Anxiety before a conventional TRUS (transrectal ultrasound guided) biopsy of the prostate is normal and natural. It’s no surprise that the prospect of being diagnosed with prostate cancer makes men nervous. However, it may come as a shock to know cancer is often not the main cause of pre-biopsy jitters. For a lot of men, 12 or more needles puncturing their prostate gland raises the possibility of pain, bleeding and infection—and the desire pretend there’s no cancer rather than go through with the biopsy.

Why does TRUS biopsy require so many needles? It’s because ultrasound does not distinguish cancerous tissue from normal tissue. Therefore, many samples are taken in a grid-like scheme from both sides of the gland. It’s systematic yet blind, and therefore has a random element. To correct for this, a newer technology called fusion can also be used to guide targeted biopsies, but since it lacks the same precision as real-time MRI, most urologists take systematic samples as well as targeted samples.

These days, a urologist doing a biopsy is likely to use numbing agents to minimize pain. This is usually successful, and that’s a good thing. It’s not a bad idea to ask in advance how the doctor plans to manage pain, and I personally would fire a doctor who says, “It’s not that bad, you won’t need anything.” Ask any patient who has been through a TRUS biopsy without a numbing injection and he will tall you it IS that bad! It doesn’t have to be painful, and an injection is used to numb the nerves is the only uncomfortable part. While, bleeding and infection are still risks, some post-biopsy blood in urine or semen (or even rectal bleeding) should not be a source of concern. Infection is a greater worry, which is why men must take antibiotics for prostate biopsy.

The thing that most patients never ask about is post-biopsy sexual function. Can a TRUS biopsy interrupt their sex lives? Well, many urologists don’t like to say it, but the truth is, yes it can. Two recent reviews of earlier studies arrived at the same bad news/good news conclusion: prostate biopsy does cause a “mild, transient decrease” in erectile dysfunction or ED (bad news), but after the first month it tends to improve within three months, and by six months it has returned to baseline (good news).^[i],[ii]

Both reviews were published in 2021. Two years earlier, Kamali, et al. (2019) conducted their own study of 80 patients (average age 64.8 years) who underwent TRUS prostate biopsy. The standard questionnaire to evaluate sexual function is the International Index of Erectile Function (IIEF), which has scores ranging from 5 (severe dysfunction) to 25 (no dysfunction). The 80 patients had average scores of 23 at one month before biopsy (baseline) and 18 at one month after. This represents a statistically significant decrease in erectile function at a month following biopsy. While the analysis in the two review articles stated that average function had returned to baseline at 6 months after biopsy, this was not the case in the Kamali study. The average erectile function score appeared to fall after the first month; at three months post-biopsy it was 17, and at six months it was 14.5. These also were significant differences from baseline.

In-bore MRI targeted biopsy reduces post-biopsy ED

The same year that the Kamali paper was published, a Dutch team published the results of a multicenter randomized and controlled comparison of three MRI-guided biopsy techniques in terms of temporary mild adverse effects (AEs), including transient ED. Their biopsy guidance methods were:

• In-bore MRI-guided targeted biopsy (MRI-TB) performed transrectally
• Fusion-guided targeted biopsy plus systematic biopsy (FUS-TB) performed transperineally
• MRI/cognitive fusion-guided targeted TRUS biopsy (COG-TB) performed transrectally

While average urinary or sexual performance were not significantly impacted by biopsy overall, the MRI TB biopsy had the fewest AEs. This is undoubtedly because only the fewest needles are required to sample the targeted area, which is clearly defined on real-time MRI. At our Center, we offer MRI targeted biopsies because we get the most accurate biopsy results using a minimal number of needles.

Since our powerful 3T multiparametric MRi scans reveal detailed prostate anatomy, we can avoid the nerve bundles that control erection. This means our patients are at very low-to-zero risk of sexual side effects after their biopsy. It also means the best patient comfort and least risk of infection, all thanks to just a few biopsy needles.

To sum up, in-bore (real time) MRI guidance for prostate biopsies offers the most accurate diagnostic information with the least risk to urinary and sexual function.

If you have a PSA test that returns a suspicious result, don’t be rushed into a biopsy. First, have an mpMRI scan of your pelvic area. If it does not reveal any area that is suspicious for clinically significant prostate cancer, you may be able to hold off on follow-up for another 12 months. But, if it a suspicious area is revealed, we can target a minimum number of needles into it, under MRI guidance, and get to the heart of the matter without putting your sex life on the line.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Fainberg J, Gaffney CD, Pierce H, Aboukhshaba A, Chughtai B, Christos P, Kashanian JA. Erectile Dysfunction is a Transient Complication of Prostate Biopsy: A Systematic Review and Meta-Analysis. J Urol. 2021 Mar;205(3):664-670.
[ii] Mehta A, Kim WC, Aswad KG, Brunckhorst O, Ahmed HU, Ahmed K. Erectile Function Post Prostate Biopsy: A Systematic Review and Meta-analysis. Urology. 2021 Sep;155:1-8.