Transperineal ultrasound-guided prostate biopsy: what the radiologist needs to know

Jack Power, Mark Murphy, Barry Hutchinson, Daragh Murphy, Michelle McNicholas, Kiaran O’Malley, John Murray & Carmel Cronin
Published: 25 April 2022
Insights into Imaging volume 13, Article number: 77 (2022)

Abstract

Transperineal ultrasound-guided (TP) prostate biopsy has been shown to significantly decrease the risk of post-procedural sepsis when compared to transrectal ultrasound-guided (TRUS) prostate biopsy. With guidance from the European Urology Association favouring adoption of a TP biopsy route, it is clear that, despite being a more technically challenging procedure, TP biopsy in an outpatient setting will replace TRUS biopsy. This paper gives the reader a succinct summary of outpatient transperineal prostate biopsy under local anaesthetic utilising a free-hand ultrasound technique. Patient preparation and consent process is outlined. A comprehensive pictorial review of the procedure, pitfalls and common post-procedural outcomes is presented. This paper provides a framework and guide for those wishing to adopt the transperineal approach under local anaesthetic.

Key Points

• Transperineal ultrasound-guided (TP) biopsy reduces the risk of post-procedural sepsis versus transrectal ultrasound-guided (TRUS) biopsy.
• TP biopsy can be performed safely as an outpatient, under local anaesthetic.
• TP biopsy can successfully replace TRUS biopsy in diagnosis of prostate cancer.

Background

Transrectal ultrasound-guided prostate (TRUS) biopsy is the most common method of prostate biopsy worldwide [1]. TRUS biopsy has long been associated with a significant risk of sepsis, with 12 biopsies usually taken through an inherently contaminated ‘transfaecal’ route [2]. In 2013, a Canadian study of 75,190 men found a fourfold increased risk of hospitalisation following TRUS biopsy over the decade 1996–2005 [3]. This risk of sepsis post-TRUS biopsy has been increasing over time due to increasing rates of multi-drug resistant bacteria with extended-spectrum β-lactamase (ESBL) and quinolone-resistant bacteria now routinely seen in rectal flora [4]. Reflecting this, a Canadian study reported that the incidence of infection had significantly increased from 0.52% in 2002–2009 to 2.15% in 2010–2011 (p < 0.001) [5]. This increasing risk of sepsis has also been seen in studies in Europe [6].

Transperineal ultrasound-guided prostate (TP) biopsy is performed with the ultrasound probe in the rectum and the biopsy samples taken through the perineum. TP biopsy is considered a ‘clean’ procedure, compared to TRUS biopsy being a ‘contaminated’ procedure. TP biopsy has traditionally been performed under general anaesthetic and ‘Template biopsy sampling’ has been employed in this setting with the number of cores varying between 20 and 45 [7]. Transperineal biopsy has been shown to have significantly reduced rates of post-procedural infection [8,9,10,11,12]. A systematic review and meta-analysis performed in 2019 showed no difference in diagnostic accuracy between TRUS and TP biopsy (RR 0.94, 95% CI 0.81–1.10), while showing a significant protection from rectal bleeding and fever in the transperineal biopsy populations (RR = 0.02, 95% CI 0.01–0.06 and RR = 0.26, 95% CI 0.14–0.28, respectively) [10]. This review involved randomised control trials (RCT) comparing the two routes of biopsy, however, the TP biopsy populations involved were primarily those performed under general anaesthetic with a template biopsy technique. This involved multiple punctures to the skin, usually in selected patients who had already undergone TRUS biopsy with either negative results and high clinical suspicion or a history of prior sepsis.

TP biopsy under local anaesthetic has the potential to be offered to all patients in an outpatient day-case setting. Szabo performed a literature review in February 2021 looking at all papers (RCT, case–control, case series) that involved ‘free-hand’ TP biopsy performed under local anaesthetic. In his review of over 7,000 biopsies, the pooled data showed 0 cases of sepsis (0.0% [0/7396]) [13]. With encouraging studies, such as those above, TP biopsy under local anaesthetic is becoming popularised. Papers such as ‘TREXIT 2020’ have highlighted the benefits of moving from a contaminated to a clean procedure and have implored radiology and urology colleagues to join them in this transition [14]. In fact, Pilatz et al. state in the recent European Association of Urology position paper on the prevention of infectious complications following prostate Biopsy that ‘Available evidence highlights that it is time for the urological community to switch from a transrectal to a transperineal PB approach despite any possible logistical challenges’ [15].’

We provide an in-depth guide for Radiologists wishing to perform this important procedure from patient consent to post-procedure care.

Read the full paper here.