Magnetic resonance imaging/ultrasound fusion-guided transperineal prostate biopsy: Protocol for a clinic-based surgical technique

Background: Prostate biopsy is a crucial diagnostic tool for detecting clinically significant prostate cancer (csPCa). Traditional transrectal ultrasound (TRUS)-guided biopsy methods are often associated with an increased infection risk of infection and limited accuracy, particularly when diagnosing anterior lesions of the prostate gland. Objective: This article presented a structured protocol for performing transperineal fusion magnetic resonance imaging/ultrasound (MRI/US) prostate biopsy, highlighting its advantages over the TRUS approach. Our study included biopsy-naïve patients with elevated prostate-specific antigen levels or abnormal digital rectal examination findings, all of whom underwent pre-biopsy multiparametric MRI to guide targeted biopsies. The key objectives of this protocol were to improve the detection rates of csPCa, minimize infection risk, and standardize a transperineal technique that combines both systematic and targeted biopsies. In addition, we provided details on patient preparation, equipment requirements, procedural steps, and follow-up protocols to ensure the safety and effectiveness of the procedure. This protocol aims to serve as a guideline for institutions to adopt MRI/US fusion-guided transperineal biopsy, thereby enhancing diagnostic accuracy and patient safety. Conclusion: The transperineal fusion MRI/US biopsy protocol enhances diagnostic accuracy, particularly for anterior lesions, while reducing infections risks. Combining targeted and systematic biopsies improves detection rates of csPCa and offers a standardized, safe approach for clinical implementation.
- Cornford P, van den Bergh RCN, Briers E, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on prostate cancer-2024 update. Part I: Screening, diagnosis, and local treatment with curative intent. Eur Urol. 2024;86(2):148-63. doi: 10.1016/j.eururo.2024.03.027
- Tu X, Liu Z, Chang T, et al. Transperineal magnetic resonance imaging-targeted biopsy may perform better than transrectal route in the detection of clinically significant prostate cancer: Systematic review and meta-analysis. Clin Genitourin Cancer. 2019;17(5):e860-e870. doi: 10.1016/j.clgc.2019.05.006
- Wu F, Gao J, Kang J, et al. Knowledge mapping of exosomes in autoimmune diseases: A bibliometric analysis (2002-2021). Front Immunol. 2022;13:939433. doi: 10.3389/fimmu.2022.939433
- Pepe P, Pennisi M. Morbidity following transperineal prostate biopsy: Our experience in 8.500 men. Arch Ital Urol Androl. 2022;94(2):155-159. doi: 10.4081/aiua.2022.2.155
- Eldred-Evans D, Burak P, Connor MJ, et al. Population-based prostate cancer screening with magnetic resonance imaging or ultrasonography: The IP1-PROSTAGRAM study. JAMA Oncol. 2021;7(3):395-402. doi: 10.1001/jamaoncol.2020.7456
- Emmett L, Buteau J, Papa N, Moon D, et al. The additive diagnostic value of prostate-specific membrane antigen positron emission tomography computed tomography to multiparametric magnetic resonance imaging triage in the diagnosis of prostate cancer (PRIMARY): A prospective multicentre study. Eur Urol. 2021;80(6):682-689. doi: 10.1016/j.eururo.2021.08.002
- Klotz L, Chin J, Black PC, et al. Comparison of multiparametric magnetic resonance imaging-targeted biopsy with systematic transrectal ultrasonography biopsy for biopsy-naive men at risk for prostate cancer: A phase 3 randomized clinical trial. JAMA Oncol. 2021;7(4):534-542. doi: 10.1001/jamaoncol.2020.7589
- Wegelin O, Exterkate L, van der Leest M, et al. The FUTURE trial: A multicenter randomised controlled trial on target biopsy techniques based on magnetic resonance imaging in the diagnosis of prostate cancer in patients with prior negative biopsies. Eur Urol. 2019;75(4):582-590. doi: 10.1016/j.eururo.2018.11.040
- Corfield J, Perera M, Bolton D, Lawrentschuk N. (68)Ga-prostate specific membrane antigen (PSMA) positron emission tomography (PET) for primary staging of high-risk prostate cancer: A systematic review. World J Urol. 2018;36(4):519-527. doi: 10.1007/s00345-018-2182-1
- Rai BP, Mayerhofer C, Somani BK, Kallidonis P, Nagele U, Tokas T. Magnetic resonance imaging/ultrasound fusion-guided transperineal versus magnetic resonance imaging/ultrasound fusion-guided transrectal prostate biopsy-a systematic review. Eur Urol Oncol. 2021;4(6):904-913. doi: 10.1016/j.euo.2020.12.012
- Gunzel K, Magheli A, Baco E, et al. Infection rate and complications after 621 transperineal MRI-TRUS fusion biopsies in local anesthesia without standard antibiotic prophylaxis. World J Urol. 2021;39(10):3861-3866. doi: 10.1007/s00345-021-03699-1
- Thomson A, Li M, Grummet J, Sengupta S. Transperineal prostate biopsy: A review of technique. Transl Androl Urol. 2020;9(6):3009-3017. doi: 10.21037/tau.2019.12.40
- Bryant RJ, Yamamoto H, Eddy B, et al. Protocol for the TRANSLATE prospective, multicentre, randomised clinical trial of prostate biopsy technique. BJU Int. 2023;131(6):694-704. doi: 10.1111/bju.15978
- Bennett HY, Roberts MJ, Doi SA, Gardiner RA. The global burden of major infectious complications following prostate biopsy. Epidemiol Infect. 2016;144(8):1784-1791. doi: 10.1017/S0950268815002885
- Xue J, Qin Z, Cai H, et al. Comparison between transrectal and transperineal prostate biopsy for detection of prostate cancer: A meta-analysis and trial sequential analysis. Oncotarget. 2017;8(14):23322-23336. doi: 10.18632/oncotarget.15056
- Xiang J, Yan H, Li J, Wang X, Chen H, Zheng X. Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: A systematic review and meta-analysis. World J Surg Oncol. 2019;17(1):31. doi: 10.1186/s12957-019-1573-0
- Hu JC, Assel M, Allaf ME, et al. Transperineal versus transrectal magnetic resonance imaging-targeted and systematic prostate biopsy to prevent infectious complications: The PREVENT randomized trial. Eur Urol. 2024;86(1):61-68. doi: 10.1016/j.eururo.2023.12.015
- Uleri A, Baboudjian M, Tedde A, et al. Is there an impact of transperineal versus transrectal magnetic resonance imaging-targeted biopsy in clinically significant prostate cancer detection rate? A systematic review and meta-analysis. Eur Urol Oncol. 2023;6(6):621-628. doi: 10.1016/j.euo.2023.08.001
- van der Leest M, Cornel E, Israel B, et al. Head-to-head comparison of transrectal ultrasound-guided prostate biopsy versus multiparametric prostate resonance imaging with subsequent magnetic resonance-guided biopsy in biopsy-naive men with elevated prostate-specific antigen: A large prospective multicenter clinical study. Eur Urol. 2019;75(4):570-578. doi: 10.1016/j.eururo.2018.11.023
- Drost FH, Osses DF, Nieboer D, et al. Prostate MRI, with or without MRI-targeted biopsy, and systematic biopsy for detecting prostate cancer. Cochrane Database Syst Rev. 2019;4(4):CD012663. doi: 10.1002/14651858.CD012663.pub2
- Rouviere O, Puech P, Renard-Penna R, et al. Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): A prospective, multicentre, paired diagnostic study. Lancet Oncol. 2019;20(1):100-109. doi: 10.1016/S1470-2045(18)30569-2
- Miah S, Hosking-Jervis F, Connor MJ, et al. A multicentre analysis of the detection of clinically significant prostate cancer following transperineal image-fusion targeted and nontargeted systematic prostate biopsy in men at risk. Eur Urol Oncol. 2020;3(3):262-269. doi: 10.1016/j.euo.2019.03.005
- Kesch C, Hansen N, Barrett T, et al. PD43-02 multicentre comparison of target and systematic biopsies using magnetic resonance and ultrasound image-fusion guided transperineal prostate biopsy in patients with a previous negative biopsy. J Urol. 2017;197:e818. doi: 10.1016/j.juro.2017.02.1907
- Brisbane WG, Priester AM, Ballon J, et al. Targeted prostate biopsy: Umbra, penumbra, and value of perilesional sampling. Eur Urol. 2022;82(3):303-310. doi: 10.1016/j.eururo.2022.01.008
- Touzani A, Fiard G, Barret E, et al. Clinical trial protocol for PERFECT: A randomised controlled trial comparing the efficiency and tolerance of transperineal fusion versus transrectal imaging-targeted prostate biopsies (CCAFU-PR1 Study). Eur Urol Open Sci. 2022;45:76-80. doi: 10.1016/j.euros.2022.09.007
- Kench JG, Judge M, Delahunt B, et al. Dataset for the reporting of prostate carcinoma in radical prostatectomy specimens: Updated recommendations from the International Collaboration on Cancer Reporting. Virchows Arch. 2019;475(3):263-277. doi: 10.1007/s00428-019-02574-0