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 Table of Contents  
Year : 2022  |  Volume : 3  |  Issue : 2  |  Page : 63-65

A case report of transperineal ultrasound-guided prostate biopsy in Benin City

1 Department of Radiology, University of Benin, Benin, Edo, Nigeria
2 Department of Radiology, Delta State University Teaching Hospital, Oghara, Delta, Nigeria

Date of Submission10-May-2022
Date of Decision30-Jun-2022
Date of Acceptance14-Jul-2022
Date of Web Publication17-Dec-2022

Correspondence Address:
Blessing Ose-Emenim Igbinedion
University of Benin, Benin, Edo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrmt.jrmt_8_22

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Prostate cancer is a common worldwide male tumor which can lead to death. Screening methods have not been optimal in detecting this malignancy. Hence, the need to obtain tissue samples for histology is paramount for early cancer detection. Transrectal (TR) prostatic biopsy was introduced in 1937 and it is still practiced in many centers worldwide. However, it has its limitations and complications. As such the transperineal (TP) approach to prostate biopsy which is also an old method have been developed to obviate some of the problems of TR. TP is fast gaining ground in many centers and appears to be a better option to TR. We report the first TP prostatic biopsy that was done in Benin City, Edo State, South-South geopolitical zone.

Keywords: Biopsy, prostate, transperineal

How to cite this article:
Igbinedion BO, Ehigiamusoe FO, Ogbeide AO. A case report of transperineal ultrasound-guided prostate biopsy in Benin City. J Radiat Med Trop 2022;3:63-5

How to cite this URL:
Igbinedion BO, Ehigiamusoe FO, Ogbeide AO. A case report of transperineal ultrasound-guided prostate biopsy in Benin City. J Radiat Med Trop [serial online] 2022 [cited 2023 Jun 3];3:63-5. Available from: http://www.jrmt.org/text.asp?2022/3/2/63/364183

  Introduction Top

Prostate cancer is the most common male cancer worldwide.[1] In Nigeria, it has a prevalence of 6.7%–10%, and it is hypothesized that the latent, clinically asymptomatic prostate cancer is noted to be less frequent in Nigerians than in African-Americans despite shared ancestry.[2] However, the mortality from prostatic cancer is high, and it can lead to reduced quality of life in many patients with this disease. Screening with prostate-specific antigen assay has a low positive predictive value of 20%–30%.[1] Hence, histological samples are required in many instances to diagnose prostate cancer either through the transrectal (TR) or transperineal (TP) approach. Before now, systematic ultrasound-guided TR prostate biopsy is the gold standard for getting prostatic samples for histology.[1],[3],[4] The complications/complication rate of TR is concerning as approximately 4%–5% of patients who had TR require hospital admission due to infection-related complications, necessitating the search for another biopsy route.[5]

Consequently, the TP prostate biopsy technique was developed as an alternative approach as it has been shown to greatly improve cancer detection rates and has fewer complications.[5],[6] TP also has the advantage that the biopsy needle can be advanced to locations where TR biopsy needle will be difficult to get to, including the anterior and apical parts of the prostate.[5],[6] In the past, TP was not commonly practiced because it required general anesthesia and multiple skin punctures. However, with recent advances and modifications of TP, image-guided systematic TP is fast gaining ground and gradually becoming the preferred method of prostate biopsy.[6]

Very few patients and clinicians are aware of TP in our environment undermining the availability of materials and expertise. TP is safer, more tolerated, and yields more histological tissue samples than TR. We successfully performed TP on the index patient with no complications and good sample yield. This is the first documented TP prostate biopsy performed in Edo State.

  Case Report Top

An 80-year-old man presented at a private hospital with acute urinary retention. A Foley's catheter was passed through his urethra into the urinary bladder to relieve the acute urinary retention. On digital rectal examination, he was suspected of having carcinoma of the prostate. He was then sent to our facility for prostatic biopsy. At our facility, he was counseled for TP prostate biopsy, to which he consented and signed the informed consent form. His full blood count and clotting parameters were within normal reference values. On physical evaluation, the patient was anicteric, not pale, and in a stable state of health. He was then taken to the interventional radiology suite for the procedure.

He was placed in the supine lithotomy position. The patient was connected to a vital sign monitoring device, and his blood pressure, pulse rate, and oxygen saturation levels were within normal range throughout the procedure. The perineum scrotum and pelvis were cleaned using cetrimide, povidone-iodine, and methylated spirit in this order. The scrotum was then plastered to the pelvis to prevent it from falling over and covering the perineum. The pelvis, perineum, and thigh were then covered with an open drape. An end cavity probe of a General Electric Logiq C5 Premium (China, 2016) was cleaned and covered with condom sheath. A TR ultrasound scan was performed. On TR ultrasound, an enlarged heterogeneous prostate gland measuring 5.63 cm × 6.01 cm × 6.45 cm with a volume of 109 ml was demonstrable. Multiple foci of calcifications were noted with central spread. The Foley's catheter coursing through the prostatic urethra to the urinary bladder was seen with the bulb within the urinary bladder. The endocavity ultrasound probe was left in situ to serve as a guide for prostatic nerve block deep local infiltration and for the actual biopsy processes.

The left side of the perineum was infiltrated with lidocaine to the prostatic plexus. A coaxial needle was then passed under ultrasound guidance to the prostate gland just beyond the capsule [Figure 1]. An 18G trucut biopsy needle was subsequently repeatedly passed through the coaxial needle into the prostate [Figure 2] to take at least six samples from different points on that side of the prostate ensuring that the midline is not crossed to avoid injury to the prostatic urethra. These were deposited in a formalin solution. The biopsy and coaxial needles were later retrieved. Manual compression of the perineal puncture site for about 6 min was undertaken. The process was then repeated for the right side of the perineum/prostate. Postprocedure state of the patient was satisfactory. We placed the patient on tablets of cefuroxime 500 mg BID for 1 day and paracetamol 1 g PRN. The patient had no complications from the procedure to report even to his clinician. The histology report stated features of high-grade prostatic adenocarcinoma that were demonstrable in 9 out of 12 samples (Gleason scores 5 + 4 = 9).
Figure 1: Picture shows the draped perineum of the index patient with the coaxial needle passed through the left side of the perineum into the prostate gland under ultrasound guidance. The transrectal probe can be seen

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Figure 2: Biopsy tract as seen on transrectal ultrasound scan during the transperineal prostate biopsy

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  Discussion Top

TP prostate biopsy was first reported about 50 years ago, but it did not get its expected acceptance because it was originally done under general anesthesia and involves multiple skin punctures.[6] However, it is fast gaining ground in recent years because new practices encompass using local anesthesia, coaxial biopsy technique, and image guidance. These modifications in TP coupled with its lesser complication rates when compared with TR have increased its acceptance and utilization. It was not surprising that the patient in this index case was very jovial at the end of the procedure, telling us that he dreaded doing prostate biopsy because he was told by those who had done it of the severe pains they experienced. In practice, we have also seen patients who underwent TR and how distressing it was for them when compared to TP. This was why we had refused to perform image-guided TR despite repeated requests due to our concerns about its complications. Since this index TP was performed about 3 months ago, we have done other TPs and it is gradually gaining popularity in our environment.

Complications of prostate biopsy include gross hematuria, perineal hematoma, urine retention, epididymitis, prostatitis, urinary tract infection, fever, sepsis, hospitalization, Fournier's gangrene, rectal bleeding, hematospermia, erectile dysfunction, and rarely death.[5],[6],[7] According to Huang et al.[5] the complication rates in TP are less than that of TR in most of the studies they reviewed. For instance, the hospitalization rate as a result of complications from the prostatic biopsy was less in the TP group (0%) than those in TR group (7.4%).[5] Furthermore, about 50% of patients who undergo TR suffers from hematuria, hematospermia, rectal bleeding, and acute urinary retention (minor complications) to anemia and syncope (severe complications) which is far less in TP.[5] Another major advantage of TP over TR is the reduced complication rate as a result of infection. The multiple punctures through the rectal mucosa in TR introduce bowel flora into the prostate.[5] TP does not inoculate the prostate with rectal orgasms. The infection complication rate in TP is further reduced if adequate cleaning of the perineum is done. In this case report, we used cetrimide, povidone-iodine, and methylated spirit in this order to clean the perineum and scrotum. After which, the scrotum was restrained from falling over to cover the perineum. In addition, infection complications and its associated morbidity and mortality are causes of concern to clinicians and surgeons in areas where multi-resistant bacteria are increasing at an alarming rate.[8] This is occasioned by the ease of getting antibiotics over-the-counter in most Nigerian states which is worsened by the fact that there is antibiotic abuse and noncompletion of antibiotic regimen by most patients, especially when they feel better. The practice of TP would serve to reduce the burden of multi-resistance bacterial infections that may occur in patients who undergo TR prostatic biopsies.

Using our technique, adequate local anesthesia was achieved by initially infiltrating the skin of the perineum with lidocaine, followed by deep local anesthesia using a spinal needle to the neurovascular plexus of the prostate to achieve nerve block. Applying LA in this fashion obviates the need for general anesthesia or spinal block. In comparison, there is significant pain, discomfort, and anxiety in a high proportion of patients undergoing TR biopsy.[9] With adequate anesthesia, the coaxial needle can be passed to the prostatic cortex easily with little or no discomfort. Using this coaxial biopsy system, only two biopsy tracks are created in the modified TP technique compared to TR. Consequently, there is reduced chance of seeding tumor along biopsy track in TP. We also used the rectal probe to guide the coaxial and biopsy needles to any site of the prostate and any focal prostatic lesion with expected improved sensitivity of sample yield. This rectal probe can be any suitable endocavity probe and not the dedicated rectal biopsy probes required in TR. Hence, the additional cost of acquiring dedicated rectal biopsy probes is avoided in TP.

Bleeding is the most frequently reported complication after prostate biopsies, but it is usually minor and resolves spontaneously.[7] Even at that, hematoma and hemorrhage are less for TP than TR.[5] We also applied perineal compression in this index patient after retrieval of the coaxial needle from each side of the perineum to reduce the incidence of perineal hematoma. In TP, there is practically no incidence of rectal bleeding except if the practitioner is not well trained and inadvertently pierces the rectum or does the procedure without proper ultrasound guidance, whereas rectal bleeding is a common occurrence in TR.

  Conclusion Top

We report the first coaxial TP prostatic biopsy in Benin City with no noticeable complication. Even though both TR and TP can be done on outpatient basis, we prefer and advocate for TP due to its reported ease of performance, expected improved tissue yield, and reduced complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Xiang J, Yan H, Li J, Wang X, Chen H, Zheng X. Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: A systematic review and meta-analysis. World J Surg Oncol 2019;17:31.  Back to cited text no. 1
Bosland MC, Nettey OS, Phillips AA, Anunobi CC, Akinloye O, Ekanem IA, et al. Prevalence of prostate cancer at autopsy in Nigeria-A preliminary report. Prostate 2021;81:553-9.  Back to cited text no. 2
Ghafoori M, Velayati M, Aliyari Ghasabeh M, Shakiba M, Alavi M. Prostate biopsy using transrectal ultrasonography; the optimal number of cores regarding cancer detection rate and complications. Iran J Radiol 2015;12:e13257.  Back to cited text no. 3
Salomon G, Köllerman J, Thederan I, Chun FK, Budäus L, Schlomm T, et al. Evaluation of prostate cancer detection with ultrasound real-time elastography: A comparison with step section pathological analysis after radical prostatectomy. Eur Urol 2008;54:1354-62.  Back to cited text no. 4
Huang GL, Kang CH, Lee WC, Chiang PH. Comparisons of cancer detection rate and complications between transrectal and transperineal prostate biopsy approaches – A single center preliminary study. BMC Urol 2019;19:101.  Back to cited text no. 5
Thomson A, Li M, Grummet J, Sengupta S. Transperineal prostate biopsy: A review of technique. Transl Androl Urol 2020;9:3009-17.  Back to cited text no. 6
Loeb S, Vellekoop A, Ahmed HU, Catto J, Emberton M, Nam R, et al. Systematic review of complications of prostate biopsy. Eur Urol 2013;64:876-92.  Back to cited text no. 7
Williamson DA, Barrett LK, Rogers BA, Freeman JT, Hadway P, Paterson DL. Infectious complications following transrectal ultrasound-guided prostate biopsy: New challenges in the era of multidrug-resistant Escherichia coli. Clin Infect Dis 2013;57:267-74.  Back to cited text no. 8
Peyromaure M, Ravery V, Messas A, Toublanc M, Boccon-Gibod L, Boccon-Gibod L. Pain and morbidity of an extensive prostate 10-biopsy protocol: A prospective study in 289 patients. J Urol 2002;167:218-21.  Back to cited text no. 9


  [Figure 1], [Figure 2]


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