Risk of hospitalization and death following prostate biopsy in Scotland

Extra-peritoneal Laparoscopic Resection of Benign Prostate Adenoma >150 CC with preservation of posterior wall of prostatic urethra: Dundee Technique and early outcomes

BACKGROUND

There are limited options for men with large benign prostates (>150cc) and bladder outflow obstruction due to benign prostatic hyperplasia (BPH). Management options include surgery (open or minimal access) and endoscopic procedures. There is a paucity of literature on outcomes for prostates >150cc.

METHODS

In this case series we describe a step-by-step, illustrated, modified extra-peritoneal technique of laparoscopic prostatectomy with preservation of the posterior prostatic urethra. This involves creation of extra-peritoneal space, transverse incision of prostate capsule, progressive adenoma dissection, resection, and closure of the capsule.

RESULTS

Ten patients underwent this procedure between 2015 and 2019. The mean age was 72.4 years and mean prostate size was 215.5cc. Mean procedure duration was 200 min and there were no intraoperative complications. Most patients were discharged on postoperative day 1. Mean intraoperative blood loss was 120 ml with no patient requiring blood transfusion. At follow up (mean 37 months) no patients had residual symptoms of BPH.

CONCLUSION

We describe a novel extraperitoneal laparoscopic technique for benign prostates of >150cc with very good outcomes. The transferability of this technique to centres with laparoscopic expertise at minimal extra cost and future adaptability in the robotic setting are some of the advantages of this technique.

Minimizing transrectal prostate biopsy-related infections; A prospective randomized trial of povidone-iodine intrarectal cleaning versus formalin needle disinfection

Introduction:

Transrectal prostate biopsies are associated with post biopsy infection and sepsis. We compared the efficacy of povidone-iodine rectal disinfection versus formalin needle disinfection in preventing post biopsy infection among patients undergoing transrectal ultrasound-guided prostate biopsy.

Methods:

Patients scheduled to undergo ultrasound-guided transrectal prostate biopsy (n = 621) over 20 months were randomized into 2 groups to receive either povidone-iodine intrarectal disinfection or formalin disinfection of needle after each core. These were compared to assess which methodology better prevented postprocedure infection. Statistical analysis were used to identify independent factors promoting infections.

Results:

Two hundred and ninety-eight patients from povidone-iodine intrarectal disinfection were compared with 300 from formalin needle disinfection group. Formalin needle disinfection was associated with significantly more infections (P = 0.02). Escherichia coli was the dominant pathogen, with >50% of cases being quinolone resistant. Type of disinfection (P = 0.002), BMI (P = 0.001), chronic prostatitis (P = 0.002), and diabetes mellitus (P = 0.01) were independent predictors of infections. BMI at 28.95 kg/m² provided the best predictive cut-off point for infections, irrespective of method of disinfection. Area under the curve for all these parameters together was 0.91.

Conclusions:

We conclude that along with oral cephalosporin prophylaxis, povidone-iodine intrarectal disinfection is a superior to formalin needle disinfection alone in preventing post biopsy infection. Patients with BMI >28.95 kg/m² should be considered at a higher risk for infections.

Prostate Cancer Biomarkers: From diagnosis to prognosis and precision-guided therapeutics

Prostate cancer (PCa) is one of the most commonly diagnosed malignancies and among the leading causes of cancer-related death worldwide. It is a highly heterogeneous disease, ranging from remarkably slow progression or inertia to highly aggressive and fatal disease. As therapeutic decision-making, clinical trial design and outcome highly depend on the appropriate stratification of patients to risk groups, it is imperative to differentiate between benign versus more aggressive states. The incorporation of clinically valuable prognostic and predictive biomarkers is also potentially amenable in this process, in the timely prevention of metastatic disease and in the decision for therapy selection. This review summarizes the progress that has so far been made in the identification of the genomic events that can be used for the classification, prediction and prognostication of PCa, and as major targets for clinical intervention. We include an extensive list of emerging biomarkers for which there is enough preclinical evidence to suggest that they may constitute crucial targets for achieving significant advances in the management of the disease. Finally, we highlight the main challenges that are associated with the identification of clinically significant PCa biomarkers and recommend possible ways to overcome such limitations.

"Free-Hand" Transperineal Prostate Biopsy Under Local Anesthesia: Review of the Literature

Background: The recent plethora of reports of "free-hand" transperineal prostate biopsy (fTP-Bx) under local anesthesia (LA) demonstrate that many centers consider this technique to be a safer and possibly more accurate approach to prostate biopsy in the clinic setting. Materials and Methods: The literature was searched for fTP-Bx, and summary tables were compiled. Studies on the costs of postprostate biopsy sepsis were also researched. Results: The search found 11,999 cases of fTP-Bx under LA with and without sedation over 29 mutually exclusive studies. Pooled averages calculated for age, prostate-specific antigen (PSA), prostate volume, PSA density, and cores sampled were 67.3 years, 10.4 ng/mL, 47.7 mL, 0.24 ng/mL/cc, and 15.3 cores, respectively. Detection of overall prostate cancer (PCa) and clinically significant (Gleason score ≥7) prostate cancer (csPCa) averaged 45.5% (3796/8338) and 25.1% (1141/4541), respectively. After subgrouping the studies by biopsy technique, studies that used MRI/ultrasound fusion-targeted biopsy in some or all biopsy cases averaged an overall PCa and csPCa detection rate of 50.0% (741/1483) (p < 0.0001) and 42.8% (635/1483) (p < 0.0001), respectively. Visual analog scale pain ratings and procedure times averaged 3.17 and 13.1 minutes, respectively. Averages for complications of sepsis and acute urinary retention were 0.0% (0/7396) and 2.1% (120/5693), respectively. A total of 10.2% (1055/10,334) of cases received no antibiotic prophylaxis. If fTP-Bx under LA replaced transrectal prostate biopsy (TR-Bx) in the United States, the estimated annual savings would be $341,676,800-$752,540,000 through the virtual elimination of admissions for postbiopsy sepsis. Conclusions: Many centers around the world have adopted fTP-Bx because it virtually eliminates sepsis, may improve detection rates of csPCa and can be easily integrated into a normal clinic workflow using only LA. If all urologists in the United States abandoned TR-Bx for fTP-Bx, the potential savings in health care costs of complications would be significant.

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.

Factors associated with appropriate and low-value PSA testing

BACKGROUND

Prostate-specific antigen (PSA) testing for early detection of prostate cancer is low-value when it is not indicated by guidelines and the harms outweigh the benefits. In this retrospective cohort study, we identify provider and patient factors associated with PSA testing, particularly in situations where testing would be low-value.

METHODS

We used electronic health record data from 2011 to 2018 representing 1,738,021 health system encounters in the United States. Using logistic generalized estimating equation models, we examined patient factors (age, comorbid illness, family history, race and prior PSA results), provider factors (gender, specialty, graduation year and medical school rank), and overall time trends associated with PSA testing in low-value and appropriate settings.

RESULTS

Comorbid illness (odds ratio (OR) 0.0 for 3+ conditions vs none) and no prior PSA testing (OR 0.2) were associated with a lower likelihood of PSA testing in low-value situations, while family history of prostate cancer (OR 1.6) and high prior PSA test results (OR 2.2 for PSA > 6 vs 0-1) were associated with a greater likelihood. Men aged 55-65 years were at greatest risk for PSA testing in low-value situations. The provider factor associated with PSA testing in low-value situations was specialty, with urologists being most likely (OR 2.3 versus advanced practice providers). Internal medicine physicians were more likely to perform PSA testing during low-value situations (OR 1.3 versus advanced practice providers) but much more likely to order a PSA test where appropriate (OR 2.2). All PSA testing decreased since 2011.

CONCLUSION

We identified several patient and provider factors associated with PSA testing in low-value settings. Some aspects suggest attention to relevant factors for PSA testing in low-value settings (e.g. comorbid illness), while others may encourage PSA testing in low-value settings (e.g. family history). The greatest likelihood of PSA testing in low-value settings is among men within the age range most commonly recommended by guidelines.

High-Throughput, Time-Resolved Mechanical Phenotyping of Prostate Cancer Cells

Worldwide, prostate cancer sits only behind lung cancer as the most commonly diagnosed form of the disease in men. Even the best diagnostic standards lack precision, presenting issues with false positives and unneeded surgical intervention for patients. This lack of clear cut early diagnostic tools is a significant problem. We present a microfluidic platform, the Time-Resolved Hydrodynamic Stretcher (TR-HS), which allows the investigation of the dynamic mechanical response of thousands of cells per second to a non-destructive stress. The TR-HS integrates high-speed imaging and computer vision to automatically detect and track single cells suspended in a fluid and enables cell classification based on their mechanical properties. We demonstrate the discrimination of healthy and cancerous prostate cell lines based on the whole-cell, time-resolved mechanical response to a hydrodynamic load. Additionally, we implement a finite element method (FEM) model to characterise the forces responsible for the cell deformation in our device. Finally, we report the classification of the two different cell groups based on their time-resolved roundness using a decision tree classifier. This approach introduces a modality for high-throughput assessments of cellular suspensions and may represent a viable application for the development of innovative diagnostic devices.

History of Urinary Retention Is a Risk Factor for Infection after Prostate Biopsy: A Nationwide, Population-Based Cohort Study

BACKGROUND AND AIM

Infection or bleeding after transrectal prostate biopsy remains a concern of both patients and urologists. We explored the risk of association of certain co-morbidities with both complications.

PATIENTS AND METHODS

Using the Taiwan National Health Insurance Research Database, we identified patients undergoing prostate biopsy from 2000 to 2013. We used logistic multivariable regression to search for associations between post-biopsy hospitalization and the two co-morbidities within a year after biopsy.

RESULTS

Among 3,601 prostate biopsies, 100 infections (3.77%) and 52 (1.44%) bleeding-related emergency room visits and hospitalizations were recorded within 30 days after biopsy. The group having the biopsy as an inpatient exhibited older age (p < 0.0001) and a higher percentage of having diabetes mellitus (p = 0.015) than patients without either complication. The logistic multivariable regression analysis showed that urinary retention, freedom from diabetes, and performance as an outpatient procedure were independent risk factors for infection-related hospitalization (odds ratios 1.81, 1.96, and 1.72; p values 0.031, 0.037, and 0.010, respectively).

CONCLUSION

Patients with a recent history of urinary retention have a higher probability of infection-related hospitalization after prostate biopsy.

Targeted antimicrobial prophylaxis for transrectal ultrasound-guided prostate biopsy during active surveillance: Effect on hospitalization

OBJECTIVES

We investigated the effect of targeted antibiotic prophylaxis using rectal swab cultures on hospitalization for infectious complications after transrectal ultrasound-guided prostate biopsy (TRUSP).

MATERIALS AND METHODS

A cohort of men (1995-2016) with prostate cancer on active surveillance receiving annual TRUSP biopsies was surveyed to determine the incidence of hospitalization for suspected postbiopsy sepsis. We compared biopsy events (i.e., unique biopsies) in the era of empiric prophylaxis to those in the era of targeted prophylaxis based on culture. The effect of fluoroquinolone resistant organisms (FQ-R), and other demographic and clinical factors, on hospitalization was assessed using logistic regression.

RESULTS

Of 1,167 men on active surveillance, 825 responded for a total of 3,361 biopsy events; 7 (0.79%) of 886 biopsies preceded by rectal swab culture resulted in hospitalization compared to 24 (0.97%) of 2,475 biopsies without culture (OR = 0.81, 95% CI: 0.35-1.89, P = 0.63). Among 886 cultures performed, FQ-R organisms were identified in 194 (21.9%); 6 out of 194 (3.1%) biopsies with swabs positive for FQ-R resulted in admission compared to 1 out of 692 (0.14%) biopsies with fluoroquinolone sensitive swabs (OR = 22.1, 95% CI: 2.6-184.3, P<0.01). Smaller prostate volume at diagnosis was significantly associated with hospitalization (OR = 2.57, 95% CI: 1.04-6.31) for<45 g vs. ≥45 g, P = 0.039).

CONCLUSION

Targeted antibiotic prophylaxis is not associated with a significant reduction in hospitalization for suspected post-TRUSP biopsy sepsis. FQ-R and prostate volume exhibited strong associations with risk of hospitalization and could be included in a risk-adapted approach to prophylaxis, but better prophylactic strategies are needed for patients identified to be at high risk of subsequent hospitalization.