30
November
2014

Abiraterone PBS listing changed from 1st December 2014

Abiraterone PBS listing changed from 1st December 2014

From December 2014 , the PBS criteria for abiraterone acetate changed, meaning that patients deemed unsuitable for chemotherapy with doxetaxel can be prescribed PBS-subsidised abiraterone.


What is abiraterone?

Abiraterone is an oral drug for metastatic prostate cancer that is castration resistant (meaning the cancer that is no longer sensitive to other forms of testosterone suppression). It works by inhibiting an enzyme involved in the production of androgens (testosterone is one of the body’s androgens).


What are the new amended PBS criteria?

Treatment must be in combination with a steroid (prednisolone)

Treatment can’t be given in combination with chemotherapy

Patients must have failed treatment with docetaxel because of resistance or intolerance, or be considered unsuitable for docetaxel chemotherapy because of proven or predicted intolerance to the chemotherapy.

Patients must have a good performance status (WHO status of 2 or less)

If progressive disease develops whilst on abiraterone, PBS-subsidised treatment with abiraterone cannot continue.

Patients cannot have previously received treatment with enzalutamide, or they must have developed intolerance to enzalutamide, which was bad enough to require that enzalutamide was stopped.

Categories: Updates, Prostate Cancer

28
November
2014

Should I have a PSA test?

Should I have a PSA test?

This short article may help you with the decision about having a PSA test (also known as PSA screening) to look for prostate cancer

Australia has one of the highest rates of prostate cancer in the developed world. The PSA test is the first investigation that can be done to look for prostate cancer. It is not a perfect test, and there are problems associated with the test, which is why you should be as well informad as possible about PSA.

Information for Patients Considering Prostate Cancer Screening

Background

  • Prostate cancer is common. Most men will develop prostate cancer if they live long enough. Despite this, only about 3% of all men will die of prostate cancer.

  • This indicates that most prostate cancers do not cause trouble in a man’s lifetime (‘low-risk’ or ‘indolent’ cancers). However, there are some more aggressive cancers that can cause trouble, and these benefit from detection and treatment.

  • Screening studies do show that the number of prostate cancer deaths can be reduced by screening with PSA. However, quite a large number of men need to be diagnosed by screening and treated to prevent one prostate cancer death.

  • One study (the Goteborg study) showed that 12 men need to be diagnosed to prevent one prostate cancer death. That means that 11 men were unnecessarily diagnosed. Another larger study demonstrated that (ERSPC) that 781 men need to be screened and 27 men need to be diagnosed to prevent one prostate cancer death. Thus 26 men are unnecessarily diagnosed.

  • Screening will detect many of these indolent cancers, and if they are detected, they may go on to be treated, perhaps unnecessarily.

  • Treatment is associated with long term complications in men, such as incontinence, erectile dysfunction (impotence) and bowel problems. Therefore, some men (indolent cancers that are treated) may have unnecessary treatment and suffer side effects.

The aim of screening

  • The aim of screening should be to identify aggressive or high-risk prostate cancers early, before they have spread beyond the prostate.

  • Some men are at higher risk of aggressive prostate cancer than others. These are men with a family history of prostate cancer, or with a strong family history of breast or ovarian cancer in females of the family, men of African-American decent, and men who have been exposed to some environmental agents (fire-fighters possibly, and veterans exposed to Agent Orange).

  • Most prostate cancers found by screening are low risk and do not need to be treated, and can just be closely followed by active surveillance (click for link to AS).

  • If you choose to be screened, there is a reasonable chance you will be diagnosed with low-risk prostate cancer, and may be in a position where you have to consider treatment that may be unnecessary.

Your decision to be screened – what sort of person are you?

  • If you have risk factors for prostate cancer (see above), your risk of prostate cancer may be higher than the general population, and this may impact your decision to be screened.

  • If you are the sort of person who would be uncomfortable not being treated if low risk prostate cancer was discovered, screening may not be the right decision for you.

  • If you are the sort of person who would accept treatment for aggressive prostate cancer, but would be happy to observe (active surveillance) things if you just had low risk prostate cancer, then you may be a good candidate for screening.

Categories: Updates, Prostate Cancer

28
May
2014

Video TeleHealth for Distant Patients

Video TeleHealth for Distant Patients

Video consultation is now available at Nick Brook Urology, to reduce the need for long distance travel for rural and country patients in South Australia. This service offers a real time consultation over a video link from your GP’s practice, so you can talk directly with a Urologist.


How does it work?


If your GP has made a new referral and has requested a video consult (‘video telehealth’), this will be sent to Nick Brook, who will review the referral and see if it is suitable for a video consultation. If so, the staff at Nick Brook Urology will contact you and your GP and a time will be arranged for you to attend your GP practice for the video consultation. One of the staff from your GP practice will be with you during the consultation to help you. You do not need to do anything special – all of the organisation will be taken care of, and all you need to do is talk with Mr Brook, as per a normal consult.

Any investigations, such as blood tests or X-rays, can be arranged easily, and will be faxed to the GP practice so you can have them done near to your home. Follow up appointments can be arranged by video as well.

Are all consults suitable for video telehealth?


You need to live in an area that is deemed appropriate for telehealth by the Government. In South Australia, this means you need to live outside of the central area coloured in red in the map below:

Map outlining Adelaide metro area

What happens if I need a physical examination by the Specialist?


Because examination cannot be done at the time of video consults, it may be that your consult may not be suitable for telehealth. You may still need to travel so that this examination can be done. Likewise, some specialised investigations may need to be done in person. However, an initial discussion by video can reduce the need for multiple visits, even if you do have to come to Adelaide for a face-to-face consult at some point.

Is the video recorded?


No, there is no video recording made. However, medical notes are made as with a standard face-to-face consultation.

How do I request a video consultation?


Ask your general practitioner if they have the facilities available for a video telehealth consultation. You can also contact Nick Brook Urology to help arrange this.

Can I have a family member or friend in the room for the consultation?


Yes you can. It is helpful if you let your GP know about this prior to the consultation.

Is your privacy respected?


Just as in a standard face-to-face consultation, your privacy is absolutely respected. The only people involved in the consultation are you, Mr Brook, and one of the staff members from your GP practice. Contact will be made before and after the consultation by practice staff, to arrange investigations and follow-up. Your medical records are recorded and stored in exactly the same way as if you had a standard consultation, on our secure electronic record system.

Generally, a program called Facetime is used, and this is an encrypted system. Facetime is streamed via Secure Real Time Protocol (SRTP) using AES-256 encryption. Likewise, WiFi and wired systems at the practice are encrypted. Both of these encryptions work separately so it would be very difficult indeed for these systems to intercepted by a third party.

A video telehealth consultation has been suggested, but I do not want one. What do I do?


You are absolutely free to decline a video consultation and have a face-to-face consultation instead. Please let your GP and Specialist know about this, and this will be arranged for you.

Categories: Updates

29
April
2014

Stereotactic Ablative Body Radiotherapy (SABR)

Stereotactic Ablative Body Radiotherapy (SABR)

Our First Guest Blog for May 2014 is by Dr Shankar Siva, a Radiation Oncologist from The Peter MacCallum Cancer Centre in Melbourne. He discusses the new technique of Sterotactic Ablative Body Radiotherapy for kidney cancer in patients who are not medically fit for surgery. This new approach is still in a study period, but may offer cancer control to patients who do not have other treatment options.


Shankar, can you explain what Stereotactic Ablative Body Radiotherapy (SABR) is, and what advantages it has over other forms of radiotherapy?


Stereotactic ablative body radiotherapy (SABR) is a high precision radiotherapy technique that involves between 1 and 5 treatments. This is very different from conventional radiotherapy that involves daily radiotherapy for up to 8 weeks. It is non-invasive, painless, delivered without any need for anaesthetic, and conveniently does not require in-patient hospitalisation. SABR requires high-tech radiotherapy equipment for safe delivery, such as motion management for the tumour, accurate image guidance, and robust immobilisation. When delivered correctly, SABR can achieve submillimetre accuracy. Because of its precision, the SABR technique allows for much higher biological doses than can be safely delivered using conventional radiotherapy techniques. As such, most studies in sites such as the brain, lung and spine report cancer control rates in the order of 90% or greater after SABR.


Sterotactic radiotherapy for some other types of tumour has been around for some time. Why has it only recently been looked at for kidney tumours?


Stereotactic radiotherapy was first devised for brain tumours by Swedish neurosurgeon Lars Leksell in 1951, who termed it “radiosurgery”, so yes, it has been around for a very long time! Cranial "radiosurgery" was performed by using a rigid frame around the skull which allowed for accurate delivery of the radiation dose. However, tumours in other organs such as the lung, liver, and kidney are all highly mobile due to normal breathing or from the pumping of the heart. Only recently have technological advances allowed us to account for and manage tumour motion during radiotherapy delivery. The kidney in particular is a challenging organ, as it is quite mobile and surrounded by many sensitive organs.


Which group of patients is likely to be suitable for this treatment for kidney tumours?


Surgery is still the standard of care for patients with kidney cancer. However, kidney cancer is typically a disease of the older population, with the average age of diagnosis being 65 years of age. Some patients have other medical conditions which make invasive procedures potentially risky, particularly those patients who may have significant pre-existing kidney dysfunction, are risky anaesthetic candidates, or have heart disease and are reliant on blood thinners. In light of this risk, other procedures such as SABR and radiofrequency or microwave ablation have emerged as treatment alternatives for inoperable patients. In contrast to SABR, the disadvantage of radiofrequency ablation and microwave ablation is that those techniques can typically treat only treat smaller tumours, require the insertion of electrodes through the skin into the kidney (invasive), and are not as effective when tumours are close to blood vessels. On the other hand, the disadvantage of SABR is that it is typically restricted to patients who have not previously received radiotherapy to the upper abdomen. Otherwise, we expect that most patients who are not suitable for surgery on medical grounds may be eligible for treatment using the SABR technique.


What are the potential side effects?


In the early period after treatment, we expect that most patients feel tired. There may be some nausea, or loose bowel actions. Some patients may experience some reflux or heartburn. We typically prescribe preventative medications to help with these side effects. There may be a mild skin reaction, similar to a very light sunburn, particularly around the back. These side effects usually resolve within the first 2-3 weeks, and we expect all of these side effects to be resolved by around 6 weeks post treatment. The longer term effects of SABR in the kidney are less well understood. There is a potential for decline in kidney function, rise in blood pressure, scarring or narrowing of the bowel, or very rarely ulceration of the bowel or stomach. To date, studies have shown that the risk of severe side effects to be less than 5%.


This treatment is currently part of a study at the Peter Mac. What do you think the future holds for this treatment for kidney tumours?


We have pioneered this technique in Australia through the FASTRACK clinical trial, one of the few clinical trials using SABR for localised kidney cancer in the world. This study is expected to be complete later in 2014, and to date the results have been very promising. We would like to make this treatment accessible to all patients in Australia. However, the problem is that technology is very complex and varies from centre to centre. The Peter Mac is one of the largest radiation oncology institutions in the southern hemisphere and an Australian leader in the SABR technique, so we are not certain whether our results can be immediately reproduced in other institutions across Australia.

The next phase in our research program is to lead a multicentre study of SABR for kidney cancer involving multiple cancer centres across Australia. All the treatment plans will be centrally reviewed by our team at the Peter Mac for quality assurance, in order for this new treatment to be safely introduced across Australia. If this study is successful, I imagine that stereotactic radiotherapy will become a readily available treatment alternative for inoperable patients with primary kidney cancer.


Click this link to display a news item and video on the SABR technique.


Dr Siva is a Radiation Oncologist, Research Staff Specialist and NHMRC Scholar at the Peter MacCallum Cancer Centre in Melbourne. His major research interests are in high-tech radiation delivery and radiation biology. He is the lead clinician of the stereotactic body radiotherapy program at the Peter MacCallum Cancer Centre, and coordinates the first dedicated Stereotactic Ablative Body Radiotherapy (SABR) clinic in Australia. He published the first original research using the SABR technique in Australia. He serves on the Radiation Oncology Research Committee (RORC) of the Royal Australian and New Zealand College of Radiologists, on the renal subcommittee of the Australian and New Zealand Urogenital and Prostate (ANZUP) trials group, and as the radiation oncologist on the Management Advisory Committee (MAC) of the Australasian Lung Cancer Trials Group (ALTG). He is the principal investigator of multiple radiotherapy clinical trials of SABR in the context of lung, kidney and prostate malignancies.

Follow this link for more information on Dr. Shankar Siva


Categories: Video, Updates, Kidney Cancer

07
April
2014

Infectious Complications of Kidney Stone Surgery

Infectious Complications of Kidney Stone Surgery

Our latest Guest Blog is by Dr Michael Wong, Director of the Singapore Urology, Fertility and Gynaecology Centre. He is a US Fellowship Trained Urologist, and previous President of the Singapore Urology Association. Michael gives an up to date and comprehensive account of Infective Complications in the Surgical Management of Urinary Stones.


Infective Complications in the Surgical Management of Urinary Stones


Introduction

Despite the significant advancements in the surgical management of urinary stones, morbidity and even mortality are still being reported. Krambeck reported in the Journal of Urology in 2013 that deaths still occur after surgery, particularly in the elderly population as their immunity is lower and there could be delay in diagnosis due to lack of classical symptoms. The importance of appropriate antibiotic prophylaxis and assessment of risk factors prior to treatment cannot be underestimated.


Infective Issues with Percutaneous Nephrolithotomy (PCNL)

PCNL is most appropriate for large renal stones. One of the feared complications of PCNL is urosepsis. A common composition for staghorn stones is struvite,5 which results from the presence of urea-splitting organisms, and non-struvite stones may also harbor bacteria. There is therefore an increased risk for sepsis during the procedure. Further, PCNL utilizes large volumes of irrigation relative to ureteroscopy, which may increase the risk of sepsis.

The practice of prophylaxis for PCNL is not for debate. David Tolley reported that the rate of UTI reduces 3 fold when using prophylaxis for PCNL. Recently, the CROES group reported a series of 162 patients from multiple institutions who underwent PCNL without pre-operative antibiotics and matched them to patients who did receive antibiotics6 All patients had negative pre-operative urine cultures and matching was based on infectious risk factors such as diabetes, nephrostomy tubes and staghorn stones. They found that antibiotic prophylaxis led to fewer fevers (2.5% vs. 7.4%) and other complications (1.9% vs. 22%) and higher stone free rate (86.3% vs. 74%). The explanation for this finding may be that stones themselves may harbor bacteria that may not manifest in a voided urine culture.

ESWL -

Techniques to culture stones were described over 40 years ago. In a study examining infection rates in patients undergoing PCNL, 35% of patients had positive stone cultures, compared with 21% of upper tract and 11% of bladder urine cultures. Stone manipulation and lithotripsy can result in the release of bacteria and contamination of urine with possible systemic transudation resulting in sepsis or systemic inflammatory response syndrome (SIRS). Stone cultures have been shown to be a better predictor of sepsis and SIRS than voided cultures. Mariappan showed a positive stone culture to have over 80% sensitivity and a positive predictive value of 70% in predicting SIRS.7 Overall, positive stone cultures increased the risk of SIRS 4-fold. Along with bacteria, stones contain endotoxins that can potentially result in a systemic immune response clinically similar to sepsis.

The greatest limitation of stone cultures is that they are only available after a procedure with some days to allow bacteria culture and so cannot influence immediate peri-operative treatment. The utility of obtaining stone cultures in clinical practice is to guide antibiotic choice in the event of sepsis following ureteroscopy or PCNL rather than predicting it. Having said this, it is reassuring to routinely collect stone cultures intraoperatively from patients undergoing PCNL.


Understanding the Risk factors for Urosepsis during PCNL

Many groups have reviewed their experience with PCNL in an attempt to identify risk factors for post-operative fever, sepsis or SIRS. A positive pre-operative urine culture was associated with increased infectious risk (OR 2.2 -16.7), as were positive pelvic urine (OR 10.2 – 24.1) and stone cultures (4.88 – 25.6). Other factors such as female sex, hydroureteronephrosis, pre-operative nephrostomy tube, large or complex stone burden, and diabetes have all been associated with an increased risk of post-operative fever or sepsis.

Korets and colleagues showed that an increased number of access tracts increased the risk of SIRS (HR 4.8) when controlling for patient sex, stone culture and composition, while several other groups have found increased operative time to be a risk factor for fever. Dogan also showed volume of irrigation fluid required was a significant predictor. These three factors are likely all surrogates for stone size and complexity, resulting in a prolonged procedure.


Infective Issues with Ureteroscopy

A 2003 RCT by Knopf et al. that included 113 patients found a single prophylactic oral dose of fluoroquinolone prior to ureteroscopy reduced the incidence of post-operative bacteriuria (1.8% vs. 12.5%, p=0.02). There were, however, no incidences of symptomatic UTI. This study guided the AUA Best Practice Policy in recommending antibiotic prophylaxis prior to ureteroscopy for the management of stone disease.3 The guideline committee states that the potential risk of bacteriuria is 30% and UTI ranges from 4% - 25% without prophylaxis. There is no difference in efficacy between oral fluoroquinolone and intravenous cefazolin.

A Korean group reviewed their experience of infectious complications following ureteroscopy and identified several risk factors.4 They noted an overall UTI rate of 3.8%. Furthermore, they found hydronephrosis, bacteriuria, and an indwelling ureteral stent or nephrostomy tube was associated with an increased risk of post-procedural fever. Administration of antibiotics after the procedure was not as effective as pre-procedural prophylaxis.

flexi scope

Eswara and colleagues retrospectively reviewed their experience with stone cultures in patients undergoing ureteroscopy (n=274) or PCNL (n=54). They found that while pre-operative urine cultures were only positive at some point in 7% of patients, stone cultures were positive in 29%. Their overall sepsis rate was about 3-4% for all patents. In patients with positive stone cultures, the sepsis rate was significantly higher at 8% compared to only 1% in those who had negative stone cultures. Ultimately, urine cultures had a sensitivity of 11% versus 64% in stone cultures and there was a concordance of 64% between the stone culture pathogen and the one causes sepsis compared to only 9% of pre-operative urine cultures. Despite the correlation of stone cultures and post-operative infection, their utilization in guiding clinical practice is limited in that it takes several days following the removal of the stone for cultures to results. They are most helpful following the development of UTI to help guide antibiotic choice.

Unfortunately we do not have a study showing the use of ureteric stent post URS reduces UTI as upper tract decompression using a stent would also play a part in reducing UTI.


Infective Issues in Extra-Corporeal Shock Wave Lithotripsy (ESWL)

In general, the incidence of urinary tract infection occurring after uncomplicated ESWL is less than 1%, rising to 2.7% for staghorn calculi. This risk of sepsis increases in the presence of bacteriuria prior to ESWL especially if there is distal obstruction.

Until recently, the practice of giving prophylactic antibiotics was controversial in patients undergoing ESWL with negative urine cultures. It has been reported that bacteriuria can develop in 5-6% of patients undergoing ESWL even in the presence of sterile urine prior to the procedure and the risk of clinical UTI can be seen in 2-3% subsequently.

The European Association of Urology guidelines on urological infections (updated in 2010) do not recommend prophylactic antibiotics in ESWL unless there are risk factors like ureteral stents, urinary catheters, nephrostomy tubes or infective stones1. More recently, in a meta-analysis reported in the Journal of Urology in 2012 covering 9 randomized trials of 1364 patients undergoing ESWL for urinary stones with sterile urine cultures2, Lu et al reported no significant differences between the prophylactic group and the control group in terms of symptoms, rate of fever, rate of positive urine culture and the incidence of urinary tract infection. They suggested that antibiotic prophylaxis is not necessary for ESWL in low risk patients.

PCNL

The American Urological Association guidelines3 were recently updated in Jan 2014 and currently do not recommend antibiotic prophylaxis for patients undergoing ESWL with negative urine culture. In the light of more recent publications, prophylactic antibiotics are recommended only in high risk stone groups with infective stones, recent instrumentation, nephrostomy tubes, positive urine cultures and a history of recent UTI or sepsis. In addition, special considerations should also be given to high risk patient groups which the AUA defines as advanced age, anatomical anomalies of the urinary tract, poor nutritional status, chronic smokers, chronic steroid users, immunodeficiency, externalized catheters and prolong hospitalisation.

In general, ESWL should only be performed if the urine is sterile and when there is no distal obstruction to minimise infective complication. Currently, prophylactic antibiotics should be considered only in high risk patients.


Conclusion

The current guidelines and practice patterns pertaining to stone surgery have evolved based on emerging clinical data. These recommendations in conjunction with patients’ individual risk factors and culture data should help guide ongoing practice patterns.


References

1. Wolf, J. S., Jr., Bennett, C.J., Dmochowski, R.R. et al. : Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol, 179:1379,2008.

2. Grabe, M., Bjerklund-Johansen, T.E., Botto, H. et al.: Guidelines on Urological infections. European Association of Urology:79,2010.

3. Lu, Y., Tianyong, F., Ping, H. et al.: Antibiotic prophylaxis for shock wave lithotripsy in patients with sterile urine before treatment may be unnecessary: a systematic review and meta-analysis. J Urol, 188:441,2012.

4. Sohn, D. W., Kim, S. W., Hong, C. G. et al.: Risk factors of infectious complication after ureteroscopic procedures of the upper urinary tract. J Infect Chemother, 2013

5. Segura, J. W., Preminger, G. M., Assimos, D. G. et al.: Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. J Urol, 151: 1648, 1994

6. Gravas, S., Montanari, E., Geavlete, P. et al.: Postoperative infection rates in low risk patients undergoing percutaneous nephrolithotomy with and without antibiotic prophylaxis: a matched case control study. J Urol, 188: 843, 2012

7. Mariappan, P., Loong, C. W.: Midstream urine culture and sensitivity test is a poor predictor of infected urine proximal to the obstructing ureteral stone or infected stones: a prospective clinical study. J Urol, 171: 2142, 2004


You can read more about Michael Wong by clicking this link

Categories: Updates, Other

19
February
2014

A Safer Way to Biopsy the Prostate

A Safer Way to Biopsy the Prostate

Jeremy Grummet is a Urological Surgeon with particular expertise in urological cancer. He has been instrumental in the introduction of transperineal prostate biopsy as an alternative to transrectal biopsy, to reduce infection rates after biopsy. Jeremy is conducting multiple clinical research projects on prostate biopsy and heads the Victorian Transperineal Biopsy Collaboration (VTBC) research group. In this article, Jeremy discusses the techniques and advantages of transperineal biopsy.


What’s wrong with the current standard method of prostate biopsy?

A biopsy is where a sample of tissue is taken for examination under a microscope, usually to determine if cancer is present. As you can see from the diagram below, the easiest way to access the prostate is via the rectum. That’s why we perform a rectal examination - so we can feel the back of the prostate for any suspicious lumps. Most prostate cancers are located towards the back of the prostate (peripheral zone), so a transrectal ultrasound-guided (TRUS) biopsy is a convenient way of sampling this area. Typically, at least 12 cores of tissue are taken during a TRUS biopsy.

TRUS biopsy

The other advantage of the TRUS biopsy is that it can be performed in just a few minutes by giving the patient intravenous sedation or using a local anaesthetic nerve block.

However, passing the needle of the biopsy gun through the wall of the rectum multiple times is problematic. As you’d expect from an organ that stores faeces, the rectum has a high concentration of bacteria. These bacteria don’t cause any problems as long as they stay in the rectum. However, passing the biopsy needle through the wall of the rectum allows these bacteria to access the prostate and its rich blood supply. This in turn can lead to a serious infection in the blood called septicaemia (sepsis). Septicaemia makes patients feel very unwell, requires hospitalization for intravenous antibiotic therapy, and can even be life-threatening.

This risk of sepsis in TRUS biopsy is well-recognised. It is therefore standard to use an antibiotic to help prevent such an infection. Unfortunately, the antibiotic doesn’t always work, so there is still a risk of sepsis, which has been measured at about 1-2%.

Today, there is the additional and growing problem of bacteria developing antibiotic resistance. This has been reported worldwide and was the subject of a major US Government report last year.

Our own research group, the Victorian Transperineal Biopsy Collaboration (VTBC), reviewed the scientific literature, finding that developing resistance is a particular problem for bacteria that live in the rectum, so that the antibiotics we would normally use, such as ciprofloxacin, can sometimes be rendered ineffective. This coincides with reports of increasing rates of TRUS biopsy sepsis even as high as 5%.

Our research has also found that, as a result of the above, some Australian and New Zealand urology practices have resorted to using big-gun broad-spectrum antibiotics on a regular basis to prevent TRUS biopsy sepsis. Whilst this may reduce sepsis for the individual patient, from a public health perspective, it is a step backwards, as widespread use of such antibiotics will lead to even more resistance. Unfortunately, we are already seeing this happening, with hospitals in Australia finding CRE (Carbapenem-Resistant Enterococci) in their wards.


What is transperineal biopsy, and why is it safer?

Fortunately, there is another approach to prostate biopsy which avoids perforation of the rectum altogether. Instead, the biopsy needle can be passed via the skin of the perineum. In men, the perineum is the part of the body between the scrotum and the anus.

TRUS biopsy

As shown in the diagram, the ultrasound probe is still passed into the rectum to provide an image of the prostate. But instead of the biopsy needle passing alongside the probe, it is passed through a grid, which itself is fixed against the probe outside the body. Prior to insertion of the ultrasound probe, the perineal skin is easily prepared in a sterile fashion, just as any other incision site is prepared before surgery to prevent wound infection. (Although worthwhile attempts have been made to sterilize the rectum, this has not been possible.)

Our group studied the experience of transperineal (TP) biopsy around the world and found that in over 6,600 patients, there were only 5 patients re-admitted to hospital for sepsis - a rate of just 0.076%, or less than 1 in a thousand. Furthermore, in our own published experience of 245 TP biopsies our rate of re-admission for infection was zero. (We have now performed over 400 TP biopsies, still without a single episode of infection.)

Based on the published scientific evidence to date then, it appears that TP biopsy is a safer option than TRUS biopsy due to its near-zero sepsis risk. It also gives the advantage of avoiding regular use of heavy-duty antibiotics, thereby avoiding promotion of resistant bacteria, now labelled by the US Government Center for Disease Control as a Serious Threat to population health worldwide. As a result, we now use TP biopsy routinely for all prostate biopsies.


Are there any downsides to the transperineal approach?

Looking at the diagram above, you would expect TP biopsy to be painful, which is why it is typically performed under a general anaesthetic (although methods of using local anaesthetic only have been reported). We routinely perform TP biopsy under GA. As a result, men experience no pain during the procedure, and very little afterwards, so that paracetamol is only required occasionally. Although a general anaesthetic is required, it is of a short duration only (less than 30 minutes) and is very safe.

Practitioners of TP biopsy initially reported a higher risk of acute urinary retention (unable to pass urine) with this approach. However, with further experience, and by deliberately avoiding the area around the urethra, this rate dropped so that it is now similar to the risk seen in TRUS biopsy (around 2%). Although a catheter has been used by some doctors, as shown in the diagram above, it is unnecessary.

Due to anecdotal experience, some urologists have been concerned that TP biopsy may lead to erectile dysfunction by damaging the erectile nerves or to more difficult surgery if cancer is found and the prostate needs to be removed. However, evidence to date, albeit scant, does not support either of these concerns.


Is it as good as TRUS at cancer detection?

According to the scientific literature, TP biopsy is at least equivalent to TRUS biopsy in its ability to detect cancer. Some research has also found improved detection of cancers at the front of the prostate (anterior). This may be due to the typically easy access TP biopsy provides to all areas of the prostate, particularly anteriorly. Conversely, it can often be difficult to reach the anterior prostate via TRUS biopsy, especially in large glands.


What other advantage might TP biopsy provide?

In TP biopsy, the ultrasound probe is stabilized by equipment that is fixed to the operating table. The grid through which the biopsy needle is passed is, in turn, stabilized against the ultrasound probe. This set-up permits accurate and reproducible biopsy needle placement.

In the past, TP biopsies were taken in a systematic fashion only, evenly sampling various areas of the prostate. Whilst this is still performed routinely, in addition we are now often performing targeted biopsies of suspicious lesions if found on a prostate MRI. The stable arrangement of TP biopsy therefore permits accurate targeting of such lesions, with the potential to further improve the accuracy of cancer detection.


You can read more about Jeremy Grummet by clicking this link

There is more information on transperineal biopsy on the AUA site.

And you can follow @JGrummet on Twitter.


Categories: Updates, Prostate Cancer, Prostate Surgery

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