Is transperineal prostate biopsy through a single access point safe and reproducible?

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Carlos Rios-Melgarejo, José Ramón Velasco-Rubio, Enrique Pulido-Contreras, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4731459/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To compare the complication rates and diagnostic efficacy between transperineal single-access ultrasound-guided prostate biopsy (TPPB) and transrectal ultrasound-guided prostate biopsy (TRPB) among patients with suspected prostate cancer. Methods We collected and analyzed data from 241 patients with prostate cancer suspicion and divided them into two groups: 171 TPPB and 70 TRPB. For the detection of complications associated with the technique, patients were followed–up for 3 months; furthermore, histopathological results to confirm prostate cancer were compiled. Results Histopathological reports showed 132 patients with malignancy (54.77%) and 109 with negative results (45.22%). TPPB detected malignancy in 60.2% of patients, compared with 41.4% detected by TRPB (p = 0.008). The most frequent complications in TPPB were hematuria (53.8%), post-procedural pain (6.4%), hematospermia (6.4%), and acute urinary retention (2.3%). All patients undergoing TRPB experienced pain during and after the procedure (p < 0.001). The TPPB technique was shown to be a protective factor against the development of complications (OR 0.028, 95% CI 0.009–0.09; p < 0.001). In contrast, complications associated with the TRPB technique were significantly higher (OR 35.5, 95% CI 10.7–117.6; p < 0.001). Conclusion Transperineal single-access prostate biopsy offers greater capability for prostate cancer detection and should be adopted as the first-choice method for prostate cancer diagnosis given its lower rates of infectious complications and can be performed on an outpatient basis with local anesthesia and sedation, without the need for prior intestinal preparation or antibiotic prophylaxis. Prostate biopsy transperineal prostate cancer diagnosis. Figures Figure 1 Is transperineal prostate biopsy through a single access point safe and reproducible? Prostate cancer is the most common non-cutaneous neoplasm in men( 1 , 2 ) and is the 5th most common cause of cancer-related death in men( 3 ). Prostate biopsy is the essential test for diagnosing prostate cancer( 4 ). With technological advances, ease of performance, and cost-effectiveness, transrectal ultrasound-guided prostate biopsy has become the gold standard worldwide owing to its high diagnostic yield( 5 , 6 ). However, this is not without severe complications. The incidence of procedure-related infections in developed countries increased from 0.52% in 2002–2009 to 2.15% in 2010–2011( 7 ), partly because of the emergence of multidrug-resistant bacteria. Hospital admissions attributable to complications following transrectal prostate biopsy ranged from 0.8–6.9%. Complications are reported in up to 7% of cases, with sepsis occurring in 0.3–3.1% of cases( 8 ). Transperineal prostate biopsy has gained popularity in recent years, especially since the European Association of Urology recommended it in their prostate cancer guidelines starting in 2015( 8 ). The potential to improve cancer detection rates has been considered an advantage, along with its lower complication rates( 9 ). Therefore, the objective of this study was to evaluate the complications of transperineal freehand single-access ultrasound-guided prostate biopsy versus the standard technique in patients with suspected prostate cancer. Materials and Methods Methodology The study was approved by the Ethics and Research Committee (Registration No. R-2022-1001-059). A Prospective cohort study was conducted on 241 patients with prostate cancer suspicion. Sociodemographic, clinical, and laboratory data were collected from the clinical archive of patients who underwent transperineal ultrasound–guided prostate biopsy (TPPB) and transrectal ultrasound–guided prostate biopsy (TRPB). For the detection of complications associated with the technique, patients were followed up through a 3–month period on subsequent medical appointments; furthermore, histopathological results to confirm prostate cancer were computed. Biopsy sample collection Transperineal prostate biopsies were performed in the urology department by a urologist expert in TPPB, alongside fellows. Transrectal biopsies were performed in the interventional radiology department. Procedure Patients suspected of prostate cancer underwent the procedure mentioned above. Transperineal biopsies were performed in an outpatient urology setting without antibiotic prophylaxis under sedation, followed by local anesthesia. Patients were placed in lithotomy position with preparation of the genital area. Ultrasound guidance was conducted using a BK 3000 ultrasound with a biplanar transducer (Copenhagen, Denmark). 1% lidocaine was applied as local anesthesia to the perineal region of the skin and subcutaneous cellular tissue without breaching the urogenital diaphragm. A single access point was used with a 16 G Jamshidi needle, positioned centrally in the perineum 1.5 cm above the anus, to access the prostate, omitting the usual lateral-bilateral access to the midline raphe described in other techniques. Saturation biopsy was performed by dividing the prostate into 6 zones (3 per side): base, mid, and apex, with 5 biopsies per zone totaling 30 cores, adjusted as needed for confirmatory biopsies in patients with elevated PSA levels. Figure 1, Biopsy guns and Bard needles (Bard® 18 G x 20 cm) were used, and their placement was confirmed in the axial and sagittal planes. Transrectal biopsies were performed in the interventional radiology department of the hospital following intestinal preparation and antibiotic prophylaxis only with local anesthesia, with an average of 12 cores per procedure. All patients underwent follow-up immediately after the procedure, at the 1st, 2nd, and 4th weeks, and at 3 months post-procedure. During urologic consultations or telephone calls, patients were queried about general and specific genitourinary symptoms. Statistical analysis The analysis from descriptive data of quantitative variables used either media and standard deviation or media and percentiles according to Kolmogorov Smirnov’s test, as well as frequency and percentage for qualitative variables. For the techniques’ (TPPB and TRPB) and their respective complications, Student’s t-test, Mann-Whitney U test, Pearson’s x 2 test, and the exact test of Fisher were used, according to the type of variable and its distribution. The Kappa index was used for the agreement analysis between the rectal examination and histopathological results. Statistical significance was established using a p- value < 0.05. IBM SPSS version 24 was used for the simple logistic regression analysis, and Forest plot graphics were generated for the complications associated with TPPB and TRPB. Results Our study included 241 patients suspected of prostate cancer. Patients were categorized based on the type of biopsy they underwent: transperineal biopsy (TPPB) was performed on 171 patients (71%), and transrectal biopsy (TRPB) on 70 patients (29%) Table 1 . Table 1 Comparison of clinical characteristics, complications, and diagnostic efficacy rates of prostate biopsy techniques in patients with suspected prostate cancer. Transperineal biopsy n = 171 Transrectal biopsy n = 70 p- value Age (years) 67.0 (62–72.5) 70.5 (64.3–76) 0.010 PSA (ng/ml) 12 (8.2–23) 14.4 (6.7–64.3) 0.38 Prostate volume (g) 40.0 (30.0–50.0) 40.5 (34.0–60.3) 0.47 PSA Density 0.3 (0.2–0.6) 0.3 (0.1–2.0) 0.82 Rectal examination (g) 113 (66.1) 55 (78.6) 0.055 Suspicious tact 67.0 (62–72.5) 70.5 (64.3–76) 0.010 General complications 96 (56%) 70 (100%) < 0.001 Hematuria 91 (53%) 19 (27%) < 0.001 Pain during procedure 1 (0.6%) 70 (100%) < 0.001 Post-procedural pain 11 (6.4%) 70 (100%) 0.99 Orchiepididymitis 3 (1.8%) 1 (1.4%) > 0.99 Hematospermia 11 (6.4%) 10 (14%) 0.05 Rectorrhagia 1 (0.6%) 51 (73%) 0.99 Anxiety 1 (0.6%) 0 (0%) > 0.99 CORES 29.0 (25.0–30.0) 12.0 (12.0–12.0) < 0.001 Histopathological result Benign Malignant 68 (39.8) 103 (60.2) 41 (58.6) 29 (41.4) 0.008 Values were expressed as medians (ranges) and frequencies (%). Clinical characteristics were compared between both groups, revealing a lower median age in patients who underwent TPPB compared with those who underwent TRPB (67.0 vs 70.5; p = 0.01). There were no statistically significant differences observed between TPPB and TRPB groups in terms of PSA levels (12.0 vs 14.4; p = 0.38), prostate volume (40 vs 40.5; p = 0.47), or PSA density (0.3 vs 0.3; p = 0.82), respectively. However, significantly more cores were obtained in patients with TPPB than in those with TRPB (29 vs 12; p < 0.001). On the other hand, the frequency of complications was evaluated in both groups. In total, 100% of patients who underwent TRPB experienced at least one complication, compared with 56% in the TPPB group (p < 0.001). Hematuria was more common in the TPPB group (53% vs 27%; p < 0.001). The incidence of acute urinary retention (2.3%) and anxiety (0.6%) was slightly higher in patients with TPPB, but the difference was not statistically significant. The TRPB group more frequently experienced hematospermia (14% vs 6.4%; p = 0.05), rectorrhagia (73% vs 0.6%; p < 0.001), and sepsis occurred in only one patient (1.4% vs 0%). Histopathological examination revealed malignant tumors in 132 (54.77%) and 109 with benign findings (45.22%). The primary complications observed in patients with benign tumors were pain during and after the procedure (38.5% and 42.2%, respectively) and hematospermia (12.8%). The frequency of complications in both groups is detailed in Table 1 . The number of biopsies (cores) obtained using each technique did not increase the risk of developing complications. Similarly, a greater number of biopsies (cores) did not increase the rate of prostate cancer diagnosis between the two groups. The risk analysis for complications after both prostate biopsy techniques were conducted using Odds Ratio. Only statistical trends were observed in the risk of developing complications between the two techniques. Patients who underwent TPPB showed a higher risk of developing hematuria (OR 0.41, 95% CI 0.15–1.14; p = 0.07). No differences were observed in the development of other complications. Discussion To our knowledge, this is the first study to describe complications of TPPB using a freehand single-access point without antibiotic prophylaxis and compare it against the standard TRPB technique with antibiotic prophylaxis. Previously, transperineal biopsy was preferred for patients with a history of rectal cancer, trauma, or inflammatory bowel disease. The potential to improve cancer detection rates has been considered an advantage( 10 ). Jiang found no differences in prostate cancer detection rates between transrectal and transperineal approaches( 11 ). In our study, we achieved a prostate cancer diagnostic rate with TPPB of 60.2%, which was higher than the transrectal technique of 41.4% (p = 0.008). Our study demonstrated a higher prostate cancer diagnostic rate compared with TRPB and most TPPB studies in which attachments such as templates( 5 ), CamProbe( 12 ), coaxial needle( 13 ), and fusion biopsy( 14 ) were used Table 2 . Table 2 Comparison of different studies evaluating transperineal prostate biopsies. Study Nature of study Year n Average PSA Average p volume PC diagnostic rate MRI Type of biopsy Used attachment Access points Prophylaxis Cores average Meyer et al. Free hand/ precision point 2018 43 6.1 42.9 48.8 Yes «Cognitive»/MRI Precision point 2 or + No «NE» Lopez et al. Free hand/ precision point 2021 1218 7.6 46 67 Yes «Cognitive»/MRI Precision point 2 or + Yes 24 Marra et al. Free hand/Fusion 2020 1014 8.1 51.3 43.9 Yes Fusion MRI/US None/coaxial 12 or + Yes 15.3 Kum et al. Free hand/ precision point 2018 176 7.9 45 79 Yes «Cognitive»/MRI Precision point 2 Yes 24.2 Ristau et al. Free hand/ precision point 2018 1000 7.9 41.8 60.7 No US Precision point 2 Yes 16 Aziz et al. Template 2022 123 15.5 68.2 43.4 Yes Fusion MRI/US Template 56 or + «NE» 56.6 Gorin et al. Free hand/ precision point 2020 95 6.9 36 83.2 Yes Fusion MRI/US Precision point 2 or + No, Only 1 12–14 Dekalo et al. Template 2017 114 14.3 63 45 Yes «Cognitive» MRI /US Template 2 or + Yes 37.6 Igsoon et al. Free hand/ precision point 2022 55 14.2 37.2 43.6 Yes «Cognitive»/MRI Jelco ® (coaxial) 2 or + Yes 20 Our study Free hand/coaxial 2024 171* 12 40 60.2. No US Jamshidi needle (coaxial) 1 No 29 The transperineal approach can detect lower-stage and anterior zone tumors( 15 ). The reason for this superiority is that an estimated up to 40% of tumors are located in the anterior portion of the prostate( 16 ). As previously mentioned, the risk of sepsis following TRPB has increased in recent years because of the increasing prevalence of multidrug-resistant bacteria (MDR), particularly Escherichia coli. In our study, the sepsis rate among patients who underwent TRPB was 1.4%, compared to 0% with TPPB, which is consistent with findings reported in the literature and supports Power’s assertion that transitioning from TRPB to TPPB virtually eliminates the risk of sepsis( 17 , 18 ). However, it's important to note that this generalization cannot be fully established statistically ( 18 ). Regarding other complications, a meta-analysis by Xiang et al. Determined that TPPB reduces the risk of rectorrhagia and fever but increased the risk of acute urinary retention (AUR). However, it is noted that AUR is mainly associated with a higher number of cores obtained, leading to subsequent prostatic edema, which is transient and resolves with the placement of a transurethral Foley catheter( 10 ). In our study, we similarly demonstrated that TPPB protects against rectorrhagia and hematospermia but poses a higher risk of hematuria. Additionally, three cases of AUR initially occurred, which we attributed to anesthesia applied below the Denonvilliers fascia, causing elevation of the prostatic apex and subsequent urethral compression. These cases were managed with Foley catheter placement, and currently, we only administered local anesthesia to the skin and perineum, with no further cases of AUR reported. There are no formal guidelines regarding the total number of biopsies that should be performed during ultrasound-guided prostate biopsy procedures. Similarly, multiple studies have concluded that more cores significantly increase the risk of complications such as infection, bleeding, pain, and urinary difficulties( 11 , 19 ). However, it is important to note that most of these studies were conducted using transrectal or transperineal biopsy samples with templates or multiple access points. In our study, TPPB was shown to be protective against the development of complications despite an average of 28 cores taken per procedure, whereas complications associated with TRPB were significantly more frequent, with an average of only 12 cores taken per procedure. Historically, prostate biopsy has been considered to require general anesthesia( 20 ). However, Hong demonstrated that 85.4% of patients found the transperineal approach tolerable under local anesthesia alone( 21 , 22 ), and they would choose the same technique if they needed a prostate biopsy, suggesting that it could be performed on an outpatient basis. Kum et al. also found acceptable pain levels in his study regarding this procedure( 23 ). In our study, transperineal biopsies were performed under local anesthesia and sedation, and excellent pain tolerance was reported during and after the procedure. Only one patient reported discomfort during and after TPPB, whereas 100% of the patients experienced pain during TRPB. The only disadvantage of the "free-hand" technique without the use of templates or adjuncts is that the needle is not attached to the transducer, which can add time to the procedure and potentially compromise adequate sampling of prostate tissue( 23 ). However, as Pilatz emphasizes, "current evidence underscores that it is time for the urological community to transition from transrectal to transperineal approaches despite any possible logistical challenges"( 24 ). Additionally, the TRexit movement, a global initiative advocating this change( 25 ), is gaining momentum( 26 ). Our study has several limitations, TRPBs were performed by radiologists in the radiology department using the sextant technique, with a different approach compared to TPPBs performed by urologists. Additionally, the lack of stratification into groups based on prostate-specific antigen levels can lead to a high rate of prostate cancer detection. It is crucial for future studies to consider these factors to provide a more accurate and comprehensive assessment of the complications and diagnostic effectiveness of different prostate biopsy techniques. Conclusion Transperineal freehand single-access prostate biopsy offers greater capability for prostate cancer detection than the transrectal technique. The transperineal approach should be adopted as the first-choice method for prostate cancer diagnosis given its lower rates of infectious complications and can be performed on an outpatient basis with local anesthesia and sedation, without the need for prior intestinal preparation or antibiotic prophylaxis. Declarations Author Contribution: Ríos – Melgarejo Carlos: Protocol development, project development, data collection, manuscript writing and manuscript editing. Velasco – Rubio José Ramón: Protocol development, project development, data collection, manuscript writing and manuscript editing. Pulido – Contreras Enrique: Protocol development, project development, data collection, manuscript writing and manuscript editing. Bonilla – Lara David: Protocol development, project development, data collection, manuscript writing and manuscript editing. Gastélum – Rivera Esteban: Protocol development, project development, data collection, manuscript writing and manuscript editing. Avendaño – Bastidas Santiago Arturo:data collection. González – Villegas Hedler Olaf:Protocol development, project development, data collection. Gómez – Mendoza Miguel: Protocol development, project development, data collection. Funding: The authors did not receive specific funding for this study. Conflicts of interest: On the part of the authors, no conflicts of interest are declared. Ethical approval: This study collected data obtained for clinical purposes, and all procedures were performed as part of routine care. The procedures used in this study adhere to the principles of the declaration of Helsinki. Informed consent: Informed consent was obtained from all participants included in the study before the procedures. References Siegel RL, Miller KD, Jemal A (2019) Cancer statistics, 2019. CA Cancer J Clin 69(1):7–34 Rico L, Contreras P, Blas L, Ríos Pita H, Vitagliano G, Ameri C (2018) ¿Es la biopsia de próstata transperineal más eficaz y segura que la biopsia transrrectal?* Is Transperineal Prostate Biopsy more effective and Safer than Transrectal Biopsy? Rev Arg de Urol · 83(1):2018–2023 DiBianco JM, Mullins JK, Allaway M (2016) Ultrasound Guided, Freehand Transperineal Prostate Biopsy: An Alternative to the Transrectal Approach. 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Eur Urol Focus Roberts MJ, Macdonald A, Ranasinghe S, Bennett H, Teloken PE, Harris P et al (2021) Transrectal versus transperineal prostate biopsy under intravenous anaesthesia: a clinical, microbiological and cost analysis of 2048 cases over 11 years at a tertiary institution. Prostate Cancer Prostatic Dis 24(1):169–176 Basourakos SP, Alshak MN, Lewicki PJ, Cheng E, Tzeng M, DeRosa AP et al (2022) Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy: A Systematic Review and Meta-analysis. European Urology Open Science, vol 37. Elsevier B.V., pp 53–63 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Bonilla-Lara","email":"","orcid":"","institution":"Hospital de Especialidades Unidad Médica de Alta Especialidad, Instituto Mexicano del Seguro Social (IMSS)","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Bonilla-Lara","suffix":""},{"id":331465783,"identity":"db91373a-d4d4-4e5f-a8dd-29ce4889f999","order_by":5,"name":"Santiago Arturo Avendaño-Bastidas","email":"","orcid":"","institution":"Hospital de Especialidades Unidad Médica de Alta Especialidad, Instituto Mexicano del Seguro Social (IMSS)","correspondingAuthor":false,"prefix":"","firstName":"Santiago","middleName":"Arturo","lastName":"Avendaño-Bastidas","suffix":""},{"id":331465784,"identity":"51217f17-3933-4c9b-af70-35c2ca7bb2df","order_by":6,"name":"Hedler Olaf Gonzalez-Villegas","email":"","orcid":"","institution":"Hospital de Especialidades Unidad Médica de Alta Especialidad, Instituto Mexicano del Seguro Social (IMSS)","correspondingAuthor":false,"prefix":"","firstName":"Hedler","middleName":"Olaf","lastName":"Gonzalez-Villegas","suffix":""},{"id":331465785,"identity":"e2cf1bf9-4994-4216-9dbe-49f470db557c","order_by":7,"name":"Miguel Gomez-Mendoza","email":"","orcid":"","institution":"Hospital de Especialidades Unidad Médica de Alta Especialidad, Instituto Mexicano del Seguro Social (IMSS)","correspondingAuthor":false,"prefix":"","firstName":"Miguel","middleName":"","lastName":"Gomez-Mendoza","suffix":""}],"badges":[],"createdAt":"2024-07-12 15:59:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4731459/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4731459/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62633133,"identity":"a4cd8a83-83d9-445a-9ea0-6b73e06a1da2","added_by":"auto","created_at":"2024-08-16 16:18:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4124549,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4731459/v1/c01f07a32a171f65f5d01ae0.jpg"},{"id":64191779,"identity":"75e83a93-b497-456a-823a-e63db6748609","added_by":"auto","created_at":"2024-09-09 18:47:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4850786,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4731459/v1/7a8d809d-1cf3-4950-9e5f-a98f49fcb056.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is transperineal prostate biopsy through a single access point safe and reproducible?","fulltext":[{"header":"Is transperineal prostate biopsy through a single access point safe and reproducible?","content":"\u003cp\u003eProstate cancer is the most common non-cutaneous neoplasm in men(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and is the 5th most common cause of cancer-related death in men(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eProstate biopsy is the essential test for diagnosing prostate cancer(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). With technological advances, ease of performance, and cost-effectiveness, transrectal ultrasound-guided prostate biopsy has become the gold standard worldwide owing to its high diagnostic yield(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, this is not without severe complications. The incidence of procedure-related infections in developed countries increased from 0.52% in 2002\u0026ndash;2009 to 2.15% in 2010\u0026ndash;2011(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), partly because of the emergence of multidrug-resistant bacteria. Hospital admissions attributable to complications following transrectal prostate biopsy ranged from 0.8\u0026ndash;6.9%. Complications are reported in up to 7% of cases, with sepsis occurring in 0.3\u0026ndash;3.1% of cases(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTransperineal prostate biopsy has gained popularity in recent years, especially since the European Association of Urology recommended it in their prostate cancer guidelines starting in 2015(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The potential to improve cancer detection rates has been considered an advantage, along with its lower complication rates(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Therefore, the objective of this study was to evaluate the complications of transperineal freehand single-access ultrasound-guided prostate biopsy versus the standard technique in patients with suspected prostate cancer.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMethodology\u003c/h2\u003e \u003cp\u003eThe study was approved by the Ethics and Research Committee (Registration No. R-2022-1001-059). A Prospective cohort study was conducted on 241 patients with prostate cancer suspicion. Sociodemographic, clinical, and laboratory data were collected from the clinical archive of patients who underwent transperineal ultrasound\u0026ndash;guided prostate biopsy (TPPB) and transrectal ultrasound\u0026ndash;guided prostate biopsy (TRPB). For the detection of complications associated with the technique, patients were followed up through a 3\u0026ndash;month period on subsequent medical appointments; furthermore, histopathological results to confirm prostate cancer were computed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eBiopsy sample collection\u003c/h2\u003e \u003cp\u003eTransperineal prostate biopsies were performed in the urology department by a urologist expert in TPPB, alongside fellows. Transrectal biopsies were performed in the interventional radiology department.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003ePatients suspected of prostate cancer underwent the procedure mentioned above. Transperineal biopsies were performed in an outpatient urology setting without antibiotic prophylaxis under sedation, followed by local anesthesia. Patients were placed in lithotomy position with preparation of the genital area. Ultrasound guidance was conducted using a BK 3000 ultrasound with a biplanar transducer (Copenhagen, Denmark). 1% lidocaine was applied as local anesthesia to the perineal region of the skin and subcutaneous cellular tissue without breaching the urogenital diaphragm. A single access point was used with a 16 G Jamshidi needle, positioned centrally in the perineum 1.5 cm above the anus, to access the prostate, omitting the usual lateral-bilateral access to the midline raphe described in other techniques. Saturation biopsy was performed by dividing the prostate into 6 zones (3 per side): base, mid, and apex, with 5 biopsies per zone totaling 30 cores, adjusted as needed for confirmatory biopsies in patients with elevated PSA levels. Figure\u0026nbsp;1, Biopsy guns and Bard needles (Bard\u0026reg; 18 G x 20 cm) were used, and their placement was confirmed in the axial and sagittal planes.\u003c/p\u003e \u003cp\u003eTransrectal biopsies were performed in the interventional radiology department of the hospital following intestinal preparation and antibiotic prophylaxis only with local anesthesia, with an average of 12 cores per procedure.\u003c/p\u003e \u003cp\u003eAll patients underwent follow-up immediately after the procedure, at the 1st, 2nd, and 4th weeks, and at 3 months post-procedure. During urologic consultations or telephone calls, patients were queried about general and specific genitourinary symptoms.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe analysis from descriptive data of quantitative variables used either media and standard deviation or media and percentiles according to Kolmogorov Smirnov\u0026rsquo;s test, as well as frequency and percentage for qualitative variables.\u003c/p\u003e \u003cp\u003eFor the techniques\u0026rsquo; (TPPB and TRPB) and their respective complications, Student\u0026rsquo;s t-test, Mann-Whitney U test, Pearson\u0026rsquo;s x\u003csup\u003e2\u003c/sup\u003e test, and the exact test of Fisher were used, according to the type of variable and its distribution. The Kappa index was used for the agreement analysis between the rectal examination and histopathological results. Statistical significance was established using a \u003cem\u003ep-\u003c/em\u003evalue\u0026thinsp;\u0026lt;\u0026thinsp;0.05. IBM SPSS version 24 was used for the simple logistic regression analysis, and Forest plot graphics were generated for the complications associated with TPPB and TRPB.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOur study included 241 patients suspected of prostate cancer. Patients were categorized based on the type of biopsy they underwent: transperineal biopsy (TPPB) was performed on 171 patients (71%), and transrectal biopsy (TRPB) on 70 patients (29%) Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of clinical characteristics, complications, and diagnostic efficacy rates of prostate biopsy techniques in patients with suspected prostate cancer.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransperineal biopsy\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;171\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTransrectal biopsy\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;70\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep-\u003c/em\u003evalue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.0 (62\u0026ndash;72.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.5 (64.3\u0026ndash;76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSA (ng/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (8.2\u0026ndash;23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.4 (6.7\u0026ndash;64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProstate volume (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.0 (30.0\u0026ndash;50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.5 (34.0\u0026ndash;60.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePSA Density\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3 (0.2\u0026ndash;0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3 (0.1\u0026ndash;2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectal examination (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113 (66.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.055\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuspicious tact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.0 (62\u0026ndash;72.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.5 (64.3\u0026ndash;76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96 (56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematuria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91 (53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain during procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-procedural pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (6.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute urinary retention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrchiepididymitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematospermia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (6.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRectorrhagia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCORES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.0 (25.0\u0026ndash;30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0 (12.0\u0026ndash;12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHistopathological result\u003c/span\u003e\u003c/p\u003e \u003cp\u003eBenign\u003c/p\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (39.8)\u003c/p\u003e \u003cp\u003e103 (60.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (58.6)\u003c/p\u003e \u003cp\u003e29 (41.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eValues were expressed as medians (ranges) and frequencies (%).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eClinical characteristics were compared between both groups, revealing a lower median age in patients who underwent TPPB compared with those who underwent TRPB (67.0 vs 70.5; p\u0026thinsp;=\u0026thinsp;0.01). There were no statistically significant differences observed between TPPB and TRPB groups in terms of PSA levels (12.0 vs 14.4; p\u0026thinsp;=\u0026thinsp;0.38), prostate volume (40 vs 40.5; p\u0026thinsp;=\u0026thinsp;0.47), or PSA density (0.3 vs 0.3; p\u0026thinsp;=\u0026thinsp;0.82), respectively. However, significantly more cores were obtained in patients with TPPB than in those with TRPB (29 vs 12; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eOn the other hand, the frequency of complications was evaluated in both groups. In total, 100% of patients who underwent TRPB experienced at least one complication, compared with 56% in the TPPB group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Hematuria was more common in the TPPB group (53% vs 27%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The incidence of acute urinary retention (2.3%) and anxiety (0.6%) was slightly higher in patients with TPPB, but the difference was not statistically significant. The TRPB group more frequently experienced hematospermia (14% vs 6.4%; p\u0026thinsp;=\u0026thinsp;0.05), rectorrhagia (73% vs 0.6%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and sepsis occurred in only one patient (1.4% vs 0%).\u003c/p\u003e \u003cp\u003eHistopathological examination revealed malignant tumors in 132 (54.77%) and 109 with benign findings (45.22%). The primary complications observed in patients with benign tumors were pain during and after the procedure (38.5% and 42.2%, respectively) and hematospermia (12.8%). The frequency of complications in both groups is detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe number of biopsies (cores) obtained using each technique did not increase the risk of developing complications. Similarly, a greater number of biopsies (cores) did not increase the rate of prostate cancer diagnosis between the two groups.\u003c/p\u003e \u003cp\u003eThe risk analysis for complications after both prostate biopsy techniques were conducted using Odds Ratio. Only statistical trends were observed in the risk of developing complications between the two techniques. Patients who underwent TPPB showed a higher risk of developing hematuria (OR 0.41, 95% CI 0.15\u0026ndash;1.14; p\u0026thinsp;=\u0026thinsp;0.07). No differences were observed in the development of other complications.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first study to describe complications of TPPB using a freehand single-access point without antibiotic prophylaxis and compare it against the standard TRPB technique with antibiotic prophylaxis.\u003c/p\u003e \u003cp\u003ePreviously, transperineal biopsy was preferred for patients with a history of rectal cancer, trauma, or inflammatory bowel disease. The potential to improve cancer detection rates has been considered an advantage(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Jiang found no differences in prostate cancer detection rates between transrectal and transperineal approaches(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In our study, we achieved a prostate cancer diagnostic rate with TPPB of 60.2%, which was higher than the transrectal technique of 41.4% (p\u0026thinsp;=\u0026thinsp;0.008). Our study demonstrated a higher prostate cancer diagnostic rate compared with TRPB and most TPPB studies in which attachments such as templates(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), CamProbe(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), coaxial needle(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and fusion biopsy(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) were used Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of different studies evaluating transperineal prostate biopsies.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNature of study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAverage PSA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAverage p volume\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePC diagnostic rate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eType of biopsy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUsed attachment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eAccess points\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eProphylaxis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eCores average\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeyer et al.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFree hand/ precision point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026laquo;Cognitive\u0026raquo;/MRI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePrecision point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2 or +\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026laquo;NE\u0026raquo;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLopez et al.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFree hand/ precision point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1218\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026laquo;Cognitive\u0026raquo;/MRI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePrecision point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2 or +\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarra et al.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFree hand/Fusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e8.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e51.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e43.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eFusion MRI/US\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eNone/coaxial\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e12 or +\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e15.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKum et al.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFree hand/ precision point\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e176\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e7.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e79\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e\u0026laquo;Cognitive\u0026raquo;/MRI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003ePrecision point\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e24.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRistau et al.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFree hand/ precision point\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e7.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e41.8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e60.7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eUS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003ePrecision point\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e16\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAziz et al.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTemplate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e123\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e15.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e68.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e43.4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eFusion MRI/US\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eTemplate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e56 or +\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003e\u0026laquo;NE\u0026raquo;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e56.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGorin et al.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFree hand/ precision point\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e95\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e6.9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e36\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e83.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eFusion MRI/US\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003ePrecision point\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e2 or +\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003eNo, Only 1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e12\u0026ndash;14\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDekalo et al.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTemplate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e114\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e14.3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e63\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e\u0026laquo;Cognitive\u0026raquo; MRI /US\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eTemplate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e2 or +\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e37.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIgsoon et al.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFree hand/ precision point\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2022\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e55\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e14.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e37.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e43.6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e\u0026laquo;Cognitive\u0026raquo;/MRI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eJelco\u003c/b\u003e\u0026reg; \u003cb\u003e(coaxial)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e2 or +\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e20\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eOur study\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFree hand/coaxial\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e171*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e40\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e60.2.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eUS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003eJamshidi needle (coaxial)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e29\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe transperineal approach can detect lower-stage and anterior zone tumors(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The reason for this superiority is that an estimated up to 40% of tumors are located in the anterior portion of the prostate(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs previously mentioned, the risk of sepsis following TRPB has increased in recent years because of the increasing prevalence of multidrug-resistant bacteria (MDR), particularly Escherichia coli. In our study, the sepsis rate among patients who underwent TRPB was 1.4%, compared to 0% with TPPB, which is consistent with findings reported in the literature and supports Power\u0026rsquo;s assertion that transitioning from TRPB to TPPB virtually eliminates the risk of sepsis(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, it's important to note that this generalization cannot be fully established statistically (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding other complications, a meta-analysis by Xiang et al. Determined that TPPB reduces the risk of rectorrhagia and fever but increased the risk of acute urinary retention (AUR). However, it is noted that AUR is mainly associated with a higher number of cores obtained, leading to subsequent prostatic edema, which is transient and resolves with the placement of a transurethral Foley catheter(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In our study, we similarly demonstrated that TPPB protects against rectorrhagia and hematospermia but poses a higher risk of hematuria. Additionally, three cases of AUR initially occurred, which we attributed to anesthesia applied below the Denonvilliers fascia, causing elevation of the prostatic apex and subsequent urethral compression. These cases were managed with Foley catheter placement, and currently, we only administered local anesthesia to the skin and perineum, with no further cases of AUR reported.\u003c/p\u003e \u003cp\u003e There are no formal guidelines regarding the total number of biopsies that should be performed during ultrasound-guided prostate biopsy procedures. Similarly, multiple studies have concluded that more cores significantly increase the risk of complications such as infection, bleeding, pain, and urinary difficulties(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). However, it is important to note that most of these studies were conducted using transrectal or transperineal biopsy samples with templates or multiple access points. In our study, TPPB was shown to be protective against the development of complications despite an average of 28 cores taken per procedure, whereas complications associated with TRPB were significantly more frequent, with an average of only 12 cores taken per procedure.\u003c/p\u003e \u003cp\u003eHistorically, prostate biopsy has been considered to require general anesthesia(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, Hong demonstrated that 85.4% of patients found the transperineal approach tolerable under local anesthesia alone(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), and they would choose the same technique if they needed a prostate biopsy, suggesting that it could be performed on an outpatient basis. Kum et al. also found acceptable pain levels in his study regarding this procedure(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In our study, transperineal biopsies were performed under local anesthesia and sedation, and excellent pain tolerance was reported during and after the procedure. Only one patient reported discomfort during and after TPPB, whereas 100% of the patients experienced pain during TRPB.\u003c/p\u003e \u003cp\u003eThe only disadvantage of the \"free-hand\" technique without the use of templates or adjuncts is that the needle is not attached to the transducer, which can add time to the procedure and potentially compromise adequate sampling of prostate tissue(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). However, as Pilatz emphasizes, \"current evidence underscores that it is time for the urological community to transition from transrectal to transperineal approaches despite any possible logistical challenges\"(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Additionally, the TRexit movement, a global initiative advocating this change(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), is gaining momentum(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study has several limitations, TRPBs were performed by radiologists in the radiology department using the sextant technique, with a different approach compared to TPPBs performed by urologists. Additionally, the lack of stratification into groups based on prostate-specific antigen levels can lead to a high rate of prostate cancer detection.\u003c/p\u003e \u003cp\u003eIt is crucial for future studies to consider these factors to provide a more accurate and comprehensive assessment of the complications and diagnostic effectiveness of different prostate biopsy techniques.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTransperineal freehand single-access prostate biopsy offers greater capability for prostate cancer detection than the transrectal technique. The transperineal approach should be adopted as the first-choice method for prostate cancer diagnosis given its lower rates of infectious complications and can be performed on an outpatient basis with local anesthesia and sedation, without the need for prior intestinal preparation or antibiotic prophylaxis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eR\u0026iacute;os \u0026ndash; Melgarejo Carlos:\u0026nbsp;Protocol development, project development, data collection, manuscript writing and manuscript editing.\u003c/p\u003e\n\u003cp\u003eVelasco \u0026ndash; Rubio Jos\u0026eacute; Ram\u0026oacute;n: Protocol development, project development, data collection, manuscript writing and manuscript editing.\u003c/p\u003e\n\u003cp\u003ePulido \u0026ndash; Contreras Enrique:\u0026nbsp;Protocol development, project development, data collection, manuscript writing and manuscript editing.\u003c/p\u003e\n\u003cp\u003eBonilla \u0026ndash; Lara David:\u0026nbsp;Protocol development, project development, data collection, manuscript writing and manuscript editing.\u003c/p\u003e\n\u003cp\u003eGast\u0026eacute;lum \u0026ndash; Rivera Esteban:\u0026nbsp;Protocol development, project development, data collection, manuscript writing and manuscript editing.\u003c/p\u003e\n\u003cp\u003eAvenda\u0026ntilde;o \u0026ndash;\u0026nbsp;Bastidas Santiago Arturo:data collection.\u003c/p\u003e\n\u003cp\u003eGonz\u0026aacute;lez \u0026ndash;\u0026nbsp;Villegas Hedler Olaf:Protocol development, project development, data collection.\u003c/p\u003e\n\u003cp\u003eG\u0026oacute;mez \u0026ndash;\u0026nbsp;Mendoza Miguel: Protocol development, project development, data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive specific funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn the part of the authors, no conflicts of interest are declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study collected data obtained for clinical purposes, and all procedures were performed as part of routine care. The procedures used in this study adhere to the principles of the declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants included in the study before the procedures.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSiegel RL, Miller KD, Jemal A (2019) Cancer statistics, 2019. CA Cancer J Clin 69(1):7\u0026ndash;34\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRico L, Contreras P, Blas L, R\u0026iacute;os Pita H, Vitagliano G, Ameri C (2018) \u0026iquest;Es la biopsia de pr\u0026oacute;stata transperineal m\u0026aacute;s eficaz y segura que la biopsia transrrectal?* Is Transperineal Prostate Biopsy more effective and Safer than Transrectal Biopsy? Rev Arg de Urol \u0026middot; 83(1):2018\u0026ndash;2023\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiBianco JM, Mullins JK, Allaway M (2016) Ultrasound Guided, Freehand Transperineal Prostate Biopsy: An Alternative to the Transrectal Approach. Urol Pract 3(2):134\u0026ndash;140\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor AK, Zembower TR, Nadler RB, Scheetz MH, Cashy JP, Bowen D et al (2012) Targeted antimicrobial prophylaxis using rectal swab cultures in men undergoing transrectal ultrasound guided prostate biopsy is associated with reduced incidence of postoperative infectious complications and cost of care. J Urol 187(4):1275\u0026ndash;1279\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSidana A, Blank F, Wang H, Patil N, George AK, Abbas H (2022) Schema and cancer detection rates for transperineal prostate biopsy templates: a review. Therapeutic Advances in Urology, vol 14. SAGE Publications Inc.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeung AK, Patil D, Howard DH, Filson CP (2020) Payments and Patient Cost Sharing for Prostate Biopsies According to Image Guidance, Practice Site and Use of Anesthesia. Urol Pract 7(2):138\u0026ndash;144\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer AR, Joice GA, Schwen ZR, Partin AW, Allaf ME, Gorin MA (2018) Initial Experience Performing In-office Ultrasound-guided Transperineal Prostate Biopsy Under Local Anesthesia Using the PrecisionPoint Transperineal Access System. Urology 115:8\u0026ndash;13\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSigle A, Suarez-Ibarrola R, Pudimat M, Michaelis J, Jilg CA, Miernik A et al (2021) Safety and side effects of transperineal prostate biopsy without antibiotic prophylaxis. Urologic Oncology: Seminars and Original Investigations. ;39(11):782.e1-782.e5\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBackhaus R, Villa T, Guzm\u0026aacute;n A, Oliva D, Tormo B, Cruz J RESUMEN ESTRATEGIAS PARA LA BIOPSIA DE PR\u0026Oacute;STATA. REVISI\u0026Oacute;N DE LA LITERATURA Estrategias para la biopsia de pr\u0026oacute;stata. Revisi\u0026oacute;n de la literatura\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiang J, Yan H, Li J, Wang X, Chen H, Zheng X (2019) Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: A systematic review and meta-analysis. World Journal of Surgical Oncology, vol 17. BioMed Central Ltd.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang CY, Shen PF, Wang C, Gui HJ, Ruan Y, Zeng H et al (2019) Comparison of diagnostic efficacy between transrectal and transperineal prostate biopsy: A propensity score-matched study. Asian J Androl 21(6):612\u0026ndash;617\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGnanapragasam VJ, Leonard K, Sut M, Ilie C, Ord J, Roux J et al (2020) Multicentre clinical evaluation of the safety and performance of a simple transperineal access system for prostate biopsies for suspected prostate cancer: The CAMbridge PROstate Biopsy DevicE (CamPROBE) study. J Clin Urol 13(5):364\u0026ndash;370\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgu IS, Ngooi MS, Ng HK, Tee KTL, Loo CH, Lim MS (2023) Freehand transperineal prostate biopsy with a coaxial needle under local anesthesia: Experience from a single institution in Malaysia. Cancer Pathogenesis Therapy 1(1):33\u0026ndash;39\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCalleris G, Marquis A, Zhuang J, Beltrami M, Zhao X, Kan Y et al (2023) Impact of operator expertise on transperineal free-hand mpMRI-fusion-targeted biopsies under local anaesthesia for prostate cancer diagnosis: a multicenter prospective learning curve. World J Urol 41(12):3867\u0026ndash;3876\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDerin O, Fonseca L, Sanchez-Salas R, Roberts MJ (2020) Infectious complications of prostate biopsy: winning battles but not war. World J Urol 38(11):2743\u0026ndash;2753\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorghesi M, Ahmed H, Nam R, Schaeffer E, Schiavina R, Taneja S et al (2017) Complications After Systematic, Random, and Image-guided Prostate Biopsy [figure presented]. European Urology, vol 71. Elsevier B.V., pp 353\u0026ndash;365\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePower J, Murphy M, Hutchinson B, Murphy D, McNicholas M, O\u0026rsquo;Malley K et al (2022) Transperineal ultrasound-guided prostate biopsy: what the radiologist needs to know. Insights Imaging. ;13(1)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastellani D, Pirola GM, Law YXT, Gubbiotti M, Giulioni C, Scarcella S et al (2022) Infection Rate after Transperineal Prostate Biopsy with and without Prophylactic Antibiotics: Results from a Systematic Review and Meta-Analysis of Comparative Studies. Journal of Urology, vol 207. Lippincott Williams and Wilkins, pp 25\u0026ndash;34\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSivaraman A, Ramasamy V, Aarthy P, Sankar V, Sivaraman PB (2022) Safety and feasibility of freehand transperineal prostate biopsy under local anesthesia: Our initial experience. Indian J Urol 38(1):34\u0026ndash;41\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomson A, Li M, Grummet J, Sengupta S (2021) Transperineal prostate biopsy: A review of technique. Translational Andrology and Urology, vol 9. AME Publishing Company, pp 3009\u0026ndash;3017\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLopez JF, Campbell A, Omer A, Stroman L, Bondad J, Austin T et al (2021) Local anaesthetic transperineal (LATP) prostate biopsy using a probe-mounted transperineal access system: a multicentre prospective outcome analysis. BJU Int 128(3):311\u0026ndash;318\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHong A, Hemmingway S, Wetherell D, Dias B, Zargar H (2022) Outpatient transperineal prostate biopsy under local anaesthesia is safe, well tolerated and feasible. ANZ J Surg 92(6):1480\u0026ndash;1485\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhanji Y, Allaway MJ, Gorin MA (2021) Recent Advances and Current Role of Transperineal Prostate Biopsy. Urologic Clinics of North America, vol 48. W.B. Saunders, pp 25\u0026ndash;33\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePilatz A, Stangl F, Kranz J, Bonkat G, Veeratterapillay R (2024) Transperineal Is the Way To Go. Eur Urol Focus\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoberts MJ, Macdonald A, Ranasinghe S, Bennett H, Teloken PE, Harris P et al (2021) Transrectal versus transperineal prostate biopsy under intravenous anaesthesia: a clinical, microbiological and cost analysis of 2048 cases over 11 years at a tertiary institution. Prostate Cancer Prostatic Dis 24(1):169\u0026ndash;176\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBasourakos SP, Alshak MN, Lewicki PJ, Cheng E, Tzeng M, DeRosa AP et al (2022) Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy: A Systematic Review and Meta-analysis. European Urology Open Science, vol 37. Elsevier B.V., pp 53\u0026ndash;63\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prostate biopsy, transperineal, prostate cancer, diagnosis.","lastPublishedDoi":"10.21203/rs.3.rs-4731459/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4731459/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo compare the complication rates and diagnostic efficacy between transperineal single-access ultrasound-guided prostate biopsy (TPPB) and transrectal ultrasound-guided prostate biopsy (TRPB) among patients with suspected prostate cancer.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe collected and analyzed data from 241 patients with prostate cancer suspicion and divided them into two groups: 171 TPPB and 70 TRPB. For the detection of complications associated with the technique, patients were followed\u0026ndash;up for 3 months; furthermore, histopathological results to confirm prostate cancer were compiled.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eHistopathological reports showed 132 patients with malignancy (54.77%) and 109 with negative results (45.22%). TPPB detected malignancy in 60.2% of patients, compared with 41.4% detected by TRPB (p\u0026thinsp;=\u0026thinsp;0.008). The most frequent complications in TPPB were hematuria (53.8%), post-procedural pain (6.4%), hematospermia (6.4%), and acute urinary retention (2.3%). All patients undergoing TRPB experienced pain during and after the procedure (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The TPPB technique was shown to be a protective factor against the development of complications (OR 0.028, 95% CI 0.009\u0026ndash;0.09; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, complications associated with the TRPB technique were significantly higher (OR 35.5, 95% CI 10.7\u0026ndash;117.6; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTransperineal single-access prostate biopsy offers greater capability for prostate cancer detection and should be adopted as the first-choice method for prostate cancer diagnosis given its lower rates of infectious complications and can be performed on an outpatient basis with local anesthesia and sedation, without the need for prior intestinal preparation or antibiotic prophylaxis.\u003c/p\u003e","manuscriptTitle":"Is transperineal prostate biopsy through a single access point safe and reproducible?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-16 16:18:40","doi":"10.21203/rs.3.rs-4731459/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"54f2edaa-a5a0-418e-abf2-4e393fa9793c","owner":[],"postedDate":"August 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T18:39:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-16 16:18:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4731459","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4731459","identity":"rs-4731459","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}