Accurate staging of high-risk localised, advanced, and metastatic prostate cancer is becoming increasingly more important in guiding local and systemic treatment. Gallium-68 prostate-specific ...membrane antigen (PSMA) positron emission tomography (PET) has increasingly been utilised globally to assess the local and metastatic burden of prostate cancer, typically in biochemically recurrent or advanced disease. Following our previous meta-analysis, a high-volume series has been reported highlighting the utility of 68Ga-PSMA PET in this setting.
To perform a systematic review and meta-analysis to update reported predictors of positive 68Ga-PSMA PET according to prior therapy and proportion of positivity in various anatomical locations with sensitivity and specificity profiles.
We performed critical reviews of MEDLINE, EMBASE, ScienceDirect, Cochrane Libraries, and Web of Science databases in July 2018 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Quality assessment was performed using Quality Assessment if Diagnostic Accuracy Studies-2 tool. Meta-analyses of proportions were performed using a random-effect model. Summary sensitivity and specificity values were obtained by fitting bivariate hierarchical regression models.
A total of 37 articles including 4790 patients were analysed. For patients with biochemical recurrence, positive 68Ga-PSMA PET scans increased with higher pre-PET prostate-specific antigen (PSA) levels. For PSA categories 0–0.19, 0.2–0.49, 0.5–0.99, 1–1.99, and ≥2ng/ml, the percentages of positive scans were 33%, 45%, 59%, 75%, and 95%, respectively. No significant differences in positivity were noted between Gleason sums ≤7 and ≥8. Significant differences in positivity after biochemical recurrence in the prostate bed were noted between radical prostatectomy (22%) and radiotherapy (52%) patients. On per-node analysis, high sensitivity (75%) and specificity (99%) were observed.
Ga-68-PSMA PET improves detection of metastases with biochemical recurrence, particularly at low pre-PET PSA levels of >0.2ng/ml (33%) and 0.2–0.5ng/ml (45%). Ga-68-PSMA-PET produces favourable sensitivity and specificity profiles on meta-analysis of pooled data. This analysis highlights different anatomic patterns of metastatic spread according to PSMA PET in the primary and biochemically recurrent settings.
Gallium-68 prostate-specific membrane antigen positron emission tomography is now an established imaging technique that has been developed in response to inadequacies in standard of care imaging modalities to improve the detection of metastatic disease in prostate cancer, particularly in the setting of disease recurrence. To date, this imaging modality in the setting of primary staging is controversial, given the paucity of data. In light of the growing body of evidence, we summarised the data to date to provide clinicians with an overview of this imaging modality.
Gallium-68 prostate-specific membrane antigen positron emission tomography is now an established imaging technique that has been developed in response to inadequacies in standard-of-care imaging modalities to improve the detection of metastatic disease in prostate cancer. In light of the growing body of evidence, we summarised the data to date to provide clinicians with an overview of this imaging modality.
There are no comparative assessments on the environmental impact of endourologic instruments. We evaluated and compared the environmental impact of single-use flexible ureteroscopes with reusable ...flexible ureteroscopes.
An analysis of the typical life cycle of the LithoVue™ (Boston Scientific) single-use digital flexible ureteroscope and Olympus Flexible Video Ureteroscope (URV-F) was performed. To measure the carbon footprint, data were obtained on manufacturing of single-use and reusable flexible ureteroscopes and from typical uses obtained with a reusable scope, including repairs, replacement instruments, and ultimate disposal of both ureteroscopes. The solid waste generated (kg) and energy consumed (kWh) during each case were quantified and converted into their equivalent mass of carbon dioxide (kg of CO
) released.
Flexible ureteroscopic raw materials composed of plastic (90%), steel (4%), electronics (4%), and rubber (2%). The manufacturing cost of a flexible ureteroscope was 11.49 kg of CO
per 1 kg of ureteroscope. The weight of the single-use LithoVue and URV-F flexible ureteroscope was 0.3 and 1 kg, respectively. The total carbon footprint of the lifecycle assessment of the LithoVue was 4.43 kg of CO
per endourologic case. The total carbon footprint of the lifecycle of the reusable ureteroscope was 4.47 kg of CO
per case.
The environmental impacts of the reusable flexible ureteroscope and the single-use flexible ureteroscope are comparable. Urologists should be aware that the typical life cycle of urologic instruments is a concerning source of environmental emissions.
Abstract Intraductal carcinoma of the prostate (IDC-P) is associated with poor prognosis. While it is often regarded as a rare pathology, the prevalence of IDC-P remains unclear, with variable ...reports from small and disparate patient populations. To determine how common IDC-P is across the spectrum of prostate cancer, we conducted a systematic review correlating IDC-P prevalence with prostate cancer risk. Electronic searches of the OVID Medline, PubMed, and Scopus literature databases identified 38 patient cohorts in 24 articles, which were divided between four prostate cancer risk categories (low, moderate, high, and recurrent or metastatic disease). This review, which included radical prostatectomy and prostate biopsy specimens from >7000 patients, revealed an unexpectedly high rate of IDC-P. The IDC-P prevalence increased from 2.1% in low-risk patient cohorts to 23.1%, 36.7%, and 56.0% in moderate-risk, high-risk, and metastatic or recurrent disease risk categories, respectively ( p < 0.0001). IDC-P was also highly prevalent in tumours following androgen deprivation therapy or chemotherapy (60%). Contrary to common perceptions, this study demonstrates a strong association between IDC-P prevalence and aggressive prostate cancer, with a significantly higher frequency in high-risk disease. Greater recognition and systematic reporting of IDC-P may improve patient risk stratification. Patient summary Prostate cancer can grow within ducts of the prostate, as well as in prostate tissue. By reviewing all reports describing prostate cancer growing within ducts, we found that it occurs more commonly than many scientists and clinicians appreciate, especially in aggressive prostate cancers. We conclude that there should be more awareness of this pattern of prostate cancer.
Objective
To compare clinical outcomes of single‐use endoscopes with those of reusable endoscopes to better define their role within urology.
Methods
A systematic search of electronic databases was ...performed. All studies comparing the clinical outcomes of participants undergoing urological procedures with single‐use endoscopes to those of participants treated with reusable endoscopes were included. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) 2020 statement.
Results
Twenty‐one studies in 3943 participants were identified. Six different single‐use flexible ureteroscopes and two different single‐use flexible cystoscopes were assessed. There were no differences in mean postoperative infection rates (4.0% vs 4.4%; P = 0.87) or overall complication rates (11.5% vs 11.9%; P = 0.88) between single‐use and reusable endoscopes. For patients undergoing flexible ureteroscopy there were no differences in operating time (mean difference −0.05 min; P = 0.96), length of hospital stay (LOS; mean difference 0.06 days; P = 0.18) or stone‐free rate (SFR; 74% vs 74.3%; P = 0.54) between the single‐use and reusable flexible ureteroscope groups.
Conclusion
This study is the largest to compare the clinical outcomes of single‐use endoscopes to those of reusable endoscopes within urology, and demonstrated no difference in LOS, complication rate or SFR, with a shorter operating time associated with single‐use flexible cystoscope use. It also highlights that the cost efficiency and environmental impact of single‐use endoscopes is largely dependent on the caseload and reprocessing facilities available within a given institution. Urologists can therefore feel confident that whether they choose to ‘use’ or to ‘reuse’ based on the financial and environmental implications, they can do so without negatively impacting patient outcomes.
Socioeconomic status (SES), race and geographical factors are known to impact prostate cancer management and outcomes. We aimed to assess these factors with regard to access to novel imaging in ...prostate cancer. Using the Prostate Cancer Outcomes Registry of Victoria (PCOR-Vic) we identified 5256 men diagnosed with prostate cancer via biopsy. Following the introduction of government rebate, the access to MRI improved with respect to SES. Access to PET imaging remains poor with respect to SES and geographical location in the absence of Federal funding. Further improvements for men with low SES and regional areas to access PET staging.
There have been substantial changes in the management of men with metastatic hormone-sensitive prostate cancer (mHSPC) over the past 5 yr, with upfront combination therapies replacing ...androgen-deprivation therapy (ADT) alone. A range of therapies have entered the space with no clear answer regarding their comparative efficacy.
To perform a systematic review and network meta-analysis to characterise the comparative efficacy of combination approaches in men with mHSPC.
We searched multiple databases and abstracts of major meetings up to June 2019 for randomised trials of patients receiving first-line therapy for metastatic disease, a combination of ADT and one (or more) of taxane-based chemotherapy, and androgen receptor-targeted therapies. The primary endpoint was overall survival (OS) and we evaluated progression-free survival as a secondary outcome. We performed subgroup analysis based on the volume of disease.
We found seven trials that met our eligibility criteria using either docetaxel, abiraterone acetate, enzalutamide, or apalutamide in combination with ADT. All agents in combination with ADT were shown to be superior to ADT alone; enzalutamide + ADT had the lowest absolute hazard ratio compared with ADT only (hazards ratio 0.53, 95% confidence interval 0.37–0.75), and an estimated 76.9% probability that it is the preferred treatment to prolong OS compared with other combination treatments, or with ADT alone. Enzalutamide appeared to have better OS compared with docetaxel in men with low-volume disease, but there was no difference in other comparisons.
Combination therapy with any of docetaxel, abiraterone acetate, enzalutamide, or apalutamide provides a significant OS benefit when compared with ADT alone. We did not identify significant differences in OS between different combination therapies. Subtle differences between these options provide clinicians considerable flexibility when selecting options for individual patients.
Many men with metastatic, hormone-sensitive prostate cancer should be managed with upfront combination therapy instead of androgen-deprivation therapy alone. Clinicians may consider many factors during the decision-making process, and thus management should be tailored for patients individually.
Combination therapy with any of docetaxel, abiraterone acetate, enzalutamide, or apalutamide provides a significant overall survival (OS) benefit when compared with androgen-deprivation therapy alone. We did not identify significant differences in OS between different combination therapies. Subtle differences between these options allow clinicians considerable flexibility when selecting options for individual patients.
The purpose of this article was to review and compare the international guidelines and surveillance protocols for post‐nephrectomy renal cell carcinoma (RCC). PubMed database searches were conducted, ...according to the PRISMA statement for reporting systematic reviews, to identify current international surveillance guidelines and surveillance protocols for surgically treated and clinically localized RCC. A total of 17 articles were reviewed. These included three articles on urological guidelines, three on oncological guidelines and 11 on proposed strategies. Guidelines and strategies varied significantly in relation to follow‐up, specifically with regard to the frequency and timing of radiological imaging. Although there is currently no consensus within the literature regarding surveillance protocols, various guidelines and strategies have been developed using both patient and tumour characteristics.
Objective
To assess and measure the capability of a single‐use disposable digital flexible ureteroscope, the LithoVue™ (Boston Scientific, Marlborough, MA, USA), and to assess if there is a benefit ...to switching to single‐use scopes.
Patients and Methods
The LithoVue was compared to two commonly used reusable flexible ureteroscopes (Olympus URF‐V Olympus, Tokyo, Japan and Karl Storz Flex‐Xc Karl Storz & Co. KG, Tuttlingen, Germany) ex vivo. An analysis of reusable ureteroscope usage was performed to evaluate damage, durability, and maintenance costs. This was then compared to the projected costs of using single‐use disposable scopes.
Results
Flexion, deflection and irrigation flow of the LithoVue was equivalent, if not better than the reusable flexible ureteroscopes. An analysis of 234 procedures with seven new Olympus URF‐V scopes, revealed 15 scope damages. Staghorn stones and lower pole/mid‐zone stones were significant risk factors for damage (P = 0.014). Once damage occurred it was likely to occur again. Total repair costs were $162 628 (Australian dollars) (£92 411 in Great British pounds), the mean cost per case was $695 (£395). Factoring in the purchase cost, cleaning and repair costs, the cumulative cost of 28 reusable flexible ureteroscopy procedures was ~$50 000 (£28 412). If the LithoVue was priced at $1 200 (£682), switching to a single‐use scope would cost ~$35 000 (£19 888).
Conclusion
The LithoVue is analogous to reusable flexible ureteroscopes in regard to standard technical metrics. Depending on its purchase cost it may also represent a cost saving for hospitals when compared to the cumulative costs of maintaining reusable scopes. Additionally, urologist may consider using the scope in cases in which reusable scope damage is anticipated.
Since the advent of prostate-specific antigen (PSA)-based testing, transrectal ultrasound (TRUS)-guided prostate biopsy has become a standard part of the diagnostic pathway for prostate cancer (PCa). ...Rectal bleeding is one of the common side effects of this transrectal route. While rectal bleeding is usually mild and self-limiting, it can be life-threatening. In this article, we examine rectal bleeding post TRUS-guided prostate biopsy and explore the literature to evaluate techniques and strategies aimed at preventing and managing this common and important complication.
A PubMed literature search was carried out using the keywords "transrectal-prostate-biopsy-bleed." A search of the bibliography of reviewed studies was also conducted. Additionally, papers in non-PubMed-listed journals of which the authors were aware were appraised.
Numerous modifiable risk factors for this bleeding complication exist, particularly anticoagulants/antiplatelets and the number of core biopsies taken. Successfully described corrective measures for such rectal bleeding include tamponade (digital/packs/catheter/tampon/condom), endoscopic sclerotherapy/banding/clipping, radiological embolization, and surgical intervention.
We advocate early consultation with the colorectal/gastroenterology and interventional radiology services and a progressive, stepwise approach to the management of post-biopsy rectal bleeding, starting with resuscitation and conservative tamponade measures, moving to endoscopic hemostasis ± radiological embolization ± transanal surgical methods. Given the infrequent but serious nature of major rectal bleeding after TRUS biopsy, we recommend the establishment of centralized databases or registries forthwith to prospectively capture such data. To the best of our knowledge, this is the first comprehensive look specifically at the management of post-TRUS biopsy rectal bleeding.
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