Urologic Oncology-seminars and Original Investigations最新文献

Background: Multiparametric MRI (Mp-MRI) is a key tool to screen for Prostate Cancer (Pca) and Clinically Significant Prostate Cancer (CsPca). It primarily includes T2-Weighted imaging (T2w), diffusion-weighted imaging (DWI), and Dynamic Contrast-Enhanced imaging (DCE). Despite its improvements in CsPca screening, concerns about the cost-effectiveness of DCE persist due to its associated side effects, increased cost, longer acquisition time, and limitations in patients with poor kidney function. Recent studies have explored Biparametric MRI (Bp-MRI) as an alternative that excludes DCE.

Objectives: The main objective of this study is to compile and evaluate updated results of Bp-MRI as a diagnostic alternative to detect CsPca.

Methods: A systematic review was conducted using PubMed, Central Cochrane, and ClinicalTrialls.gov registry. Inclusion criteria was focused on observational and experimental studies that assessed a direct comparison of Bp-MRI and Mp-MRI for CsPca detection. The primary outcomes included were necessary to create a contingency 2×2 table and CsPca prevalence from each study. The secondary outcomes included were demographic data and imaging protocol features. The statistical analysis used a Bivariate Random-Effect model to estimate the pooled sensitivity, specificity, and area under the curve (AUC). An univariate random-effect model was conducted to estimate the positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies -2 tool.

Results: From 534 articles initially identified, 19 studies met the inclusion criteria with a total of 5075 patients. The pooled sensitivity estimated was 0.89, pooled specificity was 0.73, and AUC was 0.90; these results showed a slight increase compared to previous studies.

Conclusion: The results obtained showed that Bp-MRI is a feasible alternative to detect CsPca, which demonstrates high diagnostic accuracy and avoids the drawbacks associated with DCE.

Registry: This is a sub-analysis of the protocol registered at PROSPERO (CRD42024552125).

Introduction: Utilization of neoadjuvant systemic therapy (NAT) prior to radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) is inconsistent, and optimal patient selection for NAT is unclear. The purpose of this study was to evaluate the clinical benefit of NAT in high grade UTUC undergoing RNU.

Materials and methods: The UTUC Collaborative Network (UCAN) identified patients who underwent RNU for high grade UTUC between 2000 and 2022. NAT was examined as a primary exposure. NAT was defined as any systemic therapy prior to RNU. The outcomes of interest were extra-urothelial recurrence free survival (euRFS), cancer-specific survival (CSS), and overall survival (OS).

Results: Among 461 patients meeting criteria, 51.2% received NAT. At a median follow-up of 2.9 years, 24.1% experienced extra-urothelial recurrence at a median of 2.4 (1.0-5.2) years. On multivariable Cox proportional hazards models, NAT was associated with improved CSS (HR 0.58; 95% CI 0.36-0.94). In clinically node negative patients receiving NAT, Kaplan-Meier analysis showed improved euRFS (P = 0.01), cancer-specific survival (P = 0.002), and overall survival (P = 0.002). A statistically significant benefit was not observed for clinically node positive patients receiving NAT in euRFS (P = 0.667), CSS (P = 0.200), or OS (P = 0.313).

Conclusions: NAT was associated with improved survival outcomes in patients with clinically node negative disease. These benefits were not consistently observed in those with clinically node positive disease, although there was trend toward improved outcomes on multivariable Cox models. Further prospective investigations regarding risk stratification and multimodal management are needed in patients with high grade UTUC.

Background: The current standard prostate biopsy method, which combine systematic biopsy (SB) with targeted biopsy (TB), has shortcomings such as overdiagnosis and overtreatment. To evaluate the effectiveness of ipsilateral systematic biopsy (ips-SB) combined with targeted biopsy (ips-SB+TB) and contralateral SB (con-SB) combined with TB (con-SB+TB) as potential alternatives to SB+TB.

Methods: A comprehensive literature search was conducted in Cochrane, Embase, Ovid, and PubMed databases until September 2024. 2,732 references were identified, and 11 records were included.

Main findings: The study included a total of 5,249 patients and revealed that ips-SB+TB detected slightly less PCa than SB+TB with a relative risk (RR) of 0.95 (95% CI 0.91, 1.00), P = 0.05. In terms of csPCa detection, ips-SB+TB showed a comparable detection rate with SB+TB (RR 0.98 [95% CI 0.94, 1.01], P = 0.60). There was a statistically significant difference in csPCa detection between con-SB+TB and SB+TB (RR 0.92 [95% CI 0.86, 0.99], P = 0.02). The detection rates of clinically insignificant PCa (ciPCa) were comparable between con-SB+TB vs. SB+TB (con-SB+TB vs. SB+TB: RR 0.90 [95% CI 0.79, 1.04], P = 0.15). However, fewer ciPCa cases were detected in ips-SB+TB compared to SB+TB (RR 0.86 [95% CI 0.75, 0.99], P = 0.04).

Conclusions: In this review, our analysis highlights ips-SB+TB has the comparable detection efficiency of PCa and csPCa compared to SB+TB, and its potential to be the substitute of the SB+TB with less cores and less detection of ciPCa.

Background and objective: As most Prostate Imaging Reporting and Data System (PI-RADS) 5 lesions on MRI harbor Gleason grade (GG) group ≥2 disease on biopsy, optimal management of patients with imaging-biopsy discordance remains unclear. To estimate grade misclassification, we evaluated the incidence of Gleason upgrading among patients with GG1 disease in the setting of a PI-RADS 5 lesion.

Methods: We conducted a single-institution retrospective analysis to identify patients with GG1 prostate cancer on fusion biopsy with MRI demonstrating ≥1 PI-RADS 5 lesion. Primary study outcome was identification of ≥GG2 disease on subsequent active surveillance (AS) biopsy or radical prostatectomy (RP). We used multivariable models to examine factors associated with reclassification.

Results: We identified 110 patients with GG1 disease on initial biopsy and ≥1 PI-RADS 5 lesion. There were 104 patients (94.6%) initially managed with AS and 6 (5.5%) received treatment. Sixty-one patients (58.7%) on AS underwent additional biopsies. Of these, 43 (70.5%) patients had tumor upgrading, with 32 (74.4%) upgraded on first surveillance biopsy. Forty-four (40%) patients ultimately received treatment, including prostatectomy in 15 (13.6%) and radiation in 25 (22.7%). Two patients (1.8%) developed metastases. In multivariable models, genomic classifier score was associated with upgrading. Limitations include a lack of multi-institutional data and long-term outcomes data.

Conclusions: Most patients diagnosed with GG1 prostate cancer on MRI-Ultrasound fusion biopsy in the setting of a PI-RADS 5 lesion were found to have ≥GG2 disease on subsequent tissue sampling, suggesting substantial initial misclassification and reinforcing the need for confirmatory testing.

Background: Prospective trials have shown similar outcomes with partial nephrectomy (PN) in patients with localized renal cell carcinoma (RCC), and multiple studies suggest increasing the use of the technique. We hypothesize that patients who stem from minority groups, as well as Medicare and Medical, have less access to this specialized procedure and, therefore, have a higher rate of radical nephrectomy (RN).

Methods: We interrogated the California Office of Statewide Health Planning and Development (OSHPD) database, which collects information from all inpatient admissions, emergency room visits and inpatient/outpatient procedures in the state. All patients undergoing nephrectomy for RCC were identified from 2012 to 2018 using CPT and ICD-9/10 codes to identify patients with RCC undergoing RN and PN. Variables of interest included patient demographics, comorbidities, payor status and type of institution where the surgery was performed. We performed univariate and multivariable analysis to explore associations between patient factors and type of nephrectomy performed.

Results: In total, 31,093 patients who had undergone a nephrectomy in the study period were identified. Overall, most were 57% male, with a mean age of 58 years. PN and RN were performed in 15,840 (50.9%) and 15,253 (49.1%) patients, respectively. PN rates differed according to race/ ethnicity, as it was performed in 8576 (53.1%) White, 1124 (55.3%) Black, 1286 (46.0%) Asian, 4107 (47.5%) Hispanic and 747 (50.5%) other race patients (P < 0.001). Use of PN also differed among patients based on payor status, with 6800 (56.4%) private, 5,036 (43.9%) Medicare, 1,817 (38.3%) Medical, and 2,187 (77.7%) other insurance patients (P < 0.001). On multivariate analysis controlling for age, gender, comorbidities, and frailty, race was independently associated with the type of nephrectomy, but payor was not.

Conclusions: Our study confirms that race and payor status may have an influence on the utilization of partial versus status radical nephrectomy, with the highest rate of partial nephrectomies among Black patients and those with private insurance. Although there are multiple potential confounders (e.g., latency of diagnosis and resulting tumor size/complexity), it is possible access to care is a driver of this phenomenon.

Purpose: The utility of a pelvic drain (PD) after robot-assisted radical prostatectomy (RARP) has been recently questioned. We investigated the impact of discontinuing PD placement after RARP on complications, pain, environmental benefits, and cost savings.

Methods: We identified 1,199 patients who underwent RARP with or without extended pelvic lymph node dissection from 2016 to 2023 at a referral center. Starting in 2018, PD placement was discontinued in uncomplicated RARPs. Complications were collected following the European Association of Urology (EAU) recommendations on reporting and grading. Multivariable logistic regression models (MLR) evaluated the impact of PD use on perioperative outcomes and opioid usage. The PD life cycle-associated Carbon Dioxide Equivalent Emissions (CO2e) and its economic impact were estimated.

Results: A PD was placed in a total of 555 (46%) patients, with a decreasing rate from 94% to 18% between 2016 and 2023. The rates of any and high-grade (HG) complications were similar between patients with and without PD (29 vs. 28% and 5% vs. 6%, respectively; all P ≥ 0.2). At MLR, the PD placement was not associated with the risk of any (OR:1.09, 95%CI:0.79-1.5) or HG complications (OR 1.45, 95%CI 0.80-2.63). PD placement was associated with greater postoperative opioid usage (OR:1.58, 95%CI:1.01-2.51, P = 0.045). The CO2e spared rose from 220 in 2016 to 2,180 in 2022 and cost savings per year increased from 1,855€ in 2016 to 18,506€ in 2022.

Conclusion: Unnecessary PD placement should be avoided in uncomplicated RARPs to obtain environmental benefits, reduce health-related costs, and improve patients' outcomes.

Several studies indicated that prostate cancer has a hereditary component. In particular, a significant risk of prostate cancer has been linked to a tight familial lineage. However, to provide insight into how prostate cancer is inherited, characterising its genetic profile is essential. The current body of research on the analysis of genetic mutations in prostate cancer was reviewed to achieve this. This paper reports on the effects and underlying processes of prostate cancer that have been linked to decreased male fertility. Many research approaches used have resulted in the discovery of unique inheritance patterns and manifest traits, the onset and spread of prostate cancer have also been linked to many genes. Studies have specifically examined Androgen Receptor gene variants about prostate cancer risk and disease progression. Research has shown that genetic and environmental variables are important contributors to prostate cancer, even if the true origins of the disease are not fully recognised or established. Researchers studying the genetics of prostate cancer are using genome-wide association studies more and more because of their outstanding effectiveness in revealing susceptibility loci for prostate cancer. Genome-Wide Association Studies provides a detailed method for identifying the distinct sequence of a gene that is associated with cancer risk. Surgical procedures and radiation treatments are 2 of the treatment options for prostate cancer. Notwithstanding the compelling evidence shown in this work, suggests that more research must be done to detect the gene alterations and the use of genetic variants in the treatment of prostate cancer.

Objectives: Compare functional outcomes and treatment-related regret over 10 years in Spanish- and English-speaking Hispanic men compared to non-Hispanic men following treatment of localized prostate cancer.

Methods and materials: Data from a prospective cohort study of men with localized prostate cancer treated with active surveillance, radical prostatectomy or radiotherapy were used to examine the effect of survey language (Spanish speaking vs. English speaking) and ethnicity (Hispanic vs. non-Hispanic) on functional outcomes and treatment-related regret over 10 years. Outcomes were measured using validated questionaries adjusting for baseline patient and disease characteristics.

Results: A total of 770 men were included, 12% were Spanish-speaking and 12% were English-speaking Hispanic men. Compared to non-Hispanic men, Spanish-speaking Hispanic men had clinically meaningfully better urinary incontinence scores at years 3, 5 and 10 (adjusted mean difference [aMD], 12.4, 95% CI, 4.8 to 20.0; at year 10), as well as better bowel function scores at 10 years (aMD, 5.1, 95% CI 2.3 to 8.0). English-speaking Hispanic men had clinically worse urinary incontinence at 3 and 5 years (aMD, -10.7 [95% CI, -17.6 to -3.9]; at year 5) and bowel function at 10 years (aMD, -4.3 [95% CI, -8.2 to -0.4]) compared to Spanish-speaking Hispanic men. English-speaking Hispanic men were more likely to report regret than Spanish-speaking Hispanic men at 10 years (adjusted odds ratio, 7.9, 95% CI, 1.3-46.2).

Conclusions: These findings underscore the importance of considering language and ethnicity when providing counseling and support for prostate cancer survivors, emphasizing the need for personalized patient-centered care.

Objectives: Partial cystectomy (PC) has been proposed as a less invasive alternative to radical cystectomy (RC) for the treatment of localized muscle-invasive bladder cancer (MIBC). The aim of this study was to evaluate the outcome of PC in a contemporary patient cohort to identify potential risk factors for this procedure.

Methods: Data from 58 MIBC patients who underwent PC were retrospectively analyzed. Demographics, tumor characteristics, clinical outcomes, and pathology results were collected. Statistical analysis was performed using Cox regression and Kaplan-Meier method to determine survival rates and risk factors.

Results: The cohort consisted of 58 patients with MIBC with a median age of 71 years. The 5-year overall survival (OS), cancer specific survival (CSS) and recurrence-free survival (RFS) rates were 55%, 67% and 51%, respectively. Clinical suspicion for lymph node metastases (HR 3.82, CI 1.09-13.39, P = 0.036), advanced T-stages (HR 3.80, CI 1.38-10.49, P = 0.010), a higher grading (HR 6.57, CI 0.76-49.19, P = 0.010), positive resection margins (HR 1.81, CI 1.10-2.96, P = 0.012), lymphovascular invasion (HR 5.14, CI 1.77-14.88, P = 0.003), vascular invasion (HR 6.62, CI 2.16-20.27, P = 0. 001), and longer time from initial diagnosis to surgery (HR 1.003, CI 1.001-1.01, days, P = 0.010) were associated with decreased OS. Complications within the first 30 and 90 postoperative days were observed in 31% and 36% of patients, respectively. 4% experienced a Clavien-Dino grade III/IV complication. One patient developed acute respiratory distress syndrome and died 46 days after surgery.

Conclusion: Partial cystectomy appears to be a safe bladder-sparing approach for highly selected MIBC patients with favorable oncologic outcomes and acceptable complication rates. Patient selection and assessment of tumor characteristics are essential for successful outcomes. Prospective randomized controlled trials are needed.

Background: Given the changing treatment landscape for locally advanced or metastatic urothelial carcinoma (la/mUC), this study aimed to describe real-world treatments, overall survival (OS), health care resource utilization (HCRU), and costs among US patients with la/mUC receiving first-line therapy.

Methods: This retrospective study was conducted using 100% Medicare claims data (2015-2020). Patients with la/mUC were selected; initiation of first-line therapy was the index date. Treatments and OS were assessed during follow-up (index date to the earliest of end of data availability, health plan coverage, or death). All-cause HCRU and costs (2021 USD) were assessed during the first-line treatment period (index date to the earliest of first-line discontinuation, switch to second-line therapy, end of follow-up, or death). Outpatient pharmacy costs were not included. All-cause OS from start of first-line therapy was estimated using the Kaplan-Meier approach. The HCRU, cost, and OS analyses were stratified by 3 index treatment groups-platinum-based chemotherapy, non-platinum-based chemotherapy, and programmed cell death protein 1/ligand 1 (PD-1/L1) inhibitor monotherapy-and adjusted for baseline characteristics.

Results: Of 9,939 patients included, 77.1% were men and mean age was 76 years. In total, 5,050 (50.8%) received platinum-based chemotherapy, 1,361 (13.7%) received non-platinum-based chemotherapy, and 3,242 (32.6%) received PD-1/L1 inhibitor monotherapy for first-line la/mUC. Median OS was 12.9, 12.9 (P = 0.960), and 9.0 months (P < 0.001) with platinum-based chemotherapy (reference), non-platinum-based chemotherapy, and PD-1/L1 inhibitor monotherapy, respectively. Most (> 99%) patients had ≥ 1 outpatient visit during the treatment period; mean number of visits per patient was 13.1 with platinum-based chemotherapy, 10.5 with non-platinum-based chemotherapy, and 18.3 with PD-1/L1 inhibitor monotherapy. In general, HCRU was significantly lower for patients receiving PD-1/L1 inhibitor monotherapy versus platinum-based chemotherapy. However, costs were significantly higher with PD-1/L1 inhibitor monotherapy versus platinum-based chemotherapy. Mean total monthly cost per patient was $10,285 for platinum-based chemotherapy, $8,982 for non-platinum-based chemotherapy, and $18,147 for PD-1/L1 inhibitor monotherapy.

Conclusions: From 2015 to 2020, patients with la/mUC had substantial HCRU and costs and short survival, regardless of first-line treatment. More effective therapies were needed to prolong survival and reduce the economic burden of la/mUC.