(UroToday.com) In a plenary session of the Society of Urologic Oncology Annual Meeting focused on transperineal prostate biopsy, Dr. Deborah Kaye discussed whether a transperineal biopsy should become the standard of care for patients undergoing prostate biopsy.
Dr. Kaye, summarizing the available data, argued that transperineal biopsy should not be the standard of care. In this context, she instead argued that TRUS biopsy represents the gold standard for men requiring prostate biopsy. She argued that this approach is fast, easy, effective, and safe.
She began by discussing the patient experience. In a prospective, randomized controlled trial of more than 300 patients, patients undergoing transperineal biopsy reported double the pain associated with biopsy as those who underwent a TRUS biopsy. This finding has been subsequently confirmed in other studies and systematic reviews and meta-analyses. Dr. Kaye emphasized that, for patients on active surveillance, repeated biopsies are required. Thus, for patients considering this treatment approach, the tolerability of biopsy may be key for their adherence to a conservative treatment approach.
The same randomized controlled trial that Dr. Kaye cited in terms of pain demonstrated that TRUS biopsy is considerably faster. This may indeed contribute to the subjective patient experience regarding biopsy. However, it also has important implications for workflow.
Additionally, Dr. Kaye emphasized that there is a substantially longer learning curve for transperineal biopsy: it takes approximately 12 procedures to acquire the skills necessary for a high-quality TRUS-guided prostate biopsy, meaning that this approach is widely generalizable.
Dr. Kaye then moved to a discussion of cost. In part driven by the longer durations required, transperineal prostate biopsy is substantially more expensive than the transrectal approach. In addition to procedural costs, there are additional costs associated with transperineal biopsies including capital costs for a biplanar probe ($18-22,0000 per probe) and stirrups, for disposables, for the additional time required, potentially the need for specialized staff, and for dedicated procedural suites as these cannot be performed in standard clinic rooms.
She then transitioned to a discussion of safety. Utilizing available approaches including augmented or targeted prophylaxis and the use of antibiograms, Dr. Kaye emphasized that infection rates should be less than 1%, regardless of the biopsy approach. Additionally, she highlighted the potential benefits of enemas and needle disinfection to reduce the infectious complications associated with TRUS biopsy. She further highlighted data, including a meta-analysis from Xue et al., which demonstrated no significant differences in infectious complications between biopsy approaches. This study further demonstrated no difference in other safety outcomes including 30-day emergency department visits, urinary retention, or hematuria.
Dr. Kaye then further considered other outcomes of interest. As previously highlighted in this session by Dr. George, numerous studies have shown equivalent cancer detection rates between TRUS and transperineal prostate biopsy. Further, some studies (including Hara et al.) have demonstrated higher cancer detection rates with TRUS biopsy, despite the theoretical advantages of apical and anterior gland sampling on transperineal biopsy.
She further highlighted that, while antibiotic stewardship is a reported benefit of the transperineal approach, antibiotic prophylaxis is still routinely being utilized for patients undergoing transperineal biopsy and, in fact, much of the literature on transperineal biopsy is among patients treated this way.
Finally, Dr. Kaye emphasized the benefit of TRUS biopsy in terms of efficiency – on an individual procedure basis, the procedure is quick and may be done entirely in the office setting, including with routine use of fusion biopsy. Further, there is a fast learning curve meaning that fewer patients receive “suboptimal” procedures as physicians acquire proficiency. Correspondingly, she argued that transperineal biopsy is not generalizable to most practices due to the lack of availability of sedation, procedural suites, and specialized staff that may be necessary. Further, she emphasized that it is not good for many patients including those who may be unable to tolerate prolonged lithotomy or may be prone to increased pain or anxiety.
In summary, Dr. Kaye argued that while transperineal biopsy is trendier, transrectal biopsy is both more efficient and more sensible.