Transperineal biopsy for diagnosing prostate cancer
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1.1 Local anaesthetic transperineal (LATP) prostate biopsy using the freehand needle positioning device PrecisionPoint is recommended as an option for diagnosing prostate cancer.
1.2 Although there is considerably less evidence for them, the following freehand needle positioning devices are also recommended as an option:
Trinity Perine Grid
UA1232 puncture attachment.
They are expected to have similar cancer detection rates and adverse events to PrecisionPoint because they are technically similar.
1.3 Centres are encouraged to take part in the randomised controlled trial of transrectal biopsy compared with LATP biopsy (the TRANSLATE trial, see section 3.7) to help refine clinical practice.
1.4 There is not enough evidence to recommend LATP using a double freehand technique, that is, when a needle is used without a positioning device (for example CamPROBE). Further research is recommended to understand its clinical effectiveness.
Why the committee made these recommendations
Standard prostate biopsy uses local anaesthetic transrectal ultrasound (LA-TRUS). This involves taking samples of prostate tissue by inserting a biopsy needle through the rectal wall via the anus. An alternative is LATP prostate biopsy, which involves inserting the needle through the perineum, the skin area between the anus and the scrotum.
Techniques for LATP biopsy vary. It can be done using a freehand needle positioning device, a grid and stepping device, or using a coaxial needle (double freehand).
The evidence suggests no significant difference in cancer detection rates between LATP biopsy and LA-TRUS biopsy. But it suggests lower rates of infection and sepsis after LATP biopsies. More evidence on their differences will come from the ongoing TRANSLATE trial, which may help refine clinical practice.
All the clinical evidence for freehand needle positioning devices is on the PrecisionPoint device. There is no comparative evidence for the EZU-PA3U, UA1232, or Trinity Perine Grid devices but experts suggest that cancer detection rates and adverse events should be similar between the different freehand devices.
The most likely cost effectiveness estimates for freehand needle positioning devices are within what NICE considers an acceptable use of NHS resources. Therefore LATP biopsy using a freehand needle positioning device is recommended.
There is no comparative evidence on the CamPROBE device, which uses a double freehand technique. Experts said that, because the double freehand technique is different to using the freehand needle positioning devices, it may not have the same cancer detection rates. Cost modelling suggests that double freehand techniques may not be cost effective compared with LA-TRUS biopsy. More research is needed to understand their clinical effectiveness.