The eternal enigma in prostatic biopsy access route.

Erectile dysfunction (ED) is a concern for men undergoing prostate biopsy. With the increasing adoption of transperineal (TP) biopsy over transrectal (TR) biopsy, it remains unclear which approach carries a lower risk of erectile dysfunction. This study aims to be the first meta-analysis to evaluate erectile dysfunction following TR versus TP prostate biopsy at 1, 3 and 6months intervals, thereby providing clinicians with evidence-based guidance for patient counseling and shared decision-making. This review was prospectively registered on PROSPERO (CRD42024541557) and followed PRISMA guidelines, with searches conducted in PubMed, Scopus, and the Cochrane Library databases up to July 2024. A total of 22 studies reporting erectile function outcomes (IIEF scores) at baseline and 1, 3 and 6months post-biopsy were identified. After applying inclusion and exclusion criteria, 12 studies were included in the final meta-analysis. TR and TP biopsy methods were compared using a random-effects model to assess standardized mean differences (SMD) in erectile function at each follow-up point. The risk of bias for each study was evaluated to ensure result reliability. At 1month follow-up, a significant decline in erectile function was observed overall (SMD: - 0.3785, p = 0.038). The TP approach showed a slightly more significant decline than the TR approach; however, this difference was not statistically significant (p = 0.074). At 3months follow-up, no significant differences were observed between methods overall (SMD: - 0.1663, p = 0.132), although TP biopsy alone showed a modest yet considerable decline (SMD: - 0.1868, p = 0.03). At 6months, erectile function had generally returned to baseline, with no significant differences observed between biopsy techniques (p = 0.41). Both TR and TP prostate biopsies are associated with a transient decline in erectile function. These effects typically resolve by 6months in most patients, with no significant long-term impact observed. While the initial functional impact may be slightly greater with the TP technique, this difference attenuates over time. These findings are crucial for managing patient expectations post-biopsy.

A remarkable paradigm shift has emerged regarding the preferred prostate biopsy approach, favoring the transperineal (TP) over the transrectal (TR) approach due to the reduced risk of severe urinary tract infections. However, its impact on the detection of clinically significant prostate cancer (csPCa) remains unclear. We relied on a prospectively maintained tertiary care database to identify patients who underwent either TP or TR prostate biopsy between 01/2014 and 12/2023. Of those, only patients with suspicious magnetic resonance imaging (MRI) PIRADS lesions (Likert-scale: 3,4,5) received MRI-targeted and systematic biopsies. Detection rates of csPCa (International Society of Urological Pathology [ISUP] ≥ 2) were compared between biopsy approach (TP vs. TR) according to index lesion. Subsequently, uni- and multivariable logistic regression models were applied to investigate the predictive status of the biopsy approach within each subcohort. Of 2063 patients, 1118 (54%) underwent combined MRI-guided and systematic prostate biopsy and were included in the final cohort. Of those, 127 (11%) and 991 (89%) underwent TP vs. TR. CsPCa rates, regardless of differences in patients' demographics and distribution of index PIRDAS lesions, did not differ statistically significantly and were 51 vs. 52%, respectively (p = 0.8). CsPCa detection rates for PIRDAS-3, PIRADS-4 and PIRADS-5 did not differ and were 24 vs. 23%, 48 vs. 51% and 72 vs. 76% for PIRADS-3, PIRADS-4 and PIRADS-5 subgroups for TP vs. TR, respectively (all p ≥ 0.9) Conclusions: The current results support the available data indicating that TP biopsy approach is comparable to transrectal biopsy approach regarding csPCa detection rates.

Prostate Cancer Detection and Complications of Transperineal Versus Transrectal Magnetic Resonance Imaging-fusion Guided Prostate Biopsies

Editorial Comment

Effect of Transperineal Versus Transrectal Prostate Biopsy on the Quality of Hydrogel Spacer Placement in Men Prior to Radiation Therapy for Prostate Cancer

Clinical Trial Protocol for PERFECT: A Randomised Controlled Trial Comparing the Efficiency and Tolerance of Transperineal Fusion Versus Transrectal Imaging-targeted Prostate Biopsies (CCAFU-PR1 Study)

Aim In March 2020 Derriford Hospital Urology Department changed its technique for biopsying prostates, going from a transrectal (TR) approach to a transperineal (TP) one. This method is now used for initial biopsies as well as when taking template biopsies. Our aim was to demonstrate whether either technique was more effective at diagnosing cancer, with a secondary aim of ensuring we were selecting the right patients to undergo template prostate biopsies after initially inconclusive results. Method We obtained a list of all patients who had undergone procedures coded under General Anaesthetic Prostate Biopsies between March 2019 and March 2021. We discounted patients who appeared on this list as they could not tolerate biopsies under local anaesthetic. We looked at initial biopsy technique and initial histology results, as well as number of template biopsies taken, histology results and subsequent management. Results Our sample size was small with 26 patients in total, with an even split between the 2 techniques, with 13 patients in each group. Following template biopsies, 15 patients were diagnosed with prostate cancer. 11 of these 15 patients had undergone TR biopsies initially. As a result, the management for all these patients changed. Incidentally we did also note that there was a wide variation in the amount of template biopsies taken. Conclusions It appears that TP biopsies are more effective than TR biopsies at not missing cancer. It also appears that the Derriford MDT has been selecting the correct patients to undergo further template biopsies.

BackgroundTransrectal (TR) ultrasound guided prostate biopsy and transperineal (TP) ultrasound guided prostate biopsy are the two most commonly used methods to detect prostate cancer, the detection rate of the two biopsy approaches may differ in patients with different clinical characteristics. Here we aimed to compare the prostate cancer detection rate and positive rate of biopsy cores between TR and TP prostate biopsy in patients with different clinical characteristics.MethodsWe retrospectively analyzed and compared the clinical data of 452 patients underwent TR or TP prostate biopsy in our hospital from June 2017 to September 2021. And patients were stratified according to several clinical characteristic (serum PSA level, prostate volume, PSA density, T stage and ISUP grade), cancer detection rate and positive rate of biopsy cores were compared in different stratified groups.ResultsThere was no significant difference in age, PSA level, prostate volume, and PSA density between the TR and TP groups. TR group had a higher overall cancer detection rate and positive rate of biopsy cores than TP group. Further subgroup analysis showed that TR group had a higher cancer detection rate in patients with prostate volumes 30–80 mL, and that the TR group had a higher positive rate of biopsy cores among the patients with T3–T4 stages, while TP group had a higher positive rates of biopsy cores among the patients with T1–T2 stages. There were no significant differences between the TR and TP groups for each subgroup when stratified by PSA level, PSA density and ISUP grade.ConclusionsTR approach may have advantage in patients with prostate volumes 30–80 mL and T3–T4 stages, while TP approach may have advantage in patients with T1–T2 stages.

Transrectal (TR) prostate biopsy is being increasingly abandoned in favour of a transperineal (TP) approach as well as a targeted biopsy only of the index lesion(s). It remains underreported how these changes could impact concordance at final pathology. We aimed to evaluate the impact of transitioning from standard transrectal (sTR) to cognitive targeted transperineal (cog-tTP) biopsy on final pathology including concordance and upgrading. Analysis of consecutive patients undergoing prostate biopsy and prostatectomy (RP) between January 2018 and May 2022 at a tertiary centre in Western Norway. There were 210 and 239 patients in the sTR and cog-tTP groups, respectively. The mean [IQR] number of biopsies decreased from 12 [4-12] to 3 [3-4] (p< 0.001). The overall rate of concordance between biopsy and final pathology was 64% in both groups (Table 3, Figure 1). 24% Twenty-four per cent (cog-tTP) versus 19% (sTR) had grade group (GG) upgrading, while 12% versus 17% were downgraded (p= 0.2). Regarding positive surgical margins (PSMs) that were >3 mm in extension, there were only 3.3% and 2.1% in the sTR and cog-tTP groups, respectively (p= 0.4). For surgical outcomes associated with RP, no differences in terms of postoperative complications between the groups were found (cog-tTP:10% vs. sTR:6%, p= 0.10). Transitioning from sTR biopsy to targeted cog-tTP biopsy does not compromise concordance at final pathology nor does it increase the risk of tumour upgrading.

Transperineal Versus Transrectal Prostate Biopsy: A Systematic Review and Meta-analysis of Randomized Controlled Trials Across Settings With and Without Magnetic Resonance Imaging Targeting

Clinically Significant Prostate Cancer Detection Following Transrectal and Transperineal Biopsy: Results of the Prostate Biopsy Efficacy and Complications Randomized Clinical Trial.

A Novel Magnetic Resonance Imaging/Ultrasound Fusion Prostate Biopsy Technique Using Transperineal Ultrasound: An Initial Experience

People with suspected prostate cancer are usually offered either a local anaesthetic transrectal ultrasound-guided prostate biopsy or a general anaesthetic transperineal prostate biopsy. Transperineal prostate biopsy is often carried out under general anaesthetic due to pain caused by the procedure. However, recent studies suggest that performing local anaesthetic transperineal prostate biopsy may better identify cancer in particular regions of the prostate and reduce infection rates, while being carried out in an outpatient setting. Devices to assist with freehand methods of local anaesthetic transperineal prostate may also help practitioners performing prostate biopsies. To evaluate the clinical effectiveness and cost-effectiveness of local anaesthetic transperineal prostate compared to local anaesthetic transrectal ultrasound-guided prostate and general anaesthetic transperineal prostate biopsy for people with suspected prostate cancer, and local anaesthetic transperineal prostate with specific freehand devices in comparison with local anaesthetic transrectal ultrasound-guided prostate and transperineal prostate biopsy conducted with a grid and stepping device conducted under local or general anaesthetic. We conducted a systematic review of studies comparing the diagnostic yield and clinical effectiveness of different methods for performing prostate biopsies. We used pairwise and network meta-analyses to pool evidence on cancer detection rates and structured narrative synthesis for other outcomes. For the economic evaluation, we reviewed published and submitted evidence and developed a model to assess the cost-effectiveness of the different biopsy methods. We included 19 comparative studies (6 randomised controlled trials and 13 observational comparative studies) and 4 single-arm studies of freehand devices. There were no statistically significant differences in cancer detection rates for local anaesthetic transperineal prostate (any method) compared to local anaesthetic transrectal ultrasound-guided prostate (relative risk 1.00, 95% confidence interval 0.85 to 1.18) (n = 5 randomised controlled trials), as was the case for local anaesthetic transperineal prostate with a freehand device compared to local anaesthetic transrectal ultrasound-guided prostate (relative risk 1.40, 95% confidence interval 0.96 to 2.04) (n = 1 randomised controlled trial). Results of meta-analyses of observational studies were similar. The economic analysis indicated that local anaesthetic transperineal prostate is likely to be cost-effective compared with local anaesthetic transrectal ultrasound-guided prostate (incremental cost below £20,000 per quality-adjusted life-year gained) and less costly and no less effective than general anaesthetic transperineal prostate. local anaesthetic transperineal prostate with a freehand device is likely to be the most cost-effective strategy: incremental cost versus local anaesthetic transrectal ultrasound-guided prostate of £743 per quality-adjusted life-year for people with magnetic resonance imaging Likert score of 3 or more at first biopsy. There is limited evidence for efficacy in detecting clinically significant prostate cancer. There is comparative evidence for the PrecisionPoint™ Transperineal Access System (BXTAccelyon Ltd, Burnham, UK) but limited or no evidence for the other freehand devices. Evidence for other outcomes is sparse. The cost-effectiveness results are sensitive to uncertainty over cancer detection rates, complication rates and the numbers of core samples taken with the different biopsy methods and the costs of processing them. Transperineal prostate biopsy under local anaesthetic is equally efficient at detecting prostate cancer as transrectal ultrasound-guided prostate biopsy under local anaesthetic but it may be better with a freehand device. local anaesthetic transperineal prostate is associated with urinary retention type complications, whereas local anaesthetic transrectal ultrasound-guided prostate has a higher infection rate. local anaesthetic transperineal prostate biopsy with a freehand device appears to meet conventional levels of costeffectiveness compared with local anaesthetic transrectal ultrasound-guided prostate. This study is registered as PROSPERO CRD42021266443. This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR134220) and is published in full in Health Technology Assessment Vol. 28, No. 60. See the NIHR Funding and Awards website for further award information.

Introduction Trans-perineal (TP) biopsy of prostate is a procedure done to biopsy male patients who have either a raised prostatic sensitive antigen (PSA) or abnormal MRI prostate. The goal of procedure is to diagnose prostate cancer. This approach has recently become the most preferred option for getting tissue biopsy over transrectal Ultrasound biopsy of prostate (TRUS). Since 2020 our institute have been performing TP biopsies under local anaesthetic in clinic as we believe it is well tolerated and it reduces the burden on theatre resources. We do know that one of the risks of performing TP biopsy is transient erectile dysfunction (less than 5% men) post biopsy. Objective Our aim was to assess whether doing TP biopsies had an effect on sexual and erectile function at 1 month and 6 months after biopsy. Methods We only included men who are sexually active. During the 6 month period October 2020 – June 2021 we identified 76 patients eligible for study. Out of 76 patients 36 had agreed to participate in the study. 5 patients were excluded because they declined to participate beyond 1 month after biopsy or who proceeded to go for surgery/hormonal therapy/radiation therapy. 31 patients completed study and analysed. These 31 patients were given erectile function questionnaires – international index of erectile function (IIEF-5) at prebiopsy/one month/6 months and scores were compared to see if there was any difference in sexual function. Results Results show that out of 31 participants, 4 patients exhibited impaired sexual function at 1 month period. Out of those 4, 2 of the patients still exhibited impaired sexual function at 6 month period. Interestingly 1 patient who had no change in sexual function at the 1 month mark exhibited impaired sexual function at the 6 month mark. Conclusions Our study shows that although a small proportion of patients exhibit transient sexual function at 1 month, the procedure is a relatively safe method in diagnosing prostate cancer. A re-audit in the future would be ideal to see if our rates remain the same or not. Disclosure No.

The objective of this study was to compare transperineal (TP) versus transrectal (TR) magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) fusion prostate biopsy (PBx). Consecutive men who underwent prostate MRI followed by a systematic biopsy. Additional target biopsies were performed from Prostate Imaging Reporting & Data System (PIRADS) 3–5 lesions. Men who underwent TP PBx were matched 1:2 with a synchronous cohort undergoing TR PBx by PSA, Prostate volume (PV) and PIRADS score. Endpoint of the study was the detection of clinically significant prostate cancer (CSPCa; Grade Group ≥ 2). Univariate and multivariable analyses were performed. Results were considered statistically significant if p < 0.05. Overall, 504 patients met the inclusion criteria. A total of 168 TP PBx were pair-matched to 336 TR PBx patients. Baseline demographics and imaging characteristics were similar between the groups. Per patient, the CSPCa detection was 2.1% vs 6.3% (p = 0.4) for PIRADS 1–2, and 59% vs 60% (p = 0.9) for PIRADS 3–5, on TP vs TR PBx, respectively. Per lesion, the CSPCa detection for PIRADS 3 (21% vs 16%; p = 0.4), PIRADS 4 (51% vs 44%; p = 0.8) and PIRADS 5 (76% vs 84%; p = 0.3) was similar for TP vs TR PBx, respectively. However, the TP PBx showed a longer maximum cancer core length (11 vs 9 mm; p = 0.02) and higher cancer core involvement (83% vs 65%; p < 0.001) than TR PBx. Independent predictors for CSPCa detection were age, PSA, PV, abnormal digital rectal examination findings, and PIRADS 3–5. Our study demonstrated transperineal MRI/TRUS fusion PBx provides similar CSPCa detection, with larger prostate cancer core length and percent of core involvement, than transrectal PBx.