Transperineal versus transrectal prostate fiducial insertion in radiation treatment of prostate cancer: a systematic review and meta-analysis

Abstract

Purpose: To provide more accurate and definitive conclusions regarding the clinical and technical complications associated with the transperineal (TP) and transrectal (TR) approaches, a comprehensive review of observational studies and randomized controlled trials was conducted. This systematic review covered all eligible studies to facilitate a thorough comparison of complications linked to the two fiducial marker insertion methods, TP and TR.

Methods: A comprehensive search of the literature was conducted, encompassing databases such as PubMed, Embase, and the Cochrane Library, up to July 7, 2023. The relative risk and 95% confidence interval were utilized to evaluate the diagnosis and complication rates.

Results: The final selection for the methodological quality analysis included 13 observational studies that utilized TP and TR gold fiducial insertion approaches. The meta-analysis revealed significantly lower risks of urinary tract infections (UTI) and rectal bleeding with the TP approach.

Conclusion: The use of both TP and TR techniques for placing gold seed fiducial markers has proven to be an effective, safe, and well-tolerated method for image-guided radiation therapy in prostate cancer patients. A significant benefit of the TP technique is its ability to avoid rectal puncture, thereby reducing the risk of UTIs. Although the incidence of UTIs and rectal bleeding associated with the TR method is relatively low, these complications can disrupt patient wellbeing and potentially cause delays in treatment.

Keywords: Fiducial markers; Image-guided radiotherapy; Prostatic neoplasms; Ultrasonography.

Fig. 1.. Flowchart of study assessment and selection.

Fig. 2.. Risk of bias in non-randomized studies of interventions.

Green-colored symbol corresponds to low risk of bias, yellow corresponds to moderate risk of bias, and red corresponds to high risk of bias [8,21].

Fig. 3.. Forest plot and meta-analysis for clinical complications and technical aspect between transperineal (TP) and transrectal (TR) fiducial insertion methods [8-15,17-21].

A. Urinary symptoms: Comparison of the incidence of urinary symptoms between TP and TR methods is shown. B. Urinary tract infections (UTI): Analysis shows the relative risk of UTIs associated with each insertion technique. C. Rectal bleeding: Evaluation of the occurrence of rectal bleeding in patients undergoing TP versus TR fiducial marker insertion is shown. D. Technical aspects: Assessment of technical complications, including fiducial migration and placement accuracy, between the two approaches is shown.