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BACKGROUND: Active surveillance (AS) is recommended for low-risk and some intermediate-risk prostate cancer. Uptake and practice of AS vary significantly across different settings, as does the experience of surveillance-from which tests are offered, and to the levels of psychological support. OBJECTIVE: To explore the current best practice and determine the most important research priorities in AS for prostate cancer. DESIGN, SETTING, AND PARTICIPANTS: A formal consensus process was followed, with an international expert panel of purposively sampled participants across a range of health care professionals and researchers, and those with lived experience of prostate cancer. Statements regarding the practice of AS and potential research priorities spanning the patient journey from surveillance to initiating treatment were developed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Panel members scored each statement on a Likert scale. The group median score and measure of consensus were presented to participants prior to discussion and rescoring at panel meetings. Current best practice and future research priorities were identified, agreed upon, and finally ranked by panel members. RESULTS AND LIMITATIONS: There was consensus agreement that best practice includes the use of high-quality magnetic resonance imaging (MRI), which allows digital rectal examination (DRE) to be omitted, that repeat standard biopsy can be omitted when MRI and prostate-specific antigen (PSA) kinetics are stable, and that changes in PSA or DRE should prompt MRI ± biopsy rather than immediate active treatment. The highest ranked research priority was a dynamic, risk-adjusted AS approach, reducing testing for those at the least risk of progression. Improving the tests used in surveillance, ensuring equity of access and experience across different patients and settings, and improving information and communication between and within clinicians and patients were also high priorities. Limitations include the use of a limited number of panel members for practical reasons. CONCLUSIONS: The current best practice in AS includes the use of high-quality MRI to avoid DRE and as the first assessment for changes in PSA, with omission of repeat standard biopsy when PSA and MRI are stable. Development of a robust, dynamic, risk-adapted approach to surveillance is the highest research priority in AS for prostate cancer. PATIENT SUMMARY: A diverse group of experts in active surveillance, including a broad range of health care professionals and researchers and those with lived experience of prostate cancer, agreed that best practice includes the use of high-quality magnetic resonance imaging, which can allow digital rectal examination and some biopsies to be omitted. The highest research priority in active surveillance research was identified as the development of a dynamic, risk-adjusted approach.

Active surveillance has become the preferred management strategy for patients with low risk prostate cancer, but it is unclear if active surveillance can be safely extended to favorable intermediate risk (FIR) prostate cancer patients. Furthermore, defining a favorable intermediate risk prostate cancer population safe for active surveillance remains elusive due to paucity of high-level data in this population. This article serves to review relevant data, particularly the safety of active surveillance in grade group 2 patients, and what tools are available to aid in selecting a favorable subset of intermediate risk patients.Active surveillance studies with long-term data appear to report worsened survival outcomes in intermediate risk patients when compared to those undergoing definitive treatment, but there exists a subset of intermediate risk patients with nearly equivalent outcomes to low risk patients on active surveillance. Tools such as percentage and total length of Gleason pattern 4, tumor volume, prostate specific antigen density, magnetic resonance imaging, and genomic modifiers may help to select a favorable subset of intermediate risk prostate cancer appropriate for active surveillance.Active surveillance is a viable strategy in select patients with low volume group grade 2 (GG2) prostate cancer. Prospective and retrospective data in the FIR population appear to be mostly favorable in regards to survival outcomes, but there exists some heterogeneity with respect to long-term outcomes in this patient population.

Prostate biopsy (Bx) sampling-based diagnosis of prostate cancer (PCa) has well-described inaccuracy when compared against whole gland analysis upon prostatectomy. Although upgrading of PCa Grade Group (GG) is often described, the occurrence and prognostic implications of downgrading PCa GG at the time of radical prostatectomy (RP) is less understood. Our objective was to evaluate whether downgrading PCa GG at the time of RP was associated with future tumor behavior.The SEER database was searched from 2010 to 2017 and patients were included if they were assigned pathological grades on both Bx and RP specimen. Patients were stratified into Bx GG RP GG and Bx GG ≤ RP GG groups, and tumor behavior after treatment was examined. Cox regression was used for the survival analysis.Here, 99,835 patients were included in this study. A total of 18,516 (18.5%) patients encountered downgrading from Bx GG to RP GG. A downgrading of 1 grade occurred in 13,969 (75.4%) of these patients and of 2 or more grades occurred in 4547 (24.6%) patients. A history of higher Bx GG compared with RP GG increased the risk of cancer-specific mortality (CSM) for each given RP GG controlling for age, race, preop prostate-specific antigen level, percentage of positive biopsy cores, and pathologic TNM stages. Specifically, a history of high Bx GG conferred a 45% increased risk of CSM for any given RP GG (hazard ratio = 1.45 95% confidence interval = 1.16-1.82, p 0.001).A history of higher Bx GG, and hence downgrading at the time of RP, demonstrates some value as a risk-stratification tool for future cancer outcomes after prostatectomy.

Introduction:Surgical experience requires skills traditionally taught through real-time operating room education and a variety of supplemental educational strategies. Video-based coaching i...

Introduction:Annually the U.S. spends approximately $55.6 billion on malpractice and medical liability, with urology ranked 11th out of 25 specialties for number of malpractice claims. Our ...

Our ability to prognosticate the clinical course of patients with cancer has historically been limited to clinical, histopathological, and radiographic features. It has long been clear however, that these data alone do not adequately capture the heterogeneity and breadth of disease trajectories experienced by patients. The advent of efficient genomic sequencing has led to a revolution in cancer care as we try to understand and personalize treatment specific to patient clinico-genomic phenotypes. Within prostate cancer, emerging evidence suggests that tumor genomics (e.g., DNA, RNA, and epigenetics) can be utilized to inform clinical decision making. In addition to providing discriminatory information about prognosis, it is likely tumor genomics also hold a key in predicting response to oncologic therapies which could be used to further tailor treatment recommendations. Herein we review select literature surrounding the use of tumor genomics within the management of prostate cancer, specifically leaning toward analytically validated and clinically tested genomic biomarkers utilized in radiotherapy and/or adjunctive therapies given with radiotherapy.

To validate the performance of PI-RADS v2 for detection of clinically significant prostate cancer (csPca, Gleason ≥7) within the context of a new fusion biopsy program.Patients with a PI-RADS v2 assessment category assigned on pre-biopsy mpMRI between March 2015 and November 2017 were identified. Diagnostic performance of PI-RADS v2 was calculated using fusion biopsy results as reference standard using receiver operating characteristic curve analysis. Patient and lesion characteristics were analyzed with one-way ANOVA and Wilcoxon rank sum test.Of 83 patients with 175 lesions, 115/175 (65.7%) were benign, 21/175 (12%) were Gleason 6, and 39/175 (22.3%) were Gleason ≥7. csPCa rates were 0% (0/5) for PI-RADS 1, 7.4% (2/27) for PI-RADS 2, 5.8% (3/52) for PI-RADS 3, 31.2% (24/77) for PI-RADS 4, and 71.4% (10/14) for PI-RADS 5 (p 0.0001). For prediction of csPCa, patient-level AUC was 0.68 and lesion-level AUC was 0.77. Biopsy threshold of PI-RADS ≥3 was 92.6% sensitive and 22.1% specific. A threshold of PI-RADS ≥4 was 87.2% sensitive and 58.1% specific. Rate of csPca detection on concurrent standard 12 core biopsy only was 6.7%.PI-RADS v2 assessment categories assigned prior to biopsy predict pathologic outcome reasonably well in a new prostate fusion biopsy program. Biopsy threshold of PI-RADS ≥3 is highly sensitive. A threshold of ≥4 increases specificity but misses some csPCa.

Introduction Prostate cancer has traditionally been diagnosed by an elevation in PSA or abnormal exam leading to a systematic transrectal ultrasound (TRUS)-guided biopsy. This diagnostic pathway underdiagnoses clinically significant disease while over diagnosing clinically insignificant disease. In this review, we aim to provide an overview of the recent literature regarding the role of multiparametric MRI (mpMRI) in the management of prostate cancer. Materials and Methods A thorough literature review was performed using PubMed to identify articles discussing use of mpMRI of the prostate in management of prostate cancer. Conclusion The incorporation of mpMRI of the prostate addresses the shortcomings of the prostate biopsy while providing several other advantages. mpMRI allows some men to avoid an immediate biopsy and permits visualization of areas likely to harbor clinically significant cancer prior to biopsy to facilitate use of MR-targeted prostate biopsies. This allows for reduction in diagnosis of clinically insignificant disease as well as improved detection and better characterization of higher risk cancers, as well as the improved selection of patients for active surveillance. In addition, mpMRI can be used for selection and monitoring of patients for active surveillance and treatment planning during surgery and focal therapy. United States Department of Health & Human Services National Institutes of Health (NIH) - USA ; Doris Duke Charitable Foundation (DDCF) ; American Association for Dental Research ; Colgate-Palmolive Company ; Roche Holding ; Genentech

Purpose of review The present review describes the current role of metabolic imaging techniques such as multiparametric MRI (mpMRI), magnetic resonance spectroscopic imaging (MRSI), hyperpolarized MRSI, and positron emission tomography (PET) in the diagnosis of primary prostate cancer, surveillance of low-grade disease, detection of metastases, and evaluation of biochemical recurrence after therapy. Recent findings The natural history of prostate cancer ranges from indolent disease that is optimally monitored by active surveillance, to highly aggressive disease that can be lethal. Current diagnostic methods remain imperfect in noninvasively distinguishing between silent versus aggressive tumors. Hence, there is a high demand for noninvasive imaging techniques that offer insight into biological behavior of prostate cancer cells. Characterization of prostate cancer metabolism is a promising area to provide such insights. Summary Metabolic imaging may allow for greater detection and ultimately characterization of tumor based on aggressiveness and spread. Hence, it has the potential to monitor tumor activity, predict prognostic outcomes, and guide individualized therapies.

INTRODUCTION AND OBJECTIVE:Prostate biopsy is the golden standard for the diagnosis of prostate cancer (PCa). The discordance between the PCa Grade Group (GG) on biopsy (Bx) and the PCa GG from the...

INTRODUCTION AND OBJECTIVE:While PSA has traditionally been used for prostate cancer (PCa) risk stratification, prostate MRI has more recently allowed improved diagnosis of clinically significant P...

Purpose:The optimal primary treatment of localized high grade prostate cancer in younger men remains controversial. The objective of this project was to compare the impact of initial radical prostatectomy vs radiation therapy on survival outcomes in young men less than 60 years old with high grade prostate cancer.Materials and Methods:We retrospectively analyzed the records of men younger than 60 years in the SEER (Surveillance, Epidemiology and End Results) database who underwent initial surgery or radiation therapy of high grade (Gleason score 8 or greater) localized (N0M0 TNM stage) prostate cancer from 2004 to 2012. Univariate and multivariate Cox proportional hazards regression models were used to examine prostate cancer specific and overall mortality.Results:A total of 2,228 men were identified, of whom 1,459 (65.5%) underwent initial surgery and had a median followup of 43 months and 769 (34.5%) underwent initial external beam radiation therapy with or without brachytherapy and had a median followu...

PURPOSE: We aimed to assess post-interventional and 36-month follow-up results of a single-center, single-arm, in-bore phase I trial of focal laser ablation (FLA) guided by multiparametric magnetic resonance imaging (mpMRI). METHODS: FLA procedures were done in-bore MRI using a transperineal approach. Primary endpoints were feasibility and safety expressed as lack of grade 3 complications. Secondary endpoints were changes in international prostate symptom score (IPSS), sexual health inventory for men (SHIM), quality of life (QoL) scores, and serum prostate specific antigen (PSA) levels. Treatment outcomes were assessed by combined mpMRI-ultrasound fusion-guided and extended sextant systematic biopsy after 12, 24, and optionally after 36 months. RESULTS: Fifteen participants were included. Seven patients (46.67%) had Gleason 3+3 and 8 patients (53.33%) had Gleason 3+4 cancer. All patients tolerated the procedure well, and no grade 3/4 complications occurred. All grade 1 and 2 complications were transient and resolved completely. There was no significant change in mean IPSS from baseline (−1, p = 0.460) and QoL (0, p = 0.441) scores following FLA but there was a significant drop in mean SHIM scores (−2, p = 0.010) compared to pretreatment baselines. Mean PSA significantly decreased after FLA (−2.5, p < 0.001). Seven out of 15 patients (46.67%) had residual cancer in, adjacent, or in close proximity to the treatment area (1 × 4+3=7, 1 × 3+4=7, and 5 × 3+3=6). Four out of 15 patients (26.67%) underwent salvage therapy (2 repeat FLA, 2 radical prostatectomy). CONCLUSION: After 3 years of follow-up we conclude focal laser ablation is safe and feasible without significant complications.

Background While magnetic resonance imaging (MRI)-targeted biopsy (TBx) results in better prostate cancer (PCa) detection relative to systematic biopsy (SBx), the combination of both methods increases clinically significant PCa detection relative to either Bx method alone. However, combined Bx subjects patients to higher number of Bx cores and greater detection of clinically insignificant PCa. Objective To determine if prebiopsy prostate MRI can identify men who could forgo combined Bx without a substantial risk of missing clinically significant PCa (csPC). Design, setting, and participants Men with MRI-visible prostate lesions underwent combined TBx plus SBx. Outcome measurements and statistical analysis The primary outcomes were detection rates for grade group (GG) ≥2 and GG ≥3 PCa by TBx and SBx, stratified by Prostate Imaging-Reporting and Data System (PI-RADS) score. Results and limitations Among PI-RADS 5 cases, nearly all csPCs were detected by TBx, as adding SBx resulted in detection of only 2.5% more GG ≥2 cancers. Among PI-RADS 3–4 cases, however, SBx addition resulted in detection of substantially more csPCs than TBx alone (8% vs 7.5%). Conversely, TBx added little to detection of csPC among men with PI-RADS 2 lesions (2%) relative to SBx (7.8%). Conclusions While combined Bx increases the detection of csPC among men with MRI-visible prostate lesions, this benefit was largely restricted to PI-RADS 3–4 lesions. Using a strategy of TBx only for PI-RADS 5 and combined Bx only for PI-RADS 3–4 would avoid excess biopsies for men with PI-RADS 5 lesions while resulting in a low risk of missing csPC (1%). Patient summary Our study investigated an optimized strategy to diagnose aggressive prostate cancer in men with an abnormal prostate MRI (magnetic resonance imaging) scan while minimizing the risk of excess biopsies. We used a scoring system for MRI scan images called PI-RADS. The results show that MRI-targeted biopsies alone could be used for men with a PI-RADS score of 5, while men with a PI-RADS score of 3 or 4 would benefit from a combination of MRI-targeted biopsy and systematic biopsy. This trial is registered at ClinicalTrials.gov as NCT00102544.

Introduction: The litigious environment encompassing the medical–legal domain is an increasing concern for surgical fields, with urology being no exception. The objective of our study was to system...

Prostate cancer has traditionally been diagnosed by an elevation in PSA or abnormal exam leading to a systematic transrectal ultrasound (TRUS)-guided biopsy. This diagnostic pathway underdiagnoses clinically significant disease while over diagnosing clinically insignificant disease. In this review, we aim to provide an overview of the recent literature regarding the role of multiparametric MRI (mpMRI) in the management of prostate cancer.A thorough literature review was performed using PubMed to identify articles discussing use of mpMRI of the prostate in management of prostate cancer.The incorporation of mpMRI of the prostate addresses the shortcomings of the prostate biopsy while providing several other advantages. mpMRI allows some men to avoid an immediate biopsy and permits visualization of areas likely to harbor clinically significant cancer prior to biopsy to facilitate use of MR-targeted prostate biopsies. This allows for reduction in diagnosis of clinically insignificant disease as well as improved detection and better characterization of higher risk cancers, as well as the improved selection of patients for active surveillance. In addition, mpMRI can be used for selection and monitoring of patients for active surveillance and treatment planning during surgery and focal therapy.

INTRODUCTION AND OBJECTIVE:Partial cystectomy is a comparably shorter, less morbid surgery without the need for urinary diversion and could be a suitable alternative to radical cystectomy in select...

INTRODUCTION AND OBJECTIVE:Determining the efficacy of prostate cancer (PCa) treatments like androgen-deprivation therapy (ADT) can take months. Screening metabolic responses to therapies in PCa ti...

Men with Gleason score 9–10 prostate cancer have worse outcomes compared to those with Gleason 8 disease. Upfront treatments remain controversial for these patients. Using the Surveillance, Epidemiology, and End Results (SEER) database, we evaluated the impact of initial treatment with external beam radiation therapy (EBRT), external beam radiation therapy with brachytherapy (EBRT + BT), or surgery on prostate cancer-specific mortality (PCSM) and overall mortality (OM) in Gleason 9–10 disease. The SEER database was queried for men diagnosed with biopsy Gleason 9–10 prostate cancer from 2005 to 2014. Gathered data included demographic, pathologic, therapy received, and survival outcomes. Kaplan–Meier survival curves and crude and multivariate analyses were generated for initial therapy with EBRT, EBRT + BT, or surgery. A total of 7877 men were included, 4465 (56.7%) who underwent upfront treatment with EBRT alone, 623 (7.9%) with EBRT + BT, and 2789 (35.4%) with surgery. The 7 year PCSM rates were 29.2, 15.0, and 14.6% for EBRT, EBRT + BT, and surgery respectively (p

Gleason score grading is a cornerstone of risk stratification and management of patients with prostate cancer (PCa). In this work, we derive and validate a nomogram that uses prostate multiparametric magnetic resonance imaging (MP-MRI) and clinical patient characteristics to predict biopsy Gleason scores (bGS).A predictive nomogram was derived from 143 men who underwent MP-MRI prior to any prostate biopsy and then validated on an independent cohort of 235 men from a different institution who underwent MP-MRI for PCa workup. Screen positive lesions were defined as lesions positive on T2W and DWI sequences on MP-MRI. Prostate specific antigen (PSA) density, number of screen positive lesions, and MRI suspicion were associated with PCa Gleason score on biopsy and were used to generate a predictive nomogram. The independent cohort was tested on the nomogram and the most likely bGS was noted.The mean PSA in the validation cohort was 9.25ng/mL versus 6.8ng/mL in the original cohort (A preintervention nomogram based on PSA and MRI findings can help narrow down the likely pathologic finding on biopsy. Validation of the nomogram demonstrated a significant ability to correctly identify the most likely bGS. This feasibility study demonstrates the potential of a prebiopsy prediction of bGS and based on the high negative predictive value, identification of men who may not need biopsies, which could impact future risk stratification for PCa.

Delayed diagnosis of concurrent bladder damage in a patient with blunt urethral trauma can lead to a high rate of morbidity. In patients with a high index of suspicion, genitourinary workup is recommended. In complicated patients with multi-trauma, this workup has a risk of being delayed. A proven prognostic indicator to evaluate the likelihood of bladder injury in this population has not been established. The aim of this study was to determine if there was a clinical association between the Injury Severity Score (ISS) and bladder injury involvement among these patients. Retrospective analysis was performed on a cohort of 98 patients who presented with blunt urethral trauma to R. Adams Cowley Shock Trauma Center between 2002 and 2014. Univariate analysis was performed to determine if there was an association between concurrent bladder injuries and ISS among other factors. A receiver operating characteristic curve plot was performed to analyze the association between ISS and bladder involvement. Of the 98 patients with blunt urethral trauma, 28 had concurrent bladder injury. ISS was shown to have a significant correlation with concurrent bladder injury (OR = 2.2 per 10 unit change in ISS, p = 0.0001). ROC curve analysis showed an area under the curve for the prediction of bladder injury. Patients with ISS ≥ 34 had a 54% chance of bladder injury, while patients with ISS

Prostate cancer treatment is based on the stratification of disease as low-, intermediate- or high-risk. This stratification has been largely based on anatomic pathology of the disease, as well as through the use of prostate specific antigen (PSA). However, despite this stratification, there remains heterogeneity within the current classification schema. Utilizing a metabolic approach may help to further establish novel biomolecular markers of disease aggressiveness. These markers may eventually be useful in not only the diagnosis of disease but in creating tumor specific targeted therapy for improved clinical outcomes.

Purpose To determine the association between Prostate Imaging Reporting and Data System (PI-RADS) version 2 scores and prostate cancer (PCa) in a cohort of patients undergoing biopsy of transition zone (TZ) lesions. Materials and Methods A total of 634 TZ lesions in 457 patients were identified from a prospectively maintained database of consecutive patients undergoing prostate magnetic resonance imaging. Prostate lesions were retrospectively categorized with the PI-RADS version 2 system by two readers in consensus who were blinded to histopathologic findings. The proportion of cancer detection for all PCa and for clinically important PCa (Gleason score ≥3+4) for each PI-RADS version 2 category was determined. The performance of PI-RADS version 2 in cancer detection was evaluated. Results For PI-RADS category 2 lesions, the overall proportion of cancers was 4% (one of 25), without any clinically important cancer. For PI-RADS category 3, 4, and 5 lesions, the overall proportion of cancers was 22.2% (78 of 352), 39.1% (43 of 110), and 87.8% (129 of 147), respectively, and the proportion of clinically important cancers was 11.1% (39 of 352), 29.1% (32 of 110), and 77.6% (114 of 147), respectively. Higher PI-RADS version 2 scores were associated with increasing likelihood of the presence of clinically important PCa (P.001). Differences were found in the percentage of cancers in the PI-RADS category between PI-RADS 3 and those upgraded to PI-RADS 4 based on diffusion-weighted imaging for clinically important cancers (proportion for clinically important cancers for PI-RADS 3 and PI-RADS 3+1 were 11.1% [39 of 352] and 30.8% [28 of 91], respectively; P.001). Conclusion Higher PI-RADS version 2 scores are associated with a higher proportion of clinically important cancers in the TZ. PI-RADS category 2 lesions rarely yield PCa, and their presence does not justify targeted biopsy.

Approximately 25% of the 2 million new cancer diagnoses in the United States in 2018 were comprised of malignancies of the urogenital system. Of these cancers, 75% occurred in the kidney/renal pelvis, prostate, and urinary bladder. Early diagnosis is beneficial to long-term survival. Currently, urologists rely heavily on computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), and positron emission tomography (PET) to both diagnose and offer prognoses, but these techniques are limited in their resolution and are more effective when cancers have reached macroscopic size in later stages. Recent developments in cancer metabolomics have revealed that cancerous cells preferentially upregulate specific metabolic pathways as a means of conserving their resources and maximizing their growth potential. This has opened a new avenue for early diagnosis with much higher resolution, reliability, and accuracy through 13C hyperpolarized MRI. Preferential cancer pathways can be elucidated through this technique using 13C-labeled molecules utilized for energy generation and tumor growth. As these pathways are identified, targeted therapies are being designed to inhibit these pathways to allow for treatment that is cytotoxic to malignant cells but preserves native cells. In this paper, we review the current understanding of urologic cancer metabolomics, specifically in the kidney, prostate, and bladder. We will review the basic physics of MRI and demonstrate how hyperpolarized 13C MRI offers an innovative solution to early diagnosis as well as creates novel avenues for more targeted therapy.

Objective To determine whether supplemental biopsy of hypoechoic ultrasound lesions (HUL) incidentally found during magnetic resonance imaging (MRI)-transrectal ultrasound (TRUS) fusion-targeted prostate biopsy results in improved prostate cancer (PCa) detection. Methods Patients underwent MRI-TRUS-targeted biopsy as part of an ongoing prospective trial from August 2007 to February 2015. For men with HUL, the biopsy pathology of HUL and MRI lesions was classified according to the updated 2014 International Society of Urological Pathology (ISUP) grading system. The detection of PCa by MRI-targeted biopsy with and without HUL biopsy was compared. Results Of 1260 men in the trial, 106 underwent biopsy of 119 HULs. PCa was diagnosed in 52 out of 106 men (49%) by biopsy of either MRI lesions or HUL. Biopsy of HUL in addition to MRI lesions resulted in 4 additional diagnoses of high-grade (ISUP grades 3-5) PCa versus biopsy of MRI lesions alone (20 vs 16 men, P = .046). Three of these cases were upgraded from lower grade (ISUP grades 1-2) PCa on MRI-guided biopsy alone, and only 1 case (1% of cohort) was diagnosed that would have been missed by MRI-guided biopsy alone. Supplemental biopsy of HUL did not change the PCa risk category in 96% (102 out of 106) of men with HUL. Conclusion Supplemental biopsy of HUL yields a small increase in the detection of higher grade PCa as compared with biopsy of MRI lesions alone. As upgrading is rare, routinely screening for HUL during MRI-targeted biopsy remains controversial.

BACKGROUND: Analysis of systematic 12-core biopsies (SBx) has shown that African-American (AA) men tend to harbor higher risk prostate cancer (PCa) at presentation relative to other races. Multiparametric magnetic resonance imaging (mpMRI) and MRI-ultrasound fusion-guided biopsy (FBx) have been shown to diagnose more intermediate- and high-risk PCa in the general population; however, the efficacy in AA remains largely uncharacterized. We aim to evaluate the utility of FBx in an AA patient cohort. METHODS: Men suspected of PCa underwent an mpMRI and FBx with concurrent SBx from 2007 to 2015 in this institutional review board-approved prospective cohort study. Patient demographics, imaging and fusion biopsy variables were collected. χ(2), Mann–Whitney U-test and McNemar’s tests were performed to compare proportions, means and paired variables, respectively. Clinically significant PCa (CSPCa) was defined as Gleason score ≥ 3+4. RESULTS: Fusion biopsy demonstrated exact agreement with SBx risk categories in 64% of AA men. There was no statistically significant difference in the detection of CSPCa between FBx vs SBx (68 vs 62 cases, P = 0.36). However, FBx detected 41% fewer cases of clinically insignificant PCa (CIPCa) compared with SBx (FBx 30 vs SBx 51 cases, P = 0.0004). The combined FBx/SBx biopsy approach detected significantly more cases of CSPCa (FBx/SBx 80 vs SBx 62 cases, P = 0.004) while detecting comparable number of cases of CIPCa (FBx/SBx 45 vs SBx 51 cases, P = 0.37) compared with SBx alone. FBx/SBx also detected more CSPCa in patients with a history of prior negative SBx (FBx/SBx 28 vs 19 cases, P = 0.003). CONCLUSIONS: FBx when used in combination with SBx detected more cases of CSPCa while not significantly increasing the diagnosis of CIPCa in AA men. Future multicenter studies will be needed to validate ultimately the clinical implications of FBx in AA patients.

With the long-standing controversy surrounding the use of prostate-specific antigen (PSA) for the detection, evaluation, and surveillance of prostate cancer, there is a need for a minimally invasive technique to identify and risk-stratify these patients. Additionally, in an effort to reduce the number of unnecessary biopsies and identify clinically significant prostate cancer (csPCa), there has been a shift in practice towards the use of multiparametric magnetic resonance imaging (mpMRI) in conjunction with decision-making regarding prostate cancer diagnosis and management. In the current review, we summarize the data regarding the use of mpMRI in the detection, evaluation, and surveillance of csPCa. Recent prospective clinical trials have determined that a pre-biopsy mpMRI may rule out insignificant prostate cancers, thereby reducing the number of patients who require a biopsy. The anatomic information gathered from these pre-biopsy mpMRI performed during MRI fusion biopsy in csPCa increases the accuracy of pathologic staging in terms of Gleason scores. In regard to active surveillance, prospective trials suggest little to no clinical utility for mpMRI and fusion biopsy in the surveillance of prostate cancer despite conflicting findings from retrospective studies. Recent trials suggest that mpMRI can play an important role in the detection and evaluation of csPCa. The ideal role for mpMRI in active surveillance remains limited.

PURPOSE OF REVIEW: This overview examines the rationale for dietary interventions for prostate cancer by summarizing the current evidence base and biological mechanisms for the involvement of diet in disease incidence and progression. RECENT FINDINGS: Recent data have further solidified the association between insulin resistance and prostate cancer with the homeostatic model assessment of insulin resistance (HOMA-IR). Data also show that peri-prostatic adipocytes promote extracapsular extension of prostate cancer through chemokines, thereby providing a mechanistic explanation for the association observed between obesity and high grade cancer. Regarding therapeutics, hyperinsulinemia may be the cause of resistance to PI3K inhibitors in the treatment of prostate cancer, leading to new investigations combining these drugs with ketogenic diets. SUMMARY: Given the recently available data regarding insulin resistance and adipokine influence on prostate cancer, dietary strategies targeting metabolic syndrome, diabetes and obesity should be further explored. In macronutrient-focused therapies, low carbohydrate/ketogenic diets should be favored in such interventions due to their superior impact on weight loss and metabolic parameters and encouraging clinical data. Other nutrients, including the carotenoid lycopene which is found in highest concentrations in tomatoes, may also play a role in prostate cancer prevention and prognosis through complementary metabolic mechanisms. The interplay between genetics, diet and prostate cancer is an area of emerging focus that might help optimize therapeutic dietary response in the future through personalization.

Objective To evaluate the effect of adding multiparametric magnetic resonance imaging (mpMRI) to pre-surgical planning on surgical decision making for the management of high-risk prostate cancer (HRPC). Patients and methods A survey was designed to query multiple centers on surgical decisions of 41 consecutive HRPC cases seen from 2012 to 2015. HRPC was defined by the National Comprehensive Cancer Center Network guidelines. Six fellowship-trained urologic oncologists were asked for their surgical plan in regards to the degree of planned nerve-sparing and lymph node dissection. Two rounds of surveys were administered to six external urologic oncologists. The first survey included the case description only and the second included case description with mpMRI images and report. The correct surgical plan was analyzed by correlation of the degree of planned surgical excision and consistency with the final pathologic evaluation. A priori, an effect size of 20% change was used to determine statistical significance, at p Results All cases had at least one change to surgical planning after mpMRI review. Forty (98%) patients had a change in the degree of planned nerve sparing: wider excision in 32% and increased nerve sparing in 24%. After mpMRI the correct surgical plan change was made in 49% for the right and left 51%, decreasing the potential for positive margins. Lymph node dissection was altered from standard to extended lymph node dissection in 17%. Conclusions Although mpMRI is not integrated in guidelines for preoperative planning in HRPC, its use may impact surgical planning, cancer control, and quality of life.

INTRODUCTION AND OBJECTIVES:MRI-TRUS fusion prostate biopsy(FB), also referred to as “targeted biopsy”, has been shown to improve detection of clinically significant prostate cancer and reduce the ...

Multifocal and hereditary kidney cancers often require repeated ipsilateral nephron sparing procedures with higher blood loss and complication rates compared to first time renal surgery. Consequently, many surgeons avoid minimally invasive techniques in the setting. We present the characteristics, complications, and short-term renal functional outcomes of patients who underwent a repeat robotic partial nephrectomy (rRPNx).A database was retrospectively reviewed to identify patients who underwent robotic partial nephrectomies between January 2007 and December 2013. Selection criteria for the rRPNx cohort included patients who had undergone at least two ipsilateral renal surgeries, with the second procedure being an rRPNx. All other patients comprised the initial robotic partial nephrectomy (iRPNx) group.One hundred twenty-four patients who underwent robotic partial nephrectomy during the study period were identified. rRPNx constituted 26 (21%) of the total cases. Age of the rRPNx cohort was similar (p = 0.56), but number of tumors resected was two-fold greater in the rRPNx group (p = 0.44). Neither surgery time nor renal clamp time was significantly longer in either group (p = 0.18 and p = 0.65, respectively). Importantly, estimated blood loss (EBL) was significantly larger than in the iRPNx group (p = 0.01). Both groups had similar intravenous pain medication administration durations (p = 0.32), but postsurgical length of stay was greater for the rRPNx patients (p = 0.011). There were no significant differences in clavian complication rates (p = 0.17-0.39), with the exception of urine leak which occurred more frequently in the rRPNx group (p = 0.01). There was no difference in percent change in serum creatinine or estimated glomerular filtration rate (p = 0.89 and p = 0.67, respectively).rRPNx is safe and feasible in select patients. EBL, postoperative lengths of stay, and urine leak were the only factors significantly associated with rRPNx compared to iRPNx. Patient 3-month follow-up revealed excellent and comparable outcomes between the two groups.

PURPOSE OF REVIEW: Prostate cancer (PCa) demonstrates characteristic changes in metabolism and bioenergetics in the transition from benign to malignant tissue. It is feasible that some of these changes may be targetable for therapeutic purposes. This review will highlight some of the current metabolically targeted therapies being investigated for the treatment of prostate cancer. RECENT FINDINGS: The transition from benign to malignant prostate cells is characterized by decreased intracellular zinc concentration and subsequent release of inhibition of the tricarboxylic acid cycle enzyme m-aconitase which leads to the decrease in citrate concentration within the cancer tissue. Instead of the largely glycolytic phenotype exhibited by most cancers, PCa relies on glutamine and lipids for survival and proliferation. Early studies are beginning to demonstrate that targeting some of the up-regulated pathways with inhibitors of key enzymes such as glutaminase, fatty acid synthase, HMG-CoA reductase, hexokinase, zinc transport, or complex I in the mitochondria may have significant metabolic effects and therapeutic potential. SUMMARY: The unique metabolic profile of PCa allows for many potential avenues of treatment. Future studies will continue to test if the metabolic characterization and treatment of PCa could be an important approach to provide personalized treatment for the disease.

To identify the risk factors associated with development of postoperative elevation of creatine kinase (CK) and study its effect on renal function in patients who underwent complex multifocal partial nephrectomy (PN).Patients who underwent PN at National Cancer Institute between January 2007 and December 2012 were included in the study. Elevated serum CK was defined as2000 U/L. Kidney function was assessed using serum creatinine and estimated glomerular filtration rate (eGFR). Changes were reported as percent change from preoperative values and compared using the Wilcoxon test. Regression analysis was performed to identify the predictors of elevation in CK and decline in eGFR.From 407 total cases, 207 had adequate CK data for analysis. Median number of tumors removed was 3 (1-70). Median peak CK was 1458 (82-36,788). Forty-two percent developed CK elevation2000 U/L. Factors associated with postoperative elevation of CK 2000 were young age (p = 0.009), high BMI (p = 0.003) and operating room time (p 0.001). Although CK 2000 was associated with significantly greater decline in eGFR (37.4 vs. 20.3 %, p 0.001) in immediate postoperative period, this change largely resolved to a much less clinically relevant (9.2 vs 3.3 %, p = 0.040) change after 3 months. On multivariate analysis, postoperative elevation in CK was not found to be an independent factor determining renal function at 3 months.In our cohort, a significant proportion of patients developed CK elevations2000 U/L. While patients with elevated CK had more decline in eGFR in immediate postoperative period, postoperative elevations of CK did not appear to impact overall long-term renal function in patients undergoing PN.

An important factor in the heat exchanger is the enhancement of the heat transfer rate. Heat exchangers succumb to numerous losses resulting because of convection, conduction, and radiation from the experimental set-up which hinders its performance. This project focuses on developing a parallel flow model for the analysis of DOT4 brake fluid considering the numerous energy losses based on experimental results. Various parameters like mass flow rate, inlet temperature on the overall heat transfer rate, and their effects are studied. Basis of the results, parameters are considered for better performance which has been taken into consideration for doing theoretical calculations. This project aims at analyzing the brake fluid both experimentally and theoretically by fabrication of the heat exchanger using mild steel and copper, henceforth experimenting to obtain the analysis of the fluid.

INTRODUCTION AND OBJECTIVE:Gleason score grading is a cornerstone of risk stratification and management of patients with prostate cancer (PCa). In this work, we derive and validate a nomogram that ...