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Objective: To assess, in men undergoing active surveillance (AS) for low-risk prostate cancer, whether saturation or transperineal biopsy altered oncological outcomes, compared with standard transrectal biopsy., Patients and Methods: Retrospective analysis of prospectively collected data from two cohorts with localised prostate cancer (1998-2012) undergoing AS. Prostate cancer-specific, metastasis-free and treatment-free survival, unfavourable disease and significant cancer at radical prostatectomy (RP) were compared for standard (<12 core, median 10) vs saturation (>12 core, median 16), and transrectal vs transperineal biopsy, using multivariate analysis., Results: In all, 650 men were included in the analysis with a median (mean) follow-up of 55 (67) months. Prostate cancer-specific, metastasis-free and biochemical recurrence-free survival were 100%, 100% and 99% respectively. Radical treatment-free survival at 5 and 10 years were 57% and 45% respectively (median time to treatment 7.5 years). On Kaplan-Meier analysis, saturation biopsy was associated with increased objective biopsy progression requiring treatment (log-rank P = 0.01). On multivariate Cox proportional hazards analysis, saturation biopsy (hazard ratio 1.68, P < 0.01) but not transperineal approach (P = 0.89) was associated with increased objective biopsy progression requiring treatment. On logistic regression analysis of 179 men who underwent RP for objective progression, transperineal biopsy was associated with lower likelihood of unfavourable RP pathology (odds ratio 0.42, P = 0.03) but saturation biopsy did not alter the likelihood (P = 0.25). Neither transperineal nor saturation biopsy altered the likelihood of significant vs insignificant cancer at RP (P = 0.19 and P = 0.41, respectively)., Conclusions: AS achieved satisfactory oncological outcomes. Saturation biopsy increased progression to treatment on AS; longer follow-up is needed to determine if this represents beneficial earlier detection of significant disease or over-treatment. Transperineal biopsy reduced the likelihood of unfavourable disease at RP, possibly due to earlier detection of anterior tumours., (© 2014 The Authors. BJU International © 2014 BJU International.)

Objective: To determine the rate of hospital re-admission for sepsis after transperineal (TP) biopsy using both local data and worldwide literature, as there is growing interest in TP biopsy as an alternative to transrectal ultrasonography (TRUS)-guided biopsy for patients undergoing repeat prostate biopsy., Patients and Methods: Pooled prospective databases on TP biopsy from multiple centres in Melbourne were queried for rates of re-admission for infection. A literature review of PubMed and Embase was also conducted using the search terms: 'prostate biopsy, fever, infection, sepsis, septicaemia and complications'., Results: In all, 245 TP biopsies were performed (111 at Alfred Health, 92 at Epworth Healthcare, 38 at Peter MacCallum Cancer Centre, and four at other institutions). The rate of hospital re-admission for infection was zero. The literature review showed that the rate of sepsis after TRUS biopsy appears to be rising with increasing rates of multi-resistant bacteria found in rectal flora, and is as high as 5%. However, the rate of sepsis from published series of TP biopsy approached zero., Conclusions: Both local and international data suggest a negligible rate of sepsis with TP biopsy. This compares to a concerning rise in the rate of sepsis after TRUS biopsy due to the increasing prevalence of multi-resistant bacteria in rectal flora. Although TRUS biopsy is convenient, cheap and quick to perform, we think that TP biopsy should now be offered as an option, not only to patients undergoing repeat prostate biopsy, but to all patients in whom a prostate biopsy is indicated., (© 2013 The Authors. BJU International © 2013 BJU International.)

BackgroundThe optimal interval for repeat biopsy during active surveillance (AS) for prostate cancer is yet to be defined. This study examined whether risk of upgrading (to grade group ≥ 2) or risk of converting to treatment varied according to intensity of repeat biopsy using data from the GAP3 consortium's global AS database.Materials and methodsIntensity of surveillance biopsy schedules was categorized according to centers' protocols: (a) Prostate Cancer Research International Active Surveillance project (PRIAS) protocols with biopsies at years 1, 4, and 7 (10 centers; 7532 men); (b) biennial biopsies, that is, every other year (8 centers; 4365 men); and (c) annual biopsy schedules (4 centers; 1602 men). Multivariable Cox regression was used to compare outcomes according to biopsy intensity.ResultsOut of the 13,508 eligible participants, 56% were managed according to PRIAS protocols (biopsies at years 1, 4, and 7), 32% via biennial biopsy, and 12% via annual biopsy. After adjusting for baseline characteristics, risk of converting to treatment was greater for those on annual compared with PRIAS biopsy schedules (hazard ratio [HR] = 1.66; 95% confidence interval [CI] = 1.51-1.83; p

BackgroundCareful assessment of the reasons for discontinuation of active surveillance (AS) is required for men with prostate cancer (PCa).ObjectiveUsing Movember's Global Action Plan Prostate Cancer Active Surveillance initiative (GAP3) database, we report on reasons for AS discontinuation.Design, setting, and participantsWe compared data from 10296 men on AS from 21 centres across 12 countries.Outcome measurements and statistical analysisCumulative incidence methods were used to estimate the cumulative incidence rates of AS discontinuation.Results and limitationsDuring 5-yr follow-up, 27.5% (95% confidence interval [CI]: 26.4-28.6%) men showed signs of disease progression, 12.8% (95% CI: 12.0-13.6%) converted to active treatment without evidence of progression, 1.7% (95% CI: 1.5-2.0%) continued to watchful waiting, and 1.7% (95% CI: 1.4-2.1%) died from other causes. Of the 7049 men who remained on AS, 2339 had follow-up for >5yr, 4561 had follow-up for

Objective: To assess changes in diagnosis prostate cancer (PCa) grade, biopsy and treatment approach over a decade (2011–2020) at a population level within a clinical quality cancer registry. Patients and Methods: Patients diagnosed by prostate biopsy between 2011 and 2020 were retrieved from the Victorian Prostate Cancer Outcomes Registry, a prospective, state‐wide clinical quality registry in Australia. Distributions of each grade group (GG) proportion over time were modelled with restricted cubic splines, separately by biopsy technique, age group and subsequent treatment method. Results: From 2011 to 2020, 24 308 men were diagnosed with PCa in the registry. The proportion of GG 1 disease declined from 36–23%, with commensurate rises in GG 2 (31–36%), GG 3 (14–17%) and GG 5 (9.3–14%) disease. This pattern was similar for men diagnosed by transrectal ultrasonography or transperineal biopsy. Patients aged <55 years had the largest absolute reduction in GG 1 PCa, from 56–35%, compared to patients aged 55–64 (41–31%), 65–74 (31–21%), and ≥75 years (12–10%). The proportion of prostatectomies performed for patients with GG 1 disease fell from 28% to 7.1% and, for primary radiation therapy, the proportion fell from 22% to 3.5%. Conclusion: From 2011 to 2020, there has been a substantial decrease in the proportion of GG 1 PCa diagnosed, particularly in younger men. The percentage of interventional management performed in GG 1 disease has fallen to very low levels. These results reflect the implementation of major changes to diagnostic and treatment guidelines and inform the future allocation of treatment methods. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the addition of inhaled methoxyflurane to periprostatic infiltration of local anaesthetic (PILA) during transrectal ultrasonography‐guided prostate biopsies (TRUSBs) improved pain and other aspects of the experience. Patients and Methods: We conducted a multicentre, placebo‐controlled, double‐blind, randomized phase 3 trial, involving 420 men undergoing their first TRUSB. The intervention was PILA plus a patient‐controlled device containing either 3 mL methoxyflurane, or 3 mL 0.9% saline plus one drop of methoxyflurane to preserve blinding. The primary outcome was the pain score (0–10) reported by the participant after 15 min. Secondary outcomes included ratings of other aspects of the biopsy experience, willingness to undergo future biopsies, urologists' ratings, biopsy completion, and adverse events. Results: The mean (SE) pain scores 15 min after TRUSB were 2.51 (0.22) in those assigned methoxyflurane vs 2.82 (0.22) for placebo (difference 0.31, 95% confidence interval [CI] −0.75 to 0.14; P = 0.18). Methoxyflurane was associated with better scores for discomfort (difference −0.48, 95% CI −0.92 to −0.03; P = 0.035, adjusted [adj.] P = 0.076), whole experience (difference −0.50, 95% CI −0.92 to −0.08; P = 0.021, adj. P = 0.053), and willingness to undergo repeat biopsies (odds ratio 1.67, 95% CI 1.12–2.49; P = 0.01) than placebo. Methoxyflurane resulted in higher scores for drowsiness (difference +1.64, 95% CI 1.21–2.07; P < 0.001, adj. P < 0.001) and dizziness (difference +1.78, 95% CI 1.31–2.24; P < 0.001, adj. P < 0.001) than placebo. There was no significant difference in the number of ≥ grade 3 adverse events. Conclusions: We found no evidence that methoxyflurane improved pain scores at 15 min, however, improvements were seen in patient‐reported discomfort, overall experience, and willingness to undergo repeat biopsies. [ABSTRACT FROM AUTHOR]

Purpose: There is little research assessing the impact of providing men with information about prostate cancer (PCa) treatment options at the time of referral for a prostate biopsy. Study objectives were to determine whether receiving an information booklet about PCa treatment options prior to receiving biopsy results was acceptable to patients, and if receiving this information influenced levels of anxiety, depression, distress, and treatment decisional conflict.Methods: Between June 2016 and September 2017, a randomised block design was used to allocate patients from an Australian urology practice into the intervention or control group. Patients in the intervention group were provided with written information about treatment options for localised PCa prior to their biopsy. Outcome measures including the Distress Thermometer, Generalised Anxiety Disorder-7, Patient Health Questionnaire-9, and Decisional Conflict Scale were completed pre-biopsy and 2-3 weeks post-biopsy. Ninety-eight patients referred for an initial prostate biopsy for an elevated PSA test or suspicious digital rectal exam participated in the study (response rate = 78%).Results: Multimodal repeated-measures analyses showed no significant differences between control and intervention groups in changes in distress, anxiety, or depression from pre- to post-biopsy, and in decisional conflict post-diagnosis (all p > .05). Thirty-five (87%) patients believed that the resource made it easier to understand subsequent explanation of treatment options, and 51 patients (98%) who received the intervention preferred to be given information at that time.Conclusions: Providing patients with information about treatment options prior to biopsy did not impact on changes in psychological distress and decisional conflict post-biopsy. However, the majority of patients preferred to be given such information at this time point. [ABSTRACT FROM AUTHOR]

Background The objective of this study was to compare pain intensity in patients undergoing transrectal ultrasound ( TRUS)-guided biopsy of the prostate with Penthrox alone compared with Penthrox plus periprostatic infiltration of local analgesia ( PILA). Method Seventy-two subjects participated in this study after receiving appropriate education. Forty-two patients self-administered inhaled Penthrox (3 mL methoxyflurane) alone for analgesia ( Group A), followed by 30 patients who self-administered Penthrox and received PILA with 5 mL of 2% lignocaine. All subjects had TRUS biopsy performed. Immediately after the procedure, patients were asked to rate their pain intensity using a numerical verbal rating scale from 0 to 10. Results Baseline characteristics of the two groups were similar. Patients in Group B reported significantly lower post TRUS biopsy median pain intensity of 2 (1-3) compared with Group A subjects who reported a median post TRUS biopsy pain intensity of 3 (2-5) ( P = 0.014). A total of 72 men underwent TRUS-guided biopsy. All patients indicated they would be happy to have another TRUS-guided prostate biopsy in the future. Conclusion Our study shows that Penthrox plus PILA shows promise as an efficacious and easily tolerated analgesic technique for outpatient TRUS biopsy, keeping resource use to a minimum. Planning for a multi-centre, double-blind randomized control trial comparing Penthrox plus PILA with PILA alone is presently underway. [ABSTRACT FROM AUTHOR]

Objectives To present the Victorian Transperineal Biopsy Collaboration ( VTBC) experience in patients with no prior prostate cancer diagnosis, assessing the cancer detection rate, pathological outcomes and anatomical distribution of cancer within the prostate. Patients and Methods VTBC was established through partnership between urologists performing transperineal biopsies of the prostate ( TPB) at three institutions in Melbourne. Consecutive patients who had TPB, as first biopsy or repeat biopsy after previous negative transrectal ultrasound-guided ( TRUS) biopsy, between September 2009 and September 2013 in the VTBC database were included. Data for each patient were collected prospectively (except for TPB before 2011 in one institution), based on the minimum dataset published by the Ginsburg Study Group. Univariate and multivariate analyses were used to identify factors predictive of cancer detection on TPB. Results In all, 160 patients were included in the study, of whom 57 had TPB as first biopsy and 103 had TPB as repeat biopsy after previous negative TRUS biopsies. The median patient age at TPB was 63 years, with the repeat-biopsy patients having a higher median serum PSA level (5.8 ng/ mL for first biopsy and 9.6 ng/ mL for repeat biopsy) and larger prostate volumes (40 mL for first biopsy, and 51 mL for repeat biopsy). Prostate cancer was detected in 53% of first-biopsy patients and 36% of repeat-biopsy patients, of which 87% and 81%, respectively, were clinically significant cancers, defined as a Gleason score of ≥7, or more than three positive cores of Gleason 6. Of the cancers detected in repeat biopsies, 75% involved the anterior region (based on the Ginsburg Study Group's recommended biopsy map), while 25% were confined exclusively within the anterior region; a lower proportion of only 5% of cancers detected in first biopsies were confined exclusively within the anterior region. Age, serum PSA level and prostate volume were predictive of cancer detection in repeat biopsies, while only age was predictive in first biopsies. Conclusions TPB is an alternative approach to TRUS biopsy of the prostate, offering a high rate of detection of clinically significant prostate cancer. It provides excellent sampling of the anterior region of the prostate, which is often under-sampled using the TRUS approach, and should be considered as an option for all men in whom a prostate biopsy is indicated. [ABSTRACT FROM AUTHOR]

Introduction Prostate cancer is common and may be treated immediately or managed conservatively by observation. We sought to determine how reliable multiparametric MRI is in the detection of intraprostatic prostate cancer and what role it has in risk stratification. Methods The histology from 38 whole mount prostate specimens was compared with preoperative multiparametric 3 T MRI studies with an endorectal receiver coil in place. T1-weighted, T2-weighted, diffusion (b values 50 400 800), perfusion ( Ve, Kep, Ktrans, area under the curve) and proton spectroscopic sequences were used. Results For cancers greater than 0.5 cc, the detection rate for combined T2-weighted imaging and diffusion-weighted imaging ( DWI) was 85%. For cancers 0.1 cc-0.5 cc, the sensitivity was 52%.Per patient, false positive rate was 50% for combined T2-weighted imaging and DWI. Perfusion imaging had a sensitivity of 70% for tumours greater than 0.5 cc but had a per patient false positive rate of 80% influenced by benign prostatic hypertrophy. In only 15 patients could a satisfactory spectroscopy study be obtained. Weak correlation was found between the Gleason score and tumour size ( r = 0.51), apparent diffusion coefficient ( ADC) ( r = −0.30) and (choline + creatine)/citrate ratio ( r = 0.41). Conclusion T2-weighted imaging and DWI in combination were the best strategy for detecting prostate cancer and had a sensitivity of 85% for detecting lesions greater than 0.5 cc. At 3 T, an ADC threshold of between 1100-1200.10−6 mm2/s was optimal for diagnosing prostate cancer. There are significant limitations in the use of perfusion and spectroscopy to detect prostate cancer. Magnetic resonance imaging-targeted or guided biopsy post- MRI imaging is likely to be needed in some patients to assist risk stratification. [ABSTRACT FROM AUTHOR]

Background The diagnosis of prostate cancer has long been plagued by the absence of an imaging tool that reliably detects and localises significant tumours. Recent evidence suggests that multi-parametric MRI could improve the accuracy of diagnostic assessment in prostate cancer. This review serves as a background to a recent USANZ position statement. It aims to provide an overview of MRI techniques and to critically review the published literature on the clinical application of MRI in prostate cancer., Technical Aspects The combination of anatomical (T2-weighted) MRI with at least two of the three functional MRI parameters - which include diffusion-weighted imaging, dynamic contrast-enhanced imaging and spectroscopy - will detect greater than 90% of significant (moderate to high risk) tumours; however MRI is less reliable at detecting tumours that are small (<0.5 cc), low grade (Gleason score 6) or in the transitional zone. The higher anatomical resolution provided by 3-Tesla magnets and endorectal coils may improve the accuracy, particularly in primary tumour staging., Screening The use of mpMRI to determine which men with an elevated PSA should undergo biopsy is currently the subject of two large clinical trials in Australia. MRI should be used with caution in this setting and then only in centres with established uro-radiological expertise and quality control mechanisms in place. There is sufficient evidence to justify using MRI to determine the need for repeat biopsy and to guide areas in which to focus repeat biopsy., Image-Directed Biopsy MRI-directed biopsy is an exciting concept supported by promising early results, but none of the three proposed techniques have so far been proven superior to standard biopsy protocols. Further evidence of superior accuracy and core-efficiency over standard biopsy is required, before their costs and complexities in use can be justified., Treatment Selection and Planning When used for primary-tumour staging (T-staging), MRI has limited sensitivity for T3 disease, but its specificity of greater than 95% may be useful in men with intermediate-high risk disease to identify those with advanced T3 disease not suitable for nerve sparing or for surgery at all. MRI appears to be of value in planning dosimetry in men undergoing radiotherapy, and in guiding selection for and monitoring on active surveillance. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Periprostatic infiltration of local anaesthetic (PILA) is accepted as the current 'gold standard' of analgesia for TRUS-guided biopsy. However, it does not account for discomfort of anal probe insertion and has not received wide uptake amongst clinicians. A better method is therefore sought. PenthroxTM (methoxyflurane) is an effective systemic analgesic that is self-administered via a hand-held inhaler. Its use in TRUS-guided biopsy has not been previously reported. An initial experience with a novel analgesic for TRUS-guided biopsy, which appears to be safe and effective. It has led to the planning of a randomised control trial, which will compare Penthrox with PILA for TRUS-guided biopsy. Objectives To determine the feasibility of using a novel inhaled analgesic agent ( PenthroxTM, methoxyflurane)) for transrectal ultrasonography ( TRUS)-guided biopsies of the prostate., Patients and methods Patients undergoing TRUS-guided biopsies were each given a Penthrox inhaler to self-administer during the procedure and instructed in its use., Immediately after the procedure, patients were asked to rate their pain using a verbal rating scale from 0 to 10., Results In all, 42 consecutive men underwent a TRUS-guided biopsy., The median pain score was 3., All 42 patients stated they would be happy to undergo the same procedure again. The only adverse effects reported by patients were brief light-headedness and a sickly sweet taste., Conclusion This study of our initial experience using Penthrox suggests that it may have a role in analgesia for TRUS-guided biopsy., It may provide safe, adequate analgesia that is easy for urologists to use and avoids excessive use of resources., Planning for a randomised control trial comparing Penthrox to the current 'gold standard' of prostatic infiltration of local anaesthetic is presently underway. [ABSTRACT FROM AUTHOR]

Avoiding biopsy in men with PI-RADS scores 1 and 2 on multiparametric MRI of the prostate, ready for prime time? In 2019 is it safe to avoid prostate biopsy in men with Prostate Imaging Reporting and Data System (PI-RADS) score 1 and 2 lesions reported on their multiparametric MRI (mpMRI)? Multicentre evaluation of magnetic resonance imaging supported tran-sperineal prostate biopsy in biopsy naïve men with suspicion of prostate cancer. [Extracted from the article]

The article discusses a study which examined active surveillance as a treatment option for low risk prostate cancer in an Australian setting. The outcome of active surveillance including biopsy missclassification, under grading of disease progression, and tumor volume are highlighted. Tables presented show the characteristics of men with disease progression versus men who remained on surveillance, and the percentages by general state/trait anxiety and disease specific anxiety in patients.

• The proportion of prostate cancer patients diagnosed by transperineal biopsy has increased. • This is now the predominant form of prostate cancer diagnosis in Australia and New Zealand. • Transperineal biopsy use varies between jurisdictions, hospitals, and patient groups. To describe changes in the use of prostate biopsy techniques among men diagnosed with prostate cancer in Australia and New Zealand and examine factors associated with these changes. We extracted data between 2015 and 2019 from 7 jurisdictions of the Australia and New Zealand Prostate Cancer Outcomes Registry (PCOR-ANZ). Distribution and time trend of transrectal (TR) vs. transperineal (TP) biopsy type, differences in the proportion of biopsy type by geographic jurisdiction, diagnosing institute characteristics (public vs. private, metropolitan vs. regional, case volume) and patient characteristics such as socio-economic status (SES), and location of residence were analyzed. We analyzed data from 37,638 patients. The overall proportion of prostate cancer diagnosed by TP increased from 26% to 57% between 2015 and 2019. Patients living in a major city, a more socioeconomically advantaged area or who were diagnosed in a metropolitan or private hospital were more likely to have TP than TR. While all subgroups were observed to increase their use of TP over the study period, uptake grew faster for men from low SES areas and those diagnosed at a regional or low-volume hospital but slower for men living in outer regional/remote areas or treated at a public hospital. In this binational registry, prostate cancer is now more commonly diagnosed by TP than the TR approach. While the gap between uptakes of TP has diminished for patients with low vs. high SES, disparity has widened for patients from outer regional areas vs major cities and public vs. private hospitals. [ABSTRACT FROM AUTHOR]