Diagnostic ultrasound ( PDFDrive )

CHAPTER 10 The Prostate and Transrectal Ultrasound 409
additional time to act. Ater injection, prostate measurements
are made and the SVs and prostate are examined in a standardized
manner. Suspicious areas are imaged and noted for targeted
biopsy.
Biopsy is best done by a single operator who controls both
the probe and the gun and takes samples as appropriate for the
situation. he automatic biopsy gun with 18-gauge needles
is standard and has remarkable patient acceptance and safety.
With the gun cocked, the needle is “parked” in the guide,
ensuring that the tip is safely inside the guide. he probe and
contained needle are moved to the target using the targeting
line. With end-ire probes, better samples are obtained if the
prostate is compressed during the biopsy. A simple, swit
motion advances the gun and needle tip to the surface of the
lesion. Once in position, the device is triggered and the needle
advances approximately 2 to 3 cm to cut the tissue core and
trap it in the beveled chamber of the inner needle. We sample
suspicious areas irst in case the patient cannot tolerate the
entire procedure, and inish with systematic sampling. Biopsy
through the urethra, internal urethral sphincter, and ejaculatory
ducts is avoided. When the biopsy is inished, the probe
is removed and the site is palpated for hematomas. Ater the
biopsy, we keep the patient for an hour to allow observation
and recovery, the irst 20 minutes lying down and the remainder
seated. his helps in management of late onset of vasovagal
complications.
Side Effects and Complications
Minor side efects that do not require treatment are common.
hese include bleeding in the urine (50%) and stool (30%) and
hematospermia (50%). Minor bleeding in the urine and stool
generally lasts only a few days but can continue for several weeks.
he ejaculate may remain discolored for many months. Transient
erectile dysfunction is uncommon (<1%), but it is not clear if
this is psychological as a result of concerns related to biopsy or
physiologic. 25,143,148
About 1% to 5% of patients have a hypotensive vasovagal-like
reaction ater biopsy, which can occur up to 60 minutes ater
the procedure. It is characterized by pallor, sweating, nausea and
vomiting, bradycardia of 50 to 60 beats/min, and hypotension.
Most men recover spontaneously and rapidly ater being placed
in Trendelenburg head-down position. We keep patients in the
clinic for an hour ater the biopsy to avoid problems with these
delayed vasovagal hypotensive reactions.
Signiicant biopsy complications requiring physician intervention
or hospitalization are relatively uncommon, but incidence
of hospital admissions for any reason within 30 days of biopsy
is about 4.8% to 6.9% regardless of the mode of guidance, needle
size, or approach and is probably not related to number of biopsy
cores. hese complications include minor transient fever (5%-7%),
sepsis necessitating hospitalization (1%-3%), large hematoma
(uncommon), transient symptoms of obstruction (6%-25%),
urinary retention necessitating catheterization (0.2%-2.6%), and
signiicant rectal bleeding (1%). Immediate visible rectal bleeding
usually responds to 2 to 5 minutes of inger or probe pressure.
With the use of prophylactic antibiotics, the incidence of
septic complications requiring therapy is about 1% to 2%.
Hospitalizations ater biopsy are mainly (about 70%) due to
infections with antibiotic resistant E. coli. hese infections have
been increasing owing to increased prevalence of ciproloxacin
resistance and are more common in patients at risk. Sepsis can
rapidly progress to septic shock. Patients should be advised to
seek help promptly if they start feeling feverish or unwell. Tumor
seeding is virtually unknown. 25,143,147,148
Biopsy should never be taken lightly. Some patients have
required prolonged hospitalization, and there are rare reports
of spinal infections and patients dying from biopsy-related
complications.
Indications and Sampling
Biopsy is performed in patients suspected to have signiicant
cancer in whom the results would alter clinical management.
Currently for the irst biopsy the AUA recommends only TRUS
guidance without preceding mpMRI. 153
he number of samples and locations used in prostate biopsy
have been controversial. Initially it was thought that only suspicious
areas should be sampled. It was quickly discovered, however,
that only about 50% of hypoechoic areas contained cancer, and
that signiicant cancer also could be present in normal-appearing
areas of the prostate. 131,154 his led to “targeted plus systematic”
biopsy. Currently if no lesion is seen, then obtaining 10 to 12
systematic cores is felt to be appropriate on the initial visit (Fig.
10.19). his balances the likelihood of detecting signiicant cancer
while minimizing overdetection of insigniicant disease, but also
acknowledges that about 20% to 30% of signiicant cancer could
be missed. Further increase in number of systematic cores above
12 to 14 or use of saturation biopsy is felt to be not beneicial,
nor does it appear to decrease detection-positive rate at subsequent
biopsies. Additional cores should be obtained from suspicious
areas that lie outside the systematic pattern.
Indications for Prostate Biopsy
INITIAL BIOPSY
Whenever tissue diagnosis would alter management
Abnormal indings on digital rectal examination
Unexplained PSA elevation
Abnormal indings on transrectal ultrasound
Excessive PSA velocity
Positive chips at transurethral resection of prostate
Metastatic adenocarcinoma when primary is not evident
Approved research
REPEAT BIOPSY
Initial biopsy is negative but there is continued clinical
suspicion
Initial suspicious histology (high-volume HG-PIN, ASAP,
microscopic cancer)
PSA level greater than 10 ng/mL or rising
Follow-up of men under active surveillance
Evaluation for recurrence after therapy
Approved research
ASAP, Atypical small acinar proliferation; HG-PIN, high-grade prostate
intraepithelial neoplasia; PSA, prostate-speciic antigen.