What is the recommended procedure for a prostate biopsy on an adult male with elevated Prostate-Specific Antigen (PSA) levels and symptoms suggestive of prostate cancer?

How to Perform Prostate Biopsy

Technique and Approach

Transrectal ultrasound (TRUS)-guided prostate biopsy is the standard technique, performed as an outpatient procedure with local anesthesia, obtaining a minimum of 8-12 systematic cores from the peripheral zone. 1

Pre-Procedure Preparation

Antibiotic Prophylaxis

• Administer quinolone antibiotic prophylaxis (such as ciprofloxacin) before the procedure to prevent infectious complications 2
• This is a critical safety measure that should never be omitted 2

Enema Preparation

• Enemas are not necessary and provide no clinically significant outcome advantage 2
• Omitting enemas reduces patient cost and discomfort without increasing complication rates 2

Anesthesia

• Use periprostatic nerve block with injectable local anesthetic (such as lidocaine) to reduce pain during the biopsy itself 1
• Topical lidocaine gel can be applied to reduce discomfort during probe insertion 1
• These minor anesthetic techniques greatly enhance procedure acceptability, particularly with extended biopsy templates 1
• For exceptional cases (anal strictures, inadequate nerve block), consider intravenous sedation or general anesthesia 1

Biopsy Protocol

Standard Initial Biopsy (12-Core Extended Pattern)

The recommended approach is a 12-core extended biopsy scheme that samples both the standard sextant locations and the lateral peripheral zone 1:

• Sextant cores (6 cores): Bilateral sampling from apex, mid-gland, and base in the mid-parasagittal plane 1
• Lateral peripheral zone cores (6 cores): Bilateral sampling from lateral apex, lateral mid-gland, and lateral base 1
• Additional lesion-directed cores: Target any palpable nodules or suspicious hypoechoic areas seen on TRUS 1

This extended 12-core scheme detects 31% more cancers than traditional sextant biopsies (6 cores), reducing the false-negative rate from 20% to 5%, without increasing adverse effects 1

Cores to Avoid Initially

• Do not routinely sample the transition zone during initial biopsy 1
• Transition zone biopsies have low efficacy as part of the initial biopsy protocol 1

Minimum Core Requirements

• Obtain at least 8 cores minimum, with 12 cores preferred for optimal cancer detection 1
• Taking 12 cores is particularly important when prostate volume exceeds 40 cc 1

Repeat Biopsy Strategy

Indications for Repeat Biopsy

• Persistently elevated or rising PSA despite prior negative biopsy 1
• Consider PSA velocity and adequacy of initial biopsy (number of cores, prostate size) 1

Repeat Biopsy Technique

• Use the same extended 12-core protocol as initial biopsy 1
• Add transition zone biopsies (can be considered in repeat biopsy setting) 1
• Pay particular attention to apical sampling, including the anterior apical horn (comprised of peripheral zone) 1
• Yields are highest in laterally-directed and apical cores 1

Saturation Biopsy

• Consider saturation biopsy (>20 cores) in patients with 2 prior negative extended biopsies but persistently rising PSA 1
• Sample additional tissue from anterior and transition zones 1

Alternative Approaches

Transperineal Biopsy

• Transperineal biopsy via brachytherapy grid technique offers superior sensitivity and lower sepsis rates compared to transrectal approach 3
• Typically performed under general anesthesia in lithotomy position, though local anesthesia is increasingly feasible 3
• Cores taken systematically through the perineum under ultrasound guidance 3

MRI-Targeted Biopsy

• When available, multiparametric MRI with PI-RADS v2 scoring improves detection of clinically significant cancers while decreasing detection of indolent disease 1
• MRI-directed biopsies can be performed using cognitive fusion, MRI-US fusion software, or MRI in-bore techniques 3
• This approach requires high-quality imaging and trained radiologists/urologists working in multidisciplinary teams 1

Pathology Reporting Requirements

The pathology report must include specific details that guide treatment decisions 1:

• Maximum length of cancer involvement in each core 1
• Gleason score: report both the most common pattern and the worst (highest grade) pattern 1
• Extent of involvement of each core 1
• Presence of any tertiary Gleason pattern 4 or 5 (these behave more aggressively) 1

Common Pitfalls to Avoid

• Do not rely on sextant biopsy alone - this misses approximately 20% of cancers that would be detected with extended sampling 1
• Do not skip lateral peripheral zone sampling - this is where many cancers are located that sextant biopsies miss 1, 4
• Do not routinely include transition zone in initial biopsy - reserve this for repeat biopsies 1
• Do not omit anesthesia - periprostatic nerve block significantly improves patient tolerance 1
• Do not skip antibiotic prophylaxis - this is essential for preventing infectious complications 2

Safety Profile

• TRUS-guided prostate biopsy with quinolone prophylaxis is a relatively safe procedure 2
• Clinically significant complications (requiring office visit, secondary therapy, or hospitalization) occur in approximately 3-4% of patients 2
• Transperineal approach has lower sepsis rates than transrectal approach 3