If the Crossfire debate at the (AUA) virtual annual meeting is any indication, advocates for transperineal (TP) biopsies face an uphill battle in persuading U.S. urologists to adopt the practice.
The issue of transrectal versus TP biopsies has been simmering worldwide in recent years. The not long ago adopted a guideline that designated TP as the preferred biopsy method. Transrectal biopsies have already lost favor in Norway, much of the U.K., Australia, and other countries, as urologists hope to prevent infections and potentially deadly biopsies and find more prostate cancers.
AUA, however, is just starting to address new guidelines on prostate biopsies. Only about 2.5% of prostate biopsies in the U.S. are done with TP approaches through disinfected skin between the anus and the testicles.
In the Crossfire, two American urologists took the transrectal side: Arvin George, MD, a surgeon at the University of Michigan in Ann Arbor, who specializes in diagnosis and management of genitourinary cancers; and Thomas Polascik, MD, director of surgical technology at the Duke Prostate and Urological Cancer Center in Durham, North Carolina.
Two international physicians were recruited to take the side of TP biopsies: Peter Chiu, MD, an associate professor at Prince of Wales Hospital in Australia, and of the Chinese University of Hong Kong; and Hashim Ahmed, BCh, chair of urology at Imperial College London.
Ahmed threw down the gauntlet with the "myself, my family, and my friends test."
"If you're all being honest with yourself, you would not want to have [a transrectal biopsy]. You would not want your father, or your uncle, or your grandfather to have this [biopsy]. You would choose transperineal biopsy," he said.
He stressed that the transrectal approach is really a "transfecal" approach.
"We are putting a needle through the rectum and through feces and inoculating bacteria into the prostate, and therefore risking sepsis," Ahmed said. "Even with an enema to clear out the back passage, there is still going to be feces left inside the rectum."
Polascik argued that the transrectal ultrasound (TRUS) biopsy remains the gold standard for biopsies. "It is fast, easy, and effective," he said, adding that TRUS is the model for workflow efficiency.
He said that with proper technique, post-TRUS biopsy infection hospitalization rates can be reduced to zero.
George said, "There are greater non-infectious hospitalizations with transperineal biopsy. At least that is what we see in the state of Michigan."
Is TP more painful?
Chiu said pain tolerance is "actually quite good" using free-hand TP biopsy and local anesthesia. "Usually, the most painful part is the local anesthetic injections."
But George, director of the Michigan Urological Surgery Improvement Collaborative's (MUSIC) prostate cancer quality improvement initiatives, said MUSIC's research on more than 1,200 patients has found that TP biopsies are more painful. "There's no denying that. And anybody who's done both TP and transrectal biopsy is not going to argue that point. It's driven by a significant difference in anesthetic administration," he said.
Is TP with $200 disposables and $40,000 in set-up costs acceptable?
Chiu insisted that TP biopsies are "affordable." He said there are ways around expensive disposables.
But George countered that "transperineal biopsies take significantly longer, especially when you're early on in your learning curve. We all know that [with] transrectal biopsies, you can get in and out in 3 minutes and you are done."
Neither side took up the fact that TP biopsies have easier access to the apex, where 30% or more of prostate cancers occur, and, hence, the TP technique offers the possibility of detecting more cancers.
Matthew Allaway, MD, founder and president of Perineologic, who pioneered a freehand tool for guidance of TP biopsies, said, "To quote Henry Ford: 'If I had asked people what they wanted, they would have said faster horses.'" Perhaps, in the context of this debate, the answer would be better antibiotics.
"The evolution from TR [transrectal] to TP is inevitable," Allaway continued. "Change is difficult, but if we don't learn from history, we are bound to repeat. Changing antibiotics has a marginal short-term gain, but will not move the needle on complications long term. Modern TP approaches using effective devices and methodologies are showing notable improvements in cancer detection. And finally, shouldn't the decision be the patients on how they want to be biopsied?"
The AUA Crossfire is just the opening salvo of an issue that could impact urology for years to come as American men increasingly demand TP biopsies.
The AUA is exploring its options in new guidelines, the association noted.
Raymond Wezik, JD, the AUA's director of Policy and Advocacy, told the advocacy group Active Surveillance Patients International that the guidelines panel is "finalizing the scope" of its investigation.
"The panel are researching a number of questions related to transperineal versus transrectal to look into both clinical benefit (i.e., cancer detection) as well as the associated harms of each and the need for/harms of anesthesia associated with the procedure," Wezik said. "Keep in mind that this process takes careful research, so the peer-review portion will likely be available closer to 2023."
Howard Wolinsky is a Chicago-based medical freelancer. He recently covered the emerging debate on transrectal versus transperineal biopsy in his blog about his cancer journey, which he has written for 51˶ since 2016.