Complications of ultrasound-guided transperineal prostate biopsy. A prospective study

Feasibility of transrectal and transperineal fiducial marker placement for prostate cancer before proton therapy

BACKGROUND

To compare the feasibility of transrectal and transperineal fiducial marker placement for prostate cancer before proton therapy.

MATERIALS AND METHODS

From 2013 to 2015, the first 40 prostate cancer patients that were scheduled for proton therapy underwent transrectal fiducial marker placement, and the next 40 patients underwent transperineal fiducial marker placement (the first series). Technical and clinical success and pain scores were evaluated. In the second series (n = 280), the transrectal or transperineal approach was selected depending on the presence/absence of comorbidities, such as blood coagulation abnormalities. Seven patients refused to undergo the procedure. Thus, the total number of patients across both series was 353 (262 and 91 underwent the transrectal and transperineal approach, respectively). Technical and clinical success, complications, marker migration and the distance between the two markers were evaluated.

RESULTS

In the first series, the technical and clinical success rates were 100% in both groups. The transrectal group exhibited lower pain scores than the transperineal group. The overall technical success rates of the transrectal and transperineal groups were 100% (262/262) and 99% (90/91), respectively (P > 0.05). The overall clinical success rate was 100% in both groups, and there were no major complications in either group. The migration rates of the two groups did not differ significantly. The mean distance between the two markers was 25.6 ± 7.1 mm (mean ± standard deviation) in the transrectal group and 31.9 ± 5.2 mm in the transperineal group (P < 0.05).

CONCLUSION

Both the transrectal and transperineal fiducial marker placement methods are feasible and safe.

Evaluation of robot-assisted MRI-guided prostate biopsy: needle path analysis during clinical trials

While the interaction between a needle and the surrounding tissue is known to cause a significant targeting error in prostate biopsy leading to false-negative results, few studies have demonstrated how it impacts in the actual procedure. We performed a pilot study on robot-assisted MRI-guided prostate biopsy with an emphasis on the in-depth analysis of the needle-tissue interaction in vivo. The data were acquired during in-bore transperineal prostate biopsies in patients using a 4 degrees-of-freedom (DoF) MRI-compatible robot. The anatomical structures in the pelvic area and the needle path were reconstructed from MR images, and quantitatively analyzed. We analyzed each structure individually and also proposed a mathematical model to investigate the influence of those structures in the targeting error using the mixed-model regression. The median targeting error in 188 insertions (27 patients) was 6.3 mm. Both the individual anatomical structure analysis and the mixed-model analysis showed that the deviation resulted from the contact between the needle and the skin as the main source of error. On contrary, needle bending inside the tissue (expressed as needle curvature) did not vary among insertions with targeting errors above and below the average. The analysis indicated that insertions crossing the bulbospongiosus presented a targeting error lower than the average. The mixed-model analysis demonstrated that the distance between the needle guide and the patient skin, the deviation at the entry point, and the path length inside the pelvic diaphragm had a statistically significant contribution to the targeting error (p  <  0.05). Our results indicate that the errors associated with the elastic contact between the needle and the skin were more prominent than the needle bending along the insertion. Our findings will help to improve the preoperative planning of transperineal prostate biopsies.

Association between pre-biopsy white blood cell count and prostate biopsy - related sepsis

Introduction

Despite all preventive measures and improved biopsy techniques, serious, life–threatening complications of prostate biopsy, including sepsis, still exist. In the present study, in order to identify the risk factors that may be associated with sepsis development after prostate–biopsy, we aimed to analyze retrospectively the data of our patients who underwent transrectal ultrasound–guided prostate biopsy.

Material and methods

We retrospectively reviewed the data of 889 patients who underwent prostate biopsy at our clinic. We compared pre–biopsy parameters (age, prostate volume, white blood cell (WBC) count, fasting blood glucose, free and total prostate specific antigen levels) between patients who developed sepsis and those who were sepsis–free following prostate biopsy.

Results

28 patients (3.1%) developed sepsis. Among the risk factors evaluated, only pre–biopsy WBC count was found to be a significant risk factor for biopsy–related sepsis. A 5.1 fold increase was detected in the risk for sepsis development, when the cut–off value of WBC was accepted as 11.165/μL, OR: 5.1 (95% CI: 2.3–11.5). The post–biopsy sepsis development rate in patients with pre–biopsy WBC count greater and less than 11.165/μL was 13.7% (n = 10) and 3% (n = 18) respectively.

Conclusions

Patients with a pre–biopsy WBC count greater than 11.165/μL should be informed of the increased risk of developing post–biopsy sepsis.

Advancements in MR imaging of the prostate: from diagnosis to interventions

Prostate cancer is the most frequently diagnosed cancer in males and the second leading cause of cancer-related death in men. Assessment of prostate cancer can be divided into detection, localization, and staging; accurate assessment is a prerequisite for optimal clinical management and therapy selection. Magnetic resonance (MR) imaging has been shown to be of particular help in localization and staging of prostate cancer. Traditional prostate MR imaging has been based on morphologic imaging with standard T1-weighted and T2-weighted sequences, which has limited accuracy. Recent advances include additional functional and physiologic MR imaging techniques (diffusion-weighted imaging, MR spectroscopy, and perfusion imaging), which allow extension of the obtainable information beyond anatomic assessment. Multiparametric MR imaging provides the highest accuracy in diagnosis and staging of prostate cancer. In addition, improvements in MR imaging hardware and software (3-T vs 1.5-T imaging) continue to improve spatial and temporal resolution and the signal-to-noise ratio of MR imaging examinations. Another recent advancement in the field is MR imaging guidance for targeted prostate biopsy, which is an alternative to the current standard of transrectal ultrasonography-guided systematic biopsy.

BiopSee® - transperineal stereotactic navigated prostate biopsy

In the recent years, prostate cancer was the most commonly diagnosed cancer in men. Currently secure diagnosis confirmation is done by a transrectal biopsy and following histopathological examination. Conventional transrectal biopsy success rates are rather low with ca. 30% detection upon the first and ca 20% after re-biopsy. The paper presents a novel system for stereotactic navigated prostate biopsy. The approach results into higher accuracy, reproducibility and unrestricted and effective access to all prostate regions. Custom designed ultrasound, new template design and integrated 2-axes stepper allows superior 2D and 3D prostate imaging quality and precise needle navigation. DICOM functionality and image fusion enable to import pre-operative datasets (e.g. multiparametric MRI, targets etc.) and overlay all available radiological information into the biopsy planning and guiding procedure. The biopsy needle insertion itself is performed under augmented reality ultrasound guidance. Each procedure step is automatically documented in order to provide quality assurance and permit data re-usage for the further treatment. First clinical results indicates success rates of ca. 70% by first biopsies by our approach.

Antibiotic Prophylaxis in Prostate Biopsy

Introduction

Prostate biopsy is nowadays one of the most frequent diagnostic procedures in urology. The incidence of bacteraemia, bacteriuria and infective complications is higher after the transrectal procedure than after the transperineal one. A survey demonstrated that 98% of the urologists in USA use antibiotics to prevent infective complications. The transrectal prostate biopsy is the only diagnostic intervention procedure in urology for which an antibiotic prophylaxis is recommended, also for low-risk patients, by the guidelines of the European Association of Urology. If the perineal route is adopted, the antibiotic prophylaxis is recommended only in high-risk patients.

Materials and Methods

The patient should preferably receive an evacuative enema to achieve a rectal cleansing and to ameliorate the diagnostic accuracy of transrectal ultrasound. A survey in the US demonstrated that an evacuative enema with saline solution is adopted by more than 80% of urologists. Criteria for antibiotics choice. The majority of bacteraemias are transitory, asymptomatic and self-limiting. On the other side, bacteriuria can persist for several days. Antibiotics must achieve high drug concentrations not only in plasma and tissue but also in urine. Symptomatic infections are generally caused by E. Coli and less frequently by the Streptococcus faecalis. Nevertheless, other agents as Klebsiella and Chlostridium, although rare, might cause severe infections. Thus, prophylaxis needs antibiotics at large spectrum and a single agent may not be enough for high-risk patients. Risk determination and drug schedules. It is essential to point out the infective risk of the patient. The choice of the drug, the timing and schedule of antibiotic prophylaxis are still object of debate. Several randomized studies have been conducted with contradictory results.

Results

The antibiotic prophylaxis should be tailored according to patients’ infective risk and to the procedure adopted. It is able to reduce infections rate after transrectal biopsy below 5%. The adoption of periprostatic anesthesia and the number of cores can influence the incidence of infective complications. Commonly, one-three days oral administration of fluoroquinolone is adopted. A single-dose prophylaxis can be also used with favorable results. Tolerability and route of administration should be taken into account, and also costs should be considered.

Conclusions

Considering the low cost of antibiotics adopted as short-term prophylaxis and the high cost of the treatment of infective complications, it seems reasonable to provide antibiotics prophylaxis for all patients at high risk for infective complications and for all cases submitted to transrectal prostate biopsy.

Which Technical Aspects have an Impact on Perceived Pain during Transperineal Prostate Biopsy? A Prospective Study Involving 445 Cases

To assess the technical aspects determining the perceived pain during prostate biopsy via transperineal access.

Materials and Methods

We conducted prostate biopsy with transperineal access in local anesthesia. Between January 2007 and January 2008, data on prostatic biopsies were prospectively surveyed. The patient was requested to assess perceived pain by means of a Visual Analogue Scale ranging from 0 (no pain) to 10 (unbearable pain). Complications were recorded by telephone interviews 30 days after the biopsy. The histological diagnosis was recorded.

Results

445 prostate biopsies were conducted. The average perceived pain score amounted to 2.60. At univariate analysis, a lower score was recorded in cases where the anesthetic agent was diluted with physiological saline, those in which a single cutaneous access was chosen along the middle line, those in the first bioptic series as compared to the following series and those in which no sampling involved the transition region. However, the multivariate analysis showed that only the single cutaneous access was statistically significant. In those cases, also the rates of delayed perineal pain were significantly lower. The cancer diagnosis rate showed no correlations with the type of cutaneous access.

Conclusions

A single median cutaneous access reduces the pain associated to transperineal prostatic biopsy.

Evaluating localized prostate cancer and identifying candidates for focal therapy

Can focal therapy successfully control prostate cancer? Also, if so, which patients should be considered eligible? With limited data available from relatively few patients, these questions are difficult to answer. At this writing, the most likely candidates for focal therapy are patients with low-risk, small-volume tumors, located in 1 region or sector of the prostate, who would benefit from early intervention. The difficulty lies in reliably identifying these men. The larger number of cores obtained in each needle biopsy session has increased both the detection of prostate cancer and the potential risk of overtreating many patients whose cancers pose very little risk to life or health. Urologists typically perform at least a 12-core template biopsy. Although the debate continues about the optimal template, laterally and peripherally directed biopsies have been shown to improve the diagnostic yield. However, as many as 25% of tumors arise anteriorly and can be missed with peripherally directed techniques. Prostate cancer tends to be multifocal, even in its earliest stages. However, the secondary cancers are usually smaller and less aggressive than the index cancer. They appear similar to the incidental cancers found in cystoprostatectomy specimens and appear to have little effect on prognosis in surgical series. When a single focus of cancer is found in 1 core, physicians rightly suspect that more foci of cancer are present in the prostate. Assessing the risk in these patients is challenging when determined by the biopsy data alone. To predict the presence of a very low-risk or "indolent" cancer, nomograms have been developed to incorporate clinical stage, Gleason grade, prostate-specific antigen levels, and prostate volume, along with the quantitative analysis of the biopsy results. Transperineal "mapping" or "saturation" biopsies have been advocated to detect cancers missed or underestimated by previous transrectal biopsies. This approach could provide the accurate staging, grading, and tumor localization needed for a focal therapy program. Nevertheless, for men with minimal cancer who are amenable to active surveillance or focal therapy, consensus about the most accurate biopsy strategy has not yet been reached. Imaging, particularly magnetic resonance imaging and magnetic resonance spectroscopic imaging, has been used to assess men with early-stage prostate cancer. Large-volume cancers can be seen reasonably well, but small lesions have been difficult to detect reliably or measure accurately. Factors such as voxel resolution, organ movement, biopsy artifact, and benign changes have limited the consistent estimation of the quantitative tumor volume. Nevertheless, magnetic resonance imaging and magnetic resonance spectroscopic imaging can aid in evaluating patients with prostate cancer being considered for focal therapy by providing additional evidence that the patient does not harbor an otherwise undetected high-risk, aggressive cancer. In some cases, imaging can usefully identify the location of even a limited-sized index cancer. When imaging findings are substantiated by mapping biopsy results, confidence in the accurate characterization of the cancer is enhanced. Correlating the imaging results with tissue changes during and after treatment can be of use in monitoring the ablative effects in the prostate and in assessing for tumor recurrence. More work is necessary before staging studies can uniformly characterize a prostate cancer before therapy, much less reliably identify and locate small-volume cancer within the prostate. However, exploring the role of focal ablation as a therapeutic option for selected men with low-risk, clinically localized, prostate cancer need not await the emergence of perfectly accurate staging studies, any more than the application of radical surgery or radiotherapy have. Modern biopsy strategies, combined with optimal imaging and nomograms to estimate the pathologic stage and risk, taken together, provide a sound basis for the selection of appropriate patients for entry into prospective clinical trials of focal therapy.

The morbidity of transperineal template-guided prostate mapping biopsy

OBJECTIVE

To evaluate the effect of transperineal template-guided prostate mapping biopsy (TTMB) on urinary, bowel and erectile function.

PATIENTS AND METHODS

In all, 129 men had TTMB; a median of 56 biopsy cores were obtained per patient. Tamsulosin (0.8 mg daily) was initiated 2 days before TTMB and continued for 2 weeks. The International Prostate Symptom Score (IPSS), Rectal Function Assessment Score (R-FAS), International Index of Erectile Function (IIEF)-6 and the postvoid residual volume (PVR) were assessed at baseline and after 30 days, except for the IPSS, which was also assessed at 7 days. Several variables were evaluated as predictors of TTMB-induced morbidity.

RESULTS

The mean patient age was 64.7 years with a mean prostate volume of 74.3 mL; 60 men (46.5%) were diagnosed with prostate cancer. After TTMB, 39.4%, 7.1% and 1.6% of patients remained catheter-dependent at 0, 3 and 6 days. The median catheter-dependency was 0, 1, 2 and 3 days for prostate volumes of <60, 60-90, 90-120 and >120 mL, respectively. No patient remained catheter- dependent for >12 days or required a transurethral resection secondary to TTMB. The mean IPSS before TTMB was 10.4, and was 4.6 and 3.8 at 7 and 30 days. At baseline and 30 days the mean PVR was 35 and 40 mL, and the median R-FAS and IIEF scores for patients potent before TTMB were 2.0 and 2.2, and 27.0 and 26.0, respectively.

CONCLUSIONS

TTMB is a promising procedure for diagnosing prostate cancer. TTMB-related morbidity differs from that of standard TRUS biopsy primarily in the incidence of temporary urinary retention, and is comparable in terms of urinary, bowel and erectile function.

Prostate biopsy in Switzerland: a representative survey on how Swiss urologists do it

OBJECTIVE

The procedure of prostate biopsy is often performed but has not been standardized. Therefore, a survey of all urologists in Switzerland was carried out to investigate indications, patient preparation and technique with regard to transrectal prostate biopsy.

MATERIAL AND METHODS

A questionnaire was mailed to all 178 urologists working in Switzerland, either as self-employed urologists (SEUs) or as employed urologists at a hospital (EUHs), i.e. a teaching centre.

RESULTS

The questionnaire was returned by 133 urologists (75%). Eighty-seven of the respondents (65%) are SEUs and 46 (35%) work as EUHs. If digital rectal examination (DRE) raises suspicion of cancer, 129 urologists perform a biopsy. A serum prostate-specific antigen (PSA) level of 4 ng/ml is used as a cut-off value by 84% of respondents (SEUs 83%, EUHs 87%). A fluoroquinolone antibiotic is prescribed by 126 of the respondents. Fifty-nine percent of respondents (SEUs 52%, EUHs 72%) are offering periprostatic injection of a local anaesthetic drug. At the initial biopsy, 24% of respondents (SEUs 30%, EUHs 13%) obtain six cores, 45% (SEUs 37%, EUHs 61%) 8-10 and 17% (SEUs 18%, EUHs 15%) > or =12. The subsequent procedure performed after two negative biopsy sessions varies considerably.

CONCLUSIONS

This survey provides an insight into the practice pattern of urologists in Switzerland concerning prostate biopsy. For almost all urologists, a positive DRE is an indication for prostate biopsy. The majority use a serum PSA level of 4 ng/ml as a cut-off value. A fluoroquinolone is the antibiotic of choice. Periprostatic nerve block is the commonest form of anaesthesia. Most urologists take 8-10 cores per biopsy.

Patients' tolerance and early complications of transrectal sonographically guided prostate biopsy: prospective study of 300 patients

PURPOSE

To determine the degree of pain and discomfort associated with transrectal sonography (TRS)-guided biopsy of the prostate and to analyze the complications associated with this procedure.

METHODS

Three hundred men referred as part of an investigation to exclude prostate cancer were studied. The reasons for referral were suspected prostate cancer due to increased serum prostate-specific antigen level (>4 ng/ml), the finding of a palpable nodule or greater firmness of one prostatic lobe than the other on digital rectal examination, or the finding of a suspicious area of neoplasm of the prostate on TRS biopsy. All TRS-guided biopsies were performed as outpatient procedures without anesthesia. Ciprofloxacin prophylaxis was used in all patients before biopsy. Tolerance of the procedure was recorded immediately after the examination and graded on a scale of 0-4 as follows: 0, no pain; 1, very mild pain; 2, moderate pain; 3, severe pain; 4, intolerable pain. Complications recorded in the first week after the procedure were analyzed. They included mild pain, self-limiting hematuria, hematospermia, rectal bleeding, severe hematuria, septicemia, severe hemorrhage of the anus, and vasovagal attack.

RESULTS

Out of 300 TRS-guided biopsies, 10 early complications were recorded. The most frequent was septicemia, which was seen in 5 cases (1.7%). Hematuria occurred in 29 patients, 3 of which were severe. Rectal bleeding and vasovagal attack occurred in 1 patient each. All patients made a full recovery with appropriate conservative management. Ten cases (3.33%) of severe pain (grade 3) and intolerable pain (grade 4) were observed. Three out of these 10 patients completed the procedure. The procedure was terminated in 1 patient, and 6 patients required local anesthetic due to perianal disease.

CONCLUSIONS

TRS-guided prostate biopsy can be performed without local anesthesia in 90% of patients. Prophylactic antibiotics are mandatory to minimize approximately infectious complications.

Complications of transrectal versus transperineal prostate biopsy

BACKGROUND

There are two established techniques of prostate biopsy: the more widely used transrectal technique, and the transperineal technique. Although the transrectal technique is faster, it is reported to have an increased risk of septic complications, which may be life threatening. The present study compares complication rates of both techniques at Nambour General Hospital.

METHODS

The present retrospective study was performed by reviewing all available medical charts of men who underwent prostate biopsy during the years 1996-2001. The following data were recorded in a database: date of birth; digital rectal examination findings; serum prostate specific antigen (PSA); biopsy technique; number of cores taken; number of positive cores; Gleason grade and score; complications. Results were tabulated and simple statistical analysis performed to compare both groups.

RESULTS

A total of 197 biopsies was included in the study, with 81 transperineal biopsies in 75 men, and 116 transrectal biopsies in 103 men. There was no statistically significant difference in complication rates, including sepsis, between transrectal biopsy and transperineal biopsy. The rate of sepsis was 1.2% for the transperineal technique, and 0% for the transrectal technique (P = 0.411, Fisher exact test). Overall complication rates were 22.2% for transperineal technique and 19.8% for transrectal technique (P = 0.773, Fisher exact test).

CONCLUSION

Although the present study was limited by retrospective design and size it suggests that both techniques are equally safe. A review of medical literature supports a tranperineal approach to patients who will tolerate sepsis poorly, or who have a suspected inflammatory cause of their raised PSA.

Trans-perineal implantation of radio-opaque treatment verification markers into the prostate: an assessment of procedure related morbidity, patient acceptability and accuracy

On-line imaging of prostate markers can be used to compensate for errors in radiation delivery. This study assessed the patient acceptability and morbidity associated with the trans-perineal route of implantation. A minority experienced acute pain or bleeding. Placement was accurate in all but one subject. An operator related learning curve exists. Although this is an invasive procedure most patients found it acceptable. Implementation for routine clinical practice is feasible.

Transrectal ultrasound-guided transperineal 14-core systematic biopsy detects apico-anterior cancer foci of T1c prostate cancer

AIM

The optimal biopsy strategy for prostate cancer detection, especially in men with isolated prostate-specific antigen (PSA) elevation, remains to be defined. We evaluated diagnostic yield and safety of transrectal ultrasound (TRUS)-guided transperineal systematic 14-core biopsy and compared the spatial distribution of cancer foci detected with this technique in men with and without abnormality on digital rectal examination (DRE).

METHODS

In a prospective study, 289 men aged between 50 and 87 years (median age, 70 years) underwent TRUS-guided transperineal systematic 14-core prostate biopsy because of elevated PSA and/or abnormal DRE findings. Using the fan technique, 12 cores from the peripheral zone and two cores from the transition zone were obtained systematically. To characterize the spatial distribution of cancer positive cores, site-specific overall and unique cancer detection rates were compared between stage T1c and T2 cancers.

RESULTS

Prostate cancer was detected in 105 of the 289 patients (36%). Major complications requiring prolonged hospital stay or re-hospitalization during a 4-week postbiopsy period were rare (1.4%). Sixty-seven stage T1c cancers were identified. These cancers were associated with significantly lower PSA and a smaller number of cancer positive cores when compared with stage T2 cancers (n= 38). The overall cancer detection rate was highest at the anterior peripheral zone and the posterior peripheral zone in stage T1c and stage T2 cancers, respectively. The unique cancer detection rate at the anterior peripheral zone was significantly higher in stage T1c cancers than in stage T2 cancers. Therefore, when the prostate is extensively biopsied using the transperineal approach, cancer positive cores are characteristically distributed anteriorly in stage T1c cancers and posteriorly in stage T2 cancers.

CONCLUSIONS

TRUS-guided transperineal systematic 14-core biopsy showed an apico-anterior distribution of cancer foci in stage T1c prostate cancers.

Epididymitis after transrectal ultrasound-guided needle biopsy of prostate gland

OBJECTIVES

To evaluate the incidence, predisposing factors, and time-course of epididymitis after transrectal ultrasound-guided (TRUS) needle biopsy of the prostate gland.

METHODS

A total of 739 consecutive patients underwent TRUS-guided biopsy of the prostate gland from January 2000 through December 2002 using a systematic approach, 18-gauge needles, and antibiotic prophylaxis. A median of 9 biopsies was obtained per patient (range 4 to 16). All cases of epididymitis occurring within 6 months of biopsy were attributed to the TRUS procedure. The parameters evaluated for epididymitis included patient age, prostate-specific antigen, prostate volume, prostate-specific antigen density, number of biopsies obtained, and number of biopsies positive for malignancy.

RESULTS

Five patients (0.7%) developed biopsy-related epididymitis with a median onset of 85 days (range 13 to 143) after biopsy. Patients developing epididymitis were statistically older, with a trend for a greater number of prostate biopsies (P = 0.071 on linear regression analysis). Only 1 patient developed epididymitis within 3 weeks of biopsy. All cases of epididymitis responded to therapeutic antibiotics.

CONCLUSIONS

Epididymitis after TRUS-guided biopsy is a relatively uncommon event, with an incidence of approximately 1% and an onset of weeks to months after the procedure. Patients who developed epididymitis were statistically older, with a trend for a greater number of prostate biopsies taken.

Trends and risk factors for prostate biopsy complications in the pre-PSA and PSA eras, 1980 to 1997

OBJECTIVES

To assess the secular trends in postbiopsy complications and to identify the risk factors for complications.

METHODS

Olmsted County residents who underwent a prostate biopsy between 1980 and 1997 were identified. All community medical records for the study subjects were reviewed to identify prostate biopsy-related complications, including gross hematuria, infection, pain, hematospermia, and acute urinary retention.

RESULTS

Of the 2258 prostate biopsies, 377 (17%) were associated with at least one complication. The total complication rate per biopsy remained relatively consistent at about 17% from 1980 to 1986, 1987 to 1992, and 1993 to 1997 (P for trend = 0.8). The age-adjusted complication rate (per 100,000 men) increased from 26 to 60 in 1980 to 1986 and 1993 to 1997, respectively (P <0.001). This paralleled the increase in prostate biopsy use from 138 to 374 per 100,000 men in the same periods. The prevalence (per biopsy) of gross hematuria increased, 7.5% to 12.8% (P = 0.04); postbiopsy infection declined, 4.6% to 1.4% (P = 0.001); and hospitalization for infection declined, 1.2% to 0.2% (P = 0.06) between 1980 to 1986 and 1993 to 1997. A urogenital infection 6 weeks before biopsy was associated with an increased risk of a postbiopsy complication (odds ratio = 1.7, 95% confidence interval = 1.0 to 2.8) and an increased risk of a postbiopsy infection (odds ratio = 5.5, 95% confidence interval = 2.2 to 13.8).

CONCLUSIONS

Although the complications per biopsy have stayed constant, the prevalence of postbiopsy complications in the community has increased tremendously because of the increased use of prostate biopsies. Specific strategies may be needed to reduce the incidence of postbiopsy infection in men with a recent urogenital infection before biopsy.

Multiple transrectal ultrasound guided prostatic biopsies: morbidity and tolerance

OBJECTIVE

Early detection of prostate cancer has become a matter of vital importance in modern societies. Ultrasound guided transrectal biopsy is the current standard urological procedure to detect prostate cancer. In this study our intention was to confirm the high tolerance and low complication rate of this procedure, facts already established in urologists' minds.

MATERIAL AND METHODS

In order to evaluate the morbidity as well as the acceptance of the procedure, we investigated 120 patients who underwent ultrasound guided transrectal biopsies of the prostate, in our department from September 1995 to January 1996. All patients at each biopsy underwent 6 needle passes and took periprocedural antibiotic therapy. Alongside with recording the periprocedural side effects of this method patients answered a questionnaire in order to evaluate the pain they experienced by this procedure.

RESULTS

Twenty patients were found to have prostate cancer at various stages. All patients tolerated well the whole procedure. Pain was the most common complaint among patients. Several complications were recorded; the most common of all was haematuria. Only two patients required admission to hospital because they developed fever after the procedure.

CONCLUSION

Ultrasound guided transrectal biopsy of the prostate is a well-tolerated and effective method for obtaining multiple biopsy specimens from the prostate with low incidence of serious complications. Its is also accurate enough, allowing its use in everyday urology, as a diagnostic procedure.

The impact of prostate biopsy on patient well-being: a prospective study of pain, anxiety and erectile dysfunction

PURPOSE

We prospectively studied the impact of transrectal ultrasound guided prostate biopsy on patient well-being.

MATERIALS AND METHODS

We enrolled 211 consecutive men who underwent a total of 218 biopsy events in a questionnaire based survey focusing on pain, anxiety and erectile dysfunction risk factors. Surveys were administered before, and immediately, 1 week and 1 month after biopsy. Quantitative information on the intensity of symptoms and signs was obtained using a uniform grading system.

RESULTS

Intraoperative pain considered severe in 20% of the biopsy events was associated with pain in the first 24 hours postoperatively, leading to analgesic use in 10%. Inflammatory infiltrate in the biopsy core and younger patient age correlated with persistent pain on days 2 and 7 after biopsy, respectively. Preoperative anxiety was reported in 64% of biopsy events and predictive of intraoperative pain. Anxiety peaked before result disclosure. Erectile dysfunction attributed to anxiety in anticipation of biopsy was reported in 7% of cases. At days 7 and 30, 15% of previously potent patients reported erectile dysfunction.

CONCLUSIONS

The impact of prostate biopsy on patient well-being begins while waiting for the scheduled procedure. Shortening the anticipation period before results are disclosed and administering pre-biopsy anxiety decreasing measures may benefit patients. Analgesic therapy is recommended in younger patients, those reporting moderate to severe intraoperative pain and those with known prostatic inflammatory infiltrate. The risk of acute erectile dysfunction should be discussed cautiously with patients who are potent before biopsy.

[Adverse effects of transrectal prostatic biopsy. Analysis of 303 procedures]

INTRODUCTION AND OBJECTIVE

Prostate biopsy is a basic step towards prostate cancer (Pca) diagnosis, but usually not free from complications. In this article we have reviewed the adverse effects of this procedure in our setting.

MATERIAL AND METHODS

We studied in a prospective fashion the complications arising from transrectal prostate biopsy with the aid of a questionnaire fulfilled by 303 patients who underwent this procedure, within the context of a Pca screening program. All biopsies were transrectal ultrasound guided and randomly taken (sextant). A cleaning enema was applied the night before, and 100 mg of intramuscular tobramycin were administered prior of the procedure.

RESULTS

Ninety patients (29.7%) had no adverse effects at all, and 136 (44.9%) reported at least one minor complication (hematuria, hemospermia, or autolimited dysuria). Lastly 77 (25.4%) presented with major complications--urinary retention, fever, need for medical assistance (primary or hospital care) or treatment. Thirty-five patients (11.5%) reported to present with fever after biopsy, 145 (47.8%) hematuria, 95 (31.3%) hemospermia, 77 (25.4%) rectal bleeding, 67 (22.1%) urinary difficulty, and 9 (2.9%) urinary retention. Up to 39 (12.8%) needed to visit their G.P., and 19 of them were referred to Hospital, where only 6 (1.9%) were admitted longer than 24 hours. No intensive care unit admittances or deaths were reported.

CONCLUSIONS

The rate of post-transrectal biopsy adverse effects is high in our experience. This phenomenon could be explained, in part, due to data collecting by means of a self-administered questionnaire. Probably the high fever rate presented here could be diminished with other type of antibiotic prophylaxis.

Detection of prostate cancer: a comparative study of the diagnostic efficacy of sextant transrectal versus sextant transperineal biopsy

OBJECTIVES

The optimal biopsy strategy for the detection of prostate cancer still needs to be established, since a considerable proportion of clinically significant cancers remains undiagnosed on routine sextant transrectal biopsy. To assess the efficacy of transperineal biopsy to detect prostate cancer, we compared this approach to systematic sextant transrectal biopsy in a simulation experiment.

METHODS

Ultrasound-guided sextant transverse (transrectal) biopsy and subsequent sextant longitudinal (transperineal) biopsy were performed on 40 radical prostatectomy specimens of patients with (transrectal) biopsy-detected prostate cancer. Conditions were simulative and may not be completely analogous to clinical settings. Ultrasound-determined prostate volume, biopsy tumor involvement, number of cores with cancer, and tumor volume were determined. Detailed mapping of radical prostatectomy specimens provided insight into the representativeness of the biopsy techniques.

RESULTS

Of 40 cancers, 33 (82.5%) were redetected by the transperineal approach; 29 (72.5%) were detected by repeated transrectal biopsies. For both approaches, the tumor volume of the undiagnosed cancers was significantly smaller (P <0.01) and the prostate volume was significantly larger (P <0.01) than in the redetected ones. Between the two approaches, no difference was found for either of the variables determined in the redetected cancers. Prostate maps clarified that transperineal undiagnosed tumors were either small (0.2 cm(3) or less) or notably located at the prostatic base.

CONCLUSIONS

The biopsy procedure in which the biopsy needles enter the prostate at the apex for a longitudinal direction may efficiently sample the prostatic peripheral zone. Since the experiment was artificial in design, caution should be observed in extrapolating these results to patient settings.

Patients' tolerance of transrectal ultrasound-guided prostatic biopsy: an audit of 104 cases

OBJECTIVE

To determine the frequency and severity of complications following transrectal ultrasonography (TRUS) guided prostatic biopsy, and of pain during the procedure.

PATIENTS AND METHODS

The study included 129 men undergoing TRUS-guided prostatic biopsy who were asked to complete a questionnaire about pain and complications one week after biopsy.

RESULTS

Of the 104 men who completed the questionnaire, 24% found the procedure moderately to extremely painful and 19% felt that they had had significant complications afterward, the commonest of these being painful or difficult voiding (13%) and haematuria (11%). Systemic symptoms of fever or 'sweats' occurred in 6%, with a diagnosis of septicaemia in three men, despite antibiotic prophylaxis. However, acute urinary retention occurred in only one man. Of all patients, 20% saw their general practitioner within a week, all of whom were prescribed antibiotics in addition to those given prophylactically in hospital.

CONCLUSION

TRUS-guided biopsy is often a painful experience for patients and is commonly associated with complications, particularly voiding difficulties. Of particular concern were the three patients with septicaemia, and that one in five men felt sufficiently unwell to visit their doctor within a week of the procedure.

Screening for carcinoma of the prostate: a GP based study

OBJECTIVE

To examine the feasibility and acceptability of screening for cancer of the prostate by digital rectal examination (DRE), prostate specific antigen (PSA) determination and subsequent transrectal ultrasound (TRUS) in selected patients in a single general practice in Hertfordshire.

SUBJECTS AND METHODS

A total of 568 of 856 men aged 55 to 70 accepted an invitation for a health check which included screening for prostate cancer. Of these, 80 individuals with either a raised PSA level or an abnormal DRE underwent TRUS. In 29 individuals biopsies were taken, 11 of which confirmed the presence of adenocarcinoma of the prostate giving an overall detected prevalence of 2%. Of the 11 tumours identified by screening, two were T1M0, four were T2M0, two were T3M0 and three were T3M1.

RESULTS

To assess the acceptability of the screening exercise a postal questionnaire was sent to all 568 participants: 83% replied and 69% reported no concern. Of the 67 individuals who had undergone TRUS, 69% reported discomfort. A total of 448 (95%) of respondents declared that they would be prepared to undergo the screening exercise again.

CONCLUSION

Screening for prostate cancer would seem to be technically feasible and generally acceptable. However, there is a considerable false positive rate in the PSA range 4 ng/ml to 10 ng/ml, particularly among men with clinical evidence of benign prostatic hyperplasia. To establish the true benefit of screening a large-scale prospective controlled study will be necessary.