Learning and Practice in the Surgical Field

Dr. Chui Ka Lun began performing transperineal (TP) ultrasound-guided prostate biopsies under local anaesthesia at his institution in 2018. This approach differs from the traditional transrectal (TR) route, which had long been widely adopted but carries a risk of post-biopsy urosepsis due to the needle traversing the rectum's faecal flora. Dr. Chui subsequently co-authored a comparative study in Hong Kong examining the clinical outcomes of the TP approach . His work documented a biopsy protocol (ranging from 10 to 24 cores based on prostate size) that can be performed as a day-case procedure under local anaesthesia, avoiding rectal mucosa penetration.

Evolution of Clinical Practice

Dr. Chui's work and subsequent publications contributed to a shift in urological practice in Hong Kong. Following his 2018 practice and the publication of the comparative study in 2019, there was a growing trend towards "Trexit" (transrectal exit) across the territory. By 2019, the transperineal approach had become increasingly common in Hong Kong as a frequently used option for prostate biopsies . Proficiency in the transperineal approach has also provided an anatomical and technical foundation for further surgical developments. Urologists familiar with transperineal access have gone on to adopt multimodality focal therapies, including High-Intensity Focused Ultrasound (HIFU), cryotherapy, Targeted Microwave Ablation (TMA), and NanoKnife (Irreversible Electroporation) . Dr. Chui has also applied this technique to assist in radiation oncology, performing transperineal injection of rectal spacers (SpaceOAR) and fiducial gold markers to help protect the rectum during Stereotactic Body Radiation Therapy (SBRT) and proton therapy for pelvic malignancies .

Relevance to Patient Care

The adoption of transperineal prostate biopsy has had a positive impact on patient safety and healthcare resource utilisation. One important aspect is the reduction in post-biopsy urosepsis risk. Previous territory-wide data indicated that TR biopsies resulted in a 5.7% emergency attendance rate and a 3.8% hospitalisation rate, with up to 0.9% of patients requiring ICU admission for severe urosepsis . The comparative study co-authored by Dr. Chui showed that infection and fever rates decreased from 4% (requiring 1-week IV antibiotics) to 0% with the TP approach . This has helped reduce the risk of serious infections for patients and eased pressure on the public healthcare system by decreasing emergency room visits and hospital admissions. Additionally, the TP approach reduces reliance on broad-spectrum prophylactic antibiotics (such as fluoroquinolones), which is relevant to addressing antimicrobial resistance concerns .In terms of treatment, transperineal focal therapies aim to target cancer cells while preserving urinary continence and sexual function where possible . The use of transperineal rectal spacers in SBRT and proton therapy has been associated with reduced gastrointestinal side effects, supporting tolerability for patients undergoing radiation for localised prostate cancer .

References

1.Lo KL, Chui KL, Leung CH, Ma SF, Lim K, Ng T, Wong J, Li JKM, Mak SK, Ng CF. "Outcomes of transperineal and transrectal ultrasound-guided prostate biopsy." Hong Kong Medical Journal, 2019 Jun;25(3):209-15.2.Lo KL, Leung D, Lai Z, Li C, Ma SF, Wong J, Yuen KK, Li J, Chiu P, Mak SK, Wong J, Ng CF. "Picture-in-picture video demonstration of systematic transperineal prostate biopsy." Hong Kong Medical Journal, 2021 Aug;27(4):304-5.3.Chiu PKF, Ng CF. "Primum non nocere (first, to do no harm) in prostate biopsy." Hong Kong Medical Journal, 2019 Oct;25(5):344-5.4.Yee CH, Chiu PKF, Liu AQ, Wong HF, Chan WHC, et al. "Multimodality focal therapy for prostate cancer: outcome of the à la carte approach in clinical practice." Prostate International, 2025.5.Chiu PKF, Chan CH, Yee CH, Lau SY, et al. "Transperineal targeted microwave ablation (TMA) of localized prostate cancer guided by MRI-ultrasound fusion and organ-based tracking: a pilot study." Prostate Cancer and Prostatic Diseases, 2023.6.Poon DMC, et al. "One-year clinical outcomes of MR-guided stereotactic body radiation therapy with rectal spacer for patients with localized prostate cancer." World Journal of Urology, 2024.7.Cheng KC, Lam WC, Chan HC, et al. "Emergency attendances and hospitalisations for complications after transrectal ultrasound-guided prostate biopsies: a five-year retrospective multicentre study." Hong Kong Medical Journal, 2019 Oct;25(5):349-55.