Perineal versing Transrectal prostate biopsy

[mjl1717]

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For urologists. If you were to have prostate biopsy. (12 samples) Which procedure would you do?
Perineal or transrectal and why?

 

[DoctwoB]

Honestly wouldn’t care that much.

If the Uro is skilled at in office transperineal under local and wants to eat the cost of the template probe then I’m happy to get it.

If he does a trus with augmented PPX with a shot of rocephin and a swirl of the needle in formalin between passes then I’ll happily take the faster procedure with less pain and a 1% or less infection rate.

If he wants to do transperineal in the OR then I say no and find someone who will do one of the first two.

It comes down to TP is a lower infection risk but more pain/retention and possible OR use. TRUS is higher infection risk (though quite low with certain protocols) but less pain and no need for anesthesia. The push for everyone to switch to TP is highly overblown IMO and pushed by virtue signaling within academia

 

[mjl1717]

I appreciate that!

 

[cpants]

Agree that it is not worth going to the OR to avoid a 1% infection rate. Severe sepsis or long term sequelae from post-TRUS infection is extremely rare. We do rectal swabs for quinolone resistance pre-procedure and base ppx on the culture if resistance is found. At this point mainly using perineal biopsy for fusion biopsies on smaller anterior lesions and by patient request.

 

[DoctwoB]

It’s actually something that bugs me in how this question is framed. Many academics are speaking of TP as the new standard of care implying offering TRUS is negligent. As mentioned above, I think it’s a perfectly fine option, but of extremely limited benefit and potentially significant cost/discomfort when compared to TRUS with augmented prophylaxis.

 

[nymedstudent874]

I would opt for transperineal MRI/US fusion. Almost 0% risk of post-biopsy sepsis (although TR is ~3%), minimal side effects other than perineal pain and better sampling of the anterior prostate. Having done a few dozen TP and almost a hundred something TR in residency, it's hard to imagine going back to TR