Sean Huang

Sepsis and 'superbugs': should we favour the transperineal over the transrectal approach for prostate biopsy?

To determine the rate of hospital re‐admission for sepsis after transperineal (TP) biopsy using both local data and worldwide literature, as there is growing interest in TP biopsy as an alternative to transrectal ultrasonography (TRUS)‐guided biopsy for patients undergoing repeat prostate biopsy.

Transperineal biopsy prostate cancer detection in first biopsy and repeat biopsy after negative transrectal ultrasound-guided biopsy: the Victorian Transperineal Biopsy Collaboration experience.

To present the Victorian Transperineal Biopsy Collaboration (VTBC) experience in patients with no prior prostate cancer diagnosis, assessing the cancer detection rate, pathological outcomes and anatomical distribution of cancer within the prostate.

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

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).

The ‘green whistle’: A novel method of analgesia for transrectal prostate biopsy

Periprostatic infiltration of local anaesthetic (PILA) is accepted as the current ‘gold standard’ of analgesia for TRUS‐guided biopsy. However, it does not account for discomfort of anal probe insertion and has not received wide uptake amongst clinicians. A better method is therefore sought. PenthroxTM (methoxyflurane) is an effective systemic analgesic that is self‐administered via a hand‐held inhaler. Its use in TRUS‐guided biopsy has not been previously reported.

Significant impact of transperineal template biopsy of the prostate at a single tertiary institution.

Objective: The objective was to review the impact of transperineal biopsy (TPB) at our institution by assessing rates of cancer detection/grading, treatment outcomes and complications. Patients and Methods: A retrospective review of TPBs between 2009 and 2013 was performed. Variables included reason for TPB, age, prostate-specific antigen, previous histology, TPB histology, and management outcomes. Results: In total, 110 patients underwent 111 TPBs at our institution. On average, 22 cores were taken from each procedure. Disease-upgrade occurred in 37.5% of active surveillance patients, 35% of patients with previous negative transrectal ultrasound, and 58.8% in patients undergoing TPB for other reasons. Of these patients, anterior and/or transition zones were involved in 66%, 79%, and 80%, respectively. Involvement in anterior and/or transition zones only occurred in 40%, 37%, and 10%, respectively. About 77% of patients with disease-upgrading underwent treatment with curative intent. Complications included a 6.3% rate of acute urinary retention and 2.7% of clot retention, with no episodes of urosepsis. Conclusions: Transperineal biopsy at our institution showed a high rate of disease-upgrading, with a large proportion involving anterior and transition zones. A significant amount of patients went on to receive curative treatment. TPB is a valuable diagnostic procedure with minimal risk of developing urosepsis. We believe TBP should be offered as an option for all repeat prostate biopsies and considered as an option for initial prostate biopsy.

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.

MP38-06 ZERO HOSPITAL ADMISSIONS FOR INFECTION AFTER 1359 TRANSPERINEAL PROSTATE BIOPSIES

INTRODUCTION AND OBJECTIVES: Transrectal biopsy is plagued by an increasing rate of serious infection, despite use of recommended fluoroquinolone antibiotics. Transperineal biopsy (TPB), on the other hand, has been associated with an exceedingly low rate of serious infection. The aim of this study was to determine the rate of hospital admissions for infection after transperineal biopsy of prostate. METHODS: Patients underwent transperineal biopsy of the prostate (TPB) between May 2012 and October 2016 by a private group urology practice, at multiple hospitals across Melbourne. A standard brachytherapy template grid was used, taking a number of samples from left and right prostate posterior, mid and anterior regions. Some patients had extra core biopsies taken from target areas suspicious of cancer identified on prior MRI. Data collected from these patients were entered into an ethics approved prospective database including prophylactic antibiotics used and post operative complications. RESULTS: 1359 consecutive patients underwent TPB. Initially patients were treated with quinolone prophylaxis and then later patients received cephazolin only. 1030 (75.8%) had single dose IV cephazolin, 388 (28.6%) had an oral quinolone with IV cephazolin, 107 (7.9%) had IV ceftriaxone and 2 (0.1%) had IV clindamycin, 2 (0.1%) had IV meropenem and 1 (0.1%) had IV vancomycin prophylaxis. Routine practice shifted from use of quinolones to cephazolin during the study period. 25 (1.8%) patients developed acute urinary retention and 1 patient was treated in the community with oral antibiotics for prostatitis. No patients were readmitted to hospital with infection. CONCLUSIONS: Sepsis post TPB is an exceedingly rare complication, with a 0% rate in this large prospective multicentre cohort. It is safe to use single dose cephazolin only as antibiotic prophylaxis prior to TPB, negating the need for quinolones. This study supports the current Australian Therapeutic Guidelines recommendation for TPB prophylaxis. Whether any antibiotic prophylaxis is needed at all for TPB is the subject of a future study.

Primary apocrine adenocarcinoma of scrotum suspected as urothelial carcinoma metastasis: A clinical and pathological dilemma

A 78-year-old man presented with an enlarging, tender mass in the scrotum separate to the testes. This was on the background of radical cystoprostatectomy, urethrectomy, and ileal conduit formation for high-grade urothelial carcinoma of the bladder invading submucosa 3 years prior. Examination revealed a 4 × 5 cm lesion, which was hard, fixed to the overlying skin and nodular to palpation. Ultrasound confirmed a solid mass in the scrotum extending into the perineum. Computerized tomography of the chest, abdomen, and pelvis revealed enlargement of inguinal lymph nodes but no other metastases. Complete resection of the scrotal lesion and selective removal of regional lymph nodes was performed. Rather than a cutaneous scrotal metastasis from the bladder urothelial carcinoma, histological examination suggested a primary apocrine adenocarcinoma of the scrotum. This case report explores the clinical and pathological features associated with both of these unusual differential diagnoses.