Trans Rectal Prostatic Ultrasound and Biopsy

This publication includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence-based sources. It is, therefore, a reflection of best urological practice in the UK. It is intended to supplement any advice you may already have been given by your GP or other healthcare professionals. Alternative treatments are outlined below and can be discussed in more detail with your Urologist

What does the procedure involve?

This procedure involves using an ultrasound probe, inserted via the back passage, to scan the prostate. If biopsies are needed, a needle is inserted into the prostate and tissue (normally between 10 and 18) are taken

What are the alternatives to this procedure?

• Observation with repeat blood tests
• Multi parametric MRI scan of prostate after which a biopsy may still be necessary

What should I expect before the procedure?

Prostatic ultrasound is usually performed under local anaesthetic and you will normally be admitted on the same day as the procedure. In this case, you may eat and drink as normal before your appointment and may have lunch on the same day. You will also be asked to undergo swabbing of your nose & throat to ensure that you are not carrying MRSA.

If the procedure is to be performed under general anaesthetic, you will receive an appointment for pre-assessment to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations.

If you are taking Warfarin, you must inform the clinic staff at or the pre-assessment staff so that you are advised when to stop your Warfarin prior to the procedure. Usually you are asked to withhold Warfarin for 3 days. A blood test, INR, will be performed prior to your biopsy. If you are taking Aspirin, you do not need to stop these. If you are taking Clopidogrel, you must inform the doctor in the clinic because the biopsy may need to be postponed or alternative arrangements made.

After checking for allergies, you will normally be given antibiotics to prevent infection in the prostate, the urine or the bloodstream.

Please be sure to inform your surgeon in advance of your surgery if you have any of the following:

• An artificial heart valve
• A coronary artery stent
• A heart pacemaker or defibrillator
• An artificial joint
• An artificial blood vessel graft
• A neurosurgical shunt
• Any other implanted foreign body
• A regular prescription for Warfarin, Aspirin or Clopidogrel (Plavix®)
• A previous or current MRSA infection
• A high risk of variant-CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human-derived growth hormone)

At some stage during the admission process, you will be asked to sign the second part of the consent form giving permission for your operation to take place, showing you understand what is to be done and confirming that you wish to proceed. Make sure that you are given the opportunity to discuss any concerns and to ask any questions you may still have before signing the form.

What happens during the procedure?

If the procedure is to be carried out under local anaesthetic, you will be changed into a gown and then asked to lie on a couch on your left side with your knees drawn up to your chest. The doctor will examine the prostate through the back passage (anus) before inserting the ultrasound probe. This probe is as wide as a man’s thumb and approximately 4 inches long. During the examination, which takes up to 20 minutes, you may feel some vibration from the motor within the probe.

In most cases it will be necessary to take samples (biopsies) of the prostate. Local anaesthetic is first injected around the prostate with a fine needle before the samples are taken; the taking of biopsies involves passing a needle through the centre of the probe which is activated by a spring-loaded device and makes an audible “crack”. Insertion of the needle causes mild discomfort, not dissimilar to a blood test needle. If a series of samples need to be taken, the prostate may feel “bruised” by the end of the procedure. It is usually necessary to take between 10 and 18 samples.

What happens immediately after the procedure?

In general terms, you should expect to be told how the procedure went and you should:

• Ask if what was planned to be done was achieved
• Let the medical staff know if you are in any discomfort
• Ask what you can and cannot do
• Feel free to ask any questions or discuss any concerns with the ward staff and members of the surgical team
• Ensure that you are clear about what has been done and what is the next move

When no samples have been taken, there are no side-effects. If biopsy samples have been taken, blood in the urine is common for 2-3 days but this clears quickly if you increase your fluid intake. Bleeding may also occur from the back passage for a short period and in the semen for up to 6 weeks.

You will be given antibiotics to take home for a 3-day period if biopsy samples have been taken.

The average hospital stay is less than 1 day

Are there any side-effects?

Most procedures have a potential for side-effects. You should be reassured that, although all these complications are well-recognised, the majority of patients do not suffer any problems after a urological procedure.

Common (greater than 1 in 10)

• Blood in the urine
• Blood in the semen – this may last for up to 6 weeks but is perfectly harmless and poses no problem for you or your sexual partner Blood in the stools
• Urinary infection (10% risk)
• Sensation of discomfort from the prostate due to bruising
• Haemorrhage (bleeding) causing an inability to pass urine (2% risk)

Occasional (between 1 in 10 and 1 in 50)

• Blood infection (septicaemia) requiring hospitalisation (2% risk)
• Haemorrhage (bleeding) requiring hospitalisation (1% risk)
• Failure to detect a significant cancer of the prostate
• The procedure may need to be repeated If the biopsies are inconclusive or
• your PSA level rises further at a later stage

Rare (less than 1 in 50)

Inability to pass urine (retention of urine)

Hospital-acquired infection

• Colonisation with MRSA (0.9% – 1 in 110)
• Clostridium difficile bowel infection (0.01% – 1 in 10,000)
• MRSA bloodstream infection (0.02% – 1 in 5000)

The rates for hospital-acquired infection may be greater in high-risk patients e.g. with long-term drainage tubes, after removal of the bladder for cancer, after previous infections, after prolonged hospitalisation or after multiple admissions.

What should I expect when I get home?

By the time of your discharge from hospital, you should:

• Be given advice about your recovery at home
• Ask when to resume normal activities such as work, exercise, driving, housework and sexual intimacy
• Ask for a contact number if you have any concerns once you return home
• Ask when your follow-up will be and who will do this (the hospital or your GP)
• Ensure that you know when you will be told the results of any tests done on tissues or organs which have been removed It is important that you:
• Sit quietly at home for the first 48 hours after the biopsies
• Drink twice as much fluid as you would normally for the first 48 hours after the biopsies
• Maintain regular bowel function
• Avoid physically-demanding activities
• Complete your 3-day course of antibiotics

Any discomfort in the prostate area can usually be relieved by simple painkillers.

What else should I look out for?

A fever or shivering requires urgent action and your GP or hospital should be informed immediately.

If you develop a fever outside surgery opening hours, you must telephone the emergency number at your GP surgery immediately so that a doctor can assess your condition.

If there is a lot of bleeding in the urine or from the back passage, especially with clots of blood, you should contact the Urology Department.

Are there any other important points?

You will receive an appointment for discussion of the biopsy results at the time of your examination.

It will be at approximately 14 days before the pathology results on the tissue removed are available. It is normal practice for the results of all biopsies to be discussed in detail at a multi-disciplinary meeting before any further treatment decisions are made. You and your GP will be informed of the results after this discussion. We sometimes need to order additional tests as a result of the discussion at this meeting and, as a result, you may receive appointments for a bone scintigram, CT scan or MRI scan before or after you are seen again in outpatients.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery. You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than 3 months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

What should I do with this information?

Thank you for taking the trouble to read this publication. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this publication to be filed in your hospital records for future reference, please let your Urologist know. However, if you do agree to proceed with the scheduled procedure, you will be asked to sign a separate consent form that will be filed in your hospital. You will, if you wish, be provided with a copy of the consent form.

Disclaimer

While every effort has been made to ensure the accuracy of the information contained in this publication, no guarantee can be given that all errors and omissions have been excluded. No responsibility for loss occasioned by any person acting or refraining from action as a result of the material in this publication can be accepted.