Transperineal MRI fusion biopsy

DATE OF SURGERY: 11/01/2024 PATIENT: John A. Smith DOB: 03/15/1965 MEDICAL RECORD NUMBER: 123456789 SURGEON: David Canes, M.D. PREOPERATIVE DIAGNOSIS: Elevated PSA POSTOPERATIVE DIAGNOSIS: Same PROCEDURE: Transperineal prostate biopsy with MRI fusion ANESTHESIA: General. INTRAVENOUS FLUIDS: 500 mL of crystalloid. ESTIMATED BLOOD LOSS: 0 mL. DRAINS: None SPECIMENS: 20 cores to pathology COMPLICATIONS: None. INDICATIONS: John Smith, a 59-year-old male, with elevated PSA levels and a family history of prostate cancer. After a discussion of risks, benefits, pros, cons, side effects, and alternatives, he wished to undergo prostate biopsy under sedation. I informed him aside from anesthesia complications (if an anesthetic is used), regarding trans rectal ultrasound biopsy of the prostate I discussed possible negative outcomes which may include, but are not limited to: excessive bleeding from the anus specially in patients with hemorrhoids, blood clots in the urine, blood in the ejaculate, urinary retention, and urinary tract infection or urosepsis rarely requiring hospitalization. I also went over the detailed prostate biopsy handout in the clinic with the patient and gave him a copy to take home. We have previously discussed controversies related to prostate cancer screening. I discussed the above issues with him as well as other issues related to prostate biopsy. OPERATIVE PROCEDURE IN DETAIL: After proper informed consent was obtained, the patient was brought to the endoscopy suite. Antibiotics were not necessary. He was positioned in yellowfin stirrups in lithotomy and universal protocol time-out was called using a standardized checklist. The scrotum was elevated anteriorly and taped out of the perineum. The perineum was then prepped with ChloraPrep. A perineal skin puncture site was identified at the site halfway between the lateral aspect of the prostate gland in the medial aspect of the prostate gland on both the right and left side. A local skin block with 1% lidocaine was then used to anesthetize either side. Using a precision point access needle system the puncture site on the right was stabilized with a 15 gauge needle and a long spinal needle was used to puncture the subcutaneous tissue provide local anesthesia with 1% lidocaine. The block consisted of anesthetizing the subcutaneous tissue and apically blocked just proximal to the GU diaphragm and levator muscle bilaterally. The prostate was co-registered with the software fusion platform by performing a sweep and lining up the images. The prostate gland was not resized because of accurate measurements on MRI. Using biplanar guidance the prostate was then sampled with the following (2 cores RPM and RPL, 2 Cores LPM, LPL, and 2 cores RAM, RAL, LAM, LAL, RB, LB, 20 total). These were then sent off the field for pathologic analysis. The rectal probe was then removed. The puncture sites of the skin were dressed with fluff dressing. The patient was sent to recovery. I was present throughout the entire procedure. The patient was awakened from anesthesia and transferred to the recovery room in stable and satisfactory condition. David Canes, MD 11/01/2024