Transrectal prostatic ultrasound and biopsy

What is the evidence base for this information?

This leaflet 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 practice in the UK. It is intended to supplement any advice you may already have been given by your urologist or nurse specialist as well as the surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your urologist or specialist nurse.

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 samples are taken from different areas of the prostate as well as additional biopsies from areas found to be suspicious on an MRI scan (you had before biopsies).

What are the alternatives to this procedure?

Observation with repeat blood tests but without biopsies or a transperineal prostate biopsy under local anaesthetic or general anaesthetic.

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 may also be asked to undergo swabbing of your nose and 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, approximately 14 days before your admission, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. In this event, you will be seen after admission by members of the medical team which may include the consultant, junior urology doctors and your named nurse.

If you are taking blood thinning medication, as well as methotrexate, you must inform the clinic staff or the pre assessment staff so that they can advise you appropriately when to stop taking these medicines.

After checking for allergies, you will normally be given an antibiotic tablet (usually penicillin based or another if your allergic to it) to prevent infection in the prostate, the urine or the bloodstream.

Please be sure to inform your urologist 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 prescription for Warfarin, Aspirin, Rivaroxaban, Dabigatran, Apixaban, Edoxaban or Clopidogrel , Ticagrelor or other blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

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 four 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 ‘click’. 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.

What happens immediately after the procedure?

When no samples have been taken, there are no side effects. If biopsy samples have been taken, blood in the urine is common for two to three 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 six weeks. You will be given antibiotics to take home for a three-day period if biopsy samples have been taken.

The average hospital stay is less than two hours under local anaesthetic and one day for ultrasound under general anaesthetic.

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.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

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

Occasional (between one in 10 and one in 50)

• Urinary infection (5% risk)
• 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
• Bleeding causing an inability to pass urine (2%)

Rare (less than one in 50)

• Inability to pass urine (retention of urine)

What should I expect when i get home?

It is important that you:

• undertake non strenuous activity 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 three 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 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 you have difficulty in passing urine, this requires urgent action and your GP should be informed immediately or attend accident and emergency if nearby.

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. The results of all biopsies will be discussed in detail at a multidisciplinary 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 scan, and/or CT scan before you are seen again in outpatients.

Driving after a biopsy

It is your responsibility to ensure that you are fit to drive following your biopsy.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three 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.

References

• NICE clinical guidelines (opens in a new tab)

Is there any research being carried out in this field at CUH?

Yes, Cambridge is developing safer and more accurate ways to take prostate biopsies and also doing many studies to understand benign and malignant disease of the prostate to help us in the future. You may be asked to take part in one or more trial /study and asked if you would agree to have additional biopsies taken for research during the procedure. You may also be asked if your anonymous details may be used to help with our research. You are under no obligation to take part.

Who should I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. 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 leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know. If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form. which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish.

I have read this patient information leaflet and I accept the information it provides.

Signature……………………………….……………Date…………….………………….