VISION: An Individual Patient Data Meta-analysis of Randomised Trials Comparing Magnetic Resonance Imaging Targeted Biopsy with Standard Transrectal Ultrasound Guided Biopsy in the Detection of Prostate Cancer.

BACKGROUND AND OBJECTIVE: The PRECISION and PRECISE trials compared magnetic resonance imaging targeted biopsy (MRI ± TB) with the standard transrectal ultrasound (TRUS) guided biopsy for the detection of clinically significant prostate cancer (csPCa). PRECISION demonstrated superiority of MRI ± TB over TRUS guided biopsy, while PRECISE demonstrated noninferiority. The VISION study is a planned individual patient data meta-analysis (IPDMA) comparing MRI ± TB with TRUS guided biopsy for csPCa diagnosis. METHODS: MEDLINE, EMBASE, Web of Science, Cochrane Central of Registered Trials, and ClinicalTrials.gov were searched on the November 12, 2023 for randomised controlled trials of biopsy-naïve patients with a clinical suspicion of prostate cancer undergoing MRI or standard TRUS. Studies were included if its participants with suspicious MRI underwent targeted biopsy alone and those with nonsuspicious lesion avoided biopsy. The primary outcome is the proportion of men diagnosed with csPCa (Gleason ≥3 + 4). KEY FINDINGS AND LIMITATIONS: Two studies, PRECISION and PRECISE (953 patients), were included in the IPDMA. In the MRI ± TB arm, 32.2% of patients avoided biopsy due to nonsuspicious MRI. MRI ± TB detected 8.7 percentage points (36.3% vs 27.6%; 95% confidence interval [CI] 2.8-14.6, p = 0.004) more csPCa than TRUS biopsy and 12.3 percentage points (9.6% vs 21.9%; 95% CI 7.8-16.9, p < 0.001) less clinically insignificant prostate cancer (cisPCa; Gleason 3 + 3). The overall risk of bias for the included studies were found to be low after assessment using the QUADAS-2, QUADAS-C, and ROB 2.0 tools. CONCLUSIONS AND CLINICAL IMPLICATIONS: The MRI ± TB pathway is superior to TRUS biopsy in detecting csPCa and avoiding the diagnosis of cisPCa. MRI should be included in the standard of care pathway for prostate cancer diagnosis.

Optimising prostate biopsies and imaging for the future-a review.

Conventionally, transrectal ultrasound guided prostate biopsy (TRUS-Bx) was the main technique used for the diagnosis of prostate cancer since it was first described in 1989 [1]. However, the PROMIS trial showed that this random, nontargeted approach could miss up to 18% of clinically significant cancer (csPCa) [2]. Furthermore, risk of sepsis post TRUS-Bx can be as high as 2.4% [3]. Understanding the demerits of TR-biopsy have led to the introduction of transperineal prostate biopsy (TP-Bx). The incorporation of mpMRI revolutionized prostate cancer diagnostics, allowing visualization of areas likely to harbor csPCa whilst permitting some men to avoid an immediate biopsy. Furthermore, the advent of prostate specific membrane antigen-positron emission tomography (PSMA-PET) is highly promising, because of its role in primary diagnosis of prostate cancer and its higher diagnostic accuracy over conventional imaging in detecting nodal and metastatic lesions. Our narrative review provides an overview on prostate biopsy techniques and an update on prostate imaging, with particular focus on PSMA-PET.

Quantification of Gleason Pattern 4 Metrics Identifies Pathologic Progression in Patients With Grade Group 2 Prostate Cancer on Active Surveillance.

BACKGROUND: During active surveillance (AS) for Grade Group (GG) 2 prostate cancer, pathologic progression to GG3 on surveillance biopsy is a trigger for intervention. However, this ratio of GP3:GP4, may be obscured by increases of relatively indolent disease. We aimed to explore changes in GP4 quantity during AS and propose alternative definitions for progression based on GP4 changes. DESIGN, SETTING, AND PARTICIPANTS: We assessed patients enrolled on AS between November 2014 and March 2020 with GG2 disease on diagnostic biopsy and subsequent surveillance biopsy approximately 1 year later. Outcome measures included change in overall %GP4 and total length GP4 (mm). RESULTS AND LIMITATIONS: 61 patients met the inclusion criteria, the median change in total length of GP4 and %GP4 was -0.12 mm (IQR -0.31, 0.09) and -2.5% (IQR -8.6, 0.0), respectively. Excluding the 35 patients with no evidence of GP4 on surveillance biopsy, median change in total GP4 length and %GP4 was 0.19 mm (IQR -0.04, 0.67) and 1.2% (IQR -1.6, 6.6), respectively. Three patients progressed to GG3 disease on surveillance biopsy, one of whom had only a small increase in %GP4. Conversely, an additional 2 patients who did not meet the criterion for GG3 had a large increase (> 1 mm) in total GP4 length. CONCLUSIONS: Presence of GG3 disease on surveillance biopsy as a trigger for treatment in men on AS is of questionable use alone; we suggest including other measures that do not depend on a ratio, such as an increase in total GP4 length.

Implementing Change Through an Outpatient Antibiotic Stewardship Program.

PURPOSE: We sought to implement a multi-pronged behavioral intervention to reduce and tailor antibiotic use for two common urologic outpatient procedures. MATERIALS AND METHODS: This study was a non-blinded intervention study that consisted of a pre-intervention phase (11/2018-1/2019), an intervention phase (1/2020-12/2020) in which a multi-pronged behavioral intervention was implemented, and a post-intervention phase (1/2021-3/2021). We examined antibiotic use for cystoscopy and transrectal prostate biopsy at three separate urologic outpatient clinics. A multi-pronged behavioral intervention consisted of formal physician education, modification of the electronic health order sets, clinic staff education, literature review, development and introduction of patient questionnaires, and individual audit feedback. The primary outcome was 30-day infections. Secondary outcomes were adherence to the recommended antibiotic protocols, questionnaire completion, and Escherichia coli outpatient antibiograms. RESULTS: A total of 2374 patients underwent 3047 cystoscopies and 547 patients underwent 559 prostate biopsies. The proportions of cystoscopy patients receiving antibiotic prophylaxis and prostate biopsy patients receiving augmented antibiotic prophylaxis decreased 33% and 35%, respectively. The odds of post-cystoscopy infection were not different between the pre-intervention and intervention phases and were lower in the post-intervention phase. The odds of post-biopsy infection were not changed between the pre-intervention and intervention or between the pre-intervention and post-intervention phases. CONCLUSIONS: Implementing a multi-pronged behavioral intervention reduced and tailored antibiotic use without an increase in 30-day infections. These findings suggest that outpatient antibiotic stewardship and facilitating rapid adoption of guidelines can be accomplished via this approach.

Targeted Prostate Biopsy: How, When, and Why? A Systematic Review.

OBJECTIVE: Prostate cancer, the second most diagnosed cancer among men, requires precise diagnostic techniques to ensure effective treatment. This review explores the technological advancements, optimal application conditions, and benefits of targeted prostate biopsies facilitated by multiparametric magnetic resonance imaging (mpMRI). METHODS: A systematic literature review was conducted to compare traditional 12-core systematic biopsies guided by transrectal ultrasound with targeted biopsy techniques using mpMRI. We searched electronic databases including PubMed, Scopus, and Web of Science from January 2015 to December 2024 using keywords such as "targeted prostate biopsy", "fusion prostate biopsy", "cognitive prostate biopsy", "MRI-guided biopsy", and "transrectal ultrasound prostate biopsy". Studies comparing various biopsy methods were included, and data extraction focused on study characteristics, patient demographics, biopsy techniques, diagnostic outcomes, and complications. CONCLUSION: mpMRI-guided targeted biopsies enhance the detection of clinically significant prostate cancer while reducing unnecessary biopsies and the detection of insignificant cancers. These targeted approaches preserve or improve diagnostic accuracy and patient outcomes, minimizing the risks associated with overdiagnosis and overtreatment. By utilizing mpMRI, targeted biopsies allow for precise targeting of suspicious regions within the prostate, providing a cost-effective method that reduces the number of biopsies performed. This review highlights the importance of integrating advanced imaging techniques into prostate cancer diagnosis to improve patient outcomes and quality of life.

A Propensity Score-matched Comparison of Micro-ultrasound-guided Transrectal and Magnetic Resonance Imaging/Transrectal Ultrasound Fusion-guided Transperineal Prostate Biopsies for Detection of Clinically Significant Prostate Cancer.

Background and objective: High-resolution micro-ultrasound (microUS) is an advanced imaging tool. Our objective was to determine whether systematic microUS use for transrectal biopsy (TRBx) improves the detection rate for clinically significant prostate cancer (csPCa) in comparison to transperineal biopsy (TPBx) performed with magnetic resonance imaging (MRI)/conventional transrectal ultrasound (TRUS) fusion software. Methods: We retrospectively analyzed data for men who underwent prostate biopsies, including those on active surveillance (AS). TRBx was performed under microUS guidance, while MRI/TRUS fusion was consistently used to guide TPBx. Patients were matched according to propensity score matching (PSM). The primary endpoint was comparison of the csPCa detection rate with the two approaches. Secondary endpoints included predictors of csPCa (International Society of Urological Pathology grade group ≥2, assessed via multivariable logistic regression) and complication rates. Key findings and limitations: Overall, 1423 patients were enrolled. After applying PSM we identified an analytical cohort of 1094 men, 582 in the TRBx group and 512 in the TPBx group. There was no significant difference in the csPCa detection rate between the TRBx (45%) and TPBx (51%) groups (p = 0.07). Complications occurred in nine of 1094 patients (1%). On adjusted multivariable analysis, TPBx had a similar csPCa detection rate to TRBx (adjusted odds ratio [aOR] 1.26;p = 0.09). Predictors of csPCa detection were a positive family history (aOR 1.68; 95% confidence interval [CI] 1.20-2.35; p = 0.002); age (aOR 1.04, 95% CI 1.02-1.06; p < 0.001); positive digital rectal examination (aOR 2.35, 95% CI 1.70-3.25; p < 0.001); prostate-specific antigen density ≥0.15 ng/ml/cm3 (aOR 3.23, 95% CI 2.47-4.23; p < 0.001); and a Prostate Imaging-Reporting and Data System score ≥3 (aOR 2.46; 95% CI 1.83-3.32; p < 0.001). Limitations include the retrospective nature of the study, the risk of underestimating the complication rate, and the heterogeneity of biopsy indications. Conclusions and clinical implications: TRBx using microUS alone showed a comparable csPCa detection rate to TPBx guided by MRI/TRUS fusion software. Given the better visualization and real-time detection of suspicious zones with microUS, the potential for improvement in the csPCa detection rate with greater integration of microUS in the TPBx setting warrants further investigation. Patient summary: We compared the ability of two different prostate biopsy approaches to detect clinically significant prostate cancer. We found that transrectal biopsy guided by micro-ultrasound had similar detection rates to transperineal biopsy guided by a combination of magnetic resonance imaging and conventional ultrasound. More research is needed to confirm the potential of micro-ultrasound for transperineal biopsy.

Transrectal versus transperineal prostate fusion biopsy: a pair-matched analysis to evaluate accuracy and complications.

PURPOSE: To evaluate biopsy-related complications and detection rates of any PCa and clinically significant PCa (csPCa, intended as grade group ≥ 2) between MRI-targeted TP fusion biopsies (TPBx) and TR ones (TRBx). METHODS: We performed a multicentric study on 4841 patients who underwent fusion biopsy between 2016 and 2023. A case-control matching was performed to find comparable cohorts of 646 TPBx and 646 TRBx. Mean T test and Pearson chi-square tests were used to compare continuous and categorical variables. RESULTS: Baseline characteristics were comparable between the cohorts, except for target location with a higher rate of anterior lesions in TPBx group. Complications were rare and no difference was found between the groups, with similar rates of infections after TRBx and TPBx (N = 5 (0.8%) vs N = 2 (0.3%), p 0.45). All patients in TRBx and 90.1% in TPBx group received antibiotic prophylaxis. A higher csPCa detection rate was found in TPBx over the group (50.5% vs 36.2%, p < 0.001). On average, positive targeted cores were increased in TPBx group, for any PCa (1.6 vs 1.4, p 0.04) and csPCa (1.0 vs 0.8, p 0.02). Among the limitations of study, we acknowledge the retrospective design and the possible under-reporting of complications. CONCLUSIONS: MRI-targeted fusion TPBx achieves a significantly higher csPCa detection than TRBx, with a diagnostic advantage for apical and anterior lesions. No significant differences were found in terms of complications that were rare in both groups, considering a widespread adoption of antibiotic prophylaxis.

Preventing Infections After Prostate Biopsy: Prophylactic Antibiotics, Prebiopsy Rectal Culture, and Biopsy Approach.

Prostate biopsies are commonly performed for the early detection of prostate cancer and yet are associated with risks of life-threatening infections. Drug-resistant strains of Escherichia coli are the most common etiologic agents. Multiple maneuvers can reduce the risk of postbiopsy infections and sepsis during transrectal prostate biopsy including periprocedural empiric or targeted prophylactic antibiotics (based on previous rectal culture) and prebiopsy rectal cleansing with a povidone-iodine solution. The transperineal approach is associated with a very low risk of infection without requiring antibiotic prophylaxis.

Comparison of the incidence of clinically significant prostate cancer in patients with isolated peripheral versus transitional zone PIRADS 3 lesions.

INTRODUCTION: We sought to investigate the association between isolated PIRADS 3 lesions of the transitional zone (TZ) versus the peripheral zone (PZ) and the incidence of clinically significant prostate cancer (csPCa) on systematic and targeted prostate biopsy (SB, TB). METHODS: We retrospectively reviewed our tertiary institutional database of patients who underwent mpMRI-fusion followed by TB + SB between 2016 and 2021. We compared the incidence of csPCa (Gleason Grade Group ⩾ 2) in patients with solitary TZ-only PIRADS 3 and PZ-only PIRADS 3 on SB and TB. We excluded patients with (1)known PCa, (2)PIRADS 4-5 and/or (3)lesions in both TZ and PZ. T-tests, Chi-square tests, were conducted to compare between the groups. RESULTS: Of 1913 patients, we identified 110 with PZ-only and 38 with TZ-only PIRADS 3 lesions. 73 patients in PZ-only and 19 in TZ-only met inclusion criteria. No statistically significant differences were observed between PZ and TZ groups in terms of age, median prostate-specific antigen (PSA), prostate volume, median PSA-density, or median number of targeted cores obtained, all with p > 0.05.On SB, the incidence of csPCA was higher in patients with PZ rather than TZ PIRADS-3 lesions (10/73 vs 1/19, p = 0.28). Similarly, csPCA was more common in TB of PZ versus TZ PIRADS 3 lesions (7/73 vs 0/19, p = 0.33). Based on these results, the positive predictive values of PIRADS3 as a marker of csPCA were 5.3% and 0% for TZ lesions on SB versus TB, respectively, compared to 17.7% and 9.6% in the PZ. CONCLUSIONS: PIRADS 3 lesions are rarely associated with csPCA on SB and TB, particularly when located in the TZ, which is an important factor to consider when deciding on a biopsy in patients with isolated TZ lesions.

Preventing Infectious Complications Following Prostate Biopsy: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials of Alternative Approaches to Transrectal Biopsy with Empirical Antibiotic Prophylaxis Therapy.

BACKGROUND AND OBJECTIVE: Prostate biopsy, conducted frequently through the transrectal route, is associated with significant risks of infectious complications. This study aimed to compare the efficacy of various strategies to reduce these complications, using a network meta-analysis approach. METHODS: Our study included randomized controlled trials (RCTs) identified from PubMed/MEDLINE, Embase, and the Cochrane database as of March 1, 2024. We included studies that involved adults undergoing transrectal or transperineal prostate biopsy with either standard empirical antibiotic prophylaxis or alternative interventions. The primary outcomes were assessment of sepsis, fever, urinary tract infections (UTIs), and readmissions. The study was registered with PROSPERO (CRD42024532225). KEY FINDINGS AND LIMITATIONS: Our search yielded 28 RCTs eligible for analysis, encompassing a total of 10 179 participants. Rectal cleansing had the highest rankogram score to reduce infectious complications such as sepsis (odds ratio 0.40, 95% confidence interval [0.28-0.58]; rankogram, p score = 0.917), followed by transperineal biopsy (p score = 0.496). The overall analysis also highlighted a lower incidence of UTIs and readmissions with this method. Heterogeneity among studies was minimal (I2 < 50% for all outcomes). CONCLUSIONS AND CLINICAL IMPLICATIONS: Rectal cleansing might be the most effective strategy to reduce infectious complications following transrectal prostate biopsy and could be more effective than rectal culture-based antibiotic prophylaxis and transperineal biopsy. Given the indirect nature of our comparisons, further RCTs are needed to determine the safest approach for prostate biopsy, particularly between transperineal biopsy and transrectal biopsy with rectal cleansing or rectal culture-based antibiotic prophylaxis. PATIENT SUMMARY: In this review, we analyzed different techniques to reduce infectious complications after a prostate biopsy. We found that rectal cleansing prior to performing a transrectal prostate biopsy reduced infectious complications and might be the most effective strategy. We conclude that either transperineal or transrectal prostate biopsies are acceptable approaches, albeit with rectal cleansing or rectal culture-based antibiotic prophylaxis, respectively.

Associations Between Prostate Magnetic Resonance Imaging, Genomic Testing, and Treatment for Localized Prostate Cancer.

INTRODUCTION: Although prostate MRI and tissue-based gene expression (genomic) tests improve staging and estimates of prostate cancer prognosis, their association with the intensity of treatment patients receive is not well understood. METHODS: We performed a retrospective cohort study of Medicare beneficiaries diagnosed with clinically localized prostate cancer in 2013 through 2017 in the Surveillance, Epidemiology, and End Results database. The primary study outcome was the receipt of treatment intensification in the first 12 months after diagnosis (defined as the addition of androgen deprivation therapy among patients receiving radiation or pelvic lymphadenectomy among those undergoing radical prostatectomy). We assessed associations between the receipt of prostate MRI and genomic testing and treatment intensification, adjusting for clinical and sociodemographic factors and further stratifying the analyses by risk status. RESULTS: We identified 37,064 patients with clinically localized prostate cancer, including 6,398, 22,011, and 5976 with low, intermediate, and high D'Amico-risk disease, respectively. Among all treated patients, receipt of prostate MRI was associated with increased odds of treatment intensification (odds ratio 1.76, 95% CI 1.65-1.88, P < .001). In contrast, genomic testing was not significantly associated. Among treated patients with high-risk disease, genomic testing was associated with decreased odds of intensified treatment (odds ratio 0.59, 95% CI 0.35-1.00, P = .05). CONCLUSIONS: Prostate MRI was associated with intensified treatment across risk strata, while genomic testing was associated with lower intensity of treatment among high-risk disease. Additional study is needed to determine whether use of imaging and risk stratification tools leads to improved long-term patient outcomes.

Saline cleansing can prevent infective complications after transrectal prostate biopsy: A randomized prospective study.

PURPOSE: To discern whether reduced infection rates were attributed to antiseptic solutions or mechanical rectal irrigation. PATIENTS AND METHODS: After receiving ethical approval, the study included patients who underwent transrectal prostate biopsy due to elevated PSA or abnormal digital rectal examination findings, and prostate cancer under active surveillance, at Tepecik Training and Research Hospital between April 2022 and June 2023. Standard antibiotic prophylaxis was administered. Patients were randomized into three equal groups according to the rectal irrigation strategy. RESULTS: Overall complications occurred in 4%. Despite distinct cleaning agents, there was no significant difference in infection rates (p = 0.780) or fever incidence (p = 0.776). Pathological analyses revealed comparable outcomes (p = 0.764). CONCLUSION: The study challenges the prevailing belief that antiseptic solutions are indispensable for infection prevention, as saline demonstrated similar efficacy. Limitations include data gaps from potential external hospital visits and absent rectal microorganism swab culture. While TRUS-PB remains the gold standard, this study suggests that mechanically cleansing the rectal mucosa with saline-a cost-effective, side-effect-free alternative-may be a viable infection prevention method, particularly beneficial for patients with antiseptic allergies. The findings prompt a reconsideration of the necessity of antiseptic solutions in TRUS-PB, offering an alternative approach to mitigate infectious complications.

Biparametric vs. Multiparametric MRI in the Detection of Cancer in Transperineal Targeted-Biopsy-Proven Peripheral Prostate Cancer Lesions Classified as PI-RADS Score 3 or 3+1: The Added Value of ADC Quantification.

BACKGROUND: Biparametric MRI (bpMRI) has an important role in the diagnosis of prostate cancer (PCa), by reducing the cost and duration of the procedure and adverse reactions. We assess the additional benefit of the ADC map in detecting prostate cancer (PCa). Additionally, we examine whether the ADC value correlates with the presence of clinically significant tumors (csPCa). METHODS: 104 peripheral lesions classified as PI-RADS v2.1 score 3 or 3+1 at the mpMRI underwent transperineal MRI/US fusion-guided targeted biopsy. RESULTS: The lesions were classified as PI-RADS 3 or 3+1; at histopathology, 30 were adenocarcinomas, 21 of which were classified as csPCa. The ADC threshold that maximized the Youden index in order to predict the presence of a tumor was 1103 (95% CI (990, 1243)), with a sensitivity of 0.8 and a specificity of 0.59; both values were greater than those found using the contrast medium, which were 0.5 and 0.54, respectively. Similar results were also found with csPCa, where the optimal ADC threshold was 1096 (95% CI (988, 1096)), with a sensitivity of 0.86 and specificity of 0.59, compared to 0.49 and 0.59 observed in the mpMRI. CONCLUSIONS: Our study confirms the possible use of a quantitative parameter (ADC value) in the risk stratification of csPCa, by reducing the number of biopsies and, therefore, the number of unwarranted diagnoses of PCa and the risk of overtreatment.

Cognitive Targeted Prostate Biopsy Alone for Diagnosing Clinically Significant Prostate Cancer in Selected Biopsy-Naïve Patients: Results from a Retrospective Pilot Study.

(1) Background: To identify a particular setting of biopsy-naïve patients in which it would be reasonable to offer only cognitive targeted prostate biopsy (PBx) with a transrectal approach. (2) Methods: We designed an observational retrospective pilot study. Patients with a prostatic specific antigen (PSA) level > 10 ng/mL, either a normal or suspicious digital rectal examination (DRE), and a lesion with a PI-RADS score ≥ 4 in the postero-medial or postero-lateral peripheral zone were included. All patients underwent a transrectal PBx, including both systematic and targeted samples. The detection rate of clinically significant prostate cancer (csPCa) (Gleason Score ≥ 7) was chosen as the primary outcome. We described the detection rate of csPCa in systematic PBx, targeted PBx, and overall PBx. (3) A total of 92 patients were included. Prostate cancer was detected in 84 patients (91.30%) with combined biopsies. A csPCa was diagnosed in all positive cases (100%) with combined biopsies. Systematic PBxs were positive in 80 patients (86.96%), while targeted PBxs were positive in 84 men (91.30%). Targeted PBx alone would have allowed the diagnosis of csPCa in all positive cases; systematic PBx alone would have missed the diagnosis of 8/84 (9.52%) csPCa cases (4 negative patients and 4 not csPCa) (p = 0.011). (4) Conclusions: Cognitive targeted PBx with a transrectal approach could be offered alone to diagnose csPCa in biopsy-naïve patients with PSA ≥ 10 ng/mL, either normal or suspicious DRE, and a lesion with PI-RADS score ≥ 4 in the postero-medial or postero-lateral peripheral zone.

Precision in prostate cancer detection: integrating prostate-specific antigen density (PSAD) and the Prostate Imaging Reporting and Data System (PI-RADS) to provide additional risk stratification for a more accurate diagnostic decision.

PURPOSE: This study focuses on integrating prostate-specific antigen density (PSAD) and Prostate Imaging Reporting and Data System (PI-RADS) for enhanced risk stratification in biopsy-naïve patients. METHODS: A prospective study was conducted on 339 patients with suspected prostate cancer, utilizing PSAD and PI-RADS in combination. Logistic regression models were employed, and receiver operating characteristic (ROC) analysis performed to evaluate predictive performance. The patient cohort underwent multiparametric MRI, targeted biopsy, and systematic biopsy. RESULTS: When patients were stratified into four PSAD risk groups, the rate of clinically significant prostate cancer (csPCa) increased significantly with higher PSAD levels. Logistic regression confirmed the independent contribution of PI-RADS and PSAD, highlighting their role in the prediction of csPCa. Combined models showed superior performance, as evidenced by the area under the curve (AUC) for PI-RADS category and PSAD (0.756), which exceeded that of the individual predictors (PSA AUC, 0.627, PI-RADS AUC 0.689, PSAD AUC 0.708). CONCLUSION: This study concludes that combining PSAD and PI-RADS improves diagnostic accuracy and predictive value for csPCa in biopsy-naïve men, resulting in a promising strategy to provide additional risk stratification for more accurate diagnostic decision in biopsy-naïve patients, especially in the PI-RADS 3 group.

Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted Prostate Biopsy: A Systematic Review and Meta-analysis of Prospective Studies.

BACKGROUND AND OBJECTIVE: The benefits of the detection of clinically significant prostate cancer (csPCa) and safety of magnetic resonance imaging (MRI)-targeted transperineal (TP) prostate biopsy (TP-Tbx) versus transrectal (TR) approaches are still a matter of debate. This review aims to compare the efficacy and safety of TP-Tbx and MRI-targeted TR biopsy (TR-Tbx). METHODS: A systematic literature search was performed in PubMed/Medline, Scopus, and Web of Science to identify records of prospective randomized controlled trials (RCTs) comparing TP-Tbx and TR-Tbx published until May 2024. The primary outcomes included detection rates of csPCa (International Society of Urological Pathology [ISUP] ≥2) and rates of complications. KEY FINDINGS AND LIMITATIONS: Three RCTs (PREVENT, ProBE-PC, and PERFECT) met the inclusion criteria. The TR technique was commonly administered with antibiotic prophylaxis to mitigate infection risks or after a rectal swab. No difference was found between TP-Tbx and TR-Tbx in terms of either csPCa (odds ratio [OR] 0.9, 95% confidence interval [CI]: 0.7-1.1) or ISUP 1 prostate cancer (PCa; OR 1.1, 95% CI: 0.8-1.4) detection. Postprocedural infection (OR 0.8, 95% CI: 0.4-1.8), sepsis (OR 0.6, 95% CI: 0.1-4.5), and urinary retention rates (OR 0.5, 95% CI: 0.1-1.6) were similar. Pain during the TP approach was slightly higher than during the TR approach, but after 7 d of follow-up, the differences between the two approaches were minimal. Variations in biopsy numbers per patient, patient selection, use of 5-alpha reductase inhibitors, needle sizes, TP techniques, and pain scores (reported in only one RCT), along with the multicenter nature of RCTs, limit the study. CONCLUSIONS AND CLINICAL IMPLICATIONS: TP-Tbx and TR-Tbx show similar results in detecting PCa, with comparable rates of infections, urinary retention, and effectiveness in managing biopsy-associated pain. TP-Tbx can safely omit antibiotics without increasing infection risk, unlike TR-Tbx. The tendency to exclude from practice TR-Tbx with prophylactic antibiotics due to infection concerns could be moderated; however, the directionality of some key outcomes, as infections and sepsis, favor the TP approach despite a lack of statistical significance. PATIENT SUMMARY: There were no significant differences in the prostate biopsy approaches (transperineal [TP] vs transrectal [TR]) for prostate cancer detection and complications. However, the MRI-targeted TP prostate biopsy approach may be advantageous as it can be performed safely without antibiotics, potentially reducing antibiotic resistance.

Association Between the Decipher Genomic Classifier and Prostate Cancer Outcome in the Real-world Setting.

BACKGROUND AND OBJECTIVE: Although the prognostic significance of the Decipher prostate cancer genomic classifier (GC) has been established largely from analyses of archival tissue, less is known about the associations between the results of Decipher testing and oncologic outcomes among patients receiving contemporaneous testing and treatment in the real-world practice setting. Our objective was to assess the associations between the Decipher GC and risks of metastasis and biochemical recurrence (BCR) following prostate biopsy and radical prostatectomy (RP) among patients tested and treated in the real-world setting. METHODS: A retrospective cohort study was conducted using a novel longitudinal linkage of transcriptomic data from the Decipher GC and real-world clinical data (RWD) aggregated from insurance claims, pharmacy records, and electronic health record data across payors and sites of care. Kaplan-Meier and Cox proportional hazards regressions were used to examine the associations between the GC and study outcomes, adjusting for clinical and pathologic factors. KEY FINDINGS AND LIMITATIONS: Metastasis from prostate cancer and BCR after radical prostatectomy, Decipher GC continuous score, and risk categories were evaluated. We identified 58 935 participants who underwent Decipher testing, including 33 379 on a biopsy specimen and 25 556 on an RP specimen. The median age was 67 yr (interquartile range [IQR] 62-72) at biopsy testing and 65 yr (IQR 59-69) at RP. The median GC score was 0.43 (IQR 0.27-0.66) among biopsy-tested patients and 0.54 (0.32-0.79) among RP-tested patients. The GC was independently associated with the risk of metastasis among biopsy-tested (hazard ratio [HR] per 0.1 unit increase in GC 1.21 [95% confidence interval {CI} 1.16-1.27], p < 0.001) and RP-tested (HR 1.20 [95% CI 1.17-1.24], p < 0.001) patients after adjusting for baseline clinical and pathologic risk factors. In addition, the GC was associated with the risk of BCR among RP-tested patients (HR 1.12 [95% CI 1.10-1.14], p < 0.001) in models adjusted for age and Cancer of the Prostate Risk Assessment postsurgical score. CONCLUSIONS AND CLINICAL IMPLICATIONS: This real-world study of a novel transcriptomic linkage conducted at a national scale supports the external prognostic validity of the Decipher GC among patients managed in contemporary practice. PATIENT SUMMARY: This study looked at the use of the Decipher genomic classifier, a test used to help understand the aggressiveness of a patient's prostate cancer. Looking at the results of 58 935 participants who underwent testing, we found that the Decipher test helped estimate the risk of cancer recurrence and metastasis.

Perioperative alpha blockers in voiding dysfunction secondary to prostate biopsy: A meta-analysis.

Introduction and Objectives: Voiding dysfunction remains a common side effect postprostate biopsy leading to significant morbidity. Alpha blockers have emerged as a potential therapeutic option to mitigate this risk, with various centres already incorporating its use in practice. Despite this, the literature regarding its efficacy remains inconclusive. Hence, a systematic review was performed to quantify the effect of perioperative alpha blockers on prostate biopsy-related voiding function. Methods: A systematic search in MEDLINE, Embase and PubMed between January 1989 and July 2023 was performed to identify relevant articles. Two independent reviewers independently screened abstracts, full texts and performed data extraction. Data including International Prostate Symptom Scores (IPSS), voiding flow rates (Qmax), postvoid residuals (PVR), rates of acute urinary retention (AUR) and quality of life (QoL) scores were extracted. Results were combined in an inverse variance random effects meta-analysis. Results: A total 808 patients from six randomised controlled trials (RCTs) comparing alpha blockers to controls were included. All articles excluded patients with pre-existing voiding dysfunction. Pooled outcomes demonstrated statistically significant differences favouring alpha blocker usage in all objective and subjective measures including IPSS (mean difference 4.21, 95% confidence interval [CI] 2.58-5.84, p < 0.00001), PVR (mean difference 20.41 mL, 95% CI 3.44-37.39, p = 0.02), Qmax (mean difference 3.07 mL/s, 95% CI 2.55-3.59, p < 0.00001), QoL (weighted-mean difference 0.82, CI 0.17-1.48, p = 0.01) as well as overall risk of AUR (odds ratio 0.22, CI 0.09-0.55, p = 0.001). There was variable heterogeneity (I 2 = 0-86%) between outcomes. Conclusions: This review highlights the potential role of alpha blockers in improving urinary function and reducing adverse voiding outcomes postprostate biopsy. The standard practice of incorporating the usage of perioperative alpha blockers may be considered to reduce the morbidity of voiding complications secondary to prostate biopsy.

Fluoroquinolone resistance and clinical characteristics of acute bacterial prostatitis in Japan: A multicenter study by the Japanese research group for urinary tract infection.

OBJECTIVE: This multicenter study aimed to analyze the risk factors for fluoroquinolone (FQ) resistance and to clarify the clinical characteristics of acute bacterial prostatitis (ABP) in Japan. METHODS: A total of 124 patients clinically diagnosed with ABP at 13 medical institutions participating in the Japanese Research Group for Urinary Tract Infection between January and December 2017 were retrospectively reviewed. RESULTS: Of the 124 patients included in this study, 37 were outpatients, and 87 were inpatients. The main underlying medical conditions before the onset of ABP were severe dysuria, urinary retention, transurethral manipulation, indwelling urinary catheter, and transrectal prostate biopsy (TRBx). The main symptoms were fever (≥37.5 °C), prostate tenderness, dysuria, micturition pain, urinary retention, and macrohematuria. Bacteremia was observed in 14 patients. Prostatic abscess was observed in three patients. Escherichia coli was the predominant organism, accounting for 48 % (51/106). FQ-resistant E. coli was detected in 33 % (17/51), and extended-spectrum beta-lactamase-producing E. coli in 12 % (6/51). TRBx (odds ratio [OR] = 48.60, 95 % confidence interval [CI]: 5.49-430.00, p < 0.001) and inpatient status (OR = 29.00, 95 % CI: 1.95-430.00, p = 0.014) were risk factors for the detection of FQ-resistant bacteria. CONCLUSIONS: The detection rate of FQ-resistant bacteria was significantly higher with TRBx ABP and inpatient status. These findings have important implications for the management of ABP and antimicrobial treatment, especially for TRBx ABP, which should be considered a separate category.

Urine biomarkers can predict prostate cancer and PI-RADS score prior to biopsy.

Prostate-Specific Antigen (PSA) based screening of prostate cancer (PCa) needs refinement. The aim of this study was the identification of urinary biomarkers to predict the Prostate Imaging-Reporting and Data System (PI-RADS) score and the presence of PCa prior to prostate biopsy. Urine samples from patients with elevated PSA were collected prior to prostate biopsy (cohort = 99). The re-analysis of mass spectrometry data from 45 samples was performed to identify urinary biomarkers to predict the PI-RADS score and the presence of PCa. The most promising candidates, i.e. SPARC-like protein 1 (SPARCL1), Lymphatic vessel endothelial hyaluronan receptor 1 (LYVE1), Alpha-1-microglobulin/bikunin precursor (AMBP), keratin 13 (KRT13), cluster of differentiation 99 (CD99) and hornerin (HRNR), were quantified by ELISA and validated in an independent cohort of 54 samples. Various biomarker combinations showed the ability to predict the PI-RADS score (AUC = 0.79). In combination with the PI-RADS score, the biomarkers improve the detection of prostate carcinoma-free men (AUC = 0.89) and of those with clinically significant PCa (AUC = 0.93). We have uncovered the potential of urinary biomarkers for a test that allows a more stringent prioritization of mpMRI use and improves the decision criteria for prostate biopsy, minimizing patient burden by decreasing the number of unnecessary prostate biopsies.