Multiparametric Prostate Magnetic Resonance Imaging and Cognitively Targeted Transperineal Biopsy in Patients With Previous Abdominoperineal Resection and Suspicion of Prostate Cancer

3.0-T MR-guided transgluteal in-bore-targeted prostate biopsy under local anesthesia in patients without rectal access: a single-institute experience and review of literature

PURPOSE

To describe the technique and evaluate the performance of MRI-guided transgluteal in-bore-targeted biopsy of the prostate gland under local anesthesia in patients without rectal access.

METHODS

Ten men (mean age, 69 (range 57-86) years) without rectal access underwent 13 MRI-guided transgluteal in-bore-targeted biopsy of the prostate gland under local anesthesia. All patients underwent mp-MRI at our institute prior to biopsy. Three patients had prior US-guided transperineal biopsy which was unsuccessful in one, negative in one, and yielded GG1 (GS6) PCa in one. Procedure time, complications, histopathology result, and subsequent management were recorded.

RESULTS

Median interval between rectal surgery and presentation with elevated PSA was 12.5 years (interquartile range (IQR) 25-75, 8-36.5 years). Mean PSA was 11.9 (range, 4.8 -59.0) ng/ml and PSA density was 0.49 (0.05 -3.2) ng/ml/ml. Distribution of PI-RADS v2.0/2.1 scores of the targeted lesions were PI-RADS 5-3; PI-RADS 4-6; and PI-RADS 3-1. Mean lesion size was 1.5 cm (range, 1.0-3.6 cm). Median interval between MRI and biopsy was 5.5 months (IQR 25-75, 1.5-9 months). Mean procedure time was 47.4 min (range, 29-80 min) and the number of cores varied between 3 and 5. Of the 13 biopsies, 4 yielded clinically significant prostate cancer (csPca), with a Gleason score ≥ 7, 1 yielded insignificant prostate cancer (Gleason score = 6), 7 yielded benign prostatic tissue, and one was technically unsuccessful. 3/13 biopsies were repeat biopsies which detected csPCa in 2 out of the 3 patients. None of the patients had biopsy-related complication. Biopsy result changed management to radiation therapy with ADT in 2 patients with the rest on active surveillance.

CONCLUSION

MRI-guided transgluteal in-bore-targeted biopsy of the prostate gland under local anesthesia is feasible in patients without rectal access.

Image intensifier-guided transperineal prostate biopsy for patients without a rectum: novel technique

INTRODUCTION

It is challenging to perform prostate biopsy in men with suspicion of prostate malignancy without a rectum to facilitate prostate biopsy. Nevertheless, such patients are presenting at an earlier stage, due to increased PSA testing in association with improved MRI imaging. We describe a novel technique for prostate biopsy in two such cases.

TECHNIQUE

The patient is under General Anaesthesia and in lithotomy position. The patient is catheterised and a measured volume of contrast is inserted to the catheter balloon. By using anatomical surface landmarks, placing traction on the catheter to bring the balloon to the level of the bladder neck and using fluoroscopy, the distance to the apical prostate was estimated. This facilitates image intensifier guided trans-perineal prostate biopsy.

OUTCOMES

A 67-year-old patient, with a history of panproctocolectomy for ulcerative colitis, presented with increasing PSA and a suspicious prostate on MP-MRI. The prostate couldn't be visualised on transperineal ultrasound and the patient was offered transperineal biopsy using image intensifier guidance. Several biopsy cores were taken and prostate cancer was diagnosed. The second patient was a 68-year-old who presented similarly, but with a history of panproctocolectomy for Crohn's disease. Using the above technique, biopsies were taken with low-risk prostate cancer diagnosed. Subsequently, due to rising PSA levels, a repeat set of prostate biopsies was taken 13 months later in an identical manner, upstaging his disease. There were no post-operative complications after any of the procedures.

CONCLUSION

We review the literature and discuss several techniques available to sample the prostate in this patient cohort. We conclude that we have identified a safe and effective technique, which utilises commonly available equipment, to biopsy the prostate in the post proctectomy patient.

Quality checkpoints in the MRI-directed prostate cancer diagnostic pathway

Multiparametric MRI of the prostate is now recommended as the initial diagnostic test for men presenting with suspected prostate cancer, with a negative MRI enabling safe avoidance of biopsy and a positive result enabling MRI-directed sampling of lesions. The diagnostic pathway consists of several steps, from initial patient presentation and preparation to performing and interpreting MRI, communicating the imaging findings, outlining the prostate and intra-prostatic target lesions, performing the biopsy and assessing the cores. Each component of this pathway requires experienced clinicians, optimized equipment, good inter-disciplinary communication between specialists, and standardized workflows in order to achieve the expected outcomes. Assessment of quality and mitigation measures are essential for the success of the MRI-directed prostate cancer diagnostic pathway. Quality assurance processes including Prostate Imaging-Reporting and Data System, template biopsy, and pathology guidelines help to minimize variation and ensure optimization of the diagnostic pathway. Quality control systems including the Prostate Imaging Quality scoring system, patient-level outcomes (such as Prostate Imaging-Reporting and Data System MRI score assignment and cancer detection rates), multidisciplinary meeting review and audits might also be used to provide consistency of outcomes and ensure that all the benefits of the MRI-directed pathway are achieved.

Transperineal Ultrasound Before and After Prostatectomy: Technical Approach and Description

This study assessed the feasibility of dynamic transperineal ultrasound (TPUS) pre/post-radical prostatectomy (RP). Ninety-eight patients were scanned pre-operatively and at four time-points post-operatively. TPUS was performed in 98 patients using an abdominal transducer at rest, during pelvic floor contraction (PFC) and Valsalva (VS) maneuver in supine and standing positions. Urodynamic evaluations included bladder neck angle at rest/PFC/VS, and degree of bladder neck movement. Pre-operative and post-operative measurements were technically feasible in >85% (supine) and >90% (standing) of patients. TPUS offers a reliable non-invasive dynamic assessment of the pelvic floor post-prostatectomy and may prove a useful adjunct for guiding exercises to preserve continence.

Transperineal MRI-US Fusion-Guided Target Biopsy of the Prostate after Abdominoperineal Resection: A Case Report

Main Teaching Point: MRI-US fusion-guided transperineal prostate biopsy can help sampling clinically relevant prostate cancer in patients with a history of abdominoperineal resection and is feasible under local anaesthesia and in an outpatient setting.

Prostate cancer remains one of the most diagnosed cancers in men worldwide. Prostate biopsy in patients with a history of abdominoperineal resection poses a serious challenge since transrectal ultrasound is not possible. Several techniques have been described with their respective limitations and risks. This report of such a patient aged 75, presents a Magnetic Resonance Imaging-Ultrasound fusion-guided transperineal approach to prostate biopsy which can be performed under local anaesthesia and in an outpatient setting.

Cognitively targeted transperineal prostate biopsy in patients with previous abdominoperineal excision of the rectum

Introduction:

Prostate biopsy is performed using an ultrasound probe placed in the rectum with either a transrectal or, increasingly popular, transperineal approach. This is not possible in patients with abdominoperineal excision of the rectum due to the lack of rectum. In our case series, we present a technique for prostate biopsy in this cohort and our outcomes.

Method:

The study population consisted of three consecutive patients who presented to our institution between 2018–2019 with an elevated level of prostate-specific antigen, a history of abdominoperineal excision of the rectum and undergone multiparametric magnetic resonance imaging of the prostate at our institution before a biopsy. Transperineal prostate biopsies were performed under general anaesthesia using a curved uniplanar ultrasound transducer with an attached guide to stabilise the needle. Free-hand biopsies were taken using an 18-gauge biopsy needle with an automatic spring-driven device. Multiple biopsy cores were directed to multiparametric magnetic resonance imaging target areas by visual registration.

Results:

Three men with a median age of 69 years (range 68–75 years) were included in this case series with serum index prostate-specific antigen values between 6.5–14 ng/ml. All three patients had Prostate Imaging Reporting and Data System 5 lesions identified on multiparametric magnetic resonance imaging scans. All three men were diagnosed with clinically significant prostate cancer (>Gleason grade group 2). On average, 13 biopsy cores (range: 12–15) were obtained with a median core length of 9 mm (range: 6–20 mm). All patients were discharged home on the day of the procedure and had none had postoperative complications.

Conclusion:

The use of multiparametric magnetic resonance imaging and cognitive targeted transperineal biopsy provides an option for diagnosing prostate cancer in this challenging group of patients. Level of evidence: 4

MRI in early prostate cancer detection: how to manage indeterminate or equivocal PI-RADS 3 lesions?

This review focuses on indeterminate lesions on prostate magnetic resonance imaging (MRI), assigned as PI-RADS category 3. The prevalence of PI-RADS 3 index lesion in the diagnostic work-up is significant, varying between one in three (32%) to one in five (22%) men, depending on patient cohort of first biopsies, previously negative biopsies, and active surveillance biopsies. A management strategy must be developed for this group of men with an indeterminate suspicion of having clinically significant prostate cancer (csPCa). Currently available data show that the actual prevalence of csPCa after targeted biopsy in PI-RADS 3 lesions vary between patients groups from one in five (21%) to one in six (16%), depending on previous biopsy status. Although this prevalence is lower in comparison to PI-RADS 4 and PI-RADS 5 lesions, still a considerable proportion of men harbor significant disease. Men with such a PI-RADS 3 lesion should therefore be adequately managed. In general, the clinical approach of using a threshold of PI-RADS ≥4 instead of PI-RADS ≥3 to select MRI for targeted biopsies is not supported by data from our explorative literature search using current definitions of csPCa. A possible adaptation to the threshold of PI-RADS ≥4 in combination with other clinical markers could be considered within an active surveillance protocol, where the balance between the individual risk of missing csPCa and the constant process of repeating prostate biopsies is crucial. In the future, improvements in MR imaging and interpretation, combined with molecular biomarkers and multivariate risk models will all be employed in prostate cancer detection and monitoring. These combinations will aid decision-making in challenging circumstances, such as unclear and diagnostic equivocal results for csPCa at early detection.

Lesion Targeted CT-Guided Transgluteal Prostate Biopsy in Combination With Prebiopsy MRI in Patients Without Rectal Access

With prostate and colorectal malignancies being the most common cancers in men, elevated prostate specific antigen (PSA) in patients without rectal access due to prior surgery poses a diagnostic dilemma. We report the first use of CT-guided biopsy in combination with prebiopsy MRI in 2 patients with a clinical suspicion of prostate cancer and no rectal access. In both cases, a diagnostic multiparametric MRI of the prostate was performed to detect and to localize a potential suspicious lesion. The localization served as a cognitive map for guiding needle placement using a CT-guided transgluteal approach.