Direct MRI-guided In-Bore Targeted Biopsy of the Prostate: A Step-by-Step How To and Lessons Learned

Multiparametric MRI-the most accurate imaging technique for detection of prostate cancer-has transformed the landscape of prostate cancer diagnosis by enabling targeted biopsies. In a targeted biopsy, tissue samples are obtained from suspicious regions identified at prebiopsy diagnostic MRI. The authors briefly compare the different strategies available for targeting an MRI-visible suspicious lesion, followed by a step-by-step description of the direct MRI-guided in-bore approach and an illustrated review of its application in challenging clinical scenarios. In this technique, direct visualization of the needle, needle guide, and needle trajectory during the procedure provides a precise and versatile strategy to accurately sample suspicious lesions, improving detection of clinically significant cancers. Published under a CC BY 4.0 license Test Your Knowledge questions for this article are available in the supplemental material.

Modeling study of the effect of placebo and medical therapy on storage and voiding symptoms, nocturia, and quality of life in men with prostate enlargement at risk for progression

BACKGROUND

Modeling studies using large datasets from men with lower urinary tract symptoms/benign prostate enlargement (LUTS/BPE) can predict changes in International Prostate Symptom Score (IPSS) and risk of acute urinary retention/surgery under different treatment regimens and according to predictors (baseline characteristics) that commonly define risk of progression. We assessed the impact of treatments on different symptom types (storage, voiding, and nocturia), quality of life (QoL; IPSS Q8), and BPH Impact Index [BII]).

METHODS

Generalized least squares models were used to predict each outcome. Data from the CombAT study were used to predict outcomes for active treatments (dutasteride, tamsulosin, combination therapy). Predictors included: age; IPSS total, storage, voiding, nocturia and QoL (IPSS Q8) scores; BII; prostate volume; maximum urine flow rate (Qmax), prostate-specific antigen, postvoid residual urine (PVR); alpha-blocker usage within 12 months. Data from phase III dutasteride monotherapy studies were used to predict placebo outcomes. Results were visualized using an interactive web-based tool ( www.bphtool.com ).

RESULTS

Combination therapy provided greater predicted benefit than either monotherapy for all five outcomes for most patient profiles within the CombAT inclusion criteria. PVR and corresponding subscores were significant predictors of change in both storage and voiding subscores. Alpha-blocker use within 12 months, age (storage subscore), and Qmax (voiding subscore) were also significant predictors. PVR, age, Qmax, and nocturia score were significant predictors of change in nocturia. PVR, Qmax, previous alpha-blocker use, total IPSS, and QoL (IPSS Q8) score were significant predictors of change in QoL (IPSS Q8) score. For BII, significant predictors were PVR, age, total IPSS, and BII score. The multivariable effect of covariates and treatments is best visualized through the interactive web-based tool.

CONCLUSIONS

This predictive modeling study informs our understanding of how risk factors for disease progression interact and affect treatment impact on different symptom types and QoL scores.

Aquablation versus TURP: 5-year outcomes of the WATER randomized clinical trial for prostate volumes 50-80 mL

INTRODUCTION

To report the 5-year efficacy and safety of Aquablation compared with transurethral resection of the prostate for the management of lower urinary tract symptoms secondary to benign prostatic hyperplasia in men with prostate volumes 50-80 mL.

MATERIALS AND METHODS

In a large double-blinded, multicenter, and prospective randomized controlled trial, 96 randomized men with 50-80 mL prostates who underwent Aquablation or transurethral prostate resection were prospectively identified for subgroup analysis. Follow up was performed for up to 5 years. The primary efficacy endpoint was the reduction in International Prostate Symptom Score (IPSS) at 6 months. The primary safety endpoint was the occurrence of Clavien-Dindo (CD) postoperative complications grade 1 persistent and grade 2 or higher at 3 months.

RESULTS

Both groups had comparable baseline characteristics. Reduction in IPSS score was significantly higher in the Aquablation group across 5 years of follow up (-14.1 vs. -10.8, p = 0.02). The Aquablation group achieved a significantly lower rate of CD1P and CD2 or higher events at 3 months follow up (risk difference of -23.1%). Among recorded adverse events, de novo postoperative ejaculatory dysfunction was notably lower in Aquablation (risk difference of -21.9%), while the risk of bleeding remained similar after 6 months. The surgical and medical retreatment rate at 6 months was also lower in Aquablation (risk difference of -14.4%).

CONCLUSIONS

In the 50-80 mL prostate volume subgroup, Aquablation yields superior long-term symptom relief and lower complication rates than standard transurethral resection, with notably lower rates of ejaculatory dysfunction. This further supports the adoption of Aquablation for men with medium-sized prostates.

Optimal Prostate Cancer Diagnostic Pathways for Men With Prostatomegaly in the MRI Era

OBJECTIVE

To evaluate utilities of multiparametric MRI and targeted biopsy to detect clinically significant prostate cancer in men with prostatomegaly.

MATERIALS AND METHODS

We conducted a retrospective review of multiparametric MRI obtained for elevated PSA between 2017 and 2020. We selected patients with prostates ≥80 g who had undergone biopsy. Clinically significant prostate cancer was defined as grade group ≥2. Predictive and logistic regression analyses quantified impacts of diagnostic components.

RESULTS

A total of 338 patients met inclusion criteria: 89 (26.3%) had clinically significant prostate cancer. On MRI, positive predictive value for clinically significant prostate cancer was 26.5% for PIRADS 4% and 73.5% for PIRADS 5; negative predictive value for MRI without suspicious lesions was 98.8%. Applying PSA density to MRI yielded a negative predictive value of 78.9% for PIRADS 4 lesions at PSA density <0.05 and a positive predictive value of 90.5% for PIRADS 5 lesions at PSA density ≥0.15. Targeted (versus standard) biopsy reduced likelihood of missing clinically significant prostate cancer by >50% (12.2% vs 28.3%). MRI in-bore biopsies trended towards better accuracy versus MRI-transrectal ultrasound fusion biopsies (75% versus 52%). On logistic regression analyses, MRI improved predictive accuracy (area under the curve 0.91), and PIRADS score demonstrated the strongest association with clinically significant prostate cancer (odds ratio 6.42, P < .001).

CONCLUSION

For large prostates, MRI is less predictive of clinically significant prostate cancer but effectively rules out malignancy. PSA density better informs biopsy decisions for PIRADS 4 and 5 lesions. There may be a pronounced role for targeted biopsy, specifically in-bore, in prostatomegaly.

Understanding Treatment Response in Individual Profiles of Men with Prostatic Enlargement at Risk of Progression

BACKGROUND

It is unclear how cumulative multivariable effects of clinically relevant covariates impact response to pharmacological treatments for lower urinary tract symptoms (LUTS)/benign prostatic enlargement (BPE).

OBJECTIVE

To develop models to predict treatment response in terms of International Prostate Symptom Score (IPSS) and the risk of acute urinary retention (AUR) or BPE-related surgery, based on large data sets and using as predictors baseline characteristics that commonly define the risk of disease progression.

DESIGN, SETTING, AND PARTICIPANTS

A total of 9167 patients with LUTS/BPE at risk of progression in three placebo-controlled dutasteride trials and one comparing dutasteride, tamsulosin, and dutasteride + tamsulosin combination therapy (CT) were included in the analysis to predict response to placebo up to 24 mo and active treatment up to 48 mo.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Predictors included age, IPSS, total prostate volume (PV), maximum urinary flow rate (Q_max), prostate-specific antigen, postvoid residual urine (PVR), α-blocker usage within 12 mo, and randomised treatment. A generalised least-squares model was developed for longitudinal IPSS and a Cox proportional-hazards model for time to first AUR/surgery.

RESULTS AND LIMITATIONS

The vast majority of patients benefit from dutasteride or CT when compared with tamsulosin alone. The predicted IPSS improvement with dutasteride or CT increased with greater PV and severity of symptoms at baseline. The tamsulosin effect was lower with greater baseline PV and tended to decrease over time. Predicted AUR/surgery risk was greater with tamsulosin versus CT or dutasteride; this risk increased with larger PV, higher PVR, and lower Q_max (all at baseline). An educational interactive web-based tool facilitates visualisation of the results (www.bphtool.com). Limitations include: the placebo and active-treatment predictions are from different studies, the lack of similar studies for external validation, and the focus on a population at risk of progression from the 4-yr CombAT study.

CONCLUSIONS

Predictive modelling based on large data sets and visualisation of the risk for individual profiles can improve our understanding of how risk factors for disease progression interact and affect response to different treatments, reinforcing the importance of an individualised approach for LUTS/BPE management.

PATIENT SUMMARY

We used data from previous studies to develop statistical models for predicting how men with lower urinary tract symptoms or benign prostate enlargement and at risk of disease complications respond to certain treatments according to their individual characteristics.

PSA density is associated with BPH cellular composition

BACKGROUND

Current AUA guidelines recommend 5 alpha reductase inhibitor (5ARI) treatment for patients with obstructive benign prostatic hyperplasia (BPH) that display prostate volume ≥30 cc and total prostate specific antigen (PSA) ≥1.5 ng/ml. However, BPH is highly pleomorphic and response to 5ARIs is highly variable. An understanding of cellular composition based on a noninvasive PSA density test could lead to improved clinical decision making.

METHODS

The histological composition of 307 BPH specimens was scored by a pathologist for stromo-glandular content and associated with total PSA, prostate volume, PSA density and other clinical variables using univariate and multivariate linear regression.

RESULTS

The percentage of glandular composition in prostates of 5ARI-naïve men was positively and independently associated with PSA and PSA density. It was determined through statistical modeling that a PSA density ≤0.05 ng/ml2 associated with a glandular composition of ≤30% with 76% sensitivity.

CONCLUSIONS

PSA density could provide a decisive variable for estimating BPH cellular content and may eventually improve selection of patients for 5ARI treatment. Further work is needed to demonstrate that patients with higher glandular content are more responsive to 5ARI treatment.

Identifying predictors of antispasmodic use following robotic assisted simple prostatectomy

INTRODUCTION

Anticholinergic or ß-3 agonist use following robotic simple prostatectomy (RASP) is not well described. We describe rates of antispasmodic use following RASP and identify potential predictors of medication use.

MATERIALS AND METHODS

A retrospective review of all RASP patients from 2/2016 - 1/2020 was conducted. Patients with no preoperative International Prostate Symptom Score (IPSS) were excluded. Demographics, clinical data, and postoperative medication use were collected by electronic medical record review. Multivariable logistic regression analysis using a priori variables was performed to identify independent factors associated with antispasmodic use.

RESULTS

A total of 255 patients underwent RASP at a mean age of 70.0 years ± 7.3 and mean body mass index (BMI) of 28.6 kg/m² ± 5.0. Median preoperative prostate volume was 132.3 cc ± 45.0. Rates of preoperative diabetes, obstructive sleep apnea (OSA), smoking and alcohol use were 19.6%, 6.3%, 3.1%, and 11.8% respectively; 8.6% of patients (n = 22) initiated antispasmodics at a median of 2.5 months (IQR 1.3-4.2) postoperatively. Median duration of antispasmodic use was 6.5 months (IQR 1.7-14.7). Mirabegron was most commonly prescribed (31.8%). On multivariable logistic regression analysis, OSA was independently associated with postoperative antispasmodic use (OR 8.13, 95% CI 2.02-32.67, p = 0.003); 68.8% of OSA patients were treated with continuous positive airway pressure (CPAP). Treatment was not significantly associated with postoperative antispasmodic use (p = 0.61).

CONCLUSION

Patients with OSA are over 8 times more likely to require antispasmodic medications following RASP in the short term. These patients may benefit from more tailored preoperative counseling.

MRI Features Associated with Histology of Benign Prostatic Hyperplasia Nodules: Generation of a Predictive Model

Background: Histologic phenotypic variation of benign prostatic hyperplasia (BPH) has been hypothesized to underlie response to medical therapy. We evaluate preoperative MRI of robot-assisted simple prostatectomy (RASP) specimens and determine imaging features associated with histologic phenotype. Materials and Methods: All patients undergoing RASP from November 2015 to November 2019 with a multiparametric MRI ≤1 year before RASP were included. Patients without identifiable BPH nodules on histologic specimens were excluded. Histology slides were obtained from whole mount adenoma specimens and corresponding MRI were reviewed and graded independently by a blinded expert in BPH histopathology (D.W.S.) and an experienced radiologist specializing in prostate imaging (D.N.C.), respectively. Each nodule was assigned a phenotypic score on a 5-point Likert scale (1 = predominantly glandular; 5 = predominantly stromal) by each reviewer. Scores were compared using the sign test and univariate analysis. Signal intensity relative to background transition zone and nodule texture were noted on T2, diffusion-weighted imaging (DWI), and dynamic contrast-enhanced (DCE) imaging sequences. Univariate and multivariate stepwise linear regression analysis were conducted to identify MRI features associated with histology score. All analyses were performed using Statistical Analysis System (version 9.4). Results: A total of 99 prostate nodules in 29 patients were included. Median phenotypic scores by histology and MRI were comparable (2, interquartile range [IQR] 2-3 vs 2, IQR 2-4, respectively; p = 0.63). Histology scores were positively correlated with MRI scores (Pearson's correlation 0.84, p < 0.0001). Multivariate stepwise linear regression analysis showed that low apparent diffusion coefficient (ADC) signal intensity (p < 0.001) and DCE wash-in (p = 0.03) were positively associated with more stromal histology, whereas ADC standard deviation (p = 0.03), DCE wash-out (p = 0.001), and heterogeneous T2 texture (p = 0.003) were associated with more glandular histology. Conclusion: There is a strong correlation between MRI features and the histologic phenotype of BPH nodules. MRI may provide a noninvasive method to determine underlying BPH nodule histology.

Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH

INTRODUCTION

To determine if Aquablation therapy can maintain long term effectiveness in treating men with moderate to severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with a baseline prostate volume between 30 and 80 mL at 5 years compared to TURP.

MATERIALS AND METHODS

In a double-blinded, multicenter prospective randomized controlled trial, 181 patients with moderate to severe LUTS secondary to BPH underwent TURP or Aquablation. The primary efficacy endpoint was reduction in International Prostate Symptom Score (IPSS) at 6 months. The primary safety endpoint was the occurrence of Clavien-Dindo persistent Grade 1 or Grade 2 or higher operative complications at 3 months. The assessments included IPSS, Male Sexual Health Questionnaire (MSHQ), International Index of Erectile Function (IIEF) and uroflow (Qmax). The patients were followed for 5 years.

RESULTS

The primary safety endpoint was successfully achieved at 3 months where the Aquablation group had a lower event rate than TURP (26% vs. 42%, p = .0149 for superiority). Procedure-related ejaculatory dysfunction was lower for Aquablation (7% vs. 25%, p = .0004). The primary efficacy endpoint was successfully achieved at 6 months, where the mean IPSS decreased from baseline by 16.9 points for Aquablation and 15.1 points for TURP; the mean difference in change score at 6 months was 1.8 points larger for Aquablation (p < .0001 for non-inferiority, p = .1346 for superiority). At 5 years, IPSS scores improved by 15.1 points in the Aquablation group and 13.2 points in TURP (p = .2764). However, for men with larger prostates (≥ 50 mL), IPSS reduction was 3.5 points greater across all follow up visits in the Aquablation group compared to the TURP group (p = .0123). Improvement in peak urinary flow rate was 125% and 89% compared to baseline for Aquablation and TURP, respectively. The risk of patients needing a secondary BPH therapy, defined as needing BPH medication or surgical intervention, up to 5 years due to recurrent LUTS was 51% less in the Aquablation arm compared to the TURP arm.

CONCLUSIONS

The improvement in net health outcomes from Aquablation therapy outweigh those offered by a TURP when considering the efficacy benefit along with the lower risk of needing a secondary BPH therapy and avoiding retrograde ejaculation. Following Aquablation therapy, symptom reduction and uroflow improvement at 5 years have shown to be durable and consistent across all years of follow up compared to TURP. Larger prostates (≥ 50 mL) demonstrated a larger safety and efficacy benefit for Aquablation over TURP.

5-alpha reductase inhibitors induce a prostate luminal to club cell transition in human benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is a progressive expansion of peri-urethral prostate tissue common in aging men. Patients with enlarged prostates are treated with 5-alpha reductase inhibitors (5ARIs) to shrink prostate volume by blocking the conversion of testosterone to dihydrotestosterone (DHT). A reduction in DHT levels can elicit atrophy and apoptosis of prostate secretory luminal cells, which results in a favorable clinical response characterized by improved lower urinary tract symptoms. However, the histologic response to 5ARI treatment is often heterogeneous across prostate acini and lower urinary tract symptoms can persist to require surgical intervention. We used two spatial profiling approaches to characterize gene expression changes across histologically normal and atrophied regions in prostates from 5ARI-treated men. Objective transcriptomic profiling using the Visium spatial gene expression platform showed that 5ARI-induced atrophy of prostate luminal cells correlated with reduced androgen receptor signaling and increased expression of urethral club cell genes including LTF, PIGR, OLFM4, SCGB1A1 and SCGB3A1. Prostate luminal cells within atrophied acini adapted to decreased DHT conditions by increasing NF-κB signaling and anti-apoptotic BCL2 expression, which may explain their survival. Using GeoMx digital spatial profiling with a probe set to assess ~18,000 RNA targets, we confirmed that atrophied acini expressing SCGB3A1 displayed higher levels of club cell markers compared to histologically normal acini with NKX3-1 expression. In addition, club-like cells within regions of 5ARI-induced atrophy closely resembled true club cells from the prostatic urethra. A comparison of histologically normal regions from 5ARI-treated men and histologically normal regions from untreated men revealed few transcriptional differences. Taken together, our results describe a heterogeneous response to 5ARI treatment where cells in atrophied acini undergo an adaptation from a prostate secretory luminal to a club cell-like state in response to 5ARI treatment. This article is protected by copyright. All rights reserved.

SAbR for High-Risk Prostate Cancer-A Prospective Multilevel MRI-Based Dose Escalation Trial

PURPOSE

Radiation dose intensification improves outcome in men with high-risk prostate cancer (HR-PCa). A prospective trial was conducted to determine safety, feasibility, and maximal tolerated dose of multilevel magnetic resonance imaging (MRI)-based 5-fraction SAbR in patients with HR-PCa.

METHODS AND MATERIALS

This phase I clinical trial enrolled patients with HR-PCa with grade group ≥4, prostate-specific antigen (PSA) ≥20 ng/mL, or radiographic ≥T3, and well-defined prostatic lesions on multiparametric MRI (mpMRI) into 4 dose-escalation cohorts. The initial cohort received 47.5 Gy to the prostate, 50 Gy to mpMRI-defined intraprostatic lesion(s), and 22.5 Gy to pelvic lymph nodes in 5 fractions. Radiation doses were escalated for pelvic nodes to 25 Gy and mpMRI lesion(s) to 52.5 Gy and then 55 Gy. Escalation was performed sequentially according to rule-based trial design with 7 to 15 patients per cohort and a 90-day observation period. All men received peri-rectal hydrogel spacer, intraprostatic fiducial placement, and 2 years of androgen deprivation. The primary endpoint was maximal tolerated dose according to a 90-day acute dose-limiting toxicity (DLT) rate <33%. DLT was defined as National Cancer Institute Common Toxicity Criteria for Adverse Events ≥grade 3 treatment-related toxicity. Secondary outcomes included acute and delayed gastrointestinal (GI)/genitourinary (GU) toxicity graded with Common Toxicity Criteria for Adverse Events.

RESULTS

Fifty-five of the 62 enrolled patients were included in the analysis. Dose was escalated through all 4 cohorts without observing any DLTs. Median overall follow-up was 18 months, with a median follow-up of 42, 24, 12, and 7.5 months for cohorts 1 to 4 respectively. Acute and late grade 2 GU toxicities were 25% and 20%, while GI were 13% and 7%, respectively. Late grade 3 GU and GI toxicities were 2% and 0%, respectively.

CONCLUSIONS

SAbR dose for HR-PCa was safely escalated with multilevel dose painting of 47.5 Gy to prostate, 55 Gy to mpMRI-defined intraprostatic lesions, and 25 Gy to pelvic nodal region in 5 fractions. Longer and ongoing follow-up will be required to assess late toxicity.

Choosing the Most Efficacious and Safe Oral Treatment for Idiopathic Overactive Bladder: A Systematic Review and Network Meta-analysis

CONTEXT

The choice of the most efficacious drug for patients with idiopathic overactive bladder (IOAB) remains challenging.

OBJECTIVE

The aim of this network meta-analysis was to determine the most efficacious oral antimuscarinic or β-adrenoceptor agonist accounting for adverse events for the management of IOAB.

EVIDENCE ACQUISITION

A comprehensive electronic search was done in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Ovid for studies in any language in February 2021 considering the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We included all randomized controlled trials assessing oral antimuscarinics or β-adrenoceptor agonists for the treatment of IOAB. We determined the effect of specific bothersome symptoms separately.

EVIDENCE SYNTHESIS

Fifty-four articles were included in our analysis. The most efficacious agents considering the evaluated outcomes were oxybutynin 15 mg/d in reducing incontinence episodes, imidafenacin 0.5 mg/d together with solifenacin 10 and 5 mg/d in reducing micturition episodes, fesoterodine 4 and 8 mg/d as well as solifenacin 10 mg/d in reducing urgency episodes, imidafenacin 0.5 mg/d and solifenacin 10 mg/d in reducing urgency urinary incontinence episodes, and solifenacin 10 mg/d, vibegron 50 mg/d, and fesoterodine 8 mg/d in improving the voided volume. Gastrointestinal problems, especially due to antimuscarinic agents, were the most prevalent adverse events.

CONCLUSIONS

Taken together, there is only minimal difference between the efficacy of oral antimuscarinics and that of β-adrenoceptor agonists. Although finding the best medication for all is impossible, finding the best treatment for every individual patient can be done by considering the efficacy of a medicine for the most bothersome symptom(s) in balance with drug-specific adverse events.

PATIENT SUMMARY

This study aimed to find the most efficient oral medication to treat overactive bladder, taking into consideration the adverse events. Based on our study, there is a minimal difference in the efficacy between the two major drug classes used to treat overactive bladder. Gastrointestinal problems were the most common adverse events in medical treatment of overactive bladder. Selection of the best treatment is possible through shared decision-making between the doctor and the patient based on the patient's most bothersome symptom. We provide a framework for physicians to facilitate shared decision-making with each individual patient.

Restoration of Continence after Prostatectomy is Associated With Weight Loss: A Pilot Study

OBJECTIVES

To examine association between post-prostatectomy incontinence (PPI) severity and weight changes before and after restoration of continence via artificial urinary sphincter (AUS).

METHODS

Single surgeon, retrospective review of urologic prosthetic surgery (UPS) after radical prostatectomy (RP). A cohort of post-RP inflatable penile prosthesis (IPP) patients served as a surgical control. Body Mass Index (BMI) and total body weight were assessed pre and post-UPS. Multivariable linear regression was utilized to assess BMI changes post-UPS.

RESULTS

187 AUS and 63 IPP patients met selection criteria. Greater PPI severity was associated with faster BMI gain after RP (coeff. 0.14 kg/m2, P = 0.03, per pad used) and magnitude of incontinence improvement (mean reduction in daily pad use) after AUS insertion was associated with greater BMI reduction at 12 months post-UPS (coeff. - 0.13 kg/m2, P = 0.04). On multivariable regression, AUS insertion was associated with a decrease in BMI by - 2.83 kg/m2 12 months post-UPS (P = 0.02). Twelve months post-UPS, men with AUS exhibited a mean BMI reduction of -1.0 kg/m² compared to a mean BMI increase in the IPP cohort of 0.4 kg/m² (P < 0.01). Compared to IPP, AUS patients experienced absolute body weight reduction by 6 kg [Median(IQR): 90.4 (80.3-100.1) vs 96.4 (87.1-108.8) kg, P = 0.03], with nearly one-third having clinically significant weight loss (>5% body weight) at 12 months post-UPS (31.8% vs 8.3%, P < 0.01).

CONCLUSION

Severe PPI appears to be associated with weight gain and correction of PPI via AUS insertion with weight loss.

Aquablation of the prostate: a review and update

INTRODUCTION Historically, transurethral resection of the prostate (TURP) was considered the endoscopic "gold standard" surgical treatment of benign prostatic hyperplasia (BPH). Over the years, several other endoscopic procedures emerged, including the size-independent holmium laser enucleation of the prostate (HoLEP). In an effort to reduce the cost and morbidity associated with traditional endoscopic techniques, novel minimally invasive techniques have been developed, one of which is Aquablation. This review is an update of a previously published review article looking at the most recently published available data on Aquablation.

MATERIALS AND METHODS

This review article covers the technical aspects of Aquablation and provides an update on the recently published literature regarding Aquablation compared to TURP and HoLEP.

RESULTS

At up to 3 years of follow up, Aquablation performs favorably when compared to TURP in terms of alleviation of lower urinary tract symptoms (LUTS) and preservation of sexual function compared to TURP. Safety profile was similar between Aquablation and TURP.

CONCLUSIONS

Aquablation is a safe and effective method of treating LUTS associated with BPH. At up to 3 years of follow up, it has shown a durable with efficacy similar to TURP.

UroLift and Rezum: minimally invasive surgical therapies for the management of benign prostatic hyperplasia

INTRODUCTION Minimally invasive surgical therapies for benign prostatic hyperplasia (BPH) are popular alternatives to the gold standard transurethral resection of the prostate (TURP). These procedures have fewer discernable side effects on urinary and sexual function, when compared to TURP, making it a desirable option for many patients.

MATERIALS AND METHODS

We provide an updated literature review on the current landscape of minimally invasive modalities, specifically the prostatic urethral lift (UroLift) and water vapor thermal therapy (Rezum), for the surgical treatment of BPH.

RESULTS

Both UroLift and Rezum have demonstrated excellent efficacy and durability in relieving lower urinary tract symptoms (LUTS) in the BPH patient. When compared to TURP, these minimally invasive therapies can be performed in an outpatient setting, with decreased hospitalization, operative and catheterization times, which minimizes overall healthcare costs. Moreover, these therapies have no discernable adverse effects on sexual function (both ejaculatory and erectile) or sexual satisfaction, making it a desirable option for many patients.

CONCLUSIONS

Both the UroLift and Rezum are office-based, minimally invasive techniques capable of providing durable, and significant relief of LUTS secondary to BPH. In select patients, they demonstrate comparable efficacy to TURP with the added advantage of preserving sexual function and minimizing patient morbidity and healthcare cost. An individualized, shared decision-making approach is essential in selecting the optimal treatment option for each patient.

Single-cell analysis of mouse and human prostate reveals novel fibroblasts with specialized distribution and microenvironment interactions

Stromal-epithelial interactions are critical to the morphogenesis, differentiation, and homeostasis of the prostate, but the molecular identity and anatomy of discrete stromal cell types is poorly understood. Using single-cell RNA sequencing, we identified and validated the in situ localization of three smooth muscle subtypes (prostate smooth muscle, pericytes, and vascular smooth muscle) and two novel fibroblast subtypes in human prostate. Peri-epithelial fibroblasts (APOD+) wrap around epithelial structures, whereas interstitial fibroblasts (C7+) are interspersed in extracellular matrix. In contrast, the mouse displayed three fibroblast subtypes with distinct proximal-distal and lobe-specific distribution patterns. Statistical analysis of mouse and human fibroblasts showed transcriptional correlation between mouse prostate (C3+) and urethral (Lgr5+) fibroblasts and the human interstitial fibroblast subtype. Both urethral fibroblasts (Lgr5+) and ductal fibroblasts (Wnt2+) in the mouse contribute to a proximal Wnt/Tgfb signaling niche that is absent in human prostate. Instead, human peri-epithelial fibroblasts express secreted WNT inhibitors SFRPs and DKK1, which could serve as a buffer against stromal WNT ligands by creating a localized signaling niche around individual prostate glands. We also identified proximal-distal fibroblast density differences in human prostate that could amplify stromal signaling around proximal prostate ducts. In human benign prostatic hyperplasia, fibroblast subtypes upregulate critical immunoregulatory pathways and show distinct distributions in stromal and glandular phenotypes. A detailed taxonomy of leukocytes in benign prostatic hyperplasia reveals an influx of myeloid dendritic cells, T cells and B cells, resembling a mucosal inflammatory disorder. A receptor-ligand interaction analysis of all cell types revealed a central role for fibroblasts in growth factor, morphogen, and chemokine signaling to endothelia, epithelia, and leukocytes. These data are foundational to the development of new therapeutic targets in benign prostatic hyperplasia. © 2021 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Gleason Grade Group Concordance between Preoperative Targeted Biopsy and Radical Prostatectomy Histopathologic Analysis: A Comparison Between In-Bore MRI-guided and MRI-Transrectal US Fusion Prostate Biopsies

Purpose

To determine and compare rates of grade group (GG) discrepancies between different targeted biopsy techniques (in-bore vs fusion) after propensity score weighting using whole-mount radical prostatectomy (RP) histopathologic analysis as the reference standard.

Materials and Methods

This retrospective study evaluated men who underwent targeted (fusion or in-bore) biopsy between April 2017 and January 2019 followed by prostatectomy. The primary endpoint of the study was a change in GG from biopsy to RP at a patient level. For downgrade and upgrade analysis, men with biopsy GG1 (downgrade not possible) and GG5 (upgrade not possible) were excluded, respectively. GG upgrade, downgrade, and concordance rates of each targeting approach were compared using propensity score weighting and logistic regression with inverse probability of treatment weighting. Significance level was set at .05. Index lesion GG on RP specimen served as the reference standard.

Results

A total of 191 men (90 in the in-bore [mean age, 63 years ± 7 (standard deviation)] and 101 in the fusion biopsy group [mean age, 65 years ± 7]) were eligible and included. Fewer GG upgrades were noted in the in-bore biopsy group (14%; 12 of 85) compared with the fusion plus systematic biopsy group (30%; 28 of 93) (P = .012). The incidence of GG downgrade in the in-bore group (25%; 21 of 84) was higher than in the fusion group (17%; 16 of 93); however, the difference was not statistically significant (P = .2). Of the 77 men misclassified by both biopsy techniques, the majority (56%, n = 43) had a change in GG of 2 to 3 or 3 to 2.

Conclusion

Superior sampling accuracy with MRI-guided in-bore biopsies offers a lower incidence of GG upgrades compared with MRI-transrectal US fusion biopsies upon RP.Keywords: Biopsy/Needle Aspiration, MR-Imaging, Oncology, Pathology, Prostate Supplemental material is available for this article.© RSNA, 2021.

Model-based meta-analysis of the time to first acute urinary retention or benign prostatic hyperplasia-related surgery in patients with moderate or severe symptoms

Aims

Combination therapy of 5α‐reductase inhibitor and α‐blocker is a guideline‐endorsed therapeutic approach for patients with moderate‐to‐severe lower urinary tract symptoms or benign prostatic hyperplasia (LUTS/BPH) who are at risk of disease progression. We aimed to disentangle the contribution of clinical and demographic baseline characteristics affecting the risk of acute urinary retention or BPH‐related surgery (AUR/S) from the effect of treatment with drugs showing symptomatic and disease‐modifying properties.

Methods

A time‐to‐event model was developed using pooled data from patients (n = 10 238) enrolled into six clinical studies receiving placebo, tamsulosin, dutasteride or tamsulosin‐dutasteride combination therapy. A parametric hazard function was used to describe the time to first AUR/S. Covariate model building included the assessment of relevant clinical and demographic factors on baseline hazard. Predictive performance was evaluated by graphical and statistical methods.

Results

An exponential hazard model best described the time to first AUR/S in this group of patients. Baseline International Prostate Symptom Score, prostate‐specific antigen, prostate volume and maximum urine flow were identified as covariates with hazard ratio estimates of 1.04, 1.08, 1.01 and 0.91, respectively. Dutasteride monotherapy and tamsulosin‐dutasteride combination therapy resulted in a significant reduction in the baseline hazard (56.8% and 66.4%, respectively). By contrast, the effect of tamsulosin did not differ from placebo.

Conclusions

Our analysis showed the implications of disease‐modifying properties of dutasteride and tamsulosin‐dutasteride combination therapy for the risk of AUR/S. It also elucidated the contribution of different baseline characteristics to the risk of these events. The use of tamsulosin monotherapy (symptomatic treatment) has no impact on individual long‐term risk.

Prostatic Urethral Lift Versus Medical Therapy: Examining the Impact on Sexual Function in Men with Benign Prostatic Hyperplasia

BACKGROUND

Sexual dysfunction is a common side effect of medical therapy for benign prostatic hyperplasia (BPH), whereas prostatic urethral lift (PUL) offers safe and effective relief of lower urinary tract symptoms while preserving sexual function.

OBJECTIVE

To compare the long-term impact on sexual health of PUL or daily medical therapy of doxazosin or finasteride alone or in combination in BPH patients.

DESIGN, SETTING, AND PARTICIPANTS

This was a comparative analysis of sexual function outcomes from PUL studies (L.I.F.T. [n=107], Crossover [n=42], and MedLift [n=39]) and the Medical Therapy of Prostatic Symptoms (MTOPS) trial. The men included were sexually active with International Prostate Symptom Score ≥13, Qmax ≤12ml/s, and prostate volume 30-80 cm³. MTOPS subjects completed the Brief Male Sexual Function Inventory, while PUL subjects completed the International Index of Erectile Function and the Male Sexual Health Questionnaire for Ejaculatory Function.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Mean percentage changes from baseline in erectile, ejaculatory, and sexual satisfaction domains were compared at 12, 24, 36, and 48 mo.

RESULTS AND LIMITATIONS

PUL significantly improved erectile function through 24 mo, and ejaculatory function and sexual satisfaction across all time points. Medical therapy did not improve sexual function at any time point. Finasteride significantly decreased erectile function at 48 mo, and combined therapy significantly reduced ejaculatory function at 12 and 24 mo. Comparatively, PUL was superior to finasteride in preserving erectile function at 24 and 48 mo, and superior to doxazosin and combined therapy at 12 mo. PUL outperformed all three medical therapies at all time points in improving ejaculatory function and sexual satisfaction. Limitations include the use of distinct patient-reported questionnaires and narrowed data on comorbidities that influence male sexual function.

CONCLUSIONS

Indirect comparison reveals that PUL is superior to BPH medical therapy in preserving erectile and ejaculatory function and sexual satisfaction.

PATIENT SUMMARY

In our non-head-to-head study, only patients undergoing PUL for an enlarged prostate experienced improvements in sexual health. Conversely, patients on medical therapy experienced worsening of erectile and ejaculatory function.

Urethral luminal epithelia are castration-insensitive cells of the proximal prostate

BACKGROUND

Castration-insensitive epithelial progenitors capable of regenerating the prostate have been proposed to be concentrated in the proximal region based on facultative assays. Functional characterization of prostate epithelial populations isolated with individual cell surface markers has failed to provide a consensus on the anatomical and transcriptional identity of proximal prostate progenitors.

METHODS

Here, we use single-cell RNA sequencing to obtain a complete transcriptomic profile of all epithelial cells in the mouse prostate and urethra to objectively identify cellular subtypes. Pan-transcriptomic comparison to human prostate cell types identified a mouse equivalent of human urethral luminal cells, which highly expressed putative prostate progenitor markers. Validation of the urethral luminal cell cluster was performed using immunostaining and flow cytometry.

RESULTS

Our data reveal that previously identified facultative progenitors marked by Trop2, Sca-1, KRT4, and PSCA are actually luminal epithelial cells of the urethra that extend into the proximal region of the prostate, and are resistant to castration-induced androgen deprivation. Mouse urethral luminal cells were identified to be the equivalent of previously identified human club and hillock cells that similarly extend into proximal prostate ducts. Benign prostatic hyperplasia (BPH) has long been considered an "embryonic reawakening," but the cellular origin of the hyperplastic growth concentrated in the periurethral region is unclear. We demonstrate an increase in urethral luminal cells within glandular nodules from BPH patients. Urethral luminal cells are further increased in patients treated with a 5-α reductase inhibitor.

CONCLUSIONS

Our data demonstrate that cells of the proximal prostate that express putative progenitor markers, and are enriched by castration in the proximal prostate, are urethral luminal cells and that these cells may play an important role in the etiology of human BPH.

Benign prostatic hyperplasia: an update on minimally invasive therapy including Aquablation

INTRODUCTION

Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is a common condition affecting older men. New interventional treatments have emerged and evolved over the years, each with their own distinct efficacy and safety profiles. While some have fallen out of favor, new options continue to be explored.

MATERIALS AND METHODS

We provide a review and update on minimally invasive treatment modalities for BPH, including prostatic artery embolization (PAE), Aquablation, convective water vapor thermal therapy (Rezum), and prostatic urethral lift (Urolift).

RESULTS

While current urologic guidelines recommend against PAE outside of the context of clinical trials, Aquablation, Rezum, and Urolift have demonstrated excellent efficacy and durability in relieving LUTS in the BPH patient. When compared to the gold standard, transurethral resection of the prostate (TURP), these novel therapies yield equivalent or superior objective outcomes, with the additional benefit of significantly reduced sexual side effects. Additionally, Rezum and Urolift may be performed as outpatient procedures under local anesthesia, allowing for decreased hospitalizations, operative times, catheterization duration, and financial burden on the health care system.

CONCLUSIONS

Aquablation, Rezum and Urolift are minimally invasive surgical treatment options capable of providing rapid, significant, and durable relief of LUTS secondary to BPH. Each technique demonstrates comparable efficacy to TURP with the added advantages of preserving sexual function, decreasing patient morbidity, and limiting healthcare costs.

Men's Sexual Health Questionnaire score changes vs spontaneous sexual adverse event reporting in men treated with dutasteride/tamsulosin combination therapy for lower urinary tract symptoms secondary to benign prostatic hyperplasia: A post hoc analysis of a prospective, randomised, placebo-controlled study

AIM

To assess the impact of baseline characteristics on Men's Sexual Health Questionnaire (MSHQ) total scores and to evaluate the clinical relevance of MSHQ changes and their association with spontaneously reported sexual adverse events (SexAEs) in patients with benign prostatic hyperplasia.

METHODS

This was a post hoc analysis of the Phase 4 FDC116115 study, in which patients aged ≥50 years were randomised 1:1 to receive a fixed-dose combination of dutasteride 0.5 mg and tamsulosin 0.4 mg (DUT-TAM FDC), or placebo. End-points included: change in MSHQ total scores by baseline characteristics and SexAEs; cumulative distribution function for change from baseline to month 12 in MSHQ total score and the ejaculation, erection, satisfaction and sexual desire (libido) domain scores; and relationship between changes in MSHQ scores and SexAEs.

RESULTS

The intent-to-treat population comprised 489 patients (DUT-TAM FDC, n = 243; placebo, n = 246). The mean reduction in total MSHQ score was greater in patients with SexAEs across both groups, compared with patients without SexAEs. Most patients reporting any SexAE (86% DUT-TAM FDC, 67% placebo) had a worsening of the MSHQ total score at month 12 compared with baseline. Specifically, 90% (DUT-TAM FDC) and 75% (placebo) of patients reporting an ejaculation SexAE and 73% (DUT-TAM FDC) and 87% (placebo) of patients reporting an erection SexAE had a worsening of MSHQ ejaculation and erection domain scores, respectively, at month 12. A threshold effect for incident SexAE was observed; patients showing a decrease of approximately 6-10 points in the total MSHQ score were more likely to report SexAEs.

CONCLUSION

Findings support the clinical utility of the MSHQ tool in assessing the impact of DUT-TAM on sexual function by linking numerical changes in MSHQ scores to spontaneously reported SexAEs for the first time. The threshold effect for incidence of SexAEs warrants further investigation to determine its clinical relevance.

Aquablation for benign prostatic hyperplasia in large prostates (80-150 cc): 2-year results

INTRODUCTION

To report 2-year safety and effectiveness of the Aquablation procedure for the treatment of men with symptomatic benign prostatic hyperplasia (BPH) and large-volume 80-150 cc prostates.

MATERIALS AND METHODS

Between September-December 2017, 101 men with moderate-to-severe BPH symptoms and prostate volumes of 80-150 cc underwent an ultrasound-guided robotically executed Aquablation procedure in a prospective multicenter international clinical trial (WATER II). Baseline, procedural and follow up parameters were recorded at baseline and scheduled postoperative visits. Herein we report 2-year safety and efficacy for this cohort.

RESULTS

Mean prostate volume was 107 cc (range 80-150 cc). Mean IPSS improved from 23.2 at baseline to 5.8 at 2 years (17-point improvement, p < .0001). Mean IPSS quality of life improved from 4.6 at baseline to 1.1 at 2 years (p < .0001). Maximum urinary flow increased from 8.7 to 18.2 cc/sec. Two subjects underwent a repeat procedure for BPH symptoms over the 2-year follow up period. By 2 years or study exit, all but 2 of 74 subjects stopped taking alpha blockers. Similarly, all but 4 of 32 subjects stopped taking 5α-reductase inhibitors.

CONCLUSIONS

Two-year prospective multicenter follow up demonstrated that the Aquablation procedure is safe and effective in the treatment of men with LUTS due to BPH and prostates 80-150 cc with durable treatment efficacy, acceptable safety profile and a low retreatment rate. ClinicalTrials.gov number, NCT03123250.

Safety and outcome of stereotactic body radiation therapy (SBRT) with rectal hydrogel spacer for prostate cancer

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Background: Ultra-hypofractionated radiotherapy delivered using stereotactic body radiotherapy (SBRT) is a cost-effective treatment for localized prostate cancer. Optimal dosing remains unclear, as commonly used 30-40Gy/5fx regimens appear to overestimate hypofractionation’s control benefits. Here, we report the largest experience of 45Gy/5Fx of SBRT for prostate cancer patients treated with hydrogel peri-rectal spacer (‘hydrogel’). Methods: An IRB-approved retrospective protocol was used to conduct a registry search identifying all patients with prostate cancer who received 45Gy/5Fx between 2015-2019 with hydrogel. Genitourinary (GU) and gastrointestinal (GI) toxicities were defined using the NCI Common Toxicity Criteria for Adverse Events (CTCAE) v.5.0. The ASTRO-Phoenix failure definition of Nadir+2 ng/mL was used for biochemical failure. Results: We analyzed 250 low (9.2%), intermediate (85.2%), and high-risk (5.6%) prostate cancer patients with a median follow-up of 9.9 months (range: 0-45.7 months). Acute GU and GI grade ≥ II toxicities were noted in 15.2% and 7.2% of patients, respectively. Late GU grade II and III toxicities occurred in 24.0% and 1.2% of patients, respectively, while late GI grade II and III toxicities occurred in 4.0% and 0.4% of patients, respectively. In patients (N=44) with follow-up >2 years, late GU and GI grade III toxicities occurred in 4.55% and 2.27% of patients, respectively. A significant correlation was noted for acute GI and GU toxicity predicting the respective late GI and GU toxicity (p-value < 0.001 for both). Physician-reported Grade ≥ II new onset erectile dysfunction was 17.2%. A gradual decline in prostate-specific antigen with a mean nadir of 0.04 (95% CI: [0.018, 0.067]) at 36 months was noted. The actuarial freedom from biochemical failure was 96.33% at 3 years. Overall survival was 94.09% at 3 years with no deaths attributed to prostate cancer. Conclusions: SBRT treatment of 45Gy/5Fx with hydrogel is well tolerated with GU/GI toxicities comparable to those reported for conventional fractionation. Although short, the 3-year biochemical control rate is encouraging. Longer follow-up and prospective evaluation are warranted.

Clinical Efficacy of Silodosin in Patients with Severe Lower Urinary Tract Symptoms Related to Benign Prostatic Obstruction: A Pooled Analysis of Phase 3 and 4 Trials

We performed a post hoc analysis of data from phase 3 and 4 studies to evaluate the efficacy of silodosin 8mg in patients with severe lower urinary tract symptoms (LUTS) related to benign prostatic obstruction (BPO). The presence of two or more of the following criteria was adopted to define severity: total International Prostate Symptom Score (IPSS) 20-35, quality of life (QoL) score 5-6, maximum urinary flow <5ml/s or postvoid residual volume ≥100ml, and prostate volume ≥50ml. Mean improvements in total (8.1 vs 4.7), storage (3.1 vs 2.0), voiding (5.0 vs 2.7), and QoL (1.3 vs 0.7) IPSS scores were significantly greater for patients receiving silodosin compared to placebo (all p< 0.0001). Mean improvements in total, storage, voiding, and QoL IPSS scores were similar for the severe and not severe LUTS cohorts. In conclusion, silodosin significantly improves symptoms and QoL in all LUTS/BPO patients, including those with severe symptoms. PATIENT SUMMARY: Silodosin improves symptoms and quality of life for patients with severe lower urinary tract symptoms related to benign prostatic obstruction.

A Cellular Anatomy of the Normal Adult Human Prostate and Prostatic Urethra

A comprehensive cellular anatomy of normal human prostate is essential for solving the cellular origins of benign prostatic hyperplasia and prostate cancer. The tools used to analyze the contribution of individual cell types are not robust. We provide a cellular atlas of the young adult human prostate and prostatic urethra using an iterative process of single-cell RNA sequencing (scRNA-seq) and flow cytometry on ~98,000 cells taken from different anatomical regions. Immunohistochemistry with newly derived cell type-specific markers revealed the distribution of each epithelial and stromal cell type on whole mounts, revising our understanding of zonal anatomy. Based on discovered cell surface markers, flow cytometry antibody panels were designed to improve the purification of each cell type, with each gate confirmed by scRNA-seq. The molecular classification, anatomical distribution, and purification tools for each cell type in the human prostate create a powerful resource for experimental design in human prostate disease.

Using single-cell RNA sequencing, immunofluorescence, and flow cytometry, Henry et al. create a cellular anatomy of the normal human prostate and provide the tools to identify, isolate, and localize every cell type. They identify two additional epithelial cell types enriched in the prostatic urethra and proximal prostatic ducts.

Statin use and longitudinal changes in prostate volume; results from the REduction by DUtasteride of prostate Cancer Events (REDUCE) trial

OBJECTIVE

To test the association between statin use and prostate volume (PV) change over time using data from the REduction by DUtasteride of prostate Cancer Events (REDUCE) trial, a 4-year randomised controlled trial testing dutasteride for prostate cancer chemoprevention.

SUBJECTS/PATIENTS AND METHODS

We identified men with a baseline negative prostate biopsy from REDUCE who did not undergo prostate surgery or develop prostate cancer over the trial period. Men reported statin use at baseline. PV was determined from transrectal ultrasonography performed to guide prostate biopsy at baseline, and 2- and 4-years after randomisation. Multivariable generalised estimating equations tested differences in PV change over time by statin use, overall and stratified by treatment arm. We tested for interactions between statins and time in association with PV using the Wald test.

RESULTS

Of 4106 men, 17% used statins at baseline. Baseline PV did not differ by statin use. Relative to non-users, statin users had decreasing PVs over the trial period (P = 0.027). Similar patterns were seen in the dutasteride and placebo arms, although neither reached statistical significance. The mean estimated PV was modestly but significantly lower in statin users relative to non-users in the dutasteride arm at 2-years (4.5%, P = 0.032) and 4-years (4.0%, P = 0.033), with similar (3-3.3%) but non-significant effects in the placebo arm.

CONCLUSION

If confirmed, our present findings support a role for statins in modestly attenuating PV growth, with a magnitude of effect in line with previously reported prostate-specific antigen-lowering effects of statins (~4%). Future studies are needed to assess whether this putative role for statins in PV growth could impact lower urinary tract symptom development or progression.

Evaluation of the impact of dutasteride/tamsulosin combination therapy on libido in sexually active men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH): A post hoc analysis of a prospective randomised placebo-controlled study

AIMS

Five-α reductase inhibitor (5ARI) therapy has been associated with sexual dysfunction in some patients. This study assessed the impact of a fixed-dose combination of the 5ARI dutasteride 0.5 mg and the α₁ -adrenoceptor antagonist tamsulosin 0.4 mg (DUT-TAM FDC) on Men's Sexual Health Questionnaire (MSHQ) domain scores in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH).

METHODS

This was a post hoc analysis of a double-blind, randomised, placebo-controlled, parallel-group, multicentre study in sexually active patients, aged ≥50 years, with a confirmed clinical diagnosis of BPH. Sexual activity, sexual desire, and bother domain scores of the MSHQ were assessed at baseline and at Months 1, 3, 6, 9, and 12. Correlation between MSHQ sexual activity/desire scores and ejaculation, erection, and satisfaction domains at baseline was also evaluated.

RESULTS

In the intent-to-treat population (N = 489), 243 and 246 patients were randomised to DUT-TAM FDC and placebo groups, respectively. Compared with placebo, DUT-TAM FDC therapy resulted in statistically significant reductions (worsening) from baseline in adjusted mean MSHQ sexual activity and bother domain scores at Months 1, 3, 6, 9, and 12 (all P < 0.05) and in adjusted mean MSHQ sexual desire domain scores at Months 6, 9, and 12 (all P < 0.05). Significant moderate correlations in the expected direction were observed at baseline between the sexual activity/desire domains and the ejaculation, erection, and satisfaction domains (P < 0.0001).

CONCLUSIONS

These findings help clarify the degree and impact of libido changes in sexually active men treated with DUT-TAM FDC and may support clinical decision-making.

Aquablation of the prostate: a review and update

INTRODUCTION

Invasive procedures, such as transurethral resection of the prostate (TURP), have long been the gold standard therapy for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). In recent years, newer treatment modalities have arisen, such as Aquablation, with similar efficacy and improved adverse event profiles, with particular emphasis on postoperative sexual function.

MATERIALS AND METHODS

Aquablation is a new technology that utilizes machine-controlled water jets to ablate the soft tissue of the prostate as determined by the doctor. In this review, we will discuss the techniques currently being used to complete this procedure, the outcomes and safety, and finally, the long term data as well as the adverse events associated with Aquablation.

RESULTS

Aquablation is rapidly effective in treating patients with LUTS due to BPH. Critically, in head to head comparison with TURP, Aquablation has equivalent objective results with much shorter resections times, and significantly less sexual side effects. Currently, the literature only reports results extending to 12 months post-procedure, and therefore long term durability of results beyond this time point remains unknown.

CONCLUSIONS

Aquablation is a safe and effective option for treating LUTS secondary to BPH. Aquablation is a new surgical option that shows very promising short term results, in particular, due to its short resection time regardless of gland size and low rate of sexual side effects. This technology still requires further investigation to confirm durability and efficacy over time.

Characteristics of men with untreated LUTS interested in over-the-counter tamsulosin

INTRODUCTION

Treatment for lower urinary tract symptoms (LUTS) is often delayed, as it is considered a natural progression of aging. We described baseline demographic and clinical characteristics of men currently not using prescription medications for benign prostatic hyperplasia (BPH) but interested in self-directed use of over-the-counter (OTC) tamsulosin and who had participated in OTC tamsulosin-simulated studies.

MATERIALS AND METHODS

Pooled baseline data from four OTC tamsulosin-simulated studies were analyzed for men who were currently not using BPH prescription medication and who believed that OTC tamsulosin was appropriate for use or were interested in purchasing it. Data from the OTC-simulated studies for men using BPH prescription medication and from the BPH registry, which included men diagnosed with BPH, were used for comparison.

RESULTS

Overall, 3285 non-prescription-using men (mean age +/- standard deviation [SD], 60.6 +/- 11.6 years) were included. Average American Urological Association Symptom Index (AUA-SI) total score was 17.6; 25.5% reported urinary symptoms for > 5 years. Overall, 46.7% of these men had > 1 visit/year with their physicians. Baseline characteristics of prescription users from the OTC-simulated studies (n = 364; mean age ± SD, 68.3 +/- 9.1 years; mean AUA-SI score, 18.5) and of men from the BPH registry (n = 5042; 64.8 +/- 10 years; 11.6) were similar to those of non-prescription users.

CONCLUSIONS

Non-prescription users had long term moderate-to-severe male LUTS, yet remained untreated; self-management may be a viable alternative strategy for this population. Disease characteristics of men not using BPH prescription medication and interested in using OTC tamsulosin were similar to those using BPH medication or diagnosed with BPH.

Office-based therapies for benign prostatic hyperplasia: a review and update

INTRODUCTION

Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is one of the most common conditions affecting the aging man. Over the years, various treatment modalities with distinct efficacy and safety profiles have emerged in experimental and clinical use. However, only a handful have gained in popularity and stood the test of time.

MATERIALS AND METHODS

We provide an update on minimally invasive treatment modalities for BPH, specifically focused on office-based procedures namely the prostatic urethral lift (UroLift) and the convective water vapor ablation therapy (Rezum).

RESULTS

Both the UroLift and Rezum have demonstrated excellent efficacy and durability in relieving LUTS in the BPH patient. When compared to the gold standard TURP, these novel therapies can also be performed as an outpatient procedure under local anesthesia, which allows for decreased hospitalization, operative and catheterization times, subsequently allowing for increased cost savings. Moreover, these procedures have no discernable adverse effects on postoperative sexual function, making it a desirable treatment option for many patients.

CONCLUSIONS

Both the UroLift and Rezum are minimally invasive treatment options capable of providing rapid, significant and durable relief of LUTS secondary to BPH. They demonstrate comparable efficacy to TURP with the added advantage of preserving sexual function and decreasing patient morbidity and healthcare costs.

When to Biopsy the Seminal Vesicles: A Validated Multiparametric Magnetic Resonance Imaging and Target Driven Model to Detect Seminal Vesicle Invasion of Prostate Cancer

PURPOSE

Current imaging and biopsy practices offer limited insight into preoperative detection of seminal vesicle invasion despite the implications for treatment decisions and patient prognoses. We identified magnetic resonance imaging features to assess the risk of seminal vesicle invasion and inform the inclusion of seminal vesicle sampling during biopsy.

MATERIALS AND METHODS

Patients underwent multiparametric magnetic resonance imaging and fusion targeted biopsy with or without seminal vesicle biopsy. Magnetic resonance imaging suspicion of seminal vesicle invasion, multiparametric magnetic resonance imaging of prostate base lesions of moderate or greater suspicion, extraprostatic extension, anatomical zone and biopsy data were used to generate multivariable logistic regression models. One model without and one with biopsy data were externally validated in a multi-institutional cohort. Decision curve analyses were done to determine net benefit of the 2 models.

RESULTS

The training and validation cohorts comprised 564 and 250 patients, respectively. In the training cohort 55 patients (9.8%) had pathologically confirmed seminal vesicle invasion. In the prebiopsy model magnetic resonance imaging suspicion of seminal vesicle invasion (OR 9.5, 95% CI 4.0-22.4, p <0.001), multiparametric magnetic resonance imaging base lesions of moderate or greater suspicion with extraprostatic extension (OR 13.6, 95% CI 4.0-46.5, p <0.001), and a transition and/or central zone location (OR 11.6, 95% CI 3.5-38.3, p <0.001) showed strong correlations. In the post-biopsy model the risk of pathologically confirmed seminal vesicle invasion increased with the base Gleason Group (Gleason Group 5 OR 85.3, 95% CI 11.8-619.1, p <0.001). In the validation cohort the AUC of the prebiopsy and post-biopsy models was 0.84 and 0.93, respectively (p = 0.030).

CONCLUSIONS

Magnetic resonance imaging evidence of seminal vesicle invasion or extraprostatic extension at the prostate base transition and/or central zone and high grade prostate cancer from the prostate base are significant features associated with an increased risk of pathologically confirmed seminal vesicle invasion. Our models successfully incorporated these features to predict seminal vesicle invasion and inform when to biopsy the seminal vesicles.

Does proximity of positive prostate biopsy core to capsular margin help predict side-specific extracapsular extension at prostatectomy?

INTRODUCTION

To determine whether quantifying the proximity of positive prostate biopsy cores to the capsular edge may aid in identifying patients at risk for extracapsular extension (ECE) at the time of radical prostatectomy (RP).

MATERIALS AND METHODS

We reviewed a single-surgeon experience of 429 systematic transrectal prostate biopsies from 2010-2014. Marking ink was applied to the capsular edge ex vivo following specimen acquisition, and the proximity of cancer to the stained capsular edge was measured. Primary outcome was ECE at RP. Demographics, PSA, DRE findings, Gleason score, core location and involvement, and RP pathology were recorded. Predictors of ECE were identified using multivariable logistic regression. Receiver operating characteristic (ROC) analyses were performed to assess the predictive value of variables alone and in combination.

RESULTS

One hundred and one patients who underwent staining during biopsy received RP (202 hemiprostates). Thirty-three patients (40 hemiprostates) exhibited ECE. There were 343 positive stained biopsy cores. Mean proximity of carcinoma to capsule was 4.7 mm. On univariable analysis, proximity of positive core ≤ 1 mm to capsule was predictive of side-specific ECE (OR 2.86, p = 0.013), though significance was lost in multivariable models. Area under the curve (AUC) for proximity was 0.571 alone and 0.804 in combination with PSA, cT stage, and total biopsy Gleason score.

CONCLUSION

Proximity of positive biopsy core to capsular margin may supply additional information in predicting ECE but requires validation in a larger cohort. Implementation of a staining technique at the time of systematic biopsy may be helpful in counseling patients and determining utility of nerve-sparing approaches.

Efficacy and safety of fexapotide triflutate in outpatient medical treatment of male lower urinary tract symptoms associated with benign prostatic hyperplasia

Male lower urinary tract symptoms (LUTS) is an increasingly important problem for the majority of late middle aged and elderly men. Fexapotide triflutate (FT) is a first in-class compound given by local injection via the transrectal intraprostatic route under ultrasound guidance. Data from >1700 FT and control injections in prospective randomized blinded controlled multicenter trials are reviewed and discussed in relation to current developments in the field of treatments for LUTS associated with benign prostatic hyperplasia (BPH). Long-term studies of FT in the United States have shown statistically significant improvement in BPH symptoms and objective outcomes including significant reduction in both spontaneous acute urinary retention as well as the subsequent incidence of BPH surgery. FT has been shown to be well tolerated with an excellent safety profile, and is an efficacious clinic-based treatment for BPH involving an intraprostatic injection that requires only a few minutes to administer, with no catheter nor anesthesia requirements.

Management of Male Lower Urinary Tract Symptoms in a Simulated, Over-the-Counter Setting: An Exploratory Study of Tamsulosin

BACKGROUND

Lower urinary tract symptoms (LUTS) attributed to benign prostatic hyperplasia (BPH) are common in men, considerably affecting quality of life.

AIMS

The self-directed use of over-the-counter (OTC) tamsulosin (0.4 mg) and potential safety risks were evaluated in an open-label, uncontrolled, exploratory, 8-week OTC-simulated study.

METHODS

Men (≥ 18 years) were recruited via mass advertising about bothersome LUTS. In a working retail environment, respondents reviewed the product and decided whether it was appropriate for them to use (self-selection phase). After purchasing the product, participants' ability to use it as directed by the proposed drug facts label (DFL) was assessed (home-use phase).

RESULTS

Of 1446 eligible men, 679 completed the self-selection phase, and 73.9% (502/679) self-selected to use tamsulosin correctly according to the DFL. Of 369 participants who purchased tamsulosin and entered the home-use phase, 321 took one or more doses of tamsulosin and participated in at least one telephone interview. In total, 85.4% (274/321) of participants adhered to the 'Stop Use' and 'Directions' instructions in the DFL. Overall, 139 (39.6%) participants experienced one or more adverse events (AEs); 65 (18.5%) were deemed drug-related, including dizziness (11 [3.1%]), ejaculation disorder (6 [1.7%]), and semen volume decrease (6 [1.7%]). No unexpected AEs were reported.

CONCLUSIONS

Of the men interested in self-managing their LUTS, a majority had moderate-to-severe LUTS of long duration. Most men were able to appropriately self-select and use tamsulosin in concordance with DFL instructions and directions. No unexpected AEs were reported during self-directed use. With further label refinement, an over-the-counter tamsulosin option might be feasible.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01726270.

A patient-derived explant (PDE) model of hormone-dependent cancer

Breast and prostate cancer research to date has largely been predicated on the use of cell lines in vitro or in vivo. These limitations have led to the development of more clinically relevant models, such as organoids or murine xenografts that utilize patient-derived material; however, issues related to low take rate, long duration of establishment, and the associated costs constrain use of these models. This study demonstrates that ex vivo culture of freshly resected breast and prostate tumor specimens obtained from surgery, termed patient-derived explants (PDEs), provides a high-throughput and cost-effective model that retains the native tissue architecture, microenvironment, cell viability, and key oncogenic drivers. The PDE model provides a unique approach for direct evaluation of drug responses on an individual patient's tumor, which is amenable to analysis using contemporary genomic technologies. The ability to rapidly evaluate drug efficacy in patient-derived material has high potential to facilitate implementation of personalized medicine approaches.

Over-the-counter medication availability could augment self-management of male lower urinary tract symptoms

In this review, we focus on current trends in the management of male lower urinary tract symptoms (LUTS), defined here as LUTS, namely, storage, voiding, and post-micturition symptoms presumed secondary to benign prostatic hyperplasia (BPH), and discuss possible novel approaches toward better care. According to results of a PubMed database search covering the last 10 years and using keywords pertaining to male LUTS, this condition continues to be globally undiagnosed or diagnosed late, partly because of men's hesitation to seek help for perceived embarrassing problems or problems considered a normal part of aging. In addition, the prevalence of male LUTS is continually increasing because of a constantly aging population. Male LUTS can be bothersome and affect the quality of life (QoL) and sexual function. Additional effective alternatives for managing this condition need to be identified and incorporated into the current care model. Considering that most male LUTS such as frequency, hesitancy, urgency, and intermittency are easy to self-identify, a self-management approach toward male LUTS is proposed. Limited evidence supports the efficacy of phytotherapies and herbals as self-management options for male LUTS. However, introducing over-the-counter (OTC) medication with proven efficacy, accompanied by lifestyle and behavioral modifications, may be a promising approach that will encourage more men to treat their symptoms in a timely manner. Formal guidelines, along with appropriate education programs for patients and support from the healthcare community, will be needed to ensure that the promise of this approach is fully materialized.

Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline

PURPOSE

Male lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is common in men and can have negative effects on quality of life (QoL). It is the hope that this Guideline becomes a reference on the effective evidence-based surgical management of LUTS/BPH.

MATERIALS AND METHODS

The evidence team searched Ovid MEDLINE, the Cochrane Library, and the Agency for Healthcare Research and Quality (AHRQ) database to identify studies indexed between January 2007 and September 2017. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1 in supplementary unabridged guideline, http://jurology.com/).

RESULTS

This Guideline provides updated, evidence-based recommendations regarding management of LUTS/BPH utilizing surgery and minimally invasive surgical therapies; additional statements are made regarding diagnostic and pre-operative tests. Clinical statements are made in comparison to what is generally accepted as the gold standard (i.e. transurethral resection of the prostate [TURP]-monopolar and/or bipolar). This guideline is designed to be used in conjunction with the associated treatment algorithm.

CONCLUSIONS

The prevalence and the severity of LUTS increases as men age and is an important diagnosis in the healthcare of patients and the welfare of society. This document will undergo additional literature reviews and updating as the knowledge regarding current treatments and future surgical options continues to expand.

Aquablation therapy for symptomatic benign prostatic hyperplasia: a single-centre experience in 47 patients

OBJECTIVE

To report procedure process improvements and confirm the preserved safety and short-term effectiveness of a second-generation Aquablation device for the treatment of lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH) in 47 consecutive patients at a single institution.

PATIENTS AND METHODS

Aquablation was performed in 47 patients with symptomatic BPH at a single institution. Baseline, peri-operative and 3-month urinary function data were collected.

RESULTS

The mean (range) patient age was 66 (50-79) years, and transrectal ultrasonography-measured prostate volume was 48 (20-118) mL. A median lobe was present in 25 patients (53%) and eight patients had catheter-dependent urinary retention. The mean (range) total procedure time was 35 (13-128) min and the tissue resection time was 4 (1-10) min. Five Clavien-Dindo grade I/II and five Clavien-Dindo grade III complications were recorded in eight patients. The mean (range) hospital stay was 3.1 (1-8) days and the mean (range) duration of urethral catheterization was 1.9 (1-11) days. The mean International Prostate Symptom Score (IPSS) decreased from 24.4 at baseline to 5 at 3 months; IPSS quality-of-life score decreased from 4.5 to 0.3 points; peak urinary flow rate increased from 7.1 to 16.5 mL/s and post-void residual urine volume decreased from 119 to 43 mL (all P < 0.01).

CONCLUSIONS

This study confirmed procedure process improvements resulting from system enhancements, with preservation of safety and effectiveness during use of a second-generation device for the treatment of LUTS attibutable to BPH in the largest single-institution study conducted to date.

Erectile Dysfunction and Lower Urinary Tract Symptoms

CONTEXT

Lower urinary tract symptoms (LUTSs) and erectile dysfunction (ED) are substantial health concerns with a significant impact on the overall male quality of life.

OBJECTIVE

To evaluate the available evidence of the association between LUTSs and ED in patients with benign prostatic hyperplasia (BPH), and discuss possible clinical implications for the management of LUTS/BPH.

EVIDENCE ACQUISITION

A systematic review of the existing literature published between 1997 and June 2017 and available in the Medline, Scopus, and Web of Science databases was conducted using both the Medical Subject Heading (MeSH) and free-text protocols. The MeSH search was conducted by combining the following terms: "lower urinary tract symptoms," "LUTS," "benign prostatic hyperplasia," "BPH," "erectile dysfunction," "sexual dysfunction," "BPE," and "benign prostatic enlargement." The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed.

EVIDENCE SYNTHESIS

Several community-based studies in different geographical areas have provided strong evidence of an age-independent association between LUTSs and ED. Several biological mechanisms have been proposed to explain this association, but further research is required to better understand the molecular pathways involved. It is necessary to evaluate the possible impact of the metabolic syndrome treatment on LUTS/ED management. Considering the possible relationship between LUTSs and ED, their impact on the quality of life, and the possible adverse effects associated with LUTS medical treatment, clinicians should always evaluate ED in patients with LUTSs and take the opportunity to evaluate patients reporting ED for LUTSs.

CONCLUSIONS

Data from the peer-reviewed literature suggest the existence of an association between LUTS/BPH and ED, although their casual relationship has not been established yet. Emerging data also suggest that pathophysiological mechanisms involved in the metabolic syndrome are key factors in both disorders. Considering the association, it is also recommended that men presenting with LUTSs or ED should be evaluated for both disorders. A better understanding of the molecular pathways behind this association may also help identify new possible targets and develop novel therapeutic approaches to manage LUTSs and ED.

PATIENT SUMMARY

In this manuscript, we report on all the available evidence linking erectile dysfunction and lower urinary tract symptoms. Our findings suggest the existence of a strong relationship between these two conditions. On the basis of these findings, we recommend that clinicians always explore both conditions in male patients presenting with either of symptoms.

Three-Year Outcomes of the Prospective, Randomized Controlled Rezūm System Study: Convective Radiofrequency Thermal Therapy for Treatment of Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia

OBJECTIVE

To report 3-year outcomes of a prospective, multicenter, randomized, blinded control trial after treatment with convective radiofrequency (RF) water vapor thermal therapy for moderate to severe lower urinary tract symptoms due to benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Fifteen centers enrolled and randomized 197 men ≥50 years old with International Prostate Symptom Score (IPSS) ≥13, maximum flow rate (Qmax) ≤15 mL/s, and prostate volume 30 to 80 cc to thermal therapy with Rezūm System or control (2:1). Rigid cystoscopy with simulated active treatment sound effects served as the control procedure. Convective RF thermal energy was delivered into obstructive prostate tissue including the median lobe as needed. After randomized comparison at 3 months, thermal therapy subjects were followed annually for 3 years.

RESULTS

Convective RF thermal therapy yielded IPSS improvement of 160% compared with control subjects at 3 months (P <.0001). Maximal symptom relief of at least 50% improvement in IPSS, quality of life, Qmax, and BPH Impact Index remained durable throughout 3 years (P <.0001). Subjects with a treated median lobe had similar responses. No late-related adverse events occurred, and no de novo erectile dysfunction was reported. The surgical retreatment rate was 4.4% over 3 years.

CONCLUSION

The minimally invasive convective RF thermal therapy is an office or ambulatory outpatient procedure with minimal transient perioperative side effects. It provides early effective and durable relief of BPH symptoms with preservation of sexual function in subjects followed up for 3 years and is applicable to treatment of the median lobe and hyperplastic central zone tissue.