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Is in-office transperineal biopsy the future of prostate cancer diagnosis?

DOI:10.1097/MOU.0000000000000567 Multiple studies have now documented an increase in the incidence of post-prostate biopsy sepsis. If allowed to continue, this rising source of morbidity may present an argument against prostate-specific antigen (PSA)-based prostate cancer screening and a challenge to the safety of active surveillance protocols. Transperineal prostate biopsy promises a long-term solution to the problem of prostate biopsy-related infections. Transperineal techniques have little to no incidence of infection, with some investigators omitting periprocedural antibiotics altogether [1]. Here, we summarize the improvements in technology and technique that have made transperineal biopsy a viable alternative to transrectal biopsy. MRI-targeted biopsy is rapidly becoming the standard of care for prostate cancer diagnosis based on its ability to preferentially detect high-grade cancers. This has been recapitulated in the transperineal setting. In a study of patients undergoing transperineal biopsy in which 215 patients had a prebiopsy MRI and 281 patients did not, Washino et al. [2] found that patients who had a prebiopsy MRI (with or without cognitive fusion) had a higher rate of clinically significant cancer detection than those who did not (46.0 vs. 35.2%, respectively; P1⁄40.016). Similarly, the PICTURE trial assigned 249 men to mpMRI followed by transperineal mapping biopsies, as well as image fusion biopsies in men with a lesion on MRI. This study found that transperineal fusion biopsy agreed with mapping biopsies in the detection of clinically significant cancer in 81% of cases [3]. Another recent study of 1032 men undergoing transperineal MRI fusion and transperineal mapping biopsies had similar findings, with a sensitivity of 83.8% for the detection of clinically significant prostate cancer using a cutoff of PIRADS 3 or greater [4]. Remarkably, this study also demonstrated the safety of transperineal biopsy, with no complications requiring hospital admission in any of those biopsied [4]. Recent industry developments of software to perform transperineal-targeted biopsy are promising. Using the Urofusion software, Kaufmann et al. [5] found that software-assisted transperineal-targeted biopsy was