Transperineal biopsy of the prostate--is this the future? Nat Rev Urol. 2013;10:690-702. [PMID: 24061531 DOI: 10.1038/nrurol.2013.195]

Epidemiology, diagnosis and treatment of anterior prostate cancer

Anterior prostate cancers (APCs) are a group of impalpable neoplasms located in regions anterior to the urethra, which comprise the transition zone, apical peripheral zone and anterior fibromuscular stroma. These regions are typically undersampled using conventional biopsy schemes, leading to a low detection rate for APC and a high rate of false negatives. Radical prostatectomy series suggest prevalence rates of at least 10-30%, but transperineal systematic biopsy is ideal for diagnosis, particularly where multiparametric MRI is unavailable. Combined MRI-targeted and systematic biopsies demonstrate high concordance with final histopathology and lead to the fewest incidences of upgrading and upstaging at radical prostatectomy. Thus, the use of combined biopsy techniques has important implications for preoperative work-up and surgical planning, as APCs are associated with larger cancer volumes and a higher rate of positive surgical margins than posterior prostate cancer. Nevertheless, anterior tumour location might confer a relative resistance to stage progression, as APCs exhibit lower rates of extraprostatic extension, seminal vesical invasion and lymph node metastases than the more commonly seen posterior neoplasms. Few studies have examined the long-term outcomes of partial gland approaches to APCs, but MRI-targeted techniques have the potential to provide real-time intraoperative guidance and maximize the oncological safety of anterior focal treatment options in patients with APC.

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

BACKGROUND

The pain sensation in a transperineal prostate biopsy was obvious. This study explored the clinical value of ultrasound-guided full-needle path anesthesia in transperineal prostate biopsy.

METHODS

Two hundred patients who underwent ultrasound-guided transperineal prostate biopsy at our department were randomly divided into 2 groups. The control group received routine local infiltration anesthesia, and the experimental group received ultrasound-guided full-needle path anesthesia. Immediately after biopsy, visual analog scoring was used to evaluate pain during the biopsy process. Seven days postbiopsy, telephone follow-up revealed symptoms, such as hematuria and discomfort during urination. The measured data were expressed as x ± s. The 2 groups were compared using the t test, and the differences were statistically significant (P < .05).

RESULTS

There were no significant differences in age, prostate-specific antigen (PSA) level, or prostate volume between the 2 groups, and all patients underwent prostate biopsy. The pain score of visual analog score was (2.55 ± 0.88), urination discomfort was (1.86 ± 0.67) days and hematuria time was (2.87 ± 0.91) days in the experimental group after biopsy. In the control group, the pain score of visual analog scale was (4.32 ± 0.94), the urination discomfort was (2.3 ± 0.77) days, and the hematuria time was (2.85 ± 0.83) days. Pain scores and urination discomfort were compared between the 2 groups (P < .01). Pain and urination discomfort associated with prostate biopsy in the experimental group were significantly lower than those in the control group.

CONCLUSION

Ultrasound-guided full needle path anesthesia can alleviate pain sensation in patients undergoing transperineal prostate biopsy and has high clinical value.

Cost-effectiveness analysis of different anesthesia strategies for transperineal MRI/US fusion prostate biopsy

This study aims to conduct a cost-effectiveness analysis of three different anesthesia strategies, namely chatting while under local anesthesia (Chat-LA), total intravenous anesthesia (TIVA), and general anesthesia with laryngeal mask airway (GA-LMA), employed in transperineal magnetic resonance imaging (MRI)/ultrasound (US) fusion prostate biopsy (TP-MUF-PB). A retrospective study was conducted involving 1202 patients who underwent TP-MUF-PB from June 2016 to April 2023 at The First Affiliated Hospital of Soochow University (Suzhou, China). Clinical data and outcomes, including total costs, complications, and quality-adjusted life years (QALYs), were compared. Probability sensitivity and subgroup analyses were also performed. Chat-LA was found to be the most cost-effective option, outperforming both TIVA and GA-LMA. However, subgroup analyses revealed that in younger patients (under 65 years old) and those with smaller prostate volumes (<40 ml), TIVA emerged as a more cost-effective strategy. While Chat-LA may generally be the most cost-effective and safer anesthesia method for TP-MUF-PB, personalization of anesthesia strategies is crucial, considering specific patient demographics such as age and prostate volume.

Incidence of Infection Following Local Anesthetic Transperineal Prostate Biopsy: A Single-Centre Experience

Background Local anesthetic transperineal prostate biopsy (LATP) is a widely used diagnostic procedure for prostate cancer. As a diagnostic procedure, it should carry minimal risk. However, morbidity resulting from prostate biopsy is frequent. Prostate biopsy, like any other intervention, carries a significant risk of various infections, ranging from urinary tract infections (UTIs) to potentially life-threatening conditions like sepsis. Aim This study examined the rate of infections following a prostate biopsy at a single center and sought to identify risk factors that could increase the likelihood of developing an infection. Methods A retrospective review was conducted on all 168 patients who underwent LATP biopsy between 01/04/2022 and 01/04/2023. Data were collected from the Clinical Record and Reporting System (CRRS). Patient characteristics, including age, prostate-specific antigen (PSA) levels, prostate volume, the main indication for the biopsy, number of cores taken, antibiotic prophylaxis, and comorbidities were analyzed. The inclusion criteria encompassed all patients receiving this procedure within the specified timeframe, without restrictions on age, underlying health conditions, or medical history. No exclusion criteria were applied, aiming to comprehensively analyze and capture the full spectrum of patient outcomes and characteristics associated with these biopsies during the study period. Results In terms of socio-demographics, all patients were male with an average age (mean) of 65.5 years, a mean PSA level of 13.9 ng/dL, and an average prostate volume of 66.1 mL. On average, 23.2 biopsy cores were taken. All patients received antibiotic prophylaxis, mainly ciprofloxacin. Despite this, 1.78% of patients (n=3) developed post-biopsy infections. Two of these patients had diabetes mellitus, and two had a large prostate volume of 95 mL.

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

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

[Prostate Biopsy: General Consideration and Systematic Biopsy]

Korea is rapidly entering into an aging society, and an increasing socioeconomic burden related to prostate cancer is inevitable. Therefore, the need for early detection and accurate diagnosis of prostate cancer is becoming increasingly critical. Ideally, a biopsy should accurately detect cancers using a minimum number of cores. However, as prostate cancer is often indistinguishable on imaging, image-guided targeted biopsies alone are insufficient for diagnosis. After decades of trial and error, the diagnosis of prostate cancer relies heavily on systematic biopsy, which is characterized by random and repetitive core acquisition throughout the gland. This review will provide an overview of the historical aspects of prostate cancer diagnosis. Moreover, the review will also address the general considerations involved in prostate biopsy, and discuss the periprocedural management of the patients.

Simultaneous thulium laser resection of the prostate and transperineal prostate biopsy in clinically diagnosed metastatic prostate cancer with bladder outlet obstruction

Metastatic prostate cancer (mPCa) patients complicated with bladder outlet obstruction (BOO) are often referred to a urologist. Androgen deprivation therapy (ADT) combined with indwelling catheter usually be the initial management. To retrospectively analysis the safety and efficacy of simultaneous thulium laser resection of the prostate (TmLRP) and transperineal prostate biopsy in metastatic prostate cancer with bladder outlet obstruction. From January 2016 to December 2021, 67 clinically diagnosed mPCa with BOO patients were included in this study. All patients were preoperatively assessed with international prostate symptom score (IPSS), QoL, serum prostate-specific antigen (PSA), prostate volume evaluation by transrectal ultrasound, postvoid residual urine volume (PVR), and maximum flow rate (Qmax). Preoperative and perioperative parameters at 1-, 3-, and 6-month follow-up were also evaluated. All complications were recorded. Simultaneous TmLRP and transperineal prostate biopsy had obvious advantages for clinically diagnosed mPCa patients with BOO, including short overall operation time (52 ± 23.3 min), little hemoglobin decrease (0.6 ± 0.7 g/l), and short hospital stay (average 3.8 days). In addition, simultaneous TmLRP and transperineal prostate biopsy also brought them significant improvement on IPSS, QoL score, Qmax, and PVR volume (P < 0.001) at 1-, 3-, and 6-month follow-up after operation compared to preoperative parameters. Complications were in a low incidence. Simultaneous TmLRP and transperineal prostate biopsy is a bloodless operation with immediate effect and little perioperative complication. Importantly, it is a promising technology in the diagnosis and treatment of clinically diagnosed mPCa patients with BOO.

Protocol of a multicentre randomised controlled trial assessing transperineal prostate biopsy to reduce infectiouscomplications

INTRODUCTION

Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer.

METHODS AND ANALYSIS

We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer.

ETHICS AND DISSEMINATION

The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT04815876.

Initial Outcomes of Freehand Transperineal Biopsies Regarding Diagnostic Value and Safety: An Early Experience at King Fahad Specialist Hospital, Buraydah, Saudi Arabia

BACKGROUND

Prostate cancer is a common type of cancer in Saudi Arabia with a high incidence rate. Trans-rectal ultrasound guided prostatic biopsy (TRUSBx) has been the standard diagnostic study for prostate cancer since a landmark study in 1989 which showed that it is better than digitally directed biopsy sampling of the prostate. As an alternative to TRUSBx, transperineal biopsies (TPBx) have gained popularity as they give a higher accuracy rate and avoid many complications. A new study has been conducted in Riyadh, Saudi Arabia to compare TRUSBx and TPBx showed that TPBx has a significantly higher detection rate of prostate cancer cases compared to TRUSBx (45.1% vs. 29.1%, p=0.003). The aim of this study is to determine the diagnostic value and safety of freehand transperineal prostate biopsy in patients with an elevated prostatic specific antigen (PSA) and/or abnormal digital rectal exam in King Fahad Specialist Hospital KFSH in Buraydah, Qassim region, Saudi Arabia.

METHODS

This is an observational retrospective study of all patients (n=39) who underwent transperineal biopsies at KFSH to assess the diagnostic value and safety of the procedure.

RESULTS

The mean age of the patients was 70.3 (SD 10.1) years. The most commonly found diagnosis was adenocarcinoma (61.5%), and incidence of complications was detected in (5.1%) of the patients.

CONCLUSION

We concluded that the freehand technique TPBx has a high accuracy rate in detecting prostatic cancer. However, the learning curve could be a limiting factor in implementing it. Increasing the number of biopsies could positively affect diagnostic accuracy, especially with our low complication rate in this procedure. A low number of biopsies in the older age group can give an accurate result with a low risk of complications. Although template-guided TPBx and robot-guided TPBx are better options, the freehand technique represents a cost-effective and time-saving alternative. However, more studies are needed to compare the outcome of such a technique.

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

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

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

Safety and efficacy of software-assisted MRI-TRUS fusion-guided transperineal prostate biopsy in an outpatient setting using local anaesthesia

PURPOSE

To evaluate diagnostic accuracy, safety, and efficiency of an MRI-TRUS fusion-guided transperineal prostate biopsy method in an outpatient setting under local anaesthesia.

METHODS

Patients undergoing transperineal prostate biopsy were included from March 2021 to May 2022. Biopsies were performed under local anaesthesia in an outpatient setting, using specialised fusion software. Primary outcome was (clinically significant) cancer detection rate. Secondary outcomes were procedure time, patient discomfort during the procedure and complication rate.

RESULTS

We included 203 male patients (69 years +-SD 8.2) with PI-RADS score > 2. In total 223 suspicious lesions were targeted. Overall cancer detection rate and clinically significant cancer detection rate were 73.5% and 60.1%, respectively. (Clinically significant) cancer detection rates in PI-RADS 3, 4 and 5 lesions were 46.4% (23.2%), 78.5% (66.1%) and 93.5% (89.1%), respectively. Mean duration of the procedure including fusion, targeted and systematic biopsies was 22.5 min. Patients rated injection of local anaesthesia on a numeric pain rating scale on average 3.7/10 (SD 2.09) and biopsy core sampling 1.6/10 (SD 1.65). No patient presented with acute urinary retention on follow-up consultation. Two (1%) patients presented with infectious complications. Four (2%) patients experienced a vasovagal reaction.

CONCLUSION

Transperineal targeted biopsy with MRI-TRUS fusion software has high overall and clinically significant cancer detection rates. The method is well tolerated under local anaesthesia and in an outpatient setting.

Transrectal versus transperineal prostate biopsy in detection of prostate cancer: a retrospective study based on 452 patients

BACKGROUND

Transrectal (TR) ultrasound guided prostate biopsy and transperineal (TP) ultrasound guided prostate biopsy are the two most commonly used methods to detect prostate cancer, the detection rate of the two biopsy approaches may differ in patients with different clinical characteristics. Here we aimed to compare the prostate cancer detection rate and positive rate of biopsy cores between TR and TP prostate biopsy in patients with different clinical characteristics.

METHODS

We retrospectively analyzed and compared the clinical data of 452 patients underwent TR or TP prostate biopsy in our hospital from June 2017 to September 2021. And patients were stratified according to several clinical characteristic (serum PSA level, prostate volume, PSA density, T stage and ISUP grade), cancer detection rate and positive rate of biopsy cores were compared in different stratified groups.

RESULTS

There was no significant difference in age, PSA level, prostate volume, and PSA density between the TR and TP groups. TR group had a higher overall cancer detection rate and positive rate of biopsy cores than TP group. Further subgroup analysis showed that TR group had a higher cancer detection rate in patients with prostate volumes 30-80 mL, and that the TR group had a higher positive rate of biopsy cores among the patients with T3-T4 stages, while TP group had a higher positive rates of biopsy cores among the patients with T1-T2 stages. There were no significant differences between the TR and TP groups for each subgroup when stratified by PSA level, PSA density and ISUP grade.

CONCLUSIONS

TR approach may have advantage in patients with prostate volumes 30-80 mL and T3-T4 stages, while TP approach may have advantage in patients with T1-T2 stages.

Schema and cancer detection rates for transperineal prostate biopsy templates: a review

Prostate cancer (PCa) is the most common noncutaneous malignancy in men and is the second leading cause of cancer mortality in men in the United States. Current practice requires histopathological confirmation of cancer achieved through biopsy for diagnosis. The transrectal approach for prostate biopsy has been the standard for several decades. However, the risks and limitations of transrectal biopsies have led to a recent resurgence of transperineal prostatic biopsies. Recent studies have demonstrated the transperineal approach for prostate biopsies to be effective, associated with minimal complications and superior in several aspects to traditional transrectal biopsies. While sextant and extended sextant templates are widely accepted templates for transrectal biopsy, there are a diverse set of transperineal biopsy templates available for use, without consensus on the optimal sampling strategy. We aim to critically appraise the salient features of established transperineal biopsy templates.

Antimicrobial resistance profiles for bacteria isolated from rectal swabs in patients candidate for prostate biopsy

Objective:

Infection is one of the common complications of post-prostate biopsy. Therefore, prophylaxis with fluoroquinolones and/or cephalosporins is recommended. We aimed to evaluate the prevalence of antibiotic-resistant bacteria isolated from rectal swabs in candidates for transrectal ultrasound-guided (TRUS) biopsy. The possible patient’s related risk factors attributing to resistance to antibiotics were also assessed.

Methods:

This cross-sectional study was performed on 126 male patients who were candidates for TRUS biopsy. Rectal swabs were collected and the samples were transferred to the laboratory in Amies transport medium during 2 hours and cultured on MacConkey agar with ciprofloxacin 1 mg/L and ciprofloxacin-resistant strains were identified. Kirby-Bauer disc diffusion method was used to determine the antibiotic susceptibility of the isolates.

Results:

In total, 59 bacterial isolates were obtained, which were Escherichia coli, Staphylococcus aureus and Pseudomonas aeruginosa, respectively, in terms of frequency. They showed the lowest resistance to levofloxacin. Smoking was associated with positive culture results. Age was a factor with a significant effect on carrying ciprofloxacin-resistant strains.

Conclusion:

Ciprofloxacin resistance was high in almost all strains, but post-biopsy infectious complications were very low.

Level of evidence:

Not applicable

Pilot study of the diagnostic utility of 89 Zr-df-IAB2M and 68 Ga-PSMA-11 PET imaging and multiparametric MRI in localized prostate cancer

BACKGROUND

Accurate diagnosis of localized prostate cancer (PCa) is limited by inadequacy of multiparametric (mp) MRI to fully identify and differentiate localized malignant tissue from benign pathologies. Prostate-specific membrane antigen (PSMA) represents an excellent target for molecular imaging. IAB2M, an 85-kD minibody derived from a de-immunized monoclonal antibody directed at the extracellular domain of human PSMA (huJ591), and PSMA-11, a small molecule ligand have been previously tested as probes for visualization of recurrent/metastatic PCa with PET/CT. This pilot, non-randomized trial studied their diagnostic utility in patients (pts) with localized PCa.

METHODS

Pts planned for radical prostatectomy (RP) were enrolled and underwent mpMRI and PET/CT imaging with ⁸⁹ Zr-df-IAB2M and/or ⁶⁸ Ga-PSMA-PET/CT. Image results were read by a radiologist blinded to clinical information and pathology results, mapped and compared to corresponding histopathology findings from all lesions, both clinically significant and nonsignificant. The detection rates of all three imaging modalities were measured and correlated.

RESULTS

20 pts with median age of 64.5 (46-79) years and PSA level of 7.5 (1.6-36.56) ng/ml were enrolled. 19 pts underwent RP and were imaged pre-operatively with ⁸⁹ Zr-Df-IAB2M PET/CT and mpMRI. Nine of those were imaged using ⁶⁸ Ga-PSMA-11 as well. Out of 48 intraprostatic lesions verified on surgical pathology, IAB2M PET/CT was able to detect 36 (75%). A similar proportion of pathologically confirmed, clinically significant lesions (22/29, 76%) was detected. IAB2M PET/CT was also able to identify 14/19 (74%) extraprostatic lesions. The performance of mpMRI was inferior, with 24/48 detectable lesions (50%) and 18/29 clinically significant intraprostatic lesions (62%). Compared to the current standard (mpMRI), IAB2M PET/CT had a sensitivity of 88%, specificity 38%, positive predictive value 58%, and accuracy 63%. In 9 pts who underwent Ga-PSMA-11 as well, the latter yielded a detection rate of 70% (14/20), which was also seen in clinically significant lesions (10/14, 71%). Ga-PSMA-11 PET/CT also detected 4/6 (67%) extraprostatic lesions.

CONCLUSIONS

In this pilot study, the performance of ⁸⁹ Zr-df-IAB2M was superior to mpMRI and similar to ⁶⁸ Ga-PSMA-11 PET/CT. The higher detection rate of PSMA-PET supports its use as a diagnostic tool with consequent management change implications in men with localized PCa.

Transrectal Ultrasound-Guided Biopsy Should Continue to Be a Standard of Care for The Detection of Prostate Cancer

For men choosing to screen for prostate cancer (PCa), biopsy remains critical for diagnosis. While transrectal ultrasound-guided (TRUS) biopsy has been the standard of care for many years, recent concerns regarding post-procedural infection have led to increased interest in prostatic sampling via the transperineal (TP) approach. However, TRUS biopsy features important patient-related and physician/practice-related advantages compared to the TP method, and there are several useful strategies to effectively mitigate infectious concerns. The benefits associated with TRUS biopsy, particularly patient comfort and efficient clinical workflow, are further accentuated by several key shortcomings associated with switching to the TP approach. Herein, we present an argument in favor of maintaining TRUS biopsy as standard practice, discussing significant topics including infectious complications, practice workflow and cost, cancer detection rates, and patient experience.

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.

Biopsia de próstata, acceso transperineal bajo anestesia local

Objetivo La biopsia de próstata es una ayuda esencial en el diagnóstico de cáncer, siendo el método más utilizado la biopsia transrectal guiada por ultrasonido (TRUS), con una tasa diagnóstica entre el 37% y el 45%, aunque no exenta de complicaciones como infecciones, dolor o sangrado.

El enfoque alternativo y seguro a las biopsias TRUS se encuentra en la biopsia transperineal (BTP), realizada comúnmente bajo anestesia regional o general.

El objetivo de este estudio fue determinar la efectividad de la BTP bajo anestesia local y guía ultrasonográfica transrectal, con el impacto sobre la sensibilidad del estudio y la tasa de readmisión hospitalaria por infección.

Métodos Estudio de cohorte retrospectiva en el que se evaluaron 83 pacientes sometidos a BTP con anestesia local y guía ultrasonográfica transrectal de enero de 2017 a agosto de 2018 en una ciudad intermedia de Colombia. La muestea incluyó todos los hombres mayores de 18 años con datos de historia clínica disponibles para su análisis, así como los reportes histopatológicos de las biopsias. Se excluyeron casos de rebiopsia o con datos insuficientes.

El análisis de datos nominales se realizó mediante la prueba de chi cuadrado, y el de los datos numéricos, con las prubas t de Student o de Mann-Whitney.

Resultados Un total de 83 pacientes, con media de edad de 65 ± 7.9 años fueron sometidos al análisis del estudio histopatológico. Se excluyeron nueve pacientes que no tenían información disponible en el registro clínico sistematizado, ni en historia clínica de formato físico. Se encontró una proporción de positividad y diagnóstico de cáncer de prostata en el 39.7% (33) de los pacientes, distribuidos así: grado de grupo 1 (69.7%; 23); grado de grupo 2 )15.2%; 5); grados de grupos 3 y 4 (3% cada uno de ellos; 2); y grado de grupo 5 (9%; 3). En total, 60% (50) fueron negativos para malignidad y, de estos el 54% (27) tuvo hiperplasia. El antibiótico profiláctico indicado en el 96.7% (80) de los casos fue una cefalosporina de primera generación, administrada en el 15% (12) por vía parenteral preoperatoria. En esta serie de casos, no se documentaron ingresos hospitalarios asociados a infección después del procedimiento.

Conclusiones La biopsia de próstata por vía transperineal es una técnica con rendimiento diagnostico similar al del abordaje transrectal: es segura, rápida, de fácil acceso, con bajo costo y, sobre todo, con un riesgo insignificante de infección y sepsis. Sus beneficios son altamente representativos en un sistema de salud como el de nuestro país, y la BTP facilita el acceso de la población vulnerable del área rural y de ciudades intermedias, en las que no se dispone de un urólogo experto.

Comparing outcomes of transperineal to transrectal prostate biopsies performed under local anaesthesia

Objectives

Patients and methods

Results

Conclusion

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative Effectiveness and Tolerability of Transperineal MRI-Targeted Prostate Biopsy under Local versus Sedation

OBJECTIVES

To assess the prostate cancer diagnostic yield, complications, and costs of transperineal prostate biopsies when performed with local anesthesia versus sedation.

METHODS

Data were prospectively collected for men undergoing transperineal MRI-targeted biopsy at the outpatient clinic and tertiary hospital of a single center between October 2017 to February 2020. These data included demographic, procedural, and pathologic variables and complications. Time-driven activity-based costing was performed to compare procedural costs.

RESULTS

126 men were included. Age, BMI and PSA were similar for local (n = 45) vs sedation (n = 81), all P>0.05. Detection of clinically significant prostate cancer (CSPC) on combined systematic and targeted biopsy was similar for local vs sedation (24% vs 36%; P = 0.2). Local had lower detection on targeted biopsies alone (8.9% vs 25%; P = 0.03). However, fewer targeted cores were obtained per region of interest with local vs sedation (median 3 vs 4 cores; P<0.01). For local vs sedation, the complication rate was 2.6% and 6.1% (P = 0.6). The median visual analog pain score for local vs sedation was 3/10 vs 0/10 (P<0.01). The mean procedure time for local vs sedation was 22.5 vs 17.5 minutes (48.3 minutes when including anesthesia time). Time-driven activity-based costs for local vs sedation were $961.64 vs $2208.16 (P<0.01).

CONCLUSION

Transperineal biopsy with local anesthesia is safe with comparable outcomes to sedation. While the number of cores taken differed, there was no statistical difference in the detection of clinically significant cancer.

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

BACKGROUND

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

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Chronic bacterial prostatitis leading to intrascrotal abscess after transperineal prostate biopsy

Transperineal biopsy is becoming more commonly used, driven by improved detection rates, better complication profile and increasing application of prostate MRI leading to guided biopsy. However, it can still lead to complications such as urinary retention, postoperative pain and erectile dysfunction. There is also a potential for adverse events such as severe infection, abscess and fistula. This article describes a case of an intrascrotal abscess post-transperineal biopsy, which required an orchidectomy.

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

Objective

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

Materials and methods

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

Results

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

Conclusions

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

A non-randomized prospective study on the diagnostic performance of perineal prostatic biopsy, directed via diffusion nuclear resonance, in patients with suspected prostate cancer and previous negative transrectal prostate biopsy

BACKGROUND

A definition of the best strategy is necessary to optimize the follow-up of patients with previous negative transrectal guided ultrasound biopsy (TRUS-GB) and the persistence of raised prostate-specific antigen (PSA).The purpose of this study was to evaluate the prostate cancer (PCa) diagnostic rate of targeted transperineal ultrasound guided biopsy (TPUS-GB) with cognitive multiparametric magnetic resonance imaging (mpMRI) registration with concurrent systematic biopsy in patients with previous negative systematic TRUS-GB and persistently elevated PSA levels.

MATERIALS AND METHODS

In this prospective study conducted at the University Infanta Sofia Hospital from April 2016 to November 2017, patients with one previous negative systematic TRUS-GB and persistently high PSA levels were referred for mpMRI prostate scans. All patients underwent systematic TPUS-GB and those patients with suspicious findings on mpMRI scans, Pirads 3 and 4-5, underwent a subsequent cognitive guidance mpMRI-TPUS-GB.

RESULTS

In total, 71 patients were included in this study. Suspicious findings on mpMRI scans prior to TPUS-GB were found in 50 patients (70.4%). 16 patients were diagnosed with prostate cancer (22.5%), of whom 14 (87.5%) had a mpMRI scan with Pirads 3 or Pirads 4-5. Patients with Pirads 3, 4 or 5 showed negative results in almost all cores taken by concurrent systematic TPUS-GB.

CONCLUSIONS

Cognitive mpMRI-TPUS fusion biopsy is a useful tool to diagnose PCa in patients with previous negative prostate biopsy. The samples obtained from the suspicious areas in the mpMRI detect more cases of intermediate and high risk PCa compared to the samples obtained at random or from non-suspicious areas.

Comparison of diagnostic efficacy between transrectal and transperineal prostate biopsy: A propensity score-matched study

This study compared the diagnostic efficacy of transrectal ultrasound (TRUS)-guided prostate biopsy (TRBx) and transperineal prostate biopsy (TPBx) in patients with suspected prostate cancer (PCa). We enrolled 2962 men who underwent transrectal (n = 1216) or transperineal (n = 1746) systematic 12-core prostate biopsy. Clinical data including age, prostate-specific antigen (PSA) level, and prostate volume (PV) were recorded. To minimize confounding, we performed propensity score-matching analysis. We measured and compared PCa detection rates between TRBx and TPBx, which were stratified by clinical characteristics and Gleason scores. The effects of clinical characteristics on PCa detection rate were assessed by logistic regression. For all patients, TPBx detected a higher proportion of clinically significant PCa (P < 0.001). Logistic regression analyses illustrated that PV had a smaller impact on PCa detection rate of TPBx compared with TRBx. Propensity score-matching analysis showed that the detection rates in TRBx were higher than those in TPBx for patients aged >- 80 years (80.4% vs 56.5%, P = 0.004) and with PSA level 20.1-100.0 ng ml^-1 (80.8% vs 69.1%, P = 0.040). In conclusion, TPBx was associated with a higher detection rate of clinically significant PCa than TRBx was; however, because of the high detection rate at certain ages and PSA levels, biopsy approaches should be optimized according to patents' clinical characteristics.

Identifying prostate cancer and its clinical risk in asymptomatic men using machine learning of high dimensional peripheral blood flow cytometric natural killer cell subset phenotyping data

We demonstrate that prostate cancer can be identified by flow cytometric profiling of blood immune cell subsets. Herein, we profiled natural killer (NK) cell subsets in the blood of 72 asymptomatic men with Prostate-Specific Antigen (PSA) levels < 20 ng ml^-1, of whom 31 had benign disease (no cancer) and 41 had prostate cancer. Statistical and computational methods identified a panel of eight phenotypic features ([Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text]) that, when incorporated into an Ensemble machine learning prediction model, distinguished between the presence of benign prostate disease and prostate cancer. The machine learning model was then adapted to predict the D'Amico Risk Classification using data from 54 patients with prostate cancer and was shown to accurately differentiate between the presence of low-/intermediate-risk disease and high-risk disease without the need for additional clinical data. This simple blood test has the potential to transform prostate cancer diagnostics.

Rethinking prostate cancer screening: could MRI be an alternative screening test?

In the past decade rigorous debate has taken place about population-based screening for prostate cancer. Although screening by serum PSA levels can reduce prostate cancer-specific mortality, it is unclear whether the benefits outweigh the risks of false-positive results and overdiagnosis of insignificant prostate cancer, and it is not recommended for population-based screening. MRI screening for prostate cancer has the potential to be analogous to mammography for breast cancer or low-dose CT for lung cancer. A number of potential barriers and technical challenges need to be overcome in order to implement such a programme. We discuss different approaches to MRI screening that could address these challenges, including abbreviated MRI protocols, targeted MRI screening, longer rescreening intervals and a multi-modal screening pathway. These approaches need further investigation, and we propose a phased stepwise research framework to ensure proper evaluation of the use of a fast MRI examination as a screening test for prostate cancer.

Current techniques of prostate biopsy: an update from past to present

Knowing the demerits of the transrectal ultrasound guided biopsy has led to a shift in the general techniques and technology of the prostate biopsy. In addition, the advances in magnetic resonance imaging (MRI) sensitivity and the evidence from the PROMIS trial about its ability to detect clinically significant tumours encourage urologists and industry to implement MRI-guided targeted biopsy. However, the science is still looking how to improve safety and increase its cancer detection rate (CDR).

Review article: MRI-targeted biopsies for prostate cancer diagnosis and management

PURPOSE

Transrectal ultrasound (TRUS)-guided biopsy has been the traditional biopsy route in the detection of prostate cancer. However, due to concern regarding overdetection of low-risk cancer and missed clinically significant cancers as well as risk of sepsis, alternative approaches have been explored. Transperineal template biopsy-sampling the gland every 5 m to 10 mm-reduces error by sampling the whole prostate but increases risk of detecting clinically insignificant cancers as well as conferring risks of side effects such as urinary retention and bleeding.

METHODS

There are various targeted biopsy techniques, each with different cancer detection rates, costs and learning curves. Current research focuses on refining biopsy methodology to maximize detection of significant cancers, whilst minimising invasiveness and complications. In this article, the up-to-date research data about MRI-targeted prostate biopsy were reviewed to show its utilization in prostate cancer management and diagnosis.

RESULTS AND CONCLUSION

Prostate multiparametric MRI has become an effective tool in the detection of significant cancers and an essential component of the prostate cancer diagnostic pathway incorporating MRI-guided biopsy decisions.

Infectious complications of prostate biopsy: winning battles but not war

BACKGROUND

Prostate biopsy is a standard tool for diagnosing prostate cancer, with more than 4 million procedures performed worldwide each year. Infectious complications and economic burden are reportedly rising with continued use of trans-rectal ultrasound-guided biopsy, despite the transperineal approach being associated with less infectious complications.

OBJECTIVE AND METHODS

In this review, the contemporary literature on pathophysiology, epidemiology, risk factors, causative organisms and emerging approaches for prevention of infectious complications are outlined.

RESULTS

Management of infectious complications after TRUSB has caused significant financial burden on health systems. The most frequent causative agents of infectious complications after prostate biopsy are Gram-negative bacilli are particularly concerning in the era of antibiotic resistance. Increasing resistance to fluoroquinolones and beta-lactam antibiotics has complicated traditional preventive measures. Patient- and procedure-related risk factors, reported by individual studies, can contribute to infectious complications after prostate biopsy.

CONCLUSIONS

Recent literature shows that the transrectal ultrasound-guided prostate biopsy results in higher infectious complication rate than the transperineal prostate biopsy. NAATs, recently introduced technique to detect FQr may detect all antibiotic-resistant rectal microbiota members-included MDRs-although the technique still has limitations and economical burdens. Transient solutions are escalating antibiotic prophylaxis and widening the indications for TPB.

Stereotactic robot-assisted transperineal prostate biopsy under local anaesthesia and sedation: moving robotic biopsy from operating theatre to clinic

This IRB-approved prospective pilot study evaluates the safety and feasibility of performing stereotactic robot-assisted transperineal MRI-US fusion targeted prostate biopsy under local anaesthesia (LA) with sedation. 30 patients who underwent robotic transperineal prostate biopsy between September 2017 and June 2018 were recruited. All biopsies were performed with the iSR'obot Mona Lisa^® and BK3000 ultrasound system. Intravenous paracetamol 1 g, with midazolam and fentanyl were given at positioning. After administration of 5 mL of 1%-lidocaine into the perineal skin 2 cm above and lateral to the anus, periapical prostatic block with 10 mL mixture of 1%-Lidocaine and 0.5%-Marcaine was given. The median age of patients was 66 years (range 53-80 years). Median PSA and mean prostate volume were 8.1 ng/ml (range 4.2-20.6 ng/ml) and 40.1 cc (range 18.6-70 cc). 24 (80.0%) patients had targeted prostate biopsy, with median number of targeted cores of 8 (range 5-16). All patients had saturation biopsy and median number of saturation cores was 21 (range 9-48). Mean dose of intravenous midazolam given was 1.5 mg (range 0-5 mg) and intravenous fentanyl was 75 mcg (10-150 mcg). No patient required conversion to GA. Two patients required motion compensation of 3 mm and 7.5 mm, respectively, due minor movement. Immediate post-operative pain score was 0 for all patients. 29 of 30 patients (96.7%) were discharged within 24 h of procedure. There were no immediate severe complications. Adenocarcinoma was detected in 19/30 (63.3%) cases. This pilot feasibility study showed that stereotactic robotic transperineal MRI-US fusion targeted prostate biopsy can be safely and accurately performed under LA with sedation.

Surface-projection-based transperineal cognitive fusion targeted biopsy of the prostate: an original technique with a good cancer detection rate

Background

To report a new standardized cognitive fusion technique on transperineal targeted biopsy (TB) of prostate, and to evaluate its efficacy for cancer detection combined with systematic biopsy (SB) .

Methods

We present a retrospective review of consecutive patients undergoing multiparametric magnetic resonance (mpMRI) imaging of the prostate with subsequent transperineal prostate biopsy from January 2016 to December 2018. A free-hand 12-core SB was performed for each patient. PI-RADS 3–5 lesions were further targeted for biopsy with our TB technique. Firstly, a central point of suspicious lesion (B′) was registered cognitively on a transverse section of transrectal ultrasound (TRUS). Then, biopsy gun punctured vertically through a fixed pioneer site (A) on skin of perineum, and deep into the TRUS section to get A’. Next, targeted site (B), the surface-projection of B′, would be determined on skin of perineum by A and distance from B′ to A’. Finally, puncture through B to reach B′. Pathological findings of SB and TB were analyzed.

Results

A total of 126 patients underwent transperineal prostate biopsy (47 SB only, 79 SB + TB). The age of the patients was 68.7 ± 9.2 years. The median preoperative PSA value was 11.8 ng/mL. Preoperative prostate volume was 60.5 ± 50.0 mL. The numbers of patients with PI-RADS scores of 1 through 5 were 4, 43, 27, 21 and 31, respectively. The overall detection rate of cancer was 61/126 (48.4%), and it was significantly higher in the combination cohort (56/79, 70.9%) compared with the SB only cohort (5/47, 10.6%, p<0.001). When focused on the combination cohort, TB detected a similar overall rate of PCa (53/79, 67.1% vs 52/79, 65.8%; p = 0.87) compared with SB. The clinically significant PCa (csPC) detection rate was 52/79 (65.8%), while for TB and SB the csPC/PC rate was 51/53 (96.2%) and 48/52 (92.3%), respectively(p = 0.44). TB demonstrated a better sampling performance (positive rate for each core) compared with SB (51.0% vs 31.3%, p < 0.001).

Conclusions

Surface-projection-based transperineal cognitive fusion targeted biopsy of the prostate has a good efficacy in detecting PCa.

Transperineal prostate biopsy with cognitive magnetic resonance imaging/biplanar ultrasound fusion: description of technique and early results

OBJECTIVE

To describe our technique and early results performing transperineal prostate biopsy using cognitive magnetic resonance imaging (MRI)/biplanar ultrasound fusion. Key components of this technique include use of the PrecisionPoint Transperineal Access System (Perineologic, Cumberland, MD) and simultaneous transrectal ultrasound guidance in the axial and sagittal planes.

PATIENTS AND METHODS

In total, 95 patients (38 studied retrospectively and 57 studied prospectively) underwent a transperineal MRI-targeted prostate biopsy using the technique detailed in this manuscript. All biopsies were performed by a single urologist (MAG). Data were collected with respect to cancer detection rates, tolerability, and complications. The subset of patients who were studied prospectively was assessed for complications by telephone interviews performed at 4-6 days and 25-31 days following the prostate biopsy.

RESULTS

Between February 2018 and June 2019, 95 men underwent a transperineal prostate biopsy using MRI/biplanar ultrasound fusion guidance. Patients had a total of 124 PI-RADS 3-5 lesions that were targeted for biopsy. In total, 108 (87.1%) lesions were found to harbor prostate cancer of any grade. Grade group ≥ 2 prostate cancer was found in 81 (65.3%) of targeted lesions. The detection rates for grade group ≥ 1 and grade group ≥ 2 prostate cancer rose with increasing PI-RADS score. In 65 (68.4%) cases, the patient's highest grade prostate cancer was found within an MRI target. Additionally, 12 of 55 (21.8%) patients who were found to have no or grade group 1 prostate cancer on systematic biopsy were upgraded to grade group ≥ 2 prostate cancer with MRI targeting. Only 1 (1.1%) patient received periprocedural antibiotics and no patient experienced an infectious complication. Self-limited hematuria and hematospermia were commonly reported following the procedure (75.4% and 40.4%, respectively) and only 1 (1.1%) patient developed urinary retention.

CONCLUSIONS

We demonstrate the safety and feasibility of performing transperineal prostate biopsy using cognitive MRI/biplanar ultrasound fusion guidance. The described technique affords the safety benefits of the transperineal approach as well as obviates the need for a formal fusion platform. Additionally, this method can conveniently be performed under local anesthesia with acceptable tolerability.

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.

IDEAL Stage 2a experience with in-office, transperineal MRI/ultrasound software fusion targeted prostate biopsy

Objective

Although the feasibility of transperineal biopsy under local anesthesia has been demonstrated, little is known regarding the application of MRI/ultrasound software fusion targeted biopsy for transperineal biopsy under local anesthesia. The objective of our study is to describe our initial experience with in-office transperineal MRI/ultrasound software fusion targeted biopsy (Idea, Development, Exploration, Assessment, Long-term Follow-up [IDEAL] Stage 2a).

Methods

Between October 2017 and July 2019, 33 men underwent in-office transperineal MRI-targeted biopsy using the Artemis (Eigen, Grass Valley, CA, USA) fixed-robotic arm system. The indication for biopsy was elevated prostate specific antigen (PSA) (n=14), prior negative biopsy (n=10), active surveillance (n=6), and surveillance after partial gland cryoablation (n=3). We prospectively captured patient demographic and clinical characteristics, biopsy outcomes, and complications. Complications were classified according to Common Terminology Criteria for Adverse Events (CTCAE) V.5.0.

Results

The median patient age was 67 years (IQR 61–71) and the median serum PSA level was 7.0 ng/mL (IQR 5.1–11.4). The median duration of in-office MRI-targeted transperineal biopsy was 26 min (IQR 23–28). Overall, transperineal MRI-targeted biopsy detected prostate cancer in 18 (54.6%) men, with 8 (24.2%) being clinically significant (Gleason Score ≥3+4, Grade Group ≥2). Clinically significant prostate cancer was detected in four (28.6%) biopsy naïve men, two (20.0%) men with a prior negative, one (16.7%) man on active surveillance and one (33.3%) man following partial gland ablation. Three (9.1%) men experienced complications: two hematuria and one urinary retention.

Conclusion

Our findings demonstrate the feasibility of the fixed-robotic arm fusion platform for in-office transperineal MRI-targeted biopsy and a low rate of adverse events. However, larger prostate size precludes MRI/ultrasound software fusion and pubic arch interference hindered the transperineal MRI-targeted approach in 9.1% of men. Pubic arch interference was overcome by a free-hand approach with software fusion guidance.

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.

Location and Grade of Prostate Cancer Diagnosed by Transperineal Template-guided Mapping Biopsy After Negative Transrectal Ultrasound-guided Biopsy

OBJECTIVES

To determine the location and grade of prostate cancer diagnosed by transperineal template-guided mapping (TTMB) after negative transrectal ultrasound-guided (TRUS) biopsy.

MATERIALS AND METHODS

This analysis consisted of 1118 consecutive patients who underwent TTMB from January 2005 to August 2015. Eight hundred thirty-five underwent TTMB after at least 1 negative TRUS biopsy and 283 underwent TTMB as the first biopsy procedure. The study population was divided into cohorts based on the number of prior TRUS biopsy sessions (0, 1, 2, and ≥3). No patient underwent multiparametric magnetic resonance imaging. Differences in location and cancer grade detected on TTMB were evaluated as a function of the number of prior TRUS biopsies.

RESULTS

Of the 1118 patients, 679 were diagnosed with prostate cancer. This included 208, 325, 104, and 42 patients who underwent 0, 1, 2, and ≥3 prior TRUS biopsies. The incidence of cancer detection on TTMB decreased as the number of prior TRUS biopsies increased (73.5% vs. 62.4% vs. 51.7% vs. 37.2%, P<0.001); however, it became increasingly likely that TTMB would detect anterior prostate only as the number of prior TRUS biopsies increased (P=0.007). Moreover, the incidence of high grade cancer (Gleason score ≥7) in the anterior gland increased with the number of previous TRUS biopsies.

CONCLUSIONS

TTMB detected prostate cancer in over half of the patients with one or more negative TRUS biopsies. The majority of TTMB detected cancers were Gleason score ≥7. As the number of prior TRUS biopsies increased, there was a commensurate increase in the proportion of high-grade, anterior only disease.

Prostate biopsy: when and how to perform

Prostate cancer, unlike other cancers, has been sampled in a non-targeted, systematic manner in the past three decades. On account of the low volume of prostate sampled despite the multiple cores acquired, systematic transrectal (TRUS) biopsy suffered from low sensitivity in picking up clinically significant prostate cancer. In addition, a significant number of cancers of the anterior, lateral peripheral zone, and the apex were missed as these areas were undersampled or missed during this biopsy protocol. Subsequently, the number of cores acquired was increased with special focus given to targeting the previously undersampled areas. These procedures led to an increase in the complication rates as well as detection of more clinically insignificant cancers. The advent of multiparametric magnetic resonance imaging (MRI) and its high intrinsic tissue contrast enabled better detection of prostate cancer. This led to the introduction of MRI-targeted biopsies with either MRI-TRUS fusion or under direct (in-gantry) guidance. MRI-targeted biopsies increased the percentage of positive cores and detection of clinically significant prostate cancers; however, these are expensive, time-intensive, require significant capital investment and operator expertise. This article describes the indications, workflow, complications, advantages, and disadvantages of TRUS-guided biopsy followed by MRI-guided biopsies.

Developing a five-step training model for transperineal prostate biopsies in a naïve residents' group: a prospective observational randomised study of two different techniques

PURPOSE

To evaluate a five-step training model for transperineal prostate biopsies (TPPB) and the differences in terms of the detection rate (DR) and the ease of execution when using either the "fan technique" (FT) or the use of a Free Hand technique (FH).

METHODS

A prospective observational randomised study was conducted from September 2015 to November 2017. Six naïve residents, who underwent the same five-steps training model, were randomly subdivided into two different groups of three residents based on the selected TPPB technique: A (FT) and B (FH). Patient characteristics (age, PSA, prostatic volume, DRE, MRI), intraoperative (operative time, number of samples) and postoperative parameters (histologic, pain) were evaluated in the 2 groups. The overall and stratified DR for PSA ranges and prostate volume (PV), operative time and complications were compared.

RESULTS

The overall detection rate was very high in both groups (FT 58.2% vs FH 59.6%) and not statistically different between the two techniques. There were no differences in terms of complication rates and pain. The FH showed a better detection rate in prostates smaller than 40 cc (p = 0.023) and a faster operative time (p = 0.025) compared to FT.

CONCLUSIONS

Within the TPPB, FH is associated with a higher detection rate in patients with prostate < 40 cc compared to an FT when performed by inexperienced trainees. Standardised training organised in consecutive steps seems to contribute to the achievement of overall high detection rates with both methods.

The transverse and vertical distribution of prostate cancer in biopsy and radical prostatectomy specimens

Background

Prostate biopsy is the most common method for the diagnosis of prostate cancer and the basis for further treatment. Confirmation using radical prostatectomy specimens is the most reliable method for verifying the accuracy of template-guided transperineal prostate biopsy. The study aimed to reveal the spatial distribution of prostate cancer in template-guided transperineal saturation biopsy and radical prostatectomy specimens.

Methods

Between December 2012 to December 2016, 171 patients were diagnosed with prostate cancer via template-guided transperineal prostate biopsy and subsequently underwent laparoscopic radical prostatectomy. The spatial distributions of prostate cancer were analyzed and the consistency of the tumor distribution between biopsy and radical prostatectomy specimens were compared.

Results

The positive rate of biopsy in the apex region was significantly higher than that of the other biopsy regions (43% vs 28%, P < 0.01). In radical prostatectomy specimens, the positive rate was highest at the region 0.9–1.3 cm above the apex, and it had a tendency to decrease towards the base. There was a significant difference in the positive rate between the cephalic and caudal half of the prostate (68% vs 99%, P < 0.01). There were no significant differences between the anterior and posterior zones for either biopsy or radical prostatectomy specimens.

Conclusion

The tumor spatial distribution generated by template-guided transperineal prostate biopsy was consistent with that of radical prostatectomy specimens in general. The positive rate was consistent between anterior and posterior zones. The caudal half of the prostate, especially the vicinity of the apex, was the frequently occurred site of the tumor.

Diagnostic accuracy of magnetic resonance-guided prostate biopsy and template-guided transperineal saturation biopsy

To compare the accuracy of magnetic resonance-guided prostate biopsy (MR-GPB) and template-guided transperineal prostate saturation biopsy (TTPSB).A total of 219 patients with elevated prostate-specific antigen, abnormal digital rectal examination or ultrasound findings were enrolled. All patients underwent multiparametric magnetic resonance image (mpMRI). Patients with a Prostate Imaging Reporting and Data System (PI-RADS) score of 3 to 5 underwent MR-GPB using 2 to 5 biopsy cores and then immediately underwent an 11-region TTPSB. Patients with a PI-RADS score of 1 to 2 underwent TTPSB alone. We compared the detection rates for any cancer, clinically significant prostate cancer (csPCA), and the spatial distribution of missed csPCA lesions.Among the 219 cases, 66 (30.1%) had a PI-RADS score of 1 to 2 on mpMRI. The detection rate of TTPSB in these patients was 9.1% (6/66). In total, detection rates for any cancer and csPCA were 48.9% (107/219) and 42.9% (94/219), respectively. Detection rates for any cancer (TTPSB 87/219, 39.7%; MR-GPB76/219, 34.7%, P = .161) and csPCA (TTPSB 76/219, 34.7%; MR-GPB 72/219, 32.9%, P = .636) did not significantly differ between the 2 groups. The csPCA lesions missed by MR-GPB were most commonly located on the left (8.5%, 8/94) and right (9.6%, 9/94) sides of the urethra.MR-GPB can reduce the rate of unnecessary prostate biopsies by approximately 30% and exhibits an efficacy comparable to TTPSB for the detection of any cancer and csPCA. Nevertheless, approximately 1/4 of csPCAs were missed by MR-GPB and were most commonly located on both sides of the urethra.

Antibiotic susceptibility of intestinal Escherichia coli in men undergoing transrectal prostate biopsies: a prospective, registered, multicentre study

OBJECTIVES

To determine, in a prospective, multicentre setting, the prevalence of fluoroquinolone-resistant (FQ-R) and extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli) strains in men undergoing transrectal ultrasonography-guided prostate biopsy (TRUS-Bx) in Finland; and to survey the associated risk factors for having the previously mentioned strains.

PATIENTS AND METHODS

This is a substudy of the trial investigating the role of magnetic resonance imaging (MRI) in prostate cancer diagnosis (Improved Prostate Cancer Diagnosis - Combination of Magnetic Resonance Imaging Targeted Biopsies and Biomarkers Multi-institutional Study [multi-IMPROD], NCT02241122). In all, 359 patients from four study centres were recruited to this prospective study. After having signed the informed consent form, these men with suspicion of prostate cancer completed a detailed questionnaire on their medical, smoking, and travelling history, as well as their recent use of antibiotics. After the bi-parametric MRI scan, TRUS-Bx was taken and a rectal swab sample was collected and cultured for determining the antimicrobial susceptibility profile of E. coli strains. The potential risk factors for having FQ-R or third-generation cephalosporin-resistant (3GC-R) E. coli strains were analysed using univariate and multivariate logistic regression analysis.

RESULTS

The percentage of FQ-R and 3GC-R E. coli strains amongst the study population was 13% and 8%, respectively. Amongst patients having E. coli strains, the rate of FQ-R and 3GC-R strains was 14% and 8%, respectively. Of the 3GC-R E. coli strains, 62% proved to be ESBL-producers and 88% were also FQ-R. In multivariate analysis, international travel during the preceding year significantly increased the risk of having a FQ-R E. coli strain (odds ratio [OR] 3.592, P = 0.001) and, unexpectedly, use of antibiotics during the previous year significantly decreased this risk (OR 0.442, P = 0.035). No significant risk factors for having 3GC-R E. coli were identified.

CONCLUSION

The occurrence of intestinal FQ-R and/or 3GC-R (potentially ESBL-producing) E. coli strains in men undergoing TRUS-Bx in Finland is notable. The finding is consistent with the global increase in antimicrobial resistance. International travel appears to be an indisputable risk factor for having intestinal FQ-R E. coli strains. The contemporary antimicrobial resistance situation should be taken into account in the care of post-TRUS-Bx infections.

Handling and reporting of transperineal template prostate biopsy in Europe: a web-based survey by the European Network of Uropathology (ENUP)

Transperineal template prostate biopsies (TTPB) are performed for assessments after unexpected negative transrectal ultrasound biopsies (TRUSB), correlation with imaging findings and during active surveillance. The impact of TTPBs on pathology has not been analysed. The European Network of Uropathology (ENUP) distributed a survey on TTPB, including how specimens were received, processed and analysed. Two hundred forty-four replies were received from 22 countries with TTPBs seen by 68.4% of the responders (n = 167). Biopsies were received in more than 12 pots in 35.2%. The number of cores embedded per cassette varied between 1 (39.5%) and 3 or more (39.5%). Three levels were cut in 48.3%, between 2 and 3 serial sections in 57.2% and unstained spare sections in 45.1%. No statistical difference was observed with TRUSB management. The number of positive cores was always reported and the majority gave extent per core (82.3%), per region (67.1%) and greatest involvement per core (69.4%). Total involvement in the whole series and continuous/discontinuous infiltrates were reported in 42.2 and 45.4%, respectively. The majority (79.4%) reported Gleason score in each site or core, and 59.6% gave an overall score. A minority (28.5%) provided a map or a diagram. For 19%, TTPB had adversely affected laboratory workload with only 27% managing to negotiate extra costs. Most laboratories process samples thoroughly and report TTPB similarly to TRUSB. Although TTPB have caused considerable extra work, it remains uncosted in most centres. Guidance is needed for workload impact and minimum standards of processing if TTPB work continues to increase.

Patient experience after transperineal template prostate biopsy compared to prior transrectal ultrasound guided prostate biopsy

Introduction

Transperineal template prostate biopsy (TTPB) is reported to have higher cancer detection and lower complication rate compared to transrectal ultrasound guided prostate biopsy (TRUSPB).

However, there is no report of the same patient's experience with both types of biopsy.

To compare the patient reported experience in the same cohort of patients who underwent both TRUSPB and TTPB, using validated questionnaires.

Material and methods

We retrospectively utilised the Patient Reported Outcome Methods (PROM) tool validated for TRUSPB and the International Index of Erectile Function (IIEF-5) questionnaire to collect longitudinal data at follow-up in the same cohort of patients who underwent both TTPB and TRUSPB between January 2015 and February 2016.

RESULTS

Out of 44 TTPB performed during the period, 35 patients had undergone both TRUSPB and TTPB. Patient reported pain post biopsy was significantly higher with TRUSPB (86% vs. 61%; p = 0.01). Post-biopsy urinary retention rates were significantly higher in the TTPB group (16.7% vs. 5.7%; p = 0.05, t test). Furthermore, the incidence of patient reported sexual dysfunction rates based on the IIEF-5 was significantly higher in the TTPB group (p = 0.001, t test).

Conclusions

Although overall TTPB was better tolerated in this cohort of patients with lower risk of health care contact, patients reported higher incidence of urinary retention and sexual dysfunction after TTPB compared to TRUSPB. Thus, patients should be adequately informed about potential risks with each biopsy as they may have significant impact on quality of life.

Pathologic correlation of transperineal in-bore 3-Tesla magnetic resonance imaging-guided prostate biopsy samples with radical prostatectomy specimen

PURPOSE

To determine the accuracy of in-bore transperineal 3-Tesla (T) magnetic resonance (MR) imaging-guided prostate biopsies for predicting final Gleason grades in patients who subsequently underwent radical prostatectomy (RP).

METHODS

A retrospective review of men who underwent transperineal MR imaging-guided prostate biopsy (tpMRGB) with subsequent radical prostatectomy within 1 year was conducted from 2010 to 2015. All patients underwent a baseline 3-T multiparametric MRI (mpMRI) with endorectal coil and were selected for biopsy based on MR findings of a suspicious prostate lesion and high degree of clinical suspicion for cancer. Spearman correlation was performed to assess concordance between tpMRGB and final RP pathology among patients with and without previous transrectal ultrasound (TRUS)-guided biopsies.

RESULTS

A total of 24 men met all eligibility requirements, with a median age of 65 years (interquartile range [IQR] 11.7). The median time from biopsy to RP was 85 days (IQR 50.5). Final pathology revealed Gleason 3 + 4 = 7 in 12 patients, 4 + 3 = 7 in 10 patients, and 4 + 4 = 8 in 2 patients. A strong correlation (ρ: +0.75, p < 0.001) between tpMRGB and RP results was observed, with Gleason scores concordant in 17 cases (71%). 16 of the 24 patients underwent prior TRUS biopsies. Subsequent tpMRGB revealed Gleason upgrading in 88% of cases, which was concordant with RP Gleason scores in 69% of cases (ρ: +0.75, p < 0.001).

CONCLUSION

Final Gleason scores diagnosed by tpMRGB at 3-T correlate strongly with final RP surgical pathology. This may facilitate prostate cancer diagnosis, particularly in patients with negative or low-grade TRUS biopsy results in whom clinically significant cancer is suspected or detected on mpMRI.