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Background: Evidence-practice gaps exist in urology. We previously surveyed European Association of Urology (EAU) guidelines for strong recommendations underpinned by high-certainty evidence that impact patient experience for which practice variations were suspected. The recommendation “Do not offer neoadjuvant androgen deprivation therapy (ADT) before surgery for patients with prostate cancer” was prioritised for further investigation. ADT before surgery is neither clinically effective nor cost effective and has serious side effects. The first step in improving implementation problems is to understand their extent. A clear picture of practice regarding ADT before surgery across Europe is not available. Objective: To assess current ADT use before prostate cancer surgery in Europe. Design, setting, and participants: This was an observational cross-sectional study. We retrospectively audited recent ADT practices in a multicentre international setting. We used nonprobability purposive sampling, aiming for breadth in terms of low- versus high-volume, academic, versus community and public versus private centres. Outcome measurements and statistical analysis: Our primary outcome was adherence to the ADT recommendation. Descriptive statistics and a multilevel model were used to investigate differences between countries across different factors (volume, centre type, and funding type). Subgroup analyses were performed for patients with low, intermediate, and high risk, and for those with locally advanced prostate cancer. We also collected reasons for nonadherence. Results and limitations: We included 6598 patients with prostate cancer from 187 hospitals in 31 countries from January 1, 2017 to May 1, 2020. Overall, nonadherence was 2%, (range 0–32%). Most of the variability was found in the high-risk subgroup, for which nonadherence was 4% (range 0–43%). Reasons for nonadherence included attempts to improve oncological outcomes or preoperative tumour parameters; attempts to control the cancer because of long waiting lists; and patient preference (changing one's mind from radiotherapy to surgery after neoadjuvant ADT had commenced or feeling that the side effects were intolerable). Although we purposively sampled for variety within countries (public/private, academic/community, high/low-volume), a selection bias toward centres with awareness of guidelines is possible, so adherence rates may be overestimated. Conclusions: EAU guidelines recommend against ADT use before prostate cancer surgery, yet some guideline-discordant ADT use remains at the cost of patient experience and an additional payer and provider burden. Strategies towards discontinuation of inappropriate preoperative ADT use should be pursued. Patient summary: Androgen deprivation therapy (ADT) is sometimes used in men with prostate cancer who will not benefit from it. ADT causes side effects such as weight gain and emotional changes and increases the risk of cardiovascular disease, diabetes, and osteoporosis. Guidelines strongly recommend that men opting for surgery should not receive ADT, but it is unclear how well the guidance is followed. We asked urologists across Europe how patients in their institutions were treated over the past few years. Most do not use ADT before surgery, but this still happens in some places. More research is needed to help doctors to stop using ADT in patients who will not benefit from it.

Study Type – Diagnostic (validating cohort) Level of Evidence 1b What's known on the subject? and What does the study add? Transrectal ultrasonography (TRUS)-guided biopsies can miss prostate cancer and misclassify risk in a diagnostic setting; the exact extent to which it does so in a repeat biopsy strategy in men with low–intermediate risk prostate cancer is unknown. A simulation study of different biopsy strategies showed that repeat 12-core TRUS biopsy performs poorly. Adding anterior sampling improves on this but the highest accuracy is achieved using transperineal template prostate mapping using a 5 mm sampling frame. OBJECTIVE • To determine the effectiveness of two sampling strategies; repeat transrectal ultrasonography (TRUS)-biopsy and transperineal template prostate mapping (TPM) to detect and exclude lesions of ≥0.2 mL or ≥0.5 mL using computer simulation on reconstructed three-dimensional (3-D) computer models of radical whole-mount specimens. PATIENTS AND METHODS • Computer simulation on reconstructed 3-D computer models of radical whole-mount specimens was used to evaluate the performance characteristics of repeat TRUS-biopsy and TPM to detect and exclude lesions of ≥0.2 mL or ≥0.5 mL. • In all, 107 consecutive cases were analysed (1999–2001) with simulations repeated 500 times for each biopsy strategy. • TPM and five different TRUS-biopsy strategies were simulated; the latter involved a standard 12-core sampling and incorporated variable amounts of error, as well as the addition of anterior cores. • Sensitivity, specificity, negative and positive predictive values for detection of lesions with a volume of ≥0.2 mL or ≥0.5 mL were calculated. RESULTS • The mean (sd) age and PSA concentration were 61 (6.4) years and 8.5 (5.9) ng/mL, respectively.In all, 53% (57/107) had low–intermediate risk disease. • In all, 665 foci were reconstructed; there were 149 foci ≥0.2 mL and 97 ≥ 0.5 mL in the full cohort and 68 ≥ 0.2 mL and 43 ≥ 0.5 mL in the low–intermediate risk group. • Overall, TPM accuracy (area under the receiver operating curve, AUC) was ≈0.90 compared with AUC 0.70–0.80 for TRUS-biopsy. • In addition, at best, TRUS-biopsy missed 30–40% of lesions of ≥0.2 mL and ≥0.5 mL whilst TPM missed 5% of such lesions. CONCLUSION • TPM under simulation conditions appears the most effective re-classification strategy, although augmented TRUS-biopsy techniques are better than standard TRUS-biopsy.

Definitions of prostate cancer risk are limited since accurate attribution of the cancer grade and burden is not possible due to the random and systematic errors associated with transrectal ultrasound guided biopsy. Transperineal prostate mapping biopsy may have a role in accurate risk stratification. We defined the transperineal prostate mapping biopsy characteristics of clinically significant disease.A 3-dimensional model of each gland and individual cancer was reconstructed using 107 radical whole mount specimens. We performed 500 transperineal prostate mapping simulations per case by varying needle targeting errors to calculate sensitivity, specificity, and negative and positive predictive value to detect lesions 0.2 ml or greater, or 0.5 ml or greater. Definitions of clinically significant cancer based on a combination of Gleason grade and cancer burden (cancer core length) were derived.Mean±SD patient age was 61±6.4 years (range 44 to 74) and mean prostate specific antigen was 9.7±5.9 ng/ml (range 0.8 to 36.2). We reconstructed 665 foci. The total cancer core length from all positive biopsies for a particular lesion that detected more than 95% of lesions 0.5 ml or greater and 0.2 ml or greater was 10 mm or greater and 6 mm or greater, respectively. The maximum cancer core length that detected more than 95% of lesions 0.5 ml or greater and 0.2 ml or greater was 6 mm or greater and 4 mm or greater, respectively. We combined these cancer burden thresholds with dominant and nondominant Gleason pattern 4 to derive 2 definitions of clinically significant disease.Transperineal prostate mapping may provide an effective method to risk stratify men with localized prostate cancer. The definitions that we present require prospective validation.

The proportion of men with low- to intermediate-risk prostate cancer is rising with the increasing use of formal and informal prostate-specific antigen screening. The risk-to-benefit ratio of radical therapy is large with many men suffering genitourinary side effects compared with the small degree of cancer control that they derive from surgery or radiotherapy. On the other hand, the current alternative, active surveillance, carries risk of progression as well as some psychological and healthcare burdens. Focal treatment may be an acceptable alternative: in aiming to destroy only the areas of prostate cancer, focal therapy could deliver cancer control while at the same time avoid damage to surrounding structures. This may reduce incontinence, impotence, and rectal toxicity. Improvements in localization of cancer such as template transperineal prostate-mapping biopsies as well as state-of-the-art imaging such as multiparametric MRI and novel ultrasound-based tissue characterization tools have made the delivery of focal therapy possible. Minimally invasive ablative technologies such as cryotherapy, high-intensity focused ultrasound, photodynamic therapy, photothermal therapy, or radiofrequency interstitial tumor ablation can precisely treat to within a few millimeters. Early studies evaluating focal therapy have found a lower side-effect profile with acceptable short- to medium-term cancer control rates. If these promising results are confirmed in future prospective trials, focal therapy could start to challenge the current standard of care.

What's known on the subject? and What does the study add? Transrectal ultrasonography (TRUS)-guided biopsies can miss prostate cancer and misclassify risk in a diagnostic setting; the exact extent to which it does so in a repeat biopsy strategy in men with low-intermediate risk prostate cancer is unknown. A simulation study of different biopsy strategies showed that repeat 12-core TRUS biopsy performs poorly. Adding anterior sampling improves on this but the highest accuracy is achieved using transperineal template prostate mapping using a 5 mm sampling frame.To determine the effectiveness of two sampling strategies; repeat transrectal ultrasonography (TRUS)-biopsy and transperineal template prostate mapping (TPM) to detect and exclude lesions of ≥0.2 mL or ≥0.5 mL using computer simulation on reconstructed three-dimensional (3-D) computer models of radical whole-mount specimens.Computer simulation on reconstructed 3-D computer models of radical whole-mount specimens was used to evaluate the performance characteristics of repeat TRUS-biopsy and TPM to detect and exclude lesions of ≥0.2 mL or ≥0.5 mL. In all, 107 consecutive cases were analysed (1999-2001) with simulations repeated 500 times for each biopsy strategy. TPM and five different TRUS-biopsy strategies were simulated; the latter involved a standard 12-core sampling and incorporated variable amounts of error, as well as the addition of anterior cores. Sensitivity, specificity, negative and positive predictive values for detection of lesions with a volume of ≥0.2 mL or ≥0.5 mL were calculated.The mean (SD) age and PSA concentration were 61 (6.4) years and 8.5 (5.9) ng/mL, respectively.In all, 53% (57/107) had low-intermediate risk disease. In all, 665 foci were reconstructed; there were 149 foci ≥0.2 mL and 97 ≥ 0.5 mL in the full cohort and 68 ≥ 0.2 mL and 43 ≥ 0.5 mL in the low-intermediate risk group. Overall, TPM accuracy (area under the receiver operating curve, AUC) was ≈0.90 compared with AUC 0.70-0.80 for TRUS-biopsy. In addition, at best, TRUS-biopsy missed 30-40% of lesions of ≥0.2 mL and ≥0.5 mL whilst TPM missed 5% of such lesions.TPM under simulation conditions appears the most effective re-classification strategy, although augmented TRUS-biopsy techniques are better than standard TRUS-biopsy.

The true accuracy of different biopsy strategies for detecting clinically significant prostate cancer is unknown, given the positive evaluation bias required for verification by radical prostatectomy. To evaluate how well different biopsy strategies perform at detecting clinically significant prostate cancer we used computer simulation in cystoprostatectomy cases with cancer.A computer simulation study was performed on prostates acquired at radical cystoprostatectomy. A total of 346 prostates were processed and examined for prostate cancer using 3 mm whole mount slices. The 96 prostates that contained cancer were digitally reconstructed. Biopsy simulations incorporating various degrees of random localization error were performed using the reconstructed 3-dimensional prostate computer model. Each biopsy strategy was simulated 500 times. Two definitions of clinically significant prostate cancer were used to define the reference standard, including definition 1--Gleason score 7 or greater, and/or lesion volume 0.5 ml or greater and definition 2--Gleason score 7 or greater, and/or lesion volume 0.2 ml or greater.A total of 215 prostate cancer foci were present. The ROC AUC to detect and rule out definition 1 prostate cancer was 0.69, 0.75, 0.82 and 0.91 for 12-core transrectal ultrasound biopsy with a random localization error of 15 and 10 mm, 14-core transrectal ultrasound biopsy and template prostate mapping using a 5 mm sampling frame, respectively.To our knowledge our biopsy simulation study is the first to evaluate the performance of different sampling strategies to detect clinically important prostate cancer in a population that better reflects the demographics of a screened cohort. Compared to other strategies standard transrectal ultrasound biopsy performs poorly for detecting clinically important cancer. Marginal improvement can be achieved using additional cores placed anterior but the performance attained by template prostate mapping is optimal.

Focal therapy for localized prostate cancer involves destroying the cancer focus in order to offer patients the potential of combining cancer control with minimal side-effects. Current standard of care involves either active surveillance or radical therapy. Neither of these is ideal. Active surveillance carries a risk of under- treatment, with psychological morbidity as a result of anxiety and is associated with side-effects due to repeated biopsies, although radical therapy is the gold standard for curative treatment. With the proportion of unifocal or unilateral disease among men with low-risk disease rising, a focal approach could avoid both under and over-treatment. With the advent of improved accuracy for cancer localization provided by multiparametric MRI and new biopsy strategies such as transperineal mapping biopsies, ablative modalities such as cryotherapy, high intensity focused ultrasound, photodynamic therapy and radio-interstitial tumour ablation make focal treatments a real possibility.

Focal therapy is emerging as a potential challenge to the standard of care for localized prostate cancer. Short-term quality-of-life outcomes such as genitourinary side effects, anxiety levels, and global measures of quality of life using validated questionnaires are vital although proof-of-concept trials and retrospective case series have already established lower toxicity from focal therapy in some detail. Defining what outcomes will be measured and what defines a successful focal treatment in the medium and long term is problematic. Measuring long-term efficacy or effectiveness within a randomized trial is somewhat straightforward since hard endpoints are measured such as presence or absence of metastatic disease and/or death. However, owing to the long natural history of localized prostate cancer detected in the modern prostate-specific antigen screening era, with these events usually occurring a minimum of 10 years after therapy makes such a long-term trial large, costly, and probably unfeasible now. This article discusses the optimal determinants of success or failure for focal therapy that require careful consideration within multicenter trials evaluating medium-term oncological efficacy.

Introduction: We evaluate the technical feasibility of robotic prostatectomy in renal transplant recipients.Methods: We retrospectively analyzed preoperative and perioperative settings, as well as functional and oncologic results of 12 patients operated on between 2009 and 2013. Prostatectomy was performed via a transperitoneal approach without any changing in the ports position. The average age was 61.92 ± 2.98 years. The period between transplant and the diagnosis of adenocarcinoma was 79.7 months. The mean PSA was 7.34 ng/mL (range: 4.9–11).Results: The operative time was 241.3 ± 35.6 minutes with only one conversion and one transfusion. The intervention was difficult due to adhesions on the side of the graft in 50% of cases. There was a case of obstructive acute renal failure resulting from a hematoma of the Retzius treated by percutaneous nephrostomy at D20. There was a majority of pT2c (72.7%), including 3 positive margins (27.3%) and 2 biochemical relapses treated with radiotherapy and hormonotherapy, respectively. The end point prostate-specific antigen was undetectable. There was no significant difference between preoperative and J7 creatinine (p = 0. 22).Conclusions: Robotic prostatectomy in renal transplant recipients is a safe technique with no serious effects on the allograft.