A prostate biopsy is the only medical procedure with which prostate cancer can be diagnosed conclusively.
It is performed by a urologist or radiologist when one or more anomalies have been detected in the prostate. The necessity of a biopsy is determined by a digital rectal exam, PSA test or, more recently, an MRI scan.
The exam consists of removing small samples of the organ, before analysing them under a microscope to establish the presence or absence of cancer sites, their aggressiveness and respective sizes.
Typically, ten or so samples are taken under ultrasound guidance using a fine needle approximately 1 mm in diameter and a biopsy gun. Positioned in the rectum, the ultrasound probe allows the doctor to see the prostate and guide the insertion of the needle before making the puncture.
Diagnosing prostate cancer – 2 biopsy types
A pathology affecting almost one in seven men worldwide, prostate cancer care relies, above all, on the early, accurate and reliable diagnosis of the disease.
The prostate biopsy therefore constitutes a critical stage in the patient journey. At present, there are two types of biopsy in practice.
The “blind” biopsy
The vast majority of prostate biopsies today are carried out transrectally by means of a 2D ultrasound probe. During the procedure, the doctor aims to take 12 evenly spread samples in order to maximise the chances of finding an infected site. There are two main reasons why these biopsies are referred to as “blind”:
- Conventional ultrasound techniques are not particularly effective when it comes to visualising potential cancer sites directly on the ultrasound scanner.
- The ultrasound guidance tool only allows for 2D visualisation, making it difficult to take an even spread of organ samples.
The development of multiparametric Magnetic Resonance Imaging (MRI) of the prostate has considerably improved the sensitivity and specificity of prostate cancer diagnoses – See the related studies. Given the excessive constraints associated with biopsies performed directly under MRI, an alternative has now emerged, enabling real-time integration on the ultrasound scanner of information based on MRI sequences: MRI-US fusion.
The “fusion” or “targeted” biopsy
SIU Medicine’s experience with MRI/US Fusion technology:
The development of the fusion of MRI images (interpreted by a specialist radiologist) and ultrasound images has revolutionised biopsy procedures. Thanks to fusion technology, the urologist is now able to:
- Detect potential cancer sites before carrying out the biopsy thanks to MRI test
- Locate suspect areas on the ultrasound image in real time during the biopsy
- Guide the biopsy needle directly into the suspect areas on the MRI
- Record the position of the biopsies performed in 3D prostate mapping (information that is essential for diagnosis and follow-up)
- All with the precision of a few millimetres
Result: A detailed diagnosis leading to personalised patient care.
Example of Fusion biopsy procedure:
1. Radiologist defines suspicious lesion on the MRI
2. MRI and 3D Ultrasound Image Fusion
3. Targeted Biopsy
4. 3D Mapping
Despite its performance and the clinically proven benefits, prostate fusion biopsy is still not the most common practice. The main reasons for which it is not yet widespread are the acquisition cost, the need for access to an MRI scanner, and the novelty of the technology.
Locate a urologist or a clinic on the Koelis® Solution Locator.
The MRI-US targeted biopsy procedure in detail
The prostate biopsy procedure in 4 stages
Below is the chronology of a prostate bx procedure (using MRI-Ultrasound fusion).
Important note: Naturally, this “standard prostate biopsy procedure” depends on a number of factors: national guidelines, the doctor’s knowledge and training, as well as the equipment used. Prostate biopsy techniques may vary from one practitioner to another.
Stage 1: Prediagnosis (screening) of cancer
DRE + PSA Test + MRI Digital rectal exam by a general practitioner and PSA test.
If cancer is suspected after the initial exams, an MRI scan takes place in order to view the potential cancer lesions*.
In the majority of cases, a prostate biopsy is prescribed if the digital rectal exam and/or PSA test reveal anomalies.
The potential cancer sites can be defined on the MRI*.
*Using magnetic resonance imaging (MRI) as an initial test for suspected prostate cancer patients is now recommended by the French Urology Association (AFU) and by The National Institute for Health and Care Excellence (NICE). More information about AFU New Prostate Cancer guidelines 2018 and NICE Prostate Cancer Guidelines
Stage 2: Prostate biopsy procedure
Procedure carried out in consultation with a urologist or specialist radiologist Local or general anaesthesia
Insertion of an endorectal ultrasound probe (via the rectum)
Insertion of a biopsy needle via the rectum (transrectal – TRUS approach) or perineum (transperineal – TPUS approach) Removal of 3 to 18 samples for the fusion-targeted biopsy (12 to 25 for a blind biopsy – 25 to 50 for a “saturation” biopsy) Possible side effects (pain, discomfort, bleeding, etc.) and risk of infection after the biopsy
Stage 3: Analysis of samples and diagnosis
Samples sent to the anatomical pathologist Microscopic analysis of samples Compilation of histological findings: presence or absence of cancer cells, estimated size of tumour(s), aggressiveness (cf. Gleason Score) and differentiation Results sent to the urologist Diagnosis by urologist
Stage 4: Choice of treatment
Multidisciplinary discussion between the urologist, radiologist and anatomical pathologist Discussion between the patient and doctor
Definition of best suitable care
Transperineal (TPUS Bx) or transrectal (TRUS Bx) biopsy
During the prostate biopsy procedure, the sampling needle may be inserted via the rectum or through the perineum.
The decision will be made by the doctor in consultation with the patient. A particular technique may be favored according to the patient’s wishes, the doctor’s experience, the location of the necessary biopsies and the available medical equipment.
The most common practice is a transrectal biopsy under local anesthetic.
Having long been restricted to general anesthesia, transperineal procedures are now possible under local anesthetic thanks to recent technological advances (cf. KOELIS Trinity®). On account of the reduced risk of infection after a biopsy, the use of this method is continually increasing throughout the world.
To find out more about these two methods:
Local or general anesthesia
Local or general anesthesia?
This choice is also made by the doctor, who will decide upon the most suitable protocol on the basis of their particular methods and the individual patient in question.
In order to lower the risk of morbidity and the side effects associated with general anesthesia, the biopsy may be conducted under local anesthetic regardless of the method used: transrectal or transperineal.
What are the risks? Complications and side effects
The primary complications during the prostate biopsy procedure are very much related to the anaesthesia. A prostate biopsy generally takes place without consequence, yet side effects may be observed:
- Pain and discomfort around the sampled area(s)
- Difficulty urinating
- Bleeding of the prostate – Presence of blood in urine/sperm
- Side effects due to general anaesthetic
- Risk of infection (lower for transperineal biopsy)
Once the prostate biopsy is complete, the samples taken are sent to a doctor specializing in the analysis of cancer cells: the anatomical pathologist.
This specialist will then determine whether or not cancer tissue is present in each sample. Any cancer cells are identified and classified according to their aggressiveness and size using a Gleason Score.
KOELIS® technology for Prostate Cancer biopsies
For over a decade KOELIS® has assisted urologists and radiologists from around the world in their routine clinical practice providing the latest technology. In order to bring personalized answers to every patient in the respect of their quality of life, we’ve developed KOELIS Trinity® the first image-based cartographer. This system allows physicians to perform targeted transperineal or transrectal MRI/US fusion-guided biopsies under local or general anesthesia.
“Quality management in patient diagnosis”
It is equipped with the exclusive Organ-Based Tracking Fusion® technology which enhances the accuracy of the biopsy. Without changing the usual clinical practices, this technique brings an increased quality control over biopsy localizations. A precise, individual prostate biopsy mapping is a value for the accurate diagnosis and the further management of each patient.
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