Search

To improve the management of cirrhotic patients diagnosed with new renal masses, we used a nationally representative cohort to assess the perioperative outcomes of nephrectomy in the setting of liver disease. The incidences of liver disease and renal masses are both rising in the US. Delaying liver transplantation to address other health concerns may have life changing consequences in these patients, thus these results help to guide treatment decisions at this critical junction in care.A retrospective study of the 2016-2019 Nationwide Readmissions Database was performed in adults undergoing nephrectomy for non-emergent indications. Outcomes were compared between three cohorts: no chronic liver disease (no CLD), chronic liver disease (CLD), and decompensated cirrhosis (DC). Mixed regression models were used to evaluate the association between CLD and DC with outcomes of interest including morbidity, mortality, readmission rates, non-home discharges, length of stay, and costs.A total of 183,362 patients were evaluated. The mortality rate in the DC cohort (7%) was higher than with CLD (0.4%) and no CLD (0.3%), (p0.001). DC was associated with higher mortality (OR 8.29, 95% CI 4.07 - 16.88), post-operative bleeding requiring transfusion (OR 5.55, 95% CI 3.72 - 8.26), non-home discharge (OR 5.12, 95% CI 3.16 - 8.30) and readmission (OR 1.79, 95% CI 1.09 - 2.94) compared to no CLD. The DC cohort had the greatest length of stay and costs.Patients undergoing nephrectomy with DC have increased morbidity, mortality, readmission rates, non-home discharges, LOS and costs. Alternative management strategies may be considered in these patients.

Introduction:Treatment of benign renal masses may often be unnecessary and can lead to significant morbidity, mortality, and health care costs. However, individual burdens such as decisiona...

Renal oncocytoma (RO) accounts for 5% of renal cancers and generally behaves as a benign tumor with favorable long-term prognosis. It is difficult to confidently distinguish between benign RO and other renal malignancies, particularly chromophobe renal cell carcinoma (chRCC). Therefore, RO is often managed aggressively with surgery. We sought to identify molecular biomarkers to distinguish RO from chRCC and other malignant renal cancer mimics. In a 44-patient discovery cohort, we identified a significant differential abundance of nine genes in RO relative to chRCC. These genes were used to train a classifier to distinguish RO from chRCC in an independent 57-patient cohort. The trained classifier was then validated in five independent cohorts comprising 89 total patients. This nine-gene classifier trained on the basis of differential gene expression showed 93% sensitivity and 98% specificity for distinguishing RO from chRCC across the pooled validation cohorts, with a c-statistic of 0.978. This tool may be a useful adjunct to other diagnostic modalities to decrease the diagnostic and management uncertainty associated with small renal masses and to enable clinicians to recommend more confidently less aggressive management for some tumors. PATIENT SUMMARY: Renal oncocytoma is generally a benign form of kidney cancer that does not necessarily require surgical removal. However, it is difficult to distinguish renal oncocytoma from other more aggressive forms of kidney cancer, so it is treated most commonly with surgery. We built a classification tool based on the RNA levels of nine genes that may help avoid these surgeries by reliably distinguishing renal oncocytoma from other forms of kidney cancer.

Background Although renal cell carcinoma (RCC) is believed to have a strong hereditary component, there is a paucity of published guidelines for genetic risk assessment. A panel of experts was convened to gauge current opinions. Methods A North American multidisciplinary panel with expertise in hereditary RCC, including urologists, medical oncologists, clinical geneticists, genetic counselors, and patient advocates, was convened. Before the summit, a modified Delphi methodology was used to generate, review, and curate a set of consensus questions regarding RCC genetic risk assessment. Uniform consensus was defined as ≥85% agreement on particular questions. Results Thirty-three panelists, including urologists (n = 13), medical oncologists (n = 12), genetic counselors and clinical geneticists (n = 6), and patient advocates (n = 2), reviewed 53 curated consensus questions. Uniform consensus was achieved on 30 statements in specific areas that addressed for whom, what, when, and how genetic testing should be performed. Topics of consensus included the family history criteria, which should trigger further assessment, the need for risk assessment in those with bilateral or multifocal disease and/or specific histology, the utility of multigene panel testing, and acceptance of clinician-based counseling and testing by those who have experience with hereditary RCC. Conclusions In the first ever consensus panel on RCC genetic risk assessment, 30 consensus statements were reached. Areas that require further research and discussion were also identified, with a second future meeting planned. This consensus statement may provide further guidance for clinicians when considering RCC genetic risk assessment. Lay summary The contribution of germline genetics to the development of renal cell carcinoma (RCC) has long been recognized. However, there is a paucity of guidelines to define how and when genetic risk assessment should be performed for patients with known or suspected hereditary RCC. Without guidelines, clinicians struggle to define who requires further evaluation, when risk assessment or testing should be done, which genes should be considered, and how counseling and/or testing should be performed. To this end, a multidisciplinary panel of national experts was convened to gauge current opinion on genetic risk assessment in RCC and to enumerate a set of recommendations to guide clinicians when evaluating individuals with suspected hereditary kidney cancer.

Objective To determine whether a combination of prostate cancer gene 3 (PCA3) and magnetic resonance imaging (MRI) suspicion score (mSS) could further optimize detection of prostate cancer on MRI fusion-targeted biopsy (MRF-TB) among men with no history of biopsy. Materials and Methods We included in this study 187 men presenting to our institution between June 2012 and August 2014 who underwent multiparametric MRI (mpMRI) and PCA3 before MRF-TB. Biopsy results, stratified by biopsy indication and PCA3 score, were recorded. Receiver operating characteristics curves and multivariable logistic regressions were used to model the association of PCA3 and mSS with cancer detection on MRF-TB. Results PCA3 is associated with cancer detection on MRF-TB for men with no prior biopsies (area under the curve: 0.67, 95% confidence interval: 0.59-0.76). Using a cutoff of ≥35, PCA3 was associated with cancer risk among men with mSS 2-3 ( P = .004), but not among those with mSS 4-5 ( P = .340). The interaction of PCA3 and mSS demonstrated significantly higher discrimination for cancer than mSS alone (area under the curve: 0.83 vs 0.79, P = .0434). Conclusion Urinary PCA3 is associated with mSS and the detection of cancer on MRF-TB for men with no prior biopsies. PCA3 notably demonstrates a high negative predictive value among mSS 2-3. However, in the case of high-suspicion mpMRI, PCA3 is not associated with cancer detection on MRF-TB, adding little to cancer diagnosis. Further studies are needed to evaluate the utility of PCA3 in predicting cancer among men with normal mpMRI.

Introduction The initial clinical trials for intralesional collagenase Clostridium histolyticum (CCh) injection therapy for Peyronie disease (PD) excluded men on antiplatelet or anticoagulant medications except those on low-dose aspirin. Men with PD who take such medications present a challenging clinical scenario because of a lack of evidence regarding the safety of CCh while on these drugs. Aim To evaluate safety outcomes among patients continuing anticoagulant and antiplatelet therapy during ongoing intralesional CCh injection treatment for PD. Methods An institutional review board approved a database of 187 patients treated with CCh at an academic men's health practice from January 2016 through April 2019 was reviewed. Men on antiplatelet/anticoagulant medications were not instructed to stop these agents. Data on patient demographics, comorbidities, CCh injection details, use or nonuse of antiplatelet/anticoagulant medications, and adverse events were extracted from the electronic medical record. Rates of hematoma formation, bruising, swelling, and corporal rupture were determined. Univariate statistical analysis compared clinical data and adverse events between men on or off antiplatelet/anticoagulant medications. Main Outcome Measure Statistical comparison of adverse events in those taking or not taking antiplatelet or anticoagulant medications while undergoing intralesional CCh injection therapy for PD. Results Of 187 men undergoing CCh treatment, 33 (17.6%) were on concomitant antiplatelet or anticoagulant therapy. Aspirin 81 mg alone was the most common pharmacologic agent (58% of men on antiplatelet/anticoagulants); medications also included other antiplatelet drugs, warfarin, and novel oral anticoagulants (NOACs). Men taking blood thinners during intralesional CCh injection therapy experienced no statistical difference in rates of bruising, swelling, or hematoma formation compared with men not on antiplatelet/anticoagulants. No corporal ruptures were observed in either group. Men on antiplatelet or anticoagulant therapy were more likely to be older (64 vs 58 years old, P = 0.005), have hypertension (P = 0.025), and have hyperlipidemia (0.009). Clinical Implications Intralesional CCh injection therapy may be offered to men on antiplatelet/anticoagulant medications without increased risk of adverse events. Strength & Limitations This study evaluated the experience of a single surgeon, with a systematic evaluation of adverse events captured in a robust electronic medical record. The retrospective nature of this study limits conclusions but builds upon work performed in the initial clinical trials for CCh. Conclusion Our findings suggest that antiplatelet and anticoagulant medications do not increase the risk of adverse events during intralesional CCh injection therapy for PD.

Introduction Intralesional injection therapy with collagenase Clostridium histolyticum (CCh) is an effective treatment option for Peyronie’s disease (PD), but it carries risks, costs, and the need for multiple visits, which may cause patients to discontinue therapy prematurely. Aims To identify and summarize the current literature on CCh discontinuation and present our experience with CCh discontinuation. Methods We performed a PubMed review of existing literature on discontinuation from CCh therapy and retrospectively analyzed our prospectively maintained Institutional Review Board–approved CCh database for January 2016–December 2018. Demographic information, clinical outcomes, and communication logs were collected. Reasons for discontinuation of therapy were assessed. A logistic regression to identify factors influencing dropout was performed. Main Outcome Measures Documentation of discontinuation statistics in published literature, and rates of and reasons for discontinuation in a single-institution cohort. Results Our literature review identified 15 studies with specified cohort sizes. Of these, 10 specifically quantified discontinuation rates, which ranged from 13% to 56%. Combined, these studies show a 20% dropout rate. Dissatisfaction with therapy was the most common reason for dropout. In our cohort, 100 men completed a course of 8 CCh injections. Twelve men (10.7%) discontinued therapy, including 4 due to relocation, 3 due to cost, 1 due to a hematoma, 1 due to early satisfaction, 2 due to no perceived improvement, and 1 due to a demanding work schedule. Hematoma formation was a predictor of dropout in our cohort (odds ratio 8.74; P = .037). Conclusion Additional focus must be placed on quantifying and evaluating CCh discontinuation. Our findings show that a majority of men complete a full course of 8 injections; most of the few men who dropped out of therapy did so due to relocation. Counseling to reduce CCh discontinuation should focus on initial sexual function, adverse events, and expectations. Amighi A, Eleswarapu SV, Mendhiratta N, et al. Discontinuation from Collagenase Clostridium histolyticum Therapy for Peyronie’s Disease: Review and Single-Center Cohort Analysis. Sex Med Rev 2019;7:690–698.

Early clinical trials of injectable collagenase Clostridium histolyticum (CCh) for Peyronie’s disease (PD) demonstrated safety and efficacy. Since then, modified injection protocols have been proposed. Adverse events—such as bruising, swelling, hematoma, and corporal rupture—exceed 50% in many studies, but lack of standardization of hematoma severity limits conclusions about the relative safety of protocols. We propose a modification of the standard injection technique that aims to decrease the rates of adverse events. We further describe a hematoma classification rubric that may standardize safety assessment. A modified injection procedure, termed the “fan” technique, was employed in the treatment of PD. All men receiving CCh from January 2016 through January 2019 at a single institution were included in an institutional review board (IRB) approved database. Treatment outcomes and adverse events were retrospectively assessed. A three-tiered hematoma classification rubric was devised to standardize reporting of hematoma, which was defined as concurrent bruising and swelling at the site of injection without loss of erection. Using the fan technique, 152 patients received 1323 injections. Eight hematomas (5.3% of all patients, 0.6% of all injections) were observed. The number of grade I, grade II, and grade III hematomas were 3, 2, and 3, respectively. Bruising or swelling not meeting the definition of hematoma was seen in 54.6% and 27.0% of patients, respectively. There were zero corporal ruptures. A modified injection technique results in reduced procedural morbidity. A hematoma classification system provides clarity and standardization to the assessment of safety in PD treatment. Further clinical studies with control arms are required to verify these findings.

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.

Objectives To evaluate the cancer detection rates for men undergoing 12-core systematic prostate biopsy with negative prebiopsy multiparametric magnetic resonance imaging (mpMRI) results. Materials and Methods Clinical data from consecutive men undergoing prostate biopsy who had undergone prebiopsy 3T mpMRI from December 2011 to August 2014 were reviewed from an institutional review board-approved prospective database. Men with negative prebiospy mpMRI results (negMRI) before biopsy were identified for the present analysis. Clinical features, cancer detection rates and negative predictive values were summarized. Results Seventy five men with negMRI underwent systematic 12-core biopsy during the study period. In the entire cohort, men with no previous biopsy, men with previously negative biopsy and men enrolled in active surveillance protocols, the overall cancer detection rates were 18.7, 13.8, 8.0 and 38.1%, respectively, and the detection rates for Gleason score (GS) ≥7 cancer were 1.3, 0, 4.0 and 0%, respectively. The NPVs for all cancers were 81.3, 86.2, 92.0, and 61.9, and for GS ≥7 cancer they were 98.7, 100, 96.0 and 100%, respectively. Conclusions A negative prebiopsy mpMRI confers an overall NPV of 82% on 12-core biopsy for all cancer and 98% for GS ≥7 cancer. Based on biopsy indication, these findings assist in prebiopsy risk stratification for detection of high-risk disease and may provide guidance in the decision to pursue biopsy.

MRF-TB (magnetic resonance imaging-ultrasound fusion targeted prostate biopsy) may improve the detection of prostate cancer in men presenting for prostate biopsy. We report clinical outcomes of 12-core systematic biopsy and MRF-TB in men who presented for primary biopsy and further describe pathological characteristics of cancers detected by systematic biopsy and not by MRF-TB.Clinical outcomes of 452 consecutive men who underwent prebiopsy multiparametric magnetic resonance imaging followed by MRF-TB and systematic biopsy at our institution between June 2012 and June 2015 were captured in an institutional review board approved database. Clinical characteristics, biopsy results and magnetic resonance imaging suspicion scores were queried from the database.Prostate cancer was detected in 207 of 382 men (54.2%) with a mean±SD age of 64±8.5 years and mean±SEM prostate specific antigen 6.8±0.3 ng/ml who met study inclusion criteria. The cancer detection rate of systematic biopsy and MRF-TB was 49.2% and 43.5%, respectively (p=0.006). MRF-TB detected more Gleason score 7 or greater cancers than systematic biopsy (117 of 132 or 88.6% vs 102 of 132 or 77.3%, p=0.037). Of 41 cancers detected by systematic biopsy but not by MRF-TB 34 (82.9%) demonstrated Gleason 6 disease, and 26 (63.4%) and 34 (82.9%) were clinically insignificant by Epstein criteria and a UCSF CAPRA (University of California-San Francisco-Cancer of the Prostate Risk Assessment) score of 2 or less, respectively.In men presenting for primary prostate biopsy MRF-TB detects more high grade cancers than systematic biopsy. Most cancers detected by systematic biopsy and not by MRF-TB are at clinically low risk. Prebiopsy magnetic resonance imaging followed by MRF-TB decreases the detection of low risk cancers while significantly improving the detection and risk stratification of high grade disease.

Objective To report outcomes of magnetic resonance imaging (MRI)-ultrasound fusion–targeted biopsy (MRF-TB) and 12-core systematic biopsy (SB) over a 26-month period in men with prior negative prostate biopsy. Materials and Methods Between June 2012 and August 2014, 210 men presenting to our institution for prostate biopsy with ≥1 prior negative biopsy underwent multiparametric MRI followed by MRF-TB and SB and were entered into a prospective database. Clinical characteristics, maximum mpMRI suspicion scores (mSS), and biopsy results were queried from the database, and the detection rates of Gleason ≥7 prostate cancer (PCa) and overall PCa were compared between biopsy techniques using McNemar's test. Results Forty seven (29%) of 161 men meeting inclusion criteria (mean age, 65 ± 8 years; mean prostate-specific antigen, 8.9 ± 8.9) were found to have PCa. MRF-TB and SB had overall cancer detection rates (CDRs) of 21.7% and 18.6% (P = .36), respectively, and CDR for Gleason score (GS) ≥7 disease of 14.9% and 9.3% (P = .02), respectively. Of 26 men with GS ≥7 disease, MRF-TB detected 24 (92.3%) whereas SB detected 15 (57.7%; P < .01). Using UCSF-CAPRA criteria, only 1 man was restratified from low risk to higher risk based on SB results compared to MRF-TB alone. Among men with mSS

Three Tesla multiparametric magnetic resonance imaging with PI-RADS™ (Prostate Imaging Reporting and Data System) version 2 scoring is a common tool in prostate cancer diagnosis which informs the likelihood of a cancerous lesion. We investigated whether PI-RADS version 2 also predicts adverse pathology features mainly in patients with biopsy Gleason score 3 + 4 disease.We reviewed the records of 326 consecutive men with a preoperative template and/or magnetic resonance imaging-ultrasound fusion biopsy Gleason score of 6-7 from a prospectively maintained database of men who underwent robotic radical prostatectomy. The primary analysis was done in patients with biopsy Gleason score 3 + 4 to assess the primary outcome of adverse pathology features on univariate and multivariate logistic regression. The secondary outcome was biochemical recurrence-free survival using the Kaplan-Meier method. Similar analysis was done in patients with a biopsy Gleason score of 6-7.Of men with Gleason score 3 + 4 findings 27%, 15%, 36% and 23% showed a PI-RADS version 2 score of 0-2, 3, 4 and 5, respectively. On univariate analysis PI-RADS version 2 category 5 predicted adverse pathology features vs categories 0-2 (OR 10.7, 95% CI 3.7-31, p ≤0.001). On multivariate analysis the PI-RADS version 2 category 5 was associated with adverse pathology when adjusting for preoperative magnetic resonance imaging targeted biopsy (OR 11.4, 95% CI 3.7-35, p ≤0.0001). In men with a targeted biopsy Gleason score of 3 + 4 prostate cancer PI-RADS version 2 category 5 was associated with adverse pathology (OR 14.7, 95% CI 1.5-146.9, p = 0.02). Of men with biopsy Gleason score 3 + 4 disease 92% and 58% with a PI-RADS version 2 score of 4 and 5, respectively, had 2-year biochemical recurrence-free survival.A PI-RADS version 2 category 5 lesion in patients with a biopsy Gleason score 3 + 4 lesion predicted adverse pathology features and biochemical recurrence-free survival. These findings suggest that preoperative 3 Tesla multiparametric magnetic resonance imaging may serve as a prognostic marker of treatment outcomes independently of biopsy Gleason score or biopsy type.

Neoadjuvant chemotherapy (NAC) has been shown to improve survival in patients with urothelial carcinoma (UC). However, there are a subset of patients who do not respond or progress despite systemic treatment. Data from the National Cancer Database on patients who underwent a radical cystectomy (RC) with or without NAC from 2006 to 2013 were abstracted. Covariates were balanced using inverse probability weighting methods. The primary outcome of overall survival in patients with residual disease by stage was evaluated using 90-day conditional landmark analysis and Cox proportional hazards modeling. Secondary outcome of predictors of residual disease was evaluated using multivariable logistic regression analysis. A total of 20,128 patients met our inclusion criteria; 16,058 patients underwent RC only (80%) and 4070 underwent RC with NAC (20%). Patients who received NAC were younger and healthier, treated at an academic center, and presented with higher stage. NAC was associated with improved overall survival amongst patients with cT3-4aN0 (HR 0.84 95% CI 0.73–0.97; p = 0.02) and cN+ (HR 0.70, 95% CI 0.58–0.86; p = 0.001). Predictors of no residual disease were NAC (OR 0.17, 95% CI 0.14–0.21; p

The objectives of this study were to 1) describe the patterns of repeat prostate biopsy in men with a previous negative biopsy and 2) identify predictors of prostate cancer diagnosis on repeat biopsy in these men.From a university faculty group practice we identified 1,837 men who underwent prostate biopsy between January 1, 1995 and January 1, 2010. Characteristics of repeat biopsy were examined, including the indication for biopsy, the number of repeat biopsies performed, the number of cores obtained and total prostate specific antigen before biopsy. Features of prostate cancer diagnosed on repeat biopsy were examined, including Gleason score, number of positive cores, percent of tumor and treatment choice. Multivariable logistic regression was done to identify prostate cancer predictors.Initial biopsy was negative in 1,213 men. In 255 men a total of 798 repeat biopsies were performed. Of the 63 men diagnosed with prostate cancer Gleason score was 6 or less in 33 (52%), 7 in 22 (35%) and 8-9 in 8 (13%). When categorized by Epstein criteria, the rate of clinically insignificant cancer diagnosis decreased substantially by the third and fourth repeat biopsies. Repeat biopsy in men older than 70 years, biopsies including more than 20 cores and the fourth repeat biopsy were associated with an increased likelihood of prostate cancer diagnosis.In men selected for multiple repeat biopsies clinically significant cancer is found at each sampling round. Given the continued likelihood of cancer detection even by the fifth biopsy, early consideration of saturation or image guided biopsy may be warranted in the repeat biopsy population.

Multiparametric MRI of the prostate demonstrates strong potential to address many limitations of traditional prostate cancer diagnosis and management strategies. Recent evidence supports roles for prostate MRI in prebiopsy risk stratification, guidance of targeted biopsy and preoperative disease staging. Prostate MRI may also assist the planning and follow-up of investigational partial gland ablative therapies. This article reviews the impact of prostate MRI on such diagnostic and therapeutic paradigms in contemporary prostate cancer management.

INTRODUCTION AND OBJECTIVES: Mounting evidence suggests that MRI-ultrasound fusion-targeted prostate biopsy (MRFTB) may provide clinical benefit for men with suspicion of prostate cancer. We investigated outcomes of MRF-TB over time to evaluate how the performance characteristics vary with increasing operator experience. METHODS: Between June 2012 and April 2015, 566 men underwent MRF-TB by a single surgeon. A total of 429 men with no prior prostate cancer therapy had pre-biopsy multiparametric MRI (mpMRI) performed at our institution and reviewed by a single radiologist. During this time period, quality assurance efforts included team review of MRI interpretation, biopsy maps and outcome, and discussion of discrepant cases or unexpected pathology findings. We evaluated the cancer detection rates (CDR) among men with high mpMRI suspicion scores (mSS) as a function of operator experience. Trend was assessed using the Cochrane-Armitage test, and characteristics between groups were compared by chi-square or one-way ANOVA. RESULTS: All subjects were grouped according to the order of biopsy (1-60, 61-120, 121-180, 181-240, 241-300, 301-360, 361-429). Among groups, there was no difference in serum PSA (p 1⁄4 0.131) or mSS distribution (p 1⁄4 0.957). Cancer detection among men with mSS 4 or 5 demonstrated a significant, increasing trend as a function of biopsy experience, with CDRs of 63.0%, 69.6%, 77.8%, 68.2%, 88.0%, 84.0%, and 85.7% for groups 1-7, respectively (p 1⁄4 0.014). The CDR among men with mSS 2 or 3 did not demonstrate a trend (p 1⁄4 0.386) (Figure 1). CONCLUSIONS: Among men undergoing pre-biopsy mpMRI followed by MRF-TB, the rate of cancer detection appears to increase as a function of biopsy experience for men with high mpMRI suspicion (mSS 4-5), while little to no change is noted in men at lower suspicion (mSS 2-3). Improved outcomes over time may, in part, reflect evolution of MRI technique and interpretation, but these results additionally suggest that operator experience in the conduct of MRF-TB may play a significant role in optimizing cancer detection. Source of Funding: The Joseph and Diane Steinberg Charitable Trust

INTRODUCTION AND OBJECTIVES: MRI-targeted prostate biopsy (PB) is increasingly being utilized to aid cancer diagnosis in clinical practice. Our objective was to develop a nomogram to predict the probability of Gleason score 7 prostate cancer (CaP) on MRI targeted and systematic prostate biopsy in men with no previous biopsy. METHODS: From June 2012 to June 2015, MR-US fusion targeted prostate biopsy was performed on approximately 1,140 men with suspicious regions identified on pre-biopsy 3T multiparametric-MRI along with systematic 12 core biopsy, utilizing the ProFuse|Artemis system. Logistic regression modeling was used to evaluate predictors of Gleason score 7 CaP, and corresponding nomograms were generated. Models were created with a randomly selected training sample (n1⁄4232), tested (n1⁄459), and then validated (n1⁄498). Bias-corrected using bootstrap resampling, and Akaike information criterion was used to select best-fit models. RESULTS: A total of 389 men with no previous biopsy and complete records were included for analysis (median age 66 years, PSA 4.8 ng/ml, prostate volume 46 cc, PSA density 0.09 ng/ml-cc). Statistically significant independent positive predictors of CaP on targeted and systematic PB were found to be PSA density, age, and MRI suspicion score (MRIss). A CaP probability nomogram (Figure 1) was generated using the predictors and model performance characteristics bias-corrected areas under the receiver-operating characteristic curves (AUC) were validated (Figure 2). CONCLUSIONS: PSA density, age, and MRI suspicion score predict CaP on MRI-targeted and systematic biopsy. Our CaP probability nomogram may allow further individualization of the decision to perform PB in men with clinical suspicion of prostate cancer and no previous biopsy. Source of Funding: None

Advances in multiparametric magnetic resonance imaging (mpMRI) hold promise for the improved detection and characterization of prostate cancer. MpMRI combines diffusion-weighted imaging, dynamic contrast-enhanced sequences, or spectroscopy with conventional T2-weighted sequences. With a combination of anatomic and functional imaging sequences to identify suspicious regions in the prostate, pre-biopsy mpMRI has the potential to improve prostate cancer detection and risk stratification through MRI-targeted biopsy. In this chapter we review the role of mpMRI in prostate cancer detection, the outcomes of MRI-targeted biopsy, and the critical concepts currently under evaluation in validation of an MRI-based prostate cancer risk stratification strategy.

Introduction Multiparametric-MRI (mp-MRI) is an evolving noninvasive imaging modality that increases the accurate localization of prostate cancer at the time of MRI targeted biopsy, thereby enhancing clinical risk assessment, and improving the ability to appropriately counsel patients regarding therapy. Material and methods We used MEDLINE/PubMed to conduct a comprehensive search of the English medical literature. Articles were reviewed, data was extracted, analyzed, and summarized. In this review, we discuss the mp-MRI prostate exam, its role in targeted prostate biopsy, along with clinical applications and outcomes of MRI targeted biopsies. Results Mp-MRI, consisting of T2-weighted imaging, diffusion-weighted imaging, dynamic contrast-enhanced imaging, and possibly MR spectroscopy, has demonstrated improved specificity in prostate cancer detection as compared to conventional T2-weighted images alone. An MRI suspicion score has been developed and is depicted using an institutional Likert or, more recently, a standardized reporting scale (PI-RADS). Techniques of MRI-targeted biopsy include in-gantry MRI guided biopsy, TRUS-guided visual estimation biopsy, and software co-registered MRI-US guided biopsy (MRI-US fusion). Among men with no previous biopsy, MRI-US fusion biopsy demonstrates up to a 20% increase in detection of clinically significant cancers compared to systematic biopsy while avoiding a significant portion of low risk disease. These data suggest a potential role in reducing over-detection and, ultimately, over-treatment. Among men with previous negative biopsy, 72–87% of cancers detected by MRI targeted biopsy are clinically significant. Among men with known low risk cancer, repeat biopsy by MR-targeting improves risk stratification in selecting men appropriate for active surveillance secondarily reducing the need for repetitive biopsy during surveillance. Conclusions Use of mp-MRI for targeting prostate biopsies has the potential to reduce the sampling error associated with conventional biopsy by providing better disease localization and sampling. MRI-ultrasound fusion-targeted prostate biopsy may improve the identification of clinically significant prostate cancer while limiting detection of indolent disease, ultimately facilitating more accurate risk stratification. Literature supports the clinical applications of MRI-targeted biopsy in men who have never been biopsied before, those with a prior negative biopsy, and those with low risk disease considering active surveillance.

With the increasing rate of detection of localized, low-risk cancers of the prostate, new treatment strategies are required to avoid the morbidity of traditional whole-gland therapy while limiting the risk of significant disease progression. Focal therapy is a promising method of prostate cancer treatment with the potential to bridge the gap between active surveillance and radical treatment. Emerging data regarding oncological and quality of life outcomes from clinical trials are encouraging. Although the majority of contemporary-focal therapy options have yet to demonstrate comparable levels of cancer control as whole-gland or radical therapy, refinements in candidate selection, disease mapping, and accurate targeting of ablative energy to cancer foci may facilitate improvements in oncological outcomes. Some of the remaining challenges of focal therapy, including disease mapping, treatment monitoring, and evaluation at follow-up, may be addressed with advances in MRI sequencing and interpretation techniques. However, critical questions about long-term outcomes remain, which require further exploration before protocols for focal therapy in common clinical practice can be developed.

Objective To provide insight into the impact of radical prostatectomy (RP) on prostate cancer–specific mortality (PCSM) in a primarily prostate-specific antigen screen–detected cohort of men with localized prostate cancer (PCa). Methods Between 2000 and 2013, 1864 men consented to participate in a prospective longitudinal outcomes study after RP for localized PCa by a single surgeon. Men lost to follow-up were queried to the National Death Index to acquire mortality data. Results From our cohort of 1864 men (median age 59 years, median preoperative prostate-specific antigen 5.0, median follow-up 9.1 years), Kaplan-Meier analysis demonstrated 10-year all-cause mortality and PCSM of 4.6% and 1.4%, respectively. Ten-year PCSM for low, intermediate, and high D'Amico risk were 0.9%, 1.0%, and 7.4%, respectively (P

Increasing evidence supports the use of magnetic resonance imaging (MRI)-ultrasound fusion-targeted prostate biopsy (MRF-TB) to improve the detection of clinically significant prostate cancer (PCa) while limiting detection of indolent disease compared to systematic 12-core biopsy (SB).To compare MRF-TB and SB results and investigate the relationship between biopsy outcomes and prebiopsy MRI.Retrospective analysis of a prospectively acquired cohort of men presenting for prostate biopsy over a 26-mo period. A total of 601 of 803 consecutively eligible men were included.All men were offered prebiopsy MRI and assigned a maximum MRI suspicion score (mSS). Men with an MRI abnormality underwent combined MRF-TB and SB.Detection rates for all PCa and high-grade PCa (Gleason score [GS] ≥7) were compared using the McNemar test.MRF-TB detected fewer GS 6 PCas (75 vs 121; p0.001) and more GS ≥7 PCas (158 vs 117; p0.001) than SB. Higher mSS was associated with higher detection of GS ≥7 PCa (p0.001) but was not correlated with detection of GS 6 PCa. Prediction of GS ≥7 disease by mSS varied according to biopsy history. Compared to SB, MRF-TB identified more GS ≥7 PCas in men with no prior biopsy (88 vs 72; p=0.012), in men with a prior negative biopsy (28 vs 16; p=0.010), and in men with a prior cancer diagnosis (42 vs 29; p=0.043). MRF-TB detected fewer GS 6 PCas in men with no prior biopsy (32 vs 60; p0.001) and men with prior cancer (30 vs 46; p=0.034). Limitations include the retrospective design and the potential for selection bias given a referral population.MRF-TB detects more high-grade PCas than SB while limiting detection of GS 6 PCa in men presenting for prostate biopsy. These findings suggest that prebiopsy multiparametric MRI and MRF-TB should be considered for all men undergoing prostate biopsy. In addition, mSS in conjunction with biopsy indications may ultimately help in identifying men at low risk of high-grade cancer for whom prostate biopsy may not be warranted.We examined how magnetic resonance imaging (MRI)-targeted prostate biopsy compares to traditional systematic biopsy in detecting prostate cancer among men with suspicion of prostate cancer. We found that MRI-targeted biopsy detected more high-grade cancers than systematic biopsy, and that MRI performed before biopsy can predict the risk of high-grade cancer.

INTRODUCTION AND OBJECTIVES: While PCA3 has been shown to be predictive of prostate cancer (CaP) detection in the setting of systematic biopsy (SB), performance in the setting of targeted MRI-ultrasound fusion biopsy (MRF-TB) is not well described. METHODS: Biopsy results in all men undergoing both SB and MRF-TB, using the Artemis/Pro fuse system, between June 2012 and June 2014 were reviewed. PCA3 scores, highest MRI suspicion score (mSS), and cancer detection rates were extracted from 143 patients without a previous cancer diagnosis. Receiver operating characteristics (ROC) were analyzed to determine the performance of PCA3 in predicting cancer on MRF-TB at varying thresholds. In bivariable analyses, the association between elevated PCA3 and MRF-TB findings were analyzed. The predictive capability of PCA3þmSS was compared to that of mSS alone by fitting multivariable logistic regression models and comparing ROC and areas under the curve (AUC). RESULTS: Table 1 summarizes the predictive capability for Gleason 3þ3 or higher disease on MRF-TB, stratified by threshold. In bivariable analyses using a threshold of 35, a greater proportion of those with a high PCA3 demonstrated cancer on MRF-TB than those with a low PCA3 (46.8% vs. 18.8%, p < 0.001). Similarly, patients with a high PCA3 and mSS 3 were more likely to have cancer on MRF-TB than those with a low PCA3 and mSS 3 (48.8% vs. 26.7%, p 1⁄4 0.004). In multivariable analyses, a logistic regression model containing both PCA3 and mSS was associated with significantly higher discrimination of cancer on MRF-TB compared to a model of mSS alone (AUC 0.786 vs. 0.741, p 1⁄4 0.038). Potential study cohort outcomes by threshold are detailed in Table 2 CONCLUSIONS: The predictive capability of PCA3 for prostate cancer is retained in the setting of MRF-TB. Addition of PCA3 to mSS would improve the overall diagnostic accuracy of MRF-TB, but further work is needed to determine the impact of PCA3 at individual thresholds.

INTRODUCTION AND OBJECTIVES: The aim of the study was to compare partial cystectomy (PC) and radical cystectomy (RC) with respect to 90-day mortality as well as long-term, all cause (ACM) and cancer specific mortality (CSM). METHODS: Using the SEER-Medicare database 3913 patients with T2-T3 urothelial carcinoma of the urinary bladder (UCUB) who underwent either RC (n1⁄43419) or PC (n1⁄4494) were identified. After propensity score matching to reduce potential treatment selection bias, 90day mortality, ACM-free and CSM-free rates between patients treated with PC and RC were estimated. Multivariable regression models (MVA) addressed 90-day mortality as well as 5-years ACM and CSM. RESULTS: After matching, 33% (n1⁄4494) and 67% (n1⁄4988) patients treated respectively with PC or RC remained. Median follow-up was 26months. The 90-daymortality rate was 3.2% (n1⁄416) after PC and 8.1% (n1⁄480) after RC (p1⁄40.001). In MVA, PC vs. RC was associated with a lower 90-day mortality (p