Over 1 million prostate biopsies are performed in the U.S. annually, making it one of the most common urological procedures. It is estimated that we spend $2.5 billion on prostate biopsies annually, making it a major contributor to the national health care cost burden.^1,2 Urologists should focus on the strategies that augment patient diagnosis while keeping cost containment in view. There has been an evolution of different biopsy approaches available today that offer an opportunity for the urology community to incorporate cost-mindfulness into daily practice while maintaining quality care. While cost can be a challenging metric to ascertain with intense geographical variability, we outline below some established considerations.

After the decision to biopsy, the patient and urologist must make a decision regarding approach and targeting (fig. 1), yielding several possible biopsy options, each with different cost structures (fig. 2).^3,4

Figure 1. Decision tree diagraming available options for prostate biopsy. OR, operating room.

Figure 2. Estimated median total cost of prostate biopsy by setting, MRI and approach using cost data from Leung et al (commercial claims data),³ Altok et al (academic, single institutional data)⁴ and cost of PrecisionPoint™ Transperineal Access System for TP-bx (estimated $200). Median total costs do not factor any capital or downstream cost. OR, operating room.

The traditional 12-core transrectal ultrasound-guided prostate biopsy (TR-bx) has been standard of care for over 40 years and remains the most popular approach. More recently, the transperineal approach to prostate biopsy (TP-bx) has gained traction owing to its decreased risk of infectious complications, increased accuracy and ability to sample the apex of the prostate.

Recent studies underscoring the role of magnetic resonance imaging (MRI) and ability to reduce low-risk prostate cancer diagnosis have helped usher in the “targeted biopsy era.”⁵ While deploying prebiopsy prostate MRI is becoming increasingly popular and is now the gold standard in some countries, many maintain this strategy is cost prohibitive.

Leung et al approached the issue of biopsy cost by examining commercial claims data and extracted individual costs including imaging, pathology and anesthesia. They found MRI-targeted biopsy was the most expensive modality compared to TR-bx or TP-bx ($4,396 vs $1,869 vs $2,849) largely due to cost of imaging, which contributed an average cost of $1,704.³ These cost trends have been corroborated by other groups, as well.⁴

TP-bx Methods

Traditional template TP-bx using a grid historically necessitates general anesthetic. However, evolution of a freehand TP-bx technique has gained popularity and has been shown to be well tolerated in the office. Thus, many have transitioned to TP-bx in office, offering an obvious opportunity for cost savings with some showing ability to decrease cost nearly 40% by eliminating most anesthesia and facility fees.⁴ If freehand TP-bx is performed in the office, the cost becomes nearly identical to standard TR-bx, except for the addition of a transperineal biopsy access unit. Certain centers avoid commercially available transperineal biopsy access units and instead utilize a 14 g angiocatheter for transperineal access, thereby producing additional cost savings, but at the potential impairment of precise needle localization during the procedure.

Capital Cost Considerations

Upfront cost of implementing a new biopsy technique is not insignificant. Relative to TR-bx, TP-bx requires education, a unique biopsy apparatus and may involve use of a different ultrasound probe or machine, and frequently requires new patient beds for the male in lithotomy position. A transition to MRI targeted biopsy requires the purchase of commercial hardware and software (typically in the $200,000 range) as well as a service agreement (typically $130,000 over several years) that can total more than $300,000 of capital spending (estimates of InVivo™ pricing, 2020). In addition to an MRI facility, a radiologist facile in prostate MRI interpretation is a requirement. Implementation of these modalities involves a learning curve for the urologist, as well as training for staff which adds a less tangible cost.

Downstream Cost Savings

Both TR-bx and TP-bx approaches are associated with unique downstream costs, primarily hospitalizations for biopsy-related complications and misdiagnosis at time of biopsy. Transperineal approach avoids introduction of the rectal flora into the prostate and lowers infectious complications considerably. Unfortunately, infectious complications after TR-bx can be as high as 7%, and rates of sepsis nearing 3% have been reported,⁶ whereas a recent meta-analysis revealed an infectious complication rate after TP-bx around 0.1%, regardless of prophylactic antibiotic.⁷ Cost of admissions for sepsis after prostate biopsy is significant and has been estimated to total $8,672 to $19,100 per episode.⁸ Finally, comparison of the cost to care for complications after TR-bx vs TP-bx showed over a fourfold increase in cost of admissions related to TR-bx complications relative to TP-bx.⁹

Traditional practice of random biopsy for suspicion of prostate cancer often leads to unnecessary biopsy, as well as over-diagnosis of low-risk prostate cancer, both major sources of additional downstream cost. Addition of prostate MRI to the diagnosis algorithm has been suggested to improve accuracy. A randomized study evaluating MRI-targeted or standard biopsy showed that prostate MRI decreased negative biopsy (21% vs 40%), increased detection of clinically significant prostate cancer (38% vs 26%) and helped to avoid 28% of biopsies with negative MRI.⁵ In another study using cost modeling to investigate cost-effectiveness of prostate MRI, it was shown that use of prostate MRI after elevated prostate specific antigen was more cost effective than standard biopsy alone and helped omit 15% of unnecessary biopsies.¹⁰

On a policy level, reimbursement for prostate biopsy in the U.S. is the same regardless of approach. However, in countries such as Australia, urologists are financially incentivized to perform the transperineal approach as it pays 2.4× more than the transrectal approach. If this policy were implemented in other countries, it would present an opportunity cost for urologists performing TR-bx and incentivize physicians to learn TP-bx.

Achieving a cost-effective prostate biopsy approach provides an opportunity to mitigate waste, decrease the financial burden placed on our patients and provide a high-quality diagnosis. While establishing a new biopsy modality can have expensive capital cost, it should be factored against downstream savings unique to each modality. An increasing body of evidence indicates that advances in technique and targeting have moved the needle, inching us closer to the intersection between cost and quality.