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Which Is Better: Transrectal or Transperineal Prostate Biopsy?

Author Olivia Reid covers Which Is Better: Transrectal or Transperineal Prostate Biopsy? on BackTable Urology

Olivia Reid • Nov 13, 2023 • 263 hits

Leading urologists Dr. Aditya Bagrodia, Dr. Juan Javier-DesLoges, and Dr. Matt Allaway discuss which is better between transrectal or transperineal prostate biopsies. They cover the evolution and refinement of prostate biopsy techniques, highlighting the advancements that have changed the field, specifically the transperineal prostate biopsy. The urologists emphasize the value of this new, alternative way of performing prostate biopsy from the perspectives of patient safety, diagnostic efficacy, and practicality. Transperineal prostate biopsy has shown greater cancer detection rates in various zones while simultaneously lowering the complication risks previously associated with transrectal biopsy, which range from rectal bleeding to sepsis.

As transperineal prostate biopsy spreads, it has become evident that the medical field must work towards a standardized template in an attempt to involve more practicing physicians in this technique and streamline the process. As the field continues to move towards transperineal biopsies, Dr. Bagrodia, Dr. Javier-DesLoges, and Dr. Allaway agree on the need for a collaborative approach to enhance outcomes. This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable Urology Brief

• Transperineal prostate biopsy offers a safer alternative to traditional transrectal biopsy due to lower rates of complications, according to Dr. Matt Allaway.

• Prostate cancer detection rates have shown promising results with transperineal biopsies, as this approach allows for samples to be pulled from different zones that may have previously been missed.

• As transperineal prostate biospy spreads across the medical field, there is an ongoing need to standardize the templates for transperineal biopsy, specifically the number of cores required for the most accurate diagnostics.

Which Is Better: Transrectal or Transperineal Prostate Biopsy?

Table of Contents

(1) Which Is Better: Transrectal or Transperineal Prostate Biopsy?

(2) Transperineal Prostate Biopsy: Enhancing Cancer Detection

(3) Making the Switch to Transperineal Biopsy: Insights from Experienced Practitioners

Which Is Better: Transrectal or Transperineal Prostate Biopsy?

Dr. Bagrodia, Dr. Allaway, and Dr. Javier-DesLoges give insight into the question of why transitioning from the traditional transrectal end-fire biopsy, which has been the gold standard for many years, to transperineal biopsy has lasting benefits for doctors and patients. With prostate biopsies, there are dual concerns of complications and cancer detection. Complications, including rectal bleeding, infections, and even sepsis, have led countries like Norway to ban transrectal biopsies due to the associated fatalities. There is a growing body of data indicating that the transperineal prostate biopsy approach offers a more precise way to sample the prostate, given the prostate's complex, non-rectangular shape. Because of this, the transperineal prostate biopsy has shown higher rates of cancer detection in areas that may have otherwise been missed or unreachable. Dr. Javier-DesLoges explains how the transrectal biopsy requires about 50 minutes and has been proven to be less successful and has a higher complication risk, while this transperineal approach can be done in the outpatient clinic in under 20 minutes with increased safety and efficacy.

[Dr. Aditya Bagrodia]
As I was preparing for this podcast, I was thinking to myself, I grew up on transrectal end-fire biopsies, my blocks worked, my clinically significant cancer detection rates for zones three, four, and five were 30%, 60%, and 90%. Every year or so there was a patient who got a bout of sepsis from his biopsy. Why rock the boat? Why do I need to change anything?

[Dr. Matt Allaway]
That is the question and there are two answers to the question. Obviously, the first is complications, which span from rectal bleeding, to infections, to sepsis. In fact, in Norway, they've essentially banned the transrectal biopsy because in that smaller country, they had a handful, five to eight, of deaths a year from a prostate biopsy. We've got complications on one side and then we have cancer detection on the other. There's definitely a building body of data that's showing that the transperineal approach offers the trajectory in order to really sample the prostate properly.

To understand the prostate you've got to understand that these zones are all pancaked within each other and it's not shaped like a rectangle or a box. It's a complicated sphere and we know now where the cancers are hiding and we know just by simple logic of geometrical vectors that going transrectal is not doing the best job of capturing the disease. Those I think are the two issues that in my life pushed me to dedicate the last eight years of research and work in industry to try to change that.

[Dr. Aditya Bagrodia]
I think when we think about any intervention, whether that's a surgery, a procedure, a drug, we often think about safety and efficacy. In some ways, I'm a little bit proud of myself because I do think you can teach an old dog new tricks and I've shifted towards transperineal biopsies. One of the reasons I really thought it'd be nice to have Juan on is Juan has really spearheaded our program here at UC, San Diego, in terms of moving these biopsies, which are being done by a former member of the department primarily in the OR, to the clinic.

I thought we could just walk through. You're a practicing provider, academic, private practice, small group, or large group, and one fine day you decide that it's time to start doing transperineal biopsies. When you make that decision, let's just walk through that whole process of making this a reality. Juan, what were some of the first things that you thought about when you were like, "I want to do transperineal biopsies and I want to do them in the clinic?"

[Dr. Juan Javier-DesLoges]
Back in 2001, one of my mentors, Dr. Parsons spearheaded our transperineal prostate biopsy program. I had done transperineal cryoablation and some SpaceOAR as a resident, but I'd never really done biopsies and he had encouraged me to do it. He said, "If you know how to do those, you understand how to look at things in transperineal, you should think about doing the biopsies." I was a little skeptical about it. As a resident, I had really only done fusion biopsies with the Artemis machine transrectal and I came to watch them in the OR.

The biopsies were about 50 minutes long plus turnover. We were doing somewhere around six biopsies in a day, if things were going well in our outpatient pavilion. It just was clunky to use one of your words. Then, my mentor left; he went into industry. Suddenly, I was the only person that knew how to do transperineal prostate biopsies in the department. I was like, "Well, how can I make this more efficient and effective?" I basically looked at every ultrasound you could find. I looked at every biopsy attachment. I went to the AUA course. I met Dr. Allaway there.

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: Enhancing Cancer Detection

Transperineal prostate biopsies strengthen the reproducibility and accuracy of prostate cancer detection. One reason for this is the ability of the transperineal approach to negate the issue of the medial to lateral encounters that often plague transrectal biopsies. Such encounters lead the prostate biopsy to go awry or for there to be areas of the prostate that are missed in which cancer could be present. Furthermore, the urologists emphasize the importance of examining core samples for cancerous tissue and assessing their density; a task that is made simpler with the increased control of the transperineal biopsy. The novel approach to traditional prostate biopsies has additionally given rise to the detection of cancers originating in the peripheral and anterior zones, including high-grade tumors that tended to be anticipated only from the transitional zone in the prostate.

[Dr. Matt Allaway]
I think Juan hit it on the money. I actually have a DynaCAD workstation myself. I do all my ROIs personally. It's good for teaching urologists, it's good for teaching residents, and you become really familiar with that patient's prostate. You're like, "Oh, that lesion is la, la, la." To Juan's point, if you're going to miss the lesion transperineal, it's going to be from the medial-to-lateral perspective more or less. Once you anchor your needle in the capsule at the apex and then you fire in the SEMA tissue in the relevant zone, the needle's passing all the way from the apex to the mid prostate, maybe the base, if it's short enough.

With transrectal, it's an apical to basal issue too. You've got two different ways of messing it up: if you're too medial or too lateral, or too apical or too basil. With transperineal, we eliminate that problem, and so you just plow through that. To that other point about looking at your cores, if you look at your core on a blue pathology sponge and you see two really robust meaty cores, you know that's not falsely thick because you went transrectal and veered in the TZ because the TZ cores will look like a cancer core. If you stay just in the PZ, for example, and it's a dense, thick core, you got two cores. You know you hit it out of the money. You're done. Move on. Do your systematics and call it a day. If they're flimsy and fragmented, then you might take three or four until you're certain, but you can move easily from medial to lateral saturating around the ROI. I think that's why we saw the results in that.

Juan, did you guys read the manuscript in the Journal of Urology from that big, multidisciplinary, young urology collaborative, where they compared transrectal to transperineal fusion? They had hundreds of men in both cohorts. All the men that were done transrectal were done with fusion. The transperineal cohort was done in a mixed-bag fashion, meaning I think only about a third of them were done with Fusion software. Transperineal beats the transrectal on cancer detection of all grades. This was a group of about 15 urologists. Juan is an ace. You have to remember that not everyone's a maestro. In urology, you've got various levels of skill sets. We have to make this reproducible. I think that study shows that it is reproducible in that fashion. That was a pretty exciting paper.

[Dr. Juan Javier-DesLoges]
I was going to say, yes, I read it also. I think one of the biggest differences when you go transperineal is the whole core is a peripheral zone, or it should be. When you go transrectal, you can get a fair amount of transition zone in there, kind of a mixed core. I think that that does improve the cancer detection rate, in my mind.

[Dr. Matt Allaway]
Then when you're going anterior, think about a transrectal, your vector, it's like taking a pool stick and poking up at your ceiling to get an anterior lesion. With transperineal, you're flying into the anterior zone exactly. In fact, the Italians, when I train a lot of Italians in Italy, they have the ultrasound screen upside down. The anterior prostate looks like it's posterior and vice versa. Sometimes I feel like doing that in the US so that people could really study the anterior prostate with such commitment as they do the posterior peripheral zone.

I don't know, Juan, what your experience has been, but I'm fascinated with anterior disease and I'm fascinated with how much we've missed historically and how much lives up there. It's really wild that when I trained on my 12-core transrectal, I never touched that tissue. Never. MRI told us, "Hey, guys, it's over there at the ceiling. What are you doing down there?" That was a great lesson. I think we find a lot of cancers up in the anterior horn. To get that transrectal, your vector is so biased that you often are in the capsule, in the tissue, and then out of the capsule. You're really not getting a representative sample.

[Dr. Aditya Bagrodia]
I'm again, grinning because in some of my early experiences, I did have a little bit of oversampling of the anterior fibromuscular stroma. Suffice to say that was never an issue, problem, or a concern when I was going transrectal.

[Dr. Matt Allaway]
That deserves a slight pause though. If I could only selfishly grab a moment and get your opinions. Anterior disease, everybody thinks it's anterior transitional zone. I believe firmly that no important cancers originate from the transitional zone. I have never once found a posterior transitional zone high-grade tumor that didn't invade from the peripheral zone. Not once. I've been talking with pathologists that still do whole mounts and they're like, "You're right. Never seen it." Then why would there be anterior transitional zone, high-grade lesions, and never in the posterior TZ? Doesn't make any sense at all.

Thus, it does not come from the TZ. Where are these anterior tumors coming from? They're coming from the peripheral zone that sweeps, or they're coming from some tissue. I could bore you to death showing you MRI images of these tumors that just seem to be riding very, very anterior and then they grow into the TZ. They grow easier into the TZ from anterior than they do posterior. That's why they're often larger tumors too. Not because we missed them with the past two biopsies.

Making the Switch to Transperineal Biopsy: Insights from Experienced Practitioners

Dr. Bagrodia shares his experience of switching to transperineal prostate biopsy, explaining how it was the safety and diagnostic improvements that made him confident in this new method. Dr. Javier-DesLoges details how moving from working in isolation to collaborating with others highlighted the importance of a team-based approach. This approach can improve the knowledge and skill level of the physicians individually, ultimately leading to a standardized approach in the coming years. After committing the majority of his professional life to teaching others to effectively perform transperineal biopsy, Dr. Allaway can see a bright future for this technique through the involvement of nurse practitioners and the influence of academic medicine. The group of doctors conclude by emphasizing the goal of patient-centric medicine being the focus of all technological advancements.

[Dr. Aditya Bagrodia]
Absolutely, a lot of very intelligent, experienced people are working on this. Yourself included. Well, hey, maybe I'll start out as we wrap up here, parting thoughts with the listenership. Again, I finished my training in 2016, so blink of an eye, I'm in year seven. To be perfectly candid, it was intimidating.

Ultimately, I did believe that there's a lot of value, primarily from a safety perspective, and then also potentially from a diagnostics perspective. I think with some support from your colleagues, it's quite feasible to start doing this. In my early experience, there's nothing catastrophic that's dissuaded me. I'll start with that and maybe we could have a thought from each of you, Juan and Matt, as we conclude.

[Dr. Juan Javier-DesLoges]
My concluding thought here is that we work many times in isolation. I was doing the biopsies in the basement of the OR for a year, never having actually really interacted with anybody else doing them. Then I went back to interact with all these people at AUA. You can learn a lot. I would continue to revisit the way that you're doing the biopsies to see what else you can learn from other peoples to see if there's an opportunity for you to improve your outcomes. That would be my suggestion. Work in isolation, get your technique better, and then just go back and relearn it again from somebody else, or learn other ways you can improve yourself.

[Dr. Matt Allaway]
I would say that transperineal, obviously I've committed this chunk of my life to this purpose of evangelizing this whole movement of sorts, but if we look at the experience we had in the UK, the UK, they were doing all grid-based in the operating theater under general. We came in there with some fresh new ideas, and now 80% of all the prostate biopsies last year were done this way, this precision point methodology in the clinic setting, and roughly 20% are done by nurse practitioners.

We're starting to train in the US with nurse practitioners. We can do it. We're trying to make biopsies fun again. It's fun. It's rewarding, it's satisfying, it's the future. The guidelines are shifting. They've already shifted in Europe. Time to jump in. It's not as sexy as robotic prostatectomy, but in many ways, that's how that became successful. Like-minded people got together, started talking about different techniques, different nuances, and the field just completely shifted to that robotic movement. I think we've got a lot more obstacles in the way than the robotic movement, but I can't tell you the momentum that's growing out there. It's really palpable. It's very exciting. Thanks to gentlemen like yourself at the academic level, because the dude from Cumberland, Maryland, he's tainted. He's industry, wears different hats. You guys are the ones to do it. Thank you.

[Dr. Aditya Bagrodia]
Well, hey, Matt, Juan, thanks again for offering your experience, your insight, your candor about the whole process. I think in the 21st century we all recognize that, one, you've got to evolve with the times, and two, it takes a village. I don't think industry is evil and we're all holier than thou. It's a total team-based approach. As long as everybody's moving in the right direction trying to help out patients, the future is bright. All right, guys, have a wonderful evening. Thank you again.

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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