Re: Geometric Evaluation of Systematic Transrectal Ultrasound Guided Prostate Biopsy

Re: Geometric Evaluation of Systematic Transrectal Ultrasound Guided Prostate Biopsy

LETTERS TO THE EDITOR/ERRATA 363 have personally taught all University of California, Los Angeles residents from 1971 to 1980 and all University of ...

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have personally taught all University of California, Los Angeles residents from 1971 to 1980 and all University of Southern California residents and fellows from 1980 to 2009 the importance of this technique in which the ureter after spatulation is never grasped by a forceps or any instrument, but handled only by a 4-zero polyglycolic acid traction suture that becomes the final suture of the interrupted anastomosis. This technique used in 1,964 patients undergoing open radical cystectomy from 1971 through December 2008 has resulted in a long-term durable benign ureteroenteric stricture rate of 2.5% (median followup 13.5 years). Surgical technique remains an art, and any surgeon reporting benign ureteroenteric stricture rates of more than 3% needs to seriously reevaluate his or her technique and learn great respect for the ureter to avoid instrument trauma, ischemia, crushing or excessive manipulation. There are many Massachusetts General Hospital, University of California, Los Angeles and University of Southern California trained surgical oncologists who have been taught and teach this technique with similar results. A stricture rate of 12.6% for the robot-assisted anastomosis with short followup from an experienced group is unacceptable and represents a major step backward in the modern performance of radical cystectomy. Respectfully, Donald G. Skinner Emeritus Professor and Chairman Department of Urology Keck School of Medicine University of Southern California Los Angeles, California

Reply by Authors: Surgical principles do not change despite new operative approaches, instruments or technologies. Neither gentle handling of the distal ureter nor performance of spatulated anastomosis is a novel concept. These methods are routinely understood and practiced by many surgeons who were not trained with or by Skinner. He references his series of 1,964 cases accumulated during a 37-year span. Our experience at Vanderbilt exceeds that in a shorter period. What has changed is the fidelity of publications reporting surgical complications. The standardization of complications and improved data capture have decreased some of the subjectivity and underreporting of complications so common in the historical literature. The stricture rates we report are in line with other well performed studies at large centers of excellence.1 However, what is categorized as a ureteroenteric stricture may vary considerably between publications. Honest, objective studies like ours do not represent a major step backward. Rather, they permit valid comparisons and fair assessments, and identify opportunities for improvement with the ultimate goal of decreasing the morbidity of radical cystectomy. 1. Anderson CB, Morgan TM, Kappa S et al: Ureteroenteric anastomotic strictures after radical cystectomy: does operative approach matter? Available at⫽urologicsurgery&doc⫽32446. Accessed February 8, 2013.

Re: Geometric Evaluation of Systematic Transrectal Ultrasound Guided Prostate Biopsy M. Han, D. Chang, C. Kim, B. J. Lee, Y. Zuo, H.-J. Kim, D. Petrisor, B. Trock, A. W. Partin, R. Rodriguez, H. B. Carter, M. Allaf, J. Kim and D. Stoianovici J Urol 2012; 188: 2404 –2409.

To the Editor: The authors demonstrate the unreliability of systematic transrectal ultrasound (TRUS) guided biopsies to fully evaluate the prostate. There has been increasing recognition that even experienced physicians are unable to sample the gland accurately and repeatedly via TRUS guided biopsy alone. While the systematic approach using transrectal biopsies spaced uniformly in the prostate theoretically ensures that few lesions 0.5 cm or greater are missed,1 Han et al have



shown that even within a controlled setting of simulation urologists had a mean targeting error of 7.1 mm, which led to a statistically significant poorer detection rate of lesions with a volume of 0.5 cm or greater. In a clinical setting—where one cannot control for patient factors including intolerance of the procedure, variable gland size, nonuniform distribution of cancer grade within a lesion, prostate deformity and relative inaccessibility of the anterior gland—it is not unreasonable to expect this value to be even greater. We would like to highlight a number of issues. It is possible that the assumption of the authors that all lesions were spherical may have negatively impacted detection rates, as tumors are often oval and long.2 We look forward to their further studies to evaluate this factor and encourage the use of accurately defined lesions based on radical prostatectomy or cystoprostatectomy specimens. Furthermore, the study did not incorporate grade into the definition of clinical significance to assess the degree of misgrading that others have demonstrated. This issue can be particularly pertinent since grade heterogeneity occurs within tumors, with increasing interest in the “hot spot” of a lesion.3 What are the potential solutions? As addressed in the article, transperineal biopsy requires increased resources. Outside of a trial setting this biopsy method might not be cost effective and would necessitate a large shift away from current practice. However, it does remain the gold standard in a biopsy naïve population.4 Recent work by Boniol et al certainly lends weight to a movement away from TRUS biopsy.5 Robotically placed systematic biopsies seem to increase detection but the lack of a “target” is still problematic, particularly as the proposition is to fix the number of needle deployments. What is needed is fixation of the sampling frame and ascertainment that the posterior and anterior zones are sampled.1 The combination of robotic guided biopsies to predefined areas of suspicion with targets defined by imaging (prebiopsy multiparametric magnetic resonance imaging or novel ultrasound techniques) and image registration/fusion incorporating prostate deformity may be the correction we are all looking for.6,7 Respectfully, I. A. Donaldson, C. M. Moore, M. Emberton and H. U. Ahmed Division of Surgery and Interventional Science University College London London, United Kingdom e-mail: [email protected] 1. Ahmed HU, Emberton M, Kepner G et al: A biomedical engineering approach to mitigate the errors of prostate biopsy. Nat Rev Urol 2012; 9: 227. 2. Nevoux P, Ouzzane A, Ahmed HU et al: Quantitative tissue analyses of prostate cancer foci in an unselected cystoprostatectomy series. BJU Int 2012; 110: 517. 3. van de Ven WJ, Hulsbergen-van de Kaa CA, Hambrock T et al: Simulated required accuracy of image registration tools for targeting high-grade cancer components with prostate biopsies. Eur Radiol 2013; 23: 1401. 4. Lecornet E, Ahmed HU, Hu Y et al: The accuracy of different biopsy strategies for the detection of clinically important prostate cancer: a computer simulation. J Urol 2012; 188: 974.

5. Boniol M, Boyle P, Autier P et al: Critical role of prostate biopsy mortality in the number of years of life gained and lost within a prostate cancer screening programme. BJU Int 2012; 110: 1648. 6. Moore CM, Robertson NL, Arsanious N et al: Image-guided prostate biopsy using magnetic resonance imaging-derived targets: a systematic review. Eur Urol 2013; 63: 125. 7. Vourganti S, Rastinehad A, Yerram NK et al: Multiparametric magnetic resonance imaging and ultrasound fusion biopsy detect prostate cancer in patients with prior negative transrectal ultrasound biopsies. J Urol 2012; 188: 2152.

Re: Effects of the Reduced Form of Coenzyme Q10 (Ubiquinol) on Semen Parameters in Men with Idiopathic Infertility: A Double-Blind, Placebo Controlled, Randomized Study M. R. Safarinejad, S. Safarinejad, N. Shafiei and S. Safarinejad J Urol 2012; 188: 526 –531.

To the Editor: This study has apparent inconsistencies when considered in light of 3 other series on oligoasthenoteratozoospermia published by Safarinejad et al.1–3 The current study was conducted from June 2010 to January 2011, a period of 35 weeks. However, according to the study protocol, the study lasted at least 42 weeks.