TRANSPERINEAL PROSTATE BIOPSY AFTER ABDOMINOPERINEALRESECTION

KATSUTO SHINOHARA,* MITTUL GULATI, THERESA M. KOPPIE AND MARTHA K. TERRISFrom the Department of Urology, University of California-San Francisco and University of California-San Francisco/Mt. Zion

Comprehensive Cancer Center, San Francisco, Department of Urology, Stanford University Medical Center, Stanford and Section ofUrology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California

ABSTRACT

Purpose: Prostate cancer evaluation in men who have undergone abdominoperineal resectionposes a challenge for urologists. Diagnosis and staging methods are limited because as access tothe prostate via digital rectal examination is not possible. Prostate specific antigen (PSA) hasbeen used to screen for malignancy in this population. However, the conventional diagnostictechnique with transrectal ultrasound guided biopsies cannot be used. Transperineal ultrasoundand biopsy have been described to evaluate the prostate in this setting. We report our experiencewith transperineal ultrasound biopsy for evaluating the prostate in patients with elevated PSAwho have previously undergone abdominoperineal resection.

Materials and Methods: We reviewed the records of 28 patients treated at 2 institutions. Allpatients had a history of abdominoperineal resection and subsequent transperineal ultrasoundguided prostate biopsy for evaluating elevated PSA. Mean serum PSA in this population was 22ng./ml. (median 9.5, range 4.1 to 237). Abdominoperineal resection was done in 16 patients (57%)for colorectal cancer, in 11 (39%) for ulcerative colitis and in 1 (4%) for familial polyposis coli.Average time since resection was 14 years (range 1 to 33). Five patients had previously under-gone radiation therapy as part of treatment for colorectal cancer before transperineal ultrasoundbiopsy.

Results: Of the 28 biopsies performed 23 revealed prostate cancer, 2 revealed prostatitis and 3were benign. Average Gleason grade was 6.6 (range 3 to 9). Of the 23 patients with prostatecancer 22 were treated with androgen deprivation therapy (7), prostatectomy (8), external beam(6) and high dose (1) radiation therapy. Of the 8 patients who underwent prostatectomy patho-logical stage was T2 in 3 and T3 in 4, while pathological findings were not determined in 1 patientin whom the prostate was removed in pieces.

Conclusions: In patients with a history of abdominoperineal resection and elevated PSAtransperineal ultrasound guided biopsy of the prostate can provide an accurate tissue diagnosis.

KEY WORDS: prostate, prostatic neoplasms, biopsy, ultrasonography, abdomen

Abdominoperineal resection is performed for many sur-gical disorders of the colon and rectum. Current modalitiesfor prostate cancer detection include screening serum pros-tate specific antigen (PSA) and digital rectal examinationfollowed by transrectal ultrasound guided biopsy of theprostate. However, patients who have undergone abdomi-noperineal resection in the past pose a diagnostic chal-lenge to the urologist since the previous surgery leaves noaccess to the rectum for screening by digital rectal exam-ination or for diagnosis and staging by transrectal ultra-sound. Ultrasonographic and computerized tomography(CT) guided approaches to prostate biopsy after abdomino-perineal resection have been described. Transperineal ul-trasound can provide adequate prostate imaging for biopsyand cases of successful transperineal ultrasound guidedrandom prostate biopsy have been reported in the litera-ture.1– 4 We report the experience at 2 institutions withtransperineal ultrasound guided prostate biopsy for eval-uating patients after abdominoperineal resection.

MATERIALS AND METHODS

We reviewed the medical records of 28 patients at 2 insti-tutions. All patients had a history of abdominoperineal re-

section and subsequent transperineal ultrasound guidedprostate biopsy for evaluating elevated PSA. Biopsies wereperformed by the technique described. We determinedpre-biopsy patient characteristics, including serum PSA be-fore biopsy, the indication for abdominoperineal resectionand time from resection to biopsy. Biopsy Gleason scores andfollowup PSA results were reviewed.

For the transperineal ultrasound and prostate biopsy pro-cedure each patient was placed in the lithotomy position. A16Fr Foley catheter was placed and the retention balloon wasinflated. The catheter assisted in localizing the prostate andavoiding the urethra with the biopsy needle. It also enabledbladder distention to delineate the anterior aspect of theprostate.

The scrotum was retracted anterior. After a betadine scrubthe perineal skin and soft tissue overlying the palpable ure-thral catheter and any residual rectal dimple were infiltratedwith 1% lidocaine. After generous application of sonographicjelly to the perineal area a mechanical sector transrectalultrasound probe adjusted to end-fire settings was applied tothe perineum posterior to the bulbar urethra with the fre-quency set at 6 or 5 MHz. By following the course of theurethral catheter the prostate gland could be visualized inthe transverse and longitudinal views (fig. 1).

Biopsies were obtained using an automatic spring drivenbiopsy device mounted with an 18 gauge core biopsy needle.

Accepted for publication August 16, 2002.* Financial interest and/or other relationship with ATI Medical,

Endocare and NeoSeed.

0022-5347/03/1691-0141/0 Vol. 169, 141–144, January 2003THE JOURNAL OF UROLOGY® Printed in U.S.A.Copyright © 2003 by AMERICAN UROLOGICAL ASSOCIATION DOI: 10.1097/01.ju.0000042426.03293.e9

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Our technique differed from the transrectal approach, inwhich the needle is directed at a 45-degree angle to the rectalwall and biopsies are generally obtained through the poste-rior aspect of the prostate. When using the transperinealapproach, the needle is directed in the longitudinal axis ofthe prostate and biopsies are obtained via a caudal approach(fig. 2). We obtained 6 to 12 random biopsies bilaterally fromthe prostate apex, middle, base and lateral portions.

RESULTS

From April 1993 to December 1999, 28 men 48 to 78 yearsold (median age 65) with a history of abdominoperineal re-section underwent transperineal ultrasound guided biopsiesof the prostate due to elevated PSA (mean 22 ng./ml., median9.5, range 4.1 to 237). Resection was performed due to colo-rectal malignancy in 16 patients, ulcerative colitis in 11 and

familial polyposis in 1. The mean interval from resection tobiopsy was 14 years (range 1 to 33). Five patients had pre-viously undergone radiation therapy as part of treatment forcolorectal cancer.

Transperineal ultrasound and biopsies were performed by2 urologists (M. T. and K. S.) experienced with ultrasound forprostate evaluation. The prostate was well visualized bytransperineal ultrasound. Transperineal ultrasound imagequality was adequate to allow random prostate biopsies.Unlike transrectal ultrasound, the transperineal techniquedid not provide distinct visualization of the capsule or inter-nal anatomy for staging purposes, nor was resolution suffi-cient for identifying any hypoechoic areas for lesion directedprostate biopsies.

Transperineal ultrasound guided biopsies were success-fully completed in 28 cases. Of the 28 biopsy proceduresperformed 23 (82%) revealed prostate cancer with an averageGleason score of 6.6 (range 3 to 9), including 12 (52%) witha Gleason score of 7 or higher. In the remaining 5 patients 2biopsies showed prostatitis, while 3 revealed benign tissue(table 1). Patients diagnosed with prostate cancer tended tobe older than those with benign biopsies. The 2 patients withprostatitis and 3 with benign pathological findings on biopsyhad undergone abdominoperineal resection for ulcerative co-litis, while those in whom biopsies revealed prostate cancerhad undergone resection for malignancy, ulcerative colitisand familial polyposis.

Patients with higher serum PSA appeared more likely tohave cancer on transperineal ultrasound guided biopsy (table2). Of the 17 men with a serum PSA of less than 10 ng./ml. 13(76%) had prostate cancer. Of the 5 patients with a serumPSA of 10 to 20 ng./ml. biopsies revealed cancer in 4 (80%).All 6 patients (100%) with a serum PSA greater of than 20ng./ml. had prostate cancer on transperineal ultrasoundguided prostate biopsies.

Treatment choices in our patients with prostate cancer ontransperineal biopsy included radical prostatectomy in 8,

FIG. 1. Transperineal ultrasound of prostate. A, transverse view shows urethral catheter within prostatic urethra with lateral prostatelobes on either side. Capsule is difficult to visualize. B, longitudinal view demonstrates urethral catheter and balloon guide with apex andseminal vesicles.

FIG. 2. Transperineal prostate biopsy. Note relatively acute angleof needle in regard to long axis of prostate apex. Needle becomesalmost parallel with long axis of prostate middle and base.

TABLE 1. Clinical characteristics of patients with malignant andbenign diagnoses

Ca Benign

No. pts. 23 5Mean age 67 54Mean PSA (ng./ml.) 25 7.5Mean yrs. since abdominoperineal

resection11 27

Reason for abdominoperinealresection:

Ca 16 –Ulcerative colitis 6 5Familial polyposis 1 –

TRANSPERINEAL PROSTATE BIOPSY AFTER ABDOMINOPERINEAL RESECTION142

external beam radiation therapy in 6, hormone deprivationtherapy in 7 and watchful waiting in 1. A single patient whohad previously undergone radiation therapy for colon cancerwas treated with transperineal ultrasound guided catheterplacement, followed by targeted high dose radiation therapyusing a 192iridium implant. This treatment was elected be-cause previous radiation had excluded external beam radia-tion as a therapeutic option and made a surgical approach tothe prostate difficult. Radical prostatectomy was challengingin most cases, particularly after combined abdominoperinealresection and radiation therapy. Pathological stage in the 8patients who underwent radical prostatectomy was T2 in 3and T3 in 4. In 1 patient the prostate was removed in piecesdue to difficult dissection caused by previous surgery andradiation therapy. Thus, stage could not be determined.

DISCUSSION

Treating the patient without a rectum who presents withelevated PSA poses a challenge to the urologist. Severalimaging modalities have been described to facilitate prostatebiopsy in this setting. Transperineal biopsy guided by trans-abdominal ultrasound has been previously described when alarge tumor encroached on the bladder neck.5 However, thisapproach is difficult when tumors are smaller or confinedwithin the prostate since the prostate is positioned deep withinthe pelvis beneath the pubic bone,6 leading to inaccuracy invisualizing the prostate7 and difficulty in correctly positioningthe biopsy needle.3 Transabdominal prostate biopsy risks injuryto the bowel or dorsal vein complex and may sample moreanterior tissue.3

Transurethral ultrasound guided transperineal biopsy hasalso been reported in the literature.8 While this imagingmodality allows good visualization of the capsule and hypo-echoeic lesions, prostate views are limited to the transverseplane. Thus, they have limited usefulness for needle guid-ance.

A CT guided transgluteal biopsy technique has been de-scribed.9 While CT provides limited anatomical detail of theprostate, this technique can enable adequate imaging forperipheral zone biopsies when transrectal ultrasound is notpossible. Successful magnetic resonance imaging (MRI)guided transperineal biopsy of the prostate in a patient whohad previously undergone proctocolectomy has also been re-ported,10 as has CT-MRI fusion to guide radiotherapy in apatient who had previously undergone abdominoperineal re-section.11 However, CT and MRI are time-consuming and notcost-effective.

Transperineal ultrasound can adequately image the pros-tate for biopsy and cases of successful transperineal ultra-sound guided random prostate biopsy have been reported.1–4

To our knowledge we report the largest series to date oftransperineal ultrasound guided biopsy of the prostate inpatients who have previously undergone abdominoperinealresection. In this population transperineal ultrasound pro-vided good visualization of the prostate gland and facilitatedmultiple random needle biopsies (fig. 2). However, imagequality was inadequate for staging purposes because capsuleintegrity could not be well visualized on transverse or longi-tudinal images (fig. 1).

Despite this suboptimal image quality 82% of the patientsin our series were diagnosed with prostate cancer by trans-perineal biopsy. This rate is higher than reported previouslyusing transperineal or transrectal ultrasound guided pros-

tate biopsy. Although such a high detection rate was likelyPSA driven, biases inherent in this patient population mayalso have had a role. Abdominoperineal resection was per-formed due to colon cancer in more than half of these pa-tients. To our knowledge the risk of prostate cancer in menwho have undergone abdominoperineal resection is un-known. However, at least 1 study showed that men newlydiagnosed with colorectal cancer are at increased risk forbeing diagnosed with prostate cancer within 1 year (relativerisk 2.2).12 This observation suggests that men who haveundergone abdominoperineal resection for colorectal cancermay have a higher incidence of prostate cancer than thegeneral population.

Although the detection rate of prostate cancer by trans-perineal ultrasound guided biopsy was notably elevated inthis series of patients at high risk, using this technique iscontroversial. Shinghal and Terris performed transperinealand transrectal ultrasound guided sextant biopsies beforeprostatectomy in 20 men with biopsy proved prostate can-cer.13 Transrectal ultrasound guided biopsies had 65% sen-sitivity compared with 10% for transperineal ultrasoundguided biopsies. Patients in whom cancer was detected bytransperineal ultrasound guided biopsies had higher volumedisease, higher grade and higher serum PSA than men inwhom cancer was diagnosed only by transrectal ultrasoundguided biopsies.

Despite the poor results of transperineal ultrasound in thestudy of Shinghal and Terris,13 another series suggests thattransperineal ultrasound in patients at high risk for prostatecancer may have diagnostic use. Igel et al examined 88 menvia systematic transperineal ultrasound guided template bi-opsy.14 All patients had undergone at least 1 previous set ofsextant transrectal ultrasound guided biopsies and 75 (85%)had undergone 2 or more, of which all had been negative.Study inclusion criteria included PSA velocity greaterthan 0.75 ng./ml. yearly, total PSA greater than 10 ng./ml.and/or atypical small cell acinar proliferation on previousbiopsy. Systematic transperineal ultrasound guided tem-plate biopsy identified cancer in 38 of the 88 men (43%) inthis high risk subgroup.

Igel et al pointed out that improved sampling of far lateralperipheral zone tissue was possible with the transperinealultrasound biopsy technique.14 Others established the impor-tance of sampling from the far lateral peripheral zone.15

Figure 2 shows the trajectory of the transperineal biopsyneedle relative to the long axis of the prostate. While thebiopsy needle has a relatively acute course at the prostateapex, it approaches a course parallel to the long axis of theprostate at the mid portion and base, allowing sampling ofmore peripheral zone tissue.

Our results corroborate those of Igel et al14 suggesting thattransperineal ultrasound guided biopsies may be done fordetecting prostate cancer in a certain subgroup of patients.However, prostate cancer detected after abdominoperinealresection remains difficult to stage accurately and challeng-ing to treat successfully. Thus, the importance of prostatecancer screening before abdominoperineal resection can notbe overemphasized. A recent study showed that screening 20men with PSA and digital rectal examination before sched-uled abdominoperineal resection led to abnormal findings in6. On transrectal ultrasound guided biopsy 3 of these 6 men(50% of those biopsied or 15.8% of those screened) werediagnosed with adenocarcinoma of the prostate.16

It is possible that a proportion of the men in our studycould have been diagnosed and treated earlier with lowerrisk disease if they had been appropriately screened beforeabdominoperineal resection. Unfortunately treatment op-tions after abdominoperineal resection are limited becausethere is no rectal access for brachytherapy or cryosurgery.External beam radiation is a reasonable option in patientswho have not already undergone radiation therapy as part of

TABLE 2. Percent positive biopsies according to serum PSA

PSA (ng./dl.) No. Biopsied/No. Malignant (%)

Less than 10 17/13 (76)10–20 5/4 (80)Greater than 20 6/6 (100)

TRANSPERINEAL PROSTATE BIOPSY AFTER ABDOMINOPERINEAL RESECTION 143

treatment for colorectal pathology. However, there is a risk ofradiation damage to small bowel occupying the space vacatedby the distal colon in individuals who may already have theshort gut syndrome. Although perineal or suprapubic radicalprostatectomy is feasible in this population, the procedurecan be challenging, particularly in patients who have under-gone pelvic irradiation for rectal cancer. A significant num-ber of patients in this study had undergone adjuvant externalbeam radiation for rectal cancer after abdominoperineal re-section. As described, in 1 case this previous irradiationexcluded external beam radiation as a therapeutic option forprostate cancer. This patient was successfully treated withtransperineal ultrasound guided catheter placement in theprostate, followed by high dose rate radiation therapy.

This study has limitations. It is relatively small and reflectscases treated at 2 centers, which may not be representative ofexperiences elsewhere. While this study shows that transperi-neal ultrasound can be performed in patients who have under-gone abdominoperineal resection, our experience also suggeststhat treatment in these patients can be technically challenging.These technical challenges can be mitigated by diagnosing andtreating prostate cancer in these patients before they undergoabdominoperineal resection. Additional followup data, includ-ing survival statistics and continence outcome, may furtherhelp direct management in these cases.

CONCLUSIONS

Transperineal ultrasound guided random biopsy of theprostate can provide an accurate tissue diagnosis in patientswith elevated serum PSA who have previously undergoneabdominoperineal resection. However, transperineal ultra-sound image quality is poor compared with the transrectalapproach. Transperineal ultrasound can provide imaging ad-equate for random prostate biopsies but it may not be ade-quate for lesion directed biopsies. Because diagnostic ap-proaches and treatment options are limited afterabdominoperineal resection, men older than 40 years with alife expectancy of greater than 10 years should be screenedfor prostate cancer before surgery. After abdominoperinealresection appropriate candidates should also be screened forelevated PSA on a regular basis.

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