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A Warning about a never-discussed aspect of a prostate biopsy

I want to make men aware of something I had no idea at all of prior to my MRI-guided Trans-rectal Ultrasound biopsy of the prostate.

I have a hemorrhoid but-- though it's large-- it hasn't bothered me a bit in many years. It hasn't bled, it hasn't interfered with my life in any way. I'm a runner and a speed walker and I've never had to take that hemorrhoid into account when doing my exercise.

And then came the trans-rectal biopsy. I doubt that people can sense this just from reading my post, but I'm someone who is very stoical in the face of pain. No matter what happens, there is normally not a peep out of me. But when the doctor inserted the ultrasound device, it was the most painful experience of my entire life. Without any conscious consideration of the matter, I found myself crying out in pain-- the first time that's ever happened to me in a doctor's office. And the consequences pursued me for days afterwards. The biopsy was 16 days ago, and only in the past few days have I returned to a semblance of normalcy.

I don't know if by changing his method of insertion of the ultrasound device, or by applying a topical anesthetic to the hemorrhoid, the doctor could have avoided inflicting this unbearable pain upon me, but at the very least informed consent required his mentioning beforehand that the presence of a hemorrhoid would cause an inordinate exacerbation of what normally would be at most slight discomfort from the ultrasound device.

  1. I too had issues with hemorrhoids but for some reason did not experience what you described. I did have some pain during and following the procedure . It all cleared up in a week.

    I have hemorrhoid surgery years ago Perhaps it is time to visit with a specialist for that issue and ask for some guidance. Recovery is a lot faster as MD's apparently try to use rubber bands on the hemorrhoid and it drops off - vs surgery which while described as mine did result in major recovery - Good Luck

    1. Hi Dennis, if I'm understanding you correctly, you had hemorrhoid surgery in the days before they developed the rubber band technique. When I was a child, my mother had hemorrhoid surgery, and spent the weeks prior in dread of the surgery, and the weeks following in very slow recovery from the surgery. On the day of her return from the hospital, I remember being shocked (and a little scared) by her deathly pallor, so different from her normally healthy appearance.

      But Dennis, I don't quite understand your post. If you had hemorrhoid SURGERY then it must have been a long time ago-- and, presumably, BEFORE your unfortunate encounter with prostate problems. So that means you would have had a rectum blessedly free of hemorrhoids when the ultrasound device was introduced into it. Am I mistaken in my reasoning?

  2. The medical education and research establishment that I am under treatment at have been doing PET-CT guided trans-gluteal prostate biopsies. They also call it “percutaneous biopsy”. It does not involve rectal walls and causes very little hematuria.

    1. peekaafighter, fortunately of late I've forced myself to be open-minded when introduced to ideas I normally would consider bizarre or, frankly, so inconceivable as to be unworthy of consideration. And because of this change in myself, I immediately investigated what, on the surface, sounds preposterous: a trans-gluteal prostate biopsy. But far from being an absurd outpouring of a deranged mind, what you describe is not only real but apparently a vast improvement over what I had been led to believe was the best kind of prostate biopsy, the MRI-guided TRUS.

      I was only able to read a little about this new procedure, but I infer that, first, they intravenously infuse the patient with an isotope (called Prostate Specific Membrane Antigen) that has an affinity for prostate cancer tissue and then do a PET/CT scan, which illuminates any areas of the prostate that have absorbed the isotope (presumably cancerous ones). They then use those images to guide a robotic arm that performs a targeted trans-gluteal biopsy.

      The good news: it has tremendous success in finding prostate cancer that had proven too elusive to be detected by the more conventional biopsy techniques AND was, for the most part, relatively painless (only minor pain for 64%, moderate for 36%) and, above all (to me at least) produced only occasional minor after-effects and NO infections.

      peekaafighter, you've sold me on the superiority of this mode of biopsy, and I only have one question: Is the place at which you received this biopsy in the New York City area, and, if so, exactly where?

      1. The institution where I had been under active surveillance over the past 4½ years following a Ga68 PSMA-PET scan and a TRUS biopsy insisted on a PSMA-PET guided biopsy after a mpMRI showed a slight increase in lesion dimensions even though the PSA trend had been on a steady downward trend. I also found out the PSMA-PET guided biopsy is not available everywhere in my country. Urologists in other cities frankly expressed ignorance about the procedure.

        It was done using F18 in the PSMA-PET scan. I think the institution now uses F18 in place of Ga68 due to recent validation by FDA of the former as being at par with Ga68.

        The lesion is viewed on the PET scan machine bench and accessed robotically percutaneously under local anaesthetic. They got all the cores from the lesion. The sampling inside the Prostate did cause discomfort. It was no picnic, but it was a vast improvement over the TRUS experience 4½ years ago. I experienced very mild hematuria for a day and mild discomfort of the kind one would experience after getting an inoculation at the spot.

      2. Hi . Thanks for sharing this experience. I found this article which concluded that "the present study of a selected cohort suggest that dual imaging with mpMRI and F-18-PSMA-1007-PET may improve staging of primary PCa:" Turs out that, in this study, the F-18-PSMA-1007-PET was better with seminal vesical invasion, while the mpMRI with detecting extracapsular extension. So combining the two may be best of both worlds. Best, Richard ( Team)

    2. Things are often not as simple as they seem on the surface! Richard, I know you're far too astute to have to have that pointed out to you-- I'm really saying it as a reminder to myself. I was too quick to come to a conclusion regarding the radioactive Gallium PET scans--In reading the studies you linked to (and several others) more carefully, I've come to slightly temper my enthusiasm for the PSMA-PET scan.

      My initial belief was that it could COMPLETELY REPLACE the MRI-guided TRUS, since it seemed to be vastly better at finding cancer as well as allowing for a safer procedure (trans-gluteal rather than trans-rectal biopsy). However, a closer reading of the first article you linked to (the one by the Chinese doctors published in the European Journal of Nuclear Medicine in 2021) revealed that the Gallium PET scans didn't pick up all the cancer that was present. Simplifying the results a bit, some PET scans that didn't detect Gallium-avid prostate cancer tissue, nonetheless had prostate tumors located by that most prosaic of biopsies, a systematic TRUS of the old-fashioned kind. I can only imagine how many more tumors would have been detected by an MRI-guided TRUS. So, Richard, while you were extoling the merits (in the final paragraph of the above post) of combining PET and MRI scanning in terms of locating metastases and staging the cancer, I would suggest equal praise should be bestowed upon the idea of following the PSMA PET scan biopsy (if it's negative) with an MRI-guided TRUS, and following a PSMA PET scan that doesn't even find anything WORTHY of biopsy, with an MRI-guided TRUS, assuming the patient has an MRI that shows a suspicious lesion.

      (Just to clarify my last sentence: there are two separate issues with the PSMA PET scan-1) Sometimes the areas denoted as suspicious by the scan, when biopsied, are negative for cancer, but when those patients are then given TRUS biopsies, they sometimes are positive, and 2) Many people, after the PSMA PET scan, have no areas brightly flashing as suspicious, and yet some of them, when given a TRUS, come back positive for cancer. My conclusion: Radioactive Gallium may have an affinity for prostate cancer tissue, but it's not obsessive-compulsive about it.)

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