In this presentation we will discuss about the Anatomy of Prostate Technique of Transrectal US Carcinoma Prostate and Different modes of prostatic biopsy.

1. DR. MUHAMMAD BIN ZULFIQAR
PGR IV FCPS SIMS/SHL
Alnoor Diagnostic Centre
PROSTATE BIOPSY— New
emerging trends

2. Agenda
Anatomy
Transrectal US Technique
Carcinoma Prostate
Biopsy Technique
Indications
Technique
Complications

3. Anatomy
• Shape
– Inverted flattened cone
– tip represents apex
– flattened part represents base
• Zones—Three major zones
– Peripheral (70 % glandular tissue)
– Central (20 % glandular tissue)
– Transitional (20 % glandular tissue)
– Anterior fibromuscular stroma

5. • AFS = anterior fibro muscular stroma, CZ = central zone, ED = ejaculatory
ducts, NVB = neurovascular bundle, PUT = periurethral tissue, PZ =
peripheral zone, SV = seminal vesicle, TZ = transition zone, U = urethra, V =
verumontanum.

6. ULTRASOUND TECHNIQUE
• Either the right or left lateral decubitus position (lying on left side).
• A topical anesthetic ointment is applied to the index finger prior to
performing the DRE.
• A 7.5mHz transducer is used for transrectal imaging of the
prostate.
• The probe is gently advanced into the rectum, to the base of the
bladder until the seminal vesicles are visualized.
Yacoub et al. Imaging-guided Prostate Biopsy: Conventional and Emerging Techniques.
RadioGraphics 2012; 32:819–837
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR
El-Hakim and Moussa. CUA guidelines on prostate biopsy methodology. CUAJ • April 2010 • Volume
4, Issue 2
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED

9. Biplane and 3-D Prostate Imaging
• By using advanced machines with latest
softwares and 3D probes we can acquire
prostate images in 2 planes or 3 planes
simultaneously.
• This helps us in guiding and targeting biopsy
needle to area of interest.

10. Biplane Prostate Imaging

11. • A three-dimensional US image of the prostate
acquired using an endocavity rotational three-
dimensional scanning approach (rotation of a
transrectal US transducer). The transducer was
rotated around its long axis, while three-
dimensional US images were acquired and
reconstructed. The three-dimensional US image
using an end-firing transducer is displayed using
the cube-view approach and has been sliced to
reveal: (a) a transverse view, (b) a sagittal view
and (c) a coronal view, not possible using
conventional two-dimensional US techniques.
A. Fenster et al. Three-dimensional ultrasound scanning. Interface Focus (2011) 1, 503–519

12. • Figure 11. The display for viewing the three-
dimensional US image of the prostate and to perform
the segmentation of the prostate. The user can verify
that the prostate has been segmented accurately and
perform any required edits to the boundary.
A. Fenster et al. Three-dimensional ultrasound scanning. Interface Focus (2011) 1, 503–519

13. • Figure 12. The three-dimensional US-guided prostate biopsy system
interface is composed of four windows: (top left) the three dimensional
TRUS image sliced to match the real-time TRUS probe orientation;
(bottom left) the live two-dimensional TRUS video stream; and (right side)
the three-dimensional location of the biopsy core within the three-
dimensional prostate model. The targeting ring in the bottom right
window shows all the possible needle paths that intersect the preplanned
target by rotating the TRUS about its long axis. A. Fenster et al. Three-dimensional ultrasound scanning.
Interface Focus (2011) 1, 503–519

14. VAS Deferens / Seminal Vesicle

15. Colour Doppler
• Normally, the flow is very sparse
• Role is controversial
• Increased flow within tumour mass
– flow is very slow and low
• increased flow also seen in infection
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

16. Normal Flow

17. Acute Prostatitis
Acute Prostatis

18. Prostatic Carcinoma
• Second most common malignancy in males
after lung cancer.
• Histologically it is Adenocarcinoma

19. Prostatic Carcinoma Location
• Peripheral zone-----80%
• Central zone------5%
• Transitional zone------15%
• Multifocal-------40%
Radiology Review Manual Wolfgang Dahnert, M.D.

20. Sonographic features of prostatic
Carcinoma
• Echogenicity
– Hypoechoic—61 %
– Hyperechoic—2 %
– Mixed—2 %
– Not detectable isoechoic—35%
• Asymmetric enlargement
• Deformed contour of prostate (irregular bulge
sign 75 % PPV)
• Heterogeneous texture

21. ULTRASOUND FINDINGS in CA
• Hypoechoic lesion (dark compared to normal tissue) in the peripheral zone is
usually a neoplasm.
• Classic hypoechoic peripheral zone lesion:
– Sensitivity of cancer detection of 85.5%
– Specificity of 28.4%
– Positive predictive value of 29%
– Negative predictive value of 85.2%
– Overall accuracy of 43%.
• Isoechoic or nearly invisible prostate cancers on TRUS
– 25 to 42%.
To date, no biologic differences have been noted between isoechoic and hypoechoic
prostate cancers.
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED
PROSTATE BIOPSY DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

22. Escape routes of Prostatic Cancer
• (1) capsular margin at neurovascular bundle
• posterolaterally (80%) due to intrinsic
weakness of capsule at this location
• (2) apex
• (3) seminal vesicles

23. Advanced stage of Prostate ca
• Seminal Vesicle invasion
• Bony metastases
• Bladder invasion
• Lymphadenopathy
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

24. Prostatic cancer Staging
• Stage 1: Occult (focal or
diffuse)
• Stage 2: cancer confined
to prostatic capsule
• Stage 3: Extracapsular
spread
• Stage 4: Distant
Metastases
Radiology Review Manual Wolfgang
Dahnert, M.D.

25. Known case of carcinoma prostate with bony metastasis

26. TRUS guided Prostatic biopsy
• Indications:
– Men with an abnormal DRE
– Elevated PSA (>4.0 ng/ml)
– PSA velocity (rate of PSA change) >0.4 to 0.75 ng/ml/yr.
– Repeat biopsy 3 to 12 months later who were diagnosed
with high-grade prostatic intraepithelial neoplasia (PIN) or
atypia on a previous prostate needle biopsy.
– Patient with metastatic adenocarcinoma with unknown
primary.
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

27. PATIENT’S PREPARATION
• Aspirin and non-steroidal anti-inflammatory (NSAIDS) should be
discontinued for 7-10 days.
• Low fiber diet 3 days prior to biopsy.
• One-day prophylaxis of an oral quinolone (Ciprofloxacin).
• Cleansing enema (sodium phosphate and dibasic sodium
phosphate) prior to the biopsy to eliminate gas and remove feces.
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE
BIOPSY DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

28. TRUS guided Prostatic biopsy-
Advantages / Disadvantages
• Merits
– Simple outpatient procedure
– improved patient tolerance
– fewer inadequate samples
– decreased need for anaesthesia
• Demerits
– Low sensitivity and low PPV
– bleeding into urine, rectum or semen
– Infection acute urinary retention
– Large interobserver variability
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

29. Preprocedural assessment by TRUS
• Nodule on Digital rectal examination (DRE).
• Raised > 4 ng / ml Prostate specific antigen
(PSA).
• Provide visual guidance for biopsy.
• TRUS alone should not be used as a first-line
screening study.
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

30. BIOPSY TECHNIQUE
• An 18-gauge 25 cm long biopsy needle loaded in a spring-
action automatic biopsy device.
• Needle tip to be placed precisely at the boundary of the
lesion.
If the prostate capsule is “tented up” by the needle tip, tissue
may be taken too deep inside the gland and a tumor located
in the peripheral zone may be missed.
• The excursion of the needle tip during a biopsy is
approximately 2.2 cm and the biopsy notch, which procures
the tissue, is approximately 1.5-2.0 cm.
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

31. BIOPSY TECHNIQUE—Local Anesthesia
• 65% to 95% men report some level of discomfort
during transrectal ultrasound guided prostate needle
biopsy.
• Pain predominantly occurs when the needle
penetrates the prostatic capsule and stroma, which
has a rich supply of autonomic nerve fibers.
• 10ml of 1% lidocaine is injected into the prostate
gland at the lateral edge of the gland on each side
from the base to the apex.
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

35. Contribution from Dr. Knud V Pedersen PhD, Senior Urologist, Länssjukhuset Ryhov Jönköping, Sweden

36. Contribution from Dr. Knud V Pedersen PhD, Senior Urologist, Länssjukhuset Ryhov Jönköping, Sweden

37. OPTIMIZATION OF BIOPSY
• At the prostate base:
– Lateral biopsies will sample the peripheral zone
– Medially directed biopsies are more likely to sample the
central zone
• In the mid gland:
– Medially directed biopsy in this area can traverse the
peripheral zone and predominantly sample the
transition zone.
• At the prostatic apex:
– Sample the distal aspect of the transition zone.
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

38. • AFS = anterior fibro muscular stroma, CZ = central zone, ED = ejaculatory
ducts, NVB = neurovascular bundle, PUT = periurethral tissue, PZ =
peripheral zone, SV = seminal vesicle, TZ = transition zone, U = urethra, V =
verumontanum.

39. SEXTANT biopsy sampling
• Sample from 6 sites of peripheral zone
• WHY?
– Finding may not be cancer
– cancer is often multifocal
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

40. Cross-sectional view of commonly biopsied zones.
TZ-transition zone, Mid PZ-mid peripheral zone, Lat PZ-lateral
peripheral zone, AH-anterior horn, LH-lateral horn.
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

41. • (a) Coronal (left) and axial (right) schematics show the positions of the needle and
the locations that are sampled in the prostate with the standard sextant biopsy
technique. (b) Coronal (left) and axial (right) schematics of the modified sextant
biopsy technique show more lateral positions of the needle at the middle level (M)
of the prostate with this technique than with the standard technique. (c) Coronal
schematics show the additional prostate locations (open circles) that may be
sampled in an extended systematic biopsy, for a total of eight, 10, or 12 specimens.
Filled circles indicate the six locations of sampling in a standard sextant biopsy.
a c
Yacoub et al. Imaging-guided Prostate Biopsy: Conventional and Emerging Techniques. RadioGraphics 2012; 32:819–837

42. • Photograph shows a spring-loaded 18-gauge biopsy needle
and 12 specimen cups laid out in preparation for an
extended systematic biopsy. AFS = anterior fibromuscular
stroma, CZ = central zone, ED = ejaculatory ducts, NVB =
neurovascular bundle, PUT = periurethral tissue, PZ =
peripheral zone, TZ = transition zone.
Yacoub et al. Imaging-guided Prostate Biopsy: Conventional and Emerging Techniques. RadioGraphics 2012; 32:819–837

44. Pitfalls and prevention
• Sampling error (20% to 30%)
• Lack of sampling adequacy
• Overall cancer detection rates undergoing repeat prostate
needle biopsy (10% - 38%).
• Alternate “extended pattern” biopsy schemes
– Increasing the number of core biopsies
– Directing the biopsies more laterally to better
sample the anterior horn (the far lateral regions of
the peripheral zone).
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

45. 2D Prostate Biopsy

46. 2D Prostate Biopsy

47. • The three-dimensional US-guided prostate biopsy
system interface is composed of four windows: (top left) the three
dimensional TRUS image sliced to match the real-time TRUS probe orientation;
(bottom left) the live two-dimensional TRUS video stream; and (right side) the
three-dimensional location of the biopsy core within the three-dimensional
prostate model. The targeting ring in the bottom right window shows all the
possible needle paths that intersect the preplanned target by rotating the TRUS
about its long axis. A. Fenster et al. Three-dimensional ultrasound scanning.
Interface Focus (2011) 1, 503–519

48. COMPLICATIONS
• Minor (range 60% to 79%)
• Major (range 0.4% to 4.3%)
• Hospitalization (0.4% to 3.4%)
• Immediate Complications
• Delayed complications
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

49. COMPLICATIONS
• Immediate complications
– Vasovagal episodes (5.3%)
– Rectal bleeding (8.3%)
– Hematuria (70.8%)
Persistent hematuria (47.1%) typically lasts 3 to 7
days.
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

50. COMPLICATIONS
• Delayed complications
– Dysuria (9.1%)
– Vague pelvic discomfort (13.2%)
– Persistent hematuria (47.1%)
– Hematochezia (rectal bleeding) (9.1%)
– Hematospermia (9.1%)
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY
DIAGNOSTIC ULTRASOUND Carol M. Rumack, MD, FACR

52. Indications for a repeat prostate
biopsy
• Include the following:
– 1) A highly suspicious DRE (digital rectal
examination)
– 2) A persistently rising serum PSA (> 0.4 – 0.75
ng/ml/yr.)
– PSA level greater than 10 ng/ml or rising.
– 4) Presence of PIN (prostatic intraepithelial
neoplasia) or atypia on prior biopsy
Peter Carroll, MD and Katsuto Shinohara, MD TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY

53. Take Home Message
• 12 core biplane / 3 dimensional TRUS guided
biopsy of prostate is more convenient,
effective and result oriented mode of biopsy.

54. THANK YOU