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  • Replace Transrectal Biopsies with Transperineal

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    Old 04-16-2021, 12:54 PM   #1
    ASAdvocate
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    Replace Transrectal Biopsies with Transperineal

    Howard Wolinsky, a long time prostate cancer patient activist, has asked me to help spread his petition for the replacement of transrectal biopsies with the new, simplified, transperineal procedures. Having myself had five transrectal and two transperineal biopsies, I endorse his petition, which is to the American Urological Association, Congress, and two other governing bodies.
    Here is the link to Howard's petition.

    http://chng.it/RsVH46XG
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    Seven biopsies from 2009 to 2021. Three were were positive with 5% Gleason(3+3) found.

     
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    Old 04-16-2021, 01:08 PM   #2
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    Re: Replace Transrectal Biopsies with Transperineal

    Hi ASA,

    I'm not all that familiar with it, but isn't this other procedure somewhat more invasive than the traditional rectal route?

     
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    Old 04-16-2021, 01:18 PM   #3
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    Re: Replace Transrectal Biopsies with Transperineal

    Hi Chuck, Yes, the current/older generation of TPUS biopsies were usually saturation samplings, with from 20 to 100 cores being taken in an operating room under general anesthesia. That was usually a last step when a patient had a rising PSA, but several negative TRUS biopsies.

    The new generation of Precision Point TPUS procedures only require an exam room and local anesthesia. They take the same number of cores as TRUS biopsies, being 12 systematic and any suspicious areas seen on imaging. They are done freehand, unlike the saturation biopsies, with their templates.

    An immediate advantage is that there are no serious infections, so no sepsis or need for antibiotics. Also, the perineum access easily samples the anterior of the prostate, which is hard to do from the rectum.

    The petition link has more details on the differences.
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    In Active Surveillance program at Johns Hopkins since July 2009.

    Seven biopsies from 2009 to 2021. Three were were positive with 5% Gleason(3+3) found.

     
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    Old 04-16-2021, 01:19 PM   #4
    DjinTonic
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    Re: Replace Transrectal Biopsies with Transperineal

    On an updated webpage on TPUS, the Mayo Clinic says, discussing the possible complications, that men with large prostates may still require sedation. Are you saying that TRUS should no longer be available, i.e., total replacement by TPUS?

    Djin
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    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
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    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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    Old 04-16-2021, 08:51 PM   #5
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    Re: Replace Transrectal Biopsies with Transperineal

    I did find that statement from Mayo, but it offered no details. If some men require general anesthesia, then it will probably be no more than the number who go under with TRUS now.

    Yes, Howard is advocating a total ban on transrectal biopsies, given the worsening sepsis danger. This is a hot topic on several of the AS and other patient advocacy Zoom groups i participate in. There are upcoming online seminars with prominent urologists to spread this message.

     
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    Old 04-17-2021, 04:55 AM   #6
    IADT3since2000
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    Re: Replace Transrectal Biopsies with Transperineal

    Thanks for raising this important topic.

    I just checked the most recent guideline for prostate cancer published by the National Comprehensive Cancer Network, a well-known, highly respected, widely used guideline group. It is the second version published in 20201. (https://www.nccn.org/professionals/physician_gls/pdf/prostate_blocks.pdf)

    I searched for "transperineal biopsy" and was surprised that I got no matches at all. The only match for "transperineal" alone was in a reference listing for brachytherapy. Likewise, a search for sepsis produced no relevant matches.

    The increasing sepsis problem has been known for some years now, so I was surprised by the absence of search results. History has shown again and again that changes to medical practice often take much longer than they should. It seems that this change to biopsy practice may be one of them.

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    21 years as a survivor. Doing well. Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low and stable at <0.01; apparently cured (Current PSA as of 12/2/2020). (Current T 93 12/2/2020.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. What I experienced is not a guarantee for all but shows what is possible.

     
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    Old 04-17-2021, 05:18 AM   #7
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    Re: Replace Transrectal Biopsies with Transperineal

    The consequences of antibiotic overuse. Prescribing antibiotics indiscriminately for prostate symptoms as a method of screening for prostate cancer is one of the causes, imo. Studies show men who have used antibiotics before for prostate symptoms are at higher risk latter for infections from biopsies.

     
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    Old 04-17-2021, 09:32 AM   #8
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    Re: Replace Transrectal Biopsies with Transperineal

    Although my diagnosis suggested I was a perfect candidate for AI I opted for treatment. I have three total joint replacements and the fear of a septic infection from additional biopsy and the impact that might have on my new joints weighed heavily on my decision to elect treatment. At the time of my diagnosis TRUS was the standard of care. This sounds like the better way to go.
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    Old 04-18-2021, 09:53 AM   #9
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    Re: Replace Transrectal Biopsies with Transperineal

    Quote:
    Originally Posted by ASAdvocate View Post

    The new generation of Precision Point TPUS procedures only require an exam room and local anesthesia.
    My UR ONLY does the TPUS Procedure in the Hospital OR under general anesthesia. He told me he use to do them in his office with only a Local and too many men complained of excessive discomfort.
    He has some of the latest training from Cleveland Clinic and has performed over 500 HoLEP procedures at less than 40 years old. He is in very high demand in our area and already considered one of the best UR's in the area. He also works closely with 2 of the Radiologists at one of our local Cancer Centers.
    He is the one who did my fiducial markers and SpacOar Gel procedure before I had 42 IMRT treatments. That also was done in the Hospital OR under general
    anesthesia.

    After having a TRUS and IV antibiotics I definitely would recommend the TPUS
    over the TRUS. BTW I was offered either procedure and chose TRUS due to economic factors.
    __________________
    T2a / Gleason Score 8 / PSA at Diagnosis 6.9 /
    1-5 aggressive score : 4
    12 cores= 4 positive
    NBS = Negative
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    Age at Diagnosis= 60-65 age group
    Completed 42 IMRT Sessions
    Lupron scheduled for 2 years [Started DEC 2019]

     
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    Old 04-18-2021, 11:01 AM   #10
    ASAdvocate
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    Re: Replace Transrectal Biopsies with Transperineal

    Quote:
    Originally Posted by guitarhillbilly View Post
    My UR ONLY does the TPUS Procedure in the Hospital OR under general anesthesia. He told me he use to do them in his office with only a Local and too many men complained of excessive discomfort.
    He has some of the latest training from Cleveland Clinic and has performed over 500 HoLEP procedures at less than 40 years old. He is in very high demand in our area and already considered one of the best UR's in the area. He also works closely with 2 of the Radiologists at one of our local Cancer Centers.
    He is the one who did my fiducial markers and SpacOar Gel procedure before I had 42 IMRT treatments. That also was done in the Hospital OR under general
    anesthesia.

    After having a TRUS and IV antibiotics I definitely would recommend the TPUS
    over the TRUS. BTW I was offered either procedure and chose TRUS due to economic factors.
    That is true for the older versions of TPUS. The Precision’ Point system, which is now the standard at Johns Hopkins and MSKCC, does not require an OR or general anesthesia.

     
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