Biopsy of the Prostate

Biopsy (from the Greek bios, meaning life and opsis, meaning look), is a medical examination conducted on tissue or cells – or even on a complete organ – removed from the body.

The prostate gland is an organ which produces and secretes materials into the a tube or space in the reproductive system of male mammals. In humans, the prostate is a sex gland only found in men. The diameter of a normal prostate is between 3-4 cm and it weighs about 20 grams. The gland is located at the exit of the bladder and the urethra passes through it. The closest anatomical connection to the prostate is the rectum, located behind it.

Because the prostate is in the pelvis, it can be examined using a trans-rectal test, for example, via an ultrasound, either through the rectum or using the doctor’s finger. The prostate has an important function in male fertility. It secretes the prostate fluid that is an essential part of the seminal fluid, indeed it actually protects the semen cells. In addition, it prevents the seminal fluid entering the urinary pouch during ejaculation.

A trans-rectal prostate biopsy is a procedure in which a thin needle is inserted into the prostate by ultrasound and micro tissue samples are taken to be examined for possible prostate cancer.

Prostate Specific Antigen (PSA), is a protein secreted by the prostate into the blood and the seminal fluid. It is checked in a normal blood test. A rise in PSA level is not always a sign of cancer. PSA levels can rise after a rectal examination, ejaculation, infections in the urinary tract or prostate, use of a catheter and other reasons, including benign prostate growth. It is therefore recommended not to engage in intimate relations two days before the test and not to go for a PSA blood test when the patient has an active urinary tract infection.

Having said that, a normal PSA reading does not necessarily mean the absence of cancer. Sometimes prostate cancer is still present with a PSA level of less than 0.5. Whether the PSA level is “normal,” and therefore does not indicate cancer, is a decision for the urologist to make. He or she will take into consideration your age, PSA changes over time, your prostate size , family history, previous biopsies, drugs and other data.

When should one undergo a prostate biopsy?

•  When a rectal finger examination produces abnormal results.
• When a PSA blood test produces abnormal results.
• As part of active monitoring of prostate cancer.
• When an earlier biopsy was negative but the PSA continues to increase.
• When an earlier biopsy showed abnormal but non-cancerous cells.

What is involved in a prostate biopsy?

• The biopsy is performed in the Urology Institute, usually on Mondays and Thursdays at 12:00. You will be invited to the institute about 15-20 minutes beforehand. After being welcomed by the medical secretary (who will open your file, check your kupat holim guarantee and deal with any other bureaucracy), a doctor will then look at the referral letter from your urologist, check the results of blood and urine tests you will have been asked to bring with you, check any allergy to particular drugs and explain the process to you. You will then be asked to sign on an agreement form and the doctor will give final approval for the biopsy. One of the Urology Unit nurses will then help you change clothes, measure your blood pressure, pulse and temperature, and give you antibiotics (in addition to those you may have taken at home), as the doctor has ordered.
• You will then be shown into the examination room. It is fairly dark inside so the doctor can see the ultrasound pictures better. You will be asked to lie on your left side with your knees up to your stomach. A doctor will check you with his finger before the examination and then insert a transducer (a device that converts energy from one form to another) into your rectum.
• The doctor will conduct an initial scan of your prostate and then introduce a local anesthetic using a thin needle and instilling a numbing medication (Lidocain 1%), into the base of the prostate on both sides, in the nerve area, which indicates pain in the prostate. The needle is passed through the channel in the ultrasound’s transducer and positioned as directed by the ultrasound itself. Later on the doctor will scan your prostate again and measure the volume of your prostate gland and other data if necessary.
• The biopsy will be carried out through the same channel in the transducer and guided by the ultrasound using another thin needle connected to a special device (“the pistol”) which enables the doctor to easily, efficiently and speedily take the biopsy. The pistol makes knocking noises, and the examination is safe with no risks. We usually take 12 or more biopsies from the different areas of the prostate. The biopsy procedure lasts about 10-15 minutes.
• After the test, you will be asked to remain lying down until the nurse comes to accompany you outside. You will change back into your clothes and the nurse will tell you how to act at home and what to do in various situations. You will also receive a letter with the results of the ultrasound. You will receive the actual biopsy results later.

Does it hurt?

Thanks to the local anesthetic, pain is reduced to a minimum. From our experience, and from a survey of biopsy patients, the average pain at the time the biopsy is taken, graded on a scale of 0 (no pain) to 10 (excruciating pain), is 2. There will be a little pain or discomfort at the start of the examination, as the transducer is inserted into the rectum, before the local anesthetic.

How should I prepare for the biopsy?

• Bring a referral letter from your urologist (Shaare Zedek’s Urology Institute patients do not need a letter like this, because everything is documented in your medical files at the unit.)
• Bring appropriate guarantee from your kupat holim – prostate biopsy with different approaches, Health Ministry code 55700 – or any other financial arrangement.
• Bring up to date results of urine and urine culture tests.
• Bring up to date results of a blood test to check kidney functioning (CRE, UREA).
• Take an antibiotic tablet at 8:00 on the morning of the biopsy.
• If you take a blood thinner regularly:
  1. Aspirin, Micropirin – consult with your family doctor or the doctor that prescribed you the drug and stop taking it two days before the examination.
  2. Plavix – consult with a cardiologist or the doctor that prescribed you the drug and stop taking it five days before the examination. If you can’t stop and you need to swap for another drug, contact the Head Nurse in the Urology Institute in advance.
  3. Coumadin, Sintrom – consult with a cardiologist or the doctor that prescribed you the drug and stop taking it five days before the examination. Bring the results of a blood test for coagulation functioning taken on the day or the day before the examination. If you can’t stop and you need to swap for another drug, contact the Head Nurse in the Urology Institute in advance.
• If you take other blood thinning drugs, contact the Head Nurse in the Urology Institute in advance.
• There is no need to fast before a biopsy. Eat as you would normally.

What are the risks involved in a biopsy of the prostate through the rectum?
Significant complications are rare, but one should pay attention to the following:

• Slight discomfort or pain in the anal area.
• Bleeding, usually light and usually stops by itself:
  
  1. From the anus, up to a week.
  2.  In the urine, up to 2-3 weeks.
  3. In the semen, up to 2 months.
• Difficulty in passing water, particularly if there were problems before the biopsy. Things may be worse afterwards.
•  Inability to pass water – you have a sensation of wanting to urinate but the urine doesn’t come out. In this case, come immediately to the ER at Shaare Zedek.
• Signs of infection – a high temperature (over 38°), general weakness, shivering, apathy – in any or all of these cases, come to the hospital.
• Some patients may notice disruptions in their sexual functioning for a short while after the biopsy.

How do I get the results?

The doctors at Shaare Zedek’s Pathological Institute will check your biopsy. Currently, results are ready within 2-3 weeks.

• If you are a patient at Shaare Zedek’s Urology Institute, you should make an appointment with your urologist for 3 weeks after the biopsy.
• If your urologist is somewhere else, make an appointment with him for 2-3 weeks after the biopsy. On the day before the appointment, call the Urology Institute at Shaare Zedek and ask them to send your biopsy results to your doctor.

When to take blood thinners again?

Generally, you can take blood thinners again the day after the biopsy but pay attention to any bleeding. If the bleeding does not stop, wait with the blood thinners. And if it still hasn’t stopped after three days, consult your urologist.

Do I need a companion?

Not really. The biopsy is performed under local anesthetic and doesn’t affect the patient’s functioning.
Very occasionally, we perform the biopsy under sedation, and in such cases we do recommend bringing someone with you. We suggest a close family member who can give you both physical and emotional support.

I’m a bit confused by all these explanations. What should I do?

You’re welcome to make an appointment with the Head Nurse at the Urology Institute and she will explain everything to you.

I have a catheter. Am I any different to a patient without a catheter?

People with a regular catheter tend to attract more urinary tract infections. Their urine cultures are often positive. We recommend you provide a urine culture two weeks before the biopsy. If it is positive, the doctor will prescribe antibiotic treatment. After that, you will be asked for another urine culture. If the results are now negative, you can come in for the biopsy. If they are still positive, consult the Head Nurse in the Urology Institute. Sometimes you may have to take a second round of antibiotics or maybe even come into hospital and receive them intravenously.

I take Coumadin or Sintrom as blood thinners. What should I do?

These drugs affect the blood’s coagulation system. Therefore, patients on these drugs tend to bleed during or after the biopsy. The effects of these drugs continue some time after the patient stops taking them.
There are cases when it is possible to stop taking the drug and then go back to it after the biopsy, but there are others when you should not stop taking them without replacing them with another drug.
Therefore, consult your family doctor or the doctor who gave you the prescription and – if he or she approves – stop taking the drug five days before the test and bring the results of your blood coagulation on the day of or the day before the biopsy.
If you cannot stop taking the drug and you need to switch to another drug, please contact the Head Nurse at the Urology Institute.

When should I go to the ER?

• Any sign of infection - 38° + temperature, general weakness, shuddering, apathy.
• No urine – you feel the need but nothing comes.
• Heavy bleeding from the urinary tract (red urine, blood clots)
• Heavy and continued bleeding from your anus.

Why should I take antibiotics and how?

As we have indicated, the biopsy is conducted through the rectum, which is full of germs. To prevent infection after the biopsy, we recommend taking a certain type pf antibiotic that is absorbed well by the digestive system and is able to penetrate the prostate tissue. Although there are different dosages, we recommend taking one antibiotic pill on the morning of the test and then, for the next five days, to take two – one in the morning and one in the evening. Appropriate antibiotics are Ciprofloxacin, 500 mg twice a day, or Ofloxacin, 200 mg twice a day, for five days, a total of 10 pills.