Transperineal vs Transrectal biopsy

I had a transrectal biopsy in March 2024. If I knew then, when I know now, I would do the Transperineal. However, after hearing the horror stories, I was expecting it to be a pain, but it wasn’t. I actually enjoyed watching the urologist do the procedure. She circled the area from my MRI and said she would be taking five courses from that area, and then she took 12 random courses from the rest of the prostate. I did feel just a slight jab as she biopsied the lesion area. I didn’t feel anything on the other 12 and just heard the click. I asked her why I felt the first five and she said she had to go a little deeper in the targeted area. I told her afterwards by far the worst part of the whole procedure was the two antibiotic shots in my hips.

I decided with my urologist that I would not require sedation for my upcoming transrectal biopsy, but I know he is planning to use local anesthesia. You opted out of that as well? Interesting. No pain -- or minimal discomfort?

I am followed at UCLA and my urologist continues to prefer the transrectal approach for the majority of patients. In the course of 4 years on active surveillance I have had 4 transrectal procedures, and while uncomfortable, I would not describe them as painful. Premedicated with oral antibiotics before and continued after procedure as well as an intramuscular antibiotic injection at the time of the procedure, I had no problem with infections, thankfully, and only briefly had some small blood in urine and semen. Unfortunately my most recent biopsy showed a progression fro a Gleason 3+4 to Gleason 4+5 (in spite of MRI showing no changes in primary lesion and a low Oncotype score). About to embark on SBRT and ADT, they will do a SpaceOAR rectal space er via a transperineal approach in preparation for my radiation therapy. Knowing the road I am heading down, I am feeling more anxious, and they have offered light sedation with diazepam (Valium) which I think I will accept.

which forn of SBRT?

MRI-guided SBRT. The UCLA protocol is 5 high-dose treatments delivered every other day over the course of 10 business days. 12-18 months ADT.

After studying the issue, I had mine done transperineal in Jan of this year (2025). My main reason was lower risk of infection that way, and the fact that I get really sick with infections (i.e. sepsis or near to it). Mine was MRI fusion - i.e. they did an MRI beforehand, and used that to pick the targets for the extra cores. I had it with general anesthesia so pain wasn't a consideration.

Afterwards, no pain. No concern about infection. MRI fusion is the most accurate, since in addition to the standard needles, they sample more precisely at target areas revealed by the MRI.

@rbtsch1951
Per my Mayo PCP, and my Mayo urologist, and UFHPTI and Mayo R/Os, transrectal is not the most recommended form of doing biopsies for prostate cancer. Doing it transpernia does require more experience and expertise.

It also can use things like MRI/Fusion to do biopies. I have read post on MCC that also said could do more areas of prostate. For me I did not want the extra worry of increased infection and for those who did get it would all tell you made huge mistake not asking for transperenial.

Transrectal is usually done without ansesthesia were transperenial is. Now I am not speaking for all those who got biopsies just my experience with it and what my medical providers told me.
Your orignial biopsie was postivve Gleason Score for prostate cancer. Where you offered treatments at that time? IF not why not? 3+4=7 indicates abnormal cancer cells.

You mentioned SBRT. Which form? Proton or Photon? Very different ways of radiating your prostate but both have same success rates.

At 3+4=7. If you had had a Decipher test then it could have determined your risk level. If low risk you would (at least for me) necessarily be recommended for ADT. AT 4+5 you are. So addressing it back at 3+4 should have come with recommendations on treating it to prevent it from getting worse like it did.

You mentioned some test. Consider (I had them) Decipher, PSMA. Space Oar is done to provide some space between your colon and prostate. You did not mentioned markers being put in but you mentioned SBRT. Asked if you will get markers and if not why?

I would recommend the light sedation and valum they offered with your Space/Oar. I did not like the feeling at all. I think mostly mental, stress, and fear, was main cause as I was not on MCC then so could not get the experience of others at the time. I know when I got on MCC I could not post my experience with my prostate diagnosis, tests, treatments to help those just starting off without feedback from those with personal experiences.

@jc76

Thanks for sharing your thoughts. I have complete confidence in my team at UCLA. My urologist is a national leader in the prostate cancer field, so I had no reason to question his biopsy approach. Too, he recommended active surveillance rather than intervention when first diagnosed because at Gleason 6/7 with a low Oncotype score (his choice over the Decipher test) the odds of progression to aggressive disease were low. All medical decisions are based on statistics, and in my case no matter how low the odds, my progression to Gleason 9 was 100%. No point in using questioning whether a therapeutic window was missed earlier on, I must forge forward.

Treatment plan is for MRI-guided SBRT delivered as an excelerated 5 treatment (every other day for 5 treatments) with convincing data documenting equivalent outcomes and side effects compared to the more standard extended low dose regimen. I had a Prostox (MiraDx) genetic test documenting I was at low risk for late toxicities from high-dose radiation.

Thanks for sharing your input with the SpaceOAR procedure. While I did not find the transrectal biopsies painful, I am going to request mild sedation. I believe it is simply a low dose of Valium (diazepam) given before the procedure to supplement the local anesthesia given by level
of anxiety and associated depression as I head into therapy.

My husband had transrectal biopsies for 10 years… he had increasing PSAs, but they never found anything except very low volume Gleason 6

He was monitored annually with MRIs.

Higher PIRAD lesions were being identified…. 2022 with PSA in high 20’s, MRI Fusion transrectal biopsy , 22 cores taken, all benign ( second opinion with John’s Hopkins con)

2023 Transperineal MRI Fusion biopsy

PSA 46.6 by then.
Eight cores showed cancer, Gleason 9

Transperineal would be the only choice he would recommend

You are so right. They cannot get to areas of the prostate with the transrectal biopsy that they can with the Transperineal biopsy. I wonder if that’s the reason they couldn’t find your husband’s cancer.