By Jason P. Joseph, MD
Over the past 30 years, virtually all prostate biopsies have been conducted transrectally. However, we are now seeing a gradual shift to a transperineal approach, which drastically reduces the risk of sepsis amidst the increasing prevalence of antibiotic-resistant bacteria.
Prostate cancer is the most common solid organ cancer in men in the United States. Approximately 1.2 million prostate biopsies are performed annually, following an abnormal prostate-specific antigen (PSA) screening, digital rectal exam and/or prostate MRI, or to monitor prostate cancers for active surveillance.
For transrectal biopsies, an ultrasound probe is placed into the rectum and the biopsy needle crosses through the rectal mucosa to reach the prostate, which risks the spread of rectal bacteria to the bloodstream.
While the office-based procedure is quick and well-tolerated, the danger of infection is unavoidable. Despite administration of broad-spectrum antibiotics as preventatives, one to three percent of patients will develop a serious infection requiring hospitalization.
That percentage may sound low, but even a one percent risk translates to more than 12,000 hospitalizations annually. The mortality rate for sepsis ranges between 10 to 20 percent, depending on the study cited.
Moreover, the threat of life-threatening infections is rising as the prevalence of antibiotic-resistant rectal flora, such as fluoroquinolone-resistant bacteria, increases nationally.
A separate concern is that the anterior region of the prostate tends to be poorly sampled with the systemic transrectal approach. Of the 30 percent of tumors missed by these biopsies, up to 80 percent exist in anteriorly located portions of the prostate.
During a transperineal biopsy, the ultrasound probe is still placed into the rectum, but biopsies are taken through the anesthetized skin of the perineum rather than the potentially-contaminated rectum – essentially eliminating sepsis risk.
Although the transperineal approach is not new, it hasn’t been widely embraced because it had – until recently – required general anesthesia and often was associated with significant patient discomfort. Policymakers and healthcare payers also haven’t helped accelerate the adoption of this safer approach, such as by offsetting equipment and training costs.
However, advances in technology and surgical techniques have made the procedure much more tolerable and easier for physicians to learn. Today’s biopsies can be performed under sedation in hospitals and surgical centers or, increasingly, in office settings.
Cancer detection rates are at least as good – and probably better – as with transrectal biopsy. Besides sepsis, potential side effects are also similar, including temporary blood in the urine and semen and urinary tract infections. The transperineal approach can be used for systemic or MRI-fusion biopsy, which merges previously-captured MRI and real-time ultrasound images.
Finally, transperineal procedures may be particularly advantageous for men with negative results on transrectal biopsies but persistently high PSA scores, indicating possible anterior tumors. The same goes for patients with inflammatory bowel disease or a history of infection, prostatitis or rectal bleeding.
In my opinion, transperineal prostate biopsy will quickly gain traction in Hampton Roads and across the country – all excellent news for patient safety.
Dr. Joseph is based in Urology of Virginia’s Hampton and Williamsburg offices. He specializes in minimally-invasive urologic surgery for benign and malignant disease and trained in transperineal prostate biopsy at the Mayo Clinic. urologyofva.net