Transperineal Prostate Biopsy Tools, Equipment & Instruments

[Dr. Aditya Bagrodia]
Before we get into all the details, you had the benefit of having somebody who was able to teach you and a mentor. Let's say that you don't have that benefit, you didn't do cryos or transperineal biopsies. What are the bare minimum equipment requirements that one would need? Matt, say that my platform is, I have a UroNav machine and a BK ultrasound that I use to do MRI ultrasound fusion biopsies in my clinic. Is that sufficient? Can I do a transperineal biopsy tomorrow?

[Dr. Matt Allaway]
The table that you use, the procedural table, I think is an important consideration because of the stirrups. You've got heel crutches, you've got the stirrup for the heel, and you've got the fancy sort of yellowfin stirrups, which would be like the Rolls Royce of sorts. If you're going to start your program using heel stirrups, and Juan, I don't know if you appreciated this, but when patients are in that position and they're nervous, they tighten up their legs and they actually push themselves away from you, so they're moving and sliding away from you. You really should switch over at least to the knee crutch because the knee crutch allows them to relax their legs. If they're in the heel stirrup, they have to use their leg muscles to support their knees so they don't flop aside. That's really important.

Number two, your ultrasound equipment. You mentioned you got UroNav with a BK. There you go, you're all set. Now, Juan will definitely jump in on this, but the probes, the transducers, many urologists don't even understand what they're holding in their hands. Yes, I have a biplanar probe, why can't I use that? No, we're talking about a linear array, not a micro convex biplanar probe. You can do transperineal biopsies with a biplanar transrectal probe, but the skill level to do that is quite different than if you're using your brachytherapy biplanar linear transducer.

[Dr. Juan Javier-DesLoges]
I think I looked at every single ultrasound on the market from GE, Hitachi, BK, to the cheapest $30,000 probe that you can buy, I can't even remember the name of it. In addition to that, you really need to be able to determine the difference between the transition zone and the peripheral zone with the probe. Based on the quality of your probe, you want to make sure that the ultrasound is high enough quality where you can really define the peripheral zone and the transition zone.

[Dr. Aditya Bagrodia]
We've entered this conversation assuming it's a foregone conclusion that we're going to be doing this not in the operating room. Juan, you're loud and clear that the time of the procedure, the cost, the anesthetic, all of that, it's something to consider. Certainly, for me, one of my biggest reluctances heading into this were: what if my block doesn't work or how's my familiarity with the anatomy going to be, given that I used to use end-fire. What I did, as you know, is shadowed you, worked with you, participated with you for 10, 15 cases. I said, "Okay, I think I can handle this." Then, I started doing my own cases in the operating room. Any thoughts on starting out in the OR versus the clinic? Do you have any strong opinions, Matt or Juan?

[Dr. Juan Javier-DesLoges]
I think starting in the OR has an advantage to put a plug in there. I do think that the AUA course is quite helpful for new learners. I had been doing it a year, by the time I went to the course. You pick up on a lot of little nuances that some of the other people are doing. I think just some didactics, plus doing them in the OR, would be helpful for anybody just starting up.

[Dr. Matt Allaway]
I would say those that just jump right in. I've trained hundreds of urologists in hundreds of different settings all throughout the world. I would tell you that in the US those that start under anesthesia sometimes they're not sure when to cut the umbilical cord. When am I ready to do this under local in the clinic? The ones that just dive in in the clinic, they actually get over that learning curve of getting comfortable knowing how to get the patient through it. I think they develop a good local anesthesia program faster. If you're in the OR, you always can lean on that anesthesia, so I think it's up to the individual. Those using fusion, sometimes they feel, "Well, when I trained on fusion, I prefer the patient to be under much better control, more relaxed, and I prefer it being done under anesthesia."

Well, I don't think that's the case anymore with transperineal. I think the whole point of what I worked on was I worked and developed everything with the precision point in a surgery center that we own and operate. I have a grid stepper that sits in the corridor. I never once used the grid stepper to do the biopsy because I knew that wasn't the path to mainstream the approach. The path to mainstream this approach is we've got to do it in less than 15 minutes under local anesthesia. We've got to make this teachable, we've got to make this deployable in the widespread urology community.

[Dr. Aditya Bagrodia]
This is a podcast so most people can't tell that I'm grinning and I'm grinning because I've taught myself some things like robotic retroperitoneal lymph dissection, even robotic cystectomies were not something that I was trained on in residency or fellowship, necessarily. As I reflect, I think it was actually moving transperineal biopsies to the clinic that provided me the most anxiety and consternation among all the different things I do. Your cut-the-umbilical cord analogy totally resonates with me.

I guess, that's debatable, depending on your comfort going into this and having partners that are familiar, if you want to start in the OR and also your familiarity with side-fire versus end-fire probes, I suppose, you could make a decision. Basic equipment, just basic, basic equipment, if you needed this, you wanted to watch like 10 YouTube videos: it would be a biplanar linear ultrasound probe and a grid stepper, things that your hospital already may have in the OR or do you even need the grid stepper? What would you say to that?

[Dr. Matt Allaway]
Well, I would say, this may be another discussion point. I don't want to hijack the grid dialogue, but I think Juan would probably agree with me that the grid, first of all, the experience with freehand versus grid is quite different, in my opinion. I think that people think the grid technique simplifies it because it's like playing battleship: just stick it in the hole and it goes where you think it's going to go. If you really study the trajectory of the biopsy needle, you're really having to insert a lot more needles to finesse that biopsy needle exactly into that seam. Now when I teach, I say you're playing an instrument; it's like learning to play the violin. Your music is the prostate under ultrasound, you have to read that music.

Every prostate is a little bit different. Transrectal was like "Boom, boom, boom", and you're done. There's very little appreciation for finesse and where you are in the prostate. You tend to cluster cores, even though you don't realize it. You've got to be able to read that. As a result, I think the grid is just too limiting and I don't think it serves a purpose of training wheels to help you do something better in the clinic setting. That would be my opinion.

[Dr. Juan Javier-DesLoges]
I think the grid is the historic way of doing the biopsy, that's how original transperineal biopsies were done a long time ago. We've made so much more progress over time with the attachments.

[Dr. Matt Allaway]
Yes, it's a whole new set of hand motions so much so that part of the training exercise, when you're working with urologists that have been out there for years doing transrectals, is untraining them on the habits of transrectal and teaching the new hand motions. To the fusion concept, I think when I train people on, let's say, UroNav, what I'll do is I'll actually cover the UroNav screen and force them to use their brain to anchor the biopsy needle in the vicinity of the ROI, requiring them to actually look at their own MRI and then anchoring the needle in to the capsule in the vicinity. Then and only then I take away the cover over the UroNav screen and then they introduce secondary motions and then they biopsy.

If you think that the fusion system is going to do the job for you, I compare it to this, we're trying to teach you how to play a stradivarius, but if you just think that fusion by itself is the only thing you need to know is watch that green circle and hit it, that's like playing guitar hero. You don't really know how to play the instrument. It's playing music and sometimes it's pretty good, but you've got to know. Cognitives like a Rand McNally Atlas. I'm trying to get to San Diego to visit you guys. I look at Rand McNally Atlas and I drive that way.

Fusion is like using your iPhone with one of your map apps. In 200 feet, turn right, turn left. Juan, you can please chime in, but you've got to use both of those skills. If you're not using your brain and reading that music, you could really turn the fusion experience into something like "Uh-oh, I didn't even get prostate tissue with that ROI. I got skeletal muscle or fat." If you know how to do two together, one plus one equals three. It's like icing on the cake to just be able to say, "I feel really good about it." Check cognitive, check fusion.

Then I actually sometimes like to go back after the neal is in the prostate, go back to your axial array, just on your ultrasound screen, and look for that flash and then remember the image you had in your head of the ROI on the axial T2 image and say, "Yes, that makes sense." Then, Juan, do you inspect your cores? I think you need to look at the DM core too because if you hit the ROI and it's really cancer, it's going to be dense and the core looks much different than a non-cancerous region that's all flimsy and fragmented. That's the way I kind of teach it.

[Dr. Juan Javier-DesLoges]
I don't think I've looked at the cores themselves, but it's a thing that I think I'll start thinking about doing. I completely agree with you, for cognitive, one of the things that we're doing, but we're cheating now. We've asked for access to the radiologist DynaCAD software where we can actually just see the whole length of the ROI and how they mapped it out because when you look at the MRI reports, there's one spot, but the ROI is actually quite longer. I do a combination between the two because there is registration error as hard as you try to avoid it. These tiny, little, subcentimeter lesions can be very easily missed even with the Fusion software. I think actually really knowing both really has made my biopsies better because before when I was a resident, I just was on auto drive. I was an autopilot. Artemis was going and I would just aim for the target. Now, I do Fusion, UroNavs, but I also, as you mentioned, do a little bit of cognitive, simultaneously.

[Dr. Aditya Bagrodia]
A couple of comments, and I certainly appreciate that perspective. One of the things that was a pleasant surprise is that the actual registering of the prostate with the UroNav, if you're going to go with a transperineal approach, is not markedly different from a transrectal approach. That wasn’t like an entire new skill set to learn, which I appreciated. I absolutely hear you. I think that using your analogies, which I like, Matt, I think doing a transrectal approach where you see the prostate, there's very little doubt about what exactly you're seeing. The base, and the apex, and the SVs are all fairly there. Might be the equivalent of coloring in a coloring book and then perhaps really understanding the prostate and where the lesions are are going to be something like a higher-quality piece of art. It is nice.

That was one thing that was not so intimidating when shifting towards the fusion biopsies that are actually registering as pretty comparable. Now, we've got our ultrasound probe. We've decided to really go hook line and sinker. We've got ultrasound fusion software. I also got to say, prior to coming here, I always thought that cognitive fusion biopsies were an absolute tier B option. I think that they may have more of a role transperineally. Any opinion on that?