Transperineal prostate biopsy detects significant cancer in patients with elevated prostate‐specific antigen (PSA) levels and previous negative transrectal biopsies
Authors: Dimmen Magne , Vlatkovic Ljiljana , Hole Knut‐Håkon , Nesland Jahn M. , Brennhovd Bjørn , Axcrona Karol 
Published: November 2011

Study Type – Diagnostic (exploratory cohort)Level of Evidence 2bWhat's known on the subject? and What does the study add?Several authors have previously reported that transrectal prostate biopsy has a false‐negative rate of 20–30%, and that a number of prostate cancers missed on transrectal biopsy can be detected by transperineal biopsy. It has also been shown that most of these tumours are located anteriorly in the prostate gland.The present study showed a high rate of prostate cancer in patients with previous negative transrectal biopsies but elevated PSA levels, and that the cancers were located anteriorly in the prostate gland. Also, most of these cancers were clinically significant in patients that underwent RP, i.e. a high proportion of cancers were high‐grade/high‐stage tumours. We also showed that the transperineal biopsy technique can be applied successfully to patients with a closed anal orifice after previous surgery for rectal cancer. Transperineal biopsy can be done safely without routine antibiotic prophylaxis.OBJECTIVE
To investigate the outcomes of transperineal prostate biopsies in patients with elevated prostate‐specific antigen (PSA) levels and negative transrectal biopsies. The aim of this retrospective study was to evaluate the diagnostic yield of the transperineal biopsy approach in these patients, and to evaluate the pathology findings in subsequent radical prostatectomy (RP) specimens in patients undergoing RP.
PATIENTS AND METHODS
In all, 69 consecutive patients with previous negative transrectal biopsies but elevated PSA levels investigated at urological units in Norway who had been referred to The Norwegian Radium Hospital were included.
The patients had undergone a mean (median; range) of 2.42 (2; 0–7) transrectal biopsies. The mean (range) age was 63.1 (42–78) years. The median (range) PSA level was 12 (4.3–229) ng/mL.
The patients were examined with transperineal biopsy of the prostate between July 2007 and February 2009. The results of the transperineal biopsies were reviewed for Gleason biopsy score, and these were compared with the histopathology results of the RP specimens, i.e. final Gleason scores.
Pathological stage of the prostate specimens and tumour volume were also reviewed.
RESULTS
Prostate cancer was found in the biopsies of 38 of 69 patients (55%).
In all, 20 of 38 patients had a Gleason score estimated at ≥3 + 4 = 7.
In all, 26 patients underwent RP. The surgical specimens revealed pathological stage pT2c in 65%, pT3a in 27% and pT3b in 8% of the cases.
In all, 23 of the 26 RP specimens showed a final Gleason score of ≥7. The vast majority of cancers detected were situated in the anterior/ventral portion of the prostate.
CONCLUSIONS
Transperineal biopsy of the prostate in patients with an elevated PSA level after negative transrectal prostate biopsies appears to be a feasible and important option for further investigation to detect prostate cancer.
The present study shows that the transperineal biopsy allows good access of the anterior/ventral part of the prostate.
Histopathology reports on the RP specimens obtained from the patients that underwent RP revealed significant cancer.