SUO 2021: Integrating Transperineal Prostate Biopsy Into the Clinic: Logistical Considerations for Practice

(UroToday.com) In a plenary session of the Society of Urologic Oncology Annual Meeting focused on transperineal prostate biopsy, Dr. Ashley Ross discussed integrating transperineal biopsy into the clinic.


He began by highlighting that the goals of a diagnostic prostate biopsy are to detect clinically significant disease and optimize biopsy to reduce patient morbidity and financial toxicity. One of the key ways to maximize detection of clinically significant disease, as highlighted previously by Dr. Schaeffer, is to biopsy appropriate patients on the basis of selection using multiparametric MRI and/or biomarkers to enrich for detection of clinically significant grade group 2 or greater disease while minimizing negative biopsies and the detection of grade group 1 disease.

Commenting on the historical standard of transrectal biopsy, he highlighted that the advantages of this approach including that it can be performed in the office with regional anesthesia and a short procedural time. Further, MRI-fusion approaches are readily available. However, rates of infectious complications are rising due to fluoroquinolone resistance as a result of poor antibiotic stewardship. Additionally, as highlighted by the FDA, fluoroquinolone use can lead to “disabling and potentially permanent serious side effects”.

In contrast, there are both benefits and drawbacks to a transperineal approach. There is a decreased infection rate, decreased or no need for antibiotics, and potentially improved anterior and apical sampling. However, traditionally, it has required more extensive anesthesia with increased time, cost, and patient risk, as well as an increased risk of urinary retention. However, each of these has been predicated on experience based on procedures performed in the operating room. This is largely due to the historical use of the grid/stepper approach.

However, to widely implement transperineal biopsy, we would seek to have an office-based procedure that can be performed in less than 30 minutes, is well tolerated with local/regional anesthesia, has a low complication rate, and does not compromise on diagnostic accuracy. In Dr. Ross’s view, a free hand perineal biopsy approach can accomplish this. He emphasized that this approach allows a single perineal entry point. However, it can be difficult with this approach to align the needle. More recently, Dr. Ross highlighted that the PrecisionPoint transperineal access system allows a fixed alignment of the needle guide and TRUS probe. This tethering allows for the needle to better align with the ultrasound crystals. This makes the biopsy more facile and decreases procedural time.

Dr. Ross further emphasized that it is important to allow for MRI-US fusion. Tethering devices allow for compatibility with many fusion platforms to allow for a transperineal fusion biopsy. 

He further highlighted that a freehand-based biopsy approach yields similar diagnosis rates of grade group 2-5 prostate cancer as a grid-based transperineal prostate biopsy, will have lower complication rates. In particular, a grid-based biopsy is associated with high rates of urinary retention (up to 10%), as well as longer procedural and operating times.

Currently, Dr. Ross emphasized that he performs freehand, tethered perineal biopsy using the PrecisionPoint device, with MRI-US fusion. He does not use antibiotics and uses buffered lidocaine for local and regional block (skin in the perineum and the peri-apical triangle block) without systemic anesthetic or anxiolytic. With this approach, he has less than 15 minutes of procedural time and less than 30 minutes total time. He emphasized that only the biopsying physician and a medical assistant are needed.

In terms of performing the procedure, he emphasized the importance of the lateral and vertical swinging movements of the ultrasound probe, with rotational movement being secondary.

Presented by: Ashley Ross, MD, PhD, Urology Specialist, Northwestern Medicine