Christian von Bodman

The Impact of Real-Time Elastography Guiding a Systematic Prostate Biopsy to Improve Cancer Detection Rate: A Prospective Study of 353 Patients

PURPOSEnWe evaluated whether real-time elastography guided biopsy improves prostate cancer detection compared to conventional systematic gray scale ultrasound guidance.nnnMATERIALS AND METHODSnA total of 353 consecutive patients suspicious for prostate cancer were prospectively randomized for real-time elastography (178) or gray scale ultrasound (175). Each patient enrolled in the study underwent a 10-core prostate biopsy. Six lateral prostate sectors (base, mid, apex) were scanned for cancer suspicious areas, defined as stiffer blue lesions using real-time elastography and hypoechoic lesions using gray scale ultrasound. Suspicious areas were sampled by a single targeted biopsy and considered representative of a defined prostate sector. If real-time elastography or gray scale ultrasound did not visualize a suspicious area in a sector, the biopsy core was taken systematically. Imaging findings were correlated with histopathological reports. Real-time elastography and gray scale ultrasound cases were compared in terms of cancer detection rate and imaging guidance accuracy.nnnRESULTSnCharacteristics of patients undergoing real-time elastography and gray scale ultrasound, including age, prostate specific antigen, prostate volume and digital rectal examination, were not significantly different (p>0.05). Prostate cancer was detected in 160 of 353 patients (45.3%). The prostate cancer detection rate was significantly higher in patients who underwent biopsy with the real-time elastography guided approach compared to the gray scale ultrasound guided biopsy at 51.1% (91 of 178) vs 39.4% (69 of 175) (p=0.027). Overall sensitivity and specificity to detect prostate cancer was 60.8% and 68.4% for real-time elastography vs 15% and 92.3% for gray scale ultrasound, respectively.nnnCONCLUSIONSnSensitivity to visualize and detect prostate cancer improved using real-time elastography in addition to gray scale ultrasound during prostate biopsy. Overall sensitivity did not reach levels to omit a systematic biopsy approach.

Standardized assessment of complications in a contemporary series of European patients undergoing radical cystectomy.

To examine postoperative complications in a contemporary series of patients after radical cystectomy using a standardized reporting system, and to identify readily available preoperative risk factors.

Multiparametric ultrasound of the prostate: adding contrast enhanced ultrasound to real-time elastography to detect histopathologically confirmed cancer.

PURPOSEnWe prospectively assessed whether a combined approach of real-time elastography and contrast enhanced ultrasound would improve prostate cancer visualization.nnnMATERIAL AND METHODSnBetween June 2011 and January 2012, 100 patients with biopsy proven prostate cancer underwent preoperative transrectal multiparametric ultrasound combining real-time elastography and contrast enhanced ultrasound. After initial elastographic screening for suspicious lesions, defined as blue areas with decreased tissue strain, each lesion was allocated to the corresponding prostate sector. The target lesion was defined as the largest cancer suspicious area. Perfusion was monitored after intravenous injection of contrast agent. Target lesions were examined for hypoperfusion, normoperfusion or hyperperfusion. Imaging results were correlated with final pathological evaluation on whole mount slides after radical prostatectomy.nnnRESULTSnOf 100 patients 86 were eligible for final analysis. Real-time elastography detected prostate cancer with 49% sensitivity and 73.6% specificity. Histopathology confirmed malignancy in 56 of the 86 target lesions (65.1%). Of these 56 lesions 52 (92.9%) showed suspicious perfusion, including hypoperfusion in 48.2% and hyperperfusion in 48.2%, while only 4 (7.1%) showed normal perfusion patterns (p = 0.001). The multiparametric approach decreased the false-positive value of real-time elastography alone from 34.9% to 10.3% and improved the positive predictive value of cancer detection from 65.1% to 89.7%.nnnCONCLUSIONSnPerfusion patterns of prostate cancer suspicious elastographic lesions are heterogeneous. However, the combined approach of real-time elastography and contrast enhanced ultrasound in this pilot study significantly decreased false-positive results and improved the positive predictive value of correctly identifying histopathological cancer.

Intraoperative Frozen Section of the Prostate Decreases Positive Margin Rate While Ensuring Nerve Sparing Procedure During Radical Prostatectomy

PURPOSEnWe evaluated whether intraoperative frozen section analysis of the prostate surface might provide significant information to ensure nerve sparing and minimize the positive margin rate.nnnMATERIALS AND METHODSnIn 236 patients treated with radical prostatectomy between June 2011 and September 2012 whole surface frozen section analysis of the removed prostate was done intraoperatively. The apex and base were circumferentially dissected as well as the whole posterolateral tissue corresponding to the neurovascular bundles. Multiple perpendicular sections were cut systematically for frozen section analysis. Pathology results were reported to navigate the procedure.nnnRESULTSnFrozen section analysis identified positive surgical margins in 22% of cases, including the neurovascular bundles in 56.9%, apex in 34.5% and base in 8.6%. Of positive frozen section cases 92.3% could be converted to negative status, while 7.7% remained positive. The final positive margin rate in the total cohort was 3%, including a false-negative frozen section rate of 1.6%. In 14.8% of cases the initial nerve sparing plan was changed intraoperatively due to the positive frozen section and the secondary resected specimen detected cancer in 25%. Final pathology results showed Gleason upgrading or up-staging in 40.7% of cases compared to preoperative variables. When comparing patients with positive vs negative frozen sections, preoperative variables did not significantly differ, while postoperatively pathological stage, tumor volume, operative time and final margin status differed significantly. Of patients with exclusively unilateral positive biopsies 13% had a positive surgical margin intraoperatively on the opposite, biopsy negative side.nnnCONCLUSIONSnThe surface frozen section technique is associated with a low false-negative surgical margin rate. It might allow for safer preservation of functional anatomical structures in misclassified patients or even patients at higher preoperative risk.

Impact of Real-Time Elastography on Magnetic Resonance Imaging/Ultrasound Fusion Guided Biopsy in Patients with Prior Negative Prostate Biopsies

PURPOSEnThe fusion of multiparametric resonance imaging and ultrasound has been proven capable of detecting prostate cancer in different biopsy settings. The addition of real-time elastography promises to increase the precision of the outcome of targeted biopsies. We investigated whether real-time elastography improves magnetic resonance imaging/transrectal ultrasound fusion targeted biopsy in patients after previous negative biopsies.nnnMATERIALS AND METHODSnProspectively 121 men underwent 3T magnetic resonance imaging. Using magnetic resonance imaging/real-time elastography fusion every suspicious lesion was characterized according to its tissue density and sampled by 2 fusion guided targeted biopsies. Additionally, all patients underwent 12-core systematic biopsy. The detection rate of clinically significant and insignificant cancers was compared between targeted und systematic biopsies. The accuracy to predict high grade prostate cancer was evaluated for with the PI-RADS scoring system and compared to the magnetic resonance imaging/real-time elastography fusion score.nnnRESULTSnOverall prostate cancer was detected in 52 patients (43%). Targeted fusion guided biopsy revealed prostate cancer in 32 men (26.4%) and systematic biopsy in 46 (38%). The proportion of clinically significant cancers was higher for targeted biopsy (90.6%) compared to systematic biopsy (73.9%). The detection rate per core was higher for targeted biopsies (14.7%) compared to systematic biopsies (6.5%, p <0.001). The prediction of biopsy result according to magnetic resonance imaging/real-time elastography fusion was better (AUC 0.86) than magnetic resonance imaging alone (AUC 0.79). Sensitivity and specificity for magnetic resonance imaging/real-time elastography fusion was 77.8% and 77.3% vs 74.1% and 62.9% for magnetic resonance imaging.nnnCONCLUSIONSnMagnetic resonance imaging/transrectal ultrasound fusion enhances the likelihood of detecting clinically significant cancers in a repeat biopsy setting. Adding real-time elastography to magnetic resonance imaging supports the characterization of cancer suspicious lesions.

Is there a need for the Fournier's gangrene severity index? Comparison of scoring systems for outcome prediction in patients with Fournier's gangrene

Study Type – Prognosis (prospective cohort)

Comprehensive report on prostate cancer misclassification by 16 currently used low-risk and active surveillance criteria.

Study Type – Prognosis (case series)

Predictors of short-term recovery of urinary continence after radical prostatectomy

AbstractPurposenTo evaluate treatment variables for early urinary continence status 6xa0weeks following radical prostatectomy.MethodsIn this retrospective analysis, 4,028 consecutive patients underwent open radical retropubic (RRP) or robot-assisted transperitoneal prostatectomy (RARP) at a single academic institution (07/2003–07/2013). After discharge, patients were offered 3-week treatment in a rehabilitation facility. Patients who opted for rehabilitation (nxa0=xa02,998, 74.4xa0%) represent our study cohort. Exclusion criteria were acute urinary retention after catheter removal (nxa0=xa055, 1.4xa0%), incomplete datasets (nxa0=xa050, 1.2xa0%) or refusal of rehabilitation (nxa0=xa0925, 23.0xa0%). Results of urinary continence were evaluated from final rehabilitation reports. Twenty-two clinical and oncological variables were statistically analysed in uni- and multivariable analyses to determine whether they were associated with early urinary continence status six weeks after radical prostatectomy. Odds ratios and 95xa0% CI as well as p values were calculated. A p level of 0.05 was considered as significant.ResultsSix weeks after surgery, 1,962 (65.4xa0%) patients were continent (≤1 pad/day) and 1,036 (34.6xa0%) patients were considered incontinent. Age, clinical stage, PSA, ASA score, prior TURP, seminal vesicle invasion, Gleason score, nerve-sparing status, intraoperative blood loss, catheterisation time, OR time, surgical caseload >1,000 and the surgeon were associated with continence status on univariable analysis (pxa0<xa00.05). On multivariable analysis, nerve-sparing procedure (NS), clinical stage, individual surgeon, patient age, surgical procedure (RARP vs. RRP) and duration of catheterisation were independent predictors (pxa0<xa00.05) of incontinence status.ConclusionsStrategies that can ensure NS procedures and early catheter removal should be applied to enable early recovery of urinary continence.

Effect of perioperative complications and functional outcomes on health-related quality of life after radical prostatectomy

AbstractPurposenRadical prostatectomy is a commonly performed procedure with perioperative complication rates of 30xa0% using standardized reporting methodology. We aim to determine whether perioperative complications and functional outcomes impact quality of life 1xa0year after surgical treatment.Patients and methodsQuality of life, functional and oncological outcomes were assessed in patients who underwent open retropubic radical prostatectomy at a single academic institution between 2003 and 2009, preoperatively and 1xa0year after surgery using the EORTC QLQ-C30, the IIEF-5 and an institutional questionnaire. Perioperative complications were recorded using the Clavien–Dindo classification. Patients without complications were compared to patients with any, low- or high-grade complications. The global health score domain of the EORTC QLQ-C30 is reported for various oncological and functional outcomes and contrasted to stratified categories of complications and functional outcomes.ResultsA full dataset was available for 29.5xa0% (nxa0=xa0856) of all patients. The overall complication rate was 27.5xa0% (235/856). A total of 307 complications were recorded of whom 88.9xa0% (273/307) were low grade. In this study, population global health perception did not decline after surgery (70.5xa0±xa021.2 vs. 74.4xa0±xa019.7; pxa0<xa00.0001). Complications showed only statistical but no clinical meaningful influence on global health perception as well as on functional and symptom scales. Patients who met combined outcome criteria experienced the best postoperative global health score (86.0xa0±xa013.1 and 86.0xa0±xa014.2).ConclusionsPerioperative complications and functional outcomes have a measurable impact on quality of life 1xa0year following surgery. While perioperative complications have a statistical effect, functional outcomes showed a clinically more profound effect on postoperative global health perception.

Short‐term external ureter stenting shows significant benefit in comparison to routine double‐J stent placement after ureterorenoscopic stone extraction: A prospective randomized trial – the Fast track stent study (FaST)

To determine whether short‐term stenting using an external ureter catheter following ureterorenoscopic stone extraction provides a better outcome in comparison to double‐J stent ureteral stenting.