Transperineal Biopsy of the Prostate

Research indicates that the use of sophisticated diagnostic modalities is strongly associated with accurate diagnosis, prompt treatment and early return to normal functional status. However, when it comes to reproductive or sexual organs, extreme caution is needed to minimize the risk of tissue damage and organ dysfunction during invasive testing procedures.
Transperineal biopsy of the prostate is a minimally invasive diagnostic modality that is used by clinicians to investigate prostatic malignancy. It is noteworthy that early detection of prostate cancer is associated with prolong disease-free survival and optimal reproductive/ sexual health.

What is Transperineal Biopsy of the Prostate?

The procedure involves insertion of an ultrasound guided probe via perineum to assess and scan the anterior/ ventral aspect of the prostate gland. If needed, the clinician can also take tissue biopsies via perineal skin (just behind the testicles).
It is imperative to keep in mind that more than 83.3% malignancies of prostate gland originates in the anterior wall (1).

What are the Indications of Transperineal Biopsy of the Prostate Gland?

During Transperineal biopsy of the prostate, investigators can take up to 30 – 55 samples of prostate. It is a procedure of choice in situations when the patient has undergone several inconclusive prostate biopsies (via rectal approach). Other indications are:

Persistently raised plasma levels of PSA (prostate specific antigen) suggesting a possible prostate malignancy
Any condition in which rectal biopsy cannot be performed (patient preference, surgeon’s preference or prior history of an adverse outcome to the procedure such as septicemia or infection of prostate gland since needle is inserted via rectum)
If clinicians suspects prostate malignancy along the anterior wall of prostate (which is inaccessible from the rectal approach)

According to a study reported by Nicola J. Mabjeesh and associates (2), transperineal biopsy should be offered to patients with persistently high PSA levels and at least 2 negative transrectal biopsies. In the study conducted by Mabjeesh, prostate cancer was identified in 26% patients with previous negative trans-rectal biopsies. Likewise, Magne Dimmen and colleagues (1) were able to detect malignancy in 55% of the patients with previous negative results to transrectal biopsy.

What are Contraindications to Transperineal Biopsy of the Prostate?

Since the procedure is performed under general anesthesia, comprehensive blood investigation is needed. Some contraindications to this procedure are:

All the conditions in which general anesthesia is not permitted
Blood disorders
Individuals who are on warfarin therapy or other blood thinning medications

The only alternative assessment or diagnostic tool to transperineal biopsy is serial blood measurements of PSA to see the response to therapy

What to Expect After the Procedure?

After the procedure, patient can experience:

Blood in urine (for up to 1-2 weeks)
Bruising or localized discomfort (especially in the perineal region)
Blood in semen
Mild to moderate symptom of urinary tract infection

Fortunately, most symptoms are transient and resolve spontaneously over a period of 1 -2 weeks.
In rare cases, some patients may experience severe complications like septicemia (presence of infectious agents in the blood), shock, hemorrhage, urinary retention and spike in the serum levels of PSA. If you have any cautions or concerns about this procedure, speak to your doctor regarding the indications, benefits and possible adverse effects in your case.

References:

Dimmen, M., Vlatkovic, L., Hole, K. H., Nesland, J. M., Brennhovd, B., & Axcrona, K. (2012). Transperineal prostate biopsy detects significant cancer in patients with elevated prostate‐specific antigen (PSA) levels and previous negative transrectal biopsies. BJU international, 110(2b), E69-E75.
Mabjeesh, N. J., Lidawi, G., Chen, J., German, L., & Matzkin, H. (2012). High detection rate of significant prostate tumours in anterior zones using transperineal ultrasound‐guided template saturation biopsy. BJU international, 110(7), 993-997.
Bittner, N., Merrick, G. S., Butler, W. M., Bennett, A., & Galbreath, R. W. (2013). Incidence and pathological features of prostate cancer detected on transperineal template guided mapping biopsy after negative transrectal ultrasound guided biopsy. The Journal of urology, 190(2), 509-514.
Shen, P. F., Zhu, Y. C., Wei, W. R., Li, Y. Z., Yang, J., Li, Y. T., … & Zeng, H. (2012). The results of transperineal versus transrectal prostate biopsy: a systematic review and meta-analysis. Asian J Androl, 14(2), 310-315.