Multicentre evaluation of magnetic resonance imaging supported transperineal prostate biopsy in biopsy-naïve men with suspicion of prostate cancer.

OBJECTIVES: To analyse the detection rates of primary magnetic resonance imaging (MRI)-fusion transperineal prostate biopsy using combined targeted and systematic core distribution in three tertiary referral centres. PATIENTS AND METHODS: In this multicentre, prospective outcome study, 807 consecutive biopsy-naïve patients underwent MRI-guided transperineal prostate biopsy, as the first diagnostic intervention, between 10/2012 and 05/2016. MRI was reported following the Prostate Imaging-Reporting and Data System (PI-RADS) criteria. In all, 236 patients had 18-24 systematic transperineal biopsies only, and 571 patients underwent additional targeted biopsies either by MRI-fusion or cognitive targeting if PI-RADS ≥3 lesions were present. Detection rates for any and Gleason score 7-10 cancer in targeted and overall biopsy were calculated and predictive values were calculated for different PI-RADS and PSA density (PSAD) groups. RESULTS: Cancer was detected in 68% of the patients (546/807) and Gleason score 7-10 cancer in 49% (392/807). The negative predictive value of 236 PI-RADS 1-2 MRI in combination with PSAD of <0.1 ng/mL/mL for Gleason score 7-10 was 0.91 (95% confidence interval ± 0.07, 8% of study population). In 418 patients with PI-RADS 4-5 lesions using targeted plus systematic biopsies, the cancer detection rate of Gleason score 7-10 was significantly higher at 71% vs 59% and 61% with either approach alone (P < 0.001). For 153 PI-RADS 3 lesions, the detection rate was 31% with no significant difference to systematic biopsies with 27% (P > 0.05). Limitations include variability of multiparametric MRI (mpMRI) reading and Gleason grading. CONCLUSION: MRI-based transperineal biopsy performed at high-volume tertiary care centres with a significant experience of prostate mpMRI and image-guided targeted biopsies yielded high detection rates of Gleason score 7-10 cancer. Prostate biopsies may not be needed for men with low PSAD and an unsuspicious MRI. In patients with high probability lesions, combined targeted and systematic biopsies are recommended.

Zero hospital admissions for infection after 577 transperineal prostate biopsies using single-dose cephazolin prophylaxis.

PURPOSE: To determine the rate of hospital admissions for infection after transperineal biopsy of prostate (TPB) with single-dose cephazolin prophylaxis using a prospective database. METHOD: Between April 2013 and February 2016, 577 patients undergoing TPB had 2 g of cephazolin given intravenously at induction of anaesthesia. Data collected from these patients included age, PSA, prostate volume, number of cores taken and post-operative complications. RESULTS: No patients were readmitted to hospital with infection post-TPB. Seven patients developed acute urinary retention, and one patient developed clinical prostatitis that was treated with oral antibiotics in the community. CONCLUSION: It is safe to use single-dose cephazolin only as antibiotic prophylaxis prior to TPB, negating the need for quinolones. This study supports Australia's current Therapeutic Guidelines recommendation for TPB prophylaxis and the existing evidence that sepsis post-TPB is a rare complication. Whether any antibiotic prophylaxis is needed at all for TPB is the subject of a future study.

Small-molecule induction of neural crest-like cells derived from human neural progenitors.

Neural crest (NC) cells are stem cells that are specified within the embryonic neuroectodermal epithelium and migrate to stereotyped peripheral sites for differentiation into many cell types. Several neurocristopathies involve a deficit of NC-derived cells, raising the possibility of stem cell therapy. In Hirschsprung's disease the distal bowel lacks an enteric nervous system caused by a failure of colonization by NC-derived cells. We have developed a robust method of producing migrating NC-like cells from human embryonic stem cell-derived neural progenitors using a coculture system of mouse embryonic fibroblasts. Significantly, subsequent exposure to Y27632, a small-molecule inhibitor of the Rho effectors ROCKI/II, dramatically increased the efficiency of differentiation into NC-like cells, identified by marker expression in vitro. NC-like cells derived by this method were able to migrate along NC pathways in avian embryos in ovo and within explants of murine bowel, and to differentiate into cells with neuronal and glial markers. This is the first study to report the use of a small molecule to induce cells with NC characteristics from embryonic stem cells that can migrate and generate neurons and support cells in complex tissue. Furthermore, this study demonstrates that small-molecule regulators of ROCKI/II signaling may be valuable tools for stem cell research aimed at treatment of neurocristopathies.

Transperineal vs. transrectal biopsy in MRI targeting.

Prostate biopsy is typically performed via either the transrectal or transperineal approach. MRI-targeted biopsy, whether using any of the three options of cognitive fusion, MRI-ultrasound fusion software, or in-bore MRI-guided biopsy, can also be performed via either transrectal or transperineal approaches. As an extension of traditional random prostate biopsy, the transrectal approach is far more commonly used for MRI-targeted biopsy due to its convenience. However, in the context of today's increasing multi-drug resistance of rectal flora, the transperineal approach is being used more often due to its lack of septic complications. In addition, only a first-generation cephalosporin, not a fluoroquinolone, is required as antibiotic prophylaxis. Evidence shows excellent detection rates of significant prostate cancer using magnetic resonance imaging (MRI)-targeted and/or systematic transperineal biopsy (TPB). However, there are no head-to-head studies comparing the different MRI-targeted methods within TPB. To provide truly patient-centred care, the biopsy technique using the safest method with the highest detection rate of significant cancer should be used. Depending on healthcare context and hospital resource utilization, MRI-targeted TPB is an excellent option and should be performed wherever available and feasible. Whilst building capacity for TPB in one's practice, the routine use of rectal culture swabs prior to any transrectal biopsies is strongly encouraged. Independent of biopsy route, the addition of systematic cores needs to be discussed with the patient weighing maximal detection of significant cancer against increased detection of insignificant lesions.

Penthrox alone versus Penthrox plus periprostatic infiltration of local analgesia for analgesia in transrectal ultrasound-guided prostate biopsy.

BACKGROUND: The objective of this study was to compare pain intensity in patients undergoing transrectal ultrasound (TRUS)-guided biopsy of the prostate with Penthrox alone compared with Penthrox plus periprostatic infiltration of local analgesia (PILA). METHOD: Seventy-two subjects participated in this study after receiving appropriate education. Forty-two patients self-administered inhaled Penthrox (3 mL methoxyflurane) alone for analgesia (Group A), followed by 30 patients who self-administered Penthrox and received PILA with 5 mL of 2% lignocaine. All subjects had TRUS biopsy performed. Immediately after the procedure, patients were asked to rate their pain intensity using a numerical verbal rating scale from 0 to 10. RESULTS: Baseline characteristics of the two groups were similar. Patients in Group B reported significantly lower post TRUS biopsy median pain intensity of 2 (1-3) compared with Group A subjects who reported a median post TRUS biopsy pain intensity of 3 (2-5) (P = 0.014). A total of 72 men underwent TRUS-guided biopsy. All patients indicated they would be happy to have another TRUS-guided prostate biopsy in the future. CONCLUSION: Our study shows that Penthrox plus PILA shows promise as an efficacious and easily tolerated analgesic technique for outpatient TRUS biopsy, keeping resource use to a minimum. Planning for a multi-centre, double-blind randomized control trial comparing Penthrox plus PILA with PILA alone is presently underway.