Transperineal Prostate Biopsies

The biopsy is only being considered because it is felt that there is a risk of a prostate cancer. There isn’t a better alternative to diagnose or rule out the disease with any degree of certainty. The biopsy will only be performed after a full explanation and only with your agreement. If you don’t want to have a biopsy then you can choose not to but it’s important to understand the risks of not having the procedure done.

There are usually 3 ways to take tissue from the prostate for diagnostic purposes. The traditional way are Trans Rectal biopsies. Here an ultrasound probe is placed in the rectum and the biopsy needle goes through the rectum into the prostate.

Secondly transurethral biopsies can be taken, usually under a general anaesthetic with a telescope through the water pipe up to the prostate, this is usually used at times of prostate surgery where subsequent prostate tissue can be sent for analysis.

Thirdly biopsies can be done as a transperineal route. There has been a move to transperineal biopsies due to the lower infection and sepsis rates when compared with the transrectal approach. 

Currently there are no blood, urine or semen tests that can diagnose prostate cancer with any degree of certainty like the prostate biopsies.

The Perineum is the skin between the scrotum and anus, the prostate lies just a few centimetres in from the skin. A needle (not much larger than a needle for a blood test) is passed through the skin and very small slithers of prostate tissue are taken and sent to the pathologists for examination. Each biopsy is around the size and shape of a pin, around 2cm long.

They can be either be done under local or general anaesthetic. You will not need an enema or any bowel preparation. Patients sit in a reclined chair with their legs apart.

A Prostate examination is performed and gel is put into the rectum. The skin is sterilised with an antiseptic solution. An ultrasound probe is placed into the rectum to allow visualisation of the prostate and allow targeting of the biopsies from different areas of the gland.

Local anaesthetic is injected into the perineal skin and further deep anaesthetic is injected around the prostate, this anaesthetic is given time to work. Subsequently biopsies are taken from each side of the prostate and also “targeted” biopsies are taken from any areas in the prostate that are suspicious on the MRI scan. Around 20-25 biopsies will be taken in total. It is important that any lesions seen on the MRI and specifically targeted and sent separately to the pathologists.

Another advantage of the transperineal route is that antibiotics are not needed. We would only use antibiotics if

• You are immunocompromised in any way
• You are on any drugs that affect your immune system
• You have a diseased heart valve or had a heart valve replaced
• Previously had infections with prostate biopsies

The main group of drugs that will need to be stopped are blood thinning medication such as warfarin, aspirin, clopidogrel, ticagrelor, prasugrel, rivaroxaban, dabigatran or apixaban. If you have been taking any of these please make it clear to the staff.

Medication for the prostate gland such as tamsulosin should be continued, some patients may be started on this to reduce risk of retention prior to the procedure.

All other medication is usually continued if you have any concerns please raise this with staff.

• Occasionally a small percentage of patients can feel a bit faint immediately afterwards. 
• Patients may get some bruising on the perineal skin or up into the scrotum. 
• Pain is not usually a major issue but the prostate itself can feel bruised for the first week, some patients describe it a like sitting on a golf ball. You may need paracetamol or ibuprofen for the first couple of days after the biopsies.
• You can get blood from the end of the penis immediately after or get blood in the urine in the first few days, this is not an issue but can look frightening.
• The ejaculate can initially look heavily bloodstained which changes to a dark brown colour, this can take many weeks to clear. Again there is no health risk with this.
• You may notice that the urinary flow slows down for the first week.
• Rarely around 1-2% of patients cannot pass urine and go into urinary retention. If this happens a catheter is placed for a week. It is important we make sure you can pass water before you leave hospital. Patients with large prostates or who have voiding symptoms such as slow urinary flow or feeling like the bladder doesn’t empty make be at higher risk of retention, this will be discussed with you.
• Rarely 1-2% of patients can get a urinary infection
• Rarely <1% patients develop a high temperature suggesting sepsis and will require admission for iv antibiotics, if this happens please get in touch immediately or present to your local A&E department

It takes at least 1 week for the pathologists to examine and report on all the biopsies, we usually see patients 1-2 weeks after the biopsy for the results.

We would advise that you have someone who can take you home and you should refrain from driving and work for 48 hours as long as you have no persistent symptoms from the procedure.

Yes, there is a small chance of this as no test is 100% perfect although the chances of this would be low. This would be explained to you in your follow up consultation. Occasionally if we get a negative biopsy and we feel the risk is high or we haven’t found an alternative diagnosis we may recommend a repeat biopsy. However we do feel the transperineal biopsy with targeting of MRI lesions is the most sensitive diagnostic test for prostate cancer.

No, this would be very rare. If cancer is seen on the biopsy then that is a very accurate diagnostic test. Occasionally however, the grade or volume of cancer may change between the biopsy and subsequent biopsies or final pathological assessment of the prostate after a radical prostatectomy (surgery to remove the whole prostate). Very rarely the pathologist only sees a few cells that are suspicious and may not be able to diagnose prostate cancer, if the biopsies are non-diagnostic they may ask for repeat biopsies. All this would be discussed with you.