Prostate Biopsy (PBx).pptx

A prostate biopsy is a procedure used to obtain tissue samples from the prostate gland in order to detect cancer. The biopsy is best performed with a spring-driven needle core biopsy device (or biopsy gun)

No prostate-specific antigen (PSA) value can establish with absolute certainty whether a patient has prostate cancer. Thus, the decision to proceed with prostate biopsy must be individualized. Urinary biomarkers have been shown to be useful in identifying patients at risk for prostate cancer prior to the initial biopsy. [1]

Even more difficult is the decision to perform a repeat biopsy. Patients with atypical small acinar neoplasia have an absolute indication for repeat biopsy soon after the initial biopsy. However, patients with focal high-grade prostatic intraepithelial neoplasia (HGPIN) do not need to undergo automatic biopsy, because they are not at significantly higher risk for prostate cancer. By contrast, patients with multifocal HGPIN are at significant risk for prostate cancer and should undergo delayed interval biopsy every 3 years as long as they remain healthy. Patients who have persistently abnormal or rising PSA levels or very low percentages of free PSA (< 13%) are at some risk for harboring unrecognized prostate cancer and thus should be considered for repeat biopsy.

Contraindications for prostate biopsy include the surgical absence of a rectum or the presence of a rectal fistula.

The complications encountered after TRUS biopsy are commonly minor and self-limited, including mild hematuria, hematospermia, and transient rectal bleeding. Urinary tract infection is another frequently noted complication of prostate biopsy.

1. Uro-patho Meet 2079/12/23 Dr. Rabindra Tamang MCh Resident Department of Urology and Kidney Transplant Surgery MMC, TUTH

2. Contents Case history History of prostate biopsy ( PBx ) Ultrasonographic anatomy of prostate Transrectal ultrasound (TRUS) guided PBx Advanced and investigational techniques for PBx

3. Case History Mr. Dhungana 72 yrs/M C/O: Poor stream of urine for 6 months Straining + Back pain for 3 months Past history: Hypertension for 20 years

4. DRE: Grade III prostatomegaly, hard, nodule felt on left lobe, mucosa free. Ultrasonography: Prostate: 40gm PVRU: 25ml IVPP: 3mm PSA: 35 ng /mL

5. 12 core TRUS guided Trans rectal PBx

6. HPE report: Acinar adenocarcinoma involving 10 out of 12 cores. Right apex medial and lateral: uninvolved Combined Gleason score: 3 + 5 = 8 Grade group: 4 Perineural invasion identified Lymphovascular invasion: absent

7. History of PBx 1922: Benjamin Barringer Transperineal PBx ( TPBx ) 1926: Hugh Hampton Young Open perineal PBx 1930: Russel Ferguson Modified TP needle aspiration

8. History of PBx contd. 1954: Kaufman University of California DRE guided needle Bx 1963: Takahashi TRUS 1965: Gotoh and Nashi TRUS to diagnose carcinoma prostate (CaP)

9. Ultrasonographic anatomy of the prostate

10. Ultrasonographic contd. CZ and PZ: homogenous TZ: more heterogenous Corpora amylacea : diffuse calcifications Urethra: hypoechoic Internal sphincter: funneled appearance

11. TRUS PBx Machine settings Types of endorectal probes Techniques Indications, contraindications Patient preparations

12. TRUS PBx Machine settings: Optimal brightness: Normal PZ Isoechoic Hypoechoic Hyperechoic Anechoic Magnification: low

13. TRUS PBx Types of probes

14. TRUS PBx Technique Sagittal and transverse planes Probe manipulation For transverse and sagittal imaging

15. PBx Indications for initial PBx : Initial diagnosis of CaP Suspicious DRE Diagnose CaP with symptoms s/o CaP Diagnose CaP with findings s/o metastatic disease In the setting of CaP detected on routing TURP

16. NCCN recommendations for PBX: Positive DRE regardless of PSA PSA level 4-10 ng /mL based on patient risk factors PSA ≤ 2.5 ng /mL and PSA velocity ≥ 0.35 ng /mL per year PSA ≥ 4.0 ng /mL especially if free PSA ≤ 10%

17. Indications for repeat PBx Rising and / or persistently elevated PSA Typical small acinar proliferation Extensive with Prostatic Intraepithelial Neoplasia (PIN) Positive urinary PCA3 Suspicious lesion on prostate MRI

18. PBx Indications for follow up PBx Active surveillance follow up protocol

19. Contraindications of PBx Significant coagulopathy Severe immunosuppression Acute prostatitis

20. Preparing of patient: Informed consent Aspirin: low dose can be continued Anticoagulants: Stop 7 – 10 days prior INR < 1.5

21. Preparing patient contd. 4. Antibiotic prophylaxis: Indicated in all cases Metronidazole or clindamycin Duration: Shorter course or single dose protocols

22. Antibiotic prophylaxis Route: intramuscular and oral Antibiotics: Fluoroquinolones Cephalosporins Aminoglycosides Aztreonam / Trimethoprim sulfomethoxazole

23. EAU guidelines

24. Preparing patient contd. 5. Enema: Superior acoustic window 6. Positioning: Left lateral decubitus Right lateral decubitus Lithotomy

25. Transrectal PBx technique: Perform DRE TRUS of prostate Place needle tip ~ 0.5cm posterior to the prostate capsule Perform biopsy

26. Analgesia techniques

27. Biopsy techniques: Sextant biopsy: Hodge et al 10 core biopsy: Presti et al 12 core biopsy: Bjurlin et al 13 core biopsy: Eskew et al

28. Saturation PBx Increase in Cancer Detection Rates (CDRs) Indicated in the setting of prior negative biopsy: CDRs for sextant biopsy (2nd): 5% CDRS for saturation biopsy (2nd): 30%

29. Transperineal PBx In patients lacking rectum Advantages: Reduced infection Improved identification of apical tumors Disadvantages: Extensive anesthesia Inferior visualization

30. Transurethral PBx Once advocated for TZ carcinoma prostate

31. EAU guidelines When performing systematic biopsies only, at least 12 cores are recommended [ STRONG ] Systematic transperineal biopsies are preferred over systematic transrectal biopsies for detection of clinically significant CaP [ STRONG ]

32. EAU guidelines contd. Additional cores: - suspect areas identified by DRE and TRUS At least 8 systematic biopsies are recommended in a prostate of about 30 cc 10-12 core biopsies are recommended in larger prostates

33. EAU guidelines contd. A role of TZ biopsy in men with gland >50 gm Additional yield of 15% cancer detection. SV is sampled: Palpable abnormality, PSA >30 or Brachytherapy is considered

34. Sample Handling Sample in 10% formalin No more than 2 cores in each jar

35. Labelling

36. Complications of PBx Serious complications < 1% Bleeding: most common complication Infections: 0.1 – 7.0 % Urinary retention: 0.2 % Anxiety and discomfort: 1.4 – 5.3%

37. Advanced and Investigational techniques for PBx Color Doppler Power Doppler Contrast Enhanced TRUS Elastography Prostate HistoScanning – backscattered US

38. Advanced and Investigational techniques for PBx Multiparametric prostate USG Multiparametric MRI of prostate In Bore MRI Cognitive fusion Software assisted fusion In bore MRI

39. EAU guidelines Perform MRI before PBx in biopsy naïve patients or in patients with prior negative biopsy [ STRONG ] When MRI is positive (PIRADS ≥ 3), perform PBx

40. Take Home Message Transperineal prostate biopsy is the recommended strategy Proper patient preparation is must prior to the procedure Newer modalities need to be explored more for better outcomes.

41. Thank You