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Purpose: We sought to identify facility level variation in the use of definitive therapy among men diagnosed with clinically localized, low risk prostate cancer who were more than 65 years old and had a limited life expectancy of less than 10 years., Materials and Methods: Using data from the National Cancer Database we identified 18,178 men older than 65 years with less than a 10-year life expectancy receiving definitive therapy at a total of 1,172 facilities for biopsy confirmed localized, low risk prostate cancer diagnosed between January 2004 and December 2013. A multilevel, hierarchical, mixed effects logistic regression model was fitted to predict the odds of receiving definitive therapy., Results: Overall 18,178 men (76%) older than 65 years with limited life expectancy and a diagnosis of low risk prostate cancer received definitive therapy, although the rate of therapy decreased significantly with time (p <0.001). Patients receiving definitive therapy were more often younger (80 years or older vs 66 to 69 years OR 0.12, 95% CI 0.09-0.15, p <0.001) and white rather than black (OR 0.86, 95% CI 0.75-0.98, p = 0.03). Conversely, being uninsured (OR 0.37, 95% CI 0.21-0.63, p <0.001) and receiving care at an academic medical center (OR 0.36, 95% CI 0.28-0.46, p <0.001) conferred decreased odds of undergoing definitive therapy. The proportion of men undergoing definitive therapy ranged from 0.12% to 100% across facilities., Conclusions: We found significant facility level variation in rates of definitive therapy in men with localized prostate cancer and limited life expectancy. Health care providers and policy makers alike should be aware of the varying frequency with which this potentially low value service is performed.

Purpose: The fusion of multiparametric resonance imaging and ultrasound has been proven capable of detecting prostate cancer in different biopsy settings. The addition of real-time elastography promises to increase the precision of the outcome of targeted biopsies. We investigated whether real-time elastography improves magnetic resonance imaging/transrectal ultrasound fusion targeted biopsy in patients after previous negative biopsies., Materials and Methods: Prospectively 121 men underwent 3T magnetic resonance imaging. Using magnetic resonance imaging/real-time elastography fusion every suspicious lesion was characterized according to its tissue density and sampled by 2 fusion guided targeted biopsies. Additionally, all patients underwent 12-core systematic biopsy. The detection rate of clinically significant and insignificant cancers was compared between targeted und systematic biopsies. The accuracy to predict high grade prostate cancer was evaluated for with the PI-RADS scoring system and compared to the magnetic resonance imaging/real-time elastography fusion score., Results: Overall prostate cancer was detected in 52 patients (43%). Targeted fusion guided biopsy revealed prostate cancer in 32 men (26.4%) and systematic biopsy in 46 (38%). The proportion of clinically significant cancers was higher for targeted biopsy (90.6%) compared to systematic biopsy (73.9%). The detection rate per core was higher for targeted biopsies (14.7%) compared to systematic biopsies (6.5%, p <0.001). The prediction of biopsy result according to magnetic resonance imaging/real-time elastography fusion was better (AUC 0.86) than magnetic resonance imaging alone (AUC 0.79). Sensitivity and specificity for magnetic resonance imaging/real-time elastography fusion was 77.8% and 77.3% vs 74.1% and 62.9% for magnetic resonance imaging., Conclusions: Magnetic resonance imaging/transrectal ultrasound fusion enhances the likelihood of detecting clinically significant cancers in a repeat biopsy setting. Adding real-time elastography to magnetic resonance imaging supports the characterization of cancer suspicious lesions., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We evaluated whether intraoperative frozen section analysis of the prostate surface might provide significant information to ensure nerve sparing and minimize the positive margin rate., Materials and Methods: In 236 patients treated with radical prostatectomy between June 2011 and September 2012 whole surface frozen section analysis of the removed prostate was done intraoperatively. The apex and base were circumferentially dissected as well as the whole posterolateral tissue corresponding to the neurovascular bundles. Multiple perpendicular sections were cut systematically for frozen section analysis. Pathology results were reported to navigate the procedure., Results: Frozen section analysis identified positive surgical margins in 22% of cases, including the neurovascular bundles in 56.9%, apex in 34.5% and base in 8.6%. Of positive frozen section cases 92.3% could be converted to negative status, while 7.7% remained positive. The final positive margin rate in the total cohort was 3%, including a false-negative frozen section rate of 1.6%. In 14.8% of cases the initial nerve sparing plan was changed intraoperatively due to the positive frozen section and the secondary resected specimen detected cancer in 25%. Final pathology results showed Gleason upgrading or up-staging in 40.7% of cases compared to preoperative variables. When comparing patients with positive vs negative frozen sections, preoperative variables did not significantly differ, while postoperatively pathological stage, tumor volume, operative time and final margin status differed significantly. Of patients with exclusively unilateral positive biopsies 13% had a positive surgical margin intraoperatively on the opposite, biopsy negative side., Conclusions: The surface frozen section technique is associated with a low false-negative surgical margin rate. It might allow for safer preservation of functional anatomical structures in misclassified patients or even patients at higher preoperative risk., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We prospectively assessed whether a combined approach of real-time elastography and contrast enhanced ultrasound would improve prostate cancer visualization., Material and Methods: Between June 2011 and January 2012, 100 patients with biopsy proven prostate cancer underwent preoperative transrectal multiparametric ultrasound combining real-time elastography and contrast enhanced ultrasound. After initial elastographic screening for suspicious lesions, defined as blue areas with decreased tissue strain, each lesion was allocated to the corresponding prostate sector. The target lesion was defined as the largest cancer suspicious area. Perfusion was monitored after intravenous injection of contrast agent. Target lesions were examined for hypoperfusion, normoperfusion or hyperperfusion. Imaging results were correlated with final pathological evaluation on whole mount slides after radical prostatectomy., Results: Of 100 patients 86 were eligible for final analysis. Real-time elastography detected prostate cancer with 49% sensitivity and 73.6% specificity. Histopathology confirmed malignancy in 56 of the 86 target lesions (65.1%). Of these 56 lesions 52 (92.9%) showed suspicious perfusion, including hypoperfusion in 48.2% and hyperperfusion in 48.2%, while only 4 (7.1%) showed normal perfusion patterns (p = 0.001). The multiparametric approach decreased the false-positive value of real-time elastography alone from 34.9% to 10.3% and improved the positive predictive value of cancer detection from 65.1% to 89.7%., Conclusions: Perfusion patterns of prostate cancer suspicious elastographic lesions are heterogeneous. However, the combined approach of real-time elastography and contrast enhanced ultrasound in this pilot study significantly decreased false-positive results and improved the positive predictive value of correctly identifying histopathological cancer., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We evaluated whether real-time elastography guided biopsy improves prostate cancer detection compared to conventional systematic gray scale ultrasound guidance., Materials and Methods: A total of 353 consecutive patients suspicious for prostate cancer were prospectively randomized for real-time elastography (178) or gray scale ultrasound (175). Each patient enrolled in the study underwent a 10-core prostate biopsy. Six lateral prostate sectors (base, mid, apex) were scanned for cancer suspicious areas, defined as stiffer blue lesions using real-time elastography and hypoechoic lesions using gray scale ultrasound. Suspicious areas were sampled by a single targeted biopsy and considered representative of a defined prostate sector. If real-time elastography or gray scale ultrasound did not visualize a suspicious area in a sector, the biopsy core was taken systematically. Imaging findings were correlated with histopathological reports. Real-time elastography and gray scale ultrasound cases were compared in terms of cancer detection rate and imaging guidance accuracy., Results: Characteristics of patients undergoing real-time elastography and gray scale ultrasound, including age, prostate specific antigen, prostate volume and digital rectal examination, were not significantly different (p>0.05). Prostate cancer was detected in 160 of 353 patients (45.3%). The prostate cancer detection rate was significantly higher in patients who underwent biopsy with the real-time elastography guided approach compared to the gray scale ultrasound guided biopsy at 51.1% (91 of 178) vs 39.4% (69 of 175) (p=0.027). Overall sensitivity and specificity to detect prostate cancer was 60.8% and 68.4% for real-time elastography vs 15% and 92.3% for gray scale ultrasound, respectively., Conclusions: Sensitivity to visualize and detect prostate cancer improved using real-time elastography in addition to gray scale ultrasound during prostate biopsy. Overall sensitivity did not reach levels to omit a systematic biopsy approach., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: In 2002, 10 Martin criteria were proposed that should be met when reporting complications following surgery. To date, few studies have evaluated complication rates after radical prostatectomy using these criteria. Therefore, we assessed complications in a contemporary series of open retropubic radical prostatectomy using a standardized reporting methodology., Materials and Methods: Complications in 2,893 consecutive patients who underwent radical prostatectomy at a single center between 2003 and 2009 were recorded prospectively. All 10 Martin criteria for a high quality report of complications were fulfilled. Complications within a 30-day postoperative period were graded retrospectively according to the Clavien-Dindo classification., Results: The overall complication rate was 27.7% (801 of 2,893), and 943 medical and surgical complications were recorded in 801 patients. Of these complications 596 were grade I (63.2%), 183 grade II (19.5%), 142 grade III (15.1%) and 15 grade IV (1.8%). The mortality rate (grade V) was 0.1% (4 of 2,893). Independent predictors of high grade complications (grade III or greater) on multivariate analysis were patient age (HR 1.051, p = 0.002), prostate volume (HR 1.013, p = 0.004) and lymphadenectomy (HR 2.023, p = 0.005)., Conclusions: Complications after radical prostatectomy should be reported using a standardized methodology. Using the Clavien-Dindo classification we observed an acceptable overall complication rate. In the majority of cases lower grade complications occurred. Patients of older age, those with greater prostate volume and those who had undergone simultaneous lymphadenectomy were at risk for higher grade complications., (2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)