What Is Transperineal Prostate Biopsy?

Prostate cancer is one of the most common types of cancer in the world. In the United States, one in nine men will develop this cancer at one point or another.

Although a serious disease, it’s possible to recover from prostate cancer. The key is to diagnose the condition in the early stages. For diagnosis purposes, doctors usually perform a transrectal biopsy.

However, this research is flawed and fails to diagnose many cases. Transperineally performed prostate biopsy emerges as an effective solution for this problem and an accurate diagnostic test. Read on to learn more.

What is a transperineal biopsy?

The transperineal biopsy of the prostate is a type of guided prostate biopsy where the urologist passes the biopsy needle through the perineal skin and into the almond-shaped gland. The perineum is the skin between the testicles and rectum. 

The whole purpose of this approach is to improve the cancer detection rate.

An ultrasound was placed in the rectum guides biopsy needle. In fact, several approaches for transperineal prostate biopsy exist. The choice of the technique depends on whether a fusion or a systematic biopsy is necessary. It also depends on whether the patient is in the clinic under sedation.

The first approach uses a stepper, a device that cradles the ultrasound probe and provides a guidance grid for the biopsy needle. The disadvantage of this approach is that each biopsy requires a skin puncture. As a result, this technique’s utility is limited in clinics where transperineal prostate is performed under local anesthesia only. 

The freehand approach is yet another technique. The approach uses a needle access guide. Only one or two skin punctures are necessary for each side of the prostate.

Since the needle access guide is positioned through the perineum’s anesthetized skin, the urologist can reintroduce the biopsy needle for multiple biopsies. That way, new skin puncture for each biopsy is unnecessary. The ultrasound probe in the rectum guides the biopsy needle. The freehand technique improves patient comfort.

Transperineal fusion biopsy is considered safe, highly targeted, and relatively comfortable.

How does it differ from other types of biopsies?

A transperineal prostate biopsy is not the only biopsy that can diagnose prostate cancer. A transrectal prostate biopsy is the most common option.

As you can conclude by its name, standard transrectal biopsy involves reaching the prostate through the rectum to obtain the sample. The transurethral method is also possible. In this case, the doctor uses a cystoscope (a flexible tube and viewing device) to obtain the sample through the urethra. There is also a saturation biopsy, which is performed in high-risk patients.

The whole idea of biopsy may seem complicated, and it’s useful to address it first. The doctor inserts a thin, hollow needle into the prostate gland. When they pull out the needle, it removes a small cylinder of prostate tissue called biopsy core. The techniques to obtain these samples vary and include the approaches mentioned above.

Studies show that TP biopsy has the same diagnostic accuracy as a transrectal biopsy. However, TP targeted prostate biopsy is safer and more valuable. Compared to its counterpart, transperineal biopsy has a lower risk of infection and rectal bleeding. Scientists recommend doctors to perform TP biopsy whenever they can.

Even though the transrectal technique is considered standard today, it has a higher risk of significant complications, including sepsis. Also, some areas of the prostate, including the anterior prostate, are undersampled with transrectal biopsy (TR biopsy). This means that some clinically significant prostate cancers are completely overlooked. A transperineal biopsy helps navigate around both these problems and improves prostate cancer detection.

Preparing for your biopsy

Your urologist will inform you about the targeted biopsy and the course of the procedure. Make sure to ask questions and express your concerns. 

Before the biopsy, you should let the doctor know if you’re taking some medications. This can help the doctor determine the best form of anesthesia but also to avoid potential complications.

When you arrive at the doctor’s office, hospital, or clinic, you will get a specimen pot for a urine sample. Before the biopsy can even start, the healthcare professional will check urine for the signs of infection. Should they find the presence of infection, they will need to postpone biopsy. 

To prevent infection, you will get antibiotics 40 to 60 minutes before the surgery. This practice is called antibiotic prophylaxis. Then, you will need to change into a hospital gown so the biopsy can start. 

During the biopsy

Before the biopsy starts, you will need to lie on your back on the recliner chair and place your legs on the supportive stirrups. The healthcare professional may apply tape to move the scrotum out of the way and move supportive stirrups so that your knees are bent. The urologist then performs a digital rectal exam to feel the prostate before inserting an ultrasound probe into the rectum. The transperineal ultrasound probe is covered with lubricating jelly to minimize discomfort. 

Thanks to the ultrasound guidance, the urologist can see the prostate’s image on the ultrasound screen. The imaging serves to guide the collection of the biopsy. Keep in mind that the ultrasound probe’s insertion may be uncomfortable, but it doesn’t hurt. It’s also useful to mention that MRI (magnetic resonance imaging) can guide the biopsy needle during the procedure.

The healthcare professional cleans the perineum with an antiseptic solution. After that, a patient receives either local or general anesthesia. The choice of anesthesia depends on the doctor. The doctor bases this decision on your general health and symptoms you experience. Just like the doctor chooses whether to use MR imaging or ultrasound.

When the anesthesia kicks in, the urologist inserts a guide tube into the perineum. They need to do it twice (to obtain a sample once from both the left and right side of the prostate). The biopsy needle goes through the guide tube to take those samples. As the biopsy is taken, you may hear a “click” sound if you’re under local anesthesia. This happens because a device featuring a spring-loaded needle takes the biopsy.

A transperineal prostate biopsy usually takes 20 to 40 minutes.

After the biopsy

The transperineal prostate biopsy is an outpatient procedure. You can go home the same day. However, you have to be in the hospital for at least a few hours after general anesthesia. The patient goes home when fully recovers after waking up from anesthesia. That means after he eats, drinks something, and passes urine normally. 

The medical team looking after you will ensure pain is under control before you’re discharged. Waking up from general anesthesia may still make you drowsy. You shouldn’t drive home. Drowsiness can increase the risk of accidents. 

After the procedure, the medical team will give you an absorbent pad to put in your underwear. You’ll need it due to the small amount of bleeding from the skin punctures and the urethra

For the next couple of days, you will feel discomfort in the biopsy area. Discomfort is mild, so may just need to take the usual over-the-counter painkiller. 

During the next 24 hours, it’s important to drink plenty of water or other non-alcoholic fluid.

Side effects

Generally speaking, a transperineal approach is a safe test. However, every test or procedure carries a certain risk of adverse reactions. The TP prostate biopsy is not the exception. Some of the most common side effects of this test include bleeding, pain, and infection. The risk of developing these problems is not high.

For example, infection such as sepsis affects one in 500 men. About 1% of men experience urinary retention requiring catheter placement. Less than 5% of men have temporary erectile dysfunction. These complications are possible but not so common.

When it comes to common side effects, most men have blood in urine and semen alongside bruising of the skin. These adverse reactions are mild and tend to clear out within a few days. 

The biggest advantage of transperineal biopsy is an absence of a common side effect linked with the transrectal approach. That side effect is rectal bleeding. In a transperineal biopsy, the needles don’t go through the rectal wall. As a result, you don’t experience this common yet uncomfortable side effect

When it comes to infections after TP biopsy, you can prevent them by drinking plenty of water. You see, water flushes out the blood and thereby reduces the risk of infection. If you experience the symptoms of infection, you need to call your doctor right away or go to the emergency department. The signs and symptoms of infection include:

  • Shaking or shivering

  • High temperature

  • A lot of blood in urine and stool

  • Having to pass urine very often

  • Difficulty passing urine 

Patients with infection after TP biopsy will get a prescription for antibiotics. 

Alternatives to biopsy

The only way to confirm the existence of prostate cancer is the biopsy. But, it’s not the only test your doctor may order. In fact, certain tests help rule out prostate cancer and thereby eliminate the need for biopsy. These tests include the following.

Digital rectal exam (DRE) 

During the exam, the doctor inserts a gloved finger into the rectum to feel irregularities in the prostate. DRE is a common part of a man’s routine physical examination. Your doctor may choose to perform DRE alone or in combination with the PSA test. 

DRE may seem uncomfortable, but it’s quick and simple. The exam can determine the existence of a problem such as an enlarged prostate. However, this test can’t specify the cause of these irregularities.

Additional tests are necessary to identify the root cause of irregularities spotted during a digital rectal exam. One of those irregularities is prostate cancer. Prostate cancer is diagnosed in 15% to 25% of the time when abnormal DRE findings lead to biopsy.

Urine test 

This main objective of this test is to determine the Mi-prostate score (MiPS). The MiPS score helps estimate the risk of prostate cancer, particularly an aggressive form of cancer. The doctor may order MiPS when DRE and PSA tests show irregularities with the prostate. 

This test includes DRE, after which a patient provides a urine sample. The MiPS combines three markers. They are serum PSA, PCA3, and TMPRSS2:ERG (T2:ERG). We’ll focus more on PSA below. The other two markers, PCA3 and T2:ERG, are genes found in your urine. 

A high concentration of these markers is uncommon in men without prostate cancer. The higher the levels of PCA3 and T2:ERG, the more likely a man is to have prostate cancer. The MiPS score provides more information than the PSA test alone. It can help the doctor decide whether to order a biopsy or not. But, MiPS alone can’t confirm prostate cancer. In other words, the doctor doesn’t rely only on MiPS to confirm PCa detection.

Transrectal ultrasound (TRUS) 

Transrectal ultrasound is a procedure that yields an image of a man’s prostate. The doctor usually orders TRUS, ultrasound imaging, after abnormal findings in PSA and DRE tests. To do TRUS, the healthcare provider inserts a small probe into the patient’s rectum. The probe uses sound waves to produce a picture on the screen. TRUS is uncomfortable but not painful. It doesn’t last longer than 10 minutes. 

The test helps evaluate the prostate size. Additionally, TRUS can spot abnormalities that may indicate the presence of cancer. Like other tests on this list, TRUS alone is not enough to neither rule out nor confirm prostate cancer. Moreover, TRUS can serve to guide a biopsy. TRUS biopsy is the most common approach today. It is performed more often than MRI-targeted biopsy.

Free prostate-specific antigen (PSA) test 

This is a common screening test for prostate cancer. PSA is a protein that comes from the prostate gland. The main objective of this test is to measure the concentration of PSA in a patient’s blood. 

High PSA levels could be a sign of prostate cancer, but it’s not enough to diagnose the disease. Other factors can also increase PSA, including inflammation of the prostate and urinary tract infection. Low PSA levels aren’t enough to rule out prostate cancer. That’s why a biopsy is usually considered the most reliable method of diagnosing this serious disease. 

But what is the free PSA test? 

There are two types of PSA. Bound PSA is attached to a protein, while free PSA isn’t. The free PSA test breaks down the results and shows the ratio of bound vs. free PSA. Men with prostate cancer tend to have lower levels of free PSA. However, there is no consensus regarding the ratio. The value of free PSA is still significant. 

This test gives important information the doctor can use to determine whether to proceed to biopsy or not. When performed on its own, a free PSA test can neither confirm nor rule out prostate cancer. 

Once the doctor diagnoses the problem, they will proceed to determine the stage of the disease. Gleason score is the most common grading system, and it looks at how cancer cells are arranged in the prostate.

Our Natural & Non-Invasive Prostate Biopsy Alternative

In our opinion, a far safer and gentler prostate biopsy alternative is our Advanced Prostate Cancer Risk Assessment (APCRA). This consists of non-invasive blood tests and specialized color Doppler scans. 

The variety and sophistication of some of these new blood tests make this a very realistic alternative to a prostate biopsy, especially if you have a preference for non-invasive diagnostics and treatments. 

After this testing, you will receive a thorough, 3-hour consultation from a Naturopathic Physician who is also a Professor of Urology and a very detailed, written report of your results to be discussed during the appointment.

He will walk you through the results of his assessment and explain every aspect and each option available to you, while also answering any questions that you may have.  Your consultation will be like an educational mini-seminar about the real issues facing you as a patient.

Most urologists will have a preference for the particular treatment that they provide. However, the consultant you will see has no agenda and is completely free to offer honest, independent advice. 

He will try and help with any information you need in order to arrive at your decision. But he will not try to sway you one way or the other. 

Aside from that, the greatest additional benefits of the APCRA are that it is non-invasive, does no damage, and does not close off any avenues for future treatment.

To book our Advanced Prostate Cancer Risk Assessment please call our customer service team on +1-888-868-3554 who will be happy to assist you and offer any further information.

Conclusion

The transperineal prostate biopsy is an accurate and safe diagnostic method for prostate cancer. Compared to a transrectal biopsy, the TP approach has a lower risk of complications. More research is necessary on this procedure, but it’s a promising cancer detection tool that can ensure patients get timely treatment. One of the most common treatments includes radical prostatectomy. 

Explore More

prostate cancer screening

Our Natural & Non-Invasive Advanced Prostate Cancer Risk Assessment (APCRA).

Sources

  1. Key statistics for prostate cancer. American Cancer Society https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html#:~:text=About%201%20man%20in%209,at%20diagnosis%20is%20about%2066.
  2. Skouteris, V. M., Crawford, E. D., Mouraviev, V., Arangua, P., Metsinis, M. P., Skouteris, M., Zacharopoulos, G., & Stone, N. N. (2018). Transrectal Ultrasound-guided Versus Transperineal Mapping Prostate Biopsy: Complication Comparison. Reviews in urology20(1), 19–25. https://doi.org/10.3909/riu0785
  3. Xiang J, Yan H, Li J, et al. (2019) Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: a systematic review and meta-analysis. World Journal of Surgical Oncology, 17, 31 https://doi.org/10.1186/s12957-019-1573-0
  4. Ultrasound-guided transperineal prostate biopsy. (2019) Mayo Clinic https://www.mayoclinic.org/medical-professionals/urology/news/ultrasound-guided-transperineal-prostate-biopsy/mac-20473283
  5. Screening for prostate cancer. Rogel Cancer Center https://www.rogelcancercenter.org/prostate-cancer/screening

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