AUA2021 Crossfire Debate: Prostate Biopsy Dilemma: TRUS versus Transperineal

By: Art Rastinehad, DO., FACOS; Peter Chiu, MBChB, PhD, FRCSEd; Hashim U. Ahmed, FRCS, PhD, BM, BCh, MA; Arvin George, MD; Thomas Polascik, MD | Posted on: 03 Sep 2021

The AUA Crossfire debate on Friday, September 10 will feature the timely topic, “The Prostate Biopsy Dilemma: TRUS [transrectal ultrasound] versus Transperineal Biopsy.” Four experts will debate the pros and cons of each approach, featuring Dr. Peter Chiu and Dr. Hashim Ahmed representing the transperineal side while Drs. Arvin George and Thomas Polascik will present arguments for TRUS biopsy. The debate will be moderated by Dr. Art Rastinehad.

This is a contemporary and germane topic that affects the clinical practice of almost every urologist worldwide. “For many years, TRUS prostate biopsy has been our reliable workhorse,” states Thomas Polascik, “and has performed very well across multiple settings. However, there has been growing concern for infection and quinolone resistance that has led to a paradigm shift that now favors the transperineal biopsy, at least from the vantage of a reduction of infectious complications.”

Fluoroquinolones have performed exceptionally well in the 1990s and early 2000s with minimal side effects, providing good prophylactic coverage for prostate biopsy. In fact, their use has been adopted by the AUA best practices guidelines for prostate biopsy. However, there has been an increasing number of clinical papers and reports internationally that describe the rise of fluoroquinolone resistance with an overall infection or sepsis rate of approximately 3%. Post-biopsy prostatitis symptoms and urinary tract infection following biopsy can be seen in up to 15% to 20%, depending on the definition used. To surmount the concern to prevent biopsy-induced infections in otherwise healthy patients, we have seen measures such as using various antibiotics delivered either intramuscularly or intravenously, enhanced antibiotic prophylactic utilizing more than 1 type of antibiotic or targeting antibiotic prophylaxis based on rectal swab culture results. “However, none of these enhanced antibiotic techniques have performed exceptionally well and for that reason there’s been a groundswell to convert the conventional TRUS biopsy to the transperineal approach. Indeed, for the first time, the [European Association of Urology] prostate cancer guidelines recommend [the transperineal] route as the first choice for prostate biopsy this year,” states Dr. Peter Chiu.

Dr. Hashim Ahmed will argue that the prostate cancer detection rate by the transperineal approach is very good and that many of these procedures don’t even require antibiotics when performed in a clean fashion. The infection rate for the transperineal approach has been exceedingly low with on average only 1 in 500 getting sepsis. “There is of course a greater public health case for switching to transperineal biopsy in order to meet our individual physician duty towards antibiotic stewardship.”

Discussion points for this debate will focus on what is considered standard of care in various communities, the simplicity and efficiency of the various approaches and the complication rates; also, debaters may touch on comfort levels for patients undergoing biopsy. Some of the complications, in addition to infection and sepsis, include acute retention and bleeding.

Also for debate will be some of the costs associated with these 2 techniques in terms of equipment, expense and time/resources invested. Is the transperineal approach deliverable in an outpatient office setting or does this require special equipment and anesthesia? Also, is the thinking similar or different across the continents, as Dr. Chiu will provide a perspective from Asia and Dr. Ahmed from Europe.

Even though the 4 discussants will be taking a position for 1 of these 2 biopsy approaches, all have extensive experience with both techniques.Dr. Art Rastinehad says that “physicians need to make a decision regarding which approach they will endorse and then prospectively set up a program of excellence in their practice.” In his institution, he has converted all biopsies to transperineal access, and has made it relatively straightforward and standardized for his urology partners practicing in their clinical setting. Dr. Arvin George states that there is, “some comfort and inertia level to continue with TRUS biopsies and often more challenging to implement a transperineal biopsy program with new work flow. Transperineal biopsies are in general more painful than transrectal biopsies, and in the old days used to be intolerable under local anesthesia.”

Dr. Hashim Ahmed feels that in the future we will be biopsying fewer patients, taking fewer random so-called systematic biopsies and concentrating on targeted biopsies based upon magnetic resonance imaging findings. Many urologists worldwide have already embraced this vision of the image-guided approach, but it still needs to be implemented amongst the general and community urology workforce.

The debate on the approach to prostate biopsy promises to be lively and informative. Come and see if this debate and the arguments presented will change your mind about what you will offer your patients in the future.