Comparison of diagnostic efficacy between transrectal and transperineal prostate biopsy: A propensity score-matched study

Transrectal versus transperineal prostate biopsy for cancer detection in patients with gray-zone prostate-specific antigen: a multicenter, real-world study

Knowledge about the effect of different prostate biopsy approaches on the prostate cancer detection rate (CDR) in patients with gray-zone prostate-specific antigen (PSA) is limited. We performed this study to compare the CDR among patients who underwent different biopsy approaches and had rising PSA levels in the gray zone. Two hundred and twenty-two patients who underwent transrectal prostate biopsy (TRB) and 216 patients who underwent transperineal prostate biopsy (TPB) between June 2016 and September 2022 were reviewed in this study. In addition, 110 patients who received additional targeted biopsies following the systematic TPB were identified. Clinical parameters, including age, PSA derivative, prostate volume (PV), and needle core count, were recorded. The data were fitted via propensity score matching (PSM), adjusting for potential confounders. TPB outperformed TRB in terms of the CDR (49.6% vs 28.3%, P = 0.001). The clinically significant prostate cancer (csPCa) detection rate was not significantly different between TPB and TRB (78.6% vs 68.8%, P = 0.306). In stratified analysis, TPB outperformed TRB in CDR when the age of patients was 65-75 years (59.0% vs 22.0%, P < 0.001), when PV was 25.00-50.00 ml (63.2% vs 28.3%, P < 0.001), and when needle core count was no more than 12 (58.5% vs 31.5%, P = 0.005). The CDR (P = 0.712) and detection rate of csPCa (P = 0.993) did not significantly differ among the systematic, targeted, and combined biopsies. TPB outperformed TRB in CDR for patients with gray-zone PSA. Moreover, performing target biopsy after systematic TPB provided no additional benefits in CDR.

Updated prevalence of latent prostate cancer in Chinese population and comparison of biopsy results: An autopsy-based study

Prostate cancer detected by autopsy is named latent prostate cancer. As the repertoire of clinical prostate cancer, latent cancer may better reflect the disease burden. Unlike clinical prostate specimens, which are obtained exclusively from biopsy-positive cases, prostate specimens obtained through autopsy provide information on biopsy-negative cases, helping calculate the true sensitivity of prostate biopsy. From 2014 to 2021, we collected autopsy specimens of the prostate from body donors in China and performed transperineal and transrectal biopsies on specimens before step-sectioning and pathological measurements. We found that the crude prevalence of latent prostate cancer in middle-aged and elderly men was 35.1% (81/231), which was higher than previous estimates for Chinese populations. The overall per-patient sensitivities of transperineal and transrectal biopsies were not significantly different (33.3% vs. 32.1%, p = 0.82), but the two approaches differed in preferential sampling area along the proximal-distal axis of the prostate. Transperineal biopsy had a higher sensitivity for detecting clinically significant lesions in the distal third (34.7% vs. 16.3%, p = 0.02) and distal half (30.6% vs. 18.1%, p = 0.04), while transrectal biopsy had a higher sensitivity for lesions in the proximal half (25.0% vs. 13.9%, p = 0.046). Both transperineal and transrectal methods of biopsy missed most small lesions (<0.1 mL) and 35.3% (6/17) of large lesions (>0.5 mL). In conclusion, the prevalence of latent prostate cancer in China has increased over the past 2 decades. Systematic transperineal and transrectal methods of biopsy had comparable sensitivities but had different preferential sampling areas. Both approaches miss one-third of large lesions.

Comparative diagnostic accuracy of multiparametric magnetic resonance imaging-ultrasound fusion-guided biopsy versus systematic biopsy for clinically significant prostate cancer

Purpose

To examine the accuracy of transperineal magnetic resonance imaging (MRI)-ultrasound (US) fusion biopsy (FB) in identifying men with prostate cancer (PCa) that has reached a clinically relevant stage.

Methods

This investigation enrolled 459 males. In 210 of these patients (FB group), transperineal MRI/US fusion-guided biopsies were performed on the suspicious region, and in 249 others, a systematic biopsy (SB) was performed (SB group). We compared these groups using Gleason scores and rates of cancer detection.

Results

PCa cases counted 198/459 (43.1%), including 94/249 (37.8%) in the SB group and 104/210 (49.5%) in the FB group. FB was associated with higher overall diagnostic accuracy relative to SB (88.5% and 72.3%, P = 0.024). FB exhibited greater sensitivity than SB (88.9% and 71.2%, P = 0.025). The area under the curve for FB and SB approaches was 0.837 and 0.737, respectively, such that FB was associated with an 11.9% increase in accuracy as determined based upon these AUC values. Relative to SB, FB was better able to detect high-grade tumors (GS ≥ 7) (78.85% vs. 60.64%, P = 0.025).

Conclusion

Transperineal MRI-US fusion targeted biopsy is superior to the systematic one as an approach to diagnosing clinically significant PCa, as it is a viable technical approach to prostate biopsy.

Transrectal versus transperineal prostate biopsy in detection of prostate cancer: a retrospective study based on 452 patients

BACKGROUND

Transrectal (TR) ultrasound guided prostate biopsy and transperineal (TP) ultrasound guided prostate biopsy are the two most commonly used methods to detect prostate cancer, the detection rate of the two biopsy approaches may differ in patients with different clinical characteristics. Here we aimed to compare the prostate cancer detection rate and positive rate of biopsy cores between TR and TP prostate biopsy in patients with different clinical characteristics.

METHODS

We retrospectively analyzed and compared the clinical data of 452 patients underwent TR or TP prostate biopsy in our hospital from June 2017 to September 2021. And patients were stratified according to several clinical characteristic (serum PSA level, prostate volume, PSA density, T stage and ISUP grade), cancer detection rate and positive rate of biopsy cores were compared in different stratified groups.

RESULTS

There was no significant difference in age, PSA level, prostate volume, and PSA density between the TR and TP groups. TR group had a higher overall cancer detection rate and positive rate of biopsy cores than TP group. Further subgroup analysis showed that TR group had a higher cancer detection rate in patients with prostate volumes 30-80 mL, and that the TR group had a higher positive rate of biopsy cores among the patients with T3-T4 stages, while TP group had a higher positive rates of biopsy cores among the patients with T1-T2 stages. There were no significant differences between the TR and TP groups for each subgroup when stratified by PSA level, PSA density and ISUP grade.

CONCLUSIONS

TR approach may have advantage in patients with prostate volumes 30-80 mL and T3-T4 stages, while TP approach may have advantage in patients with T1-T2 stages.

Transperineal ultrasound-guided prostate biopsy: what the radiologist needs to know

Transperineal ultrasound-guided (TP) prostate biopsy has been shown to significantly decrease the risk of post-procedural sepsis when compared to transrectal ultrasound-guided (TRUS) prostate biopsy. With guidance from the European Urology Association favouring adoption of a TP biopsy route, it is clear that, despite being a more technically challenging procedure, TP biopsy in an outpatient setting will replace TRUS biopsy. This paper gives the reader a succinct summary of outpatient transperineal prostate biopsy under local anaesthetic utilising a free-hand ultrasound technique. Patient preparation and consent process is outlined. A comprehensive pictorial review of the procedure, pitfalls and common post-procedural outcomes is presented. This paper provides a framework and guide for those wishing to adopt the transperineal approach under local anaesthetic.

Comparison of transperineal and transrectal targeted prostate biopsy using Mahalanobis distance matching within propensity score caliper method: A multicenter study of Turkish Urooncology Association

OBJECTIVE

To compare the clinically significant prostate cancer (csPC)-detecting results of transperineal and transrectal targeted biopsy (TPTB and TRTB, respectively) by performing matching analysis.

PATIENTS AND METHODS

This study has used the PC and prostate biopsy database from the Turkish Urooncology Association. A total of 1143 patients with Prostate Imaging-Reporting and Data System (PI-RADS) with ≥3 lesions on multiparametric magnetic resonance imaging (mpMRI) and who had received a software-guided transperineal/transrectal MRI/transrectal ultrasound (TRUS) fusion prostate biopsy with concomitant standard systematic 12-core biopsy were included in this study. csPC detection rates of the TP and TR approaches were compared following Mahalanobis distance matching within propensity score caliper method. The following four variables were selected as covariates for the matching procedure: age, digital rectal examination findings, PSA density, and the index lesion PI-RADS score.

RESULTS

The matched sample included 508 TR and 276 TP patients. In both the TP and the TR groups, targeted biopsy was superior to systematic biopsy in detecting csPC (27.5% vs. 24.6%, p < 0.001 and 19.5% vs. 16.3%, p < 0.0001, respectively). Both TPTB and TP systematic biopsy was found to be superior to TRTB and TR systematic biopsy in terms of csPC detection (27.5% vs. 19.5%, p = 0.012 and 24.6% vs. 16.3%, p = 0.006). In patients with an anterior index lesion, an apical index lesion, and a larger prostate, the superiority of TPTB to TRTB was found to be more prominent in terms of csPC detection (37.8% vs. 18.3%, p = 0.044; 34.6% vs. 14.7%, p = 0.002; and 25% vs. 5.1%, p = 0.033, respectively).

CONCLUSION

Targeted biopsy was found to be superior to systematic biopsy in detecting csPC in both the TP and the TR approaches. The TP approach is preferred because of its clear superiority in detecting csPC in targeted biopsy, especially in patients with anterior and apical lesions and with larger prostates.

Transperineal versus transrectal multi-parametric magnetic resonance imaging fusion targeted prostate biopsy

OBJECTIVES

To compare transperineal biopsies (TPBx) with transrectal ultrasound-guided biopsy (TRUSBx) in order to provide evidence, making clinicians able to select the appropriate biopsy approach under different conditions.

METHODS

A comparative prospective study, conducted in King Khalid University Hospital (KKUH) and King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia, between March 2019 and February 2020. All patients with raised prostate-specific antigen or atypical digital rectal examination findings were subjected to multi-parametric magnetic resonance imaging (MRI). Those with positive findings were referred to targeted fusion- guided biopsy either TPBx or TRUSBx, randomly. Complication rate, cancer detection rate, and procedure time were recorded.

RESULTS

Transperineal biopsies and TRUSBx had an equivalent complication rate. However, both case detection rate and clinically significant cancer detection rate were significantly higher in TPBx versus TRUSBx (45.1% versus 29.1%, p=0.003; and 71.8% versus 43.7%, p=0.002; respectively). Transperineal biopsies was a longer procedure than TRUSBx (41.2±0.7 min versus 13±2.3 min, p=0.0001).

CONCLUSION

No difference in complication rate was detected between the 2 procedures; however, TPBx was more effective for cancer detection in general and clinically significant cancer detection in particular.

"Free-Hand" Transperineal Prostate Biopsy Under Local Anesthesia: Review of the Literature

Background: The recent plethora of reports of "free-hand" transperineal prostate biopsy (fTP-Bx) under local anesthesia (LA) demonstrate that many centers consider this technique to be a safer and possibly more accurate approach to prostate biopsy in the clinic setting. Materials and Methods: The literature was searched for fTP-Bx, and summary tables were compiled. Studies on the costs of postprostate biopsy sepsis were also researched. Results: The search found 11,999 cases of fTP-Bx under LA with and without sedation over 29 mutually exclusive studies. Pooled averages calculated for age, prostate-specific antigen (PSA), prostate volume, PSA density, and cores sampled were 67.3 years, 10.4 ng/mL, 47.7 mL, 0.24 ng/mL/cc, and 15.3 cores, respectively. Detection of overall prostate cancer (PCa) and clinically significant (Gleason score ≥7) prostate cancer (csPCa) averaged 45.5% (3796/8338) and 25.1% (1141/4541), respectively. After subgrouping the studies by biopsy technique, studies that used MRI/ultrasound fusion-targeted biopsy in some or all biopsy cases averaged an overall PCa and csPCa detection rate of 50.0% (741/1483) (p < 0.0001) and 42.8% (635/1483) (p < 0.0001), respectively. Visual analog scale pain ratings and procedure times averaged 3.17 and 13.1 minutes, respectively. Averages for complications of sepsis and acute urinary retention were 0.0% (0/7396) and 2.1% (120/5693), respectively. A total of 10.2% (1055/10,334) of cases received no antibiotic prophylaxis. If fTP-Bx under LA replaced transrectal prostate biopsy (TR-Bx) in the United States, the estimated annual savings would be $341,676,800-$752,540,000 through the virtual elimination of admissions for postbiopsy sepsis. Conclusions: Many centers around the world have adopted fTP-Bx because it virtually eliminates sepsis, may improve detection rates of csPCa and can be easily integrated into a normal clinic workflow using only LA. If all urologists in the United States abandoned TR-Bx for fTP-Bx, the potential savings in health care costs of complications would be significant.

Peripheral zone PSA density: a predominant variable to improve prostate cancer detection efficiency in men with PSA higher than 4 ng ml-1

To improve the diagnostic efficiency of prostate cancer (PCa) and reduce unnecessary biopsies, we defined and analyzed the diagnostic efficiency of peripheral zone prostate-specific antigen (PSA) density (PZ-PSAD). Patients who underwent systematic 12-core prostate biopsies in Shanghai General Hospital (Shanghai, China) between January 2012 and January 2018 were retrospectively identified (n = 529). Another group of patients with benign prostatic hyperplasia (n = 100) were randomly preselected to obtain the PSA density of the non-PCa cohort (N-PSAD). Prostate volumes and transition zone volumes were measured using multiparameter magnetic resonance imaging (mpMRI) and were combined with PSA and N-PSAD to obtain the PZ-PSAD from a specific algorithm. Receiver operating characteristic (ROC) curve analysis was used to assess the PCa detection efficiency in patients stratified by PSA level, and the area under the ROC curve (AUC) of PZ-PSAD was higher than that of PSA, PSA density (PSAD), and transition zone PSA density (TZ-PSAD). PZ-PSAD could amend the diagnosis for more than half of the patients with inaccurate transrectal ultrasonography (TRUS) and mpMRI results. When TRUS and mpMRI findings were ambiguous to predict PCa (PIRADS score ≤3), PZ-PSAD could increase the positive rate of biopsy from 21.7% to 54.7%, and help 63.8% (150/235) of patients avoid unnecessary prostate biopsy. In patients whose PSA was 4.0–10.0 ng ml⁻¹, 10.1–20.0 ng ml⁻¹, and >20.0 ng ml⁻¹, the ideal PZ-PSAD cut-off value for predicting clinically significant PCa was 0.019 ng ml⁻², 0.297 ng ml⁻², and 1.180 ng ml⁻², respectively (sensitivity >90%). Compared with PSA, PSAD, and TZ-PSAD, the efficiency of PZ-PSAD for predicting PCa is the highest, leading to fewer missed diagnoses and unnecessary biopsies.