Transperineal Prostate Biopsy Research Articles

Erectile dysfunction (ED) is a concern for men undergoing prostate biopsy. With the increasing adoption of transperineal (TP) biopsy over transrectal (TR) biopsy, it remains unclear which approach carries a lower risk of erectile dysfunction. This study aims to be the first meta-analysis to evaluate erectile dysfunction following TR versus TP prostate biopsy at 1, 3 and 6months intervals, thereby providing clinicians with evidence-based guidance for patient counseling and shared decision-making. This review was prospectively registered on PROSPERO (CRD42024541557) and followed PRISMA guidelines, with searches conducted in PubMed, Scopus, and the Cochrane Library databases up to July 2024. A total of 22 studies reporting erectile function outcomes (IIEF scores) at baseline and 1, 3 and 6months post-biopsy were identified. After applying inclusion and exclusion criteria, 12 studies were included in the final meta-analysis. TR and TP biopsy methods were compared using a random-effects model to assess standardized mean differences (SMD) in erectile function at each follow-up point. The risk of bias for each study was evaluated to ensure result reliability. At 1month follow-up, a significant decline in erectile function was observed overall (SMD: - 0.3785, p = 0.038). The TP approach showed a slightly more significant decline than the TR approach; however, this difference was not statistically significant (p = 0.074). At 3months follow-up, no significant differences were observed between methods overall (SMD: - 0.1663, p = 0.132), although TP biopsy alone showed a modest yet considerable decline (SMD: - 0.1868, p = 0.03). At 6months, erectile function had generally returned to baseline, with no significant differences observed between biopsy techniques (p = 0.41). Both TR and TP prostate biopsies are associated with a transient decline in erectile function. These effects typically resolve by 6months in most patients, with no significant long-term impact observed. While the initial functional impact may be slightly greater with the TP technique, this difference attenuates over time. These findings are crucial for managing patient expectations post-biopsy.

Objective To evaluate the incremental diagnostic value of combining free prostate-specific antigen density (FPSAD) with Prostate Imaging Reporting and Data System version 2.1 (PI-RADS v2.1) for clinically significant prostate cancer (csPCa,defined as Gleason score≥3+4) in the diagnostic gray zone (tPSA 4–10 ng/mL).Methods: This retrospective study analyzed 137 patients (75 with csPCa and 62 with non-clinically significant prostate cancer (ncsPCa) who underwent transperineal prostate biopsy at Xiangtan Central Hospital between January 2022 and January 2024. PI-RADS v2.1 scores were assigned based on magnetic resonance (MR) imaging, and prostate volume (PV) and FPSAD were calculated. Statistical analyses included chi-square/Fisher’s exact tests for categorical variables and independent t-tests for continuous variables. Logistic regression identified independent predictors of csPCa, and a nomogram model was developed. Model performance was evaluated using calibration curves and receiver operating characteristic (ROC) analysis.Results Significant differences were observed in FPSAD, PI-RADS v2.1 scores, and free PSA (fPSA) between the csPCa and ncsPCa groups (P < 0.01). FPSAD (OR = 1.95, 95% CI: 1.22–2.22, P < 0.01) and PI-RADS v2.1 scores (OR = 2.41, 95% CI: 1.57–3.70, P < 0.01) were independent predictors of csPCa. The combined FPSAD and PI-RADS v2.1 model demonstrated superior diagnostic performance (AUC =0.829) compared to FPSAD alone (AUC = 0.69) or PI-RADS v2.1 alone (AUC = 0.773) (P < 0.01), with 91% sensitivity and 32% fewer unnecessary biopsies than PI-RADS≥3 criteria. In PI-RADS 3 subgroup (n=41), FPSAD correctly reclassified 13/18 (72.2%) indeterminate cases.Conclusion For Asian men with tPSA 4–10 ng/mL, the FPSAD+PI-RADS algorithm (cutoffs: >0.017 and ≥4) provides 15–20% higher accuracy than either marker alone, while reducing biopsies by 25%. This approach is particularly valuable for PI-RADS 3 cases, where it resolved >65% of diagnostic uncertainties in our cohort.

Multiparametric magnetic resonance imaging (MRI) is the most widely used approach for prostate MRI. While biparametric MRI (BP-MRI) involves shorter acquisition time and decreased cost, its diagnostic accuracy compared to multiparametric MRI (MP-MRI) is not well known. We aim to compare the detection of clinically significant prostate cancer with BP-MRI and MP-MRI prior to biopsy. We retrospectively analyzed men who underwent BP-MRI or MP-MRI between January 2019 and December 2022, interpreted by a single expert radiologist. All patients underwent systematic and targeted transperineal prostate biopsy. Diagnostic performance was compared using Receiver operating characteristic curves, test performance parameters, and assessed net benefit with decision curve analysis, using biopsy with Grade Group ≥ 2 disease as the reference standard. Among 310 patients (192 MP-MRI, 118 BP-MRI), suspicious lesions were identified in 63% vs. 47%, respectively. Area under the curve values were 0.81 for MP-MRI and 0.88 for BP-MRI (p = 0.4). At PI-RADS ≥ 4, BP-MRI sensitivity/specificity were 71%/79% vs. 79%/55% for MP-MRI. At PI-RADS ≥ 3, sensitivities were similar but specificities were lower for both. Decision curve analysis showed similar net benefit for both protocols across clinically relevant thresholds. In multivariable analysis adjusting for age and PI-RADS, MRI type was not associated with clinically significant cancer detection (OR 0.88, 95% CI 0.53-1.45). Biparametric and multiparametric MRI protocols demonstrate comparable accuracy in the detection of clinically significant prostate cancer, suggesting that dynamic contrast enhancement offers limited clinical benefit. Biparametric MRI should be considered the standard for pre-biopsy imaging in patients with suspected prostate cancer.

IntroductionAlthough local anesthetic transperineal (LATP) prostate biopsy is now widely adopted, evidence remains limited, and no clear consensus exists on the optimal follow-up strategy for men with benign histology. This gap is particularly important given the increasing preference for LATP over the transrectal approach and the substantial proportion of patients who receive benign biopsy results. This study evaluated the follow-up of benign LATP biopsy findings and compared them with current international guidelines.MethodsA retrospective analysis was conducted at Worcestershire Acute Hospitals NHS Trust on patients who underwent LATP biopsy between November 2023 and April 2024. Patients with benign histology were identified and categorized by follow-up strategy: monitored, discharged to primary care, underwent repeat biopsy, or unclear. Outcomes of repeat biopsies and associated clinical parameters were assessed.ResultsOf 616 patients, 206 (33.4%) had benign histology. Sixteen patients underwent repeat biopsy due to clinical or radiological suspicion. Among those re-biopsied, six (37.5%) were diagnosed with prostate cancer, including 2 (12.5%) with clinically significant disease (Gleason Grade Group ≥2). Immediate repeat biopsy detected cancer in 50% of cases, particularly in patients with inadequate initial sampling or Prostate Imaging-Reporting and Data System (PI-RADS) 5 lesions. Complication rates were low across the cohort, although three patients developed urosepsis.ConclusionsLATP biopsy is safe and effective, but benign findings warrant structured follow-up due to a measurable false-negative rate. Our experience supports guideline recommendations that emphasize multidisciplinary evaluation, prostate-specific antigen kinetics, and imaging. Vigilant monitoring reduces the risk of missed cancers while avoiding unnecessary procedures.

ObjectiveOne known side effect of transperineal (TP) prostate biopsies is acute urine retention (AUR). We aimed to create and evaluate a predictive model for the post-paracentesis risk of acquiring AUR.MethodsThis study included 599 patients undergoing prostate biopsies (April 2020-July 2023) at the Second Affiliated Hospital of Nantong University, selected based on abnormal digital rectal examination and/or PSA (prostate-specificantigen) > 4 ng/mL. Acute urinary retention (AUR) was defined as the inability to void within 72 hours post-biopsy, requiring catheterization. Patients were randomly divided into training (419 cases) and test (180 cases) sets. Univariate logistic analysis and feature selection Boruta and LASSO (Least absolute shrinkage and selection operator) identified predictors, followed by multivariate logistic regression to develop a predictive nomogram for AUR. Internal validation used the test set, with model performance assessed via the c-index, ROC (Receiver Operating Characteristic) curve, calibration plot, and decision curve analysis. The nomogram demonstrated strong discrimination, calibration, and clinical utility for AUR risk prediction.ResultsIn 86 patients (14.3%), AUR happened. An examination of multivariate logistic regression revealed six distinct risk variables for AUR. Based on these independent risk factors, a nomogram was constructed. The training and validation groups’ c-indices showed the model’s high accuracy and stability. The calibration curve demonstrates that the corrective effect of the training and verification groups is perfect, and the area under the receiver operating characteristic curve indicates great identification capacity. DCA (Decision Curve Analysis) curves, or decision curve analysis, demonstrated the model’s significant net therapeutic effect.DiscussionThe nomogram model created in this work can offer a personalized and intuitive analysis of the risk of AUR and has intense discrimination and accuracy. It can help create efficient preventative measures and identify high-risk populations.

Participant-Reported Outcome Measures Following Transrectal and Transperineal Prostate Biopsy in a Randomized Clinical Trial.

Association Between Race and Detection of Clinically Significant Prostate Cancer in Transperineal and Transrectal Biopsies.

Abstract Background Transperineal prostate biopsy (TPPBx) under local anaesthesia (LA) has gained momentum in recent years. It is a simple, alternative office procedure to transrectal biopsy of prostate, with higher cancer detection and lower infection rates. This is the first reported transperineal biopsy in Malaysia using PrecisionPoint. We aim to determine clinically significant prostate cancer with TPPBx and its associated complication utilizing this method of biopsy. Methods We retrospectively reviewed medical records of patients who underwent TPPBx between November 2020 and September 2022. Electronic medical system was utilized to review patients’ information, PSA results, mpMRI reports (prostate volume, PI-RADS scoring) and complications experienced. Data were analysed to determine clinically significant prostate cancer (biopsy result with International Society of Urological Pathology (ISUP) grade 2 and above). Local anaesthesia was given through perineal skin infiltration as well as periprostatic nerve block. We performed our procedure using transrectal linear probe with biplane transducer for visual guidance using cognitive fusion. Biopsies were done in accordance with Ginsburg protocol. Ethics approval was obtained from University of Malaya Research Ethics Committee (UMREC) Results Total of 65 patients underwent transperineal biopsy under local anaesthesia from November 2020 to May 2022. All patients had mpMRI prior to the procedure. Prostate cancer was detected in 32 (49.2%) patients regardless of whether they had a previously negative transrectal prostate biopsy. Of the 65 patients, 27 (41.5%) were diagnosed with clinically significant prostate cancer requiring active treatment. The number of patients with clinically significant cancer was highest in the mpMRI reported PI-RADS 5 group with 15 patients (51.7%), followed by PI-RADS 4 group, with 10 patients (38.5%) and the PI-RADS 3 group, with two patients (20%). Complications reported were haematuria (33.8%) and acute urinary retention (6%). There were no reported urinary tract infections or sepsis as well as rectal bleeding after freehand transperineal biopsy of prostate. Conclusion Freehand transperineal biopsy of prostate using PrecisionPoint demonstrated an acceptable cancer detection yield while avoiding significant infection.

BackgroundProstate cancer is a common malignancy among men, and health systems are adopting faster diagnostic pathways to improve outcomes. Traditional transrectal ultrasound-guided (TRUS) biopsies under sedation carry a notable risk of infection, prompting a shift toward transperineal (TP) prostate biopsy under local anesthesia (LATP) in outpatient settings. We aimed to evaluate a new clinic-based LATP pathway for prostate cancer diagnosis in terms of speed, safety, and patient experience.MethodsWe retrospectively reviewed all patients referred with suspected prostate cancer who underwent the outpatient LATP pathway at a London NHS trust over a six-month period (May to November 2024). The pathway included an initial one-stop clinic visit (assessment and prostate-specific antigen test), rapid multiparametric MRI, and an office-based TP prostate biopsy under local anesthesia. Data were collected from electronic records and a post-biopsy patient survey. Key outcomes included diagnostic timelines (from urgent referral to biopsy to definitive diagnosis), compliance with the 28-day Faster Diagnosis Standard (FDS), procedure-related complications within 30 days, and patient-reported measures (pain, tolerability, satisfaction, and anesthesia preference).ResultsA total of 115 men (mean age ~68 years) were included. The mean interval from urgent referral to biopsy was ~10 days, and from biopsy to confirmed diagnosis ~5 days, resulting in an average referral-to-diagnosis time of about 14.5 days. Overall, 85.4% of patients received a definitive diagnosis within 28 days of referral, exceeding the national FDS target of 77%. Only 14.6% exceeded 28 days, typically by just a few days due to minor delays. Prostate cancer was diagnosed in 65% of patients, of whom 76% had clinically significant disease (Grade Group ≥2). Complications were infrequent and minor. There were 2 cases of urosepsis (1.7%), both managed successfully with brief hospitalization, and 2 vasovagal episodes (1.7%) with no lasting effects. No patients experienced urinary retention, significant bleeding, or other serious adverse events (overall complication rate ~3.5%). Patient feedback was positive: the average pain score during biopsy was 6.2/10 (moderate discomfort), but tolerability was rated favorably (mean 3.2/10 on a 0-10 difficulty scale). The mean satisfaction score with the diagnostic process was 8.2/10. Among surveyed patients, 68% indicated they would choose the same local anesthetic biopsy again, 20% were unsure, and 12% would prefer sedation or general anesthesia if another biopsy were needed. Patients valued avoiding a hospital stay and receiving results quickly.ConclusionsImplementation of an outpatient LATP biopsy pathway substantially accelerated prostate cancer diagnosis, with most patients receiving a diagnosis within two weeks of referral and more than 85% within 28 days. This fast-track performance exceeded national standards without compromising cancer detection rates (~65% overall) or patient safety. The complication rate was very low, confirming the safety of the TP approach. Patient-reported outcomes indicate that although the procedure can cause discomfort, it was generally well tolerated given the advantages of avoiding general anesthesia and hospitalization. Our single-center experience supports broader use of clinic-based LATP pathways to speed diagnosis and improve patient convenience, with general anesthesia reserved for the minority who need it.

Reply to Editorial Comment on "Antibiotic Prophylaxis Is Not Required Before MRI-Guided Transperineal Prostate Biopsy".

To evaluate the application effect of mindfulness-based stress reduction (MBSR) therapy on the patients treated with image fusion-guided transperineal prostate biopsy. A total of 160 patients who underwent image fusion-guided transperineal prostate biopsy in the Urology Department from April 2023 to April 2024 were included. Patients were randomly assigned to a control group and an observation group, with 80 cases in each group. The control group received routine care, while the observation group received combined MBSR on the basis of routine care. The surgical indicators, pain levels, psychological states, nursing satisfaction, and postoperative complication rates of both groups were compared. There was no statistically significant difference in general personal information and clinical data between the two groups（P>0.05）. The surgery duration, secondary fusion rate, and postoperative complication rate in the observation group were all lower than those in the control group (［23.54±2.07］min vs ［26.25±1.69］min, P<0.05； 8.75% vs 22.50%, P=0.017； 17% vs 29%, P=0.036), and nursing satisfaction was higher in the observation group than in the control group ( 77% vs 69%, P=0.025). The VAS scores biopsy (5.11±0.93 vs 6.27±1.32, P=0.041), discharge (0.74±0.67 vs 1.85±0.95, P=0.004), and scores of SDS (47.76±2.06 vs 50.46±2.07, P=0.009) and SAS (46.89±2.68 vs 49.75±2.83, P=0.031) in the observation group were all lower than those in the control group. The application of MBSR in image fusion-guided prostate biopsy can synergistically utilize the advantages of minimally invasive technology, significantly optimize surgical indicators, and improve patients' psychological experiences, which is worthy of clinical application and promotion.

ObjectivesTo evaluate the feasibility and safety of hydrodissection of the prostato‐rectal space using 10% dextrose for focal therapy of posterior prostate tumours.Patients and methodsWe included consecutive patients who underwent focal therapy for a posterior prostate tumour with a prior injection of 10% dextrose in the prostato‐rectal space, between October 2024 and February 2025. The main outcomes were to evaluate the space created using this technique. As the technique used for hydrodissection was modelled on periprostatic nerve block, we analysed a cohort of patients who underwent transperineal prostate biopsies with periprostatic nerve block using 20 ml of lidocaine, to compare the prostato‐rectal spaces created by 10% dextrose and by lidocaine.ResultsA total of 11 patients underwent a focal therapy with a prior 20 ml 10% dextrose hydrodissection of the prostato‐rectal space. Fifteen patients who underwent prostatic biopsies using a periprostatic nerve block (20 ml of lidocaine), with similar characteristics, were included. The median prostato‐rectal space created with dextrose and with lidocaine was 8.9 [8.0; 9.9] and 6.7 [6.4; 8.4] mm, respectively (p = 0,17). The prostato‐rectal space decreased slower with dextrose: 0.03 mm/min vs 0.1 mm/min (p = 0,02). The prostato‐rectal space was higher at the end of focal therapy procedures (7.9 vs 6.6 mm, p = 0,033), despite a longer procedure time in focal therapy (37 vs 8 min, p < 0,001). At the end of focal therapy procedures, all patients had a prostato‐rectal space > 5 mm. No hydrodissection‐related adverse event was observed.ConclusionsThese initial results suggest that hydrodissection of the prostate–rectal space using 20 ml 10% dextrose, injected following a standard periprostatic nerve block protocol, is feasible, reproducible and safe for a focal therapy procedure for localized posterior prostate tumours.

Spindle cell lesions of the prostate originate from the specialized stroma or prostate epithelium. At present, these lesions are relatively rare, but the histomorphological features they involve are extremely diverse, which can easily lead to misdiagnosis in the clinical diagnosis process. This study reports on 3 cases of different types of spindle cell lesions of the prostate, with the aim of providing valuable reference information for clinicians when dealing with such cases, to help them make more accurate and effective clinical decisions. A retrospective analysis of the clinical data of 3 patients diagnosed with different spindle cell lesions of the prostate at the Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, from January 2023 to October 2024. All 3 patients underwent transperineal prostate biopsy with 12 needles. Two patients were diagnosed with the assistance of fluorescence in situ hybridization (FISH). Based on pathological examination and immunohistochemical testing results, 1 patient was diagnosed with nodular hyperplasia of prostatic interstitial smooth muscle. The other 2 patients who underwent FISH testing were diagnosed with prostatic stromal sarcoma in one case and prostatic synovial sarcoma in the other. One patient elected to undergo transurethral holmium laser-induced prostatectomy. Another patient received targeted therapy with anlotinib. The third patient received liposome doxorubicin combined with ifosfamide chemotherapy. For the cases of nodular hyperplasia of prostatic interstitial smooth muscle, no signs of recurrence have been found so far. The patient with prostatic stromal sarcoma unfortunately passed away after 3 months of follow-up. However, during the subsequent observation period, the tumor volume of patients with synovial sarcoma of the prostate exhibited a reduction, and no further deterioration was noted. Spindle cell lesions of the prostate have diverse histological manifestations. A diagnosis can only be confirmed through the results of a biopsy and immunohistochemistry. Classification of some tumors should also be diagnosed with the assistance of FISH. Once diagnosed, timely intervention is required, including surgery, adjuvant radiotherapy, adjuvant chemotherapy, targeted therapy, etc. Malignant tumors, in particular, progress rapidly and have a poor prognosis, so a detailed treatment plan needs to be formulated.

Background/Objective: The CamPROBE device offers a simple, low-cost method to facilitate double-free-hand local anaesthetic transperineal prostate biopsies (LATPBx). Here we present data from prospective implementation of its use for first biopsy cancer detection. Methods: The outcomes of two centres who adopted the CamPROBE were compared to a retrospective series of biopsies using an in-line (single-free-hand) device. All biopsies were done by clinicians new to the device. Outcomes were the detection of any cancer and clinically significant prostate cancer (csPCa) defined as ≥Grade Group 2 and ≥Grade Group 3 (GG2/3) and composite ≥NICE Cambridge Prognostic Group 2 and 3 (CPG2/3), as well as sampling accuracy of MRI-defined lesions. Results: Device cohorts were well matched for pre-biopsy PSA, T stage, and MRI visibility in both centres. In centre 1 (100 CamPROBE vs. 97 in-line biopsies), there were no differences in detection of any cancer or csPCa: ≥GG2 60.0% vs. 56.7% (p = 0.64), ≥GG3 31% vs. 20.6% (p = 0.09), ≥CPG2 62.0% vs. 60.8% (p = 0.86), and ≥CPG3 (p = 0.55). There were also no differences between devices in target biopsy positivity: 67.4% vs. 63.5% (p = 0.59). Data from centre 2 (38 CamPROBE vs. 44 in-line) re-capitulated these findings. The MRI target detection rate of the CamPROBE (assessed in Centre 1) was not affected by prostate volume, lesion laterality, anatomical position, or lesion size. Limitations include modest sample sizes, lack of randomization, and patient-reported outcomes. Conclusions: These data demonstrate that the CamPROBE device is a highly effective method of performing prostate biopsies with excellent cancer detection rates and accuracy, supporting its wider dissemination and use.

Background. Transrectal (TR) prostate biopsy remains the ”gold standard” but is associated with infectious risks; transperineal (TP) biopsy is considered a safer alternative with comparable diagnostic accuracy. Objective. To compare the diagnostic performance, complication rates, pain levels, and short-term outcomes of TR- and TP-guided prostate biopsies. Materials and methods. A prospective randomized study included 68 men aged ≥40 years with suspected prostate cancer (PSA4 ng/mL, positive DRE, and/or PIRADS≥3). Patients were randomized into the TP group (n=53) and the TR group (n=15). A 12-core transrectal ultrasound-guided biopsy was performed with targeted sampling of PIRADS 3–5 lesions. Overall and clinically significant cancer detection rates (Gleason score ≥7), complications (Clavien–Dindo classification), pain using the Visual Analog Scale (VAS), and events within 30 days were analyzed; p0.05 was considered statistically significant. Results. Prostate cancer was detected in 72.1% of patients: 75.5% in the TP group and 60.0% in the TR group (p=0.62). Clinically significant cancer accounted for 59.2% of cases (45.3% in TP vs 33.3% in TR; p=0.59). No Clavien grade III or higher complications or cases of urosepsis were observed. Minor complications occurred in 32.1% of TP and 40.0% of TR patients (p=0.69); low-grade fever requiring oral antibiotics (Clavien grade II) was reported only in 3.8% of TP cases. The procedure duration was longer for TP (20.6±5.2 min vs 10.3±3.8 min; p0.001) but was associated with lower pain scores (2.6±1.1 points vs 4.7±1.5 points; p0.01); 81% of TP patients rated the pain as minimal. No delayed complications were reported at 30-day follow-up. Conclusion. Transperineal biopsy provides comparable detection of clinically significant prostate cancer, results in less procedural pain, and demonstrates an absence of severe complications, offering a safe alternative to the TR approach, particularly for patients with a higher risk of infection or difficult-to-access magnetic resonance imaging lesions.

Antibiotic Prophylaxis Is Not Required Before MRI-Guided Transperineal Prostate Biopsy.

Concordance with radical prostatectomy specimen of in-bore MRI-guided transperineal vs US-guided transrectal prostate biopsies: A propensity score matched analysis.

Transperineal MR Imaging-Guided Prostate Biopsy: A Prospective Randomized Controlled Study on Safety and Effectiveness Compared with Transrectal Biopsy.

Infection rates of trans-perineal versus trans-rectal prostate biopsy: A Middle Eastern tertiary center experience—Time for a change?

ObjectiveTo evaluate the carbon footprint of transperineal prostate biopsy (TPPB). Climate change is the biggest global public health threat of the 21st century. Healthcare contributes 5% to global greenhouse gas emissions. Despite growing enthusiasm for sustainable urology, there is little data on the environmental impact of urological practice.Patients and methodsEmissions associated with TPPB (under local anaesthesia) at a hospital in Aotearoa New Zealand were estimated from electricity consumption, procurement of equipment/supplies, travel of staff and patients, waste disposal and sterilisation of linen. Emissions coefficients were used to determine CO2 equivalents (kgCO2e) emitted.ResultsTPPB was associated with 70 kgCO2e of emissions per case. This equates to 280 km of travel by car, or an economy seat on a 70‐minute flight. The largest contributors were procurement (76%) and travel (23%). Electricity, waste disposal and sterilisation of linen did not contribute significantly to emissions (cumulatively <1.5%).ConclusionsThis is the first study to evaluate the carbon footprint of a TPPB. Emissions were derived mostly from procurement and travel. These may be mitigated by review of standardised equipment packs, transitioning to reusables and introducing outreach biopsy clinics. Adherence to pragmatic evidence‐based guidelines for prostate cancer may reduce emissions associated with overdiagnosis and unnecessary biopsies. Further research is required to characterise the broader environmental impact of urology services.