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Transperineal vs Transrectal biopsy

Posted by mauk @mauk, Aug 27 9:28pm

I am up for a biopsy mid-September, and needed advice on which route to take, I called up the UCSF urology dept and was informed that it would be Transrectal not sure if the person knew the right answer. After doing research I found out most center are not performing transrectal but leaning towards transperineal. Any thought from folks who gone through the biopsy process.

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jc76 | @jc76 | Sep 4 4:26pm
In reply to @chardsaus "I had two transperineal biopsies done both under general anesthesia. From my research (and now ChatGPT..." + (show)
Profile picture for chardsaus @chardsaus

I had two transperineal biopsies done both under general anesthesia.

From my research (and now ChatGPT is awesome at comparing the two). I found Europe and some American hospitals are no longer doing transrectal. The transperineal is less risk of infection and from what some articles have posted, offers greater access to the whole prostate.

I wasn't sure what to expect from where they went in, but it was the equivalent to a mark left by a blood draw. There was no minimal blood on the band aid and no bleeding from where they entered for the biopsy (blood in urine, feces and ejaculate is not uncommon for a bit but clears up pretty quickly).

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@chardsaus
I would just echo your post so will just say your information is very accurate and helpful.

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heavyphil | @heavyphil | Sep 4 8:47pm
In reply to @steveapplebaugh "I would not do both - that is for sure. The Mayo Clinic said that they..." + (show)
Profile picture for steveapplebaugh @steveapplebaugh

I would not do both - that is for sure. The Mayo Clinic said that they would use the results of my biopsy next week along with my MRI and labs (to date) during the consultation on 10/27 and plan from there. In my mind, it is a matter of timing. My Tucson team will be able to discuss forward planning by the end of September, with a new option for me to consult with Dr. Frendl. If I wait to do anything until I see the Mayo doc, then all possible treatments are delayed. I have a new HUGE consideration. Starting in January 2026, an AI company and its AI "mechanism" will decide which procedures I will be able to have covered by Medicare. I really DO NOT want to wait too long so that my decisions with urologists input will be null and void.

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OMG…your ins co has AI involved?? And you have a gun to your head as well…oh well, best of luck with all that!
Phil

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hammer101 | @hammer101 | Sep 5 7:26am

I had a transperineal biopsy about 4 years ago, found Gleason 7 (4+3). This was done at Mayo-Rochester with local numbing, doctor's office. It was not that bad, and took less than 30 minutes. I had 17 biopsy samples taken - First few needles did not feel good, but latter were much much better - I am not good with needles, and still did not think it was horrible. Also, the ability schedule the biopsy within 1-2 weeks and walk in/out within an hour was awesome. Based on my research, I would never go with the transrectal biopsy - This procedure opens you up to more chances for infection and does not allow for a complete biopsy to be performed.

Good luck and pray all goes well for your biopsy and any potential follow-up treatment!!

Jim

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steveapplebaugh | @steveapplebaugh | Sep 5 7:58am
In reply to @heavyphil "OMG…your ins co has AI involved?? And you have a gun to your head as well…oh..." + (show)
Profile picture for heavyphil @heavyphil

OMG…your ins co has AI involved?? And you have a gun to your head as well…oh well, best of luck with all that!
Phil

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It is my "insurance company" because I am using traditional, everyday Medicare. It is the government that is electing to use AI to reduce the costs of care by economically selecting care for Medicare patients (preauthorization). The trial starts January 2026 and is starting in 6 states: Arizona, NJ, Washington, Ohio, Oklahoma and Texas. Involved AI companies stand to reap a bonus of 30% of savings by choosing cheaper (cost-saving) treatments. Sam Altman and other AI leaders praised the administration at a recent AI lunch at the WH. Maybe Open AI is participating in the trial - very likely so. Politics aside, I would like to make my health decisions with my doctor, not an AI algorithm.

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steveapplebaugh | @steveapplebaugh | Sep 5 8:03am
In reply to @peterj116 "From what I've read, transrectal isn't common these days, due to the possibility of infection. Transperineal..." + (show)
Profile picture for peterj116 @peterj116

From what I've read, transrectal isn't common these days, due to the possibility of infection.

Transperineal seems to be the standard.
That's what I had, anyway.

But that doesn't get us out of the horrible rectal invasion.
I can only speak to the experience that I had.
Although the actual biopsy needle goes in through the perineum, my urologist also slid in an ultrasound probe in the rectum. (totally the not-fun experience it sounds like)

The idea is that they have the MRI scan available & use that as a guide, using a grid system.
The ultrasound enables them to pinpoint exactly where the needle is going.
So they basically play Battleship with your prostate.

It's not all bad, though.
This is just a day at the office for them & my urologist kept me distracted with a long chat about arcade games.
It totally worked.

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I don't think that transperineal is the standard in the USA, yet. I was not offered it in Tucson - a fairly large and progressive city. In fact, researching Mayo Arizona, I found that they claim to be one of the few centers (of excellence!) in Arizona that offers the transperineal biopsy. I am scheduled for transrectal biopsy next week - MRI fusion-guided - because that is what my urologist offers. I will see a Mayo Clinic doctor for consultation and consideration of unique focal treatment in late October, which is the first appointment available. The Mayo doctor said to keep my appointment and get the biopsy done now, then send pathology report to him. I was "freaking out" about this topic until I saw a great, detailed presentation by urologist, Dr. Michael Ahdoot on YouTube. His presentation helped me understand and relax. You should see it!!! https://youtu.be/bK1ozkOgatw?si=Hy1DrRFDWweg8rIz

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rbtsch1951 | @rbtsch1951 | Sep 5 11:38am
In reply to @steveapplebaugh "I don't think that transperineal is the standard in the USA, yet. I was not offered..." + (show)
Profile picture for steveapplebaugh @steveapplebaugh

I don't think that transperineal is the standard in the USA, yet. I was not offered it in Tucson - a fairly large and progressive city. In fact, researching Mayo Arizona, I found that they claim to be one of the few centers (of excellence!) in Arizona that offers the transperineal biopsy. I am scheduled for transrectal biopsy next week - MRI fusion-guided - because that is what my urologist offers. I will see a Mayo Clinic doctor for consultation and consideration of unique focal treatment in late October, which is the first appointment available. The Mayo doctor said to keep my appointment and get the biopsy done now, then send pathology report to him. I was "freaking out" about this topic until I saw a great, detailed presentation by urologist, Dr. Michael Ahdoot on YouTube. His presentation helped me understand and relax. You should see it!!! https://youtu.be/bK1ozkOgatw?si=Hy1DrRFDWweg8rIz

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Thanks for sharing the video. For those interested here is the link to the published article from the randomized trial described. Bottom line is that the difference in the risk of infection between the two procedures is not statistically significant if appropriate antibiotic prophylaxis is used with transrectal procedures (antibiotics are not needed with the transperineal procedure) and the diagnostic yield statistically equivalent. Best to go with your Urologist's experience and recommendations as both procedures have value. Transperineal biopsies may ultimately become the procedure of choice primarily due to concerns regarding emergence of antibiotic resistant bacteria:
https://pmc.ncbi.nlm.nih.gov/articles/PMC11976521/
And this article documents the diagnostic yield from TR vs TP approach:
https://pmc.ncbi.nlm.nih.gov/articles/PMC9883893/pdf/12894_2023_Article_1176.pdf

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tmc5206 | @tmc5206 | Sep 5 12:42pm

I had transrectal biopsy in 2023 - no cancer was found. Then I had a Transperineal biopsy 14 months later and advanced cancer was found-gleason 9. My understanding/experience says that Transperineal yields better diagnosis.

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jeff Marchi | @jeffmarc | Sep 5 2:26pm
In reply to @tmc5206 "I had transrectal biopsy in 2023 - no cancer was found. Then I had a Transperineal..." + (show)
Profile picture for tmc5206 @tmc5206

I had transrectal biopsy in 2023 - no cancer was found. Then I had a Transperineal biopsy 14 months later and advanced cancer was found-gleason 9. My understanding/experience says that Transperineal yields better diagnosis.

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That’s because it can get to areas of the prostate that cannot be reached by the transrectal biopsy.

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heavyphil | @heavyphil | Sep 5 2:40pm
In reply to @jeffmarc "That’s because it can get to areas of the prostate that cannot be reached by the..." + (show)
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That’s because it can get to areas of the prostate that cannot be reached by the transrectal biopsy.

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That article posted by @rbtsch1951 suggests that the larger the prostate volume and the higher the grade (T3/4) the better transrectal performed.
The smaller the prostate and lower grade cancers were detected better by transperineal approach due to where the needles enter the gland.
You would have to sort thru all the data/tables, but my read is that TP finds everything - large or small - while TR finds the larger more advanced tumors (in size).
They go on to day that both approaches performed equally…not so sure about that.
Phil

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steveapplebaugh | @steveapplebaugh | Sep 5 4:01pm
In reply to @rbtsch1951 "Thanks for sharing the video. For those interested here is the link to the published article..." + (show)
Profile picture for rbtsch1951 @rbtsch1951

Thanks for sharing the video. For those interested here is the link to the published article from the randomized trial described. Bottom line is that the difference in the risk of infection between the two procedures is not statistically significant if appropriate antibiotic prophylaxis is used with transrectal procedures (antibiotics are not needed with the transperineal procedure) and the diagnostic yield statistically equivalent. Best to go with your Urologist's experience and recommendations as both procedures have value. Transperineal biopsies may ultimately become the procedure of choice primarily due to concerns regarding emergence of antibiotic resistant bacteria:
https://pmc.ncbi.nlm.nih.gov/articles/PMC11976521/
And this article documents the diagnostic yield from TR vs TP approach:
https://pmc.ncbi.nlm.nih.gov/articles/PMC9883893/pdf/12894_2023_Article_1176.pdf

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Thanks for the additional information and links.

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