Indications, Utilization and Complications Following Prostate Biopsy: New York State Analysis

Enhancing prostate cancer diagnosis and reducing unnecessary biopsies with [18F]DCFPyL PET/CT imaging in PI-RADS 3/4 patients

For patients presenting with prostate imaging reporting and data system (PI-RADS) 3/4 findings on magnetic resonance imaging (MRI) examinations, the standard recommendation typically involves undergoing a biopsy for pathological assessment to ascertain the nature of the lesion. This course of action, though essential for accurate diagnosis, invariably amplifies the psychological distress experienced by patients and introduces a host of potential complications associated with the biopsy procedure. However, [18F]DCFPyL PET/CT imaging emerges as a promising alternative, demonstrating considerable diagnostic efficacy in discerning benign prostate lesions from malignant ones. This study aims to explore the diagnostic value of [18F]DCFPyL PET/CT imaging for prostate cancer in patients with PI-RADS 3/4 lesions, assisting in clinical decision-making to avoid unnecessary biopsies. 30 patients diagnosed with PI-RADS 3/4 lesions through mpMRI underwent [18F]DCFPyL PET/CT imaging, with final biopsy pathology results as the "reference standard". Diagnostic performance was assessed through receiver operating characteristic (ROC) analysis, evaluating the diagnostic efficacy of molecular imaging PSMA (miPSMA) visual analysis and semi-quantitative analysis in [18F]DCFPyL PET/CT imaging. Lesions were assigned miPSMA scores according to the prostate cancer molecular imaging standardized evaluation criteria. Among the 30 patients, 13 were pathologically confirmed to have prostate cancer. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of visual analysis in [18F]DCFPyL PET/CT imaging for diagnosing PI-RADS 3/4 lesions were 61.5%, 88.2%, 80.0%, 75.0%, and 76.5%, respectively. Using SUVmax 4.17 as the optimal threshold, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for diagnosis were 92.3%, 88.2%, 85.7%, 93.8%, and 90.0%, respectively. The area under the ROC curve (AUC) for semi-quantitative analysis was 0.94, significantly higher than visual analysis at 0.80. [18F]DCFPyL PET/CT imaging accurately diagnosed benign lesions in 15 (50%) of the PI-RADS 3/4 patients. For patients with PI-RADS 4 lesions, the positive predictive value of [18F]DCFPyL PET/CT imaging reached 100%. [18F]DCFPyL PET/CT imaging provides potential preoperative prediction of lesion nature in mpMRI PI-RADS 3/4 patients, which may aid in treatment decision-making and reducing unnecessary biopsies.

Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted and Systematic Prostate Biopsy to Prevent Infectious Complications: The PREVENT Randomized Trial

BACKGROUND AND OBJECTIVE

The transrectal biopsy approach is traditionally used to detect prostate cancer. An alternative transperineal approach is historically performed under general anesthesia, but recent advances enable transperineal biopsy to be performed under local anesthesia. We sought to compare infectious complications of transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis.

METHODS

We assigned biopsy-naïve participants to undergo transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis (rectal culture screening for fluoroquinolone-resistant bacteria and antibiotic targeting to culture and sensitivity results) through a multicenter, randomized trial. The primary outcome was post-biopsy infection captured by a prospective medical review and patient report on a 7-d survey. The secondary outcomes included cancer detection, noninfectious complications, and a numerical rating scale (0-10) for biopsy-related pain and discomfort during and 7-d after biopsy.

KEY FINDINGS AND LIMITATIONS

A total of 658 participants were randomized, with zero transperineal versus four (1.4%) transrectal biopsy infections (difference -1.4%; 95% confidence interval [CI] -3.2%, 0.3%; p = 0.059). The rates of other complications were very low and similar. Importantly, detection of clinically significant cancer was similar (53% transperineal vs 50% transrectal, adjusted difference 2.0%; 95% CI -6.0, 10). Participants in the transperineal arm experienced worse periprocedural pain (0.6 adjusted difference [0-10 scale], 95% CI 0.2, 0.9), but the effect was small and resolved by 7-d.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Office-based transperineal biopsy is tolerable, does not compromise cancer detection, and did not result in infectious complications. Transrectal biopsy with targeted prophylaxis achieved similar infection rates, but requires rectal cultures and careful attention to antibiotic selection and administration. Consideration of these factors and antibiotic stewardship should guide clinical decision-making.

PATIENT SUMMARY

In this multicenter randomized trial, we compare prostate biopsy infectious complications for the transperineal versus transrectal approach. The absence of infectious complications with transperineal biopsy without the use of preventative antibiotics is noteworthy, but not significantly different from transrectal biopsy with targeted antibiotic prophylaxis.

Shifting to transperineal prostate biopsy: A narrative review

To address the limitations and challenges associated with transrectal (TR) biopsy and to present transperineal (TP) biopsy as a viable and potentially safer alternative to TR biopsy. Prostate cancer (PCa) is a significant global health concern. The prevalence of advanced-stage prostate cancer in Asia is higher than that in the United States, emphasizing the need for effective screening and diagnosis methods. The gold standard of diagnosis is a TR biopsy. However, it has limitations due to the risk of infection and potential complications, such as injury to the rectal artery. Efforts have been made to address issues such as false-negative biopsies, under-sampling, and over-sampling through MRI-guided biopsies. However, the TR approach makes it difficult to access the apical and anterior regions of the prostate. TP biopsy has emerged as an alternative to address the limitations of TR biopsy. Nevertheless, a TP biopsy is a painful procedure, requiring the use of general anesthesia and expensive equipment. As a result, it has been perceived as costly and time-consuming. In addition, it requires a steep learning curve. The introduction of local anesthesia such as pudendal nerve block and the adoption of freehand techniques have contributed to the feasibility of performing TP biopsy. Recent research indicates that freehand TP biopsy can yield comparable diagnostic results to template-guided approaches. The diagnostic performance, cancer detection rates, and complication rates of TP biopsy have demonstrated its potential as a safe and effective diagnostic method.

Evaluating the Learning Curve for In-office Freehand Cognitive Fusion Transperineal Prostate Biopsy

OBJECTIVE

To define the learning curve of the in-office, freehand MRI-ultrasound cognitive fusion transperineal prostate biopsy (CTPB) by assessing cancer detection, biopsy core quantity and quality, procedure times, and complications over the initial experience.

METHODS

We reviewed 110 consecutive CTPB performed March 2021-September 2022 by a urologist inexperienced with the PrecisionPoint platform. The study period was divided into quarters to assess for temporal variation in outcomes. Univariable and multivariable analysis modeled the learning curve.

RESULTS

Across quarters, there were no differences in the detection of clinically significant prostate cancer (Q1:50%, Q2:52%, Q3:50%, Q4:48%, P > .9) or Gleason grade group upgrading by targeted vs systematic biopsy (P = .6). Median procedure times improved with experience (Q1:17 minutes, Q2:14 minutes, Q3:12 minutes, Q4:13 minutes, P = .018). On multivariable analysis, procedure times decreased by 1minute per 20 cases (P < .001). On linear regression, CTPB procedure times approximated transrectal biopsy times after 90 cases (P < .001). The histopathologic core quality did not differ, as evidenced by consistent core length (P = .13) and presence of minimal fibromuscular tissue (P > .9). The most common complications, hematuria and hematospermia, were similar across quarters (P = .7, P = .3, respectively). There was a single episode of urinary retention and no reported infections.

CONCLUSION

There is no evidence of a learning curve for CTPB as shown by consistent clinically significant prostate cancer detection, high-quality biopsy cores, and low complications. However, CTPB procedural times begin to approximate cognitive targeted transrectal biopsy times after 90 cases.

Trends and variation in prostate cancer diagnosis via transperineal biopsy in Australia and New Zealand

BACKGROUND

To describe changes in the use of prostate biopsy techniques among men diagnosed with prostate cancer in Australia and New Zealand and examine factors associated with these changes.

METHODS

We extracted data between 2015 and 2019 from 7 jurisdictions of the Australia and New Zealand Prostate Cancer Outcomes Registry (PCOR-ANZ). Distribution and time trend of transrectal (TR) vs. transperineal (TP) biopsy type, differences in the proportion of biopsy type by geographic jurisdiction, diagnosing institute characteristics (public vs. private, metropolitan vs. regional, case volume) and patient characteristics such as socio-economic status (SES), and location of residence were analyzed.

RESULTS

We analyzed data from 37,638 patients. The overall proportion of prostate cancer diagnosed by TP increased from 26% to 57% between 2015 and 2019. Patients living in a major city, a more socioeconomically advantaged area or who were diagnosed in a metropolitan or private hospital were more likely to have TP than TR. While all subgroups were observed to increase their use of TP over the study period, uptake grew faster for men from low SES areas and those diagnosed at a regional or low-volume hospital but slower for men living in outer regional/remote areas or treated at a public hospital.

CONCLUSIONS

In this binational registry, prostate cancer is now more commonly diagnosed by TP than the TR approach. While the gap between uptakes of TP has diminished for patients with low vs. high SES, disparity has widened for patients from outer regional areas vs major cities and public vs. private hospitals.

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.

Initial Outcomes of Freehand Transperineal Biopsies Regarding Diagnostic Value and Safety: An Early Experience at King Fahad Specialist Hospital, Buraydah, Saudi Arabia

BACKGROUND

Prostate cancer is a common type of cancer in Saudi Arabia with a high incidence rate. Trans-rectal ultrasound guided prostatic biopsy (TRUSBx) has been the standard diagnostic study for prostate cancer since a landmark study in 1989 which showed that it is better than digitally directed biopsy sampling of the prostate. As an alternative to TRUSBx, transperineal biopsies (TPBx) have gained popularity as they give a higher accuracy rate and avoid many complications. A new study has been conducted in Riyadh, Saudi Arabia to compare TRUSBx and TPBx showed that TPBx has a significantly higher detection rate of prostate cancer cases compared to TRUSBx (45.1% vs. 29.1%, p=0.003). The aim of this study is to determine the diagnostic value and safety of freehand transperineal prostate biopsy in patients with an elevated prostatic specific antigen (PSA) and/or abnormal digital rectal exam in King Fahad Specialist Hospital KFSH in Buraydah, Qassim region, Saudi Arabia.

METHODS

This is an observational retrospective study of all patients (n=39) who underwent transperineal biopsies at KFSH to assess the diagnostic value and safety of the procedure.

RESULTS

The mean age of the patients was 70.3 (SD 10.1) years. The most commonly found diagnosis was adenocarcinoma (61.5%), and incidence of complications was detected in (5.1%) of the patients.

CONCLUSION

We concluded that the freehand technique TPBx has a high accuracy rate in detecting prostatic cancer. However, the learning curve could be a limiting factor in implementing it. Increasing the number of biopsies could positively affect diagnostic accuracy, especially with our low complication rate in this procedure. A low number of biopsies in the older age group can give an accurate result with a low risk of complications. Although template-guided TPBx and robot-guided TPBx are better options, the freehand technique represents a cost-effective and time-saving alternative. However, more studies are needed to compare the outcome of such a technique.

Utilizing a Questionnaire to Implement a Risk-based Antibiotic Prophylaxis Protocol for Transrectal Prostate Biopsy

OBJECTIVE

To develop and evaluate a risk-based antibiotic prophylaxis protocol for patients undergoing transrectal prostate biopsy.

METHODS

We created a risk-based protocol for antibiotic prophylaxis before transrectal prostate biopsy. Patients were screened for infection risk-factors with a self-administered questionnaire. The protocol was implemented from January 1, 2020 to March 31, 2020. We compared patient risk-factors, antibiotic regimens, and 30-day infection rates for patients undergoing transrectal prostate biopsies during the intervention and for a 3-month period before the intervention.

RESULTS

There were 116 prostate biopsies in the preintervention group and 104 in the intervention group. Although there was no significant difference in the number of high-risk patients between the 2 groups (48% vs 55%; P = .33), the percentage of patients treated with augmented prophylaxis decreased from 74% to 45% (P = 0.03). The duration of antibiotic administration and the median number of doses prescribed also decreased significantly. Despite significant decreases in antibiotic use, there were no differences in infection rates (5% vs 5%; P = .90) or sepsis rates (1% vs 2%; P = .60).

CONCLUSION

We developed a risk-based protocol for prophylactic antibiotics before prostate biopsy. The protocol was associated with less antibiotic use but did not lead to an increase in infectious complications.

Quality-of-Life Outcomes and Toxicity Profile Among Patients With Localized Prostate Cancer After Radical Prostatectomy Treated With Stereotactic Body Radiation: The SCIMITAR Multicenter Phase 2 Trial

PURPOSE

Postoperative radiation therapy (RT) is an underused standard-of-care intervention for patients with prostate cancer and recurrence/adverse pathologic features after radical prostatectomy. Although stereotactic body RT (SBRT) is a well-studied and convenient option for definitive treatment, data on the postprostatectomy setting are extremely limited. The purpose of this study was to evaluate short-term physician-scored genitourinary (GU) and gastrointestinal (GI) toxicities and patient-reported outcomes after postprostatectomy SBRT.

METHODS AND MATERIALS

The SCIMITAR trial was a phase 2, dual-center, open-label, single-arm trial that enrolled patients with postoperative prostate-specific antigen >0.03 ng/mL or adverse pathologic features. Coprimary endpoints were 4-year biochemical recurrence-free survival, physician-scored acute and late GU and GI toxicities by the Common Terminology Criteria for Adverse Events (version 4.03) scale, and patient-reported quality-of-life (QOL) outcomes, as represented by the Expanded Prostate Cancer Index-26 and the International Prostate Symptom Score. Patients received SBRT 30 to 34 Gy/5 fractions to the prostate bed ± bed boost ± pelvic nodes with computed tomography (CTgRT) or magnetic resonance imaging guidance (MRgRT) in a nonrandomized fashion. Physician-scored toxicities and patient-reported QOL outcomes were collected at baseline and at 1, 3, and 6 months of follow-up. Univariable and multivariable analyses were performed to evaluate predictors of toxicities and QOL outcomes.

RESULTS

One hundred participants were enrolled (CTgRT, n = 69; MRgRT, n = 31). The median follow-up was 29.5 months (CTgRT: 33.3 months, MRgRT: 22.6 months). The median (range) prostate bed dose was 32 (30-34) Gy. Acute and late grade 2 GU toxicities were both 9% while acute and late grade 2 GI toxicities were 5% and 0%, respectively. Three patients had grade 3 toxicity (n = 1 GU, n = 2 GI). No patient receiving MRgRT had grade 3 GU or grade ≥2 GI toxicity. Compared with CTgRT, MRgRT was associated with a 30.5% (95% confidence interval, 11.6%-49.5%) reduction in any-grade acute GI toxicity (P = .006). MRgRT was independently associated with improved any-grade GI toxicity and improved bowel QOL.

CONCLUSIONS

Postprostatectomy SBRT was well tolerated at short-term follow-up. MRgRT may decrease GI toxicity. Longer toxicity and/or efficacy follow-up and randomized studies are needed.

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.

The use of advanced imaging in guiding the further investigation and treatment of primary prostate cancer

In the era of precision medicine, oncological imaging techniques are advancing at a rapid pace, particularly molecular imaging with promising new targets for prostate cancer (PC) such as gastrin releasing peptide receptors (GRPR) along the established and indispensable prostate specific membrane antigen (PSMA). As PC is characterized by heterogenous tumor biology ranging from indolent to aggressive disease, distinguishing clinically significant tumors from indolent disease is critical. Multiparametric MRI- and PET-targeted prostate biopsies mitigate the shortcomings and risks of standard systematic template biopsy by identifying more significant cancers.Focal treatment for localized disease is a minimally invasive approach that targets the index tumor - the lesion of the highest grade - while sparing the surrounding healthy tissue. Real-time MRI-guidance and thermal control with MR-thermometry, improves treatment accuracy and results in lower rates of functional side effects. PET imaging could be an useful tool to assess response to treatment compared to invasive prostate biopsies.In this comprehensive review, we focus on the image-guided detection and treatment of localized primary prostate cancer, its current status and future perspectives.

Augmenting prostate magnetic resonance imaging reporting to incorporate diagnostic recommendations based upon clinical risk calculators

Risk calculators have offered a viable tool for clinicians to stratify patients at risk of prostate cancer (PCa) and to mitigate the low sensitivity and specificity of screening prostate specific antigen (PSA). While initially based on clinical and demographic data, incorporation of multiparametric magnetic resonance imaging (MRI) and the validated prostate imaging reporting and data system suspicion scoring system has standardized and improved risk stratification beyond the use of PSA and patient parameters alone. Biopsy-naïve patients with lower risk profiles for harboring clinically significant PCa are often subjected to uncomfortable, invasive, and potentially unnecessary prostate biopsy procedures. Incorporating risk calculator data into prostate MRI reports can broaden the role of radiologists, improve communication with clinicians primarily managing these patients, and help guide clinical care in directing the screening, detection, and risk stratification of PCa.

A machine learning approach to predict progression on active surveillance for prostate cancer

PURPOSE

Robust prediction of progression on active surveillance (AS) for prostate cancer can allow for risk-adapted protocols. To date, models predicting progression on AS have invariably used traditional statistical approaches. We sought to evaluate whether a machine learning (ML) approach could improve prediction of progression on AS.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients diagnosed with very-low or low-risk prostate cancer between 1997 and 2016 and managed with AS at our institution. In the training set, we trained a traditional logistic regression (T-LR) classifier, and alternate ML classifiers (support vector machine, random forest, a fully connected artificial neural network, and ML-LR) to predict grade-progression. We evaluated model performance in the test set. The primary performance metric was the F1 score.

RESULTS

Our cohort included 790 patients. With a median follow-up of 6.29 years, 234 developed grade-progression. In descending order, the F1 scores were: support vector machine 0.586 (95% CI 0.579 - 0.591), ML-LR 0.522 (95% CI 0.513 - 0.526), artificial neural network 0.392 (95% CI 0.379 - 0.396), random forest 0.376 (95% CI 0.364 - 0.380), and T-LR 0.182 (95% CI 0.151 - 0.185). All alternate ML models had a significantly higher F1 score than the T-LR model (all p <0.001).

CONCLUSION

In our study, ML methods significantly outperformed T-LR in predicting progression on AS for prostate cancer. While our specific models require further validation, we anticipate that a ML approach will help produce robust prediction models that will facilitate individualized risk-stratification in prostate cancer AS.

Outcomes of Freehand Transperineal Prostate Biopsy with Omission of Antibiotic Prophylaxis

OBJECTIVE

To assess the utility of antimicrobial prophylaxis when performing freehand systematic transperineal biopsy.

PATIENTS AND METHODS

From 1/2012 to 2/2020, freehand transperineal prostate biopsy via angiocatheters or the PrecisionPoint Transperineal Access System was performed on consecutive men with clinical suspicion of prostate cancer or confirmed prostate cancer. Biopsies were performed by a single urologist (developer of the PrecisionPoint system). Clinical data was collected retrospectively. Pre-procedural antibiotics were given to all patients through September 6th, 2016. After this date, antibiotics were omitted from those without risk factors (chronic catherization, concurrent endoscopic procedure, history of sepsis after transrectal (TR) biopsy, history of TR biopsy within the last year, prosthetic joints/heart valves). Patients were assessed one week after biopsy for symptoms, Emergency Department visits, and hospital admissions. Patients who received antimicrobial prophylaxis were compared to those who did not and infectious complications were analyzed. Additionally, oncologic outcomes are reported.

RESULTS

988 biopsies (median PSA 7.7 ng/ml) were included in the analysis on 756 men. 538 biopsies (54.4%) received prophylaxis and 450 (48.6%) did not receive prophylaxis. There was a statistical difference in the median age (67 vs 69 years, p < 0.001), abnormal DRE (13% vs 5%, p < 0.001), and history of mpMRI (15% vs 31%, p < 0.001) between the prophylaxis and no prophylaxis cohorts, respectively. There were no documented complications in those who received antibiotics. Within the no prophylaxis cohort, there were three (0.66%) complications (p = 0.09). Two (0.44%) patients had UTIs and one (0.22%) patient experienced post-procedural urinary retention. No patients required hospital admission or ED visit. Clinically significant cancer was detected in 152 (40.0%) and 64 (39.0%) men on initial biopsy and prior negative biopsy, respectively.

CONCLUSIONS

This data suggests that antimicrobial prophylaxis may be safely omitted in selected patients when utilizing the freehand transperineal approach.

Association of Prostate-Specific Antigen Velocity With Clinical Progression Among African American and Non-Hispanic White Men Treated for Low-Risk Prostate Cancer With Active Surveillance

IMPORTANCE

The association of prostate-specific antigen velocity (PSAV) with clinical progression in patients with localized prostate cancer managed with active surveillance remains unclear and, to our knowledge, has not been studied in African American patients.

OBJECTIVES

To test the hypothesis that PSAV is associated with clinical progression in patients with low-risk prostate cancer treated with active surveillance and to identify differences between African American and non-Hispanic White patients.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective population-based cohort study using patient records from the Veterans Heath Administration Informatics and Computing Infrastructure on 5296 patients with a diagnosis of localized prostate cancer from January 1, 2001, to December 31, 2015, who were managed with active surveillance. Follow-up extended through March 31, 2020. Low-risk prostate cancer was defined as International Society of Urologic Pathology grade group (GG) 1 clinical tumor stage 2A or lower, PSA level of 10 ng/dL or lower, active surveillance, and no definitive treatment within the first year after diagnosis with at least 1 additional staging biopsy after diagnostic biopsy.

EXPOSURES

Prostate-specific antigen testing.

MAIN OUTCOMES AND MEASURES

The primary outcome was GG progression detected after repeated biopsy or prostatectomy, defined as GG2 or higher or GG3 or higher. The secondary outcome was incident metastases. Cumulative incidence functions and multivariable Cox proportional hazards regression models were used to test associations between PSAV and outcomes.

RESULTS

The final cohort (n = 5296) included 3919 non-Hispanic White men (74.0%; mean [SD] age, 65.7 [5.8] years) and 1377 African American men (26.0%; mean [SD] age, 62.8 [6.6] years). Compared with African American patients, non-Hispanic White patients were older (mean [SD] age, 65.7 [5.8] years vs 62.8 [6.6] years; P < .001), presented with higher cT stage (stage T2, 608 [15.5%] vs 111 [8.1%]; P < .001), had a higher Charlson Comorbidity Index score (1 and ≥2, 912 [23.3%] vs 273 [19.8%]; P = .002), had higher median income ($60 000 to ≥$100 000, 1223 [31.2%] vs 282 [20.5%]; P < .001), and had a higher median level of education (20% to ≥30% with college degree, 1192 [30.4%] vs 333 [24.2%]; P < .001). Progression to GG2 or higher occurred in 2062 patients (38.9%), with a cumulative incidence of 43.2%, and progression to GG3 or higher occurred in 728 patients (13.7%). Fifty-four patients (1.0%) developed metastases. On multivariable analysis, PSAV was significantly associated with progression to GG2 (hazard ratio, 1.32 [95% CI, 1.26-1.39]), GG3 (hazard ratio, 1.51 [95% CI, 1.41-1.62]), and metastases (hazard ratio, 1.38 [95% CI, 1.10-1.74]). Optimal PSAV thresholds that were associated with progression were significantly lower for African American patients (0.44 ng/mL/y) compared with non-Hispanic White patients (1.18 ng/mL/y).

CONCLUSIONS AND RELEVANCE

This study suggests that PSAV is significantly associated with grade progression among patients with low-risk prostate cancer managed with active surveillance, but at lower values for African American patients compared with non-Hispanic White patients. These data suggest that serial PSA measures may potentially substitute for multiple prostate biopsies and that African American patients may merit increased frequency of PSA testing.

Preventing Prostate Biopsy Complications: to Augment or to Swab?

OBJECTIVE

To use data from a large, prospectively- acquired regional collaborative database to compare the risk of infectious complications associated with three American Urologic Association- recommended antibiotic prophylaxis pathways, including culture-directed or augmented antibiotics, following prostate biopsy.

METHODS

Data on prostate biopsies and outcomes were collected from the Pennsylvania Urologic Regional Collaborative, a regional quality collaborative working to improve the diagnosis and treatment of prostate cancer. Patients were categorized as receiving one of three prophylaxis pathways: culture-directed, augmented, or provider-discretion. Infectious complications included fever, urinary tract infections or sepsis within one month of biopsy. Odds ratios of infectious complication by pathway were determined, and univariate and multivariate analyses of patient and biopsy characteristics were performed.

RESULTS

11,940 biopsies were included, 120 of which resulted in infectious outcomes. Of the total biopsies, 3246 used "culture-directed", 1446 used "augmented" and 7207 used "provider-discretion" prophylaxis. Compared to provider-discretion, the culture-directed pathway had 84% less chance of any infectious outcome (OR= 0.159, 95% CI = [0.074, 0.344], P < 0.001). There was no difference in infectious complications between augmented and provider-discretion pathways.

CONCLUSIONS

The culture-directed pathway for transrectal prostate biopsy resulted in significantly fewer infectious complications compared to other prophylaxis strategies. Tailoring antibiotics addresses antibiotic-resistant bacteria and reduces future risk of resistance. These findings make a strong case for incorporating culture-directed antibiotic prophylaxis into clinical practice guidelines to reduce infection following prostate biopsies.

Using Prostate Imaging-Reporting and Data System (PI-RADS) Scores to Select an Optimal Prostate Biopsy Method: A Secondary Analysis of the Trio Study

BACKGROUND

While magnetic resonance imaging (MRI)-targeted biopsy (TBx) results in better prostate cancer (PCa) detection relative to systematic biopsy (SBx), the combination of both methods increases clinically significant PCa detection relative to either Bx method alone. However, combined Bx subjects patients to higher number of Bx cores and greater detection of clinically insignificant PCa.

OBJECTIVE

To determine if prebiopsy prostate MRI can identify men who could forgo combined Bx without a substantial risk of missing clinically significant PCa (csPC).

DESIGN, SETTING, AND PARTICIPANTS

Men with MRI-visible prostate lesions underwent combined TBx plus SBx.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcomes were detection rates for grade group (GG) ≥2 and GG ≥3 PCa by TBx and SBx, stratified by Prostate Imaging-Reporting and Data System (PI-RADS) score.

RESULTS AND LIMITATIONS

Among PI-RADS 5 cases, nearly all csPCs were detected by TBx, as adding SBx resulted in detection of only 2.5% more GG ≥2 cancers. Among PI-RADS 3-4 cases, however, SBx addition resulted in detection of substantially more csPCs than TBx alone (7.5% vs 8%). Conversely, TBx added little to detection of csPC among men with PI-RADS 2 lesions (2%) relative to SBx (7.8%).

CONCLUSIONS

While combined Bx increases the detection of csPC among men with MRI-visible prostate lesions, this benefit was largely restricted to PI-RADS 3-4 lesions. Using a strategy of TBx only for PI-RADS 5 and combined Bx only for PI-RADS 3-4 would avoid excess biopsies for men with PI-RADS 5 lesions while resulting in a low risk of missing csPC (1%).

PATIENT SUMMARY

Our study investigated an optimized strategy to diagnose aggressive prostate cancer in men with an abnormal prostate MRI (magnetic resonance imaging) scan while minimizing the risk of excess biopsies. We used a scoring system for MRI scan images called PI-RADS. The results show that MRI-targeted biopsies alone could be used for men with a PI-RADS score of 5, while men with a PI-RADS score of 3 or 4 would benefit from a combination of MRI-targeted biopsy and systematic biopsy. This trial is registered at ClinicalTrials.gov as NCT00102544.

Fosfomycin-trometamol (FT) or fluoroquinolone (FQ) as single-dose prophylaxis for transrectal ultrasound-guided prostate biopsy (TRUS-PB): A prospective cohort study

OBJECTIVES

The increasing incidence of fluoroquinolones (FQ) resistance may lower its efficacy in preventing UTI following transrectal ultrasound-guided prostate biopsy (TRUS-PB). We assessed the efficacy and safety of FQ and fosfomycin-trometamol (FT) in patients undergoing TRUS-PB.

METHODS

A prospective observational study was conducted between April 2017 and June 2019 and enrolled men undergoing TRUS-PB and receiving a single-dose of FQ (FQ-arm) or FT (FT-arm) for UTI prophylaxis per physician's choice. The primary efficacy endpoint was self-reported TRUS-PB UTI. We assessed baseline factors associated with UTI with logistic regression.

RESULTS

A total of 222 men were enrolled, 141/222 (64%) received FQ, and 81/222 (36%) FT. The median age was 67.6 years [IQR, 61.4-72.1] and the Charlson score was 3 [IQR, 3-5]. The overall incidence of self-reported TRUS-PB UTI was 12% (24/197, (95%CI, 8%-17%)): 15% (17/116, (95% CI, 10%-17%)) in FQ-arm, versus 9% (7/81, 95% CI (5%-13%)) in FT-arm (RR = 0.55 (95% CI, 0.22-1.40), p-value = 0.209). No baseline characteristic was significantly associated with TRUS-PB UTI. Safety was similar between the arms: the rate of the reported adverse event was 31% (36/116, (95% CI, 25%-37%) in the FQ-arm versus 36% (28/81, (95% CI, 28%-41%)) in the FT-arm (RR = 1.17 (95% CI, 0.64-2.15), p = 0.602).

CONCLUSIONS

TRUS-PB UTI prophylaxis with FT and FQ has similar efficacy and safety. A randomized comparison of these two antibiotics is warranted.

A Retrospective Comparison of Transrectal and Transperineal Prostate Biopsies: Experience of a Single Surgeon

Background: Transrectal ultrasound-guided prostate biopsy (TRUS) is the gold standard for undertaking prostate biopsy, however, it has been associated with higher rates of post-biopsy sepsis than transperineal prostate biopsy (TP). Objective: To compare complication rates between transrectal prostate biopsy and TP for a single surgeon. Materials and Methods: Data were collected for all prostate biopsies undertaken by a single experienced urologist through his private rooms between February 2012 and March 2018. In total, 693 cases were included (560 individual men) in the final analysis (transrectal = 276 and transperineal = 417). All patients were followed up 2 weeks post-biopsy, and complications were recorded (sepsis, urinary tract infection [UTI], bleeding, and acute urinary retention [AUR]). Results: Complications occurred in 37 cases (transrectal = 3 and transperineal = 34). Sepsis occurred in one case following transrectal biopsy (0.36%) and two cases following TP (0.48%). UTI occurred in two cases following transrectal biopsy (0.72%) and two cases following transperineal (0.48%). Bleeding occurred in one case following TP (0.24%). The most common complication was AUR, which occurred in 28 cases following TP (6.71%). Conclusions: Data from this study compared complication rates for both transperineal and transrectal prostate biopsies in a single-surgeon study.

The impact of complications after initial prostate biopsy on repeat protocol biopsy acceptance rate. Results from the Prostate Cancer Research International: Active Surveillance JAPAN study

BACKGROUND

Patients with favorable-risk prostate cancer on active surveillance (AS) are strictly followed for safer execution. Repeat protocol biopsy is essential for evaluating cancer aggressiveness. However, the acceptance rate of repeat biopsy is not high enough because of the burdens of biopsy. We assessed the impact of complications after the initial biopsy on repeat protocol biopsy at 1 year using data from the Prostate Cancer Research International: Active Surveillance (PRIAS)-JAPAN study.

METHODS

We performed a retrospective analysis using a prospective cohort in the PRIAS-JAPAN study. Patients with favorable-risk prostate cancer (n = 856) who consented to participate in the PRIAS-JAPAN study from 2010 to 2018 were enrolled. Follow-up evaluations included regular prostate-specific antigen, digital rectal examination and biopsy. Rates of complications after biopsies and repeat protocol biopsy non-acceptance rate at 1 year were reported. Logistic regression analysis explored the association between the complications after the initial biopsy and repeat protocol biopsy non-acceptance.

RESULTS

Altogether, 759 patients (88.7%) actually proceeded to protocol at 1 year. Repeat protocol biopsy non-acceptance rate at 1 year was 14.9%. Regarding complications after the initial biopsy, hematuria (p = 0.028) and pain (p < 0.001) rates were significantly higher in the repeat biopsy non-acceptance group, but infection (p = 0.056) and hematospermia (p = 0.337) rates were not different. On multivariate logistic regression analysis, pain was a significant predictor for repeat protocol biopsy non-acceptance (odds ratio 4.68, 95% confidence interval 1.864-11.75; p = 0.001).

CONCLUSIONS

Pain at the initial biopsy negatively impacts patients' compliance with further protocol biopsies during AS.

Transrectal versus transperineal prostate biopsy under intravenous anaesthesia: a clinical, microbiological and cost analysis of 2048 cases over 11 years at a tertiary institution

BACKGROUND

Transrectal (TR) and transperineal (TP) approaches for prostate biopsy have different morbidity profiles. Our institution transitioned to a preference for multiparametric MRI-based triage and TP biopsy since 2014. The aim of this study was to compare clinical, microbiological and health economic outcomes between TR and TP prostate biopsy.

METHODS

A consecutive cohort study considered prostate biopsies over an 11 year period. Hospital presentations across the region within 30 days of biopsy were analysed for details and subsequent outcomes according to biopsy approach. Cost for each encounter (routine and unplanned) were analysed and generalised linear models applied, as well as cost implications for inclusion of mpMRI-based triage and TP biopsy preference.

RESULTS

In total, 2048 prostate biopsies were performed. Similar re-presentation rates per occurred for each biopsy approach (90 patients, TR 4.8%, TP 3.8%, p = 0.29), with 23 patients presenting more than once (119 total presentations). Presentations after TR biopsy were more likely to be of infectious aetiology (TR 2.92%, TP 0.26% de novo, p < 0.001) and result in hospital admission (TR 43/49, 93.4%; TP 14/24, 58.3%; p = 0.007) for similar rates of urinary retention (TR 2.76% vs TP 3.63%, p = 1). The mean overall cost (biopsy and re-presentations) was higher for the TP group (p < 0.001), adjusted for year and age, but reduced over time and was similar for patients who re-presented (p = 0.98). Incorporation of mpMRI (with subsequently avoided biopsies), TP biopsy and re-presentations resulted in AU$783.27 saving per biopsy.

CONCLUSIONS

TR biopsy resulted in more infectious complications and hospital admissions than TP biopsy for similar rates of re-presentation and urinary retention. TP biopsy costs reduced over time and use in conjunction with mpMRI provides an overall cost saving. Routine TP biopsy is safe and feasible, with further cost savings expected with other approaches (local anaesthetic) under investigation.

The clinical and financial implications of a decade of prostate biopsies in the NHS: analysis of Hospital Episode Statistics data 2008-2019

OBJECTIVE

To evaluate the clinical and financial implications of a decade of prostate biopsies performed in the UK National Health Service (NHS) through the transrectal (TR) vs the transperineal (TP) route.

METHODS

We conducted an evaluation of the TR vs the TP biopsy approach in the context of 28 days post-procedure complications and readmissions. A secondary evaluation of burden of expenditure in NHS hospitals over the entire decade (2008-2019) was conducted through examination of national Hospital Episode Statistics (HES) data.

RESULTS

In this dataset of 486 467 prostate biopsies (387 879 TR and 98 588 TP biopsies), rates of infection and sepsis were higher for the TR compared to the TP cohort (0.53% vs 0.31%; P < 0.001, confidence interval 99% ). Rates of sepsis have more than doubled for TR biopsies in the last 2 years compared to the previous decade (1.12% vs 0.53%). Infective complications were the main reasons for readmissions in the TR cohort, whereas urinary retention was the predominant reason for readmission in the TP cohort. Over the last decade, non-elective (NEL) readmissions seem higher for the TP group; however, in the last 2 years these have reduced compared to the TR group (3.54% vs 3.74%). The cost estimates for NEL readmissions for the entire decade were £33,589,527.00 and £7,179,926.00 respectively, for TR and TP cohorts (P < 0.001). Estimated costs per patient readmission were £2,225.00 and £1,758.00 in the TR and TP groups (P < 0.001).

CONCLUSIONS

Evaluation of nearly half a million prostate biopsies in the NHS over the entire decade gives sufficient evidence for the distinct advantages of the TP route over the TR route in terms of reduced infections and burden of expenditure. In addition, there is a potential for savings both in upstream and downstream costs if biopsy is performed under a local anaesthetic.

Comparison of complications after transrectal and transperineal prostate biopsy: a national population-based study

OBJECTIVES

To assess the complications of transrectal (TR) compared to transperineal prostate (TP) biopsies.

PATIENTS AND METHODS

Men diagnosed with prostate cancer between 1 April 2014 and 31 March 2017 in England were identified in the National Prostate Cancer Audit. Administrative hospital data were then used to categorize the type of prostate biopsy and subsequent complications requiring hospital admission. Administrative hospital data were used to identify patients staying overnight immediately after biopsy and those readmitted separately for hospital admissions because of sepsis, urinary retention or haematuria. Procedure-related mortality and total length of hospital stay within 30 days were also recorded. Generalized linear models were used to calculate adjusted risk differences (aRDs).

RESULTS

A total of 73 630 patients undergoing prostate biopsy were identified. Those undergoing TP biopsy (n = 13 723) were more likely to have an overnight hospital stay (12.3% vs 2.4%; aRD 9.7%, 95% confidence interval [CI] 7.1-12.3), were less likely to be readmitted because of sepsis (1.0% vs 1.4%; aRD -0.4%, CI -0.6 to -0.2), and were more likely to be readmitted with urinary retention (1.9% vs 1.0%; aRD 1.1%, CI 0.7-1.4) than those undergoing a TR biopsy (n = 59 907). There were no significant differences in the risk of haematuria or mortality.

CONCLUSIONS

Our results showed that TP biopsy had a lower risk of readmission for sepsis but a higher risk of readmission for urinary retention than TR biopsy. Use of the TP route would prevent one readmission for sepsis in 278 patients at the cost of three additional patients readmitted for urinary retention.

Risk of Prostate Cancer-related Death Following a Low PSA Level in the PLCO Trial

Longer-than-annual screening intervals have been suggested to improve the balance of benefits and harms in prostate cancer screening. Many researchers, societies, and guideline committees have suggested that screening intervals could depend on the prostate-specific antigen (PSA) result. We analyzed data from men (N = 33,897) ages 55-74 years with a baseline PSA test in the intervention arm of the Prostate, Lung, Colorectal and Ovarian Cancer Screening trial (United States, 1993-2001). We estimated 5- and 10-year risks of aggressive cancer (Gleason ≥8 and/or stage III/IV) and 15-year risks of prostate cancer-related mortality for men with baseline PSA ≤ 0.5 ng/mL (N = 4,862), ≤1 ng/mL (N = 15,110), and 1.01-2.5 ng/mL (N = 12,422). A total of 217 men died from prostate cancer through 15 years, although no men with PSA ≤ 1 ng/mL died from prostate cancer within 5 years [95% confidence interval (CI), 0.00%-0.03%]. The 5-year incidence of aggressive disease was low (0.08%; 95% CI, 0.03%-0.12%) for men with PSA ≤ 1 ng/mL, and higher for men with baseline PSA 1.01-2.5 ng/mL (0.51%; 95% CI, 0.38%-0.74%). No men aged ≥65 years with PSA ≤ 0.5 ng/mL died from prostate cancer within 15 years (95% CI, 0.00%-0.32%), and their 10-year incidence of aggressive disease was low (0.25%; 95% CI, 0.00%-0.53%). Compared with white men, black men with PSA ≤ 1 ng/mL had higher 10-year rates of aggressive disease (1.6% vs. 0.4%; P < 0.01). Five-year screening intervals may be appropriate for the 45% of men with PSA ≤ 1 ng/mL. Men ages ≥65 years with PSA ≤ 0.5 ng/mL could consider stopping screening. Substantial risk disparities suggest appropriate screening intervals could depend on race/ethnicity.

Data on the quality and methods of studies reporting healthcare costs of post-prostate biopsy sepsis

This data article presents the supplementary material for the review paper "Healthcare Costs of Post-Prostate Biopsy Sepsis" (Gross et al., 2019). A general overview is provided of 18 papers, including the details about year and journal of publication, country of dataset, data population characteristics, cost basis, and potential for bias evaluation. Quality assessment and the risk of bias of the 18 papers are detailed and summarized.

Race and prostate imaging: implications for targeted biopsy and image-based prostate cancer interventions

Purpose

For men with an elevated prostate-specific antigen (PSA), there is a strong evidence for prostate MRI to assess the risk of clinically significant prostate cancer (CSPC) and guide targeted-biopsy interventions. Prostate MRI is assessed using the Prostate Imaging-Reporting and Data System (PI-RADS), which is scored from 1 to 5. Equivocal or suspicious findings (PI-RADS 3–5) are recommended for subsequent targeted biopsy, for which the risk of infection and sepsis is increasing. However, PI-RADS was developed primarily in men of European descent. We sought to elucidate PI-RADS and MRI-targeted biopsy outcomes in Asian men, a rapidly growing population in the USA, Europe, Australia and internationally.

Materials and methods

A prospective cohort of 544 men with elevated PSA without a diagnosis of prostate cancer who underwent MRI-targeted biopsy at our institution from January 2012 to December 2018 was analyzed. We categorized the cohort by self-designated race then used a validated algorithm which uses surname lists to identify a total of 78 (14%) Asian-Americans. The primary outcome was the likelihood of diagnosing CSPC (Gleason grade group >1) in Asian-Americans versus non-Asian-Americans. Multivariable logistic regression was used to determine the association of demographic and other characteristics with CSPC.

Results

Overall, MRI-targeted biopsy identified CSPC in 17% of Asian-American men versus 39% of non-Asian-American men (p<0.001). Notably for PI-RADS 3, only 6% of Asian-Americans versus 15% of others were diagnosed with CSPC. In adjusted analyses, Asian-American men were less likely to be diagnosed on MRI-targeted biopsy with CSPC (OR 0.30, 95% CI 0.14 to 0.65, p=0.002) and indolent prostate cancer (OR 0.37, 95% CI 0.15 to 0.91, p=0.030) than other races. Regardless of race those who were biopsy naïve were more likely (OR 2.25, 95% CI 1.45 to 3.49, p<0.001) to be diagnosed with CSPC.

Conclusion

We found that PI-RADS underperforms in Asian-American men. For instance, only 2 of 35 (6%) Asian-American men with PI-RADS 3 were diagnosed with CSPC on MRI targeted biopsy. This has significant implications for overuse of diagnostic and image-guided interventional approaches in Asian-Americans, given the increasing risk of infectious complications from biopsy. Additional validation studies are needed to confirm our findings.

Feasibility of prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques

BACKGROUND

Routinely, after receiving prostate specific antigen (PSA) testing and digital rectum examination, patients with suspected prostate cancer are required to undergo prostate biopsy. However, the ability of ultrasound-guided prostate biopsy to detect prostate cancer is limited. Nowadays, a variety of diagnostic methods and more sensitive diagnostic methods, such as multi-parameter prostate magnetic resonance imaging (mpMRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) can be applied clinically. Furthermore, laparoscopic/robot-assisted prostatectomy is also a safe and effective procedure for the treatment of benign prostatic hyperplasia. So maybe it is time to reconsider the necessary to perform prostate biopsy before radical prostatectomy.

AIM

To explore the feasibility of radical prostatectomy without prostate biopsy in the era of new imaging technology and minimally invasive techniques.

METHODS

From June 2014 to November 2018, 11 cases of laparoscopic radical prostatectomy without prostate biopsy were performed at the three tertiary medical centers involved in this study. All patients received prostate magnetic resonance imaging and prostate cancer was suspected, including six patients with positive ⁶⁸Ga-PSMA PET/CT results. Laparoscopic radical prostatectomy and pelvic lymph node dissection were performed for all patients.

RESULTS

All surgeries were accomplished successfully. The mean age was 69 ± 7.7 year, the mean body mass index was 24.7 ± 1.6 kg/m², the range of serum PSA was 4.3 to >1000 ng/mL, and the mean prostate volume was 40.9 ± 18.3 mL. The mean operative time was 96 ± 23.3 min, the mean estimated blood loss was 90 ± 90.9 mL, and the median duration of catheter placement was 14 d. The final pathology confirmed that all specimens were prostate cancer except one case of benign prostatic hyperplasia. No major complications occurred in 90 d postoperatively.

CONCLUSION

The current practice of mandating a prostatic biopsy before prostatectomy should be reconsidered in the era of new imaging technology and minimally invasive techniques. Radical prostatectomy could be carried out without the evidence of malignancy. Large-sample randomized controlled trials are definitely required to confirm the feasibility of this new concept.

Contemporary Trends in Percutaneous Nephrolithomy Across New York State: A Review of the Statewide Planning and Research Cooperative System

Introduction and Objectives: Percutaneous nephrolithotomy (PCNL) is a complex multistep surgery that has shown a steady increase in use for the past decade in the United States. We sought to evaluate the trends and factors associated with PCNL usage across New York State (NYS). Our goal was to characterize patient demographics and socioeconomic factors across high-, medium-, and low-volume institutions. Materials and Methods: We searched the NYS, Statewide Planning and Research Cooperative System (SPARCS) database from 2006 to 2014 using ICD-9 Procedure Codes 55.04 (percutaneous nephrostomy with fragmentation) for all hospital discharges. Patient demographics including age, gender, race, insurance status, and length of hospital stay were obtained. We characterized each hospital as a low-, medium-, or high-volume center by year. Patient and hospital demographics were compared and reported using chi-square analysis and Student's t-test for categorical and continuous variables, respectively, with statistical significance as a p-value of <0.05. Results: We identified a total of 4576 procedures performed from 2006 to 2014 at a total of 77 hospitals in NYS (Table 1). Total PCNL volume performed across all NYS hospitals increased in the past decade, with the greatest number of procedures performed in 2012 to 2013. Low-volume institutions were more likely to provide care to minority populations (21.4% vs 17.3%, p < 0.001) and those with Medicaid (25.5% vs 21.5%, p < 0.001). High-volume institutions provided care to patients with private insurance (42.1% vs 34.0%, p < 0.001) and had a shorter length of stay (3.3 days vs 4.1 days, p < 0.001). Conclusion: Our data provide insight into the patient demographics of those treated at high-, medium-, and low-volume hospitals for PCNL across NYS. Significant differences in race, insurance status, and length of stay were noted between low- and high-volume institutions, indicating that racial and socioeconomic factors play a role in access to care at high-volume centers.

Use of multiparametric magnetic resonance imaging in prostate cancer active surveillance

OBJECTIVES

To review the role of multiparametric magnetic resonance imaging (mpMRI) for active surveillance (AS) of prostate cancer.

MATERIALS AND METHODS

We performed a comprehensive search of Medline and Embase databases for relevant articles in the English language. Search terms included 'prostate cancer', 'active surveillance' or 'monitoring', 'expectant management', and 'MRI'. We also reviewed practice guidelines from recognized international associations or societies involved in prostate cancer care. Articles were selected by both authors for relevance to the subject matter.

RESULTS

The ability of mpMRI to visualize primarily high-grade tumours within the prostate may improve risk stratification for men considering AS for prostate cancer. Multiple mostly single-institution studies have found that the addition of mpMRI and a targeted biopsy strategy can improve AS patient selection over standard TRUS biopsy alone. The high negative predictive value of mpMRI may allow men to avoid early repeat biopsy and may offer the possibility to tailor biopsy strategies. The presence of a radiographically positive lesion on mpMRI at baseline is predictive of higher likelihood of radiographic progression over time while on AS.

CONCLUSIONS

MRI has shown promise in both patient selection and monitoring for men who undergo AS for prostate cancer. There are multiple barriers to the widespread use of mpMRI for AS including quality, cost and access to care.

Phase 1 Trial of SBRT to the Prostate Fossa After Prostatectomy

PURPOSE

The primary objective was to evaluate the maximum tolerated dose (within 10 weeks after treatment) associated with increasing hypofractionation to the prostate fossa (PF). We hypothesized that escalating the dose per fraction (fx) to the PF would have acceptable toxicity.

MATERIALS AND METHODS

Tested dose levels (DLs) were 3.6 Gy × 15 fx (DL1); 4.7 Gy × 10 fx (DL2); and 7.1 Gy × 5 fx (DL3). Escalation followed a 6 + 6 rules-based design with 12 patients required at the maximum tolerated dose. Dose-limiting toxicity was defined as grade (G) ≥3, gastrointestinal (GI) or genitourinary (GU) toxicity by National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.03). Patients completed quality-of-life questionnaires.

RESULTS

Twenty-four patients with indications for adjuvant or salvage radiation therapy (RT) enrolled (6 at DL1 and 2; 12 at DL3). All patients had at least 6 months of follow-up (median follow-up, 14.1 months). Four patients received concurrent androgen deprivation therapy. No G ≥ 3 GI or GU toxicity was seen at any DL; 2 of 6 patients in the DL1 group, 3 of 6 in DL2, and 7 of 12 in DL3 experienced G2 GI toxicity during RT. Except in 1 patient, all acute G2 GI toxicity resolved by 10 weeks. Three of 12 patients reported an increase to G1 and G2 GU toxicity in the 2 weeks after RT in groups DL1 and DL2 and 1 of 12 patients in DL3. At week 2 after RT, decline in the 26-item Expanded Prostate Cancer Index Composite bowel domain met criteria for a minimally important difference in 71% of patients. At week 10, 1 of 6, 2 of 6, and 7 of 11 patients at DLs 1, 2, and 3, respectively, still met minimally important difference criteria. International Prostate Symptom Scores worsened 2 weeks after treatment but improved by 6 to 10 weeks.

CONCLUSIONS

Dose escalation up to 7.1 Gy × 5 fx to the PF was completed without acute G ≥ 3 toxicity. There was transient G2 rectal toxicity at all DLs during and immediately after RT. We must perform long-term follow-up and assessment of late toxicity of SBRT to the PF.

Effectiveness of a transrectal prostate needle biopsy protocol with risk-tailored antimicrobials in a veterans cohort

PURPOSE

To prospectively implement a prostate biopsy protocol to identify high-risk patients for bleeding or infectious complications and use risk-tailored antimicrobials, patient education, and postbiopsy monitoring with the objective of reducing complications.

MATERIALS AND METHODS

Overall, 637 consecutive patients from June 2014 to August 2016 underwent prostate biopsy at our Veterans Affairs hospital. In the protocol cohort, patients were screened before biopsy and prophylaxis was tailored (high risk = ceftriaxone; low risk = ciprofloxacin). Patients were also provided additional education about bleeding and monitored for up to 1-hour. We defined complications as any deviation from normal postbiopsy activities. Comparisons were made between preprotocol/postprotocol cohorts. Logistic regression was used to identify risk factors for admissions or complications.

RESULTS

Median age was 67 years (IQR: 64-69, P = 0.29) in both groups (pre n = 334, post n = 303). Preprotocol, 99% patients received ciprofloxacin; postprotocol, 86% received ciprofloxacin and 14% received ceftriaxone (P<0.001). There were no deaths in either group. There were decreased 30-day complication and hospitalization rates in the postprotocol group (pre 15% vs. post 8.9%, P = 0.025; 3.3% vs. 1.0%, P = 0.048). Sepsis occurred in 2 patients preprotocol and no patients postprotocol. Postprotocol group was associated with decreased 30-day complications on multivariable logistic regression (OR = 0.58, 95% CI: 0.35-0.95, P = 0.031).

CONCLUSIONS

A screening protocol before prostate biopsy is a targeted approach for selecting prophylactic antimicrobials and closer monitoring postbiopsy for bleeding. Our results suggest that the protocol has a favorable effect on complication and hospitalization rates.

Adoption of Prebiopsy Magnetic Resonance Imaging for Men Undergoing Prostate Biopsy in the United States

OBJECTIVE

To assess adoption of prebiopsy prostate magnetic resonance imaging (MRI) in the United States and to evaluate factors associated with magnetic resonance imaging-guided prostate biopsy (MRI-Bx) use. Prior reports have shown improved cancer detection with MRI-Bx vs transrectal ultrasound-guided methods (transrectal ultrasound-guided biopsy [TRUS-Bx]). Population-based trends of their use and outcomes have not been previously characterized.

MATERIALS AND METHODS

Using private insurance claims (2009-2015), we identified men who underwent prostate biopsy. Exposures were biopsy year and geographic region defined by metropolitan statistical area. Outcomes included biopsy type (MRI-Bx, TRUS-Bx, or transperineal biopsy) based on procedure codes and cancer detection based on a new diagnosis for prostate cancer (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] 185). Hierarchical mixed-effects multivariable regression estimated odds of undergoing MRI-Bx.

RESULTS

We identified 241,681 men (mean age 57.5 ± 5.4 years) who underwent biopsy. The use of MRI-Bx rose rapidly (0.2% in 2009 to 6.5% in 2015, P <.001). Overall, 3429 men underwent MRI before biopsy, more commonly in metropolitan statistical areas (odds ratio 1.90, 95% confidence interval 1.66-2.19). In 2015, nearly 18% of men with prior negative biopsy underwent a prebiopsy MRI. Patients with prior negative biopsies were over 4 times more likely to use MRI guidance (vs no prior biopsies, odds ratio 4.63, 95% confidence interval 4.27-5.02) and had a greater chance of cancer detection with MRI-Bx (25.2%) vs TRUS-Bx (19.7%, P = .010).

CONCLUSION

Among men undergoing prostate biopsy, prebiopsy prostate MRI utilization was concentrated within urban areas and among patients with prior negative biopsies, where its use was associated with superior cancer detection compared with traditional TRUS-Bx.

The effectiveness of targeted relative to empiric prophylaxis on infectious complications after transrectal ultrasound-guided prostate biopsy: a meta-analysis

PURPOSE

Rectal culture screening for fluoroquinolone (FQ)-resistant Enterobacteriaceae before transrectal ultrasound guided prostate (TRUSPB) biopsy and targeted antibiotic prophylaxis (TAP) may decrease post-TRUSPB infection rates compared to empiric (EAP) regimens. The objective of this study was to evaluate the effectiveness of targeted relative to empiric prophylaxis regimens on rates of infectious complications after TRUSPB and to determine the baseline prevalence of FQ resistance based on prior rectal swabs.

METHODS

An electronic search within literature databases including EMBASE and Web of Science (all databases) for articles assessing TAP as an approach to TRUSPB prophylaxis was conducted. Quality assessment was performed using the Hoy instrument. Meta-analysis was performed using MetaXL 5.3.

RESULTS

From 15 studies (eight retrospective and seven prospective) representing 12,320 participants, infectious complication incidence was 3.4% in EAP and 0.8% in TAP patients. The number needed to treat with TAP to avoid one more infection when compared to the EAP group was 39. Effect sizes were homogeneous. Prevalence of FQ resistance showed low (15%) and high (28%) subgroups, likely due to region of origin (within and outside USA, respectively).

CONCLUSIONS

Rectal culture prior to TRUSPB and use of TAP adjusts for endemic FQ resistance and is associated with less infectious complications and resulting morbidity when compared to EAP. Overtreatment associated with augmented prophylaxis approaches may be reduced as a result. Further prospective assessment and cost-benefit analyses are required before widespread implementation can be recommended.

Comparison of fosfomycin against fluoroquinolones for transrectal prostate biopsy prophylaxis: an individual patient-data meta-analysis

PURPOSE

To systematically review and meta-analyse available evidence comparing fosfomycin trometamol (FT) to fluoroquinolone (FQ) prophylaxis to prevent transrectal ultrasound-guided prostate biopsy (TRUSPB) related infectious complications.

METHODS

Electronic databases were queried for studies comparing FT to FQ-based TRUSPB prophylaxis. Studies were assessed for comparable outcomes and methodological quality (ROBINS-I modification). The primary outcome measure was the relative odds of overall infectious complications following TRUSPB according to FT/FQ treatment, which was evaluated with meta-analysis. Safety and tolerability were also assessed. The relative odds of infections of different severity [Grade 1, bacteriuria and afebrile urinary tract infection (UTI); Grade 2, bacteraemia, febrile UTI, and urosepsis] according to FT/FQ treatment were also estimated.

RESULTS

Five studies, being three prospective randomised trials and two retrospective cohort studies, representing 3112 patients, were included. The relative odds of an infectious complication (OR 0.22, 95% CI 0.09-0.54) or of a more severe (Grade 2) infection (OR 0.13, 95% CI 0.07-0.26) were significantly lower in those receiving FT compared to FQ prophylaxis. A low incidence of medication-related side effects was observed. There were less observed infections due to FQ-resistant pathogens in those receiving FT prophylaxis.

CONCLUSIONS

Patients who received FT prophylaxis were less likely than those who received FQ prophylaxis to develop infections overall, as well as severe and resistant infections after TRUSPB. Assessing the performance of FT in other geographic locations or in comparison to targeted prophylaxis based on risk assessment or rectal cultures is desired.

Trans-rectal Ultrasound-Guided Autologous Blood Injection in the Interprostatorectal Space Prior to Percutaneous MRI-Guided Cryoablation of the Prostate

OBJECTIVE

To report a novel technique of ultrasound-guided injection of autologous blood in the interprostatorectal space, in an attempt to facilitate ablative prostatic procedures by widening durably the space between the rectum and the prostate.

MATERIALS AND METHODS

Between April and November 2016, four consecutive patients underwent the haemoprotection injection technique. For each patient, we recorded the time to perform the technique, the amount of injected blood, the achieved distances between the rectum and the prostate post-injection at fixed defined points (apex, middle, and base of prostate at the midline, left, and right sides of the gland), the extension of the ice ball outside the prostate capsule at those fixed points, and whether any residual blood was present on 1-month follow-up MRI.

RESULTS

Mean time to perform haemoprotection injection was 54 min, with an average blood volume of 103 cc. Mean distance achieved at the apex, middle, and base of the prostate, respectively, was 12, 13, and 16 mm in the midline; 8, 10, and 13 mm on the left side; and 9, 10, and 13 mm on the right side. The mean extension distance of the ice ball beyond the capsule was 4, 6, and 6 mm in the midline; 4, 5, and 6 mm on the left side; and 1, 3, and 3 mm on the right side. No residual blood was present on 1-month follow-up MRI in all patients. No rectal fistula occurred.

CONCLUSION

Haemoprotection may create a safe and effective virtual space between the prostate and rectum.

Ruling out clinically significant prostate cancer with negative multi-parametric MRI

PURPOSE

To evaluate the negative predictive value (NPV) of a negative prostate multi-parametric magnetic resonance imaging (mpMRI) in ruling out clinically significant prostate upon 12-core systematic biopsy.

METHODS

We retrospectively reviewed 114 men evaluated at our institution who underwent systematic 12-core biopsy within 1 year of a negative prostate mpMRI. Clinicopathologic features were evaluated and NPV was calculated for detection of clinically significant (Gleason ≥ 7) cancer. Regression analysis was performed to identify clinical predictors of biopsy outcome.

RESULTS

Overall, 88 (77.2%) patients in our cohort had no cancer detected upon biopsy. The highest pathologic grade was Gleason 6 (3 + 3) in 22 (19.3%) patients, and Gleason ≥ 7 in 4 (3.6%) patients. NPV for detecting Gleason ≥ 7 cancer was 96.5% (95% CI 93.1-99.9%) in the entire negative MRI cohort, 100% in those who were prostate biopsy naïve (n = 20), 100% in those with a prior negative biopsy (n = 53), and 90% in those who have had a previous positive biopsy and on active surveillance (n = 41). Regression analysis identified no predictors of significant cancer in our cohort.

CONCLUSION

In our cohort of men with no lesions detected on prostate mpMRI, we found very low rates of clinically significant cancer on systematic 12-core biopsy. In the few patients who diagnosed with prostate cancer, the majority had low-risk disease and could remain on active surveillance. Although validation studies and greater sample size is needed before clinical recommendations can be made, our data suggest patients with negative mpMRI evaluated by experienced radiologists may avoid unnecessary prostate biopsy and potential overtreatment.

Urinary tract infection after voiding cystourethrogram

BACKGROUND

Reported rates of post-procedural urinary tract infection (ppUTI) after voiding cystourethrogram (VCUG) are highly variable (0-42%).

OBJECTIVE

This study aimed to determine the risk of ppUTI after cystogram, and evaluate predictors of ppUTI.

STUDY DESIGN

A retrospective cohort study of children undergoing VCUG or radionuclide cystogram (henceforth 'cystogram') was conducted. Children with neurogenic bladder who underwent cystogram in the operating room and without follow-up at the study institution were excluded. Incidence of symptomatic ppUTI within 7 days after cystogram was recorded. Predictors of ppUTI were evaluated using univariate statistics.

RESULTS

A total of 1108 children (54% female, median age 1.1 years) underwent 1203 cystograms: 51% were on periprocedural antibiotics, 75% had a pre-existing urologic diagnosis (i.e., vesicoureteral reflux (VUR) or hydronephrosis; not UTI alone), and 18% had a clinical UTI within 30 days before cystogram. Of the cystograms, 41% had an abnormal cystogram and findings included VUR (82%), ureterocele (6%), and diverticula (6%). Twelve children had a ppUTI (1.0%; four girls, five uncircumcised boys, three circumcised boys; median age 0.9 years). Factors significantly associated with diagnosis of a ppUTI (Summary fig.) included: pre-existing urologic diagnosis prior to cystogram (12/12, 100% of patients with ppUTI), abnormal cystogram results (11/12, 92%), and use of periprocedural antibiotics (11/12, 92%). All 11 children with an abnormal cystogram had VUR ≥ Grade III. However, among all children with VUR ≥ Grade III, 4% (11/254) had a ppUTI.

DISCUSSION

This is the largest study to date that has examined incidence and risk factors for ppUTI after cystogram. The retrospective nature of the study limited capture of some clinical details. This study demonstrated that the risk of ppUTI after a cystogram is very low (1.0% in this cohort). Having a pre-existing urologic diagnosis such as VUR or hydronephrosis was associated with ppUTI; therefore, children with moderate or high-grade VUR on cystogram may be at highest risk. Development of ppUTI after cystogram also highlighted the potential for a delay in diagnosis or oversight of a healthcare-associated infection due to several factors: 1) cystograms may be ordered, performed/interpreted, and followed up by multiple different providers; and 2) such infections are not captured by traditional healthcare-associated infection surveillance strategies.

CONCLUSIONS

The risk of ppUTI after a cystogram is very low. Only children with pre-existing urologic diagnoses developed ppUTI in this study. This study's findings suggest that children undergoing a cystogram should not be given peri-procedural antibiotic prophylaxis for the sole purpose of ppUTI prevention.

Transperineal vs. transrectal biopsy in MRI targeting

Prostate biopsy is typically performed via either the transrectal or transperineal approach. MRI-targeted biopsy, whether using any of the three options of cognitive fusion, MRI-ultrasound fusion software, or in-bore MRI-guided biopsy, can also be performed via either transrectal or transperineal approaches. As an extension of traditional random prostate biopsy, the transrectal approach is far more commonly used for MRI-targeted biopsy due to its convenience. However, in the context of today’s increasing multi-drug resistance of rectal flora, the transperineal approach is being used more often due to its lack of septic complications. In addition, only a first-generation cephalosporin, not a fluoroquinolone, is required as antibiotic prophylaxis. Evidence shows excellent detection rates of significant prostate cancer using magnetic resonance imaging (MRI)-targeted and/or systematic transperineal biopsy (TPB). However, there are no head-to-head studies comparing the different MRI-targeted methods within TPB. To provide truly patient-centred care, the biopsy technique using the safest method with the highest detection rate of significant cancer should be used. Depending on healthcare context and hospital resource utilization, MRI-targeted TPB is an excellent option and should be performed wherever available and feasible. Whilst building capacity for TPB in one’s practice, the routine use of rectal culture swabs prior to any transrectal biopsies is strongly encouraged. Independent of biopsy route, the addition of systematic cores needs to be discussed with the patient weighing maximal detection of significant cancer against increased detection of insignificant lesions.

Variation in Use of Prostate Biopsy Following Changes in Prostate Cancer Screening Guidelines

PURPOSE

Prostate biopsy rates have paralleled decreasing prostate specific antigen screening rates since 2012. We hypothesized that biopsy rates and the change in rates since 2012 would vary considerably across hospital referral regions.

MATERIALS AND METHODS

Using Medicare data from 2012 through 2014 we identified prostate biopsies performed by physicians who performed 11 or more biopsies annually. We calculated annual biopsy rates and changes in rates from 2012 to 2014 across 306 hospital referral regions. We performed multivariable regression adjusting for factors associated with annual biopsy rates (eg percent of patients older than 75 who were screened with prostate specific antigen and percent of the population that was African American). We also estimated adjusted prostate biopsy rates and changes with time across regions.

RESULTS

We identified 395,993 biopsies. The overall rates decreased from 11.68 biopsies per 1,000 men in 2012 to 10.23 per 1,000 in 2014 (-12.4%, p = 0.11). Biopsy rates were higher in regions in which a greater percentage of the population was African American (β = 0.810, 95% CI 0.235-1.384, p = 0.006), ambulatory surgical centers were available where biopsy could be performed (β = 0.892, 95% CI 0.108-1.676, p = 0.026) and prostate specific antigen testing occurred more frequently (β = 2.462, 95% CI 1.153-3.771, p <0.001). There was marked geographic variation in the adjusted average biopsy rate (median adjusted rate 9.08 biopsies per 1,000 men, IQR 7.65-10.76) and in the change in biopsy rates with time (median adjusted rate change -1.49 biopsies per 1,000 men, IQR -1.94--1.22 per 1,000).

CONCLUSIONS

Since 2012 there has been considerable geographic variation in the performance of prostate biopsies as well as changes with time after prostate specific antigen recommendations changed. Characterizing the role of unmeasured patient and physician level factors is crucial to optimize the use and minimize the harms of prostate biopsy.

New and developing diagnostic technologies for urinary tract infections

Timely and accurate identification and determination of the antimicrobial susceptibility of uropathogens is central to the management of UTIs. Urine dipsticks are fast and amenable to point-of-care testing, but do not have adequate diagnostic accuracy or provide microbiological diagnosis. Urine culture with antimicrobial susceptibility testing takes 2-3 days and requires a clinical laboratory. The common use of empirical antibiotics has contributed to the rise of multidrug-resistant organisms, reducing treatment options and increasing costs. In addition to improved antimicrobial stewardship and the development of new antimicrobials, novel diagnostics are needed for timely microbial identification and determination of antimicrobial susceptibilities. New diagnostic platforms, including nucleic acid tests and mass spectrometry, have been approved for clinical use and have improved the speed and accuracy of pathogen identification from primary cultures. Optimization for direct urine testing would reduce the time to diagnosis, yet these technologies do not provide comprehensive information on antimicrobial susceptibility. Emerging technologies including biosensors, microfluidics, and other integrated platforms could improve UTI diagnosis via direct pathogen detection from urine samples, rapid antimicrobial susceptibility testing, and point-of-care testing. Successful development and implementation of these technologies has the potential to usher in an era of precision medicine to improve patient care and public health.