Can transperineal prostate biopsy replace transrectal prostate biopsy in Hong Kong? A retrospective single centre comparison between 200 cases of transperineal prostate biopsy and 200 cases of transrectal prostate biopsy

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Authors (including presenting author) :
1. Ka Lun LO, FHKAM (Surg) 1 2. Ka Lun CHUI, FHKAM (Surg) 1 3. Steven C.H. LEUNG, MSc 2 4. Leo CHAN, MBChB 1 5. Siu Fai MA, MBChB 1 6. Kevin LIM MBChB 1 7. Julius WONG, MBChB 1 8. Timothy NG, MBChB 1 9. Joseph K.M. LI, FHKAM (Surg) 1 10. Siu King MAK, FHKAM (Surg) 1 11. Chi Fai NG, FHKAM (Surg) 1,2
Affiliation :
1. Division of Urology, North District Hospital, New Territory East Cluster Urology Unit, Prince of Wales Hospital, Shatin, Hong Kong 2. SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong
Introduction :
According to the Hong Kong Cancer Registry, prostate cancer is the third most common cancer in male population. As in other cancers, prostate biopsy is required for the histological confirmation of the diagnosis of prostate cancer before initiation of treatment. With aging population, it is expected the incidence rate of this cancer must be increasing. So, the utilization of prostate biopsy will also increase accordingly. Hodge et al. introduced the systematic sextant biopsy protocol under transrectal ultrasound guidance. Since then, transrectal prostate biopsy (TRUSPB) has become a widely-accepted and routinely-performed technique to detect prostate cancer. In Hong Kong, most Urologists use TRUSPB to confirm the diagnosis in patients who are suspicious of having prostate cancer, including elevated PSA, abnormal digital rectal examination or for active surveillance of prostate cancer. However, there are some potential complications related to the use of TRUSPB in patients. During the procedure, as the procedure is performed via the rectum, it has the potential risk of causing sepsis after the procedure. The incidence of sepsis increased from < 1% to 2%–4% in contemporary series. Fatal sepsis has also been reported. Although there are some possible complications related to the use of TRUSPB in patients, not many studies have been reported about transperineal prostate biopsy (TPUSPB). Until recently, more and more studies have reported notable success in cancer diagnosis with extended biopsy using this technique. Kojima et al. retrospectively reported usefulness of TPUSPB. In fact, TPUSPB differs from TRUSPB in terms of patients’ positions, puncture routes, puncture sites and ultrasound probes. TPUSPB enables the Urologists to thoroughly prepare the perineum with a disinfectant solution to eliminate skin flora. Also, it punctures perineal skin under the guidance of side-fire ultrasound probe without penetrating rectal mucosa, avoiding blood exposure to bowel flora. The Australian study group has shown that TPUSPB, in combination with antibiotic prophylaxis, can achieve a near-zero septic complication rate. Some authors even suggest that TPUSPB may not necessitate antibiotic prophylaxis to avoid unnecessary antibiotic resistance. With the above potential benefit, our center has introduced TPUSPB in our service since January 2018. Since then, we have replaced TRUSPB by TPUSPB. Therefore, in this study, we aim to compare the outcome of our initial series of TPUSPB with our previous cohort of TRUSPB.
Objectives :
To compare the clinical outcomes and pathological findings of transperineal prostate biopsy (TPUSPB) and transrectal prostate biopsy (TRUSPB) in North District Hospital.
Methodology :
This was a retrospective cohort to compare the first 200 cases of TPUSPB of our center with the last 200 cases of our previous cohort of TRUSPB. The study had been approved by institutional ethic committee. The patients in the TPUSPB arm were recruited from January 2018 to October 2018, while those in the TRUSPB arm were the last 200 cases reported in our previous cohort study from June 2015 to April 2016. The following data were retrieved from the hospital records and then compared: patient’s ages, serum PSA levels, prostate sizes, PSA densities, prostate cancer detection rates, complications including admissions due to acute retention of urine, per-rectal bleeding, hematuria, fever and sepsis. We followed the third international consensus definition of sepsis (Sepsis-3) as an acute change in total Sequential Organ Failure Assessment (SOFA) score ≥2 points consequent to the infection: • Respiratory rate ≥22/min • Altered mentation • Systolic blood pressure ≤100 mm Hg The indications for prostatic biopsies, for both arms, were serum PSA level > 4 ng /dL, abnormal digital rectal examination or follow-up biopsy for patients underwent active surveillance. All patients have pre-procedure blood tests and urine tests done to ensure they have no bleeding tendency and positive urine culture. Patients using antiplatelet or anticoagulants would require stopping the drugs prior to biopsies. For all patients, fleet enema (per rectal) would be used in the morning of the procedure, and then oral prophylactic antibiotics, 1g oral amoxicillin-clavulanate and 500 mg ciprofloxacin, would be taken 2 hours before the procedure. For TPUSPB, 5% EMLA cream was applied over perineal region 1 hour before the procedure and 1% Lignocaine (20ml in total) was injected over the perineum as local anesthesia just prior to the prostate biopsy. After the procedure, all patients were given additional one-day course of 1g oral amoxicillin-clavulanate and 500mg ciprofloxacin. The results were tabulated and statistical analysis was performed to compare both groups. T-test, Mann-Whitney U test, Chi-squared test, Cochran-Mantel-Haenszel test and Fisher’s exact test were used as appropriate. The expected cut off for statistically significant, i.e. p-value was less than 0.05.
Result & Outcome :
The patients’ characteristics, prostate cancer detection rates and complications between these two groups were compared. There was no statistical difference between the mean ages of the two groups. The mean prostate size of TPUSPB was smaller than TRUSPB (50.5ml vs 60ml, p = 0.001) and higher median PSA level (10.95ng/dL vs 10ng/dL, p=0.158). So, the median PSA density of TPUSPB was higher (0.231 vs 0.172, p = 0.001). The prostate cancer detection rate of TPUSPB was statistically higher than that of TRUSPB (34.5% and 25%, p = 0.038). TPUSPB also showed better prostate cancer detection rate after stratifying PSA density and prostate size. For complications, there was no fever developed in TPUSPB group, while 4% of TRUSPB group had fever, requiring admission of at least one-week course of intravenous antibiotic. (p = 0.004). On the other hand, TPUSPB had more post-procedure acute retention of urine (3% vs 1%, p = 0.317) and haematuria requiring admission (1% vs 0%, p = 0.500), but none suffered from per-rectal bleeding (0% vs 0.5%, p = 0.156). In Summary, TPUSPB avoids penetrating rectal mucosa and blood exposure to bowel flora during the procedure. This accounted for zero infection complication rate in the study. For prostate cancer detection rate, TPUSPB has shown better prostate cancer detection rate as compared with TRUSPB. So, it is believed that more and more Urologists would adopt this technique in the nearest future.

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