Why have I been asked to do a prostate biopsy procedure?
A prostate biopsy is recommended when there is suspicion of prostate cancer based on prostate-specific antigen (PSA) blood test, digital rectal examination, and MRI scan findings.
It helps diagnose prostate cancer and how aggressive cancer cells are.
Many men who undergo a prostate biopsy tolerate the procedure well.
Is an MRI prostate scan always needed before a biopsy?
Multiparametric magnetic resonance imaging (mpMRI) of the prostate is always recommended before performing the biopsy as per American Cancer Society (ACS), European Association of Urology (EAU) and National Health and Care Excellence (NICE) guidelines.
The MRI-guided prostate cancer biopsy has been pivotal, as many men are spared unnecessary biopsies. The detailed images combined with computer-aided software highlight specific clinically significant prostate cancer areas.
Additional crucial information derived from the mpMRI includes:
- size of the prostate gland
- stage prostate cancer
- if prostate cancer has spread
What are the implications of having a biopsy?
Pros of prostate biopsy
- Determines if you have cancer and how aggressive it is.
- The information on the location(s) of the cancer cells in the prostate gland helps your NHS prostate consultant or private urologist tailor treatment accordingly. One can only access clinical trials if a biopsy confirms prostate cancer.
Cons of prostate biopsy
- Biopsies sample the prostate; hence, they may miss the presence of cancer cells.
- Low-risk prostate cancer that is slow-growing may be picked up, and a significant proportion of it does not impact your life. The knowledge of having cancer influences men differently. You may need to explore different management options.
- All surgical procedures, including prostate biopsies, carry a risk of complications.
- If you take medicines to thin your blood for specific medical conditions, these may need to be stopped, exposing you to potential risks.
What type of anaesthesia is given for prostate biopsies?
Most prostate biopsies are done under local anaesthetic. The procedure is tolerable.
You may be asked to do them under general anaesthetic;
- if a higher number of biopsies are needed
- if you are very anxious
- if you suffer from needle phobia,
- if you did not tolerate the prostate biopsy under local anaesthetic
- your wish to be put to sleep
How to prepare for your biopsy
A detailed medical and surgical history will be taken. You must inform your caring healthcare provider about all your medications.
If you are on blood thinners, it is imperative to highlight this, as these will need to be stopped before the biopsy. Various blood thinners are on the market, and each has a different period when it must be stopped and restarted. During the off period, you are at increased risk of heart attack, stroke or clots in the deep veins or lungs. An in-depth conversation explaining what needs to be done and the risks is essential.
If you are booked for a transrectal biopsy, a swab from the back passage is usually taken to check the resistance profile of the gut flora so that antibiotics can be planned according to the sensitivity.
Antibiotics may be prescribed one to two hours before the biopsy to prevent infection for transrectal biopsy.
You can eat and normally drink if your biopsies are under local anaesthetic.
If your biopsies are under general anaesthetic, one should not eat anything at least 6 hours before the biopsy and only allow clear fluids up to one hour before (in some centres, clear liquids are only allowed up to two hours before). Check with your local hospital, as each hospital has its protocol.
If you are anxious, your family doctor may prescribe an anxiolytic two hours before the biopsy to calm down.
Whether it is done under local or general anaesthetic, it is best to come for the biopsy with a loved one, make necessary arrangements to be driven home, and have someone be with you for the first 24 hours.
What are the three common types of prostate biopsies?
- Transperineal biopsy
- Transrectal Ultrasound (TRUS) biopsy
- MRI-guided prostate biopsy
Transperineal template biopsy
Before your biopsy, the caring healthcare person will explain the procedure steps and ask you to sign a consent form.
The skin area between the scrotum (the skin that holds the testicles) and back passage is called the perineum.
Most of the transperineal biopsies are done under local anaesthesia. A general anaesthetic (a man is put to sleep) is recommended in specific clinical situations.
A rectal exam is performed to feel the prostate is done. A lubricated ultrasound probe is introduced in the back passage. The high-frequency sound waves emitted from the probe will define the prostate gland's outline and inner parts.
If biopsies are done under local anaesthesia, the first step is to give a local anaesthetic to the perineal skin, inner layer and prostate gland via a fine needle.
The health care specialist uses a biopsy gun to insert the biopsy needle through the perineum into the prostate. The MRI images show targeted biopsies taken from the suspicious areas. Then general biopsies are taken from each sector of the prostate gland.
Is transperineal prostate biopsy under local painful?
You will feel the initial sharp scratches.
As biopsies are taken, men report that the pressure of the needles is felt, which amounts to discomfort but not pain.
How long does an ultrasound-guided Transperineal prostate biopsy take?
A transperineal biopsy usually takes about 30 minutes.
TRUS biopsy
Before your biopsy, the caring healthcare person will explain the procedure steps and ask you to sign a consent form.
TRUS-guided biopsy is done under local anaesthesia as a day-case procedure.
You will lie on your side and bring your knees to your chest. A digital rectal exam is performed to feel the prostate. A lubricated ultrasound probe is introduced in the back passage. The ultrasound images show the outline and the inner parts of the prostate gland.
A local anaesthetic is given at the apex or base of the prostate. You may feel a sharp scratch. As biopsies are taken, men report that the pressure of the needles is felt, which amounts to discomfort but not pain. This makes the procedure tolerable.
A biopsy device directs the thin needle through the probe, the rectum wall, and into the prostate. Up to 12 biopsies can be taken. If more are planned, having a general anaesthetic is better; however, the risk of infection is higher.
TRUS-guided biopsy may still play a role, but they are not the mainstay biopsies anymore as the anterior part of the prostate cannot be reached, and there is a high risk of infection.
MRI-guided prostate biopsy
The urologist or radiologist may use a technique called MRI/TRUS fusion. This method combines MR images with real-time US images to pinpoint the biopsy site areas where the needles should be directed. MRI fusion biopsy can be performed both with transperineal biopsy and transrectal biopsy. The entire procedure takes around 45 mins to complete.
Yet no research shows that fusion is better than transperineal biopsy. The experience of the person performing the biopsy is vital.
Which type of prostate biopsy is best?
A transperineal prostate biopsy has become the gold standard approach.
It allows the person performing the biopsies to access all areas of the prostate gland. The risk of infection is lower as the needle does not pass through the rectal wall.
What happens after prostate biopsy samples are taken?
- You will be asked to stay for a couple of hours after the procedure to ensure you are well, comfortable and able to pass urine.
- You need to take the day off
- You can continue on a regular diet
- If you are habitually constipated, take laxatives to open your bowel easily.
- Avoid strenuous activity for a few days (usually five days) to lower the bleeding risk.
- You can have sexual intercourse after a biopsy; however, if you receive anal sex, it is recommended to abstain for two weeks.
What are the potential side effects of a biopsy?
- pain or discomfort
- bleeding (blood in the semen or blood in urine or blood in faeces)
- infection
- acute urinary retention
- erectile dysfunction
Pain or discomfort for a few days
Discomfort can be felt in the back passage, the lower part of the tummy, the genital area or the perineum.
One can take paracetamol for a few days. If the discomfort does not settle, seek medical attention.
Bleeding
Around 35% of men see light bleeding in their semen, urine or bowels that may last up to six weeks. Blood in your semen can appear brownish or rusty in colour. This resolves by itself. You should seek medical attention if it takes longer or is very heavy.
If you have a transperineal biopsy, bruising is commonly seen in the perineal area.
Infection
TRUS biopsies carry a higher risk of infection than transperineal biopsies.
If you have a urine infection, you may experience the following:
- pain or burning when passing urine
- cloudy or foul-smelling urine
- frequent urination
- chills or shivering, high temperatures or feeling unusually cold
- pain in the lower part of the tummy, perineum (especially when sitting down) or lower back (prostatitis)
- If your experience any of the above, you need urgent antibiotics. Around 1% of men who undergo a TRUS biopsy can get sepsis, a severe infection requiring hospital admission.
Acute urinary retention
Around 5% of men experience an inability to pass urine. The prostate would have swollen from the inflammation that the biopsies can cause. A temporary catheter for a week or two may be needed to relieve the blockage until the inflammation settles down. You may be prescribed an anlpha blocker like tamsulosin to help you empty better and speed up the resolution fo the inflammation.
Acute urine retention is more common when more biopsies are taken, like template perineal biopsies.
Erectile dysfunction
A small number of men may experience erectile dysfunction. It is usually temporary and will resolve a few months after a biopsy.
Who interprets the results, and how do I get them?
Once the biopsies are taken, they are sent to the pathology laboratory. A pathologist, a person specialised in interpreting cells, will issue a pathology report detailing the findings for each of the prostate tissue samples taken. The report usually takes 7 to 14 days, depending on laboratory pressures.
If there are cancerous cells, the pathologist will determine the type of prostate cancer and report on the Gleason score, volume, the number of cores taken, and the number of tissue samples involved with cancer.
What happens if there is prostate cancer?
If the results show prostate cancer, your case will be discussed in a specialist meeting that will tailor treatment options accordingly. You will have a consultation explaining the grade of the cancer cells, imaging, and each treatment option in detail. Information leaflets and contact numbers for specialist nurses will be provided.
What happens if there is no prostate cancer?
If your biopsy results show no cancer, you will still have a consultation (telephone or face-to-face) to inform you about the results and if follow-up, for example, with a PSA test or other tests, is still needed.
If there is still a suspicion that there is prostate cancer, but it has not been found, further tests (biopsies or imaging) may be requested.
Sometimes, a biopsy may show changes called
- prostatic intraepithelial neoplasia (PIN)
- atypical small acinar proliferation (ASAP)
These are changes in prostate cells that can potentially become cancer cells. Your NHS consultant or private urologist will guide you.
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