• transperineal biopsy;
  • prostate cancer;
  • biopsy;
  • staging;
  • complications;
  • active surveillance


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Conflict of Interest
  8. References


  • To describe a protocol for transperineal sector biopsies (TPSB) of the prostate and present the clinical experience of this technique in a UK population.

Patients and Methods

  • A retrospective review of a single-centre experience of TPSB approach was undertaken that preferentially, but not exclusively, targeted the peripheral zone of the prostate with 24–38 cores using a ‘sector plan’. Procedures were carried out under general anaesthetic in most patients.
  • Between January 2007 and August 2011, 634 consecutive patients underwent TPSB for the following indications: prior negative transrectal biopsy (TRB; 174 men); primary biopsy in men at risk of sepsis (153); further evaluation after low-risk disease diagnosed based on a 12-core TRB (307).


  • Prostate cancer was found in 36% of men after a negative TRB; 17% of these had disease solely in anterior sectors.
  • As a primary diagnostic strategy, prostate cancer was diagnosed in 54% of men (median PSA level was 7.4 ng/mL).
  • Of men with Gleason 3+3 disease on TRB, 29% were upgraded and went on to have radical treatment.
  • Postoperative urinary retention occurred in 11 (1.7%) men, two secondary to clots. Per-urethral bleeding requiring hospital stay occurred in two men. There were no cases of urosepsis.


  • TPSB of the prostate has a role in defining disease previously missed or under-diagnosed by TRB. The procedure has low morbidity.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Conflict of Interest
  8. References

The usual clinical pathway for diagnosis of localised prostate cancer relies on transrectal biopsy (TRB). A standard 10–12-core TRB may inadequately sample the prostate particularly at the apex and anteriorly leading to an underestimation of the volume, grade and risk stratification of cancer .

Increased interest in active surveillance (AS) and focal treatments for localised prostate cancer require accurate disease characterisation. The poor reproducibility of TRB pathology and the potential significant morbidity of patients undergoing TRB, particularly sepsis related hospital admission in up to 4% of patients , has led to the development of transperineal biopsy approaches . The clinicopathological results have shown close correlation with radical prostatectomy specimens .

Traditionally, transperineal sector prostate biopsies have followed a template-mapping protocol , or a local modification , with ≈1 core taken per millilitre of gland evaluated, using a brachytherapy grid as the template. A minimum of 40 cores is taken but often between 60 and 90 and sometimes more in very large glands.

The present study describes the use of a transperineal sector biopsy (TPSB) technique, which preferentially targets the peripheral zone by anatomical sectors: anterior, mid, posterior and basal. TPSB minimise sampling of the transition zone and between 24 and 38 cores are taken.

Patients and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Conflict of Interest
  8. References

A retrospective study was undertaken using a prospectively collected database. This report concerns 634 consecutive men who underwent TPSB between January 2007 and August 2011 at our institution for the following indications:

  • Persistent suspicion of prostate cancer despite negative 12-core TRB (174 men).
  • Suspicion of prostate cancer in men without a prior biopsy who were considered to be at high risk of septic complications from TRB (153 men). Reasons included immunosuppression, recent history of travel to South-East Asia and use of quinolone antibiotics within the preceding year.
  • Men considered suitable for AS (307 men) based on a 12-core TRUS-guided TRB, i.e. life expectancy of >10 years, PSA level of <15 ng/mL, Gleason score of 3+3 and clinical stage of ≤T2a. These men had TPSB ≤6 months of the initial TRB to confirm or refute their suitability for AS.
  • Men with symptomatic LUTS and chronic retention of urine were offered simultaneous TURP and were excluded from this analysis.

TPSB Technique

TPSB was conducted as day case procedures under general anaesthesia in most patients, and local anaesthesia in a few selected cases. Amikacin (500 mg, i.v.) was given at induction and oral ciprofloxacin (500 mg) twice daily for 3 days. A catheter was not used. Patients already taking an α-blocker continued their usual medication, but otherwise no further prescriptions were made.

Our intention was to treat all patients as day cases. However, because the unit is a tertiary centre some men travelled long distances and therefore required admission for transport the next day.

Other than in very specialised cases, there was no prior institutional experience of transperineal biopsy, although the practitioners were well-versed with TRB and transperineal prostate brachytherapy.

The extended dorso-lithotomy position was used to minimise pubic arch interference. A biplanar transrectal ultrasound 8848 brachytherapy probe (BK Medical, Herlev, Denmark) covered with a water-filled brachytherapy balloon (CIVCO, Iowa, USA) was introduced into the rectum attached to a stepping unit with a disposable grid (CIVCO) abutting the perineum.

Transrectal ultrasound images of the prostate were evaluated initially in the transverse view and the widest prostate image determined and centralised on the middle vertical column ‘D’ on the standard brachytherapy grid.

The peripheral zone was targeted preferentially and divided into anterior, mid and posterior sectors on each side with the latter two representing the peripheral zone posterior to the prostatic urethra, the verumontanum and the bladder neck. Biopsies through these sectors also sampled the central zone at the base on either side of the midline (Figs 1,2).


Figure 1. TPSB of the anterior mid and posterior sectors, preferentially targeting the peripheral zones (A) and basal sector, corresponding to McNeal's central zone (B).

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Figure 2. Mid and posterior cores are sub urethral as are basal sector biopsies.

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The prostate volume was estimated by ellipsoid assumption (volume = width × height × length × π/6). If glands were <30 mL then 24 cores were sampled in total: four from each anterior, mid and posterior sectors. In glands >30 mL, additional basal biopsies were taken via the mid and posterior sectors avoiding sampling of the transition zone. In glands >50 mL, five cores were taken per sector with eight basal biopsies in addition, yielding a maximum of 38 cores (Tables 1,2).

Table 1. Patient demographics and pathological outcomes
IndicationsnMedian (range)Patients with positive TPSB (detection rate), n (%)Disease ≥3+4, nMedian (range) prostate volume, mLPatients with anterior disease, n/NPatients including mid-gland disease, n/NPatients including posterior disease, n/NPatients including basal disease, n/N
Age, yearsPSA level, ng/mLPSA density, ng/mL/cm3
Previous negative TRB17463 (42–80)9.2 (2.5–54)0.17 (0.04–0.85)63 (36)3743 (18–108)26/6325/6326/639/63
Primary TPSB15362 (38–81)7.2 (0.7–23).0.16 (0.02–1.03)83 (54)4544 (17–150)29/8327/8329/838/83
Further evaluation30764 (43–81)6.6 (0.99–30.4)0.14 (0.02–2.0)

245 (80)

[90 (29) upgraded]

9345 (13–150)193/245108/245138/24543/245
Table 2. Positive sectors for size of prostate
Prostate volume, mLA% (n)M% (n)P% (n)A + M% (n) M + P% (n)A + P% (n)A + M + P% (n) Including base% (n)
  1. A, anterior sector; M, nid-zone sector; P, posterior sector.

<405.5 (35)3 (19)3.62 (23)3.62 (23)2.21 (14)2.21 (14)12.61 (80)1.89 (12)
40–807.41 (47)3 (19)12.77 (81)8.2 (52)6.15 (39)2.68 (17)12.3 (78)7.41 (47)
>801.1 (7)1.42 (9)1.42 (9)0.31 (2)0.16 (1)0.16 (1)0.31 (2)0.47 (3)

Biopsies were taken using an 18-G needle, 20 cm with 22 mm depth coaxial needle (Bard Max-Core, Bard, Murray Hill, NJ, USA), which was inserted through the grid and guided by real-time sagittal ultrasound images.

Originally sector cores were shaken in to six to eight formalin filled vials, with one vial used per sector. The use of vials resulted in significant fragmentation with difficulty extracting the cores, which were placed on the slide in a disorganised fashion. Since 2010, the cores were placed onto a sponge, loaded into a cassette, with one sponge used per sector. The sponge is pre-cut on one corner to indicate the side being biopsied and aid orientation of the cores within the sector. The use of the sponge stabilised the cores, minimised fragmentation and helped maintain the orientation of the cores during laboratory processing.

Maintaining this orientation in each sector allowed the pathologist to report on the sector involved, the Gleason score of individual cores, the core length, the cancer length (in mm) and percentage of the core involved.

All patients were reviewed 2 weeks after biopsy and complications that required hospital admission or the passage of a urinary catheter were confirmed to capture data on patients who may have been managed outside of our institution.

Data Analysis and Presentation

Data were analysed from a prospective database. These included: patient age and date of birth, PSA level, biopsy indication, prostate volume and histopathological data on TPSB, any preceding prostate biopsies and complications.

The local institutional governance committee approved the use of TPSB in the unit and approved this study as an audit.

Data are presented as mean averages with standard deviation (parametric) or median with range (non-parametric).


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Conflict of Interest
  8. References

The population characteristics and pathological outcomes are summarised in Table 1. Table 2 summarises positive sectors for size of prostate.

Of the men with prior negative TRB, a third of patients had had two or more sets [median (range) 2, 1–5]. Of the 63 men (36%) who had positive findings from TPSB, anterior disease was present in 26 (41%), with 11 (17%) in the anterior sector alone. In all, 37 (21%) of these men were diagnosed with Gleason ≥3+4 cancer.

The breakdown of positive TPSB results classified by the number of previous negative TRBs is given in Table 3. There was no significant relationship between number of previous negative TRBs and the chances of positive TPSB (P = 0.36, chi-squared test).

Table 3. Diagnosis of prostate cancer made on TPSB categorised by number of previous negative TRBs
 No. of sets of prior negative TRBsTotal
Positive histology on TPSB, n/N (%)36/106 (34)17/51 (33)8/13 (62)1/21/263/174 (36)

In patients biopsied as a primary strategy, cancer was detected overall in 54% and in the anterior sector alone in 9.6% of positive biopsies. Gleason ≥3+4 was detected in 45 patients (29% of patients biopsied).

In the 307 patients with Gleason 3+3 being re-evaluated after positive TRBs to re-assess suitability for AS, 90 (29%) were upgraded from Gleason 3+3 disease: 72 (23%) to Gleason 3+4, and 18 (6%) to Gleason ≥4+3.

There were no cases of urosepsis. In all, 11 patients (1.7%) had acute urinary retention after TPSB, two of these were associated with clot haematuria and in addition one of these men had epididymo-orchitis. Four men subsequently passed a voiding trial without catheter; seven went on to have bladder outflow surgery. In addition, two men were readmitted to hospital with haematuria that settled with conservative measures. In total, nine patients required hospital admission for the management of complications.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Conflict of Interest
  8. References

The present analysis has shown the role of TPSB in the identification of significant disease after under diagnosis at TRB. Significant disease is found anteriorly beyond the scope of divergent transrectal approaches. The procedure is associated with low morbidity and the sector-guided approach limits the histopathological demands associated with more extensive mapping regimes.

The initial purpose of TPSB in our centre was to identify anterior disease in patients with previous negative TRBs and to better evaluate patients being considered for AS. Although the extended transperineal mapping protocol had been described and was well established , there were practical limitations in the authors' view, because of the high intraoperative and pathological resource requirements: other groups have reported transperineal-mapping techniques that routinely submit 60–90 cores and up to 120 in larger glands . In addition, extended protocols involve significant sampling of the transition zone potentially adding to morbidity .

The senior author adopted the protocol described by Bott et al. in 2006 with some modifications. The first was the introduction of anatomical sectors anterior, mid and posterior that follow the anatomical distribution of the peripheral zone rather than simply dividing the prostate into thirds. Secondly, separate basal sector biopsies are sampled in glands >30 mL rather than using proximal and distal biopsies. Thirdly, the total number of cores is limited to a maximum of 38 (Figs 1,2). The limitations of the TPSB approach are that it may not be a comprehensive assessment of the prostate (in comparison with more extensive mapping protocols) and still requires increased resources (in comparison with transrectal local anaesthetic approaches). Any biopsy strategy must strike a balance between sampling and resource: the TPSB technique appears to provide comparable pathological outcomes to other transperineal strategies, whilst offering a pragmatic approach with reduced pathological processing requirements . It is not intended to provide mapping data for focal treatment; however, information may be used to plan targeted treatment, e.g. dose optimisation and preferential loading of brachytherapy or wide margins in subsequent prostatectomy .

The present study does not make any direct comparison with alternative biopsy strategies. However, the cohort that underwent TPSB after negative TRB clearly shows the limitations of the latter technique. Whilst there is a risk of over diagnosis by more extensive sampling from TPSB, we did find significant disease in these patients misdiagnosed by TRB. It is the authors' view that over-diagnosis is not so much an issue as over-treatment or under treatment. Better evaluation of ‘low-risk’ disease should allow better selection of patients in whom more radical treatment options could be avoided whilst avoiding the under-diagnosis of patients most likely to benefit.

The present study was not designed or powered to assess the relationship between the number of previous negative TRBs and the chance of positive histology on TPSB. However, the lack of relationship given these limitations is not altogether surprising, as the transperineal approach allows access to parts of the prostate not previously sampled.

Furthermore, TPSB lends itself to the targeting of lesions noted on MRI. Evidence is accumulating to suggest that with improved MRI techniques, identification and biopsy of significant tumours may be undertaken whilst avoiding insignificant ones .

TPSB is more expensive than TRB, as it requires the use of a general anaesthetic. Whilst local anaesthetic may be used, we found that patients generally found this uncomfortable. The population undergoing prostate evaluation for localised disease is in general healthy and at low anaesthetic risk. In this series there were no anaesthetic complications.

There have been anecdotal concerns about an association between transperineal prostate biopsy and scarring at the apex. Analysis of robot-assisted laparoscopic radical prostatectomy specimens after transperineal biopsy has shown evidence of previous sampling in the form of iron-laden macrophages and pockets of inflammation. With longer duration between biopsy and surgery, some fibrosis would be inevitable; however, we have not experienced any specific increased anastomotic complications or increased positive apical margins .

From a safety perspective, the lack of urosepsis in this relatively large series that included an at-risk population makes TPSB an attractive alternative to TRB. This is consistent with other series and is related to the ability to clean and prepare the operative field .

Compared with other series, the urinary retention rate in the present series was very low at 1.7% . There are two probable reasons for this. Firstly, because anatomically the biopsies avoided the urethra and periurethral transition zone reducing gland oedema; and secondly being, patients at risk of acute retention with symptomatic LUTS and chronic retention (including patients with indwelling catheters) were offered TURP at the same time. During the time frame of the study, there were 61 such patients: these were not included in the analysis.

AS is considered to be a management option in low- to intermediate-risk prostate cancer by National Institute for Health and Clinical Excellence (NICE) ; however, our experience of TPSB suggests there is a danger in using TRB to select patients as candidates for AS studies. The under-sampling inherent in TRB results in progression rates of 30%, with less than satisfactory outcomes in those undergoing subsequent treatment . Similar to the findings of Ayres et al. , almost a third of the present patients considered low risk on TRB had significant disease on TPSB, often anteriorly. As the TPSB was undertaken generally within 3–6 months of TRB, this suggests under-diagnosis at initial TRB rather than progression of disease. Confirmatory identification of patients with low-risk disease after TPSB should allow for AS with a higher degree of confidence. The vast majority of men in the present series shown to have low-grade low-volume disease were subsequently managed by AS. Whether the progression rates and long-term outcomes of AS are altered as a result of TPSB is a research priority.

In summary, TPSB offers a biopsy strategy with low morbidity and limited resource requirements, with the ability to identify significant disease that is missed by 12-core TRB.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Conflict of Interest
  8. References
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transperineal sector biopsy


transrectal biopsy