Journal Pre-proof

Comparison of Transabdominal and Transrectal Ultrasound for Sizing

of the Prostate

W.R. Pate , N. Garg , L.B. Wang , S.E. Wason , P.V. Barbosa

PII: S0090-4295(20)30436-2
DOI: https://doi.org/10.1016/j.urology.2020.04.054
Reference: URL 22132

To appear in: Urology

Received date: 13 February 2020

Revised date: 5 April 2020
Accepted date: 9 April 2020

Please cite this article as: W.R. Pate , N. Garg , L.B. Wang , S.E. Wason , P.V. Barbosa , Compar-
ison of Transabdominal and Transrectal Ultrasound for Sizing of the Prostate, Urology (2020), doi:
https://doi.org/10.1016/j.urology.2020.04.054

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© 2020 Published by Elsevier Inc.

Title: Comparison of Transabdominal and Transrectal Ultrasound for Sizing of the
Prostate

Authors: Pate WR1, Garg N1, Wang LB1, Wason SE1, Barbosa PV1,2

Author Affiliations:
1. Department of Urology, Boston Medical Center, Boston, MA, USA.
2. Department of Urology, Beth Israel Deaconess Medical Center, Boston, MA,
USA.

Corresponding Author:
Wesley R Pate, MD
Department of Urology, Boston Medical Center, Boston, MA, USA.
725 Albany St
Suite 3B
Boston, MA 02118
wesley.pate@bmc.org
617-638-8485

Declarations of Interest: none

Word Count:
Abstract - 246
Text - 2146

Key Words:
prostate volume; transrectal ultrasound; transabdominal ultrasound; benign prostatic
hypertrophy

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OBJECTIVE: To compare the accuracy of prostate sizing between pelvic abdominal
(PUS) and transrectal (TRUS) ultrasound in a large, diverse cohort of men at our
institution. Prostate volume plays a vital role in all types of prostate disease. AUA
guidelines (2018) for surgical management of benign prostatic hyperplasia (BPH) now
includes consideration of prostate volume measurement prior to surgical intervention.
Ultrasound is a quick and radiation-free imaging modality.

METHODS: We performed a single-center, retrospective study of 299 patients with

prostate sizing between January 1, 2012 and August 31, 2017. Prostate volume was
derived from ellipsoid volume calculation using dimensions measured on ultrasound.
PUS and TRUS were compared by calculating the Pearson correlation coefficient and
ICC, and agreement between modalities assessed using the Bland Altman analysis.
This analysis was done for the whole sample population as well as for specific
groupings according to BMI, prostate size, and time between exams.

RESULTS: 236 patients had PUS followed by TRUS and met study inclusion criteria.
Median age was 63, median PSA value prior to PUS was 7.6 ng/mL, and only 20%
were white. Mean volume differences between the two modalities for the data (vol PUS –
volTRUS) was (-0.3 ± 1.1) cm3. Bland-Altman analysis showed agreement between PUS
and TRUS only for prostates ≤ 30 cm3.

CONCLUSIONS: For prostates less than 30cc, we found that PUS is interchangeable
with TRUS in estimating prostate volume. However, for larger prostates where size may
alter surgical management, we would recommend TRUS or cross-sectional imaging.

2
Introduction

Prostate volume plays a vital role in all types of prostate disease. National AUA

guidelines (2018) for surgical management of benign prostatic hyperplasia (BPH) now

includes consideration of prostate volume measurement prior to surgical intervention1.

Sizing is gaining in importance because of the increasing number of treatment options

based on the volume of the prostate gland.

In addition to voiding symptoms from BPH, we have long known that prostate size has

implications in prostate cancer management and decision making. A 2010 study of 2880

patients were analyzed showed that smaller glands were associated with higher grade

disease when compared to larger prostates2. In patients receiving radiation therapy,

prostate volume prior to treatment has been associated with acute genitourinary

toxicity3. Prostate volumes greater than 50cc may also exclude patients from certain

treatment options such as brachytherapy and may identify patients who may benefit

from pre-treatment androgen deprivation therapy for volume reduction4. An accurate

method of determining prostate volume pre-treatment is thus imperative to appropriate

patient selection and counseling regarding therapeutic options and expected outcomes.

When estimating prostate volume, ultrasound (US) is considered the gold standard as it

is fast, radiation free, and cost-effective. Two methods of US used for estimation of

prostate volume are transabdominal pelvic (PUS) and transrectal (TRUS) ultrasound.

TRUS has been shown to be comparable to excised cadaveric weights and is the most

commonly employed method for assessing prostate volume5. Despite this accuracy,

3
TRUS is an invasive imaging modality that can cause discomfort and anxiety to

patients.

Prior studies comparing PUS to TRUS are limited. A study from 2004 comparing

prostate volume in 100 patients between PUS and TRUS concluded that there was no

statistically significant difference between modalities6. Another prospective study from

2009 of 100 patients with LUTS found strong correlation between PUS and TRUS

(r=0.94), even after stratifying prostates to above and below 50cc7. A more

contemporary cross-sectional study by Jandaghi et al. in 2015 of 40 patients who

underwent PUS and TRUS concluded that the two methods did not agree. However, it

is important to note that this was a small group of culturally homogenous men 8.

It is clear that prostate sizing has clinical implications for treatment of prostate disease.

We seek to compare the accuracy of prostate sizing between PUS and TRUS in a large,

diverse cohort of men at our institution.

Materials and Methods

After IRB approval, we retrospectively reviewed the records of patients who underwent

prostate needle biopsy at our institution between January 1, 2012 and August 31, 2017.

All patients who had PUS followed by TRUS measurements within one year of each

other were included. All measurements were performed by either an experienced in-

house ultrasonographer, or an attending urologist with ultrasound certification. PUS was

performed transabdominally with the bladder full as possible. If multiple ultrasound

4
measurements were performed, only pairs that had the shortest time frame between

exams were analyzed. Patient demographics and clinical data including BMI, PSA,

prostate biopsy results, use of an alpha blocker or 5-alpha reductase inhibitor, as well

as presence or absence of a median lobe were recorded.

Prostate volume was derived from ellipsoid volume calculation (length x width x height x

π/6) using dimensions measured on US (Prosound α6 by Aloka). The mean of the

volume of the differences is equal to volPUS – volTRUS. We utilized the Pearson

coefficient and intraclass correlation (ICC) to assess correlation prostate volume

between US modalities. A cutoff p-value of p<0.05 was used to determine statistical

significance. A p-value of p<0.05 was used to determine statistical significance.

Univariate and multivariate analysis was also performed.

In addition to calculating correlation, we also utilized the Bland-Altman (BA) analysis to

measure agreement between the two imaging methods. BA analysis plots the difference

between the measurements of the two imaging methods on the y-axis versus the mean

of the same two measurements on the x-axis. There are also plotted lines on the graph

that represent the 95% confidence interval to visualize how much of the patient data fits

within these limits. This interval is also known as the limits of agreement (LOA). As we

did in this study, some investigators may add their own predetermined acceptable range

that helps frame the data in a clinical context.

5
Results

A total of 299 male patients underwent transrectal ultrasound and prostate needle

biopsy for either an elevated PSA or abnormal digital rectal exam. Of these, 236

patients had both a PUS and TRUS performed and met inclusion criteria. Patient

characteristics are summarized in Table 1. The median age of patients in this study was

63 (43-86) years old, 49% were black, 20% were white, and 17% were Hispanic. Mean

volume differences between the two modalities for the data (volPUS – volTRUS) was (-0.3

± 1.1) cc.

There was a strong overall linear correlation with R2 of 0.75 between groups (Figure 1).

Pearson correlation coefficient (PCC) and intraclass correlation coefficient (ICC)

between the two imaging modalities were calculated, which were found to be 0.87 and

0.93 (0.91-0.95), respectively. PCC and ICC were also calculated for BMI subgroups

(<25 kg/m2, 25-30 kg/m2, and >30 kg/m2) and time between exams (1-14 days, 15-31

days, 32-61 days, >61 days). For BMI, the PCC values were 0.90, 0.85, and 0.82, and

the ICC values were 0.95 (0.91-0.97), 0.92 (0.88-0.95), and 0.90 (0.83-0.94),

respectively. For time between exams, the PCC values were 0.95, 0.82, 0.90, and 0.80,

and the ICC values were 0.97 (0.95-0.98), 0.90 (0.84-0.94), 0.95 (0.91-0.97), and 0.88

(0.80-0.93), respectively.

The median prostatic volume was 52 (17-239) cc for PUS and 50 (18-215) mL for

TRUS. BA plots for comparison of PUS against TRUS were constructed (Figures 2 and

3). Recall that BA analysis provides a visual tool to determine if there is agreement

6
between two measurement methods.

We further stratified prostate volumes into four clinically significant groups; (a) <30 cc,

(b) 31-50 cc, (c) 51-80 cc and >80 cc to determine the LOA and to determine if PUS and

TRUS can be used interchangeably. When the clinically acceptable LOA is set at ±10

cc, the number of patients falling outside the predetermined clinical limit are 3%, 17%,

40%, and 67% (Figure 3a-3d).

Discussion

Previous studies have shown a strong positive correlation between PUS and TRUS (r 2=

0.94)7 and (r2=0.97)8. We similarly showed a strong correlation (Pearson correlation

coefficient=0.87 and ICC=0.93) when comparing US modalities and is the largest study

to date. These findings persisted after controlling for BMI and time between exams. It

has previously been demonstrated that BMI does not have a significant impact on

accuracy of TRUS. Sajadi et al. compared volumes measured by TRUS to specimen

weights after radical prostatectomy and found no significant difference 9. Our study

similarly found that all BMI subgroups had strong correlation between modalities.

Although it is clear there is a strong correlation between PUS and TRUS, we sought to

determine if agreement exists through the Bland-Altman analysis. Establishing

agreement would imply that both methods can be used interchangeably. We set our

clinically acceptable LOA as ±10cc, as we felt that a volume difference of 10cc would

unlikely to change treatment recommendations.

7
When stratified by prostate volume, it was clear from our BA plots that the LOA were

concordant with our clinically acceptable range of ±10 cc only for prostates <30 cc.

There was one outlier in the initial data for this range of prostates, but excluding this

outlier changes the 95% CI from (-20,10) cc to (-13, 6) cc, which falls within the clinically

acceptable range. This data point was deemed an outlier using the interquartile rule for

outliers, and therefore could reasonably be excluded. For prostates 31-50 cc, the

number of patients outside the clinically acceptable range increased to 17 (21%), and

the modalities cannot be used interchangeably. This was also the case for prostates 51-

80 cc and >80 cc, which had over 40% and 67% of the data fall outside of our

acceptable LOA. Therefore, for prostates >30 cc, PUS and TRUS could not reliably be

used interchangeably.

Our study had several limitations, one of which is the way in which the prostate volume

is calculated. In our study, we used the ellipsoid formula. However, we recognize that

other formulas to estimate prostate volume exist. One prospective study in 1991 had

150 patients who underwent TRUS as well as radical prostatectomy or

cystoprostatectomy10. 15 different methods of volume estimation were used and

compared to specimen weights. Interestingly, for glands <40 grams as well as 40-80

grams, they found that best estimate was rendered by the prolate spheroid volume

formula:

( )

For prostates greater than 80 grams, the best formula was:

8
 .

The fact that a different formula describes prostate volume at larger sizes may suggest

that as the prostate grows it does not do so uniformly and its shape is affected by

surrounding tissues (bladder, rectum, pelvic floor). As not all necessary dimensions

were readily available in the medical record, we were unable to evaluate the accuracy of

this formula in our patient population.

Secondly, we could not adequately account for median lobe volume. The presence or

absence of a median lobe was noted, but it is not routine to perform a separate volume

measurement in our practice. We found that the median lobe was generally easier to

note in TRUS exams but not as well with PUS unless it was very large. Knowing the

specific dimensions of the median lobe would be useful to exclude from the

measurement since a median lobe will not fit the ellipsoid calculation. Future studies

would attempt to quantify median lobe volume separately and take this into account

when calculating overall prostate volume.

Another limitation of our study was the inability to control for bladder volume at the time

of PUS. Yuen et al. found that there was decreasing intravesical protrusion with

increasing bladder volumes11. They specifically concluded that PUS measurements of

the same prostate measured correlated well when bladder volumes were less than 400

milliliters. In our practice, we encourage patients to come to the clinic with a full bladder

prior to imaging, however volumes are variable and is a potentially confounding variable

based on the amount of intravesical prostatic protrusion.

9
Lastly, there may have been both inter-operator variability and variability within a single

operator in ultrasound measurements. Although all ultrasounds were performed by our

dedicated ultrasonographer, a small percentage of the PUS were performed by

attending urologists. Our analysis could have been strengthened by having all

measurements performed by a single operator or centrally read, however, considering

the small percentage of measurements performed by attending urologists, the findings

of our study would unlikely change significantly. Regarding variability within a single

operator, a study in 1996 by Bazinet et al found an average of 25% variability between

two consecutive measurements of the prostate for the same patient when measured by

one of five attending urologists who had performed 5000 cumulative TRUS

evaluations12. While we recognize that variability is a concern in many practices, our

dedicated and certified ultrasonographer has performed more than 10,000 of each PUS

and TRUS exams in his 40 year career. Additionally, ultrasound technology has

improved over the last few decades, especially with respect to spatial resolution, which

in turn would decrease the variability of prostate measurements and calculated

volumes13,14,15,16. While potential variability in measurements cannot be ignored, the

recent improvements in ultrasound technology and extensive experience of our

ultrasonographer help minimize this effect.

In addition to limitations of our study, it is worthwhile to note that while ultrasound helps

guide surgical management of patients with BPH, there are situations in which imaging

alone is insufficient and cystoscopy is warranted. This would include concern for

10
secondary pathology such as urethral stricture, tumor, or bladder stones. In select

circumstances, findings on cystoscopy may alter surgical planning if anatomy suggests

that a transurethral approach is not feasible and a simple prostatectomy is more

appropriate.

Ultrasound remains an invaluable tool in the urologist’s arsenal. It is rapid, portable,

cheap, and every attempt should be made to minimize patient discomfort. We have

shown that PUS is an excellent surrogate for TRUS in the majority of cases, but its

utility may be limited in patients with extremely large prostates that require a surgical

intervention. As the technology advances (i.e. 3D, high resolution, high frequency, step-

section planimetry), it is likely that the accuracy of prostate volume measurement will

improve and compete with that of cross-sectional imaging. A future study by our group

will similarly compare volumes measured by prostate US versus magnetic resonance

imaging (MRI) in the same population. Additionally, given the limited agreement at

larger prostates in our study, comparing different volume estimation formulas would

shed light on what calculation method is best for different sizes.

Conclusion

For prostates less than 30cc, we found that PUS is interchangeable with TRUS in

estimating prostate volume. However, for larger prostates where size may alter surgical

management, we would recommend TRUS or cross-sectional imaging.

11
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Figures legends:

 Figure 1. Correlation scatter plot of prostate volumes measured by TRUS versus

PUS. Dashed line is the trendline for the scatter plot. R2 is variance and is equal

to 0.7529.

 Figure 2. Bland-Altman analysis plot of prostate volumes measured by TRUS

versus PUS. Middle solid line is the mean difference (volPUS – volTRUS). The upper

and lower dashed lines are the limits of agreement (95% confidence interval).

Upper and lower solid lines are the clinically acceptable limits, defined in our

study as within 10cc of the mean difference.

 Figure 3. Bland-Altman analysis plot of prostate volumes measured by TRUS

versus PUS for (a) ≤ 30cm3, (b) 31-50 cm3 (c) 51-80 cm3, and (d) > 80 cm3.

Middle dashed line is the mean difference (volPUS – volTRUS). The upper and lower

dashed lines are the limits of agreement (95% confidence interval). Upper and

lower solid lines are the clinically acceptable limits, defined in our study as within

10cc of the mean difference.

15
 Table 1. Patient characteristics
______________________________________________________________________
Total number of patients 236
Median age (years) 63
Median PSA (ng/mL) 7.6
3
Median prostate size (cm )
Measured by PUS 52
Measured by TRUS 50

No. race (%) No. BMI (%)

Black 114 <25 kg/m2 50 (21)
(49)
White 48 (20) 25-30 kg/m2 95 (40)
Hispanic 41 (17) >30 kg/m2 51 (22)
Asian 12 (5) Not recorded 40 (17)
Other/Unknown 21 (9)

No. prostate size by PUS (%) No. time between US (%)

≤ 30 cm3 31 (13) 1-14 days 56 (24)
31-50 cm3 80 (34) 15-31 days 61 (26)
51-80 cm3 77 (33) 32-61 days 54 (23)
>80 cm3 48 (20) >61 days 65 (28)

16
Fig 1

17
Fig 2

18
Fig 3

19