© 2 0 0 4 B J U I N T E R N A T I O N A L | 9 3 , 6 2 9 – 6 3 0 | doi:10.1111/j.1464-410X.2004.04677.x 629 Original Article BRACHYTHERAPY TEMPLATE TO STANDARDIZE PROSTATIC BIOPSY S.R.J. BOTT et al. A brachytherapy template approach to standardize saturation prostatic biopsy S.R.J. BOTT, A. HENDERSON, E. MCLARTY and S.E.M. LANGLEY Department of Urology, The Royal Surrey County Hospital, Guildford, Surrey, UK Accepted for publication 30 November 2003 INDICATIONS The increasing use of PSA testing has resulted in more men undergoing prostatic biopsy to diagnose or exclude malignancy. However, the standard sextant or octant biopsy regimen is reported to miss 15–35% of ‘significant’ prostate cancers [1–3]. The finding of ‘no evidence of malignancy’ on standard biopsy in the presence of a rising PSA level, a rapid PSA doubling time or a suspicious DRE may prompt further biopsies. Several studies have reported sites inadequately sampled using standard techniques, including the anterior transition zone superior and lateral to the urethra, the inferior part of the anterior horn where the peripheral zone wraps round the transition zone, and the midline of the peripheral zone [2,4,5]. Increasing the number of biopsies and targeting these sites after a negative standard prostatic biopsy results in increased cancer detection [1,2,5]. Saturation biopsy involves taking a large number of biopsies (14–45) using a periprostatic block, sedation, spinal or general spinal anaesthesia [6–8]. In men with a clinical suspicion of prostate cancer and previously negative sextant biopsies, transrectal saturation biopsies have a cancer detection rate of 14–34% [6–8]. We describe a systematic and comprehensive technique to take saturation prostatic biopsies through the perineum. METHODS After appropriate antibiotic prophylaxis and under general anaesthesia the patient is placed in the extended lithotomy position. A 16 F Foley catheter is passed and a bladder syringe containing 20 mL of aerated aqueous gel is attached to the catheter. The gel is instilled to assist the ultrasonographic identification of the urethra. A biplanar TRUS probe is used with a silicone offset to lift the prostate anteriorly into the area accessible for perineal biopsy. The probe is attached to a brachytherapy stepping unit (Sure-point TM , Amertek, Medical Inc, Florida) with a standard 0.5 cm brachytherapy template and positioned over the perineum. The prostate volume is measured as the width and height (the x and y axis, respectively) in the transverse plane and the length (z axis) in the longitudinal plane. The prostate is aligned so that the posterior aspect lies on the ‘1’ row and the urethra on the ‘D’ column (Fig. 1a.). The prostate is divided into right and left portions by the D column, and is further divided equally into anterior, middle and posterior areas, marking these divisions on the ultrasound monitor with a dry marker pen (Fig. 1b). The prostate can be further subdivided in the longitudinal plane (inferior and superior) if a needle biopsy placed at the apex does not adequately sample the base of the gland. Systematic biopsies may then be taken using the brachytherapy template, through the perineum. The 18 G biopsy needle, loaded on the Magnum TM gun (Bard Urological, Covington, GA) is introduced, e.g. at point 3.5, C (Fig. 1b), with TRUS in the transverse mode. On visualizing the needle in the correct site in the transverse plane (3.5, C) TRUS is switched to the longitudinal mode.