Editorial Comment

Abstract

Prostate biopsy is one of the most common procedures performed by urologists with an estimated >2 million performed in the United States and Europe every year, 1 Borghesi M. Ahmed H. Nam R. et al. Complications after systematic, random, and image-guided prostate biopsy. Eur Urol. 2017; 71: 353-365 Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar , 2 Loeb S. Carter H.B. Berndt S.I. et al. Complications after prostate biopsy: data from SEER-Medicare. J Urol. 2011; 186: 1830-1834 Abstract Full Text Full Text PDF PubMed Scopus (451) Google Scholar and is the gold standard for the diagnosis of prostate cancer. The majority of prostate biopsies in the United States are done in the office setting using the ultrasound probe through a transrectal approach. The proximity of the posterior prostate to the anterior rectal wall provides easy access the peripheral zone which is known to harbor >70% of malignancies. 3 McNeal J.E. Normal histology of the prostate. Am J Surg Pathol. 1988; 12: 619-633 Crossref PubMed Scopus (421) Google Scholar However, this approach is associated with a significant risk of infectious complications, with rates ranging from 1 to 17.5% in the literature. Furthermore, the risk of serious infectious complications requiring hospitalization has been shown to be increasing over time, 4 Anastasiadis E. van der Meulen J. Emberton M. Hospital admissions after transrectal ultrasound-guided biopsy of the prostate in men diagnosed with prostate cancer: a database analysis in England. Int J Urol. 2015; 22: 181-186 Crossref PubMed Scopus (35) Google Scholar likely as a result of the increased prevalence of fluoroquinolone-resistant Escherichia coli. 5 Tukenmez Tigen E. Tandogdu Z. Ergonul O. et al. Outcomes of fecal carriage of extended-spectrum beta-lactamase after transrectal ultrasound-guided biopsy of the prostate. Urology. 2014; 84: 1008-1015 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Partly in response to this, several centers are increasingly using the transperineal (TP) approach to prostate biopsy. Rather than using broad-spectrum prophylaxis, which contributes to antibiotic resistance, TP biopsies are often performed after a single prophylactic dose of first generation cephalosporin. Large series using this approach have reported sepsis rates approaching zero. 1 Borghesi M. Ahmed H. Nam R. et al. Complications after systematic, random, and image-guided prostate biopsy. Eur Urol. 2017; 71: 353-365 Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar To date, TP biopsy has been mostly performed under general anesthesia, having important implications on health care resources, cost and time. Although the TP approach has been more widely adopted in other countries, in the United States it has been mostly reserved for special situations where the transrectal approach is either not possible or is unsafe. In recent years, several devices have been developed allowing TP prostate biopsies to be performed in the office, under local anesthesia, without the need for bulky, cumbersome, expensive equipment. The authors of this manuscript present their initial experience using 1 such device, and demonstrate the safety and feasibility of office TP prostate biopsy in a small number of men. What is now needed are studies in larger cohorts of patients demonstrating safety on a large scale using standardized reporting, patient tolerability using validated pain questionnaires and confirmation of the diagnostic accuracy for prostate cancer. Advances in prostate imaging (eg magnetic resonance imaging) aim to decrease the overuse of prostate biopsy, similarly modifications of the approach and instrumentation for prostate biopsy aim to decrease the morbidity of the procedure. These efforts will continue to shift the balance in favor of screening and diagnosis of prostate cancer, and will thus benefit the population on a large scale.