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Abstract Bleeding is the most common complication after a prostate biopsy, commonly self-limited. We describe a case of a patient who developed a hemoperitoneum after a transperineal prostate biopsy. A 65-year-old man with a history of prostate cancer diagnosed in 2016 by transurethral resection, with no further urologic control until 2020 when a rise in the serum prostate-specific antigen was diagnosed: 4.49 ng/ml. Pros tate digital rectal examination had no pathologic findings. Magnetic resonance imaging informed anequivocal lesion. A target transperineal fusion biopsy was performed, guided by ultrasound (US). Pre-surgical blood tests, including coagulogram, were normal. No immediate postoperative complications were recorded, and the patient was discharged. Hours later, he returned after a head concussion due to orthostatic hypotension and diffuse abdominal pain. Blood test showed a drop in hematocrit and hemoglobin values. Abdominal US and abdomi nopelvic computed tomography scan showed free intraperitoneal fluid and intraperitoneal hematic collection on top of the bladder of 104 × 86 mm with no active bleeding. The patient was admitted to intensive care unit due to persistent hypotension despite fluid restoration. He received a single-unit blood transfusion and had a good response to vasopressors. Abdominal pain decreased. He was finally discharged with stable hematocrit 48 hours after admission. Clinical management with no surgery or radiologic angio-embolization was required. We found no clear origin of the intraperitoneal bleeding, but we hypothesize that maybe the previous transurethral resection of the prostate made anatomical changes that facilitated blood passage to the abdominal cavity after puncture of branches from the inferior vesical artery.
Resumen La complicación más frecuente tras una biopsia prostática es el sangrado, generalmente autolimitado. Aquí describimos un caso de he moperitoneo secundario a dicho procedimiento. Hombre de 65 años con antecedentes de cáncer de próstata diagnosticado en 2016 por una resección transuretral de próstata, sin seguimiento urológico, consultó en 2020 por aumento del antígeno prostático específico: 4.49 ng/ml, asociado a tacto rectal normal y una resonancia multiparamétrica de próstata mostró una lesión indeterminada. Se realizó una biopsia prostática transperineal por fusión guiado por ecografía. Los análisis preoperatorios, incluido coagulograma, eran normales. No se registraron complicaciones intraquirúrgicas y se indicó el alta. Horas más tarde, consultó al hospital por hipotensión ortos tática y dolor abdominal difuso. Los análisis demostraron caída del hematocrito y hemoglobina. Una ecografía y posterior tomografía computada evidenciaron una colección supravesical de 104 × 86mm sin signos de sangrado activo. Se indicó internación en sala de cuidados intensivos debido a hipotensión refractaria a expansiones con requerimiento de vasopresores. Recibió una transfusión de glóbulos rojos. Por favorable evolución, 48 horas después del ingreso recibió el alta. En este caso, fue posible un manejo conservador, sin requerimiento de cirugía o embolización. Si bien no se encontró sitio exacto del sangrado, creemos que la resección transuretral previa podría haber generado cambios anatómicos que facilitaran el pasaje de sangre, posiblemente proveniente de ramas de la arteria vesical inferior a cavidad abdominal luego de la punción.
ABSTRACT
Objective:To investigate the feasibility, effectiveness and safety of ultrasound-guided transperineal prostate biopsy (TPB) with coaxial needle technique, and to improve the pain perception of TPB patients by reducing the number of direct perineal needling.Methods:A total of 200 patients who underwent ultrasound-guided TPB at the first clinical college of Three Gorges University & Yichang Central People′s Hospital from January 2019 to December 2020 were randomly divided into coaxial needle group (coaxial needle positioning puncture, n=100) and traditional group (traditional puncture frame guided repeated transperineal puncture, n=100). Visual analog scale (VAS) was used to evaluate the pain of patients during puncture. The number of samples, time-consuming of puncture, cancer detection rate, VAS pain score and complications between the two groups were compared. Results:The success rate of puncture in the coaxial needle group and the traditional group was 100%, and there was no significant difference in the cancer detection rate between the two groups (48% vs 40%, P>0.05). The average number of samples in the coaxial needle group was larger than that in the traditional group, the average puncture time in the coaxial needle group was less than that in the traditional group, and the average intraoperative VAS score of the coaxial needle group was lower than that of the traditional group, the differences were statistically significant[(14.8±1.8) vs (12.1±1.1), (12.9±1.3)min vs (16.5±1.9)min, (2.6±1.2) vs (4.4±1.4); all P<0.001]. The complication rate of the coaxial needle group was lower than that of the traditional group, the difference was statistically significant (18% vs 39%, P<0.001), the incidences of perineal hematoma and perineal pain in the coaxial needle group were lower than that in the traditional group (1% vs 8%, 8% vs 19%; all P<0.05). Conclusions:Coaxial needle technology for ultrasound-guided TPB can ensure the number of samples and accurate sampling in different areas, significantly reduce the number of direct perineal puncture, improve the pain in the process of puncture, reduce the incidence of postoperative perineal pain, with shorter operation time and fewer complications, which is worthy of clinical promotion.
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Objective@#To assess the clinical value and safety of pelvic MRI combined with transurethral ultrasound (TRUS)-guided transperineal template mapping biopsy (TTMB) in the diagnosis of prostate cancer.@*METHODS@#A total of 164 men underwent MRI plus TRUS-guided TTMB for the diagnosis of prostate cancer from December 2015 to May 2018. The patients averaged 71.2 years of age and, based on the PSA level, were divided into four groups: PSA 100 μg/L (n = 27). All the patients received digital rectal examination, pelvic MRI and TRUS-guided X+12-core TTMB.@*RESULTS@#The procedures of TRUS-guided TTMB were successfully completed in all the patients, with an average number of 14.2 (14－16) cores and mean operation time of 18 (15－28) minutes. Post-biopsy complications included transient hematuria in 4 cases, perineal hematoma in 12 and fever in 1, but no acute urinary retention. Pathological results revealed 95 cases of prostate cancer, 2 cases of ductal epithelial carcinoma, 63 cases of prostatic hyperplasia with benign interstitial inflammation, and 4 cases of atypical prostatic hyperplasia. The positive biopsy rates in the PSA 100 μg/L groups were 25.00%, 42.86%, 73.58% and 100.00% respectively, with statistically significant difference between the PSA 100 μg/L groups (P < 0.01), but not between the PSA <10 μg/L and PSA 10－20 μg/L groups (P = 0.086).@*CONCLUSIONS@#Pelvic MRI combined with TRUS-guided X+12-core TTMB, with the advantages of high accuracy and low rate of complications, is an ideal approach to the diagnosis of prostate cancer.
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OBJECTIVE@#MRI-Ultrasound fusion guided targeted biopsy has revolutionized the diagnosis of prostatecancer through accurate identification, localization and characterization of prostatic lesions utilizingthe prostate imaging reporting and data system (PI-RADS) scoring system by multiparametric MRI(MPMRI). The fusion prostate biopsy system on the other hand, enables accurate targeting and easyaccess of the tumor. The study objective is to determine the detection rate of clinically-significantprostate cancer using fusion biopsy, and to establish the correlation between PI-RADS score andGleason's score.@*PATIENTS AND METHODS@#A retrospective cohort study was conducted to determine the correlation betweenPI-RADS score and the presence of prostate cancer using MRI-Ultrasound fusion guided transperinealprostate biopsy. This was carried out from June 2017 to July 2018 in a single institution. One hundredthirty five (135) men were included in this study. They presented with an elevated PSA, abnormalDRE or a previous negative prostate biopsy, but with a persistent rise in PSA. A total of 220 prostatelesions were identified. The following characteristics were measured: patient age; the size, location,the PI-RADS score of each lesion, the maximum PI-RADS score for select patients; and the Gleasonscore of discovered tumors.@*RESULTS@# Two hundred twenty PI-RADS 3, 4 and 5 lesions were detected in 135 patients by MPMRI.131 of the 220 lesions were scored as PI-RADS 3, 61 as PI-RADS 4 and 28 as PI-RADS 5. Theselesions were biopsied using the MRI-Ultrasound fusion guided transperineal prostate biopsy system.Thirty-three out of the 131 PI-RADS 3 lesions (25.2%), 44 out of the 61 PI-RADS 4 lesions (72.1%)and 24 out of the 28 PI-RADS 5 lesions (85.7%) respectively were positive for malignancy. Overall,there were 101 (45.9%) lesions classified as PI-RADS 3 to 5 that were positive for prostate carcinoma.Seventy four (74) of the 135 patients (54.8%) were diagnosed with prostate adenocarcinoma. Nineteenout of 65 patients with a maximum score of PI-RADS 3 (29.2%), 33 of 44 with a maximum of PI-RADS 4 (75%) and 22 of 26 with a maximum of PI-RADS 5 (84.6%) harbored malignancy. In termsof location, 45 of the 101 (44.6%) malignancies were in the peripheral sector, 31 (30.7%) in theanterior sector, and 25 (24.8%) in the central sector of the prostate. The mean Gleason grade of PI-RADS 3, 4 and 5 lesions were 6.61, 7.73, and 7.38, respectively. Using Spearman correlation, the rhocoefficient was 0.3153 (p-value =.00013) which denotes a significant positive relationship betweenGleason and PI-RADS score.@*CONCLUSION@#This is the first comprehensive Philippine study on Multiparametric MRI-Ultrasoundfusion-guided transperineal prostate biopsy. Present data validate the superiority of MPMRI in theidentification, localization and characterization of prostate cancers. The authors also verified thepositive correlation between PI-RADS score and Gleason score. Finally, they demonstrated theaccuracy of the MRI- ultrasound fusion-guided transperineal prostate biopsy system in targetingprostate lesions.
ABSTRACT
PURPOSE: The aim of this study is to confirm the detection rate of transperineal biopsy after multiparametric magnetic resonance imaging (mpMRI) and compared it to that of transrectal biopsy. We also examined the role of mpMRI and the rate of complications for each method. MATERIALS AND METHODS: In a retrospective study, we analyzed 147 patients who underwent mpMRI before prostate biopsy because of elevated serum prostate-specific antigen and/or abnormal digital rectal examination findings at Korea University Hospital, Seoul, Korea from March 2017 to April 2018. Regions on the mpMRI that were suggestive of prostate cancer were categorized according to the Prostate Imaging–Reporting and Data System (PI-RADS v2). For transperineal biopsy, a 20-core saturation biopsy was performed by MRI-TRUS cognitive or fusion techniques and a 12-core biopsy was performed in transrectal biopsy. RESULTS: Sixty-three and 84 patients were enrolled in transperineal group and transrectal group, respectively. The overall detection rate of prostate cancer in transperineal group was 27% higher than that in transrectal group. Classification according to PI-RADS score revealed a significant increase in detection rate in all patients, as the PI-RADS score increased. Frequency of complications using the Clavien-Dindo classifications revealed no significant differences in the total complications rate, but two patients in transrectal group received intensive care unit care due to urosepsis. CONCLUSIONS: Our results confirmed that transperineal biopsy is superior to transrectal biopsy for the detection of prostate cancer. From the complication point of view, this study confirmed that there were fewer severe complications in transperineal biopsy.