REDUCING RECTAL INJURY FROM SONO GRAPHICALLY- GUIDED TRANSRECTAL NEEDLE BIOPSY OF PROSTATE The "Rule of Finger"
WILLIAM H . COONER, M .D . From the Mobile Urology Group, and Section of Urology, University of South Alabama College of Medicine, Mobile, Alabama
srectal needle biopsy of the prostate perd under sonographic guidance has beowe a useful tool for the urologist .1,2 When armed under digital guidance, transrectal ohsy results in occasional instances of rectal deeding due to penetration of blood vessels lylt~ 'near the anus .3 Usually this is recognized on withdrawal of the finger from the rectum, and digital compression for a few minutes most ofn ' controls the bleeding quite satisfactorily. However, there have been a few anecdotal reorts of rectal bleeding from sonographically irected biopsy which was of sufficient magnitude to require anoscopic ligation . Whether or riot this is more common following sonographically guided biopsy compared with digitally guided biopsy is unknown, but needle puncture under sonographic guidance does introduce one possible factor which does not exist when the biopsy is done under digital control . During sonography, the examiner must, in gall parlance, "keep his eye on the ball," which,
e
in this instance, is the television monitor . Only by so doing will he learn the hand/eye coordination necessary to perform the examination with maximum skill . He cannot, obviously, watch the probe without missing the information being displayed on the screen . While concentrating on the monitor, he may lose awareness of the position of the tip of a biopsy needle which has been inserted into the needle guide of the probe, and may inadvertently allow it to extrude beyond the distal port of the guide . The needle tip is not seen on the monitor until it has passed beyond the guide tip for a variable distance . Thus, if the operator assumes that the needle tip is in a safe position because it is not visible on the screen, he may well subject the rectum or its blood vessels to tearing if he moves the probe in an effort to place the suspicious lesion on the biopsy guide line of the instrument . This phenomenon is generic and is not related to any particular machine brand or probe configuration . When performing biopsy in the
Itc-RE I . (A) Sector seamier, longitudinal ''i"u'- showing 8-mm "NiO"needle extrusion . (B) Linear array scanshowing 18-mm bli rl"needle extrusion .
LLU,OGY / AUGUST 1990 / VOLUME XXXVI, NUMBER 2
191
FIGURE 2 . (A) Biplane probe, longitudina orientation, showing 18mm "blind" needle extrusion . (B) Biplane probe, transaxial orientation, 28-mm "blind" showing needle extrusion .
FIGURE 3 . The "rule of finger" showing electrical cord of probe held between fourth and fifth fingers of same hand that holds biopsy instrument . longitudinal plane of the ultrasound scanner, varying degrees of invisible needle extrusion are encountered with transducer arrangements of differing types (Fig . 1) . The problem is much more severe if biopsy is performed in the transaxial plane, since the needle is not visible on the monitor until it penetrates the plane of scan (Fig . 2) . Avoidance of the problem of invisible needle extrusion is easily managed as long as one recognizes that it does occur . Some machine manufacturers incorporate a cradle into which a Biopty* instrument can be placed, with a guide to indicate the point at which the needle exits the needle channel . Even in those instruments that do not employ such a cradle, or when the
*C . R . Bard, Inc ., 8195 Industrial Boulevard, Covington, Georgia 30109 .
192
operator prefers the freedom of manipilatjc(1 possible without a cradle, the problem is stilj easily handled by using a "rule of finger ." Oii ~, simply grasps the stiff electrical cord ()f _the transducer handle between the fourth and Wfh fingers, while using the second and third finti rs of the same hand to hold the biopsy instr omen and the thumb to release the trigger meehamSni (Fig . 3) . By holding the cord and the bic ~>sy, p strument with one hand, inadvertent distal mi gration of the needle is prevented by the stiff& ness of the electrical cord . Once the lesion }i~f been placed visually in the optimum biopsy p0 sition, the cord is dropped from betwe,~n :.tl fingers, and the biopsy instrument is ad,, ante into position for the tissue sampling to to place . After the instrument has been fir,, d ; t needle is removed from the patient as rapidly' P; possible . Utilization of the "rule of finger" has been= assistance to us in the performance of biopsies without laceration of the rectum 0 associated vessels . Mobile Urolog} t 1720 Center Street, Suite; Mobile, Alabama 3660-1 References 1 . Hodge KK, McNeal JE, Terris MK, and Stamey ' dom systematic versus directed ultrasound-guided transr, biopsies of the prostate, J Urol 142 : 71 (1989) . 2 . Torp-Pedersen S, et al : Transrectal biopsy o£ th guided with transrectal US : longitudinal and multiply I '4 ning, Radiology 170 : 23 (1989) . 3 . Dowlen LW, Block NL, and Politano VA : Complil ", transrectal biopsy examination of the prostate, South NJ 1453 (1974) .
UROLOGY / AUGUST 1990 / VOLUME XXXVI, NI Vi/
WILLIAM H . COONER, M .D . From the Mobile Urology Group, and Section of Urology, University of South Alabama College of Medicine, Mobile, Alabama
srectal needle biopsy of the prostate perd under sonographic guidance has beowe a useful tool for the urologist .1,2 When armed under digital guidance, transrectal ohsy results in occasional instances of rectal deeding due to penetration of blood vessels lylt~ 'near the anus .3 Usually this is recognized on withdrawal of the finger from the rectum, and digital compression for a few minutes most ofn ' controls the bleeding quite satisfactorily. However, there have been a few anecdotal reorts of rectal bleeding from sonographically irected biopsy which was of sufficient magnitude to require anoscopic ligation . Whether or riot this is more common following sonographically guided biopsy compared with digitally guided biopsy is unknown, but needle puncture under sonographic guidance does introduce one possible factor which does not exist when the biopsy is done under digital control . During sonography, the examiner must, in gall parlance, "keep his eye on the ball," which,
e
in this instance, is the television monitor . Only by so doing will he learn the hand/eye coordination necessary to perform the examination with maximum skill . He cannot, obviously, watch the probe without missing the information being displayed on the screen . While concentrating on the monitor, he may lose awareness of the position of the tip of a biopsy needle which has been inserted into the needle guide of the probe, and may inadvertently allow it to extrude beyond the distal port of the guide . The needle tip is not seen on the monitor until it has passed beyond the guide tip for a variable distance . Thus, if the operator assumes that the needle tip is in a safe position because it is not visible on the screen, he may well subject the rectum or its blood vessels to tearing if he moves the probe in an effort to place the suspicious lesion on the biopsy guide line of the instrument . This phenomenon is generic and is not related to any particular machine brand or probe configuration . When performing biopsy in the
Itc-RE I . (A) Sector seamier, longitudinal ''i"u'- showing 8-mm "NiO"needle extrusion . (B) Linear array scanshowing 18-mm bli rl"needle extrusion .
LLU,OGY / AUGUST 1990 / VOLUME XXXVI, NUMBER 2
191
FIGURE 2 . (A) Biplane probe, longitudina orientation, showing 18mm "blind" needle extrusion . (B) Biplane probe, transaxial orientation, 28-mm "blind" showing needle extrusion .
FIGURE 3 . The "rule of finger" showing electrical cord of probe held between fourth and fifth fingers of same hand that holds biopsy instrument . longitudinal plane of the ultrasound scanner, varying degrees of invisible needle extrusion are encountered with transducer arrangements of differing types (Fig . 1) . The problem is much more severe if biopsy is performed in the transaxial plane, since the needle is not visible on the monitor until it penetrates the plane of scan (Fig . 2) . Avoidance of the problem of invisible needle extrusion is easily managed as long as one recognizes that it does occur . Some machine manufacturers incorporate a cradle into which a Biopty* instrument can be placed, with a guide to indicate the point at which the needle exits the needle channel . Even in those instruments that do not employ such a cradle, or when the
*C . R . Bard, Inc ., 8195 Industrial Boulevard, Covington, Georgia 30109 .
192
operator prefers the freedom of manipilatjc(1 possible without a cradle, the problem is stilj easily handled by using a "rule of finger ." Oii ~, simply grasps the stiff electrical cord ()f _the transducer handle between the fourth and Wfh fingers, while using the second and third finti rs of the same hand to hold the biopsy instr omen and the thumb to release the trigger meehamSni (Fig . 3) . By holding the cord and the bic ~>sy, p strument with one hand, inadvertent distal mi gration of the needle is prevented by the stiff& ness of the electrical cord . Once the lesion }i~f been placed visually in the optimum biopsy p0 sition, the cord is dropped from betwe,~n :.tl fingers, and the biopsy instrument is ad,, ante into position for the tissue sampling to to place . After the instrument has been fir,, d ; t needle is removed from the patient as rapidly' P; possible . Utilization of the "rule of finger" has been= assistance to us in the performance of biopsies without laceration of the rectum 0 associated vessels . Mobile Urolog} t 1720 Center Street, Suite; Mobile, Alabama 3660-1 References 1 . Hodge KK, McNeal JE, Terris MK, and Stamey ' dom systematic versus directed ultrasound-guided transr, biopsies of the prostate, J Urol 142 : 71 (1989) . 2 . Torp-Pedersen S, et al : Transrectal biopsy o£ th guided with transrectal US : longitudinal and multiply I '4 ning, Radiology 170 : 23 (1989) . 3 . Dowlen LW, Block NL, and Politano VA : Complil ", transrectal biopsy examination of the prostate, South NJ 1453 (1974) .
UROLOGY / AUGUST 1990 / VOLUME XXXVI, NI Vi/
