Figure 1 demonstrates an interesting illustration of prostate cancer screening and its results and risks provided by the US. Preventative Services Task Force.
Figure 1 - The US. Preventative Services Task Force illustration of prostate cancer screening:
The standard transrectal ultrasound-guided prostate biopsy has been the traditional method of biopsy for many years and has been well described (Figure 2).
Figure 2 – Transrectal ultrasound-guided prostate biopsy:
The American Urological Association White paper on the prevention and treatment of the more common complications related to prostate biopsy shows the known Transrectal ultrasound (TRUS)-guided prostate biopsy risks, complications, and their frequency (Table 1). To reduce the rate of infectious complications, enemas have been incorporated in TRUS-guided prostate biopsies. In a study assessing the role of prebiopsy enema and its role in lowering bacteriuria and bacteremia, the enema was not shown to decrease the rate of bacteriuria (44% vs. 44%) but did reduce the rate of bacteremia (28% vs. 4%).1
Table 1 – The possible risks of prostate biopsy and frequency:
The current suggested algorithm of the American Urological Association (AUA) to reduce infection rate is shown in Figure 3. One of the options is to augment the antibiotic provided before the TRUS procedure. According to the US center for disease control and prevention, there is a significant threat of antibiotic resistance in the US. More than 2.8 million antibiotic-resistant infections occur in the US each year, and over 35,000 people die. We must remember that antibiotics are a limited source, and the more they are used, the less likely they will be effective in the future.
The advantages of the transperineal biopsy are numerous. Firstly, it allows improved sampling of the anterior zone of the prostate in a clean approach compared to the contaminated approach utilized in TRUS. Additionally, there is data stating that antibiotics are not necessary for clean, percutaneous procedures.2 Moreover, the transperineal biopsy can be done in a simple and effective manner under local anesthesia,3 in an office-based setting.4 There have been various templates that have been tested in the transperineal approach, and various fusion platforms that are available:
- Artemis
- Ex3 Stepper and MiM
- Navigo
- Invivo
- Koelis
Figure 3 – AUA white paper suggested algorithm to reduce prostate biopsy infections:
Dr. Hu ended his presentation describing an ongoing randomized trial that he is leading, comparing transperineal vs. transrectal MRI-targeted prostate biopsy. The aim of this study is to compare adverse events following in-office transperineal vs. transrectal MRI-targeted biopsy. This will include a comparison of infection rates, bleeding complications, urinary retention, pain and discomfort, and detection of prostate cancer rates.
Presented by: Jim Hu, MD, MPH, Weill Cornell Medicine, New York, NY
Written by: Hanan Goldberg, MD, MSc, Assistant Professor, Urology Department, SUNY Upstate Medical University, Syracuse, NY, USA @GoldbergHanan at the 2020 Society of Urologic Oncology Annual Meeting – December 2-5, 2020 – Washington, DC
References:
- Lindert KA, Kabalin JN, Terris MK. Bacteremia and bacteriuria after transrectal ultrasound-guided prostate biopsy. The Journal of urology 2000; 164(1): 76-80.
- Venkatesan AM, Kundu S, Sacks D, et al. Practice Guideline for Adult Antibiotic Prophylaxis during Vascular and Interventional Radiology Procedures. Journal of Vascular and Interventional Radiology 2010; 21(11): 1611-30.
- Kubo Y, Kawakami S, Numao N, et al. Simple and effective local anesthesia for transperineal extended prostate biopsy: application to three-dimensional 26-core biopsy. International journal of urology : official journal of the Japanese Urological Association 2009; 16(4): 420-3.
- Meyer AR, Joice GA, Schwen ZR, Partin AW, Allaf ME, Gorin MA. Initial Experience Performing In-office Ultrasound-guided Transperineal Prostate Biopsy Under Local Anesthesia Using the PrecisionPoint Transperineal Access System. Urology 2018; 115: 8-13.