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Article of the week: mpMRI and follow‐up to avoid prostate biopsy in 4259 men

October 30, 2019/by Wulphert Venderink

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a video prepared by the authors. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Multiparametric magnetic resonance imaging and follow‐up to avoid prostate biopsy in 4259 men

Wulphert Venderink*, Annemarijke van Luijtelaar*, Marloes van der Leest*, Jelle O. Barentsz*, Sjoerd F.M. Jenniskens*, Michiel J.P. Sedelaar^†,Christina Hulsbergen-van de Kaa^‡, Christiaan G. Overduin* and Jurgen J. Fütterer*

*Department of Radiology and Nuclear Medicine, ^†Department of Urology, and ^‡Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands

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Abstract

Objective

To determine the proportion of men avoiding biopsy because of negative multiparametric magnetic resonance imaging (mpMRI) findings in a prostate MRI expert centre, and to assess the number of clinically significant prostate cancers (csPCa) detected during follow‐up.

Patients and method

Retrospective study of 4259 consecutive men having mpMRI of the prostate between January 2012 and December 2017, with either a history of previous negative transrectal ultrasonography‐guided biopsy or biopsy naïve. Patients underwent mpMRI in a referral centre. Lesions were classified according to Prostate Imaging Reporting And Data System (PI‐RADS) versions 1 and 2. Negative mpMRI was defined as an index lesion PI‐RADS ≤2. Follow‐up until 13 October 2018 was collected by searching the Dutch Pathology Registry (PALGA). Gleason score ≥3 + 4 was considered csPCa. Kaplan–Meier analysis and univariable logistic regression models were used in the cohort of patients with negative mpMRI and follow‐up.

Fig. 2. Distribution of PI‐RADS scored in the entire cohort.

Results

Overall, in 53.6% (2281/4259) of patients had a lesion classified as PI‐RADS ≤2. In 320 patients with PI‐RADS 1 or 2, follow‐up mpMRI was obtained after a median (interquartile range) of 57 (41–63) months. In those patients, csPCa diagnosis‐free survival (DFS) was 99.6% after 3 years. Univariable logistic regression analysis revealed age as a predictor for csPCa during follow‐up (P < 0.05). In biopsied patients, csPCa was detected in 15.8% (19/120), 43.2% (228/528) and 74.5% (483/648) with PI‐RADS 3, 4 and 5, respectively.

Conclusion

More than half of patients having mpMRI of the prostate avoided biopsy. In those patients, csPCa DFS was 99.6% after 3 years.

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What’s the diagnosis?

October 25, 2019/by Admin

From Mirmilstein et al (BJUI 2019) reporting on the use of NeuroSAFE

No such quiz/survey/poll

Article of the week: Androgen receptor (AR) splice variant 7 and full‐length AR expression is associated with clinical outcome: a translational study in patients with castrate‐resistant prostate cancer

October 23, 2019/by Romano Danesi

In addition to the article itself, there is an editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Androgen receptor (AR) splice variant 7 and full‐length AR expression is associated with clinical outcome: a translational study in patients with castrate‐resistant prostate cancer

Marzia Del Re*, Stefania Crucitta*, Andrea Sbrana^†, Eleonora Rofi*, Federico Paolieri^†, Giulia Gianfilippo*, Luca Galli^†, Alfredo Falcone^†, Riccardo Morganti^‡, Camillo Porta^§¶, Eleni Efstathiou**, Ron van Schaik^††, Guido Jenster^‡‡and Romano Danesi*

*Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, ^†Medical Oncology Unit, Department of Translational Research and New Technologies in Medicine, ^‡Section of Statistics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, ^§Department of Internal Medicine, University of Pavia, ^¶Division of Translational Oncology, I.R.C.C.S. Istituti Clinici Scientifici Maugeri, Pavia, Italy, **Division of Cancer Medicine, Department of Genitourinary Medical Oncology, University of Texas MD Anderson Cancer Centre, Houston, TX, USA, ^††Department of Clinical Chemistry, and ^‡‡Department of Urology, Erasmus University Medical Centre, Rotterdam, The Netherlands

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Abstract

Objectives

To investigate if full‐length androgen receptor (AR‐FL) is associated with resistance to androgen receptor (AR)‐directed therapy independently and/or combined with AR splice variant 7 (AR‐V7).

Patients and Methods

Plasma samples were prospectively collected from 73 patients with castrate‐resistant prostate cancer before first‐ or second‐line AR‐directed therapy. mRNA was isolated from exosomes and AR‐FL and AR‐V7 were analysed by droplet digital PCR.

Results

AR‐FL was detected in all patients and 22% of them were AR‐V7‐positive at baseline. AR‐FL expression was significantly higher in AR‐V7‐positive vs AR‐V7‐negative patients (P < 0.0001). After stratifying patients by tertile for AR‐FL expression, progression‐free survival (PFS) was 22 vs 18 vs 4 months for lower vs intermediate vs higher tertile, respectively (P = 0.0003). The median PFS and overall survival were significantly longer in AR‐V7‐negative vs AR‐V7‐positive patients (20 vs 4 months, P < 0.0001; not reached vs 9 months, P < 0.0001, respectively).

Conclusions

Resistance to AR‐directed therapy was associated with the presence of AR‐V7; however, AR‐FL expression may help better refine response and survival of patients to AR‐directed therapy. Both biomarkers, if validated in prospective trials, could be used to select the best treatment strategy.

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What’s the diagnosis?

October 18, 2019/by Admin

Image from Martini et al (BJUI 2019)

No such quiz/survey/poll

Article of the week: The global prevalence of erectile dysfunction: a review

October 16, 2019/by Mieke Van Hemelrijck

In addition to the article itself, there is a video prepared by the authors. Please use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

The global prevalence of erectile dysfunction: a review

Anna Kessler*, Sam Sollie*, Ben Challacombe^†, Karen Briggs^† and Mieke Van Hemelrijck*

*School of Cancer and Pharmaceutical Sciences, King’s College London, Translational Oncology and Urology Research (TOUR) and ^†Urology Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

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Abstract

Objective

To evaluate the global prevalence of erectile dysfunction (ED); as well as its association with physiological and pathological ageing by examining the relationship between ED and cardiovascular disease (CVD), benign prostatic hyperplasia (BPH), and dementia. We also aimed to explain the treatment for erectile dysfunction and characterize discrepancies caused by the use of different ED screening tools.

Methods

The Excerpta Medica dataBASE (EMBASE) and Medical Literature Analysis and Retrieval System Online (MEDLINE) were searched to find population‐based studies investigating the prevalence of ED and the association between ED and CVD, BPH and dementia in the general population.

Results

The global prevalence of ED was 3–76.5%. ED was associated with increasing age. Use of the International Index of Erectile Function (IIEF) and Massachusetts Male Aging Study (MMAS)‐derived questionnaire identified a high prevalence of ED in young men. ED was positively associated with CVD. Men with ED have an increased risk of all‐cause mortality odds ratio (OR) 1.26 (95% confidence interval [CI] 1.01–1.57), as well as CVD mortality OR 1.43 (95% CI 1.00–2.05). Men with ED are 1.33–6.24‐times more likely to have BPH then men without ED, and 1.68‐times more likely to develop dementia than men without ED.

Conclusion

ED screening tools in population‐based studies are a major source of discrepancy. Non‐validated questionnaires may be less sensitive than the IIEF and MMAS‐derived questionnaires. ED constitutes a large burden on society given its high prevalence and impact on quality of life, and is also a risk factor for CVD, dementia and all‐cause mortality.

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BJUI at the Indonesian Urological Association Annual Scientific Meeting

October 11, 2019/by Admin

The Indonesian Urological Association Annual Scientific meeting was held at The Golden Tulip Hotel, Banjarmasin – 3-5 October 2019.

The main conference was preceded by pre-congress workshops at the University of Indonesia Medical Education and Research Institute (IMERI) in Jakarta.

Masterclass with Consultant Urologist Mr Brian Chaplin

Furthermore, the BJUI held a plenary lecture entitled: High Risk Non-Muscle-Invasive Bladder Cancer : The Promise of New Therapies by Consultant Urologist Miss Jo Cresswell, also from the South Tees Hospitals NHS Foundation trust in the UK.

[caption id=”attachment_40134″ align=”aligncenter” width=”243′ label=’ Promoting knowledge: Miss Jo Cresswell at the Masterclass

The conference also featured the increasingly popular 10 and 5 Km Uroruns and a Urowalk starting at 6 and 7am on the Saturday morning.

What’s the diagnosis?

October 11, 2019/by Admin

Images from Lebacle et al (BJUI 2019) demonstrating a technique to allow shift from radical to partial nephrectomy

No such quiz/survey/poll

Residents’ podcast: NICE guidelines – renal and ureteric stones

October 10, 2019/by Nikita Bhatt

Nikita Bhatt is a Specialist Trainee in Urology in the East of England Deanery and a BURST Committee member @BURSTUrology

NICE Guideline – Renal and ureteric stones: assessment and management

Read the full article

Context

Renal and ureteric stones usually present as an acute episode with severe pain, although some stones are picked up incidentally during imaging or may present as a history of infection. The initial diagnosis is made by taking a clinical history and examination and carrying out imaging; initial management is with painkillers and treatment of any infection.

Ongoing treatment of renal and ureteric stones depends on the site of the stone and size of the stone (less than 10 mm, 10 to 20 mm, greater than 20 mm; staghorn stones). Options for treatment range from observation with pain relief to surgical intervention. Open surgery is performed very infrequently; most surgical stone management is minimally invasive and the interventions include shockwave lithotripsy (SWL), ureteroscopy (URS) and percutaneous stone removal (surgery). As well as the site and size of the stone, treatment also depends on local facilities and expertise. Most centres have access to SWL, but many use a mobile machine on a sessional basis rather than a fixed‐site machine, which has easier access during the working week. The use of a mobile machine may affect options for emergency treatment, but may also add to waiting times for non‐emergency treatment.

Although URS for renal and ureteric stones is increasing (there has been a 49% increase from 12,062 treatments in 2009/10, to 18,066 in 2014/15 [Hospital Episode Statistics data]), there is a trend towards day‐case/ambulatory care, with this increasing by 10% to 31,000 cases a year between 2010 and 2015. The total number of bed‐days used for renal stone disease has fallen by 15% since 2009/10. However, waiting times for treatment are increasing and this means that patient satisfaction is likely to be lower.

Because the incidence of renal and ureteric stones and the rate of intervention are increasing, there is a need to reduce recurrences through patient education and lifestyle changes. Assessing dietary factors and changing lifestyle have been shown to reduce the number of episodes in people with renal stone disease.

Adults, children and young people using services, their families and carers, and the public will be able to use the guideline to find out more about what NICE recommends, and help them make decisions. These recommendations apply to all settings in which NHS‐commissioned care is provided.

Table 2.Surgical treatment (including SWL) of ureteric stones in adults, children and young people Abbreviations: PCNL, percutaneous nephrolithotomy; SWL, shockwave lithotripsy; URS, ureteroscopy.

More podcasts

BJUI Podcasts now available on iTunes, subscribe here https://itunes.apple.com/gb/podcast/bju-international/id1309570262

Article of the week: A four‐group urine risk classifier for predicting outcomes in patients with prostate cancer

October 9, 2019/by Shea P. Connell

If you only have time to read one article this week, it should be this one.

A four‐group urine risk classifier for predicting outcomes in patients with prostate cancer

Shea P. Connell*, Marcelino Yazbek-Hanna*, Frank McCarthy^†, Rachel Hurst*, MartynWebb*, Helen Curley*, Helen Walker^‡, Rob Mills^‡, Richard Y. Ball^‡, Martin G. Sanda^§, Kathryn L. Pellegrini^§, Dattatraya Patil^§, Antoinette S. Perry^¶, Jack Schalken**, Hardev Pandha^††, Hayley Whitaker^‡‡, Nening Dennis^†, Christine Stuttle^†, Ian G. Mills^§§¶¶***, Ingrid Guldvik^¶¶, Movember GAP1 Urine Biomarker Consortium¹, Chris Parker^†††, Daniel S. Brewer*^‡‡‡, Colin S. Cooper* and Jeremy Clark*

*Norwich Medical School, University of East Anglia, Norwich, ^†Institute of Cancer Research, Sutton, ^‡Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK, ^§Department of Urology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA , ^¶School of Biology and Environmental Science, Science West, University College Dublin, Dublin 4, Ireland, **Nijmegen Medical Centre, Radboud University Medical Centre, Nijmegen, The Netherlands, ^††Faculty of Health and Medical Sciences, The University of Surrey, Guildford, ^‡‡Molecular Diagnostics and Therapeutics Group, University College London, London, ^§§School of Medicine, Dentistry and Biomedical Sciences, Institute for Health Sciences, Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, UK, ^¶¶Centre for Molecular Medicine, University of Oslo, Oslo, Norway, ***Nuffield Department of Surgical Sciences, University of Oxford, Oxford, ^†††Royal Marsden Hospital, Sutton and ^‡‡‡Earlham Institute, Norwich, UK

Read the full article

Abstract

Objectives

To develop a risk classifier using urine‐derived extracellular vesicle (EV)‐RNA capable of providing diagnostic information on disease status prior to biopsy, and prognostic information for men on active surveillance (AS).

Patients and Methods

Post‐digital rectal examination urine‐derived EV‐RNA expression profiles (n = 535, multiple centres) were interrogated with a curated NanoString panel. A LASSO‐based continuation ratio model was built to generate four prostate urine risk (PUR) signatures for predicting the probability of normal tissue (PUR‐1), D’Amico low‐risk (PUR‐2), intermediate‐risk (PUR‐3), and high‐risk (PUR‐4) prostate cancer. This model was applied to a test cohort (n = 177) for diagnostic evaluation, and to an AS sub‐cohort (n = 87) for prognostic evaluation.

Table 2. NanoString gene probes incorporated by LASSO regularization in the final optimal model used to produce the prostate urine risk signatures

Results

Each PUR signature was significantly associated with its corresponding clinical category (P < 0.001). PUR‐4 status predicted the presence of clinically significant intermediate‐ or high‐risk disease (area under the curve = 0.77, 95% confidence interval [CI] 0.70–0.84). Application of PUR provided a net benefit over current clinical practice. In an AS sub‐cohort (n = 87), groups defined by PUR status and proportion of PUR‐4 had a significant association with time to progression (interquartile range hazard ratio [HR] 2.86, 95% CI 1.83–4.47; P < 0.001). PUR‐4, when used continuously, dichotomized patient groups with differential progression rates of 10% and 60% 5 years after urine collection (HR 8.23, 95% CI 3.26–20.81; P < 0.001).

Conclusion

Urine‐derived EV‐RNA can provide diagnostic information on aggressive prostate cancer prior to biopsy, and prognostic information for men on AS. PUR represents a new and versatile biomarker that could result in substantial alterations to current treatment of patients with prostate cancer.

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Read the blog article

A taster week in urology and renal transplant in the UK

October 8, 2019/by Matthew Byrne

A taster week is a training opportunity offered to UK doctors in their first two years of clinical practice to try a new specialty. They are an important learning experience for doctors at this stage, who will have experienced working in six different specialties at most. While taster weeks are only five days long, they offer a unique insight into a new specialty, as well as the chance to network with registrars and consultants.

During medical school I was interested in transplantation, as I found the combination between surgery and immunology interesting. This led me to complete a Master of Research in Transplantation while at medical school. During this degree, I looked at urinary tract infection in transplant patients and this started my interest in urology.

In the UK, the majority of trainees enter the field of transplantation following training in General Surgery. In clinical practice, it is good to have urologists with an active interest in Renal Transplantation for the betterment of these patients but there are few centres where this can be learnt. However, the Freeman Hospital in Newcastle, UK offers a one to two-year fellowship in renal transplantation which can be completed at the end of urology training. I contacted one of the urology and renal transplant surgeons and organised a week’s visit to the Freeman Hospital.

During my taster week I had the opportunity to shadow a urology and renal transplant surgeon. I joined urology and transplant ward rounds, including a renal transplant grand round, and I also attended a transplant nephrology clinic where I saw the long-term management of patients who had received kidney transplants. I observed theatre lists in both urology and transplant and saw the wide variety of operations that urology and transplant surgeons are involved in, such as renal access surgery for dialysis and robotic partial nephrectomy for renal cancer.

I also had a chance to attend multi-disciplinary team meetings about new transplant recipients as well as an x-ray imaging meeting concerning live kidney donors.

Speaking to urology and renal transplant surgeons was an invaluable experience and helped me plan the next steps in my career as well as solidify it as a preferred career choice.

The highlight of my taster week was attending regional surgical teaching. I spent a day in one of the few world-class cadaveric training laboratories in the UK and learnt how to perform an orchidopexy for testicular torsion and vascular anastomosis; two operations that are no doubt necessary for a urology and renal transplant surgeon.

I am very glad I completed a taster week in urology and renal transplantation. It allowed me to experience the variety of work involved in this niche specialty. It was an experience that would have only been available much later in my career otherwise, which would be at a point too late for a career change.

by Matthew Byrne

Matthew Byrne recently completed two years as an Academic Foundation Doctor in Cambridge, UK. He graduated MBBS from Newcastle where he also completed a Master of Research in Transplantation. He is now a Urology Clinical Fellow in Cambridge, UK.