Nearly two million prostate biopsies are performed globally each year to diagnose and monitor prostate cancer, which is the second most common cause of cancer death among American men.[1][2] For the past 30 years, the standard of care for prostate biopsies has been the transrectal approach. This method requires urologists to access and take samples of the prostate by passing a needle through the rectum, putting patients at risk of infection by introducing fecal bacteria into the prostate.

As a urologist, it was difficult to accept the known complications and limitations with the transrectal approach to prostate biopsy. I decided that there must be a better approach that would not put my patients at risk. In the last several years, I developed a device and surgical method that accesses the prostate through the perineum – known as the transperineal approach. This method provides a better, safer way of performing the same biopsy procedure that is shown to result in better cancer detection rates and patient outcomes.

Shifting Clinician Perspectives
When the transrectal biopsy became the gold standard in the 1980s, there was no effective technology available to perform a transperineal biopsy. In recent years, more clinicians, patients, and their families have become aware of the new options and devices available to perform the transperineal approach, but unfortunately, more than 90% of biopsies are still performed using the transrectal approach.

The transrectal biopsy typically requires 12 needle sticks through the rectum to access the prostate for biopsy samples – this puts patients at risk of infection with each pass of the needle. Patients are often given antibiotics pre- or post-procedure to help avoid infection, but due to societal overuse of antibiotics, up to 25% of bacteria are antibiotic resistant. [3] About 1-6% of patients worldwide develop an infection resulting in hospitalization due to these infections, called sepsis.[4] Sepsis is a serious complication of infection – between 12-25% of cases are fatal.[5] Other potential complications of the transrectal biopsy are rectal bleeding, temporary inability to urinate, pain, and erectile dysfunction/ [6]

An additional drawback of the transrectal approach is that it is often difficult to access certain areas of the prostate where cancer is often found, including the anterior portion of the prostate. As a result, up to 30% of cancer is either not identified or mis-classified with transrectal biopsies.7 Missing cancer often means patients need to undergo multiple transrectal biopsies before it is found, exposing them to the same risks outlined above with each procedure. Misclassification of cancer could indicate that patients have a low-risk disease when they have a higher-risk disease that requires active treatment rather than active surveillance.

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As more advanced technologies became available over the years, some clinicians transitioned to using the transperineal approach to prostate biopsy to reduce risks to patients associated with the transrectal approach. In early 2000, many clinicians started using a device called a grid stepper to perform the transperineal approach. While this method dramatically improved accuracy and eliminated the need to go through the rectum, the procedure is long (up to one hour), involves general anesthesia, and requires clinicians to puncture patients up to 60 times, which presents a new set of potential complications.

Given the challenges with the grid stepper, many clinicians have been hesitant to switch to the transperineal approach and continue to use the gold standard transrectal approach. But it is important for clinicians to understand that there is a new device and surgical technique now available to perform transperineal biopsies in an accurate, safe and effective way.

Pioneering a New Safe, Precise, and Efficient Biopsy Technique
Our new approach uses the PrecisionPoint™ System to perform transperineal biopsies but unlike the grid stepper, it can thoroughly sample the prostate with only two needle sticks. This offers little or no discomfort to patients. This technique can also be performed under local anesthesia in an office setting in a brief procedure, whereas a transrectal biopsy or traditional transperineal biopsy with a grid stepper has to be done in an operating room or ambulatory surgery center.

With this system, clinicians can detect cancer even in the most difficult to reach areas of the prostate including the anterior portion, resulting in about 30% better cancer detection rates. [8] By accessing the entire prostate through the perineum rather than the rectum, this system also significantly reduces the risk of infection (to nearly 0%)9 compared to a 5-7% infection rate on average with the transrectal approach.10 It also reduces the risk of other complications such as bleeding and urinary retention.

This new surgical method also allows clinicians to perform transperineal biopsies free-handed, while still being able to manipulate the biopsy needle together with the ultrasound probe and maintain full control of the procedure. They can target the desired locations with certainty in a strategic and parallel direction and are not restricted to biopsy locations as seen with a grid stepper configuration. The free-handed technique also allows clinicians to use hand-eye skills that they already use with transrectal biopsies, which often results in a short learning curve.

The Future of Prostate Biopsies
This new innovative system changes the paradigm of prostate cancer detection and presents several benefits for both clinicians and patients. It is widely known in the urologic community that the transperineal approach to prostate biopsy is safer for patients compared to the transrectal approach, but due to prior limitations in technology, this method has not been broadly adopted among clinicians. The primary focus among all clinicians is to provide the best care possible to patients to improve their overall health and quality of life. Now with the availability of a new technique to perform transperineal biopsies that offer increased cancer detection and reduced risk of infection, while being able to accurately sample the entire prostate, this approach is well-positioned to transform modern urology practice in the years ahead.

[1] Thomson, A., Li, M., Grummet, J., & Sengupta, S. (2020). Transperineal prostate biopsy: a review of technique. Translational Andrology and Urology, 9(6), 3009–3017. [Article]
[2] Key Statistics for Prostate Cancer. (2021, Jan 12). American Cancer Society. Online. Last accessed October 1, 2021.
[3] Liss, M., et al. (2021). Prevalence and Significance of Flouroquinolone Resistance of Escherichia Coli in Patients Undergoing Transrectal Ultrasound Guided Prostate Needle Biopsy. The Journal of Urology, 84: 395-99. [Article]
[4] Loeb, S., et al. (2013). Systematic Review of Complications of Prostate Biopsy. European Urology, 64: 876. [Article]
[5] Fleischmann, C., et al. (2016). Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. American Journal of Respiratory and Critical Care Medicine, 193(3): 259-72. [Article]
[6] Weiner, A., et al. (2020). The Cost of Prostate Biopsies and Their Complications: A Summary of Data of All Medicare Fee For Service over 2 Years. Urology Practice, 7(2): 145-51. [Article]
[7] Szabo, R. (2021). “Free-Hand” Transperineal Biopsy Under Local Anesthesia: Review of Literature. Journal of Endourology, 35(4). [Article]
[8] Ristau, B., et al. (2018). Free-Hand Transperineal Prostate Biopsy Provides Acceptable Cancer Detection and a Minimum Risk of Infection: Evolving Experience with a 10-Sector Template. Urologic Oncology: Seminars and Original Investigations, 36; 528. [Article]
[9] Lopez, J., et al. (2021). Local Anesthesia Transperineal (LATP) Prostate Biopsy Using a Probe-Mounted Transperineal Access System: A Multicentre Prospective Outcome Analysis. BJU International, 128(3); 311-18. [Article]
[10] The Prevention and Treatment of the More Common Complications Related to Prostate Biopsy Update. (2012, updated 2016). American Urological Association. [Article]

Featured Image: PrecisionPoint™ System, the device that makes the procedure work. The PrecisionPoint™ Transperineal Access System revolutionizes the methodology for obtaining prostate biopsies. This medical system takes full advantage of the transperineal path to more thoroughly sample all regions of the prostate including those difficult to access with the transrectal approach. Since the technique is freehand, the practitioner can easily target the desired locations with certainty and through a single puncture of the skin. In addition, the PrecisionPoint™ minimizes the potential for infection, since the passage of the biopsy needle avoids the rectal wall contaminants entirely. Courtesy: © 2021 Perineologic. Used with permission.

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