Transperineal prostate biopsy: tips & tricks

Transperineal biopsy for prostate consists of sampling tissue to look for cancer cells in the prostate, passing through the perineal skin. Until now, transrectal approach is the most performed by urologists around the world, but international authorities and guidelines recommend using transperineal way to reduce infection and use the same route from diagnosis to treatment (see our article “Exploring transperineal prostate biopsy”).

As the shift is moving, more and more urologists are getting interested in performing transperineal prostate biopsies. In this article, we provide some concrete tips and tricks to set up this approach in healthcare facilities.

Learning curve of transperineal prostate biopsy

Today, transrectal approach is the most performed because it is the way physicians learn at school. So as urologists are used to performing it, it could be difficult at the beginning to change the practice, and they think it is easier than transperineal. But, once again, things are moving. Students or interns are now performing transperineal approach if their mentors are using it, and teaching methods are evolving.

Concretely, Transreactal approach is not easier to learn than transperineal approach, it is just a new technique, so it takes time to handle it perfectly. According to Dr Anract (from Hôpital Cochin in Paris), if we ask students which approach is faster to learn, they will answer transperineal.

The sagittal view offered by transperineal approach gives an ideal picture of the prostate: from the base to the apex. It is easier to understand than transrectal approach because you don’t need to move the probe and analyze plans that are not even parallel.

“I mean, the human spirit is not designed to analyze planes who are not parallel. So, I think it's really, really more difficult. The problem is people know how to do transrectal, so they think it's easy, but actually transperineal is easier. ”

Dr Julien Anract, Hôpital Cochin, Paris (France).

Why switching from transrectal route to transperineal approach?

If physicians are not convinced yet, the first argument to switch from transperineal to transrectal approach is that it is a safe technique, with less infection rate. Then, there are today a lot of studies and researches that show evidence that transperineal route is safe, feasible and efficient. This is the first step to a big move.

Performing transperineal approach is now a strong recommendation from EAU guidelines since 2021, and one day, it could be a standard of care. So, physicians should follow the guidelines!

“Remember, 15 years ago, there was probably that guy saying like, what? Playing music, taking picture, going on the Internet with just a phone. No way it's going to work. So, you know, when everyone is taking the train, you don't want to be that guy.”

Dr Julien Anract, Hôpital Cochin, Paris (France)

Tips and tricks to switch from transrectal to transperineal route

Concretely, how to change the practice? Here are some advises:

• Practice first cases under general anesthesia

It is easier to learn under general anesthesia. It is better for the patient, and it gives time and serenity to the physician when he is learning. Then, when people are used to this technique, the choice can be done directly by the patient. But, for the first cases, it is better to perform under general anesthesia.

• Get all the material

It is important to get all the material needed near to the physician: the fusion system of course, but also the right probe, the needles and the most important: the stabilization arm for the hand free technique. It is easier and more comfortable when doctors are learning transperineal prostate biopsy procedure.

• Learn from experimented urologists

What can be better than learning from colleagues? Instead of learning alone, it is better to learn from a surgeon who knows the technique, he will help other physicians to learn faster the technique, with the do and don’t of the system chosen. It is way more comfortable than learning from scratch.

Transperineal prostate biopsies tend to become standard in prostate care management, as lot of studies have shown the benefits and urologists are more and more performing this approach. So, it is time to switch!

Sources :

• Podcast de Dr Anract (https://open.spotify.com/episode/5NyuiNsHGnnUnUHykZVZLH?si=EkW35PEGQa2v3tORdC7dEA)
• https://uroweb.org/guidelines/prostate-cancer/chapter/diagnostic-evaluationhttps://pubmed.ncbi.nlm.nih.gov/25663102/
• Infection rate and complications after 621 transperineal MRI-TRUS fusion biopsies in local anesthesia without standard antibiotic prophylaxis, Gunzel et al, World Journal of Urology, January 2021