Franck Bladou

MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis

Background Multiparametric magnetic resonance imaging (MRI), with or without targeted biopsy, is an alternative to standard transrectal ultrasonography–guided biopsy for prostate‐cancer detection in men with a raised prostate‐specific antigen level who have not undergone biopsy. However, comparative evidence is limited. Methods In a multicenter, randomized, noninferiority trial, we assigned men with a clinical suspicion of prostate cancer who had not undergone biopsy previously to undergo MRI, with or without targeted biopsy, or standard transrectal ultrasonography–guided biopsy. Men in the MRI‐targeted biopsy group underwent a targeted biopsy (without standard biopsy cores) if the MRI was suggestive of prostate cancer; men whose MRI results were not suggestive of prostate cancer were not offered biopsy. Standard biopsy was a 10‐to‐12–core, transrectal ultrasonography–guided biopsy. The primary outcome was the proportion of men who received a diagnosis of clinically significant cancer. Secondary outcomes included the proportion of men who received a diagnosis of clinically insignificant cancer. Results A total of 500 men underwent randomization. In the MRI‐targeted biopsy group, 71 of 252 men (28%) had MRI results that were not suggestive of prostate cancer, so they did not undergo biopsy. Clinically significant cancer was detected in 95 men (38%) in the MRI‐targeted biopsy group, as compared with 64 of 248 (26%) in the standard‐biopsy group (adjusted difference, 12 percentage points; 95% confidence interval [CI], 4 to 20; P=0.005). MRI, with or without targeted biopsy, was noninferior to standard biopsy, and the 95% confidence interval indicated the superiority of this strategy over standard biopsy. Fewer men in the MRI‐targeted biopsy group than in the standard‐biopsy group received a diagnosis of clinically insignificant cancer (adjusted difference, ‐13 percentage points; 95% CI, ‐19 to ‐7; P<0.001). Conclusions The use of risk assessment with MRI before biopsy and MRI‐targeted biopsy was superior to standard transrectal ultrasonography–guided biopsy in men at clinical risk for prostate cancer who had not undergone biopsy previously. (Funded by the National Institute for Health Research and the European Association of Urology Research Foundation; PRECISION ClinicalTrials.gov number, NCT02380027.)

Impact of laparoscopy simulator training on the technical skills of future surgeons in the operating room: a prospective study

BACKGROUND The efficacy of laparoscopy simulators remains controversial. METHODS This was a comparative prospective study that evaluated the impact of simulator training on technical competence during a real surgical procedure. Residents were divided into 3 groups: the Mcgill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) group, training on a simple simulator; LAP Mentor group, training on a virtual simulator; and control group. An initial evaluation was made by a validated score during a laparoscopic cholecystectomy. Each resident was then trained for 1 month. A second evaluation was then performed. RESULTS Before/after scores were significantly improved in the MISTELS (P = .042) and LAP Mentor (P = .026) groups. It was not the case in the control group. There was a better progression in the MISTELS (P = .026) and LAP Mentor (P = .007) groups than in the control group. There was no significant difference between the MISTELS and LAP Mentor groups. CONCLUSIONS Simulator training provides a more rapid acquisition of competence in surgical technique.

Seminal vesicle invasion: what is the best adjuvant treatment after radical prostatectomy?

Study Type – Therapy (individual cohort)

20 A HEAD TO HEAD COMPARISON OF NOMOGRAMS PREDICTING THE PROBABILITY OF LYMPHNODE INVASION IN PATIENTS UNDERGOING EXTENDED PELVIC LYMPH NODE DISSECTION

INTRODUCTION AND OBJECTIVE: Active surveillance is acceptable for selected patients with low-risk prostate cancer. Patient selection is based on predictors of low risk disease including serum PSA, digital rectal examination, and biopsy Gleason score (GS). However, the accuracy of such parameters in predicting minimal disease that would be associated with an indolent course is not well-established. We investigated clinical preoperative predictors that were associated with “minimal disease” in the radical prostatectomy specimens. METHODS: We reviewed the preoperative, biopsy and pathological parameters of over 1700 patients who underwent roboticassisted laparoscopic radical prostatectomy at the University of Chicago Medical Center between 2003 and 2008. A total of 1526 cases having complete information for all evaluated variables entered the study cohort. The surgical specimens were examined by the modified Stanford technique and minimal disease was defined as less than 5% of the gland involved by pathological GS 6, pathological stage pT2 and no perineural invasion (group 1); as opposed to all others (group 2). The two groups were compared with regard to age, preoperative PSA level, BMI, biopsy GS, clinical stage, maximal % of cancer is a biopsy core, and % positive cores. Univariate and multivariate logistic regression analyses were performed to detect independent predictors. RESULTS: 241 patients (16%) were defined as Group 1. The two groups significantly differed in the following parameters: mean BMI (27.6 and 28.4 in Groups 1 and 2, respectively), biopsy GS 6 (92% versus 51%, respectively), clinical stage T1c (88% versus 72%, respectively), maximal % of cancer in biopsy core (7.8% versus 29.8%, respectively), and % of positive cores (13.6% versus 31.2%, respectively). Multivariate analysis found the following as predictors of minimal disease: biopsy GS (OR 0.21, 95%CI 0.12-0.38), maximal % of cancer in biopsy core (OR 0.94, 95%CI 0.92-0.96), and %positive cores (OR 0.95, 95%CI 0.93-0.97). CONCLUSIONS: Based on our data patients with a biopsy GS 6, apparent in less than 7.8% of the maximally involved biopsy core and whose mean % of positive cores is under 13.6% are expected to have minimal disease in the radical prostatectomy specimen. These parameters may be considered as selection tools for active surveillance.