Introduction: There remains concern for prostate cancer in men who have a persistently elevated or rising serum PSA despite having a non-diagnostic transrectal ultrasound-guided biopsy (TRUS-B). Stereotactic transperineal prostate biopsy (STPB) may address this challenging clinical dilemma. Using transrectal ultrasound guidance and a transperineal template allows for comprehensive prostatic tissue sampling and lower likelihood of underestimating disease volume and grade. This study sought to determine occult prostate cancer detection rates utilizing STPB in men following negative TRUS-B.
Methods: Consecutive patients at a single institution between 2004 to 2020 who underwent STPB following a non-diagnostic TRUS-B were included. Patients who had primary STPB, non-STPB biopsy, a prior positive biopsy, or no core sampling were excluded. Well-protocolized STPB using prostate brachytherapy clinical setup and systematic comprehensive tissue sampling has been previously described in detail (Moran et al. Urology 2009). Multivariate logistic regression models were constructed to evaluate potential predictors of positive STPB.
Results: Out of 3756 patients, 2647 (70%) met final inclusion criteria and were analyzed (median age: 64 years, IQR: 59-69 years). Included patients had at least one prior negative TRUS-B (median 1, IQR: 1-2) before STPB and had median pre-STPB serum PSA levels of 8.1 ng/mL (IQR: 5.7-11.6 ng/mL). Median prostate size and number of cores sampled were 47 cc (IQR: 36-63 cc) and 37 (IQR: 30-44), respectively. STPB detected prostate adenocarcinoma in 956 of the 2647 patients (36%, 95% CI: 34-38%) with a median of 2 cores positive (IQR: 1-3). Of those with positive STPB, pathology findings revealed grade group 1-5 disease rates of 51%, 22%, 14%, 9%, and 4%, respectively. On multivariate analyses, older age (OR 1.79, 95% CI: 1.59-2.01, p <0.001) and higher pre-STPB PSA levels (OR 1.35, 95% CI: 1.19-1.52, p <0.001) were associated with higher odds of obtaining a positive STPB result, while large prostate size (OR 0.38, 95% CI: 0.34-0.44, p <0.001) and higher number of prior negative biopsies (OR 0.89, 95% CI: 0.82-0.97, p=0.011) were associated with lower odds.
Conclusions: STPB can detect a significant number of occult and clinically significant prostate cancer in men with prior negative TRUS-B. This is the largest series to date and further supports the use of STPB to address this difficult clinical dilemma.