Selective transperineal prostate biopsy for fluoroquinolone-resistance patients reduces sepsis and cost

Background:Urosepsis is a recognized complication of transrectal ultrasound-guided prostate biopsy (TRUS-Bx). Pre-biopsy rectal swabs have been used to identify patients with microorganisms in the rectal flora resistant to the conventionally used empirical prophylaxis. The transperineal route of biopsy (TP-Bx) has a lower complication risk but comes at an increased cost.Materials and methods:Retrospective cohort study including patients undergoing prostate biopsies between October/2015 and April/2018. The intervention cohort, a rectal swab was performed, the result of which dictated the biopsy route; TRUS-Bx against TP-Bx. TP-Bx for patients with fluoroquinolone resistance or extended-spectrum β-lactamase. The control cohort underwent TRUS without a rectal swab receiving empirical antibiotics—oral ciprofloxacin and intravenous gentamicin.Results:Total 1000 patients were included in which 500 underwent a swab, 14 (2.8%) developed post-TRUS biopsy infective complications with 3 having positive bacteremia (0.6%); 500 had no swab, 47 (9.4%) developed post-TRUS biopsy infective complications with 22 (4.4%, p < 0.05) having positive bacteremia. Three patients (0.6%) of patients who underwent swab developed urinary tract infection symptoms whilst 12 (2.4%) had urinary tract infection in the control group. In those patients that underwent a swab, 14 required hospitalization with mean length of stay of 2.5 days versus 43 patients of the control with 3.6 days. Cost analysis concluded savings of this strategy was £18,711.Conclusions:We have demonstrated a protocol that reserves template biopsies for higher risk patients and can significantly reduce sepsis and other infectious complication rates whilst also proving to be a cost-efficient strategy. We recommend that units not utilizing rectal swabs to uncover the fluoroquinolone resistance rate by introducing them. We advocate units that already utilize rectal swabs, to introduce transperineal biopsy for their higher risk patients.     

Intrafraction monitoring of prostate motion during radiotherapy using the Clarity® Autoscan Transperineal Ultrasound (TPUS) system

IntroductionImplementation of the Clarity^® Autoscan (Elekta) Transperineal Ultrasound (TPUS) system in Bristol is the first of its kind in the UK and we have already shown its utility in interfractional Image Guided Radiotherapy (IGRT).¹⁴ This study establishes the extent of intrafraction prostate motion as measured by Clarity and explores the potential benefits of TPUS for intrafraction monitoring.MethodsMonitoring data was analysed for 526 fractions from 20 localised prostate cancer patients. Intrafraction prostate displacements exceeding thresholds of 3 mm, 7 mm and 10 mm along patient axes were assessed for frequency and duration of motion.ResultsProstate motion exceeds the above displacement thresholds during 52%, 8%, and 2% of fractions analysed. Displacement at the 3 mm threshold occurred for 100% of patients, 60% at 7 mm and 35% at 10 mm. The mean frequency and duration of displacements is low for the overall population. In contrast specific patients exhibit much higher displacement values. Posterior motion is most common, averaging at 24% of the treatment time at 3 mm, 3% at 7 mm and 1% at 10 mm, ranging up to 92%, 35% and 10% for individual patients.ConclusionsIntrafraction monitoring with Clarity has the potential to improve accuracy through application of in-treatment motion correction. This is most beneficial for specific patients who exhibit a higher frequency and/or duration of prostate motion. Consideration must be given to the added time implications and radiographer workload in clinical practice to correct for prostate motion. Clarity could help facilitate future protocols using tighter treatment margins, although further research is required.     

Transperineal ultrasonography

PURPOSE: The aim of this preliminary study was to present an alternative method to assess the anal sphincters by ultrasonography using a conventional ultrasound surface probe by transperineal approach. METHODS: Transperineal ultrasonography was performed in 20 asymptomatic volunteers to assess the anal sphincters. Ultrasonographic findings were compared with conventional anal endosonography pictures available in the literature. RESULTS: Images of the anal sphincters obtained by transperineal ultrasound were found to be similar to those produced by conventional anal endosonography. Internal and external anal sphincters were easily demonstrated in addition to mucosal and submucosal layers. CONCLUSIONS: Transperineal ultrasonography is a new technique that enables imaging of anal sphincters and anal canal structures with potential application in functional and inflammatory anorectal disorders.Dr. Kleinübing was supported by grant from National Agency CAPES Brazil.Presented at 1° Encontro Catarinense de Colo-Proctologia, Joinville—SC—Brazil, December 12, 1997.     

Pelvic floor dysfunction—Does menopause duration matter?

Objective

To explore the effect of menopause and hormone replacement therapy on pelvic organ prolapse and pelvic floor muscle function.

Methods

The records of patients who attended a tertiary urogynaecological center were reviewed retrospectively. A standardised interview included menopausal age, i.e. years since last period or onset of menopausal symptoms, current or previous hormone use. The clinical examination included prolapse assessment (POP-Q) and palpation of the levator ani muscle. 4D transperineal ultrasound, supine and after voiding, was performed in all patients. Volume data sets were analysed for pelvic organ descent and measures of contractility and distensibility of the pelvic floor at a later date, blinded to all clinical data.

Results

Of 311 women seen during the inclusion period, 65% were postmenopausal. Current systemic or local hormone use was reported by 7% and 6%, respectively. 163 women (52%) reported prolapse symptoms with a mean bother of 5.7/10. Significant pelvic organ prolapse was found on clinical examination (POP-Q stage ≥ 2) in 77%, and diagnosed on ultrasound in 61%. On multivariate analysis, controlling for calendaric age, parity and levator avulsion, there was no evidence for menopausal age as an independent predictor of any symptom and sign of pelvic organ prolapse and pelvic floor muscle function. Local oestrogen use and past or present hormone replacement therapy had no detectable effect on any pelvic floor parameter.

Conclusions

Hormone deficiency following menopause is unlikely to play a major role in pelvic organ support and levator ani function. Hence, both do not appear to be substantially influenced by local or systemic hormone replacement therapy.     

经会阴和经阴道三维肛外超声成像评估女性肛门括约肌的对比研究

通过经会阴和经阴道三维超声对比评估女性肛门括约肌,探讨不同肛外超声成像方式在评估女性肛门括约肌的应用价值。 方法 选取101例女性同时进行经会阴和经阴道三维超声检查对肛门括约肌进行成像,分别记为经会阴组和经阴道组。测量肛门内括约肌（IAS）和肛门外括约肌（EAS）在肛管横断面3、6、9、12点钟方向上的厚度,调节断层超声模式评估肛门括约肌损伤情况,记录结果并进行统计分析。 结果 IAS厚度测量值在肛管横断面12点钟方向上,经阴道组比经会阴组更薄,差异具有统计学意义（P<0.05）;EAS厚度测量值在肛管横断面6点、12点钟方向上,经阴道组比经会阴组更薄,差异具有统计学意义（P<0.05）。两组IAS及EAS测量值在肛管横断面全部4个方向上有良好的相关性且均具有统计学意义（P均<0.05）。经会阴组筛查出IAS损伤6例（5.94%）,EAS损伤16例（15.84%）,IAS合并EAS损伤13例（12.87%）;经阴道组筛查出IAS损伤8例（7.92%）,EAS损伤17例（16.83%）,IAS合并EAS损伤9例（8.91%）。两组在评估肛门括约肌损伤的一致性较好且具有统计学意义（Kappa=0.736,P<0.05） 结论 经会阴和经阴道三维超声在评估女性肛门括约肌具有较好的相关性和一致性,两者均为评估女性肛门括约肌良好的肛外超声成像方式。     

经会阴超声在不同程度压力性尿失禁分级诊断中的应用价值

目的分析经会阴超声在不同程度压力性尿失禁（SUI）诊断中的应用价值。 方法选取2016年9月至2019年2月在华北理工大学附属医院就诊的SUI女性患者为病例组（其中56例轻度患者、48例中度患者、30例重度患者）,选择同期因健康体格检查就诊后排除SUI的女性40名为健康对照组,对上述女性行经会阴超声检查,测量膀胱颈在X轴后移的距离（ΔDx）、在Y轴下移的距离（ΔDy）、移动度（Mu）和旋转角度（θ）,采用方差分析比较组间上述指标的差异,并构建不同程度SUI患者上述指标的ROC曲线,初步确定不同程度SUI诊断界值。 结果4组间比较,ΔDx、ΔDy、Mu、θ值差异均有统计学意义（P均<0.05）,且随着SUI严重程度的增加呈增加趋势。经过ROC曲线分析,ΔDy、Mu、θ值诊断SUI的界值、敏感度、特异度分别为10.56 mm、55.2%、97.5%;11.66 mm、80.6%、90.5%;24.18°、82.1%、92.5%;ΔDx、ΔDy、Mu、θ值诊断中重度SUI的界值、敏感度、特异度分别为6.31 mm、50.0%、88.8%;10.64 mm、68.4%、78.6%;12.75 mm、97.4%、75.5%;28.85°、84.2%、84.7%;ΔDy、Mu、θ值诊断重度SUI的界值、敏感度、特异度分别为9.36 mm、86.7%、59%;15.09 mm、93.3%、88.2%;34.75°、90.0%、86.1%。 结论经会阴超声检查在SUI的诊断中具有重要的应用价值,其中Mu、θ值对SUI及其严重程度的诊断意义较大,有望作为临床诊断轻、中、重度SUI的参考指标。     

Treatment of advanced cancer of the cervix with transperineal interstitial irradiation

A pilot study using transperineal interstitial implantation to the parametrium in patients with locally advanced carcinoma of the cervix or with distorted anatomy is presented. Twenty-one consecutive patients (2 cervical stump Stage IB, 3 Stage IIB,15 Stage IIIB, 1 Stage IV,,) received one (12) or two (9) implants following 40–45 Gy whole pelvis external irradiation. In addition 8 patients underwent staging laparotomies concurrently with the first implant procedure. Control of the pelvic tumor was accomplished in 18 of 21 patients (85%) with a mean follow-up of 26 months (range 15 to 48 months). Seven patients (33%) developed long term complications (fistula 3, superficial necrosis of the vagina 1, severe proctitis or cystitis 3). Six of the complications occurred in 8 patients (75 % ) who had radioactive sources placed on the surface of the vaginal obturator as a substitute for the lack of tandem. In contrast, only I in the remaining 13 patients (8%) who did not have obturator sources placed, developed long term complications.     

Acute urinary retention after transperineal template-guided prostate biopsy

PURPOSE: Urinary retention occurs in 5%-36% of patients with prostate cancer after implantation of radioactive seeds for brachytherapy. We used transperineal biopsy as a model to determine the influence of needle trauma on urinary retention. METHODS AND MATERIAL: We retrospectively reviewed medical records of 157 men with high risk of prostate cancer who underwent systematic ultrasound-guided biopsy of the prostate with the transperineal template technique and an 18-gauge automated biopsy device. RESULTS: Eighteen of 157 patients (11.5%; 95% confidence interval, 6.9%-17.5%) had urinary retention within 48 hours after biopsy. Median age was 68.5 years in patients with retention vs. 67.0 years in patients without (p = 0.319); median calculated prostate volume, 76.5 vs. 51.5 mL (p = 0.015); and median number of biopsy cores, 22.0 vs. 20.0 (p = 0.038). Age distribution differed between groups (p = 0.047), with more younger men in the no-retention group. On multivariate analysis, only number of biopsy cores significantly predicted urinary retention (p = 0.003). Four patients required transurethral resection; 1 had an indwelling catheter until radical prostatectomy; and 13 were catheter-free within 1-5 days. CONCLUSIONS: Needle trauma alone may cause urinary retention in men undergoing transperineal procedures. The number of needle incursions and prostate size are predictors of postprocedure urinary retention.     

扇型超声引导下经会阴前列腺穿刺活检的应用

目的探讨扇型超声引导下经会阴前列腺6针穿刺活检术诊断前列腺癌的价值.方法对可疑前列腺癌的104例患者,扇型超声引导下经会阴行双侧叶6点法穿刺活检术,对穿刺的阳性率和并发症及影响穿刺阳性率的因素进行分析.结果经病理诊断,检出前列腺癌24例,检出率23%,其余80例为良性前列腺增生(BPH).术后未出现严重并发症.经分析发现在tPSA≥10μg/L、fPSA≥2μg/L、fPSA/tPSA＜0.16、PSAD≥0.2和前列腺体积＜40 ml时是影响前列腺穿刺阳性率的重要因素(P＜0.05).结论扇型超声引导下经阴会6针前列腺穿刺活检,是一种安全准确的前列腺癌检出方法.