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Purpose: Accurate prediction of extraprostatic extension (EPE) is pivotal for surgical planning. Herein, we aimed to provide an updated model for predicting EPE among patients diagnosed with MRI-targeted biopsy., Materials and Methods: We analyzed a multi-institutional dataset of men with clinically localized prostate cancer diagnosed by MRI-targeted biopsy and subsequently underwent prostatectomy. To develop a side-specific predictive model, we considered the prostatic lobes separately. A multivariable logistic regression analysis was fitted to predict side-specific EPE. The decision curve analysis was used to evaluate the net clinical benefit. Finally, a regression tree was employed to identify three risk categories to assist urologists in selecting candidates for nerve-sparing, incremental nerve sparing and non-nerve-sparing surgery., Results: Overall, data from 3169 hemi-prostates were considered, after the exclusion of prostatic lobes with no biopsy-documented tumor. EPE was present on final pathology in 1,094 (34%) cases. Among these, MRI was able to predict EPE correctly in 568 (52%) cases. A model including PSA, maximum diameter of the index lesion, presence of EPE on MRI, highest ISUP grade in the ipsilateral hemi-prostate, and percentage of positive cores in the ipsilateral hemi-prostate achieved an AUC of 81% after internal validation. Overall, 566, 577, and 2,026 observations fell in the low-, intermediate- and high-risk groups for EPE, as identified by the regression tree. The EPE rate across the groups was: 5.1%, 14.9%, and 48% for the low-, intermediate- and high-risk group, respectively., Conclusion: In this study we present an update of the first side-specific MRI-based nomogram for the prediction of extraprostatic extension together with updated risk categories to help clinicians in deciding on the best approach to nerve-preservation., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose: To investigate national trends of surgical treatment for benign prostatic obstruction (BPO)., Methods: The Care Register for Healthcare in Finland was used to investigate the annual numbers and types of surgical procedures, operation incidence and duration of hospital stay between 2004 and 2018 in Finland. Procedures were classified using the Nordic Medico-Statistical Committee Classification of Surgical Procedures coding. Trends in incidence were analyzed with two-sided Cochran-Armitage test. Trends in duration of hospital stay and patient age were analyzed with linear regression., Results: Transurethral resection of the prostate (TURP) was the most common operation type during the study period, covering over 70% of operations for BPO. Simultaneous with the implementation of photoselective vaporization of the prostate (PVP), the incidence of TURP, minimally invasive surgical therapies, transurethral vaporization of the prostate (TUVP) and open prostatectomies decreased (p < 0.05). The mean operation incidence rate in the population between 2004 and 2018 was 263 per 100,000. The duration of hospital stay shortened (p < 0.05), and the average age of operated patients increased by 2 years (p < 0.0001)., Conclusion: The implementation of PVP did not challenge the dominating position of TURP in Finland, but it has probably influenced the overall use of other surgical therapies, excluding transurethral incision of the prostate.  The results might suggest that the conservative treatment is accentuated, patient selection is more thorough, and surgical intervention might be placed at a later stage of BPO.

Background: Although prostate cancer (PCa) is the most common cancer in men in Western countries, there is significant variability in geographical incidence. This might result from genetic factors, discrepancies in screening policies, or differences in lifestyle. Gut microbiota has recently been associated with cancer progression, but its role in PCa is unclear., Objective: Characterization of the gut microbiota and its functions associated with PCa., Design Setting and Participants: In a prospective multicenter clinical trial (NCT02241122), the gut microbiota profiles of 181 men with a clinical suspicion of PCa were assessed utilizing 16S rRNA sequencing., Outcome Measurements and Statistical Analysis: Sequences were assigned to operational taxonomic units, differential abundance analysis, and α- and β-diversities, and predictive functional analyses were performed. Plasma steroid hormone levels corresponding to the predicted microbiota steroid hormone biosynthesis profiles were investigated., Results and Limitations: Of 364 patients, 181 were analyzed, 60% of whom were diagnosed with PCa. Microbiota composition and diversity were significantly different in PCa, partially affected by Prevotella 9 , the most abundant genus of the cohort, and significantly higher in PCa patients. Predictive functional analyses revealed higher 5-α-reductase, copper absorption, and retinol metabolism in the PCa-associated microbiome. Plasma testosterone was associated negatively with the predicted microbial 5-α-reductase level., Conclusions: Gut microbiota of the PCa patients differed significantly compared with benign individuals. Microbial 5-α-reductase, copper absorption, and retinol metabolism are potential mechanisms of action. These findings support the observed association of lifestyle, geography, and PCa incidence., Patient Summary: In this report, we found that several microbes and potential functions of the gut microbiota are altered in prostate cancer compared with benign cases. These findings suggest that gut microbiota could be the link between environmental factors and prostate cancer., (© 2024 The Author(s).)

Background: Transurethral resection of the prostate (TURP) is the standard surgical treatment for benign prostate enlargement (BPE). Photoselective vaporization of the prostate (PVP) is an alternative, but there is limited real-life evidence of PVP risks., Objective: To compare short- and long-term risks of PVP to those of TURP in the treatment of BPE., Materials and Methods: Consecutive patients who underwent elective PVP or TURP between 2006 and 2018 in 20 hospitals in Finland were retrospectively studied using a combination of national registries ( n  = 27,408; mean age 71 years). Short-term risks were postoperative mortality, major adverse cardiovascular events (MACE), and reoperations for bleeding. Long-term risks were reoperations for BPE or any urethral operations within 12 years. Differences between treatment groups were balanced by inverse probability of treatment weighting. Risks were analyzed using the Kaplan-Meier method and Cox regression., Results: There were no differences in postoperative mortality or MACE between the study groups. Reoperations for bleeding were less frequent after PVP (0.9%, HR: 0.72, p  = 0.042). Bleeding was more likely in patients with atrial fibrillation (number needed to treat [NNT] for PVP vs TURP: 61). Cumulative incidence for reoperation was higher after PVP (23.5%) than after TURP in long-term follow-up (17.8%; HR: 1.20, p  < 0.0001, NNT: -31.7)., Conclusions: PVP is associated with lower postoperative bleeding risk but higher long-term reoperation risk than TURP. Patients with high bleeding risk and a low likelihood of needing reoperation appear most suitable for laser vaporization.KEY MESSAGEPVP is associated with lower postoperative bleeding risk but higher long-term reoperation risk than TURP. PVP appears an attractive treatment option, especially for patients with high bleeding risk and a low likelihood of needing a reoperation.

Background: Automatic detection and segmentation of intraprostatic lesions (ILs) on preoperative multiparametric-magnetic resonance images (mp-MRI) can improve clinical workflow efficiency and enhance the diagnostic accuracy of prostate cancer and is an essential step in dominant intraprostatic lesion boost., Purpose: The goal is to improve the detection and segmentation accuracy of 3D ILs in MRI by a proposed a deep learning (DL)-based algorithm with histopathological ground truth., Methods: This retrospective study included 262 patients with in vivo prostate biparametric MRI (bp-MRI) scans and were divided into three cohorts based on their data analysis and annotation. Histopathological ground truth was established by using histopathology images as delineation reference standard on cohort 1, which consisted of 64 patients and was randomly split into 20 training, 12 validation, and 32 testing patients. Cohort 2 consisted of 158 patients with bp-MRI based lesion delineation, and was randomly split into 104 training, 15 validation, and 39 testing patients. Cohort 3 consisted of 40 unannotated patients, used in semi-supervised learning. We proposed a non-local Mask R-CNN and boosted its performance by applying different training techniques. The performance of non-local Mask R-CNN was compared with baseline Mask R-CNN, 3D U-Net and an experienced radiologist's delineation and was evaluated by detection rate, dice similarity coefficient (DSC), sensitivity, and Hausdorff Distance (HD)., Results: The independent testing set consists of 32 patients with histopathological ground truth. With the training technique maximizing detection rate, the non-local Mask R-CNN achieved 80.5% and 94.7% detection rate; 0.548 and 0.604 DSC; 5.72 and 6.36 95 HD (mm); 0.613 and 0.580 sensitivity for ILs of all Gleason Grade groups (GGGs) and clinically significant ILs (GGG > 2), which outperformed baseline Mask R-CNN and 3D U-Net. For clinically significant ILs, the model segmentation accuracy was significantly higher than that of the experienced radiologist involved in the study, who achieved 0.512 DSC (p = 0.04), 8.21 (p = 0.041) 95 HD (mm), and 0.398 (p = 0.001) sensitivity., Conclusion: The proposed DL model achieved state-of-art performance and has the potential to help improve radiotherapy treatment planning and noninvasive prostate cancer diagnosis., (© 2023 American Association of Physicists in Medicine.)

Background: Bacillus Calmette-Guérin (BCG) therapy using the Southwest Oncology Group (SWOG) maintenance protocol is the standard in non-muscle-invasive bladder cancer (NMIBC). Maintenance with monthly instillations is also widely used, but evidence comparing the two maintenance protocols is scarce., Objective: To compare monthly and SWOG instillation schedules in maintenance BCG therapy., Design, Setting, and Participants: We retrospectively identified patients with NMIBC treated with maintenance BCG according to either the monthly or the SWOG instillation regimen in two tertiary care centers in Finland between 2009 and 2019., Outcome Measurements and Statistical Analysis: We compared discontinuation rates of the monthly and SWOG maintenance protocols due to toxicity, and recurrence and progression rates by protocols. Baseline characteristics were compared with the Wilcoxon rank sum test, chi-square test, and Fisher's exact test. The Kaplan-Meier method and Cox proportional hazards model were used to evaluate the discontinuation of BCG due to toxicity and oncological efficacy., Results and Limitations: We identified 723 patients, of whom 545 (75%) and 178 (25%) received maintenance according to the monthly and SWOG protocols, respectively. The median follow-up time was 66 (interquartile range: 45-99) mo. In the monthly and SWOG groups, 131 (24%) and 50 (28%) patients, respectively, discontinued BCG due to toxicity, with no difference in a univariate or multivariate analysis (hazard ratio 1.01, 95% confidence interval [CI]: 0.73-1.40, p = 0.940). The 5-yr recurrence-free survival rates in the monthly and SWOG groups were 65% (95% CI: 61-69%) and 71% (95% CI: 64-79%, p = 0.370), respectively. The 5-yr progression-free survival rates were 89% (95% CI: 86-92%) and 91% (95% CI: 86-96%, p = 0.240), respectively., Conclusions: Monthly maintenance is a comparable alternative to the SWOG protocol., Patient Summary: In this study, we compared two schedules of intravesical bacillus Calmette-Guérin (BCG) treatment used in the treatment of non-muscle-invasive bladder cancer. We found that there were no significant differences between the two instillation schedules in terms of tolerability or efficacy., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Purpose: The primary aim of this study was to evaluate if exposure to 5-alpha-reductase inhibitors (5-ARIs) modifies the effect of MRI for the diagnosis of clinically significant Prostate Cancer (csPCa) (ISUP Gleason grade ≥ 2)., Methods: This study is a multicenter cohort study including patients undergoing prostate biopsy and MRI at 24 institutions between 2013 and 2022. Multivariable analysis predicting csPCa with an interaction term between 5-ARIs and PIRADS score was performed. Sensitivity, specificity, and negative (NPV) and positive (PPV) predictive values of MRI were compared in treated and untreated patients., Results: 705 patients (9%) were treated with 5-ARIs [median age 69 years, Interquartile range (IQR): 65, 73; median PSA 6.3 ng/ml, IQR 4.0, 9.0; median prostate volume 53 ml, IQR 40, 72] and 6913 were 5-ARIs naïve (age 66 years, IQR 60, 71; PSA 6.5 ng/ml, IQR 4.8, 9.0; prostate volume 50 ml, IQR 37, 65). MRI showed PIRADS 1-2, 3, 4, and 5 lesions in 141 (20%), 158 (22%), 258 (37%), and 148 (21%) patients treated with 5-ARIs, and 878 (13%), 1764 (25%), 2948 (43%), and 1323 (19%) of untreated patients (p < 0.0001). No difference was found in csPCa detection rates, but diagnosis of high-grade PCa (ISUP GG ≥ 3) was higher in treated patients (23% vs 19%, p = 0.013). We did not find any evidence of interaction between PIRADS score and 5-ARIs exposure in predicting csPCa. Sensitivity, specificity, PPV, and NPV of PIRADS ≥ 3 were 94%, 29%, 46%, and 88% in treated patients and 96%, 18%, 43%, and 88% in untreated patients, respectively., Conclusions: Exposure to 5-ARIs does not affect the association of PIRADS score with csPCa. Higher rates of high-grade PCa were detected in treated patients, but most were clearly visible on MRI as PIRADS 4 and 5 lesions., Trial Registration: The present study was registered at ClinicalTrials.gov number: NCT05078359., (© 2023. The Author(s).)

Purpose: Bilateral extended pelvic lymph node dissection at the time of radical prostatectomy is the current standard of care if pelvic lymph node dissection is indicated; often, however, pelvic lymph node dissection is performed in pN0 disease. With the more accurate staging achieved with magnetic resonance imaging-targeted biopsies for prostate cancer diagnosis, the indication for bilateral extended pelvic lymph node dissection may be revised . We aimed to assess the feasibility of unilateral extended pelvic lymph node dissection in the era of modern prostate cancer imaging., Materials and Methods: We analyzed a multi-institutional data set of men with cN0 disease diagnosed by magnetic resonance imaging-targeted biopsy who underwent prostatectomy and bilateral extended pelvic lymph node dissection. The outcome of the study was lymph node invasion contralateral to the prostatic lobe with worse disease features, ie, dominant lobe. Logistic regression to predict lymph node invasion contralateral to the dominant lobe was generated and internally validated., Results: Overall, data from 2,253 patients were considered. Lymph node invasion was documented in 302 (13%) patients; 83 (4%) patients had lymph node invasion contralateral to the dominant prostatic lobe. A model including prostate-specific antigen, maximum diameter of the index lesion, seminal vesicle invasion on magnetic resonance imaging, International Society of Urological Pathology grade in the nondominant side, and percentage of positive cores in the nondominant side achieved an area under the curve of 84% after internal validation. With a cutoff of contralateral lymph node invasion of 1%, 602 (27%) contralateral pelvic lymph node dissections would be omitted with only 1 (1.2%) lymph node invasion missed., Conclusions: Pelvic lymph node dissection could be omitted contralateral to the prostate lobe with worse disease features in selected patients. We propose a model that can help avoid contralateral pelvic lymph node dissection in almost one-third of cases.