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Transperineal Prostate Biopsy - Comparing Diagnostic Accuracy and Patient Reported Pain to Standard TRUS and MRI/US Fusion Biopsy techniques.
Aaron Berkenwald, MD¹, Kristian Stensland, MD¹, Colette Osborne, MAS¹, Linda Tropjian, BS¹, Lori-Lyn Price, MAS², Alireza Moinzadeh, MD, MHL¹, William Faust, MD¹.
¹Lahey, Burlington, MA, USA, ²Tufts Medical Center, Boston, MA, USA.

Introduction:Transperineal Prostate Biopsy (TPBx) using the PrecisionPoint system (Perineologic, Cumberland, MD) allows for office based prostate cancer detection with the benefit of lower infectious complications when compared to Transrectal Prostate Biopsy (TRUSBx). We sought to evaluate our institutional experience, focusing on differences in pain experienced during TPBx vs. TRUSBx techniques, time of procedure, Cancer Detection Rate (CDR), clinically significant CDR (csCDR) and thirty-day complication rates.
Methods:After Institutional Review Board approval, a retrospective review of all consecutive patients undergoing prostate biopsy (June 2019-Feb 2020) at a single institution was performed. A 10-point Numerical Rating Scale (NRS) was used to record for pain during probe insertion, anesthetic block, biopsy and post-procedure. Mean NRS scores were compared using the ANOVA test. CDR and csCDR (defined as Gleason Grade Group 2 or higher cancer) was compared between TPBx, TRUSBx and TRUS/MRI fusion biopsy using Fisher's exact test.
Results:316 patients met inclusion criteria for cancer detection. CDR for TPBx, TRUSBx and MRI fusion were 0.65, 0.47 and 0.67 (p=0.005), while csCDR were 0.38, 0.30 and 0.44 respectively (p=0.10). NRS pain scores were reported in 253 total biopsies. Mean patient reported NRS scores for TPBx vs. TRUSBx or TRUS/MRI fusion showed a significant difference during anesthetic injection only (3.9 vs. 2.7 and 2.8 respectively, p=0.002). Notably, probe insertion scores were lower in the TPBx group vs. TRUSBx or TRUS/MRI fusion (2.5 vs. 3.0 and 3.1 respectively, p=0.14). Procedural time was 13, 8.5 and 12.4 minutes respectively. The Transrectal groups had nine total 30-day complications including two sepsis events. The TPBx group had no 30-day complications reported.
Conclusions:Patients undergoing TPBx report similar levels of discomfort for all aspects of the procedure when compared to transrectal biopsies with the exception of anesthetic block (modest increase in pain). Procedural times were longer in the TPBx and TRUS/MRI fusion groups compared to standard TRUS. Both the CDR and csCDR were higher in the TPBx group versus the TRUSBx group, although no direct comparison was made. Additionally, TRUS/MRI fusion appears superior to both TRUSBx and TPBx in clinically significant cancer detection, however this cohort contained over twice as many patients on active surveillance. Finally, our study supports the assertion that TPBx has fewer infectious complications than standard transrectal approach.

Table 1.
	TRUS	TPBX	TRUS/MRI Fusion	P Values
n	94	106	116
Age (mean (SD))	64.0 (6.5)	64.9 (8.3)	65.2 (7.2)	0.50
PSA (median [25th, 75thpercentile]	7.0[4.8, 9.8]	6.7[5.0, 10.4]	7.6[5.3, 10.3]	0.57
Purpose (n (%))				0.003
Cancer screening	81 (86.2)	93 (87.7)	83 (71.6)
Active surveillance	13 (13.8)	13 (12.3)	33 (28.4)
DRE (n (%))				0.16
Normal	67 (71.2)	86 (81.0)	94 (81.0)
Abnormal	27 (28.8)	20 (19.0)	22 (19.0)
Complication (n (%))				0.053
Grade I	2 (2.1)	-	5 (4.3)
Grade II	-	-	2 (1.7)
Cancer detection (n (%))
No cancer	50 (53.2)	37 (34.9)	38 (32.8)	0.005
Gleason Grade ≥ 1	44 (46.8)	69 (65.1)	78 (67.2)	0.005
Gleason Grade ≥ 2	28 (29.8)	40 (37.7)	51 (44.4)	0.10

Table 2.

NRS scores(mean (SD))	TRUSN=67	TPBxN=93	TRUS/MRI FusionN=93	p-value
Probe insertion	3.0 (2.2)	2.5 (2.4)	3.1 (2.2)	0.14
Anesthetic block	2.7 (2.0)	3.9 (2.7)	2.8 (2.2)	0.002
Biopsy	2.3 (2.2)	3.0 (2.3)	2.9 (2.4)	0.11
Post-procedure	0.7 (1.2)	1.3 (1.9)	1.0 (1.6)	0.09
Procedural time (average minutes)	8.5	13.0	12.4

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