All about prostate biopsy in an office urology setting

<p class="article-intro">In 2017 the section of office urologists (ESUO) was founded within the EAU. The first ESUO Meeting of the new section was organized at the annual EAU congress 2018 in Kopenhagen.</p> <hr /> <p class="article-content"><p>Prostate biopsy is a core procedure in urologic office. During the meeting all relevant aspects of prostate biopsy in an office setting were presented by recognized specialists: indication, the procedure itself, the management of complications and modern imaging. The session was chaired by office urologists and thus the focus on the outpatient situation was ensured. Discussions of crucial cases with the audience were an important task of this interactive meeting.</p> <h2>Indication</h2> <p>&ldquo;Do not subject men to prostate-specific antigen (PSA) testing without counselling them on the potential risks and benefits&rdquo;¹. &ldquo;Inform men who ask for screening about advantages and disadvantages. Illustrate benefits and risks &ndash; overdiagnosis and therapy &ndash; in numbers and graphics. Demonstrate the meaning of positive and negative test results.&rdquo;² These are the recommendations of the EAU and the AWMF.<br /> The need for prostate biopsy is based on PSA level and/or suspicious DRE. Age, potential comorbidity and therapeutic consequences should also be considered and discussed beforehand. Risk stratification is a potential tool for reducing the number of unnecessary biopsies. Risk calculators can be used. New biomarkers might be able to reduce the number of unnecessary biopsies in the future.<br /> Indications for repeat biopsies after negative biopsy are rising or persistently elevated PSA levels, atypical small acinar proliferation, extensive (multiple biopsy sites, i.e., &gt;3) high-grade prostatic intraepithelial neoplasia, and intraductal carcinoma as a solitary finding.</p> <h2>Preparation</h2> <p>Before a transrectal biopsy is performed UTI diagnostics and antibiotic prophylaxis should be installed. In transperineal biopsies a single dose i.v. cephalosporine is recommended, while in transrectal biopsies a long course of 3&ndash;5 days of antibiotic treatment should be done. Quinolones are still the drug of choice while new recommendations are upcoming.<br /> Oral anticoagulation should be stopped before biopsy, low dose aspirin can be continued.</p> <h2>Procedure</h2> <p>Ultrasound guided biopsy is the standard of care. Local anaesthesia is performed by periprostatic infiltration with 15ml lidocaine 1 % . A transrectal approach is used for most prostate biopsies, although some urologists prefer a perineal approach. Cancer detection rates are comparable.<br /> On baseline biopsies, the sample sites should be bilateral from apex to base, as far posterior and lateral as possible in the peripheral gland. Additional cores should be obtained from suspect areas by DRE/ TRUS. Ten or twelve core biopsies of at least 10mm length are recommended. Each site of biopsy is delivered to the pathologist on a separate tray. The pathologist should use a standardized terminology, reporting typing, grading, extent of cancer per biopsy and perineural invasion.</p> <h2>Complications</h2> <p>The best management of complications is to avoid them. A concept of a checklist for prostate biopsy is recommended. It should include history, risk factors for infection, bleeding disorders, allergies to local anaesthesia/antibiotics, current medication e.g. anticoagulants.<br /> Risk factors for infections are shown in table 1. Hospitalisation and sepsis rates are higher after transrectal biopsies than after perineal biopsies. But there seems to be no statistically relevant difference between empirical and targeted antibiotics. Hence, a rectal culture before transrectal biopsy has no place in daily practice.<br /> A prostate biopsy is considered as an intervention with an intermediate bleeding risk. Rectal bleeding and hematospermia are mostly selflimited. Severe hematuria can be handled by inserting a catheter and irrigating the bladder with NaCl. The risk of adverse cardiovascular complications is less than 1 % . A bridging therapy sometimes needs an interdisciplinary management. In patients with high risk for arterial or stent thrombosis an interdisciplinary management with a cardiologist is advisable.</p> <h2>The advantages of ultrasoundbased imaging</h2> <p>The urologists are familiar with US. The technique is not harmful, it is quick, cheap and simple. It serves already for diagnosis and treatment of PCa and might be helpful for monitoring of treatment. It seems to be the ideal imaging technique. PCa lesions usually present themselves as hypoechoic area. Contrast enhanced US=CEUS, elastography and computerized transrectal ultrasound ANNA/C-TRUS, high frequency US seem to be the future of urological prostate imaging.</p> <h2>The role of MRI fusion biopsy</h2> <p>A multiparametric MRI is possible before baseline biopsy, but not part of routine diagnostics. It should be performed before repeat biopsy.<br /> There is a need of standardized MRI reports for reliable information transfer. With these informations the urologist is able to perform a cognitive fusion of the MRI and the transrectal ultrasound. Several software-based fusion techniques exist. But even the software-based fusion techniques are prone to systematic error (the more steps, the higher the risk), misalignment and overestimation of capabilities. There seems to be an advantage for software fusion in anterior lesions, very small lesions, in cases of limited information transfer from radiology to urology, in case of limited experience with MRI and/or US, and when there is a need for documentation.<br /> The detection rate in repeat biopsies seems to be higher when high quality prostate magnetic resonance imaging is available. This is the major achievement for safety in active surveillance.</p> <h2>How can MRI fusion biopsy be integrated in an office urology setting?</h2> <p>A possible way could be a kind of a fusion network. The collaboration of urologists, radiologists and hospitals could help to establish cost-intensive innovation. Further advantages are the increase of competence of all partners, the increase of patient comfort and the ability to keep the patients instead of referring them to big centers. The establishment of such models of collaboration can be a rewarding challenge for office urologists and their partners.</p> <p><img src="/custom/img/files/files_datafiles_data_Zeitungen_2018_Leading Opinions_Uro_1802_Weblinks_lo_uro_1802_s18_tab1+fig1+2.jpg" alt="" width="1417" height="1979" /></p> <h2>Conclusion</h2> <p>The section of office urologists is going to play an important role within the European Association of Urology, as the basic urological services as well as complex operating procedures in some countries are provided by office urologists. The section is still trying to get in contact with office urologists all over Europe. An evaluation of an EAU survey about office urology took place, and a questionnaire was sent to country representatives to get an overview about the number, if possible the addresses and the working fields of the office urologists, as well as country specific particularities. During the next EAU Congress 2019 in Barcelona we will organize two meetings. One about urinary tract infections and the other one will cover the topic of &ldquo;How to run a urological office successfully&rdquo;.<br /> If you feel addressed by these projects or if you could imagine to work together with colleagues from all over Europe, please feel free to contact our president Prof. Helmut Haas (hf.haas hp@t online. de) or the author of this article, or best directly esuo@uroweb.org. We would be pleased to hear from you.</p></p> <p class="article-footer"> <a class="literatur" data-toggle="collapse" href="#collapseLiteratur" aria-expanded="false" aria-controls="collapseLiteratur" >Literatur</a> <div class="collapse" id="collapseLiteratur"> <p><strong>1</strong> EAU Guidelines on Prostate Cancer 2017 <strong>2</strong> AWMF S3 Guideline on Prostate Cancer 2017</p> </div> </p>