What is the procedure for a prostate biopsy?

Prostate Biopsy Procedure

Prostate biopsy is standardly performed as a transrectal ultrasound-guided procedure with 10-12 core samples targeting the peripheral zone at the apex, mid-gland, and base of the prostate. 1, 2

Standard Biopsy Approach

Preparation

• Antibiotic prophylaxis: Quinolone antibiotics (typically ciprofloxacin) should be administered before the procedure to prevent infectious complications 1, 2
• Rectal preparation: An enema may be used, although evidence suggests it provides no significant clinical advantage in reducing complications 3
• Anticoagulation management: Aspirin and nonsteroidal anti-inflammatory drugs should be discontinued 7-10 days before the procedure to reduce bleeding risk 1, 4

Procedure Components

1. Positioning: Patient is typically placed in left lateral decubitus position
2. Anesthesia: Local anesthesia is administered as a periprostatic nerve block using ultrasound guidance 1, 5
3. Imaging guidance: Transrectal ultrasound probe is inserted to visualize the prostate 1, 6
4. Biopsy technique:
   • Standard approach uses an 18-gauge spring-loaded biopsy needle 6
   • 10-12 core samples are taken systematically from the peripheral zone 2
   • Samples target the apex, mid-gland, and base of the prostate bilaterally 1
   • Additional samples may be taken from suspicious areas identified on imaging 1

Alternative Approaches

MRI-Targeted Biopsy

• Increasingly used when suspicious lesions are identified on multiparametric MRI 1
• Can be performed using:
  • MRI-ultrasound fusion technology
  • In-bore MRI guidance
  • Cognitive fusion (visual estimation)
• Rated highly appropriate (8/9) for patients with prior negative biopsy 1

Transperineal Biopsy

• Emerging alternative approach with lower infection risk
• Can be performed under local anesthesia in an office setting
• May not require antibiotic prophylaxis (0.6% infection rate) 7
• Well-tolerated with low pain scores 7

Potential Complications

Common Minor Complications (63.6% of patients experience at least one) 4

• Hematuria: Most common (47.1%), typically persists for 3-7 days 4
• Hematospermia: Common but self-limiting
• Rectal bleeding: Usually minor and self-limiting

Serious Complications (rare, <5% of cases) 1

• Infection: Fever (1.7%), urinary tract infection (0.3-4%), sepsis (<2%) 1, 4
• Severe bleeding: Rarely requires transfusion
• Urinary retention: Uncommon
• Vasovagal reactions: Uncommon

Special Considerations

Repeat Biopsy Indications

• Previous high-grade prostatic intraepithelial neoplasia (PIN): 23-35% risk of cancer on subsequent biopsy 1
• Previous atypical small acinar proliferation: 42-49% risk of cancer on subsequent biopsy 1
• Rising PSA despite previous negative biopsy 1

Extended Biopsy Protocols

• Extended schemes (>12 cores) can decrease false-negative rates from 20% to 5% 2
• Saturation biopsy (>20 cores) may be considered after multiple negative biopsies 2

Common Pitfalls to Avoid

• Inadequate antibiotic prophylaxis, increasing infection risk 2
• Insufficient number of core samples, increasing false-negative rates 1
• Failure to sample the peripheral zone adequately, where most cancers originate 1
• Not considering MRI before repeat biopsy in patients with prior negative results 1
• Overlooking the need for anesthesia, especially with extended biopsy protocols 1, 5

The transrectal ultrasound-guided biopsy remains the most common approach, though the transperineal approach is gaining favor due to lower infection rates. Regardless of approach, proper preparation, adequate sampling, and appropriate post-procedure monitoring are essential for optimal outcomes.