It is time to abandon transrectal prostate biopsy for perineal biopsy. Con Argument

Transcription

1 It is time to abandon transrectal prostate biopsy for perineal biopsy Con Argument Erik P. Castle M.D., F.A.C.S. Professor of Urology Mayo Clinic Department of Urology Phoenix, AZ

2 None Financial Disclosures

3 Risk of hospitalization due to post-biopsy sepsis following transrectal prostate biopsy is: -A. 0.5% -B. 1-7% -C. 5-10% -D % Audience Questions

4 Introduction Ultimately depends on what we are talking about: -Cancer detection rate -Infection risk -In this era of MRI imaging and targeting -Cost -Convenience

5 Cancer Detection Rate Transperineal biopsy vs transrectal Overall equal detection rates Ease of detecting anterior tumors with perineal approach Role of MRI cognitive vs. fusion

6 Cancer Detection Rate Hara et al. Urology patients with PSA 4-20 ng/ml - randomized - Cancer detection rate 42.1% with transperineal approach vs 48.3% with transrectal approach (p=0.323) - No difference in complication rates Even in post-prostatectomy specimens, finding correlated with TP and TR biopsies with anterior tumors more liekly to be identified by the perineal approach

7 Infection risk Transperineal biopsy is clearly superior in minimizing risk of biopsy related sepsis Hospital admission risks within 30 days significantly less with transperineal <1% Overall about 1 6.9% risk of significant biopsy related infections with transrectal biopsy

8 Infection risk

9

10 Era of MRI imaging Incorporation of MRI for prostate cancer detection, biopsy targeting seen in guidelines and recommendations Primarily for the patient with previously negative prostate biopsy but seeing expanded use MRI mostly used with transrectal due to ease of use and available technology

11 MRI advantages: Era of MRI imaging -Identification of clinically significant cancers -Identification of anteriorly located tumors -Possible avoidance of clinically insignificant cancers MRI disadvantages -Standardization? Endorectal coil vs other methods -Experienced radiologists needed

12 Cost Depends on how the biopsy is performed What kind of anesthesia is used How many cores are taken during the biopsy Cost of the procedure vs. cost of complications

13 Compared: -TRUS -Sedation TRUS -Gen Anes TP -Sedation Fusion Biopsy -Sedation in-bore MRI biopsy

14 Compared: -TRUS -Sedation TRUS - x 1.9 (90%) -Gen Anes TP - x 2.5 (153%) -Sedation Fusion Biopsy - x 2.5 (150%) -Sedation in-bore MRI biopsy x2.2 (125%)

15 Convenience Most transrectal biopsies can be performed in an office setting under local anesthesia Most transperineal biopsies performed with general anesthetic and/or in the operating room Risk of post biopsy retention higher with transperineal -Prostate volume risk -Ratio of transition zone enlargement to peripheral zone Logistics and available technology

16 Summary Transperineal clearly has lower rate of infection risk Transrectal is easier for most urologists currently and possibly for patients May need to tailor which technique to use based on patient characteristics: - Risk of infection - Risk of retention

17 Conventional wisdom Are we going to completely abandon transrectal prostate biopsy? - Of course not! Should we consider increased application of transperineal prostate biopsy? - Yes

18 Risk of hospitalization due to post-biopsy sepsis following transrectal prostate biopsy is: -A. 0.5% -B. 1-7% -C. 5-10% -D % Audience Questions

19 Risk of hospitalization due to post-biopsy sepsis following transrectal prostate biopsy is: -A. 0.5% -B. 1-7% -C. 5-10% -D % Audience Questions