|Year : 2015 | Volume
| Issue : 1 | Page : 110-114
Transperineal versus transrectal prostate biopsy: Our findings in a tertiary health institution
EI Udeh1, OC Amu1, II Nnabugwu2, OFN Ozoemena2
1 Department of Surgery, ESUT Teaching Hospital, Parklane, Enugu, Nigeria
2 Department of Surgery, University of Nigeria, Teaching Hospital Enugu, Enugu, Nigeria
|Date of Submission||20-Jul-2014|
|Date of Web Publication||15-Dec-2014|
E I Udeh
Department of Surgery, ESUT Teaching Hospital, Parklane, Enugu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context and Objective: Prostate cancer is a major public health issue. Its incidence is rising, especially in Nigeria. Prompt diagnosis is necessary by histology. Transperineal and transrectal approaches to prostate biopsy are well-documented. Both methods are fraught with complications though, most times minor. Studies carried out to compare both methods were carried out mainly on Caucasians, generating conflicting results. This study aims to compare the complication rates and tissue yield of these two methods in Nigerian men.
Materials and Methods: Seventy-five patients completed the study. Forty-five patients had transperineal prostate biopsy (TPbx), while 30 patients had transrectal prostate biopsy. Pain perception for all patients was determined by visual analog scale; whereas the complications were ascertained by a validated purpose designed questionnaire administered on the 7 th and 30 th day post operatively.
Results: The risk of rectal bleeding was higher for transrectal prostate biopsy compared to transperineal (Odds ratio: 0.03; 95% confidence interval (CI): 0.001-0.450; P = 0.012). TPbx was more painful than transrectal (P < 0.0001; df: 75; t: 4.98; 95%CI of difference in mean: −2.98−[−1.28]). There was no statistical difference between transperineal and transrectal prostate biopsy in hemospermia, fever, prostatic abscess, urethral bleeding, acute retention and tissue yield.
Conclusion: TPbx is more painful than transrectal prostate biopsy though with a significantly reduced risk of rectal bleeding. There appears to be no significant difference with respect to risk of fever, urethral bleeding, hematospermia, prostatic abscess and acute retention. Both routes provided sufficient prostate tissue for histology.
Keywords: Comparative analysis, transperineal prostate biopsy, transrectal prostate biopsy
|How to cite this article:|
Udeh E I, Amu O C, Nnabugwu I I, Ozoemena O. Transperineal versus transrectal prostate biopsy: Our findings in a tertiary health institution
. Niger J Clin Pract 2015;18:110-4
|How to cite this URL:|
Udeh E I, Amu O C, Nnabugwu I I, Ozoemena O. Transperineal versus transrectal prostate biopsy: Our findings in a tertiary health institution
. Niger J Clin Pract [serial online] 2015 [cited 2019 Oct 18];18:110-4. Available from: http://www.njcponline.com/text.asp?2015/18/1/110/146991
| Introduction|| |
Prostate cancer (PC) constitute a major public health issue , accounting for a greater percentage of the neoplastic lesion in men.  The incidence of PC is on the rise , necessitating the need to screen. Serum prostate specific antigen (PSA) has been widely adopted for screening, with the aim of detecting early disease. Following elevated PSA, a histological diagnosis is required in order to guide treatment. Over the years, different methods were adopted to biopsy the prostate for histology.
Initially, it was by digital guided prostate biopsy  which may be transperineal or transrectal. Later, this was replaced by ultrasound guided prostate biopsy. Recently, the extended approaches through either ultrasound guided transrectal or transperineal routes have been adopted. 
In most developing countries, patients tend to present late.  Most times, on presentation digital rectal examination (DRE) is already abnormal with elevated PSA. Unfortunately, in most centers in these resource poor settings, there is a paucity of transrectal ultrasound (TRUS) to guide prostate biopsy and urologists still rely on digital guidance for prostate biopsy. Though, this may be argued to occasionally miss the lesions, some studies have demonstrated no significant difference between TRUS guidance and digital guidance to direct systematic biopsies of the prostate, especially if there are obvious lesions on DREs. , They concluded that the value of routine TRUS in screening program in such situations is doubtful.
However, for patients with elevated PSA but have normal DRE findings, such individuals are usually referred to the few centers with TRUS so as to have their repeat biopsies if the digital guided biopsy is negative.
Transrectal prostate biopsy is the commonest procedure for PC detection. Transperineal prostate biopsy (TPbx) is rarely used.  Interestingly, only few institutions still perform transperineal prostate biopsy, , though a prospective study has proven its superiority over transrectal prostate biopsy in cancer detection.  There are different reasons in support of transrectal prostate biopsy against transrectal. These arguments bothered on rate of complications, comfort of the patient and tissue yield. Few studies  have compared transrectal, and transperineal prostate biopsies, and these were done mainly on Caucasians. As such there is a knowledge gap in African blacks on the best approach to prostate biopsy. This study aims to fill this gap by comparing rate of complications, tissue yield and procedure related pain of transperineal with transrectal biopsy.
| Materials and Methods|| |
This study was carried out by the urology division of Enugu State University Teaching Hospital, which is located in Enugu, Nigeria. A total of 100 patients who presented to the urology clinic was enrolled into this study between January and December 2011.
The sample size was calculated using a statistical formula shown below:
One hundred patients were randomly allocated to two groups. Once a patient met the indication for biopsy, he was assigned to a particular group based on a "lucky dip." The two groups (A and B) were wrapped differently in pieces of paper and placed in an envelop; each envelop has ten equal wraps of group A and B. The patient dips and picks, whatever group picked, the patient gets assigned to it. The selected wrap is replaced before another patient does his lucky dip. The Inclusion criteria were: Patients with PSA greater than 4 ng/ml or abnormal DRE findings. The exclusion criteria were: Patients who were uraemic or had uncontrolled hypertension or bleeding diathesis or patients on anticoagulants or antiplatelets medications.
A detailed history was taken from all participants to identify any predilection for bleeding or any history of being on anticoagulant medications (i.e. warfarin, or heparin) or antiplatelet drugs like aspirin. In the period of the study, no patient presented with ecchymosis that is commoner among hemophiliacs. All the patients had routine investigations which included full blood count, serum urea, and creatinine and clotting profile for all patients with a history of anticoagulant or antiplatelet medications.
Twenty-five patients were lost to follow up. Twenty patients never showed up on the 30 th day post operative, while five patients presented 3 months after biopsy on account of financial constraint. Seventy-five patients completed the study. The study was approved by Enugu State University Teaching Hospital Ethical committee. Informed consent was obtained from all patients recruited for the study.
These procedures were done by two urologists who have seven years urological experience. Prior to the biopsy the patients were educated on the use of visual analog scale (VAS) to ascertain their level of pain following biopsy.
The VAS is a psychometric response scale which in this study, respondents had to specify their level of agreement to a statement by indicating a position along a continuous line between two end-points (0 and 10). The zero end points signify no discomfort while the ten end points signify most-severe pains. There is evidence showing that VAS have superior metrical characteristics than discrete scales, thus a wider range of statistical methods can be applied to the measurements. 
The respondents were also educated on the possible symptoms that may arise as complications from the biopsy procedure.
| Procedure|| |
The position adopted for biopsy in this study was lithotomy. Intravenous (IV) ciprofoxacin 200 mg, IV metronidazole 400 mg.  and IV (pentazocine 30 mg) were given to patients in both groups (A and B). The perineum was cleaned and draped.
For transrectal prostate biopsy, 10 mls of 2% plain xylocaine was infiltrated in the periprostatic tissue at 3, 4, 8, 9 and 12 O'clock positions using size 21G hypodermic needle. With the aid of a spring loaded disposable 18G biopsy needle, eight core tissue were taken guided by a finger in the rectum. For the transperineal prostate biopsy, 15 ml of 2% plain xylocaine was infiltrated into the perineum adjacent to the prostate including the periprostatic tissue using a 21G hypodermic needle. With the aid of a spring loaded disposable 18G biopsy needle, eight core tissues were taken through the perineum, guided by a finger in the rectum.
Immediately after the biopsy, the patient quantifies his pains with the aid of the VAS. He is later discharged home on a 5 day course of oral ciprofloxacin 500 mg bd and tabs metronidazole 400 mg tds. The patient visits the clinic on the 7 th and 30 th day after the procedure where a validated purpose designed questionnaire is administered to measure complications associated with the procedure. Tissue yield is measured by histology report confirming adequacy of tissue and reporting a histological diagnosis; while any bleeding per rectum that occurred after the procedure or within a month after the procedure was considered as post procedure rectal bleeding or rectal bleeding during the procedure resulting in haemodynamic changes.
The data generated in the study was analyzed by STATA; Level of significance was set at a two-tailed P < 0.05. The data were tested for normality using Skewness and Kurtosis test; pnorm was used to test for normality of residuals. The VAS for both groups was tested by t-test for a significant difference in mean; while the remaining variables were tested for a significant difference using the odds ratio (OR).
| Results|| |
Sixty-five percent of the participants were farmers and uneducated, 13% of the participants who are civil servants were educated.
The mean age of the 75 patients recruited for the study was 64.01 ± 10.1 years. The mean VAS in the study is 7.178 ± 2.09. For TRbx, the mean VAS score was 5.9 ± 1.5; while the mean VAS score for TPbx was 8.02 ± 2.[Table 1] Subjecting these VAS scores to paired Student's t-test for a significant difference in mean, revealed a statistical significant difference between the two procedures (P < 0.0001;df: 75; t: 4.98; 95% confidence interval (CI) of difference in mean: −2.98−[−1.28])
Complications associated with prostatic biopsy are shown in [Table 2]. The risk of developing fever is not significantly different between the two groups, 13.6% for TPbx versus 13.3% for TRbx (OR: 1.38; 95%CI: 0.32-6.02; P = 0.66). The risk of rectal bleeding was higher for transrectal prostate biopsy compared to transperineal prostate biopsy (OR: 0.03; 95%CI: 0.001-0.45; P = 0.012). The "number needed to treat" for TPbx to avoid rectal bleeding is 4 (RR: 2.98; 95%CI: 2.0-4.31; P < 0.001). With respect to the rest of the complications considered, there was no statistically significant difference between TRbx and TPbx [Table 2].
| Discussion|| |
The mean VAS >5 for transrectal biopsy in this study is similar to the observations made by Damiano et al.  in their study on TRUS guided prostate biopsy. Apparently, TPbx appears more painful than TRbx in the study. This finding is different from the observation of Hara et al.  in their study, whereby they concluded there was no significant difference in perception of pains. A closer look at their study showed they used spinal anesthesia for TPbx unlike in our study where a local infiltration of the perineum with periprostatic block was adopted. This implies that local infiltration of the perineum with periprostatic anaesthesia will not achieve sufficient anesthesia for TPbx. As such, unlike transrectal biopsy, it may be necessary to embrace other forms of anesthesia like pudendal block, caudal block or spinal anesthesia in order to achieve good pain control. , This opinion is not supported by some studies that found periprostatic block effective as well in TPbx. , The adequacy of periprostatic anaesthesia for TRbx was demonstrated by Maccagnano et al.  in their study using 1 or 2% lidocaine (10 ml). They concluded that it was the most effective anesthetic technique for TRbx.
Additionally, most complications following prostate biopsy are minor and self-limiting.  However, the rates of complications varied between the two methods of prostate biopsy in this study. With respect to post-procedure pyrexia, its rate was higher for transperineal compared to transrectal. The OR of 1.38 implied an increased risk of fever in TPbx compared to TRbx. However, the observed difference lacked statistical significance as reflected in the P value and 95%CI, which has a value >1. The fever noted in the study were low grade in agreement with similar findings by Rietbergen et al.  The findings of 10.3% and 13.64% rates of fever following transrectal and TPbx is lower than the observed rate in the study done by Rosario et al. 
Moreover, urethral bleeding was more pronounced in TPbx than transrectal in this study though the difference lacked statistical significance. However, urethral bleeding is not usually associated with hemodynamic changes,  it could be a source of concern to patients and their relatives.
Furthermore, there was no case of rectal bleeding following TPbx in this study compared to TRbx in which 27.59% had rectal bleeding. This observed difference was proven to be statistically significant buttressing the fact that there is increased the risk of rectal bleeding via the transrectal route. This observation may be useful to the urologist when evaluating patients who have poorly controlled hypertension or obstructive nephropathy. Such patients usually have a higher risk of rectal bleeding and may benefit from TPbx. Rosario et al.  in their study noted that 36.8% of patients had rectal bleeding following prostate biopsy. This value exceeded that of TRbx in this study. Occasionally rectal bleeding could be massive necessitating blood transfusion and sometimes embolization.  In our series we experienced no case of massive rectal bleeding, which required blood transfusion. 
Surprisingly, there were no observed cases of hemospermia for both TRbx and TPbx. Though, in the literature, it is acknowledged that it is rare.  Our study participants are elderly and generally less sexually active which may account for the absence of any observed case of hemospermia. In addition, the caliber of the needle used (18G) may be contributory. Though, this has been refuted by Cicione et al.  who compared the outcomes of a 16G and 18G biopsy needle and found out no significant difference in outcome.
Generally, most studies that compared TRbx and TPbx concluded there was no significant difference in complication rates. ,, A systematic review by Shen et al.  also, revealed there was no significant difference in cancer detection between TRbx and TPbx irrespective of DRE findings or PSA level prior to biopsy. With respect to complications, there was no significant difference in the incidence of major or minor complications between the two groups. A limitation of this review is that a few randomized controlled studies were considered.
This result should be reproducible in ultrasound guided biopsies considering that some studies have shown no significant difference in outcomes between digital guided and ultrasound guided biopsies. ,,
This study is limited by its inability to make provisions for the losses to follow up; however, its findings should stimulate an elaborate multi centered randomized clinical trial to evaluate the differences in both procedures considering that there are very few published randomized studies available in the literature.
| Conclusion|| |
Transperineal prostate biopsy is more painful than transrectal prostate biopsy though with a significantly reduced risk of rectal bleeding. There appears to be no significant difference with respect to risk of fever, urethral bleeding, hematospermia, prostatic abscess and acute retention. Both routes provide sufficient prostate tissue for histology.
| References|| |
Centers for Disease Control and prevention. United States Cancer Statistics United States of America: Centers for Disease Control and prevention; 2013. Available from: http://www.cdc.gov/uscs. [Last cited on 2014 Feb 19].
Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin 2010;60:277-300.
Jemal A, Siegel R, Ward E, Murray T, Xu J, Smigal C, et al.
Cancer statistics, 2006. CA Cancer J Clin 2006;56:106-30.
Eke N, Sapira M. Prostate cancer in Portharcourt, Nigeria; features and outcomes. Niger J Surg Res 2002;4:34-44.
Ezenwa E, Tijani K, Jeje A, ogunjimi A, Ojewola R. Prevalence of prostate cancer among Nigerians with intermediate total prostate specific antigen levels (4-10ng/Ml): Experience At Lagos University Teaching Hospital, Nigeria. Internet J Urol 2012;9:3.
Wangensteen OH, Sarah D. The Rise of Surgery: From Empire Craft to Scientific Discipline. U.S.A: Dawson Publishing; 1978.
Kawakami S, Yamamoto S, Numao N, Ishikawa Y, Kihara K, Fukui I. Direct comparison between transrectal and transperineal extended prostate biopsy for the detection of cancer. Int J Urol 2007;14:719-24.
Bennett CL, Ferreira MR, Davis TC, Kaplan J, Weinberger M, Kuzel T, et al.
Relation between literacy, race, and stage of presentation among low-income patients with prostate cancer. J Clin Oncol 1998;16:3101-4.
Figueiredo AJ, Seeni K, Anson KM, Furtado AJ, Miller RA. Are transrectal ultrasonically guided biopsies required for the accurate diagnosis of carcinoma of the prostate? Can digitally guided systematic biopsies offer an acceptable alternative? Br J Urol 1995;76:187-91.
Waisman J, Adolfsson J, Löwhagen T, Skoog L. Comparison of transrectal prostate digital aspiration and ultrasound-guided core biopsies in 99 men. Urology 1991;37:301-7.
Shandera KC, Thibault GP, Deshon GE Jr. Variability in patient preparation for prostate biopsy among American urologists. Urology 1998;52:644-6.
Vis AN, Boerma MO, Ciatto S, Hoedemaeker RF, Schröder FH, van der Kwast TH. Detection of prostate cancer: A comparative study of the diagnostic efficacy of sextant transrectal versus sextant transperineal biopsy. Urology 2000;56:617-21.
Kang SG, Tae BS, Min SH, Ko YH, Kang SH, Lee JG, et al.
Efficacy and cost analysis of transrectal ultrasound-guided prostate biopsy under monitored anesthesia. Asian J Androl 2011;13:724-7.
Emiliozzi P, Longhi S, Scarpone P, Pansadoro A, DePaula F, Pansadoro V. The value of a single biopsy with 12 transperineal cores for detecting prostate cancer in patients with elevated prostate specific antigen. J Urol 2001;166:845-50.
Shen PF, Zhu YC, Wei WR, Li YZ, Yang J, Li YT, et al.
The results of transperineal versus transrectal prostate biopsy: A systematic review and meta-analysis. Asian J Androl 2012;14:310-5.
Araoye OM. Research Methodology with Statistics for Health and Social Sciences. Illorin: Nathadex Publishers; 2003. p. 400.
Reips UD, Funke F. Interval-level measurement with visual analogue scales in Internet-based research: VAS Generator. Behav Res Methods 2008;40:699-704.
Clemens JQ, Goldman HB, Bertsch LL, Stinchcomb CP, Aquino K, Hitt E, e
. AUA/SUNA White Paper on the Incidence, Prevention and Treatment; 2012.
Damiano R, Oliva A, Cantiello F, Esposito C, Perdonà S, De Sio M, et al.
Questionnaire based evaluation of prostate biopsy complication comparing different bioptic schemes. Arch Ital Urol Androl 2003;75:40-5.
Hara R, Jo Y, Fujii T, Kondo N, Yokoyoma T, Miyaji Y, et al.
Optimal approach for prostate cancer detection as initial biopsy: Prospective randomized study comparing transperineal versus transrectal systematic 12-core biopsy. Urology 2008;71:191-5.
Iremashvili VV, Chepurov AK, Kobaladze KM, Gamidov SI. Periprostatic local anesthesia with pudendal block for transperineal ultrasound-guided prostate biopsy: A randomized trial. Urology 2010;75:1023-7.
Kubo Y, Kawakami S, Numao N, Takazawa R, Fujii Y, Masuda H, et al.
Simple and effective local anesthesia for transperineal extended prostate biopsy: Application to three-dimensional 26-core biopsy. Int J Urol 2009;16:420-3.
Maccagnano C, Scattoni V, Roscigno M, Raber M, Angiolilli D, Montorsi F, et al.
Anaesthesia in transrectal prostate biopsy: Which is the most effective technique? Urol Int 2011;87:1-13.
Berger AP, Gozzi C, Steiner H, Frauscher F, Varkarakis J, Rogatsch H, et al.
Complication rate of transrectal ultrasound guided prostate biopsy: A comparison among 3 protocols with 6, 10 and 15 cores. J Urol 2004;171:1478-80.
Rietbergen JB, Kruger AE, Kranse R, Schröder FH. Complications of transrectal ultrasound-guided systematic sextant biopsies of the prostate: Evaluation of complication rates and risk factors within a population-based screening program. Urology 1997;49:875-80.
Rosario DJ, Lane JA, Metcalfe C, Donovan JL, Doble A, Goodwin L, et al.
Short term outcomes of prostate biopsy in men tested for cancer by prostate specific antigen: Prospective evaluation within ProtecT study. BMJ 2012;344:d7894.
Loeb S, Vellekoop A, Ahmed HU, Catto J, Emberton M, Nam R, et al.
Systematic review of complications of prostate biopsy. Eur Urol 2013;64:876-92.
Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: Etiology, therapy, and outcomes. Gastrointest Endosc 1999;49:228-38.
Khan SA, Hu KN, Marder C, Smith NL. Hemorrhoidal bleeding following transrectal prostatic biopsy. Etiology and management. Dis Colon Rectum 1982;25:817-9.
Cicione A, Cantiello F, De Nunzio C, Tubaro A, Damiano R. Prostate biopsy quality is independent of needle size: A randomized single-center prospective study. Urol Int 2012;89:57-60.
Miano R, De Nunzio C, Kim FJ, Rocco B, Gontero P, Vicentini C, et al.
Transperineal versus transrectal prostate biopsy for predicting the final laterality of prostate cancer: Are they reliable enough to select patients for focal therapy? Results from a multicenter international study. Int Braz J Urol 2014;40:16-22.
Garcia G, Chevallier D, Amiel J, Toubol J, Michiels JF. Prospective study comparing ultrasonography guided trans-rectal biopsy and finger guided trans-perineal biopsy in the diagnosis of prostatic cancer. Prog Urol 2001;11:40-3.
[Table 1], [Table 2]