Whilst there has been a dramatic shift in how patients are investigated for potential prostate cancer, transrectal ultrasound (TRUS) and biopsy remains the most commonly used technique for tissue sampling. In this single centre, retrospective analysis, 634 men, over a 55-month period, were offered and underwent a transperineal sector biopsy (TPSB) where a maximum of 38 cores were taken using a modification of a previously described technique. The aim was to avoid transitional zone biopsies, and the morbidity this may bring, with the majority performed under general anaesthetic (GA). Indications included a prior negative TRUS biopsy (174 men), to reduce septic risk in those deemed high risk (153) and to clarify the appropriateness of active surveillance (AS) in those with low-risk disease (307). For glands <30mls, 24 cores were taken with additional basal biopsies in larger glands, all using a template guide. In those with a previous negative prostate biopsy, 36% had a positive TPSB, with 41% of cases showing anterior disease and 21% having Gleason 3+4=7 or worse. Fifty-four percent of the group with a high risk of sepsis were positive, with 9.6% being anterior disease alone and 29% being Gleason 3+4=7 or worse.
More worrying was the 29% of men (in keeping with other studies) that were upgraded in those potentially suitable for AS, who could then have had a worse prognosis due to initial under-grading. No cases of urosepsis occurred, acute retention developed in 1.7% with seven men ultimately requiring transurethral resection of the prostate (TURP). This excluded the 61 men who were excluded from the trial as they had a simultaneous TURP and biopsy. The authors felt that this technique reduced morbidity when compared to TRUS and biopsy was more targeted in finding disease and reduced the risk of inducing retention. Less pathological analysis was required than a standard template and patients’ disease status was more accurately assessed, ensuring more appropriate management. However, it is more costly than TRUS and biopsy uses more resources (most cases were performed under GA) and may still miss some disease, as this was not benchmarked against a standard template.
With the increasing use of MRI, the move towards image-guided biopsies, using an approach similar to this, seems inevitable and a cost-benefit analysis comparing the traditional pathway (which may involve numerous biopsies and morbidity) would be useful to see whether this approach truly does cost more. Methods of performing a TPSB under local anaesthetic or sedation would be welcome to reduce the burden on theatre list utilisation.