Risk factors for infectious complications following transrectal ultrasound-guided prostate biopsy

Research on the mean maximum Young's modulus value as a new diagnostic parameter for prostate cancer

Ultrasound-based shear wave elastography (SWE) can non-invasively assess prostate tissue stiffness for the diagnosis of prostate cancer (PCa). So far, there is no widely recognized standard for the detection process and calculation method of Young's modulus value in transrectal SWE ultrasound imaging (TSWEUI). In our study, the mean maximum Young's modulus value (m-Emax) of the maximum cross-section of prostate is obtained by calculating the mean of 12 measured Emax in the four quadrants. This retrospective study included 209 suspected malignant prostate disease patients with pathological results in our hospital. Among the 209 patients, 75 patients completed TSWEUI, and 63 of the 75 patients completed magnetic resonance imaging (MRI). The area under the receiver operating characteristic (ROC) curve (AUC) of 75 patients for m-Emax was 0.754. The prostate volume, prostate-specific antigen, and m-Emax were used to develop a nomogram (AUC = 0.868). The nomogram could effectively predict the probability of PCa, thereby reducing the needle biopsy rate for diagnosing PCa. The AUC of 63 patients was not statistically different between m-Emax (AUC = 0.717) and MRI (AUC = 0.787) (P = 0.361). These indicate that m-Emax can be used as an innovative parameter in TSWEUI to diagnosis PCa. TSWEUI is more cost-effective than MRI in diagnosing PCa.

Assessment of complications after transperineal and transrectal prostate biopsy using a risk-stratified pathway identifying patients at risk for post-biopsy infections

INTRODUCTION

Evidence of transperineal (TP) superiority over transrectal (TR) biopsy is growing due to lower infectious complication rates. However, TR biopsy is the most common procedure, and it seems that a cross-over to TP is delayed by logistical challenges such as costs, complexity, and lack of experience. We investigate whether well-selected patients without any risk factors may further undergo TR biopsy if all precautions to avoid infections are warranted.

MATERIALS AND METHODS

Data were collected in our academic institution between August 2021 and March 2022 and after clinical implementation of the currently updated European Association of Urology guideline recommendations on the performance of prostate biopsy. Patients underwent either TP or TR biopsy according to a riskstratification based on risk factors of infectious complications. Follow-up asked for post-biopsy complications. Inverse Probability of Treatment Weighting (IPTW) propensity score was used to balance baseline characteristics. Complications were subdivided into infectious and non-infectious complications.

RESULTS

In total, 294 patients were included with 161 patients undergoing TR vs. 133 patients undergoing TP biopsy. Complication rates were 2.2% for TP vs. 5.5% for TR biopsy concerning all complications. Infectious complication rates only were 0.7% for TP vs. 1.8% for TR biopsy. After IPTW adjustment, differences were statistically significant different (p = 0.01).

CONCLUSION

Our study revealed that even in a well-selected patient cohort with presumably lower risk of infectious complications, TR biopsy leads to more post-biopsy complications than TP biopsy. This conclusion should motivate the urological community to switch to TP biopsy.

Antibiotic prophylaxis in patients who had undergone to prostate biopsy in between the EMA warning era: effects of fluoroquinolones in diabetic and non-diabetic patients. Results of an observational cohort study

PURPOSE

To investigate the effects of different antibiotic prophylaxis regimens in patients with diabetes mellitus (DM) candidates to trans-rectal ultrasound-guided prostate biopsy (TRUSPB).

METHODS

143 outpatients with DM who underwent TRUSPB during the period 2018-2020 were selected from a cohort of 1150 patients in 3 different institutions. Exclusion criteria were allergies, concomitant anti-platelet therapies and uncontrolled DM. Different antibiotic prophylaxis regimens were adopted. Bacterial resistance levels to fluoroquinolones into the different communities were also collected. Univariable and multivariable binomial logistic regression analyses were used to assess the odds ratio (OR) with 95% confidence intervals (CIs) testing the risk of infective complications' occurrence after adjusting for clinical covariates.

RESULTS

Overall, DM patients were significantly associated with infective complications' occurrence (p < 0.001). No differences on the event of sepsis were found between diabetic and non-diabetic patients. Clinically relevant infections with fever > 37 °C were found in 9.1% and 1.5% (p < 0.001) in diabetic and non-diabetic patients, respectively. Trimethoprim-sulphametoxazole and fluoroquinolones were six times more efficient than Cefixime in non-diabetic patients. Fluoroquinolones confirmed the same effect in diabetic patients although the level of resistance in the period of study decreased only from 56 to 46%.

CONCLUSION

Fluoroquinolones were active in antibiotic prophylaxis of diabetic patients who had undergone to TRUSPB independently from the level of bacterial resistance found in the community. These results conflict with the recent European warning and support the Japanese and American guidelines on the topic.

Effect of alpha-blocker use on morbidity and lower urinary tract symptoms in patients undergoing transrectal ultrasound-guided prostate biopsy

OBJECTIVE

To evaluate voiding dysfunction and morbidity after transrectal ultrasound (TRUS)-guided prostate biopsy and to investigate whether pre-intervention alpha-blocker treatment had any effect on morbidity and voiding dysfunction.

MATERIAL AND METHODS

The study included 197 consecutive patients who underwent TRUS-guided prostate biopsy between January 2014 and January 2018. The patients were divided into two groups, those receiving alpha-blocker (silodosin) and those not receiving alpha-blocker treatment before the procedure (controls). All patients were evaluated before and one week after the procedure with the International Prostate Symptom Score (IPSS), measurements of maximum flow rate (Q_max), post-void residual urine volume (PVR) and prostate volume, and procedure-related complications were also recorded. All analyzed parameters were compared by within-group and between-group evaluations.

RESULTS

There was no significant difference between the two groups in terms of IPSS, Q_max and prostate volume values before biopsy. In the follow-up evaluation performed on the seventh day after biopsy, IPSS, PVR and prostate volume were found to be increased, whereas Q_max was decreased in the control group (p < 0.05). In the silodosin group, an increase in prostate volume was observed, but there were no significant changes in IPSS, Q_max and PVR values. Acute urinary retention (AUR) after the biopsy procedure developed in two patients (2%) in the silodosin group, and in nine patients (9.1%) in the control group (p = 0.02). No significant difference was found between the two groups in terms of biopsy-related complications, except for AUR.

CONCLUSION

We believe that alpha-blocker treatment initiated before biopsy may be advantageous in preventing voiding dysfunction that may develop after the procedure.

MRI-Based Nomogram of Prostate Maximum Sectional Area and Its Zone Area for Prediction of Prostate Cancer

Objective

To reduce unnecessary prostate biopsies, we designed a magnetic resonance imaging (MRI)-based nomogram prediction model of prostate maximum sectional area (PA) and investigated its zone area for diagnosing prostate cancer (PCa).

Methods

MRI was administered to 691 consecutive patients before prostate biopsies from January 2012 to January 2020. PA, central gland sectional area (CGA), and peripheral zone sectional area (PZA) were measured on axial T2-weighted prostate MRI. Multivariate logistic regression analysis and area under the receiver operating characteristic (ROC) curve were performed to evaluate and integrate the predictors of PCa. Based on multivariate logistic regression coefficients after excluding combinations of collinear variables, three models and nomograms were generated and intercompared by Delong test, calibration curve, and decision curve analysis (DCA).

Results

The positive rate of PCa was 46.74% (323/691). Multivariate analysis revealed that age, PSA, MRI, transCGA, coroPZA, transPA, and transPAI (transverse PZA-to-CGA ratio) were independent predictors of PCa. Compared with no PCa patients, transCGA (AUC = 0.801) was significantly lower and transPAI (AUC = 0.749) was significantly higher in PCa patients. Both of them have a significantly higher AUC than PSA (AUC = 0.714) and PV (AUC = 0.725). Our best predictive model included the factors age, PSA, MRI, transCGA, and coroPZA with the AUC of 0.918 for predicting PCa status. Based on this predictive model, a novel nomogram for predicting PCa was conducted and internally validated (C-index = 0.913).

Conclusions

We found the potential clinical utility of transCGA and transPAI in predicting PCa. Then, we firstly built the nomogram based on PA and its zone area to evaluate its diagnostic efficacy for PCa, which could reduce unnecessary prostate biopsies.

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.

Minimizing transrectal prostate biopsy-related infections; A prospective randomized trial of povidone-iodine intrarectal cleaning versus formalin needle disinfection

INTRODUCTION

Transrectal prostate biopsies are associated with post biopsy infection and sepsis. We compared the efficacy of povidone-iodine rectal disinfection versus formalin needle disinfection in preventing post biopsy infection among patients undergoing transrectal ultrasound-guided prostate biopsy.

METHODS

Patients scheduled to undergo ultrasound-guided transrectal prostate biopsy (n = 621) over 20 months were randomized into 2 groups to receive either povidone-iodine intrarectal disinfection or formalin disinfection of needle after each core. These were compared to assess which methodology better prevented postprocedure infection. Statistical analysis were used to identify independent factors promoting infections.

RESULTS

Two hundred and ninety-eight patients from povidone-iodine intrarectal disinfection were compared with 300 from formalin needle disinfection group. Formalin needle disinfection was associated with significantly more infections (P = 0.02). Escherichia coli was the dominant pathogen, with >50% of cases being quinolone resistant. Type of disinfection (P = 0.002), BMI (P = 0.001), chronic prostatitis (P = 0.002), and diabetes mellitus (P = 0.01) were independent predictors of infections. BMI at 28.95 kg/m2 provided the best predictive cut-off point for infections, irrespective of method of disinfection. Area under the curve for all these parameters together was 0.91.

CONCLUSIONS

We conclude that along with oral cephalosporin prophylaxis, povidone-iodine intrarectal disinfection is a superior to formalin needle disinfection alone in preventing post biopsy infection. Patients with BMI >28.95 kg/m2 should be considered at a higher risk for infections.

Preventing Prostate Biopsy Complications: to Augment or to Swab?

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intraprostatic prophylactic antibiotic injection in patients undergoing transrectal ultrasonography-guided prostate biopsy

OBJECTIVES

To evaluate the efficacy of intraprostatic injection of prophylactic antibiotics for the prevention of infections following transrectal ultrasonography-guided prostate biopsy.

METHODS

In this prospective interventional study, patients aged between 40 and 70 years with clinical indications for transrectal ultrasonography-guided prostate biopsy were enrolled. Consecutive patients who received intraprostatic injection of amikacin coupled with oral ciprofloxacin were compared with historical controls receiving only prophylactic oral fluoroquinolones prior to biopsy. Patients were followed for 7 days after biopsy for signs and symptoms of infection.

RESULTS

A total of 210 patients were included in this study (mean age 65.7 ± 7.8 years). Among patients without intraprostatic injection, nine (8.6%) developed infectious complications (lower urinary tract infection in seven patients, and prostatitis in two), which led to hospitalization in six patients (5.7%). None of the patients who received intraprostatic antibiotic injection developed infectious complications. The difference in the incidence of post-transrectal ultrasonography-guided biopsy infections between the two groups was statistically significant (P = 0.003).

CONCLUSION

Local intraprostatic antibiotic injection during transrectal ultrasonography-guided prostate biopsy adjuvant to oral fluoroquinolones can significantly reduce the rate of post-biopsy infectious complications.

The Potential of hsa-mir-106b-5p as Liquid Biomarker in Prostate Cancer Patients in Indonesia

Purpose:

This study aims to explore the potential of hsa-mir-106b-5p as a new liquid biomarker for prostate cancer sufferers in Indonesia.

Methods:

Analysis of hsa-mir-106b-5p expression of two tissue samples from BPH patients and two PCa patients used NanoString nCounter Expression Assay then validated by qRT-PCR using 10 patient urine samples for prostate cancer and BPH. Furthermore, analysis of the role of hsa-mir-106b-5p in prostate cancer was carried out bioinformatically.

Results:

The results of this study indicated that the expression of hsa-mir-106b-5p in prostate cancer tissue was 1.23 times higher than that of BPH and urine of Indonesian patients (1.72 times). Moreover, this miRNA was upregulated in prostate cancer cells compared to normal cells 1.37 times. The hsa-mir-106b-5p appeared to be involved in the development of prostate cancer through the binding of genes involved in endoplasmic reticulum stress pathways and tumor suppressor genes.

Conclusion:

hsa-mir-106b-5p could modulate prostate cancer by interfering with the endoplasmic reticulum stress repair pathways and decreasing the expression of tumor suppressor genes involved in many biological processes. These updates our understanding of the role of hsa-mir-106b-5p in cancer and its potential as a candidate of a biomarker for clinical diagnosis of prostate cancer.

Major post-prostate biopsy complications under antibiotic augmentation prophylaxis protocol

Objective:

To identify risk factors for major post-biopsy complications under augmented prophylaxis protocol. The risk factors already described mainly comprise outdated antibiotic prophylaxis protocols.

Material and methods:

This retrospective cohort study included patients that underwent transrectal ultrasound-guided biopsies, from 2011 to 2016. All patients had received antibiotic prophylaxis with ciprofloxacin and gentamicin. Patients were grouped according to the presence or absence of post-biopsy complications. Demographic variables and possible risk factors based on routine clinical assessment were registered. Correlation tests, univariate and multivariate analyses were used to identify risk factors for post-biopsy complications.

Results:

Of the 404 patients that were included, 25 (6.2%) presented 27 post-biopsy complications, distributed as follows: acute urinary retention ( n = 14, 3.5%), infections ( n = 11, 2.7%) and hemorrhage ( n = 2, 0.5%). On univariate analysis, patients who presented complications showed higher body mass index and post-voiding residual volumes. Multivariate analysis identified ethnicity and prostate-specific antigen (PSA) density as possible risk factors for biopsy complications. The presence of bacterial resistance identified by rectal swabs did not correlate with the incidence of complications and infections.

Conclusions:

Non-infectious post-biopsy complications were more frequent than infectious ones in this cohort. Higher post-voiding residual volumes and PSA density, that indicates prostate enlargement, were identified as risk factors and interpreted as secondary to bladder outlet obstruction. The higher body mass index and ethnicity were also identified as risk factors and attributed to the heterogeneity of the patients included.

Level of evidence:

Not applicable for this multicentre audit.

Retrospective Study of the Etiology and Risk Factors of Systemic Inflammatory Response Syndrome After Systematic Transrectal Ultrasound-Guided Prostate Biopsy

Objective

To explore the risk factors, pathogenic bacteria distribution and drug resistance of systematic transrectal ultrasound-guided prostate biopsy (TRUS-Bx), 329 cases of TRUS-Bx were collected, retrospectively, in the Second Affiliated Hospital, Army Military Medical University, from April 2017 to October 2019.

Methods

A total of 329 cases were all qualified and grouped into the SIRS group (25 cases) and the non-SIRS group (304 cases). Of all the cases, incidence and risk factors of systemic inflammatory response syndrome (SIRS) were analyzed. Urine and blood samples of patients with SIRS after TRUS-Bx were also collected for bacterial culture and drug sensitivity test.

Results

Multivariate logistic regression analysis showed that BMI ≥ 25 kg/m² (OR = 1.66, 95% CI = 1.34–2.12, P <0.001), history of diabetes (OR = 5.48, 95% CI = 1.53–19.68, P = 0.008), urinary infection before operation (OR = 9.19, 95% CI = 2.92–20.93, P < 0.001) and erythrocyte sedimentation (ESR) ≥ 20 mm/h (OR = 1.04, 95% CI = 1.01–1.08, P = 0.039) were independent risk factors of SIRS after TURS-PB.

Conclusion

The incidence of SIRS and urinary sepsis was 7.59% and 2.13%, respectively, and major pathogens of SIRS after TRUS-Bx were Escherichia coli (58.33%), Klebsiella pneumoniae (12.5%) and Pseudomonas aeruginosa (12.5%). Imipenem, meropenem, tigecycline, piperacillin/tazobactam, teicoplanin, vancomycin, amikacin and cefoperazone/sulbactam had a very strong inhibitory effect to those pathogenic bacteria (sensitivity 85.72%~100%). Levofloxacin, ciprofloxacin, gentamicin, penicillin G, compound neonomine and second-generation cephalosporins showed less but also worked as a good inhibitor to pathogenic bacteria (42.86%~80.95%).

Risk factors for infection complications after transrectal ultrasound-guided transperineal prostate biopsy

BACKGROUND

To investigate the influence factors of infection complications of transrectal ultrasound-guided transperineal prostate biopsy.

METHODS

A total of 2192 patients who underwent prostate biopsy under transperineal prostate biopsy were analyzed retrospectively from December 2010 to May 2020.We collected the clinical characteristics and the incidence of complications, and used univariate and multivariate logistic regression analyses to analyze independent risk factors for infection complications after transperineal prostate biopsy.

RESULTS

Univariate analysis showed that the following factors were associated with the infection complications: diabetes, bacterial prostatitis, history of urinary retention, history of urinary infection, and number of cores. Furthermore, multivariate logistic analysis revealed that diabetes (OR 2.037, 95% CI 1.143-3.572, P = 0.021) and history of urinary retention (OR 2.563, 95% CI 1.284-3.901, P = 0.013) were independent risk factors for infection complications after transperineal prostate biopsy.

CONCLUSIONS

Patients with diabetes and history of urinary retention were more likely to have infection complications after transperineal prostate biopsy.

The Value of Prostate-Specific Antigen-Related Indexes and Imaging Screening in the Diagnosis of Prostate Cancer

Objective

The aim of this study was to explore the value of the prostate-specific antigen (PSA) levels, the ratio of free PSA to total PSA (fPSA/TPSA), the PSA density (PSAD), digital rectal examination (DRE), transrectal prostate ultrasound (TRUS), and multiparameter MRI (MP-MRI) in the differential diagnosis of benign prostatic hyperplasia (BPH) and prostate cancer (PCa).

Methods

From February 2016 to September 2019, data from 620 patients who underwent systematic transrectal ultrasound-guided prostate biopsy (STURS-PB) in our hospital were retrospectively collected, including the PSA levels, the fPSA/TPSA ratio, the PSAD, DRE, TRUS, MP-MRI, prostate volume, and other clinical data.

Results

Among the 620 patients, 249 patients were in the PCa group, and 371 patients in the BPH group. The positive puncture rate was 40.16%. The positive predictive values of DRE, TRUS, mpMRI, and TPSA levels for PCa were 39.91%, 39.38%, 64.14%, and 41.57%, respectively; the sensitivity of these parameters was 37.35%, 51.41%, 74.69%, and 57.43%, respectively; and the specificity of these parameters was 62.26%, 46.90%, 71.97%, and 45.82%, respectively. When the TPSA concentration was in the range of 4-20 ng/mL, the positive puncture rate of STURS-PB was 23.18%, with a high rate of misdiagnosis. When the TPSA concentration was in the range of 4-20 ng/mL, the fPSA/TPSA ratio was 0.15, the PSAD was 0.16, the comprehensive evaluation of PCa was optimal (the sensitivity of these parameters was 88.85% and 84.09%, respectively; the specificity was 80.17% and 67.29%, respectively; the positive predictive value was 57.41% and 51.39%, respectively). When the TPSA concentration >4 ng/mL, the fPSA/TPSA ratio ≤0.15 and the PSAD ≥0.16, the sensitivity, specificity, and correctness index of the PCa and BPH diagnosis were 80.54%, 82.75%, and 67.07%, respectively.

Conclusion

When using DRE, TRUS, and MP-MRI to screen for PCa, MP-MRI has a relatively high sensitivity and specificity. Using these three thresholds (TPSA >4 ng/mL combined with an fPSA/TPSA ratio ≤0.15 and a PSAD ≥0.16) is significantly better than using TPSA levels alone for the differential diagnosis of PCa and BPH.

Comparison of levofloxacin-based prophylaxis regimens for transrectal prostate biopsy: a prospective randomized single-center study

To develop an optimal prophylactic regimen among Chinese patients who accept transrectal prostate biopsy. We enrolled 420 patients who accepted transrectal prostate biopsy. They were randomly classified into three groups (n = 140 for each): Group A received a single 500-mg tablet of levofloxacin without enema; group B received a single 500-mg tablet of levofloxacin plus enema; group C received 3-day levofloxacin orally plus enema. Patients were assessed if they had a febrile urinary tract infection (FUTI). The incidence of FUTI was compared among groups. Subgroup analysis was performed between patients at high and low risk of infection in each group. There were 15 cases developed FUTI: 7 (5%), 6 (4.3%), and 2 (1.4%), respectively, in groups A, B, and C. Of the 15 patients who developed FUTI, Escherichia coli was detected in blood culture in two cases. Urine culture results were all negative. FUTI patients (73.3% (11/15)) had at least one high risk factor. Subgroup analysis showed that the incidence of FUTI in group A was significantly higher than that in group C among high-risk patients. There was no statistical difference between group A and group B among both high- and low-risk patients. A single 500-mg dose of levofloxacin without enema represents excellent prophylaxis for transrectal prostate biopsy in Chinese patients at low risk of infection. For those at high risk, 3-day levofloxacin prophylaxis is the optimal regimen. Prebiopsy enema provides no clinically significant outcome advantage and is unnecessary.