Micro-ultrasound (MicroUS) is a novel high-resolution ultrasound technology operating at 29 MHz. This increased frequency enables detailed visualization of prostate tissue ductal architecture, facilitating the detection of structural changes associated with prostate cancer and allowing real-time transperineal biopsy1. Suspicious lesions are evaluated using the Prostate Risk Identification using MicroUS (PRI-MUS) scoring system (score 1–5), which correlates strongly with the Prostate Imaging Reporting and Data System (PI-RADS)2. MicroUS-guided prostate biopsy has emerged as an effective, non-inferior alternative to magnetic resonance imaging (MRI)-targeted biopsy for diagnosing clinically significant prostate cancer3. In this video, we demonstrate our clinical experience performing MicroUS-guided cognitive transperineal prostate biopsy.

Under general anesthesia (GA), the patient is positioned in the lithotomy position, with the anus at the edge of the bed. The scrotum is elevated using tape to fully expose the perineum. Approximately 50 mL of ultrasound gel is introduced into the rectum to enhance visualization during the biopsy. After cleansing the perineal skin with iodine, the MicroUS probe is gently inserted into the rectum and advanced until the mid-prostate is centered on the screen. The probe is swept from the right lateral border to the left lateral border of the prostate to visualize the entire gland and calculate its volume. Both the transition zone and peripheral zone are carefully assessed using the PRI-MUS score. Lesions with a PRI-MUS score ≥3 are targeted for biopsy. A biopsy needle is then inserted through the perineal skin under real-time MicroUS guidance to sample the identified lesions. Once all biopsies are acquired, the ultrasound probe is removed. Alternatively, this procedure can be performed under local anesthesia (LA) by anesthetizing the perineal soft tissue and the peri-apical triangle (bounded medially by the urethra, laterally by the levator ani, and posteriorly by Denonvilliers' fascia). The biopsy technique remains the same as described above.

From January to March 2025, 23 patients underwent MicroUS-guided transperineal prostate biopsies at our institution. Of these, 22 procedures were performed under GA, and one under LA. The mean operative time was 15.1 minutes (SD: 4.9 minutes). All patients were discharged the same day, with no intraoperative or postoperative complications reported.

MicroUS-guided transperineal prostate biopsy represents a recent advancement in prostate cancer diagnostics. While further validation of its diagnostic accuracy is warranted, our video demonstrates that the procedure can be safely performed under either GA or LA.