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Evidence‐based approaches

Rationale

A prostate biopsy should only be considered and undertaken if it influences the management of the patient. It should be determined on the basis of the PSA level and/or a suspicious digital rectal examination (DRE) and/or suspicious prostate MRI. Factors such as patient age and co‐morbidities should also be considered (Batura and Gopal Rao [9]).

Indications

There are many indications for prostate biopsy which include:
  • raised PSA level in the absence of urinary tract infection, acute urinary retention or acute prostatitis
  • abnormalities identified through DRE or MRI of the prostate
  • patients being assessed for radiation failure (i.e. PSA increases post radiotherapy)
  • patients on an active surveillance protocol requiring repeat biopsies
  • patients with previous histology requiring repeat biopsy (e.g. high‐grade prostatic intra‐epithelial neoplasia or suspicious but not diagnostic for carcinoma)
  • patients on an ethically approved clinical trial (NICE [110], Turner et al. [164]).

Contraindications

It is important to note that patients with the following risk factors may require special preparation:
  • patients on anticoagulation therapy or with coagulation disorders that may interfere with haemostasis and increase the risk of haemorrhage. Low‐dose aspirin (75–150 mg) is not a contraindication but discontinuation should be discussed with the medical team
  • patients with an identified urinary tract infection as the risk of septicaemia may be increased
  • patients with an allergy to latex, antibiotics or local anaesthetic
  • patients with diabetes mellitus who may be at increased risk of infection
  • patients on steroid medication which may increase the risk of infection
  • patients who are immunocompromised. It may be necessary to seek advice from other healthcare professionals on complex medical conditions
  • patients with urinary obstruction (Giannarini et al. [54], Lange et al. [87], Loeb et al. [92]).
There is a lack of agreement in the literature specifying those with an absolute increased risk of complications. It is therefore at the discretion of the person performing the procedure to proceed to biopsy based on local policy and/or professional judgement. However, it has been suggested that certain patient groups should undergo biopsy by a transperineal approach only (Miller et al. [99]). This includes those with:
  • prosthetic cardiac valve or prosthetic material used for cardiac valve repair
  • congenital heart disease (CHD)
  • completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
  • repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
  • cardiac transplantation recipients who develop cardiac valvulopathy.
Some patients should be considered for exclusion from biopsy altogether and managed conservatively. This will require local agreement. Such patients are those with:
  • previous infective endocarditis
  • CHD (dependent on clinical assessment and review)
  • unrepaired cyanotic CHD, including palliative shunts and conduits.
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