Rate and characteristics of infection after transrectal prostate biopsy: a retrospective observational study

Does Formalin Disinfection Reduce Bacterial Colonization of Biopsy Needle? A Prospective Study

OBJECTIVE

To investigate the efficacy of formalin disinfection of the needle tip in transrectal prostate biopsy (TRB) procedure to reduce infectious complications. The primary aim is to assess the impact of formalin on bacterial contamination of biopsy needle tips and its association with post-biopsy infective events.

MATERIALS AND METHODS

We have employed a bacterial culture-based observational cohort design in this study. Two groups, formalin disinfection and non-formalin group, both underwent systematic 12-core TRB. In the formalin group, the biopsy needle tip was immersed in 10% formalin solution after each core, while in the non-formalin group, no formalin solution immersion was used. The primary outcomes include bacterial growth on biopsy needle tips and post-biopsy infective events.

RESULTS

Formalin disinfection significantly reduced bacterial growth on needle tips (P <.001). The formalin group had no post-biopsy infections or sepsis, while the non-formalin group experienced a 7.5% infective event rate after TRB.

CONCLUSION

Formalin disinfection of biopsy needle tip significantly reduces bacterial growth on biopsy needle and urinary tract infectious complications developed secondary to TRB. Further multicenter randomized controlled studies with larger cohorts are warranted to validate and establish formalin disinfection as a routine practice in TRB procedures.

Minimally invasive biopsy-based diagnostics in support of precision cancer medicine

Precision cancer medicine (PCM) to support the treatment of solid tumors requires minimally invasive diagnostics. Here, we describe the development of fine-needle aspiration biopsy-based (FNA) molecular cytology which will be increasingly important in diagnostics and adaptive treatment. We provide support for FNA-based molecular cytology having a significant potential to replace core needle biopsy (CNB) as a patient-friendly potent technique for tumor sampling for various tumor types. This is not only because CNB is a more traumatic procedure and may be associated with more complications compared to FNA-based sampling, but also due to the recently developed molecular methods used with FNA. Recent studies show that image-guided FNA in combination with ultrasensitive molecular methods also offers opportunities for characterization of the tumor microenvironment which can aid therapeutic decisions. Here we provide arguments for an increased implementation of molecular FNA-based sampling as a patient-friendly diagnostic method, which may, due to its repeatability, facilitate regular sampling that is needed during different treatment lines, to provide tumor information, supporting treatment decisions, shortening lead times in healthcare, and benefit healthcare economics.

Transitioning from transrectal to transperineal prostate biopsy using a freehand cognitive approach

OBJECTIVES

To report a single-centre experience of a complete transition from transrectal (TR) to transperineal (TP) prostate biopsy under local anaesthesia using a freehand cognitive coaxial approach and without use of antibiotic prophylaxis.

PATIENTS AND METHODS

Analysis was performed of a prospective database of patients undergoing prostate biopsy performed by four surgeons between 1 June 2018 and 31 May 2022. Outcomes of interest were complications, cancer detection rate, inter-operator reliability, and tolerability.

RESULTS

Overall, 1915 patients underwent 2337 separate prostate biopsy sessions. Only 2.4% patients in the TP group received antibiotic prophylaxis, while 100% received antibiotics in the TR group. The complication rate was significantly lower in the TP group compared to the TR group (0.3% vs 5.0%, P < 0.001). In contrast to the TR group, there were no cases of urosepsis or admissions to intensive care in the TP group. The total cancer detection rate by TP biopsy was 70% and the overall pathology detection rate was 88.4%. There was no difference in cancer or pathology detection between operators. A stable level of cancer detection was reached early on for both Prostate Imaging-Reporting and Data System 4 and 5 lesions. All cases performed were performed successfully without need for early termination.

CONCLUSION

Implementing a complete transition from TR to TP biopsy can result in a significant reduction in complications and hospital re-admissions. A cognitive freehand coaxial technique is well tolerated by patients and achieves a high cancer detection rate.

Risk factors for infection and acute urinary retention following transperineal prostate biopsy

PURPOSE

To calculate the frequency of infection and acute urinary retention (AUR) following transperineal (TP) prostate biopsy at a single high-volume academic institution and determine risk factors for developing these post-biopsy conditions.

METHODS

Men undergoing TP prostate biopsy from 2012 to 2022 at our institution were retrospectively identified and chart reviewed. TP biopsies were performed with TR ultrasound (TRUS) guidance with anesthesia using a brachytherapy grid template. TRUS volumes were recorded during the procedure, and magnetic resonance imaging (MRI) volumes were calculated using the ellipsoid formula. When available, MRI volume was used for all analysis, and when absent, TRUS volume was used. AUR was defined as requiring urinary catheter placement within 72 h post-biopsy for inability to urinate. Univariable analysis was performed and variables with p < 0.1 and/or established clinical relevance were included in a backward binary logistic regression to produce an optimized model that fit the data without collinearity between variables.

RESULTS

A total of 767 TP biopsies were completed in the study window. The frequency of infection was 1.83% (N = 14/767). The total frequency of AUR was 5.48% (N = 42/767). On multivariable regression, patients who went into AUR were five times as likely to develop infection (p = 0.020). Patients with infection post-TP biopsy were four times as likely to develop AUR (p = 0.047) and with prostates > 61.21 cc were three times as likely (p = 0.019).

CONCLUSION

According to our model, AUR is the greatest risk factor for infection post-TP biopsy. With regard to AUR risks, infection post-biopsy and prostate size > 61.21 cc are the greatest risk factors.

Office-based Magnetic Resonance Imaging-guided Transperineal Prostate Biopsy Without Antibiotic Prophylaxis: A Real-world Clinical Utility Study

Background and objective

Advances in for magnetic resonance imaging (MRI)-guided transperineal biopsy (TPBx) techniques have facilitated outpatient prostate biopsies under local anaesthesia to lower postbiopsy infection rates. However, there is debate regarding antibiotic prophylaxis because of concerns regarding antibiotic resistance and interactions. Our objective was to assess the transition from office-based transrectal biopsy to TPBx performed under local anaesthesia without antibiotic prophylaxis despite potential risk factors for infectious complications.

Methods

We conducted a prospective assessment of 665 men undergoing office-based MRI-guided TPBx. The primary outcome was the rate of urosepsis or febrile urinary tract infections requiring hospitalisation and/or antibiotics within 2 wk after biopsy. Secondary outcomes included patient-reported procedure tolerability and the prostate cancer detection rate.

Key findings and limitations

TPBx using a median of nine cores per patient (range 4-15) detected prostate cancer in 534/665 men (80%). Only four men (0.6%) were hospitalised for suspected postbiopsy infection; no patient experienced urosepsis. The TPBx procedure was well tolerated, with low pain scores (median Visual Analogue Scale score of 2, interquartile range [IQR] 1-3) and positive patient ratings (median rating 1 [no problem], IQR 1-2). Limitations include the single-centre analysis and lack of randomisation for antibiotic prophylaxis.

Conclusions and clinical implications

An office-based TPBx strategy under local anaesthesia without antibiotic prophylaxis is well tolerated and has a very low risk of side effects. This approach should be considered as the standard of care. Further studies may determine if a subgroup of predisposed men could benefit from antibiotic prophylaxis.

Patient summary

For prostate biopsy the sampling needle can be inserted through the rectum or through the perineum, which is the skin between the rectum and the scrotum. Our study confirms that in everyday clinical practice, prostate biopsy via the perineum can be carried out under local anaesthetic and without routine use of antibiotics because of its lower risk of infection. Patients reported low pain scores and positive ratings for the overall experience.

Fluoroquinolone-resistant Escherichia coli among the rectal flora is the predominant risk factor for severe infection after transrectal ultrasound-guided prostate biopsy: a prospective observational study

BACKGROUND

Infection of the prostate gland following biopsy, usually with Escherichia coli, is a common complication, despite the use of antimicrobial prophylaxis. A fluoroquinolone (FQ) is commonly prescribed as prophylaxis. Worryingly, the rate of fluoroquinolone-resistant (FQ-R) E. coli species has been shown to be increasing.

OBJECTIVE

This study aimed to identify risk factors associated with infection after transrectal ultrasound-guided prostate biopsy (TRUS-Bx).

METHODS

This was a prospective study on patients undergoing TRUS-Bx in southeast Sweden. Prebiopsy rectal and urine cultures were obtained, and antimicrobial susceptibility and risk-group stratification were determined. Multivariate analyses were performed to identify independent risk factors for post-biopsy urinary tract infection (UTI) and FQ-R E. coli in the rectal flora.

RESULTS

In all, 283 patients were included, of whom 18 (6.4%) developed post-TRUS-Bx UTIs. Of these, 10 (3.5%) had an UTI without systemic inflammatory response syndrome (SIRS) and 8 (2.8%) had a UTI with SIRS. Being in the medium- or high-risk groups of infectious complications was not an independent risk factor for UTI with SIRS after TRUS-Bx, but low-level FQ-resistance (minimum inhibitory concentration (MIC): 0.125-0.25 mg/L) or FQ-resistance (MIC > 0.5 mg/L) among E. coli in the faecal flora was. Risk for SIRS increased in parallel with increasing degrees of FQ-resistance. Significant risk factor for harbouring FQ-R E.coli was travelling outside Europe within the previous 12 months.

CONCLUSION

The predominant risk factor for UTI with SIRS after TRUS-Bx was FQ-R E. coli among the faecal flora. The difficulty in identifying this type of risk factor demonstrates a need for studies on the development of a general approach either with rectal swab culture for targeted prophylaxis, or prior rectal preparation with a bactericidal agent such as povidone-iodine before TRUS-Bx to reduce the risk of FQ-R E. coli-related infection.

Protocol of a multicentre randomised controlled trial assessing transperineal prostate biopsy to reduce infectiouscomplications

INTRODUCTION

Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer.

METHODS AND ANALYSIS

We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer.

ETHICS AND DISSEMINATION

The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT04815876.

Transperineal vs. transrectal biopsy to reduce postinterventional sepsis

PURPOSE OF REVIEW

Prostate biopsy is commonly performed in men suspected to have prostate cancer. It has traditionally been performed using a transrectal approach, but transperineal prostate biopsy has been increasingly adopted in part because of its lower associated infectious risk. We review recent studies evaluating the rate of potentially life-threatening post-biopsy sepsis and potential preventive strategies.

RECENT FINDINGS

After performing a comprehensive literature search, 926 records were screened and 17 studies published in 2021 or 2022 were found to be relevant. Studies varied in periprocedural perineal and transrectal preparation, antibiotic prophylaxis, and definition of sepsis. The sepsis rates after transperineal ultrasound-guided versus transrectal ultrasound-guided biopsy ranged between 0 and 1 versus 0.4 and 9.8%. Mixed efficacy was found for the topical application of antiseptics before transrectal biopsy to decrease postprocedural sepsis. Promising strategies include the use of topical rectal antiseptics before transrectal prostate biopsy and using a rectal swab to guide the antibiotic selection and the route of the biopsy.

SUMMARY

The transperineal approach to biopsy is increasingly used because of lower associated sepsis rates. Our review of the recent literature supports this practice pattern change. Hence, transperineal biopsy should be offered as an option to all men.

Cost Effectiveness of Rectal Culture-based Antibiotic Prophylaxis in Transrectal Prostate Biopsy: The Results from a Randomized, Nonblinded, Multicenter Trial

Background

Culture-based antibiotic prophylaxis is a plausible strategy to reduce infections after transrectal prostate biopsy (PB) related to fluoroquinolone-resistant pathogens.

Objective

To assess the cost effectiveness of rectal culture-based prophylaxis compared with empirical ciprofloxacin prophylaxis.

Design setting and participants

The study was performed alongside a trial in 11 Dutch hospitals investigating the effectiveness of culture-based prophylaxis in transrectal PB between April 2018 and July 2021 (trial registration number: NCT03228108).

Intervention

Patients were 1:1 randomized for empirical ciprofloxacin prophylaxis (oral) or culture-based prophylaxis. Costs for both prophylactic strategies were determined for two scenarios: (1) all infectious complications within 7 d after biopsy and (2) culture-proven Gram-negative infections within 30 d after biopsy.

Outcome measurements and statistical analysis

Differences in costs and effects (quality-adjusted life-years [QALYs]) were analyzed from a healthcare and societal perspective (including productivity losses, and travel and parking costs) using a bootstrap procedure presenting uncertainty surrounding the incremental cost-effectiveness ratio in a cost-effectiveness plane and acceptability curve.

Results and limitations

For the 7-d follow-up period, culture-based prophylaxis (n = 636) was €51.57 (95% confidence interval [CI] 6.52-96.63) more expensive from a healthcare perspective and €16.95 (95% CI -54.29 to 88.18) from a societal perspective than empirical ciprofloxacin prophylaxis (n = 652). Ciprofloxacin-resistant bacteria were detected in 15.4%. Extrapolating our data, from a healthcare perspective, 40% ciprofloxacin resistance would lead to equal cost for both strategies. Results were similar for the 30-d follow-up period. No significant differences in QALYs were observed.

Conclusions

Our results should be interpreted in the context of local ciprofloxacin resistance rates. In our setting, from a healthcare perspective, culture-based prophylaxis was significantly more expensive than empirical ciprofloxacin prophylaxis. From a societal perspective, culture-based prophylaxis was somewhat more cost effective against the threshold value customary for the Netherlands (€80.000).

Patient summary

Culture-based prophylaxis in transrectal prostate biopsy was not associated with reduced costs compared with empirical ciprofloxacin prophylaxis.

Ciprofloxacin Alone vs. Ciprofloxacin plus an Aminoglycoside for the Prevention of Infectious Complications following a Transrectal Ultrasound-Guided Prostate Biopsy: A Retrospective Cohort Study

The purpose of this study was to evaluate the impact of augmented prophylaxis (ciprofloxacin augmented with an aminoglycoside) compared with that of empirical prophylaxis (ciprofloxacin alone) on transrectal post-prostate biopsy infectious complication (PBIC) rates. A retrospective cohort study evaluated 2835 patients receiving either augmented or empirical prophylactic regimen before undergoing a transrectal ultrasound-guided prostate biopsy between January 2010 and October 2018. The patients were compared according to prophylactic regimen received. The incidence of PBICs and the impact of risk factors were evaluated. A total of 1849 patients received the empirical regimen, and 986 patients received the augmented regimen. The composite PBIC rate was 2.1% (n = 39) and 0.9% (n = 9) (p = 0.019), respectively, and the SIRS rate was 1.9% and 0.8% (p = 0.020), respectively. Of the 50 patients presenting with a PBIC, 29 (58%) had positive cultures (blood and/or urine) for Escherichia coli, of which 28 (97%) were ciprofloxacin-resistant. Taking a fluoroquinolone in the previous 6 months and having a previous urinary tract infection within 1 year prior to the biopsy had significant impact on PBIC rates (p = 0.009 and p = 0.011, respectively). Compared with ciprofloxacin alone, augmented prophylaxis was associated with significantly lower PBICs.

Occurrence and significance of fluoroquinolone-resistant and ESBL-producing Escherichia coli and Klebsiella pneumoniae complex of the rectal flora in Ghanaian patients undergoing prostate biopsy

Background

Reports suggest that fluoroquinolone (FQ)-resistant and ESBL-producing rectal flora are associated with infectious complications in men undergoing transrectal ultrasound-guided prostate needle biopsy (TRUS-B)

Objectives

We investigated the relationship between carriage of FQ-resistant and ESBL-producing Escherichia coli and Klebsiella pneumoniae complex of the rectal flora, and the 30 day incidence rate of post-TRUS-B infectious complications.

Methods

From 1 January 2018 to 30 April 2019, rectal swabs of 361 patients were cultured pre-TRUS-B for FQ-resistant and ESBL-producing flora. Patients were followed up for 30 days for infectious complications post-biopsy. Multivariable logistic regression analyses were used to identify risk factors.

Results

Overall, 86.4% (n = 312/361) and 62.6% (n = 226/361) of patients carried FQ-resistant and ESBL-producing E. coli and K. pneumoniae complex, respectively. Approximately 60% (n = 289/483) of the FQ-resistant and 66.0% (n = 202/306) of the ESBL-positive isolates exhibited in vitro resistance to the pre-biopsy prophylactic antibiotic regimen of levofloxacin and gentamicin. Amikacin and meropenem were the most effective antibiotics against the MDR rectal E. coli and K. pneumoniae complex (78.7% and 84.3%, respectively). The 30 day incidence rate for post-biopsy infections was 3.1% (n = 11/361), with an overall high probability (96.9%) of staying free of infections within the 30 day period post-TRUS-B. Antibiotic use in the previous 3 months was a risk factor for rectal carriage of FQ-resistant and ESBL-positive isolates. Rectal colonization by ESBL-positive E. coli and K. pneumoniae complex comprised an independent risk factor for post-biopsy infectious complications.

Conclusions

The findings suggest that a change in prophylactic antibiotics to a more targeted regimen may be warranted in our institution.

Antibiotic prophylaxis versus no antibiotic prophylaxis in transperineal prostate biopsies (NORAPP): a randomised, open-label, non-inferiority trial

BACKGROUND

The benefit of antibiotic prophylaxis is uncertain when performing transperineal prostate biopsies. Judicious use of antibiotics is required as antimicrobial resistance increases worldwide. We aimed to assess whether antibiotic prophylaxis can be omitted when performing transperineal prostate biopsies under local anaesthesia as an outpatient procedure.

METHODS

In this randomised, open-label, non-inferiority trial, we aimed to enrol all patients with a suspicion of prostate cancer undergoing transperineal prostate biopsies at two hospitals in Norway and Germany. Patients with a high risk of infection or ongoing infection were excluded. Patients were randomised (1:1) to receive intramuscular (in Norway) or intravenous (in Germany) 1·5 g cefuroxime antibiotic prophylaxis or not. Follow-up assessments were done after 2 weeks and 2 months. The primary outcome was rate of sepsis or urinary tract infections requiring hospitalisation within 2 months. The secondary outcome was the rate of urinary tract infections not requiring hospitalisation. These outcomes were assessed in all eligible randomly allocated participants with a prespecified non-inferiority margin of 4%. Biopsies were performed using an MRI-transrectal ultrasound fusion transperineal technique under local anaesthesia. Patients with a positive MRI underwent 2-4 biopsies per target; in addition, 8-12 systematic biopsies were performed in biopsy naive and MRI-negative patients. This study is registered with ClinicalTrials.gov, NCT04146142.

FINDINGS

Between Nov 11, 2019, and Feb 23, 2021, 792 patients were referred for biopsy, of whom 555 (70%) were randomly allocated to treatment groups. 277 (50%) patients received antibiotic prophylaxis and 276 (50%) did not; two (&lt;1%) patients were excluded after randomisation because of unknown allergy to study drug. Sepsis or urinary tract infections requiring hospitalisation occurred in no patients given antibiotic prophylaxis (0%, 95% CI 0 to 1·37) or not given antibiotic prophylaxis (0%, 0 to 1·37; difference 0% [95% CI -1·37 to 1·37]). Urinary tract infections not requiring hospitalisation occurred in one patient given antibiotic prophylaxis (0·36%, 95% CI 0·01 to 2·00) and three patients not given antibiotic prophylaxis (1·09%, 0·37 to 3·15; difference 0·73% [95% CI -1·08 to 2·81]). The number needed to treat with antibiotic prophylaxis to avoid one infection was 137.

INTERPRETATION

The non-inferiority margin of 4% was not exceeded, suggesting rates of infections were not higher in patients not receiving antibiotic prophylaxis before transperineal prostate biopsy than in those receiving it. Therefore, antibiotic prophylaxis might be omitted in this population.

FUNDING

Oslo University Hospital, Oslo, Norway and Vivantes Klinikum Am Urban, Berlin, Germany.

Schema and cancer detection rates for transperineal prostate biopsy templates: a review

Prostate cancer (PCa) is the most common noncutaneous malignancy in men and is the second leading cause of cancer mortality in men in the United States. Current practice requires histopathological confirmation of cancer achieved through biopsy for diagnosis. The transrectal approach for prostate biopsy has been the standard for several decades. However, the risks and limitations of transrectal biopsies have led to a recent resurgence of transperineal prostatic biopsies. Recent studies have demonstrated the transperineal approach for prostate biopsies to be effective, associated with minimal complications and superior in several aspects to traditional transrectal biopsies. While sextant and extended sextant templates are widely accepted templates for transrectal biopsy, there are a diverse set of transperineal biopsy templates available for use, without consensus on the optimal sampling strategy. We aim to critically appraise the salient features of established transperineal biopsy templates.

Efficacy of additional periprostatic apex nerve block on pain in each of 12 transrectal prostate core biopsies: a retrospective study

BACKGROUND

We identified pain variation according to prostate biopsy sites and compared differences in pain relief according to the site of periprostatic nerve block (PNB).

METHODS

This retrospective study collected data from 312 patients who underwent transrectal prostate biopsies between January 2019 and August 2020. Patients were stratified into two groups according to the site of local anesthesia (base vs. base and apex PNB), with each block achieved with 2.5 cm3 of 2% lidocaine. Pain scores were assessed using the visual analog scale at the following time points: probe insertion, PNB at base, PNB at apex, each of the 12 core biopsy sites, and 15 min after biopsy. The results were analyzed using a linear mixed model.

RESULTS

The average pain scores were significantly higher in the base-only PNB group than were those in the base and apex PNB group (3.88 vs 2.82, p < 0.001). In the base-only PNB group, the pain scores increased from base to apex (p < 0.001), and the pain at each site also gradually increased as the biopsy proceeded (p < 0.001). In contrast, in the base and apex PNB group, there was minor change in pain scores throughout the procedure.

CONCLUSIONS

The pain scores varied at each site during the prostate biopsy. The provision of a base and apex PNB provided greater pain relief than does base-only PNB during prostate biopsy.

Prostate biopsy quality and patient experience with the novel Forsvall biopsy needle - a randomized controlled non-inferiority trial

BACKGROUND

Transrectal prostate biopsy (TRbx) carries an increasing risk of infection. The Forsvall Needle Prototype (FNP) is a novel biopsy needle that reduces bacterial load brought across the rectum and may therefore reduce infection risk. The objective of this study was to compare biopsy length, quality and patient experience for the FNP Version 2 (FNP2) versus a standard Tru-Cut needle.

METHODS

We conducted a randomized, parallel-group, non-inferiority trial with twenty consecutive patients eligible for TRbx. Participants were randomized to undergo TRbx using either FNP2 or a standard Tru-Cut needle. The primary outcome was difference in mean biopsy lengths measured by the pathologist. FNP2 biopsy lengths ≤1.35 mm of the standard needle length were considered non-inferior. Secondary outcomes were biopsy length in the needle chamber and immediately after removal, biopsy quality, biopsy fragmentation, patient discomfort/pain, and complications (immediate and after 14 and 30 days).

RESULTS

Mean pathologist-measured FNP2 biopsy length was non-inferior compared to the standard Tru-Cut needle (0.02 mm longer, 95%CI-0.73 to 0.76 mm). Biopsy length in the needle chamber and immediately after removal were also non-inferior. Biopsy quality and patient discomfort were not significantly different for the FNP2 and the standard Tru-Cut needle. Biopsy fragmentation was more common in the FNP2 group.

CONCLUSIONS

The FNP2 biopsy needle is non-inferior to the Tru-Cut needle in terms of biopsy length and not significantly different in terms of biopsy quality and patient experience. Future studies will evaluate the Forsvall needle design's effect on post-biopsy infection risk.