Although transrectal ultrasonography (TRUS)-guided biopsy is the most commonly used technique for making the histologic diagnosis of prostate cancer, rising readmission rates of subsequent sepsis have given urologic surgeon Jeremy P. Grummet, MBBS, MS, FRACS, pause.
Chair of the Genito-Urinary Cancer Multidisciplinary Team at Alfred Health in Melbourne, Victoria, Australia, Dr. Grummet performs almost exclusively transperineal prostate biopsies, with a postprocedural sepsis readmission rate of zero to date, as he and his colleagues have reported in BJU International.
Dr. Grummet discussed his change in practice with Renal & Urology News.
What inspired you to examine the issue of sepsis rates following transrectal vs transperineal (TP) prostate biopsy?
Dr. Grummet: Like other urologists, I was trained in doing TRUS biopsies. It was, and still is, considered the norm, and the risk of sepsis was accepted as part of it, so we always gave prophylactic antibiotics for it.
I continued doing TRUS biopsies in my own practice, but despite the usual prophylactic quinolones, I was seeing too many men in my own and my colleagues’ practices coming back to the hospital septic. And these guys were sick. They felt awful, and sometimes needed intensive care support—all this just because of a minor diagnostic procedure.
But we had started to do TP biopsies as a confirmatory biopsy for active-surveillance patients, so we gained some experience with this approach as well. As TP biopsy avoids breach of the rectal wall altogether, it seemed logical that it would carry a much lower risk of sepsis, so we checked the literature as well as our own experience.
Is TP prostate biopsy considered controversial?
Dr. Grummet: I don’t think TP biopsy is controversial in terms of cancer detection. There’s no reason why it should be inferior to TRUS biopsy in this regard, and the evidence to date supports that.
Rather, the controversy is based on whether we as urologists have access to the necessary equipment and to the operating-room time needed to perform TP biopsy, as it typically requires a general anesthetic.
What would stop physicians from adopting TP prostate biopsy?
Dr. Grummet: A TRUS biopsy under local anesthetic can be performed in the urologist’s office in under 10 minutes. So it’s quick, easy, relatively cheap, and very convenient. You can even do it between consultations. TP biopsy, on the other hand, requires booking your patient onto an operating list, having more sophisticated equipment, and giving a general anesthetic, and it takes considerably longer to do (although once you’ve got the process streamlined, it’s less than 20 minutes).
So not only do you need additional resources, if you’re a busy practicing urologist it’s hard to make the mental shift to offering TP biopsy. But it’s a procedure that’s easy enough to learn, so the learning curve shouldn’t be a barrier.
In your 2014 BJU International study (“Sepsis and ‘superbugs’: should we favour the transperineal over the transrectal approach for prostate biopsy?”), you state that there has been a noticeable rise in the rate of TRUS-biopsy sepsis with the increasing prevalence of multi-resistant organisms.
How can wider use of TP biopsy help to combat this?
Dr. Grummet: TP biopsy essentially renders multiresistant organisms irrelevant. These bacteria are becoming more and more common in rectal flora. But as long as they stay in the rectum, they don’t cause an issue, as is the case with TP biopsy. TRUS biopsy, on the other hand, allows entry of these multi-resistant rectal bacteria via the biopsy gun directly into the vascular prostate, and thereon into the bloodstream.
In your study, none (zero) of 245 patients who underwent TP prostate biopsy had to be readmitted to the hospital for sepsis infection, whereas the rate of sepsis after TRUS biopsy is as high as 5%.
Why is it so important to reduce the rate of post-biopsy sepsis even further, to the point of changing the gold standard of prostate biopsy (TRUS)?
Dr. Grummet: First of all, I think it’s important to remember that TRUS biopsy sepsis rates are usually lower than 5%, although that rate has certainly been reported. Our own region’s sepsis rate is more in the order of 1%–2%. But I would argue that even that’s too high given the morbidity that sepsis causes, especially when we have an alternative available where sepsis is exceedingly rare.
Many practicing colleagues would seem to agree that current rates of sepsis are a real concern as evidenced by the increasing use of carbapenems such as meropenem as prophylaxis for TRUS biopsy.
Whilst this is a well-meaning attempt to minimize TRUS biopsy sepsis in individual patients, it is surely a step backwards in preventing further development of multiresistant bacteria, such as CRE [carbapenem-resistant enterococci], which the CDC has labeled an urgent threat to public health.
Carbapenems are almost never required in TP biopsy for treatment as sepsis rarely occurs, and are certainly not needed for prophlyaxis.
So TP biopsy can reduce the morbidity of sepsis in individual patients as well as potentially help reduce the public health risk of antibiotic resistance. In doing so, TP biopsy could also reduce the enormous financial costs of these problems. These offsets must also be borne in mind when we consider the cost of the procedure of TP biopsy itself, and our group is researching this at the moment.