Prostate Cancer and Prostatic Diseases最新文献

In recent years, the criteria determining eligibility for active surveillance (AS) for prostate cancer (PCa) patients have evolved considerably. Factors such as disease stage, PSA values, core involvement at biopsies, Gleason Score (GS), and comprehensive risk score classifications [1, 2] have been reassessed to expand the cohort of patients suitable for AS. Despite this broader eligibility, more than 40% of patients with low-risk disease are treated immediately in the United States (U.S.), leading to an increased number of patients receiving unnecessary treatment [3]. Historically, the implementation of AS within the U.S. has been predominantly associated with academic institutions, with lower adoption rates in community-based urology practices. However, recent trends indicate a substantial and rapid expansion in the utilization of AS across a broader spectrum of healthcare institutions, leading to significant increase of active monitoring among the U.S. population diagnosed with PCa [4, 5].

Interestingly, the broader eligibility criteria have not only resulted in an increased number of patients choosing AS, but also extended the period during which individuals commit to this management strategy. This paradigm shift has consequently led to a rise in the incidence of symptomatic benign prostatic hyperplasia (BPH) among patients in AS, a condition that typically emerges around the age of 40 and becomes progressively more common thereafter [6]. Currently, there are no specific recommendations regarding the management of patients developing moderate to severe LUTS secondary to BPH requiring surgery during AS, what the preferred surgical intervention should be, and what are the potential implications on the subsequent management of PCa.

Background

Shared decision-making (SDM) is recommended for prostate-specific antigen (PSA) testing but appears underutilized. This population-based study assessed the prevalence and determinants of SDM for PSA testing among US men.

Methods

We assessed PSA testing rates and SDM engagement in men aged 40 and older without prostate cancer history using the 2019 National Health Interview Survey. SDM was defined as discussing the advantages and disadvantages of PSA testing with a physician. We used multivariable logistic regression with machine learning to identify factors associated with lack of SDM.

Results

Among 9723 eligible participants (mean age 58 years), lifetime PSA testing prevalence was 45.9% and the 1-year testing incidence was 29.1%. Only 24.1% reported engaging in SDM with a physician, while 62.9% never discussed PSA testing. Younger age and lower education levels were the primary determinants of decreased SDM engagement. Men with less education engaged in SDM less than half as often as those with higher education levels across all age groups.

Conclusions

Societal guidelines recommend SDM for PSA testing. However, most men, regardless of age, have never engaged in SDM conversations with a healthcare provider about PSA testing, especially those with less education. More efforts are needed to improve patient-provider conversations about the potential benefits and harms of PSA testing.

The systematic review by Saouli et al. investigates the role of radical prostatectomy (RP) in managing oligometastatic prostate cancer (omPCa) [1]. They analyzed the existing literature to assess the oncological and functional outcomes of RP for these patients. RP is feasible and has an acceptable risk of complications. However, the lack of consensus on the definitions of omPCa and the low-quality evidence of the available comparative and retrospective studies, RP in omPCa should not be recommended outside of clinical trials.

Background

The surgical landscape for Lower Urinary Tract Symptoms (LUTS) and Benign Prostatic Hyperplasia (BPH) has evolved with the introduction of Minimally Invasive Surgical Therapies (MISTs), recognizing the impact of sexual function on patients’ well-being, and prioritizing ejaculation-sparing approaches.

Methods

This systematic review explored ejaculation sparing after classic endoscopic procedures and MISTs (iTind, Rezūm, Urolift, Aquablation, and TPLA) and a literature search yielded 41 studies.

Results

While all procedures demonstrated efficacy in improving LUTS/BPH symptoms (IPSS, QoL, Qmax), a subset of studies evaluated ejaculatory function. Positive outcomes were noted, challenging the historical association of BPH surgeries with ejaculatory dysfunction. Variations in study design, patient cohorts, and limited long-term data present challenges. Notably, the lack of baseline specificity, use of alpha-blockers, and non-specific sexual function assessments underscore potential biases.

Conclusions

Despite limitations, the review tentatively concluded that MISTs, including iTind, Rezūm, Urolift, Aquablation, and TPLA, appear comparable in sparing ejaculation. Long-term studies are essential to validate sustainability, and comparative research should assess trade-offs between MISTs and traditional surgeries. Incorporating patient-reported outcomes and quality of life assessments will enhance future investigations, refining MISTs as standard therapeutic options for LUTS/BPH.

Background

Certain widely used pathological outcome prediction models that were developed in tertiary centers tend to overpredict outcomes in the community setting; thus, the Michigan Urological-Surgery Improvement Collaborative (MUSIC) model was developed in general urology practice to address this issue. Additionally, the development of these models involved a relatively small proportion of Black men, potentially compromising the accuracy of predictions in this patient group. We tested the validity of the MUSIC and three widely used nomograms to compare their overall and race-stratified predictive performance.

Methods

We extracted data from 4139 (1138 Black) men from the Shared Equal Access Regional Cancer Hospital (SEARCH) database of the Veterans Affairs health system. The predictive performance of the MUSIC model was compared to the Memorial-Sloan Kettering (MSK), Briganti-2012, and Partin-2017 models for predicting lymph-node invasion (LNI), extra-prostatic extension (EPE), and seminal vesicle invasion (SVI).

Results

The median PSA of Black men was higher than White men (7.8 vs. 6.8 ng/ml), although they were younger by a median of three years and presented at a lower-stage disease. MUSIC model showed comparable discriminatory capacity (AUC:77.0%) compared to MSK (79.2%), Partin-2017 (74.6%), and Briganti-2012 (76.3%), with better calibration for LNI. AUCs for EPE and SVI were 72.7% and 76.9%, respectively, all comparable to the MSK and Partin models. LNI AUCs for Black and White men were 69.6% and 79.6%, respectively, while EPE and SVI AUCs were comparable between races. EPE and LNI had worse calibration in Black men. Decision curve analysis showed MUSIC superiority over the MSK model in predicting LNI, especially among Black men.

Conclusion

Although the discriminatory performance of all models was comparable for each outcome, the MUSIC model exhibited superior net benefit to the MSK model in predicting LNI outcomes among Black men in the SEARCH population.

Background

While transurethral resection of the prostate (TURP) is the standard-of-care, Holmium laser enucleation of the prostate (HoLEP) is widely accepted as a size-independent method for surgical treatment of patients with lower urinary tract symptoms (LUTS) secondary to bladder outlet obstruction (BOO). However, in an ageing society an increasing number of patients presents with BOO due to locally advanced prostate cancer. There is currently no guidelines recommendation as to the enucleation or resection technique. Therefore, we compared intraoperative performance, postoperative outcomes, and safety for palliative (p)TURP and (p)HoLEP.

Methods

We conducted a retrospective, propensity score-matched analysis of 1373 and 2705 men who underwent TURP or HoLEP for LUTS/BOO between 2014 and 2021, respectively. Patients were matched for age, prostate size and preoperative international prostate symptom score (IPSS). Patients were stratified by technique and groups were compared for perioperative parameters, safety, and functional outcomes.

Results

While postoperative symptoms and urodynamic parameters improved irrespective of technique, we report significantly increased resection and enucleation times for palliative indication. For corresponding efficiency parameters, we observed a two-fold higher surgical performance (g/min) for both techniques in patients without prostate cancer. While adverse events were comparable between groups, we found a two-fold higher hemoglobin drop in palliative patients.

Conclusions

Currently, there is no standard-of-care for patients with BOO and locally advanced prostate cancer. Our data show that both TURP and HoLEP offer adequate symptom improvement and comparable safety profiles. While HoLEP is feasible even in larger prostates, both procedures become more difficult in patients with prostate cancer. Taken together, this study covers an important gap in current literature, helping urological surgeons to make evidence-based decisions for the benefit of their patients.