Fox Chase Cancer Center’s urologic oncology group shares an educational video that provides instruction on how to perform a device-free, free-handed transperineal prostate biopsy.
Urologic oncologists at Fox Chase Cancer Center have adopted a minimally invasive and device-free approach to prostate biopsy called the free-handed transperineal prostate biopsy.
Traditionally, prostate biopsy was performed transrectally. A transrectal biopsy could involve 12 or more separate needle punctures inside the rectum. The transperineal approach can be done in-office and involves only two needle punctures – one for each side of the prostate. Other benefits include a lower risk of post-biopsy sepsis, reduced risk of rectal bleeding, and a lower barrier to cognitive targeting.
The majority of providers offering the transperineal approach use a mount that couples the ultrasound probe to needle aperture. With this device-free, free-handed approach, clinicians are able to forgo the ultrasound needle mount, which saves hundreds of dollars per procedure and allows for anterior posterior pivoting.
For the patient, the transperineal approach is a safer, more comfortable approach that can be performed anesthesia-free when necessary. Additionally, studies have shown that the transperineal approach may be more effective in detecting cancer than transrectal biopsies.
In this video, an experienced clinician first demonstrates equipment and table setup prior to the procedure and models the transperineal prostate template. The video includes demonstrations of patient positioning, marking of angiocatheter placement, positioning of the ultrasound probe, and administration of superficial and deep anesthetic. Next, the clinicians demonstrate the freehanded biopsy approach.
Importantly, the video includes a demonstration of core hand off. Proper core hand off ensures that the cores architecture remains intact, which greatly enhances the pathological interpretation of the specimens.
This video demonstrates that free-handed transperineal prostate biopsies can be performed safely and effectively in the office with good patient anesthesia providing substantial benefits compared with transrectal biopsies.
This is an instructional video on how to perform an in office device. Free transparent real biopsy. While the following video was recorded on a consent patient under sedation. The technique that we demonstrate works extremely well under local anesthesia in the office setting and is conducted routinely in our practice. The benefits of the transparent a prostate biopsy include a much lower risk of post biopsy sepsis. While supporting antibiotic stewardship, it largely eliminates the rectal bleeding risk has easier access to interior and typical areas of the prostate and a lower barrier to cognitive targeting. While the large majority of transparent real approach providers utilize a disposable transcranial access system that couples the ultrasound probe to needle aperture. We choose to forgo this answer equipment for several reasons, the technique that we demonstrate not only save several hundreds of dollars of cost per procedure, but it also allows for an additional degree of freedom by pivoting in the anterior posterior plane to reach the wings and anterior prostate. This ability to pivot also prevents the need to restrict the patient for any additional entry site. As such, a tool of two entry sites are utilized for all procedures. This avoids the need for administration of additional anesthetic to other entry sites, which is cumbersome in the office setting equipment required for this procedure has shown on the two tables going from left to right includes large decoder biopsy gun, Healthy specimen pads cut into 1" pieces with corresponding specimen cubs. Surgical loop prep sticks, a marking pen to 14 gauge angel catheters sterile gloves, A spinal needle and 3 10 C. Syringes filled with quarter percent. Like taking an ultrasound machine with my pain rectal probe. Not shown here is also utilized for this technique At Fox Chase. We have chosen to model our transcranial prostate template shown here on the 12 core trans rectal template with this template. To courts are taken from each of the media, peripheral zones, lateral peripheral zones and wings. The prostate. Interior biopsies are only obtaining select circumstances when there is an interior abnormality. On multi parametric MRI targeted cores may also be taken for any lesions identified on prior imaging consensus for the optimal transparent biopsy template has not been established. Other common templates that have been proposed and are also used by Fox Chase providers include the philadelphia hybrid, an atomic transcranial template and others. These templates obtained more than 12 cores and systematically sample the anterior gland. The procedure is initiated by placing the patient in the autonomy position. The scrotum is tape superior early using a large together um exposing the perineum on stretch, relax premium. May distort topical landmarks and make proper angio cath trajectory placement difficult in the event that the ticket um does not achieve appropriate perennial stretch two inch silk tape is utilized by some providers. Once positioned we insert the ultrasound probe to survey and measure the prostate. Once the prostitute has been adequately surveyed. Sites for angio cath replacement are marked using a skin marker has shown location chosen superior lateral to the upper anus and a mickey mouse ear configuration angio cath placement, incredible here as this will be the sole puncture sites for the duration of the procedure and therefore the site should be adjusted according to each patient. Once a site for the Andrew cast has been marked the perineum, scratch and sand fashion using topical disinfectant. No antibiotic prophylaxis is required. Local injection of quarter percent lidocaine is then administered five CCs is injected at both mark sides using a standard 21 gauge needle to form a wheel. This will serve to nest size the skin and subcutaneous tissue for the spinal needle. In angio cath placement. A spinal needle filled with 10 CCs is then used to necessary. Is the track along which the bodies will occur. It is critical to hold the trans rectal biplane or ultrasound directly parallel to the superior inferior access of the prostate without moving it off. Midline visualizing the urethra in the satchel plane as the guiding an atomic landmark. The needle is inserted largely parallel to the pro bowl, twisting the probe to find the needle tip in the sagittal view. It's important to note here this technique of isolating shallow, back and forth, twist the probe without fearing off this plane to assure visualization of the tip of the needle and audits. More proximal shaft. Anesthesia is administered along the subcutaneous tracked and into the elevator and I musculature the same twisting motions and used to identify the periodical triangle between the elevator and I in the prostate, ideal injection should a cure the most superior portion of this triangle on each side of the prostate, which will provide adequate anesthesia throughout the rest of the procedure, some providers prefer to make a wheel followed by a deeper injection of the same needle. This is followed by angio cath placement, which minimizes the length of track needed to an exercise in this approach. The spinal needle is then used to injected the medial border of the later and I with pulses at the superficial and deep aspects of the musculature. Deep transverse perennial muscles are also an exercise. If seen, The 14 gauge angio cap is in place at the Primark site. It's critical that the urethra is visualized in the midline via the sagittal view, and Andrew Kathy's place parallel to the probe. Improper insulation at the time of placement will inevitably make the subsequent biopsies more challenging. With the needle removed, the biopsy gun is in directed through the angio cath. Using an index finger for stabilization. Once again, we use the same positioning of the ultrasound probe along the horizontal axis of the prostate and twist our probe to localize the correct trajectory of our biopsy gun in the sagittal view, we keep our needle largely parallel to the probe and pivot the needle to each preached in our template location. Keeping the pro parallel to the superior inferior prostatic plane while only rotating to visualize the needle tip again. Key anatomical landmarks such as the Aretha. Should be identified to guide correct biopsy specimen acquisition. However, course may be obtained out of order to minimize readjustment of the needle to hand off course. The chief is open and the needle is pre rotated counterclockwise. Using the index finger to stabilize the needle the course and deployed onto the Telfer pads with the clockwise sweep. Maintaining a course integrity is important as it allows architecture remain intact, facilitating the pathological interpretation of the specimens. Fragmentation. Of course, specimens should be minimized as fragmented or crumbled course can present a challenge to pathologists. This process is repeated for all remaining cores on the initial side. After complete. On the first side, the angio cath is removed while observing for any bleeding peer pressure can be held at this time if needed. However, hematomas were in common. The processes then repeat on the contra lateral side in the same fashion Upon completion of the 12 cores in any additional targeted biopsies, the Angio Cath is removed along with the ultrasound probe and the texture. When multi parametric prostate MRI demonstrates high risk legions, these are targeted using cognitive fusion, prospective randomized data has confirmed that in experienced hands, cognitive fusion does not compromise tissue sampling when compared with image guided techniques. Moreover, prostatic imaging with biplane or ultrasound probe is largely the same plane as the saddle and actual reconstruction of MRI imaging as such, directing the needle to lesions seen on camera. Using biplane imaging is reduced to targeting in the Xy plane while needle direction in the seaplane pierces, the lesion data are starting to emerge. The cognitive targeting of multi parametric MRI allegiance. Using the transparent approach is highly accurate. After the procedure, patients should be counseled regarding standard prostate biopsy. Side effects including he materia prima to spur mia and risk of retention, risk infection. Following transplant biopsies are under the order of .5% and risk of rectal bleeding are largely eliminated and our practice we require patients to avoid prior to leaving the office as local Dema can cause urinary retention. Our experience underscores the device. Free transparent prostate biopsies can be performed safely and effectively in the office with excellent tissue sampling patient cholera bility and without an additional expense over trans rectal biopsies.