The Transperineal Fusion Prostate Biopsy Edge: Enhancing Prostate Cancer Detection While Minimizing Infection Risks

Prostate cancer is one of the most common cancers diagnosed in men worldwide[1]. Early and accurate diagnosis is critical for determining the best treatment approach. While prostate-specific antigen (PSA) blood tests and digital rectal exams can suggest the presence of prostate cancer, the only definitive way to diagnose prostate cancer is through a prostate biopsy[13].

A prostate biopsy involves using a needle to take small samples of tissue from the prostate gland. A pathologist then examines the tissue under a microscope to check for cancer cells. Traditionally, prostate biopsies have been done using a transrectal approach, where the biopsy needle is inserted through the wall of the rectum. However, this approach has limitations and risks.

The transperineal fusion biopsy approach has emerged as a superior alternative in recent years. With this technique, the biopsy needle is inserted through the perineum (the area of skin between the scrotum and anus) and into the prostate. MRI images of the prostate are fused with real-time ultrasound to guide the needle to suspicious areas.

Dr. Bevan-Thomas, a leading urologist and a Founding Partner of Urology Partners of North Texas, strongly prefers the transperineal fusion biopsy approach over traditional transrectal biopsy. Let’s explore why and look at some compelling statistics supporting this preference.

The Importance of the Prostate MRI

Before diving into the specifics of transperineal fusion biopsy, it’s essential to understand the critical role that prostate MRI plays in the diagnostic process. Multiparametric MRI (mpMRI) provides detailed images of the prostate and can help identify suspicious areas that may be cancerous.

Studies have shown that prostate MRI has a high sensitivity for detecting clinically significant prostate cancer. In the PROMIS trial, mpMRI was found to have a sensitivity of 93% for detecting clinically significant cancer (defined as Gleason score ≥4+3 or a maximum cancer core length ≥6mm)[4].

Dr. Bevan-Thomas relies heavily on prostate MRI to determine whether a biopsy is necessary. In fact, he rarely performs a biopsy if the MRI is negative, as the risk of missing a significant cancer is low. However, there are exceptions to this rule. The quality of the MRI, the PSA density, and other genetic tests may show evidence that a biopsy is warranted despite a negative MRI. An excellent MRI, however, is particularly helpful. A systematic review found that the negative predictive value of mpMRI for ruling out clinically significant cancer was 91%[20].

Advantages of Transperineal Fusion Biopsy

Now, let’s examine why Dr. Bevan-Thomas and many other urologists have shifted to favoring transperineal fusion biopsies over the traditional transrectal approach. The key advantages include:

1. Reduced infection risk: One of the main drawbacks of the transrectal biopsy is the risk of infection. Because the biopsy needle passes through the rectal wall, bacteria can be introduced into the prostate, leading to severe infections like sepsis. With the transperineal biopsy, the needle does not pass through the rectum, virtually eliminating this infection risk. A study found that the hospitalization rate for infection after transrectal biopsy was 3.7%, compared to 0% for transperineal biopsy[17].
2. Improved cancer detection: The Transperineal biopsy allows for more thorough sampling of the prostate, particularly in the anterior and apical regions, which can be difficult to access with the transrectal approach. Fusion with MRI also enables targeted biopsies of suspicious lesions. A study comparing transperineal fusion biopsy to transrectal biopsy found that the cancer detection rate was 70.2% vs. 45.7%[2]. Another study reported that transperineal fusion biopsy detected 11% more clinically significant cancers compared to transrectal biopsy[11].
3. Reduced risk of undersampling: The Transperineal biopsy allows for a more comprehensive sampling from the prostate regions at highest risk for prostate cancer (referred to as the peripheral zone of the prostate). Compared to the transrectal approach, there is a lower risk of missing or undersampling significant cancer [20]. This is especially important for cancers located in the anterior prostate, which a transrectal biopsy may miss.
4. Increased patient comfort: Transperineal biopsies are typically performed under sedation or anesthesia, with minimal discomfort for the patient[19]. In contrast, transrectal biopsies can be pretty uncomfortable, with blood in the stool for several days or weeks after the procedure. For those patients with hemorrhoids, the pain can be even more challenging.

Supporting Statistics

A growing body of research supports the advantages of transperineal fusion biopsy. Here are some key statistics that highlight its superiority over transrectal biopsy:

• In a study of 779 patients, the transperineal fusion biopsy detected high-risk prostate cancer in 11% of patients compared to only 6% with the transrectal biopsy[2].
• The Transperineal fusion biopsy has been shown to increase the detection of clinically significant prostate cancer by 39% compared to transrectal biopsy[2].
• The negative predictive value of transperineal fusion biopsy for ruling out clinically significant cancer has been reported to be as high as 96%[6]. This refers to the Transperineal saturation biopsy along with the fusion biopsy.
• In a randomized trial, transperineal biopsy reduced the risk of infection to 0% compared to 1.4% with transrectal biopsy[2].
• Transperineal fusion biopsy has demonstrated a 97% sensitivity and 5% specificity for detecting clinically significant prostate cancer[11].

These statistics provide strong evidence for the advantages of transperineal fusion biopsy in cancer detection, risk reduction, and diagnostic accuracy. As a result, many leading urology practices like Dr. Bevan-Thomas’ have adopted this approach as their standard of care.

The Bottom Line

Prostate biopsy plays a critical role in the early detection and diagnosis of prostate cancer. While the prostate MRI is a valuable tool for identifying suspicious areas, a biopsy is still necessary to confirm the presence of cancer and determine its aggressiveness if an abnormality is seen on the prostate MRI.

The transperineal fusion biopsy approach offers significant advantages over traditional transrectal biopsy, including reduced infection risk, improved cancer detection, more accurate sampling, and increased patient comfort. The compelling statistics presented here demonstrate why Dr. Bevan-Thomas and other top urologists prefer this technique.

If you have an elevated PSA or abnormal prostate exam, do not hesitate to contact Dr. Bevan-Thomas at Urology Partners of North Texas for a consultation. As one of the more experienced robotic surgeons in the country, Dr. Bevan-Thomas has been at the forefront of prostate cancer diagnosis and treatment for nearly two decades. He takes a personalized approach with each patient, working closely with you to determine if a prostate MRI and transperineal fusion biopsy may be warranted for the most accurate diagnosis.

Dr. Bevan-Thomas is dedicated to detecting prostate cancer at its earliest stages when treatment is most effective. Under his expert guidance, you can feel confident receiving the most advanced diagnostic care to achieve the best possible outcome. Schedule an appointment with Dr. Bevan-Thomas of the Urology Partners of North Texas team to take a proactive step toward your prostate health.

Citations:

• https://www.uptodate.com/contents/the-role-of-magnetic-resonance-imaging-in-prostate-cancer
• https://ncbi.nlm.nih.gov/pmc/articles/PMC8057359/
• https://urology.ucsf.edu/prostate-magnetic-resonance-imaging-mri
• https://advances.massgeneral.org/urology/article.aspx?id=1252
• https://upnt.com/physicians/md-richard-bevan-thomas/
• https://drbevan-thomas.com/meet-dr-bevan-thomas/

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