Evidence for local anaesthetic transperineal biopsy versus transrectal prostate biopsy
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj-2023-078175 (Published 02 December 2024) Cite this as: BMJ 2024;387:e078175
- Alastair D Lamb, Cancer Research UK clinician scientist fellow, honorary consultant urologist1 2,
- Filipa Landeiro, senior researcher3,
- Ioana R Marian, senior medical statistician4,
- Steve Tuck, emeritus chairman5,
- Richard J Bryant, associate professor of urology, honorary consultant urologist12
- 1Nuffield Department of Surgical Sciences, University of Oxford, UK
- 2Department of Urology, Oxford University NHS Foundation Trust
- 3Nuffield Department of Population Health, University of Oxford
- 4Oxford Clinical Trials Research Unit (OCTRU) Centre for Statistics in Medicine (CSM), University of Oxford
- 5Oxford Prostate Cancer Support Group, Oxford
- Correspondence to A Lamb alastair.lamb{at}nds.ox.ac.uk
What you need to know
Prostate biopsy under local anaesthetic can be performed via the transrectal (TRUS) or transperineal (LATP) routes. Both use transrectal ultrasound
Each prostate biopsy technique has pros and cons, including differences in targeting multiparametric MRI visible lesions, potential complications, patient tolerability, expense, and time to undertake the procedure in the outpatient clinic
Three randomised controlled trials show no difference for infection or overall cancer detection between TRUS and LATP. However, these trials were underpowered to detect a difference, mainly because of the better than expected performance of TRUS in both categories. A further larger trial is awaited.
Prostate cancer is usually diagnosed using image guided needle biopsy. Approximately 70 000 such biopsies are performed annually in the UK,1 but these numbers have fallen since the widespread introduction of prostate multiparametric magnetic resonance imaging (mpMRI) scanning as a pre-biopsy investigation for men suspected to have prostate cancer.23 Initial suspicion normally arises following blood test results that show a raised level of prostate specific antigen (PSA) and/or an abnormal prostate examination, which are usually undertaken as part of case finding or opportunistic screening.4 However, prostate biopsies are an expensive intervention and have significant side effects for patients, and uncertainty persists on the need for further biopsies in the case of negative results.
Over the past three decades, prostate biopsy techniques have been increasingly refined, centring around transrectal ultrasound (TRUS), image guidance of biopsy needle placement, use of pre-biopsy mpMRI, and needle guidance access systems. The past five years have seen a gradual trend away from transrectal biopsy towards local anaesthetic transperineal biopsy (LATP), precipitated primarily by concerns about the infection risk of transrectal biopsy, along with the perceived superiority of transperineal biopsy in targeting mpMRI visible lesions.5 Transperineal access systems have removed the need for either a large fixed …
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