Transrectal Prostate Ultrasound and Prostate Biopsy Report

Transrectal Prostate Ultrasound and Prostate Biopsy Report

Name________________________________ MR# _____________

DIAGNOSIS:

¡õ Elevated PSA

¡õ Abnormal Exam

PROCEDURES:

¡õ Echography of Prostate

¡õ US Guidance for needle biopsy

¡õ Transrectal needle biopsy of prostate

Date_________

Current PSA__________

SURGEON: ___________________________ Signature: __________________________

TRANSRECTAL ULTRASOUND:

¡õ

¡õ

¡õ

¡õ

¡õ

¡õ

¡õ

¡õ

¡õ

¡õ

PSA density: ________ ng/cc

Prostate measurements: Height_____ mm; Width ______ mm; Length ______ mm

Prostate volume: ________ cc

No hypoechogenic areas suggestive of cancer are seen.

Hypoechogenic areas exist which could represent areas of malignancy.

These are seen in the following locations: ___________________________________

Hyperdense echos are seen suggestive of calculi in the capsule.

Seminal vesicles: ¡õ normal

¡õ other ______________________________________

Prostate median lobe: ¡õ absent ¡õ present, size: ________________________________

Bladder exam: ¡õ normal ¡õ abnormal _________________________________________

Documentation images were taken.

OPERATIVE DESCRIPTION: Informed consent was obtained and signed. The patient was

placed in the left lateral decubitus position. The 7.0 mHz biplanar transrectal ultrasound probe

was placed in the rectum. Imaging in transverse and longitudinal views was done with the

findings as indicated. (Example only ¨C each urologist should formulate his/her own

operative description.)

ULTRASONIC GUIDED PROSTATE BIOPSY:

¡õ

¡õ

¡õ

¡õ

¡õ

Prostate anesthetic block was performed using 1% Xylocaine.

Biopsies of abnormal appearing areas were performed.

Biopsies were taken from the base, mid-gland and apex bilaterally as indicated.

Total number of biopsies taken: __________.

Documentation images were taken.

OPERATIVE DESCRIPTION: Multiple biopsies of the prostate via needle were obtained

using ultrasonic guidance into the rectum. Post operative instructions were given to the patient

in detail per post op instruction sheet. Patient will be contacted with the biopsy result when

available. (Example only ¨C each urologist should formulate his/her own operative

description.)

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