This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited. © 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada. SIUJ • Volume 4, Number 3 • May 2023 SIUJ.ORG Key Words Competing Interests Article Information Prostatic neoplasm, needle biopsy, neoplasm metastasis, prostate-specific antigen, early detection of cancer See Acknowledgements. Patient Consent: Obtained. Received on October 28, 2022 Accepted on November 6, 2022 Soc Int Urol J. 2023;4(3):232–233 DOI: 10.48083/ZHVJ6978 232 CLINICAL PICTURE The Prostate Problem You Can’t Put Your Finger on the Normal Way: A Case of Perineal Prostate Cancer Post Transperineal Prostate Biopsy Kevin Yinkit Zhuo,1,2 James Kovacic,1,2Amanda Chung,1,2,3 Thomas Eade,3,4 Venu Chalasani,1,2,3 1 Department of Urology, Royal North Shore Hospital, Sydney, Australia 2 North Shore Urology Research Group, Sydney, Australia 3 University of Sydney, Sydney, Australia 4 Radiation Oncology Department, Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia Transperineal biopsy needle-tract tumour seeding is a rare complication, with sparse published literature[1].  We describe the management of metastatic prostate cancer secondary to transperineal biopsy needle-tract seeding. An 80-year-old male presented with an otherwise asymptomatic, hard perineal mass that had progressively enlarged over a few months. The patient’s urological history included prostate adenocarcinoma of the right prostatic- apex, prostatic urethra, and lymph nodes (ISUP-Grade 4 [4 + 4 = 8], PIRADs-5, PSA-level 2.7µg/L), diagnosed via transperineal biopsy and TURP 3 years prior. His prostate cancer was definitively managed with TURP, ADT, and radiotherapy with a post-treatment PSA-level of 0.05µg/L. On pelvic examination, a perineal 2cm fixed lump was palpable. Pelvic-MRI demonstrated a 20mm irregular mass in the perineal fat immediately below the penile base (Figure 1A). Repeat PSA-level was 6.0µg/L. Subsequent PSMA PET-scan revealed a PSMA-avid lesion in the perineal midline, consistent with prostatic neoplasm metastasis without other metastatic disease (Figure 1B). Cystoscopy showed no obvious urinary-tract cancer recurrence. The patient’s case was discussed in a multi-disciplinary team meeting and excision was recommended. The patient then underwent a wide-local excision, requiring partial resection of bulbar-spongiosum (Figure 1C). Histopathology revealed a complete excision of his prostate adenocarcinoma metastasis, with post-excision PSA-levels of 0.12µg/L. No adjuvant therapies were given. Needle-tract seeding following transperineal prostate biopsy is rare and should not preclude patients from under- going biopsies. This case highlights the need for patient follow-up after cancer treatment and exemplifies the practi- cality of PSMA PET-scans if there is evidence of rising PSA-levels after definitive prostate cancer treatment. Acknowledgements Competing interests: Dr Amanda Chung: Proctor for Medtronic and Boston Scientific. The other authors have no competing interests. Reference 1. Volanis D, Neal DE, Warren AY, Gnanapragasam VJ. Incidence of needle-tract seeding following prostate biopsy for suspected cancer: a review of the literature. BJU Int.2015 May;115(5):698-704. http://SIUJ.org mailto:K.Zhuo2%40gmail.com?subject=SIUJ SIUJ.ORG SIUJ • Volume 4, Number 3 • May 2023 FIGURE 1A. Pelvic-MRI. Mass in perineal fat abutting fascia around inferior corpora spongiosis. FIGURE 1B. PSMAPET (ongoing resolving right prostatic posterolateral peripheral zone and equivocal left pre-sacral node uptake. New PSMA-avid lesion in the perineal midline (SUV-max 21.7) FIGURE 1C. Intraoperative image demonstrating perineal metastatic lesion abutting bulbospongiosus. The urethra, however, was clear of disease. 1C1B1A PSMA- avid lesion abutting fascia around inferior corpora spongiosis in perinael midline Lesion Bulbospongiosus 233 The Prostate Problem You Can’t Put Your Finger on the Normal Way: A Case of Perineal Prostate Cancer Post Transperineal Prostate Biopsy http://SIUJ.org