Transrectal Ultrasound in Prostate Cancer: Current Utilization, Integration with mpMRI, HIFU and Other Emerging Applications

Figures & data

Table 1 Commonly Reported Complication Rates Following Transrectal and Transperineal Prostate Biopsy

Biopsy Technique	Study	Number of Patients	Median Age (Years)	Mean PSA (ng/mL)	Median Cores Collected	Hematuria	Hematospermia	Rectal Bleeding	Pain Urinating	Urethrorrhaggia	Infection or Fever	Sepsis	Urinary Retention
Transrectal Biopsy	Ecke et al (2010)^Citation128 (7.5 MHz Probe)	332	67	16.79	–	6.6%	–	–	6.3%	–	1.8%	–	0.3%
	Ecke et al (2010)^Citation128 (5–10 MHz Probe)	101	67	9.99	–	12.9%	–	–	9.9%	–	4.0%	–	1.0%
	Chowdhury et al (2012)^Citation129	617	68	19.0 (µg/L)	8–10	37.0%	13.8%	11.5%	–	–	–	–	–
	Kariotis et al (2010)^Citation130	282	64.3 (mean)	7.3	13.1 (mean)	60.6%	86.9%	25.9%	–	–	–	–	–
	Raheem et al (2012)^Citation131	95	63.5 (mean)	7.8	12	63%	10%	39%	–	–	8%	0%	–
	Skouteris et al (2018)^Citation37	265	65	5.5	12.8	–	–	–	–	–	4.2%	–	0.0%
	Berry et al (2020)^Citation36	59.907	–	–	–	–	–	–	–	–	–	1.0%	1.9%
	Joshi et al (2020)^Citation132	50	67.8 (mean)	39.6	6–12	4%	0%	2%	–	–	6%	0%	20%
	Huang et al (2019)^Citation28	108	67.1 (mean)	10.9 (median)	10	13.8%	–	–	–	–	6.4%	7.0%	12.0%
Transperineal Biopsy	Pepe & Aragona (2013)^Citation133	915	66	–	12	8.1%	10.7%	–	–	2.0%	3.0%	0.0%	4.1
	Pepe & Aragona (2013)^Citation133	1330	66	–	18	9.7%	21.0%	–	–	1.5%	2.2%	0.0%	7.1
	Pepe & Aragona (2013)^Citation133	630	66	–	24	10.4%	30.4%	–	–	3.0%	2%	0.0%	11.1
	Symons et al (2013)^Citation38	409	63.3 (mean)	9.69	22	49.3% (minor), 2.4% (major)	–	–	16.4%	–	3.2%	0.2%	4.2%
	Skouteris et al (2018)^Citation37	379	65	5.5	51.5	–	–	–	–	–	0.79%	–	7.9%
	Berry et al (2020)^Citation36	13,723	–	–	–	–	–	–	–	–	–	1.4%	1.0%
	Lin Huang et al (2019)^Citation28	130	66.6 (mean)	9.3 (median)	10	5.3%	–	–	–	–	0.0%	0.0%	3.0%
	Wetterauer et al (2020)^Citation42	400	66	6.4	13	–	–	–	–	–	0.0%	0.0%	1%

Abbreviations: PSA, prostate specific antigen; ng/mL, nanograms per milliliter; ng/dL, nanograms per deciliter; csPCa, clinically significant prostate cancer; PCa, prostate cancer.

Table 2 Cancer Detection Rates of Transrectal and Transperineal Prostate Biopsy

Biopsy Technique	Transrectal Biopsy						Transperineal Biopsy
Study	Number of Patients	Mean Age (Years)	Mean PSA (ng/mL)	Median Number of Cores Collected	Overall PCa Detection Rate	csPCa Detection Rate	Number of Patients	Mean Age (Years)	Mean PSA (ng/mL)	Median Number of Cores Collected	Overall PCa Detection Rate	csPCA Detection Rate
Stefanova et al (2019)^Citation33	–	–	–	–	–	–	1287	66	7.05	–	49.8%	29.9%
Cowan et al (2020)^Citation32	–	–	–	–	–	–	508	67	7.91	20	–	69.0%
Huang et al (2019)^Citation28	108	67.1	10.9 (median)	10	49%	–	130	66.6	9.3 (median)	10	45%	–
Winoker et al (2020)^Citation134	211	65.0	7.9	12	69%	54%	168	68.0	7.9	12	79%	59%
Lo et al (2019)^Citation135	100	69.1	9.5 ng/dL	10	25.0%	—	100	67.7	12.0 ng/dL	10	35.0%	–
Di Franco et al (2017)^Citation136	111	66	7.8 (median)	–	34.26%	–	108	68	6.9 (median)	–	26.13%	–
Wetteraueret al (2020)^Citation42	–	–	–	–	–	–	400	66	6.4	13	64.5%	–

Abbreviations: PSA, prostate-specific antigen; ng/mL, nanograms per milliliter; %, percentage.

Figure 1 PIRADS VERSION 2 (American College of Radiology. Prostate Imaging – Reporting and Data System. 2019. Version 2.1. PIRADS).

Notes: Reproduced from the Radiology Assistant.¹⁴⁶

Abbreviations: DWI, diffusion weighted imaging; DCE, dynamic contrast enhanced; WI, weighted imaging; ADC, apparent diffusion coefficient; BPH, benign prostatic hyperplasia.

Table 3 Summary of Studies from the Last 5 Years Assessing Clinical Effectiveness of Micro-Ultrasound for Prostate Cancer Detection

Study	Technique	Number of Patients	Median Patient Age (Years)	Mean PSA (ng/mL)	Positive Predictive value	Negative Predictive value	Sensitivity	Specificity	Overall PCa Detection Rate	csPCa Detection Rate
Klotz et al (2021)^Citation102	mUS-guided systematic biopsy with mpMRI	1040	67	7.0 (median)	44%	85%	94%	22%	61%	39.5%
Lughezzani et al (2020)^Citation103	mUS-targeted and randomized biopsies following suspicious MRI	320	65	7.3	40.8%	81.5%	89.7%	26.0%	79.7%	36.3%
Eure et al (2019)^Citation104	mUS-targeted biopsy following mpMRI and standard TRUS	9	66	6.0	12.0–36.0%	96–98%	56–89%	45–92%	–	89%
Rodríguez Socarrás et al (2020)^Citation137	Transperineal prostate biopsy combining mUS and ultrasound fusion biopsy	194	62	6.5	46.0–62.3%	95.6–99.2%	98.9–99.7%	23.1–29.3%	56%	42%
Wiemer et al (2020)^Citation105	mUS-guided targeted biopsy	159	70	7.59 (median)	52%	75%	95%	15%	71%	49%
Claros et al (2020)^Citation138	MRI cognitive-guided mUS biopsy, targeted + random	47	68	7.8 (median)	–	–	–	–	64%	40%
Cornud et al (2020)^Citation139	MRI-directed mUS-guided biopsy	118	66 (mean)	11	–	–	100%	100%	57.6%	51.4%
Abouassaly et al (2020)^Citation140	mUS-guided targeted and systematic prostate biopsy	67	66	5.37 (median)	–	–	–	–	56.7%	31.3%
Lughezzani et al (2019)^Citation141	mUS targeted biopsy	104	64.5 (mean)	7.9	40%	90%	94%	28%	54%	34%
Chessa et al (2021)^Citation142	Transrectal mUS imaging on patients previously confirmed to have PCa via fusion biopsy	68	67.5	9.6	93%	31%	68%	31%	72%	–
Avolio et al (2021)^Citation143	mUS imaging prior to transperineal or transrectal fusion biopsy	43	63	6 (median)	27.2%	100%	100%	33.7%	38.7%	20%

Abbreviations: PSA, prostate-specific antigen; ng/mL, nanograms per milliliter; csPCa, clinically significant prostate cancer; PCa, prostate cancer; mUS, micro-ultrasound; mpMRI, multiparametric MRI.

Table 4 Summary of Studies Assessing Clinical Outcomes Following HIFU Focal Therapy for Prostate Cancer

Study	Treatment Technique	Number of Patients	Mean Age (Years)	Mean PSA (ng/mL)	Median Follow-Up (Months)	Failure Free Survival Rate	Bladder Continence	Erectile Function	Urethral Stricture	Hematuria
Guillaumier et al (2018)^Citation119	HIFU focal therapy	625	65	7.2	56	88%	98%	–	–	–
Rischmann et al (2017)^Citation122	HIFU Hemiablation	111	64.8	6.2	12	95%	97%	78%	1.0%	4.8%
Huber et al (2020)^Citation144	Anterior focal-HIFU therapy	45	64	7.5	–	62.2%	–	–	–	–
Huber et al (2020)^Citation144	Posterior focal-HIFU therapy	222	66	6.92	–	79.7%	–	–	–	–
Bakavicius et al (2019)^Citation124	HIFU focal therapy	210	68	7.4	11	–	–	–	1.9%	8.1%
Shoji et al (2020)^Citation145	HIFU focal therapy	90	70	7.26	21	92.2%	100%	86%	3.3%	–
Checcucci et al (2021)^Citation123	HIFU for salvage therapy	20	74.6	3.22	12	90%	–	–	0%	30%

Abbreviations: PSA, prostate-specific antigen; ng/mL, nanograms per milliliter; HIFU, high-intensity focused ultrasound.

Ecke TH, Gerullis H, Heuck CJ, et al. Does a new ultrasound probe change the complication rates of transrectal ultrasound-guided needle biopsies of the prostate? Anticancer Res. 2010;30(7):3071–3076.

 PubMed Web of Science ®Google Scholar

Chowdhury R, Abbas A, Idriz S, Hoy A, Rutherford EE, Smart JM. Should warfarin or aspirin be stopped prior to prostate biopsy? An analysis of bleeding complications related to increasing sample number regimes. Clin Radiol. 2012;67(12):e64–70. doi:10.1016/j.crad.2012.08.005

 PubMed Web of Science ®Google Scholar

Kariotis I, Philippou P, Volanis D, Serafetinides E, Delakas D. Safety of ultrasound-guided transrectal extended prostate biopsy in patients receiving low-dose aspirin. Int Braz J Urol. 2010;36(3):308–316. doi:10.1590/s1677-55382010000300007

 PubMed Web of Science ®Google Scholar

Raheem OA, Casey RG, Galvin DJ, et al. Discontinuation of anticoagulant or antiplatelet therapy for transrectal ultrasound-guided prostate biopsies: a single-center experience. Korean J Urol. 2012;53(4):234–239. doi:10.4111/kju.2012.53.4.234

 PubMedGoogle Scholar

Skouteris VM, Crawford ED, Mouraviev V, et al. Transrectal ultrasound-guided versus transperineal mapping prostate biopsy: complication comparison. Rev Urol. 2018;20(1):19–25. doi:10.3909/riu0785

 PubMedGoogle Scholar

Berry B, Parry MG, Sujenthiran A, et al. Comparison of complications after transrectal and transperineal prostate biopsy: a national population-based study. BJU Int. 2020;126(1):97–103. doi:10.1111/bju.15039

 PubMed Web of Science ®Google Scholar

Joshi R. Transrectal ultrasound guided prostatic biopsy and its complications: a descriptive cross-sectional study. JNMA J Nepal Med Assoc. 2020;58(221):44–47. doi:10.31729/jnma.4820

 PubMed Web of Science ®Google Scholar

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(1):101. doi:10.1186/s12894-019-0539-4

 PubMed Web of Science ®Google Scholar

Pepe P, Aragona F. Morbidity after transperineal prostate biopsy in 3000 patients undergoing 12 vs 18 vs more than 24 needle cores. Urology. 2013;81(6):1142–1146. doi:10.1016/j.urology.2013.02.019

 PubMed Web of Science ®Google Scholar

Symons JL, Huo A, Yuen CL, et al. Outcomes of transperineal template-guided prostate biopsy in 409 patients. BJU Int. 2013;112(5):585–593. doi:10.1111/j.1464-410X.2012.11657.x

 PubMed Web of Science ®Google Scholar

Wetterauer C, Shahin O, Federer-Gsponer JR, et al. Feasibility of freehand MRI/US cognitive fusion transperineal biopsy of the prostate in local anaesthesia as in-office procedure-experience with 400 patients. Prostate Cancer Prostatic Dis. 2020;23(3):429–434. doi:10.1038/s41391-019-0201-y

 PubMed Web of Science ®Google Scholar

Stefanova V, Buckley R, Flax S, et al. Transperineal prostate biopsies using local anesthesia: experience with 1287 patients. Prostate cancer detection rate, complications and patient tolerability. J Urol. 2019;201(6):1121–1126. doi:10.1097/ju.0000000000000156

 PubMed Web of Science ®Google Scholar

Cowan T, Baker E, McCray G, Reeves F, Houlihan K, Johns-Putra L. Detection of clinically significant cancer in the anterior prostate by transperineal biopsy. BJU Int. 2020;126(Suppl 1):33–37. doi:10.1111/bju.15124

 PubMed Web of Science ®Google Scholar

Winoker JS, Wajswol E, Falagario U, et al. Transperineal versus transrectal targeted biopsy with use of electromagnetically-tracked MR/US fusion guidance platform for the detection of clinically significant prostate cancer. Urology. 2020;146:278–286. doi:10.1016/j.urology.2020.07.072

 PubMed Web of Science ®Google Scholar

Lo KL, Chui KL, Leung CH, et al. Outcomes of transperineal and transrectal ultrasound-guided prostate biopsy. Hong Kong Med J. 2019;25(3):209–215. doi:10.12809/hkmj187599

 PubMed Web of Science ®Google Scholar

Di Franco CA, Jallous H, Porru D, et al. A retrospective comparison between transrectal and transperineal prostate biopsy in the detection of prostate cancer. Arch Ital Urol Androl. 2017;89(1):55–59. doi:10.4081/aiua.2017.1.55

 PubMedGoogle Scholar

Radiology Assistant. Prostate Imaging – Reporting and Data System. 2019. Version 2.1. PIRADS. Available from: https://radiologyassistant.nl/abdomen/prostate/prostate-cancer-pi-rads-v2. Accessed March 19, 2022.

 Google Scholar

Klotz L, Lughezzani G, Maffei D, et al. Comparison of micro-ultrasound and multiparametric magnetic resonance imaging for prostate cancer: a multicenter, prospective analysis. Can Urol Assoc J. 2021;15(1):E11–E16. doi:10.5489/cuaj.6712

 PubMed Web of Science ®Google Scholar

Lughezzani G, Maffei D, Saita A, et al. Diagnostic accuracy of microultrasound in patients with a suspicion of prostate cancer at magnetic resonance imaging: a single-institutional prospective study. Eur Urol Focus. 2020. doi:10.1016/j.euf.2020.09.013

 Google Scholar

Eure G, Fanney D, Lin J, Wodlinger B, Ghai S. Comparison of conventional transrectal ultrasound, magnetic resonance imaging, and micro-ultrasound for visualizing prostate cancer in an active surveillance population: a feasibility study. Can Urol Assoc J. 2019;13(3):E70–E77. doi:10.5489/cuaj.5361

 PubMed Web of Science ®Google Scholar

Rodriguez Socarras ME, Gomez Rivas J, Cuadros Rivera V, et al. Prostate mapping for cancer diagnosis: the Madrid protocol. transperineal prostate biopsies using multiparametric magnetic resonance imaging fusion and micro-ultrasound guided biopsies. J Urol. 2020;204(4):726–733. doi:10.1097/ju.0000000000001083

 PubMed Web of Science ®Google Scholar

Wiemer L, Hollenbach M, Heckmann R, et al. Evolution of targeted prostate biopsy by adding micro-ultrasound to the magnetic resonance imaging pathway. Eur Urol Focus. 2020;7:1292–1299. doi:10.1016/j.euf.2020.06.022

 PubMedGoogle Scholar

Claros OR, Tourinho-Barbosa RR, Fregeville A, et al. Comparison of initial experience with transrectal magnetic resonance imaging cognitive guided micro-ultrasound biopsies versus established transperineal robotic ultrasound magnetic resonance imaging fusion biopsies for prostate cancer. J Urol. 2020;203(5):918–925. doi:10.1097/ju.0000000000000692

 PubMed Web of Science ®Google Scholar

Cornud F, Lefevre A, Flam T, et al. MRI-directed high-frequency (29MhZ) TRUS-guided biopsies: initial results of a single-center study. Eur Radiol. 2020;30(9):4838–4846. doi:10.1007/s00330-020-06882-x

 PubMed Web of Science ®Google Scholar

Abouassaly R, Klein EA, El-Shefai A, Stephenson A. Impact of using 29 MHz high-resolution micro-ultrasound in real-time targeting of transrectal prostate biopsies: initial experience. World J Urol. 2020;38(5):1201–1206. doi:10.1007/s00345-019-02863-y

 PubMed Web of Science ®Google Scholar

Lughezzani G, Saita A, Lazzeri M, et al. Comparison of the diagnostic accuracy of micro-ultrasound and magnetic resonance imaging/ultrasound fusion targeted biopsies for the diagnosis of clinically significant prostate cancer. Eur Urol Oncol. 2019;2(3):329–332. doi:10.1016/j.euo.2018.10.001

 PubMed Web of Science ®Google Scholar

Chessa F, Schiavina R, Ercolino A, et al. Diagnostic accuracy of the Novel 29 MHz micro-ultrasound “ExactVuTM” for the detection of clinically significant prostate cancer: a prospective single institutional study. A step forward in the diagnosis of prostate cancer. Arch Ital Urol Androl. 2021;93(2):132–138. doi:10.4081/aiua.2021.2.132

 PubMedGoogle Scholar

Avolio PP, Lughezzani G, Paciotti M, et al. The use of 29 MHz transrectal micro-ultrasound to stratify the prostate cancer risk in patients with PI-RADS III lesions at multiparametric MRI: a single institutional analysis. Urol Oncol. 2021;39:832.e1–832.e7. doi:10.1016/j.urolonc.2021.05.030

 PubMed Web of Science ®Google Scholar

Guillaumier S, Peters M, Arya M, et al. A multicentre study of 5-year outcomes following focal therapy in treating clinically significant nonmetastatic prostate cancer. Eur Urol. 2018;74(4):422–429. doi:10.1016/j.eururo.2018.06.006

 PubMed Web of Science ®Google Scholar

Rischmann P, Gelet A, Riche B, et al. Focal high intensity focused ultrasound of unilateral localized prostate cancer: a prospective multicentric hemiablation study of 111 patients. Eur Urol. 2017;71(2):267–273. doi:10.1016/j.eururo.2016.09.039

 PubMed Web of Science ®Google Scholar

Huber PM, Afzal N, Arya M, et al. Focal HIFU therapy for anterior compared to posterior prostate cancer lesions. World J Urol. 2021;39(4):1115–1119. doi:10.1007/s00345-020-03297-7

 PubMed Web of Science ®Google Scholar

Bakavicius A, Sanchez-Salas R, Muttin F, et al. Comprehensive evaluation of focal therapy complications in prostate cancer: a standardized methodology. J Endourol. 2019;33(7):509–515. doi:10.1089/end.2018.0809

 PubMed Web of Science ®Google Scholar

Shoji S, Hiraiwa S, Uemura K, et al. Focal therapy with high-intensity focused ultrasound for the localized prostate cancer for Asian based on the localization with MRI-TRUS fusion image-guided transperineal biopsy and 12-cores transperineal systematic biopsy: prospective analysis of oncological and functional outcomes. Int J Clin Oncol. 2020;25(10):1844–1853. doi:10.1007/s10147-020-01723-9

 PubMed Web of Science ®Google Scholar

Checcucci E, De Luca S, Piramide F, et al. The real-time intraoperative guidance of the new HIFU Focal-One(®) platform allows to minimize the perioperative adverse events in salvage setting. J Ultrasound. 2021. doi:10.1007/s40477-021-00594-8

 PubMed Web of Science ®Google Scholar