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We have developed a 3-D acoustic radiation force impulse (ARFI) prostate imaging system to identify regions suspicious for cancer and guide a targeted prostate biopsy in a single visit. The system uses a side-fire transrectal probe and an automated rotation stage to acquire ARFI and B-mode image volumes, combined with 3-D visualization and targeting software to enable biopsy target identification and guide a transperineal (TP) biopsy. The system was tested in the first clinical trial of its kind, with subjects serially undergoing ARFI-guided targeted TP biopsy, multiparametric magnetic resonance imaging (mpMRI)-ultrasound fusion TP biopsy, and systematic sampling TP biopsy. The findings indicate that the ARFI system is feasible for guiding a targeted biopsy. For lower-grade cancer (grade groups [GG] 1-2), ARFI underperformed mpMRI and systematic sampling, detecting cancer in 54% of GG 2 subjects. However, ARFI performance improved with increasing cancer grade; for higher-grade cancer (GG 3-5), ARFI performed comparably to the other biopsy approaches, and detected cancer in all GG 4 and 5 subjects. The findings also suggest the benefit of using 2-D ARFI imaging to confirm target location during live B-mode imaging, which could improve existing ultrasonic fusion biopsy workflows. This study is registered with ClinicalTrials.gov as NCT04607135., Competing Interests: Declaration of Conflicting InterestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: K. R. Nightingale and M. L. Palmeri have intellectual property related to radiation force-based imaging technologies that has been licensed to Siemens, Samsung, and MicroElastic Ultrasound Systems.

The lack of accuracy in the current prostate specific antigen (PSA) test for prostate cancer (PCa) screening causes around 60-75% of unnecessary prostate biopsies. Therefore, alternative diagnostic methods that have better accuracy and can prevent over-diagnosis of PCa are needed. Researchers have examined various potential biomarkers for PCa, and of those fatty acids (FAs) markers have received special attention due to their role in cancer metabolomics. It has been noted that PCa metabolism prefers FAs over glucose substrates for continued rapid proliferation. Hence, we proposed using a urinary FAs based model as a non-invasive alternative for PCa detection. Urine samples collected from 334 biopsy-designated PCa positive and 232 biopsy-designated PCa negative subjects were analyzed for FAs and lipid related compounds by stir bar sorptive extraction coupled with gas chromatography/mass spectrometry (SBSE-GC/MS). The dataset was split into the training (70%) and testing (30%) sets to develop and validate logit models and repeated for 100 runs of random data partitioning. Over the 100 runs, we confirmed the stability of the models and obtained optimal tuning parameters for developing the final FA based model. A PSA model using the values of the patients' PSA test results was constructed with the same cohort for the purpose of comparing the performances of the FA model against PSA test. The FA final model selected 20 FAs and rendered an AUC of 0.71 (95% CI = 0.67-0.75, sensitivity = 0.48, and specificity = 0.83). In comparison, the PSA model performed with an AUC of 0.51 (95% CI = 0.46-0.66, sensitivity = 0.44, and specificity = 0.71). The study supports the potential use of urinary FAs as a stable and non-invasive alternative test for PCa diagnosis., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Noriega Landa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To assess Duke's experience on the utility of transperineal template mapping biopsy (TTMB) for re-evaluating patients with persistently elevated prostate-specific antigen after prior negative biopsy, with pre-existing prostate cancer (PCa) already on active surveillance (AS), or considering focal therapy (FT)., Methods: We retrospectively reviewed Duke patients undergoing TTMB. Functional outcomes were evaluated using International Index of Erectile Function-5 (IIEF-5) and International Prostate Symptom Score (IPSS). Complications within 30 days were recorded. Nonparametric statistical analyses compared functional measures from baseline to 2 and 6 weeks post-TTMB., Results: From 8/2009 to 1/2021, 218 patients underwent TTMB, with 57-month median follow-up. Complication rate was 17.4%, with the majority Clavien I. Overall PCa detection was 72.9%, with clinically significant PCa in 53.2%; for those without prior PCa diagnosis (n = 117), overall detection was 64.1% with clinically significant PCa in 49.5%. Of those on AS at TTMB (n = 86), 36 (41.8%) had Gleason upgrading. TTMB changed management for 59 (68.6%) patients, with 38 (44.2%) proceeding to whole-gland therapy and 21 (24.4%) electing FT. Regarding functional outcomes, IPSS were insignificantly different from baseline at 6 weeks (P = NS). Overall functional score impacts were minimal across subgroups; in groups with significant declines in IIEF-5, median score drops were ≤1 point and caused minimal/no movement in IIEF-5 scoring category., Conclusion: In this cohort, TTMB offered enhanced cancer detection with overall minimal impact to functional outcomes. We conclude from this comprehensive assessment that TTMB provides value to rule out PCa, prevent overtreatment of those that can remain on AS, evaluate FT candidacy, and identify those needing whole-gland management., Competing Interests: DECLARATION OF COMPETING INTEREST None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

There is uncertainty with how to proceed when targeted prostate biopsy of suspicious multiparametric magnetic resonance imaging (mpMRI) lesions return without clinically significant prostate cancer (csPCa). While possible, there are error sources that could contribute to such discordance including the mpMRI read, mpMRI-ultrasound fusion, biopsy technique, and histologic classification. Consequences are potentially significant; mistakenly missing csPCa can lead to delays in curative treatment. Conversely, in cases of incorrect mpMRI interpretation, the patient may be subjected to unnecessary workup/burden. At our institution, we implemented a quality improvement (QI) initiative triggered after a discordant case occurs. This multidisciplinary review process incorporates mpMRI re-review and assessment of accurate lesion-sampling, termed "reverse-fusion." Herein, we describe the protocol, present sample cases, and discuss clinical implications., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Prostate multiparametric magnetic resonance imaging (mpMRI) can identify lesions within the prostate with characteristics identified in Prostate Imaging Reporting and Data System (PI-RADS) v2.1 associated with clinically significant prostate cancer (csPCa) or Gleason grade group (GGG) ≥ 2 at biopsy., Objective: To assess concordance (PI-RADS 5 lesions with csPCa) of PI-RADS v2/2.1 with targeted, fusion biopsy results and to examine causes of discordance (PI-RADS 5 lesions without csPCa) with aim to provide a structured approach to resolving discordances and develop quality improvement (QI) protocols., Methods: A retrospective study of 392 patients who underwent mpMRI at 3 Tesla followed by fusion biopsy. PI-RADS v2/2.1 scores were assigned to lesions identified on mpMRI and compared to biopsy results expressed as GGG. Positive predictive value (PPV) of PI-RADS v2/2.1 was calculated for all prostate cancer and csPCa. Discordant cases were re-reviewed by a radiologist with expertise in prostate mpMRI to determine reason for discordance., Results: A total of 521 lesions were identified on mpMRI. 121/521 (23.2%), 310/524 (59.5%), and 90/521 (17.3%) were PI-RADS 5, 4, and 3, respectively. PPV of PI-RADS 5, 4, and 3 for all PCa and csPCa was 0.80, 0.55, 0.24 and 0.63, 0.33, and 0.09, respectively. 45 cases of discordant biopsy results for PI-RADS 5 lesions were found with 27 deemed "true" discordances or "unresolved" discordances where imaging re-review confirmed PI-RADS appropriateness, while 18 were deemed "false" or resolved discordances due to downgrading of PI-RADS scores based on imaging re-review. Adjusting for resolved discordances on re-review, the PPV of PI-RADS 5 lesions for csPCa was deemed to be 0.74 and upon adjusting for presence of csPCa found in cases of unresolved discordance, PPV rose to 0.83 for PI-RADS 5 lesions., Conclusion: Although PIRADS 5 lesions are considered high risk for csPCa, the PPV is not 100% and a diagnostic dilemma occurs when targeted biopsy returns discordant. While PI-RADS score is downgraded in some cases upon imaging re-review, a number of "false" or "unresolved" discordances were identified in which MRI re-review confirmed initial PI-RADS score and subsequent pathology confirmed presence of csPCa in these lesions., Clinical Impact: We propose a structured approach to resolving discordant biopsy results using multi-disciplinary re-review of imaging and archived biopsy strikes as a quality improvement pathway. Further work is needed to determine the value of re-biopsy in cases of unresolved discordance and to develop robust QI systems for prostate MRI., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: To introduce and assess the efficacy of a Reduced Core Targeted (RCT) biopsy template (image-targeted + laterally directed sextant biopsy) to detect clinically-significant cancer in patients with elevated PSA and a previous negative biopsy or on active surveillance. The performance and added value of either targeted alone vs random sextant vs combined biopsy template was appraised., Methods: Data from 113 patients with a suspicious lesion on mpMRI and previous history of extended 10-12 core standard biopsy who subsequently had a RCT-biopsy were analyzed. These patients had at least one prior negative standard 10-12 core biopsy (n = 70) or were on active surveillance (n = 43). At least two samples were taken from each mpMRI lesion as a targeted biopsy together with the classic laterally-directed sextant biopsy., Results: In patients having previous negative biopsy (n = 70), the RCT biopsy detected any cancer versus clinically-significant cancer in 62.9% versus 32.9%, respectively. Targeted biopsy diagnosed more clinically-significant cancers than sextant biopsy (31.4% versus 25.7%, p < 0.01). In this cohort, the use of targeted fusion biopsy upgraded the biopsy grade group (GrGp) in 15 (21.4%) patients compared to sextant biopsy. In patients on active surveillance, the RCT biopsy identified any cancer versus clinically-significant cancer for detection rates of 74.4% versus 39.5%, respectively. Fusion targeted biopsy diagnosed more clinically-significant cancers than sextant biopsy did (37.2% versus 18.6%, p = 0.002). The use of targeted biopsy upgraded the biopsy GrGp in 12 (27.9%) patients., Conclusion: As a preliminary study, among men with MRI suspicious lesions and previous negative prostate biopsy or those under active surveillance, an image-targeted plus sextant biopsy platform can be associated with increased efficiency of detecting clinically-significant prostate cancer with fewer random cores. Future large series are needed to validate the clinical implication of this reduced core template in comparison with targeted fusion biopsy plus standard 12-core schema., (Published by Elsevier B.V.)

Purpose: We assessed the predictive value of prostate specific antigen density to detect clinically significant prostate cancer, defined as prostate cancer grade group 2 or greater, in a series of men undergoing prostate biopsy with prostate specific antigen 4 to 10 ng/ml. We sought to define an optimum cutoff point for prostate specific antigen density and assess how race and body mass index affects prostate specific antigen density performance., Materials and Methods: We analyzed data on 2,162 men, of whom 56% were African American, with serum prostate specific antigen 4 to 10 ng/ml who underwent prostate biopsy. We compared the AUC between prostate specific antigen and prostate specific antigen density to predict clinically significant and any prostate cancer vs no cancer. We calculated the negative predictive value of prostate specific antigen density cutoff points ranging from 0.05 to 0.15 by every 0.01 step. We a priori defined the optimal cutoff point of prostate specific antigen density as a negative predictive value of 95% and tested whether the cutoff was sensitive to body mass index and race by comparing the negative predictive value across strata., Results: Median prostate specific antigen was 5.6 ng/ml (IQR 4.8-7) and median prostate specific antigen density was 0.15 ng/ml/cc (IQR 0.1-0.22). Prostate specific antigen density improved the performance of prostate specific antigen to detect significant cancer (AUC 0.58 to 0.68) and any cancer (AUC 0.55 to 0.69, each p <0.001). We identified a prostate specific antigen density cutoff point of less than 0.08 ng/ml/cc with a 96% negative predictive value for grade group 2 or greater. This was largely unchanged among different races and body mass indexes., Conclusions: Regardless of race or body mass index men with prostate specific antigen density less than 0.08 were unlikely to harbor grade group 2 or greater disease when prostate specific antigen was 4 to 10 ng/ml. If validated, prostate specific antigen density is a simple inexpensive and available tool that can be used to identify men who can likely forego prostate biopsies, thus reducing the over detection and morbidity of unnecessary biopsies., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The 4Kscore® test accurately detects aggressive prostate cancer and reduces unnecessary biopsies. However, its performance in African American men has been unknown. We assessed test performance in a cohort of men with a large African American representation., Materials and Methods: Men referred for prostate biopsy at 8 Veterans Affairs medical centers were prospectively enrolled in the study. All men underwent phlebotomy for 4Kscore test assessment prior to prostate biopsy. The primary outcome was the detection of Grade Group 2 or higher cancer on biopsy. We assessed the discrimination, calibration and clinical usefulness of 4Kscore to predict Grade Group 2 or higher prostate cancer and compared it to a base model consisting of age, digital rectal examination and prostate specific antigen. Additionally, we compared test performance in African American and nonAfrican American men., Results: Of the 366 enrolled men 205 (56%) were African American and 131 (36%) had Grade Group 2 or higher prostate cancer. The 4Kscore test showed better discrimination (AUC 0.81 vs 0.74, p <0.01) and higher clinical usefulness on decision curve analysis than the base model. Test prediction closely approximated the observed risk of Grade Group 2 or higher prostate cancer. There was no difference in test performance in African American and nonAfrican American men (0.80 vs 0.84, p = 0.32), The test outperformed the base model in each group., Conclusions: The 4Kscore test accurately predicts aggressive prostate cancer for biopsy decision making in African American and nonAfrican American men., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the diagnostic properties of multiparametric magnetic resonance imaging in the detection, localization and characterization of prostate cancer using three-dimensional transperineal template mapping biopsy histopathology as the comparator., Methods: A retrospective analysis of patients undergoing prostate multiparametric magnetic resonance imaging followed by three-dimensional transperineal template mapping biopsy was carried out. For imaging and pathology data, the prostate was divided in octants with the urethra being the midline. The index test properties were calculated using the biopsy histopathology as the reference test with the following end-points: any cancer, any Gleason ≥7, any Gleason ≥7 or cancer length of ≥4 mm and any Gleason ≥7 or 6 mm in any given core. The latter two definitions correspond to 0.2 and 0.5 mL of cancer volume, respectively. Diagnostic properties including sensitivity, specificity, positive and negative predictive values were calculated., Results: A total of 50 patients were included in the study. A median of 55 (interquartile range 42-63) biopsy cores were obtained per patient. Of 400 prostate octants evaluated, 28.5% had prostate cancer on mapping biopsy, whereas 23% of octants were considered suspicious for cancer on imaging. Multiparametric magnetic resonance imaging negative predictive values for Gleason ≥7 and clinically significant cancers were 84-100%. Similarly, specificity ranged between 79% and 85%. Sensitivity and positive predictive value remained moderate for all the reference test definitions., Conclusions: Multiparametric magnetic resonance imaging is a useful minimally-invasive tool for detection, localization and characterization of prostate cancer. This imaging modality has high negative predictive value and specificity, and therefore it could be used to reliably rule out clinically significant cancer, obviating the multicore mapping biopsy., (© 2016 The Japanese Urological Association.)

Context: Focal therapy of prostate cancer has been proposed as an alternative to whole-gland treatments., Objective: To summarize the evidence regarding sources of energy employed in focal therapy., Evidence Acquisition: Embase and Medline (PubMed) were searched from 1996 to October 31, 2015 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Ongoing trials were selected from electronic registries. The stage of assessment of each source of energy was determined using the Idea, Development, Exploration, Assessment, Long-term study recommendations., Evidence Synthesis: Thirty-seven articles reporting on 3230 patients undergoing focal therapy were selected. Thirteen reported on high-intensity focused ultrasound, 11 on cryotherapy, three on photodynamic therapy, four on laser interstitial thermotherapy, two on brachytherapy, three on irreversible electroporation, and one on radiofrequency. High-intensity focused ultrasound, cryotherapy, photodynamic therapy, and brachytherapy have been assessed in up to Stage 2b studies. Laser interstitial thermotherapy and irreversible electroporation have been evaluated in up to Stage 2a studies. Radiofrequency has been evaluated in one Stage 1 study. Median follow-up varied between 4 mo and 61 mo, and the median rate of serious adverse events ranged between 0% and 10.6%. Pad-free leak-free continence and potency were obtained in 83.3-100% and 81.5-100%, respectively. In series with intention to treat, the median rate of significant and insignificant disease at control biopsy varied between 0% and 13.4% and 5.1% and 45.9%, respectively. The main limitations were the length of follow-up, the absence of a comparator arm, and study heterogeneity., Conclusions: Focal therapy has been evaluated using seven sources of energy in single-arm retrospective and prospective development studies up to Stage 2b. Focal therapy seems to have a minor impact on quality of life and genito-urinary function. Oncological effectiveness is yet to be defined against standard of care., Patient Summary: Seven sources of energy have been employed to selectively ablate discrete areas of prostate cancer. There is high evidence that focal therapy is safe and has low detrimental impact on continence and potency. The oncological outcome has yet to be evaluated against standard of care., (Copyright © 2016 European Association of Urology. All rights reserved.)

Unlabelled: Multiparametric magnetic resonance imaging (mpMRI) is increasingly used in staging early prostate cancer (PCa) but remains heavily reader-dependent. We aim to define the incremental utility of mpMRI over clinical parameters in determining the pathologic extracapsular extension (pECE) of PCa interpreted in a standard radiologic setting and when further over-read by a specialized reader. We retrospectively reviewed 120 men with clinically localized PCa undergoing mpMRI and radical prostatectomy. We obtained radiologic prediction of pECE from standard radiologic reports (standard read) and by a specialized reader blinded to clinical and pathologic findings (specialized read). We determined the incremental benefit of standard read and specialized read by sequential addition to a baseline clinical parameters-only logistic regression model predicting pECE. The sensitivity and specificity of standard read were 77% and 44%, respectively, whereas those of specialized read were 86% and 81%. The positive likelihood ratio was 1.7 at baseline, 1.7 adding standard read, and 6.5 adding specialized read. The negative likelihood ratio was 0.6 at baseline, 0.5 adding standard read, and 0.1 adding specialized read. Standard read modestly improved prediction of pECE, whereas specialized read improved it moderately., Patient Summary: The incremental benefit of mpMRI over clinical information is small but increases to moderate with a specialized second opinion. This second opinion may be useful when considering active surveillance, nerve-sparing surgery, or focal therapy., (Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose of Review: In the absence of whole gland treatment for prostate cancer, both active surveillance and focal therapy share the common need of requiring a more thorough, detailed and precise analysis of the biological threats within the prostatic parenchyma if one chooses to monitor or selectively eradicate only specific neoplastic targets. In addition, focal therapy utilizes active surveillance post-treatment to monitor the untreated sectors of the prostate. We aim to evaluate the current modalities available to modernize active surveillance protocols in order to distinguish patients who may be safely observed from those who require intervention., Recent Findings: Traditional active surveillance protocols by today's standards are rudimentary given the rapidly evolving technologies now available to clinicians. There is growing evidence for the adoption and use of multiparametric MRI and MRI-targeted biopsy to identify and localize prostate cancers of higher stage and grade. In addition, serum markers and prostate tissue DNA, RNA and methylation markers provide novel information that extends beyond Gleason grade to better characterize and define prostate cancer prognosis. Current active surveillance protocols should incorporate these modalities to improve patient stratification to surveillance, focal or whole gland interventions., Summary: Active surveillance protocols should be modernized to include cancer localization modalities and molecular prognostic markers to improve tumour characterization and better stratify men to surveillance, focal or radical intervention.

Background: Focal therapy as a treatment option for localized prostate cancer (PCa) is an increasingly popular and rapidly evolving field., Objective: To gather expert opinion on patient selection, interventions, and meaningful outcome measures for focal therapy in clinical practice and trial design., Design, Setting, and Participants: Fifteen experts in focal therapy followed a modified two-stage RAND/University of California, Los Angeles (UCLA) Appropriateness Methodology process. All participants independently scored 246 statements prior to rescoring at a face-to-face meeting. The meeting occurred in June 2013 at the Royal Society of Medicine, London, supported by the Wellcome Trust and the UK Department of Health., Outcome Measurements and Statistical Analysis: Agreement, disagreement, or uncertainty were calculated as the median panel score. Consensus was derived from the interpercentile range adjusted for symmetry level., Results and Limitations: Of 246 statements, 154 (63%) reached consensus. Items of agreement included the following: patients with intermediate risk and patients with unifocal and multifocal PCa are eligible for focal treatment; magnetic resonance imaging-targeted or template-mapping biopsy should be used to plan treatment; planned treatment margins should be 5mm from the known tumor; prostate volume or age should not be a primary determinant of eligibility; foci of indolent cancer can be left untreated when treating the dominant index lesion; histologic outcomes should be defined by targeted biopsy at 1 yr; residual disease in the treated area of ≤3 mm of Gleason 3+3 did not need further treatment; and focal retreatment rates of ≤20% should be considered clinically acceptable but subsequent whole-gland therapy deemed a failure of focal therapy. All statements are expert opinion and therefore constitute level 5 evidence and may not reflect wider clinical consensus., Conclusions: The landscape of PCa treatment is rapidly evolving with new treatment technologies. This consensus meeting provides guidance to clinicians on current expert thinking in the field of focal therapy., Patient Summary: In this report we present expert opinion on patient selection, interventions, and meaningful outcomes for clinicians working in focal therapy for prostate cancer., (Copyright © 2014 The Authors. Published by Elsevier B.V. All rights reserved.)

Prostate cancer (PCa) is the most common non-cutaneous malignancy among men in the United States and the second leading cause of cancer-related death. Multi-parametric magnetic resonance imaging (mpMRI) has gained recent popularity to characterize PCa. Acoustic Radiation Force Impulse (ARFI) imaging has the potential to aid PCa diagnosis and management by using tissue stiffness to evaluate prostate zonal anatomy and lesions. MR and B-mode/ARFI in vivo imaging datasets were compared with one another and with gross pathology measurements made immediately after radical prostatectomy. Images were manually segmented in 3D Slicer to delineate the central gland (CG) and prostate capsule, and 3D models were rendered to evaluate zonal anatomy dimensions and volumes. Both imaging modalities showed good correlation between estimated organ volume and gross pathologic weights. Ultrasound and MR total prostate volumes were well correlated (R(2) = 0.77), but B-mode images yielded prostate volumes that were larger (16.82% ± 22.45%) than MR images, due to overestimation of the lateral dimension (18.4% ± 13.9%), with less significant differences in the other dimensions (7.4% ± 17.6%, anterior-to-posterior, and -10.8% ± 13.9%, apex-to-base). ARFI and MR CG volumes were also well correlated (R(2) = 0.85). CG volume differences were attributed to ARFI underestimation of the apex-to-base axis (-28.8% ± 9.4%) and ARFI overestimation of the lateral dimension (21.5% ± 14.3%). B-mode/ARFI imaging yielded prostate volumes and dimensions that were well correlated with MR T2-weighted image (T2WI) estimates, with biases in the lateral dimension due to poor contrast caused by extraprostatic fat. B-mode combined with ARFI imaging is a promising low-cost, portable, real-time modality that can complement mpMRI for PCa diagnosis, treatment planning, and management., (© The Author(s) 2014.)

Purpose: To evaluate the impact of dedicated reader education on accuracy/confidence of peripheral zone index cancer and anterior prostate cancer (PCa) diagnosis with mpMRI; secondary aim was to assess the ability of readers to differentiate low-grade cancer (Gleason 6 or below) from high-grade cancer (Gleason 7+)., Materials and Methods: Five blinded radiology fellows evaluated 31 total prostate mpMRIs in this IRB-approved, HIPAA-compliant, retrospective study for index lesion detection, confidence in lesion diagnosis (1-5 scale), and Gleason grade (Gleason 6 or lower vs. Gleason 7+). Following a dedicated education program, readers reinterpreted cases after a memory extinction period, blinded to initial reads. Reference standard was established combining whole mount histopathology with mpMRI findings by a board-certified radiologist with 5 years of prostate mpMRI experience., Results: Index cancer detection: pre-education accuracy 74.2%; post-education accuracy 87.7% (p = 0.003). Confidence in index lesion diagnosis: pre-education 4.22 ± 1.04; post-education 3.75 ± 1.41 (p = 0.0004). Anterior PCa detection: pre-education accuracy 54.3%; post-education accuracy 94.3% (p = 0.001). Confidence in anterior PCa diagnosis: pre-education 3.22 ± 1.54; post-education 4.29 ± 0.83 (p = 0.0003). Gleason score accuracy: pre-education 54.8%; post-education 73.5% (p = 0.0005)., Conclusions: A dedicated reader education program on PCa detection with mpMRI was associated with a statistically significant increase in diagnostic accuracy of index cancer and anterior cancer detection as well as Gleason grade identification as compared to pre-education values. This was also associated with a significant increase in reader diagnostic confidence. This suggests that substantial interobserver variability in mpMRI interpretation can potentially be reduced with a focus on education and that this can occur over a fellowship training year.

Objective: To evaluate side-effects, erectile function and capability to preserve adjacent tissues of bilateral focal prostate ablation using low-energy direct current (LEDC) in a canine model., Materials and Methods: In all, 12 male Beagle dogs underwent bilateral focal prostate ablation using the NanoKnife™ LEDC system. Three 19 G monopolar electrodes were transperineally placed on each side of the prostate under transrectal ultrasonographic (TRUS) guidance using a triangular probe array. Intra- and postoperative side-effects were recorded. Erectile function was evaluated at baseline and 4-5 and 26-27 days after ablation. The dogs were killed humanely at 7 (six) and 30 days (six) for gross and microscopic evaluation of the prostate and adjacent organs., Results: The median (range) prostate volume on TRUS was 12.1 (8.9-17.2) mL. The electrodes were placed at a median distance of 0.55-0.66 cm from the capsule, urethra and rectum. All procedures were completed successfully and recovery was uneventful. There were no episodes of urinary retention. All the dogs were able to achieve erections after ablation. Pathological analyses revealed inflammatory changes in the ablation zone at 7 days and replacement by fibrosis at 30 days. On microscopic examination no histological injury to the capsule, urethra, rectal wall or nervous structures was identified., Conclusions: In this study, bilateral focal prostate ablation using LEDC was safe and had a favourable side-effects profile limited to transient minor events. LEDC ablation effectively spared adjacent structures as well as physiological functions in all the dogs., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objective: To assess the complications and erectile and urinary functional outcomes of transperineal template mapping biopsy (TTMB) of the prostate., Methods: We retrospectively reviewed the records of 84 patients undergoing TTMB at our institution and recorded complications and functional outcomes. Erectile and urinary functions were measured at baseline, 2 weeks, and 6 ± 2 weeks after TTMB using the International Index of Erectile Function short version (IIEF-5) and International Prostate Symptom Score questionnaires. Erectile and urinary function parameters were compared between baseline and 2 and 6 weeks after TTMB in a paired fashion. A subanalysis of erectile function was performed in preoperatively potent men (IIEF-5 >17)., Results: Sixteen patients (19%) experienced complications. The most common events were transient urinary retention (6%), prostatitis (4%) and local events, including perineal hematoma, bruising, or perineal pain (5%). One patient with hematuria required intervention. IIEF-5 scores at baseline, 2 weeks, and 6 weeks were 20 (interquartile range [IQR], 16-23), 18 (IQR, 12-22), and 18 (IQR, 12-22), respectively (P = .096 and P = .034). Among preoperatively potent men, IIEF-5 scores at baseline, 2 weeks, and 6 weeks were 22 (IQR, 20-24), 21 (IQR, 18-24), and 22 (IQR, 18-24), respectively (P = .011 and P = .018). International Prostate Symptom Scores were 6 (IQR, 3.5-11) at baseline, rose to 10 (IQR, 4.8-15) at 2 weeks (P = .012), and returned to 7 (IQR, 3.5-13) at 6 weeks (P = .628)., Conclusion: TTMB has a favorable morbidity profile, with mostly mild and transient complications. Urinary retention occurred in 6%, and only 1 patient required intervention with bladder irrigation. Despite a statistically significant decline in erectile function from baseline, the median change in IIEF-5 score was 1 point. Urinary symptoms worsened initially but returned to baseline within 6 weeks., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: Prostate cancer (CaP) cryosurgery utilizes PSA nadir level and radiotherapy criteria as surrogates for success. We attempted to correlate PSA doubling time (PSAdt) and time of undetectable PSA (TUPSA) with biopsy-proven cancer recurrence (BPR) in men treated with primary third-generation cryotherapy for clinically localized CaP., Materials and Methods: Demographic, clinical, and pathologic data was retrieved including age, race, use of preoperative hormones or 5-α reductase inhibitors (5-ARIs), initial biopsy PSA, biopsy Gleason score, cT stage, prostate volume, presence/absence median lobe, and follow-up. Post-cryotherapy biopsy was considered for PSA levels ≥ 0.5 ng/ml. PSAdt was determined by the log-slope method. TUPSA was defined as time from surgery to a PSA value ≥ 0.2 ng/ml or most recent follow-up if undetectable., Results: Ninety-seven patients were identified. Preoperative hormonal manipulation was used in 25 (26%); 5 (5%) were using a 5-ARI. Twenty-seven (29%) underwent post-cryotherapy biopsy, 12 (12%) had a BPR. In 41 (42%), PSAdt was calculated (median 11.9 months, IQR 6.6-34.8); no significant difference between patients with BPR and without CaP was found (P = 0.46). TUPSA was a median of 4.9 months (IQR 3.2-9.9) vs. 15.6 months (IQR 6.1-30.3) for BPR or no CaP, respectively (P = 0.005). On proportional hazards regression, TUPSA was the only independent predictor of BPR (P = 0.03, OR 0.91)., Conclusions: Post-cryosurgery PSAdt does not appear to be associated with BPR risk, whereas TUPSA reduces the risk of BPR by 9% per month. This may help guide management if local failure is suspected., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Previous observational studies have reported associations between prostate cancer and alpha-linolenic acid (ALA). However, few investigations have been able to study this relationship prospectively and in well-controlled settings. Moreover, no studies have determined whether single nucleotide polymorphisms (SNPs) that influence ALA metabolism are associated with this common cancer. The purpose of this study was to explore associations between prostatic levels of ALA, SNPs and prostate cancer-specific biomarkers in samples collected from a previous randomized clinical trial conducted using a presurgical model and which tested the effects of flaxseed supplementation, a rich source of ALA, prior to prostatectomy (n = 134). Serum prostate-specific antigen (PSA) was determined and immunohistochemistry was used to assess tumor proliferation rate (Ki67). Prostatic ALA was determined with gas chromatography. Seven previously identified SNPs associated with delta-6 desaturase activity (rs99780, rs174537, rs174545, rs174572, rs498793, rs3834458 and rs968567) were tested for associations with prostatic ALA, PSA and Ki67. Despite consuming seven times more ALA per day, men in the flaxseed arm had similar amounts of prostatic ALA relative to men not consuming flaxseed. In unadjusted analysis, there were significant positive associations between prostatic ALA and PSA (ρ = 0.191, p = 0.028) and Ki67 (ρ = 0.186, p = 0.037). After adjusting for covariates (flaxseed, age, race, BMI and statin-use) the association between ALA and PSA remained (p = 0.004) but was slightly attenuated for Ki67 (p = 0.051). We did not observe associations between any of the SNPs studied and prostatic ALA; however, in models for PSA there was a significant interaction between rs498793 and ALA and for Ki67 there were significant interactions with ALA and rs99780 and rs174545. Independent and inverse associations were observed between rs174572 and Ki67. This study provides evidence that prostatic ALA, independent of the amount of ALA consumed, is positively associated with biomarkers of aggressive prostate cancer and that genetic variation may modify this relationship.

Reliably detecting prostate cancer (PCa) has been a challenge for current imaging modalities. Acoustic radiation force impulse (ARFI) imaging is an elasticity imaging method that uses remotely generated, focused acoustic beams to probe tissue stiffness. A previous study on excised human prostates demonstrated ARFI images portray various prostatic structures and has the potential to guide prostate needle biopsy with improved sampling accuracy. The goal of this study is to demonstrate the feasibility of ARFI imaging to portray internal structures and PCa in the human prostate in vivo. Custom ARFI imaging sequences were designed and implemented using a modified Siemens Antares™ scanner with a three-dimensional (3-D) wobbler, end-firing, trans-cavity transducer, EV9F4. Nineteen patients were consented and imaged immediately preceding surgical prostatectomy. Pathologies and anatomic structures were identified in histologic slides by a pathologist blinded to ARFI data and were then registered with structures found in ARFI images. The results demonstrated that when PCa is visible, it generally appears as bilaterally asymmetric stiff structures; benign prostatic hyperplasia (BPH) appears heterogeneous with a nodular texture; the verumontanum and ejaculatory ducts appears softer compared with surrounding tissue, which form a unique 'V' shape; and the boundary of the transitional zone (TZ) forms a stiff rim separating the TZ from the peripheral zone (PZ). These characteristic appearances of prostatic structures are consistent with those found in our previous study of prostate ARFI imaging on excised human prostates. Compared with the matched B-mode images, ARFI images, in general, portray prostate structures with higher contrast. With the end-firing transducer used for this study, ARFI depth penetration was limited to 22 mm. Image contrast and resolution were decreased as compared with the previous ex vivo study due to the small transducer aperture. Even with these limitations, this study suggests ARFI imaging holds promise for guidance of targeted prostate needle biopsy and focal therapy, as well as aiding assessment of changes during watchful waiting/active surveillance., (Copyright © 2012 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

We evaluate the reliability of routine sextant prostate biopsy to detect unilateral lesions. A total of 365 men with complete records including all clinical and pathologic variables who underwent a preoperative sextant biopsy and subsequent radical prostatectomy (RP) for clinically localized prostate cancer at our medical center between January 1996 and December 2006 were identified. When the sextant biopsy detects unilateral disease, according to RP results, the NPV is high (91%) with a low false negative rate (9%). However, the sextant biopsy has a PPV of 28% with a high false positive rate (72%). Therefore, a routine sextant prostate biopsy cannot provide reliable, accurate information about the unilaterality of tumor lesion(s)., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To determine the adequacy of T2 prostate cancer (PCa) sub-staging as an independent Predictor of biochemical disease-free survival (bDFS) after radical prostatectomy., Materials and Methods: The Duke Prostate Center database was queried for patients who underwent radical prostatectomy between 1988 and 2007 and had pT2 PCa, identifying 1990 cases. Prostate-specific antigen (PSA) recurrence was defined as a single value ≥0.2 ng/mL. Kaplan-Meier curves compared differences in bDFS between T2 sub-divisions. Multivariate analysis was performed, adjusting for age, pathological Gleason sum, surgical margin status, preoperative PSA, race, total tumour percentage and prostate weight on biochemical recurrence., Results: The mean age at surgery was 62 years, and 16% of patients were African-American. Median prostate weight was 40 g [interquartile range (IQR) 31-52] and median preoperative PSA was 5.6 (IQR 4.2-7.8). Pathological Gleason score was ≤6 in 57%, 7 in 38%, and ≥8 in 5%; pathological T stage distribution was 18% T2a, 6% T2b, and 76% T2c; and percentage tumour involvement was ≤5% in 43%, between 5.1 and 10% in 24%, between 10.1 and 15% in 10%, and >15% in 19%. 366 (18.4%) patients had a biochemical recurrence after a median of 4.6 years (IQR 2.1-8.2) follow-up. bDFS was significantly (P= 0.006) higher for pT2a disease than for pT2b and pT2c, which were comparable. Adjusting for demographic and other pathological variables, T2 sub-divisions lost statistical significance., Conclusions: Pathological T2a prostate cancer has significantly higher bDFS than the pT2b or pT2c sub-groups in univariate but not multivariate analyses. Different pathological features should be explored to create more meaningfully predictive pathological T2 sub-divisions., (© 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.)

Acoustic Radiation Force Impulse (ARFI) imaging has been previously reported to portray normal anatomic structures and pathologies in ex vivo human prostates with good contrast and resolution. These findings were based on comparison with histological slides and McNeal's zonal anatomy. In ARFI images, the central zone (CZ) appears darker (smaller displacement) than other anatomic zones and prostate cancer (PCa) is darker than normal tissue in the peripheral zone (PZ). Since displacement amplitudes in ARFI images are determined by both the underlying tissue stiffness and the amplitude of acoustic radiation force that varies with acoustic attenuation, one question that arises is how the relative displacements in prostate ARFI images are related to the underlying prostatic tissue stiffness. In linear, isotropic elastic materials and in tissues that are relatively uniform in acoustic attenuation (e.g., liver), relative displacement in ARFI images has been shown to be correlated with underlying tissue stiffness. However, the prostate is known to be heterogeneous. Variations in acoustic attenuation of prostatic structures could confound the interpretation of ARFI images due to the associated variations in the applied acoustic radiation force. Therefore, in this study, co-registered three-dimensional (3D) ARFI datasets and quantitative shear wave elasticity imaging (SWEI) datasets were acquired in freshly-excised human prostates to investigate the relationship between displacement amplitudes in ARFI prostate images and the matched reconstructed shear moduli. The lateral time-to-peak (LTTP) algorithm was applied to the SWEI data to compute the shear-wave speed and reconstruct the shear moduli. Five types of prostatic tissue (PZ, CZ, transition zone (TZ) and benign prostatic hyperplasia (BPH), PCa and atrophy) were identified, whose shear moduli were quantified to be 4.1 +/- 0.8 kPa, 9.9 +/- 0.9 kPa, 4.8 +/- 0.6 kPa, 10.0 +/- 1.0 kPa and 8.0 kPa, respectively. Linear regression was performed to compare ARFI displacement amplitudes and the inverse of the corresponding reconstructed shear moduli at multiple depths. The results indicate an inverse relation between ARFI displacement amplitude and reconstructed shear modulus at all depths. These findings support the conclusion that ARFI prostate images portray underlying tissue stiffness variations.

Objective: to analyse the relationship between African American (AA) race and obesity in men with prostate cancer., Patients and Methods: in all, 4196 patients who underwent radical prostatectomy from 1988 to 2008 were identified in the Duke Prostate Center database. A subset of 389 (AA 20.9% and non-AA 79.1%) patients with a body mass index (BMI) of ≥30 kg/m(2) , T1c disease and a prostate-specific antigen (PSA) level of <10 ng/mL were stratified by race and analysed. Age at surgery, race, surgical margin status, pathological tumour stage (pT2, pT3/4), pathological Gleason sum (<7, 3 + 4, 4 + 3, >7), extracapsular extension (ECE), seminal vesicle invasion and tumour percentage were assessed by univariate analysis followed by Cox regression analysis., Results: in the entire cohort, 143 (38.1%) AA men were obese, compared to 509 (25.0%) of the non-AA men. AA men had a significantly higher tumour percentage (15% vs 10%, P= 0.002), and a greater proportion of pT3/4 disease (45.1% vs 26.2%, P= 0.039), pathological Gleason sum ≥ 7 (70.7% vs 50.5%, P= 0.003), positive ECE (37.8% vs 23.1%, P= 0.007), and positive surgical margin (52.4% vs 36.8%, P= 0.010) than non-AA men. AA men had a greater risk of PSA recurrence on Kaplan Meier (P= 0.004) and Cox regression analysis (P= 0.040, hazard ratio 1.72), Conclusion: a greater proportion of AA men was obese in this cohort. Obese AA with impalpable cancer and a PSA level of <10 ng/mL have a higher risk of pathological features than obese non-AA men, as well as a higher risk of PSA recurrence. Obesity might be responsible for the racial disparity seen in prostate cancer.

Focal therapy (FT) for the management of clinically localized prostate cancer (PCa) is growing from a concept to reality because of increased interest of both patients and physicians. Selection protocols, however, are yet to be established. We discuss the role of prostate biopsy in candidate selection for FT and highlight the different strategies and technical aspects of the use of prostate biopsy in this setting. In our opinion, prostate biopsy plays a major role in the selection process and tailoring appropriate treatment strategy to the patient. FT necessitates dedicated biopsy schemes that would reliably predict the extent, nature, and location of PCa in selected patients. Currently, there is insufficient scientific evidence to propose a specific biopsy scheme that could fit every candidate, providing accurate characterization of the disease in the individual patient. Further research is necessary to establish solid selection protocols that would reliably identify appropriate candidates for FT of PCa.

It has been challenging for clinicians using current imaging modalities to visualize internal structures and detect lesions inside human prostates. Lack of contrast among prostatic tissues and high false positive or negative detection rates of prostate lesions have limited the use of current imaging modalities in the diagnosis of prostate cancer. In this study, acoustic radiation force impulse (ARFI) imaging is introduced to visualize the anatomical and abnormal structures in freshly excised human prostates. A modified Siemens Antares ultrasound scanner (Siemens Medical Solutions USA Inc., Malvern, PA) and a Siemens VF10-5 linear array were used to acquire ARFI images. The transducer was attached to a three-dimensional (3-D) translation stage, which was programmed to automate volumetric data acquisition. A depth dependent gain (DDG) method was developed and applied to 3-D ARFI datasets to compensate for the displacement gradients associated with spatially varying radiation force magnitudes as a function of depth. Nine human prostate specimens were collected and imaged immediately after surgical excision. Prostate anatomical structures such as seminal vesicles, ejaculatory ducts, peripheral zone, central zone, transition zone and verumontanum were visualized with high spatial resolution and in good agreement with McNeal's zonal anatomy. The characteristic appearance of prostate pathologies, such as prostate cancerous lesions, benign prostatic hyperplasia, calcified tissues and atrophy were identified in ARFI images based upon correlation with the corresponding histologic slides. This study demonstrates that ARFI imaging can be used to visualize internal structures and detecting suspicious lesions in the prostate and appears promising for image guidance of prostate biopsy., (Copyright 2010 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the diagnostic properties of routine office-based sextant and extended biopsies for unilateral prostate cancer, as validated by final pathology, because focal therapy of prostate cancer is gaining acceptance as a viable treatment option and thus patient selection is of paramount consideration., Patients and Methods: We retrospectively analysed records of patients who had a radical prostatectomy (RP) for biopsy confirmed prostate cancer at our institution between 1990 and 2007. Records with incomplete data were excluded. Diagnostic properties for sextant and extended biopsies were calculated and compared for diagnostic accuracy, sensitivity, specificity, positive and negative predictive values (PPV, NPV) and false-positive and -negative rates., Results: We identified 882 records (729 sextant, 153 extended biopsies) matching our criteria. Overall, unilateral prostate cancer was confirmed in 151 (16%) of pathological RP specimens. The sensitivity improved from 84.1% to 88.0% on sextant and extended biopsy, respectively. Similarly, the PPV increased from 21.9% to 27.2%, specificity from 37.1% to 53.9% (P < 0.05), and NPV from 91.8% to 95.8% (P < 0.05). These changes are reflected in the decrease in false-positive rates (from 62.9% to 46.1%) and false-negative rates (from 15.9% to 12.0%). The overall diagnostic accuracy increased from 49% on sextant to 59% on extended biopsy (P < 0.05)., Conclusions: Taking more prostate biopsy cores improves the diagnostic properties for identifying unilateral prostate cancer. However, a 12-core biopsy is not an ideal diagnostic test to select patients for focal therapy, and should be interpreted in conjunction with imaging and clinical variables. Additional research should investigate the diagnostic gain associated with a further increase in the number of biopsy cores., (© 2009 THE AUTHORS. JOURNAL COMPILATION © 2009 BJU INTERNATIONAL.)

Purpose: We determined the predictive power of tumor percent involvement on prostate specific antigen recurrence in patients when stratified by prostate weight., Materials and Methods: Data on 3,057 patients who underwent radical prostatectomy between 1988 and 2008 was retrieved from our institutional prostate cancer database. Patients with data on tumor percent involvement, prostate volume and prostate specific antigen recurrence were included in analysis. Patients were divided into 3 groups based on prostate volume less than 35, 35 to 45 and greater than 45 cc. The variables tumor percent involvement, age at surgery, race, prostate specific antigen, pathological Gleason score, positive surgical margins, extraprostatic extension, seminal vesicle invasion and surgery year were analyzed using the chi-square and Mann-Whitney tests to determine individual effects on prostate specific antigen recurrence. Tumor percent involvement and prostate specific antigen were evaluated as continuous variables. Significant variables on univariate analysis were included in multivariate Cox regression analysis to compare their effects on prostate specific antigen recurrence., Results: Tumor percent involvement significantly predicted prostate specific antigen recurrence in men with a small prostate (p = 0.006) but not in those with a prostate of greater than 35 cc. Black race was a marginally significant predictor of prostate specific antigen recurrence in men with a medium prostate (p = 0.055). Age at surgery was a predictor of prostate specific antigen recurrence in men with a larger prostate (p = 0.003). Prostate specific antigen, positive surgical margins, seminal vesicle invasion and pathological Gleason score 7 or greater predicted prostate specific antigen recurrence in men with all prostate sizes., Conclusions: In men with a prostate of less than 35 cc tumor percent involvement is an important variable when assessing the risk of prostate specific antigen recurrence. Tumor percent involvement and prostate volume should be considered when counseling patients and determining who may benefit from heightened surveillance after radical prostatectomy., (2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To compare the effects of tumor volume (TV), tumor percentage involvement (TPI), and prostate volume (PV) on prostate-specific antigen (PSA) recurrence (PSAR) after radical prostatectomy (RP)., Methods: A cohort of 3528 patients receiving RP between 1988 and 2008 was retrieved from the Duke Prostate Center. Patients were stratified by TV (< 3, 3-6, > 6 cm(3)), TPI (< 10%, 10%-20%, > 20%), and PV (< 35, 35-45, > 45 cm(3)) and their effects on PSAR evaluated using Kaplan-Meier analysis. Clinicopathologic variables included in univariate analysis were age at surgery, race, year of surgery, PSA, pathologic Gleason score, pathologic tumor stage, margin status, extracapsular extension, and seminal vesicle invasion. The effects of TV, TPI, and PV (as continuous and categorical variables) on PSAR were compared using Cox analysis., Results: TPI, TV, and PV were predictive of PSAR (P <.05) in Kaplan-Meier analysis. In multivariate analysis as continuous variables, TPI and PV were predictive of PSAR (hazard ratio [HR] = 1.16 and HR = 0.65, P <.05). As categorical variables, TPI > 20% and PV 10-35 cm(3) were predictive of PSAR (HR = 1.45 and OR = 1.25, P <.05). TV was not predictive of PSAR in either analysis. Pathologic Gleason score > or = 7, PSA, positive margins, seminal vesicle invasion, and tumor stage T3/T4 were found to be predictors of PSAR (P <.05)., Conclusions: TV, TPI, and PV were predictive of PSAR in univariate analysis, but in multivariate analysis, only TPI and PV were predictive of PSAR. TPI and PV should be considered when evaluating, assessing, and counseling patients regarding PSAR risk., (2010 Elsevier Inc. All rights reserved.)

Purpose: We compared the results of a preoperative (111)In-capromab pendetide scan co-registered with computerized tomography with pathological findings in the surgically excised prostate to determine whether the scan can efficiently detect cancer in the prostate., Materials and Methods: This prospective trial included 25 hormone naïve men with clinically localized prostate cancer who underwent (111)In-capromab pendetide single photon emission computerized tomography/computerized tomography as part of the preoperative evaluation. In addition to routine histological analysis, representative prostate sections were stained for prostate specific membrane antigen using the same antibody used in the scan. A pathologist and a radiologist were blinded to pathology and imaging findings, respectively. Prostate specific membrane antigen immunohistochemistry was correlated with the 3-dimensional location of the prostate specific membrane antigen signal detected by scan., Results: Scan sensitivity was 37% to 87% for 4 quadrants (right vs left and apical vs basal) with 0% to 50% specificity, as validated by final pathological assessment of the same quadrants. Stratifying positive scan signal strength did not statistically improve specificity (p = 0.35). There was no significant correlation between prostate specific membrane antigen over expression and tumor stage distribution (p = 0.23)., Conclusions: The scan did not localize prostate cancer to a particular quadrant based on comparison with radical prostatectomy specimen pathology. The antibody used has affinity for benign and malignant prostatic glands in excised, formalin fixed prostate tissue, which may contribute to low scan specificity in vivo. The scan cannot be used to reliably detect or image cancer foci in the prostate.

Objective: To explore the ability of a novel transrectal ultrasonography (TRUS) device (TargetScan, Envisioneering Medical Technologies, St. Louis MO) that creates a three-dimensional map of the prostate and calculates an optimal biopsy scheme, to accurately sample the prostate and define the true extent of disease, as standard TRUS-guided prostate biopsy relies on the operator to distribute the biopsy sites, often resulting in under- and oversampling regions of the gland., Patients and Methods: In a multicentre retrospective chart review evaluating patients who had a TargetScan prostate biopsy between January 2006 and June 2007, we determined the overall cancer detection rate in all patients and in subgroups based on prostate specific antigen level, digital rectal examination, and indication for biopsy. We assessed the pathological significance of cancer detected, defined as a Gleason score of > or = 7, positive margins, extracapsular disease or > 20% tumour volume in the prostatectomy specimen. We also evaluated the concordance in Gleason score between the biopsy and prostatectomy specimen., Results: Cancer was detected in 50 (35.7%) of the 140 patients biopsied, including 39 (47.6%) with no previous biopsies. Of 23 prostatectomy specimens, 20 (87%) had pathologically significant disease. The biopsy predicted the prostatectomy Gleason score in 12 patients (52%), overestimated in two (9%), underestimated in eight (35%), and biopsy Gleason score could not be assigned in one (4%)., Conclusions: Template-guided biopsy potentially produces a higher cancer detection rate and more accurate assessment of grade. Prostatectomy specimens did not have a high rate of pathologically insignificant disease.

Objectives: To determine the effect of prior benign prostate biopsies on the surgical and clinical outcomes of patients treated with radical perineal prostatectomy for prostate cancer., Methods: A total of 1369 patients with clinically localized prostate cancer underwent radical prostatectomy by a single surgeon between 1991 and 2001. A subset of 203 patients (14.9%), who had undergone at least one prior benign prostate biopsy for a rising prostate-specific antigen and/or abnormal digital rectal examination, constituted our study population. A total of 1115 patients with no prior biopsy represented our control group. After prostatectomy, patients were evaluated at 6-month intervals for biochemical evidence of recurrence, defined as a prostate-specific antigen level of 0.5 ng/mL or greater., Results: Patients with a prior benign biopsy had more favorable pathologic features with more organ-confined (74% versus 64%; P <0.001) and less margin-positive (9.8% versus 18%) disease. Only 24 patients (12%) in the study group (versus 20% in control group; P = 0.01) had eventual evidence of biochemical failure. Kaplan-Meier analyses suggested that patients with prior benign biopsies have improved biochemical disease-free survival, especially for those with more aggressive disease (Gleason sum 7 or greater; P <0.01). Overall, patients in the study group had lower probability (odds ratio 0.57, P <0.001) of biochemical failure compared with those in the control group., Conclusions: A prior benign prostate biopsy may be independently associated with more favorable surgical and biochemical outcomes after prostatectomy. Additional studies are needed to confirm these findings.

Arterial insufficiency is a major factor responsible for impotence in men following nerve sparing radical prostatectomy. Previously, accessory internal pudendal arteries have been identified traveling over the anterolateral surface of the prostate. Based on this observation, during the last 7 years we have consistently looked for the presence of these arteries and have developed a surgical technique for their preservation. Between 1987 and 1994, 835 potent men underwent radical prostatectomy and accessory pudendal arteries were identified in 33 (4%). Following the development of the surgical technique, it was possible to preserve arteries in 19 of 24 patients (79%). Followup evaluation of 1 year or longer was available for 22 men who did not undergo wide excision of a neurovascular bundle. Recovery of erection sufficient for unassisted intromission and orgasm occurred in 8 of 12 patients (67%) in whom the arteries were preserved and in 5 of 10 (50%) in whom the arteries were sacrificed. We conclude that 1) the presence of accessory internal pudendal arteries is rare (4%); 2) although these arteries were preserved in 79% of the patients, dissection of these arteries from the dorsal vein complex may be associated with excessive bleeding, and 3) because potency rates are similar in men with or without preservation of accessory arteries, routine preservation may not be productive.

In vitro bioassay has been used extensively to test the effects of culturing cancer cells in sera from humans participating in dietary interventions, i.e, studies of modified intake of nutrients for the purpose of reducing cancer risk or progression. It has been hypothesized that cell proliferation rates determined by the in vitro bioassay indicate whether modification of dietary intake could decrease cancer cell growth in vivo. It has been suggested, however, that the in vitro bioassay may not correlate with tumor cell proliferation rates in prostate cancer. We investigated the concordance of cell proliferation rates from surgically excised prostate tumor tissue with the in vitro bioassay using sera from matched patients. We used samples from an earlier randomized clinical trial that showed that supplementation with flaxseed significantly inhibited prostate cancer cell proliferation rates in vivo as indicated by Ki67 staining in tumor specimens. Proliferation rates of LNCaP, DU145 and PC3 cell lines cultured in 10% human sera from participants in the flaxseed trial were determined using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Spearman's Rho correlation coefficients (ρ) indicated no association between Ki67 staining in prostate tumors and the in vitro bioassay for the three cell lines. These disparate findings suggest that the in vitro bioassay may not provide an accurate assessment of the environment in vivo. [ABSTRACT FROM AUTHOR]