Prostate Biopsy

I personally try to avoid or minimise prostate biopsy. While the topic remains very contentious I believe it is often possible to diagnose prostate cancer without a biopsy with a combination of blood tests (PSA +/- PHI) and imaging (mpMRI and PSMA PET scan). I have personally operated on more than 100 men with prostate cancer who did not have a biopsy prior to surgery. I am a passionate advocate of this for several reasons:

  1. Prostate biopsy is invasive and carries a small but real risk of significant complications.

  2. Prostate biopsy makes nerve sparing prostatectomy harder. It causes scarring about the prostate. Having dedicated my career to mastering the procedure of prostatectomy I now find the biggest determinant of my ability to successfully perform nerve sparing surgery with minimal trauma to the erectile mechanism is prostate biopsy or lack of it. If biopsy is required to be confident with the diagnosis I aim to take as few biopsies as possible e.g. 2-3.

  3. When biopsy isn’t performed I am able to trust the way the tissue behaves when operating. If tissue doesn’t want to separate easily from the prostate it is likely due to cancer. This helps obtain clear (or negative) surgical margins. When biopsy is performed this luxury is lost as the scarring from biopsy dominates the way the tissues behaves.

Prostate biopsy may be required to diagnose prostate cancer. It is the only way to operatively obtain a histological grade which helps guide treatment decisions. Prostate biopsy is invasive. It is important to determine the need for biopsy and if it is required to perform it safely.


Example of a Diagnosis of Prostate Cancer without Prostate Biopsy

This man presented with a PSA of 11. The mpMRI showed a PIRADs 5 lesion which has a ~90% positive predictive value for prostate cancer. The PSMA PET scan (far right) shows the mpMRI lesion is intensely PSMA avid with a SUV max of 15. Whilst standard advice is to perform a biopsy and obtain histological diagnosis I was confident the diagnosis had already been established and we proceeded directly to robotic prostatectomy.

Transperineal prostate biopsy

This is Dr Coughlin's preferred technique for performing prostate biopsy. The needle is passed through the skin of the perineum and this reduces the risk of infection to an extremely low level. It is performed under a general anaesthetic (you will be asleep). All areas of the prostate can be accessed via this approach. If a cancer is suspected on MRI that area can then be specifically targeted during biopsy.

MRI guided prostate biopsy

If a suspicious lesion is identified in the prostate on MRI scan it is possible to biopsy this under MRI guidance. This usually involves 2-4 needle biopsies performed in the MRI scanner. The main downside of this technique is the needles are passed into the prostate transrectally (i.e. through the bowel wall) and this increases the risk of infection which can be serious. At present there is no data to suggest this technique is more accurate than targeted transperineal prostate biopsy. The procedure is currently relatively expensive and there is no medicare or private insurance rebate available.

TRUS prostate biopsy

Transrectal ultrasound guided biopsy is the most common technique used for prostate biopsy. Dr Coughlin does not perform this due to a 1-2% risk of infection which can be life threatening. Also only the back portion of the prostate is able to be reliably biopsied in this fashion. Under sedation a needle is passed through the bowel wall of the rectum into the prostate for biopsy. 12-18 needle biopsies are typically performed. Dr Coughlin recommends against undergoing this procedure.