Prostate biopsy

What it actually is

A prostate biopsy involves taking small tissue samples with a fine needle guided by ultrasound, for a pathologist to examine under the microscope. It is the only method that confirms or rules out prostate cancer: neither the PSA nor the MRI diagnoses it, they only indicate that a look is needed.

Several samples are taken: some targeted at the suspicious area the MRI identified, and others distributed systematically through the rest of the gland. It takes fifteen to thirty minutes, it is a day procedure, and you walk out.

The myths, and what the evidence says

These are the ones I hear in clinic. I put them first because they are the reason many patients delay by months a biopsy they needed.

Before the biopsy: the MRI

This is the most important change of the past decade and it is still not applied everywhere. Multiparametric MRI comes before the needle, not after.

• If the MRI finds no suspicious lesion and the rest of the picture agrees, a proportion of patients can avoid biopsy and stay under surveillance.
• If it finds a lesion, it allows the needle to be directed at it rather than sampling at random, which increases detection of the tumours that matter.
• And it reduces the finding of irrelevant tumours, which are the ones that lead to overtreatment.

In the elevated PSA guide I explain when a biopsy is justified and what can alter the figure before deciding.

The two routes, and what distinguishes each

The needle can enter through the rectum or through the skin of the perineum, the area between scrotum and anus. Both obtain the same tissue and detect cancer equally. They differ in other respects, and neither is the right one for every case:

What the procedure is like

• Preparation. Whether you take anticoagulants or antiplatelets is reviewed and a decision made on stopping them. For the transrectal route, antibiotics and rectal preparation are prescribed.
• Anaesthesia. A local prostatic block, with sedation if you prefer it or the case calls for it.
• Duration. Fifteen to thirty minutes.
• Afterwards. A period of observation and home. No admission is needed.
• Result. The pathology report usually takes five to ten days.

Afterwards: what is normal and what is not

Normal:

• Blood in the urine for a few days.
• Blood in the semen, rust or brown coloured, for four to six weeks. It is the most frightening and the most harmless.
• Slight rectal bleeding for a couple of days, if the route was transrectal.
• Perineal discomfort and urinary urgency for a few days.

Not normal, and you should seek help immediately:

• Fever with rigors, above all in the first 48 hours. It is the sign that matters most.
• Inability to pass urine.
• Heavy bleeding, or clots that do not settle.
• Severe and increasing pain.

Understanding the result

• If there is cancer, the report carries a grade —the ISUP group, derived from the Gleason score— and how many samples it appeared in. The risk classification follows from that, and with it every subsequent decision.
• If there is no cancer, it is compared with the MRI and the PSA. An image-targeted negative biopsy is highly reassuring, though not absolutely so.
• Intermediate findings such as intraepithelial neoplasia or atypical small acinar proliferation are not cancer, but they change the follow-up and sometimes indicate repeating.

A diagnosed cancer does not mean immediate surgery: a proportion of patients enter active surveillance and never need treatment.

Decided beforehand, delivered afterwards

Why it matters who looks after you

A biopsy looks like a simple technical procedure, and in a way it is. The difficulty lies around it: deciding whether it is needed, choosing the route, aiming the needle well, and knowing what to do with whatever comes back.

• Deciding whether it appliesMany men are biopsied unnecessarily, while others have their PSA repeated for years when they should already have been investigated. The prior MRI is what separates a decision from a hunch.
• Choosing the route and explaining whyThe location of the lesion, your history and the infection risk point to one route or the other. It is a decision that deserves explaining rather than assuming.
• Aiming the needle where the lesion isAn MRI-fusion biopsy finds the tumours that matter and stops finding the ones that do not. It requires equipment and training, not merely intent.
• Sustaining whatever followsIf it is cancer, the path continues without changing doctor. If it is negative, someone has to design the follow-up rather than leave you with a sheet of paper and a "come back in a year".

Put plainly: what costs most in this disease is not a badly performed biopsy, it is a biopsy that was never done out of fear of a myth.

A urologic oncologist is a urologist who additionally completed a postgraduate fellowship devoted solely to urological cancer. Mine was at Centro Médico Nacional Siglo XXI, accredited by UNAM. It can be verified. What exactly changes →