Editing Prostate Biopsy (section)

=== Transperineal ===

* See video accompanying [https://pubmed.ncbi.nlm.nih.gov/31374287/ article]
*See [https://www.youtube.com/watch?v=_DTbRREJsSk&list=PLmlqgyiBVx1EvCpovdviVhpHLlWhov98i&index=57 video]
*Position: usually lithotomy
*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
**Secure scrotum anteriorly with tape
**Trim hair, if needed
**Prepare perineum with chlorhexidine 
**Perform pudendal nerve block, if performing without sedation
***Pudendal nerves located 2cm lateral to anterior medial edge of anal canal and 3cm deep to perineal skin
***Mark 2cm lateral to anterior medial edge on each side
***Puncture with needle at each mark and advance 3cm. Infiltrate with local anesthetic (5cc 1% lidocaine without epinephrine)
**Insert the lubricated ultrasound probe slowly and with pressure to dilate the anal sphincter.
***At this point the access needle is not engaged into the skin but rather is positioned several millimeters away from the perineum so that it can be used as an external gauge of the rotational angle of the linear ultrasound array
**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
****In axial view, right side of prostate will be on left side of screen and left side of prostate will be on right side of screen
****In sagittal view, rotate probe counter-clockwise to view right lobe of prostate, and clockwise to view left lobe of prostate
**Perform perineal skin block with local anesthetic 1cm lateral and 1cm superior to the superior aspect of the anus
***Inject 5cc local anesthetic on each side
**Perform periprostatic nerve block
***Pass spinal needle through access canula through skin marking
***Guide spinal needle towards apex of prostate under ultrasound vision
***Inject local anesthetic in between space of prostate and pelvic floor muscles, and along the track extending from the prostate to the skin
**Measure prostate size, if not done previously
***Measure the prostate in 3 planes.
****Typically, in the axial/transverse view, height and width are measured and in the sagittal/lateral view, length is measured
**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
***Choose aperture position on device based on height of the intended area of biopsy and engage access needle into the perineal skin
****No more than 2 aperture positions should be needed to sample prostate
***20 cores (2 cores (different locations) taken from 5 sites on each side) +/- target(s)[https://pubmed.ncbi.nlm.nih.gov/34048827/]
****5 sites
****#Posterior medial
****#Anterior medial
****#Posterior lateral
****#Anterior lateral
****#Base
***3-4 cores from target(s)
**Remove ultrasound probe and apply pressure to perineum to reduce bleeding
**Inform patient of reasons to return to hospital