MRI guided prostate biopsy advice needed

Thanks for the advice. Is there a particular kind of MRI that I should ask for? Like 3t or anything? My PSA has gone from 6.5 to 3.5 to 9.5 in the last year. No new drugs in that time except but b12 and a D vitamin. I'm having difficulty in keeping my cool about this as I've been telling first UROL, PC and current UROL for the last year that I'm in screaming pain, and have been to the ER three times when it got really bad. I just don't know how I'll be able to handle it if it turns out that the lost year made a difference. I know my first priority is to get well (if it's not too late). And my COBRA only has four months left. So I cannot afford to get the cheap biopsy first then have to wait several months for the better MRI one. I can't even imagine trying to get another policy with a PC diagnosis. My last visit with my PC doctor a month ago after I say for the tenth time time about the pain I'm in - he says, somewhat patronizingl, 'Are you afraid of dying?'. well, yeah doc, now I am. Sorry to be so whiney - I get it that lots of guys have it worse.

Hello again

As for MRI, the formal name for it is a multi parametric 3T, but I understand that in most cases when offered a 3T MRI, it means a multi parametric 3T MRI.

As mentioned earlier, the main thing is to have a MRI, be it 3T or 1.5T reported by an experienced radiologist that specialises in prostate imaging.

I wanted a 3T but my history prohibits that, so I went for a 1.5T which was reported upon by a radiologist experienced in prostate imaging.

And I can't stress enough how useful such a MRI is before a biopsy is performed. A biopsy guided by the MRI, that is.

And make sure that you have all your PSA tests performed by the same lab as different labs have small differences in the way they measure.

Well, the last two, the 3.5 and 9.5 were the same UROL practice, tho different doctors. The current doctor is the best of the three I have seen there. The first two said 'come back in three month's despite the pain I was in. And the current one never mentioned the non-rectal route for biopsy. And only mentioned the MRI pre-scan in passing, saying the ins company would never approve it. I think this is an issue for me as I'm supposed to take antibiotics for even dental exam due to my recent shoulder surgery and the risk of infections. If there is a lighter side to this, my first UROL practice is the one in Ohio that just recently got all of its patient records hacked by the Russians. Maybe Boris will contact me with a cure... the odd part of this is that I've been in unreal pain for a year and prostate cancer isn't supposed to hurt initially. I've got no family but a cat who listens but offers no advice. Btw, when I said 'PC' in my posts I meant 'primary care'.

Thank you again Sir,

Words cannot express my gratitude for your timely concern and advice. First thing tomorrow morning I'm going to contact the urologist and ask them to hold off on the insurance presubmission until I can check with my orthopedic surgeon and primary care doctor. I imagine my chances of getting the MRI approved will be better if I get all my ducks in a row first instead of being denied and having to file an appeal (which probably would take much, much longer). Hopefully the surgeon will verify that immediate post surgical patients like myself (total shoulder replacement) cannot take the increased risk of sepsis which the blind prostate rectal biopsy would entail. And hopefully also my primary care doctor will verify that I have been complaining of intense prostate and epididymal pain for over a year. Funny that the urologist did not even mention the option of the transperineal biopsy, though lucky for me he did let it slip that the MRI guided biopsy was better but unlikely to be approved. And I'm crossing my fingers that he has experience with the transperineal method. I'm guess I'm not asking any new questions now (though wait till tomorrow after I run the medical gauntlet), but I have found that writing a letter helps me to get my thoughts in order. And maybe it might someone in the future who may find themself in a similar situation. Thanks again

I am in Australia, and now realise you're in the USA.

Not that it matters much.

A few things come to mind.

You wrote that you were not offered the Transperineal biopsy.

Not unexpected.

It is relatively new and those who offer the trans rectal method rarely offer the Transperineal. After all, they assume, who is going to question them? And, why should they learn a new technique?

In both biopsies, antibiotics are given before and after the procedure, but as I said, the Transperineal has a much lower chance of infection.

Given you're in the Buckeye State and have suffered at the hands of less than satisfactory urologists, if you're not thrilled with the latest urologist you have then  I suggest you mosey on over to the Cleveland Clinic and see a urologist there. Assuming your insurance will cover all or some of the costs.

Cleveland Clinic is a world class facility which should be able to sort you out very quickly. You have spent enough time with lousy physicians. 

I forgot to add that the quality of data obtained be urologist  from a MRI u/s guided biopsy is not just better than from an unguided biopsy, but SIGNIFICANTLY better.

Also remember to think ahead. By this I mean, if you are considering surgery then have the biopsy performed by the guy who you want to operate on you, if the biopsy indicates that is what's to follow.

Some, not all, urologists are strange inasmuch as they will not want to deal with a biopsy performed by another physician.

Yup, the first UROL was a pompous ass. His modus operandi was to just keep throwing antiboitics st me. After three months of that I asked for a cat scan. Come the day and I was astonished to find out that they were just going to do the groin, whereas I had read that the kidneys were also routinely done at the same time to rule out some renal causes. I put my foot down and low and behold we found 4-5 mm kidney stones on each side. I was less than diplomatic in pointing out in the presence of his assistant that he screwed up, as that could have been the problem which he never would have caught. they also found a module on my pancreas which an MRI showed to be benign. As I was still in quite alot of pain I demanded to know what tests he was going to do next. At which point

He told me to take a hike. Really. Six wasted months while whatever I have went undiagnosed and the prostate pain morphed into even nastier prostate/epididymis pain. I am making a supreme effort to control my emotions this time with this urologist, but I just cannot afford to lose any more time and need to make informed decisions in a cool-headed and informed manner. Though you make another good suggestion about the Cleveland clinic. Better to accept nothing less that a doctor who is willing and able to give the best treatment than settle for second rate care because it's quicker and you feel the need to do something NOW. This is the first time in my life dealing with substandard doctors and substandard care. And the first time I've ever been this sick, if pain means anything.

I empathise with your situation,

if nothing else you must get another opinion. After all, if the current urologist screwed up and say your problem is kidney stones, then it is hard to get him to admit his error and for him to treat you for the malady you have.

If I were you I would cease dealing with second rate medicos.

They sadly don't have the depth of experience that say folk at the Cleveland Clinic have.

I would call and say that you have pain and have been poorly treated for say a year. And the pain is progressively worse.

How soon can I see a urologist?

Summarise your medical history into a paragraph.

Have  it ready to email whoever's name you get to see at the Cleveland Clinic or similar facility.

It was the first UROL with the kidneys stone thing, not the current one. It was one reason why I switched.

Thank you for the clarification.

I forgot to say that the only prostate related pain that I know of is pelvic pain. Before going to another urologist, in case you do, I suggest you get all the a can you have to rule out non private related issues eg kidney ailment.

The more scan you arrive with at a urologist's office, the better and the sooner the diagnosis.

My UROL said they never did the transperineal biopsy, and the UROL at the Cleveland clinic said they'd heard of it but never did it either. Go USA! On the bright side have the 3t MRI scheduled for nine am tomorrow - no preauthorization needed with my insurance. But the idiots weren't even going to try because ' it always gets rejected'. They would have had me going straight to the transrectal with no MRI. So, depending on what they find maybe biopsy won't be needed, though I'm not optimistic given my pain and urological symptoms. I'm a PADI dive master BTW, always wanted to make it to the great barrier reef. I must have emphasized 3t four times with the scheduler, but when the hospital called with pre-admission instructions they had it as 1.5t or 2t. You honestly have to be your own doctor these days. Thanks for listening.

As mentioned:

The key is not a 3T v 1.5T MRI, but having the images read by a radiologist specialising in prostate imaging v one that does not. Frankly in your case I would go for the caliber of the Cleveland Clinic because a definitive "no" to prostate cancer in the MRI will go a long way to keep you far from the biopsy table.

An "indeterminate" MRI reading by a ho-hum radiologist will not advance your thinking. Don't forget that if you have implants you may be able to undergo a 3.0T scan.

As to you being told that many have not heard of the trans perineal approach....I am not surprised. It is relatively new and frankly it doesn't pay urologists pushing the trans rectal approach to learn a new method. Literally it does not pay them.

You can I am sure see that approaching the prostate from beneath will yield less risk of infection merely by by passing the bottom.

I am speaking as someone who underwent the 1.5T, read by a specialist in prostate images and then had the trans perineal. Took antibiotics before and after the biopsy. Suffered no ill effects.