Safety and feasibility of freehand transperineal prostate biopsy under local anesthesia: Our initial experience

With the emergence of multidrug-resistant organisms causing urosepsis after transrectal biopsy of prostate, the need for an alternative approach has increased. We assessed the safety and feasibility of transrectal ultrasound (TRUS) guided free-hand transperineal prostate biopsy under local anesthesia (LA) for suspected prostate cancer.

This prospective study was conducted from July 2019 to December 2020 in which patients with elevated prostate-specific antigen (PSA) and/or abnormal digital rectal examination underwent magnetic resonance imaging-TRUS cognitive fusion transperineal prostate biopsy (target and systematic) using coaxial needle. Demographic, perioperative, and outcome data of 50 consecutive patients were analyzed.

The mean age of the patients was 69.6 ± 7.61 years, median PSA 13.55 ng/mL (4.17-672) and prostate size 45cc (16-520). Prostate Imaging-Reporting and Data System (PIRADS) 2, 3, 4, and 5 lesions were found in 2, 12, 12, and 24 patients, respectively. Average procedure duration was 20 min (15-40 min) and number of cores ranged from 12 to 38 (median 20). Forty out of fifty (40/50) patients experienced only mild pain with visual analog scale ≤2. Histopathological examination showed adenocarcinoma, benign prostatic hyperplasia, and chronic prostatitis in 41, 5, and 4 patients respectively with 82% cancer detection rate (CDR). Over 95% of cases showed clinically significant cancer (International Society of Urological Pathology class ≥ 2) and 91.7% of patients with PIRADS score 4/5 and 66.7% with PIRADS score 3 had malignancy. Three patients developed complications (two hematuria, one urinary retention), both were managed conservatively and none had urosepsis.

Free-hand transperineal prostate biopsy by coaxial needle technique under LA is safe and feasible with good tolerability, high CDR, and minimal complications particularly reduced urosepsis.