Transperineal Prostate Biopsy Safe, Effective Under Local Anesthesia

By Marilynn Larkin

July 19, 2021

NEW YORK (Reuters Health) - Transperineal prostate biopsy with local anesthesia is safe and achieved similar outcomes to sedation in detecting clinically significant cancer in a small retrospective study.

"The transperineal approach to prostate biopsy is a clean, percutaneous approach, in contrast to the traditional transrectal approach, which has a 2%-5% risk of post-biopsy infection," Dr. Jim Hu of Weill Cornell Medicine/NewYork Presbyterian in New York City told Reuters Health by email. "However, the transperineal approach was traditionally performed under sedation due to the perception that it is more painful and patients cannot tolerate it."

"More recently, the use of MRI-targeting has also been incorporated," he said. "Therefore, we wanted to compare outcomes."

As reported in Urology, the study included 126 men (median age, about 67) undergoing transperineal MRI-targeted biopsy at a single center. Age, BMI and PSA were similar for the 45 men undergoing local anesthesia and the 81 undergoing sedation.

Men were classified as being biopsy-naïve, on active surveillance, or post-treatment (radiation or focal therapy).

Detection of clinically significant prostate cancer on combined systematic and targeted biopsy was similar for both approaches: local, 24% and sedation, 36%.

Local had lower detection on targeted biopsies alone (8.9% vs. 25%). However, fewer targeted cores were obtained per region of interest with local (median 3 vs. 4 cores).

The median visual analog pain score (10, highest) was 3 for local versus 0 for sedation. Further, the complication rate was 2.6% versus 6.1%.

The mean procedure time for local versus sedation was 22.5 vs. 17.5 minutes (48.3 minutes when including anesthesia time). Notably, time-driven activity-based costs were $961.64 versus $2208.16.

Dr. Hu said, "This was a small, retrospective study, and there were differences in patient selection; however, we demonstrate that the transperineal approach under local was tolerable at a significantly lower cost."

"Of note," he added, "there have been more recent innovations for transperineal biopsy, such as a disposable trocar, that further improves the efficiency of the procedure under local anesthesia."

"Ultimately, a large prospective randomized controlled trial is needed to compare the transperineal versus the transrectal approach," Dr. Hu concluded.

Urologist Dr. Ram Anil Pathak, Director of Medical Education at Wake Forest University School of Medicine in Winston-Salem, commented on the study in an email to Reuters Health. "Prostate biopsy has undergone many transformations over the years (and) there has been a recent push to adopt transperineal biopsy due to lower infectious complications without compromising diagnostic yield," he said.

"Relatively recently," he added, "improvements in local anesthesia delivery have made in-office transperineal biopsy possible."

"When interpreting the findings (of the current study), a few caveats should be noted," he said. "First, biopsies performed under local anesthesia had a lower detection rate. The findings make it difficult to exclude if detection rate on the targeted biopsy is compromised due to a lack of sedation. Clinicians may be pressured to complete the procedure more quickly, sacrificing the number of biopsies performed under local anesthesia (median number of targeted biopsies was 3 for local anesthesia vs. 4 for sedation)."

"Second," he noted, "VAS pain scores were significantly higher in the local anesthesia group (3 vs. 0). Patient selection is key, and clinicians may want to exclude patients with pelvic floor disorders or chronic pain issues."

"Lastly," he added, "in cases of smaller targeted lesions (PiRADs < 5 lesions), clinicians may have to account for subtle patient movements that can disrupt fusion alignment of the ultrasound to the MRI.

Nonetheless, he said, "I find the study... encouraging. Having to put patients asleep to do transperineal biopsy is no longer a valid excuse for choosing transrectal over the transperineal approach."

SOURCE: Urology, online July 1, 2021.