- Email: [email protected]
Re: Marco Borghesi, Hashim Ahmed, Robert Nam, et al. Complications After Systematic, Random, and Image-guided Prostate Biopsy. Eur Urol 2017;71:353–65
EURURO-7091; No. of Pages 2 EUROPEAN UROLOGY XXX (2016) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Letter to the Editor Re: Marco Borghesi, Hashim Ahmed, Robert Nam, et al. Complications After Systematic, Random, and Image-guided Prostate Biopsy. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2016.08.004 In a recent review, Borghesi et al [1] concluded that sepsis is the most troublesome complication following transrectal prostate biopsy and that its incidence continues to increase due to the ongoing rise of fluoroquinolone resistance. We believe the time is nigh to abandon the transrectal approach. In performing transrectal biopsy, we forsake basic surgical principles of sterility for the convenience of this approach, using antibiotics as a substitute for hygiene. Quinolones are recommended as standard prophylaxis, but are losing their effect. The US Center for Disease Control states that ‘‘use of antibiotics is the single most important factor leading to resistance around the world’’ [2]. The World Health Organization implores us to reduce unnecessary antibiotic usage for fear of creating a postantibiotic era. Proposed preventative solutions to prostate biopsy sepsis involving multidrug or broader spectrum prophylaxis are therefore in direct contravention of these warnings and are irresponsible. Furthermore, in July 2016, the US Food and Drug Administration issued a safety announcement that due to ‘‘disabling and potentially permanent side effects’’ fluoroquinolones should not be used unless there are no other treatment options [3]. The current standard practice of antibiotic prophylaxis for transrectal biopsy is therefore no longer sustainable. Transperineal biopsy, however, represents a clean alternative, with minimal infection risk and no need for quinolones, let alone other broader spectrum antibiotics. Borghesi et al [1] quote our early experience of transperineal biopsy in 245 consecutive cases with a hospital readmission rate for infection of zero [4]. Our series has since grown to 1194 consecutive cases performed at five centers across Melbourne, Australia, by six urologists in a private group practice. All patients were followed up by the same urologists who performed their biopsy and all data were recorded on an Institutional Ethics Committeeapproved prospective database. Our rate of infective
readmission remains at zero. This compares to a population-based study we performed in our state of Victoria over a 5-yr period to 2012, showing a rate of 1.7% of infective readmission [5]. Using transperineal biopsy exclusively, we have eliminated postbiopsy sepsis from our practice. Importantly, the latter 710 (59.5%) patients in our series were only given a single dose of intravenous cephazolin as prophylaxis. This is in accordance with the new recommendations on antibiotic prophylaxis for transperineal biopsy in Australia’s Therapeutic Guidelines series. Borghesi et al [1] state that the transperineal biopsy is infrequently used due to logistics. Transperineal biopsy is typically performed under general anesthesia and would have a major impact on workflow if uptake were to become routine. However, techniques for performing transperineal biopsy as an office procedure have been recently developed. Furthermore, it has been shown that multiparametric magnetic resonance imaging could reduce unnecessary prostate biopsies by up to half [6], thereby substantially mitigating this resource issue. From a medico-legal standpoint it is difficult to justify the risk of sepsis to patients as an acceptable complication when a cleaner biopsy alternative is available. In this era of patient-centered care and increasingly ineffective antibiotic prophylaxis, we believe that logistical reasons are no longer an excuse for transrectal biopsy. Conflicts of interest: Grummet was sponsored to attend the Urological Association of Asia Congress in 2016 by Biobot, makers of the Mona Lisa robotic transperineal device. Acknowledgments: This work has been supported by grants from Ipsen and Tolmar.
References [1] Borghesi M, Ahmed H, Nam R, et al. Complications after systematic, random, and image-guided prostate biopsy. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2016.08.004. [2] Centers for Disease Control and Prevention. Antibiotic resistance threat search results. https://stacks.cdc.gov/gsearch?collection= &terms=antibiotic+resistance+threat. [3] US Food and Drug Administration. FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. http://www.fda.gov/Drugs/ DrugSafety/ucm511530.htm.
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2016.08.004. http://dx.doi.org/10.1016/j.eururo.2016.10.015 0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Grummet J, et al. Re: Marco Borghesi, Hashim Ahmed, Robert Nam, et al. Complications After Systematic, Random, and Image-guided Prostate Biopsy. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2016.08.004. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.10.015
EURURO-7091; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2016) XXX–XXX
[4] Grummet JP, Weerakoon M, Huang S, et al. Sepsis and ‘‘superbugs’’:
Jeremy Grummet*
should we favor the transperineal over the transrectal approach for
Lana Pepdjonovic
prostate biopsy? BJU Int 2014;114:384–8. [5] Roth H, Millar JL, Cheng AC, Byrne A, Evans S, Grummet J. The state
Daniel Moon Australian Urology Associates, Monash University, Victoria, Australia
of TRUS biopsy sepsis: readmissions to Victorian hospitals with TRUS biopsy-related infection over 5 years. BJU Int 2015;116(Suppl 3):49–53.
*Corresponding author. Australian Urology Associates, Monash University, Surgery, 322 Glenferrie Road, Malvern, Victoria 3144,
[6] Pokorny MR, de Rooij M, Duncan E, et al. Prospective study of
Australia. Tel. +61 428888920.
diagnostic accuracy comparing prostate cancer detection by trans-
E-mail address: [email protected] (J. Grummet).
rectal ultrasound-guided biopsy versus magnetic resonance (MR) imaging with subsequent MR-guided biopsy in men without
October 9, 2016
previous prostate biopsies. Eur Urol 2014;66:22–9.
Please cite this article in press as: Grummet J, et al. Re: Marco Borghesi, Hashim Ahmed, Robert Nam, et al. Complications After Systematic, Random, and Image-guided Prostate Biopsy. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2016.08.004. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.10.015
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Letter to the Editor Re: Marco Borghesi, Hashim Ahmed, Robert Nam, et al. Complications After Systematic, Random, and Image-guided Prostate Biopsy. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2016.08.004 In a recent review, Borghesi et al [1] concluded that sepsis is the most troublesome complication following transrectal prostate biopsy and that its incidence continues to increase due to the ongoing rise of fluoroquinolone resistance. We believe the time is nigh to abandon the transrectal approach. In performing transrectal biopsy, we forsake basic surgical principles of sterility for the convenience of this approach, using antibiotics as a substitute for hygiene. Quinolones are recommended as standard prophylaxis, but are losing their effect. The US Center for Disease Control states that ‘‘use of antibiotics is the single most important factor leading to resistance around the world’’ [2]. The World Health Organization implores us to reduce unnecessary antibiotic usage for fear of creating a postantibiotic era. Proposed preventative solutions to prostate biopsy sepsis involving multidrug or broader spectrum prophylaxis are therefore in direct contravention of these warnings and are irresponsible. Furthermore, in July 2016, the US Food and Drug Administration issued a safety announcement that due to ‘‘disabling and potentially permanent side effects’’ fluoroquinolones should not be used unless there are no other treatment options [3]. The current standard practice of antibiotic prophylaxis for transrectal biopsy is therefore no longer sustainable. Transperineal biopsy, however, represents a clean alternative, with minimal infection risk and no need for quinolones, let alone other broader spectrum antibiotics. Borghesi et al [1] quote our early experience of transperineal biopsy in 245 consecutive cases with a hospital readmission rate for infection of zero [4]. Our series has since grown to 1194 consecutive cases performed at five centers across Melbourne, Australia, by six urologists in a private group practice. All patients were followed up by the same urologists who performed their biopsy and all data were recorded on an Institutional Ethics Committeeapproved prospective database. Our rate of infective
readmission remains at zero. This compares to a population-based study we performed in our state of Victoria over a 5-yr period to 2012, showing a rate of 1.7% of infective readmission [5]. Using transperineal biopsy exclusively, we have eliminated postbiopsy sepsis from our practice. Importantly, the latter 710 (59.5%) patients in our series were only given a single dose of intravenous cephazolin as prophylaxis. This is in accordance with the new recommendations on antibiotic prophylaxis for transperineal biopsy in Australia’s Therapeutic Guidelines series. Borghesi et al [1] state that the transperineal biopsy is infrequently used due to logistics. Transperineal biopsy is typically performed under general anesthesia and would have a major impact on workflow if uptake were to become routine. However, techniques for performing transperineal biopsy as an office procedure have been recently developed. Furthermore, it has been shown that multiparametric magnetic resonance imaging could reduce unnecessary prostate biopsies by up to half [6], thereby substantially mitigating this resource issue. From a medico-legal standpoint it is difficult to justify the risk of sepsis to patients as an acceptable complication when a cleaner biopsy alternative is available. In this era of patient-centered care and increasingly ineffective antibiotic prophylaxis, we believe that logistical reasons are no longer an excuse for transrectal biopsy. Conflicts of interest: Grummet was sponsored to attend the Urological Association of Asia Congress in 2016 by Biobot, makers of the Mona Lisa robotic transperineal device. Acknowledgments: This work has been supported by grants from Ipsen and Tolmar.
References [1] Borghesi M, Ahmed H, Nam R, et al. Complications after systematic, random, and image-guided prostate biopsy. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2016.08.004. [2] Centers for Disease Control and Prevention. Antibiotic resistance threat search results. https://stacks.cdc.gov/gsearch?collection= &terms=antibiotic+resistance+threat. [3] US Food and Drug Administration. FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. http://www.fda.gov/Drugs/ DrugSafety/ucm511530.htm.
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2016.08.004. http://dx.doi.org/10.1016/j.eururo.2016.10.015 0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Grummet J, et al. Re: Marco Borghesi, Hashim Ahmed, Robert Nam, et al. Complications After Systematic, Random, and Image-guided Prostate Biopsy. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2016.08.004. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.10.015
EURURO-7091; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2016) XXX–XXX
[4] Grummet JP, Weerakoon M, Huang S, et al. Sepsis and ‘‘superbugs’’:
Jeremy Grummet*
should we favor the transperineal over the transrectal approach for
Lana Pepdjonovic
prostate biopsy? BJU Int 2014;114:384–8. [5] Roth H, Millar JL, Cheng AC, Byrne A, Evans S, Grummet J. The state
Daniel Moon Australian Urology Associates, Monash University, Victoria, Australia
of TRUS biopsy sepsis: readmissions to Victorian hospitals with TRUS biopsy-related infection over 5 years. BJU Int 2015;116(Suppl 3):49–53.
*Corresponding author. Australian Urology Associates, Monash University, Surgery, 322 Glenferrie Road, Malvern, Victoria 3144,
[6] Pokorny MR, de Rooij M, Duncan E, et al. Prospective study of
Australia. Tel. +61 428888920.
diagnostic accuracy comparing prostate cancer detection by trans-
E-mail address: [email protected] (J. Grummet).
rectal ultrasound-guided biopsy versus magnetic resonance (MR) imaging with subsequent MR-guided biopsy in men without
October 9, 2016
previous prostate biopsies. Eur Urol 2014;66:22–9.
Please cite this article in press as: Grummet J, et al. Re: Marco Borghesi, Hashim Ahmed, Robert Nam, et al. Complications After Systematic, Random, and Image-guided Prostate Biopsy. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2016.08.004. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.10.015