Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Transrectal Ultrasonography of the Prostate

  • Author: Sugandh Shetty, MD, FRCS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Aug 12, 2015
 

Background

Urologists have incorporated transrectal ultrasonography (TRUS) of the prostate into their practices; moreover, TRUS is also widely used to deliver treatments such as brachytherapy and to monitor cryotherapy treatment for prostate cancer. TRUS has become an extension of the urologist’s finger in the early detection of prostate cancer. The evolution of end-firing probes has further enhanced urologists’ ability to monitor the entire process of prostate biopsy.[1]

The use of sound waves to detect distant objects on the basis of their reflective properties became popular after World War II. In medicine, the initial use of ultrasound was in the detection of brain tumors. In urology, ultrasound was first used to detect renal stones during surgery.

The early applications of ultrasonography in medicine involved sound-wave generators, cathode-ray tubes, Polaroid photography, or 35-mm film recording. However, the invention of the silicone microchip gave birth to the modern ultrasonography revolution.

Early investigators in prostatic ultrasonography conducted experiments with ultrasound probes and recording devices. One of the earliest devices was a chair-type apparatus with a probe mounted in the center of the chair. The patient sat on the probe, which was guided into the rectum. Improvements in gray-scale ultrasound display and multiplanar scanning have resulted in user-friendly hand-held probes.

Earlier studies concentrated on the ultrasonographic appearances of prostate abnormalities such as benign prostatic hyperplasia (BPH), carcinoma of the prostate (CAP), prostatitis, prostatic abscess, and prostatic calculi. Since the introduction of the prostate-specific antigen (PSA) screening test and early detection of prostate cancer, the role of TRUS has changed; it is mainly used to visualize the prostate (see the image below) and to aid in guided needle biopsy.

Axial image of a prostate. White arrows show the a Axial image of a prostate. White arrows show the asymmetrical anterior prostate. This could only be appreciated on TRUS images.

PSA guidelines

The American Urological Association (AUA) has published updated guidelines for the early detection of prostate cancer (CAP) to guide urologists in the screening of asymptomatic men.[2] The panel recommended against screening men younger than 40 years and the routine screening of men aged 40 to 54 years who are at average risk for CAP. Men younger than 55 years who are at increased risk for CAP (family history or African American race) should discuss an individualized approach to prostate cancer screening with their urologists. Men aged 55 to 69 years appear to derive the greatest benefit from screening. For men in this age group, the panel strongly recommended shared decision-making regarding PSA screening and proceeding at 2-year intervals depending on the individual’s values and preferences. PSA screening is not recommended for men older than 70 years or for any man with less than 10-15 years of life expectancy.[2]

Future applications

Possible future applications involving TRUS include the following:

  • Color Doppler scanning
  • Contrast-enhanced prostate biopsy
  • Intermittent and harmonic ultrasonography
  • High-intensity focused ultrasound (HIFU)
  • Elastography
  • MRI Ultrasound Coregistration

Color Doppler scanning has been used to enhance the diagnosis of CAP as an adjunct to TRUS. Several investigators have demonstrated that the addition of color Doppler improved the specificity of prostate biopsy findings. However, differentiating a focus of prostatitis from cancer was difficult. The addition of power Doppler was not advantageous.

The use of microbubble contrast agents can enhance gray-scale imaging and Doppler imaging. Newer agents that remain in the vascular compartment have been used for prostate imaging. Currently available agents include the following:

  • Perflenapent emulsion (EchoGen)
  • Galactose–palmitic acid (Levovist)
  • Perflexane lipid microspheres (Imavist)
  • Galactose suspension (Echovist)
  • Perflutren lipid microsphere (DMP 115, Definity)
  • Perfluorobutane microspheres (NC100-100, Sonazoid)

Several investigators have evaluated contrast-enhanced prostate ultrasonography. Ragde et al used EchoGen to study 15 patients with rising PSA levels and previous negative biopsy findings and found that only 2 of the 8 patients with abnormal vascular patterns were diagnosed with cancer.[3]

Similarly, Watanabe et al studied 9 cases in which Levovist was used and demonstrated enhanced images of all cancers.[4] Halpern et al evaluated 26 patients with elevated PSA levels and found significant image enhancement after using Imavist.[5] However, the extra cost of this technique may be the limiting factor in its widespread use.

The rationale for intermittent and harmonic ultrasonography is that conventional ultrasonography destroys the microbubbles of the contrast agents used in ultrasonographic imaging. Intermittent ultrasonography increases the enhancement provided by the contrast agents. In harmonic imaging, the reverberations produced by the contrast agent are visualized at a different frequency than the insonating frequency, which can provide a better image.

With extracorporeal HIFU, temperatures higher than 60°C can be achieved in the target tissue. The prostate can be easily treated with this modality via a transrectal probe. The size of the thermal lesion can be controlled by the power and the duration of the ultrasound pulse. Higher in situ intensities (>3055 W/cm2) create the cavitation phenomenon and bubble effect, which are difficult to monitor.

The currently available HIFU devices use 3-4 MHz transducers. Experimental studies have shown core temperatures of 75°C, with a peak of 99°C during insonification.

Gelet et al pioneered the use of transrectal HIFU in the treatment of prostate cancer.[6] Currently, the procedure is used in Europe to treat localized prostate cancer and is performed with the patient under anesthesia and in a decubitus position. Rectal cooling is employed to prevent rectal burns.

Prostates smaller than 40 mL or those with an anteroposterior diameter of less than 5 cm are best suited for this treatment. During the procedure, the whole gland is treated (in contrast to focal therapy).

After the procedure, a suprapubic tube is left in place for 5-7 days. In a multicenter trial of 402 patients treated with HIFU, the median duration for catheter use was 5 days.[7] Prolonged retention occurred in 9% of patients, and 3.6% developed urethral strictures. Incontinence following HIFU was rare (0.6%). Rectourethral fistula developed in 1.2% of the patients.

Complication rates are higher with salvage HIFU after radiation therapy, radical prostatectomy, or HIFU. Erectile function can be preserved in 20-46% of patients who undergo only 1 session of HIFU.

After a minimum follow-up period of 6 months, Thuroff et al reported negative biopsy results in 87% of patients and a median nadir PSA level of 0.4 ng/mL after HIFU.[7] Gelet at al reported that 78% of low-risk patients were disease-free and had negative biopsy results at an actuarial 5-year follow-up.[6]

Gelet et al also reported salvage HIFU after failed radiation in 71 patients.[8] Among these patients, biopsy results were negative in 80%, and 61% had a PSA level nadir below 0.5 ng/mL. Complication rates after salvage HIFU were higher: total incontinence developed in 6%, rectourethral fistula in 6%, and vesical neck contracture in 17%.

Prostate elastography

Digital rectal exam, PSA testing, and color Doppler transrectal ultrasonography TRUS-guided systematic biopsy are the basis for the diagnosis of prostate cancer. As alluded to earlier, TRUS has not been proven as a reliable imaging technique for localizing cancer foci within the prostate. Krouskop et al[9] theorized that cell density is greater in neoplastic tissue, causing a change in tissue elasticity. This line of thinking formed the basis for elastography, which was developed in the early 1990’s. As elastography developed, it has been increasingly applied for prostate cancer imaging. In 2005, Konig et al[10] studied 404 patients with suspected prostate cancer and found that elastography detected 84% of the 151 true positive cancer patients.

In Miyanaga’s 2006 study,[11] of 29 patients with untreated prostate cancer, the sensitivity of elastography, TRUS, and DRE were 93%, 59%, and 55%, respectively. Pallwein et al[12] studied 15 patients who were initially studied with standard ultrasound and elastography before undergoing robot-assisted laparoscopic prostatectomy, and they found that elastography was 88% sensitive for detecting cancer foci and that 78.3% of the cases correlated with the histologic findings. Further analysis showed that the best sensitivity and specificity were found in the apex region.

In terms of targeted prostate biopsy, a larger study, by Pallwein et al,[13] concluded that elastography was 2.9 times more likely to detect prostate cancer than systematic TRUS biopsy. Furthermore, elastography required fewer than half the number of biopsy cores. When evaluating elastography for the staging of prostate cancer, Salomon et al[14] evaluated 15 patients who underwent elastography after radical prostatectomy and found that 14 of 15 patients were correctly identified for the presence or absence of extracapsular disease.

Elastography certainly has shown promise as an alternative to conventional TRUS, and further clinical trials are currently being conducted, which will likely lead to better understanding of the exact role for elastography in the management of prostate cancer.

Real-time targeting of prostate biopsy has emerged as a potential replacement for conventional systematic biopsy in an effort to improve quality, reduce the number of clinically insignificant cancer diagnoses, and improve targeting of high-grade and clinically significant tumors.

Prostate MRI was first reported over 30 years ago.[15] MRI "in bore" biopsy has been the most widely examined prostate biopsy procedure; however, because of increased cost, lack of availability, and overall clinical outcomes, it is unlikely to replace systematic biopsy. MRI coregistration with ultrasound, commonly referred to as MR-US fusion, has been an area of increasing research and is a potential replacement for systematic biopsy moving forward.

MR-US fusion allows MRI data to be used to obtain biopsies under ultrasound guidance. Cognitive fusion refers to the operator viewing lesions on MRI, allowing one to attempt biopsy of the visualized location from memory using real-time US. Obvious disadvantages include potential for human error and the steep learning curve and variability of results. In an effort to reduce this variability, several fusion devices have been developed and are now approved by the FDA.

The Artemis device (Eigen) utilizes tracking of the TRUS probe by a directly attached robotic arm that translates the 2D US into a 3D model, which is fused with the preprocedure MRI and allows targeting of suspicious lesions.[15] The device also tracks biopsy sites. allowing rebiopsy of the exact site at a later time.

Sonn et al[16] found that in men undergoing active surveillance with previously negative biopsy results, the Artemis device detected cancer in 55% of men overall and 94% of those with the highest level of suspicion on MRI. They also found that there was a clinically significant increase in the detection of significant cancers and a decreased detection of insignificant cancers, as compared to systematic biopsy.

Disadvantages of using the Artemis device include the bulkiness of the device and difficulty with in-office use. The UroNav device (Invivo) utilizes a sensor that attaches to the TRUS probe, and using a small electromagnetic field placed in close proximity to the patient, it fuses the MRI data.[15] It is a free-hand technique that is generally more familiar to urologists. However, it has the disadvantage of an electromagnetic field, as opposed to the accuracy of the robot.

Vourganti et al[17] found that in patients with previous negative biopsy results, UroNav detected cancer in 37% of patients, including 11% with high-grade disease. The Urostation device (Koelis) utilizes real-time 3D TRUS in a recreated model of the prostate to localize each biopsy site.[15] The model is reset with each probe firing to adjust for any changes. This device has the advantage of a free-hand platform, though the inherent error in any free-hand technique still exists. Portalez et al[18] studied 129 men with at least 1 previous negative biopsy and found that 48% were found to have cancer. Of patients with high suspicion for disease on MRI, 83% had cancer on fusion biopsy.

Delongchamps et al[19] compared cognitive and fusion MR-US devices with systematic biopsy. In their study of 391 patients, they found no difference in the rate of cancer detection for visually targeted versus random biopsy. The fusion MR-US devices did increase the detection of high-grade cancer with fewer cores, while decreasing the rate of micro focal cancer detection.

Puech et al[20] studied men with a suspicious lesion on MRI, and each man underwent 12 random core biopsies, 2 visually guided biopsies, and 2 MR-US fusion software-targeted biopsies. The study found that targeted biopsy detected clinically significant cancer in more men than random biopsy; however, there was no significant difference in cancer detection between cognitive fusion and MR-US fusion software.

MR-US coregistration has shown promise as a targeted method of sampling the prostate leading to more accurate identification of clinically significant prostate cancer. However, it remains unclear whether the biopsy results can be applied to the conventional risk-stratification systems that were designed for systematic and random biopsy. It is also unclear how exactly this will impact the practicing urologist. Long-term studies are certainly required. Nonetheless, it is an important advancement in the ongoing effort to improve the management of prostate cancer.

Next

Indications

TRUS has both diagnostic and therapeutic indications. Diagnostic indications for TRUS include early diagnosis of CAP. However, ultrasonographic findings alone cannot be used to establish or exclude the diagnosis of CAP: definitive diagnosis must be based on biopsy results, along with abnormal digital rectal examination (DRE) findings, elevated PSA levels, or both.

TRUS is also used diagnostically to determine the volume of the prostate gland and thereby facilitate the planning of brachytherapy, cryotherapy, or minimally invasive BPH therapy (eg, radiofrequency or microwave therapy). In addition, TRUS is used to evaluate prostate volume during hormonal downsizing for brachytherapy. Finally, TRUS is used in the evaluation of men with azoospermia to rule out ejaculatory-duct cysts, seminal vesicular cysts, müllerian cysts, or utricular cysts.

Therapeutic indications for TRUS include the following:

  • Brachytherapy for CAP
  • Cryotherapy for CAP
  • Deroofing or aspiration of ejaculatory ducts, prostatic cysts, or prostatic abscesses
Previous
Next

Contraindications

Contraindications for TRUS-guided biopsy of the prostate include an acute painful perianal disorder and a hemorrhagic diathesis. As a rule, patients should be discouraged from taking aspirin or nonsteroidal anti-inflammatory drugs for at least 10 days before the procedure, but recent use of these agents should not be considered an absolute contraindication for prostate biopsy.

Previous
Next

Technical Considerations

Prostate anatomy

The adult prostate is a chestnut-shaped organ enveloped in a fibrous capsule. The base of the prostate is attached to the bladder neck, and the apex is fixed to the urogenital diaphragm. The prostatic urethra traverses the gland. The verumontanum is a longitudinal ridge in the prostatic apex onto which the ejaculatory ducts open.

The prostate is located superior and posterior to the seminal vesicles. The ampullae of the vas deferens run medial to the seminal vesicles along the posterior surface of the prostate. Anteriorly, the fibrous capsule thickens at the level of the apex to form puboprostatic ligaments, which attach the prostate to the back of the symphysis pubis.

The dorsal venous complex (ie, the Santorini plexus) runs along the puboprostatic ligaments. The prostate gland lies beneath the endopelvic fascia. Posteriorly, the 2 layers of Denonvilliers fascia separate the prostate from the rectum. The rectourethralis muscle attaches the rectum to the prostatic apex.

A rich plexus of veins encompasses the prostate gland between the true fibrous capsule of the gland and the lateral prostatic fascia; these are visible landmarks on sonograms (see the image below). The neurovascular bundles run craniocaudally along the posterolateral aspects of the prostate. The prostate gland is supplied by the prostatic artery, which is usually a branch of the inferior vesical artery. The prostatic artery divides into a urethral branch, which supplies the transition zone, and a capsular branch.

Sagittal image of a prostate. White arrows show da Sagittal image of a prostate. White arrows show darkly hypoechoic areas suggestive of periprostatic veins.

Venous drainage from the prostate moves into the Santorini plexus and eventually into the internal iliac vein. The prostatic venous plexus communicates freely with the extradural venous plexus (ie, the Batson plexus), and this communication is thought to be a factor in the spread of prostate cancer. Initially, lymphatic drainage of the prostate is into the obturator lymph nodes and into the hypogastric chain.

The nerve supply to the prostate is both sympathetic, from the hypogastric plexus (L1-2), and parasympathetic, from the pelvic nerve (nervi erigentes, S2-S4). Although the cavernous nerves run along the posterior aspect of the prostate, the 2 distinct areas from which prostatic nerves leave the gland are thought to be the superior and inferior pedicles. These areas are the first sites of extraprostatic spread of cancer.

Internal anatomy

According to the classic work by McNeal, the prostatic urethra, which is the main reference point of the prostate, divides the gland into an anterior fibromuscular stroma and a posterior glandular organ. The urethra is angled 35° anteriorly in the proximal portion of the prostate. The ejaculatory ducts run in the same plane as the distal prostatic urethra to join the verumontanum.

Lowsley’s concept of a 5-lobed prostate has been replaced by McNeal’s concept of zonal architecture. In this scheme, the prostate has 4 glandular zones, each with its own ductal system. The peripheral zone, the transition zone, and the periurethral glands have a similar histologic appearance and are derived from the urogenital sinus. However, the central zone is histologically distinct from the other 3 zones and is derived from mesonephric tissues (ie, wolffian tissue).

Peripheral zone

The peripheral zone constitutes almost 75% of the normal prostate gland. It occupies the distal prostate gland, the area around the urethra distal to the verumontanum. The acini are small, round, and smooth-walled, and their ducts drain into the urethra distal to the verumontanum. The stroma is loosely woven with randomly oriented muscle fibers. Approximately 70% of CAP cases arise in this zone.

Central zone

The central zone constitutes 25% of the normal prostate and occupies the part of the prostate behind the proximal prostatic urethra. The ejaculatory ducts pass through the central zone. The acini are large and irregular, with significant intraluminal folds and ridges. They are also surrounded by muscular tissue that closely follows the shape of the acini. Approximately 5-10% of CAP cases arise in this zone.

Transition zone

The transition zone makes up approximately 5-10% of the normal prostate gland (see the image below). The transition zone lies on either side of the proximal prostatic urethra, lateral to the internal sphincter. The glandular architecture is similar to that of the peripheral zone; however, the stroma is more compact. The transition zone is where BPH originates and where approximately 20% of CAP cases arise.

Transverse image of the prostate showing a hypertr Transverse image of the prostate showing a hypertrophied transition zone (yellow arrows) and a compressed peripheral zone (blue arrows).

Periurethral glands

The periurethral glands make up less than 1% of the glandular tissue. These glands are embedded in the smooth muscle of the prostatic sphincter. This is the site of origin of the large median lobe of BPH.

Anterior fibromuscular stroma

The anterior part of the prostate is composed mainly of fibromuscular stroma, which is continuous with detrusor fibers. Toward the apex of the gland, this fibromuscular tissue blends with striated muscle from the levator. Puboprostatic ligaments also blend with this area.

Invaginated extraprostatic space

As the ejaculatory ducts enter the prostate posteriorly, an invaginated extraprostatic space (IES) surrounds them and invaginates into the prostate. The IES surrounds the ejaculatory ducts, ends at the verumontanum, and communicates with the periurethral space.

In 1989, Lee introduced the concept that invasion of the IES may be the first sign of extraprostatic extension of prostate cancer and an early sign of invasion of seminal vesicles. In 2005, Amin et al evaluated the pathological significance of the invasion of IES in 80 patients with prostate cancer and concluded that IES involvement was consistently seen in cases with seminal vesicle invasion.[21]

Bladder neck and internal sphincter

The internal sphincter runs from the bladder neck to the level of the verumontanum. The smooth muscle fibers of the sphincter are continuous with the superficial layer of the trigone. In healthy males, the bladder neck and the internal sphincter are closed. In males with a neurogenic bladder, the bladder neck and the prostatic urethra are wide open, and some investigators have used TRUS to monitor the lower urinary tract in patients with spinal injuries.

See Prostate Anatomy and Seminal Vesicle Anatomy for more information.

Complication prevention

Gill and Ukimura, in a study reporting on the use of TRUS monitoring with Doppler during laparoscopic radical prostatectomy to identify the blood flow in the neurovascular bundles, found that identification and preservation of pulsatile blood vessels within these bundles resulted in superior recovery of erectile activity postoperatively.[22]

Preprocedural enema

More than 80% of urologists administer an enema before TRUS and prostate biopsy. However, some authors consider this practice unnecessary.

Antibiotic prophylaxis

More than 90% of urologists administer prophylactic oral antibiotics. Reported regimens include a total of 11 different antibiotics, with 20 different dosages and treatment durations ranging from 1 to 17 days.

There is increasing support for a simpler prophylactic regimen in patients with uncomplicated medical conditions. The protocol most commonly recommended consists of 2 doses of a fluoroquinolone, with the first given before the procedure and the second 12 hours later. Targeted antimicrobial prophylaxis has been employed in cases of infections caused by fluoroquinolone-resistant organisms.[23]

In patients with prosthetic implants or valvular heart disease, additional prophylaxis with ampicillin 1 g intramuscularly (IM)—or, in penicillin-allergic patients, vancomycin 1 g intravenously (IV)—plus gentamicin 80 mg IM is recommended.

Previous
 
 
Contributor Information and Disclosures
Author

Sugandh Shetty, MD, FRCS Associate Professor of Urology, Oakland University William Beaumont School of Medicine; Attending Physician, Department of Urology, William Beaumont Hospital

Sugandh Shetty, MD, FRCS is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Chirag Dave, MD Resident Physician, Department of Surgery (Urology), William Beaumont Health System

Chirag Dave, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Physicians, American Urological Association

Disclosure: Nothing to disclose.

Zubin Shetty George Mason University and Georgetown University

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

Martha K Terris, MD, FACS Professor, Department of Surgery, Section of Urology, Director, Urology Residency Training Program, Medical College of Georgia; Professor, Department of Physician Assistants, Medical College of Georgia School of Allied Health; Chief, Section of Urology, Augusta Veterans Affairs Medical Center

Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, Association of Women Surgeons, American Society of Clinical Oncology, Society of Urology Chairpersons and Program Directors, Society of Women in Urology, Society of Government Service Urologists, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, Society of University Urologists

Disclosure: Nothing to disclose.

Acknowledgements

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Martha K Terris, MD, FACS Professor, Department of Surgery, Section of Urology, Director, Urology Residency Training Program, Medical College of Georgia; Professor, Department of Physician Assistants, Medical College of Georgia School of Allied Health; Chief, Section of Urology, Augusta Veterans Affairs Medical Center

Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Society of Clinical Oncology, American Urological Association, Association of Women Surgeons, New York Academy of Sciences, Society of Government Service Urologists, Society of University Urologists, Society of Urology Chairpersons and Program Directors, and Society of Women in Urology

Disclosure: Nothing to disclose.

References
  1. Guideline developed in collaboration with the American College of Radiology, Society of Radiologists in Ultrasound. AIUM Practice Guideline for the Performance of an Ultrasound Evaluation of the Prostate (and Surrounding Structures). J Ultrasound Med. 2015 Aug. 34 (8):1-6. [Medline].

  2. Auffenberg GB, Meeks JJ. Application of the 2013 American Urological Association early detection of prostate cancer guideline: Who will we miss?. World J Urol. 2014 Jun 20. [Medline].

  3. Ragde H, Kenny GM, Murphy GP, Landin K. Transrectal ultrasound microbubble contrast angiography of the prostate. Prostate. 1997 Sep 1. 32(4):279-83. [Medline].

  4. Watanabe A, Otake R, Nozaki T, Morii A, Ogawa R, Fujimoto S, et al. Effects of microbubbles on ultrasound-mediated gene transfer in human prostate cancer PC3 cells: comparison among Levovist, YM454, and MRX-815H. Cancer Lett. 2008 Jun 28. 265(1):107-12. [Medline].

  5. Halpern EJ, Verkh L, Forsberg F, et al. Initial experience with contrast-enhanced sonography of the prostate. AJR Am J Roentgenol. 2000 Jun. 174(6):1575-80. [Medline].

  6. Gelet A, Chapelon JY. Effects of high intensity focussed ultrasound on malignant cells and tissues. Maberger, ed. Application of Newer Forms of Therapeutic Energy in Urology. Oxford ISIS; 1995. 107-14.

  7. Thüroff S, Chaussy C, Vallancien G, Wieland W, Kiel HJ, Le Duc A. High-intensity focused ultrasound and localized prostate cancer: efficacy results from the European multicentric study. J Endourol. 2003 Oct. 17(8):673-7. [Medline].

  8. Gelet A, Chapelon JY, Poissonnier L, Bouvier R, Rouvière O, Curiel L. Local recurrence of prostate cancer after external beam radiotherapy: early experience of salvage therapy using high-intensity focused ultrasonography. Urology. 2004 Apr. 63(4):625-9. [Medline].

  9. Krouskop TA, Wheeler TM, Kallel F, Garra BS, Hall T. Elastic moduli of breast and prostate tissues under compression. Ultrason Imaging. 1998 Oct. 20(4):260-74. [Medline].

  10. König K, Scheipers U, Pesavento A, Lorenz A, Ermert H, Senge T. Initial experiences with real-time elastography guided biopsies of the prostate. J Urol. 2005 Jul. 174(1):115-7. [Medline].

  11. Miyanaga N, Akaza H, Yamakawa M, Oikawa T, Sekido N, Hinotsu S, et al. Tissue elasticity imaging for diagnosis of prostate cancer: a preliminary report. Int J Urol. 2006 Dec. 13(12):1514-8. [Medline].

  12. Pallwein L, Mitterberger M, Gradl J, Aigner F, Horninger W, Strasser H, et al. Value of contrast-enhanced ultrasound and elastography in imaging of prostate cancer. Curr Opin Urol. 2007 Jan. 17(1):39-47. [Medline].

  13. Pallwein L, Mitterberger M, Struve P, Horninger W, Aigner F, Bartsch G, et al. Comparison of sonoelastography guided biopsy with systematic biopsy: impact on prostate cancer detection. Eur Radiol. 2007 Sep. 17(9):2278-85. [Medline].

  14. Salomon G, Graefen M, Heinzer H, Huland H, Pallwein L, Aigner F, et al. [The value of real-time elastography in the diagnosis of prostate cancer]. Urologe A. 2009 Jun. 48(6):628-36. [Medline].

  15. Sonn GA, Margolis DJ, Marks LS. Target detection: Magnetic resonance imaging-ultrasound fusion-guided prostate biopsy. Urol Oncol. 2013 Nov 13. [Medline]. [Full Text].

  16. Sonn GA, Natarajan S, Margolis DJ, MacAiran M, Lieu P, Huang J, et al. Targeted biopsy in the detection of prostate cancer using an office based magnetic resonance ultrasound fusion device. J Urol. 2013 Jan. 189(1):86-91. [Medline]. [Full Text].

  17. Vourganti S, Rastinehad A, Yerram NK, Nix J, Volkin D, Hoang A, et al. Multiparametric magnetic resonance imaging and ultrasound fusion biopsy detect prostate cancer in patients with prior negative transrectal ultrasound biopsies. J Urol. 2012 Dec. 188(6):2152-7. [Medline]. [Full Text].

  18. Portalez D, Mozer P, Cornud F, Renard-Penna R, Misrai V, Thoulouzan M, et al. Validation of the European Society of Urogenital Radiology scoring system for prostate cancer diagnosis on multiparametric magnetic resonance imaging in a cohort of repeat biopsy patients. Eur Urol. 2012 Dec. 62(6):986-96. [Medline].

  19. Delongchamps NB, Peyromaure M, Schull A, Beuvon F, Bouazza N, Flam T, et al. Prebiopsy magnetic resonance imaging and prostate cancer detection: comparison of random and targeted biopsies. J Urol. 2013 Feb. 189(2):493-9. [Medline].

  20. Puech P, Rouvière O, Renard-Penna R, Villers A, Devos P, Colombel M, et al. Prostate cancer diagnosis: multiparametric MR-targeted biopsy with cognitive and transrectal US-MR fusion guidance versus systematic biopsy--prospective multicenter study. Radiology. 2013 Aug. 268(2):461-9. [Medline].

  21. Amin MB, de-Peralta Venturina M, Killeen TC. Pathological significance of the invaginated extraprostatic space involvement by prostatic carcinoma. A study of 80 cases of stage T3b prostatic carcinoma. Mod Pathol. 2005. 18 (supplement 1):126 A.

  22. Gill IS, Ukimura O. Thermal energy-free laparoscopic nerve-sparing radical prostatectomy: one-year potency outcomes. Urology. 2007 Aug. 70(2):309-14. [Medline].

  23. Taylor AK, Zembower TR, Nadler RB, Scheetz MH, Cashy JP, Bowen D, et al. Targeted Antimicrobial Prophylaxis Using Rectal Swab Cultures in Men Undergoing Transrectal Ultrasound Guided Prostate Biopsy is Associated With Reduced Incidence of Postoperative Infectious Complications and Cost of Care. J Urol. 2012 Feb 15. [Medline].

  24. Pareek G, Armenakas NA, Fracchia JA. Periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a randomized, double-blind, placebo controlled study. J Urol. 2001 Sep. 166(3):894-7. [Medline].

  25. Alavi AS, Soloway MS, Vaidya A, Lynne CM, Gheiler EL. Local anesthesia for ultrasound guided prostate biopsy: a prospective randomized trial comparing 2 methods. J Urol. 2001 Oct. 166(4):1343-5. [Medline].

  26. Mutaguchi K, Shinohara K, Matsubara A, et al. Local anesthesia during 10 core biopsy of the prostate: comparison of 2 methods. J Urol. 2005 Mar. 173(3):742-5. [Medline].

  27. Cantiello F, Cicione A, Autorino R, Cosentino C, Amato F, Damiano R. Pelvic Plexus Block is More Effective than Periprostatic Nerve Block for Pain Control During Office Transrectal Ultrasound Guided Prostate Biopsy: A Single Center, Prospective, Randomized, Double Arm Study. J Urol. 2012 Aug. 188(2):417-22. [Medline].

  28. Pinkhasov GI, Lin YK, Palmerola R, Smith P, Mahon F, Kaag MG, et al. Complications following prostate needle biopsy requiring hospital admission or emergency department visits - experience from 1000 consecutive cases. BJU Int. 2012 Feb 7. [Medline].

  29. Davis BJ, Horwitz EM, Lee WR, Crook JM, Stock RG, Merrick GS, et al. American Brachytherapy Society consensus guidelines for transrectal ultrasound-guided permanent prostate brachytherapy. Brachytherapy. 2012 Jan. 11(1):6-19. [Medline].

  30. Cohen JK, Miller RJ Jr, Rooker GM. Four year PSA and biopsy results after cryosurgical ablation of the prostate for localized adenocarcinoma of the prostate. J Urol. 1997. 157:419.

  31. Ghafar MA, Johnson CW, De La Taille A, et al. Salvage cryotherapy using an argon based system for locally recurrent prostate cancer after radiation therapy: the Columbia experience. J Urol. 2001 Oct. 166(4):1333-7; discussion 1337-8. [Medline].

 
Previous
Next
 
Transverse image of the prostate showing a hypertrophied transition zone (yellow arrows) and a compressed peripheral zone (blue arrows).
Large hypoechoic area along the left peripheral zone, suggestive of carcinoma.
Sagittal image of the prostate showing a hypoechoic area (white arrow). This area was a focus of cancer on biopsy findings.
A large hypoechoic area in the left peripheral zone suggestive of prostate cancer.
Axial and sagittal images of the prostate showing extensive hypoechoic areas. This patient had a prostate-specific antigen level of 17 ng/mL and digital rectal examination findings highly suggestive of cancer. Biopsy revealed granulomatous prostatitis.
Axial image of a prostate. White arrows show the asymmetrical anterior prostate. This could only be appreciated on TRUS images.
Sagittal image of a prostate. White arrows show darkly hypoechoic areas suggestive of periprostatic veins.
Axial images of the seminal vesicles. White arrows indicate the ampulla of the vas deferens.
Sagittal image of the prostate. White arrows indicate calcification in the prostatic urethra.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.