Quantification of Gleason Pattern 4 at MRI-Guided Biopsy to Predict Adverse Pathology at Radical Prostatectomy in Intermediate-Risk Prostate Cancer Patients.

BACKGROUND: Data on Gleason pattern 4 (GP4) amount in biopsy tissue is important for prostate cancer (PC) risk assessment. We aim to investigate which GP4 quantification method predicts adverse pathology (AP) at radical prostatectomy (RP) the best in men diagnosed with intermediate-risk (IR) PC at magnetic resonance imaging (MRI)-guided biopsy. METHODS: We retrospectively included 123 patients diagnosed with IR PC (prostate-specific antigen <20 ng/mL, grade group (GG) 2 or 3, no iT3 on MRI) at MRI-guided biopsy, who underwent RP. Twelve GP4 amount-related parameters were developed, based on GP4 quantification method (absolute, relative to core, or cancer length) and site (overall, targeted, systematic biopsy, or worst specimen). Additionally, we calculated PV×GP4 (prostate volume × GP4 relative to core length in overall biopsy), aiming to represent the total GP4 volume in the prostate. The associations of GP4 with AP (GG ≥ 4, ≥pT3a, or pN1) were investigated. RESULTS: AP was reported in 39 (31.7%) of patients. GP4 relative to cancer length was not associated with AP. Of the 12 parameters, the highest ROC AUC value was seen for GP4 relative to core length in overall biopsy (0.65). an even higher AUC value was noted for PV × GP4 (0.67), with a negative predictive value of 82.8% at the optimal threshold. CONCLUSIONS: The lack of an association of GP4 relative to cancer length with AP, contrasted with the better performance of other parameters, indicates directions for future research on PC risk stratification to accurately identify patients who may not require immediate treatment. Incorporating formulas aimed at GP4 volume assessment may lead to obtaining models with the best discrimination ability.

Patient-reported pain associated with grid-based transperineal magnetic resonance imaging (MRI)/ultrasound (US) software fusion biopsy of the prostate under local anesthesia: a multicenter experience.

Background: Biopsy by transperineal (TP) approach is recommended standard for prostate cancer (PC) diagnosis. To avoid pain, patients undergoing TP biopsy may be offered sedation or general anesthesia. Our aim was to investigate the degree of patient-reported pain for magnetic resonance imaging (MRI)/ultrasound (US) fusion biopsy of the prostate being performed under local anesthesia (LA) and to study for possible factors associated with increased risk of significant pain (SP) in this setting. Methods: In this retrospective observational study, we reviewed data of consecutive patients without a prior diagnosis of PC who underwent MRI/US software fusion biopsy of the prostate under LA with lidocaine at two centers between May 2020 and April 2022, and who reported their periprocedural pain on a Wong-Baker FACES Pain Rating Scale (0-10). We defined SP as reported pain score of 6-10. Patient and procedure characteristics together with SP were studied for interdependencies. Results: A total of 299 patients were included. Median pain score was 2 (interquartile range: 2-4), with SP having been reported by 55 (18.4%) patients. Among patient characteristics, only age demonstrated association with SP [odds ratio (OR), per 10 years =0.53, 95% confidence interval (CI): 0.35-0.80, P=0.003] and patients aged 62 or above were significantly less likely to report SP (OR =0.33, 95% CI: 0.18-0.60, P<0.001). Conclusions: Performing TP MRI/US fusion prostate biopsy under LA is associated with low rates of SP, with the risk being significantly lower in older men. The results of this study can serve as evidence resource for preprocedural counselling in patients especially concerned about the risk of pain.

Prostate Biopsy in the Case of PIRADS 5-Is Systematic Biopsy Mandatory?

Combining systematic biopsy (SB) with targeted biopsy (TB) in the case of a positive result from multiparametric magnetic resonance imaging (mpMRI) is a matter of debate. The Prostate Imaging Reporting and Data System (PIRADS) score of 5 indicates the highest probability of clinically significant prostate cancer (csPC) detection in TB. Potentially, omitting SB in the case of PIRADS 5 may have a marginal impact on the csPC detection rate. The aim of this study was to determine whether SB can be avoided in the case of PIRADS 5 and to identify potential factors allowing for performing TB only. This cohort study involved n = 225 patients with PIRADS 5 on mpMRI (PIRADS 2.0/2.1) who underwent transperineal or transrectal combined biopsy (CB). CsPC was diagnosed in 51.6% (n = 116/225) of cases. TB and SB resulted in the detection of csPC in 48% (n = 108/225) and 20.4% (n = 46/225) of cases, respectively (TB vs. SB, p < 0.001). When the TB was positive, SB detected csPC in n = 38 of the cases (38/108 = 35%). SB added to TB significantly improved csPC detection in 6.9% of cases in absolute terms (n = 8/116) (TB vs. CB, p = 0.008). The multivariate regression model proved that the significant predictors of csPC detection via SB were the densities of the prostate-specific antigen-PSAD > 0.17 ng/mL2 (OR = 4.038, 95%CI: 1.568-10.398); primary biopsy setting (OR = 2.818, 95%CI: 1.334-5.952); and abnormal digital rectal examination (DRE) (OR = 2.746, 95%CI: 1.328-5.678). In a primary biopsy setting (n = 103), SB detected 10% (n = 6/60) of the additional cases of csPC (p = 0.031), while in a repeat biopsy setting (n = 122), SB detected 3.5% (n = 2/56) of the additional cases of csPC (p = 0.5). In the case of PSAD > 0.17 ng/mL2 (n = 151), SB detected 7.4% (n = 7/95) of additional cases of csPC (p = 0.016), while in the case of PSAD < 0.17 ng/mL2 (n = 74), SB detected 4.8% (n = 1/21) of the additional cases of csPC (p = 1.0). The omission of SB had an impact on the csPC diagnosis rate in patients with PIRADS 5 score lesions. Patients who have already undergone prostate biopsy and those with low PSAD are at a lower risk of missing csPC when SB is avoided. However, performing TB only may result in missing other csPC foci located outside the index lesion, which can alter treatment decisions.

The Impact of the Ongoing COVID-19 Epidemic on the Increasing Risk of Adverse Pathology in Prostate Cancer Patients Undergoing Radical Prostatectomy.

We aimed to assess whether the ongoing course of the COVID-19 epidemic has been associated with an increased risk of adverse pathology (AP) findings in prostate cancer (PC) patients treated with radical prostatectomy (RP). We performed a retrospective data analysis which included 408 consecutive, non-metastatic, previously untreated PC patients who underwent RP in our institution between March 2020 and September 2021. Patients were divided into two equally numbered groups in regard to the median surgery date (Early Epidemic [EE] and Late Epidemic [LE]) and compared. Adverse pathology was defined as either grade group (GG) ≥ 4, pT ≥ 3a or pN+ at RP. Patients in the LE group demonstrated significantly higher rates of AP than in the EE group (61 vs. 43% overall and 50 vs. 27% in preoperative non-high-risk subgroup, both p < 0.001), mainly due to higher rates of upgrading. On multivariable analysis, consecutive epidemic week (odds ratio: 1.02, 95% confidence interval: 1.00−1.03, p = 0.009) as well as biopsy GG ≥ 2 and a larger prostate volume (mL) were associated with AP in non-high-risk patients. The study serves as a warning call for increased awareness of risk underassessment in contemporarily treated PC patients.

High-Intensity Focused-Ultrasound Focal Therapy Versus Laparoscopic Radical Prostatectomy: A Comparison of Oncological and Functional Outcomes in Low- and Intermediate-Risk Prostate Cancer Patients.

To compare oncological and functional outcomes of high-intensity focused-ultrasound (HIFU) focal therapy (FT) versus laparoscopic radical prostatectomy (LRP) in patients treated for low- or intermediate-risk prostate cancer (PCa), we retrospectively analyzed data of consecutive patients comprising 30 men, who underwent HIFU-FT, and 96 men who underwent LRP, in an academic center. Oncological outcomes were assessed based on the follow-up prostate-specific antigen values. We used the International Index of Erectile Function short form score to assess erectile function (EF). Urinary continence status was defined based on the number of pads used per day. Median follow-up was 12.5 and 19.1 months in the LRP and HIFU-FT groups, respectively. The effects were computed after propensity score matching and expressed as average treatment effect (ATE). Compared to LRP, HIFU-FT was associated with increased risk of treatment failure (ATE 0.103-0.164, depending on definition, p < 0.01) and lower risk of urinary incontinence (ATE -0.808 at 12 months, p < 0.01). Risk of erectile dysfunction was higher in the LRP group (ATE 5.092, p < 0.01). Our results demonstrate that HIFU-FT may be a reasonable treatment option in selected PCa patients, willing to preserve their EF and urinary continence yet accepting a higher risk of treatment failure.

Predictors of Clinically Significant Prostate Cancer in Patients with PIRADS Categories 3-5 Undergoing Magnetic Resonance Imaging-Ultrasound Fusion Biopsy of the Prostate.

Prostate biopsy is recommended in cases of positive magnetic resonance imaging (MRI), defined as Prostate Imaging Reporting and Data System (PIRADS) category ≥ 3. However, most men with positive MRIs will not be diagnosed with clinically significant prostate cancer (csPC). Our goal was to evaluate pre-biopsy characteristics that influence the probability of a csPC diagnosis in these patients. We retrospectively analyzed 740 consecutive men with a positive MRI and no prior PC diagnosis who underwent MRI-ultrasound fusion biopsies of the prostate in three centers. csPC detection rates (CDRs) for each PIRADS category were calculated. Patient, disease, and lesion characteristics were studied for interdependencies with the csPC diagnosis. The CDR in patients with PIRADS categories 3, 4, and 5 was 10.5%, 30.7%, and 54.6%, respectively. On both uni- and multivariable regression models, older age, being biopsy-naïve, prostate specific antigen ≥ 10 ng/mL, smaller prostate volume, PIRADS > 3, a larger maximum lesion size, a lesion in the peripheral zone, and a positive digital rectal examination were associated with csPC. In this large, multicenter study, we provide new data regarding CDRs in particular PIRADS categories. In addition, we present several strong predictors that further alter the risk of csPC in MRI-positive patients. Our results could help in refining individual risk assessment, especially in PIRADS 3 patients, in whom the risk of csPC is substantially low.

The molecular mechanisms of fluoroquinolone resistance found in rectal swab isolates of Enterobacterales from men undergoing a transrectal prostate biopsy: the rationale for targeted prophylaxis.

BACKGROUND: Transrectal ultrasound-guided prostate biopsy (TRUS-Bx) is considered an essential urological procedure for the histological diagnosis of prostate cancer. It is, however, considered a "contaminated" procedure which may lead to infectious complications. Recent studies suggest a significant share of fluoroquinolone-resistant rectal flora in post-biopsy infections. METHODS: The molecular mechanisms of fluoroquinolone resistance, including PMQR (plasmid-mediated quinolone resistance) as well as mutation in the QRDRs (quinolone-resistance determining regions) of gyrA, gyrB, parC and parE, among Enterobacterales isolated from 32 of 48 men undergoing a prostate biopsy between November 2015 and April 2016 were investigated. Before the TRUS-Bx procedure, all the patients received an oral antibiotic containing fluoroquinolones. RESULTS: In total, 41 Enterobacterales isolates were obtained from rectal swabs. The MIC of ciprofloxacin and the presence of common PMQR determinants were investigated in all the isolates. Nine (21.9%) isolates carried PMQR with qnrS as the only PMQR agent detected. DNA sequencing of the QRDRs in 18 Enterobacterales (E. coli n = 17 and E. cloacae n = 1) isolates with ciprofloxacin MIC ≥ 0.25 mg/l were performed. Substitutions in the following codons were found: GyrA-83 [Ser → Leu, Phe] and 87 [Asp → Asn]; GyrB codon-605 [Met → Leu], ParC codons-80 [Ser → Ile, Arg] and 84 [Glu → Gly, Met, Val, Lys], ParE codons-458 [Ser → Ala], 461 [Glu → Ala] and 512 [Ala → Thr]. Six isolates with ciprofloxacin MIC ≥ 2 mg/l had at least one mutation in GyrA together with qnrS. CONCLUSIONS: This study provides information on the common presence of PMQRs among Enterobacterales isolates with ciprofloxacin MIC ≥ 0.25 mg/l, obtained from men undergoing TRUS-Bx. This fact may partially explain why some men develop post-TRUS-Bx infections despite ciprofloxacin prophylaxis.

Should all specimens taken during surgical treatment of patients with benign prostatic hyperplasia be assessed by a pathologist?

INTRODUCTION: In some patients submitted to transurethral resection of the prostatic (TURP) or prostatectomy (OAE) due to benign prostate hyperplasia (BPH), pathological evaluations (PE) revealed coexistence of prostate cancer (PCa) and BPH. The aim of the study is to evaluate the incidence of PCa diagnosed incidentally in prostate specimens taken during BPH surgery, to assess the need of routine PE and to define the group of patients in whom PE could be abandoned without the risk of omitting clinically significant PCa. MATERIAL AND METHODS: 968 consecutive men were subjected to surgical treatment due to BPH in Jan. 2004-Sep. 2010. RESULTS: 823 (85%) underwent TURP and 145 (15%) OAE. Incidental (Inc) PCa was diagnosed in 34(3.5%) pts. T1a and T1b stages were determined in 19 (2%) and 15 (1.5%) cases. Preoperative prostate biopsy due to abnormal prostate specific antigen (PSA) or digital rectal exam (DRE) was performed in 85 (8.8%) pts. Of PCa pts, 7 (20.58%) had undergone a cancer negative biopsy preoperatively. In BPH pts, 78 (8.35%) had undergone a prostate biopsy previously (p <0.01). Univariate and logit regression analyses had not revealed any correlations between age, Pv, serum PSA and frequency of IncPCa. The difference in rate of PCa diagnosed in patients with PSAD ≥0.15 and <0.15 was 8 pts (14.04%) and 20 pts (4.05%), respectively (p <0.001). Gls in those pts was >6 only in 4 cases. CONCLUSIONS: Despite the fact of low PCa detection rate observed in our study, this condition was clinically relevant in 15 (1.5%) subjects. It is difficult to establish any cut off values of pts' age, Pv, serum PSA level suggestive of negligible risk for prostate cancer.