In elderly patients with elevated PSA, abnormal pelvic mpMRI, or abnormal digital rectal examination, who are sickly, have a short life expectancy, and have bladder outlet obstruction, prostate puncture biopsy should be performed with the informed consent of the patient or the patient's family to further confirm the diagnosis. On the one hand, both patients and clinicians want clear diagnosis. On the other hand, based on the patient's medical condition, both parties are concerned about over-evaluation and over-diagnosis, which can lead to unnecessary prostate biopsy or over-treatment of clinically meaningless PCa. Advances in medical imaging, especially the popularity of mpMRI, have made it possible to identify suspected prostate cancer early [8]. As a common minimally invasive surgery in urology, prostate biopsy is very important for accurate cancer diagnosis and subsequent treatment. At present, targeted biopsy under direct MRI guidance is expensive, time-consuming and not widely used, while TRUS-guided prostate biopsy, despite its low detection rate, has the advantages of simple operation, low cost and wider accessibility [9]. Therefore, cognitive or software-guided MRI/TRUS fusion prostate puncture biopsy has become the standard diagnostic procedure for MRI-guided biopsy[10, 11]. Therefore, in order to improve the positive rate of puncture biopsy and the detection rate of clinically significant PCa, MRI/TRUS fusion-guided prostate biopsy, as a technique covering targeted sampling of specific suspected lesions, has been widely welcomed by clinicians[12, 13]. In this study, 48 patients underwent transperineal prostate puncture biopsy under the guidance of fusion of mpMRI and TURS after perfecting mpMRI, among which 43 patients were diagnosed with prostate cancer.
At present, the common radical treatment options include radical prostatectomy, radical external radiation therapy and interstitial brachytherapy, but the standard treatment for elderly prostate cancer patients remains unclear[14]. Multiple clinical studies have shown that the incidence of prostate cancer-related death is not high in prostate cancer patients treated conservatively[15–17]. Another view points out that elderly cancer patients should be managed according to their own health status, rather than solely according to age, and healthy elderly patients should receive the same treatment as young patients[14]. In view of the fact that some elderly PCa patients have weak constitution, multiple comorbidities, and short life expectancy, and that the first clinical appeal of most elderly patients is to relieve lower urinary tract obstruction rather than tumor control, patients and their families have taken into account the risks and complications associated with the treatment of PCa by curative means after the clinicians have fully informed the disease treatment plan. Simple treatments with few side effects are often chosen to resolve the patient's difficulty urinating as quickly as possible and minimize the impact on the patient's quality of life. Therefore, assessing patient life expectancy and health status is critical in clinical decision making for screening, diagnosis, and treatment of PCa patients with lower urinary tract obstruction. The development of an individualized comprehensive treatment plan for the patient has become a central step in the treatment of sickly elderly men with prostate cancer.
Although prostate cancer has good biological characteristics and relatively slow disease progression, radical treatment (radical prostatectomy or radical radiation therapy) can show excellent therapeutic effect on early and localized prostate cancer [18, 19]. However, due to the significant heterogeneity of prostate cancer, about 10.7% of patients have metastases when diagnosed with prostate cancer[20]. Clinically, for patients with advanced prostate cancer complicated with lower urinary tract obstruction, palliative transurethral prostate surgery can be performed to relieve lower urinary tract obstruction, and androgen blocking (ADT) or new endocrine drugs can be given after surgery in order to avoid long-term indurating catheter or vesicostomy. The program has become an option for older prostate cancer patients who are sickly, have multiple complications, and have a short life expectancy. However, palliative transurethral surgery for prostate cancer does not conform to the principle of tumor free surgery in theory. At the same time, whether palliative transurethral surgery may lead to tumor spread and overgrowth is still controversial in the academic community for the application of this method in the treatment of advanced prostate cancer patients.
Severe lower urinary tract obstruction leads to the need for long-term indwelling urinary tube or vesicostomy tube, which not only affects the quality of life and psychological status of patients, but also faces the risk of repeated urinary tract infection with frequent indwelling catheter-related complications, which not only requires regular catheter replacement, but also greatly increases the medical burden. Although palliative transurethral surgery can not eradicate prostate cancer, it can effectively relieve the symptoms of urinary tract obstruction and significantly improve the quality of life of patients. Transurethral resection of prostate (TURP) is currently considered to be the preferred treatment for patients with lower urinary tract obstruction caused by benign prostatic hyperplasia[21]. In recent years, with the development of medical equipment, PVP has been widely used in the treatment of lower urinary tract obstruction. The efficacy of PVP is similar to that of TURP, with better hemostatic effect and fewer operative complications than TURP[22]. Therefore, our center conducted perineal prostate biopsy and PVP under the guidance of fusion of mpMRI and TURS for suspected prostate cancer patients at the same time.
In this study, the health status of enrolled patients was evaluated in detail before surgery. For elderly patients with suspected prostate cancer with lower urinary tract obstruction, MRI/TRUS fusion-guided prostate puncture biopsy and PVP were performed at the same time. At the same time of the diagnosis of the patient's disease, transurethral surgery was performed at the same time to solve the symptoms of the patient's dysuria as soon as possible. Among the 48 patients enrolled, a total of 43 were pathologically indicated as prostate acinar adenocarcinoma, and 5 were pathologically indicated as benign prostatic hyperplasia. Because transurethral surgery did not completely vaporize all tumor cells, 36 of the 43 patients with prostate cancer received further treatment such as endocrine therapy and external radiation therapy after surgery, while the remaining 7 patients did not receive further treatment due to early tumors or poor systemic underlying conditions, 3 patients chose active monitoring, and 4 patients chose waiting for observation. Reviewing the clinical data of the 48 enrolled patients, due to the advantages of PVP surgery compared with traditional transurethral electric resection of prostate (TURP), such as less bleeding and faster recovery, prostate puncture biopsy and PVP surgery at the same time did not significantly increase the operative time and blood loss of patients. The IPSS score, QOL score, TPSA and PRV levels of patients at 3 months, 6 months and 12 months after surgery were significantly decreased, while the Qmax level was significantly increased.
Our study has certain limitations. First of all, since this is a retrospective survey of clinical data of patients in a single center, the sample size is small and the follow-up time is short, so a longer follow-up or randomized controlled trial of a large number of patients is needed to draw a clear conclusion. In addition, our study lacked comorbidity analysis. Although the patients in the study maintained good physical condition, at least one comorbidities were common in elderly patients, and the health status of elderly patients with prostate cancer determined the development and implementation of a patient-specific comprehensive treatment plan.