The Future of Prostate Biopsy: Why the Transperineal Approach is Taking Center Stage
Prostate cancer is the second-leading cause of cancer death among American men, 1 underscoring the critical importance of early and accurate diagnostics. One of the important methods of detecting prostate cancer is the ultrasound-guided biopsy, which involves taking tissue samples for microscopic evaluation when screening tests like PSA levels or imaging studies indicate concern.
Let’s dive into some of the newest, most exciting advances in prostate biopsy techniques, including the transperineal prostate biopsy, which is gaining attention for its potential to reduce infection risks and improve diagnostic accuracy.
The Current Standard Approach: Transrectal Ultrasound-Guided Biopsy (TRUS)
For decades, the transrectal ultrasound-guided prostate biopsy (TRUS) has been the gold standard for prostate cancer diagnostics, 2 and involves inserting a biopsy needle through the rectum into the prostate using ultrasound guidance to obtain tissue samples.
Advantages of TRUS
1. Accessibility Across Practices
TRUS is widely used due to its straightforward implementation and minimal need for specialized equipment. 3
2. Established Familiarity
Most clinicians are extensively trained in TRUS, making it an accessible technique. 4
3. Outpatient Convenience
TRUS biopsies are typically performed in-office, with procedures able to be performed in just ten minutes. 3
Disadvantages of TRUS
1. Higher Infection Risks
The procedure involves passing a needle through the rectum, which introduces rectal bacteria into the body and carries a 0.1 to 7.0% risk of infectious complication, including a 0.3% to 3.1% rate of sepsis, depending on antibiotic prophylaxis regimens. 5
2. Sampling Limitations
Systematic TRUS is often less effective at accessing certain regions of the prostate, such as the anterior zones, where clinically significant cancers may be located. 6
3. Complications
Complications such as rectal bleeding, fever, sepsis, hematuria and acute urinary retention remain common concerns for patients. 7
New Developments For Transforming Prostate Biopsies
Technological advancements are driving significant breakthroughs in prostate cancer diagnostics, enhancing diagnostic accuracy and patient care. Developments include:
1. MRI-Targeted Biopsy Integration
By using both MRI and ultrasound together, doctors can more accurately aim at problem areas during a biopsy and avoid taking samples from healthy tissue. This method, called fusion biopsy, helps physicians to find serious cancers. 8
2. Micro-Ultrasound Imaging (29 MHz)
Micro-ultrasound is a new, advanced type of ultrasound that helps doctors identify suspicious areas and provide clear, real-time images of the prostate. Early research from the Cleveland Clinic suggests this high-resolution 29 MHz technology may detect more clinically significant cancers than MRI or traditional biopsy methods alone. 9
The Rising Star: Transperineal Prostate Biopsy (TPBx)
What Is the Transperineal Approach?
The transperineal biopsy (TPBx) involves accessing the prostate through the perineum (the area between the rectum and scrotum) rather than the rectum. 6 Although traditionally performed under general anesthesia due to procedural complexity, technological advancements now enable transperineal biopsies in outpatient settings using local anesthesia. 10
Key Advantages of the Transperineal Approach
1.Superior Patient Safety
Transperineal biopsies minimize infection risks, including a 1 in 500 risk of sepsis (compared to the transrectal approach’s 1-2 in 100), as the needle bypasses the rectum entirely, avoiding exposure to fecal bacteria and reducing the need for antibiotics. 6 11
2. Expanded Prostate Access
The approach has shown improved sampling of hard-to-reach areas, such as the anterior and apical prostate regions. 12
3. Fewer Complications
By avoiding the rectal passage, transperineal biopsies reduce risks like rectal bleeding. 6
Supporting Technological Developments
The increased adoption of transperineal biopsies has been facilitated by:
With its dramatic reduction in infection risk, ability to target difficult regions of the prostate, and compatibility with cutting-edge imaging technologies, the transperineal biopsy represents a paradigm shift in prostate cancer diagnostics, setting a new benchmark for efficiency, precision, and patient safety.
References:
COPYRIGHT © 2025. ALL RIGHTS RESERVED. CIVCO IS A REGISTERED TRADEMARK OF CIVCO MEDICAL SOLUTIONS. ALL OTHER TRADEMARKS ARE THE PROPERTY OF THEIR RESPECTIVE OWNERS. ALL PRODUCTS MAY NOT BE LICENSED IN ACCORDANCE WITH CANADIAN LAW. PRINTED IN USA. 2025M-3429 REV. 1
Let’s dive into some of the newest, most exciting advances in prostate biopsy techniques, including the transperineal prostate biopsy, which is gaining attention for its potential to reduce infection risks and improve diagnostic accuracy.
The Current Standard Approach: Transrectal Ultrasound-Guided Biopsy (TRUS)
For decades, the transrectal ultrasound-guided prostate biopsy (TRUS) has been the gold standard for prostate cancer diagnostics, 2 and involves inserting a biopsy needle through the rectum into the prostate using ultrasound guidance to obtain tissue samples.
Advantages of TRUS
1. Accessibility Across PracticesTRUS is widely used due to its straightforward implementation and minimal need for specialized equipment. 3
2. Established Familiarity
Most clinicians are extensively trained in TRUS, making it an accessible technique. 4
3. Outpatient Convenience
TRUS biopsies are typically performed in-office, with procedures able to be performed in just ten minutes. 3
Disadvantages of TRUS
1. Higher Infection Risks
The procedure involves passing a needle through the rectum, which introduces rectal bacteria into the body and carries a 0.1 to 7.0% risk of infectious complication, including a 0.3% to 3.1% rate of sepsis, depending on antibiotic prophylaxis regimens. 5
2. Sampling Limitations
Systematic TRUS is often less effective at accessing certain regions of the prostate, such as the anterior zones, where clinically significant cancers may be located. 6
3. Complications
Complications such as rectal bleeding, fever, sepsis, hematuria and acute urinary retention remain common concerns for patients. 7
New Developments For Transforming Prostate Biopsies
Technological advancements are driving significant breakthroughs in prostate cancer diagnostics, enhancing diagnostic accuracy and patient care. Developments include:
1. MRI-Targeted Biopsy Integration
By using both MRI and ultrasound together, doctors can more accurately aim at problem areas during a biopsy and avoid taking samples from healthy tissue. This method, called fusion biopsy, helps physicians to find serious cancers. 82. Micro-Ultrasound Imaging (29 MHz)
Micro-ultrasound is a new, advanced type of ultrasound that helps doctors identify suspicious areas and provide clear, real-time images of the prostate. Early research from the Cleveland Clinic suggests this high-resolution 29 MHz technology may detect more clinically significant cancers than MRI or traditional biopsy methods alone. 9
The Rising Star: Transperineal Prostate Biopsy (TPBx)
What Is the Transperineal Approach?
The transperineal biopsy (TPBx) involves accessing the prostate through the perineum (the area between the rectum and scrotum) rather than the rectum. 6 Although traditionally performed under general anesthesia due to procedural complexity, technological advancements now enable transperineal biopsies in outpatient settings using local anesthesia. 10
Key Advantages of the Transperineal Approach
1.Superior Patient Safety
Transperineal biopsies minimize infection risks, including a 1 in 500 risk of sepsis (compared to the transrectal approach’s 1-2 in 100), as the needle bypasses the rectum entirely, avoiding exposure to fecal bacteria and reducing the need for antibiotics. 6 11
2. Expanded Prostate Access
The approach has shown improved sampling of hard-to-reach areas, such as the anterior and apical prostate regions. 12
3. Fewer Complications
By avoiding the rectal passage, transperineal biopsies reduce risks like rectal bleeding. 6
Supporting Technological Developments
The increased adoption of transperineal biopsies has been facilitated by:
Freehand Needle-Guidance Devices
Devices such as the TP Pivot Pro™ can help to enable a freehand, minimally invasive approach to ultrasound-guided transperineal prostate biopsies.
- MRI/Ultrasound Integration
Transperineal biopsies performed via MRI/ultrasound fusion enhance the accuracy of lesion-focused diagnostics. 8
With its dramatic reduction in infection risk, ability to target difficult regions of the prostate, and compatibility with cutting-edge imaging technologies, the transperineal biopsy represents a paradigm shift in prostate cancer diagnostics, setting a new benchmark for efficiency, precision, and patient safety.
References:
- American Cancer Society – Key Statistics for Prostate Cancer
- Healio – “Transperineal prostate biopsies reduce infection, should be a ‘gold standard’
- Grummet J, Pepdjonovic L, Huang S, Anderson E, Hadaschik B. Transperineal vs. transrectal biopsy in MRI targeting. Translational andrology and urology. 2017;6(3):368-375. doi:10.21037/tau.2017.03.58
- Panzone J, Byler T, Bratslavsky G, Goldberg H. Transrectal Ultrasound in Prostate Cancer: Current Utilization, Integration with mpMRI, HIFU and Other Emerging Applications. Cancer Management and Research. 2022;14:1209-1228.
- Liss MA, Ehdaie B, Loeb S, et al. An Update of the American Urological Association White Paper on the Prevention and Treatment of the More Common Complications Related to Prostate Biopsy. The Journal of Urology. 2017;198(2):329-334. doi:10.1016/j.juro.2017.01.103 Medscape – “Death Spurs Country's Shift to Safer Prostate Biopsies”
- Mayo Clinic – “Ultrasound-guided transperineal prostate biopsy”
- Xiang J, Yan H, Li J, Wang X, Chen H, Zheng X. Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: a systematic review and meta-analysis. World Journal of Surgical Oncology. 2019;17(1):1-11. doi:10.1186/s12957-019-1573-0
- Marks L, Young S, Natarajan S. MRI-ultrasound fusion for guidance of targeted prostate biopsy. Current opinion in urology. 2013;23(1):43-50. doi:10.1097/MOU.0b013e32835ad3ee
- Abouassaly R, Klein EA, El-Shefai A, Stephenson A. Impact of using 29 MHz high-resolution micro-ultrasound in real-time targeting of transrectal prostate biopsies: initial experience. World journal of urology. 2020;38(5):1201-1206. doi:10.1007/s00345-019-02863-y
- Bryant RJ, Marian IR, Williams R, et al. Local anaesthetic transperineal biopsy versus transrectal prostate biopsy in prostate cancer detection (TRANSLATE): a multicentre, randomised, controlled trial. The Lancet. Oncology. 2025;26(5):583-595. doi:10.1016/S1470-2045(25)00100-7
- Basourakos SP, Alshak MN, Lewicki PJ, et al. Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy: A Systematic Review and Meta-analysis. European Urology Open Science. 2022;37:53-63. doi:10.1016/j.euros.2022.01.001
- Urology Times – “The case for transperineal prostate biopsy vs. the transrectal approach”
COPYRIGHT © 2025. ALL RIGHTS RESERVED. CIVCO IS A REGISTERED TRADEMARK OF CIVCO MEDICAL SOLUTIONS. ALL OTHER TRADEMARKS ARE THE PROPERTY OF THEIR RESPECTIVE OWNERS. ALL PRODUCTS MAY NOT BE LICENSED IN ACCORDANCE WITH CANADIAN LAW. PRINTED IN USA. 2025M-3429 REV. 1
