Editing Prostate Biopsy (section)

== Preparing for biopsy ==

=== Anti-coagulation ===
* '''<span style="color:#ff0000">Low-dose aspirin does not need to be discontinued</span>[https://pubmed.ncbi.nlm.nih.gov/24859439/]'''
* '''<span style="color:#ff0000">Warfarin and clopidogrel should be stopped 7-10 days before prostate biopsy</span>'''
* '''<span style="color:#ff0000">Novel oral anticoagulants apixaban, dabigatran, and rivaroxaban are stopped 2-5 days before</span>'''
** Rivaroxaban may increase stroke risk if stopped; therefore bridging with some other anticoagulant such as heparin is recommended.
* For patients with underlying coagulopathy or on warfarin, prostatic biopsy should not be performed until the INR has been corrected < 1.5 if the patient has low risk for a thromboembolic event. Because of the higher risk for thromboembolic events (e.g., mechanical valves) on warfarin, bridging anticoagulation with unfractionated heparin or low-molecular weight heparin is suggested.

=== Antibiotic prophylaxis</span> ===

==== Transrectal ====
*'''<span style="color:#ff0000">Recommended for all patients undergoing prostate biopsy</span>'''
* '''<span style="color:#ff0000">Regimen:</span>'''
** '''[https://pubmed.ncbi.nlm.nih.gov/31441676/ 2019 AUA Antibiotic Prophylaxis Guidelines]: fluoroquinolone OR 1st/2nd/3rd gen. cephalosporin (ceftriaxone commonly used) + aminoglycoside'''
** 2015 CUA Antibiotics Prophylaxis Guidelines: no specific regimen
** Campbell’s: For patients at risk for developing endocarditis or infection of prosthetic joints, pacemakers, and automated implanted cardiac defibrillators, prophylaxis should consist of intravenous ampicillin (vancomycin, if penicillin allergic) and gentamicin preoperatively, followed by 2 to 3 days of an oral fluoroquinolone.
** Presence of fluoroquinolone resistant organisms on a rectal swab culture may not always be associated with clinical infection. 
***A multi-institutional cohort study of 136 men undergoing rectal swab cultures immediately before biopsy found fluoroquinolone resistant E. coli in 22% of cultures. Patients received ciprofloxacin +/- gentamycin for prophylaxis. Post-biopsy fever occurred in 5 patients, and only 1 of them had a positive rectal screen for resistant E. coli.[https://pubmed.ncbi.nlm.nih.gov/21334021/]
** '''The use of targeted prophylaxis after rectal flora swabbing and culture has been shown to have some utility compared with empirical antibiotic prophylaxis in some series'''
* '''<span style="color:#ff00ff">2011 Cochrane review evaluating antibiotic prophylaxis for TRUS biopsy of the prostate</span>[https://pubmed.ncbi.nlm.nih.gov/21563156/]'''
** 19 studies including 3,599 patients.
** '''Comparing antibiotics vs. placebo/no antibiotics''' (9 trials): '''antibiotics significantly reduce risk of (5):'''
**# '''Bacteriuria''' (risk ratio (RR) 0.25)
**# '''UTI''' (RR 0.37)
**# '''Bacteremia''' (RR 0.67)
**# '''Fever''' (RR 0.39)
**# '''Hospitalization''' (RR 0.13)
**#* Most data derived from studies with quinolones
** '''Comparing antibiotics +/- enema, only the risk of bacteremia''' (RR 0.25, 95% CI 0.08-0.75) '''was diminished in the antibiotic + enema group'''
** '''Comparing short-course (1 day) versus long-course (3 days) antibiotics''' (7 trials): '''long course significantly better than short-course treatment only for bacteriuria''' (RR 2.09)
** Comparing '''s'''ingle versus multiple dose: significantly greater risk of bacteriuria for single-dose treatment (RR 1.98)
** Comparing oral versus systemic administration - intramuscular injection (IM), or intravenous (IV) - of antibiotics, no significant differences in the groups for bacteriuria, fever, UTI and hospitalization.
** Zani, Emerson L., Otavio Augusto Camara Clark, and Nelson Rodrigues Netto Jr. "[https://pubmed.ncbi.nlm.nih.gov/21563156/ Antibiotic prophylaxis for transrectal prostate biopsy.]" Cochrane Database of Systematic Reviews 5 (2011).

==== Transperineal ====

* Risk of infection is decreased compared to transrectal since trajectory avoids rectum
* '''<span style="color:#ff00ff">NORAPP Trial (2022)</span>[https://pubmed.ncbi.nlm.nih.gov/35839791/]'''
** Population: 555 patients referred for prostate biopsies
*** Excluded patients at high-risk (clinical suspicion of urinary tract infection together with a positive urine dipstick for leukocytes and nitrate, recurring or recent urinary tract infection (<1 month), indwelling urinary catheter, immunodeficiencies, high risk of infective endocarditis, or history of thromboembolic disease) of post-biopsy infection
*** All patients with a positive MRI underwent two to four biopsies per target. Systematic biopsies were done as an addition to target biopsies in biopsy naive patients and in all patients with a negative MRI.
** Randomized (open-label) to antibiotics (cefuroxime 1.5g IV or IM 30 minutes before biopsy) vs. no antibiotics
** Outcomes:
*** Primary: difference in the rate of urosepsis or urinary tract infections requiring hospitalisation up to 2 months after biopsy 
*** Secondary: difference in the rate of urinary tract infections not requiring hospitalisation by 2 months
** Results:
*** Primary outcome: no significant different in rate of urosepsis or UTI requiring hospitalisation up to 2 months after biopsy (0% antibiotics vs. 0% no antibiotics)
*** Secondary outcome: no significant difference in rate of UTI not requiring hospitalisation by 2 months (0.4% antibiotics vs. 1.1% no antibiotics)
**** NNT with antibiotic prophylaxis to avoid one UTI not requiring hospitalisation: 137
** '''Interpretation: In patients undergoing transperineal biopsy, antibiotics do not significantly reduce the risk of infections'''
** Jacewicz, Maciej, et al. "[https://pubmed.ncbi.nlm.nih.gov/35839791/ Antibiotic prophylaxis versus no antibiotic prophylaxis in transperineal prostate biopsies (NORAPP): a randomised, open-label, non-inferiority trial.]" ''The Lancet Infectious Diseases'' (2022).

=== Cleansing Enema ===
* Advantages
**Decreases the amount of feces in the rectum, thereby producing a superior acoustic window for prostate imaging
**Effect on reducing infections is debatable
* Disadvantage
**Requires coordinating timing of biopsy to effect of cleansing enema
* '''2015 CUA Antibiotics Prophylaxis Guidelines: insufficient evidence to recommend routine use of enemas'''

=== Number and location of cores ===
* '''Approach'''
**'''Transrectal'''
***The extended 12-core systematic biopsy that incorporates apical and far-lateral cores is the current recommended method.
**** Previously, the standard number of cores was 6. However, it has been shown that increasing the number of cores from 6 to 12 significantly increases cancer detection rate.
***** Increasing the number of cores to 18 or 21 (often termed saturation biopsy) as an initial biopsy strategy does not appear to result in a similar increase from 6 to 12. Saturation biopsy is more likely to be considered in the setting of a prior negative biopsy, though in the era of MRI this may not be relevant.
**'''Transperineal'''
***20 cores (2 cores (different locations) taken from 5 sites on each side)[https://pubmed.ncbi.nlm.nih.gov/34048827/]
****5 sites
****#Posterior medial
****#Anterior medial
****#Posterior lateral
****#Anterior lateral
****#Base
**'''<span style="color:#ff0000">≥2 needle biopsy cores per target should be obtained in patients with suspicious prostate lesion(s) on MRI.[https://pubmed.ncbi.nlm.nih.gov/23659877/]</span>'''
***≥2 cores per target provides the most reproducible and accurate cancer detection rate.
**** The optimal number of biopsy cores per MRI target may differ based on multiple factors including
*****Patient characteristics (e.g., age, PSA, biopsy naïve versus prior biopsy)
*****Target characteristics (e.g., size, location, PIRADS classification)
*****Biopsy approach/technique (e.g., software fusion versus cognitive fusion, transrectal vs. transperineal).
****The incremental value in cancer detection is diminished after obtaining >3 cores per target.
***For prostate cancer risk group stratification, all cores from the same MRI target should be considered as a single core.
*'''The transitional zone and seminal vesicles are not routinely sampled because these regions have been shown to have consistently low yields for cancer detection at initial biopsy'''
** '''Isolated transition zone tumors without peripheral zone involvement occur < 5% of the time.'''
** '''Transitional zone and anteriorly directed biopsies may occasionally prove necessary to diagnose prostate cancer in those patients with persistently elevated PSA levels and prior negative biopsies. More recently, MRI is often used to detect and guide biopsies of these anterior tumors that may escape standard TRUS prostate biopsy'''
** The seminal vesicles are not routinely performed unless there is a palpable abnormality, with some authors recommending seminal vesicle biopsy when the PSA is > 30 or if brachytherapy is being considered
* '''When biopsy specimens are taken from different sextant areas of the prostate, they should be submitted to pathology in separate containers'''
** ''An AUA white paper recently outlined the recommended processing of prostate biopsy samples, and the review did not provide compelling evidence that individual site–specific labeling of cores benefits clinical decision making regarding the management of prostate cancer (Bjurlin et al, 2013). [still relevant?]''