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Transperineal Prostate Biopsy Tools, Equipment & Instruments

Author Olivia Reid covers Transperineal Prostate Biopsy Tools, Equipment & Instruments on BackTable Urology

Olivia Reid • Nov 13, 2023 • 171 hits

Urologists Aditya Bagrodia, Matt Allaway, and Juan Javier-DesLoges explore the role of various equipment, tools, and instruments in switching from a traditional transrectal biopsy to the more efficient transperineal biopsy approach. This includes the procedural table, choice of ultrasound equipment, location of the procedure, and needle sheath to minimize patient discomfort. This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable Urology Brief

• The procedural table, choice of ultrasound equipment, location of the procedure, and needle sheath all collectively impact the efficiency of the transperineal prostate biopsy procedure and the comfort level of the patient.

• UroNav's functionality facilitates more effective control during the procedure which involves different hand motions than the traditional transrectal biopsy.

• The diversity in prostate biopsy tools allows flexibility, but the consensus is that investing in quality equipment is essential, given the lasting impact it has on the success of transperineal biopsies.

• Live dual-screen capabilities, particularly available with BK systems, provide a significant advantage in visualizing the biopsy needle's trajectory.

• Combining cognitive skills with fusion technology allows for precise targeting when performing a prostate cancer biopsy, as the fusion system alone can be insufficient for accurate results.

Transperineal Prostate Biopsy Tools, Equipment & Instruments

Table of Contents

(1) Setting up for a Transperineal Prostate Biopsy

(2) Transperineal Prostate Biopsy Tool Selection: Probing the Options

(3) Transperineal Biopsies for Prostate Cancer: Combining Cognitive and Fusion Approaches

Setting up for a Transperineal Prostate Biopsy

In terms of transperineal prostate biopsy tool requirements and procedural nuances, Dr. Allaway emphasizes the significance of a suitable procedural table. Transitioning from heel stirrups to knee crutches ensures patient comfort and cooperation, as this setup allows for the patient to be more at ease giving them the ability to relax their muscles during the procedure. The choice of ultrasound equipment, particularly understanding the probe type, is necessary to distinguish the peripheral and transition zones of the prostate.

The transperineal prostate biopsy can be performed in either an operating room or outpatient clinic setting. The operating room gives the option for increased reliance on anesthesia, while the clinic allows for quicker turnover between cases and the ability to spread the technique to a wider audience. When comparing the freehand technique and grid stepper, Dr. Allaway explains that the grid stepper technique can cause limitations for the physician, limiting the amount of flexibility to move smoothly through the prostate. The insights serve as a valuable guide for clinicians, offering a clear path toward proficiency in this critical procedure.

[Dr. Aditya Bagrodia]
Before we get into all the details, you had the benefit of having somebody who was able to teach you and a mentor. Let's say that you don't have that benefit, you didn't do cryos or transperineal biopsies. What are the bare minimum equipment requirements that one would need? Matt, say that my platform is, I have a UroNav machine and a BK ultrasound that I use to do MRI ultrasound fusion biopsies in my clinic. Is that sufficient? Can I do a transperineal biopsy tomorrow?

[Dr. Matt Allaway]
The table that you use, the procedural table, I think is an important consideration because of the stirrups. You've got heel crutches, you've got the stirrup for the heel, and you've got the fancy sort of yellowfin stirrups, which would be like the Rolls Royce of sorts. If you're going to start your program using heel stirrups, and Juan, I don't know if you appreciated this, but when patients are in that position and they're nervous, they tighten up their legs and they actually push themselves away from you, so they're moving and sliding away from you. You really should switch over at least to the knee crutch because the knee crutch allows them to relax their legs. If they're in the heel stirrup, they have to use their leg muscles to support their knees so they don't flop aside. That's really important.

Number two, your ultrasound equipment. You mentioned you got UroNav with a BK. There you go, you're all set. Now, Juan will definitely jump in on this, but the probes, the transducers, many urologists don't even understand what they're holding in their hands. Yes, I have a biplanar probe, why can't I use that? No, we're talking about a linear array, not a micro convex biplanar probe. You can do transperineal biopsies with a biplanar transrectal probe, but the skill level to do that is quite different than if you're using your brachytherapy biplanar linear transducer.

[Dr. Juan Javier-DesLoges]
I think I looked at every single ultrasound on the market from GE, Hitachi, BK, to the cheapest $30,000 probe that you can buy, I can't even remember the name of it. In addition to that, you really need to be able to determine the difference between the transition zone and the peripheral zone with the probe. Based on the quality of your probe, you want to make sure that the ultrasound is high enough quality where you can really define the peripheral zone and the transition zone.

[Dr. Aditya Bagrodia]
We've entered this conversation assuming it's a foregone conclusion that we're going to be doing this not in the operating room. Juan, you're loud and clear that the time of the procedure, the cost, the anesthetic, all of that, it's something to consider. Certainly, for me, one of my biggest reluctances heading into this were: what if my block doesn't work or how's my familiarity with the anatomy going to be, given that I used to use end-fire. What I did, as you know, is shadowed you, worked with you, participated with you for 10, 15 cases. I said, "Okay, I think I can handle this." Then, I started doing my own cases in the operating room. Any thoughts on starting out in the OR versus the clinic? Do you have any strong opinions, Matt or Juan?

[Dr. Juan Javier-DesLoges]
I think starting in the OR has an advantage to put a plug in there. I do think that the AUA course is quite helpful for new learners. I had been doing it a year, by the time I went to the course. You pick up on a lot of little nuances that some of the other people are doing. I think just some didactics, plus doing them in the OR, would be helpful for anybody just starting up.

[Dr. Matt Allaway]
I would say those that just jump right in. I've trained hundreds of urologists in hundreds of different settings all throughout the world. I would tell you that in the US those that start under anesthesia sometimes they're not sure when to cut the umbilical cord. When am I ready to do this under local in the clinic? The ones that just dive in in the clinic, they actually get over that learning curve of getting comfortable knowing how to get the patient through it. I think they develop a good local anesthesia program faster. If you're in the OR, you always can lean on that anesthesia, so I think it's up to the individual. Those using fusion, sometimes they feel, "Well, when I trained on fusion, I prefer the patient to be under much better control, more relaxed, and I prefer it being done under anesthesia."

Well, I don't think that's the case anymore with transperineal. I think the whole point of what I worked on was I worked and developed everything with the precision point in a surgery center that we own and operate. I have a grid stepper that sits in the corridor. I never once used the grid stepper to do the biopsy because I knew that wasn't the path to mainstream the approach. The path to mainstream this approach is we've got to do it in less than 15 minutes under local anesthesia. We've got to make this teachable, we've got to make this deployable in the widespread urology community.

[Dr. Aditya Bagrodia]
This is a podcast so most people can't tell that I'm grinning and I'm grinning because I've taught myself some things like robotic retroperitoneal lymph dissection, even robotic cystectomies were not something that I was trained on in residency or fellowship, necessarily. As I reflect, I think it was actually moving transperineal biopsies to the clinic that provided me the most anxiety and consternation among all the different things I do. Your cut-the-umbilical cord analogy totally resonates with me.

I guess, that's debatable, depending on your comfort going into this and having partners that are familiar, if you want to start in the OR and also your familiarity with side-fire versus end-fire probes, I suppose, you could make a decision. Basic equipment, just basic, basic equipment, if you needed this, you wanted to watch like 10 YouTube videos: it would be a biplanar linear ultrasound probe and a grid stepper, things that your hospital already may have in the OR or do you even need the grid stepper? What would you say to that?

[Dr. Matt Allaway]
Well, I would say, this may be another discussion point. I don't want to hijack the grid dialogue, but I think Juan would probably agree with me that the grid, first of all, the experience with freehand versus grid is quite different, in my opinion. I think that people think the grid technique simplifies it because it's like playing battleship: just stick it in the hole and it goes where you think it's going to go. If you really study the trajectory of the biopsy needle, you're really having to insert a lot more needles to finesse that biopsy needle exactly into that seam. Now when I teach, I say you're playing an instrument; it's like learning to play the violin. Your music is the prostate under ultrasound, you have to read that music.

Every prostate is a little bit different. Transrectal was like "Boom, boom, boom", and you're done. There's very little appreciation for finesse and where you are in the prostate. You tend to cluster cores, even though you don't realize it. You've got to be able to read that. As a result, I think the grid is just too limiting and I don't think it serves a purpose of training wheels to help you do something better in the clinic setting. That would be my opinion.

[Dr. Juan Javier-DesLoges]
I think the grid is the historic way of doing the biopsy, that's how original transperineal biopsies were done a long time ago. We've made so much more progress over time with the attachments.

Listen to the Full Podcast

Transperineal Prostate Biopsy: A Practical Startup Guide with Dr. Matthew Allaway and Dr. Juan Javier-DesLoges on the BackTable Urology Podcast)
Ep 96 Transperineal Prostate Biopsy: A Practical Startup Guide with Dr. Matthew Allaway and Dr. Juan Javier-DesLoges
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Transperineal Prostate Biopsy Tool Selection: Probing the Options

The preferences for various supplier options for probes most often comes down to location. For instance, the West Coast population tends to lean towards Hitachi, while the East Coast is predominantly BK. Dr. Allaway explains that BK has an advantage over the competition with their production of the live dual screen option on the typically preferred biplanar linear transducer. This live dual screen allows for clinicians to run both the sagittal and axial views live simultaneously, which aids in the teaching of new learners who are trying to master seeing the biopsy needle from varying perspectives. The main feature that is needed in a proper transducer for performing transperineal biopsies is the ability to see the delineations between each zone in the prostate. Dr. Allaway asserts that the BK Specto allows him to do just that through the use of the cognitive biopsy specifically.

In addition to the changing equipment needs, switching to transperineal biopsies also requires different hand motions than were most common with the transrectal approach. This leads to the use of the UroNav system because the probe can be pitched up and down, as well as moving medially and laterally, whereas the motions for transrectal involve moving the probe in and out of the rectum while rolling the device. Dr. Javier-DesLoges concludes by ensuring that although the new equipment can be expensive, it makes the transperineal prostate biopsy run smoothly and can be used for other procedures.

[Dr. Matt Allaway]
Well, I created the precision point to be agnostic. I understood that on the West Coast, they like Hitachi and they like BK, but you see a little more concentration of Hitachi. In the Midwest, East Coast, it's predominantly BK, but you've also got GE. You have some of the new smaller players. You've got Terason which is sold by the sales team at Hitachi, which has now been bought by Fuji, and GE bought BK. You've got Terason, you've got the Arietta with Fuji, you've got the BK systems, then you've got Mindray and you've got SonoSite, which are the lower-cost systems.

In Europe, about 20% of our users use the transrectal probe. It's not the linear side fire probe biplanar. It's actually the old transrectal probe. We tried to do that in the US, but let me tell you, if you've got the money and resources and you have the option of either in the holster or ultrasound, you'll never choose the micro convex biplanar probe. You'll always go grab your biplanar linear transducer. Now, BK has one advantage over the competition. You can run a live dual screen, so you can run sagittal and axial live, simultaneously. That's a huge advantage for the new learner because they can start to wrap their head around seeing the biopsy needle flash from both perspectives.

When I developed the system, I used an old BK that was called a pro focus. You couldn't run them live dual because once you learn the technique, you're going to pretty much depend on your sagittal array. When you look at the sagittal linear transducer array, why does it cost so much money? It costs so much money because if you look at how long that array is compared to a micro convex, each one of those diamond crystals is positioned by hand. Each crystal has a wire going in it and a wire going out of it. It's almost theoretically impossible to make a proper probe and sell it for much less than about $15,000 because somebody's got to make a little bit of profit. I've had people use every level of equipment and I think Juan hit it right though. You've got to be able to see the delineations between the zones. I personally use a BK Specto because if you've got people coming in, I have people coming into my training facility all month and if they don't have access to fusion, we've got to teach them cognitive. I think having both live images simultaneously really helps you train somebody on how to do a proper cognitive biopsy. That's one big advantage.

If you just look at linear arrays technology, I think the Fuji is excellent. I think GE has a new system where they've re-released the biplanar probe with linear. I think the visuals on that are quite nice also and then when you get it, you get what you pay for like anything else. I think most urologists need to understand that if you're going to make this transition, I don't really have users that say, "Oh, I use transperineal for this and I use transrectal for that." It's pretty much a shift and once you make that shift, you might as well invest in good equipment that's going to last you. Do you want to drive a Tesla or do you want to drive a Chevy Volt? The choice is yours, but I'd probably pick the Tesla if I could. It's capital equipment and you get a lot of hemming and hawing at the university levels on capital purchases, but you get what you pay for and the quality equipment lasts longer, but please, respect the probe too. I tell people, "Handle the probe more carefully than a baby." A baby can bounce. An ultrasound probe doesn't bounce. It hits the floor and you're out. You're out $15,000 to $20,000, so remember that.

[Dr. Aditya Bagrodia]
I appreciate that, Matt. I'm pretty sure if you just showed them a bill from the last urosepsis, I had a nice ICU stay with ID, and everybody and their mom consulted, the financials level would be pretty compelling. Good. Juan, we've decided that we're going to purchase our linear probe and I hear you loud and clear, especially as a historic end-fire guy, the dual live view is massive, so specifically you can see the prostate and the axle views and the side views as well. That's really nice.

Now you mentioned, Matt, cognitive versus a true fusion. Juan, I believe you were trained on OR cognitive fusion. Some of it was fortunate that we needed some work on our previous MRI ultrasound fusion machine. How did you decide that it was probably the UroNav transperineal transrectal fusion software that we were going to go with?

[Dr. Juan Javier-DesLoges]
When we were looking at it, we looked at KOELIS and we looked at Artemis and we looked at UroNav, which I think are basically the three major platforms. I think micro-ultrasound has some fusion which is like a fancy or less fancy cognitive version. The Artemis does not translate well to transperineal because it is a fixed arm. You really need to be able to move your arm around and have more of a fixed needle as opposed to a fixed ultrasound.

Many of the hand motions that you use when you do a transperineal are quite different from transrectal. When we do transrectal, we move the probe in and out of the rectum and we do a twisting motion or a roll. We roll the probe back and forth to do the biopsy. When we do transperineal, it's like the old aircraft terminology, you pitch the probe up and down so you can access the anterior and the posterior and you move it medial and lateral. Those motions, for the large part, really the only one that I could find worked well was the UroNav system. I realize there are other people that do it with some other stuff. For us, I think UroNav made the most sense.

To go back to the capital equipment cost, all the stuff we've bought, we use it for SpaceOAR in the clinic too. It's multi-use. Just because you bought a transperineal probe doesn't mean you can just do biopsies. You can do the SpaceOAR, which we're looking to roll out soon. It can be used for multiple things.

Transperineal Biopsies for Prostate Cancer: Combining Cognitive and Fusion Approaches

Dr. Allaway, Dr. Javier-DesLoges, and Dr. Bagrodia discuss the intricacies of transperineal biopsies for prostate cancer screening. To begin, the instructing clinicians are often challenged with teaching new physicians how to unlearn the methods that they have been using for years when performing transrectal biopsies, as the hand motions and procedural process as a whole are different for the two. When balancing between cognitive and fusion approaches, it is optimal to blend the two together to strengthen the transperineal prostate biopsy. Relying solely on fusion technology can lead to the misinterpretation that the equipment can do the process on its own, rather than being able to use the skills and the technology in tandem for the most accurate performance. Dr. Allaway compares the reliance on fusion technology to playing Guitar Hero instead of truly mastering an instrument. With this, it is vital to check both cognitive and fusion approaches before proceeding into the delicate prostate tissue.

[Dr. Matt Allaway]
Yes, it's a whole new set of hand motions so much so that part of the training exercise, when you're working with urologists that have been out there for years doing transrectals, is untraining them on the habits of transrectal and teaching the new hand motions. To the fusion concept, I think when I train people on, let's say, UroNav, what I'll do is I'll actually cover the UroNav screen and force them to use their brain to anchor the biopsy needle in the vicinity of the ROI, requiring them to actually look at their own MRI and then anchoring the needle in to the capsule in the vicinity. Then and only then I take away the cover over the UroNav screen and then they introduce secondary motions and then they biopsy.

If you think that the fusion system is going to do the job for you, I compare it to this, we're trying to teach you how to play a stradivarius, but if you just think that fusion by itself is the only thing you need to know is watch that green circle and hit it, that's like playing guitar hero. You don't really know how to play the instrument. It's playing music and sometimes it's pretty good, but you've got to know. Cognitives like a Rand McNally Atlas. I'm trying to get to San Diego to visit you guys. I look at Rand McNally Atlas and I drive that way.

Fusion is like using your iPhone with one of your map apps. In 200 feet, turn right, turn left. Juan, you can please chime in, but you've got to use both of those skills. If you're not using your brain and reading that music, you could really turn the fusion experience into something like "Uh-oh, I didn't even get prostate tissue with that ROI. I got skeletal muscle or fat." If you know how to do two together, one plus one equals three. It's like icing on the cake to just be able to say, "I feel really good about it." Check cognitive, check fusion.

Then I actually sometimes like to go back after the neal is in the prostate, go back to your axial array, just on your ultrasound screen, and look for that flash and then remember the image you had in your head of the ROI on the axial T2 image and say, "Yes, that makes sense." Then, Juan, do you inspect your cores? I think you need to look at the DM core too because if you hit the ROI and it's really cancer, it's going to be dense and the core looks much different than a non-cancerous region that's all flimsy and fragmented. That's the way I kind of teach it.

[Dr. Juan Javier-DesLoges]
I don't think I've looked at the cores themselves, but it's a thing that I think I'll start thinking about doing. I completely agree with you, for cognitive, one of the things that we're doing, but we're cheating now. We've asked for access to the radiologist DynaCAD software where we can actually just see the whole length of the ROI and how they mapped it out because when you look at the MRI reports, there's one spot, but the ROI is actually quite longer. I do a combination between the two because there is registration error as hard as you try to avoid it. These tiny, little, subcentimeter lesions can be very easily missed even with the Fusion software. I think actually really knowing both really has made my biopsies better because before when I was a resident, I just was on auto drive. I was an autopilot. Artemis was going and I would just aim for the target. Now, I do Fusion, UroNavs, but I also, as you mentioned, do a little bit of cognitive, simultaneously.

[Dr. Aditya Bagrodia]
A couple of comments, and I certainly appreciate that perspective. One of the things that was a pleasant surprise is that the actual registering of the prostate with the UroNav, if you're going to go with a transperineal approach, is not markedly different from a transrectal approach. That wasn’t like an entire new skill set to learn, which I appreciated. I absolutely hear you. I think that using your analogies, which I like, Matt, I think doing a transrectal approach where you see the prostate, there's very little doubt about what exactly you're seeing. The base, and the apex, and the SVs are all fairly there. Might be the equivalent of coloring in a coloring book and then perhaps really understanding the prostate and where the lesions are are going to be something like a higher-quality piece of art. It is nice.

That was one thing that was not so intimidating when shifting towards the fusion biopsies that are actually registering as pretty comparable. Now, we've got our ultrasound probe. We've decided to really go hook line and sinker. We've got ultrasound fusion software. I also got to say, prior to coming here, I always thought that cognitive fusion biopsies were an absolute tier B option. I think that they may have more of a role transperineally. Any opinion on that?

Podcast Contributors

Dr. Matthew Allaway discusses Transperineal Prostate Biopsy: A Practical Startup Guide on the BackTable 96 Podcast

Dr. Matthew Allaway

Dr. Matthew Allaway is a practicing urologist at Urology Associates in Cumberland and the founder and CEO of Perineologic.

Dr. Juan Javier-DesLoges discusses Transperineal Prostate Biopsy: A Practical Startup Guide on the BackTable 96 Podcast

Dr. Juan Javier-DesLoges

Dr. Juan Javier-DesLoges is a urologic oncologist at UC San Diego in California.

Dr. Aditya Bagrodia discusses Transperineal Prostate Biopsy: A Practical Startup Guide on the BackTable 96 Podcast

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Cite This Podcast

BackTable, LLC (Producer). (2023, May 3). Ep. 96 – Transperineal Prostate Biopsy: A Practical Startup Guide [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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