Editing Prostate Biopsy (section)

=== Transrectal ===

* See videos
**[https://www.youtube.com/watch?v=_DTbRREJsSk&list=PLmlqgyiBVx1EvCpovdviVhpHLlWhov98i&index=56 Transperineal biopsy (UColorado)]
**[https://www.youtube.com/watch?v=0p5aK69r6AI Transperineal biopsy (UMichigan)]
*'''Position: usually left lateral decubitus position with knees and hips flexed 90°; can also be done lithotomy'''
**Lithotomy is preferred for brachytherapy treatment planning or placement of fiducial gold markers for external-beam therapy

*Step by step
**Perform a DRE to (2):
**#Rule out any rectal pathology that would contraindicate insertion of the probe
**#Allow identification of any palpable prostatic abnormalities to which special attention could be paid during ultrasound examination
** Insert the lubricated ultrasound probe slowly and with pressure to dilate the anal sphincter.
** Adjust the gain to provide a uniform mid-gray image of the normal peripheral zone
*** The shading of the peripheral zone should be the homogenous gray standard by which other areas of the prostate are classified as hyperechoic, hypoechoic, or isoechoic.
** Scan the prostate, from the base to the apex
*** Evaluate for any hypoechoic lesions in the prostate
*** Scan in the axial/transverse plane, followed by the sagittal plane
**** Rotate probe counter-clockwise to access right lobe of prostate, and clockwise to access left lobe of prostate
** Measure the prostate size.
*** Measuring the prostate size is recommended prior to infiltration of local anaesthesia[14]
*** The prostate is measured in 3 planes. Typically, in the axial/transverse view, height and width are measured and in the sagittal/lateral view, length is measured
** Perform periprostatic nerve block
** Warn patients that they should expect a loud click when the biopsy gun is fired.
** Take biopsies following appropriate template
*** Use needle guide button on ultrasound machine, if available
*** 12-core
**** Lateral apex, mid, base
**** Medial apex, mid, base
**** The initial biopsy is taken midway between the mid-point of the prostate gland and the lateral margin
**** The probe is then rotated laterally and a subsequent biopsy is taken at the same level but more laterally placed to sample tissue from the anterior horn of the peripheral zone (PZ).
*** Use needle guide button on ultrasound machine, if available
*** It is important to place the biopsy needle correctly at the prostate capsule in order to sample the outer-most part of the PZ.
**** The biopsy needle travels a few millimetres forward of its position on TRUS and a frequent error is the insertion of the biopsy needle into the PZ prostatic tissue which results in the biopsy needle passing further into then gland and not sampling the area close to the capsule which is frequently the site of the PZ cancers.
*** It is important to ensure the biopsy sampling is spatially distributed correctly at the base, mid-gland and apex.
*** Care must be taken not to rebiopsy the same area particularly in smaller prostates as this can give misleading information about the extent of the cancer within the gland.
** Remove ultrasound probe and apply digital pressure to biopsied area to reduce bleeding
**Inform patient of reasons to return to hospital

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