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Transperineal Biopsy

David Chen MD FACS

Prostate Cancer Biopsy Update From Fox Chase Cancer Center

For some men who need a biopsy to test for prostate cancer, Fox Chase Cancer Center now offers an alternative approach that is safer, with significantly lower risks of infection, and potentially higher rate of tumor detection.

This new procedure, called transperineal biopsy, uses an external entry point in the perineum area, instead of the more traditional transrectal (through the rectum wall) approach. A rectal ultrasound probe helps the physician guide the biopsy instrument to reach more areas in the prostate, including the anterior region that is more difficult to access using the transrectal method.

The procedure may be appropriate for patients who must have repeat biopsies and who may have already had a procedure-related infection.

“We are always looking for ways to improve on our results, including with the diagnosis of prostate cancer using the standard transrectal biopsy procedure and by introducing this new transperineal approach,” says David Y.T. Chen, MD, FACS, a urologic oncologist at Fox Chase. “Improvements in imaging technology through ultrasounds and MRIs have allowed us to offer this additional technique that may offer some patients an advantage.”

How Transperineal Biopsies Benefit Patients

David Y.T. Chen, MD, FACS

David Y.T. Chen, MD, FACS

David Y.T. Chen, MD, FACS, and his urologic oncology team at Fox Chase Cancer Center are leading Philadelphia by offering this alternative biopsy technique, which they began offering to patients earlier this year.

How is the procedure done?

Patients have the transperineal biopsy procedure in an operating room under a sedation level of anesthesia as an outpatient surgical procedure. The use of more than local anesthesia helps with patient comfort and makes it easier for the patient to stay still during the procedure. An ultrasound probe is inserted in the rectum to allow imaging of the prostate, and the Precisionpoint™ guide enables biopsies to be taken from each side of the organ through only two primary skin puncture sites. This lets the doctor take a distribution of samples from throughout the prostate, including access to the anterior and apical regions of the prostate.

By comparison, a typical transrectal biopsy collects samples of prostate tissue using a specialized biopsy instrument that is directed through the rectal wall into the prostate. Samples are taken from a uniform distribution throughout the prostate, which is located near the rectum and is commonly examined in a manual physical exam done by a doctor.

Urologic Oncology Team

RichardEGreenbergMDFACS_3

Richard E. Greenberg, MD, FACS

AlexanderKutikovMDFACS

Alexander Kutikov, MD, FACS

MarcSmaldoneMDMSHPFACS

Marc Smaldone, MD, MSHP, FACS

RobertGUzzoMDFACS

Robert G. Uzzo, MD, FACS

RosaliaViterboMDFACS

Rosalia Viterbo, MD, FACS

The standard transrectal biopsy procedure is usually done in the doctor’s office with the patient fully awake. Local anesthesia is injected around the prostate to numb the area prior to obtaining biopsies. To take samples, the doctor places an ultrasound probe into the rectum, and the biopsy device is directed parallel to the probe and pierces through the rectum wall and into the prostate; each sample requires a new puncture. A typical biopsy procedure will take about 12 tissue samples.

“Both bleeding and infection risk are minimized when we use a transperineal approach,” Dr. Chen notes. “While we may never be able to get to totally zero complications for this procedure, we expect the overall risks can be significantly lower with the transperineal approach.”

 

Who is a good candidate for transperineal biopsy?

  • Patients who are on “active surveillance” for a slow-growing prostate cancer and are expected to need repeated biopsies
  • Patients with high PSA scores whose previous standard transrectal biopsies did not detect cancer (which may be a false-negative)
  • Patients suspected to possibly have tumors in the anterior or apical areas of the prostate
  • Patients with anxiety who may benefit from a greater level of anesthesia and sedation during the prostate biopsy procedure
  • Patients who had infections related to a prior prostate biopsy

Advantages of the transperineal procedure

  • Improved detection of disease, including in the anterior and ventral regions of the prostate
  • Reduced risk of infections, including antibiotic-resistant ones
  • Reduced risk of procedurerelated bleeding
  • A viable option for patients with anxiety about having a prostate biopsy procedure while fully awake, and who would prefer to be under a greater level of sedation or anesthesia during the biopsy.

Research Studies

  • A study out of University of Cambridge, United Kingdom, published in the journal BJU International, found that:
    • Transperineal biopsy detected more high-grade/high-stage tumors in patients with elevated prostate-specific antigen (PSA) levels and previous negative transrectal biopsies. These cancers also were found in the anterior area of the prostate, which is more easily reached through the transperineal procedure
    • Urinary retention requiring catheterization was slightly less common in the transperineal group (5.6 percent) than in the transrectal group (8.3 percent)
    • Bleeding from the rectum was significantly lower in the transperineal group (1.1 percent) than in the transrectal group (14.2 percent)
  • A Norwegian study showed that 20-30 percent of transrectal biopsies do not detect cancer (a false-negative result), while subsequent transperineal biopsies are able to identify the tumor
  • Israeli researchers also have found increased cancer detection rates using the transperineal approach
  • A recent study of transrectal biopsies performed throughout New York showed the chance of infection related complications increased from 2.6 to 3.5 percent between 2011 and 2014. By comparison, studies about transperineal biopsies have shown that the infection rate is nearly zero.