Transperineal template-guided saturation biopsy using a modified technique: outcome of 270 cases requiring repeat prostate biopsy

Are systematic prostate biopsy still necessary in biopsy naive men?

PURPOSE

Multiparametric MRI and the transperineal approach have become standard in the diagnostic pathway for suspected prostate cancer. Targeting of MRI lesions is performed at most centers, but the routine use of systematic cores is controversial. We aim to assess the value of obtaining systematic cores in patients undergoing cognitive fusion targeted double-freehand transperineal prostate biopsy.

MATERIALS AND METHODS

Patients who underwent a cognitive fusion, freehand TPB at a single tertiary urology service (Perth, Australia) between November 2020 and November 2021 were retrospectively reviewed. Patients were included if they were biopsy naive and had a clinical suspicion of prostate cancer, based on their mpMRI results. Both targeted and systematic cores were taken at the time of their biopsy.

RESULTS

One hundred forty patients suited the selection criteria. Clinically significant cancer was identified in 63% of patients. Of those that had clinically significant cancer, the target lesion identified 91% of the disease, missing 9% of patients whom the target biopsy detected non-clinically significant cancer but was identified in the systematic cores. Higher PI-RADS category patients were also found to be associated with an increasing likelihood of identifying clinically significant cancer within the target.

CONCLUSIONS

In patients with PI-RADS 3 and higher, the target biopsy can miss up to 9% of clinically significant cancer. Systematic cores can add value as they can also change management by identifying a high-risk disease where only intermediate cancer was identified in the target. A combination of targeted and systematic cores is still required to detect cancer.

Do alpha blockers reduce the risk of urinary retention post-transperineal prostate biopsy? A systematic narrative review

BACKGROUND

Transperineal Prostate Biopsy (TPB) is a commonly used technique for the diagnosis of prostate cancer due to growing concerns related to infectious complications associated with transrectal ultrasound-guided prostate biopsy (TRUSB). TPB is associated with an infective complication rate of near zero, however, acute urinary retention (AUR) remains the leading complication causing morbidity. Previously in TRUSB, there was weak evidence that alpha-blockers reduce AUR rates, and their usage has been extrapolated to clinical practice with TPB. This review aims to explore if there is an evidence base for using alpha-blockers to prevent AUR following TPB.

METHODS

A systematic approach was used to search Ovid Medline and Embase using keywords related to "Transperineal" and "Retention". Articles were then screened by applying inclusion and exclusion criteria to find studies that compared alpha-blocker recipients to no alpha-blocker use in the perioperative period and the subsequent effect on AUR in TPB.

RESULTS

361 records were identified in the initial search to produce 5 studies included in the final review. No randomised controlled trials (RCTs) were identified. One observational study showed a reduction in AUR rate from 12.5% to 5.3% with a single dose of tamsulosin. A previous systematic review of complications associated with prostate biopsy concluded there may be a potential benefit to alpha-blockers given in the TPB perioperative period. Three observational studies demonstrated a harmful effect related to alpha-blocker use; however, this was well explained by their clear limitations.

CONCLUSION

Based on this review and the extrapolation from TRUSB data, perioperative alpha-blockers may offer some weak benefits in preventing AUR following TPB. However, there is significant scope and need for an RCT to further develop the evidence base further given the significant gap in the literature and lack of a standard alpha blocker protocol in TPB.

Prostate biopsy approach and complication rates

Prostate biopsy is the gold standard to confirm prostate cancer. In addition to standard 12-core biopsies, magnetic resonance imaging (MRI)-guided prostate biopsies have recently been introduced to improve the detection of clinically significant prostate cancer. The present study aimed to compare the complications after standard transrectal ultrasound-guided and standard plus targeted (MRI-guided) prostate biopsies, to study the impact of the number of biopsy cores on complication rates, and to compare complication rates after transrectal ultrasound-guided prostate biopsies with those following transperineal prostate biopsies from the literature. A prospective study was performed, which included 135 patients who underwent transrectal ultrasound-guided prostate biopsies between April 1 and June 30, 2022, at the Urology Department of the University Hospital of Pointe à Pitre (Pointe à Pitre, Guadeloupe). A total of 51 patients were excluded because of missing information concerning their post-biopsy surveillance. The median age at the time of biopsy was 69 years, median prostate-specific antigen value was 8.9 ng/ml, median prostate volume was 57.5 ml, and median number of cores was 15. A total of 35 of the 84 included patients (41.7%) had a standard biopsy only and 49 (58.3%) had targeted (MRI-guided) plus standard biopsies. A total of 53 patients (63.1%) experienced early side effects, whereas only 24 patients (28.6%) experienced late side effects. Three patients (3.6%) required hospitalization for post-biopsy complications. Early side effects, especially hematuria and hematospermia, occurred significantly more frequently in the targeted plus standard group, with more cores taken, with no significant difference concerning late side effects or infectious complications between the standard and standard plus targeted groups. The admission rate for sepsis after transperineal biopsy has been reported to vary between 0 and 1%, whereas the present study had an admission rate of 2.29% using the transrectal approach. Further studies are required to analyze the complications requiring hospitalization after transrectal and transperineal biopsies.

Factors affecting the selection of eligible candidates for focal therapy for prostate cancer

PURPOSE

Focal therapy (FT) is a treatment modality for prostate cancer that aims to reduce side effects. However, it remains difficult to select eligible candidates. We herein examined eligibility factors for hemi-ablative FT for prostate cancer.

METHODS

We identified 412 patients who were diagnosed with unilateral prostate cancer by biopsy and had undergone radical prostatectomy between 2009 and 2018. Among these patients, 111 underwent MRI before biopsy, had 10-20 core biopsies performed, and did not receive other treatments before surgery. Fifty-seven patients with prostate-specific antigen ≥ 15 ng/mL and biopsy Gleason score (GS) ≥ 4 + 3 were excluded. The remaining 54 patients were evaluated. Both lobes of the prostate were scored using Prostate Imaging Reporting and Data System version 2 on MRI. Ineligible patients for FT were defined as those with ≥ 0.5 mL GS6 or GS ≥ 3 + 4 in the biopsy-negative lobe, ≥ pT3, or lymph node involvement. Selected predictors of eligibility for hemi-ablative FT were analyzed.

RESULTS

Among our cohort of 54 patients, 29 (53.7%) were eligible for hemi-ablative FT. A multivariate analysis identified a PI-RADS score < 3 in the biopsy-negative lobe (p = 0.016) as an independent predictor of eligibility for FT. Thirteen out of 25 ineligible patients had GS ≥ 3 + 4 tumors in the biopsy-negative lobe, half of whom (6/13) also had a PI-RADS score < 3 in the biopsy-negative lobe.

CONCLUSION

The PI-RADS score in the biopsy-negative lobe may be important in the selection of eligible candidates for FT. The findings of this study will help reduce missed significant prostate cancers and improve FT outcomes.

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

CONTEXT

Transperineal prostate biopsy is associated with a significantly lower risk of infectious complications than the transrectal approach. In fact, the risk of infectious complications with transperineal prostate biopsy is so low that the utility of administering periprocedural antibiotics with this procedure has come under question.

OBJECTIVE

To perform a systematic review and meta-analysis to assess for differences in the rates of infectious complications (septic, nonseptic, and overall) after performing transperineal prostate biopsy with and without the administration of periprocedural antibiotic prophylaxis.

EVIDENCE ACQUISITION

Three electronic databases (PubMed, Embase, and MEDLINE) were searched, and studies were included if they included patients who underwent transperineal prostate biopsy, were published after January 2000, included information on periprocedural antibiotic administration, and reported postbiopsy complications. Preferred Reporting Items for Systematic Reviews and Meta-analyses and Agency for Healthcare Research and Quality guidelines were utilized.

EVIDENCE SYNTHESIS

A total of 106 unique studies describing 112 cohorts of patients were identified, of which 98 (37 805 men) received antibiotic prophylaxis and 14 (4772 men) did not receive it. All patients were included in the analysis of septic complications. In total, there were 19/37 805 (0.05%) episodes of sepsis in the group of men who received antibiotics, which was similar to the no antibiotic group with 4/4772 (0.08%) episodes (p = 0.2). For overall infections (septic plus nonseptic), there were 403/29 880 (1.35%) versus 58/4772 (1.22%) events among men with evaluable data who received and did not receive antibiotic prophylaxis, respectively (p = 0.8). Restricting our analysis to studies with a comparable low number of biopsy cores (<25 cores), there remained no difference in the rates of sepsis between groups, but there was a small, statistically significant lower risk of infectious complications with antibiotic administration-67/12 140 (0.55%) versus 58/4772 (1.22%; p < 0.01).

CONCLUSIONS

The likelihood of septic infections after transperineal prostate biopsy is low with and without antibiotic prophylaxis. The omission of periprocedural antibiotics with this procedure stands to benefit patients by avoiding potential drug reactions. Furthermore, this practice is in line with calls throughout the medical community for improved antibiotic stewardship.

PATIENT SUMMARY

In a large systematic review and meta-analysis, we evaluated infectious complications after transperineal prostate biopsy with or without the administration of prophylactic antibiotics. We conclude that prophylactic antibiotics do not decrease the rate of postbiopsy sepsis but may have a small benefit in terms of preventing less serious infections.

Targeted and systematic cognitive freehand-guided transperineal biopsy: is there still a role for systematic biopsy?

OBJECTIVES

To assess whether targeted cognitive freehand-assisted transperineal biopsies using a Precisionpoint^TM device still require additional systematic biopsies to avoid missing clinically significant prostate cancer, and to investigate the benefit of a quadrant-only biopsy approach to analyse whether a quadrant or extended target of the quadrant containing the target only would have been equivalent to systematic biopsy.

PATIENTS AND METHODS

Patients underwent combined systematic mapping and targeted transperineal prostate biopsies at a single institution. Biopsies were performed using the Precisionpoint device (Perineologic, Cumberland, MD, USA) under either local anaesthetic (58%, 163/282), i.v. sedation (12%, 34/282) or general anaesthetic (30%, 85/282). A mean (range) of 24 (5-42) systematic and 4.2 (1-11) target cores were obtained. Magnetic resonance imaging (MRI) scans were reported using the Likert scale. Clinically significant cancer was defined as Gleason 7 or above. Histopathological results were correlated with the presence of an MRI abnormality within a spatial quadrant and the other adjoining or non-adjoining (opposite) quadrants. Histological concordance with radical prostatectomy specimens was analysed.

RESULTS

A total of 282 patients were included in this study. Their mean (range) age was 66.8 (36-80) years, median (range) prostate-specific antigen level 7.4 (0.91-116) ng/mL and mean prostate volume 45.8 (13-150) mL. In this cohort, 82% of cases (230/282) were primary biopsies and 18% (52/282) were patients on surveillance. In all, 69% of biopsies (195/282) were identified to have clinically significant disease (Gleason ≥3 + 4). Any cancer (Gleason ≥3 + 3) was found in 84% (237/282) of patients. Of patients with clinically significant disease, the target biopsies alone picked up 88% (171/195), with systematic biopsy picking up the additional 12% (24/195) that the target biopsies missed. This altered with Likert score; 73% of Likert score 3 disease was detected by target biopsy, 92% of Likert score 4 and 100% of Likert score 5. Target biopsies with additional same-quadrant-only systematic cores picked up 75% (18/24) of significant cancer that was missed on target only, found in the same quadrant as the target.

CONCLUSION

Systematic biopsy is still an important tool when evaluating all patients referred for prostate biopsy, but the need is decreased with increasing suspicion on MRI. Patients with very high suspicion of prostate cancer (Likert score 5) may not require systematic cores, unless representative surrounding biopsies are required for other specific treatments (e.g. focal therapy, or operative planning). More prospective studies are needed to evaluate this in full.

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.

Mullerian duct cyst treated with template-guided transperineal aspiration: a case report and review of the literature

Template-guided transperineal aspiration is a minimally invasive treatment option for patients with Mullerian duct cysts. The precise targeting provided by the brachytherapy template grid enables specific targeting, quick recovery and resolution of symptoms without complications.

Evidenced-based clinical practice guideline for prostate cancer (summary: Japanese Urological Association, 2016 edition)

These guidelines cover a wide range of topics from prostate cancer epidemiology to palliative care. Questions arising in daily clinical practice have been extracted and formulated as clinical questions. In the 4 years since the previous edition, there have been major changes - for example, robot-assisted prostatectomy has rapidly come into widespread use, and new hormones and anticancer drugs have been developed for castration-resistant prostate cancer. In response to these developments, the number of fields included in this guideline was increased from 11 in the 2012 edition to 16, and the number of clinical questions was increased from 63 to 70. The number of papers identified in searches of the existing literature increased from 4662 in the first edition, published in 2006, to 10 490 in the 2012 edition. The number of references has reached 29 448 just during this review period, indicating the exponential increase in research on the topic of prostate cancer. Clinical answers have been prepared based on the latest evidence. Recommendation grades for the clinical answers were determined by radiologists, pathologists, and other specialists in addition to urologists in order to reflect the recent advances and diversity of prostate cancer treatment. Here, we present a short English version of the original guideline, and overview its key clinical issues.

Prevention of infectious complications after prostate biopsy procedure

Although febrile complications are rarely encountered after a prostate biopsy procedure, in recent years the number of cases of fatal infection after that have increased along with increases in resistant bacteria. The available biopsy approaches are transrectal and transperineal, with the transrectal approach primarily used. As the invasion path of the puncture needle differs between these approaches, pretreatment and the method of administration of preventive antimicrobial drugs should be separately considered for infection prevention. Recently, the Japanese guidelines for perioperative infection prevention in the field of urology were revised after receiving approval from the Japanese Urological Association. With use of the transrectal approach, attempts have been made to selectively administer prophylactic antibiotics by confirming the presence or absence of resistant bacteria in rectal swab culture results before carrying out a prostate biopsy procedure because of potential problems associated with resistant bacteria in rectal flora. For preventive antibiotics, a single dose of oral quinolone is recommended for patients with low risk, whereas daily administrations of piperacillin/tazobactam are recommended for those considered to be high risk. In contrast, for the transperineal procedure, a single dose of oral quinolone is recommended as a preventive antibiotic. With both approaches, it is important to empirically administer broad-spectrum antimicrobials when occurrence of a febrile infection after a prostate biopsy procedure is confirmed.

Transperineal template-guided saturation biopsy aimed at sampling one core for each milliliter of prostate volume: 103 cases requiring repeat prostate biopsy

Background

We evaluated the cancer detection rate of prostate cancer using transperineal template-guided saturation biopsy aimed at sampling one core for each milliliter of prostate volume for patients requiring repeated prostate biopsies.

Methods

In total, 103 consecutive patients with repeated prostate biopsies were enrolled in this retrospective study. The number of biopsy cores was defined by prostate volume. In principle, one biopsy core covered 1 mL of prostate volume. We used a prostate brachytherapy template with a 5-mm grid and adopted a transperineal needle biopsy.

Results

The median age, prostate-specific antigen level, and prostate volume were 69 (range, 37–83) years, 9.2 (range, 1.9–107) ng/mL, and 34.7 (range, 18–76.7) mL, respectively. The median number of biopsy cores was 37 (range, 18–75 cores). Fifty-three patients (51.5%) were diagnosed with prostate cancer. The Gleason score was 6, 7, and 8–10 in 24.5, 64.2 and 11.3% patients, respectively. Forty-two patients (79.2%) were diagnosed with clinically significant PCa. Acute urinary retention was detected in 2 patients (1.9%).

Conclusions

Transperineal template-guided saturation biopsy with one core per milliliter of prostate volume helped achieve a high cancer detection rate and high significant cancer detection rate with acceptable biopsy-associated adverse events.

Magnetic Resonance and Ultrasound Image Fusion Supported Transperineal Prostate Biopsy Using the Ginsburg Protocol: Technique, Learning Points, and Biopsy Results

BACKGROUND

Prostate biopsy supported by transperineal image fusion has recently been developed as a new method to the improve accuracy of prostate cancer detection.

OBJECTIVE

To describe the Ginsburg protocol for transperineal prostate biopsy supported by multiparametric magnetic resonance imaging (mpMRI) and transrectal ultrasound (TRUS) image fusion, provide learning points for its application, and report biopsy results. The article is supplemented by a Surgery in Motion video.

DESIGN, SETTING, AND PARTICIPANTS

This single-centre retrospective outcome study included 534 patients from March 2012 to October 2015. A total of 107 had no previous prostate biopsy, 295 had benign TRUS-guided biopsies, and 159 were on active surveillance for low-risk cancer.

SURGICAL PROCEDURE

A Likert scale reported mpMRI for suspicion of cancer from 1 (no suspicion) to 5 (cancer highly likely). Transperineal biopsies were obtained under general anaesthesia using BiopSee fusion software (Medcom, Darmstadt, Germany). All patients had systematic biopsies, two cores from each of 12 anatomic sectors. Likert 3-5 lesions were targeted with a further two cores per lesion.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Any cancer and Gleason score 7-10 cancer on biopsy were noted. Descriptive statistics and positive predictive values (PPVs) and negative predictive values (NPVs) were calculated.

RESULTS AND LIMITATIONS

The detection rate of Gleason score 7-10 cancer was similar across clinical groups. Likert scale 3-5 MRI lesions were reported in 378 (71%) of the patients. Cancer was detected in 249 (66%) and Gleason score 7-10 cancer was noted in 157 (42%) of these patients. PPV for detecting 7-10 cancer was 0.15 for Likert score 3, 0.43 for score 4, and 0.63 for score 5. NPV of Likert 1-2 findings was 0.87 for Gleason score 7-10 and 0.97 for Gleason score ≥4+3=7 cancer. Limitations include lack of data on complications.

CONCLUSIONS

Transperineal prostate biopsy supported by MRI/TRUS image fusion using the Ginsburg protocol yielded high detection rates of Gleason score 7-10 cancer. Because the NPV for excluding Gleason score 7-10 cancer was very high, prostate biopsies may not be needed for all men with elevated prostate-specific antigen values and nonsuspicious mpMRI.

PATIENT SUMMARY

We present our technique to sample (biopsy) the prostate by the transperineal route (the area between the scrotum and the anus) to detect prostate cancer using a fusion of magnetic resonance and ultrasound images to guide the sampling.

Patient-Reported Experience of Modified Transperineal Template Guided Saturation Biopsy Under General Anaesthesia and without Prophylactic Catheterisation

Results of patient feedback questionnaire following transperineal template guided saturation biopsy (TPSB) without prophylactic catheterisation.

INTRODUCTION AND OBJECTIVE

TPSB is increasingly utilised in the diagnosis and characterisation of prostate cancer. However, there is little data on patient experience after undergoing this procedure. We circulated a questionnaire to 511 consecutive patients from July 2007 to December 2014 and now analyse the responses.

MATERIALS AND METHODS

The mean age for the cohort was 64 (range 43-82). A mean of 28 biopsy cores (range 13-43) were taken under general anaesthesia (GA), as day case procedure. Patients received diclofenac 100 mg suppository on completion of the procedure. The questionnaire explored symptoms at 1 h, 1, 3 and 7 days postoperatively.

RESULTS

There were 301 responses (59%). Following TPSB, 38% initially experienced rectal bleeding, falling significantly to 3% on day 7 (p < 0.001) and it was not a serious condition in all cases. A majority reported haematuria at 1 h but persisting at 1 week in over one quarter (p < 0.001). Nevertheless, although initially often dark, none had other than pale pink by the end of the reporting period. In contrast, the incidence of haematospermia increased over 7 days, rising significantly to 38% by this stage (p < 0.001). Several patients commented that the procedure was more tolerable than their previous conventional TRUS biopsy and 20 (6.6%) with voiding difficulty required catheterisation. In all, 23% patients felt pain, and out of these 23% only 5% required minor analgesia at day 7.

CONCLUSION

TPSB under GA without prophylactic catheterisation is well tolerated, carrying acceptable postoperative symptom rates. Interestingly, a significant proportion of patients ejaculate within 7 days, which again suggests good tolerance to the procedure. Patients should be provided with this data preoperatively when they are considering TPSB.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Dose painting to treat single-lobe prostate cancer with hypofractionated high-dose radiation using targeted external beam radiation: Is it feasible?

Targeted focal therapy strategies for treating single-lobe prostate cancer are under investigation. In this planning study, we investigate the feasibility of treating a portion of the prostate to full-dose external beam radiation with reduced dose to the opposite lobe, compared with full-dose radiation delivered to the entire gland using hypofractionated radiation. For 10 consecutive patients with low- to intermediate-risk prostate cancer, 2 hypofractionated, single-arc volumetric-modulated arc therapy (VMAT) plans were designed. The first plan (standard hypofractionation regimen [STD]) included the entire prostate gland, treated to 70 Gy delivered in 28 fractions. The second dose painting plan (DP) encompassed the involved lobe treated to 70 Gy delivered in 28 fractions, whereas the opposing, uninvolved lobe received 50.4 Gy in 28 fractions. Mean dose to the opposing neurovascular bundle (NVB) was considerably lower for DP vs STD, with a mean dose of 53.9 vs 72.3 Gy (p < 0.001). Mean penile bulb dose was 18.6 Gy for DP vs 19.2 Gy for STD (p = 0.880). Mean rectal dose was 21.0 Gy for DP vs 22.8 Gy for STD (p = 0.356). Rectum V70 (the volume receiving ≥70 Gy) was 2.01% for DP vs 2.74% for STD (p = 0.328). Bladder V70 was 1.69% for DP vs 2.78% for STD (p = 0.232). Planning target volume (PTV) maximum dose points were 76.5 and 76.3 Gy for DP and STD, respectively (p = 0.760). This study demonstrates the feasibility of using VMAT for partial-lobe prostate radiation in patients with prostate cancer involving 1 lobe. Partial-lobe prostate plans appeared to spare adjacent critical structures including the opposite NVB.

Role of transperineal template biopsy in prostate cancer

Prostate cancer is the most common neoplasm diagnosed in men. Whilst treatment modalities have progressed, diagnostic investigations in terms of biopsy methods have been assessed but there is no consensus of when the different diagnostic methods in terms of transrectal ultrasound (TRUS) or transperineal template (TPT) should be utilised. TPT biopsy has a higher diagnostic yield than TRUS in those with a primary biopsy, in those with previous negative biopsies with TRUS as well as those undergoing saturation biopsies. Despite the increased likelihood of diagnosing cancer with TPT than TRUS this maybe secondary to the increased number of biopsies being utilised. However there is no consensus regarding the ideal number of biopsies that should be utilised with TPT. Furthermore it is felt that the increased number of biopsies utilised with TPT is associated the higher complication rates with TPT. The role of TPT biopsy is recognised in those with previous negative biopsies with transrectal ultrasound but further work is required regarding the ideal number of biopsies. Furthermore, it is felt that TPT biopsy may have a role in primary biopsy.

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

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

Transperineal template-guided mapping biopsy of the prostate

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

Value of transition zone biopsy in active surveillance of prostate cancer

PURPOSE

For patients on active surveillance there are limited data on transition zone sampling upon followup biopsy. We verified the value of transition zone biopsy in the active surveillance setting.

MATERIALS AND METHODS

Our study included 1,059 sets of prostate biopsies from a total of 534 patients on active surveillance at the Johns Hopkins Hospital. Each set comprised at least 14 cores with 2 or more from the transition zone. Of these men 53 underwent radical prostatectomy.

RESULTS

Patients with tumors in the peripheral zone as well as the transition zone had a higher maximum Gleason score and an increased maximum percent of cancer per core than men with tumor in the peripheral or transition zone only. In 12 of the 534 patients (2.2%) the tumor on active surveillance biopsy was limited to transition zone core(s). Of the 534 patients 11 (2.1%) had tumor with a high Gleason score (greater than 6) or extensive involvement (greater than 50%) of any core exclusively on transition zone biopsy. However, in 10 of 15 radical prostatectomy cases (66.7%) with prior positive transition zone biopsies the tumors had little or no transition zone component. In addition, transition zone status on biopsy had no significant relationship with Gleason score, extraprostatic extension or seminal vesicle involvement at radical prostatectomy.

CONCLUSIONS

Our data suggest that the additional yield is sufficiently low to argue against routine transition zone sampling in men undergoing followup biopsy on active surveillance. However, further study is needed to make definitive recommendations.

A retrospective study of prostate cancer cases mimicking urothelial cell carcinoma of the bladder

BACKGROUND

Prostate cancer (PCa) originating from the prostate base may intrude into the urinary bladder and may be misdiagnosed as bladder cancer. In this retrospective study, we reviewed the clinic data on PCa cases which were initially misdiagnosed as bladder cancer in order to identify diagnostic methods that would allow a better differential diagnosis for PCa.

METHODS

Out of a total of 455 patients treated for PCa at our hospital between April 2003 and June 2011, 14 patients (3.1%) had been initially misdiagnosed as urinary bladder urothelial cell carcinoma. The clinical data on these 14 cases was retrieved and analyzed.

RESULTS

Of the 14 patients, 11 patients were eventually diagnosed with PCa after MRI examination, and seven out of these had PCa with bladder neck invasion. Prostate needle biopsy or transurethral resection of prostate (TURP) revealed that all 14 patients had adenocarcinoma of prostate with Gleason scores ranging from 7 to 9. Nine patients received TURP for hematuria or lower urinary tract blockage. The mean follow-up was 37 months, during which six patients survived.

CONCLUSIONS

As clinical presentation and in emergency settings, prostate cancer originating from the prostate base can be confused with bladder cancer originating from the neck or the triangle region of the urinary bladder. Serum prostate specific antigen (PSA) levels and digital rectal examination, in combination with transrectal ultrasound (TRUS), MRI, and prostate needle biopsy are valuable tools for definitive differential diagnosis of the basal prostate cancer.