OBJECTIVES:To investigate whether nurse navigator-led triaging of high-risk patients may reduce prostate cancer (PCa) diagnosis and treatment times using an in-house bespoke PRostate cancer diAGnosis and MAnagement Triage In the Clinial care pathway (PRAGMATIC) triaging system, as locally advanced/metastatic disease should be diagnosed and treated rapidly, and UK targets allow 28 days for diagnosis, and 62 days to commence treatment. PATIENTS AND METHODS:We reviewed diagnosis and treatment timelines for patients undergoing 28/62-day investigation for suspected PCa at a tertiary unit in a 3-month period (2022). We then introduced nurse navigator-led triaging of urgent referrals and evaluated a subsequent 3-month period (2024), with streamlining for rapid investigation and treatment based on prostate-specific antigen, magnetic resonance imaging (MRI) staging, and histology. We hypothesised nurse navigator-led triaging would improve investigation and treatment times for high-risk localised, or locally advanced, or metastatic PCa. RESULTS:A total of 165 and 327 consecutive patients were on the 28/62-day PCa pathway in the pre- (2022) and post-nurse navigator-led (2024) triaging periods, respectively. The median time from referral to first appointment (8 vs 4 days), MRI (12 vs 6 days), MRI result (26 vs 17 days), biopsy decision (25 vs 16 days), biopsy procedure (48 vs 22 days), biopsy result communication (64 vs 44 fays), and prostate-specific membrane antigen positron emission tomography computed tomography staging scan (87 vs 56 days) was reduced following nurse navigator triaging of high-risk cases (all P < 0.001). The median time from referral to treatment for Gleason Grade Group ≥3, or T3, or ≥N1, or ≥M1 disease (104 vs 70 days; 49/75 [65.3%] vs 72/128 [56.3%] patients), and for M1b disease (47 vs 27 days; 15/75 [20%] vs 32/128 [25%] patients), was reduced (P < 0.05). CONCLUSIONS:Nurse navigator-led triaging and stratification of the most clinically urgent suspected PCa cases was associated with improved imaging, biopsy diagnosis, and treatment times for the highest-risk patients.

BACKGROUND AND OBJECTIVE:A local anaesthetic ultrasound-guided transperineal (LATP) prostate biopsy has advantages over transrectal ultrasound (TRUS)-guided biopsy, with improved magnetic resonance imaging (MRI)-guided prostate cancer detection and lower rates of infection-related complications. However, uncertainty remains regarding the cost effectiveness of an LATP biopsy compared with a TRUS biopsy. METHODS:Between December 2021 and September 2023, the TRANSLATE randomised clinical trial allocated 1126 men to receive either a TRUS (n = 564) or an LATP (n = 562) biopsy at ten sites in the UK. All men were biopsy naïve and underwent prebiopsy MRI. Participants were followed up for 4 mo after a biopsy. The economic analysis is a within-trial analysis at 4 mo after biopsy, conducted from a National Health Service perspective. We assessed resource use, health care costs, and quality-adjusted life years (QALYs) across 4 mo of follow-up from an intention-to-treat perspective. We addressed missing data using multiple imputation. Incremental cost-effectiveness ratios were calculated, with uncertainty characterised using nonparametric bootstrapping. The TRANSLATE trial is registered at ISRCTN (ISRCTN98159689) and is complete. KEY FINDINGS AND LIMITATIONS:The total mean costs over the 4 mo of follow-up were £1062 in the LATP arm and £917 in the TRUS arm (adjusted mean difference £149; 95% confidence interval [CI] £61-236, p = 0.001). The total mean QALYs at 4 mo were 0.282 in the LATP arm and 0.284 in the TRUS arm (adjusted mean difference -0.004; 95% CI -0.009 to 0.001, p = 0.098). CONCLUSIONS AND CLINICAL IMPLICATIONS:An LATP biopsy has a higher mean cost, and no significant difference in mean QALYs, compared with a TRUS biopsy at 4 mo after the procedure. A time of 4 mo is too soon to reflect any impact from the 5.7% diagnostic uplift for LATP versus TRUS biopsy on the detection of intermediate-/high-grade prostate cancer seen in the TRANSLATE trial. A further analysis beyond this period is needed to fully interpret the cost-effectiveness results.

Extension of prostate cancer beyond the primary site by local invasion or nodal metastasis is associated with poor prognosis. Despite significant research on tumour evolution in prostate cancer metastasis, the emergence and evolution of cancer clones at this early stage of expansion and spread are poorly understood. We aimed to delineate the routes of evolution and cancer spread within the prostate and to seminal vesicles and lymph nodes, linking these to histological features that are used in diagnostic risk stratification. We performed whole-genome sequencing on 42 prostate cancer samples from the prostate, seminal vesicles and lymph nodes of five treatment-naive patients with locally advanced disease. We spatially mapped the clonal composition of cancer across the prostate and the routes of spread of cancer cells within the prostate and to seminal vesicles and lymph nodes in each individual by analysing a total of > 19,000 copy number corrected single nucleotide variants. In each patient, we identified sample locations corresponding to the earliest part of the malignancy. In patient 10, we mapped the spread of cancer from the apex of the prostate to the seminal vesicles and identified specific genomic changes associated with the transformation of adenocarcinoma to amphicrine morphology during this spread. Furthermore, we show that the lymph node metastases in this patient arose from specific cancer clones found at the base of the prostate and the seminal vesicles. In patient 15, we observed increased mutational burden, altered mutational signatures and histological changes associated with whole genome duplication. In all patients in whom histological heterogeneity was observed (4/5), we found that the distinct morphologies were located on separate branches of their respective evolutionary trees. Our results link histological transformation with specific genomic alterations and phylogenetic branching. These findings have implications for diagnosis and risk stratification, in addition to providing a rationale for further studies to characterise the genetic changes causally linked to morphological transformation. Our study demonstrates the value of integrating multi-region sequencing with histopathological data to understand tumour evolution and identify mechanisms of prostate cancer spread.

Prostate-specific membrane antigen (PSMA) is increasingly used to image prostate cancer in clinical practice. We sought to develop and test a humanised PSMA minibody IAB2M conjugated to the fluorophore IRDye 800CW-NHS ester in men undergoing robot-assisted laparoscopic radical prostatectomy (RARP) to image prostate cancer cells during surgery. The minibody was evaluated pre-clinically using PSMA positive/negative xenograft models, following which 23 men undergoing RARP between 2018 and 2020 received between 2.5 mg and 20 mg of IR800-IAB2M intravenously, at intervals between 24 h and 17 days prior to surgery. At every step of the procedure, the prostate, pelvic lymph node chains and extra-prostatic surrounding tissue were imaged with a dual Near-infrared (NIR) and white light optical platform for fluorescence in vivo and ex vivo. Histopathological evaluation of intraoperative and postoperative microscopic fluorescence imaging was undertaken for verification. Twenty-three patients were evaluated to optimise both the dose of the reagent and the interval between injection and surgery and secure the best possible specificity of fluorescence images. Six cases are presented in detail as exemplars. Overall sensitivity and specificity in detecting non-lymph-node extra-prostatic cancer tissue were 100 https://www.isrctn.com/ISRCTN10046036 .

Atypical small acinar proliferation (ASAP), found in 5% of prostate biopsies, represents a focus of atypical cells that fall short of a cancer diagnosis.1 ASAP may be associated with a diagnosis of prostate cancer (PCa) upon repeat biopsy in 25%–50% of patients within 5 years.1 The proportion of these cases that may be classified as being intermediate- or high-grade PCa varies in the literature, ranging from 6.0% to 22.5%.2, 3 Until recently, diagnosis of ASAP was an indication for early repeat biopsy in international guidelines. However, recent studies referenced by the European Association of Urology (EAU) guidelines suggest low rates of subsequent Gleason grade group (GG) ≥ 2 PCa, similar to following a previous negative biopsy, leading to a softening of the recommendation for ASAP as an indication for performing early repeat biopsy.4 We therefore aimed to test the hypothesis that prostate cancer diagnosed on early re-biopsy after detection ASAP is always low grade by interrogating a large prospective pathology database. We also aimed to determine the time interval between detection of ASAP and diagnosis of csPCa, if present. We scrutinised pathology records according to a prospectively derived protocol (ID: CU96T) for all consecutive patients with ASAP on needle biopsy, transurethral resection of the prostate (TURP) chippings, or holmium laser enucleation of the prostate (HoLEP) specimens between January 2010 and November 2021 at a single tertiary institution. We classified pathological upgrading to csPCa as any Gleason pattern 4 disease identified within 2 years of the initial biopsy/TURP/HoLEP specimen detecting ASAP. Where available, we reviewed pre-biopsy multiparametric MRI (mpMRI) reports for PI-RADS scores at the time of ASAP diagnosis and obtained the prostate volume in order to derive the PSA density (PSAD). A multi-variable logistic regression model (including age, PSAD and PI-RADS) was constructed to determine factors associated with the development of csPCa. Approximately 13 240 prostate samplings were performed (11 240 needle biopsy and 2000 HoLEP/TURP specimens) over the 10-year period. ASAP was identified in 617 (4.7%) biopsy samplings, involving 523 patients. Of these, 51 (9.7%) patients had a pre-existing history of PCa and were excluded from further analysis, leaving a sample size of 472 individuals with de novo ASAP (Table 1). The baseline characteristics of the cohort are summarised in Table 1. Two hundred and thirty-seven (50.2%) patients had a repeat biopsy (Table S1) within a median of 92 days (IQR: 56–283). The median PSA within 3–6 months of ASAP detection was higher amongst patients who underwent repeat biopsy (6.7 vs. 5.08 ng/ml, p = 0.001) consistent with clinical judgement advocating repeat biopsy. In the 248 of 472 (52.5%) patients with pre-biopsy MRI, logistic regression revealed age <65 years (OR: 3.11; 95% CI: 1.74–5.69), PSAD > 0.15 ng/ml2 (OR: 2.06; 95% CI: 1.13–3.80), and PI-RADS ≥ 3 (OR: 1.88; 95% CI: 1.05–3.42) were independently associated with patients undergoing repeat biopsy following detection of ASAP. In the 237 patients who underwent repeat biopsies, intermediate- or high-grade PCa (GG ≥ 2) was found in 57 (24.1%) patients (18 high-grade [GG 4/5] versus 39 intermediate-grade [GG 2/3]) within 2 years at a median interval of 128 days (IQR: 61–260). Low-grade PCa (GG1) was detected in 77 (32.5%) patients. GG ≥ 2 PCa was detected on the ipsilateral side of ASAP diagnosis in 46 of 57 (80.8%) patients, which we therefore hypothesise to be related to the original diagnosis of ASAP. Amongst patients who underwent repeat biopsy following detection of ASAP, mpMRI was performed with PI-RADS data available for 74 patients (31.2%; from December 2014). Of these, 48 (64.8%) patients had PI-RADS ≥ 3. A PSAD > 0.15 ng/ml2 at time of ASAP diagnosis was independently associated (OR: 3.21; 95% CI: 1.12–9.74) with the detection of GG ≥ 2 PCa (Table 1). A subgroup of 16 patients with pre-biopsy PI-RADS 4–5 lesions were not found to have csPCa on repeat biopsy within 2 years. Repeat mpMRI (median interval of 526 days from detection of ASAP) was performed in 14 of 16 of these patients, of which five lesions were downgraded to PI-RADS 3 and a further five to PI-RADS 1/2. Expressed as a proportion of all men with ASAP, PI-RADS score 4/5 was associated with the development of GG ≥ 2 PCa (OR: 5.86; 95% CI: 2.01–19.6), as expected for MRI visible lesions. There were 103 patients without pre-biopsy PI-RADS score (predating regular pre-biopsy MRI), hence excluded from the above regression analysis, ROC curve analysis showed that the AUC for PSAD > 0.15 ng/ml2 was 0.734 (95% CI: 0.642–0.827) for the detection of GG ≥ 2 PCa within 2 years (Figure S1). The positive predictive value (PPV) and negative predictive value (NPV) for PSAD threshold of 0.15 ng/ml2 were 68.8% and 83.3%. At a higher PSAD threshold of 0.20 ng/ml2, the PPV and NPV were 74.0% and 80.0%, respectively (Table S2) . The rate of detection of ASAP in our cohort is 4.7%, which is consistent with the rate of approximately 5% previously reported in the literature. Younger patients, those with a raised PSAD, and those with positive mpMRI findings (PI-RADS ≥ 3) were more likely to undergo re-biopsy. It is also likely that the decision to re-biopsy was influenced by guideline recommendations, which have varied during this time period. The rate of clinically important PCa, adopting a definition of any Gleason pattern 4 disease within 2 years, was 24.1%. This is at odds with studies suggesting GG≥ 2 PCa is not diagnosed after ASAP4 and is consistent with Kim et al. who reported GG ≥ 2 PCa in 19.6% of patients with ASAP, this being similar to reports in other contemporary studies.2, 5, 6 In a meta-analysis including 16 studies and 1796 patients, those who underwent repeat biopsy within 6 months of ASAP diagnosis, had lower clinically important PCa detection (9%) compared to those who had repeat biopsy after (22.1%).7 On analysis of repeat MRIs, 71.4% of patients with PI-RADS 4–5 lesions who did not have GG ≥ 2 PCa on repeat biopsy had the PI-RADS score downgraded to ≤3 upon repeat mpMRI. Although we only focused on ASAP, this is consistent with the report by Meng et al. who observed a PI-RADS score downgrade of 73% from PI-RADS 4–5 to ≤3 amongst patients with any benign biopsy sub-type.8 This may suggest that microenvironmental changes associated with ASAP could predispose to false positive mpMRI changes. PSAD > 0.15 ng/ml2 at time of ASAP diagnosis was independently associated with the subsequent detection of GG ≥ 2 PCa at repeat biopsy. A reduced rate of false positives was observed with increasing PSAD thresholds. In a report by Warlick et al., PSAD was an independent predictor of detection of GG ≥ 2 PCa at repeat biopsy within 1 year of a diagnosis of ASAP.9 We observed an association between the laterality of ASAP diagnosis and subsequent GG ≥ 2 PCa detection, highlighting importance for adequate ipsilateral sampling given tissue heterogeneity.10, 11 This study has several limitations. Firstly, the number of men who underwent repeat biopsy will have been influenced by clinical decision-making. Secondly, we only adjusted for a limited number of baseline clinicopathological variables as per our protocol. Next, the lack of a control group with completely negative biopsies precludes comparison to determine whether ASAP is an independent predictor for development of GG ≥ 2 PCa. Finally, this is single-centre data reflecting one pathology department's criteria for reporting ASAP. Overall, we must reject our initial hypothesis that prostate cancer diagnosed after ASAP is always low grade. Contrary to this supposition, we have observed an important rate of detection of GG ≥ 2 PCa following a previous diagnosis of ASAP at needle biopsy or following histological analysis of TURP/HoLEP specimens. These findings support that patients diagnosed with ASAP should be followed up for consideration of repeat mpMRI and/or sampling. Further studies may guide development of risk-stratification tools based on clinicopathologic factors such as PSAD and pre-biopsy mpMRI PI-RADS score at the time of initial ASAP diagnosis. This would enable clinicians to better counsel patients and identify those requiring more stringent follow-up, potentially with re-biopsy or repeat mpMRI follow-up. Conceptualisation: Mutie Raslan, Claudia Mercader, Francisco Lopez and Alastair D. Lamb. Data curation: Kanchan Ghosh, Philip Macklin, Richard Colling, Lisa Browning, Ian Roberts. Formal analysis: Thineskrishna Anbarasan, Mutie Raslan and Alastair D. Lamb. Methodology: Thineskrishna Anbarasan, Mutie Raslan, Richard J. Bryant, Richard Colling, Clare Verrill and Alastaiir D. Lamb. Supervision: Richard J. Bryant, Clare Verrill, Freddie C. Hamdy and Alastair D. Lamb. Writing (original draft): Thineskrishna Anbarasan, Mutie Raslan and Alastair D. Lamb. Writing (review and editing): Thineskrishna Anbarasan, Mutie Raslan, Kanchan Ghosh, Philip Macklin, Claudia Mercader, Tom Leslie, Freddie C. Hamdy, Richard Colling, Lisa Browning, Ian Roberts, Clare Verrill, Richard J. Bryant, Francisco Lopez and Alastair D. Lamb. We acknowledge the contribution of patients included and the Oxford Centre for Histopathology Research. Lisa Browning receives funding for a study (ArticulatePro) evaluating Paige Prostate, which is funded by the NHSX Artificial Intelligence in Health and Care Award: Driving system-wide improvements with real-world economics evidence and subspecialist-led adoption guidelines for full workflow implementation of AI with Paige Prostate cancer detection (Paige AI 2020, New York), grading and quantification tool in histopathology departments (AI_AWARD02269). Richard Colling is part funded by UKRI (WCT WVI MAP project and PathLAKE project in-kind partnership with Philips), mdxhealth (research funding), NHSX (ARTICULATE PRO: evaluating Paige AI), and the Clarendon Fund (University of Oxford). Richard Bryant receives grant funding for TRANSLATE Trial (NIHR-HTA: NIHR131233), PART Trial Funding (NIHR-HTA: 17/150/01), Cancer Research Clinician Scientist Fellowship (A22748). Participates in STAMINA Trial Programme Steering Committee. Ian Roberts receives consulting fees from Novartis and Travere Therapeutics and support for attending meetings from American Society of Nephrology, International Academy of Pathology and Asia Pacific Society of Nephrology. Alastair Lamb receives grant funding for TRANSLATE Trial (NIHR-HTA: NIHR131233). ADL was supported by a Cancer Research UK Clinician Scientist Fellowship award (C57899/A25812). Figure S1. Schematic summary of the sub-group of patients with complete clinicopathologic data available for regression analysis. Table S1. Demographics and clinical characteristics of patients with ASAP with respect to whether repeat biopsy was performed. Table S2. Positive (PPV) and negative (NPV) predictive values at various PSA density (PSAD) thresholds for development of GG ≥ 2 PCa within 2 years of ASAP diagnosis in the sub-group of patients without pre-biopsy mpMRI data (n = 103). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Background: Detection of metastatic disease is important to inform prostate cancer management. Objectives: Evaluate local and distant staging by initial 18F-PSMA-1007 PET in primary and secondary prostate cancer. Design, Setting, and Participants: We retrospectively identified a consecutive series of 18F-PSMA-1007 PET scans from the date of introduction of 18F-PSMA-1007 PET in September 2019 until April 2022 at a single UK tertiary referral center. Our protocol was registered in advance (OSF registration ID: KTE3R). Results: We identified 1335 PSMA-PET scans, from 1220 men. Across 623 initial scans for primary staging, we observed PSMA-PET avidity in 97.6% cases positive for local disease, 29.5% for nodal disease, and 26.5% for metastatic disease. PSMA-PET identified a 13.2% absolute increase in nodal lesions compared with MRI and a 24.0% absolute increase in metastatic lesions compared with MRI marrow. The sensitivity for detection of local disease among 79 patients who had radical prostatectomy was 96.2% for PSMA-PET vs 89.4% for multiparametric MRI. Across 612 scans for secondary staging, we observed PSMA-PET positive avidity in 51.2% of cases for local recurrence, 46.6% for nodal disease, and 43.0% for metastatic disease. When evaluated by the PSA range for patients receiving secondary staging, using the PSA values of 0.2 to 0.49, 0.5 to 0.99, 1 to 1.99, and ≥ 2 ng/mL, PSMA-PET scans were positive in 57.8%, 75.0%, 83.8%, and 95.5% of cases, respectively. PSMA-PET identified a 26.2% absolute increase in metastatic lesions compared with MRI marrow or other skeletal MRI (n = 61) and a 14.7% absolute increase in metastatic lesions compared with the bone scan (n = 42). Conclusion: 18F-PSMA-1007 PET identifies a higher number of nodal and metastatic lesions compared with conventional cross-sectional imaging. However, the high number of indeterminate lesions and stage migration necessitates discussion of 18F-PSMA-1007 PET imaging within a multidisciplinary team and places a higher burden on these teams.

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy II (MP52)1 May 2024MP52-09 EARLY RETURN TO CONTINENCE, ONCOLOGICAL SAFETY AND SIGNIFICANCE OF MEMBRANOUS URETHRAL LENGTH IN ANTERIOR RETZIUS SPARING ROBOT ASSISTED RADICAL PROSTATECTOMY (RARP) Nithesh M. Ranasinha, Anthony S. Bates, Thineskrishna Anbarasan, Abhishek Sharma, Richard J. Bryant, Tom Leslie, Aaron Leiblich, Francisco Lopez, and Alastair D. Lamb Nithesh M. RanasinhaNithesh M. Ranasinha , Anthony S. BatesAnthony S. Bates , Thineskrishna AnbarasanThineskrishna Anbarasan , Abhishek SharmaAbhishek Sharma , Richard J. BryantRichard J. Bryant , Tom LeslieTom Leslie , Aaron LeiblichAaron Leiblich , Francisco LopezFrancisco Lopez , and Alastair D. LambAlastair D. Lamb View All Author Informationhttps://doi.org/10.1097/01.JU.0001008864.84854.b7.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The anterior Retzius sparing (ARS) approach to robot-assisted radical prostatectomy (RARP) preserves key structures aligned with urinary continence. Moreover, unlike posterior approach Retzius sparing surgery, ARS maintains the familiar transperitoneal anterior approach and can be modified more easily to accommodate for oncological requirements. We investigated differences in early return to continence and oncological safety between ARS and standard anterior RARP, alongside pre-operative variables. METHODS: We conducted a retrospective review of a continuously-collected, prospectively-maintained RARP database at Oxford University Hospitals NHS Trust, Oxford, UK. Patients undergoing full or modified ARS were compared to patients undergoing non-ARS standard approach RARP surgery. Multiple regression analysis assessed pre-operative variables including membranous urethral length (MUL), age, BMI, MRI PIRADs score, prostate volume, and biopsy Gleason grade group on early return to continence (defined as 0-1 pad usage per day) and oncological safety (defined as positive surgical margin (PSM) rate). ROC curve analysis was used to identify MUL cut-offs to predict 6-week continence. RESULTS: Of 508 RARPs from 14/02/2017 to 21/08/2023, 429 ARS cases were compared to 79 non-ARS standard anterior approach cases.There was no difference in baseline pre-operative variables of MUL, age, BMI, MRI PIRADS, GGG and prostate volume between ARS and non-ARS cohorts.There was an increase in 6-week continence for ARS compared to non-ARS cohorts (292/420 (70%)vs 36/74 (49%), p=0.002). There was no difference in PSM rate in ARS vs non-ARS cohorts (104/429 (25%) vs 20/79 (25%) p=0.75) (Table 1).In the ARS cohort, lower age (OR 0.92; 95%CI 0.85 – 0.99) and longer MUL (OR 1.22; 95%CI 1.09 – 1.38) were independently associated with continence at 6-weeks.ROC curve analysis for MUL identified an 80% sensitivity for 6-week continence for MUL >11.4mm in ARS cohort vs >15mm in the non-ARS cohort. CONCLUSIONS: This study highlights improved early return to continence in the ARS vs non-ARS approaches without impacting oncological safety. We identify lower age and longer MUL as independent predictive factors for early return to continence in ARS patients. Source of Funding: Nil © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e855 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Nithesh M. Ranasinha More articles by this author Anthony S. Bates More articles by this author Thineskrishna Anbarasan More articles by this author Abhishek Sharma More articles by this author Richard J. Bryant More articles by this author Tom Leslie More articles by this author Aaron Leiblich More articles by this author Francisco Lopez More articles by this author Alastair D. Lamb More articles by this author Expand All Advertisement PDF downloadLoading ...

The introduction of robotic surgery during the last decade has revolutionised minimally invasive surgery, changed surgical approach and transformed theatre set up. While the main surgeon conducts the operation remotely, with no direct control at the bedside, the assistant remains scrubbed at the patient's side. Thus, robotic assistants must be technically familiar with the robot but also have good laparoscopic skills. This makes the role of robotic bedside assistant crucial for a successful robotic procedure. Initially, robotic surgery was mainly used in pelvic and urological procedures but it has now spread to other areas such as cardiothoracic and ear, nose and throat (ENT) specialties. Although each specialty and surgery may have specific considerations, certain qualities of the robotic assistant are universal. In this video, we present ten tips on how to be a good robotic assistant.

Background: It is important to investigate, diagnose and commence treatment for locally advanced and metastatic prostate cancer quickly to optimise treatment outcomes. Since the introduction of national 2-week wait and 31/62-day targets in the United Kingdom for investigation of suspected prostate cancer over 2 decades ago, the clinical pathway has become increasingly complex. This may lead to some patients with the most clinically significant disease having the rapidity of their diagnosis and commencement of treatment compromised by resource use in diagnosing less significant, or clinically insignificant, disease. Methods: We will conduct a retrospective review of timelines for diagnosis and commencement of treatment for all men referred to a tertiary unit for investigation of suspected prostate cancer on the 2-week wait pathway in a 3-month period in 2023. In parallel, we will introduce triaging of all new 2-week wait referrals in a prospective 3-month period, with a dedicated nurse navigator streamlining patients for the most rapid investigation and treatment, based on pre-specified risk criteria including PSA, pre-biopsy mpMRI findings including TNM staging, and histology results. We hypothesise that this bespoke triaging system, above and beyond the 2-week wait and 2022 Faster Diagnostic Pathway guidance issued by NHS England, will improve timings for investigation and commencement of treatment for the most clinically significant prostate cancer cases. Conclusions: The use of in-house criteria for triaging and stratification of the most clinically urgent and significant prostate cancer cases, identified by a nurse specialist navigator, may improve clinical outcomes for patients with greatest need for rapid prostate cancer imaging, diagnosis and treatment.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThis study did not receive any funding.### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:We have registered an actionable review of the entire 2-week wait and 28/62-day prostate cancer diagnosis and treatment pathway at our Institution (Oxford University Hospitals NHS Foundation Trust). This registered QIP (OUH reference number 8381) aims to allow all those engaged in the various multiple steps of the 2-week wait and 28/62-day pathway to triage the highest risk cases for the most rapid diagnosis and treatment, whilst simultaneously safeguarding against undue delay for lower-risk cases as an unintended consequence.I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesAll data produced in the present work are contained in the manuscript.

Objectives Primary objectives: to determine whether local anaesthetic transperineal prostate (LATP) biopsy improves the detection of clinically significant prostate cancer (csPCa), defined as International Society of Urological Pathology (ISUP) Grade Group ≥2 disease (i.e., any Gleason pattern 4 disease), compared to transrectal ultrasound‐guided (TRUS) prostate biopsy, in biopsy‐naïve men undergoing biopsy based on suspicion of csPCa. Secondary objectives: to compare (i) infection rates, (ii) health‐related quality of life, (iii) patient‐reported procedure tolerability, (iv) patient‐reported biopsy‐related complications (including bleeding, bruising, pain, loss of erectile function), (v) number of subsequent prostate biopsy procedures required, (vi) cost‐effectiveness, (vii) other histological parameters, and (viii) burden and rate of detection of clinically insignificant PCa (ISUP Grade Group 1 disease) in men undergoing these two types of prostate biopsy. Patients and Methods The TRANSLATE trial is a UK‐wide, multicentre, randomised clinical trial that meets the criteria for level‐one evidence in diagnostic test evaluation. TRANSLATE is investigating whether LATP biopsy leads to a higher rate of detection of csPCa compared to TRUS prostate biopsy. Both biopsies are being performed with an average of 12 systematic cores in six sectors (depending on prostate size), plus three to five target cores per multiparametric/bi‐parametric magnetic resonance imaging lesion. LATP biopsy is performed using an ultrasound probe‐mounted needle‐guidance device (either the ‘Precision‐Point’ or BK UA1232 system). TRUS biopsy is performed according to each hospital's standard practice. The study is 90% powered to detect a 10% difference (LATP biopsy hypothesised at 55% detection rate for csPCa vs 45% for TRUS biopsy). A total of 1042 biopsy‐naïve men referred with suspected PCa need to be recruited. Conclusions This trial will provide robust prospective data to determine the diagnostic ability of LATP biopsy vs TRUS biopsy in the primary diagnostic setting.

Irreversible electroporation (IRE) is a recent and minimally invasive method of partial prostate ablation. However, knowledge of the essential landmarks of prostate anatomy is crucial to achieving safe and effective partial ablation by IRE. High-quality imaging of the prostate is essential before the procedure. The individual morphological pattern of the prostate must be taken into account and detailed mapping with measurement of the lesion is necessary to determine optimal needle placement. The entire tumour volume must be covered while ensuring the safety of critical anatomical structures such as the rectum, urethra, nerve bundles and sphincter muscle.

You have accessJournal of UrologyCME1 Apr 2023MP55-09 NATURAL HISTORY OF ATYPICAL SMALL ACINAR PROLIFERATION (ASAP): A 10-YEAR CONTEMPORARY SERIES Thineskrishna Anbarasan, Mutie Raslan, Kanchan Ghosh, Philip Macklin, Claudia Mercader, Tom Leslie, Freddie Hamdy, Richard Colling, Clare Verrill, Richard Bryant, Francisco Lopez, and Alastair Lamb Thineskrishna AnbarasanThineskrishna Anbarasan More articles by this author , Mutie RaslanMutie Raslan More articles by this author , Kanchan GhoshKanchan Ghosh More articles by this author , Philip MacklinPhilip Macklin More articles by this author , Claudia MercaderClaudia Mercader More articles by this author , Tom LeslieTom Leslie More articles by this author , Freddie HamdyFreddie Hamdy More articles by this author , Richard CollingRichard Colling More articles by this author , Clare VerrillClare Verrill More articles by this author , Richard BryantRichard Bryant More articles by this author , Francisco LopezFrancisco Lopez More articles by this author , and Alastair LambAlastair Lamb More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003308.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Atypical small acinar proliferation (ASAP), found in 5% of prostate biopsies, represents a focus of atypical cells. There is a paucity of high-quality evidence on follow-up of ASAP with repeat biopsies. We aim to assess the incidence of ASAP and detection of PCa, particularly the proportion which are clinically significant (csPCa). METHODS: We conducted a retrospective review of electronic patient records (OSF protocol registration ID: CU96T) for all consecutive patients between Jan 2010 and Nov 2021 at a single tertiary institution. csPCa was defined as any Gleason pattern 4 disease. Between group median PSA levels were compared using the Kruskal-Wallis test. RESULTS: Approximately 13000 prostate samplings were performed (11000 needle biopsy and 2000 HOLEP/TURP specimen). ASAP was identified in 617/13000 (4.7%) biopsy samplings involving 523 patients. Of these, 10 (1.9%) and 41 (7.8%) patients had concurrent or a history of PCa respectively and were excluded from further analysis (N=472). At detection of ASAP, the median age was 66 years (IQR:61-71) with a median pre-biopsy PSA of 7.25ng/mL (IQR: 5.35-10.75). A total of 237 (50.2%) patients had a repeat biopsy within a median of 92 days (IQR:56-283). Median PSA after 3-6 months of ASAP detection was higher among patients who subsequently underwent repeat biopsy (6.70 vs 5.08ng/mL, p=0.001). Of 237 patients who underwent repeat biopsies within 2 years, csPCa was found in 57 (24.1%) patients (18 high grade vs 39 intermediate grade) at a median interval of 128 days (IQR:61-260). Clinically insignificant PCa was more common on follow-up, detected in 77 (32.5%) patients. The incidence of csPCa was lower in those younger than 65 years (0.20 vs 0.32, p=0.026) (Figure 1). csPCa was detected on the ipsilateral side of ASAP diagnosis in 46/57 (80.8%) patients. When including patients who did not undergo repeat biopsies and had stable PSA on follow-up (<10 ng/mL over 2 years; n=78), overall incidence of csPCa was 18.1% (57/315). CONCLUSIONS: PCa detected in follow-up biopsies in patients with ASAP was clinically significant in approximately one quarter of cases. Ipsilateral side with ASAP should be adequately sampled owing to association with detection of csPCa. Current guidelines should be revised to consider resampling following detection of ASAP. Source of Funding: NIL © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e766 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thineskrishna Anbarasan More articles by this author Mutie Raslan More articles by this author Kanchan Ghosh More articles by this author Philip Macklin More articles by this author Claudia Mercader More articles by this author Tom Leslie More articles by this author Freddie Hamdy More articles by this author Richard Colling More articles by this author Clare Verrill More articles by this author Richard Bryant More articles by this author Francisco Lopez More articles by this author Alastair Lamb More articles by this author Expand All Advertisement PDF downloadLoading ...

INTRODUCTION AND OBJECTIVE: Recent studies have shown the superiority of PSMA-PET in staging of prostate cancer compared to conventional cross-sectional imaging. To date, most PSMA-PET scans have been performed for secondary prostate cancer and use a Gallium-68 ligand. Our objectives were to quantify local and distant staging by 18F PSMA PET in primary PCa. METHODS: We identified retrospectively a consecutive series of 18F PSMA-PET scans which we interrogated using a prospectively registered protocol (OSF registration ID: KTE3R). All PET scans were performed for staging of prostate cancer at a single UK tertiary referral centre, from the date of introduction of PSMA PET in September 2019 until August 2021. For primary staging, we compared PSMA PET to MRI and prostatectomy histology (for T and N staging), and MRI Marrow (for M staging). RESULTS: We identified 820 PSMA PET scans from 765 men, of which 354 were for primary staging. The mean age was 69.0 years (SD[7.4 years), and D'Amico risk classification was: 0.3% low risk; 72.0% intermediate risk; 27.7% high risk. We observed PSMA PET avidity in 96.9% of cases for local disease, 33.1% for nodal disease, and 32.5% for metastatic disease. PSMA PET identified local disease similar to MRI (96.6% versus 96.9%, respectively), and identified 14.72% more nodal lesions than MRI, and 27.2% more metastatic lesions than MRI Marrow (Figure 1). Some 47 men underwent radical prostatectomy after both PSMA-PET and MRI, of which all had positive histology. The sensitivity of PSMA-PET was 97.8% versus 93.6% with MRI for any primary lesion. A total of 21 of these patients had lymph node dissection, of which two had positive histology. The sensitivity of PSMA-PET for any nodal disease was 50% versus 0% with MRI. Narrow slice MRI was used to corroborate skeletal lesions in 14 PSMA PET scans. None of the PSMA PET scans were positive on Narrow slice MRI, indicating an estimated false-positive rate for skeletal lesions of at least 6.7% (14 false positives versus 195 negative PSMA PET scans). CONCLUSIONS: 18F PSMA-PET adds value over MRI in identification of local disease as well as nodal and distant metastatic spread. However, there is a notable estimated false-positive rate of at least 6.7%. Source of Funding: None

INTRODUCTION AND OBJECTIVE: Covid-19 caused major disruptions to cancer diagnosis and treatment. We aimed to evaluate the longitudinal disruption to prostate cancer management. METHODS: We completed a prospective service evaluation from 01/09/2019 to 31/08/2021 of all referrals, investigations, and treatments for prostate cancer at a single centre. The first UK Covid-19 lockdown occurred from 23/03/20 to 04/07/2020: monthly data for the time period before, during, and after the first UK lockdown were compared using ANOVA and Tukey HSD. RESULTS: We identified 4501 patients for inclusion. There was a profound decrease in all aspects of prostate cancer management during the first lockdown period. For pre-lockdown, lockdown, and postlockdown periods respectively, the mean monthly rates were: 256 v 125 v 363 PSA tests (p=0.0003);86 v 40 v 79 two-week-wait referrals (p=0.0005);62 v 18 v 54 MRI imaging for possible cancer (p<0.0001);32 v 15 v 36 diagnoses (p=0.002);17 v 9 v 14 prostatectomies (p=0.06). In the period after the first lockdown, despite the previous drop, we did not observe an increase in the number of referrals, MRI imaging, diagnoses, or treatment required (including active monitoring, chemotherapy, radiotherapy, prostatectomy, and palliative care) in comparison to pre-lockdown levels (all p>0.05). However, interestingly, we did see an increase in the number of PSA tests performed (p=0.04), which continued through the two subsequent UK lockdowns. CONCLUSIONS: To our knowledge, this is the first study to provide an overview of the impact of COVID-19 national lockdowns on the whole prostate cancer management pathway - from initial referral to final treatment. Despite the disruption to prostate cancer management during the first UK Covid-19 lockdown leading to a decrease in referrals, diagnoses and treatment in the context of reduced PSA testing, we have not seen a subsequent increase in these numbers after lockdown despite a rise in PSA testing. The rise in the number PSA tests performed post-lockdown may suggest a degree of compensatory PSA observation in the community. (Figure Presented).

You have accessJournal of UrologyCME1 May 2022V07-11 VARYING APPROACHES TO THE PROSTATE APEX TO OPTIMIZE URETHRAL STABILITY AND EARLY CONTINENCE RECOVERY AFTER ROBOTIC RADICAL PROSTATECTOMY Claudia Mercader, J. Francisco Lopez, Nitesh Ranasinha, Mutie Raslan, Ruth McPherson, Richard Bell, Tom Leslie, Richard Bryant, Freddie Hamdy, Alastair, and Lamb Claudia MercaderClaudia Mercader More articles by this author , J. Francisco LopezJ. Francisco Lopez More articles by this author , Nitesh RanasinhaNitesh Ranasinha More articles by this author , Mutie RaslanMutie Raslan More articles by this author , Ruth McPhersonRuth McPherson More articles by this author , Richard BellRichard Bell More articles by this author , Tom LeslieTom Leslie More articles by this author , Richard BryantRichard Bryant More articles by this author , Freddie HamdyFreddie Hamdy More articles by this author , AlastairAlastair More articles by this author , and Lamb Lamb More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pre-operative membranous urethral length (MUL) is a well-known non-modifiable factor predicting continence recovery after surgery, but there are also refinements in surgical techniques to optimize early continence after robotic-assisted radical prostatectomy (RARP). These include modifications in apical dissection to maximize urethral length and maximizing preservation of periurethral structures responsible for urethral stability. METHODS: We reviewed data of patients who underwent RARP between January 2018 and October 2021. MUL, anterior Retzius sparing approach and continence (pads) 6-weeks after surgery were recorded. We present five surgical scenarios often encountered while planning the apical dissection in RARP: non urethral preservation, half-supported full or non-full-length urethral preservation, full length unstable urethra, full length stable urethra and full-length stable preservation in the context of unusual apical anatomy. All patients consented to data storage and video-recording. RESULTS: Following on from the video footage of this surgical scenarios, we present 342 patients for quantitative analysis. Those patients with a MUL >10 mm had 9.7 increased chance of being completely dry at 6-weeks (OR 9.7 CI 95% 2.2–42.1). Those patients with a MUL >10 mm who also had anterior Retzius sparing their chances increased by a further 4.3 (OR 4.3 IC 95% 2.1–8.8). CONCLUSIONS: The apical approach in a RARP can be planned and tailored for each case depending on both patients and tumour anatomy to optimize urethral stability post-RARP and early continence recovery. We advocate both preservation of urethral length and those structures responsible for urethral stability. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e662 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Claudia Mercader More articles by this author J. Francisco Lopez More articles by this author Nitesh Ranasinha More articles by this author Mutie Raslan More articles by this author Ruth McPherson More articles by this author Richard Bell More articles by this author Tom Leslie More articles by this author Richard Bryant More articles by this author Freddie Hamdy More articles by this author Alastair More articles by this author Lamb More articles by this author Expand All Advertisement PDF downloadLoading ...

Introduction:Multi-parametric magnetic resonance imaging (mp-MRI) is currently used to triage patients with suspected prostate cancer, before deciding on prostate biopsies. In our study, we evaluated normal and equivocal pre-biopsy mp-MRIs to see whether it is safe to avoid biopsy with such findings. Methods:A retrospective study was conducted at a district general hospital in the UK between August 2017 and July 2018. Patients with negative and equivocal prebiopsy mp-MRI with high clinical suspicion of cancer had proceeded to biopsy. MRI reports with prostate imaging reporting and data system (PI-RADS) scores 1, 2, 3 and normal MRI were evaluated against the transrectal ultrasound-guided prostate biopsy (TRUS-PB) outcomes to demonstrate benign pathology, clinically insignificant or clinically significant cancer (csCa). CsCa was defined as Gleason score (GS) ≥3 + 4. Results:Out of 265 mp-MRIs studied, five (1.9%) were PI-RADS 1, 109 (41.1%) and 84 (31.7%) were PI-RADS 2 and 3 lesions respectively; 67 (25.3%) were reported as normal. Seventy-five (27.3%) patients did not have biopsies following their MRI and 73.3% (51/75) of them had benign feeling prostate. Negative MRIs (PI-RADS 1, 2 and normal MRI) showed 8.8% and PI-RADS 3 lesions demonstrated 11.9% csCa. Negative predictive value for normal MRI was 91.2%. Mean PSA density (PSAD) among the benign, GS 3 + 3 and csCa was 0.14, 0.16 and 0.27 ng/ml/ml respectively and this was statistically significant (p < 0.001). The average percentage of cancer found in GS 3 + 3 and csCa was 3.2% and 20.1%, respectively. Conclusion:Avoiding TRUS-PB following normal or equivocal mp-MRI should carefully be decided as 18.5% of cancer was demonstrated in this group and 9.8% of those who were diagnosed with cancer were csCa. PSAD and DRE findings provide additional information to help with this decision.