Predictors of prostate cancer on repeat transrectal ultrasound-guided systematic prostate biopsy

BACKGROUND: We analyzed the outcome of repeated transrectal ultrasound (TRUS)-guided systematic prostate biopsy in Japanese men whose clinical findings were suspected of prostate cancer after previous negative biopsies. METHODS: Between January 1993 and March 2002, 1045 patients underwent TRUS-guided prostate biopsy. Among them, 104 patients underwent repeat biopsy due to indications of persistent elevated serum prostate-specific antigen (PSA), abnormal digital rectal examination (DRE) or TRUS, increased PSA velocity, and/or previous suspicious biopsy findings. Several clinicopathological factors were evaluated for their ability to predict the detection of prostate cancer on repeat biopsy. RESULTS: Prostate cancer was detected in 22 of 104 patients (21.2%) who underwent repeat biopsies. PSA concentration and PSA density at both the initial and repeat biopsies, and PSA velocity in men with positive repeat biopsy were significantly greater than those in men with negative repeat biopsy. The incidence of abnormal findings in DRE and TRUS at initial biopsy in men with positive repeat biopsy was also significantly higher than that in men with negative repeat biopsy. However, neither the presence of prostatic intraepithelial neoplasia nor number of biopsy cores at initial biopsy had a significant association with the results of the repeat biopsy. Furthermore, multivariate analysis revealed that PSA and PSA density at both the initial and repeat biopsies, PSA velocity, and DRE and TRUS findings at initial biopsy were independent predictors of malignant disease on repeat biopsy. CONCLUSION: Despite an initial negative biopsy, repeat TRUS-guided biopsy should be carried out to exclude prostate cancer in cases of suspicious clinical findings, such as elevated PSA or PSA-related parameters, or abnormal findings of DRE or TRUS.     

两种不同局麻方法在经直肠前列腺穿刺活检术中的镇痛疗效比较

目的比较经直肠超声引导前列腺神经阻滞术和直肠内灌注2％利多卡因凝胶在前列腺穿刺活检术中的镇痛疗效。方法160例接受经直肠超声引导13点前列腺系统穿刺活检术的患者随机分为A、B两组。A组患者84例，在经直肠超声引导下，于前列腺基底部，左、右两侧精囊与前列腺交接处分别注射1％利多卡因5ml；B组患者76例，于活检前5min直肠内灌注2％利多卡因凝胶10ml。采用视觉模拟评分（VAS）评估两组患者在穿刺活检术中的疼痛程度。结果两组患者在平均年龄（t=0．73）、PSA水平（t=0．34）和前列腺体积（t=0．55）的差异无统计学意义（P〉0.05），具有可比性。A组患者VAS评分0～3分者76例，4～5分者6例，6～10分者2例。B组患者则分别为48例、18例、10例。两组患者VAS评分均值分别为1，2分、2．6分，差异具有高度统计学意义（t=4．73，P〈0.01）。两组患者均未出现局麻药的不良反应。结论经直肠超声引导前列腺神经阻滞术的镇痛疗效明显优于直肠内灌注2％利多卡因凝胶，值得临床推广应用。     

经直肠超声引导13点法前列腺穿刺活检术诊断前列腺癌

目的：评价经直肠超声引导13点法前列腺系统穿刺活检术诊断前列腺癌的临床价值。方法：按照Eskew描述的方法,在标准的经直肠超声引导6点法前列腺系统穿刺活检术的基础上,增加在前列腺的中间部位及前列腺两侧旁正中线远侧的穿刺点数,总共穿刺活检13处。将增加的7处活检部位的病理结果与标准的6点法前列腺系统穿刺活检术进行比较,并对经直肠超声引导13点法前列腺系统穿刺活检术的并发症进行了讨论。结果：总共51例患者中有20例确诊为前列腺癌（20/51）,占39%,此20例前列腺癌患者若仅采用标准的经直肠超声引导6点法前列腺系统穿刺活检术,将有5例患者漏诊,占25%。所有接受经直肠超声引导13点法法前列腺系统穿刺活检术的患者无一例出现严重的并发症。结论：经直肠超声引导13点法前列腺系统穿刺活检术可明显提高前列腺癌的临床检出率,是一种安全、有效的前列腺系统穿刺活检术式,值得在临床推广应用。     

Update on transrectal ultrasound-guided needle biopsy of the prostate

Over the past decade, the sextant biopsy technique has emerged as the standard of care in the detection of prostate cancer. This technique is easy to learn and well tolerated by patients and has a major complication rate of <1%. However, limitations in cancer detection have been appreciated, particularly a false-negative rate approaching 25%. This high failure rate has led investigators to refine biopsy techniques to improve cancer detection. Intuitively, increasing the total number of cores should improve cancer detection. However, the optimal core number has yet to be defined. Confounding factors include variability of prostate size, tumor volume, and tumor location. Currently, a new standard is emerging prescribing a minimum of eight cores, of which at least three are directed at the lateral aspect of the peripheral zone. These additional biopsies appear to enhance cancer detection by about 15%. The improved yield is most pronounced among patients with a serum prostate specific antigen concentration between 4 and 10 ng/mL and larger gland volume (>50 cc). These additional biopsies may decrease the need for repeat biopsies. In the meantime, strategies are being developed for the optimal technique of repeat biopsies among patients with persistent clinical suspicion in the setting of a prior negative biopsy. Currently, recommendations include increasing the biopsy number to a minimum of 10 cores, including sampling of the lateral peripheral and transition zones.     

Vertebral osteomyelitis following transrectal ultrasound-guided biopsy of the prostate

Transrectal ultrasound-guided needle biopsy of the prostate (TRUS) is a well-tolerated and standardized procedure for the diagnosis of prostate cancer. Complications associated with TRUS requiring emergency room visits or hospital admissions are relatively low and include complications, such as a 1% risk of urinary retention and less than 1% chance of bacterial sepsis. Vertebral osteomyelitis is a rare complication of TRUS; there are 3 reported cases. Vertebral osteomyelitis has an insidious onset and usually resolves following medical intervention. We present an extremely rare case of vertebral osteomyelitis following TRUS, its clinical outcome and management.     

Hemospermia following transrectal ultrasound-guided prostate biopsy: a prospective study

Hemospermia is known to be associated with transrectal ultrasound-guided prostate biopsy (TRUS-PB). The true incidence of hemospermia, its duration and implications are not well established. We performed a prospective observational study involving patients undergoing TRUS-PB for suspected prostate cancer at our institution. Sixty-three eligible men were included in the study. Most men (84%) undergoing TRUS-PB, who were able to ejaculate, experienced hemospermia, which was associated with some degree of anxiety. The mean duration of hemospermia was 3.5 (+/-1.7) weeks. The number of ejaculations before the complete resolution of hemospermia was 8 (+/-6.7). None of the clinical and pathological factors was a significant predictor of the duration of hemospermia. Patients should be adequately counseled before TRUS-PB to avoid undue anxiety and alterations in sexual activity.     

超声引导的经直肠前列腺穿刺活检术（附121例报告）

为提高前列腺癌的诊断水平，应用端扫式双平面高频（７．５ＭＨｚ）探头的腔内Ｂ超为指引，配以自动弹射式组织芯活检装置，对１２１例可疑前列腺癌患者行经直肠前列腺穿刺活检术。结果：前列腺增生７８例，前列腺癌３３例，前列腺炎１０例。该技术简单、准确、取材满意、并发症少，但必须掌握其适应证，避免不必要的活检，提高对前列腺癌的活检阳性率。     

Transrectal biopsy of the prostate guided by transrectal ultrasound

The use of transrectal ultrasound in combination with the Biopty System provides a high accurate, efficient, and safe method for the diagnosis and staging of prostate cancer. Because both diagnosis and staging may be attained easily using one comprehensive procedure, we recommend ultrasound guidance be used for all initial biopsies of the prostate. When transrectal ultrasound-guided biopsy of a palpable hypoechoic abnormality is negative for cancer, digitally guided biopsy must subsequently be performed. In some cases, palpable abnormality may not be seen on ultrasound. We advocate the use of our biopsy procedure as an integral extension of transrectal ultrasound of the prostate. In an outpatient setting, biopsy may be performed immediately after finding a suspect lesion on ultrasound. In this way, patients are spared time and anxiety, and society is spared medical costs.     

经直肠超声引导13点前列腺系统穿刺活检术的并发症及防治

目的探讨经直肠超声引导13点前列腺系统穿刺活检术的并发症及防治措施.方法回顾性分析本组1998年8月至2004年12月336例接受经直肠超声引导13点前列腺穿刺活检术患者的临床资料.结果336例患者中出现的并发症有:血尿218例;血便67例,血精10例,感染10例,明显疼痛(VAS评分大于5分)85例,血管迷走神经反应10例等.结论经直肠超声引导13点前列腺系统穿刺活检术用于诊断前列腺癌常可见小的并发症,大的并发症则很少见.该术式用于诊断前列腺是安全的.     

Anterior rectal wall hematoma: complication of transrectal ultrasound-guided biopsy of prostate.

Transrectal biopsy of the prostate, because of its directness and simplicity, is utilized by many practicing urologists to obtain prostatic tissue for histologic evaluation. Complications arising from this procedure are primarily of an infectious origin and less commonly of a vascular etiology. We report on the first known patient in whom a large hematoma of the anterior rectal wall with nearly total occlusion of the rectal lumen developed following a transrectal ultrasound-guided biopsy of the prostate. Guidelines to reduce the likelihood of vascular complications following biopsy of the prostate gland for patients consuming medications that may alter normal platelet function or interfere with the various clotting factors are described.     

A meta-analysis of local anesthesia for transrectal ultrasound-guided biopsy of the prostate

This meta-analysis evaluated the efficacy and safety of periprostatic nerve block (PPNB) and intrarectal local anesthestic (IRLA) gel in alleviating pain during prostate biopsy. Electronic databases MEDLINE, Cochrane Central Register of Controlled Trials and EMBASE were searched to identify all randomized controlled trials comparing PPNB with periprostatic placebo injection, no injection or with IRLA. Studies for inclusion were identified and extracted by two authors independently. The main outcome measure was patients' assessment of mean pain scores on a 10-point scale at the end of the biopsy procedure. Secondary outcomes were complications and adverse events. Continuous data from the trials were combined by calculating the weighted mean difference (WMD) with its 95% confidence interval. In total, 25 studies met the inclusion criteria. Twenty studies involving 1685 patients compared PPNB with either no anesthesia or with placebo injection controls, showing a significant reduction in pain score in the anesthetic group (WMD -2.09, 95% CI -2.44 to -1.75, P<0.00001). Five studies with 466 patients compared IRLA and control. Although IRLA was associated with pain reduction, the effect size was not statistically significant (WMD -0.22, 95% CI -0.56 to 0.12). Six studies with 872 patients compared PPNB with IRLA, showing a significant pain reduction in the former group (WMD -1.53, 95% CI -2.67 to -0.39, P=0.008). No trials reported an increase in complications in the treatment arms. In conclusion, the evidence from randomized controlled trials shows that local anesthetic given as a PPNB, but not as an intrarectal instillation, is effective and safe in alleviating pain from transrectal ultrasound biopsy of the prostate.     

16G和18G穿刺针在超声引导下经直肠前列腺活检对前列腺癌的诊断效果及并发症比较

目的:增加穿刺针的直径可能通过获取更多组织而提高前列腺癌的检出率。本研究旨在比较16G和18G穿刺针在超声引导下经直肠前列腺活检诊断前列腺癌的效果及并发症。方法:本研究为前瞻性随机对照研究。2015年7月至2018年7月在超声引导下经直肠前列腺活检的142例患者作为研究对象,采用随机数表法将142例患者分为16G组和18G组,每组各71例。穿刺后比较两组血尿、出血和感染事件的发生率。采用Clavien-Dindo评分对并发症进行分级。结果:18G组前列腺癌检出率明显低于16G组(12.68%vs 36.62%),差异有统计学意义(χ^2=10.958,P=0.001)。当f/tPSA≤0.15时,18G组前列腺癌检出率仍明显低于16G组(8.51%vs 44.44%),差异有统计学意义(χ^2=12.617,P=0.001)。当f/tPSA>0.15时,两组间PCa穿刺检出率的差异无统计学意义(P<0.05)。两组活检后直肠出血(21.13%vs 15.49%)和尿道出血(18.31%vs 16.90%)的发生率比较无统计学差异(χ^2=0.753,P=0.385;χ^2=0.049,P=0.826),两组均未见感染并发症的发生。根据Clavien-Dindo分级:18G组Ⅰ级26例,16G组20例;两组均无Ⅱ级;18G组Ⅲa级2例,16G组3例,两组Clavien-Dindo分级的比较无统计学差异(Z=-0.698,P=0.458)。结论:活检针16G前列腺癌的检出率比18G高,且不增加并发症的发生率。     

Comparison of four different anesthesia methods for relief of all pain during transrectal ultrasound-guided prostate biopsy

Introduction To find the most beneficial method, we assessed patient comfort and morbidity rates during prostate biopsy procedures performed using periprostatic nerve blockade, unilateral pudendal nerve blockade, intrarectal lidocaine gel, and a combination of periprostatic nerve blockade and intrarectal lidocaine gel. Materials and methods A total of 159 patients were included in this study. Pain evaluation results were retrospectively assessed and retrieved from the patient charts. Patients in group 1 (n = 64) received no anesthesia, group 2 (n = 34) received periprostatic nerve blockade, group 3 (n = 26) received unilateral pudendal nerve blockade, group 4 (n = 20) received intrarectal lidocaine gel, and group 5 (n = 15) received a combination of periprostatic nerve blockade and intrarectal lidocaine gel. A visual analog scale (VAS) was used for pain evaluations. Results According to pain scores (VAS) during probe insertion, only group 2 did not show a statistically significant difference (P > 0.05), while the other groups were found to be significantly different when compared to group 1. Groups 2, 3, and 5 were found to be significantly different when compared to group 1 according to pain scores (VAS) during insertion of needles. Groups 3 and 5 displayed statistically significant differences when compared to group 1 as regards pain scores during both the insertion of the probe and biopsy. Conclusions Our data suggests that using either a combination of intrarectal lidocaine gel and periprostatic block or solely unilateral pudendal nerve block for prostate biopsy procedures provides efficient patient comfort by reducing pain both during probe insertion and needle passing through the prostate gland.     

Tolerance of pain during transrectal ultrasound-guided biopsy of the prostate: risk factors

Transrectal ultrasound-guided needle biopsy of the prostate is routinely performed to diagnose prostate cancer. We performed a prospective study to assess the pain and identify risk factors of pain during prostate biopsy. Prospectively, 131 patients were enrolled. Transrectal ultrasound-guided needle prostate biopsies were performed without any anesthesia. Pain was assessed by using an immediate postbiopsy anonymous questionnaire including a linear visual analog scale (VAS). Six factors were studied (age, prostate volume, cores number, operator, previous biopsy and first core location). Most of the patients tolerated the biopsy with acceptable discomfort. Among the risk factors studied, only first core location influenced the pain. Apex biopsy first was more painful. We recommend starting biopsy with the base.