key: cord-0899611-8hutrqn8
authors: Yuwono, Arianto; Salada, Rolando; Tan, Teck Wei
title: TREXIT: initial experience with transperineal prostate biopsy under local anesthesia in an outpatient setting in South East Asia
date: 2021-03-26
journal: Asian J Androl
DOI: 10.4103/aja.aja_24_21
sha: a35b23adbb4a89cc0f6db5e673d257c25ced495e
doc_id: 899611
cord_uid: 8hutrqn8

nan

Compared to transrectal prostate biopsy, transperineal (TP) prostate biopsy avoids rectal bacteria, and thus, significantly reduces the risk of sepsis. Previous studies have shown extremely low rates of infection following TP prostate biopsies. 1, 2 Traditionally, TP prostate biopsies have been performed in the operating theater under general or spinal anesthesia. However, the introduction of the PrecisionPoint Transperineal Access System (Perineologic, Cumberland, MD, USA) facilitates freehand TP prostate biopsies to be performed under local anesthesia (LA). 1, 2 In this study, we present our initial experience with TP prostate biopsy using the device under LA in an outpatient setting. This is the first report of TP prostate biopsy under LA in South East Asia. This is an institutional review board-approved audit of patients who underwent TP prostate biopsy from September 2019 to June 2020 in Tan Tock Seng Hospital (Singapore). Patients with raised serum prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE) were offered TP prostate biopsy. Patients were advised to undergo multiparametric magnetic resonance imaging (mpMRI) prostate prior to TP biopsy, as per the international guidelines. 3 Patients with Prostate Imaging Reporting and Data System (PI-RADS) 3 to 5 lesions seen on mpMRI prostate proceeded with TP cognitive-targeted and systematic prostate biopsies. 4 Those with no suspicious lesion on MRI prostate underwent systematic biopsies only. Written informed consent was obtained from all patients before biopsy. Patients were prescribed a single dose of oral cefuroxime 500 mg (Zinnat, Aspen Pharmacare Australia Pte Ltd., Canberra, Australia) on the morning of the prostate biopsy. All biopsies were performed or supervised by a single urologist (TWT). Procedural techniques are outlined in Figure 1 . Data of patients who underwent TP prostate biopsy were entered into our database. Clinically significant prostate cancer (csPCa) was defined as Gleason grade group ≥2 cancer. During the study, 72 TP prostate biopsies under LA were performed. The median age of patients was 70 (range: 46-83) years. The median prostate volume was 42.2 (range: 11.2-368.7) ml and the median PSA was 8.3 (range: 0.7-411.0) ng ml −1 . Sixty patients underwent mpMRI prostate before the prostate biopsy, and 26 patients had PI-RADS 3-5 lesions and underwent both cognitive-targeted and systematic prostate biopsies. prostate biopsy. 6 Second, TP prostate biopsy allows increased detection of anterior cancers, which tend to be missed in transrectal prostate biopsies. 7 In our study, the majority of patients (83.3%) underwent mpMRI prostate before proceeding with TP prostate biopsy. Although only 26 patients underwent MRI-targeted biopsies in our study, the detection rate for csPCa is quite similar to our previous study, which utilized software fusion for transrectal MRI-targeted biopsies. 8 There are several limitations in our study. First, we acknowledge that the sample size is small, but this is a report of our initial experience with the LA TP prostate biopsy. In addition, the COVID-19 pandemic which has affected Singapore since the late January 2020 has had a significant impact on our outpatient urological services with a significant reduction in prostate biopsy sessions. We expect the number of patients scheduled for LA TP prostate biopsy to increase in the coming months with the gradual resumption of urology outpatient services. Second, we did not formally compare our results with transrectal ultrasound (TRUS) prostate biopsies in our center. However, a previous audit of our TRUS prostate biopsies (unpublished) had found a sepsis rate of 2.0%, which is in line with the reported range of clinical infectious complications of 1%-17.5% reported in a review by Borghesi et al. 9 In conclusion, TP prostate biopsy under LA is a safe, effective, and well-tolerated procedure. Thus, it is progressively replacing transrectal biopsies in our center.

AY, RS and TWT researched on the topic. AY wrote the first draft. AY and RS prepared all the figures. AY and TWT critically evaluated the findings in the paper. All authors read and approved the final manuscript.

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©The Author(s)(2021) (b) Iodine is used to clean the perineum prior to draping. The perineal skin is marked to demarcate the lateral boundaries of the prostate. One percent lignocaine was used to infiltrate the skin on both sides of the midline. (c) A spinal needle is advanced through the PrecisionPoint access guide under ultrasound visualization to inject 1% lignocaine around the perineal body and to the apex of the prostate on each side. (d) PrecisionPoint device is inserted through the skin and advanced into the perineum until the tip is visualized with the biplanar ultrasound. Cognitive-targeted biopsies are first performed in patients with MRI targets, and this is followed by systematic biopsies, which are taken as per the distribution recommended by the Ginsburg Study Group. 6 LA: local anesthesia; MRI: magnetic resonance imaging. 

Initial outcomes of local anaesthetic freehand transperineal prostate biopsies in the outpatient setting

Initial experience performing in-office ultrasound-guided transperineal prostate biopsy under local anesthesia using the PrecisionPoint transperineal access system

Guidelines on prostate cancer -2020 update

Prostate Imaging Reporting and Data System version 2.1: 2019 update of Prostate Imaging Reporting and Data System version 2

Systematic review of complications of prostate biopsy

Definitions of terms, processes and a minimum dataset for transperineal prostate biopsies: a standardization approach of the Ginsburg Study Group for enhanced prostate diagnostics

High detection rate of significant prostate tumours in anterior zones using transperineal ultrasound-guided template saturation biopsy

MRI fusion-targeted transrectal prostate biopsy and the role of prostate-specific antigen density and Prostate Health Index for the detection of clinically significant prostate cancer in Southeast Asian men

Complications after systematic, random, and image-guided prostate biopsy

We thank Dr. Sharon Eu-Kiang Yeo, Head of the Department of Urology in Tan Tock Seng Hospital (Singapore) for supporting us in starting TP prostate biopsy under local anaesthesia service in the hospital. We also would like to thank all the staffs in the Department of Urology and clinic 2A in Tan Tock Seng Hospital for their help and efforts in making TP prostate biopsy under local anaesthesia service available in the hospital.