Transrectal Prostate Biopsy Procedure Note

Procedure: Transrectal ultrasound-guided prostate biopsy

Date/Time: [Date and time of procedure]

Location: [Procedure location/site]

Operator(s): [Primary operator and assistants if applicable]

Anesthesia: [local periprostatic block / local with sedation / spinal / general] (Specify agent, concentration, and total volume if local used)

Patient Position: [left lateral decubitus / lithotomy / supine]

Indication & Pre-Procedure Context

[Primary indication for biopsy: elevated PSA / rising PSA / abnormal DRE / MRI lesion / active surveillance / prior biopsy follow-up / other]. PSA: [value] ng/mL ([date]). (If PSA unavailable, state "PSA not available in chart at time of procedure.") DRE: [findings / not performed / not documented].

(Include if MRI-targeted biopsy performed) MRI: [date], PI-RADS [score(s)], lesion location(s): [side/zone/level]. (If MRI details unavailable, state "MRI details not documented.") Prior prostate biopsy history: [prior date(s) and result(s) / none / not documented]. Patient counseled on rationale, risks, benefits, and potential outcomes of biopsy and agreed to proceed.

Pre-Procedure Checklist

• Informed Consent: Obtained. Risks discussed: infection/sepsis, bleeding (hematuria, rectal bleeding, hematospermia), urinary retention, sampling limitations. Alternatives reviewed. [Patient-specific modifiers if applicable]
• Time-Out: Performed with verification of patient identity, procedure, allergies, antibiotic plan, and anticoagulation status.
• Antibiotic Prophylaxis: [REQUIRED - agent/dose/route/timing] (If culture-directed or augmented regimen, specify. If not given, document explicit reason.)
• Rectal Preparation: Enema: [yes / no]. Rectal antiseptic: [agent / none] (Document if not performed.)
• Anticoagulation/Antiplatelet Status: Agents: [none / agent name(s) and dose(s)]. Management: [held / continued]. Last dose if held: [date/time]. Planned restart: [timing / per managing clinician]. (Do not infer—document exactly what was done.)

Procedure Details

DRE: [findings / not performed]. A lubricated TRUS probe was placed per rectum without difficulty. Prostate appearance on TRUS: [homogeneous / heterogeneous], hypoechoic lesions: [present with location / none], calcifications: [present / none], median lobe: [prominent / not prominent]. Prostate measurements: [length] × [width] × [height] cm; calculated volume: [value] mL. (If not measured, state "Prostate measurements not obtained.")

Local anesthesia: [Technique] with [agent] [concentration]% [volume] mL. Biopsy performed using [gauge] core biopsy needle under ultrasound guidance. Systematic sampling followed a [12-core / extended / other] template. (If MRI-targeted cores obtained) Targeting approach: [cognitive fusion / software fusion with system name / in-bore]. Deviations from standard technique: [none / describe deviation and reason].

Core Map

Total Cores: [REQUIRED]

Systematic Cores: [number]

Targeted Cores: [number] (0 if none)

MRI Targets Sampled: [number] (0 if none)

Systematic Template

• Right base lateral: [# cores]
• Right base medial: [# cores]
• Right mid lateral: [# cores]
• Right mid medial: [# cores]
• Right apex lateral: [# cores]
• Right apex medial: [# cores]
• Left base lateral: [# cores]
• Left base medial: [# cores]
• Left mid lateral: [# cores]
• Left mid medial: [# cores]
• Left apex lateral: [# cores]
• Left apex medial: [# cores]

(Adjust sites and counts to reflect actual sampling template used.)

Targeted Lesions

(Include only if targeted biopsy performed.)

• Target 1: [side/level/zone], PI-RADS [score / not documented], targeting: [cognitive / software fusion / in-bore], [# cores]
• Target 2: [side/level/zone], PI-RADS [score / not documented], targeting: [method], [# cores]
• (Add additional targets as needed)

Specimen Handling

Specimens submitted to pathology as labeled below. (Document total container count and grouping method—one core per container or grouped.)

• Specimen A: [Site name] ([# cores])
• Specimen B: [Site name] ([# cores])
• (Continue for all systematic sites)
• (If targeted) Specimen T1: Target 1 ([# cores]); Specimen T2: Target 2 ([# cores]) (Ensure targeted specimens are distinguishable from systematic cores.)

Complications & Tolerance

[Patient tolerated procedure well. No immediate complications. EBL minimal.] (If complications occurred, document: event, severity, intervention, outcome, and disposition. Include estimated blood loss.)

Post-Procedure Instructions

• Disposition: [Observed for duration / voided prior to discharge / discharged home / transferred / admitted]
• Medications: Post-procedure antibiotic: [agent, dose, duration]. Pain management: [recommendations]. Anticoagulant restart: [specific timing / per managing clinician].
• Expected Symptoms: Mild hematuria, mild rectal bleeding, and hematospermia are common and typically self-limited.
• Return Precautions: Seek care for fever/chills, inability to urinate, heavy or persistent bleeding, or severe pain. Contact: [clinic number/on-call instructions].

Follow-Up

Pathology results will be communicated via [phone call / patient portal / follow-up visit] in approximately [timeframe]. (If targeted cores obtained, note that results will be correlated with MRI findings.) Results review appointment: [date/time or scheduling plan].

Attestation

I was present for and performed the procedure as documented above.
Electronic signature: [Name, credentials, date/time]

(Do not infer PSA values, MRI findings, or anticoagulation decisions—if not stated, document as "not documented" or "not available." If antibiotic prophylaxis details are missing, retain "[REQUIRED - agent/dose/route/timing]" placeholder. If total core count is missing, retain "[REQUIRED]" placeholder. If MRI-targeted biopsy is mentioned but target details are absent, prompt for lesion location, targeting method, PI-RADS, and cores per target. Omit targeted lesions subsection if targeted biopsy not performed, but always retain summary counts with zeros where appropriate.)