Transperineal vs. transrectal: Which is worse?

I was scheduled for a transrectal biopsy 6/2 using twilight sedation (so I didn't move during the procedure, not for pain management). However, it was cancelled the day before due to problems reading the MRI and they told me that they would try to reschedule sometime in August. Since I was Pi-Rads 4 this wasn't acceptable, so I contacted Johns Hopkins last Friday and sent them my MRI report and they saw me the next Monday! They immediately scheduled a trans perineal biopsy for 7/6. This is to be done with local only and I guess that the movement issue is not a consideration since I'll be up in stirrups and may not be able to move. The bad news was that the JH radiologist also read my MRI and upgraded my reading from 4 to 4/5. Since this is a COE I put more stock in his interpretation.

I had three markers and a spacer put in yesterday transperineally ,for my future proton treatment, my question after checking further this morning. I found out that I was not shaved. I found that odd is that the norm

I've been on this journey over a year since my RP in April 2025. This is the first time that I ever heard of or read about "spacer and fiducial markers." What are they and why are they needed? Thanks

@rlpostrp
Since you had a RP, these would never have come up. They are used to direct and focus radiation treatments from the various different radiation protocols that might be used and to reduce radiation to organs adjacent to your prostate .

@wheel1

Not true. Some centers use fiducial markers for salvage RT - yes rarely, but they do.

My husband is having salvage RT and will have gold beads placed in the pelvic floor area.

There are studies done that proved that even spacer can offer protection for patents that had RP but it requiters very skilled person to insert one when gland is absent.

I had local. The procedure itself was fine. I had a bit of pain and bleeding afterwards. Not pleasant but manageable.

@mtsenior My experience yesterday was the same. Rectal ultrasound probe was really the worst part of it.

I just had three fiducial markers and the SpaceOAR emplaced this morning. Procedure was easy. Just a little perineal discomfort. Urologist cleared me for normal activities; wish I hadn’t backed out of Thursday’s golf match. My next step is the trial run with the R O on July 2.

@surftohealth88
There are exceptions and rarely done to everything. I cannot find the long term randomized studies with multiple numbers of patients on the spacer. Please post

@surftohealth88
Higher Rate of Severe Complications: Clinical data indicates that placing spacers in patients undergoing salvage radiation involves a higher rate of rectal complications than initial, intact prostate treatments.