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Technology Advances for Prostate Biopsy and Needle Therapies

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Technology Advances for Prostate Biopsy and Needle Therapies Technology Advances for Prostate Biopsy and Needle Therapies IN 2012 an estimated 241,740 new prostate cancers ers and chemopreventive agents, and correlate novel (PCas) will be diagnosed in the United States alone.1 A PCa imaging modalities with gold standard pathology large number of them represent indolent tumors un- results from biopsy specimens. likely to limit the life span of the patient due to com- Several novel biopsy devices are currently being peting comorbidities. A recent study has shown that it investigated or are under development. They apply is necessary to treat 48 men to prevent 1 death from to biopsy and also to needle ablative therapies, such PCa, suggesting that significant overtreatment ex- as brachytherapy and cryoablation. The most com- ists.2 Still, many PCas are aggressive, causing an es- mon needle paths are transrectal and transperineal. timated 28,170 mortalities this year.1 Therefore, a Approaches are gland distributed sextant schemata comprehensive approach is urgently needed to in- or targeted biopsies. The most common image guid- crease the diagnostic accuracy of PCa.3 ance modality remains TRUS but registration (im- Freehand transrectal ultrasound (TRUS) guided age fusion) to pre-acquired PCa images, such as prostate biopsy is the most frequently performed bi- multiparametric magnetic resonance imaging (MRI) opsy means for diagnosing PCa with more than 1.2 and even direct MRI guided systems, are emerging. million procedures performed annually in the United Biopsy guiding devices are based on 3-dimensional States. However, standard grayscale ultrasound pro- (3D) TRUS, probe position tracking and robotic tech- vides minimal PCa specific information, being unreli- nologies. Robots can handle the probe and/or a nee- able in differentiating normal prostate gland from can- dle guide. Few systems automate needle insertion. cer tissue. Accordingly, biopsies do not specifically Using 3D TRUS alone for guiding the biopsy is target cancer suspicious regions of the prostate (CSR). difficult because the unsegmented prostate is difficult Instead, cancer detection and characterization rely on to observe and 3D images are not in real time. At the nontargeted, systematic, sextant biopsy schemata. same time, automatic real-time prostate segmentation However, executing the schema with freehand TRUS from TRUS is an active area of research. Several probe is a challenging procedure that is beyond typical hand- tracking (continuously measuring) methods have been eye coordination and quality control is subjective. As developed for 3D as well as 2-dimensional (2D) ultra- such, samples are often clustered, miss regions and do sound. With special navigation software they show the not follow the biopsy schema.4,5 Over diagnosis of clin- location of the probe in the image space as it is used ically insignificant cancer and under diagnosis of po- freehand by the urologist, so that he or she can apply tentially lethal cancer exist in the population at risk.3 this feedback to guide the intervention. Several com- Novel genomic, proteomic and image biomarkers mercial systems are already available with probe are currently being investigated for the assessment of tracking accessories, such as the LOGIQ® E9 system. PCa aggressiveness. However, their gold standard val- A TRUS tracking system developed purposely for idation relies heavily on pathology results from pros- prostate biopsy is the Artemis (Eigen®). The Artemis tatectomy specimens, which provide single-step stage system tracks a 3D TRUS witha4dfencoded passive information in the progression of the disease. Instead, arm. An important advantage of this mechanical ap- biopsy specimens could provide information with time proach is that the arm can be locked in place to support for longitudinal progression studies but they are typi- the probe while performing the biopsy. cally unreliable due to localization errors. Another commercial system is TargetScan®. This In short, the common TRUS guided prostate biopsy motorizes the insertion motion of the TRUS probe for represents a critical barrier in the field. Clinically, it ultrasound scanning. Because TargetScan was de- creates diagnosis and localization uncertainty, which signed for prostate brachytherapy, it is readily appli- are directly related to the current overtreatment of cable to transperineal biopsy but difficult to use for PCa. Its low repeatability increases the complexity of common transrectal biopsy. active surveillance and focal therapies. In research it Perhaps one of the most active areas of new tech- makes it difficult to monitor the response of biomark- nology clinical trials in urology is MRI fused TRUS 0022-5347/12/1884-1074/0 http://dx.doi.org/10.1016/j.juro.2012.06.127 THE JOURNAL OF UROLOGY® Vol. 188, 1074-1075, October 2012 © 2012 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. 1074 www.jurology.com TECHNOLOGY ADVANCES FOR PROSTATE BIOPSY AND NEEDLE THERAPIES 1075 guided biopsy. Interventional TRUS and pre-acquired shown to reduce targeting errors.11 The key novelty is MRI volumes are registered to each other at the be- its ability to track prostate motion, which allows the ginning of the biopsy procedure.5,6 This enables CSR depth of needle insertion to be adjusted interactively identified in MRI to be targeted under TRUS guid- during insertion, further reducing targeting errors. ance. Studies suggest that biopsy targeting improves Several novel types of robots are currently under PCa detection. Current limiting factors remain the development for direct MRI guided biopsy. The MrBot challenging cross-modality image-to-image registra- robot (URobotics, Johns Hopkins Medicine, Baltimore, tion, deformable registration methods and the limited Maryland) is an MRI safe (ASTM F2503–08) system means of verifying the registration, especially after the that goes alongside the patient in the MRI scanner initial alignment. and orients a needle guide under direct MRI guid- Robotic systems have also been proposed for biopsy. ance.12 Compared to pre-acquired images, direct im- In addition to tracking, robots may perform automated age guidance eliminates image fusion errors, provides motion for scanning with 2D TRUS and automated interventional PCa imaging feedback and may de- needle targeting. A robot that manipulates the TRUS crease prostate motion and deformation errors.13 probe with the same 4 df available when used free- In conclusion, numerous technologies are under de- hand7 was developed and applied for intraoperative ultrasound based prostatectomy navigation.8 The velopment and being investigated clinically to address BioXbot robot (BioBot Surgical, Singapore) handles a the current limitations of prostate biopsy technology. 2D TRUS probe, similar to TargetScan, but includes a While they require further validation, clinical studies robotic transperineal needle guide that angles the suggest substantial improvements over the standard guide to target zones of the prostate that otherwise are of care. Under TRUS guidance, the prostate motion difficult to access.6,9 and deformations inherently induced by the TRUS An interesting and original way to measure the probe remain a major potential source of targeting location of TRUS for biopsy navigation is used by the errors that are typically unhandled. The research pre- KOELIS prostate biopsy system (La Tronche, France). sented by Long et al in this issue is the first to use Using a 3D probe and recording a full prostate scan, prostate tracking software during biopsy. Further di- the relative location of the TRUS probe is determined rections of research are related to MRI-TRUS image by co-registering the scanned prostate volumes. In fusion validation, prostate displacement and deforma- other words, rather than using a probe tracker, the tion tracking with compensation software and/or ro- system calculates the location of the probe from the botic hardware means of minimizing these deflections, images. The system applies to biopsy quality control transrectal biopsy TRUS guided robots, MRI safe ro- but it has been difficult to use to guide the biopsy. bots for direct targeted biopsy and focal therapy, and Nevertheless, in this issue of the Journal Long et al other techniques based on novel biomarker research. (page 1369) from the University of Grenoble, the tech- nology founder, report the development of the Prosper Dan Stoianovici robot for transperineal needle access.10 Similar to the Robotics Laboratory BioXbot, Prosper can change the direction of the nee- Urology Department dle to avoid pubic arch interference. In addition, this Johns Hopkins University performs automated needle insertion and spinning, Baltimore, Maryland REFERENCES 1. Siegel R, Naishadham D, Jemal A: Cancer sta- 6. Ukimura O, Hung AJ and Gill IS: Innovations in 10. Long JA, Hungr N, Baumann M et al: Develop- tistics, 2012. CA Cancer J Clin 2012; 62: 10. prostate biopsy strategies for active surveillance ment of a novel robot for transperineal needle and focal therapy. Curr Opin Urol 2011; 21: 115. based interventions: focal therapy, brachytherapy 2. Barry MJ: Screening for prostate cancer—the and prostate biopsies. J Urol 2012; 188: 1369. controversy that refuses to die. N Engl J Med 7. Stoianovici D, Kim C, Schäfer F et al: Endocavity 2009; 360: 1351. 11. Badaan S, Petrisor D, Kim C et al: Does needle ultrasound probe manipulators. IEEE/ASME Trans rotation improve lesion targeting? Int J Med Ro- 3. Kelloff GJ, Choyke P and Coffey DS: Challenges Mechatron 2012; 99: 1. bot 2011; 7: 138. in clinical prostate cancer: role of imaging. AJR Am J Roentgenol 2009; 192: 1455. 8. Han M, Kim C, Mozer P et al: Tandem-robot 12. Muntener M, Patriciu A, Petrisor D et al: Trans- assisted laparoscopic radical prostatectomy to perineal prostate intervention: robot for fully au- 4. Han M, Kim C, Chang D et al: Geometric evalu- improve the neurovascular bundle visualization: a tomated MR imaging—system description and ation of systematic transrectal ultrasound-guided feasibility study. Urology 2011; 77: 502. proof of principle in a canine model. Radiology prostate biopsy. Unpublished data. 2008; 247: 543. 5. Turkbey B, Xu S, Kruecker J et al: Documenting 9.
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  • Efficacy of Intrarectal Lidocaine Hydrochloride Gel for Pain Control in Patients Undergoing Transrectal Prostate Biopsy
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