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Transperineal MRI-Ultrasound Fusion Prostate Biopsy

If you’ve been advised to undergo a prostate biopsy due to elevated prostate specific antigen (PSA) levels or an abnormal magnetic resonance imaging (MRI) scan, you may feel concerned about what lies ahead. A transperineal MRI-ultrasound fusion prostate biopsy combines detailed MRI imaging with real-time ultrasound guidance. This diagnostic procedure allows urologists to precisely target suspicious areas within the prostate gland, improving cancer detection rates. Performing the biopsy through the skin (transperineal route) rather than through the rectum (transrectal route) also minimises complications, including severe urinary tract infection and rectal bleeding. Dr Tan Teck Wei uses this established technology to provide accurate diagnoses that guide appropriate treatment decisions. He was the earliest doctor in Singapore to publish on MRI-ultrasound fusion prostate biopsies in 2017, and transperineal prostate biopsy under local anaethesia in an outpatient setting in 2021. His expertise in conducting MRI-targeted prostate biopsies also led to his advisory role with Singapore’s Ministry of Health’s Agency for Care Effectiveness.

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Dr Tan Teck Wei

MBBS|DFD (CAW)|MRCS|MMed (Surgery)|FAMS (Urology)

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Overview Candidate Techniques Process Recovery Benefits Risks Considerations FAQ
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FAQ

What is Transperineal MRI-Ultrasound Fusion Prostate Biopsy?

A transperineal MRI-ultrasound fusion prostate biopsy is a diagnostic procedure that combines pre-procedure MRI scan images with real-time ultrasound imaging to obtain tissue samples from the prostate gland. The “transperineal” approach means the biopsy needles are inserted through the perineum (the skin between the scrotum and anus) rather than through the rectum.

This procedure uses specialised software to overlay or “fuse” the detailed MRI images onto live ultrasound images during the biopsy. This fusion technology enables urologists to precisely target suspicious areas identified on the MRI scan, improving the accuracy of cancer detection compared to traditional ‘blind’ systematic biopsies.

Studies have shown that MRI-ultrasound fusion biopsies detect clinically significant prostate cancers more effectively than conventional approaches, while reducing the detection of insignificant cancers that may not require immediate treatment.

Who is a Suitable Candidate?

Ideal Candidates

Ideal Candidates

  • Men with elevated or rising PSA levels requiring tissue diagnosis
  • Patients with suspicious findings on multiparametric MRI scans (PI-RADS 3, 4, or 5 lesions)
  • Those with previous negative biopsies but persistent clinical suspicion of prostate cancer
  • Men on active surveillance for low-risk prostate cancer requiring repeat assessment
  • Patients with abnormal digital rectal examination findings
  • Men seeking an accurate diagnostic approach with reduced infection risk
Contraindications

Contraindications

  • Active urinary tract infections that must be treated before the procedure
  • Severe bleeding disorders or patients on anticoagulation therapy that cannot be safely discontinued
  • Anatomical abnormalities preventing transperineal access
  • Severe medical conditions making the procedure risks unacceptable

The decision to proceed with a transperineal MRI-ultrasound fusion prostate biopsy requires careful evaluation by an experienced urologist. Your medical history, current medications, and overall health status will be thoroughly assessed to ensure the procedure is appropriate and safe for your specific situation.

Treatment Techniques & Approaches

  • MRI-Ultrasound Fusion Technology

    The fusion technology creates a three-dimensional map of your prostate by combining the detailed anatomical information from MRI scans with real-time ultrasound images. Software is used to align these images, allowing the urologist to visualise both the prostate anatomy and any suspicious regions identified on the MRI. This technology enables precise needle placement into areas of concern to obtain biopsy specimens.

  • Transperineal Biopsy Technique

    The transperineal approach involves inserting biopsy needles through the skin of the perineum. This method provides access to all regions of the prostate, including the anterior zone which is often difficult to reach with transrectal approaches. The rectum can never be thoroughly disinfected from faecal content, and the transperineal biopsy technique minimises infection risk as the needles do not need to pass through the rectum, eliminating bacterial contamination. In addition, there is no risk of rectal bleeding.

  • Systematic and Targeted Sampling

    Modern MRI-ultrasound fusion biopsy protocols combine targeted sampling of suspicious areas with systematic sampling of the entire prostate. Typically, 3 to 5 targeted samples are taken from each suspicious lesion identified on the MRI scan. About 10% of prostate cancers may not be visible on MRI scans. As part of the biopsy protocol, usually 12 systematic samples are taken from various zones of the prostate, in order to pick up these “MRI-invisible” cancers. This comprehensive approach ensures thorough evaluation while focusing on areas most likely to harbour significant cancer.

Wondering which approach is right for you?

Dr Tan Teck Wei will evaluate your specific needs and recommend the most suitable technique.

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The Treatment Process

Pre-Treatment Preparation

Before your biopsy, you will undergo a MRI prostate scan if it has not already been performed. This MRI scan takes about 40 minutes to perform and results are available within 24 hours. You will receive specific instructions about temporarily stopping blood-thinning medications, and you will be prescribed antibiotics to be taken on the morning of the procedure. Laxatives are usually given on the day before the biopsy to clear the bowels, which can improve the image quality of the real-time ultrasound images.

On the day of the biopsy, you will need to fast for 6 hours if sedation or general anaesthesia is planned. If the procedure can be done under local anaesthesia, no fasting is required. Arrange for someone to drive you home after the procedure.

During the Procedure

The procedure typically takes about 30 minutes and is performed in an operating theatre or specialised procedure room. After positioning you comfortably on your back with legs elevated, the anaesthetist team will administer either general anaesthesia or sedation, ensuring you are completely comfortable. If the procedure is to be done under local anaesthesia instead, injections will be given through the perineal skin to minimise pain during the procedure.

Your urologist will insert an ultrasound probe into the rectum to visualise the prostate, then activate the fusion software to overlay the MRI images. The machine can guide the biopsy needle precisely to each target area. You may hear clicking sounds as the spring-loaded biopsy device collects tissue samples. The targeted and systematic prostate samples are labelled separately for pathological analysis.

Immediate Post-Treatment

Following the procedure, you’ll recover in a monitored area for 1-2 hours. Medical staff will check your vital signs and ensure you can urinate normally before discharge. Mild discomfort and blood in the urine are expected and typically resolve within a few days. You will receive detailed written instructions about post-procedure care and emergency contact information.

Recovery & Aftercare

  • First 24-48 Hours

    During the initial recovery period, rest is important but complete bed rest is not necessary. You may experience mild perineal discomfort, which can be managed effectively with pain medication if needed. Blood in your urine is normal and should gradually decrease. Drink plenty of fluids to help flush the urinary system and prevent clot formation.

    Avoid strenuous activities, heavy lifting, and vigorous exercise. You can shower normally but avoid soaking in baths or swimming pools. Continue your prescribed antibiotics as directed to prevent infection. Most men can return to desk work within 1-2 days.

  • First Week

    As you progress through the first week, any discomfort should steadily improve. You may notice blood in your semen, which can persist for several weeks and is harmless. Continue avoiding intense physical activities but gentle walking is encouraged to promote healing.

    Your follow-up appointment is typically scheduled about a week after the biopsy to discuss the pathology results. This consultation is crucial for understanding your diagnosis and planning any necessary treatment. Monitor for signs of infection such as fever, chills, or worsening pain, though these are very rare with the transperineal biopsy approach.

  • Long-term Recovery

    Most men experience complete recovery within 2 weeks of the procedure. You can gradually resume all normal activities, including exercise and sexual activity, as comfort allows. Blood in the semen may continue for the first 5 to 10 ejaculations but does not indicate any problems.

    If cancer is detected, your urologist will discuss treatment options based on the biopsy findings, including cancer grade, location, and extent. If results are negative but clinical suspicion remains, your doctor may recommend continued monitoring with PSA tests and possible repeat MRI scan or biopsy in the future.

Dr Tan Teck Wei provides comprehensive post-procedure support to ensure optimal recovery.

Schedule your consultation to learn more about what to expect.

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Benefits of Transperineal MRI-Ultrasound Fusion Prostate Biopsy

This diagnostic approach offers significant advantages over traditional biopsy methods. The usage of MRI to guide prostate biopsies improves the detection rate of significant prostate cancer compared to systematic biopsy alone. By precisely targeting suspicious areas, fewer biopsy cores may be needed while achieving better diagnostic accuracy.

The transperineal approach virtually eliminates the risk of serious infections associated with transrectal biopsies. Studies show infection rates below 1% with the transperineal technique compared to 2-6% with transrectal approaches. This reduction in sepsis risk is particularly important given increasing antibiotic resistance.

The procedure provides comprehensive prostate sampling, including areas difficult to reach with transrectal techniques. This thorough evaluation reduces the likelihood of missing significant cancers and provides accurate risk stratification. The detailed mapping helps guide future treatments if cancer is detected, whether surgery, radiation, or focal therapy is considered.

Risks & Potential Complications

Common Side Effects

Most patients experience mild side effects that resolve without intervention. Blood in the urine occurs in nearly all patients but typically clears within a few days. Temporary difficulty urinating affects less than 10% of men, usually resolving within a week. Mild perineal bruising and discomfort are common but well-controlled with standard pain medications if necessary.

Blood in the semen is expected and may persist for several weeks without clinical significance. Some men experience temporary changes in erections, though permanent erectile dysfunction from the biopsy itself is very rare.

Rare Complications

Serious complications are rare with modern techniques and if performed by experienced urologists. Urinary retention requiring temporary catheterisation occurs in less than 2% of cases. Significant bleeding requiring intervention is rare, affecting fewer than 1 in 500 patients. The transperineal approach has reduced infection rates, with serious infections now exceptionally rare.

Dr Tan minimises risks through careful patient selection, meticulous sterile technique, and appropriate antibiotic prophylaxis. The use of MRI guidance can reduce the number of biopsy cores needed, decreasing complication risks while improving diagnostic accuracy.

Cost Considerations

The cost of transperineal MRI-ultrasound fusion prostate biopsy varies based on several factors. These include the complexity of your case, the number of targeted lesions, anaesthesia type, and facility fees. The procedure cost typically encompasses the surgical fee, anaesthesia services, operating room use, pathology analysis, and immediate post-procedure care.

While this technique may have higher upfront costs than traditional biopsies, its accuracy often prevents the need for repeat procedures. The reduced infection risk avoids potentially costly complications. Many patients find the investment in accurate diagnosis worthwhile for appropriate treatment planning.

During your consultation, our team will provide a detailed cost breakdown specific to your situation. We can discuss payment options and help you understand what is included in the quoted fee.

Dr Tan Scrubs Photo

Dr Tan Teck Wei

MBBS (S’pore)

DFD (CAW)

MRCS (Edin)

MMed (Surgery)

FAMS (Urology)

Dr Tan Teck Wei is a Senior Consultant Urologist in Singapore who specialises in the management of complex urological cancers, including those affecting the kidneys, prostate, and bladder.

He is fellowship-trained in open, laparoscopic and robotic surgery. He also specialises in the management of other urological conditions including:

  • Prostate Enlargement
  • Recurrent Urinary Tract Infections
  • Stones

To date, Dr Tan Teck Wei has been involved in more than 500 robot-assisted surgeries, building up his volume of cases from his fellowship training days and cementing his expertise in robotic surgery.

Dr Tan Teck Wei believes in the holistic management of his patients, and seeks to journey with them from diagnosis to cure.  Dr Tan is effectively bilingual in English and Mandarin, making him a popular choice with the young and old, as well as international patients.

Dr Tan Teck Wei possesses a wealth of specialist experience in the field of Urology. He has previously held positions as a Consultant Urologist and Director of Genitourinary Oncology at Tan Tock Seng Hospital.

Dr Tan’s expertise in conducting MRI-targeted Prostate Biopsies led to his advisory role with the Ministry of Health’s Agency for Care Effectiveness. Furthermore, he has served as an Adjunct Assistant Professor and Clinical Teacher at the National University of Singapore (NUS) Yong Loo Lin School of Medicine and the Nanyang Technological University-Imperial College London’s Lee Kong Chian School of Medicine respectively.

He has actively participated in humanitarian initiatives as a member of the Singapore Navy surgical team, collaborating with the Indonesian Navy to provide healthcare services to the communities in Padang and Ambon. It is his passion to improve the standards of healthcare to patients both in Singapore and overseas.

  • Former Consultant Urologist and Director of Genitourinary Oncology, Tan Tock Seng Hospital
  • Adjunct Assistant Professor, National University of Singapore (NUS) Yong Loo Lin School of Medicine
  • Clinical Teacher, Nanyang Technological University-Imperial College London’s Lee Kong Chian School of Medicine
  • Advisor, Ministry of Health’s Agency for Care Effectiveness
  • Surgical Team, Singapore Navy
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Ready to Take the Next Step?

If you’re considering transperineal MRI-ultrasound fusion prostate biopsy, Dr Tan Teck Wei can help you understand if it is the right choice for your needs. With extensive experience in MRI-ultrasound fusion prostate biopsy techniques, he provides personalised care throughout your diagnostic journey.

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    Frequently Asked Questions

    How accurate is MRI-ultrasound fusion biopsy compared to standard biopsy?

    MRI-ultrasound fusion biopsy improves the detection of clinically significant prostate cancers compared to the standard systematic biopsy alone. The technology allows precise targeting of suspicious areas seen on MRI, minimising the risk of sampling error inherent in the standard technique.

    Is the transperineal approach more painful than transrectal biopsy?

    With appropriate anaesthesia, most patients report minimal discomfort during the procedure itself. The transperineal biopsy is typically performed under sedation or general anaesthesia, ensuring complete comfort during the procedure. Post-procedure discomfort is generally mild and well-managed with standard pain medications. Many patients report less overall discomfort compared to their previous transrectal biopsy experiences.

    How long do I need to wait for biopsy results?

    Pathology results are typically available within about a week. The tissue samples undergo detailed analysis by specialised pathologists who evaluate for the presence of cancer, grade of the cancer, and assess its extent. Your urologist will schedule a follow-up appointment to discuss the results comprehensively, explain their implications, and outline any recommended next steps.

    Can I have an MRI-ultrasound fusion biopsy if I have hip replacements or other implants?

    Most modern implants are MRI-compatible, but this must be confirmed before scheduling your MRI scan. Hip replacements typically do not prevent MRI imaging, though they may create some local image distortion. Your urologist will review your implant details and may consult with the radiologists to ensure safe, effective imaging. Alternative imaging or biopsy approaches can be considered if MRI is not suitable.

    What happens if the biopsy finds cancer?

    If cancer is detected, your urologist will explain the findings in detail, including the cancer grade (Gleason score), extent, and location. Treatment options tailored to your specific situation will be discussed, which may include active surveillance, surgery, radiation therapy, or other approaches. The detailed information from the biopsy helps guide these decisions. You will have time to consider your options and may seek additional opinions before deciding on your treatment.

    When can I resume sexual activity after the biopsy?

    Most urologists recommend waiting at least one week before resuming sexual activity, allowing initial healing to occur. Blood in semen is expected for several weeks and is not harmful to you or your partner. If you experience any pain or significant bleeding with ejaculation, please inform your urologist.

    Is repeat biopsy ever necessary after a negative MRI-ultrasound fusion biopsy?

    While MRI-ultrasound fusion biopsy is highly accurate, repeat biopsy may be recommended in certain situations. These include persistently rising PSA levels, or new suspicious findings on follow-up MRI. The decision for repeat biopsy is individualised based on your specific risk factors and clinical picture. Your urologist will discuss ongoing monitoring strategies if initial results are negative.

    Conclusion

    Transperineal MRI-ultrasound fusion prostate biopsy represents an advancement in prostate cancer diagnosis, offering accuracy with reduced complications. By combining detailed MRI imaging with real-time ultrasound guidance, this procedure enables precise targeting of suspicious areas while comprehensively evaluating the entire prostate. The transperineal approach virtually eliminates serious infection risks, providing a safer diagnostic option for patients requiring prostate tissue diagnosis.