Significant prostate cancer risk after MRI-guided biopsy showing benign findings: Results from a cohort of 381 men

BACKGROUND

MRI-guided biopsy (MGB) contributes to the diagnosis of clinically significant Prostate Cancer (csPCa). However, there are no clear recommendations for the management of men after a negative MGB. The aim of this study was to assess the risk of csPCa after a first negative MGB.

METHODS

Between 2014 and 2020, we selected men with a PI-RADS score ≥ 3 on MRI and a negative MGB (showing benign findings) performed for suspected prostate cancer. MGB (targeted and systematic biopsies) was performed using fully integrated mobile fusion imaging (KOELIS). The primary endpoint was the rate of csPCa (defined as an ISUP grade ≥ 2) diagnosed after a first negative MGB.

RESULTS

A total of 381 men with a negative MGB and a median age of 65 (IQR: 59-69, range: 46-85) years were included. During the median follow-up of 31 months, 124 men (32.5%) had a new MRI, and 76 (19.9%) were referred for a new MGB, which revealed csPCa in 16 (4.2%) of them. We found no statistical difference in the characteristics of men diagnosed with csPCa compared with men with no csPCa after the second MGB.

CONCLUSION

We observed a risk of significant prostate cancer in 4% of men two years after a negative MRI-guided biopsy. Performing a repeat MRI could improve the selection of men who will benefit from a repeat MRI-guided biopsy, but a clear protocol is needed to follow these patients.

LEVEL OF EVIDENCE: 4

Photodynamic cystoscopy for bladder cancer diagnosis and for NMIBC follow-up: An overview of systematic reviews and meta-analyses

INTRODUCTION

Currently, bladder cancer detection is based on cytology and cystoscopy. White light cystoscopy (WLC) is an invasive procedure and may under-detect flat lesions. Blue light cystoscopy (BLC) and narrow band imaging (NBI) cystoscopy are new modalities that could improve the detection of non-muscle invasive bladder cancer (NMIBC) and its recurrence or progression to muscle invasive bladder cancer. We present a systematic review on BLC and NBI cystoscopy for bladder cancer diagnosis and NMIBC follow-up.

MATERIAL AND METHODS

All available systematic reviews and meta-analyses on cystoscopy published in PubMed® between May 2010 and March 2021 were identified and reviewed. The main endpoints were clinical performance for bladder cancer diagnosis and for recurrence or progression detection during NMIBC follow-up, and additional value compared with cytology and/or WLC.

RESULTS

Most of the meta-analyses and systematic reviews published suggest a better sensitivity of BLC and NBI cystoscopy compared to WLC, particularly for the detection of flat lesions (CIS). NBI- and BLC-guided TURBT could decrease the recurrence rates. However, their clinical utility to reduce progression rate and increase survival is still unclear.

CONCLUSIONS

BLC and NBI cystoscopy are efficient techniques for bladder cancer diagnosis and NMIBC follow-up. However, their clinical benefit remains to be confirmed.

Prognostic significance of PI-RADS 5 lesions in patients treated by radical prostatectomy

PURPOSE

To analyse the pathological features and survival of patients with a PI-RADS 5 lesion on pre-biopsy MRI.

METHODS

We extracted from a European multicentre prospectively gathered database the data of patients with a PI-RADS 5 lesion on pre-biopsy MRI, diagnosed using both systematic and targeted biopsies and subsequently treated by radical prostatectomy. The Kaplan-Meier model was used to assess the biochemical-free survival of the whole cohort and univariable and multivariable Cox models were set up to study factors associated with survival.

RESULTS

Between 2013 and 2019, 539 consecutive patients with a PI-RADS 5 lesion on pre-biopsy MRI were treated by radical prostatectomy and included in the analysis. Follow-up data were available for 448 patients. Radical prostatectomy and lymph node dissection specimens showed non-organ confined disease in 297/539 (55%), (including 2 patients with a locally staged pT2 lesion and lymph node involvement (LNI)). With a median follow-up of 25 months (12-39), the median biochemical recurrence-free survival was 54% at 2 years (95% CI 45-61) and 28% at 5 years (95% CI 18-39). Among the factors studied, MRI T stage [T3a vs T2 HR 3.57 (95%CI 1.78-7.16); T3b vs T2 HR 6.17 (95% CI 2.99-12.72)] and PSA density (HR 4.47 95% CI 1.55-12.89) were significantly associated with a higher risk of biochemical recurrence in multivariable analysis.

CONCLUSION

Patients with a PI-RADS 5 lesion on pre-biopsy MRI have a high risk of early biochemical recurrence after radical prostatectomy. MRI T stage and PSA density can be used to improve patient selection and counselling.

French AFU Cancer Committee Guidelines - Update 2022-2024: Upper urinary tract urothelial cancer (UTUC)

INTRODUCTION

The aim was to propose an update of the French Urology Association Cancer Committee (ccAFU) Recommendations on the management of upper urinary tract urothelial carcinomas (UUT-UC).

METHODS

A systematic Medline search was performed between 2020 and 2022, taking account of the diagnosis, treatment options and follow-up of UUT-UC, while evaluating the references with their levels of evidence.

RESULTS

The diagnosis of this rare pathology is based on CTU acquisition during excretion and flexible ureterorenoscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment. Nevertheless conservative treatment can be discussed for low risk lesions: tumour of low-grade, with no infiltration on imaging, unifocal<2cm, eligible for full treatment therefore requiring close endoscopic surveillance by flexible ureteroscopy in compliant patients. After RNU, postoperative instillation of chemotherapy is recommended to reduce the risk of recurrence in the bladder. Adjuvant chemotherapy has shown clinical benefits compared to surveillance after RNU for tumours (pT2-T4 N0-3 M0).

CONCLUSION

These updated recommendations should contribute to improving not only patients' level of care, but also the diagnosis and decision-making concerning treatment for UUT-UC.

French AFU Cancer Committee Guidelines - Update 2022-2024: Muscle-Invasive Bladder Cancer (MIBC)

OBJECTIVE

To update the CCAFU recommendations for the management of muscle invasive bladder carcinoma (MIBC).

METHODS

A systematic review (Medline) of the literature from 2020 to 2022 was performed taking account of the diagnosis, treatment options and surveillance of NMIBC and MIBC, while evaluating the references with their levels of evidence.

RESULTS

MIBC is diagnosed after the most complete tumour resection possible. MIBC grading is based on CTU along with chest CT. Multiparametric pelvic MRI could be an alternative. Cystectomy with extensive lymphadenectomy is the gold standard treatment for non-metastatic MIBC. It should be preceded by platinum-based neoadjuvant chemotherapy in patients in good general health with satisfactory renal function. Enterocystoplasty is proposed in men and women in the absence of contraindications and when the urethral resection is negative on extemporaneous examination. Otherwise, transileal cutaneous ureterostomy is the recommended method of urinary diversion. Inclusion of all patients in an ERAS (Enhanced Recovery After Surgery) protocol is recommended. For metastatic MIBC, first line treatment with platinum-based chemotherapy (GC or MVAC) is recommended, if general health (PS>1) and renal function (clearance>60mL/min) so allow (only 50% of the cases). Pembrolizumab immunotherapy has demonstrated an overall survival benefit in second-line treatment.

CONCLUSION

Updating the ccAFU recommendations should contribute to improving patient management, as well as the diagnosis and decision-making concerning MIBC treatment.

French AFU Cancer Committee Guidelines - Update 2022-2024: Non-muscle-invasive bladder cancer (NMIBC)

OBJECTIVE

To update the ccAFU recommendations for the management of bladder tumours that do not infiltrate the bladder muscle (NBMIC).

METHODS

A systematic review (Medline) of the literature from 2020 to 2022 was performed, taking account of the diagnosis, treatment options and surveillance of NMIBC, while evaluating the references with their levels of evidence.

RESULTS

The diagnosis of NMIBC (Ta, T1, CIS) is made after complete full-thickness tumour resection. The use of bladder fluorescence and the indication of a second look (4-6 weeks) help to improve the initial diagnosis. The EORTC score is used to assess the risk of recurrence and/or tumour progression. Through the stratification of patients in low, intermediate and high-risk categories, adjuvant treatment can be proposed: intravesical chemotherapy (immediate postoperative, initiation regimen) or BCG (initiation and maintenance regimen) instillations, or even the indication of cystectomy for BCG-resistant patients.

CONCLUSION

Updating the ccAFU recommendations should contribute to improving patient management, as well as the diagnosis and treatment of NMIBC.

[Bladder-sparing trimodal therapy for muscle invasive bladder cancer]

Organ-sparing strategies in the management of local or locally advanced cancers meet a dual objective: tumor control and preservation of the function of the involved organ. Given the morbidity and mortality of cystectomy and its impact on quality of life and bladder function, bladder-sparing strategies have emerged for the management of urothelial muscle invasive bladder cancer, mostly through trimodal treatment, which consists in maximal trans-urethral resection of bladder tumor, followed by chemo-radiotherapy. This review presents the modalities of trimodal treatment, before exposing the advantages and limitations of this strategy compared to cystectomy among operable patients. Despite the absence of comparative data from randomized trials, the two approaches seem to provide similar oncological results among appropriately selected patients. In modern series, the rate of salvage cystectomy is approximately 15% at 5 years; this delayed cystectomy does not seem to be associated with greater morbidity and mortality as compared to upfront cystectomy. Emphasis is placed in the review on quality of life data of these two approaches. In order to optimize the selection of patients eligible to trimodal therapy, the classical predictive factors of response to radio(chemo)therapy are critically analyzed, with the perspective of innovative molecular biomarkers. Finally, a close multidisciplinary collaboration is needed for the choice and the execution of the therapeutic strategy, and the patient should be fully involved in the decision-making process.

[De novo or secondary metastatic prostate cancer management in France: Observational study from "sentinel multidisciplinary meeting" of the French Association of Urology]

INTRODUCTION

Metastatic prostate cancer (mPCa) is an heterogeneous disease. Metachronous mPCa (MM) seems to have a better prognosis than synchronous mPCa (SM). However, it is difficult to analyze their specificities from national registries. Data from the so-called "sentinel multidisciplinary meeting" (SMDM) would represent a "real life" data collection. The objective of this national pilot study was to evaluate the concept of SMDM through the description and comparison of the diagnosis, management and follow-up of patients with synchronous or metachronous mPCa in 2018.

METHODS

A survey covering clinical, biological, radiological data as well as treatment initiated and follow-up at 3 and 6 months was sent to the SMDM. All patients diagnosed with metastatic disease (SM or MM) between 01/01/2018 and 11/30/2018 were included.

RESULTS

In total, 780 patients from 39 centers were included, 408 SM and 372 MM. SM were more symptomatic and had a higher metastatic burden than MM. PET were mostly performed in MM without a prior standard staging. SM patients received more chemotherapy than MM patients whereas new generation androgen deprivation therapy was mostly given to MM patients. At 6 months, there were no more significant difference in clinical presentation between the two groups.

CONCLUSION

Specificities of SM and MM patients in terms of clinical presentation, metastatic burden and management were described, validating the concept of SMDM as a source of reliable informations.

LEVEL OF EVIDENCE: 4

Assessment of oncological and functional outcomes of retropubic radical prostatectomy: An academic center experience

PURPOSE

To report perioperative, pathological, oncological and functional outcomes of a contemporary series of retropubic radical prostatectomy (RRP), performed by one experienced surgeon.

METHODS

We analyzed data from a prospectively gathered database of consecutive patients who were treated by an RRP as first-line treatment for localized prostate cancer, from January 2014 to December 2019, in a single French academic center.

RESULTS

Overall, 364 patients were included. Median age and PSA were 65.7 years and 8.0ng/mL. According to D'Amico risk classification, 13.7% patients had a low-risk prostate cancer, 41.5% a favorable intermediate-risk, 23.4% an unfavorable intermediate-risk and 21.4% a high-risk prostate cancer. The rates of pT2 and pT3 were 48.6% (n=177) and 51.4% (n=187), respectively. The rates of non-nerve sparing surgery (NSS), unilateral NSS and bilateral NSS were 19.5% (n=71), 32.7% (n=119) and 47.8% (n=174). Total positive surgical margin (PSM) rate was 12.6% (n=46). Total pT2 PSM and pT3 PSM rates were 0.6% (n=1) and 24.1% (n=45) and achieved a statistical difference (P<0.001). At a median follow-up of 1.9-year, biochemical recurrence (BCR) occurred in 47 (12,9%) patients. Extracapsular extension was associated with a poor BCR-free survival as compared to organ confined disease (P<0.0001). At 2.7 years of follow-up, urinary continence rate was 88% (322/364). After exclusion of non-NSS RRP and non-interpretable questionnaires (score 1-4), median IIEF-5 score was 16 (8-20).

CONCLUSION

Retropubic radical prostatectomy ensures optimal pathological and functional results, in a current predominantly population of intermediate-risk prostate cancer and high-risk prostate cancer.

LEVEL OF EVIDENCE

3.

[French ccAFU guidelines - update 2020-2022: upper urinary tract urothelial carcinoma]

INTRODUCTION

-The purpose was to propose an update of the French guidelines from the national committee ccAFU on upper tract urothelial carcinomas (UTUC).

METHODS

- A systematic Medline search was performed between 2018 and 2020, as regards diagnosis, options of treatment and follow-up of UTUC, to evaluate different references with levels of evidence.

RESULTS

- The diagnosis of this rare pathology is based on CT-scan acquisition during excretion and ureteroscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment, nevertheless a conservative endoscopic approach can be proposed for low risk lesion: unifocal tumor, possible complete resection and low grade and absence of invasion on CT-scan. Close monitoring with endoscopic follow-up (flexible ureteroscopy) in compliant patients is therefore necessary. After RNU, bladder instillation of chemotherapy is recommended to reduce risk of bladder recurrence. A systemic chemotherapy is recommended after RNU in pT2-T4 N0-3 M0 disease.

CONCLUSION

- These updated guidelines will contribute to increase the level of urological care for diagnosis and treatment for UTUC.

[French ccAFU guidelines - update 2020-2022: bladder cancer]

OBJECTIVE

- To update French guidelines for the management of bladder cancer specifically non-muscle invasive (NMIBC) and muscle-invasive bladder cancers (MIBC).

METHODS

- A Medline search was achieved between 2018 and 2020, notably regarding diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

RESULTS

- Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS <1) and renal function (creatinine clearance >60 mL/min) allow it (only in 50% of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

CONCLUSION

- These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment of patients diagnosed with NMIBC and MIBC.

[Living-donor robotic-assisted kidney transplantation: French academic center experience]

INTRODUCTION

The main objective was to report the intra-, post-operative and functional outcomes of living-donor robotic-assisted kidney transplantation (RAKT), performed by a surgeon skilled in robotic surgery. The secondary objective was to compare the results of RAKT, based on the surgeon's experience.

METHODS

For this retrospective cohort study, we analyzed data from consecutive patients who underwent living-donor RAKT from July 2015 to March 2020 and compared the results of RAKT according to the surgeon's experience (group 1: 1-14th RAKT versus group 2: 15-29th RAKT).

RESULTS

Twenty-nine living-donor RAKT were performed. The median age and BMI of the recipients were: 57.0 (44.0-66.0) years and 32.7 (23.5-39.6)kg/m². The median overall operative time and median console time were: 140.0 (122.5-165.0) and 120.0 (107.5-137.5) minutes. The median rewarming time, arterial, venous and urinary anastomoses durations were: 35.0 (27.5-45.0), 15.0 (11.0-20.0), 12.0 (10.0-16.0), 20.0 (16.0-23.0) minutes. Two (6.9%) minor and 5 (17.2%) major (Clavien-Dindo≥III) postoperative complications occurred. At 2 years of follow-up, patient and transplant survival was 100% (n=29) and 93.1% (n=27). After the 14th RAKT, the rewarming time (P=0.01) and venous anastomosis duration (P=0.004) were statistically shorter.

CONCLUSION

Living-donor robotic-assisted kidney transplantation, performed by a surgeon skilled robotic surgery, ensures good functional results in the medium term.

LEVEL OF EVIDENCE

3.

[Survival analysis of adjustable continence therapy device (ACT®/proACT®): a new message for patients]

INTRODUCTION

The main purpose was to assess the failure free survival of adjustable continence therapy ACT®/proACT® after continence was obtained and to seek factors influencing it.

MATERIAL AND METHODS

Retrospective, single-center survival study of peri-urethral balloons implanted between 2007 and 2014. Efficacy was defined by the wearing of 0 or 1 safety pad per day. The primary end point was time to failure estimated from a survival curve (Kaplan-Meier). Factors that could influence failure free survival were: sex, age, radiotherapy, diabetes, number of pad before surgery, number of balloon inflation, early complications, mixed urinary incontinence and previous ACT®/proACT® placement. They were analyzed in a COX regression.

RESULTS

Of the 82 peri-urethral balloons placed, 41 were effective in 36 patients. The failure free survival was 50 % at 60 months. Radiotherapy, diabetes and previous peri-urethral balloon placement appeared to significantly decrease survival (P=0.031;P=0.025;P=0.029, respectively). Fifteen peri-urethral balloons were still effective at the last follow-up, one was lost to follow-up and 25 required re-intervention for loss of efficacy. The main cause of efficacy loss was system leakage. Fifty-two percent of peri-urethral balloons that became ineffective were replaced by new peri-urethral balloons and 28% by an artificial urinary sphincter.

CONCLUSION

Patients who became continent with adjustable continence therapy (ACT®/proACT®) had a 50 % new surgery probability at 5 years for a loss of efficacy. Radiotherapy seems to be the main risk factor of the efficacy loss.

LEVEL OF EVIDENCE

IV.

Quality of life and functional outcomes after radical cystectomy with ileal orthotopic neobladder replacement for bladder cancer: a multicentre observational study

PURPOSE

Ileal orthotopic neobladder (IONB) reconstruction is the preferred urinary diversion among selected patients who have undergone radical cystectomy (RC) for bladder cancer (BCa). There is insufficient data regarding patients' quality of life (QoL), sexual and urinary outcomes. Our objectives were to assess QoL in a multicentre cohort study, and to identify related clinical, oncological and functional factors.

METHODS

Patients who underwent RC with IONB reconstruction for BCa from 2010 to 2017 at one of the three French hospitals completed the following self-reported questionnaires: European Organization for Research and Treatment of Cancer (EORTC) generic (QLQ-C30) and bladder cancer specific instruments (QLQ-BLM30). To assess urinary symptoms, patients completed the Urinary Symptom Profile questionnaire (USP) and a three-day voiding diary. Univariate and multivariate analyses were computed to identify clinical, pathological, and functional predictors of global QoL score.

RESULTS

Seventy-three patients completed questionnaires. The median age was 64 years and 86.3% were men. The median interval between surgery and responses to questionnaires was 36 months (range 12-96). Fifty-five percent of patients presented a high global QoL (EORTC-QLQC30, median score 75). A pre-RC American Society of Anesthesiologists score > 2, active neoplasia, sexual inactivity, and stress urinary incontinence were associated with a worse QoL. After a multivariate analysis, sexual inactivity was the only independent factor related to an altered QoL.

CONCLUSION

Patients with IONB reconstruction after RC have a high global QoL. Sexual activity could independently impact the global QoL, and it should be assessed pre- and post-operatively by urologists.