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.
You are wheeled into the OR with the basic hospital gown. You know, the kind that is hopeless to tie and leaves your backside exposed no matter what you do. You slide over to the OR table and then you are instructed to get into the fetal position on your left side, knees almost up to chest. Your butt is then available for the team to examine as they start the procedure. I suspect it’s not all that much different than your average alien abduction with the optional anal probe. Except that you are not sedated at all and remember everything, of course. First, they numb your anus with jelly and then do another DRE. Mine was negative, thankfully.
Then, the fun begins. The probe goes in and they have to administer local anesthesia. Basically, you get two shots of lidocane, similar to having a tooth numbed before a filling, except that it’s inside your butt. It wasn’t quite as bad as the sharp pinch and burning they warned about, but still not real pleasant, either. Then the probe gets moved around up inside so they can take a background 3D ultrasound to get images to align the live feed ultrasound to the detailed MRI results from the day before. The team seemed encouraged by the good match of the MRI to the ultrasound. That lets them map the exact location of any suspicious areas for targeting. You have to remain very still to keep the alignment for the targeted biopsies.
Once the numbing is complete and everything is aligned, they prepare for the biopsies. You are facing the monitors showing you 2D slices of the 3D prostate MRI/ultrasound fused images. This tells them exactly where to skewer your rectum to get a core sample of the prostate from the suspicious area. As they described, you feel the pressure before each “POP” of the needle biopsy gun, though the pinch isn’t nearly as bad as the first ones due to the local anesthesia. Honestly, the anticipation of each puncture was worse than the needle itself.
In my case, my understanding is that the resident took two roughly perpendicular core samples of the one suspicious lesion and the team felt they got a very good target hit. You can see the needle pop in on the screen and it gives them an indication if they targeted correctly according to the MRI and software fusion system, called UroNAV (and developed in part from this trial). Apparently, the system has improved considerably since the early version used on my last trip 10 years ago. After the two targeted samples, they took the standard sextant set of 12 core samples, one in each section of the prostate to look for stray or diffuse cancer cells.
Overall, it wasn’t horrible, but honestly, between the waiting and the procedure, I don’t want to ever have to do it again. I figure it was about 30 minutes in the OR and perhaps 15 minutes of anal probing and skewering. Sadly, I expect this could be the new norm for me depending on the results. And now, I wait again:-(
The worry is compounded by the fact that MRI results were not as good as last time. They indicated a chance of clinically significant cancer in the form of a suspicious area that did not appear on my previous MRI, located in a region that was not sampled by biopsy previously. The good news, if there is that, is that it is only a single lesion and it appears to be contained within the prostate. Beyond that, nothing more is known until the biopsy results are available in about 2 weeks. The waiting is now indeed the hardest part. For anyone still reading this rarely updated blog, send a few prayers or wish me luck. I am certainly hoping it is either a benign lesion or at least a low-grade malignant one that often does not require immediate major surgical intervention.
And before I have biopsy results, I’ll likely be posting again about post-op side effects, which is basically blood, blood and more blood in various things coming out of your body:-( Here’s my popular(?) version from 10 years ago: https://www.prostatebiopsyblog.com/what-to-expect-after-your-prostate-biopsy/