PANEL DISCUSSION: Transrectal vs Transperineal Biopsy for Detecting Prostate Cancer

By: Edward Schaeffer, MD, PhD, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Jim C. Hu, MD, MPH, Weill Cornell Medicine, New York, New York | Posted on: 06 Apr 2023

Back to the Future. Learn why urologists should consider adopting percutaneous transperineally prostate biopsy at the AUA2023 plenary session Friday, April 28. This session will focus on transperineal prostate biopsies—best approaches, special considerations, and adoption into practice.

In the U.S., more than one million prostate biopsies are performed annually.1 Despite advances in pre-biopsy biomarkers and MRI that reduced the number of prostate biopsies, there will still be an overall rise in biopsy volume due to demographic growth of the aging male population. Moreover, 44% of U.S. men undergoing an initial biopsy will have a repeat biopsy within 5 years.2 Additionally, more than half of men diagnosed with prostate cancer currently opt for active surveillance that leads to use of serial repeat prostate biopsies to monitor for disease progression.3 Thus, there are several compelling reasons why prostate biopsy volume will increase significantly with time.

Prostate biopsies are not a procedure completely free of risk. Throughout the last century prostate biopsy techniques evolved, with technological advances and urology-led refinements in biopsy technique. The early prostate biopsies were performed through a percutaneous, transperineal approach, which fell out of favor when transrectal ultrasound technology advanced and permitted enhanced image-guided biopsies. In the last decade, the transrectal approach was further enhanced with the addition of MRI-ultrasound fusion platforms. Several randomized trials demonstrated that these modern approaches enhance the detection of higher-grade prostate cancers while reducing unnecessary biopsies.4 Despite these advantages, transrectal prostate biopsies have a 5%-7% risk of post-biopsy infection despite antimicrobial prophylaxis.5 These infections significantly impact individual patients and, more broadly, the health care system. With this in mind, professional guidelines recommend strategies to minimize biopsy-related infection risk, such as transperineal biopsy and targeted prophylaxis.5

More recently, urologists reimagined transperineal prostate biopsy, as it offers the potential for both lower infection risks and enhanced cancer detection through better sampling of the anterior prostate (see Figure).6-10 Preliminary evidence was derived from transperineal prostate biopsies performed under general anesthesia with a brachytherapy grid-based approach. Although effective, this approach is associated with different and equally significant complications that include increased bleeding risk, pain, and urinary retention.9 Also, there are enhanced health care–related costs due to the augmented care required in a surgery center with anesthesia/sedation. Together, these headwinds limited widespread adoption of percutaneous transperineal prostate biopsies. However, in the last decade, an improved understanding of administering transperineal anesthesia11,12 and a click-on adapter to ultrasound probe pioneered by urologist Matthew Allaway, enabled a freehand, cognitive MRI-ultrasound fusion approach that has a relatively short learning curve, merging the potential benefits of percutaneous transperineal prostate biopsy with an in-office platform.

Figure. Sagital view of male pelvis demonstrating 2 approaches (transperineal and transrectal) to access the prostate gland for a biopsy.

Targeted prophylaxis is another strategy to decrease the risk of transrectal biopsy infection, and it is vastly underutilized compared to augmented prophylaxis. Moreover, while targeted prophylaxis promotes antibiotic stewardship, there are few prospective studies assessing its effectiveness. Our AUA2023 plenary session will address this evolving space and significant evidence gaps concerning the comparative effectiveness of transperineal vs transrectal prostate biopsy in improving infections, noninfectious complications (bleeding, urinary retention), pain and discomfort, and detection of clinically significant cancer.

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