Transperineal & Transrectal Prostate Biopsies for Cancer Detection

According to the American Cancer Society (ACS), prostate cancer (PCa) currently ranks as the second most common cancer among men in the United States, with approximately 288,300 new cases each year.¹ Often capable of being detected at an early stage, prostate cancer is usually identified through various methods, including digital rectal exams (DRE) ² and blood tests that measure levels of prostate-specific antigen (PSA).³ In cases where either assessment suggests the presence of prostate cancer, a biopsy may then be performed to confirm their diagnosis, during which a sample of prostate tissue is removed and examined under a microscope. ⁴

With over 1 million procedures performed annually, ⁵ prostate biopsies have become a widely accepted and frequently used method for detecting prostate cancer early, with two specific approaches - TRUS-guided transperineal biopsy (TPBx) and TRUS-guided transrectal biopsy (TRBx) – currently being among the most frequently utilized.

Transrectal Biopsy (TRBx):

During a TRBx procedure, physicians pass a thin biopsy needle through the rectum and into the prostate, where cores are obtained from different regions for later testing. ⁶ Transrectal biopsies are often performed with an end-fire probe, which helps to better facilitate sampling in the most lateral parts of the peripheral zone of the prostate, an area that typically sees significant tumor growth. ⁷ As of 2022, TRUS biopsies are the most common method of transrectal ultrasound prostate biopsy performed in the United States, with millions of procedures performed per year. ⁵

Benefits/advantages of TRBx:

• Accessibility and convenience for patients:
  • TRBx is a minimally invasive procedure that can typically be performed on an outpatient basis, with a relatively quick recovery time for patients. ⁸
• Cost-effectiveness and short learning curve for healthcare providers:
  • A cost-effective procedure compared to other diagnostic tests for prostate cancer, such as MRI, ⁹ TRBx is favored among doctors for its low cost and short learning curve. Additionally, since TRBx procedures are often conducted under local anesthesia, the need for specialized staff/equipment and dedicated operating rooms is eliminated. ⁸
• Rapid results and prompt initiation of treatment:
  • A systematic freehand transrectal biopsy may be performed in-office in as little as 10 minutes. ⁸ Moreover, the biopsy samples obtained through TRBx are usually processed quickly in the laboratory, allowing for rapid diagnosis and treatment. ¹⁰
• Established procedure:
  • TRBx is a commonly utilized procedure for detecting prostate cancer, often executed with a high level of physician expertise. ¹¹

Transperineal Biopsy (TPBx):

Conversely, during TPBx procedures, the needle is inserted through the perineal skin into the prostate.¹² While the number of samples taken can vary depending on the size of the prostate – total sampling numbers can range from anywhere between 10-18 cores – the transperineal approach for prostate biopsy is increasingly popular in the U.S. and other countries, with an infection risk for sepsis considerably lower than that found in the transrectal biopsy. Particularly prominent in TPBx procedures are the utilization of “stepper” devices, which are used to cradle the ultrasound probe and provide a guidance grid for biopsy needle insertion, allowing easier access to all portions of the prostate.^{12 13}

Benefits/advantages of TPBx:

• Improved patient safety with significantly lower infection risk:
  • TPBx is associated with a significantly lower risk of infectious complications, including a 1 in 500 risk of sepsis (compared to the transrectal approach’s 1 in 100). During transperineal procedures, the needle is inserted through the perineum – as opposed to the rectum, where it avoids exposure to feces or other potentially dangerous substances – allowing for a sterile procedure and reducing the need for antibiotics.^{12 14}
• Superior targeting of anterior regions:
  • TPBx biopsies allow for more precise targeting of the prostate gland, including within the apical and the anterior regions, areas of the prostate that are often under-sampled for cancer cells, often resulting in higher percentages of prostate cancer. ⁸
• Minimized rectal bleeding:
  • TPBx procedures are often reported to have a lower incidence of rectal bleeding compared to transrectal biopsy, a direct effect of the needle not passing through the rectal wall. ¹²
• Compatibility with different anesthesia types and fusion imaging techniques:
  • While commonly conducted under general anesthesia, transperineal biopsies can also be carried out using local anesthesia, allowing for expeditious procedures to be performed in-office with minimal invasion.⁸ Transperineal biopsies are also well-suited for prostate MRI/ultrasound fusion imaging, offering users a significant improvement in the ability to visualize and detect suspicious prostate tissue.¹⁵

Addressing Concerns and Safety Measures: Choosing the Best Prostate Biopsy Procedure

Unfortunately, prostate biopsy procedures are not entirely free of risk. Transrectal prostate biopsies in particular pose a higher (6%) risk of infection compared to transperineal biopsies, as the needle used in the procedure comes into contact with fecal matter, potentially introducing bacteria into the bloodstream or prostate gland.¹⁶

Consequently, many physicians will often prescribe a prophylactic antibiotic treatment to their patients – such as fluoroquinolone –prior to a transrectal prostate biopsy. Long-term debilitating side effects and potential antibiotic resistance to such medications, however, prompted the European Commission to restrict the use of fluoroquinolones in 2019. This resulted in a change to prostate biopsy guidelines in Europe, with physicians required to now perform a transperineal biopsy instead, or prescribe a specific antibiotic prophylaxis for transrectal biopsies via various methods (i.e. rectal swabs, stool cultures, etc.) ^{17 18}

According to Dr. Craig Rogers of the Henry Ford Medical Center, the transperineal method of prostate biopsy represents a markedly safer approach than the transrectal method. "If you have a million biopsies a year in the U.S. and up to1-2% of those are going to get a serious infection, [to the point] where they could even up in the hospital or in an ICU, that - to me - is just unacceptable; [and] even unethical to be offering that. So we do this technique simply for safety for patients," Dr. Rogers said. ¹⁹

TP Pivot Pro is the first transperineal biopsy guide to offer precise access to the entire prostate gland through its unique pivoting feature. Designed with clinicians, for clinicians, the guide offers parallel and angling options of the introducer needle while maintaining visualization within the imaging plane. Easy height and pivoting adjustments can be made without the need to remove the introducer needle from the guide or the patient. TP Pivot Pro also securely attaches to a range of biplane probe diameters, removing the need to tape the transducer. 

Explore TP Pivot Pro at www.civco.com/tp-pivot-pro.

Proper Ultrasound Probe Disinfection

Proper ultrasound probe disinfection is also crucially important in preventing the spread of infections between patients, with improper disinfection having the potential to result in the transmission of harmful microorganisms, which can cause serious health complications.

CIVCO’s ASTRA® VR Automated Probe Disinfection System for vaginal/rectal probes, including biplane probes up to 16 inches long, is designed to streamline your disinfection process, helping you to achieve workflow efficiency, significant savings, and a compliant workflow. ASTRA’s automated data logging and consumable tracking remove the need for any manual logging, helping you to stay compliant with The Joint Commission standards. Even better, ASTRA helps to reduce long-term operating costs with your choice of reusable, industry-leading disinfectants, including UltrOx™ HLD (hydrogen peroxide), Revital-Ox^® RESERT^® HLD (hydrogen peroxide), CIDEX^® OPA, and MetriCide™ OPA Plus.

Important too for maintaining patient safety is maintaining proper probe transportation and storage post-procedure, such as with CIVCO’s Endocavity Probe Transport Bags and Ultrasound Probe Storage Cabinet, which are essential in maintaining the integrity of the equipment and preventing damage or contamination. 

Optimizing Prostate Cancer Detection & Treatment with Innovative Solutions from CIVCO

CIVCO’s Endocavity Needle Guides for improved transrectal guidance procedures:

CIVCO’s Endocavity Needle Guides are designed to correspond with on-screen system guidelines, enabling precise instrument placement. The guides offer a secure and efficient method for conducting a variety of endocavity procedures, including tissue biopsy, fluid aspiration, and treatment procedures. They are also fully disposable and can be conveniently packaged with a probe cover, allowing greater infection control.

CIVCO’s AccuCARE steppers, stabilizers, template grids, and endocavity balloons for precise transperineal procedures:

AccuCARE by CIVCO Medical Solutions is a comprehensive line of prostate treatment equipment and accessories designed to assist clinicians in performing an array of ultrasound-guided transperineal procedures, including preplan and real-time brachytherapy procedures, fiducial marker placement, template-guided biopsies, and cryotherapy.

Make Informed Decisions with CIVCO

Early detection and accurate diagnosis of prostate cancer are essential for improving treatment outcomes and ultimately saving patient lives, with both transperineal and transrectal prostate biopsies representing effective methods for detecting prostate cancer. CIVCO offers a suite of innovative solutions to optimize the biopsy process and improve patient outcomes. By enhancing visualization and precision during the biopsy, CIVCO’s solutions can help healthcare providers to detect cancer more accurately, reduce patient discomfort and complications, and ultimately improve the overall quality of care for prostate cancer patients. 

 To learn more about how CIVCO can help you to enhance the detection and treatment of prostate cancer, visit here.

References:

1. American Cancer Society (ACS), “Key Statistics for Prostate Cancer,” 2022. https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html
2. National Cancer Institute (NCI), “Definition – “Digital Rectal Examination,”” 2022. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/digital-rectal-examination
3. National Cancer Institute (NCI), “Prostate-Specific Antigen (PSA) Test,” 2022. https://www.cancer.gov/types/prostate/psa-fact-sheet
4. Mayo Clinic. “Prostate Biopsy.” https://www.mayoclinic.org/tests-procedures/prostate-biopsy/about/pac-20384734 
5. Schmeusser B. Levin B. Lama D. & Sidana A. (2022). Hundred years of transperineal prostate biopsy. Therapeutic Advances in Urology. https://doi.org/10.1177/17562872221100590
6. Cancer Research UK (CRUK), “Transrectal ultrasound scan (TRUS) and biopsy for prostate cancer,” 2022. https://www.cancerresearchuk.org/about-cancer/cancer-in-general/tests/transrectal-ultrasound-guided-trus-biopsy
7. Ching, C. B., Moussa, A. S., Li, J., Lane, B. R., Zippe, C., & Jones, J. S. (May 01, 2009). Does transrectal ultrasound probe configuration really matter? End fire versus side fire probe prostate cancer detection rates. The Journal of Urology, 181, 5, 2077. https://pubmed.ncbi.nlm.nih.gov/19286200/
8. Focal Healthcare - Transrectal vs. Transperineal Approach for Prostate Biopsy: https://focalhealthcare.com/transperineal-vs-transrectal-approach-for-prostate-biopsy/#:....
9. Altok M. Kim B. Patel B. B. Shih Y.-C. T. Ward J. F. McRae S. E. Chapin B. F. Pisters L. L. Pettaway C. A. & Kim J. (2018). Cost and efficacy comparison of five prostate biopsy modalities: a platform for integrating cost into novel-platform comparative research. Prostate Cancer and Prostatic Diseases 524–532. https://doi.org/10.1038/s41391-018-0056-7
10. Guo L.-H. Wu R. Xu H.-X. Xu J.-M. Wu J. Wang S. Bo X.-W. & Liu B.-J. (2015). Comparison between ultrasound guided transperineal and transrectal prostate biopsy: a prospective randomized and controlled trial. Scientific Reports 16089–16089. https://doi.org/10.1038/srep16089
11. Panzone J. Byler T. Bratslavsky G. & Goldberg H. (2022). Transrectal ultrasound in prostate cancer: current utilization integration with mpmri hifu and other emerging applications 1209–1228. Retrieved June 15 2023 from https://doaj.org/article/faa6bbca10084e959cdc8074bd39649c.
12. Mayo Clinic – Ultrasound-guided transperineal prostate biopsy: https://www.mayoclinic.org/medical-professionals/urology/news/ultrasound-guided-transperineal-prostate-biopsy/mac-20473283#:~:text=In%20transperineal%20biopsy%2C%20the%20urologist,ultrasound%20placed%20in%20the%20rectum 
13. Thomson A. Li M. Grummet J. & Sengupta S. (2020). Transperineal prostate biopsy: a review of technique. Translational Andrology and Urology 3009–3017. https://doi.org/10.21037/tau.2019.12.40
14. Basourakos S. P. Alshak M. N. Lewicki P. J. Cheng E. Tzeng M. DeRosa A. P. Allaway M. J. Ross A. E. Schaeffer E. M. & Patel H. D. (2022). Role of prophylactic antibiotics in transperineal prostate biopsy: a systematic review and meta-analysis. European Urology Open Science 53–63. https://doi.org/10.1016/j.euros.2022.01.001
15. El-Achkar A. Abou Heidar N. Labban M. Al-Moussawy M. Moukaddem H. Nasr R. Khauli R. El-Hajj A. & Bulbul M. (2022). Mri/us fusion transperineal versus transrectral biopsy of prostate cancer: outcomes and complication rates a tertiary medical center experience in the middle east. Turkish Journal of Urology 98–105. https://doi.org/10.5152/tud.2022.21248
16. Mayo Clinic Q and A: New techniques for prostate biopsies virtually eliminates risk of infection: https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-q-and-a-new-technique-for-prostate-biopsies-virtually-eliminates-risk-of-infection/ 
17. Gabriele T. Sofia G. Piero M. Alessio T. Tommaso D. Rosa G. Alessandro Z. Marta R. Alberto A. & Nicola P. (2022). Comparison of fluoroquinolones and other antibiotic prophylaxis regimens for preventing complications in patients undergoing transrectal prostate biopsy 415–415. https://doi.org/10.3390/antibiotics11030415   
18. Mike W. Jost von Maria N. Samuel D. Benedikt H. & Clarissa W. (2021). Monoprophylaxis with cephalosporins for transrectal prostate biopsy after the fluoroquinolone-era: a multi-institutional comparison of severe infectious complications. https://doi.org/10.3389/fonc.2021.684144 
19. "Systematic Transperineal Prostate Biopsy Using TP Pivot Pro Guide by CIVCO - Dr. Craig Rogers - Henry Ford Medical Center (0:57-1:16): https://www.youtube.com/watch?v=PNkoPASMXYY&t=2s 

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