Cutting Edge Urology

T his PDF belongs to matthew.hooson@springer.co INTERVENTIONAL ULTRASOUND: TRANSPERINEAL AND TRANSRECTAL PROSTATIC BIOPSY • 23  route allows for easier access to the anterior zone of the gland, where incidence of PCa is from 10 to 20% at repeat biopsy [32–36]. Transperineal template-guided biopsy, utilizing 30–60 cores, is suggested for men with previously negative biopsies and persistent suspicious of cancer, in local PCa staging and in the re-evaluation of patients enrolled in active surveillance (AS) protocols [37–40]. Despite ultrasound sensitivity improvement through combined use of color power Doppler (CDU) and a contrast medium agent [41–43] or elasto-sonography [44], the accuracy of trans- perineal and transrectal approach in the diagnosis of PCa performing targeted biopsies has not improved. On the contrary, combined use of multiparametric MRI (magnetic resonance imaging) and MRI/TRUS transperineal fusion targeted biopsy has high accuracy in detecting significant PCa [44–51]. In fact, multiparametric MRI/TRUS targeted biopsy produces a higher detection rate of PCa for each single core compared to extended biopsy schemes (15–20% vs. 5–10%) [50, 51] (Video 26.7) (Figs. 8, 9, 10, and 11); multiparametric MRI/TRUS transperineal targeted biopsy improves diagnosis of significant PCa most notably in AS protocols [44, 48–52]. Prostate biopsy is the gold standard in re-evaluation of men enrolled in AS protocols, and the highest percentage of patients being reclassified at confirmatory prostate biopsy repeat biopsy (25–30%of the cases) [48] following unfavourable histology results (i.e., Gleason score >6, number of positive c ores >2, greatest perce ntage of cancer “GPC” >50%). Despite the fact that both the appropriate n umber of biopsy co res (extended vs. saturation vs. template-guided schemes) and the approach (transr ectal vs. tra nsperineal) [43–55] have not been established, transperineal biopsy seems more accurat e in t he identification of patients at risk of PCa in AS protocols [48], resulting in a lower incidence of adverse definitive histology specimens compared to transrectal approach [53– 56]. Multiparametric MRI/TRUS fusion targeted biopsy has improved staging in AS giving 10% reassignment [57] in patients undergoing standard biopsy [58, 59]; moreover, MRI/TRUS fusion transperineal targeted biopsy has good accuracy in the diagnosis of anterior PCa [59–63] and in the re-evaluation of micro-focal cancer (a single positive core of Gleason score equal to 6 Fig. 6: Transperineal prostate biopsy (longitudinal scan): the needle (18 gauge tru-cut) is used to perform the biopsy in the periphery of the gland. Fig. 7: Transperineal prostate biopsy (longitudinal scan): the needle (18 gauge tru-cut) is used to perform the biopsy in the anterior zone of the gland. Cutting EDGE_Urology(SUN)_final.indd 23 27-Mar-18 10:00:29 AM