Institutional adoption and apprenticeship of fusion targeted prostate biopsy

$\textit {Introduction:}$ There are limited data on the learning curve of magnetic resonance imaging/transrectal ultrasound (MRI/TRUS)-fusion targeted prostate biopsies (tBx). $\textit {Objective:}$ The aim of this study was to investigate the difference in prostate cancer (PCa) detection rate between an experienced urologist and novice resident performing tBx. $\textit {Methods:}$ A total of 183 patients underwent tBx from 2012 to 2016 for a total of 518 tBx cores. Biopsies in this study were performed by an experienced urologist (investigator A) or a novice resident (investigator B). The outcome was the detection of PCa on tBx. Using a multivariable logistic regression model, we estimated odds ratios for the detection of PCa. Inverse probability treatment weighting (IPTW) was used to balance patients' baseline characteristics and compare detection rates of PCa. Before performance of tBx, all patients underwent MRI. $\textit {Results:}$ On multivariable logistic regression analysis, investigator experience was associated with a higher odds of detection of PCa (OR = 1.003; 95% confidence interval 1.002–1.006, $\it p$ = 0.037). After IPTW adjustment, there was no significant difference between the detection rate of investigator A (23%) and investigator B (32%; $\it p$ = 0.457). $\textit {Conclusions:}$ Data revealed a positive association between investigator experience and the odds of PCa detection, although there was no difference in the detection rates of the investigators

Psychosocial distress in the early recovery period after radical prostatectomy

$\bf Purpose:$ This study aimed to evaluate psychosocial distress in the context of continence and oncological outcome during the early recovery period after radical prostatectomy (RP) for prostate cancer. $\bf Patients and Methods:$ Retrospectively collected data from 587 patients who underwent inpatient rehabilitation after RP in 2016 and 2017 were analyzed. Psychosocial distress (measured by using a Questionnaire on Stress in Cancer Patients [QSC-R10]) and continence status (urine loss on a 24-h pad test and urine volume on uroflowmetry) were evaluated at the beginning (T1) and end (T2) of a 3-week inpatient rehabilitation. Multivariate logistic regression was performed to identify predictors for high distress (QSC-R10 score $\geq$15). $\bf Results:$ The median patient age was 65 years. At the start of rehabilitation, 204 patients (34.8%) demonstrated high distress. Psychosocial distress decreased significantly ($\it p$ < 0.001) from a median of 11.0 at T1 (median 16 days after surgery) to a median of 6.0 at T2 (median 37 days after surgery). Complete continence increased significantly ($\it p$ < 0.001) from 39.0% at T1 to 58.9% at T2. The median urine volume increased significantly ($\it p$ < 0.001) from 161 mL at T1 to 230 mL at T2. Often, distress is higher in younger patients, whereas incontinence is higher in older patients. Multivariate logistic regression analysis identified age $\leq$69 years ($\it p$ = 0.001) and tumor stage $\geq$pT3 ($\it p$ = 0.006) as independent predictors of high distress. $\bf Conclusions:$ Distress and incontinence decreased significantly during the 3 weeks of inpatient rehabilitation after RP. Patient age $\leq$69 years and tumor stage $\geq$pT3 are independent predictors of high psychosocial distress

Probability of prostate cancer diagnosis following negative systematic and targeted MRI: transrectal ultrasound fusion biopsy

$\bf Introduction:$ The risk of occult prostate carcinoma (PCa) after negative multiparametric MRI (mpMRI)-transrectal fusion biopsy (F-Bx) is unknown. To determine the false-negative predictive value, we examined PCa detection after prior negative F-Bx. $\bf Methods:$ Between December 2012 and November 2016, 491 patients with suspected PCa and suspicious mpMRI findings underwent transrectal F-Bx. Patients with benign pathology ($\it n$ = 191) were eligible for our follow-up (FU) survey. Patient characteristics and clinical parameters were correlated to subsequent findings of newly detected PCa. $\bf Results:$ Complete FU with a median of 31 (interquartile range: 17–39) months was available for 176/191 (92.2%) patients. Of those, 54 men had either surgical interventions on the prostate or re-Bxs. Newly detected PCa was evident in 14/176 (7.95%) patients stratified to ISUP $\leq$ 2 in 10 and $\geq$ 3 in 4 cases. The comparison of patients with newly detected PCa to those without cancerous findings in FU showed significant differences in prostate-specific antigen (PSA) density (0.16 vs. 0.13 ng/mL$^{2}$) and prostate volume (45 vs. 67 mL, both $\it p$ < 0.05). Both factors are significant predictors for newly detected cancer after initial negative F-Bx. $\bf Conclusion:$ Only PSA density (>0.13 ng/mL$^{2}$) and small prostate volume are significant predictors for newly detected PCa after initial negative F-Bx. Despite negative mpMRI/TRUS F-Bx results, patients should be further monitored due to a risk of developing PCa over time. Notwithstanding the limitation of our study that not all patients underwent another Bx, we assume that the false-negative rate is low but existing. Our data represent a real-world scenario

How many cores should be sampled during systematic prostate biopsy in case of negative multiparametric magnetic resonance imaging?

$\bf Introduction:$ This study aimed to investigate the number of cores needed in a systematic biopsy (SB) in men with clinical suspicion of prostate cancer (PCa) but negative prebiopsy multiparametric magnetic resonance imaging and to test prostate-specific antigen (PSA) density as an indicator for reduced SB. $\bf Methods:$ Two hundred and seventy-four patients were analyzed, extracted from an institutional database. Detection rates of any PCa and clinically significant (CS) PCa for different reduced biopsy protocols were compared by using Fisher’s exact test. $\bf Results:$ In total, 12-core SB revealed PCa in 103 (37.6%) men. Detection rates of reduced biopsy protocols were 74 (27%, 6-core) and 82 (29.9%, 8-core). Regarding CSPCa, 12-core SB revealed a detection rate of 26 (9.5%). Reduced biopsy protocols detected less CSPCa: 15 (5.5%) and 18 (6.6%), respectively. All differences were statistically significant, $\it p$ < 0.05. PSA density $\geq$0.15 did not help to filter out men in whom a reduced biopsy may be sufficient. $\bf Conclusions:$ Twelve-core SB still has the highest detection rate of any PCa and CSPCa compared to reduced biopsy protocols. If the investigator and patient agree – based on individual risk calculation – to perform a biopsy, this SB should contain at least 12 cores regardless of PSA density

Avoiding prostate biopsies in patients at low risk for prostate cancer

$\textbf {Introduction and objectives}$: Decision-making to perform prostate biopsy should include individual risk assessment. Patients classified as low risk by the Rotterdam Prostate Cancer Risk Calculator are advised to forego biopsy (PBx). There is concern about missing clinically significant prostate cancer (csPCa). A clear pathway for follow-up is needed. $\textbf {Material and Methods:}$ Data for 111 consecutive patients were collected. Patients were encouraged to adhere to a PSA-density-based safety net after PBx was omitted. Cut off values indicating a re-evaluation were PSA density >0.15 ng/mL/ccm in PBx-naïve patients and >0.2 ng/mL/ccm in men with past-PBx. Primary endpoint was whether men had their PSA taken regularly. Secondary endpoint was whether a new multiparametric MRI was performed when PSA-density increased. Tertiary endpoint was whether biopsy was performed when risk stratification revealed an increased risk. $\bf Results:$ Median follow-up was 12 months (IQR 9–15 months). The primary endpoint was reached by 97.2% ($\it n$ = 106). The secondary endpoint was reached by 30% (($\it n$ = 3). The tertiary endpoint was reached by 50% (($\it n$ = 2). Histopathologic analyses revealed csPCa in none of these cases. Risk stratification did not change (($\it p$ = 0.187) with the majority of patients (89.2%, ($\it n$ = 99). $\bf Conclusion:$ The concern of missing csPCa when omitting PBx in the risk-stratified pathway may be negated. Changes in risk stratification during follow-up should lead to subsequent PBx. We suggest implementing a safety net based on PSA density and digital rectal examination (DRE)