Prostate Biopsies

The shift from transrectal (TRUS) to transperineal (TP) prostate biopsies was driven by key clinical data highlighting significant advantages in safety, diagnostic accuracy, and infection control. Below is a summary of the critical clinical evidence that prompted this transition:

Key Clinical Data for Prostate Biopsies


Infection Rates

Transrectal Biopsies:

- Risk of infection due to rectal flora entering the bloodstream.

- Post-biopsy sepsis rates ranged from 2-7%, even with prophylactic antibiotics.

Transperineal Biopsies:

- Avoid the rectal wall, significantly reducing infection risk.

- Sepsis rates are almost negligible (<0.1%) when performed with sterile technique.



Accuracy in Cancer Detection

Transperineal Biopsies:

- Improved sampling of anterior (top) and apical regions of the prostate, areas often under-sampled with TRUS.

- More accurate in detecting clinically significant prostate cancer, particularly in men with anterior lesions or prior negative biopsies.

- Studies show higher detection rates for Gleason ≥3+4 cancers with TP biopsies.



Complication Profiles

Transrectal Biopsies:

- Higher rates of urinary tract infections (UTIs), prostatitis, and rectal bleeding.

Transperineal Biopsies:

- Lower rates of complications, including hematuria and bleeding.

- Minimal post-procedure discomfort due to local anesthesia or sedation.


Emerging Technologies and Techniques

- The introduction of MRI-Targeted Biopsy using a transperineal approach facilitated precise sampling.

- TP biopsies allow for better integration of fusion imaging for targeted biopsy and saturation techniques for comprehensive sampling.



Antibiotic Resistance Concerns

- Increasing global prevalence of multi-drug-resistant organisms made reliance on antibiotics in TRUS biopsies less effective and riskier.

- TP biopsies reduced dependence on prophylactic antibiotics, addressing this public health issue.



Patient Outcomes

- Improved detection of aggressive cancers and reduced detection of clinically insignificant cancers, minimizing overtreatment.

- Enhanced patient safety, especially in high-risk populations (e.g., immunocompromised or diabetic patients).



Landmark Studies and Guidelines

- Giorgio Gandaglia et al. (2017): Demonstrated lower infection rates and superior detection of anterior prostate cancers with TP biopsies.

- PRECISION Trial (2018): Highlighted the effectiveness of MRI-targeted biopsies, often performed transperineally.

- EAU Guidelines: Recommend transperineal biopsy for its superior safety profile and accuracy.

- BAUS and NICE Guidelines (UK): Endorse TP biopsies as the preferred method for prostate cancer diagnosis.



Conclusion

The move from TRUS to TP biopsies reflects a paradigm shift driven by evidence of reduced infection risks, improved diagnostic accuracy, and better patient outcomes, making TP biopsies the gold standard for prostate cancer diagnosis in many centres worldwide.

How does a transperineal biopsy work?

How effective is a TP biopsy in diagnosing prostate cancer?

Check out this 2023 report by the National Institute for Health and Care Excellence (NICE).