Developing story: AUA put TR and TP biopsies on a par-- as Euro uros say no to TRectals
In early 2021, the European Association of Urologists adopted the position that transrectal (TR) biopsies presented too great of a risk for patients because of potentially disabling and deadly sepsis and other infections.
Hein Van Poppel, MD, a patient advocate and policy chief for EAU, recently told me that TRs are considered “medical malpractice” in Europe. Instead, EAU supports transperineal biopsies that avoid the germy rectum, prevent sepsis, and reduce risks from germ-resistant antibiotics.
The death of a single patient in Norway from a TR-caused biopsy triggered an international movement to drop transrectals in favor of transperineal biopsies. Here’s my 2021 story “Death By Prostate Biopsy.” And a more recent story in Medscape.
I knew that the American Urological Association (AUA), which gathers this week for its annual meeting in Chicago, was writing its new guidelines, including reviewing its position on biopsies.
In 2018, AUA’s early detection guidelines did not pick a favorite, but indicated both types of biopsies carried similar risks. This is the first time AUA has said anything at all on this topic in its guidelines.
What would AUA do in 2023? Follow the Euro uros? Or stick with its position that transrectal and transperineal biopsies essentially were equals?
Tuesday, I learned that the new AUA new guidelines were out. Drum roll, please.
And the status quo holds.
The new AUA guideline states: “Clinicians may use either a transrectal or transperineal biopsy route when performing a biopsy. (Conditional Recommendation; Evidence Level: Grade C).” [C is a low grade.]
I’ll be getting reaction from other sources, including European researchers and policy-makers and an AUA guideline committee member. So I’ll have a follow-up.
Are European prostates different from American prostates? You might think so.
AUA acknowledges; “Use of transperineal versus transrectal biopsy varies widely by country and within regions of specific countries. While the transperineal approach may lower the risk of infection without compromising diagnostic capabilities, it is unknown whether prophylactic antibiotics provide value while adequate training and resources are required for wider implementation. ”
So training in TP is lagging even though AUA runs training courses at its meetings.
Two years ago, only 5% of biopsies in the U.S. used TP. It’s up to 10% now nationally. Use among patients attending support groups is about 25% and growing.
AUA says: “Multiple randomized trials of transrectal versus transperineal are ongoing and will provide necessary comparative effectiveness data.”
Sources tell me that large, randomized trials from the U.S. on TP vs. TR are coming soon. So we’ll see soon. If favorable, I hope AUA won’t drag its feet.
Meanwhile, here’s the AUA's position:
--Recent meta-analyses and retrospective reviews of single center data suggest a lower risk of infection with the transperineal approach; however, prospective, randomized data are lacking to make a definitive conclusion. Given the concern surrounding the rising rate of sepsis and antibiotic resistance, using transperineal biopsy to mitigate these concerns is a reasonable approach and is gaining traction. But AUA still is sticking with transrectal biopsies.
--There is some suggestion that transperineal biopsy may detect anterior and apical cancers at a higher rate; however prospective, randomized data are lacking and existing data are contradictory.
--Wth a suspicion for GG2+ prostate cancer (Gleason 3+4), who are undergoing biopsy, the cancer detection rate associated with transrectal versus transperineal biopsy route are not significantly different.
--Recent meta-analyses and retrospective reviews of single center data suggest a lower risk of infection with the transperineal approach; however, prospective, randomized data are lacking to make a definitive conclusion.
--Use of transperineal biopsies may have some value in patients who have experienced infectious complications with a prior biopsy, are at higher risk for biopsy-related infection, or have anterior lesions that may not be as easily accessible transrectally. There are at least two randomized controlled trials listed in clinicaltrials.gov that address this question (https://clinicaltrials.gov/ct2/show/NCT04815876 and https://clinicaltrials.gov/ct2/show/NCT05179694) and the results are pending.
--Use of the transrectal approach may be appropriate in certain situations (e.g., patient preference/comfort, patient cannot be placed into the lithotomy position, clinician training/experience, or lack of appropriate equipment for the transperineal approach).
--Moreover, use of adjunctive measures (e.g., rectal swab cultures, augmented antibiotic approaches) to reduce sepsis for a transrectal biopsy approach have also been shown to reduce sepsis in a large statewide registry consisting of 30 practices.
Stay tuned. More to come.
Hopkin’s Dr. Epstein to hold a Q&A at ASPI on April 29
By Howard Wolinsky
Talking about biopsies.
In a last-minute addition, Johns Hopkins uropathologist Jonathan Epstein will answer questions on active surveillance, biopsies and second opinions at the meeting of Active Surveillance Patients International (ASPI) on April 29.
Originally, the meeting at 12 p.m. Eastern April 29 was only going to premiere the latest episode of the Active Surveillance 101 video series: "Second Opinions and Biopsies," featuring our intrepid researchers, PCa patient Larry White and his savvy wife Nancy White, interviewing uropathology legend Epstein.
But thanks to some schedule changes, Epstein will join a Q&A session after the video is aired.
Register: https://zoom.us/meeting/register/tJYtdeqsrDorGt0ujT6Ifo0Jx0FU30yoAt3L
If you sign up and can’t make it, you’ll get a link to the recording.
If you have questions, send them to me at howard.wolinsky@gmail.com
Dr. Epstein is prepared to handle all-comers.
(Thanks to Meyer Quaynor from Prostate Cancer Support Canada for designing the flyer.)
Co-sponsors of the AS 101 series under the Active Surveillance Coalition include AnCan Foundation, Prostate Cancer Support Canada, Prostate Cancer Research Institute, and TheActiveSurveillor.com newsletter.
To view the full AS 101 series to date, covering PSAs, diagnosis, and Active Surveillance, go to https://aspatients.org/a-s-101/https://aspatients.org/a-s-101/