BackgroundMultiparametric magnetic resonance imaging (mpMRI) is now recommended pre-biopsy in numerous healthcare regions based on the findings of high-quality studies from expert centres. Concern remains about reproducibility of mpMRI to rule-out clinically significant prostate cancer (csPCa) in real-world settings.
ObjectiveTo assess the diagnostic performance of mpMRI for csPCa in a real-world setting.
Design, Setting, and ParticipantsA multicentre, retrospective cohort study including men referred with a raised PSA or abnormal digital rectal exam who had undergone mpMRI followed by transrectal or transperineal biopsy. Patients could be biopsy naïve or have had previous negative biopsies.
Outcome Measurements and Statistical AnalysisThe primary definition for csPCa was defined as ISUP Grade Group 2 or higher (any Gleason >/=7); the accuracy for other definitions was also evaluated.
Results and LimitationsAcross 10 sites 2642 men were included (January/2011-November/2018). Mean age and PSA were 65.3 years (SD 7.8 years) and 7.5ng/ml (SD 3.3ng/ml). 35.9% had a 'negative' MRI' (score 1-2). 51.9% underwent transrectal biopsy and 48.1% had transperineal biopsy; with 43.4% diagnosed with csPCa overall. The sensitivity and negative predictive value (NPV) for 5 ISUP GG >/=2 were 87.3% and 87.5%, respectively. The NPV was 87.4% and 88.1% for men undergoing transrectal and transperineal biopsy, respectively. Specificity and positive predictive value of MRI were 49.8% and 49.2%, respectively. The sensitivity and NPV increased to 96.6% and 90.6% when a PSA-density threshold 0.15ng/ml/ml was used in MRI scores 1-2; these metrics increased to 97.5% and 91.2%, respectively, for PSA density 0.12ng/ml/ml. ISUP GG >/=3 (Gleason >/=4+3) was found in 2.4% (15/617) of men with MRI score 1-2. They key limitation of this study is the heterogeneity and retrospective nature of the data.
ConclusionsmpMRI when used in real-world settings is able to accurately rule-out csPCa suggesting that about one-third of men might avoid an immediate biopsy. Men should be counselled about the risk of missing some significant cancers.
Background: Ureteric colic is a major clinical and economic burden on the National Health Service. There has been a recent paradigm shift to consider definitive surgery as the primary intervention at the time of initial presentation. Objective: To systematically evaluate the outcomes of primary/emergency ureteroscopy versus delayed/elective ureteroscopy. Methods: We performed a critical review of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials–CENTRAL, CINAHL, Clinicaltrials.gov, Google Scholar and individual urological journals in April 2020. A robust database search was performed using a combination of the terms ‘primary ureteroscopy’, ‘immediate ureteroscopy’, ‘delayed ureteroscopy’ and ‘emergency ureteroscopy’. Adult patients (> 16 years) with ureteric stones presenting as an emergency were included. Results: Twelve studies met the inclusion criteria, with 4 studies directly comparing primary/emergency to delayed/elective ureteroscopy for an acute presentation of ureteric colic. Across the studies, 1708 patients underwent primary/emergency ureteroscopy for ureteric calculi and 990 underwent delayed ureteroscopy. No significant differences in stone-free rates were found between both groups with primary/emergency achieving 85% and delayed/elective 91% ( p = 0.68). The majority of stones treated were located in the distal ureter in both groups. Overall, there were no differences in complications between the groups ( p = 0.42) or major complications (0.17). However, there were fewer minor complications in the primary URS group ( p = 0.02). Ureteral catheter or double-J stent insertion was used in 71% of delayed/elective ureteroscopy cases, compared to 46.8% of primary/emergency cases (p = 0.001). For patients undergoing primary/emergency ureteroscopy, 6.4% patients required auxiliary procedures. In the delayed/elective group, 7.6% required further definitive treatment (NS). Conclusion: Primary ureteroscopy is a safe and feasible procedure, when performed in suitable patients in the acute setting. It is associated with significantly lower stent usage, equivalent stone clearance, no increase in overall or major complications including sepsis, and fewer minor complications when compared to delayed/elective ureteroscopy. Prospective studies will do well to explore this area further but on current evidence, primary ureteroscopy is the safe procedure. Level of evidence: Not applicable
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