Prostate Magnetic Resonance Imaging Research Articles

Prostate MRI versus PSA screening for prostate cancer detection (the MVP Study): a randomised clinical trial

ObjectivesOur objective was to compare prostate cancer detection rates between patients undergoing serum prostate-specific antigen (PSA) vs magnetic resonance imaging (MRI) for prostate cancer screening.DesignPhase III open-label randomised controlled trial.SettingSingle...

Improving turnaround times and quality of prostate MR imaging across Northern Care Alliance NHS Foundation Trust

Improving turnaround times and quality of prostate MR imaging across Northern Care Alliance NHS Foundation Trust

Prostate Magnetic Resonance Imaging Delta-Radiomics during Image-Guided Conventional Fractionation and Stereotactic Ablative Radiotherapy

<h3>Purpose/Objective(s)</h3> The ability to detect changes during radiotherapy to the prostate with radiomics techniques may allow prediction of clinical outcomes and influence subsequent treatment choices. In this feasibility study, we aimed to assess changes in features (delta-radiomics) across a course of treatment in men undergoing MRI-guided radiotherapy for prostate cancer. We compared changes between conventional fractionation and ultrahypofractionated SABR treatment. <h3>Materials/Methods</h3> MRI images from men receiving radiotherapy only to the prostate on an MR Linac developed by a precision radiation medicine company in a large tertiary cancer center were analyzed. Treatment localization scans were transferred from one treatment planning system, (from a precision radiation medicine company, Crawley UK) to a different treatment planning system. The whole prostate was re-contoured from T2 sequences obtained at fraction 1 and at 4 evenly spread time points. For SABR this was at fractions 2 to 5 and for conventional fractionation at fraction 5, 10, 15 and 20 respectively. Radiomics data was extracted with an open-source software platform. Data for energy, entropy, kurtosis and shape parameters were analyzed using a linear mixed-effects model to explore changes over time within a patient (within subject variability) as well as between subject variability between men treated with conventional fractionation v SABR. <h3>Results</h3> 40 men were analyzed, 20 receiving conventional fractionation (60Gy in 20 fractions over four weeks) and 20 receiving SABR (36.25Gy in 5 fractions over two weeks) respectively. Mean age was 69.3years (range 53-82) and mean PSA at diagnosis 9.37 (range 2.18 – 32). Gleason score was 6 in 1 patient, 7 in 38 patients and 8 in 1 patient. Five men did not receive any androgen deprivation therapy prior to radiotherapy (3 patients receiving conventional fractionation, 2 receiving SABR). The only radiomics variable that showed a time-trend was first order entropy in the conventional fractionation group, not in the SABR group (p<0.001). Treatment type was not a significant covariate for any of the other metrics. I.e., in long fractionation a reduction in entropy is observed during treatment, showing the prostate gray values become more homogeneous over time. <h3>Conclusion</h3> Our analyses showed a reduction in entropy for conventional fractionation rather than ultrahypofractionated SABR suggesting that image changes only become apparent over longer treatment courses. During SABR, no radiomics features showed a significant trend. These may still develop on later imaging as changes in cell appearance from DNA damage may only be apparent over time. Further analyses are planned to explore the relationship between delta radiomics and clinical outcomes and whether entropy can be used as an imaging biomarker.

Prostate-specific Antigen Density Cutoff of 0.15 ng/ml/cc to Propose Prostate Biopsies to Patients with Negative Magnetic Resonance Imaging: Efficient Threshold or Legacy of the Past?

BackgroundA prostate-specific antigen density (PSAd) cutoff of 0.15 ng/ml/cc is a commonly recommended threshold to identify patients with negative prostate magnetic resonance imaging (MRI) who should proceed to a prostate biopsy. We were unable to find any study that explicitly examined the properties of this threshold compared with others. ObjectiveTo investigate whether the 0.15 cutoff is justified for selecting patients at risk of harboring high-grade cancer (Gleason score ≥3 + 4) despite negative MRI. Design, setting, and participantsA cohort of 8974 prostate biopsies provided by the Prostate Biopsy Collaborative Group (PBCG) was included in the study. Outcome measurements and statistical analysisLocally weighted scatterplot smoothing was used to investigate whether there was a change in the risk of high-grade cancer around this value. We examined whether the use of this cutoff in patients with negative MRI corresponds to a reasonable threshold probability for a biopsy (defined as a 10% risk of high-grade disease). To do so, we applied the negative likelihood ratio of MRI, calculated from eight studies on prostate MRI, to the risk curve derived from the PBCG. Results and limitationsThere was no discontinuity in the risk of high-grade prostate cancer at a PSAd cutoff of 0.15. This cutoff corresponded to a probability of high-grade disease ranging from 2.6% to 10%, depending on MRI accuracy. Using 10% as threshold probability, the corresponding PSAd cutoff varied between 0.15 and 0.38, with the threshold increasing for greater MRI accuracy. Possible limitations include difference between studies on MRI and the use of ultrasound to measure prostate volume. ConclusionsThe 0.15 cutoff to recommend prostate biopsies in patients with negative MRI is justified only under an extreme scenario of poor MRI properties. We recommend a value of at least ≥0.20. Our results suggest the need for future studies to look at how to best identify patients who need prostate biopsies despite negative MRI, likely by using individualized risk prediction. Patient summaryIn this study, we investigated whether the commonly used prostate-specific antigen density cutoff of 0.15 is justified to identify patients with negative magnetic resonance imaging (MRI) who should proceed to a prostate biopsy. We found that this cutoff is appropriate only in case of very poor MRI quality, and a higher cutoff (≥0.20) should be used for the average MRI.

Optimized biparametric magnetic resonance imaging protocol for prostate cancer detection

BACKGROUND: Prostate cancer is one of the most commonly diagnosed cancers in men worldwide. PI-RADS v2.1 contains the requirements for the magnetic resonance imaging protocol, which cannot be fully implemented on a significant component of functioning scanners. Consequently, magnetic resonance imaging approaches vary in different medical organizations and often do not allow for a qualitative interpretation of images and diagnosis of the target pathology.&#x0D; AIM: To develop a biparametric magnetic resonance imaging protocol optimized for the existing magnetic resonance imaging scanners for the diagnosis of prostate cancer and to allow the screening and detection of neoplasms as early as possible. Simultaneously, the protocol should fulfill the current PI-RADS v2.1 recommendations to the maximum possible extent and meet the requirements of effective workflow in the radiology department.&#x0D; MATERIALS AND METHODS: Preliminary analysis of prostate magnetic resonance imaging scanning in medical organizations of the Moscow Health Care Department showed the absence of a unified approach. Using the iterative adjustment of scanning parameters, we adjusted the protocol to ensure acceptable quality with maximum available compliance with PI-RADS v2.1.&#x0D; To quantify the quality of the images, we used the magnetic resonance imaging phantom recommended by the American College of Radiology.&#x0D; RESULTS: The biparametric protocol was developed for Excelart Vantage 1.5 T, including T2-weighted images in three planes and diffusion-weighted images, which took less than 11 min. Moreover, the image quality parameters (intensity inhomogeneity, nonlinearity, resolution, and slice thickness) were within the acceptable ranges recommended by the magnetic resonance imaging manufacturer.&#x0D; CONCLUSION: The prostate may be effectively evaluated using the proposed magnetic resonance imaging protocol. Introducing it into practice could have a significant impact on the detection of prostate cancer in men. The entire duration of the protocol provides a possibility to supplement it with any sequences, depending on the final purpose of investigation.

Correlation Between Prostate-Specific Antigen Density and Findings from Multiparametric Magnetic Resonance Imaging of Prostate

Correlation Between Prostate-Specific Antigen Density and Findings from Multiparametric Magnetic Resonance Imaging of Prostate

Incidental findings on prostate MRI: a close look at the field of view in this anatomical region.

Magnetic resonance imaging (MRI) has been widely used as an advanced imaging modality to detect prostate cancer and indicate suspicious areas to guide biopsy procedures. The increasing number of prostate examinations with MRI has provided an opportunity to detect incidental lesions, and some might be very significant to elucidate patient symptoms or occult neoplastic process in the early stages. These incidental lesions might be located in the prostate gland, adjacent tissues, or organs around the prostate gland or out of the genitourinary system. The field of view of prostate MRI includes not only the prostate gland but also other critical pelvic organs in this specific anatomical region. Some of these incidental lesions might cause the same symptoms as prostate cancer and might explain the symptoms of the patient, and some might indicate early cancer stages located outside the prostate. Reporting these lesions might be life-saving by initiating early disease treatment. Awareness of the predicted locations of congenital anomalies would also be beneficial for the radiologists to mention these incidental findings.

Fully automated detection and localization of clinically significant prostate cancer on MR images using a cascaded convolutional neural network.

PurposeTo develop a cascaded deep learning model trained with apparent diffusion coefficient (ADC) and T2-weighted imaging (T2WI) for fully automated detection and localization of clinically significant prostate cancer (csPCa).MethodsThis retrospective study included 347 consecutive patients (235 csPCa, 112 non-csPCa) with high-quality prostate MRI data, which were randomly selected for training, validation, and testing. The ground truth was obtained using manual csPCa lesion segmentation, according to pathological results. The proposed cascaded model based on Res-UNet takes prostate MR images (T2WI+ADC or only ADC) as inputs and automatically segments the whole prostate gland, the anatomic zones, and the csPCa region step by step. The performance of the models was evaluated and compared with PI-RADS (version 2.1) assessment using sensitivity, specificity, accuracy, and Dice similarity coefficient (DSC) in the held-out test set.ResultsIn the test set, the per-lesion sensitivity of the biparametric (ADC + T2WI) model, ADC model, and PI-RADS assessment were 95.5% (84/88), 94.3% (83/88), and 94.3% (83/88) respectively (all p > 0.05). Additionally, the mean DSC based on the csPCa lesions were 0.64 ± 0.24 and 0.66 ± 0.23 for the biparametric model and ADC model, respectively. The sensitivity, specificity, and accuracy of the biparametric model were 95.6% (108/113), 91.5% (665/727), and 92.0% (773/840) based on sextant, and were 98.6% (68/69), 64.8% (46/71), and 81.4% (114/140) based on patients. The biparametric model had a similar performance to PI-RADS assessment (p > 0.05) and had higher specificity than the ADC model (86.8% [631/727], p< 0.001) based on sextant.ConclusionThe cascaded deep learning model trained with ADC and T2WI achieves good performance for automated csPCa detection and localization.

Combined MRI and PSA Strategy Improves Biopsy Decisions Compared with PSA Only: Longitudinal Observations of a Cohort of Patients with a PSA Level Less Than 20 ng/mL

To assess the diagnostic performances of prostate specific antigen (PSA) and PSA with prostate magnetic resonance imaging (MRI) to predict prostate cancer in patients with PSA ≤ 20 ng/mL. Patients suspected of prostate cancer with a PSA test and prebiopsy MRI were included (n=881). Prostate biopsy results or follow-up clinical data for 2 years were used to determine the presence of prostate cancer. The diagnostic performance of PSA, MRI, and PSA with MRI (referred to as the protocol) was evaluated. The positive predictive value (PPV) and negative predictive value (NPV) of the MRI were calculated in subgroups of patients with specific ranges of PSA level. Prostate cancer and CSC were diagnosed in 220 and 162 patients, respectively. Adding MRI to PSA could greatly improve specificity and PPV (0.833 and 0.567) for detecting CSC, compared to PSA ≥ 4 ng/mL alone (0.248 and 0.0219). Even though the sensitivity of the protocol (0.679) was lower than PSA (0.938), the NPV of the protocol was comparable to PSA (0.929 vs. 0.924). The protocol consistently showed the superior PPV and NVP to PSA only in not only patients within the gray zone of PSA, but also in patients with higher PSA. In conclusion, this longitudinal observational study confirmed that adding prebiopsy MRI to PSA was consistently beneficial in patients with PSA ≤ 20 ng/mL for avoiding unnecessary biopsy despite decrease in the sensitivity.

Therapy decisions after diagnosis of prostate cancer in men with negative prostate MRI.

To investigate the clinical implications of magnetic resonance imaging(MRI) negative prostate cancer (PCa) in a cohort of men undergoing transperineal prostate biopsy. We included all men without prior diagnosis of PCa undergoing transperineal template saturation ± fusion-guided targeted biopsy of the prostate between November 2014and March 2018. Before biopsy, all patients underwent MRI and biopsies were performed irrespective of imaging results. Baseline characteristics, imaging, biopsy results, and follow-up information were retrieved from the patient charts. Patients were classified as either MRI negative (Prostate Imaging Reporting and Data System[PIRADS] ≤ 2) or positive (PIRADS ≥ 3). ISUP grade group 1 was defined as clinically nonsignificant (nsPCa) and ≥2 as clinically significant PCa (csPCa). Primary outcome was the individual therapeutic decision after diagnosis of PCa stratified according to MRI visibility. Secondary outcomes were the sensitivity and specificity of MRI, and the urooncological outcomes after radical prostatectomy (RP). From 515 patients undergoing prostate biopsy, 171 (33.2%) patients had a negative and 344 (66.8%) a positive MRI. Pathology review stratified for MRI negative and positive cases revealed nsPCa in 27 (15.8%) and 32 (9.3%) and csPCa in 26 (15.2%) and 194 (56.4%) of the patients, respectively. The rate of active treatment in the MRI negative was lower compared with the MRI positive cohort (12.3% vs. 53.2%; odd ratio [OR] = 0.12; p < 0.001). While men with negative MRI were more likely to undergo active surveillance (AS) than MRI positive patients (18.1% vs. 10.8%; OR = 1.84; p = 0.027), they rarely underwent RP (6.4% vs. 40.7%, OR = 0.10; p < 0.001). Logistic regression revealed that a negative MRI was independently protective for active treatment (OR = 0.32, p = 0.014). The specificity, sensitivity, negative, and positive predictive value of MRI for detection of csPCa were 49.2%, 88.2%, 56.4%, and 84.8%, respectively. The rate of adverse clinicopathological outcome features (pT3/4, ISUP ≥4, or prostate-specific antigen[PSA]-persistence) following RP was 4.7% for men with MRI negative compared to 17.4% for men with MRI positive PCa (OR = 3.1, p = 0.19). Only few men with MRI negative PCa need active cancer treatment at the time of diagnosis, while the majority opts for AS. Omitting prostate biopsies and performing a follow-up MRI may be a safe alternative to reduce the number of unnecessary interventions.

Holmium laser enucleation of the prostate in men on active surveillance for prostate cancer with refractory lower urinary tract symptoms secondary to enlarged prostates.

The surgical treatment of men with lower urinary tract symptoms (LUTS) and significantly enlarged symptomatic prostates on active surveillance (AS) for low-risk prostate cancer (PCa) is not well defined. We report our single-institution initial experience with holmium laser enucleation of the prostate (HoLEP) for LUTS in men with low-risk PCa being managed with AS. Men on AS who underwent HoLEP between 2013 and 2019 were identified. Data regarding preoperative cancer workup, prostate-specific antigen (PSA), perioperative outcomes, and voiding parameters were analyzed. Postoperative surveillance for PCa including PSA nadir, prostate magnetic resonance imaging, prostate biopsy (PBx), and PSA at last follow-up were evaluated. Twenty men met the inclusion criteria. Preoperative mean max flow 7.9 ml/s, median postvoid residual 101 cc, and mean transrectal ultrasound prostate size 99 cc. Patients had a median adjusted preoperative PSA of 8.5 (interquartile range[IQR]: 4.8-13.2) ng/ml. Mean resected tissue weight was 65.5 gwith improved postoperative flow rate and significantly decreased residual. A total of 5/20 men had PCa in the specimen (all GleasonGrade Group 1).The median postoperative PSA nadir was 1.2 (IQR: 0.5-1.8) ng/ml at median of 5 months. At the last follow-up (median 18.5 months, IQR: 10.5-37.8), the median postoperative PSA was 1.4 (IQR: 0.63-2.48) ng/ml. Nine men underwent postoperative multiparametric magnetic resonance imaging(mpMRI) with the identification of a new prostate imaging reporting and data system 5 lesion in onepatient who underwent negative fusion biopsy. Five men underwent post-HoLEP PBx with progression in two patients, who both successfully underwent radical prostatectomy. Men on AS for low-risk PCa can safely undergo HoLEP with significantly improved voiding parameters. Postoperative monitoring with PSA, mpMRI, and PBx can detect disease progression requiring definitive treatment. Further research is needed to optimize surveillance strategies and long-term cancer-specific outcomes.

Variability in contrast and apparent diffusion coefficient of kiwifruit used as prostate MRI phantom: 1-week validation.

Kiwifruit has been proposed as a phantom for prostate magnetic resonance imaging (MRI) to adjust multiparametric MRI factors. This study evaluated the variability in contrasts and apparent diffusion coefficients (ADCs) via repeated scans of kiwifruits for 1 week. All scans were performed using a 3T MRI system. Six kiwifruits were prepared as phantoms. Each kiwifruit was scanned consecutively for 1 week, and T2-weighted and diffusion-weighted images were acquired. Contrasts between the peripheral placenta (PP) and central placenta (CP), and between the outer pericarp (OP) and CP were calculated. The ADCs of the PP, OP, and CP were also determined. The Friedman test with Scheffé's post hoc comparison was used to assess contrast and ADC variability over 1 week; no significant differences between the contrasts or ADCs were found. Thus, each kiwifruit phantom exhibited low variability when used as a prostate MRI phantom.

Histopathological Correlation of Current Prostate Imaging Reporting and Data System Scores with 3 Tesla Multiparametric Prostate Magnetic Resonance Imaging in Detecting Prostate Cancer

Histopathological Correlation of Current Prostate Imaging Reporting and Data System Scores with 3 Tesla Multiparametric Prostate Magnetic Resonance Imaging in Detecting Prostate Cancer

T2 Turbo Spin Echo With Compressed Sensing and Propeller Acquisition (Sampling k-Space by Utilizing Rotating Blades) for Fast and Motion Robust Prostate MRI: Comparison With Conventional Acquisition.

The aim of this study was to compare a new compressed sensing (CS) method for T2-weighted propeller acquisitions (T2 CS ) with conventional T2-weighted propeller sequences (T2 conv ) in terms of achieving a higher image quality, while reducing the acquisition time. Male participants with a clinical suspicion of prostate cancer were prospectively enrolled and underwent prostate magnetic resonance imaging at 3 T. Axial and sagittal images of the T2 conv sequence and the T2 CS sequence were acquired. Sequences were qualitatively assessed by 2 blinded radiologists concerning artifacts, image-sharpness, lesion conspicuity, capsule delineation, and overall image quality using 5-point Likert items ranging from 1 (nondiagnostic) to 5 (excellent). The apparent signal-to-noise ratio and apparent contrast-to-noise ratio were evaluated. PI-RADS scores were assessed for both sequences. Statistical analysis was performed by using Wilcoxon signed rank test and paired samples t test. Intrarater and interrater reliability of qualitative image evaluation was assessed using intraclass correlation coefficient (ICC) estimates. A total of 29 male participants were included (mean age, 66 ± 8 years). The acquisition time of the T2 CS sequence was respectively 26% (axial plane) and 24% (sagittal plane) shorter compared with the T2 conv sequence (eg, axial: 171 vs 232 seconds; P < 0.001). In the axial plane, the T2 CS sequence had fewer artifacts (4 [4-4.5] vs 4 [3-4]; P < 0.001), better image-sharpness (4 [4-4.5] vs 3 [3-3.5]; P < 0.001), better capsule delineation (4 [3-4] vs 3 [3-3.5]; P < 0.001), and better overall image quality (4 [4-4] vs 4 [3-4]; P < 0.001) compared with the T2 conv sequence. The ratings of lesion conspicuity were similar (4 [4-4] vs 4 [3-4]; P = 0.166). In the sagittal plane, the T2 CS sequence outperformed the T2 conv sequence in the categories artifacts (4 [4-4] vs 3 [3-4]; P < 0.001), image sharpness (4 [4-5] vs 4 [3-4]; P < 0.001), lesion conspicuity (4 [4-4] vs 4 [3-4]; P = 0.002), and overall image quality (4 [4-4] vs 4 [3-4]; P = 0.002). Capsule delineation was similar between both sequences (3 [3-4] vs 3 [3-3]; P = 0.07). Intraobserver and interobserver reliability for qualitative scoring were good (ICC intra: 0.92; ICC inter: 0.86). Quantitative analysis revealed a higher apparent signal-to-noise ratio (eg, axial: 52.2 ± 9.7 vs 22.8 ± 3.6; P < 0.001) and a higher apparent contrast-to-noise ratio (eg, axial: 44.0 ± 9.6 vs 18.6 ± 3.7; P ≤ 0.001) of the T2 CS sequence. PI-RADS scores were the same for both sequences in all participants. CS-accelerated T2-weighted propeller acquisition had a superior image quality compared with conventional T2-weighted propeller sequences while significantly reducing the acquisition time.

Augmenting prostate magnetic resonance imaging reporting to incorporate diagnostic recommendations based upon clinical risk calculators.

Risk calculators have offered a viable tool for clinicians to stratify patients at risk of prostate cancer (PCa) and to mitigate the low sensitivity and specificity of screening prostate specific antigen (PSA). While initially based on clinical and demographic data, incorporation of multiparametric magnetic resonance imaging (MRI) and the validated prostate imaging reporting and data system suspicion scoring system has standardized and improved risk stratification beyond the use of PSA and patient parameters alone. Biopsy-naïve patients with lower risk profiles for harboring clinically significant PCa are often subjected to uncomfortable, invasive, and potentially unnecessary prostate biopsy procedures. Incorporating risk calculator data into prostate MRI reports can broaden the role of radiologists, improve communication with clinicians primarily managing these patients, and help guide clinical care in directing the screening, detection, and risk stratification of PCa.

Preoperative Multiparametric Prostate Magnetic Resonance Imaging Structured Report Informs Risk for Positive Apical Surgical Margins During Radical Prostatectomy.

The prostatic apex is the most frequent location of positive surgical margin (PSM) after surgery. Data regarding the ability of multiparametric magnetic resonance imaging (mpMRI) to prospectively identify men at risk for apical PSMs (aPSMs) using a structured report are lacking. The aims of the study are to determine and to compare the rate of aPSM in men with versus without prospectively flagged at-risk prostate lesions during clinical mpMRI interpretation using whole-mount histopathology as the reference standard. This single-center, retrospective study of prospectively collected data included treatment-naive men with abnormal 3T mpMRI (PI-RADS v2 score ≥3) between January 2016 and December 2018 followed by surgery. During routine clinical interpretation, radiologists flagged prostate lesions abutting the apical most gland and/or encircling the distal most prostatic urethra using standardized language available as a "pick list" option in the structured report. Logistic regression was used to compare the rate of PSM in 2 groups (flagged vs nonflagged men). Propensity score covariate adjustment corrected for potential selection bias according to age, prostate-specific antigen (PSA), PSA density, grade group, and pT stage. The estimate was further adjusted by including surgeon as a covariate. A total of 428 men were included. A statistically significant higher proportion of aPSMs was noted in flagged (56% [51/91]) compared with nonflagged apical lesions (31% [105/337]; adjusted odds ratio, 2.5; 95% confidence interval, 1.6-4.1; P < 0.01). The difference in aPSM between both groups also varied according to the surgeon performing the RP. Prostate-specific antigen, PSA density, lesion size, apical location, Prostate Imaging Reporting & Data System score, grade group, pT stage, and surgeon's experience were associated with higher PSM rate. Biochemical recurrence, defined as PSA greater than 0.2 ng/mL on 2 measurements after RP, was significantly associated with PSM status (propensity score adjusted odds ratio, 3.1; 95% confidence interval, 1.8-5.3; P < 0.0001); however, patients flagged by radiologists did not have a significant difference in biochemical recurrence rates as compared with nonflagged patients ( P = 0.11). Standard language built into structured reports for mpMRI of the prostate helps identify preoperatively patients at risk for aPSM. Multiparametric MRI is able to identify patients at increased risk for aPSM, and this information can be conveyed in a structured report to urologists, facilitating patient counseling and treatment decisions.

Performance of multiparametric prostate magnetic resonance imaging validated by targeted and systematic transperineal biopsies.

To measure the performance of multiparametric (mp) magnetic resonance imaging (MRI) to identify intraprostatic tumour deposits using a systematic and targeted MR-guided transperineal prostate biopsy technique. Patients underwent a combined systematic and targeted MR-guided transperineal biopsy procedure in the dorsal lithotomy position under general anaesthesia. Systematic biopsies were spaced 10 mm or less apart and additional biopsies targeted any Prostate Imaging-Reporting and Data System (PI-RADS) 3, 4 or 5 lesions identified on mpMRI. Cancer detection rates were calculated on a per patient and per lesion basis. A total of 125 patients underwent the biopsy procedure. The positive predictive value (PPV) of mpMRI per patient was 59% for any cancer and 49% for Gleason score (GS) ≥ 7 cancer. The negative predictive value (NPV) of mpMRI per patient was 67% for any cancer and 88% for GS ≥ 7 cancer. On a per lesion basis, the PPV of PI-RADS 3 lesions for any and GS ≥ 7 cancer was 24% and 10%. For PI-RADS 4 lesions it was 42% and 32%. For PI-RADS 5 lesions, it was 76% and 70%. MpMRI failed to identify GS ≥ 7 cancer found on systematic biopsy in 22% of patients. Based on a combination of systematic and targeted transperineal prostate biopsies, mpMRI showed a high NPV and low PPV for GS ≥ 7 cancer on a per patient basis. The PPV of mpMRI on a per lesion basis increased with increasing PI-RADS score. However, there were a significant number of both false positive as well as false negative (mpMRI invisible) areas within the prostate that contained GS ≥ 7 cancer. Therefore, pathologic confirmation using both targeted and systematic mapping biopsy is necessary to accurately identify all intraprostatic tumour deposits.

Prostate Cancer Detection Percentages of Repeat Biopsy in Patients with Positive Multiparametric Magnetic Resonance Imaging (Prostate Imaging Reporting and Data System/Likert 3–5) and Negative Initial Biopsy. A Mini Systematic Review

Multiparametric magnetic resonance imaging (mpMRI) has high sensitivity but low specificity for prostate cancer (PCa) diagnosis. The aim of our systematic review was to investigate the proportion of PCa found at a repeat biopsy in patients with a negative initial prostate biopsy, despite initial positive mpMRI. Included patients had a Prostate Imaging Reporting and Data System (PI-RADS)/Likert 3–5 lesion on mpMRI prior to the initial mpMRI-targeted prostate biopsy, which was negative for PCa on histology. The main outcomes were the overall and clinically significant PCa (csPCa; International Society of Urological Pathology >1 or any provided definition) percentages at a repeat biopsy. Out of 1179 articles identified, nine studies were included (a total of 485 patients). For patients with PI-RADS 3 lesions, overall and csPCa detection percentages ranged from 0% to 80% and from 0% to 20%, respectively, while for patients with PI-RADS ≥4 lesions, the corresponding percentages were 15.4–86% and 7.7–57%. An overall cancer detection percentage of 87.5% was reported in patients with Likert 5 lesions. Limitation of our review is the small number of studies and the protocol revision that allowed studies with <50 patients. In patients with a positive MRI result and a negative initial MRI-targeted biopsy, we suggest MRI re-reading and follow-up with repeat mpMRI or the standard repeat biopsy in cases at the highest risk. Patient summaryLiterature has shown that in men with an abnormal prostate magnetic resonance imaging (MRI) scan but a normal biopsy, a significant prostate cancer can be present. MRI scans should be double checked, followed by standard checkups or repeat prostate biopsy, especially in highly suspicious cases.

Risk of prostate cancer and death after benign transurethral resection of the prostate-A 20-year population-based analysis.

The oncological risks after benign histology on a transurethral resection of the prostate (TURP) remain largely unknown. Here, the risk of prostate cancer incidence and mortality following a benign histological assessment of TURP is investigated in a population-based setting. Between 1995 and 2016, 64,059 men in Denmark underwent TURP without prior biopsy of the prostate; 42,558 of these men had benign histology. The risks of prostate cancer, prostate cancer with a Gleason score ≥ 3 + 4, and prostate cancer-specific death were assessed with competing risks. Specific risks for pre-TURP prostate-specific antigen (PSA) levels at 10 and 15 years were visualized by locally estimated scatterplot smoothing. The median age at TURP was 72 years (interquartile range [IQR], 65-78 years), and the median follow-up was 15 years (IQR, 10-19 years). The 10-year risks of any prostate cancer and prostate cancer with a Gleason score ≥ 3 + 4 and the 15-year risk of prostate cancer death showed clear visual relations with increasing PSA. The 15-year cumulative incidence of prostate cancer-specific death after benign TURP was 1.4% (95% confidence interval [CI], 1.3%-1.6%) for all men and 0.8% (95% CI, 0.6%-1.1%) for men with PSA levels <10 ng/ml. The primary limitation was exclusion due to missing PSA data. Men with low PSA levels and a benign TURP can be reassured about their cancer risk and do not need to be monitored differently than any other men. Patients with high PSA levels can be considered for further follow-up with prostate magnetic resonance imaging. These findings add to the literature suggesting that normal histology from the prostate entails a low risk of death from the disease. There is little knowledge about the oncological risks after the surgical treatment of benign prostatic hyperplasia. This study shows a very low risk of adverse oncological outcomes in men with prostate-specific antigen (PSA) levels below 10 ng/ml at the time of transurethral resection of the prostate. Patients with higher PSA levels may need more extensive follow-up.

Single-port Robotic Transvesical Partial Prostatectomy for Localized Prostate Cancer: Initial Series and Description of Technique

BackgroundPartial prostatectomy has been described as an alternative to focal therapy for the management of localized low- and intermediate-risk prostate cancer. ObjectiveTo describe early outcomes and technique for single-port (SP) transvesical partial prostatectomy. Design, setting, and participantsA retrospective analysis was performed for nine patients with low-volume, localized, low- to intermediate-risk prostate cancer (Gleason ≤7) undergoing SP transvesical partial prostatectomy replicating the inclusion criteria for focal therapy by a single surgeon from November 2020 to March 2022. Surgical procedureThe daVinci SP access port was inserted percutaneously into the bladder and pnuemovesicum was achieved. The camera, robotic instruments, assistant port, and flexible suction tubing were introduced through the access port. The Koelis transrectal ultrasound with preoperative prostate magnetic resonance imaging fusion was used for intraoperative guidance. MeasurementsDemographic information, intraoperative variables, and postoperative outcomes were collected in an institutional review board–approved database, and a descriptive statistical analysis was performed. Results and limitationsAll cases were completed without requiring extra ports or conversion. No intraoperative complications were noted, and all patients were discharged on the day of surgery. Pathology showed Gleason scores of 3 + 3 = 6 in one case, 3 + 4 = 7 in seven cases, and 4 + 3 = 7 in one case, all with negative intraoperative margin assessment. At 6 wk, the median prostate-specific antigen was 0.5 and the median Sexual Health Inventory for Men score was 17.5 from 23 preoperatively. All patients were continent at 6 wk. The limitations include a small number of patients, short follow-up, and single-surgeon experience. ConclusionsWe demonstrated the feasibility of the SP robotic transvesical partial prostatectomy. Early functional outcomes show impressive time to continence and erectile function. Continued follow-up will evaluate long-term oncologic outcomes. Patient summaryWe performed partial prostatectomies in selected patients as an alternative to focal therapy using a novel transvesical single-port approach. Our approach was safe and feasible, with fewer complications and promising initial return to continence and erectile function.