Overcoming Barriers to Performing Transperineal Prostate Biopsies - Editorial

Much of the push to perform transperineal prostate biopsy has been driven by concerns about increasing rates of sepsis associated with the transrectal approach to needle biopsy.

Historically, the strategy to minimize the infective complications of prostate biopsy had relied upon using more and more potent antibiotic regimens to combat growing bacterial resistance. A more recent approach to mitigate the risk of sepsis has been to use the more potent antibiotics in a targeted manner guided by rectal swabs prior to biopsy. However, the concept of chasing increasing antibiotic resistance with increasingly powerful antibiotics is a strategy that will never win. 

The transperineal approach to prostate needle biopsy is a logical way forward given that the risk of biopsy sepsis is minimal. It should be the standard of care approach to prostate biopsy but there is a reluctance to change practice and much of this is based upon the arguments that expensive equipment is necessary and that a general anesthetic is necessary. Recent advances are seeing these issues overcome.

The article “Feasibility of freehand MRI/US cognitive fusion transperineal biopsy of the prostate in local anesthesia as in-office procedure— experience with 400 patients” by Wetterauer and colleagues seeks to address the anesthetic issues. This study does use an inexpensive freehand approach that does not require special equipment but the focus of the study is directed to the feasibility of the local anesthesia approach with transperineal prostate biopsy.

The technique for the delivery of local anesthetic is different from the transrectal approach. Following initial skin infiltration at a single entry point approximately 1.5cm, 45 degrees above and lateral to the anus on each side, a 16 gauge needle is placed and acts as a guide for the biopsy gun needle. The cohort of 400 subjects in this study included those undergoing targeted biopsies, systematic biopsies or both.

The median pain score was 2 based upon a visual analog scale and the median number of biopsy cores taken was 13. It was interesting to note the impressions of 42 men who had undergone transrectal prostate biopsies previously. Just over half of these men considered the transperineal approach to be less painful, and about a third considered the two approaches to be associated with similarly low levels of pain. These results are of course potentially influenced by recall bias and researcher bias.

In spite of study limitations in being a single surgeon, single-center and retrospective cohort study, it appears that performing transperineal biopsies under local anesthetic is feasible. Some might insist that there should be a randomized controlled trial to examine pain differences. However, there is perhaps a greater argument that performing such a trial could be unethical on the basis of known sepsis risk following transrectal prostate biopsies.

We can expect to see more data to confirm that the barriers to performing transperineal prostate biopsies can be overcome. There can only be excuses for so long.

Written by: Henry Woo, MBBS, DMedSc, FRACS, Professor of Surgery, Sydney Adventist Clinical School, University of Sydney, Director of Uro-Oncology, Professor of Robotic Cancer Surgery, Chris O’Brien Lifehouse Comprehensive Cancer Centre, Camperdown, Australia

Read the Full-Text Article: Feasibility of Freehand MRI/US Cognitive Fusion Transperineal Biopsy of the Prostate in Local Anaesthesia as In-Office Procedure— Experience with 400 Patients - Full-Text Article

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