Osama Zaytoun

Emergence of fluoroquinolone-resistant Escherichia coli as cause of postprostate biopsy infection: implications for prophylaxis and treatment.

OBJECTIVES To report the sensitivity and resistance of Escherichia coli in patients with infectious complications after prostate biopsy in a North American cohort. Increasing antibiotic-resistant E. coli has been observed worldwide. METHODS Data were available for 1446 patients who had undergone transrectal ultrasound-guided prostate biopsy from 2001 to 2010. Of the 1446 patients, 932 were administered 500 mg of ciprofloxacin 1 hour before prostate biopsy and 514 were administered a 3-day course of ciprofloxacin starting 1 day before biopsy plus an enema the night before. The sensitivity and resistance of E. coli were attained through the analysis of the blood and urine cultures of patients with suspected infection. RESULTS Of the 1446 patients, 40 (2.77%) developed an infection after biopsy. Of these 40 patients, 31 (2.14%) had a febrile urinary tract infection and 9 (0.62%) were diagnosed with sepsis requiring hospitalization. Of the 40 patients, 20 (50%) had urine cultures positive for E. coli. Of these 20 patients, 11 (55%) had fluoroquinolone-resistant infection and 9 had fluoroquinolone-sensitive E. coli. Of the remaining 20 patients, culture was not obtained for 9, and 5 had negative urine culture findings. Of the 7 patients (78%) with sepsis had blood cultures positive for E. Coli; 4 (57.1%) of which were fluoroquinolone-resistant and 3 were fluoroquinolone-sensitive. CONCLUSIONS In the present study, a significant risk of fluoroquinolone-resistant E. coli was observed in patients with both febrile urinary tract infection and sepsis after prostate biopsy. Alternative prophylactic antibiotics should be researched further, and postbiopsy infections developing after standard quinolone prophylaxis should be treated with cephalosporins until culture findings are available to guide therapy.

Office based transrectal saturation biopsy improves prostate cancer detection compared to extended biopsy in the repeat biopsy population.

PURPOSE Multiple studies have shown significant prostate cancer detection for repeat biopsy. However, the best approach regarding core number and location remains controversial. Transrectal saturation biopsy is believed to increase cancer detection but to our knowledge no studies comparing it to 12 to 14-core extended biopsy have been published. We compared saturation and extended repeat biopsy protocols after initially negative biopsy. MATERIALS AND METHODS A total of 1,056 men underwent prostate biopsy after initially negative biopsy. The extended biopsy group included 393 men with 12 to 14-core repeat biopsy. The saturation biopsy group included 663 men with 20 to 24-core repeat biopsy. We analyzed demographics and prostate cancer between the 2 groups. We compared prostate cancer detection in patients with previous atypical small acinar proliferation and/or high grade prostatic intraepithelial neoplasia as well as the risk of detecting clinically insignificant tumors. RESULTS Prostate cancer was detected in 315 of the 1,056 patients (29.8%). Saturation biopsy detected almost a third more cancers (32.7% vs 24.9%, p=0.0075). In patients with a benign initial biopsy saturation biopsy achieved significantly greater prostate cancer detection (33.3% vs 25.6%, p=0.027). For previous atypical small acinar proliferation and/or high grade prostatic intraepithelial neoplasia there was a trend toward higher prostate cancer detection rate in the saturation group but it did not attain statistical significance (31.2% vs 23.3%, p=0.13). Of 315 positive biopsies 119 (37.8%) revealed clinically insignificant cancer (40.1% vs 32.6%, p=0.2). CONCLUSIONS Compared to extended biopsy, office based saturation biopsy significantly increases cancer detection on repeat biopsy. The potential for increased detection of clinically insignificant cancer should be weighed against missing significant cases.

Morbidity Of Prostate Biopsy After Simplified Versus Complex Preparation Protocols: Assessment of Risk Factors

OBJECTIVE To determine whether prostate biopsy complications were affected by 2 varying prebiospy protocols implemented at our institution. Although transrectal ultrasound (TRUS) guided prostate biopsy is considered generally safe, it is associated with significant complications. METHODS We retrospectively evaluated a total of 1438 TRUS-guided prostate biopsies between January 2001 and June 2008. In group A, 931 men had only one dose of a quinolone antibiotic immediately before the procedure, and no enema was performed. In group B, 507 men who underwent a prebiopsy enema and were given oral antibiotics starting the day before the procedure for 3 days. We analyzed demographics and biopsy complications between the 2 groups. RESULTS The overall complication rates were categorized as infection (2.2%), urine retention (0.8%), hematuria (4.4%), rectal bleeding (1.5%), sepsis (0.2%). There was no significant statistical difference in the incidence of infection or sepsis between the 2 groups (2.7% vs 1.4%, P = .157 and 0.1% vs 0.4%, P = .285 respectively, for group A vs B). Both hematuria and hematospermia were more common in group B (2.5% vs 7.9%, P < .001 and 0.2% vs 2%, P < .001 respectively, for group A vs B). Prostate size was a significant risk for both hematuria (odds ratio = 1.7, 95% confidence interval = 1.2-2.44, P = .003) and acute urinary retention (odds ratio = 4.45, 95% confidence interval = 2.01-9.84, P < .001). CONCLUSIONS This study demonstrates that a single antibiotic dose before prostate biopsy may be sufficient. In addition, use of prebiopsy enemas is unnecessary to decrease overall complication rates.

Robotic single port suprapubic transvesical enucleation of the prostate (R‐STEP): initial experience

Study Type – Therapy (case series)

Development of Improved Nomogram for Prediction of Outcome of Initial Prostate Biopsy Using Readily Available Clinical Information

OBJECTIVES To construct a nomogram that can be used to estimate the risk of prostate cancer (PCa) and high-grade PCa using readily available clinical information for men undergoing initial extended prostate biopsy (PBx). Many nomograms have been developed to predict the outcome of initial PBx. However, most require information not available at the decision to biopsy. METHODS From March 2000 to April 2010, 1551 men with a prostate-specific antigen (PSA) of ≤10 ng/mL who underwent initial extended PBx were included in the present study. The nomogram predictor variables were patient age, race, prostate-specific antigen (PSA) level, percent free PSA, family history of PCa, and the digital rectal examination findings. The area under the receiver operating characteristic curve was calculated as a measure of discrimination. The calibration was assessed graphically. RESULTS Of the 1551 men, 606 (39.1%) had PCa on biopsy. The mean value for age, PSA, and percent free PSA was 63.4 years, 5.1 ng/mL, and 21.4%, respectively. Also, 25.1% and 7.8% of patients with positive PBx findings had digital rectal examination abnormalities and a positive family history, respectively. The univariate and multivariate analyses suggested that all 6 risk factors were predictors of PCa in the study cohort (P < .05). The area under the curve for all factors in a model predicting PCa was 0.73 (95% confidence interval 0.71-0.76). The area under the curve for predicting high-grade PCa was 0.71 (95% confidence interval 0.69-0.74). CONCLUSIONS The present predictive model allows an assessment of the risk of PCa and high-grade PCa for men undergoing initial extended PBx using readily available, noninvasively obtained clinical data.

Prostate cancer detection after a negative prostate biopsy: Lessons learnt in the Cleveland Clinic experience

Urologists are often faced with the dilemma of managing patients with a negative initial prostate biopsy in whom clinical or pathological risk for prostate cancer still exists. Such real‐life challenging scenarios might raise questions such as: Who should undergo further biopsies? What are the optimal predictors for prostate cancer on subsequent biopsies? What is the optimal biopsy protocol that should be used? When to stop the biopsy cascade? The last decade has witnessed numerous studies that have analyzed factors conferring a significant risk for cancer discovered on repeat biopsies. We and others have developed predictive models to aid decision‐making regarding pursuing further biopsies. For decades, high‐grade prostatic intraepithelial neoplasia has been considered a strong risk indicator for subsequent cancer. However, it has been recently shown that only through segmentation of this heterogeneous population does the real risk profile emerge. Biopsy templates underwent modification regarding the number and location of cores with emergence of the transrectal or brachytherapy grid transperineal saturation biopsy. However, the best biopsy protocol remains controversial. We have refined the initial biopsy template to a 14 core initial biopsy template that optimizes cancer detection, and have shown that transrectal saturation biopsy significantly improves cancer detection for repeat biopsy. Another concern is the overdiagnosis of clinically insignificant cancer on repeat biopsies, so we explored ways to limit this, and to deal with its ramifications. Through carrying out a Medline literature search, we critically evaluated pertinent articles together with emphasis of our own journey in this arena to assist in the decision‐making process for repeat biopsy population.

When serial prostate biopsy is recommended: most cancers detected are clinically insignificant

Study Type – Disagnostic (exploratory cohort)

Type of transrectal ultrasonography probe influences prostate cancer detection rates on repeat prostate biopsy.

Study Type – Diagnostic (case series)

Using a Saturation Biopsy Scheme Increases Cancer Detection During Repeat Biopsy in Men With High-grade Prostatic Intra-epithelial Neoplasia

OBJECTIVE To determine the role of transrectal saturation biopsy for cancer detection in men with high-grade prostatic intra-epithelial neoplasia (HGPIN) diagnosed by extended biopsy. HGPIN was clearly associated with cancer risk in the sextant biopsy era, but this has not been clearly demonstrated in the extended biopsy era. MATERIALS AND METHODS From 1999 to 2009, 314 men had at least 1 or more repeat biopsy due to the presence of exclusive HGPIN (without any other pathologic finding) in a previous extended biopsy. They were divided into 2 groups according to the initial follow-up biopsy scheme, 178 men were followed up using a second standard extended biopsy scheme and 136 were followed up using the saturation biopsy scheme. RESULTS In the standard repeat biopsy group, 35 of 178 (19.7%) men had cancer on initial repeat biopsy. In the saturation biopsy group, 42 of 136 (30.9%) had cancer on initial repeat biopsy (overall, P = .04). Multivariate analysis demonstrates that the biopsy scheme on repeat biopsy is an independent predictor of prostate cancer detection (OR 1.85, (95% CI; 1.03, 3.29), exclusive of age, PSA, days from initial biopsy, DRE status and multifocal PIN. Furthermore, there appears to be no further increase in Gleason 6 disease with usage of saturation biopsy in this unique population. CONCLUSION Cancer detection in men with HGPIN in the contemporary extended biopsy era is substantially improved using saturation technique.

Early infectious complications with transponder placement for external beam radiation therapy for prostate cancer.

Study Type – Therapy (case series)