Is further screening of men with baseline PSA < 1 ng ml(-1) worthwhile? The discussion continues-Results of the Swiss ERSPC (Aarau).

Recent studies indicate frequent early PSA retesting unrelated of men's baseline PSA, which increases the harms of early detection especially among men with low PSA. The current study investigates the PCa incidence among men with baseline PSA <1.0 ng ml(-1) in order to adjust retest intervals for more targeted early detection. Between 1998 and 2012, 2,416 men with baseline PSA <1.0 ng ml(-1) were prospectively observed. Primary endpoint was PCa diagnosis. Negative predictive value (NPV) and number needed to screen (NNS) to detect one PCa were calculated. During a median follow-up time of 12.1 years, 54 (2.2%) PCa were diagnosed with n = 26 (48.1%) among men with baseline PSA of 0.75 ≤ 1.0 ng ml(-1) (upper baseline PSA quartile). The 10-year probability of being diagnosed with PCa increased significantly from 0.19% (baseline PSA < 0.40 ng ml(-1) ) to 2.0% (baseline PSA 0.40 ≤ 0.56 ng ml(-1) ), 2.5% (baseline PSA 0.56 ≤ 0.75 ng ml(-1) ) over 4.4% (baseline PSA 0.75 ≤ 1.0 ng ml(-1) ) (all p values <0.0001), respectively. The frequency of Gleason ≥7 PCa increased from 1 (0.17%) to 8 (1.4%), 5 (0.8) over 11 (1.8%) in these groups. The 8-year NPV for Gleason ≥ 7 PCa were 99.8 (baseline PSA < 0.40 ng ml(-1) ), 99.8 (baseline PSA 0.40 ≤ 0.56 ng ml(-1) ), 100 (baseline PSA 0.56 ≤ 0.75 ng ml(-1) ) and 99.5 (baseline PSA 0.75 ≤ 1.0 ng ml(-1) ), respectively. During 12 years, the numbers were 99.8, 98.6, 99.2, and 98.2, respectively. Therefore, due to the very low rate of Gleason ≥ 7 PCa, further screening might be omitted in men with baseline PSA < 0.4 ng ml(-1) . Between 0.4 and 1.0 ng ml(-1) , an 8-year interval can be discussed.

Differences among men on active surveillance for very low-risk prostate cancer detected through population-based versus opportunistic prostate-specific antigen-screening.

INTRODUCTION: Very low-risk prostate cancer (PCa) is being increasingly managed by active surveillance (AS). Our aim was to assess the influence of the origin of diagnosis on PCa characteristics and treatment rates among men with very low-risk PCa in our prospective AS cohort. METHODS: Overall, 191 men with very low-risk PCa fulfilling Epstein-criteria underwent protocol-based AS. These men originated either from the prospective population-based screening program (P-AS) or were diagnosed by opportunistic screening (O-AS). RESULTS: Overall, n = 86 (45.0%) originated from the P-AS group, whereas n = 105 (55.0%) from the O-AS group. On univariate Cox regression analysis, age (HR 0.96, 95% CI 0.92-1.00; p = 0.05), origin of diagnosis (HR 0.72, 95% CI 0.41-1.28; p = 0.001), number of positive cores (HR 2.15, 95% CI 1.18-3.90; p = 0.01) and maximum core involvement (HR 1.03, 95% CI 0.99-1.05; p = 0.05) were predictors for treatment necessity. On multivariate analysis, age (HR 0.95, 95% CI 0.89-0.99; p = 0.05), number of positive cores (HR 2.07, 95% CI 1.10-3.88; p = 0.02), maximum core involvement (HR 1.03, 95% CI 1.00-1.06; p = 0.04) but not origin of diagnosis were independent predictors for treatment necessity. Four men developed biochemical recurrence (all from O-AS group [p = 0.05]). CONCLUSION: The origin of PCa diagnosis in men undergoing AS had no influence on disease progression and treatment necessity.

Influence of metformin use on PSA values, free-to-total PSA, prostate cancer incidence and grade and overall survival in a prospective screening trial (ERSPC Aarau).

PURPOSE: To analyze the effect of the oral antidiabetic drug metformin on PSA level, free-to-total PSA ratio (f/t-ratio), PCa incidence and grade as well as mortality in men participating in a population-based screening trial. METHODS: Data from 4,314 men aged 55-70 years from a population-based PSA-screening trial (ERSPC Aarau) were analyzed. Information on metformin exposure was obtained by a self-administered questionnaire. Serum PSA threshold at ≥3 ng/ml triggered prostate biopsy. Data on PCa incidence and mortality were obtained through registry linkages. RESULTS: Median follow-up time was 7.6 years. Mean age at baseline was 65.5 years (±SD 4.4). In all, n = 150 (3.5 %) men used metformin [metf+]. Mean baseline PSA levels were comparable between both groups ([metf+] 1.6 ng/ml ± 2.4 vs. [metf-] 1.8ug/l ± 2.2, p = 0.4) while f/t-ratio was slightly higher in metformin users ([metf+] 30.7 % ± 10.9 vs. [metf-] 27.3 % ± 10.9, p = 0.01). Overall, n = 372 (8.6 %) PCa cases were detected. Neither cumulative PCa incidence (n = 11; 7.3 % [metf+] vs. n = 361 8.7 % [metf-]; p = 0.5) nor d`Amico risk groups were significantly different between both groups. One man in each group (metf+ 0.7 % and metf- 0.02 %) died from PCa (p < 0.0001), respectively. All-cause mortality was significantly higher among met + compared to met- (adjusted OR 2.50, 95 %CI 1.59-3.82; p = 0.0001). CONCLUSION: No significant differences in PSA levels or PCa incidence and grade were observed. The slightly higher f/t-ratio did not result in lower PCa detection rate. Metformin users were at significantly higher risk of all-cause mortality. The relatively small number of men on metformin is a main limitation of the study.

A "PSA pyramid" for men with initial prostate-specific antigen ≤3 ng/ml: a plea for individualized prostate cancer screening.

BACKGROUND: In daily routine business, various prostate-specific antigen (PSA) retest strategies are being promoted. OBJECTIVE: To investigate rescreening intervals according to baseline PSA <3 ng/ml stratified by any and aggressive prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS: From 1998 to 2012, data from 4350 men aged 55-70 yr were analyzed from a population-based prospective screening study (median follow-up: 11.6 yr). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary end point was detection of aggressive PCa (Gleason score 7-10). Cox regression analysis was used to examine the relationship between covariates. RESULTS AND LIMITATIONS: Baseline PSA of <1.0 ng/ml, 1-1.9 ng/ml, and 2-2.9 ng/ml was present in 2416 men (55.5%: group 1), 1371 men (31.6%: group 2), and 563 men (12.9%: group 3), respectively. Stratified according to these PSA groups, aggressive PCa was detected in 25 patients (1.0%), 80 patients (5.8%), and 34 patients (6.0%), respectively. During 4 yr, these numbers were 0.0%, 0.29%, and 1.8%, whereas during 8 yr, the numbers were 0.2%, 1.4%, and 2.5%, respectively. In multivariable Cox regression analysis, the only independent risk factor for aggressive PCa was baseline PSA (hazard ratio [HR]: 6.06; 95% confidence interval [CI], 3.82-9.61; p<0.0001, group 2 vs group 1; and HR: 7.33; 95% CI, 4.29-12.52; p<0.0001, group 3 vs group 1). CONCLUSIONS: Baseline PSA was the only predictor regarding aggressive PCa. According to the low rate of potentially missed PCa in these groups, rescreening intervals can be safely adapted to baseline PSA values corresponding to a "PSA pyramid": 6-8 yr if baseline PSA is <1.0 ng/ml, 3-4 yr if baseline PSA is 1-1.99 ng/ml, and yearly if baseline PSA is 2-2.99 ng/ml. PATIENT SUMMARY: We observed men with a prostate-specific antigen (PSA) value ≤3 ng/ml during 12 yr and found that men can be retested according to their initial PSA value ("PSA pyramid"): PSA <1 (base), retest interval every 8 yr; PSA 1-2 (center), retest interval every 4 yr; and PSA 2-3 (top), retest yearly after risk stratification.

A prospective trial comparing consecutive series of open retropubic and robot-assisted laparoscopic radical prostatectomy in a centre with a limited caseload.

BACKGROUND: Robot-assisted radical prostatectomy (RALP) is performed worldwide, even in institutions with limited caseloads. However, although the results of large RALP series are available, oncologic and functional outcomes as well as complications from low-caseload centres are lacking. OBJECTIVE: To compare perioperative, oncologic, and functional outcomes from two consecutive series of patients with localised prostate cancer treated by retropubic radical prostatectomy (RRP) or recently established RALP in our hospital, which has a limited caseload. DESIGN, SETTING, AND PARTICIPANTS: One hundred fifty consecutive patients were enrolled. Their data and outcomes were collected and extensively evaluated. INTERVENTION: Seventy-five consecutive patients underwent RRP, and 75 consecutive patients underwent RALP, including all patients of the learning curve. MEASUREMENTS: Patient baseline characteristics, perioperative and postoperative outcomes, and complications were evaluated. End points were oncologic data (positive margins, prostate-specific antigen [PSA]), perioperative complications, urinary continence, and erectile function at 3- and 12-mo follow-up. RESULTS AND LIMITATIONS: The preoperative parameters from the two groups were comparable. The positive surgical margin (PSM) rates were 32% for RRP and 16% for RALP (p=0.002). For RRP and RALP, the PSA value was <0.2 ng/ml in 91% and 88% of patients 3 mo postoperatively (p=0.708) and in 87% and 89% of patients 12 mo postoperatively (p=0.36), respectively. Continence rates for RRP and RALP were 83% and 95% at 3-mo follow-up (p=0.003) and 80% and 89% after 12-mo follow-up (p=0.092), respectively. Among patients who were potent without phosphodiesterase type 5 inhibitors (PDE5-I) before RRP and RALP, recovery of erectile function with and without PDE5-Is was achieved in 25% (12 of 49 patients) and 68% (25 of 37 patients) 3 mo postoperatively (p=0.009) and in 26% (12 of 47 patients) and 55% (12 of 22 patients) 12 mo postoperatively (p=0.009), respectively. Minimal follow-up for RRP was 12 mo; median follow-up for the RALP group was 12 mo (range: 3-12). According to the modified Clavien system, major complication rates for RRP and RALP were 28% and 7% (p=0.025), respectively; minor complication rates were 24% and 35% (p=0.744), respectively. CONCLUSIONS: Despite a limited caseload and including the learning curve, RALP offers slightly better results than RRP in terms of PSM, major complications, urinary continence, and erectile function.

Intra-abdominal fire due to insufflating oxygen instead of carbon dioxide during robot-assisted radical prostatectomy: case report and literature review.

We report the first case of intra-abdominal combustion involving the plastic covering of monopolar scissors secondary to use of incorrect gas (oxygen [O(2)] instead of carbon dioxide [CO(2)]) during robot-assisted laparoscopic radical prostatectomy (RALP). The insufflating system was connected to a provisional O(2) gate into the operating theater. A patient underwent RALP and extended pelvic lymph node dissection for localized prostate cancer, according to standard technique. Approximately 1.5 h after the start of surgery, flames arose from the scissor tips during monopolar coagulation. After extinguishing the fire, we promptly withdrew and changed instruments before recognizing and resolving the cause of the incident. The procedure was carried out without patient injury, and the postoperative period was uneventful.

Life-threatening complication after right renal extracorporeal shock wave lithotripsy: large hepatic haematoma requiring embolisation of the right hepatic artery.

We present the case of a young female patient who developed a large subcapsular hepatic haematoma following extracorporeal shock wave lithotripsy (ESWL) administered to a stone in the right kidney. Severe haemorrhagic shock required a partial coiling embolisation of the right hepatic artery.