Letter: Comparison of Collagenase Clostridium histolyticum to Surgery for the Management of Peyronie's Disease: A Randomized Trial

Abstract

overweighting of the contribution of antibiotic prophylaxis to the primary outcome. Our RCT compared the 2 prostate biopsy procedures exactly as those were being performed in our system prior to initiating the trial utilizing an unstratified randomization approach, that is, a real-world pragmatic design. The details of the procedural protocol would not affect the actual random assignment of an individual to a given procedure.The authors are concerned that the lack of antibiotic prophylaxis for transperineal prostate biopsy (TP-Bx) may have contributed to an overestimation of infectious complications in this group. The implication is that this could have placed the TP-Bx group at a disadvantage, and that the use of antibiotic prophylaxis in this group could have resulted in fewer infectious complications. In RCTs, some procedural or cohort differences are not unusual, and their effect on the study outcome is not uniformly weighted. For example, the transrectal prostate biopsy (TR-Bx) group had twice as many patients with previous antibiotic exposure (a known risk factor for postbiopsy infections) which could place the TR-Bx group at a relative disadvantage. 2 More importantly, the main concern expressed by the authors is addressed by studies referenced in the letter indicating that infection rates after TP-Bx were similar regardless of the use of antibiotic prophylaxis. 3 Accordingly, it is unlikely that the use of prophylactic antibiotics in the TP-Bx group in our study would have resulted in a lower infection rate or a favorable outcome for the TP-Bx group.The letter refers to an infectious advantage to TP-Bx (over TR-Bx), yet no such advantage has been demonstrated by any level 1 evidence from our and other trials. 4 The authors suggest a potential increased burden and cost of antibiotic prophylaxis, but mere inference is insufficient, and this should be elaborated and specifically studied. In conducting a holistic assessment of comparative effectiveness of these procedures, it's important to include all costs and burdens of the procedures and not selectively focus on one aspect alone.The use of antibiotic prophylaxis perhaps invokes variable reactions and different meanings for different practitioners. It is critical to maintain proper context and not unduly equate a single-dose, single-day antibiotic prophylaxis with long-term prophylaxis and its attendant downstream negative consequences. 5 It is instructive for the readers to consider that the ongoing trials mentioned in the letter, as perhaps more appropriate comparisons, are designed to evaluate cancer detection as the prespecified primary outcome, and not infectious or prophylaxis assessment. Such extrapolations to draw secondary or tertiary inferences, or assert alternative hypotheses that align with our beliefs are inevitable.However, such extrapolations are also scientifically unsound, especially when those encroach upon the prespecified primary outcomes. We look forward to the ongoing studies for robust evaluation of other important aspects includ...