Vinay Prabhu

Ten-year Outcomes of Sexual Function After Radical Prostatectomy: Results of a Prospective Longitudinal Study

BACKGROUND The long-term impact of radical prostatectomy (RP) on sexual function (SF) and erectile function (EF) has important implications related to the risk-to-benefit ratio of this treatment. OBJECTIVE To determine the long-term effect of RP on male SF and EF over 10 yr of follow-up. DESIGN, SETTING, AND PARTICIPANTS This was a prospective, longitudinal outcomes study in 1836 men following RP at a university hospital. Men were invited to complete the University of California, Los Angeles, Prostate Cancer Index SF survey at baseline, 3, 6, 12, 24, 96, and 120 mo postoperatively and a survey at 4 and 7 yr postoperatively assessing global changes in their EF over the preceding 2 yr. INTERVENTION All men underwent open RP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multiple, generalized linear regression models were used to evaluate the association between time following RP and SF and EF scores controlling for age, prostate-specific antigen, Gleason scores, stage, nerve sparing, race, and marital status. RESULTS AND LIMITATIONS After an expected initial decline, time-dependent improvements in SF and EF were observed through 2 yr postoperatively. Overall, SF and EF were both generally stable between 2 and 10 yr following RP. The subgroups of younger men and men with better preoperative function were more likely to maintain their EF and SF through 10 yr following RP. The primary limitation is the potential bias attributable to nonresponders. CONCLUSIONS The recovery of EF can extend well beyond 2 yr. There is a significant association between younger age and better preoperative function and the likelihood of experiencing improvements beyond 2 yr. Assessing the comparative effectiveness of treatment options for localized prostate cancer must examine SF beyond 2 yr to account for delayed treatment effects and the natural history of SF in the aging male population.

Long-term continence outcomes in men undergoing radical prostatectomy for clinically localized prostate cancer

BACKGROUND Urinary incontinence is a common short-term complication of radical prostatectomy (RP). Little is known about the long-term impact of RP on continence. OBJECTIVE To elucidate the long-term progression of continence after RP. DESIGN, SETTING, AND PARTICIPANTS From October 2000 through September 2012, 1788 men undergoing open RP for clinically localized prostate cancer by a single surgeon at an urban tertiary care center prospectively signed consent to be followed before RP and at 3, 6, 12, 24, 96, and 120 mo after RP. A consecutive sampling method was used and all men were included in this study. INTERVENTION Men underwent open RP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Regression models controlled for preoperative University of California, Los Angeles-Prostate Cancer Index urinary function score (UCLA-PCI-UFS), age, prostate-specific antigen level, Gleason score, stage, nerve-sparing status, race, and marital status were used to evaluate the association of time since RP with two dependent variables: UCLA-PCI-UFS and continence status. RESULTS AND LIMITATION The mean UCLA-PCI-UFS declined between 2 yr and 8 yr (83.8 vs 81.8; p=0.007) and marginally between 8 yr and 10 yr (81.8 vs 79.6; p=0.036) after RP, whereas continence rate did not significantly change during these intervals. Men ≥ 60 yr old experienced a decline in mean UCLA-PCI-UFS between 2 yr and 8 yr (p=0.002) and a marginal decline in continence rate between 2 yr and 10 yr (p=0.047), whereas these variables did not change significantly in men <60 yr old. These outcomes are for an experienced surgeon, so caution should be exercised in generalizing these results. CONCLUSIONS Between 2 yr and 10 yr after RP, there were slight decreases in mean UCLA-PCI-UFS and continence rates in this study. Men aged <60 yr had better long-term outcomes. These results provide realistic long-term continence expectations for men undergoing RP.

Twitter response to the United States Preventive Services Task Force recommendations against screening with prostate-specific antigen.

To examine public and media response to the draft (October 2011) and finalised (May 2012) recommendations of the United States Preventive Services Task Force (USPSTF) against prostate‐specific antigen (PSA) testing via Twitter, a popular social network with over 200 million active users.

Utility of Diffusional Kurtosis Imaging as a Marker of Adverse Pathologic Outcomes Among Prostate Cancer Active Surveillance Candidates Undergoing Radical Prostatectomy

OBJECTIVE The purpose of this study was to compare findings at nongaussian diffusional kurtosis imaging and conventional diffusion-weighted MRI as markers of adverse pathologic outcomes among prostate cancer patients who are active surveillance candidates and choose to undergo prostatectomy. MATERIALS AND METHODS Fifty-eight active surveillance candidates (prostate-specific antigen concentration, < 10 ng/mL; clinical tumor category less than T2a; Gleason score, 3 + 3; ≤ 25% of biopsy cores positive for tumor; ≤ 50% tumor involvement of any individual core; ≤ 20% tumor involvement across all cores) who underwent prostatectomy and preoperative 3-T MRI including diffusional kurtosis imaging (b values, 0, 500, 1000, 1500, and 2000 s/mm(2)) were included. Adverse pathologic features at prostatectomy were defined using two schemes of varying stringency. One scheme (less stringent) was presence of a Gleason score greater than 6 or extracapsular extension (n = 19). The other scheme (more stringent) was presence of a Gleason score greater than 6, extracapsular extension, or an index tumor 10 mm or larger (n = 35). Parametric maps displaying standard apparent diffusion coefficient (ADC), kurtosis (K) representing nongaussian diffusion behavior, and diffusion (D) representing a diffusion coefficient adjusted for nongaussian (kurtosis) behavior were reviewed, and the most abnormal region was recorded for each metric. Associations between these metrics and the presence of adverse final pathologic findings were assessed with unpaired Student t tests and receiver operating characteristic analyses. RESULTS For both schemes, only D was significantly lower in patients with adverse final pathologic findings (p = 0.006, p = 0.025). K tended to be greater in patients with adverse final pathologic findings for the more stringent scheme (p = 0.072). ADC was not significantly different in the presence of adverse final pathologic findings for either scheme (p = 0.357, p = 0.383). With either scheme, D had a larger area under the receiver operating characteristics curve (AUC) for predicting adverse final pathologic results (AUC, 0.691 and 0.743) than did ADC (AUC, 0.569 and 0.655) or K (AUC, 0.617 and 0.714), but the difference was not significant (p = 0.183, p = 0.734). CONCLUSION Preliminary results suggest that diffusional kurtosis imaging findings may have more value than findings at conventional diffusion-weighted MRI as a marker of adverse final pathologic outcome among active surveillance candidates.

Radical Prostatectomy Improves and Prevents Age Dependent Progression of Lower Urinary Tract Symptoms

PURPOSE The prevalence of lower urinary tract symptoms increases with age and impairs quality of life. Radical prostatectomy has been shown to relieve lower urinary tract symptoms at short-term followup but the long-term effect of radical prostatectomy on lower urinary tract symptoms is unclear. MATERIALS AND METHODS We performed a prospective cohort study of 1,788 men undergoing radical prostatectomy. The progression of scores from the self-administered AUASS (American Urological Association symptom score) preoperatively, and at 3, 6, 12, 24, 48, 60, 84, 96 and 120 months was analyzed using models controlling for preoperative AUASS, age, prostate specific antigen, pathological Gleason score and stage, nerve sparing, race and marital status. This model was also applied to patients stratified by baseline clinically significant (AUASS greater than 7) and insignificant (AUASS 7 or less) lower urinary tract symptoms. RESULTS Men exhibited an immediate worsening of lower urinary tract symptoms that improved between 3 months and 2 years after radical prostatectomy. Overall the difference between mean AUASS at baseline and at 10 years was not statistically or clinically significant. Men with baseline clinically significant lower urinary tract symptoms experienced immediate improvements in lower urinary tract symptoms that lasted until 10 years after radical prostatectomy (13.5 vs 8.81, p <0.001). Men with baseline clinically insignificant lower urinary tract symptoms experienced a statistically significant but clinically insignificant increase in mean AUASS after 10 years (3.09 to 4.94, p <0.001). The percentage of men with clinically significant lower urinary tract symptoms decreased from baseline to 10 years after radical prostatectomy (p = 0.02). CONCLUSIONS Radical prostatectomy is the only treatment for prostate cancer shown to improve and prevent the development of lower urinary tract symptoms at long-term followup. This previously unrecognized long-term benefit argues in favor of the prostate as the primary contributor to male lower urinary tract symptoms.

The Learning Curve in Prostate MRI Interpretation: Self-Directed Learning Versus Continual Reader Feedback

OBJECTIVE The purpose of this study is to evaluate the roles of self-directed learning and continual feedback in the learning curve for tumor detection by novice readers of prostate MRI. MATERIALS AND METHODS A total of 124 prostate MRI examinations classified as positive (n = 52; single Prostate Imaging Reporting and Data System [PI-RADS] category 3 or higher lesion showing Gleason score ≥ 7 tumor at MRI-targeted biopsy) or negative (n = 72; PI-RADS category 2 or lower and negative biopsy) for detectable tumor were included. These were divided into four equal-sized batches, each with matching numbers of positive and negative examinations. Six second-year radiology residents reviewed examinations to localize tumors. Three of the six readers received feedback after each examination showing the preceding cases solution. The learning curve, plotting accuracy over time, was assessed by the Akaike information criterion (AIC). Logistic regression and mixed-model ANOVA were performed. RESULTS For readers with and without feedback, the learning curve exhibited an initial rapid improvement that slowed after 40 examinations (change in AIC > 0.2%). Accuracy improved from 58.1% (batch 1) to 71.0-75.3% (batches 2-4) without feedback and from 58.1% to 72.0-77.4% with feedback (p = 0.027-0.046), without a difference in the extent of improvement (p = 0.800). Specificity improved from 53.7% to 68.5-81.5% without feedback and from 55.6% to 74.1-81.5% with feedback (p = 0.006-0.010), without a difference in the extent of improvement (p = 0.891). Sensitivity improved from 59.0-61.5% (batches 1-2) to 71.8-76.9% (batches 3-4) with feedback (p = 0.052), though did not improve without feedback (p = 0.602). Sensitivity for transition zone tumors exhibited larger changes (p = 0.024) with feedback than without feedback. Sensitivity for peripheral zone tumors did not improve in either group (p > 0.3). Reader confidence increased only with feedback (p < 0.001). CONCLUSION The learning curve in prostate tumor detection largely reflected self-directed learning. Continual feedback had a lesser effect. Clinical prostate MRI interpretation by novice radiologists warrants caution.

Long-Term Satisfaction and Predictors of Use of Intracorporeal Injections for Post-Prostatectomy Erectile Dysfunction

PURPOSE Intracorporeal injections have low use rates and high discontinuation rates. We examined factors associated with intracorporeal injection use, long-term satisfaction with intracorporeal injection and reasons for discontinuation in men treated with radical prostatectomy. MATERIALS AND METHODS Between October 2000 and September 2003, 731 men who underwent open radical retropubic prostatectomy were enrolled in a prospective outcomes study. The 8-year followup evaluation included the UCLA-PCI, and a survey capturing intracorporeal injection use, satisfaction and reasons for discontinuation. Logistic regression was used to determine associations between intracorporeal injection use and preoperative variables. RESULTS The 8-year self-assessment was completed by 368 (50.4%) men. Of these men 140 (38%) indicated prior or current intracorporeal injection use, with only 34 using intracorporeal injection at 8 years. Overall, 44% of the men were satisfied with intracorporeal injections. Reasons for discontinuation included dislike (47%), pain (33%), return of erection (19%), inefficacy (14%) and no partner (6%). Men trying intracorporeal injections had greater preoperative UCLA-PCI sexual function scores (75.2 vs 65.62, p = 0.00005) as well as greater decreases in this score at 3 months (p = 0.0002) and 2 years (p = 0.003). Higher preoperative sexual function scores were independently associated with the use of intracorporeal injections in a model adjusted for age, marital status, nerve sparing status and body mass index (OR 1.021, 95% CI 1.008-1.035). CONCLUSIONS Men pursuing intracorporeal injections have better baseline erectile function and experience greater deterioration in erectile function during the early postoperative period. Despite the high efficacy of injections, many men discontinue intracorporeal injections due to dislike or discomfort. Satisfaction rates for intracorporeal injections indicate their long-term role in restoring sexual function in men with post-prostatectomy erectile dysfunction.

Prostate Cancer: Diffusion-weighted MR Imaging for Detection and Assessment of Aggressiveness—Comparison between Conventional and Kurtosis Models

Purpose To compare standard diffusion-weighted (DW) imaging and diffusion kurtosis (DK) imaging for prostate cancer (PC) detection and characterization in a large patient cohort, with attention to the potential added value of DK imaging. Materials and Methods This retrospective institutional review board-approved study received a waiver of informed consent. Two hundred eighty-five patients with PC underwent 3.0-T phased-array coil prostate magnetic resonance (MR) imaging, including a DK imaging sequence (b values 0, 500, 1000, 1500, and 2000 sec/mm2) before prostatectomy. Maps of apparent diffusion coefficient (ADC) and diffusional kurtosis (K) were derived by using maximal b values of 1000 and 2000 sec/mm2, respectively. Mean ADC and K were obtained from volumes of interest (VOIs) placed on each patients dominant tumor and benign prostate tissue. Metrics were compared between benign and malignant tissue, between Gleason score (GS) ≤ 3 + 3 and GS ≥ 3 + 4 tumors, and between GS ≤ 3 + 4 and GS ≥ 4 + 3 tumors by using paired t tests, analysis of variance, receiver operating characteristic (ROC) analysis, and exact tests. Results ADC and K showed significant differences for benign versus tumor tissues, GS ≤ 3 + 3 versus GS ≥ 3 + 4 tumors, and GS ≤ 3 + 4 versus GS ≥ 4 + 3 tumors (P < .001 for all). ADC and K were highly correlated (r = -0.82; P < .001). Area under the ROC curve was significantly higher (P = .002) for ADC (0.921) than for K (0.902) for benign versus malignant tissue but was similar for GS ≤ 3 + 3 versus GS ≥ 3 + 4 tumors (0.715-0.744) and GS ≤ 3 + 4 versus GS ≥ 4 + 3 tumors (0.694-0.720) (P > .15). ADC and K were concordant for these various outcomes in 80.0%-88.6% of patients; among patients with discordant results, ADC showed better performance than K for GS ≤ 3 + 4 versus GS ≥ 4 + 3 tumors (P = .016) and was similar to K for other outcomes (P > .136). Conclusion ADC and K were highly correlated, had similar diagnostic performance, and were concordant for the various outcomes in the large majority of cases. These observations did not show a clear added value of DK imaging compared with standard DW imaging for clinical PC evaluation.

Adult UrologySexual Function/InfertilityLong-Term Satisfaction and Predictors of Use of Intracorporeal Injections for Post-Prostatectomy Erectile Dysfunction

PURPOSE Intracorporeal injections have low use rates and high discontinuation rates. We examined factors associated with intracorporeal injection use, long-term satisfaction with intracorporeal injection and reasons for discontinuation in men treated with radical prostatectomy. MATERIALS AND METHODS Between October 2000 and September 2003, 731 men who underwent open radical retropubic prostatectomy were enrolled in a prospective outcomes study. The 8-year followup evaluation included the UCLA-PCI, and a survey capturing intracorporeal injection use, satisfaction and reasons for discontinuation. Logistic regression was used to determine associations between intracorporeal injection use and preoperative variables. RESULTS The 8-year self-assessment was completed by 368 (50.4%) men. Of these men 140 (38%) indicated prior or current intracorporeal injection use, with only 34 using intracorporeal injection at 8 years. Overall, 44% of the men were satisfied with intracorporeal injections. Reasons for discontinuation included dislike (47%), pain (33%), return of erection (19%), inefficacy (14%) and no partner (6%). Men trying intracorporeal injections had greater preoperative UCLA-PCI sexual function scores (75.2 vs 65.62, p = 0.00005) as well as greater decreases in this score at 3 months (p = 0.0002) and 2 years (p = 0.003). Higher preoperative sexual function scores were independently associated with the use of intracorporeal injections in a model adjusted for age, marital status, nerve sparing status and body mass index (OR 1.021, 95% CI 1.008-1.035). CONCLUSIONS Men pursuing intracorporeal injections have better baseline erectile function and experience greater deterioration in erectile function during the early postoperative period. Despite the high efficacy of injections, many men discontinue intracorporeal injections due to dislike or discomfort. Satisfaction rates for intracorporeal injections indicate their long-term role in restoring sexual function in men with post-prostatectomy erectile dysfunction.

Frequency and Outcomes of Incidental Breast Lesions Detected on Abdominal MRI Over a 7-Year Period

OBJECTIVE Our aim was to evaluate the frequency and outcomes of incidental breast lesions detected on abdominal MRI examinations. MATERIALS AND METHODS Abdominal MRI reports for 11,462 women imaged at our institution from November 2007 through December 2014 were reviewed to identify those reporting an incidental breast lesion. Available breast imaging and pathology results were assessed to identify outcomes in these lesions. RESULTS Incidental breast lesions were described in the MRI reports of 292 (3%) patients who underwent abdominal MRI during the study period; breast imaging was recommended for 192 of these 292 (66%) patients. Sixty-three of the 192 (33%) patients for whom follow-up breast imaging was recommended underwent such imaging at our institution. Twenty-one of these 63 (33%) lesions underwent biopsy or surgery; histologic sampling of these lesions yielded seven incidental cancers (invasive ductal, n = 6; invasive lobular, n = 1) and 14 benign diagnoses. Three additional cancers (invasive ductal, n = 2; invasive lobular, n = 1) and three benign diagnoses were discovered at pathology at outside institutions. Of the remaining 165 patients without a histologic diagnosis, the lesions in 95 (58%) patients were presumed to be benign because of stability over time. Seven of the 10 patients with a diagnosis of incidental cancer (age range, 53-86 years; mean ± SD, 67.0 ± 10.6 years) had not undergone screening mammography at our institution. The frequency of incidental breast cancer was 11% of patients subsequently undergoing follow-up breast imaging at our institution, 3% of all patients with reported breast lesions, and 0.09% of patients undergoing abdominal MRI examinations. CONCLUSION Although incidental breast lesions were rarely detected on abdominal MRI, a considerable number of these lesions were found to represent breast cancer, particularly when leading to a recommendation for follow-up breast imaging. Therefore, it is important for radiologists interpreting abdominal MRI examinations to carefully evaluate for the presence of breast abnormalities.