ABSTRACT
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.
ABSTRACT
The management of high-risk prostate cancer (PCa) presents a significant clinical challenge, often necessitating treatment intensification due to the potential presence of micrometastases. While radical prostatectomy (RP) constitutes one of the primary treatment modalities, the integration of neoadjuvant and adjuvant therapies suggests a paradigm shift towards more aggressive treatment strategies, also guided by new imaging modalities like positron emission tomography using prostate-specific membrane antigen (PSMA-PET). Despite the benefits, treatment intensification raises concerns regarding increased side effects. This review synthesizes the latest evidence on perioperative treatment intensification and de-escalation for high-risk localized and locally advanced PCa patients eligible for surgery. Through a non-systematic literature review conducted via PubMed, Scopus, Web of Science, and ClinicalTrials.gov, we explored various dimensions of perioperative treatments, including neoadjuvant systemic therapies, adjuvant therapies, and the role of novel diagnostic technologies. Emerging evidence provides more support for neoadjuvant systemic therapies. Preliminary results from studies suggest the potential for treatments traditionally reserved for metastatic PCa to show apparent benefit in a non-metastatic setting. The role of adjuvant treatments remains debated, particularly the use of androgen deprivation therapy (ADT) and adjuvant radiotherapy in patients at higher risk of biochemical recurrence. The potential role of radio-guided PSMA lymph node dissection emerges as a cutting-edge approach, offering a targeted method for eradicating disease with greater precision. Innovations such as artificial intelligence and machine learning are potential game-changers, offering new avenues for personalized treatment and improved prognostication. The intensification of surgical treatment in high-risk PCa patients is a dynamic and evolving field, underscored by the integration of traditional and novel therapeutic approaches. As evidence continues to emerge, these strategies will refine patient selection, enhance treatment efficacy, and mitigate the risk of progression, although with an attentive consideration of the associated side effects.