Ultrasound Guided Prostate Biopsy

Authors: Dr Alain Lavoipierre*
                            Prof Rob Gibson *

What is an ultrasound guided prostate biopsy?

An ultrasound guided prostate biopsy is a procedure where a special needle is inserted into the prostate gland to take a small sample of tissue from the gland. The sample is then sent to a laboratory for testing, to determine the presence or absence of prostate cancer.

Why would my doctor refer me to have this procedure?

Your doctor would refer you to have this procedure, usually for one of three reasons:

• Your prostate-specific antigen (PSA), measured through a blood test, is high or rising rapidly.
• Your doctor may have felt an abnormality in your prostate when carrying out a digital rectal examination (DRE), where your doctor had inserted a gloved finger in your rectum (anus) to feel your prostate for any abnormal enlargement or other abnormality.
• If you have a very strong family history of prostate cancer.

How do I prepare for an ultrasound guided prostate biopsy?

Preparation for an ultrasound guided prostate biopsy includes:

• Taking antibiotic tablets by mouth, usually for 1 or 2 days before the biopsy, and on the morning of the procedure, to help prevent any risk of infection.
• You may have a small enema inserted into your rectum half an hour or so before the procedure to clean out your bowels and clear the rectum of faeces (so that the prostate may be seen more clearly with the ultrasound, and to lower the risk of infection).
• You may have an injection of antibiotics just before the procedure (again to stop infection).
• When you make your appointment for the ultrasound guided prostate biopsy, you need to let the hospital radiology clinic or department know if you are taking any blood thinning medication, such as warfarin, clopidogrel, dabigatran, prasugrel, dipyridamole or asantin (for more information about these medications, go to NPS: www.nps.org.au/medicines).
• Blood thinning medications will need to be stopped for a period of days, or your normal dose reduced, before this procedure is carried out. It is very important that you do not stop any of these medications or change the dose without consulting both the hospital radiology clinic or department and your own doctor. They will give you specific instructions about when to stop and restart the medication. These drugs are usually prescribed to prevent stroke or heart attack, so it is very important that you do not stop taking them without being instructed to do so by your doctor or the radiology practice or both. Aspirin is usually not stopped.
• A blood test may be required to check your blood clotting on the day of the procedure.
• The urologist, medical oncologist or radiation oncologist (specialist doctors) who referred you for the biopsy procedure will discuss and arrange your appropriate preparation with you.
• If you suffer from any heart valve condition or have an artificial heart valve or similar device, you must inform the radiologist (specialist doctor) carrying out the biopsy before having the procedure so that you can be given additional antibiotic cover.
• Often, an intramuscular injection (an injection into a muscle) of an antibiotic called Gentamicin is given to further reduce the likelihood of infection.

What happens during an ultrasound guided prostate biopsy?

During the procedure, you will be asked to lie on your left side, with your legs bent up.

The radiologist will first carry out a DRE with a gloved finger.
An ultrasound probe, which is about the thickness of a thumb, will then be inserted into your rectum. The probe is sterilised, covered with two condoms to ensure protection from any infection or contamination, and a lubricant to help it glide easily into your rectum.

Sometimes an injection of local anaesthetic or sedative may be given into the area of your rectum to minimise discomfort during the procedure.

Often the procedure is carried out after you have been given a light general anaesthetic, which means you will be asleep or sedated during the procedure.

After having examined your prostate with the ultrasound, the radiologist will then take biopsies. To take the biopsies, a very fine needle is guided, using pictures or images the radiologist can see on the ultrasound screen, through the wall of your rectum into the prostate and a sample of tissue is taken. The sample is sent to a pathology laboratory for analysis by another specialist doctor called a pathologist.

This biopsy sampling is repeated several times to ensure that any visible abnormal area is adequately sampled, and that as much of the prostate gland as is necessary is also sampled. Usually, between six and 14 individual samples will be taken and sent for analysis.

When this is over, the probe is removed and, if you have had a general anaesthetic, you are woken up. You are then given a small pad to wear around your bottom in case of any bleeding, and you will be kept under observation for a while until you can urinate. When the doctor or nurse is happy with your condition, you are allowed to leave – provided someone can take you home.

NOTE: The ultrasound guided prostate biopsy can sometimes be carried out through the perineum (the area of skin between the base of the penis and the rectum). This is called a trans-perineal approach. A local anaesthetic is injected into the perineum to numb the area before the biopsy. The ultrasound probe is inserted into the rectum to guide the biopsy, but the samples from the prostate are taken through the skin with a prostate needle.

This approach is used if:

• it is the radiologist’s preferred method;
• a possible cancer is suspected at the front of the prostate gland, the part furthest away from the rectum; or
• you do not have a rectum.

The radiologist can advise you before the procedure whether a trans-rectal or trans-perineal approach is being used.

Are there any after effects of an ultrasound guided prostate biopsy?

The after effects of an ultrasound guided prostate biopsy include:

Some discomfort in the area of the prostate as a result of the biopsies being taken.

Haematospermia. This means blood (or sometimes clots) in your sperm or ejaculate, and is extremely common after this type of procedure.

Haematuria (or blood in your urine). A common side-effect, it results from the fact that the urethra – the small canal transporting urine from your bladder to the penis – goes through the prostate and will therefore transport some blood into the urine.

Blood or clots when you first open your bowels, because the biopsies are taken through the rectum.

Infection. This is extremely rare, because of all the precautions taken. To help prevent this, your antibiotic cover may be continued for some days after the procedure. If you do get an infection, you will start feeling unwell as if you are getting the flu, often will have a fever, and sometimes may experience shivering. This will generally happen within 12–72 hours after the procedure. It is important that you notify your doctor immediately, or go to the nearest hospital emergency department.

Bleeding immediately after the procedure. Occasionally, some patients experience a small amount of bleeding from the rectum immediately after the procedure, sometimes when they are still on the procedure table. If this occurs, it will cease with gentle pressure, and is seldom of concern.

If you have had a light general anaesthetic or sedation, you will usually have a feeling of mild ‘wooliness’ in the head for a day or so.

How long does an ultrasound guided prostate biopsy take?

The ultrasound and biopsy procedure itself takes approximately 30 minutes.

The procedure together with preparation such the blood test, enema, injection of antibiotics, and observation time afterwards will take a couple of hours. If rectal bleeding occurs immediately after the procedure (a rare occurrence), you may be kept a little longer for observation until the radiologist or nurse feels that it is safe for you to go home.

What are the risks of an ultrasound guided prostate biopsy?

For the risks of an ultrasound guided biopsy, please also refer to the section on after effects.

Haematospermia (blood in the sperm) occurs in over 90% of patients having the procedure and this can persist for 2 or more weeks.

Haematuria (blood in urine) is very common (over 60% of patients).

Blood in the faeces is fairly common, but is usually mild.

Infection is very rare (less than 1% of patients overall), but this can be severe if untreated.

Internal haemorrhage. This is exceedingly uncommon (less than 0.01% of patients), but if severe may require surgery

Rarely, urine retention can occur. If the prostate is very enlarged to start with, and bleeding occurs within the prostate as a result of having the biopsy, this relatively small amount of bleeding may be enough to cause a blockage of the urethra – the canal that transports urine out of the bladder and passes through the prostate. This can then lead to retention, which is the temporary inability to pass urine. This is relieved by the passage of a catheter, a sterile rubber tube, which is inserted into the urethra to relieve the blockage.

What are the benefits of an ultrasound guided prostate biopsy?

The main benefit of an ultrasound guided prostate biopsy is that it helps accurately diagnose the presence or otherwise of cancer in the prostate.
If cancer is found, it helps diagnose the extent of the cancer and the appropriate treatment can then be undertaken.

Who does the ultrasound guided prostate biopsy?

The ultrasound guided prostate biopsy is carried out by a radiologist or urologist (specialist doctors), assisted by a sonographer (a trained technologist who helps to prepare and operate the ultrasound equipment), and often a nurse who helps look after the patient.

An anaesthetist will be present if the procedure is carried out using an anaesthetic.

Where is an ultrasound guided prostate biopsy done?

An ultrasound guided prostate biopsy is carried out either in a hospital as an outpatient procedure or in a day procedure centre. It can also be carried out in a radiology clinic.

When can I expect the results of my ultrasound guided prostate biopsy?

The pathology result generally takes a few days to be available to your doctor.

The time it takes your doctor to receive a written report on the test or procedure will vary depending on:

• the urgency with which the results are required by your doctor;
• the complexity of the test or procedure;
• whether more information is needed from your doctor before the test or procedure can be interpreted by the radiologist;
• whether you have had previous X-rays or other medical imaging that need to be compared with this test or procedure (this is commonly the case if you have a disease or condition that is being assessed as to its progress);
• how the report is sent to your doctor (i.e. phone, email, fax or mail).

Please feel free to ask the private practice, clinic, or hospital when the written report will be provided to your doctor.

It is important that you discuss the results with your doctor, either in person or on the telephone, so that they can explain what the results mean for you.

Useful websites about ultrasound guided prostate biopsy:

Trans-rectal Ultrasound Guided Prostate Biopsy:
urology.ucsf.edu/patientGuides/pdf/uroOnc/Prostate_Biopsy.pdf
Prostate Biopsy Procedure, Effects, Uses, Complications, and More:
www.webmd.com/men/prostate-biopsy
Prostate Biopsy Procedure:
www.prostate-cancer.com/prostate-cancer-treatment-overview/overview-biopsy.html

*The author has no conflict of interest with this topic.

Page last modified on 26/7/2017.