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Article of the week: Management of patients with advanced prostate cancer in the Asia Pacific region: ‘real‐world’ consideration of results from the Advanced Prostate Cancer Consensus Conference 2017

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. There is also a video produced by the authors describing the ‘real-world’ findings.

If you only have time to read one article this week, it should be this one.

Management of patients with advanced prostate cancer in the Asia Pacific region: ‘real‐world’ consideration of results from the Advanced Prostate Cancer Consensus Conference 2017

Edmund Chionga, Declan G. Murphyb,c, Hideyuki Akazad, Nicholas C. Buchane,f, Byung Ha Chungg, Ravindran Kanesvaranh, Makarand Khochikari, Jason Letranj, Bannakij Lojanapiwatk, Chi-fai Ngl, Teng Ongm, Yeong-Shiau Pun, Marniza Saado, Kathryn Schubachq, Levent Türkeris, Rainy Umbast, Vu Le Chuyenu, Scott Williamsv,r, Ding-Wei Yew, ANZUP Cancer Trials Groupx and Ian D. Davisy,z,r

 

aDepartment of Urology, National University Hospital, National University Health System Singapore, hDivision of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore, bDivision of Cancer Surgery, vDivision of Radiation Oncology, Peter MacCallum Cancer Centre Melbourne, yMonash University, zEastern Health, Melbourne, cSir Peter MacCallum Department of Oncology, University Melbourne, Parkville, qAustralian New Zealand Urology Nurses (ANZUNS), Melbourne, VIC, Australia, rANZUP Cancer Trials Group, xLifehouse, Camperdown, Sydney, NSW, Australia, dStrategic Investigation on Comprehensive Cancer Network, The University of Tokyo, Tokyo, Japan, eCanterbury Urology Research Trust, fCanterbury District Health Board, Christchurch, New Zealand, gDepartment of Urology, Yonsei University College of Medicine, Seoul, Korea, iSiddhi Vinayak Ganapati Cancer Hospital, Miraj, India, jSection of Urology, Department of Surgery, University of Santo Tomas, Manila, Philippines, kDivision of Urology, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, lDepartment of Surgery, SH Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong, wDepartment of Urology, Fudan University Shanghai Cancer Center, Shanghai, China, mDivision of Urology, Department of Surgery, oDepartment of Clinical Oncology, Faculty of Medicine, University of Malaya, Kuala Lumpur,Malaysia, nDepartment of Urology, National Taiwan University Hospital, Taipei, Taiwan, sDepartment of Urology, Acibadem University, Istanbul, Turkey, tDepartment of Urology, University of Indonesia, Jakarta, Indonesia, and uDepartment of Urology, Binh dan Hospital, Ho Chi Minh City, Vietnam

 

Abstract

Objective

The Asia Pacific Advanced Prostate Cancer Consensus Conference (APAC APCCC 2018) brought together 20 experts from 15 APAC countries to discuss the real‐world application of consensus statements from the second APCCC held in St Gallen in 2017 (APCCC 2017).

Findings

Differences in genetics, environment, lifestyle, diet and culture are all likely to influence the management of advanced prostate cancer in the APAC region when compared with the rest of the world. When considering the strong APCCC 2017 recommendation for the use of upfront docetaxel in metastatic castration‐naïve prostate cancer, the panel noted possible increased toxicity in Asian men receiving docetaxel, which would affect this recommendation in the APAC region. Although androgen receptor‐targeting agents appear to be well tolerated in Asian men with metastatic castration‐resistant prostate cancer, access to these drugs is very limited for financial reasons across the region. The meeting highlighted that cost and access to contemporary treatments and technologies are key factors influencing therapeutic decision‐making in the APAC region. Whilst lower cost/older treatments and technologies may be an option, issues of culture and patient or physician preference mean, these may not always be acceptable. Although generic products can reduce cost in some countries, costs may still be prohibitive for lower‐income patients or communities. The panellists noted the opportunity for a coordinated approach across the APAC region to address issues of access and cost. Developments in technologies and treatments are presenting new opportunities for the diagnosis and treatment of advanced prostate cancer. Differences in genetics and epidemiology affect the side‐effect profiles of some drugs and influence prescribing.

Box 1: Management of advanced prostate cancer in the APAC region: real‐world challenges in implementing the St Gallen APCCC recommendations.

  1. Differences in toxicity: safety data for docetaxel are not fully established in Asian men and concerns about the toxicity profile and risk of neutropaenia may influence prescribing.
  2. Disparities in access to imaging technology: variable access to imaging technology may limit prescribing according to precise definitions.
  3. Disparities in access and cost of treatment: availability and cost of treatments are the most significant factor influencing prescribing decisions in the region; lower‐cost alternatives are not always culturally acceptable, and informed choice is important.
  4. Variability in MDT approaches: the importance of multidisciplinary input to treatment recommendations is understood but MDTs are a challenge in some APAC countries; virtual MDT participation should be encouraged.
  5. Variability in demographics: genetics and epidemiology in Asian men with prostate cancer may result in different treatment responses; collaborative registry studies and trials in APAC populations are likely to be valuable.

Conclusions

As the field continues to evolve, collaboration across the APAC region will be important to facilitate relevant research and collection and appraisal of data relevant to APAC populations. In the meantime, the APAC APCCC 2018 meeting highlighted the critical importance of a multidisciplinary team‐based approach to treatment planning and care, delivery of best‐practice care by clinicians with appropriate expertise, and the importance of patient information and support for informed patient choice.

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Editorial: The Advanced Prostate Cancer Consensus on a regional level – what can we learn?

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In this issue of BJUI Chiong et al [1] present the results of the Asia Pacific (APAC) Advanced Prostate Cancer Consensus Conference (APCCC) 2018, during which the implications of the APCCC 2017 findings were discussed in the context of the APAC region. For background, it is important to understand the concept of the original APCCC and why it was initiated [1,2,3].

The consensus conference aims to target areas of controversy in the clinical management of advanced prostate cancer where evidence is either limited or lacking or where interpretation of evidence is controversial. The expert consensus aims to complement existing clinical practice guidelines that are mostly based on high‐level evidence. The APCCC’s most prominent aim is knowledge translation, in the sense of improving care of men with advanced prostate cancer worldwide who are treated outside of centres of excellence. During the original APCCC in St Gallen, where 61 prostate cancer experts and scientists were assembled, the majority of the consensus questions were discussed; these had been prepared prior to the conference under the idealistic assumption that all diagnostic procedures and treatments (including expertise in their interpretation and application) mentioned were readily available. These assumptions have been specifically chosen, because availability of systemic treatment options for advanced prostate cancer, access to next‐generation imaging (whole‐body MRI and positron‐emission tomography [PET]) and expertise in molecular techniques and interpretation of results vary widely across the world. The original global APCCC did not generally address regional or country‐specific situations, but APCCC 2017 did have a special session and also voting questions for treatment options in countries with limited resources. Importantly, consensus recommendations may even inform and influence regulatory authorities, for example, if a specific treatment is considered to be the best option by the majority of experts and availability in a certain country is lacking.

The APAC APCCC 2018 consisted of 20 experts (mostly urologists) from 15 countries and discussed the findings and voting results of five of the 10 APCCC 2017 topics. Whether or not Turkey should be considered an APAC country is unclear. The most relevant observations were as set out below:

  • There is huge variation in access to drugs used for treatment of advanced prostate cancer in the APAC region. Australia and Hong Kong have access to almost all treatment options (notably cabazitaxel is not mentioned) compared with countries such as Vietnam or the Philippines, where there is limited availability of many compounds. Regarding imaging technologies (standard CT is not mentioned), there seems to be wide availability of next‐generation imaging such as whole‐body MRI and choline‐ or PSMA‐PET technologies; however, these imaging methods are often not reimbursed.
  • Pharmaco‐ethnic issues have so far not been considered by the original APCCC and the APAC report clearly highlights the need to address such issues. The higher toxicity of docetaxel in Asian men may influence treatment recommendations, especially in situations such as low‐volume metastatic castration‐naïve prostate cancer, where the role of early addition of docetaxel to androgen deprivation therapy is less clear.
  • The authors of the APAC meeting state that ketoconazole and bicalutamide are still widely used despite the proven superiority of enzalutamide vs bicalutamide. A possible reason for this is the lack of reimbursement in some APAC countries.
  • There is an obvious need for clinical trials in the APAC region because of variations in genetics, genomics, epidemiology and pharmaco‐ethnicity. Such trials may answer questions about toxicity/tolerability and also optimal use of resources in the context of economic limitations.

In summary, the APAC APCCC 2018 is an excellent example of how the global APCCC findings should be discussed and integrated on a regional or even country‐specific level. The authors are therefore to be congratulated for their efforts and for writing up the discussions. The next APCCC  (2019; apccc.org) will take up a number of points raised by the APAC meeting, namely, more panel experts from APAC countries and pharmaco‐ethnic topics.

References

  1. Edmund C, Declan GM, Hideyuki A et al. Management of patients with advanced prostate cancer in the Asia Pacific region: ‘real‐world’ consideration of results from the Advanced Prostate Cancer Consensus Conference (APCCC) 2017. BJU Int 2019; 123: 22–34
  2. Gillessen S, Omlin A, Attard G et al. Management of patients with advanced prostate cancer: recommendations of the St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) 2015. Ann Oncol 2015; 26: 1589–604
  3. Gillessen S, Attard G, Beer TM et al. Management of patients with advanced prostate cancer: the report of the Advanced Prostate Cancer Consensus Conference APCCC 2017. Eur Urol 2018; 73: 178–211

 

 

Resident’s podcast: Retzius‐sparing robot‐assisted radical prostatectomy

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Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the Week:

Retzius‐sparing robot‐assisted radical prostatectomy (RS‐RARP) vs standard RARP: it’s time for critical appraisal

Thomas Stonier*, Nick Simson*, John Davis† and Ben Challacombe‡

 

*Department of Urology, Princess Alexandra Hospital, Harlow, ‡Urology Centre, Guy ’s Hospital, London, UK and †Department of Urology, MD Anderson Cancer Center, Houston, TX, USA

 

Read the full article

Abstract

Since robot‐assisted radical prostatectomy (RARP) started to be regularly performed in 2001, the procedure has typically followed the original retropubic approach, with incremental technical improvements in an attempt to improve outcomes. These include the running Van‐Velthoven anastomosis, posterior reconstruction or ‘Rocco stitch’, and cold ligation of the Santorini plexus/dorsal vein to maximise urethral length. In 2010, Bocciardi’s team in Milan proposed a novel posterior or ‘Retzius‐sparing’ RARP (RS‐RARP), mirroring the classic open perineal approach. This allows avoidance of supporting structures, such as the puboprostatic ligaments, endopelvic fascia, and Santorini plexus, preserving the normal anatomy as much as possible and limiting damage that may contribute to improved postoperative continence and erectile function. There has been much heralding of the excellent functional outcomes in both the medical and the lay press, but as yet no focus or real mention of any potential downsides of this new technique.

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Editorial: Urinary incontinence and the causality dilemma

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Fundamentally, the aetiology of most female urinary incontinence (UI) remains an enigma. Although we gain comfort in our conceptualisations of anatomical defects and neurological compromise as contributing factors, most of our therapies for UI are directed at symptomatic control instead of a disease prevention or modification. Thus, the principal drivers of female UI symptoms remain elusive. The premise of the series published in this issue by Markland et al. [1], to identify patterns of comorbid conditions in patients with various types of UI, is a valid and intriguing question, and this effort provides an important component of emerging concepts of the pathophysiology of UI development in women. The authors describe the analysis of cross‐sectional data from the National Health and Nutrition Examination Surveys (NHANES) and report on 3800 women with UI. Exploration of associations between UI with patient demographics and medical conditions revealed fascinating relationships and not surprisingly, a high prevalence of comorbid conditions in patients with self‐reported UI. Thus, despite the known limitations of such a cross‐sectional analysis, this study by Markland et al. [1] provides provocative information to achieve actionable mandates.

The novel approach described in the article of developing cluster analysis revealed four distinct patterns between UI and multiple chronic conditions. One of the most dominant relationships that merits intense exploration is the relationship between common conditions of hypertension, hyperlipidaemia, and increased cardiovascular disease (CVD) risk. Indeed, CVD remains a leading cause of death in women in the USA [2]. Population‐based analysis has hinted at possible connections between CVD and UI, although determinative causality has not been established [3, 4]. UI in women may reflect a similar vascular pathology to erectile dysfunction (ED) in men, potentially resultant from a gradual compromise of the delicate neurovascular anatomy required for normal sphincter and detrusor activity. In women, no such prodromal syndrome or symptom such as ED in men has been acknowledged to prompt CVD screening in otherwise asymptomatic patients.

Alternately, one might interpret this cluster data to indicate that multimorbid chronic conditions and increasing age are sufficient in the development of UI, although assigning such risk silos is disposed to misconceptions. The contribution of polypharmacy in these clusters is a decidedly substantial component for careful consideration. However, data extracted from such survey sampling have inherent complexities that limit defining causality, so how do we retrospectively discern understanding viewing the insults of a lifetime resulting in UI? The short answer is, we do not.

We must extract ourselves from the realm of symptom suppression for women with UI and direct resources to a broader view of the life course of the condition. In addition to the expansive phenotyping efforts ongoing from the National Institute of Diabetes and Digestive Kidney Disease (NIDDK) through the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN), no initiative speaks to the endeavor to principally change paradigms about bladder health in women more than the pioneering concept of The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium [5]. The PLUS consortium is dedicated to promoting prevention of LUTS across the woman’s life spectrum, which roots in the appreciation of progression of factors contributing to disease. Without this critical transdisciplinary approach, comprehension of the base aetiology of UI, and our continued attempts to mask symptoms, may propagate further deterioration of systemic manifestations of primary high‐risk diseases in our patients.

References

  1. Markland AD, Vaughn CP, Okosun IS, Goode PS, Burgio KL, Johnson TM, 2nd. Cluster analysis of multiple chronic conditions associated with urinary incontinence among women in the USA. BJU Int 2018; 122: 1041–8
  2. National Institutes of Health and National Heart, Lung, and Blood Institute. Morbidity & Mortality: 2009 Chart Book on Cardiovascular, Lung, and Blood Diseases. Available at: https://ecopmc.files.wordpress.com/2012/04/2009_chartbook.pdf. Accessed July 2018
  3. Coyne KS, Kaplan SA, Chapple CR et al. Risk factors and comorbid conditions associated with lower urinary tract symptoms: EpiLUTS. BJU Int 2009; 103 (Suppl. 3): 24–32
  4. Andersson KE, Sarawate C, Kahler KH, Stanley EL, Kulkarni AS. Cardiovascular morbidity, heart rates and use of antimuscarinics in patients with overactive bladder. BJU Int 2010; 106: 268–74
  5. Harlow BL, Bavendam TG, Palmer MH et al. The Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium: a transdiciplinary approach toward promoting bladder health and preventing lower urinary tract symptoms in women across the life course. J Womens Health (Larchmt) 2018; 27: 283–9

 

 

Infographic: Development of a side‐specific, mpMRI‐based nomogram for the prediction of extracapsular extension of PCa

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Infographic: Development of a side‐specific, mpMRI‐based nomogram for the prediction of extracapsular extension of PCa

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Article of the week: Development of a side‐specific, mpMRI‐based nomogram for the prediction of extracapsular extension of PCa

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there are two accompanying editorials written by prominent members of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. There is also a video produced by the authors. 

If you only have time to read one article this week, it should be this one.

Development and internal validation of a side‐specific, multiparametric magnetic resonance imaging‐based nomogram for the prediction of extracapsular extension of prostate cancer

Alberto Martini*†, Akriti Gupta*, Sara C. Lewis‡, Shivaram Cumarasamy*, Kenneth G. Haines III§, Alberto Briganti†, Francesco Montorsi† and Ashutosh K. Tewari*

 

Departments of *Urology, ‡Radiology, §Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA and †Department of Urology, Vita-Salute San Raffaele University, Milan, Italy
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Abstract

Objectives

To develop a nomogram for predicting side‐specific extracapsular extension (ECE) for planning nerve‐sparing radical prostatectomy.

Materials and Methods

We retrospectively analysed data from 561 patients who underwent robot‐assisted radical prostatectomy between February 2014 and October 2015. To develop a side‐specific predictive model, we considered the prostatic lobes separately. Four variables were included: prostate‐specific antigen; highest ipsilateral biopsy Gleason grade; highest ipsilateral percentage core involvement; and ECE on multiparametric magnetic resonance imaging (mpMRI). A multivariable logistic regression analysis was fitted to predict side‐specific ECE. A nomogram was built based on the coefficients of the logit function. Internal validation was performed using ‘leave‐one‐out’ cross‐validation. Calibration was graphically investigated. The decision curve analysis was used to evaluate the net clinical benefit.

Results

The study population consisted of 829 side‐specific cases, after excluding negative biopsy observations (n = 293). ECE was reported on mpMRI and final pathology in 115 (14%) and 142 (17.1%) cases, respectively. Among these, mpMRI was able to predict ECE correctly in 57 (40.1%) cases. All variables in the model except highest percentage core involvement were predictors of ECE (all P ≤ 0.006). All variables were considered for inclusion in the nomogram. After internal validation, the area under the curve was 82.11%. The model demonstrated excellent calibration and improved clinical risk prediction, especially when compared with relying on mpMRI prediction of ECE alone. When retrospectively applying the nomogram‐derived probability, using a 20% threshold for performing nerve‐sparing, nine out of 14 positive surgical margins (PSMs) at the site of ECE resulted above the threshold.

Conclusion

We developed an easy‐to‐use model for the prediction of side‐specific ECE, and hope it serves as a tool for planning nerve‐sparing radical prostatectomy and in the reduction of PSM in future series.

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Editorial: A picture is worth a thousand words… but does it add utility to a nomogram to predict extraprostatic extension?

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Martini et al. [1] ask whether adding in prostate MRI data to a preoperative nomogram can usefully aid in the decision to nerve‐spare on one or both sides in men undergoing radical prostatectomy, using a dataset of 829 positive prostate lobes in 561 men. The nomogram includes PSA, maximum ipsilateral Gleason grade, percentage core involvement, and presence of extracapsular extension (ECE) on MRI, although the percentage core involvement (< or >50%) was not found to be significant. Pathological ECE was noted in 142 (17.1%) of the lobes, and radiological suspicion of ECE was noted in 115 (14%) lobes.

The incorporation of MRI in the decision‐making process is to be welcomed. However, MRI only correctly predicted ECE in 57/142 (40.1%) cases, showing significant over‐ and under‐detection on MRI criteria alone. Nerve‐sparing was done in 78% of men, and 30 men had a positive surgical margin. The authors found the nomogram to have greater accuracy in predicting ECE than MRI alone, with an area under the curve for MRI alone of 68.83%, compared to 82.92% for the nomogram. The use of the nomogram to inform a decision to nerve‐spare, made independently for each side, is proposed.

We need to be clear about the different definitions that are being applied here. The MRI features used for assessing ECE, namely bulging/irregular margin, obliteration of the rectoprostatic angle, >1 cm capsular abutment, and neurovascular bundle invasion, set a somewhat high threshold, which we would expect to correlate with significant histological burden and ECE. The exact pathological definition of ECE is not described by the authors and so presumably includes presence of any cancer outside the surgical capsule, whilst the presence of a positive surgical margin is defined as any tumour touching an inked margin. This difference in the threshold for radiological and pathological significance of ECE has been noted by others [2]. In addition, there is some discussion of the long‐term clinical significance of a positive surgical margin of <3 mm [3], although both ECE and PSM are recognised as predictors of recurrence.

Even given this discrepancy in definitions, there are other possible reasons why MRI was less predictive than might be expected [4]. The majority (76%) of the MRI scans were done after biopsy, which is known to reduce the accuracy of MRI, resulting in both under‐ and over‐staging. These post‐biopsy effects can persist for some considerable time, often past the 4 week post‐biopsy recovery period used as the minimum in this series, and in many institutions [5]. Differences in prevalence of pathological ECE (17% in this series [1] vs 32.4% in the series reported by Gaunay et al. [4]) could also affect the performance characteristics of MRI for staging.

An alternative to the preoperative nomogram approach is the use of techniques such as neurovascular structure‐adjacent frozen‐section examination (NeuroSAFE) [6]. This allows an intraoperative decision on the extent of excision, based on frozen‐section examination, and it has been shown to increase the ability to nerve‐spare, with associated improved functional outcomes, whilst reducing positive surgical margins. However, it does have significant cost implications and is not widely available.

It makes sense to use preoperative MRI, currently widely recommended for staging, in combination with clinical parameters, to maximise the use of nerve‐sparing to favour functional outcomes, whilst minimising positive surgical margins. Martini et al. [1] present a nomogram based on readily available parameters, which could be readily adopted in the routine setting. The move towards MRI before first biopsy is likely to give us more accurate imaging data, which should help us to further refine the decision to nerve‐spare for men undergoing radical prostatectomy.

References

  1. Martini A, Gupta A, Lewis S et al. Development and internal validation of a side‐specific, multiparametric magnetic resonance imaging‐based nomogram for the prediction of extracapsular extension of prostate cancer. BJU Int 2018; 122: 1025–33
  3. Dev HS, Wiklund P, Patel V et al. Surgical margin length and location affect recurrence rates after robotic prostatectomy. Urol Oncol 2015; 33: 109.e7‐13
  4. Gaunay GS, Patel V, Shah P et al. Multi‐parametric MRI of the prostate: factors predicting extracapsular extension at the time of radical prostatectomy. Asian J Urol 2017; 4: 31–6
  5. Latifoltojar A, Dikaios N, Ridout A et al. Evolution of multi‐parametric MRI quantitative parameters following transrectal ultrasound‐guided biopsy of the prostate. Prostate Cancer Prostatic Dis 2015; 18: 343–51
  6. Mirmilstein G, Rai BP, Gbolahan O et al. The neurovascular structure‐adjacent frozen‐section examination (NeuroSAFE) approach to nerve sparing in robot‐assisted laparoscopic radical prostatectomy in a British setting ‐ a prospective observational comparative study. BJU Int 2018; 121: 854–62

 

 

Article of the week: Multicentre international experience of 532‐nm laser PVP with GreenLight XPS in men with very large prostates

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this week, it should be this one.

Roger Valdivieso*, Pierre‐Alain Hueber*, Malek Meskawi*, Eric Belleville*, Khaled Ajib*, Franck Bruyere†, Alexis E. Te‡, Bilal Chughtai‡, Dean Elterman§, Vincent Misraiand Kevin C. Zorn*

 

*Division of Urology, Centre Hospitalier de l’Universite de Montreal (CHUM), Montreal, QC, Canada, †Department of Urology, CHU, Tours, France, ‡Department of Urology, Cornell University, New York, NY, USA, §Department of Urology, University of Toronto, Toronto, ON, Canada, and Department of Urology, Clinique Pasteur, Toulousse, France

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Abstract

Objectives

To describe peri‐operative results, functional outcomes and complications of laser photoselective vaporization, using the GreenLight system, of prostate glands ≥200 mL in volume.

Methods

Retrospective analysis of a prospectively maintained multicentre database was performed to select a subgroup of patients with very large prostates (volume ≥200 mL) treated with the GreenLight XPS laser. A subgroup of patients with prostate volumes 100–200 mL was used for comparison. International Prostate Symptom Score, maximum urinary flow rate, postvoid residual urine volume and prostate‐specific antigen levels were measured at 6, 12, 24, 36 and 48 months. Durability was evaluated using benign prostatic hyperplasia re‐treatment rate at 12, 24 and 36 months. Additionally, complications were recorded using Clavien–Dindo classification.

Results

A total of 33 patients (38%) had prostates ≥200 mL. Baseline characteristics were similar between patients with prostates ≥200 mL and those with prostates 100–200 mL. Patients with very large prostates (≥200 mL) had longer operating times (129 vs 93 min), less energy delivered, a greater number of fibres used (3 vs 2) and a higher conversion rate to transurethral resection of the prostate (16% vs 4%). In terms of complications and functional outcomes, we did not find any differences between the groups. Retreatment rate was also comparable.

Conclusions

Our results show that PVP GreenLight XPS‐180W is an acceptable technique for very large prostates (≥200 mL); however, operating times, energy delivery, fibres used and conversion to TURP are a concern in this particular subgroup. This should be used for patient counselling and surgery planning.

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Article of the week: Does the introduction of prostate multi-parametric MRI into the AS protocol for localized PCa improve patient re-classification?

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Does the introduction of prostate multiparametric magnetic resonance imaging into the active surveillance protocol for localized prostate cancer improve patient re-classification?

Richard J. Bryant*† , Bob Yang* , Yiannis Philippou*, Karla Lam*, Maureen Obiakor*, Jennifer Ayers*, Virginia Chiocchia†‡, Fergus Gleeson§, Ruth MacPherson§, Clare Verrill†¶, Prasanna Sooriakumaran†**, Freddie C. Hamdy*† and Simon F. Brewster*

*Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, †Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK, ‡National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK, §Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK, and **Department of Uro-Oncology, University College London Hospital NHS Foundation Trust, London, UK

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Abstract

Objectives

To determine whether replacement of protocol‐driven repeat prostate biopsy (PB) with multiparametric magnetic resonance imaging (mpMRI) ± repeat targeted prostate biopsy (TB) when evaluating men on active surveillance (AS) for low‐volume, low‐ to intermediate‐risk prostate cancer (PCa) altered the likelihood of or time to treatment, or reduced the number of repeat biopsies required to trigger treatment.

Patients and Methods

A total of 445 patients underwent AS in the period 2010–2016 at our institution, with a median (interquartile range [IQR]) follow‐up of 2.4 (1.2–3.7) years. Up to 2014, patients followed a ‘pre‐2014’ AS protocol, which incorporated PB, and subsequently, according to the 2014 National Institute for Health and Care Excellence (NICE) guidelines, patients followed a ‘2014–present’ AS protocol that included mpMRI. We identified four groups of patients within the cohort: ‘no mpMRI and no PB’; ‘PB alone’; ‘mpMRI ± TB’; and ‘PB and mpMRI ± TB’. Kaplan–Meier plots and log‐rank tests were used to compare groups.

Results

Of 445 patients, 132 (30%) discontinued AS and underwent treatment intervention, with a median (IQR) time to treatment of 1.55 (0.71–2.4) years. The commonest trigger for treatment was PCa upgrading after mpMRI and TB (43/132 patients, 29%). No significant difference was observed in the time at which patients receiving a PB alone or receiving mpMRI ± TB discontinued AS to undergo treatment (median 1.9 vs 1.33 years; P = 0.747). Considering only those patients who underwent repeat biopsy, a greater proportion of patients receiving TB after mpMRI discontinued AS compared with those receiving PB alone (29/66 [44%] vs 32/87 [37%]; P = 0.003). On average, a single set of repeat biopsies was needed to trigger treatment regardless of whether this was a PB or TB.

Conclusion

Replacing a systematic PB with mpMRI ±TB as part of an AS protocol increased the likelihood of re‐classifying patients on AS and identifying men with clinically significant disease requiring treatment. mpMRI ±TB as part of AS thereby represents a significant advance in the oncological safety of the AS protocol.

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Residents’ podcast: Urinary, bowel and sexual health in older men from Northern Ireland

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Maria Uloko is a Urology Resident at the University of Minnesota Hospital and Giulia Lane is a Female Pelvic Medicine and Reconstructive Surgery Fellow at the University of Michigan.

In this podcast they discuss the following BJUI Article of the Week:

Urinary, bowel and sexual health in older men from Northern Ireland

David W. Donnelly*, Conan Donnelly†, Therese Kearney*, David Weller‡, Linda Sharp§, Amy Downing¶, Sarah Wilding¶, PennyWright¶, Paul Kind**, James W.F. Catto††, William R. Cross‡‡, Malcolm D. Mason§§, Eilis McCaughan¶¶, Richard Wagland***, Eila Watson†††, Rebecca Mottram¶, Majorie Allen, Hugh Butcher‡‡‡, Luke Hounsome§§§, Peter Selby, Dyfed Huws¶¶¶, David H. Brewster****, EmmaMcNair****, Carol Rivas††††, Johana Nayoan***, Mike Horton‡‡‡‡, Lauren Matheson†††, Adam W. Glaser and Anna Gavin*

*Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast, Belfast, UK, †National Cancer Registry Ireland, Cork, Ireland, ‡Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK, §Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK, Leeds Institute of Cancer and Pathology/Leeds Institute of Data Analytics, University of Leeds, Leeds, UK, **Institute of Health Sciences, University of Leeds, Leeds, UK, ††Academic Urology Unit, University of Sheffield, Sheffield, UK, ‡‡Department of Urology, St James’s University Hospital, Leeds, UK, §§Division of Cancer and Genetics, School of Medicine, Velindre Hospital, Cardiff University, Cardiff, UK, ¶¶Institute of Nursing and Health Research, Ulster University, Coleraine, UK, ***Faculty of Health Sciences, University of Southampton, Southampton, UK, †††Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK, ‡‡‡Yorkshire Cancer Patient Forum, c/o Strategic Clinical Network and Senate, Yorkshire and The Humber, Harrogate, UK, §§§National Cancer Registration and Analysis Service, Public Health England, Bristol, UK, ¶¶¶Welsh Cancer Intelligence and Surveillance Unit, Cardiff, UK, ****Information Services Division, NHS National Services Scotland, Edinburgh, UK, ††††Department of Social Science, UCL Institute of Education, University College London, London, UK, and ‡‡‡‡Psychometric Laboratory for Health Sciences, Academic Department of Rehabilitation Medicine, University of Leeds, Leeds, UK

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Abstract

 Objectives

To provide data on the prevalence of urinary, bowel and sexual dysfunction in Northern Ireland (NI), to act as a baseline for studies of prostate cancer outcomes and to aid service provision within the general population.

Subjects and Methods

A cross‐sectional postal survey of 10 000 men aged ≥40 years in NI was conducted and age‐matched to the distribution of men living with prostate cancer. The EuroQoL five Dimensions five Levels (EQ‐5D‐5L) and 26‐item Expanded Prostate Cancer Composite (EPIC‐26) instruments were used to enable comparisons with prostate cancer outcome studies. Whilst representative of the prostate cancer survivor population, the age‐distribution of the sample differs from the general population, thus data were generalised to the NI population by excluding those aged 40–59 years and applying survey weights. Results are presented as proportions reporting problems along with mean composite scores, with differences by respondent characteristics assessed using chi‐squared tests, analysis of variance, and multivariable log‐linear regression.

Results

Amongst men aged ≥60 years, 32.8% reported sexual dysfunction, 9.3% urinary dysfunction, and 6.5% bowel dysfunction. In all, 38.1% reported at least one problem and 2.1% all three. Worse outcome was associated with increasing number of long‐term conditions, low physical activity, and higher body mass index (BMI). Urinary incontinence, urinary irritation/obstruction, and sexual dysfunction increased with age; whilst urinary incontinence, bowel, and sexual dysfunction were more common among the unemployed.

Conclusion

These data provide an insight into sensitive issues seldom reported by elderly men, which result in poor general health, but could be addressed given adequate service provision. The relationship between these problems, raised BMI and low physical activity offers the prospect of additional health gain by addressing public health issues such as obesity. The results provide essential contemporary population data against which outcomes for those living with prostate cancer can be compared. They will facilitate greater understanding of the true impact of specific treatments such as surgical interventions, pelvic radiation or androgen‐deprivation therapy.

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