Transperineal prostate biopsy under local anaesthetic

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Who, and the MRI first The man with a raised age-specific PSA or an abnormal prostate on examination, fit enough and willing to be treated if cancer is found, or already on active surveillance and due a repeat. Multiparametric MRI comes before any needle: a Likert or PI-RADS score of 3 or more is offered biopsy with targeted cores; a score of 1 or 2 with a low PSA density can be offered no biopsy after a discussion of what may be missed. The MRI report gives the lesion, its zone, side and size, and the prostate volume; the PSA density is calculated from it. Active surveillance, a previous negative biopsy with a rising PSA, or an equivocal MRI is a targeted and systematic biopsy with the question written on the request.
2. Consent and preparation, no rectal route The consent names haematuria in most men for a week or two, haematospermia for weeks, perineal bruising, discomfort during the block, acute retention in a few per cent, infection in well under one per cent, a small chance of a non-diagnostic biopsy and a repeat, and that a negative biopsy does not exclude cancer. Antibiotic prophylaxis is a single dose or none according to local policy, since the transperineal route does not cross the rectal mucosa. Aspirin continues; other antiplatelets and anticoagulants follow the local bleeding policy and are stopped or bridged before the list. A urine dip that shows infection postpones the biopsy. No enema, no starvation, a chaperone and a nurse for the awake patient, who has emptied his bladder.
3. Position, the probe and the template or freehand grid Lithotomy with the perineum at the edge of the table and the scrotum lifted out of the field with tape. A biplanar transrectal probe on a stepper or held by the assistant, with lubricant and a condom, gives the sagittal and axial views. The prostate is measured, the urethra found in the midline as the echogenic line from bladder neck to apex, and the MRI lesion located by zone and by clock position. With the freehand technique an access needle with a guide is placed through one puncture on each side of the midline, about a centimetre and a half above the anus, and angled to reach every sector; with the grid technique a brachytherapy template on the stepper gives five millimetre coordinates. The perineal skin is prepared and draped.
   where it bites: the urethra runs in the midline from bladder neck to apex; every needle path is planned around it, not through it.
4. Local anaesthetic: skin, then the periprostatic and apical block Lidocaine 1 per cent, 10 to 20 millilitres, with the total dose calculated for the man's weight. A skin bleb at each puncture site, then the subcutaneous fat and the pelvic floor infiltrated along the intended track while watching the needle on the sagittal view. The periprostatic block is placed at the apex where the neurovascular bundles enter, between the prostate and the rectum, five to ten millilitres on each side, and seen to spread as a hypoechoic wheal that lifts the gland; some add a second deposit along the lateral border. Three to five minutes are allowed to pass. The awake man is told what he will feel: pressure, the click of the gun, an urge to pass urine when the needle is near the apex.
   where it bites: the rectal wall lies immediately behind the apex; the block needle is watched on the sagittal view so that it does not enter the rectum and carry organisms forward.
5. Targeted cores to the lesion The MRI lesion first, while the gland is undisturbed and the ultrasound is not clouded by blood. With software fusion the MRI contour is overlaid on the ultrasound and the needle guided into it; with cognitive fusion the operator places the needle by zone, side, level and clock position from the report and from what is seen on the screen, since many lesions are visible as a hypoechoic area. The 18 gauge spring-loaded needle is advanced to the edge of the target on the sagittal view, fired, and the core inspected for length. Three to five cores are taken from each lesion, through and around it, into a pot labelled with the lesion number and side. A second lesion is sampled separately.
6. Systematic cores, sector by sector Then the systematic cores, because a proportion of significant cancer lies outside the MRI lesion and because the systematic pattern maps the gland for surveillance and for planning. The gland is divided into sectors, base, mid and apex on each side, medial and lateral, and one or two cores are taken from each into a labelled pot, about twelve cores in a freehand biopsy and more in a template mapping biopsy with sectors five millimetres apart. The needle is angled in the sagittal plane so that each core lies along the long axis of its sector and includes the peripheral zone, and the ultrasound is watched for the needle passing the urethra or into the bladder. The count is kept aloud with the nurse.
   where it bites: a core fired toward the bladder neck from the base can pass through the bladder wall; the tip and the throw are seen on the sagittal view before every shot.
7. The apex and the anterior gland These are the two regions the transrectal route missed and the transperineal route reaches by design. The apical cores are taken with the needle nearly parallel to the urethra, entering low and staying in the peripheral zone under the sphincter, with the block already placed there because these are the cores that hurt. The anterior gland, the anterior fibromuscular stroma and the anterior horns of the peripheral and transition zones, is sampled by angling the needle upward from the same puncture so that the core runs through the anterior third; in a large gland a longer path or a second, higher puncture is needed. The anterior lesion on MRI in the man with several previous negative biopsies is the classic finding.
   where it bites: the external sphincter sits just beyond the apex; the apical core stays within the gland and the needle is not fired through the sphincter to reach it.
8. After: haematuria, haematospermia, retention The punctures are pressed and dressed and the man sits up when he is ready. He passes urine before he leaves, and he is told what is normal: blood in the urine for a week or two, blood in the semen for several weeks, a bruise in the perineum, and some discomfort on sitting. He is told what is not normal: fever, rigors, inability to pass urine, or heavy bleeding with clots, and who to call. Acute retention follows in a few per cent, more after a large gland or a template biopsy, and is treated with a catheter, an alpha blocker and a trial without catheter at about a week. Sepsis is rare but is treated as sepsis: cultures and intravenous antibiotics without waiting for the results.
9. Results and the MDT The pots go to histopathology with the labelling on the form matching the labelling on the pots, the MRI lesion number, the side and the sector, so that the report can be read against the MRI. The report gives the grade group, the number of cores and the percentage involved per sector, and perineural or extraprostatic extension where seen. Every positive biopsy goes to the multidisciplinary meeting, where the grade group, the PSA, the PSA density, the MRI stage and the man's fitness and wishes decide between surveillance and treatment. A negative biopsy with a persistent MRI lesion or a rising PSA density is not discharged: it is a repeat biopsy or an MRI at a defined interval, and the plan is written to the man and his general practitioner.

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FRCS viva questions

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Evidence and guidance