Antibiotic free Local Anaesthetic Transperineal Prostate (LATP) biopsies: a review of the first 791 cases.

Abstract

Introduction
A predominantly nurse-performed LATP service using PrecisionPoint was newly started in July 2019. Initial indications were repeat biopsy, anterior lesions, and AS patients. Service was expanded in March 2020 to all prostate pathway patients according to BAUS COVID guidance.
Methods
All patients underwent prebiopsy MRI and dedicated image-review meetings. Biopsies were performed in PIRADS 3-5, or PSAD>0.15. PIRADS 3-5 lesions were targeted with ≥3 cores (sent separately). Systematic Ginsburg protocol biopsies were also performed (each zone sent separately). Tamsulosin was started for BOO patients.
No antibiotics were used unless immunocompromised or previous sepsis. A prospective database at point of care was created detailing patient information, MRI and biopsy characteristics. Patient Reported Outcome Measures (PROMs) are collected. Histology and complications are also reported.
Results
750 consecutive patients analysed. Detection of significant cancer (Gl≥3+4) in PIRAD1-2, 3, 4, 5 groups was 25%, 40%, 59%, 92% respectively. Systematic biopsy alone detected significant cancer in 36%, systematic plus targeted achieved 63%. Of AS patients; 40% with Gl3+3 were upgraded, and 49% with Gl3+4 were upgraded to Gl≥4+3.
5 experienced vasovagal episodes. Only 5 patients were readmitted (0.6%): 2 UTI, 2 AUR, 1 urosepsis.
PROMs demonstrated majority favourable results regarding pain (98%), discomfort (97%), embarrassment (96%) and further biopsies (89%).
Conclusion
We have set up a safe, effective, antibiotic free LATP biopsy service, with high cancer detection rates and low complication rates. PROMs data suggests this is well tolerated by patients.

Full text

Antibiotic free Local Anaesthetic Transperineal Prostate (LATP)
biopsies: a review of the first 791 cases
INTRODUCTION
A new LATP service was started in July 2019.
The COVID-19 pandemic was used as an opportunity
to stop TRUS biopsies altogether, and all patients now
undergo LATP biopsies.
We share our initial results.
PROMS (n=299)
RESULTS
METHODS
●Data collected from July 2019 - March 2021
●All patients underwent pre-biopsy mpMRI Prostate
●All MRIs reviewed in consultant led image review
meetings
●Biopsies performed in PIRADS3-5 or PSAD≥0.15
●Antibiotic free pathway
○(Unless immunocompromised or previous urosepsis)
●Systematic Ginsburg protocol sampling
○24 cores (18 cores for smaller prostates)
●≥3x Target cores in all PIRADS3-5
●Freehand biopsy, using PrecisionPoint TP Access
SystemTM
●Biopsies performed by 3x surgical practitioner & middle
grade surgeons
●All patients LUTS assessed
●Prospectively updated database at point of care
References
Kum F, Elhage O, Maliyil J, Wong K, Faure Walker N, Kulkarni M, Namdarian B, Challacombe B, Cathcart P, Popert R. Initial outcomes
of local anaesthetic freehand transperineal prostate biopsies in the outpatient setting. BJU Int. 2020 Feb;125(2):244-252. doi:
10.1111/bju.14620. Epub 2019 Dec 3. PMID: 30431694.
Lopez JF, Campbell A, Omer A, Stroman L, Bondad J, Austin T, Reeves T, Phelan C, Leiblich A, Philippou Y, Lovegrove CE, Ranasinha N,
Bryant RJ, Leslie T, Hamdy FC, Brewster S, Bell CR, Popert R, Hodgson D, Elsaghir M, Eddy B, Bolomytis S, Persad R, Reddy UD, Foley
C, van Rij S, Lam W, Lamb AD. Local anaesthetic transperineal (LATP) prostate biopsy using a probe-mounted transperineal access
system: a multicentre prospective outcome analysis. BJU Int. 2021 Jan 15. doi: 10.1111/bju.15337. Epub ahead of print. PMID:
33448607.
AIM
To review local LATP diagnostic rates
Clinically significant(CS) Pr. Ca. = ≥Gl 3+4
To obtain prevalence of complications/adverse outcomes
To review Patient Reported Outcome Measures (PROMs)
Contact Information
Mark Yao ST4 Urology, Kent Surrey Sussex Deanery
mark.yao@doctors.org.uk
@marky_urol
M. Yao1, C. Phelan1, S. Folkard1, A. Rajagopalan1, B. Varga1, J. Rusere3, A. Lamb2, R. Popert3, S. S. Kommu1, B. A. Eddy1
1. Kent and Canterbury Hospital, East Kent Hospitals University NHS Foundation Trust
2. Churchill Hospital, Oxford University Hospitals NHS Foundation Trust
3. Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust
Mean Age 67 (30 - 99y)
Median Age 68y (IQR 62 - 73y)
Mean PSA 13.7ng/ml (0.3 -1000ng/ml)
Median PSA 6.9ng/ml (IQR 4.6 - 10.5ng/ml)
Mean prostate volume 52ml (9 - 190ml)
Median prostate volume 46ml (IQR 34 - 62ml)
Surveillance v Primary
27.0%
44.7%
72.4%
81.2%
59.3%
20.4%
16.3%
10.3%
9.4%
15.9%
52.6%
39.0%
17.2%
9.4%
24.8%
22.3%
36.4%
82.6%
90.6%
59.1%
16.5%
17.2%
8.7%
0.8%
14.2%
56.8%
46.3%
8.7%
8.2%
26.7%
Prior TRUS Understaging Surveillance Pathway
n = 166
Previous risk
(TRUS)
% (n) % Upstaged (n) % Upstaged CS
Ca (n)
Benign 6.6% (11/166) 45% (5/11) 36.4% (4/11)
Low risk 53.6% (89/166) 44% (39/89) 44% (39/89)
Int. risk 38.6% (64/166) 6% (4/64) 6% (4/64)
Hi. risk 1.2% (2/166) N/A N/A
44% patients previously graded low risk via TRUS were upstaged to
CS PrCa via LATP on AS pathway.
Do systematic biopsies affect management?
Of 357 biopsy naive patients who had both targeted and
systematic biopsies, 22.9% (82/357) had -ve target histology
but CS +ve systematic histology.
Complications
Total 1.6% (13/791)
Readmission 0.1% (1/791)
•Urinary tract infection 0.3% (n=2)
•Acute urinary retention 0.3% (n=2)
•Vasovagal syncope (discharged) 0.6% (n=5)
•Rebooked for GA 0.4% (n=3)
•Urosepsis (admitted with fever) 0.1% (n=1)
The other 4 questions in the questionnaire (regarding
discomfort, embarrassment, dignity, recommending biopsy
to a friend) all returned similarly positive responses.Conclusion
●Antibiotic free LATP biopsy is:
○Safe; low rates of sepsis/complications
○Accurate; high rates of PrCa diagnosis
○Well tolerated; according to patient responses
●We advocate for the continued use of targeted and
systematic biopsies in PIRADS3-5 lesions given its
detection rates of CS PrCa