Unnecessary Prostate Biopsy?

This blog started over 10 years ago out of concern over unnecessary prostate biopsies.  These procedures are so common now that they are done as routine outpatient procedures.  They generate a lot of money for urologists and hospitals.  They also have a relatively high risk of complications and false negative rate.  Though blood, urine and MRI technology are improving, for many men, the necessity of a random 12+ core biopsy to search for cancerous cells is a page out of a 1960s medicine book.  Improvements in the procedure have been made, but the basic theory is still using one needle to find another proverbial needle in the haystack.  The problem is this particular needle costs over $1000 and can cause major complications, like sepsis.

In 2009, I had my first prostate biopsy.  I had hoped to avoid it if at all possible, but multiple physicians deemed it necessary.  At least I was able to do so in a free study designed to improve MRI imaging of the prostate that might some day reduce the need for biopsies.  As it turned out, my first biopsy was probably unnecessary, other than any value to the research study.  I didn’t have any major risk factors for prostate cancer, other than a relatively high PSA caused by an enlarged prostate.  My MRI didn’t show any lesions and was determined to be low risk (PI-RADS score of 1).  The biopsy was negative.

By 2019, newer technology is starting to help with protocols to reduce unnecessary biopsies.  From advanced biomarker blood and urine tests to high resolution MRI, the hope is that some combination can help many men avoid an unnecessary prostate biopsy.  Sadly, it didn’t help me avoid another one.  My second MRI showed a moderately high risk lesion in my prostate (PI-RADS 4).  Fortunately, the biopsy (12 sextant cores plus 2 targeted cores) was negative in my case.

I am so thankful that I have twice avoided a biopsy positive for cancer.  I have also avoided serious infection and other major side effects of a trans-rectal prostate biopsy.  I now have some personal experience with both necessary and unnecessary prostate biopsy.  I am still of the opinion that a trans-rectal biopsy is probably performed far too often.  The problem is that there is little consensus of what combination of less invasive tests and metrics might reduce unnecessary prostate biopsies.


A Negative Prostate Biopsy but Concerning MRI?

I’ve had two prostate biopsies.  Both were negative.  Both were targeted MRI/fusion biopsies.  The first MRI had no lesion or tumor to target, but the second one did.  I had a PI-RADS 4 lesion about 0.5 cm in size.  The team at the National Institutes of Health believe they successfully sampled it with two targeted biopsy cores.  Neither one showed cancer, but clearly, something has become abnormal in that area of my prostate over the last 10 years.

Prostate biopsies can miss cancer.  The inherent flaw in a biopsy to search for cancer is a relatively high false negative rate because the biopsies can only sample a very small percentage of the prostate volume.  Even a targeted MRI/Ultrasound fusion biopsy can miss cancerous cells.  My prognosis is to keep with regular PSA and exams with my urologist and followup if there are any changes.  Clearly, I have BPH, and possibly a benign tumor as well.  With a PSA level around 5 at age 51, I have a few risk factors for future prostate cancer.

One thing I am considering is the ConfirmMDx test.  This test uses the tissue samples obtained during your prostate biopsy.  It checks them for certain biomarkers that are indicative of prostate cancer that might be lurking just outside the sampled cores of biopsy tissue.  I’m not sure if I will proceed or if my tissues samples are even eligible for this additional testing, but I am investigating it.  The results may affect how long I wait until I decide to get another MRI or biopsy.  Other blood and urine tests for genomic indicators and biomarkers of prostate cancer may also be indicated for high-risk patients with negative biopsies.



MRI and Biopsy Results: PI-RADS, Gleason and PCa

The waiting is brutal.  Three weeks ago, I was shown my prostate TRUS MRI fusion results.  I was given a PI-RADS score of 4 on a scale of 5, with a 5 being most likely for cancer.  For reference, ten years ago, my MRI report score was a  PI-RADS 1, or “highly unlikely” to have clinically significant cancer.  A score of 4 means that, “Clinically significant cancer is likely to be present.”  The modified scale used by the NIH was only slightly better, “Moderately likely for prostate cancer.”

As you can imagine, it considerably freaked me out to learn this in the hours of worrying while I waited to be taken for my biopsy procedure.  On the plus side, it also told me that I was doing the right thing.  A half-centimeter size lesion was shown on the MRI, and a random biopsy might miss that small of a lesion altogether.  Armed with the MRI results, they were able to precisely target this tumor with two separate biopsy samples from different angles, along with 12 other random cores to see if cancer was present or had spread elsewhere in the prostate.  Ten years ago, I did not have any cancer, nor was any type of lesion or tumor indicated on the MRI.   Things were not  nearly as promising on this one:

Making lemonade out of lemons, the fact that only a single lesion was present was relatively good news.  Plus, there was no indication it had spread beyond the prostate or into any other tissues within the prostate.  These might all be positive considerations for less invasive focal treatments.  There are a number of studies out there showing the correlation of PI-RADS to biopsy results for cancer.   Thankfully, it seems that a PI-RADS score of 4 isn’t nearly as bad as a score of 5, but on a scale of 1-5, even a 4 feels pretty bad to a patient.   The correlations for a score of 4 just aren’t as well established yet, and that’s why these studies continue.  On the other hand, a PI-RADS score of 5 is usually bad news and has a much higher correlation to cancer.

Suffice to say that while a score of 4 does not usually indicate the presence of the most aggressive cancers (Gleason score of 8 or more), it often shows concerning cancers with a Gleason score of 7.  PI-RADS 4 lesions also can be benign or less aggressive cancer with a Gleason score of 6 or less.  In plain English, based on the MRI results and on various studies I have read over the three longest weeks in my life, I figured I had about a 50-50 chance of having a clinically significant cancer that required some sort of treatment in the near future.  For the optimist, maybe only a 40% chance or even a bit lower, depending on which study you read and whether or not the physician recommends treatment for Gleason grade 7 cancers.

Yes, I intentionally put off discussing my biopsy results to the end of this article.  This was to give anyone reading only a tiny fraction of how it feels to wait THREE WEEKS after seeing a PI-RADS score of 4 on my MRI.   Some days it has been almost paralyzing to wonder why it was taking so long, when I was originally told 5-8 business days.  Were the results so bad that a second opinion on the biopsy cores was needed?  Did they have to develop a treatment plan before contacting me?  Was a radical prostatectomy and all its risks, side effects and quality-of-life issues now a given for me in the near future?  Yeah, that stuff and worse goes through your mind every night at 3am, and even during the day.

I am both blessed and greatly relieved to say that I dodged a second bullet, both in terms of infection and biopsy results.  My phone call came an hour ago and NO cancer was indicated in the results.  Presumably, the targeted lesion is simply a benign tumor or other abnormality, one to be monitored for changes in the future.

Of course, prostate biopsies have a significant false negative rate.  Even with MRI/Ultrasound targeting guidance, they can miss cancerous cells that exist elsewhere in the prostate.  Sadly, no better diagnostic exists today, which is why I participate in this NIH study.  Trans-rectal prostate biopsies are not at all pleasant, and if you get a resistant infection, they can even be fatal in rare cases.  Improving non-invasive diagnostics like MRI, blood and urine tests is critical to reducing the need for random rectal biopsies that seem like a holdover from 1960s medicine.

Suffice to say I am very thankful to God, the universe and to the NIH/NCI Urology team, not only that no cancer was found and that I have no major side effects of the biopsy, but also that I hopefully don’t have to see them again for many years!



Is Active Surveillance a Good Choice?

Given the risks of prostate biopsy and the major potential side effects of a radical prostatectomy, many men are choosing to monitor their prostate symptoms, rather than seek invasive treatments.  The decision to pursue Active Surveillance (AS) varies based upon a number of factors and should be carefully discussed with physicians.



“AS is a safe and effective approach which spares any properly selected men younger than 60 years with low risk prostate cancer from intervention, provides adequate time for intervention if required, and shows durable disease specific survival.” 

Transperineal or Transrectal Prostate Biospy

If you are like me, the thought of serious infection or sepsis is a very scary prospect if you must have a prostate biopsy.  Prostate cancer is bad enough, but it usually isn’t an immediate threat and is often treatable.  Sepsis is a very real and very urgent life-threatening risk.  In the case of resistant bacteria, treatments may not be guaranteed.

Here is a nice guide to compare trans-rectal (TRUS) to trans-perineal biopsies (TPB):

Transrectal or transperineal biopsy: which is best?

There is apparently less risk of infection for this type of biopsy that goes in through the skin under the anus, rather than from inside the rectum.   It may also allow for better sampling of some areas of the anterior prostate, such that it’s the preferred method when extra cores saturating more of the prostate are needed. The main drawback seems to be that it is usually done under general anesthesia, which isn’t necessarily a bad thing in my experience.  This does usually mean at least one night in the hospital in many cases.   I have survived two trans-rectal biopsies without infection, but consider myself lucky. I will seriously consider a TPB in the future if the option is available.

Prostate Biopsy Recovery, Side Effects & Complications

My Personal Experience with Trans-Rectal Ultrasound MRI Fusion-Guided Prostate Biopsy: A Guide of what to expect after your prostate biopsy.

Since 10 years ago, there is a lot more information on what to expect after your trans-rectal ultrasound (TRUS) prostate biopsy.  Back then, many websites omitted some key side effects, such as blood in your ejaculate.  Even some very reputable health and medical websites buried things like the possibility of serious infection or sepsis as a small bullet point.  It turns out, this is a very real, increasingly likely and possibly fatal complication.  Urinary infection or inability to urinate are also possible complications.  Urinary incontinence and erectile dysfunction are less common risks.

Of all the potential side effects, I was most shocked 10 years ago when my semen looked like thick blood because it wasn’t on my care sheet or mentioned by the medical staff.  So, I created an article back then to help others that generated over 600 comments. Please feel free to reply with your experiences as a comment after this article, you are welcome to use an anonymous username and email. Thankfully, more websites and care sheets acknowledge blood in the semen now compared to a decade ago.   This is good because if you aren’t expecting it, you might think you have a serious bleeding issue or internal hemorrhaging.   You aren’t. Opaque red or rust-colored ejaculate is not unusual after a prostate biopsy and can last a month or longer after the procedure, hopefully diminishing over time and number of ejaculations.  Even my doc, nurse and care sheet mentioned it this time, unlike 10 years ago.

This new care sheet is pretty good based on my experiences.  Here is another reasonable webpage more centered on the risks, except that “…you also may see traces of blood in your semen” doesn’t come remotely close to describing it for some men:


How common is hematospermia (or hemospermia)?  One report indicated that various studies showed that between 5% of men and 90% of men had blood in their semen after a biopsy.  When eliminating men who did not ejaculate after the procedure, they found about 90% had blood in the semen that lasted around 4 weeks and 6 ejaculations after the procedure.  A similar study had very similar results.  As you can see in these studies, it is not all that uncommon to have blood red semen, rather than having a tint or “altered color.”

I’m going to discuss my own, personal recovery experience following my second TRUS guided prostate biopsy, done under local anesthesia.  It was pretty similar to my first one.  If you are squeamish or don’t like the TMI type of details, STOP READING NOW.  The rest of this article is definitely Too Much Information unless you really want to know from first-hand experience. Continue reading Prostate Biopsy Recovery, Side Effects & Complications

What to Expect After Your Prostate Biopsy?

You’ll probably get a care sheet from your urologist.  Maybe you found a website with a list of possible side effects on the internet.  Beyond that, there aren’t a lot of reports with personal experiences from a prostate biopsy.  Probably for obvious reasons.  Most guys don’t want to talk about it.  Some are just too tough or too cool to tell it like it really is.  With a careful Google search, you can find some personal experiences on the procedure.  There are even a few horror stories.  If you’re squeamish when reading about unpleasant medical complications, STOP READING NOW! Continue reading What to Expect After Your Prostate Biopsy?

2nd Visit to NIH for UroNav fusion MRI/TRUS Prostate Biopsy

My Personal Experience on What to Expect During a Trans-Rectal Ultrasound Prostate Biopsy Under Local Anesthetic

Almost 10 years ago, I headed to the National Institutes of Health, National Cancer Institute for a 3T MRI/Ultrasound fusion Prostate Biopsy. You can read about it here: https://www.prostatebiopsyblog.com/first-day-at-the-nih/

This week, I made a second visit due to increasing PSA levels. I again flew into Reagan airport in Washington DC.  I used the DC Metro for everything, no need for cabs, buses or ride shares.  Last time, I stayed at the Hyatt Regency Bethesda, which is literally right on the Metro, 1 stop from NIH.  This time, I found a much better rate at the nearby Hilton Garden Inn Bethesda, about a 2 block walk from the Metro, also easy and very reasonable.

After arriving at NIH, I started with blood and urine tests, an EKG and an IV for administering contrast during the MRI.  No chest X-ray was done this time. The MRI sure seemed longer than I recall from last time, but was apparently done in about half the time at just over 30 minutes of motionless time on my back.  Thankfully, they apparently no longer use the endorectal coil, which was as unpleasant as it sounds.  MRI results were not in by my appointment later in the afternoon, but given my history, the resident physician at the consultation confirmed that a biopsy was indicated.  I had pretty much assumed that.  Last time it was unpleasant, but this time was going to be local anesthesia rather than general, so I was still anxious.  My PSA level was 4.7 in their test, a bit lower than before but still within daily variations.

So, the next morning, I started at 5AM with the enema, unpleasant in itself.  After my bowels calmed down, I arrived at the NIH at 7AM for my 7:30 am appointment.  And waited, and waited, and waited.  Others arrived later but had their procedures earlier, including one gentleman who was clearly angry when he hadn’t been admitted 15 minutes after he sat down for his 9:30 appointment and began demanding to be seen with every nurse that came into the room.  I was about to tell him I had been there almost 3 hours already, when a nurse came to have me fill out some paperwork.  I also then asked if my MRI results were available and she went to get them.  As she returned, she also gave the other gentleman his forms to complete, and then he was off to OR before me…  Squeaky wheel, as they say.

Here is a very good guide on the procedure from a physician’s perspective:


The 5 hours waiting for the procedure was also pretty difficult for me, but eventually, my name was called just after noon.  Basically, under general, you’re wheeled in, put to sleep and wake up in post-op.  Under local anesthesia, it’s a bit different.  Okay, a lot different.  Here it is from a patient’s perspective. If you don’t want the details, don’t read on.  STOP HERE.



. Continue reading 2nd Visit to NIH for UroNav fusion MRI/TRUS Prostate Biopsy