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Light A, Lazic S, Houghton K, Bayne M, Connor MJ, Tam H, Ahmed HU, Shah TT, Barwick TD. Diagnostic Performance of 68Ga-PSMA-11 PET/CT Versus Multiparametric MRI for Detection of Intraprostatic Radiorecurrent Prostate Cancer. J Nucl Med 2024; 65:379-385. [PMID: 38212074 DOI: 10.2967/jnumed.123.266527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/04/2023] [Accepted: 10/04/2023] [Indexed: 01/13/2024] Open
Abstract
For men with prostate cancer who develop biochemical failure after radiotherapy, European guidelines recommend reimaging with 68Ga-PSMA-11 PET/CT and multiparametric MRI (mpMRI). However, the accuracy of 68Ga-PSMA-11 PET/CT for detecting intraprostatic recurrences is unclear, both with and without mpMRI. Methods: A single-center retrospective study of a series of patients investigated for radiorecurrence between 2016 and 2022 is described. All patients underwent 68Ga-PSMA-11 PET/CT, mpMRI, and prostate biopsy. PET/CT images were interpreted independently by 2 expert readers masked to other imaging and clinical data. The primary outcome was the diagnostic accuracy of PET/CT versus mpMRI and of PET/CT with mpMRI together versus mpMRI alone. The secondary outcome was the proportion of cancers missed by mpMRI but detected by PET/CT. Diagnostic accuracy analysis was performed at the prostate hemigland level using cluster bootstrapping. Results: Thirty-five men (70 hemiglands) were included. Cancer was confirmed by biopsy in 43 of 70 hemiglands (61%). PET/CT sensitivity and negative predictive values (NPVs) were 0.89 (95% CI, 0.78-0.98) and 0.79 (95% CI, 0.62-0.95), respectively, which were not significantly different from results by MRI (sensitivity of 0.72; 95% CI, 0.61-0.83; P = 0.1) (NPV of 0.59; 95% CI, 0.41-0.75; P = 0.07). Specificity and positive predictive values were not significantly different. When PET/CT and MRI were used together, the sensitivity was 0.98 (95% CI, 0.92-1.00) and NPV was 0.93 (95% CI, 0.75-1.00), both significantly higher than MRI alone (P = 0.003 and P < 0.001, respectively). Specificity and positive predictive values remained not significantly different. MRI missed 12 of 43 cancers (28%; 95% CI, 17%-43%), of which 11 of 12 (92%; 95% CI, 62%-100%) were detected by PET/CT. Conclusion: For detecting intraprostatic radiorecurrence, 68Ga-PSMA-11 PET/CT has high sensitivity that is not significantly different from mpMRI. When 68Ga-PSMA-11 PET/CT and mpMRI were used together, the results conferred a significantly greater sensitivity and NPV than with mpMRI alone. 68Ga-PSMA-11 PET/CT may therefore be a useful tool in the diagnosis of localized radiorecurrence.
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Affiliation(s)
- Alexander Light
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Stefan Lazic
- Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; and
| | - Kate Houghton
- Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; and
| | - Max Bayne
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Martin J Connor
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Henry Tam
- Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; and
| | - Hashim U Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Taimur T Shah
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Tara D Barwick
- Department of Imaging, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; and
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Light A, Kanthabalan A, Otieno M, Pavlou M, Omar R, Adeleke S, Giganti F, Brew-Graves C, Williams NR, Emara A, Haroon A, Latifoltojar A, Sidhu H, Freeman A, Orczyk C, Nikapota A, Dudderidge T, Hindley RG, Virdi J, Arya M, Payne H, Mitra AV, Bomanji J, Winkler M, Horan G, Moore CM, Emberton M, Punwani S, Ahmed HU, Shah TT. The Role of Multiparametric MRI and MRI-targeted Biopsy in the Diagnosis of Radiorecurrent Prostate Cancer: An Analysis from the FORECAST Trial. Eur Urol 2024; 85:35-46. [PMID: 37778954 DOI: 10.1016/j.eururo.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 08/01/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The role of multiparametric magnetic resonance imaging (MRI) for detecting recurrent prostate cancer after radiotherapy is unclear. OBJECTIVE To evaluate MRI and MRI-targeted biopsies for detecting intraprostatic cancer recurrence and planning for salvage focal ablation. DESIGN, SETTING, AND PARTICIPANTS FOcal RECurrent Assessment and Salvage Treatment (FORECAST; NCT01883128) was a prospective cohort diagnostic study that recruited 181 patients with suspected radiorecurrence at six UK centres (2014 to 2018); 144 were included here. INTERVENTION All patients underwent MRI with 5 mm transperineal template mapping biopsies; 84 had additional MRI-targeted biopsies. MRI scans with Likert scores of 3 to 5 were deemed suspicious. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS First, the diagnostic accuracy of MRI was calculated. Second, the pathological characteristics of MRI-detected and MRI-undetected tumours were compared using the Wilcoxon rank sum test and chi-square test for trend. Third, four biopsy strategies involving an MRI-targeted biopsy alone and with systematic biopsies of one to two other quadrants were studied. Fisher's exact test was used to compare MRI-targeted biopsy alone with the best other strategy for the number of patients with missed cancer and the number of patients with cancer harbouring additional tumours in unsampled quadrants. Analyses focused primarily on detecting cancer of any grade or length. Last, eligibility for focal therapy was evaluated for men with localised (≤T3bN0M0) radiorecurrent disease. RESULTS AND LIMITATIONS Of 144 patients, 111 (77%) had cancer detected on biopsy. MRI sensitivity and specificity at the patient level were 0.95 (95% confidence interval [CI] 0.92 to 0.99) and 0.21 (95% CI 0.07 to 0.35), respectively. At the prostate quadrant level, 258/576 (45%) quadrants had cancer detected on biopsy. Sensitivity and specificity were 0.66 (95% CI 0.59 to 0.73) and 0.54 (95% CI 0.46 to 0.62), respectively. At the quadrant level, compared with MRI-undetected tumours, MRI-detected tumours had longer maximum cancer core length (median difference 3 mm [7 vs 4 mm]; 95% CI 1 to 4 mm, p < 0.001) and a higher grade group (p = 0.002). Of the 84 men who also underwent an MRI-targeted biopsy, 73 (87%) had recurrent cancer diagnosed. Performing an MRI-targeted biopsy alone missed cancer in 5/73 patients (7%; 95% CI 3 to 15%); with additional systematic sampling of the other ipsilateral and contralateral posterior quadrants (strategy 4), 2/73 patients (3%; 95% CI 0 to 10%) would have had cancer missed (difference 4%; 95% CI -3 to 11%, p = 0.4). If an MRI-targeted biopsy alone was performed, 43/73 (59%; 95% CI 47 to 69%) patients with cancer would have harboured undetected additional tumours in unsampled quadrants. This reduced but only to 7/73 patients (10%; 95% CI 4 to 19%) with strategy 4 (difference 49%; 95% CI 36 to 62%, p < 0.0001). Of 73 patients, 43 (59%; 95% CI 47 to 69%) had localised radiorecurrent cancer suitable for a form of focal ablation. CONCLUSIONS For patients with recurrent prostate cancer after radiotherapy, MRI and MRI-targeted biopsy, with or without perilesional sampling, will diagnose cancer in the majority where present. MRI-undetected cancers, defined as Likert scores of 1 to 2, were found to be smaller and of lower grade. However, if salvage focal ablation is planned, an MRI-targeted biopsy alone is insufficient for prostate mapping; approximately three of five patients with recurrent cancer found on an MRI-targeted biopsy alone harboured further tumours in unsampled quadrants. Systematic sampling of the whole gland should be considered in addition to an MRI-targeted biopsy to capture both MRI-detected and MRI-undetected disease. PATIENT SUMMARY After radiotherapy, magnetic resonance imaging (MRI) is accurate for detecting recurrent prostate cancer, with missed cancer being smaller and of lower grade. Targeting a biopsy to suspicious areas on MRI results in a diagnosis of cancer in most patients. However, for every five men who have recurrent cancer, this targeted approach would miss cancers elsewhere in the prostate in three of these men. If further focal treatment of the prostate is planned, random biopsies covering the whole prostate in addition to targeted biopsies should be considered so that tumours are not missed.
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Affiliation(s)
- Alexander Light
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Abi Kanthabalan
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Marjorie Otieno
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Menelaos Pavlou
- Department of Statistical Science, University College London, London, UK
| | - Rumana Omar
- Department of Statistical Science, University College London, London, UK
| | - Sola Adeleke
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Cancer & Pharmaceutical Sciences, King's College London, London, UK
| | - Francesco Giganti
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Chris Brew-Graves
- Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Norman R Williams
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Amr Emara
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Athar Haroon
- Department of Nuclear Medicine, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK; Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arash Latifoltojar
- Division of Medicine, Faculty of Medicine, University College London, London, UK; Department of Radiology, Royal Marsden NHS Foundation Trust, Surrey, UK
| | - Harbir Sidhu
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK; Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Clement Orczyk
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Ashok Nikapota
- Sussex Cancer Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard G Hindley
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Jaspal Virdi
- Department of Urology, The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Manit Arya
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Heather Payne
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Anita V Mitra
- Department of Oncology, University College London Hospital NHS Foundation Trust, London, UK
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mathias Winkler
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Gail Horan
- Department of Oncology, Queen Elizabeth Hospital, The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Caroline M Moore
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK; Division of Medicine, Faculty of Medicine, University College London, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery & Interventional Science, University College London, London, UK
| | - Taimur T Shah
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK; Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery & Interventional Science, University College London, London, UK.
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Light A, Peters M, Reddy D, Kanthabalan A, Otieno M, Pavlou M, Omar R, Adeleke S, Giganti F, Brew-Graves C, Williams NR, Emara A, Haroon A, Latifoltojar A, Sidhu H, Freeman A, Orczyk C, Nikapota A, Dudderidge T, Hindley RG, Virdi J, Arya M, Payne H, Mitra AV, Bomanji J, Winkler M, Horan G, Moore C, Emberton M, Punwani S, Ahmed HU, Shah TT. External validation of a risk model predicting failure of salvage focal ablation for prostate cancer. BJU Int 2023; 132:520-530. [PMID: 37385981 PMCID: PMC10615865 DOI: 10.1111/bju.16102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVES To externally validate a published model predicting failure within 2 years after salvage focal ablation in men with localised radiorecurrent prostate cancer using a prospective, UK multicentre dataset. PATIENTS AND METHODS Patients with biopsy-confirmed ≤T3bN0M0 cancer after previous external beam radiotherapy or brachytherapy were included from the FOcal RECurrent Assessment and Salvage Treatment (FORECAST) trial (NCT01883128; 2014-2018; six centres), and from the high-intensity focussed ultrasound (HIFU) Evaluation and Assessment of Treatment (HEAT) and International Cryotherapy Evaluation (ICE) UK-based registries (2006-2022; nine centres). Eligible patients underwent either salvage focal HIFU or cryotherapy, with the choice based predominantly on anatomical factors. Per the original multivariable Cox regression model, the predicted outcome was a composite failure outcome. Model performance was assessed at 2 years post-salvage with discrimination (concordance index [C-index]), calibration (calibration curve and slope), and decision curve analysis. For the latter, two clinically-reasonable risk threshold ranges of 0.14-0.52 and 0.26-0.36 were considered, corresponding to previously published pooled 2-year recurrence-free survival rates for salvage local treatments. RESULTS A total of 168 patients were included, of whom 84/168 (50%) experienced the primary outcome in all follow-ups, and 72/168 (43%) within 2 years. The C-index was 0.65 (95% confidence interval 0.58-0.71). On graphical inspection, there was close agreement between predicted and observed failure. The calibration slope was 1.01. In decision curve analysis, there was incremental net benefit vs a 'treat all' strategy at risk thresholds of ≥0.23. The net benefit was therefore higher across the majority of the 0.14-0.52 risk threshold range, and all of the 0.26-0.36 range. CONCLUSION In external validation using prospective, multicentre data, this model demonstrated modest discrimination but good calibration and clinical utility for predicting failure of salvage focal ablation within 2 years. This model could be reasonably used to improve selection of appropriate treatment candidates for salvage focal ablation, and its use should be considered when discussing salvage options with patients. Further validation in larger, international cohorts with longer follow-up is recommended.
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Affiliation(s)
- Alexander Light
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Deepika Reddy
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
| | - Abi Kanthabalan
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Marjorie Otieno
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Menelaos Pavlou
- Department of Statistical Science, University College London, London, UK
| | - Rumana Omar
- Department of Statistical Science, University College London, London, UK
| | - Sola Adeleke
- Department of Oncology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- School of Cancer & Pharmaceutical Sciences, King’s College London, London, UK
| | - Francesco Giganti
- Division of Surgery and Interventional Sciences, University College London, London, UK
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Chris Brew-Graves
- Division of Medicine, Faculty of Medicine, University College London, UK
| | - Norman R. Williams
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Amr Emara
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Athar Haroon
- Department of Nuclear Medicine, St Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arash Latifoltojar
- Division of Medicine, Faculty of Medicine, University College London, UK
- Department of Radiology, Royal Marsden NHS Foundation Trust, Surrey, UK
| | - Harbir Sidhu
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
- Division of Medicine, Faculty of Medicine, University College London, UK
| | - Alex Freeman
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Clement Orczyk
- Division of Surgery and Interventional Sciences, University College London, London, UK
- Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Ashok Nikapota
- Sussex Cancer Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard G. Hindley
- Department of Urology, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Jaspal Virdi
- Department of Urology, The Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Manit Arya
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
| | - Heather Payne
- Department of Histopathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Anita V. Mitra
- Department of Oncology, University College London Hospital NHS Foundation Trust, London, UK
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mathias Winkler
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
| | - Gail Horan
- Department of Oncology, Queen Elizabeth Hospital, The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust, King's Lynn, UK
| | - Caroline Moore
- Division of Surgery and Interventional Sciences, University College London, London, UK
- Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Mark Emberton
- Division of Surgery and Interventional Sciences, University College London, London, UK
- Department of Urology, University College London Hospital NHS Foundation Trust, London, UK
| | - Shonit Punwani
- Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
- Division of Medicine, Faculty of Medicine, University College London, UK
| | - Hashim U. Ahmed
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Taimur T. Shah
- Imperial Prostate, Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London UK
- Division of Surgery and Interventional Sciences, University College London, London, UK
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Connor MJ, Gorin MA, Eldred-Evans D, Bass EJ, Desai A, Dudderidge T, Winkler M, Ahmed HU. Landmarks in the evolution of prostate biopsy. Nat Rev Urol 2023; 20:241-258. [PMID: 36653670 DOI: 10.1038/s41585-022-00684-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2022] [Indexed: 01/19/2023]
Abstract
Approaches and techniques used for diagnostic prostate biopsy have undergone considerable evolution over the past few decades: from the original finger-guided techniques to the latest MRI-directed strategies, from aspiration cytology to tissue core sampling, and from transrectal to transperineal approaches. In particular, increased adoption of transperineal biopsy approaches have led to reduced infectious complications and improved antibiotic stewardship. Furthermore, as image fusion has become integral, these novel techniques could be incorporated into prostate biopsy methods in the future, enabling 3D-ultrasonography fusion reconstruction, molecular targeting based on PET imaging and autonomous robotic-assisted biopsy.
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Affiliation(s)
- Martin J Connor
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK. .,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK.
| | - Michael A Gorin
- Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Eldred-Evans
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Edward J Bass
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Ankit Desai
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK
| | - Tim Dudderidge
- Department of Urology, University Hospital Southampton, Southampton, UK
| | - Mathias Winkler
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Hashim U Ahmed
- Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, W6 8RF, London, UK.,Imperial Urology, Imperial College Healthcare NHS Trust, London, UK
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