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Article of the Month: Partin Tables in the Contemporary Era

May 3, 2017/by admin Z.9

Every Month the Editor-in-Chief selects an Article of the Month 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.

Prediction of pathological stage based on clinical stage, serum prostate-specific antigen, and biopsy Gleason score: Partin Tables in the contemporary era

Jeffrey J. Tosoian, Meera Chappidi, Zhaoyong Feng, Elizabeth B. Humphreys, Misop Han, Christian P. Pavlovich, Jonathan I. Epstein, Alan W. Partin and Bruce J. Trock

The James Buchanan Brady Urological Institute and Department of Urology at the Johns Hopkins University School of Medicine, Baltimore, MD, USA

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How to Cite this Article

Tosoian, J. J., Chappidi, M., Feng, Z., Humphreys, E. B., Han, M., Pavlovich, C. P., Epstein, J. I., Partin, A. W. and Trock, B. J. (2017), Prediction of pathological stage based on clinical stage, serum prostate-specific antigen, and biopsy Gleason score: Partin Tables in the contemporary era. BJU International, 119: 676–683. doi: 10.1111/bju.13573

Abstract

Objective

To update the Partin Tables for prediction of pathological stage in the contemporary setting and examine trends in patients treated with radical prostatectomy (RP) over the past three decades.

Patients and Methods

From January 2010 to October 2015, 4459 men meeting inclusion criteria underwent RP and pelvic lymphadenectomy for histologically confirmed prostate cancer at the Johns Hopkins Hospital. Preoperative clinical stage, serum prostate-specific antigen (PSA) level, and biopsy Gleason score (i.e. prognostic Grade Group) were used in a polychotomous logistic regression model to predict the probability of pathological outcomes categorised as: organ-confined (OC), extraprostatic extension (EPE), seminal vesicle involvement (SV+), or lymph node involvement (LN+). Preoperative characteristics and pathological findings in men treated with RP since 1983 were collected and clinical-pathological trends were described.

Results

The median (range) age at surgery was 60 (34–77) years and the median (range) PSA level was 4.9 (0.1–125.0) ng/mL. The observed probabilities of pathological outcomes were: OC disease in 74%, EPE in 20%, SV+ in 4%, and LN+ in 2%. The probability of EPE increased substantially when biopsy Gleason score increased from 6 (Grade Group 1, GG1) to 3 + 4 (GG2), with smaller increases for higher grades. The probability of LN+ was substantially higher for biopsy Gleason score 9–10 (GG5) as compared to lower Gleason scores. Area under the receiver operating characteristic curves for binary logistic models predicting EPE, SV+, and LN+ vs OC were 0.724, 0.856, and 0.918, respectively. The proportion of men treated with biopsy Gleason score ≤6 cancer (GG1) was 47%, representing a substantial decrease from 63% in the previous cohort and 77% in 2000–2005. The proportion of men with OC cancer has remained similar during that time, equalling 73–74% overall. The proportions of men with SV+ (4.1% from 3.4%) and LN+ (2.3% from 1.4%) increased relative to the preceding era for the first time since the Partin Tables were introduced in 1993.

Conclusions

The Partin Tables remain a straightforward and accurate approach for projecting pathological outcomes based on readily available clinical data. Acknowledging these data are derived from a tertiary care referral centre, the proportion of men with OC disease has remained stable since 2000, despite a substantial decline in the proportion of men with biopsy Gleason score 6 (GG1). This is consistent with the notion that many men with Gleason score 6 (GG1) disease were over treated in previous eras.

Editorial: Is there a role for pure clinical prediction models in prostate cancer in the contemporary era?

May 3, 2017/1 Comment/by Giorgio Gandaglia

The identification of men with localised prostate cancer at higher risk of adverse pathological outcomes after radical prostatectomy (RP) would assist physicians in preoperative patient counselling and in tailoring the most appropriate treatment strategy. In this issue of the BJUI, Tosoian et al. [1] have updated the Partin Tables in contemporary patients with localised prostate cancer. The authors should be commended for undertaking a well-performed study evaluating a large cohort of patients treated at a high-volume centre. Notably, they were able to show that the Partin Tables still represent an accurate tool for identifying men at higher risk of adverse pathological features [1]. Having said this, the first question we should ask ourselves is whether preoperative models based on clinical variables only still play a role in contemporary patients. The Partin Tables were developed in 1993 and since then they have undergone a series of updates, all of which are based on virtually the same variables included in the original analyses [1]. However, recent implementations, including biomarkers and imaging, have been introduced to better stage prostate cancer. These novel approaches are usually added to clinical variables to improve patient risk stratification. Multi-parametric MRI (mp-MRI) represents the major game changer in this setting, being now recommended for prostate cancer staging in all men with high-risk disease and in those with less favourable intermediate-risk prostate cancer [2]. In the era of modern and sophisticated approaches, are models using clinical variables only still clinically valuable? To answer this question, we can consider two major settings, namely nodal and local staging.

When assessing the risk of lymph node invasion (LNI) at diagnosis, mp-MRI and positron emission tomography/CT scan are characterised by a low sensitivity and, therefore, are not recommended for the identification of patients who should receive a lymph node dissection (LND) [2, 3]. Conversely, the updated Partin Tables depicted a remarkably high accuracy (>90%) in predicting LNI. This supports what is currently recommended by virtually all guidelines, which indicate that candidates for extended LND (eLND) should still be identified according to a combination of clinical variables only. However, although the Partin Tables might assist clinicians in identifying patients more likely to harbour LNI, the lack of the uniform adoption of an eLND template might have resulted in a substantial under-estimation of the real LNI risk [4]. Other tools specifically developed to predict LNI among men treated with eLND could better assist clinicians in identifying men who should receive an eLND [2, 5].

Similarly, when considering local staging, mp-MRI is characterised by a high specificity but a relatively low sensitivity in detecting small, microscopic foci of extracapsular extension and seminal vesicle invasion (SVI) [6]. Conversely, the updated Partin Tables depicted a predictive accuracy of >80% in predicting SVI, despite the lack of individualised data on the extent and volume of extraprostatic extension. For all these reasons, clinical risk models still represent the cornerstone for the identification of men at higher risk of adverse pathological findings. Additional data coming from sophisticated imaging modalities may further improve individualised risk predictions [6] and better assist clinicians in tailoring the most appropriate treatment approach. However, imaging and biomarkers should complement, rather than substitute, currently available clinical risk models.

In conclusion, preoperative predictive tools based on clinical parameters still play an important role in the management of patients with clinically localised prostate cancer. Any staging model including additional approaches, such as imaging and/or biomarkers, is welcomed only when it is shown to improve prostate cancer staging in terms of both accuracy and cost-effectiveness.

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How to Cite

Gandaglia, G., Fossati, N., Dell’Oglio, P., Montorsi, F. and Briganti, A. (2017), Is there a role for pure clinical prediction models in prostate cancer in the contemporary era?. BJU International, 119: 652–653. doi: 10.1111/bju.13833

Giorgio Gandaglia,*† Nicola Fossati,*†Paolo Dell’Oglio,*†Francesco Montorsi,*† and Alberto Briganti*†

*Division of Oncology/Unit of Urology, Urological Research Institute, L’ Istituto di Ricovero e Cura a Carattere Scientiﬁco (IRCCS), Ospedale San Raffaele, and †Vita-Salute San Raffaele University, Milan, Italy

References

1 TosoianJJ, Chappidi M, Feng Z et al. Prediction of pathological stage based on clinical stage, serum prostate-speciﬁc antigen, and biopsy Gleason score: Partin Tables in the contemporary era. BJU Int 2017; 119: 676– 83

2 Mottet N, Bellmunt J, Bolla M et al. EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol 2017; 71: 618–29

3 Budaus L, Leyh-Bannurah SR, Salomon G et al. Initial experience of (68) Ga-PSMA PET/CT imaging in high-risk prostate cancer patients prior to radical prostatectomy. Eur Urol 2016; 69: 393–6

4 Kluth LA, Abdollah F, Xylinas E et al. Pathologic nodal staging scores in patients treated with radical prostatectomy: a postoperative decision tool. Eur Urol 2014; 66: 439–46

5 Briganti A, Larcher A, Abdollah F et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur Urol 2012; 61: 480–7

6 de Rooij M, Hamoen EH, Witjes JA, Barentsz JO, Rovers MM . Accuracy of magnetic resonance imaging for local staging of prostate cancer: a diagnostic meta-analysis. Eur Urol 2016; 70: 233–45

Infographic: Partin Tables in the Contemporary Era

May 3, 2017/by admin Z.9

The Partin Tables in the Contemporary Era: Infographic to accompany the May 2017 Article of the Month

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In search of the ROSETTA stone (again)?

October 31, 2016/2 Comments/by Prokar Dasgupta

We are having an amazing year of scientific discovery in our specialty. 2016 has already seen the results of the only randomised trial comparing open versus robotic radical prostatectomy from Australia and the ProtecT trial from UK discussed intensively on Blogs@BJUI. The PROMIS of MRI is expected to change the practice of prostate biopsies in response to a raised PSA. The teams completing these trials deserve our heartiest congratulations as it is well known how difficult randomised trials in surgery are to initiate and complete.

As if this was not enough, this month the randomised controlled trial comparing Botox (Onabotulinum toxin A) to Interstim (sacral neuromodulation) in patients with refractory overactive bladder has been reported in JAMA. It is otherwise known as the ROSETTA study (Refractory Overactive Bladder: Sacral NEuromodulation v. BoTulinum Toxin Assessment).

This is an example of what collaboration between individuals and teams within a pelvic floor group can achieve. Cindy Amundsen, the lead author, presented the trial results at the #AUA16 late breaking abstract session in San Diego.

The CONSORT diagram is shown here

The primary outcome measure showing Botox winning over Interstim (narrowly) in reducing urgency urinary incontinence is demonstrated in this diagram.

The summary results are shown here

So what would you do for your patient with refractory overactive bladder who has failed Anticholinergics and Mirabegron?

I have spent the last week thinking about the trial results carefully and was asked exactly this question at the International Endourology Forum in China. There are a number of important aspects to consider. The dose of Botox used in the trial was 200 units while the licensed dose is 100 units for overactive bladder of non-neurogenic origin. We know that one size does not fit all and indeed some patients failing 100 units need higher doses of Botox. It remains unknown as to what would have happened if 100 units of Botox was compared to Interstim as the authors are quite guarded about their own conclusions about the benefits.

The side effects also need to be carefully discussed with the patient. The UTI rate in the Botox group is about three times that of the Interstim group. Most patients may accept a period of oral antibiotics to counter this. The risk of CISC dropped from 8% at 1 month to 2% at 6 months in the Botox group. This is lower than previously reported in Phase lll studies. The need for revision or removal in the Interstim patients was around 3% – small but not to be ignored.

Punchline
If I was the patient in question, I would have Botox initially, preserving Interstim for later. It is less invasive and can be repeated roughly once a year if needed. Call me “lilly livered” but I do not like the idea of having a little box, however tiny, inside my bum and occasionally having to sit on it! I look forward to the smarter new generation of minimally invasive or even non-invasive nerve stimulators. But then it would need another randomised trial, many years of unanswered questions, perhaps even wastage of a lot of grant money…………..yawn!!

In the meantime, I will take my chances with Botox and counsel my patients accordingly. Unlike the famous ROSETTA stone, the key to understanding the mystery behind hieroglyphs and the controversy as to whether it should at all be in the British museum, I fail to see any such controversy with this nice trial in JAMA.

My thoughts and message are clear. Are yours?

Article of the Week: Predictive value of negative 3T multiparametric MRI of the prostate on 12-core biopsy results

October 5, 2016/by admin Z.9

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.

Predictive value of negative 3T multiparametric magnetic resonance imaging of the prostate on 12-core biopsy results

James S. Wysock, Neil Mendhiratta, Fabio Zattoni, Xiaosong Meng, Marc Bjurlin,

William C. Huang, Herbert Lepor, Andrew B. Rosenkrantz* and Samir S. Taneja

Department of Urology, and *Department of Radiology, NYU Langone Medical Center, New York, NY, USA

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Objectives

To evaluate the cancer detection rates for men undergoing 12-core systematic prostate biopsy with negative prebiopsymultiparametric magnetic resonance imaging (mpMRI) results.

Materials and Methods

Clinical data from consecutive men undergoing prostate biopsy who had undergone prebiopsy 3T mpMRI from December 2011 to August 2014 were reviewed from an institutional review board-approved prospective database. Men with negative prebiospy mpMRI results (negMRI) before biopsy were identified for the present analysis. Clinical features, cancer detection rates and negative predictive values were summarized.

Results

Seventy five men with negMRI underwent systematic 12-core biopsy during the study period. In the entire cohort, men with no previous biopsy, men with previously negative biopsy and men enrolled in active surveillance protocols, the overall cancer detection rates were 18.7, 13.8, 8.0 and 38.1%, respectively, and the detection rates for Gleason score (GS) ≥7 cancer were 1.3, 0, 4.0 and 0%, respectively. The NPVs for all cancers were 81.3, 86.2, 92.0, and 61.9, and for GS ≥7 cancer they were 98.7, 100, 96.0 and 100%, respectively.

Conclusions

A negative prebiopsy mpMRI confers an overall NPV of 82% on 12-core biopsy for all cancer and 98% for GS ≥7 cancer. Based on biopsy indication, these findings assist in prebiopsy risk stratification for detection of high-risk disease and may provide guidance in the decision to pursue biopsy.

Editorial: Some prostate cancers are invisible to magnetic resonance imaging!

October 5, 2016/1 Comment/by admin Z.9

A test to exclude the presence of aggressive prostate cancer would be highly desirable. In the article by Wysock et al. [1], the authors examine pathological results in 75 men who underwent 12-core systematic biopsy using the Artemis device; all had a pre-biopsy MRI showing no suggestion of cancer. In 74 patients no cancer with Gleason score ≥7 was found on biopsy, which translates into a remarkable 98.7% negative predictive value (NPV) for potentially aggressive disease. The implication is that virtually all serious prostate cancers can be seen on MRI, and thus a negative MRI obviates the need for a biopsy. If this finding were to be confirmed, the majority of prostate biopsies could be avoided, a truly laudable goal.

However, for several reasons, we are not yet able to endorse the blanket concept, ‘get a negative MRI and skip the biopsy’. The authors acknowledged their study is not definitive: it is a retrospective look at 29% of eligible participants; how were they chosen? Further, the ‘gold standard’ for identifying cancer, microscopic examination of whole mount prostatectomy specimens, was not available. Thus, the data presented are striking because of the near-perfect findings, but not entirely convincing. Our work, involving >2 000 MRI/ultrasound-fusion biopsies, teaches that if biopsy is indicated on clinical grounds e.g., palpable abnormality, family or racial history, persistent PSA suspicion, a negative MRI should not preclude a systematic (template) biopsy [2]. Clinical information, especially increased PSA density, may help to select patients for biopsy beyond use of MRI data alone.

Another reason why a ‘negative’ MRI should not always negate the need for biopsy relates to the current proliferation of prostate MRI studies. Many of the new MRI studies are being performed and interpreted by radiologists not adequately trained in this niche. Despite attempts at standardisation [3], the variability of MRI readings, from place to place and from one radiologist to another, can be remarkable. In the recent past I have seen lesions called Prostate Imaging-Reporting and Data System (PI-RADS) Grade 5 ‘disappear’ when scrutinised by more-experienced readers; the reverse has also been seen. Even among expert readers using the latest Version 2 of PI-RADS, agreement in prostate MRI interpretation is only moderate at best (κ ≈0.5) [4]. Therefore, widely varying interpretations of prostate MRI can be expected for the near-term future. A formal training programme and certification in MRI interpretation, which is sorely needed, has not yet been established.

In Figure 1 above, a falsely negative MRI from our institution is shown [2]. The MRI-invisible cancer is not a rarity. In a consecutive series of 1 042 men undergoing template biopsy regardless of MRI findings, the incidence of clinically significant prostate cancer in men with no MRI-suspicious lesions (biopsy-naïve subgroup) was 12% [5]. Further, when looking carefully at whole-mount prostatectomy specimens, the incidence of clinically significant prostate cancer not seen on expertly read MRI was 28% [6]. Still further, some Gleason 6 cancers thought to be insignificant may have the biological potential for de-differentiation [7] and require follow-up. Therefore, at this point in time, a negative MRI should not preclude prostate biopsy, which otherwise would be indicated on clinical grounds. We are still learning about prostate MRI!

Figure 1: Example of falsely negative MRI. Patient was a Caucasian male (PSA level 3.8 ng/mL) aged 68 years, who on a previous conventional biopsy was found to have a microfocus of Gleason 3 + 3 = 6 prostate cancer. He was considered for active surveillance, and multiparametric MRI of prostate was obtained (A): prostate volume was found to be 35 mL; no region of interest was identified. Mapping biopsy was performed by following the 12-point template of the Artemis device (B). A tissue core from the left lateral apex revealed 6 mm of Gleason 3 + 5 = 8 prostate cancer (C, ×4; D, ×20). Radical prostatectomy was performed, revealing a tumour on the left side of the prostate with diameters of 15 × 12 × 9 mm. Falsely negative MRI is not uncommon. When biopsy is clinically indicated, a negative MRI should not preclude mapping biopsy. Reproduced with permission from Nassiri et al., 2015 [1].

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Leonard S. Marks

Professor and deKernion Endowed Chair, Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

1 Wysock JS, Mendhiratta N, Zattoni F et al. Predictive value of negative 3T multiparametric magnetic resonance imaging of the prostate on 12-core biopsy results. BJU Int 2016; 118: 515–20

2 Nassiri N, Natarajan S, Margolis DJ, Marks LS. Targeted prostate biopsy: lessons learned midst the evolution of a disruptive technology. Urology 2015; 86: 432–8

3 Weinreb JC, Barentsz JO, Choyke PL et al. PI-RADS Prostate Imaging – Reporting and Data System: 2015, Version 2. Eur Urol 2016; 69: 16–40

4 Rosenkrantz AB, Ginocchio LA, Cornfeld D et al. Inter-observer reproducibility of the PI-RADS Version 2 Lexicon: A multi-center study of six experienced prostate radiologists. Radiology 2016; 280: 793–804

5 Filson CP, Natarajan S, Margolis DJ et al.Prostate cancer detection with magnetic resonance-ultrasound fusion biopsy: The role of systematic and targeted biopsies. Cancer 2016; [Epub ahead of print]. doi: 10.1002/cncr.29874

6 Le JD, Tan N, Shkolyar E et al. Multifocality and prostate cancer detection by multiparametric magnetic resonance imaging: correlation with whole-mount histopathology. Eur Urol 2015; 67: 569–76

7 Palapattu GS, Cani AK, Huang J et al. Progression of low- to high-grade prostate cancer: Molecular profiling of tissue obtained by serial targeted biopsy. J Clin Oncol 2015; 33 (Suppl.): Abstract 501

Article of the Week: Complications after serial prostate biopsies in men on AS

August 31, 2016/by admin Z.9

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

Complications after prostate biopsies in men on active surveillance and its effects on receiving further biopsies in the Prostate cancer Research International: Active Surveillance (PRIAS) study

Leonard P. Bokhorst*, Inari Lepisto†, Yoshiyuki Kakehi‡, Chris H. Bangma*, Tom Pickles§, Riccardo Valdagni¶, Arnout R. Alberts*, Axel Semjonow**, Petra Str
olin††, Manuel F. Montesino‡‡, Viktor Berge§§, Monique J. Roobol* and Antti Rannikko†

*Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands,
†Department of Urology, Helsinki University Central Hospital, Helsinki, Finland,
‡ Department of Urology, Kagawa University Faculty of Medicine, Kagawa, Japan,
§Department of Radiation Oncology, British Columbia Cancer Agency, Vancouver, BC, Canada,
¶Prostate Cancer Program and Radiation Oncology 1, Fondazione IRCSS Istituto Nazionale dei Tumori, Milan, Italy,
**Department of Urology, Prostate Center, University Hospital Muenster, Muenster,
††Department of Urology, Martini Klinik, Hamburg, Germany,
‡‡Department of Urology, Hospital Virgen del Camino, Pamplona, Spain, and
§§Department of Urology, Oslo University Hospital, Oslo, Norway

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Objective

To study the risk of serial prostate biopsies on complications in men on active surveillance (AS) and determine the effect of complications on receiving further biopsies.

Patients and methods

In the global Prostate cancer Research International: Active Surveillance (PRIAS) study, men are prospectively followed on AS and repeat prostate biopsies are scheduled at 1, 4, and 7 years after the diagnostic biopsy, or once yearly if prostate-specific antigen-doubling time is <10 years. Data on complications after biopsy, including infection, haematuria, haematospermia, and pain, were retrospectively collected for all biopsies taken during follow-up in men from several large participating centres. Generalised estimating equations were used to test predictors of infection after biopsy. Competing risk analysis was used to compare the rates of men receiving further biopsies between men with and without previous complications.

Results

In all, 2 184 biopsies were taken in 1 164 men. Infection was reported after 55 biopsies (2.5%), and one in five men reported any form of complication. At multivariable analysis, the number of previous biopsies was not a significant predictor of infection (odds ratio 1.04, 95% confidence interval 0.76–1.43). The only significant predictor for infection was the type of prophylaxis used. Of all men with a complication at the diagnostic or first repeat biopsy, 21% did not have a repeat biopsy at the time a repeat biopsy was scheduled according to protocol, vs 12% for men without a previous biopsy complication.

Conclusion

In our present cohort of men on AS, we found no evidence that repeat prostate biopsy in itself posed a risk of infection. However, complications after biopsy were not uncommon and after a complication men were less likely to have further biopsies. We should aim to safely reduce the amount of repeat biopsies in men on AS.

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Editorial: Active surveillance for prostate cancer: is it too active?

August 31, 2016/by admin Z.9

The wide dissemination of prostate cancer screening has increased the number of men diagnosed with low-risk, indolent cancers that are better managed with active surveillance (AS) rather than immediate treatment. During the past decade, the number of men managed with AS has increased from <10% to 40% in community based practice registries [1]. Prostate needle biopsy has a central role in diagnosis and reclassification of cancer for men on AS, and the number of these procedures has increased on an individual patient level and overall in the population. The rise of prostate biopsies repeated in the same patients has mirrored the increased rate of biopsy related infectious complications. An association between the number of repeat prostate biopsies and risk of infectious complications was reported in a single-centre observational study [2].

In this issue of BJUI, Bokhort et al. [3] report the risk of complications of serial prostate biopsies in men on AS in the multi-institutional Prostate cancer Research International Active Surveillance (PRIAS) study. Although they did not identify the number of previous biopsies as an independent predictor of infection, the type of prophylactic antibiotic was associated with risk of infection. Overall, one in five men reported any complication during AS and the rate of infectious complications was 2.5%. These figures are more relevant if we consider that men in whom an infection occurred were twice as likely to discontinue AS. Although the rate of attrition may have confounded the association of repeat biopsies on infectious complications or guided a more augmented antibiotic prophylaxis regimen, the most important finding of this study remains the significant morbidity associated with AS.

In the PRIAS study, institutions are guided to perform surveillance biopsies at 1, 4, and 7 years after the diagnostic biopsy. However, the schedule of biopsies varies significantly globally across institutions. In some academic centres, prostate biopsies are taken annually for men on AS, while other experts in AS have discussed taking biopsies every 5 years [4, 5]. As more studies emerge demonstrating the oncological safety of AS, we must address how ‘active’ AS should be and develop individualised recommendations based on tumour characteristics. A barrier to AS remains the burden of morbidity associated with prostate biopsies and efforts to reduce these procedures will contribute to further reducing the overtreatment of men with low-risk prostate cancer. In addition, the patient costs associated with serial office visits and the burden on physicians and healthcare systems stemming from the increased clinical volume following these patients remain an unmet need for the future.

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Behfar Ehdaie

Department of Surgery, Urology Service, and Department of Epidemiology and Biostatistics, Center of Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA

References

1. Cooperberg MR, Carroll PR. Trends in management for patients with localized prostate cancer, 1990–2013. JAMA 2015; 314: 80–2

2. Ehdaie B, Vertosick E, Spaliviero M et al. The impact of repeat biopsies on infectious complications in men with prostate cancer on active surveillance. J Urol 2014; 191: 660–4

3. Bokhorst LP, Lepistö I, Kakehi Y et al. Complications after prostate biopsies in men on active surveillance and its effects on receiving further biopsies in the Prostate cancer Research International: Active Surveillance (PRIAS) study. BJU Int 2016; 118: 366–71

4. Tosoian JJ, Mamawala M, Epstein JI et al. Intermediate and longer-term outcomes from a prospective active-surveillance program for favorable-risk prostate cancer. J Clin Oncol 2015; 33: 3379–85

5. Klotz L. Active surveillance: current and future directions. Curr Opin Urol 2013; 23: 237–8

Highlights from BAUS 2016

July 5, 2016/3 Comments/by Nishant Bedi

In the week following Britain’s exit from Europe after the BREXIT referendum, BAUS 2016 got underway in Liverpool’s BT convention Centre. This was the 72^nd meeting of the British Association of Urological Surgeons and it was well attended with 1120 delegates (50% Consultant Member Urologists, 30% Trainees, 10% Non member Urologists/Other, 10% Nurses, HCP’S, Scientists).

Monday saw a cautionary session on medicolegal aspects in Andrology, focusing on lawsuits over the last year. Mr Mark Speakman presented on the management issue of testicular torsion. This sparked further discussion on emergency cover for paediatrics with particular uncertainty noted at 4 and 5 year olds and great variation in approach dependent on local trust policy. Mr Julian Shah noted the most litigious areas of andrology, with focus on cosmesis following circumcisions. Therefore serving a reminder on the importance of good consent to manage patients’ expectations.

In the Dragons’ Den, like the TV show, junior urologists pitched their ideas for collaborative research projects, to an expert panel. This year’s panel was made up of – Mark Emberton, Ian Pearce, and Graeme MacLennan. The session was chaired by Veeru Kasivisvanathan, Chair of the BURST Research Collaborative.

Eventual winner Ben Lamb, a trainee from London, presented “Just add water”. The pitch was for an RCT to investigate the efficacy of water irrigation following TURBT against MMC in reducing tumour recurrence. Ben proposed that water, with its experimental tumouricidal properties, might provide a low risk, low cost alternative as an adjuvant agent following TURBT. Judges liked the scientific basis for this study and the initial planning for an RCT. The panel discussed the merits of non-inferiority vs. superiority methodology, and whether the team might compare MMC to MMC with the addition of water, or water instead of MMC. They Dragons’ suggested that an initial focus group to investigate patients’ views on chemotherapy might help to focus the investigation and give credence to the final research question, important when making the next pitch- to a funding body, or ethics committee.

Other proposals were from Ryad Chebbout, working with Marcus Cumberbatch, an academic trainee from Sheffield. Proposing to address the current controversy over the optimal surgical technique for orchidopexy following testicular torsion. His idea involved conducting a systematic review, a national survey of current practice followed by a Delphi consensus meeting to produce evidence based statement of best practice. The final presentation was from Sophia Cashman, East of England Trainee for an RCT to assess the optimal timing for a TWOC after urinary retention. The panel liked the idea of finally nailing down an answer to this age-old question.

Waking up on Tuesday with England out of the European football cup as well as Europe the conference got underway with an update from the PROMIS trial (use of MRI to detect prostate cancer). Early data shows that multi-parametric MRI may be accurate enough to help avoid some prostate biopsies.

The SURG meeting provided useful information for trainees, with advice on progressing through training and Consultant interviews. A debate was held over run through training, which may well be returning in the future. The Silver cystoscope was awarded to Professor Rob Pickard voted for by the trainees in his deanery, for his devotion to their training.
Wednesday continued the debate on medical expulsion therapy (MET) for ureteric stones following the SUSPEND trial. Most UK Urologists seem to follow the results of the trial and have stopped prescribing alpha blockers to try and aid stone passage and symptoms. However the AUA are yet to adopt this stance and feel that a sub analysis shows some benefit for stones >5mm, although this is not significant and pragmatic outcomes. Assistant Professor John Hollingsworth (USA) argued for MET, with Professor Sam McClinton (UK) against. A live poll at the end of the session showed 62.9% of the audience persuaded to follow the SUSPEND trial evidence and stop prescribing MET.

In the debate of digital versus fibreoptic scopes for flexible ureteroscopy digital triumphed, but with a narrow margin.

In other updates and breaking news it appears that BCG is back! However during the shortage EMDA has shown itself to be a promising alternative in the treatment of high grade superficial bladder cancer.
The latest BAUS nephrectomy data shows that 90% are performed by consultant, with 16 on average per consultant per year. This raises some issues for registrar training, however with BAUS guidelines likely to suggest 20 as indicative numbers this is looking to be an achievable target for most consultants. Robotic advocates will be encouraged, as robotic partial nephrectomy numbers have overtaken open this year. The data shows 36% of kidney tumours in the under 40 years old are benign. Will we have to consider biopsying more often? However data suggests we should be offering more cytoreductive nephrectomies, with only roughly 1/10 in the UK performed compared to 3/10 in the USA.

The andrology section called for more recruitment to The MASTER trial (Male slings vs artificial urinary sphincters), whereas the OPEN trial has recruited(open urethroplasty vs optical urethotomy). In the treatment of Peyronie’s disease collagenase has been approved by NICE but not yet within the NHS.

Endoluminal endourology presentation showed big increases in operative numbers with ureteroscopy up by 50% and flexible ureteroscopy up by 100%. Stents on strings were advocated to avoid troubling stent symptoms experienced by most patients. New evidence may help provide a consensus on defining “stone free” post operation. Any residual stones post-operatively less than 2mm were shown to pass spontaneously and therefore perhaps may be classed as “stone free”.

Big changes seem likely in the treatment of benign prostatic hyperplasia, with a race to replace the old favorite TURP. Trials have of TURP (mono and bipolar) vs greenlight laser are already showing similar 2 year outcomes with the added benefit of shorter hospital stays and less blood loss. UROLIFT is an ever more popular alternative with data showing superiority to TURP in lifestyle measures, likely because it preserves sexual function, and we are told it can be performed as a 15 minute day case operation. The latest new therapy is apparently “Aquabeam Aquablation”, using high pressured water to remove the prostate. Non surgical treatments are also advancing with ever more accurate super selective embolisation of the prostatic blood supply.

This year all accepted abstracts were presented in moderated EPoster sessions. The format was extremely successful removing the need for paper at future conferences? A total of 538 abstracts were submitted and 168 EPosters displayed. The winner of best EPoster was P5-5 Altaf Mangera: Bladder Cancer in the Neuropathic Bladder.

The best Academic Paper winner was Mark Salji of the CRUK Beatson institute, titled “A Urinary Peptide Biomarker Panel to Identify Significant Prostate Cancer”. Using capillary electrophoresis coupled to mass spectrometry (CE-MS) they analysed 313 urine samples from significant prostate cancer patients (Gleason 8-10 or T3/4 disease) and low grade control disease. They identified 94 peptide urine biomarkers which may provide a useful adjunct in identifying significant prostate cancer from insignificant disease.

The Office of Education offered 20 courses. Popular off-site courses were ultrasound for the Urologist, at Broadgreen Hospital, a slightly painful 30 min drive from the conference centre. However well worth the trip, delivered by Radiology consultants this included the chance to scan patients volunteers under guidance, with separate stations for kidneys, bladder and testicles and learning the “knobology” of the machines.

Organised by Tamsin Greenwell with other consultant experts in female, andrology and retroperitoneal cancer, a human cadaveric anatomy course was held at Liverpool university. The anatomy teaching was delivered by both Urology consultants and anatomists allowing for an excellent combination of theory and functional anatomy.

BAUS social events are renowned and with multiple events planned most evenings were pretty lively. The official drinks reception was held at the beautiful Royal Liver Building. The venue was stunning with great views over the waterfront and the sun finally shining. Several awards were presented including the Gold cystoscope to Mr John McGrath for significant contribution to Urology within 10 years appointment as consultant. The Keith Yeates medal was awarded to Mr Raj Pal, the most outstanding candidate in the first sitting of the intercollegiate specilaity examination, with a score of over 80%.

During the conference other BAUS awards presented include the St Peter’s medal was awarded to Margeret Knowles, Head of section of molecular oncology, Leeds Institute of Cancer and Pathology, St James University hospital Leeds. The St Paul’s medal awarded to Professor Joseph A. Smith, Vanderbilt University, Nashville, USA. The Gold medal went to Mr. Tim Terry, Leicester General Hospital.

An excellent industry exhibition was on display, with 75 Exhibiting Companies present. My personal fun highlight was a flexible cystoscope with integrated stent remover, which sparked Top Gear style competiveness when the manufacturer set up a time-trial leaderboard. Obviously this best demonstrated the speed of stent removal with some interesting results…

Social media review shows good contribution daily.

Thanks BAUS a great conference, very well organised and delivered with a great educational and social content, looking forward to Glasgow 2017! #BAUS2017 #Glasgow #BAUSurology

Nishant Bedi

Specialist Training Registrar North West London

Twitter: @nishbedi

Article of the Week: A prospective study of erectile function after transrectal ultrasonography-guided prostate biopsy

August 26, 2015/by admin Z.9

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Katie Murray discussing her paper.

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

A prospective study of erectile function after transrectal ultrasonography-guided prostate biopsy

Murray KS¹, Bailey J², Zuk K³, Lopez-Corona E⁴, Thrasher JB^1,⁴.

Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA.

Kansas City University of Medicine and Biosciences, Kansas City, KS, USA.

University of Kansas School of Medicine, Kansas City, KS, USA.

Kansas City Veterans Administration Medical Center, Kansas City, KS, USA.

Read the full article

OBJECTIVE

To prospectively evaluate the effect of transrectal ultrasonography (TRUS)-guided prostate biopsy on erectile and voiding function at multiple time-points after biopsy.

PATIENTS AND METHODS

All men who underwent TRUS-guided prostate biopsy completed a five-item version of the International Index of Erectile Function (IIEF-5) and the International Prostate Symptom Score (IPSS) before and at 1, 4 and 12 weeks after TRUS-guided biopsy. Statistical analyses used were a general descriptive analysis, continuous variables using a t-test and categorical data using chi-square analysis. A paired t-test was used to compare each patient’s baseline score to their own follow-up survey scores.

RESULTS

In all, 220 patients were enrolled with a mean age of 64.1 years and PSA level of 6.7 ng/dL. At initial presentation, 38.6% reported no erectile dysfunction (ED), 22.3% mild ED, 15.5% mild-to-moderate ED, 10% moderate ED, and 13.6% severe ED. On paired t-test there was a statistically significant reduction in IIEF-5 score at 1 week after biopsy compared with before biopsy (18.2 vs 15.5; P < 0.001). This remained significantly reduced at 4 (18.4 vs 17.3; P = 0.008) and 12 weeks (18.4 vs 16.9, P = 0.004) after biopsy.

CONCLUSIONS

The effects of TRUS-guided prostate biopsy on erectile function have probably been underestimated. It is important to be aware of these transient effects so patients can be appropriately counselled. The exact cause of this effect is yet to be determined.