Letter to the Editor Regarding “Challenging the Evolving Nomenclature of Ultrasound‐Guided Transperineal Prostate Biopsy: A Call for Standardization”

We read with great interest the recent article by Ravizzini et al. calling for standardization in the nomenclature of ultrasound-guided transperineal prostate biopsy (TPB) [1]. This is an important issue in urology that has not received sufficient attention. In our previous report, we also raised similar concerns and proposed a three-tier nomenclature, classifying TPB techniques as mechanical arm-assisted, needle guide-assisted (NGA), and true freehand biopsy [2]. In line with the authors, we also recommended that the term “freehand” should be reserved only for procedures performed without a needle guide, where the ultrasound transducer and biopsy needle are manipulated independently. As the authors emphasize, the correct use of the term “freehand” is not merely a semantic issue; it has direct clinical implications. The biopsy technique is closely related to cancer detection rates, patient discomfort, and complication profiles. Mislabeling techniques can therefore make it difficult to interpret and compare published results. We agree that biopsy techniques using a template or grid should be considered a separate category. In grid-based approaches, each biopsy core requires a separate perineal skin puncture at different locations. For this reason, these procedures are generally not practical under local anesthesia and may be associated with higher complication rates due to multiple entry points. However, we believe that some aspects of the authors' proposed three-tier nomenclature require further consideration. First, the authors suggest that all biopsies performed without a needle guide, regardless of whether a stepper or mechanical arm is used, should be classified as “freehand.” We respectfully disagree. The use of a mechanical or robotic stepper changes the nature of the procedure, as probe movements are no longer directly controlled by the physician's hand but by a mechanical system. This may affect patient discomfort related to probe movement. In addition, improved probe stability with a stepper may increase targeting accuracy and potentially improve cancer detection rates. Moreover, to our knowledge, coaxial needle techniques are not used in stepper-based systems; instead, biopsies are often performed through the same entry points with repeated needle insertions, which may affect both feasibility under local anesthesia and complication rates. In contrast, in manually controlled techniques, a coaxial approach is typically used, allowing multiple cores to be obtained through a single entry site on each side, making the procedure more suitable for local anesthesia. For these reasons, we believe that stepper-assisted techniques should not be grouped under the same “freehand” category as manually controlled approaches. Template/grid-based techniques, Stepper- or mechanical arm-stabilized techniques. Techniques in which the probe is manually controlled should also be divided into two groups: Needle guide-assisted (NGA) techniques, as we previously proposed, or probe-mounted guide techniques, as suggested by the authors, Freehand technique, reserved strictly for procedures performed without a needle guide, where both the probe and the needle are manipulated independently. Beyond terminology, there is also considerable technical variation within the proposed probe-mounted guide group. Technological developments have introduced further distinctions for this group. Traditional needle guides keep the needle in a fixed plane relative to the probe, whereas newer systems, such as PERINO-FLEX (GEOTEK) and TP Pivot Pro (CIVCO), allow angle and height adjustment of the needle. In our previous report describing the PERINO-FLEX technique, we stated that these features may make it possible to target different regions of the prostate with minimal probe movement within the rectum, potentially reducing patient discomfort and improving access to anatomically challenging areas [3]. These differences may also influence procedure time and cancer detection rates, although larger studies are still needed. For this reason, we suggest that, if a needle guide is used, reports should specify whether a fixed-angle or angle-adjustable needle guide is used. This would improve clarity and make it easier to compare results across studies. In conclusion, there is still no clear consensus on TPB nomenclature. Technical differences between biopsy approaches have direct clinical implications, affecting procedural aspects, patient comfort, complication rates, and diagnostic performance. Clear and consistent terminology is therefore essential for both scientific accuracy and clinical practice. We believe that this topic deserves broader attention within the urological community and that an expert consensus panel would be helpful in resolving these issues. The authors have nothing to report. The corresponding author, Eriz Özden, declares that he is the inventor and co-patent holder of the PERINO-FLEX needle guide system. Erdem Öztürk and İsa Dağlı have no conflicts of interest to declare with respect to the present letter. Data sharing is not applicable to this letter, as no new data were created or analyzed in this study.