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Background: To examine clinical characteristics, treatment modalities and oncological outcomes of prostate cancer (PCa) according to young (≤50) vs. old age., Methods: Of 407,599 men with primary adenocarcinoma of the prostate within the Surveillance, Epidemiology and End Results (SEER)-database (2004 to 2013), 18,387 were aged ≤50 years (4.5%). Time trends, cumulative incidence, and competing risks regression (CRR) analyses tested for differences between young and old patients. Multi-variable analyses were adjusted for year of diagnosis, race, marital status, Gleason Score, clinical tumor stage, and lymph node status., Results: Younger men had more favorable tumor characteristics: lower Gleason Score, lower median PSA, and lower rates of metastases at diagnosis compared to their older counterparts. Over time, no local treatment (NLT) rates increased, radical prostatectomy (RP), and brachytherapy (BT) rates decreased and external beam radiation (EBRT) rates remained unchanged. Moreover, the rate of de novo metastatic prostate cancer increased in young patients from 2% (2004) to 3.2% (2013) (p = 0.004). CRR models showed no difference in prostate cancer-specific mortality (PCSM) between young and old, across all local treatment types., Conclusions: Young PCa patients have more favorable disease characteristics at presentation, are less frequently treated with RP or BT and more frequently benefit of NLT. PCSM did not differ between young and old patients. However, it is worrisome that recently more young PCa patients are diagnosed at a metastatic stage.

Background: The optimal prostate-specific antigen (PSA) level after radical prostatectomy (RP) for defining biochemical recurrence and initiating salvage radiation therapy (SRT) is still debatable. Whereas adjuvant or extremely early SRT irrespective of PSA progression might be overtreatment for some patients, SRT at PSA >0.2 ng/ml might be undertreatment for others. The current study addresses the optimal timing of radiation therapy after RP., Patients and Methods: Cohort 1 comprised 293 men with PSA 0.1-0.19 ng/ml after RP. Cohort 2 comprised 198 men with SRT. PSA progression and metastases were assessed in cohort 1. In cohort 2, we compared freedom from progression according to pre-SRT PSA (0.03-0.19 vs. 0.2-0.499 ng/ml). Multivariable Cox regression analyses predicted progression after SRT., Results: In cohort 1, 281 (95.9%) men had further PSA progression ≥0.2 ng/ml and 27 (9.2%) men developed metastases within a median follow-up of 74.3 months. In cohort 2, we recorded improved freedom from progression according to lower pre-SRT PSA (0.03-0.19 vs. 0.2-0.499 ng/ml: 69 vs. 53%; log-rank p = 0.051). Patients with higher pre-SRT PSA ≥0.2 ng/ml were at a higher risk of progression after SRT (hazard ratio: 1.8; p < 0.05)., Conclusion: The vast majority of patients with PSA ≥0.1 ng/ml after RP will progress to PSA ≥0.2 ng/ml. Additionally, early administration of SRT at post-RP PSA level <0.2 ng/ml might improve freedom from progression. Consequently, we suggest a PSA threshold of 0.1 ng/ml to define biochemical recurrence after RP.

Background: The aim of this study was to compare 11 active surveillance (AS) protocols in contemporary European men treated with radical prostatectomy (RP) at the Martini-Clinic Prostate Cancer Center., Patients and Methods: Analyzed were 3498 RP patients, from 2005 to 2016, who underwent ≥ 10 core biopsies and fulfilled at least 1 of 11 examined AS entry definitions. We tested proportions of AS eligibility, ineligibility, presence of primary Gleason 4/5, upstage, and combinations thereof at RP, as well as 5-year biochemical recurrence-free survival (BFS)., Results: The most and least stringent criteria were very low risk National Comprehensive Cancer Network and Royal Marsden with 18.8% and 96.1% of AS-eligible patients, respectively. Rates of primary Gleason 4/5 at RP, upstaging, or both features, respectively, ranged from 2.3% to 6.7%, 6.1% to 18.2%, and 7.1% to 21.0% for those 2 AS entry definitions. The range of individuals deemed AS-ineligible between the same 2 AS entry definitions, despite not harboring unfavorable pathology (primary Gleason pattern 4/5, upstage, or both), was 80.3% to 3.7%, 78.3% to 3.4%, and 77.8% to 3.4%, respectively. BFS rates showed narrow variability, with a range of 85.9% to 91.8%., Conclusion: Use of stringent AS entry definitions reduces the number of AS-eligible patients, which is related to a select range in individual entry parameters. Moreover, rates of unfavorable pathology at RP as much as tripled between most and least stringent AS entry definitions. However, less stringent AS entry definitions result in the lowest AS-ineligibility rates, in men without unfavorable pathology. BFS rates were virtually invariably high. Clinicians should know differences in key parameters underlying each AS entry definition, associated effect on rates of eligibility, and potential misclassification of individuals., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Treatment of the primary, termed local therapy (LT), may improve survival in metastatic prostate cancer (mPCa) versus no local therapy (NLT)., Objective: To assess cancer-specific mortality (CSM) after LT versus NLT in mPCa., Design, Setting, and Participants: Within the Surveillance, Epidemiology and End Results database (2004-2013), 13 692 mPCa patients were treated with LT (radical prostatectomy [RP] or radiation therapy [RT]) or NLT., Outcome Measurements and Statistical Analysis: Multivariable competing risk regression analyses (MVA CRR) tested CSM after propensity score matching (PSM) in two analyses, (1) NLT versus LT and (2) RP versus RT, and were complemented with interaction, sensitivity, unmeasured confounder, and landmark analyses., Results and Limitations: Of 13 692 mPCa patients, 474 received LT: 313 underwent RP and 161 RT. In MVA CRR, after PSM, LT (n=474) results in lower CSM (subhazard ratio [SHR] 0.40, 95% confidence interval [CI] 0.32-0.50) versus NLT (n=1896). In MVA CRR after PSM, RP (n=161) results in lower CSM (SHR 0.59, 95% CI 0.35-0.99) versus RT (n=161). Invariably, lowest CSM rates were recorded for Gleason ≤7, ≤cT3, and M1a substage. Interaction and sensitivity analyses confirmed the robustness of results, and landmark analyses rejected the bias favouring LT. A strong unmeasured confounder (HR=5), affecting 30% of NLT patients, could obliterate LT benefit. Data were retrospective., Conclusions: In mPCa, LT results in lower mortality relative to NLT. Within LT, lower mortality is recorded after RP than RT. Patients with most favourable grade, local stage, and metastatic substage derive most benefit from LT. They also derive most benefit from RP, when LT types are compared (RP vs RT). It is important to consider study limitations until ongoing clinical trials confirm the proposed benefits., Patient Summary: Individuals with prostate cancer that spreads outside of the prostate might still benefit from prostate-directed treatments, such as radiation or surgery, in addition to receiving androgen deprivation therapy., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Previous studies have examined testosterone levels after external beam radiation (EBRT) monotherapy, but since 2002 only sparse contemporary data have been reported., Aim: To examine testosterone kinetics in a large series of contemporary patients after EBRT., Methods: The study was conducted in 425 patients who underwent definitive EBRT for localized prostate cancer from 2002 through 2014. Patients were enrolled in several phase II and III trials. Exclusion criteria were neoadjuvant or adjuvant androgen-deprivation therapy or missing data. Testosterone was recorded at baseline and then according to each study protocol (not mandatory in all protocols). Statistical analyses consisted of means and proportions, Kaplan-Meier plots, and logistic and Cox regression analyses., Outcomes: Testosterone kinetics after EBRT monotherapy and their influence on biochemical recurrence., Results: Median follow-up of 248 assessable patients was 72 months. One hundred eighty-six patients (75.0%) showed a decrease in testosterone. Median time to first decrease was 6.4 months. Median percentage of decrease to the nadir was 30% and 112 (45.2%) developed biochemical hypogonadism (serum testosterone < 8 nmol/L). Of all patients with testosterone decrease, 117 (62.9%) recovered to at least 90% of baseline levels. Advanced age, increased body mass index, higher baseline testosterone level, and lower nadir level were associated with a lower chance of testosterone recovery. Subgroup analyses of 166 patients treated with intensity-modulated radiotherapy confirmed the results recorded for the entire cohort. In survival analyses, neither testosterone decrease nor recovery was predictive for biochemical recurrence., Clinical Implications: EBRT monotherapy influences testosterone kinetics, and although most patients will recover, approximately 45% will have biochemical hypogonadism., Strengths and Limitations: We report on the largest contemporary series of patients treated with EBRT monotherapy in whom testosterone kinetics were ascertained. Limitations are that testosterone follow-up was not uniform and the study lacked information on health-related quality-of-life data., Conclusion: Our findings indicate that up to 75% of patients will have a profound testosterone decrease, with up to a 40% increase in rates of biochemical hypogonadism, although the latter events will leave biochemical recurrence unaffected. Pompe RS, Karakrewicz PI, Zaffuto E, et al. External Beam Radiotherapy Affects Serum Testosterone in Patients With Localized Prostate Cancer. J Sex Med 2017;14:876-882., (Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Obesity negatively affects several prostate cancer (PCa) outcomes, including mortality to PCa. However, the validity of several such associations is still under debate, including its effect on pathological stage at radical prostatectomy (RP) and subsequent biochemical recurrence (BCR), which represents the focus of this study., Methods: We relied on patients with PCa treated with RP at the Martini-Klinik Prostate Cancer Center between 2004 and 2015. First, multivariable logistic regression analyses tested for association between obesity and non-organ-confined disease (≥pT3 or pN1). Second, multivariable Cox regression analyses examined obesity effect on BCR. Last, in a propensity score-matched cohort, Kaplan-Meier analyses assessed BCR-free survival according to body mass index (kg/m 2 ) (BMI) strata (≥30 vs.<25)., Results: Of 16,014 individuals, 2,403 (15%) men were obese (BMI≥30). Median follow-up was 36.4 months (interquartile range: 13.3-60.8). Obese patients were more likely to harbor non-organ-confined disease at final pathology (odds ratio = 1.27; 95% CI: 1.13-1.43; P<0.001) but did not have higher BCR rates (hazard ratio = 0.98; 95% CI: 0.86-1.11; P = 0.7). Similarly, BCR-free survival was not different between obese and nonobese men, after propensity score matching (log rank P = 0.9)., Conclusion: Obesity (BMI ≥30) might predispose to higher rates of non-organ-confined disease at RP. However, obesity was not an independent predictor of BCR after surgery. Consequently, the unfavorable effect of obesity on PCa might be limited to local spread of the disease and might be neutralized after RP., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The role of adjuvant chemotherapy (AC) within urothelial carcinoma of the urinary bladder (UCUB) patients after radical cystectomy (RC) is under debate. We assessed contemporary AC utilization rates. We also examined the rates of AC according to patient disease and sociodemographic characteristics., Methods: We relied on the SEER-Medicare database for non-organ-confined, muscle-invasive T2 N+ -T4a UCUB patients who underwent RC between 1991 and 2009 without neoadjuvant chemotherapy delivery. Multivariable logistic regression analyses tested predictors of AC use; T-stage, N-stage, year of diagnosis, age, gender, race, radiotherapy (RT) administration, marital urban and socioeconomic status, tumor grade and Charlson Comorbidity Index (CCI)., Results: Overall, 2681 patients were identified. Of those, 667 (24.9%) received AC. The rate of AC were 21.4%, 23.5%, 24.6% and 29.9% over time (1991-1999 vs. 2000-2002 vs. 2003-2005 vs. 2006-2009) (P=0.002). In multivariable analyses stages pT2N+ (odds ratio (OR): 4.7; P<0.001) and pT3/4aN+ (OR: 4.0; P<0.001), year of diagnosis (OR: 1.9; P<0.001), RT (OR: 1.7; P<0.001), married status (OR: 1.4; P=0.001) and advanced age (OR: 0.3; P<0.001) were independent predictors of AC. Neither race nor CCI demonstrated significance., Conclusions: In conclusion, we report lower than anticipated overall (24.9%) use of AC. Nonetheless, the rate increased from 13.6% (1991) to 24.1% (2009). Presence of lymph node invasion at RC regardless of T2 or T3/4a stage was the most important variable that increased AC use. Older and unmarried individuals were less likely to receive AC. AC rates were higher in T2N+ UCUB patients than in T3-T4a individuals.

Background: Patients treated with robot-assisted radical prostatectomy (RARP) are frequently selected according to more favorable characteristics. Such patient selection might decrease according to increasing experience., Methods: We relied on the Martini Clinic Prostate Cancer Center database and focused on patients treated with RARP between 2004 and 2013. Differences in clinical, pathological and surgical characteristics at RARP over time (2004-2010, 2011-2012 and 2013) were assessed., Results: Overall, 1783 RARP patients were identified. Of those, 407 (22.8%), 764 (42.8%) and 612 (34.3%) were treated between 2004 and 2010, in 2011-2012 and in 2013, respectively. Unfavorable characteristics rate, such as biopsy Gleason Score ≥4+4 (8 vs. 9 vs. 15%, P<0.001), D'Amico high-risk (12 vs. 14 vs. 19%, P=0.001) and pathological Gleason score ≥4+4 (3 vs. 4 vs. 6%, P<0.001) increased over time. Pelvic lymph node dissection (PLND) was more frequently performed over time (62 vs. 83 vs. 84%, P<0.001), especially in D'Amico intermediate or high-risk patients (82 vs. 94 vs. 96%, P<0.001). Lymph node yield increased over time in overall (7 vs. 9 vs. 13, P<0.001), D'Amico intermediate (6 vs. 9 vs. 12, P<0.001) and D'Amico high-risk patients (9 vs. 12 vs. 18, P<0.001). No differences in surgical margin (P=0.7) and nerve sparing rates (P=0.09) were found., Conclusions: A clear trend towards more unfavorable tumor characteristics over time was recorded. Additionally, the rates and extent of PLND increased with increasing experience. RAR P does not represent a barrier to PLND at our institution.

Purpose: Treatment decisions in patients with prostate cancer are affected by patient age regardless of higher life expectancy compared to the baseline population. Our aim was to quantify cancer specific and other cause mortality rates after radical prostatectomy., Materials and Methods: A total of 8,741 patients with prostate cancer underwent radical prostatectomy between 1992 and 2009 at a European center. Ten-year other cause and cancer specific mortality rates were determined by age and comorbidities, and age and Cancer of the Prostate Risk Assessment Post-Surgical (CAPRA-S) risk groups. Competing risk regression was used for risk factor analyses including clinical and pathological variables., Results: Ten-year other cause mortality rates increased with patient age, including 4.8%, 9.8%, 13.6% and 16.5% in men younger than 60, 60 to 64, 65 to 69 and 70 years or older, respectively. Cancer specific mortality was the leading cause of death in CAPRA-S high risk cases regardless of age. On multivariate analyses age groups achieved independent predictor status for other cause mortality (ages 60 to 64 years HR 1.81, 95% CI 1.26-2.62, 65 to 69 years HR 2.48, 95% CI 1.73-3.56 and 70 years or greater HR 3.02, 95% CI 1.97-4.62) as well as Charlson comorbidity indexes 1 (HR 1.45, 95% CI 1.00-2.09) and 3 or greater (HR 3.99, 95% CI 1.57-10.1). Gleason score 3 + 4 and 4 + 3 or greater, pT3b stage, lymph node invasion and positive margin status achieved independent predictor status when the end point was cancer specific mortality. The CAPRA-S high risk constellation increased cancer specific mortality risk in multifold fashion (HR 26, 95% CI 16-56)., Conclusions: In patients with the CAPRA-S high risk constellation the rate of cancer specific mortality increased in multifold fashion and contributed to most deaths regardless of patient age. Low other cause mortality rates in all age groups showed reasonable patient selection., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The role of elastography in patients initially and at repeat prostate biopsy is still indeterminate. The existing literature is sparse and controversial., Materials and Methods: We studied patients who underwent elastography based and systematic biopsy between October 2009 and February 2015 at Braunschweig Prostate Cancer Center. Patients were separated according to first vs repeat biopsy setting. Each prostate sextant was considered an individual case. The sensitivity, specificity, positive and negative predictive values, and accuracy of elastography to predict biopsy results were analyzed. The 95% CIs were determined by bootstrapping analysis of 2,000 samples., Results: Overall 679 men and a total of 4,074 sextants were identified. Of the 679 men 160 (23.6%) underwent first biopsy and 519 (76.4%) underwent repeat biopsy. In the 160 men at first biopsy sensitivity was 18.0% (95% CI 14.5-21.3), specificity was 87.7% (95% CI 85.3-89.9), positive predictive value was 36.6% (95% CI 28.4-45.4), negative predictive value was 73.0% (95% CI 67.5-77.9) and accuracy was 67.9% (95% CI 63.4-72.2). Results in 519 men (76.4%) at repeat biopsy were 19.8% (95% CI 16.0-23.7), 90.9% (95% CI 89.9-91.9), 20.1% (95% CI 15.8-24.8), 90.7% (95% CI 89.0-92.3) and 83.5% (95% CI 81.6-85.2), respectively., Conclusions: We found limited reliability of elastography prediction at prostate biopsy in patients at first and repeat biopsies. Based on our analyses we cannot recommend a variation of well established systematic biopsy patterns or a decrease in biopsy cores based on elastography., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: To verify the reliability of HistoScanning™-based, true targeting (TT)-derived prostate biopsy., Methods: We relied on 40 patients suspicious for prostate cancer who underwent standard and TT-derived prostate biopsy. Sensitivity, specificity, positive predictive value, negative predictive value and the area under the curve (AUC) were assessed for the prediction of biopsy results per octant by HistoScanning™, using different HistoScanning™ signal volume cutoffs (>0, >0.2 and >0.5 ml)., Results: Overall, 319 octants were analyzed. Of those, 64 (20.1 %) harbored prostate cancer. According to different HistoScanning™ signal volume cutoffs (>0, >0.2 and >0.5 ml), the AUCs for predicting biopsy results were: 0.51, 0.51 and 0.53, respectively. Similarly, the sensitivity, specificity, positive predictive and negative predictive values were: 20.7, 78.2, 17.4 and 81.6 %; 20.7, 82.0, 20.3 and 82.3 %; and 12.1, 94.6, 33.3 and 82.9 %, respectively., Conclusions: Prediction of biopsy results based on HistoScanning™ signals and TT-derived biopsies was unreliable. Moreover, the AUC of TT-derived biopsies was low and did not improve when additional signal volume cutoffs were applied (>0.2 and >0.5 ml). We cannot recommend a variation of well-established biopsy standards or reduction in biopsy cores based on HistoScanning™ signals.

Introduction: High-dose-rate brachytherapy (HDR-BT) with external-beam radiation therapy and radical prostatectomy (RP) are common treatment options for clinically localized prostate cancer. The aim was to describe risk factors for biochemical recurrence (BCR) and death, as well as BCR rates and overall survival (OS) rates in both treatment groups., Patients and Methods: Overall, 5,619 patients with localized prostate cancer underwent either RP (n = 5,200) or HDR-BT (n = 419) between 1999 and 2009. Median follow-up time was 72.4 months. Kaplan-Meier analyses and multivariable Cox regression analyses were performed for the overall cohort and for a propensity score-matched cohort to predict BCR and OS rates. Within the matched cohort, stratified analyses were repeated for HDR-BT alone (n = 206) and HDR-BT plus androgen deprivation therapy (ADT) (n = 213). Sensitivity analyses were performed to adjust for prostate-specific antigen rebound., Results: The 5-year BCR-free survival rates were 82.1% vs. 80.3% (P<0.01) for RP and HDR-BT, respectively. Corresponding 5-year OS rates were 97.1% vs. 92.4% (P<0.01). In the propensity score-matched cohort, 5-year BCR-free survival rates were 80.3% vs. 77.1%; P = 0.06 and 5-year OS rates were 95.7% vs. 92.4%; P = 0.5. In multivariable models, the overall HDR-BT exerted no significant effect on BCR, and the same results were recorded in the matched cohort. In stratified analyses, HDR-BT alone vs. RP increased BCR risk (1.45; P<0.01); conversely, HDR-BT plus ADT vs. RP decreased BCR risk (hazard ratio = 0.66; P = 0.02)., Conclusions: First, RP offers equivalent oncological control without the need for concurrent hormone therapy and its morbidity. Second, patients who have RP avoid ADT (2%) and the need for salvage and adjuvant external-beam radiation therapy is low at 11% and 3%, respectively., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Given the growing body of literature since first description of HistoScanning™ in 2008, there is an unmet need for a contemporary review., Evidence Acquisition: Studies addressing HistoScanning™ in prostate cancer (PCa) were considered to be included in the current review. To identify eligible reports, we relied on a bibliographic search of PubMed database conducted in January 2015., Evidence Synthesis: Twelve original articles were available to be included in the current review. The existing evidence was reviewed according to the three following topics: prediction of final pathology at radical prostatectomy, prediction of disease stage and application at prostate biopsy., Conclusions: High sensitivity and specificity for HistoScanning™ to predict cancer foci ≥0.5 ml at final pathology were achieved in the pilot study. These results were questioned, when HistoScanning™ derived tumor volume does not correlate with final pathology results. Additionally, HistoScanning™ was not able to provide reliable staging information according to neither extraprostatic extension, nor seminal vesicle invasion prior to radical prostatectomy. Controversy data also exist according to the use of HistoScanning™ at prostate biopsy. Specifically, most encouraging results were recorded in a small patient cohort. Conversely, HistoScanning™ achieved poor prediction of positive biopsies, when relying on larger studies. Finally, the combination of HistoScanning™ and conventional ultrasound achieved lower detection rates than systematic biopsy. Currently, evidence is at best weak and questions whether HistoScanning™ might improve the detection of PCa.

Context: Debates on overdiagnosis and overtreatment of prostate cancer (PCa) are ongoing and there is still huge uncertainty regarding misclassification of prostate biopsy results. Several imaging techniques that have emerged in recent years could overcome over- and underdiagnosis in PCa., Objective: To review the literature on transrectal ultrasound (TRUS)-based techniques (contrast enhancement, HistoScanning, elastography) and magnetic resonance imaging (MRI)-based techniques for a nonsystematic overview of their benefits and limitations., Evidence Acquisition: A comprehensive search of the PubMed database between August 2004 and August 2014 was performed. Studies assessing grayscale TRUS, contrast-enhanced (CE)-TRUS, elastography, HistoScanning, multiparametric MRI (mpMRI), and MRI-TRUS fusion biopsy were included. Publications before 2004 were included if they reported the principle or the first clinical results for these techniques., Evidence Synthesis: Grayscale TRUS alone cannot detect PCa foci (detection rate 23-29%). TRUS-based (elastography) and MRI-based techniques (MRI-TRUS fusion biopsy) have significantly improved PCa diagnostics, with sensitivity of 53-74% and specificity of 72-95%. HistoScanning does not provide convincing or homogeneous results (specificity 19-82%). CE-TRUS seems to be user dependent; it is used in a low number of high-volume centers and has wide ranges for sensitivity (54-79%) and specificity (42-95%). For all the techniques reviewed, prospective multicenter studies with consistent definitions are lacking., Conclusions: Standard grayscale TRUS is unreliable for PCa detection. Among the techniques reviewed, mpMRI and MRI-TRUS fusion biopsy seem to be suitable for enhancing PCa diagnostics. Elastography shows promising results according to the literature. CE-TRUS yields very inhomogeneous results and might not be the ideal technique for clinical practice. The value of HistoScanning must be questioned according to the literature., Patient Summary: New imaging modalities such as elastography and magnetic resonance imaging/transrectal ultrasound fusion biopsies have improved the detection of prostate cancer. This may lower the burden of overtreatment as a result of more precise diagnosis., (Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Intermediate-risk prostate cancer (PCa) represents a heterogeneous disease, where a non-negligible proportion of patients harbor favorable pathologic characteristics and are potentially eligible for active surveillance (AS). We aimed at developing a model for the identification of pathologically favorable PCa at radical prostatectomy (RP) among intermediate-risk patients., Methods: Overall, 3,821 intermediate-risk patients treated with RP at two centers between 2005 and 2013 were identified. Pathologically favorable PCa was defined as low-grade organ-confined disease. Age, biopsy Gleason, PSA density (PSAD), and the percentage of positive cores were included in multivariable logistic regression analyses predicting favorable PCa and formed the basis for a logistic regression-based risk calculator. The internally validated discrimination and calibration of the risk calculator were quantified using 200 bootstrap resamples. Decision curve analysis (DCA) provided an estimate of the net benefit obtained using this model versus treating no one and treating everyone., Results: Overall, 10.0% of all intermediate risk patients had favorable disease. In multivariable analyses, patients with biopsy Gleason score ≤6 had higher probability of favorable disease compared to those with higher-grade disease (P < 0.001). Similarly, age, PSAD, and percentage of positive cores were associated with the probability of favorable disease (all P ≤ 0.01). The risk calculator achieved a validated accuracy of 82.5%. The DCA showed that our prediction model is better than both treating no one and treating everyone., Conclusions: One out of ten intermediate-risk patients harbors favorable disease at RP. Our novel, pre-operative, validated risk calculator may help clinicians identifying patients who could be considered for conservative therapy approaches such as AS., (© 2015 Wiley Periodicals, Inc.)

Introduction: The aim of our study was to reexamine the prevalence of baseline cardiovascular (CV) morbidity and the rates of CV mortality in a contemporary cohort of patients with prostate cancer (PCa) exposed to androgen deprivation therapy (ADT)., Materials and Methods: Records of patients aged 65 years and older with metastatic PCa who received ADT were abstracted from the Surveillance, Epidemiology, and End Results-Medicare database between 1991 and 2009. The primary end points comprised 5-year CV mortality rates. Survival rates were stratified according to age and Charlson comorbidity index (CCI). Competing-risks Poisson regression methodologies were performed., Results: Overall, 9596 patients with metastatic PCa treated with ADT were identified. At baseline, 3049 patients (31.8%) had preexisting CV disease. The 5-year CV mortality rates were 9.8% and 14.8% in the overall population and in patients with preexisting CV disease, respectively. The 5-year CV mortality rates increased with advanced age and higher CCI score. In multivariate competing-risks regression analyses, age, year of diagnosis, CV comorbidities, CCI, and marital status represented independent predictors of CV mortality, after accounting for the risk of dying from other causes (all P ≤ .04). Of those, preexisting CV disease contributed to the highest risk of CV mortality. Our study is limited by its retrospective nature., Conclusion: CV mortality represents a common event in patients with metastatic PCa treated with ADT. Preexisting CV disease represented the strongest risk factor., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: To examine the impact of marital status on prostate cancer characteristics at radical prostatectomy and oncological outcome after surgery at a high-volume center., Methods: We relied on the Martini-Clinic Prostate Cancer database and investigated 8088 prostate cancer patients treated with radical prostatectomy between January 2000 and March 2011. We analyzed differences in clinical and pathological characteristics according to marital status (married and partnership vs single). Additionally, we relied on multivariable Cox regression analyses to predict biochemical recurrence, metastases and death after radical prostatectomy. Finally, Kaplan-Meier analyses were used in a propensity score-matched cohort, adjusted for clinical and pathological characteristics, to examine differences in biochemical recurrence-free, metastases-free and overall survival according to marital status., Results: According to marital status, no significant differences were recorded within clinical and pathological characteristics (all P > 0.05). The impact of marital status on biochemical recurrence (hazard ratio 1.0, 95% confidence interval 0.9-1.3, P = 0.7), metastases (hazard ratio 1.3, 95% confidence interval 0.8-2.1, P = 0.3) and death (hazard ratio 0.8, 95% confidence interval 0.4-1.6, P = 0.6) after radical prostatectomy was not significant (median follow up 48 months). Kaplan-Meier analyses recorded no significant differences for biochemical recurrence-free, metastases-free and overall survival (all log-rank P > 0.05) according to marital status., Conclusions: Marital status does not affect the clinical and pathological characteristics of radical prostatectomy patients treated at a high-volume center. Furthermore, marital status does not affect biochemical recurrence-free and metastases-free survival after radical prostatectomy., (© 2015 The Japanese Urological Association.)

Background: The role of additional androgen deprivation therapy (ADT) in prostate cancer (PCa) patients treated with combined HDR brachytherapy (HDR-BT) and external beam radiotherapy (EBRT) is still unknown., Patients and Methods: Consecutive PCa patients classified as D'Amico intermediate and high-risk who underwent HDR-BT and EBRT treatment ± ADT at our institution between January 1999 and February 2009 were assessed. Multivariable Cox regression models predicting biochemical recurrence (BCR) were performed. BCR-free survival was assessed with Kaplan-Meier analyses., Results: Overall, 392 patients were assessable. Of these, 221 (56.4 %) underwent trimodality (HDR-BT and EBRT and ADT) and 171 (43.6 %) bimodality (HDR-BT and EBRT) treatment. Additional ADT administration reduced the risk of BCR (HR: 0.4, 95 % CI: 0.3-0.7, p < 0.001). D'Amico high-risk patients had superior BCR-free survival when additional ADT was administered (log-rank p < 0.001). No significant difference for BCR-free survival was recorded when additional ADT was administered to D'Amico intermediate-risk patients (log-rank p = 0.2)., Conclusions: Additional ADT administration improves biochemical control in D'Amico high-risk patients when HDR-BT and EBRT are combined. Physicians should consider the oncological benefit of ADT administration for these patients during the decision-making process.

Purpose: Shear wave elastography allows the detection of cancer by using focused ultrasound pulses for locally deforming tissue. The differences in tissue elasticity and stiffness have been used increasingly in breast cancer imaging and help detect potential tumor lesions in the prostate. In this study we localized prostate cancer lesions using shear wave elastography before radical prostatectomy and assessed the examiner independent elasticity threshold for cancer foci detection., Materials and Methods: Shear wave elastography scanning of the whole prostate was performed before radical prostatectomy in 60 consecutive patients with high, intermediate and low risk disease. Localization of suspected lesions and density threshold (kPa) were recorded in up to 12 areas and resulted in 703 different fields. Shear wave elastography findings were correlated with final pathology. Initially 381 areas were used to establish shear wave elastography cutoffs (development cohort 32 patients). Subsequently these cutoffs were validated in 322 areas (validation cohort 28 patients)., Results: Using shear wave elastography significant differences were recorded for the elasticity of benign tissue vs prostate cancer nodules at 42 kPa (range 29 to 71.3) vs 88 kPa (range 54 to 132) (all p <0.001). Median cancer lesion diameter was 26 mm (range 18 to 41). Applying the most informative cutoff of 50 kPa to the validation cohort resulted in 80.9% and 69.1% sensitivity and specificity, respectively, and 74.2% accuracy for detecting cancer nodules based on final pathological finding. The corresponding positive and negative predictive values were 67.1% and 82.2%, respectively., Conclusions: Shear wave elastography allows the identification of cancer foci based on shear wave elastography differences. Moreover, reliable cutoffs for this approach can be established, allowing examiner independent localization of prostate cancer foci., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: An increased tumor volume threshold (<2.5 ml) is suggested to define insignificant prostate cancer (iPCa). We hypothesize that an increasing tumor volume within iPCa patients increases the risk of biochemical recurrence (BCR) after radical prostatectomy (RP)., Methods: We relied on RP patients treated between 1992 and 2008. Multivariable Cox regression analyses predicting BCR within patients harboring favorable pathological characteristics (≤pT2, pN0/Nx, Gleason 3 + 3). Kaplan-Meier analysis was performed for BCR-free survival within iPCa patients (≤pT2, pN0/Nx, Gleason 3 + 3, tumor volume: <0.5 vs. 0.5-2.49 ml)., Results: From 1,829 patients, 141 (7.7%) and 310 (16.9%) harbored iPCa (tumor volume: <0.5 vs. 0.5-2.49 ml), respectively. Of those, 21 (14.9%) versus 31 (10.0%) had PSA >10 ng/ml. Tumor volume achieved independent predictor status for BCR. Specifically, iPCa patients with increasing tumor volume (0.5-2.49 ml) were at higher risk of BCR after RP than those with tumor volume <0.5 ml (HR: 8.8, 95% CI: 1.2-65.9, P = 0.04). Kaplan-Meier analysis recorded superior BCR-free survival in iPCa patients with lower tumor volume (<0.5 ml) (log-rank P = 0.009). The 10-year cancer-specific death rate was 0 versus 0.5%., Conclusions: Contemporary iPCa definition incorporates intermediate and high-risk patients (PSA: 10-20 and >20 ng/ml). Despite most favorable pathological characteristics, iPCa patients are not devoid of BCR after RP. Moreover, iPCa patients were at higher risk of BCR, when increasing tumor volume up to 2.49 ml was at play. Taken together the contemporary concept of iPCa is suboptimal. Especially, an increased tumor volume threshold for defining iPCa cannot be recommended according to our data. Clinicians might take these considerations into account during decision-making process., (© 2014 Wiley Periodicals, Inc.)

Objective: To examine the accuracy of HistoScanning (HS) in detecting seminal vesicle (SV) invasion (SVI) within prostate cancer (PCa) patients., Methods: We relied on our prospective institutional database. Patients who received HS before radical prostatectomy were included in the study cohort. An experienced HS examiner retrospectively reanalyzed the HS data blinded to patient characteristics and pathologic results. The HS results for every single SV were compared with the corresponding findings from the final pathologic report after radical prostatectomy. An area under the receiver operating characteristic curve for the prediction of SVI by HS was calculated. Depending on HS signal volume cut-offs (>0, >0.2, and >0.5 mL), the sensitivity, specificity, positive predictive value, and negative predictive value for the prediction of SVI were assessed., Results: Overall, 131 patients and 262 SVs were assessable. Of those, 23 (17.5%) men had SVI, and 39 (14.9%) single SVs were infiltrated by tumor overall. The area under the receiver operating characteristic curve for predicting SVI by HS was 0.54. Depending on the HS signal volume cut-offs (>0, >0.2, and >0.5 mL), the sensitivity, specificity, positive predictive value, and negative predictive value for predicting SVI were 76.9%, 10.8%, 13.1%, and 72.7%; 61.5%, 24.2%, 12.4%, and 78.3%; and 46.2%, 50.2%, 14.0%, and 84.2%, respectively., Conclusion: HS results did not allow a reliable prediction of SVI within PCa patients. Despite, the application of HS signal volume cut-offs (>0.2 and >0.5 mL), the prediction of SVI within PCa patients remained insufficient., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The lack of reliable imaging tools in detecting prostate cancer makes a random biopsy still the standard of care to detect prostate cancer. To reduce the number of cores during a biopsy and therefore the risk of biopsy-related complications, an imaging tool which provides reliable guided biopsies is required. Transrectal real-time elastography has shown to have the ability to visualize prostate cancer foci to some extent. In addition to the conventional B-mode image of transrectal ultrasound, it adds information about the stiffness of the prostate tissue. This review highlights the most important studies on elastography to follow the improvements in techniques and to outline the ability to detect prostate cancer and guide biopsies.

Historically, open radical nephrectomy (ORN) represented the standard of care for localized renal cell carcinoma (RCC). While the incidence of T1 RCC is rising, treatment options are developing fast and the standard of care according to European and American guidelines has changed to partial nephrectomy (PN), or laparoscopic radical nephrectomy in patients not suitable for PN. To assess the implementation of guideline recommendations and to profile recent surgical and technical innovations, we reviewed the current literature. We observed that ORN still represents the most commonly used treatment in T1 RCC patients. Utilization of PN increased over time but implementation is still in progress. Whereas PN is frequently used in tertiary care centers, population-based studies suggest discrepancies in the diffusion of standard of care treatments. Alternative minimally invasive approaches for PN are available but their superiority is not yet proven. Further efforts in improving the training of urologic surgeons are required to continue the implementation of guideline recommendations.