No more stabbing in the dark!

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Having just returned from speaking at the world’s largest urology conference in New Orleans, the American Urology Association’s Annual Meeting, it’s clear that the blind transrectal ultrasound-guided (TRUS) biopsy will thankfully soon be a thing of the past.


For years now, as urologists we have performed prostate biopsy by randomly sampling the prostate gland without knowing where the cancer, if present, might be located. We’ve known that most cancers of the prostate arise in the part called the peripheral zone, but ultrasound doesn’t show us where in the peripheral zone, it just shows us where the prostate is – hence calling the procedure a “blind” TRUS biopsy.


As I wrote about in the recent article in this month’s Medical Journal of Australia, solid published evidence is burgeoning around the world, including from Australia, that multiparametric MRI clearly has a role to play in the diagnosis of prostate cancer. A multitude of updates were presented on this in New Orleans.


The reason MRI is causing such a stir is that, when performed by experienced and well-trained radiologists on the right MRI machines, it rarely misses aggressive and potentially lethal prostate cancer. This is in sharp contrast to blind TRUS biopsy, where aggressive cancer may be missed up to 30% of the time. Regrettably, this can often lead to a patient undergoing multiple unnecessary biopsy procedures, especially if his PSA level keeps rising.


The exact role of MRI in prostate cancer diagnosis remains to be determined. However, if performed prior to a biopsy, it may show an area suspicious of cancer, which can then be targeted by the biopsy needles. The remainder of the prostate can also be sampled at the same time so that patients get the “best of both worlds” in a single procedure. This is further enhanced when performed via the perineal skin (transperineal) to minimize the risk of severe infection.


In a nutshell, MRI allows us to make an accurate diagnosis one way or the other the first time around, so that we’re not left guessing and potentially subjecting our patients to repeated invasive procedures.


However, I must stress the importance of having it done properly. Multiparametric MRI is a non-invasive form of imaging, but it is complex. It is therefore critical that expertise in it is disseminated appropriately, so that patients do not have to suffer the learning curve of inexperienced radiologists.


TRUS biopsy made sense when there was no alternative. But now that multiparametric MRI can clearly show where aggressive cancer is in the prostate in the vast majority of cases, blind TRUS biopsy seems archaic.


I am very confident that MRI will indeed revolutionise how we diagnose prostate cancer, so it’s very exciting, along with other Australian urologists, to be a part of the revolution!


Dr Grummet established the Victorian Transperineal Biopsy Collaboration which holds a monthly MRI Prostate Multidisciplinary Meeting at Epworth Richmond and includes urologists, radiologists, and pathologists. The meeting has been invaluable for providing direct feedback to radiologists and accelerating the development of expertise of all concerned.