Prostate cancer is the second most diagnosed cancer in the world and the fifth leading cause of cancer death in men, with 12.6% of men developing prostate cancer in their lifetime. It occurs when prostate cells undergo an abnormal change, causing them to grow uncontrollably and bind together, forming a tumor. While many prostate cancers are relatively slow growing, some cases are more aggressive and will require immediate treatment.
Prostate cancer is identified through annual screenings, which are recommended for men ages 55-70 or earlier for populations with higher risk, such as African Americans or those with a family history of prostate cancer. Screenings include clinical history, blood test, prostate-specific antigen (PSA) test, and digital rectal exam (DRE). If a DRE is abnormal or PSA levels are elevated, patients undergo a prostate tissue biopsy.
Since prostate biopsies are so commonly performed each year, the technique should be as safe and accurate as possible for patient well-being and outcomes. The transrectal biopsy is the current standard, but this technique poses risks that patients can avoid with a transperineal biopsy, a newer technique steadily gaining traction in the medical community.
Transperineal Biopsy Technique vs. Transrectal Ultrasound Guided Prostate Biopsy
The transrectal ultrasound-guided prostate biopsy (TRUS biopsy) is the most common way prostate biopsies are performed in the U.S. However, due to the rectal pathway, it's an inherently contaminated procedure.
"The main risk of a transrectal biopsy is infection. The risk of sepsis is low but significant at 0.3% to 3.1%, but other infectious complications, such as E. coli urinary infection," said Dr. Michael Poch, surgeon in the Department of Genitourinary Oncology. "The second primary risk is under-sampling the anterior portion of the prostate, which could cause clinically significant cancers to be missed."
Transperineal prostate biopsies (TPP biopsies) eliminate these issues. It's an inherently clean procedure, using an ultrasound probe in the rectum as a guide and biopsies taken through punctures in the perineum rather than the rectum. This cleaner approach greatly reduces the risk of infection. In a 2021 literature review and analysis of over 7,000 transperineal biopsies, pooled data showed 0 cases of sepsis.
It also allows medical teams to better sample the anterior prostate and surrounding tissues, decreasing the risk of missing clinically significant tumors and improving accuracy.
TPP biopsies are often performed under full sedation, but further experience and evidence will support moving the procedure into a clinical setting with only local anesthesia, making it far more accessible. It's also only 5-10 minutes longer than transrectal.
Benefits of Transperineal Biopsy
- Safety: The sepsis risk of a transperineal biopsy is lowered to under 1%, which is approximately 40-70 times less than the risk of transrectal. There’s a lowered general risk of infection and no risk of rectal bleeding. It is well-suited for anyone with a history of previous infectious complications, prostatitis, inflammatory bowel disease, rectal bleeding complications, or who has a previous negative transrectal biopsy with a suspected anterior tumor.
- Diagnostic Accuracy: Research so far supports a similar diagnostic yield as transrectal biopsy, but some studies show slightly higher detection rates with transperineal. Other data shows the transperineal technique is superior in sensitivity, especially for anterior prostate cancers.
- Access to Anterior Prostate: It’s much easier to access the anterior prostate with a transperineal approach, whereas anterior tumors may be missed with a transrectal approach.
- Cost: There are no additional costs associated with this method as it’s billed the same as a transrectal prostate biopsy.
What’s Next
In 2021, the European Association of Urology published a strong position on the state of prostate biopsies. "Available evidence highlights that it is time for the urological community to switch from a transrectal to a transperineal PB approach despite any possible logistical challenges," the position paper states.
This is just one example of the tides turning when it comes to diagnosing prostate cancer. As more medical centers conduct trials, train staff, and purchase equipment necessary for the procedure, the TPP biopsy technique will begin to replace the TRUS method as the standard prostate cancer biopsy procedure.
The Department of Genitourinary Oncology at Moffitt has dedicated experts in the field of prostate cancer who perform both transrectal and transperineal prostate biopsies.
As transperineal prostate biopsies become more common, outpatient access to them may motivate more patients to get screened, which may result in earlier and more accurate detection, improving patient outcomes.
At Moffitt, our prostate cancer treatment outcomes exceed 1.5 times the national average. The five-year survival rate for Moffitt patients with advanced-stage prostate cancer is 92.5%, compared to the 79.3% national average.
If you'd like to refer a patient to Moffitt Cancer Center, complete our online form or contact a physician liaison for assistance. As part of our efforts to shorten referral times as much as possible, online referrals are typically responded to within 24 - 48 hours.
