In a Solomonic move, the American Urological Association (AUA) and the Society of Urologic Oncology (SUO) for the first time have taken a position on the type of biopsy men with prostate lesions should undergo, endorsing both transperineal and transrectal biopsy instead of choosing one over the other.
The new guidelines, issued at the American Urological Association 2023 Annual Meeting, in Chicago, contrast with 2021 recommendations from the European Association of Urologists (EAU), which regard the transperineal approach as superior and safer than the transrectal approach.
The new guidelines state: “Clinicians may use either a transrectal or transperineal biopsy route when performing a biopsy. (Conditional Recommendation; Evidence Level: Grade C).” Grade C is the lowest grade of acceptance the guideline committee could issue, according to Daniel Lin, MD, vice-chair of the AUA guideline panel.
“The AUA looked at all the higher-level data comparing the two procedures. There was a lack of that data,” Lin, chief of urologic oncology at the University of Washington, in Seattle, told Medscape Medical News. He said the literature consists mainly of systematic single-center reviews, rather than multicenter randomized trials.
But Hendrik Van Poppel, MD, policy chief for the EAU, said that in Europe, transrectal biopsies are now considered “medical malpractice.”
Philip Cornford, MD, associate professor of urology at the University of Liverpool, England, and chair of the prostate biopsy guidelines panel for the EAU, said the society in 2021 concluded that the transperineal approach is the preferred one.
The EAU stated that transperineal prostate biopsies should be performed “due to the lower risk of infectious complications.” EAU described the evidence as strong: A meta-analysis of seven studies that included 1330 patients showed that for patients undergoing transperineal biopsy, infectious complications were significantly reduced.
Cornford said in essence, EAU made its decision out of concern about infections, whereas AUA and SUO made based their decision on the ability of the methods to detect cancer.
Advocates for transperineal procedures cite several studies that show that the rate of infection, including sepsis, with such biopsies is virtually zero.
However, Lin said the committee said existing data on infection did not support this position. He also cited a “a fairly compelling” single-center randomized study with 750 patients that showed no difference in infection rates. The study was presented April 30 at the AUA meeting.
Agents of Death and Destruction?
Badar Mian, MD, professor of surgery at Albany Medical College, in New York, who led the study, told an AUA session that urology has been trapped in an “echo chamber” regarding the relative safety of biopsies.
Clinicians hear “loud proclamations, which get repeated and magnified, that there is a real zero risk of complications after transperineal biopsies as compared to the horrendous 5% to 10% or higher rate of transrectal biopsy complications and that you, with your transrectal biopsies, are the cause of death and destruction all around,” Mian said. “Well, if you step out of the echo chamber, what you’ll find is that the accurate complications amongst the two procedures are not that dramatically different, much less dramatic than what you’ve been told to believe.”
The campaign to end transrectal biopsies in Europe started in 2018 with the death of a Norwegian man who experienced an infection after the procedure. Truls Bjerklund Johansen, MD, who’d performed the biopsy on the patient and who worked with the man’s daughter to change national practice, persuaded EAU to look at the issue.
Advocates also say transperineal biopsies are better at detecting anterior and apical cancers.
“I would agree the data on cancer detection is less convincing, but that is not the basis of the EAU recommendation,” Cornford said.
Arvin George, MD, leads the transperineal biopsy program at the University of Michigan, in Ann Arbor, and directs the transperineal training program at the AUA’s annual meeting. He said his course was sold out early and included about 60 trainees.
George said the new guideline statement “is not an unequivocal endorsement for transperineal biopsy as the preferred approach for diagnostic sampling but rather an acknowledgment of this approach as an alternative option.”
He said that although the new position statement should increase awareness of the transperineal approach in the United States, “without a strong recommendation, the guideline statement is unlikely to spark a large switch to the transperineal biopsy but rather supports the continued slow and steady adoption.”
Matthew Allaway, DO, founder of Perineologic, developer of the PrecisionPoint Transperineal Access System, said industry figures show that about 10% of the 1.5 million prostate biopsies performed in the United States annually are performed transperineally, a doubling in 2 years.
Jeremy Grummet, MD, clinical professor of urology at Monash University, in Melbourne, Australia, and leader of the TREXIT (Transperineal Exit) movement to abandon transrectal procedures, said the AUA guidelines are biased toward “physician convenience.”
Lack of Training
AUA said another reason it did not endorse the transperineal approach was that currently, American urologists lack training and experience with transperineal procedures.
Grummet blamed major medical centers for any gap in the familiarity of clinicians with transperineal biopsies, which have been available for more than a decade.
“It is incumbent on the leaders of urology departments globally to ensure that their colleagues are trained in transperineal biopsy and have access to the appropriate equipment,” he told Medscape. “Lack of training didn’t seem to prevent the rapid uptake of robotic prostatectomy ― a far more complex procedure.”
The authors have disclosed no relevant financial relationships.
American Urological Association (AUA) 2023 Annual Meeting.
Howard Wolinsky is a Chicago-based medical writer, and an advocate for active surveillance. He is cofounder of Active SUrveillance Patients International. He has been on AS since 2010. He was a patient reviewer of the AUA guidelines. This was his second stint in that role, representing the AnCan Foundation. He is editor of the Substack newsletter, TheActiveSurveillor.com.
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