Freehand Transperineal Biopsy

Freehand transperineal biopsy” seems to be the latest buzzword in the urology world, and for good reason. Compared to transrectal, transperineal is proven to be the cleaner and ultimately safer approach for prostate biopsies. The support for transperineal is growing, as mounting evidence continues to debunk previous misconceptions of tolerability, feasibility and accuracy. We won’t rehash all of the dirty details, as we’ve already covered the key differences between the two here and made a case for transperineal biopsies here. Basically, it boils down to three key points:

  1. Transperineal virtually eliminates the risk of sepsis and the need for prophylactics, which has major savings for both clinics and patients. How major? If all urologists in the United States switched to transperineal, the potential savings on admissions for post transrectal biopsy sepsis would amount to between $341,676,800 and $752,540,000, which saves about $173 to $382 for every transrectal biopsy performed. This estimate does not even include the savings of costly emergency visits for post biopsy rectal bleeding, urinary tract infections and prostatitis, which occurs in 2.5%, 5% and 7% of all cases, respectively.1 
  2. Transperineal is well tolerated by patients under local anesthesia, which means the procedure can be performed in-office (no general anesthesia or dedicated operating room necessary). Several studies report the average pain score of transperineal patients as slightly higher than transrectal, but not significantly different and all rated around 3/10 or less.1, 5 
  3. MRI-targeted fusion biopsies performed via the transperineal route may be more effective at detecting clinically significant cancer than transrectal, especially in the anterior regions. Recent evidence shows MRI-US fusion transperineal biopsies yielded 50%-60% more clinically significant cancer than its transrectal counterpart. Detection was also 3.5 times more frequent in the anterior region.1

So… What’s the Deal With Freehand?

Transperineal and freehand are kind of like Sting and Shaggy; an unlikely duo of 2 icons from different genres that work surprisingly well together. No longer reduced to template biopsy and TRUS, together, they upstage their respective greatest hits. Traditionally, transperineal biopsies have been performed using a stepper, stabilizer and brachytherapy grid. The holes on the grid dictate where the needle may go, but because the grid is fixed, it means the physician will puncture the perineum at multiple different sites, especially so with systematic sampling.2

Fig 1. Transperineal Biopsy with Brachytherapy Grid

Although the grid method allows for some sort of standardization, which may be easier for less experienced physicians, it may not be ideal for every case. Sometimes, the pelvic skeleton can shield parts of a large prostate. 

Fig 2. Pelvis Blocking Anterior Edges of Prostate

This prevents the physician from taking a straight shot at it. When the stars align for that lucky handful of patients, those parts of the prostate can only be sampled at an angle.3 This is where the freehand transperineal method really shines. It reduces the stepper/ stabilizer setup down to the good old steady hand, a needle guide and an access needle. Commonly associated with transrectal, the term freehand means the probe is held by the physician and for the most part, free to move in all directions.

Fig 3. Freehand Transperineal Biopsy

Here, it gives new meaning to transperineal- instead of puncturing the perineum several times at zero degrees, freehand accesses the prostate through a puncture point using an introducer or access needle positioned at (mostly) any angle. Once inserted through the needle guide, the probe directs the needle by pivoting around the puncture site.2 This allows for multiple biopsies to be taken while minimizing the number of punctures to the perineum. This fresh collaboration between two classics is something to talk about; there’s hardly any specialized hardware, experienced physicians are likely already familiar with freehand and it integrates into existing workflows. 

“Freehand” Transperineal Biopsies with the Fusion Bx

Fusion Bx System with Linear Needle Guide

Recent advances in needle guide technologies have popularized freehand by making it easier to pivot around the puncture holes. These are great for systematic biopsies, but are even better when used with a fusion system like the Fusion Bx for MRI-targeted biopsies. With a single puncture near the site of the lesion or region of interest (ROI), multiple cores can be taken. This allows a physician to sample the center of the ROI as well as the extremities to determine the exact extent of the ROI. All of this while keeping the introducer or access needle in the same spot. Transperineal biopsies performed with Focal Healthcare’s Fusion Bx system offers the same advantages as freehand, in addition to hands-free support, stability and repeatability. The key benefit to freehand is the ability to freely move the probe around a single pivot point. With 6 degrees of freedom, our robotic arm allows the operator to do just that. The counterbalance provides the added bonus of hands-free support by keeping the probe steady in any position. Yes, there’s a lot more specialized hardware, but it’s there for a reason- more accurate fusion means more accurate sampling. We’ve gone into detail on these specific topics, but here’s the gist of it:

  1. The arm eliminates the shaky hand factor by stabilizing the probe and maintaining consistent pressure on the prostate. This minimizes the likelihood of prostate deformation, which is key for accurate tracking.
  2. Because our fusion is software assisted, it levels the playing field by saving the operator the cognitive effort of guesstimating where regions of interest (obtained from an MRI) are on real time ultrasound.3 Using a combination of rigid and elastic registration not only standardizes the fusion technique, but also accounts for differences between MRI and US images.
  3. Encoders in the arm allow our system to spatially track the probe and maintain MRI-US coupling, even during patient movement. Since the probe (and needle path) location is consistently tracked, core locations can be recorded and resampled during active surveillance.

By eliminating as many sources of operator error and inconsistencies as possible, we believe our system is an accurate, efficient and accessible targeted biopsy solution. To see it in action, contact us at sales@focalhealthcare.com.

1 Hilton, L. (2021, March 19). Freehand transperineal prostate biopsy case series and review support widespread use. Urology Times.

2 Thomson, A., Li, M., Grummet, J., & Sengupta, S. (2020). Transperineal prostate biopsy: a review of technique. Translational Andrology and Urology, 9(6), 3009–3017. https://doi.org/10.21037/tau.2019.12.40

3 Martorana, E., Pirola, G. M., Aisa, M. C., Scialpi, P., Blasi, A. D., Saredi, G., D’Andrea, A., Signore, S., Grisanti, R., & Scialpi, M. (2019).Prostate MRI and transperineal TRUS/MRI fusion biopsy for prostate cancer detection: clinical practice updates. Turkish Journal of Urology, 45(4), 237–244. https://doi.org/10.5152/tud.2019.19106

4 Neale, A., Stroman, L., Kum, F., Jabarkhyl, D., Di Benedetto, A., Mehan, N., Rusere, J., Chandra, A., Challacombe, B., Cathcart, P., Dasgupta, P., Elhage, O., & Popert, R. (2020). Targeted and systematic cognitive freehand-guided transperineal biopsy: is there still a role for systematic biopsy?. BJU International, 126(2), 280–285. https://doi.org/10.1111/bju.15092

5 Birtch, N. (2021, January 13). A Case for Transperineal Biopsies. Focal Healthcare.

6 Hilton, L. (2020, October 21). Transperineal targeted prostate biopsy comparable to transrectal fusion-guided approach. Urology Times.