In an earlier post, I indicated my choice four years ago to have my confirmatory biopsy at Brigham Women's Hospital in Boston, MA. I chose to have an MRI-guided in-bore transperineal biopsy performed by an interventional radiologist. At the time, I had read about the differences in approaches – a biopsy through the rectum as opposed to the perineum, and although I didn’t know much more than the advice given to me at the time – that it carried much less risk of infection than the transrectal approach – I made the trip to Boston. One of the subjective readings on my first MRI contained a PI-RADS 4/5 score, and it was that reading used to target suspicious areas. As I was also inside the MRI tube, the doctor could see images transmitted from the machine, and with those, he included a systematic sampling of the prostate during the procedure.
The results were all benign, and with some noticeable relief, I continued on a path of Active Surveillance.
Since then, I learned that transperineal biopsy had been around as early as the start of the 20th century. See this abstract for a comprehensive examination of the TP approach and its history, published by the NIH, https://pubmed.ncbi.nlm.nih.gov/35620643/ with the complete article available at https://journals.sagepub.com/doi/10.1177/17562872221100590. For your quick reference, the following is the conclusion:
“The modern TP PBx reflects a significant reversion to what was once the gold standard. Dating back nearly one century ago, a TP approach was first utilized to biopsy the prostate with an open perineal PBx persisting as standard for much of the 20th century. Moving forward, the TP approach evolved in efforts to maximize diagnostic accuracy and minimize morbidity. Despite these innovations, TR PBx has persisted as the dominant method since the 1980s due to the convenience and efficacy found with the use of TRUS and sextant sampling. Recently, data have accumulated indicating significant infectious concerns and some diagnostic limitations of a TR approach versus a TP approach. Furthermore, major advancements in prostate imaging, development of effective local anesthesia technique, assistive technology (i.e., TP access systems, robotic assistance), and implications in newer treatments (i.e., focal therapy) have made TP PBx more convenient, safe, and efficacious. This significant evolution over the past 100 years has facilitated the modern TP PBx’s movement into standard practice that will likely persist for years to come.”
Fast forward to an abstract published in February 2021 titled “Transperineal prostate biopsy: The modern gold standard to prostate cancer diagnosis,” the conclusion of which states:
“…The transperineal approach for prostate biopsy offers superior features when compared with TRPBx and is a feasible procedure in the inpatient and outpatient setting. Multiparametric MRI offers an additional advantage to the transperineal approach. Nevertheless, prospective studies directly comparing TRPBx and TPPBx with mpMRI-targeted biopsies are needed to prove superiority of either concept.
Main Points
· Transperineal prostate biopsy achieves comparable cancer detection rates with transrectal prostate biopsy in biopsy-naive patients but is superior in cases of prior transrectal biopsies and active surveillance.
· Transperineal biopsy offers a superior access to the anterior and apical prostate regions.· Infectious complications are nullified with the transperineal method.
· Transperineal biopsy can also be performed with local anesthesia, is feasible in an outpatient setting, has a moderate learning curve and a good reproducibility.
· Multiparametric MRI augments the function of transperineal prostate biopsy and focal therapy can be easily applied transperineally.”
Read the full abstract here:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057359/
There are plenty of studies of the transperineal approach’s efficacy over the transrectal in the US and abroad. The 2022 European Association of Urology guidelines champion its use https://uroweb.org/guidelines/prostate-cancer, although its prevalence of use in Europe has not moved the needle in the US as the preferred approach over TRUS; neither the NCCN nor the AUA has included it in their guidelines.
TP is gaining more traction lately, especially with patients, given the amount of attention the subject receives in the prostate cancer support circles. With the invention of the Precision Point Transperineal Access System (PPTAS) by Matthew Allaway, MD of Cumberland, Maryland, and CEO of the medical device company, Perineologic, https://perineologic.com/aboutpl-2/ men have a choice, where possible, of undergoing this biopsy in an office setting with local anesthesia only, or a hospital if the patient chooses a form of sedation or general anesthesia. And although, in certain circumstances, they might be used, the inventor intended to obviate the need for antibiotics—more on this in upcoming installments.
Similar to what lies behind many PCa screenings, tests, and procedures, patients often hear conflicting viewpoints. The TP approach is no exception to that rule. My main point in this series of posts on TP biopsies is to unravel some of the mysteries of why it may not be so available to many patients across the country – without some requisite travel. I aim to inform men following the AS management protocol AND those who have just been screened or are awaiting their first PSA screening test or results from biomarkers such as the MRI (pre-biopsy). I include the latter group because, down the line, if it comes to pass that a man's urologist gives him the results of a PSA blood draw which could very well eventually lead to a biopsy, my wish is that every one of those men knows that they might want to ask their doctors where they may avail themselves of the transperineal approach, from the get-go, reducing the amount of TRUS biopsies that have been, and still are, performed in urologists' offices.
In the following installments, I’ll discuss the parameters around having a transperineal biopsy and why it hasn’t caught on as fast as it has outside our borders. I’ll include data from research studies to convince you why you may want to push for the transperineal approach for your next biopsy.
And finally, I have had the pleasure of speaking with several in the prostate cancer medical community, including Dr. Allaway, specifically regarding aspects of PPTAS, and Michael Gorin, MD & Associate Professor of Urology at the Icahn School of Medicine at Mount Sinai in New York, who has embraced the TP biopsy as a best practice for his patients. You’ll want to stay tuned for more.