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Dr. Hu discusses the “inertia” of the transrectal approach to prostate biopsy in the US 


"One of the factors that goes into why transperineal [biopsies] aren't performed more readily in the US is lack of exposure," says Jim C. Hu, MD, MPH.

In this video, Jim C. Hu, MD, MPH, discusses the hesitancy of urologists in the US to utilize the transperineal approach to prostate biopsy over the transrectal approach. Hu is a urologic oncologist and the vice chair of clinical research at Weill Cornell Medicine in New York, New York.

Video Transcript:

However, at least in the United States, there's been reluctance, or you could call it inertia of the transrectal approach, for several reasons. It's been estimated currently, that about 5% to 10% of all biopsies nationally may be performed transperineally, because transrectal was the first way that it was described, and it's been around for decades. So, some of that inertia is due to the fact that to perform a transperineal biopsy, number 1, this is something that's become more popular in the last 5 to 6 years, and therefore the majority of urologists have not received training during their residencies. Moreover, the young urologist who currently just started practice also probably never received this training during their residency. We conducted an international survey to look at the exposure of current residents to the transperineal approach, and it was very limited. So, one of the factors that goes into why transperineals aren't performed more readily in the US is lack of exposure, no training.

The second, and I think the more important reason is there isn't a separate CPT code, or Current Procedural Terminology. That's how Medicare or private insurances recognize what procedure is being performed and reimbursed for. Well, why is this relevant? Well, in our largely fee-for-service system in the United States, the transperineal approach, the way that most people do it, the way that I do it, for example, requires a disposable device that costs at least $200 per case. If there's not the recognition by payers of a separate distinct code for how a transperineal biopsy is performed in contrast to transrectal, then the insurance company is not going to compensate the urologist office for the effort, the greater time, [and] the greater cost of doing a transperineal biopsy.

While that may sound too transactional or businesslike in medicine, since we do have a higher calling to do the best thing for our patients, when you think about the number of biopsies that are performed by a urologist, even weekly, you could talk about 10 biopsies being done and those 10 biopsies transperineally being different by $2,000 that's coming out of the practice and not reimbursed. Also, transperineal again, because the lack of exposure, there's a learning curve, that may cause the cases to take longer. Therefore, I think it's critical that there is higher level evidence generated, similar to what Dr. Mian's group has done, because in the absence of having this high level evidence that pushes the urologic community, particularly in the United States, to embrace better practice, then the inertia of continuing to do transrectal biopsies – because of the higher costs of transperineal, because of the less experience – that's going to continue.

This transcription has been edited for clarity.

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