Transrectal Approach Research Articles

Detection of clinically significant cancer in the anterior prostate by transperineal biopsy.

To determine the incidence of clinically significant prostate cancer (csPCa) detected exclusively in the anterior prostate using transperineal prostate biopsy. Histopathology results of all patients who underwent transperineal prostate biopsy between February 2016 and March 2018 at a single institution were assessed for distribution of cancer within the prostate. Patients with cancer found exclusively in the anterior prostate were then compared to those with any cancer found in the posterior or lateral prostate with International Society of Urological Pathology Grade Group 2-5 cancers being considered csPCa. A total of 508 patients were included. Overall, 12.0% of the cohort had csPCa detected only in anterior biopsies. When stratified by prostate-specific antigen (PSA) level, 6.6% of men with a PSA level of 4.1-10.0ng/mL and 8.2% of men with a PSA level of >10.0ng/mL had csPCa detected in the anterior prostate alone. Transperineal biopsy has the ability to diagnose anteriorly located csPCa that would potentially have been missed by the transrectal approach.

Antibiotic Prophylaxis for the Prevention of Infectious Complications following Prostate Biopsy: A Systematic Review and Meta-Analysis.

Infectious complications following prostate biopsy are increasing and fluoroquinolone prophylaxis has recently been banned by the European Commission. In this systematic review we summarize the evidence for different antibiotic prophylaxis regimens. We searched MEDLINE®, Embase® and Cochrane Database for randomized controlled trials (inception to October 2019) assessing antimicrobial interventions in prostate biopsy. Primary outcome was infectious complications. Exclusion criteria were simultaneous interfering interventions. GRADE (Grading of Recommendations, Assessment, Development and Evaluations) was used to assess the certainty of evidence. Protocol was registered with PROSPERO (CRD42015026354). Overall 59 randomized controlled trials (14,153 participants) and 7 different antimicrobial interventions were included. Antibiotic prophylaxis reduced infectious complications compared to no prophylaxis (RR 0.56, 95% CI 0.40-0.77, p=0.0005, I2=15%, participants 1,753, studies 11). A short-term prophylaxis (single shot to 3 days) was inferior to a long-term prophylaxis (1 to 7 days) with fluoroquinolone (RR 1.89, 95% CI 1.37-2.61, p=0.0001, I2=0%, participants 3,999, studies 17). Fosfomycin trometamol was an alternative to fluoroquinolone with reduced rates of infectious complications (RR 0.49, 95 CI 0.27-0.87, p=0.02, I2=54%, participants 1,239, studies 3). Empiric prophylaxis was inferior to targeted prophylaxis (RR 1.81, 95% CI 1.28-2.55, p=0.0008, I2=48%, participants 1,511, studies 6). Standard prophylaxis was inferior to augmented prophylaxis (using multiple rather than single agent) using a fixed model (RR 2.10, 95% CI 1.53-2.88, p <0.0001, I2=71%, participants 2,597, studies 9), but not using a random model (p=0.07). No difference was observed in infectious complications based on route or timing of antimicrobial prophylaxis. The certainty of evidence was rated as low/very low. In countries where fluoroquinolones are allowed as antibiotic prophylaxis, a minimum of a full 1-day administration as well as targeted therapy in case of fluoroquinolone resistance is recommended. In countries with a ban on fluoroquinolones, fosfomycin is a good alternative, as is augmented prophylaxis, although no established standard combination exists to date.

EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series.

Background and AimsPelvic fluid collections (PFCs) are frequent adverse events of abdominal surgery or inflammatory conditions. A percutaneous approach to deep PFCs could be challenging and result in a longer, painful recovery. The transvaginal approach has been considered easy but is limited by the difficulty of leaving a stent in place. The transrectal approach has been described, but issues related to fecal contamination were hypothesized. Data on EUS-guided transrectal drainage (EUS-TRD) with lumen-apposing metal stents (LAMSs) are few and suggest unsatisfactory outcomes. The aim of this study was to evaluate the safety and efficacy of EUS-TRD with LAMSs in patients with PFCs.MethodsA retrospective analysis of a prospectively maintained database on therapeutic EUS was conducted. All EUS-TRD procedures were included.ResultsFive patients (2 male, age 44-89 years) were included. Four patients had postoperative PFCs, and 1 presented with a pelvic abscess complicating acute diverticulitis. Two of 5 had fecal diversion; the remaining 3 had unaltered large-bowel anatomy. One case had a concomitant abdominal collection, treated with percutaneous drainage in the same session. An electrocautery-enhanced LAMS delivery system (15 × 10 mm) was used in all cases. EUS-TRD was performed with the direct-puncture technique and lasted less than 10 minutes in 4 cases; in the remaining case, needle puncture and LAMS placement over a guidewire was required, and the procedure length was 14 minutes. The clinical success rate was 100%. LAMSs were removed after a median of 14 (range, 12-24) days. One patient reported partial proximal LAMS migration after 24 days (mild adverse event). No PFC recurrence was observed.ConclusionEUS-TRD with LAMSs is a safe and effective technique for treatment of PFCs. The use of 15- × 10-mm LAMSs allows rapid PFC resolution. EUS-TRD could be performed not only in patients with fecal diversion but also in cases of unaltered anatomy.

Evolution of Transanal Total Mesorectal Excision.

Minimally invasive techniques continue to transform the field of colorectal surgery. Because traditional surgical approaches for rectal cancer are associated with significant mortality and morbidity, developing less invasive approaches to this disease is paramount. Natural orifice transluminal endoscopic surgery (NOTES), commonly known as "no incision surgery," represents the ultimate minimally invasive approach to disease. Although transgastric and transvaginal approaches for NOTES surgery were the initially explored, a transrectal approach for colorectal disease is intuitive given that it makes use of the resected organ for transluminal access. Furthermore, the transanal approach allows for improved, precise visualization of the presacral mesorectal plane compared with an abdominal viewpoint, particularly in the narrow, male pelvis. Finally, experience with existing transanal platforms that have been used for decades for local excision of rectal disease made the development of a transanal approach to total mesorectal excision (TME) feasible. Here, we will review the evolution of minimally invasive and transanal surgical techniques that allowed for the development of transanal TME and its introduction into clinical practice.

PD17-01 OUTPATIENT TRANS-RECTAL MR-GUIDED LASER FOCAL THERAPY PHASE II CLINICAL TRIAL: TEN-YEAR INTERIM RESULTS

You have accessJournal of UrologyProstate Cancer: Localized: Ablative Therapy I (PD17)1 Apr 2020PD17-01 OUTPATIENT TRANS-RECTAL MR-GUIDED LASER FOCAL THERAPY PHASE II CLINICAL TRIAL: TEN-YEAR INTERIM RESULTS John Feller*, Bernadette Greenwood, Wes Jones, Rob Toth, Steve Gunberg, Jeffrey Herz, and Indian Wells, CA John Feller* John Feller* More articles by this author , Bernadette GreenwoodBernadette Greenwood More articles by this author , Wes JonesWes Jones More articles by this author , Rob TothRob Toth More articles by this author , Steve GunbergSteve Gunberg More articles by this author , Jeffrey HerzJeffrey Herz More articles by this author , and Indian Wells, CAIndian Wells, CA More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000860.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In the United States alone, new prostate cancer cases for 2019 were estimated at 174,650 and deaths at 31,620. Focal therapies for low risk and intermediate risk localized prostate cancer are increasingly being explored. Our objective is to investigate the efficacy of using MR-guided laser focal therapy for MR visible prostate cancer utilizing a trans-rectal approach for laser applicator placement and therapy delivery in an outpatient setting for treatment naive and salvage patients. METHODS: All MR-guided therapy was delivered using a 1.5 Tesla Philips Achieva XR system (Philips Healthcare, Best, The Netherlands) for both image acquisition and real-time thermometry. DynaCAD and DynaLOC (Invivo, Orlando, FL, USA) software were used for image analysis and laser fiber placement planning. Laser focal therapy was delivered using a Visualase (Medtronic, Minneapolis, MN, USA) 15W, 980 nm diode laser applicator introduced trans-rectally using the DynaTRIM (Invivo, Orlando, FL, USA). RESULTS: Under an IRB-approved, HIPAA-compliant protocol, 158 men and 248 cancer foci were treated. No serious adverse events or morbidity were reported. Of the 122 men that underwent 6 mo. biopsy of the treatment site, 32/122 (26%) of men were positive and clinically significant*, while 71/122 (59%) of men were negative. The remaining 18 men (15%) were positive but clinically insignificant. In addition, while most of the positive results were of marginal recurrence, 6 men (5%) had clinically significant incidence cancers. We observed a 37% decrease in mean PSA at 12 months post therapy and no statistically significant change in IPSS and SHIM scores. At ten years, the metastasis free survival rate is 99%, the prostate cancer specific survival rate is 100%, and the overall survival rate is 98%. * Excludes Gleason score 3+3 (Grade Group 1) CONCLUSIONS: Ten year outcomes data indicate that outpatient, trans-rectally delivered MRI-guided laser focal therapy for prostate cancer has similar oncologic control as whole-gland therapy without the associated morbidity. In 94% of the treatment naive patients, whole gland therapy was safely avoided. Focal treatment of prostate cancer may be an attractive option in a subset of men appropriately risk stratified. The precision and safety achieved using laser focal therapy under MRI-guidance may have a favorable impact on cost effectiveness and quality of life without eliminating the possibility of whole-gland treatment. We will continue to follow these men for twenty years as part of an IRB-approved clinical trial (NCT# 02243033)3. Source of Funding: Patient funded research. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e369-e369 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Feller* More articles by this author Bernadette Greenwood More articles by this author Wes Jones More articles by this author Rob Toth More articles by this author Steve Gunberg More articles by this author Jeffrey Herz More articles by this author Indian Wells, CA More articles by this author Expand All Advertisement PDF downloadLoading ...

Combination of Multiparametric Magnetic Resonance Imaging With Elastic-fusion Biopsy Has a High Sensitivity in Detecting Clinically Significant Prostate Cancer in Daily Practice.

The index lesion (IL) is the largest cancer focus, usually harbors the highest grade, and might drive the history of prostate cancer (PCA). Multiparametric magnetic resonance imaging (mp-MRI) has a high negative predictive value in ruling out clinically significant (cs)PCA. We aimed evaluating the efficiency of mp-MRI and targeted biopsy in detecting csPCA and the concordance between the MRI index lesion (MRI-IL) and the presence of csPCA inside it. We retrospectively evaluated 158 men who underwent prostate biopsy after a positive pre-biopsy mp-MRI scan. All mp-MRI lesions were biopsied using a transrectal ultrasound elastic-fusion approach (2-4 targeted plus 10-12 random systematic biopsies). csPCA was defined as grading group≥ 2 or > 3 cores with cancer or≥ 50% of core involved by tumor. mp-MRI detected 158 ILs and 46 non-ILs. One hundred were Prostate Imaging-Reporting and Data System version 2 (PI-RADS v2) score 3, 84 score 4, and 20 score 5. csPCA was found in 63.9% of the MRI-ILs. Eighty percent of detected cancer using mp-MRI and targeted biopsy was clinically significant. Eighty-seven percent of the transitional zone lesions were clinically non-significant or negative for cancer. The probability of detecting csPCA increases with increasing size of MRI-IL, and every extra millimeter raises the odds of detecting csPCA of 12.2%. All PI-RADS v2 score lesions showed a strong association with csPCA. The risk of matching between MRI-IL and csPCA inside it increases by 36.2% as the total percentage of cancer in all cores increases. mp-MRI showed high sensitivity in detecting csPCA in the peripheral zone, with concordance between MRI-IL and csPCA.

A noninferiority within-person study comparing the accuracy of transperineal to transrectal MRI\u2013US fusion biopsy for prostate-cancer detection

BackgroundMagnetic resonance imaging (MRI) and ultrasound (US) fusion prostate-biopsies can be performed in a transrectal (TR-fusion) or transperineal (TP-fusion) approach. Prospective comparative evidence is limited. In this study we compared the detection rate of clinically-significant prostate-cancer (csPCa) within an index lesion between TR and TP-fusion.Patients and methodsThis was a prospective, noninferiority, and within-person trial. Men scheduled for MRI–US-fusion with a discrete MRI PI-RRAD ≥ 3 lesion were included. A dominant index lesion was determined for each subject and sampled by TR and TP-fusion during the same session. The order of biopsies was randomized and equipment was reset to avoid chronological and incorporation bias. For each subject, the index lesion was sampled 4–6 times in each approach. All biopsies were performed using Navigo fusion software (UC-Care, Yokneam, Israel). csPCa was defined as: Grade Group ≥ 2 or cancer-core length ≥ 6 mm. We used a noninferiority margin of 10% and a one-sided alpha level of 5%.ResultsSeventy-seven patients completed the protocol. Median age was 68.2 years (IQR:64.2–72.2), median PSA was 8.9 ng/ml (IQR:6.18–12.2). Ten patients (13%) were biopsy naive, others (87%) had a previous biopsy. csPCa was detected in 32 patients (42%). All of these cases were detected by TP-fusion, while only 20 (26%) by TR-fusion. Absolute difference for csPCa diagnosis was 15.6 (CI 90% 27.9–3.2%) in favor of TP-fusion (p = 0.029). TP-fusion was noninferior to TR-fusion. The lower boundary of the 90% confidence-interval between TP-fusion and TR-fusion was greater than zero, therefore TP-fusion was also found to be superior. Exploratory subgroup analyses showed TP-fusion was consistently associated with higher detection rates of csPCa compared with TR-fusion in patient and index-lesion derived subgroups (size, location, PI-RADS, PSA, and biopsy history).ConclusionsIn this study, TP-fusion biopsies were found to be noninferior and superior to TR-fusion biopsies in detecting csPCa within MRI-visible index lesion. Centers experienced in both TP and TR-fusion should consider these results when choosing biopsy method.

Feasibility of freehand MRI/US cognitive fusion transperineal biopsy of the prostate in local anaesthesia as in-office procedure-experience with 400 patients.

Transrectal (TR) ultrasound-guided prostate biopsy is one of the most commonly performed urologic procedures worldwide. The major drawback of this approach is the associated risk for infectious complications. Sepsis rates are increasing due to rising antibiotic resistance, representing a global issue. The transperineal (TP) approach for prostate biopsy has recently been adopted at many centres as an alternative to the TR biopsy, and it was shown to be associated with a lower risk for sepsis. The aim of this study was to assess safety and tolerability of TP prostate biopsy performed in local anaesthesia. We retrospectively analysed data of patients who had undergone office-based TP prostate biopsy in local anaesthesia, performed by a single surgeon between January 2015 and May 2019. We evaluated the patients' acceptance of the procedure by a pain score, as well as its safety and diagnostic performance. Four hundred patients were included. Median age was 66 years [range, 49-86]. Median prostate-specific antigen (PSA) concentration was 6.4 ng/ml [range, 0.3-1400], median PSA density was 0.15 ng/ml2 [range, 0-31.1] and median prostate volume was 40 ml [range, 6-150]. A total of 118 (29.5%) and 105 (26.2%) patients had orally received two and one doses of 500 mg fluoroquinolone, respectively, and 177 (44.3%) patients did not receive any antibiotic prophylaxis. No infectious complications occurred. Median pain score was 2.0 (range, 0-8). Overall cancer detection rate was 64.5% (258/400). Freehand TP prostate biopsy in local anaesthesia is a safe, effective and well-tolerated outpatient procedure with a high cancer detection rate. The elimination of infectious complications and its high accuracy make this technique a feasible alternative to the TR approach for the urological office. We assume that the single puncture and our trocar-like access sheath introduction technique diminish tissue trauma and bacterial exposition, and thus contribute to these promising results.

Pregnancy diagnosis in dromedary: comparison between transrectal and transabdominal ultrasonography

This study aimed to compare between transrectal and transabdominal ultrasonography for visualization of camel conceptus during different stages of gestation in dromedary. A group of six pregnant female dromedary camels was used in this study. Consecutive transrectal and transabdominal ultrasonography were performed once weekly between the second and 42nd weeks of pregnancy and every 2 weeks from the 42nd week until parturition. Six areas were selected for transabdominal ultrasound examination, namely caudal abdominal (CAA, right and left, above the base of the udder), middle abdominal (MIA, right and left, from the base of the udder to the umbilicus); and cranial abdominal (CRA, right and left, from the umbilicus to the xiphoid cartilage). On each examination, attempts were made to imagine the conceptus and to estimate the biparietal diameter (BPD), eyeball diameter (EBD), abdominal diameter (ABD) and ruminal diameter (RUD). The result revealed that between the 4th and 5th weeks, the conceptus could only be visualized by the transrectal approach (100%). Between the 6th and the 12th weeks, the conceptus was mostly observed through the left CAA (100%) and the transrectal (97.6%) approaches, but less repeatedly over the right CAA (66.7%) approach. From the 13th to the 27th weeks, the conceptus was mostly observed over the left CAA (100%), but less regularly through the right CAA (50%) and transrectal (31.8%) approaches. Between the 28th and 52nd weeks, the conceptus was chiefly detected via the left CRA approach (92.3%), but less often over right CRA (69.2%) and transrectal (60.3%) approaches. The EBD was the greatest accessible fetal parameter throughout transrectal and transabdominal examinations and the ABD was the slightest. It could be concluded that the transrectal, left CAA, and left CRA ultrasonography are the preeminent techniques for pregnancy diagnosis during early, mid-, and late gestation, respectively.

Quantifying the effect of biopsy lateral decubitus patient positioning compared to supine prostate magnetic resonance image scanning on prostate translocation and distortion.

More than a quarter of tumors are missed by magnetic resonance imaging/ultrasound (MRI/US) fusion-guided biopsy, the majority due to software-based misregistration. Transrectal approaches to biopsy are typically performed in the lateral decubitus position; conversely, diagnostic MRI is performed with the patient lying supine. Any position-related difference in prostate location or gland deformation could potentially exacerbate misregistration at subsequent biopsy. Fifteen healthy male volunteers (mean age 35.9 years, range 27-53) were included in this prospective, institutional review board-approved study. Each volunteer had an MRI performed in the supine position, followed by the second in the lateral decubitus position (mimicking a typical biopsy position). MRI images were co-registered and analyzed in order to assess prostate translocation and distortion. Whole prostate translocation of ≥5 mm was observed in 20% of patients and of ≥3 mm in 60% of patients. When dividing the prostate into prostatic sectors, the prostatic base demonstrated the largest positional difference. When plotting the translocation directions with relative volume difference, there was a moderate negative correlation trend in the latero-lateral direction. Only minimal distortion was observed, with similar distortion among all prostatic sectors. Positional change affects the prostate translocation, however, the effect on prostate distortion appears to be negligible. Prostate translocation in latero-lateral direction can be minimized with larger bladder volumes. Prostate translocation needs to be considered alongside software misregistration error; however, positional change should not affect software registration of MRI/US fusion-guided prostate biopsy.

Comparisons of cancer detection rate and complications between transrectal and transperineal prostate biopsy approaches - a single center preliminary study

BackgroundProstate biopsy remains the gold standard approach to verify prostate cancer diagnosis. Transrectal (TR) biopsy is a regular modality, while transperineal (TP) biopsy is an alternative for the patients who display persistently high levels of prostate-specific antigen (PSA) and thus have to undergo repeat biopsy. This study aimed to compare the cancer detection rates between TR and TP approaches and assess the post-bioptic complications of the two procedures. Besides, the feasibility of performing TP biopsies under local anesthesia was also evaluated.MethodsA total of 238 outpatient visits meeting the criteria for prostate cancer biopsy were enrolled for this study. They were divided into two groups: the TP group (n = 130) consists of patients destined to undergo local anesthetic TP biopsy; and the TR group (n = 108) contained those who received TR biopsy as comparison. Age, PSA level, digital rectal exam (DRE) finding, prostate volume, and biopsy core number were used as the parameters of the multivariable analyses. The comparable items included cancer detection rate, complication rate, admission rate and visual analog scale (VAS) score.ResultsThe cancer detection rates between TP and TR groups were quite comparable (45% v.s. 49%) (p = 0.492). However, the TP group, as compared to the TR group, had significantly lower incidence of infection-related complications (except epididymitis and prostatitis) that commonly occur after biopsies. None of the patients in the TP group were hospitalized due to the post-bioptic complications, whereas there was still a minor portion of those in the TR group (7.4%) requiring hospitalization after biopsy. Medians (25–75% quartiles) of visual analog scale (VAS) were 3 [3, 4] and 4 [3–5] respectively for the TP and TR procedures under local anesthesia, but no statistical significance existed between them (p = 0.085).ConclusionsPatients receiving TP biopsy are less likely to manifest infection-related complications. Therefore, TP biopsy is a more feasible local anesthetic approach for prostate cancer detection if there are concerns for infectious complications and/or the risk of general anesthesia.

2171 EUS-Guided Transrectal Drainage and Stent Placement for Large Presacral Abscess Secondary to Acute Appendicitis

INTRODUCTION: A presacral abscess is one of the most difficult abscesses to be drained. It is very challenging to drain it through the transabdominal route due to overlying pelvic structures. We present a patient with sizeable presacral abscess secondary to acute appendicitis that was drained transrectal under an endoscopic-ultrasound (EUS) guidance with stent placement. CASE DESCRIPTION/METHODS: A 23-year old male presented with worsening pelvic pain, fever, and chills for four weeks. He denies any change in the bowel movement, dysuria, recent trauma, or bladder or bowel incontinence. Past medical history was unremarkable and had no surgeries. Vital signs were normal except for the temperature of 101.2 F. Abdomen was soft, non-tender, with audible bowel sound. The rectal and genital exam was normal. Labs revealed Hgb 11.2 g/dl, WBC 17.9k/mm3, platelets 545k/mm3, creatinine 0.7 mg/dl, CRP 18.8 mg/dl, negative HIV, and negative urine and blood cultures. CT scan of the abdomen and pelvis revealed large presacral abscess and possibly ruptured acute appendicitis. Magnetic resonance enterography (MRE) showed 9.6 × 2.6 × 6.1 cm presacral abscess with acute ruptured appendicitis (Figure 1). Interventional Radiologist was consulted for drainage, but abscess was not amenable to be drained percutaneously. Despite being on intravenous antibiotics, the patient continued to be spiking febrile and having persistent pelvic pain. So, rectal endoscopic ultrasound (EUS) was performed and showed 5 cm × 3.5 cm abscess in the pre-rectal space (Figure 2). Aspiration was done with the 19-gauge needle using a transrectal approach. A 7Fr x 5 cm double pigtail plastic stent and a 10Fr x 5 cm double pigtail plastic stent were placed into the abscess (Figure 3). Good drainage from the stent was visualized into the rectum. Patient’s symptoms improved. Fluid cultures remained negative, Leukocytosis resolved, and he was discharged in a stable condition. He will follow up with a repeated CT pelvis in 2 weeks to assess for resolution of abscess and interval appendectomy. DISCUSSION: The presacral abscess is a complication with difficult management in the course of acute appendicitis. It is challenging to drain with the transabdominal route because of the overlying pelvic structures. EUS-guided transrectal drainage is safer and effective in these cases. The clinician should be aware of this treatment modality and considered as the first-line option.

2192 Endoscopic Drainage of a Perirectal Abscess Into the Rectal Lumen With a Lumen-Apposing Metal Stent Avoiding Percutaneous Drainage and the Presence of a Trans-Gluteal Catheter

INTRODUCTION: A 37-year-old woman developed abdominal pain, and diarrhea six weeks after a total hysterectomy with bilateral Salpingo-Oophorectomy was performed for a benign indication. A computer tomography (CT) scan of the abdomen and pelvis with intravenous contrast showed a perirectal abscess, measuring 6.2 × 5.7 × 6.1cm Figure 1. The perirectal abscess was drained transrectally by placement of a cautery enhanced 10 × 10 mm lumen opposing metal (LAM) stent, creating a fistula between the abscess and the rectum. CASE DESCRIPTION/METHODS: Using a transrectal approach, the perirectal abscess was imaged by endoscopic ultrasound (EUS). Under doppler ultrasound and fluoroscopic guidance, the abscess was punctured with a 19gauge fine needle aspiration (FNA) needle. A 450cm x 0.025-inch wire was passed through the needle and allowed to coil multiple times in the abscess for stability. The LAM stent was advanced over the wire 4 cm into the abscess and deployed in position Figure 2. There were no complications. Three weeks after the endoscopic placement of the LAM stent, a CT scan showed complete resolution of the perirectal abscess Figure 3. The same week, the stent was removed endoscopically without complications. DISCUSSION: This case demonstrates that LAM stents can be safely use for drainage of perirectal abscesses and non-malignant, wall mature perirectal fluid collections. The dumbbell shape design of the stent keeps the fistula tract intact preventing leaks and decreasing the incidence of stent migration and perforations. To safely deploy the distal end of the stent inside the fluid collection, the stent's catheter needs to be advanced 4 cm into the collection before deployment. If this is not accomplished the distal end of the stent may be deployed outside of the fluid collection causing a perforation. If a stable position of the EUS scope is secured there is no need to puncture the fluid collection with a 19-gauge FNA needle, nor to pass the wire into the cavity, because it can be directly accessed with the cautery enhanced tip of the stent's catheter affording a much shorter procedure time.Cases of bleeding have been reported after the collection has been drained and the cavity has collapsed; it is therefore suggested that the optimal time for stent removal is three weeks after stent placement once the fistula tract has been formed and resolution of the collection is confirmed by cross sectional imaging.

Complications and Adverse Events of Three Magnetic Resonance Imaging–based Target Biopsy Techniques in the Diagnosis of Prostate Cancer Among Men with Prior Negative Biopsies: Results from the FUTURE Trial, a Multicentre Randomised Controlled Trial

BackgroundThree techniques of magnetic resonance imaging (MRI)-based targeted biopsy (TB) of the prostate exist. There is no superiority regarding diagnostic efficacy of prostate cancer (PCa) detection. ObjectiveTo compare adverse events (AEs) among three TB techniques and to evaluate the effect on urinary and erectile function. Design, setting, and participantsPost hoc analysis of a multicentre randomised controlled trial among men with negative systematic biopsy (SB) and suspicion of PCa. InterventionIn 234 patients, 3-T multiparametric MRI demonstrated PIRADS≥ 3 lesions, and patients were randomised 1:1:1 for TB: transrectal in-bore MRI TB (MRI-TB), transperineal MRI-transrectal ultrasound (TRUS) fusion TB (FUS-TB), and transrectal cognitive TRUS TB (COG-TB). Outcome measurements and statistical analysisAEs (Clavien-Dindo) were compared using Pearson chi-square test. Univariate logistic regression tests were performed for the number of cores, biopsy approach, and usage of anticoagulants. The participants filled in baseline and 30-d postbiopsy International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) questionnaires. The delta between measurements was compared using one-way analysis of variance. Results and limitationsThere were significant differences in minor AEs: 53% in MRI-TB, 71% in FUS-TB, and 85% in COG-TB (p < 0.001). The number of cores was associated with AEs (odds ratio [OR] 1.11 per extra biopsy [95% confidence interval {CI} 1.06–1.17, p < 0.001]). Anticoagulants were not associated with bleeding complications (OR 1.24 [95% CI 0.66–2.35, p = 0.5]). Transrectal approach (MRI-TB + COG-TB) increased the risk of any AE (OR 2.54 [95% CI 1.16–5.77, p < 0.05]) and nonsignificantly increased the risk of urinary tract infections (OR 3.69 [95% CI 0.46–168.4, p = 0.3]). Biopsy did not impact urinary (ΔIPSS 0.3, p = 0.1) and erectile function (ΔIIEF-5 –0.4, p = 0.5). The main limitation was that additional SB was performed in FUS-TB and COG-TB, and was omitted in MRI-TB, making comparison difficult. ConclusionsThere was a significant difference in minor AEs among groups. An increase in the number of cores increased the overall risk of AEs. A low AE occurrence in MRI-TB was likely caused by the omission of SB. Prostate biopsy did not impact self-reported urinary and erectile functions. Patient summaryIn this study, we compared the complication rates of three techniques of magnetic resonance imaging (MRI)-based targeted biopsy of the prostate. We found a significant difference in the occurrence of minor complication rates among three groups in favour of transrectal in-bore MRI targeted biopsy, likely caused by the omission of additional systematic biopsy in this group.

Surgical resection for diverticulitis using robotic natural orifice intracorporeal anastomosis and transrectal extraction approach: the NICE procedure

Numerous studies have confirmed significant benefits of intracorporeal anastomosis (ICA)following colorectal procedures; however technical challenges have limited this approach following conventional laparoscopic surgery. The robotic Xiplatform serves as an enabling technology and has resulted in a surge of reports for right-sided ICA, however, there are no reports involving more complex left-sided procedures such as diverticulitis.Furthermore, there are no reports of natural orifice-assisted techniques using robotic Xiin which the specimen can be removed and the anvil can be placed transrectally, thereby completely eliminating the need for an abdominal wall incision other than for port sites. We present a pilot study to investigate the safety, feasibility and short-term outcomes of robotic Natural orifice-assisted IntraCorporeal anastomosis with transrectal Extraction of specimen, called the robotic NICE procedure. Consecutive patients presenting for elective resection for diverticulitis with formation of a colorectal anastomosis were entered into an IRB database. All patients underwent the robotic NICE procedure. Demographic data, intraoperative data and outcomes data were assessed and analyzed. Ten patients (five males and five females) underwent resection.The mean age and BMI were 56years (43-66) and 29kg/m2 (21-35). All procedures were successfully completed including transrectal extraction of the specimen and formation of an ICA. The mean operative time was198min (146-338)and mean EBL was35ml (15-50). Mean time to first flatus was 16h (10-22) and mean length of stay was 1.9days (1.6-2.6). There were no intraoperative or postoperative complications. There was no unexpected ICU stay, reoperation or readmission. Colorectal left-sided resections such as for diverticulitis were safely accomplished using natural orifice-assisted extraction of the specimen as well as complete intracorporeal anastomosis in this pilot study. The NICE procedure resulted in early return of bowel function, short length of stay and low complication. The complete elimination of abdominal wall incision likely accounts for these findings and larger cohorts of patients are to be investigated to explore this promising approach afforded by robotic technology.

Three-year experience of a dedicated prostate mpMRI pre-biopsy programme and effect on timed cancer diagnostic pathways

To evaluate the effect of pre-biopsy magnetic resonance imaging (MRI) on cancer diagnostic times, and to report MRI-directed pathology outcomes. In total, 1483 patients were referred with prostate cancer suspicion during a 30-month period. Upfront MRI was performed in 745 patients: 332 MRIs in the 15 months prior to dedicated scanning slots (group 1), and 413 in the 15 months post-introduction (group 2). A further 88 patients had initial MRI following clinical assessment. Biopsy via the transrectal (TR) or transperineal (TP) approach was performed, with MRI/ultrasound fusion for MRI targets. Clinically significant cancer (csPCa) was defined as Gleason ≥3+4. Negative MRIs were defined as Likert 1-2. Per-case clinical decisions were taken to biopsy or not. 44.4% of patients avoided biopsy. 484/833 (58.1%) MRIs were negative; 37.4% of these patients had biopsy with a negative predictive value (NPV) of 92.8% for Gleason ≥3+4 and 98.3% for ≥4+3. Overall prostate cancer prevalence was 34.3% (24.6% csPCa). In 323 MRI-positive cases, any cancer was present in 78.9% (csPCa 60.4%). Of the 1483 patients, 1232 (83.1%) completed all diagnostic tests within 28 days. Upfront MRI patients met this standard in 621/833 (74.5%), improving from 66.9% to 81.1% with reserved slots (group 2) with a reduced diagnostic time from median 25.5 to 20.9 days. Biopsy scheduling delayed the pathway in 69.7%, with MRI responsible in 22.3%, reducing to 10.3% in group 2. TP biopsies met the 28-day standard in significantly less cases (29.7%), compared to TR (67.4%, p<0.0001). Reserved MRI slots reduces time-to-diagnosis, and upfront MRI safely avoids biopsy in a significant proportion of men, whilst maintaining expected csPCa detection rates.

Lateral pararectal versus transrectal stoma placement for prevention of parastomal herniation.

A parastomal hernia is defined as an incisional hernia related to a stoma, and belongs to the most common stoma-related complications. Many factors, which are considered to influence the incidence of parastomal herniation, have been investigated. However, it remains unclear whether the enterostomy should be placed through, or lateral to the rectus abdominis muscle, in order to prevent parastomal herniation and other important stoma complications. To assess if there is a difference regarding the incidence of parastomal herniation and other stoma complications, such as ileus and stenosis, in lateral pararectal versus transrectal stoma placement in people undergoing elective or emergency abdominal wall enterostomy. For this update, we searched for all types of published and unpublished randomized and non-randomized studies in four medical databases: CENTRAL, PubMed, LILACS, Science Ciation Index, and two trials registers: ICTRP Search Portal and ClinicalTrials.gov to 9 November 2018. We applied no language restrictions. Randomized and non-randomized studies comparing lateral pararectal versus transrectal stoma placement with regard to parastomal herniation and other stoma-related complications. Two authors independently assessed study quality and extracted data. We conducted data analyses according to the recommendations of Cochrane and the Cochrane Colorectal Cancer Group (CCCG). We rated quality of evidence according to the GRADE approach. Randomized controlled trials (RCT)Only one RCT met the inclusion criteria. The participants underwent enterostomy placement in the frame of an operation for: rectal cancer (37/60), ulcerative colitis (14/60), familial adenomatous polyposis (7/60), and other (2/60).The results between the lateral pararectal and the transrectal approach groups were inconclusive for the incidence of parastomal herniation (risk ratio (RR) 1.34, 95% confidence interval (CI) 0.40 to 4.48; low-quality evidence); development of ileus or stenosis (RR 2.0, 95% CI 0.19 to 20.9; low-quality evidence); or skin irritation (RR 0.67, 95% CI 0.21 to 2.13; moderate-quality evidence). The results were also inconclusive for the subgroup analysis in which we compared the effect of ileostomy versus colostomy on parastomal herniation. The study did not measured other stoma-related morbidities, or stoma-related mortality, but did measure quality of life, which was not one of our outcomes of interest.Non-randomized studies (NRS)Ten retrospective cohort studies, with a total of 864 participants, met the inclusion criteria. The indications for enterostomy placement and the baseline characteristics of the participants (age, co-morbidities, disease-severity) varied between studies. All included studies reported results for the primary outcome (parastomal herniation) and one study also reported data on one of the secondary outcomes (stomal prolapse).The effects of different surgical approaches on parastomal herniation (RR 1.22, 95% CI 0.84 to 1.75; 10 studies, 864 participants; very low-quality evidence) and the occurrence of stomal prolapse (RR 1.23, 95% CI 0.39 to 3.85; 1 study, 145 participants; very low-quality evidence) are uncertain.None of the included studies measured other stoma-related morbidity or stoma-related mortality. The present systematic review of randomized and non-randomized studies found inconsistent results between the two compared interventions regarding their potential to prevent parastomal herniation.In conclusion, there is still a lack of high-quality evidence to support the ideal surgical technique of stoma formation. The available moderate-, low-, and very low-quality evidence, does not support or refute the superiority of one of the studied stoma formation techniques over the other.

MRI-TRUS fusion biopsy of the prostate: Quality of image fusion in a clinical setting.

Prostate cancer (PCa) is one of the most common malignancies in men. The diagnostic standard to confirm prostate cancer is the transrectal ultrasound-guided biopsy. However, this procedure is associated with the underdetection of clinically significant prostate cancer and therefore needs to be improved. In the last years MRI fusion based targeted biopsy gained importance as consequence. In this study, we evaluated the quality of MRI ultrasound image fusion and evaluated factors influencing the image fusion quality. This was done by comparing fusion quality with the histopathological findings in the defined MRI target on the one hand and the PIRADS score on the other hand. Single arm study including patients with elevated prostate specific antigen (PSA) and a multiparametric MRI showing a suspicious lesion underwent a MRI fusion targeted biopsy at our institution. MRI fusion targeted biopsy and an additional 12-core transrectal ultrasound (TRUS) guided biopsy was performed using the Philips Percunav device (Philips Medical Systems, Bothell, WA). The fusion accuracy was rated by two experienced clinicians (1 radiologist, 18 years of experience, 1 urologist, 5 years of experience) using a five-point rank scale (1 = best) and comparing the result with the histological findings in the target and the PIRADS score. The detection rate of clinically significant cancer (Gleason 7a or greater) by MRI-ultrasound fusion targeted biopsy was 58.6% (17/29) compared to 50% (19/38) in the standard transrectal ultrasound-guided approach. PCa was found in 36.4% (4/11 patients) of patients with a PIRADS 3 lesion, in 57.7% (15/26 patients) of patients with a PIRADS 4 lesion. In 76.9% (10/13 patients) of patients with a PIRADS 5 lesion PCa was diagnosed. No statistical significance was found comparing the quality of registration either with the PIRADS (p = 0.7873) nor with the Gleason score (p = 0.4376). The study is limited by the small number of patients. MRI fusion based targeted biopsy improves the identification of clinical significant cancer. The Gleason score of detected PCa is not influenced by the quality of fusion.

Clinical Impact of Endoscopic Ultrasound in the Evaluation of Subepithelial Lesions of the Lower Gastrointestinal Tract: 10-Year, Single-Center Experience

Introduction: Endoscopic ultrasound (EUS) is the most accurate imaging method for evaluation of subepithelial lesions (SELs) of the gastrointestinal (GI) tract. However, reports on the use of EUS in SELs of the lower GI tract are currently limited. We aim to analyze the utility of EUS and its role in the management of lower GI SELs. Methods: Records of all patients who were referred for lower EUS evaluation of a SEL at a tertiary center between 2007 and 2018 were retrospectively reviewed after IRB approval. Data collection included patient and lesion characteristics, technical details of the procedure as well as pathology results and follow-up if available. Lesions were further subcategorized according to their size, location and final diagnosis. Results: A total of 53 patients underwent 57 EUS exams for the evaluation of a suspected SEL in the lower GI tract. Most patients were referred for EUS examinations because of abnormal findings on other imaging methods (64%). The lesions were located most frequently in the rectum (48%), followed by sigmoid (21%), cecum (10.5%) and transverse colon (9%). A statistically significant correlation between gender and location of SELs was found, with lesions located in the rectum being more frequent in women (p=0.04). The main characteristics of the SELs detected on EUS are summarized in Table 1. EUS scope (linear or radial) was used in 44 cases while EUS miniprobe was used in 13 cases. In 13 patients (22.8%), no lesion could be identified by EUS. In 2 of these cases the final diagnosis was low grade neuroendocrine tumor, and the lesion was seen on endoscopy but the size was too small to be detected on EUS. Twenty-two EUS-guided fine needle aspirations and 8 EUS-core biopsies were performed, with only 3 non-diagnostic samples and 95.3% of the remaining samples confirming the presumptive diagnosis (Figure 1). All the lesions that were samples were 1 cm or larger. None of the patients developed any complications related to the EUS procedure.505 Figure 1. 33-year-old male with perirectal mass of unknown etiology identified during workup of tenesmus A. Endoscopic findings: A subepithelial non-obstructing large mass (5cm in length) was found in the distal rectum. B. Endosonographic findings: A heterogenous (hypoechoic and hyperechoic), well-defined mass was found in the right-lateral perirectal space. It appeared to be contiguous with the muscularis propria suggesting that it is arising from the muscularis propria or is invading it. C. Elastography: Quality assessment indicated an overall hard tumor, highly suggestive of malignancy D. Fine needle aspiration for cytology was performed. Three passes were made with the 22 gauge needle using a transrectal approach. Fine needle biopsy was also performed. Two passes were made with the 20 gauge ProCore biopsy needle using a transrectal approach. Pathology results: cytology- smears showed tumor cells with oval nuclei and scant cytoplasm and sclerotic stroma; core biopsy-solitary fibrous tumor (IHC: tumor cells positive for STAT6 with patchy positivity for CD34).Conclusion: To the best of our knowledge, this is the largest cohort study regarding the clinical impact of EUS in the evaluation of SELs in the lower GI tract. EUS is a safe and accurate method as it provides valuable information regarding the location of the lesions (intramural or extramural), echogenic characteristics and their malignant potential. EUS-guided fine needle aspiration or core biopsies are feasible and safe and can be used to obtain tissue from SELs located deeper to the mucosa with a high diagnostic accuracy.

Determination of the gestational age through ultrasound measurements of some uterine and foetal parameters in Bulgarian local goats.

The aim of the current study was to determine the gestational age in goats through the measurement of some foetal and uterine structures. Twenty-four pregnant Bulgarian local goats were submitted to ultrasound foetometry by transrectal and transabdominal approaches. Ultrasound measurement of studied parameters was done at 7-day intervals during the first trimester of gestation (days 21-49) and at 14-day intervals between gestation days 49 and 133. Associations of foetometry data with foetal age were investigated by linear (y=a+bx), quadratic (y=ax2 +bx+c) and exponential (y=axn ) equations. According to the results, some biometric parameters (uterine lumen diameter, crown-rump length, trunk diameter, biparietal diameter, foetal aortic diameter) exhibited a stronger correlation to gestational age (R2 ≥0.90) and lower standard error of the estimate (SEE≤8) as compared to foetal eye orbit diameter, and outer and inner placentome diameters (R2 ≤0.90; SEE≥8). Each of these biometric parameters could be measured in different periods of gestation, thus allowing for monitoring and determination of foetal age at almost all stages of pregnancy.