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Transperineal Prostate Biopsy Feasible in Outpatient Practice

Key findings

  • This study evaluated the feasibility and outcomes of incorporating transperineal prostate biopsy into the outpatient urologic clinic at Massachusetts General Hospital
  • Study subjects were the first 130 patients who underwent in-office transperineal biopsy (30% with MRI/ultrasound fusion) and 130 matched patients with targetable lesions on MRI who underwent in-office fusion transrectal biopsy
  • The overall complication rate was higher for transperineal than transrectal biopsy (6.1% vs. 0.8%, P=0.04); there were no infections in the transperineal group and one in the transrectal group
  • Antibiotic stewardship was possible with transperineal biopsy; antibiotic prophylaxis was prescribed in 48% of patients vs. 100% of those undergoing transrectal biopsy
  • Clinically significant prostate cancer (Gleason grade group ≥2) was detected in 25% of patients in the transperineal group and 36% in the transrectal group (P=0.08)

Complications after transrectal prostate biopsies increased over the last decade because rising rates of antibiotic-resistant bacteria led to greater morbidity and mortality from infections. Transperineal biopsy is a solution but until recently it had to be performed under general anesthesia in the operating room.

Douglas Middleton Dahl, MD, is a urologic surgeon in the Department of Urology, director of Robotic Surgery at Massachusetts General Hospital, and chief of the Division of Urologic Oncology at the Mass General Cancer Center, and colleagues have described the first 130 men who underwent transperineal biopsy under local anesthesia at Mass General. Their report on its feasibility appears in Urology.

Study Methods

The researchers compared two cohorts:

  1. The first 130 men who underwent in-office transperineal biopsy by five urologists between December 2018 and March 2020 using the PrecisionPoint Transperineal Access System for needle guidance
  2. 130 men with targetable lesions on multiparametric magnetic resonance imaging (MRI) who underwent in-office transrectal biopsy by five urologists between July 2014 and January 2018; they were matched to the transperineal biopsy cohort on age, prostate-specific antigen and presence of prostate cancer diagnosis prior to biopsy

All patients underwent systematic templated biopsies. Those who had lesions visible on MRI had software-assisted MRI/ultrasound fusion integrated into the procedure (100% in the transrectal group per selection criteria and 30% in the transperineal group after MRI was conducted mid-procedure).

Number of Cores

A median of 15 biopsy cores were taken in the transrectal group versus 20 in the transperineal group (P<0.001).

Antibiotic Prophylaxis

All patients (100%) in the transrectal group received antibiotic prophylaxis. Of them, 48% in the transperineal group received prophylaxis at the urologist's discretion given the patient's history, comorbidities and allergies.


Complications were recorded for eight patients in the transperineal group (6.1%) and one in the transrectal group (0.8%; P=0.04). The patient in the transrectal group developed an infection that required multiple rounds of oral antibiotics.

No infections occurred after the transperineal biopsy. The complications in that group were:

  • Clot retention requiring cystoscopy under general anesthesia (n=1)
  • Acute urinary retention requiring catheterization (n=2)
  • Syncope requiring evaluation in the emergency department (n=3)
  • Scrotal ecchymoses managed supportively (n=2)

Cancer Detection

A quarter of patients (25%) in the transperineal group were found to have clinically significant prostate cancer (Gleason grade group ≥2). The proportion was similar in the transrectal group, 36% (P=0.08).

A total of 48 patients had prostate cancer detected in the anterior zone on transperineal biopsy. Of the 39 who had MRI reports available, imaging identified lesions with Prostate Imaging-Reporting and Data System Score ≥3 in only eight (20%).

More to Discover

In-office transperineal biopsy is associated with a steep learning curve. Fortunately, the complications described have not carried through to mature experience at Mass General.

Important questions remain about transperineal biopsy under local anesthesia:

  • Should any antibiotic prophylaxis be used?
  • What is the optimal template and how can it be translated to the extensive body of experience with templates for transrectal biopsy?
  • How can the cost of disposables be recouped?

A randomized, controlled trial is needed to determine the efficacy of transperineal biopsy for cancer detection; this study was underpowered for that purpose.

rate of antibiotic prophylaxis with in-office transperineal prostate biopsy

infection rate with in-office transperineal prostate biopsy

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Refer a patient to the Department of Urology


Massachusetts General Hospital physicians have developed an office-based transperineal fusion prostate biopsy for accurate, safe prostate cancer diagnosis.


Douglas Middleton Dahl, MD, is chief of the Division of Urologic Oncology at Massachusetts General Hospital, as well as director of Robotic Surgery. In this video, he discusses his translational research on prostate cancer cells and explains how this work will advance patient care.