The results of transperineal versus transrectal prostate biopsy: a systematic review and meta-analysis. Asian J Androl. 2012;14:310-315. [PMID: 22101942 DOI: 10.1038/aja.2011.130]

Prevention of infectious complications after transrectal ultrasound-guided prostate biopsy: comparison of povidone-iodine, chlorhexidine, and formalin disinfection

PURPOSE

We aimed to compare the efficacy of three different antiseptic methods to determine the most effective prophylactic approach to prevent infectious complications after transrectal ultrasound-guided prostate biopsy (TRUS-PB). The methods evaluated were transrectal povidone-iodine injection (TRPI), biopsy needle disinfection with chlorhexidine, and biopsy needle disinfection with formalin.

METHODS

Between January 2018 and January 2023, 904 patients who underwent TRUS-PB were retrospectively analyzed. All patients had prophylactic antibiotic use and negative urine/rectal culture results. Patients were divided into three groups according to the antiseptic protocol: Group 1 (n = 245) received only TRPI injection into the rectum before biopsy, Group 2 (n = 295) received only chlorhexidine needle disinfection before biopsy, and Group 3 (n = 364) received only formalin needle disinfection before biopsy. The biopsy needles used in our clinic are not single-use and are used on other patients after sterilization. The primary endpoint was the incidence of infectious complications within 30 days post-procedure. Continuous variables were analyzed using the Mann-Whitney U test, while categorical variables were analyzed using the Chi-square test, and post-hoc analysis was applied for pairwise comparisons between groups. Univariate and multivariate logistic regression analysis was performed to evaluate factors associated with postoperative infection.

RESULTS

The overall infection rate was 20.4%. Infection rates were 4.5% in the TRPI group, 16.6% in the chlorhexidine group, and 34.1% in the formalin group (p < 0.001). The TRPI group showed significantly lower rates of all infectious complications compared to other groups. Disinfection of biopsy needles with chlorhexidine was found to be significantly more effective in preventing infectious complications compared to disinfection with formalin (p < 0.001).

CONCLUSION

TRPI injection before TRUS-PB appears to be more effective in preventing post-biopsy infectious complications compared to needle disinfection with chlorhexidine or formalin. This method may be considered as a preferred antiseptic approach for TRUS-PB procedures.

Fusion MRI/Ultrasound-Guided Transperineal Biopsy: A Game Changer in Prostate Cancer Diagnosis

Background/Objectives: Multiparametric-Magnetic Resonance Imaging(mp-MRI) presents the ability to detect clinically significant cancer, aiming to avoid biopsy if the results are negative or target an abnormal lesion if a suspected lesion of the prostate is found. Recent guidelines recommend the performance of 12 standard biopsies along with 3 to 5 targeted biopsies in suspected prostate lesions, depending on the size of the prostate lesion. In addition, prostate biopsy can be performed by either the transperineal or the transrectal approach. The aim of this comprehensive review is to highlight the role of both standard and targeted MRI/Ultrasound (US) fusion transperineal biopsy (TPB) in the diagnostic approach of prostate cancer cases, to report its diagnostic efficacy and complication rates and to suggest the promising usage of MRI/US fusion TPB in the future. Methods: A comprehensive review of the existing literature, including systematic reviews, meta-analyses, and clinical guidelines, was conducted to compare the efficacy and safety of transperineal and transrectal approaches in prostate cancer detection. Special emphasis was placed on mp-MRI-guided targeted biopsy and its combination with systematic sampling. Results: Prostate biopsy via the transperineal approach is related to increased detection rates, especially for anterior lesions, and decreased infection risk compared to the transrectal approach, while complication rates (hematuria, hemospermia, etc.) remain similar. Due to lower infection rates via the transperineal route, the performance of prostate biopsy using the transperineal approach is strongly recommended. Finally, transperineal fusion MRI/US biopsy can be valuable for repeat biopsies in patients who had an initial negative biopsy or for the follow-up of patients that undergo active surveillance. Conclusions: MRI/US fusion-guided TPB represents a significant advancement in prostate cancer diagnostics, combining improved precision with reduced infection risks. Although TPB presents higher detection rates for anterior prostatic lesions and lower post-biopsy infection rates, there is no significant difference in cancer detection rates compared to TRB. Targeted training and investment may reduce long-term expenses of TPB by lowering hospitalizations, antibiotic usage, and related costs. Future research should further refine this approach and explore its integration with emerging technologies like artificial intelligence for enhanced lesion targeting and diagnostic accuracy.

Comparing the Efficacy and Safety of the Transperineal Versus Transrectal Prostate Biopsy Approach in the Diagnosis of Prostate Cancer: A Systematic Review and Meta-Analysis

Prostate cancer (PCa) has high prevalence rates in men and is a leading cause of cancer-related death. Transrectal (TR) biopsy has traditionally been the gold standard for diagnosis, but transperineal (TP) biopsy is increasingly favoured due to its lower infection risk. However, debate remains regarding which method has superior cancer detection rates. This review compares the efficacy and safety of the TP as compared to the TR prostate biopsy approach, summarizing the largest body of evidence available to date. A literature search was performed on the PubMed, Google Scholar, Cochrane Library, and Embase databases. We searched from the inception of the databases up to August 2024 for relevant studies comparing the cancer detection rate of TP versus TR prostate biopsy and compared their complication rates. Twenty-one studies met the inclusion criteria. The pooled odds ratios with 95% confidence intervals were calculated to evaluate the differences between the TR and TP groups in the PCa detection rate. This meta-analysis included 21 studies (6 randomized control trials and 15 cohort studies) with a total of 13,818 patients (TP = 7917; TR = 5901), who were accrued between 2008 and 2024 and divided into the TR group and the TP group. The analysis revealed no significant difference in prostate cancer detection rates between the TP and TR approaches in both RCTs (OR 1.02, 95% CI (0.74, 1.41), p = 0.90) and cohort studies (OR 1.07, 95% CI (0.85, 1.35), p = 0.36). Complication profiles were largely comparable; TP demonstrated a significantly lower risk of urinary tract infections (OR 0.26, 95% CI (0.11, 0.61)) but no notable differences in acute urinary retention, haematuria, or rectal bleeding. Our findings advocate the TP approach as a safer biopsy alternative where feasible, particularly in infection-sensitive populations, without compromising diagnostic accuracy. MRI should complement biopsy strategies to enhance diagnostic precision. Future research should focus on standardized, large-scale RCTs to further refine and personalize prostate cancer diagnostic pathways.

Transperineal biopsy as a new technique versus well-established transrectal biopsy for diagnosis of prostate cancer - A comparative study

Introduction

Transrectal (TR) prostate biopsy has been the gold standard for prostate cancer diagnosis for years. With the emergence of transperineal (TP) prostatic biopsy, there is a shift in practice across medical services to adopt TP biopsy as the primary method of prostatic biopsy.

Objective

The objective of the study is to compare cancer detection rates and complications between TP and TR biopsies in our region providing single-center experience with introduction of TP biopsy.

Patients and Methods

This is a retrospective study utilizing a prospectively designed database comparing consecutive 80 cases of TP biopsy to 80 cases of TR biopsy in a single center.

Results

Prebiopsy PSA was 14.2 ± 24.9 ng/dl in the TP group versus 23.7 ± 71.3 ng/dl in the TR group with P = 0.108. Prostate Imaging-Reporting and Data System (PIRAD) 4 and 5 lesions were found in 47 (58.9%) cases of TP biopsy versus 44 (60.3%) of TR group cases and P = 0.131. Cancer was detected in 49 (61.25%) patients in the TP group versus 45 (56.25%) in the TR group with no statistically significant difference and P = 0.665. No cases of hematochezia was reported in TP group, vs 14 (17.5%) reported in TR group with P value <.001. There were no statistically significant differences regarding the incidence of febrile urinary tract infection (UTI), hematuria, and hematospermia in the TP group 0 (0%), 7 (8.75%), and 3 (3.75%) versus 2 (2.50%), 14 (17.50%), and 5 (6.25%) in the TR group with P = 0.497, 0.159, and 0.719 consecutively.

Conclusion

TP and TR biopsy have comparable cancer detection rates. TP biopsy has a significantly lower rectal bleeding rate than TR biopsy. There is a trend toward lower febrile UTI in the TP group; however, it did not reach statistical significance.

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.

Transrectal Prostate Biopsy Approach in Men Undergoing Kidney Transplant: A Retrospective Cohort Study at Three Referral Academic Centers

BACKGROUND

Currently, there are no studies evaluating the feasibility of a prostate biopsy approach in men undergoing a kidney transplant (KT). Owing to this evidence, we planned a retrospective population-based study to evaluate our experience of a transrectal prostate biopsy (TR-PB) approach and studied the impact on the complication rate and outcomes in patients undergoing KT with suspected prostate cancer (PCa).

METHODS

We collected data from KT patients who underwent PB with a transrectal approach. One week and two weeks after the PB, patients' information was collected regarding possible complications during the post-biopsy period.

RESULTS

A total of 121 patients were included in this study. Among them, Group 1 was composed of 59 patients undergoing TR-PB with an ultrasound (US) standard technique, and Group 2 consisted of 62 patients undergoing TR-PB with an MRI-US cognitive technique. We observed a 28.9% Clavien-Dindo grade ≤ 2 of early side effect rates (mostly rectal bleeding and other minor hematuria), with a very low rate of hospital re-admission for acute urinary retention (3.3%); only one man required hospitalization for rectal bleeding, and there were no major complications.

CONCLUSIONS

We can affirm that TR-PB can be a safe procedure with a low risk of severe complications when performed by skilled specialists with a standardized procedural pathway.

Morbidity of Transrectal MRI-Fusion Targeted Prostate Biopsy at a Tertiary Referral Academic Centre: An Audit to Guide the Transition to the Transperineal Approach

Despite transrectal prostate biopsy (TRPB) being still widespread globally, the EAU Guidelines strongly recommend the transperineal approach, due to the reported lower infectious risk. Our study aims to evaluate the impact of a standardized clinical pathway for TRPB on post-operative complications. We prospectively collected data from all patients undergoing mpMRI-targeted TRPB at our Academic Centre from January 2020 to December 2022. All patients followed a standardized, structured multistep pathway. Post-procedural complications were collected and classified according to the Clavien-Dindo (CD) Classification. Among 458 patients, post-procedural adverse events were reported by 203 (44.3%), of which 161 (35.2%) experienced CD grade 1 complications (hematuria [124, 27.1%], hematochezia [22, 4.8%], hematospermia [14, 3.1%], or a combination [20, 4.4%]), and 45 (9.0%) reported CD grade 2 complications (acute urinary retention or hematuria needing catheterization, as well as urinary tract infections, of which 2 cases required hospitalization). No major complications, including sepsis, were observed. At uni- and multivariable analysis, age > 70 years and BMI > 25 kg/ m2 for patients were identified as predictors of post-operative complications. The results of our study confirm that TRPB is a safe and cost-effective procedure with a low risk of severe adverse events in experienced hands and following a standardized pathway.

Transrectal versus transperineal prostate biopsy in detection of prostate cancer: a retrospective study based on 452 patients

BACKGROUND

Transrectal (TR) ultrasound guided prostate biopsy and transperineal (TP) ultrasound guided prostate biopsy are the two most commonly used methods to detect prostate cancer, the detection rate of the two biopsy approaches may differ in patients with different clinical characteristics. Here we aimed to compare the prostate cancer detection rate and positive rate of biopsy cores between TR and TP prostate biopsy in patients with different clinical characteristics.

METHODS

We retrospectively analyzed and compared the clinical data of 452 patients underwent TR or TP prostate biopsy in our hospital from June 2017 to September 2021. And patients were stratified according to several clinical characteristic (serum PSA level, prostate volume, PSA density, T stage and ISUP grade), cancer detection rate and positive rate of biopsy cores were compared in different stratified groups.

RESULTS

There was no significant difference in age, PSA level, prostate volume, and PSA density between the TR and TP groups. TR group had a higher overall cancer detection rate and positive rate of biopsy cores than TP group. Further subgroup analysis showed that TR group had a higher cancer detection rate in patients with prostate volumes 30-80 mL, and that the TR group had a higher positive rate of biopsy cores among the patients with T3-T4 stages, while TP group had a higher positive rates of biopsy cores among the patients with T1-T2 stages. There were no significant differences between the TR and TP groups for each subgroup when stratified by PSA level, PSA density and ISUP grade.

CONCLUSIONS

TR approach may have advantage in patients with prostate volumes 30-80 mL and T3-T4 stages, while TP approach may have advantage in patients with T1-T2 stages.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with prostate cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of prostate cancer was published in 2020. It was therefore decided, by both the ESMO and the Singapore Society of Oncology (SSO), to convene a special, virtual guidelines meeting in November 2021 to adapt the ESMO 2020 guidelines to take into account the differences associated with the treatment of prostate cancer in Asia. These guidelines represent the consensus opinions reached by experts in the treatment of patients with prostate cancer representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with prostate cancer across the different regions of Asia.

Non-infectious Complications Following Transrectal Prostate Needle Biopsy – Outcomes from over 8000 Procedures

Background

Prostate needle biopsy (PNB) remains the referent standard for diagnosing prostate cancer. Contemporary data highlight an increase in PNB-related infections particularly when performed transrectally. Non-infectious complications, however, may similarly contribute to biopsy-related morbidity. We review the incidence and predictors of non-infectious complications following transrectal PNB in a large statewide quality registry.

Methods

Transrectal ultrasound-guided prostate needle biopsies performed between 2015 and 2018 were retrospectively reviewed. The incidence and distribution of non-infectious complications were annotated. Clinical, demographic, and biopsy variables of interest were evaluated by logistic regression for potential association with specific types of non-infectious complications.

Results

Of 8,102 biopsies, 277 (3.4%) biopsies had reported post-procedure complications including 199 (2.5%) non-infectious and 78 (0.9%) infectious. Among the non-infectious complications, the most common events included urinary or rectal bleeding (74; 0.9%), urinary retention (70, 0.9%), vasovagal syncope (13, 0.2%), and severe post-operative pain (10, 0.1%). Approximately 56% of these non-infectious complications required an Emergency Department visit (111/199) and 27% (54/199) hospital admission for monitoring. Increasing transrectal ultrasound prostate volume was associated with post-procedure urinary retention (Odds ratio (OR) 1.07, 1.02–1.11, p = 0.002). No specific variables noted association with post-biopsy bleeding.

Conclusion

Non-infectious complications occurred 2.5 times more often than infectious complications following transrectal ultrasound prostate needle biopsies. Larger prostate size was associated with a greater risk of post-procedure urinary retention. These data originating from experience from over 100 urologists across different health systems provide an important framework in counseling patients regarding expectations following transrectal prostate biopsy.

Transrectal Ultrasound in Prostate Cancer: Current Utilization, Integration with mpMRI, HIFU and Other Emerging Applications

Transrectal ultrasound (TRUS) has been an invaluable tool in the assessment of prostate size, anatomy and aiding in prostate cancer (PCa) diagnosis for decades. Emerging techniques warrant an investigation into the efficacy of TRUS, how it compares to new techniques, and options to increase the accuracy of prostate cancer diagnosis. Currently, TRUS is used to guide both transrectal and transperineal biopsy approaches with similar cancer detection rates, but lower rates of infection have been reported with the transperineal approach, while lower rates of urinary retention are often reported with the transrectal approach. Multiparametric MRI has substantial benefits for prostate cancer diagnosis and triage such as lesion location, grading, and can be combined with TRUS to perform fusion biopsies targeting specific lesions. Micro-ultrasound generates higher resolution images that traditional ultrasound and has been shown effective at diagnosing PCa, giving it the potential to become a future standard of care. Finally, high-intensity focused ultrasound focal therapy administered via TRUS has been shown to offer safe and effective short-term oncological control for localized disease with low morbidity, and the precise nature makes it a viable option for salvage and repeat therapy.

Hundred years of transperineal prostate biopsy

The earliest recorded efforts to biopsy prostate, in the early 20th century, were made through transperineal (TP) approach, with open perineal prostate biopsy (PBx) being considered the gold standard for prostate cancer (PCa) diagnosis in that era. Later, to minimize morbidity and increase diagnostic accuracy, several technical modifications and transrectal ultrasound (TRUS) assistance were incorporated. However, in the 1980s, the transrectal (TR) approach became the predominant PBx method following the introduction of TRUS-TR PBx with sextant sampling, providing a convenient and efficacious method for prostate sampling. With modernization of PCa diagnosis, a recent resurgence of the TP PBx has been observed, driven primarily by TR drawbacks of infectious complications and sampling limitations. TP PBx is rapidly emerging as the new PBx standard, being officially recommended as the initial approach for biopsy in Europe and is increasingly being conducted and studied in the United States. The modern era of TP PBx is based on the improvements in local anesthesia techniques, TP access systems, and robotic assistance. These modifications and advancements have improved the ease of use, patient comfort, and diagnostic outcomes with TP PBx. Herein, we present a history of the evolution of TP PBx spanning over 100 years and explore the basis of the technique that merits future utilization.

Biopsia de próstata, acceso transperineal bajo anestesia local

Objetivo La biopsia de próstata es una ayuda esencial en el diagnóstico de cáncer, siendo el método más utilizado la biopsia transrectal guiada por ultrasonido (TRUS), con una tasa diagnóstica entre el 37% y el 45%, aunque no exenta de complicaciones como infecciones, dolor o sangrado.

El enfoque alternativo y seguro a las biopsias TRUS se encuentra en la biopsia transperineal (BTP), realizada comúnmente bajo anestesia regional o general.

El objetivo de este estudio fue determinar la efectividad de la BTP bajo anestesia local y guía ultrasonográfica transrectal, con el impacto sobre la sensibilidad del estudio y la tasa de readmisión hospitalaria por infección.

Métodos Estudio de cohorte retrospectiva en el que se evaluaron 83 pacientes sometidos a BTP con anestesia local y guía ultrasonográfica transrectal de enero de 2017 a agosto de 2018 en una ciudad intermedia de Colombia. La muestea incluyó todos los hombres mayores de 18 años con datos de historia clínica disponibles para su análisis, así como los reportes histopatológicos de las biopsias. Se excluyeron casos de rebiopsia o con datos insuficientes.

El análisis de datos nominales se realizó mediante la prueba de chi cuadrado, y el de los datos numéricos, con las prubas t de Student o de Mann-Whitney.

Resultados Un total de 83 pacientes, con media de edad de 65 ± 7.9 años fueron sometidos al análisis del estudio histopatológico. Se excluyeron nueve pacientes que no tenían información disponible en el registro clínico sistematizado, ni en historia clínica de formato físico. Se encontró una proporción de positividad y diagnóstico de cáncer de prostata en el 39.7% (33) de los pacientes, distribuidos así: grado de grupo 1 (69.7%; 23); grado de grupo 2 )15.2%; 5); grados de grupos 3 y 4 (3% cada uno de ellos; 2); y grado de grupo 5 (9%; 3). En total, 60% (50) fueron negativos para malignidad y, de estos el 54% (27) tuvo hiperplasia. El antibiótico profiláctico indicado en el 96.7% (80) de los casos fue una cefalosporina de primera generación, administrada en el 15% (12) por vía parenteral preoperatoria. En esta serie de casos, no se documentaron ingresos hospitalarios asociados a infección después del procedimiento.

Conclusiones La biopsia de próstata por vía transperineal es una técnica con rendimiento diagnostico similar al del abordaje transrectal: es segura, rápida, de fácil acceso, con bajo costo y, sobre todo, con un riesgo insignificante de infección y sepsis. Sus beneficios son altamente representativos en un sistema de salud como el de nuestro país, y la BTP facilita el acceso de la población vulnerable del área rural y de ciudades intermedias, en las que no se dispone de un urólogo experto.

Anaesthesia in PROstate Biopsy Pain Obstruction Study: A Study Protocol for a Multicentre Randomised Controlled Study Evaluating the Efficacy of Perineal Nerve Block in Controlling Pain in Patients Undergoing Transperineal Prostate Biopsy

Introduction: Transperineal prostate biopsy is as effective as the transrectal biopsy in detecting prostate cancer and has a lower risk of infection. However, concerning the procedural pain of the transperineal route, a higher level of anaesthesia is needed, which prevents this approach from being widely used. Although several methods of local anaesthesia to relieve pain during transperineal biopsy have been described, few well-designed trials have been conducted to assess the efficacy of local anaesthesia.

Methods: This is a prospective, multicentre, randomised controlled study in men suspected of having prostate cancer and planning to undergo transperineal prostate biopsy. The aim of this trial is to determine whether the perineal nerve block and periprostatic block relieve pain to different extents in men undergoing transperineal biopsy. The main inclusion criteria are men aged between 18 and 80 years old, a prostate-specific antigen (PSA) level of 4–20 ng/ml, or/and suspicious rectal examination findings. A sample size of 190 participants, accounting for a 10% loss, is required. All participants will be randomly allocated at a ratio of 1:1 to the perineal nerve block (n = 95) and periprostatic block groups (n = 95). The primary outcome will be the level of the worst pain experienced during the transperineal prostate biopsy procedure, which will be measured by a numerical rating scale (NRS). The key secondary outcomes will include the pain severity score at 1, 6, and 24 h after prostate biopsy.

Results: The primary outcome is the level of the worst pain experienced during the prostate biopsy procedure. The main secondary outcomes are as follows: (1) Post-biopsy pain severity score at 1, 6, and 24 h after the prostate biopsy; (2) Changes in blood pressure, heart rate and breathing rate during the biopsy procedure; (3) External manifestations of pain during biopsy; (4) Anaesthesia satisfaction; (5) The detection rate for clinically significant prostate cancer and any prostate cancer.

Conclusion: Anaesthesia in PROstate biopsy Pain Obstruction Study (APROPOS) is randomised controlled trial aiming to determine the efficacy of the perineal nerve block in controlling pain in patients undergoing prostate biopsy via the transperineal approach.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04501055.

Transrectal ultrasound-guided prostate needle biopsy remains a safe method in confirming a prostate cancer diagnosis: a multicentre Australian analysis of infection rates

PURPOSE

Worldwide, transrectal ultrasound-guided prostate needle remains the most common method of diagnosing prostate cancer. Due to high infective complications reported, some have suggested it is now time to abandon this technique in preference of a trans-perineal approach. The aim of this study was to report on the infection rates following transrectal ultrasound-guided prostate needle biopsy in multiple Australian centres.

MATERIALS AND METHODS

Data were collected from seven Australian centres across four states and territories that undertake transrectal ultrasound-guided prostate needle biopsies for the diagnosis of prostate cancer, including major metropolitan and regional centres. In four centres, the data were collected prospectively. Rates of readmissions due to infection, urosepsis resulting in intensive care admission and mortality were recorded.

RESULTS

12,240 prostate biopsies were performed in seven Australian centres between July 1998 and December 2020. There were 105 readmissions for infective complications with rates between centres ranging from 0.19 to 2.60% and an overall rate of 0.86%. Admission to intensive care with sepsis ranged from 0 to 0.23% and overall 0.03%. There was no mortality in the 12,240 cases.

CONCLUSION

Infective complications following transrectal ultrasound-guided prostate needle biopsies are very low, occurring in less than 1% of 12,240 biopsies. Though this study included a combination of both prospective and retrospective data and did not offer a comparison with a trans-perineal approach, TRUS prostate biopsy is a safe means of obtaining a prostate cancer diagnosis. Further prospective studies directly comparing the techniques are required prior to abandoning TRUS based upon infectious complications.

Transrectal povidone-iodine efficiency in reducing infections occurring after transrectal ultrasound guided biopsy of the prostate

ABSTRACT

The present study aimed to compare infectious complications in men undergoing transrectal ultrasound-guided prostate biopsy (TRUS-Bx) with and without povidone-iodine transrectal injection using a gavage syringe.The records of 112 patients, who underwent TRUS-Bx between January 2016 and December 2019, were retrospectively reviewed. The biopsy indication was considered high prostate-specific antigen (PSA) level and/or suspicious digital rectal prostate examination findings. Patients' ages, underlying diseases, PSA levels, prostate volumes, pathologic results, and infectious complications after the biopsy were investigated. All the patients received 1500 mg of ciprofloxacin (750 mg twice a day) for 5 days, starting from the day before the procedure. Forty-seven (41.96%) patients received ciprofloxacin prophylaxis with povidone-iodine transrectal injection, while 65 (58.03%) only received ciprofloxacin prophylaxis. All the patients, who were readmitted to the hospital after the procedure, especially with a temperature of higher than 37.8°C, were detected. For the purposes of the study, the priority was placed on the emergence of the rate of febrile infectious complications. Differences in febrile infectious complications in patients, who received ciprofloxacin prophylaxis with transrectal povidone-iodine, and those, who received ciprofloxacin prophylaxis alone before TRUS-Bx, were studied.Febrile infectious complications developed in 10 cases (15.38%) in patients, who received ciprofloxacin antibiotics prophylaxis alone. In the povidone-iodine rectal disinfection group, there was only 1 case of febrile infectious complication (2%). There was no significant difference by clinicopathologic features, age, PSA level, and cancer detection rate between both groups (P > .05). Multivariate logistic regression analysis did not identify any patient subgroups at a significantly higher risk of infection after prostate biopsy. There was no significant side effect associated with povidone iodine.In addition to the use of prophylactic antibiotics, transrectal povidone-iodine was useful in reducing the febrile infection complications following TRUS-Bx.

The effect of heated lidocaine gel on pain reduction during transrectal ultrasound-guided prostate biopsy: a randomized-controlled study

PURPOSE

To determine whether intrarectal local anesthesia (IRLA) with heated lidocaine gel provides pain reduction during transrectal ultrasound (TRUS)-guided prostate biopsy.

METHODS

We conducted a randomized-controlled study with 153 participants who underwent TRUS-guided, systematic 12-core prostate biopsy from May 2018 to June 2019. These participants were divided into three test groups. Before prostate biopsy, group A (51 patients) received no local anesthesia, group B (51 patients) received IRLA with 20 mL 2% lidocaine gel stored at room temperature, and group C (51 patients) received IRLA with heated (40 ℃) 20 mL 2% lidocaine gel. Pain was assessed using the 0-10 visual analogue scale (VAS) at three time points: VAS-1: during probe insertion, VAS-2: during biopsy, VAS-3: 30 min after the procedure. Complications during and after the procedure were evaluated.

RESULTS

The mean VAS-2 score was significantly lower in group C compared to groups A and B (A, 4.6; B, 4.2; and C, 3.2; p < 0.05). There was no significant difference among the three groups in mean VAS-1 and VAS-3 scores. No significant difference was detected in incidence of complications between the three groups. No allergic reactions to lidocaine gel were observed.

CONCLUSION

IRLA with heated lidocaine gel provides more effective pain control during TRUS-guided prostate biopsy than does conventional IRLA and no local anesthesia, without an increase of complications.

Positive Culture Prior to Transperineal Prostate Biopsy Was Not Associated with Post-Biopsy Febrile Urinary Tract Infection Development

Purpose

To investigate the association between urine culture before transperineal prostate biopsy and post-biopsy febrile urinary tract infection (fUTI).

Patients and Methods

We retrospectively reviewed 307 patients who underwent urine culture before transperineal prostate biopsy between April 2017 and September 2020. Patients with indwelling urinary catheters (n=7) were excluded. Urine culture was performed 1–3 days before the biopsy, and all patients received prophylactic cefazolin regardless of culture results. A urine culture was defined as positive if cell density was more than 1×10⁵ colony-forming units per mL. Baseline characteristics and the incidence of post-biopsy fUTI were compared between patients showing positive pre-biopsy culture results and those showing negative findings.

Results

Out of 300, seven patients (2.3%) had positive urine culture results before the biopsy. Age (p=0.077); prostate-specific antigen at diagnosis (p=0.267); prostate volume (p=0.78); number of biopsy cores (p=0.277); percentage of patients testing positive for cancer on biopsy (p=0.71); and percentages of patients with a history of biopsy (p>0.999), diabetes mellitus (p=0.604), and immunosuppressive medication use (p>0.999) were similar between the two groups. No patient in the positive urine culture group had post-biopsy fUTI. However, 1.7% (five patients) of the negative urine culture group had the disease (p>0.999) (four patients with prostatitis and one with pyelonephritis). Among them, two patients were diagnosed by urine culture at the time of post-biopsy fUTI.

Conclusion

In asymptomatic patients, positive pre-biopsy cultures were not associated with the development of post-biopsy fUTI.

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.

Risk assessment of multi-factorial complications after transrectal ultrasound-guided prostate biopsy: a single institutional retrospective cohort study

BACKGROUND

Transrectal ultrasound-guided prostate biopsy (TRUSPB) is widely used to diagnose prostate cancer (PCa). The aim of this study was to evaluate the risk of multi-factorial complications (febrile genitourinary tract infection (GUTI), rectal bleeding, and urinary retention) after TRUSPB.

METHODS

N = 2053 patients were Japanese patients undergoing transrectal or transperineal TRUSPB for suspicious of PCa. To assess risk of febrile GUTI adequately, the patients were divided into four groups: low-risk patients before starting a rectal culture, low-risk patients after starting a rectal culture, high-risk patients, and patients undergoing transperineal TRUSPB. Furthermore, to identify risk of rectal bleeding and urinary retention, patients were divided into transrectal and transperineal group.

RESULTS

Febrile GUTI significantly decreased owing to risk classification. The frequency of rectal bleeding was 1.43% (transrectal: 25/1742), while it did not happen in transperineal group. The patients with rectal bleeding had a significantly lower body mass index (BMI) (P < 0.01). The frequency of urinary retention was 5.57% (transrectal: 97/1742), while it did not happen in transperineal group. The patients with urinary retention had a significantly higher prostate-specific antigen (PSA) (P = 0.01) in transrectal group.

CONCLUSIONS

Risk classification, rectal swab culture, and selected antimicrobial prophylaxis for transrectal TRUSPB were extremely effective to reduce the risk of febrile GUTI. Furthermore, lower BMI and higher PSA were novel clinical predictors for rectal bleeding and urinary retention, respectively. When urologists perform transrectal TRUSPB to their patients, they can correctly understand and explain each complication risk to their patients based on these novel risk factors.

Comparative Effectiveness and Tolerability of Transperineal MRI-Targeted Prostate Biopsy under Local versus Sedation

OBJECTIVES

To assess the prostate cancer diagnostic yield, complications, and costs of transperineal prostate biopsies when performed with local anesthesia versus sedation.

METHODS

Data were prospectively collected for men undergoing transperineal MRI-targeted biopsy at the outpatient clinic and tertiary hospital of a single center between October 2017 to February 2020. These data included demographic, procedural, and pathologic variables and complications. Time-driven activity-based costing was performed to compare procedural costs.

RESULTS

126 men were included. Age, BMI and PSA were similar for local (n = 45) vs sedation (n = 81), all P>0.05. Detection of clinically significant prostate cancer (CSPC) on combined systematic and targeted biopsy was similar for local vs sedation (24% vs 36%; P = 0.2). Local had lower detection on targeted biopsies alone (8.9% vs 25%; P = 0.03). However, fewer targeted cores were obtained per region of interest with local vs sedation (median 3 vs 4 cores; P<0.01). For local vs sedation, the complication rate was 2.6% and 6.1% (P = 0.6). The median visual analog pain score for local vs sedation was 3/10 vs 0/10 (P<0.01). The mean procedure time for local vs sedation was 22.5 vs 17.5 minutes (48.3 minutes when including anesthesia time). Time-driven activity-based costs for local vs sedation were $961.64 vs $2208.16 (P<0.01).

CONCLUSION

Transperineal biopsy with local anesthesia is safe with comparable outcomes to sedation. While the number of cores taken differed, there was no statistical difference in the detection of clinically significant cancer.

Transperineal versus transrectal multi-parametric magnetic resonance imaging fusion targeted prostate biopsy

OBJECTIVES

To compare transperineal biopsies (TPBx) with transrectal ultrasound-guided biopsy (TRUSBx) in order to provide evidence, making clinicians able to select the appropriate biopsy approach under different conditions.

METHODS

A comparative prospective study, conducted in King Khalid University Hospital (KKUH) and King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia, between March 2019 and February 2020. All patients with raised prostate-specific antigen or atypical digital rectal examination findings were subjected to multi-parametric magnetic resonance imaging (MRI). Those with positive findings were referred to targeted fusion- guided biopsy either TPBx or TRUSBx, randomly. Complication rate, cancer detection rate, and procedure time were recorded.

RESULTS

Transperineal biopsies and TRUSBx had an equivalent complication rate. However, both case detection rate and clinically significant cancer detection rate were significantly higher in TPBx versus TRUSBx (45.1% versus 29.1%, p=0.003; and 71.8% versus 43.7%, p=0.002; respectively). Transperineal biopsies was a longer procedure than TRUSBx (41.2±0.7 min versus 13±2.3 min, p=0.0001).

CONCLUSION

No difference in complication rate was detected between the 2 procedures; however, TPBx was more effective for cancer detection in general and clinically significant cancer detection in particular.

"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.

Transrectal ultrasound guided prostate biopsy performed by supervised junior and senior residents is safe and does not result in inferior outcomes

PURPOSE

To compare transrectal ultrasound guided prostate biopsy (TRUSBx) cancer detection and complication rates between residents at different levels of training and attending physicians at a single academic center.

METHODS

We performed a retrospective review of consecutive series of 623 men undergoing TRUSBx from June 2014 to February 2017. The procedure was performed either by resident physicians under direct supervision by an attending physician or by an attending physician. In total, junior residents, senior residents and attending physicians performed 244, 212, and 167 biopsies, respectively. Prostate cancer detection, 30-day complications, and 30-day hospitalizations rates were the outcomes of interest. We performed multivariable logistic regression analysis to identify predictors of these outcomes and examined the hypothesis that TRUSBx performed by trainees would not be associated with inferior outcomes.

RESULTS

There was no statistically significant difference in patient populations between the three groups when stratified by age, BMI, Charleston co-morbidity index, aspirin use, PSA level and palpable nodule on DRE. Prostate cancer was detected in 43.8% of the biopsies and there was no difference in detection rates (P = 0.53), Gleason score (P = 0.11), number of positive cores (P = 0.95), 30-day hospitalization (P = 0.86), and 30-day complication rates (P = 0.67) between TRUSBx performed by trainees and attending physicians.

CONCLUSIONS

TRUSBx performed by residents and attending physicians yielded equivalent rates of cancer detection with no significant difference in 30-day complications or 30-day hospitalizations rates. There was no difference in outcomes between junior and senior residents suggesting that with adequate faculty supervision, it is safe for trainees at all levels to perform prostate biopsies.

Interventions using behavioural insights to influence children's diet-related outcomes: A systematic review

The global prevalence of children with overweight and obesity continues to rise. Obesity in childhood has dire long-term consequences on health, social and economic outcomes. Promising interventions using behavioural insights to address obesity in childhood have emerged. This systematic review examines the effectiveness and health equity implications of interventions using behavioural insights to improve children's diet-related outcomes. The search strategy included searches on six electronic databases, reference lists of previous systematic reviews and backward searching of all included studies. One-hundred and eight papers describing 137 interventions were included. Interventions using behavioural insights were effective at modifying children's diet-related outcomes in 74% of all included interventions. The most promising approaches involved using incentives, changing defaults and modifying the physical environment. Information provision alone was the least effective approach. Health equity implications were rarely analysed or discussed. There was limited evidence of the sustainability of interventions-both in relation to their overall effectiveness and cost-effectiveness. The limited evidence on health equity, long-term effectiveness and the cost-effectiveness of these interventions limit what can be inferred for policymakers. This review synthesises the use of behavioural insights to improve children's diet-related outcomes, which can be used to inform future interventions.

Recent Advances and Current Role of Transperineal Prostate Biopsy

"Approximately 1 million prostate biopsies are performed each year in the United States. This procedure has traditionally been performed using a transrectal approach, which is associated with a significant risk of infectious complications including sepsis. In recent years, transperineal prostate biopsy has been increasingly adopted due to its lower associated infectious risk. In this review, we explore the benefits of the transperineal approach for performing prostate biopsy and detail technical advancements that have allowed for this procedure to now be routinely performed in the outpatient settings under local anesthesia."

Transperineal prostate biopsy: a review of technique

As the second most diagnosed cancer worldwide, prostate cancer is confirmed via tissue biopsy. Given the large number of prostate biopsies performed each year, the technique should be as accurate and safe as possible for the patient’s well-being. Transrectal ultrasound guided prostate biopsy (TRUS-biopsy) is most offered worldwide. Transperineal biopsy (TPP-biopsy), on the other hand, has been gaining popularity due to its superior sensitivity and lower rate of sepsis. This article offers a review of the brachytherapy grid technique used to perform a TPP-biopsy, as well as a discussion of possible variations in the procedure. TPP-biopsy is typically performed under general anaesthesia with patient in lithotomy. Through the perineum, cores of tissue are taken systematically, with or without targeting, under US guidance. Different fusion techniques (cognition, MRI-US fusion software, MRI in-bore) can be used to target pre-identified lesions on MRI. The sampling can be done either by free hand or using a brachytherapy grid. Robotic assisted prostate biopsy is also available on the market as an alternative. In recent years, there has been accumulating evidence showing that it is safe and feasible to perform TPPB under local anaesthesia. This may improve the uptake of TPPB as the preferred biopsy technique for prostate cancer.

Multicentre clinical evaluation of the safety and performance of a simple transperineal access system for prostate biopsies for suspected prostate cancer: The CAMbridge PROstate Biopsy DevicE (CamPROBE) study

Objectives:

To report the prospective multicentre clinical evaluation of a first-in-man disposable device, Cambridge Prostate Biopsy Device, to undertake local anaesthetic outpatient transperineal prostate biopsies.

Material and methods:

Disposable single-use Cambridge Prostate Biopsy devices were manufactured based on a previous prototype. The lead site developed a user training course and disseminated the method to other sites. The Cambridge Prostate Biopsy Device (CamPROBE) was offered as an alternative to transrectal ultrasound guided biopsy to men due for a biopsy as part of their clinical management. Data on safety (infections and device performance), clinical utility, patient reported experience, biopsy quality and cancer detection were collected. Procedure time and local anaesthetic use was recorded in the lead site. The study was funded by a United Kingdom National Institute for Health Research (NIHR) i4i product development award.

Results:

A total of 40 patients were recruited (median age 69 y) across six sites; five sites were new to the procedure. Overall, 19/40 were first prostate biopsies and 21/40 repeat procedures. Both image-targeted and systematic biopsy cores taken. There were no infections, device deficiencies or safety issues reported. The procedure was well tolerated with excellent patient-reported perception and low pain scores (median of 3, scale 0–10). Histopathology quality was good and the overall cancer diagnosis rate (first diagnostic procedures) was 68% (13/19) and for significant cancers (⩾ histological Grade Group 2), 47% (9/19). In the lead centre (most experienced), median procedure time was 25 minutes, and median local anaesthetic use 11 ml (n=17).

Conclusions:

Data from this device evaluation study demonstrate that the United Kingdom-developed Cambridge Prostate Biopsy Device/method for transperineal biopsies is safe, transferable and maintains high diagnostic yields. The procedure is well tolerated by patients, suited to the local anaesthetic outpatient setting and could directly replace transrectal ultrasound guided biopsy.

Level of evidence:

Level III

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.

The clinical and financial implications of a decade of prostate biopsies in the NHS: analysis of Hospital Episode Statistics data 2008-2019

OBJECTIVE

To evaluate the clinical and financial implications of a decade of prostate biopsies performed in the UK National Health Service (NHS) through the transrectal (TR) vs the transperineal (TP) route.

METHODS

We conducted an evaluation of the TR vs the TP biopsy approach in the context of 28 days post-procedure complications and readmissions. A secondary evaluation of burden of expenditure in NHS hospitals over the entire decade (2008-2019) was conducted through examination of national Hospital Episode Statistics (HES) data.

RESULTS

In this dataset of 486 467 prostate biopsies (387 879 TR and 98 588 TP biopsies), rates of infection and sepsis were higher for the TR compared to the TP cohort (0.53% vs 0.31%; P < 0.001, confidence interval 99% ). Rates of sepsis have more than doubled for TR biopsies in the last 2 years compared to the previous decade (1.12% vs 0.53%). Infective complications were the main reasons for readmissions in the TR cohort, whereas urinary retention was the predominant reason for readmission in the TP cohort. Over the last decade, non-elective (NEL) readmissions seem higher for the TP group; however, in the last 2 years these have reduced compared to the TR group (3.54% vs 3.74%). The cost estimates for NEL readmissions for the entire decade were £33,589,527.00 and £7,179,926.00 respectively, for TR and TP cohorts (P < 0.001). Estimated costs per patient readmission were £2,225.00 and £1,758.00 in the TR and TP groups (P < 0.001).

CONCLUSIONS

Evaluation of nearly half a million prostate biopsies in the NHS over the entire decade gives sufficient evidence for the distinct advantages of the TP route over the TR route in terms of reduced infections and burden of expenditure. In addition, there is a potential for savings both in upstream and downstream costs if biopsy is performed under a local anaesthetic.

Efficacy and safety of periprostatic nerve block combined with perineal subcutaneous anaesthesia and intrarectal lidocaine gel in transrectal ultrasound guided transperineal prostate biopsy: A Prospective Randomised Controlled Trial

BACKGROUND

To determine the efficacy and safety of a periprostatic nerve block combined with perineum subcutaneous anaesthesia and intrarectal lidocaine gel for transrectal ultrasound-guided transperineal prostate biopsy (TPBx) through a prospective randomised controlled trial.

METHODS

In total, 216 patients from May 2018 to November 2018 were randomly assigned to the experimental group and the control group at a ratio of 1:1. The experimental group received a periprostatic nerve block combined with subcutaneous perineal anaesthesia and intrarectal lidocaine gel. The control group received total intravenous anaesthesia. A visual analogue scale (VAS) score (0-10) was used to evaluate pain at different stages. The operative time, duration of hospitalisation, intraoperative vital signs, perioperative complications and clinicopathological features were recorded.

RESULTS

The overall detection rate of prostate cancer was 40.74%, and the median Gleason score was 8 for all patients diagnosed with prostate cancer. No significant differences in terms of detection rates, Gleason scores and ISUP/WHO Grade Groups were found between the two groups (P > 0.05). The experimental group had no pain or just met the criteria for mild pain during the biopsy, which was significantly alleviated after the biopsy, and had a shorter operation time compared with that of the control group (P < 0.05). Compared with the control group, the experimental group had more stable haemodynamics and respiratory status and fewer surgical complications (P < 0.05).

CONCLUSIONS

In multiple aspects, a periprostatic nerve block combined with subcutaneous perineal anaesthesia and intrarectal lidocaine gel is a safer and more efficient approach to local anaesthesia for TPBx that can almost replace total intravenous anaesthesia and is worthwhile applying in the clinical setting.

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.

Stereotactic robot-assisted transperineal prostate biopsy under local anaesthesia and sedation: moving robotic biopsy from operating theatre to clinic

This IRB-approved prospective pilot study evaluates the safety and feasibility of performing stereotactic robot-assisted transperineal MRI-US fusion targeted prostate biopsy under local anaesthesia (LA) with sedation. 30 patients who underwent robotic transperineal prostate biopsy between September 2017 and June 2018 were recruited. All biopsies were performed with the iSR'obot Mona Lisa^® and BK3000 ultrasound system. Intravenous paracetamol 1 g, with midazolam and fentanyl were given at positioning. After administration of 5 mL of 1%-lidocaine into the perineal skin 2 cm above and lateral to the anus, periapical prostatic block with 10 mL mixture of 1%-Lidocaine and 0.5%-Marcaine was given. The median age of patients was 66 years (range 53-80 years). Median PSA and mean prostate volume were 8.1 ng/ml (range 4.2-20.6 ng/ml) and 40.1 cc (range 18.6-70 cc). 24 (80.0%) patients had targeted prostate biopsy, with median number of targeted cores of 8 (range 5-16). All patients had saturation biopsy and median number of saturation cores was 21 (range 9-48). Mean dose of intravenous midazolam given was 1.5 mg (range 0-5 mg) and intravenous fentanyl was 75 mcg (10-150 mcg). No patient required conversion to GA. Two patients required motion compensation of 3 mm and 7.5 mm, respectively, due minor movement. Immediate post-operative pain score was 0 for all patients. 29 of 30 patients (96.7%) were discharged within 24 h of procedure. There were no immediate severe complications. Adenocarcinoma was detected in 19/30 (63.3%) cases. This pilot feasibility study showed that stereotactic robotic transperineal MRI-US fusion targeted prostate biopsy can be safely and accurately performed under LA with sedation.

IDEAL Stage 2a experience with in-office, transperineal MRI/ultrasound software fusion targeted prostate biopsy

Objective

Although the feasibility of transperineal biopsy under local anesthesia has been demonstrated, little is known regarding the application of MRI/ultrasound software fusion targeted biopsy for transperineal biopsy under local anesthesia. The objective of our study is to describe our initial experience with in-office transperineal MRI/ultrasound software fusion targeted biopsy (Idea, Development, Exploration, Assessment, Long-term Follow-up [IDEAL] Stage 2a).

Methods

Between October 2017 and July 2019, 33 men underwent in-office transperineal MRI-targeted biopsy using the Artemis (Eigen, Grass Valley, CA, USA) fixed-robotic arm system. The indication for biopsy was elevated prostate specific antigen (PSA) (n=14), prior negative biopsy (n=10), active surveillance (n=6), and surveillance after partial gland cryoablation (n=3). We prospectively captured patient demographic and clinical characteristics, biopsy outcomes, and complications. Complications were classified according to Common Terminology Criteria for Adverse Events (CTCAE) V.5.0.

Results

The median patient age was 67 years (IQR 61–71) and the median serum PSA level was 7.0 ng/mL (IQR 5.1–11.4). The median duration of in-office MRI-targeted transperineal biopsy was 26 min (IQR 23–28). Overall, transperineal MRI-targeted biopsy detected prostate cancer in 18 (54.6%) men, with 8 (24.2%) being clinically significant (Gleason Score ≥3+4, Grade Group ≥2). Clinically significant prostate cancer was detected in four (28.6%) biopsy naïve men, two (20.0%) men with a prior negative, one (16.7%) man on active surveillance and one (33.3%) man following partial gland ablation. Three (9.1%) men experienced complications: two hematuria and one urinary retention.

Conclusion

Our findings demonstrate the feasibility of the fixed-robotic arm fusion platform for in-office transperineal MRI-targeted biopsy and a low rate of adverse events. However, larger prostate size precludes MRI/ultrasound software fusion and pubic arch interference hindered the transperineal MRI-targeted approach in 9.1% of men. Pubic arch interference was overcome by a free-hand approach with software fusion guidance.

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.

Assessment of the influence of transrectal and transperineal prostate biopsies on erectile function: A prospective observational single-center study

OBJECTIVES

To assess the impact of transrectal versus transperineal prostate biopsy on erectile function.

METHODS

This was a single-center, observational, prospective study of consecutive patients who underwent a prostate biopsy (transrectal or transperineal/fusion biopsy). Study participants completed the International Index of Erectile Function-5 questionnaire before the procedure, and 3 and 6 months after. Prostatic biopsies were carried out following the standard procedure for both techniques.

RESULTS

The study included 135 male patients with a mean age of 63.5 years. At baseline, 28 patients (21%) presented normal erectile function, whereas 107 patients (82%) presented erectile dysfunction, which was severe in four (3%), moderate in 49 (36%) and mild in 54 (40%), with an overall mean International Index of Erectile Function-5 score of 17.70. After 3 months, the rates were 29%, 3%, 27% and 38%, respectively (mean International Index of Erectile Function-5 score 17.95). At 6 months, the rates were 30%, 6%, 28% and 34%, respectively (mean International Index of Erectile Function-5 score of 17.77). No significant differences between pre- and post-biopsy International Index of Erectile Function-5 scores at 3 and 6 months were observed, even when analyzing transrectal and transperineal separately. The number of biopsy cores and number of previous biopsies did not influence the International Index of Erectile Function-5 scores.

CONCLUSIONS

Our findings suggest that prostate biopsy technique, number of biopsy cores and history of previous biopsy do not significantly impact erectile function in the medium term up to 6 months.

Update on techniques to prevent infections associated with prostate needle biopsy

PURPOSE OF REVIEW

Postbiopsy infections (PBIs) are among the most common complications associated with transrectal ultrasound-guided prostate biopsy (TRUSPB). This article discusses the pathogenesis of TRUSPB-associated infectious complications and reviews the most recent findings on techniques to prevent PBIs.

RECENT FINDINGS

Risk stratification is a powerful tool for identifying TRUSPB candidates whom warrant additional preventive measures. Bowel preparation with povidone-iodine-based enemas and needle disinfection with formalin solution are simple and attractive strategies, but their effectiveness needs to be thoroughly assessed. Antibiotic prophylaxis represents the mainstay for the prevention of PBIs: the prophylactic regimen must respect the principles of antimicrobial stewardship, and local antibiotic resistance patterns among uropathogens should always be considered. Augmented and targeted antibiotic prophylaxes are powerful options, but their role in current clinical practice has yet to be clarified. The transperineal approach has shown a near-zero rate of PBIs, and should therefore be considered for the highest-risk patients.

SUMMARY

Several procedures have been introduced to prevent TRUSPB-related infectious complication, but their utility and applicability in the clinical practice has yet to be elucidated. More robust evidence based on randomized control trials is needed to establish the efficacy of these tools in improving patient outcomes.

Prostate biopsy: guidelines and evidence

PURPOSE OF REVIEW

To summarize the highest level evidence that was acquired within the last years, with regard to diagnosis of prostate cancer. With many secondary diagnostic tools becoming available, and not being mentioned in the guidelines, this review is meant to assist clinical decision-making in initial biopsy and rebiopsy settings.

RECENT FINDINGS

The PROMIS Trial delivered level 1b evidence about the diagnostic accuracy of prostate multiparametric MRI (mpMRI) as a triage tool for prostate biopsy. MRI-ultrasound-fusions-targeted biopsy has been evaluated and compared with the standard of care, and has been found to have a higher cancer detection rate. The different approaches to MRI-guided biopsies do not show significant differences. Urine biomarkers analysing RNA as well as genetic assays of biopsy specimen have also shown to be helpful in the decision to (re-)biopsy a patient, especially in combination with MRI.

SUMMARY

Patients and doctors alike have been trying to avoid prostate biopsies, the risks, and the side effects of potential overtreatment. Imaging and other biomarkers are used to increase diagnostic accuracy, yielding more precise information to act on. None of these secondary diagnostic tools are perfect, yet they can, and should be used if one stays aware of their limitations.

Hemostatic effect and psychological impact of an oxidized regenerated cellulose patch after transrectal ultrasound-guided prostate biopsy: A prospective and retrospective study

To investigate the usefulness of the oxidized regenerated cellulose patch (ORCP) for postbiopsy hemostasis, anxiety, and depression in patients undergoing transrectal ultrasound-guided prostate biopsy.This was a prospective-retrospective study of 300 patients who underwent systematic 12-core prostate biopsy from August 2016 through March 2018. The ORCP was inserted into the rectum immediately after prostate biopsy in the prospective group (n = 150), while the retrospective group (n = 150) underwent prostate biopsy alone. The frequency rate and duration of hematuria, rectal bleeding, and hematospermia were compared between the 2 groups. Anxiety and depression were assessed with the hospital anxiety and depression scale before and after prostate biopsy in the prospective group.The frequency rates of hematuria and hematospermia showed no significant differences between the prospective versus retrospective groups (64.7% vs 66.7%, P = .881; 18 vs 20%, P = .718; respectively). Frequency of rectal bleeding was significantly lower in the prospective group than in the retrospective group (26.7% vs 42.7%, P = .018). However, there were no significant differences in median duration of rectal bleeding, hematuria, or hematospermia between the 2 groups (2, 5, and 2 days vs 2, 7, and 1 day, P > .05, respectively, for the prospective vs retrospective group). Multivariate analysis found that ORCP insertion was a significant protective factor against postbiopsy rectal bleeding (P = .038, odds ratio 0.52). Only anxiety level in the prospective group before versus after prostate biopsy was significantly reduced (5 vs 4, P = .011).ORCP insertion after prostate biopsy is an effective and simple method for decreasing rectal bleeding. ORCP insertion may also alleviate anxiety in patients undergoing prostate biopsy.

Update on Strategies to Reduce Infectious Complications After Prostate Biopsy

CONTEXT

Prostate biopsy is one of the most performed procedures in urology. As a diagnostic procedure it should be of low risk. However, morbidity following prostate biopsy is common due to infectious complications.

OBJECTIVE

To describe how to reduce infectious complications following prostate biopsy. We report on antibiotic and technical interventions to reduce infectious complications.

EVIDENCE ACQUISITION

The data presented are based on a narrative review. Search in PubMed and Medline was performed until May 2018 with a focus on randomised controlled trials and meta-analyses. Articles were reviewed for data on symptomatic infections, hospitalisation, and adverse events.

EVIDENCE SYNTHESIS

Antibiotic prophylaxis is the standard of care. However, the duration of antibiotic preemptive treatment is still under debate. The use of augmented antibiotic prophylaxis as well as targeted antibiotic prophylaxis might be of potential value, but evidence is currently limited. Moreover, no antibiotic class was shown to be clearly superior to another. The evaluation of the technical aspects during prostate biopsy reveals that rectal preparation with povidone-iodine is clearly effective to reduce infectious complications. Transperineal biopsy has a potential benefit to reduce infectious complications, but powerful randomised controlled studies are missing. Finally, the number of biopsy cores, the application of periprostatic nerve block, or the use of a cleansing enema has no impact on prostate biopsy in terms of infectious complications.

CONCLUSIONS

The available data only suggest that rectal preparation with povidone-iodine as well as antibiotic prophylaxis is of significant advantage to reduce infectious complications following prostate biopsy. The augmented and targeted antibiotic prophylaxis shows some potential, but need further validation.

PATIENT SUMMARY

In this review we evaluate the best management strategy to prevent infectious complications following prostate biopsy. We show that antibiotic prophylaxis is essential for prostate biopsy and that rectal preparation with povidone-iodine is mandatory.

Improving the safety and tolerability of local anaesthetic outpatient transperineal prostate biopsies: A pilot study of the CAMbridge PROstate Biopsy (CAMPROBE) method

OBJECTIVES

The aim of this study was to pilot the use of a bespoke device (CAMPROBE, the CAMbridge PROstate Biopsy) to enable routine outpatient free-hand local anaesthetic (LA) transperineal prostate biopsies.

MATERIALS AND METHODS

The CAMPROBE prototype was designed and built in our institution. Men on active surveillance due prostate resampling were invited to have a CAMPROBE biopsy as an alternative to repeat transrectal ultrasound-guided prostate biopsies (TRUSBx) as part of an approved trial (NCT02375035). Biopsies were performed using LA infiltration only, without sedation or additional analgesia. Patient-reported outcomes were recorded at day 0 and 7 using validated questionnaires and visual analogue scales (VAS). Complications were recorded prospectively.

RESULTS

Thirty men underwent biopsies with a median of 11 cores taken per procedure (interquartile range 10-12). There were no infections, sepsis or retention episodes. Haematuria and haematospermia occurred in 67% and 62% of patients, which are similar to rates reported for TRUSBx. Mean VAS for pain (0-10 scale) was less than 3 for every part of the procedure. All 30 men described the procedure as tolerable under LA. In total, 26/30 (86.7%) men expressed a preference for a CAMPROBE procedure over TRUSBx and a further 3 (10.0%) would have either.

CONCLUSIONS

In this small pilot study, the CAMPROBE device and method appears to be a safe, simple and well-tolerated out-patient transperineal replacement for TRUSBx. A major new National Institute for Health Research grant will allow its further development from a prototype to a single use, low-cost disposable device ready for multi-centre testing.

LEVEL OF EVIDENCE

1b: individual cohort study.

Management of men with previous negative prostate biopsy

PURPOSE OF REVIEW

Up to 70% of prostate biopsies are negative in men with suspected prostate cancer. Because of inherent limitations in biopsy strategies, a significant proportion of cancers are missed on initial biopsy. Following negative biopsy, men frequently exhibit persistently elevated prostate-specific antigen - raising concerns for missed diagnosis. We highlight the recent updates in the management of negative prostate biopsy.

RECENT FINDINGS

Advances in noninvasive diagnostics are available and assist clinicians in further substratifying risk of prostate cancer. Despite limited data, urinary prostate cancer antigen 3 and transmembrane protease serine 2 appear to have a promising predictive value for patients suspected of prostate cancer. The advent of multiparametricMRI allows the visualization of intermediate and high-grade prostate cancer, particularly in the troublesome anterior prostate. This modality may further provide the potential for magnetic resonance-guided targeted biopsies. Current data suggest that in the presence of suspicious radiological findings, magnetic resonance-guided biopsies have superior sensitivity profiles compared with traditional rebiopsy approaches. In the absence of multiparametricMRI or suspicious findings, traditional saturation biopsies are sufficient.

SUMMARY

The management of negative biopsies is evolving rapidly with emerging diagnostics to stratify risk of prostate cancer in men with previous negative biopsies. An increasing body of information supports the use of magnetic resonance-guided biopsies.

Antibiotic Prophylaxis in Prostate Biopsies: Contemporary Practice Patterns in Germany

Purpose

Prostate biopsy (pbx) is the most common outpatient procedure in urology. Complications are urinary tract infections, including hospitalization and sepsis. Recommendations on antibiotic prophylaxis (apx) are scarce, and healthcare data are not available. The study addressed the following endpoints: the duration and spectrum of antimicrobial prophylaxis in transrectal and transperineal pbx in the hospital and the practice setting.

Methods

A questionnaire compiled data about age, gender, board certification, and place of work. Information about the frequency of pbx, duration and type of apx, usage of disinfecting lubricant, and urine or rectal swab cultures was collected. The study refers to German urologists.

Results

Overall 478 urologists answered the questionnaire. 15.5% (74) of respondents were residents. 50.8% (243) of urologists work in a practice; the rest in a hospital. Only 4.8% do not perform pbx. Transrectal pbx are performed a median of two times a week. The majority (446, 98%) prescribe an apx, mostly fluoroquinolones (407, 89.5%). In total, 10.1% (46) of the participants use a single-shot-apx. apx has a median duration of 4 days. One-third uses a disinfecting lubricant. Urine and rectal swab cultures are analyzed by 45.5% (207) and 24.4% (111), respectively.

Conclusion

Most urologists prescribe an extended apx for both transrectal and transperineal pbx. Perineal pbx is still a deviation from everyday practice and not an established alternative to transrectal pbx. Urologists are aware of the increasing fluoroquinolone-resistance and are adapting with rectal swab and urine cultures. Further studies need to evaluate alternatives to 5-day apx and results should be addressed in our guidelines. This is of importance in light of the increasing resistance rates and fluoroquinolone side effects.

Outbreak of Achromobacter xylosoxidans and Ochrobactrum anthropi Infections after Prostate Biopsies, France, 2014

We report an outbreak of healthcare-associated prostatitis involving rare environmental pathogens in immunocompetent patients undergoing transrectal prostate biopsies at Hôpital Édouard Herriot (Lyon, France) during August 13-October 10, 2014. Despite a fluoroquinolone-based prophylaxis, 5 patients were infected with Achromobacter xylosoxidans and 3 with Ochrobactrum anthropi, which has not been reported as pathogenic in nonimmunocompromised persons. All patients recovered fully. Analysis of the outbreak included case investigation, case-control study, biopsy procedure review, microbiologic testing of environmental and clinical samples, and retrospective review of hospital records for 4 years before the outbreak. The cases resulted from asepsis errors during preparation of materials for the biopsies. A low-level outbreak involving environmental bacteria was likely present for years, masked by antimicrobial drug prophylaxis and a low number of cases. Healthcare personnel should promptly report unusual pathogens in immunocompetent patients to infection control units, and guidelines should explicitly mention asepsis during materials preparation.

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

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