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Objective: To assess the potential for molecular staging in biopsies of the prostatic fossa after radical prostatectomy (RP) by searching for occult tumour cells through analysis of glutathione S-transferase P1 (GSTP1) methylation status., Patients and Methods: We analysed 2446 biopsies: 2286 biopsies from a group of 254 patients with clinically organ-confined prostate cancer who underwent RP and 160 biopsies from a control group of 32 patients. After prostate gland excision, biopsies were obtained from defined areas of the prostatic fossa and bisected for histopathological and molecular genetics analyses. Results were related to clinicopathological data including tumour stage, lymph node status, resection status, tumour grading, initial PSA level, and biochemical recurrence., Results: In total, 34 patients (13.4%) had at least one core positive for the GSTP1 promoter hypermethylation, six of whom (17.6%) were characterised as having a clinically localised tumour stage (pT2, pN0) and 28 (82.4%) as an advanced tumour stage (≥pT3 and/or pN1). GSTP1 promoter hypermethylation significantly correlated with tumour stage (P < 0.001), International Society of Urological Pathology grading (P = 0.001), lymph node status (P < 0.001), surgical margin status (P < 0.001), and biochemical recurrence (P = 0.001). Furthermore, in 46 patients (18.1%) further analysis led to a down- or upgrading of conventional surgical margin status. Classical R-status (margins of the specimen) is significantly superior to histological sampling from the fossa (P = 0.006) but not to GSTP1 analysis from the fossa (P = 0.227)., Conclusion: For the detection of residual tumour in the fossa after RP in order to better predict recurrence, molecular GSTP1 promoter hypermethylation has some value; however, the classical R-status (margins of the specimen) is simpler and more widely applicable with similar results., (© 2021 The Authors. BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Purpose: To evaluate the additional value of systematic biopsies (SB) when performing transperineal MRI/TRUS fusion biopsies (MRI/TRUS TPBx) with needle tracking., Methods: From January 2019 to March 2021 969 Patients after a MRI/TRUS TPBx were evaluated separately for target biopsies (TB) and systematic biopsies regarding PCa detection and PCa risk evaluation. Needle tracking in the axial sequences of multiparametric MRI was used to assess the localisation of the detected PCa in the biopsy cores related to the reported PI-RADS lesions., Results: The overall cancer detection rate (CDR) for PCa and clinically significant (cs) PCa (ISUP ≥2) with the combination of TB and SB were 66 and 49%. TB detected 46% csPCa and SB 22% csPCa. SB identified 1.5% additional csPCa outside of the reported PI-RADS lesions. 16 patients (1.7%) showed a relevant upgrading from clinically insignificant PCa in TB to csPCa. In 736 patients with unilateral suspicious lesions on MRI, 145 patients (20%) were detected with contralateral PCa-positive SB. 238 patients (25%) showed PCa positive systematic biopsy cores outside of the described PI-RADS lesions., Conclusions: Needle tracking optimizes the 3D-localisation of cancer in the prostate. Our results show that the added value of SB with a reduced systematic biopsy scheme is low with regard to prostate cancer (PCa) detection and PCa risk evaluation. However, there is a relevant added value for localizing multifocal PCa in the primary diagnostic by a MRI/TRUS fusion biopsy of the prostate., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Various convolutional neural network (CNN) based concepts have been introduced for the prostate's automatic segmentation and its coarse subdivision into transition zone (TZ) and peripheral zone (PZ). However, when targeting a fine-grained segmentation of TZ, PZ, distal prostatic urethra (DPU) and the anterior fibromuscular stroma (AFS), the task becomes more challenging and has not yet been solved at the level of human performance. One reason might be the insufficient amount of labeled data for supervised training. Therefore, we propose to apply a semi-supervised learning (SSL) technique named uncertainty-aware temporal self-learning (UATS) to overcome the expensive and time-consuming manual ground truth labeling. We combine the SSL techniques temporal ensembling and uncertainty-guided self-learning to benefit from unlabeled images, which are often readily available. Our method significantly outperforms the supervised baseline and obtained a Dice coefficient (DC) of up to 78.9%, 87.3%, 75.3%, 50.6% for TZ, PZ, DPU and AFS, respectively. The obtained results are in the range of human inter-rater performance for all structures. Moreover, we investigate the method's robustness against noise and demonstrate the generalization capability for varying ratios of labeled data and on other challenging tasks, namely the hippocampus and skin lesion segmentation. UATS achieved superiority segmentation quality compared to the supervised baseline, particularly for minimal amounts of labeled data., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background and Objective: Accurate and reliable segmentation of the prostate gland in MR images can support the clinical assessment of prostate cancer, as well as the planning and monitoring of focal and loco-regional therapeutic interventions. Despite the availability of multi-planar MR scans due to standardized protocols, the majority of segmentation approaches presented in the literature consider the axial scans only. In this work, we investigate whether a neural network processing anisotropic multi-planar images could work in the context of a semantic segmentation task, and if so, how this additional information would improve the segmentation quality., Methods: We propose an anisotropic 3D multi-stream CNN architecture, which processes additional scan directions to produce a high-resolution isotropic prostate segmentation. We investigate two variants of our architecture, which work on two (dual-plane) and three (triple-plane) image orientations, respectively. The influence of additional information used by these models is evaluated by comparing them with a single-plane baseline processing only axial images. To realize a fair comparison, we employ a hyperparameter optimization strategy to select optimal configurations for the individual approaches., Results: Training and evaluation on two datasets spanning multiple sites show statistical significant improvement over the plain axial segmentation (p<0.05 on the Dice similarity coefficient). The improvement can be observed especially at the base (0.898 single-plane vs. 0.906 triple-plane) and apex (0.888 single-plane vs. 0.901 dual-plane)., Conclusion: This study indicates that models employing two or three scan directions are superior to plain axial segmentation. The knowledge of precise boundaries of the prostate is crucial for the conservation of risk structures. Thus, the proposed models have the potential to improve the outcome of prostate cancer diagnosis and therapies., (Copyright © 2020. Published by Elsevier B.V.)

Objectives: We investigated the diagnostic efficacy of the prostate health index (PHI) and PHI density (PHID) to avoid unnecessary prostate biopsies in 3 urological practices., Methods: In 122 patients, total prostate-specific antigen (PSA), free PSA (f-PSA), the quotient from total PSA and f-PSA (f-PSA%), and [-2]pro-PSA were measured in the serum; PHI, PHID, and PSA density (PSAD) were calculated prior to prostate biopsy. Tissue sampling via transrectal biopsy was indicated in case of suspicious PSA (progression and/or elevation of PSA) and/or suspicious digital rectal examination. PSAD, PHI, and PHID were not used for biopsy indication. The diagnostic efficacy was determined with receiver-operating characteristic (ROC)and decision curve analyses., Results: Based on prostate biopsies, 38% (n = 46) of the cases had no prostate carcinoma (PCa), 21% (n = 26) no clinically significant (insignificant) PCa, and 41% (n = 50) had clinically significant PCa. ROC analyses of the PSA parameters showed higher diagnostic efficacy for PHI and PHID (AUC 0.722 and 0.739) than for f-PSA%, PSA, and PSAD (AUC 0.612, 0.595, and 0.698, respectively) regarding carcinoma diagnosis. With a combined use of PHI and PHID (cutoff >40 and >0.9, respectively), only 1 clinically significant PCa would have been missed (sensitivity 98%); in 24 (20%) patients, biopsy could have been avoided., Conclusion: The integration of PHI and PHID could improve the diagnostic efficacy of risk calculators to avoid unnecessary prostate biopsies. However, as a prerequisite, validation of cutoff values in prospective studies is urgently required., (© 2020 S. Karger AG, Basel.)

Objective: The aim of our study was (1) to establish an in-bore targeted biopsy of suspicious prostate lesions, avoiding bowel penetration using a transgluteal approach and (2) to assess operator setup, patient comfort and safety aspects in the clinical setting for freehand real-time MR-guidance established for percutaneous procedures in an open MR-scanner., Material and Methods: 30 patients with suspect prostate lesions were biopsied in a cylindrical 3T-MRI system using a transgluteal approach in freehand technique. One to three biopsies were sampled using continuous dynamic imaging. Size, location and visibility of the lesion, intervention time, needle artefact size, interventional complications and histopathological diagnosis were recorded., Results: All biopsies were technically successful. Nineteen patients showed evidence of prostate carcinoma. Cancer detection rate was 50 % in patients with previously negative TRUS-biopsy. The average intervention time was 26 min including a learning curve as the time was 13 min by the end of the study. No antibiotic prophylaxis was performed as none of the patients showed signs of infection., Conclusions: MR-guided targeted freehand biopsies of prostate lesions using a transgluteal approach are both technically feasible and time efficient in a standard closed-bore 3T-MR scanner as well as safe for the individual patient., Key Points: • Open-bore freehand interventional principles were adapted to closed-bore systems. • Prostate MR-guided freehand biopsies were feasible in a clinical setting. • A transgluteal approach provides a short and simplified work flow. • An inoculation of the prostate with bowel flora is avoided. • The intervention time is comparable to the stereotactic approach.

A more than 100-year period, where the prostate was only seen and treated as a whole is coming to an end right now. Finally, high resolution imaging is providing deep insights and detailed information so that new therapeutic procedures can aim for the smallest targets within the gland. The long-standing wish of patients for individual noninvasive diagnostics and treatment of prostate diseases can now be fulfilled by providing new tailored concepts; however, in order to transfer the enormous amount of new information into the specific clinical patient situation, a closely knit interdisciplinary approach is required. In this setting, the traditional outpatient consultation service is overstretched in every aspect. It is now the time for new innovative constructs. The current one-sided service concept for urologists, radiologists and radiation therapists is therefore behind the times and the development of a "prostate management team" with equally cooperating partners from each specialty is the task for the future.

Background: The GOLIATH study is a 2-yr trial comparing transurethral resection of prostate (TURP) to photoselective vaporization with the GreenLight XPS Laser System (GL-XPS) for the treatment of benign prostatic obstruction (BPO). Noninferiority of GL-XPS to TURP was demonstrated based on a 6-mo follow-up from the study., Objective: To determine whether treatment effects observed at 6 mo between GL-XPS and TURP was maintained at the 2-yr follow-up., Design, Setting, and Participants: Prospective randomized controlled trial at 29 centers in nine European countries involving 281 patients with BPO., Intervention: Photoselective vaporization using the 180-W GreenLight GL-XPS or conventional (monopolar or bipolar) TURP., Outcome Measurements and Statistical Analysis: The primary outcome was the International Prostate Symptom Score for which a margin of three was used to evaluate the noninferiority of GL-XPS. Secondary outcomes included Qmax, prostate volume, prostate specific antigen, Overactive Bladder Questionnaire Short Form, International Consultation on Incontinence Questionnaire Short Form, occurrence of surgical retreatment, and freedom from complications., Results and Limitations: One hundred and thirty-six patients were treated using GL-XPS and 133 using TURP. Noninferiority of GL-XPS on International Prostate Symptom Score, Qmax, and freedom from complications was demonstrated at 6-mo and was sustained at 2-yr. The proportion of patients complication-free through 24-mo was 83.6% GL-XPS versus 78.9% TURP. Reductions in prostate volume and prostate specific antigen were similar in both arms and sustained over the course of the trial. Compared with the 1(st) yr of the study, very few adverse events or retreatments were reported in either arm. Treatment differences in the Overactive Bladder Questionnaire Short Form observed at 12-mo were not statistically significant at 24-mo. A limitation was that patients and treating physicians were not blinded to the therapy., Conclusions: Twenty-four-mo follow-up data demonstrated that GL-XPS provides a durable surgical option for the treatment of BPO that exhibits efficacy and safety outcomes similar to TURP., Patient Summary: The long-term effectiveness and safety of GLP-XLS was similar to conventional TURP for the treatment of prostate enlargement., (Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: The comparative outcome with GreenLight (GL) photoselective vaporisation of the prostate and transurethral resection of the prostate (TURP) in men with lower urinary tract symptoms due to benign prostatic obstruction (BPO) has been questioned., Objective: The primary objective of the GOLIATH study was to evaluate the noninferiority of 180-W GL XPS (XPS) to TURP for International Prostate Symptom Score (IPSS) and maximum flow rate (Qmax) at 6 mo and the proportion of patients who were complication free., Design, Setting, and Participants: Prospective randomised controlled trial at 29 centres in 9 European countries involving 281 patients with BPO., Intervention: 180-W GL XPS system or TURP., Outcome Measurements and Statistical Analysis: Measurements used were IPSS, Qmax, prostate volume (PV), postvoid residual (PVR) and complications, perioperative parameters, and reintervention rates. Noninferiority was evaluated using one-sided tests at the 2.5% level of significance. The statistical significance of other comparisons was assessed at the (two-sided) 5% level., Results and Limitations: The study demonstrated the noninferiority of XPS to TURP for IPSS, Qmax, and complication-free proportion. PV and PVR were comparable between groups. Time until stable health status, length of catheterisation, and length of hospital stay were superior with XPS (p<0.001). Early reintervention rate within 30 d was three times higher after TURP (p=0.025); however, the overall postoperative reintervention rates were not significantly different between treatment arms. A limitation was the short follow-up., Conclusions: XPS was shown to be noninferior (comparable) to TURP in terms of IPSS, Qmax, and proportion of patients free of complications. XPS results in a lower rate of early reinterventions but has a similar rate after 6 mo., Trial Registration: ClinicalTrials.gov, identifier NCT01218672., (Copyright © 2013. Published by Elsevier B.V.)

Background: Transurethral resection of the prostate (TURP) is a challenging operation for residents with limited endoscopic experience. A number of virtual TURP simulators have been validated in the past. This study is the first description and preliminary evaluation of a non-virtual, low-cost TURP trainer as a teaching tool for residents in urology., Methods: Dr K. Forke's prostatic resection trainer (PRT; LS 10-2/S, Samed GmbH, Dresden, Germany) was tested during the surgical training of a resident. Under the supervision of an experienced senior surgeon, three aspects were examined: the resection trainer's approximation to reality, the ease of instruction, and the potential capability to improve surgeons' psychomotor abilities with regard to the three-dimensional (3D) guidance of the instrument. The improvement in resection speed (RS) of residents with no PRT training (control group) was also compared to the results of the PRT-trained resident., Results: During the PRT training, the resident displayed clear improvement in resection quality (RQ) and a 27% increase in RS (p = 0.03). In the post-training stage, the PRT-trained resident showed a more constant progress rate, to a maximum RS of 0.37 g/min (35% increase; p = 0.01), whereas the control group displayed varied RS learning curves. Composed of a synthetic material, which can be resected by standard instruments, the trainer offers a haptical experience that is particularly realistic and may provide an increased learning rate., Conclusion: From the findings, we conclude that this novel PRT is suitable for daily use and offers an effective and more affordable alternative to virtual simulators. Further validation studies will follow and new fields of application will be tested., (Copyright © 2011 John Wiley & Sons, Ltd.)

Introduction: Prostate sextant biopsy is considered the gold standard of invasive prostate cancer diagnostics. However, numerous studies have shown that greater detection rates are achieved by increasing the number of biopsies. Chen et al. found ten "ideal" biopsy sites using a computer model. This study examines the clinical value of this variation of number and localisation of biopsies., Material and Method: Ultrasound-guided ten-core prostate biopsies are performed in our department. Following the model of Chen, three prostate biopsies instead of on are taken from the middle plane. The two additional specimens are obtained in the paraurethral and ventral regions., Results: Between July 2003 and February 2004, 191 patients scheduled for a 10-core prostate biopsy were included in the study. Assessable results were obtained in 176 cases. A carcinoma was detected in 61/176 (34.7 %) of the patients. The carcinoma was found only in the standard sextant localisations (27.8 %) in 17/61 patients and additionally in the paraurethral or ventral region in 35/61 (57.3 %). The carcinoma was located only paraurethrally in 1/62 (1.6 %) and only ventrally in 6/62 (9.7 %). Altogether, the prostate carcinoma was detected only by the additional biopsies in 6 patients (9.8 %). A clinically relevant disease was seen in 5/6 (83.3 %). A carcinoma was detected most frequently in the following biopsies: base right (17.1 %), central lat. right (17.5 %) and apex right (16.5 %) and most rarely paraurethral right (12 %) and ventral right (10.2 %). Statistically significant differences were found only between these groups., Conclusion: The modification and increase of biopsies from six to ten according to the model suggested by Chen et al. detected 9.8 % more carcinomas in our patients.

Objectives: To examine, in a prospective, randomized study, the effect of different anesthetic techniques versus no anesthesia in a 10-core prostate biopsy. Reports thus far have shown a high variability in assessing the pain intensity of prostate biopsies and the effectiveness of anesthesia., Methods: Ultrasound-guided 10-core prostate biopsy was performed. Patients were prospectively randomized into four groups: no local anesthesia (group 1); anesthetic block of the prostatic plexus (group 2); local anesthesia onto the capsula of the apex (group 3); and a combination of the anesthesia used for groups 2 and 3 (group 4). The degree of pain was recorded using the visual analog scale/numeric analog scale (VAS/NAS) score., Results: The study included 187 patients. Results were assessed in 170 patients: 44 in group 1, 44 in group 2, 40 in group 3, and 42 in group 4. In group 1 (no anesthesia), 2 (4.5%) of 44 patients had no pain during biopsy (VAS/NAS = 0); the pain was mild (VAS/NAS of 1 to 4) in 38 (86.4%), moderate (VAS/NAS of 4 to 7) in 3 (6.8%), and severe (VAS/NAS of greater than 7) in 1 (2.3%) of 44 patients. The mean pain scores were 2.33 in group 1, 1.68 in group 2 (P = 0.05), 1.07 in group 3 (P <0.001), and 1.23 in group 4 (P <0.001). Pain caused by the local anesthesia itself was 0 in group 1, 1.52 in group 2 (P = 0.001), 1.05 in group 3 (P = 0.001), and 1.79 in group 4 (P = 0.001)., Conclusions: Local anesthesia significantly reduces pain. An injection onto the capsule at the apex was the most effective technique. It is technically easier to perform than an anesthetic block of the prostatic plexus and can be recommended.

Locally confined prostate cancer (PCa) can be treated by various treatment options (e.g. radical prostatectomy or radiation therapy) with comparable results but different possible side effects. Therefore, treatment recommendations can vary between urologists and radiation oncologists. In 2001 the Charité-Campus Benjamin Franklin (CBF, Berlin), established the first interdisciplinary consulting service for prostate cancer patients in Germany. The aim was to offer a comprehensive and neutral consultation on all treatment options and to make treatment recommendations. The study examines what benefits may be derived from this type of consultation. A total of 362 patients presented to the consulting service between May 2001 and April 2003. Two questionnaires were used. The first one contained epidemiological questions as well as questions covering information already available on PCa. It also examined feelings and fears about the disease and possible treatment options. The second questionnaire was completed 2 weeks after the consultation to evaluate the treatment decision, determine the patient’s satisfaction with the consultation and trace the development of feelings and fears. Of the patients, 334 (92.2%) were completely assessable. All patients had already obtained information about the disease and possible treatment options and wished to be involved in the decision-making process through objective and neutral consultation. Nearly all of them had a great fear of the possible side effects of therapy. Such a comprehensive consultation is time-consuming (average of 35 min) but largely received a very positive assessment in that a total of 66% found it either helpful (n=74, 22%) or very helpful (n=147, 44%). Patients felt they had been completely informed in 92% of the cases. Only 22 (9.7%) had still failed to make a decision after 2 weeks, 115 patients had stage T1c, PSA<10 ng/ml and a Gleason score =7. In these cases an equivalent recommendation for radical prostatectomy, percutaneous radiotherapy or permanent seed implantation was given. Of these, 49 (43.4%) decided on the surgical intervention, 48 (42.5%) on a type of radiotherapy and only 18 (15.6%) remained undecided. The histological examination of prostatectomy specimens from patients who had decided to undergo radical surgery at CBF showed a significant decrease in the rate of extracapsular disease extension (=T3) from 38% to 20% during the observation period. The interdisciplinary approach has made the process of deciding on an appropriate treatment much easier for the patient. The time-consuming consultation enables better selection of individual treatment modalities and their possible side effects from the point of view of both the patients and the attending physicians. In this study, patients chose either radical surgery or radiotherapy with equal frequency. [ABSTRACT FROM AUTHOR]

One of the oldest methods used in minimally invasive surgeries is the transurethral resection. This is an operation technique in which diseased tissue from the bladder or the prostate is removed using a resectoscope through the urethra [Schostak M, Blana A, Hrsg. Alternative operative Therapien in der Uroonkologie. Berlin, Heidelberg, Springer Berlin Heidelberg; 2016]. A resectoscope has a channel for the view of the surgeon, a liquid supply, a working channel and a hand piece which could rotate up to 360 degrees. A RF- electrode on the tip of the resectoscope is used to cut out pathological growths. For diseased tissue which is located in the bladder on the ventral side, a rotation of the resectoscope up to 180 degrees is necessary. This means on the one side tiring of the hands, wrist pain and a change of the position of the operating surgeon. On the other side a reorganization of the connected tubes and cables is necessary. To avoid these problems and integrate additional features a standard resectoscope was adapted with an easy to use twist mechanism. After discussion with experienced urological surgeons a complete new design of the resectoscope with a twist mechanism in combination with a gyro sensor and a reference display was realized.