Prostate biopsy
What to expect if you undergo a prostate biopsy
If your PSA levels are high, you might need further tests. Your doctor may refer you for a prostate biopsy. A biopsy is a procedure in which small samples of your prostate are removed and sent for laboratory testing.
A biopsy is performed by a radiologist or urologist. A sonographer and a nurse will assist. A biopsy is performed using ultrasound guidance. During the procedure, an ultrasound probe (about 10cm), covered in lubricating jelly, is inserted in your rectum. This provides the doctor with images of your prostate to help guide the collection of samples.
There are two types of biopsies:
- A transrectal ultrasound-guided (TRUSP) biopsy
- A transperineal (the area between the anus and the scrotum) ultrasound-guided (TPUSP) biopsy
What to expect before a biopsy
(The below may apply to both a TRUSP biopsy and a TPUSP biopsy)
Your doctor will tell you how to prepare based on the type of biopsy you will undergo. Generally, your doctor will briefly review your medical history and medications prior to a prostate biopsy.
It is important that you inform your doctor if you have any implants (e.g. stent, joint replacement, pacemaker, heart valve, blood vessel graft), use blood thinners (e.g. warfarin, aspirin, clopidogrel, rivaroxaban, dabigatran), recently (or currently) had an infection, or underwent a corneal transplant, had neurosurgery, or if you are treated with human growth hormones.
If you use warfarin, you may need to stop taking the drug five days before the procedure. Your doctor may advice you to use heparin injections as ‘bridging’ therapy while you are not using warfarin.1,2,3
If you take clopidogrel or other blood thinners listed above, you will be asked to stop seven days before the biopsy. This will help prevent excessive bleeding during and after the biopsy. If you use low dose aspirin (75mg) you can continue to do so.
You may need to take oral antibiotics a day before and the morning of the biopsy. This will help prevent infection.
A biopsy can be done under local or general anaesthesia in an outpatient setting. On the day of the biopsy, your doctor will briefly discuss the procedure with you and you will be asked to sign a consent form. If you have any questions or concerns, raise them with your doctor before you sign the consent form.
Before you undergo a biopsy, you will be asked for a urine sample to make sure that you do not have a urine infection. If you do have a urine infection, your doctor will postpone the procedure.
You may need a small enema about half an hour before the biopsy to clear out your bowel and rectum. This allows the doctor to see the prostate more clearly, and it helps lower the risk of infection.
The anaesthetist will discuss pain relief after the procedure with you. You may be provided with a pair of compression stockings to wear. These help to prevent blood clots from developing while you are anaesthetised and passing into your lungs. Your medical team will decide whether you need to continue with these after you go home.
What to expect during TRUSP biopsy
If the biopsy is done under local anaesthesia, you will be asked to undress, change into a gown, and lie on a couch on your left side, with your knees drawn up to your chest. Your scrotum will be taped to make sure they are not in the way. Before the procedure starts, your doctor will perform a rectal examination.3 You will be given an injection to numb your prostate. This will sting for a few second. Once the area is sufficiently numb, a guide tube will be inserted into your rectum. The tube contains a spring-driven needle core biopsy device, which is used to take samples. Each time the device is activated, you will hear a ‘click’ sound.
The doctor will take between 10-18 samples. If you experience discomfort during any part of the biopsy, inform your doctor. The entire biopsy takes about 20-30 minutes and you may go home the same day.
What to expect during a TPUSP biopsy
A TPUSP biopsy is done under local or general anaesthesia. Before the procedure starts, your doctor will perform a rectal examination. In a TPUSP biopsy, your doctor will pass the biopsy needle through the perineal skin and into the prostate, rather than passing the biopsy needle through your rectum. The biopsy needle is still guided by an ultrasound placed in the rectum (see TRUSP biopsy).
If the biopsy is done under local anaesthesia, you will be asked to undress, change into a gown, lie on your back on a recliner chair with your legs placed in supportive stirrups. The biopsy takes about 20 minutes. If you find this position uncomfortable, speak to the attending nurse about alternatives. Your scrotum will be taped to make sure they are not in the way. Before the procedure starts, your doctor will perform a rectal examination.You will be given two injections to numb the area. The first injection is given under the skin of your perineum to numb the entry point of the biopsy needle, and the second to numb your prostate. This will sting for a few second.1
Once the area is sufficiently numb, a guide tube will be inserted into your rectum. The biopsy needle is inserted in the perinium using a special device to take a sample from the left side of your prostate. A new biopsy needle is inserted to take a sample from the right side of your prostate. Your doctor will take about 24 samples, depending on the size of your prostate. You will hear a loud ‘click’ sound and feel a flicking sensation when the samples are taken. This may uncomfortable but should be pain-free.
However, if you feel any pain when the biopsy needle is inserted, inform your doctor immediately. The entire biopsy takes about 20 minutes and you may go home the same day.
What to expect after a biopsy?
Immediately after the biopsy, you may feel lightheaded, so take it easy and ask someone to drive you home. You will be given an absorbent pad to place inside your underwear to soak up the small amount of blood from the puncture wounds.
For a few days after the biopsy, your prostate may feel a bit ‘bruised’, which may result in temporary erection difficulties. All patients have blood in their urine and stool, as well as in their semen (for up to six weeks). This is normal and will resolve in a few days following the biopsy.
Are there any risks involved?
In some extremely rare instances, the biopsy may not detect significant cancer in your prostate and you may need a second biopsy.
Although the procedure is done under sterile conditions, one in 10 patients may develop a urinary infection and less than 1% may develop septicaemia (blood poisoning), which require urgent medical attention.
One in 20 patients experience difficulty passing urine, which may result in urine retention, one in 50 patients may develop a blood clot that prevents them from passing urine, which may require urgent medical attention.1,3,5
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