WEBVTT

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This podcast is created by Coelis.

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We don't believe one approach is better than the other.

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Our philosophy is that we tailor the choice based on patient factors and target factors.

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Welcome to today's episode of Prostatalk,

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where we are getting to the bottom of a topic that might have you...

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Shifting in your seat,

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biopsy techniques for prostate cancer.

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We know talking about biopsy isn't exactly dinner table conversation,

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but hey,

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we promise to keep it as painless as possible.

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Today,

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we are focusing on two key approaches,

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the transperineal and transrectal biopsy.

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Now,

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we know this is a familiar territory for our audience of experts,

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but today,

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we are focusing on something that deserves more attention,

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the pain.

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patient's experience.

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Joining us is Dr.

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Louis L'Enfant from the hospital Pitié-Salé-Petrière in Paris,

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a highly respected urologist and a leader in the field of prostate cancer diagnostics.

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Together,

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we will discuss the clinical advantages of each approach,

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but with a critical focus on minimizing discomfort and maximizing outcomes.

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Dr.

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L'Enfant will share his views on how we can balance technical and precision

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with the equally important task of keeping our patients comfortable and informed.

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Because after all,

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a well-prepared patient is a less anxious patient.

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So,

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whether you're turning in to refine your practice or just to listen to our soft voices,

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we've got plenty to offer.

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Let's jump in,

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but not too quickly.

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We like to keep these things gentle here.

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Hi Dr.

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L'Enfant,

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we are really pleased to welcome you to our podcast Prostate Talk.

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Just a little aside for our listeners,

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we are currently live from the CFU meeting in Paris,

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and I have heard that you have very straight and gerda.

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Am I right?

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Well,

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Thomas,

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thank you for having me.

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I'm really glad to be here with you.

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Yes,

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the Congress is particularly rich this year with very exciting topics.

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For example,

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I was invited to talk on the Prostate Club sessions on prostate segmentation,

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and we showed a paper.

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about volume difference between the MRI segmentation and the ultrasound segmentation that we published recently in European

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Urology and Oncology.

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I also have a plenary session on transrectal versus transperineal biopsies.

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I have,

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of course,

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the workshop by Coelis about the choice of the approach,

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but I also have some other subjects,

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particularly about the artificial urinary sphincter,

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but this is clearly another topic.

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pleased to come back in a few minutes.

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But before getting to the heart of the matter,

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could you please tell us who is Dr.

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Louis L'Enfant for our listeners?

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I'm a urologist since 2022.

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I work at the Pitié-Salpêtrière Hospital in Paris.

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My main fields of expertise include localized prostate cancer management,

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and particularly prostate biopsies,

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but also radical prostatectomy.

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But I also have another topic,

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which is functional urology and reconstructive urology.

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In fact,

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our department is also highly specialized in managing patients with neurological conditions,

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such as spinal cord injuries,

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multiple sclerosis.

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We need to address the urological challenges that come with them.

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What education path led you to this career?

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Well,

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I graduated in that.

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2015 from Université Paris Descartes.

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Following that,

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I completed my residency in Paris.

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In 2018,

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I pursued a master's degree and later I undertook a research fellowship at the Cleveland Clinic.

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I worked with Dr.

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Jihad Keouk on the SignalPort robotic platform,

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which was really new at that time.

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And now I'm completing a PhD in AI and prostate biopsy.

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I work with the TIMSE lab in Grenoble,

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but also in the

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ISIR institute in Paris from Sorbonne University.

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And the goal of this PhD is trying to work on the AI to ease,

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to facilitate the segmentation of the prostate ultrasound,

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which is a quite complicated task to achieve for a urologist.

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And the idea with this PhD is to go from a technology that is available for approximately 10%

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of the urologists and make it mass market and make it available for everyone.

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I'm also an assistant professor at Pitié-Salpêtrière.

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Let's talk about prostate biopsies now,

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because it's why we are here,

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obviously.

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Could you tell us about your practice?

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Which approach are you performing?

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Transperineal,

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transrectals?

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First,

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I'd like to highlight that in our department at La Pitié,

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we were kind of pioneer in prostate biopsy.

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I had the chance to work with

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Professor Moser,

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for instance,

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and he completed his PhD in 2006,

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and he worked...

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with Antoine Leroy at that time,

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probably a familiar name to you and to many.

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And at that time,

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they worked on the idea that we needed tools to navigate and to help the physicians to do a precise biopsy.

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We need to know where we come from,

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and we need to remember that at that time,

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we used to do random biopsy.

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We used to just put...

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course in the prostate,

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hoping that we would find something.

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And I think that their work was really interesting because it led the way to do really precise biopsy.

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And now more than 1 million patients have been biopsied.

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I mean,

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it's really an advance in the field.

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So my department was really involved in this technology.

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And so prostate biopsy is kind of really important in our department.

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So

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So back to your question,

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currently we perform both transrectal and transperineal biopsies.

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We do approximately 300 biopsies every year.

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Since the guideline updates in 2021,

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especially the EAU guidelines,

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we increased the number of TP biopsies and we do them only under local anesthesia,

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except for some very selected patients that we do in the OR.

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If I understand right.

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the standard of prostate biopsy in your service is the transparent renal,

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am I right?

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Not really.

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So basically,

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maybe we need to do a little bit of history here.

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Okay.

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So for nearly 100 years,

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we did transrectal biopsies,

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okay?

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And then in 2021,

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the EIU changed the guidelines because of infectious risk,

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basically.

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But this was based on low evidence studies.

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And then we had more high-evidence studies to confirm this change of guidelines.

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But in the latest studies that we have,

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especially the perfect studies,

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we see that we should not throw away the transrectal biopsy,

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especially because the infectious risk in a randomized setting was equivalent between the transrectal and transperineal.

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Transperineal without antibioprophylaxis and transrectal with antibioprophylaxis.

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But for posterior lesions,

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what we see is the transrectal performs better than the transperineal in perfect studies.

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So in our department,

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we believe that we should not throw away the transrectal.

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We should not abandon the transrectal.

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And we should do both based on the patients,

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but also the lesion location.

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I mean,

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this is really a reflection for every patient.

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based on his medical history and the location of the target.

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So is there a patient profile that brings you to choose one approach?

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Or another one?

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I mean,

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the prostate size,

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the lesion size you mentioned,

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the age maybe?

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Yeah,

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absolutely.

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We don't believe one approach is better than the other.

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Our philosophy is that we tailor the choice based on patient factors and target factors.

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We evaluate the patient risk of infection,

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for example,

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if he had like a prostate infection in the past month.

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We think that this is a very high risk of having a prostate infection after the biopsy.

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So maybe we will cancel the patient to go for a TP.

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We look at the prostate size because not every lesions are accessible to transperineal biopsy in very,

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very large glands,

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for example.

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But we also,

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as I said,

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look on the lesion location.

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What we believe is that posterior lesions in a patient without any risk of infection is a very good candidate for a transrectal biopsy.

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On the other hand,

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if we have a lesion at the apex or a lesion on the anterior side of the prostate,

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this is probably a good candidate for a TP biopsy.

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That brings me to my next questions.

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What brings you to perform transparent prostate biopsy?

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So,

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as I said,

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we consider patients with higher risk of infection,

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patients without very large prostate,

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but also target lesion located at the apex or interior part of the prostate.

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So,

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from a very,

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very practical perspective,

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the aim is to minimize the distance between the entry point in the capsule of the prostate to the target.

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For instance,

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posterior lesions are closer to the rectum and therefore more easily accessible via transrectal biopsy.

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And as we mentioned before,

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studies like PERFECT trial have highlighted better detection of clinically significant prostate cancer.

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and posterior targets with transrectal.

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But on the other hand,

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conversely,

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apex or anterior lesions are farther from the rectum,

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increasing the risk of needle deflection in TR biopsy.

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For these,

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TP is often more precise and effective.

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And I have a practical question about that.

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What would you say to physicians who want to switch from

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TR to TP approach?

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Yeah,

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first,

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it's essential to have the right tools.

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So you need to have the probe,

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and the probe between transperineal and transrectal is different.

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For transrectal,

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you have an inside fire probe,

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okay?

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And for the transperineal,

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you would have a lateral fire probe.

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Then you need to have something to fix the probe for the transperineal setting.

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Second,

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I recommend attending workshops to learn practical tips.

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particularly on local anesthesia if you want to do your prostate biopsy under local and the probe manipulation,

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of course.

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Mastery of the grid system is also key to success because when you do transperineal biopsy,

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you can either use what I call a T-grid or you can use the full grid.

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And the technique is a little bit different depending on the grid you choose.

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I think that physician who will start their...

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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

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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

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in front of the target,

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then you do what we call a virtual biopsy and meaning like,

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hey,

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if I do the biopsy here,

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will it be in the target,

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right?

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Then if you are in the target virtually,

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you do the real one.

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But in transrectal biopsy,

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you can always have a little bit movement of the probe,

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patient movements.

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So this can,

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you know,

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alter the precision of the biopsy.

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In the TP setting,

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it's really different because the probe...

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is fixed on the arm,

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so there is no movement of the probe between the virtual and the real biopsy.

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So this is a reduction of the human factor,

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and probably,

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I think,

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it's really helpful for the physician.

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Can you share an experience that significantly shaped your approach in prostate cancer management?

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Yeah,

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of course.

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So

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I think that the most important experience in this field for me is my ongoing PhD on prostate biopsy.

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It's really interesting to be on the other side because we think with a real scientific approach,

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we need to master and to understand all the software,

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hardware behind the biopsy procedure.

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Our goal is to use AI for ultrasound segmentation.

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So this has really deepened my understanding of the technology supporting urologists in target biopsy.

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I think that the evolution of the software using AI really will simplify the procedure and make it available to the wider urology community.

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What is indispensable for your job,

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especially in the prostate field?

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You mentioned previously to have the right tools,

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but do you have anything else?

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Yeah,

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of course.

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I mean,

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several skills and tools are...

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crucial to do prostate biopsy.

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One of the most important ones is to understand the natural history of prostate cancer.

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And this is the first thing to understand,

283
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to understand the disease before understanding the technology.

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I think this is crucial because when you do the biopsy,

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the patient is here.

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I mean,

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it's in their local anesthesia.

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You spend 30 minutes with the patient and you need to,

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you know,

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have a really a conversation with him,

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explain the disease.

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So this is very,

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00:14:47.378 --> 00:14:47.598
very,

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very important.

295
00:14:49.019 --> 00:14:51.581
Then prostate biopsy is complex,

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okay?

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I mean,

298
00:14:52.842 --> 00:14:53.482
at that time.

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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.

300
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This is very,

301
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very important because you have to locate the target.

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You have to be sure that it is the right target.

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So either you master the MRI,

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you know how to read it,

305
00:15:11.875 --> 00:15:12.695
or you have very,

306
00:15:12.755 --> 00:15:14.957
very good radiologists in your team.

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00:15:15.793 --> 00:15:16.953
Then the last one is

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00:15:17.534 --> 00:15:19.914
3D spatial visualization.

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00:15:20.414 --> 00:15:22.415
Because when you look at the MRI,

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you need to be able to locate the target in your head,

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00:15:25.696 --> 00:15:27.156
helping you to move the probe.

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If you want to go at the apex of the prostate,

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00:15:29.537 --> 00:15:30.937
you move it in a certain way.

314
00:15:31.377 --> 00:15:31.877
And having

315
00:15:33.258 --> 00:15:38.539
3D visualization is really helpful to help you navigate in the prostate.

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00:15:39.219 --> 00:15:42.000
Last thing is you need to have some tools,

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00:15:42.320 --> 00:15:43.621
visualization tools,

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00:15:43.641 --> 00:15:45.221
to help you guide the procedure.

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00:15:45.813 --> 00:15:49.716
but also to help the patient understand what you're doing.

320
00:15:49.796 --> 00:15:51.578
And at the end of every procedure,

321
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I show my patient his MRI.

322
00:15:54.220 --> 00:15:56.342
I show my patient the ultrasound.

323
00:15:56.402 --> 00:15:57.323
I show the fusion.

324
00:15:57.983 --> 00:16:00.385
I show him the location of the target,

325
00:16:01.186 --> 00:16:02.487
the location of the cores,

326
00:16:02.867 --> 00:16:09.833
explaining him how we did the biopsy and why we did targeted biopsy and where the core are located.

327
00:16:09.953 --> 00:16:12.355
And I think this is really reassuring for the patient,

328
00:16:12.375 --> 00:16:13.876
knowing that this is a very,

329
00:16:13.936 --> 00:16:14.757
very accurate.

330
00:16:15.253 --> 00:16:18.714
procedure with a result that can be trusted.

331
00:16:19.254 --> 00:16:22.795
I definitely like the way that you include the patient in your practice.

332
00:16:23.195 --> 00:16:27.476
It's very important and I'm sure it would be very helpful if urologists would listen to us.

333
00:16:28.277 --> 00:16:30.317
We approach the end of our episode,

334
00:16:30.357 --> 00:16:31.677
but I had another question.

335
00:16:32.258 --> 00:16:37.919
What do you think of the opposition between transrectal or transperineal approach?

336
00:16:39.400 --> 00:16:39.560
Yeah,

337
00:16:39.620 --> 00:16:42.780
I think the two approaches are complementary for sure.

338
00:16:43.381 --> 00:16:44.581
Each has strength

339
00:16:45.069 --> 00:16:48.190
And the choice should always be patient-specific,

340
00:16:48.230 --> 00:16:48.970
as we said before,

341
00:16:49.030 --> 00:16:51.091
depending on the risk of infection,

342
00:16:51.151 --> 00:16:52.091
the target location,

343
00:16:52.151 --> 00:16:52.271
etc.

344
00:16:53.351 --> 00:16:55.492
So no TR team and no TP team,

345
00:16:55.512 --> 00:16:56.432
but just one team,

346
00:16:56.712 --> 00:16:57.532
the patient team.

347
00:16:57.692 --> 00:16:58.193
Just both.

348
00:16:58.373 --> 00:16:58.493
Yeah.

349
00:16:59.653 --> 00:17:02.114
Thanks for all this interesting information,

350
00:17:02.234 --> 00:17:02.374
Dr.

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00:17:02.534 --> 00:17:02.914
L'Enfant.

352
00:17:03.054 --> 00:17:04.374
What is the next step for you?

353
00:17:04.714 --> 00:17:07.035
Are you involved in a new research project?

354
00:17:07.755 --> 00:17:08.475
Yeah,

355
00:17:08.495 --> 00:17:10.636
I'm actively working on projects involving

356
00:17:11.076 --> 00:17:12.216
AI, for sure,

357
00:17:12.557 --> 00:17:13.717
linked with my PhD.

358
00:17:14.293 --> 00:17:19.675
but also national health database research with the Assurance Maladie database.

359
00:17:20.175 --> 00:17:21.395
There's a lot to look forward to,

360
00:17:21.775 --> 00:17:22.135
for sure.

361
00:17:22.836 --> 00:17:24.996
We can't wait to follow these exciting projects.

362
00:17:25.656 --> 00:17:26.277
Before you leave,

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00:17:26.317 --> 00:17:27.557
I have one special question,

364
00:17:27.577 --> 00:17:30.258
but I'm sure you already knew this question.

365
00:17:30.958 --> 00:17:31.518
What is the

366
00:17:32.078 --> 00:17:33.199
Dr. Louis D'Enfant's songs,

367
00:17:33.259 --> 00:17:34.299
your favorite songs?

368
00:17:34.439 --> 00:17:37.140
I like to ask this particular question to my guest.

369
00:17:37.320 --> 00:17:38.140
I think I would say,

370
00:17:38.460 --> 00:17:39.160
Country Road,

371
00:17:39.300 --> 00:17:39.841
Take Me Home.

372
00:17:43.562 --> 00:17:44.763
Thanks again for your time.

373
00:17:44.843 --> 00:17:48.865
I hope we will host you for another episode to share your new recent project.

374
00:17:49.125 --> 00:17:50.266
And thank you again for your time.

375
00:17:50.266 --> 00:17:50.666
Thomas Poulin Yeah.

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00:17:50.666 --> 00:17:51.727
Thanks for the invitation,

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00:17:51.787 --> 00:17:52.087
Thomas.

378
00:17:52.087 --> 00:17:52.707
It was really,

379
00:17:53.068 --> 00:17:53.788
really a pleasure.

380
00:17:53.788 --> 00:17:55.429
Thomas Poulin Thank you very much.

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00:18:10.121 --> 00:18:11.662
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383
00:18:11.863 --> 00:18:14.505
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384
00:18:15.085 --> 00:18:16.987
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385
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386
00:18:20.590 --> 00:18:21.131
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387
00:18:21.191 --> 00:18:21.511
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388
00:18:21.832 --> 00:18:23.133
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389
00:18:23.573 --> 00:18:27.056
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390
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391
00:18:29.979 --> 00:18:33.362
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392
00:18:33.982 --> 00:18:36.805
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393
00:18:37.301 --> 00:18:40.066
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394
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395
00:18:42.951 --> 00:18:44.092
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