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Pre‐procedural considerations

General assessment

A general assessment of the patient's fitness for the procedure is required. This is to include the ability to use local anaesthesia, including previous allergies to local anaesthetics. Identify any risk factors for which special precautions may be required. Determine the need for the biopsy and decide whether or not to proceed. If not already done, take a comprehensive health history including presenting complaint, health history, medication, family and social history.

Voiding studies

Before biopsy, the patient should undergo uroflowmetry with post urinary residual measurement. This should be recorded in the patient's notes and annotated in the post biopsy letter. If the post void residual urine is >150 mL, an alpha‐blocker should be considered (Bozlu et al. [13]).

Equipment

It is important that the environment is suitably prepared and all the required equipment is available and checked to be in working order before commencing the procedure. All staff should be familiar with their expected roles and emergency procedures, the location of any emergency equipment and the ability to contact a senior clinician should the need arise. An ultrasound machine and probe must be available and in working order and used as per manufacturer's guidelines (Figure 20.9). Various needles and biopsy guns are available (Figure 20.10) and should be used as per manufacturer's guidelines.
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Figure 20.9  Ultrasound machine and probe.
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Figure 20.10  Example of TRUS biopsy equipment.

Emergency equipment

Emergency equipment should be easily accessible in the rare event of a major complication such as uncontrollable bleeding per rectum or per urethra, retention of urine, anaphylaxis or vasovagal syncope.

Pharmacological support

Aerobic or anaerobic organisms may be introduced when performing TRUSBx, the more common being Escherichia coli, Streptococcus faecalis and Bacteroides. Thus, the use of broad‐spectrum antibiotics is common practice but guidelines should be made locally in consultation with microbiology advice taking into consideration regional antibiotic resistance (Kapoor et al. [78], Sieber et al. [149], Zani et al. [178]).
Currently fluoroquinolones are the antibiotics of choice in transrectal US‐guided prostate biopsy. Fluoroquinolones are well absorbed orally and have good prostate tissue levels (Hori et al. [67], Lange et al. [87]). Evidence suggests that one dose is as effective as multiple‐dose prophylaxis (Aron et al. [4]). The addition of gentamicin or metronidazole is optional (Bootsma et al. [12]).
As a standard, all patients should have a negative midstream urine (MSU) previous to the biopsy. If a negative MSU was obtained more than 4 weeks before the biopsy, a confirmatory dipstick test should be done on the day of the procedure.
There is a clear trend towards an increase in the rates of infectious complications after TRUS biopsy in the past few decades (Loeb et al. [92], Nam et al. [100]). Accordingly, many authors reported rising rates of antimicrobial, particularly quinolone, resistance (Feliciano et al. [47], Williamson et al. [172]). It is therefore important to consider risk factors for pre‐biopsy quinolone resistance (Challacombe et al. [25], Patel et al. [120], Taylor et al. [160]) such as:
  • travel to Asia/Africa/Latin America in the previous 8 weeks
  • use of quinolone in the previous 6 weeks
  • chronic immunosuppression – chronic obstructive pulmonary disease (COPD), diabetes mellitus or long‐term steroids use
  • indwelling urinary catheter
  • history of recurrent urinary tract infections.
If a patient has one of these risk factors a rectal swab should be considered to screen for quinolone resistance (Liss et al. [91], Taylor et al. [160]). If this is not available, consider adding intravenous gentamicin 5 mg/kg (based on ideal bodyweight if the patient is obese, i.e. actual bodyweight is 20% higher than ideal bodyweight), 60 minutes before the procedure in this high‐risk group of patients (Ho et al. [66]).
Lidocaine 1% is the standard agent for an ultrasound‐guided peri‐prostatic block. In addition, an intrarectal instillation of local anaesthetic can be done (Raber et al. [124], Yun et al. [177]) 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]).

Special recommendations

A cleansing enema before biopsy provides no clinically significant outcome advantage and potentially increases patient cost and discomfort. It is therefore not recommended (Carey and Korman [24]).
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