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Joint meeting presents hot topics on urological imaging

Updates on PI-RADS (Prostate Imaging Reporting and Data System) and radio-guided surgery were the hot topics of the session “Prepare for the future: Prevent, detect, strike back!”. This Joint Meeting of the EAU Section of Infections in Urology (ESIU) and the EAU Section of Urological Imaging (ESUI) was chaired by Prof. Georg Salomon (DE) and Prof. Dr. Florian Wagenlehner (DE).

In his lecture, “PI-RADS: Past, present and future — what’s next in PI-RADS v3.0”, Prof. Dr. Jurgen Futterer (NL) enumerated suggestions and improvements needed for PI-RADS v2.0. These include improvement of the transition zone lesion detection; quantification of apparent diffusion coefficient (ADC); biparametric prostate magnetic resonance imaging (MRI) without Dynamic Contrast Enhanced (DCE) imaging; and retrieval of as much clinical information as possible is important, especially in patients under active surveillance.

Regarding follow-up and biopsy, Prof. Futterer suggested to implement the recommendations into PI-RADS v3:

  • Score 1 (very low likelihood of cancer): No biopsy, no follow-up
  • Score 2 (low likelihood of cancer): No biopsy, follow-up, multiparametric MRI if PSA increases
  • Score 3 (intermediate likelihood of cancer): If prostate specific antigen density (PSAD) < 0.15, follow-up; if PSAD > 0.2, MRI-guided biopsy
  • Score 4 (high likelihood of cancer): MRI-guided biopsy
  • Score 5 (very high likelihood of cancer): MRI-guided biopsy

Radio-guided surgery

Will prostate-specific membrane antigen radio guided surgery (PSMA-RGS) become state-of-the-art?  Assoc. Prof. Tobias Maurer (DE) said data points to “yes”.

During his presentation “Early biochemical recurrence: Will radio-guided surgery will become state of the art?, he stated that “PSMA-RGS provides exact localization. You don’t need to do frozen section analysis, and you might even detect additional lesions,” he stated. “Additionally, the surgical guidance provides more security especially in areas urologists don’t usually navigate to during surgery.”

Prof. Maurer also mentioned the PSMA-RGS drawbacks such as PSMA-RGS may not be necessary in “easy” cases; logistics (e.g. facilities, certifications); regulations on use of PSMA-ligands; and the benefit of salvage lymph node dissection (SLND) still unknown.

ESUI Vision Award

Dr. Giorgio Gandaglia (IT) received the coveted ESUI Vision Award for his lecture “A Novel Nomogram to Identify Candidates for Extended Pelvic Lymph Node Dissection Among Patients with Clinically Localized Prostate Cancer Diagnosed with Magnetic Resonance Imaging Targeted and Systematic Biopsies”.

The objectives of his study were to assess the accuracy of available tools in predicting lymph node invasion (LNI) and to develop a novel model for men diagnosed via MRI-targeted biopsies. A total of 497 patients were diagnosed via MRI-targeted biopsies and treated with radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND) at five institutions.

Currently, available models predicting LNI are characterised by suboptimal accuracy and clinical net-benefit for patients diagnosed via MRI-targeted biopsies. Dr. Gandaglia stated that to identify patients at higher-risk of LNI and who should be considered for an ePLND, a novel nomogram specifically focused on men undergoing multi-parametric MRI (mpMRI) should be used. He added that adoption of this model using a 7% cut-off to identify candidates for ePLND could avoid up to 60% of these procedures at the cost of missing only 1.6% patients with LNI.