The procedure can be performed both in the lateral decubitus position (lying on your side and with your legs bent) (Fig. 26.1) and in gynecological position.

Before any operation is practiced, rectal examination to rule out the presence of concomitant abnormalities of the rectal wall should be performed.

Transrectal biopsy is performed under local anesthesia. The ultrasound probe introduced into the rectum is provided with a channel for the passage of fine needles. So with an 18 gauge 25 cm needle, it is possible to reach every part of the prostate (Figs. 26.3, 26.4, and 26.5).

Only patients with high comorbidity may require the procedure in the operating room under sedation or anesthesia.

The procedure is performed in gynecological position. The doctor performs a rectal examination to rule out the presence of concomitant abnormalities of the rectal wall. The patient is asked to raise a hand with the testicles, or claims are with gauze fixed with patches to “hammock” groin. The skin located between the testicles and the anus is shaved and disinfected. The entry point of the needle is located 1.5 cm above the anus. At this level, it injects a few ml of local anesthetic with a needle thin and short. In point prior anesthesia, a thin needle of greater length that allows the injection of the local anesthetic around the prostate is then introduced.

A thin metal channel cable is introduced along the path anesthetized until reaching the suspected area. This system will make it easy and not annoying for the patient because of the repeated passage of the needle biopsy. The ultrasound probe allows the patient to see at any time the areas that are reached by the needle biopsy. When the procedure is performed, a mild compression dressing is performed with the entry of the needle.

Transperineal prostate biopsy has come to the foreground as a result of lower incidence of sepsis, better detection rate for anterior prostate cancer (PCa), and the opportunity to perform the template-guided prostate biopsy [15, 16]. Transrectal and transperineal prostate biopsy procedures require different techniques and are recommended with the same level of evidence [17]. Candidates for transperineal biopsy should be studied with coagulation blood tests and receive antibiotic prophylaxis; if sedation is required (saturation or template-guided biopsy), both blood tests and cardiologic evaluation are recommended. Transperineal biopsy needs multifrequency linear or biplanar probes to show perineal passage of the needle; this approach is recommended for patients that have been previously subjected to abdominoperineal amputation or that are affected by severe disease of the rectum (Figs. 26.6 and 26.7).

Transperineal and transrectal prostate biopsy provides similar detection rates for prostate cancer (PCa) both for first procedure (34–40 %) and for repeat procedure (22–43 %) performing at least 12 (extended biopsy) vs. >20 (saturation biopsy) cores, respectively [18–31]. Transperineal route allows for easier access to the anterior zone of the gland, where incidence of PCa is from 10 to 20 % at repeat biopsy [32–36]. Transperineal template-guided biopsy, utilizing 30–60 cores, is suggested for men with previously negative biopsies and persistent suspicious of cancer, in local PCa staging and in the re-evaluation of patients enrolled in active surveillance (AS) protocols [37–40].

Despite ultrasound sensitivity improvement through combined use of color power Doppler (CDU) and a contrast medium agent [41–43] or elasto-sonography [44], the accuracy of transperineal and transrectal approach in the diagnosis of PCa performing targeted biopsies has not improved. On the contrary, combined use of multiparametric MRI (magnetic resonance imaging) and MRI/TRUS transperineal fusion targeted biopsy has high accuracy in detecting significant PCa [44–51]. In fact, multiparametric MRI/TRUS targeted biopsy produces a higher detection rate of PCa for each single core compared to extended biopsy schemes (15–20 % vs. 5–10 %) [50, 51] (Video 26.7) (Figs. 26.8, 26.9, 26.10, and 26.11); multiparametric MRI/TRUS transperineal targeted biopsy improves diagnosis of significant PCa most notably in AS protocols [44, 48–52].

Prostate biopsy is the gold standard in re-evaluation of men enrolled in AS protocols, and the highest percentage of patients being reclassified at confirmatory prostate biopsy repeat biopsy (25–30 % of the cases) [48] following unfavourable histology results (i.e., Gleason score >6, number of positive cores >2, greatest percentage of cancer “GPC” >50 %). Despite the fact that both the appropriate number of biopsy cores (extended vs. saturation vs. template-guided schemes) and the approach (transrectal vs. transperineal) [43–55] have not been established, transperineal biopsy seems more accurate in the identification of patients at risk of PCa in AS protocols [48], resulting in a lower incidence of adverse definitive histology specimens compared to transrectal approach [53–56]. Multiparametric MRI/TRUS fusion targeted biopsy has improved staging in AS giving 10 % reassignment [57] in patients undergoing standard biopsy [58, 59]; moreover, MRI/TRUS fusion transperineal targeted biopsy has good accuracy in the diagnosis of anterior PCa [59–63] and in the re-evaluation of micro-focal cancer (a single positive core of Gleason score equal to 6 and GPC <5 %) [64] at risk for clinically insignificant PCa. Highest diagnostic accuracy of clinically significant PCa in the re-evaluation of men in AS [65] is still, at present, obtained through extended or saturation prostate biopsy schemes combined with MRI/TRUS targeted biopsy.

Finally, the transperineal approach reduces the incidence of sepsis (at most 0.07 %) compared with 1–2 % for the transrectal approach [11, 61, 66–74].

In conclusion, the transperineal approach could be recommended in persistent suspicion of PCa following one or more negative transrectal biopsies as this approach increases the detection of anterior PCa; furthermore, the transperineal route significantly reduces the incidence of sepsis in patients with previous prostatitis and/or recurrent urinary tract infection [75–77].

On baseline biopsies, the sample sites should be bilateral from apex to base as far as posteriorly and laterally as possible in the peripheral gland (Videos 26.2, 26.3, 26.4, 26.5, and 26.6). Additional cores should be obtained from suspect areas by DRE/TRUS and MRI (Video). Sextant biopsy is no longer considered adequate. Ten to 12 core biopsies are recommended [78], with >12 cores not being significantly more conclusive [79, 80].

The prostate biopsy is a safe procedure and generally associated with few complications.

During the execution of the biopsy, with both transperineal and transrectal approaches, the patient may experience pain even after executing anesthesia. Rarely, the patient may experience a general malaise characterized by increased sweating and feeling of loss of consciousness. Exceptional is the appearance of allergic reactions to the local anesthetic.

After the procedure, a rare complication (less than 2 % of cases) can be represented by the inability to empty the bladder spontaneously. In such a case, the placement of a urinary catheter which may be held in place for a few days or removed immediately is necessary.

For a few weeks after the biopsy with transrectal approach, you can assist in the loss of blood from the rectum (rectal). Such event is observed in 10–40 % of cases. The presence of blood in urine (hematuria) and/or urethrorrhagia is common in both the transrectal and the transperineal biopsies. Both are observed in approximately 30–60 % of cases; they persist for some days and generally disappear spontaneously.

Prostate biopsy is considered a safe technique, with incidence of severe complications <1 %; among these are the most dangerous infections of antibiotic-resistant germs. Severe postprocedural infections were initially reported in 1 % of cases, but have increased as a consequence of antibiotic resistance [8–11].

Low-dose aspirin is no longer an absolute contraindication [86]. Percentage of complications per biopsy session, irrespective of the number of cores, are as follows: hematospermia 37.4 %, hematuria >1 day 14.5 %, rectal bleeding <2 days 2.2 %, prostatitis 1 %, fever >38.5 °C 0.8 %, epididymitis 0.7, rectal bleeding >2 days +/− surgical intervention 0.7 %, urinary retention 0.2 %, and other complications requiring hospitalization 0.3 % [11].

After transperineal biopsy, seldom is the formation of a hematoma at the site of entry of the needle (less than 0.5 % of cases). The clinical complications following transperineal prostate biopsy in men submitted to extended vs. saturation biopsy are listed in Table 26.1 [68].

In less than 1 % of cases, it is possible to observe the onset of high fever with shivering that may require hospitalization.

After the “execution of the procedure is an appropriate observation period of about a” time to highlight the appearance of any immediate complications. After transperineal biopsy, a mild compression level with the entry of the needle could be instituted.