In today’s new reports we summarize information from recent papers dealing with:
- Apical biopsy cores in initial diagnosis of prostate cancer
- Imaging studies in the initial work-up of newly diagnosed patients
- Intrafascial dissection of peri-prostatic tissue during laparoscopic surgery
- Similarity of short-term rates of biochemical recurrence after open surgery or RALP
- Does how we define post-surgical biochemical recurrence matter — and if so, when?
Moussa et al. have published new data (from a series of Egyptian patients) emphasizing the clinical value of “extreme” apical biopsy cores in patients undergoing initial prostate biopsies. (The “apical” area of the prostate is the bottom part of the prostate, farthest away from the bladder.) In their recent study, prostate cancer was detected in 86/181 patients (47.5 percent) who were given a standard 12-core biopsy under transrectal ultrasound guidance as well as having 2 additional cores taken from the extreme anterior apex (the site immediately next to the junction of the apex of the prostate and the urethra . The total of six apical cores (3 on each side) taken using this biopsy procedure showed the highest cancer detection rate (73.6 percent of all cancers identified), and the additional extreme anterior apical cores (1 on each side) achieved the highest rate of unique cancer detection. The authors conclude that appropriately selected apical biopsy cores, and especially the extreme apical cores, increase prostate cancer detection on a first biopsy and minimize the potential for misdiagnosis and the need for repeat biopsy.
Isbarn et al. have reported that — at least at their German institution — clinicians may have their priorities wrong in the use of CT scans, MRIs, and bone scans in the work-up of newly diagnosed patients. According to their recent article, there is reason to believe that these scans may be overused in the work-up of prostate cancer patients with low-risk, localized disease and underused in the evaluation of patients at highest risk for non-localized prostate cancer.
In a very technical paper, Neill et al. have discussed the relative merits of two different ways in which to carry out intrafascial dissection of peri-prostatic tissue during nerve-sparing radical prostatectomy (RP) carried out using the non-robot-assisted laparoscopic technique. They conclude that the so-called “curtain dissection” technique was more beneficial in terms of time to return of continence post-surgery, but that otherwise there was minimal impact on outcomes as a result of using this technique as opposed to standard intrafascial dissection.
Barocas et al. have published data from another, large, single-institution series of patients suggesting that the prostate cancer-specific outcomes after open surgery as opposed to robot-assisted laparoscopic prostatectomy (RALP) are comparable and that “Surgical approach was not a significant predictor of biochemical recurrence.” However, this report provides no information about the side effects of surgery, and is focused solely on short-term biochemical failure.
Definitions of “biochemical failure” after RP vary significantly across the research literature — although the differences tend to be small. Cronin et al. have now demonstrated that — in general — these small differences may not be important when it comes to the prognostic implications of the precise definition on long-term outcomes of surgery. Having said that, however, there are situations in which the specific definition does need to be carefully evaluated, and it would be gratifying if the urology community could settle on a standardized definition of biochemical failure after RP!