Transperineal Prostate Biopsy 'Well Tolerated,' Study Shows

Kate Johnson

March 23, 2015

MADRID — For patients who undergo prostate biopsy, patient-reported adverse effects and attitudes are similar when either a transperineal approach or the more traditional transrectal approach is used, according to a prospective questionnaire-based study.

"The best thing is to try to avoid going through the fecal route, if possible. Obviously, the transperineal route is ideal for that, if we can get it working," lead investigator Karan Wahda, MD, from the University of Cambridge, United Kingdom.

Although evidence points to lower infection rates and better prostate cancer detection rates with transperineal biopsies, the transrectal approach is still used by most clinicians because it can be done in an office setting without general anesthesia, Dr Wahda told Medscape Medical News.

He presented results from the first prospective evaluation of patient-reported complications, symptoms, and experience with systematic transperineal prostate biopsy here at the European Association of Urology 30th Annual Congress.

The newer transperineal procedure, which is performed with the patient under general anesthesia, is also used with some MRI fusion biopsy techniques, Dr Wahda explained. It has become popular in recent years because the rate of cancer detection is higher than with transrectal ultrasound-guided biopsy of the prostate, especially in the repeat biopsy setting, and the rate of postprocedure infection is lower.

The study involved 429 men with an elevated prostate-specific antigen level or abnormal findings on digital rectal examination. Of the cohort, 201 underwent systematic transperineal biopsy guided by ultrasound and MRI and 228 underwent transrectal biopsy guided by ultrasound.

Men in the transperineal group underwent about half the number of biopsies as men in the transrectal (27.1 vs 12.3).

For men undergoing transperineal procedures, it was their second biopsy, whereas for men undergoing transrectal procedures, it was their first biopsy, Dr Wahda reported. Although the patient populations were therefore inherently different, the comparison still provided a benchmark, he said.

Patients were asked about their experience using the Prostate Biopsy Effect (PROBE) PROM tool immediately after the procedure and at follow-up 7 to 14 days later.

There was little difference between the two groups in attitudes about the procedure; the procedures were described as "uncomfortable" or a "minor intervention" by a similar number of men in each group.

It is possible that the general anesthesia led to a significantly better experience with the transperineal procedure than with the transrectal procedure. However, "until we can perform transperineal under local anesthesia, this is our best comparison," Dr Wahda said.

The questionnaire asked about symptoms, the idea of a rebiopsy, the use of healthcare, adverse events, and erectile dysfunction.

Pain was considered a moderate/major problem by fewer patients in the transperineal group than in the transrectal group (4.7% vs 8.1%; P = .178).

In addition, the rate of hematochezia was significantly lower in the transperineal group than in the transrectal group (1.1% vs 14.2%; P < .001).

And urinary retention requiring catheterization was slightly less common in the transperineal group than in the transrectal group (5.6% vs 8.3%; P = .286).

However, there were no differences between groups in terms of self-reported pain, fever, shivers, hematuria, hemoejaculate, nausea, feeling unwell, postprocedure healthcare contact, use of painkillers, or antibiotic requirements.

Men in both groups experienced erectile dysfunction after the procedure, but most said they would have a repeat biopsy if necessary.

Performance of the transperineal procedure under local anesthesia is being investigated and will a key factor in getting it into most office settings, said Dr Wahda. However, there are still some challenges to this.

"With the MRI-fusion software we use, the patient has to be very still. All the factors that affect the movement of the prostate will be magnified 100-fold if the patient is awake," he explained. "If we can develop it to a point where we feel that the accuracy we're getting under general anesthetic is the same as we're getting under local, we'd be very happy to do it under local."

The investigators "should be congratulated for examining patient-reported outcomes after prostate biopsy," said Stacy Loeb, MD, from New York University in New York City. She was involved in a systematic review of complications related to prostate biopsy (Eur Urol. 2013;64:876-892).

Her team found that "the rates of various biopsy-related complications varied widely in the literature, largely due to a lack of standardization in how they were evaluated."

Therefore, "asking patients directly about their experience with the two techniques using a validated questionnaire" is a useful contribution, said Dr Loeb.

"Previous studies have suggested that transperineal biopsy may have a lower risk of infection. However, it is interesting to note that, in this study, the rate of requiring an antibiotic prescription appears similarly high between men who had a transrectal and a transperineal biopsy (approximately 9%)," she noted.

In addition, she said, "I am surprised that the frequency of patients expressing discomfort was so high with transperineal biopsy, considering that the procedures were performed under general anesthesia. I am also surprised at the results for urinary retention. Previous studies have reported higher rates of retention after transperineal biopsy."

Dr Wahda and Dr Loeb have disclosed no relevant financial relationships.

European Association of Urology (EAU) 30th Annual Congress: Abstract 120. Presented March 21, 2015.

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