? Case History: How would you manage this 74 y/o w/m status post abdominoperineal resection 5 years ago for adenoca. of colon. Serum PSA rise from 2.4 to 28 ng/mL in past year. No FHx Cap, no overt hx UTI How would you manage this ?

Questions: 1. Should this pt. be biopsied? (What if his PSA = 9.0 ng/mL?) 2. What techniques would you use? –Patient preparation? –General anesthesia vs. local? –Pt. Positioning? –Transabdominal vs. Perineal US-guidance?

Ultrasound-guided Transperineal Biopsy of the Prostate in Patients Without a Rectum Neil F. Wasserman, M.D. Department of Radiology University of Minnesota Minneapolis, MN

Purpose 5 patients without rectums presenting with elevated prostate specific antigen (PSA) were biopsied using transabdominal (TA) or transperineal (TP) ultrasound guidance and a transperineal biopsy approach. Indications, techniques and results will be presented.

Indications for Biopsy Elevated PSA for age Progressively Increasing PSA Abnormal PSA Velocity Blastic skeletal changes, positive bone scan, or other evidence of metastatic prostate cancer

Material and Methods I Patient Preparation Summary of Techniques: Patient Preparation Suspend anticoagulants including asperin 5-7 days prior to procedure NPO 4 hrs. prior to procedure Amikacin® 500 mg IM prior to procedure Lithotomy position on examination table Sterile preparation and drape of perineum Foley catheter in bladder

Material and Methods II Summary of Techniques (cont.): Distend urinary bladder with normal saline. Improves “acoustic window” to prostate Attempt to image prostate transabdominally. If successful, use TA guidance for biopsy If prostate not well seen, use TP US guidance Infiltrate perineum w/2% lidocaine to prostatic apex using 22g spinal needle. After superficial infiltration, deeper infiltration can be accomplished by placing needle into prostate under US-guidance, then withdrawing into deep perineum inferior to apex before injecting.

Material and Methods III Summary of Techniques (concl.): Alternatively, Light general anesthesia in OR Bilateral biopsy of prostate with 18g needle using Bard Magnum spring loaded device. 22 mm needle throw setting 2-5 cores per side depending on patient tolerance and ability to visualize prostate gland If bladder bleeding occurs, flush with normal saline till clear to prevent clots. Remove Foley catheter. Ciprofloxicin500 mg tab. 2 hrs. after dinner.

Materials and Methods IV Case 1: Transabdominal Axial & Sagittal Scouts Relatively discrete prostate boundaries B P TA Axial Scout TA Sagittal Scout

Material and Methods V Transabdominal Bx Case 1 (Arrow indicates needle tip) Sagittal TA Bx Left Sagittal TA Bx Right

Materials and Methods VI Case 2: TA Axial and Sagittal Scouts Relatively indiscrete prostate boundaries Axial TA Scout B P Sagittal TA Scout B P

Material and Methods VII Case 2: Tranabdominal Bx (arrow indicates Bx needle tip) B Sagittal TA

Materials and Methods VIII Case 4: Transperineal Coronal Scout B P UGD Symph. P B UGD * * Urogenital “Diaphragm” Unflipped Coronal TP

Materials and Methods IX Transperineal Biopsy (arrow indicates needle tip) Foley B UGD Flipped TP Coronal - Bx Left (arrow)

Results

Comment: Case 5 Bx requested on basis on rising PSA = 9.1 ng/mL from 1 yr. earlier value of 6.1 in patient with no overt interval UTI and no DRE abnormality. TP Bx. neg. for malignancy. Subsequent PSA values over next 2 years ranged from 6.7-5.7 ng/mL on four blood samples.

Conclusions Prostate boundries are harder to visualize in postoperative patients. Transabdominal US is the preferred image guidance technique. Foley catheter very helpful in distending bladder and visualizing prostate on US Localizing needle tip for biopsy

Conclusions Transperineal biopsy of the prostate in patients without a rectum is challanging and the decision to biopsy should be carefully weighed. For patients with PSA < 20 ng/mL & no evid. Mets recommend antibiotic therapy and follow-up PSA reevalulation to exclude prostatitis and avoid unnecessary transperineal procedure