Question: What can Ask a Doctor tell me about a ultrasound-guided transperineal prostate biopsy? Do they put you out for this? How do you feel afterward? — Henry, of Lima
This is a particularly good question. This is a common procedure done to study the disease of prostate gland.
What is a prostate biopsy and who should get one?
The prostate is an organ located in the lower end of the trunk in men below the urinary bladder. In the U.S., prostate cancer is the most common cancer other than skin cancer. While some forms of prostate cancer do not cause death, it is the second leading cause of death from cancer in American men. This makes early detection and screening for prostate cancer of a paramount significance.
Prostate specific antigen is a blood test that is used to screen for prostate cancer. If your PSA level or the prostate exam is abnormal your doctor may refer you to an urologist, a surgeon who is specialized in the urinary system including prostate. Although PSA is far from being a perfect test, it is still one of the very useful tests if combined with evaluation of patient age, family history and prostate exam.
There are three possible scenarios after the evaluation and discussion with the patient based on the clinical suspicion of prostate cancer:
• If there is low suspicion “risk” of having prostate cancer, the patient is reassured and he is encouraged to continue screening based on the recommended guidelines.
• If the suspicion is high, I recommend proceeding with a prostate biopsy.
• Some patients are in the gray zone. For these patients further testing is recommended. We will review some of these tests.
Fortunately, nowadays we have advanced blood and urine tests that can be ordered prior to proceeding with a prostate biopsy. In our practice, we do special blood tests to increase the accuracy of calculating prostate cancer risk. In addition, a common imaging modality called Magnetic Resonance Imaging is becoming more important in diagnosing prostate cancer. We adopt these technologies to help assessing the patient prior to proceeding with more invasive testing such as prostate biopsy. Benefiting from advanced innovations, the images of MRI may be used to guide us getting targeted biopsies of the prostate lesions.
Nevertheless, prostate cancer is usually diagnosed based on the results of a prostate biopsy. The biopsy is a procedure done either in the office or as an outpatient in the operating room to obtain samples of the prostate using exceptionally fine special needles. The samples are later sent to the pathologist who reviews them under the microscope to look for abnormal cells and glands of the prostate.
The prostate is surrounded by other organs and tissues. Therefore there are two ways to get to the prostate to get a biopsy: through the rectum (the last portion of the large intestines terminating at the anus) and through the perineum (the area between the scrotum and the anus).
Trans Rectal Prostate Biopsy: An ultrasound probe is usually inserted in the rectum and used to assess the prostate and guide the biopsies. This is called a transrectal prostate biopsy, which is usually performed in the office after numbing the prostate using local anesthetics. It is less painful than other routes and relatively quick; it usually takes 10-15 minutes. In addition, transrectal prostate biopsy can be combined with MRI of the prostate to get targeted biopsies of suspicious lesions. Antibiotics, usually by mouth, and enema to clear the stool from the rectum are prescribed for the patient to be taken a few hours prior to the procedure. I usually recommend that patients avoid prolonged driving and sexual activity for 24-48 hours afterwards. Patients may notice blood in urine, stool and semen, but this is usually trivial. However, the patient may get an infection. While this is very uncommon, it can be serious and may require hospitalization for few days for getting intravenous antibiotics.
Transperineal Prostate Biopsy: The infections from transrectal biopsies made urologists in some centers adopt other routes such as getting prostate biopsy through the perineum called transperineal prostate biopsy. Transperineal biopsy requires getting more biopsies, usually through a template to guide the needles through the layers of skin and muscles to get to the prostate with the aid of an ultrasound. This makes this route more painful than transrectal approach, and often requires the patient to be placed under anesthesia. In addition, transperineal prostate biopsy has a higher rate of complications including bleeding and urinary retention, the inability to urinate that requires insertion of a catheter in the bladder. Nevertheless, the chance of getting an infection is very low. Unfortunately, techniques to combine transperineal prostate biopsy with MRI are still under development.
As I mentioned earlier, the MRI imaging can be combined with the ultrasound in what is usually called, MR/Ultrasound fusion targeted biopsy of the prostate. This enables us to get biopsies of specific lesions, which is invaluable in increasing the accuracy of the biopsy and minimizing the unpleasant and harmful effects of this invasive procedure. However, caution should be exercised to get the best results of this advanced approach and a collaborative team is needed. The team consists of radiology technicians, a specialized radiologist, fusion system technician and a urologist. In addition, the MRI images should be interpreted based on the patient history and examination.
The decision to choose either approach of biopsy is ideally made after a discussion between the patient and the urologist. In addition, considerations should be given to the frequency of infection in the local area and the availability of advanced technologies. Given the common and various presentations of prostate cancer, along with the seriousness of some of its types, we believe that the decision about diagnosing and treating prostate cancer needs to be individualized.
I hope your transperineal prostate biopsy goes smoothly.
Jaber Alanzi, MD, Midwest Surgical Specialists, Urology, 1005 Bellefontaine Ave. #125, Lima, OH 45804, 419-998-8276