PROSTATE BIOPSY

AND RENAL
BIOPSY
I NT R OD UC TI ON
• A biopsy is a medical
procedure that
involves taking a small
sample of body tissue
so it can be examined
under a microscope
• Usually performed by
interventional
radiologists, surgeons
(in this case urologists)
PROSTATE BIOPSY
WHY IS A PROSTATE BIOPSY
IMPORTANT?
• U LT I M AT E G O L D S TAT E F O R P R O S TAT E
CANCER DIAGNOSIS
• More than 47,500 men are diagnosed with prostate
cancer every year – that's 129 men every day.
• Every 45 minutes one man dies from prostate cancer –
that's more than 11,500 men every year.
• 1 in 8 men will be diagnosed with prostate cancer in their
lifetime.
• Around 400,000 men are living with and after prostate
cancer.
 NORMAL PROSTATE
STRUCTURE
• The prostate is located just below
the bladder and in front of the
rectum. It is about the size of a
walnut and surrounds the urethra
(the tube that empties urine from
the bladder). It produces fluid that
makes up a part of semen.
• The prostate's primary function
is to produce the fluid that
nourishes and transports sperm
(seminal fluid). Gives a pathway
for urine flow
 INDICATIONS OF
PROSTATE BIOPSY
Abnormal digital rectal
exam (DRE)
Increased prostatic-
specific antigen (PSA) -
4ng/ml
Clinical suspicion of
prostate cancer
• Pollakuria
• Nocturia
• Urgency
• Hesitancy
• Ischuria
• Hematospermia
 Coagulopathy

Painful anorectal conditions

C O N T R A I N D I C AT I O N
O F P R O S TAT E Significant immunosuppression
BIOPSY
Acute prostatitis
An absent rectum – imperforate
rectum
 Transrectal
method
TYPES OF
PROSTATE Perineal method
BIOPSY

Transurethral
method
 T RA N S R E C TA L
METHOD: - THIS IS
DONE THROUGH THE
RECTUM AND IS THE MOST
COMMON.

• Usually done in local anesthesia

• The patient is NOT under NPO
(patient can have food and
drinks normally)
• Method: -
• Ultrasound probe is lubricated
with gel and gently placed into
rectum
• Size of prostate is checked and
then a numbing agent is placed
through probe
• A needle is then inserted using
the needle 12 tiny pieces of
prostate tissue is taken
• Send for pathologist for
examination.
• Complication: - Recent studies
suggest 5 – 7 % risk of
prostatitis, Fecal coliform
bacteria can enter the prostate.
T RA N S P E R I N E A L
P R O S TAT E
B I O P S Y: - T H I S I S
DONE THROUGH THE
SKIN BETWEEN THE Advantages of transperineal prostate biopsy over TRUS
SCROTUM AND THE • Less risk of infection
RECTUM. • Equal or greater diagnostic value

More commonly done under general or spinal anesthesia,

can also be done with local anesthesia

Procedure

• Patient is placed in dorsal lithotomy position

• Perineal and rectal region cleaned with iodine solution
• Transrectal probe is inserted to the rectum after lubrication with lubricating gell
• If done under local anesthesia patient perineum is anesthetaized at this stage,
Lateral 1cm to midline.
• Using Biopsy Needle insert it through cannula, then take sample from anterior
apex, anterior base, posterior apex, posterior base, right and left lateral region
TRANSURETHRA
L METHOD: -
THIS IS DONE
THROUGH THE
URETHRA USING A • Usually done in general anesthesia
CYSTOSCOPE (A • Lift the penis upward
FLEXIBLE TUBE AND • Well lubricated cystoscope is used, inserted through urethra
VIEWING DEVICE) • When it reaches maximum length then the penis is pulled down
• Push the cystoscope upto prostate, then a sharp edged wire is
inserted, to get a sample
• Then using this tool the doctor takes a prostate sample
• Complication: -
• Severe hematuria upto 6 months (may require transfusion)
• Infections
• Erectile disfunction
• Urethral stricture
 RESULTS OF PROSTATE BIOPSY
• Biopsied tissue is sent to a laboratory, where a pathologist views the cells under a microscope.
When healthy cells become cancerous, their appearance begins to change. The more altered the
cells look, the more dangerous the cancer is likely to be.
• The results from a prostate biopsy are usually given in the form of the Gleason score.
• On the simplest level, this scoring system assigns a number from 2 to 10 to describe how
abnormal the cells appear under a microscope.
• A score of 2 to 4 means the cells still look very much like normal cells and pose little danger of
spreading quickly.
• A score of 8 to 10 indicates that the cells have very few features of a normal cell and are likely
to be aggressive.
• A score of 5 to 7 indicates intermediate risk.
• The pathologist also check the number of samples which cancer is present, as we usually send
12, if all 12 has cancer it is very severe. Usually gleason score is given by the highest number
containing sample out of 12
 GLEASON
SCORE
• Most common grade is
given at first
• For example 3, or 4

• Second most common

grade is given second
• For example 5 or 6

• Total is given with both

together
• 3 + 4

• If only one grade is give

summation of same grade
is given
• 4 + 4
 EPSTEIN GRADING SYSTEM
• Five grades are present
• 3 + 3 = Grade 1
• 3 + 4 = Grade 2
• 4 + 3 = Grade 3
• 4 + 4 = Grade 4
• 5 + 5 / 5 + 4 / 4 + 5 = Grade 5
KIDNEY
BIOPSY
 NORMAL KIDNEY STRUCTURE
• The kidneys are located on the Posterior abdominal wall, with one on either side of the
vertebral column, in the Perirenal space. The long axis of the kidney is parallel to the
lateral border of the Psoas muscle and lies on the quadratus lumborum muscle. In
addition, the kidneys lie at an oblique angle, that is the superior renal pole is more
medial and posteriorly than the inferior pole. Due to the right lobe of the liver, the
right kidney usually lies slightly lower than the left kidney.
• The renal parenchyma has two layers: cortex and medulla. The renal cortex lies
peripherally under the capsule while the renal medulla consists of 10-14
renal pyramids, which are separated from each other by an inward extension of the
renal cortex called renal columns.
• Urine is produced in the renal lobes, which consists of the renal pyramid with the
associated overlying renal cortex and adjacent renal columns. Each renal lobe drains
at a papilla into a minor calyx, four or five of these unite to form a major calyx. Each
kidney normally has two or three major calyces, which unite to form the Renal pelvis
NORMAL
KIDNEY
 INDICATIONS OF KIDNEY BIOPSY
• Unexplained renal failure
• Acute nephritic syndrome
• Nephrotic syndrome
• Isolated non - nephrotic Proteinuria
• Isolated glomerular hematuria
• Renal masses (primary or secondary)
• Renal transplant rejection
• Renal transplant dysfunction
CONTRAINDICATION OF KIDNEY BIOPSY
• Absolute contraindications to renal biopsy include the following:
• Uncorrectable bleeding diathesis
• Uncontrollable severe hypertension
• Active renal or perirenal infection
• Skin infection at biopsy site

• The following are relative contraindications to renal biopsy:

• Uncooperative patient
• Anatomic abnormalities of the kidney that may increase risk
• Small kidneys
• Solitary kidney
 BEFORE RENAL BIOPSY
• Renal imaging must be done
• Blood pressure measuring (diastolic less than 95mmHg)
• Urine culture must be sterile to rule out a urinary tract
infection
• Coagulation status
• Platelet count
• Prothrombin time
• Clotting time
 PROCEDURE OF KIDNEY BIOPSY
• Percutaneous renal biopsy
• Transjugular kidney biopsy
• Surgical biopsy
• Perioperative renal biopsy
 PERCUTANEOUS
RENAL BIOPSY
• Patient is placed in prone position, a wedge
is placed to reduce lumbar lordosis
• Firstly Ultrasound is done to localize lower
pole, then mark the region of skin
• The povidone-iodine solution is used to
clean the area
• Skin region is selected at the local
infiltration of anesthesia is done
• Small incision is done to allow insertion of
needle, a local anesthetic is used to
infiltrate capsule
• Biopsy needle is inserted with the help of
ultrasound guidance
• Then the sample is sent for pathologist for
reviewing
 TRANSJUGUL AR RENAL BIOPSY
• Initially performed in the 1990s, the transjugular kidney
biopsy is most commonly performed for patients requiring
a simultaneous liver/kidney biopsy. Some case series
showed no difference in the diagnostic yield or the
complication rate compared with PRB. Potential
complications are Contrast induced nephropathy as well as
capsular perforation that could require coil embolization.
 OPEN RENAL BIOPSY
• In some cases, Percutaneous biopsy is not the recommended approach, in
such cases we do a Laparoscopic kidney biopsy, performed by urologists,
can be the best approach in cases of morbidly obese patients, failed
attempts at PRB, severe coagulopathy, a solitary kidney, or very complex
anatomy. The major advantages are direct visualization and a biopsy of the
kidney with good hemostatic control of the biopsy site. The biopsy material
is usually abundant and sufficient to make the diagnosis of the underlying
condition.
• You receive medicine (anesthesia) that allows you to sleep and be pain-
free. The surgeon makes a small surgical cut (incision). The surgeon
locates the part of the kidney from which the biopsy tissue needs to be
taken. The tissue is removed. The incision is closed with stitches (sutures).
 COMPLICATION OF RENAL BIOPSY
• The most common complication of renal biopsy is pain and bleeding at the biopsy site. Bleeding may
occur in 3 distinct locations within the kidney: into the collecting system, under the renal capsule, or
into the perinephric space. If the bleeding enters the collecting system, blood is seen in the urine and
can cause pain and obstruction. If the bleeding is subcapsular, it can create enough of a mechanical
compressive effect onto the kidney to cause hypertension owing to an increase in the release of renin,
which is a hormone that is secreted by the juxtaglomerular apparatus of the kidney in the proximal
convoluted tubule to increase systemic blood pressure. The injured kidney can also undergo fibrosis
and, ultimately, chronic hypertension and perhaps even renal failure can result if the contralateral
kidney is compromised. This phenomenon is known as the Page kidney effect after Dr Irvine Page, who
first demonstrated in 1939 that wrapping cellophane tightly around animal kidneys can cause
hypertension. Perinephric bleeding can ultimately cause hemodynamic instability as it continues to
pool in the retroperitoneal space, necessitating blood transfusion. Another known complication of a
renal biopsy is the development of an arteriovenous fistula. Up to 18% of patients undergoing renal
biopsy may develop this complication. However, in most cases, the arteriovenous fistula is
asymptomatic and heals before causing symptoms. Nonetheless, some patients may experience
symptoms such as hematuria, hypertension, and renal insufficiency. It is important to treat
symptomatic fistulas as soon as possible to prevent further deterioration.