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Kim SY, Park KJ. [MR-Guided Targeted Prostate Biopsy from Radiologists' Perspective]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:1220-1232. [PMID: 38107690 PMCID: PMC10721410 DOI: 10.3348/jksr.2023.0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 12/19/2023]
Abstract
The prostate cancer diagnosis has traditionally been based on a systematic biopsy method in which tissue samples are randomly obtained from the prostate 10-12 sites. However, there are concerns as the method can fail to diagnose all prostate cancers or lead to over-detection of clinically insignificant cancers. MRI-guided prostate targeted biopsy has been proposed to address these shortcomings. This method involves identifying suspicious lesions using MRI and performing targeted biopsies under ultrasound or MRI guidance. We review the methods of MRI-based targeted biopsy and discuss recent guidelines and trends in prostate cancer diagnosis.
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Alnosayan H, Alharbi MA, Alharbi AH, Aloraini AS, Alfayyadh AM, Almansour M. Initial Outcomes of Freehand Transperineal Biopsies Regarding Diagnostic Value and Safety: An Early Experience at King Fahad Specialist Hospital, Buraydah, Saudi Arabia. Cureus 2023; 15:e39318. [PMID: 37351252 PMCID: PMC10282500 DOI: 10.7759/cureus.39318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 06/24/2023] Open
Abstract
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.
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Affiliation(s)
- Hatim Alnosayan
- Department of Urology, College of Medicine, Qassim University, Qassim, SAU
| | - Mohannad A Alharbi
- Department of Urology, College of Medicine, Qassim University, Qassim, SAU
| | - Adel H Alharbi
- Department of Urology, College of Medicine, Qassim University, Qassim, SAU
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Kanagarajah A, Hogan D, Yao HH, Dundee P, O'Connell HE. A systematic review on the outcomes of local anaesthetic transperineal prostate biopsy. BJU Int 2023; 131:408-423. [PMID: 36177521 DOI: 10.1111/bju.15906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To conduct a systematic review of the literature to assess the diagnostic ability, complication rate, patient tolerability, and cost of local anaesthetic (LA) transperineal prostate biopsy. METHODS Two reviewers searched Medline, the Cochrane Library, and Embase for publications on LA transperineal prostate biopsy up to March 2021. Outcomes of interest included cancer detection rates, complication rates, pain assessments and cost. RESULTS A total of 35 publications with 113 944 men were included in this review. The cancer detection rate for LA transperineal prostate biopsy in patients undergoing primary biopsy was 52% (95% confidence interval [CI] 0.45-0.60; I2 = 97) and the clinically significant cancer detection rate (Gleason≥3 + 4) was 37% (95% CI 0.24-0.52; I2 = 99%). The rate of infection-related complications in the included studies was 0.15% (95% CI 0.0000-0.0043; I2 = 86). The LA transperineal procedures had a low rate of procedural abandonment (26/6954, 0.37%), with the greatest pain scores measured during LA administration. No formal cost analyses on LA transperineal prostate biopsies were identified in the literature. The overall risk of bias in the included studies was high, with considerable study heterogeneity and publication bias. CONCLUSION Transperineal prostate biopsy performed under LA is a viable option for centres interested in avoiding the risk of infection associated with transrectal biopsy, and the logistical burden of general anaesthesia. Further investigation into LA transperineal prostate biopsy with comparative studies is warranted for its consideration as the standard in prostate biopsy technique.
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Affiliation(s)
- Abbie Kanagarajah
- Department of Urology, Western Health, Melbourne, Vic., Australia
- Austin Health, Melbourne, Vic., Australia
| | - Donnacha Hogan
- Department of Urology, Western Health, Melbourne, Vic., Australia
- University College Cork, Cork, Ireland
| | - Henry H Yao
- Department of Urology, Western Health, Melbourne, Vic., Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Philip Dundee
- Department of Urology, Western Health, Melbourne, Vic., Australia
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Lai HC, Chen CL, Huang YH, Wu KL, Huang RC, Lin BF, Chan SM, Wu ZF. Comparison of 2 effect-site concentrations of remifentanil with midazolam during transrectal ultrasound-guided prostate biopsy under procedural analgesia and sedation: A randomized controlled study. Medicine (Baltimore) 2022; 101:e30466. [PMID: 36086764 PMCID: PMC10980449 DOI: 10.1097/md.0000000000030466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/02/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Until now, target-controlled infusion of remifentanil with midazolam for transrectal ultrasound-guided prostate biopsy has not been described. Here, we investigate 2 effect-site concentrations of remifentanil with intermittent bolus midazolam for transrectal ultrasound-guided prostate biopsy under procedural analgesia and sedation. METHODS A prospective, randomized controlled trial including patients who received a transrectal ultrasound-guided prostate biopsy between February 2019 and January 2021 was conducted. Group 1 and Group 2 were respectively administered an initial effect-site concentration of remifentanil of 1.0 ng/mL and 2.0 ng/mL by a target-controlled infusion pump with Minto model. In both groups, maintenance of the effect-site concentration of remifentanil was adjusted upward and downward by 0.5 ng/mL to keep patient comfort with acceptable pain (remaining moveless), and mean arterial pressure and heart rate within baseline levels ± 30%, and using intermittent bolus midazolam to keep the Observer's Assessment of Alertness/Sedation scale between 2 and 4. The primary outcome was to determine which effect-site concentration of remifentanil provide adequate patient comfort with acceptable pain (remaining moveless) during the procedure. RESULTS A total of 40 patients in Group 1 and 40 patients in Group 2 were eligible for analysis. Most parameters were insignificantly different between Group 1 and Group 2, except Group 1 having higher peripheral oxygen saturation while probe insertion compared with Group 2. Group 2 patients had less intraoperative movements affecting the procedure (2 vs 18; P < .001), and less total times of target-controlled infusion pump adjustment (0 [0-1] vs 1 [0-3], P < .001) compared with group 1. However, group 1 patients had less apnea with desaturation (peripheral oxygen saturation < 90%; 0 vs 9, P = .002) and less remifentanil consumption (94.9 ± 25.5 μg vs 106.2 ± 21.2 μg, P = .034) compared to Group 2. CONCLUSION In transrectal ultrasound-guided prostate biopsy, target-controlled infusion with remifentanil Minto model target 2.0 ng/mL with 3 to 4 mg midazolam use provided sufficient analgesia and sedation, and appropriate hemodynamic and respiratory conditions.
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Affiliation(s)
- Hou-Chuan Lai
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chin-Li Chen
- Division of Urological Surgery, Department of Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yi-Hsuan Huang
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Ke-Li Wu
- Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Ren-Chih Huang
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Bo-Feng Lin
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Shun-Ming Chan
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Zhi-Fu Wu
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, Republic of China
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, Republic of China
- Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, Republic of China
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He J, Guo Z, Huang Y, Wang Z, Huang L, Li B, Bai Z, Wang S, Xiang S, Gu C, Pan J. Comparisons of efficacy and complications between transrectal and transperineal prostate biopsy with or without antibiotic prophylaxis. Urol Oncol 2022; 40:191.e9-191.e14. [DOI: 10.1016/j.urolonc.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 12/05/2021] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
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El-Achkar A, Al-Mousawy M, Abou Heidar N, Moukaddem H, Hussein H, Mouallem N, El-Hajj A, Bulbul M. Magnetic resonance imaging /ultrasonography fusion transperineal prostate biopsy for prostate cancer: Initial experience at a Middle Eastern tertiary medical centre. Arab J Urol 2021; 19:454-459. [PMID: 34881061 PMCID: PMC8648043 DOI: 10.1080/2090598x.2021.1926727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/20/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: To report on the outcomes of magnetic resonance imaging (MRI)/ultrasonography (US)-fusion transperineal prostate (TP) biopsy at a tertiary medical centre in the Middle East including detection rate of clinically significant prostate cancer (csPCa), complications, and tolerability of the procedure. Patients and methods: Between May 2019 and June 2020, 98 MRI/US-fusion TP biopsies were performed in the US suite using light sedation. All patients had pre-biopsy 3-T multiparametric MRI. Data on patient characteristics, PCa detection rate and complication rates were collected retrospectively. A Gleason score ≥3 + 4 was defined as csPCa. RESULTS There were 98 patients, with a mean (SD) age of 65 (9.1) years, and a median (SD) prostate-specific antigen level prior to biopsy of 7.53 (12.97) ng/mL and prostate volume of 51 (31.1) mL. PCa was detected in 54 (55%) patients, with csPCa detected in 43 (44%). A total of 124 Prostate Imaging-Reporting and Data System (PI-RADS) 3-5 lesions were targeted. Grade Group ≥2 PCa was found in 35.5% of the targeted lesions. Random biopsies detected one csPCa Gleason score 3 + 4 in one patient with a negative target. None of the patients had post-biopsy haematuria or retention. Only one patient developed acute prostatitis requiring in-patient intravenous antibiotics. CONCLUSIONS MRI/US-fusion TP biopsy has an adequate detection rate of csPCa with minimal complications and low infection rates after biopsy. This is one of the first TP biopsy series in the Middle East paving the way for wider adoption in the region. ABBREVIATIONS AS: active surveillance; AUR: acute urinary retention; GG: Grade Group; IQR: interquartile range; mpMRI: multiparametric MRI; (cs)PCa: (clinically significant) prostate cancer; PI-RADS: Prostate Imaging-Reporting and Data System; TP: transperineal; US: ultrasonography; TRUS: transrectal Ultrasound guided.
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Affiliation(s)
- Adnan El-Achkar
- American University of Beirut Medical Center, Department of Surgery, Division of Urology, Beirut, Lebanon
| | - Mouhammad Al-Mousawy
- American University of Beirut Medical Center, Department of Surgery, Division of Urology, Beirut, Lebanon
| | - Nassib Abou Heidar
- American University of Beirut Medical Center, Department of Surgery, Division of Urology, Beirut, Lebanon
| | - Hisham Moukaddem
- American University of Beirut Medical Center, Department of Diagnostic Radiology, Beirut, Lebanon
| | - Hero Hussein
- American University of Beirut Medical Center, Department of Diagnostic Radiology, Beirut, Lebanon
| | - Nadim Mouallem
- American University of Beirut Medical Center, Department of Diagnostic Radiology, Beirut, Lebanon
| | - Albert El-Hajj
- American University of Beirut Medical Center, Department of Surgery, Division of Urology, Beirut, Lebanon
| | - Muhammad Bulbul
- American University of Beirut Medical Center, Department of Surgery, Division of Urology, Beirut, Lebanon
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MRI-Targeted Prostate Biopsy Techniques: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:1263-1281. [PMID: 34259038 DOI: 10.2214/ajr.21.26154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Prostate cancer is the second most common malignancy in men worldwide. Systematic transrectal prostate biopsy is commonly used to obtain tissue to establish the diagnosis. However, in recent years, MRI-targeted biopsy (based on an MRI examination performed prior to consideration of biopsy) has been shown to detect more clinically significant cancer and less clinically insignificant cancer compared to systematic biopsy. This approach of performing MRI prior to biopsy has become, or is becoming, a standard of practice in centers throughout the world. This growing use of an MRI-directed pathway is leading to performance of a larger volume of MRI-targeted prostate biopsies. The three common MRI-targeted biopsy techniques are cognitive biopsy, MRI-ultrasound software fusion biopsy, and MRI in-bore guided biopsy. These techniques for using MRI information at the time of biopsy can be performed via a transrectal or transperineal approach. This narrative review presents the three MRI-targeted biopsy techniques along with their advantages and shortcomings. Comparisons among the techniques are summarized based on the available evidence. Studies to date have provided heterogeneous results, and the preferred technique remains debated.
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Mehmood S, Alothman KI, Alwehaibi A, Alhashim SM. Diagnostic efficacy and safety of transperineal prostate targeted and systematic biopsy: The preliminary experience of first 100 cases. ACTA ACUST UNITED AC 2021; 93:127-131. [PMID: 34286542 DOI: 10.4081/aiua.2021.2.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Post-biopsy urosepsis is a major concern for patient morbidity and cost. Trasperineal biopsy is reported to have less complications and higher detection rate of clinically significant prostate cancer (csPCa). OBJECTIVES To determine the diagnostic efficacy and safety of transperineal prostate biopsy in patients with elevated prostatic specific antigen (PSA). MATERIAL AND METHODS A prospective study included men with elevated PSA > 3 ng/ml and previous negative biopsy from January 2018 to April 2019. All patients had multiparametric magnetic resonance imaging (mpMRI) and suspicious lesions reported as Prostate Imaging Reporting and Data System (PIRADS) score version 2. Average twelve systematic and two targeted cores were biopsied under general anaesthesia. Patients received single dose of antibiotic prebiopsy. RESULTS 100 Consecutive patients having median age 64.0 years and median PSA of 6.1ng/ml were included for mpMRI-US fusion transperineal biopsies. Cancer detection rate was 45% (targeted 38% and systematic 22%) and csPCa were detected in 75.55% (targeted 86.84% and systematic 59.09%). MRI-US fusion targeted biopsies detected 63.88% csPCa in PIRADS 5, 33.33% in PIRADS 4 and 5.88% in PIRADS 3 lesions. PSA > 10 (p = 0.012), PSA density > 0.15 (p = 0.0002), and PIRADS 5 (0.0001) were significantly associated with PCa. Factors like Age (0.0001), initial PSA (0.022) and PSA density (0.006) were significant on univariate analysis while age (0.0001) was significant on multivariate analysis. There was no case of urinary tract infection. CONCLUSIONS Transperineal prostate biopsy is safe and effective in diagnosing csPCa. There is no risk of sepsis and major complications.
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Affiliation(s)
- Shahbaz Mehmood
- King Faisal Specialist Hospital and Research Center, Riyadh.
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Rabah D, Al-Taweel W, Khan F, Arafa M, Mehmood S, Mokhtar A, Farhat K. Transperineal versus transrectal multi-parametric magnetic resonance imaging fusion targeted prostate biopsy. Saudi Med J 2021; 42:649-654. [PMID: 34078727 PMCID: PMC9149710 DOI: 10.15537/smj.2021.42.6.20200771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/29/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Danny Rabah
- From the Department of Surgery (Rabah, Khan), College of Medicine; from the Cancer Research Chair (Rabah, Arafa, Farhat), King Saud University, and from the Department of Urology (Rabah, Al-Taweel, Mokhtar), King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia.
| | - Waleed Al-Taweel
- From the Department of Surgery (Rabah, Khan), College of Medicine; from the Cancer Research Chair (Rabah, Arafa, Farhat), King Saud University, and from the Department of Urology (Rabah, Al-Taweel, Mokhtar), King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia.
| | - Farrukh Khan
- From the Department of Surgery (Rabah, Khan), College of Medicine; from the Cancer Research Chair (Rabah, Arafa, Farhat), King Saud University, and from the Department of Urology (Rabah, Al-Taweel, Mokhtar), King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia.
| | - Mostafa Arafa
- From the Department of Surgery (Rabah, Khan), College of Medicine; from the Cancer Research Chair (Rabah, Arafa, Farhat), King Saud University, and from the Department of Urology (Rabah, Al-Taweel, Mokhtar), King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia.
| | - Shahbaz Mehmood
- From the Department of Surgery (Rabah, Khan), College of Medicine; from the Cancer Research Chair (Rabah, Arafa, Farhat), King Saud University, and from the Department of Urology (Rabah, Al-Taweel, Mokhtar), King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia.
| | - Alaa Mokhtar
- From the Department of Surgery (Rabah, Khan), College of Medicine; from the Cancer Research Chair (Rabah, Arafa, Farhat), King Saud University, and from the Department of Urology (Rabah, Al-Taweel, Mokhtar), King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia.
| | - Karim Farhat
- From the Department of Surgery (Rabah, Khan), College of Medicine; from the Cancer Research Chair (Rabah, Arafa, Farhat), King Saud University, and from the Department of Urology (Rabah, Al-Taweel, Mokhtar), King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia.
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John JB, MacCormick A, MacDonagh R, Speakman MJ, Vennam R, Burns-Cox N. Complications following local anaesthetic transperineal prostate biopsies without antibiotic prophylaxis: An institution’s experience. JOURNAL OF CLINICAL UROLOGY 2021. [DOI: 10.1177/2051415820987661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objectives: This study aimed to describe a UK institution’s experience with local anaesthetic (LA) transperineal (TP) prostate biopsies (PB), and to report 30-day complications following LATPPB, including a large cohort that did not receive antibiotic prophylaxis. Patients and methods: A prospective database of 313 consecutive patients undergoing LATPPB was maintained, describing patient and disease characteristics, and complications. From September 2019 to January 2020, antibiotic prophylaxis was given before LATPPB ( n=149). Following a change to routine care, from January 2020 to July 2020, prophylactic antibiotics were not given before LATPPB ( n=164). A comparative analysis was performed to determine complication rates following antibiotic prophylaxis discontinuation using electronic hospital and primary care records. Results: Patient and disease characteristics were comparable in antibiotic and non-antibiotic cohorts, and representative of PB and prostate cancer cohorts described in the urological literature. The infection-related complication rate was 0.32% across all patients, and 0% for those not receiving antibiotic prophylaxis. The overall complication rate was 0.64%, and 0.61% for those not receiving antibiotic prophylaxis. There were no severe (Clavien–Dindo 3–5) complications. The unplanned hospital admission rate was 0.64%. Conclusion: The complication rate after LATPPB was low, with no infection-related complications in patients who did not receive antibiotic prophylaxis. This provides further evidence supporting the discontinuation of routine prophylactic antibiotics before TPPB. Level of evidence: Level 2b.
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Affiliation(s)
- Joseph B John
- Department of Urology, Royal Devon and Exeter NHS Foundation Trust, UK
| | | | | | | | - Ramesh Vennam
- Department of Urology, Somerset NHS Foundation Trust, UK
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Transrectal versus transperineal prostate biopsy under intravenous anaesthesia: a clinical, microbiological and cost analysis of 2048 cases over 11 years at a tertiary institution. Prostate Cancer Prostatic Dis 2020; 24:169-176. [PMID: 32759972 DOI: 10.1038/s41391-020-0263-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/10/2020] [Accepted: 07/24/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Transrectal (TR) and transperineal (TP) approaches for prostate biopsy have different morbidity profiles. Our institution transitioned to a preference for multiparametric MRI-based triage and TP biopsy since 2014. The aim of this study was to compare clinical, microbiological and health economic outcomes between TR and TP prostate biopsy. METHODS A consecutive cohort study considered prostate biopsies over an 11 year period. Hospital presentations across the region within 30 days of biopsy were analysed for details and subsequent outcomes according to biopsy approach. Cost for each encounter (routine and unplanned) were analysed and generalised linear models applied, as well as cost implications for inclusion of mpMRI-based triage and TP biopsy preference. RESULTS In total, 2048 prostate biopsies were performed. Similar re-presentation rates per occurred for each biopsy approach (90 patients, TR 4.8%, TP 3.8%, p = 0.29), with 23 patients presenting more than once (119 total presentations). Presentations after TR biopsy were more likely to be of infectious aetiology (TR 2.92%, TP 0.26% de novo, p < 0.001) and result in hospital admission (TR 43/49, 93.4%; TP 14/24, 58.3%; p = 0.007) for similar rates of urinary retention (TR 2.76% vs TP 3.63%, p = 1). The mean overall cost (biopsy and re-presentations) was higher for the TP group (p < 0.001), adjusted for year and age, but reduced over time and was similar for patients who re-presented (p = 0.98). Incorporation of mpMRI (with subsequently avoided biopsies), TP biopsy and re-presentations resulted in AU$783.27 saving per biopsy. CONCLUSIONS TR biopsy resulted in more infectious complications and hospital admissions than TP biopsy for similar rates of re-presentation and urinary retention. TP biopsy costs reduced over time and use in conjunction with mpMRI provides an overall cost saving. Routine TP biopsy is safe and feasible, with further cost savings expected with other approaches (local anaesthetic) under investigation.
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Tops SCM, Koldewijn EL, Somford DM, Huis AMP, Kolwijck E, Wertheim HFL, Hulscher MEJL, Sedelaar JPM. Prostate biopsy techniques and pre-biopsy prophylactic measures: variation in current practice patterns in the Netherlands. BMC Urol 2020; 20:24. [PMID: 32164686 PMCID: PMC7066741 DOI: 10.1186/s12894-020-00592-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 02/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The clinical landscape of prostate biopsy (PB) is evolving with changes in procedures and techniques. Moreover, antibiotic resistance is increasing and influences the efficacy of pre-biopsy prophylactic regimens. Therefore, increasing antibiotic resistance may impact on clinical care, which probably results in differences between hospitals. The objective of our study is to determine the (variability in) current practices of PB in the Netherlands and to gain insight into Dutch urologists' perceptions of fluoroquinolone resistance and biopsy related infections. METHODS An online questionnaire was prepared using SurveyMonkey® platform and distributed to all 420 members of the Dutch Association of Urology, who work in 81 Dutch hospitals. Information about PB techniques and periprocedural antimicrobial prophylaxis was collected. Urologists' perceptions regarding pre-biopsy antibiotic prophylaxis in an era of antibiotic resistance was assessed. Descriptive statistical analysis was performed. RESULTS One hundred sixty-one responses (38.3%) were analyzed representing 65 (80.3%) of all Dutch hospitals performing PB. Transrectal ultrasound guided prostate biopsy (TRUSPB) was performed in 64 (98.5%) hospitals. 43.1% of the hospitals (also) used other image-guided biopsy techniques. Twenty-three different empirical prophylactic regimens were reported among the hospitals. Ciprofloxacin was most commonly prescribed (84.4%). The duration ranged from one pre-biopsy dose (59.4%) to 5 days extended prophylaxis. 25.2% of the urologists experienced ciprofloxacin resistance as a current problem in the prevention of biopsy related infections and 73.6% as a future problem. CONCLUSIONS There is a wide variation in practice patterns among Dutch urologists. TRUSPB is the most commonly used biopsy technique, but other image-guided biopsy techniques are increasingly used. Antimicrobial prophylaxis is not standardized and prolonged prophylaxis is common. The wide variation in practice patterns and lack of standardization underlines the need for evidence-based recommendations to guide urologists in choosing appropriate antimicrobial prophylaxis for PB in the context of increasing antibiotic resistance.
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Affiliation(s)
- Sofie C. M. Tops
- Department of Medical Microbiology, Radboud Center Infectious Diseases, Radboudumc, huispost 777, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | | | - Diederik M. Somford
- Department of Urology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Anita M. P. Huis
- Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Eva Kolwijck
- Department of Medical Microbiology, Radboud Center Infectious Diseases, Radboudumc, huispost 777, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - Heiman F. L. Wertheim
- Department of Medical Microbiology, Radboud Center Infectious Diseases, Radboudumc, huispost 777, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - Marlies E. J. L. Hulscher
- Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
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13
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Grummet J, Gorin MA, Popert R, O'Brien T, Lamb AD, Hadaschik B, Radtke JP, Wagenlehner F, Baco E, Moore CM, Emberton M, George AK, Davis JW, Szabo RJ, Buckley R, Loblaw A, Allaway M, Kastner C, Briers E, Royce PL, Frydenberg M, Murphy DG, Woo HH. "TREXIT 2020": why the time to abandon transrectal prostate biopsy starts now. Prostate Cancer Prostatic Dis 2020; 23:62-65. [PMID: 31932659 PMCID: PMC7027966 DOI: 10.1038/s41391-020-0204-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 12/11/2019] [Accepted: 01/06/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Jeremy Grummet
- Department of Surgery, Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Michael A Gorin
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | | | - Erik Briers
- European Cancer Patient Coalition, Brussels, Belgium
| | - Peter L Royce
- Department of Surgery, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | | | - Declan G Murphy
- Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Henry H Woo
- Sydney Adventist Hospital, University of Sydney, Sydney, NSW, Australia
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14
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Marra G, Ploussard G, Futterer J, Valerio M. Controversies in MR targeted biopsy: alone or combined, cognitive versus software-based fusion, transrectal versus transperineal approach? World J Urol 2019; 37:277-287. [PMID: 30610359 DOI: 10.1007/s00345-018-02622-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 12/29/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Giancarlo Marra
- Department of Urology, San Giovanni Battista Hospital, Città della Salute e della Scienza and University of Turin, C.so Bramante 88/90, 10100, Turin, Italy.
| | - Guillaume Ploussard
- Department of Urology, Saint Jean Languedoc Hospital and Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
| | - Jurgen Futterer
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Massimo Valerio
- Department of Urology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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15
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Goldman H, Singh N, Harding C, McGirr J, Seal A, Duncan I, Sowter S. Accuracy of multiparametric magnetic resonance imaging to detect significant prostate cancer and index lesion location. ANZ J Surg 2018; 89:106-110. [DOI: 10.1111/ans.14754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 05/02/2018] [Accepted: 06/01/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Hariette Goldman
- School of Medicine; The University of Notre Dame Australia; Sydney New South Wales Australia
- Rural Clinical School; The University of New South Wales; Wagga Wagga New South Wales Australia
| | - Neha Singh
- Rural Clinical School; The University of New South Wales; Wagga Wagga New South Wales Australia
- Wagga Wagga Base Hospital; Wagga Wagga New South Wales Australia
- Calvary Healthcare Regional Imaging; Wagga Wagga New South Wales Australia
| | - Catherine Harding
- School of Medicine; The University of Notre Dame Australia; Sydney New South Wales Australia
| | - Joe McGirr
- School of Medicine; The University of Notre Dame Australia; Sydney New South Wales Australia
| | - Alexa Seal
- School of Medicine; The University of Notre Dame Australia; Sydney New South Wales Australia
| | - Ian Duncan
- Calvary Healthcare Regional Imaging; Wagga Wagga New South Wales Australia
| | - Steven Sowter
- Rural Clinical School; The University of New South Wales; Wagga Wagga New South Wales Australia
- Wagga Wagga Base Hospital; Wagga Wagga New South Wales Australia
- Riverina Urology; Wagga Wagga New South Wales Australia
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16
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Mischinger J, Kaufmann S, Russo GI, Harland N, Rausch S, Amend B, Scharpf M, Loewe L, Todenhoefer T, Notohamiprodjo M, Nikolaou K, Stenzl A, Bedke J, Kruck S. Targeted vs systematic robot-assisted transperineal magnetic resonance imaging-transrectal ultrasonography fusion prostate biopsy. BJU Int 2018; 121:791-798. [DOI: 10.1111/bju.14089] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
| | - Sascha Kaufmann
- Department of Diagnostic and Interventional Radiology; Eberhard Karls University; Tübingen Germany
| | - Giorgio I. Russo
- Department of Urology; Eberhard Karls University; Tübingen Germany
| | - Niklas Harland
- Department of Urology; Eberhard Karls University; Tübingen Germany
| | - Steffen Rausch
- Department of Urology; Eberhard Karls University; Tübingen Germany
| | - Bastian Amend
- Department of Urology; Eberhard Karls University; Tübingen Germany
| | - Marcus Scharpf
- Institute of Pathology; Eberhard Karls University; Tübingen Germany
| | - Lorenz Loewe
- Department of Urology; Eberhard Karls University; Tübingen Germany
| | | | - Mike Notohamiprodjo
- Department of Diagnostic and Interventional Radiology; Eberhard Karls University; Tübingen Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology; Eberhard Karls University; Tübingen Germany
| | - Arnulf Stenzl
- Department of Urology; Eberhard Karls University; Tübingen Germany
| | - Jens Bedke
- Department of Urology; Eberhard Karls University; Tübingen Germany
| | - Stephan Kruck
- Department of Urology; Eberhard Karls University; Tübingen Germany
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17
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Bangash HK, Hawks C, McCombie SP, Brown M, Hayne D. Transrectal prostate biopsy sepsis rate following reduced quinolone antibiotic prophylaxis from six doses to single dose. ANZ J Surg 2018; 88. [PMID: 29316136 DOI: 10.1111/ans.14360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/20/2017] [Accepted: 11/24/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study aimed to evaluate the rates of infective complication related to transrectal prostate biopsy (TRPB) as our centre changed its protocol from six doses over 3 days to a single pre-procedure prophylactic dose. METHODS This prospective cohort study identified infective complication in patients who attended and subsequently underwent TRPB at the time of their one-stop prostate clinic at our public tertiary hospital between August 2011 and April 2017. Patients who underwent TRPB between August 2011 and November 2014 received six doses of 500 mg of ciprofloxacin, taken twice daily over 3 days. This protocol was changed to a single dose of 500 mg of ciprofloxacin prior to biopsy from February 2015 to April 2017. Patients who had travelled to South East Asia in the 6 months prior to TRPB received a single dose of 1 g intravenous ertapenem prior to biopsy, and this remained unchanged throughout the study period. The rates of infective complication were recorded and compared between the groups of patients who had undergone six doses versus a single dose of prophylactic ciprofloxacin. RESULTS A total of 766 patients underwent TRPB from August 2011 to April 2017. Of these, 357 patients received the 3-day course of prophylaxis (Group 1) and 409 patients received the single dose prophylaxis (Group 2). Fifty-five patients were excluded from analysis. There was no significant difference in infective complications between the two groups (3.4% (11/326) Group 1 versus 4.9% (19/385) Group 2, P = 0.40). CONCLUSION Our study supports the use of a single dose of ciprofloxacin as sufficient antibiotic prophylaxis prior to TRPB.
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Affiliation(s)
- Haider K Bangash
- UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Cynthia Hawks
- UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Steve P McCombie
- UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Matthew Brown
- UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Dickon Hayne
- UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia
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18
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Grummet J, Pepdjonovic L, Huang S, Anderson E, Hadaschik B. Transperineal vs. transrectal biopsy in MRI targeting. Transl Androl Urol 2017; 6:368-375. [PMID: 28725578 PMCID: PMC5503965 DOI: 10.21037/tau.2017.03.58] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Prostate biopsy is typically performed via either the transrectal or transperineal approach. MRI-targeted biopsy, whether using any of the three options of cognitive fusion, MRI-ultrasound fusion software, or in-bore MRI-guided biopsy, can also be performed via either transrectal or transperineal approaches. As an extension of traditional random prostate biopsy, the transrectal approach is far more commonly used for MRI-targeted biopsy due to its convenience. However, in the context of today’s increasing multi-drug resistance of rectal flora, the transperineal approach is being used more often due to its lack of septic complications. In addition, only a first-generation cephalosporin, not a fluoroquinolone, is required as antibiotic prophylaxis. Evidence shows excellent detection rates of significant prostate cancer using magnetic resonance imaging (MRI)-targeted and/or systematic transperineal biopsy (TPB). However, there are no head-to-head studies comparing the different MRI-targeted methods within TPB. To provide truly patient-centred care, the biopsy technique using the safest method with the highest detection rate of significant cancer should be used. Depending on healthcare context and hospital resource utilization, MRI-targeted TPB is an excellent option and should be performed wherever available and feasible. Whilst building capacity for TPB in one’s practice, the routine use of rectal culture swabs prior to any transrectal biopsies is strongly encouraged. Independent of biopsy route, the addition of systematic cores needs to be discussed with the patient weighing maximal detection of significant cancer against increased detection of insignificant lesions.
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Affiliation(s)
- Jeremy Grummet
- Australian Urology Associates, Melbourne, Australia.,Alfred Health, Melbourne, Australia.,Monash University, Melbourne, Australia
| | | | - Sean Huang
- Australian Urology Associates, Melbourne, Australia.,Monash University, Melbourne, Australia
| | - Elliot Anderson
- Australian Urology Associates, Melbourne, Australia.,Alfred Health, Melbourne, Australia.,Monash University, Melbourne, Australia
| | - Boris Hadaschik
- Department of Urology, University Hospital Essen, Essen, Germany
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Prostate Biopsy-related Infection: A Systematic Review of Risk Factors, Prevention Strategies, and Management Approaches. Urology 2016; 104:11-21. [PMID: 28007492 DOI: 10.1016/j.urology.2016.12.011] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/05/2016] [Accepted: 12/12/2016] [Indexed: 12/14/2022]
Abstract
A systematic review to identify risk factors for prostate biopsy-related infection, preventative strategies, and optimal management of infectious complications was conducted. Significant risk factors for postbiopsy infection include urogenital infection, antibiotic use, international travel, hospital exposure, bacteriuria, previous transrectal biopsy, and resistance of fecal flora to antibiotic prophylaxis (especially fluoroquinolones). Patients at risk may benefit from an adjusted biopsy protocol comprising transrectal biopsy under targeted prophylaxis, and/or the use of rectal disinfection techniques or using a transperineal approach. Management of biopsy-related infection should be based on individual risk and local resistance profiles with input from multiple specialties.
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20
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Pepdjonovic L, Tan GH, Huang S, Mann S, Frydenberg M, Moon D, Hanegbi U, Landau A, Snow R, Grummet J. Zero hospital admissions for infection after 577 transperineal prostate biopsies using single-dose cephazolin prophylaxis. World J Urol 2016; 35:1199-1203. [DOI: 10.1007/s00345-016-1985-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 12/02/2016] [Indexed: 12/29/2022] Open
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21
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Combined T2 and diffusion-weighted MR imaging with template prostate biopsies in men suspected with prostate cancer but negative transrectal ultrasound-guided biopsies. World J Urol 2016; 35:213-220. [PMID: 27236302 PMCID: PMC5272897 DOI: 10.1007/s00345-016-1855-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/14/2016] [Indexed: 11/23/2022] Open
Abstract
Purpose Transperineal template prostate (TPB) biopsy has been shown to improve prostate cancer detection in men with rising PSA and previous negative TRUS biopsies. Diagnostic performance of this approach especially MR imaging and using reliable reference standard remains scantly reported. Materials and methods A total of 200 patients, who were previously TRUS biopsy negative, were recruited in this study. All the participants had at least 28-core TPB under general anesthetic within 8 weeks of previous negative TRUS biopsies. In 15 men undergoing laparoscopic radical prostatectomy, prostate specimens were sectioned using custom-made molds and analyzed by experienced pathologist as a feasibility study. Results In total, 120 of 200 patients (60 %) had positive TPB biopsy results. All of these men had at least one negative biopsy from transrectal route. T2 diffusion-weighted MR imaging showed no lesion in almost one-third of these men (61/200; 30.5 %). Out of these, 33 (33/61; 54 %) showed malignancy on TPB including high-grade tumors (>Gleason 7). Out of 15 patients underwent surgery with a total of 52 lesions (mean 3.5) on radical prostatectomy histology analyses, TPB detected 36 (70 %) lesions only. Some of these lesions were Gleason 7 and more mostly located in the posterior basal area of prostate. Conclusions Transperineal template biopsy technique is associated with significantly high prostate cancer detection rate in men with previous negative TRUS biopsies, however compared to radical prostatectomy histology map, a significant number of lesions can still be missed in the posterior and basal area of prostate.
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