Prostate Biopsy-related Infection: A Systematic Review of Risk Factors, Prevention Strategies, and Management Approaches

Enhancing Prostate Cancer Detection Accuracy in Magnetic Resonance Imaging-targeted Prostate Biopsy: Optimizing the Number of Cores Taken

Background and objective

The shift toward targeted biopsy (TBx) aims at enhancing prostate cancer (PCa) detection while reducing overdiagnosis of clinically insignificant disease. Despite the improved ability of TBx in identifying clinically significant PCa (csPCa), the optimal number and location of targeted cores remain unclear. This review aims to assess the optimal number of prostate biopsy magnetic resonance imaging (MRI)-targeted cores to detect csPCa.

Methods

A narrative literature search was conducted using PubMed, focusing on studies published between January 2014 and January 2024, addressing factors influencing targeted core numbers during prostate biopsy. The search included both retrospective and prospective studies, prioritizing those with substantial sample sizes and employing terms such as "prostate biopsy", "mpMRI", "core number", and "cancer detection".

Key findings and limitations

Two biopsy cores identified csPCa in 55-65% of cases. This detection rate improved to approximately 90% when the number of cores was ≥5. The inclusion of perilesional and systematic biopsies could maximize the detection of csPCa (from 10% to 45%), especially in patients under active surveillance or with prior negative biopsy results, although there is an increase in the overdiagnosis of indolent tumors (from 4% to 20%). Transperineal software-assisted target prostate biopsy may enhance cancer detection, particularly for tumors located at the apex/anterior part of the prostate. Increasing the number of TBx cores may incrementally raise the risk of complications (by 2-14% with each added core) and result in severe pain and significant discomfort for up to 17% and 25% of TBx patients, respectively. However, the overall rate and severity of these complications remain within acceptable limits.

Conclusions and clinical implications

The optimal number of cores for targeted prostate biopsies should balance minimizing sampling errors with effective cancer detection and should be tailored to each patient's unique prostate characteristics. Up to five cores per MRI target may be considered to enhance the detection of csPCa, with adjustments based on factors such as prostate and lesion volume, Prostate Imaging Reporting and Data System, biopsy techniques, complications, patient discomfort, and anxiety.

Patient summary

In this report, we found that increasing the number of biopsy cores up to ≥5 improves the detection rates of significant prostate cancer significantly to around 90%. Although inclusion of nearby and systematic biopsies enhances detection, increasing the biopsy count may lead to higher risks of complications and indolent tumors. A customized biopsy approach based on multiple variables could be helpful in determining the appropriate number of targeted biopsies on a case-by-case basis.

EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer-2024 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent

BACKGROUND AND OBJECTIVE

The European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Urological Pathology (ISUP)-International Society of Geriatric Oncology (SIOG) guidelines provide recommendations for the management of clinically localised prostate cancer (PCa). This paper aims to present a summary of the 2024 version of the EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on the screening, diagnosis, and treatment of clinically localised PCa.

METHODS

The panel performed a literature review of all new data published in English, covering the time frame between May 2020 and 2023. The guidelines were updated, and a strength rating for each recommendation was added based on a systematic review of the evidence.

KEY FINDINGS AND LIMITATIONS

A risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is considered, a combination of targeted and regional biopsies should be performed. Prostate-specific membrane antigen positron emission tomography imaging is the most sensitive technique for identifying metastatic spread. Active surveillance is the appropriate management for men with low-risk PCa, as well as for selected favourable intermediate-risk patients with International Society of Urological Pathology grade group 2 lesions. Local therapies are addressed, as well as the management of persistent prostate-specific antigen after surgery. A recommendation to consider hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term intensified hormonal treatment.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. These PCa guidelines reflect the multidisciplinary nature of PCa management.

PATIENT SUMMARY

This article is the summary of the guidelines for "curable" prostate cancer. Prostate cancer is "found" through a multistep risk-based screening process. The objective is to find as many men as possible with a curable cancer. Prostate cancer is curable if it resides in the prostate; it is then classified into low-, intermediary-, and high-risk localised and locally advanced prostate cancer. These risk classes are the basis of the treatments. Low-risk prostate cancer is treated with "active surveillance", a treatment with excellent prognosis. For low-intermediary-risk active surveillance should also be discussed as an option. In other cases, active treatments, surgery, or radiation treatment should be discussed along with the potential side effects to allow shared decision-making.

Clinical value of ultrasound-guided full-needle path anesthesia in transperineal prostate biopsy: An observational study

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.

Natural history of histologically benign PIRADS 4-5 lesions in multiparametric MRI: Real-life experience in an academic center

INTRODUCTION

The follow-up findings of patients who underwent prostate biopsy for prostate image reporting and data system (PIRADS) 4 or 5 multiparametric magnetic resonance imaging (mpMRI) findings and had benign histology were retrospectively reviewed.

METHODS

There were 190 biopsy-naive patients. Patients with at least 12 months of follow-up between 2012 and 2023 were evaluated. All MRIs were interpreted by two very experienced uroradiologists. Of the patients, 125 had either cognitive or software fusion MR-targeted biopsies with 4 + 8/10 cores. The remaining 65 patients had in-bore biopsies with 4-5 cores. Prostate-specific antigen (PSA) levels below 4 ng/mL were defined as PSA regression following biopsy. PIRADS 1-3 lesions on new MRI images were classified as MRI regression.

RESULTS

Median patient age and PSA were 62 (39-82) years and six (0.4-33) ng/mL, respectively, at the initial work-up. During a median follow-up period of 44 months, 37 (19.4%) patients were lost to follow-up. Of the remaining 153 patients, 82 (53.6%) had persistently high PSA. Among them, 72 (87.8%) had repeat mpMRI within 6-24 months which showed regressive findings (PIRADS 1-3) in 53 patients (73.6%) and PIRADS 4-5 index lesion persistence in 19 cases (26.4%). The latter group was recommended to have rebiopsy. Of these 19 patients, 16 underwent MRI-targeted rebiopsy. Prostate cancer was diagnosed in six (37.5%) patients and of these four (25%) were clinically significant (>Grade Group 1). Totally, clinically significant prostate cancer was detected in 4/153 (2.6%) patients followed up.

CONCLUSION

Patients should be warned against the relative relaxing effect of a negative biopsy after identification of PIRADS 4-5 index lesion. While PSA decrease was observed in many patients during follow-up, persistent MRI findings were present in nearly a quarter of patients with persistently high PSA. A rebiopsy is warranted in these patients, with significant prostate cancer diagnosed in a quarter of patients with rebiopsy.

Comparison of ciprofloxacin versus fosfomycin versus fosfomycin plus trimethoprim/sulfamethoxazole for preventing infections after transrectal prostate biopsy

BACKGROUND

To evaluate antibiotic prophylaxis in transrectal prostate biopsies due to the recommendation of the European Medicines Agency (EMA): We describe our single center experience switching from ciprofloxacin to fosfomycin trometamol (FMT) alone and to an augmented prophylaxis combining fosfomycin and trimethoprim/sulfamethoxazole (TMP/SMX).

METHODS

Between 01/2019 and 12/2020 we compared three different regimes. The primary endpoint was the clinical diagnosis of an infection within 4 weeks after biopsy. We enrolled 822 men, 398 (48%) of whom received ciprofloxacin (group-C), 136 (16.5%) received FMT (group-F) and 288 (35%) received the combination of TMP/SMX and FMT (group-BF).

RESULTS

Baseline characteristics were similar between groups. In total 37/398 (5%) postinterventional infections were detected, of which 13/398 (3%) vs 18/136 (13.2%) vs 6/288 (2.1%) were detected in group-C, group-F and group-BF respectively. The relative risk of infectious complication was 1.3 (CI 0.7-2.6) for group-C vs. group-BF and 2.8 (CI 1.4-5.7) for group-F vs. group-BF respectively.

CONCLUSION

The replacement of ciprofloxacin by fosfomycin alone resulted in a significant increase of postinterventional infections, while the combination of FMT and TMP/SMX had a comparable infection rate to FQ without apparent adverse events. Therefore, this combined regimen of FMT and TMP/SMX is recommended.

PSA-density, DRE, and PI-RADS 5: potential surrogates for omitting biopsy?

OBJECTIVE

In contrast to other malignancies, histologic confirmation prior treatment in patients with a high suspicion of clinically significant prostate cancer (csPCA) is common. To analyze the impact of extracapsular extension (ECE), cT-stage defined by digital rectal examination (DRE), and PSA-density (PSA-D) on detection of csPCA in patients with at least one PI-RADS 5 lesion (hereinafter, "PI-RADS 5 patients").

MATERIALS AND METHODS

PI-RADS 5 patients who underwent MRI/Ultrasound fusion biopsy (Bx) between 2016 and 2020 were identified in our institutional database. Uni- and multivariable logistic-regression models were used to identify predictors of csPCA-detection (GGG ≥ 2). Risk models were adjusted for ECE, PSA-D, and cT-stage. Corresponding Receiver Operating Characteristic (ROC) curves and areas under the curve (AUC) were calculated.

RESULTS

Among 493 consecutive PI-RADS 5 patients, the median age and PSA was 69 years (IQR 63-74) and 8.9 ng/ml (IQR 6.0-13.7), respectively. CsPCA (GGG ≥ 2) was detected in 405/493 (82%); 36/493 patients (7%) had no cancer. When tabulating for PSA-D of > 0.2 ng/ml/cc and > 0.5 ng/ml/cc, csPCA was found in 228/253 (90%, PI-RADS5 + PSA-D > 0.2 ng/ml/cc) and 54/54 (100%, PI-RADS5 + PSA-D > 0.5 ng/ml/cc). Finally, a model incorporating PSA-D and cT-stage achieved an AUC of 0.79 (CI 0.74-0.83).

CONCLUSION

In PI-RADS 5 patients, PSA-D and cT-stage emerged as strong predictors of csPCA at biopsy. Moreover, when adding the threshold of PSA-D > 0,5 ng/ml/cc, all PI-RADS 5 patients were diagnosed with csPCA. Therefore, straight treatment for PCA can be considered, especially if risk-factors for biopsy-related complications such as obligatory dual platelet inhibition are present.

Infectious complications of transrectal prostate biopsy in patients receiving targeted antibiotic prophylaxis after urethral and rectal swab versus standard prophylaxis: A prospective comparative study

Background

To evaluate the role of targeted antibiotic prophylaxis (TAP) after rectal and urethral swab cultures compared to empiric antibiotic prophylaxis (EAP) for the prevention of infectious complications after transrectal ultrasound-guided prostate biopsy (TRUS-Bx).

Methods

We conducted a prospective comparative study on 141 patients who underwent TRUS-Bx and were allocated in two groups. The first group (n = 71) received EAP with ciprofloxacin and the second (n = 70) received TAP according to rectal and urethral cultures. Post-biopsy infectious complications rates were compared between the two groups. Fluoroquinolone resistance (FQ-R) in the urethral and rectal swabs was recorded. Baseline characteristics were analyzed to assess their relationship with infectious complications and antibiotic resistance.

Results

A total of 8 infectious complications were observed, 7 of them in the EAP group (9.85%) and 1 in the TAP group (1.4%). There was a statistically significant difference in febrile UTIs between the two groups (6 vs 0, P = 0.028). FQ-R rate was 4.3% and 12.9% for rectal and urethral samples, respectively. Recent antibiotic exposure was associated with higher post-biopsy infection rates for EAP group and FQ-R rates for TAP group.

Conclusion

Combination of rectal and urethral swab cultures for TAP was able to detect FQ-R bacteria carriers and was associated with fewer infectious complications compared to EAP.

Targeted augmented reality-guided transperineal prostate biopsies study: initial experience

Background

Transperineal biopsy of magnetic resonance imaging (MRI)-detected prostate lesions is now the established technique used in prostate cancer (CaP) diagnostics. Virtual Surgery Intelligence (VSI) Holomedicine by Apoqlar (Hamburg, Germany) is a mixed reality (MR)/augmented reality (AR) software platform that runs on the HoloLens II system (Microsoft, Redford, USA). Multiparametric prostate MRI images were converted into 3D holograms and added into a MR space, enabling visualization of a 3D hologram and image-assisted prostate biopsy.

Objective

The Targeted Augmented Reality-GuidEd Transperineal (TARGET) study investigated the feasibility of performing AR-guided prostate biopsies in a MR framework, using the VSI platform in patients with MRI-detected prostate lesions.

Methods

Ten patients with a clinical suspicion of CaP on MRI (Prostate Imaging-Reporting and Data System, PI-RADS 4/5) were uploaded to the VSI HoloLens system. Two MR/AR-guided prostate biopsies were then acquired using the PrecisionPoint Freehand transperineal biopsy system. Cognitive fusion biopsies were performed as standard of care following the MR/AR-guided prostate biopsies.

Results

All 10 patients successfully underwent MR/AR-guided prostate biopsy after 3D MR images were overlaid on the patient's body. Prostatic tissue was obtained in all MR/AR-guided specimens. Seven patients (70%) had matching histology in both the standard and MR/AR-guided biopsies. The remaining three had ISUP (International Society of Urological Pathology) Grade 2 CaP. There were no immediate complications.

Conclusion

We believe this is a world first. The initial feasibility data from the TARGET study demonstrated that an MR/AR-guided prostate biopsy utilizing the VSI Holomedicine system is a viable option in CaP diagnostics. The next stage in development is to combine AR images with real-time needle insertion and to provide further data to formally appraise the sensitivity and specificity of the technique.

Efficacy of fosfomycin compared to second generation cephalosporin flumarin as antimicrobial prophylaxis for transrectal ultrasound-guided prostate biopsy: a single center retrospective study

BACKGROUND

Fluoroquinolone has been the historic choice of antimicrobial prophylaxis for transrectal ultrasound (TRUS) guided prostate biopsy. However, increased fluoroquinolone resistance and recent restrictions of its use for antimicrobial prophylaxis has led to the emergence of alternative agents for antimicrobial prophylaxis for TRUS guided prostate biopsy including fosfomycin and cephalosporins. This study aimed to compare the efficacy of fosfomycin and a second-generation cephalosporin flumarin as alternative antimicrobials for TRUS-guided prostate biopsy in terms of the incidence of infectious complications after TRUS-guided prostate biopsy.

METHODS

A retrospective chart review of all patients who underwent TRUS-guided prostate biopsy between November 2009 to January 2023 was undertaken. Comparison of baseline characteristics and the incidence of infectious complications was done between those who received fosfomycin as antimicrobial prophylaxis for TRUS-guided prostate biopsy and those who received flumarin. Multivariate logistic regression analysis was conducted to identify risk factors for infectious complications after TRUS-guided prostate biopsy.

RESULTS

Of 2,900 patients identified as eligible candidates for analysis, 333 (11.5%) received fosfomycin and 2,567 (88.5%) received flumarin. The overall rate of infectious complications was approximately 3% lower in patients who received fosfomycin, although such difference did not reach statistical significance (5.7% vs. 8.6%, p = 0.074). Multivariate logistic regression analysis showed that history of operation done under general anaesthesia within six months of the biopsy (odds ratio [OR]: 2.216; 95% confidence interval [CI]: 1.042-4.713; p = 0.039) and history of prior antimicrobial use within six months (OR: 1.457; 95% CI: 1.049-2.024; p = 0.025) were significant risk factors for infectious complications after TRUS-guided prostate biopsy.

CONCLUSION

Fosfomycin was comparable to second-generation cephalosporin flumarin in preventing infectious complications after TRUS-guided prostate biopsy. Coupled with its properties such as ease of administration, low adverse effects, low resistance rate, and low collateral damage, fosfomycin might be an attractive alternative antimicrobial prophylaxis for TRUS-guided prostate biopsy.

Morbidity of Transrectal MRI-Fusion Targeted Prostate Biopsy at a Tertiary Referral Academic Centre: An Audit to Guide the Transition to the Transperineal Approach

Despite transrectal prostate biopsy (TRPB) being still widespread globally, the EAU Guidelines strongly recommend the transperineal approach, due to the reported lower infectious risk. Our study aims to evaluate the impact of a standardized clinical pathway for TRPB on post-operative complications. We prospectively collected data from all patients undergoing mpMRI-targeted TRPB at our Academic Centre from January 2020 to December 2022. All patients followed a standardized, structured multistep pathway. Post-procedural complications were collected and classified according to the Clavien-Dindo (CD) Classification. Among 458 patients, post-procedural adverse events were reported by 203 (44.3%), of which 161 (35.2%) experienced CD grade 1 complications (hematuria [124, 27.1%], hematochezia [22, 4.8%], hematospermia [14, 3.1%], or a combination [20, 4.4%]), and 45 (9.0%) reported CD grade 2 complications (acute urinary retention or hematuria needing catheterization, as well as urinary tract infections, of which 2 cases required hospitalization). No major complications, including sepsis, were observed. At uni- and multivariable analysis, age > 70 years and BMI > 25 kg/ m2 for patients were identified as predictors of post-operative complications. The results of our study confirm that TRPB is a safe and cost-effective procedure with a low risk of severe adverse events in experienced hands and following a standardized pathway.

[MR-Guided Targeted Prostate Biopsy from Radiologists' Perspective]

The prostate cancer diagnosis has traditionally been based on a systematic biopsy method in which tissue samples are randomly obtained from the prostate 10-12 sites. However, there are concerns as the method can fail to diagnose all prostate cancers or lead to over-detection of clinically insignificant cancers. MRI-guided prostate targeted biopsy has been proposed to address these shortcomings. This method involves identifying suspicious lesions using MRI and performing targeted biopsies under ultrasound or MRI guidance. We review the methods of MRI-based targeted biopsy and discuss recent guidelines and trends in prostate cancer diagnosis.

Is Active Surveillance Too Active?

PURPOSE OF REVIEW

Many prostate cancer active surveillance protocols mandate serial monitoring at defined intervals, including but certainly not limited to serum PSA (often every 6 months), clinic visits, prostate multiparametric MRI, and repeat prostate biopsies. The purpose of this article is to evaluate whether current protocols result in excessive testing of patients on active surveillance.

RECENT FINDINGS

Multiple studies have been published in the past several years evaluating the utility of multiparametric MRI, serum biomarkers, and serial prostate biopsy for men on active surveillance. While MRI and serum biomarkers have promise with risk stratification, no studies have demonstrated that periodic prostate biopsy can be safely omitted in active surveillance. Active surveillance for prostate cancer is too active for some men with seemingly low-risk cancer. The use of multiple prostate MRIs or additional biomarkers do not always add to the prediction of higher-grade disease on surveillance biopsy.

Fosfomycin for Antibiotic Prophylaxis in Men Undergoing a Transrectal Prostate Biopsy: A Systematic Review and Meta-Analysis

Background and Objectives: To assess the effects of fosfomycin compared with other antibiotics as a prophylaxis for urinary tract infections (UTIs) in men undergoing transrectal prostate biopsies. Materials and Methods: We searched multiple databases and trial registries without publication language or status restrictions until 4 January 2022. Parallel-group randomized controlled trials (RCTs) and non-randomized studies (NRS) were included. The primary outcomes were febrile UTI, afebrile UTI, and overall UTI. We used GRADE guidance to rate the certainty of evidence of RCTs and NRSs. The protocol was registered with PROSPERO (CRD42022302743). Results: We found data on five comparisons; however, this abstract focuses on the primary outcomes of the two most clinically relevant comparisons. Regarding fosfomycin versus fluoroquinolone, five RCTs and four NRSs with a one-month follow-up were included. Based on the RCT evidence, fosfomycin likely resulted in little to no difference in febrile UTIs compared with fluoroquinolone. This difference corresponded to four fewer febrile UTIs per 1000 patients. Fosfomycin likely resulted in little to no difference in afebrile UTIs compared with fluoroquinolone. This difference corresponded to 29 fewer afebrile UTIs per 1000 patients. Fosfomycin likely resulted in little to no difference in overall UTIs compared with fluoroquinolone. This difference corresponded to 35 fewer overall UTIs per 1000 patients. Regarding fosfomycin and fluoroquinolone combined versus fluoroquinolone, two NRSs with a one- to three-month follow-up were included. Based on the NRS evidence, fosfomycin and fluoroquinolone combined may result in little to no difference in febrile UTIs compared with fluoroquinolone. This difference corresponded to 16 fewer febrile UTIs per 1000 patients. Conclusions: Compared with fluoroquinolone, fosfomycin or fosfomycin and fluoroquinolone combined may have a similar prophylactic effect on UTIs after a transrectal prostate biopsy. Given the increasing fluoroquinolone resistance and its ease to use, fosfomycin may be a good option for antibiotic prophylaxis.

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.

Systematic Evaluation of Studies in the Fields of Diagnosis and Management of Prostate Cancer in Coronavirus Disease 2019 Era

Background: Prostate cancer is one of the most common cancers worldwide. The proper management of this cancer during the coronavirus disease 2019 (COVID-19) or similar outbreaks could be a serious challenge. Proper timing of surgery, radiotherapy, and other medical modalities are essential in providing the most effective treatment. Objectives: This systematic review aimed at evaluating the proper management of prostate cancer during the COVID-19 outbreak. Methods: This study was conducted from 2019 to 2022. An internet search was conducted using the keywords: Diagnosis, management, radical prostatectomy, radiotherapy, hormone ablation therapy, chemotherapy and prostate cancer, and COVID-19. The visited databases included PubMed, Scopus, Web of Sciences, Google Scholar, and Scientific Information Database. The review was performed based on the preferred reporting items for a systematic review and meta-analyses (PRISMA) guidelines. Results: Postponing the biopsy for up to three months and adopting of non-invasive diagnostic methods were likely reasonable during the COVID-19 pandemic. Patients with cancer were more prone to severe injuries and were more likely to have serious complications. Surgery, radiation therapy, brachytherapy, palliative radiation, hormone ablation therapy, and chemotherapy were among the pre-institutional treatments that had to be performed according to medical protocols as well as health and professional guidelines. Conclusions: It was recommended that the prostate cancer screening should not be performed for asymptomatic men during the COVID-19 outbreak. It was also suggested that the treatment should be performed in the shortest possible time and in the safest way.

Perineal nerve block versus periprostatic block for patients undergoing transperineal prostate biopsy (APROPOS): a prospective, multicentre, randomised controlled study

Background

We aimed to investigate perineal nerve block versus periprostatic block in pain control for men undergoing a transperineal prostate biopsy.

Methods

In this prospective, randomised, blinded and parallel-group trial, men in six Chinese hospitals with suspected prostate cancer were randomly assigned (1:1) at the point of local anaesthesia to receive a perineal nerve block or periprostatic block and followed by a transperineal prostate biopsy. Centres used their usual biopsy procedure. Operators who performed anaesthesia were trained in both techniques before the trial and were masked to the randomised allocation until the time of anaesthesia and were not involved in the subsequent biopsy procedure and any assessment or analysis. Other investigators and the patients were masked until trial completion. The primary outcome was the level of the worst pain experienced during the prostate biopsy procedure. Secondary outcomes included pain (post-biopsy at 1, 6 and 24 h), changes in blood pressure, heart rate and breathing rate during the biopsy procedure, external manifestations of pain during biopsy, anaesthesia satisfaction, the detection rate of PCa and clinically significant PCa. This trial is registered on ClinicalTrials.gov, NCT04501055.

Findings

Between August 13, 2020, and July 20, 2022, 192 men were randomly assigned to perineal nerve block or periprostatic block, 96 per study group. Perineal nerve block was superior for the relief of pain during the biopsy procedure (mean 2.80 for perineal nerve block and 3.98 for periprostatic block; adjusted difference in means -1.17, P < 0.001). Although the perineal nerve block had a lower mean pain score at 1 h post-biopsy compared with the periprostatic block (0.23 vs 0.43, P = 0.042), they were equivalent at 6 h (0.16 vs 0.25, P = 0.389) and 24 h (0.10 vs 0.26, P = 0.184) respectively. For the change in vital signs during biopsy procedure, perineal nerve block was significantly superior to periprostatic block in terms of maximum value of systolic blood pressure, maximum value of mean arterial pressure and maximum value of heart rate. There are no statistical differences in average value of systolic blood pressure, average value of mean, average value of heart rate, diastolic blood pressure and breathing rate. Perineal nerve block was also superior to periprostatic block in external manifestations of pain (1.88 vs 3.00, P < 0.001) and anaesthesia satisfaction (8.93 vs 11.90, P < 0.001). Equivalence was shown for the detection rate of PCa (31.25% for perineal nerve block and 29.17% for periprostatic block, P = 0.753) or csPCa (23.96% for perineal nerve block and 20.83% for periprostatic block, P = 0.604). 33 (34.8%) of 96 patients in the perineal nerve block group and 40 (41.67%) of 96 patients in the periprostatic block group had at least one complication.

Interpretation

Perineal nerve block was superior to periprostatic block in pain control for men undergoing a transperineal prostate biopsy.

Funding

Grant 2019YFC0119100 from the National Key Research and Development Program of China.

Should Transperineal Prostate Biopsy Be the Standard of Care?

PURPOSE OF REVIEW

We reviewed the advantages and disadvantages of transperineal prostate biopsy (TP-bx) to evaluate its potential role as the standard of care for prostate biopsy.

RECENT FINDINGS

Studies have suggested no difference in prostate cancer (PCa) detection rate between TP-bx and transrectal biopsy (TR-bx) but have suggested potentially increased detection of anterior prostate tumors. Advances in anesthetic technique have obviated the need for sedation thus allowing TP-bx to become an office-based procedure, which in turn can decrease the overall cost of TP-bx. Furthermore, given the low rate of infectious complications after TP-bx, some have foregone peri-procedural antibiotics without a change in the rate of infectious complications. Recent procedural advances have made TP-bx a tolerable, office-based procedure. Given the similar diagnostic performance and the benefits for the patient and community, TP-bx should become the standard of care for prostate biopsy for most patients. Future efforts should address the barriers for more universal adoption.

Assessment of complications after transperineal and transrectal prostate biopsy using a risk-stratified pathway identifying patients at risk for post-biopsy infections

INTRODUCTION

Evidence of transperineal (TP) superiority over transrectal (TR) biopsy is growing due to lower infectious complication rates. However, TR biopsy is the most common procedure, and it seems that a cross-over to TP is delayed by logistical challenges such as costs, complexity, and lack of experience. We investigate whether well-selected patients without any risk factors may further undergo TR biopsy if all precautions to avoid infections are warranted.

MATERIALS AND METHODS

Data were collected in our academic institution between August 2021 and March 2022 and after clinical implementation of the currently updated European Association of Urology guideline recommendations on the performance of prostate biopsy. Patients underwent either TP or TR biopsy according to a riskstratification based on risk factors of infectious complications. Follow-up asked for post-biopsy complications. Inverse Probability of Treatment Weighting (IPTW) propensity score was used to balance baseline characteristics. Complications were subdivided into infectious and non-infectious complications.

RESULTS

In total, 294 patients were included with 161 patients undergoing TR vs. 133 patients undergoing TP biopsy. Complication rates were 2.2% for TP vs. 5.5% for TR biopsy concerning all complications. Infectious complication rates only were 0.7% for TP vs. 1.8% for TR biopsy. After IPTW adjustment, differences were statistically significant different (p = 0.01).

CONCLUSION

Our study revealed that even in a well-selected patient cohort with presumably lower risk of infectious complications, TR biopsy leads to more post-biopsy complications than TP biopsy. This conclusion should motivate the urological community to switch to TP biopsy.

Comparison of amikacin with fosfomycin as an add-on to ciprofloxacin for antibiotic prophylaxis in transrectal prostate biopsy: A single-center retrospective study

PURPOSE

To assess the effect of ciprofloxacin (CP) and fosfomycin compared with CP and amikacin in patients with a fluoroquinolone (FQ)-resistant rectal flora who have undergone transrectal ultrasound-guided prostate biopsy (TRUSPB).

MATERIALS AND METHODS

In total, 516 patients with FQ-resistant rectal flora based on rectal swab cultures were divided into two groups according to prophylactic antibiotics. Patients in both groups were administered CP (400 mg, intravenous [IV], twice daily) on the same day as TRUSPB and 1 day after biopsy. The amikacin group (n=260) was administered a single injection of amikacin (1 g, IV) 1 hour before TRUSPB, whereas the fosfomycin group (n=256) was administered fosfomycin (3 g, orally) the night before the procedure. The primary endpoint was the rate of infectious complications in the two groups.

RESULTS

Overall, 13 patients (2.5%) reported infectious complications: 12 patients (4.62%) in the amikacin group compared with 1 patient (0.39%) in the fosfomycin group (risk ratio, 0.09; 95% confidence interval [CI], 0.01-0.65), respectively, which was a statistically significant difference (p=0.017). This corresponds to a number needed to treat of 24 patients (95% CI, 15-65) to prevent one infectious complication. In the multivariate analysis to assess variables related to infectious complications, prophylactic antibiotics with added fosfomycin was associated with infectious complications (odds ratio, 0.060; 95% CI, 0.008-0.459).

CONCLUSIONS

In the era of FQ resistance, CP and fosfomycin may reduce the rate of infectious complications compared with CP and amikacin prophylaxis.

Fosfomycin Trometamol for the Prevention of Infectious Complications After Prostate Biopsy: A Consensus Statement by an International Multidisciplinary Group

CONTEXT

Transrectal ultrasound-guided prostate biopsy (TRPB) has been a standard of care for diagnosing prostate cancer but is associated with a high incidence of infectious complications.

OBJECTIVE

To achieve an expert consensus on whether fosfomycin trometamol provides adequate prophylaxis in TRPB and discuss its role as prophylaxis in transperineal prostate biopsy (TPPB).

EVIDENCE ACQUISITION

An international multidisciplinary group of experts convened remotely to discuss how to best use fosfomycin in various clinical settings and patient situations. Six statements related to prostate biopsy and the role of fosfomycin were developed, based on literature searches and relevant clinical experience.

EVIDENCE SYNTHESIS

Consensus was reached for all six statements. The group of experts was unanimous regarding fosfomycin as a preferred candidate for antimicrobial prophylaxis in TRPB. Fosfomycin potentially also meets the requirements for empiric prophylaxis in TPPB, although further clinical studies are needed to confirm or refute its utility in this setting. There is a risk of bias due to sponsorship by a pharmaceutical company.

CONCLUSIONS

Antimicrobial prophylaxis is mandatory in TRPB, and fosfomycin trometamol is an appropriate candidate due to low rates of resistance, a good safety profile, sufficient prostate concentrations, and demonstrated efficacy in reducing the risk of infectious complications following TRPB.

PATIENT SUMMARY

Patients undergoing transrectal ultrasound-guided prostate biopsy (TRPB) have a high risk of infectious complications, and antimicrobial prophylaxis is mandatory. However, increasing antimicrobial resistance, as well as safety concerns with fluoroquinolones, has restricted the number of antimicrobial options. Fosfomycin trometamol meets the requirements for a preferred antimicrobial in the prophylaxis of TRPB.

GEOGRAPHIC VARIATION OF INFECTIOUS COMPLICATIONS FOLLOWING PROSTATE BIOPSY IN THE UNITED STATES: RESULTS FROM A POPULATION-BASED COHORT OF PRIVATELY INSURED PATIENTS

OBJECTIVE

To elucidate regional trends of infectious complications following transrectal ultrasound prostate biopsy (TRUS-PB) from a national, privately-insured database.

MATEREIAL AND METHODS

Using Market Scan, we identified all men who underwent TRUS-PB from 2010 to 2015. Infectious complications (UTI, prostatitis, sepsis) occurring 30 days after the prostate biopsy from emergency room (ER) visits or hospital admissions constituted the primary outcomes. We analyzed unadjusted and adjusted rates of infectious complications from ER visits and hospital admissions per 100 prostate biopsies by state. Multivariable logistic regression analyses were used to identify patient covariates associated with infectious complications.

RESULTS

During the study interval, we identified 193,490 patients who underwent TRUS-PB. The mean age was 57.6 years (SD: 5.0). Over time the unadjusted national rates of infectious complications remained similar from 0.4 ER visits per 100 prostate biopsies in 2010 to 0.2 in 2015 (p=0.83), and 1.2 hospital admissions per 100 prostate biopsies in 2010 to 1.1 in 2015 (p=0.58). Connecticut had the lowest unadjusted infectious complication rate per 100 biopsies at 0.64, whereas West Virginia had the highest at 2.34. Multivariable analysis revealed higher Elixhauser status and patient age were associated with higher odds of infectious complications (p<0.05).

CONCLUSIONS

While rates of infectious complications attributable to prostate biopsies remain relatively stable, significant variation exists at the state level regarding this adverse outcome.

Accuracy of a new electronic nose for prostate cancer diagnosis in urine samples

Objective

To evaluate the accuracy of a new electronic nose to recognize prostate cancer in urine samples.

Methods

A blind, prospective study on consecutive patients was designed. Overall, 174 subjects were included in the study: 88 (50.6%) in prostate cancer group, and 86 (49.4%) in control group. Electronic nose performance for prostate cancer was assessed using sensitivity and specificity. The diagnostic accuracy of electronic nose was reported as area under the receiver operating characteristic curve.

Results

The electronic nose in the study population reached a sensitivity 85.2% (95% confidence interval 76.1–91.9; 13 false negatives out of 88), a specificity 79.1% (95% confidence interval 69.0–87.1; 18 false positives out of 86). The accuracy of the electronic nose represented as area under the receiver operating characteristic curve 0.821 (95% confidence interval 0.764–0.879).

Conclusions

The diagnostic accuracy of electronic nose for recognizing prostate cancer in urine samples is high, promising and susceptible to supplemental improvement. Additionally, further studies will be necessary to design a clinical trial to validate electronic nose application in diagnostic prostate cancer nomograms.

Non-infectious Complications Following Transrectal Prostate Needle Biopsy – Outcomes from over 8000 Procedures

Background

Prostate needle biopsy (PNB) remains the referent standard for diagnosing prostate cancer. Contemporary data highlight an increase in PNB-related infections particularly when performed transrectally. Non-infectious complications, however, may similarly contribute to biopsy-related morbidity. We review the incidence and predictors of non-infectious complications following transrectal PNB in a large statewide quality registry.

Methods

Transrectal ultrasound-guided prostate needle biopsies performed between 2015 and 2018 were retrospectively reviewed. The incidence and distribution of non-infectious complications were annotated. Clinical, demographic, and biopsy variables of interest were evaluated by logistic regression for potential association with specific types of non-infectious complications.

Results

Of 8,102 biopsies, 277 (3.4%) biopsies had reported post-procedure complications including 199 (2.5%) non-infectious and 78 (0.9%) infectious. Among the non-infectious complications, the most common events included urinary or rectal bleeding (74; 0.9%), urinary retention (70, 0.9%), vasovagal syncope (13, 0.2%), and severe post-operative pain (10, 0.1%). Approximately 56% of these non-infectious complications required an Emergency Department visit (111/199) and 27% (54/199) hospital admission for monitoring. Increasing transrectal ultrasound prostate volume was associated with post-procedure urinary retention (Odds ratio (OR) 1.07, 1.02–1.11, p = 0.002). No specific variables noted association with post-biopsy bleeding.

Conclusion

Non-infectious complications occurred 2.5 times more often than infectious complications following transrectal ultrasound prostate needle biopsies. Larger prostate size was associated with a greater risk of post-procedure urinary retention. These data originating from experience from over 100 urologists across different health systems provide an important framework in counseling patients regarding expectations following transrectal prostate biopsy.

Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy: A Systematic Review and Meta-analysis

Context

Objective

Evidence acquisition

Evidence synthesis

Conclusions

Patient summary

Cognitive magnetic resonance imaging-ultrasound fusion transperineal targeted biopsy combined with randomized biopsy in detection of prostate cancer

BACKGROUND

Prostate cancer (PCa) is one of the most common cancers among men. Various strategies for targeted biopsy based on multiparametric magnetic resonance imaging (mp-MRI) have emerged, which may improve the accuracy of detecting clinically significant PCa in recent years.

AIM

To investigate the diagnostic efficiency of a template for cognitive MRI-ultrasound fusion transperineal targeted plus randomized biopsy in detecting PCa.

METHODS

Data from patients with an increasing prostate-specific antigen (PSA) level but less than 20 ng/mL and at least one lesion suspicious for PCa on MRI from December 2015 to June 2018 were retrospectively analyzed. All patients underwent cognitive fusion transperineal template-guided targeted biopsy followed by randomized biopsy outside the targeted area. A total of 127 patients with complete data were included in the final analysis. A multivariable logistic regression analysis was conducted, and a two-sided P < 0.05 was considered statistically significant.

RESULTS

PCa was detected in 66 of 127 patients, and 56 cases presented clinically significant PCa. Cognitive fusion targeted biopsy alone detected 59/127 cases of PCa, specifically 52/59 cases with clinically significant PCa and 7/59 cases with clinically insignificant PCa. A randomized biopsy detected seven cases of PCa negative on targeted biopsy, and four cases had clinically significant PCa. PSA density (OR: 1.008, 95%CI: 1.003-1.012, P = 0.001; OR: 1.006, 95%CI: 1.002-1.010, P = 0.004) and Prostate Imaging-Reporting and Data System (PI-RADS) scores (both P < 0.001) were independently associated with the results of cognitive fusion targeted biopsy combined with randomized biopsy and targeted biopsy alone.

CONCLUSION

This single-centered study proposed a feasible template for cognitive MRI-ultrasound fusion transperineal targeted plus randomized biopsy. Patients with higher PSAD and PI-RADS scores were more likely to be diagnosed with PCa.

A novel enema method can prevent infectious complications of transrectal ultrasound-guided prostate biopsy: A single-centre experience

BACKGROUND

TRUS biopsy is the preferred method for diagnosing prostate cancer, but it can cause infectious complications that arise with the contribution of fluoroquinolone resistance. We aimed to explore the potential protective effect of a second rectal enema before biopsy.

METHODS

From January 2015 to December 2020, 419 patients were assessed retrospectively. Patients with a history of anticoagulant use, uncontrolled diabetes, urological surgery, prostate biopsy or recent hospitalisation or overseas travel, as well as those with the previous prostatitis, were excluded from the study. The patients were subsequently divided into two groups: Group 1 (n = 223) had received one enema, on the morning of the biopsy and Group 2 (n = 196) had received two, with the additional enema administered half an hour before the procedure.

RESULTS

There was no significant difference between the groups in terms of age(P = .076), BMI (P = .489), diabetes (P = .265), prostate-specific antigen (PSA) level (P = .193), free/total PSA (f/t PSA) ratio (P = .518) and prostate size (P = .661) or in relation to cancer detection (P = .428). The median hospitalisation date was significantly higher in Group 1 (P = .003) as was urinary tract infection (UTI) development (P = .004). However, there was no significant difference in terms of fever and sepsis (P = .524 and P = .548, respectively). Additionally, subgroup analysis demonstrated that UTI was significantly lower in patients with diabetes mellitus who had received a second enema (P = .004), though there was no significant difference in UTI between the groups in those without diabetes mellitus (P = .215). Multivariable analysis showed that age and diabetes were significant risk factors for the development of UTI (OR: 1.074, 95% CI: 1.027-1.130, P = .002 and OR: 1.220, 95% CI: 0.131-0.665, P = .003, respectively). Furthermore, the second enema was a significant protective factor for preventing UTI (OR: -1.794, 95% CI: 2.208-16.389, P < .001).

CONCLUSION

Older age and the presence of diabetes mellitus are independent risk factors for UTI after prostate biopsy. A second enema procedure before biopsy may protect patients from related infectious complications and could therefore be used as an alternative preventative method.

Is transrectal ultrasound-guided systematic biopsy necessary after PI-RADS 4 is targeted?

Purpose: Target biopsy is usually performed in Prostate Imaging Reporting and Data System (PI-RADS) 4. Still, it is unclear if adding systematic biopsy to target biopsy influences cancer detection. The aim was to assess the role of systematic biopsy for detecting significant cancer after PI-RADS 4 is targeted.Methods: Between March 2014 and November 2018, 182 men with PI-RADS 4 underwent transrectal ultrasound (TRUS)-guided biopsy. Systematic biopsy was added to target biopsy in 128 men (Group I) by May 2018 because PI-RADS 4 was not completely visible on TRUS, while it was done in 54 men (Group II) from June 2018 regardless of lesion visibility. Significant cancer detection rates (CDRs) were compared between the groups regarding target and systematic biopsies. Major complication rate was also compared. Significant cancer was defined as a Gleason score ≥7 tumor. Standard reference was biopsy examination. Fisher’s exact were used for statistical analysis.Results: The significant CDRs were 21.9% (28/128) in the Group I and 38.9% (21/54) in the Group II (P= 0.0273). The significant cancers of Group I and II were missed in two (1.6%) and in one (1.9%) by target biopsy, respectively. Major complication rates of these groups were 0.8% (1/128) and 0% (0/54), respectively (P= 0.999).Conclusion: Systematic biopsy should be added to target biopsy even though PI-RADS 4 is clearly visible on ultrasound. A significant number of significant cancers are detected with systematic biopsy.

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.

Enhanced antibiotic prophylaxis and infection-related complications following prostate biopsy

PURPOSE

Sepsis after prostate biopsy is a costly and potentially lethal complication. We sought to assess whether enhanced antibiotic prophylaxis regimens combining oral and parenteral antibiotics may decrease the risk of post-biopsy urinary tract infection and sepsis compared to regimens with only oral antibiotics.

METHODS

We identified men with commercial insurance who underwent prostate biopsy (2009-2015) with prophylactic antibiotic coverage. Our primary exposure of interest was antibiotic regimen: enhanced, oral-only, and parenteral-only. Post-biopsy outcomes of interest included urinary tract infections and sepsis/bacteremia after prostate biopsy. We used bivariate testing to assess associations between outcomes, exposures, and other covariates of interest. Multivariable regression was used to estimate adjusted odds of infectious outcomes based on antibiotic regimen.

RESULTS

We identified 163,831 men who underwent prostate biopsy. The proportion of men with infectious complications (5.5% in 2009 to 6.9% in 2015, p < 0.001) and sepsis (0.24% in 2009 to 0.30% in 2015, p = 0.327) increased over the timeframe of our analysis. Use of fluoroquinolones was associated with a decreased risk of infectious outcomes (5.8 vs 7.3% without, OR 0.83, 95% CI 0.79-0.88). Use of enhanced antibiotic regimens was associated with an increased risk of infectious outcomes (6.8 vs 5.7% oral, OR 1.23, 95% CI 1.16-1.31) and sepsis (0.34 vs 0.24% oral, OR 1.40, 95% CI 1.08-1.82) among our cohort.

CONCLUSION

We did not observe a significant reduction in infectious complications among men who received enhanced antibiotics regimens before prostate biopsy. This may be due to increased antibiotic resistance or unmeasured risk factors among those receiving enhanced regimens.

Comparison of Complication Rates with Antibiotic Prophylaxis with Cefpodoxime Versus Fluoroquinolones After Transrectal Prostate Biopsy

BACKGROUND

After recommended restriction of the use of fluoroquinolones, the optimal antibiotic prophylaxis for transrectal prostate biopsy is still under debate.

OBJECTIVE

To test the effectiveness of cefpodoxime as oral antibiotic prophylaxis for transrectal prostate biopsies and the complication rates relative to fluoroquinolones.

DESIGN, SETTING, AND PARTICIPANTS

Antibiotic prophylaxis for transrectal prostate biopsies at the Department of Urology at University Hospital Frankfurt was fluoroquinolones for 342 consecutive patients in January 2018 and December 2019 and cefpodoxime for 100 patients from January 2020 to July 2020. Data were prospectively evaluated and retrospectively analyzed. Patients were followed up according to clinical routine at 6 wk after biopsy at the earliest. Patients without follow-up (n = 98) and those receiving antibiotic prophylaxis other than cefpodoxime or fluoroquinolones (n = 15) were excluded.

INTERVENTION

Use of cefpodoxime or fluoroquinolones as antibiotic prophylaxis for transrectal prostate biopsies.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Logistic regression models were used to predict biopsy-related complications according to antibiotic prophylaxis.

RESULTS AND LIMITATIONS

Of 442 patients, 100 (22.6%) received cefpodoxime as antibiotic prophylaxis. Patient baseline and biopsy characteristics were comparable between the cefpodoxime and fluoroquinolone groups. Moreover, there were no differences in the number of prior prostate biopsies or the proportions of systematic vs. fusion biopsies (p > 0.05). There were no differences between the groups in infectious complications such as epididymitis and prostatitis after biopsy. Infectious complication rates were very low, at 2.0% in the cefpodoxime and0.9%fluoroquinolone group. Moreover, there were no differences between the groups in patient-reported complications, such as gross hematuria occurring at more than 5 d after biopsy, hematospermia, or rectal bleeding. In multivariable analyses, after adjustment for patient and prostate biopsy characteristics, cefpodoxime was not associated with higher complication rates than fluoroquinolones (p > 0.05).

CONCLUSIONS

Complications after transrectal prostate biopsies are rare and cefpodoxime might be a sufficient choice as oral antibiotic prophylaxis and noninferior compared to fluoroquinolones.

PATIENT SUMMARY

Cefpodoxime might be a sufficient choice as an easily applicable oral antibiotic prophylaxis for transrectal prostate biopsy. The safety profile of cefpodoxime is comparable to the safety profile of fluoroquinolones.

Rationale and protocol for randomized study of transrectal and transperineal prostate biopsy efficacy and complications (ProBE-PC study)

BACKGROUND

Rrisk of infection and hospitalization after transrectal prostate biopsy (TRBx) has been increasing worldwide. Several modified antibiotic regimens have met with variable success in preventing such infections. Transperineal prostate biopsy (TPBx) is increasingly recommended as the preferred alternative due to a potentially lower risk of post-biopsy infections. Aim of this review is to define the magnitude of post-biopsy complications and the effectiveness of preventive strategies, including TPBx approach.

METHODS

We performed a focused review of literature on infectious complications after TRBx and detailed the use of various preventive measures. We summarized the effectiveness of several preventive measures, including TPBx, and outlined the inconsistencies in reported outcomes. We identified potential barriers to the uptake of TPBx, including the gap in knowledge such as lack of high-quality evidence.

RESULTS

Several antibiotic prophylaxis protocols, including targeted and augmented, have been utilized for TRBx without demonstrating a clearly superior regimen. Of the non-antibiotic preventive measure, povidone-iodine rectal prep appears to be most effective strategy. Several single-arm cohort studies have reported very low rates of infections after TPBx and demonstrated the feasibility of an office-based procedure. However, barriers to the adoption of TPBx exist including retrospective data, and conflicting results showing minimal reduction in complications with increased burden of resource utilization. Presently, there are no randomized studies comparing the infectious complications after TRBx and TPBx. We discuss the rationale and protocol for a randomized controlled trial to determine the comparative effectiveness of biopsy techniques.

CONCLUSIONS

TPBx approach has the potential to lower the rate of post-biopsy infections and hospitalizations. However, there are several barriers to widespread adoption of this approach including inconsistencies in reported outcomes and lack of Level-1 evidence. Randomized controlled studies are required to directly compare the infectious complications associated with each biopsy procedure.

The accuracy of prostate cancer diagnosis in biopsy-naive patients using combined magnetic resonance imaging and transrectal ultrasound fusion-targeted prostate biopsy

Background

This study aimed to estimate whether multiparametric magnetic resonance imaging (mpMRI)-transrectal ultrasound (TRUS) fusion biopsy (FUS-TB) increases the detection rates of clinically significant prostate cancer (csPCa) compared with TRUS-guided systematic biopsy (TRUS-GB).

Methods

This retrospective study focused on patients who underwent mpMRI before prostate biopsy (PB) with Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) scores ≥3 and prostate-specific antigen (PSA) level between 2.5 and 20 ng/mL. Before FUS-TB, the biopsy needle position was checked virtually using three-dimensional mapping. After confirming the position of the target within the prostate, biopsy needle was inserted and PB was performed. Suspicious lesions were generally targeted with 2 to 4 cores. Subsequently, 10–12 cores were biopsied for TRUS-GB. The primary endpoint was the PCa detection rate (PCDR) for patients with PCa who underwent combined FUS-TB and TRUS-GB.

Results

According to PI-RADS v2, 76.7% of the patients with PI-RADS v2 score ≥3 were diagnosed with PCa. The PCDRs in patients with PI-RADS v2 score of 4 or 5 were significantly higher than those in patients with PI-RADS v2 score of 3 (3 vs. 4, P<0.001; 3 vs. 5, P<0.001; 4 vs. 5, P=0.073). According to PCDR, the detection rates of PCa and csPCa in the FUS-TB were significantly higher than that in the TRUS-GB.

Conclusions

Following detection of suspicious tumor lesions on mpMRI, FUS-TB use detects a higher number of PCa cases compared with TRUS-GB.

Magnetic resonance imaging /ultrasonography fusion transperineal prostate biopsy for prostate cancer: Initial experience at a Middle Eastern tertiary medical centre

Objective: To report on the outcomes of magnetic resonance imaging (MRI)/ultrasonography (US)-fusion transperineal prostate (TP) biopsy at a tertiary medical centre in the Middle East including detection rate of clinically significant prostate cancer (csPCa), complications, and tolerability of the procedure. Patients and methods: Between May 2019 and June 2020, 98 MRI/US-fusion TP biopsies were performed in the US suite using light sedation. All patients had pre-biopsy 3-T multiparametric MRI. Data on patient characteristics, PCa detection rate and complication rates were collected retrospectively. A Gleason score ≥3 + 4 was defined as csPCa.

RESULTS

There were 98 patients, with a mean (SD) age of 65 (9.1) years, and a median (SD) prostate-specific antigen level prior to biopsy of 7.53 (12.97) ng/mL and prostate volume of 51 (31.1) mL. PCa was detected in 54 (55%) patients, with csPCa detected in 43 (44%). A total of 124 Prostate Imaging-Reporting and Data System (PI-RADS) 3-5 lesions were targeted. Grade Group ≥2 PCa was found in 35.5% of the targeted lesions. Random biopsies detected one csPCa Gleason score 3 + 4 in one patient with a negative target. None of the patients had post-biopsy haematuria or retention. Only one patient developed acute prostatitis requiring in-patient intravenous antibiotics.

CONCLUSIONS

MRI/US-fusion TP biopsy has an adequate detection rate of csPCa with minimal complications and low infection rates after biopsy. This is one of the first TP biopsy series in the Middle East paving the way for wider adoption in the region.

ABBREVIATIONS

AS: active surveillance; AUR: acute urinary retention; GG: Grade Group; IQR: interquartile range; mpMRI: multiparametric MRI; (cs)PCa: (clinically significant) prostate cancer; PI-RADS: Prostate Imaging-Reporting and Data System; TP: transperineal; US: ultrasonography; TRUS: transrectal Ultrasound guided.

Diagnostic efficacy and safety of transperineal prostate targeted and systematic biopsy: The preliminary experience of first 100 cases

BACKGROUND

Post-biopsy urosepsis is a major concern for patient morbidity and cost. Trasperineal biopsy is reported to have less complications and higher detection rate of clinically significant prostate cancer (csPCa).

OBJECTIVES

To determine the diagnostic efficacy and safety of transperineal prostate biopsy in patients with elevated prostatic specific antigen (PSA).

MATERIAL AND METHODS

A prospective study included men with elevated PSA > 3 ng/ml and previous negative biopsy from January 2018 to April 2019. All patients had multiparametric magnetic resonance imaging (mpMRI) and suspicious lesions reported as Prostate Imaging Reporting and Data System (PIRADS) score version 2. Average twelve systematic and two targeted cores were biopsied under general anaesthesia. Patients received single dose of antibiotic prebiopsy.

RESULTS

100 Consecutive patients having median age 64.0 years and median PSA of 6.1ng/ml were included for mpMRI-US fusion transperineal biopsies. Cancer detection rate was 45% (targeted 38% and systematic 22%) and csPCa were detected in 75.55% (targeted 86.84% and systematic 59.09%). MRI-US fusion targeted biopsies detected 63.88% csPCa in PIRADS 5, 33.33% in PIRADS 4 and 5.88% in PIRADS 3 lesions. PSA > 10 (p = 0.012), PSA density > 0.15 (p = 0.0002), and PIRADS 5 (0.0001) were significantly associated with PCa. Factors like Age (0.0001), initial PSA (0.022) and PSA density (0.006) were significant on univariate analysis while age (0.0001) was significant on multivariate analysis. There was no case of urinary tract infection.

CONCLUSIONS

Transperineal prostate biopsy is safe and effective in diagnosing csPCa. There is no risk of sepsis and major complications.

Monoprophylaxis With Cephalosporins for Transrectal Prostate Biopsy After the Fluoroquinolone-Era: A Multi-Institutional Comparison of Severe Infectious Complications

Background

To compare severe infectious complication rates after transrectal prostate biopsies between cephalosporins and fluoroquinolones for antibiotic monoprophylaxis.

Material and Methods

In the multi-institutional cohort, between November 2014 and July 2020 patients received either cefotaxime (single dose intravenously), cefpodoxime (multiple doses orally) or fluoroquinolones (multiple-doses orally or single dose intravenously) for transrectal prostate biopsy prophylaxis. Data were prospectively acquired and retrospectively analyzed. Severe infectious complications were evaluated within 30 days after biopsy. Logistic regression models predicted biopsy-related infectious complications according to antibiotic prophylaxis, application type and patient- and procedure-related risk factors.

Results

Of 793 patients, 132 (16.6%) received a single dose of intravenous cefotaxime and were compared to 119 (15%) who received multiple doses of oral cefpodoxime and 542 (68.3%) who received fluoroquinolones as monoprophylaxis. The overall incidence of severe infectious complications was 1.0% (n=8). No significant differences were observed between the three compared groups (0.8% vs. 0.8% vs. 1.1%, p=0.9). The overall rate of urosepsis was 0.3% and did not significantly differ between the three compared groups as well.

Conclusion

Monoprophylaxis with third generation cephalosporins was efficient in preventing severe infectious complications after prostate biopsy. Single intravenous dose of cefotaxime and multiday regimen of oral cefpodoxime showed a low incidence of infectious complications <1%. No differences were observed in comparison to fluoroquinolones.

Rate and characteristics of infection after transrectal prostate biopsy: a retrospective observational study

OBJECTIVES

The aim of this study was to assess the incidence of infection after transrectal prostate biopsy (TRbx). Secondary objectives were to describe infection characteristics, antibiotic resistance patterns, ICD-10 coding, and costs.

METHODS

TRbx carried out at the hospitals of Ängelholm and Helsingborg, Scania, Sweden, between October 2017 and March 2019, were identified based on the NOMESCO Classification of Surgical Procedures code for TRbx, TKE00. All patients received per oral antibiotic prophylaxis, usually 750 mg ciprofloxacin at biopsy. Other preventative measures were not used. Medical care within 30 days of the biopsy was evaluated through a manual retrospective medical chart review. Data on patient and infection characteristics were collected. The costs of infections causing hospitalization were estimated.

RESULTS

After 36 (5.4%) of 670 biopsies, the patient developed post-biopsy infection within 30 days after TRbx. Twenty-six patients (3.9%) required hospitalization for an average of 6 days, at an estimated direct cost of USD 9174 (EUR 8031) per patient. Nine patients (1.3%) had a complicated infection leading to intensive care, multiple hospitalizations or emergency department visits. The inpatient care episodes for the 26 hospitalized patients were categorized with 15 different ICD-codes. In 6 episodes no ICD-code related to infection was used.

CONCLUSIONS

In this study, we found an infection rate of 5.4% after TRbx; 3.9% of the patients were hospitalized for a post-TRbx infection and 1.3% had complicated infections. A specific ICD code for post-TRbx infections would facilitate evaluation and monitoring of this common, costly, and sometimes serious complication.

Intraprostatic prophylactic antibiotic injection in patients undergoing transrectal ultrasonography-guided prostate biopsy

OBJECTIVES

To evaluate the efficacy of intraprostatic injection of prophylactic antibiotics for the prevention of infections following transrectal ultrasonography-guided prostate biopsy.

METHODS

In this prospective interventional study, patients aged between 40 and 70 years with clinical indications for transrectal ultrasonography-guided prostate biopsy were enrolled. Consecutive patients who received intraprostatic injection of amikacin coupled with oral ciprofloxacin were compared with historical controls receiving only prophylactic oral fluoroquinolones prior to biopsy. Patients were followed for 7 days after biopsy for signs and symptoms of infection.

RESULTS

A total of 210 patients were included in this study (mean age 65.7 ± 7.8 years). Among patients without intraprostatic injection, nine (8.6%) developed infectious complications (lower urinary tract infection in seven patients, and prostatitis in two), which led to hospitalization in six patients (5.7%). None of the patients who received intraprostatic antibiotic injection developed infectious complications. The difference in the incidence of post-transrectal ultrasonography-guided biopsy infections between the two groups was statistically significant (P = 0.003).

CONCLUSION

Local intraprostatic antibiotic injection during transrectal ultrasonography-guided prostate biopsy adjuvant to oral fluoroquinolones can significantly reduce the rate of post-biopsy infectious complications.

Magnetic resonance imaging-guided prostate biopsy-A review of literature

Objective

Multiparametric magnetic resonance imaging (MP-MRI) helps to identify lesion of prostate with reasonable accuracy. We aim to describe the various uses of MP-MRI for prostate biopsy comparing different techniques of MP-MRI guided biopsy.

Materials and methods

A literature search was performed for "multiparametric MRI", "MRI fusion biopsy", "MRI guided biopsy", "prostate biopsy", "MRI cognitive biopsy", "MRI fusion biopsy systems", "prostate biopsy" and "cost analysis". The search operation was performed using the operator "OR" and "AND" with the above key words. All relevant systematic reviews, original articles, case series, and case reports were selected for this review.

Results

The sensitivity of MRI targeted biopsy (MRI-TB) is between 91%-93%, and the specificity is between 36%-41% in various studies. It also has a high negative predictive value (NPV) of 89%-92% and a positive predictive value (PPV) of 51%-52%. The yield of MRI fusion biopsy (MRI-FB) is similar, if not superior to MR cognitive biopsy. In-bore MRI-TB had better detection rates compared to MR cognitive biopsy, but were similar to MR fusion biopsy.

Conclusions

The use of MRI guidance in prostate biopsy is inevitable, subject to availability, cost, and experience. Any one of the three modalities (i.e. MRI cognitive, MRI fusion and MRI in-bore approach) can be used. MRI-FB has a fine balance with regards to accuracy, practicality and affordability.

EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent

OBJECTIVE

To present a summary of the 2020 version of the European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Geriatric Oncology (SIOG) guidelines on screening, diagnosis, and local treatment of clinically localised prostate cancer (PCa).

EVIDENCE ACQUISITION

The panel performed a literature review of new data, covering the time frame between 2016 and 2020. The guidelines were updated and a strength rating for each recommendation was added based on a systematic review of the evidence.

EVIDENCE SYNTHESIS

A risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. Risk-adapted screening should be offered to men at increased risk from the age of 45 yr and to breast cancer susceptibility gene (BRCA) mutation carriers, who have been confirmed to be at risk of early and aggressive disease (mainly BRAC2), from around 40 yr of age. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is performed, a combination of targeted and systematic biopsies must be offered. There is currently no place for the routine use of tissue-based biomarkers. Whilst prostate-specific membrane antigen positron emission tomography computed tomography is the most sensitive staging procedure, the lack of outcome benefit remains a major limitation. Active surveillance (AS) should always be discussed with low-risk patients, as well as with selected intermediate-risk patients with favourable International Society of Urological Pathology (ISUP) 2 lesions. Local therapies are addressed, as well as the AS journey and the management of persistent prostate-specific antigen after surgery. A strong recommendation to consider moderate hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term hormonal treatment.

CONCLUSIONS

The evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. The 2020 EAU-EANM-ESTRO-ESUR-SIOG guidelines on PCa summarise the most recent findings and advice for their use in clinical practice. These PCa guidelines reflect the multidisciplinary nature of PCa management.

PATIENT SUMMARY

Updated prostate cancer guidelines are presented, addressing screening, diagnosis, and local treatment with curative intent. These guidelines rely on the available scientific evidence, and new insights will need to be considered and included on a regular basis. In some cases, the supporting evidence for new treatment options is not yet strong enough to provide a recommendation, which is why continuous updating is important. Patients must be fully informed of all relevant options and, together with their treating physicians, decide on the most optimal management for them.

Retrospective Study of the Etiology and Risk Factors of Systemic Inflammatory Response Syndrome After Systematic Transrectal Ultrasound-Guided Prostate Biopsy

Objective

To explore the risk factors, pathogenic bacteria distribution and drug resistance of systematic transrectal ultrasound-guided prostate biopsy (TRUS-Bx), 329 cases of TRUS-Bx were collected, retrospectively, in the Second Affiliated Hospital, Army Military Medical University, from April 2017 to October 2019.

Methods

A total of 329 cases were all qualified and grouped into the SIRS group (25 cases) and the non-SIRS group (304 cases). Of all the cases, incidence and risk factors of systemic inflammatory response syndrome (SIRS) were analyzed. Urine and blood samples of patients with SIRS after TRUS-Bx were also collected for bacterial culture and drug sensitivity test.

Results

Multivariate logistic regression analysis showed that BMI ≥ 25 kg/m² (OR = 1.66, 95% CI = 1.34–2.12, P <0.001), history of diabetes (OR = 5.48, 95% CI = 1.53–19.68, P = 0.008), urinary infection before operation (OR = 9.19, 95% CI = 2.92–20.93, P < 0.001) and erythrocyte sedimentation (ESR) ≥ 20 mm/h (OR = 1.04, 95% CI = 1.01–1.08, P = 0.039) were independent risk factors of SIRS after TURS-PB.

Conclusion

The incidence of SIRS and urinary sepsis was 7.59% and 2.13%, respectively, and major pathogens of SIRS after TRUS-Bx were Escherichia coli (58.33%), Klebsiella pneumoniae (12.5%) and Pseudomonas aeruginosa (12.5%). Imipenem, meropenem, tigecycline, piperacillin/tazobactam, teicoplanin, vancomycin, amikacin and cefoperazone/sulbactam had a very strong inhibitory effect to those pathogenic bacteria (sensitivity 85.72%~100%). Levofloxacin, ciprofloxacin, gentamicin, penicillin G, compound neonomine and second-generation cephalosporins showed less but also worked as a good inhibitor to pathogenic bacteria (42.86%~80.95%).

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.