Search

INTRODUCTION AND OBJECTIVES: To report pathologic progression (PP) and curative intervention (CI) in 361 men on active surveillance (AS) in comparison between with and without use of 5alpha reductase inhibitors (5-ARI). METHODS: Total 361 patients were grouped: with use of 5-ARI (n1⁄4 119, 33%) or without use of 5-ARI (No 5-ARI), n1⁄4242 (67%). All the patients had at least two years of follow up and the median follow up time was 5.1 years for 5-ARI vs 5.3 years for No 5-ARI (p1⁄40.6). The AS protocol included PSA (6 monthly), multi-parametric transrectal ultrasound (TRUS) annually, and surveillance biopsy (2-3 yearly, or as indicated). PP was defined as upgrade on Gleason score, increase in cancer core length (>4mm) or percent (>25%), or clinical progression on the follow up. CI was defined as discontinuing AS to undergo any kind of curative or hormonal therapy. Clinical variables were compared between the two groups. Kaplan-Meier method was conducted to estimate survivals for PP and CI, and multivariable Cox regression for predictors of PP. RESULTS: At the entry, the two groups were similar: age (63 vs. 61yrs, p1⁄40.1), PSA (4.8 vs. 4.8ng/ml, p1⁄40.5), prostate volume on TRUS (41cc vs. 35cc, p1⁄40.1), clinical stage T1c/T2a (85%/13% vs. 90%/9%, p1⁄40.06), biopsy Gleason score (6/3þ4/4þ3 1⁄4 88%/10%/2% vs. 87%/11%/2%, p1⁄40.9), biopsy cancer core length (1.5mm vs. 1mm, p1⁄40.37) and percent (10% vs. 8.5%, p1⁄40.2) of index cancer, and number of positive cores (1 vs. 1, p1⁄40.1), respectively for 5-ARI vs No 5-ARI groups. Predictors of PP were: not taking 5-ARI (p1⁄40.017), entry PSA > 4ng/ml (p1⁄40.009) and Gleason pattern 4 in biopsy (p

We developed and assessed a technique of: (i) expanding Denonvilliers' space by hydrogel (polyethylene glycol) during focal cryoabation; and (ii) temperature mapping to ensure protection of the rectal wall. In a fresh cadaver, 20 cc of hydrogel was injected transperineally into Denonvilliers' space under transrectal ultrasound guidance. Successful expansion of Denonvilliers' space was achieved with a range of 9-11 mm thickness covering the entire posterior prostate surface. Two freeze-thaw cycles were used to expand the iceball reaching the rectal wall as an end-point. Intraoperative transrectal ultrasound monitoring and temperature mapping in Denonvilliers' space by multiple thermocouples documented real-time iceball expansion up to 10 mm beyond the prostate, and safety in protecting the rectal wall from thermal injury. The lowest temperatures of the thermocouples with a distance of 0 mm, 5 mm and 10 mm from the prostate were: -35°C, -18°C and 0°C (P < 0.001), respectively. In gross and microscopic examination, the hydrogel mass measured 11 × 40 × 34 mm, which was identical to the intraoperative transrectal ultrasound measurements, there was no infiltration of the hydrogel into the rectal wall or prostate and no injury to the pelvic organs. In conclusion, the expansion of Denonvilliers' space by transperineal injection of hydrogel is feasible and a promising technique to facilitate energy-based focal therapy of prostate cancer.

To assess the feasibility of a novel percutaneous navigation system (Translucent Medical, Inc., Santa Cruz, CA, USA) that integrates position-tracking technology with a movable tablet display.A total of 18 fiducial markers, which served as the target centres for the virtual tumours (target fiducials), were implanted in the prostate and kidney of a fresh cadaver, and preoperative computed tomography (CT) was performed to allow three-dimensional model reconstruction of the surgical regions, which were registered on the body intra-operatively. The position of the movable tablet's display could be selected to obtain the best recognition of the interior anatomy. The system was used to navigate the puncture needle (with position-tracking sensor attached) using a colour-coded, predictive puncture-line. When the operator punctured the target fiducial, another fiducial, serving as the centre of the ablative treatment (treatment fiducial), was placed. Postoperative CT was performed to assess the digitized distance (representing the real distance) between the target and treatment fiducials to evaluate the accuracy of the procedure.The movable tablet display, with position-tracking sensor attached, enabled the surgeon to visualize the three-dimensional anatomy of the internal organs with the help of an overlaid puncture line for the puncture needle, which also had a position-tracking sensor attached. The mean (virtual) distance from the needle tip to the target (calculated using the computer workstation), was 2.5 mm. In an analysis of each digitalized axial component, the errors were significantly greater along the z-axis (P0.01), suggesting that the errors were caused by organ shift or deformation.This virtual navigation system, integrating a position-tracking sensor with a movable tablet display, is a promising advancement for facilitating percutaneous interventions. The movable display over the patient shows a preoperative three-dimensional image that is aligned to the patient. Moving the display moves the image, creating the feeling of looking through a window into the patient, resulting in instant perception and a direct, intuitive connection between the physician and the anatomy.

Prostate biopsies targeted by elastic fusion of magnetic resonance (MR) and three-dimensional (3D) transrectal ultrasound (TRUS) images may allow accurate identification of the index tumor (IT), defined as the lesion with the highest Gleason score or the largest volume or extraprostatic extension.To determine the accuracy of MR-TRUS image-fusion biopsy in characterizing ITs, as confirmed by correlation with step-sectioned radical prostatectomy (RP) specimens.Retrospective analysis of 135 consecutive patients who sequentially underwent pre-biopsy MR, MR-TRUS image-fusion biopsy, and robotic RP at two centers between January 2010 and September 2013.Image-guided biopsies of MR-suspected IT lesions were performed with tracking via real-time 3D TRUS. The largest geographically distinct cancer focus (IT lesion) was independently registered on step-sectioned RP specimens.A validated schema comprising 27 regions of interest was used to identify the IT center location on MR images and in RP specimens, as well as the location of the midpoint of the biopsy trajectory, and variables were correlated.The concordance between IT location on biopsy and RP specimens was 95% (128/135). The coefficient for correlation between IT volume on MRI and histology was r=0.663 (p0.001). The maximum cancer core length on biopsy was weakly correlated with RP tumor volume (r=0.466, p0.001). The concordance of primary Gleason pattern between targeted biopsy and RP specimens was 90% (115/128; κ=0.76). The study limitations include retrospective evaluation of a selected patient population, which limits the generalizability of the results.Use of MR-TRUS image fusion to guide prostate biopsies reliably identified the location and primary Gleason pattern of the IT lesion in90% of patients, but showed limited ability to predict cancer volume, as confirmed by step-sectioned RP specimens.Biopsies targeted using magnetic resonance images combined with real-time three-dimensional transrectal ultrasound allowed us to reliably identify the spatial location of the most important tumor in prostate cancer and characterize its aggressiveness.

patients > 69 years ranged from 42% to 86% for individual practices (p1⁄40.0008). For patients with PSA 60 cc were less likely to predict prostate cancer detection than size < 30 cc (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.440.64 and OR 0.23, 95% CI 0.18-0.29, respectively). CONCLUSIONS: Cancer detection rates are higher than previously reported. Practice patterns and cancer yield for prostate biopsy vary widely across urology practices in Michigan. These data serve as a foundation for our efforts to understand and improve patient selection for prostate biopsy.

INTRODUCTION AND OBJECTIVES: The aim of this study is to compare the characteristics of the biopsy-proven cancer between magnetic resonance imaging (MRI)-fusion-guided targeted biopsy and transrectal ultrasound (TRUS) systematic random biopsy on the consecutive patients who underwent multi-parametric MRI prior to biopsy. METHODS: Between January 2010 and September 2012, 131 consecutive patients underwent both pre-biopsy MRI (T2w-, DWI/ADC, and contrast enhanced MRI using 3 Tesla body-coil) and outpatient TRUS biopsy using the real-time 3-dimensional (3D) TRUS-tracking system (Urostation®, Koelis, France), which enabled MR/US fusion targeted biopsies. It was realized by the same operator. If MRI suggested a concerned focal lesion, 3D volume data of the MRI was elastically fused with TRUS at the time of biopsy. The MRI suggested the concerned focal lesion in 87 of the 131 patients (66.5%). Overall 1483 systematic biopsies (SB) and 255 MRI fusion targeted biopsies (MR-TB) were performed. The mean number of cores per patients was 11.3 for SB and 2.9 for MR-TB for patients who had prior MRI. RESULTS: Of the 131 patients the mean age (65 years), PSA (8.15ng/ml), and prostate volume (52 ml). 74 (57%) of the 131 patients had positive biopsy for cancer. In comparison of cancer detection rate per patient: 45% for SB versus 53.4% for MR-TB (p 0.003). In comparison of cancer detection rate per core: only 12.5% (185/1483) of the SB cores versus 43.5% (111/255) for MR-TB (p 0.004). Using a criteria for clinical significant cancer on biopsy defined as Gleason 4 3 or/and cancer core length of 5mm or greater, 34 patients of 46 (70%) were determined as significant cancer by MR-TB whereas only 23 patients (40%) by SB (p 0.031). The median cancer core length (CCL) and the primary Gleason grade (PGG) were significantly higher in patients with MR-TB: CCL 7.51mm [0.5-18] and PGG 3.75 and only CCL 4.12mm [0.3-15] (p 0.00005) and PGG 3.29 for SB (p 0.03). In all cases the spatial location of each biopsy was documented using 3D TRUS-image based tracking technique, to document accurate localization of the biopsy-proven cancer, allowing per-lesion based follow-up. CONCLUSIONS: MR-fusion-guided targeted prostate biopsy identifies greater cancer core involvement and higher Gleason grade in comparison to systematic image-blind random biopsies. Image-based targeted biopsy using pre-biopsy MRI and documentation of cancer location would enhance per-lesion based management of prostate cancer.