Are there courses that you recommend?
There are many courses available through radiology conferences and urology conferences, and I don’t have specifics on which is better than the other. At the AUA annual meeting in Boston, there was a line out the door for a course called “Prostate MR Imaging: What a Urologist Should Know.” There’s clearly interest and energy on the urologists’ part to enhance their skills.
What do you do with PI-RADS 3 or 2 lesions?
Currently we don’t take extra samples from PI-RADS 2 lesions. But standard of care nowadays and in the consensus guidelines is any PI-RADS 3 through 5 lesion deserves some extra attention, with a minimum of two samples from that area.
How do you handle the patient whom you’re concerned about but whose MRI is negative for PI-RADS 3, 4, and 5? Do you proceed with a saturation biopsy? Do you do anything differently in the clinical setting?
That’s a complex situation, and the good news and bad news is that a number of different strategies are available. There are the imaging biomarkers like MRI. There are many serum and urine biomarkers that can be helpful in that space. It really depends on your level of clinical concern. I think we underutilize some tools that are readily available to us such as a percent-free PSA or a prostate volume. Those are helpful in deciding whether to simply see this patient again in 6 months, utilize one of the more advanced biomarkers to help make a decision, or—if you are very concerned—do an extensive biopsy.
Is there anything else you would say to urologists pertinent to an MRI program?
I think it’s really important to recognize the things MRI is very good at and the things it’s not as good at. For instance, it is very good at identifying sizable lesions. It is very good at identifying most, but not all, high-grade lesions. However, the operating characteristics of finding microscopic extracapsular extension are not very good. Why is that relevant? It’s incredibly relevant because many men now get an MRI prior to their prostatectomy. It is not appropriate to take the MRI findings as gospel and plan your nerve-sparing surgery or your resection status based on that.
Do you use MRI at all to help formulate your operative approach?
I do, but it’s important to get into the nuances of it. I do not routinely obtain an MRI before every prostatectomy, although our center does have a pre-prostatectomy grant in which hundreds of men have gotten them. I think of the MRI before prostatectomy as a useful piece of information that gets integrated with everything else I already know about the patient to help make a smart decision before and during the surgery on whether to spare part or all of the nerves on a specific side.
What I don’t like to hear from colleagues is, “The MRI suggests extracapsular extension, so I’m definitely going wide on that side,” or “There’s no extracapsular extension on the MRI, so I’m going to aggressively nerve spare.” To my point, a published randomized trial from Europe looked at about 400 men randomized before prostatectomy to MRI versus no MRI. The primary endpoint was surgical margin status, and there was absolutely no difference between the two study arms.
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