Effects of Prior Biopsies on Complications of Multiparametric Magnetic Resonance Imaging / Transrectal Ultrasonography Fusion Prostate Biopsy: An Analytic Cross- Sectional Analysis of Prospectively Recorded Data

Effects of Prior Biopsies on Complications of Multiparametric Magnetic Resonance Imaging / Transrectal Ultrasonography Fusion Prostate Biopsy: An Analytic Cross- Sectional Analysis of Prospectively Recorded Data | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of Prior Biopsies on Complications of Multiparametric Magnetic Resonance Imaging / Transrectal Ultrasonography Fusion Prostate Biopsy: An Analytic Cross- Sectional Analysis of Prospectively Recorded Data Caglar Dizdaroglu, Akif Erbin, Feyzi Sinan Erdal, Ufuk Caglar, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5940546/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Objective Insufficient data exists about the examination of the impact of previous biopsies on complications in multiparametric magnetic resonance imaging (Mp-MRI) and transrectal ultrasonography (TRUS) fusion biopsies. We aimed to compare the complications of Mp-MRI / TRUS fusion transrectal prostate biopsy in patients who have not undergone a prostate biopsy before and in patients whose prior biopsy or biopsies. Methods The study consisted of a retrospective review of prospectively recorded data. The cohort of patients (n = 780) was categorized into three groups: group 1 (biopsy naive patients, n = 390), group-2a (consisting of patients who underwent a single biopsy, n = 278), and group-2b (consisting of patients who underwent at least two biopsies, n = 112). The demographic data of the patients, comorbidities, prostate-specific antigen results, Mp-MRI characteristics, biopsy data, and complications were compared between the groups. Results There was no significant difference between the groups in terms of metabolic syndrome, anticoagulant use, urinary infection history in the last 3 months, and antibiotic use in the last 3 months. While there was no difference between the groups in terms of post-procedural complication rates, peri-procedural complications (urethrorrhagia and rectal bleeding) were significantly higher in group 2b than in the other two groups. Conclusion When considering the Mp-MRI / TRUS fusion prostate biopsy for patients with a history of two or more previous biopsies, it is important to consider the risk of bleeding and take proper precautions for this specific group of patients. Alternatively, a transperineal biopsy may be considered. Image-Guided Biopsy Multiparametric Magnetic Resonance Imaging Prostate Figures Figure 1 Figure 2 Introduction Prostate cancer (PCa) ranks as the second most common cancer detected in males and the fifth most significant factor contributing to mortality on a global scale. The occurrence and death rates of PCa are closely linked to age, with the highest occurrence observed in men over the age of 65 [ 1 ]. The presence of elevated levels of prostate-specific antigen (PSA) and/or abnormal findings during a digital rectal examination (DRE) are indicative of a potential diagnosis of PCa, and the diagnosis is achieved by conducting biopsies using transrectal ultrasonography (TRUS) [ 2 ]. In recent years, there has been a significant focus on adopting multiparametric magnetic resonance imaging (Mp-MRI) and Mp-MRI-guided targeted biopsy techniques as enhanced methods for identifying PCa. So far, three Mp-MRI-guided biopsy techniques have been introduced, namely MRI-TRUS fusion biopsy, cognitive targeted biopsy, and in-bore biopsy [ 3 ]. Among these methods, the MRI / TRUS fusion biopsy technique has gained more prominence both in clinical practice and in the literature. Despite these advancements, prostate biopsies still have a high likelihood of complications. During or after the biopsy, pain, urinary retention, bleeding-related complications (such as rectal bleeding, urethrorrhagia, hematuria, and hematospermia), and infective complications (such as cystitis, epididymitis, prostatitis, urinary tract infection, and urosepsis) may develop [ 4 ]. Among these, significant bleeding and sepsis in particular have the potential to be life-threatening. Therefore, it is imperative to do a comprehensive analysis of the likelihood of complications specific to the patient before performing a prostate biopsy. Prior studies have mostly examined the cancer detection rates of Mp-MRI / TRUS fusion biopsy techniques and the subsequent planning of targeted treatments (focal therapies) based on the biopsy results [ 5 – 7 ]. There is no data in the literature analyzing the complications of this technique in depth, particularly with the potential impact of previous biopsies on prostate fusion biopsy complications. In this context, we aimed to assess and compare the complications of Mp-MRI/TRUS fusion transrectal prostate biopsy in patients who have not undergone a prostate biopsy before and in patients whose prior biopsy or biopsies. Methods Compliance with ethical standards The presented study was conducted at the Urology Clinic of the University of Health Sciences Haseki Training and Research Hospital, which is a tertiary center, after the approval of the Haseki Training and Research Hospital ethics committee dated March 29, 2023 and numbered 69-2023. This study was also approved by the Institutional Review Board IRB of the University of Health Sciences Haseki Training and Research Hospital on February 10, 2023 (protocol number: 64). Prior to the procedure, the patients were provided with a comprehensive explanation of all the specifics about the biopsy method (All written consents are available in the patient files). The presented article was an urology assistant thesis study by Dr. Caglar Dizdaroglu (thesis advisor: Assoc. Prof. Akif Erbin) that has been approved by the University of Health Sciences, Turkey. Study design Prospectively recorded data were reviewed retrospectively in the study, which was designed as an analytic cross-sectional study, a form of observational studies. Mp-MRI / TRUS f usion biopsy, and cognitive fusion biopsy have been performed at our institution since 2016. Since this date, more than 2000 Mp-MRI / TRUS f usion biopsies have been performed in our clinic. However, the data of the first years (2016–2020) were not included in the study due to the fact that the limited experience may have a potential negative effect on the outcomes; the 2021 and later period data, which reflect the most extensive experience, were used in the study. Patients who underwent an Mp-MRI / TRUS fusion transrectal prostate biopsy due to suspicion of PCa between January 2021 and January 2023 were included in the study. PCa active surveillance patients, patients who underwent transperineal fusion prostate biopsy, and patients with incomplete medical records were excluded from the study. The cohort of patients (n = 780) was categorized into three groups: group 1 (biopsy naive patients, n = 390), group-2a (consisting of patients who underwent a single biopsy, n = 278) and group-2b (consisting of patients who underwent at least two biopsies, n = 112) (Figure 1). The demographic data of the patients, comorbidities, PSA results, Mp-MRI characteristics, biopsy data, and complications were prospectively recorded and compared between the groups. Biopsy procedure Antibiotic prophylaxis was administered with a single oral dosage of 3 g of fosfomycin, taken 24 hours before and 24 hours after the biopsy. The patients had a rectal enema prior to the biopsy in the morning. Prior to the surgery, lidocaine gel was administered intrarectally. For completely painless transrectal access and biopsy, firstly, a percutaneous injection of 5 ml of 1% lidocaine (10 ml in total) was performed right posterior the ischial spine at the point where the sacrospinous ligament attaches, with the guidance of a DRE (bilateral pudendal nerve block). Secondly, a total of 10 ml of prilocaine hydrochloride was enjected with an 18-G Chiba needle between the prostate base and seminal vesicle to provide local anesthesia (bilateral bi-basal periprostatic nerve block). A Mp-MRI / TRUS fusion transrectal prostate biopsy was performed using the BioJet fusion system (D&K Technologies, Barum, Germany) with a transrectal probe and an automatic trucut prostate biopsy gun with an 18G needle in the lithotomy position. The biopsy was performed with a total of at least 3 pieces of the target, including at least 2 pieces from the center of the target, and 10–12 pieces of systematic sampling (Figure 2). The samples were sent for pathologic examination in separate tubes. Assessment of complications The evaluation of complications in the post-external period was done prospectively using control visits 7 days and 30 days after the prostate biopsy. Complications were assessed as major (massive rectal bleeding, macroscopic heamaturia, acute prostatitis, and urosepsis) and minor (urethrorrhagia hematospermia, self-limiting macroscopic hematuria, self-limiting rectal bleeding, acute urinary retention). Massive rectal bleeding was defined as the expulsion of bright red blood from the rectum, occurring more than 12 hours after the biopsy, or any bleeding that necessitates immediate treatment such as rectal tamponade or blood transfusion, regardless of when it happens. To classify the grade of complications, a modified Clavien-Dindo classification system was used [8]. Statistical analysis The statistical analysis of the study was carried out using SPSS for Windows software version 27 (SPSS, IBM Corp., Armonk, NY, USA). The distribution of the data was assessed for normality using the Shapiro-Wilk test. Normally distributed data were expressed as mean ± standard deviation values, whereas non-normally distributed data were expressed as median values and interquartile range values. The one-way ANOVA test was used to compare the normally distributed variables between the groups, whereas the Kruskal-Wallis test was used for non-normally distributed data. Categorical variables are represented as n (%), and the chi-square test was used to compare categorical variables between the groups. In order to compare between paired groups, a Tukey post-hoc analysis was performed. A p-value of 0.05 or lower was accepted as statistically significant. Results Group 2 had a significantly higher mean age compared to Group 1 (Table 1). Table 1. Comparison of patients' demographic data between the groups Group 1 (n = 390) Group 2a (n = 278) Group 2b (n = 112) p value Age (years) , mean ± sd 61.6 ± 6.9 a 62.9 ± 6.4 b 64.2 ± 5.2 b 0.001 x BMI (kg/m 2 ) , mean ± sd 27.4 ± 3.3 27.5 ± 3.4 27.5 ± 3.9 0.939 x sd : standard deviation, BMI : body mass index x : One-way ANOVA test was used a,b : Paired group comparisons are shown in lowercase letters. The same letters (a-a or b-b) indicate statistical similarity; different letters (a-b) indicate statistical difference. There was no significant difference between the groups in terms of comorbidities other than hypertension (group 2b had a higher rate of hypertension than other groups, p = 0.007), metabolic syndrome (MetS), anticoagulant use, urinary infection history in the last 3 months, and antibiotic use in the last 3 months (Tablo 2). Table 2 . Comparison of comorbidities between the groups Group 1 (n = 390) Group 2a (n = 278) Group 2b (n = 112) p value Comorbidity, n (%) Hypertension Diabetes mellitus CAD COPD CKD 125 (32.1 %) a 67 (17.2 %) 47 (12.1 %) 19 (4.9 %) 7 (1.8 %) 110 (39.6 %) a 48 (17.3 %) 31 (11.2 %) 16 (5.8 %) 4 (1.4 %) 53 (47.3 %) b 13 (11.6 %) 11 (9.8 %) 7 (6.3 %) 2 (1.8 %) 0.007 x 0.344 x 0.798 x 0.841 x 0.932 x MetS , n (%) 56 (14.4 %) 36 (12.9 %) 19 (17.0 %) 0.576 x Use of anticoagulants, n (%) 105 (26.9 %) 66 (23.7 %) 32 (28.6 %) 0.524 x History of UTI in the last 3 months , n (%) 23 (6.3 %) 24 (10.1 %) 7 (7.2 %) 0.225 x Antibiotic use in the last 3 months, n (%) 71 (19.3 %) 44 (18.5 %) 19 (19.6 %) 0.963 x MetS : metabolic syndrome, CAD: Coronary artery disease, COPD : Chronic obstructive pulmonary disease, CKD : Chronic kidney disease, UTI : Urinary tract infection x : Chi square test was used a,b : Paired group comparisons are shown in lowercase letters. The same letters indicate statistical similarity; different letters indicate statistical difference. While the Prostate Imaging-Reporting and Data System (PIRADS) scores of the lesions were similar between the groups, group 2b had a significantly lower number of systemic samplings and total number of cores taken compared to the other two groups (Table 3). Table 3 . Comparison of PSA values, Mp-MRI and biopsy features Group 1 (n = 390) Group 2a (n = 278) Group 2b (n = 112) p value Total PSA (ng / ml)* 5.9 (4.4 – 8.6) a 7.0 (5.1 – 10.0) b 8.6 (6.2 – 14.4) b 0.001 x Pv (cc)* 48.0 (34.0 – 67.0) a 60.0 (44.8 – 80.0) b 72.5 (52.8 – 102.0) c 0.001 x PSA density * 0.1 (0.1 – 0.2) 0.1 (0.1 – 0.2) 0.1 (0.1 – 0.2) 0.380 x PIRADS category , n (%) PIRADS 3 PIRADS 4 PIRADS 5 298 (76.4 %) 78 (20.0 %) 14 (3.6 %) 220 (79.1 %) 47 (16.9 %) 11 (4.0 %) 80 (71.4 %) 28 (25.0 %) 4 (3.6 %) 0.493 z Number of cores ** Lesion Systematic Total 5.2 ± 2.0 a, b 11.8 ± 1.1 a 17.0 ± 2.0 a 4.9 ± 1.7 a 11.5 ± 2.3 a 16.4 ± 2.2 b 5.5 ± 2.1 b 10.1 ± 4.2 b 15.6 ± 3.4 c 0.006 y 0.001 y 0.001 y mp- MRI: multiparametric magnetic resonance imaging, PSA: prostate-specific antigen , PV: prostate volume PIRADS: Prostate Imaging-Reporting and Data System *: median (interquartile range) **: mean ± sd x : Kruskal-Wallis test was used y : One-way ANOVA test was used z : Chi square test was used a,b,c : Paired group comparisons are shown in lowercase letters. The same letters indicate statistical similarity; different letters indicate statistical difference. While there was no difference between the groups in terms of post-procedural complication rates, peri-procedural complications (urethrorrhagia and rectal bleeding) were significantly higher in group 2b than in the other 2 groups (Table 4). All complications were minor complications (Clavien-Dindo Classification ≤ 2). Tablo 4 . Comparison of peri- and post-procedural complications Group 1 (n = 390) Group 2a (n = 278) Group 2b (n = 112) p value Peri-procedural complications , n (%) Urethrorrhagia (grade 1) Rectal bleeding (grade 1) Urethrorrhagia + rectal bleeding 17 (4.3 %) a 14 (3.5 %) a 2 (0.5 %) a - 14 (5.0 %) a 12 (4.3 %) a - a 1 (0.4 %) 15 (13.4 %) b 11 (9.8 %) b 3 (2.6 %) b - 0.002 x 0.022 x 0.010 x NA Post-procedural complications , n (%) Hematuria (grade 1) Hematospermia (grade 1) Rectal bleeding (grade 1) Acute urinary retention (grade 2) Fever (grade 1&2; if antibiotics/antipyretics required) 64 (16.4 %) 14 (3.6 %) 11 (2.8 %) 3 (0.8 %) 8 (2.1 %) 56 (20.1 %) 10 (3.6 %) 13 (4.7 %) 1 (0.4 %) 3 (1.1 %) 22 (19.6 %) 4 (3.6 %) 3 (2.7 %) 1 (0.9 %) - 0.426 x 1.000 x 0.389 x 0.862 x 0.207 x NA: not applicable x : Chi square test was used a,b : Paired group comparisons are shown in lowercase letters. The same letters indicate statistical similarity; different letters indicate statistical difference. PCa was found in 59.3% of the patients in group 1, 24% in group 2, and 24.8% in group 3, while prostatitis was found in 13.8%, 18.7%, and 24.4% of the patients, respectively. Discussion There is a scarcity of studies that examine the complications related to the Mp-MRI / TRUS fusion prostate biopsy approach or compare them to prior procedures. A study comparing conventional 14-core TRUS biopsy with Mp-MRI / TRUS fusion transrectal prostate biopsy found that the rate of complications was 1.9% in the TRUS biopsy group and 1.75% in the fusion biopsy group. All of these complications were minor, and there was no significant difference in the occurrence of complications between the two methods [9]. A recent study involving 458 patients examined the complications of Mp-MRI / TRUS fusion biopsy and reported that 203 patients (44.3%) experienced adverse events after the procedure. Among these, 161 patients (35.2%) had Clavien-Dindo grade 1 complications, which included hematuria (124 cases, 27.1%), hematochezia (22 cases, 4.8%), hematospermia (14 cases, 3.1%), or a combination of these (20 cases, 4.4%). Additionally, 45 patients (9.0%) had Clavien-Dindo grade 2 complications, such as acute urinary retention or hematuria requiring catheterization, as well as urinary tract infections (2 cases requiring hospitalization). In the study, it was also reported that no major complications were observed, and age > 70 years and body mass index (BMI) > 25 kg/m 2 were found to be predictors of post-operative complications [10].In our study, given that the patients' average age was below 70 years and there was no disparity in BMI across the groups, we think that these two factors are not effective in explaining the differences in complications between the groups. In a recent study comparing TRUS biopsy with Mp-MRI / TRUS fusion transrectal prostate biopsy, which is the most extensive study (10,325 patients underwent 12-core TRUS biopsy and 576 patients underwent Mp-MRI / TRUS fusion biopsy), comparing these two techniques in terms of complications and cancer detection, it was found that there was no difference in complications between these two techniques. However, it was observed that PV played a significant role in predicting overall complications, infectious complications, bleeding-related complications, and complications that scored ≥2 on the Clavien-Dindo scale [11]. Prostate volume is also important in repeat biopsy; it has been suggested that 20% of patients with a prostate volume of 50 cc and 35% of individuals with a prostate volume of >75 cc require a repeat biopsy [12]. Our study found that the patient group who had undergone two or more previous biopsies (group-2b) exhibited significantly greater age, total PSA, and PV levels. These patients had been suffering from benign prostatic hyperplasia for a much longer duration. The higher biopsy rate in this patient group may be associated with the augmented PV. Enhanced collateral abnormal vascularization and inflammation stemming from recurrent interventions on the prostate tissue may also play a role in urethrorrhagia and rectal bleeding complications. Because, group 2b exhibited the highest incidence of prostatitis, according to the pathology results. Massive rectal bleeding after a biopsy is infrequent, but it can be life-threatening in extremely rare circumstances. The number of core samples obtained has a statistically significant positive correlation with rectal bleeding. Our study found that despite a smaller number of sample in group 2b, there was a higher incidence of rectal bleeding. This supports the result that past biopsies had a significant impact on bleeding. Effective interventions for rectal bleeding include tamponade (using digital pressure, packs, catheters, and tampons), endoscopic procedures (sclerotherapy, banding, and endoclipping), radiological embolization, and surgical procedures [13]. Rectal tamponade was performed quickly using sponges in our patients who experienced rectal bleeding during the procedure, and no severe bleeding was noted in any patient in the study post-procedural period. The number of biopsy cores taken was strongly related to the development of hematuria and hematospermia in the FUTURE trial, which was undertaken in patients with a prior negative biopsy and based on MRI-guided biopsies [14]. The PRECISION trial found that a four-core targeted biopsy had significantly fewer adverse effects than a 12-core TRUS-biopsy. This was most likely owing to a lower percentage of men undergoing biopsy in the TB group (biopsy was omitted in cases of negative mp-MRI) and fewer biopsy cores retrieved during biopsy (no systemic sampling was undertaken in the targeted biopsy group). Surprisingly, they reported comparable rates of serious complications in both groups [15]. While the number of cores taken in group 2b was lower in our study, the fact that there were more bleeding-related complications supports our main finding, which is that previous biopsies increase bleeding-related complications. Otherwise, more bleeding would be expected in group 1, which had a higher number of samples. The European Medicines Agency issued a warning on March 11th, 2019, stating that quinolones and fluoroquinolones should not be used for the prophylaxis of TUR and prostate biopsy. This warning was based on a review of resistance rates and the occurrence of serious, disabling, and potentially permanent adverse events, especially affecting the musculoskeletal and nervous systems [16]. Starting from this date, our clinic ceased the use of quinolone prophylaxis and instead implemented fosfomycin prophylaxis for prostate biopsies (for both conventional TRUS biopsy, Mp-MRI / TRUS fusion prostate biopsy, and cognitive fusion biopsy). No instances of a major enfective complication were observed since this date. In a retrospective multicenter cohort of 550 patients from three different centers undergoing transperineal prostate biopsy, it was reported that no patient had urosepsis, even though antibiotic prophylaxis was not used [17]. Nevertheless, there is currently no guideline that supports the notion that the utilization of antibiotics in transperineal prostate biopsy is unnecessary. The first and most important limitation was that it was retrospective in nature. However, the prospective data collection especially prospective evaluation of complications undermines this limitation and enhances the worth of the study. Furthermore, our study did not include any findings pertaining to cancer patients who are on active surveillance. The presence of a tumoral lesion in the prostate gland could potentially lead to complications. To ensure the consistency of the study population, we excluded patients undergoing active surveillance from our study. An exclusive analysis focusing just on patients under active survaillance will address the gaps in this subject. One of the strengths of the study is that patient-related factors (comorbidities, MetS, use of anticoagulants, history of Urinary tract infection, and antibiotic use) that will affect post-procedure complications are similar between the groups. Furthermore, existing literature includes several studies that analyze the complications of Mp-MRI / TRUS prostate fusion biopsy; however, none of these studies have specifically examined the impact of prior biopsies on the complications of the planned Mp-MRI / TRUS fusion biopsy. Within this particular framework, the outcomes of the study being presented will make a valuable contribution to both clinical practice and the existing body of literature. Conclusion In patients with a history of two or more previous prostate biopsies, the Mp-MRI / TRUS fusion transrectal prostate biopsy may be associated with complications related to bleeding. When considering the Mp-MRI / TRUS fusion prostate biopsy for patients with a history of two or more previous biopsies, it is important to consider the risk of bleeding and take proper precautions such as insertion of the urethral catheter, urethral catheter traction, elastic penile bandage, and rectal tamponade during the biopsy procedure and in the early post-procedure period. Alternatively, a transperineal biopsy may be considered for this specific group of patients. Declarations Conflict of interest: No conflict declared Funding Declaration: The authors received no financial support for the research, authorship, and/or publication of this article. Human Ethics and Consent to Participate declarations : not applicable’. Ethical approval for the study: The study was approvad by the Haseki Training and Research Hospital ethics committee dated March 29, 2023 and numbered 69-2023. Approval of the research protocol by an Institutional Reviewer Board: The study was approved by the Institutional Review Board of the University of Health Sciences Haseki Training and Research Hospital on February 10, 2023 (protocol number: 64). Informed consent for procudure: Prior to the procedure, the patients were provided with a comprehensive explanation of all the specifics about the biopsy method. Consent for publication: Not applicable (Our study is a retrospective study) Clinical trial number: not applicable Authorship contributions Caglar Dizdaroglu: Conception and design, Acquisition of data, Analysis and interpretation of data, Drafting of the manuscript Akif Erbin: Conception and design, Analysis and interpretation of data, Drafting of the manuscript, Critical revision of the manuscript for important intellectual content, Statistical analysis, Supervision Feyzi Sinan Erdal: Conception and design, Analysis and interpretation of data, Drafting of the manuscript Ufuk Caglar: Conception and design, Drafting of the manuscript, Statistical analysis, Supervision Abdullah Esmeray: Conception and design, Acquisition of data, Critical revision of the manuscript for important intellectual content Nazim Furkan Gunay: Acquisition of data, Critical revision of the manuscript for important intellectual content, Statistical analysis Mucahit Gelmis: Acquisition of data, Drafting of the manuscript, Critical revision of the manuscript for important intellectual content Arda Meric: Conception and design, Acquisition of data, Drafting of the manuscript Omer Sarilar: Analysis and interpretation of data, Critical revision of the manuscript for important intellectual content, Supervision References Rawla, Prashanth. 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Complications and Adverse Events of Three Magnetic Resonance Imaging–based Target Biopsy Techniques in the Diagnosis of Prostate Cancer Among Men with Prior Negative Biopsies: Results from the FUTURE Trial, a Multicentre Randomised Controlled Trial. Eur Urol Oncol. 2019;2:617-624. Kasivisvanathan V, Rannikko AS, Borghi M, et al. MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med 2018;378:1767–77. European Medicines Agency. Summary of the EMA public hearing on quinolone and fluoroquinolone antibiotics: Public hearing held on 13 June 2018 [Internet]. Available from: https://www.ema.europa.eu/documents/report/summary-emapublic-hearing-quinolone-fluoroquinolone-antibiotics Kohl T, Sigle A, Kuru T, et al. Comprehensive analysis of complications after transperineal prostate biopsy without antibiotic prophylaxis: results of a multicenter trial with 30 days' follow-up. Prostate Cancer Prostatic Dis. 2022;25:264–268. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 18 Feb, 2025 Editor assigned by journal 14 Feb, 2025 Submission checks completed at journal 14 Feb, 2025 First submitted to journal 01 Feb, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5940546","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":415825584,"identity":"f4a7f43e-663e-4d59-ad5a-7536d5fbf36c","order_by":0,"name":"Caglar Dizdaroglu","email":"","orcid":"","institution":"Haseki Training and Research Hospital, Department of Urology, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Caglar","middleName":"","lastName":"Dizdaroglu","suffix":""},{"id":415825585,"identity":"b3ecc8a4-5dd1-416f-b952-1cc54c480094","order_by":1,"name":"Akif Erbin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACHsaGDwwMB3gY2BuAPAMLorQ0zgBr4TkA0iJBjBYGRpAWBgaJBBCXCC38PYcbGz7uuSNjLvn86oYfBRIM/O3dCXi1SJxtbGyc8ewZj+XsnLKbPUCHSZw5uwG/NecZ2x/zHDjMY3A7J+0GD1CLgUQufi3y5xkbm/+AtNw8k3bzDzFaDIAOa2YAabnBfuw2UbYYnjnY2Nhz4BmPwZkcttsyBhI8BP0idyb9YcOPA3fsDY4ff3bzzR8bOf72XgLeRwAeAzBJrHIQYH9AiupRMApGwSgYQQAAJWBQ5zqAwx4AAAAASUVORK5CYII=","orcid":"","institution":"Haseki Training and Research Hospital, Department of Urology, Istanbul","correspondingAuthor":true,"prefix":"","firstName":"Akif","middleName":"","lastName":"Erbin","suffix":""},{"id":415825586,"identity":"d44a8deb-47dd-4dcd-b77b-9115f193fc99","order_by":2,"name":"Feyzi Sinan Erdal","email":"","orcid":"","institution":"Haseki Training and Research Hospital, Department of Urology, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Feyzi","middleName":"Sinan","lastName":"Erdal","suffix":""},{"id":415825587,"identity":"fdc14ee9-5c0f-4a57-a577-c7c25bc6d99d","order_by":3,"name":"Ufuk Caglar","email":"","orcid":"","institution":"Haseki Training and Research Hospital, Department of Urology, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Ufuk","middleName":"","lastName":"Caglar","suffix":""},{"id":415825588,"identity":"3a65c45d-89ea-4661-9abb-087bc0224c9d","order_by":4,"name":"Abdullah Esmeray","email":"","orcid":"","institution":"Haseki Training and Research Hospital, Department of Urology, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Abdullah","middleName":"","lastName":"Esmeray","suffix":""},{"id":415825589,"identity":"12fb81af-dc46-4a1d-8b71-2a07f15e2b7b","order_by":5,"name":"Nazim Furkan Gunay","email":"","orcid":"","institution":"Haseki Training and Research Hospital, Department of Urology, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Nazim","middleName":"Furkan","lastName":"Gunay","suffix":""},{"id":415825590,"identity":"9108b23e-b492-48a2-b814-f026c76eeb6a","order_by":6,"name":"Mucahit Gelmis","email":"","orcid":"","institution":"Haseki Training and Research Hospital, Department of Urology, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Mucahit","middleName":"","lastName":"Gelmis","suffix":""},{"id":415825591,"identity":"efac6455-b748-4159-815f-0147eb114731","order_by":7,"name":"Arda Meric","email":"","orcid":"","institution":"Haseki Training and Research Hospital, Department of Urology, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Arda","middleName":"","lastName":"Meric","suffix":""},{"id":415825592,"identity":"f4cde3c7-b178-4243-88ea-17bd4a2bcddd","order_by":8,"name":"Omer Sarilar","email":"","orcid":"","institution":"Haseki Training and Research Hospital, Department of Urology, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Omer","middleName":"","lastName":"Sarilar","suffix":""}],"badges":[],"createdAt":"2025-02-01 07:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5940546/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5940546/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":76686392,"identity":"13788358-645f-472d-8397-43df044d9150","added_by":"auto","created_at":"2025-02-19 16:09:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":92985,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5940546/v1/c03c27976a31213d5a2736ec.png"},{"id":76686401,"identity":"e3feb451-970a-4465-9ca1-c0ee732abf16","added_by":"auto","created_at":"2025-02-19 16:09:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":359001,"visible":true,"origin":"","legend":"\u003cp\u003eTarget sampling from a PIRADS-4 lesion (red arrow) with a transrectal approach in the sagittal plane in the Mp-MRI / TRUS fusion prostate biopsy\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5940546/v1/d7c7a69a623db088e4fb6766.png"},{"id":76686764,"identity":"e967845e-b5d1-4883-be89-a18d9540b180","added_by":"auto","created_at":"2025-02-19 16:17:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2197916,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5940546/v1/60e58dc6-cfc2-467d-ac61-9c2a78c048c4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of Prior Biopsies on Complications of Multiparametric Magnetic Resonance Imaging / Transrectal Ultrasonography Fusion Prostate Biopsy: An Analytic Cross- Sectional Analysis of Prospectively Recorded Data","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProstate cancer (PCa) ranks as the second most common cancer detected in males and the fifth most significant factor contributing to mortality on a global scale. The occurrence and death rates of PCa are closely linked to age, with the highest occurrence observed in men over the age of 65 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The presence of elevated levels of prostate-specific antigen (PSA) and/or abnormal findings during a digital rectal examination (DRE) are indicative of a potential diagnosis of PCa, and the diagnosis is achieved by conducting biopsies using transrectal ultrasonography (TRUS) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn recent years, there has been a significant focus on adopting multiparametric magnetic resonance imaging (Mp-MRI) and Mp-MRI-guided targeted biopsy techniques as enhanced methods for identifying PCa. So far, three Mp-MRI-guided biopsy techniques have been introduced, namely MRI-TRUS fusion biopsy, cognitive targeted biopsy, and in-bore biopsy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Among these methods, the MRI / TRUS fusion biopsy technique has gained more prominence both in clinical practice and in the literature. Despite these advancements, prostate biopsies still have a high likelihood of complications. During or after the biopsy, pain, urinary retention, bleeding-related complications (such as rectal bleeding, urethrorrhagia, hematuria, and hematospermia), and infective complications (such as cystitis, epididymitis, prostatitis, urinary tract infection, and urosepsis) may develop [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Among these, significant bleeding and sepsis in particular have the potential to be life-threatening. Therefore, it is imperative to do a comprehensive analysis of the likelihood of complications specific to the patient before performing a prostate biopsy.\u003c/p\u003e \u003cp\u003ePrior studies have mostly examined the cancer detection rates of Mp-MRI / TRUS fusion biopsy techniques and the subsequent planning of targeted treatments (focal therapies) based on the biopsy results [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. There is no data in the literature analyzing the complications of this technique in depth, particularly with the potential impact of previous biopsies on prostate fusion biopsy complications. In this context, we aimed to assess and compare the complications of Mp-MRI/TRUS fusion transrectal prostate biopsy in patients who have not undergone a prostate biopsy before and in patients whose prior biopsy or biopsies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCompliance with ethical standards\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe presented study was conducted at the Urology Clinic of the University of Health Sciences Haseki Training and Research Hospital, which is a tertiary center, after the approval of the Haseki Training and Research Hospital ethics committee dated March 29, 2023 and numbered 69-2023.\u0026nbsp;\u003c/strong\u003eThis study was also approved by the Institutional Review Board IRB of the University of Health Sciences Haseki Training and Research Hospital on February 10, 2023 (protocol number: 64). \u003cstrong\u003ePrior to the procedure, the patients were provided with a comprehensive explanation of all the specifics about the biopsy method (All written consents are available in the patient files).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe presented article was an urology assistant thesis study by Dr. Caglar Dizdaroglu (thesis advisor: Assoc. Prof. Akif Erbin) that has been approved by the University of Health Sciences, Turkey.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProspectively recorded data were reviewed retrospectively in the study, which was designed as an analytic cross-sectional study, a form of observational studies. Mp-MRI / TRUS \u0026nbsp;f\u003cstrong\u003eusion biopsy, and cognitive fusion biopsy have been performed at our institution since 2016. Since this date, more than 2000\u0026nbsp;\u003c/strong\u003eMp-MRI / TRUS \u0026nbsp;f\u003cstrong\u003eusion biopsies have been performed in our clinic. However, the data of the first years (2016\u0026ndash;2020) were not included in the study due to the fact that the limited experience may have a potential negative effect on the outcomes; the 2021 and later period data, which reflect the most extensive experience, were used in the study.\u0026nbsp;\u003c/strong\u003ePatients who underwent an Mp-MRI / TRUS fusion transrectal prostate biopsy due to suspicion of PCa between January 2021 and January 2023 were included in the study. PCa active surveillance patients, patients who underwent transperineal fusion prostate biopsy, and patients with incomplete medical records were excluded from the study. The cohort of patients (n = 780) was categorized into three groups: group 1 (biopsy naive patients, n = 390), group-2a (consisting of patients who underwent a single biopsy, n = 278) and group-2b (consisting of patients who underwent at least two biopsies, n = 112) (Figure 1). The demographic data of the patients, comorbidities, PSA results, Mp-MRI characteristics, biopsy data, and complications were prospectively recorded and compared between the groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBiopsy procedure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAntibiotic prophylaxis was administered with a single oral dosage of 3 g of fosfomycin, taken 24 hours before and 24 hours after the biopsy. The patients had a rectal enema prior to the biopsy in the morning. Prior to the surgery, lidocaine gel was administered intrarectally. For completely painless transrectal access and biopsy, firstly, a percutaneous injection of 5 ml of 1% lidocaine (10 ml in total) was performed right posterior the ischial spine at the point where the sacrospinous ligament attaches, with the guidance of a DRE (bilateral pudendal nerve block). Secondly, a total of 10 ml of prilocaine hydrochloride was enjected with an 18-G Chiba needle between the prostate base and seminal vesicle to provide local anesthesia (bilateral bi-basal periprostatic nerve block). A Mp-MRI / TRUS fusion transrectal prostate biopsy was performed using the BioJet fusion system (D\u0026amp;K Technologies, Barum, Germany) with a transrectal probe and an automatic trucut prostate biopsy gun with an 18G needle in the lithotomy position. The biopsy was performed with a total of at least 3 pieces of the target, including at least 2 pieces from the center of the target, and 10\u0026ndash;12 pieces of systematic sampling (Figure 2). The samples were sent for pathologic examination in separate tubes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAssessment of complications\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe evaluation of complications in the post-external period was done prospectively using control visits 7 days and 30 days after the prostate biopsy. Complications were assessed as major (massive rectal bleeding, macroscopic heamaturia, acute prostatitis, and urosepsis) and minor (urethrorrhagia hematospermia, self-limiting macroscopic hematuria, self-limiting rectal bleeding, acute urinary retention). Massive rectal bleeding was defined as the expulsion of bright red blood from the rectum, occurring more than 12 hours after the biopsy, or any bleeding that necessitates immediate treatment such as rectal tamponade or blood transfusion, regardless of when it happens. To classify the grade of complications, a modified Clavien-Dindo classification system was used [8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical analysis of the study was carried out using SPSS for Windows software version 27 (SPSS, IBM Corp., Armonk, NY, USA). The distribution of the data was assessed for normality using the Shapiro-Wilk test. Normally distributed data were expressed as mean \u0026plusmn; standard deviation values, whereas non-normally distributed data were expressed as median values and interquartile range values. The one-way ANOVA test was used to compare the normally distributed variables between the groups, whereas the Kruskal-Wallis test was used for non-normally distributed data. Categorical variables are represented as n (%), and the chi-square test was used to compare categorical variables between the groups. In order to compare between paired groups, a Tukey post-hoc analysis was performed. A p-value of 0.05 or lower was accepted\u003cem\u003e\u0026nbsp;\u003c/em\u003eas statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eGroup 2 had a significantly higher mean age compared to Group 1 (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Comparison of patients\u0026apos; demographic data between the groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.106%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.2185%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 390)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.7086%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2a\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 278)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.7086%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2b\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 112)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2583%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.106%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e, \u003cem\u003emean \u0026plusmn; sd\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.2185%;\"\u003e\n \u003cp\u003e61.6 \u0026plusmn; 6.9 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.7086%;\"\u003e\n \u003cp\u003e62.9 \u0026plusmn; 6.4 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.7086%;\"\u003e\n \u003cp\u003e64.2 \u0026plusmn; 5.2 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2583%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.001\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.106%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e, \u003cem\u003emean \u0026plusmn; sd\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.2185%;\"\u003e\n \u003cp\u003e27.4 \u0026plusmn; 3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.7086%;\"\u003e\n \u003cp\u003e27.5 \u0026plusmn; 3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.7086%;\"\u003e\n \u003cp\u003e27.5 \u0026plusmn; 3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2583%;\"\u003e\n \u003cp\u003e0.939 \u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003esd\u003c/em\u003e\u003c/strong\u003e: standard deviation, \u003cstrong\u003e\u003cem\u003eBMI\u003c/em\u003e\u003c/strong\u003e: body mass index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e One-way ANOVA test was used\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ea,b\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Paired group comparisons are shown in lowercase letters. The same letters (a-a or b-b) indicate statistical similarity; different letters (a-b) indicate statistical difference.\u003c/p\u003e\n\u003cp\u003eThere was no significant difference between the groups in terms of comorbidities other than hypertension (group 2b had a higher rate of hypertension than other groups, p = 0.007), metabolic syndrome (MetS), anticoagulant use, urinary infection history in the last 3 months, and antibiotic use in the last 3 months (Tablo 2). \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Comparison of comorbidities between the groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2665%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 390)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2a\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 278)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8997%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2b\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 112)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.45559%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2665%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidity,\u003c/strong\u003e \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hypertension\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Diabetes mellitus\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; CAD\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; COPD\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; CKD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e125 (32.1 %) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e67 (17.2 %)\u003c/p\u003e\n \u003cp\u003e47 (12.1 %)\u003c/p\u003e\n \u003cp\u003e19 (4.9 %)\u003c/p\u003e\n \u003cp\u003e7 (1.8 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e110 (39.6 %) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e48 (17.3 %)\u003c/p\u003e\n \u003cp\u003e31 (11.2 %)\u003c/p\u003e\n \u003cp\u003e16 (5.8 %)\u003c/p\u003e\n \u003cp\u003e4 (1.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8997%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e53 (47.3 %) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e13 (11.6 %)\u003c/p\u003e\n \u003cp\u003e11 (9.8 %)\u003c/p\u003e\n \u003cp\u003e7 (6.3 %)\u003c/p\u003e\n \u003cp\u003e2 (1.8 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.45559%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.007\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.344\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.798\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.841\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.932\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2665%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMetS\u003c/em\u003e\u003c/strong\u003e, \u003cem\u003en (%)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e56 (14.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e36 (12.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8997%;\"\u003e\n \u003cp\u003e19 (17.0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.45559%;\"\u003e\n \u003cp\u003e0.576\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2665%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUse of anticoagulants,\u003c/strong\u003e \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e105 (26.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e66 (23.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8997%;\"\u003e\n \u003cp\u003e32 (28.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.45559%;\"\u003e\n \u003cp\u003e0.524\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2665%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of UTI in the last 3 months\u003c/strong\u003e, \u003cem\u003en (%)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e23 (6.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e24 (10.1 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8997%;\"\u003e\n \u003cp\u003e7 (7.2 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.45559%;\"\u003e\n \u003cp\u003e0.225\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 43.2665%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntibiotic use in the last 3 months,\u003c/strong\u003e \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e71 (19.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.1891%;\"\u003e\n \u003cp\u003e44 (18.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8997%;\"\u003e\n \u003cp\u003e19 (19.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.45559%;\"\u003e\n \u003cp\u003e0.963\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMetS\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003emetabolic syndrome, \u003cstrong\u003e\u003cem\u003eCAD:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eCoronary artery disease,\u003cstrong\u003e\u003cem\u003e\u0026nbsp;COPD\u003c/em\u003e\u003c/strong\u003e: Chronic obstructive pulmonary disease, \u003cstrong\u003e\u003cem\u003eCKD\u003c/em\u003e\u003c/strong\u003e: Chronic kidney disease, \u003cstrong\u003e\u003cem\u003eUTI\u003c/em\u003e\u003c/strong\u003e: Urinary tract infection\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Chi square test was used \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ea,b\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Paired group comparisons are shown in lowercase letters. The same letters indicate statistical similarity; different letters indicate statistical difference.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile the Prostate Imaging-Reporting and Data System (PIRADS) scores of the lesions were similar between the groups, group 2b had a significantly lower number of systemic samplings and total number of cores taken compared to the other two groups (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e. \u0026nbsp;Comparison of PSA values, Mp-MRI and biopsy features\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7254%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8796%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 390)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2a\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 278)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2b\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 112)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.69163%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7254%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal PSA\u003c/strong\u003e (ng / ml)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8796%;\"\u003e\n \u003cp\u003e5.9 (4.4 \u0026ndash; 8.6) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e7.0 (5.1 \u0026ndash; 10.0) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e8.6 (6.2 \u0026ndash; 14.4) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.69163%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.001\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7254%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePv\u003c/strong\u003e (cc)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8796%;\"\u003e\n \u003cp\u003e48.0 (34.0 \u0026ndash; 67.0)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e60.0 (44.8 \u0026ndash; 80.0)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e72.5 (52.8 \u0026ndash; 102.0)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.69163%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.001\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7254%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSA density\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8796%;\"\u003e\n \u003cp\u003e0.1 (0.1 \u0026ndash; 0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e0.1 (0.1 \u0026ndash; 0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e0.1 (0.1 \u0026ndash; 0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.69163%;\"\u003e\n \u003cp\u003e0.380 \u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7254%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePIRADS category\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; PIRADS 3\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; PIRADS 4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; PIRADS 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8796%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e298 (76.4 %)\u003c/p\u003e\n \u003cp\u003e78 (20.0 %)\u003c/p\u003e\n \u003cp\u003e14 (3.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e220 (79.1 %)\u003c/p\u003e\n \u003cp\u003e47 (16.9 %)\u003c/p\u003e\n \u003cp\u003e11 (4.0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e80 (71.4 %)\u003c/p\u003e\n \u003cp\u003e28 (25.0 %)\u003c/p\u003e\n \u003cp\u003e4 (3.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.69163%;\"\u003e\n \u003cp\u003e0.493 \u003csup\u003ez\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 26.7254%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of cores\u003c/strong\u003e**\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Lesion\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Systematic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.8796%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.2 \u0026plusmn; 2.0 \u003csup\u003ea, b\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e11.8 \u0026plusmn; 1.1\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e17.0 \u0026plusmn; 2.0 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.9 \u0026plusmn; 1.7 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e11.5 \u0026plusmn; 2.3 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e16.4 \u0026plusmn; 2.2 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.8517%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.5 \u0026plusmn; 2.1 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e10.1 \u0026plusmn; 4.2 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e15.6 \u0026plusmn; 3.4 \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.69163%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.006\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.001\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.001\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003emp- MRI:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003emultiparametric magnetic resonance imaging, \u003cstrong\u003e\u003cem\u003ePSA:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eprostate-specific antigen\u003cstrong\u003e\u003cem\u003e, PV:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eprostate volume\u003cstrong\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp;PIRADS:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eProstate Imaging-Reporting and Data System\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*:\u0026nbsp;\u003c/strong\u003emedian (interquartile range)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e**:\u003c/strong\u003e mean \u0026plusmn; sd \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Kruskal-Wallis test was used \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ey\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e One-way ANOVA test was used \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ez\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Chi square test was used \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ea,b,c\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Paired group comparisons are shown in lowercase letters. The same letters indicate statistical similarity; different letters indicate statistical difference.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhile there was no difference between the groups in terms of post-procedural complication rates, peri-procedural complications (urethrorrhagia and rectal bleeding) were significantly higher in group 2b than in the other 2 groups\u0026nbsp;\u003c/strong\u003e(Table 4). All complications were minor complications (Clavien-Dindo Classification \u0026le; 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTablo 4\u003c/strong\u003e. \u0026nbsp;Comparison of peri- and post-procedural complications\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"718\" style=\"margin-right: calc(9%); width: 91%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.3086%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6804%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 390)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9371%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2a\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 278)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.236%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2b\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n = 112)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.7146%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.3086%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeri-procedural complications\u003c/strong\u003e, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Urethrorrhagia (grade 1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Rectal bleeding (grade 1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Urethrorrhagia + rectal bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6804%;\"\u003e\n \u003cp\u003e17 (4.3 %) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e14 (3.5 %) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e2 (0.5 %) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9371%;\"\u003e\n \u003cp\u003e14 (5.0 %) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e12 (4.3 %) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e-\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e1 (0.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.236%;\"\u003e\n \u003cp\u003e15 (13.4 %) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e11 (9.8 %) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e3 (2.6 %) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.7146%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.002\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003e\u0026nbsp;x\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.022\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0.010\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44.3086%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-procedural complications\u003c/strong\u003e, \u003cem\u003en (%) \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hematuria (grade 1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hematospermia (grade 1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Rectal bleeding (grade 1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Acute urinary retention (grade 2)\u003c/p\u003e\n \u003cp\u003eFever (grade 1\u0026amp;2; if antibiotics/antipyretics \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;required)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6804%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e64 (16.4 %)\u003c/p\u003e\n \u003cp\u003e14 (3.6 %)\u003c/p\u003e\n \u003cp\u003e11 (2.8 %)\u003c/p\u003e\n \u003cp\u003e3 (0.8 %)\u003c/p\u003e\n \u003cp\u003e8 (2.1 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.9371%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e56 (20.1 %)\u003c/p\u003e\n \u003cp\u003e10 (3.6 %)\u003c/p\u003e\n \u003cp\u003e13 (4.7 %)\u003c/p\u003e\n \u003cp\u003e1 (0.4 %)\u003c/p\u003e\n \u003cp\u003e3 (1.1 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.236%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (19.6 %)\u003c/p\u003e\n \u003cp\u003e4 (3.6 %)\u003c/p\u003e\n \u003cp\u003e3 (2.7 %)\u003c/p\u003e\n \u003cp\u003e1 (0.9 %)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.7146%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.426 \u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e1.000 \u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.389 \u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.862 \u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e0.207 \u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNA:\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ex\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Chi square test was used\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003ea,b\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Paired group comparisons are shown in lowercase letters. The same letters indicate statistical similarity; different letters indicate statistical difference.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePCa was found in 59.3% of the patients in group 1, 24% in group 2, and 24.8% in group 3, while prostatitis was found in 13.8%, 18.7%, and 24.4% of the patients, respectively.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThere is a scarcity of studies that examine the complications related to the Mp-MRI / TRUS fusion prostate biopsy approach or compare them to prior procedures. A study comparing conventional 14-core TRUS biopsy with Mp-MRI / TRUS fusion transrectal prostate biopsy found that the rate of complications was 1.9% in the TRUS biopsy group and 1.75% in the fusion biopsy group. All of these complications were minor, and there was no significant difference in the occurrence of complications between the two methods [9].\u003c/p\u003e\n\u003cp\u003eA recent study involving 458 patients examined the complications of Mp-MRI / TRUS fusion biopsy and reported that 203 patients (44.3%) experienced adverse events after the procedure. Among these, 161 patients (35.2%) had Clavien-Dindo grade 1 complications, which included hematuria (124 cases, 27.1%), hematochezia (22 cases, 4.8%), hematospermia (14 cases, 3.1%), or a combination of these (20 cases, 4.4%). \u0026nbsp;Additionally, 45 patients (9.0%) had Clavien-Dindo grade 2 complications, such as acute urinary retention or hematuria requiring catheterization, as well as urinary tract infections (2 cases requiring hospitalization). In the study, it was also reported that no major complications were observed, and age \u0026gt; 70 years and body mass index (BMI) \u0026gt; 25 kg/m\u003csup\u003e2\u003c/sup\u003e were found to be predictors of post-operative complications [10].In our study, given that the patients\u0026apos; average age was below 70 years and there was no disparity in BMI across the groups, we think that these two factors are not effective in explaining the differences in complications between the groups.\u003c/p\u003e\n\u003cp\u003eIn a recent study comparing TRUS biopsy with Mp-MRI / TRUS fusion transrectal prostate biopsy, which is the most extensive study (10,325 patients underwent 12-core TRUS biopsy and 576 patients underwent Mp-MRI / TRUS fusion biopsy), comparing these two techniques in terms of complications and cancer detection, it was found that there was no difference in complications between these two techniques. However, it was observed that PV played a significant role in predicting overall complications, infectious complications, bleeding-related complications, and complications that scored \u0026ge;2 on the Clavien-Dindo scale [11]. Prostate volume is also important in repeat biopsy; it has been suggested that 20% of patients with a prostate volume of 50 cc and 35% of individuals with a prostate volume of \u0026gt;75 cc require a repeat biopsy [12]. Our study found that the patient group who had undergone two or more previous biopsies (group-2b) exhibited significantly greater age, total PSA, and PV levels. These patients had been suffering from benign prostatic hyperplasia for a much longer duration. The higher biopsy rate in this patient group may be associated with the augmented PV. Enhanced collateral abnormal vascularization and inflammation stemming from recurrent interventions on the prostate tissue may also play a role in urethrorrhagia and rectal bleeding complications. Because, group 2b exhibited the highest incidence of prostatitis, according to the pathology results.\u003c/p\u003e\n\u003cp\u003eMassive rectal bleeding after a biopsy is infrequent, but it can be life-threatening in extremely rare circumstances. The number of core samples obtained has a statistically significant positive correlation with rectal bleeding. Our study found that despite a smaller number of sample in group 2b, there was a higher incidence of rectal bleeding. This supports the result that past biopsies had a significant impact on bleeding. Effective interventions for rectal bleeding include tamponade (using digital pressure, packs, catheters, and tampons), endoscopic procedures (sclerotherapy, banding, and endoclipping), radiological embolization, and surgical procedures [13]. Rectal tamponade was performed quickly using sponges in our patients who experienced rectal bleeding during the procedure, and no severe bleeding was noted in any patient in the study post-procedural period.\u003c/p\u003e\n\u003cp\u003eThe number of biopsy cores taken was strongly related to the development of hematuria and hematospermia in the FUTURE trial, which was undertaken in patients with a prior negative biopsy and based on MRI-guided biopsies [14]. The PRECISION trial found that a four-core targeted biopsy had significantly fewer adverse effects than a 12-core TRUS-biopsy. This was most likely owing to a lower percentage of men undergoing biopsy in the TB group (biopsy was omitted in cases of negative mp-MRI) and fewer biopsy cores retrieved during biopsy (no systemic sampling was undertaken in the targeted biopsy group). Surprisingly, they reported comparable rates of serious complications in both groups [15]. While the number of cores taken in group 2b was lower in our study, the fact that there were more bleeding-related complications supports our main finding, which is that previous biopsies increase bleeding-related complications. Otherwise, more bleeding would be expected in group 1, which had a higher number of samples.\u003c/p\u003e\n\u003cp\u003eThe European Medicines Agency issued a warning on March 11th, 2019, stating that quinolones and fluoroquinolones should not be used for the prophylaxis of TUR and prostate biopsy. This warning was based on a review of resistance rates and the occurrence of serious, disabling, and potentially permanent adverse events, especially affecting the musculoskeletal and nervous systems [16]. Starting from this date, our clinic ceased the use of quinolone prophylaxis and instead implemented fosfomycin prophylaxis for prostate biopsies (for both conventional TRUS biopsy, Mp-MRI / TRUS fusion prostate biopsy, and cognitive fusion biopsy). No instances of a major enfective complication were observed since this date. In a retrospective multicenter cohort of 550 patients from three different centers undergoing transperineal prostate biopsy, it was reported that no patient had urosepsis, even though antibiotic prophylaxis was not used [17]. Nevertheless, there is currently no guideline that supports the notion that the utilization of antibiotics in transperineal prostate biopsy is unnecessary.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe first and most important limitation was that it was retrospective in nature. However, the prospective data collection especially prospective evaluation of complications undermines this limitation and enhances the worth of the study. Furthermore, our study did not include any findings pertaining to cancer patients who are on active surveillance. The presence of a tumoral lesion in the prostate gland could potentially lead to complications. To ensure the consistency of the study population, we excluded patients undergoing active surveillance from our study. An exclusive analysis focusing just on patients under active survaillance will address the gaps in this subject.\u003c/p\u003e\n\u003cp\u003eOne of the strengths of the study is that patient-related factors (comorbidities, MetS, use of anticoagulants, history of Urinary tract infection, and antibiotic use) that will affect post-procedure complications are similar between the groups. Furthermore, existing literature includes several studies that analyze the complications of Mp-MRI / TRUS prostate fusion biopsy; however, none of these studies have specifically examined the impact of prior biopsies on the complications of the planned Mp-MRI / TRUS fusion biopsy. Within this particular framework, the outcomes of the study being presented will make a valuable contribution to both clinical practice and the existing body of literature.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn patients with a history of two or more previous prostate biopsies, the Mp-MRI / TRUS fusion transrectal prostate biopsy may be associated with complications related to bleeding. When considering the Mp-MRI / TRUS fusion prostate biopsy for patients with a history of two or more previous biopsies, it is important to consider the risk of bleeding and take proper precautions such as insertion of the urethral catheter, urethral catheter traction, elastic penile bandage, and rectal tamponade during the biopsy procedure and in the early post-procedure period. Alternatively, a transperineal biopsy may be considered for this specific group of patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eNo conflict declared\u003cstrong\u003e\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u0026nbsp;\u003c/strong\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e: not applicable\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval for the study:\u0026nbsp;\u003c/strong\u003eThe study was approvad by the\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eHaseki Training and Research Hospital ethics committee dated March 29, 2023 and numbered 69-2023.\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eApproval of the research protocol by an Institutional Reviewer Board:\u0026nbsp;\u003c/strong\u003eThe\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003estudy was approved by the Institutional Review Board of the University of Health Sciences Haseki Training and Research Hospital on February 10, 2023 (protocol number: 64).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent for procudure: \u003cstrong\u003ePrior to the procedure, the patients were provided with a comprehensive explanation of all the specifics about the biopsy method.\u0026nbsp;\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable (Our study is a retrospective study)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthorship contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCaglar Dizdaroglu:\u003c/strong\u003e Conception and design, Acquisition of data, Analysis and interpretation of data, Drafting of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAkif Erbin:\u0026nbsp;\u003c/strong\u003eConception and design, Analysis and interpretation of data, Drafting of the manuscript, Critical revision of the manuscript for important intellectual content, Statistical analysis, Supervision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFeyzi Sinan Erdal:\u003c/strong\u003e Conception and design, Analysis and interpretation of data, Drafting of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUfuk Caglar:\u0026nbsp;\u003c/strong\u003eConception and design, Drafting of the manuscript, Statistical analysis, Supervision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbdullah Esmeray:\u0026nbsp;\u003c/strong\u003eConception and design, Acquisition of data, Critical revision of the manuscript for important intellectual content\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNazim Furkan Gunay:\u003c/strong\u003e Acquisition of data, Critical revision of the manuscript for important intellectual content, Statistical analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMucahit Gelmis:\u0026nbsp;\u003c/strong\u003eAcquisition of data, Drafting of the manuscript, Critical revision of the manuscript for important intellectual content\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eArda Meric:\u0026nbsp;\u003c/strong\u003eConception and design, Acquisition of data, Drafting of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOmer Sarilar:\u0026nbsp;\u003c/strong\u003eAnalysis and interpretation of data, Critical revision of the manuscript for important intellectual content, Supervision\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRawla, Prashanth. \u0026quot;Epidemiology of prostate cancer.\u0026quot; World journal of oncology 10.2 (2019): 63 -89. \u003c/li\u003e\n\u003cli\u003eVito Lorusso, Boukary Kabre, Geraldine Pignot, et al. External validation of the computerized analysis of TRUS of the prostate with the ANNA/C-TRUS system: a potential role of artificial intelligence for improving prostate cancer detection. World J Urol. 2023;41:619-625. \u003c/li\u003e\n\u003cli\u003eJohn T Wei, Daniel Barocas, Sigrid Carlsson, Fergus Coakley, Scott Eggener, Ruth Etzioni\u003csup\u003e \u003c/sup\u003e. Early Detection of Prostate Cancer: AUA/SUO Guideline Part II: Considerations for a Prostate Biopsy. J Urol. 2023;210:54-63.\u003c/li\u003e\n\u003cli\u003eKayvon Kiani\u003csup\u003e \u003c/sup\u003e, Simon P Kim\u003csup\u003e \u003c/sup\u003e, Rodrigo Rodrigues Pessoa\u003csup\u003e,\u003c/sup\u003e et al. Association of Frailty and Complications Following Prostate Biopsy: Results From a Population-Based, Privately Insured Cohort. Urol Pract. 2024;11:117-122.\u003c/li\u003e\n\u003cli\u003eHo K, Zhu D, Gupta K, et al. Performance of cognitive vs. image-guided fusion biopsy for detection of overall and clinically significant prostate cancer in a multiethnic population. Urol Oncol. 2023 Dec 18:S1078-1439(23)00358-7. Online ahead of print.\u003c/li\u003e\n\u003cli\u003eDaniel A Adamo, Bernadette Marie Greenwood, Pejman Ghanouni, Sandeep Arora. MR Imaging-Guided Prostate Cancer Therapies. Radiol Clin North Am. 2024;62:121-133.\u003c/li\u003e\n\u003cli\u003eHector Ayerra Perez, Javier Ferm\u0026iacute;n Barba Abad, Javier Extramiana Cameno. An Update on Focal Therapy for Prostate Cancer. Clin Genitourin Cancer. 2023;21:712.e1-712.e8.\u003c/li\u003e\n\u003cli\u003eYoon PD, Chalasani V, Woo HH. Use of Clavien-Dindo classification in reporting and grading complications after urological surgical procedures: analysis of 2010 to 2012. \u003cem\u003eJ Urol\u003c/em\u003e. 2013;190:1271\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eQueiroz MRG, Falsarella PM, Mariotti GC, et al. \u003cbr\u003e Comparison of complications rates between multiparametric magnetic resonance imaging-transrectal ultrasound (TRUS) fusion and systematic TRUS prostatic biopsies. Abdom Radiol (NY). 2019;44:732-738.\u003c/li\u003e\n\u003cli\u003eAndrea Alberti, Rossella Nicoletti, Paolo Polverino, et al. Morbidity of Transrectal MRI-Fusion Targeted Prostate Biopsy at a Tertiary Referral Academic Centre: An Audit to Guide the Transition to the Transperineal Approach. Cancers (Basel). 2023:11;15:5798.\u003c/li\u003e\n\u003cli\u003eByeongdo Song\u003csup\u003e \u003c/sup\u003e, Sung Il Hwang, et al. Comparison of systematic randomized 12-core transrectal ultrasonography-guided prostate biopsy with magnetic resonance imaging-transrectal ultrasonography fusion-targeted prostate biopsy. Medicine (Baltimore). 2022;101(40):e30821.\u003c/li\u003e\n\u003cli\u003eDjavan B, Remzi M, Schulman CC, Marberger M, Zlotta AR. Repeat prostate biopsy: who, how and when?. a review. Eur Urol. 2002;42:93-103.\u003c/li\u003e\n\u003cli\u003eMark R. Quinlan, MD,\u003csup\u003e \u003c/sup\u003e Damien Bolton, MD,\u003csup\u003e \u003c/sup\u003eand Rowan G. Casey. The management of rectal bleeding following transrectal prostate biopsy: A review of the current literature. Can Urol Assoc J. 2018;12: E146\u0026ndash;E153. \u003c/li\u003e\n\u003cli\u003eOlivier Wegelin, Leonie Exterkate, Marloes van der Leest, Johannes C Kelder, J L H Ruud Bosch, Jelle O Barentsz et al. Complications and Adverse Events of Three Magnetic Resonance Imaging\u0026ndash;based Target Biopsy Techniques in the Diagnosis of Prostate Cancer Among Men with Prior Negative Biopsies: Results from the FUTURE Trial, a Multicentre Randomised Controlled Trial. Eur Urol Oncol. 2019;2:617-624.\u003c/li\u003e\n\u003cli\u003eKasivisvanathan V, Rannikko AS, Borghi M, et al. MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med 2018;378:1767\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eEuropean Medicines Agency. Summary of the EMA public hearing on quinolone and fluoroquinolone antibiotics: Public hearing held on 13 June 2018 [Internet]. Available from: https://www.ema.europa.eu/documents/report/summary-emapublic-hearing-quinolone-fluoroquinolone-antibiotics\u003c/li\u003e\n\u003cli\u003eKohl T, Sigle A, Kuru T, et al. Comprehensive analysis of complications after transperineal prostate biopsy without antibiotic prophylaxis: results of a multicenter trial with 30 days\u0026apos; follow-up. Prostate Cancer Prostatic Dis. 2022;25:264\u0026ndash;268.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Image-Guided Biopsy, Multiparametric Magnetic Resonance Imaging, Prostate","lastPublishedDoi":"10.21203/rs.3.rs-5940546/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5940546/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eInsufficient data exists about the examination of the impact of previous biopsies on complications in multiparametric magnetic resonance imaging (Mp-MRI) and transrectal ultrasonography (TRUS) fusion biopsies. We aimed to compare the complications of Mp-MRI / TRUS fusion transrectal prostate biopsy in patients who have not undergone a prostate biopsy before and in patients whose prior biopsy or biopsies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study consisted of a retrospective review of prospectively recorded data. The cohort of patients (n\u0026thinsp;=\u0026thinsp;780) was categorized into three groups: group 1 (biopsy naive patients, n\u0026thinsp;=\u0026thinsp;390), group-2a (consisting of patients who underwent a single biopsy, n\u0026thinsp;=\u0026thinsp;278), and group-2b (consisting of patients who underwent at least two biopsies, n\u0026thinsp;=\u0026thinsp;112). The demographic data of the patients, comorbidities, prostate-specific antigen results, Mp-MRI characteristics, biopsy data, and complications were compared between the groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere was no significant difference between the groups in terms of metabolic syndrome, anticoagulant use, urinary infection history in the last 3 months, and antibiotic use in the last 3 months. While there was no difference between the groups in terms of post-procedural complication rates, peri-procedural complications (urethrorrhagia and rectal bleeding) were significantly higher in group 2b than in the other two groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWhen considering the Mp-MRI / TRUS fusion prostate biopsy for patients with a history of two or more previous biopsies, it is important to consider the risk of bleeding and take proper precautions for this specific group of patients. Alternatively, a transperineal biopsy may be considered.\u003c/p\u003e","manuscriptTitle":"Effects of Prior Biopsies on Complications of Multiparametric Magnetic Resonance Imaging / Transrectal Ultrasonography Fusion Prostate Biopsy: An Analytic Cross- Sectional Analysis of Prospectively Recorded Data","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-19 16:08:53","doi":"10.21203/rs.3.rs-5940546/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-18T18:54:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-14T11:58:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-02-14T11:57:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2025-02-01T07:41:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc57c908-8e3e-466f-9578-d4949714989c","owner":[],"postedDate":"February 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-02-22T12:23:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-19 16:08:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5940546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5940546","identity":"rs-5940546","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}