Transrectal prostatic ultrasound and transperineal 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 Addenbrookes. 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. Biopsies are taken through the skin behind the testicles (the perineum) using a needle guide. The sampling is targeted and the number of samples taken depends on the size of the prostate and the number of target lesions, usually ranging from 12 to 36 samples.

The reason this approach is adopted is because this may allow better access to the area of your prostate which is of interest for targeting and it carries a lower risk of infection.

Transperineal biopsy may be done under local, general or spinal anaesthetic depending on the reason for biopsy and in discussion with you.

What are the alternatives to this procedure?

Observation with repeat blood tests but without biopsies.

What should I expect before the procedure?

Please be sure to inform your urologist in advance of the procedure 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 blood thinning medication (you will need to stop this medication prior to the biopsy and the timeframe will be advised at the time of biopsy booking).
• A prescription for methotrexate - you will be advised if you need to omit dose prior to the biopsy.
• 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)

If the procedure takes place in the outpatient department and under local anaesthesia, you will be asked to arrive early with comfortably full bladder to perform a urinary flow test as well as bring a urine sample. You will be checked in by the nurses, perform a bladder scan and you will be asked to change into a gown. You will then be seen by a member of the medical team.

If the procedure takes place in theatre (under general anaesthetic or sedation), you will normally undergo pre-assessment on the day of your clinic or an appointment for pre- assessment will be made from clinic, to assess your general fitness and to perform some baseline investigations. You will usually be admitted on the day of your surgery.

After admission, you will be seen by a member of the medical team.

After checking for allergies, you will normally be given an oral antibiotic and may be given a suppository to help clear the bowels out.

What happens during the procedure?

If performed in theatre, patients will receive a general or spinal anaesthesia first.

Your legs will be placed in special supports so that the surgeon can gain access to the skin behind the testicles and insert the ultrasound probe into the rectum. 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.

If the procedure is performed under local anaesthetic, this is injected into the skin and tissue to the prostate at this point.

In order to take samples (biopsies) of the prostate, a needle guide is used to help accessing the prostate through the tissue behind the testicles. The biopsy needles are inserted into the prostate through the skin of the perineum under visual guidance of the ultrasound probe and the previous MRI image (if appropriate). After the sampling has been completed, a pad will be applied to the perineum and held in place with support pants.

What happens immediately after the procedure?

You will normally be able to go home later the same day after checks have been made to ensure that you are passing urine normally.

The average hospital or clinic stay is less than one 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.

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 for up to 10 days
• 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
• Bruising in the perineal area
• 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)

• 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
• Inability to pass urine (retention of urine)

Rare (less than one in 50)

• Urinary infection (1%)
• Blood infection (septicaemia) requiring hospitalisation (less than 0.5%)
• Bleeding requiring hospitalisation (1%)

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

It is important that you:

• undertake only 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 course of antibiotics if you are asked to so
• Any discomfort can usually be relieved by simple painkillers.

What else should I look out for?

If you experience a fever, shivering or develop symptoms of cystitis (frequency and burning on passing urine), you should contact your GP. If there is a lot of bleeding in the urine, especially with clots of blood, you should contact the urology department.

If you experience difficulty passing urine, this requires urgent action and your GP should be informed immediately or attend Accident and Emergency.

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

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 2 weeks 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 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 scintigram, CT scan or MRI scan before 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 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.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/or specialist one to one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

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

There are a number of research projects involving MRI and transperineal biopsy taking place at Addenbrookes and you may be approached by the prostate research nursing team. There is no specific research in this area at the moment but all operative procedures performed in the department are subject to rigorous audit at a monthly audit and clinical governance meeting.

Who should I contact for more help or information?

Oncology nurses

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…………….………………….