Objective To evaluate whether injection with pericapsular lignocaine before transrectal ultrasonography (TRUS)-guided biopsy reduces the perceived pain of prostatic biopsy. Patients and methods The study included 121 patients referred for TRUS-guided biopsy of the prostate; 27 underwent biopsy with no previous injection and 94 were randomized to pericapsular injection with either 1% lignocaine or a placebo (saline). Both patient and operator were unaware of the content of the injection. The injection was delivered under TRUS guidance to the apex of the prostate. Routine sextant biopsies were taken using an 18 G needle in a spring-loaded biopsy gun. A validated pain scale, the NRS11 (0, no pain, to 10, unbearable pain), was used to record the pain of each biopsy.Results No significant placebo effect was detected between the 'no injection' and the placebo-injection group, with mean (95% confidence interval) pain scores of 3.58 (2.77-4.39) and 4.01 (3.46-4.51), respectively, using the unpaired Student's t -test ( P = 0.409). There was a statistically significant lower mean pain score in the lignocaine group, at 2.54 (2.00-3.10), than in the placebo-injection group ( P < 0.001). Conclusion Pericapsular injection with 1% lignocaine significantly reduces the perceived pain of TRUS-guided prostatic biopsy.

INTRODUCTION AND OBJECTIVE: Multiple transperineal prostate (TP) biopsy templates exist but with uncertainty regarding the optimal sampling strategy. Prior work shows that anterior base cores from the transition zone have minimal diagnostic yield. Thus, we aimed to compare the cancer detection rate (CDR) between the 12-core modified Barzell (MB) template with a novel Michigan Urological Surgery Improvement Collaborative (MUSIC) TP biopsy template created to increase peripheral zone sampling where cancer detection is greatest. METHODS: All patients undergoing freehand TP biopsy from June 2017 to November 2020 were included. The MB template was used from June 2017 to January 2019 and modified to develop the MUSIC TP template which was performed from January 2019 onwards. Patient demographic, clinical, and pathological variables were collected. Bivariate and multivariable logistic regression model was performed to compare CDR between MB and MUSIC TP biopsy templates. RESULTS: A total of 283 biopsies were included utilizing the MB (n[139) and MUSIC template (n[144). Overall CDR of the MB and MUSIC TP templates were 38.1% and 47.2%, respectively (p[0.122). CDR of !Gleason Grade group (GG) 2 for the MB and MUSIC TP templates were 21.6% and 25%, respectively, (p[0.497). Controlling for age, race, PSA, digital rectal exam, urologist, prior diagnosis and family history of prostate cancer, no significant difference between the templates in overall CDR (OR[1.11, CI 0.61-2.04, p[0.73) or !GG2 CDR (OR[1.15, CI 0.68-1.94, p[0.59) was observed. A subset of MUSIC TP biopsies (n[103) that had 1-2 additional midline core(s) obtained (apex, base) were identified. The addition of the midline cores only resulted in a single GG1 diagnosis and no cases of higher risk disease not identified with the standard MUSIC template.CONCLUSIONS: There is no significant difference in CDR between the MB and MUSIC TP biopsy templates. The addition of midline peripheral zone cores to the MUSIC TP template does not improve cancer diagnosis and should not be routinely included in sampling. Continued evaluation with greater power may demonstrate a significant difference in CDR between sampling strategies.

INTRODUCTION AND OBJECTIVES: Prostate Specific Antigen (PSA) is the most commonly utilised serum marker for Prostate cancer (Pca) screening and monitoring. However, the validity of PSA as a screening tool is still controversial. In order to improve the predictive accuracy of PSA for Pca detection, the concept of age adjusted reference values have been proposed. This review aims to compare and combine the age specific reference values for PSA amongst the different international populations.METHODS: In concordance with the PRISMA statement, a systematic review of published English articles using Medline, Embase and Cochrane databases, from inception to June 2018 was conducted. Additional studies were identified from reference screening of relevant articles. Studies that reported the reference value for PSA, defined as upper limit of the 95th percentile, in healthy men aged 40 e 79, were included. Two independent authors identified the eligible articles and extracted the data using predefined fields. Risk of bias was assessed with a modified version of the Agency for Healthcare Research and Quality methodological checklist for cross-sectional studies.RESULTS: 45 studies were included in the final qualitative analysis, of which 40 studies were included in the meta-analysis. Weighted analysis revealed that PSA reference values significantly increased with age (Pearson correlation score [ 0.81, p < 0.001). Pooled age adjusted reference values for PSA were 2.06, 2.97, 4.65 and 6.46 ng/ml for men aged in the 40s, 50s, 60s and 70s respectively. The studies were of average quality with low to moderate bias. Significant differences in PSA reference values observed between the cohorts. This was attributed to heterogeneity in the populations and PSA measurement assays.CONCLUSIONS: This is the first systematic review and metaanalysis of PSA reference values. PSA increased with age and significant variability existed in PSA among the different populations.

INTRODUCTION AND OBJECTIVE: Prostate biopsies have traditionally been performed via the transrectal (TR) route. The transperineal (TP) route of prostate biopsy is increasingly being adopted as studies have suggested better diagnosis of anterior and apical prostate lesions. Also, the risk of sepsis and bleeding is reduced. Here we compare the outcomes of our centre's experience with TP prostate biopsies under local anaesthetic and compare it with our prior series of TR prostate biopsies.METHODS: We prospectively analyzed 117 consecutive patients undergoing TP prostate biopsy under local anaesthesia at our institution from October 2018 to September 2019. Patients who underwent TP biopsy either had no antibiotics or once dose Cefuroxime 500mg prior to biopsy. TP prostate biopsy was performed with the Pre-cisionPoint TM Transperineal Access System with a BK MedicalÒ Endocavity 8848 transrectal probe. Patients were in lithotomy position with local anaesthesia infiltrated transperineally prior to the procedure. Patient demographics, prostate size, prostate specific antigen and digital rectal examination findings were recorded. We compared the detection and complication rates of prostate cancer using the TP method to our historical cohort of 179 patients that underwent the traditional TR biopsy.RESULTS: All 117 patients underwent TP prostate biopsy under local anaesthesia. The mean age was 70 years old and the median PSA was 12.41. Mean prostate volume was 43.27AE29.46mls with a median of 12 cores taken per patient. Patient demographics were comparable to that of our TR prostate biopsy historical cohort. The mean age in the TR group was 68 years old and median PSA was 10.76. Mean prostate volume was 49.62AE27.76, with a median of 12 cores taken as well. 73 of 117 patients (68%) in the TP prostate biopsy group had detection of prostate cancer, out of which 86% were Grade Group 2 (GG2) and above. Comparatively, 88 of 179 patients (48%) in the TR prostate biopsy group had detection of prostate cancer, of which 85% was GG2 and above. The detection of clinically insignificant prostate cancer (GG1) was similar in both cohorts. The incidence of sepsis was lower in the TP biopsy group compared to the TR group, 0.9% versus 2.2% respectively. 0.9% of patients in the TP cohort had bleeding and clot retention compared to 1.7% in the TR cohort.CONCLUSIONS: Our data suggests that TP prostate biopsy under local anaesthesia may have a higher sensitivity in diagnosing prostate cancer compared with the traditional TR approach and may be safer in terms of bleeding and septic complications.

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