EURURO Vol. 71 No. 5

E143 844

Letter to the Editor
Re: Marco Borghesi, Hashim Ahmed, Robert Nam, et al.
Complications After Systematic, Random, and
Image-guided Prostate Biopsy. Eur Urol 2017;71:353–65
In a recent review, Borghesi et al 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’’ . The
World Health Organization implores us to reduce unneces-
sary 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’’ fluor-
oquinolones should not be used unless there are no other
treatment options[2_TD$DIFF] .
The current standard practice of antibiotic prophylaxis
for transrectal biopsy is therefore no longer sustainable.
Transperineal biopsy, however, represents a clean alterna-
tive, with minimal infection risk and no need for
quinolones, let alone other broader spectrum antibiotics.
Borghesi et al quote our early experience of
transperineal biopsy in 245 consecutive cases with a
hospital readmission rate for infection of zero[3_TD$DIFF] 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
Committee-approved 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 . 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 trans-
perineal biopsy in Australia’s Therapeutic Guidelines series.
Borghesi et al 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 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[1_TD$DIFF].
References
[1]
.
[2] Centers for Disease Control and Prevention. Antibiotic resistance
threat search results.
.
[3] US Food and Drug Administration. FDA Drug Safety Communica-
tion: FDA updates warnings for oral and injectable fluoroquinolone
antibiotics due to disabling side effects.
ava ilable at
journal homepage:
DOI of original article: .
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.