MRI/US Fusion Guided Prostate Biopsy under Local Anesthesia: Transperineal approach

Abstract

Introduction: Prostate cancer is the most common non-cutaneous cancer and the second most common cause of death from malignancy among men 1. A prostate biopsy is the gold standard for cancer diagnosis in this gland. However, the standard ultrasound transrectal method used for men with elevated PSA, an abnormal digital rectal examination may initiate a potential cascade of harm starting with sepsis (about 1 every 20) and highlighted with overdiagnosis and overtreatment.2 Prostate multiparametric MRI and MRI/US target fusion prostate biopsies have come as tools to decreased overdiagnosis as well as adverse effects associated with prostate biopsies.3-5 Sampling MRI targets with real-time Ultrasound by using a fusion software can achieve better results for urologists.5 Furthermore, this procedure is quite accurate through a Transperineal approach,3 avoiding rectal wall penetration with a consequent near-zero risk of infection.2,3 These advances in MRI, fusion imaging along with the US Task Force screening recommendations propelled a challenge in the paradigm to do better.6 Such events leads us to focus on Transperineal MRI/US Fusion biopsies. In 2014, we developed a local perineal block that allowed for in-office execution without general anesthesia.7 In this video, we present our technique. Methods: This video shows the MRI/US Transperineal fusion guided prostate biopsy (MRUS_TPBx) procedure on a 72-year-old male with a medical history of an elevated prostate-specific antigen. A Multiparametric MRI showed suggestive images of malignant prostate lesions at the peripheral zones. The Dicom MRI images were obtained and loaded into the MRI/US fusion software, the biopsy plan was designed using all MRI sequences. The perineal approach was taken under local anesthetic superficial block of the region. Then, the neurovascular bundles block under ultrasound guidance was executed. MRI and Ultrasound images were matched in both transverse and sagittal planes by MRI/US fusion software. Biopsy sampling was performed following the needle targets and coordinates indicated by the fusion software along with zonal sampling of non-target areas. Results: The procedure time was 20 minutes. The pain level reported by the patient was 4 (Wong-Baker pain scale). There was no significant blood loss. There were neither short term nor long term complications. The patient recovered successfully after the procedure and was sent home. Pathology of the needle biopsy corresponding to the coordinate (E2.5) reported: Prostatic Adenocarcinoma, Gleason 4+3=7, Percentage of pattern 4=80% (Grade Group 3). Involving approximately 90% of the core. In 2018 we presented our experience on 626 patients with MRUS_TPBx. Notably, the most common adverse event requiring intervention was urinary retention seen in 21 (3%) of patients. Besides, 6 had UTIs, 4 patients had epidydimo-orchitis, and 2 required admission (one with thrombosed hemorrhoids and one with a UTI).8 As of July 2020, we have performed 1,699 MRUS_TPBx under local anesthesia in the office setting in three urological offices. The Median Pain score was between 3 (IQR 1,5), The Median procedure time was 20 minutes (IQR 16,22). No urosepsis event has been registered. We abandoned Transrectal Biopsies for good in 2017 (Fig1). Conclusions: MRUS_TPBx is a feasible, reliable, reproducible, and well-tolerated procedure. Moreover, it delivers a precise diagnostic tumor location, perspectives on management with limited adverse events. Furthermore, our approach is performed in the office setting avoiding regional or general anesthesia while limiting “HARM” effects such as sepsis classically associated with the diagnosis of prostate cancer.