#1 reason TP is lagging in the U.S. is that people (in this case, doctors) don't like change. #2 $$$ as detailed in the article. #3 Would require training of 1000s of Urologists. And sadly, most U.S. physicians don't care about antibiotic stewardship. I review charts as part of my job and most antibiotics are prescribed inappropriately in an outpatient setting.
Seems to me the antibiotics stewardship issue should be front and center, not buried in the discussion. Do the studies that compare TR favorably with TP do so only because of prophylactic antibiotics? Are biopsies killing not just the people being biopsied? One leading urologist told me he was proud of his TR safety record. Are American urologists proud of the squandering of antibiotics? This is a genuine "moral hazard" issue. – Peter Swenson
I agree. When I tried to persuade AUA's early detection committee to support transperineal, I felt saving even one life was a justification. Now they're caught up in the randomized clinical trial loop. The European urologists took a more humane approach--lives first.
Meanwhile, a hawk-eyed physician reader told me a couple letters in the medical lit this week have indicated that the Albany study technically is NOT an RCT.
He said: :\"You might want to correct this by mentioning that the paper in the Journal of Urology, Mian et al, Was not a randomized controlled trial, even though it was published as such. That is because all the transrectal biopsies received prophylactic antibiotics whereas all but two of the transperineal biopsies received no prophylactic antibiotics.
"This was brought to everyone’s attention by two letters to the editor, just published this week.
The obvious question is, if the transperineal biopsies had also received prophylactic antibiotics, would their infection rates have been much lower and thus would there not have been a significantly lower infection rate compared to the transrectal biopsies?
And as Dr. Grummet said, the true reason urologists have been switching to the transperineal approach is to avoid the complication of sepsis. Retrospective studies have demonstrated an overwhelmingly significantly lower incidence of sepsis with transperineal biopsies. However, there was not one case of sepsis in either arm in this comparison so this study certainly does not answer the question of whether or not there is a significant difference in sepsis between the two approaches."
Thanks, Keith.
You're right about resistance to change. "i've mentioned that in previous stories,
And thanks forthe point about antibiotics.
Howard
John,
Can you shrewhat happened in 2008.
Hope you're OK.
HW
#1 reason TP is lagging in the U.S. is that people (in this case, doctors) don't like change. #2 $$$ as detailed in the article. #3 Would require training of 1000s of Urologists. And sadly, most U.S. physicians don't care about antibiotic stewardship. I review charts as part of my job and most antibiotics are prescribed inappropriately in an outpatient setting.
TR at WashU/Barnes, 2008. Sepsis. Almost died. Never again.
Who says prostate cancer isn't funny. Just think of the digital rectal exam ...
And now what's funny about, sepsis, antibiotics and "superbugs"?
Not much. Just look hard enough and a prostate cancer patient will find an angle.
An anonymous Gleason 6 jokester, a winner of the Glee in Gleason Score prostate humor contest, submitted this bit of infectious levity:
"Did you hear the one about the AS patient who was given antibiotic pills before his TR? Didn’t work, they kept falling out!"
HW
(Translations available for the uninitiated for TR and AS.)
Just as I thought. RCT?! Like comparing apples and oranges, or should I say pumpkins and toasters.
Seems to me the antibiotics stewardship issue should be front and center, not buried in the discussion. Do the studies that compare TR favorably with TP do so only because of prophylactic antibiotics? Are biopsies killing not just the people being biopsied? One leading urologist told me he was proud of his TR safety record. Are American urologists proud of the squandering of antibiotics? This is a genuine "moral hazard" issue. – Peter Swenson
Thanks, Peter.
I agree. When I tried to persuade AUA's early detection committee to support transperineal, I felt saving even one life was a justification. Now they're caught up in the randomized clinical trial loop. The European urologists took a more humane approach--lives first.
Meanwhile, a hawk-eyed physician reader told me a couple letters in the medical lit this week have indicated that the Albany study technically is NOT an RCT.
He said: :\"You might want to correct this by mentioning that the paper in the Journal of Urology, Mian et al, Was not a randomized controlled trial, even though it was published as such. That is because all the transrectal biopsies received prophylactic antibiotics whereas all but two of the transperineal biopsies received no prophylactic antibiotics.
"This was brought to everyone’s attention by two letters to the editor, just published this week.
The obvious question is, if the transperineal biopsies had also received prophylactic antibiotics, would their infection rates have been much lower and thus would there not have been a significantly lower infection rate compared to the transrectal biopsies?
And as Dr. Grummet said, the true reason urologists have been switching to the transperineal approach is to avoid the complication of sepsis. Retrospective studies have demonstrated an overwhelmingly significantly lower incidence of sepsis with transperineal biopsies. However, there was not one case of sepsis in either arm in this comparison so this study certainly does not answer the question of whether or not there is a significant difference in sepsis between the two approaches."
The beat goes on.
HW