Mounting Evidence for Single-Freehand Local Anaesthetic Transperineal Prostate Biopsy

New clinical studies highlight improved cancer detection, reduced infection rates and better patient tolerability & patient reported outcomes

A new international collaborative study titled ‘Local anaesthetic transperineal (LATP) prostate biopsy using a probe-mounted transperineal access system: a multicentre prospective outcome analysis,’ published in BJU International, has looked at 1218 patients who underwent LATP biopsies across ten participating centres from around the globe between April 2018 and March 2020. This research assesses the feasibility of the LATP single-freehand technique using a TP access device (PrecisionPoint™) and reports initial cancer detection, infection rates, and tolerability across the centres using the device for the first time.

The data suggest that LATP biopsy using a TP access system mounted to the ultrasound probe achieves excellent PCa detection, with a very low sepsis rate (0.16%,) and is safe and well tolerated. The study also found improved csPCa diagnosis compared to historic transrectal biopsy series.

Regarding patient perception of pain during the biopsy, 148 men described the procedure as either ‘not at all’ or ‘a little’ painful. Only 16 men found it ‘very embarrassing’. When exploring their attitude to re-biopsy, 111 said it would be ‘not a problem’, while conversely, 45 considered it would be a ‘moderate’ and 19 a ‘major’ problem. Also, when asked how they would describe the biopsy, 81% of men said that it was a minor or moderate procedure tolerable under local anaesthesia.

Urinary retention is commonly considered to be a risk after TP biopsy, with rates reported to be as high as 10%. However, an alternative explanation is that the urinary retention rate in older TP series may be related to the use of general anaesthetic, rather than to the approach itself. This phenomenon is well-recognised in orthopaedic surgery and may be relevant regarding TP biopsy under general anaesthesia. This can be confirmed when analysing LATP series, which reports urinary retention rates of 2%, which are similar to TRUS-guided biopsy, and consistent with a 1.6% rate in this series.

In another study, which was designed to compare the complications and diagnostic ability between freehand (FH) and grid-based (GB) transperineal biopsy (TPB), it was found that FH transperineal biopsy demonstrates a cancer yield equivalent to that of GB transperineal biopsy with no risk of sepsis, a significantly reduced risk of urinary retention, and reduced anaesthesia needs.

The research titled ‘Freehand versus Grid-Based Transperineal Prostate Biopsy: A Comparison of Anatomical Region Yield and Complications,’ published in the Journal of Urology, is the first study comparing the cancer detection and complication rates of two transperineal biopsy techniques performed by a single surgeon. It identified 478 consecutive patients who underwent transperineal biopsies from August 2014 through September 2020. Of these 478 patients, 174 underwent GB TPB (August 2014-April 2018), and 304 underwent FH TPB with PrecisionPoint™.

The main drawbacks of TPB have historically included its high urinary retention rate; need for general anaesthesia; and the resultant higher costs. However, the PrecisionPoint™ Transperineal Access System, introduced in 2018, enables surgeons to use a freehand (FH) technique for TPB with normally only two skin punctures. PrecisionPoint™ can be used with only sedation or local anaesthesia, reducing the anaesthesia typically required during GB TPB. The technique also allows greater needle mobility, possibly improving the sampling of various regions, while reducing unnecessary sampling of the transition zone.

From the results of the study, it was found that the GB patient group had a significantly higher overall complication rate than the FH group did (p <0.01), which was most prominent in post-biopsy urinary retention rates (10% vs 1%; p<0.01). Additionally, the FH group had a significantly lower operating room and procedure time (35 vs 51 minutes; p<0.001). Overall, the higher number of cores with GGG-2 PCa involvement in the FH group suggests that FH transperineal biopsy can sample the prostate better than GB-transperineal biopsy methods can.

Additionally, transrectal biopsy (TRB), commonly accepted as standard workup for PCa diagnosis, underestimates up to 47% of tumours 0.5cc, under represents the tumour grade in up to 38% of patients, and under samples the anterior apical region. It was found that most patients who previously underwent TRB reported that TPB was less painful than TRB. In addition, the authors observed no infectious complications, even in patients without antibiotic prophylaxis. The low pain scores and low rates of infectious complication and urinary retention among patients who underwent FH biopsy are likely because FH TPB requires only 1 or 2 skin punctures, whereas GB TPB requires multiple punctures.

The last study looks at the use of local anaesthetic transperineal (LATP) prostate biopsies by NHS East Kent Hospitals University and BAUS and is titled “Antibiotic Free Local Anaesthetic Transperineal Prostate (LATP) biopsies: A review of the first 791 cases.

The report highlights the new LATP service that was started in July 2019, and a year later, the COVID-19 pandemic was used as the catalyst to stop TRUS biopsies altogether, with all patients now undergoing LATP biopsies.

The study’s aim was to review local LATP diagnostic rates, as well as patient reported outcome measures (PROMs), as well as to obtain any prevalence of complications/adverse outcomes. This was done by collecting data between July 2019-March 2021 from patients who underwent pre-biopsy mpMRI prostate.

The study concluded that antibiotic free LATP biopsy is safe, with low rates of sepsis and complications, and is well tolerated according to patient responses. It also found that due to high rates of PrCa diagnosis, this biopsy technique is also highly accurate. The study reinforces the Trust’s advocacy for the continued use of targeted and systematic biopsies in PIRADS3-5 lesions given its detection rates of CS PrCa.

As evidenced by these most recent studies, the body of evidence continues to mount – not only for the further eradication of the TRUS biopsy, but also for the continued adoption of the single-freehand LATP methodology, with PrecisionPoint.