How does your doctor do prostate biopsies?

So (in our opinion) the time has come — for a whole bunch of reasons — for actual and potential prostate cancer patients to start asking their urologists about whether they are able to carry out transperineal as opposed to transrectal biopsies.

Once upon a time — back in the 1970s — before we had PSA tests to “screen” for risk of prostate cancer, and transrectal ultrasound equipment to help guide transrectal biopsies, and a relatively low risk for biopsy-related infections with antibiotic-resistant bacteria, older forms of transperineal biopsy were a very normal way to carry out prostate biopsies. But they weren’t very good and they weren’t easy to do.

So, to be clear, a transperineal prostate biopsy is carried out through the skin between the rectum and the testes (sometimes referred to as the “taint”). By comparison, transrectal biopsy is carried out through the skin inside the rectum and comes with a relatively high risk for prostatic infections, including serious infections like septicemia that can lead to hospitalization and even death.

This link to information on the Mayo Clinic web site provides a pretty straightforward introduction (with pictures) to the relative merits of transperineal as opposed to transrectal biopsies. It is worth noting, in particular, the following:

  • The vast majority of prostate biopsies here in the US are carried out transrectally, but in countiries like The Netherlands and the United Kingdom, nearly 50 percent of all such biopsies are now carried out transperineally
  • The rate of severe biopsy-induced infection (sepsis) when biopsies are carried out transrectally in about 1 or 2 in 100. By comparison, the rate of sepsis when biopsies are carried out transperineally is just 1 in 500 (five to ten time lower).
  • Most men who are given transperineal biopsies do not need to be given prophylactic antibiotics to lower risk for infection.
  • Transperineal biopsies are generally much better at being able to biopsy areas like the apex of the prostate, which can be difficult to biopsy using the transrectal method.
  • Transperineal biopsies — like transrectal biopsies — can by guided by transrectal ultrasound and by MRI scans or both.

The reasons that most urologists here in the USA don’t use the transperineal method for carrying out prostate biopsies are:

  • They have never learned to do this and/or they think it is too difficult to do.
  • They think it has to be done under full anesthesia — which is not true. It can be done very successfully under local anesthesia.
  • They think it can’t be done in an “office” setting and has to be done in a hospital — again, this is not true.
  • They already own all the equipment to carry out prostate biopsies transrectally, and they would need to buy some new equipment to do these biopsies transperineally.
  • Like many doctors they are simply “resistant to change”.

The bottom line here is that there is an increasingly credible amount of data suggesting that:

  • Transperineal biopsies are more accurate than transrectal biopsies, with a low rate for false negative findings.
  • The risk for side effects and complications of transperineal biosies seems to be lower than the risk when transrectal biopsies are used.

Discussion of this issue has already started to take place within the urology community (see, for example, here, here, here, and here), but the average patient simply won’t have become aware that this is an important issue that potentially may impact his health and the quality of his care. This is particularly the case for those patients who may require multiple biopsies over time (e.g., those who may be on active surveillance for 5, 10, or 15 years).

Now we do need to be clear that transperineal biopsies do come with risk for some side effects. They include the following:

  • Infection, and serious infections, such as sepsis (see above)
  • Blood in the urine (most men, mild )
  • Blood in the semen (most men, lasting up to 3 months)
  • Temporary erectile dysfunction (less than 5 percent of men)
  • Bruising of the skin (most men, mild)
  • Urinary retention requiring catheter placement (1 percent of men)

These side effects are also common and mostly mild when a transrectal biopsy is being carried out. The other thing that is very different, however (apart from the level of risk for infection) is that there is no risk for rectal bleeding, for the very simple reason that the biopsy needles are not going through the rectal wall.

Prostate Cancer International and The “New” Prostate Cancer InfoLink believe that now is the time for serious discussion about the potential for modern forms of TRUS-guided and TRUS/MRI fusion-guided transperineal biopsies to replace transrectal biopsies, and a concentrated focus by the American Urological Association (AUA) to be specific about the preferred use of this type of biopsy in diagnostic and management guidelines for prostate cancer.

Greater awareness on the part of patients to ask their doctors about availability of this type of biopsy will be just one tool to accelerate change in this area, along with training of all new urologists to ensure that they are guided toward the use of this type of biopsy as opposed to transrectal biopsies.

Such a change in clinical practice will take time, but, in our humble opinion, this change, along with other changes in the diagnosis and management of prostate cancer over the next few years, will be highly beneficial to the quality of care of men at risk for prostate cancer.

12 Responses

  1. i have heard TP biopsy has serious risk of nerve damage. … Is this true?

  2. Yet no mention of multiparametric MRI findings being used to determine which method is most likely to hit the worse bits of the tumor. I learned this 6 years ago with my mpMRI in London.

  3. Thank you for this article and helpful opinion. In trying to research this subject some time ago I came across a comment by someone online who said, “Beware, what they don’t tell you and is not reported is erectile disfunction in up to 50% of people for up to 6 months” with these TP bxs. I could not find more information on this but made a note of it to ask a provider if this type of biopsy was needed.

    Another specialist doing these TP biopsies related that there is a problem with biopsies of large prostates because the anterior of the prostate can’t be reached because the pelvis is in the way for these TP bxs. In these folks, he thought the TRUS bx was preferable.

  4. Doug:

    I suspect that that might be the case if the urologist hasn’t been properly trained to do this procedure, and here in the US mot urologist have not. It might also be more of a problem with what are known with “saturation” transperineal biopsies, when 20 or more biopsy cores are taken at a time. I have not seen specific references to this problem in the literature (but that is no guarantee that it cannot happen).

  5. Dear Walter:

    It is not clear to me exactly what types of TP biopsy are being referred to in the comments you relate. For example, saturation TP biopsies do indeed come with an increase in risk for ED, but we are not talking about saturation TP biopsies.

    The current experts in the use of “standard” TP biopies In Europe and here in the US) state that there is no significant difference in risk for ED after a TP as opposed to a TR biopsy, but appropriate training and experience with any new surgical procedure is clearly a factor.

    Thirdly, it is bound to be the case that some patients will have individual characteristics that make a TP biopsy less appropriate than a TR biopsy. We are going to need to learn more about that. The key factor that is clear, however, is that if most biopsies are done by TP procedures as opposed to TR procedures, there is a massive reduction in risk for TR infections, and there is an increase in the general accuracy of the biopsy results.

  6. Dear Mr. Wadsworth:

    The appropriate role of mpMRI in the conduct of either type of biopsy is generally well established, but it is still not “absolute” because in the past 18 months or so it has become very clear that the “reading” of mpMRI results using the PI-RADs system is simply not sufficiently accurate. Until we find a way for radiologists to be able to administer and “read” the results of mpMRI scans in a consistent and accurate manner, what the MRI scan can offer is “guidance” as to the areas of the prostate that may need to be targeted in addition to “systematic” core samples being taken. There is also a serious cost consideration. In most of Europe, Australasia, and elsewhere, where there are “nationalized” healthcare systems, the costs pf MRI scans are far lower than they are here in the US. Many people simply don’t have the resources to pay for such MRI scans here in the US and their health insurance providers will not cover the costs.

    Also, if you read what is written above, there was clear reference to the appropriate use of MRI/TRUS fusion guidance of biopsies. The problem is that there is still no consensus with respect to the “appropriateness” of the use of such biopsy guidance, quite apart from the cost factors.

  7. Bravo!

    I did want to talk about the “local” anesthesia with it. “Local” has different meanings to different people. To some, it just means some numbing of the skin with a lidocaine gel .followed by an injection of lidocaine under the skin. That is inadequate, IMHO. There are better ways. The two main candidates are: (1) periprostatic nerve block and (2) pelvic plexus nerve block. There are other candidates as well. The urologist has to be experienced at finding those nerves using the transrectal US probe. I think some urologists aren’t trained in this.

    Pelvic plexus nerve block seems to be superior to periprostatic nerve block; see, for example <a href= here and here. This trial found that injecting into the branches of the perineal nerve may be even better:

    It is also important that the lidocaine is injected on the way in to the nerve with adequate time left for numbing to take place before going deeper.

    The patient should ask for a urologist experienced in finding those nerves and who is willing to take his time. This means that the urologist who does the biopsy may be different from the usual urologist. If your urologist says that he doesn’t do it, shop around to find one who does. The major tertiary care hospitals will probably have someone, but it may be impossible to find someone in community practice. From my personal experience, it is worth traveling for.

  8. Allen:

    There is no doubt that the average urologist here in the US has little to no experience in the conduct of high-quality TP biopsies. That is why the academic centers and the AUA and LUGPA are all going to have to “step up” to make sure appropriate training is available. There will be no point in switching from TR to TP biopsies if we simply replace the risk for infection through the conduct of TR biopises with other risks associated with the failure to carry out TR biopsies as well as possible.

    The other part of this question that will also be important is whether we can become much better at determining who really needs a biopsy at all through the use of new, objective data from urine and blood tests that are starting to become available.

  9. Sitemaster, I don’t think we are in disagreement. My point is that I traveled to Europe twice, six years ago for mpMRI prior to second biopsy and again three years ago for PSMA PET CT combined with nanoparticle MRI (Ferrotran) post failed salvage RT because the US is so far behind in prostate and prostate cancer imaging.

  10. Dear Murray:

    I am not suggesting that we are in disagreement. The basic problem here in the US is that our health care system is based on multiple elements of the system making a profit, and most of the imaging techniques (like the PSMA PET/CT scans that are available in Europe and eleswhere) haven’t been patentable in the US and so — until very recently — no imaging company wanted to develop them. There are new forms of PSMA PET/CT scan coming that are patentable and that MAY have benefits under appropriate circumstances, but whether anyone’s insurance provider will be keen to cover the costs once they do become available is a whole other issue.

    In Australia today, in contrast, gallium-67 PSMA PET/CT scans are pretty much standard practice for anyone with a suspected diagnosis of intermediate- or high-risk prostate cancer because the cost is relatively low. Unfortunately, this sort of price issue can profoundly impact access to good quality care here in the USA (if the products are even available).

  11. Yes, the US is behind and unnecessarily more American men will die or end up on ADT because the US is so far behind.

  12. One million dangerous prostate blind biopsies are performed in the USA each year and they should be banned: Invasive, dangerous, degrading and unnecessary. Men with a high PSA tests result are often sent to a urologist for a blind biopsy. This technology is (obsolete) 30 years old. Would you use a cell phone or drive a car that was designed 30 years ago? Blind prostate biopsy cost in the USA is at least $3 billion annually. False positives and false negatives can occur. Men should be told about other options; Percent free PSA test, 4Kscore test, PCA3 test or a 3T MRI test before receiving a blind biopsy. These tests can often eliminate the need for a risky and invasive blind biopsy. Unfortunately, sometimes insurance companies may not pay for other tests. Insertion of 12 or 18 large hollow needles through the dirty rectum into a gland the size of a walnut, a blind biopsy can result in pain, infections, a risk of temporary or permanent erectile dysfunction. Biopsies can cause, urinary problems, An infection rate of 7.2%, up to a 6.9% hospitalization rate within 30 days from a complication, sometimes even death from sepsis (About 1.3 to 3.5 deaths per 1,000. There is also debate that a biopsy may spread cancer because of needle tracking. A blind biopsy is degrading and can also increase PSA reading for several weeks or months, further frightening men into unnecessary treatment. Blind biopsies are almost never performed on other organs.

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