Transperineal Prostate Biopsy Under Local Anaesthetic

Why have I been given this leaflet?

You have been given this leaflet because your consultant has referred you for transperineal ultrasound guided biopsies to be taken of your prostate. This will be performed under local anaesthetic (LA). You will be awake and the area will be numbed with a local anaesthetic injection.

This will take place in the Outpatient Department at Dorset County Hospital.

Please read this leaflet before you come to your appointment. The doctor and specialist nurse will go through the information with you at your appointment and will answer any questions you may have.

What is a transperineal ultrasound prostate biopsy?

A prostate biopsy involves taking a small sample of tissue (a biopsy) from your prostate. Approximately 12-15 samples will be taken, although this may vary depending on the size of your prostate.

These tissue samples will then be sent to be examined under a microscope by a specialist doctor to check whether there is cancer in the prostate. A transperineal biopsy involves taking the tissue sample through the perineal area; this is the area of skin situated between the scrotum and the rectum (back passage).

You may have been offered a transperineal biopsy because:

• You have previously had a transrectal prostate biopsy that shows no cancer, but have a high PSA level (a blood test that can indicate cancer), or a suspicious area identified from an MRI scan
• You have a suspicious area, which has been identified on your MRI scan, which may be easier to reach for a biopsy through the perineal area than through the rectum
• You have a very large prostate
• You have known prostate cancer that has not required treatment but the doctor wants to check whether the cancer has changed and may require treatment.

What are the alternatives to this procedure?

• Transrectal ultrasound guided biopsies; these are also carried out under local anaesthetic. The samples are taken through the rectum
• Transperineal biopsies under a general anaesthetic (where you are unconscious)
• Further monitoring of your PSA or MRI scan results without further biopsies.

The most suitable option will have been discussed with you at your consultation.

Preparing for your transperineal biopsy

Can I eat and drink before the biopsy?
Yes, you can eat and drink before you have your biopsy procedure.

Should I take my usual medications on the day of my biopsy?
Most medications can be taken as normal. There are some medications that do need to be stopped prior to the procedure; see below:

• Anticoagulants: If you are taking warfarin, this should be stopped five days before your biopsy. Your INR will be checked in the hospital on the day before you have your procedure. Your urology doctor will have discussed your medications with you and decided whether or not you will need any heparin injections whilst you are off your warfarin (this is known as ‘bridging therapy’). If you are on any of the following anticoagulants – Rivaroxaban, Apixaban, Dabigatran or Edoxaban, the urology doctor should have advised you when to stop taking these prior tothe biopsies. Normally it should be stopped 48 hours before the procedure. Please confirm with your doctor when you should restart your anticoagulants before you leave the hospital after your biopsies have been taken. If you have any concerns, or are unsure which medications you should stop taking, please telephone the urology nurses on 01305 255145 and they will advise you.
• Antiplatelets: You can continue to take low dose aspirin (75mg). If you are taking Clopidogrel and other antiplatelet medication, these should be stopped seven days before the biopsy procedure. If you are taking this medication because you have had coronary (heart) stents inserted within the last year, please contact the urology nurses (see number below) to discuss, before you stop your medication.

What do I need to bring with me?

Please bring with you:

• A current list of your medications
• A dressing gown and slippers.

What should I expect when I arrive?

Please come to the reception area at Dorset County Hospital, Outpatients Department. You should expect to be in the department for approximately two hours. This gives us time to prepare you for your biopsy and make sure you are well afterwards. The biopsy should take approximately 45 minutes.

When you arrive you will be asked to provide a urine sample. This is to check that you do not have a urine infection. If you do, this may mean that your procedure will have to be delayed until it is treated.

A nurse will go through your medications with you and ask you some questions. You will be given some antibiotics, Ciprofloxacillin, to help prevent infection and need to be given 40-60 minutes before your procedure. You will be asked to put on a hospital gown and remove your lower clothes.

What should I expect during the biopsy?

You will be asked to lie on your back on the operating trolley, with your legs placed in supportive hydraulic leggings. In order to facilitate taking the biopsies, it will be necessary to shave the perineal area with clippers and remove any excess hair. Some tape will be used to move the scrotal area out of the way. Your legs will be raised and bent at the knees.

If you find this position difficult, or will find it too uncomfortable, please tell the doctor or nurse and we will try to make the position more comfortable for you. You will be in this position for about 30 minutes.

The doctor will examine your prostate by placing a finger in your back passage; this is called a digital rectal examination, or DRE. The doctor will then insert an ultrasound probe, covered in lubricated jelly, into your back passage. This will allow them to see an image of your prostate on the ultrasound screen, which will be used as a guide for collecting the biopsies. This can be uncomfortable but should not be painful.

The doctor will use an antiseptic solution to clean your perineal area from where the biopsies will be taken.

You will be given an injection of local anaesthetic to make the area go numb. This is given in two stages, firstly under the skin of your perineum to numb the entry point, and then deeper to numb the area around your prostate. This will sting for a moment but should quickly wear off and become numb. The anaesthetic will then be given time to take full effect.

A needle guide will be inserted into the perineum; once to take samples from the one side of the prostate and then again to do the other. The biopsy needle is inserted through the needle guide to take the samples.

If you feel pain when having the biopsies taken, you should let the doctor know and they will give you more local anaesthetic.

The biopsies are taken with a device that contains a spring loaded needle. You will hear a load ‘click’ sound and feel a flicking sensation as the biopsy is being taken. You may find the whole procedure uncomfortable, but you should not find it painful.

What should I expect after the biopsy?

After the biopsy you can get up slowly and get dressed. It is important to take it slowly, as you may feel lightheaded after the procedure.

You will have an absorbent pad dressing applied to the biopsy area as there may be a small amount of bleeding from the skin puncture sites and from your urethra (water pipe). If you feel faint or unwell after leaving the biopsy room, please tell the nurse. We would recommend that you have someone with you to drive you home. We also recommend that you have a drink and something to eat before you leave the hospital.

What are the risks and side effects of having a transperineal prostate biopsy?

Most procedures have possible risks and side effects. Your doctor will go through these with you before the procedure. Please let them know if you have any questions or concerns.

What should I look out for at home?

• You may feel some discomfort in the perineal area from where the procedure was carried out; this could last a couple of days. You can take regular paracetamol or your usual pain relief as prescribed on the packaging.
• You are likely to see blood in your urine and semen. To help with this, drink plenty of fluids.
• If you are suffering from offensive smelling, cloudy urine, or feeling pain when passing urine, this may be a sign of infection. Please contact your GP, as you may require antibiotics.

Please go to your nearest Emergency Department if you experience any of the following:

• A high temperature (above 37.5c)
• Chills and shivers
• After trying for two hours, you are unable to pass urine, despite having a full bladder and drinking plenty of fluids.

Risks and side effects

• Blood in your urine for up to 10 days: Almost all men.
• Blood in your semen which can last up to six weeks; this may be red or brown in colour: Almost all men.
• Bruising in your perineal area and discomfort in your prostate, caused by bruising from the biopsies: Up to five out of 10 men.
• Temporary problems with erections caused by bruising from biopsies: One in 20 men.
• Inability to pass urine, acute retention of urine: One in 20 men.
• Blood in urine preventing you from passing urine, clot retention: One in 50 men.
• Failure to detect a significant cancer in your prostate: Up to five out of 50 men.
• Need to repeat procedure if biopsies are inconclusive or your PSA level raises further: Up to five out of 50 men.
• Blood in your urine requiring emergency admission for treatment: One in 100 men.
• Infection in your urine requiring antibiotics: One in 100 men.
• Septicaemia blood infection, requiring emergency admission: One in 1,000 men.

Contact numbers

We hope that you have found this information useful. If you have any questions or are worried about anything, or unable to attend your appointment, please speak to the following Dorset County Hospital staff:

Hospital admissions: 01305 254507

To contact the urology nurses office (8am-4pm, Mon-Fri): 01305 255145. Please leave a message and we will return your call as soon as possible.

Useful websites

Prostate Cancer UK: www.prostatecanceruk.org

British Association of Urological Surgeons: www.baus.org.org.uk/patients

About this leaflet

Authors: Mr N Afzal, Consultant Urologist and Victoria Frost, Urology CNS
Written: June 2020
Approved: July 2020
Review date: July 2023
Edition: 1

If you have feedback regarding the accuracy of the information contained in this leaflet, or if you would like a list of references used to develop this leaflet, please email patientinformation.leaflets@dchft.nhs.uk