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To quantitatively assess 12-month prostate volume (PV) reduction based on T2-weighted MRI and immediate post-treatment contrast-enhanced MRI non-perfused volume (NPV), and to compare measurements with predictions of acute and delayed ablation volumes based on MR-thermometry (MR-t), in a central radiology review of the Phase I clinical trial of MRI-guided transurethral ultrasound ablation (TULSA) in patients with localized prostate cancer. Treatment day MRI and 12-month follow-up MRI and biopsy were available for central radiology review in 29 of 30 patients from the published institutional review board-approved, prospective, multi-centre, single-arm Phase I clinical trial of TULSA. Viable PV at 12 months was measured as the remaining PV on T2-weighted MRI, less 12-month NPV, scaled by the fraction of fibrosis in 12-month biopsy cores. Reduction of viable PV was compared to predictions based on the fraction of the prostate covered by the MR-t derived acute thermal ablation volume (ATAV, 55°C isotherm), delayed thermal ablation volume (DTAV, 240 cumulative equivalent minutes at 43°C thermal dose isocontour) and treatment-day NPV. We also report linear and volumetric comparisons between metrics. After TULSA, the median 12-month reduction in viable PV was 88%. DTAV predicted a reduction of 90%. Treatment day NPV predicted only 53% volume reduction, and underestimated ATAV and DTAV by 36% and 51%. Quantitative volumetry of the TULSA phase I MR and biopsy data identifies DTAV (240 CEM43 thermal dose boundary) as a useful predictor of viable prostate tissue reduction at 12 months. Immediate post-treatment NPV underestimates tissue ablation. • MRI-guided transurethral ultrasound ablation (TULSA) achieved an 88% reduction of viable prostate tissue volume at 12 months, in excellent agreement with expectation from thermal dose calculations. • Non-perfused volume on immediate post-treatment contrast-enhanced MRI represents only 64% of the acute thermal ablation volume (ATAV), and reports only 60% (53% instead of 88% achieved) of the reduction in viable prostate tissue volume at 12 months. • MR-thermometry-based predictions of 12-month prostate volume reduction based on 240 cumulative equivalent minute thermal dose volume are in excellent agreement with reduction in viable prostate tissue volume measured on pre- and 12-month post-treatment T2w-MRI.

The effect of warm ischemia time (WIT) on longterm renal function after partial nephrectomy remains controversial. In this retrospectively cohort study, 75 solitary kidney patients were included and the effects of warm ischemia time, preoperative renal function and resected normal parenchyma volume on long-term renal function were evaluated. Multivariable analysis showed that the preoperative renal function baseline was significantly associated with renal function 12 months postoperation (P=0.01), adjusting for age and comorbidities factors. Meanwhile, perioperative acute renal failure (ARF) events significantly affected postoperative renal function at postoperative time points of 12 months (P=0.001) and 60 months (P=0.03), as well as renal function change at postoperative 12 months (PIn conclusion, the quality of preoperative kidney primarily determines long-term postoperative renal function, while the quantity of preserved functional parenchyma volume was the main determinant for long-term kidney recovery. ARF was an independent risk factor while WIT was indirectly associated with postoperative renal function by causing perioperative ARF.

We aimed to determine short-term patient-reported outcomes in men having general anesthetic transperineal (TP) prostate biopsies. A prospective cohort study was performed in men having a diagnostic TP biopsy. This was done using a validated and adapted questionnaire immediately post-biopsy and at follow-up of between 7 and 14 days across three tertiary referral hospitals with a response rate of 51.6%. Immediately after biopsy 43/201 (21.4%) of men felt light-headed, syncopal, or suffered syncope. Fifty-three percent of men felt discomfort after biopsy (with 95% scoring

Non-prostatic bed recurrence of prostate cancer (PCa) is usually treated with androgen deprivation therapy (ADT). We analyzed the impact of salvage extended lymph node dissection (sLND) on cancer control in patients with rising PSA and lymph node (LN) metastases. Between 2009 and 2016 we performed sLND in 87 patients with biochemical recurrence (BCR) and positive LNs on 18FEC and 68Ga-PSMA positron emission tomography/X-ray computer tomography (PET/CT) after primary treatment (PT) of PCa. Intra- and postoperative complications according to Clavien-Dindo were assessed and the rates of biochemical response (BR), BCR-free and clinical recurrence (CR)-free survival, as well as time to initiation of systemic treatment were evaluated. Mean age of patients and mean PSA at sLND was 66.7 years (46–80 years) and 2.63 ng ml−1 (1.27–3.75 ng ml−1), respectively. With 87.4% radical prostatectomy (RP) was the most common PT. In all, 57.9% of patients additionally underwent adjuvant/salvage radiation therapy (RT) and 18.4% received ADT before sLND. Complete BR (cBR) was diagnosed in 27.5% of patients and incomplete BR in 40.6%. In total, 62.2% of patients remained without ADT at follow-up. With a median follow-up of 21 months (1–75 months), the cancer-specific mortality rate was 3.7%. The 3-year BCR-free, systemic therapy-free and CR-free survival rates for patients with cBR were 69.3%, 77.0% and 75%, respectively. sLND can be performed without significant complications and achieves an immediate BR, thus allowing a significant postponement of systemic therapy in selected patients with BCR and nodal recurrence of PCa. Therefore, sLND following 68Ga-PSMA PET/CT should be considered as part of a multimodal diagnostic and treatment concept for selective patients.

Die fokale Therapie des Prostatakarzinoms gehort zu den aktuellen Innovationen in der Urologie. Ihr Ansatz: Tumorgewebe eliminieren ohne umgebende Strukturen zu schadigen. Jedoch sollten Patienten unter dieser Therapie derzeit noch in Studienprotokolle eingebunden sein.

355 Background: There is an ongoing trend towards perineal prostate biopsies for the detection of prostate cancer. For many reasons the issue of antibiotic prophylaxis in prostate biopsies is becoming more important, especially with quinolone antibiotics being excluded from this indication and an increasing antibiotic resistance. Considering that the perineal biopsy is a sterile procedure, not giving antibiotics for prophylaxis seems to be an alluring approach. Methods: At the General Hospital Leverkusen, transperineal (TP) MRI TRUS fusion biopsies are performed using the Ginsburg Protocol with a template and software-guided approach in general anesthesia. Patients received single dose antibiotics (Ciprofloxacine 500 mg) two hours prior to surgery from Jan 2019 to Aug 2019 (group 1). Starting in Sep 2019, no antibiotics were used for prophylaxis (group 2). Surgical disinfection using Povidone-iodine was performed ahead of every procedure. In this study, postoperative infection rates were assessed. Patients were followed up by telephone interview at least two weeks after biopsy and were asked about the need for postoperative antibiotics to treat regular UTI, fever, prostatitis or for readmission to other hospitals. Results: A total of 180 TP biopsies were performed with a median of 22 cores (min 18, max 28). Out of 115 cases with antibiotic prophylaxis, no patient was readmitted to the hospital due to infection or fever. Group 2 included 65 patients. No one was readmitted with fever or prostatitis. At the time of abstract admission 45 out of 65 patients in this group were followed up by telephone interview. None needed antibiotics and none was readmitted to a hospital elsewhere. Conclusions: The study shows an infection rate of 0 % for perineal prostate biopsies with or without antibiotic prophylaxis. The results argue in favor of perineal prostate biopsies and challenge the dogma of prostate biopsies needing an antibiotic prophylaxis irrespective of the approach. However, a larger prospective multicenter study should be initiated to ensure patient safety.

A growing number of patients search for health information online. An early investigation of websites about bladder cancer (BCa) revealed mostly incomplete and particularly inaccurate information. We analyzed the quality, readability, and popularity of the most frequented websites on BCa. An Internet search on www.google.com was performed for the term “bladder cancer.” After selecting the most frequented websites for patient information, HONcode quality certification, Alexa popularity rank, and readability scores (according to US grade levels) were investigated. A 36-point checklist was used to assess the content according to the EAU guidelines on BCa, which was categorized into seven topics. The popularity of the 49 websites analyzed was average, with a median Alexa popularity rank of 41,698 (interquartile range [IQR] 7–4,671,246). The readability was rated difficult with 11 years of school education needed to understand the information. Thirteen (27%) websites were HONcode certified. Out of 343 topics (seven EAU guideline topics each on 49 websites), 79% were mentioned on the websites. Of these, 10% contained incorrect information, mostly outdated or biased, and 34% contained incomplete information. Publically provided websites mentioned more topics per website (median [IQR] 7 [5.5–7] vs. 5.5 [3.3–7]; p = 0.022) and showed less incorrect information (median [IQR] 0 [0–1] vs. 1 [0–1]; p = 0.039) than physician-provided websites. Our study revealed mostly correct but partially incomplete information on BCa websites for patients. Physicians and public organizations should strive to keep their website information up-to-date and unbiased to optimize patients’ health literacy.

We evaluated focal therapy with high intensity focused ultrasound hemiablation in a prospective trial.We performed a prospective, multicenter, single arm study in patients with unilateral low/intermediate risk prostate cancer who were treated from April 2013 through March 2016 in Germany in AUO (Arbeitsgemeinschaft Urologische Onkologie) Study Protocol AP 68/11. Unilateral prostate cancer was assessed by transrectal ultrasound guided biopsy and multiparametric magnetic resonance imaging. Hemiablation was done using the Ablatherm® or the Focal One® device. The oncologic outcome was assessed by the salvage treatment rate, multiparametric magnetic resonance imaging and rebiopsy at 12 months. Functional outcome, quality of life, anxiety and depression were measured by validated questionnaires at baseline and every 3 months.Of the 54 recruited patients 51 completed 12-month or greater visits. Mean ± SD followup was 17.4 ± 4.5 months. Mean prostate specific antigen decreased from 6.2 ± 2.0 to 2.9 ± 1.9 ng/ml at 12 months (p0.001). Biopsy at 12 months was positive for any prostate cancer and for clinically significant prostate cancer in 13 (26.5%) and 4 (8.2%) of the 49 patients, respectively. Posttreatment multiparametric magnetic resonance imaging had limited 25% sensitivity for clinically significant prostate cancer. Ten patients (19.6%) underwent salvage treatment. Potency was maintained in 21 of the 30 men who were potent preoperatively. There was no increase in incontinence. Quality of life, anxiety and depression did not change postoperatively. The study was limited by a short followup and the lack of a control arm.Focal therapy hemiablation is safe with little alteration of functional outcome. The oncologic outcome is acceptable on short-term followup. Followup multiparametric magnetic resonance imaging performed poorly and should not replace repeat biopsy. Focal therapy has no impact on posttreatment anxiety and depression.

Purpose: Multiparametric magnetic resonance imaging and magnetic resonance imaging targeted biopsy may improve the detection of clinically significant prostate cancer. However, standardized prospective evaluation is limited.Materials and Methods: A total of 294 consecutive men with suspicion of prostate cancer (186 primary, 108 repeat biopsies) enrolled in 2013 underwent 3T multiparametric magnetic resonance imaging (T2-weighted, diffusion weighted, dynamic contrast enhanced) without endorectal coil and systematic transperineal cores (median 24) independently of magnetic resonance imaging suspicion and magnetic resonance imaging targeted cores with software registration (median 4). The highest Gleason score from each biopsy method was compared. McNemar’s tests were used to evaluate detection rates. Predictors of Gleason score 7 or greater disease were assessed using logistic regression.Results: Overall 150 cancers and 86 Gleason score 7 or greater cancers were diagnosed. Systematic, transperineal biopsy m...

OBJECTIVE To compare 2 previously presented algorithms for extracting parameters from intravoxel incoherent motion (IVIM) studies and investigate them in the context of tissue differentiation. METHODS Magnetic resonance imaging (MRI) was performed in 23 patients without histologically proven prostate carcinoma (PCa) and 27 patients with histologically proven PCa. Two methods were used to determine IVIM parameters (f, D, D*). Receiver operating characteristic analysis was performed for IVIM parameters and apparent diffusion coefficient for discrimination of prostate tissue. RESULTS The IVIM parameters showed no significant difference between patients without PCa and normal areas in patients with PCa (r = 0.46-0.99). Results for D were not significantly different for both methods (P = 0.22), whereas f from method 1 was significantly higher than the f from method 2 (P < 0.05). The diffusion parameters D (both methods) and apparent diffusion coefficient could discriminate between tumor and normal areas (receiver operating characteristic analysis, area under the curve, ≥0.90). Additionally, in subgroup analysis, only D was able to discriminate between low- and high-grade PCa. CONCLUSIONS For tumor detection, IVIM diffusion does not yield a clear added value, but the perfusion-free diffusion constant D may hold potential for improved image-based tumor grading.

Objectives To evaluate the Prostate Imaging Reporting and Data System (PIRADS) in multiparametric magnetic resonance imaging (mpMRI) based on single cores and single-core histology. To calculate positive (PPV) and negative predictive values (NPV) of different modalities of mpMRI. Patients and Methods We performed MRI-targeted transrectal ultrasound-guided perineal prostate biopsies on 50 patients (mean age 66 years, mean PSA level of 9.9 ng/mL) with suspicion of prostate cancer. The biopsy trajectories of every core taken were documented in three dimensions (3D) in a 3D-prostate model. Every core was evaluated separately for prostate cancer and the performed biopsy trajectories were projected on mpMRI images. PIRADS scores of 1177 cores were then assessed by a histology ‘blinded’ uro-radiologist in T2-weighted (T2W), dynamic contrast-enhanced (DCE), diffusion-weighted imaging (DWI) and magnetic resonance spectroscopy (MRS). Results The PIRADS score was significantly higher in cores positive for cancer than in negative cores. There was a significant correlation between the PIRADS score and histopathology for every modality. Receiver operating characteristic (ROC) analysis showed excellent specificity for T2W (90% peripheral zone/97% transition zone) and DWI (98%/97%) images regardless of the prostate region observed. These numbers decreased for DCE (80%/93%) and MRS (76%/83%). All modalities had NPVs of 99%, if a PIRADS score threshold of 2 (for T2W, DCE, and MRS) or 3 (for DWI) was used. However, PPVs were low. Conclusions Our results show that PIRADS scoring is feasible for clinical routine and allows standardised reporting. PIRADS can be used as a decision-support system for targeting of suspicious lesions. mpMRI has a high NPV for prostate cancer and, thus, might be a valuable tool in the initial diagnostic evaluation.

Objectives To define terms and processes and agree on a minimum dataset in relation to transperineal prostate biopsy procedures and enhanced prostate diagnostics. To identify the need for further evaluation and establish a collaborative research practice. Patients and Methods A 19-member multidisciplinary panel rated 66 items for their appropriateness and their definition to be incorporated into the international databank using the Research and Development/University of California Los Angeles Appropriateness Method. The item list was developed from interviews conducted with healthcare professionals from urology, radiology, pathology and engineering. Results The panel agreed on 56 items that were appropriate to be incorporated into a prospective database. In total, 10 items were uncertain and were omitted. These items were within the categories: definitions (n = 2), imaging (n = 1), surgical protocols (n = 2) and histology (n = 5). Conclusions The components of a minimum dataset for transperineal prostate biopsy have been defined. This provides an opportunity for multicentre collaborative data analysis and technique development. The findings of the present study will facilitate prospective studies into the application and outcome of transperineal prostate biopsies.

Rhabdomyosarcomas are the most common soft tissue sarcomas in children. Here we present management of an 18-month-old boy with metastatic rhabdomyosarcoma of the bladder/prostate. After radiochemotherapy, high-spatial-resolution 3-Tesla multiparametric magnetic resonance imaging (MRI) showed regressive systemic disease but a residual mass at the right seminal vesicle. For histologic re-evaluation, 3-dimensional-controlled stereotactic MRI/transrectal ultrasound (TRUS)-fusion biopsy specimens were taken. Because histologic analysis showed nonvital tissue, a decision could be made against adjuvant radical cystoprostatectomy. Advanced 3-Tesla imaging and MRI/TRUS-fusion biopsies in children are feasible and represent an effective tool to examine suspicious pelvic lesions. Depending on histology, this can lead to a significant reduction of therapy-associated morbidity.

Objective: To optimize image-guided prostate biopsy by minimizing the target error with trocar-sharpened needle tips instead of beveled needles, which constantly deviate away from the bevel. Materials and Methods: We performed stereotactic biopsies on two prostate phantoms, which incorporate three randomly placed TRUS-visible lesions. Four stereotactic biopsies per lesion were taken under live-ultrasound guidance through a template: two biopsies with conventional beveled needles and two biopsies with novel trocar-sharpened needles. The procedural targeting error (PTE) between the virtually planned biopsy trajectory and the manually registered 3D needle position of every single biopsy core taken was calculated. Results: The absolute overall targeting error using the novel needle-tip design was 0.13 mm (SD: ± 0.15 mm) with the highest PTE in the sagittal plane (0.18 ± 0.16 mm), followed by the coronal (0.13 ± 0.17 mm) and axial (0.09 ± 0.05 mm) planes. Comparing the PTE of the novel trocar-shaped needles with conventional beveled needles, there was a statistically significant difference in the axial plane [p (overall) = 0.47, p(axial) = 0.03]. Conclusion: The targeting error of stereotactic biopsies using trocar-sharpened needles is significantly lower than the targeting error of classical beveled needles. Thus, trocar-tip configurations improve the accuracy of computer-assisted biopsies and allow precise assessment of suspicious lesions in the prostate and in other organs accessible to image-guided biopsy.

RRP radical retropubic prostatectomy, HDR high dose rate brachytherapy, Cryo cryoablation, HIFU high-intensity focused ultrasound, TURP transurethral resection of the prostate, OIU optic internal urethrotomy, SD standard deviation, IIEF-5 5-item version of the international index of erectile function, IPSS international prostate symptom score, QoL quality of life *Erectile dysfunction and Mean scores for IIEF-5 were restricted to those men who reported IIEF-5 17 at baseline Vol. 195, No. 4S, Supplement, Friday, May 6, 2016 THE JOURNAL OF UROLOGY e201

The integration of magnetic resonance imaging into urologic routine may be highly beneficial and change our standards for prostate cancer treatment.

To determine the targeting error of a novel stereotactic prostate biopsy system that integrates preinterventional MRI with peri-interventional ultrasonography (US) for perineal navigated prostate biopsies.We performed stereotactic biopsies on five prostate phantoms (one CIRS 053-MM and four CIRS 066). Phantom 053-MM incorporates three MRI- and transrectal ultrasonography (TRUS)-visible lesions, while lesions within phantom 066 are only detectable on MRI. In both phantoms, the 0.5 cc volume lesions are placed randomly. The phantoms were examined by 3T-MRI preinterventionally. Then three stereotactic biopsies from one lesion in phantom 053-MM and from all US-invisible lesions in the 066 phantoms were taken under live-fusion imaging guidance. During intervention, a mix of blue ink and gadobutrol was injected into each biopsy channel. Afterward, another 3T-MRI was obtained. These MRI images were then fused again with the intraoperative TRUS data. Thus, the targeting error (TE) between the planned and performed biopsy cores could be measured. In addition, the procedural targeting error (PTE) between the virtually planned biopsy trajectory and the manually registered three-dimensional needle position of every single biopsy core taken was calculated.The overall TE of the 39 biopsy cores taken was 0.83 mm (standard deviation [SD]: 0.48 mm) with the highest TE in the sagittal plane (1.09 ± 0.54 mm), followed by the coronal (0.72 ± 0.43 mm) and axial (0.69 ± 0.34 mm) planes. The procedural TE, which is provided intraoperatively, was 0.26 mm on average (SD: 0.46 mm). Comparing PTE and TE, there was no statistically significant difference (P=0.39).The TE of stereotactic biopsies using our novel perineal prostate biopsy system is below 1 mm and can be estimated in vivo by the automatically calculated procedural TE. Thus, stereotactic prostate biopsies guided by the combination of MRI and US allow effective and precise examination of MRI lesions.

Purpose We developed an effective way to precisely diagnose prostate cancer using a novel prostate biopsy system that integrates pre-interventional magnetic resonance imaging with peri-interventional ultrasound for perineal navigated prostate biopsy. Materials and Methods A total of 106 men with findings suspicious for prostate cancer (median age 66 years, prostate specific antigen 8.0 ng/ml and prostate volume 47 ml) underwent multiparametric 3 Tesla magnetic resonance imaging. Suspicious lesions were marked and data were transferred to the novel biopsy system. Using a custom-made biplane transrectal ultrasound probe mounted on a stepper we gathered 3-dimensional ultrasound data and fused them with magnetic resonance imaging data. As a result, suspicious magnetic resonance imaging lesions were superimposed over the transrectal ultrasound data. Three-dimensional biopsy planning was done, including systematic biopsies. Perineal biopsies were taken under live ultrasound guidance and the precise site of each biopsy was documented in 3 dimensions. We evaluated feasibility, safety and cancer detection. Results Prostate cancer was detected in 63 of 106 patients (59.4%). Magnetic resonance imaging findings correlated positively with histopathology in 71 of 103 patients (68.9%). In magnetic resonance imaging lesions marked as highly suspicious, the detection rate was 95.8% (23 of 24 cases). Lesion targeted cores had a significantly higher positivity rate than nontargeted cores. The procedural targeting error of the first 2,461 biopsy cores was 1.7 mm. Regarding adverse effects, 2 patients experienced urinary retention and 1 had a perineal hematoma. Urinary tract infections did not develop. Conclusions Perineal stereotactic prostate biopsies guided by the combination of magnetic resonance imaging and ultrasound enable effective examination of suspicious magnetic resonance imaging lesions. Each biopsy core taken is documented accurately for its location in 3 dimensions, enabling magnetic resonance imaging validation and tailored treatment planning. The morbidity of the procedure was minimal.

Um die Prostatakarzinomdiagnostik zu optimieren wurde ein neues System fur perineale Prostatastanzbiopsien entwickelt, welches eine Echtzeitubertragung von MRT-Daten auf den periinterventionellen Ultraschall gestattet. Hierdurch konnen suspekte Lasionen gezielt biopsiert werden. Daruber hinaus erlaubt das System, den Entnahmeort jeder einzelnen Biopsie in einer virtuell dreidimensional (3D-)konfigurierten Prostata zu dokumentieren. Bei 50 konsekutiven Patienten (Alter 67 Jahre, PSA 8,9 ng/ml, Prostatavolumen 51 ml) wurden ein multiparametrisches 3-T-MRT ohne Endorektalspule und anschliesend eine stereotaktische Biopsie durchgefuhrt. Mit Hilfe eines eigens konstruierten TRUS-Schallkopfes, der auf einem speziellen Fuhrungssystem montiert ist, wurde ein 3D-Datensatz der Prostata generiert und mit dem MRT fusioniert. Anschliesend wurden suspekte MRT-Befunde gezielt perineal biopsiert. Daruber hinaus wurden nicht auffallige Prostataareale systematisch gestanzt. Bei 27 von 50 Patienten wurde ein Prostatakarzinom diagnostiziert. Bei zuvor negativ biopsierten Mannern erfolgte ein Tumornachweis in 36%. Eine positive Korrelation zwischen MRT-Befund und Histopathologie fand sich bei 36/50 Patienten (72%). Bei hochsuspekten MRT-Lasionen lag die Detektionsrate bei 100% (13/13). Betrachtet man die einzelnen Zylinder aus hochsuspekten Arealen, so waren 40/75 (53%) positiv. Zum Vergleich waren nur 7% der systematischen Stanzen positiv (66/927). Die Abweichung zwischen der geplanten und der tatsachlich biopsierten Position in der Prostata betrug bei 1159 Stanzen im Mittel 1,7 mm. An Nebenwirkungen wurden ein Harnverhalt und ein Hamatom beobachtet. Harnwegsinfekte traten nicht auf. Perineale stereotaktische Prostatabiopsien unter Zuhilfenahme fusionierter MRT und Ultraschall Datensatze ermoglichen eine effektive Untersuchung von MRT-suspekten Lasionen. Zusatzlich ist es moglich, jede einzelne Biopsie exakt zu dokumentieren. Dadurch konnen MRT-Daten validiert und Therapien differenziert geplant werden. Die Morbiditat des Eingriffs ist minimal.

32 Background: Risk stratification for patients diagnosed with prostate cancer (PCa) through MR-TRUS fusion biopsy still relies on Gleason (GL) grading of the biopsy specimens. GL grading of the same sample can differ between pathologists. In our tertiary high-volume center GL grading of the biopsy specimens is crucial for further therapy planning. Methods: Reference pathology of 42 patients after transperineal MR-TURS fusion plus saturation biopsy was assessed by one specialized genitourinary pathologist. GL grading of the original pathology and the reference pathology for the saturation and targeted biopsy cores were compared. Risk groups for this study were set as GL 6 for low, GL 7a and GL 7b for intermediate and GL 8, GL 9 and GL 10 for high-risk. Results: In 42 patients 49 lesions were identified by mpMRI (PI-RADS 3-5) in which 150 biopsy cores were taken. In addition, 709 cores were taken as saturation biopsies. The highest GL grading per patient differed in 18 (43 %) of the cases. In 16 cases, there was a difference within the targeted biopsies but only in 8 cases there was a difference in the saturation biopsies. In 6 cases both saturation and fusion biopsies were different. Taking risk stratification into account there was a misclassification with low- and intermediate risk in 9 (21 %) cases, an intermediate- and high risk in 2 cases and a misclassification within the same risk group in 6 (14 %) cases. In 16 of the 18 differences there was an upgrading of the Gleason score by the reference pathologist whereas only in 2 cases there was a downgrading. Conclusions: The data shows that in times of mpMRIs and transperineal MRI-TRUS fusion biopsies it still is the GL score graded by the pathologist who accounts for many potential therapy plan mistakes. In this study 21 % of the patients were misclassified as GL 6 while reference pathology graded for GL 7a or GL 7b. The demonstrated data suggests that there should be a reference pathology at least for every GL 6 cancer and that the quality of GL grading should be monitored. Also this data again addresses the need for a better risk stratification irrespective of the GL score that can be done in a more objective way with less potential for misclassification.

Background Magnetic resonance imaging–guided transurethral ultrasound ablation (MRI-TULSA) is a novel minimally invasive technology for ablating prostate tissue, potentially offering good disease control of localized cancer and low morbidity. Objective To determine the clinical safety and feasibility of MRI-TULSA for whole-gland prostate ablation in a primary treatment setting of localized prostate cancer (PCa). Design, setting, and participants A single-arm prospective phase 1 study was performed at three tertiary referral centers in Canada, Germany, and the United States. Thirty patients (median age: 69 yr; interquartile range [IQR]: 67–71 yr) with biopsy-proven low-risk (80%) and intermediate-risk (20%) PCa were treated and followed for 12 mo. Intervention MRI-TULSA treatment was delivered with the therapeutic intent of conservative whole-gland ablation including 3-mm safety margins and 10% residual viable prostate expected around the capsule. Outcome measurements and statistical analysis Primary end points were safety (adverse events) and feasibility (technical accuracy and precision of conformal thermal ablation). Exploratory outcomes included quality of life, prostate-specific antigen (PSA), and biopsy at 12 mo. Results and limitations Median treatment time was 36min (IQR: 26–44) and prostate volume was 44ml (IQR: 38–48). Spatial control of thermal ablation was ±1.3mm on MRI thermometry. Common Terminology Criteria for Adverse Events included hematuria (43% grade [G] 1; 6.7% G2), urinary tract infections (33% G2), acute urinary retention (10% G1; 17% G2), and epididymitis (3.3% G3). There were no rectal injuries. Median pretreatment International Prostate Symptom Score 8 (IQR: 5–13) returned to 6 (IQR: 4–10) at 3 mo (mean change: −2; 95% confidence interval [CI], −4 to 1). Median pretreatment International Index of Erectile Function 13 (IQR: 6–28) recovered to 13 (IQR: 5–25) at 12 mo (mean change: −1; 95% CI, −5 to 3). Median PSA decreased 87% at 1 mo and was stable at 0.8 ng/ml (IQR: 0.6–1.1) to 12 mo. Positive biopsies showed 61% reduction in total cancer length, clinically significant disease in 9 of 29 patients (31%; 95% CI, 15–51), and any disease in 16 of 29 patients (55%; 95% CI, 36–74). Conclusions MRI-TULSA was feasible, safe, and technically precise for whole-gland prostate ablation in patients with localized PCa. Phase 1 data are sufficiently compelling to study MRI-TULSA further in a larger prospective trial with reduced safety margins. Patient summary We used magnetic resonance imaging–guided transurethral ultrasound to heat and ablate the prostate in men with prostate cancer. We showed that the treatment can be targeted within a narrow range (1mm) and has a well-tolerated side effect profile. A larger study is under way. Trial registration NCT01686958, DRKS00005311.

Background: Primary melanoma of the prostate has an extremely rare incidence. Only five cases have been reported in the literature and prognosis is poor. The most likely origin of prostatic melanoma is the transitional epithelium of the prostatic urethra. Surgical care for primary melanoma of mucosal sites is less well established than for primary cutaneous melanoma, but excision of the primary is recommended if the patient has no systemic disease. Case presentation: Here, we describe a case of primary malignant melanoma of the prostate. A 37-year-old male patient with history of both chemo- and radiation therapy for Hodgkin’s disease was admitted to the University Hospital Heidelberg on suspicion of pleomorphic sarcoma of the bladder. In-house diagnostic work-up revealed a malignant melanoma of the prostate. We then performed radical prostatectomy with extended lymphadenectomy. Despite presumably curative surgery, the patient suffered from early relapse of disease with pulmonary metastasis. Systemic chemotherapy and subsequent immuno-oncologic treatment was thereafter initiated. Conclusion: Since prostatic melanoma is a rare disease and a melanoma metastasis of unknown primary is the differential diagnosis, a multidisciplinary approach including early imaging to rule out possible metastases and to search for another potentially existing primary is advisable. To prevent complications related to local tumor progression and to receive tissue for mutational analysis, we recommend complete surgical resection to reduce the tumor mass. Novel immune and targeted oncologic therapies can lead to an improved survival in some cases and support of clinical trials is needed.

Introduction: Published results of HistoScanning™ (HS) for prostate cancer (PCa) diagnostics are inconsistent and their value remains unclear. We prospectively analyzed the detection rate and tumor volume concordance in PCa patients. Material and Methods: Two hundred and eighty-two patients with biopsy-proven PCa scheduled for radical prostatectomy (RP) were included. All patients underwent ultrasonographical examination by HS prior to surgery. HS was evaluated compared to RP specimen as to (1) the prediction of overall tumor volume and (2) accuracy of HS in detection of PCa lesions larger than 0.2/0.5 ml, separated for each sextant. For each sextant, receiver operating characteristic (ROC)-analysis and area under the curve were determined. Sensitivity and specificity were calculated and visualized in ROC-curves. Results: HS tends to underestimate volume of cancerous lesions, particularly larger lesions >8 ml. Using a 0.2 ml detection threshold, specificity and sensitivity of HS were between 29-68% and 46-78%. For a 0.5 ml detection threshold, sextant-specific specificity increased to 59-92% and sensitivity decreased to 16-54%. Stratification according to pre-operational PSA values did not improve performance characteristics of HS. Conclusions: Our results do not support a significant contribution of HS to PCa diagnostics.

OBJECTIVES The purpose of the study was to evaluate and validate diffusion kurtosis imaging (DKI) for detection grading of peripheral zone prostate cancer (PCa) compared with standard diffusion-weighted imaging (DWI) in a cohort of patients with biopsy-proven PCa. MATERIALS AND METHODS In this retrospective, single-institutional study, 55 patients (age, 67.5 ± 6.9 years; range, 52-84 years) who underwent multiparametric magnetic resonance imaging (MRI) before transperineal magnetic resonance/transrectal ultrasound-guided fusion biopsy were included. Suspicious lesions identified in multiparametric MRI underwent image-guided targeted biopsy procedure using a hybrid magnetic resonance/transrectal ultrasound-guided fusion biopsy system. Multiparametric MRI examinations were performed at 3.0 T using a 16-channel phased array coil. Diffusion kurtosis imaging has been acquired with 9 b values (0, 50, 250, 500, 750, 1000, 1250, 1500, and 2000 s/mm). In patients with histologically proven PCa, a representative tumor region was determined as region of interest (ROI) on axial T2-weighted images in consensus by 2 board-certified radiologists. For quantitative evaluation, ROIs located in malignant and contralateral tumor-free regions were transferred to diffusion-weighted images. Diffusion kurtosis imaging parameters (Dapp and Kapp) and apparent diffusion coefficient (ADC) values of the ROIs in tumor and contralateral remote areas were calculated. Estimation of the kurtosis-derived parameters was performed using a voxel-by-voxel fit followed by an ROI-based averaging and a second fit to ROI-averaged signal values. A subgroup analysis was performed to determine the influence of aggressiveness of PCa using ADC, Dapp, and Kapp. The receiver operating characteristic (ROC) curves were calculated for DKI parameters and ADC values. RESULTS In the 55 patients, the average prostate-specific antigen level was 12.4 ± 12.6 ng/mL (range, 2.7–75.0 ng/mL), and the median Gleason score was 7 (range, 6–10). Dapp (units, 10(-3) mm(2)/s) was significantly lower in tumor compared with control regions (1.48 ± 0.35 vs 2.00 ± 0.32, P < 0.05), and Kapp was significantly higher (1.01 ± 0.21 vs 0.76 ± 0.14, P < 0.05). Dapp was significantly higher than standard ADC (units, 10(-3) mm(2)/s) both in tumor regions and in controls (1.48 ± 0.35 vs 1.10 ± 0.25 and 2.00 ± 0.32 vs 1.43 ± 0.25, P < 0.05). Neither the ROI-based calculation of the kurtosis parameters nor the application of the noise correction significantly changed the DKI parameter estimation. There was no significant difference for the applied fitting method for DKI-derived parameters considering the differentiation between tumor and control tissue. Subsequent ROC analyses did not reveal a significant difference between DKI and ADC for detection of PCa. Sensitivities derived by Youden J statistics cutoff values ranged from 69% to 91% for DKI parameters; specificities ranged from 71% to 89%. Subgroup analysis for DKI (Dapp, Kapp) and ADC for assessing aggressiveness of PCa found significant difference (P < 0.05) for discrimination between high- and low-grade findings. However, no significant difference could be obtained between standard DWI- and DKI-derived parameters. CONCLUSIONS The results of this study demonstrated no significant benefit of DKI for detection and grading of PCa as compared with standard ADC in the peripheral zone determined from b values of 0 and 800 s/mm. For clinical routine application, ADC derived from monoexponential fitting of DWI data remains the standard for characterizing peripheral zone cancer of the prostate.

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

Context Debates on overdiagnosis and overtreatment of prostate cancer (PCa) are ongoing and there is still huge uncertainty regarding misclassification of prostate biopsy results. Several imaging techniques that have emerged in recent years could overcome over- and underdiagnosis in PCa. Objective To review the literature on transrectal ultrasound (TRUS)-based techniques (contrast enhancement, HistoScanning, elastography) and magnetic resonance imaging (MRI)-based techniques for a nonsystematic overview of their benefits and limitations. Evidence acquisition A comprehensive search of the PubMed database between August 2004 and August 2014 was performed. Studies assessing grayscale TRUS, contrast-enhanced (CE)-TRUS, elastography, HistoScanning, multiparametric MRI (mpMRI), and MRI-TRUS fusion biopsy were included. Publications before 2004 were included if they reported the principle or the first clinical results for these techniques. Evidence synthesis Grayscale TRUS alone cannot detect PCa foci (detection rate 23–29%). TRUS-based (elastography) and MRI-based techniques (MRI-TRUS fusion biopsy) have significantly improved PCa diagnostics, with sensitivity of 53–74% and specificity of 72–95%. HistoScanning does not provide convincing or homogeneous results (specificity 19–82%). CE-TRUS seems to be user dependent; it is used in a low number of high-volume centers and has wide ranges for sensitivity (54–79%) and specificity (42–95%). For all the techniques reviewed, prospective multicenter studies with consistent definitions are lacking. Conclusions Standard grayscale TRUS is unreliable for PCa detection. Among the techniques reviewed, mpMRI and MRI-TRUS fusion biopsy seem to be suitable for enhancing PCa diagnostics. Elastography shows promising results according to the literature. CE-TRUS yields very inhomogeneous results and might not be the ideal technique for clinical practice. The value of HistoScanning must be questioned according to the literature. Patient summary New imaging modalities such as elastography and magnetic resonance imaging/transrectal ultrasound fusion biopsies have improved the detection of prostate cancer. This may lower the burden of overtreatment as a result of more precise diagnosis.

To show the benefit of trocar-sharpened needles for image-guided prostate biopsy compared with standard bevelled needles in patients.Twenty-four men underwent magnetic resonance imaging-targeted fusion-guided transperineal saturation prostate biopsy, each with half standard bevelled and half trocar-sharpened needles. All taken biopsies were scored (1=worse to 5=best) by one urologist for the following criteria. (1) Accuracy of matching between planned and performed biopsy. (2) Histologic quality of the sample. (3) Elegance, which is the easiness to take the biopsy in proper time, planned position, and best histologic quality. Afterward, the histologic sample quality was evaluated by a blinded pathologist. To show a possible training effect, blinded untrained junior residents performed biopsies in four men (103 cores).Overall, 600 single biopsies were analyzed. The trocar-sharpened needles demonstrated a significantly (p0.05) better scoring for accuracy and elegance rated by the urologist. The histologic quality scored by the pathologist was superior. Moreover, significantly lower target errors with trocar-sharpened needles were achieved by untrained residents, but not by the experienced user.Using trocar-sharpened needles helps urologists to perform targeted prostate biopsy more elegantly and accurately. In addition, the histopathologic sample quality was superior, which may directly improve diagnostic certainty. There is an undeniable training effect in image-guided biopsy and unexperienced users can significantly reduce target errors with trocar-sharpened needles.

This research was also made possible through the National Institutes of Health Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and generous contributions to the Foundation for the NIH from Pfizer Inc., The Doris Duke Charitable Foundation, The Alexandria Real Estate Equities, Inc. and Mr. and Mrs. Joel S. Marcus, and the Howard Hughes Medical Institute, as well as other private donors. For a complete list, please visit the Foundation website at: http://fnih.org/work/education-training0/medical-research-scholars-program

To test the hypothesis that MRI–TRUS fusion technique can increase the detection rate of prostate cancer (PC) in patients with previously negative biopsy. Patient records of men with persisting suspicion for PC after previous negative biopsy having undergone either extensive transrectal prostate biopsies (MD Anderson protocol; MDA), transperineal saturation (STP) or magnetic resonance imaging (MRI)/transrectal ultrasound (TRUS) fusion transperineal biopsies (MTTP) in three consecutive time intervals were reviewed retrospectively. The respective approach was the standard for the above indication at these episodes. In Cambridge, 70 patients underwent MDA biopsies, 75 STP underwent biopsies and 74 patients underwent MTTP biopsies. In total, 164 MTTP patients with the same indication from Heidelberg were analysed as reference standard. In total, 383 men were included into analysis. Low-grade PC was defined as Gleason score 7 (3 + 4) or lower. Even though MTTP patients had significantly larger prostates, the overall cancer detection rate for PC was the highest in MTTP (24.2 % MDA, 41.3 % STP, 44.5 % MTTP, p = 0.027, Kruskal–Wallis test). The detection rate for clinically relevant high-grade PC was highest in MTTP; however, this did not reach statistical significance compared with MDA (23.5 % MDA, 12.9 % STP, 27.2 % MTTP, p = 0.25, Fischer’s exact test). Comparing MTTP between Cambridge and Heidelberg, detection rates did not differ significantly (44.5 vs. 48 %, p = 0.58). There was a higher detection rate of high-grade cancer in Heidelberg. (36.3 vs. 27.2 %, p = 0.04). Patients whom are considered for repeat biopsies may benefit from undergoing MRI-targeted TRUS fusion technique due to higher cancer detection rate of significant PC.

To evaluate the Prostate Imaging Reporting and Data System (PI-RADS) proposed by the European Society of Urogenital Radiology (ESUR) for detection of prostate cancer (PCa) by multiparametric magnetic resonance imaging (mpMRI) in a consecutive cohort of patients with magnetic resonance/transrectal ultrasound (MR/TRUS) fusion-guided biopsy.Suspicious lesions on mpMRI at 3.0 T were scored according to the PI-RADS system before MR/TRUS fusion-guided biopsy and correlated to histopathology results. Statistical correlation was obtained by a Mann-Whitney U test. Receiver operating characteristics (ROC) and optimal thresholds were calculated.In 64 patients, 128/445 positive biopsy cores were obtained out of 95 suspicious regions of interest (ROIs). PCa was present in 27/64 (42%) of the patients. ROC results for the aggregated PI-RADS scores exhibited higher areas under the curve compared to those of the Likert score. Sensitivity/Specificity for the following thresholds were calculated: 85 %/73 % and 67 %/92 % for PI-RADS scores of 9 and 10, respectively; 85 %/60 % and 56 %/97 % for Likert scores of 3 and 4, respectively [corrected.The standardised ESUR PI-RADS system is beneficial to indicate the likelihood of PCa of suspicious lesions on mpMRI. It is also valuable to identify locations to be targeted with biopsy. The aggregated PI-RADS score achieved better results compared to the single five-point Likert score.• The ESUR PI-RADS scoring system was evaluated using multiparametric 3.0-T MRI. • To investigate suspicious findings, transperineal MR/TRUS fusion-guided biopsy was used. • PI-RADS can guide biopsy locations and improve detection of clinically significant cancer. • Biopsy procedures can be optimised, reducing unnecessary negative biopsies for patients. • The PI-RADS scoring system may contribute to more effective prostate MRI.

Diagnosis and precise risk stratification of prostate cancer is essential for individualized treatment decisions. Magnetic resonance imaging/transrectal ultrasound fusion has shown encouraging results for detecting clinically significant prostate cancer. We critically evaluated magnetic resonance imaging targeted, transrectal ultrasound guided transperineal fusion biopsy in routine clinical practice.Included in this prospective study were 347 consecutive patients with findings suspicious for prostate cancer. Median age was 65 years (range 42 to 84) and mean prostate specific antigen was 9.85 ng/ml (range 0.5 to 104). Of the men 49% previously underwent transrectal ultrasound guided biopsies, which were negative, and 51% underwent primary biopsy. In all patients 3 Tesla multiparametric magnetic resonance imaging was done. Systematic stereotactic prostate biopsies plus magnetic resonance imaging targeted, transrectal ultrasound guided biopsies were performed in those with abnormalities on magnetic resonance imaging. Imaging data and biopsy results were analyzed. A self-designed questionnaire was sent to all men on further clinical history and biopsy adverse effects.Of 347 patients biopsy samples of 200 (58%) showed prostate cancer and 73.5% of biopsy proven prostate cancer were clinically relevant according to National Comprehensive Cancer Network (NCCN) criteria. On multiparametric magnetic resonance imaging 104 men had findings highly suspicious for prostate cancer. The tumor detection rate was 82.6% (86 of 104 men) with a Gleason score of 7 or greater in 72%. Overall targeted cores detected significantly more cancer than systematic biopsies (30% vs 8.2%). Of 94 patients without cancer suspicious lesions on magnetic resonance imaging 11 (11.7%) were diagnosed with intermediate risk disease. Regarding adverse effects, 152 of 300 patients (50.6%) reported mild hematuria, 26% had temporary erectile dysfunction and 2.6% needed short-term catheterization after biopsy. Nonseptic febrile urinary tract infections developed in 3 patients (1%).Magnetic resonance imaging targeted, transrectal ultrasound guided transperineal fusion biopsy provides high detection of clinically significant tumors. Since multiparametric magnetic resonance imaging still has some limitations, systematic biopsies should currently not be omitted. The morbidity of the transperineal saturation approach is reasonable and mainly self-limiting.

Objective To evaluate the diagnostic performance of an automated analysis tool for the assessment of prostate cancer based on multiparametric magnetic resonance imaging (mpMRI) of the prostate. Methods A fully automated analysis tool was used for a retrospective analysis of mpMRI sets (T2-weighted, T1-weighted dynamic contrast-enhanced, and diffusion-weighted sequences). The software provided a malignancy prediction value for each image pixel, defined as Malignancy Attention Index (MAI) that can be depicted as a colour map overlay on the original images. The malignancy maps were compared to histopathology derived from a combination of MRI-targeted and systematic transperineal MRI/TRUS-fusion biopsies. Results In total, mpMRI data of 45 patients were evaluated. With a sensitivity of 85.7% (with 95% CI of 65.4–95.0), a specificity of 87.5% (with 95% CI of 69.0–95.7) and a diagnostic accuracy of 86.7% (with 95% CI of 73.8–93.8) for detection of prostate cancer, the automated analysis results corresponded well with the reported diagnostic accuracies by human readers based on the PI-RADS system in the current literature. Conclusion The study revealed comparable diagnostic accuracies for the detection of prostate cancer of a user-independent MAI-based automated analysis tool and PI-RADS-scoring-based human reader analysis of mpMRI. Thus, the analysis tool could serve as a detection support system for less experienced readers. The results of the study also suggest the potential of MAI-based analysis for advanced lesion assessments, such as cancer extent and staging prediction.

242 Background: According to the risk constellation recurrence rate of prostate cancer following local therapy is up to 60%. Early salvage radiotherapy already showed a benefit in progression-free survival. We analyzed the impact of salvage extended lymph node dissection on cancer control in patients with rising PSA and nodal recurrence in PET/CT scan. Methods: Between 2003 and 2015 we performed a salvage extended lymph node dissection in 95 patients with rising PSA and nodal recurrence in PET/CT scan after previous local therapy for prostate cancer. The extent of resection field was adjusted to the pre-operative imaging. Results: We identified 95 patients with rising PSA and nodal recurrence in PET/CT scan with a mean age of 66 years (55-76 years). There were no significant intraoperative complications. Postoperatively, 12% had Clavien/Dindo grade 3 complications. Complete PSA response, defined as a postoperative PSA level < 0.2 ng/ml, was diagnosed in 36% of patients. With a median follow-up of 19 months (1-101 months) cancer-specific mortality rate was less than 1%. Median progression-free survival was 7 months (1-43 months). The interval until the initiation of systemic treatment was 12 months (1-43 months). Conclusions: Salvage LND can be performed without significant complications. Immediate complete PSA response can be achieved in one third of patients and systemic therapy can be delayed by one year. For a general treatment recommendation individual predictive markers are currently still missing.

INTRODUCTION AND OBJECTIVES: The key challenge for focal therapy of prostate cancer is to identify index lesions. In this context, we describe our initial experience with a new stereotactic prostate biopsy system, which integrates pre-interventional MRI data with periinterventional ultrasound for perineal prostate biopsies. METHODS: 33 patients were stereotactically biopsied (mean age of 64yrs., mean PSA level of 8.2ng/ml and mean prostate vol. of 40ml). 21 of these 33 patients had already had a negative transrectal US-guided biopsy. All men underwent multimodal 3 Tesla MRI without endorectal coil including diffusion weighted imaging and dynamic contrast enhanced sequences as well as MR-spectroscopy. Suspicious lesions were marked by radiologists with over 10 years experience in reading prostate MRI before the obtained data were transferred to the stereotactic biopsy system. Using a custom-made biplane TRUS probe mounted on a stepper device, 3D ultrasound data were generated to set the anatomic landmarks. Then MRI and TRUS imaging data were fused manually. As a result, the suspicious MRI lesions were superimposed onto the TRUS data. Next, 3D biopsy planning was performed including systematic biopsies from the peripheral and transitional zones of the prostate. Perineal biopsies were taken under live US imaging, and the location of each biopsy was documented in 3D. RESULTS: 14 out of 33 patients were diagnosed with prostate cancer. These results showed a positive correlation between MRI findings and histopathology in 22 out of 33 patients. In MRI lesions marked as highly suspicious, the detection rate was 100%. Evaluating the biopsies from lesions marked as highly and as questionable suspicious together, prostate cancer was detected in 27.95%. In comparison, only 8% of the additional systematic biopsies were positive. Target registration error of the first 554 biopsy cores was 1.9 mm. For adverse effects, one patient experienced urinary retention. Postinterventional hemorrhage or urinary tract infection did not occur. CONCLUSIONS: Perineal stereotactic prostate biopsies guided by the combination of MRI and ultrasound enable effective examination of suspicious MRI lesions. Additionally, each biopsy core taken may be documented accurately for its location in 3D. Thus, MRI data may be validated and different treatment options stratified in depth. At the same time the morbidity of the procedure was minimal.

Purpose: To report our experience with temsirolimus in 2nd-, 3rd- and 4th-line therapy for patients with metastatic renal cell carcinoma (mRCC). Patients and Methods: In our prospectively maintained tumor registry, we identified 6 mRCC patients with temsirolimus in >1st-line systemic therapy. Patients were followed by weekly clinical and laboratory examination during admission of temsirolimus. Re-staging with chest CT and abdominal MRI was performed every 3 months. Results: We observed excellent response rates. Progression-free survival (PFS) ranged from 6 to 40 months with a median of 15 months. Treatment was generally well tolerated. However, pneumonitis was observed in 4 of 6 patients. Drug-related pneumonitis led to severe dyspnea, with the result that treatment with temsirolimus had to be interrupted for a short period of time in 2 patients and discontinued in 1 patient. Conclusions: Temsirolimus proved to be a very good treatment option in 2nd- to 4th-line therapy with excellent response rates and manageable side effects. The incidence of pneumonitis must not be underestimated.

96 Background: In the search of optimized screening for prostate cancer (PCa), HistoScanning (HS) has been introduced to support detection and assessment of cancer foci. The aim of our study was the evaluation of the impact of HS in the diagnosis of prostate cancer by a comparison with the histopathological results after prostatectomy. Methods: 282 patients between 37 and 75 years with histologically confirmed, organ-confined PCa that were scheduled for radical prostatectomy underwent transrectal ultrasound prior to surgery. HS was evaluated compared to histology that was performed on removed prostates as to: 1) prediction of overall tumor volume and 2) accuracy of HS in detection of PCa lesions bigger than 0.2 or 0.5 ml, respectively, separated for each sextant. Results: HS tends to underestimate volume of cancerous lesions, particularly larger lesions > 8 ml. Using a 0.2 ml detection threshold, specificity and sensitivity of HS was between 29%-68% and 46-78%, depending on the sextant. For a 0.5 ml detection threshold, sextant-specific specificity increased to 59-92% and sensitivity decreased to 16-54%. Stratification according to pre-operational PSA-values did not improve performance characteristics of HS. Separate analysis of data from low grade tumor after d’Amico criteria showed that HS is not able to reliably detect these tumors. Conclusions: Overall, our study does not support a significant contribution of HS to PCa diagnostics.

176 Background: Androgen deprivation (ADT) represents the standard treatment for PCA with osseous metastases. We explored the role of cytoreductive radical prostatectomy in PCA with low volume skeletal metastases in terms of a feasibility study. Methods: 32 patients with biopsy proven PCA, minimal osseous metastases (≤ 3 hot spots on bone scan), absence of visceral or extensive lymph node metastases and PSA decrease to < 1.0 ng/ml after neoadjuvant ADT were included in the feasibility study. 38 men with metastatic PCA who were treated by ADT without local therapy served as control group (group B). Surgery-related complications, biochemical progression-free, symptomatic-free, cancer-specific and overall survival were analyzed using descriptive statistical analysis. Results: Mean age was 61 (42-69) and 64 (47-83) years in group A and B, respectively, with similar patient characteristics in terms of initial PSA, biopsy Gleason score, clinical stage, extent of metastatic disease. The mean follow-up was 40.6 (3-71) and 44 (24-96) months in group A and B, respectively. Pathohistology revealed vital PCA with metastatic potential in all 32 patients despite neoadjuvant ADT. 12% of pts in group A developed Clavien grade III complications. According to the ICSmaleSF questionnaire 30/32 (93.7%) pts were continent. Patients in group A experienced significantly better bPFS (36.8 versus 23.1 months, p=0.042), clinical PFS (38.6 versus 26.5 months, p=0.032) and cancer specific survival rate (95.6% versus 84.2%, p=0.043) whereas the overall survival was similar. 0% and 29% of men in group A and B, respectively, underwent palliative surgical procedures for locally progressing PCA. Conclusions: CRP is feasible with good functional and oncological results in well selected men with metastatic PCA who respond well to neoadjuvant ADT. These men have a long life expectancy and CRP reduces the risk of locally recurrent PCA and local complications. CRP might be a treatment option in the multimodality management of PCA with minimal osseous metastases.

Dear Editor, The report by Yadav et al. concerned 12 patients with abscesses within the prostate which were treated with transrectal ultrasound (TRUS) guided needle aspiration (1). Of these 12 patients, 4 had residual abscesses detected in a follow-up TRUS after 1 week and 3 needed further intervention. All patients were treated with antibiotics for 4 weeks. The treatment of acute prostatitis has frequently been described (2-5). There is wide consensus, that abscesses of the prostate which are visible in a TRUS should be evacuated (4). If the abscess is located in the transition zone of the prostate or concomitant benign prostatic hyperplasia is present, a transurethral resection of the prostatic tissue can also be performed (2). Abscess drainage can be accomplished using either aspiration alone or by temporary drainage placement. This decision should be based on the patient’s general condition, age, comorbidities and abscess volume. If such an intervention is needed, we would recommend the transperineal approach either for needle aspiration or drainage placement. This type of technique has been described previously (6). The advantage of the perineal approach is in preserving the integrity of the rectal wall and Denonvillier’s fascia to avoid further periprostatic or systemic spread of bacteria during the intervention, which could lead to general sepsis. Regarding the residual abscess rate of 33% (4/12) intermittent drainage instead of pure aspiration may have been a more appropriate treatment approach. However, this decision has to be made with consideration of all the patient’s clinical aspects at the time of admittance. Regardless of the intervention a 4-week antibiotic treatment according to the microbiology results is common standard practice.

e16063 Background: Precise staging of prostate cancer (PC) is essential for individualized treatment decisions. However, the majority of transrectal biopsies are negative for prostate cancer or show imprecise results. Additionally, the rate of upgrading in Gleason scores between biopsy and prostatectomy specimen is around 30-40%. MRI/TRUS fusion has shown encouraging results for detecting clinically significant prostate cancer. Methods: 412 consecutive patients with suspicion of PC were prospectively included in our database. The median age of patients was 65 years (range 42-84). Mean PSA level was 9.56 ng/ml (± 7.9ng/ml, SD). 55% of men had previous TRUS-guided biopsies, 45% underwent primary biopsy. Imaging data and biopsy results were analyzed and a self-designed questionnaire was send to all men regarding further clinical history and adverse effects of the biopsy. Results: In 236 of 412 (57.3%) biopsy samples showed PC. 71.6% of biopsy proven PC were clinically significant (D’Amico criteria). On multiparametric (mp)-MRI, 120 men were reported as highly suspicious for PC and in these tumor detection rate was 83.3% (100/120). In patients without cancer-suspicious MRI-lesions, 31,8% (42/132) men were diagnosed with significant disease (Table 1). Regarding adverse effects, 152 patients (49%) reported hematuria after biopsy. 9 patients (2%) needed temporary catheterization after biopsy due to prostate swelling. In three patients (0.7%) febrile urinary tract infection occurred after biopsy. Major limitation is the limited follow-up of 12-months of biopsy-negative patients. Conclusions: MRI-targeted TRUS-guided transperineal fusion biopsy provides high detection rates of clinically significant tumors. mp-MRI still has its limitations, and therefore systematic biopsies should currently not be omitted. The morbidity of the transperineal saturation approach is reasonable and mainly self-limiting. [Table: see text]