Transrectal or Transperineal Prostate Biopsy
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At present, my doctor is trying cipro on me to try and reduce my recent spiked PSA down from 13 back to its usual 2.4. My MRI provided a PIRAD 2 score, with no lesions or Gleason 4 or 5 evident. My doctor said "we" may need to consider a prostate biopsy. So...a bit of research indicates they come in two distinct types:
1. Transrectal - the most common version, though prone to urinary infections, some very serious afterwards.
2. Transperineal - the least used, though best for finding difficult to find PCa, and virtually no infections afterwards.
From a little research, it appears the medical profession use the transrectal method 97% of the time. This means one to 25 biopsy needles will be inserted through the rectum wall into the prostate. The procedure usually takes 15-25 minutes. The biopsy if blind, meaning a 12-16 needle gun will punch holes through the rectum into the prostate. If the biopsy is guided via MRI or ultrasound, then a single needle, one at a time, is used. Usually, the guided method requires less needle samples because the lesion to test is seen.
This inevitably means faecal matter from the bowel is often inserted deep into the prostate. This in turn can lead to serious infections, including sepsis requiring a hospital stay, and can be life threatening. To reduce the chance of infections, patients are given some sort of course of antibiotic prior, during and after the biopsy. This often does not prevent infection.
Recent travel to certain areas of the world can increase the chance of you carrying resistant bacteria and the transperineal prostate biopsy may be recommended if you have a higher chance of carrying those bacteria (e.g. ESBL). Likewise, if you have been treated with the antibiotics ciprofloxacin or Norfloxacin in the prior 6 months, you may be at risk of carrying resistant bacteria and a transperineal biopsy may be safer for you.
If the Biopsy is carried out as a transperineal prostate biopsy, then usually 12 to 24 needles, one by one, will be passed through a special grid with 5mm spacing's through the perineal skin into the prostate. As this route avoids the bowel, no faecal matter is carried into the prostate and infections are rare. Antibiotics are given prior, during and afterwards to assist in reducing infections.
The transperineal prostate biopsy procedure usually requires a general anaesthetic, though a local can be used. The procedure usually takes approximately one hour and is usually carried out as a day surgery visit. The transperineal prostate biopsy is the gold standard of biopsy. It can reach areas of the prostate transrectal can't. With an MRI image, the special grid can be referenced on that image to target the biopsy, and reduce the number of needle samples required.
At the 2015 European Association of Urology 30th Annual Congress. Research data, conducted from 2010 and 2013 as a side study of the Global Prevalence of Infections in Urology study, involved 1214 patients from 136 countries in Africa, Asia, Europe, and South America was presented.
It was stated, "Infection rates after transrectal prostate biopsy are on the rise, and are "considerably higher" than they were a decade ago, a worldwide prevalence study suggests". Outcome data 2 weeks after biopsy were available for 876 patients. Of this cohort, 97% had undergone transrectal biopsy and 98% had received prophylactic antibiotics (82% with Fluoroquinolone-based agents...eg, cipro).
Of these patients, 50% developed symptomatic urinary tract infections, 3% developed febrile urinary tract infections, and 4% were hospitalized for these infections. One patient died as a result. This is really a terrible result for the patient. It means half of the group developed urinary tract infections.
One doctor said, "If their risk of infection or hospitalisation is higher than the chances of high-grade prostate cancer, I would recommend against prostate biopsy."
In summary, despite evidence that transperineal biopsies pose significantly less infection risk than the transrectal approach, this worldwide study shows that 97% of clinicians still use the transrectal route. Probably because no general anaesthetic required, is a quicker procedure, and maybe, more cynically, more monies can be made.
Looking on this forum, it is littered with people who became infected after a transrectal biopsy and required treatment, sometimes in hospital. Some of the people to this day, 2 or more years after their transrectal biopsy still have long term issues.
If it is decided I do require a biopsy to determine what is going on with my prostate, then I will use the transperineal version, which just happens to be the method provided by my urologist.
Geoff
0 likes, 12 replies
david53732 geoff90305
Posted
geoff90305 david53732
Posted
barney34567 geoff90305
Posted
I had a transperineal biopsy 6 weeks ago.
I read about the different types of biopsies and their pros and cons.
Then I met two urologists. One offered transperineal (MRI u/s guided) biopsy and the other offered (a stab in the dark, with the risk of contracting sepsis) transrectal.
The urologist that offered transperineal was the fellow who performed the bipsy and later operated on me.
I can't see why folk would choose transrectal, except in the situation where trasmpereneal isn't offered.
geoff90305 barney34567
Posted
If the cipro I am on for the next 6 weeks does not bring down my PSA, then we have to decide on what to do next. My MRI indicated no lesion to biopsy. My urologist said for low grade PCa, this is a comon MRI finding due to the tissue being so close in signal. However....there is a chance it could be more serious, it is just that the MRI did not pick it.
As my urologist only does transperineal biopsies, then if I have to have one, then I will get this done in November
Geoff
aksns61 geoff90305
Posted
Im in the US, have had several biopsy's over ten years- no problems, fast recovery both times. Im currently 74. I question any "gleason score" without an actual tissue sample. That s the ONLY way to actually identify the cancer. An MRI is not a substitute for a biopsy. Before my diagnosis in May, my prostate looked great, PSA was 8, and holding, but my urologist thought a updated biopsy would be the only way to tell if anything was happening. 12 samples were taken- the standard selection, covering the entire prostate. 10 cores showed slow growth cancer ( 3+3) and 2 cores showed intermediate growth ( 3+4). I elected to have 6 months of ADT, with seed implants.The NCCN treatment guidelines for my PCa did NOT recommend surgery. If you have access to the internet, please look at the last several ASTRO research studies of 84,000 patients with low to intermediate risk cancer. Your radiologist should have explained the new guidelines and not rush you into surgery. The survival rate is very high for low to intermediate risk even if NOTHING is done. ASTRO is the professional association of Radiologists. The NCCN guidelines are revised annualy and/or when a significant research result has an impact on patient treatment.
geoff90305 aksns61
Posted
Anyway, urologist has agreed to cipro for 6 weeks to see if it can calm a prostate infection. Urologist did warn me, the infection could be non bacterial, meaning cipro will do nothing. If the PSA does not retreat, then only option is for a biopsy. He always does this via transperineal, and will I guess provide some further information as to why the PSA rise, and my journey continues.
barney34567 geoff90305
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geoff90305 barney34567
Posted
barney34567 geoff90305
Posted
If a 3T MRI or for that matter, a 1.5T MRI which was reported on by someone who specialises in prostate imaging recorded no lesions, then that is good news.
My emphasis is on "someone who specialises in prostate imaging".
geoff90305 barney34567
Posted
Well, I guess these days it would be difficult to find a MRI technician who only does prostate images. I did ask the technician at the time," do you do many of these", he said, "yes, 2 or 3 during the day, and on the nightshift from 5 pm until 9 pm, we mostly do 3 or 4 prostates".
You have to rely on the urologist to a certain extent, though I did lots of reading about mpMRI and who was considered best in Brisbane, and that the urologists prefer to use. As my urologist apparently is a MRI reading guru, he said he "only" uses the company I went to because of the 3T machine, the technicians ability for clear pictures, and if they see some are not clear, OR they see some that will grab the radiologists attention, they will make sure those images are very clear, and a very experienced team of radiologists, of which one or more or prostate readers - this company has two such radiologists, one being the boss radiologist, that my urologists uses.
barney34567 geoff90305
Posted
You misunderstand.
The key is not the technician who takes the pictures and mans the MRI ( the radiographer).
The key is the radiologist who interpets the pictures.
You mention you're in or near Brisbane. Are you considering Wesley Hospital?
geoff90305 barney34567
Posted
I do not disagree that the radiologist has a key role in the diagnosis chain, but he/she is just one part, an important part, of the chain. If the images are not as clear as they could be, maybe an incorrect report. My urologist said, while the MRI report is important, it is one brick in the wall he needs to consider. In my case, considering the 'good' MRI report and his viewing concours nothing too serious, a quickly rising PSA means the prostate is unhappy due to "something". We have to find that "something". Urologist thinks it maybe the UTI, but is equally open to PCa, along with BPH causing the PSA rise.
My urologist is based and mostly works in the Mater Private Hospital, but also works at the Wesley as well as a few other places.
Anyway, in a few weeks I will finish my 6 week course of cipro (I have been lucky, as no serious side effects) and get the PSA test done, and...if still dodgy, the biopsy.
barney, what was involved with the transperineal biopsy? I presume day surgery for several hours? etc