Advantages of transperineal approach
Holm described the first transrectal ultrasound-guided transperineal prostate biopsy (TP-Bx) in 1981 (J Urol 1981; 126:385). This approach has seen a resurgence in clinical practice due to its superiority in sampling both the anterior prostate and apical region (Cancer 2005; 103:1826-32; Eur Urol 2006; 50:266-71).
Multiple systematic reviews and meta-analyses have demonstrated equivalent prostate cancer detection rates between TR-Bx and TP-Bx (Asian J Androl 2012; 14:310-5; World J Surg Onc 2019; 14:31). However, the major driver for increased interest in TP-Bx has been the associated reduction in infection rates. Pepe reported a series of 3,000 patients with an infections complication rate under 1%, and a meta-analysis conducted by Grummet reported a sepsis rate of less than 0.1% (Urology 2013; 81:1142-1146; BJU Int 2014; 114:384–8).
While these outcomes may exhibit an improvement for TP-Bx over TR-Bx, there are concerns about potential drawbacks leading to a slow rate of acceptance. These concerns seem to be rooted in the perceived need for general anesthesia and increased cost. While the TP-Bx approach has historically been described in the setting of general anesthesia, recent papers have demonstrated efficacy with local anesthetic techniques and acceptable patient-reported tolerability outcomes (BJU Int 2017; 120:164-7; Prostate Cancer Prostatic Dis 2017; 20:311-7). Additionally, while TP-Bx has traditionally been performed using a brachytherapy grid and stepper, free-hand approaches to TP-Bx have been shown to minimize costs associated with instrumentation in the outpatient setting (J Urol 2016; 195:e466-7).
A plethora of research is growing that suggests TP-Bx offers equivalent prostate cancer detection rates, lower infectious complications, and increased technical feasibility. The ubiquitous adoption of office-based transperineal prostate biopsy appears to be imminent.
Section Editor Christopher M. Gonzalez, MD, MBA, is professor and chair of the department of urology at Loyola University Chicago Stritch School of Medicine, Maywood, IL.