Indications for Extended 14-Core Transrectal Ultrasound-Guided Prostate Biopsy

Efficacy of nitrous oxide in adults undergoing puncture biopsy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Nitrous oxide (N2O) with rapid analgesic effect is often used to relieve pain induced by diagnostic procedures. This review was conducted to evaluate the efficacy and safety of N2O in patients undergoing puncture biopsy.

METHODS

We systematically searched PubMed, Embase, the Cochrane Library, Web of Science, Scopus and the ClinicalTrials.gov up to March, 2022. Randomized controlled trials (RCTs) were included if they investigated the effect of N2O in adults undergoing puncture biopsy. The primary outcome was pain score. Secondary outcomes included anxiety score, patient satisfaction and side effects.

RESULTS

Twelve RCTs with 1070 patients were included in the qualitative review, of which eleven RCTs were included in the meta-analysis. Pooled analysis suggested that compared with the controls (placebo, lidocaine and midazolam), N2O had better analgesic effect (MD -1.12, 95% CI -2.12 to -0.13, P = 0.03; I2 = 94%). In addition, N2O significantly alleviated patient anxiety (MD = -1.79, 95% CI -2.41 to -1.18, P<0.00001; I2 = 0%) and improved patient satisfaction (MD 1.81, 95% CI 0.11 to 3.50, P = 0.04; I2 = 92%). There was no significant difference regrading the risk of nausea (RR 2.56; 95% CI 0.70 to 9.31, P = 0.15; I2 = 0%), headache (RR 0.62, 95% CI 0.17 to 2.33, P = 0.48; I2 = 46%), dizziness (RR 1.80, 95% CI 0.63 to 5.13, P = 0.27; I2 = 0%) or euphoria (RR 2.67, 95% CI 0.81 to 8.79, P = 0.11; I2 = 8%) between the N2O group and the control group.

CONCLUSION

The present review suggested that N2O might be effective for pain management in patients undergoing puncture biopsy.

Dynamic Contrast-Enhanced MRI of Prostate Lesions of Simultaneous [68Ga]Ga-PSMA-11 PET/MRI: Comparison between Intraprostatic Lesions and Correlation between Perfusion Parameters

We aimed to retrospectively compare the perfusion parameters measured from dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) of prostate benign lesions and malignant lesions to determine the relationship between perfusion parameters. DCE-MRI was performed in patients with PCa who underwent simultaneous [68Ga]Ga-prostate-specific membrane antigen (PSMA)-11 positron emission tomography (PET)/MRI. Six perfusion parameters (arrival time (AT), time to peak (TTP), wash-in slope (W-in), wash-out slope (W-out), peak enhancement intensity (PEI), and initial area under the 60-s curve (iAUC)), and a semi-quantitative parameter, standardized uptake values maximum (SUVmax) were calculated by placing regions of interest in the largest area of the lesions. The DCE-MRI parameters between prostate benign and malignant lesions were compared. The DCE-MRI parameters in both the benign and malignant lesions subgroup with SUVmax ≤ 3.0 and SUVmax > 3.0 were compared. The correlation of DCE-MRI parameters was investigated. Malignant lesions demonstrated significantly shorter TTP and higher SUVmax than did benign lesions. In the benign and malignant lesions subgroup, perfusion parameters of lesions with SUVmax ≤ 3.0 show no significant difference to those with SUVmax > 3.0. DCE-MRI perfusion parameters show a close correlation with each other. DCE-MRI parameters reflect the perfusion characteristics of intraprostatic lesions with malignant lesions, demonstrating significantly shorter TTP. There is a moderate to strong correlation between DCE-MRI parameters. Semi-quantitative analysis reflects that malignant lesions show a significantly higher SUVmax than benign lesions.

A 50-50% mixture of nitrous oxide-oxygen in transrectal ultrasound-guided prostate biopsy: A randomized and prospective clinical trial

Introduction

Transrectal ultrasound-guided biopsy (TUSPB) is the standard method of diagnosis for prostate cancer, and although it is well tolerated by some patients, it presents a discomfort rate of 65 to 90%, which may be associated with pain. For convenience, it is agreed that a method of analgesia and sedation is necessary. For this purpose, this study aimed to evaluate the impact of inhalation of a 50–50% N₂O-O₂ gas mixture on pain intensity in these patients.

Material and methods

Randomized, double-blinded clinical trial, conducted at Antônio Pedro University Hospital (Hospital Universitário Antônio Pedro), Niterói, RJ, Brazil, containing two groups of 42 patients: a control (C) group, which received 100% oxygen inhalation, and a nitrous oxide (NO) group, which received inhalation of the 50–50% N₂O-O₂ mixture, self-administered during TUSPB. The pain intensity and degree of satisfaction were evaluated through a visual analogue scale (VAS), as was the frequency of adverse events.

Results

Eighty-four patients were included in the study, with 42 in each group. The mean pain intensity was lower in the NO group than in the C group [2.52 (0–10) vs 5.95 (0–10), p < 0.001], and the degree of satisfaction was higher in the NO group than in the C group (8.14 vs. 4.69, p < 0.001). The adverse effects were somnolence, dizziness, nausea, vomiting, discomfort and euphoria without differences between the groups.

Conclusion

The 50–50% N₂O-O₂ mixture was effective in reducing pain intensity and increasing the degree of satisfaction in TUSPB, with tolerable side effects.

Recent advances in imaging-guided interventions for prostate cancers

The numbers of patients diagnosed with prostate cancers is increasing due to the widespread application of prostate-specific antigen screening and subsequent prostate biopsies. The methods of systemic administration of therapeutics are not target-specific and thus cannot efficiently destroy prostate tumour cells while simultaneously sparing the surrounding normal tissues and organs. Recent advances in imaging-guided minimally invasive therapeutic techniques offer considerable potential for the effective management of prostate cancers. An objective understanding of the feasibility, effectiveness, morbidity, and deficiencies of these interventional techniques is essential for both clinical practice and scientific progress. This review presents the recent advances in imaging-guided interventional techniques for the diagnosis and treatment of prostate cancers.

Initial management of prostate-specific antigen-detected, low-risk prostate cancer and the risk of death from prostate cancer

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The recently published Prostate Cancer Intervention versus Observation Trial (PIVOT) did not identify differences in prostate cancer-specific mortality or all-cause mortality among patients with low-risk disease managed conservatively vs those managed definitively; however, recently published data suggest that older men may harbour more aggressive disease than is identified at biopsy owing to sampling error and undergrading. Whether older men with apparent low-risk disease are placed at risk of prostate cancer-specific mortality when managed conservatively remains unknown. The study used population-level data to show that non-curative approaches for older men with low-risk prostate cancer do result in an increased risk of prostate cancer-specific mortality. Differences between our study and the PIVOT trial include the fact that we included a larger sample size, analysed the data using an 'as-treated' approach, and included a healthier cohort of men as evinced by lower 4-year all-cause mortality estimates in our study than in the PIVOT. Our results suggest that older men with apparent low-risk prostate cancer are at risk of undergrading, which probably explains the differences in prostate cancer-specific mortality observed between men managed conservatively vs those managed definitively. Our study suggests that alternative approaches to excluding occult, high grade prostate cancer are needed in such men.

OBJECTIVE

To evaluate whether older age in men with low-risk prostate cancer increases the risk of prostate cancer-specific mortality (PCSM) when non-curative approaches are selected as initial management.

PATIENTS AND METHODS

The study cohort consisted of 27 969 men, with a median age of 67 years, with prostate-specific antigen (PSA)-detected, low-risk prostate cancer (clinical category T1c, Gleason score ≤6, and PSA ≤10) identified by the Surveillance, Epidemiology and End Results programme between 2004 and 2007. Fine and Gray's competing risk regression analysis was used to evaluate whether management with non-curative vs curative therapy was associated with an increased risk of PCSM after adjusting for PSA level, age at diagnosis and year of diagnosis.

RESULTS

After a median follow-up of 2.75 years, 1121 men died, 60 (5.4%) from prostate cancer. Both older age (adjusted hazard ratio [AHR] 1.05; 95% confidence interval (CI) 1.02-1.08; P < 0.001) and non-curative treatment (AHR 3.34; 95% CI 1.97-5.67; P < 0.001) were significantly associated with an increased risk of PCSM. Men > the median age experienced increased estimates of PCSM when treated with non-curative as opposed to curative intent (P < 0.001); this finding was not seen in men ≤ the median age (P = 0.17).

CONCLUSION

Pending prospective validation, our study suggests that non-curative approaches for older men with 'low-risk' prostate cancer result in an increased risk of PCSM, suggesting the need for alternative approaches to exclude occult, high grade prostate cancer in these men.

Is an initial saturation prostate biopsy scheme better than an extended scheme for detection of prostate cancer? A systematic review and meta-analysis

CONTEXT

The optimal initial prostate biopsy core number is still an issue with many unanswered questions and significant controversy.

OBJECTIVE

To compare diagnostic values of initial saturation prostate biopsy scheme and extended scheme with respect to prostate-specific antigen (PSA) levels, prostate volume (PV), and PSA density (PSAD).

EVIDENCE ACQUISITION

Electronic databases including Medline, Web of Knowledge, and the Cochrane Library were searched through November 1, 2012. Experts were consulted, and references from relevant articles were scanned. The meta-analysis was conducted with RevMan 5.1, according to the PRISMA guidelines. Mantel-Haenszel estimates were calculated and pooled under a fixed or random effect model, with data expressed as risk difference (RD) and 95% confidence interval (CI).

EVIDENCE SYNTHESIS

We analyzed eight trials with a total of 11997 participants who underwent transrectal ultrasound guided prostate biopsies for the first time and met inclusion criteria. Studies consisted of one paired design study, two randomized clinical trials, and five nonrandomized studies. Saturation biopsy scheme showed a significant advantage in prostate cancer (PCa) detection over an extended scheme (RD: 0.04; 95% CI, 0.01-0.08; p=0.02). In addition, subgroup analyses found a saturation protocol to be superior to an extended protocol in the detection of PCa in men with PSA <10 ng/ml (RD: 0.04; 95% CI, 0.01-0.07; p=0.002), PV >40 ml (RD: 0.05; 95%CI, 0.01-0.09; p=0.02), or PSAD <0.25 ng/ml per gram (RD: 0.04; 95% CI, 0.00-0.09; p=0.04).

CONCLUSIONS

The existing evidence indicates that an initial saturation biopsy scheme is more efficient than an extended scheme for PCa detection, especially for those men with lower PSA levels, higher PV, or lower PSAD, without increasing complications and the amount of insignificant cancer.

Findings in 12-core transrectal ultrasound-guided prostate needle biopsy that predict more advanced cancer at prostatectomy: analysis of 388 biopsy-prostatectomy pairs

We analyzed 5 features on 12-core transrectal ultrasound-guided prostate needle biopsy (TRUS) to predict the extent of cancer at radical prostatectomy (RP). In 388 TRUS-RP pairs, number of positive cores (NPC), percentage of each core involved (%PC), perineural invasion (PNI), Gleason score (GS), distribution of positive cores (DPC), and preoperative prostate-specific antigen (PSA) were correlated with extraprostatic extension (EPE), seminal vesicle invasion (SVI), positive surgical margin (R1), positive lymph nodes (N1), and tumor volume. All features predicted EPE and SVI. NPC, GS, %PC, and PNI strongly predicted R1 status. RP tumor volume was directly proportional to the NPC and %PC. PSA alone and with selected biopsy findings correlated with tumor volume, stage, SVI, and N1 (P < .0001). Contiguous DPC was a significant risk for EPE and SVI (P < .0001) compared with isolated positive cores. Findings at 12-core TRUS along with preoperative PSA reliably predict advanced local disease and have practical value as guides to effective planning for surgical resections.