Pre‐procedure

ActionRationale

1. 1.Show
   Check the environment, equipment and medication to ensure that everything is present for the procedure, including access to relevant personnel and emergency equipment.
   To ensure the procedure will take place without delay for the patient and to ensure that the safety of the patient is addressed (Turner et al. [164], E).
2. 2.Show
   Ask assistant to set up trolley with sterile urology pack and in date sterile equipment.
   To maintain infection control standards and minimize cross‐infection and contamination (RCN [132], C).
3. 3.Show
   Prepare the ultrasound machine by ensuring it is clean and prepare the probe by inserting some ultrasound gel into the end of the condom then roll the condom over the probe and carefully attach the needle guide without splitting the condom.
   To ensure the equipment is functioning and ready for use (Turner et al. [164], E).
4. 4.Show
   Read the patient's record, referral letter and the results of any relevant investigations and identify any special instructions, investigations or items for which you need to seek advice or clarification.
   To ensure correct identification of the patient and to identify details that might require an adaptation of the procedure (Turner et al. [164], E).
5. 5.Show
   Greet and accurately identify the patient and introduce yourself and any colleagues present.
   To reduce patient anxiety and to ensure correct identification of the patient (Turner et al. [164], E).
6. 6.Show
   Take a written consent using a dedicated consent form in which the following should be discussed with the patient:

   • how the biopsy is taken
   • the risks and benefits of the procedure, potential complications of the procedure and whether the risk is major or minor
   • the number of cores that will be taken
   • if any additional cores will be taken using MRI fusion.
   The healthcare professional responsible for carrying out the procedure is ultimately responsible for the patient consent for the examination (BAUS [19], C; DH [34], C; Turner and Pati [163], E)
7. 7.Show
   Ensure the patient has removed clothing below the waist and offer a gown.
   To provide privacy and comfort for the patient. E. To minimize the risk of a hospital acquired infection (BAUS and BAUN [17], C).
8. 8.Show
   Ensure the patient has taken antibiotic prophylaxis as prescribed locally.
   To ensure appropriate steps have been taken to prevent infection (Kapoor et al. [78], 1b; Sieber et al. [149], C; Zani et al. [178], R1a).
9. 9.Show
   Position the patient correctly for the procedure (left lateral position ensuring that the knees are bent up towards the chest) and ensure their comfort within the constraints of the procedure, taking appropriate action to protect the patient's privacy and dignity throughout.
   The left lateral position is preferred, particularly with an end firing probe, as imaging of the apex is easier and more comfortable for the patient (Vassalos and Rooney [165], C).
10. 10.Show
    Wash and dry hands using a bactericidal soap and apply non‐sterile gloves.
    To minimize the risk of infection (Loveday et al. [93], C).
11. 11.Show
    Undertake a digital rectal examination to identify symmetry, size, the presence of nodules, and tenderness and pain associated with the prostate. Careful attention should also be paid to exclude the presence of anal pathology or any other anomalies that may influence the procedure.
    Any abnormality in shape of the prostate may necessitate additional biopsies to the standard biopsy protocol that is used. However, if the rectum is full of faeces and/or anal pathology is identified, transrectal biopsy is contraindicated (Greene et al. [58], C).
12. 12.Show
    Remove gloves and dispose of them. Wash and dry hands.
    To minimize the risk of cross‐infection (Loveday et al. [93], C).

    To dispose of clinical waste (DH [35], C; HSE [68], C).
13. 13.Show
    Apply non‐sterile gloves and check the local anaesthetic agent to be used then draw up required volume into a syringe and attach the spinal needle ready for administration (the use of intrarectal lidocaine gel is optional).
    To minimize the risk of cross‐infection (Loveday et al. [93], C),

    To ensure patient is comfortable. E.

Procedure

1. 14.Show
   Apply lubricating gel to the covered TRUS probe and insert the probe gently into the patient's rectum, whilst monitoring progress on the ultrasound image.
   To promote patient comfort and enhance the quality of the scan (Turner et al. [164], E).
2. 15.Show
   Scan and identify the prostate gland, seminal vesicles and surrounding structures, locating the apex and base of the prostate on the ultrasound image. The prostate volume should be measured in three dimensions. In the transverse view:

   • anterior to posterior (width)
   • height and, in the longitudinal plane,
   • from the bladder neck to the apex (length).

   Final volume can be calculated using the formula: H × W × L × 0.52.
   To orientate the operator and to identify areas to biopsy (Greene et al. [58], C).
3. 16.Show
   Take volume measurements and make note of any abnormalities detected on ultrasound and either print images or store them on the ultrasound machine for future reference.
   To provide information that may be useful when discussing treatment options with the patient in the future. E.
4. 17.Show
   Inform the patient that the local anaesthetic is about to be administered.
   To reduce patient anxiety (Greene et al. [58], C).
5. 18.Show
   Introduce the local anaesthetic needle through the biopsy channel of the ultrasound probe until the needle tip can be visualized on the screen in the peri‐prostatic tissue.
   To promote patient comfort. To reduce pain (Turner et al. [164], E).
6. 19.Show
   Commence infiltration of the local anaesthetic observing the passage of the fluid throughout the peri‐prostatic area.
   Ultrasound‐guided peri‐prostatic block is standard. It does not make any difference whether the depot is apical or basal as long as it is given into Denonvilliers’ fascia. In addition, an intrarectal instillation of local anaesthetic can be done (Raber et al. [124], R1b; Yun et al. [177], R1b) at the discretion of the examiner. However, it should not be used as an isolated method as it is inferior to the peri‐prostatic block (Lee and Woo [90], R1a).
7. 20.Show
   Withdraw the needle and discard into a large 5 litre sharps bin.
   To prevent sharps injury (DH [35], C; HSE [68], C).
8. 21.Show
   Identify the appropriate locations for the biopsy samples according to clinical need, e.g. MRI findings, DRE findings or confidence in diagnosis of cancer.
   To ensure the correct areas are biopsied and minimum number of cores taken to ensure a diagnosis is made (Greene et al. [58], C).
9. 22.Show
   Introduce the biopsy needle along the biopsy channel until the needle tip can be visualized on the screen in the peri‐prostatic tissue, adjacent to the target area.
   To ensure the correct areas are biopsied and minimum number of cores taken to ensure a diagnosis is made (Greene et al. [58], C).
10. 23.Show
    Inform the patient that the biopsy is about to be taken and warn them of the sound of the biopsy gun (sounds like a staple gun) and commence taking tissue samples.
    To ensure patient comfort and to reduce anxiety (Greene et al. [58] C).
11. 24.Show
    Fire the biopsy gun and then withdraw it after firing on each occasion, in order to lay each tissue sample onto a sponge (a maximum of two per sponge). Repeat process.

    Lay a second sponge on top of the first after two samples have been taken.
    Prostate biopsy cores taken from different sites should be sent to the laboratory with the use of sponges and cartridges in separate pots. This ensures that the cores do not become fragmented during transportation to the lab (Heidenreich et al. [63], C).
12. 25.Show
    Ensure that the samples taken are adequate for histopathology by comparing the length of the core with the length of the needle notch.
    To ensure the correct length is taken and there is consistency of sampling (Greene et al. [58] C).
13. 26.Show
    Take additional samples only where there is clinical concern, e.g. abnormality found on DRE or seen on ultrasound or MRI.
    To ensure the correct areas are biopsied and minimum number of cores taken to ensure a diagnosis is made (Greene et al. [58], C).
14. 27.Show
    Assess the patient's tolerance throughout the procedure and ensure they are happy to continue.
    To ensure patient comfort. E.
15. 28.Show
    Direct the assisting nurse to place each sponge sandwich into a cassette before inserting into a correctly and accurately pre‐labelled sample container containing 10% formalin.
    To ensure specimen is labelled correctly (NMC [114], C; WHO [171], C).
16. 29.Show
    Remove the TRUS probe from the patient's rectum and insert prophylactic antibiotic if indicated by local policy.
    To minimize the risk of infection (Kapoor et al. [78], R1b; Sieber et al. [149], C; Zani et al. [178], R1a).

Post‐procedure

1. 30.Show
   Wipe rectum, offer a surgical pad to protect the patients underwear and remove and discard gloves
   To promote patient comfort. E.
2. 31.Show
   Assist the patient into a sitting position.
   To promote patient comfort. E.
3. 32.Show
   Assess the patient for any complications and take appropriate action.
   To ensure patient safety and comfort. (Greene et al. [58], C).
4. 33.Show
   Recognize the need for immediate management of acute emergencies associated with the procedure and respond appropriately.
   To ensure patient safety and comfort (Greene et al. [58], C).
5. 34.Show
   Assess the patient's needs following the procedure and offer any verbal support, as required.
   To promote patient comfort. E.
6. 35.Show
   Ensure the patient has all required information and medication. Reiterate the possible complications and how they should be managed.
   To ensure patient safety and reduce the risk of serious side‐effects following the procedure (Greene et al. [58], C).
7. 36.Show
   Assess the patient's fitness for discharge by ensuring patient has voided and there are no other adverse events.
   To ensure patient safety (Greene et al. [58], C).
8. 37.Show
   Ensure the ultrasound probe is cleaned in line with local infection control policy.
   To ensure the safety of staff and patients. E.
9. 38.Show
   Ensure that single‐use items and sharps are disposed of and that non‐disposable equipment is cleaned and/or sterilized.
   To minimize the risk of cross‐contamination and infection risks (DH [35], C; HSE [68], C).
10. 39.Show
    Complete the histopathology request form ensuring it matches patient identity and includes all relevant clinical details, particularly relevant previous treatment, procedures and biopsies.
    To ensure the correct results go to the correct patient (NMC [114], C; WHO [171], C).
11. 40.Show
    Record the details of the procedure in the patient's record, including details of the local anaesthetic and any medication given.
    To ensure patient safety and accurate records for other practitioners who may see the patient (NMC [114], C; WHO [171], C).
12. 41.Show
    Ensure that steps are taken to inform any other relevant practitioners of the procedure and plan, e.g. GP.
    To ensure all relevant healthcare providers are informed of the procedure and its outcome. E.
13. 42.Show
    Make the patient a follow‐up appointment to discuss the results of the biopsy (usually 1–2 weeks).
    To ensure adequate post‐procedure follow‐up (Greene et al. [58] C).
14. 43.Show
    Recognize when you need help and/or seek advice from appropriate sources.
    To ensure patient safety (Greene et al. [58], C).