Patient Tolerability With Office Transperineal Biopsy Using a Reusable Needle Guide.

OBJECTIVE: Transrectal ultrasound-guided (TRUS) prostate biopsy is associated with a 1%-5% risk of severe sepsis, despite the use of prophylactic antibiotics. Recent studies have demonstrated the feasibility of transperineal (TP) prostate biopsy in the outpatient setting under local anesthetic (LA). We demonstrate the safety, efficacy, and tolerability of our technique for performing TP biopsy under LA in the clinic setting using a reusable needle guide. METHODS: A biplanar ultrasound probe with an attached adjustable, reusable needle guide was evaluated for transperineal biopsy. A 17 gauge x 10 cm coaxial needle is attached to the needle guide. The skin is infiltrated, bilaterally, approximately 2 cm anterolateral to the anal verge with 1% lidocaine using a 25 gauge needle. A deeper prostatic block is then performed using a 20 gauge spinal needle. Administration of the anesthetic is delivered to the musculature of the pelvic floor, superficial-to-deep. Prostate samples are obtained using an 18 gauge x 25cm biopsy gun. All biopsies on a side can be obtained utilizing a single perineal skin puncture site. Patients who underwent office TP biopsy after May 2019 also completed a 10-item patient experience questionnaire regarding pain or discomfort experienced during the procedure. RESULTS: In 2019, a total of 74 patients underwent office TP prostate biopsy under local anesthesia using a reusable needle guide, while 564 underwent office TRUS biopsy. Prostate biopsy was positive for malignancy in 58.1% of TP patients vs 57.6% in TRUS patients (P = .93). TP biopsy had a lower utilization of prophylactic antibiotics compared to TRUS biopsy: 33.8% vs 99.5% (P < .001), yet there were no admissions, UTI, or sepsis for TP patients, compared to 6 admissions (1.1%) for TRUS biopsy (P = .01)). The mean VAS score ± SD for pain or discomfort caused by the overall office TP biopsy was 3.68 ± 1.96. CONCLUSION: We demonstrate that office TP biopsy under LA with a reusable needle guide can be safely introduced with equivalent cancer detection rates whilst nearly eliminating the risk of urinary sepsis. This was achieved while also significantly reducing the use of prophylactic antibiotics. The procedure was well tolerated, with the most common complaint being local infiltration of anesthetic. We believe that office TP biopsy under LA can be performed with good patient tolerability, as almost 94% of patients were willing to undergo the procedure again. There is also the potential for reduction in overall cost with the use of a reusable needle guide.

Use of ultra-low dose computed tomography versus abdominal plain film for assessment of stone-free rates after shock-wave lithotripsy: implications on emergency room visits, surgical procedures, and cost-effectiveness.

The aims of this investigation were: (1) to compare residual stone-fragment (RSF) detection rates of ultra-low dose computed tomography (ULD-CT) and abdominal plain film (KUB) in urolithiasis patients undergoing shock-wave lithotripsy (SWL), and (2) to evaluate the downstream sequelae of utilizing these two disparate imaging pathways of differing diagnostic fidelity. A retrospective chart-review of patients undergoing SWL at two high-volume surgical centers was undertaken (2013-2016). RSF diagnostic rates of ULD-CT and KUB were assessed, and the impact of imaging modality used on subsequent emergency room (ER) visits, unplanned procedures, and cost-effectiveness was investigated. Adjusted analyses examined association between imaging modality used and outcomes, and Markov decision-tree analysis was performed to identify a cost advantageous scenario for ULD-CT over KUB. Of 417 patients studied, 57 (13.7%) underwent ULD-CT while the remaining 360 underwent KUB. The RSF rates were 36.8% and 22.8% in the ULD-CT and KUB groups, respectively (p = 0.019). A 5.6% and 18% of the patients deemed stone-free on ULD-CT and KUB, respectively, returned to the ER (p = 0.040). Similarly, 2.8% and 15.1% needed an unplanned surgery (p = 0.027). These findings were confirmed on multivariable analyses, Odds ratios CT-ULD versus KUB: 0.19 and 0.10, respectively, p < 0.05. With regards to cost-effectiveness, at low ULD-CT charges, the ULD-CT follow-up pathway was economically more favorable, but with increasing ULD-CT charges, the KUB follow-up pathway superseded. ULD-CT seems to provide a more 'true' estimate of stone-free status, and in consequence mitigates unwanted emergency and operating room visits by reducing untimely stent removals and false patient reassurances. Further, at low ULD-CT costs, it may also be economically more favorable.