Morbidity and psychological impact of prostate biopsy: the future calls for a change

Current Approach to Complications and Difficulties during Transrectal Ultrasound-Guided Prostate Biopsies

Prostate cancer is one of the most common male malignancies worldwide. It affects middle-aged men (45-60 years) and is the leading cause of cancer-related mortality in Western countries. The TRUS (trans rectal ultrasound)-guided prostate biopsy has been a standard procedure in prostate cancer detection for more than thirty years, and it is recommended in male patients with an abnormal PSA (prostate-specific antigens) or abnormalities found during digital rectal examinations. During this procedure, urologists might encounter difficulties which may cause subsequent complications. This manuscript aims to present both the complications and the technical difficulties that may occur during TRUS-guided prostate biopsy, along with resolutions and solutions found in the specialized literature. The conclusions of this manuscript will note that the TRUS-guided prostate biopsy remains a solid, cost-efficient, and safe procedure with which to diagnose prostate cancer. The complications are usually self-limiting and do not require additional medical assistance. The difficulties posed by the procedure can be safely overcome if there are no other available alternatives. Open communication with the patients improves both pre- and post-procedure compliance.

Evaluation of Semen Self-Sampling Yield Predictors and CTC Isolation by Multi-Color Flow Cytometry for Liquid Biopsy of Localized Prostate Cancer

Liquid biopsy (LB) for prostate cancer (PCa) detection could represent an alternative to biopsy. Seminal fluid (SF) is a source of PCa-specific biomarkers, as 40% of ejaculate derives from the prostate. We tested the feasibility of an SF-based LB by evaluating the yield of semen self-sampling in a cohort of >750 patients with clinically localized PCa. The overall SF collection yield was 18.2% (39% when considering only compliant patients), with about a half of the patients (53.15%) not consenting to SF donation. Independent favorable predictors for SF collection were younger age and lower prostate volume. We implemented a protocol to enrich prostate-derived cells by multi-color flow cytometry and applied it on SF and urine samples from 100 patients. The number of prostate-enriched cells (SYTO-16+ PSMA+ CD45-) was variable, with higher numbers of cells isolated from SF than urine (p value < 0.001). Putative cancer cells (EpCAM^high) were 2% of isolated cells in both specimens. The fraction of EpCAM^high cells over prostate-enriched cells (PSMA+) significantly correlated with patient age in both semen and urine, but not with other clinical parameters, such as Gleason Score, ISUP, or TNM stage. Hence, enumeration of prostate-derived cells is not sufficient to guide PCa diagnosis; additional molecular analyses to detect patient-specific cancer lesions will be needed.

Prostate cancer screening: Continued controversies and novel biomarker advancements

Prostate cancer (PCa) screening remains one of the most controversial topics in clinical and public health. Despite being the second most common cancer in men worldwide, recommendations for screening using prostate-specific antigen (PSA) are unclear. Early detection and the resulting postscreening treatment lead to overdiagnosis and overtreatment of otherwise indolent cases. In addition, several unwanted harms are associated with PCa screening process. This literature review focuses on the limitations of PSA-specific PCa screening, reasons behind the screening controversy, and the novel biomarkers and advanced innovative methodologies that improve the limitations of traditional screening using PSA. With the verdict of whether or not to screen not yet unanimous, we hope to aid in resolution of the long-standing debate.

Expression Analysis of miRNAs and Their Potential Role as Biomarkers for Prostate Cancer Detection

Prostate cancer (PCa) is the second most frequent cancer diagnosed in men worldwide. The detection methods for PCa are either unreliable, like prostate-specific antigen (PSA), or extremely invasive, such as in the case of biopsies. Therefore, there is an urgent necessity for reliable and less invasive detection procedures that can differentiate between patients with benign diseases and those with cancer. In this matter, microRNAs (miRNAs) are suggested as potential biomarkers for cancer. MiRNAs have been found to be dysregulated in several different cancers, and these genetic alterations may present specific signatures for a given malignancy. Here, we examined the expression of miR141-3p, miR145-5p, miR146a-5p, and miR148b-3p in human tissue samples of PCa (n = 41) and benign prostatic diseases (BPD) (n = 30) using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). We combined the expression results with patient clinicopathological characteristics in logistic regression models to create accurate PCa predictive models. A model including information of miR148b-3p and patient age showed relevant prediction results (area under the curve [AUC] = 0.818, precision = 0.763, specificity = 0.762, and accuracy = 0.762). A model including all four miRNAs and patient age presented outstanding prediction results (AUC = 0.918, precision = 0.861, specificity = 0.861, and accuracy = 0.857). Our results represent a potential novel procedure based on logistic regression models that utilize miRNA expressions and patient age to assist with PCa diagnosis.

Selective Microfluidic Capture and Detection of Prostate Cancer Cells from Urine without Digital Rectal Examination

Simple Summary

Prostate cancer is the second most common cancer and the fifth leading cause of cancer death in men worldwide. The current diagnosis methods for prostate cancer are invasive and costly. In particular, digital rectal examination (DRE) or prostate massage adds considerable discomfort to patients, reduces compliance to cancer screening schedules, and raises the cost of the diagnostic procedure. New technologies are urgently needed for the effective and yet noninvasive detection of these conditions. This manuscript describes streamlined biotechnology for the noninvasive detection of prostate cancer from malignant cells shed in urine. For the first time, a whole-cell immunocapture approach combined with photodynamic diagnostic principles is used in a device to detect whole cancer cells from unprocessed patient urine samples collected without prior DRE.

Abstract

Urine-based biomarkers have shown suitable diagnostic potential for prostate cancer (PCa) detection. Yet, until now, prostatic massage remains required prior to urine sampling. Here, we test a potential diagnostic approach using voided urine collected without prior digital rectal examination (DRE). In this study, we evaluated the diagnostic performance of a microfluidic-based platform that combines the principle of photodynamic diagnostic with immunocapture for the detection of PCa cells. The functionality and sensitivity of this platform were validated using both cultured cells and PCa patient urine samples. Quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) demonstrated this platform had a detection limit of fewer than 10 cells per 60 µL and successfully validated the presence of a PCa biomarker in the urine of cancer patients without prior DRE. This biosensing platform exhibits a sensitivity of 72.4% and a specificity of 71.4%, in suitable agreement with qRT-PCR data. The results of this study constitute a stepping stone in the future development of noninvasive prostate cancer diagnostic technologies that do not require DRE.

Psychological distress among patients awaiting histopathologic results after prostate biopsy: An unaddressed concern

BACKGROUND

Prostate cancer is the most commonly diagnosed neoplasm in men. From the introduction of PSA testing, an increasing number of men undergoes prostate biopsy (PBX). While the physical side effects of PBx have been well investigated, its psychological impact has been under-evaluated.

AIM

The aim of our study is to investigate the presence of psychological distress (anxiety and depression) in patients waiting for histopathological results after prostate biopsy (PBx).

METHODS

From February to April 2019, 51 consecutive patients undergoing prostate biopsies at our institution were included. Age, PSA, DRE, familiarity for prostate cancer, number of previous biopsies, type of anesthesia, number of cores were recorded. All patients filled the Hospital Anxiety and Depression Scale (HADS), a psychometric Likert-scale questionnaire, before receiving the histopathological results of their PBx.

RESULTS

The prevalence of psychological distress among patients awaiting histopathologic results is 41% (21/51 patients), with anxiety being the main component of their distress. On multivariate analysis, PSA, family history, and repeat biopsy were significantly associated with anxiety and depression.

CONCLUSION

Patients undergoing PBx experience a burden of psychological distress waiting for histopathologic results, especially anxiety. Appropriate counseling should be offered to patients at high risk of developing psychological distress after PBx. Future goals would include technological improvements to shorten the time between biopsy and definitive results.

Seminal plasma metabolomics reveals lysine and serine dysregulation as unique features distinguishing between prostate cancer tumors of Gleason grades 6 and 7

BACKGROUND

Prostate cancer (PCa) is a metabolic disease. Most men are diagnosed with low grade indolent disease and differentiating these men from those who have life threatening cancer is a challenging but important clinical dilemma. There are currently limited biomarkers that can distinguish between the indolent Gleason grade 6 and higher-grade disease. Moreover, some individuals initially diagnosed with low grade disease progress to higher grade disease. Currently prostate biopsies are the only reliable methods of stratifying risk, but biopsies can cause significant morbidity, sample only a small portion of the gland and are costly. Therefore, biomarkers distinguishing between indolent and aggressive patterns of PCa are urgently required to minimize biopsy-associated morbidity, prevent over-treatment of indolent PCa and to better stratify patients for appropriate treatment.

METHODS

Seminal fluid samples were collected from normal individuals (n = 13) Before infertility treatment and histologically confirmed PCa patients (n = 51). ¹ H Nuclear magnetic resonance spectroscopy and orthogonal partial least square discriminant analysis were used to compare the populations.

RESULTS

Alterations in amino acids levels, specifically lysine and serine and changes in glycolytic intermediates were the most significant metabolic features associated with differences between healthy controls and PCa and between Gleason grade 6 (GS6) and Gleason grade 7 (GS7) samples. Orthogonal partial least square plots discriminated healthy controls from PCa samples (R ²  = 0.54, Q ²  = 0.31; area under the receiver operating characteristics curve [AUC] = 0.96), and GS6 from GS7 samples (R ²  = 0.62, Q ²  = 0.49; AUC = 0.98) based on lysine and serine content.

CONCLUSION

This study suggests that seminal plasma metabolomics profiling of seminal fluid is a promising means of differentiating indolent from aggressive disease. Particularly, lysine and serine levels may be able to differentiate GS6 from GS7 disease.

Pelvic Plexus Block Versus Periprostatic Nerve Block for Ultrasound-Guided Prostate Biopsy: A Meta-Analysis

Background

To relieve prostate biopsy-related pain, various local anesthetic methods have been used. The best approach was periprostatic nerve block (PNB) in the past decade. Recently, pelvic plexus block (PPB) was employed to ultrasound-guided prostate biopsy. Compared with the PNB, the PPB may block a more extensive area. Therefore, PPB may be more effective in relieving prostate biopsy-related pain. However, several prospective randomized controlled trials (RCTs) comparing PPB and PNB drew conflicting conclusions, so we compared the difference of pain control between PPB and PNB for prostate biopsy.

Methods

The following databases were retrieved up to October 2020: PubMed, Chinese biomedicine literature database, the Cochrane Library, China National Knowledge Internet databases, Wan fang databases and Google Scholar. Only the RCTs were included. The main outcome measures were Visual Analog Scale (VAS) score and complications. The literature quality and extracted data were evaluated by two authors independently. The software Review Manager (version 5.3) was used to perform the data analysis that comparing the difference of VAS score and complications between PPB and PNB.

Results

After screening, six articles including 336 patients from PPB group and 337 patients from PNB group were performed meta-analysis in this study. The results showed that there were no significant difference of pain control in probe insertion and local anesthetic injection between PPB and PNB, while compared with PNB, patients with PPB experienced less pain during biopsy and 30 min after biopsy, respectively(MD = −0.57, 95% CI: −1.11 to −0.03, Z = 2.06, P = 0.04; MD = −0.21, 95% CI: −0.40 to −0.02, Z = 2.15, P = 0.03). In subgroup analysis, the pooled results showed that PPB was superior to PNB in 12-cores biopsy (pooled MD = −1.16, 95% CI: −1.61 to −0.71, P < 0.00001), and more than 40-ml prostate size, regardless of transrectal or transperineal prostate biopsy. The reported major complications were urinary retention, hematuria, infection and hemospermia. The pooled results showed that there were no obvious difference in complications between PPB group and PNB group.

Conclusions

Overall, this meta-analysis suggests that PPB provides safe and effective pain control of ultrasound-guided prostate biopsy, and PPB is superior to PNB. In future, it also needs more high quality, large samples RCTs to verify.

Anxiety and depression associated with a positive prostate biopsy result: A comparative, prospective cohort study

Purpose

To investigate the course of anxiety and depression before and after transrectal ultrasound-guided prostate biopsy (TRUS-Bx) and in the postoperative 1st month when the histopathological biopsy result was obtained.

Methods

In between June 2017- January 2019, 204 patients who underwent TRUS-Bx and completed the questionnaires assessing anxiety and depression were included in the study. Questionnaires were completed immediately before the biopsy, immediately after the biopsy and at the end of the first month when the histopathological biopsy results were given. State-Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS) and perceived stress scale (PSS) forms were used to assess anxiety and depression. After the histopathological examination patients were divided into two groups as patients without cancer (Group 1) and with cancer (Group 2). Data was compared between the groups.

Results

PSA level was negatively correlated with STAI TX-1 scores of the patients immediately after TRUS-Bx, whereas it was positively correlated with STAI TX-1 and TX-2 30 days after the TRUS-Bx. PSA level was positively correlated with HADS-A and HADS-D scores immediately before and 30 days after TRUS-Bx. Biopsy results showed a significant difference in 30 day post-biopsy related data. STAI TX-1, STAI TX-2, HADS-A, HADS-D and PSS scores were higher in Group 2 compared with Group 1.

Conclusions

Pre-biopsy anxiety disappeared after bx, but there was a significant increase in anxiety and depression in patients after the diagnosis of malignancy. Patients were seriously concerned about the diagnosis of prostate cancer.

A systematic review and meta-analysis of magnetic resonance imaging and ultrasound guided fusion biopsy of prostate for cancer detection-Comparing transrectal with transperineal approaches

Targeted biopsy using multiparametric magnetic resonance imaging increases the detection rate of clinically significant prostate cancer (csCaP). In this meta-analysis, we compare the diagnostic accuracy of transrectal (TR) vs transperineal (TP) approaches for MRI-guided software fusion biopsy (FB) in the detection of csCaP. A literature search was performed in PubMed, Cochrane and Embase electronic databases up until July 2019 following the preferred reporting items for systematic review and meta-analysis system. The pooled sensitivity and specificity of either approach was evaluated using radical prostatectomy or systematic biopsies with ≥24 biopsy cores to be the reference standard. Fourteen papers with a total of 2002 patients were selected. Seven hundred and sixty-five patients underwent TR FB, while 1,387 underwent TP FB. One hundred and fifty of the patients underwent both TR and TP approaches. Both approaches were similar in terms of sensitivity (TR vs. TP: 0.81 vs 0.80) and specificity (TR vs. TP: 0.99 vs 0.95). In terms of likelihood ratios and diagnostic odds ratio, TR performed better than TP approach. The area under the receiving operator curve for both approaches was similar (0.91 vs 0.88 respectively). However, there was substantial heterogeneity across the studies for both approaches. TP and TR approaches to software-based FB yield similar diagnostic performance for the detection of csCaP. When deciding on the approach, physicians should consider other inherent features of either technique that suit their practice.

Detection of individual prostate cancer via multiparametric magnetic resonance imaging in own material - initial experience

Purpose

Multiparametric magnetic resonance imaging (mpMRI) is an evolving non-invasive imaging modality that increases the accurate localization of prostate cancer (PCa) at the time of MRI targeted biopsy, enhancing clinical risk assessment, and improving the ability to appropriately counsel patients regarding therapy.

Material and methods

A total of forty patients with prostate-specific antigen (PSA), mpMRI and Gleason score (based on MRI template-guided cognitive biopsy) results were analyzed in this study, with eight patients (20%) diagnosed with PCa. The mpMRI was performed to facilitate the decision to perform prostate biopsy. Spearman’s coefficient analysis was used to evaluate the relationships between characteristics. Diagnostic performance was assessed measuring the area under the curve (AUC) of the receiver operating characteristic (ROC) analysis. Diagnostic accuracy, sensitivity, and specificity were determined using the best cut-off on each ROC.

Results

Out of all the study group, 55% of patients were subjected to primary biopsy and 45% were directed to repeated TRUS-Bx with the suspicion of prostate cancer. Forty suspected lesions on MRI images were identified with 5% of PI-RADS 1, 17.5% of PI-RADS 2, 32.5% of PI-RADS 3, 27.5% of PI-RADS 4 (27.5%) and 17.5% of PI-RADS 5. The highest correlation was observed for mpMRI results and Gleason score with Spearman’s coefficient equal to 0.41 (95% CI: 0.104-0.646). ROC analysis revealed that mpMRI discriminates between directing the patients for prostate biopsy or active surveillance with AUC = 0.771 (0.117, 95% CI: 0.542-1.001).

Conclusions

Introducing pre-biopsy mpMRI into our contemporary PCa diagnosis pathway increased the diagnostic yield of transrectal biopsy by increasing the prostate cancer detection. This enabled the introduction of clinically significant prostate cancer (csPCa) treatment. mpMRI application also allowed biopsy to be avoided among patients with no csPCa.