Feasibility of prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques

BACKGROUND Routinely, after receiving prostate specific antigen (PSA) testing and digital rectum examination, patients with suspected prostate cancer are required to undergo prostate biopsy. However, the ability of ultrasound-guided prostate biopsy to detect prostate cancer is limited. Nowadays, a variety of diagnostic methods and more sensitive diagnostic methods, such as multi-parameter prostate magnetic resonance imaging (mpMRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) can be applied clinically. Furthermore, laparoscopic/robot-assisted prostatectomy is also a safe and effective procedure for the treatment of benign prostatic hyperplasia. So maybe it is time to reconsider the necessary to perform prostate biopsy before radical prostatectomy. AIM To explore the feasibility of radical prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques. METHODS From June 2014 to November 2018, 11 cases of laparoscopic radical prostatectomy without prostate biopsy were performed at the three tertiary medical centers involved in this study. All patients received prostate magnetic resonance imaging and prostate cancer was suspected, including six patients with positive 68Ga- PSMA PET/CT results. Laparoscopic radical prostatectomy and pelvic lymph node dissection were performed for all patients. RESULTS All surgeries were accomplished successfully. The mean age was 69 ± 7.7 year, the mean body mass index was 24.7 ± 1.6 kg/m2, the range of serum PSA was 4.3 to >1000 ng/mL, and the mean prostate volume was 40.9 ± 18.3 mL. The mean operative time was 96 ± 23.3 min, the mean estimated blood loss was 90 ± 90.9 mL, and the median duration of catheter placement was 14 d. The final pathology confirmed that all specimens were prostate cancer except one case of benign prostatic hyperplasia. No major complications occurred in 90 d postoperatively. CONCLUSION The current practice of mandating a prostatic biopsy before prostatectomy should be reconsidered in the era of new imaging technology and minimally invasive techniques. Radical prostatectomy could be carried out without the evidence of malignancy. Large-sample randomized controlled trials are definitely required to confirm the feasibility of this new concept.

Rapid Determination of Dopamine and Its Metabolites During in vivo Cerebral Microdialysis by Routine High Performance Liquid Chromatography With Electrochemical Detection

To determine dopamine and its metabolites during in vivo cerebral microdialysis by routine high performance liquid chromatography with electrochemical detection. Methods Microdialysis probes were placed into the right striatum of Wistar rat brains and perfused with Ringer＇s solution at a rate of 1.5 pL/min. A reverse phase HPLC with electrochemistry was used to assay DA, DOPAC, and HVA after cerebral microdialysates were collected every 20 minutes from awake and freely moving rats. In order to identify the reliability of this method, its selectivity, linear range, precision and accuracy were tested and the contents of DA, DOPAC, and HVA in rat microdialysates were determined. Results The standard curve was in good linear at the concentration ranging from 74 nmol/L to 1.5 pmol/L for DOPAC （r^2= 0.9996）, from 66 nmol/L to 1.3 gmol/L for DA （r^2=l.0000） and from 69 nmol/L to 1.4 pmol/L for HVA （r^2=0.9992）. The recovery of DOPAC （0.30, 0.77, 1.49 gmol/L）, DA （0,26, 0.69, 1.32 gmol/L）, and HVA （0.27, 0.71, 1.37 gmol/L） was 82.00±1.70%, 104.00±4.00%, 98.70±3.10%; 92.30± 1.50%, 105.30±2.30%, 108.00±2.00%; 80.00±7.80%, 107.69±8.00%, and 108.66±3.10%, respectively at each concentration. Their intra-day RSD was 3.3%, 3.4%, and 2.5%, and inter-day RSD was 4.2%, 2.3%, and 5.6%, respectively. The mean extracellular concentrations of DOPAC, DA, and HVA in rat brain microdialysates were 10.7, 2.4, and 9.2 gmol/L （n=6）, respectively. Conclusion The findings of our study suggested that the simple, accurate and stable method can be applied to basic researches of diseases related to monoamines neurotransmitters by cerebral microdialysis in rats.

Post-dilatation improves stent apposition in patients with ST-segment elevation myocardial infarction receiving primary percutaneous intervention: A multicenter, randomized controlled trial using optical coherence tomography

Stent failure is more likely in the lipid rich and thrombus laden culprit lesions underlying ST-segment elevation myocardial infarction (STEMI). This study assessed the effectiveness of post-dilatation in primary percutaneous coronary intervention (pPCI) for acute STEMI. METHODS: The multi-center POST-STEMI trial enrolled 41 consecutive STEMI patients with symptom onset <12 hours undergoing manual thrombus aspiration and Promus Element stent implantation. Patients were randomly assigned to control group (n=20) or post-dilatation group (n=21) in which a non-compliant balloon was inflated to >16 atm pressure. Strut apposition and coverage were evaluated by optical coherence tomography (OCT) after intracoronary verapamil administration via thrombus aspiration catheter, post pPCI and at 7-month follow-up. The primary endpoint was rate of incomplete strut apposition (ISA) at 7 months after pPCI. RESULTS: There were similar baseline characteristics except for stent length (21.9 [SD 6.5] mm vs. 26.0 [SD 5.8] mm, respectively, P=0.03). In post-dilatation vs. control group, ISA rate was lower (2.5% vs. 4.5%, P=0.04) immediately after pPCI without affecting nal TIMI ow 3 rate (95.2% vs. 95.0%, P>0.05) or corrected TIMI frame counts (22.6±9.4 vs .22.0±9.7, P>0.05);and at 7-month follow-up (0.7% vs .1.8%, P<0.0001), the primary study endpoint, with similar strut coverage (98.5% vs. 98.4%, P=0.63) and 1-year rate of major adverse cardiovascular events (MACE). CONCLUSION: In STEMI patients, post-dilatation after stent implantation and thrombus aspiration improved strut apposition up to 7 months without affecting coronary blood ow or 1-year MACE rate. Larger and longer term studies are warranted to further assess safety.

Optimized strategy of rotational atherectomy of underexpanded coronary stents in patients with acute coronary syndrome

BACKGROUND:Stent under-expansion is a main cause of acute coronary syndrome(ACS),which can lead to serious clinical outcomes.The rotational atherectomy of underexpanded coronary stents(academically called stent ablation,SA)by intravascular ultrasound(IVUS)may provide more visual reference in the intervention.We aim to analyze the procedural and long-term outcomes of the optimized strategy of SA in patients with ACS and to provide real-world data on this technique.METHODS:A total of 11 patients with ACS who underwent SA between April 2017 and January 2019 were analyzed.Clinical follow-ups were obtained either by telephone call or by scheduled visit.Clinical end-points included periprocedural and postprocedural myocardial infarction,stent thrombosis,target lesion revascularization,and major adverse cardiac events.RESULTS:The mean age of patients was 69.6±6.5 years,and five(45.5%)patients were males.All cases presented with unstable angina and were admitted with ACS.All patients required at least two burrs during the intervention and the size of the burr was selected based on the data of minimum lumen diameter(MLD),and the fi rst and the second burr/stent MLD ratios were 0.93(0.88-0.99)and 1.09(1.02-1.14),respectively.Nine patients were treated with drug-eluting stents and two were treated with drug-coated balloons.There were no complications including no fl ow,perforation,or burr entrapment during the intervention.No in-hospital deaths or major adverse cardiac events were documented during the follow-up period.In our study,less contrast agent and a lower dose of radiation were used during the intervention.CONCLUSIONS:SA guided by IVUS can reduce the risk of complications,assess the results of surgery,inform the selection of stent size,and decrease the required dose of radiation and contrast.

Fractional Flow Reserve Guided Percutaneous Coronary ntervention Improves Clinical Outcome with Reduced Cost in Contemporary Clinical Practice

Background：Fractional flow reserve （FFR） is currently considered as the gold standard for evaluating the functional significance of coronary stenosis.However,its potential benefits in real-world practice remain unknown in China.This study aimed to test the hypothesis that the use of FFR is associated with improved outcome and reduced cost in Chinese real-world clinical practice.Methods：A retrospective cohort study was carried out using the database of Second Affiliated Hospital of Zhejiang University,a tertiary and high-volume center in China.Clinical events were compared using the Cox proportional hazards model during a median follow-up of 13 months.Results：The study cohort consisted of 366 consecutive patients referred for coronary revascularization with adjunct FFR and 366 matched controls,from 2010 to 2014.Major adverse cardiac events （MACEs） （death,myocardial infarction,repeated revascularization,or hospitalization for angina） at 4 years were found in 12.0% ofangiography-guided patients and 4.9% in the FFR-guided group （P 〈 0.001）.The mean number of implanted stents was significantly lower in FFR treated subjects （0.52 ± 0.82 stents） compared with the angiography-guided group （0.93 ± 0.96 stents） （P 〈 0.001）.No difference in overall costs at initial hospitalization was observed between angiography-guided percutaneous coronary intervention （PCI） compared with FFR-guided PCI （RMB 33,000 Yuan,range：RMB 7393-44,700 Yuan） versus RMB 21,200 Yuan （RMB 19,100-47,100 Yuan） （P =0.54）.However,costs for MACEs during follow-up were significantly reduced in the FFR-guided arm （P 〈 0.001）.Conclusions：In the contemporary clinical practice,FFR-guided PCI is associated with decreased use of stents,improved clinical outcome,and reduced costs,compared with angiography-guided PCI.

Safety and Efficacy of a Novel Technique in the Use of Fractional Flow Reserve in Complex Coronary Artery Lesions

Background:Fractional flow reserve (FFR) has become an increasingly important index when making decisions with respect to revascularization of coronary artery stenosis.However,the pressure guidewire used in obtaining FFR measurements is difficult to control and manipulate in certain complex coronary artery lesions,resulting in increased fluoroscopy time and contrast dye usage.This study examined a novel (NOV) technique for obtaining FFR measurements in hope of easing the difficulties associated with evaluating and treating complex coronary artery lesions.Methods:Fifty-six patients with complex coronary artery lesions were assigned to a conventional (CON) FFR technique group or a NOV FFR technique group.The NOV technique involved the use of a balloon and wire exchange within the coronary artery.The fluoroscopy time,contrast dye usage,and FFR-related complications were assessed after completing the FFR measurement procedure for each patient.Results:The median time required for fluoroscopy in the NOV technique group was significantly less than that in the CON technique group; additionally,lesser amounts of contrast dye were used in the NOV technique group (both P ＜ 0.05).The NOV technique was successfully performed in thirty patients,without any FFR-related complications.However,the CON technique failed in three patients,including two who experienced coronary artery spasms (P ＞ 0.05).Conclusions:Compared to the CON technique used for measuring FFR,the new technique reduced the fluoroscopy time and amount of contrast dye used when evaluating complex coronary artery lesions.The new technique did not increase the risk of operation or decrease the success rate.

Impact of Cytoreductive Nephrectomy on Survival in Patients with Metastatic Renal Cell Carcinoma Treated by Targeted Therapy

Background：The metastatic renal cell carcinoma （mRCC） patients treated with upfront cytoreductive nephrectomy combined with α-interferon yields additional overall survival （OS） benefits.It is unclear whether mRCC patients treated with vascular endothelial growth factor receptor-tyrosine kinase inhibitor （VEGFR-TKI） will benefit from such cytoreductive nephrectomy either.The aim of the study was to identify variables for selection of patients who would benefit from upfront cytoreductive nephrectomy for mRCC treated with VEGFR-TKI.Methods：Clinical data on 74 patients enrolled in 5 clinical trials conducted in Cancer Hospital （Institute）,Chinese Academy of Medical Sciences from January 2006 to January 2014 were reviewed retrospectively.The survival analysis was performed by the Kaplan-Meier method.Comparisons between patient groups were performed by Chi-square test.A Cox regression model was adopted for analysis of multiple factors affecting survival,with a significance level of α =0.05.Results：Fifty-one patients underwent cytoreductive nephrectomy followed by targeted therapy （cytoreductive nephrectomy group） and 23 patients were treated with targeted therapy alone （noncytoreductive nephrectomy group）.The median OS was 32.2 months and 23.0 months in cytoreductive nephrectomy and noncytoreductive nephrectomy groups,respectively （P =0.041）.Age ≤45 years （P =0.002）,a low or high body mass index （BMI 〈19 or 〉30 kg/m2） （P =0.008）,a serum lactate dehydrogenase （LDH） concentration 〉 1.5 × upper limit of normal （P =0.025）,a serum calcium concentration 〉1 0 mg/ml （P =0.034）,and 3 or more metastatic sites （P =0.023） were independent preoperative risk factors for survival.The patients only with 0-2 risk factors benefited from upfront cytoreductive nephrectomy in terms of OS when compared with the patients treated with targeted therapy alone （40.0 months vs.23.2 months,P =0.042）,while those with more than 2 risk factors did not.Conclusions：Five risk factors （age,BMI,LDH,serum calcium,and number of metastatic sites） seemed to be helpful for selecting patients who would benefit from undergoing upfront cytoreductive nephrectomy.