How many cores?
PCFA recommendation – take 21 – 24 cores in initial biopsies.
EAU guidelines – 10 – 12 core schemes optimal in most prostates, with > 12 cores “not being significantly more conclusive”
In a systematic non targeted transperineal biopsy I will generally take 18 – 24 cores depending on prostate size, in 6 different pots (PZ apex, PZ base, anterior/TZ bilaterally)
Transperineal or transrectal?
| Pros | Cons | |
| Transperineal | Very low infection/sepsis rates
Better sampling anterior zones
Minimise antibiotic use and resistance |
More expensive
Higher rates urinary retention
Done under GA mostly (LA emerging)
Takes longer
|
| Transrectal | Can be done under local or sedation
Fast
Less equipment required |
Higher infection / sepsis rates
Requires strong antibiotic use |
No difference in cancer detection rates between methods.
Worldwide shift towards transperineal biopsies, including in European guidelines.
Other points on biopsy
Bowel prep – evidence says no difference – I don’t use for transperineal
Antibiotics – I use cefazolin 2g on induction (TRUS – ciprofloxacin +/- betadine)
Risks – haematuria, haematospermia, urinary retention. Infection rare with TPBx.
Systematic vs targeted vs both
Ahdoot NEJM 2020
- 8.8 % ISUP 3+ cancers missed if just targeted biopsy vs combined
- Rates of upgrading at RP much lower with combined biopsy
- More ISUP 1 cancer found on systematic/combined biopsy
Indications for biopsy:
- PIRADs 3 + lesion on MRI
- If normal MRI but PSA > 3.0, recommend biopsy if PSA density > 0.15, or family history
- Abnormal DRE
- During active surveillance