Transrectal ultrasound–guided prostate biopsy

Transrectal ultrasound–guided prostate biopsy is considered the standard approach for prostate biopsy and is most commonly performed on an outpatient with abasis following positive screening for prostate cancer.  It is not a targeted biopsy procedure. 

Nowadays, with the MRI capacity for depicting abnormal areas of the prostate, it is possible to obtainperform targeted sampling of prostate lesions with the use ofguided by real-time MR imaging–guided prostate biopsy.

Indications

Prostate cancer screening consists of PSA concentrationprostate specific antigen (PSA) measurement in the serum and a digital rectal examination. Positivity in one of these tests make patients candidates for further diagnostic evaluation with a transrectal ultrasonography–guided prostate biopsy.

Contraindications

The contraindications must be considered individually in each case. Overall, the most important contraindicationcontraindications are:

• uncooperative patient
  • sedation with a hypnotic agent (eg(e.g. propofol or midazolam) couldmight be performed and monitoredrequired +/- monitoring by an anaesthetist.
• uncorrectable bleeding diathesis (abnormal coagulation indices)

Procedure

Pre-procedurePreprocedure

Antibacterial prophylaxis areis recommended and may follow institutional protocols. The recommended antibiotics for transrectal prostate biopsies madepublished by american urology associationthe American Urology Association include: quinolones, 1st / 2nd / 3rd generation cephalosporins,aminoglycoside +, aminoglycoside and metronidazole or clindamycin, and aztreonam +metronidazoleand metronidazole or clindamycin. 

SomeIn some institutions standardized a small, an enema is performed before the procedure to clean out the bowels and clear the rectum of faeces. Evidence However evidence shows that there wasis no significant difference in rates of infectious complications between patients submitted or not tohaving/not having formal bowel preparationprep if they are on antibacterial prophylaxis⁴.

Laboratory parameters for a safe procedure

Many patients that underwentundergo prostate biopsy have increased cardiovascular risk and make continued use ofare on anticoagulants or antiplatelet therapymedication. The decision to suspend or maintain these therapies must be taken together with the patient's physician, taking into account the risks of bleeding and of a cardiovascular event.

In patients without disease or use of drugs that cause bleeding diathesisantibleeding agents, pre-procedure laboratory exams may not be necessary. Although, some institutional protocols andin some specific cases could demand for ainstitutions it is standard protocol to obtain blood testtests in all cases.

Complete blood count - Platelet: platelets > 50000;50000/mm²³  (Some(some institutions determineuse other values between 50000-100000/mm³)²

Coagulation profile: Some studies showedshow that having a normal INR or prothrombin time is no reassuranceguarantee that the patient will not bleed after the procedure.

• international normalized ratio (INR) ≤ 1 ≤1.5 ²
• normal prothrombin time (PT), partial thromboplastin time (PTT)

Positioning

Patient may be positionedplaced in the left lateral decubitus position with semi-flexedsemiflexed knees.

Biopsy

1. Thethe lubricated ultrasound transducer is inserted into the patient’s rectum. Lidocaine gelA lidocaine preparation may be used as ultrsoundultrasound gel.
2. Regionalregional block is administered around both neurovascular bundles (lidocaine).
3. Biopsybiopsy needle is introduced. US–guided prostate biopsy is not a targeted biopsy procedure. The
4. the prostate sampling technique is based on the sextant protocol, described by Hodge et al. and modified later, in which samples wereare obtained of the more peripheral zone (where the diagnostic yield is higher) from the base through the middle to the apex of the gland, bilaterally. Usually are 12 samples are taken, two per sextantesextant.

Post-procedure care

The recovery process will vary depending on the type of anesthesia that is used. In the usual technique, with only local anesthetic, the patient canmay resume yourtheir normal activities and diet. 

Patient should be instructedconsented about somepossible light bleeding from histhe rectum. That he may note blood in urine or stools, mild haematuria and/or haematochezia for a few days and that his semen may have a red or rust-colored tint caused by a small amount of blood.

It should be reemphasizedre-emphasized the continued use of antibiotic, as institutional protocols.

Complications

Minor complications are frequent, such as limited hematuria and hematospermia (may persist as long as 1 week after the biopsy). Reported infection rates are variable but low with the use of prophylactic antibiotics (Septicemia(septicemia requiring hospitalization occurred in less than 4% of patients¹).