This podcast is created by Coelis.
We don't believe one approach is better than the other.
Our philosophy is that we tailor the choice based on patient factors and target factors.
Welcome to today's episode of Prostatalk,
where we are getting to the bottom of a topic that might have you...
Shifting in your seat,
biopsy techniques for prostate cancer.
We know talking about biopsy isn't exactly dinner table conversation,
but hey,
we promise to keep it as painless as possible.
Today,
we are focusing on two key approaches,
the transperineal and transrectal biopsy.
Now,
we know this is a familiar territory for our audience of experts,
but today,
we are focusing on something that deserves more attention,
the pain.
patient's experience.
Joining us is Dr.
Louis L'Enfant from the hospital Pitié-Salé-Petrière in Paris,
a highly respected urologist and a leader in the field of prostate cancer diagnostics.
Together,
we will discuss the clinical advantages of each approach,
but with a critical focus on minimizing discomfort and maximizing outcomes.
Dr.
L'Enfant will share his views on how we can balance technical and precision
with the equally important task of keeping our patients comfortable and informed.
Because after all,
a well-prepared patient is a less anxious patient.
So,
whether you're turning in to refine your practice or just to listen to our soft voices,
we've got plenty to offer.
Let's jump in,
but not too quickly.
We like to keep these things gentle here.
Hi Dr.
L'Enfant,
we are really pleased to welcome you to our podcast Prostate Talk.
Just a little aside for our listeners,
we are currently live from the CFU meeting in Paris,
and I have heard that you have very straight and gerda.
Am I right?
Well,
Thomas,
thank you for having me.
I'm really glad to be here with you.
Yes,
the Congress is particularly rich this year with very exciting topics.
For example,
I was invited to talk on the Prostate Club sessions on prostate segmentation,
and we showed a paper.
about volume difference between the MRI segmentation and the ultrasound segmentation that we published recently in European
Urology and Oncology.
I also have a plenary session on transrectal versus transperineal biopsies.
I have,
of course,
the workshop by Coelis about the choice of the approach,
but I also have some other subjects,
particularly about the artificial urinary sphincter,
but this is clearly another topic.
pleased to come back in a few minutes.
But before getting to the heart of the matter,
could you please tell us who is Dr.
Louis L'Enfant for our listeners?
I'm a urologist since 2022.
I work at the Pitié-Salpêtrière Hospital in Paris.
My main fields of expertise include localized prostate cancer management,
and particularly prostate biopsies,
but also radical prostatectomy.
But I also have another topic,
which is functional urology and reconstructive urology.
In fact,
our department is also highly specialized in managing patients with neurological conditions,
such as spinal cord injuries,
multiple sclerosis.
We need to address the urological challenges that come with them.
What education path led you to this career?
Well,
I graduated in that.
2015 from Université Paris Descartes.
Following that,
I completed my residency in Paris.
In 2018,
I pursued a master's degree and later I undertook a research fellowship at the Cleveland Clinic.
I worked with Dr.
Jihad Keouk on the SignalPort robotic platform,
which was really new at that time.
And now I'm completing a PhD in AI and prostate biopsy.
I work with the TIMSE lab in Grenoble,
but also in the
ISIR institute in Paris from Sorbonne University.
And the goal of this PhD is trying to work on the AI to ease,
to facilitate the segmentation of the prostate ultrasound,
which is a quite complicated task to achieve for a urologist.
And the idea with this PhD is to go from a technology that is available for approximately 10%
of the urologists and make it mass market and make it available for everyone.
I'm also an assistant professor at Pitié-Salpêtrière.
Let's talk about prostate biopsies now,
because it's why we are here,
obviously.
Could you tell us about your practice?
Which approach are you performing?
Transperineal,
transrectals?
First,
I'd like to highlight that in our department at La Pitié,
we were kind of pioneer in prostate biopsy.
I had the chance to work with
Professor Moser,
for instance,
and he completed his PhD in 2006,
and he worked...
with Antoine Leroy at that time,
probably a familiar name to you and to many.
And at that time,
they worked on the idea that we needed tools to navigate and to help the physicians to do a precise biopsy.
We need to know where we come from,
and we need to remember that at that time,
we used to do random biopsy.
We used to just put...
course in the prostate,
hoping that we would find something.
And I think that their work was really interesting because it led the way to do really precise biopsy.
And now more than 1 million patients have been biopsied.
I mean,
it's really an advance in the field.
So my department was really involved in this technology.
And so prostate biopsy is kind of really important in our department.
So
So back to your question,
currently we perform both transrectal and transperineal biopsies.
We do approximately 300 biopsies every year.
Since the guideline updates in 2021,
especially the EAU guidelines,
we increased the number of TP biopsies and we do them only under local anesthesia,
except for some very selected patients that we do in the OR.
If I understand right.
the standard of prostate biopsy in your service is the transparent renal,
am I right?
Not really.
So basically,
maybe we need to do a little bit of history here.
Okay.
So for nearly 100 years,
we did transrectal biopsies,
okay?
And then in 2021,
the EIU changed the guidelines because of infectious risk,
basically.
But this was based on low evidence studies.
And then we had more high-evidence studies to confirm this change of guidelines.
But in the latest studies that we have,
especially the perfect studies,
we see that we should not throw away the transrectal biopsy,
especially because the infectious risk in a randomized setting was equivalent between the transrectal and transperineal.
Transperineal without antibioprophylaxis and transrectal with antibioprophylaxis.
But for posterior lesions,
what we see is the transrectal performs better than the transperineal in perfect studies.
So in our department,
we believe that we should not throw away the transrectal.
We should not abandon the transrectal.
And we should do both based on the patients,
but also the lesion location.
I mean,
this is really a reflection for every patient.
based on his medical history and the location of the target.
So is there a patient profile that brings you to choose one approach?
Or another one?
I mean,
the prostate size,
the lesion size you mentioned,
the age maybe?
Yeah,
absolutely.
We don't believe one approach is better than the other.
Our philosophy is that we tailor the choice based on patient factors and target factors.
We evaluate the patient risk of infection,
for example,
if he had like a prostate infection in the past month.
We think that this is a very high risk of having a prostate infection after the biopsy.
So maybe we will cancel the patient to go for a TP.
We look at the prostate size because not every lesions are accessible to transperineal biopsy in very,
very large glands,
for example.
But we also,
as I said,
look on the lesion location.
What we believe is that posterior lesions in a patient without any risk of infection is a very good candidate for a transrectal biopsy.
On the other hand,
if we have a lesion at the apex or a lesion on the anterior side of the prostate,
this is probably a good candidate for a TP biopsy.
That brings me to my next questions.
What brings you to perform transparent prostate biopsy?
So,
as I said,
we consider patients with higher risk of infection,
patients without very large prostate,
but also target lesion located at the apex or interior part of the prostate.
So,
from a very,
very practical perspective,
the aim is to minimize the distance between the entry point in the capsule of the prostate to the target.
For instance,
posterior lesions are closer to the rectum and therefore more easily accessible via transrectal biopsy.
And as we mentioned before,
studies like PERFECT trial have highlighted better detection of clinically significant prostate cancer.
and posterior targets with transrectal.
But on the other hand,
conversely,
apex or anterior lesions are farther from the rectum,
increasing the risk of needle deflection in TR biopsy.
For these,
TP is often more precise and effective.
And I have a practical question about that.
What would you say to physicians who want to switch from
TR to TP approach?
Yeah,
first,
it's essential to have the right tools.
So you need to have the probe,
and the probe between transperineal and transrectal is different.
For transrectal,
you have an inside fire probe,
okay?
And for the transperineal,
you would have a lateral fire probe.
Then you need to have something to fix the probe for the transperineal setting.
Second,
I recommend attending workshops to learn practical tips.
particularly on local anesthesia if you want to do your prostate biopsy under local and the probe manipulation,
of course.
Mastery of the grid system is also key to success because when you do transperineal biopsy,
you can either use what I call a T-grid or you can use the full grid.
And the technique is a little bit different depending on the grid you choose.
I think that physician who will start their...
tp experience we'll discover and this is a very very big advantage that is sometimes a little bit put aside but i think it's very important to mention it tp help you to reduce the human factor why because when you do a
transpareneal biopsy there is no movement of the of the probe between the virtual biopsy and the real biopsy so when you do a targeted biopsy what you usually do is you put your probe
in front of the target,
then you do what we call a virtual biopsy and meaning like,
hey,
if I do the biopsy here,
will it be in the target,
right?
Then if you are in the target virtually,
you do the real one.
But in transrectal biopsy,
you can always have a little bit movement of the probe,
patient movements.
So this can,
you know,
alter the precision of the biopsy.
In the TP setting,
it's really different because the probe...
is fixed on the arm,
so there is no movement of the probe between the virtual and the real biopsy.
So this is a reduction of the human factor,
and probably,
I think,
it's really helpful for the physician.
Can you share an experience that significantly shaped your approach in prostate cancer management?
Yeah,
of course.
So
I think that the most important experience in this field for me is my ongoing PhD on prostate biopsy.
It's really interesting to be on the other side because we think with a real scientific approach,
we need to master and to understand all the software,
hardware behind the biopsy procedure.
Our goal is to use AI for ultrasound segmentation.
So this has really deepened my understanding of the technology supporting urologists in target biopsy.
I think that the evolution of the software using AI really will simplify the procedure and make it available to the wider urology community.
What is indispensable for your job,
especially in the prostate field?
You mentioned previously to have the right tools,
but do you have anything else?
Yeah,
of course.
I mean,
several skills and tools are...
crucial to do prostate biopsy.
One of the most important ones is to understand the natural history of prostate cancer.
And this is the first thing to understand,
to understand the disease before understanding the technology.
I think this is crucial because when you do the biopsy,
the patient is here.
I mean,
it's in their local anesthesia.
You spend 30 minutes with the patient and you need to,
you know,
have a really a conversation with him,
explain the disease.
So this is very,
very,
very important.
Then prostate biopsy is complex,
okay?
I mean,
at that time.
And I think that one of the skills that the urologist needs to have is first understanding the MRI and how to interpret an MRI.
This is very,
very important because you have to locate the target.
You have to be sure that it is the right target.
So either you master the MRI,
you know how to read it,
or you have very,
very good radiologists in your team.
Then the last one is
3D spatial visualization.
Because when you look at the MRI,
you need to be able to locate the target in your head,
helping you to move the probe.
If you want to go at the apex of the prostate,
you move it in a certain way.
And having
3D visualization is really helpful to help you navigate in the prostate.
Last thing is you need to have some tools,
visualization tools,
to help you guide the procedure.
but also to help the patient understand what you're doing.
And at the end of every procedure,
I show my patient his MRI.
I show my patient the ultrasound.
I show the fusion.
I show him the location of the target,
the location of the cores,
explaining him how we did the biopsy and why we did targeted biopsy and where the core are located.
And I think this is really reassuring for the patient,
knowing that this is a very,
very accurate.
procedure with a result that can be trusted.
I definitely like the way that you include the patient in your practice.
It's very important and I'm sure it would be very helpful if urologists would listen to us.
We approach the end of our episode,
but I had another question.
What do you think of the opposition between transrectal or transperineal approach?
Yeah,
I think the two approaches are complementary for sure.
Each has strength
And the choice should always be patient-specific,
as we said before,
depending on the risk of infection,
the target location,
etc.
So no TR team and no TP team,
but just one team,
the patient team.
Just both.
Yeah.
Thanks for all this interesting information,
Dr.
L'Enfant.
What is the next step for you?
Are you involved in a new research project?
Yeah,
I'm actively working on projects involving
AI, for sure,
linked with my PhD.
but also national health database research with the Assurance Maladie database.
There's a lot to look forward to,
for sure.
We can't wait to follow these exciting projects.
Before you leave,
I have one special question,
but I'm sure you already knew this question.
What is the
Dr. Louis D'Enfant's songs,
your favorite songs?
I like to ask this particular question to my guest.
I think I would say,
Country Road,
Take Me Home.
Thanks again for your time.
I hope we will host you for another episode to share your new recent project.
And thank you again for your time.
Thomas Poulin Yeah.
Thanks for the invitation,
Thomas.
It was really,
really a pleasure.
Thomas Poulin Thank you very much.
Huge thanks to our dedicated listeners.
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