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OBJECTIVES To investigate the impact of implementing magnetic resonance imaging (MRI) and ultrasonography fusion technology on biopsy and prostate cancer (PCa) detection rates in men presenting with clinical suspicion for PCa in the clinical practice setting. PATIENTS AND METHODS We performed a review of 1 808 consecutive men referred for elevated prostate-specific antigen (PSA) level between 2011 and 2014. The study population was divided into two groups based on whether MRI was used as a risk stratification tool. Univariable and multivariable analyses of biopsy rates and overall and clinically significant PCa detection rates between groups were performed. RESULTS The MRI and PSA-only groups consisted of 1 020 and 788 patients, respectively. A total of 465 patients (45.6%) in the MRI group and 442 (56.1%) in the PSA-only group underwent biopsy, corresponding to an 18.7% decrease in the proportion of patients receiving biopsy in the MRI group (P < 0.001). Overall PCa (56.8% vs 40.7%; P < 0.001) and clinically significant PCa detection (47.3% vs 31.0%; P < 0.001) was significantly higher in the MRI vs the PSA-only group. In logistic regression analyses, the odds of overall PCa detection (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.29-2.35; P < 0.001) and clinically significant PCa detection (OR 2.04, 95% CI 1.48-2.80; P < 0.001) were higher in the MRI than in the PSA-only group after adjusting for clinically relevant PCa variables. CONCLUSION Among men presenting with clinical suspicion for PCa, addition of MRI increases detection of clinically significant cancers while reducing prostate biopsy rates when implemented in a clinical practice setting.

Long-term outcomes from large cohorts are not yet available upon which to base recommended follow-up protocols after prostate focal therapy. This is an updated summary of a 2015 SIU-ICUD review of the best available current evidence and expert consensus on guidelines for surveillance after prostate focal therapy. We performed a systematic search of the PubMed, Cochrane and Embase databases to identify studies where primary prostate focal therapy was performed to treat prostate cancer. Multiparametric magnetic resonance imaging (mpMRI) should be performed at 3–6 months, 12–24 months and at 5 years after focal therapy. Targeted biopsy of the treated zone should be performed at 3–6 months and fusion biopsy of any suspicious lesion seen on mpMRI. Additionally, a systematic biopsy should be performed at 12–24 months and again at 5 years. In histological diagnosis, characteristic changes of each treatment modality should be noted and in indeterminate situations various immunohistochemical molecular markers can be helpful. Small volume 3 + 3 (Prognostic grade group [PGG] 1) or very small volume (

To assess for usefulness and validity evidence for incorporating the C-Arm Trainer (CAT) simulator into the annual AUA hands on course for training percutaneous nephrolithotomy (PCNL). The course started with a didactic session followed by four stations for training the “bull’s eye” technique using the CAT simulator. Each station included a pre-test, 30-min practice on the simulator, and post-test. All participants were assessed using a 4-item checklist. All participants were asked to fill in a qualitative self-assessment questionnaire after the pre- and the post-test, and respond to a course evaluation questionnaire and post-course survey. A total of 38 physicians, who attended the hands on course, voluntarily participated in the study. Only 21.1% had previous practice on PCNL simulators. Compared with the results of the checklist total score and the qualitative self-assessment questionnaire scores after the pre-test, there was significant improvement in the checklist total score (p

Review the multiparametric MRI (mpMRI) findings of transition zone (TZ) prostate cancer (PCa) using T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and dynamic contrast-enhanced (DCE) MRI and to integrate mpMRI findings with clinical history, laboratory values, and histopathology. TZ prostate tumors are challenging to detect clinically and at MRI. mpMRI using the combination of sequences has the potential to improve accuracy of TZ cancer detection and staging.

PURPOSE To compare a faster diagonal diffusion-weighted imaging (d-DWI) to conventional three-scan trace DWI (t-DWI) acquisition for prostate magnetic resonance imaging (MRI) in terms of image quality, tumor detection/conspicuity, Prostate Imaging Reporting and Data System (PI-RADS) characterization, quantitative estimated signal-to-noise ratio (eSNR), and apparent diffusion coefficient (ADC) measurement. PATIENTS AND METHODS A total of 34 consecutive men with suspected prostate cancer (PCa) who underwent 3T MRI of the prostate were assessed. MRI included t-DWI and d-DWI (using b-values of 50, 1000, and 1600 s/mm2 , number of averages 1/5/10 for t-DWI vs. 2/8/14 for d-DWI, acquisition time 6:21 min vs. 4:17 min, respectively). Two independent observers evaluated image quality, including image sharpness, anatomic distortion, and artifacts on a 5-point scale (1-5) and assessed tumor detection, conspicuity, and PI-RADS classification with both DWI sequences. eSNR and ADC were measured in the peripheral zone (PZ), transitional zone (TZ), and detected tumors. Data was compared using paired Wilcoxon signed rank tests and McNemar test. Coefficients of variations (CV) between ADC obtained with both sequences were calculated. RESULTS Significantly fewer artifacts were observed on d-DWI at b 1600 for observer 2 (P < 0.01), while the other image quality scores were equivalent for both sequences. eSNR was lower with d-DWI vs. t-DWI in PZ and TZ for b 1000 (P < 0.01 and P = 0.03, respectively) and b 1600 (P < 0.01 for both). ADC reproducibility between sequences was excellent (CV

Purpose To quantify Tofts model (TM) and shutter-speed model (SSM) perfusion parameters in prostate cancer (PCa) and noncancerous peripheral zone (PZ) and to compare the diagnostic performance of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to Prostate Imaging and Reporting and Data System (PI-RADS) classification for the assessment of PCa aggressiveness. Materials and Methods Fifty PCa patients (mean age 60 years old) who underwent MRI at 3.0T followed by prostatectomy were included in this Institutional Review Board-approved retrospective study. DCE-MRI parameters (Ktrans, ve, kep [TM&SSM] and intracellular water molecule lifetime τi [SSM]) were determined in PCa and PZ. Differences in DCE-MRI parameters between PCa and PZ, and between models were assessed using Wilcoxon signed-rank tests. Receiver operating characteristic (ROC) analysis for differentiation between PCa and PZ was performed for individual and combined DCE-MRI parameters. Diagnostic performance of DCE-MRI parameters for identification of aggressive PCa (Gleason ≥8, grade group [GG] ≥3 or pathology stage pT3) was assessed using ROC analysis and compared with PI-RADSv2 scores. Results DCE-MRI parameters were significantly different between TM and SSM and between PZ and PCa (P 0.213). Conclusion SSM DCE-MRI did not increase the diagnostic performance of DCE-MRI for PCa characterization. PI-RADS outperformed both TM and SSM DCE-MRI for identification of aggressive cancer. Level of Evidence: 3 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;46:837–849

Purpose To define the role of focal laser ablation (FLA) as clinical treatment of prostate cancer (PCa) using the Delphi consensus method. Methods A panel of international experts in the field of focal therapy (FT) in PCa conducted a collaborative consensus project using the Delphi method. Experts were invited to online questionnaires focusing on patient selection and treatment of PCa with FLA during four subsequent rounds. After each round, outcomes were displayed, and questionnaires were modified based on the comments provided by panelists. Results were finalized and discussed during face-to-face meetings. Results Thirty-seven experts agreed to participate, and consensus was achieved on 39/43 topics. Clinically significant PCa (csPCa) was defined as any volume Grade Group 2 [Gleason score (GS) 3+4]. Focal therapy was specified as treatment of all csPCa and can be considered primary treatment as an alternative to radical treatment in carefully selected patients. In patients with intermediate-risk PCa (GS 3+4) as well as patients with MRI-visible and biopsy-confirmed local recurrence, FLA is optimal for targeted ablation of a specific magnetic resonance imaging (MRI)-visible focus. However, FLA should not be applied to candidates for active surveillance and close follow-up is required. Suitability for FLA is based on tumor volume, location to vital structures, GS, MRI-visibility, and biopsy confirmation. Conclusion Focal laser ablation is a promising technique for treatment of clinically localized PCa and should ideally be performed within approved clinical trials. So far, only few studies have reported on FLA and further validation with longer follow-up is mandatory before widespread clinical implementation is justified. Electronic supplementary material The online version of this article (10.1007/s00345-019-02636-7) contains supplementary material, which is available to authorized users.

Purpose To evaluate outcomes after prostatic artery embolization (PAE) in patients with severe intravesical prostatic protrusion (IPP). Materials and Methods This was a retrospective, single health system, 2-hospital study from April 2015 to December 2018 of 54 patients who underwent elective PAE procedures (age mean 67.5 years; standard deviation [SD] 8.5). The cohort had a mean ellipsoid prostate volume of 100.1 cm3 (SD 56.7), a mean baseline International Prostate Symptom Score (IPSS) of 18.7 (SD 8.2), a mean baseline quality of life (QOL) score of 4.1 (SD 1.4), and a median follow-up of 38 days (range 10–656 days). Outcomes including IPSS and QOL score reduction (where a lower QOL score indicates an improvement in QOL), and clinical success were compared between severe (≥10 mm) and nonsevere ( Results No significant differences in patient characteristics were found between nonsevere (n = 17) and severe (n = 37) IPP patients. Both cohorts showed IPSS reduction (nonsevere 6.0, P = .0397; severe 8.2, P Conclusions There were no significant differences in early outcomes in PAE between patients with severe and nonsevere IPP.

INTRODUCTION AND OBJECTIVES:The presence of tertiary pattern 5 (TP5) on radical prostatectomy specimens has been associated with worse long-term outcomes. However, the molecular underpinnings of TP...

OBJECTIVE To investigate the genomic features of tertiary pattern 5 (TP5) on radical prostatectomy specimens in an effort to explain the poor clinical outcomes associated with this disease subtype. PATIENTS AND METHODS Data from 159 men with Gleason Grade Group (GGG) 3 or 4 were considered. All patients had Decipher diagnostic testing with transcript profiles and single-channel array normalisation (SCAN)-normalised expression of coding genes. The relationship between Decipher and TP5 was investigated by linear and binary logistic regressions. A differential transcriptomic analysis between patients with and without TP5 was performed. The prognostic role of these genes on progression-free survival (PFS) and overall survival (OS) was evaluated using The Cancer Genome Atlas. RESULTS In all, 52/159 (33%) patients had GGG 3-4 with TP5 disease. TP5 was associated with a higher Decipher score (β 0.07, 95% confidence interval [CI] 0.02-0.13; P = 0.04) and higher likelihood of falling within the intermediate- or high-risk categories (odds ratio 3.34, 95% CI 1.34-8.35; P = 0.01). Analysis of microarray data revealed an 18-gene signature that was differentially expressed in patients with TP5; 13 genes were over- and five under-expressed in the TP5 cohort. The overexpression of cyclin dependent kinase inhibitor 2B (CDKN2B), polo-like kinase 1 (PLK1), or cell division cycle 20 (CDC20) was associated with worse PFS. The group harbouring overexpression of at least one gene had a 5-year PFS rate of 50% vs 74% in the group without overexpression (P

Item does not contain fulltext OBJECTIVES: Recent advances have led to the use of magnetic resonance imaging (MRI) alone or with fusion to transrectal ultrasound (TRUS) images for guiding biopsy of the prostate. Our group sought to develop consensus recommendations regarding MRI-guided prostate biopsy based on currently available literature and expert opinion. METHODS: The published literature on the subject of MRI-guided prostate biopsy was reviewed using standard search terms and synthesized and analyzed by four different subgroups from among the authors. The literature was grouped into four categories-MRI-guided biopsy platforms, robotic MRI-TRUS fusion biopsy, template mapping biopsy and transrectal MRI-TRUS fusion biopsy. Consensus recommendations were developed using the Oxford Center for Evidence Based Medicine criteria. RESULTS: There is limited high level evidence available on the subject of MRI-guided prostate biopsy. MRI guidance with or without TRUS fusion can lead to fewer unnecessary biopsies, help identify high-risk (Gleason >/= 3 + 4) cancers that might have been missed on standard TRUS biopsy and identify cancers in the anterior prostate. There is no apparent significant difference between MRI biopsy platforms. Template mapping biopsy is perhaps the most accurate method of assessing volume and grade of tumor but is accompanied by higher incidence of side effects compared to TRUS biopsy. CONCLUSIONS: Magnetic resonance imaging-guided biopsies are feasible and better than traditional ultrasound-guided biopsies for detecting high-risk prostate cancer and anterior lesions. Judicious use of MRI-guided biopsy could enhance diagnosis of clinically significant prostate cancer while limiting diagnosis of insignificant cancer.

Purpose To evaluate the performance of apparent diffusion coefficient (ADC) and lesion volume in potentially risk-stratifying patients with prostate cancer (PCa). Materials and Methods Men with elevated prostate-specific antigen or abnormal digital rectal exam underwent a 3T multiparametric magnetic resonance imaging (mpMRI) with endorectal coil. ADC maps were calculated using b values of 0, 500, 1000, and 1500; additional images were obtained with b value of 2000. We prospectively enrolled 312 men with lesions suspicious for cancer (suspicion score 2–5) on mpMRI. MRI/ultrasound fusion-guided prostate biopsies were performed. Mean ADC of suspicious lesions were correlated against lesion volume, Gleason and D'Amico risk. Results The cancer detection rate of fusion biopsy per lesion was 45.6% (206/452). Cancerous lesions were larger (median volume: 0.40 vs. 0.30 cm3; P = 0.016). The median ADC (×10−6 mm2/sec) for lesions negative and positive for PCa were 984.5 and 666.5, respectively (P < 0.0001). The AUC of ADC in predicting PCa was 0.79. Larger lesions were associated with higher risk PCa (Gleason and D'Amico) and lower ADC (all P < 0.0001). Conclusion The mean ADC of suspicious lesions on mpMRI was inversely correlated, while lesion volume had a direct correlation with PCa detection. Future follow-up studies are needed to assess longitudinal cancer risks of suspicious mpMRI lesions. Level of Evidence: 2 J. Magn. Reson. Imaging 2017;45:610–616.

The gold standard treatment for upper tract urothelial carcinoma (UTUC) is radical nephroureterectomy (RNU). The role of endoscopic resection is limited to low-risk patients. In this study, we present our 30-year experience in the endoscopic management of UTUC.In this retrospective study, we identified 141 patients who underwent percutaneous UTUC resection. Demographic and clinical data were collected, including tumor characteristics, bacillus Calmette-Guérin (BCG) and mitomycin use, tumor recurrence, progression to RNU, and overall survival (OS), and compared in univariate and multivariate analyses.Median follow-up was 66 months. Recurrence occurred in 37% of low-grade patients and 63% of high-grade (HG) patients, with a median time to recurrence of 71.4 vs 36.4 months, respectively. Grade was the only predictor of recurrence (HR 2.12, p = 0.018). The latest time to recurrence occurred after 116 months of surveillance. RNU was avoided by 87% of patients. Age, imperative indications for endoscopy, a history of bladder cancer, and tumor stage and grade were predictors of OS; however, in multivariate analysis, grade and stage lost significance. BCG and mitomycin did not protect against recurrence, progression to RNU, or death over resection alone.Percutaneous management of UTUC allows for renal preservation in the majority of patients with resectable disease. Patients with HG tumors are more likely to experience recurrence, but are not at an increased risk of death. Intraluminal BCG and mitomycin continue to have a limited adjuvant role to resection. Recurrence may occur many years following initial resection and therefore prolonged surveillance is advised.

Key Points Question What are the costs associated with positive surgical margins (PSMs) during radical prostatectomy? Findings In this cohort study of 230 175 US men, the attributable cost of a PSM was $17 356. The overall health burden attributable to PSMs was estimated to be $52 068 000 each year. Meaning The financial burden of PSMs is substantial, and efforts in reducing the rate of PSMs could be associated with a reduction in the overall health costs associated with surgically treated prostate cancer., This cohort study estimates the financial costs associated with a positive surgical margin during radical prostatectomy according to the odds of undergoing adjuvant radiation therapy., Importance Prostate cancer is the most common malignant neoplasm among men and is the one with the highest positive surgical margin (PSM) rate. This high rate is due to the difficulty in balancing the risk of extraprostatic disease and excising periprostatic structures, which ultimately affects patients’ quality of life. In the case of a PSM, the appropriateness of adjuvant radiation therapy (aRT) should be discussed. The financial burden of PSMs on health systems has not been investigated. Objective To estimate the financial costs associated with a PSM during radical prostatectomy on the basis of the odds of undergoing aRT. Design, Setting, and Participants This cohort study used data on men with prostate cancer from the US National Cancer Database (January 1, 2010, through December 31, 2015). Data were requested in March 2019, accessed in April 2019, and analyzed in August 2019. Exposure Treatment with radical prostatectomy followed by aRT, if indicated. Main Outcomes and Measures The attributable risk fraction of PSMs on undergoing aRT was estimated from a logistic regression with aRT administration as the outcome. The analysis was adjusted for patients’ socioeconomic and demographic characteristics and tumor characteristics. The aRT cost for the year 2019 was calculated using the Medicare Physician Fee Schedule and the Hospital Outpatient Prospective Payment System. The fraction of this cost attributable to a PSM was estimated according to its attributable risk fraction. Results In total, 230 175 men were identified (median [interquartile range] age at diagnosis, 62.0 [56.0-67.0] years). Overall, 22.8% of the patients had a PSM. Patients with PSMs were more likely than those without PSMs to be older (median [interquartile range] age, 62.0 [56.0-66.0] years vs 62.0 [57.0-67.0] years) and nonwhite (9320 patients [17.8%] vs 29 872 patients [16.8%]), to have higher comorbidity scores (1604 patients [3.1%] vs 4884 patients [2.7%] with a Charlson-Deyo Comorbidity Index score ≥2) and worse tumor characteristics (category T3 and T4 disease, 26 394 patients [50.3%] vs 36 040 patients [20.3%]), and to have lower socioeconomic indicators (median annual income

Objective To assess the usefulness of incorporating the C-Arm Trainer (CAT) simulator into the annual American Urological Association (AUA) hands-on course for training of the percutaneous nephrolithotomy (PCNL) procedure. Methods This prospective study was conducted during the annual meeting of the AUA in 2017. The course included four stations for training the ‘bull’s eye’ technique for obtaining fluoroscopic-guided percutaneous renal access (PCA) using the CAT. After a didactic session, all participants were asked to complete a short questionnaire and undergo a pre-test to obtain a PCA in the posterior middle calyx. This was followed by 30-min practice on the simulator prior to undergoing a post-test. All participants were assessed during the pre-test and the post-test using a four-item checklist. Furthermore, all participants were asked to complete a qualitative analysis self-assessment questionnaire after the pre- and the post-test. Immediately after the course, all participants were invited to complete a course evaluation questionnaire. At 2 months after the course, all participants were asked to respond to a post-course survey to assess the usefulness and clinical impact of the course. Results A total of 38 physicians, who attended the hands-on course, voluntarily participated in the study. Most of them were attending urologists (79%), with a mean of 9-years of independent practice. Only 21.1% had previous practice on PCNL simulators. Compared with the pre-test, there was significant improvement in the checklist total score ( P P = 0.003), situational stress ( P = 0.003), and performance ( P = 0.003 ) during the post-test. The participants considered the CAT very useful for training in PCA (score 5.3/6). A total of 14 (36%) participants responded to the course evaluation questionnaire, seven (50%) evaluated the course as excellent, four (28.6%) as very good, and three (21.4%) as good. Conclusion The CAT simulator was considered useful for training in PCA. There was significant improvement in the qualitative and quantitative parameters during the post-test compared with the pre-test.

To discuss contemporary data on the value of multiparametric MRI (mpMRI) for guiding the decision to biopsy men at risk for prostate cancer, as well as its utility in active surveillance programs.Although a systematic 12-core biopsy is the current standard of care for men with increased suspicion for prostate cancer, MRI with or without targeted biopsy has been shown to reliably improve the detection of clinically significant disease following a prior negative biopsy. At the same time, there is a growing body of evidence to support the use of MRI for diagnostic purposes in biopsy-naive patients, as well for enrolling and monitoring men on active surveillance programs.mpMRI is an evolving technology with great promise for altering our approach to prostate cancer diagnosis and surveillance. In conjunction with targeted biopsies, MRI offers greater specificity for the detection of clinically significant cancer and therefore may help to reduce overdetection of indolent disease while minimizing the risks and limitations of systematic biopsies.

Men diagnosed with low- to intermediate-risk, clinically localized prostate cancer (PCa) often face a daunting and difficult decision with respect to treatment: active surveillance (AS) or radical therapy. This decision is further confounded by the fact that many of these men diagnosed, by an elevated PSA, will have indolent disease and never require intervention. Radical treatments, including radical prostatectomy and whole-gland radiation, offer greater certainty for cancer control, but at the risk of significant urinary and/or sexual morbidity. Conversely, AS preserves genitourinary function and quality of life in exchange for burdensome surveillance and the psychological impact of living with cancer.

Purpose To systematically review and perform a meta-analysis on the safety and efficacy of endovascular therapy in the treatment of the two most common etiologies of vasculogenic erectile dysfunction (ED): veno-occlusive dysfunction (VOD) and arterial insufficiency (AI). Materials and Methods PubMed, Web of Science, ScienceDirect, and Scopus databases were searched for published English literature regarding endovascular ED treatments. Case series (n ≥ 3) were included. Multiple data points were obtained, including demographic data, etiology, diagnosis method, imaging studies, treatment approach, technical success, clinical success, complications, and follow-up. Results Sixteen relevant articles were obtained and a total of 212 patients with VOD and 162 with AI were identified. The VOD cohort were treated either percutaneously (60.4%; n = 128) or after surgical exposure of the deep dorsal vein (33.5%, n = 71), or it was unspecified (6.1%; n = 13). The most common embolic used was n-butyl cyanoacrylate (51.9%; n = 109). Meta-analysis found an overall clinical success rate of 59.8% in VOD patients. Complications occurred in 5.2% of patients (n = 11), with 9 considered to be mild and 2 considered to be severe. The AI cohort contained 162 patients most commonly treated via stenting of the internal pudendal artery (40.1%; n = 65). Meta-analysis found an overall clinical success rate of 63.2% in AI patients. Complications occurred in 4.9% of patients (n = 8), with 4 considered to be mild and 4 considered to be severe. Conclusions Endovascular therapy for medically refractory ED is safe and may provide a treatment alternative to more invasive surgical management; however, conclusions are limited by the heterogeneity of clinical success definitions among the included studies.

INTRODUCTION AND OBJECTIVES: Patients with persistently elevated prostate specific antigen (PSA) and prior negative 12-core TRUS prostate biopsy (or biopsies) (SBx) are a diagnostic challenge. Repeat SBx or saturation biopsy in this cohort has been shown to have an even lower yield. The aim of our study is to compare the prostate cancer yield of MRI fusion biopsy (FBx) to SBx in a multi-institutional cohort comprised of patients with prior negative biopsies. METHODS: A multi-institutional review was performed on patients with a history of one or more prior negative SBx who underwent multiparametric MRI (MpMRI), followed by FBx and SBx in the same session. Imaging protocol was standardized across institutions and institutional genitourinary radiologists and pathologists reviewed mpMRI and pathology, respectively. Gleason Score (GS) distribution and risk classifications were recorded. Prostate cancer with GS ≥ 3+4 was defined as clinically significant (CS). Univariate and multivariable logistic regression was done to identify predictors of cancer detection on SBx and FBx. RESULTS: Seven-hundred seventy-nine patients from four institutions were included in the study. Median age and PSA (IQR) were 63.1 (58.5-68.0) years and 8.5 (5.9-13.1) ng/dL, respectively. Median number of prior negative biopsies (range) was 2.0 (1-16). The cancer detection rate (CDR) in the cohort was 346/779 patients (44.4%). Total CS CDR was 30.7% (239/779 patients), with FBx detecting 26.3% (205/779) of patients with CS disease and SBx diagnosing an additional 4.4% (34/779) of patients (p6) (One negative biopsy 11.5% versus 3.6%, 2-3 negative biopsy 10.3% versus 5.3%, 4 or more negative biopsies 19.1% versus 1.1%). On multivariable analysis, the number of prior negative biopsies was a significant negative predictor of CS CDR on SBx (p=0.006), but not on FBx (p=0.151). CONCLUSIONS: Using a large multi-institutional cohort, we were able to demonstrate that FBx outperformed SBx in patients with prior negative systematic biopsy. This was due, in part, to the decreasing CS CDR by SBx with increased number of prior biopsies. The yield of FBx stayed constant and did not decrease with increased number of prior negative biopsies. Therefore, repeat SBx alone in patients with multiple prior negative biopsies will be hindered by lower yield and FBx should be utilized concurrently in these patients.

The recent advent of radiomics has enabled the development of prognostic and predictive tools which use routine imaging, but a key question that still remains is how reproducible these features may be across multiple sites and scanners. This is especially relevant in the context of MRI data, where signal intensity values lack tissue specific, quantitative meaning, as well as being dependent on acquisition parameters (magnetic field strength, image resolution, type of receiver coil). In this paper we present the first empirical study of the reproducibility of 5 different radiomic feature families in a multi-site setting; specifically, for characterizing prostate MRI appearance. Our cohort comprised 147 patient T2w MRI datasets from 4 different sites, all of which were first pre-processed to correct acquisition-related for artifacts such as bias field, differing voxel resolutions, as well as intensity drift (non-standardness). 406 3D voxel wise radiomic features were extracted and evaluated in a cross-site setting to determine how reproducible they were within a relatively homogeneous non-tumor tissue region; using 2 different measures of reproducibility: Multivariate Coefficient of Variation and Instability Score. Our results demonstrated that Haralick features were most reproducible between all 4 sites. By comparison, Laws features were among the least reproducible between sites, as well as performing highly variably across their entire parameter space. Similarly, the Gabor feature family demonstrated good cross-site reproducibility, but for certain parameter combinations alone. These trends indicate that despite extensive pre-processing, only a subset of radiomic features and associated parameters may be reproducible enough for use within radiomics-based machine learning classifier schemes.

Men diagnosed with low- to intermediate-risk, clinically localized prostate cancer (PCa) often face a daunting and difficult decision with respect to treatment: active surveillance (AS) or radical therapy. This decision is further confounded by the fact that many of these men diagnosed, by an elevated PSA, will have indolent disease and never require intervention. Radical treatments, including radical prostatectomy and whole-gland radiation, offer greater certainty for cancer control, but at the risk of significant urinary and/or sexual morbidity. Conversely, AS preserves genitourinary function and quality of life in exchange for burdensome surveillance and the psychological impact of living with cancer.

Robust and accurate alignment of multimodal medical images is a very challenging task, which however is very useful for many clinical applications. For example, magnetic resonance (MR) and transrectal ultrasound (TRUS) image registration is a critical component in MR-TRUS fusion guided prostate interventions. However, due to the huge difference between the image appearances and the large variation in image correspondence, MR-TRUS image registration is a very challenging problem. In this paper, an adversarial image registration (AIR) framework is proposed. By training two deep neural networks simultaneously, one being a generator and the other being a discriminator, we can obtain not only a network for image registration, but also a metric network which can help evaluate the quality of image registration. The developed AIR-net is then evaluated using clinical datasets acquired through image-fusion guided prostate biopsy procedures and promising results are demonstrated.

Objectives To evaluate the performance of multiparametric magnetic resonance imaging (mpMRI) in predicting prostate cancer on repeat biopsy; and to compare the cancer detection rates (CDRs) of MRI/transrectal ultrasonography (TRUS) fusion-guided biopsy with standard 12-core biopsy in men with at least one previous negative biopsy. Patients and Methods We prospectively enrolled men with elevated or rising PSA levels and/or abnormal digital rectal examination into our MRI/TRUS fusion-guided prostate biopsy trial. Participants underwent a 3 T mpMRI with an endorectal coil. Three radiologists graded all suspicious lesions on a 5-point Likert scale. MRI/TRUS fusion-guided biopsies of suspicious prostate lesions and standard TRUS-guided 12-core biopsies were performed. Analysis of 140 eligible men with at least one previous negative biopsy was performed. We calculated CDRs and estimated area under the receiver operating characteristic curves (AUCs) of mpMRI in predicting any cancer and clinically significant prostate cancer. Results The overall CDR was 65.0% (91/140). Higher level of suspicion on mpMRI was significantly associated with prostate cancer detection (P < 0.001) with an AUC of 0.744 compared with 0.653 and 0.680 for PSA level and PSA density, respectively. The CDRs of MRI/TRUS fusion-guided and standard 12-core biopsy were 52.1% (73/140) and 48.6% (68/140), respectively (P = 0.435). However, fusion biopsy was more likely to detect clinically significant prostate cancer when compared with the 12-core biopsy (47.9% vs 30.7%; P < 0.001). Of the cancers missed by 12-core biopsy, 20.9% (19/91) were clinically significant. Most cancers missed by 12-core biopsy (69.6%) were located in the anterior fibromuscular stroma and transition zone. Using a fusion-biopsy-only approach in men with an MRI suspicion score of ≥4 would have missed only 3.5% of clinically significant prostate cancers. Conclusions Using mpMRI and subsequent MRI/TRUS fusion-guided biopsy platform may improve detection of clinically significant prostate cancer in men with previous negative biopsies. Addition of a 12-core biopsy may be needed to avoid missing some clinically significant prostate cancers.

Purpose To correlate quantitative diffusion-weighted imaging (DWI) parameters derived from conventional monoexponential DWI, stretched exponential DWI, diffusion kurtosis imaging (DKI), and diffusion-tensor imaging (DTI) with quantitative histopathologic tumor tissue composition in prostate cancer in a preliminary hypothesis-generating study. Materials and Methods This retrospective institutional review board-approved study included 24 patients with prostate cancer (mean age, 63 years) who underwent magnetic resonance (MR) imaging, including high-b-value DWI and DTI at 3.0 T, before prostatectomy. The following parameters were calculated in index tumors and nontumoral peripheral zone (PZ): apparent diffusion coefficient (ADC) obtained with monoexponential fit (ADC

Purpose: To codify the use of multiparametric magnetic resonance imaging (mpMRI) for the interrogation of prostate neoplasia (PCa) in clinical practice and focal therapy (FT). Methods: An international collaborative consensus project was undertaken using the Delphi method among experts in the field of PCa. An online questionnaire was presented in three consecutive rounds and modified each round based on the comments provided by the experts. Subsequently, a face-to-face meeting was held to discuss and finalize the consensus results. Results: mpMRI should be performed in patients with prior negative biopsies if clinical suspicion remains, but not instead of the PSA test, nor as a stand-alone diagnostic tool or mpMRI-targeted biopsies only. It is not recommended to use a 1.5 Tesla MRI scanner without an endorectal or pelvic phased-array coil. mpMRI should be performed following standard biopsy-based PCa diagnosis in both the planning and follow-up of FT. If a lesion is seen, MRI-TRUS fusion biopsies should be performed for FT planning. Systematic biopsies are still required for FT planning in biopsy-naïve patients and for patients with residual PCa after FT. Standard repeat biopsies should be taken during the follow-up of FT. The final decision to perform FT should be based on histopathology. However, these consensus statements may differ for expert centers versus non-expert centers. Conclusions: The mpMRI is an important tool for characterizing and targeting PCa in clinical practice and FT. Standardization of acquisition and reading should be the main priority to guarantee consistent mpMRI quality throughout the urological community., SCOPUS: ar.j, info:eu-repo/semantics/published

The nontargeted sampling of standard 12-core transrectal ultrasound (TRUS) biopsy has resulted in considerable undergrading of clinically significant prostate cancers. Magnetic resonance imaging (MRI)/transrectal ultrasound fusion-guided biopsy has emerged as an option for improved detection of prostate cancer. This novel technology, which combines high-resolution anatomic and functional prostate imaging via MRI with real-time TRUS biopsy probe guidance, allows for precise targeted biopsies of specified lesions. As initial studies have illustrated, this biopsy method has the potential to revolutionize the way prostate cancer is screened for, identified, and potentially treated. Herein, we provide a comprehensive review of the MRI/TRUS fusion biopsy technique, as well as a broad overview of the currently available fusion biopsy platforms and their clinical outcomes.

Objectives To determine the diagnostic yield of analysing biparametric (T2- and diffusion-weighted) magnetic resonance imaging (B-MRI) for prostate cancer detection compared with standard digital rectal examination (DRE) and prostate-specific antigen (PSA)-based screening. Patients and Methods Review of patients who were enrolled in a trial to undergo multiparametric-prostate (MP)-MRI and MR/ultrasound fusion-guided prostate biopsy at our institution identified 143 men who underwent MP-MRI in addition to standard DRE and PSA-based prostate cancer screening before any prostate biopsy. Patient demographics, DRE staging, PSA level, PSA density (PSAD), and B-MRI findings were assessed for association with prostate cancer detection on biopsy. Results Men with detected prostate cancer tended to be older, with a higher PSA level, higher PSAD, and more screen-positive lesions (SPL) on B-MRI. B-MRI performed well for the detection of prostate cancer with an area under the curve (AUC) of 0.80 (compared with 0.66 and 0.74 for PSA level and PSAD, respectively). We derived combined PSA and MRI-based formulas for detection of prostate cancer with optimised thresholds. (i) for PSA and B-MRI: PSA level + 6 x (the number of SPL) > 14 and (ii) for PSAD and B-MRI: 14 × (PSAD) + (the number of SPL) >4.25. AUC for equations 1 and 2 were 0.83 and 0.87 and overall accuracy of prostate cancer detection was 79% in both models. Conclusions The number of lesions positive on B-MRI outperforms PSA alone in detection of prostate cancer. Furthermore, this imaging criteria coupled as an adjunct with PSA level and PSAD, provides even more accuracy in detecting clinically significant prostate cancer.

Objective To define the role of multiparametric MRI (mpMRI) for treatment planning, guidance and follow-up in focal therapy for prostate cancer based on a multidisciplinary Delphi consensus project. Materials and Methods An online consensus process based on a questionnaire was circulated according to the Delphi method. Discussion points were identified by literature research and were sent to the panel via an online questionnaire in three rounds. A face-to-face consensus meeting followed the three rounds of questions that were sent to a 48-participant expert panel consisting of urologists, radiologists and engineers. Participants were presented with the results of the previous rounds. Conclusions formulated from the results of the questionnaire were discussed in the final face-to-face meeting. Results Consensus was reached in 41% of all key items. Patients selected for focal therapy should have biopsy-proven prostate cancer. Biopsies should ideally be performed after mpMRI of the prostate. Standardization of imaging protocols is essential and mpMRIs should be read by an experienced radiologist. In the follow-up after focal therapy, mpMRI should be performed after 6 months, followed by a yearly mpMRI. mpMRI findings should be confirmed by targeted biopsies before re-treatment. No consensus was reached on whether mpMRI could replace transperineal template saturation biopsies to exclude significant lesions outside the target lesion. Conclusions Consensus was reached on a number of areas related to the conduct, interpretation and reporting of mpMRI for use in treatment planning, guidance and follow-up of focal therapy for prostate cancer. Future studies, comparing mpMRI with transperineal saturation mapping biopsies, will confirm the importance of mpMRI for a variety of purposes in focal therapy for prostate cancer.

BACKGROUND The Prostate Cancer Prevention Trial risk calculator for high-grade (PCPTHG) prostate cancer (CaP) was developed to improve the detection of clinically significant CaP. In this study, the authors compared the performance of the PCPTHG against multiparametric magnetic resonance imaging (MP-MRI) in predicting men at risk of CaP. METHODS Men with an abnormal prostate-specific antigen (PSA) level or digital rectal examination (DRE) and a suspicious lesion on a 3-Tesla MP-MRI were enrolled prospectively. Three radiologists reviewed and graded all lesions on a 5-point Likert scale. Biopsy of suspicious lesion(s) was performed using a proprietary MRI/transrectal ultrasound fusion-guided prostate biopsy system, after which 12-core biopsy was performed. A genitourinary pathologist reviewed all pathology slides. The performance of PCPTHG was compared with that of MP-MRI in predicting clinically significant CaP. RESULTS Of 175 men who were eligible for analysis, 64.6% (113 of 175 men) were diagnosed with CaP, including 93 of 113 men (82.3%) who had clinically significant disease. Age, abnormal DRE, PSA, PSA density, prostate size, extraprostatic extension on MRI, apparent diffusion coefficient value, and MRI lesion size were identified as significant predictors of high-grade CaP (all P