Author name: Mr Bachar Zelhof

Mr. Bachar Zelhof is a Consultant Urological Surgeon at Manchester University NHS Foundation Trust and a leading Northwest expert in robotic kidney surgery, kidney stones, and complex endometriosis. An accomplished academic with over 30 publications and an MD with honours, he serves as a Senior Honorary Lecturer at the University of Manchester and was named the 2021 Northwest Urology Trainer of the Year.

brachytherapy

What is LDR Brachytherapy? Know it’s step by step procedure

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Low-dose rate (LDR) brachytherapy is a method of delivering radiation at a rate of less than 2.0 Gy/h by placing sealed radiation sources directly in or near the treatment area. In plain terms, it is an internal form of radiation therapy; “brachy” comes from the Greek word for “short distance,” reflecting that the radiation source is placed very close to or within the tumour itself.  What is LDR Brachytherapy? LDR brachytherapy is a type of internal radiation treatment used to treat localised prostate cancer. During the procedure, tiny radioactive seeds are placed directly into the prostate gland, where they slowly release radiation over time. Since the radiation is focused directly on the cancer, it can destroy tumour cells more precisely while helping to protect nearby healthy tissues, such as the bladder and rectum.  This treatment is considered minimally invasive and is usually completed in a single procedure, allowing many patients to return to their normal routine more quickly compared to surgery or several weeks of external beam radiotherapy. LDR brachytherapy is also known for offering good long-term cancer control outcomes, while helping many men maintain better urinary continence and sexual function than some alternative treatments. Unlike prostate removal surgery, which completely removes the prostate gland, brachytherapy treats the cancer from inside the body without major incisions. It may be recommended for men with localised or low-to-intermediate risk prostate cancer, depending on their overall health and cancer stage. How does LDR Brachytherapy help treat prostate cancer? Low-dose rate (LDR) brachytherapy, often called seed implantation or prostate brachytherapy, is a form of internal radiation treatment used for prostate cancer. The procedure involves placing tiny radioactive seeds directly into the prostate gland, allowing radiation to target the cancer more precisely while limiting exposure to nearby healthy tissues. As the treatment is minimally invasive, it does not involve major surgery, and most patients only need a short hospital stay, often returning home the same day or within 24 hours. Recovery is generally quick, with many men resuming their normal daily activities within a few days. LDR brachytherapy differs from external beam radiotherapy (EBRT), where radiation is delivered from outside the body using high-energy X-rays. In EBRT, the radiation must pass through surrounding tissues before reaching the prostate, which can sometimes affect nearby healthy areas. In contrast, brachytherapy delivers radiation from inside the prostate itself, helping concentrate treatment directly on the tumour site. What is the procedure? Before undergoing LDR brachytherapy, patients usually attend a consultation with an oncologist to prepare for treatment. Depending on the hospital, this planning appointment may take place a few days or weeks before the procedure, while some centres complete the planning on the same day as treatment. At this stage, doctors may use imaging techniques like ultrasound or MRI scans. It helps in providing a more detailed view of the prostate gland. These images help the medical team identify the exact location of the tumour and calculate the most suitable radiation dose for treatment. The procedure itself is carried out under either general anaesthesia or spinal anaesthesia. Small radioactive seeds, each roughly the size of a grain of rice, are carefully placed into the prostate through fine hollow needles. Ultrasound guidance is commonly used throughout the procedure to ensure accurate placement of the seeds. The needles are inserted through the perineum, which is the area between the scrotum and the anus, and removed once the seeds are positioned correctly. LDR brachytherapy is typically completed within about an hour. After recovering from the anaesthetic, most patients can return home later the same day. A follow-up CT scan may be arranged within several weeks after treatment to review the placement of the seeds and assess the treatment plan further. The implanted seeds remain inside the prostate and gradually release radiation over several months. This targeted approach helps destroy cancer cells while reducing exposure to surrounding healthy tissues, allowing many patients to continue with their normal daily activities with minimal disruption. Who is suitable for this procedure? LDR brachytherapy is often recommended for men with localised prostate cancer, meaning the cancer is contained within the prostate gland. It may be suitable for patients with low-risk or intermediate-risk prostate cancer, depending on factors such as: In some cases, LDR brachytherapy may be combined with other treatments, including hormone therapy or external beam radiotherapy. A specialist will assess whether the treatment is appropriate based on each patient’s individual condition. What are the benefits? LDR brachytherapy offers several advantages for suitable patients, including: The procedure does not involve major surgical incisions, which can reduce recovery time and hospital stay. Radiation is delivered directly into the prostate, helping reduce exposure to nearby healthy organs and tissues. Most patients return to normal daily activities within a few days following treatment. Many men are discharged on the same day as the procedure or after a short overnight stay. LDR brachytherapy has demonstrated strong long-term outcomes in appropriately selected patients with localised prostate cancer. Compared with some other prostate cancer treatments, many patients experience lower rates of urinary incontinence and preservation of sexual function. What are the possible side effects of LDR Brachytherapy Although LDR brachytherapy is generally well tolerated, some side effects may occur during recovery. These can include: These symptoms are usually temporary and often settle down as time goes on. However, patients should contact their healthcare team if symptoms become severe or persistent. LDR Brachytherapy vs External Beam Radiotherapy (EBRT) Both LDR brachytherapy and external beam radiotherapy are used to treat prostate cancer, but they deliver radiation differently. In external beam radiotherapy, radiation is directed at the prostate from outside the body using high-energy X-rays. The radiation must pass through surrounding tissues before reaching the tumour. In contrast, LDR brachytherapy places radioactive seeds directly inside the prostate. This allows radiation to target the tumour more precisely while limiting exposure to nearby healthy structures. Another difference is treatment duration. External beam radiotherapy often requires multiple hospital visits over several weeks, while LDR brachytherapy is usually completed

Home, Prostate Health

Prostate Biopsy Under Local Anaesthesia| How to perform

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A prostate biopsy is one of the most important procedures used to diagnose prostate cancer and investigate abnormal prostate findings. Traditionally, many prostate biopsies were performed under sedation or general anaesthesia, but advances in medical techniques now allow many men to safely undergo a prostate biopsy under local anaesthesia in an outpatient setting. This modern approach is minimally invasive, well tolerated by most patients, and allows for quicker recovery while maintaining excellent diagnostic accuracy. In particular, transperineal prostate biopsy under local anaesthesia is increasingly being adopted worldwide because of its lower infection risk and improved patient safety.  What is a Prostate Biopsy? A prostate biopsy is a procedure in which small tissue samples are taken from the prostate gland and examined under a microscope to check for cancer or other abnormalities. Doctors may recommend a prostate biopsy if: What is Prostate Biopsy under Local Anaesthesia? Local anesthesia means the area being treated is numbed while the patient remains awake during the procedure. Unlike general anesthesia, patients do not need to be fully unconscious. During a prostate biopsy, the doctor injects local anesthetic medication into the biopsy area to reduce discomfort. Patients may still feel pressure or mild sensations, but significant pain is usually minimised. Many modern transperineal prostate biopsies can now be safely performed under local anesthesia in a clinic or outpatient setting.  Why is local anesthesia becoming more popular? Local anesthesia offers several benefits compared to general anesthesia or sedation. How is a Prostate Biopsy under Local Anesthesia performed? Although techniques may vary slightly between hospitals and clinics, the procedure generally follows these steps: Before the biopsy: The patient lies comfortably while the doctor prepares the biopsy area. The skin and deeper tissues are numbed using local anesthetic injections. Patients may feel a brief stinging sensation during this step. An ultrasound probe is inserted into the rectum to guide accurate needle placement. Small biopsy samples are taken from targeted areas of the prostate. MRI-targeted biopsies may also be performed if suspicious lesions are identified on imaging. The entire procedure usually takes around 20–45 minutes, depending on the number of samples required.  Does a local anesthesia for prostate biopsy hurts? Most men experience mild to moderate discomfort rather than severe pain. The anesthetic injections are often the most uncomfortable part of the procedure. Once the area becomes numb, many patients report only pressure sensations or brief discomfort during sampling. Patient experiences can vary depending on anxiety levels, prostate size, biopsy technique, and individual pain tolerance. Community experiences shared online also suggest that while some men find the procedure uncomfortable, many tolerate it better than expected under local anesthesia.  Benefits of Transperineal Prostate Biopsy Under Local Anesthesia What are the possible side effects and risks? Although prostate biopsy is generally safe, some temporary side effects are common. Common Side Effects: These symptoms usually improve within days to weeks.  Less Common Risks: Patients should contact their doctor immediately if they develop fever, severe pain, inability to urinate, or heavy bleeding after the procedure. Recovery after a Prostate Biopsy Recovery after a local anesthetic biopsy is usually straightforward. Most patients are advised to: Blood in semen can sometimes persist for several weeks and is usually not dangerous. Who may benefit most from this procedure? Transperineal prostate biopsy under local anesthesia may be especially helpful for: Is Local Anesthetic Prostate Biopsy effective? Yes, Studies show that transperineal biopsy under local anesthesia provides excellent cancer detection rates while improving patient safety and reducing the risk of infection. Many specialists now consider it one of the preferred modern biopsy approaches.  Conclusion Prostate biopsy under Local Anesthesia has become a safe, effective, and minimally invasive option for diagnosing prostate cancer. With lower infection risk, shorter recovery time, and improved patient comfort, transperineal biopsy under local anesthesia is increasingly being preferred by both patients and specialists. Although mild discomfort may occur, modern techniques have made the procedure more accurate and better tolerated than ever before. Consult the best urologist in Manchester to know more about the prostate biopsy procedure. FAQs

Case Studies

Why are urologists shifting from Transrectal to Transperineal Prostate Biopsy?

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For decades, the transrectal biopsy has been the standard method for diagnosing prostate cancer. However there were increased concerns regarding infection risk, antibiotic resistance, and diagnostic limitations. Healthcare providers are prioritising safer, more accurate, and cost-effective approaches in their clinical settings. In the field of urological diagnostics, the shift from Transrectal Ultrasound-guided (TRUS) biopsies to Transperineal (TP) biopsies represents one of the most significant safety and accuracy upgrades in recent clinical history. For procurement heads and department leads, the transition is no longer just a clinical preference—it is a strategic move to reduce post-operative complications and long-term hospital costs. What is Transrectal Prostate Biopsy? A transrectal prostate biopsy is a procedure in which a needle is passed through the wall of the rectum into the prostate to collect tissue samples, usually guided by ultrasound. Since the needle passes through the rectum, there is a higher risk of infection, and antibiotics are typically required. Challenges with Transrectal Biopsy The transrectal approach involves passing the biopsy needle through the rectal wall, which introduces bacteria into the prostate and bloodstream. This significantly increases the risk of infection and necessitates the routine use of prophylactic antibiotics, contributing to growing global concerns around antibiotic resistance. This method is associated with a higher rate of post-procedure complications. Parameter Data Infection / Sepsis Rate 2% – 7% Hospital Admissions 1% – 3% Antibiotic Usage 100% of patients Risk Factor Bacterial contamination via rectum What is Transperineal Prostate Biopsy? A transperineal prostate biopsy involves inserting the needle through the skin between the anus and scrotum (the perineum) to reach the prostate. This approach avoids the rectum, significantly reducing the risk of infection and improving access to all areas of the prostate. It is increasingly preferred by 50% of urologists across the UK due to its safety, better diagnostic accuracy, and reduced need for antibiotics. Advantages of Transperineal Biopsy The transperineal approach eliminates rectal involvement by accessing the prostate through the perineal skin, significantly improving safety and clinical outcomes. (i) Near-Zero Infection Risk By avoiding the rectal pathway, the transperineal method reduces bacterial exposure, resulting in extremely low infection rates. Parameter Data Infection / Sepsis Rate <0.1% – 0.5% Clinical Outcome Many centres report zero sepsis cases (ii) Improved Diagnostic Accuracy Transperineal biopsy provides better access to the anterior region of the prostate, which is often missed in transrectal procedures. This leads to improved detection of clinically significant cancers. Method Detection Rate Transperineal ~45% – 55% Transrectal ~35% – 45% (iii) Reduced Antibiotic Dependency With minimal infection risk, transperineal biopsy can often be performed without antibiotics, addressing concerns around antimicrobial resistance. (iv) Cost Efficiency for Healthcare Systems Although initial setup costs for transperineal biopsy may be slightly higher, the reduction in complications leads to significant long-term savings. Cost Factor Transrectal Transperineal Infection-related hospitalisation £1,500 – £3,000 per case Negligible Annual financial impact High due to complications Significantly reduced Estimated annual savings after switching procedure The estimated annual savings when switching from transrectal to transperineal prostate biopsy primarily come from the significant reduction in infection-related complications. While transperineal biopsy may have a slightly higher upfront procedure cost, it dramatically lowers infection rates from around 2–7% in transrectal procedures to less than 0.5% in transperineal approaches.  This reduction leads to fewer hospital admissions, decreased antibiotic use, and minimal post-procedure complications. In a typical hospital performing around 1,000 biopsies per year, transrectal biopsy can result in approximately 30 infection cases annually, each costing between £1,500 and £3,000 for treatment. The transperineal biopsy reduces this to 0–5 cases per year, resulting in substantial cost savings. Lets understand with the help of a case example; During the Transperineal Approach After Transperineal Implementation Real World Adoption Trends Healthcare systems, particularly in the United Kingdom are rapidly transitioning toward transperineal biopsy as the new standard of care. Procurement & Clinical Benefits The transperineal prostate biopsy offers significant clinical, financial, and operational advantages. It is a much safer procedure with minimal infection risk and provides a higher detection rate of clinically significant cancers. The procedure can be performed under local anaesthesia, enables faster patient recovery, and improves overall patient throughput and workflow efficiency within healthcare settings. Conclusion The transition from transrectal to transperineal prostate biopsy represents a critical advancement in prostate cancer diagnostics. With substantially lower infection rates, improved diagnostic accuracy, and significant cost savings, transperineal biopsy is emerging as the preferred standard for modern healthcare systems. For hospitals and procurement leaders, adopting this approach is not only a clinical decision but also a strategic investment in patient safety, operational efficiency, and long-term sustainability.

Case Studies

Why are hospitals moving to Transperineal Prostate Biopsy?

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Introduction Prostate cancer is one of the most common cancers among men worldwide. Accurate diagnosis depends on prostate biopsy procedures that allow clinicians to collect tissue samples for histopathological analysis. Hospitals are rapidly shifting from the traditional transrectal (TR) to the transperineal (TP) biopsy for prostate cancer diagnosis primarily because the TP approach eliminates the risk of serious infection/sepsis by avoiding the needle passage through the rectum. This shift is fueled by increasing antibiotic resistance in rectal flora and improved technology that allows TP biopsy to be performed in an office setting under local anesthesia. For decades, the transrectal ultrasound-guided prostate biopsy was the most widely used technique. However, growing concerns regarding infection risk, diagnostic limitations, and healthcare costs have prompted hospitals to reconsider their biopsy pathways. Lets understand why are hospitals moving to Transperineal Prostate Biopsy. What are the challenges faced by hospitals? Hospitals using the traditional transrectal biopsy method face several clinical and operational challenges. 1. Infection and Sepsis Risk Transrectal biopsy involves passing a biopsy needle through the rectal wall, exposing patients to bacteria present in the rectum. Studies show that this approach can lead to urinary tract infections, prostatitis, and sepsis in some patients. Infection rates following transrectal biopsy have been reported as high as 5–7% in some cases, even when antibiotic prophylaxis is used. Sepsis rates following TR biopsy have been reported between 0.4% and 9.8%, making infection one of the most significant complications of the procedure. These complications increase hospital admissions, antibiotic usage, and healthcare costs. 2. Limited access to certain areas of the Prostate Another limitation of the transrectal approach is the difficulty in accessing the anterior region of the prostate. Missing these lesions can delay diagnosis and treatment. Studies indicate that transrectal biopsy can miss cancers located in these areas, with approximately 10% of prostate cancers occurring exclusively in the anterior prostate. 3. Rising healthcare costs Post-biopsy infections can lead to: These complications significantly increase the cost burden for healthcare systems. Shift towards Transperineal Biopsy To address the above mentioned challenges, hospitals have increasingly adopted the transperineal biopsy technique. Instead of passing through the rectum, the biopsy needle is inserted through the perineum, allowing direct access to the prostate while avoiding rectal bacteria. This change in approach has demonstrated several clinical and operational advantages. What are the clinical benefits of Transperineal Biopsy? Transperineal prostate biopsy is increasingly preferred over the traditional transrectal approach because it offers better diagnostic accuracy and improved patient safety. Below are the main clinical benefits of transperineal biopsy. Some of the clinical benefits of Transperineal Biopsy are as follows. 1. Significantly lower Infection Risk One of the most important advantages of the transperineal approach is its reduced infection risk. Research shows that transperineal biopsy is associated with up to 77% lower risk of hospitalisation due to infectious complications compared with transrectal biopsy. Some studies report infection rates below 1% and sepsis rates under 0.5% following transperineal biopsy. In clinical trials, patients undergoing transperineal biopsy experienced zero infections, while infections were observed in the transrectal group. Because the needle  does not pass through the rectum, exposure to bacteria is greatly reduced. 2. Improved Cancer Detection The transperineal approach allows clinicians to sample all regions of the prostate, including the anterior and apical zones that are difficult to reach via the transrectal route. This improves diagnostic accuracy and helps clinicians detect clinically significant prostate cancers earlier. Studies also indicate that the cancer detection rate is comparable or slightly better than the traditional approach. 3. Reduced Antibiotic Dependence Because the infection risk is much lower, transperineal biopsy can often be performed without prophylactic antibiotics, reducing antibiotic resistance concerns. This is particularly important in modern healthcare systems that are trying to reduce unnecessary antibiotic use. What are the operational benefits for hospitals? Beyond clinical advantages, the transperineal approach also improves operational efficiency. 1. Standardised Biopsy Workflow Modern transperineal systems use grid-based or freehand guidance devices, allowing clinicians to perform systematic sampling with greater precision. 2. Day Case Procedure The procedure can often be performed under local anaesthesia, enabling same-day discharge for most patients. 3. Reduced Complication Costs Lower infection rates reduce: This makes the procedure more cost-effective for healthcare providers. Case Example: Hospital Implementation Hospital Profile Previous Method Transrectal ultrasound guided biopsy and the challenges includes: Implementation The hospital transitioned to transperineal ultrasound-guided biopsy using a stepper stabiliser and biopsy grid system. Let’s analyze the results after implementation. Metric Before (TR) After (TP) Infection Rate ~2–3% <1% Sepsis Cases Occasional Rare Anterior Cancer Detection Limited Improved Hospital Admissions Higher Reduced Antibiotic Use Required Minimal What are the economic impacts of Transperineal Biopsy? International clinical guidelines are increasingly supporting the transperineal approach. Lower infection rates significantly reduced hospital costs associated with post-biopsy complications.  In addition, streamlined biopsy workflows allowed the department to increase procedural capacity. For example, European urology guidelines recommend transperineal biopsy as a preferred method due to its lower risk of infectious complications. Similarly, health technology assessments have concluded that transperineal biopsy systems can be cost-effective options for diagnosing prostate cancer. Conclusion The transition from transrectal to transperineal prostate biopsy represents a significant advancement in prostate cancer diagnostics. Hospitals are adopting this approach because it offers: As clinical evidence continues to grow, the transperineal biopsy technique is rapidly becoming the preferred standard for prostate biopsy procedures worldwide.

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