Initial experience and cancer detection rates of office-based transperineal magnetic resonance imaging-ultrasound fusion prostate biopsy under local anesthesia

IntroductionWe aimed to demonstrate feasibility and cancer detection rates of office-based ultrasound-guided transperineal magnetic resonance imaging-ultrasound (MRI-US) fusion (TFB) prostate biopsy under local anesthesia.MethodsWith institutional review board approval, records of men undergoing TFB in the office setting under local anesthesia were reviewed. Baseline patient characteristics, MRI findings, cancer detection rates, and complications were recorded. The PrecisionPoint Transperineal Access System (Perineologic, Cumberland, MD, U.S.), along with UroNav 3.0 image-fusion system (Invivo International, Best, The Netherlands) were used for all procedures. Following biopsy, men were surveyed to assess patient experience.ResultsBetween January 2019 and February 2020, 200 TFBs were performed, of which 141 (71%) were positive for prostate cancer, with 117 (83%) Gleason grade group 2 or higher. A total of 259 of 265 MRI lesions were biopsied, with 127 (49%) positive overall. Prostate Imaging–Reporting and Data System (PI-RADS) 4–5 lesions were positive for prostate cancer in 59% of cases. The mean procedural time was 20 minutes, with a patient enter-to-exit room time of 54 minutes. There were no septic complications, no patients required post-procedure hospital admission, and all procedures were successfully completed. Seventy-five percent of patients surveyed reported complete resolution of pain at three days following the procedure.ConclusionsOffice-based TFB represents a viable approach to prostate cancer detection following prostate MRI. Larger-scale assessment is needed to categorize cancer detection rates more accurately by PI-RADs subset, patient selection factors, complication rate, and cost relative to TFB under anesthesia.     

Magnetic resonance spectroscopy-guided transperineal prostate biopsy and brachytherapy for recurrent prostate cancer

Brachytherapy targeted to the peripheral zone with magnetic resonance imaging (MRI) guidance is a prostate cancer treatment option with potentially fewer complications than other treatments. Follow-up MRI when failure is suspected is, however, difficult because of radiation-induced changes. Furthermore, MR spectroscopy (MRS) is compromised by susceptibility artifacts from radioactive seeds in the peripheral zone. We report a case in which combined MRI/MRS was useful for the detection of prostate cancer in the transitional zone in patients previously treated with MR-guided brachytherapy. We propose that MRI/MRS can help detect recurrent prostate cancer, guide prostate biopsy, and help manage salvage treatment decisions.     

Clinical utility of transperineal template-guided mapping biopsy of the prostate after negative magnetic resonance imaging−guided transrectal biopsy

PurposeWe evaluated the prostate cancer detection with transperineal template-guided mapping biopsy in patients with elevated prostate-specific antigen and negative magnetic resonance imaging (MRI)−guided biopsy.Materials and methodsTotally 75 patients underwent transperineal template-guided mapping biopsy for prior negative MRI−guided (cognitive registration) biopsy during April 2013 to August 2014. Primary objective was to report clinically significant cancer detection in this cohort of patients. Significant cancer was defined using varying thresholds of MCL or Gleason grade 3+4 or greater or both. Cancers with more than 80% of positive core length anterior to the level of urethra were termed anterior zone cancer. Secondary objective was to evaluate the potential clinical and radiological predictors for significant cancer detection.ResultsThe mean age was 61.6±6.5 years and median prostate-specific antigen was 10.4 ng/dl (7.9−18) with a mean MRI target size of 7.2 mm (4−11). Transperineal template-guided mapping biopsy identified cancer in 36% (27/75) patients and 66.6% (18/27) of them were anterior zone cancers. The rates of detection of clinically significant and insignificant cancer according to the several definitions used range from 22.7% to 30.7% and 5.3% to 13.3%, respectively. Multivariate analysis did not identify any predictors for finding clinically significant and anterior cancers in this group of patients.ConclusionTransperineal template-guided mapping biopsy appears to be an excellent biopsy protocol for downstream management following negative MRI−guided biopsy. Most of the cancers detected were predominantly anterior tumors.     

Detection of clinically significant prostate cancer by transperineal multiparametric magnetic resonance imaging-ultrasound fusion targeted prostate biopsy in smaller prostates

PurposeTransperineal (TP) multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy (TBx) has been shown to detect more clinically significant (cs) prostate cancer (PCa) than standard template biopsies (SBx). Current data supports the inclusion of both TBx and SBx in obtaining an optimal csPCa detection rate. We compared csPCa detection rates in patients with different prostate volumes to examine the benefit of performing TBx in smaller prostates through the TP approach.MethodsWe identified all men who with suspicious lesions on mpMRI and underwent TP TBx (3-core) and concomitant SBx (20-core) in our single hospital from September 2019 to February 2021. Clinical, MRI and biopsy pathological characteristics were evaluated and compared between TBx and SBx. Grade group 2 or greater prostate adenocarcinoma was defined as csPCa.ResultsThree hundred and one (n = 301) men were included. The median prostate volume by MRI was 45 ml. The patients were divided by prostate volume into three groups: ≤30ml group (19.9%), >30 to ≤45 ml group (31.3%) and >45ml group (48.8%). Patients in the ≤30ml group showed significantly higher frequency of combined (both TBx and/or SBx) csPCa detection rate (65.0%) than patients in the >45ml group (39.5%) but similar frequency to the >30 to ≤45 ml group (54.2%,). By TBx only (55.0% vs 27.9%) or by SBx only (56.7% vs. 34.0%), patients in the ≤30ml group consistently showed significantly higher rates of csPCa detection than patients in the >45 ml group. In the ≤30ml group, the detection rate of csPCa was comparable by TBx, SBx or when combined. Four of 6 csPCa cases missed by TBx but detected by SBx were present at the base location.ConclusionOur data suggest that performing TBx with limited additional cores may potentially achieve the same csPCa detection rate as the combined SBx and TBx in smaller prostates.     

Transperineal magnetic resonance image guided prostate biopsy

PURPOSE: We report the findings of a transperineal magnetic resonance image (MRI) guided biopsy of the prostate in a man with increasing prostate specific antigen who was not a candidate for a transrectal ultrasound guided biopsy. MATERIALS AND METHODS: Using an open configuration 0.5 Tesla MRI scanner and pelvic coil, a random sextant sample was obtained under real time MRI guidance from the peripheral zone of the prostate gland as well as a single core from each MRI defined lesion. The patient had previously undergone proctocolectomy for ulcerative colitis and, therefore, was not a candidate for transrectal ultrasound guided biopsy. Prior attempts to make the diagnosis of prostate cancer using a transurethral approach were unsuccessful. RESULTS: The random sextant samples contained benign prostatic hyperplasia, whereas Gleason grade 3 + 3 = 6 adenocarcinoma was confirmed in 15% and 25% of the 2 cores obtained from the MRI targeted specimens of 2 defined lesions. The procedure was well tolerated by the patient. CONCLUSIONS: Transperineal MRI guided biopsy is a new technique that may be useful in detecting prostate cancer in men with increasing prostate specific antigen who are not candidates for transrectal ultrasound guided biopsy.     

Recto-peritoneal fistula following transperineal prostate biopsy

A recto-peritoneal fistula is an extremely rare complication after prostate biopsy. We report herein on a peritonitis arising from a recto-peritoneal fistula 5 days after undergoing prostate biopsy. To our knowledge, this is the first case of recto-peritoneal fistula following transperineal needle biopsy of the prostate in the published literature.     

Complications of transrectal versus transperineal prostate biopsy

BACKGROUND: There are two established techniques of prostate biopsy: the more widely used transrectal technique, and the transperineal technique. Although the transrectal technique is faster, it is reported to have an increased risk of septic complications, which may be life threatening. The present study compares complication rates of both techniques at Nambour General Hospital. METHODS: The present retrospective study was performed by reviewing all available medical charts of men who underwent prostate biopsy during the years 1996-2001. The following data were recorded in a database: date of birth; digital rectal examination findings; serum prostate specific antigen (PSA); biopsy technique; number of cores taken; number of positive cores; Gleason grade and score; complications. Results were tabulated and simple statistical analysis performed to compare both groups. RESULTS: A total of 197 biopsies was included in the study, with 81 transperineal biopsies in 75 men, and 116 transrectal biopsies in 103 men. There was no statistically significant difference in complication rates, including sepsis, between transrectal biopsy and transperineal biopsy. The rate of sepsis was 1.2% for the transperineal technique, and 0% for the transrectal technique (P = 0.411, Fisher exact test). Overall complication rates were 22.2% for transperineal technique and 19.8% for transrectal technique (P = 0.773, Fisher exact test). CONCLUSION: Although the present study was limited by retrospective design and size it suggests that both techniques are equally safe. A review of medical literature supports a tranperineal approach to patients who will tolerate sepsis poorly, or who have a suspected inflammatory cause of their raised PSA.     

超声引导下经会阴定位模板的前列腺饱和穿刺活检

目的探讨超声引导下经会阴定位模板前列腺饱和穿刺活检的准确性、安全性。方法303例PSA〉4．0ng／ml和（或）DRE异常和（或）前列腺B超、CT或MRI异常者接受经会阴定位模板饱和穿刺活检。年龄35～90岁，平均69．7岁。PSA0．2～3000．0ng／ml，中位数13．7ng／ml。前列腺体积7～190ml，中位数47ml。结果每区活检1～4针，共11～44针，平均23．7针。前列腺癌活检阳性率37．6％（114／303）。PSA0～4．0、4．1～10．0、10．1～20．0、20．1～30．0、30．1～70．0及〉70．0ng／ml者阳性率分别为22．2％（4／18）、8．2％（6／73）、21．6％（22／102）、48．4％（15／31）、68．4％（26／38）及100．0％（41／41）。前列腺体积〈20、20～40、41～60及〉60ml者阳性率分别为68．0％（17／25）、51．4％（54／105）、27．5％（19／69）及23．1％（24／104）。无一例出现严重并发症。结论TRUS引导下经会阴定位模板饱和穿刺活检精确而安全，对于前列腺癌的准确分期有重要意义。     

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 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.     

Continued administration of antithrombotic agents during transperineal prostate biopsy

Purpose

To determine the safety of continued administration of antithrombotic agents during transperineal (TP) prostate biopsy.

Patients and Methods

A total of 811 men who underwent transrectal ultrasound (TRUS)-guided TP biopsy from January 2008 to June 2012 at our two institutions were retrospectively analyzed. Among these 811 men, 672 received no antithrombotic agents (group I), 103 received and continued administration of antithrombotic agents (group II), and 36 interrupted administration of antithrombotic agents (group III). Overall complications were graded and hemorrhagic complications were compared (group I with group II) using propensity score matching (PSM) analysis.

Results

An overall complication rate of 4.6% was recorded. Hemorrhagic complications occurred in 1.8% and they were virtually identical in all the three groups, and no severe hemorrhagic complications occurred. One patient in group III required intensive care unit admission for cerebral infarction. PSM analysis revealed no statistical difference between groups I and II with regard to the incidence of gross hematuria, perineal hematoma, and rectal bleeding. Multiple regression analysis revealed that hemorrhagic complications were associated with lower body mass index (<21 kg/m², P=0.0058), but not with administration of antithrombotic agents.

Conclusions

Continued administration of antithrombotic agents does not increase the risk of hemorrhagic complications; these agents are well tolerated during TP biopsy.     

A software system for interventional magnetic resonance image-guided prostate brachytherapy.

OBJECTIVE: Current prostatic brachytherapy implant procedures use ultrasound imaging for geometric guidance during surgery, with pre-surgical planning based on ultrasound images and post-surgical dosimetry based on computed tomography (CT). This procedure suffers from the poor soft-tissue contrast of ultrasound and CT and problems inherent in the repositioning of the patient at surgery. We have designed and implemented an integrated real-time imaging and treatment-planning software system that combines the superior soft-tissue contrast of magnetic resonance (MR) images with the real-time acquisition of those images for localization, verification, and dosimetric purposes. The system permits the surgeon and patient to complete all phases of treatment in one setting. MATERIALS AND METHODS: We utilize an intra-operative MR unit that permits real-time imaging and stereotactic localization during a surgical procedure. Our software system integrates with the unit and features (i) a calibration schema to calibrate the prostatic surgical implant template within the unit, (ii) full volumetric data acquisition of the prostate, (iii) interactive three-dimensional (3D) treatment planning with volumetric dose evaluation, and (iv) geometric and dosimetric feedback during the surgical procedure. We utilize a software architecture that uses mediators between the abstract data types, or objects. These mediators communicate state changes in individual objects (e.g., a change in a catheter position) to other objects (e.g., a dose-volume histogram) that depend on these changes. A consistent 3D representation of the treatment volumes allows interactive reconstruction of the volumes on arbitrary MR image sections and real-time dose computations. RESULTS: We have successfully implemented the system clinically and have treated 143 patients (as of August 2000). The system supports four clinical phases. The first consists of calibrating the implant template with respect to the patient's anatomy and the MR unit. The second consists of acquiring a complete volumetric MR data set of the prostatic volume. The third consists of delineating the treatment volume (often a sub-volume of the prostate) and the dose-limiting critical volumes. These volumes are used in determining the surgical treatment plan based on catheter and seed placement in the prostate and a dosimetric evaluation of all volumes. The final phase consists of implanting the catheters with the radioactive seeds, where each catheter is imaged and compared to the planned position of the catheter, thus allowing a direct comparison, and possible adjustment, of the implanted versus planned catheter position. CONCLUSIONS: The system is highly interactive, and has great flexibility in its design, maintainability, and clinical practice. The system provides an efficient model to support the surgical procedure. The system significantly improves the diagnostic information provided to the clinician and the treatment planner and the geometric accuracy of the surgical procedure compared to ultrasound procedures. The system allows excellent critical structure sparing, both through interactive placement of the catheters with high geometric accuracy and through the definition of the actual sub-prostatic volumes possible with MR.