Andrew Siegel MD 6/1/19
Today’s entry takes you through the details of a prostate biopsy, which–although scary in concept–is a brief and simple office procedure that obtains valuable and potentially life-saving information.
Hopefully, you will never need to undergo a biopsy of your prostate gland. However, many men will ultimately require one if there is concern for, or suspicion of the possibility of prostate cancer—most commonly based upon an elevation in PSA, a PSA acceleration, or an abnormal digital rectal exam. Other indications are to reevaluate pre-cancerous lesions, including high grade prostate intra-epithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP), monitoring patients on active surveillance, and in the evaluation of men who have received prior prostate cancer treatment and have rising PSAs.
Although digital rectal exam, PSA blood testing, and MRI are suggestive and helpful tests, it is the biopsy that is definitive. “The buck stops here” with prostate biopsy, the most conclusive diagnostic test.
Attribution of Image Above: Cancer Research UK uploader [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)%5D…Note prostate, ultrasound probe and needle biopsy, translated from Polish
Prostate ultrasound is a means of prostate imaging using sound waves (like sonar on a submarine) generated by an ultrasound probe placed in the rectum. Reflected echoes create a high-resolution image of the prostate to measure the prostate volume, check for abnormalities, and precisely guide biopsies. The ultrasound image alone is not sufficient to diagnose prostate cancer without a tissue biopsy. MRI is often used prior to the biopsy to ascertain if there are any discrete abnormalities that can be targeted by the biopsy.
Preparation for ultrasound-guided prostate biopsy involves a Fleet enema the evening before the biopsy to cleanse the rectum, discontinuing blood thinner medications for a week or so prior to the procedure and starting a short course of oral antibiotics prior to the biopsy, since the biopsies are performed via the rectum.
The prostate biopsy can be performed using a local anesthetic or, alternatively, with intravenous sedation. I prefer to do the biopsies in the office setting using intravenous sedation provided by an anesthesiologist, which makes the experience much more pleasant for the patient and avoids the need for local anesthetic injections into the prostate, which can increase the risk of infection. Two antibiotics are administered intravenously immediately prior to the biopsy.
The ultrasound/biopsy is about a 10-15-minute procedure, although one needs to arrive 30 minutes prior to and remain for about 30 minutes or so after the procedure. In the knee-chest position while lying on one’s side, the ultrasound probe is gently placed into the rectum. After obtaining imaging and volume measurements, prostate biopsies are obtained with a spring-driven needle device that is passed through the needle guide attached to the ultrasound probe. The biopsies are tiny, about the size of eyelashes. Generally, a minimum of 12 biopsies are obtained—six from each side with two biopsies each from the apex, mid-gland and base, providing a pathological “map” of the prostate. Each biopsy is placed in a separate specimen container noting the site of the biopsy and is carefully examined by a pathologist to make a diagnosis.
If an abnormality is visualized on ultrasound—classically a hypo-echoic region (an area with less echoes than adjacent prostate tissue)— this specific area will be biopsied as well. Often, MRI is performed prior to the biopsy and any specific area of suspicion identified on MRI is matched with the ultrasound, and targeted biopsies are obtained of these areas, as well as the standard 12 mapping biopsies. MRI/ultrasound fusion-guided biopsy is a means of fusing pre-biopsy MRI prostate imaging with ultrasound-guided prostate biopsy images in real time, so that the suspicious regions seen on MRI can be precisely targeted. Fusion-guided biopsies require sophisticated hardware and software technology and the combined efforts of the radiologist, technician and urologist. Alternatively, cognitive-guided biopsies are ultrasound-guided biopsies performed while simultaneously viewing the pre-biopsy MRI images to target the regions of concern.
After the biopsy, it is important to stay well hydrated, complete the prescribed antibiotics, and to take it easy for a day or so. Urinary and/or rectal bleeding following a biopsy is common and typically resolves within a few days or so. However, it is not uncommon to experience some blood in the semen for up to 6 weeks after the biopsy. It generally takes 7-10 days or so to receive the biopsy results.
Trans-perineal (via the anatomical region between scrotum and anus) mapping prostate biopsies are sometimes done as an alternative to the trans-rectal biopsy described above. Ultrasound is used to image the prostate and numerous mapping biopsies—typically at 5 mm intervals—are done via a perineal template. This provides a pathological map of the entire prostate, sometimes used to obtain a primary biopsy but more often used as a confirmatory biopsy that improves staging because of the number of biopsies obtained at precise anatomical locations.
Coming next week…What you will learn from the prostate biopsy report.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.
The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families
Video trailer for Prostate Cancer 20/20
Preview of Prostate Cancer 20/20
Andrew Siegel MD Amazon author page
Prostate Cancer 20/20 on Apple iBooks
Dr. Siegel’s other books:
PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food
MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health
Tags: Andrew Siegel MD, MRI, prostate, prostate biopsy, prostate cancer, Prostate Cancer 20/20, ultrasound-guided
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