Ep. 21 - Everything You Need to Know About Prostate Biopsies with Dr. James Wysock

00:43:05
https://www.youtube.com/watch?v=I0L5PHeAaZg

Resumo

TLDRIn this podcast episode, Dr. James Wysock, a urologic oncologist at NYU Langone, discusses the necessity and types of prostate biopsies, focusing on transrectal and transperineal techniques. He highlights the importance of obtaining tissue for prostate cancer diagnosis and explains how advancements in imaging, particularly MRI, enhance targeting of biopsies. Dr. Wysock details the procedures involved in each type of biopsy, the potential risks and complications, and the differences in patient management, especially regarding infection rates. He emphasizes the evolving landscape of prostate cancer detection and the individualized approach needed in deciding on biopsy techniques.

Conclusões

  • 🔍 Prostate biopsies are essential for diagnosing prostate cancer.
  • ✨ MRI enhances the accuracy of biopsy targeting.
  • 📋 Understanding the risks of various biopsy types is crucial.
  • 💉 Transrectal and transperineal biopsies have different complications.
  • 💡 Blood in urine is a common outcome of biopsies.
  • 🦠 Antibiotic use can lower the risk of infection after biopsy.
  • 📉 Saturation biopsies may be performed when cancer suspicion is high.
  • 🤝 Better imaging techniques are leading to changing practices in prostate cancer management.

Linha do tempo

  • 00:00:00 - 00:05:00

    The podcast hosts a discussion about prostate biopsies with Dr. James Wysock, a specialist in urologic oncology from NYU Langone. They emphasize the reluctance of men to undergo prostate biopsies, even with elevated PSA levels, while highlighting that biopsies remain the gold standard for diagnosing prostate cancer.

  • 00:05:00 - 00:10:00

    Dr. Wysock shares his background and journey from being a chemical engineer to a urologic oncologist specializing in prostate cancer treatment and imaging. His interest in advanced imaging techniques, particularly multi-parametric MRI, shapes his approach to prostate cancer.

  • 00:10:00 - 00:15:00

    The conversation shifts to the necessity of prostate biopsies and the challenges associated with diagnosing prostate cancer. The hosts emphasize the importance of tissue diagnosis and discuss the scenarios that necessitate a biopsy, including rising PSA levels and concerning imaging results.

  • 00:15:00 - 00:20:00

    The hosts describe the prostate biopsy process, including the traditional finger-guided method and the advent of ultrasound-guided biopsies. They discuss the significance of anesthesia and patient comfort during the procedure, while also touching on the psychological aspects men face during biopsies.

  • 00:20:00 - 00:25:00

    They explain potential complications following a biopsy, including urinary retention and infection risks. The need for post-biopsy monitoring and hydration is stressed, and they share anecdotes about the importance of clear communication with patients regarding what to expect post-procedure.

  • 00:25:00 - 00:30:00

    The conversation addresses the technical aspects of prostate biopsies, including the number of cores sampled. Dr. Wysock explains the rationale behind standard sampling sizes and saturation biopsies in different contexts, such as larger prostates or previous negative results.

  • 00:30:00 - 00:35:00

    The hosts introduce the concept of transperineal biopsies as a safer alternative to traditional transrectal biopsies, outlining the advantages of reduced infection risks. They discuss ongoing investigations into the effectiveness of both methodologies when it comes to targeting suspicious lesions.

  • 00:35:00 - 00:43:05

    Finally, the podcast wraps up with insights into MRI-guided biopsies, emphasizing the importance of utilizing MRI before procedures to improve diagnostic accuracy. Dr. Wysock encourages patients to seek further information regarding their prostate health and options for biopsy.

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Vídeo de perguntas e respostas

  • What is the purpose of a prostate biopsy?

    A prostate biopsy is necessary to determine if a patient has prostate cancer, as it provides a tissue diagnosis.

  • What types of prostate biopsies are there?

    The two main types discussed are transrectal and transperineal biopsies.

  • What are the risks of a prostate biopsy?

    Risks include bleeding, infection, and urinary retention.

  • How long should a patient wait after a biopsy to get a PSA test?

    It's recommended to wait six weeks after a biopsy for an accurate PSA test.

  • What is the role of MRI in prostate biopsies?

    MRI helps better target suspicious lesions for biopsy and improves diagnostic accuracy.

  • How many cores are usually taken during a biopsy?

    Typically, about 12 cores are taken, but this can vary based on prostate size and previous results.

  • What is a saturation biopsy?

    A saturation biopsy refers to taking a larger number of samples to ensure thorough sampling, especially when there's suspicion of missed cancer.

  • What are the advantages of a transperineal biopsy?

    Transperineal biopsies may lower the risk of infection and can provide better access to certain prostate regions.

  • How does anesthesia work in these procedures?

    Local anesthesia is often used for both transrectal and transperineal biopsies, making the procedure more tolerable for patients.

  • What improvements are being researched in biopsy techniques?

    Research includes refining techniques for better targeting of biopsies and decreasing antibiotic use to reduce resistance.

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Rolagem automática:
  • 00:00:00
    look i think most men are trying to
  • 00:00:02
    avoid a prostate biopsy despite their
  • 00:00:06
    psa being elevated
  • 00:00:08
    today we're going to interview a
  • 00:00:10
    colleague a friend from nyu langone
  • 00:00:13
    department of urology dr james wysock
  • 00:00:16
    who's a specialist in urologic oncology
  • 00:00:19
    and even more so in advance imaging
  • 00:00:22
    techniques and treatment tools for men
  • 00:00:24
    with prostate cancer
  • 00:00:28
    the reality is you don't want a prostate
  • 00:00:30
    biopsy
  • 00:00:31
    but sometimes you need one and is the
  • 00:00:33
    gold standard way of determining if you
  • 00:00:35
    have prostate cancer today we'll learn
  • 00:00:37
    and take a deep dive in
  • 00:00:40
    when do you need a biopsy and if you do
  • 00:00:42
    need one what's the best
  • 00:00:44
    type to get
  • 00:00:48
    interview with dr james weisoff
  • 00:00:50
    let's go
  • 00:00:52
    [Music]
  • 00:01:00
    welcome to the dr geo podcast i am your
  • 00:01:03
    host dr geo
  • 00:01:05
    where
  • 00:01:06
    it is my goal to help you with your
  • 00:01:08
    urological function
  • 00:01:10
    improve urological function and live
  • 00:01:12
    better with age
  • 00:01:14
    today we have special guest dr james
  • 00:01:17
    wysock urologic oncologist from new york
  • 00:01:20
    university langone medical center jim
  • 00:01:23
    welcome to the show
  • 00:01:25
    thanks for having me gio this is quite a
  • 00:01:27
    pleasure the pleasure is mine i i we've
  • 00:01:29
    been talking about you having you for i
  • 00:01:32
    think even before i had a podcast
  • 00:01:34
    actually and it's so amazing that here
  • 00:01:36
    you are here we are talking about
  • 00:01:38
    something that i think is really
  • 00:01:39
    important we get i get asked all the
  • 00:01:41
    time so we'll dive right in in a second
  • 00:01:43
    in terms of biopsies and
  • 00:01:45
    what are the different types of prostate
  • 00:01:47
    biopsies available which one is best so
  • 00:01:49
    forth
  • 00:01:50
    but jim let's start
  • 00:01:52
    with a little background tell us a
  • 00:01:54
    little bit about yourself and
  • 00:01:56
    why did you get into
  • 00:01:58
    i know you're a urologic oncologist but
  • 00:02:01
    i think
  • 00:02:02
    you're prostate i mean we work together
  • 00:02:04
    so you pretty much do mostly prostate
  • 00:02:07
    cancer from a urological standpoint so
  • 00:02:09
    take us back
  • 00:02:10
    who are you who is dr james weissach
  • 00:02:13
    sure so you know look i guess it kind of
  • 00:02:16
    is a long story i'll try to keep it
  • 00:02:18
    brief but the bottom line is i i'm
  • 00:02:20
    mostly from the midwest i moved around a
  • 00:02:22
    lot growing up and
  • 00:02:24
    ultimately was uh on an earlier career
  • 00:02:27
    path where i was a chemical engineer for
  • 00:02:29
    a few years i never envisioned myself
  • 00:02:31
    becoming a physician or a urologist or a
  • 00:02:33
    specifically a prostate cancer
  • 00:02:35
    specialist in any way
  • 00:02:36
    when i was younger but ultimately sort
  • 00:02:38
    of through an evolution of decisions and
  • 00:02:41
    and experiences found myself wanting to
  • 00:02:43
    go to medical school where so i went to
  • 00:02:45
    northwestern university in chicago where
  • 00:02:49
    equally sort of without um
  • 00:02:52
    predestination found myself interested
  • 00:02:55
    in urology and from there uh ended up
  • 00:02:59
    matching in the match process to new
  • 00:03:01
    york presbyterian while cornell's brady
  • 00:03:03
    department of urology where i had the
  • 00:03:06
    good fortune to get a very strong uh
  • 00:03:09
    urologic training and in that experience
  • 00:03:12
    uh you know i was really drawn initially
  • 00:03:14
    into what uh robotic surgery was being
  • 00:03:17
    performed at the time and robotic
  • 00:03:18
    surgery at that time was almost
  • 00:03:20
    exclusively
  • 00:03:22
    prostate cancer
  • 00:03:23
    prostate
  • 00:03:25
    and that was sort of the foundation and
  • 00:03:28
    i found that was always really
  • 00:03:29
    fascinating prostate cancer surgery is
  • 00:03:31
    still an evolving
  • 00:03:33
    technique and art form and is a really
  • 00:03:36
    challenging and interesting surgery and
  • 00:03:39
    and
  • 00:03:39
    certainly something that i'm always
  • 00:03:41
    interested in improving and learning
  • 00:03:43
    more about but through that process
  • 00:03:44
    there was an introduction in my training
  • 00:03:46
    of a novel imaging
  • 00:03:49
    called multi-parametric mri of the
  • 00:03:51
    prostate and i started to see these
  • 00:03:52
    images come through because some of my
  • 00:03:55
    my attendings when i was a resident were
  • 00:03:57
    utilizing these in a very early form and
  • 00:04:00
    i found from that
  • 00:04:01
    a really interesting new look at
  • 00:04:04
    prostates
  • 00:04:05
    something we hadn't had in the past and
  • 00:04:07
    right that really opened my eyes to hey
  • 00:04:10
    there's a lot
  • 00:04:11
    to this
  • 00:04:12
    of course imaging is so powerful it
  • 00:04:14
    gives you a new way to observe something
  • 00:04:16
    and open insights into into something
  • 00:04:20
    and i essentially sought out an
  • 00:04:23
    opportunity to do
  • 00:04:25
    a fellowship in that area which was at
  • 00:04:28
    nyu with dr samir tunisia who was one of
  • 00:04:31
    the leaders
  • 00:04:32
    and remains one of the thought leaders
  • 00:04:34
    and
  • 00:04:35
    you know prime drivers in this area i
  • 00:04:37
    had the great fortune to come down and
  • 00:04:39
    and do a project with him as part of my
  • 00:04:42
    fellowship under him
  • 00:04:44
    and my master's thesis
  • 00:04:46
    looking at
  • 00:04:47
    something we can touch upon today but
  • 00:04:49
    the utilization
  • 00:04:51
    of mri in guiding the detection of
  • 00:04:54
    prostate cancer and specifically what
  • 00:04:55
    i'm talking about is through a targeted
  • 00:04:57
    biopsy technique right and we call that
  • 00:05:00
    mri ultrasound fusion
  • 00:05:02
    so that's really the story of where i
  • 00:05:05
    started and sort of have grown from and
  • 00:05:08
    from that there are many different
  • 00:05:09
    pathways and many different additional
  • 00:05:10
    stories we could tell but ultimately
  • 00:05:12
    that was my my path to this prostate
  • 00:05:15
    cancer
  • 00:05:16
    arena in which i i live now
  • 00:05:19
    you know i i consider you one of the
  • 00:05:21
    experts nationwide and
  • 00:05:24
    maybe there's a little bias but i you
  • 00:05:27
    know i've seen your presentations at the
  • 00:05:29
    aua conferences the papers you've
  • 00:05:32
    written since you were a fellow at nyu
  • 00:05:34
    by the way i remember when you were a
  • 00:05:36
    fellow at nyu i remember our
  • 00:05:38
    conversations where we met and until
  • 00:05:40
    yeah i do this holistic urology and
  • 00:05:43
    actually i was impressed with your
  • 00:05:44
    interest in what i did because
  • 00:05:47
    throughout my career though i've worked
  • 00:05:48
    in medical institutions there's been
  • 00:05:52
    some interest
  • 00:05:53
    or not so much or in some with some
  • 00:05:55
    other people
  • 00:05:56
    you know a little bit more so you're
  • 00:05:58
    keenly interested in and
  • 00:06:00
    what i did and how i did what i do with
  • 00:06:03
    uh patients with prostate cancer i
  • 00:06:05
    remember those days and then you
  • 00:06:07
    left and came back and that was
  • 00:06:10
    a happy day for me i was happy that you
  • 00:06:12
    were back at nyu so you're one of the
  • 00:06:14
    thought leaders in terms of uh in my
  • 00:06:16
    mind anyway this this better way of
  • 00:06:19
    finding
  • 00:06:20
    cancer in the prostate that we should
  • 00:06:22
    pay attention to i think that from a
  • 00:06:25
    patient's standpoint you and i have
  • 00:06:26
    talked about this right no one wakes up
  • 00:06:28
    in the morning saying man i can't wait
  • 00:06:31
    to get a prostate biopsy today this is
  • 00:06:34
    this will be great no one really wakes
  • 00:06:36
    up
  • 00:06:37
    feeling that way in fact the opposite is
  • 00:06:39
    true so it becomes a question of
  • 00:06:42
    when we need it
  • 00:06:43
    which is the best type to get
  • 00:06:46
    and um um what's the best approach to uh
  • 00:06:49
    so from that standpoint as like dr
  • 00:06:51
    wysock i mean and of course dr tenisha
  • 00:06:54
    and we just have a great group at nyu
  • 00:06:56
    you would think they're paying me for
  • 00:06:57
    this podcast right they're not
  • 00:06:59
    you think nyu our department is paying
  • 00:07:02
    me for this anyway let's dive right in
  • 00:07:05
    and the reason i'm starting with
  • 00:07:07
    this one fact which is
  • 00:07:10
    there's no way of diagnosing prostate
  • 00:07:12
    cancer without a prostate biopsy period
  • 00:07:15
    end of story
  • 00:07:17
    i want to make sure that that's true and
  • 00:07:19
    i know that is but the part of the
  • 00:07:21
    reason is because this
  • 00:07:23
    other people
  • 00:07:24
    some will call them even quacks that are
  • 00:07:27
    doing other things and diagnosing and
  • 00:07:29
    treating prostate cancer without a
  • 00:07:31
    prostate biopsy so can you go into that
  • 00:07:33
    a little bit
  • 00:07:35
    so i think that's a really great
  • 00:07:37
    question and it is a compelling question
  • 00:07:40
    because
  • 00:07:40
    when you say there's no other way to
  • 00:07:42
    diagnose prostate cancer
  • 00:07:44
    other than getting a prostate biopsy is
  • 00:07:47
    by and large true today but that may not
  • 00:07:49
    always remain true i mean hopefully we
  • 00:07:51
    would consider
  • 00:07:53
    diagnostic modalities in the future that
  • 00:07:55
    could evolve but
  • 00:07:57
    ultimately right now in the current
  • 00:07:59
    state of our medical technology and our
  • 00:08:01
    science
  • 00:08:02
    a tissue diagnosis is what's required
  • 00:08:05
    okay there are
  • 00:08:07
    ways that we can infer from other
  • 00:08:09
    information
  • 00:08:10
    and be fairly confident we're diagnosing
  • 00:08:13
    prostate cancer
  • 00:08:15
    and when i say fairly confident i mean
  • 00:08:17
    99.9 for example if you have a psa of a
  • 00:08:20
    thousand and we see
  • 00:08:22
    you know that your prostate is firm and
  • 00:08:24
    very hard on an examination and there's
  • 00:08:27
    multiple sites of what look like
  • 00:08:29
    metastatic disease on an image set you
  • 00:08:31
    could infer
  • 00:08:33
    fairly confidently that it is prostate
  • 00:08:35
    cancer but again it always rests upon a
  • 00:08:39
    tissue diagnosis and a tissue diagnosis
  • 00:08:41
    must be obtained
  • 00:08:42
    from the tissue and that typically comes
  • 00:08:45
    from a biopsy
  • 00:08:46
    of that tissue now that tissue doesn't
  • 00:08:49
    always mean the prostate if there is a
  • 00:08:51
    concerning site outside of the prostate
  • 00:08:53
    we could get that tissue and that's a
  • 00:08:55
    biopsy of say a lymph node or a bone
  • 00:08:58
    but
  • 00:08:59
    most men
  • 00:09:00
    and like you mentioned aren't really
  • 00:09:02
    looking to go to the urologist but most
  • 00:09:03
    men do see a doctor
  • 00:09:06
    and part of that visit may entail
  • 00:09:09
    getting a psa test and a psa test
  • 00:09:13
    is a subject for another discussion
  • 00:09:15
    right that's a different conversation
  • 00:09:16
    isn't it
  • 00:09:17
    it is a marker it is a trigger if you
  • 00:09:21
    will to investigate and sometimes that
  • 00:09:25
    investigation will raise enough flags
  • 00:09:27
    that i'd say you know what we need to do
  • 00:09:30
    a tissue evaluation because that's the
  • 00:09:32
    only way i'm going to be able to give
  • 00:09:33
    you either a yes or no on prostate
  • 00:09:36
    cancer and
  • 00:09:37
    beyond that
  • 00:09:38
    if it is prostate cancer what type of
  • 00:09:40
    prostate cancer are we dealing with
  • 00:09:42
    because there is an array of pathways an
  • 00:09:45
    array of options that we need to
  • 00:09:47
    consider and we'll go into that for sure
  • 00:09:50
    in order to be accurate though we need
  • 00:09:52
    to know that tissue
  • 00:09:54
    correct that's the only way at this
  • 00:09:56
    moment in time as you mentioned yeah for
  • 00:09:58
    sure
  • 00:09:59
    yeah you did say and i want to make sure
  • 00:10:01
    that our audience doesn't think that
  • 00:10:03
    they heard wrong
  • 00:10:05
    you could have a psa of a thousand
  • 00:10:07
    you could have a psa of 3 000. uh what's
  • 00:10:10
    the highest you've ever
  • 00:10:11
    the highest psa i've ever seen is 7 000
  • 00:10:15
    how about you jim
  • 00:10:17
    i think around five somewhere five
  • 00:10:19
    yeah yeah yeah yeah i saw one seven
  • 00:10:22
    thousand uh that and i think i only saw
  • 00:10:25
    that once and and i was like wow that's
  • 00:10:28
    i mean anything above you know i don't
  • 00:10:30
    know whatever number certainly in the
  • 00:10:31
    hundreds is high but seven thousand i
  • 00:10:33
    thought that was interesting
  • 00:10:37
    when
  • 00:10:38
    one goal so so they have a psa and
  • 00:10:41
    perhaps other biomarkers and mri that's
  • 00:10:45
    indicating you need a biopsy
  • 00:10:48
    you undergo the biopsy
  • 00:10:50
    tell us about that process
  • 00:10:53
    and tell us about the once they are done
  • 00:10:56
    there is a
  • 00:10:57
    a period there where they have to stay
  • 00:10:59
    in the office and make sure they urinate
  • 00:11:01
    well and so tell us why that's done and
  • 00:11:04
    and and what what are the what are the
  • 00:11:06
    possible adverse events that can occur
  • 00:11:09
    from a biopsy
  • 00:11:10
    so i guess it take to answer that
  • 00:11:13
    best we should sort of take a step back
  • 00:11:15
    and say okay well what does it mean to
  • 00:11:17
    get tissue from the prostate think about
  • 00:11:19
    where prostate is anatomically the
  • 00:11:21
    prostate's within the pelvis it's not
  • 00:11:23
    readily accessible there are many
  • 00:11:24
    different biopsies we can do for other
  • 00:11:26
    parts of the body we're very
  • 00:11:27
    straightforward for example skin biopsy
  • 00:11:29
    if you have a mole
  • 00:11:31
    you know it's not really a major
  • 00:11:32
    consideration you go to the
  • 00:11:33
    dermatologist but if
  • 00:11:35
    you are uh
  • 00:11:37
    concerned about prostate cancer and we
  • 00:11:39
    need to get tissue from your prostate
  • 00:11:40
    well how do we even begin to do that
  • 00:11:43
    well the first way to do that
  • 00:11:46
    40 years ago was we would you know place
  • 00:11:49
    a needle over our finger if you will in
  • 00:11:53
    with the finger in the rectum and sort
  • 00:11:54
    of guide it onto the prostate blindly
  • 00:11:57
    and take a sample now that's a finger
  • 00:11:59
    guided biopsy that's pretty crude uh but
  • 00:12:01
    that was all we had at that time
  • 00:12:03
    enter in ultrasound technology so ultra
  • 00:12:07
    which is now considered a blind biopsy
  • 00:12:09
    back then it was revolutionary we don't
  • 00:12:12
    we no longer using our fingers you're
  • 00:12:13
    using ultrasound wow now that's
  • 00:12:16
    considered a blind biopsy but this is an
  • 00:12:18
    incredible revolution because ultrasound
  • 00:12:21
    allowed us
  • 00:12:22
    in a fairly non-invasive and i we could
  • 00:12:24
    talk about this but it's a fairly
  • 00:12:26
    non-invasive way to see the prostate
  • 00:12:28
    finally right and this was an ultrasound
  • 00:12:31
    signal
  • 00:12:31
    sent through a probe place in the rectum
  • 00:12:34
    now most men would think that's majorly
  • 00:12:37
    invasive and i would agree with them
  • 00:12:39
    it's an uncomfortable portion of the
  • 00:12:40
    procedure but i like to consider this
  • 00:12:42
    similar to going to the dentist meaning
  • 00:12:45
    that it's going to be uncomfortable but
  • 00:12:47
    it really shouldn't be too painful you
  • 00:12:50
    get through the dentist work and it's
  • 00:12:51
    not fun but you know what at the end of
  • 00:12:53
    the day it wasn't the worst thing and
  • 00:12:55
    unfortunately the ultrasound probe is
  • 00:12:57
    required at this point we do have to and
  • 00:12:59
    that's because you do anesthetize the
  • 00:13:01
    prostate prior to the biopsy correct 100
  • 00:13:05
    so what we would do is with that
  • 00:13:06
    ultrasound probe place it into the
  • 00:13:08
    rectum so a man would come to our office
  • 00:13:09
    let's just kind of break it down in the
  • 00:13:11
    process of the biopsy so let's say okay
  • 00:13:13
    you need a prostate biopsy that's the
  • 00:13:15
    recommendation we won't even talk about
  • 00:13:17
    trans rectal or transparent at this
  • 00:13:19
    point what we're going to just talk
  • 00:13:20
    about is what it means to come to the
  • 00:13:22
    office for a prostate biopsy in our
  • 00:13:24
    office for example we'd say look if you
  • 00:13:26
    need to have a prostate biopsy what we
  • 00:13:27
    want you to do is come to the office
  • 00:13:30
    starting an antibiotic by mouth the day
  • 00:13:32
    before and we can get into this because
  • 00:13:34
    this is really pertinent to the type of
  • 00:13:36
    biopsies we would have you start a
  • 00:13:38
    prostate antibiotic the day before
  • 00:13:41
    and that would be a three-day course
  • 00:13:43
    we'd have you do an enema that you'd
  • 00:13:45
    administer at home the night before in
  • 00:13:47
    the morning of the biopsy and that's
  • 00:13:49
    probably new to most men as well
  • 00:13:52
    come to the office on the day of you're
  • 00:13:54
    fully awake you're totally
  • 00:13:55
    unanesthetized you don't take any
  • 00:13:56
    medication pain medication or anything
  • 00:13:58
    else otherwise and we'd have you lie
  • 00:13:59
    down on your side you lie down on your
  • 00:14:01
    left side in our office and first thing
  • 00:14:03
    that would happen is i would
  • 00:14:05
    give an injection in the backside of an
  • 00:14:07
    additional antibiotic an intramuscular
  • 00:14:09
    antibiotic and we can get into those
  • 00:14:11
    details in a moment because those are
  • 00:14:13
    very pertinent to the type of biopsy
  • 00:14:15
    that we do but the next step is to place
  • 00:14:17
    an ultrasound probe in the rectum now
  • 00:14:19
    this is important this is not
  • 00:14:20
    anesthetized this is just an ultrasound
  • 00:14:22
    probe that we slide into the rectum with
  • 00:14:24
    a lot of lubricating jelly it's
  • 00:14:26
    uncomfortable but most men
  • 00:14:28
    can tolerate that and actually after it
  • 00:14:31
    passes into the rectum it's actually
  • 00:14:33
    the worst part is just opening and
  • 00:14:34
    dilating the sphincter as the probe goes
  • 00:14:36
    in okay most men can tolerate that then
  • 00:14:39
    through that probe a nest and anesthesia
  • 00:14:42
    can be placed into and around the
  • 00:14:44
    prostate and that will in effect
  • 00:14:47
    numb up the prostate for the rest of the
  • 00:14:48
    procedure
  • 00:14:50
    so that's really what we would expect as
  • 00:14:52
    the starting point and then it can kind
  • 00:14:54
    of diverge from there
  • 00:14:56
    then it's psychological a little bit i
  • 00:14:58
    hear i i don't do biopsies and i've
  • 00:15:00
    never had one done but i've been with
  • 00:15:02
    you guys in the biopsy room a few times
  • 00:15:05
    and i hear that clicking noise drives
  • 00:15:08
    them
  • 00:15:08
    if if we can invent jim we could we
  • 00:15:11
    should start working on this
  • 00:15:12
    some mechanism
  • 00:15:14
    to not have that clicking noise which is
  • 00:15:16
    just drives these guys crazy
  • 00:15:20
    absolutely because look at the end of
  • 00:15:21
    the day we end up anesthetizing the
  • 00:15:23
    prostate and it's not going to be that
  • 00:15:24
    painful but there's one thing that is
  • 00:15:26
    associated with each of those biopsies
  • 00:15:28
    and that's the spring of the biopsy gun
  • 00:15:30
    and it makes a loud clacking sound i've
  • 00:15:32
    worn men every time and you're right if
  • 00:15:34
    we had a silent biopsy gun i think it
  • 00:15:36
    would be appreciated across the board
  • 00:15:42
    so talk you were talking a little bit
  • 00:15:44
    about
  • 00:15:46
    i don't think i knew this actually
  • 00:15:48
    intra prostatic antibiotic
  • 00:15:51
    no no intramuscular injection
  • 00:15:53
    intramuscular on the buttocks and that
  • 00:15:56
    helps give a broad coverage so what i've
  • 00:15:58
    been describing is primarily our
  • 00:16:00
    approach which is to use what's called a
  • 00:16:02
    trans rectal biopsy right and so with
  • 00:16:05
    that initial biopsy technology was
  • 00:16:07
    developed to use an ultrasound the idea
  • 00:16:09
    was look we can see the prostate with
  • 00:16:12
    the ultrasound now how do we sample it
  • 00:16:14
    one of the ways that was developed early
  • 00:16:15
    on was doing what's called a
  • 00:16:17
    trans-rectal guided biopsy so along the
  • 00:16:19
    ultrasound probe there's a needle guide
  • 00:16:21
    yeah so after we've anesthetized the
  • 00:16:23
    prostate we can put a needle in that
  • 00:16:25
    guide and then we can direct it into the
  • 00:16:28
    prostate tissue and that's where that
  • 00:16:30
    spring loaded sound so because we're now
  • 00:16:33
    passing a needle through the probe
  • 00:16:36
    across the rectum and into the prostate
  • 00:16:38
    tissue
  • 00:16:39
    the rectum is not a sterile environment
  • 00:16:42
    in fact it can't be sterilized it is
  • 00:16:45
    full of good bacteria that we need as
  • 00:16:48
    part of our own microbiome microbiome
  • 00:16:51
    it's incred incredibly important for us
  • 00:16:53
    and you can't eradicate it you can't
  • 00:16:56
    eradicate it but those bacteria do not
  • 00:17:00
    need to be in your bloodstream
  • 00:17:02
    they could make you severely ill they
  • 00:17:04
    could generate sepsis and so what we do
  • 00:17:07
    with the antibiotics because we are
  • 00:17:09
    going to be penetrating that barrier
  • 00:17:11
    between the rectum and the prostate and
  • 00:17:12
    therefore risking the introduction of
  • 00:17:14
    those bacteria into the bloodstream we
  • 00:17:16
    try to lower the bacteria count by
  • 00:17:20
    giving the short antibiotics and then
  • 00:17:22
    that intramuscular injection at the time
  • 00:17:24
    of the biopsy also serves to reduce the
  • 00:17:26
    risk
  • 00:17:27
    of
  • 00:17:28
    becoming septic after the biopsy so that
  • 00:17:31
    is trans-rectal biopsy uh biggest
  • 00:17:34
    problem
  • 00:17:36
    is that there is an infection risk
  • 00:17:38
    inherent to passing the needles across
  • 00:17:40
    the rectum and into the prostate and
  • 00:17:42
    that introduction of bacteria
  • 00:17:44
    varies in its risk in some environments
  • 00:17:47
    there are reports that it could be as
  • 00:17:48
    high as five seven percent i mean you
  • 00:17:51
    walk into the office and you have a five
  • 00:17:53
    to seven percent chance after that
  • 00:17:54
    biopsy that you will end up
  • 00:17:56
    septic
  • 00:17:58
    in the next four years so typically the
  • 00:18:00
    scenario is where at some point later
  • 00:18:02
    after the biopsy they start developing
  • 00:18:04
    fever
  • 00:18:06
    and
  • 00:18:07
    that's a that's a quick sign that they
  • 00:18:09
    just need to go to the emergency room
  • 00:18:12
    telltale fevers chills shaking chills
  • 00:18:16
    right go to the emergency room call your
  • 00:18:17
    doctor go to the emergency room right
  • 00:18:21
    i can't tell you i mean like
  • 00:18:24
    i see
  • 00:18:25
    almost
  • 00:18:27
    probably not all uh the men after biopsy
  • 00:18:30
    in our practice but i see quite a few i
  • 00:18:32
    don't remember the last time there was a
  • 00:18:34
    scenario like that in our institution is
  • 00:18:37
    that because
  • 00:18:39
    they do what they need to do uh they
  • 00:18:41
    take the antibiotics they do the animal
  • 00:18:42
    you know when you do the the proper
  • 00:18:45
    protocol that significantly reduces the
  • 00:18:47
    risk
  • 00:18:49
    correct so i believe that the
  • 00:18:51
    contribution of a low sepsis race with
  • 00:18:53
    the transrectal approach that we are
  • 00:18:56
    happy that we are seeing at nyu with our
  • 00:18:58
    practice of primarily doing trans-rectal
  • 00:19:00
    biopsies is coming through proper use of
  • 00:19:02
    antibiotics proper use of that expanded
  • 00:19:05
    antibiotic that injection in the muscle
  • 00:19:08
    probably contributes to significant
  • 00:19:10
    protection the enemas help considerably
  • 00:19:13
    one other very important
  • 00:19:15
    piece that i feel
  • 00:19:17
    is is critical is what we call a rectal
  • 00:19:20
    culture a rectal swab culture which is
  • 00:19:23
    essentially a tool that i utilize for
  • 00:19:25
    men when i they initially see me right
  • 00:19:28
    or my nurse practitioner
  • 00:19:30
    uh dana costanzo when she evaluates men
  • 00:19:33
    either she or i will obtain a rectal
  • 00:19:36
    culture at the time of that initial
  • 00:19:38
    evaluation and all that means is at the
  • 00:19:39
    time of your digital rectal exam we
  • 00:19:41
    actually just obtain a little bit of
  • 00:19:43
    this culture and what we're looking for
  • 00:19:45
    are antibiotic or
  • 00:19:47
    what we're looking for are bacterial
  • 00:19:49
    resistance patterns and if we see one
  • 00:19:51
    and flag one before the biopsy we can
  • 00:19:53
    adjust the antibiotic approach to lower
  • 00:19:55
    those sepsis rates so we're looking at
  • 00:19:57
    our sepsis rate in our practice much
  • 00:19:59
    lower than one percent which is great at
  • 00:20:01
    you know i was quoting earlier
  • 00:20:03
    much higher rates that are in the
  • 00:20:05
    literature right we don't see that but i
  • 00:20:07
    attribute a lot of that to the expanded
  • 00:20:09
    antibiotics and the use of the rectal
  • 00:20:11
    cultures fabulous
  • 00:20:14
    the
  • 00:20:16
    how many cores
  • 00:20:18
    and we could talk about uh
  • 00:20:20
    saturation and all these things the
  • 00:20:22
    standard is typically about 12. what
  • 00:20:25
    determines 12 cores versus 16 20 or even
  • 00:20:28
    more can you break that down for us
  • 00:20:31
    well that's a complicated question in
  • 00:20:33
    terms of the what determines it i think
  • 00:20:36
    there's no real clear
  • 00:20:39
    guidance as to what really should
  • 00:20:40
    determine it i mean if you have a 400 cc
  • 00:20:43
    prostate you probably need more than 12
  • 00:20:45
    to fully sample it in a systematic way
  • 00:20:47
    for context a 400 cc prostate it's a
  • 00:20:51
    is
  • 00:20:52
    an orange i don't know like the size of
  • 00:20:53
    a medium-sized orange this is a bit of
  • 00:20:56
    hyperbole i'd say the average prostate
  • 00:20:58
    is around 40 cc so i was just sort of
  • 00:21:01
    hyperbolizing there because i wanted to
  • 00:21:03
    explain that what we have used as a
  • 00:21:06
    standard of number of cores has been
  • 00:21:09
    driven largely by uh studies performed
  • 00:21:13
    on the blind biopsy
  • 00:21:15
    and we ultimately determined that
  • 00:21:17
    somewhere between 10 and 12 is
  • 00:21:20
    your optimal
  • 00:21:22
    diagnostic yield and that ultimately if
  • 00:21:25
    you go beyond that with a blind biopsy
  • 00:21:27
    say to
  • 00:21:28
    16 18 24 you don't detect significantly
  • 00:21:32
    more cancer and you just increase the
  • 00:21:34
    rate of
  • 00:21:35
    complications associated with the biopsy
  • 00:21:38
    without improving the diagnostic yield
  • 00:21:40
    right so ultimately settling it in that
  • 00:21:43
    is probably the best way to sample
  • 00:21:45
    around the gland and try to get enough
  • 00:21:48
    tissue with enough confidence that if
  • 00:21:50
    you found something you've got it and if
  • 00:21:52
    you didn't find anything there's nothing
  • 00:21:54
    there right that's the idea meaning that
  • 00:21:56
    ultimately we use that as our driving
  • 00:21:58
    force but it has a lot of flaws
  • 00:22:01
    you refer to blind biopsy and i want to
  • 00:22:03
    make sure the listener knows that you're
  • 00:22:04
    referring to just an ultrasound guided
  • 00:22:06
    biopsy
  • 00:22:08
    as compared to a mri targeted biopsy
  • 00:22:11
    just to be clear to our audience
  • 00:22:14
    yeah correct so blind biopsy i should
  • 00:22:16
    probably call systematic sampling right
  • 00:22:20
    saturation biopsies how many cores
  • 00:22:22
    typically and why is that the same
  • 00:22:24
    scenario very big prostate so we have to
  • 00:22:27
    you know
  • 00:22:28
    pick more course
  • 00:22:30
    well saturation tip
  • 00:22:32
    it really comes from the concept of we
  • 00:22:35
    are concerned enough that there's cancer
  • 00:22:38
    whether it's based on psa or even on mri
  • 00:22:42
    or prior biopsy with just 12 chorus is
  • 00:22:44
    negative but psa keeps rising absolutely
  • 00:22:47
    so suspicion continues to rise so we
  • 00:22:49
    might entertain the concept of a
  • 00:22:50
    saturation biopsy now saturation biopsy
  • 00:22:53
    in essence means we're going to sample
  • 00:22:54
    almost everything that we can and then
  • 00:22:57
    it becomes dependent upon the size of
  • 00:22:58
    the prostate i've done as many as 60 to
  • 00:23:01
    70 biopsies in a large gland with a
  • 00:23:03
    saturation biopsy or it could be around
  • 00:23:06
    30. it also depends on you know what
  • 00:23:08
    your what and how you saturate but
  • 00:23:10
    ultimately a saturation biopsy has very
  • 00:23:12
    few situations where it's where it's
  • 00:23:14
    beneficial great thank you thank you for
  • 00:23:16
    clarifying that so bigger prostate
  • 00:23:19
    probably with a situation with a
  • 00:23:22
    a prior biopsy that shows negative but
  • 00:23:24
    the psa velocity is so significant that
  • 00:23:26
    you're thinking i'm missing something so
  • 00:23:28
    then that that may require 30 to 60
  • 00:23:31
    cores
  • 00:23:32
    correct so for example if you have uh
  • 00:23:35
    you know a psa that continues to rise
  • 00:23:37
    your biopsies have been done in the
  • 00:23:39
    systematic standard way and you do not
  • 00:23:41
    have a yield of any cancer but you're
  • 00:23:43
    concerned enough you could say look
  • 00:23:44
    we're going to go ahead and expand our
  • 00:23:46
    sampling rate because we think we may be
  • 00:23:48
    missing something so saturation gets
  • 00:23:50
    entertained in that setting now
  • 00:23:53
    saturation should be said is not done
  • 00:23:55
    uh often awake and under local
  • 00:23:57
    anesthesia if we're starting to take
  • 00:23:58
    that many cores it would be done in an
  • 00:24:01
    environment where we'd have an
  • 00:24:02
    anesthesiologist and the patient would
  • 00:24:04
    be under some form of anesthesia ah
  • 00:24:06
    that's a good point that's a good point
  • 00:24:10
    okay so they get the biopsy they have to
  • 00:24:13
    hang around for like 30 minutes until
  • 00:24:15
    they have their first urination
  • 00:24:18
    what is that about and what are the
  • 00:24:20
    complications that you're trying to uh
  • 00:24:22
    pinpoint before they go home
  • 00:24:25
    so again it all relates to where the
  • 00:24:27
    prostate is and what the prostate's
  • 00:24:29
    function is you know prostate is a
  • 00:24:31
    sexual function gland it's within the
  • 00:24:33
    urinary tract the urinary tract passes
  • 00:24:36
    through
  • 00:24:37
    the prostate so if we take some needle
  • 00:24:40
    biopsies of the prostate tissue there's
  • 00:24:42
    going to be some
  • 00:24:43
    pretty readily obvious complications or
  • 00:24:46
    side effects if you will right away one
  • 00:24:48
    of those is blood in the urine okay so a
  • 00:24:50
    man can expect to see blood in the urine
  • 00:24:52
    after a biopsy that ranges in how long
  • 00:24:54
    it lasts sometimes it's only a few days
  • 00:24:56
    but sometimes it can persist for a few
  • 00:24:58
    and in the semen and in the semen
  • 00:24:59
    importantly in the semen the semen
  • 00:25:01
    actually can last quite a long time
  • 00:25:03
    because it depends upon unlike the urine
  • 00:25:05
    where you're going to be emptying the
  • 00:25:06
    urinary tract frequently and daily the
  • 00:25:09
    the seminal vesicles and the semen
  • 00:25:11
    system in the prostate may not be
  • 00:25:13
    emptied as frequently and so that
  • 00:25:16
    actually blood may linger for quite a
  • 00:25:18
    while so i encourage them to be aware of
  • 00:25:20
    these uh they're going to see these
  • 00:25:23
    initial
  • 00:25:25
    signs and their first urination after
  • 00:25:27
    the biopsy and just be ready for it so
  • 00:25:29
    hydrate well afterwards and be expecting
  • 00:25:31
    to see this blood
  • 00:25:32
    the what we're worried about
  • 00:25:34
    specifically in terms of the urination
  • 00:25:36
    however is if you can imagine if you put
  • 00:25:38
    a needle in the prostate and it's in the
  • 00:25:39
    urinary tract it will cause the prostate
  • 00:25:42
    to swell up a little bit if the urine if
  • 00:25:44
    the prostate swells up a little bit you
  • 00:25:46
    can imagine your urinary strength and
  • 00:25:48
    stream may slow down a little bit and if
  • 00:25:50
    your urinary stream slows down enough
  • 00:25:53
    you may not be able to urinate and what
  • 00:25:55
    we're really looking for here is what we
  • 00:25:57
    call urinary retention which means the
  • 00:25:59
    man can't pee right and in those
  • 00:26:01
    settings we have to help uh we'd have to
  • 00:26:03
    put a catheter in in some settings and
  • 00:26:05
    make sure the urine can leave the
  • 00:26:06
    bladder because it becomes incredibly
  • 00:26:07
    painful if the bladder can't handle and
  • 00:26:09
    is that due to
  • 00:26:10
    a blood clot it's mostly due to i think
  • 00:26:12
    prostate swelling you know these
  • 00:26:14
    biopsies can cause the prostate to swell
  • 00:26:17
    now sometimes yes blood if it injured is
  • 00:26:19
    introduced into the urinary tract could
  • 00:26:21
    actually also block the pathway but both
  • 00:26:23
    of those mechanisms contribute i'd say
  • 00:26:25
    that the majority of the time i was due
  • 00:26:27
    to swelling great so i've seen psas
  • 00:26:30
    after a biopsy within a month's time and
  • 00:26:32
    it's just freaking out the patient right
  • 00:26:34
    because of course that psa is going to
  • 00:26:35
    be really high
  • 00:26:37
    how far after a biopsy is it safe to get
  • 00:26:40
    a psa that will give you an accurate
  • 00:26:41
    reading that has nothing to do with um
  • 00:26:44
    from the result of the biopsy itself
  • 00:26:46
    yeah i mean you need to be careful
  • 00:26:47
    whenever whenever you take a psa that
  • 00:26:49
    you haven't had a contributing event to
  • 00:26:52
    causing that psa to be elevated for a
  • 00:26:54
    benign reason for that reason i tell men
  • 00:26:57
    abstaining from sexual activity for 72
  • 00:26:59
    hours before you obtain your psa i think
  • 00:27:00
    that's important because even sexual
  • 00:27:02
    activity will cause the piece to go up
  • 00:27:04
    so you can imagine if sexual activity
  • 00:27:06
    causes the psa to rise if you put 16
  • 00:27:09
    needles in your prostate and you go get
  • 00:27:10
    your your psa tested it will be up
  • 00:27:12
    considerably i actually have a an
  • 00:27:14
    interesting anecdote on that i had a
  • 00:27:16
    patient who we did a
  • 00:27:17
    you know a 20 core biopsy on under
  • 00:27:19
    anesthesia and in the recovery room they
  • 00:27:21
    drew his psa his psa is usually you know
  • 00:27:24
    you know four it was 100 and so you know
  • 00:27:27
    if you look at that on a piece of paper
  • 00:27:29
    you say oh my goodness you know the
  • 00:27:30
    prostate cancer is metastasized
  • 00:27:33
    accelerating
  • 00:27:34
    yeah it's all just uh related to the
  • 00:27:37
    sampling time uh so psa then should
  • 00:27:40
    probably not be drawn anywhere near an
  • 00:27:42
    inflammatory process or any sort of
  • 00:27:44
    biopsy of the prostate or sexual
  • 00:27:47
    activity uh you know six weeks after a
  • 00:27:49
    biopsy would be my first time pointing
  • 00:27:51
    at testing and that may still be high
  • 00:27:53
    you think it could be
  • 00:27:54
    look you just have
  • 00:27:56
    yeah falsely elevated and so you need to
  • 00:27:59
    take that into consideration when you
  • 00:28:00
    interpret it but at the same time
  • 00:28:03
    knowing exactly when is it you you're
  • 00:28:06
    out of the woods is hard to say but by
  • 00:28:08
    three months you should absolutely be
  • 00:28:10
    for most uh situations but there can be
  • 00:28:13
    lingering prostatitis and chronic
  • 00:28:15
    prostatitis conditions which cause the
  • 00:28:16
    psa to be elevated for a significantly
  • 00:28:19
    prolonged time period sure
  • 00:28:22
    all right so let's segue into something
  • 00:28:24
    that i think you're doing a really good
  • 00:28:27
    job on and i and
  • 00:28:29
    again one of the leaders in this area in
  • 00:28:31
    the country which is transparent
  • 00:28:33
    biopsies so up until now we we've been
  • 00:28:36
    talking about trans-rectal biopsies
  • 00:28:39
    but now you're doing something different
  • 00:28:41
    not you're doing
  • 00:28:43
    now it's been several years
  • 00:28:44
    but now you're doing transparent neal
  • 00:28:46
    biopsies where the biopsy needles are
  • 00:28:48
    going
  • 00:28:49
    in between the scrotum and the anus
  • 00:28:55
    why
  • 00:28:56
    are you kind of still investigating you
  • 00:28:59
    can you can let us know if it's still an
  • 00:29:00
    investigation or if it's still something
  • 00:29:02
    that's uh become will become more or
  • 00:29:04
    less standard what are the areas that
  • 00:29:07
    you are able to locate
  • 00:29:09
    when
  • 00:29:11
    that is very difficult from a
  • 00:29:12
    trans-rectal biopsy uh that you can get
  • 00:29:14
    through a transparent eel
  • 00:29:16
    and pros and cons versus
  • 00:29:19
    trans-rectal and transparent neo
  • 00:29:21
    actually i have more so many
  • 00:29:24
    all right we'll go one at a time why are
  • 00:29:26
    we doing this so first and foremost
  • 00:29:28
    transparenteel it is a different way of
  • 00:29:31
    getting the tissue right so we're back
  • 00:29:32
    to this concept we have an ultrasound
  • 00:29:34
    probe in the rectum how do we get to the
  • 00:29:36
    prostate well as i mentioned before the
  • 00:29:38
    closest way is to go to the prostate
  • 00:29:41
    through that trans-rectal approach but
  • 00:29:42
    that is risky there is that bacterial
  • 00:29:45
    and sepsis risk and that is a
  • 00:29:46
    devastating complication that's not like
  • 00:29:49
    a couple weeks of blood in the urine the
  • 00:29:50
    transparent approach is unique and is
  • 00:29:53
    desirable
  • 00:29:55
    more recently as those infection risks
  • 00:29:57
    and rates were starting to increase
  • 00:29:59
    because you're going to now pass the
  • 00:30:01
    needle
  • 00:30:02
    through
  • 00:30:03
    a pathway that goes directly to the
  • 00:30:04
    prostate but there's
  • 00:30:06
    no rectum involved
  • 00:30:08
    just some skin and then you can pass the
  • 00:30:10
    needle through the skin and into the the
  • 00:30:12
    prostate under ultrasound guidance again
  • 00:30:15
    the ultrasound in the rectum is the same
  • 00:30:17
    that doesn't change it still allows us
  • 00:30:19
    to visualize it but you can imagine now
  • 00:30:20
    we put a needle through the skin and
  • 00:30:22
    into the prostate now this
  • 00:30:23
    avoids that zero chance that's of an
  • 00:30:26
    infection nothing is zero uh i'm looking
  • 00:30:29
    for i'm always prodding for that zero
  • 00:30:32
    percent of anything in medicine it never
  • 00:30:34
    never seems to happen correct there's no
  • 00:30:36
    there's no uh zero percent scenario here
  • 00:30:40
    but it's
  • 00:30:41
    lower than transrectal okay so it's in
  • 00:30:44
    in when we were when i was quoting those
  • 00:30:46
    five to seven percent sepsis rates and
  • 00:30:49
    the transparent approach would be
  • 00:30:51
    orders of magnitude lower now in our
  • 00:30:54
    practice where our rates of sepsis are
  • 00:30:56
    less than one percent it's not an order
  • 00:30:58
    of magnitude less but it is still
  • 00:31:01
    safer simply because we're not crossing
  • 00:31:04
    the
  • 00:31:05
    rectal wall
  • 00:31:06
    now interestingly i described earlier
  • 00:31:08
    that antibiotic profile
  • 00:31:10
    meaning that we took three days of
  • 00:31:12
    antibiotics then we gave an
  • 00:31:13
    intramuscular injection
  • 00:31:15
    and then you uh keep your risk of sepsis
  • 00:31:18
    low when you're taking a transparent new
  • 00:31:20
    approach there are emerging data that
  • 00:31:23
    you may not even need any antibiotics
  • 00:31:26
    you just need to have your skin surface
  • 00:31:28
    cleaned very thoroughly right before the
  • 00:31:30
    biopsies with a skin prep an ordinary
  • 00:31:33
    skin correct which we use for any
  • 00:31:35
    vision etc so that actually is going to
  • 00:31:37
    lower your rate of uh
  • 00:31:39
    antibiotic exposure which is actually
  • 00:31:42
    something that we know we've presented
  • 00:31:44
    on some work i've done at nyu which is
  • 00:31:46
    to show that
  • 00:31:47
    as we
  • 00:31:48
    increase the use of techniques like
  • 00:31:50
    active surveillance for prostate cancer
  • 00:31:52
    or even prostate partial gland ablation
  • 00:31:54
    focal therapy techniques and men require
  • 00:31:56
    multiple biopsies over time they get
  • 00:31:59
    exposed to antibiotics over and over
  • 00:32:01
    again we see that antibiotic
  • 00:32:05
    uh resistance patterns do increase over
  • 00:32:07
    time and probably at a rate of about one
  • 00:32:09
    out of every six uh men becomes now rich
  • 00:32:13
    that's not insignificant one out of
  • 00:32:14
    every six yeah so you think about it we
  • 00:32:17
    will eventually run out of runway with
  • 00:32:19
    these antibiotics and so if you can
  • 00:32:21
    start limit exposure that's a very
  • 00:32:23
    advantageous strategy and so that's
  • 00:32:25
    where transparent neil in the modern use
  • 00:32:28
    has really been coming
  • 00:32:29
    from it is to avoid the antibiotics and
  • 00:32:32
    lower those infection risks and i think
  • 00:32:34
    that there is a significant rationale
  • 00:32:36
    for utilizing is there
  • 00:32:38
    an improved diagnostic value from a
  • 00:32:41
    transparent eel versus a transrectal
  • 00:32:43
    that i would tell you is to be
  • 00:32:45
    determined
  • 00:32:46
    that is to be determined i would say
  • 00:32:48
    that we are
  • 00:32:50
    currently seeing data sets out there
  • 00:32:53
    that would suggest
  • 00:32:54
    both sides of that story
  • 00:32:56
    i have uh presented data from our own
  • 00:32:59
    transparent new data sets and
  • 00:33:02
    specifically looking at whether or not
  • 00:33:04
    transparent targeting of a an mri
  • 00:33:07
    finding versus trans rectal targeting of
  • 00:33:09
    that same finding if there's any
  • 00:33:11
    diagnostic differences and i do not see
  • 00:33:13
    that in that particular set
  • 00:33:16
    there are some ongoing prospective
  • 00:33:18
    trials
  • 00:33:19
    and these are i think critically
  • 00:33:21
    important to answering that question
  • 00:33:23
    what's your opinion jim
  • 00:33:24
    we won't hold you to it what's your
  • 00:33:26
    opinion is it a better diagnostic tool
  • 00:33:29
    for
  • 00:33:30
    getting not only prostate cancer which
  • 00:33:32
    is i think we're on the same page we're
  • 00:33:34
    not interested in just finding prostate
  • 00:33:35
    cancer we're interested in finding
  • 00:33:37
    prostate cancer that we can treat and
  • 00:33:40
    save someone's life from dying from the
  • 00:33:42
    disease you know gleason sevens and
  • 00:33:43
    higher absolutely so that comes down to
  • 00:33:46
    which is the better diagnostic pathway
  • 00:33:48
    and i don't know that i'd say that i
  • 00:33:49
    would say that i can't give you a
  • 00:33:51
    blanket which one's better what i would
  • 00:33:52
    tell you is this it's an individual
  • 00:33:53
    scenario what i would also say is there
  • 00:33:56
    are certain spots of the prostate that
  • 00:33:58
    may be better sampled with a trans
  • 00:34:01
    perineal approach versus a transrectal
  • 00:34:03
    and vice versa so on an individual basis
  • 00:34:07
    if you had a risk
  • 00:34:09
    profile that said to me i need to do a
  • 00:34:11
    biopsy i could then also say do you know
  • 00:34:13
    what this may be the better approach to
  • 00:34:16
    diagnosing that spot
  • 00:34:18
    one of those spots oh this isn't
  • 00:34:20
    scientifically proven uh in our data
  • 00:34:23
    sets yet but it's just conceptually
  • 00:34:25
    sound in my mind is that if the
  • 00:34:27
    lesion or the part of the prostate is
  • 00:34:30
    very much at the distal what we call
  • 00:34:32
    apex give us some sort of an idea where
  • 00:34:34
    that process where the prostate we call
  • 00:34:36
    it the base where it connects to the
  • 00:34:37
    bladder and the apex where it connects
  • 00:34:40
    to the urethra so as the urine passes
  • 00:34:41
    through it goes from the base towards
  • 00:34:43
    the apex that apical region meaning
  • 00:34:45
    towards the urethra is a little bit more
  • 00:34:48
    challenging to sample with a trans
  • 00:34:50
    rectal approach and a transparent needle
  • 00:34:52
    approach will actually start there and i
  • 00:34:55
    think you will get a better sampling of
  • 00:34:57
    that particular region and there are a
  • 00:34:59
    few other anatomical considerations of
  • 00:35:01
    spots that may be more accurately
  • 00:35:04
    biopsied with the transparent eel for
  • 00:35:06
    example another one is right behind the
  • 00:35:09
    urethra so where that urine tube is
  • 00:35:11
    passing through if we take a transrectal
  • 00:35:14
    approach to do that tissue the needle
  • 00:35:16
    will go through that tissue but also
  • 00:35:18
    right through the urethra which will
  • 00:35:19
    induce a lot of bleeding or increased
  • 00:35:21
    bleeding and probably increased rates of
  • 00:35:23
    retention whereas if i take a
  • 00:35:25
    transparent approach i may be able to go
  • 00:35:27
    right through that behind it and not
  • 00:35:29
    create that level of trauma so there's a
  • 00:35:31
    few of these
  • 00:35:33
    anatomical considerations based upon the
  • 00:35:35
    lesion lesion location that i might
  • 00:35:38
    utilize to say hey you know what you
  • 00:35:39
    would be better served as your
  • 00:35:41
    diagnostic biopsy with transparent eel
  • 00:35:44
    now i use transparadilla in another way
  • 00:35:46
    as well which is a different discussion
  • 00:35:48
    and a different concept but it's to say
  • 00:35:51
    you have a diagnostic biopsy it doesn't
  • 00:35:53
    matter if it was obtained transparently
  • 00:35:54
    or transrectally that says yes you do
  • 00:35:56
    have significant prostate cancer that we
  • 00:35:59
    want to manage with some form of
  • 00:36:01
    treatment we think you shouldn't just
  • 00:36:03
    watch it
  • 00:36:04
    how would we approach it well if it's a
  • 00:36:08
    single site of cancer
  • 00:36:10
    and it does not appear that there's any
  • 00:36:12
    other parts of your prostate that have
  • 00:36:13
    cancer and that single site is visible
  • 00:36:16
    on mri i would then say to a man look
  • 00:36:18
    you are a possibly a candidate and this
  • 00:36:20
    is for intermediate risk disease only at
  • 00:36:23
    this time but you are a candidate for
  • 00:36:25
    what we call focal therapy or partial
  • 00:36:27
    gland prostate ablation
  • 00:36:30
    those men i offer a transparenteel
  • 00:36:33
    mapping biopsy and what that entails is
  • 00:36:36
    under anesthesia doing a transparent
  • 00:36:39
    neural sampling
  • 00:36:40
    almost a saturation sampling of the
  • 00:36:42
    tumor itself so that i better can
  • 00:36:44
    delineate
  • 00:36:46
    the boundaries of that tumor where it
  • 00:36:47
    stops and starts so that when i then
  • 00:36:49
    take them for a prostate
  • 00:36:51
    ablation or a focal focal therapy i can
  • 00:36:54
    more accurately treat them
  • 00:36:56
    the limitation stemming from that the
  • 00:36:58
    mri may tell me where the heart of the
  • 00:37:01
    tumor is but it doesn't necessarily tell
  • 00:37:02
    me with accuracy where the boundaries of
  • 00:37:04
    that tumor are so this biopsy gives me
  • 00:37:07
    that kind of information so that's
  • 00:37:09
    another use of transparent where i do
  • 00:37:10
    not think there's a good trans-rectal
  • 00:37:13
    version of that so it helps you from a
  • 00:37:14
    therapeutic perspective
  • 00:37:16
    which
  • 00:37:17
    the which type of focal ablation or
  • 00:37:20
    where to target the focal ablation
  • 00:37:23
    treatment primarily where to target and
  • 00:37:24
    focal ablation treatment very briefly
  • 00:37:27
    are includes it could be cryos right it
  • 00:37:30
    could be uh high food high intensity
  • 00:37:32
    focal ultrasound there's quite a few
  • 00:37:34
    yeah there's a number of energies
  • 00:37:35
    available but the the concept is that if
  • 00:37:37
    we can localize the disease
  • 00:37:40
    find exactly where it is and it's
  • 00:37:41
    limited to one space
  • 00:37:43
    we can then take an energy form to that
  • 00:37:45
    space and treat the tumor in that space
  • 00:37:48
    and spare to non-cancerous parts of the
  • 00:37:51
    prostate and this is a significant
  • 00:37:53
    advantage in terms of side effect
  • 00:37:55
    profile
  • 00:37:56
    and that's something that we're actively
  • 00:37:59
    investigating
  • 00:38:02
    fascinating um
  • 00:38:05
    for a transparent biopsy is local
  • 00:38:08
    anesthesia an option or is it always
  • 00:38:11
    general anesthesia
  • 00:38:13
    absolutely local anesthesia is an option
  • 00:38:15
    you do not have to have
  • 00:38:17
    an anesthesiologist there present to do
  • 00:38:20
    a
  • 00:38:21
    very
  • 00:38:23
    effective and easy transparent biopsy we
  • 00:38:26
    use local anesthesia in the skin again a
  • 00:38:28
    bit like going to the dentist
  • 00:38:29
    uncomfortable but shouldn't be painful i
  • 00:38:31
    can anesthetize the skin i can
  • 00:38:33
    anesthetize around the prostate again
  • 00:38:35
    similar to with the trans rectal
  • 00:38:37
    and then we could take the biopsies but
  • 00:38:39
    it's a slightly different approach you
  • 00:38:40
    know so you know a man would have to lie
  • 00:38:42
    on his back
  • 00:38:43
    and his legs would be in a set of
  • 00:38:45
    stirrups
  • 00:38:46
    and your stirrups would raise the legs
  • 00:38:48
    and so that region of your body uh
  • 00:38:50
    behind the scrotum between the anus and
  • 00:38:52
    the scrotum and getting to that area is
  • 00:38:54
    a slightly different uh
  • 00:38:58
    mechanical approach if you will so you
  • 00:39:00
    you lie in that position and then we
  • 00:39:02
    have to anesthetize the skin a little
  • 00:39:03
    bit differently and then pass the
  • 00:39:05
    needles in in that regard you still hear
  • 00:39:06
    the clicking sound that doesn't go away
  • 00:39:09
    you still have the blood in the urine
  • 00:39:10
    you still have the blood in the demon
  • 00:39:12
    and you still have to make sure you can
  • 00:39:13
    urinate afterwards so in essence the
  • 00:39:15
    real advantage to it is
  • 00:39:18
    recently we had a mutual patient jim who
  • 00:39:20
    had a transparent biopsy
  • 00:39:23
    he said
  • 00:39:24
    he didn't bleed
  • 00:39:26
    at all in his urine afterwards
  • 00:39:29
    is that a common scenario well that
  • 00:39:31
    scenario occurs even with trans-rectal
  • 00:39:33
    it all depends on how the needles create
  • 00:39:36
    the trauma around the prostate when they
  • 00:39:37
    pass in sometimes they put a little bit
  • 00:39:40
    more blood into the urinary pathway
  • 00:39:41
    versus others so i think that there is
  • 00:39:44
    not a great way to predict that uh
  • 00:39:47
    always but i would not attribute that
  • 00:39:49
    entirely to the transparent approach
  • 00:39:51
    before we wrap it up
  • 00:39:53
    what is the use of an mri as it relates
  • 00:39:56
    to a trans perennial so we know from a
  • 00:39:58
    trans-rectal perspective which is called
  • 00:40:01
    a targeted
  • 00:40:02
    biopsy which means that you can actually
  • 00:40:04
    target suspicious lesions a whole lot
  • 00:40:06
    better than without an ultrasound uh or
  • 00:40:09
    i'm sorry you can target suspicious
  • 00:40:11
    lesions a whole lot better than with an
  • 00:40:13
    ultrasound
  • 00:40:14
    what's the benefit if any
  • 00:40:17
    uh to use an mri
  • 00:40:19
    and is there such thing as a targeted
  • 00:40:22
    mri biopsy from a transparent
  • 00:40:24
    perspective so yes absolutely the short
  • 00:40:26
    answer is 100 percent you can do a
  • 00:40:29
    targeted biopsy trans rectally and you
  • 00:40:31
    can do a targeted biopsy transparently
  • 00:40:33
    there's a lot of great technologies out
  • 00:40:35
    there i've exploring and am exploring
  • 00:40:38
    continually different technologies to
  • 00:40:40
    try to improve the targeting both
  • 00:40:42
    transrectally and transparently but with
  • 00:40:44
    a major focus lately on trying to find
  • 00:40:47
    the really best way to continue doing
  • 00:40:49
    targeted biopsies but in a transparent
  • 00:40:51
    way so that technology is out there and
  • 00:40:53
    it absolutely can be done and i would
  • 00:40:56
    encourage men who have a prostate cancer
  • 00:40:58
    concern that they should have an mri in
  • 00:41:01
    my opinion before getting a biopsy so
  • 00:41:03
    that the biopsy can be directed you're
  • 00:41:06
    going to get a better understanding of
  • 00:41:08
    the disease volume the disease grade
  • 00:41:10
    when you have that information
  • 00:41:12
    beforehand and so that influences
  • 00:41:15
    transparenteel as well i don't think
  • 00:41:16
    that transparenteel
  • 00:41:18
    circumvents that that right
  • 00:41:22
    you know this has been great i
  • 00:41:24
    you know one of the things and from an
  • 00:41:26
    integrative
  • 00:41:28
    medicine perspective which is what i do
  • 00:41:30
    people think oh man you must be bored
  • 00:41:32
    because
  • 00:41:33
    this is all you do urology prostate kind
  • 00:41:35
    of like no i'm always
  • 00:41:36
    i'm not up to date even though i read
  • 00:41:38
    all this thing and i'm working with all
  • 00:41:40
    these great uh experts and and
  • 00:41:42
    practitioners i i hear again i i've
  • 00:41:45
    learned
  • 00:41:46
    from this podcast jim thanks so much
  • 00:41:48
    listen
  • 00:41:49
    thanks for wearing a chicago cubs hat
  • 00:41:52
    and not a meds hat or a boston red sox
  • 00:41:55
    fat i
  • 00:41:56
    i i appreciate that man uh because i
  • 00:41:59
    don't think we would be doing this
  • 00:42:00
    podcast with a with a boston hat and i
  • 00:42:03
    have i do have love for the cubs uh
  • 00:42:06
    hopefully they'll get it together and
  • 00:42:07
    start winning again
  • 00:42:08
    uh jim where can uh my audience find you
  • 00:42:12
    nyu langone dr finder physician finder
  • 00:42:15
    james weisock that's why sock that's my
  • 00:42:19
    my uh
  • 00:42:20
    my uh website there i don't have any
  • 00:42:23
    other personal uh social media presence
  • 00:42:26
    of any note there the twitter and my
  • 00:42:28
    handle is at wysock but quite honestly
  • 00:42:30
    that's not something i'm active on uh
  • 00:42:32
    for better or for worse so i would just
  • 00:42:34
    refer people to that
  • 00:42:36
    nyu website listen it's been real jim
  • 00:42:38
    thanks so much for uh doing this is on a
  • 00:42:40
    saturday morning when i know you have
  • 00:42:42
    all sorts of family responsibilities so
  • 00:42:44
    thank you i appreciate you and i'll see
  • 00:42:46
    you on monday geo my pleasure thanks for
  • 00:42:48
    having me and happy to discuss any time
  • 00:42:50
    all right brother thank you
  • 00:42:54
    [Music]
Etiquetas
  • Prostate Biopsy
  • Urologic Oncology
  • MRI
  • Transrectal Biopsy
  • Transperineal Biopsy
  • PSA Testing
  • Tissue Diagnosis
  • Prostate Cancer
  • Biopsy Risks
  • Medical Imaging