Prostate biopsy
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Prostate biopsy is a procedure in which small hollow needle-core samples are removed from a man's
prostate gland The prostate is an male accessory gland, accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found in all male mammals. It differs between species anatomically, chemica ...
to be examined for the presence of
prostate cancer Prostate cancer is the neoplasm, uncontrolled growth of cells in the prostate, a gland in the male reproductive system below the bladder. Abnormal growth of the prostate tissue is usually detected through Screening (medicine), screening tests, ...
. It is typically performed when the result from a PSA blood test is high. It may also be considered advisable after a
digital rectal exam Digital rectal examination (DRE), also known as a prostate exam (), is an internal examination of the rectum performed by a healthcare provider. Prior to a 2018 report from the United States Preventive Services Task Force, a digital exam was a c ...
(DRE) finds possible abnormality. PSA screening is controversial as PSA may become elevated due to non-cancerous conditions such as
benign prostatic hyperplasia Benign prostatic hyperplasia (BPH), also called prostate enlargement, is a noncancerous increase in size of the prostate gland. Symptoms may include frequent urination, trouble starting to urinate, weak stream, urinary retention, inability t ...
(BPH), by infection, or by manipulation of the prostate during surgery or
catheterization In medicine, a catheter ( ) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Catheters are man ...
. Additionally many prostate cancers detected by screening develop so slowly that they would not cause problems during a man's lifetime, making the complications due to treatment unnecessary. The most frequent side effect of the procedure is
blood in the urine Hematuria or haematuria is defined as the presence of blood or red blood cells in the urine. "Gross hematuria" occurs when urine appears red, brown, or tea-colored due to the presence of blood. Hematuria may also be subtle and only detectable with ...
(31%). Other side effects may include infection (0.9%) and death (0.2%).


Ultrasound-guided prostate biopsy

The procedure may be performed transrectally, through the
urethra The urethra (: urethras or urethrae) is the tube that connects the urinary bladder to the urinary meatus, through which Placentalia, placental mammals Urination, urinate and Ejaculation, ejaculate. The external urethral sphincter is a striated ...
or through the
perineum The perineum (: perineums or perinea) in placentalia, placental mammals is the space between the anus and the genitals. The human perineum is between the anus and scrotum in the male or between the anus and vulva in the female. The perineum is ...
. The most common approach is transrectally, and historically this was done with tactile finger guidance. The most common method of prostate biopsy was transrectal
ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...
-guided prostate (TRUS) biopsy. Extended biopsy schemes take 12 to 14 cores from the prostate gland through a thin needle in a systematic fashion from different regions of the prostate. A biopsy procedure with a higher rate of cancer detection is template prostate mapping (TPM) or transperineal template-guided mapping biopsy (TTMB), whereby typically 50 to 60 samples are taken of the prostate through the outer skin between the rectum and
scrotum In most terrestrial mammals, the scrotum (: scrotums or scrota; possibly from Latin ''scortum'', meaning "hide" or "skin") or scrotal sac is a part of the external male genitalia located at the base of the penis. It consists of a sac of skin ...
, to thoroughly sample and map the entire prostate, through a template with holes every 5 mm, usually under a general or spinal
anaesthetic An anesthetic (American English) or anaesthetic (British English; see spelling differences) is a drug used to induce anesthesia ⁠— ⁠in other words, to result in a temporary loss of sensation or awareness. They may be divided into t ...
.PROMIS - Prostate MRI Imaging Study. An evaluation of multi-parametric magnetic resonance imaging in the diagnosis and characterisation of prostate cancer. (UK) Medical Research Council - Clinical Trials Unit - PROMIS Trials Office. MRC: PR11, 2 February 2012
Antibiotics An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
are usually prescribed to minimize the risk of infection. A healthcare provider may also prescribe an
enema An enema, also known as a clyster, is the rectal administration of a fluid by injection into the Large intestine, lower bowel via the anus.Cullingworth, ''A Manual of Nursing, Medical and Surgical'':155 The word ''enema'' can also refer to the ...
to be taken in the morning of the procedure. During the transrectal procedure, an ultrasound probe is inserted into the rectum to assist in guiding the biopsy needles. Following this, a
local anesthetic A local anesthetic (LA) is a medication that causes absence of all sensation (including pain) in a specific body part without loss of consciousness, providing local anesthesia, as opposed to a general anesthetic, which eliminates all sensati ...
, such as
lidocaine Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia and ventricular fibrillation. When used for local anae ...
, is administered into the tissue surrounding the prostate. Subsequently, a spring-loaded biopsy needle is inserted into the prostate, resulting in a clicking sound. When the local anesthetic is effective, any discomfort experienced is minimal.


MRI-guided targeted biopsy

Since the mid-1980s, TRUS biopsy has been used to diagnose prostate cancer in essentially a blind fashion because prostate cancer cannot be seen on ultrasound due to poor soft tissue resolution. However, multi-parametric
magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...
(mpMRI) has since about 2005 been used to better identify and characterize prostate cancer. A study correlating MRI and surgical pathology specimens demonstrated a sensitivity of 59% and specificity of 84% in identifying cancer when T2-weighted, dynamic contrast enhanced, and diffusion-weighted imaging were used together. Many prostate cancers missed by conventional biopsy are detectable by MRI-guided targeted biopsy. In fact, a side-by-side comparison of TRUS versus MRI-guided targeted biopsy that was conducted as a prospective, investigator-blinded study demonstrated that MRI-guided biopsy improved detection of significant prostate cancer by 17.7%, and decreased the diagnosis of insignificant or low-risk disease by 89.4%. Two methods of MRI-guided, or "targeted" prostate biopsy, are available: (1) direct "in-bore" biopsy within the MRI tube, and (2) fusion biopsy using a device that fuses stored MRI with real-time ultrasound (MRI-US). Visual or cognitive MRI-US fusion have been described. When MRI is used alone to guide prostate biopsy, it is done by an
interventional radiologist Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both ...
. Correlation between biopsy and final pathology is improved between MRI-guided biopsy as compared to TRUS. In the fusion MRI-US prostate biopsy, a prostate MRI is performed before biopsy and then, at the time of biopsy, the MRI images are fused to the ultrasound images to guide the
urologist Urology (from Greek οὖρον ''ouron'' "urine" and ''-logia'' "study of"), also known as genitourinary surgery, is the branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs. Org ...
to the suspicious targets. Fusion MRI-US biopsies can be achieved in an office setting with a variety of devices. MRI-guided prostate biopsy appears to be superior to standard TRUS-biopsy in prostate cancer detection. Several groups in the U.S., and Europe, have demonstrated that targeted biopsies obtained with fusion imaging are more likely to reveal cancer than blind systematic biopsies. In 2015, AdMeTech Foundation, American College of Radiology and European Society of Eurogenital Radiology developed Prostate Imaging Reporting and Data System (PI-RADS v2) for global standardization of image acquisition and interpretation, which similarly to BI-RADS standardization of breast imaging, is expected to improve patient selection for biopsies and precisely-targeted tissue sampling. PI-RADS v2 created standards for optimal mpMRI image reporting and graded the level of suspicion based on the score of one to five, with the goal to improve early detection (and exclusion) of clinically significant (or aggressive) prostate cancer. The higher suspicion on mpMRI and the higher PI-RADS v2 score, the greater the likelihood of aggressive prostate cancer on targeted biopsy. Considerable experience and training is required by the reader of prostate mpMRI studies. Up to 2013, indications for targeted biopsy have included mainly patients for whom traditional TRUS biopsies have been negative despite concern for rising PSA, as well as for patients enrolling in a program of active surveillance who may benefit from a confirmatory biopsy and/or the added confidence of more accurate non-invasive monitoring. Increasingly, men undergoing initial biopsy are requesting targeted biopsy, and thus, the use of pre-biopsy MRI is growing rapidly. Clinical trials of mpMRI and PI-RADS v2, including NIH-funded studies are underway to further clarify the benefits of targeted prostate biopsy.


Side effects

Side effects of a TRUS or TPM biopsy include: * rectal pain or discomfort (very common) * burning when passing urine (very common) * bruising (very common with TPM only) * bloody urine for 2–3 days (very common) * bloody semen for ~3 months (30% with TRUS; ~100% with TPM) * poor erections for ~8 weeks (30% with TRUS; ~100% with TPM) * infection of skin or urine (1–8%) * infection of skin or urine requiring hospitalisation and intravenous antibiotics (1–4%) * difficulty urinating (1% with TRUS; >5% with TPM)


Gleason score

The tissue samples are examined under a microscope to determine whether cancer cells are present, and to evaluate the microscopic features (or Gleason score) of any cancer found. Gleason score, PSA, and digital rectal examination together determine clinical risk, which then dictates treatment options.


Tumor markers

Tissue samples can be stained for the presence of PSA and other tumor markers in order to determine the origin of malignant cells that have metastasized.


References

{{Male genital procedures Biopsy Histopathology Male genital surgery Prostatic procedures Prostate cancer