Transperineal laser ablation of the prostate as a treatment for benign prostatic hyperplasia and prostate cancer: The results of a Delphi consensus project

Objective: To evaluate transperineal laser ablation (TPLA) with Echolaser® (Echolaser® TPLA, Elesta S.p.A., Calenzano, Italy) as a treatment for benign prostatic hyperplasia (BPH) and prostate cancer (PCa) using the Delphi consensus method.Methods: Italian and international experts on BPH and PCa participated in a collaborative consensus project. During two rounds, they expressed their opinions on Echolaser® TPLA for the treatment of BPH and PCa answering online questionnaires on indications, methodology, and potential complications of this technology. Level of agreement or disagreement to reach consensus was set at 75%. If the consensus was not achieved, questions were modified after each round. A final round was performed during an online meeting, in which results were discussed and finalized.Results: Thirty-two out of forty invited experts participated and consensus was reached on all topics. Agreement was achieved on recommending Echolaser® TPLA as a treatment of BPH in patients with ample range of prostate volume, from <40 mL (80%) to >80 mL (80%), comorbidities (100%), antiplatelet or anticoagulant treatment (96%), indwelling catheter (77%), and strong will of preserving ejaculatory function (100%). Majority of respondents agreed that Echolaser® TPLA is a potential option for the treatment of localized PCa (78%) and recommended it for low-risk PCa (90%). During the final round, experts concluded that it can be used for intermediate-risk PCa and it should be proposed as an effective alternative to radical prostatectomy for patients with strong will of avoiding urinary incontinence and sexual dysfunction. Almost all participants agreed that the transperineal approach of this organ-sparing technique is safer than transrectal and transurethral approaches typical of other techniques (97% of agreement among experts). Pre-procedural assessment, technical aspects, post-procedural catheterization, pharmacological therapy, and expected outcomes were discussed, leading to statements and recommendations.Conclusion: Echolaser® TPLA is a safe and effective procedure that treats BPH and localized PCa with satisfactory functional and sexual outcomes.

The results of transperineal versus transrectal prostate biopsy： a systematic review and meta-analysis

This systematic review was performed to compare the efficacy and complications of transperineal （TP） vs. transrectal （TR） prostate biopsy. A systematic research of PUBM ED, EMBASE and the Cochrane Library was performed to identify all clinical controlled trials on prostate cancer （PCa） detection rate and complications achieved by TP and TR biopsies. Prostate biopsies included sextant, extensive and saturation biopsy procedures. All patients were assigned to a TR group and a TP group. Subgroup analysis was performed according to prostate-specific antigen （PSA） levels and digital rectal examination （DRE） findings. The Cochrane Collaboration＇s RevMan 5.1 software was used for the meta-analysis. A total of seven trials, including three randomized controlled trials （RCTs） and four casecontrol studies （CCS）, met our inclusion criteria. There was no significant difference in the cancer detection rate between the sextant TR and TP groups （risk difference （RD）, -0.02; 95% confidence interval （CI）, -0.08-0.03; P=0.34）. Meta-analysis for RCTs combined with CCS showed that there was no difference in the cancer detection rate between the extensive TR and TP group （RD, -0.01; 95% CI, -0.05-0.04; P=0.81）. There was no significant difference in PCa detection rate between the saturation TR and TP approaches （31.4% vs. 25.7%, respectively;P=0.3）. There were also no significant differences in cancer detection between the TR and TP groups in each subgroup. Although the data on complications were not pooled for the meta-analysis, no significant difference was found when comparing TR and TP studies. TR and TP biopsies were equivalent in terms of efficiency and related complications. TP prostate biopsy should be an available and alternative procedure for use by urologists.

Stapled transperineal repair for low-and mid-level rectovaginal fistulas:A 5-year experience and comparison with sutured repair

BACKGROUND Currently,rectovaginal fistula(RVF)continues to be a surgical challenge worldwide,with a relatively low healing rate.Unclosed intermittent suture and poor suture materials may be the main reasons for this.AIM To evaluate the efficacy and safety of stapled transperineal repair in treating RVF.METHODS This was a retrospective cohort study conducted in the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University(Guangzhou,China).Adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included.Among the 82 total patients,37 underwent repair with direct suturing and 45 underwent repair with stapling.Patient demographic data,Wexner faecal incontinence score,and operative data were analyzed.Recurrence rate and associated risk factors were assessed.RESULTS The direct suture and stapled repair groups showed similar clinical characteristics for aetiology,surgical history,fistula features,and perioperative Wexner score.The stapled repair group did not show superior results over the suture repair group in regard to operative time,blood loss,and hospital stay.However,the stapled repair group showed better postoperative Wexner score(1.04±1.89 vs 2.73±3.75,P=0.021),less intercourse pain(1/45 vs 17/37,P=0.045),and lower recurrence rate(6/45 vs 17/37,P=0.001).There was no protective effect from previous repair history,smaller diameter of fistula(<0.5 cm),better control of defecation(Wexner<10),or stapled repair.Direct suture repair and preoperative high Wexner score(>10)were risk factors for fistula recurrence.Furthermore,stapled repair gave better efficacy in treating complex RVFs(i.e.,multiple transperineal repair history,mid-level fistula position,and poor control of defecation).CONCLUSION Stapled transperineal repair is advantageous for management of RVF,providing a high primary healing rate and low recurrence rate.

Outcomes of combination MRI-targeted and transperineal template biopsy in restaging low-risk prostate cancer for active surveillance

Objective:Active surveillance(AS)offers a strategy to reduce overtreatment and now is a widely accepted treatment option for low-risk prostate cancer.An ideal tool for risk-stratification would detect aggressive cancers and exclude such men from taking up AS in the first place.We evaluate if a combination of transperineal template biopsy with magnetic resonance imaging(MRI)-targeted biopsy identifies significant prostate cancer amongst men initially diagnosed with low-risk prostate cancer.Methods:This prospective,single-blinded study included men with low-risk prostate cancer(D’Amico’s Criteria)diagnosed on conventional transrectal ultrasound-guided biopsy.Patients first underwent multiparametric MRI of the prostate
6 weeks after initial biopsy.Each suspicious lesion is mapped and assigned a Prostate Imaging Reporting and Data System(PIRADS)score.Template biopsy is first performed with the surgeon blinded to MRI findings followed by MRI-targeted biopsy using a robotic transperineal biopsy platform.Results:The age of the 19 men included is 65.4±4.9 years(mean±SD).Prostate specific antigen(PSA)at diagnosis and at the time of transperineal biopsy were comparable(7.3±1.7 ng/mL and 7.0±1.8 ng/mL,p Z 0.67),so were prostate volumes(34.2±8.9 mL and 32.1±13.4 mL,p Z 0.28).MRI-targeted biopsy had a higher percentage of cancer detection per core compared to template biopsy(11.7%vs.6.5%,p Z 0.02),this was more than 3 times superior for Gleason 7 disease(5.9%vs.1.6%,p<0.01).Four of 18(22.2%)patients with MRI lesions had significant disease with MRI-targeted biopsy alone.Three of 19 patients(15.8%)had significant disease with template biopsy alone.In combination,both techniques upclassified five patients(26.3%),all of whom underwent radical prostatectomy.Whole mount histology confirmed tumour location and grade.All six patients with PIRADS 5 lesions had cancer detected(66.6%significant disease).Conclusion:A combination of MRI-targeted and template biopsy may optimally risk-classify“low-risk”patients diagnosed on initial conventional transrectal ultrasonography(TRUS)prostate biopsy.

Literature review of the outcome of and methods used to improve transperineal repair of rectocele

BACKGROUND Rectocele is commonly seen in parous women and sometimes associated with symptoms of obstructed defecation syndrome(ODS).AIM To assess the current literature in regard to the outcome of the classical transperineal repair(TPR)of rectocele and its technical modifications.METHODS An organized literature search for studies that assessed the outcome of TPR of rectocele was performed.PubMed/Medline and Google Scholar were queried in the period of January 1991 through December 2020.The main outcome measures were improvement in ODS symptoms,improvement in sexual functions and continence,changes in manometric parameters,and quality of life.RESULTS After screening of 306 studies,24 articles were found eligible for inclusion to the review.Nine studies(301 patients)assessed the classical TPR of rectocele.The median rate of postoperative improvement in ODS symptoms was 72.7%(range,45.8%-83.3%)and reduction in rectocele size ranged from 41.4%-95.0%.Modifications of the classical repair entailed omission of levatorplasty,addition of implant,concomitant lateral internal sphincterotomy,changing the direction of plication of rectovaginal septum,and site-specific repair.CONCLUSION The transperineal repair of rectocele is associated with satisfactory,yet variable,improvement in ODS symptoms with parallel increase in quality-of-life score.Several modifications of the classical TPR were described.These modifications include omission of levatorplasty,insertion of implants,performing lateral sphincterotomy,changing the direction of classical plication,and site-specific repair.The indications for these modifications are not yet fully clear and need further prospective studies to help tailor the technique to rectocele patients.

Current applications of transperineal ultrasound in gastroenterology

Transperineal ultrasound is an inexpensive,safe and painless technique that dynamically and non-invasively evaluates the anorectal area.It has multiple indications,mainly in urology,gynaecology,surgery and gastroenterology,with increased use in the last decade.It is performed with conventional probes,positioned directly above the anus,and may capture images of the anal canal,rectum,puborectalis muscle(posterior compartment),vagina,uterus,(central compartment),urethra and urinary bladder(anterior compartment).Evacuatory disorders and pelvic floor dysfunction,like rectoceles,enteroceles,rectoanal intussusception,pelvic floor dyssynergy can be diagnosed using this technique.It makes a dynamic evaluation of the interaction between pelvic viscera and pelvic floor musculature,with images obtained at rest,straining and sustained squeezing.This technique is an accurate examination for detecting,classifying and following of perianal inflammatory disease.It can also be used to sonographically guide drainage of deep pelvic abscesses,mainly in patients who cannot undergo conventional drainage.Transperineal ultrasound correctly evaluates sphincters in patients with fecal incontinence,postpartum and also following surgical repair of obstetric tears.There are also some studies referring to its role in anal stenosis,for the measurement of the anal cushions in haemorrhoids and in chronic anal pain.

Role of transperineal template biopsy in prostate cancer

Prostate cancer is the most common neoplasm diagnosed in men. Whilst treatment modalities have progressed, diagnostic investigations in terms of biopsy methods have been assessed but there is no consensus of when the different diagnostic methods in terms of transrectal ultrasound(TRUS) or transperineal template(TPT) should be utilised. TPT biopsy has a higher diagnostic yield than TRUS in those with a primary biopsy, in those with previous negative biopsies with TRUS as well as those undergoing saturation biopsies. Despite the increased likelihood of diagnosing cancer with TPT than TRUS this maybe secondary to the increasednumber of biopsies being utilised. However there is no consensus regarding the ideal number of biopsies that should be utilised with TPT. Furthermore it is felt that the increased number of biopsies utilised with TPT is associated the higher complication rates with TPT. The role of TPT biopsy is recognised in those with previous negative biopsies with transrectal ultrasound but further work is required regarding the ideal number of biopsies. Furthermore, it is felt that TPT biopsy may have a role in primary biopsy.

Transperineal core-needle biopsy of a rectal subepithelial lesion guided by endorectal ultrasound after contrast-enhanced ultrasound: A case report

BACKGROUND Rectal subepithelial lesions(SELs) are commonly seen in endoscopic examination, generally manifested as bumps with a smooth surface. Precise preoperative diagnoses for rectal SELs are difficult because abnormal tissues are not easily to be obtained by regular endoscopic forceps biopsy. Traditional guidance modalities of preoperative biopsy, including endoscopic ultrasound, computed tomography, and transabdominal ultrasound, are often unsatisfactory. An updated, safe, and effective biopsy guidance method is required. We herein report a new biopsy guidance modality—endorectal ultrasound(ERUS) combined with contrastenhanced ultrasound(CEUS).CASE SUMMARY A 32-year-old woman complained of a mass inside the rectovaginal space for 9 years, which became enlarged within 1 year. A rectal SEL detected by endoscopy was suspected to be a gastrointestinal stromal tumor or exophytic uterine fibroid. Pathological diagnosis was difficult because of unsuccessful transabdominal core needle biopsy with insufficient tissues, as well as vaginal hemorrhage. A second biopsy was suggested after multiple disciplinary treatment discussion, which referred to a transperineal core needle biopsy(CNB) guided by ERUS combined with CEUS. Adequate samples were procured and rectal gastrointestinal stromal tumor was proved to be the pathological diagnosis. Imatinib was recommended for first-line therapy by multiple disciplinary treatment discussion. After the tumor shrunk, resection of the rectal gastrointestinal stromal tumor was performed through the posterior vaginal wall. Adjuvant therapy was applied and no recurrence or metastasis has been found by the last follow-up on December 13, 2019.CONCLUSION Transperineal CNB guided by ERUS and CEUS is a safe and effective preoperative biopsy of rectal SELs yet with some limitations.

Transrectal versus transperineal prostate biopsy for cancer detection in patients with gray-zone prostatespecific antigen:a multicenter,real-world study

Knowledge about the effect of different prostate biopsy approaches on the prostate cancer detection rate(CDR)in patients with gray-zone prostate-specific antigen(PSA)is limited.We performed this study to compare the CDR among patients who underwent different biopsy approaches and had rising PSA levels in the gray zone.Two hundred and twenty-two patients who underwent transrectal prostate biopsy(TRB)and 216 patients who underwent transperineal prostate biopsy(TPB)between June 2016 and September 2022 were reviewed in this study.In addition,110 patients who received additional targeted biopsies following the systematic TPB were identified.Clinical parameters,including age,PSA derivative,prostate volume(PV),and needle core count,were recorded.The data were fitted via propensity score matching(PSM),adjusting for potential confounders.TPB outperformed TRB in terms of the CDR(49.6%vs 28.3%,P=0.001).The clinically significant prostate cancer(csPCa)detection rate was not significantly different between TPB and TRB(78.6%vs 68.8%,P=0.306).In stratified analysis,TPB outperformed TRB in CDR when the age of patients was 65–75 years(59.0%vs 22.0%,P<0.001),when PV was 25.00–50.00 ml(63.2%vs 28.3%,P<0.001),and when needle core count was no more than 12(58.5%vs 31.5%,P=0.005).The CDR(P=0.712)and detection rate of csPCa(P=0.993)did not significantly differ among the systematic,targeted,and combined biopsies.TPB outperformed TRB in CDR for patients with gray-zone PSA.Moreover,performing target biopsy after systematic TPB provided no additional benefits in CDR.

Freehand transperineal prostate biopsy with a coaxial needle under local anesthesia:Experience from a single institution in Malaysia

Background Freehand transperineal prostate biopsy(TPPBx)using a coaxial needle technique offers an alternative to probe-mounted freehand or template-guided techniques in the diagnosis of prostate cancer(PCa).It only requires the same equipment used for transrectal ultrasound-guided(TRUS)biopsy.Our study is the first in Malaysia to report this experience and its outcomes.We aim to determine PCa detection rate and pain tolerability of freehand TPPBx utilizing a coaxial needle under local anesthesia(LA).Methods Institutional review board approval was obtained from National Medical Research Register(NMRR ID-21-02052-VIL).We retrospectively reviewed the medical records of patients who underwent TPPBx between August 2020 and April 2022.Records were reviewed for patients’characteristics,prostate volume,prostate-specific antigen(PSA)results,biopsy results and pain tolerability.Data was analyzed to determine PCa and clinically significant prostate cancer(csPCa)detection rate.LA was achieved using perineal skin infiltration and a periprostatic nerve block.The commonly used standard side-firing transrectal ultrasound with its Prostate Biplane Transducer was used as an imaging guide.The principles of the Ginsburg protocol were followed.Pain tolerability was assessed using a visual analog scale.Results A total of 55 patients with elevated PSA levels underwent freehand TPPBx under LA.The mean age was 67.3 years,the median PSA was 14.2 ng/mL,and the median PSA density(PSAD)was 0.33 ng/mL/cc.The optimal PSAD cutoff for predicting csPCa was 0.35 ng/mL/cc(area under the curve[AUC],0.792;sensitivity,87.5%;specificity,69.2%).PCa was detected in 24 patients(43.6%),of whom 16(29.1%)had csPCa.The median pain scores during LA infiltration and biopsy were four and two,respectively,which were significant different(P<0.05).TPPBx exhibited an infection rate of zero.Conclusion The PCa detection rate and patient tolerability of freehand TPPBx using a coaxial needle are similar to those of a contemporary published series.The use of existing equipment that is used for TRUS biopsy allows for widespread use and transition from TRUS biopsy.

Transperineal prostate biopsies for diagnosis of prostate cancer are well tolerated： a prospective study using patient-reported outcome measures

We aimed to determine short-term patient-reported outcomes in men having general anesthetic transperineal （TP） prostate biopsies. A prospective cohort study was performed in men having a diagnostic TP biopsy. This was done using a validated and adapted questionnaire immediately post-biopsy and at follow-up of between 7 and 14 days across three tertiary referral hospitals with a response rate of 51.6%. Immediately after biopsy 43/201 （21.4%） of men felt light-headed, syncopal, or suffered syncope. Fifty-three percent of men felt discomfort after biopsy （with 95% scoring 〈5 in a 0-10 scale）. Twelve out of 196 men （6.1%） felt pain immediately after the procedure. Despite a high incidence of symptoms （e.g., up to 75% had some hematuria, 47% suffered some pain）, it was not a moderate or serious problem for most, apart from hemoejaculate which 31 men suffered. Eleven men needed catheterization （5.5%）. There were no inpatient admissions due to complications （hematuria, sepsis）. On repeat questioning at a later time point, only 25/199 （12.6%） of men said repeat biopsy would be a significant problem despite a significant and marked reduction in erectile function after the procedure. From this study, we conclude that TP biopsy is well tolerated with similar side effect profiles and attitudes of men to repeat biopsy to men having TRUS biopsies. These data allow informed counseling of men prior to TP biopsy and a benchmark for tolerability with local anesthetic TP biopsies being developed for clinical use.

Is the transperineal ultrasonography approach effective for the diagnosis of rectocele?

Background Transperineal ultrasonography has been used as a diagnostic imaging modality for rectocele for many years.However,the consistency of ultrasonography and defecography in evaluating the severity of rectocele was not satisfactory.This study aimed to evaluate the agreement in the measurement of rectocele parameters between the two methods in different positions and provide clinical implications for the diagnosis of rectocele.Methods In this pilot study,participants were recruited in an outpatient clinic of a tertiary hospital between December 2017 and December 2019.All participants separately underwent defecation proctography at sitting and squatting positions,and undertook transperineal ultrasonography at left lateral,sitting,and squatting positions.The consistency of ultrasonography and defecography was evaluated.Results Thirty female volunteers with rectocele were included in this study.The degree of anorectal angle was significantly larger at rest and during contraction,maximal Valsalva,and evacuation;the depth of the rectocele was significantly deeper during maximal Valsalva and evacuation;and the length of the perineumdescending was significantly longer during contraction and maximal Valsalva in using squatting position compared to the sitting position when performing the defecation proctography.The degree of anorectal angle,the depth of rectocele,the area of levator hiatus,and the volume of the rectocele were significantly different in using squatting,sitting,and left lateral positions when performing the transperineal ultrasonography.Bland-Altman semi-quantitative plots showed good consistency in the measurement of the anorectal angle and the depth of the rectocele between proctography and ultrasonography in both sitting and squatting positions.Conclusions The findings of our study may be considered as the preliminary evidence to support the use of transperineal ultrasonography with sitting and squatting positions as the imaging test of choice for evaluating patients with rectocele.

Value of contrast-enhanced ultrasound in deep angiomyxoma using a biplane transrectal probe:A case report

BACKGROUND Deep angiomyxoma(DAM)is a very rare tumor type.Magnetic resonance imaging(MRI)is considered the best imaging modality for diagnosing DAM.Computed tomography(CT)is used mainly to assess the invasion range of DAM.The value of ultrasonography in the diagnosis of DAM is still controversial.Through a literature review,we summarized the current state of ultrasonic examination for DAM and reported for the first time the contrast-enhanced ultrasound(CEUS)features of DAM seen using a biplane transrectal probe.CASE SUMMARY A 37-year-old woman presented with a sacrococcygeal mass that had gradually increased in size over the previous 6 mo.MRI and CT examinations failed to allow a definite diagnosis to be made.Transperineal core needle biopsy(CNB)guided by transrectal ultrasound and CEUS was suggested after a multidisciplinary discussion.Grayscale ultrasound of the lesion showed a layered appearance with alternating hyperechoic and hypoechoic patterns.Transrectal CEUS showed a laminated distribution of the contrast agent that was consistent with the layered appearance of the tumor on grayscale ultrasound.We performed transperineal CNB of the enhanced area inside the tumor under transrectal CEUS guidance and finally made a definitive diagnosis of DAM through histopathology.The patient underwent laparoscopic-assisted transabdominal surgery combined with transperineal surgery for large pelvic tumor resection and pelvic floor peritoneal reconstruction.No recurrence or metastasis was found at the ninemonth follow-up.CONCLUSION Transrectal CEUS can show the layered perfusion characteristics of the contrast agent,guiding subsequent transperineal CNB of the enhanced area within the DAM.

Minimally invasive surgical therapies(MISTs)for lower urinary tract symptoms(LUTS):promise or panacea?

The increasing importance of treatment of lower urinary tract symptoms(LUTS),while avoiding side effects and maintaining sexual function,has allowed for the development of minimally invasive surgical therapies(MiSTs).Recently,the European Association of Urology guidelines reported a paradigm shift from the management of benign prostatic hyperplasia(BPH)to the management of nonneurogenic male LUTS.The aim of the present review was to evaluate the efficacy and safety of the most commonly used MisTs:ablative techniques such as aquablation,prostatic artery embolization,water vapor energy,and transperineal prostate laser ablation,and nonablative techniques such as prostatic urethral lift and temporarily implanted nitinol device(iTIND).MiSTs are becoming a new promise,even if clinical trials with longer follow-up are still lacking.Most of them are still under investigation and,to date,only a few options have been given as a recommendation for use.They cannot be considered as standard of care and are not suitable for all patients.Advantages and disadvantages should be underlined,without forgetting our objective:treatment of LUTS and re-treatment avoidance.