Safety and feasibility of freehand transperineal prostate biopsy under local anesthesia: Our initial experience

Abstract

Introduction: With the emergence of multidrug-resistant organisms causing urosepsis after transrectal biopsy of prostate, the need for an alternative approach has increased. We assessed the safety and feasibility of transrectal ultrasound (TRUS) guided free-hand transperineal prostate biopsy under local anesthesia (LA) for suspected prostate cancer.

Materials and methods: This prospective study was conducted from July 2019 to December 2020 in which patients with elevated prostate-specific antigen (PSA) and/or abnormal digital rectal examination underwent magnetic resonance imaging-TRUS cognitive fusion transperineal prostate biopsy (target and systematic) using coaxial needle. Demographic, perioperative, and outcome data of 50 consecutive patients were analyzed.

Results: The mean age of the patients was 69.6 ± 7.61 years, median PSA 13.55 ng/mL (4.17-672) and prostate size 45cc (16-520). Prostate Imaging-Reporting and Data System (PIRADS) 2, 3, 4, and 5 lesions were found in 2, 12, 12, and 24 patients, respectively. Average procedure duration was 20 min (15-40 min) and number of cores ranged from 12 to 38 (median 20). Forty out of fifty (40/50) patients experienced only mild pain with visual analog scale ≤2. Histopathological examination showed adenocarcinoma, benign prostatic hyperplasia, and chronic prostatitis in 41, 5, and 4 patients respectively with 82% cancer detection rate (CDR). Over 95% of cases showed clinically significant cancer (International Society of Urological Pathology class ≥ 2) and 91.7% of patients with PIRADS score 4/5 and 66.7% with PIRADS score 3 had malignancy. Three patients developed complications (two hematuria, one urinary retention), both were managed conservatively and none had urosepsis.

Conclusions: Free-hand transperineal prostate biopsy by coaxial needle technique under LA is safe and feasible with good tolerability, high CDR, and minimal complications particularly reduced urosepsis.

Figure 1

(i) ARIETTA 60 HITACHI diagnostic ultrasound system Biplanar tranrectal probe (CC41R1) installed with PRECISION POINT DEVICE (PrecisionPoint™-BXTAccelyon) and loaded with Coaxial biopsy needle - BARD Truguide 13-gauge × 7.8 cm (C1410A) (A) aerial view, (B) lateral view (II) PRECISION POINT DEVICE loaded with Coaxial biopsy needle (A) end-on view, (B) lateral view

Figure 2

Infiltration of local anaesthesia (a) Trans rectal ultrasound (TRUS) image sagittal and axial view (white arrow – infiltration given in the “Space of Allaway” i.e., between prostatic apical capsule and pelvic floor muscle, yellow arrow – needle tract) (b) TRUS probe with 22-gauge Chiba needle inserted via coaxial needle

Figure 3

MRI-TRUS cognitive fusion (I and II) MRI line diagram - sagittal and axial showing sectors (purple-anterior, blue-mid, red-posterior, green-basal). (III) TRUS sagittal and axial images. (IV) probe manipulation (A) apex-depress/withdraw probe, (B) Midgland - raise/insert probe, (C) Base - Insert further from midgland. (V) Urethra (A) MRI line diagram (B) TRUS images (yellow). SV = Seminal vesicle, AFS = Anterior fibromuscular stroma, TZ = Transitional zone, CZ = Central zone, PZ = Peripheral zone, U = Urethra, MRI = Magnetic resonance imaging, TRUS = Transrectal ultrasound

Figure 4

(i) TRUS sagittal and axial images showing systematic biopsy from different sectors of prostate (A) right anterior (B) left middle (C) right posterior (yellow arrows - needle tract). (II) PRECISION POINT Device with coaxial needle at different levels (A-C) anterior, middle and posterior sectors respectively. (III) TRUS probe manipulation for (A) Left lobe - probe rotated clockwise/moved to contralateral side (B) right lobe – probe rotated anticlockwise/moved to contralateral side. TRUS = Transrectal ultrasound

Figure 5

TRUS-MRI COGNITIVE FUSION TARGET BIOPSY (i) MRI sectoral line diagram with target lesion (red dot) (A and B) sagittal and axial. (II) TRUS sagittal and axial images with target lesion (within red circle) in the right base (yellow arrows - needle tract). (III) MRI images with target lesion (yellow arrows) in different sequences (A) T2 coronal, (B) T1 axial, (C) DCE, (D) DWI, (E) apparent diffusion co-efficient (ADC) sequence. TRUS = Transrectal ultrasound, MRI = Magnetic resonance imaging, DCE = Dynamic contrast enhancement, DWI = Diffusion weighted image, TZ = Transitional zone, PZ = Peripheral zone, CZ = Central zone, AFS = Anterior fibromuscular stroma