Infectious complications and hospital admissions after prostate biopsy in a European randomized trial

Preventing Infections After Prostate Biopsy: Prophylactic Antibiotics, Prebiopsy Rectal Culture, and Biopsy Approach

Prostate biopsies are commonly performed for the early detection of prostate cancer and yet are associated with risks of life-threatening infections. Drug-resistant strains of Escherichia coli are the most common etiologic agents. Multiple maneuvers can reduce the risk of postbiopsy infections and sepsis during transrectal prostate biopsy including periprocedural empiric or targeted prophylactic antibiotics (based on previous rectal culture) and prebiopsy rectal cleansing with a povidone-iodine solution. The transperineal approach is associated with a very low risk of infection without requiring antibiotic prophylaxis.

Risk Factors for Infection After Transrectal Prostate Biopsy: A Population-based Register Study

Background and objective

Infection after transrectal prostate biopsy (TPBx) is a well-known risk. A comprehensive investigation of risk factors may identify measures for safe TPBx as an alternative to a change in biopsy route. The aim of this study was to identify risk factors for infection after TPBx.

Methods

We included all outpatient TPBx cases in Region Kronoberg, Sweden, from January 2010 to December 2019. The primary outcome was post-TPBx infection, defined as prescription of antibiotics indicated for urinary tract infection (UTI) or inpatient care for infection within 30 d. We analysed the following factors in relation to post-TPBx infection: age, diabetes mellitus, prostate cancer diagnosed at index biopsy, previous prostate biopsy, two or more biopsies in the past 24 mo, a positive urine culture, two or more negative urine cultures (UCs) in the past 24 mo, antibiotic treatment grouped as four types, and medication for benign prostatic hyperplasia (BPH). Logistic regression was used to calculate odds ratios (ORs).

Key findings and limitations

Of 5788 TPBx procedures in 4040 patients, 405 (7.0%) led to an infection and 170 (2.9%) to inpatient care for infection. Risk factors for post-TPBx infection (ORs 1.5-2.5) were diabetes mellitus, antibiotic treatment for a UTI, fluoroquinolone treatment, and a positive urine culture. Weaker risk factors (ORs 1.3-1.5) were non-UTI antibiotic treatment, BPH medication, and negative UCs before TPBx.

Conclusions and clinical implications

Our results confirm that diabetes mellitus and previous UTI are risk factors for infection after TPBx. Lower urinary tract symptoms and treatment with any kind of antibiotic were associated with infection, which has not been previously reported.

Patient summary

In a large population-based study from Sweden, we investigated which clinical factors increase the risk of an infection after transrectal prostate biopsy. Our results confirm that diabetes and a previous urinary tract infection are risk factors. We also found two new factors associated with the risk of infection after biopsy: lower urinary tract symptoms and any antibiotic treatment.

Histopathological concordance between prostate biopsies and radical prostatectomy specimens-implications of transrectal and transperineal biopsy approaches

BACKGROUND

This study aimed to evaluate the histopathological concordance rates between prostate biopsies and radical prostatectomy specimens according to the applied biopsy approach (transrectal or transperineal).

METHODS

We studied patients who had been newly diagnosed with clinically significant prostate cancer and who underwent a radical prostatectomy between 2018 and 2022. Patients were included if they underwent a prebiopsy magnetic resonance imaging and if they had not been previously treated for prostate cancer. Histopathological grading on prostate biopsies was compared with that on radical prostatectomy specimens. Univariable and multivariable logistic regression analyses were performed to assess the effect of the applied biopsy approach on histopathological concordance. Additional analyses were performed to assess the effect of the applied biopsy approach on American Urological Association risk group migration, defined as any change in risk group after radical prostatectomy.

RESULTS

In total, 1058 men were studied, of whom 49.3% (522/1058) and 50.7% (536/1058) underwent transrectal and transperineal prostate biopsies, respectively. Histopathological disconcordance was observed in 37.8% (400/1058) of men while American Urological Association risk group migration was observed in 30.2% (320/1058) of men. A transperineal biopsy approach was found to be independently associated with higher histopathological concordance rates (OR 1.33 [95% CI 1.01-1.75], p = 0.04) and less American Urological Association risk group migration (OR 0.70 [95% CI 0.52-0.93], p = 0.01).

CONCLUSIONS

The use of a transperineal biopsy approach improved histopathological concordance rates compared to the use of a transrectal biopsy approach. A transperineal biopsy approach may provide more accurate risk stratification for clinical decision-making. Despite recent improvements, histopathologic concordance remains suboptimal and should be considered before initiating management.

Comparison of different regimens of short-term antibiotic prophylaxis in transrectal prostate biopsy

BACKGROUND

Prostate cancer is the most common malignant solid tumour in men aged >70 years and is the second most common cause of death from oncological circumstances.

AIM

To evaluate the effect of different short-term prophylactic antibiotic regimens in transrectal prostate biopsy (PB) on the incidence of infectious complications.

METHODS

Patients who underwent transrectal ultrasound-guided PB between January 2021 and December 2022 were included in the prospective randomized study. According to the regimen of prophylaxis, patients were randomized into three groups: (1) fosfomycin trometamol 3 g, 3 h before the procedure + ciprofloxacin 500 mg, 2 h before the procedure; (2) fosfomycin trometamol 3 g, 3 h before and 24 h after the procedure; (3) ciprofloxacin 500 mg 12, 2 h before the procedure, and 12 h after the procedure. A rectal swab was performed 1-2 weeks before PB to evaluate the culture findings. Complications were evaluated during follow-up visits within one month after PB.

FINDINGS

In the monitored period, 605 PBs were performed, and 544 patients met the inclusion criteria (184, 161, and 199 in groups 1, 2, and 3). Infectious complications occurred in 10 cases (1.83%), namely 3, 4, and 3 according to patient groups. There was no statistically significant difference between the individual groups. None of the patients required hospitalization and all were free of symptoms of sepsis.

CONCLUSION

Short-term antibiotic prophylaxis in PB using fosfomycin trometamol, ciprofloxacin, or their combination appears to be effective. Fosfomycin trometamol is a suitable alternative to fluoroquinolone antibiotics.

Emotion-centered versus fact-centered medical information to alleviate pain and anxiety in prostate biopsy: A randomized trial

BACKGROUND

To test the efficacy of emotion-centered (EC) versus fact-centered (FC) written medical information for prostate biopsy to alleviate pain and anxiety in a randomized controlled trial.

METHODS

In a single-center, single-blinded study participants were randomized to receive FC or EC (DRKS00022361; 2020). In the EC, the focus was on possible stress reactions and stress-reducing strategies. Participants were asked to complete questionnaires on the day of MRI acquisition (T0) directly before (T1) and after the procedure (T2). The primary outcome measure was the assessment of worst pain in the last 2 h measured by the adapted brief pain inventory. Secondary outcome measures included state anxiety measured by the state-trait anxiety inventory and the subjective evaluation of the impact of the written medical information at T2. For statistical analysis, mixed models were calculated.

RESULTS

Of 137 eligible patients, 108 (79%) could be recruited and were randomized. There was a significant effect for time for the outcome variables pain and anxiety. Regarding the comparison for the primary outcome variable worst pain there was a significantly lower increase from T1 to T2 after FC compared to EC (p < 0.004). The course of anxiety displayed no overall group differences. The FC was evaluated as significantly more helpful regarding stress, pain, and anxiety with moderate effect sizes.

CONCLUSIONS

FC was favorable with regard to worst experienced pain, assuming that the brief introduction of emotional issues such as stress and coping in written information might be counterproductive particularly in men not used to these subjects.

Risk factors for infection and acute urinary retention following transperineal prostate biopsy

PURPOSE

To calculate the frequency of infection and acute urinary retention (AUR) following transperineal (TP) prostate biopsy at a single high-volume academic institution and determine risk factors for developing these post-biopsy conditions.

METHODS

Men undergoing TP prostate biopsy from 2012 to 2022 at our institution were retrospectively identified and chart reviewed. TP biopsies were performed with TR ultrasound (TRUS) guidance with anesthesia using a brachytherapy grid template. TRUS volumes were recorded during the procedure, and magnetic resonance imaging (MRI) volumes were calculated using the ellipsoid formula. When available, MRI volume was used for all analysis, and when absent, TRUS volume was used. AUR was defined as requiring urinary catheter placement within 72 h post-biopsy for inability to urinate. Univariable analysis was performed and variables with p < 0.1 and/or established clinical relevance were included in a backward binary logistic regression to produce an optimized model that fit the data without collinearity between variables.

RESULTS

A total of 767 TP biopsies were completed in the study window. The frequency of infection was 1.83% (N = 14/767). The total frequency of AUR was 5.48% (N = 42/767). On multivariable regression, patients who went into AUR were five times as likely to develop infection (p = 0.020). Patients with infection post-TP biopsy were four times as likely to develop AUR (p = 0.047) and with prostates > 61.21 cc were three times as likely (p = 0.019).

CONCLUSION

According to our model, AUR is the greatest risk factor for infection post-TP biopsy. With regard to AUR risks, infection post-biopsy and prostate size > 61.21 cc are the greatest risk factors.

Clinical and economic impact of the introduction of pre-biopsy MRI-based assessment on a large prostate cancer centre diagnostic population and activity: 10 years on

INTRODUCTION

Prostate mpMRI was introduced in 2011 as a secondary test and subsequently integrated into a prostate cancer (PCa) diagnostics unit representing a population of approximately 550,000 people. The following represents an audit of its step-wise introduction between 2 index years, 2009 and 2018, focusing on the activity, patient outcomes and economic benefits. PATIENTS AND METHODS: The 2 distinct years were selected for relying on a transrectal ultrasound biopsy pathway in 2009 to an mpMRI-based pathway in 2018. All referrals were retrospectively screened and compared for age, PSA levels, DRE findings, biopsy history, biopsy and mpMRI allocation data. Cost analysis was determined using local unit procedure costs.

RESULTS

Patients referred included 648 in 2009 and 714 in 2018. mpMRI seldomly informed decision to biopsy in 2009 (9.8%), while in 2018 it was performed in the pre-biopsy setting in 87.9% cases and enabled biopsy avoidance in 137 patients. In 2018, there was a 31.8% decrease in the number of biopsies in patients without previous PCa diagnosis, coupled with an increase in diagnostic rates of csPCa, from 28.6 to 49.0% (p < 0.0001) and a reduction in negative biopsy rates from 52.3 to 33.8%. mpMRI had a positive impact on the system with reduced patient morbidity and post-procedural complications. The estimated overall cost savings amount to approximately £75,000/year for PCa diagnosis and £11,000/year due to reduced complications.

CONCLUSION

Our evaluation shows the mpMRI-based pathway has improved early detection of csPCa and reduction of repeat biopsies, resulting in significant financial benefits for the local healthcare system.

A brief mind-body intervention to reduce pain and anxiety during prostate needle biopsy: a clinically integrated randomized controlled trial with 2-staged consent

OBJECTIVES

Many patients experience pain, anxiety, and discomfort with prostate biopsy, which may discourage enrollment in active surveillance programs or follow-up biopsy. Guided meditation can significantly reduce pain and anxiety during percutaneous biopsy. We sought to evaluate the effectiveness of a brief mind-body intervention on patient-reported outcomes after prostate biopsy.

METHODS AND MATERIALS

We performed a clinically-integrated randomized controlled trial of a brief mind-body intervention during biopsy compared to usual care at a single tertiary care center from 2018 to 2022. All patients offered transrectal ultrasound-guided prostate biopsy in the clinic with local anesthesia were eligible for enrollment. This clinically integrated trial was conducted simultaneously with a randomized controlled trial of 1-stage and 2-stage consent. The primary outcome was patient-reported pain, anxiety, discomfort, and tolerability on a visual-analog scale (0-10). A 15% improvement was prespecified as clinically relevant. We compared the proportion of men in each arm reporting a severe score (7-10) on any of the 4 scales using Fisher's exact test and then compared means for each scale separately using ANCOVA with randomization stratum (first vs. prior biopsy) as a covariate.

RESULTS

Of 263 eligible patients, 238 enrolled (119 per arm). One hundred seventy-two (72%) enrolled with 2-stage consent. A total of 37/94 (39%) and 38/102 (37%) patients randomized to usual care and intervention, respectively, reported severe scores in any of the 4 domains, a difference of 2.1% (95% confidence interval [CI] -13, 17%, P = 0.8). There was no evidence of a difference in mean postbiopsy anxiety (P = 0.3), discomfort (P = 0.09), pain (P = 0.4) or tolerability scores (P = 0.2).

CONCLUSIONS

A clinically meaningful benefit for this brief mind-body intervention during prostate biopsy is unlikely. Robust patient enrollment is feasible using 2-stage consent.

Preliminary study on miRNA in prostate cancer

OBJECTIVE

To screen for miRNAs differentially expressed in prostate cancer and prostate hyperplasia tissues and to validate their association with prostate cancer.

METHODS

Patients diagnosed by pathology in the Department of Urology of the First Affiliated Hospital of Xinjiang Medical University from October 2021 to June 2022 were selected, and their general clinical information, blood samples, and prostate tissue samples were collected. miRNA microarray technology was performed to obtain differentially expressed miRNAs in prostate cancer and hyperplasia tissues, and miRNAs to be studied were screened by microarray results and review of relevant literature. The detection of miRNA expression in the patients' blood and prostate tissue samples was measured. The miRNA-222-mimics were transfected into PC3 cells, and cell biology experiments such as CCK8, scratch, Transwell, and flow cytometry were performed to detect the effects of overexpressed miRNA-222 on the growth and proliferation, invasive ability, apoptotic ability, and metastatic ability of prostate cancer cells.

RESULTS

The results of the miRNA microarray showed that there were many differentially expressed miRNAs in prostate cancer and hyperplasia tissues, and four miRNAs, miRNA-144, miRNA-222, miRNA-1248, and miRNA-3651 were finally selected as the subjects by reviewing relevant literature. The results showed that the expression of miRNA-222 in prostate cancer tissues was lower than that in prostate hyperplasia tissues (P < 0.05). The expression of miRNA-222, miRNA-1248, and miRNA-3651 in blood samples of prostate cancer patients was lower than that in prostate hyperplasia patients (P < 0.05). The analysis results indicated that the f/t ratio and the relative expression of miRNA-222 and miRNA-1248 were independent influences of prostate cancer (P < 0.05), in which overexpression of miRNA-222 decreased the proliferative, invasive, and metastatic abilities of PC3 cells and enhanced the level of apoptosis of cancer cells.

CONCLUSIONS

Although there was no significant change in the overall incidence of prostate cancer in this study, significant changes occurred in the incidence of prostate cancer with different characteristics. In addition, the nomogram prediction model of prostate cancer-specific survival rate constructed based on four factors has a high reference value, which helps physicians to correctly assess the patient-specific survival rate and provides a reference basis for patient diagnosis and prognosis evaluation.

Fabrication of a translational photoacoustic needle sensing probe for interstitial photoacoustic spectral analysis

In our previous study, we demonstrated the feasibility of using an all-optical interstitial photoacoustic (PA) needle sensing probe for quantitative study of tissue architectures with PA spectral analysis (PASA). In this work, we integrated the optical components into an 18 G steel needle sheath for clinical translation. The dimensions of the needle probe are identical to those of a core biopsy probe and are fully compatible with standard procedures such as prostate biopsy. To our knowledge, this is the first interstitial PA probe that can acquire signals with sufficient temporal length for statistics-based PASA. We treated the inner surface of the steel needle sheath and successfully suppressed the vibrational PA signals generated at the surface. Purposed at boosting the measurement sensitivity and extending sensing volume, we upgraded the Fabry-Pérot hydrophone with a plano-concave structure. The performance of the translational needle PA sensing probe was examined with phantoms containing microspheres. The trend of the linear spectral slopes shows negatively correlated to the microsphere dimensions while the midband-fits are positively correlated to microsphere diameters and concentrations. The PASA quantifications show the ability to differentiate microspheres with varied dimensions.

Protocol of a multicentre randomised controlled trial assessing transperineal prostate biopsy to reduce infectiouscomplications

INTRODUCTION

Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer.

METHODS AND ANALYSIS

We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer.

ETHICS AND DISSEMINATION

The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT04815876.

A systematic method introduced a common lncRNA-miRNA-mRNA network in the different stages of prostate cancer

Introduction

The present study aimed to investigate the interaction of the common lncRNA-miRNA-mRNA network involved in signaling pathways in different stages of prostate cancer (PCa) by using bioinformatics and experimental methods.

Methods

Seventy subjects included sixty PCa patients in Local, Locally Advanced, Biochemical Relapse, Metastatic, and Benign stages, and ten healthy subjects were entered into the current study. The mRNAs with significant expression differences were first found using the GEO database. The candidate hub genes were then identified by analyzing Cytohubba and MCODE software. Cytoscape, GO Term, and KEGG software determined hub genes and critical pathways. The expression of candidate lncRNAs, miRNAs, and mRNAs was then assessed using Real-Time PCR and ELISA techniques.

Results

4 lncRNAs, 5 miRNAs, and 15 common target genes were detected in PCa patients compared with the healthy group. Unlike the tumor suppressors, the expression levels of common onco-lncRNAs, oncomiRNAs, and oncogenes showed a considerable increase in patients with advanced stages; Biochemical Relapse and Metastatic, in comparison to the primary stages; Local and Locally Advanced. Additionally, their expression levels significantly increased with a higher Gleason score than a lower one.

Conclusion

Identifying a common lncRNA-miRNA-mRNA network associated with prostate cancer may be clinically valuable as potential predictive biomarkers. They can also serve as novel therapeutic targets for PCa patients.

Reliability of prostate imaging reporting and data system version 2.1 for excluding clinically significant prostate cancer using a 1.5 tesla scanner

INTRODUCTION

Multiparametric magnetic resonance imaging (mpMRI) of the prostate gland is now the recommended initial investigation of choice for the detection of Prostate cancer (PCa). It effectively identifies patients who require prostate biopsies due to the risk of clinically significant PCa. It helps patients with clinically insignificant PCa avoid the invasive biopsies and possible accompanying complications. Large clinical trials have investigated the accuracy of mpMRI in detecting PCa. We performed a local review to examine the reliability of omitting tissue sampling in men with a negative (PIRADS 2 (P2) or less) mpMRI in the primary diagnostic setting.

METHODS

This was a retrospective study of patients with clinical suspicion of PCa within a 2-year period. Patients had a mpMRI prior to having trans-perineal prostate gland biopsies. Clinically significant disease was defined as Gleason 7 and above. The descriptive data was analysed using contingency table methods. A p-value less than 0.05 was statistically significant.

RESULTS

Out of 700 patients 90 had an mpMRI score of PIRADS 2. Seventy-seven (85.5%) of these patients had a negative biopsy, 9(10%) showed Gleason 6, 4 patients showed Gleason 7 or above. 78 patients with PIRADS 2 had a PSA density of < 0.15, none of which had a clinically significant biopsy result. The negative predictive value of mpMRI from this study is 95%.

CONCLUSION

Our results are in line with negative predictive values demonstrated in the current literature. This local study, likely applicable to other district general hospitals, shows that mpMRI is a safe and reliable initial investigation to aid decisions on which patients require biopsies.

[Common errors, pitfalls, and management of complications of prostate biopsy : The most common diagnostic and procedural challenges of transrectal fusion prostate biopsy in the initial diagnosis of clinically significant prostate cancer]

BACKGROUND

Transrectal (TR) prostate biopsy is the gold standard in diagnosis of prostate cancer (PC). It requires a precise and safe technique for sample acquisition.

OBJECTIVE

Several approaches will be discussed to avoid overdiagnosis, false-negative results, and complications of the procedure.

MATERIALS AND METHODS

We analyzed national and European guidelines, systematic reviews, meta-analyses, as well as prospective and retrospective studies to describe current trends in indication and performance of biopsies.

RESULTS

Incorporation of risk calculators and magnetic resonance imaging (MRI) into daily routine reduces biopsy rates and results in a more precise diagnosis of clinically significant prostate cancer (csPC). Combination of random- and MRI-fusion guided biopsy-but also extending the radius of sampling by 10 mm beyond the MRI lesion and a transperineal (TP) sampling approach - lead to a higher tumor-detection rate. Bleeding is the most common complication after prostate biopsy and is usually self-limiting. Postbiopsy infection rates can be reduced through TP biopsy.

CONCLUSION

TR MRI-fusion guided biopsy is a widely acknowledged tool in primary diagnostics of csPC. Higher detection rates and safety can be achieved through a TP sampling approach.

Rectal Culture-Based Versus Empirical Antibiotic Prophylaxis to Prevent Infectious Complications in Men Undergoing Transrectal Prostate Biopsy: A Randomized, Nonblinded Multicenter Trial

BACKGROUND

An increase in infections after transrectal prostate biopsy (PB), related to an increasing number of patients with ciprofloxacin-resistant rectal flora, necessitates the exploration of alternatives for the traditionally used empirical prophylaxis of ciprofloxacin. We compared infectious complication rates after transrectal PB using empirical ciprofloxacin prophylaxis versus culture-based prophylaxis.

METHODS

In this nonblinded, randomized trial, between 4 April 2018 and 30 July 2021, we enrolled 1538 patients from 11 Dutch hospitals undergoing transrectal PB. After rectal swab collection, patients were randomized 1:1 to receive empirical prophylaxis with oral ciprofloxacin (control group [CG]) or culture-based prophylaxis (intervention group [IG]). Primary outcome was any infectious complication within 7 days after biopsy. Secondary outcomes were infectious complications within 30 days, and bacteremia and bacteriuria within 7 and 30 days postbiopsy. For primary outcome analysis, the χ2 test stratified for hospitals was used. Trial registration number: NCT03228108.

RESULTS

Data from 1288 patients (83.7%) were available for analysis (CG, 652; IG, 636). Infection rates within 7 days postbiopsy were 4.3% (n = 28) (CG) and 2.5% (n = 16) (IG) (P value = .08; reduction: -1.8%; 95% confidence interval, -.004 to .040). Ciprofloxacin-resistant bacteria were detected in 15.2% (n = 1288). In the CG, the presence of ciprofloxacin-resistant rectal flora resulted in a 6.2-fold higher risk of early postbiopsy infection.

CONCLUSIONS

Our study supports the use of culture-based prophylaxis to reduce infectious complications after transrectal PB. Despite adequate prophylaxis, postbiopsy infections can still occur. Therefore, culture-based prophylaxis must be weighed against other strategies that could reduce postbiopsy infections. Clinical Trials Registration. NCT03228108.

Perineal nerve block versus periprostatic block for patients undergoing transperineal prostate biopsy (APROPOS): a prospective, multicentre, randomised controlled study

Background

We aimed to investigate perineal nerve block versus periprostatic block in pain control for men undergoing a transperineal prostate biopsy.

Methods

In this prospective, randomised, blinded and parallel-group trial, men in six Chinese hospitals with suspected prostate cancer were randomly assigned (1:1) at the point of local anaesthesia to receive a perineal nerve block or periprostatic block and followed by a transperineal prostate biopsy. Centres used their usual biopsy procedure. Operators who performed anaesthesia were trained in both techniques before the trial and were masked to the randomised allocation until the time of anaesthesia and were not involved in the subsequent biopsy procedure and any assessment or analysis. Other investigators and the patients were masked until trial completion. The primary outcome was the level of the worst pain experienced during the prostate biopsy procedure. Secondary outcomes included pain (post-biopsy at 1, 6 and 24 h), changes in blood pressure, heart rate and breathing rate during the biopsy procedure, external manifestations of pain during biopsy, anaesthesia satisfaction, the detection rate of PCa and clinically significant PCa. This trial is registered on ClinicalTrials.gov, NCT04501055.

Findings

Between August 13, 2020, and July 20, 2022, 192 men were randomly assigned to perineal nerve block or periprostatic block, 96 per study group. Perineal nerve block was superior for the relief of pain during the biopsy procedure (mean 2.80 for perineal nerve block and 3.98 for periprostatic block; adjusted difference in means -1.17, P < 0.001). Although the perineal nerve block had a lower mean pain score at 1 h post-biopsy compared with the periprostatic block (0.23 vs 0.43, P = 0.042), they were equivalent at 6 h (0.16 vs 0.25, P = 0.389) and 24 h (0.10 vs 0.26, P = 0.184) respectively. For the change in vital signs during biopsy procedure, perineal nerve block was significantly superior to periprostatic block in terms of maximum value of systolic blood pressure, maximum value of mean arterial pressure and maximum value of heart rate. There are no statistical differences in average value of systolic blood pressure, average value of mean, average value of heart rate, diastolic blood pressure and breathing rate. Perineal nerve block was also superior to periprostatic block in external manifestations of pain (1.88 vs 3.00, P < 0.001) and anaesthesia satisfaction (8.93 vs 11.90, P < 0.001). Equivalence was shown for the detection rate of PCa (31.25% for perineal nerve block and 29.17% for periprostatic block, P = 0.753) or csPCa (23.96% for perineal nerve block and 20.83% for periprostatic block, P = 0.604). 33 (34.8%) of 96 patients in the perineal nerve block group and 40 (41.67%) of 96 patients in the periprostatic block group had at least one complication.

Interpretation

Perineal nerve block was superior to periprostatic block in pain control for men undergoing a transperineal prostate biopsy.

Funding

Grant 2019YFC0119100 from the National Key Research and Development Program of China.

Cost Effectiveness of Rectal Culture-based Antibiotic Prophylaxis in Transrectal Prostate Biopsy: The Results from a Randomized, Nonblinded, Multicenter Trial

Background

Culture-based antibiotic prophylaxis is a plausible strategy to reduce infections after transrectal prostate biopsy (PB) related to fluoroquinolone-resistant pathogens.

Objective

To assess the cost effectiveness of rectal culture-based prophylaxis compared with empirical ciprofloxacin prophylaxis.

Design setting and participants

The study was performed alongside a trial in 11 Dutch hospitals investigating the effectiveness of culture-based prophylaxis in transrectal PB between April 2018 and July 2021 (trial registration number: NCT03228108).

Intervention

Patients were 1:1 randomized for empirical ciprofloxacin prophylaxis (oral) or culture-based prophylaxis. Costs for both prophylactic strategies were determined for two scenarios: (1) all infectious complications within 7 d after biopsy and (2) culture-proven Gram-negative infections within 30 d after biopsy.

Outcome measurements and statistical analysis

Differences in costs and effects (quality-adjusted life-years [QALYs]) were analyzed from a healthcare and societal perspective (including productivity losses, and travel and parking costs) using a bootstrap procedure presenting uncertainty surrounding the incremental cost-effectiveness ratio in a cost-effectiveness plane and acceptability curve.

Results and limitations

For the 7-d follow-up period, culture-based prophylaxis (n = 636) was €51.57 (95% confidence interval [CI] 6.52-96.63) more expensive from a healthcare perspective and €16.95 (95% CI -54.29 to 88.18) from a societal perspective than empirical ciprofloxacin prophylaxis (n = 652). Ciprofloxacin-resistant bacteria were detected in 15.4%. Extrapolating our data, from a healthcare perspective, 40% ciprofloxacin resistance would lead to equal cost for both strategies. Results were similar for the 30-d follow-up period. No significant differences in QALYs were observed.

Conclusions

Our results should be interpreted in the context of local ciprofloxacin resistance rates. In our setting, from a healthcare perspective, culture-based prophylaxis was significantly more expensive than empirical ciprofloxacin prophylaxis. From a societal perspective, culture-based prophylaxis was somewhat more cost effective against the threshold value customary for the Netherlands (€80.000).

Patient summary

Culture-based prophylaxis in transrectal prostate biopsy was not associated with reduced costs compared with empirical ciprofloxacin prophylaxis.

Variables Associated with False-Positive PSA Results: A Cohort Study with Real-World Data

(1) Background: There are no real-world data evaluating the incidence of false-positive results. We analyzed the clinical and analytical factors associated with the presence of false-positive results in PSA determinations in practice. (2) Methods: A prospective cohort study of patients with a PSA test was performed in clinical practice. We followed the patients by reviewing their medical records for 2 years or until the diagnosis of PCa was reached, whichever came first. (3) Results: False-positive PSA rate was 46.8% (95% CI 44.2-49.2%) and false-negative PSA rate was 2.8% (95% CI 2-3.5%). Patients aged 61-70 years and those over 70 years were more likely to have a false-positive result than those under 45 years (aOR 2.83, 95% CI 1.06-7.55, p = 0.038, and aOR 4.62, 95% CI 1.75-12.22, p = 0.002, respectively). Patients with urinary tract infection were more likely to have a false-positive result (aOR 8.42, 95% CI 2.42-29.34, p = 0.001). Patients with diabetes mellitus were less likely to have a false-positive result (aOR 0.63, 95% CI 0.41-0.98, p = 0.038); (4) Conclusions: This study has generated relevant information that could be very useful for shared decision making in clinical practice.

Short term ciprofloxacin and clindamycin combination antibiotic therapy before and after transrectal ultrasound scan and prostate biopsy: Its impact on major components of gut microbiome

The perturbation of gut microbiome is a risk factor for a number of adverse conditions. Among other factors antibiotic therapy is a common culprit. We characterized the short-term alteration of gut microbiome after antibiotic therapy. Nine patients (age (median [range]): 67 [57-75 years]) were subjected to prostate biopsy. Ciprofloxacin and clindamycin, 500 mg and 150 mg, respectively, were administered twice a day; this combination therapy was started the day before and continued until 5th and 8th day, respectively, following biopsy. 16s RNA sequencing data from fecal swabs taken before antibiotic therapy and 14 days after biopsy were analysed. At phylum level, the abundance of Actinobacteria and Firmicutes decreased, while that of Bacteroides and Proteobacteria increased after antibiotic therapy. The ratio of Firmicutes:Bacteroides inversed (from 2.81 to 0.74, p = 0.035). At order level, the abundance of Bacteroidales and Veillonellales increased, while that of Clostridiales and Coriobacteriales decreased. At genus level the abundance of Bacteroides increased, while those of Roseburia, Faecalibacterium and Collinsella decreased. These findings indicate that short-term antibiotic exposure skews gut microbiome composition. The current level of knowledge does not allow to decide whether this skewness is detrimental and has any long-term effect on disease including prostate pathology.

Improving multiparametric MR-transrectal ultrasound guided fusion prostate biopsies with hyperpolarized 13 C pyruvate metabolic imaging: A technical development study

PURPOSE

To develop techniques and establish a workflow using hyperpolarized carbon-13 (13 C) MRI and the pyruvate-to-lactate conversion rate (kPL ) biomarker to guide MR-transrectal ultrasound fusion prostate biopsies.

METHODS

The integrated multiparametric MRI (mpMRI) exam consisted of a 1-min hyperpolarized 13 C-pyruvate EPI acquisition added to a conventional prostate mpMRI exam. Maps of kPL values were calculated, uploaded to a picture archiving and communication system and targeting platform, and displayed as color overlays on T2 -weighted anatomic images. Abdominal radiologists identified 13 C research biopsy targets based on the general recommendation of focal lesions with kPL  >0.02(s-1 ), and created a targeting report for each study. Urologists conducted transrectal ultrasound-guided MR fusion biopsies, including the standard 1 H-mpMRI targets as well as 12-14 core systematic biopsies informed by the research 13 C-kPL targets. All biopsy results were included in the final pathology report and calculated toward clinical risk.

RESULTS

This study demonstrated the safety and technical feasibility of integrating hyperpolarized 13 C metabolic targeting into routine 1 H-mpMRI and transrectal ultrasound fusion biopsy workflows, evaluated via 5 men (median age 71 years, prostate-specific antigen 8.4 ng/mL, Cancer of the Prostate Risk Assessment score 2) on active surveillance undergoing integrated scan and subsequent biopsies. No adverse event was reported. Median turnaround time was less than 3 days from scan to 13 C-kPL targeting, and scan-to-biopsy time was 2 weeks. Median number of 13 C targets was 1 (range: 1-2) per patient, measuring 1.0 cm (range: 0.6-1.9) in diameter, with a median kPL of 0.0319 s-1 (range: 0.0198-0.0410).

CONCLUSIONS

This proof-of-concept work demonstrated the safety and feasibility of integrating hyperpolarized 13 C MR biomarkers to the standard mpMRI workflow to guide MR-transrectal ultrasound fusion biopsies.

Cost-Effectiveness Analysis of Stockholm 3 Testing Compared to PSA as the Primary Blood Test in the Prostate Cancer Diagnostic Pathway: A Decision Tree Approach

OBJECTIVE

This study evaluated the cost effectiveness of using Stockholm 3 (STHLM3) testing compared to the prostate-specific antigen (PSA) test in the diagnostic pathway for prostate cancer.

METHODS

We created a decision tree model for PSA (current standard) and STHLM3 (new alternative). Cost effectiveness was evaluated in a hypothetical cohort of male individuals aged 50-69 years. The study applied a Danish hospital perspective with a time frame restricted to the prostate cancer diagnostic pathway, beginning with the initial PSA/STHLM3 test, and ending with biopsy and histopathological diagnosis. Estimated values from the decision-analytical model were used to calculate the incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analyses were conducted to test the robustness of the base-case analysis.

RESULTS

The model-based analysis revealed that STHLM3 testing was more effective than the PSA, but also more costly, with an incremental cost-effectiveness ratio of €511.7 (95% credible interval, 359.9-674.3) for each additional correctly classified individual. In the deterministic sensitivity analysis, variations in the cost of STHLM3 had the greatest influence on the incremental cost-effectiveness ratio. In the probabilistic sensitivity analysis, all iterations were positioned in the north-east quadrant of the incremental cost-effectiveness scatterplot. At a willingness to pay of €700 for an additional correctly classified individual, STHLM3 had a 100% probability of being cost effective.

CONCLUSIONS

Compared to the PSA test as the initial testing modality in the prostate cancer diagnostic workup, STHLM3 testing showed improved incremental effectiveness, however, at additional costs. The results were sensitive to the cost of the STHLM3 test; therefore, a lower cost of the STHLM3 test would improve its cost effectiveness compared with PSA tests.

GEOGRAPHIC VARIATION OF INFECTIOUS COMPLICATIONS FOLLOWING PROSTATE BIOPSY IN THE UNITED STATES: RESULTS FROM A POPULATION-BASED COHORT OF PRIVATELY INSURED PATIENTS

OBJECTIVE

To elucidate regional trends of infectious complications following transrectal ultrasound prostate biopsy (TRUS-PB) from a national, privately-insured database.

MATEREIAL AND METHODS

Using Market Scan, we identified all men who underwent TRUS-PB from 2010 to 2015. Infectious complications (UTI, prostatitis, sepsis) occurring 30 days after the prostate biopsy from emergency room (ER) visits or hospital admissions constituted the primary outcomes. We analyzed unadjusted and adjusted rates of infectious complications from ER visits and hospital admissions per 100 prostate biopsies by state. Multivariable logistic regression analyses were used to identify patient covariates associated with infectious complications.

RESULTS

During the study interval, we identified 193,490 patients who underwent TRUS-PB. The mean age was 57.6 years (SD: 5.0). Over time the unadjusted national rates of infectious complications remained similar from 0.4 ER visits per 100 prostate biopsies in 2010 to 0.2 in 2015 (p=0.83), and 1.2 hospital admissions per 100 prostate biopsies in 2010 to 1.1 in 2015 (p=0.58). Connecticut had the lowest unadjusted infectious complication rate per 100 biopsies at 0.64, whereas West Virginia had the highest at 2.34. Multivariable analysis revealed higher Elixhauser status and patient age were associated with higher odds of infectious complications (p<0.05).

CONCLUSIONS

While rates of infectious complications attributable to prostate biopsies remain relatively stable, significant variation exists at the state level regarding this adverse outcome.

Morbidity following transperineal prostate biopsy: Our experience in 8.500 men

INTRODUCTION

To evaluate clinical complications following transperineal prostate biopsy in 8.500 patients.

MATERIALS AND METHODS

From January 2000 to January 2022, 8,500 men (median age: 62.8 years) underwent transperineal prostate biopsy; since 2011, 1,850 patients were submitted to mpMRI and in the presence of a PI-RADS score ≥ 3, a transperineal targeted biopsy was added to systematic prostate biopsy (4 cores). All patients underwent antibiotic prophylaxis (2000-2011: levoxacin 500 tablet; 2012-2022: 2 grams intravenous of cefazolin). Among 8.500 men 1.350 (15.8%) vs. 4.520 (53.3%) vs. 2.630 (30.9%) underwent 12 vs. 18 vs. > 24 needle cores, respectively. The prostate biopsy-related complications were evaluated within 20 days from prostate biopsy; the number of patients who needed hospital admission or emergency department visit (EDV) was recorded.

RESULTS

Prostate cancer was found in 3.150/8.500 (37.1%) patients; overall, hospital admission and EDV were equal to 1.5% and 8.9% and the side effects were directly correlated with the number of needle cores resulting equal to 17.4% (12 cores), 38.7% (18 cores) and 55.3% (> 24 cores) (p = 0.001). Hospital admission and EDV in men who underwent 12 vs. 18 vs. > 24 cores occurred in 1.5% and 7.4% vs. 1.4% and 8.7% vs. 1.7% and 10.6% (p > 0.05), respectively.

CONCLUSIONS

Clinical complications following transperineal prostate biopsy involved 35.9% of the patients but only 1.5% of them required hospital admission; urinary tract infection with fever was the most frequent cause of hospital recovery (33.4% of the cases), but none of the patients developed sepsis.

Transperineal ultrasound-guided prostate biopsy: what the radiologist needs to know

Transperineal ultrasound-guided (TP) prostate biopsy has been shown to significantly decrease the risk of post-procedural sepsis when compared to transrectal ultrasound-guided (TRUS) prostate biopsy. With guidance from the European Urology Association favouring adoption of a TP biopsy route, it is clear that, despite being a more technically challenging procedure, TP biopsy in an outpatient setting will replace TRUS biopsy. This paper gives the reader a succinct summary of outpatient transperineal prostate biopsy under local anaesthetic utilising a free-hand ultrasound technique. Patient preparation and consent process is outlined. A comprehensive pictorial review of the procedure, pitfalls and common post-procedural outcomes is presented. This paper provides a framework and guide for those wishing to adopt the transperineal approach under local anaesthetic.

Comparison of transperineal and transrectal targeted prostate biopsy using Mahalanobis distance matching within propensity score caliper method: A multicenter study of Turkish Urooncology Association

OBJECTIVE

To compare the clinically significant prostate cancer (csPC)-detecting results of transperineal and transrectal targeted biopsy (TPTB and TRTB, respectively) by performing matching analysis.

PATIENTS AND METHODS

This study has used the PC and prostate biopsy database from the Turkish Urooncology Association. A total of 1143 patients with Prostate Imaging-Reporting and Data System (PI-RADS) with ≥3 lesions on multiparametric magnetic resonance imaging (mpMRI) and who had received a software-guided transperineal/transrectal MRI/transrectal ultrasound (TRUS) fusion prostate biopsy with concomitant standard systematic 12-core biopsy were included in this study. csPC detection rates of the TP and TR approaches were compared following Mahalanobis distance matching within propensity score caliper method. The following four variables were selected as covariates for the matching procedure: age, digital rectal examination findings, PSA density, and the index lesion PI-RADS score.

RESULTS

The matched sample included 508 TR and 276 TP patients. In both the TP and the TR groups, targeted biopsy was superior to systematic biopsy in detecting csPC (27.5% vs. 24.6%, p < 0.001 and 19.5% vs. 16.3%, p < 0.0001, respectively). Both TPTB and TP systematic biopsy was found to be superior to TRTB and TR systematic biopsy in terms of csPC detection (27.5% vs. 19.5%, p = 0.012 and 24.6% vs. 16.3%, p = 0.006). In patients with an anterior index lesion, an apical index lesion, and a larger prostate, the superiority of TPTB to TRTB was found to be more prominent in terms of csPC detection (37.8% vs. 18.3%, p = 0.044; 34.6% vs. 14.7%, p = 0.002; and 25% vs. 5.1%, p = 0.033, respectively).

CONCLUSION

Targeted biopsy was found to be superior to systematic biopsy in detecting csPC in both the TP and the TR approaches. The TP approach is preferred because of its clear superiority in detecting csPC in targeted biopsy, especially in patients with anterior and apical lesions and with larger prostates.

Recent Trends in Prostate Biopsy Complication Rates and the Role of Aztreonam in Periprocedural Antimicrobial Prophylaxis—A Nationwide Population-Based Study from Korea

An increase in the rate of complications after prostate biopsy (PB) due to increased antibiotic-resistant bacteria is a global issue. We report the safety of aztreonam as a prophylactic antibiotic in patients undergoing PB. We investigated the complication rates according to several antibiotic regimens, including aztreonam. We hypothesized that PB complications increased following a rise in antibiotic-resistant bacteria. We examined the annual rates of complications among patients in our hospital (clinical cohort) and the Korea Health Insurance Review and Assessment Service (HIRA) cohort. Data regarding complications, hospitalization, emergency room (ER) visits, and febrile urinary tract infections occurring within 2 weeks after PB were recorded. The rate of complications was significantly lower in patients who received oral quinolone and intravenous aztreonam than in those who received oral quinolone. The complication rates did not increase throughout the study period. Additionally, 1754 patients from the HIRA cohort were included. The rates of complications, hospitalizations, and ER visits did not increase among these patients. Oral quinolone combined with intravenous aztreonam reduced the rate of febrile complications compared to quinolone alone and was safe to use after PB. Therefore, we recommend intravenous aztreonam with oral quinolone as a prophylactic antibiotic regimen before PB.

Safety and Diagnostic Yield of 68Ga Prostate-specific Membrane Antigen PET/CT Guided Robotic-assisted Transgluteal Prostatic Biopsy

Background Transrectal US-guided biopsy with or without MRI fusion is performed for diagnosing prostate cancer (PCa) but has limitations. Gallium 68 (⁶⁸Ga) prostate-specific membrane antigen (PSMA) PET/CT-guided targeted biopsy has the potential to improve diagnostic yield of PCa. Purpose To evaluate the safety and diagnostic yield of ⁶⁸Ga PSMA PET/CT-guided, robotic-arm assisted transgluteal prostatic biopsy. Materials and Methods In this single-center nonrandomized prospective trial, participants with a clinical suspicion of PCa (serum prostate-specific antigen level > 4 ng/mL) were recruited from January 2019 to September 2020. After whole-body ⁶⁸Ga PSMA PET/CT, participants with PSMA-avid intraprostatic lesions underwent PET-guided transgluteal biopsy by using an automated robotic arm. To assess safety and diagnostic yield, procedure-related complications and histopathologic results were documented. Pain during the procedure was scored by a visual analog scale. Descriptive statistics were applied; qualitative variables were reported in percentages. Results Seventy-eight participants (mean age, 66 years ± 7 [standard deviation]; 36 participants [46%] with prior negative results at transrectal US-guided biopsy) were enrolled. Fifty-six (72%) participants had PSMA-avid lesions (prior negative results at transrectal US-guided biopsy in 22 of 56 [39%]) and underwent targeted biopsy. PCa was confirmed in 54 of 56 (96%) participants, and clinically significant PCa (Gleason score ≥ 7) was confirmed in 24 of 54 (44%). Two participants had nonrepresentative samples that required rebiopsy. All participants experienced pain during the procedure, mild (median visual analog scale score, 1; interquartile range, 1-2) in 36 of 56 (64%) and moderate (median visual analog scale score, 5; interquartile range, 5-6) in 20 of 56 (36%). Postprocedure complications were noted in five of 56 (9%) participants and were minor (hematuria, four participants; hematospermia, one participant; and gluteal pain, two participants). No participant developed a postprocedural infection. Conclusion Transgluteal prostate-specific membrane antigen (PSMA) PET/CT-guided, robotic-targeted prostatic biopsy is safe with a high diagnostic yield of prostate cancer for PSMA-avid lesions. Clinical trial registration no. NCT05022576 © RSNA, 2022.

Post-prostate biopsy acute bacterial prostatitis and screening cultures using selective media: An overview

The development of several culture media and the availability to isolate and treat pathogens prior to a surgical procedure give us the ability to minimize treatment-related complications, and ultimately results in better outcomes for patients and avoidance of unwanted post-procedure inpatient admissions. In the last decade, an increasing incidence of multidrug-resistant Escherichia coli, especially extended-spectrum beta-lactamase-producing E. coli and fluoroquinolone-resistant pathogens, has been reported. These resistant species frequently colonize the rectal flora and gain access to the systemic circulation via the rectal plexus following a prostate biopsy. The bacteria can eventually lead to life-threatening complications, which is especially important in high-risk patients with multiple co-morbidities. Previously published studies have focused on the isolation of these pathogens with selective media before an invasive procedure and the potential benefits of incorporating the use of selective media as a mandatory pre-operative step. This preventive measure will allow us to offer a tailored prophylactic treatment that benefits patients and reduces the economic burden for the hospital.

Biomarkers for prostate cancer detection and risk stratification

Although prostate cancer (PCa) is the most commonly diagnosed cancer in men, most patients do not die from the disease. Prostate specific antigen (PSA), the most widely used oncologic biomarker, has revolutionized screening and early detection, resulting in reduced proportion of patients presenting with advanced disease. However, given the inherent limitations of PSA, additional diagnostic and prognostic tools are needed to facilitate early detection and accurate risk stratification of disease. Serum, urine, and tissue-based biomarkers are increasingly being incorporated into the clinical care paradigm, but there is still a limited understanding of how to use them most effectively. In the current article, we review test characteristics and clinical performance data for both serum [4 K score, prostate health index (phi)] and urine [SelectMDx, ExoDx Prostate Intelliscore, MyProstateScore (MPS), and PCa antigen 3 (PCA3)] biomarkers to aid decisions regarding initial or repeat biopsies as well as tissue-based biomarkers (Confirm MDx, Decipher, Oncotype Dx, and Polaris) aimed at risk stratifying patients and identifying those patients most likely to benefit from treatment versus surveillance or monotherapy versus multi-modal therapy.

Comparison of drug susceptibility between Escherichia coli detected in stool cultures of patients undergoing transrectal prostate needle biopsy and Escherichia coli in hospital-wide urine antibiograms

A prostate biopsy is essential for prostate cancer diagnosis. However, infections are one of the biopsy-associated complications, and post-biopsy fever is estimated to occur in approximately 1% of all cases. It may thus be beneficial to perform a rectal swab culture before a transrectal prostate biopsy to confirm the presence of resistant bacteria and select preventive antibacterial agents according to the drug susceptibility results. This study aimed to determine whether there is a difference between the drug susceptibility of bacteria detected in the stool of patients who were scheduled to undergo prostate biopsy and the hospital-wide urine antibiogram. Patients suspected of having prostate cancer who underwent transrectal prostate biopsy via transrectal ultrasonography between August 1, 2016, and June 30, 2020, were included in this study. Stool samples were collected and cultured before biopsy. Overall, 99 patients underwent prostate biopsy, and of these, culture results were available for 81 patients (81.8%). Escherichia coli was detected in 74.0% (60 samples) of the stool culture samples, of which 4 samples were extended-spectrum β-lactamase-producing types. We found greater susceptibility of Escherichia coli to ampicillin, fluoroquinolones, sulfamethoxazole/trimethoprim, and cefixime in the stool culture antibiogram than in the hospital-wide urine antibiogram. We also found a significantly low incidence of ESBL-positive Escherichia coli in the stool culture antibiogram with p-values of 0.009, 0.007, and 0.03 compared to the hospital-wide urine antibiograms for 2017, 2018, and 2019, respectively. Stool culture of prostate cancer patients undergoing biopsy may provide useful information for selecting prophylactic antimicrobial agents.

Clinical significance of STEAP1 extracellular vesicles in prostate cancer

BACKGROUND

Extracellular vesicles (EVs) are cell-derived lipid bilayer enclosed structures shed from the plasma membrane by all cell types. Evidence of EV presence in biological fluids has led to considerable efforts focused on identifying their cargo and determining their utility as a non-invasive diagnostic platform for cancer. In this study, we identify circulating STEAP1 (six-transmembrane epithelial antigen of the prostate 1)-positive EVs in the plasma of healthy males and prostate cancer patients and evaluate its diagnostic and prognostic significance.

METHODS

STEAP1 was identified on EVs in prostate cancer patient plasma. EVs were validated using electron microscopy, Western blot, nanoparticle tracking analysis, and nanoscale flow cytometry. STEAP1-positive EVs were quantified for 121 males with prostate cancer and 55 healthy age-matched control males. An evaluation of STEAP1 in prostate cancer tissue was also performed using established prostate cancer cohort data (TCGA, MSKCC, and SU2C/PCF Dream Team).

RESULTS

Evaluation of STEAP1-positive EVs by nanoscale flow cytometry identified a significant increase in prostate cancer patient plasma compared to healthy males. However, no association was found between total STEAP1 EV levels and disease recurrence or overall survival. Cohort data from prostate cancer tissue also found STEAP1 to be elevated in prostate cancer while no significant association with recurrence or overall survival was identified.

CONCLUSIONS

STEAP1 is known to be enriched on the cells of the prostate with potential clinical significance in prostate cancer. Our results identify and quantitate STEAP1-positive EVs in plasma and provide rationale for a STEAP1 EV-based liquid biopsy as a diagnostic strategy in prostate cancer.

EXIT from TRansrectal prostate biopsies (TREXIT): sepsis rates of transrectal biopsy with rectal swab culture guided antimicrobials versus freehand transperineal biopsy

BACKGROUND

Transrectal prostate biopsy (TRUSBx) holds a risk of prostate biopsy related sepsis. We discuss our step-wise strategies aiming to reduce this risk, including targeted antimicrobials and switching to a freehand transperineal approach (FHTPBx).

SUBJECTS AND METHODS

This longitudinal cohort study included three groups. Group A underwent TRUSBx with empirical augmented antimicrobial prophylaxis; Group B underwent TRUSBx with targeted antimicrobial prophylaxis, based on rectal-swab cultures/sensitivity; Group C underwent FHTPBx with empirical antimicrobial prophylaxis. Post biopsy sepsis, defined according to the surviving sepsis campaign and confirmed with blood or urinary cultures, were determined and rates between groups were analysed using fisher's exact test.

RESULTS

Of all 1501 patients, 23 developed post biopsy sepsis; Group A (12/609, 2.0%), B (9/403, 2.2%), C (2/489, 0.4%). Targeted antimicrobials did not reduce the risk of post biopsy sepsis following TRUSBx (A vs B, 2.0% vs 2.2%; p = 0.82). Patients with antimicrobial-resistant rectal flora had an increased post biopsy sepsis rate following TRUSBx despite targeted antimicrobials (9.1% vs 1.1%, p = 0.003). Switching to FHTPBx reduced the risk of developing post biopsy sepsis (A vs C, 2% vs 0.4%, p = 0.03; B vs C, 2.2% vs 0.4%, p = 0.03).

CONCLUSIONS

Targeted antimicrobials based on rectal swab culture failed to reduce the overall risk of post biopsy sepsis, while FHTPBx nearly eliminated this risk. We recommend the use of transperineal prostate biopsies for all patients as the most effective method to reduce the risk of sepsis.

Characterizing the aggressiveness of prostate cancer using an all-optical needle photoacoustic sensing probe: feasibility study

In our previous studies, we have developed a prototype interstitial needle sensing probe that can acquire broadband A-line photoacoustic (PA) signals encoding both tissue microarchitecture and histochemical information comparable to that accessible by histology. Paving the road toward clinical translation of this technology, we replaced the piezoelectric hydrophone in the needle PA probe with a fiber optic hydrophone that enabled both broader bandwidth and sufficient signal-to-noise ratio (SNR) for PA signal detection. Such an all-optical design also facilitated disposability and significantly reduced the footprint of the needle PA sensing probe. Experiments were performed on well-controlled phantoms and human prostate tissues. The microarchitectures in each sample were quantitatively evaluated by both the nonlinear spectral slope of the PA signal power spectrum and the generalized gamma (GG) parameter a by implementing envelope statistics to the PA signal. In the studies on phantoms containing optically absorbing microspheres with various sizes and concentrations, the nonlinear spectral slope showed a strong correlation of r=-0.80 with the microsphere dimensions, and a relatively weak correlation of r=-0.54 with the microsphere concentrations, while the GG parameter a showed a strong correlation with the microsphere dimensions (r=0.72) and a moderate correlation with the microsphere concentrations (r=0.63). In the studies on human prostate tissues containing progressive cancer stages, both the nonlinear spectral slope and the GG parameter a demonstrated a statistically significant difference between benign and nonaggressive cancer tissues (p<0.01), and between nonaggressive and aggressive cancer tissues (p<0.01). In addition, a multivariate analysis combining the two quantitative measurements demonstrated the boundaries among the different progressive stages of prostate cancer.

Magnetic resonance imaging /ultrasonography fusion transperineal prostate biopsy for prostate cancer: Initial experience at a Middle Eastern tertiary medical centre

Objective: To report on the outcomes of magnetic resonance imaging (MRI)/ultrasonography (US)-fusion transperineal prostate (TP) biopsy at a tertiary medical centre in the Middle East including detection rate of clinically significant prostate cancer (csPCa), complications, and tolerability of the procedure. Patients and methods: Between May 2019 and June 2020, 98 MRI/US-fusion TP biopsies were performed in the US suite using light sedation. All patients had pre-biopsy 3-T multiparametric MRI. Data on patient characteristics, PCa detection rate and complication rates were collected retrospectively. A Gleason score ≥3 + 4 was defined as csPCa.

RESULTS

There were 98 patients, with a mean (SD) age of 65 (9.1) years, and a median (SD) prostate-specific antigen level prior to biopsy of 7.53 (12.97) ng/mL and prostate volume of 51 (31.1) mL. PCa was detected in 54 (55%) patients, with csPCa detected in 43 (44%). A total of 124 Prostate Imaging-Reporting and Data System (PI-RADS) 3-5 lesions were targeted. Grade Group ≥2 PCa was found in 35.5% of the targeted lesions. Random biopsies detected one csPCa Gleason score 3 + 4 in one patient with a negative target. None of the patients had post-biopsy haematuria or retention. Only one patient developed acute prostatitis requiring in-patient intravenous antibiotics.

CONCLUSIONS

MRI/US-fusion TP biopsy has an adequate detection rate of csPCa with minimal complications and low infection rates after biopsy. This is one of the first TP biopsy series in the Middle East paving the way for wider adoption in the region.

ABBREVIATIONS

AS: active surveillance; AUR: acute urinary retention; GG: Grade Group; IQR: interquartile range; mpMRI: multiparametric MRI; (cs)PCa: (clinically significant) prostate cancer; PI-RADS: Prostate Imaging-Reporting and Data System; TP: transperineal; US: ultrasonography; TRUS: transrectal Ultrasound guided.

Active Surveillance Strategies for Low-Grade Prostate Cancer: Comparative Benefits and Cost-effectiveness

Background Active surveillance (AS) is the recommended treatment option for low-risk prostate cancer (PC). Surveillance varies in MRI, frequency of follow-up, and the Prostate Imaging Reporting and Data System (PI-RADS) score that would repeat biopsy. Purpose To compare the effectiveness and cost-effectiveness of AS strategies for low-risk PC with versus without MRI. Materials and Methods This study developed a mathematical model to evaluate the cost-effectiveness of surveillance strategies in a simulation of men with a diagnosis of low-risk PC. The following strategies were compared: watchful waiting, prostate-specific antigen (PSA) and annual biopsy without MRI, and PSA testing and MRI with varied PI-RADS thresholds for biopsy. MRI strategies differed regarding scheduling and use of PI-RADS score of at least 3, or a PI-RADS score of at least 4 to indicate the need for biopsy. Life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios were calculated by using microsimulation. Sensitivity analysis was used to assess the impact of varying parameter values on results. Results For the base case of 60-year-old men, all strategies incorporating prostate MRI extended QALYs and life-years compared with watchful waiting and non-MRI strategies. Annual MRI strategies yielded 16.19 QALYs, annual biopsy with no MRI yielded 16.14 QALYs, and watchful waiting yielded 15.94 QALYs. Annual MRI with PI-RADS score of at least 3 or of at least 4 as the biopsy threshold and annual MRI with biopsy even after MRI with negative findings offered similar QALYs and the same unadjusted life expectancy: 23.05 life-years. However, a PI-RADS score of at least 4 yielded 42% fewer lifetime biopsies. With a cost-effectiveness threshold of $100 000 per QALY, annual MRI with biopsy for lesions with PI-RADS scores of 4 or greater was most cost-effective (incremental cost-effectiveness ratio, $67 221 per QALY). Age, treatment type, risk of initial grade misclassification, and quality-of-life impact of procedural complications affected results. Conclusion The use of active surveillance (AS) with biopsy decisions guided by findings from annual MRI reduces the number of biopsies while preserving life expectancy and quality of life. Biopsy in lesions with PI-RADS scores of 4 or greater is likely the most cost-effective AS strategy for men with low-risk prostate cancer who are younger than 70 years. © RSNA, 2021 Online supplemental material is available for this article. An earlier incorrect version appeared online. This article was corrected on July 13, 2021.

Diagnostic efficacy and safety of transperineal prostate targeted and systematic biopsy: The preliminary experience of first 100 cases

BACKGROUND

Post-biopsy urosepsis is a major concern for patient morbidity and cost. Trasperineal biopsy is reported to have less complications and higher detection rate of clinically significant prostate cancer (csPCa).

OBJECTIVES

To determine the diagnostic efficacy and safety of transperineal prostate biopsy in patients with elevated prostatic specific antigen (PSA).

MATERIAL AND METHODS

A prospective study included men with elevated PSA > 3 ng/ml and previous negative biopsy from January 2018 to April 2019. All patients had multiparametric magnetic resonance imaging (mpMRI) and suspicious lesions reported as Prostate Imaging Reporting and Data System (PIRADS) score version 2. Average twelve systematic and two targeted cores were biopsied under general anaesthesia. Patients received single dose of antibiotic prebiopsy.

RESULTS

100 Consecutive patients having median age 64.0 years and median PSA of 6.1ng/ml were included for mpMRI-US fusion transperineal biopsies. Cancer detection rate was 45% (targeted 38% and systematic 22%) and csPCa were detected in 75.55% (targeted 86.84% and systematic 59.09%). MRI-US fusion targeted biopsies detected 63.88% csPCa in PIRADS 5, 33.33% in PIRADS 4 and 5.88% in PIRADS 3 lesions. PSA > 10 (p = 0.012), PSA density > 0.15 (p = 0.0002), and PIRADS 5 (0.0001) were significantly associated with PCa. Factors like Age (0.0001), initial PSA (0.022) and PSA density (0.006) were significant on univariate analysis while age (0.0001) was significant on multivariate analysis. There was no case of urinary tract infection.

CONCLUSIONS

Transperineal prostate biopsy is safe and effective in diagnosing csPCa. There is no risk of sepsis and major complications.

Managing Discordant Findings Between Multiparametric Magnetic Resonance Imaging and Transrectal Magnetic Resonance Imaging-directed Prostate Biopsy-The Key Role of Magnetic Resonance Imaging-directed Transperineal Biopsy

BACKGROUND

Discordant findings between multiparametric magnetic resonance imaging (mpMRI) and transrectal image-guided biopsies of the prostate (TRUS-P) may result in inadequate risk stratification of localized prostate cancer.

OBJECTIVE

To assess transperineal image-guided biopsies of the index target (TPER-IT) in terms of disease reclassification and treatment recommendations.

DESIGN, SETTING, AND PARTICIPANTS

Cases referred for suspicion or treatment of localized prostate cancer were reviewed in a multidisciplinary setting, and discordance was characterized into three scenarios: type I-negative biopsies or International Society of Urological Pathology (ISUP) grade 1 cancer in Prostate Imaging Reporting and Data System (PI-RADS) ≥4 index target (IT); type II-negative biopsies or ISUP grade 1 cancer in anterior IT; and type III-<3 mm stretch of cancer in PI-RADS ≥3 IT. Discordant findings were characterized in 132/558 (23.7%) patients after TRUS-P. Of these patients, 102 received reassessment TPER-IT.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary objective was to report changes in treatment recommendations after TPER-IT. Therefore, cores obtained by primary TRUS-P and TPER-IT were analyzed in terms of cancer detection, ISUP grade, and Cambridge Prognostic Group classification using descriptive statistics.

RESULTS AND LIMITATIONS

TPER-IT biopsies that consisted of fewer cores than the initial TRUS-P (seven vs 14, p < 0.0001) resulted in more cancer tissue materials for analysis (56 vs 42.5 mm, p = 0.0003). As a result, 40% of patients initially considered for follow-up (12/30) and 49% for active surveillance (30/61) were reassigned after TPER-IT to surgery or intensity-modulated radiotherapy.

CONCLUSIONS

Nonconcordance between pathology and imaging was observed in a significant proportion of patients receiving TRUS-P. TPER-IT better informed the presence and grade of cancer, resulting in a significant impact on treatment recommendations. A multidisciplinary review of mpMRI and TRUS-P findings and reassessment TPER-IT in type I-II discordances is recommended.

PATIENT SUMMARY

In this report, patients with suspicious imaging of the prostate, but no or well-differentiated cancer on transrectal image-guided -biopsies, were offered transperineal image-guided biopsies for reassessment. We found that a large share of these had a more aggressive cancer than initially suspected. We conclude that discordant results warrant reassessment transperineal image-guided biopsies as these may impact disease risk classification and treatment recommendations.

Do the Prostate-Specific Antigen (PSA) Tests That Are Ordered in Clinical Practice Adhere to the Pertinent Guidelines?

Scientific societies have provided guidelines to reduce PSA-specific harms. We studied the potential non-compliance of PSA testing with current guidelines in general practice. A cross-sectional study of a random sample of 1291 patients with a PSA test was performed between January and April 2018 in primary health care. Patients with a previous prostate cancer diagnosis or those who were being followed-up for previous high PSA values were excluded. Two independent researchers classified whether each test was potentially non-compliant with recommendations. We estimated frequencies of potentially non-compliant PSA determinations and calculated prevalence ratios (PR) to assess their relationship with possible explanatory variables. A total of 66% (95% CI: 62-69%) of PSA requests in asymptomatic patients were potentially non-compliant with the current guideline. This was associated with having a previous diagnosis of neoplasm (PR adjusted by age and life expectancy: 1.18; 95% CI: 1.02-1.37) as well as being a current consumer of tobacco, alcohol, or other drugs (PR: 0.80; 95% CI: 0.67-0.97). Real world data shows that patients are still frequently exposed to overdiagnosis risk with a PSA potentially non-compliant with recommendations. Patients diagnosed with another neoplasm or non-consumers of toxic substances were more exposed, probably due to increased contact with doctors or health-seeking behaviour.

Blood-Derived Biomarkers of Diagnosis, Prognosis and Therapy Response in Prostate Cancer Patients

Prostate cancer is among the most frequent cancers in men worldwide. Despite the fact that multiple therapeutic alternatives are available for its treatment, it is often discovered in an advanced stage as a metastatic disease. Prostate cancer screening is based on physical examination of prostate size and prostate-specific antigen (PSA) level in the blood as well as biopsy in suspect cases. However, these markers often fail to correctly identify the presence of cancer, or their positivity might lead to overdiagnosis and consequent overtreatment of an otherwise silent non-progressing disease. Moreover, these markers have very limited if any predictive value regarding therapy response or individual risk for therapy-related toxicities. Therefore, novel, optimally liquid biopsy-based (blood-derived) markers or marker panels are needed, which have better prognostic and predictive value than the ones currently used in the everyday routine. In this review the role of circulating tumour cells, extracellular vesicles and their microRNA content, as well as cellular and soluble immunological and inflammation- related blood markers for prostate cancer diagnosis, prognosis and prediction of therapy response is discussed. A special emphasis is placed on markers predicting response to radiotherapy and radiotherapy-related late side effects.

Safety and side effects of transperineal prostate biopsy without antibiotic prophylaxis

STUDY AIMS

To investigate safety and side effects of transperineal prostate biopsy without antibiotic prophylaxis. Secondary aim was to identify whether the number of cores influenced the occurrence of complications.

PATIENTS AND METHODS

A cohort of 184 patients undergoing perineal prostate biopsy without antibiotic prophylaxis from 2015 to 2017 was analyzed retrospectively. On average, 41 cores were taken via two perineal skin punctures. Demographic and clinical data were obtained from patients´ electronic medical records. Binary logistic regression was performed to identify predictors for complications with the following covariates: age, prostate specific antigen (PSA), prostate volume, Prostate Imaging Reporting and Data System score, history of prostatitis, therapeutic anticoagulation, risk factors for urinary tract infection, surgery duration, and the number of biopsy cores. Furthermore, we calculated chi-squared tests with post hoc analyses for differences in the occurrence of complications between quartiles of the above-mentioned parameters.

RESULTS

The overall complication rate was 10.8% (20/185). Out of 20, 19 (95 %) complications were ≤ grade 2 according to the Clavien-Dindo classification. There were two cases of afebrile urinary tract infection, and no patient developed fever or sepsis. Acute urinary retention was reported in 10 patients (5.4 %). The total number of cores was not associated to infectious complications or acute urinary retention rates.

CONCLUSIONS

Transperineal prostate biopsy without antibiotic prophylaxis is a safe procedure. Neither postoperative fever nor sepsis occurred. An increased number of cores through two skin punctures was not associated with more complications.

Probability of Prostate Cancer Diagnosis following Negative Systematic and Targeted MRI: Transrectal Ultrasound Fusion Biopsy: A Real-Life Observational Study

INTRODUCTION

The risk of occult prostate carcinoma (PCa) after negative multiparametric MRI (mpMRI)-transrectal fusion biopsy (F-Bx) is unknown. To determine the false-negative predictive value, we examined PCa detection after prior negative F-Bx.

METHODS

Between December 2012 and November 2016, 491 patients with suspected PCa and suspicious mpMRI findings underwent transrectal F-Bx. Patients with benign pathology (n = 191) were eligible for our follow-up (FU) survey. Patient characteristics and clinical parameters were correlated to subsequent findings of newly detected PCa.

RESULTS

Complete FU with a median of 31 (interquartile range: 17-39) months was available for 176/191 (92.2%) patients. Of those, 54 men had either surgical interventions on the prostate or re-Bxs. Newly detected PCa was evident in 14/176 (7.95%) patients stratified to ISUP ≤2 in 10 and ≥3 in 4 cases. The comparison of patients with newly detected PCa to those without cancerous findings in FU showed significant differences in prostate-specific antigen (PSA) density (0.16 vs. 0.13 ng/mL2) and prostate volume (45 vs. 67 mL, both p < 0.05). Both factors are significant predictors for newly detected cancer after initial negative F-Bx.

CONCLUSION

Only PSA density (>0.13 ng/mL2) and small prostate volume are significant predictors for newly detected PCa after initial negative F-Bx. Despite negative mpMRI/TRUS F-Bx results, patients should be further monitored due to a risk of developing PCa over time. Notwithstanding the limitation of our study that not all patients underwent another Bx, we assume that the false-negative rate is low but existing. Our data represent a real-world scenario.

Challenges and Opportunities of Genomic Approaches in Therapeutics Development

The magnitude of all therapeutic responses is significantly determined by genome structure, variation, and functional interactions. This determination occurs at many levels which are discussed in the current review. Well-established examples of structural variation between individuals are known to dictate an individual's response to numerous drugs, as clearly illustrated by warfarin. The exponential rate of genomic-based interrogation is coupled with an expanding repertoire of genomic technologies and applications. This is leading to an ever more sophisticated appreciation of how structural variation, regulation of transcription and genomic structure, both individually and collectively, define cell therapeutic responses.

Prostate cancer incidence and diagnosis in men with PSA levels >20 ng/ml: is it possible to decrease the number of biopsy cores?

OBJECTIVES

To define if less number of cores would be sufficient to diagnose prostate cancer (PCa) in men with PSA levels >20 ng/ml and to reveal the cancer detection rates in this population.

METHODS

The data of the men who had 12-core prostate biopsy with a PSA value >20 ng/mg were reviewed. We recorded age, prostate volume, PSA level, and pathology report findings. Patients grouped according to PSA levels and compared for PCa detection rates, and several parameters. We created 16 prostate biopsy scenarios (S1-S16) and applied these to our database to find out the best biopsy protocol to detect PCa.

RESULTS

A total of 336 patients with a mean age of 70.5 (47-91) years were included. Mean PSA level was 190.6 (20-5474) ng/ml. PCa detection rates were 55.3%, 81.0%, and 97.7% in patients with PSA levels 20-49.99, 50-99.99, and ≥100 ng/ml, respectively. PSA level was correlated to clinically more important digital rectal examination findings. We selected 2 cores in S1-S6, 4 cores in S7-S12, and 6 cores in S13-S16. We calculated the sensitivity of each scenario and found that all scenarios in PSA Group 3 had a sensitivity >95%. In Group 2, S8, S10, S13, and S14 and in Group 1, only S14 had sensitivity >95%.

CONCLUSIONS

It is not necessary to take 10-12 core biopsy samples in men with PSA levels >20 ng/ml. We recommend taking 2, 4, and 6 samples for patients with PSA levels ≥100 ng/ml, 50-99.99 ng/ml, and 20-49.99 ng/ml, respectively.

Transperineal prostate biopsy: The modern gold standard to prostate cancer diagnosis

In patients suspicious for prostate cancer, a prostate biopsy should be performed. Biopsies are possible either by the transrectal or transperineal routes. Compared with the transrectal prostate biopsy (TRPBx), transperineal prostate biopsy (TPPBx) offers a non-inferior cancer detection rate (CDR), especially in patients undergoing re-biopsy for persistently elevated PSA and in cases of active surveillance (AS), in which TPPBx seems to be superior. Moreover, the transperineal route achieves superior sampling of the anterior and apical regions, especially after previous multiple negative TRPBx. Infectious complications are nullified due to avoidance of needle passage through the rectal mucosa, and there is a highly significant evidence of reduced fever and sepsis rates when compared with TRPBx, with maintaining acceptable urinary retention rates. This is an important upcoming topic due to the increasing antibiotic resistance rates, thus reducing periinterventional hospitalization and health care costs. To date, TPPBx is perfectly feasible in the inpatient and out-patient settings and under local anesthesia, characterized by a moderate learning curve and a good reproducibility. By applying mpMRI as a diagnostic tool, clinically significant prostate cancer (csPCa) detection seems to be comparable to transrectal MRI-fusion biopsy (TR-MRIFBx). Finally, focal treatment of localized disease is currently performed exclusively through a TP approach.

Risk factors for infection complications after transrectal ultrasound-guided transperineal prostate biopsy

BACKGROUND

To investigate the influence factors of infection complications of transrectal ultrasound-guided transperineal prostate biopsy.

METHODS

A total of 2192 patients who underwent prostate biopsy under transperineal prostate biopsy were analyzed retrospectively from December 2010 to May 2020.We collected the clinical characteristics and the incidence of complications, and used univariate and multivariate logistic regression analyses to analyze independent risk factors for infection complications after transperineal prostate biopsy.

RESULTS

Univariate analysis showed that the following factors were associated with the infection complications: diabetes, bacterial prostatitis, history of urinary retention, history of urinary infection, and number of cores. Furthermore, multivariate logistic analysis revealed that diabetes (OR 2.037, 95% CI 1.143-3.572, P = 0.021) and history of urinary retention (OR 2.563, 95% CI 1.284-3.901, P = 0.013) were independent risk factors for infection complications after transperineal prostate biopsy.

CONCLUSIONS

Patients with diabetes and history of urinary retention were more likely to have infection complications after transperineal prostate biopsy.