Which Is Better: Transrectal or Transperineal Prostate Biopsy?

[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.

[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.