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Prostate Biopsy: Difference between revisions

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# '''<span style="color:#ff0000">Acute prostatitis</span>'''
# '''<span style="color:#ff0000">Acute prostatitis</span>'''


== Approach: Transrectal vs. transperineal ==
== Approach: Transrectal vs. Transperineal ==
 
* '''Cancer detection rates associated with transrectal versus transperineal biopsy route are not significantly different.[https://pubmed.ncbi.nlm.nih.gov/23659877/]'''


=== Transrectal biopsy ===
=== Transrectal biopsy ===


* Trajectory of needle is through rectum and into prostate
* Trajectory of needle is through rectum and into prostate
*'''Advantages[https://pubmed.ncbi.nlm.nih.gov/23659877/]'''
*#'''Patient preference/comfort'''
*#'''Patient cannot be placed into the lithotomy position'''
*#'''Clinician training/experience or lack of appropriate equipment for the transperineal approach.'''
=== Transperineal biopsy ===
=== Transperineal biopsy ===
* Trajectory of needle is through skin (avoids rectum) and into prostate
* Trajectory of needle is through skin (avoids rectum) and into prostate
*'''Advantages (3):'''
*'''Advantages (3):'''
*# '''Reduced infectious and other complication rates'''
*# '''Reduced infectious and other complication rates'''
*# '''Improved identification of apical tumors'''
*# '''May detect anterior and apical cancers at a higher rate''' (prospective, randomized data are lacking and existing data are contradictory.)'''[https://pubmed.ncbi.nlm.nih.gov/23659877/]'''
*# '''Can be done in patients without a rectum''' (e.g., surgical extirpation, congenital anomaly)
*# '''Can be done in patients without a rectum''' (e.g., surgical extirpation, congenital anomaly)
* '''Disadvantages (1):'''
* '''Disadvantages (1):'''
*# '''May need for more anesthesia''', but can be done under local anesthetic
*# '''May need for more anesthesia''', but can be done under local anesthetic
*'''<span style="color:#ff0000">Transperineal biopsies may have some value in patients (3):[https://pubmed.ncbi.nlm.nih.gov/23659877/]</span>'''
*# '''<span style="color:#ff0000">Infectious complications with a prior biopsy</span>'''
*#'''<span style="color:#ff0000">Higher risk for biopsy-related infection</span>'''
*#'''<span style="color:#ff0000">Anterior lesions that may not be as easily accessible transrectally</span>'''
== Preparing for biopsy ==
== Preparing for biopsy ==


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=== Number and location of cores ===
=== Number and location of cores ===
* Approach
* '''Approach'''
**Transrectal
**'''Transrectal'''
***The extended 12-core systematic biopsy that incorporates apical and far-lateral cores is the current recommended method.
***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.
**** 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.
***** 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
**'''Transperineal'''
***20 cores (2 cores (different locations) taken from 5 sites on each side)[https://pubmed.ncbi.nlm.nih.gov/34048827/]
***20 cores (2 cores (different locations) taken from 5 sites on each side)[https://pubmed.ncbi.nlm.nih.gov/34048827/]
****5 sites
****5 sites
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****#Anterior lateral
****#Anterior lateral
****#Base
****#Base
***3-4 cores from target
**'''<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'''
*'''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.'''
** '''Isolated transition zone tumors without peripheral zone involvement occur < 5% of the time.'''
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***Randomized trials found no significant difference in prostate cancer detection rates between these two approaches[https://pubmed.ncbi.nlm.nih.gov/24725491/]
***Randomized trials found no significant difference in prostate cancer detection rates between these two approaches[https://pubmed.ncbi.nlm.nih.gov/24725491/]
**'''The best visualization of the biopsy/needle path is in the sagittal plane'''
**'''The best visualization of the biopsy/needle path is in the sagittal plane'''
**Transperineal biopsy cannot be done with an end-fire probe or a side-fire probe with a short linear array[https://pubmed.ncbi.nlm.nih.gov/29409845/]
***Linear array needs to be long enough to visualize from just beyond the perineal skin to the apex of the prostate
* Disposable sheaths to cover the TRUS probes (e.g. condom)
* Disposable sheaths to cover the TRUS probes (e.g. condom)
**See [https://www.youtube.com/watch?v=izurJz0qXF4 Video] on preparing TRUS probe with lubrication and condom
*'''18-guage biopsy instrument'''
*'''18-guage biopsy instrument'''
**The biopsy instrument advances the needle ≈0.5 cm and samples the subsequent ≈1.5 cm of tissue with the tip extending ≈0.5 cm beyond the area sampled.  
**The biopsy instrument advances the needle ≈0.5 cm and samples the subsequent ≈1.5 cm of tissue with the tip extending ≈0.5 cm beyond the area sampled.  
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* '''Approaches[https://pubmed.ncbi.nlm.nih.gov/16439219/]'''
* '''Approaches[https://pubmed.ncbi.nlm.nih.gov/16439219/]'''
** '''Periprostatic nerve block'''
** '''Regional anesthetic'''
***Nerves can be blocked with either unilateral or bilateral injection, around the apex or base of the gland (in the groove between the gland and seminal vesicles).
***'''Periprostatic nerve block'''
***Typically performed using a 7 inch 22-gauge spinal needle, and the biopsy channel of the ultrasound probe
****Nerves can be blocked with either unilateral or bilateral injection, around the apex or base of the gland (in the groove between the gland and seminal vesicles).
***'''Aspirate the syringe before injecting to ensure that the vascular system has not been entered'''
****Typically performed using a 7 inch 22-gauge spinal needle, and the biopsy channel of the ultrasound probe
***'''Method 1[https://pubmed.ncbi.nlm.nih.gov/8558671/][https://pubmed.ncbi.nlm.nih.gov/24725491/]'''
****'''Aspirate the syringe before injecting to ensure that the vascular system has not been entered'''
****'''In the region of the neurovascular bundle at the base of the prostate, just lateral to the junction between the prostate and seminal vesicle'''
****'''Method 1[https://pubmed.ncbi.nlm.nih.gov/8558671/][https://pubmed.ncbi.nlm.nih.gov/24725491/]'''
***** '''Can be easily identified as a hypoechoic (dark) area on TRUS'''
*****'''In the region of the neurovascular bundle at the base of the prostate, just lateral to the junction between the prostate and seminal vesicle'''
*****See [https://pubmed.ncbi.nlm.nih.gov/8558671/ Figure 2 in link] and [https://www.semanticscholar.org/paper/Pain-during-Transrectal-Ultrasound-Guided-Prostate-Nazir/8c1020245b7d2c8f298441aa0355ffe577cd2fde/figure/3 Figure]
****** '''Can be easily identified as a hypoechoic (dark) area on TRUS'''
*****See [https://www.youtube.com/watch?v=Mo3DO1mFTdU Video]
******See [https://pubmed.ncbi.nlm.nih.gov/8558671/ Figure 2 in link] and [https://www.semanticscholar.org/paper/Pain-during-Transrectal-Ultrasound-Guided-Prostate-Nazir/8c1020245b7d2c8f298441aa0355ffe577cd2fde/figure/3 Figure]
****Ultrasound monitoring can confirm separation of the tissue planes caused by injection
******See [https://www.youtube.com/watch?v=Mo3DO1mFTdU Video]
****The injection is performed twice, once either side the midline.
*****Ultrasound monitoring can confirm separation of the tissue planes caused by injection
***Method 2 (transrectal)[https://pubmed.ncbi.nlm.nih.gov/16439219/]
*****The injection is performed twice, once either side the midline.
****A position just lateral to the midline, and away form the external sphincter is chosen. The needle is passed through rectal mucosa and local anaesthetic instilled, so that the anaesthetic pools within fascial layers (presumed to the Denonvillers' fascia) and bathes the posterior surface of the gland, from the apex up to the base.
****Method 2 (transrectal)[https://pubmed.ncbi.nlm.nih.gov/16439219/]
****The injection is performed twice, once either side of the midline.
*****A position just lateral to the midline, and away form the external sphincter is chosen. The needle is passed through rectal mucosa and local anaesthetic instilled, so that the anaesthetic pools within fascial layers (presumed to the Denonvillers' fascia) and bathes the posterior surface of the gland, from the apex up to the base.
***Conflicting evidence if direct infiltration into the prostate (intraprostatic injection) can augment the anesthetic benefit seen with periprostatic injection
*****The injection is performed twice, once either side of the midline.
** Topical rectal anaesthetic gel
****Conflicting evidence if direct infiltration into the prostate (intraprostatic injection) can augment the anesthetic benefit seen with periprostatic injection
***Pudendal nerve block[https://pubmed.ncbi.nlm.nih.gov/31374287/]
****Pudendal nerves are located 2cm lateral to anterior medial edge of anus and 3cm deep to skin
** Topical rectal anesthetic gel
** Variations in probe design
** Variations in probe design
** Glyceryl trinitrate (GTN) paste
** Glyceryl trinitrate (GTN) paste
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=== Transrectal ===
=== Transrectal ===


* See [https://www.youtube.com/watch?v=Mo3DO1mFTdU Video]
* 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'''
*'''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
**Lithotomy is preferred for brachytherapy treatment planning or placement of fiducial gold markers for external-beam therapy
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*** 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.
*** 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
** Remove ultrasound probe and apply digital pressure to biopsied area to reduce bleeding
**Take biopsies following appropriate template
***12 cores (1 core taken from 6 sites on each side)  +/- target(s)
****6 sites
****#Lateral apex
****#Lateral mid
****#Lateral base
****#Medial apex
****#Medial mid
****#Medial base
****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.
***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 millimeters 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.
**Remove ultrasound probe and apply digital rectal pressure to biopsied area to reduce bleeding
**Inform patient of reasons to return to hospital
**Inform patient of reasons to return to hospital


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***Puncture with needle at each mark and advance 3cm. Infiltrate with local anesthetic (5cc 1% lidocaine without epinephrine)
***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.
**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
**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.
***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.
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****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 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
****In sagittal view, rotate probe counter-clockwise to view right lobe of prostate, and clockwise to view left lobe of prostate
**Identify and mark the lateral edges of the prostate at the midprostate where access canula aligns with skin
**Perform perineal skin block with local anesthetic 1cm lateral and 1cm superior to the superior aspect of the anus
***Extend the line with an angle that aligns with the holes for the access canula
***Inject 5cc local anesthetic on each side
**Perform perineal skin block with local anesthetic along access canula line
***Inject 5cc local anesthetic along each skin marking
**Perform periprostatic nerve block
**Perform periprostatic nerve block
***Pass spinal needle through access canula through skin marking
***Pass spinal needle through access canula through skin marking
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**Take biopsies following appropriate template
**Take biopsies following appropriate template
***Use needle guide button on ultrasound machine, if available
***Use needle guide button on ultrasound machine, if available
***Choose aperture position on device based on area of biopsy
***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 positions should be needed to sample prostate
****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/]
***20 cores (2 cores (different locations) taken from 5 sites on each side) +/- target(s)[https://pubmed.ncbi.nlm.nih.gov/34048827/]
****5 sites
****5 sites
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#* Initial cancer detection rate for patients with a PSA between 4 and 10 μg/mL is 22%; subsequent biopsies for an elevated PSA result in a cancer detection rate of 10% on the second biopsy, 5% on the third, and 4% on the forth
#* Initial cancer detection rate for patients with a PSA between 4 and 10 μg/mL is 22%; subsequent biopsies for an elevated PSA result in a cancer detection rate of 10% on the second biopsy, 5% on the third, and 4% on the forth
#* Data from the large European screening study suggested that as the number of biopsy sessions increased to ultimately diagnose prostate cancer, the cancers diagnosed after several biopsy sessions were generally of lower grade and stage
#* Data from the large European screening study suggested that as the number of biopsy sessions increased to ultimately diagnose prostate cancer, the cancers diagnosed after several biopsy sessions were generally of lower grade and stage
#'''<span style="color:#ff0000">Identifying prostate cancer that does not require treatment</span>'''
##Discussing this risk prior to biopsy may optimize use of AS


== Advanced and investigational techniques for prostate biopsy ==
== Advanced and investigational techniques for prostate biopsy ==


* Newer imaging modalities allowing for the potential of targeted biopsy include Doppler to determine vessel density, determination of the elasticity of an area, endorectal MRI with dynamic contrast enhancement and diffusion weighting, and MRI spectroscopy
* Newer imaging modalities allowing for the potential of targeted biopsy include Doppler to determine vessel density, determination of the elasticity of an area, endorectal MRI with dynamic contrast enhancement and diffusion weighting, and MRI spectroscopy
* '''TRUS/MRI fusion via a software platform'''
* '''Targeted prostate biopsy of a visible lesion on mpMRI can be performed using real-time ultrasound with (2):[https://pubmed.ncbi.nlm.nih.gov/23659877/]'''
** Combines the familiarity of realtime TRUS guidance with detailed information from a diagnostic multiparametric MRI and superimposes both images via software image reconstruction
**'''Software-based registration of mpMRI images OR'''
* '''Cognitive fusion biopsy'''
**'''Cognitive registration.'''
** Requires no additional equipment and relies on an experienced operator reviewing a suspicious lesion on MRI and then directing the biopsy needle in the direction of suspicious lesions during the standard TRUS biopsy procedure.
***'''Software-based registration'''
** A primary disadvantage of this technique is the inability to record and confirm biopsy needle placement as well as interuser variability. In expert hands, this has been shown to be as good as software fusion
**** Combines the familiarity of real-time TRUS guidance with detailed information from a diagnostic multiparametric MRI and superimposes both images via software image reconstruction
****Disadvantages of software based fusion biopsy program:[https://pubmed.ncbi.nlm.nih.gov/23659877/]
*****Technical issues (e.g., software bugs, system crashes)
*****Operator error
*****Unusual anatomy (e.g., large prostates, previous transurethral resections of the prostate).
******The ability to perform cognitive fusion techniques using anatomic fiducial markers such as intraprostatic cysts may augment software-based fusion approaches in some cases such as to minimize the risk of misregistration.
*** '''Cognitive registration'''
**** Requires no additional equipment and relies on an experienced operator reviewing a suspicious lesion on MRI and then directing the biopsy needle in the direction of suspicious lesions during the standard TRUS biopsy procedure.
**** A primary disadvantage of this technique is the inability to record and confirm biopsy needle placement as well as interuser variability. In expert hands, this has been shown to be as good as software fusion
****Clinicians who adopt the cognitive fusion technique exclusively should undergo advanced training in MRI interpretation to optimize cancer detection.[https://pubmed.ncbi.nlm.nih.gov/23659877/]
***Conflicting evidence on cancer detection rates comparing software-based vs. cognitive registration[https://pubmed.ncbi.nlm.nih.gov/23659877/]


== Questions ==
== Questions ==
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*Harvey, C. J., et al. "[https://pubmed.ncbi.nlm.nih.gov/22844031/ Applications of transrectal ultrasound in prostate cancer.]" ''The British journal of radiology'' 85.special_issue_1 (2012): S3-S17.
*Harvey, C. J., et al. "[https://pubmed.ncbi.nlm.nih.gov/22844031/ Applications of transrectal ultrasound in prostate cancer.]" ''The British journal of radiology'' 85.special_issue_1 (2012): S3-S17.
*Zimmerman, Michael E., et al. "[https://pubmed.ncbi.nlm.nih.gov/31374287/ In-office transperineal prostate biopsy using biplanar ultrasound guidance: a step-by-step guide.]" ''Urology'' 133 (2019): 247.
*Zimmerman, Michael E., et al. "[https://pubmed.ncbi.nlm.nih.gov/31374287/ In-office transperineal prostate biopsy using biplanar ultrasound guidance: a step-by-step guide.]" ''Urology'' 133 (2019): 247.
*Meyer, Alexa R., et al. "[https://pubmed.ncbi.nlm.nih.gov/29409845/ Initial experience performing in-office ultrasound-guided transperineal prostate biopsy under local anesthesia using the precisionpoint transperineal access system.]" ''Urology'' 115 (2018): 8-13.
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