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Berridge C, Omer A, Lopez F, Bryant RJ, Lamb AD. Perspectives on technology - prostate cancer: is local anaesthetic transperineal prostate biopsy really better than transrectal biopsy? BJU Int 2024; 134:166-174. [PMID: 38584582 DOI: 10.1111/bju.16349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
For many years, transrectal ultrasound-guided (TRUS) prostate biopsies have been performed to establish a histological diagnosis of prostate cancer. This has been the recommended standard of care procedure, but has always carried risks, in particular the risk of post-procedural sepsis, and the associated antibiotic burden and risk of development of antibiotic resistance. Transperineal (TP) prostate biopsies performed under local anaesthetic (LA) have been proposed as a possible solution to these issues, with potentially lower infectious complications, and avoidance of need for antibiotic prophylaxis. The European Association of Urology produced guidance in 2023 with 'weak' recommendations in favour of LATP biopsy as a new standard of care, citing its safety profile. Both the National Institute for Health and Care Excellence in the UK, and the American Urological Association in the United States, have concluded for now that the body of evidence is inadequate and not offered a similar recommendation. We discuss the available evidence, pros and cons of each technique, and the status of current trials in the field. We believe that clinical equipoise remains necessary, given the disparity in national and international guidelines highlighting the need for large randomised controlled trials to answer the question: is LATP biopsy really better than TRUS biopsy?
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Affiliation(s)
- Christopher Berridge
- Department of Urology, University Hospitals Coventry and Warwickshire NHS Trust, University Hospital, Coventry, UK
| | - Altan Omer
- Department of Urology, University Hospitals Coventry and Warwickshire NHS Trust, University Hospital, Coventry, UK
| | - Francisco Lopez
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Richard J Bryant
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Alastair D Lamb
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Lu D, Zhou J, Cai J, Liu L, Ni Y. Clinical value of ultrasound-guided full-needle path anesthesia in transperineal prostate biopsy: An observational study. Medicine (Baltimore) 2024; 103:e39008. [PMID: 39029080 PMCID: PMC11398780 DOI: 10.1097/md.0000000000039008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND The pain sensation in a transperineal prostate biopsy was obvious. This study explored the clinical value of ultrasound-guided full-needle path anesthesia in transperineal prostate biopsy. METHODS Two hundred patients who underwent ultrasound-guided transperineal prostate biopsy at our department were randomly divided into 2 groups. The control group received routine local infiltration anesthesia, and the experimental group received ultrasound-guided full-needle path anesthesia. Immediately after biopsy, visual analog scoring was used to evaluate pain during the biopsy process. Seven days postbiopsy, telephone follow-up revealed symptoms, such as hematuria and discomfort during urination. The measured data were expressed as x ± s. The 2 groups were compared using the t test, and the differences were statistically significant (P < .05). RESULTS There were no significant differences in age, prostate-specific antigen (PSA) level, or prostate volume between the 2 groups, and all patients underwent prostate biopsy. The pain score of visual analog score was (2.55 ± 0.88), urination discomfort was (1.86 ± 0.67) days and hematuria time was (2.87 ± 0.91) days in the experimental group after biopsy. In the control group, the pain score of visual analog scale was (4.32 ± 0.94), the urination discomfort was (2.3 ± 0.77) days, and the hematuria time was (2.85 ± 0.83) days. Pain scores and urination discomfort were compared between the 2 groups (P < .01). Pain and urination discomfort associated with prostate biopsy in the experimental group were significantly lower than those in the control group. CONCLUSION Ultrasound-guided full needle path anesthesia can alleviate pain sensation in patients undergoing transperineal prostate biopsy and has high clinical value.
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Affiliation(s)
- DianYuan Lu
- Department of Ultrasound, Chongming Hospital Affiliated to Shanghai University of Medicine and Health Sciences, Shanghai, China
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3
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Kanagarajah A, Hogan D, Yao HH, Dundee P, O'Connell HE. A systematic review on the outcomes of local anaesthetic transperineal prostate biopsy. BJU Int 2023; 131:408-423. [PMID: 36177521 DOI: 10.1111/bju.15906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To conduct a systematic review of the literature to assess the diagnostic ability, complication rate, patient tolerability, and cost of local anaesthetic (LA) transperineal prostate biopsy. METHODS Two reviewers searched Medline, the Cochrane Library, and Embase for publications on LA transperineal prostate biopsy up to March 2021. Outcomes of interest included cancer detection rates, complication rates, pain assessments and cost. RESULTS A total of 35 publications with 113 944 men were included in this review. The cancer detection rate for LA transperineal prostate biopsy in patients undergoing primary biopsy was 52% (95% confidence interval [CI] 0.45-0.60; I2 = 97) and the clinically significant cancer detection rate (Gleason≥3 + 4) was 37% (95% CI 0.24-0.52; I2 = 99%). The rate of infection-related complications in the included studies was 0.15% (95% CI 0.0000-0.0043; I2 = 86). The LA transperineal procedures had a low rate of procedural abandonment (26/6954, 0.37%), with the greatest pain scores measured during LA administration. No formal cost analyses on LA transperineal prostate biopsies were identified in the literature. The overall risk of bias in the included studies was high, with considerable study heterogeneity and publication bias. CONCLUSION Transperineal prostate biopsy performed under LA is a viable option for centres interested in avoiding the risk of infection associated with transrectal biopsy, and the logistical burden of general anaesthesia. Further investigation into LA transperineal prostate biopsy with comparative studies is warranted for its consideration as the standard in prostate biopsy technique.
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Affiliation(s)
- Abbie Kanagarajah
- Department of Urology, Western Health, Melbourne, Vic., Australia
- Austin Health, Melbourne, Vic., Australia
| | - Donnacha Hogan
- Department of Urology, Western Health, Melbourne, Vic., Australia
- University College Cork, Cork, Ireland
| | - Henry H Yao
- Department of Urology, Western Health, Melbourne, Vic., Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Philip Dundee
- Department of Urology, Western Health, Melbourne, Vic., Australia
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Power J, Murphy M, Hutchinson B, Murphy D, McNicholas M, O'Malley K, Murray J, Cronin C. Transperineal ultrasound-guided prostate biopsy: what the radiologist needs to know. Insights Imaging 2022; 13:77. [PMID: 35467261 PMCID: PMC9038983 DOI: 10.1186/s13244-022-01210-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/14/2022] [Indexed: 11/25/2022] Open
Abstract
Transperineal ultrasound-guided (TP) prostate biopsy has been shown to significantly decrease the risk of post-procedural sepsis when compared to transrectal ultrasound-guided (TRUS) prostate biopsy. With guidance from the European Urology Association favouring adoption of a TP biopsy route, it is clear that, despite being a more technically challenging procedure, TP biopsy in an outpatient setting will replace TRUS biopsy. This paper gives the reader a succinct summary of outpatient transperineal prostate biopsy under local anaesthetic utilising a free-hand ultrasound technique. Patient preparation and consent process is outlined. A comprehensive pictorial review of the procedure, pitfalls and common post-procedural outcomes is presented. This paper provides a framework and guide for those wishing to adopt the transperineal approach under local anaesthetic.
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Affiliation(s)
- Jack Power
- Radiology Department, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland. .,School of Medicine, University College Dublin (UCD), Dublin, Ireland.
| | - Mark Murphy
- Radiology Department, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland
| | - Barry Hutchinson
- Radiology Department, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland
| | - Daragh Murphy
- School of Medicine, University College Dublin (UCD), Dublin, Ireland.,Mater Private Hospital, Dublin, Ireland
| | - Michelle McNicholas
- Radiology Department, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland.,Mater Private Hospital, Dublin, Ireland
| | - Kiaran O'Malley
- Radiology Department, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland.,Mater Private Hospital, Dublin, Ireland
| | - John Murray
- Radiology Department, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland.,Mater Private Hospital, Dublin, Ireland
| | - Carmel Cronin
- Radiology Department, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland.,Mater Private Hospital, Dublin, Ireland
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Basourakos SP, Alshak MN, Lewicki PJ, Cheng E, Tzeng M, DeRosa AP, Allaway MJ, Ross AE, Schaeffer EM, Patel HD, Hu JC, Gorin MA. Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy: A Systematic Review and Meta-analysis. EUR UROL SUPPL 2022; 37:53-63. [PMID: 35243391 PMCID: PMC8883190 DOI: 10.1016/j.euros.2022.01.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2022] [Indexed: 12/25/2022] Open
Abstract
CONTEXT Transperineal prostate biopsy is associated with a significantly lower risk of infectious complications than the transrectal approach. In fact, the risk of infectious complications with transperineal prostate biopsy is so low that the utility of administering periprocedural antibiotics with this procedure has come under question. OBJECTIVE To perform a systematic review and meta-analysis to assess for differences in the rates of infectious complications (septic, nonseptic, and overall) after performing transperineal prostate biopsy with and without the administration of periprocedural antibiotic prophylaxis. EVIDENCE ACQUISITION Three electronic databases (PubMed, Embase, and MEDLINE) were searched, and studies were included if they included patients who underwent transperineal prostate biopsy, were published after January 2000, included information on periprocedural antibiotic administration, and reported postbiopsy complications. Preferred Reporting Items for Systematic Reviews and Meta-analyses and Agency for Healthcare Research and Quality guidelines were utilized. EVIDENCE SYNTHESIS A total of 106 unique studies describing 112 cohorts of patients were identified, of which 98 (37 805 men) received antibiotic prophylaxis and 14 (4772 men) did not receive it. All patients were included in the analysis of septic complications. In total, there were 19/37 805 (0.05%) episodes of sepsis in the group of men who received antibiotics, which was similar to the no antibiotic group with 4/4772 (0.08%) episodes (p = 0.2). For overall infections (septic plus nonseptic), there were 403/29 880 (1.35%) versus 58/4772 (1.22%) events among men with evaluable data who received and did not receive antibiotic prophylaxis, respectively (p = 0.8). Restricting our analysis to studies with a comparable low number of biopsy cores (<25 cores), there remained no difference in the rates of sepsis between groups, but there was a small, statistically significant lower risk of infectious complications with antibiotic administration-67/12 140 (0.55%) versus 58/4772 (1.22%; p < 0.01). CONCLUSIONS The likelihood of septic infections after transperineal prostate biopsy is low with and without antibiotic prophylaxis. The omission of periprocedural antibiotics with this procedure stands to benefit patients by avoiding potential drug reactions. Furthermore, this practice is in line with calls throughout the medical community for improved antibiotic stewardship. PATIENT SUMMARY In a large systematic review and meta-analysis, we evaluated infectious complications after transperineal prostate biopsy with or without the administration of prophylactic antibiotics. We conclude that prophylactic antibiotics do not decrease the rate of postbiopsy sepsis but may have a small benefit in terms of preventing less serious infections.
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Affiliation(s)
- Spyridon P. Basourakos
- Department of Urology, New York Presbyterian Hospital/Weil Cornell Medicine, New York, NY, USA
| | - Mark N. Alshak
- Department of Urology, New York Presbyterian Hospital/Weil Cornell Medicine, New York, NY, USA
| | - Patrick J. Lewicki
- Department of Urology, New York Presbyterian Hospital/Weil Cornell Medicine, New York, NY, USA
| | - Emily Cheng
- Department of Urology, New York Presbyterian Hospital/Weil Cornell Medicine, New York, NY, USA
| | - Michael Tzeng
- Department of Urology, New York Presbyterian Hospital/Weil Cornell Medicine, New York, NY, USA
| | - Antonio P. DeRosa
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY, USA
| | | | - Ashley E. Ross
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Edward M. Schaeffer
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hiten D. Patel
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | - Jim C. Hu
- Department of Urology, New York Presbyterian Hospital/Weil Cornell Medicine, New York, NY, USA
| | - Michael A. Gorin
- Urology Associates and UPMC Western Maryland, Cumberland, MD, USA
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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6
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Islam M, Da Silva RD, Quach A, Gustafson D, Nogueira L, Clark N, Kim FJ. Are outpatient transperineal prostate biopsies without antibiotic prophylaxis equivalent to standard transrectal biopsies for patient safety and cancer detection rates?A retrospective cohort study in 222 patients. Patient Saf Surg 2021; 15:28. [PMID: 34419137 PMCID: PMC8380346 DOI: 10.1186/s13037-021-00303-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To describe our experience with outpatient transperineal biopsy (TPB) without antibiotics compared to transrectal biopsy (TRB) with antibiotics and bowel preparation. The literature elicits comparable cancer detection, time, and cost between the two. As antibiotic resistance increases, antimicrobial stewardship is imperative. METHODS In our retrospective review, we compared the TPB to TRB in our institution for outpatient prostate biopsies with local anesthesia from June 1st, 2017 to June 1st, 2019. Patients had negative urinalysis on day of procedure. Patients presenting with symptoms concerning for UTI followed by positive urine culture were determined to have a UTI. RESULTS Two hundred twenty-two patients met inclusion criteria. Age, race, BMI, pre-procedure PSA, history of UTI, BPH or other GU history were similar between both groups. Two TPB patients (1.8%) had post-procedure UTI; one received oral antibiotics and one received a dose of intravenous and subsequent oral antibiotics. There were no sepsis events or admissions. Six TRB patients (5.4%) had post-procedure UTI; five received oral antibiotics, and one received intravenous antibiotics and required admission for sepsis. One TPB patient (0.9%) had post-procedure retention and required catheterization, while four TRB patients (3.6%) had retention requiring catheterization. No significant difference noted in cancer detection between the two groups. CONCLUSION Outpatient TPB without antibiotic prophylaxis/bowel prep is comparable to TRB in regard to safety and cancer detection. TPB without antibiotics had a lower infection and retention rate than TRB with antibiotics. Efforts to reduce antibiotic resistance should be implemented into daily practice. Future multi-institutional studies can provide further evidence for guideline changes.
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Affiliation(s)
- Majdee Islam
- Department of Surgery / Division of Urology, Denver Health Medical Center, 777 Bannock St, Denver, Pavilion A, 3RD Floor, Surgery Administration, Denver, CO, 80204, USA
| | - Rodrigo Donalisio Da Silva
- Department of Surgery / Division of Urology, Denver Health Medical Center, 777 Bannock St, Denver, Pavilion A, 3RD Floor, Surgery Administration, Denver, CO, 80204, USA.
| | - Alan Quach
- Department of Surgery / Division of Urology, Denver Health Medical Center, 777 Bannock St, Denver, Pavilion A, 3RD Floor, Surgery Administration, Denver, CO, 80204, USA
| | - Diedra Gustafson
- Department of Surgery / Division of Urology, Denver Health Medical Center, 777 Bannock St, Denver, Pavilion A, 3RD Floor, Surgery Administration, Denver, CO, 80204, USA
| | - Leticia Nogueira
- Department of Surgery / Division of Urology, Denver Health Medical Center, 777 Bannock St, Denver, Pavilion A, 3RD Floor, Surgery Administration, Denver, CO, 80204, USA
| | - Nathan Clark
- Department of Surgery / Division of Urology, Denver Health Medical Center, 777 Bannock St, Denver, Pavilion A, 3RD Floor, Surgery Administration, Denver, CO, 80204, USA
| | - Fernando J Kim
- Department of Surgery / Division of Urology, Denver Health Medical Center, 777 Bannock St, Denver, Pavilion A, 3RD Floor, Surgery Administration, Denver, CO, 80204, USA
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Cricco-Lizza E, Wilcox Vanden Berg RN, Laviana A, Pantuck M, Basourakos SP, Salami SS, Hung AJ, Margolis DJ, Hu JC, McClure TD. Comparative Effectiveness and Tolerability of Transperineal MRI-Targeted Prostate Biopsy under Local versus Sedation. Urology 2021; 155:33-38. [PMID: 34217762 DOI: 10.1016/j.urology.2021.06.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/14/2021] [Accepted: 06/21/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the prostate cancer diagnostic yield, complications, and costs of transperineal prostate biopsies when performed with local anesthesia versus sedation. METHODS Data were prospectively collected for men undergoing transperineal MRI-targeted biopsy at the outpatient clinic and tertiary hospital of a single center between October 2017 to February 2020. These data included demographic, procedural, and pathologic variables and complications. Time-driven activity-based costing was performed to compare procedural costs. RESULTS 126 men were included. Age, BMI and PSA were similar for local (n = 45) vs sedation (n = 81), all P>0.05. Detection of clinically significant prostate cancer (CSPC) on combined systematic and targeted biopsy was similar for local vs sedation (24% vs 36%; P = 0.2). Local had lower detection on targeted biopsies alone (8.9% vs 25%; P = 0.03). However, fewer targeted cores were obtained per region of interest with local vs sedation (median 3 vs 4 cores; P<0.01). For local vs sedation, the complication rate was 2.6% and 6.1% (P = 0.6). The median visual analog pain score for local vs sedation was 3/10 vs 0/10 (P<0.01). The mean procedure time for local vs sedation was 22.5 vs 17.5 minutes (48.3 minutes when including anesthesia time). Time-driven activity-based costs for local vs sedation were $961.64 vs $2208.16 (P<0.01). CONCLUSION Transperineal biopsy with local anesthesia is safe with comparable outcomes to sedation. While the number of cores taken differed, there was no statistical difference in the detection of clinically significant cancer.
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Affiliation(s)
- Eliza Cricco-Lizza
- Department of Urology, Weill Cornell Medicine, New York Presbyterian, New York, NY
| | | | - Aaron Laviana
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas, Austin, TX
| | - Morgan Pantuck
- Department of Urology, Weill Cornell Medicine, New York Presbyterian, New York, NY
| | | | - Simpa S Salami
- Department of Urology, University of Michigan, Ann Arbor, MI; Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | - Andrew J Hung
- Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Daniel J Margolis
- Department of Radiology, Weill Cornell Medicine, New York Presbyterian, New York, NY
| | - Jim C Hu
- Department of Urology, Weill Cornell Medicine, New York Presbyterian, New York, NY.
| | - Timothy D McClure
- Department of Urology, Weill Cornell Medicine, New York Presbyterian, New York, NY; Department of Interventional Radiology, Weill Cornell Medicine, New York Presbyterian, New York, NY
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8
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Crump RT, Remmers S, Van Hemelrijck M, Helleman J, Nieboer D, Roobol MJ, Venderbos LDF, Trock B, Ehdaie B, Carroll P, Filson C, Logothetis C, Morgan T, Klotz L, Pickles T, Hyndman E, Moore C, Gnanapragasam V, Van Hemelrijck M, Dasgupta P, Bangma C, Roobol M, Villers A, Robert G, Semjonow A, Rannikko A, Valdagni R, Perry A, Hugosson J, Rubio-Briones J, Bjartell A, Hefermehl L, Shiong LL, Frydenberg M, Sugimoto M, Chung BH, van der Kwast T, Hulsen T, de Jonge C, van Hooft P, Kattan M, Xinge J, Muir K, Lophatananon A, Fahey M, Steyerberg E, Nieboer D, Zhang L, Steyerberg E, Nieboer D, Beckmann K, Denton B, Hayen A, Boutros P, Guo W, Benfante N, Cowan J, Patil D, Park L, Ferrante S, Mamedov A, LaPointe V, Crump T, Stavrinides V, Kimberly-Duffell J, Santaolalla A, Nieboer D, Olivier J, France B, Rancati T, Ahlgren H, Mascarós J, Löfgren A, Lehmann K, Lin CH, Cusick T, Hirama H, Lee KS, Jenster G, Auvinen A, Bjartell A, Haider M, van Bochove K, Buzza M, Kouspou M, Paich K, Bangma C, Roobol M, Helleman J. Using the Movember Foundation's GAP3 cohort to measure the effect of active surveillance on patient-reported urinary and sexual function-a retrospective study in low-risk prostate cancer patients. Transl Androl Urol 2021; 10:2719-2727. [PMID: 34295757 PMCID: PMC8261406 DOI: 10.21037/tau-20-1255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 04/29/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Active surveillance (AS) for low-risk prostate cancer (PCa) is intended to overcome potential side-effects of definitive treatment. Frequent prostate biopsies during AS may, however, impact erectile (EF) and urinary function (UF). The objective of this study was to test the influence of prostate biopsies on patient-reported EF and UF using multicenter data from the largest to-date AS-database. METHODS In this retrospective study, data analyses were performed using the Movember GAP3 database (v3.2), containing data from 21,169 AS participants from 27 AS-cohorts worldwide. Participants were included in the study if they had at least one follow-up prostate biopsy and completed at least one patient reported outcome measure (PROM) related to EF [Sexual Health Inventory for Men (SHIM)/five item International Index of Erectile Function (IIEF-5)] or UF [International Prostate Symptom Score (IPSS)] during follow-up. The longitudinal effect of the number of biopsies on either SHIM/IIEF-5 or IPSS were analyzed using linear mixed models to adjust for clustering at patient-level. Analyses were stratified by center; covariates included age and Gleason Grade group at diagnosis, and time on AS. RESULTS A total of 696 participants completed the SHIM/IIEF-5 3,175 times, with a median follow-up of 36 months [interquartile range (IQR) 20-55 months]. A total of 845 participants completed the IPSS 4,061 times, with a median follow-up of 35 months (IQR 19-56 months). The intraclass correlation (ICC) was 0.74 for the SHIM/IIEF-5 and 0.68 for the IPSS, indicating substantial differences between participants' PROMs. Limited heterogeneity between cohorts in the estimated effect of the number of biopsies on either PROM were observed. A significant association was observed between the number of biopsies and the SHIM/IIEF-5 score, but not for the IPSS score. Every biopsy was associated with a decrease in the SHIM/IIEF-5 score of an average 0.67 (95% CI, 0.47-0.88) points. CONCLUSIONS Repeated prostate biopsy as part of an AS protocol for men with low-risk PCa does not have a significant association with self-reported UF but does impact self-reported sexual function. Further research is, however, needed to understand whether the effect on sexual function implies a negative clinical impact on their quality of life and is meaningful from a patient's perspective. In the meantime, clinicians and patients should anticipate a potential decline in erectile function and hence consider incorporating the risk of this harm into their discussion about opting for AS and also when deciding on the stringency of follow-up biopsy schedules with long-term AS.
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Affiliation(s)
| | - Sebastiaan Remmers
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mieke Van Hemelrijck
- King’s College London, Faculty of Life Sciences and Medicine, Translational Oncology & Urology Research (TOUR), London, UK
| | - Jozien Helleman
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daan Nieboer
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Monique J. Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Szabo RJ. "Free-Hand" Transperineal Prostate Biopsy Under Local Anesthesia: Review of the Literature. J Endourol 2021; 35:525-543. [PMID: 33380279 DOI: 10.1089/end.2020.1093] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Richard J Szabo
- Department of Urology, Kaiser Permanente, Irvine, California, USA.,Department of Urology, Cinical Associate Professor, University of California, Irvine, Orange, California, USA.,Department of Urology, Volunteer Faculty, Veterans Administration Healthcare System, Long Beach, California, USA
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Sectoral cancer detection and tolerability of freehand transperineal prostate biopsy under local anaesthesia. Prostate Cancer Prostatic Dis 2020; 24:431-438. [PMID: 32999465 DOI: 10.1038/s41391-020-00293-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/11/2020] [Accepted: 09/18/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND To investigate the feasibility of a freehand transperineal (TP) systematic prostate biopsy protocol under local anaesthesia (LA) and the value of different sectors in diagnosing prostate cancer (PCa). METHODS A total of 611 consecutive freehand TP biopsies under LA in 2 hospitals were prospectively evaluated. Cancer detection rate in each of the four different sectors (anterior, mid, posterior, basal) was recorded to evaluate the value of each sector. Procedure tolerability was assessed by pain score and complications were documented. RESULTS Systematic biopsies were performed in 556 out of 611 men with a median of 20 (IQR 12-24) biopsy cores taken. The median PSA was 9.9 (Inter-quartile range[IQR] 6.4-16.2) ng/mL, and 89.0% were first biopsies. All PCa and ISUP grade group (GG) ≥ 2 PCa (HGPCa) were diagnosed in 41.4% (230/556) and 28.2% (157/556) biopsies respectively. 77.0% HGPCa was diagnosed in ≥2 sectors. Single-sector HGPCa was predominantly found in anterior or posterior sector. Omitting base sector would have missed 1.5% (1/65) HGPCa out of the 219 cases with ≥24-core biopsies performed. Further omission of mid sector would have missed 3.1% (2/65) HGPCa and 7.4% (7/94) ISUP GG1 PCa (in which 3/7 involved 2 sectors). LA TP biopsy was well tolerated and the mean pain scores of the different steps of the procedure were between 1.9-3.1 (out of 10). Post-biopsy fever occurred in 0.3% of patients (2/611) and no sepsis was reported. The risk of urinary retention in men with ≥20 cores in ≥60 ml prostate was 7.8% (14/179), compared with 1.7% (7/423) in other groups (p < 0.001). CONCLUSIONS TP sectoral prostate biopsy under LA was well tolerated with minimal sepsis risk. Basal sector biopsies had minimal additional value to HGPCa detection and its omission can be considered.
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Abstract
PURPOSE OF REVIEW Prostate cancer (PCa) diagnostics have undergone a number of changes as a result of efforts to reduce the detection rate of indolent prostate cancer and to increase the hit rate for clinically significant prostate cancer (csPCa). Here, we look at those studies that have shifted our knowledge and the impact these have had on clinical practice. RECENT FINDINGS The introduction of multiparametric MRI (mpMRI) and approaches to active surveillance have changed the landscape in prostate cancer diagnostics, reducing the number of men that need biopsy, but increasing the need for accuracy in mapping the extent of prostate cancer. As mpMRI reporting has become more accurate at predicting PCa, biopsy techniques have also evolved towards lesion (PI-RADS score 3-5) targeted biopsies. Uncertainty remains regarding the preferred approach to targeted biopsy, the need for systematic biopsies, and the place of software ultrasound/MRI fusion or in-bore MRI biopsy techniques versus 'cognitive' fusion techniques. SUMMARY Prostate biopsies remain essential for the diagnosis of PCa. But how best to do this? Latest guidelines advocate performing both targeted and systematic biopsies. Traditionally, prostate biopsies have been performed transrectally (TRUS) with hospital readmission rates of around 3% mainly because of infection. Additionally, TRUS prostate biopsies can miss anterior prostatic lesions. The transperineal approach addresses both these issues, but has historically required general anaesthetic such that adoption for front-line diagnostics is very difficult. Recent techniques to undertake transperineal biopsy under local anaesthetic have fundamentally changed this paradigm offering the genuine possibility that in 5 years' time, all front-line diagnostic biopsies will be performed as LATP.
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Affiliation(s)
- Altan Omer
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford
- University Hospital Coventry & Warwickshire, Coventry
| | - Alastair D Lamb
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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