Transperineal template-guided prostate biopsy for patients with persistently elevated PSA and multiple prior negative biopsies

Prostate Cancer Detection and Complications of Transperineal Versus Transrectal Magnetic Resonance Imaging-fusion Guided Prostate Biopsies

OBJECTIVE

To assess the rates of detection of clinically significant prostate cancer (csPCa) and complications associated with transperineal (TP) and transrectal (TR) biopsy approaches to magnetic resonance imaging (MRI)-fusion targeted biopsy.

MATERIALS AND METHODS

We retrospectively identified men who underwent TP or TR MRI-targeted biopsy with concurrent systematic random biopsy from August 2020 to August 2021. Primary outcomes were detection rates of csPCa and 30-day complication rates between the 2 MRI-biopsy groups. Data were additionally stratified by prior biopsy status.

RESULTS

A total of 361 patients were included in the analysis. No demographic differences were observed. No significant differences were observed between TP and TR approaches on any of the outcomes of interest. TR MRI-targeted biopsies identified csPCa in 47.2% of patients, and TP MRI-targeted biopsies identified csPCa in 48.6% of patients (P = .78). No significant differences were observed in csPCa detection between the 2 approaches for patients on active surveillance (P = .59), patients with prior negative biopsy (P = .34), and patients who were biopsy naïve (P = .19). Complication rates did not vary by approach (P = .45).

CONCLUSION

Neither the identification of csPCa by MRI-targeted biopsy nor rates of complications differed significantly based on a TR or TP approach. No differences were seen between MRI-targeted approaches based on prior biopsy or active surveillance status.

Landmarks in the evolution of prostate biopsy

Approaches and techniques used for diagnostic prostate biopsy have undergone considerable evolution over the past few decades: from the original finger-guided techniques to the latest MRI-directed strategies, from aspiration cytology to tissue core sampling, and from transrectal to transperineal approaches. In particular, increased adoption of transperineal biopsy approaches have led to reduced infectious complications and improved antibiotic stewardship. Furthermore, as image fusion has become integral, these novel techniques could be incorporated into prostate biopsy methods in the future, enabling 3D-ultrasonography fusion reconstruction, molecular targeting based on PET imaging and autonomous robotic-assisted biopsy.

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

Context

Objective

Evidence acquisition

Evidence synthesis

Conclusions

Patient summary

Development and internal validation of a prediction model of prostate cancer on initial transperineal template-guided prostate biopsy

BACKGROUND

Due to the invasiveness of prostate biopsy, a prediction model of the individual risk of a positive biopsy result could be helpful to guide clinical decision-making. Most existing models are based on transrectal ultrasonography (TRUS)-guided biopsy. On the other hand, transperineal template-guided prostate biopsy (TTPB) has been reported to be more accurate in evaluating prostate cancer. The objective of this study is to develop a prediction model of the detection of high-grade prostate cancer (HGPC) on initial TTPB.

RESULT

A total of 1352 out of 3794 (35.6%) patients were diagnosed with prostate cancer, 848 of whom had tumour with Grade Group 2-5. Age, PSA, PV, DRE and f/t PSA are independent predictors of HGPC with p < 0.001. The model showed good discrimination ability (c-index 0.886) and calibration during internal validation and good clinical performance was observed through decision curve analysis. The external validation of CPCC-RC, an existing model, demonstrated that models based on TRUS-guided biopsy may underestimate the risk of HGPC in patients who underwent TTPB.

CONCLUSION

We established a prediction model which showed good discrimination ability and calibration in predicting the detection of HGPC by initial TTPB. This model can be used to aid clinical decision making for Chinese patients and other Asian populations with similar genomic backgrounds, after external validations are conducted to further confirm its clinical applicability.

Complementing the active surveillance criteria with multiparametric magnetic resonance imaging

PURPOSE

To evaluate the usefulness of multiparametric magnetic resonance imaging (mpMRI) to avoid misclassification of patients with clinically significant prostate cancer (PCa) into active surveillance (AS).

MATERIALS AND METHODS

Patients with Gleason grade group (GG) 1 PCa on systematic biopsy who underwent mpMRI before radical prostatectomy (RP) were included. mpMRI and pathologic results were compared between the AS and NOT-AS candidates. Unfavorable disease was defined as the identification of T3-4 disease or GG upgrade in the RP specimen. We established an ideal cutoff Prostate Imaging Reporting and Data System (PI-RADS) score for predicting unfavorable disease, and analyzed the location of index lesions on mpMRI.

RESULTS

PI-RADS scores were not significantly different between AS candidates (n=64) and NOT-AS candidates (n=136; p=0.629). Among 64 AS candidates, GG upgrading and unfavorable disease were diagnosed after RP in 24 (37.5%) and 25 (39.1%) patients, respectively. The rate of unfavorable disease was greater for patients with a PI-RADS score of 5 (83.3%) than in those with a score ≤4 (34.5%; p=0.030). Moreover, most PI-RADS 5 lesions in AS candidates were located in the anterior half of the prostate, with GG upgrading on targeted biopsy in 75.0% of cases.

CONCLUSIONS

Among the patients with GG 1 PCa, PI-RADS scores did not differ significantly between AS and NOT-AS candidates. Nonetheless, AS candidates with PI-RADS 5 lesions were diagnosed with unfavorable disease in >80% of RP specimens. Significant cancer located in the anterior half of the prostate including the transitional zone can be missed by systematic biopsy.

Transperineal prostate biopsy: The modern gold standard to prostate cancer diagnosis

In patients suspicious for prostate cancer, a prostate biopsy should be performed. Biopsies are possible either by the transrectal or transperineal routes. Compared with the transrectal prostate biopsy (TRPBx), transperineal prostate biopsy (TPPBx) offers a non-inferior cancer detection rate (CDR), especially in patients undergoing re-biopsy for persistently elevated PSA and in cases of active surveillance (AS), in which TPPBx seems to be superior. Moreover, the transperineal route achieves superior sampling of the anterior and apical regions, especially after previous multiple negative TRPBx. Infectious complications are nullified due to avoidance of needle passage through the rectal mucosa, and there is a highly significant evidence of reduced fever and sepsis rates when compared with TRPBx, with maintaining acceptable urinary retention rates. This is an important upcoming topic due to the increasing antibiotic resistance rates, thus reducing periinterventional hospitalization and health care costs. To date, TPPBx is perfectly feasible in the inpatient and out-patient settings and under local anesthesia, characterized by a moderate learning curve and a good reproducibility. By applying mpMRI as a diagnostic tool, clinically significant prostate cancer (csPCa) detection seems to be comparable to transrectal MRI-fusion biopsy (TR-MRIFBx). Finally, focal treatment of localized disease is currently performed exclusively through a TP approach.

Additive Value of Transrectal Systematic Ventral Biopsies in Combination with Magnet Resonance Imaging/Ultrasound Fusion-Guided Biopsy in Patients with 3 or More Negative Prostate Biopsies

INTRODUCTION

Patients with consistent suspicion for prostate cancer (PCa) and multiple negative prebiopsies prior to multiparametric magnetic resonance imaging (mpMRI) are still frequently evaluated for an image-guided biopsy and are reported with heterogeneous detection rates. The inclusion of a systematic biopsy (SB) is also still recommended with predominant sampling within the posterior/peripheral zone of the prostate. The aim of this study was (I) to evaluate PCa detection rates using a modified 10 core SB template including anterior biopsies in combination with mpMRI/ultrasound fusion-guided targeted biopsy (TB) in patients with 3 or more negative prebiopsies and (II) to compare mpMRI index lesion localization with histologically confirmed locali-zation from associated prostatectomy samples.

METHODS

Overall 1,337 consecutive patients underwent sensor-based registration TB of the prostate and a subsequent 10-core SB between January 2012 and December 2015 at our institution. For this study, 101 patients with ≥3 negative prebiopsies and prostate imaging - reporting data system lesions ≥3 were pooled prospectively and underwent TB and a modified SB including 2 ventral (anterior) biopsies. Detection rates were estimated for the modified SB, TB, and its combination. A subgroup analysis of 35 patients undergoing prostatectomy was performed by a head-to-head comparison of mpMRI index lesion and histologically confirmed PCa index lesion localization.

RESULTS

The overall detection rate for PCa was 54.5%. The combination of TB and SB detected 14 (25.4%) more cases missed by TB alone (p < 0.001) and 7 (12.7%) more cases missed by SB alone (p = 0.016), respectively. A postoperative Gleason upgrade was seen in 12/35 (34.3%) cases within the TB group and in 14/35 (40.0%) in the SB group, respectively. The subgroup analysis showed a predominant location of PCa index lesions anteriorly at the level of the midgland. The MRI detection rate of the anteriorly located index lesions was 70.4% (15/21 cases) with a clinically significant Gleason score (≥3 + 4 = 7a [International Society of Urological Pathology grade 2]) in 80.9%. Interestingly a modified SB template detected 90.5% (19/21) of the anteriorly located index lesions.

CONCLUSION

Our data suggest that in patients with multiple prebiopsies PCa seems to be predominantly located anteriorly. We suggest the general integration of anterior biopsies despite TB in repeat biopsy patients.

Cost and efficacy comparison of five prostate biopsy modalities: a platform for integrating cost into novel-platform comparative research

BACKGROUND

The cornerstone of prostate cancer diagnosis remains the transrectal ultrasound-guided biopsy (TRUS-BX), which most frequently occurs in the office setting under local anesthesia. However, there are now other techniques of prostate biopsy aimed at improving outcomes such as patient comfort, significant cancer detection, and infectious complications. The purpose of the present study is to compare the cost and efficacy outcomes of five different approaches.

METHODS

We compared the comprehensive costs of a random sample size of 20-30 cases from each of the following: (1) local anesthesia TRUS-BX (reference), (2) sedation TRUS-BX, (3) general anesthesia transperineal template biopsy (TP), (4) sedation MRI-TRUS fusion biopsy (FB), and (5) sedation in-bore MRI biopsy (IB-MRI). Cost categories included pre-procedure, anesthesia pharmacy and recovery, and the technical/professional costs from urology, radiology, and pathology services. For procedure outcomes, we compared the larger cohorts of TRUS-BX, TP, and FB in terms of indication, cancer yield, and downstream decision impact.

RESULTS

Compared with standard TRUS-BX, the total costs of sedation TRUS-BX, TP, FB, and IB-MRI increased significantly ×1.9 (90%), ×2.5 (153%), ×2.5 (150%), and ×2.2 (125%), respectively (p < 0.001). Although there was no statistical difference between the total costs of TP, FB, and IB-MRI, these costs were significantly higher than those of TRUS-BX under either local anesthesia or sedation (p < 0.05). The cost of TRUS-BX under sedation was significantly higher than that of TRUS-BX under local anesthesia (p < 0.001). Compared to TRUS-BX, more significant cancers were detected in FB (16% vs. 36%) and TP (16% vs. 34%) groups (p < 0.001).

CONCLUSIONS

Compared with standard TRUS-BX, the additions of imaging, sedation anesthesia, and transperineal template increase costs significantly, and can be considered along with known improvements in accuracy and side effects. Ongoing efforts to combine imaging and transperineal biopsy, especially in an outpatient/local anesthesia setting may lead to a higher cost/benefit.

Beyond transrectal ultrasound-guided prostate biopsies: available techniques and approaches

OBJECTIVES

Recent advances have led to the use of magnetic resonance imaging (MRI) alone or with fusion to transrectal ultrasound (TRUS) images for guiding biopsy of the prostate. Our group sought to develop consensus recommendations regarding MRI-guided prostate biopsy based on currently available literature and expert opinion.

METHODS

The published literature on the subject of MRI-guided prostate biopsy was reviewed using standard search terms and synthesized and analyzed by four different subgroups from among the authors. The literature was grouped into four categories-MRI-guided biopsy platforms, robotic MRI-TRUS fusion biopsy, template mapping biopsy and transrectal MRI-TRUS fusion biopsy. Consensus recommendations were developed using the Oxford Center for Evidence Based Medicine criteria.

RESULTS

There is limited high level evidence available on the subject of MRI-guided prostate biopsy. MRI guidance with or without TRUS fusion can lead to fewer unnecessary biopsies, help identify high-risk (Gleason ≥ 3 + 4) cancers that might have been missed on standard TRUS biopsy and identify cancers in the anterior prostate. There is no apparent significant difference between MRI biopsy platforms. Template mapping biopsy is perhaps the most accurate method of assessing volume and grade of tumor but is accompanied by higher incidence of side effects compared to TRUS biopsy.

CONCLUSIONS

Magnetic resonance imaging-guided biopsies are feasible and better than traditional ultrasound-guided biopsies for detecting high-risk prostate cancer and anterior lesions. Judicious use of MRI-guided biopsy could enhance diagnosis of clinically significant prostate cancer while limiting diagnosis of insignificant cancer.

Utility of early transperineal template-guided prostate biopsy for risk stratification in men undergoing active surveillance for prostate cancer

OBJECTIVE

To assess the accuracy and utility of routine multiparametric magnetic resonance imaging (mpMRI) and transperineal template-guided prostate biopsy (TPB) after enrolment in active surveillance (AS).

PATIENTS AND METHODS

From April 2012 to December 2016 consecutive men from our single institution, diagnosed with low- or intermediate-risk prostate cancer on transrectal ultrasonography-guided biopsy, were offered further staging with early mpMRI and TPB within 12 months of diagnosis. Data were collected prospectively. Eligibility criteria comprised: age ≤77 years; Gleason score ≤3 + 4; clinical stage T1-T2; PSA ≤15 ng/mL; and <50% positive biopsy cores.

RESULTS

A total of 208 men were enrolled, including 196 with Gleason score 3 + 3 and 12 with Gleason score 3 + 4 disease. The median (range) number of TPB cores was 50 (17-161), with a mean TPB core density of 1.2 cores/cm³ prostate volume. A total of 83 men (39.9%) underwent histopathological upgrading after TPB, including 76 men (38.8%) with Gleason score 3 + 3 disease and seven men (58.3%) with Gleason score 3 + 4 disease. Of these, 26 (31.3%) were found to harbour primary pattern Gleason grade ≥4 disease. In all, 24 (28.9%) upgraded cases had Prostate Imaging Reporting and Data System (PI-RADS) score 1 or 2 lesions on mpMRI, including five men with Gleason score ≥4 + 3 disease. Of these, 14 (58.3%) had a prostate-specific antigen (PSA) density of ≥0.15, including four out of the five men with Gleason ≥4 + 3 disease. Overall there was a change in prostate cancer management in 77 men (37.0%) after TPB.

CONCLUSIONS

Early TPB during AS is associated with significant upgrading and a change in treatment plan in over a third of men. If TPB was omitted in men with a PI-RADS score <3 and a PSA density <0.15, 12% of those harbouring more significant disease would have been misclassified.

Characteristics of prostate cancer detection rate (PCDR) in Chinese Han population under different prostate biopsy methods

We analyzed the improvement of prostate cancer detection rate (PCDR) in Chinese Han population and summarized the characteristics of prostate cancer (PCa) with the advancement of prostate biopsy technologies. From March 1999 to March 2015, 3762 patients underwent the systematic 6-, 8- or 13-core biopsy, guided by finger or transrectal ultrasound (TRUS) at our center. The PCDR under different PSA intervals and different biopsy methods were analyzed. The trends of PSA level, age and Gleason score of PCa patients were summarized. The PCDR of finger-guided 6- and 8-core biopsies were 30.8% (340/1103) and 36.7% (147/401) respectively. In 2258 patients with TRUS-guided 13-core biopsies, 992 (43.9%) were diagnosed as PCa, higher than that with finger-guided biopsies (43.9% vs. 32.4%, p < 0.001). The PCDR of prostate peripheral zone was higher than that of medial zone (37.5% vs. 31.4%, p < 0.001). Interestingly, the PCDR of extra 13th core was higher than the mean positive rate of other 12 cores (70.7% vs. 56.0%, p < 0.001). The systematic 13-core prostate biopsy guided by TRUS is safe, effective, and economic for PCa diagnosis in developing countries like China. The extra 13th core biopsy is beneficial to increase the PCDR.

A low invasiveness patient’s specific template for spine surgery

Free-hand pedicle screw placement is still conventional in surgery, although it has potentially high risks. The surgical procedures such as pedicle screw placement are usually designed based on medical imaging, but during surgery, the procedures are not normally followed due to the fact that some points are missed in two-dimensional images and seen only during surgery. In this regards, some highly accurate computer-assisted systems have been proposed and are currently used. Moreover, it is possible to reduce or completely avoid hand working by applying modern digital technology. Therefore, using these technologies has remarkable advantages. In this study, we have presented a new approach of pedicle screw placement in the lumbar and sacral regions using a specific drill guide template. The template was created by additive manufacturing technology and was verified in a clinical study as well. The main aim of this research includes the following: design, analyze, manufacture and evaluate the accuracy of a new patient-specific drill guide template, for lumbar pedicle screw placement, and compare the template to the free-hand technique under fluoroscopy supervision. Our results show that the incidence of cortex perforation is substantially reduced compared to existing methods. Finally, we believe that this approach remarkably lowers the incidence of cortex perforation and could be potentially used in clinical applications, particularly in certain selected cases.

Combined T2 and diffusion-weighted MR imaging with template prostate biopsies in men suspected with prostate cancer but negative transrectal ultrasound-guided biopsies

Purpose

Transperineal template prostate (TPB) biopsy has been shown to improve prostate cancer detection in men with rising PSA and previous negative TRUS biopsies. Diagnostic performance of this approach especially MR imaging and using reliable reference standard remains scantly reported.

Materials and methods

A total of 200 patients, who were previously TRUS biopsy negative, were recruited in this study. All the participants had at least 28-core TPB under general anesthetic within 8 weeks of previous negative TRUS biopsies. In 15 men undergoing laparoscopic radical prostatectomy, prostate specimens were sectioned using custom-made molds and analyzed by experienced pathologist as a feasibility study.

Results

In total, 120 of 200 patients (60 %) had positive TPB biopsy results. All of these men had at least one negative biopsy from transrectal route. T2 diffusion-weighted MR imaging showed no lesion in almost one-third of these men (61/200; 30.5 %). Out of these, 33 (33/61; 54 %) showed malignancy on TPB including high-grade tumors (>Gleason 7). Out of 15 patients underwent surgery with a total of 52 lesions (mean 3.5) on radical prostatectomy histology analyses, TPB detected 36 (70 %) lesions only. Some of these lesions were Gleason 7 and more mostly located in the posterior basal area of prostate.

Conclusions

Transperineal template biopsy technique is associated with significantly high prostate cancer detection rate in men with previous negative TRUS biopsies, however compared to radical prostatectomy histology map, a significant number of lesions can still be missed in the posterior and basal area of prostate.

Assessment of the Performance of Magnetic Resonance Imaging/Ultrasound Fusion Guided Prostate Biopsy against a Combined Targeted Plus Systematic Biopsy Approach Using 24-Core Transperineal Template Saturation Mapping Prostate Biopsy

Objective. To compare the performance of multiparametric resonance imaging/ultrasound fusion targeted biopsy (MRI/US-TBx) to a combined biopsy strategy (MRI/US-TBx plus 24-core transperineal template saturation mapping biopsy (TTMB)). Methods. Between May 2012 and October 2015, all patients undergoing MRI/US-TBx at our institution were included for analysis. Patients underwent MRI/US-TBx of suspicious lesions detected on multiparametric MRI +/− simultaneous TTMB. Subgroup analysis was performed on patients undergoing simultaneous MRI/US-TBx + TTMB. Primary outcome was PCa detection. Significant PCa was defined as ≥Gleason score (GS) 3 + 4 = 7 PCa. McNemar's test was used to compare detection rates between MRI/US-TBx and the combined biopsy strategy. Results. 148 patients underwent MRI/US-TBx and 80 patients underwent MRI/US-TBx + TTMB. In the MRI/US-TBx versus combined biopsy strategy subgroup analysis (n = 80), there were 55 PCa and 38 significant PCa. The detection rate for the combined biopsy strategy versus MRI/US-TBx for significant PCa was 49% versus 40% (p = 0.02) and for insignificant PCa was 20% versus 10% (p = 0.04), respectively. Eleven cases (14%) of significant PCa were detected exclusively on MRI/US-TBx and 7 cases (8.7%) of significant PCa were detected exclusively on TTMB. Conclusions. A combined biopsy approach (MRI/US-TBx + TTMB) detects more significant PCa than MRI/US-TBx alone; however, it will double the detection rate of insignificant PCa.

Confirmatory biopsy for the assessment of prostate cancer in men considering active surveillance: reference centre experience

OBJECTIVES

To evaluate how accurate a 12-core transrectal biopsy derived low-risk prostate cancer diagnosis is for an active surveillance programme by comparing the histological outcome with that from confirmatory transperineal sector biopsy.

SUBJECTS AND METHODS

The cohort included 166 men diagnosed with low volume Gleason score 3+3 prostate cancer on initial transrectal biopsy who also underwent a confirmatory biopsy. Both biopsy techniques were performed according to standard protocols and samples were taken for histopathology analysis. Subgroup analysis was performed according to disease severity at baseline to determine possible disease parameters of upgrading at confirmatory biopsy.

RESULTS

After confirmatory biopsy, 34% demonstrated Gleason score upgrade, out of which 25% were Gleason score 3+4 and 8.5% primary Gleason pattern 4. Results remained consistent for the subgroup analysis and a weak positive association, but not statistically significant, between prostate specific antigen (PSA), age, and percentage of positive cores, and PCa upgrading at confirmatory biopsy was found.

CONCLUSION

In our single centre study, we found that one-third of patients had higher Gleason score at confirmatory biopsy. Furthermore 8.5% of these upgraders had a primary Gleason pattern 4. Our results together with previously published evidence highlight the need for the revision of current guidelines in prostate cancer diagnosis for the selection of men for active surveillance.

Significant impact of transperineal template biopsy of the prostate at a single tertiary institution

Objective:

The objective was to review the impact of transperineal biopsy (TPB) at our institution by assessing rates of cancer detection/grading, treatment outcomes and complications.

Patients and Methods:

A retrospective review of TPBs between 2009 and 2013 was performed. Variables included reason for TPB, age, prostate-specific antigen, previous histology, TPB histology, and management outcomes.

Results:

In total, 110 patients underwent 111 TPBs at our institution. On average, 22 cores were taken from each procedure. Disease-upgrade occurred in 37.5% of active surveillance patients, 35% of patients with previous negative transrectal ultrasound, and 58.8% in patients undergoing TPB for other reasons. Of these patients, anterior and/or transition zones were involved in 66%, 79%, and 80%, respectively. Involvement in anterior and/or transition zones only occurred in 40%, 37%, and 10%, respectively. About 77% of patients with disease-upgrading underwent treatment with curative intent. Complications included a 6.3% rate of acute urinary retention and 2.7% of clot retention, with no episodes of urosepsis.

Conclusions:

Transperineal biopsy at our institution showed a high rate of disease-upgrading, with a large proportion involving anterior and transition zones. A significant amount of patients went on to receive curative treatment. TPB is a valuable diagnostic procedure with minimal risk of developing urosepsis. We believe TBP should be offered as an option for all repeat prostate biopsies and considered as an option for initial prostate biopsy.

Transperineal template-guided prostate biopsy: 10 years of experience

OBJECTIVE

To assess the efficacy and safety of transperineal template-guided prostate biopsy.

MATERIALS AND METHODS

From December 2003 to December 2013, a total of 3 007 patients (30-91 years old, mean age 69.1) who met the inclusion criteria underwent 11-region transrectal ultrasound-guided transperineal template prostate biopsy. The inclusion criteria included a prostate-specific antigen (PSA) level of 4.0 ng/mL or greater and abnormal prostate gland findings on digital rectal examination, ultrasound, CT or MRI. The median PSA level was 11.0 ng/mL (range 0.2-100 ng/mL). The prostate cancer detection rate and prostate biopsy adverse effects, as well as prostate cancer spatial distribution were analyzed.

RESULTS

A mean of 19.3 cores (range 11-44) were obtained for each biopsy, and more cores were obtained in larger prostates than in smaller ones. One to four cores were collected from each region. Prostate cancer was detected in 1 067 of the 3 007 patients (35.5%). The prostate cancer detection rates in groups with PSA levels of 0-4.0 ng/mL, 4.1-10.0 ng/mL, 10.1-20.0 ng/mL, 20.1-50.0 ng/mL, and 50.1-100.0 ng/mL were 15.3% (27/176), 21.0% (248/1 179), 32.6% (318/975), 56.0% (232/414), and 92.0% (241/262), respectively. The mean positives for cancer in regions 1-10 and region 11 (the apical region) were 46.7% vs 52.0% (P = 0.014). Regarding adverse effects, 47.0% of the patients reported hematuria, 6.1% developed hemospermia, 1.9% required short-term catheterization after biopsy because of acute urinary retention, and 0.03% (one patient) developed urosepsis.

CONCLUSIONS

Transrectal ultrasound-guided transperineal template prostate biopsy is safe and accurate. The current study suggests that prostate carcinoma foci are more frequently localized in the apical region.

Transperineal biopsy prostate cancer detection in first biopsy and repeat biopsy after negative transrectal ultrasound-guided biopsy: the Victorian Transperineal Biopsy Collaboration experience

OBJECTIVES

To present the Victorian Transperineal Biopsy Collaboration (VTBC) experience in patients with no prior prostate cancer diagnosis, assessing the cancer detection rate, pathological outcomes and anatomical distribution of cancer within the prostate.

PATIENTS AND METHODS

VTBC was established through partnership between urologists performing transperineal biopsies of the prostate (TPB) at three institutions in Melbourne. Consecutive patients who had TPB, as first biopsy or repeat biopsy after previous negative transrectal ultrasound-guided (TRUS) biopsy, between September 2009 and September 2013 in the VTBC database were included. Data for each patient were collected prospectively (except for TPB before 2011 in one institution), based on the minimum dataset published by the Ginsburg Study Group. Univariate and multivariate analyses were used to identify factors predictive of cancer detection on TPB.

RESULTS

In all, 160 patients were included in the study, of whom 57 had TPB as first biopsy and 103 had TPB as repeat biopsy after previous negative TRUS biopsies. The median patient age at TPB was 63 years, with the repeat-biopsy patients having a higher median serum PSA level (5.8 ng/mL for first biopsy and 9.6 ng/mL for repeat biopsy) and larger prostate volumes (40 mL for first biopsy, and 51 mL for repeat biopsy). Prostate cancer was detected in 53% of first-biopsy patients and 36% of repeat-biopsy patients, of which 87% and 81%, respectively, were clinically significant cancers, defined as a Gleason score of ≥7, or more than three positive cores of Gleason 6. Of the cancers detected in repeat biopsies, 75% involved the anterior region (based on the Ginsburg Study Group's recommended biopsy map), while 25% were confined exclusively within the anterior region; a lower proportion of only 5% of cancers detected in first biopsies were confined exclusively within the anterior region. Age, serum PSA level and prostate volume were predictive of cancer detection in repeat biopsies, while only age was predictive in first biopsies.

CONCLUSIONS

TPB is an alternative approach to TRUS biopsy of the prostate, offering a high rate of detection of clinically significant prostate cancer. It provides excellent sampling of the anterior region of the prostate, which is often under-sampled using the TRUS approach, and should be considered as an option for all men in whom a prostate biopsy is indicated.

The role of transperineal template biopsies of the prostate in the diagnosis of prostate cancer: a review

The incidence of prostate cancer has shown a significant increase, highlighting the importance of early diagnosis. Current practice considers histological diagnosis a necessity in the majority of the cases. The limitations of transrectal biopsies led to the development of the promising transperineal prostatic biopsies. The latter offers a safer approach by avoiding the rectum, utilizing brachytherapy template grid to detect anterior zone disease and provides accurate prostatic mapping by systematically sampling the whole gland. It also helps to direct biopsies based on images obtained from previous prostate scanning and identify those eligible for focal therapy to direct focal treatment accurately. The current literature provides enough reassurance that transperineal template biopsies are effective, efficient and superior to the traditional and inaccurate transrectal biopsies. The absence of consensus on the technical aspect of template biopsies is a drawback, yet it highlights the need to develop robust guidelines to standardize the procedure.

Transperineal template-guided mapping biopsy of the prostate

Accurate diagnosis of prostate cancer has eluded clinicians for decades. With our current understanding of prostate cancer, urologists should devise and confidently present the available treatment options – active surveillance/radical treatment/focal therapy to these patients. The diagnostic modalities used for prostate cancer have the dual problem of false negativity and overdiagnosis. Various modifications in the prostate biopsy techniques have increased the accuracy of cancer detection, but we are still far from an ideal diagnostic technique. Transperineal template-guided mapping biopsy of the prostate is an exhaustive biopsy technique that has been improvised over the past decade, and has shown superior results to other available modalities. We have carried out a PubMed search on the available experiences on this diagnostic modality, and along with our own experiences, we present a brief review on transperineal template-guided mapping biopsy of the prostate.

Transperineal biopsy of the prostate--is this the future?

Transperineal prostate biopsy is re-emerging after decades of being an underused alternative to transrectal biopsy guided by transrectal ultrasonography (TRUS). Factors driving this change include possible improved cancer detection rates, improved sampling of the anteroapical regions of the prostate, a reduced risk of false negative results and a reduced risk of underestimating disease volume and grade. The increasing incidence of antimicrobial resistance and patients with diabetes mellitus who are at high risk of sepsis also favours transperineal biopsy as a sterile alternative to standard TRUS-guided biopsy. Factors limiting its use include increased time, training and financial constraints as well as the need for high-grade anaesthesia. Furthermore, the necessary equipment for transperineal biopsy is not widely available. However, the expansion of transperineal biopsy has been propagated by the increase in multiparametric MRI-guided biopsies, which often use the transperineal approach. Used with MRI imaging, transperineal biopsy has led to improvements in cancer detection rates, more-accurate grading of cancer severity and reduced risk of diagnosing clinically insignificant disease. Targeted biopsy under MRI guidance can reduce the number of cores required, reducing the risk of complications from needle biopsy.

Transperineal template-guided biopsy for diagnosis of prostate cancer in patients with at least two prior negative biopsies

OBJECTIVE

To evaluate the prostate cancer (PCa) detection rate, PCa location, PCa significance and complications of a standardized 24-core template-guided transperineal biopsy (TPB) approach in patients with at least two negative transrectal biopsies.

METHODS

We prospectively recruited 50 men who had at least two negative transrectal ultrasound-guided extended biopsies in the past 24 months, a prostate-specific antigen (PSA) < 20 ng/mL, a prostate volume < 100 mL, and life expectancy of at least 90 % at 10 years. All patients underwent a standardized 24-core template-guided TPB biopsy. The PCa detection rate, PCa location, PCa significance, and complications were recorded.

RESULTS

Median age was 57.5 years and the median PSA level was 7.3 ng/ml. PCa was detected in 24 patients (48 %). The anterior zone was involved in 16 (32 %) PCa. Six PCa (25 %) were insignificant. Biopsy related complications occurred in 2 patients (4 %).

CONCLUSIONS

A 24-core TPB is a safe procedure with a high PCa detection rate. Few of the detected PCa are clinically insignificant. Men with at least two negative transrectal biopsies may be counseled to undergo TPB.

Systematic review of complications of prostate biopsy

CONTEXT

Prostate biopsy is commonly performed for cancer detection and management. The benefits and risks of prostate biopsy are germane to ongoing debates about prostate cancer screening and treatment.

OBJECTIVE

To perform a systematic review of complications from prostate biopsy.

EVIDENCE ACQUISITION

A literature search was performed using PubMed and Embase, supplemented with additional references. Articles were reviewed for data on the following complications: hematuria, rectal bleeding, hematospermia, infection, pain, lower urinary tract symptoms (LUTS), urinary retention, erectile dysfunction, and mortality.

EVIDENCE SYNTHESIS

After biopsy, hematuria and hematospermia are common but typically mild and self-limiting. Severe rectal bleeding is uncommon. Despite antimicrobial prophylaxis, infectious complications are increasing over time and are the most common reason for hospitalization after biopsy. Pain may occur at several stages of prostate biopsy and can be mitigated by anesthetic agents and anxiety-reduction techniques. Up to 25% of men have transient LUTS after biopsy, and <2% have frank urinary retention, with slightly higher rates reported after transperineal template biopsy. Biopsy-related mortality is rare.

CONCLUSIONS

Preparation for biopsy should include antimicrobial prophylaxis and pain management. Prostate biopsy is frequently associated with minor bleeding and urinary symptoms that usually do not require intervention. Infectious complications can be serious, requiring prompt management and continued work into preventative strategies.

Short-term functional outcomes and complications associated with transperineal template prostate mapping biopsy

OBJECTIVE

To assess the complications and erectile and urinary functional outcomes of transperineal template mapping biopsy (TTMB) of the prostate.

METHODS

We retrospectively reviewed the records of 84 patients undergoing TTMB at our institution and recorded complications and functional outcomes. Erectile and urinary functions were measured at baseline, 2 weeks, and 6 ± 2 weeks after TTMB using the International Index of Erectile Function short version (IIEF-5) and International Prostate Symptom Score questionnaires. Erectile and urinary function parameters were compared between baseline and 2 and 6 weeks after TTMB in a paired fashion. A subanalysis of erectile function was performed in preoperatively potent men (IIEF-5 >17).

RESULTS

Sixteen patients (19%) experienced complications. The most common events were transient urinary retention (6%), prostatitis (4%) and local events, including perineal hematoma, bruising, or perineal pain (5%). One patient with hematuria required intervention. IIEF-5 scores at baseline, 2 weeks, and 6 weeks were 20 (interquartile range [IQR], 16-23), 18 (IQR, 12-22), and 18 (IQR, 12-22), respectively (P = .096 and P = .034). Among preoperatively potent men, IIEF-5 scores at baseline, 2 weeks, and 6 weeks were 22 (IQR, 20-24), 21 (IQR, 18-24), and 22 (IQR, 18-24), respectively (P = .011 and P = .018). International Prostate Symptom Scores were 6 (IQR, 3.5-11) at baseline, rose to 10 (IQR, 4.8-15) at 2 weeks (P = .012), and returned to 7 (IQR, 3.5-13) at 6 weeks (P = .628).

CONCLUSION

TTMB has a favorable morbidity profile, with mostly mild and transient complications. Urinary retention occurred in 6%, and only 1 patient required intervention with bladder irrigation. Despite a statistically significant decline in erectile function from baseline, the median change in IIEF-5 score was 1 point. Urinary symptoms worsened initially but returned to baseline within 6 weeks.