Attitude is everything: keep probe pitch neutral during side-fire prostate biopsy. A simulator study

Objectives To develop and validate on a simulator a learnable technique to decrease deviation of biopsied cores from the template schema during freehand, side-fire systematic prostate biopsy (sPBx) with the goal of reducing prostate biopsy (PBx) false-negatives, thereby facilitating earlier sampling, diagnosis and treatment of clinically significant prostate cancer. Participants and Methods Using a PBx simulator with real-time three-dimensional visualization, we devised a freehand, pitch-neutral (0 degrees, horizontal plane), side-fire, transrectal ultrasonography (TRUS)-guided sPBx technique in the left lateral decubitus position. Thirty-four trainees on four Canadian and US urology programmes learned the technique on the same simulator, which recorded deviation from the intended template location in a double-sextant template as well as the TRUS probe pitch at the time of sampling. We defined deviation as the shortest distance in millimeters between a core centre and its intended template location, template deviation as the mean of all deviations in a template, and mastery as achieving a template deviation <= 5.0 mm. Results All results are reported as mean +/- sd. The mean absolute pitch and template deviation before learning the technique (baseline) were 8.2 +/- 4.1 degrees and 8.0 +/- 2.7 mm, respectively, and after mastering the technique decreased to 4.5 +/- 2.7 degrees (P = 0.001) and 4.5 +/- 0.6 mm (P < 0.001). Template deviation was related to mean absolute pitch (P < 0.001) and increased by 0.5 mm on average with each 1 degrees increase in mean absolute pitch. Participants achieved mastery after practising 3.9 +/- 2.9 double-sextant sets. There was no difference in time to perform a double-sextant set at baseline (277 +/- 102 s) and mastery (283 +/- 101 s; P = 0.39). Conclusion A pitch-neutral side-fire technique reduced template deviation during simulated freehand TRUS-guided sPBx, suggesting it may also reduce PBx false-negatives in patients in a future clinical trial. This pitch-neutral technique can be taught and learned; the University of Florida has been teaching it to all Urology residents for the last 2 years.