What are the steps and precautions for a patient undergoing a prostatic biopsy?

Prostatic Biopsy: Steps and Precautions

Prostate biopsy should be performed as a transrectal ultrasound-guided procedure with local anesthesia, obtaining 8-12 systematic cores from the peripheral zone, with mandatory antibiotic prophylaxis and rectal preparation to minimize infectious complications. 1

Pre-Procedure Patient Preparation

Antibiotic Prophylaxis and Bowel Preparation

• Administer prophylactic antibiotics effective against Gram-negative bacteria 1
• Perform rectal preparation with enema prior to the procedure 1
• These measures are standard requirements to prevent infectious complications 1

Patient Counseling Requirements

• Explain the aim and practical aspects of the investigation to the patient before proceeding 1
• Provide emergency department contact information in case complications occur post-procedure 1
• Discuss that serious complications (rectal/urinary hemorrhage, infection, urinary retention) occur infrequently 1

Biopsy Technique

Anesthesia and Setting

• Administer local anesthesia through a needle inserted into the rectal probe 1
• Local anesthesia decreases pain/discomfort and should be offered to all patients 1
• The procedure can be performed in day-hospital or outpatient settings 1
• A minority of patients may require locoregional or general anesthesia 1

Core Sampling Protocol

For initial biopsy, obtain a minimum of 8-12 systematic cores targeting specific zones: 1

• Sample the peripheral zone at the apex, mid-gland, and base bilaterally 1
• Include laterally directed cores on each side 1
• Extended biopsy schemes (12 cores) improve cancer detection by 25% compared to sextant biopsies, especially when prostate volume exceeds 40cc 1
• This approach decreases the false-negative rate from 20% to 5% 1

Additional Sampling Considerations

• Biopsy any zones appearing abnormal on digital rectal examination or ultrasound 1
• Transition zone biopsies may be added on repeat biopsy if PSA remains persistently elevated 1
• Anteriorly directed biopsies are not routinely supported in initial biopsy 1

Special Circumstances

Repeat Biopsy Strategies

If initial biopsy is negative but suspicion remains high: 1

• Consider multiparametric MRI to identify regions missed on prior biopsies after at least one negative biopsy 1
• Extended biopsy with increased sampling from the transition zone and peripheral zone laterally 1
• For high-risk men with multiple negative biopsies, consider saturation biopsy (>20 cores) including transperineal techniques 1

High-Grade PIN or Atypical Findings

• Perform repeat biopsy within 3 months if high-grade prostatic intraepithelial neoplasia (PIN) or suspicious lesions are diagnosed 1
• High-grade PIN diagnosis alone should not lead to treatment 1
• Extended pattern rebiopsy with increased sampling of affected sites and adjacent areas for atypia suspicious for cancer 1

Common Pitfalls to Avoid

Technical Errors

• Do not use transurethral resection as first-line biopsy when prostate cancer is suspected 1
• Avoid limiting biopsies to only 6 cores (sextant technique), as this misses 20-35% of tumors 1
• Do not skip lateral peripheral zone sampling 1

Patient Selection Issues

• When curative treatment is not planned (life expectancy <10 years, patient preference), fewer biopsies can be performed or biopsy may be deferred entirely 1
• Recognize that prostate biopsies are imperfect—they sometimes miss cancer even when present 1

Post-Procedure Monitoring

Complications are usually self-limiting and infrequently serious 1, 2:

• Rectal hemorrhage (usually minor)
• Urinary hemorrhage (typically resolves spontaneously)
• Infection (prevented by prophylactic antibiotics)
• Urinary retention (uncommon)

The procedure remains well-tolerated with proper technique and precautions 1, 2