• The decision to proceed to prostate biopsy is based primarily on PSA and DRE results.
However, one should take into account multiple factors, including free and total PSA,
patient age, PSA velocity, PSA density, family history, ethnicity, prior biopsy history
• Contraindications to prostate biopsy include acute painful perianal disorders, bleeding
diathesis, acute prostatitis, and severe immunosuppression.
• Transrectal ultrasound-guided prostate biopsy is impossible in patients lacking a rectum,
as those who have undergone ano-rectal resection. In those cases, transgluteal
biopsy under CT guidance is performed.
• The patient should discontinue oral anticoagulants approximately 7–10 days prior to
• Coagulation parameters are not routinely checked unless there is a reason for them
to be abnormal. For patients on warfarin or with an underlying coagulopathy,
International Normalized Ratio (INR) should be corrected to below 1.5 and platelets
• Patients receive oral antibiotics on the day prior, the day of, and for 5 days after the
procedure. Agents commonly used are oral fluoroquinolones, e.g., levofloxacin.
• The prostate is split into four distinct zones: the central zone, peripheral zone, and transition
zone, as well as the fibromuscular stroma.
• In young men, the peripheral zone comprises 75% of the volume of the prostate. After
the age of 40, benign prostatic hyperplasia begins in the transition zone.
• Prostate cancer is located in the peripheral zone in approximately 70% of patients.
• Transrectal ultrasound transducer with needle guide
• 18 gauge cutting needle biopsy gun
• A cleansing enema on the morning of the procedure is optional.
• One dose of parenteral antibiotics is given just prior to the procedure. This usually is a
dose of gentamycin 80 mg. It is given IM; if the patient has prosthetic cardiac valves or
joints, it has to be given IV.
• The necessity for periprocedural pain control is debatable. There are many methods
used; the most popular approach being the peri-prostatic nerve block. The nerves can be
blocked with lidocaine injection at the hyperechoic fat pad that demarcates the junction
of the seminal vesicles and the prostate bilaterally.