Prostate health index can stratify patients with Prostate Imaging Reporting and Data System score 3 lesions on magnetic resonance imaging to reduce prostate biopsies

We aim to evaluate prostate health index as an additional risk-stratification tool in patients with Prostate Imaging Reporting and Data System score 3 lesions on multiparametric magnetic resonance imaging.Men with biochemical or clinical suspicion of having prostate cancer who underwent multiparametric magnetic resonance imaging in two tertiary centers(Queen Mary Hospital and Princess Margaret Hospital,Hong Kong,China)between January 2017 and June 2022 were included.Ultrasound-magnetic resonance imaging fusion biopsies were performed after prostate health index testing.Those who only had Prostate Imaging Reporting and Data System score 3 lesions were further stratified into four prostate health index risk groups and the cancer detection rates were analyzed.Out of the 747 patients,47.3%had Prostate Imaging Reporting and Data System score 3 lesions only.The detection rate of clinically significant prostate cancer in this group was 15.0%.The cancer detection rates of clinically significant prostate cancer had statistically significant differences:5.3%in prostate health index<25.0,7.4%in prostate health index 25.0-34.9,17.9%in prostate health index 35.0-54.9,and 52.6%in prostate health index≥55.0(P<0.01).Among the patients,26.9%could have avoided a biopsy with a prostate health index<25.0,at the expense of a 5.3%risk of missing clinically significant prostate cancer.Prostate health index could be used as an additional risk stratification tool for patients with Prostate Imaging Reporting and Data System score 3 lesions.Biopsies could be avoided in patients with low prostate health index,with a small risk of missing clinically significant prostate cancer.

Surgical approach affecting long-term urinary continence status after robot-assisted laparoscopic prostatectomy prospectively evaluated using self-reported functional status(Expanded Prostate Cancer Index Composite,EPIC-26)

Purpose:The aim of the study was to examine the influence of the surgical approach for robot-assisted laparoscopic prostatectomy(RALP)on long-term urinary continence status in the era of self-reported functional status measures using the Expanded Prostate Cancer Index Composite 26.Materials and methods:This is a prospective evaluation of 232 patients undergoing RALP between September,2019 and September,2020.Urinary continence status and postoperative incontinence(pad usage)were evaluated 12 months after RALP using Expanded Prostate Cancer Index Composite 26 questionnaires.Patients were categorized according to their surgical approach and outcome into the following groups:successful nerve sparing(NS),primarily without nerve sparing(prim.NNS),and no nerve sparing by secondary resection(NNS by SR).The median levels of their questionnaire outcomes were evaluated and compared using the Wilcoxon rank sum test with continuity correction.Results:Urinary continence status 12 months after RALP differed significantly between the NS and prim.NNS(p=0.0071)and the NS and NNS by SR(p=0.0076)groups.There was no significant difference between the prim.NNS and NNS by SR(p=0.53)groups.Pad usage 12 months after RALP had no significant difference with regard to SR of the neurovascular bundle(p=0.14).Conclusions:Patient-reported outcomes of long-term urinary continence status seem to show no difference in postoperative continence,regardless of whether a non-nerve-sparing result was planned or reached through SR.Instead,preservation of neurovascular bundle seems to lead to better long-term continence rates.

Fluoroquinolone-macrolide combination therapy for chronic bacterial prostatitis： retrospective analysis of pathogen eradication rates, inflammatory findings and sexual dysfunction

We previously demonstrated the safety and efficacy of fluoroquinolone-macrolide combination therapy in category Ⅱ chronic bacterial prostatitis （CBP）. The aim of this study is to retrospectively compare the microbiological and clinical findings of two treatment schemes for CBP based on the combination of azithromycin （500 rag, thrice-weekly） with a once-daily 500- or 750-mg dose of ciprofloxacin （Cipro-500 or Cipro-750 cohort, respectively）. Combined administration of azithromycin （1500 mg week^-1） with ciprofloxacin at the rate of 750 mg day^- 1 for 4 weeks rather than at 500 mg day^- 1 for 6 weeks increased the eradication rates from 62.35% to 77.32% and the total bacteriological success from 71.76% to 85.57%. A significant decrease in pain and voiding signs/symptoms and a significant reduction in inflammatory leukocyte counts and serum prostate-specific antigen （PSA） were sustained throughout an 18-month follow-up period in both groups. Ejaculatory pain, haemospermia and premature ejaculation were significantly attenuated on microbiological eradication in both groups, but the latter subsided more promptly in the Cipro-750 cohort. In total, 59 Cipro-750 patients showed mild-to-severe erectile dysfunction （ED） at baseline, while 22 patients had no ED on microbiological eradication and throughout the follow-up period. In conclusion fluoroquinolone-macrolide therapy resulted in pathogen eradication and CBP symptom attenuation, including pain, voiding disturbances and sexual dysfunction. A once-daily 750-mg dose of ciprofloxacin for 4 weeks showed enhanced eradication rates and lower inflammatory white blood cell counts compared to the 500-mg dose for 6 weeks. Our results are open to further prospective validation.

Semen analysis in chronic bacterial prostatitis： diagnostic and therapeutic implications

The significance and diagnostic value of semen analysis in chronic bacterial prostatitis has been extensively debated and remains controversial. To investigate the diagnostic relevance of semen culture in the bacteriological workup of prostatitis patients, we retrospectively analyzed a clinical database of 696 symptomatic patients. All patients were routinely subjected to a four-glass test, followed by semen culture and analysis. This allowed to dissect from the database three different diagnostic scenarios, and to compare the ＇two-glass＇ pre-/post- massage test and the standard ＇four-glass＇ test with a ＇five-glass＇ test （four-glass plus post-VB3 semen culture）. The ＇five-glass＇ test showed 3.6- or 6.5-fold increases in relative sensitivity and lesser reductions （-13.2% or -14.7%） in relative specificity for traditional uropathogens （TUs） compared with the four-glass or two-glass test, respectively. The area under the ROC curve and Jouden＇s index were increased, whereas positive and negative likelihood ratios were lower than comparators, indicating that the ＇five-glass＇ assay may be superior in confirming the negative outcome of both standard tests. The five-, four-, and two-glass tests detected TUs （Enterobacteriaceae, Enterococci, etc.） in 120, 33, and 20 patients and unusual pathogens （Streptococci, other Gram-positive species, Mycoplasmata, and others） in 130, 56, and 45 patients, respectively. When patients were subjected to pharmacological treatment, including a combination of a fluoroquinolone and a macrolide, no differences in eradication rates were observed between groups diagnosed with different tests, irrespective of pathogen category. Eradication was associated with long-term sign/symptom remission; no significant intergroup differences in sign/symptom scores were observed throughout a 24-month off-therapy follow-up period. In conclusion, our data support the usefulness of semen analysis in the diagnostic workup ofprostatitis patients when this test is used to complement the four-glass Meares and Stamey test. Improvement of microbiological assays conveys important diagnostic and therapeutic implications.

The combined role of MRI prostate and prostate health index in improving detection of significant prostate cancer in a screening population of Chinese men

Using prostate-specific antigen(PSA)for prostate cancer(PCa)screening led to overinvestigation and overdiagnosis of indolent PCa.We aimed to investigate the value of prostate health index(PHI)and magnetic resonance imaging(MRI)prostate in an Asian PCa screening program.Men aged 50–75 years were prospectively recruited from a community-based PSA screening program.Men with PSA 4.0–10.0 ng ml^(−1) had PHI result analyzed.MRI prostate was offered to men with PSA 4.0–50.0 ng ml−1.A systematic prostate biopsy was offered to men with PSA 4.0–9.9 ng ml^(−1) and PHI≥35,or PSA 10.0–50.0 ng ml^(−1).Additional targeted prostate biopsy was offered if they had PI-RADS score≥3.Clinically significant PCa(csPCa)was defined as the International Society of Urological Pathology(ISUP)grade group(GG)≥2 or ISUP GG 1 with involvement of≥30%of total systematic cores.In total,12.8%(196/1536)men had PSA≥4.0 ng ml^(−1).Among 194 men with PSA 4.0–50.0 ng ml^(−1),187(96.4%)received MRI prostate.Among them,28.3%(53/187)had PI-RADS≥3 lesions.Moreover,7.0%(107/1536)men were indicated for biopsy and 94.4%(101/107)men received biopsy.Among the men received biopsy,PCa,ISUP GG≥2 PCa,and csPCa was diagnosed in 42(41.6%),24(23.8%),and 34(33.7%)men,respectively.Compared with PSA/PHI pathway in men with PSA 4.0–50.0 ng ml^(−1),additional MRI increased diagnoses of PCa,ISUP GG≥2 PCa,and csPCa by 21.2%(from 33 to 40),22.2%(from 18 to 22),and 18.5%(from 27 to 32),respectively.The benefit of additional MRI was only observed in PSA 4.0–10.0 ng ml^(−1),and the number of MRI needed to diagnose one additional ISUP GG≥2 PCa was 20 in PHI≥35 and 94 in PHI<35.Among them,45.4%(89/196)men with PSA≥4.0 ng ml^(−1) avoided unnecessary biopsy with the use of PHI and MRI.A screening algorithm with PSA,PHI,and MRI could effectively diagnose csPCa while reducing unnecessary biopsies.The benefit of MRI prostate was mainly observed in PSA 4.0–9.9 ng ml^(−1) and PHI≥35 group.PHI was an important risk stratification step for PCa screening.

Performance of the Prostate Health Index in predicting prostate biopsy outcomes among men with a negative digital rectal examination and transrectal ultrasonography

The [-2]proPSA （p2PSA） and its derivatives, the p2PSA-to-free PSA ratio （%p2PSA）, and the Prostate Health Index （PHI） have greatly improved discrimination between men with and without prostate cancer （PCa） in prostate biopsies. However, little is known about their performance in cases where a digital rectal examination （DRE） and transrectal ultrasonography （TRUS） are negative. A prospective cohort of 261 consecutive patients in China with negative DRE and TRUS were recruited and underwent prostate biopsies. A serum sample had collected before the biopsy was used to measure various PSA derivatives, including total prostate-specific antigen （tPSA）, free PSA, and p2PSA. For each patient, the free-to-total PSA ratio （%fPSA）, PSA density （PSAD）, p2PSA-to-free PSA ratio （%p2PSA）, and PHI were calculated. Discriminative performance was assessed using the area under the receiver operating characteristic curve （AUC） and the biopsy rate at 91% sensitivity. The AUC scores within the entire cohort with respect to age, tPSA, %fPSA, PSAD, p2PSA, %p2PSA, and PHI were 0.598, 0.751, 0.646, 0.789, 0.814, 0.808, and 0.853, respectively. PHI was the best predictor of prostate biopsy results, especially in patients with a tPSA of 10.1-20 ng ml-1. Compared with other markers, at a sensitivity of 91%, PHI was the most useful for determining which men did not need to undergo biopsy, thereby avoiding unnecessary procedures. The use of PHI could improve the accuracy of PCa detection by predicting prostate biopsy outcomes among men with a negative DRE and TRUS in China.

Prostate Health Index(phi)and its derivatives predict Gleason score upgrading after radical prostatectomy among patients with low-risk prostate cancer

To analyze the performance of the Prostate Health Index(phi)and its derivatives for predicting Gleason score(GS)upgrading between prostate biopsy and radical prostatectomy(RP)in the Chinese population,an observational,prospective RP cohort consisting of 351 patients from two medical centers was established from January 2017 to September 2020.Pathological reclassification was determined by the Gleason Grade Group(GG).The area under the receiver operating characteristic curve(AUC)and logistic regression(LR)models were used to evaluate the predictive performance of predictors.In clinically low-risk patients with biopsy GG≤2,phi(odds ratio[OR]=1.80,95%confidence interval[95%CI]:1.14-2.82,P=0.01)and its derivative phi density(PHID;OR=2.34,95%CI:1.30-4.20,P=0.005)were significantly associated with upgrading to GG≥3 after RP,and the results were confirmed by multivariable analysis.Similar results were observed in patients with biopsy GG of 1 for the prediction of upgrading to RP GG≥2.Compared to the base model(AUC=0.59),addition of the phi or PHID could provide additional predictive value for GS upgrading in low-risk patients(AUC=0.69 and 0.71,respectively,both P<0.05).In conclusion,phi and PHID could predict GS upgrading after RP in clinically low-risk patients.

Prostate volume does not provide additional predictive value to prostate health index for prostate cancer or clinically significant prostate cancer:results from a multicenter study in China

To evaluate whether prostate volume(PV)would provide additional predictive utility to the prostate health index(phi)for predicting prostate cancer(PCa)or clinically significant prostate cancer,we designed a prospective,observational multicenter study in two prostate biopsy cohorts.Cohort 1 included 595 patients from three medical centers from 2012 to 2013,and Cohort 2 included 1025 patients from four medical centers from 2013 to 2014.Area under the receiver operating characteristic curves(AUC)and logistic regression models were used to evaluate the predictive performance of PV-based derivatives and models.Linear regression analysis showed that both total prostate-specific antigen(tPSA)and free PSA(fPSA)were significantly correlated with PV(all P<0.05).[-2]proPSA(p2PSA)was significantly correlated with PV in Cohort 2(P<0.001)but not in Cohort 1(P=0.309),while no significant association was observed between phi and PV.When combining phi with PV,phi density(PHID)and another phi derivative(PHIV,calculated as phi/PV°5)did not outperform phi for predicting PCa or clinically significant PCa in either Cohort 1 or Cohort 2.Logistic regression analysis also showed that phi and PV were independent predictors for both PCa and clinically significant PCa(all P<0.05);however,PV did not provide additional predictive value to phi when combining these derivatives in a regression model(all models vs phi were not statistically significant,all P>0.05).In conclusion,PV-based derivatives(both PHIV and PHID)and models incorporating PV did not improve the predictive abilities of phi for either PCa or clinically significant PCa.

Can we omit systematic biopsies in patients undergoing MRI fusion-targeted prostate biopsies?

Magnetic resonance imaging(MRI)-targeted prostate biopsy is the recommended investigation in men with suspicious lesion(s)on MRI.The role of concurrent systematic in addition to targeted biopsies is currently unclear.Using our prospectively maintained database,we identified men with at least one Prostate Imaging-Reporting and Data System(PI-RADS)≥3 lesion who underwent targeted and/or systematic biopsies from May 2016 to May 2020.Clinically significant prostate cancer(csPCa)was defined as any Gleason grade group≥2 cancer.Of 545 patients who underwent MRI fusion-targeted biopsy,222(40.7%)were biopsy naïve,247(45.3%)had previous prostate biopsy(s),and 76(13.9%)had known prostate cancer undergoing active surveillance.Prostate cancer was more commonly found in biopsy-naïve men(63.5%)and those on active surveillance(68.4%)compared to those who had previous biopsies(35.2%;both P<0.001).Systematic biopsies provided an incremental 10.4%detection of csPCa among biopsy-naïve patients,versus an incremental 2.4%among those who had prior negative biopsies.Multivariable regression found age(odds ratio[OR]=1.03,P=0.03),prostate-specific antigen(PSA)density≥0.15 ng ml^(−2)(OR=3.24,P<0.001),prostate health index(PHI)≥35(OR=2.43,P=0.006),higher PI-RADS score(vs PI-RADS 3;OR=4.59 for PI-RADS 4,and OR=9.91 for PI-RADS 5;both P<0.001)and target lesion volume-to-prostate volume ratio≥0.10(OR=5.26,P=0.013)were significantly associated with csPCa detection on targeted biopsy.In conclusion,for men undergoing MRI fusion-targeted prostate biopsies,systematic biopsies should not be omitted given its incremental value to targeted biopsies alone.The factors such as PSA density≥0.15 ng ml^(−2),PHI≥35,higher PI-RADS score,and target lesion volume-to-prostate volume ratio≥0.10 can help identify men at higher risk of csPCa.