What is the recommended procedure for a patient requiring a Transrectal Ultrasound (TRUS) guided biopsy?

TRUS-Guided Prostate Biopsy Procedure Recommendations

For patients requiring a Transrectal Ultrasound (TRUS) guided prostate biopsy, an extended-pattern 12-core biopsy is the recommended standard procedure, including systematic sampling of the sextant medial and lateral peripheral zones plus any lesion-directed biopsies. 1

Initial Biopsy Procedure

Standard Technique

• Extended 12-core biopsy scheme is the recommended approach:
  • 6 cores from standard sextant locations (apex, mid-gland, and base on both right and left sides)
  • 6 cores from lateral peripheral zone (lateral apex, lateral mid-gland, lateral base on both sides)
  • Additional lesion-directed biopsies for any palpable nodules or suspicious images 1

Anesthesia

• Local anesthesia should be used to reduce patient discomfort:
  • Periprostatic nerve block is more effective for pain during the biopsy itself
  • Topical lidocaine gel is more effective for reducing pain during probe insertion 1
• For exceptional cases (anal strictures or inadequate block), intravenous sedation may be considered 1

Technical Considerations

• TRUS guidance is essential for proper needle placement and visualization 1
• Anteriorly directed biopsy is not recommended for routine initial biopsy 1
• Transition zone biopsies are not recommended for initial biopsy 1

Repeat Biopsy Scenarios

For patients with prior negative biopsies but persistent clinical suspicion (rising PSA):

MRI Before Repeat Biopsy

• MRI followed by targeted biopsy is strongly recommended before repeat biopsy for patients with persistently elevated or rising PSA after a negative initial biopsy 1, 2
• MRI-targeted biopsy approaches have cancer detection rates of 34-51% in men with previous negative biopsies 1, 2

Combined Approach

• A combined approach using both systematic 12-core biopsy plus targeted biopsy of suspicious MRI lesions is recommended to maximize cancer detection 2
• This combined approach detects more clinically significant cancers than either method alone:
  • Targeted biopsies identify up to 91% of significant cancers
  • Standard systematic biopsy alone identifies only about 54% of significant cancers 2

Additional Considerations for Repeat Biopsy

• Particular attention should be given to apical sampling, including the anterior apical horn 1
• Transition zone biopsies can be considered in repeat biopsy settings 1
• Anteriorly directed biopsies can be added to extended protocol in repeat biopsy if PSA remains elevated 1
• Saturation biopsy strategies (>20 cores) may be considered after 2 negative extended biopsies with persistently rising PSA 1

Special Considerations

Large Prostates

• Patients with large prostates (>80g) are at higher risk of sampling error with standard systematic biopsy alone 2
• MRI-targeted approaches are particularly valuable in these cases 2

Complications and Risks

• Most common complication is persistent hematuria (47.1% of cases), typically lasting 3-7 days 3
• Recent use of aspirin or NSAIDs is not an absolute contraindication 3
• Infectious complications are rare (1.7% incidence of fever) with appropriate antibiotic prophylaxis 3
• Younger patients may experience more discomfort during the procedure and may benefit from additional analgesia 3

Emerging Technologies

• MRI-TRUS fusion platforms are becoming increasingly important, especially for repeat biopsies 1, 2
• Three main targeted biopsy techniques are available:
  1. Cognitive/visual targeting (using ultrasound based on MRI images)
  2. TRUS-MRI fusion platforms (merging stored MRI with real-time ultrasound)
  3. Direct in-bore MR-guided biopsy (performed by interventional radiologist) 1

By following these evidence-based recommendations for TRUS-guided prostate biopsy, clinicians can optimize cancer detection while minimizing patient discomfort and complications.