Best approach for prostate cancer detection: a prospective study on transperineal versus transrectal six-core prostate biopsy

Shifting to transperineal prostate biopsy: A narrative review

To address the limitations and challenges associated with transrectal (TR) biopsy and to present transperineal (TP) biopsy as a viable and potentially safer alternative to TR biopsy. Prostate cancer (PCa) is a significant global health concern. The prevalence of advanced-stage prostate cancer in Asia is higher than that in the United States, emphasizing the need for effective screening and diagnosis methods. The gold standard of diagnosis is a TR biopsy. However, it has limitations due to the risk of infection and potential complications, such as injury to the rectal artery. Efforts have been made to address issues such as false-negative biopsies, under-sampling, and over-sampling through MRI-guided biopsies. However, the TR approach makes it difficult to access the apical and anterior regions of the prostate. TP biopsy has emerged as an alternative to address the limitations of TR biopsy. Nevertheless, a TP biopsy is a painful procedure, requiring the use of general anesthesia and expensive equipment. As a result, it has been perceived as costly and time-consuming. In addition, it requires a steep learning curve. The introduction of local anesthesia such as pudendal nerve block and the adoption of freehand techniques have contributed to the feasibility of performing TP biopsy. Recent research indicates that freehand TP biopsy can yield comparable diagnostic results to template-guided approaches. The diagnostic performance, cancer detection rates, and complication rates of TP biopsy have demonstrated its potential as a safe and effective diagnostic method.

A prospective cohort of men with localized prostate cancer on active surveillance protocol in Hong Kong, China: what did we learn?

This study aimed to report the outcomes of active surveillance (AS) in the management of low-risk prostate cancer (PCa). It recruited 87 men who were prospectively followed up according to the Prostate Cancer Research International Active Surveillance (PRIAS) protocol with local adaptation at SH Ho Urology Centre, Prince of Wales Hospital, Hong Kong, China. We investigated the predictors of disease progression and found that baseline prostate-specific antigen density (PSAD) and the presence of the highest Prostate Imaging-Reporting and Data System (PI-RADS) score 5 lesion on magnetic resonance imaging (MRI) are significantly correlated with disease progression. Moreover, men with PSAD >0.2 ng ml-2 or PI-RADS 4 or 5 lesions had significantly worse upgrading-free survival compared to those with PSAD ≤0.2 ng ml-2 and PI-RADS 2 or 3 lesions. The study concludes that AS is a safe and effective management strategy for selected patients to defer radical treatment and that most disease progression can be detected after the first repeated biopsy. The combination of PSAD >0.2 ng ml-2 and PI-RADS 4 or 5 lesions may serve as a useful predictor of early disease progression and provide a guide to optimize follow-up protocols for men in different risk groups.

Updated prevalence of latent prostate cancer in Chinese population and comparison of biopsy results: An autopsy-based study

Prostate cancer detected by autopsy is named latent prostate cancer. As the repertoire of clinical prostate cancer, latent cancer may better reflect the disease burden. Unlike clinical prostate specimens, which are obtained exclusively from biopsy-positive cases, prostate specimens obtained through autopsy provide information on biopsy-negative cases, helping calculate the true sensitivity of prostate biopsy. From 2014 to 2021, we collected autopsy specimens of the prostate from body donors in China and performed transperineal and transrectal biopsies on specimens before step-sectioning and pathological measurements. We found that the crude prevalence of latent prostate cancer in middle-aged and elderly men was 35.1% (81/231), which was higher than previous estimates for Chinese populations. The overall per-patient sensitivities of transperineal and transrectal biopsies were not significantly different (33.3% vs. 32.1%, p = 0.82), but the two approaches differed in preferential sampling area along the proximal-distal axis of the prostate. Transperineal biopsy had a higher sensitivity for detecting clinically significant lesions in the distal third (34.7% vs. 16.3%, p = 0.02) and distal half (30.6% vs. 18.1%, p = 0.04), while transrectal biopsy had a higher sensitivity for lesions in the proximal half (25.0% vs. 13.9%, p = 0.046). Both transperineal and transrectal methods of biopsy missed most small lesions (<0.1 mL) and 35.3% (6/17) of large lesions (>0.5 mL). In conclusion, the prevalence of latent prostate cancer in China has increased over the past 2 decades. Systematic transperineal and transrectal methods of biopsy had comparable sensitivities but had different preferential sampling areas. Both approaches miss one-third of large lesions.

A Novel Magnetic Resonance Imaging/Ultrasound Fusion Prostate Biopsy Technique Using Transperineal Ultrasound: An Initial Experience

OBJECTIVE

To report an initial experience with a novel, "fully" transperineal (TP) prostate fusion biopsy using an unconstrained ultrasound transducer placed on the perineal skin to guide biopsy needles inserted via a TP approach.

METHODS

Conventional TP prostate biopsies for detection of prostate cancer have been performed with transrectal ultrasound, requiring specialized hardware, imposing limitations on needle trajectory, and contributing to patient discomfort. Seventy-six patients with known or suspected prostate cancer underwent 78 TP biopsy sessions in an academic center between June 2018 and April 2022 and were included in this study. These patients underwent TP prostate fusion biopsy using a grid or freehand device with transrectal ultrasound as well as TP prostate fusion biopsy using TP ultrasound in the same session. Per-session and per-lesion cancer detection rates were compared for conventional and fully TP biopsies using Fisher exact and McNemar's tests.

RESULTS

After a refinement period in 30 patients, 92 MRI-visible prostate lesions were sampled in 46 subsequent patients, along with repeat biopsies in 2 of the 30 patients from the refinement period. Grade group ≥2 cancer was diagnosed in 24/92 lesions (26%) on conventional TP biopsy (17 lesions with grid, 7 with freehand device), and in 25/92 lesions (27%) on fully TP biopsy (P = 1.00), with a 73/92 (79%) rate of agreement for grade group ≥2 cancer between the two methods.

CONCLUSION

Fully TP biopsy is feasible and may detect prostate cancer with detection rates comparable to conventional TP biopsy.

Transperineal vs. transrectal prostate biopsies under local anesthesia: A prospective cohort study on patient tolerability and complication rates

OBJECTIVES

An increasing number of urologists is switching from transrectal (TR) to transperineal (TP) biopsy procedures for the diagnosis of prostate cancer. Local anesthesia (LA) might be advantageous in terms of patient management, risks and costs. We aimed to evaluate the tolerability and complication rates of TP prostate biopsy performed under LA.

METHODS

This is a monocentric, prospective, comparative, observational cohort study. Between July 2020 and July 2021 we included 128 consecutive patients (TR, n = 61; TP, n = 67), with a suspicion of prostate cancer. Transrectal vs. transperineal prostate biopsies were both performed under LA. To evaluate the tolerability we administered a validated visual analog pain score (VAS) during the different steps of the biopsy procedure as well as at 12-, 24- and 48-hours post procedure. The International Prostate Symptom Score (IPSS) questionnaire was administered before the procedure and at the same time intervals. The presence of hematuria, hematospermia, rectal blood loss, acute retention and febrile urinary tract infection (UTI) were also monitored.

RESULTS

There were no significant differences in pain or IPSS between groups, except for a significantly higher pain score during the LA of the prostate in the TP group. In general, complication rates were similar, only the prevalence of hematuria at 24 hours was significantly higher in the TP group, as was rectal blood loss at 12 hours postprocedure in the TR group.

CONCLUSIONS

In conclusion, our study showed that transperineal prostate biopsy under local anesthesia could be performed with similar pain scores and complication rates, compared to the transrectal procedure.

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.

Image-guided prostate biopsy robots: A review

At present, the incidence of prostate cancer (PCa) in men is increasing year by year. So, the early diagnosis of PCa is of great significance. Transrectal ultrasonography (TRUS)-guided biopsy is a common method for diagnosing PCa. The biopsy process is performed manually by urologists but the diagnostic rate is only 20%-30% and its reliability and accuracy can no longer meet clinical needs. The image-guided prostate biopsy robot has the advantages of a high degree of automation, does not rely on the skills and experience of operators, reduces the work intensity and operation time of urologists and so on. Capable of delivering biopsy needles to pre-defined biopsy locations with minimal needle placement errors, it makes up for the shortcomings of traditional free-hand biopsy and improves the reliability and accuracy of biopsy. The integration of medical imaging technology and the robotic system is an important means for accurate tumor location, biopsy puncture path planning and visualization. This paper mainly reviews image-guided prostate biopsy robots. According to the existing literature, guidance modalities are divided into magnetic resonance imaging (MRI), ultrasound (US) and fusion image. First, the robot structure research by different guided methods is the main line and the actuators and material research of these guided modalities is the auxiliary line to introduce and compare. Second, the robot image-guided localization technology is discussed. Finally, the image-guided prostate biopsy robot is summarized and suggestions for future development are provided.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Transperineal ultrasound-guided prostate biopsy: what the radiologist needs to know

Transperineal ultrasound-guided (TP) prostate biopsy has been shown to significantly decrease the risk of post-procedural sepsis when compared to transrectal ultrasound-guided (TRUS) prostate biopsy. With guidance from the European Urology Association favouring adoption of a TP biopsy route, it is clear that, despite being a more technically challenging procedure, TP biopsy in an outpatient setting will replace TRUS biopsy. This paper gives the reader a succinct summary of outpatient transperineal prostate biopsy under local anaesthetic utilising a free-hand ultrasound technique. Patient preparation and consent process is outlined. A comprehensive pictorial review of the procedure, pitfalls and common post-procedural outcomes is presented. This paper provides a framework and guide for those wishing to adopt the transperineal approach under local anaesthetic.

Magnetic Resonance Imaging/Ultrasound Fusion-guided Transperineal Versus Magnetic Resonance Imaging/Ultrasound Fusion-guided Transrectal Prostate Biopsy-A Systematic Review

CONTEXT

Magnetic resonance imaging (MRI)-targeted biopsies have changed the dogma in prostate cancer diagnosis. Biopsies can be performed either transrectally (MRI-guided and transrectal ultrasound fusion transrectal biopsy [MRI-TRUSB]) or transperineally (MRI-guided and transrectal ultrasound fusion transperineal biopsy [MRI-TPB]).

OBJECTIVE

To evaluate the detection and complication rates of MRI-TRUSB and MRI-TPB.

EVIDENCE ACQUISITION

We performed a literature search in PubMed, Scopus, EMBASE, and CENTRAL, and selected randomized controlled trials (RCTs) and observational studies comparing MRI-TRUSB versus MRI-TPB.

EVIDENCE SYNTHESIS

Our search identified 3608 studies; we included five in the qualitative and two in the quantitative synthesis. On per-patient pooled analysis for clinically significant prostate cancer (csPCa), MRI-TPB detection rates were significantly higher (relative risk 1.28 [95% confidence interval {CI} 1.03-1.60], p =  0.03). On a per-lesion analysis, MRI-TPB anterior csPCa detection rates were statistically significantly higher (relative risk 2.46 [95% CI 1.22-4.98], p =  0.01). On a per-lesion analysis, MRI-TPB and MRI-TRUSB overall cancer detection rates were 75% and 81.6% (p= 0.53), and csPCa detection rates were 65.7% and 75.5% (p =  0.40), respectively. MRI-TPB had lower complication rates (odds ratio 2.56 [95% CI 1.14-5.56, p <  0.05]). On Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evaluation, we rated all outcomes as "very low" certainty of the evidence for all outcome measures.

CONCLUSIONS

This review highlights the paucity of good-quality evidence comparing MRI-TPB and MRI-TRUSB. MRI-TPB achieves better detection for csPCa, anterior tumors, and lower infective complications. While RCTs are the highest quality of evidence that can address existing evidence limitations, there are concerns regarding infective complications associated with the MRI-TRUSB. Therefore, the authors propose that researchers and clinicians adopt a pragmatic approach by maintaining prospective databases, internal auditing of the MRI-TPB approach, and comparing these data with historical MRI-TRUSB cohorts.

PATIENT SUMMARY

We looked at the outcomes by comparing magnetic resonance imaging (MRI)-guided and transrectal ultrasound fusion transrectal biopsy with MRI-guided and transrectal ultrasound fusion transperineal biopsy (TPB). The analysis suggests, based on very low certainty evidence, that MRI-TPB has better detection for clinically significant prostate cancer, anterior tumors, and lower complications.

Assessing the diagnostic performance of systematic freehand PrecisionPoint transperineal prostate biopsy: Comparison of observed outcomes to PBCG nomogram predictions

OBJECTIVE

We assessed the diagnostic performance of freehand systematic transperineal biopsy (fTPb) by using the Prostate Biopsy Collaborative Group (PBCG) nomogram, which is a contemporary update to the PCPT nomogram.

METHODS

From 1/2012 to 12/2018, fTPb was performed on consecutive men with clinical suspicion of prostate cancer. Patients included in this study had no previous diagnosis of prostate cancer, PSA between 2.5 ng/ml and 20 ng/ml, and underwent at least 12 core biopsies. In addition, those men who underwent pre-biopsy multiparametric magnetic resonance imaging of the prostate were considered separately from those without prebiopsy imaging. Biopsies were performed by a single urologist who developed the needle guidance device used in the procedure. Clinical and pathological data were collected retrospectively. We compared observed biopsy outcomes with those predicted by PBCG nomogram utilizing chi-square statistical analysis.

RESULTS

Systematic fTPb (without pre-biopsy MRI) was performed in 301 men (median age 67, mean PSA 6.9 ng/mL). These men had a median of 20 biopsy cores. Clinically significant cancer (ISUP 2 or greater) was found in 33.9% of men. In men without pre-biopsy MRI, using PBCG Nomogram, we found no significant difference between the expected and observed number of clinically significant cancer (96 vs. 102; P = 0.09). An additional 73 men (median age 67, mean PSA 7.8 ng/ml) underwent pre-biopsy MRI imaging. The addition of MRI targets to systematic sampling resulted in a median of 25 cores. Clinically significant cancer was found in 49.3%. Using the PBCG Nomogram, in the men with pre-biopsy MRI we found clinically significant cancer in significantly more men than was expected by PBCG nomogram predictions (36 vs. 20; P = <0.01). There were no biopsy-related infectious complications.

CONCLUSION

The fTPb technique is a promising method to sample the prostate which provides cancer detection that is comparable to that expected from systematic TRUS biopsy. We found that pre-biopsy mpMRI resulted in greater than expected detection of clinically significant cancer when utilizing this technique.

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

Objectives

Patients and methods

Results

Conclusion

Are outpatient transperineal prostate biopsies without antibiotic prophylaxis equivalent to standard transrectal biopsies for patient safety and cancer detection rates?A retrospective cohort study in 222 patients

BACKGROUND

To describe our experience with outpatient transperineal biopsy (TPB) without antibiotics compared to transrectal biopsy (TRB) with antibiotics and bowel preparation. The literature elicits comparable cancer detection, time, and cost between the two. As antibiotic resistance increases, antimicrobial stewardship is imperative.

METHODS

In our retrospective review, we compared the TPB to TRB in our institution for outpatient prostate biopsies with local anesthesia from June 1st, 2017 to June 1st, 2019. Patients had negative urinalysis on day of procedure. Patients presenting with symptoms concerning for UTI followed by positive urine culture were determined to have a UTI.

RESULTS

Two hundred twenty-two patients met inclusion criteria. Age, race, BMI, pre-procedure PSA, history of UTI, BPH or other GU history were similar between both groups. Two TPB patients (1.8%) had post-procedure UTI; one received oral antibiotics and one received a dose of intravenous and subsequent oral antibiotics. There were no sepsis events or admissions. Six TRB patients (5.4%) had post-procedure UTI; five received oral antibiotics, and one received intravenous antibiotics and required admission for sepsis. One TPB patient (0.9%) had post-procedure retention and required catheterization, while four TRB patients (3.6%) had retention requiring catheterization. No significant difference noted in cancer detection between the two groups.

CONCLUSION

Outpatient TPB without antibiotic prophylaxis/bowel prep is comparable to TRB in regard to safety and cancer detection. TPB without antibiotics had a lower infection and retention rate than TRB with antibiotics. Efforts to reduce antibiotic resistance should be implemented into daily practice. Future multi-institutional studies can provide further evidence for guideline changes.

Evaluation of In-Office MRI/US Fusion Transperineal Prostate Biopsy via Free-hand Device during Routine Clinical Practice

OBJECTIVES

To describe our recent experience with in-office transperineal prostate biopsy, including the adoption of software-assisted MRI/US fusion technology. Technological improvements have recently allowed transperineal biopsy to be effectively integrated into outpatient practices with negligible risk of infection.

METHODS

We retrospectively reviewed a cohort of men undergoing transperineal prostate biopsy from 2018-2020, at a single institution. We compared this to another cohort of men undergoing transrectal fusion biopsy from 2014-2018, matched to the first cohort based on age, PSA, and presence of prostate cancer diagnosis prior to biopsy. All patients underwent systematic transperineal templated biopsies in addition to fusion biopsies of MRI-visible lesions. Baseline characteristics, MRI findings, biopsy results, and complications were analyzed and compared between the 2 groups.

RESULTS

One-hundred and thirty men underwent transperineal prostate biopsy, and 130 men underwent transrectal fusion biopsy. Of those who underwent transperineal biopsy, 30% underwent fusion biopsy while all men with the transrectal biopsy underwent fusion biopsy. Men who underwent transperineal vs transrectal biopsy demonstrated lower infection rates (0% vs 0.8%, P = .31) with fewer prophylactic antibiotics prescribed at provider's discretion (48% vs 100%), yet higher total post-biopsy complication rates (6.1% vs 0.8%, P = .036).

CONCLUSION

Our initial experiences with transperineal prostate biopsy confirm prior findings demonstrating feasibility in outpatient urologic practice without infectious complication. Software-assisted MRI/US fusion technology can be successfully integrated with transperineal biopsies to target suspicious lesions. Higher rates of non-infectious complications were observed compared with transrectal biopsy. Further analysis is needed to determine whether risk profiles improve over the learning curve of this newly implemented approach.

Development of a transperineal prostate biopsy robot guided by MRI-TRUS image

BACKGROUND

In the transrectal ultrasound (TRUS)-guided transperineal prostate biopsy, doctors determine the biopsy target by observing the prostate region in TRUS images. However, ultrasound images with low imaging quality make doctors easy to be interfered when determining the biopsy route, which reduces the biopsy success rate.

METHODS

This paper introduces the guidance method of magnetic resonance image (MRI) registration to ultrasound image and develops a 5-degrees of freedom robot for prostate biopsy guided by MRI-TRUS image. The robot uses a structure attached to the ultrasound probe to reduce the space occupied. By registering the posture relationship between MRI, TRUS image, ultrasonic probe and the robot base, the accurate localization of the suspected lesion area can be achieved with the preoperative MRIs.

RESULTS

The prostate phantom biopsy based on the robotic biopsy system in this paper, the average biopsy error is 1.44 mm, and the maximum biopsy error is 2.23 mm.

CONCLUSIONS

We build a robotic biopsy platform with prostate phantom, and evaluate the biopsy accuracy of MRI-TRUS guided prostate biopsy robot, the results meet clinical prostate biopsy requirements.

Free-Hand Transperineal Prostate Biopsy Under Local Anesthesia in the Office Without Antibiotic Prophylaxis: Experience with 304 Cases

Background: We present our series of free-hand transperineal prostate biopsy (fTP-Bx) using a novel coaxial needle introducer guide. All cases were performed in the office under local anesthesia (LA) without sedation. The majority received no prophylactic antibiotics. Materials and Methods: We retrospectively reviewed the electronic medical records of 242 consecutive fTP-Bx cases using the PrecisionPoint™ Transperineal Access System (PPTAS) performed under LA without sedation by a single urologist (R.J.S.) at Kaiser Permanente Southern California. We compared complication rates of this series of cases to our initial series of 62 fTP-Bx cases without the PrecisionPoint as well as 133 transrectal prostate biopsy cases performed before we adopted the transperineal approach. Results: Of the 242 consecutive free-hand transperineal biopsies performed between August 26, 2016 and December 31, 2018, 212 (88%) received no antibiotic prophylaxis. Medians for age, prostate-specific antigen, prostate volume, prostate-specific antigen density, and cores sampled were 63 years, 7.2 ng/mL, 50 mL, 0.15 ng/mL/cc, and 20 cores, respectively. Detection rates of overall and clinically significant prostate cancer averaged 43.4% (105/242) and 14% (35/242), respectively. Average visual analog scale pain rating was 3.9 and average procedure time was 20 minutes. Complication rates of sepsis, acute urinary retention, clot retention, and perianal abscess were 0.0% (0/242), 0.4% (1/242), 1.2% (3/242) and 0.4% (1/242), respectively. Conclusions: This series of office-based free-hand transperineal biopsy under LA without sedation performed with the PPTAS contains a large number of cases in which prophylactic antibiotics were not administered, yet there were no complications of postbiopsy sepsis. However, there was one case of a delayed perianal abscess. fTP-Bx under LA enables the easy integration of transperineal biopsy into a normal outpatient clinic workflow.

"Free-Hand" Transperineal Prostate Biopsy Under Local Anesthesia: Review of the Literature

Background: The recent plethora of reports of "free-hand" transperineal prostate biopsy (fTP-Bx) under local anesthesia (LA) demonstrate that many centers consider this technique to be a safer and possibly more accurate approach to prostate biopsy in the clinic setting. Materials and Methods: The literature was searched for fTP-Bx, and summary tables were compiled. Studies on the costs of postprostate biopsy sepsis were also researched. Results: The search found 11,999 cases of fTP-Bx under LA with and without sedation over 29 mutually exclusive studies. Pooled averages calculated for age, prostate-specific antigen (PSA), prostate volume, PSA density, and cores sampled were 67.3 years, 10.4 ng/mL, 47.7 mL, 0.24 ng/mL/cc, and 15.3 cores, respectively. Detection of overall prostate cancer (PCa) and clinically significant (Gleason score ≥7) prostate cancer (csPCa) averaged 45.5% (3796/8338) and 25.1% (1141/4541), respectively. After subgrouping the studies by biopsy technique, studies that used MRI/ultrasound fusion-targeted biopsy in some or all biopsy cases averaged an overall PCa and csPCa detection rate of 50.0% (741/1483) (p < 0.0001) and 42.8% (635/1483) (p < 0.0001), respectively. Visual analog scale pain ratings and procedure times averaged 3.17 and 13.1 minutes, respectively. Averages for complications of sepsis and acute urinary retention were 0.0% (0/7396) and 2.1% (120/5693), respectively. A total of 10.2% (1055/10,334) of cases received no antibiotic prophylaxis. If fTP-Bx under LA replaced transrectal prostate biopsy (TR-Bx) in the United States, the estimated annual savings would be $341,676,800-$752,540,000 through the virtual elimination of admissions for postbiopsy sepsis. Conclusions: Many centers around the world have adopted fTP-Bx because it virtually eliminates sepsis, may improve detection rates of csPCa and can be easily integrated into a normal clinic workflow using only LA. If all urologists in the United States abandoned TR-Bx for fTP-Bx, the potential savings in health care costs of complications would be significant.

Optimizing biopsy strategy for prostate cancer: Bayesian framework of network meta-analysis and hierarchical summary receiver operating characteristic model for diagnostic accuracy

Overdiagnosis and overtreatment are well known problems in prostate cancer (PCa). The transrectal ultrasound (TRUS) Guided biopsy (GB) as a current gold standard investigation has a low positive detection rate resulting in unnecessary biopsies. The choice of optimal biopsy strategy needs to be defined. Therefore, we undertook a Bayesian network meta analysis (NMA) and Bayesian prediction in the hierarchical summary receiver operating characteristic (HSROC) model to present a method for optimizing biopsy strategy in PCa. Twenty eight relevant studies were retrieved through online databases of EMBASE, MEDLINE, and CENTRAL up to February 2020. Markov chain Monte Carlo simulation and Surface Under the Cumulative RAnking curve were used to calculate the rank probability using odds ratio with 95% credible interval. HSROC model was used to formulate the predicted true sensitivity and specificity of each biopsy strategy. Six different PCa biopsy strategies including transrectal ultrasound GB (TRUS GB), fusion GB (FUS GB), fusion + transrectal ultrasound GB (FUS + TRUS GB), magnetic resonance imaging GB (MRI GB), transperineal ultrasound GB (TPUS GB), and contrast enhanced ultrasound GB were analyzed in this study with a total of 7584 patients. These strategies were analyzed on five outcomes including detection rate of overall PCa, clinically significant PCa, insignificant PCa, complication rate, and HSROC. The rank probability showed that the overall PCa detection rate was higher in FUS + TRUS GB, MRI GB, and FUS GB. In terms of clinically significant PCa detection, FUS + TRUS GB and FUS GB had a relatively higher clinically significant PCa detection rate, whereas TRUS GB had a relatively lower rate for clinically significant PCa detection rate. MRI GB (91% and 81%) and FUS GB (82% and 83%) had the highest predicted true sensitivity and specificity, respectively, whereas TRUS GB (62% and 83%) had a lower predicted true sensitivity and specificity. MRI GB, FUS GB, and FUS + TRUS GB were associated with lower complication rate, whereas TPUS GB and TRUS GB were more associated with higher complication rate. This NMA and HSROC model highlight the important finding that FUS + TRUS GB, FUS GB, and MRI GB were superior compared with other strategies to avoid the overdiagnosis and overtreatment of PCa. FUS GB, MRI GB, and FUS + TRUS GB had lower complication rates. These results may assist in shared decision making between patients, carers, and their surgeons.

Transperineal prostate biopsy: The modern gold standard to prostate cancer diagnosis

In patients suspicious for prostate cancer, a prostate biopsy should be performed. Biopsies are possible either by the transrectal or transperineal routes. Compared with the transrectal prostate biopsy (TRPBx), transperineal prostate biopsy (TPPBx) offers a non-inferior cancer detection rate (CDR), especially in patients undergoing re-biopsy for persistently elevated PSA and in cases of active surveillance (AS), in which TPPBx seems to be superior. Moreover, the transperineal route achieves superior sampling of the anterior and apical regions, especially after previous multiple negative TRPBx. Infectious complications are nullified due to avoidance of needle passage through the rectal mucosa, and there is a highly significant evidence of reduced fever and sepsis rates when compared with TRPBx, with maintaining acceptable urinary retention rates. This is an important upcoming topic due to the increasing antibiotic resistance rates, thus reducing periinterventional hospitalization and health care costs. To date, TPPBx is perfectly feasible in the inpatient and out-patient settings and under local anesthesia, characterized by a moderate learning curve and a good reproducibility. By applying mpMRI as a diagnostic tool, clinically significant prostate cancer (csPCa) detection seems to be comparable to transrectal MRI-fusion biopsy (TR-MRIFBx). Finally, focal treatment of localized disease is currently performed exclusively through a TP approach.

Infectious complications of prostate biopsy: winning battles but not war

BACKGROUND

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

OBJECTIVE AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Transperineal Free-hand mpMRI Fusion-targeted Biopsies Under Local Anesthesia: Technique and Feasibility From a Single-center Prospective Study

OBJECTIVE

To evaluate the feasibility of "in-office" TPFBx under local anesthesia (LA).

MATERIALS AND METHODS

We prospectively screened for eligibility data of 724 consecutive men undergoing either TPFBx (target and systematic cores) or TPSBx (systematic cores only) from September 2016 to June 2018 due to suspicion of prostate cancer (CaP), according to predefined exclusion criteria.

RESULTS

We included 459 men (TPFBx n = 279 including n = 338 mpMRI lesions, Pi-RADS 4 in 63.6%; TPSBx n = 180). Median procedural time and maximum pain were 19 minutes and 5 numeric rating scale (NRS) points; pain was highest at the time of LA. Only 1 major complication occurred (Clavien 3a). Hematuria and hematospermia were frequent (72.6% and 54.2%). Vaso-vagal reactions and AUR were rare (0.7% and 0.4%). No cases of UTI and 1 case of fever were recorded. No significant changes in erectile and urinary functions were noted from baseline compared to 40 days after TPFBx (P = .86 and P = .89). In comparison with TPSBx the sole differences were pain during prostatic sampling (P = .03), duration of hematospermia (P <.0001) and procedural time (P <.001) all higher for TPFBx. Clinically significant (cs) CaP was detected in n = 150 (53.8%) patients in the TPFBx group (34.9%, 51.7%, and 75% of Pirads 3, 4, and 5, respectively). Addition of systematic cores detected n = 25 csCaP that were missed by targeted cores (17.4% of all csCaP).

CONCLUSION

TPFBx under LA are feasible, yielding high tolerability, low complications, no impact on erectile and urinary function and good csCaP detection. Addition of systematic to targeted cores remains recommended. Further studies are needed to confirm our findings.

A noninferiority within-person study comparing the accuracy of transperineal to transrectal MRI-US fusion biopsy for prostate-cancer detection

BACKGROUND

Magnetic resonance imaging (MRI) and ultrasound (US) fusion prostate-biopsies can be performed in a transrectal (TR-fusion) or transperineal (TP-fusion) approach. Prospective comparative evidence is limited. In this study we compared the detection rate of clinically-significant prostate-cancer (csPCa) within an index lesion between TR and TP-fusion.

PATIENTS AND METHODS

This was a prospective, noninferiority, and within-person trial. Men scheduled for MRI-US-fusion with a discrete MRI PI-RRAD ≥ 3 lesion were included. A dominant index lesion was determined for each subject and sampled by TR and TP-fusion during the same session. The order of biopsies was randomized and equipment was reset to avoid chronological and incorporation bias. For each subject, the index lesion was sampled 4-6 times in each approach. All biopsies were performed using Navigo fusion software (UC-Care, Yokneam, Israel). csPCa was defined as: Grade Group ≥ 2 or cancer-core length ≥ 6 mm. We used a noninferiority margin of 10% and a one-sided alpha level of 5%.

RESULTS

Seventy-seven patients completed the protocol. Median age was 68.2 years (IQR:64.2-72.2), median PSA was 8.9 ng/ml (IQR:6.18-12.2). Ten patients (13%) were biopsy naive, others (87%) had a previous biopsy. csPCa was detected in 32 patients (42%). All of these cases were detected by TP-fusion, while only 20 (26%) by TR-fusion. Absolute difference for csPCa diagnosis was 15.6 (CI 90% 27.9-3.2%) in favor of TP-fusion (p = 0.029). TP-fusion was noninferior to TR-fusion. The lower boundary of the 90% confidence-interval between TP-fusion and TR-fusion was greater than zero, therefore TP-fusion was also found to be superior. Exploratory subgroup analyses showed TP-fusion was consistently associated with higher detection rates of csPCa compared with TR-fusion in patient and index-lesion derived subgroups (size, location, PI-RADS, PSA, and biopsy history).

CONCLUSIONS

In this study, TP-fusion biopsies were found to be noninferior and superior to TR-fusion biopsies in detecting csPCa within MRI-visible index lesion. Centers experienced in both TP and TR-fusion should consider these results when choosing biopsy method.

Comparisons of cancer detection rate and complications between transrectal and transperineal prostate biopsy approaches - a single center preliminary study

Background

Prostate biopsy remains the gold standard approach to verify prostate cancer diagnosis. Transrectal (TR) biopsy is a regular modality, while transperineal (TP) biopsy is an alternative for the patients who display persistently high levels of prostate-specific antigen (PSA) and thus have to undergo repeat biopsy. This study aimed to compare the cancer detection rates between TR and TP approaches and assess the post-bioptic complications of the two procedures. Besides, the feasibility of performing TP biopsies under local anesthesia was also evaluated.

Methods

A total of 238 outpatient visits meeting the criteria for prostate cancer biopsy were enrolled for this study. They were divided into two groups: the TP group (n = 130) consists of patients destined to undergo local anesthetic TP biopsy; and the TR group (n = 108) contained those who received TR biopsy as comparison. Age, PSA level, digital rectal exam (DRE) finding, prostate volume, and biopsy core number were used as the parameters of the multivariable analyses. The comparable items included cancer detection rate, complication rate, admission rate and visual analog scale (VAS) score.

Results

The cancer detection rates between TP and TR groups were quite comparable (45% v.s. 49%) (p = 0.492). However, the TP group, as compared to the TR group, had significantly lower incidence of infection-related complications (except epididymitis and prostatitis) that commonly occur after biopsies. None of the patients in the TP group were hospitalized due to the post-bioptic complications, whereas there was still a minor portion of those in the TR group (7.4%) requiring hospitalization after biopsy. Medians (25–75% quartiles) of visual analog scale (VAS) were 3 [3, 4] and 4 [3–5] respectively for the TP and TR procedures under local anesthesia, but no statistical significance existed between them (p = 0.085).

Conclusions

Patients receiving TP biopsy are less likely to manifest infection-related complications. Therefore, TP biopsy is a more feasible local anesthetic approach for prostate cancer detection if there are concerns for infectious complications and/or the risk of general anesthesia.

Prostate MRI and transperineal TRUS/MRI fusion biopsy for prostate cancer detection: clinical practice updates

This narrative review summarizes the current knowledge about multiparametric and biparametric magnetic resonance imaging of the prostate. This is provided from both a radiological and a urological point of view analyzing the technical aspects of fusion-targeted biopsy using the transperineal approach. We report practical considerations concerning pure cognitive and software-assisted settings, discuss the principal transperineal fusion software now available, and debate the pros and cons of choosing one approach over the other.

Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: a systematic review and meta-analysis

Background

Because conventional prostate biopsy has some limitations, optimal variations of prostate biopsy strategies have emerged to improve the diagnosis rate of prostate cancer. We conducted the systematic review to compare the diagnosis rate and complications of transperineal versus transrectal prostate biopsy.

Main body of the abstract

We searched for online publications published through June 27, 2018, in PubMed, Scopus, Web of Science, and Chinese National Knowledge Infrastructure databases. The relative risk and 95% confidence interval were utilized to appraise the diagnosis and complication rate. The condensed relative risk of 11 included studies indicated that transperineal prostate biopsy has the same diagnosis accuracy of transrectal prostate biopsy; however, a significantly lower risk of fever and rectal bleeding was reported for transperineal prostate biopsy. No clue of publication bias could be identified.

Short conclusion

To conclude, this review indicated that transperineal and transrectal prostate biopsy have the same diagnosis accuracy, but the transperineal approach has a lower risk of fever and rectal bleeding. More studies are warranted to confirm these findings and discover a more effective diagnosis method for prostate cancer.

Electronic supplementary material

The online version of this article (10.1186/s12957-019-1573-0) contains supplementary material, which is available to authorized users.

Controversies in MR targeted biopsy: alone or combined, cognitive versus software-based fusion, transrectal versus transperineal approach?

PURPOSE

To review the evidence addressing current controversies around prostate biopsy. Specific questions explored were (1) mpMRI targeted (TgBx) alone versus combined with systematic (SBx) biopsy; (2) cognitive versus software-based targeted biopsy; (3) transrectal or transperineal route (TP).

METHODS

We performed a literature search of peer-reviewed English language articles using PubMed and the words "prostate" AND "biopsy". Web search was implemented by manual search.

RESULTS

Prostate mpMRI is revolutionizing prostate cancer (PCa) diagnosis, and TgBx improves the detection of clinically significant (cs) PCa compared to SBx alone. The utility of combining SBx-TgBx is variable, but in non-expert centres the two should be combined to overcome learning curve-limitations. Whether SBx should be maintained in expert centres depends on what rate of missed cancer the urological community and patients are prone to accept; this has implications for insignificant cancer diagnosis as well. TgBx may be more precise using a software-based-approach despite cognitive TgBx proved non-inferior in some studies, and may be used for large accessible lesions. TP-biopsies are feasible in an in-office setting. Avoidance of the rectum and accessibility of virtually all prostate areas are attractive features. However, this has to be balanced with local setting and resources implications. Ongoing trials will shed light on unsolved issues.

CONCLUSION

The prostate biopsy strategy should be tailored to local expertise, needs and resources availability. Targeted biopsy enhance the ratio between cs and insignificant cancer diagnosis, although some csPCa might be missed. Software-based TgBx are likely to be more precise, especially for new users, although the additional cost might be not justified in all cases. TPBx have ideal attributes for performing TgBx and avoiding infection, although this has resources implications.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Ten-Year Study of Prostate Cancer: A Southern Iranian Experience

BACKGROUND

Prostate cancer is the most common malignancy among the male population in the United States and the 3rd most common non-skin cancer among men in Iran. Its prevalence has shown a rising trend in recent decades. The aim of this study was to report the epidemiological features of prostate cancer in patients referred for prostate biopsy in the south of Iran and to evaluate the accuracy of the levels of the prostate-specific antigen (PSA) and the PSA-density (PSAD) as well as the extension of the disease in the prediction of the biological behavior of prostate cancer.

METHODS

This is a retrospective study on the medical records of 1982 consecutive patients who underwent transrectal ultrasound-guided biopsy due to an abnormal digital rectal examination and/or an elevated PSA level following referral from the Urology Ward to the Radiology Department of Shahid Faghihi Hospital in Shiraz, southern Iran, between December 2003 and July 2014.

RESULTS

The overall cancer detection rate was 33.1%. Although the cancer was more prevalent among the elderly patients, a significant fraction (7%) of the patients were aged < 55 years. The sensitivity and specificity of the PSA were 97.4% and 8.7% and those of the PSAD were 82.9% and 52%, respectively. Of the 637 patients with prostate cancer, 250 (39.2%) had unilateral disease, 378 (59.4%) had bilateral disease, and 9 (1.4%) had inner-gland involvement. Most of the patients with bilateral involvement had high-grade Gleason scores.

CONCLUSION

Our study underlines the relationship between age and the frequency of cancer; the levels of the PSA and the PSAD and the Gleason score; and the extent of tumor involvement and the grade of prostate cancer and also highlights the significance of screening, especially in younger patients.

Optimal biopsy strategy for prostate cancer detection by performing a Bayesian network meta-analysis of randomized controlled trials

Objective: With the increasing recognition of the over-diagnosis and over-treatment of prostate cancer (PCa), the choice of a better prostate biopsy strategy had confused both the patients and clinical surgeons. Hence, this network meta-analysis was conducted to clarify this question. Methods: In the current network meta-analysis, twenty eligible randomized controlled trials (RCTs) with 4,571 participants were comprehensively identified through Pubmed, Embase and Web of Science databases up to July 2017. The pooled odds ratio (OR) with 95% credible interval (CrI) was calculated by Markov chain Monte Carlo methods. A Bayesian network meta-analysis was conducted by using R-3.4.0 software with the help of package "gemtc" version 0.8.2. Results: Six different PCa biopsy strategies and four clinical outcomes were ultimately analyzed in this study. Although, the efficacy of different PCa biopsy strategies by ORs with corresponding 95% CrIs had not yet reached statistical differences, the cumulative rank probability indicated that overall PCa detection rate from best to worst was FUS-GB plus TRUS-GB, FUS-GB, CEUS, MRI-GB, TRUS-GB and TPUS-GB. In terms of clinically significant PCa detection, CEUS, FUS-GB or FUS-GB plus TRUS-GB had a higher, whereas TRUS-GB or TPUS-GB had a relatively lower significant detection rate. Meanwhile, TPUS-GB or TRUS-GB had a higher insignificant PCa detection rate. As for TRUS-guided biopsy, the general trend was that the more biopsy cores, the higher overall PCa detection rate. As for targeted biopsy, it could yield a comparable or even a better effect with fewer cores, compared with traditional random biopsy. Conclusion: Taken together, in a comprehensive consideration of four clinical outcomes, our outcomes shed light on that FUS-GB or FUS-GB plus TRUS-GB showed their superiority, compared with other puncture methods in the detection of PCa. Moreover, TPUS or TRUS-GB was more easily associated with the over-diagnosis and over-treatment of PCa. In addition, targeted biopsy was obviously more effective than traditional random biopsy. The subsequent RCTs with larger sample sizes were required to validate our findings.

Detection rate of prostate cancer following biopsy among the northern Han Chinese population: a single-center retrospective study of 1022 cases

BACKGROUND

Prostate cancer is known to have ethnic and regional differences. The study aimed to clinically evaluate the detection rate of prostate cancer on transrectal ultrasonography (TRUS)-guided prostate biopsy and analyze its characteristics among the northern Han Chinese population at a single center.

METHODS

Between October 2009 and September 2016, a total of 1027 Chinese men, who had undergone TRUS-guided prostate biopsy at Qingdao Municipal Hospital, were retrospectively analyzed. Prostate biopsies were performed in the case of an abnormally elevated serum PSA level, and/or abnormal digital rectal examination (DRE) findings, and/or suspicious prostatic imaging findings.

RESULTS

Of the 1022 men enrolled in the analysis, 438 patients (42.8%) were diagnosed with prostate adenocarcinoma histologically. When serum PSA levels were divided into five subgroups (less than 4.0, 4.0 to 10.0, 10.0 to 20.0, 20.0 to 100.0, and ≥ 100.0 ng/ml), the detection rates of prostate cancer were 12.4, 15.9, 34.1, 66.2, and 93.8%, respectively. With serum PSA levels of 4.0 to 10.0 ng/ml, the cancer detection rates for a normal DRE and a suspect DRE finding were 13.5 and 58.2%, respectively. Accordingly, the cancer detection rates for a normal imaging and a suspect imaging finding were 13.5 and 58.2%, respectively. Besides, a large proportion of the patients were in the clinically advanced stage.

CONCLUSIONS

The present study data reported a relatively higher prostate cancer detection rate of 42.8% and that the majority of the patients presented with clinically advanced prostate cancers within a local clinical urologic practice. An early detection and screening program for prostate cancer is of great need to reduce the burden from this disease among the northern Han Chinese population.

Characteristics of prostate cancer detection rate (PCDR) in Chinese Han population under different prostate biopsy methods

We analyzed the improvement of prostate cancer detection rate (PCDR) in Chinese Han population and summarized the characteristics of prostate cancer (PCa) with the advancement of prostate biopsy technologies. From March 1999 to March 2015, 3762 patients underwent the systematic 6-, 8- or 13-core biopsy, guided by finger or transrectal ultrasound (TRUS) at our center. The PCDR under different PSA intervals and different biopsy methods were analyzed. The trends of PSA level, age and Gleason score of PCa patients were summarized. The PCDR of finger-guided 6- and 8-core biopsies were 30.8% (340/1103) and 36.7% (147/401) respectively. In 2258 patients with TRUS-guided 13-core biopsies, 992 (43.9%) were diagnosed as PCa, higher than that with finger-guided biopsies (43.9% vs. 32.4%, p < 0.001). The PCDR of prostate peripheral zone was higher than that of medial zone (37.5% vs. 31.4%, p < 0.001). Interestingly, the PCDR of extra 13th core was higher than the mean positive rate of other 12 cores (70.7% vs. 56.0%, p < 0.001). The systematic 13-core prostate biopsy guided by TRUS is safe, effective, and economic for PCa diagnosis in developing countries like China. The extra 13th core biopsy is beneficial to increase the PCDR.

Comparison between transrectal and transperineal prostate biopsy for detection of prostate cancer: a meta-analysis and trial sequential analysis

To systematically assess the efficacy and complications of transrectal (TR) versus transperineal (TP) prostate biopsy in the detection of prostate cancer (PCa). A meta-analysis was performed by searching the databases Pubmed, Embase and Web of science for the relevant available studies until September 1st, 2016, and thirteen studies met the inclusion criteria. The pooled odds ratios with 95% confidence intervals were calculated to evaluate the differences of TR and TP groups in PCa detection rate. Then, trial sequential analysis was performed to reduce the risk of type I error and estimated whether the evidence of the results was reliable. Overall, this meta-analysis included a total of 4280 patients, who had been accrued between April 2000 and Aug 2014 and randomly divided into TR group and TP group. Prostate biopsies included sextant, extensive and saturation biopsy procedures. Patients who received TP prostate biopsy had no significant improvement in PCa detection rate, comparing TR group. Moreover, when comparing TR and TP studies, no significant difference was found in abnormal DRE findings, serum PSA level measurement, Gleason score, prostate volume. Besides, this meta-analysis showed no obvious differences between these two groups in terms of relevant complications. Therefore, this meta-analysis revealed that no significant differences were found in PCa detection rate between TP and TR approaches for prostate biopsy. However, with regard to pain relief and additional anesthesia, TR prostate needle biopsy was relatively preferable, compared to TP prostate biopsy.

Comparison between Ultrasound Guided Transperineal and Transrectal Prostate Biopsy: A Prospective, Randomized, and Controlled Trial

This prospective study of comparing transperineal prostate biopsy (TPBx) with transrectal prostate biopsy (TRBx) was aimed to provide evidence for clinicians to select the appropriate biopsy approach under different conditions. TPBx (n = 173) and TRBx (n = 166) were performed randomly for 339 patients who were suspicious of prostate cancer (PCa). The cancer detection rate (CDR), complication rate, visual analogue scale (VAS) score, most painful procedure, number of repeated biopsy and additional anesthesia, and operating time (starting from lying down on the operating table to getting up) were recorded. The results showed that TPBx and TRBx were equivalent in CDR (35.3% vs. 31.9%) and minor complication rate (44.9% vs. 41.0%) (both P > 0.05). The major complication rate was lower in TPBx than in TRBx (0.6% vs. 4.3%, P < 0.05). TPBx was more time-consuming (17.51 ± 3.33 min vs. 14.73 ± 3.25 min) and painful (VAS score: 4.0 vs. 2.0); and it had higher rates of repeated biopsy (3.2% vs. 1.1%) and additional anesthesia (15.0% vs. 1.2%) (all P < 0.05). In summary, both TPBx and TRBx are effective to detect PCa. The major complication rate for TRBx is higher, whereas TPBx procedure is more complex and painful.

Transperineal template-guided prostate biopsy: 10 years of experience

OBJECTIVE

To assess the efficacy and safety of transperineal template-guided prostate biopsy.

MATERIALS AND METHODS

From December 2003 to December 2013, a total of 3 007 patients (30-91 years old, mean age 69.1) who met the inclusion criteria underwent 11-region transrectal ultrasound-guided transperineal template prostate biopsy. The inclusion criteria included a prostate-specific antigen (PSA) level of 4.0 ng/mL or greater and abnormal prostate gland findings on digital rectal examination, ultrasound, CT or MRI. The median PSA level was 11.0 ng/mL (range 0.2-100 ng/mL). The prostate cancer detection rate and prostate biopsy adverse effects, as well as prostate cancer spatial distribution were analyzed.

RESULTS

A mean of 19.3 cores (range 11-44) were obtained for each biopsy, and more cores were obtained in larger prostates than in smaller ones. One to four cores were collected from each region. Prostate cancer was detected in 1 067 of the 3 007 patients (35.5%). The prostate cancer detection rates in groups with PSA levels of 0-4.0 ng/mL, 4.1-10.0 ng/mL, 10.1-20.0 ng/mL, 20.1-50.0 ng/mL, and 50.1-100.0 ng/mL were 15.3% (27/176), 21.0% (248/1 179), 32.6% (318/975), 56.0% (232/414), and 92.0% (241/262), respectively. The mean positives for cancer in regions 1-10 and region 11 (the apical region) were 46.7% vs 52.0% (P = 0.014). Regarding adverse effects, 47.0% of the patients reported hematuria, 6.1% developed hemospermia, 1.9% required short-term catheterization after biopsy because of acute urinary retention, and 0.03% (one patient) developed urosepsis.

CONCLUSIONS

Transrectal ultrasound-guided transperineal template prostate biopsy is safe and accurate. The current study suggests that prostate carcinoma foci are more frequently localized in the apical region.

Prostate Biopsy Using Transrectal Ultrasonography; The Optimal Number of Cores Regarding Cancer Detection Rate and Complications

BACKGROUND

Transrectal ultrasound guided biopsy of the prostate is the most common modality used to diagnose prostate cancer.

OBJECTIVES

The aim of this study was to evaluate the optimal number of cores at prostate biopsy, which have the most diagnostic value with least adverse effects.

PATIENTS AND MATERIALS

Transrectal ultrasonography (TRUS) guided biopsy was performed in 180 patients suspicious for prostate cancer due to either abnormal rectal examination or elevated PSA. The patients were divided randomly into three groups of six-core, twelve-core and eighteen-core biopsies. The detection rate of prostate cancer in each group with the rate of post biopsy urinary infection and prostatitis were compared.

RESULTS

Prostate cancer was diagnosed in 8 (13.3%), 21 (35%) and 24 (40%) patients in six, twelve and eighteen core biopsy groups, respectively. Urinary tract infection and prostatitis occurred in 17 (28.3%), 23 (38.3%) and 35 (58.3%) patients in six, twelve and eighteen core biopsy groups, respectively. Considering the detection rate of prostate cancer, there was a significant difference between 6 and 12 core biopsy groups (P = 0.006) and 12-core biopsies detected more cases of prostate cancer, but there was no significant difference between 12 and 18 core biopsy groups (P = 0.572). Considering the infection rate, there was no significant difference between 6 and 12 core biopsy groups (P = 0.254), but there was a significant difference between 12 and 18 core biopsy groups (P = 0.028) and infectious complications occurred more frequently in 18-core biopsy group.

CONCLUSIONS

The best balance between detection rate of prostate cancer and infectious complications of biopsies achieved in twelve-core biopsy protocol. Twelve-core biopsy enhances the rate of prostate cancer detection with minimum adverse effects.

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.

When prostate cancer remains undetectable: The dilemma

Since the first report on the efficacy of sextant biopsy under transrectal ultrasound guidance, there have been many modifications related to the total number of cores and the localization of biopsies to improve the prostate cancer (PCa) detection rate. The 2010 National Comprehensive Cancer Network Early PCa Detection Guidelines noted the 12-core biopsy scheme as the standard. However, this extended biopsy scheme still fails to detect 20% of high-grade PCa that can be detected by detailed pathological evaluation of radical prostatectomy; therefore, there is need for saturation biopsies. The existence of suspicions of PCa after previous negative biopsy or biopsies represents a valid indication for saturation biopsy. There has been no significant increment in morbidity or in insignificant PCa detection rates when a saturation biopsy scheme was used with an extended biopsy scheme. Along with the improvement in the PCa detection rate, accurate oncological mapping of PCa is another important consideration of saturation biopsies. The ideal number of cores and the diagnostic value of saturation biopsy after the failure of initial therapy are some of the issues that need to be addressed. Preliminary reports have shown that magnetic resonance imaging can improve the PCa detection rate, save patients from unnecessary biopsies, and decrease the need for a high number of cores; however, multiple limitations continue to exist.

Analysis of prostate cancer localization toward improved diagnostic accuracy of transperineal prostate biopsy

PURPOSE

Delineating the precise localization of prostate cancer is important in improving the diagnostic accuracy of prostate biopsy.

METHODS

In Juntendo University Nerima Hospital, initial 12-core or repeat 16-core biopsies were performed using a transrectal ultrasound guided transperineal prostate biopsy method. We step-sectioned prostates from radical prostatectomy specimens at 5-mm intervals from the urethra to the urinary bladder and designated five regions: the (1) Apex, (2) Apex-Mid, (3) Mid, (4) Mid-Base, and (5) Base. We then mapped prostate cancer localization on eight zones around the urethra for each of those regions.

RESULTS

Prostate cancer was detected in 93 cases of 121 cases (76.9%) in the Apex, in 115 cases (95.0%) in the Apex-Mid, in 101 cases (83.5%) in the Mid, in 71 cases (58.7%) in the Mid-Base, and in 23 cases (19.0%) in the Base. In 99.2% of all cases, prostate cancers were detected from the Apex to Mid regions. For this reason, transperineal prostate biopsies have routinely been prioritized in the Apex, Apex-Mid, and Mid regions, while the Base region of the prostate was considered to be of lesser importance. Our analyses of prostate cancer localization revealed a higher rate of cancer in the posterior portion of the Apex, antero-medial and postero-medial portion of the Apex-Mid and antero-medial and postero-lateral portion of the Mid. The transperineal prostate biopsies in our institute performed had a sensitivity of 70.9%, a specificity of 96.6%, a positive predictive value (PPV) of 92.2% and a negative predictive value (NPV) of 85.5%.

CONCLUSIONS

The concordance of prostate cancer between prostatectomy specimens and biopsies is comparatively favorable. According to our study, the diagnostic accuracy of transperineal prostate biopsy can be improved in our institute by including the anterior portion of the Apex-Mid and Mid regions in the 12-core biopsy or 16-core biopsy, such that a 4-core biopsy of the anterior portion is included.

The role of transperineal template prostate biopsies in prostate cancer diagnosis in biopsy naïve men with PSA less than 20 ng ml(-1.)

BACKGROUND

To compare prostate cancer detection rates between transrectal ultrasound (TRUS) prostate biopsy and transperineal template prostate biopsy (TPTPB) in biopsy naïve men. TRUS biopsy is still regarded as gold standard for prostate cancer diagnosis. TPTPB has been shown to improve prostate cancer detection in men with rising PSA and previous negative TRUS biopsies. We carried out a prospective study performing both biopsies in the same group of men with a benign feeling digital rectal examination (DRE), PSA <20 ng ml(-1) and no previous prostate biopsies.

METHODS

A total of 50 patients with mean age of 67 years (range: 54-84), mean prostate volume 58 cc (range: 19-165) and mean PSA 8 ng l(-1) (range: 4-18) underwent standard 12-core TRUS biopsy followed immediately by 36-core TPTPB under general anaesthetic. We determined the prostate cancer detection rate between the two diagnostic modalities.

RESULTS

In total, 20/50 (40%) had benign pathology. Of 30/50 (60%) diagnosed with prostate cancer, 16 (32%) had positive results in both TRUS and TPTPB, whereas 14 (28%) had negative TRUS but positive TPTPB. No cancers were detected solely by TRUS biopsy. TRUS biopsy detected cancer in 32% versus 60% with TPTPB. In total, 19/30(63%) cancers detected by TPTPB had Gleason score > or =7.2 (4%) experienced urosepsis, 7 (14%) temporary urinary retention, 16 (32%) mild haematuria and 19 (38%) haematospermia.

CONCLUSIONS

TPTPB is associated with significantly higher prostate cancer detection rate than TRUS biopsies in biopsy naïve men with a benign feeling DRE and PSA <20 ng ml(-1). PSA appears to be better biomarker than previously thought.

Transperineal biopsy of the prostate--is this the future?

Transperineal prostate biopsy is re-emerging after decades of being an underused alternative to transrectal biopsy guided by transrectal ultrasonography (TRUS). Factors driving this change include possible improved cancer detection rates, improved sampling of the anteroapical regions of the prostate, a reduced risk of false negative results and a reduced risk of underestimating disease volume and grade. The increasing incidence of antimicrobial resistance and patients with diabetes mellitus who are at high risk of sepsis also favours transperineal biopsy as a sterile alternative to standard TRUS-guided biopsy. Factors limiting its use include increased time, training and financial constraints as well as the need for high-grade anaesthesia. Furthermore, the necessary equipment for transperineal biopsy is not widely available. However, the expansion of transperineal biopsy has been propagated by the increase in multiparametric MRI-guided biopsies, which often use the transperineal approach. Used with MRI imaging, transperineal biopsy has led to improvements in cancer detection rates, more-accurate grading of cancer severity and reduced risk of diagnosing clinically insignificant disease. Targeted biopsy under MRI guidance can reduce the number of cores required, reducing the risk of complications from needle biopsy.

Computer-aided (HistoScanning) biopsies versus conventional transrectal ultrasound-guided prostate biopsies: do targeted biopsy schemes improve the cancer detection rate?

OBJECTIVE

To define potential improvement in prostate cancer detection by application of a computer-aided, targeted, biopsy regimen using HistoScanning.

MATERIALS AND METHODS

We analyzed 80 patients who underwent systematic transrectal, targeted transrectal, and targeted perineal biopsies. Each patient was diagnosed preoperatively by HistoScanning, defining a maximum of 3 suspicious areas. These areas were biopsied, both transrectally and via the perineum, with a maximum of 3 cores per location.

RESULTS

We detected prostatitis in 30 patients (37.5%), premalignant lesions in 10 (12.5%), and prostate cancer in 28 (35%). The transrectal technique was used to detect 78.6% of all cancers using 14 cores by systematic biopsy. With a maximum of 9 targeted cores, 82.1% of all cancers were detected with the targeted perineal approach and 53.6% were detected with the targeted transrectal approach. Although our data did not show significant difference in the performance of targeted transperineal compared with systematic transrectal biopsies, the detection rate of targeted transrectal biopsies was significantly lower.

CONCLUSION

The presented targeted biopsy scheme achieved an overall detection rate of 85% of prostate-specific antigen-relevant pathologic lesions within the prostate. Thus, the presented procedure shows an improved detection rate compared with standard systematic prostate biopsies, and the number of cores required is reduced. Furthermore, the perineal HistoScanning-aided approach seems to be superior to the transrectal approach with respect to the prostate cancer detection rate. The presented procedure might be a step toward reliable ultrasound-based tissue characterization and toward fulfilling the requirements of novel therapeutic strategies.