Is transperineal prostate biopsy more accurate than transrectal biopsy in determining final Gleason score and clinical risk category? A comparative analysis

Abstract

Objectives To assess the degree of upgrading and increase in clinical risk category of transperineal template biopsy (TTB) compared with transrectal ultrasonography‐guided prostate biopsy (TRUSB). Upgrading of TRUSB Gleason grade and sum after radical prostatectomy (RP) is well recognised. TTB may offer a more thorough mapping of the prostate than TRUSB, as well as a more accurate assessment of the tumour. In this retrospective cohort study of prospectively collected data, we compare the initial TRUSB and TTB Gleason grade and sum with the final assessment at RP. Patients and Methods Following Ethics Committee approval, 431 laparoscopic and robotic RP specimens of two urologists, fellowship‐trained in minimally invasive RP, were examined in the private sector between April 2009 and October 2013. Final RP Gleason grade and sum were compared with the initial prostate biopsy. All pathological assessments were performed by a dedicated uropathology unit, experienced in prostate pathology. Upgrading was defined either as an increase in the primary Gleason grade, or as identification of a higher grade tertiary pattern at final RP analysis. Increase in clinical risk category was defined as an increase from low‐ (Gleason ≤6), to either intermediate‐ (Gleason 7) or high‐risk disease (Gleason 8–10); or as an increase from intermediate‐ to high‐risk disease. The chi‐squared test was used to compare categorical variables, while the Wilcoxon rank sum was used for continuous quantitative variables. Results The 431 RP specimens comprised 283 in which the prostate cancer was diagnosed at TRUSB and 148 diagnosed at TTB. There was no difference between TRUSB and TTB in mean prostate weight (46.4 vs 44.2 g), final RP pathological stage (pT2: 187 vs 102; pT3 97 vs 48; P = 0.65) or mean tumour volume (2.15 vs 2.14 mL). Overall, 33.22% of TRUSB and 30.41% of TTB were upgraded, which was not significantly different (P = 0.55). Similarly there was no difference in whether there was an increase to a higher Gleason sum (TRUSB 23.3% vs TTB 20.9%; P = 0.57). TTB was more reflective of the actual clinical risk category, with TRUSB more likely to show an increase in clinical risk (TRUSB 22.3% vs TTB 14.2%; P = 0.04). Conclusions In this series, TTB more accurately predicted clinical risk category than TRUSB. TTB should be considered before active surveillance, to ensure that occult higher risk disease has not been under diagnosed. Upgrading and increase in clinical risk category was relatively common in each group highlighting the need for improved pretreatment staging accuracy.

Gleason group concordance between biopsy and radical prostatectomy specimens: A cohort study from Prostate Cancer Outcome Registry – Victoria

“…Few studies have demonstrated this association. In one recent study, 27 the likelihood of upgrade with transperineal biopsies (30.41%) was less than with TRUS biopsies (33.22%), but the reduction was not statistically significant ( P  = 0.55).…”

Comparison of the complications of traditional 12 cores transrectal prostate biopsy with image fusion guided transperineal prostate biopsy

“…This changed after several reports of fatalities following septic complications of transrectal biopsy [17]. Image fusion guided TP biopsy is increasingly popular as a mean for accurate diagnosis and risk stratification [11, 18]. An increasing number of studies have showed that MRI/US image-fusion guided TP is an effective and accurate method for prostate cancer diagnosis.…”

“…Recently, transperineal prostate biopsy has been becoming an increasingly popular approach for accurate diagnosis and risk stratification of prostate cancer [11]. MRI/US-fusion-guided biopsyis a potential approach to offer improved diagnostic information over systematic 12-core transrectal prostate biopsy guided by TURS alone [12, 13].…”

Safety of transrectal ultrasound-guided prostate biopsy in patients affected by Crohn’s disease

“…Compared with TR biopsy, TP approach may offer a more aseptic method, with fewer infective complications in light of evidence of fluoroquinolone-resistant bacteria in bowel. However, TP biopsy is a more costly alternative, with longer procedural times and higher risks of acute retention postoperatively (9,10,22,24). In our Department we usually employ a TR approach using an end-fire probe, because we believe that to perform prostate biopsy in the anterior area of the gland it is the most appropriate technique.…”

“…Therefore, approximately 20-30% of men with CD will require a prostate biopsy within their lifetime, and compared with men non affected, they are at increased risk of developing complications following this procedure (7,8). Although cancer detection rates or the complication rates between transrectal (TR) biopsy and transperineal (TP) biopsy are greatly debated (9,10), in this retrospective study we analysed the use and the safety of transrectal ultrasound-guided prostate biopsy (TRUSBx) in a small cohort of five patients with CD.…”