Transperineal Biopsy of the Prostate—the Future or “Back to the Future?"

Selected by Pietro Cazzola

ProstateTransperineal prostate biopsy is often considered an “older” diagnostic technique. While transrectal ultrasound (TRUS) biopsy is the current standard of care, reduced infectious and other complication rates and improved identification of apical tumors are considered benefits to the transperineal approach. The main trade-off appears to be the need for more extensive anesthesia when using the perineum to approach the prostate.
As interest in transperineal prostate biopsy increases there are several points to consider. The authors note that consensus does not exist regarding the optimal number of cores for transperineal biopsy. As Chang and associates note, the transperineal biopsy can extend from a limited sampling to saturation biopsy using a brachytherapy-style template. This issue has been recently addressed for the TRUS biopsy scheme in an AUA consensus paper, which states that the optimum should be a 12-core systematic biopsy that incorporates apical and far-lateral cores.1 Perhaps it is time that the optimized schema be evaluated in terms of a specific transperineal prostate biopsy consensus statement.
MRI-TRUS fusion biopsy is gaining momentum in the diagnosis of prostate cancer. At the present time, the only FDA-approved units in the US are based on the TRUS biopsy approach. There is only one fusion system with published data from Greece in which the prostate biopsy is performed transperineally. This system is not available in the US. It will be interesting to see if the US-approved MRI-TRUS fusion units can or will be adapted by the manufacturers to take advantage of the potential benefits of the transperineal approach.
Dr. Chang and associates provide a very thorough discussion of transperineal prostate biopsy. It may not be as an historic technique as many of us believe. Their review highlights recent literature in which dozens of papers have continued to explore and identify the opportunities of using the transperineal approach both for initial and follow-up biopsy. They provide compelling arguments on why the transperineal approach will have an increasing role in the future building on the positive experiences of the past.

References
Bjurlin MA, Carter HB, Schellhammer P, et al. Optimization of initial prostate biopsy in clinical practice: sampling, labeling and specimen processing. J Urol. 2013;189(6):2039-2046.