A prostate biopsy is a medical procedure used to remove small samples of tissue from the prostate gland, which is located just below the bladder in males. This tissue removal is performed specifically to examine the cells under a microscope for the presence of cancer. A physician typically recommends this procedure after initial screening tests, such as a Prostate-Specific Antigen (PSA) blood test, show an elevated level, or if a Digital Rectal Exam (DRE) reveals an abnormal area. The biopsy is the only definitive method available to confirm a prostate cancer diagnosis and determine the characteristics of any cancerous cells found.
Preparing for the Procedure
Before the scheduled biopsy, patients receive specific instructions designed to minimize complications. A major step involves adjusting medications, particularly those that increase the risk of bleeding. Blood-thinning agents like aspirin and warfarin are generally stopped for several days leading up to the procedure, but this change must always be coordinated with the prescribing physician.
To reduce the risk of infection, prophylactic antibiotics are a standard requirement. Patients often begin taking these antibiotics, frequently a fluoroquinolone, a few hours before the biopsy to ensure a therapeutic level is present during the procedure. Bowel preparation is also necessary to clear the rectum, often involving a small, at-home cleansing enema administered shortly before the appointment.
The Procedure: Execution and Methods
The prostate biopsy is performed using image guidance to ensure accurate sampling of the gland, and it relies on a thin, spring-loaded needle mechanism. Local anesthesia is injected to numb the area around the prostate, which helps manage discomfort during the collection of tissue cores. The procedure generally follows one of two main approaches, named for the path the needle takes to reach the prostate tissue.
The Transrectal Approach
The Transrectal Ultrasound (TRUS) guided biopsy is the more traditional approach. An ultrasound probe is inserted into the rectum to create real-time images of the prostate. The biopsy needle is passed through the wall of the rectum and into the prostate gland, with the ultrasound images guiding the physician to target specific areas. Typically, 10 to 12 tissue samples, or cores, are systematically collected from different regions of the prostate. While widely used, this method carries a slightly higher risk of infection because the needle passes through the bacteria-rich rectal wall.
The Transperineal Approach
The Transperineal approach is a more recent and increasingly preferred method. The biopsy needle is inserted through the perineum, the skin area between the scrotum and the anus. This technique avoids the rectal wall, which significantly lowers the risk of introducing rectal bacteria into the prostate and bloodstream. Guidance often utilizes a combination of ultrasound and pre-biopsy Magnetic Resonance Imaging (MRI) scans, which are fused together to provide a detailed map of suspicious areas. The transperineal path also allows for better access to the anterior (front) part of the prostate, which can be difficult to reach with the transrectal method.
Immediate Recovery and Potential Side Effects
Following the biopsy, patients can expect temporary side effects, which are generally mild and resolve within a few days to weeks. It is normal to observe blood in the urine, a condition known as hematuria, for several days as the small puncture sites heal. Light bleeding from the rectum, or hematochezia, may occur, particularly after a transrectal procedure, and is usually limited to spotting on toilet paper.
A common side effect that can persist longer is blood in the semen, called hemospermia, which may give the fluid a reddish or rust color for several weeks or even a couple of months. Physicians recommend that patients limit strenuous physical activity, such as heavy lifting or vigorous exercise, for at least 24 to 48 hours to minimize the chance of prolonged bleeding. Patients are also instructed to watch for signs that require prompt medical evaluation, including a fever or chills, which can signal a serious infection. Severe pain or a sudden inability to urinate are also symptoms that warrant immediate contact with the healthcare provider.
Understanding the Pathology Report
Once the tissue cores are collected, they are sent to a lab where a pathologist examines them under a microscope. The pathologist determines whether cancer cells are present and, if so, assesses how aggressive they appear. The findings are summarized in a pathology report, which is shared with the patient and the urologist.
The most important information in the report is the Gleason Score, a system that grades the appearance of the cancer cells on a scale of 1 to 5. Since most prostate cancers contain cells with two different patterns, the pathologist assigns a primary grade (most common pattern) and a secondary grade, and the two are added together to create a sum, or score. Gleason Scores range from 6 to 10, with a lower score indicating a less aggressive cancer. This score is often translated into a simpler Grade Group system, ranging from 1 to 5, which provides a clearer indication of the cancer’s potential behavior.