Morbidity of Prostatic Biopsy for Different Biopsy Strategies: Is There a Relation to Core Number and Sampling Region?

Optimal Number of Systematic Biopsy Cores Used in Magnetic Resonance Imaging/Transrectal Ultrasound Fusion Targeted Prostate Biopsy

Background

In recent years, the effectiveness of magnetic resonance imaging (MRI)-ultrasound fusion targeted biopsy (MRF-TB) has been widely reported. In this study, we assessed the effect of reduction of the number of systematic biopsy (SB) cores on the cancer detection rate (CDR).

Methods

Patients with a high prostate-specific antigen (PSA) level underwent prostate MRI. The Prostate Imaging-Reporting and Data System version 2 (PI-RADS) was then used to rate the lesions. The inclusion criteria were as follows: (1) PSA level between 4.0 and 30.0 ng/mL and (2) patients with one or more lesions on MRI and a PI-RADS score of 3 or more. All enrolled patients were SB naïve or had a history of one or more prior negative SBs. A total of 104 Japanese met this selection criterion. We have traditionally performed 14-core SB following the MRF-TB. In this study, the CDRs of 10-core SB methods, excluding biopsy results at the center of the base and mid-level on both sides, were compared with those of the conventional biopsy method.

Results

We compared CDRs of the 14-core and 10-core SBs used in combination. The overall CDR was 55.8% for the former and 55.8% for the latter, thereby indicating that there was no significant difference (P = 1.00) between the two. In addition, the CDRs of csPCa were 51.9% for the former and 51.1% for the latter, which indicated that there was no significant difference (P = 0.317).

Conclusion

There was no significant difference in the CDR when the number of SB cores to be used in combination was 14 and 10.

Update on Strategies to Reduce Infectious Complications After Prostate Biopsy

CONTEXT

Prostate biopsy is one of the most performed procedures in urology. As a diagnostic procedure it should be of low risk. However, morbidity following prostate biopsy is common due to infectious complications.

OBJECTIVE

To describe how to reduce infectious complications following prostate biopsy. We report on antibiotic and technical interventions to reduce infectious complications.

EVIDENCE ACQUISITION

The data presented are based on a narrative review. Search in PubMed and Medline was performed until May 2018 with a focus on randomised controlled trials and meta-analyses. Articles were reviewed for data on symptomatic infections, hospitalisation, and adverse events.

EVIDENCE SYNTHESIS

Antibiotic prophylaxis is the standard of care. However, the duration of antibiotic preemptive treatment is still under debate. The use of augmented antibiotic prophylaxis as well as targeted antibiotic prophylaxis might be of potential value, but evidence is currently limited. Moreover, no antibiotic class was shown to be clearly superior to another. The evaluation of the technical aspects during prostate biopsy reveals that rectal preparation with povidone-iodine is clearly effective to reduce infectious complications. Transperineal biopsy has a potential benefit to reduce infectious complications, but powerful randomised controlled studies are missing. Finally, the number of biopsy cores, the application of periprostatic nerve block, or the use of a cleansing enema has no impact on prostate biopsy in terms of infectious complications.

CONCLUSIONS

The available data only suggest that rectal preparation with povidone-iodine as well as antibiotic prophylaxis is of significant advantage to reduce infectious complications following prostate biopsy. The augmented and targeted antibiotic prophylaxis shows some potential, but need further validation.

PATIENT SUMMARY

In this review we evaluate the best management strategy to prevent infectious complications following prostate biopsy. We show that antibiotic prophylaxis is essential for prostate biopsy and that rectal preparation with povidone-iodine is mandatory.

Marked Prognostic Impact of Minimal Lymphatic Tumor Spread in Prostate Cancer

BACKGROUND

Nodal metastasis (N1) is a strong prognostic parameter in prostate cancer; however, lymph node evaluation is always incomplete.

OBJECTIVE

To study the prognostic value of lymphatic invasion (L1) and whether it might complement or even replace lymph node analysis in clinical practice.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of pathological and clinical data from 14 528 consecutive patients.

INTERVENTION

Radical prostatectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The impact of L1 and N1 on patient prognosis was measured with time to biochemical recurrence as the primary endpoint.

RESULTS AND LIMITATIONS

Nodal metastases were found in 1602 (12%) of 13 070 patients with lymph node dissection. L1 was seen in 2027 of 14 528 patients (14%) for whom lymphatic vessels had been visualized by immunohistochemistry. N1 and L1 continuously increased with unfavorable Gleason grade, advanced pT stage, and preoperative prostate-specific antigen (PSA) values (p<0.0001 each). N1 was found in 4.3% of 12 501 L0 and in 41% of 2027 L1 carcinomas (p<0.0001). L1 was seen in 11% of 9868 N0 and in 61% of 1360 N1 carcinomas (p<0.0001). Both N1 and L1 were linked to PSA recurrence (p<0.0001 each). This was also true for 17 patients with isolated tumor cells (ie, <200 unequivocal cancer cells without invasive growth) and 193 metastases ≤1mm. Combined analysis of N and L status showed that L1 had no prognostic effect in N1 patients but L1 was strikingly linked to PSA recurrence in N0 patients. N0L1 patients showed a similar outcome as N1 patients.

CONCLUSIONS

Analysis of lymphatic invasion provides comparable prognostic information than lymph node analysis. Even minimal involvement of the lymphatic system has pivotal prognostic impact in prostate cancer. Thus, a thorough search for lymphatic involvement helps to identify more patients with an increased risk for disease recurrence.

PATIENT SUMMARY

Already minimal amounts of tumor cells inside the lymph nodes or intraprostatic lymphatic vessels have a severe impact on patient prognosis.

Complications of transrectal ultrasound-guided 12-core prostate biopsy: a single center experience with 2049 patients

OBJECTIVE

Currently, transrectal ultrasound-guided (TRUS) systematic prostate biopsy is the standard procedure in the diagnosis of prostate cancer. Although TRUS-guided prostate biopsy is a safe method, it is an invasive procedure that is not free from complications. In this prospective study we evaluated the complications of a TRUS-guided 12-core prostate biopsy.

MATERIAL AND METHODS

The study included 2049 patients undergoing transrectal ultrasound-guided 12-core prostate biopsy used in the diagnosis of prostate cancer. The indications for the prostate biopsy were abnormal digital rectal examination findings and/or an elevated serum total prostate specific antigen (PSA) level (greater than 4 ng/mL). The participants received prophylactic oral ciprofloxacin (500 mg) the night before and the morning of the biopsy, followed by 500 mg orally twice daily for 2 days. To prevent development of voiding disorders, the patients also received oral alpha blockers for 30 days starting the day before the procedure. A Fleet enema was self-administered the night before the procedure for rectal cleansing. The complications were assessed both 10 days and 1 month after the biopsy.

RESULTS

The mean age, serum total PSA level and prostate volume of the patients were 65.4±9.6 years, 18.6±22.4 ng/mL and 51.3±22.4 cc, respectively. From these 2.042 biopsies, 596 cases (29.1%) were histopathologically diagnosed as prostate adenocarcinoma. Minor complications, such as hematuria (66.3%), hematospermia (38.8%), rectal bleeding (28.4%), mild to moderate degrees of vasovagal episodes (7.7%), and genitourinary tract infection (6.1%) were noted frequently. Major complications were rare and included urosepsis (0.5%), rectal bleeding requiring intervention (0.3%), acute urinary retention (0.3%), hematuria necessitating transfusion (0.05%), Fournier's gangrene (0.05%), and myocardial infarction (0.05%).

CONCLUSION

TRUS-guided prostate biopsy is safe for diagnosing prostate cancer with few major but frequent minor complications. However, patients should be informed and followed-up after biopsy regarding possible complications.

Transrectal prostate biopsy

Grayscale transrectal ultrasonographic prostate biopsy using local anesthesia remains the standard approach to the definitive diagnosis of prostate cancer. Careful patient evaluation and preparation are essential to maximize the results and minimize the complications of the biopsy procedure.

The Prostate Cancer Detection Rate on the Second Prostate Biopsy according to Prostate-Specific Antigen Trend

Purpose

To identify the prostate cancer detection rate on the patients who had second prostate biopsy out of the patients who were reported negative in their first biopsy.

Materials and Methods

From July 2006 to February 2012, prostate biopsy was performed on 843 patients with over 4 ng/ml and on 618 biopsy negative patients PSA was performed from between 6 months and 9 months after biopsy. On 164 patients, second biopsy was performed, and 42 patients were selected. If there was less than 10% change between PSA before the prostate biopsy and PSA measured during 6 to 9 months after the first biopsy it was considered as no change. If above 10% increase, it was considered increase and if above 10% decrease it was considered as decrease.

Results

The cancer detection rate in PSA increase group was 20%, the detection rate in no change in PSA level but still over the normal range group 8.3%, and that in the PSA decrease group was 0%. When comparing prostate cancer group and non-cancer group, it is more probable to have prostate cancer when they are older, prostate volume is smaller and PSA density is higher.

Conclusions

The second biopsy is strongly recommended when PSA level shows no change or increase, age is older, prostate volume is smaller or PSA density is higher.

Antibiotic prophylaxis for transrectal prostate biopsy

BACKGROUND

Transrectal prostate biopsy (TRPB) is a well established procedure used to obtain tissue for the histological diagnosis of carcinoma of the prostate. Despite the fact that TRPB is generally considered a safe procedure, it may be accompanied by traumatic and infective complications, including asymptomatic bacteriuria (bacteria in the urine), urinary tract infection (UTI), transitory bacteremia (bacteria in the blood), fever episodes, and sepsis (pathogenic microorganisms or their toxins in the blood). Although infective complications after TRPB are well known, there is uncertainty about the necessity and effectiveness of routine prophylactic antibiotics and their adverse effects, as well as a clear lack of standardization.

OBJECTIVES

To evaluate the effectiveness and adverse effects of prophylactic antibiotic treatment in TRPB.

SEARCH STRATEGY

The search covered the principal electronic databases: MEDLINE, EMBASE, LILACS and the Cochrane Central Register of Controlled Trials (CENTRAL). Experts were consulted and references from the relevant articles were scanned.

SELECTION CRITERIA

All randomized, controlled trials (RCTs) of men who underwent TRPB and received prophylactic antibiotics or placebo/no treatment, were selected, and all RCTs looking at one type of antibiotic versus another, including comparable dosages, routes of administration, frequency of administration, and duration of antibiotic treatment.

DATA COLLECTION AND ANALYSIS

Two reviewers (ELZ, OACC) independently selected included trials and extracted study data. Any disagreements were resolved by a third party (NRNJ).

MAIN RESULTS

Overall, more than 3500 references were considered and 19 original reports with a total of 3599 patients were included.There were 9 trials analysing antibiotics versus placebo/no treatment, with all outcomes significantly favouring antibiotic use (P < 0.05) (I(2) = 0%), including bacteriuria (risk ratio (RR) 0.25 (95% confidence interval (CI) 0.15 to 0.42), bacteremia (RR 0.67, 95% CI 0.49 to 0.92), fever (RR 0.39, 95% CI 0.23 to 0.64), urinary tract infection (RR 0.37, 95% CI 0.22 to 0.62), and hospitalization (RR 0.13, 95% CI 0.03 to 0.55). Several classes of antibiotics were effective prophylactically for TRPB, while the quinolones, with the highest number of studies (5) and patients (1188), were the best analysed. For 'antibiotics versus enema', we analysed four studies with a limited number of patients. The differences between groups for all outcomes were not significant. For 'antibiotic versus antibiotic + enema', only the risk of bacteremia (RR 0.25, 95% CI 0.08 to 0.75) was diminished in the 'antibiotic + enema group'. Seven trials reported the effects of short-course (1 day) versus long-course (3 days) antibiotics. Long course was significantly better than short-course treatment only for bacteriuria (RR 2.09, 95% CI 1.17 to 3.73). For 'single versus multiple dose', there was significantly greater risk of bacteriuria for single-dose treatment (RR 1.98, 95% CI 1.18 to 3.33). Comparing oral versus systemic administration - intramuscular injection (IM), or intravenous (IV) - of antibiotics, there were no significant differences in the groups for bacteriuria, fever, UTI and hospitalization.

AUTHORS' CONCLUSIONS

Antibiotic prophylaxis is effective in preventing infectious complications following TRPB. There is no definitive data to confirm that antibiotics for long-course (3 days) are superior to short-course treatments (1 day), or that multiple-dose treatment is superior to single-dose.

A prospective, randomized trial comparing the Vienna nomogram to an eight-core prostate biopsy protocol

OBJECTIVE

• To compare prostate cancer detection rates using the Vienna nomogram versus an 8-core prostate biopsy protocol. To compare the complication rates of transrectal prostate biopsy in the two groups.

PATIENTS AND METHODS

• In a prospective randomized trial, men with a serum PSA ≥ 2.5 ng/ml were stratified according to serum PSA (I = PSA 2.5-10; II = PSA 10.1-30; III = PSA 30.1-50 ng/mL) and were then randomized to group A (number of cores determined according to the Vienna nomogram) or group B (8-core prostate biopsy). • Statistical analysis was performed using Student's t-test for parametric data, Mann-Whitney test for nonparametric data and Fisher's exact test for contingency tables. A two-tailed p-value <0.05 was accepted as statistically significant.

RESULTS

• In the period July 2006 to July 2009, 303 patients were randomized to group A (n = 152) or group B (n = 151). There were no significant differences in serum PSA, prostate volume, PSA density or post-biopsy complications between the groups. • The cancer detection rate was lower in group A than in group B for the whole study cohort (35.5% vs 38.4%), for those with PSA < 10 ng/ml (28.1% vs 33%) and for those with prostate volume >50 ml (22% vs 25.8%). These differences were not statistically significant (NSS).

CONCLUSION

• These findings suggest that there is no significant advantage in using the Vienna nomogram to determine the number of prostate biopsy cores to be taken, compared to an 8-core biopsy protocol.

Prostate biopsy in selecting candidates for hemiablative focal therapy

Focal therapy (FT) for the management of clinically localized prostate cancer (PCa) is growing from a concept to reality because of increased interest of both patients and physicians. Selection protocols, however, are yet to be established. We discuss the role of prostate biopsy in candidate selection for FT and highlight the different strategies and technical aspects of the use of prostate biopsy in this setting. In our opinion, prostate biopsy plays a major role in the selection process and tailoring appropriate treatment strategy to the patient. FT necessitates dedicated biopsy schemes that would reliably predict the extent, nature, and location of PCa in selected patients. Currently, there is insufficient scientific evidence to propose a specific biopsy scheme that could fit every candidate, providing accurate characterization of the disease in the individual patient. Further research is necessary to establish solid selection protocols that would reliably identify appropriate candidates for FT of PCa.

Effect of the number of biopsy cores on prostate cancer detection and staging

Digital rectal examination, serum concentration of prostate cancer-specific antigen and transrectal ultrasound-guided biopsies are currently the main diagnostic tools to detect evidence of prostate cancer. Different prostatic biopsy strategies have been proposed in order to achieve an optimal prostate cancer detection rate and an accurate characterization of prostate cancer stage and grade. We examined the role of the number of biopsy cores on prostate cancer detection rates at initial and repeat biopsies. Moreover, we examined the relationship between the number of biopsy cores and the detection of insignificant prostate cancer. Finally, we reviewed the ability of biopsy cores in predicting prostate cancer stage and grade at radical prostatectomy. We relied on a PubMed systematic review of the contemporary English language literature using the terms ‘prostate cancer’, ‘diagnosis’, ‘transrectal ultrasound’ and ‘prostate biopsy’.

Antibiotic Prophylaxis in Prostate Biopsy

Introduction

Prostate biopsy is nowadays one of the most frequent diagnostic procedures in urology. The incidence of bacteraemia, bacteriuria and infective complications is higher after the transrectal procedure than after the transperineal one. A survey demonstrated that 98% of the urologists in USA use antibiotics to prevent infective complications. The transrectal prostate biopsy is the only diagnostic intervention procedure in urology for which an antibiotic prophylaxis is recommended, also for low-risk patients, by the guidelines of the European Association of Urology. If the perineal route is adopted, the antibiotic prophylaxis is recommended only in high-risk patients.

Materials and Methods

The patient should preferably receive an evacuative enema to achieve a rectal cleansing and to ameliorate the diagnostic accuracy of transrectal ultrasound. A survey in the US demonstrated that an evacuative enema with saline solution is adopted by more than 80% of urologists. Criteria for antibiotics choice. The majority of bacteraemias are transitory, asymptomatic and self-limiting. On the other side, bacteriuria can persist for several days. Antibiotics must achieve high drug concentrations not only in plasma and tissue but also in urine. Symptomatic infections are generally caused by E. Coli and less frequently by the Streptococcus faecalis. Nevertheless, other agents as Klebsiella and Chlostridium, although rare, might cause severe infections. Thus, prophylaxis needs antibiotics at large spectrum and a single agent may not be enough for high-risk patients. Risk determination and drug schedules. It is essential to point out the infective risk of the patient. The choice of the drug, the timing and schedule of antibiotic prophylaxis are still object of debate. Several randomized studies have been conducted with contradictory results.

Results

The antibiotic prophylaxis should be tailored according to patients’ infective risk and to the procedure adopted. It is able to reduce infections rate after transrectal biopsy below 5%. The adoption of periprostatic anesthesia and the number of cores can influence the incidence of infective complications. Commonly, one-three days oral administration of fluoroquinolone is adopted. A single-dose prophylaxis can be also used with favorable results. Tolerability and route of administration should be taken into account, and also costs should be considered.

Conclusions

Considering the low cost of antibiotics adopted as short-term prophylaxis and the high cost of the treatment of infective complications, it seems reasonable to provide antibiotics prophylaxis for all patients at high risk for infective complications and for all cases submitted to transrectal prostate biopsy.

Screening: should more biopsies be taken in larger prostates?

OBJECTIVE

To assess the number of missed prostate cancers and the frequency of aggressive disease when taking lateralized sextant prostate biopsies, irrespective of the total prostate volume (Pvol), during screening for prostate cancer.

SUBJECTS AND METHODS

Men participating in the European Randomized Study of Screening for Prostate Cancer, Rotterdam section, aged 55-74 years, with a prostate-specific antigen (PSA) level of ≥3.0 ng/mL, and a negative sextant biopsy result at the initial screening round, were followed for 8 years. Cases of prostate cancer detected during the follow-up by screening, or detected clinically as interval cancers, were assessed. Pvol at the initial screening round was related to the number of cancers found during the follow-up. Furthermore, the frequency of aggressive cancer (N1 or M1, PSA >20 ng/mL, Gleason >7) was evaluated using multivariate logistic regression analysis, including age, PSA level and Pvol.

RESULTS

In the total of 1305 men, 152 prostate cancers were detected during 8 years of follow-up (11.6%); 23 were classified as aggressive (15.1%), and 50 (32.9%) were detected as interval cancers. There was a significant relation between a larger Pvol at the initial screening round and fewer cancers (odds ratio 0.1, P < 0.001). In multivariate logistic regression, the initial PSA level (odds ratio 3.21, 95% confidence interval, CI 1.2-8.3) and smaller Pvol (0.08, 95% CI 0.03-0.26) were statistically significant predictors for all cancers and aggressive cancers (PSA odds ratio 70.37, 95% CI 13.5-366.2; Pvol odds ratio 0.03, 95% CI 0.01-0.35).

CONCLUSIONS

Men with a smaller Pvol and an initially high PSA level were at greater risk of cancer detection and of an aggressive cancer during the follow-up. The use in clinical practice of volume-adjusted biopsy schemes should not be implemented automatically in screening programmes with repeated screening.

Complication rates of ultrasound-guided prostate biopsy: a nation-wide survey in Japan

OBJECTIVE

To assess the morbidity secondary to ultrasound-guided systematic prostate biopsy in Japan.

METHODS

Five hundred and forty-eight principal urological training institutions certified by the Japanese Urological Association participated in the survey. A retrospective analysis of complications after prostate biopsy was conducted.

RESULTS

Medical records of 212 065 procedures carried out between 2004 and 2006 were reviewed. Seventy-six percent of procedures had been carried out transrectally, and 23% transperineally. Hematuria, rectal bleeding and hematospermia occurred in 12%, 5.9% and 1.2% of cases, respectively. Voiding symptoms were reported after biopsy in 1.9% of cases and urinary retention in 1.1%. Fever (>38 degrees C) was observed in 1.1% and sepsis occurred in 0.07%. Hospitalization was required in 0.69% of cases for the treatment of biopsy-related complications.

CONCLUSIONS

Overall, contemporary ultrasound-guided systematic prostate biopsy is safely carried out in Japan. However, minor complications are not infrequent, whereas major ones remain very rare but life-threatening if they occur. Thus, adequate information should be provided to patients undergoing prostate biopsy.

The morbidity of transperineal template-guided prostate mapping biopsy

OBJECTIVE

To evaluate the effect of transperineal template-guided prostate mapping biopsy (TTMB) on urinary, bowel and erectile function.

PATIENTS AND METHODS

In all, 129 men had TTMB; a median of 56 biopsy cores were obtained per patient. Tamsulosin (0.8 mg daily) was initiated 2 days before TTMB and continued for 2 weeks. The International Prostate Symptom Score (IPSS), Rectal Function Assessment Score (R-FAS), International Index of Erectile Function (IIEF)-6 and the postvoid residual volume (PVR) were assessed at baseline and after 30 days, except for the IPSS, which was also assessed at 7 days. Several variables were evaluated as predictors of TTMB-induced morbidity.

RESULTS

The mean patient age was 64.7 years with a mean prostate volume of 74.3 mL; 60 men (46.5%) were diagnosed with prostate cancer. After TTMB, 39.4%, 7.1% and 1.6% of patients remained catheter-dependent at 0, 3 and 6 days. The median catheter-dependency was 0, 1, 2 and 3 days for prostate volumes of <60, 60-90, 90-120 and >120 mL, respectively. No patient remained catheter- dependent for >12 days or required a transurethral resection secondary to TTMB. The mean IPSS before TTMB was 10.4, and was 4.6 and 3.8 at 7 and 30 days. At baseline and 30 days the mean PVR was 35 and 40 mL, and the median R-FAS and IIEF scores for patients potent before TTMB were 2.0 and 2.2, and 27.0 and 26.0, respectively.

CONCLUSIONS

TTMB is a promising procedure for diagnosing prostate cancer. TTMB-related morbidity differs from that of standard TRUS biopsy primarily in the incidence of temporary urinary retention, and is comparable in terms of urinary, bowel and erectile function.

Transperineal ultrasound-guided saturation biopsies using 11-region template of prostate: report of 303 cases

OBJECTIVES

To assess the prostate cancer detection rate and safety of transperineal ultrasound-guided saturation biopsies of the prostate using an 11-region template of the gland in a Chinese screening population.

METHODS

A total of 303 patients (mean age, 69.7 years) were prospectively enrolled in this study to undergo an 11-region template-guided transperineal saturation biopsy of the prostate. The inclusion criteria included a prostate-specific antigen level of 4.0 ng/mL or greater, suspicious findings on the digital rectal examination, or abnormal prostate gland findings on ultrasonography, computed tomography, or magnetic resonance imaging. The median prostate-specific antigen level was 13.7 ng/mL (range, 0.2 to 100), and the median prostate volume was 47.0 cm3 (range, 7 to 190).

RESULTS

A mean of 23.7 cores (range, 11 to 44) were obtained, with an overall prostate cancer detection rate of 37.6% (114 of 303). The cancer detection rate in the groups with a prostate-specific antigen level of 0 to 4.0, 4.1 to 10.0, 10.1 to 20.0, 20.1 to 30.0, 30.1 to 70.0, and greater than 70.1 ng/mL was 22.2% (4 of 18), 8.2% (6 of 73), 21.6% (22 of 102), 48.4% (15 of 31), 68.4% (26 of 38), and 100% (41 of 41), respectively. No serious complications occurred during the procedure.

CONCLUSIONS

Transperineal ultrasound-guided saturation biopsy of the prostate is safe and feasible. Moreover, the application of an 11-region template of the prostate resulted in an encouraging cancer detection rate.

Individualized prostate biopsy strategy for Chinese patients with different prostate-specific antigen levels

AIM

To evaluate the best individualized prostate biopsy strategies for Chinese patients with suspected prostate cancer.

METHODS

The present study included 221 Chinese patients who underwent transrectal ultrasound guided prostate biopsies for the first time. All patients underwent the same 10-core biopsy protocol. In addition to the Hodge sextant technique, four more biopsies were obtained from the base and middle regions of bilateral peripheral zones. The differences between 10-core and sextant strategies in cancer detection among patients with different prostate specific antigen (PSA) levels were evaluated. The relationship between PSA level, number of positive biopsy cores and organ-confined cancer rate in prostate cancer patients was also analyzed.

RESULTS

The overall prostate cancer detection rate was 40.7% in the 221 patients. The 10-core strategy increased cancer detection by 6.67% (6/90) in our patients (P < 0.05). The increased cancer detection rates decreased significantly when the patient PSA level increased from 0-20 ng/mL to 20.1-50 ng/mL and > 50 ng/mL (P < 0.01). The number of positive biopsy cores in prostate cancer patients increased significantly with increasing patient PSA level (P < 0.01). The rate of organ-confined prostate cancer decreased significantly with increasing patient PSA level (P < 0.01).

CONCLUSION

The extended 10-core strategy is recommended for Chinese patients with PSA = or < 20 ng/mL and the sextant strategy is recommended for those with PSA > 50 ng/mL. For patients with PSA ranging from 20.1 ng/mL to 50 ng/mL, the 10-core strategy should be applied in patients with life expectancy = or > 10 years and the sextant strategy should be applied in those with life expectancy < 10 years.

Factors influencing pain during transrectal ultrasonography-guided prostate biopsy

We prospectively investigated the clinical parameters that influenced pain during prostate biopsies. From 12 hospitals 1781 patients were enrolled. The patients completed a visual analogue scale questionnaire for the pain during the procedure. Age, enema preparation, analgesia use and number of biopsy punctures influenced the level of pain during prostate biopsy in univariate linear regression analysis. However, multivariate analysis showed enema preparation, analgesia use and number of biopsy punctures were independent factors associated with the pain during the procedure. Our study confirmed enema preparation before biopsy and the number of biopsy punctures were associated with the pain during prostate biopsy.

Endoscopic therapy of a massive rectal bleeding after prostate biopsy

We report on the case of a 65-year-old man with an indication for a transrectal multibiopsy of the prostate based on a PSA value of 4.5 ng/ml. A massive haemoglobin effective rectal bleeding occurred post-intervention, which due to haemodynamic instability required the administration of erythrocyte concentrates. Both manual compression and rectal tamponade failed to stop the bleeding, and immediate haemostasis was achieved through an endoscopic injection of adrenaline. We present this case in detail and additionally describe current data on the complications of the ultrasound-guided transrectal biopsy of the prostate and the options for treating the fulminant rectal bleeding that is a consequence of this procedure.

Hematospermia: imaging findings

Hematospermia is an anxiety provoking but otherwise generally benign and self-limited condition that is infrequently associated with significant underlying pathology, and is most often considered to be idiopathic in nature. Management with routine clinical evaluation, watchful waiting, and reassurance generally suffice without further diagnostic workup or treatment. Noninvasive imaging may play an important role in the diagnostic workup of men with hematospermia, particularly in those who are >40 years old, have other associated symptoms or signs of disease, or have persistence of hematospermia. Many entities may be encountered in association with hematospermia at imaging, and specific therapeutic interventions may be used if certain treatable underlying pathologies are coincidentally detected. In this comprehensive review, we discuss the potential etiologies, diagnostic workup, imaging techniques, relevant male pelvic anatomy, imaging appearance of specific associated pathologies, and treatment for hematospermia.

Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: a systematic review

PURPOSE

Several new extended prostate biopsy schemes (greater than 6 cores) have been proposed. We compared the cancer detection rates and complications of different extended prostate biopsy schemes for diagnostic evaluation in men scheduled for biopsy to identify the optimal scheme.

MATERIALS AND METHODS

In a systematic review we searched 13 electronic databases, screened relevant urological journals and the reference lists of included studies, and contacted experts. We included studies that compared different systematic prostate biopsy methods using sequential sampling or a randomized design in men scheduled for biopsy due to suspected prostate cancer. We pooled data using a random effects model when appropriate.

RESULTS

We analyzed 87 studies with a total of 20,698 patients. We pooled data from 68 studies comparing a total of 94 extended schemes with the standard sextant scheme. An increasing number of cores were significantly associated with the cancer yield. Laterally directed cores increased the yield significantly (p = 0.003), whereas centrally directed cores did not. Schemes with 12 cores that took additional laterally directed cores detected 31% more cancers (95% CI 25 to 37) than the sextant scheme. Schemes with 18 to 24 cores did not detect significantly more cancers. Adverse events for schemes up to 12 cores were similar to those for the sextant pattern. Adverse event reporting was poor for schemes with 18 to 24 cores.

CONCLUSIONS

Prostate biopsy schemes consisting of 12 cores that add laterally directed cores to the standard sextant scheme strike the balance between the cancer detection rate and adverse events. Taking more than 12 cores added no significant benefit.

Comparison of Gleason grade and score between preoperative biopsy and prostatectomy specimens in prostate cancer

AIM

Although the histopathological findings obtained from biopsy specimens are important for choosing the appropriate management of prostate cancer, there have been some discrepancies in Gleason grade and consequently, score between biopsy and surgical specimens. A comparison of findings between these two kinds of specimens was performed.

METHODS

Radical prostatectomy was performed at Asahi General Hospital on 223 cases of T1b-T3 without previous cancer treatment, and the Gleason grade and score of the biopsy and surgical specimens were compared.

RESULTS

A 37% coincidence in Gleason score was obtained between biopsy and surgical specimens; coincidence including one digit difference in score was approximately 70%. Upgrading was more than downgrading. Disagreement in secondary grade was greater than that in primary grade. Disagreement in Gleason score was roughly similar among different score items and was not influenced by level of prostate-specific antigen, however, the small volume of the cancer tissues more affected the discrepancy in score.

CONCLUSION

The use of biopsy findings is required to be taken into account regarding the discrepancy.

Role of transperineal six-core prostate biopsy in patients with prostate-specific antigen level greater than 10 ng/mL and abnormal digital rectal examination findings

OBJECTIVES

To define whether six-core biopsies still have a role in patients presenting with prostate-specific antigen (PSA) levels greater than 10 ng/mL and abnormal digital rectal examination (DRE) findings. Recent studies have suggested that the six-core biopsy is inadequate for the diagnosis of prostate cancer; however, it remains controversial whether an increased number of cores is justified in all patients.

METHODS

From June 2002 to February 2005, 122 (18.8%) of 650 patients underwent prostate biopsy because of a PSA level greater than 10 ng/mL and abnormal DRE findings. All patients underwent transperineal ultrasound-guided prostate biopsy in a standardized fashion: a six-core biopsy was performed first, followed by six additional cores during the same session, four in the peripheral and two in the transition zone.

RESULTS

The detection rate in patients with a PSA level greater than 10 ng/mL and abnormal DRE findings was 72.1% (88 of 122) and 75.4% (92 of 122) using the 6-core and 12-core biopsy, respectively. One case of tumor was missed by the six-core biopsy among patients with a PSA level greater than 15 ng/mL and abnormal DRE findings. No cases of tumor were missed by six-core biopsy in the group with a PSA level greater than 20 ng/mL and abnormal DRE findings.

CONCLUSIONS

Six-core biopsy provided a similar cancer detection rate compared with 12-core biopsy in patients with PSA levels greater than 10 ng/mL and abnormal DRE findings. An initial approach with 6-core biopsy is reasonable in patients with a PSA level greater than 10 ng/mL and abnormal DRE findings and is advocated in those with PSA greater than 20 ng/mL and abnormal DRE findings.

Patients' tolerance and early complications of transrectal sonographically guided prostate biopsy: prospective study of 300 patients

PURPOSE

To determine the degree of pain and discomfort associated with transrectal sonography (TRS)-guided biopsy of the prostate and to analyze the complications associated with this procedure.

METHODS

Three hundred men referred as part of an investigation to exclude prostate cancer were studied. The reasons for referral were suspected prostate cancer due to increased serum prostate-specific antigen level (>4 ng/ml), the finding of a palpable nodule or greater firmness of one prostatic lobe than the other on digital rectal examination, or the finding of a suspicious area of neoplasm of the prostate on TRS biopsy. All TRS-guided biopsies were performed as outpatient procedures without anesthesia. Ciprofloxacin prophylaxis was used in all patients before biopsy. Tolerance of the procedure was recorded immediately after the examination and graded on a scale of 0-4 as follows: 0, no pain; 1, very mild pain; 2, moderate pain; 3, severe pain; 4, intolerable pain. Complications recorded in the first week after the procedure were analyzed. They included mild pain, self-limiting hematuria, hematospermia, rectal bleeding, severe hematuria, septicemia, severe hemorrhage of the anus, and vasovagal attack.

RESULTS

Out of 300 TRS-guided biopsies, 10 early complications were recorded. The most frequent was septicemia, which was seen in 5 cases (1.7%). Hematuria occurred in 29 patients, 3 of which were severe. Rectal bleeding and vasovagal attack occurred in 1 patient each. All patients made a full recovery with appropriate conservative management. Ten cases (3.33%) of severe pain (grade 3) and intolerable pain (grade 4) were observed. Three out of these 10 patients completed the procedure. The procedure was terminated in 1 patient, and 6 patients required local anesthetic due to perianal disease.

CONCLUSIONS

TRS-guided prostate biopsy can be performed without local anesthesia in 90% of patients. Prophylactic antibiotics are mandatory to minimize approximately infectious complications.

Ultrasound-guided transrectal extended prostate biopsy: a prospective study

AIM

To evaluate the diagnostic value of the 10 systematic transrectal ultrasound-guided (TRUS) prostate biopsy compared with the sextant biopsy technique for patients with suspected prostate cancer.

METHODS

One hundred and fifty-two patients with suspected prostate cancer were included in the study. Patients were entered in the study because they presented with high levels of prostate specific antigen (PSA) (over 4 ng/mL) and/or had undergone an abnormal digital rectal examination (DRE). In addition to sextant prostate biopsy cores, four more biopsies were obtained from the lateral peripheral zone with additional cores from each suspicious area revealed by transrectal ultrasound. Sextant, lateral peripheral zone and suspicious area biopsy cores were submitted separately to the pathological department.

RESULTS

Cancer detection rates were 27.6% (42/152) and 19.7% (30/152) for the 10-core and sextant core biopsy protocols, respectively. Adding the lateral peripheral zone (PZ) to the sextant prostate biopsy showed a 28.6% (12/42) increase in the cancer detection rate in patients with positive prostate cancer (P < 0.01). The cancer detection rate in patients who presented with elevated PSA was 29.3% (34/116). When serum PSA was 4-10 ng/mL TRUS-guided biopsy detected cancer in 20.6%, while the detection rate was 32.4% and 47.0% when serum PSA was 10-20 ng/mL and above 20 ng/mL, respectively.

CONCLUSION

The 10 systematic TRUS-guided prostate biopsy improves the detection rate of prostate cancer by 28.6% when compared with the sextant biopsy technique alone, without increase in the morbidity. We therefore recommend the 10-core biopsy protocol to be the preferred method for early detection of prostate cancer.

Molecular biomarker in prostate cancer: the role of CpG island hypermethylation

CpG island hypermethylation may be one of the earliest somatic genome alterations to occur during the development of multiple cancers. Recently, aberrant methylation patterns for different tumors have been reported. We present a comprehensive review of the literature describing the role of CpG island hypermethylation of DNA from prostatic tissue and bodily fluids from men with prostate cancer. We reviewed the literature to evaluate CpG island hypermethylation in tissue and bodily fluids of men with primary and metastatic prostate cancer. Additionally, we reviewed the literature with respect to CpG island hypermethylation patterns in other urological malignancies. Using modern analytic methods, CpG island hypermethylation detection can be achieved. In men with prostate cancer, correlations between specific gene regulatory region hypermethylation analyses and Gleason score, pathologic stage and tumor recurrence have been demonstrated. CpG island hypermethylation may serve as a useful molecular biomarker for the detection and diagnosis of patients with prostate cancer.