Transrectal Ultrasound (TRUS) Guided Prostate Biopsies- Diagnostic Procedure

Cystoscopy :: Digital Rectal Examination ::  Pathology
PSA :: Radiology :: Urodynamics :: TRUS

This relatively new technique allows us to visualise the entire prostate gland with ultrasound waves. It gives information about the actual size of the prostate gland and whether or not there are suspicious areas.

The prostate ultrasound is a recent advance that has helped to dramatically improve the urologist's ability to detect cancer at an early, curable stage. Most importantly, the ultrasound is able to assist us to focus biopsies more accurately on areas that may be suspicious for cancer.

When is ultrasound and biopsy needed?

If your PSA is elevated or your rectal examination is suspicious, your doctor may recommend that you have a prostate ultrasound with biopsies. At times, an ultrasound may be done without biopsies.

What is a prostate biopsy?

In a biopsy of the prostate, multiple tiny sliver-like pieces of tissue are obtained for microscopic analysis to ascertain if cancer is present. These pieces are obtained through a long, but very thin needle, specifically designed to open inside the prostate, take the sample and then close. Biopsies are usually done as an outpatient office procedure. Studies show that there should probably be at least six separate biopsies at the time of the procedure to get an adequate sampling of the gland. Some experts now call for additional biopsies of deeper areas in the gland as some cancers can be present and they are occasionally missed.

How is a prostate ultrasound done?

A lubricated ultrasound probe is gently inserted into the rectum. Sound waves are emitted from the end of the probe. They bounce off the prostate and are detected by the probe. These sound waves bouncing off the different tissues are transformed into a picture of the entire prostate.

How is a transrectal biopsy done?

For transrectal biopsy, the needle is inserted into the prostate through the rectal wall. The rectal wall is thin so it is possible to place the needle very accurately and with little injury to other tissues. Because of its simplicity and accuracy, this is by far the most common technique used.

Does the ultrasound and biopsy hurt?

Some men describe a cramping sensation that usually passes in a few minutes. Most say afterwards that it wasn't as bad as they had anticipated.

Does biopsy allow the cancer to spread?

There is no evidence that cancer spreads through a biopsy.

What are the risks attached to the biopsy?

The risks include -

1. Infection
2. Bleeding
   
   
1. Infection can occur because of the introduction of a needle through the rectal wall into the prostate gland, but with appropriate antibiotic before biopsy and antibiotic afterwards infection is very rare.
   
   
2. Some bleeding after prostate biopsies is very common. This is because the needles pass through the rectal wall and into the prostate which is surrounded by many veins.

Patients should expect to see some blood in the urine, semen and with bowel movements on and off, sometimes up to a few weeks after the biopsy. Occasionally, blood can be seen in the semen for a few months after prostate biopsy. This is expected and patients should not be alarmed.

Rarely, severe infection called sepsis can occur. This is very uncommon and an infection in the blood stream with high fevers and shaking chills when it occurs is serious but fortunately this side effect is quite rare.

Very occasionally severe or major haemorrhage may occur. This again is rare, especially today when we are careful to cease aspirin for 10 days prior to the biopsy being performed.

What if the report isn't sure there is cancer?

Sometimes pathologists don't have enough tissue to give a definite answer. When this happens, the pathologist may recommend that further biopsies be done.

If you have had a biopsy that shows no cancer, what are the odds cancer is present but was simply missed by the biopsies?

A relatively small percentage, about 15%, of men with a negative biopsy still have cancer of the prostate and they may need repeat biopsies and close, regular follow-up. Unfortunately, there is no way to know which patients are that 15%. We need to follow up everyone who has an abnormal examination, an elevated PSA and a negative biopsy.

When will we know the results?

It may take between 4 - 7 days for a detailed biopsy report to be available.

Routine Instructions For Patients Before Prostate Ultrasound

1. No aspirin products for 1 week before the procedure. Aspirin keeps normal clotting mechanisms from working. It blocks the blood product called platelets from functioning. This means that you can have an increased risk of bleeding.
   
   
2. No anti-inflammatory medications for 48 hours before procedure.
   
   
3. No blood thinners such as Warfarin or Heparin.
   
   
4. You will be given an antibiotic to take on the day of the procedure. You will also usually be given two tablets to take at home after the procedure. This helps prevent infection.
   
   
5. Do not empty the bladder for one hour before the procedure as the bladder should be
   approximately half full prior to ultrasound and biopsy.
   
   
6. A Microlax enema will be given to you to use 1 - 2 hours before the procedure. This will work
   in 15 - 20 minutes. Use your bowels when you feel the need as it is important that the rectum
   is empty.

Easy Directions for Use of The Enema

1. Remove the cap from the nozzle, squeeze a drop of the enema on to the tip of the tube. This will make the tube easier to insert.
   
   
2. Insert the nozzle into the rectum. The nozzle can be completely inserted. Squeeze out the entire contents of the tube into the rectum and then remove the nozzle.

• Normally is a Day Only Procedure.
  
  
• Please note following general anaesthetic, you must not drive or travel on public transport alone for 24 hours and you must ensure that you have someone to take you home from the hospital. You may travel by taxi home.
  
  
• Check medication list given to you by the rooms. Please cease any medication on list 5 to 10 days prior to procedure. (stated on list)
  
  
• PREPARATION PRIOR TO PROCEDURE: Take medication-Ciprofloxacin (contents in envelope given to you by Dr Vass’s Rooms)
  
  
• On the day of the biopsy take one tablet 1-4 hrs before the procedure with a sip of water
  
  
• Take one table after the biopsy before bed
  
  
• On the day after the biopsy take one tablet in the morning and one tablet before bed
  
  
• Arrange your post operative appointment for one week after the procedure.

Post Operative Care

The main risks associated with the procedure are:

• Bleeding – which may occur in the bowel motions, the urine and in the seminal fluid. This usually clears within a few days although sometimes it may persist as dark blood in the seminal fluid for a little longer, up to 2-4 weeks. This is not serious.
  
  
• Urinary difficulty – sometimes the procedure may cause some temporary swelling of the prostate and you may experience some difficulties with urination. On rare occasions the urethra may block stopping you urinating and you may need to have a catheter inserted. If this occurs contact your doctor or present to the nearest hospital.
  
  
• Infection – severe infections are rare but you may experience some fevers and sometimes shivers. If this occurs contact your doctor or present to the nearest casualty department. To prevent the risks of infection, continue to take the antibiotics as prescribed.

Please follow these instructions to prevent complications from the procedure.

• Continue taking antibiotics as directed pre-operatively by Dr Vass
• Increase your fluid intake for the next 1-2 days to decrease formation of blood clots in your urine.
• Limit physical activity for 24 hours.

Note: It is important to contact your doctor OR present to the nearest casualty department if you experience any of the following:

• Chills
• Fever
• Blood clots or excessive blood in the urine or stool
• Difficulty or inability urinating