A recent study shows more complications with the alternative prostate biopsy method.

If a prostate cancer screening test produces an abnormal result, the next step is usually a biopsy. In the United States, this is almost always done by inserting a biopsy needle into the prostate through the rectum. By looking through an ultrasound machine, doctors can see where the hand is going. This procedure, called transrectal ultrasound biopsy (TRUS), carries a small but growing risk of infections which, in turn, are increasingly resistant to current antibiotics.

To minimize the risk of infection, doctors can also pass the biopsy needle through an area of ​​skin between the anus and the scrotum called the perineum, thereby avoiding rectal bacteria. These so-called transperineal (PT) biopsies offer an additional advantage because they allow better access to the prostate's tip (or apex), where 30% of cancers occur. However, they are also more painful for the patient. Until recently, they were only performed in operating rooms of hospitals under general anesthesia.

Today, technical advances allow physicians to perform PT biopsies under local anesthesia in their own offices. And with this development, the pressure is mounting to limit infections by taking this approach.

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In a recent study, Harvard scientists looked at how the two methods stack up in cancer detection and complication rates. A total of 260 men were included in the study, each one very similar in terms of age, race, PSA levels, and other diagnostic findings. Half of the men had TRUS biopsies, and half had PT biopsies, and all procedures were performed in a single doctor visit between 2014 and 2020. According to standard clinical protocols, all men in the TRUS group received took prophylactic antibiotics to prepare. In contrast, only 43% of men in the TP group took antibiotics, depending on the doctor's preference.

 The results showed minimal differences in the cancer detection rate, 62% in the TP group and 74% in the men who had TRUS biopsies. But more importantly, 15% of men with cancer in the TP group had vertex tumors that the TRUS biopsies "might have missed," the study authors wrote.

 No more complications with the TP approach

Regarding complications, a man in the TRUS group developed an infection treated with several rounds of oral antibiotics. None of the men who had a PT biopsy contracted a disease. Still, eight of them had other complications: one had blood clots in the urine, which were treated in hospital, two were catheterized for acute urinary retention, three were assessed medically for dizziness, and two had temporarily swollen blood clots from the scrotum.

 Why were the rates of non-infectious complications of PD higher? It is not entirely clear. For various reasons, doctors took more prostate samples (called carrots) on average from the men in the TP group than from the men in the TRUS group. The authors suggest that if an equivalent number of carrots had been taken from men in either group, the complication rates could have been more similar. (In fact, more extensive, hospital-based, comparative studies show no difference in complication rates when an equal number of carrots are obtained.) But the doctors in the present study also had more experience with TRUS biopsies. And that could also explain the gap, suggest the authors. And as general practitioners gain experience with the PT method, complication rates may decrease.

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