Transrectal Approach Research Articles

MR imaging-guided prostate interventional imaging: Ready for a clinical use?

Prostate interventional magnetic resonance imaging (MRI) is now routinely performed in many centers. Its more widespread acceptance is limited by the cost of the use of MRI largely related to the long duration time of the procedures. However, the benefit of a robotic assistance has generated a new interest, because it substantially shortens the procedure time, while improving the accuracy. MRI-guided biopsy is considered as an appealing alternative to transrectal ultrasound (TRUS)-guided fusion biopsy, given the limitations of TRUS-MRI image registration systems. MRI-guided focal treatment also benefits from robotic assistance and from the unique property of MRI, which allows the measurement of the temperature in real-time during tumor ablation. The transrectal and transperineal approaches can be used and the respective indications of each pathway will depend on several factors, including the location of the tumor and the examination time, which will condition the occupation time of the MR room, a major factor influencing the overall cost of MRI-guided procedures. This review addresses the current practice of prostate MRI-guided interventional procedures and potential future applications.

National survey of fiducial marker insertion for prostate image guided radiotherapy

IntroductionIn the United Kingdom fiducial marker IGRT is the second most common verification method employed in radical prostate radiotherapy yet little evidence exists to support centres introducing or developing this practice. We developed a survey to elicit current fiducial marker practices adopted in the UK, to recommend standardisation of practice. MethodsA 16 question survey was distributed across UK Radiotherapy centres via promotion at the British Uro-Oncology Group Conference, 2016. Included were questions relating to workforce planning, patient preparation, insertion procedure and verification methods. The survey was open from September 2016 to January 2017. ResultsResults from 15 centres routinely inserting fiducial markers for prostate IGRT are presented. Eleven professional groups insert fiducial markers across the UK. Fourteen centres insert fiducial markers trans-rectally; one trans-perineally. Centres adopting a trans-rectal approach administer prophylactic ciprofloxacin as a single agent or combined with gentamicin or metronidazole; poor agreement between regimes presented. One centre has introduced targeted antibiotic prophylaxis.Five brands of fiducial markers are utilised nationally. Fourteen centres standardly insert three single fiducial markers, two common configurations emerged. Coupled fiducial markers are routinely implanted by one centre.All centres delay at least one week between fiducial marker insertion and planning CT; seven centres wait two weeks. The most common fiducial verification method is two-dimensional, paired kilo Voltage imaging. ConclusionVariation in fiducial marker practice across the UK is considerable. Standardisation is required to support centres and healthcare professionals developing this service. Seven recommendations, to unify practice, have been proposed based on survey results and literature.

Pelvic abscess drainage: outcome with factors affecting the clinical success.

We aimed to evaluate the success and complication rates of image-guided pelvic abscess drainage with emphasis on factors affecting the clinical success. During a 7-year period, 185 pelvic abscesses were treated in 163 patients under ultrasonography and fluoroscopy (n=140) or computed tomography (n=45) guidance with transabdominal (n=107), transvaginal (n=39), transrectal (n=21) and transgluteal (n=18) approaches. Abscess characteristics (etiology, number, size, intrastructure, microbiological content, presence of fistula), patient demographics (age, sex, presence of malignancy, primary disease, antibiotic treatments), procedure-related factors (guidance method, access route, catheter size) and their effects on clinical success, complications, and duration of catheterization were statistically analyzed. Technical and clinical success rates were 100% and 93.9%, respectively. Procedure-related mortality or major complications were not observed. Minor complications such as catheter dislodgement, obstruction, or kinking were detected in 6.7% of the patients. Clinical failure was observed in 10 patients (6.1%). Fistulization was observed in 14 abscesses. Fistulization extended the duration of catheter use (P < 0.001) and decreased the clinical success rate (P < 0.001). The presence of postoperative malignant, complex-multilocular abscesses, and fungus infection in the cavity extended catheter duration (P < 0.001, P = 0.018, and P = 0.007, respectively), whereas the presence of sterile abscess and endocavitary catheterization reduced the catheter duration (P = 0.009 and P = 0.011, respectively). Image-guided pelvic abscess drainage has high clinical success and low complication rates. The only factor affecting the clinical success rate is the presence of fistula.

Two dimensional trans-rectal ultrasonographic studies in early pregnant murrah buffaloes

Two dimensional ultrasonographic studies were conducted in six pregnant Murrah buffaloes using 5.0-7.5 MHz frequency rectal probe twice a week from day 18 to 60 days followed by weekly interval up to 90 days postin semination. Two dimensional images of antenatal fetal organs particularly fetal stomach, eye, limbs, heart, umbilical cord, thorax, liver and placentomes were imaged and variat ions in size of placentome, stomach and crown rump length were measured. Fetal heart beat was measured from day 26 to 90 which decreased with advancement of gestation. From the present study it may be concluded that early pregnancy can be diagnosed ultrasonogra phicallythrough trans-rectal approach by day 26 post insemination.

Fused-data transrectal EIT for prostate cancer imaging

Objective: Prostate cancer is a significant problem affecting 1 in 7 men. Unfortunately, the diagnostic gold-standard of ultrasound-guided biopsy misses 10%–30% of all cancers. The objective of this study was to develop an electrical impedance tomography (EIT) approach that has the potential to image the entire prostate using multiple impedance measurements recorded between electrodes integrated onto an end-fired transrectal ultrasound (TRUS) device and a biopsy probe (BP). Approach: Simulations and sensitivity analyses were used to investigate the best combination of electrodes, and measured tank experiments were used to evaluate a fused-data transrectal EIT (fd-TREIT) and BP approach. Main results: Simulations and sensitivity analysis revealed that (1) TREIT measurements are not sufficiently sensitive to image the whole prostate, (2) the combination of TREIT + BP measurements increases the sensitive region of TREIT-only measurements by 12×, and (3) the fusion of multiple TREIT + BP measurements collected during a routine or customized 12-core biopsy procedure can cover up to 76.1% or 94.1% of a nominal 50 cm3 prostate, respectively. Three measured tank experiments of the fd-TREIT + BP approach successfully and accurately recovered the positions of 2–3 metal or plastic inclusions. Significance: The measured tank experiments represent important steps in the development of an algorithm that can combine EIT from multiple locations and from multiple probes—data that could be collected during a routine TRUS-guided 12-core biopsy. Overall, this result is a step towards a clinically deployable impedance imaging approach to scanning the entire prostate, which could significantly help to improve prostate cancer diagnosis.

Performance Characteristics of Transrectal Shear Wave Elastography Imaging in the Evaluation of Clinically Localized Prostate Cancer: A Prospective Study

We tested the diagnostic accuracy of shear wave elastography to detect and phenotypically characterize prostate cancer compared with whole mount radical prostatectomy histopathology. In this prospective, protocol driven, diagnostic accuracy study 212 consecutive men undergoing laparoscopic radical prostatectomy for clinically localized prostate cancer were recruited. Quantitative stiffness data on the prostate gland were obtained in each patient using an endocavitary transrectal transducer before laparoscopic radical prostatectomy. Those data were compared with a detailed histopathological examination of the radical prostatectomy specimen using 3-dimensional printing mold based technology to ensure an improved image histology orientation. ROC curves were assessed between the groups. Quantitative stiffness data estimated in kPa were significantly higher in malignant compared with benign areas. At a cutoff of 82.6 kPa the sensitivity and specificity of shear wave elastography were 96.8% and 67.8%, respectively (p<0.01). Significant differences were observed for different cancer grades with the Young moduli, including 91.6, 102.3 and 131.8 kPa for low grade (Gleason score 6), intermediate grade (Gleason score 7) and high grade (Gleason score 8 or greater) prostate cancer, respectively (p <0.05). Shear wave elastography also detected capsular breaches with significant prediction of prostate cancer pathological staging. Potential limitations include selection bias and study being single center site. Quantitative shear wave elastography via the transrectal approach accurately detected cancer foci and revealed significant differences between cancerous and benign tissue. Moreover, this technique can be used to reliably phenotype prostate cancer aggressiveness.

An update on prostate biopsy in the era of magnetic resonance imaging.

Prostate cancer (PCa) is a singular disease owing to absence of imaging technique able to detect suspicious glandular area at higher risk of disease. Nowadays, magnetic resonance imaging (MRI) has been used as a way to detect PCa and simplify targeting prostate biopsy (PB). The aim of this study is to review the most recent data regarding standard BP and MRI-guided PB. A comprehensive systematic MEDLINE search was performed in December 2017 for English-language reports by using the following terms: "prostate biopsy," "multiparametric magnetic resonance imaging," "prostate cancer," "transrectal and transperineal ultrasound," "target biopsy." Previous published reviews and recent published original articles were preferred in order to meet our study scope. Retrieved studies of greater interest were reported in two main sections: standard PB and MRI-guided BP. Thus, the main items regarding PB were analyzed. Briefly, clinical suspicious of PCa is based on prostate specific antigen level and digital rectal examination findings although a PCa risk assessment through a nomogram risk calculator is nowadays advised. Ten-eighteen biopsy cores, depending on prostate volume, and peripheral sampling seem the suitable scheme for initial biopsy while a saturation template (>20 cores including transitional prostate area) is widely used in case of repeat PB. Performing a local anesthesia is now the standard of care with several available techniques. No difference exists in term of PCa detection rate between transperienal and transrectal approaches however the last one is mostly used. The use of MRI-guided biopsy seems to be a promising imaging technique able to identify an index lesion at higher suspicious of PCa. In particular, MRI shows a higher accuracy than standard PB in the detection of clinically significant PCa. No general consensus exists on which MRI-guided biopsy should be used with three different ways currently available to take biopsy core. However, the initial MRI cognitive PB has been replaced by fusion MRI technique to guide biopsy with reproducible results. Absence of standardization founded in initial MRI studies has been recently revised by introduction of common criteria to assess PCa presence on MRI. PB is the cornerstone in diagnosis and management of PCa. Although ultrasound transrectal and transperineal PB are still considered as the standard, emerging data confirm the role of MRI-guided biopsy, particularly in patients with a previous negative biopsy. However, MRI costs and the moderate inter-reader reproducibility of the exam are still significant concerns requiring further studies to define the right role of MRI in the PCa diagnostic pathway.

Editorial Comment

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.

Identification of occult prostate malignancy in a large patient cohort using a stereotactic transperineal prostate biopsy technique.

9 Background: Continued rising PSA, despite prior transrectal prostate biopsy (TRPB), can cause significant anxiety for patients and physicians. This study investigates the detection rate of non-palpable, isoechoic occult malignancy using a stereotactic transperineal prostate biopsy (STPB) technique in patients with previous negative TRPB. Methods: 2,565 men with continued rising prostate specific antigen (PSA) with a minimum of 1 prior benign TRPB, underwent STPB at a single out-patient institution between 04/04 - 02/17 (See table). Specimens were obtained according to x, y, and z coordinates from 8 equal octants with pathology reported accordingly. A greater number of specimens were obtained from the apical half than the basilar half of the prostate; this was attributed to smaller glands in which the apical specimens sufficiently sampled the anterior curvature of the gland. Results: STPB yielded adenocarcinoma in 965/2,565 (37.6%) patients. The number of biopsy cores obtained per patient approximated the prostate gland volume in cm3. Statistical analysis demonstrated there was a significant difference in detection rates with the apex having a higher incidence of malignancy than the base of the prostate gland (p=.000). Furthermore, the anterior apex harbored significantly more adenocarcinoma when compared to the posterior apex (p=.026). Conclusions: STPB is efficacious for diagnosis of non-palpable, isoechoic occult prostate malignancy. Repeated sequential analysis of malignancy identification has consistently resulted in approximately 40% positive yield. Furthermore, a possible explanation for the significant finding in this study that occult malignancies occupy a higher percentage of apical biopsies using STPB may be related to difficulty and limitations of apical sampling using a standard transrectal biopsy approach. [Table: see text]

Clinical Application of Ultrasound in Male Voiding Dysfunction

Ultrasound is the most widely used imaging modality in the assessment of male voiding dysfunction. The lower urinary tract can be in imaged by transabdominal, transrectal, and transperineal approaches. There is an emerging role of transperineal ultrasound in pelvic floor physiotherapy and also in the evaluation of male sling, especially in failed sling cases. Common applications of ultrasound in lower urinary tract (LUT) dysfunction include measurement of post-void residual volume, prostate size, bladder wall thickness, and intravesical protrusion of the prostate (IPP). IPP measurement by transabdominal ultrasound of the bladder base is the most established non-invasive imaging parameter in the diagnosis of bladder outlet obstruction (BOO).

Interpretation of Chinese guidelines for the diagnosis and treatment of constipation surgery (2017)

The Chinese Society of Coloproctology (CSCP) released the updated "guidelines for the diagnosis and treatment of constipation surgery" in 2017. The major amendments include the following aspects: (1) According to defecation reflex involving parts of the classification, the cause of constipation is divided into three parts, including colorectal factors, internal and external colorectal factors. The new division is more rational, easy to make clear the location and the possible pathogenesis. (2) Constipation is divided into slow transit constipation, outlet obstructive constipation and mixed constipation. The main consideration of this division is the name of the surgery for the outlet obstructive constipation, such as the rectal prolapse and the rectocele. (3) The 6-hour observation time point is added in the colonic transit test and to make clear whether the stomach and the small intestine has slow transit. (4) Micro ecological preparations, promoting dynamic drugs and promoting secretion drugs as well as psychological treatment and acupuncture treatment are added in non-surgical treatment of constipation (5) The antegrade colonic enema is removed from surgical treatment of slow transit constipation; in the surgical treatment of internal rectal prolapse, STARR surgery is added and Delorme surgery is deleted; transrectal and transperineal approach are added in the surgical treatment of rectocele. In this paper, we compare the domestic and international constipation-related guidelines, and summarize the main revisions in the 2017 edition of "guidelines for the diagnosis and treatment of constipation surgery".

Current Progress and Controversies in Prostate Cancer Management.

Objective:The optimal management strategy for prostate cancer (PCa) remains controversial. We performed a systemic review of current progress and controversies regarding the diagnosis and treatment of PCa.Data Sources:We searched PubMed for recently published articles up to July 2017 using the following key words: “prostate cancer,” “progress,” “controversy,” “immunotherapy,” and “prevention.”Study Selection:Articles were obtained and reviewed to provide a systematic review of the current progress and controversies regarding PCa management.Results:The value of serum prostate-specific antigen (PSA) screening remains controversial, but PSA screening is recommended to facilitate the early diagnosis of PCa in high-risk groups. Prostate biopsy via the transrectal or perineal approach has both advantages and disadvantages. There was a significant correlation between testosterone levels and PCa prognosis. The current research is focused on the mechanisms responsible for PCa. Active surveillance has been proposed as a management strategy for low-risk, localized PCa, but there is an urgent need for further clinical studies to establish the criteria for recommending this approach. The main complications of radical resection for PCa are urinary incontinence and erectile dysfunction, though three-dimensional laparoscopic and robot-assisted laparoscopic techniques have obvious advantages over radical surgery. Radiotherapy is also a therapeutic option for PCa, while immunotherapies may alter the prostate tumor microenvironment. Ongoing studies aim to provide guidance on effective sequential and combination strategies. Prevention remains an important strategy for reducing PCa morbidity and mortality.Conclusions:The diagnosis, treatment, and prevention of PCa are complex issues, worthy of intensive study. Further studies are needed to improve the management of PCa.

P18.09: Retzius' retroperitoneal bladder endometriosis: a new entity of an enigmatic disease

To report Retzius' space retroperitoneal bladder deep infiltrating endometriosis (DIE), a new and unusual anatomic site which makes challenging both the diagnosis than the surgical treatment. Consecutive fertile women with DIE complaining endometriosis-related urinary symptoms were prospectively enrolled. 3D- transvaginal sonography (TVS) was performed in all patients with the GE Voluson E8 unit, using a wide-band 3-9 MHz transducer. 3D-TVS was performed with a properly strict methodology as diagnostic tool, based on a properly mid-filled bladder volume (100-150 mL). VCI analysis by 2mm slices of the stored 3D multiplanar examinations was considered for the evaluation of bladder nodules. Surgery was based on laparoscopic management of retroperitoneal bladder DIE, medical treatment on continuous oral contraceptives (COC). Demographic, medical, imaging and surgical data were recorded. Eight patients were enrolled. Median age was 34 years (range 24-43) years. Retroperitoneal bladder endometriotic nodules typically appear as ventral smooth, hypoechoic, homogeneous oval-shaped lesions. Laparoscopic surgery, performed in two cases, showed negative peritoneal findings, with the need to approach to the Retzius space in combination with a transurethral endoscopic approach and/or transrectal sonography to intra-operatively identify otherwise macroscopically normal appearance bladder wall. Medical therapy by COC permitted to control pain in most of symptomatic patients. 3D-TVS confirmed to be the standard technique to investigate patients complaining DIE-related urinary symptoms. Laparoscopic surgery might be incomplete because of negative peritoneal findings. A combined transurethral endoscopic and/or transrectal sonographic approach is a safe and easy technique for the management of Retzius' space retroperitoneal bladder DIE, with low risks and good resolution of symptoms.

Abstract CT103: A phase II study to evaluate outpatient magnetic resonance image-guided laser focal therapy for prostate cancer: A 20-year survival study (seven-year interim results)

Abstract Purpose: In the United States alone, new prostate cancer cases for 2016 were estimated at 180,890 and deaths at 26,120. Focal therapies for low risk and intermediate risk localized prostate cancer are increasingly being explored. Additionally, new treatments for patients with biochemical recurrence of prostate cancer are also under investigation. Our objective is to investigate the safety and feasibility of using outpatient MR-guided laser focal therapy for MR visible prostate cancer utilizing a transrectal approach for laser applicator placement and therapy delivery in an outpatient setting. Method and Materials: All MRI-guided therapy was delivered using a 1.5 Tesla MRI system for both image acquisition and real-time thermometry. Commercially available hardware and software were used for image analysis and interventional planning. Laser therapy was delivered using a 15W, 980 nm diode laser applicator with fiber-cooling catheter introduced transrectally using a commercially available MRI-compatible introducer system. Results: 80 men were treated. 112 cancer foci were treated. Total procedure time was between 1.5 and four hours MRI volume of coagulation necrosis ranged from 0.57 to 22.93 cc. No serious adverse events or morbidity were reported. 17 treatment regions were positive at six months biopsy, consistent with residual or recurrent cancer 26% of subjects 18% of treated regions.We observed a 40% decrease in mean PSA at 1 year post therapy and no statistically significant change in IPSS and SHIM scores at 6 months post-treatment. Conclusion: Our data indicate that outpatient, transrectally delivered MRI-guided laser focal therapy for prostate cancer is both safe and feasible. Clinical Relevance/Application: In the current climate of cost-reduction and emphasis on minimally-invasive treatment of cancer, focal treatment of prostate cancer may be an attractive option. The precise energy delivery under MRI-guidance may have favorable results for cost control and quality of life without eliminating the possibility of whole-gland treatment in the patient’s future. Citation Format: Bernadette Marie Greenwood, John F. Feller, Stuart T. May, Wes Jones, Axel Winkel. A phase II study to evaluate outpatient magnetic resonance image-guided laser focal therapy for prostate cancer: A 20-year survival study (seven-year interim results) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr CT103. doi:10.1158/1538-7445.AM2017-CT103

Role of 18F-Choline PET/CT in guiding biopsy in patients with risen PSA levels and previous negative biopsy for prostate cancer

ObjectivesTo study 18F-Choline PET/CT in the diagnosis and biopsy guide of prostate cancer (pCa) in patients with persistently high prostate-specific antigen (PSA) and previous negative prostate biopsy. To compare the clinical risk factors and metabolic variables as predictors of malignancy. MethodsPatients with persistently elevated PSA in serum (total PSA >4ng/mL) and at least a previous negative or inconclusive biopsy were consecutively referred for a whole body 18F-Choline PET/CT.Patient age, PSA level, PSA doubling time (PSAdt) and PSA velocity (PSAvel) were obtained.PET images were visually (positive or negative) and semiquantitatively (SUVmax) reviewed. 18F-Choline uptake prostate patterns were defined as focal, multifocal, homogeneous or heterogeneous. Histology on biopsy using transrectal ultrasound-guided approach was the gold standard.Sensitivity (Se), specificity (Sp) and accuracy (Ac) of PET/CT for diagnosis of pCa were evaluated using per-patient and per-prostate lobe analysis. Receiver-operating-characteristic (ROC) curve analysis was used to assess the value of SUVmax to diagnose pCa.Correlation between PET/CT and biopsy results per-prostate lobe was assessed using the Chi-square test. Univariate and multivariate logistic regression analysis were applied to compare clinical risk factors and metabolic variables as predictors of malignancy. ResultsThirty-six out of 43 patients with histologic confirmation were included. In 11 (30.5%) patients, pCa was diagnosed (Gleason score from 4 to 9). The mean values of patient age, PSA level, PSAdt and PSAvel were: 65.5 years, 15.6ng/ml, 28.1 months and 8.5ng/mL per year, respectively.Thirty-three patients had a positive PET/CT; 18 had a focal pattern, 7 multifocal, 4 homogeneous and 4 heterogeneous. Se, Sp and Ac of PET/CT were of 100%, 12% and 38% in the patient based analysis, and 87%, 29% and 14% in the prostate lobe based analysis, respectively. The ROC curve analysis of SUVmax showed an AUC of 0.568 (p=0.52).On a lobe analysis, poor agreement was observed between PET/CT findings and biopsy results (p=0.097). In the univariate/multivariate analysis, none of clinical and metabolic variables were statistically significant as predictor of pCa. ConclusionCholine PET/CT is a suitable procedure for the detection of pCa in highly selected patients, however, a high rate of false positive should be expected.

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.

Prevention of infectious complications after prostate biopsy procedure.

Although febrile complications are rarely encountered after a prostate biopsy procedure, in recent years the number of cases of fatal infection after that have increased along with increases in resistant bacteria. The available biopsy approaches are transrectal and transperineal, with the transrectal approach primarily used. As the invasion path of the puncture needle differs between these approaches, pretreatment and the method of administration of preventive antimicrobial drugs should be separately considered for infection prevention. Recently, the Japanese guidelines for perioperative infection prevention in the field of urology were revised after receiving approval from the Japanese Urological Association. With use of the transrectal approach, attempts have been made to selectively administer prophylactic antibiotics by confirming the presence or absence of resistant bacteria in rectal swab culture results before carrying out a prostate biopsy procedure because of potential problems associated with resistant bacteria in rectal flora. For preventive antibiotics, a single dose of oral quinolone is recommended for patients with low risk, whereas daily administrations of piperacillin/tazobactam are recommended for those considered to be high risk. In contrast, for the transperineal procedure, a single dose of oral quinolone is recommended as a preventive antibiotic. With both approaches, it is important to empirically administer broad-spectrum antimicrobials when occurrence of a febrile infection after a prostate biopsy procedure is confirmed.

The anterior sagittal transrectal approach (ASTRA) for cases associated with rectal implantation of the urethra: A retrospective review of six cases

Severe genital abnormalities such as urogenital sinus and urethral duplication with ectopic urethra in the rectum represent a major challenge in reconstructive urology. We aimed to review our cases presenting with functional ectopic urethra implanted in the rectum that were treated through an ASTRA approach. We reviewed the medical records of all patients who had undergone an ASTRA approach from 2005-2016. We collected data with interest to primary diagnosis, clinical presentation, additional procedure, immediate clinical outcome, complications, bowel habits after surgery, voiding and bladder emptying pattern and long term follow-up. Since 2005, we treated 6 cases using this method, consisting of 3 patients with congenital aphallia and 3 with Y-type urethral duplication. Two aphallia patients underwent De Castro's neophalloplasty with simultaneous anastomosis of proximal urethra to a tubed buccal mucosa neourethra and one had a neophalloplasty with transverse skin flaps and primary perineal urethrostomy. Two patients with Y-type urethral duplication had a complete urethroplasty performed (one end-to-end anastomosis and a two-stage repair). Last patient had a definitive perineal urethrostomy. At mean follow-up of 83.5 meses, only one patient voids through the urethra, four have a Mitrofanoff channel and two have a perineal urethrostomy. Immediate follow-up was uneventful and none of our patients had any bowel complications nor fecal incontinence. Domini et al. were the first proponents of the anterior sagittal transanorectal approach (ASTRA) as an alternative to classic Peña approach. Later, De Castro popularized specifically this technique as a relevant part of his neophalloplasty procedure to treat congenital aphallia. We did not find in this series any complications related to ASTRA technique in regards to bowel habits, fecal incontinence or infection but most of cases we tried to create a new anterior urethra and connect to the proximal stump failed. Moreover, we are skeptic to support simultaneous urethral repair when there is a dysplastic bulbar segment between the proximal stump and the end of the penile urethra normally at penoscrotal junction area by urethral duplication. Treatment at two-stages is also prone to fail in the midterm. At end, most of them will have either a Mitrofanoff or perineal urethral stoma as shown in our data. The ASTRA approach proved to be useful for cases of rectal implantation of the urethra. No complications related to anterior sphincter incision were documented. We believe it should be regarded as the treatment of choice for cases alike ours.

Evaluation of MRI/Ultrasound Fusion-Guided Prostate Biopsy Using Transrectal and Transperineal Approaches.

Purpose To evaluate transrectal (TR) and transperineal (TP) approaches for MRI/ultrasound (MRI/US) fusion-guided biopsy to detect prostate cancer (PCa). Materials and Methods 154 men underwent multiparametric MRI and MRI/US fusion-guided biopsy between July 2012 and October 2016. 79/154 patients were biopsied with a TR approach and 75/154 with a TP approach. MRI was retrospectively analyzed according to PI-RADS version 2. PI-RADS scores were compared with histopathological results. Descriptive statistics, accuracy, and negative and positive predictive values were calculated. Histopathological results of first, second, and third MRI targeted biopsy cores were compared to evaluate the impact of one verus multiple targeted cores. Results Detection rates of PCa were 39% for TR biopsy and 75% for TP biopsy. Sensitivity/specificity for tumor detection with PI-RADS ≥ 4 were 81/69% for TR biopsy and 86/84% for TP biopsy. In 31% for TR biopsy and 19% for TP biopsy, PCa was found in the second or third MRI targeted biopsy core only. Conclusion MRI/US fusion-guided biopsy may be conducted with the TR as well as the TP approach with high accuracy, giving more flexibility for diagnosis and the option for focal treatment of PCa.

Fate of males with urethral “Y-duplication”: 40-year long follow-up in 8 patients

PurposeThe spectrum of male urethral duplication is heterogeneous and it includes the Y-duplication. The malformation is rare and there is only a few case series reported in the literature. The management of Y-forms remains challenging for the surgeon and the long-term follow-up is still scarcely investigated. We report our 40-year experience in the management of patients with Y-duplication. Materials and methodsWe conducted a restrospective analysis collecting information of patients with urethral Y-duplication treated at our department from April 1975 to April 2015. We investigated long-term effects of surgery by using a questionnaire. ResultsTen male patients with Y-duplication came to our attention. One was treated conservatively, seven underwent surgery and two were lost. Surgery consisted of removal of the ectopic branch (via perineal or ASTRA/anterior sagittal trans-rectal approach approach) and reconstruction of the orthotopic urethra. Post-operative complications included stenosis and infections. Long-term results are influenced by associated anomalies and significant problems (incontinence, urinary tract infections and orchiepididimitis) have been reported. ConclusionsY-duplication (or λ-duplication, as we prefer calling it) is a particular form of urethral duplication. The management of patients should be based upon the identification of the functional channel. The removal of the ectopic channel with ASTRA approach is safe and feasible. On the other hand, the reconstruction of the anterior urethra (when steno-atresic) is more challenging and justifies the need for many procedures. The P.A.D.U.A. (progressive augmentation by dilating the anterior urethra) technique was not effective. Skin tube grafts were responsible for infections (“hairy urethra”). BMFG (bladder mucosa free graft) urethroplasty is a good alternative, although associated with well-known complications. Associated anomalies influence long-term outcomes.Clinical study with type IV level of evidence.