This document aims to share information about transperineal prostate fusion biopsy under local anesthesia, with Koelis Trinity™ system.
The following information relies on observations and advice from urologists such as:
- Dr Baco, from Aker University Hospital, Oslo, Norway.
- Dr Bott from Frimley Park Hospital, Camberley, United Kingdom.
- Dr Messas from American Hospital of Paris, France.
Moreover, some information is drawn from congress workshops, such as during AUA19: “Introduction to Office-Based Transperineal Prostate Intervention: MR/US Fusion biopsy” with Transperineal rationale (Chad Ellimootti, MD MS); Transperineal biopsy techniques (Arvin K. George, MD)
1. Materials check-list
The following tab summarize the items used to perform transperineal prostate biopsies
|Needle||Microlance 3||BD||300400 or 300800(1)||Subcutaneous anesthesia|
|Coaxial needle (2)||TruGuide||Bard||C1816A||Skin perforation before biopsy needle insertion|
|20mL syringe||Luer-lok||BD||300629||Anesthetic injection|
|Probe protection with little elastic bands||PROcovers||CIVCO||610-213||Protection and lubrification|
|Sterile gel for ultrasound||20mL||EDM Medical Imaging||PC020||Lubrification and US transmission|
|Cupula / cups||60mL, graduated||Asterie||1729003A||Betadine container|
|Waterproof table protection||Avoid table stain from betadine|
|Cotton balls||Perineal area disinfection|
|Biopsy pads||Samples biopsy storage|
|Anapathology pots||Sample conservation|
|Cassettes for samples||Storage|
|Large tape||Fix patient testicles|
|medical mob cap or sterile protection||Optional. Sterile manipulation of the mouse|
|Endoscope sterile drape||Camera drape (universal)||Premier Guard||10-1112||Optional. Sterile manipulation of Steady Pro®|
(1) Longest subcutaneous needle as possible.
(2) Single path technique only, see Dr. Bott below
|Steady Pro®||Steady Pro®||Koelis||Probe holder|
|Side-fire probe||3D endocavity side-fire Probe||Koelis||K3DEL00||Needle and organs visualization|
|Transperineal guide||Perine Grid® 18G or Perine full Grid®||Koelis||KRNG.EL1.18-5 or KRNG.EL4.18-5||Guide the needle through perineum|
|Stirrups (boot shape)||Lift patient legs|
|Trolley||Sterile products preparation|
|Bin||Throw disposables component|
2. Preparation before patient arrival
Find below further information about the different steps to set up and probe installation (dorsal decubitus only)
1- You can easily see if the external part is well locked as described below:
2- Check the probe holder alignment with the bed, from above. Find below further information about the different steps to set up and probe installation
3- Then check the horizontal alignment of the probe holder with the bed
3. After patient arrival
At the patient entry, follow the regular medical procedure control:
- Urine examination (ECBU)
- Rectal enema
- EMLA cream
- Etc …
Then you can install the patient in the bed
Note that two patient positions are possible to perform transperineal biopsy under local anesthesia:
- The dorsal decubitus, also known as lithotomy position, is the most commonly used.
- The lateral decubitus, performed by few physicians in some medical centers, compatible with KOELIS Perine Grid™ 18G only.
Anesthesia targets the perineum deeper plane which contains a nervous plexus, responsible for its sensibility.
Before performing anesthesia, you have to prepare a 3D prostate exam for your patient, registered in Trinity™ system:
- Start the Trinity™ system
- Go to “Prostate cartography”
- Click on the patient name (if needed, create a new one)
- Go to “Mapping”
- Choose either:
- “Import” if you want to import MRI,
- “1st look” if images are already loaded
- “2nd look” if you want to perform new biopsies over previous 3D map.
Ultrasound image is displayed on the right.
Depending on doctors, peri-prostatic anesthesia process can be described in several steps.
4. KOELIS Workflow
Beginning of a cartography session
This step marks the beginning of Koelis workflow. As you were using the prostate cartography interface to perform the anesthesia, you just have to check some points before launching the 3D acquisition:
- Make sure the prostate is included in the yellow square. The deepness and focal point can be changed in parameters if necessary.
- Fully lock Steady Pro™ (black screw).
- There must be no air artifacts on the ultrasound image.
The reference ultrasound volume acquisition can be done.
Dr. Messas performing systematic biopsies
Biopsy cores can be labeled individually according to their X, Y coordinates on the grid and Z coordinates relating to whether it is basal or apical.
The alternative is to divide the prostate into zones. There are also several ways to divide the prostate into anatomical zones.
For example, Barzell et al. initially divided the prostate into octants and then further divided them into three zones, yielding 26 separate specimen pots.
The main issue remained that this template saturated the gland with biopsies, that’s why the National Health Service (NHS) introduced the modified Barzell zones where the prostate was segmented into 20 zones.
Then later, it was finally reduced into 12 zones only to reduce the resource burden on pathology services.
However, transperineal biopsies templates are still under investigation and several templates raise among the scientific community, such as Ginsburg biopsy protocol or template from Michigan Urological Surgery Improvement Collaborative – MUSIC Urology.