Biopsy, Prostate

Synonym/acronym: N/A.

Common use

To assist in diagnosing prostate cancer.

Specimen

Prostate tissue.

Normal findings

(Method: Microscopic examination of tissue cells) No abnormal cells or tissue.

Description

Biopsy of the prostate gland is performed to identify cancerous cells, especially if serum prostate-specific antigen (PSA) is increased. New technology makes it possible to combine data such as analysis of molecular biomarkers and cellular structure specific to the individual’s biopsy tissue, standard tissue biopsy results, Gleason’s score, number of positive tumor cores, tumor stage, presurgical and postsurgical PSA levels, and postsurgical margin status with computerized mathematical programs to create a personalized report that predicts the likelihood of post-prostatectomy disease progression. Serial measurements of PSA in the blood are often performed before and after surgery. Approximately 15% to 40% of patients who have had their prostate removed will encounter an increase in PSA. Patients treated for prostate cancer and who have had a PSA recurrence can still develop a metastasis as much as 8 yr after the postsurgical PSA level increased. The majority of tumors develop slowly and require minimal intervention, but patients with an increase in PSA greater than 2.0 ng/mL in a year are more likely to have an aggressive form of prostate cancer with a greater risk of death. The Prostate Health Index (PHI) is another multi-marker strategy used to improve the positive prediction rate of prostate cancer, especially when PSA levels are considered to be moderately increased (between 4–10 ng/mL). The PHI applies information provided by the results of prostate marker blood tests to a mathematical formula and offers additional information for clinical decision making. The three tests used in the formula are the total PSA, free PSA, and p2PSA (an isoform of PSA, where: PHI = p2PSA/[free PSA × total PSA]). Personalized medicine provides a technology to predict the progression of prostate cancer, likelihood of recurrence, or development of related metastatic disease. New technology makes it possible to combine data such as analysis of molecular biomarkers and cellular structure specific to the individual’s biopsy tissue, standard tissue biopsy results, Gleason score, number of positive tumor cores, tumor stage, presurgical and postsurgical PSA levels, and postsurgical margin status with computerized mathematical programs to create a personalized report that predicts the likelihood of post-prostatectomy disease progression.

This procedure is contraindicated for

high alertPatients with bleeding disorders (related to the potential for prolonged bleeding from the biopsy site)

Indications

Evaluate prostatic hypertrophy of unknown etiology
Investigate suspected cancer of the prostate

Potential diagnosis

Positive findings in prostate cancer

Gleason Grading
1	Simple round glands, closely packed rounded masses with well-defined edges. Closely resemble normal prostate tissue.
2	Simple round glands, loosely packed in vague, rounded masses with loosely packed edges. Closely resemble normal prostate tissue.
3	Discrete glands of varying size and shape interposed among nonneoplastic cells.
4	Small, medium, or large ill-defined glands fused into cords, chains, or ragged infiltrating masses; glands may be perforated or have a hypernephromatoid pattern.
5	No glandular differentiation, solid sheets, cords, single cells with central necrosis.

Gleason’s score is the sum of two grades assigned by the pathologist during microscopic examination of the biopsy samples. The score ranges from 1 to 10 with 10 being the worst. The first number assigned is the primary grade (1 to 5), which indicates where the cancer is the most prominent. The second number is the secondary grade (1 to 5), which indicates where the cancer is next most prominent. It is important to have the breakdown in grading as well as the total score. For example, Patient A’s Gleason’s score is 4 + 3 = 7, and Patient B’s Gleason’s score is 3 + 4 = 7. Even though both patients have the same Gleason’s score, Patient B has a slightly better prognosis because the primary area is graded a 3.

TNM Classification of Tumors
T refers to the size of the primary tumor
T₀	No evidence of primary tumor
T_IS	Carcinoma in situ
T_1–4	Increasing degrees in tumor size and involvement
N refers to lymph node involvement
N₀	No evidence of disease in lymph nodes
N_1–4	Increasing degrees in lymph node involvement
N_X	Regional lymph nodes unable to be assessed clinically
M refers to distant metastases
M₀	No evidence of distant metastases
M_1–4	Increasing degrees of distant metastatic involvement, including distant nodes

Critical findings

Assessment of clear margins after tissue excision
Classification or grading of tumor
Identification of malignancy
It is essential that critical findings be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.
Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. The notification processes will vary among facilities. Upon receipt of the critical finding the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical finding, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.
The various sampling approaches have individual drawbacks that should be considered: Transurethral sampling does not always ensure that malignant cells will be included in the specimen, whereas transrectal sampling carries the risk of perforating the rectum and creating a channel through which malignant cells can seed normal tissue.

Nursing Implications and Procedure

Pretest

Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
Patient Teaching: Inform the patient this procedure can assist in establishing a diagnosis of prostate disease.
Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex or anesthetics.
Obtain a history of the patient’s genitourinary system, any bleeding disorders or other symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
Note any recent procedures that can interfere with test results.
Obtain a list of the patient’s current medications including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure.
Review the procedure with the patient. Inform the patient that it may be necessary to remove hair from the site before the procedure. Instruct the patient that prophylactic antibiotics may be administered before the procedure. Address concerns about pain and explain that a sedative and/or analgesia will be administered to promote relaxation and reduce discomfort before the percutaneous biopsy; general anesthesia will be administered before the open biopsy. Explain to the patient that no pain will be experienced during the test when general anesthesia is used but that any discomfort with a needle biopsy will be minimized with local anesthetics and systemic analgesics. Inform the patient that the biopsy is performed under sterile conditions by an HCP, with support staff, specializing in this procedure. The surgical procedure usually takes about 30 min to complete, and sutures may be necessary to close the site. A needle biopsy usually takes about 20 min to complete. Instructions regarding the appropriate transport container for molecular diagnostic studies should be obtained from the laboratory prior to the procedure.
Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
Explain that an IV line will be inserted to allow infusion of IV fluids, antibiotics, anesthetics, and analgesics.
Instruct the patient that to reduce the risk of nausea and vomiting, solid food and milk or milk products have been restricted for at least 8 hr, and clear liquids have been restricted for at least 2 hr prior to general anesthesia, regional anesthesia, or sedation/analgesia (monitored anesthesia). The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. Patients on beta blockers before the surgical procedure should be instructed to take their medication as ordered during the perioperative period. Protocols may vary among facilities.
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

Potential complications:
Bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners) or seeding of the biopsy tract with tumor cells
Ensure that the patient has complied with dietary restrictions.
Ensure that anticoagulant therapy has been withheld for the appropriate number of days before the procedure. The number of days to withhold medication depends on the type of anticoagulant. Notify the HCP if patient anticoagulant therapy has not been withheld. Ensure that patients on beta-blocker therapy have continued their medication regimen as ordered.
Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
Have emergency equipment readily available.
Have the patient void before the procedure. Administer enemas if ordered.
Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen containers with the corresponding patient demographics, initials of the person collecting the specimen, date and time of collection, and site location.
Assist the patient to a comfortable position, and direct the patient to breathe normally during the beginning of the general anesthesia.
Cleanse the biopsy site with an antiseptic solution, use clippers to remove hair from the surgical site if appropriate, and drape the area with sterile towels.
Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities.

Transurethral Approach

After administration of general anesthesia, position the patient on a urological examination table with the feet in stirrups. The endoscope is inserted into the urethra. The tissue is excised with a cutting loop and is placed in formalin solution.

Transrectal Approach

Adhere to Surgical Care Improvement Project (SCIP) quality measures. Administer ordered prophylactic antibiotics 1 hr before incision, and use antibiotics that are consistent with current guidelines specific to the procedure.
After administration of general anesthesia, position the patient in the Sims’ position (left lateral). A rectal examination is performed to locate suspicious nodules. A biopsy needle guide is placed at the biopsy site, and the biopsy needle is inserted through the needle guide. The cells are aspirated, the needle is withdrawn, and the sample is placed in formalin solution.

Perineal Approach

Adhere to Surgical Care Improvement Project (SCIP) quality measures. Administer ordered prophylactic antibiotics 1 hr before incision, and use antibiotics that are consistent with current guidelines specific to the procedure.
After administration of general anesthesia, position the patient in the lithotomy position. Clean the perineum with an antiseptic solution, and protect the biopsy site with sterile drapes. A small incision is made, and the sample is removed by needle biopsy or biopsy punch and placed in formalin solution.

General

Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis).
Apply digital pressure to the biopsy site. If there is no bleeding after the perineal approach, place a sterile dressing on the biopsy site. Immediately notify the HCP if there is significant bleeding.
Place tissue samples for standard biopsy examination in properly labeled specimen containers containing formalin solution, place tissue samples for molecular diagnostic studies in properly labeled specimen containers, and promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
Instruct the patient to resume preoperative diet, as directed by the HCP. Assess the patient’s ability to swallow before allowing the patient to attempt liquids or solid foods.
Nutritional Considerations: There is growing evidence that inflammation and oxidation play key roles in the development of numerous diseases, including prostate cancer. Research also shows that diets containing dried beans, fresh fruits and vegetables, nuts, spices, whole grains, and smaller amounts of red meats can increase the amount of protective antioxidants. Regular exercise, especially in combination with a healthy diet, can bring about changes in the body’s metabolism that decrease inflammation and oxidation.
Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Discontinue prophylactic antibiotics within 24 hr after the conclusion of the procedure. Protocols may vary among facilities.
Instruct the patient on intake and output recording and provide appropriate measuring containers.
Encourage fluid intake of 3,000 mL unless contraindicated.
Observe/assess for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
Instruct the patient in the care and assessment of the site.
Instruct the patient to report any chills, fever, redness, edema, bleeding, or pain at the biopsy site.
Assess for infection, hemorrhage, or perforation of the urethra or rectum.
Inform the patient that blood may be seen in the urine after the first or second postprocedural voiding.
Instruct the patient to report any further changes in urinary pattern, volume, or appearance.
Assess for nausea, pain, and bladder spasms. Administer antiemetic, analgesic, and antispasmodic medications as needed and as directed by the HCP.
Administer antibiotic therapy if ordered. Remind the patient of the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.
Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services. Provide contact information, if desired, for the National Cancer Institute (www.cancer.gov).
Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Decisions regarding the need for and frequency of routine PSA testing or other cancer screening procedures should be made after consultation between the patient and HCP. Recommendations made by various medical associations and national health organizations regarding prostate cancer screening are moving away from routine PSA screening and toward informed decision making. The American Cancer Society’s guidelines recommend that discussions about screening should begin at age 50 years for men at average risk, 45 years for men at high risk, and 40 years for men at the highest risk of developing prostate cancer. The most current guidelines for prostate cancer screening of the general population as well as of individuals with increased risk are available from the American Cancer Society (www.cancer.org) and the American Urological Association (www.aua.org). Counsel the patient, as appropriate, that sexual dysfunction related to altered body function, drugs, or radiation may occur. Answer any questions or address any concerns voiced by the patient or family.
Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage him to review corresponding literature provided by a pharmacist.
Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

Related tests include cystoscopy, cystourethrography voiding, PAP, PSA, retrograde ureteropyelography, semen analysis, and US prostate.
Refer to the Genitourinary System table at the end of the book for related tests by body system.