Complications of local anaesthetic transperineal ultrasound-guided prostate biopsy: A systematic literature review

The prostate cancer pathway has evolved rapidly over the last decade responding to evidence-based recommendations. These changes were accelerated further over the last 5 years due to the Covid-19 pandemic and the antibiotic stewardship policies regarding nosocomial/iatrogenic infections. Local anaesthetic transperineal ultrasound-guided biopsy is a relatively new technique that became gold-standard practice for prostate cancer diagnosis due to decreased sepsis rates. However, data that justified its implementation was more focused on its efficacy and clinically significant cancer detection rates, lacking robust methodological complications data, including in some cases the utilization of validated tools to assess complications. In patients subjected to local anaesthetic transperineal ultrasound-guided prostate biopsies, what are the most recent reported complications? This systematic literature review followed Bettany-Saltikov and McSherry's Manual guidance for systematic literature reviews. Patient/target, Intervention, Comparison, Outcome (PICO) research method, and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) were used to structure the search strategy and report results. This review was conducted using PubMed/Medline, Excerpa Medica database (EMBASE), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Inclusion criteria focused on recent studies which matched current national and international prostate cancer pathway guidelines (National Institute for Health and Care Excellence and European Association of Urology). Quality assessments were performed using Critical Appraisal Skills Programme checklists. Four cohort studies were included in this review. A total of 946 men were submitted to local anaesthetic transperineal prostate biopsy. Patient experience showed procedure was tolerated with the most painful part of the procedure being local anaesthetic infiltration with Visual Analogue Score variation [2–5]. Few complications were reported. Haematuria had broad definitions across studies, being difficult to interpret the results of this complication. Only one case reported gross haematuria leading to acute urinary retention. Historically, acute urinary retention was mentioned as one of the main adverse effects of transperineal biopsies. However, in this systematic literature review it had similar incidence as transrectal biopsies, particularly when local anaesthesia was utilized. Lower urinary tract symptoms and erectile dysfunction seemed to not be affected by prostate biopsy procedures, however, more data is required as only two studies addressed these issues. Six urinary tract infection patients were reported (0.63%), and one urosepsis case (0.10%). This seems to demonstrate few urinary infections occur and fewer sepsis cases, particularly when compared with transrectal biopsies data, concurring with previous research. Marginal difference was noted between infection rates with or without antibiotic prophylaxis. Local anaesthetic transperineal ultrasound-guided prostate biopsies seem to remain a safe procedure from a complications rate point of view. It has been proven before to have fewer urinary tract infections and sepsis episodes. Low-risk patients can have LATPUS biopsies without antibiotic prophylaxis. High-risk patients need clinician assessment and judicious utilization of antibiotics. Other complications require further studies with standardized biopsy techniques, clear complication definitions, and use of validated tools to measure complications.