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Randomized Controlled Trial
. 2024 Jul;86(1):61-68.
doi: 10.1016/j.eururo.2023.12.015. Epub 2024 Jan 11.

Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted and Systematic Prostate Biopsy to Prevent Infectious Complications: The PREVENT Randomized Trial

Jim C Hu  1 , Melissa Assel  2 , Mohamad E Allaf  3 , Behfar Ehdaie  4 , Andrew J Vickers  2 , Andrew J Cohen  3 , Benjamin T Ristau  5 , David A Green  6 , Misop Han  3 , Michael E Rezaee  3 , Christian P Pavlovich  3 , Jeffrey S Montgomery  7 , Keith J Kowalczyk  8 , Ashley E Ross  9 , Shilajit D Kundu  9 , Hiten D Patel  9 , Gerald J Wang  6 , John N Graham  10 , Jonathan E Shoag  11 , Ahmed Ghazi  3 , Nirmish Singla  3 , Michael A Gorin  12 , Anthony J Schaeffer  9 , Edward M Schaeffer  9
Affiliations
Randomized Controlled Trial

Transperineal Versus Transrectal Magnetic Resonance Imaging-targeted and Systematic Prostate Biopsy to Prevent Infectious Complications: The PREVENT Randomized Trial

Jim C Hu et al. Eur Urol. 2024 Jul.

Abstract

Background and objective: The transrectal biopsy approach is traditionally used to detect prostate cancer. An alternative transperineal approach is historically performed under general anesthesia, but recent advances enable transperineal biopsy to be performed under local anesthesia. We sought to compare infectious complications of transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis.

Methods: We assigned biopsy-naïve participants to undergo transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis (rectal culture screening for fluoroquinolone-resistant bacteria and antibiotic targeting to culture and sensitivity results) through a multicenter, randomized trial. The primary outcome was post-biopsy infection captured by a prospective medical review and patient report on a 7-d survey. The secondary outcomes included cancer detection, noninfectious complications, and a numerical rating scale (0-10) for biopsy-related pain and discomfort during and 7-d after biopsy.

Key findings and limitations: A total of 658 participants were randomized, with zero transperineal versus four (1.4%) transrectal biopsy infections (difference -1.4%; 95% confidence interval [CI] -3.2%, 0.3%; p = 0.059). The rates of other complications were very low and similar. Importantly, detection of clinically significant cancer was similar (53% transperineal vs 50% transrectal, adjusted difference 2.0%; 95% CI -6.0, 10). Participants in the transperineal arm experienced worse periprocedural pain (0.6 adjusted difference [0-10 scale], 95% CI 0.2, 0.9), but the effect was small and resolved by 7-d.

Conclusions and clinical implications: Office-based transperineal biopsy is tolerable, does not compromise cancer detection, and did not result in infectious complications. Transrectal biopsy with targeted prophylaxis achieved similar infection rates, but requires rectal cultures and careful attention to antibiotic selection and administration. Consideration of these factors and antibiotic stewardship should guide clinical decision-making.

Patient summary: In this multicenter randomized trial, we compare prostate biopsy infectious complications for the transperineal versus transrectal approach. The absence of infectious complications with transperineal biopsy without the use of preventative antibiotics is noteworthy, but not significantly different from transrectal biopsy with targeted antibiotic prophylaxis.

Keywords: Cancer detection; Infections; Transperineal biopsy; Transrectal biopsy.

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Conflict of interest statement

Financial disclosures: Jim C. Hu certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.

Figures

Fig. 1–
Fig. 1–
CONSORT diagram showing the flow of participants through various stages of a randomized trial. MRI = magnetic resonance imaging.
See this image and copyright information in PMC

Comment in

References

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