Prospective assessment of the efficacy of single dose versus traditional 3‐day antimicrobial prophylaxis in 12‐core transrectal prostate biopsy

Objectives: To prospectively evaluate the efficacy of single dose antibiotic prophylaxis in 12‐core transrectal ultrasonography (TRUS) guided prostate biopsy. Methods: A total of 400 patients who underwent prostate biopsy with TRUS guidance were included. The patients were prospectively randomized in three groups regarding antibiotic prophylaxis. The first group (139 patients) received a single gram of intramuscular ceftriaxone, while the second group (131 patients) had a 3‐day course of oral ciprofloxacin. The third group (130 patients) had single oral 500 mg of ciprofloxacin. All patients had urine cultures prior to biopsy and on the second day after biopsy. Results: The study groups were compared in terms of the results of urine cultures and clinical parameters. Overall, only seven patients (1.8% of the cases) had positive urine cultures with no difference between these three groups. Additionally, no significant difference was observed regarding morbidity rates in all groups. Only eight patients (2%) developed major complications requiring hospitalization. There was no increase in the rate of infectious complications when the biopsy core numbers were increased up to 12. Conclusions: The current study suggests that a single oral dose of antimicrobial prophylaxis is reasonable in TRUS prostate biopsy even in the case of 12‐core sampling.     

The role of a standardized 36 core template-assisted transperineal prostate biopsy technique in patients with previously negative transrectal ultrasonography-guided prostate biopsies

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Template assisted transperineal biopsy of the prostate has become increasingly popular over the past decade. Several studies have demonstrated that transperineal prostate biopsy (TPB) is associated with an increased rate of cancer detection, increased histological concordance with final prostatectomy samples and an increase in anterior and apical prostate cancers than standard TRUS biopsy. However, interpretation of the literature is difficult due to considerable variation between studies in terms of technique and equipment. We examined a small cohort (n= 40) of patients using a standardized 36 core template assisted TPB technique. We show that utilising this technique is associated with high cancer (68%) detection rate in patients with two previous negative TRUS biopsies. Of patients were found to have anterior gland tumours which would not have been detected by standard TRUS guided biopsy.

OBJECTIVE

? To determine the efficacy and safety of a standardized 36 core template‐assisted transperineal biopsy technique for detecting prostate cancer in patients with previously negative transrectal ultrasonography‐guided prostate biopsies and elevated prostate‐specific antigen (PSA) levels.

PATIENTS AND METHODS

? Between April 2008 to September 2010, a total of 40 patients with a mean (range) age of 63 (49–73) years, a mean (range) elevated PSA level of 21.9 (4.7–87) ng/mL and two previous sets of negative TRUS‐guided prostate biopsies underwent standardized 36 core template‐assisted transperineal prostate biopsies under general anaesthetic as a day case procedure. ? The cancer detection rate and complications for all cases were evaluated.

RESULTS

? In total, 27 of 40 (68%) patients were found to have adenocarcinoma of the prostate, two patients (5.0%) had atypical small acinar proliferation, one had high‐grade prostatic intraepithelial neoplasia (2.5%), four (10%) had chronic active inflammation and six (15%) had benign histology. ? Gleason scores were in the range 6–9, with a median Gleason score of 7. ? There were no cases of urosepsis, urinary tract infections or haematuria. A single patient experienced acute urinary retention, with a subsequent succesful trial without a catheter, and haematospermia was common, although minor.

CONCLUSIONS

? Our standardized 36 core template‐assisted transperineal prostate biopsy technique is safe and associated with a high detection rate of prostate cancer. ? This technique should be considered in patients with elevated PSA levels and previously negative TRUS‐guided prostate biopsies.     

One preoperative dose randomized against 3‐day antibiotic prophylaxis for transrectal ultrasonography‐guided prostate biopsy

OBJECTIVE

To compare the incidence of infective events between a single dose and 3‐day antibiotic prophylaxis for transrectal ultrasonography (TRUS)‐guided prostate biopsy.

PATIENTS AND METHODS

Patients were randomized to receive either one preoperative dose consisting of two ciprofloxacin 500 mg tablets 2 h before prostate biopsy, or 3 days of ciprofloxacin treatment. They had a clinical examination at study inclusion, the day of the biopsy and 3 weeks later. The day after the procedure all patients were contacted by telephone to inquire about any significant event. Biological testing and urine cultures were conducted 5 days before and then 5 and 15 days after the biopsy; a self‐administered symptom questionnaire was completed by the patient 5 days before and then at 5 and 15 days.

RESULTS

The study group included 288 men, of whom 139 were randomized to the single‐dose arm and 149 to the 3‐day arm. Six patients in each group had an asymptomatic bacteriuria with no leukocyturia. One patient in each group had documented prostatitis, with Escherichia coli identified on urine culture. The strain identified in the patient from the 3‐day group was resistant to ciprofloxacin. There was no difference between groups in symptoms at 5 and 21 days after biopsy.

CONCLUSIONS

Current TRUS‐guided prostate biopsy techniques lead to very few clinical infectious complications when accompanied by antibiotic prophylaxis. We found no argument to advocate the use of more than one dose of antibiotic prophylaxis.     

预防性抗生素在经会阴前列腺穿刺活检中应用的价值

目的通过两种经会阴前列腺穿刺活检围操作期准备的比较,评价预防性抗菌应用的价值。方法通过经会阴前列腺穿刺活检围操作期无预防性抗生素应用组与预防性抗生素应用组的比较来评估穿刺术后感染发生率。结果对1998年8月～2005年12月的661例患者进行了经会阴前列腺穿刺活检,其中无预防性抗生素应用组为350例,预防性抗生素应用组为311例。无预防性抗生素应用组与预防性抗生素应用组的术后发生尿路感染分别为2例(0．57%)和2例(0．64%)；发热者分别为2例(0．57%)和1例(0．32%)；LUTS者分别为31例(8．86%)和28例(9．00%),均无显著性差异。两组均无败血症、脓毒血症、前列腺脓肿和附睾炎发生。结论经会阴前列腺穿刺活检无需预防性应用抗生素。     

The results of transperineal versus transrectal prostate biopsy: a systematic review and meta-analysis

This systematic review was performed to compare the efficacy and complications of transperineal (TP) vs. transrectal (TR) prostate biopsy. A systematic research of PUBMED, EMBASE and the Cochrane Library was performed to identify all clinical controlled trials on prostate cancer (PCa) detection rate and complications achieved by TP and TR biopsies. Prostate biopsies included sextant, extensive and saturation biopsy procedures. All patients were assigned to a TR group and a TP group. Subgroup analysis was performed according to prostate-specific antigen (PSA) levels and digital rectal examination (DRE) findings. The Cochrane Collaboration's RevMan 5.1 software was used for the meta-analysis. A total of seven trials, including three randomized controlled trials (RCTs) and four case-control studies (CCS), met our inclusion criteria. There was no significant difference in the cancer detection rate between the sextant TR and TP groups (risk difference (RD), -0.02; 95% confidence interval (CI), -0.08-0.03; P=0.34). Meta-analysis for RCTs combined with CCS showed that there was no difference in the cancer detection rate between the extensive TR and TP group (RD, -0.01; 95% CI, -0.05-0.04; P=0.81). There was no significant difference in PCa detection rate between the saturation TR and TP approaches (31.4% vs. 25.7%, respectively; P=0.3). There were also no significant differences in cancer detection between the TR and TP groups in each subgroup. Although the data on complications were not pooled for the meta-analysis, no significant difference was found when comparing TR and TP studies. TR and TP biopsies were equivalent in terms of efficiency and related complications. TP prostate biopsy should be an available and alternative procedure for use by urologists.     

The role of targeted prophylactic antimicrobial therapy before transrectal ultrasonography‐guided prostate biopsy in reducing infection rates: a systematic review

To compare the incidence of infective complications after transrectal ultrasonography (TRUS)‐guided biopsy with either empirical fluoroquinolone or culture‐based targeted antimicrobial prophylaxis, and the prevalence of fluoroquinolone resistance (FQ‐R) in men undergoing prostate biopsy. A systematic review of the literature was performed following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. We included studies of patients undergoing TRUS‐guided biopsy that compared infective outcomes of those who received targeted antimicrobial therapy based on the results of pre‐procedural rectal swab cultures, with those receiving empiric fluoroquinolone antimicrobial prophylaxis. The prevalence of FQ‐R was recorded as a secondary outcome measure. Studies with no control group were excluded. From 125 studies screened, nine studies (4 571 patients) met the inclusion criteria. All studies were of cohort design, and included a combination of retrospective and prospective data. Six studies included were undertaken in North America. The remaining studies were undertaken in Spain, Turkey and Columbia. Within these studies, 2 484 (54.3%) patients received empirical fluoroquinolone prophylaxis, whilst 2 087 (45.7%) patients had pre‐biopsy rectal swabs and targeted antibiotics. The mean FQ‐R was 22.8%. Post‐biopsy infection and sepsis rates were significantly higher in groups given empirical prophylaxis (4.55% and 2.21%) compared with groups receiving targeted antibiotics (0.72% and 0.48%). Based on these results 27 men would need to receive targeted antibiotics to prevent one infective complication. Our systematic review suggests that targeted prophylactic antimicrobial therapy before TRUS‐guided prostate biopsy is associated with lower rates of sepsis. We therefore recommend changing current pathways to adopt this measure.     

经会阴前列腺穿刺与经直肠前列腺穿刺活检在前列腺癌诊断的初探

目的 对比经会阴与经直肠前列腺穿刺活检在前列腺癌诊断中的阳性率及并发症。方法 回顾分析2017年1月到2019年12月行前列腺穿刺活检的病例,经直肠组187例,经会阴组68例。结果 经直肠组阳性穿刺率为34.7%,经会阴组阳性穿刺率为29.4%,两组无统计学差异（P>0.05）。穿刺后经直肠组和经会阴组的血尿发生率分别为40.1%、42.6%,尿潴留发生率分别为6.9%、7.3%,直肠出血发生率分别为1.1%、0%,差别无统计学意义（P>0.05）。穿刺后经直肠组和经会阴组的会阴肿胀的发生率分别为2.6%、13.2%,两组有统计学差异（P<0.05）。结论 超声引导下经直肠、经会阴前列腺穿刺活检均为前列腺癌诊断的有效方法。两者穿刺阳性率无明显差异,但并发症各有特点。     

The morbidity of transperineal template-guided prostate mapping biopsy

OBJECTIVE

To evaluate the effect of transperineal template‐guided prostate mapping biopsy (TTMB) on urinary, bowel and erectile function.

PATIENTS AND METHODS

In all, 129 men had TTMB; a median of 56 biopsy cores were obtained per patient. Tamsulosin (0.8 mg daily) was initiated 2 days before TTMB and continued for 2 weeks. The International Prostate Symptom Score (IPSS), Rectal Function Assessment Score (R‐FAS), International Index of Erectile Function (IIEF)‐6 and the postvoid residual volume (PVR) were assessed at baseline and after 30 days, except for the IPSS, which was also assessed at 7 days. Several variables were evaluated as predictors of TTMB‐induced morbidity.

RESULTS

The mean patient age was 64.7 years with a mean prostate volume of 74.3 mL; 60 men (46.5%) were diagnosed with prostate cancer. After TTMB, 39.4%, 7.1% and 1.6% of patients remained catheter‐dependent at 0, 3 and 6 days. The median catheter‐dependency was 0, 1, 2 and 3 days for prostate volumes of <60, 60–90, 90–120 and >120 mL, respectively. No patient remained catheter‐ dependent for >12 days or required a transurethral resection secondary to TTMB. The mean IPSS before TTMB was 10.4, and was 4.6 and 3.8 at 7 and 30 days. At baseline and 30 days the mean PVR was 35 and 40 mL, and the median R‐FAS and IIEF scores for patients potent before TTMB were 2.0 and 2.2, and 27.0 and 26.0, respectively.

CONCLUSIONS

TTMB is a promising procedure for diagnosing prostate cancer. TTMB‐related morbidity differs from that of standard TRUS biopsy primarily in the incidence of temporary urinary retention, and is comparable in terms of urinary, bowel and erectile function.     

Transrectal ultrasound-guided transperineal 14-core systematic biopsy detects apico-anterior cancer foci of T1c prostate cancer

AIM: The optimal biopsy strategy for prostate cancer detection, especially in men with isolated prostate-specific antigen (PSA) elevation, remains to be defined. We evaluated diagnostic yield and safety of transrectal ultrasound (TRUS)-guided transperineal systematic 14-core biopsy and compared the spatial distribution of cancer foci detected with this technique in men with and without abnormality on digital rectal examination (DRE). METHODS: In a prospective study, 289 men aged between 50 and 87 years (median age, 70 years) underwent TRUS-guided transperineal systematic 14-core prostate biopsy because of elevated PSA and/or abnormal DRE findings. Using the fan technique, 12 cores from the peripheral zone and two cores from the transition zone were obtained systematically. To characterize the spatial distribution of cancer positive cores, site-specific overall and unique cancer detection rates were compared between stage T1c and T2 cancers. RESULTS: Prostate cancer was detected in 105 of the 289 patients (36%). Major complications requiring prolonged hospital stay or re-hospitalization during a 4-week postbiopsy period were rare (1.4%). Sixty-seven stage T1c cancers were identified. These cancers were associated with significantly lower PSA and a smaller number of cancer positive cores when compared with stage T2 cancers (n= 38). The overall cancer detection rate was highest at the anterior peripheral zone and the posterior peripheral zone in stage T1c and stage T2 cancers, respectively. The unique cancer detection rate at the anterior peripheral zone was significantly higher in stage T1c cancers than in stage T2 cancers. Therefore, when the prostate is extensively biopsied using the transperineal approach, cancer positive cores are characteristically distributed anteriorly in stage T1c cancers and posteriorly in stage T2 cancers. CONCLUSIONS: TRUS-guided transperineal systematic 14-core biopsy showed an apico-anterior distribution of cancer foci in stage T1c prostate cancers.     

经会阴前列腺24针饱和穿刺活检与14针活检在PSA＜20μg/L患者中筛检前列腺癌的对比性研究

目的:探讨超声引导下经会阴前列腺24针饱和穿刺活检与14针穿刺活检方案对PSA<20μg/L可疑前列腺癌患者的筛检阳性率及其相关并发症。方法:选取116例可疑前列腺癌患者行经会阴超声引导下14针穿刺活检(14针组),另136例患者,行经会阴24针饱和前列腺穿刺活检(24针饱和组),比较两组前列腺癌筛检阳性率、标本阳性率及穿刺后肉眼血尿、泌尿系感染、尿潴留等并发症的发生率。结果:两组患者平均年龄、穿刺前PSA水平、平均前列腺体积等指标均无统计学差异(P>0.05)。24针饱和组及14针组前列腺癌筛检总体阳性率分别为48.53%和17.24%,存在显著性差异(P<0.001),标本阳性率分别为8.09%和2.83%(P=0.012);其中24针饱和组前列腺尖部肿瘤的检出率(11.76%)显著高于14针组(1.72%,P<0.05)。两组穿刺后尿潴留、泌尿系感染和肉眼血尿等发生率均无统计学差异(P>0.05)。结论:24针经会阴前列腺饱和穿刺活检方法显著提高PSA<20μg/L患者中前列腺癌的筛检阳性率,尤其是增加了前列腺尖部区域的肿瘤筛检阳性率,而并未增加相关并发症。     

Direct comparison between transrectal and transperineal extended prostate biopsy for the detection of cancer

AIM: To establish whether extended transrectal (TR) and extended transperineal (TP) biopsies are equivalent in detecting prostate cancer. METHODS: Due to an elevated prostate-specific antigen (PSA) greater than 2.5 ng/mL or abnormal digital rectal examination findings, 783 men underwent a transrectal ultrasound-guided three-dimensional 26-core biopsy, a combination of TR 12-core and TP 14-core biopsies. Using recursive partitioning, the best combination of sampling sites that gave the highest cancer detection rate at a given number of biopsy cores was selected either with a TR or a TP approach. The cancer detection rate and characteristics of detected cancers were compared between the TP 14-core and the TR 12-core biopsies and between selected subset biopsy schemes. RESULTS: Prostate cancer was detected in 283 of the 783 men (36%). There was no statistical difference in cancer detection rate or in the characteristics of detected cancers between TP 14-core and TR 12-core biopsies. As far as the best combination of sampling sites was selected, there was no statistical difference in cancer detection rates or in the characteristics of detected cancers between the TP and the TR subset biopsy schemes up to 12 cores. TP and TR biopsies performed equally, regardless of a history of negative biopsy, a digital rectal examination finding, the PSA level or the prostate volume. CONCLUSIONS: We demonstrated for the first time that extended TP biopsy is as effective as its TR counterpart in detecting cancer and the characteristics of detected cancers, as far as sampling sites are selected to maximize the cancer detection rate.     

经会阴及经直肠前列腺穿刺活检术的临床应用分析

目的:比较经直肠及经会阴两种前列腺穿刺活检术的阳性率及并发症。方法:回顾性分析2009年1月至2014年1月间156例前列腺穿刺活检病例,其中经直肠径路97例,经会阴径路59例。结果:经直肠径路组穿刺阳性率为48.4%,经会阴径路组为44.1%。根据不同的PSA水平分层,两种径路穿刺活检的阳性率无显著性差异(P0.05)。穿刺后经直肠径路组与经会阴径路组血尿发生率分别为54.6%、42.4%,尿频尿急尿痛发生率分别为17.5%、22.0%,排尿困难发生率分别为9.3%、6.8%,急性尿潴留发生率分别为7.2%、6.8%,上述并发症发生率在两组间差异无统计学意义(P0.05);发热发生率分别为15.5%、3.4%,血便发生率分别为50.5%、3.4%,经直肠径路组要显著高于经会阴径路组(P0.05及P0.01);会阴肿胀发生率分别为3.1%、13.6%,经会阴径路组显著性增高(P0.05)。结论:超声引导下经直肠和经会阴前列腺穿刺活检术都是诊断前列腺癌的有效方法。两种方式的穿刺阳性率无显著性差异,但并发症发生率各有特点,具体方式选择应根据患者情况决定。