevier]

Summary: Penile cancer is a rare malignancy affecting more than 400 men per year in the UK. Studies on the aetiopathogenesis of this cancer have focused on its association with the human papilloma virus; however, there have also been several studies on the genetic and molecular changes that occur. Human papilloma virus has shown differential levels of prevalence in association with different types of penile cancer. The virus seems to act as a trigger for this disease via its oncogenes. We review this process, and assess the independent genetic events that occur in penile cancer. Knowledge of this cancer is progressing slowly and could be furthered by multicentre cooperation and the formation of national tumour banks, which will aid the development of novel therapeutic agents to reduce the morbidity and mortality of penile cancer. [Copyright &y& Elsevier]

: Background:The number of people in the United States with spinal cord injury (SCI) is estimated at about 200,000. The prevalence of gallbladder disease in this population is about three times as high as in neurally intact people, but the results of surgical treatment have received little attention.: MethodsA retrospective, population-based study of patients with SCI who later received cholecystectomy for benign gallbladder disease was performed. National computer data sets of all patients receiving medical care in all Department of Veterans Affairs (DVA) medical centers for fiscal years 1994 to 1998 were used. Computer-based data were augmented with chart-based resources.: ResultsDuring the period of interest, there were 21,849 patients with ICD-9-CM codes for SCI in the DVA computer system, among whom 367 had codes for cholecystectomy. After retrieval and review of data from individual charts, 118 were deemed evaluable. There were 68 who had successful laparoscopic cholecystectomy and 14 who required conversion to open cholecystectomy after laparoscopic efforts failed (conversion rate 14 of 82=17%). There were 36 who received planned open cholecystectomy. Patients under the age of 60 years were more likely to have a laparoscopic approach (P <0.05). Emergency cholecystectomies were more likely to be performed via the open route (P <0.01). The morbidity rate was 8 of 68 (12%) for successful laparoscopic cholecystectomy, 4 of 14 (29%) for failed laparoscopic surgery completed by conventional open technique, and 11 of 36 (31%) for planned open surgery. The mortality rate in the traditional surgery group was 1 of 36 (3%). There were no deaths in the other groups.: ConclusionsWe believe this series is the largest so far reported. The mortality rate of cholecystectomy in SCI patients is comparable to that in neurally intact individuals, but the morbidity rate is high. Contractures, stomas, heterotopic ossification, and other sequelae of SCI do not generally cause technical difficulties with surgery. If complications of cholecystectomy are indeed SCI-related, attention to perioperative SCI care could improve outcomes of cholecystectomy. Future research should continue to explore this important research topic. [Copyright &y& Elsevier]

Multiparametric magnetic resonance imaging (MP-MRI) is established in the diagnosis of prostate cancer, but the need for enhanced sequences has recently been questioned. To assess whether dynamic contrast-enhanced imaging (DCE) improves accuracy over T2 and diffusion sequences. PROMIS was a multicentre, multireader trial, with, in this part, 497 biopsy-naïve men undergoing standardised 1.5T MP-MRI using T2, diffusion, and DCE, followed by a detailed transperineal prostate mapping (TPM) biopsy at 5 mm intervals. Likert scores of 1–5 for the presence of a significant tumour were assigned in strict sequence, for (1) T2 + diffusion and then (2) T2 + diffusion + dynamic contrast-enhanced images. For the primary analysis, the primary PROMIS outcome measure (Gleason score ≥4 + 3 or ≥6 mm maximum cancer length) on TPM was used, and an MRI score of ≥3 was considered positive. Sensitivity without and with DCE was 94% and 95%, specificity 37% and 38%, positive predictive value 51% and 51%, and negative predictive value 90% and 91%, respectively (p > 0.05 in each case). The number of patients avoiding biopsy (scoring 1–2) was similar (123/497 vs 121/497, p = 0.8). The number of equivocal scores (3/5) was slightly higher without DCE (32% vs 28% p = 0.031). The proportion of MRI equivocal (3/5) and positive (4–5) cases showing significant tumours were similar (23% and 71% vs 20% and 69%). No cases of dominant Gleason 4 or higher were missed with DCE, compared with a single case with T2 + diffusion-weighted imaging. No attempt was made to correlate lesion location on MRI and histology, which may be considered a limitation. Radiologists were aware of the patient's prostate-specific antigen. Contrast adds little when MP-MRI is used to exclude significant prostate cancer. An intravenous injection of contrast may not be necessary when magnetic resonance imaging is used as a test to rule out significant tumours in the prostate. The addition of dynamic contrast-enhanced imaging did not offer a statistically significant improvement in diagnostic accuracy compared with T2 + diffusion sequences alone, although there was a marginal reduction of equivocal (3/5) magnetic resonance imaging results. [ABSTRACT FROM AUTHOR]

Introduction: Focal therapy for localized prostate cancer has the potential for oncological control without the side effects of radical therapies. However, there is currently no validated method for monitoring treatment success. We assessed the diagnostic performance of prostate-specific antigen (PSA) parameters and MRI compared to histological outcomes following focal therapy.Patients and Methods: Patients from 3 Ethics Review Board approved prospective studies of focal high intensity-focused ultrasound (HIFU) (Sonablate 500) for localized prostate cancer (T1c-T3a, Gleason grade≤4+3, and PSA≤20). Post-HIFU PSA nadir, 6-month PSA, PSA density, and early (<3wk) and late (6mo) MRI (T2-weighted, dynamic contrast-enhanced±diffusion-weighted) was assessed for predictive accuracy of cancer on postoperative biopsy, using receiver operating characteristic (ROC) analysis and sensitivity, specificity, and positive and negative predictive estimates. ROC areas for MRI and PSA were compared. Calculations for statistical significance (P≤0.05) were obtained in a subset of patients comparing area under ROC for 6-month MRI and PSA criteria, across 4 different histological definitions of disease significance.Results: Of 118 men, 111 underwent at least 1 postoperative biopsy (median 6 cores), with an overall positive biopsy rate of 37% (41/118), over a mean follow-up period of 716 days post-HIFU. Areas under ROC for early and late MRI were (depending on definition of significant disease) 0.65 to 0.76 and 0.77 to 0.85, respectively, with sensitivity, specificity, and negative predictive values of 68% to 91%, 52% to 55%, and 85% to 98% (early MRI), and 63% to 80%, 67% to 73%, and 86% to 97% (late MRI). The area under the ROC curve was statistically significantly higher for late MRI than 6 months and nadir PSA for residual disease >3mm or any Gleason 4 tumor.Conclusions: Early and late MRI performed better than PSA measurements in the detection of residual tumor after focal therapy. [ABSTRACT FROM AUTHOR]

The current diagnostic and therapeutic strategy for localized prostate cancer is not working. In fact, it is severely flawed and, as such, fraught with controversy. Our current strategy has arisen from the imprecision of our diagnostic pathway. We do not know where the cancer is, so we subject the prostate to randomly placed needles in the hope of hitting the tumor. This leads to overdiagnosis, underdiagnosis, missclassification of risk and overtreatment and undertreatment. If we do find cancer, we usually subject the entire prostate to radiotherapy or surgery, which damages the surrounding structures—neurovascular bundles, external urinary sphincter, rectum, and bladder neck. Multiparametric magnetic resonance imaging, coupled with an intensive sampling strategy (targeted biopsies), might be able to rule out clinically significant lesions with a negative predictive value in the order of 90% to 95%. Focal therapy certainly leads to less genitourinary and rectal side effects. Current data from more than 3,000 men treated internationally show that incontinence after focal therapy is 0% to 5% (radical therapy can lead to incontinence in 15%–20%) whereas erectile dysfunction occurs in 5% to 10% of men with good baseline function (radical therapy rates vary between 30% and 60%). Early to medium cancer control using biopsies after treatment shows between 80% and 90% of patients have a successful treatment, with 10% to 15% of men requiring redo-treatment with minimal additional morbidity. [ABSTRACT FROM AUTHOR]

Purpose: To assess the performance of multiparametric magnetic resonance imaging (mp-MRI) in patients with previous negative transrectal ultrasound (TRUS) guided prostate biopsy.Materials and Methods: Fifty-four patients with at least 1 previous negative TRUS prostate biopsy underwent mp-MRI in the form of T2-weighted, diffusion-weighted, and dynamic contrast-enhanced imaging. This was followed by transperineal template systematic prostate biopsies. Analysis was done based on 2 sectors per prostate, right and left (108 sectors out of 54 prostates). mp-MRI was scored using an ordinal scale 1 to 5 based on the suspicion of the presence of clinically significant disease. We used 6 different definitions for clinically significant disease and tested the performance of mp-MRI at each single definition.Results: Median age was 64 (range, 39-75), median PSA level was 10 (range, 2-23), and median number of biopsies was 45 (range, 21-137). Cancer of any volume and any grade was detected in 34 of 54 (63%) patients. mp-MRI accuracy at detection of clinically significant cancer using University College London (UCL) definition 2 (any Gleason score of 4 or maximum cancer core length of ≥ 4 mm or both) showed sensitivity of 76%, specificity of 42%, positive predictive value of 38%, and negative predictive value of 79%. For a different definition of significant tumor (UCL definition 1; dominant Gleason score 4 or maximum cancer core length ≥ 6 mm or both), the sensitivity was 90%, specificity 42%, positive predictive value 26%, and negative predictive value 95%.Conclusions: mp-MRI showed good performance at both detection and ruling out clinically significant disease, according to the definition used. mp-MRI can then be used as a triage test in the population with persistently elevated or rising PSA levels to select patients that can avoid unnecessary prostate biopsy. [ABSTRACT FROM AUTHOR]