Research Article: Adherence to Guidelines among Italian Urologists on Imaging Preoperative Staging of Low-Risk Prostate Cancer: Results from the MIRROR (Multicenter Italian Report on Radical Prostatectomy Outcomes and Research) Study

Date Published: May 15, 2012

Publisher: Hindawi Publishing Corporation

Author(s): Alchiede Simonato, Virginia Varca, Mauro Gacci, Paolo Gontero, Ottavio De Cobelli, Massimo Maffezzini, Roberto Salvioni, Marco Carini, Andrea Decensi, Vincenzo Mirone, Giorgio Carmignani.


Objective. A number of evidence-based guidelines for diagnosis and management of prostate cancer have been published. The aim of this study is to evaluate the adherence of Italian urologists to the guidelines concerning the preoperative imaging staging of prostate cancer. Methods. In October 2007 a multicentric observational perspective study called Multicentric Italian Report on Radical prostatectomy Outcome and Research (MIRROR) was started in 135 Italian urology centers. Recruitment was closed in December 2008 and 2,408 cases were collected. In this paper we have taken into consideration all examinations carried out for preoperative imaging staging, evaluating compliance with the recommendations in the American Urological Association (AUA) and European Association of Urology (EAU) guidelines. Results. Five hundred sixty-seven (53.34%) patients were not managed according to the EAU guidelines concerning T-staging, 545 (51.27%) concerning N-staging and 757 (71.21%) concerning M-staging. According to AUA guidelines, we also analyzed patients with a Gleason grade of biopsy specimens of 7: 238 (57.35%) of these patients had undergone testing for T staging, 244 (57.35%) for N-staging and 322 (77.60%) for M-staging. Conclusions. The compliance of Italian urologists with the guidelines is low, leading to an inappropriate increase in cost of care and unnecessary anxiety for the patients.

Partial Text

Radical prostatectomy (RP) is an operation which is routinely performed in all Italian urology centers; the indications for this operation vary, and the preoperative workup may also vary from center to center and according to the stage of the disease.

An independent multicenter perspective observational study called MIRROR (Multicenter Italian Report on Radical prostatectomy Outcome and Research) was begun in Italy in October 2007 with the aim of creating a register of the radical prostatectomies carried out, independently of the surgical technique used, collecting as many data as possible on a digital electronic Case Report Form (e-CRF) held by an independent third party Clinical Research Organization (CRO) Clicon srl of Reggio Emilia, Italy. The study was promoted by Leading Urological No profit foundation Advanced research (LUNA), the research foundation of the Italian Urological Association (SIU) which supported the study with an unrestricted grant.

We identified 1,288 patients overall with PSA <20 and Gleason score <6. Among these, we were able to evaluate 1,063 patients. As far as the other 225 patients concern, we do not have data concerning on preoperative staging so we excluded them from the analysis. The average age was 63.2 ± 6.5 years (median 62), ranging from 43 to 74. Preoperative PSA was 6.5 ± 7.2 ng/mL, median 5,8 g/mL. All patients undergone DRE and as regards the clinical stages, 956 patients were classified as T1 (89.9%) and 107 as T2 (10.1%). Preoperative prostate needle biopsy was performed transperineally in 307 (28.9%) patients and transrectally in 756 (71.1%). The Gleason grade of biopsy specimens was 4 in 34 patients (3.19%), 5 in 121 (11.38%), and 6 in 908 (85.42%). A centralized pathological review was not performed. The patients' characteristics are summarized in Table 1. The purpose of the guidelines in general and, therefore, also of the EAU and AUA guidelines is not to be prescriptive as to how a clinician should treat a patient, but rather to provide a guide and an authoritative reference on the most appropriate clinical pathway currently available. The MIRROR study shows that the international guidelines are at present only partially observed by Italian urologists. The important effect of this is an unnecessary and inappropriate increase in cost of care, radiation exposure, and, possibly, unnecessary anxiety for the patients. The reasons for noncompliance may vary, but they should be a matter for study and reflection by the office boards of scientific urological associations.   Source:


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