Articles tagged with: PSA screening

08
September
2015

Prostate biopsy infection - antibiotic resistance

Prostate biopsy infection - antibiotic resistance

Infections associated with prostate biopsy have increased over time, and there is growing evidence of infections that are resistant to the antibiotics used to prevent infection.

Resistant infections after trans-rectal prostate biopsy (TRUS)

About 1-2% of patients who have a TRUS biopsy of the prostate will develop a febrile infection, which can be serious. Antibiotics (usually ciprofloxacin) are used before and after biopsy to keep this infection rate at 1-2%. However, there is increasing evidence that many of us carry bacteria in our gut (and rectum, where the needle is passed through to reach the prostate) that are resistant to ciprofloxacin.

A recent study from the Journal of Urology (Liss et al.) looked at 2673 men from 6 different medical centres undergoing biopsy and discovered cirpofloxacin-resistant bacteria in the rectum in 20.5% of men.

We know that some men are at increased risk of carrying such resistant bacteria (known as ESBL), and these include men who have been treated with ciprofloxacin in the prior six months, and those that have travelled to SE Asia or the Indian subcontinent in the recent past. The bacteria are harmless in the gut, but become dangerous if seeded into the prostate by biopsy.

How can the risk of infection be reduced?

One of the ways to reduce the risk of infection is to consider a transperineal biopsy instead of a transrectal biopsy. In transperineal biopsy, the needles for biopsy are not passed through the rectum, but instead through the skin of the perineum, and the infection risk is greatly reduced. A study from Jeremy Grummet in Melbourne demonstrated a reduction in serious infection, with a greater than 10x reduction in risk compared to transrectal biopsy.

You can read more about this study by following this link to an article by Jeremy Grummet.

Follow this link to read more about transperineal biopsy.



Categories: Updates, Prostate Cancer

19
February
2014

A Safer Way to Biopsy the Prostate

A Safer Way to Biopsy the Prostate

Jeremy Grummet is a Urological Surgeon with particular expertise in urological cancer. He has been instrumental in the introduction of transperineal prostate biopsy as an alternative to transrectal biopsy, to reduce infection rates after biopsy. Jeremy is conducting multiple clinical research projects on prostate biopsy and heads the Victorian Transperineal Biopsy Collaboration (VTBC) research group. In this article, Jeremy discusses the techniques and advantages of transperineal biopsy.


What’s wrong with the current standard method of prostate biopsy?

A biopsy is where a sample of tissue is taken for examination under a microscope, usually to determine if cancer is present. As you can see from the diagram below, the easiest way to access the prostate is via the rectum. That’s why we perform a rectal examination - so we can feel the back of the prostate for any suspicious lumps. Most prostate cancers are located towards the back of the prostate (peripheral zone), so a transrectal ultrasound-guided (TRUS) biopsy is a convenient way of sampling this area. Typically, at least 12 cores of tissue are taken during a TRUS biopsy.

TRUS biopsy

The other advantage of the TRUS biopsy is that it can be performed in just a few minutes by giving the patient intravenous sedation or using a local anaesthetic nerve block.

However, passing the needle of the biopsy gun through the wall of the rectum multiple times is problematic. As you’d expect from an organ that stores faeces, the rectum has a high concentration of bacteria. These bacteria don’t cause any problems as long as they stay in the rectum. However, passing the biopsy needle through the wall of the rectum allows these bacteria to access the prostate and its rich blood supply. This in turn can lead to a serious infection in the blood called septicaemia (sepsis). Septicaemia makes patients feel very unwell, requires hospitalization for intravenous antibiotic therapy, and can even be life-threatening.

This risk of sepsis in TRUS biopsy is well-recognised. It is therefore standard to use an antibiotic to help prevent such an infection. Unfortunately, the antibiotic doesn’t always work, so there is still a risk of sepsis, which has been measured at about 1-2%.

Today, there is the additional and growing problem of bacteria developing antibiotic resistance. This has been reported worldwide and was the subject of a major US Government report last year.

Our own research group, the Victorian Transperineal Biopsy Collaboration (VTBC), reviewed the scientific literature, finding that developing resistance is a particular problem for bacteria that live in the rectum, so that the antibiotics we would normally use, such as ciprofloxacin, can sometimes be rendered ineffective. This coincides with reports of increasing rates of TRUS biopsy sepsis even as high as 5%.

Our research has also found that, as a result of the above, some Australian and New Zealand urology practices have resorted to using big-gun broad-spectrum antibiotics on a regular basis to prevent TRUS biopsy sepsis. Whilst this may reduce sepsis for the individual patient, from a public health perspective, it is a step backwards, as widespread use of such antibiotics will lead to even more resistance. Unfortunately, we are already seeing this happening, with hospitals in Australia finding CRE (Carbapenem-Resistant Enterococci) in their wards.


What is transperineal biopsy, and why is it safer?

Fortunately, there is another approach to prostate biopsy which avoids perforation of the rectum altogether. Instead, the biopsy needle can be passed via the skin of the perineum. In men, the perineum is the part of the body between the scrotum and the anus.

TRUS biopsy

As shown in the diagram, the ultrasound probe is still passed into the rectum to provide an image of the prostate. But instead of the biopsy needle passing alongside the probe, it is passed through a grid, which itself is fixed against the probe outside the body. Prior to insertion of the ultrasound probe, the perineal skin is easily prepared in a sterile fashion, just as any other incision site is prepared before surgery to prevent wound infection. (Although worthwhile attempts have been made to sterilize the rectum, this has not been possible.)

Our group studied the experience of transperineal (TP) biopsy around the world and found that in over 6,600 patients, there were only 5 patients re-admitted to hospital for sepsis - a rate of just 0.076%, or less than 1 in a thousand. Furthermore, in our own published experience of 245 TP biopsies our rate of re-admission for infection was zero. (We have now performed over 400 TP biopsies, still without a single episode of infection.)

Based on the published scientific evidence to date then, it appears that TP biopsy is a safer option than TRUS biopsy due to its near-zero sepsis risk. It also gives the advantage of avoiding regular use of heavy-duty antibiotics, thereby avoiding promotion of resistant bacteria, now labelled by the US Government Center for Disease Control as a Serious Threat to population health worldwide. As a result, we now use TP biopsy routinely for all prostate biopsies.


Are there any downsides to the transperineal approach?

Looking at the diagram above, you would expect TP biopsy to be painful, which is why it is typically performed under a general anaesthetic (although methods of using local anaesthetic only have been reported). We routinely perform TP biopsy under GA. As a result, men experience no pain during the procedure, and very little afterwards, so that paracetamol is only required occasionally. Although a general anaesthetic is required, it is of a short duration only (less than 30 minutes) and is very safe.

Practitioners of TP biopsy initially reported a higher risk of acute urinary retention (unable to pass urine) with this approach. However, with further experience, and by deliberately avoiding the area around the urethra, this rate dropped so that it is now similar to the risk seen in TRUS biopsy (around 2%). Although a catheter has been used by some doctors, as shown in the diagram above, it is unnecessary.

Due to anecdotal experience, some urologists have been concerned that TP biopsy may lead to erectile dysfunction by damaging the erectile nerves or to more difficult surgery if cancer is found and the prostate needs to be removed. However, evidence to date, albeit scant, does not support either of these concerns.


Is it as good as TRUS at cancer detection?

According to the scientific literature, TP biopsy is at least equivalent to TRUS biopsy in its ability to detect cancer. Some research has also found improved detection of cancers at the front of the prostate (anterior). This may be due to the typically easy access TP biopsy provides to all areas of the prostate, particularly anteriorly. Conversely, it can often be difficult to reach the anterior prostate via TRUS biopsy, especially in large glands.


What other advantage might TP biopsy provide?

In TP biopsy, the ultrasound probe is stabilized by equipment that is fixed to the operating table. The grid through which the biopsy needle is passed is, in turn, stabilized against the ultrasound probe. This set-up permits accurate and reproducible biopsy needle placement.

In the past, TP biopsies were taken in a systematic fashion only, evenly sampling various areas of the prostate. Whilst this is still performed routinely, in addition we are now often performing targeted biopsies of suspicious lesions if found on a prostate MRI. The stable arrangement of TP biopsy therefore permits accurate targeting of such lesions, with the potential to further improve the accuracy of cancer detection.


You can read more about Jeremy Grummet by clicking this link

There is more information on transperineal biopsy on the AUA site.

And you can follow @JGrummet on Twitter.


Categories: Updates, Prostate Cancer, Prostate Surgery

27
January
2014

Prostate Cancer Smartphone Apps

Prostate Cancer Smartphone Apps

The first guest blog for February is by Jim Duthie, a Urologist in Tauranga, New Zealand. Jim has written two Apps to make it easier for patients to be actively involved in their prostate cancer management. One app helps track PSA over time along with a history of prostate biopsies and treatments. The other greatly helps consolidate treatment for patients who are on ADT (hormone treatment).


For any question, the clichéd answer is now “There’s an App for that”, referring to the ubiquitous mobile applications for smartphones that seem to solve many of our problems, real or imagined. For medical conditions, this is increasingly the case. The “Medical” category is currently the most rapidly growing domain in the Apple App store. You can now download anything from a nomogram for predicting your risk of heart disease, to the somewhat questionable App that can treat whatever ails you by using your iPhone torch as a form of phototherapy. For me, designing mobile Apps was an effective solution for specific problems facing Urology patients.


Androgen Deprivation Therapy App

The process began with a concern that men undertaking Androgen Deprivation Therapy (ADT) were poorly followed up in terms of the myriad potential side effects that this treatment causes, from bone density to dyslipidaemia, to depression, and hot flushes. It is unclear exactly how many men are receiving ADT, let alone what percentage receive adequate follow up care. As Urologists, we are not experts in managing the complexities of, for example, cardiac risk factors.

Despite best intentions, we also lack the time and expertise to manage depression and cognitive impairment. It makes sense for General Practicioners/Family Physicians (GPs/FPs) to coordinate this follow up, but the physiological effects may seem complex and intimidating for a non-specialist. Perhaps Endocrinologists may be better equipped, but not from the point of view of coordinating patient management, and again a GP/FP usually has a better understanding of psychosocial issues. With this lack of clarity around responsibility it is easy for uncomplaining patients to slip through the cracks. In practice, men receiving ADT may only attract medical attention after suffering a significant complication of their treatment.

To improve this situation, I considered that a centralized ADT database where men are recruited at the time of initiation of therapy, then sent reminders at regular follow up intervals would be ideal, and could additionally provide a bank of men available for clinical trials and retrospective study. Unfortunately, database creation and management is prohibitively expensive, and despite my best efforts such a structure is some way off yet.

I identified the core follow up issue as being getting the right investigations performed at the right time. To achieve this GPs/FPs need to be aware of the necessary tests, and patients informed about when to see their doctor for follow up. The ADT App attempts to achieve this with automated “push notifications” (alerts appearing on the smartphone) when they are due to see their GP, as well as listing recommended investigations according to the elapsed time since commencing treatment. The patient can also read about potential side effects by body system, and follow links for explanations about why the specific tests are required in terms of the physiological effects of androgen deprivation. This is an App aimed at patients, however the intention is that a GP/FP could also have this on their phone as a reference and educational aid.


PSA Manager App

This App addresses a broader group, any man either undertaking prostate cancer treatment or PSA screening. The idea of a “PSA Tracker” is not new. Before the advent of iTunes I encountered a retired accountant who had graphed his PSA over time by hand. An electronic equivalent is easy to achieve, but does it add much to the patient’s care? I thought that an “all in one” manager for prostate cancer screening and treatment would be more useful. The PSA Manager App allows the input of results of prostate biopsies, dates and modalities of treatment for cancer and benign prostate disease including surgery, radiation, and newer novel techniques, and results of imaging investigations such as CT, MRI, or bone scans with a facility for entering a free-text description of the results of these. The data are then presented on a graph with colour-coded markers to represent the timing of the interventions. PSA velocity and doubling time can also be calculated. The intention is to allow men a clear overview of their PSA changes during screening, and if applicable, the evolution and treatment of their prostate cancer.

Identifying barriers to care is an essential part of equitable health delivery, and something I considered at length. The first challenge I identified for men using these Apps, particularly the ADT App, was advanced age. We may think of men on ADT as being elderly, perhaps frail, and probably not expert in using technology. Firstly, this perception ignores the group of men receiving ADT as neoadjuvant/adjuvant treatment for radiation therapy, which constitutes a younger and healthier cohort of men. Secondly, many ADT patients attend clinic with a younger family member, and my experience has been that when I ask if anyone in the family has an iPod, iPad, or iPhone, the answer is usually yes. As long as one tech-savvy person can enter the data, the Apps work well by proxy. In designing the interface, details such as larger buttons to suit male fingers and presbyopic vision were considered.

Finally, any financial cost will constitute a barrier to some patients. The solution was the make the Apps free to download. This meant securing funding which was generously provided by unrestricted grants from Australian Prostate Cancer Research and Ipsen for the ADT and PSA Manager Apps respectively. Although I receive no reimbursement from the development of either App, I believe patients feel more confident in a product provided solely for their benefit, and I can promote the Apps to them and my colleagues with no financial conflict of interest.


Follow this link to download the ADT App

Follow this link to download the PSA App

Jim Duthie is a Urologist at Tauranga, New Zealand with an interest in Urologic Oncology, Robotic Surgery, and Medical Communication. You can follow @JamesDuthie1 on Twitter.


Categories: Updates, Prostate Cancer, Prostate Surgery

14
October
2013

Biopsy Techniques for Prostate Cancer

Biopsy Techniques for Prostate Cancer

This week’s Guest Post is by highly regarded expert in the early detection of prostate cancer, Dr. Stacy Loeb. Stacy takes questions on prostate biopsy, and discusses its use, potential problems, and some developments in the field.

Dr Stacy Loeb is an Assistant Professor of Urology and Population Health at New York University (NYU) and the Manhattan Veterans Affairs Medical Center, specializing in prostate cancer. Dr. Loeb has published over 170 peer-reviewed articles and 8 book chapters, primarily on prostate cancer. She is on the Editorial Board for the British Journal of Urology International and Reviews in Urology, and authored the chapter on “Early Detection, Diagnosis, and Staging of Prostate Cancer” for Campbell-Walsh Urology, the primary textbook for the field. Stacy also frequently gives international lectures and courses on prostate cancer for other urologists, and hosts the Men’s Health Show on Sirius XM 81 satellite radio.


Stacy, TRUS biopsy is the most common technique for the diagnosis of prostate cancer. Can you give us an idea of the potential complications and the rates at which they occur?

The most common complication of prostate biopsy is bleeding, which can be in the urine, stool or ejaculate. Fortunately in most cases it is mild and self-limiting. Less common but often more serious is the potential for infection after biopsy. Indeed, the frequency of serious infections requiring hospitalization after prostate biopsy has increased in recent years. Other potential complications of prostate biopsy include pain and urinary difficulties, which are usually transient.


Is it a painful procedure to have done, and what techniques are used to reduce pain?

Prostate biopsy can cause both discomfort and anxiety, although there are many ways to mitigate these problems. Optimising patient positioning and simple relaxation techniques (such as deep breathing, listening to music, or even medication) may be useful to reduce anxiety. For pain, many different anesthetic options are available. For transrectal biopsy, several studies have shown that lidocaine jelly can ease insertion of the ultrasound probe, which is among the more uncomfortable parts of the procedure. Periprostatic nerve block is also commonly employed to successfully reduce pain during outpatient transrectal prostate biopsies. Other forms of biopsy such as the transperineal approach are frequently performed under sedation/general anesthesia, also effective forms of pain control. Overall, there are very few high-quality studies comparing the different methods for pain reduction during prostate biopsy, so the choice may be governed by patient-specific and procedural factors.


Some men require more than one biopsy to diagnose prostate cancer. There has been concern that repeat biopsies can predispose men to erectile dysfunction; can you comment on this?

There is conflicting evidence on the link between repeat prostate biopsies and the risk of erectile dysfunction. A study from the Johns Hopkins active surveillance program suggested that greater biopsy number was associated with erectile dysfunction after adjusting age, prostate volume and PSA, but a similar study from UCSF failed to confirm these results. Possible mechanisms for a link between repeated biopsies and erectile dysfunction include psychological factors as well as potential inflammation in the area around that prostate that houses the nerves involved in erections. Although this issue remains unresolved at this time, each procedure has potential risks making careful patient selection of critical importance. Hopefully, ongoing improvements in markers and imaging will reduce the need for repeat biopsies in the future.


You mentioned infection rates above. Are we seeing a rise in infection following TRUS biopsy of the prostate, and if so, why?

In the United States Medicare population, our research group reported a recent increase in hospitalisations for infection after prostate biopsy. Similar results have been confirmed in other populations, including Canada and Europe. The most likely explanation for these findings is increasing antimicrobial resistance in the community. Traditionally, the majority of patients were given fluoroquinolones as prophylaxis for prostate biopsy, but fluoroquinolone resistance has been on the rise. As a result, recent studies have explored other options for prostate biopsy prophylaxis, One option is to use more broad-spectrum antibiotics, although this may ultimately lead to greater antibiotic resistance in the future. An alternative option is to tailor the antimicrobial regimen based upon the local hospital antibiogram or individual rectal swab cultures performed at the visit prior to prostate biopsy. Other key recommendations are to assess the patient for risk factors for a prostate biopsy infection (such as diabetes, recent antibiotic use and foreign travel) and to counsel patients to seek immediate medical attention at the first sign of an infection.


Transperineal biopsy is another way to biopsy the prostate. Can you outline the advantages and disadvantages of this technique?

In the United States, most prostate biopsies are performed in the outpatient clinic through the rectum (transrectal) using ultrasound guidance. An alternate way to access the prostate for tissue sampling is through the skin of the perineum. Recent studies have suggested that the transperineal approach may reduce the risk of infectious complications. However, unlike transrectal biopsy, it is typically performed in the operating theatre with general anesthesia, thus involving greater time and expense. Transperineal prostate biopsies may also involve a greater risk of urinary retention, a situation where the patient is temporarily unable to urinate.


There has been a lot of interest in the use of MRI as a way of reducing 'unnecessary' biopsies. What are your views on this?

MRI technology has advanced substantially in recent years. At New York University, we have a well-established prostate imaging program using a 3 Tesla multiparametric MRI without an endorectal coil. Most patients tolerate the procedure well and it provides a very detailed anatomic view of the entire prostate, including regions that are poorly sampled during a traditional prostate biopsy. Suspicious lesions found on MRI can then be targeted during the prostate biopsy as a way to increase diagnostic yield. MRI may be particularly useful for men with a persistently elevated PSA and previous negative prostate biopsies, as well as for monitoring patients during active surveillance.


You can read more about Stacy by following the link to NYU Langone Medical Centre and you can follow her @loebstacy on Twitter.


Categories: Prostate Cancer

01
October
2013

Melbourne Consensus Statement on Prostate Cancer Testing

Melbourne Consensus Statement on Prostate Cancer Testing

This is the fourth in a series of posts by highly respected guest authors in Urology. Drs. Matt Cooperberg and Declan Murphy answer questions on the recently released Melbourne Consensus Statement on Prostate Cancer Testing


Matthew Cooperberg is Associate Professor of Urology and Epidemiology & Biostatistics at the UCSF Helen Diller Family Comprehensive Cancer Center. He is a urologic oncologist specialising in prostate cancer management. Matt is a highly published academic surgeon, having written/co-authored 130 peer-reviewed journal articles and 12 book chapters. He is Associate Editor for European Urology and sits on multiple other editorial boards.

Declan Murphy is Uro-Oncologist and Associate Professor of Surgery at the University of Melbourne, Peter MacCallum Cancer Centre. He is an Associate Editor at the BJUI and holds other senior editorial positions at European Urology and Nature Reviews Urology.


Declan, what was the rationale behind writing the Melbourne PSA Consensus Statement?

“The Melbourne Statement was a response to the very confused landscape we found ourselves in after the release of the USPSTF Recommendation last year and to a lesser extent, the AUA PSA Guideline a few months ago. While the USPSTF recommendation was frankly ridiculous and unworkable (PSA is not going to go away), the AUA Guideline did have some merit. However we felt that it did not adequately address some areas, e.g. how should we approach the average man in his 40’s who does not want to die of prostate cancer? Knowing that we would have a gathering of highly respected experts in prostate cancer in Melbourne in August 2013 we decided to release a simple document, which would provide straightforward guidance for GPs and others.”


Matt, has the statement been well received by Urologists, Patients and GPs/Family Doctors in the US?

“I was quite impressed with the press coverage in Australia and even in the U.S. when it was presented at the PCWC conference in Melbourne. We’ll see how much more discussion it generates when the final document is published in British Journal of Urology International. Ultimately, though, at least in the U.S., urologists’ recommendations don’t carry much weight with the primary care providers who are really making PSA testing decisions. They give far more credence to the USPSTF, unfortunately. Likewise in Australia, the RCGP Red Book is the bible for many GPs and it is very anti-PSA testing. Nevertheless we have had much positive feedback from GPs already.”


Matt, the USPSTF position statement essentially came out against PSA testing. Has this had a measurable impact on PSA testing in the US?

“This is hard to say so far. In 2009 the USPSTF came out against testing among older men, and multiple papers have shown that the recommendation had virtually no impact on PSA testing rates in the older population. However, this time it seems to be different. While there are no published data yet, multiple anecdotes seem to suggest that many primary care providers are simply abandoning PSA testing—equally for younger men in good health as for older ones with significant comorbidity. It is very much a case of throwing the baby out with the bath water.”


Matt, if the reductions in metastasis and prostate cancer mortality with PSA testing are so large, why does the consensus not support a population-wide screening programme?

“That term (population-wide screening) tends to imply reflexive PSA testing without any a priori discussion with the individual man. Enough controversy and confusion exists regarding both screening and prostate cancer treatment—and overtreatment is still enough of a problem in the U.S. and elsewhere—that we should not be screening men without warning them of the possible outcomes of testing. The relative cancer-specific mortality reductions are large, but the absolute reductions are not with 10-15 year follow-up, thus leading to calculations of relatively high numbers needed to screen and diagnose to prevent one cancer death. Though these numbers fall substantially with longer follow-up (a horizon of 30 years or more is entirely appropriate for a 50 year old man facing a screening decision), most men with prostate cancer die of cardiac disease, just like those without prostate cancer.”


Declan, are there any improvements or changes to the document planned?

“The document is set to evolve. One of the benefits of publishing it as a blog at bjui.org was to get it into circulation very quickly and also to allow others to comment. Within 72 hours the Melbourne Statement had become the most-read and most-commented blog at BJUI. The print version will appear in the BJUI in coming months.”


Matt, what is the future for PSA testing in your view?

“It’s very hard to say. I think many of us know the way PSA screening should evolve: men should be offered testing at a relatively young age—with the express understanding that testing is intended to detect high-risk prostate cancer, and that if a low-risk tumour is identified, it does not need immediate treatment. Those with low baseline PSAs can be re-screened less frequently than they are now. Evolving biomarkers will help determine who needs a biopsy and who needs treatment, but PSA is not going anywhere as a first screen. From what I understand, most national policies are evolving toward some variation on a “smarter screening” approach. Unfortunately, in the U.S. it will likely require a legislative remedy to force the USPSTF to accept actual expert opinion before the policy is corrected. There is a bill working its way through Congress to do just this, but it is not a quick process.

"In the meantime, the best we as urologists can do is to implement smarter screening in practice, to strive to reduce overtreatment and to improve quality of treatment when it is needed, to continue to advocate for USPSTF reform, and to reach out to local groups of primary care providers to educate them that the truth about PSA—which, as is usually the case in medicine, is neither black nor white. Only through understanding the truth in the shades of grey can we at once maximise the benefits of screening and minimize its harms.”


You can follow both Declan Murphy @declangmurphy and Matt Cooperberg @dr_coops on Twitter.


Categories: Prostate Cancer

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