WEBVTT

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This podcast is created by Coelis.

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It takes time to change the practice.

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We are now living the evolution and it will probably take years to totally abandon transrectal.

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Prostate Talk.

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Welcome to Prostate Talk,

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where we delve into the lightest advancements and breakthroughs in the field of urology.

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I'm your host,

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Thomas.

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and I'm delighted to be here with you today.

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I couldn't resist bringing a touch of French flair to this first episode,

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and what better way to do it than with a guest who expertises as impressive as his ability to pronounce prostate with an impeccable French accent.

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In this episode,

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we are privileged to have Dr.

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Honracht,

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a renowned French expert in the field,

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joining us to shed light on the nuances of this evolving trend.

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Dr.

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Honracht will provide

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insight into the advantages,

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challenges,

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and implications of the Transparent Rinal approach,

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offering a comprehensive understanding of its impact on both patients and urologists alike.

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Without further ado,

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let's give a warm virtual welcome to Dr.

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Julien Rac.

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Get ready for a conversation that promises to be both educational and,

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dare I say,

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a tad more charming than your average podcast.

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Merci beaucoup for joining us and let's make this episode magnificent.

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Hi,

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Dr.

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Anurag.

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We are really pleased to welcome you for the first episode of this podcast.

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How are you?

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Hello,

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Thomas.

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Thank you very much for that kind introduction.

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I'm fine and I'm really happy to be here.

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Today,

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we'll talk about transperineal prostate biopsy.

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But before to start,

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could you please introduce yourself to our listeners?

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Yes,

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my name is Julien Ract.

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I live in Paris.

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I'm a urologist in Hôpital Cochin.

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I work there since four years now.

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Before that,

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I did my med school in Descartes Université,

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also in Paris,

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and I was a resident in Paris.

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Everything in Paris.

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So

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I started to work on the biopsy during my medical degree.

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I also work in a research unit in Hôpital Necker Enfants Malades.

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we study basic sciences in the field of prostatic disease in general.

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Thank you so much for this presentation.

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So just to be curious,

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why did you choose urology during your medical studies?

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It's a good question because actually,

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you know,

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at the beginning I wanted to do general surgery in order to be a liver transplantation surgeon.

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But doing my urology residency,

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it appears to me that the urology includes every aspect of the patient care from the diagnoses,

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to the follow-up.

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You know,

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prostate cancer is a good example,

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actually,

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because you take care of the screening,

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you know,

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the PSA,

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the population,

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the patient questions,

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the diagnosis,

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the biopsy.

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I mean,

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you do your own biopsy.

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It's a particularity in neurology.

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I think it's very important.

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Then you take care of the therapy,

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the treatment.

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It could be the prostatectomy,

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the surgery,

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and then you follow your patient.

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So liver transplantation is an amazing specialty.

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you do amazing surgery.

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I admire liver transplantation surgeon but

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I choose to do a specialty that I consider maybe more complex and more complete.

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So let's now talk about transperineal prostate biopsy.

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As you mentioned we know that many physicians are mainly performing transrectal so why are you performing transperineal approach?

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We started the transperineal in 2019.

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At the time,

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everybody was using the transrectal route and people were concerned about infectious complications.

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So for this infectious complications,

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several solutions were offered.

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We offered to do a rectal swab and antibioprophylaxis adapted to this rectal swab.

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They proposed to do povidone iodine and using the transrectal route and they also proposed to use the transperineal route in order to

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avoid the rectum and the rectal contamination of the urine.

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But transperineal was supposed to be painful because,

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you know,

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in the 50s,

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both routes were used,

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transperineal and transrectal.

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And for decades,

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everybody practiced either transperineal or transrectal.

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And

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In 2000,

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people were getting interested in the fusion.

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So the question was not the route.

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The question was the fusion.

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How do we target the lesion?

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So people forget about the route and they focused about the fusion.

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And everybody used transrectal because it was more simple,

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because it was not painful.

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So after that,

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in 2019,

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when people started...

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to try to do transparent biopsy.

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They did it under general anesthesia and it implied more time,

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access to the operating room.

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You have to remember in 2019,

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it's COVID time.

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So we don't have really access to the operating room.

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So we tried to do in-office procedure under local anesthesia in Hospital Cochin and actually it worked.

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So several teams at this time published their experiences in the field and they confirmed that transparent is

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feasible and safe under local anesthesia.

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In the same time,

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studies confirmed that there is a very low infectious complication.

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You know,

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it's around 1%,

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which is very,

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very low because transrectal is between 5%

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and 7%

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of infection.

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And in 2021,

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the European guidelines,

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they recommend to use the transparent approach.

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And careful,

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it's a strong recommendation.

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So it's new in the field of prostate diagnoses.

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So for all these reasons,

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we perform now only transperineal in Hospital Cochin.

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And did you talk about it with the other physicians in the

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Hospital Cochin,

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for example,

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about this change to move from transrectal to transperineal approach?

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Or it's just an opinion that you had in 2019?

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No,

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no,

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we talked with them.

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Actually,

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some people disagreed.

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And we said we have to switch to Transparenol,

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it's better.

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And the first reaction was,

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why should we switch to Transparenol?

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We do Transrectal,

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we always did it,

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it works.

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So we don't want to change.

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And then we presented our work,

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we presented data,

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scientific data,

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our data.

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And with the time,

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we convinced the people in our department.

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And it took two years,

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but everybody switched.

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And now everybody's convinced.

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that transperinol is better.

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Talking about benefits,

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what are the advantages of transperinol approach?

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As we just said,

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the first benefit is the low rate of infections.

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But if we look closer,

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we have studies and even meta-analysis that says that povidone iodine and transrectal root can do the same.

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In fact,

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it's in the EAU guidelines since 2021.

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If you use transrectal

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Despite the guidelines,

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actually,

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you have to use povidone iodine.

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But with povidone iodine,

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you have almost 1%

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of infection.

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So the real benefit regarding infectious complications is that you decrease the infectious rate,

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but you decrease it without any antibiotics.

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In 2021,

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European guidelines recommend transperineal,

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but they recommend it with antibiotics.

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Most of the time,

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it was cefazoline.

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But in 2023...

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The European guidelines offers to do Transparenal with no antibiotic at all.

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This is based on studies using no antibiotic with the same low infectious rate.

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And that is the real point to use no antibiotic.

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Because we have to remember,

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in 2021,

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fluoroquinolones were banished from the European guidelines,

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even for Transparenal,

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because that was the first problem.

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Using fluoroquinolones for every biopsy,

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blinded from rectal swab,

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we increased the fluoroquinolone resistance.

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In France,

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the fluoroquinolone resistance,

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it's almost 15%

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in 2022.

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It's huge.

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So that is the reason why the infectious rates decreased with the transrectal and why we switched to transperineal.

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Because,

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you know,

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you have more resistance,

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so you have more infection and you continue to use the antibiotics.

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So that's the problem in the first place.

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So now we don't put rectal escherichia coli in the urine.

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Okay.

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But we don't risk new resistance in 10 years because we don't use any antibiotics.

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And that's the main point.

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So except that crucial point,

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the second aim of the transparent renal is to have a unique approach for biopsy and focal therapy,

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because we have to realize that focal therapy is rising.

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And sooner or later,

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it's going to be a standard of care for selected patients that we still have to precisely define.

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But still,

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it's going to be a standard one day.

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And whatever the energy.

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Focal therapy will be performed by transperineal route because we have to avoid infection,

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but we have to avoid rectal injuries.

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So we have to perform it with the transperineal way.

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So looking at this picture,

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biopsy should be done using the same route.

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And I can go further.

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It has to be done with the exact same technique,

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the same device and the same surgeon.

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It's easier,

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it's safer and it's reproducible.

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So there is no question in that.

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To end this,

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at the beginning.

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we thought that transperineal was maybe less precise than the transrectal.

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And actually,

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the recent data say that transperineal is even better than transrectal for the detection rate.

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So for me,

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there is no question.

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If there are so many advantages,

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why urologists are still performing transrectal prostate biopsies?

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That's a good question.

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But,

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you know,

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it takes time to change the practice.

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We have to realize that the technique is new.

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European guidelines changed only two years ago.

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It's yesterday.

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The French guidelines will probably change soon,

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but we are now living the evolution and it will probably take years to totally abandon transrectal.

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The first barrier is the device.

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People need to change the device.

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It takes time.

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It takes money.

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You have to negotiate with the hospital.

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The second barrier is human.

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The majority of urologists always practice transrectal.

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It's the same for every change.

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The first step.

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is the evidence.

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You have to do the science,

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then you do the guidelines,

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then you have to spread the message.

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That's actually what we are doing in this podcast.

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And then you have to teach the technique,

272
00:10:59.940 --> 00:11:01.861
facilitating the access to the device,

273
00:11:01.901 --> 00:11:02.021
etc.,

274
00:11:02.461 --> 00:11:02.581
etc.

275
00:11:03.021 --> 00:11:04.362
So it takes time.

276
00:11:05.902 --> 00:11:06.582
Very interesting.

277
00:11:06.922 --> 00:11:08.783
You mentioned the barriers.

278
00:11:08.843 --> 00:11:09.763
So according to you,

279
00:11:10.303 --> 00:11:14.284
is transperineal approach easier to learn than transrectal approach?

280
00:11:15.065 --> 00:11:16.185
I think it's easier,

281
00:11:16.245 --> 00:11:16.465
yes.

282
00:11:17.225 --> 00:11:20.606
Most of urologists who do transrectal would say no,

283
00:11:21.146 --> 00:11:24.027
but I think it's only because they are used to transrectal.

284
00:11:24.647 --> 00:11:25.327
As an example,

285
00:11:25.948 --> 00:11:27.928
I teach residents the biopsy technique,

286
00:11:28.168 --> 00:11:31.949
and I had the occasion to teach both transperineal and transrectal.

287
00:11:32.429 --> 00:11:38.651
And I have to say that it's so much faster to teach the transperineal route than the transrectal route.

288
00:11:39.411 --> 00:11:44.473
I think the reason is that the sagittal view of the transperineal sonograph

289
00:11:44.945 --> 00:11:48.007
offers you an ideal picture of the prostate.

290
00:11:48.207 --> 00:11:48.948
You see the base,

291
00:11:48.948 --> 00:11:49.708
you see the apex,

292
00:11:50.109 --> 00:11:53.271
and you see the whole needle going from the apex to the base.

293
00:11:53.731 --> 00:11:55.953
And this is very easy to understand.

294
00:11:56.393 --> 00:11:57.994
When you use the transrectal route,

295
00:11:58.514 --> 00:11:59.695
you have to move your probe,

296
00:11:59.715 --> 00:12:00.876
you have different planes.

297
00:12:01.236 --> 00:12:03.238
You have to realize that in the transrectal,

298
00:12:03.258 --> 00:12:05.059
the planes are not even parallel.

299
00:12:05.439 --> 00:12:05.679
I mean,

300
00:12:05.980 --> 00:12:09.602
the human spirit is not designed to analyze planes who are not parallel.

301
00:12:09.902 --> 00:12:11.063
So I think it's really,

302
00:12:11.123 --> 00:12:11.984
really more difficult.

303
00:12:12.244 --> 00:12:13.525
The problem is people know.

304
00:12:13.765 --> 00:12:14.825
how to do transrectal,

305
00:12:14.905 --> 00:12:15.906
so they think it's easy,

306
00:12:16.386 --> 00:12:18.566
but actually transperineal is easier.

307
00:12:19.707 --> 00:12:22.548
So I'm sure you already knew my next question,

308
00:12:22.708 --> 00:12:28.869
but do you have practical tips and tricks for our listeners to switch from transrectal to transperineal approach?

309
00:12:30.010 --> 00:12:34.791
My first advice would be to practice the first cases under general anesthesia.

310
00:12:35.511 --> 00:12:36.752
I think it gives you time,

311
00:12:37.152 --> 00:12:37.692
serenity,

312
00:12:38.212 --> 00:12:40.353
you don't have to deal with the patient,

313
00:12:40.353 --> 00:12:41.233
you know the question.

314
00:12:41.533 --> 00:12:44.235
The local anesthesia is a technique you have to learn also.

315
00:12:44.976 --> 00:12:45.596
For example,

316
00:12:45.717 --> 00:12:46.657
in Cochin Hospital,

317
00:12:46.837 --> 00:12:50.941
we practice transparineal under local anesthesia or general anesthesia.

318
00:12:51.982 --> 00:12:52.802
We ask the patient,

319
00:12:53.103 --> 00:12:55.625
do you want to get asleep or do you want to be aware?

320
00:12:56.065 --> 00:12:57.266
And patient choose.

321
00:12:57.626 --> 00:13:01.690
And I have to say that when the patients are asleep,

322
00:13:01.970 --> 00:13:02.971
it's more comfortable.

323
00:13:03.611 --> 00:13:05.313
So that's my first advice.

324
00:13:05.353 --> 00:13:08.836
My second advice would be to have all the material you need,

325
00:13:09.476 --> 00:13:09.997
especially.

326
00:13:10.337 --> 00:13:11.538
the stabilization arm.

327
00:13:12.619 --> 00:13:13.660
It's really easier.

328
00:13:13.900 --> 00:13:15.041
It gets you stability.

329
00:13:15.361 --> 00:13:16.863
It gets you your left hand free.

330
00:13:17.283 --> 00:13:18.364
I think it's a real help.

331
00:13:18.544 --> 00:13:24.249
So you should get it and you should be in the real good condition to try a new technique.

332
00:13:25.370 --> 00:13:25.930
And finally,

333
00:13:26.531 --> 00:13:27.752
like every surgery,

334
00:13:28.052 --> 00:13:30.394
and the urologists are very aware of that,

335
00:13:30.774 --> 00:13:33.437
you have to try it with someone who knows how to do it.

336
00:13:33.877 --> 00:13:35.398
So if someone teaches you,

337
00:13:35.819 --> 00:13:38.341
you're going to be so much faster and so much comfortable.

338
00:13:38.685 --> 00:13:40.105
than if you try to do it alone.

339
00:13:40.766 --> 00:13:44.987
So earlier you have talked about general anesthesia to start with a transparent approach,

340
00:13:45.587 --> 00:13:50.408
but does it mean that we can perform the procedure under local anesthesia?

341
00:13:51.028 --> 00:13:51.288
Yes,

342
00:13:51.549 --> 00:13:56.770
we can do it under local anesthesia and the technique is the periprostatic nerve block.

343
00:13:57.410 --> 00:13:59.271
It is a safe and efficient technique.

344
00:13:59.671 --> 00:14:01.591
It allows you to do it in office,

345
00:14:01.771 --> 00:14:04.032
which is crucial for a lot of centers because,

346
00:14:04.452 --> 00:14:05.292
as we said before,

347
00:14:05.392 --> 00:14:07.853
they don't have an easy access to the operating room.

348
00:14:08.517 --> 00:14:13.900
So the periprostatic nerve block should be done under ultrasound guidance.

349
00:14:15.040 --> 00:14:16.421
After a good skin anesthesia,

350
00:14:16.501 --> 00:14:25.365
it's very important because you have to be comfortable for you and the patient with a good skin anesthesia before starting the deep anesthesia.

351
00:14:26.166 --> 00:14:31.528
That technique is crucial because you have to remember the problem of transperineal was the pain.

352
00:14:31.989 --> 00:14:34.030
So now we know a good technique.

353
00:14:35.150 --> 00:14:36.051
It's efficient,

354
00:14:36.431 --> 00:14:37.092
it's pain-free,

355
00:14:37.392 --> 00:14:37.812
it's safe.

356
00:14:37.812 --> 00:14:38.593
So we can say it,

357
00:14:38.993 --> 00:14:44.298
transparent renal biopsy are feasible and safe in office under local anesthesia.

358
00:14:45.038 --> 00:14:46.820
Does it allow you to reach more patients?

359
00:14:47.620 --> 00:14:48.121
Sometimes,

360
00:14:48.281 --> 00:14:48.641
I think,

361
00:14:48.801 --> 00:14:51.764
because we see patients more and more informed.

362
00:14:52.324 --> 00:14:53.965
I think this phenomenon is growing.

363
00:14:54.306 --> 00:14:55.647
They have access to internet,

364
00:14:55.747 --> 00:14:57.348
they have access to the guidelines.

365
00:14:57.688 --> 00:14:58.649
Maybe this podcast,

366
00:14:58.669 --> 00:14:59.530
if they listen to it,

367
00:14:59.570 --> 00:14:59.930
I don't know,

368
00:14:59.970 --> 00:15:00.391
I hope.

369
00:15:01.171 --> 00:15:03.493
But they're going to get more and more informed.

370
00:15:03.653 --> 00:15:04.514
So they will ask.

371
00:15:05.222 --> 00:15:09.344
Please do me transperineal biopsy because I read transperineal is better.

372
00:15:09.424 --> 00:15:11.065
So please do me transperineal biopsy.

373
00:15:12.445 --> 00:15:12.765
So yeah,

374
00:15:12.785 --> 00:15:13.746
I think in the next year,

375
00:15:14.786 --> 00:15:17.947
we will see this situation more and more.

376
00:15:18.208 --> 00:15:23.630
And I think it's a chance to can offer the good technique to the patient,

377
00:15:23.790 --> 00:15:25.351
especially if he knows it.

378
00:15:26.011 --> 00:15:26.851
I totally agree.

379
00:15:26.951 --> 00:15:32.113
And we definitely see in the previous year that the patients are more informed,

380
00:15:32.293 --> 00:15:33.454
are more involved in there.

381
00:15:33.674 --> 00:15:34.755
pathology in their disease.

382
00:15:35.335 --> 00:15:38.177
And I think it's called the empowerment of patient now.

383
00:15:38.257 --> 00:15:42.861
It's a new term to say that the patient wants to take in hand their choices and their journey.

384
00:15:43.341 --> 00:15:44.422
So I'm totally agree with you.

385
00:15:44.622 --> 00:15:44.882
Anyway,

386
00:15:45.382 --> 00:15:50.646
so why is transpirineal prostate biopsy approach isn't the prostate biopsy standard yet?

387
00:15:51.707 --> 00:15:52.047
Actually,

388
00:15:52.788 --> 00:15:54.669
it's the standard in Europe,

389
00:15:54.789 --> 00:15:56.831
according to the European guidelines.

390
00:15:57.511 --> 00:15:58.112
In France,

391
00:15:58.532 --> 00:15:58.892
it's true.

392
00:15:58.952 --> 00:16:00.593
We have our own guidelines,

393
00:16:00.654 --> 00:16:00.894
but

394
00:16:01.470 --> 00:16:03.191
They will follow this trend very soon,

395
00:16:03.231 --> 00:16:03.591
I'm sure.

396
00:16:04.131 --> 00:16:05.112
In the United States,

397
00:16:05.172 --> 00:16:06.092
it's still different,

398
00:16:06.212 --> 00:16:08.673
but we have to remember that in the whole world,

399
00:16:09.073 --> 00:16:12.515
everybody is practicing the evidence-based medicine.

400
00:16:12.915 --> 00:16:13.455
And actually,

401
00:16:13.495 --> 00:16:14.916
we have the evidence.

402
00:16:15.336 --> 00:16:16.276
So for me,

403
00:16:16.656 --> 00:16:16.896
yes,

404
00:16:17.337 --> 00:16:18.317
it's a standard of care.

405
00:16:19.177 --> 00:16:19.397
Okay.

406
00:16:20.018 --> 00:16:22.779
So before to conclude this amazing interview,

407
00:16:23.099 --> 00:16:27.181
if you have to choose two arguments to convince the naysayers,

408
00:16:27.681 --> 00:16:28.301
what would they be?

409
00:16:29.782 --> 00:16:30.362
First of all,

410
00:16:30.738 --> 00:16:34.299
I would reassure them about the fact that it's an easy technique.

411
00:16:35.119 --> 00:16:36.820
It's even easier than the one they know.

412
00:16:37.540 --> 00:16:38.620
But I understand it.

413
00:16:38.720 --> 00:16:39.740
Nobody likes to change.

414
00:16:40.361 --> 00:16:41.941
I know how to do transrectal.

415
00:16:42.041 --> 00:16:43.561
Why should I do transperineal,

416
00:16:43.561 --> 00:16:43.822
you know?

417
00:16:44.602 --> 00:16:49.543
But we have to realize that the practice in changing right now with good evidence,

418
00:16:49.783 --> 00:16:50.683
so it's inevitable.

419
00:16:51.464 --> 00:16:52.924
It's the same thing with every progress,

420
00:16:52.924 --> 00:16:53.164
you know?

421
00:16:53.244 --> 00:16:54.584
Some people will persist.

422
00:16:55.165 --> 00:16:55.525
Remember

423
00:16:55.865 --> 00:16:56.605
15 years ago,

424
00:16:56.805 --> 00:16:58.626
there was probably that guy saying like,

425
00:16:58.746 --> 00:16:59.006
what?

426
00:16:59.326 --> 00:17:00.026
Playing music?

427
00:17:00.286 --> 00:17:01.046
taking pictures,

428
00:17:01.166 --> 00:17:03.447
go on the internet with just a phone.

429
00:17:03.707 --> 00:17:04.767
No way it's going to work.

430
00:17:05.127 --> 00:17:05.247
So,

431
00:17:05.648 --> 00:17:05.908
you know,

432
00:17:06.608 --> 00:17:07.968
when everyone is taking the train,

433
00:17:08.268 --> 00:17:09.309
you don't want to be that guy.

434
00:17:09.349 --> 00:17:10.449
So you should be the guy who say,

435
00:17:10.509 --> 00:17:10.669
yeah,

436
00:17:10.729 --> 00:17:10.889
yeah,

437
00:17:11.209 --> 00:17:11.749
it's going to work.

438
00:17:11.749 --> 00:17:13.470
So I'm going to do transparent right now.

439
00:17:14.010 --> 00:17:16.310
Thank you a lot for all this precious information,

440
00:17:16.371 --> 00:17:16.651
Dr.

441
00:17:16.691 --> 00:17:17.231
Julien Ract.

442
00:17:17.491 --> 00:17:18.211
And for your time,

443
00:17:18.291 --> 00:17:21.432
we hope that you enjoy it because I enjoy it.

444
00:17:21.892 --> 00:17:25.073
I would like to finish this interview with one last question.

445
00:17:25.653 --> 00:17:26.333
And you know,

446
00:17:26.353 --> 00:17:27.914
it's a funny question if I,

447
00:17:27.914 --> 00:17:28.514
if I may say.

448
00:17:29.114 --> 00:17:30.035
If you were a song,

449
00:17:30.335 --> 00:17:30.715
would it be?

450
00:17:31.216 --> 00:17:31.996
If I were a song?

451
00:17:32.177 --> 00:17:32.357
Yeah.

452
00:17:33.718 --> 00:17:33.938
Happy?

453
00:17:34.398 --> 00:17:34.619
Happy.

454
00:17:34.779 --> 00:17:35.439
Pharrell Williams.

455
00:17:35.780 --> 00:17:36.240
Perfect.

456
00:17:37.001 --> 00:17:39.683
Because I was very happy to share this podcast with you.

457
00:17:40.103 --> 00:17:40.363
Thank you,

458
00:17:40.383 --> 00:17:40.704
Thomas.

459
00:17:41.144 --> 00:17:41.504
Thank you,

460
00:17:41.544 --> 00:17:41.865
Julien.

461
00:17:41.865 --> 00:17:42.925
And thank you for your time.

462
00:17:43.066 --> 00:17:43.546
Bye-bye.

463
00:17:45.487 --> 00:17:48.110
That's a wrap for today's Prostatalk episode.

464
00:17:49.591 --> 00:17:52.053
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465
00:17:52.513 --> 00:17:54.054
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466
00:17:54.255 --> 00:17:56.877
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467
00:17:57.477 --> 00:17:58.158
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468
00:17:58.498 --> 00:17:59.319
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469
00:18:01.060 --> 00:18:02.601
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470
00:18:02.941 --> 00:18:03.822
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471
00:18:04.202 --> 00:18:05.483
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472
00:18:05.943 --> 00:18:10.326
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473
00:18:10.326 --> 00:18:11.947
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474
00:18:12.348 --> 00:18:15.730
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475
00:18:16.350 --> 00:18:19.172
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476
00:18:19.673 --> 00:18:22.454
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477
00:18:23.375 --> 00:18:24.996
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478
00:18:25.336 --> 00:18:26.477
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479
00:18:26.897 --> 00:18:27.518
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480
00:18:27.931 --> 00:18:28.957
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