Ultrasound guided transrectal core biopsies of the palpably abnormal prostate

[Perineal prostate biopsy]

The prostate biopsy is an essential tool for diagnosing prostate cancer (PCa). While transrectal biopsy (TR-Bx) continues to be considered the gold standard in Germany, the European Association of Urology (EAU) guidelines increasingly recommend transperineal biopsy (TP-Bx) due to lower infection rates and higher tumor detection rates. This article provides an overview of the history and development of the perineal biopsy, compares TR-Bx and TP-Bx and discusses the need for antibiotic prophylaxis before TP-Bx. Current studies have shown that TP-Bx can be performed without antibiotic prophylaxis and new techniques such as robotic-assisted and vector biopsy show very precise results. The establishment of TP-Bx is being promoted by extrabudgetary funding and technological advancements, with the choice of biopsy method remaining an individual decision jointly made in dialogue with the patient.

Investigation of the Effectiveness of Prostate Biopsy Density in Predicting Prostate Cancer Under Cognitive and Systematic Biopsy in Multi-Parametric Magnetic Resonance Imaging (mpMRI)

Objective

To explore the effectiveness of prostate biopsy density in predicting prostate cancer under cognitive and systematic biopsy mode in multi-parametric magnetic resonance imaging (mpMRI).

Methods

A retrospective analysis was conducted on clinical data of 204 patients who were suspected of having prostate cancer with prostate-specific antigen (PSA) levels less than 50 ng mL-1 and underwent cognitive and systematic biopsy through the perineal approach in our hospital from 2022 to 2023. Univariate and multivariate logistic regression analyses were used to evaluate the odds ratios of prostate biopsy density and relevant clinical indicators. Logistic regression analysis was performed to establish a predictive model combining indicators with predictive value. The predictive value of each indicator and the new model was evaluated using receiver operating characteristic (ROC) curves and the area under the curve (AUC).

Results

The detection rate of prostate cancer in the study population was 32.35%. Multivariate analysis showed that age, PSAD, PI-RADS 2.1 score, and prostate biopsy density were independent predictors of prostate cancer. The ROC curve analysis revealed an AUC of 0.707 (95% CI 0.625-0.790) for biopsy density, with a cutoff value of approximately 0.22 needle mL-1. The best predictive model consisted of age, PSAD, PI-RADS 2.1 score, and biopsy density, with an AUC of 0.857.

Conclusion

Biopsy density is associated with the detection of prostate cancer, with a critical value of 0.22 needle mL-1. Combining biopsy density with other clinical indicators can significantly improve the ability to predict prostate cancer and avoid unnecessary prostate biopsy cores.

Transperineal magnetic resonance imaging targeted biopsy versus transrectal route in the detection of prostate cancer: a systematic review and meta-analysis

PURPOSE

Magnetic resonance imaging (MRI) has deeply altered the prostate biopsy strategy to detect prostate cancer. However, it is still debatable whether the detection rate differs between transrectal (TR) and transperineal (TP) MRI-targeted biopsy (MRI-TB). To compare the effectiveness of these two methods for detecting both overall prostate cancer (PCa) and clinically significant PCa (csPCa), We performed a review and meta-analysis.

METHODS

Until January 2023, we conducted a thorough search of Cochrane, Embase, Ovid, and PubMed. In total, 1482 references were identified, and 15 records were finally included. For PCa and csPCa discovered by TP and TR MRI-TB, we combined the relative sensitivity (RR) with 95% confidence intervals (CI). The RR between the TP and TR routes was established.

RESULTS

Our study included 8826 patients in total and revealed that TP MRI-TB detected more PCa (RR 1.25 [95% CI 1.12, 1.39], p < 0.0001). In patients who underwent TP MRI-TB and TR MRI-TB at the same time or separately, TP MRI-TB had a greater detection rate of csPCa in per-patient analysis (one cohort (RR 1.33 [95% CI 1.09, 1.63], p = 0.005); two cohorts (RR 1.37 [95% CI 1.16, 1.61], p  = 0.0002)). However, the detection rate of csPCa between the TP route and the TR route was comparable in per-lesion analysis (RR 0.91 [95% CI 0.76, 1.08], p  = 0.28). Additionally, in the prostate's anterior region, we found that TP MRI-TB detected more csPCa (per-lesion (RR 1.52 [95% CI 1.04, 2.23], p  = 0.03); per-patient (RR 2.55 [95% CI 1.56, 4.16], p  = 0.0002)).

CONCLUSION

According to this comprehensive study, TP MRI-TB is more effective than TR MRI-TB at detecting PCa and csPCa. Significant results persisted for detecting csPCa located in the anterior zone. The results need to be taken carefully notwithstanding the heterogeneity among the included studies.

Comparison of Transrectal Ultrasonography-Guided Prostate Biopsies Analgesia's; Rectal Lidocaine Gel Versus Sandwich Anesthesia (Transurethral Plus Transrectal Lidocaine Gel Administration): A Double-Blind, Randomized, Controlled and Prospective Study

Objectives

We aimed to evaluate the effectiveness of the additive transurethral anesthetic agent to transrectal anesthetic agent.

Methods

Transrectal ultrasound-guided 12 core prostate biopsy planned, 237 patients included in our study. The patients randomly divided into two groups. Group 1 (n=113): Only transrectal 2% lidocaine, Group 2 (n=124): Transrectal + Transurethral(Sandwiches) lidocaine gel given to the patients 10 min before the procedure as anesthesia. Immediately after the biopsy, the patient questioned about the level of pain he felt during the needle entry. The evaluation measured by the VAS score. Immediately after biopsy satisfaction rate with the procedure and if rebiopsy was required, acceptance was scored between 1 and 4. The two groups compared statistically.

Results

The mean VAS score of Group 1 and Group 2 was 4.88±1.89 and 3.77±1.83, respectively. The pain level of Group 2 was lower than Group 1' pain level. The difference between the two groups was considered statistically significant (p<0.001). The patient satisfaction rates of Group 1 and Group 2 found to be 2.45±0.71 and 2.78±0.66, and the acceptance rate of rebiopsy was 2.81±0.69 and 3.02±0.51, respectively. The patient satisfaction rate and acceptance rate of the rebiopsy of Group 2 were higher than Group 1. Patient satisfaction level (p<0.001) and rebiopsy acceptance rate (p=0.014) between the two groups found to be statistically significant.

Conclusion

In the TRUS-guided prostate biopsies, sandwich anesthesia is a cheap, convenient, tolerable, and effective method.

Is systematic prostate biopsy an overkill in metastatic prostate carcinoma ? A prospective validation

PURPOSE

To assess the efficacy of 2-core prostate biopsy in advanced prostate cancer patients. This included a retrospective analysis of 12-core prostate biopsies and a prospective validation that a reduced number of cores are sufficient for histopathological diagnosis.

METHODS

The first phase analyzed retrospective data from 12-core prostate biopsies between January 2013 and 2018. In the second phase, from January 2018 to January 2022, in a prospective setting, patients with PSA > 75 ng/dl underwent bone scans first. Those with positive bone scans underwent a 2-core biopsy. Cancer detection rate and complications were analyzed to validate the findings of the first phase.

RESULTS

In the retrospective analysis, the number of positive cores in metastatic disease was 12 in 93 (73.8%), 11 in 14 (11.1%), and 10 in 7 (5.6%) patients. Using probability analysis, 94% of patients with metastasis could be detected with a single core and 97.8% with a 2-core biopsy. In the prospective analysis, 52 patients with PSA > 75 were enrolled. 3/52 (5.7%) patients had a negative bone scan. 49 were assigned for 2-core biopsy, out of which 48 (97.9%) had a positive result. One patient underwent a repeat 12-core biopsy. The prospective cohort's complications (p = 0.003) and pain score (p = 0.03) were lower compared to patients who underwent standard 12-core biopsies during phase one of the study period.

CONCLUSION

A 2-core biopsy is adequate in almost all patients with metastatic prostate cancer with PSA > 75, and this avoids excess complications and morbidity associated with a systematic 12-core prostate biopsy.

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.

Urinary extracellular vesicles miRNA-A new era of prostate cancer biomarkers

Prostate cancer is the second most common male cancer worldwide showing the highest rates of incidence in Western Europe. Although the measurement of serum prostate-specific antigen levels is the current gold standard in PCa diagnosis, PSA-based screening is not considered a reliable diagnosis and prognosis tool due to its lower sensitivity and poor predictive score which lead to a 22%-43% overdiagnosis, unnecessary biopsies, and over-treatment. These major limitations along with the heterogeneous nature of the disease have made PCa a very unappreciative subject for diagnostics, resulting in poor patient management; thus, it urges to identify and validate new reliable PCa biomarkers that can provide accurate information in regard to disease diagnosis and prognosis. Researchers have explored the analysis of microRNAs (miRNAs), messenger RNAs (mRNAs), small proteins, genomic rearrangements, and gene expression in body fluids and non-solid tissues in search of lesser invasive yet efficient PCa biomarkers. Although the presence of miRNAs in body fluids like blood, urine, and saliva initially sparked great interest among the scientific community; their potential use as liquid biopsy biomarkers in PCa is still at a very nascent stage with respect to other well-established diagnostics and prognosis tools. Up to date, numerous studies have been conducted in search of PCa miRNA-based biomarkers in whole blood or blood serum; however, only a few studies have investigated their presence in urine samples of which less than two tens involve the detection of miRNAs in extracellular vesicles isolated from urine. In addition, there exists some discrepancy around the identification of miRNAs in PCa urine samples due to the diversity of the urine fractions that can be targeted for analysis such as urine circulating cells, cell-free fractions, and exosomes. In this review, we aim to discuss research output from the most recent studies involving the analysis of urinary EVs for the identification of miRNA-based PCa-specific biomarkers.

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.

Modern paradigms for prostate cancer detection and management

Early detection and management of prostate cancer has evolved over the past decade, with a focus now on harm minimisation and reducing overdiagnosis and overtreatment, given the proven improvements in survival from randomised controlled trials. Multiparametric magnetic resonance imaging (mpMRI) is now an important aspect of the diagnostic pathway in prostate cancer, improving the detection of clinically significant prostate cancer, enabling accurate localisation of appropriate sites to biopsy, and reducing unnecessary biopsies in most patients with normal magnetic resonance imaging scans. Biopsies are now performed transperineally, substantially reducing the risk of post-procedure sepsis. Australian-led research has shown that prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) has superior accuracy in the staging of prostate cancer than conventional imaging (CT and whole-body bone scan). Localised prostate cancer that is low risk (International Society for Urological Pathology [ISUP] grade 1, Gleason score 3 + 3 = 6; and ISUP grade group 2, Gleason score 3 + 4 = 7 with less than 10% pattern 4) can be offered active surveillance, reducing harms from overtreatment. Prostatectomy and definitive radiation remain the gold standard for localised intermediate and high risk disease. However, focal therapy is an emerging experimental treatment modality in Australia in carefully selected patients. The management of advanced prostate cancer treatment has evolved to now include several novel agents both in the metastatic hormone-sensitive and castration-resistant disease settings. Multimodal therapy with androgen deprivation therapy, additional systemic therapy and radiotherapy are often recommended. PSMA-based radioligand therapy has emerged as a treatment option for metastatic castration-resistant prostate cancer and is currently being evaluated in earlier disease states.

Design and evaluation of an MRI-ready, self-propelled needle for prostate interventions

Prostate cancer diagnosis and focal laser ablation treatment both require the insertion of a needle for biopsy and optical fibre positioning. Needle insertion in soft tissues may cause tissue motion and deformation, which can, in turn, result in tissue damage and needle positioning errors. In this study, we present a prototype system making use of a wasp-inspired (bioinspired) self-propelled needle, which is able to move forward with zero external push force, thereby avoiding large tissue motion and deformation. Additionally, the actuation system solely consists of 3D printed parts and is therefore safe to use inside a magnetic resonance imaging (MRI) system. The needle consists of six parallel 0.25-mm diameter Nitinol rods driven by the actuation system. In the prototype, the self-propelled motion is achieved by advancing one needle segment while retracting the others. The advancing needle segment has to overcome a cutting and friction force while the retracting needle segments experience a friction force in the opposite direction. The needle self-propels through the tissue when the friction force of the five retracting needle segments overcomes the sum of the friction and cutting forces of the advancing needle segment. We tested the performance of the prototype in ex vivo human prostate tissue inside a preclinical MRI system in terms of the slip ratio of the needle with respect to the prostate tissue. The results showed that the needle was visible in MR images and that the needle was able to self-propel through the tissue with a slip ratio in the range of 0.78–0.95. The prototype is a step toward self-propelled needles for MRI-guided transperineal laser ablation as a method to treat prostate cancer.

Comparison of Fluoroquinolones and Other Antibiotic Prophylaxis Regimens for Preventing Complications in Patients Undergoing Transrectal Prostate Biopsy

Our study aimed to compare the incidence of infective complications after transrectal ultrasound-guided prostate biopsy (TRUSBx) when adopting different antimicrobial prophylaxis regimens. A multi-institutional cohort of 1150 patients who underwent TRUSBx was retrospectively analyzed. Procedures were performed between 2017 and 2019 (before and after the EMA warning about the use of fluoroquinolones for the antibiotic prophylaxis of patient candidates to TRUSBx). The primary endpoint was the occurrence of infective complications, including sepsis and/or fever. The population was stratified according to the antibiotic prophylaxis adopted: fluoroquinolones (levofloxacin, ciprofloxacin, prulifloxacin), cephalosporins (cefixime, ceftriaxone) or trimethoprim/sulfamethoxazole. Univariable and multivariable binomial logistic regression models were used to assess the odds ratio (OR) with 95% confidence interval (CI) testing of the risk of infective complication after adjusting for each prebiopsy covariate. In total, 478 (41.6%) patients received fluoroquinolone-based prophylaxis. Among these, 443 (38.5%), 25 (2.2%) and 10 (0.9%) patients received levofloxacin prophylaxis, ciprofloxacin and prulifloxacin, respectively while 14.6% received cefixime, 20.7% received the comedication of ceftriaxone/fosfomycin and 23.1% received trimethoprim/sulfamethoxazole. The trimethoprim/sulfamethoxazole and fluoroquinolone regimens were significantly associated with a lower risk of infective complications (OR 0.15, 95% CI 0.03−0.48, p = 0.003 and OR 0.17, 95% CI 0.06−0.43, p < 0.001, respectively). The ceftriaxone/fosfomycin (OR 0.21, 95% CI 0.04−0.92, p = 0.04) and fluoroquinolone (OR 0.07, 95% CI 0.00−0.70, p = 0.048) prophylaxis were associated with a lower risk of infective sequelae. Fluoroquinolone-based prophylaxis was associated with a lower risk of infective complications after TRUSBx compared to other prophylaxis regimens although its clinical application was recently forbidden by European Medical Agency restrictions.

Hundred years of transperineal prostate biopsy

The earliest recorded efforts to biopsy prostate, in the early 20th century, were made through transperineal (TP) approach, with open perineal prostate biopsy (PBx) being considered the gold standard for prostate cancer (PCa) diagnosis in that era. Later, to minimize morbidity and increase diagnostic accuracy, several technical modifications and transrectal ultrasound (TRUS) assistance were incorporated. However, in the 1980s, the transrectal (TR) approach became the predominant PBx method following the introduction of TRUS-TR PBx with sextant sampling, providing a convenient and efficacious method for prostate sampling. With modernization of PCa diagnosis, a recent resurgence of the TP PBx has been observed, driven primarily by TR drawbacks of infectious complications and sampling limitations. TP PBx is rapidly emerging as the new PBx standard, being officially recommended as the initial approach for biopsy in Europe and is increasingly being conducted and studied in the United States. The modern era of TP PBx is based on the improvements in local anesthesia techniques, TP access systems, and robotic assistance. These modifications and advancements have improved the ease of use, patient comfort, and diagnostic outcomes with TP PBx. Herein, we present a history of the evolution of TP PBx spanning over 100 years and explore the basis of the technique that merits future utilization.

Developments in optimizing transperineal prostate biopsy

PURPOSE OF REVIEW

Prostate biopsy is a very commonly performed office procedure leading to the diagnosis of the most prevalent solid-organ malignancy in American men. Although the transrectal technique for prostate biopsy remains the gold standard, there is increasing interest in the transperineal approach as it offers a clean, percutaneous approach that significantly decreases the risk for infection. In this review, we discuss emerging developments in transperineal prostate biopsy that may optimize the way biopsies are performed in clinical practice.

RECENT FINDINGS

Similarly, to transrectal biopsy, the transperineal approach also allows for the performance of systematic and MRI-targeted biopsy cores. As transperineal biopsy obviates the translocation of rectal bacteria to the prostate or bloodstream, in contrast to transrectal biopsy, it is feasible to forgo peri-procedural antibiotics in accordance with professional guidelines. This may attenuate antimicrobial resistance that may be associated with augmented prophylaxis. In addition, although transperineal biopsy may be traditionally performed under general anesthesia using a template grid, it may also be performed freehand under local anesthesia or sedation. Avoiding prophylactic antibiotics and general anesthesia as well as reducing infections/hospitalizations for transperineal biopsy scaled nationally will likely result in significant healthcare savings.

SUMMARY

Transperineal biopsy with combined systematic and MRI-targeted cores, offers several advantages over conventional transrectal biopsy. Transperineal biopsy under local anesthesia and without periprocedural antibiotic is emerging as a promising method for prostate cancer diagnosis and surveillance.

Towards targeted ultrasound-guided prostate biopsy by incorporating model and label uncertainty in cancer detection

PURPOSE

Systematic prostate biopsy is widely used for cancer diagnosis. The procedure is blind to underlying prostate tissue micro-structure; hence, it can lead to a high rate of false negatives. Development of a machine-learning model that can reliably identify suspicious cancer regions is highly desirable. However, the models proposed to-date do not consider the uncertainty present in their output or the data to benefit clinical decision making for targeting biopsy.

METHODS

We propose a deep network for improved detection of prostate cancer in systematic biopsy considering both the label and model uncertainty. The architecture of our model is based on U-Net, trained with temporal enhanced ultrasound (TeUS) data. We estimate cancer detection uncertainty using test-time augmentation and test-time dropout. We then use uncertainty metrics to report the cancer probability for regions with high confidence to help the clinical decision making during the biopsy procedure.

RESULTS

Experiments for prostate cancer classification includes data from 183 prostate biopsy cores of 41 patients. We achieve an area under the curve, sensitivity, specificity and balanced accuracy of 0.79, 0.78, 0.71 and 0.75, respectively.

CONCLUSION

Our key contribution is to automatically estimate model and label uncertainty towards enabling targeted ultrasound-guided prostate biopsy. We anticipate that such information about uncertainty can decrease the number of unnecessary biopsy with a higher rate of cancer yield.

Is a sampling transition zone important to increase the detection of prostate cancer in systematic prostatic biopsies?

BACKGROUND

Use of transrectal ultrasound (US)-guided biopsies improved diagnosis and treatment for patients with high prostate-specific antigen (PSA) or abnormal digital rectal exam (DRE).

PURPOSE

To investigate whether taking two transition zone (TZ) biopsies in addition to routine prostate double-sextant biopsies (12-cores) would improve detection rates of prostate cancer (PCa).

MATERIAL AND METHODS

A retrospective analysis of 1107 in a single institution database after Institutional Review Board approval, which underwent US-guided prostate biopsies from January 2014 to June 2016. All patients with suspected PCa based on positive DRE or high PSA submitted to US-guided prostate biopsy (double-sextant 12-cores alone and 12-cores with two TZ extra cores) were included.

RESULTS

A total of 1107 patients were included; 120 patients underwent double-sextant 12-cores alone and 987 underwent 12-cores with two TZ extra cores. Among patients submitted to two TZ extra cores, TZs of 755 (76.5%) patients were negative to neoplasia and 232 (23.5%) were positive to neoplasia. Among these patients, 26 (2.6%) had their final Gleason score increased with TZ core; TZ fragments of 20 (2.0%) patients led to a treatment change (re biopsy, active surveillance or from active surveillance to radiation therapy or radical prostatectomy). When the complication rate is analyzed (with or without hospital admission), among the patients submitted to TZ cores, 259 (26.2%) complications were observed; between those submitted to double-sextant 12-cores, 26 (21.7%) complications were observed (P=0.279).

CONCLUSION

Extended core biopsy protocol with two TZ extra fragments improves detection rates of cancer when compared to double-sextant biopsy protocol without increasing complication rates. TZ routine cores should be considered.

MRI-targeted prostate biopsy: the next step forward!

Aim

For decades, the gold standard technique for diagnosing prostate cancer was the 10 to 12 core systematic transrectal or transperineal biopsy, under ultrasound guidance. Over the past years, an increased rate of false negative results and detection of clinically insignificant prostate cancer has been noted, resulting into overdiagnosis and overtreatment. The purpose of the current study was to evaluate the changes in diagnosis and management of prostate cancer brought by MRI-targeted prostate biopsy.

Methods

A critical review of literature was carried out using the Medline database through a PubMed search, 37 studies meeting the inclusion criteria: prospective studies published in the past 8 years with at least 100 patients per study, which used multiparametric magnetic resonance imaging as guidance for targeted biopsies.

Results

In-Bore MRI targeted biopsy and Fusion targeted biopsy outperform standard systematic biopsy both in terms of overall and clinically significant prostate cancer detection, and ensure a lower detection rate of insignificant prostate cancer, with fewer cores needed. In-Bore MRI targeted biopsy performs better than Fusion biopsy especially in cases of apical lesions.

Conclusion

Targeted biopsy is an emerging and developing technique which offers the needed improvements in diagnosing clinically significant prostate cancer and lowers the incidence of insignificant ones, providing a more accurate selection of the patients for active surveillance and focal therapies.

Preventing Prostate Biopsy Complications: to Augment or to Swab?

OBJECTIVE

To use data from a large, prospectively- acquired regional collaborative database to compare the risk of infectious complications associated with three American Urologic Association- recommended antibiotic prophylaxis pathways, including culture-directed or augmented antibiotics, following prostate biopsy.

METHODS

Data on prostate biopsies and outcomes were collected from the Pennsylvania Urologic Regional Collaborative, a regional quality collaborative working to improve the diagnosis and treatment of prostate cancer. Patients were categorized as receiving one of three prophylaxis pathways: culture-directed, augmented, or provider-discretion. Infectious complications included fever, urinary tract infections or sepsis within one month of biopsy. Odds ratios of infectious complication by pathway were determined, and univariate and multivariate analyses of patient and biopsy characteristics were performed.

RESULTS

11,940 biopsies were included, 120 of which resulted in infectious outcomes. Of the total biopsies, 3246 used "culture-directed", 1446 used "augmented" and 7207 used "provider-discretion" prophylaxis. Compared to provider-discretion, the culture-directed pathway had 84% less chance of any infectious outcome (OR= 0.159, 95% CI = [0.074, 0.344], P < 0.001). There was no difference in infectious complications between augmented and provider-discretion pathways.

CONCLUSIONS

The culture-directed pathway for transrectal prostate biopsy resulted in significantly fewer infectious complications compared to other prophylaxis strategies. Tailoring antibiotics addresses antibiotic-resistant bacteria and reduces future risk of resistance. These findings make a strong case for incorporating culture-directed antibiotic prophylaxis into clinical practice guidelines to reduce infection following prostate biopsies.

Ultrasound-guided prostate biopsy: indication, morbidity and outcome at Hopital General Idrissa Pouye

Background

Magnetic resonance imaging (MRI)-guided prostate biopsy has a higher sensitivity than the ultrasound-guided biopsy, but its realization requires a dedicated interventional MRI, specific material, which is not available in our context; hence, ultrasound-guided biopsy remains of great interest. Currently, ultrasound-guided biopsy outside of a clinical trial is the gold standard for the diagnosis of prostate cancer. The objective of our work is to evaluate our practice of transrectal ultrasound-guided prostate biopsy using an endorectal probe by describing the technique and evaluating the morbidity and results.

Methods

This is a descriptive study of ultrasound-guided prostatic biopsies performed over a 2-year period. The parameters studied were frequency of the procedure, age, rectal examination findings, total PSA level, prostate biopsy morbidities and results. Descriptive statistics were performed, and comparison of qualitative variables was made by the Chi-square test with statistical significance set for α < 5%

Results

Two hundred and thirty-one patients were included over a two-year period. The mean age of our patients was 65 ± 8.2 years. Rectal examination finding was suspicious in 36.9% and the median total PSA was 19.8 ng/ml (0.1-5936 ng/ml). Seventy-seven percent of patients reported their pathology results. Prostatic adenocarcinoma was the most common finding accounting for 53.7% of results. Complications were observed in 16 patients (6.9%) with a predominance of initial hematuria, voiding pain and fever.

Conclusion

In our series, the cancer detection rate was significant and the complications rate was acceptable at 6.9%.

Endoscopic Therapy in the Management of Patients With Severe Rectal Bleeding Following Transrectal Ultrasound-Guided Prostate Biopsy: A Case-Based Systematic Review

Rectal bleeding is a known complication of transrectal ultrasound-guided prostate biopsy. It is usually mild and resolves spontaneously. However, massive life-threatening hemorrhage can also rarely occur in this setting, potentially presenting a therapeutic conundrum. We hereby delineate the case of a patient who experienced severe intermittent lower gastrointestinal bleeding following a transrectal ultrasound-guided prostate biopsy. Traditional tamponade methods failed to control the hemorrhage. Subsequently, an urgent flexible sigmoidoscopy revealed an anterior rectal wall prominence with biopsy punctures as the possible source of bleeding. Endoclip was successfully applied at the bleeding site, achieving permanent hemostasis. The patient had an uneventful recovery and was discharged from the hospital. While the use of endoclipping has been widely reported in gastrointestinal endoscopy, its application remains exceedingly rare in this group of patients. To our knowledge, this case represents only the third report of endoclipping alone to treat massive rectal bleeding follwing a prostate biopsy procedure. In addition, we systematically review published medical literature to evaluate endoscopic techniques aimed at managing this important complication. This article illustrates that endoscopic therapy may present an efficient, noninvasive method to deal with severe post-biopsy rectal hemorrhage. Therefore, prompt consultation with the gastroenterology service should be advocated.

The role of multiparametric resonance and biopsy in prostate cancer detection: comparison with definitive histological report after laparoscopic/robotic radical prostatectomy

Purpose

Magnetic Resonance Imaging (MRI) targeted biopsy increases overall detection rates and decreases the risk of clinically insignificant PCa detection. The aim of this retrospective study is to compare concordance rates regarding side of lesion and Gleason Score at fusion targeted/systematic biopsy and MRI with the definitive histologic report of prostatectomy specimen.

Methods

115 patients underwent multiparametric (mp) MRI and successively fusion targeted/systematic biopsy. 107 patients, with a positive biopsy for PCa, further underwent laparoscopic/robotic radical prostatectomy. We compared surgical histologic report with biopsy histologic report for side of lesion and Gleason Score. We further compared PIRADS score at mpMRI with Gleason Score of both histologic reports.

Results

Concordance rate for mpMRI lesion side was 74% compared to biopsy and 52.3% compared to surgical histologic report (p < 0.0001). Fusion targeted/systematic biopsy reported a concordance rate with surgical histologic report of 67.3% for side of the lesion, while Gleason Score was concordant for 73.6% for clinically significant cancer (Gleason Score ≥ 7) (p < 0.0001). PIRADS score ≥ 3 was further associated with clinically significant cancer at surgical histologic report in 92.4% of cases (p = 0.359).

Conclusion

Multiparametric MRI of the prostate reaches a good and improvable accuracy in the detection of suspicious PCa before biopsy. A combined approach of fusion targeted and systematic biopsy could further increase the overall accuracy in PCa diagnosis, especially in biopsy-naïve patients, reaching concordance rates with definitive histologic report up to 52.3% and 85.5%.

Prostate cancer incidence and diagnosis in men with PSA levels >20 ng/ml: is it possible to decrease the number of biopsy cores?

OBJECTIVES

To define if less number of cores would be sufficient to diagnose prostate cancer (PCa) in men with PSA levels >20 ng/ml and to reveal the cancer detection rates in this population.

METHODS

The data of the men who had 12-core prostate biopsy with a PSA value >20 ng/mg were reviewed. We recorded age, prostate volume, PSA level, and pathology report findings. Patients grouped according to PSA levels and compared for PCa detection rates, and several parameters. We created 16 prostate biopsy scenarios (S1-S16) and applied these to our database to find out the best biopsy protocol to detect PCa.

RESULTS

A total of 336 patients with a mean age of 70.5 (47-91) years were included. Mean PSA level was 190.6 (20-5474) ng/ml. PCa detection rates were 55.3%, 81.0%, and 97.7% in patients with PSA levels 20-49.99, 50-99.99, and ≥100 ng/ml, respectively. PSA level was correlated to clinically more important digital rectal examination findings. We selected 2 cores in S1-S6, 4 cores in S7-S12, and 6 cores in S13-S16. We calculated the sensitivity of each scenario and found that all scenarios in PSA Group 3 had a sensitivity >95%. In Group 2, S8, S10, S13, and S14 and in Group 1, only S14 had sensitivity >95%.

CONCLUSIONS

It is not necessary to take 10-12 core biopsy samples in men with PSA levels >20 ng/ml. We recommend taking 2, 4, and 6 samples for patients with PSA levels ≥100 ng/ml, 50-99.99 ng/ml, and 20-49.99 ng/ml, respectively.

Transrectal ultrasound biopsy of the prostate: does it still have a role in prostate cancer diagnosis?

Transrectal ultrasound (TRUS) guided biopsy of the prostate has been a standard diagnostic approach for prostate cancer over the past thirty years. Today, the role of TRUS biopsy is being challenged by transperineal (TP) prostate biopsy due to concerns over the safety and diagnostic yield of TRUS biopsy. TRUS biopsy still offers a convenient, reliable and accessible tool for diagnosing prostate cancer in the majority of patients. It continues to play a role in prostate cancer diagnosis, especially where hospital resource allocation is limited, including the public sector. TRUS biopsy has low rates of severe complications, although there remains room for improvement in current practice to improve the tolerability and reduce the incidence of post-biopsy infection.

Multiple instance learning combined with label invariant synthetic data for guiding systematic prostate biopsy: a feasibility study

PURPOSE

Ultrasound imaging is routinely used in prostate biopsy, which involves obtaining prostate tissue samples using a systematic, yet, non-targeted approach. This approach is blinded to individual patient intraprostatic pathology, and unfortunately, has a high rate of false negatives.

METHODS

In this paper, we propose a deep network for improved detection of prostate cancer in systematic biopsy. We address several challenges associated with training such network: (1) Statistical labels: Since biopsy core's pathology report only represents a statistical distribution of cancer within the core, we use multiple instance learning (MIL) networks to enable learning from ultrasound image regions associated with those data; (2) Limited labels: The number of biopsy cores are limited to at most 12 per patient. As a result, the number of samples available for training a deep network is limited. We alleviate this issue by effectively combining Independent Conditional Variational Auto Encoders (ICVAE) with MIL. We train ICVAE to learn label-invariant features of RF data, which is subsequently used to generate synthetic data for improved training of the MIL network.

RESULTS

Our in vivo study includes data from 339 prostate biopsy cores of 70 patients. We achieve an area under the curve, sensitivity, specificity, and balanced accuracy of 0.68, 0.77, 0.55 and 0.66, respectively.

CONCLUSION

The proposed approach is generic and can be applied to several other scenarios where unlabeled data and noisy labels in training samples are present.

Magnetic resonance as imaging diagnostic tool in prostate cancer: New evidences-The EAU Section of Uro-Technology position

Prostate cancer (PCa) is the second leading cause of cancer-related mortality and the most frequently diagnosed male malignant disease among men. The manifestation of PCa ranges from indolent to highly aggressive disease and due to this high variation in PCa progression, the diagnosis and subsequent treatment planning can be challenging. The current diagnostic approach with PSA testing and digital rectal examination followed by transrectal ultrasound biopsies lack in both sensitivity and specificity in PCa detection and offers limited information about the aggressiveness and stage of the cancer. Scientific work supports the rapidly growing use of multiparametric magnetic resonance imaging as the most sensitive and specific imaging tool for detection, lesion characterization and staging of PCa. Therefore, we carried out an updated review of magnetic resonance imaging in the diagnostic PCa reviewing the latest papers published in PubMed.

All change in the prostate cancer diagnostic pathway

Following detection of high levels of serum prostate-specific antigen, many men are advised to have transrectal ultrasound-guided biopsy in an attempt to locate a cancer. This nontargeted approach lacks accuracy and carries a small risk of potentially life-threatening sepsis. Worse still, it can detect clinically insignificant cancer cells, which are unlikely to be the origin of advanced-stage disease. The detection of these indolent cancer cells has led to overdiagnosis, one of the major problems of contemporary medicine, whereby many men with clinically insignificant disease are advised to undergo unnecessary radical surgery or radiotherapy. Advances in imaging and biomarker discovery have led to a revolution in prostate cancer diagnosis, and nontargeted prostate biopsies should become obsolete. In this Perspective article, we describe the current diagnostic pathway for prostate cancer, which relies on nontargeted biopsies, and the problems linked to this pathway. We then discuss the utility of prebiopsy multiparametric MRI and novel tumour markers. Finally, we comment on how the incorporation of these advances into a new diagnostic pathway will affect the current risk-stratification system and explore future challenges.

New Biopsy Techniques and Imaging Features of Transrectal Ultrasound for Targeting PI-RADS 4 and 5 Lesions

PURPOSE

To introduce new biopsy techniques and imaging features of transrectal ultrasound (TRUS) for targeting Prostate Imaging Reporting and Data System (PI-RADS) 4 and 5 lesions Methods: TRUS-guided targeted and/or systematic biopsies were performed in 432 men with PI-RADS 4 and 5 lesions following magnetic resonance imaging examination. A TRUS operator who was familiar with the new techniques and imaging features performed lesion detection. Overall and significant cancer detection rates (CDRs) were compared among the men with PI-RADS 4 and 5 lesions. The CDRs in the peripheral and transition zones were compared. Additionally, we assessed whether targeted or systematic biopsies contributed to cancer detection. The standard reference was a biopsy examination.

RESULTS

The overall CDRs in the men with PI-RADS 4 and 5 lesions were 49.5% (139/281) and 74.8% (113/151) (p < 0.0001); significant CDRs were 33.1% (93/281) and 58.3% (88/151) (p < 0.0001); and CDRs in the peripheral and transition zones were 53.6% (187/349) and 78.3% (65/83) (p < 0.0001), respectively. Of the 139 men with clinically significant cancer PI-RADS 4 lesions, 107 (77.0%) were diagnosed by targeted biopsy, 5 (3.6%) by systematic biopsy, and 27 (19.4%) by both. Of the 113 men with clinically significant cancer PI-RADS 5 lesions, 97 (85.8%) were diagnosed by targeted biopsy, 3 (2.7%) by systematic biopsy, and 13 (11.5%) by both.

CONCLUSIONS

Most PI-RADS 4 and 5 lesions can be targeted with TRUS if the new techniques and imaging features are applied.

Does transrectal ultrasonography-guided biopsy of the prostate lead to possible further metastasis via circulating tumor cells?

Background/aim

We evaluate whether transrectal ultrasonography (TRUS)-guided prostate biopsy might lead to spillage of tumor cells into peripheral blood as a result of disruption of the epithelial barrier and ultimately result in metastasis.

Materials and methods

Eighty-eight patients underwent TRUS-guided prostate needle biopsy due to prostate-specific antigen (PSA) increase or abnormal digital rectal examination at the Samsun Research and Training Hospital (Samsun, Turkey) between April 2016 and September 2018. Approximately 10 mL of whole blood was collected from patients before, 1 week after, and 1 month after biopsy. Samples were analyzed for CD117 positivity and prostate-specific membrane antigen (PSMA) levels using flow cytometry. Patients with pathologically determined prostate cancer and without CD117 positivity before biopsy were included in the study. The study group thus consisted of 55 patients.

Results

Subjects’ PSA levels ranged from 2.3 to 40.0 ng/mL (median: 7.9 ng/mL), and their Gleason score was a median of 7 (range: 5–9). PSMA levels ranged between 9.3 ng/mL and 118.5 ng/mL and CD117 antigen levels between 0 and 5. We detected no CD117- positive cells in blood samples collected 7 days or 1 month after biopsy.

Conclusion

We detected no circulating tumor cells in the peripheral circulation following biopsy. Prostate needle biopsy seems to be a safe method in terms of spillage of tumor cells into blood circulation as a possible cause of further metastasis.

Patient-reported pain, discomfort, and anxiety during magnetic resonance imaging-targeted prostate biopsy

INTRODUCTION

The addition of targeted prostate biopsy to systemic biopsy impacts patient experience. We examined patient-reported pain, discomfort, anxiety, and tolerability among men undergoing magnetic resonance imaging (MRI)-targeted prostate biopsy in addition to transrectal ultrasound-guided systematic biopsy compared to those undergoing systematic biopsy alone.

METHODS

All patients underwent transrectal systematic 14-core biopsies. Patients with regions of interest on MRI underwent additional targeted biopsies. All patients received equivalent periprostatic nerve block. Four single-item, standard, 11-point numerical rating scales evaluating pain, discomfort, anxiety, and tolerability were completed immediately after biopsy. Differences in means were compared using t-tests. Correlation between rated domains was tested using Spearman's correlation coefficient.

RESULTS

Of 273 consecutive patients, 195 (71%) underwent targeted biopsy and 188 (69%) had undergone prior biopsy. In all men, the median score for pain and tolerability was 3, while the median score for discomfort and anxiety was 4. Pain was rated at 7 or above by 15% of patients. Moderate correlation between pain, discomfort, anxiety, and tolerability of repeat biopsy was observed (Spearman's ρ between 0.48 and 0.76). Compared to patients undergoing systematic biopsy alone, men who received both targeted and systematic biopsies reported higher anxiety scores (difference 1.2; 95% confidence interval [CI] 0.4-2.0; p=0.004) and discomfort (difference 1.0; 95% CI 0.3-1.7; p<0.001).

CONCLUSIONS

Patients undergoing targeted and systematic biopsies report more discomfort and anxiety than patients undergoing systematic biopsies alone. Absolute differences are small, and patients are willing to undergo repeat biopsy if advised. Interventions to reduce biopsy-related anxiety are needed.

Comparison of prostate cancer detection rates of various prostate biopsy methods for patients with prostate-specific antigen levels of <10.0 ng/mL in real-world practice

Purpose

Several strategies of prostate biopsy (PBx) have been introduced to improve prostate cancer (PCa) detection rates. However, studies comparing cancer detection rates (CDRs) according to biopsy methods in real-world practice are scarce. This study aimed to investigate CDRs according to the biopsy methods for patients with prostate-specific antigen (PSA) <10.0 ng/mL.

Materials and Methods

From 2006 to 2015, patients who underwent PBx were initially selected. All patients were categorized according to the biopsy methods performed (magnetic resonance imaging targeted biopsy [MR-TBx], 12+2 hypoechoic lesion target biopsy, saturation biopsy [sPBx], extended biopsy, and 12-core PBx). The CDR of MR-TBx was compared to that of sPBx and other protocols. Volume per core (VPC) was defined as prostate volume divided by the number of biopsy cores. Patients previously diagnosed with PCa were excluded.

Results

Of the 1,598 patients (median PSA, 5.41 ng/mL), 401 (25.1%) were diagnosed with PCa. Among the biopsy methods, MR-TBx has the highest CDR and proportion of Gleason score ≥7 (3+4). Biopsy methods, VPC, age, prostate volume, and PSA were associated with PCa detection. In the sub-analysis for initial biopsy, MR-TBx had no significant difference with sPBx, but had higher CDR than the other biopsy protocols. For repeat biopsy, VPC, rather than the biopsy method, was associated with CDR.

Conclusions

This study reaffirmed the efficacy of MR-TBx on CDR in real-world practice. In cases with barriers to performing magnetic resonance imaging, VPC might be useful for adjusting the optimal number of biopsy cores in repeat biopsy.

Optimizing prostate biopsy techniques

PURPOSE OF REVIEW

Prostate cancer (PCa) diagnostics have undergone a number of changes as a result of efforts to reduce the detection rate of indolent prostate cancer and to increase the hit rate for clinically significant prostate cancer (csPCa). Here, we look at those studies that have shifted our knowledge and the impact these have had on clinical practice.

RECENT FINDINGS

The introduction of multiparametric MRI (mpMRI) and approaches to active surveillance have changed the landscape in prostate cancer diagnostics, reducing the number of men that need biopsy, but increasing the need for accuracy in mapping the extent of prostate cancer. As mpMRI reporting has become more accurate at predicting PCa, biopsy techniques have also evolved towards lesion (PI-RADS score 3-5) targeted biopsies. Uncertainty remains regarding the preferred approach to targeted biopsy, the need for systematic biopsies, and the place of software ultrasound/MRI fusion or in-bore MRI biopsy techniques versus 'cognitive' fusion techniques.

SUMMARY

Prostate biopsies remain essential for the diagnosis of PCa. But how best to do this? Latest guidelines advocate performing both targeted and systematic biopsies. Traditionally, prostate biopsies have been performed transrectally (TRUS) with hospital readmission rates of around 3% mainly because of infection. Additionally, TRUS prostate biopsies can miss anterior prostatic lesions. The transperineal approach addresses both these issues, but has historically required general anaesthetic such that adoption for front-line diagnostics is very difficult. Recent techniques to undertake transperineal biopsy under local anaesthetic have fundamentally changed this paradigm offering the genuine possibility that in 5 years' time, all front-line diagnostic biopsies will be performed as LATP.

Comparison of prostate cancer detection rates between the Vienna nomogram and the 10-core biopsy protocol

OBJECTIVE

To compare the Vienna nomogram and the 10-core prostate biopsy protocol regarding whether there is superiority in prostate cancer detection.

METHODS

Between January and December 2012, a total of 215 patients applying to our outpatient clinic with lower urinary tract symptoms were evaluated, prospectively. Patients with a prostate-specific antigen level of 2.5-10 ng/mL and/or suspicious digital rectal examination were included in the study. Exclusion criteria were determined as recent pelvic radiotherapy, lower urinary tract surgery, history of acute urinary retention, or indwelling urinary catheter. Biopsies were taken systematically with at least 10 cores considering prostate volume and patient age. According to Vienna nomogram, in patients requiring 6- or 8-core biopsies, tissue sampling was completed to 10 cores (our standard protocol), whereas in patients requiring more than 10 cores additional tissue sampling was performed.

RESULTS

After the determination of inclusion/exclusion criteria, 170 patients were enrolled in our study. The median (min-max) age, prostate-specific antigen value, and prostate volume were 65 (48-86) years, 7.6 ng/dL (2.5-10), and 55 cc (17-150), respectively. Prostate cancer was detected in 49 (28.8%) patients with transrectal ultrasound-guided prostate biopsy according to the Vienna nomogram. We found that our standard 10-core biopsy protocol would have diagnosed prostate cancer in 46 (27.1%) patients in the same study group showing no statistically significant difference (p > 0.005).

CONCLUSION

The findings of this study suggest that considering cancer detection rates no statistically significant differences were found between both methods. Further prospective research in this aspect is needed to define the ultimate prostate biopsy protocol.

Landmarks in prostate cancer

The field of prostate cancer has been the subject of extensive research that has resulted in important discoveries and shaped our appreciation of this disease and its management. Advances in our understanding of the epidemiology, natural history, anatomy, detection, diagnosis, grading, staging, imaging, and management of prostate cancer have changed clinical practice and influenced guideline recommendations. The development of the Gleason score and subsequent modifications enabled accurate prediction of prognosis. Increased anatomical understanding and improved surgical techniques resulted in the development of nerve-sparing surgery for radical prostatectomy. The advent of active surveillance has changed the management of low-risk disease, and chemotherapy and hormonal therapy have improved the outcomes of patients with distant disease. Ongoing research and clinical trials are expected to yield more practice-changing results in the near future.

Anatomy and Imaging of Rat Prostate: Practical Monitoring in Experimental Cancer-Induced Protocols

The rat has been frequently used as a model to study several human diseases, including cancer. In many research protocols using cancer models, researchers find it difficult to perform several of the most commonly used techniques and to compare their results. Although the protocols for the study of carcinogenesis are based on the macroscopic and microscopic anatomy of organs, few studies focus on the use of imaging. The use of imaging modalities to monitor the development of cancer avoids the need for intermediate sacrifice to assess the status of induced lesions, thus reducing the number of animals used in experiments. Our work intends to provide a complete and systematic overview of rat prostate anatomy and imaging, facilitating the monitoring of prostate cancer development through different imaging modalities, such as ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI).

Update on Strategies to Reduce Infectious Complications After Prostate Biopsy

CONTEXT

Prostate biopsy is one of the most performed procedures in urology. As a diagnostic procedure it should be of low risk. However, morbidity following prostate biopsy is common due to infectious complications.

OBJECTIVE

To describe how to reduce infectious complications following prostate biopsy. We report on antibiotic and technical interventions to reduce infectious complications.

EVIDENCE ACQUISITION

The data presented are based on a narrative review. Search in PubMed and Medline was performed until May 2018 with a focus on randomised controlled trials and meta-analyses. Articles were reviewed for data on symptomatic infections, hospitalisation, and adverse events.

EVIDENCE SYNTHESIS

Antibiotic prophylaxis is the standard of care. However, the duration of antibiotic preemptive treatment is still under debate. The use of augmented antibiotic prophylaxis as well as targeted antibiotic prophylaxis might be of potential value, but evidence is currently limited. Moreover, no antibiotic class was shown to be clearly superior to another. The evaluation of the technical aspects during prostate biopsy reveals that rectal preparation with povidone-iodine is clearly effective to reduce infectious complications. Transperineal biopsy has a potential benefit to reduce infectious complications, but powerful randomised controlled studies are missing. Finally, the number of biopsy cores, the application of periprostatic nerve block, or the use of a cleansing enema has no impact on prostate biopsy in terms of infectious complications.

CONCLUSIONS

The available data only suggest that rectal preparation with povidone-iodine as well as antibiotic prophylaxis is of significant advantage to reduce infectious complications following prostate biopsy. The augmented and targeted antibiotic prophylaxis shows some potential, but need further validation.

PATIENT SUMMARY

In this review we evaluate the best management strategy to prevent infectious complications following prostate biopsy. We show that antibiotic prophylaxis is essential for prostate biopsy and that rectal preparation with povidone-iodine is mandatory.

Accuracy of the magnetic resonance imaging pathway in the detection of prostate cancer: a systematic review and meta-analysis

BACKGROUND

Although magnetic resonance imaging and subsequent targeted biopsy ('MRI pathway') have been widely adopted in routine clinical practice, it is still a common practice to perform systematic biopsy concurrently, because the accuracy of the MRI pathway is yet to be fully defined. This systematic review of the literature assessed the sensitivity of the MRI pathway for detecting clinically significant prostate cancer.

METHODS

Multiple databases were searched up to May 2017 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement for studies assessing the accuracy of MR-guided biopsy (MRGB) compared to a reference standard which consisted of both MRGB and systematic biopsy with at least 20-cores. The primary outcome was the sensitivity of detecting clinically significant prostate cancer defined as Gleason ≥7 disease.

RESULTS

A total of 15 studies met the predefined inclusion criteria. Overall, studies were assessed to be of low quality with inadequate blinding of personnel, which could introduce performance and detection bias. The calculated summary sensitivity of the MRI pathway was 78.3% [95%CI 75.0-81.4%]. There was moderate heterogeneity between the included studies (I² = 36%). Subgroup analysis was performed based on clinical setting, the strength of MRI magnet and mode of image fusion as factors but no interaction was identified between any of the subgroups. No publication bias was identified.

CONCLUSION

The MRI pathway cannot yet be solely relied upon to diagnose clinically significant disease and hence additional systematic sampling should still be performed during the biopsy procedure.

Impact of a novel biopsy instrument with a 25-mm side-notch needle on the detection of prostate cancer in transrectal biopsy

OBJECTIVES

To evaluate the impact of a novel biopsy instrument that extends the length of the side-notch on the detection of prostate cancer in transrectal needle biopsy.

METHODS

We collaborated with a biopsy needle manufacturer and developed a novel biopsy instrument (PRIMECUT II long-notch type) with a 25-mm side-notch length and 28-mm stroke length to take longer tissue cores. The sampled core length, cancer detection rate, pain and complications of 489 patients who underwent transrectal biopsy using the long-notch needle were compared with those of 469 patients who underwent biopsy using a normal instrument with a 19-mm side-notch length and 22-mm stroke length.

RESULTS

The mean length of tissue taken by the long-notch needle was significantly longer than that of tissue taken by the normal-notch needle (16.3 vs 22.4 mm, P < 0.001). The overall cancer detection rate was 42.0% for the normal-notch needle and 51.1% for the long-notch needle (P = 0.005). In patients with a prostate volume of 20-40 mL, the cancer detection rate for the long-notch needle was especially higher than that for the normal-notch needle (74.2% vs 47.5%, P < 0.001). Multivariate analysis showed that the long-notch needle improved cancer detection significantly (odds ratio 1.702, P < 0.001). There were no differences of pain during biopsy and complication between the two groups.

CONCLUSIONS

The novel biopsy instrument with a 25-mm side-notch can take longer tissue samples safely and has a significantly higher rate of prostate cancer detection in transrectal biopsy.

Comparing use of lidocaine periprostatic nerve block and diclofenac suppository alone for patients undergoing transrectal ultrasound guided prostate biopsy

Introduction

The objective of this study is to make a comparison between the effectiveness of the diclo- fenac suppository alone and periprostatic local anaesthesia infiltration alone to reduce the pain during a transrectal ultrasound-guided prostate biopsy procedure.

Material and methods

Between January 2014 and December 2015, 100 patients from two centres who were scheduled for transrectal ultrasound guided prostate biopsy (TRUS Bx) were included in the study. Patients were divided into two groups; diclofenac suppository group (Group 1) and Lidocaine group (Group 2). After the prostate biopsy, patients were requested to fill out a visual analogue scale in order to evaluate their pain level during the procedure.

RESULTS

Since each group had been examined for VAS score, statistical differences were detected for VAS 0 and VAS 1. VAS 0 score was stated in 38 (71%) patients in Group 2, and in 25 (50%) patients in Group 1 (p = 0.040). VAS 1 score was stated in 9 (17%) patients in group 2 and 19 (38%) patients in Group 1 (p = 0.030).

CONCLUSIONS

Although statistical difference was detected at lower VAS scores (0 and 1) in favor of the lidocaine group during transrectal ultrasound guided prostate biopsies, there was not a significant difference in higher (>2) VAS scores; which was made with 100 mg of diclofenac suppository. Therefore, diclofenac suppository can be used as an alternative to periprostatic nerve block made with lidocaine.

Natural history of prostatic lesions on serial multiparametric magnetic resonance imaging

INTRODUCTION

The natural history of prostatic lesions identified on multiparametric magnetic resonance imaging (mpMRI) is largely unknown. We aimed to describe changes observed over time on serial MRI.

METHODS

All patients with ≥2 MRI studies between 2008 and 2015 at our institution were identified. MRI progression was defined as an increase in Prostate Imaging Reporting and Data System (PI-RADS; version 2) or size of existing lesions, or the appearance of a new lesion PIRADS ≥4. Patients on active surveillance (AS) were analyzed for correlation of MRI progression to biopsy reclassification.

RESULTS

A total of 83 patients (54 on AS and 29 for diagnostic purposes) underwent serial MRI, with a mean interval of 1.9 years between scans. At baseline, 115 lesions (66 index, 49 non-index) were identified. Index lesions were more likely than non-index lesions to increase in size ≥2 mm (36.2 vs. 7.3 %; p=0.002). Overall progression was more likely to be seen among the index cohort (34.8 vs. 7.6%; p<0.001). New lesions with PI-RADS ≥4 were seen on second imaging in 13 (16.5%) men, and became the index lesion in 29 cases (34.9%). Eighteen men on AS showed evidence of MRI progression (five with new lesions, 13 with progression of a previous lesion). Biopsy reclassification was present in three men (16.7%) with and seven men without MRI progression (19.4%).

CONCLUSIONS

Overall changes in size and PI-RADS scores of index lesions on MRI were small. New lesions were common, but usually did not alter management.

Imaging for the selection and monitoring of men on active surveillance for prostate cancer

Traditional prostate imaging is fairly limited, and only a few imaging modalities have been used for this purpose. Until today, grey scale ultrasound was the most widely used method for the characterization of the prostatic gland, however its limitations for prostate cancer (PCa) detection are well known and hence ultrasound is primarily used to localize the prostate and facilitate template prostate biopsies. In the past decade, multiparametric magnetic resonance imaging (mpMRI) of the prostate has emerged as a promising tool for the detection of PCa. Evidence has shown the value of mpMRI in the active surveillance (AS) population, given its ability to detect more aggressive disease, with data building up and supporting its use for the selection of patients suitable for surveillance. Additionally, mpMRI targeted biopsies have shown an improved detection rate of aggressive PCa when compared to regular transrectal ultrasound (TRUS) guided biopsies. Current data supports the use of mpMRI in patients considered for AS for reclassification purposes; with a negative mpMRI indicating a decreased risk of reclassification. However, a percentage of patients with negative imaging or low suspicion lesions can experience reclassification, highlighting the importance of repeat confirmatory biopsy regardless of mpMRI findings. At present, no robust data is available to recommend the substitution of regular biopsies with mpMRI in the follow-up of patients on AS and efforts are being made to determine the role of integrating genomic markers with imaging with the objective of minimizing the need of biopsies during the follow up period.

Anatomic and Molecular Imaging in Prostate Cancer

Prostate cancer is characterized by a complex set of heterogeneous disease states. This review aims to describe how imaging has been studied within each specific state. As physicians transition into an era of precision medicine, multiparametric magnetic resonance imaging (mpMRI) is proving to be a powerful tool leading the way for a paradigm shift in the diagnosis and management of localized prostate cancer. With further research and development, molecular imaging modalities will likely change the way we approach recurrent and metastatic disease. Given the range of possible oncological progression patterns, a thorough understanding of the underlying carcinogenesis, as it relates to imaging, is a requisite if we are to appropriately manage prostate cancer in future decades.

Multiparametric magnetic resonance imaging: Overview of the technique, clinical applications in prostate biopsy and future directions

Multiparametric magnetic resonance imaging (mpMRI) has managed to change the paradigms on prostate cancer detection and risk classification. The most clear-cut indication of mpMRI in guidelines is the patients with a history of negative biopsy/increasing prostate-specific antigen (PSA), and presence of additional findings supporting its use in non biopsied patients and active surveillance. mpMRI complements standard clinical exam, PSA measurements, and systematic biopsy, and will miss some tumors that lack enough size or change in tissue density. Use of mpMRI is likely to increase, and further developments in the technique will be important for safe adoption of focal therapy concepts. Here we present a brief summary about mpMRI and its use in detection, risk classification and follow-up of prostate cancer.

Endoscopic Band Ligation to Treat a Massive Hemorrhoidal Hemorrhage Following a Transrectal Ultrasound-Guided Prostate Biopsy

Prostate cancer is commonly diagnosed by using a transrectal ultrasound (TRUS)-guided biopsy. Although this procedure is usually well tolerated, rarely it may be complicated by massive rectal bleeding. We report a case of a 77-year-old male who underwent a TRUS biopsy and subsequently developed recurrent episodes of rectal bleeding with syncope and anemia requiring the transfusion of multiple units of blood. A sigmoidoscopy revealed the source of the bleeding: a large hemorrhoid on the anterior wall of the rectum with an overlying ulceration. We successfully applied a band to ligate the hemorrhoid, and the patient's condition improved. To our knowledge, this case represents the first report of a successful band ligation to treat massive bleeding from a hemorrhoid that had been punctured in the course of the TRUS biopsy procedure.