1. ? 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 ?

2. 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?

3. 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

4. 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.

5. 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

6. 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

7. 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.

8. 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.

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

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

11. 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

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

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

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

15. Results

16. 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 ng/mL on four blood samples.

17. 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

18. 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