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Name:
MRI Fusion Transperineal Prostate Biopsy
Description:
MRI Fusion Transperineal Prostate Biopsy
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https://cadmoremediastorage.blob.core.windows.net/c42038e6-a151-4966-bacc-ce00e7e4081d/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=z6LrW62Sk7K%2B05OVYTJUXngmtsDjlkT9mKnmRXblhZo%3D&st=2026-05-22T06%3A26%3A05Z&se=2026-05-22T10%3A31%3A05Z&sp=r
Duration:
T00H11M38S
Embed URL:
https://stream.cadmore.media/player/c42038e6-a151-4966-bacc-ce00e7e4081d
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/c42038e6-a151-4966-bacc-ce00e7e4081d/MRI-Fusion-Transperineal-Prostate-Biopsy.mp4?sv=2019-02-02&sr=c&sig=jpsl2zP76gaQcwaTOtQC5KurYsMx5g%2B1R3FB9mkKikM%3D&st=2026-05-22T06%3A26%3A06Z&se=2026-05-22T08%3A31%3A06Z&sp=r
Upload Date:
2023-10-19T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 Introduction.
SPEAKER: Welcome to our video, entitled "MRI Fusion Transperineal Prostate Biopsy Instructions and Troubleshooting." In this video, we will discuss the indications and show the instruments and optimal layout for this procedure. The biopsy will be performed, troubleshooting techniques will be shown, and the post-operative care will be discussed. Increasing randomized control trial data
Segment:2 Indications.
SPEAKER: is showing that MRI fusion prostate biopsy increases the detection of clinically significant prostate cancer while minimizing diagnosis of clinically insignificant cancer.
SPEAKER: Although MRI fusion prostate biopsy has not become the standard of care, multi-parametric prostate MRI has become well-integrated into many risk nomograms and active surveillance protocols. The transrectal prostate biopsy technique was widely adopted with the invention of the transrectal ultrasound probe, but carries an approximately 1% to 3% risk of post-biopsy sepsis, with increasing prevalence of multidrug-resistant organisms.
SPEAKER: The transperineal approach is becoming increasingly adopted to avoid this infectious risk and to more precisely target anterior lesions. The MRI fusion transperineal prostate biopsy combines the advantages of these two techniques. We begin with the instruments and equipment layout
Segment:3 Preoperative Preparation.
SPEAKER: required for this procedure. The transrectal ultrasound probe is lying next to its probe cover and an attached Luer lock syringe with water.
SPEAKER: A toomey syringe is also filled with ultrasound gel. The stepper holds the transrectal ultrasound probe and grid plate. It has fins that move up and down to change the angle of the grid plate. The stepper also telescopes forward to push the grid plate flush against the perineum. The back table setup includes sterile gloves, blue towels, biopsy gun, grid plate, 1% lidocaine with a 25-gauge needle for the subcutaneous injection, 18-gauge spinal or 25-gauge Chiba needle for the seminal vesicle injection, cup of Betadine, bowl of sterile water, and Tegaderm dressing.
SPEAKER: The GU bed is used with Allen stirrups, the crossbars attached in place of the bottom attachment. The crossbar contains the stepper arm, which should be secured in line with the patient's left hip. The field generator of the UroNav system is attached to a Bookwalter post clamp. The field generator is placed cephalad to the Allen stirrups. The UroNav system is placed near the right Allen stirrup, and the ultrasound machine is placed in closer proximity to the surgeon to aid in real-time prostate visualization.
SPEAKER: The ultrasound probe is inserted into the probe cover upside-down and with the probe tip angled towards the ground so that air collects on the opposite side of the transducer. The probe covers is then inflated with water from the Luer lock syringe. Air is then aspirated with the probe tip angled towards the ground in order to de-gas the probe cover.
SPEAKER: Physically tapping the air bubbles can also facilitate their release. The probe is then loaded into the stepper. The metal pin and water tubing on the lateral aspects should slide into their respective grooves. The probe is then screwed into place.
Segment:4 Patient Positioning.
SPEAKER: The patient should enter the room and sit at the foot of the OR bed. The patient should immediately place their legs into the stirrups and lie in the dorsal lithotomy position.
SPEAKER: The edge of the buttocks should be at the edge of the OR bed. A seat belt should be applied across the patient's abdomen for security. The stirrups should be raised superiorly before sedation to ensure that the patient does not have hip pain. After this hip check is complete, the anesthesiologist can proceed with sedation. The loaded stepper is then loaded onto the stepper holder at the bed.
SPEAKER: The trackers are loaded onto the sides of the stepper holder. Ultrasound gel from the toomey syringe is applied to the ultrasound probe tip and inside the rectum. The ultrasound probe is then inserted into the rectum, and the stepper arm is tightened once in place. The scrotum is taped towards the abdomen to expose the perineal skin. Lastly, the legs are raised to move the patient's pelvis prior to fusion.
SPEAKER: The legs are draped with the cystoscopy pack, and the suprapubic area is covered with a sterile blue towel. The ultrasound probe is also covered with a sterile blue towel.
Segment:5 Local Anesthesia.
SPEAKER: Local anesthesia is injected in three locations. First, the perineal subcutaneous tissue is injected with 10 cc's of 1% lidocaine. This aspect of local anesthesia should be performed quickly, since it only provides anesthesia at the needle insertion sites at the skin level.
SPEAKER: The prostate nerve block is then performed by injecting 5 cc's of 1% lidocaine between the prostate capsule and levator muscles. Air should be removed from the syringe prior to injection to prevent the introduction of air artifact around the prostate. Lidocaine should be visualized expanding the distance between these two structures if given in the correct space.
SPEAKER: This is also performed on the contralateral side. The prostate nerve block is finalized by injecting 5 cc's of 1% lidocaine between the seminal vesicles and lateral aspect of the prostate. The needle should be visualized as it passes between the rectal wall and posterior prostate. Lidocaine should be visualized expanding the distance between the seminal vesicles and prostate if given in the correct space.
SPEAKER: This is also performed on the contralateral side. The grid plate is attached to the stepper after the administration of local anesthesia. The grid plate pins are secured on each side. Prostate ultrasound and MRI segmentation is then performed.
Segment:6 MRI/Ultrasound Segmentation.
SPEAKER: A multi-parametric prostate MRI must be segmented and uploaded prior to the procedure using DynaCAD software. The UroNav system can then access the segmented prostate MRI from DynaCAD and download the MRI images for fusion with the live ultrasound images.
SPEAKER: Proper prostate segmentation is crucial to ensuring that the live ultrasound image correlates well with the uploaded MRI images. This begins with a smooth and uniform speed sweep of the prostate. The borders of the prostate are first selected, and then segmentation is performed by properly outlining the prostate edge and the axial and sagittal views.
SPEAKER: Segmentation should be performed as the prostate is scrolled through in each view. Blending should be performed between the ultrasound and MRI images to ensure that the bladder and seminal vesicles align well with the prostate in both images. The prostate can then be dragged and rotated to better align with these images. The green prostate outline from the ultrasound image should then correlate well with the pink prostate outline from the MRI image before proceeding.
Segment:7 Surgical Steps.
SPEAKER: We can now begin obtaining prostate biopsy specimens. Biopsies should first be obtained from PIRADS lesions and regions of interest that were identified and segmented on MRI. The desired biopsy location is selected on the UroNav system and visualized in real time on the ultrasound machine. The biopsy gun is inserted through the select grid plate hole and fired once the location is satisfactory. The biopsy specimen is placed into the specimen container, and the biopsy gun is dipped in Betadine and rinsed with sterile water.
SPEAKER: A total of four specimens are obtained from each lesion, while only one specimen is obtained from each systematic biopsy. Once all biopsies are obtained, the grid plate is removed. The biopsy probe is removed from the patient by loosening the stepper holder. The tracker clips are removed and hung on the side. The biopsy probe and stepper are removed from the holder and immediately cleaned.
SPEAKER: Cleaning and sterilization of the ultrasound probe is often the rate-limiting step to performing biopsies, since surgical centers often do not own more than a few probes. Manual pressure is held at the perineum
Segment:8 Postoperative Care.
SPEAKER: to aid in hemostasis immediately after the transrectal probe is removed. The perineal wound is covered with Bacitracin, Telfa, and Tegaderm. The patients have a voiding requirement in the PACU, and are not discharged with any prescription medications.
SPEAKER: Patients are instructed to keep their wound covered and to change the dressing as necessary with Bacitracin and gauze. Home antiplatelet and anticoagulation can be restarted once urine is clear yellow. The multitude of steps, equipment, and interfaces
Segment:9 Trouble Shooting.
SPEAKER: results in common problems that will be addressed in this troubleshooting section. Success begins from the setup.
SPEAKER: The median raphe should be in line with the biopsy probe. The biopsy probe should be pointed downwards to follow the trajectory of the rectum. The perineum should also be parallel and flush with the edge of the bed and crossbar. Air at any interface produces artifact that prevents adequate visualization. To remove air between the probe cover and the rectal wall, the probe can be wiggled quickly in a lateral direction.
SPEAKER: The probe should then be relaxed off of the prostate to allow the prostate to expand into its native position and form. Enough pressure should remain between the ultrasound probe and rectal wall interface to provide sharp visualization of the hypoechoic areas within the prostate. This can be achieved by a slight inflation of the rectal balloon.
SPEAKER: Now that prostate visualization is optimized, we can discuss various techniques to obtain your desired target. The target should first be visualized on the transverse images with complete visualization of the area surrounding the target on the ultrasound screen to identify the most hypoechoic areas suspicious for malignancy. The details of these hypoechoic lesions are best visualized on the larger ultrasound machine screen, and can be obscured by the cartoon on the UroNav screen.
SPEAKER: The segmented prostate outline should then be moved and rotated to align with the prostate edge that is closest in proximity to the target lesion. Once the edge has been appropriately adjusted in the transverse view, this should be repeated in the sagittal view. The stepper holder fins can be moved on either side to alter the holes of the grid plate. We recommend visualizing the desired lesion on the ultrasound machine and then moving the fins to align the grid plate hole with the current view.
SPEAKER: The next technique is utilizing the biopsy gun bevel to change the direction of the biopsy. The biopsy follows the direction of the bevel. At the skin, the bevel should be down, and then rotated upwards for posterior lesions to avoid the rectal wall and rotated medially for lateral lesions. The top of the grid plate can be pushed towards the patient to assist in bevel down and pulled away from the patient to assist in bevel up.
SPEAKER: Anterior prostate lesions may be difficult to access due to the location of the pubic bone. The patient's legs can be further raised to move the pubic bone away from the prostate. The downward angle of the ultrasound probe can also be lowered to change the trajectory of the biopsies. Attention must be given to the behavior of the biopsy needle as it passes through the perineal subcutaneous tissue and approaches the prostate lesion.
SPEAKER: The needle should be visualized on the larger ultrasound machine screen as the needle beveling and grid plate adjustments are made in reaction to the needle's behavior. These real-time adjustments should precisely place the needle in the desired location. Obtaining precise biopsies from the hypoechoic areas within the target lesion visualized on the ultrasound screen is more important than hitting the UroNav cartoon, since the cartoon is the estimated middle of the segmented target calculated by the UroNav system.
Segment:10 Credits.
SPEAKER: This concludes our video presentation. Thank you for your time, and feel free to contact us with any questions.
Segment:1 Introduction.
SPEAKER: Welcome to our video, entitled "MRI Fusion Transperineal Prostate Biopsy Instructions and Troubleshooting." In this video, we will discuss the indications and show the instruments and optimal layout for this procedure. The biopsy will be performed, troubleshooting techniques will be shown, and the post-operative care will be discussed. Increasing randomized control trial data
Segment:2 Indications.
SPEAKER: is showing that MRI fusion prostate biopsy increases the detection of clinically significant prostate cancer while minimizing diagnosis of clinically insignificant cancer.
SPEAKER: Although MRI fusion prostate biopsy has not become the standard of care, multi-parametric prostate MRI has become well-integrated into many risk nomograms and active surveillance protocols. The transrectal prostate biopsy technique was widely adopted with the invention of the transrectal ultrasound probe, but carries an approximately 1% to 3% risk of post-biopsy sepsis, with increasing prevalence of multidrug-resistant organisms.
SPEAKER: The transperineal approach is becoming increasingly adopted to avoid this infectious risk and to more precisely target anterior lesions. The MRI fusion transperineal prostate biopsy combines the advantages of these two techniques. We begin with the instruments and equipment layout
Segment:3 Preoperative Preparation.
SPEAKER: required for this procedure. The transrectal ultrasound probe is lying next to its probe cover and an attached Luer lock syringe with water.
SPEAKER: A toomey syringe is also filled with ultrasound gel. The stepper holds the transrectal ultrasound probe and grid plate. It has fins that move up and down to change the angle of the grid plate. The stepper also telescopes forward to push the grid plate flush against the perineum. The back table setup includes sterile gloves, blue towels, biopsy gun, grid plate, 1% lidocaine with a 25-gauge needle for the subcutaneous injection, 18-gauge spinal or 25-gauge Chiba needle for the seminal vesicle injection, cup of Betadine, bowl of sterile water, and Tegaderm dressing.
SPEAKER: The GU bed is used with Allen stirrups, the crossbars attached in place of the bottom attachment. The crossbar contains the stepper arm, which should be secured in line with the patient's left hip. The field generator of the UroNav system is attached to a Bookwalter post clamp. The field generator is placed cephalad to the Allen stirrups. The UroNav system is placed near the right Allen stirrup, and the ultrasound machine is placed in closer proximity to the surgeon to aid in real-time prostate visualization.
SPEAKER: The ultrasound probe is inserted into the probe cover upside-down and with the probe tip angled towards the ground so that air collects on the opposite side of the transducer. The probe covers is then inflated with water from the Luer lock syringe. Air is then aspirated with the probe tip angled towards the ground in order to de-gas the probe cover.
SPEAKER: Physically tapping the air bubbles can also facilitate their release. The probe is then loaded into the stepper. The metal pin and water tubing on the lateral aspects should slide into their respective grooves. The probe is then screwed into place.
Segment:4 Patient Positioning.
SPEAKER: The patient should enter the room and sit at the foot of the OR bed. The patient should immediately place their legs into the stirrups and lie in the dorsal lithotomy position.
SPEAKER: The edge of the buttocks should be at the edge of the OR bed. A seat belt should be applied across the patient's abdomen for security. The stirrups should be raised superiorly before sedation to ensure that the patient does not have hip pain. After this hip check is complete, the anesthesiologist can proceed with sedation. The loaded stepper is then loaded onto the stepper holder at the bed.
SPEAKER: The trackers are loaded onto the sides of the stepper holder. Ultrasound gel from the toomey syringe is applied to the ultrasound probe tip and inside the rectum. The ultrasound probe is then inserted into the rectum, and the stepper arm is tightened once in place. The scrotum is taped towards the abdomen to expose the perineal skin. Lastly, the legs are raised to move the patient's pelvis prior to fusion.
SPEAKER: The legs are draped with the cystoscopy pack, and the suprapubic area is covered with a sterile blue towel. The ultrasound probe is also covered with a sterile blue towel.
Segment:5 Local Anesthesia.
SPEAKER: Local anesthesia is injected in three locations. First, the perineal subcutaneous tissue is injected with 10 cc's of 1% lidocaine. This aspect of local anesthesia should be performed quickly, since it only provides anesthesia at the needle insertion sites at the skin level.
SPEAKER: The prostate nerve block is then performed by injecting 5 cc's of 1% lidocaine between the prostate capsule and levator muscles. Air should be removed from the syringe prior to injection to prevent the introduction of air artifact around the prostate. Lidocaine should be visualized expanding the distance between these two structures if given in the correct space.
SPEAKER: This is also performed on the contralateral side. The prostate nerve block is finalized by injecting 5 cc's of 1% lidocaine between the seminal vesicles and lateral aspect of the prostate. The needle should be visualized as it passes between the rectal wall and posterior prostate. Lidocaine should be visualized expanding the distance between the seminal vesicles and prostate if given in the correct space.
SPEAKER: This is also performed on the contralateral side. The grid plate is attached to the stepper after the administration of local anesthesia. The grid plate pins are secured on each side. Prostate ultrasound and MRI segmentation is then performed.
Segment:6 MRI/Ultrasound Segmentation.
SPEAKER: A multi-parametric prostate MRI must be segmented and uploaded prior to the procedure using DynaCAD software. The UroNav system can then access the segmented prostate MRI from DynaCAD and download the MRI images for fusion with the live ultrasound images.
SPEAKER: Proper prostate segmentation is crucial to ensuring that the live ultrasound image correlates well with the uploaded MRI images. This begins with a smooth and uniform speed sweep of the prostate. The borders of the prostate are first selected, and then segmentation is performed by properly outlining the prostate edge and the axial and sagittal views.
SPEAKER: Segmentation should be performed as the prostate is scrolled through in each view. Blending should be performed between the ultrasound and MRI images to ensure that the bladder and seminal vesicles align well with the prostate in both images. The prostate can then be dragged and rotated to better align with these images. The green prostate outline from the ultrasound image should then correlate well with the pink prostate outline from the MRI image before proceeding.
Segment:7 Surgical Steps.
SPEAKER: We can now begin obtaining prostate biopsy specimens. Biopsies should first be obtained from PIRADS lesions and regions of interest that were identified and segmented on MRI. The desired biopsy location is selected on the UroNav system and visualized in real time on the ultrasound machine. The biopsy gun is inserted through the select grid plate hole and fired once the location is satisfactory. The biopsy specimen is placed into the specimen container, and the biopsy gun is dipped in Betadine and rinsed with sterile water.
SPEAKER: A total of four specimens are obtained from each lesion, while only one specimen is obtained from each systematic biopsy. Once all biopsies are obtained, the grid plate is removed. The biopsy probe is removed from the patient by loosening the stepper holder. The tracker clips are removed and hung on the side. The biopsy probe and stepper are removed from the holder and immediately cleaned.
SPEAKER: Cleaning and sterilization of the ultrasound probe is often the rate-limiting step to performing biopsies, since surgical centers often do not own more than a few probes. Manual pressure is held at the perineum
Segment:8 Postoperative Care.
SPEAKER: to aid in hemostasis immediately after the transrectal probe is removed. The perineal wound is covered with Bacitracin, Telfa, and Tegaderm. The patients have a voiding requirement in the PACU, and are not discharged with any prescription medications.
SPEAKER: Patients are instructed to keep their wound covered and to change the dressing as necessary with Bacitracin and gauze. Home antiplatelet and anticoagulation can be restarted once urine is clear yellow. The multitude of steps, equipment, and interfaces
Segment:9 Trouble Shooting.
SPEAKER: results in common problems that will be addressed in this troubleshooting section. Success begins from the setup.
SPEAKER: The median raphe should be in line with the biopsy probe. The biopsy probe should be pointed downwards to follow the trajectory of the rectum. The perineum should also be parallel and flush with the edge of the bed and crossbar. Air at any interface produces artifact that prevents adequate visualization. To remove air between the probe cover and the rectal wall, the probe can be wiggled quickly in a lateral direction.
SPEAKER: The probe should then be relaxed off of the prostate to allow the prostate to expand into its native position and form. Enough pressure should remain between the ultrasound probe and rectal wall interface to provide sharp visualization of the hypoechoic areas within the prostate. This can be achieved by a slight inflation of the rectal balloon.
SPEAKER: Now that prostate visualization is optimized, we can discuss various techniques to obtain your desired target. The target should first be visualized on the transverse images with complete visualization of the area surrounding the target on the ultrasound screen to identify the most hypoechoic areas suspicious for malignancy. The details of these hypoechoic lesions are best visualized on the larger ultrasound machine screen, and can be obscured by the cartoon on the UroNav screen.
SPEAKER: The segmented prostate outline should then be moved and rotated to align with the prostate edge that is closest in proximity to the target lesion. Once the edge has been appropriately adjusted in the transverse view, this should be repeated in the sagittal view. The stepper holder fins can be moved on either side to alter the holes of the grid plate. We recommend visualizing the desired lesion on the ultrasound machine and then moving the fins to align the grid plate hole with the current view.
SPEAKER: The next technique is utilizing the biopsy gun bevel to change the direction of the biopsy. The biopsy follows the direction of the bevel. At the skin, the bevel should be down, and then rotated upwards for posterior lesions to avoid the rectal wall and rotated medially for lateral lesions. The top of the grid plate can be pushed towards the patient to assist in bevel down and pulled away from the patient to assist in bevel up.
SPEAKER: Anterior prostate lesions may be difficult to access due to the location of the pubic bone. The patient's legs can be further raised to move the pubic bone away from the prostate. The downward angle of the ultrasound probe can also be lowered to change the trajectory of the biopsies. Attention must be given to the behavior of the biopsy needle as it passes through the perineal subcutaneous tissue and approaches the prostate lesion.
SPEAKER: The needle should be visualized on the larger ultrasound machine screen as the needle beveling and grid plate adjustments are made in reaction to the needle's behavior. These real-time adjustments should precisely place the needle in the desired location. Obtaining precise biopsies from the hypoechoic areas within the target lesion visualized on the ultrasound screen is more important than hitting the UroNav cartoon, since the cartoon is the estimated middle of the segmented target calculated by the UroNav system.
Segment:10 Credits.
SPEAKER: This concludes our video presentation. Thank you for your time, and feel free to contact us with any questions.
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