Augmented Reality-Assisted Rectum-Free Transperineal Prostate Biopsy: A Next-Generation Image-Guided Technique
by Central European Journal of Urology | Abdulrahman Al-Bayati, Nicolas A. Soputro, Karim Daher, Mohamad Watfa, Salim K. Younis, Ruben Olivares, Jihad Kaouk, Zeyad R. Schwen
Compared with the transrectal approach, transperineal prostate biopsy offers wider access to lesions and lower morbidity, yet it remains limited by patient discomfort, dependence on transrectal ultrasound, and challenging anatomy in some cases. This video describes the safety, feasibility, and workflow of augmented reality (AR)-assisted transperineal biopsy leveraging the MediView XR90 system, integrating preoperative imaging and electromagnetic tracking in a rectum-free workflow.
A 68-year-old man with PSA 4.7 ng/ml and a 1.3 cm PI-RADS 4 anterior transition-zone lesion underwent AR-assisted transperineal biopsy with the MediView XR90 system. The XR90 fuses preoperative magnetic resonance imaging (MRI) or prostate-specific membrane antigen (PSMA) positron emission tomography (PET) with transperineal ultrasound via electromagnetic tracking, displaying the fused 3D anatomy on a HoloLens 2 headset that projects the prostate and target lesion onto the operative field. Bilateral 14-gauge angiocatheters guided an 18-gauge tracked biopsy needle under AR visualization, without reliance on a transrectal ultrasound probe.
The procedure was completed in 33 minutes without complications. Four targeted and two systematic cores were obtained, yielding grade group 2 cancer in 2 targeted cores and grade group 1 in 1 systematic core. The workflow allowed accurate needle tracking, improved lesion visualization, and enhanced surgeon comfort. In conclusion, AR-assisted transperineal biopsy using the MediView XR90 system is feasible and ergonomically efficient. The rectum-free “REXIT” approach enhances patient comfort, expands applicability to those with anorectal pathology (severe hemorrhoids, fissures, strictures, or inaccessible rectum), and improves spatial awareness and targeting accuracy using AR guidance with PSMA PET or MRI as the preoperative imaging source, supporting integration into future biopsy protocols.
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