Prostate Cancer Risk Assessment and Diagnosis

Prostate cancer may be suspected if a man has a nodular prostate gland on digital rectal examination or if his PSA level is consistently higher than normal for his age. Your risk of prostate cancer is also affected by age and family history of prostate or breast cancer. By utilizing a combination of these parameters we can advise you of your risk of having prostate cancer diagnosed.

The next step in evaluation of a man with suspected prostate cancer is often a prostate biopsy however, in recent years multi-parametric MRI scans of the prostate are increasing used prior to consideration of biopsy. Multi-parametric MRI allows a non-invasive and very detailed assessment of the whole prostate gland. MRI is very accurate at identifying large and fast growing tumours. It is less sensitive at detecting smaller and slower growing cancers. If an abnormal area is seen then biopsy is usually recommended.

Transperineal Fusion Prostate Biopsy

MRI guided trans-perineal prostate biopsies are performed in men with an abnormality visible on prostate MRI. The abnormal area seen on the MRI scan is accurately targeted by computer assisted ‘fusion’ of the MRI images with live ultrasound images.

Compared to non-guided biopsy this allows more accurate detection of significant prostate cancer, often with the passage of fewer needles into the prostate. Trans-perineal biopsies have a very low risk of infection.

Wakefield Hospital has New Zealand’s first  trans-perineal fusion biopsy technology.

Procedure

The abnormal area on the MRI scan is outlined by the urologist.

At the time of biopsy a general anaesthetic is given. An ultrasound probe is inserted into the lower rectum to view the prostate gland. The MRI image with outlined abnormal area is overlayed onto the live ultrasound image.

A biopsy needle is then guided into the abnormal area and several small samples of prostate taken. Sampling of other areas of the prostate may also be undertaken.

The procedure takes 25 minutes to complete. Usually you are able to go home the same day. If the biopsy has been performed in the afternoon then staying overnight is a possibility. Before leaving hospital you need to pass urine. There will be temporary swelling and bruising of the perineum and scrotum. It is normal for blood to drip from the urethra and be seen in the urine for several days afterwards, this may even last for two weeks or more, especially in men who take blood thinners such as aspirin. There may be blood in your semen for up to six weeks following biopsy.

Pre-procedure

Aspirin, clopidogrel, dabigatran, warfarin and any other blood thinning medications will need to be stopped prior to surgery. We will advise you when to stop and re-start these medications A urine sample needs to be provided to the laboratory 1 week prior to surgery.

Post-procedure

Normally you are able to go home the same day of surgery. Before leaving you need to pass urine. There will be temporary swelling and bruising of the perineum and scrotum. It is normal for blood to drip from the urethra and be seen in the urine for several days afterwards, this may even last for two weeks or more, especially in men who take blood thinners such as aspirin. There will be blood in your semen for up to six weeks following the biopsy.

Risks

There is a very small risk of urinary blockage (urinary retention) following biopsy. If you feel that voiding has become difficult then contact us or attend the Emergency Department, as a catheter may need to be temporarily inserted. Some men experience temporary impairment in erections following biopsy. This is due to bruising of the nerves which cause erection & usually resolves within three months.

Return to Work

Following your biopsy we recommend that you take the remainder of the day off work. There may be an uncomfortable feeling in your pelvis in the hours following a biopsy. Paracetamol tablets are helpful for this.

Results

The biopsies are sent to the pathology laboratory. We usually have the results within 2-3 weeks. An appointment will be made to discuss the results with you.

Transrectal Ultrasound Guided Prostate Biopsy (TRUS biopsy)

The purpose of a TRUS biopsy is to sample the prostate gland to determine if prostate cancer is present. TRUS biopsies are most commonly performed in men with an elevated PSA level or an abnormal prostate examination (a prostate nodule).

Procedure

TRUS biopsy is usually an office-based procedure, which takes approximately fifteen minutes to perform. On the morning of the biopsy, an enema may help empty the bowels. One hour prior to the biopsy our clinic nurse will administer an injection of an antibiotic (Ertapenem) into your buttock. this reduces the risk of an infection developing as a result of the biopsy.

The biopsy is performed with you lying on your left side facing away from the urologist. A slim ultrasound probe is inserted through the anus, allowing the urologist to view the prostate gland. Local anaesthetic is then slowly injected alongside the probe into and around the prostate gland. Several minutes are allowed for this to take effect. The prostate gland dimensions are then measured.

Biopsies are taken using a biopsy gun, which sends a needle through the wall of the rectum and into the prostate taking a core of tissue as it does so. Twelve core samples (each approximately 1cm long and < 0.5mm wide) are taken from throughout the prostate. In certain circumstances, such as in a repeat biopsy then more samples may be taken. TRUS biopsy is mildly uncomfortable for most men.  There is also the option of light oral sedation prior to biopsy. Some men may prefer the option of a general anaesthetic.

Pre-procedure

Aspirin, clopidogrel, dabigatran, warfarin and any other blood-thinning medications will need to be stopped prior to surgery. We will advise you on the timing of when to stop and re-start these medications. A urine sample needs to be provided to the laboratory about 1 week prior to surgery. If the biopsy is to be performed under a local anaesthetic then food and fluid can be continued up until the biopsy. If a general anaesthetic is planned, then you will need to have no food or fluid for six hours prior to the biopsy.

Post-procedure

Most men feel quite well immediately afterwards however it is not uncommon for men to experience a brief period of light-headedness and sweating within ten minutes of the procedure. It is normal for blood to drip from the urethra and be seen in the urine and bowel motions for several days afterwards, this may even last for two weeks or more, especially in men who take blood thinners such as aspirin. There will be blood in your semen for up to six weeks following the biopsy. There is no restriction on driving afterwards unless the biopsy was performed under sedation or a general anaesthetic.

Risks

The main risk we are concerned about is an infection, which can be quite severe. Since beginning using Ertapenem routinely, we have not experienced serious infection in over 400 biopsies. However, if you notice symptoms of infection within two weeks of the biopsy such as fever, shivering or sweating, then you need to immediately present at the Emergency Department of the hospital.

There is a very small risk of urinary blockage (urinary retention) following biopsy. If you feel that voiding has become difficult then contact us or attend the Emergency Department, as a catheter may need to be temporarily inserted.

Return to Work

Following your biopsy, we recommend that you take the remainder of the day off work. There may be an uncomfortable feeling in your pelvis in the hours following a biopsy. Paracetamol tablets are helpful for this.

Results

The biopsies are sent to the pathology laboratory. We usually have the results within 2-3 weeks. An appointment will be made to discuss the results with you.