Indications
• The decision to proceed to prostate biopsy is
based primarily on PSA and DRE results.
However, one should take into account multiple
factors, including free and total PSA,
patient age, PSA velocity, PSA density, family
history, ethnicity, prior biopsy history
and comorbidities.
Contraindications
• Contraindications to prostate biopsy include
acute painful perianal disorders, bleeding
diathesis, acute prostatitis, and severe
immunosuppression.
• Transrectal ultrasound-guided prostate biopsy
is impossible in patients lacking a rectum,
as those who have undergone ano-rectal
resection. In those cases, transgluteal
biopsy under CT guidance is performed.
Patient Preparation
• The patient should discontinue oral
anticoagulants approximately 7–10 days prior to
the procedure.
• Coagulation parameters are not routinely
checked unless there is a reason for them
to be abnormal. For patients on warfarin or
with an underlying coagulopathy,
International Normalized Ratio (INR) should be
corrected to below 1.5 and platelets
above 50,000.
• Patients receive oral antibiotics on the day
prior, the day of, and for 5 days after the
procedure. Agents commonly used are oral
fluoroquinolones, e.g., levofloxacin.
Anatomy
• The prostate is split into four distinct zones:
the central zone, peripheral zone, and transition
zone, as well as the fibromuscular stroma.
• In young men, the peripheral zone comprises 75%
of the volume of the prostate. After
the age of 40, benign prostatic hyperplasia
begins in the transition zone.
• Prostate cancer is located in the peripheral
zone in approximately 70% of patients.
Equipment
• Transrectal ultrasound transducer with needle
guide
• 18 gauge cutting needle biopsy gun
Pre-procedure Medications
• A cleansing enema on the morning of the
procedure is optional.
• One dose of parenteral antibiotics is given
just prior to the procedure. This usually is a
dose of gentamycin 80 mg. It is given IM; if
the patient has prosthetic cardiac valves or
joints, it has to be given IV.
• The necessity for periprocedural pain control
is debatable. There are many methods
used; the most popular approach being the
peri-prostatic nerve block. The nerves can be
blocked with lidocaine injection at the
hyperechoic fat pad that demarcates the junction
of the seminal vesicles and the prostate
bilaterally.
