Gender-affirming Clitoroplasty and Construction of the Clitoro-urethral Complex: An Anatomy Guided Selection of Two Techniques

OBJECTIVE

To present 2 clitoroplasty techniques-the preputial skin and urethral flap-and describe our rationale for using each technique to construct the clitoro-urethral complex in gender-affirming vaginoplasty.

METHODS

For uncircumcised patients or circumcised patients with greater than 2 cm of inner preputial skin and at least 8 cm of shaft skin proximal to the circumcision scar, we use the preputial skin clitoroplasty, a modification of the Ghent style clitoroplasty. The entire corona is used after medial glans and urethral mucosa is excised. The corona is brought together 1 cm from midline to create the visible ovoid clitoris; the remaining coronal tissue remains lateral to the clitoris for erogenous sensation as clitoral corpora. The clitoris is anchored to the proximal tunica, positioned at the level of the adductor longus tendon. The folded neurovascular bundle is fixed in the suprapubic area. The ventral urethral is spatulated and urethral flap approximated to the clitoris. Preputial skin is sutured proximally as tension allows. The clitoro-urethral complex is inset into an opening created in the penile skin flap. For patients with less skin, we use the urethral flap clitoroplasty. More corpus spongiosum is used, as the urethra creates the clitoral hood; this is described in the literature and attributed to Pierre Brassard. The clitoris is inset following a dorsal urethrotomy, with a small collar of preputial skin sewn to the spongiosum and urethral mucosa. The urethra is transected about 1 cm distally. The ventral urethra is then spatulated and the urethroplasty completed.

RESULTS

We prefer the preputial skin flap technique for its' greater coronal tissue volume for erogenous sensation and better esthetics, in our opinion. Circumcised patients should have at least 2 cm of skin distal to the circumcision scar. To avoid using skin graft for the introitus-a risk for introital stenosis-shaft skin proximal to the circumcision line should be at least 8 cm.

CONCLUSION

We present 2 technical options for clitoroplasty and construction of the clitoro-urethral complex in gender-affirming vaginoplasty.

Penile and testicular prosthesis following gender-affirming phalloplasty and scrotoplasty: a narrative review and technical insights

Background and Objective

Transgender and gender diverse (TGD) individuals may seek gender-affirming phalloplasty with specific functional goals, including erectile function sufficient for penetrative sexual intercourse. Individuals seeking penile prosthesis placement must accept the potential risks to their phallic anatomy.

Methods

We review current practices at our center and narrative review of literature discussing techniques for penile prosthesis and testicular prosthesis placement after phalloplasty and scrotoplasty, as well as surgical outcomes, and quality of life outcomes where available.

Key Content and Findings

Early discussion of a staged approach to phallic construction with a last step of implant placement is important during initial phalloplasty counseling. Pre-operative counseling at our multi-disciplinary center includes: discussion of surgical history, complications, goals and priorities; physical exam to evaluate phallic size and position, scrotal size, and other anatomic findings that may influence prosthesis selection; urinary evaluation, including uroflowmetry with post-void residual, and a cystoscopy with retrograde urethrogram if indicated based on symptoms or urinary studies, and discussion of surgical risks, benefits and alternatives. Although none of the commercially available penile prosthesis devices in the United States are designed for phalloplasty, modern inflatable and malleable prostheses are adapted for use in the post-phalloplasty setting. Due to the lack of native corpora cavernosa, highly variable phallic anatomy, and the need to adapt implants designed for natal penile anatomy, complication rates of prosthesis placement after phalloplasty remain high, with reported ranges of complications from 20% to 80%.

Conclusions

Major complications requiring surgical revision are common relative to implant placement in natal penile anatomy, and include: infection requiring explantation, device extrusion, erosion, migration or malposition, inadequate rigidity, poor aesthetic result, pain, decrease or loss of erogenous and/or tactile sensation, device failure, injury to the urethra, and injury to the neurovascular supply of the penis with resultant partial or complete flap loss. This broad range of complication rates represents the variability with which results are reported and reflect a lack of clear reporting guidelines, significant variability in techniques, and need for more standardization. To optimize outcomes, it is important that surgeons have an in-depth understanding of phalloplasty anatomy and are equipped to manage potential complications in the short- and long-term.

Wound related complications and the anterior rectus sheath versus Gibson approach to kidney transplantation: A single center randomized controlled trial

INTRODUCTION

Wound related complications (WRC) are a significant source of morbidity in kidney transplant recipients, and may be mitigated by surgical approach. We hypothesize that the anterior rectus sheath approach (ARS) may decrease WRC and inpatient opiate use compared to the Gibson Approach (GA).

METHODS

This double-blinded randomized controlled trial allocated kidney transplant recipients aged 18 or older, exclusive of other procedures, 1:1 to ARS or GA at a single hospital. The ARS involves a muscle-splitting paramedian approach to the iliopsoas fossa, compared to the muscle-cutting GA. Patients and data analysts were blinded to randomization.

RESULTS

Seventy five patients were randomized to each group between August 27, 2019 and September 18, 2020 with a minimum 12 month follow-up. There was no difference in WRC between groups (p = .23). Nine (12%) and three patients (4%) experienced any WRC in the ARS and GA groups, respectively. Three and one Clavien IIIb complications occurred in the ARS and GA groups, respectively. In a multiple linear regression model, ARS was associated with decreased inpatient opioid use (β = -58, 95% CI: -105 to -12, p = .016).

CONCLUSIONS

The ARS did not provide a WRC benefit in kidney transplant recipients, but may be associated with decreased inpatient opioid use.

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy

Transgender and non-binary (TGNB) individuals are seeking penile reconstruction in greater numbers; many pursue urethral lengthening surgery with a goal of voiding while standing. Changes in urinary function and urologic complications-i.e., urethrocutaneous fistulae and urinary stricture-are common. Familiarity with presenting symptoms and management strategies for urinary complaints after genital gender-affirming surgery (GGAS) can improve patient counseling and outcomes. We will describe current gender-affirming penile construction options with urethral lengthening and review associated urinary complications that present as urinary incontinence. The incidence and impact of lower urinary tract symptoms after metoidioplasty and phalloplasty are poorly characterized due to limited post-operative follow-up. Post-phalloplasty, urethrocutaneous fistula is the most common urethral complication, ranging in incidence from 15-70%. Assessment of concomitant urethral stricture is necessary. No standard technique exists for management of these fistula or strictures. Metoidioplasty studies report lower rates of stricture and fistula, 2% and 9% respectively. Other common voiding complaints include dribbling, urethral diverticula and vaginal remnants. History and physical exam in the post-GGAS evaluation require understanding of prior surgeries and attempted reconstructive efforts; adjuncts to physical exam include uroflowmetry, retrograde urethrography, voiding cysto-urethrogram, cystoscopy, and MRI. Following gender-affirming penile construction, TGNB patients may experience a host of urinary symptoms and complications that impact quality of life. Due to anatomic differences, symptoms require tailored evaluation which can be done by urologists in an affirming environment.

Bilateral Cavernosal Artery Ligation to Treat Ischemic Priapism Following Inflatable Penile Prosthesis Implantation

OBJECTIVE

To describe the first known case of recurrent acute priapism after penile prosthesis implantation.

MATERIALS AND METHODS

A 60-year-old gentleman with a history of recurrent ischemic priapism without hemoglobinopathy presented with refractory erectile dysfunction and underwent uncomplicated penile prosthesis placement. His course was complicated by early acute ischemic priapism confirmed via ultrasound. Due to his pain, attempts to relieve the priapism using ultrasound-guided phenylephrine injections were attempted but were unsuccessful.

RESULTS

He subsequently underwent exploration with confirmation of distal ischemic priapism followed by brisk bright red blood from the proximal corpora upon device externalization. A perineal exploration was performed and the bilateral cavernosal arteries were suture ligated with immediate relief. The device was reimplanted and the patient recovered uneventfully.

CONCLUSION

We report the first known case of ischemic priapism following inflatable penile prosthesis implantation. The details of this case challenge the dogma that priapism is a binary event and instead supports an imbalance between unopposed cavernosal artery inflow possibly due to vascular calcifications and compromised venous outflow due to the presence of the device. Prosthetic urologists should be aware of this rare phenomenon and consider all available approaches on an individualized case-by-case basis.

Causes of death among people with myelomeningocele: A multi-institutional 47-year retrospective study

PURPOSE

This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD.

METHODS

A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics.

RESULTS

Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47).

CONCLUSION

COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.

Contemporary management of advanced prostate cancer: an evolving landscape

Recent population-based studies suggest that the incidence of advanced and metastatic prostate cancer may be increasing. Concurrently with this apparent stage migration toward advanced disease, several major developments have occurred in the treatment paradigm for men with advanced prostate cancer. These include the US Food and Drug Administration approval of 8 novel agents over the last decade. In addition to novel pharmaceuticals, rapidly evolving diagnostic tools have emerged. This review provides a primer for clinicians who treat men with advanced prostate cancer, including medical oncologists, radiation oncologists, and urologists.

The role of pulse width manipulation compared to program changes alone for unsatisfactory sacral neuromodulation therapy: A retrospective matched-cohort analysis

AIM

Pulse width (PW) influences neuromodulation by its impact on nerve fiber recruitment. A paucity of data regarding the manipulation of PW in sacral neuromodulation (SNM) exists. This study describes the clinical features and outcomes of PW manipulation for unsatisfactory SNM therapy.

METHODS

A retrospective, single-institution review was performed of reprogrammed SNM patients between 2010 and 2019. Two cohorts were created: those with PW changes ± program changes and age-matched controls with program changes alone. Patients lacking follow-up and non-InterStim II models were excluded.

RESULTS

Out of 710 SNM interrogations, 147 (20.7%) had PW changes and 80 met inclusion criteria. Most PW changes were shortened (61/80, 76.3%). Clinical features did not differ between cohorts except by indication for reprogramming. The most common indication for PW change was painful stimulation (34/80, 43%), whereas in controls it was suboptimal efficacy (76/80, 95%). Clinical success was stratified by indication. There was a higher improvement in efficacy in the PW cohort (61%, 17/28 vs. 36%, 27/76, p = .02). PW manipulation successfully relieved painful stimulation in 50% (17/34 vs. 0/3, p = .23), which was more likely with a shortened compared to extended PW (14/15, 93.3% vs. 0/6, 0%, p < .01). PW resulted in improvement in localization of the stimulus in 94% (17/18 vs. 0/1, p = .10). The subsequent lead revision or explant was significantly higher in the PW cohort (43% vs. 25%, p = .03).

CONCLUSION

PW manipulation may aid the salvage of unsatisfactory SNM therapy. These findings represent an initial assessment of the role of PW in SNM, particularly regarding the efficacy and painful stimuli. The further prospective investigation is warranted.

Ectopic expression of L1CAM ectodomain alters differentiation and motility, but not proliferation, of human neural progenitor cells

Adult human neural progenitor and stem cells have been implicated as a potential source of brain cancer causing cells, but specific events that might cause cells to progress towards a transformed phenotype remain unclear. The L1CAM (L1) cell adhesion/recognition molecule is expressed abnormally by human glioma cancer cells and is released as a large extracellular ectodomain fragment, which stimulates cell motility and proliferation. This study investigates the effects of ectopic overexpression of the L1 long ectodomain (L1LE; ˜180 kDa) on the motility, proliferation, and differentiation of human neural progenitor cells (HNPs). L1LE was ectopically expressed in HNPs using a lentiviral vector. Surprisingly, overexpression of L1LE resulted in reduced HNP motility in vitro, in stark contrast to the effects on glioma and other cancer cell types. L1LE overexpression resulted in a variable degree of maintenance of HNP proliferation in media without added growth factors but did not increase proliferation. In monolayer culture, HNPs expressed a variety of differentiation markers. L1LE overexpression resulted in loss of glutamine synthetase (GS) and β3-tubulin expression in normal HNP media, and reduced vimentin and increased GS expression in the absence of added growth factors. When co-cultured with chick embryonic brain cell aggregates, HNPs show increased differentiation potential. Some HNPs expressed p-neurofilaments and oligodendrocytic O4, indicating differentiation beyond that in monolayer culture. Most HNP-L1LE cells lost their vimentin and GFAP (glial fibrillary acidic protein) staining, and many cells were positive for astrocytic GS. However, these cells rarely were positive for neuronal markers β3-tubulin or p-neurofilaments, and few HNP oligodendrocyte progenitors were found. These results suggest that unlike for glioma cells, L1LE does not increase HNP cell motility, but rather decreases motility and influences the differentiation of normal brain progenitor cells. Therefore, the effect of L1LE on increasing motility and proliferation appears to be limited to already transformed cells.

Posterior Vaginal Wall Prolapse: Suture-Based Repair

Pelvic organ prolapse is common in parous women, although few report symptoms. The incidence of posterior compartment prolapse, or rectocele, is less well-reported. Posterior vaginal wall prolapse is associated with pain, constipation, and splinting. Surgery is the mainstay of therapy for symptomatic rectoceles. Though several surgical techniques have been described, no clear indications for type of repair have emerged. This article reviews the management strategies and draws conclusions about suture-based and site-specific techniques.

Kidney, Ureteral, and Bladder Cancer: A Primer for the Internist

Malignancies of the urinary tract (kidney, ureter, and bladder) are distinct clinical entities. Hematuria is a unifying common presenting symptom for these malignancies. Surgical management of localized disease continues to be the mainstay of treatment, and early detection is important in the prognosis of disease. Patients often require life-long follow-up and assessment for recurrence.

The prostate cancer prevention trial risk calculator 2.0 performs equally for standard biopsy and MRI/US fusion-guided biopsy

BACKGROUND

The Prostate Cancer Prevention Trial Risk Calculator 2.0 (PCPTRC) is a widely used risk-based calculator used to assess a man's risk of prostate cancer (PCa) before biopsy. This risk calculator was created from data of a patient cohort undergoing a 6-core sextant biopsy, and subsequently validated in men undergoing 12-core systematic biopsy (SBx). The accuracy of the PCPTRC has not been studied in patients undergoing magnetic resonance imaging/ultrasound (MRI/US) fusion-guided biopsy (FBx). We sought to assess the performance of the PCPTRC for straitifying PCa risk in a FBx cohort.

METHODS

A review of a prospective cohort undergoing MRI and FBx/SBx was conducted. Data from consecutive FBx/SBx were collected between August 2007 and February 2014, and PCPTRC scores using the PCPTRC2.0R-code were calculated. The risk of positive biopsy and high-grade cancer (Gleason ⩾7) on biopsy was calculated and compared with overall and high-grade cancer detection rates (CDRs). Receiver operating characteristic curves were generated and the areas under the curves (AUCs) were compared using DeLong's test.

RESULTS

Of 595 men included in the study, PCa was detected in 39% (232) by SBx compared with 48% (287) on combined FBx/SBx biopsy. The PCPTRC AUCs for the CDR were similar (P=0.70) for SBx (0.69) and combined biopsy (0.70). For high-grade disease, AUCs for SBx (0.71) and combined biopsy (0.70) were slightly higher, but were not statistically different (P=0.55).

CONCLUSIONS

In an MRI-screened population of men undergoing FBx, PCPTRC continues to represent a practical method of accurately stratifying PCa risk.

Evaluating the Relationship Between Participation in Student-Run Free Clinics and Changes in Empathy in Medical Students

Purpose: We explored differences in changes in medical student empathy in the third year of medical school between volunteers at JeffHOPE, a multisite medical student–run free clinic of Sidney Kimmel Medical College (SKMC), and nonvolunteers. Method: Volunteerism and leadership experience at JeffHOPE were documented for medical students in the Class of 2015 (n = 272) across their medical educations. Students completed the Jefferson Scale of Empathy at the beginning of medical school and at the end of the third year. Students who reported participation in other Jefferson-affiliated clinics (n = 44) were excluded from this study. Complete data were available for 188 SKMC students. Results: Forty-five percent of students (n = 85) volunteered at JeffHOPE at least once during their medical educations. Fifteen percent of students (n = 48) were selected for leadership positions involving weekly clinic participation. Nonvolunteers demonstrated significant decline in empathy in medical school (P = 0.009), while those who volunteered at JeffHOPE at least once over the course of their medical educations did not show any significant decline (P = 0.07). Conclusions: These findings suggest that medical students may benefit from volunteering at student-run free clinics to care for underserved populations throughout medical school.

Should Hypoechoic Lesions on Transrectal Ultrasound Be Sampled During Magnetic Resonance Imaging-targeted Prostate Biopsy?

OBJECTIVE

To determine whether supplemental biopsy of hypoechoic ultrasound lesions (HUL) incidentally found during magnetic resonance imaging (MRI)-transrectal ultrasound (TRUS) fusion-targeted prostate biopsy results in improved prostate cancer (PCa) detection.

METHODS

Patients underwent MRI-TRUS-targeted biopsy as part of an ongoing prospective trial from August 2007 to February 2015. For men with HUL, the biopsy pathology of HUL and MRI lesions was classified according to the updated 2014 International Society of Urological Pathology (ISUP) grading system. The detection of PCa by MRI-targeted biopsy with and without HUL biopsy was compared.

RESULTS

Of 1260 men in the trial, 106 underwent biopsy of 119 HULs. PCa was diagnosed in 52 out of 106 men (49%) by biopsy of either MRI lesions or HUL. Biopsy of HUL in addition to MRI lesions resulted in 4 additional diagnoses of high-grade (ISUP grades 3-5) PCa versus biopsy of MRI lesions alone (20 vs 16 men, P = .046). Three of these cases were upgraded from lower grade (ISUP grades 1-2) PCa on MRI-guided biopsy alone, and only 1 case (1% of cohort) was diagnosed that would have been missed by MRI-guided biopsy alone. Supplemental biopsy of HUL did not change the PCa risk category in 96% (102 out of 106) of men with HUL.

CONCLUSION

Supplemental biopsy of HUL yields a small increase in the detection of higher grade PCa as compared with biopsy of MRI lesions alone. As upgrading is rare, routinely screening for HUL during MRI-targeted biopsy remains controversial.

Preoperative Multiparametric Magnetic Resonance Imaging Predicts Biochemical Recurrence in Prostate Cancer after Radical Prostatectomy

Objectives

To evaluate the utility of preoperative multiparametric magnetic resonance imaging (MP-MRI) in predicting biochemical recurrence (BCR) following radical prostatectomy (RP).

Materials/Methods

From March 2007 to January 2015, 421 consecutive patients with prostate cancer (PCa) underwent preoperative MP-MRI and RP. BCR-free survival rates were estimated using the Kaplan-Meier method. Cox proportional hazards models were used to identify clinical and imaging variables predictive of BCR. Logistic regression was performed to generate a nomogram to predict three-year BCR probability.

Results

Of the total cohort, 370 patients met inclusion criteria with 39 (10.5%) patients experiencing BCR. On multivariate analysis, preoperative prostate-specific antigen (PSA) (p = 0.01), biopsy Gleason score (p = 0.0008), MP-MRI suspicion score (p = 0.03), and extracapsular extension on MP-MRI (p = 0.03) were significantly associated with time to BCR. A nomogram integrating these factors to predict BCR at three years after RP demonstrated a c-index of 0.84, outperforming the predictive value of Gleason score and PSA alone (c-index 0.74, p = 0.02).

Conclusion

The addition of MP-MRI to standard clinical factors significantly improves prediction of BCR in a post-prostatectomy PCa cohort. This could serve as a valuable tool to support clinical decision-making in patients with moderate and high-risk cancers.

The role of MRI in active surveillance for prostate cancer

Approximately one in seven American men will be diagnosed with prostate cancer during his lifetime, and at least 50% of newly diagnosed patients will present with low-risk disease. In the last decade, the decision-making paradigm for management has shifted due to high rates of disease detection and overtreatment, attributed to prostate-specific antigen screening, with more men deferring definitive treatment for active surveillance. The advent of multiparametric magnetic resonance imaging (MP-MRI) and MRI/ transrectal ultrasound-guided fusion-guided prostate biopsy has refined the process of diagnosis, identifying patients with clinically-significant cancer and larger disease burden who would most likely benefit from intervention. In parallel, the utilization of MP-MRI in the surveillance of low-grade, low-volume disease is on the rise, reflecting support in a growing body of literature. The aim of this review is to appraise and summarize the data evaluating the role of magnetic resonance imaging in active surveillance for prostate cancer.

The significance of anterior prostate lesions on multiparametric magnetic resonance imaging in African-American men

INTRODUCTION

African-American (AA) men tend to harbor high-risk prostate cancer (PCa) and exhibit worse outcomes when compared to other groups. It has been postulated that AA men may harbor more anterior prostate lesions (APLs) that are undersampled by the standard transrectal ultrasound guided-biopsy (SBx), potentially resulting in greater degree of Gleason score (GS) upgrading at radical prostatectomy. We aimed to evaluate the detection rate of anterior PCa significance of APLs in AA men on multiparametric magnetic resonance imaging (mpMRI) and compare it to a matched cohort of White/Other (W/O) men.

MATERIALS AND METHODS

A review of 1,267 men who had an mpMRI with suspicious prostate lesions and who underwent magnetic resonance transrectal ultrasound fusion-guided biopsy (FBx) with concurrent SBx in the same biopsy session was performed. All AA men were matched to a control group of W/O using a 1:1 propensity score-matching algorithm with age, prostate-specific antigen, and prostate volume as matching variables. Logistic regression analysis was used to determine predictors of APLs in AA men.

RESULTS

Of the 195 AA men who underwent mpMRI, 93 (47.7%) men had a total of 109 APLs. Prior negative SBx was associated with the presence of APLs in AA men (Odds ratio = 1.81; 95% CI: 1.03-3.20; P = 0.04). On multivariate logistic regression analysis, smaller prostate (P = 0.001) and rising prostate-specific antigen (P = 0.007) were independent predictors of cancer-positive APLs in AA men. Comparative analysis of AA (93/195, 47.7%) vs. W/O (100/194, 52%) showed no difference in the rates of APLs (P = 0.44) or in cancer detection rate within those lesions or the distribution of GS within those cancers (P = 0.63) despite an overall higher cancer detection rate in AA men (AA: 124/195 [63.6%] vs. W/O: 97/194 [50.0%], P = 0.007). In cases where APLs were positive for PCa on FBx, the GS of APL was equal to the highest GS of the entire gland in 82.9% (29/35) and 90.9% (30/33) of the time in AA and W/O men, respectively.

CONCLUSION

Cancer-positive APLs represented the highest risk GS in most cases. AA men with prior negative SBx are twice as likely to harbor a concerning APL. In our cohort, AA and W/O men had comparable rates of APLs on mpMRI. Thus, differences in APLs do not explain the higher risk of AA men for deahth due to PCa. However, targeting of APLs via FBx can clinically improve PCa risk stratification and guide appropriate treatment options.

Prostate Cancer Diagnosis on Repeat Magnetic Resonance Imaging-Transrectal Ultrasound Fusion Biopsy of Benign Lesions: Recommendations for Repeat Sampling

PURPOSE

Urologists face a dilemma when a lesion identified on multiparametric magnetic resonance imaging is benign on image guided fusion biopsy. We investigated the detection rate of prostate cancer on repeat fusion biopsy in multiparametric magnetic resonance imaging lesions initially found to be pathologically benign on fusion biopsy.

MATERIALS AND METHODS

We reviewed the records of all patients from 2007 to 2014 who underwent multiparametric magnetic resonance imaging and image guided fusion biopsy. We identified men who underwent rebiopsy of the same discrete lesion after initial fusion biopsy results were benign. Data were documented on a per lesion basis. We manually reviewed UroNav system (Invivo, Gainesville, Florida) needle tracking to verify accurate image registration. Multivariate analysis was used to identify clinical and imaging factors predictive of prostate cancer detection at repeat fusion biopsy.

RESULTS

A total of 131 unique lesions were rebiopsied in 90 patients. Of these 131 resampled lesions 21 (16%) showed prostate cancer, which in 13 (61.9%) was Gleason 3 + 3. On multivariate analysis only lesion growth on repeat multiparametric magnetic resonance imaging was significantly associated with prostate cancer detection at repeat biopsy (HR 3.274, 95% CI 1.205-8.896, p = 0.02).

CONCLUSIONS

Pathologically benign multiparametric magnetic resonance imaging lesions on initial image guided fusion biopsy are rarely found to harbor clinically significant prostate cancer on repeat biopsy. When prostate cancer was identified, most disease was low risk. An increase in lesion diameter was an independent predictor of prostate cancer detection. While these data are retrospective, they may provide some confidence in the reliability of negative initial image guided fusion biopsies despite a positive multiparametric magnetic resonance imaging finding.

Reproducibility of Multiparametric Magnetic Resonance Imaging and Fusion Guided Prostate Biopsy: Multi-Institutional External Validation by a Propensity Score Matched Cohort

PURPOSE

As the adoption of magnetic resonance imaging/ultrasound fusion guided biopsy expands, the reproducibility of outcomes at expert centers becomes essential. We sought to validate the comprehensive NCI (National Cancer Institute) experience with multiparametric magnetic resonance imaging and fusion guided biopsy in an external, independent, matched cohort of patients.

MATERIALS AND METHODS

We compared 620 patients enrolled in a prospective trial comparing systematic biopsy to fusion guided biopsy at NCI to 310 who underwent a similar procedure at Long Island Jewish Medical Center. The propensity score, defined as the probability of being treated outside NCI, was calculated using the estimated logistic regression model. Patients from the hospital were matched 1:1 for age, prostate specific antigen, magnetic resonance imaging suspicion score and prior negative biopsies. Clinically significant disease was defined as Gleason 3 + 4 or greater.

RESULTS

Before matching we found differences between the cohorts in age, magnetic resonance imaging suspicion score (each p <0.001), the number of patients with prior negative biopsies (p = 0.01), and the overall cancer detection rate and the cancer detection rate by fusion guided biopsy (each p <0.001). No difference was found in the rates of upgrading by fusion guided biopsy (p = 0.28) or upgrading to clinically significant disease (p = 0.95). A statistically significant difference remained in the overall cancer detection rate and the rate by fusion guided biopsy after matching. On subgroup analysis we found a difference in the overall cancer detection rate and the rate by fusion guided biopsy (p <0.001 and 0.003) in patients with prior negative systematic biopsy but no difference in the 2 rates (p = 0.39 and 0.51, respectively) in biopsy naïve patients.

CONCLUSIONS

Improved detection of clinically significant cancer by magnetic resonance imaging and fusion guided biopsy is reproducible by an experienced multidisciplinary team consisting of dedicated radiologists and urologists.

Multi-institutional evaluation of multiparametric MRI and fusion-guided prostate biopsy in a biopsy-naive population

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Background: Multiparametric MRI (mpMRI) and fusion biopsy (FB) has proven beneficial in men with a prior negative systematic biopsy (SB) or diagnosis of prostate cancer (CaP). The aim of the study was to evaluate mpMRI and FB in a biopsy-naive population. Methods: A multi-institutional review was performed on patients with no prior biopsy history who underwent mpMRI followed by concurrent FB and SB. Imaging protocol was standardized across institutions. Gleason score (GS) distribution/risk classifications were recorded. Univariate analysis was performed to compare FB versus SB. Results: A total of 361 biopsy-naive men were identified from 4 institutions. GS distribution/risk classification for FB and SB are presented in the table. Overall cancer detection rate (CDR) was 65.4%. In biopsy-naive men, FB detected a greater absolute number of high grade disease with 13% more high risk CaP than SB (78 vs 69). Additionally, FB detected 21% fewer cases of GS 6 CaP (57 vs 69). The CDR for FB alone was 57.3% with only 3 intermediate-risk and 1 high-risk patient not identified. The addition of SB to FB resulted in diagnosing 25 added cases of low-risk disease for each high risk CaP detected. The CDR of SB alone was 59.6%, however, 2 intermediate- and 4 high-risk CaP were missed. The addition of FB to SB alone resulted in only 4 added cases of low-risk CaP for each high-risk CaP detected. Conclusions: In biopsy-naive men, mpMRI and fusion biopsy detects a greater number of patients with high-risk disease while decreasing the detection of low-risk CaP. Additional studies with greater power will be required to validate the potential benefit of mpMRI and FB in patients with no prior biopsy history. [Table: see text]

Expanded criteria in men on active surveillance monitored by MRI-TRUS fusion biopsy

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Background: Active surveillance (AS) is an established option for men with prostate cancer. Studies have shown that multiparametric-MRI along with MRI-TRUS fusion-guided biopsy (FB) may better assess risk in patients eligible for AS, compared to 12-core biopsy, due to improved detection of clinically significant cancers. The objective is to evaluate the performance of expanded criteria eligibility in men on AS being monitored with MRI-TRUS guided biopsy. Methods: Men on AS were included if they had mp-MRI and pathology data for 2 or more FB sessions. FB procedures consisted of targeted biopsies and random 12 core biopsies. Men participated in AS with low and intermediate risk prostate cancer, Gleason score ≤ 3+4=7 with no restriction on percent core involvement or number of cores positive. Progression was defined by patients with initial Gleason 3+3=6 to any Gleason 4, and Gleason 3+4=7 disease progressing to a primary Gleason 4 or higher. Results: 124 men on AS met study criteria. Low risk men had a mean age of 61.3 years versus intermediate risk men with a mean age of 65.5 years (p=0.0062). Mean PSA levels of the low and intermediate risk groups were 5.8 and 5.76 ng/ml (p=0.95), respectively. The mean length of follow-up was 22.56 months (range: 3.6 – 74.4 mo). Rates of pathologic progression in the intermediate and low risk patients were, 38.5% vs. 28.5% (p=0.33). Intermediate risk men had a mean progression-free survival (PFS) of 2.8 years compared to low risk men of 3.9 years (p=0.27). Patients were stratified according to established AS criteria (Epstein, Toronto, PRIAS) and rates of progression are summarized in the Table. 69% of patients met Epstein criteria for AS of which 29.4% (20/68) progressed compared to 28.5% for the low risk cohort overall. Conclusions: Men in our cohort who met strict criteria for AS had the same rate of progression as the entire expaned criteria low risk cohort, 29.4% vs 28.5%, respectively. Our data suggests that with accurate initial Gleason classification other AS criteria such as percent core or number of cores positive have no added benefit in predicting which men may have reclassification or progression of disease. [Table: see text]

Combined Biparametric Prostate Magnetic Resonance Imaging and Prostate-specific Antigen in the Detection of Prostate Cancer: A Validation Study in a Biopsy-naive Patient Population

OBJECTIVE

To validate the use of biparametric (T2- and diffusion-weighted) magnetic resonance imaging (B-MRI) and prostate-specific antigen (PSA) or PSA density (PSAD) in a biopsy-naive cohort at risk for prostate cancer (PCa).

METHODS

All patients (n = 59) underwent PSA screening and digital rectal exam prior to a B-MRI followed by MRI or transrectal ultrasound fusion-guided targeted biopsy. Previously reported composite formulas incorporating screen positive lesions (SPL) on B-MRI and PSA or PSAD were developed to maximize PCa detection. For PSA, a patient was considered screen positive if PSA level + 6 × (the number of SPL) >14. For PSAD, screening was positive if PSAD × 14 + (the number of SPL) >4.25. These schemes were employed in this new test set to validate the initial formulas. Performance assessment of these formulas was determined for all cancer detection and for tumors with Gleason ≥3 + 4.

RESULTS

Screen positive lesions on B-MRI had the highest sensitivity (95.5%) and negative predictive value of 71.4% compared with PSA and PSAD. B-MRI significantly improved sensitivity (43.2-72.7%, P = .0002) when combined with PSAD. The negative predictive value of PSA increased with B-MRI, achieving 91.7% for B-MRI and PSA for Gleason ≥3 + 4. Overall accuracies of the composite equations were 81.4% (B-MRI and PSA) and 78.0% (B-MRI and PSAD).

CONCLUSION

Validation with a biopsy-naive cohort demonstrates the parameter SPL performed better than PSA or PSAD alone in accurately detecting PCa. The combined use of B-MRI, PSA, and PSAD resulted in improved accuracy for detecting clinically significant PCa.

Lymph node staging in prostate cancer

Nodal staging is important in prostate cancer treatment. While surgical lymph node dissection is the classic method of determining whether lymph nodes harbor malignancy, this is a very invasive technique. Current noninvasive approaches to identifying malignant lymph nodes are limited. Conventional imaging methods rely on size and morphology of lymph nodes and have notoriously low sensitivity for detecting malignant nodes. New imaging techniques such as targeted positron emission tomography (PET) imaging and magnetic resonance lymphography (MRL) with iron oxide particles are promising for nodal staging of prostate cancer. In this review, the strengths and limitations of imaging techniques for lymph node staging of prostate cancer are discussed.

MRI/US fusion-guided biopsy to detect clinically significant prostate cancer in the central gland correlating with index lesion

44

Background: Central gland (CG) prostate cancers (CaP) are reported with lesser incidence and smaller tumor volume compared to the peripheral zone (PZ). Index tumor lesions defined by highest grade may be missed when in the CG. MRI/US fusion-guided biopsy allows targeting of lesions, potentially identifying cancer outside the traditional TRUS biopsy template. Methods: Retrospective review of 1,003 patients who underwent multiparametric MRI (mpMRI) found 2,119 suspicious lesions. Targets were biopsied and stratified by zonal distribution, CG or PZ. Cancer detection rates (CDR) were tabulated by location and correlated with PSA, Gleason score, prostate volume and MRI suspicion. Results: Fusion-guided biopsy targeted lesions in the central (711, 34%) or peripheral (1408, 66%) prostatic zones. CDR was similar between zones: 35.2% CG compared to 33.6% PZ (Table). CDR of clinically significant disease (Gleason >4+3) was similar in the CG and PZ despite higher prostate volume in those with CG lesions. In contrast to TRUS biopsy, upgrading occurred in 18.5% of CG patients versus 13.3% PZ (p=0.024). 36.6% (77/210) of CG lesions represented the highest risk lesion on MRI, translating to 13% (77/592) of the biopsy-proven CaP cohort. Conclusions: CG cancers occur at a similar frequency as PZ CaP. CG lesions were more likely to be upgraded from TRUS biopsy, frequently representing the index lesion. In upgraded patients, CG targets constituted the index lesion in a third of all males. MRI/US fusion-guided biopsy identifies clinically significant disease of the CG not captured on traditional biopsy. [Table: see text]

Can mpMRI predict biochemical recurrence after radical prostatectomy? Implications for preoperative staging and surgical planning

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Background: Multiparametric magnetic resonance imaging (mpMRI) used in conjunction with MR/TRUS fusion-guided biopsy has improved detection and localization of clinically significant prostate cancer. We aim to evaluate the utility of preoperative MRI characteristics to predict biochemical recurrence (BCR) following radical prostatectomy. Methods: Patients who underwent robotic assisted radical prostatectomy (RARP) between 2007-2014 at the National Institutes of Health were reviewed. We identified patients with BCR defined following the guidelines of the AUA Localized Prostate Cancer Update Panel report (serum PSA ≥0.2 ng/ml with a subsequent confirmatory value). Bivariate analysis and logistic regression were used to determine the association of mpMRI and preoperative patient characteristics with BCR. Results: Of 365 patients who had RARP, 21 met criteria for BCR with a median follow up of 19 months (IQR: 10-34). Mean preoperative PSA (ng/mL) [p<0.001], high MRI suspicion level [p=0.016], presence of extracapsular extension (ECE) on MRI [p=0.003], and total prostate volume by MRI (cc) [p<0.001] were associated with BCR. Increasing MRI suspicion corresponded to increases in rates of BCR within suspicion levels (2.22% of low, 3.88% of moderate, and 10.64% of high). The rates of BCR were significantly greater in men with ECE on final pathology [p<0.001]. Gleason grade trended toward significance [p=0.058]. Controlling for potentially confounding preoperative variables on multivariate analysis, MRI suspicion score, ECE on MRI, and total prostate volume by MRI remained significantly associated with predicting BCR. Conclusions: MRI suspicion score, ECE on mpMRI, and total prostate volume were associated with BCR in patients undergoing RARP. Preoperative mpMRI characteristics aid in risk stratification, patient counseling, and modification of surgical technique in those with high risk imaging features for BCR. The integration of mpMRI characteristics into a comprehensive model of BCR may provide robust tools for preoperative staging and surgical planning.

External validation of multiparametric MRI and fusion-guided prostate biopsy: A matched cohort analysis

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Background: MRI/US fusion-guided biopsy has been shown to improve the detection of clinically significant prostate cancer (PCa). As adoption of this novel technology expands, the reproducibility of outcomes from expert centers becomes essential. The objective of our study was to validate the comprehensive NCI experience of multiparametric MRI and fusion-guided biopsy (FB) with an external, independent, matched cohort of patients. Methods: We compared 1,003 patients enrolled from August 2007 through February 2014 in a prospective trial comparing systematic 12-core biopsy (SB) to FB at the NCI to 256 patients that underwent an identical procedure at Long Island-Jewish Hospital (LIJH) from February 2012 to June 2014. Patients from LIJH were matched 1:1 for age, PSA, and MRI suspicion score to a corresponding cohort of NCI patients. Clinically-significant (CS) disease was defined as a Gleason score of ≥4+3 in any biopsy core. Results: The overall cancer detection rate was 564/1,003 (56%) of NCI patients and 167/256 (65%) of LIJH patients. In the matched cohort analysis, cancer detection rate (CDR) by FB between cohorts was 52% NCI vs. 54% LIJH (p=0.67). Both cohorts demonstrated a similar rates of upgrading by FB compared to SB, 29% NCI vs. 23% LIJH (p=0.42). This trend applied to patients that upgraded to CS disease by FB, 12.7% NCI vs. 12.6% LIJH (p=0.42) (Table). Conclusions: The improved detection of clinically-significant cancer by mpMRI and FB is reproducible in the hands of an experienced multi-disciplinary team. Our results suggest that with appropriate training in the interpretation of mpMRI and performance of FB, dissemination of this technology can render equivalent outcomes. [Table: see text]

How reliable is a negative MRI/TRUS fusion biopsy? The predictive value of targeted biopsy for prostate cancer

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Background: Multiparametric MRI (mpMRI) has been shown to improve clinically significant prostate cancer (CaP) detection. Targeted biopsy using MRI/transrectal ultrasonography (TRUS) fusion is a novel diagnostic tool. The negative predictive value (NPV) of an MRI/TRUS fusion targeted biopsy of a suspicious lesion on mpMRI was determined. Methods: 30 of 181 men who underwent prostatectomy from 2008-2014 were retrospectively identified and had at least one lesion on mpMRI negative for cancer on MRI/TRUS fusion biopsy. Whole mount pathology specimens, gold standard for CaP detection, were aligned with MRI to assess true histopathology of all identified targets. Lesions negative for CaP on biopsy and not identified as cancer on pathology were considered true negatives (TN). Lesions biopsied negative but later found to possess foci of CaP on whole mount were considered false negatives (FN). Calculations of NPV were then made per biopsy year, MRI suspicion score, and lesion size on MRI. Results: 48 lesions of a total 81 identified on mpMRI were reported negative for CaP in the 30 patients who underwent fusion biopsy. Of these, 37 lesions were found to be truly negative on histopathology, while 11 lesions had CaP foci on whole mount specimen. Overall NPV was 77% (37/48). The NPV increased over time (Table 1), and was as high as 85.7% most recently. Conclusions: This series demonstrated a NPV of 77% for targeted MRI/TRUS fusion biopsy of lesions seen on mpMRI. The increasing NPV trend noted over time may have further applications to assess the learning curve for this diagnostic method. Not surprisingly, NPV is higher for low and moderately suspicious lesions than for highly suspicious lesions. This data may help physicians interpret the clinical implications of a negative fusion biopsy. [Table: see text]

Use of multiparametric MRI to alter management pathways: Treatment patterns of prostate cancer in the targeted biopsy era

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Background: As the use of multiparametric MRI (mpMRI) to diagnose prostate cancer (PCa) becomes established, better knowledge of treatment patterns is needed to counsel patients. Prior studies have shown 40-55% undergo Radical Prostatectomy (RP), while only 6% prefer Active Surveillance (AS), and that stratification by risk does not greatly alter treatment pathways. We aim to delineate the distribution of PCa treatment modalities in the MRI/US fusion-guided prostate biopsy (FB) era. Methods: A retrospective review was performed of all patients who underwent FB at the NIH from 2010 to present. Demographics, Gleason scores, MRI Suspicion scores and treatment outcomes were recorded. Patients were stratified according to D’Amico Risk Criteria, and outcomes were coded into four categories: AS; RP; Radiation (XRT, Brachytherapy); and Other (Systemic or Focal therapy). Results: 839 men were reviewed. Mean age was 62.6 years old and mean PSA was 9.7 ng/mL. Total cancer detection rate was 70% (n = 589). Of FB positive men, 474 had treatment information available. Overall 225 (47.5%) entered AS, 158 (33.3%) underwent RP, 61 (12.9%) received XRT, and 30 (6.3%) received other intervention. Subgroup analysis by MRI suspicion score (Table) showed 47.4% frequency of RP in the high vs. 30.9% and 19.4% for moderate and low suspicion groups, respectively. Analysis by D’Amico Risk (Table) showed 86% of low risk men chose AS vs. 0% of high risk men. Conversely 9.7% of low, 44.5% of intermediate and 55.7% of high risk men underwent RP. Conclusions: FB was associated with a higher rate of AS choice as a treatment modality for low risk disease. However most patients with clinically significant PCa still chose RP as their treatment. FB is an additional tool that allows the urologist to better counsel patients and provides individualized treatment for PCa. [Table: see text]