John McLoughlin

From prostate-specific antigen (PSA) to precursor PSA (proPSA) isoforms: a review of the emerging role of proPSAs in the detection and management of early prostate cancer

Despite the popularity of PSA blood testing for prostate cancer, there are a number of important limitations of this popular serum marker including the limited ability to accurately distinguish patients with and without prostate cancer and those who harbour an aggressive form of the disease. This is especially true when the total PSA is <10 ng/mL. Thus, significant efforts have been placed to find new serum markers that can help overcome these limitations.

First 500 cases of robotic-assisted laparoscopic radical prostatectomy from a single UK centre: learning curves of two surgeons

Study Type – Therapy (case series)

Changing antibiotic prophylaxis for transrectal ultrasound-guided prostate biopsies: are we putting our patients at risk?

Sir, We read with interest the fi ndings of a UK case series [ 1 ] that suggested that oral co-amoxiclav prophylaxis given 1 h before TRUS-guided prostate biopsy (TRUSgpb) and for 3 days afterwards was less likely to prevent sepsis than a historical control group who received ciprofl oxacin prophylaxis also administered 1 h before TRUSgpb and for 3 days subsequently. No cases of Clostridium diffi cile (C. diffi cile ) were identifi ed during the course of the study.

Changing antibiotic prophylaxis for transrectal ultrasound-guided prostate biopsies: are we putting our patients at risk?: CHANGING ANTIBIOTIC PROPHYLAXIS FOR TRUSgpb

Study Type – Harm/Safety (case series)
Level of Evidence 4

Development and validation of risk score for predicting positive repeat prostate biopsy in patients with a previous negative biopsy in a UK population

BackgroundLittle evidence is available to determine which patients should undergo repeat biopsy after initial benign extended core biopsy (ECB). Attempts have been made to reduce the frequency of negative repeat biopsies using PSA kinetics, density, free-to-total ratios and Kattans nomogram, to identify men more likely to harbour cancer but no single tool accurately predicts biopsy outcome. The objective of this study was to develop a predictive nomogram to identify men more likely to have a cancer diagnosed on repeat prostate biopsy.MethodsPatients with previous benign ECB undergoing repeat biopsy were identified from a database. Association between age, volume, stage, previous histology, PSA kinetics and positive repeat biopsy was analysed. Variables were entered stepwise into logistic regression models. A risk score giving the probability of positive repeat biopsy was estimated. The performance of this score was assessed using receiver characteristic (ROC) analysis.Results110 repeat biopsies were performed in this period. Cancer was detected in 31% of repeat biopsies at Hospital (1) and 30% at Hospital (2). The most accurate predictive model combined age, PSA, PSA velocity, free-to-total PSA ratio, prostate volume and digital rectal examination (DRE) findings. The risk model performed well in an independent sample, area under the curve (AUCROC) was 0.818 (95% CI 0.707 to 0.929) for the risk model and 0.696 (95% CI 0.472 to 0.921) for the validation model. It was calculated that using a threshold risk score of > 0.2 to identify high risk individuals would reduce repeat biopsies by 39% while identifying 90% of the men with prostate cancer.ConclusionAn accurate multi-variable predictive tool to determine the risk of positive repeat prostate biopsy is presented. This can be used by urologists in an outpatient setting to aid decision-making for men with prior benign histology for whom a repeat biopsy is being considered.

Long-Term Outcome of Epididymectomy for the Management of Chronic Epididymal Pain

PURPOSE We evaluated the long-term outcomes of patients who underwent epididymectomy for the treatment of chronic epididymal pain. MATERIALS AND METHODS All 72 patients who underwent epididymectomy at our institution between 1994 and 2007 were invited to participate in the study. Patients were mailed questionnaires covering various aspects of the treatment. Questions regarding pain were rated on a scale between 0 and 10 (0--no pain, 10--severe pain). Patients who did not return the questionnaires were followed up by telephone and the medical case notes of all respondents were reviewed. Statistical analysis was performed using the Wilcoxon signed-rank and Fishers exact tests with p <0.05 considered statistically significant. RESULTS A total of 53 patients participated (74% response rate) and mean followup was 7.4 years. Of these patients 45 (84.9%) underwent epididymectomy for post-vasectomy pain and the remainder (8 of 53, 15.1%) had the procedure for various nonvasectomy reasons. There were significant improvements in pain score in the post-vasectomy (mean 7.3 preoperative to 2.4 postoperative, p <0.001) and nonvasectomy (mean 7 preoperative to 2.8 postoperative, p = 0.002) groups. Of the patients in the post-vasectomy group 93.3% (42 of 45) had less or no pain postoperatively compared to 75% (6 of 8) in the nonvasectomy group. The satisfaction rate with epididymectomy was also higher in the post-vasectomy (42 of 45, 93.3%) compared to the nonvasectomy (5 of 8, 62.5%) group (p = 0.038). CONCLUSIONS With high patient satisfaction and a favorable long-term outcome epididymectomy appears to be an effective treatment option particularly for post-vasectomy chronic epididymal pain.

Can a trained non-physician provider perform transrectal ultrasound-guided prostatic biopsies as effectively as an experienced urologist?

PSA testing has resulted in a large number of patients being referred to urologists for investigation of potential prostate cancer. Despite limited evidence, non‐physician providers now perform a number of routine urological procedures such as transrectal ultrasound‐guided prostatic biopsies (TRUSP) in a bid to help relieve this increasing workload. In the largest series to date, we provide evidence that an adequately trained non‐physician provider is able to perform TRUSP as effectively as an experienced urologist after an initial learning curve.

A Prospective Randomised Trial of Extended Core Prostate Biopsy Protocols Utilizing 12 versus 15 Cores

Objective: To prospectively evaluate the diagnostic yield of 12 versus 15 core ultrasound-guided needle prostate biopsy protocol for detection of prostate cancer. Patients and Methods: 244 patients were prospectively randomized to undergo 12 (group A), or 15 (group B) biopsies. The cancer detection rate was compared between these groups and within group B. Results: There were no differences in the age, PSA, prostate volume or Gleason score of diagnosed cancers between groups. 113 (46%) of all patients were found to have carcinoma. The number of cancers diagnosed in each group was: 63 (51.6%) in group A, and 50 (41.0%) in group B. In both groups, performing 12 biopsies increased the number of cancer cases identified by around 10% compared to 6. The frequency of cancer cases increased when 15 biopsies were performed, but not significantly (1.7%). The probability of finding a cancer after 12 biopsies was the same as after 15 biopsies (p = 0.125, McNemar’s test). Conclusions: There was no advantage in increasing the number of biopsy cores from 12 to 15 for the diagnosis of prostate cancer in men with an elevated PSA but normal digital rectal examination.

Radical prostatectomy for High Grade Prostatic Intra-epithelial Neoplasia

High Grade Prostatic Intraepithelial Neoplasia (HGPIN)has been recognizedas the most likely precursor of invasive carcinoma of the prostate. Closesurveillance and follow-up are indicated if subsequent procedures fail toidentify carcinoma. There is still considerable controversy about thenatural history of high grade PIN and most authors agree that itsidentification should not influence or dictate therapeutic decisions. Weperformed a prophylactic radical prostatectomy in such a case which hasnot been reported in the world literature.

General Practitioner perception of prostate-specific antigen testing has improved, but more awareness of prostate cancer risk in younger patients is still awaited

Background In 2006, a county-wide survey of general practitioners (GPs) in the United Kingdom (UK) identified a reluctance to refer younger men with abnormal prostate specific antigen (PSA) levels. Younger men have the most to gain from early-detection of prostate cancer (PCa), which remains a national government priority in the UK and around the world. We sought to assess changes in perception of abnormal PSA-values amongst UK GPs over the past 10 years. Materials and methods A total of 500 self-administered paper questionnaires were distributed to individually named GPs. One hundred and forty two responded (28.4%), representing a patient population of ∼600,000. A series of visual analogue questions assessed referral thresholds and understanding of risk factors related to the development of PCa. Results GPs with a median of 23-years experience responded. Although mean PSA threshold for referral to urology did fall between 2006 and 2016 in both the 45-year (5.42 ng/mL vs. 4.61 ng/mL P = 0.0003) and 55-year (5.81 ng/mL vs. 5.30 ng/mL P = 0.0164) age groups, the median referral values were unchanged. Significantly, referral thresholds quoted for younger men (<65 years) were considerably higher than recommended UK maximum PSA-levels. Using case-based scenarios, practitioners appeared more likely to refer older men with abnormal PSA values, with GPs reporting an average 56.2% likelihood of referring an asymptomatic 55-year-old with elevated age-adjusted PSA of 4.6 ng/mL. A total of 95.1% recognised a family history of PCa to be a potential risk factor but other at-risk categories were not so clearly understood. Conclusion Awareness of abnormal PSA values in UK primary care is improving, but continues to lag behind the evidence. Strategies to disseminate knowledge of maximum PSA-values to GPs should focus especially on those for younger patients.