Propensity score matched analysis of functional outcome in five thousand cases of robot-assisted radical prostatectomy versus high-intensity focused ultrasound.

Background: To evaluate functional outcome after robot-assisted radical prostatectomy (RARP) and high-intensity focused ultrasound (HIFU) ablation for prostate cancer. Methods: We retrospectively reviewed 4,983 RARP and 230 HIFU procedures performed at a single tertiary center. A 1:4 ratio propensity score matching (PSM) was performed to achieve baseline equivalence in age, body mass index (BMI), comorbidities, clinical stage, prostate specific antigen (PSA), prostate volume, biopsy grade, and number of positive cores. Functional outcomes based on International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF-5) scores, and incontinence rates were evaluated at 6, 12, and 24 months. Results: total of 193 HIFU cases matched to 760 cases of RARP, were included. No differences were observed in perioperative IPSS at all follow-up periods. Despite comparative erectile function at baseline, HIFU showed significantly better erectile function preservation compared to RARP, with mean IIEF-5 scores of 9.5 versus 4.8, 9.5 versus 5.8, and 8.4 versus 6.7 at 6, 12, and 24 months, respectively (all P < 0.001). Pad-free rates at 6 and 12 months were comparable, with over 96% achieving continence at 12 months in both groups, although the rate of ≤1 pad/day at last follow-up was slightly better in HIFU (98.9% vs. 96.7%, P = 0.049). Subgroup analysis on partial (PGA) and whole gland ablation (WGA) showed no differences in IIEF-5 and incontinence but increased voiding difficulty in WGA versus PGA after 12 months of therapy (P < 0.05). Preoperative IIEF-5 ≥17 and HIFU were significant predictors of early erectile function recovery at 6 months (HR 4.4 and 5.0; all P < 0.001). No differences were observed in treatment-free survival between PGA, WGA, and RARP. Conclusion: HIFU shows better performance in early recovery and preservation of erectile function after treatment for prostate cancer without increasing the risk of treatment failure. Patients with moderate to severe erectile dysfunction (IIEF-5 <17) prior to surgery should be warned of poor recovery after treatment.

Exploring the potential of ex-vivo 7-T magnetic resonance imaging on patients with clinically significant prostate cancer: visibility and size perspective.

Background: Despite progress in multiparametric magnetic resonance imaging (MRI), issues of prostate cancer invisibility and underestimated tumor burden persist. This study investigates the potential of an ultra-high field MRI at 7-T in an ex-vivo setting to address these limitations. Methods: This prospective study included 54 tumors from 20 treatment-naïve clinically significant prostate cancer patients, confirmed by biopsy, despite negative findings on preoperative 3-T MRI. Ex-vivo 7-T MRI of resected prostates was performed, with assessment on tumor visibility and size. Factors influencing visibility were analyzed using logistic regression analyses. Results: Tumor visibility was confirmed in 80% of patients, and 48% of all tumors on ex-vivo imaging. Gleason pattern 4 percentage (odds ratio 1.09) and tumor size on pathology (odds ratio 1.36) were significantly associated with visibility (P < 0.05). Mean MRI-visible and invisible tumor sizes were 10.5 mm and 5.3 mm, respectively. The size discrepancy between MRI and pathology was 2.7 mm. Conclusion: Tumor visibility on ex-vivo 7-T MRI was influenced by tumor grade and size. The notable tumor visibility initially overlooked on 3-T MRI, along with small size discrepancy with pathology, suggests potential improvements in resolution.

Association between preradiation therapy prostate-specific antigen levels and radiation therapy failure after prostatectomy: a propensity score matched analysis.

Purpose: We sought to determine the association between the pre-radiation therapy prostate-specific antigen (pre-RT PSA) 0.5 and RT failure in post-radical prostatectomy (post-RP) patients. Our study also investigated the prognostic factors for the failure of RT given concurrently with hormone therapy (HT) after RP. Materials and methods: We retrospectively reviewed our institutional RP data from July 2004 to November 2021. Patients without concurrent hormone therapy were excluded. Propensity score matching was performed. Kaplan-Meier (KM) curve analysis was employed for RT failure-free survival, overall survival (OS), and cancer-specific survival (CSS). Cox regression analysis was used for the RT failure hazard ratio (HR). Results: After propensity score matching, 193 patients were assigned to the pre-RT PSA ≥0.5 (high-P) arm, and 193 patients were assigned to the pre-RT PSA <0.5 (low-P) arm. There were no significant differences between the two arms after propensity score matching in terms of baseline characteristics and pathologic outcomes. High-P was associated with RT failure-free survival (P = 0.004), OS (P = 0.046), and CSS (P = 0.027). In a multi-variable Cox proportional hazards regression analysis, seminal vesicle invasion, lymph node invasion, the absence of prostatic intraepithelial neoplasia (PIN), and high-P were identified as significant risk factors for RT failure. Conclusion: High-P was significantly unfavorable with RT failure-free survival, OS, and CSS in patients who underwent RT after radical prostatectomy with concurrent HT. Seminal vesicle invasion, lymph node invasion, and the absence of PIN were identified as significant prognostic factors for RT failure.

Comparison of partial and total cystectomy for colorectal cancer with histologically confirmed bladder invasion.

BACKGROUND: Although organs are preserved and quality of life is improved, insufficient evidence is available for the oncologic safety of partial cystectomy in patients with colorectal cancer with suspected bladder invasion. Therefore, we aimed to compare partial and total cystectomy outcomes in patients with pathologically confirmed or clinically suspected bladder invasion. METHODS: Patients with colorectal cancer with suspected bladder invasion who underwent R0 resection from 2000 to 2020 were evaluated. Long-term outcomes were determined in patients with histologically confirmed bladder invasion. RESULTS: Of the 151 consecutive patients, 96 (64.6%) had histologically confirmed bladder involvement, and 105 (69.5%) underwent partial cystectomy. Operative time, estimated blood loss, and reoperation rate in ≤30 days were significantly worse in the total cystectomy group than in the partial cystectomy group. The overall recurrence rate was significantly higher in the total cystectomy group than in the partial cystectomy group (39.1% vs 21.9%; P = .046). Five-year overall survival (75.8% vs 53.2%; P = .006) rates were higher in the partial cystectomy group than in the total cystectomy group; however, disease-free survival (60.8% vs 41.6%; P = .088) rates were similar in patients with suspected bladder invasion. In patients with histologically confirmed bladder invasion, 5-year overall survival rates (78.1% vs 52.1%; P = .017) were higher in the partial cystectomy group than in the total cystectomy group; however, disease-free survival rates (53.4% vs 41.2%; P = .220) did not differ significantly. CONCLUSION: R0 resection is associated with favorable long-term outcomes in patients with locally advanced colorectal cancer. If R0 resection is possible, partial cystectomy is considered safe.

Evaluation of histological variants of upper tract urothelial carcinoma as prognostic factor after radical nephroureterectomy.

PURPOSE: To evaluate the impact of variant histology on patients with upper tract urothelial carcinoma (UTUC) survival outcomes. MATERIALS AND METHODS: A total of 519 patients underwent radical nephroureterectomy without neoadjuvant therapy for UTUC at a single institution between May 2003 and December 2019. Multivariate Cox regression analysis evaluated the impact of variant histology on progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS). RESULTS: Among 84 patients (16.2%) with variant histology, the most frequent variant type was squamous cell differentiation (64.3%), followed by glandular differentiation (25.0%) and sarcomatoid variant (2.4%). They showed pathologically advanced T stage (for ≥ T3, 59.5% vs 33.3%, p < 0.001), higher tumor grade (96.4% vs 85.7%, p = 0.025), and higher rates of lymph node metastasis (17.9% vs 7.8%, p = 0.015), angiolymphatic invasion (41.7% vs 25.7%, p = 0.003), tumor necrosis (57.1% vs 29.0%, p < 0.001) and positive surgical margin (13.1% vs 5.7%, p = 0.015). On multivariate Cox regression analyses, variant histology was significantly associated with worse PFS (hazard ratio [HR] 2.23; 95% confidence interval [CI] 1.55-3.21; p < 0.001), CSS (HR 2.67; 95% CI 1.35-5.30; p = 0.005) and OS (HR 2.22; 95% CI 1.27-3.88; p = 0.005). In subgroup analysis, no significant survival gains of adjuvant chemotherapy occurred in patients with variant histology. CONCLUSIONS: Variant histology was associated with adverse pathologic features and poor survival outcomes. Our results suggest that patients with variant histology may require a close follow-up schedule and novel adjuvant therapy other than chemotherapy postoperatively.

Shifting to transperineal prostate biopsy: A narrative review.

To address the limitations and challenges associated with transrectal (TR) biopsy and to present transperineal (TP) biopsy as a viable and potentially safer alternative to TR biopsy. Prostate cancer (PCa) is a significant global health concern. The prevalence of advanced-stage prostate cancer in Asia is higher than that in the United States, emphasizing the need for effective screening and diagnosis methods. The gold standard of diagnosis is a TR biopsy. However, it has limitations due to the risk of infection and potential complications, such as injury to the rectal artery. Efforts have been made to address issues such as false-negative biopsies, under-sampling, and over-sampling through MRI-guided biopsies. However, the TR approach makes it difficult to access the apical and anterior regions of the prostate. TP biopsy has emerged as an alternative to address the limitations of TR biopsy. Nevertheless, a TP biopsy is a painful procedure, requiring the use of general anesthesia and expensive equipment. As a result, it has been perceived as costly and time-consuming. In addition, it requires a steep learning curve. The introduction of local anesthesia such as pudendal nerve block and the adoption of freehand techniques have contributed to the feasibility of performing TP biopsy. Recent research indicates that freehand TP biopsy can yield comparable diagnostic results to template-guided approaches. The diagnostic performance, cancer detection rates, and complication rates of TP biopsy have demonstrated its potential as a safe and effective diagnostic method.

Prognosis after radical prostatectomy in men older than 75 years: long-term results from a single tertiary center.

Background: Despite longer lifespans, guidelines for prostate cancer treatment recommend surgery for those with over 10 years of life expectancy, potentially leaving older patients undertreated. This study examines the outcomes of radical prostatectomy (RP) in a large cohort of men older than 75 years. Materials and methods: We retrospectively analyzed 636 patients from a pool of 4,500 RP cases at a single tertiary institution from 2004 to 2022. Patients younger than 75 years or with incomplete records were excluded. Baseline clinical variables, including PSA and biopsy grade group (GG), as well as postoperative pathology and oncological outcomes, were assessed. Achievement of continence based on no pads and ≤1 pad at last follow-up were evaluated. Results: Mean age and PSA were 76.4 years and 15.3 ng/ml, respectively. At biopsy, GG1 and 2 were found in 18.1% and 31.5%, respectively, with 28.5% harboring GG4-5 tumors. After RP, 41.5% had GG upgrade compared to biopsy results, with 46.5% with ≥pT3 tumors. In a mean follow-up of 41.5 months, 82.3% were able to attain total continence of 0 pads, and 89.5% used ≤1 pads at the last follow-up. Overall and cancer-specific mortality was observed in 4.3% and 0.9%, respectively, and biochemical recurrence (BCR) occurred in 20.3% after a median of 154 months. At multivariate analysis, age was not a significant factor for BCR, whereas preoperative PSA, biopsy GG, margin positivity, and lymph node invasion were significant. Conclusion: RP is feasible in men older than 75 years with decent oncological outcome, with absolute age insignificant within this age group. Risk of undertreatment should be acknowledged, and definite treatment must be considered.

Oncological Outcomes in Men with Metastatic Castration-Resistant Prostate Cancer Treated with Enzalutamide with versus without Confirmatory Bone Scan.

PURPOSE: In men with metastatic castration-resistant prostate cancer (mCRPC), new bone lesions are sometimes not properly categorized through a confirmatory bone scan, and clinical significance of the test itself remains unclear. This study aimed to demonstrate the performance rate of confirmatory bone scans in a real-world setting and their prognostic impact in enzalutamide-treated mCRPC. MATERIALS AND METHODS: Patients who received oral enzalutamide for mCRPC during 2014-2017 at 14 tertiary centers in Korea were included. Patients lacking imaging assessment data or insufficient drug exposure were excluded. The primary outcome was overall survival (OS). Secondary outcomes included performance rate of confirmatory bone scans in a real-world setting. Kaplan-Meier analysis and multivariate Cox regression analysis were performed. RESULTS: Overall, 520 patients with mCRPC were enrolled (240 [26.2%] chemotherapy-naïve and 280 [53.2%] after chemotherapy). Among 352 responders, 92 patients (26.1%) showed new bone lesions in their early bone scan. Confirmatory bone scan was performed in 41 patients (44.6%), and it was associated with prolonged OS in the entire population (median, 30.9 vs. 19.7 months; p < 0.001), as well as in the chemotherapy-naïve (median, 47.2 vs. 20.5 months; p=0.011) and post-chemotherapy sub-groups (median, 25.5 vs. 18.0 months; p=0.006). Multivariate Cox regression showed that confirmatory bone scan performance was an independent prognostic factor for OS (hazard ratio 0.35, 95% confidence interval, 0.18 to 0.69; p=0.002). CONCLUSION: Confirmatory bone scan performance was associated with prolonged OS. Thus, the premature discontinuation of enzalutamide without confirmatory bone scans should be discouraged.

Clinical value of prostate health index as an indicator for recommending magnetic resonance imaging in patients with gray-zone prostate-specific antigen level.

PURPOSE: To evaluate the usefulness of prostate health index (PHI) as an indicator for recommending magnetic resonance imaging (MRI) in patients with prostate-specific antigen (PSA) gray zone level < 10 ng/mL. METHODS: 443 patients who underwent prostate biopsy (PB) after serum PHI test and MRI between April 2019 and December 2022 were enrolled. For patients with visible lesion on MRI with Prostate Imaging Reporting and Data System Score (PI-RADS) ≥ 3, MRI-targeted PB was performed in addition to systematic 12-core PB. RESULTS: The optimal cutoff value of PHI for predicting PI-RADS ≥ 3 lesions was 39.6, which was significantly associated with overall prostate cancer (OR 3.07, p = 0.018) and clinically significant prostate cancer (csPCa) (OR 4.15, p = 0.006) at MRI-targeted PB cores. When MRI was restricted to patients with PHI ≥ 39.6 alone, 28.7% of unnecessary MRI could be saved at the cost of missing 13.6% of csPCa. When omitting MRI for patients with PHI < 39.6 and PSAD < 0.12 ng/mL2, unnecessary MRI could be reduced by 20.1% with the risk of missing 6.2% of csPCa. With addition of systematic PB, 21.0% of patients with negative MRI-targeted PB were diagnosed as csPCa. CONCLUSIONS: For patients in PSA gray zone, PHI of 39.6 might be an indicator for MRI and further MRI-targeted PB in additional to PSAD of 0.12 ng/mL2, reducing 20.1% of unnecessary MRI with the minimal risk of missing 6.2% of csPCa. To maximize csPCa detection, combining both MRI-targeted and systematic PB should be also considered.

Partial gland ablation using high-intensity focused ultrasound versus robot-assisted radical prostatectomy: a propensity score-matched study.

Background: We compared the clinical outcomes of robot-assisted radical prostatectomy (RARP) and partial gland ablation (PGA) using high-intensity focused ultrasound (HIFU) in localized prostate cancer. Methods: We analyzed 3,859 patients who had undergone RARP and PGA using HIFU. According to the propensity score for each treatment, 137 patients after PGA were matched to 3,722 patients after RARP at a 1:4 ratio using the nearest neighbor method. Results: The matched cohort comprised 685 subjects (RARP, 548; PGA, 137), with a median follow-up period of 22 months. Treatment failures were identified in 13.9% and 9.1% of patients in the PGA and RARP groups, respectively, after a median follow-up of 36 months postoperatively. Kaplan-Meier analyses revealed significantly longer failure-free (P < 0.001) and salvage-free survival (P = 0.003) in the RARP group than in the PGA group. There was no significant difference in the postoperative urinary symptom score (P = 0.748), but the postoperative erectile function score was significantly higher in the PGA group (P < 0.001). The rate of urinary incontinence (any pad) was significantly lower in the PGA group than that in the RARP group (P < 0.001). Postoperative complications were more frequent in the PGA group (P = 0.003); however, there was no significant difference in high-grade complications (≥3) (P = 0.467). Conclusion: PGA using HIFU showed statistically inferior oncological outcomes compared with RARP for failure-free survival and salvage-free survival. However, functional outcomes regarding postoperative incontinence and erectile dysfunction were more favorable in the PGA group.

Computer tomography-based shape of tumor contour and texture of tumor heterogeneity are independent prognostic indicators for clinical T1b-T2 renal cell carcinoma.

PURPOSE: To evaluate association between computer tomography (CT)-based features of renal cell carcinoma (RCC) and survival outcomes. METHODS: Data of 958 patients with clinical T1b-T2 RCC who underwent partial/radical nephrectomy from June 2003 to March 2022 were retrospectively evaluated. CT images of patients were reviewed by two radiologists for texture analysis of tumor heterogeneity and shape analysis of tumor contour. Patients were divided into three groups according to patterns of CT-based features: (1) favorable feature group (n = 117); (2) intermediate feature group (n = 606); and (3) unfavorable feature group (n = 235). Kaplan-Meier survival analysis and multivariate Cox regression analysis were performed to evaluate overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). RESULTS: RCCs with unfavorable CT-based feature showed larger size on CT, higher nuclear grade, higher rate of histologic necrosis, and higher rate of capsular invasion than those in the other two groups (all p < 0.001). Unfavorable feature was associated with poorer OS (p = 0.001), CSS (p < 0.001), and RFS (p < 0.001) on Kaplan-Meier analysis. In multivariate analysis, intermediate and unfavorable features were independent predictors for recurrence (hazard ratio [HR] 2.51, 95% confidence interval [CI] 1.09-5.79, p = 0.031 and HR 3.71, 95% CI 1.58-8.73, p = 0.003, respectively), but not for overall death or RCC-specific death. CONCLUSIONS: A combination of irregular tumor contour feature with heterogeneous tumor texture feature on CT is associated with poor RFS in clinical T1b-T2 RCC preoperatively.

Tumor contact length with bladder wall provides effective risk stratification for lesions with a VIRADS score of 2-3.

OBJECTIVES: To evaluate the diagnostic performance of the tumor contact length (TCL) in the prediction of MIBC (muscle-invasive bladder cancer) in lesions corresponding to the vesical imaging-reporting and data system (VIRADS) score 2-3. METHODS: This is a single institution, retrospective study targeting 191 consecutive patients assigned of VIRADS score 2-3, who had pre-transurethral resection MRI from July 2019 to September 2021. Logistic regression analyses were performed to determine meaningful predictors of MIBC for this score group, and a nomogram was plotted with those variables. The diagnostic performance of each predictor was compared at predefined thresholds (VIRADS score 3 and TCL 3 cm) using the generalized linear model and ROC analysis. RESULTS: Both VIRADS score and TCL remained independent predictors of MIBC for this score group (odds ratio 7.3 for VIRADS score, and 1.3 for TCL, p < 0.01 for both). The contribution of TCL to the probability of MIBC in the nomogram was greater than that of the VIRADS score. VIRADS score had a sensitivity of 0.54 (14/26), specificity of 0.92 (203/221), and diagnostic accuracy of 0.88 (217/247), and TCL showed a sensitivity of 0.89 (23/26), specificity of 0.95 (209/221), and diagnostic accuracy of 0.94 (232/247). The difference in sensitivity (p = 0.03) and accuracy (p = 0.04) was statistically significant. The AUC was also significantly wider for TCL than for VIRADS (0.97 vs. 0.73, p < 0.01). CONCLUSION: A simple index, TCL, may be helpful in further risk stratification for MIBC in patients with a score of VIRADS 2-3. CLINICAL RELEVANCE STATEMENT: For bladder cancer patients with insufficient qualitative evidence of muscle layer invasion using VIRADS categorization, TCL, a simple quantitative indicator defined as the curvilinear contact length between the bladder wall and the tumor, may be helpful in risk stratification. KEY POINTS: • Even when only lesions with score 2-3 were targeted, VIRADS was still a meaningful indicator of MIBC. • With a predefined threshold of 3 cm applied, TCL outperformed VIRADS in the score 2-3 group, in predicting MIBC. • A longer TCL for a lesion with a VIRADS score 2 may warrant an additional warning for MIBC, whereas a shorter TCL for a lesion with a score 3 may indicate a lower risk of MIBC.

Diagnostic performance of MRI for prediction of recurrent prostate cancer after high-intensity focused ultrasound: a systematic review and meta-analysis.

Purpose: This article aims to evaluate the pooled diagnostic performance control MRI for prediction of recurrent prostate cancer (PCa) after high-intensity focused ultrasound (HIFU). Materials and methods: MEDLINE, EMBASE, and Cochrane library databases up to December 31, 2021, were searched. We included studies providing 2×2 contingency table for diagnostic performance of MRI in predicting recurrent PCa after HIFU, using control biopsy as reference standard. The quality of the included studies was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Sensitivity and specificity were pooled and displayed in a summary receiver operating characteristics (SROC) plot. Meta-regression analysis using clinically relevant covariates was performed for the causes of heterogeneity. Results: Nineteen studies (703 patients) were included. All included studies satisfied at least four of the seven QUADAS-2 domains. Pooled sensitivity was 0.81 (95% CI 0.72-0.90) with specificity of 0.91 (95% CI 0.86-0.96), with area under the SROC curve of 0.81. Larger studies including more than 50 patients showed relatively poor sensitivity (0.68 vs. 0.84) and specificity (0.75 vs. 0.93). The diagnostic performance of studies reporting higher nadir serum prostate-specific antigen levels (>1 ng/mL) after HIFU was inferior, and differed significantly in sensitivity (0.54 vs. 0.78) rather than specificity (0.85 vs. 0.91). Conclusions: Although MRI showed adequate diagnostic performance in predicting PCa recurrence after HIFU, these results may have been exaggerated.

Detection of recurrence sites using 18F-fluorocholine PET/CT in prostate cancer patients with PSA failure.

Background: The optimal condition for the clinical application of 18F-fluorocholine positron emission tomography-computed tomography (FCH-PET/CT) to detect recurrence sites in prostate-specific antigen (PSA) failure remains unclear due to the heterogeneity of prostate cancer failure. We aimed to evaluate the detection rate of FCH-PET/CT in prostate cancer patients with PSA failure and to determine the optimal PSA level for performing FCH-PET/CT. Methods: FCH-PET/CT was conducted in 89 patients diagnosed with PSA failure after radical treatment (radical prostatectomy in 75 and definitive radiotherapy in 14) between November 2018 and May 2021. Detection rates were examined via receiver operating characteristic (ROC) analysis, and multivariable logistic regression was performed to identify factors affecting positive FCH-PET/CT findings. We also conducted subgroup analyses according to the PSA failure patterns after the radical treatment (persistently high PSA [N = 48] and biochemical recurrence [BCR] [N = 41]). Results: FCH-PET/CT demonstrated a 59.6% overall detection rate, and the optimal PSA threshold for detecting positive findings was ≥ 1.00 ng/mL at the time of imaging. On multivariable analysis, PSA > 1.00 ng/mL (P < 0.001) was a significant predictor of positive FCH-PET/CT findings, especially regarding distant bone metastases (P < 0.001) and recurrence outside the pelvis (P < 0.001). In a subgroup analysis of patients with BCR after initial radical treatment, the area under the ROC curve (AUC) was 0.82, and PSA ≥ 1.75 ng/mL was the optimal value for identifying positive FCH-PET/CT findings. This PSA value was also associated with significantly higher detection rates of distant bone metastases and outside-pelvis metastasis (P < 0.001, both). Conclusion: FCH-PET/CT is a clinically useful tool for detecting tumor recurrence sites in prostate cancer patients with PSA failure if PSA has exceeded a certain value at the time of imaging. Particularly, higher AUC values were observed when FCH-PET/CT was performed in patients with BCR after initial treatment.

Machine learning based prediction for oncologic outcomes of renal cell carcinoma after surgery using Korean Renal Cell Carcinoma (KORCC) database.

We developed a novel prediction model for recurrence and survival in patients with localized renal cell carcinoma (RCC) after surgery and a novel statistical method of machine learning (ML) to improve accuracy in predicting outcomes using a large Asian nationwide dataset, updated KOrean Renal Cell Carcinoma (KORCC) database that covered data for a total of 10,068 patients who had received surgery for RCC. After data pre-processing, feature selection was performed with an elastic net. Nine variables for recurrence and 13 variables for survival were extracted from 206 variables. Synthetic minority oversampling technique (SMOTE) was used for the training data set to solve the imbalance problem. We applied the most of existing ML algorithms introduced so far to evaluate the performance. We also performed subgroup analysis according to the histologic type. Diagnostic performances of all prediction models achieved high accuracy (range, 0.77-0.94) and F1-score (range, 0.77-0.97) in all tested metrics. In an external validation set, high accuracy and F1-score were well maintained in both recurrence and survival. In subgroup analysis of both clear and non-clear cell type RCC group, we also found a good prediction performance.

Germline DNA-Repair Genes and HOXB13 Mutations in Korean Men with Metastatic Prostate Cancer: Data from a Large Korean Cohort.

PURPOSE: Germline mutations in DNA damage repair (DDR) genes such as BRCA2 have been associated with prostate cancer (PC) risk but has not been thoroughly evaluated for metastatic prostate cancer (mPC) in Asian men. This study attempts to evaluate frequency of DDR mutations in the largest cohort of Koreans. MATERIALS AND METHODS: We recruited 340 patients with mPC unselected for family history of cancer and compared to 495 controls. Whole genome sequencing was applied to assess germline pathogenic/likely pathogenic variants (PV/LPVs) in 26 DDR genes and HOXB13, including 7 genes (ATM, BRCA1/2, CHEK2, BRIP1, PALB2, and NBN) associated with hereditary PC. Comparisons to published Caucasian and Japanese cohorts were performed. RESULTS: Total of 28 PV/LPVs were identified in 30 (8.8%) patients; mutations were found in 13 genes, including BRCA2 (15 men [4.41%]), ATM (2 men [0.59%]), NBN (2 men [0.59%], and BRIP1 (2 men [0.59%]). Only one patient had HOXB13 mutation (0.29%). A lower rate of overall germline variant frequency was observed in Korean mPC compared to Caucasians (8.8% vs. 11.8%), but individual variants notably differed from Caucasian and geographically similar Japanese cohorts. PV/LPVs in DDR genes tended to increase gradually with higher Gleason scores (GS 7, 7.1%; GS 8, 7.5%; GS 9-10, 9.9%). CONCLUSIONS: BRCA2 was the most frequently mutated gene common to different cohorts supporting its importance, but differences in variant distribution in Korean mPC underscore the need for ethnic-specific genetic models. Future ethnic-specific analyses are warranted to verify our findings.

Total Intracorporeal Versus Open Bladder Cuffing in Robotic Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma.

OBJECTIVE: To evaluate a single institution experience of total intracorporeal bladder cuffing and distal ureterectomy (DUBC) in robotic radical nephrouretectomy (RNU) for upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS: One hundred sixty-eight patients treated for UTUC with robotic RNU at our institution from May 2009 to October 2019 were retrospectively analyzed. Ninety-two patients underwent total intracorporeal DUBC after robotic dock repositioning, whereas 76 patients underwent open methods via Gibson incision. Perioperative outcomes including operation time, estimated blood loss (EBL), transfusion rates, use of painkillers, Visual analogue scale (VAS) pain scores, and complication rates were compared, as well as pathological and oncological outcomes. Uni- and multi-variate Cox regression models were performed for survival analysis. RESULTS: There were no significant differences in baseline patient characteristics between the 2 groups. Patients who underwent intracorporeal bladder cuffing had less EBL (169.8 ± 150.4 vs 214.6 ± 157.0, P = .091) and decreased pain at 1 week (VAS score 1.18 ± 1.1 vs 2.2 ± 1.1, P = .017). Pathological outcomes were not significantly different, and oncological outcomes including local and intravesical recurrence, cancer-specific and overall mortality were comparable to patients who received extracorporeal bladder cuffing. Intracorporeal bladder cuffing was not associated with increased risk of progression on univariate analysis (HR 0.600, 95% CI, 0.314-1.147; P = .122). CONCLUSION: Based on our experience, intracorporeal DUBC can be a safe and oncologically non-inferior alternative method to RNU, with benefits of decreased EBL and postoperative pain. Future prospective trials are necessary to further validate our results.

Polygenic risk score for tumor aggressiveness and early-onset prostate cancer in Asians.

We attempted to assess the performance of an ethnic-specific polygenic risk score (PRS) designed from a Korean population to predict aggressive prostate cancer (PCa) and early-onset (age < 60). A PRS score comprised of 22 SNPs was computed in 3695 patients gathered from one of 4 tertiary centers in Korea. Males with biopsy or radical prostatectomy-proven PCa were included for analysis, collecting additional clinical parameters such as age, BMI, PSA, Gleason Group (GG), and staging. Patients were divided into 4 groups of PRS quartiles. Intergroup differences were assessed, as well as risk ratio and predictive performance based on GG using logistic regression analysis and AUC. No significant intergroup differences were observed for BMI, PSA, and rate of ≥ T3a tumors on pathology. Rate of GG ≥ 2, GG ≥ 3, and GG ≥ 4 showed a significant pattern of increase by PRS quartile (p < 0.001, < 0.001, and 0.039, respectively). With the lowest PRS quartile as reference, higher PRS groups showed sequentially escalating risk for GG ≥ 2 and GG ≥ 3 pathology, with a 4.6-fold rise in GG ≥ 2 (p < 0.001) and 2.0-fold rise in GG ≥ 3 (p < 0.001) for the highest PRS quartiles. Combining PRS with PSA improved prediction of early onset csPCa (AUC 0.759) compared to PRS (AUC 0.627) and PSA alone (AUC 0.736). To conclude, an ethnic-specific PRS was found to predict susceptibility of aggressive PCa in addition to improving detection of csPCa when combined with PSA in early onset populations. PRS may have a role as a risk-stratification model in actual practice. Large scale, multi-ethnic trials are required to validate our results.

Diagnostic value of multiparametric MRI in detecting residual or recurrent prostate cancer after high-intensity focused ultrasound.

PURPOSE: To evaluate the diagnostic performance of follow-up multiparametric MRI for prediction of recurrent prostate cancer after high-intensity focused ultrasound (HIFU), and to find other, if any, clinical or radiological predictors. MATERIALS AND METHODS: Post-HIFU MRIs of 110 consecutive patients who underwent follow-up biopsies between August 2019 and April 2021 were retrospectively analyzed and the likelihood of recurrence was assessed on a five-point Likert scale by two board-certified uroradiologists. Diagnostic performance of the Likert scale assigned to the post-HIFU MRI was assessed using the follow-up biopsy results as a reference standard. Among the clinical and radiological variables, predictors of the recurrence were examined through logistic regression. RESULTS: In per-patient and per-sector analyses, Likert scale on post-HIFU MRI showed a sensitivity and specificity of 0.37 and 0.97, and 0.42 and 0.87, respectively, in predicting recurrence. Two patients with high suspicion on MRI required additional treatment to regain biochemical control despite negative biopsies. High suspicion on post-HIFU MRI (odds ratio = 1.74; p < 0.01), and more cancer-positive cores on initial biopsy (odds ratio = 1.25; p = 0.03) were independent predictors of recurrence. CONCLUSION: Albeit with low sensitivity, high suspicion on post-HIFU MRI may be clinically important because of its high specificity, especially when considering the possibility of sampling error in biopsies. Patients with a high number of cancer-positive cores at diagnosis should avoid HIFU as they have an increased risk of recurrence.