Hundred years of transperineal prostate biopsy

Abstract

The earliest recorded efforts to biopsy prostate, in the early 20th century, were made through transperineal (TP) approach, with open perineal prostate biopsy (PBx) being considered the gold standard for prostate cancer (PCa) diagnosis in that era. Later, to minimize morbidity and increase diagnostic accuracy, several technical modifications and transrectal ultrasound (TRUS) assistance were incorporated. However, in the 1980s, the transrectal (TR) approach became the predominant PBx method following the introduction of TRUS-TR PBx with sextant sampling, providing a convenient and efficacious method for prostate sampling. With modernization of PCa diagnosis, a recent resurgence of the TP PBx has been observed, driven primarily by TR drawbacks of infectious complications and sampling limitations. TP PBx is rapidly emerging as the new PBx standard, being officially recommended as the initial approach for biopsy in Europe and is increasingly being conducted and studied in the United States. The modern era of TP PBx is based on the improvements in local anesthesia techniques, TP access systems, and robotic assistance. These modifications and advancements have improved the ease of use, patient comfort, and diagnostic outcomes with TP PBx. Herein, we present a history of the evolution of TP PBx spanning over 100 years and explore the basis of the technique that merits future utilization.

Keywords: prostate; prostate biopsy; prostate cancer; transperineal; urology.

Figure 1.

Illustrations from Young’s Practice of Urology (1926) describing the process of open perineal prostate exposure, used primarily for prostatectomy but also could be used for PBx: (a) perineal incision, (b) blunt dissection on either side of central tendon, (c) division of central tendon, (d) central tendon divided to expose recto-urethralis, (e) membranous urethra exposed, and (f) tractor drawing prostate down to expose prostate covered with anterior Denonvilliers’ fascia, allowing for suspicious lesion biopsy. (Public Domain as of 1 January 2022).

Figure 2.

Ferguson’s illustration depicting the technique used for TP needle aspiration of the prostate. (a) Needle within the capsule with syringe closed. (b) Plunger pulled as needle advanced into suspected prostatic tissue. (c) Angling of needle to cut off plugged tissue. Following the cutting off plugged tissue, the needle is withdrawn. Permission for use granted by Elsevier, License number 5206040909934, 11 December 2021.

Figure 3.

Artist’s illustration of technique used by Kaufman et al. A digit inserted rectally guided a transperineally inserted needle to a suspicious prostate nodule (permission granted by the BMJ).

Figure 4.

Illustration of the setup used by Holm et al. for TRUS-guided placement of the needle for TP PBx. Permission for use granted by Wolters Kluwer Health, Inc., License number 5145320111525, 10 September 2021.