Balancing infections, antimicrobial stewardship and PCa detection

Developed by section chair Assoc. Prof. Zafer Tandogdu (GB), the webinar programme offered an in-depth comparison of the two main methods for prostate biopsy: transperineal (TP) and transrectal ultrasound-guided (TRUS). Both techniques are well-established in PCa detection, yet they differ significantly in infection risk and procedural logistics. Prof. Johansen, an esteemed Emeritus at the University of Oslo, moderated the webinar, and emphasised the urgent challenges faced by urologists today. He noted that PCa is the most common cancer among men, underscoring the critical importance of precise diagnostic practices. 

The threat of antimicrobial resistance (AMR)

Dr. Schneidewind provided an insightful presentation on the global and European challenges posed by antimicrobial resistance, sharing alarming statistics: if current trends continue, AMR could become a leading cause of death by 2050, even surpassing cancer. She emphasised the importance of a comprehensive approach to combat AMR by considering: 

Global and local perspectives: Since antimicrobial resistance varies by region, it is crucial for healthcare providers to understand and adapt antibiotic prophylaxis to local resistance patterns. Antimicrobial stewardship: Effective stewardship programmes are essential. These initiatives focus on optimising antibiotic use by selecting the appropriate drug and minimising treatment duration. Dr. Schneidewind also stressed the need to educate both healthcare professionals and patients on the risks of antibiotic overuse and on the importance of reducing the contamination category of urological procedures. 

Balancing benefits and harms of the transrectal and transperineal approach Transrectal (TRUS) biopsy: The traditional approach Higher infection risk: The TRUS biopsy remains widely used, but carries a higher risk of infections, including severe complications like sepsis. This risk arises because the procedure involves passing the biopsy needle through the contaminated rectal wall, thereby exposing the prostate to bacteria present in the rectum. Importance of targeted antibiotic prophylaxis: For urologists still using the TRUS method, the webinar underscored the importance of targeted antimicrobial prophylaxis, such as rectal swab cultures to tailor antibiotic prophylaxis based on local resistance patterns.  Experts also highlighted that adhering to infection prevention measures, like rectal cleansing with povidone-iodine, is essential. 

Transperineal (TP) biopsy: An emerging standard Lower infection rates: TP biopsy has emerged as a preferred option in many urology centres due to significantly lower risk of infectious complications compared to TRUS biopsy. By bypassing the rectal flora, TP biopsy greatly reduces bacterial exposure in the prostate. 

Reduced need for antibiotics: One of the webinar’s key messages was that TP biopsies can often be performed without prophylactic antibiotics for patients without risk factors for infection, which is a major advantage given the increasing need for antimicrobial stewardship. This shift could help mitigate the development of antibiotic-resistant bacteria.

Technical requirements and training: Despite its advantages, the TP approach is technically more complex and requires specific training and equipment. Dr. Stangl noted, however, that with proper training and practice, TP biopsies can be efficiently performed even in outpatient settings. 

Key findings from recent studies 

Hospitalisation and sepsis rates: Studies consistently show that TP biopsy is associated with a significantly lower risk of severe infections requiring hospitalisation compared to TRUS biopsy. Dr. Stangl presented an unpublished meta-analysis performed by the newly formed YAU working group for infections in urology (Abstract presented at the German National Congress and EMUC24). Their analysis revealed a 72% reduction in hospitalisation rate with TP biopsy. 

Antibiotic use: Data indicate that in most cases, TP biopsy does not necessitate antibiotic prophylaxis, which represents a shift from traditional practices. This is a critical finding for advancing antimicrobial stewardship. 

Cancer detection rates: Both TP and TRUS biopsies demonstrate comparable effectiveness in detecting PCa. However, the TP approach allows better access to specific regions of the prostate, such as the apical anterior region. 

Practical recommendations for clinicians 

The webinar concluded with practical recommendations for urologists, presented by Dr. Kranz, co-chair of the Guidelines Panel on Urological Infections. Her key points included: 

Adopting the TP approach: Dr. Kanz advocated for adopting transperineal biopsy as the new standard wherever possible. While this shift requires investment in training and equipment, it offers significant long-term benefits in terms of patient safety and infection control. 

Prophylaxis guidelines: Until more robust evidence is available, clinicians should continue basing antibiotic prophylaxis on local guidelines and patient-specific risk factors for infection. However, increasing evidence supports that antibiotics may not be necessary for TP biopsies in low-risk patients. 

Education and training: Dr. Kranz stressed the importance of continuous education and mentorship. Institutions and high-volume centres are encouraged to develop training programmes to support urologists in becoming proficient with TP biopsy techniques. 

Closing remarks 

The webinar provided a comprehensive overview of how prostate biopsy techniques are evolving in response to the global threat of AMR. The key message was clear: prioritising infection prevention and antimicrobial stewardship is not just beneficial but essential. As research advances, it will be crucial for guidelines to keep pace, ensuring that prostate cancer diagnostics remain both effective and safe. You can watch this webinar on-demand here as an e-course: A balance among infections, antimicrobial stewardship and prostate cancer detection: TP vs. TRUS prostate biopsy. The shift towards safer, more sustainable practices in prostate cancer diagnostics is underway, making it essential for practitioners to stay informed.