Journal of Ultrasound in MedicineVolume 40, Issue 5 p. E25-E29 Practice ParameterFree Access AIUM Practice Parameter for the Performance of Ultrasound Evaluations of the Prostate (and Surrounding Structures) First published: 04 March 2021 https://doi.org/10.1002/jum.15666AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Introduction The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. The AIUM Practice Parameter for the Performance of Ultrasound Evaluations of the Prostate (and Surrounding Structures) was developed (or revised) by the American Institute of Ultrasound in Medicine (AIUM) in collaboration with other organizations whose members use ultrasound for performing this examination(s) (see “Acknowledgments”). Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately. Ultrasound examination of the prostate and surrounding structures is used in the diagnosis of prostate cancer, benign prostatic enlargement, prostatitis, prostatic abscess, congenital anomalies, ejaculatory dysfunction, and male infertility, as well as for the treatment of prostatic cancer, abscess, and benign prostatic enlargement.1 Ultrasound-guided biopsy of the prostate is useful for evaluating those patients who have abnormal digital rectal examinations or an abnormal serum prostatic-specific antigen (PSA) level, azoospermia, a low ejaculatory volume, and those in whom tissue diagnosis is needed for further management. Ultrasound findings may be used to guide systematic biopsy of the prostate or guide a targeted biopsy approach, which is performed to supplement the standard systematic biopsy protocol in order to improve the positive cancer yield of prostate biopsy.2, 3 Conventional ultrasound techniques using grayscale Doppler, color Doppler, and power Doppler imaging are not sufficient to confirm or exclude the presence of prostate cancer and they should not be used to preclude the performance of prostate biopsy.4-6 Although newer techniques using elastography and contrast-enhanced ultrasound may provide superior detection of prostate cancer, these techniques are not sufficiently established to be included as standard of care at this time. This Practice Parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high-quality ultrasound examinations. The parameter reflects what the AIUM considers the appropriate criteria for this type of ultrasound examination but is not intended to establish a legal standard of care. Examinations performed in this specialty area are expected to follow the parameter with recognition that deviations may occur depending on the clinical situation. Indications Indications for prostate ultrasound include, but are not limited to, the following: Guidance for biopsy in the presence of an abnormal digital rectal examination or elevated PSA7 or a suspicious prostatic lesion detected on MR. This includes use of transrectal ultrasound (TRUS) biopsy as part of the TRUS/MRI fusion technique6 Assessment of prostate volume prior to medical, surgical, or radiation therapy8, 9 and to calculate PSA density10 Real-time guidance for the placement of brachytherapy seeds11 Assessment of lower urinary tract symptoms12 Assessment of congenital anomalies13 Infertility including azoospermia and a low ejaculatory volume Hematospermia Evaluation for suspected recurrence in the prostatectomy bed in patients who have undergone prostatectomy Ejaculatory dysfunction or painful ejaculation Qualifications and Responsibilities of Personnel Physicians interpreting or performing this type of ultrasound examination should meet the specified AIUM Training Guidelines in accordance with AIUM accreditation policies. Sonographers performing the ultrasound examination should be appropriately credentialed in the specialty area in accordance with AIUM accreditation policies. Physicians not personally performing the examination must provide supervision, as defined by the Centers for Medicare and Medicaid Services Code of Federal Regulations 42 CFR §410.32. Request for the Examination The written or electronic request for an ultrasound examination must originate from a physician or other appropriately licensed health care provider or under the provider's direction. The clinical information provided should allow for the performance and interpretation of the appropriate ultrasound examination and should be consistent with relevant legal and local health care facility requirements. Specifications of the Examination The following practice parameters describe the examination of the prostate and surrounding structures. Prostate The transrectal approach to ultrasound of the prostate is the method of choice because the resulting image quality is superior to transabdominal or transperineal examinations. In patients for whom the transrectal approach is not possible, a transperineal ultrasound examination may be used to direct a biopsy procedure.14 A transabdominal approach can be useful to obtain an estimate of prostate size in some settings. The prostate should be imaged in its entirety in at least two orthogonal planes, sagittal and axial or longitudinal and coronal, from the apex to the base of the gland. An estimated volume is determined from measurements in three orthogonal planes (volume = length × height × width × 0.52).15, 16 The volume of the prostate may be correlated with the PSA level. Alternatively, prostate volume can be calculated using prostate planimetry, which allows greater accuracy by accommodating individual variations in prostate shape.17 The gland should be evaluated for focal mass, echogenicity, symmetry, and continuity of margins. Color and power Doppler sonography may be helpful in detecting areas of increased vascularity that can be used to select potential sites for biopsy.18 A cine loop survey scan, taken in both longitudinal and transverse projections, can be obtained and stored with the rest of the study. The periprostatic fat and neurovascular bundle should be evaluated for symmetry and echogenicity. Demonstration of any interruption in the normal fat plane along the anterior perirectal space may be particularly important to aid characterization of malignant lesions in the prostate and for evaluation of periprostatic spread of cancer. The course of the prostatic urethra should be documented when possible, and asymmetry between left and right periurethral tissues as well as any effect on the base of the bladder should be noted. Seminal Vesicles, Vasa Deferentia, and Perirectal Space The seminal vesicles should be evaluated for size, shape, position, symmetry, and echogenicity from their insertion into the prostate via the ejaculatory ducts to their cranial and lateral extents. Particular attention should be given to the normal tapering of the seminal vesicle as it joins the prostate. In patients being evaluated for infertility, the vasa deferentia must be evaluated. The presence and size of seminal vesicle, ejaculatory, müllerian, or utricle cysts or evidence of seminal vesicle or ejaculatory duct obstruction should be noted. Documentation Accurate and complete documentation is essential for high-quality patient care. Written reports and ultrasound images/video clips that contain diagnostic information should be obtained and archived, with recommendations for follow-up studies if clinically applicable, in accordance with the AIUM Practice Parameter for Documentation of an Ultrasound Examination. Equipment Specifications Equipment Endorectal ultrasound of the prostate should be conducted with a transrectal (also termed endorectal) transducer using the highest clinically appropriate frequency (usually 6 MHz or higher), realizing that there is a trade-off between resolution and beam penetration. Both side-fire and end-fire transducers may be used. A lower-frequency transducer may be necessary for transabdominal and transperineal examinations, which may be performed with curvilinear or sector transducers. Ultrasound-guided prostate biopsy can be performed with side-fire probe, end-fire probe, or biplanar or triplanar transducer configuration, acknowledging that transducer selection may vary with specific anatomic considerations.19 Care of the Equipment The transrectal probe, after ultrasound gel application, must be covered by a disposable sheath prior to its insertion. Additional gel should be applied after covering the probe with a disposable sheath to aid in comfort with probe insertion and optimizing transducer to target interface. Following the examination and disposal of the sheath, the probe must be disinfected. The method of disinfection may vary by manufacturer recommendations and institutional practices. It is optimal to use a high-level disinfection protocol. Disposable accessory items used during the study must be discarded after each examination. Reusable accessory items should be processed or sterilized according to appropriate guidelines and procedures. Quality and Safety Policies and procedures related to quality assurance and improvement, safety, infection control, and equipment performance monitoring should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices. ALARA (As Low as Reasonably Achievable) Principle The potential benefits and risks of each examination should be considered. The ALARA principle should be observed for factors that affect the acoustic output and by considering the transducer dwell time and total scanning time. Further details on ALARA may be found in the current AIUM publication Medical Ultrasound Safety. Infection Control Transducer preparation, cleaning, and disinfection should follow manufacturer recommendations and be consistent with the AIUM's Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients, Safe Handling, and Use of Ultrasound Coupling Gel. Equipment Performance Monitoring Monitoring protocols for equipment performance should be developed and implemented in accordance with the AIUM's Standards and Guidelines for the Accreditation of Ultrasound Practice. Acknowledgments This parameter was revised by the AIUM in collaboration with the American College of Radiology (ACR) and the Society of Radiologists in Ultrasound (SRU). We are indebted to the many volunteers who contributed their time, knowledge, and energy to developing this document. Collaborative Subcommittees AIUM Pat Fulgham, MD Bruce Gilbert, MD, PhD Harvey Nisenbaum, MD ACR Vikram Dogra, MD, chair Christopher Fung, MD Subramaniyan Ramanathan, MD Marjorie W. Stein, MD Sadhna Verma, MD SRU Carol B. Benson, MD Ulrike M. Hamper, MD, MBA AIUM Clinical Standards Committee Bryann Bromley, MD, chair James M. Shwayder, MD, JD, vice chair Nirvikar Dahiya, MD Rob Goodman, MBBCh, MBA, BMSc Rachel Bo-ming Liu, MD Jean Spitz, MPH, CAE, RDMS John Stephen Pellerito, MD Original copyright 1991; revised 2020, 2015, 2010, 2006 Renamed 2015 References 1Wasserman NF. Benign prostatic hyperplasia: a review and ultrasound classification. Radiol Clin North Am 2006; 44: 689– 710. viii. CrossrefPubMedWeb of Science®Google Scholar 2Onur MR, Turgut AT, Dogra V. Ultrasound-guided biopsy of the prostate: new updates. Ultrasound Clin 2014; 9: 81– 94. CrossrefGoogle Scholar 3Turgut AT, Kismali E, Dogra V. Prostate biopsies and controversies. Ultrasound Clin 2013; 8: 605– 615. CrossrefGoogle Scholar 4Hricak H, Choyke PL, Eberhardt SC, Leibel SA, Scardino PT. Imaging prostate cancer: a multidisciplinary perspective. Radiology 2007; 243: 28– 53. CrossrefPubMedWeb of Science®Google Scholar 5Kundra V, Silverman PM, Matin SF, Choi H. Imaging in oncology from the University of Texas M. D. Anderson cancer center: diagnosis, staging, and surveillance of prostate cancer. AJR Am J Roentgenol 2007; 189: 830– 844. CrossrefPubMedWeb of Science®Google Scholar 6Xu S, Kruecker J, Turkbey B, et al. Real-time MRI-TRUS fusion for guidance of targeted prostate biopsies. Comput Aided Surg 2008; 13: 255– 264. CrossrefPubMedWeb of Science®Google Scholar 7Ozden E, Turgut AT, Yaman O, Gulpinar O, Baltaci S. Follow-up of the transrectal ultrasonographic features of the prostate after biopsy: does any ultrasonographically detectable lesion form secondary to the first biopsy? J Ultrasound Med 2005; 24: 1659– 1663. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 8Dubinsky TJ, Cuevas C, Dighe MK, Kolokythas O, Hwang JH. High-intensity focused ultrasound: current potential and oncologic applications. AJR Am J Roentgenol 2008; 190: 191– 199. CrossrefPubMedWeb of Science®Google Scholar 9Kirkham AP, Emberton M, Hoh IM, Illing RO, Freeman AA, Allen C. MR imaging of prostate after treatment with high-intensity focused ultrasound. Radiology 2008; 246: 833– 844. CrossrefPubMedWeb of Science®Google Scholar 10Boczko J, Messing E, Dogra V. Transrectal sonography in prostate evaluation. Radiol Clin North Am 2006; 44: 679– 687. viii. CrossrefPubMedWeb of Science®Google Scholar 11Stock RG, Stone NN. Current topics in the treatment of prostate cancer with low-dose-rate brachytherapy. Urol Clin North Am 2010; 37: 83– 96. Table of Contents. CrossrefPubMedWeb of Science®Google Scholar 12La Vignera S, Calogero AE, Arancio A, Castiglione R, De Grande G, Vicari E. Transrectal ultrasonography in infertile patients with persistently elevated bacteriospermia. Asian J Androl 2008; 10: 731– 740. Wiley Online LibraryPubMedWeb of Science®Google Scholar 13Galosi AB, Montironi R, Fabiani A, Lacetera V, Galle G, Muzzonigro G. Cystic lesions of the prostate gland: an ultrasound classification with pathological correlation. J Urol 2009; 181: 647– 657. CrossrefPubMedWeb of Science®Google Scholar 14Shonohara KGM, Koppie T, Terris MK. Transperineal prostate biopsy after abdominoperineal resection. J Urol 2003; 169: 141– 144. CrossrefPubMedWeb of Science®Google Scholar 15Halpern EJ. Measurement of the prostate gland. In: J McGahan, BB Goldberg (eds). Atlas of Ultrasound Measurements. 2nd ed. Chicago, Ill: Mosby Year Book; 2005. Google Scholar 16Kim SH. Correlations between the various methods of estimating prostate volume: transabdominal, transrectal, and three-dimensional US. Korean J Radiol 2008; 9: 134– 139. CrossrefPubMedWeb of Science®Google Scholar 17McAchran SE, Dogra V, Resnick MI. Office urologic ultrasound. Urol Clin North Am 2005; 32: 337– 352. vii. CrossrefPubMedWeb of Science®Google Scholar 18Zalesky M, Urban M, Smerhovsky Z, Zachoval R, Lukes M, Heracek J. Value of power Doppler sonography with 3D reconstruction in preoperative diagnostics of extraprostatic tumor extension in clinically localized prostate cancer. Int J Urol 2008; 15: 68– 75. discussion 75. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 19Ching CB, Moussa AS, Li J, Lane BR, Zippe C, Jones JS. Does transrectal ultrasound probe configuration really matter? End fire versus side fire probe prostate cancer detection rates. J Urol 2009; 181: 2077– 2082. discussion 82–83. CrossrefPubMedWeb of Science®Google Scholar Volume40, Issue5May 2021Pages E25-E29 ReferencesRelatedInformation