How Is a Prostate Biopsy Done? Preparation, Procedure and Aftercare

Being told you need a biopsy after a raised PSA or a suspicious finding on a prostate MRI can be worrying for many men. Knowing why the procedure is done, how it goes and what to expect afterwards reduces this worry considerably. In this article we explain a prostate biopsy step by step, from preparation to results.

Why is a prostate biopsy done?

A prostate biopsy is the taking of small tissue samples from the prostate with a fine needle and their examination in a pathology laboratory. A definitive diagnosis of prostate cancer can only be made with a biopsy. The PSA test, examination and MRI raise a suspicion; the biopsy shows whether that suspicion is confirmed.

A biopsy is usually considered in the following situations:

• A PSA that stays high on repeated measurements
• Hardness or a nodule in the prostate on rectal examination
• An area on a prostate MRI that is suspicious for cancer
• A PSA that keeps rising despite a previous clear biopsy

We explain in detail how a PSA result is interpreted in our article on what a raised PSA means.

Should a prostate MRI be done before a biopsy?

Current European Association of Urology (EAU) guidelines recommend a multiparametric prostate MRI before the decision on a biopsy. The MRI shows suspicious areas within the prostate, and these areas are scored on a scale from 1 to 5 called PI-RADS. The higher the score, the greater the likelihood of clinically significant cancer.

MRI makes two important contributions: it allows samples to be targeted at the suspicious area, and in some low-risk patients, when considered together with other findings, it helps with the decision on whether a biopsy is needed at all.

What is the difference between an MRI fusion biopsy and a systematic biopsy?

A systematic biopsy takes samples, usually 10–12, from specific areas of the prostate in a standard pattern. The aim is to sample the gland as a whole.

A targeted (MRI-guided) biopsy, on the other hand, takes samples directly from the suspicious area seen on MRI. Different methods are used for this:

• Fusion biopsy: During the procedure, the MRI images are combined with the ultrasound image using software, and the needle is guided to the suspicious area.
• Cognitive targeting: The doctor works out the location of the MRI area on the ultrasound image themselves and takes the samples.
• In-bore MRI biopsy: The procedure is done directly inside the MRI scanner; it is offered at a more limited number of centres.

In patients with a suspicious area on MRI, targeted and systematic samples are often taken together. Which method is suitable depends on the MRI findings, the size of the prostate and the individual’s risk.

What is the difference between a transrectal and a transperineal biopsy?

The prostate can be reached by two different routes:

• Transrectal biopsy: The needle reaches the prostate through the bowel wall, alongside an ultrasound probe placed in the back passage. This method has been widely used for many years.
• Transperineal biopsy: The needle reaches the prostate through the skin between the scrotum and the back passage (the perineum). Because it does not pass through the bowel wall, the risk of infection is lower.

Current European guidelines recommend that the transperineal route is preferred where conditions allow, because of its lower risk of infection. Both methods can be done under local anaesthetic, sedation or general anaesthetic. Which route is chosen is decided together with your doctor, according to your situation and the centre’s facilities.

How do you prepare for a prostate biopsy?

• Blood thinners: If you take a blood thinner or a medicine that affects clotting, always tell your doctor in advance. Do not stop your medicine on your own; whether to pause it is decided together with the doctor who prescribed it.
• Urine test: If there is an active urinary tract infection, the biopsy is postponed. For this reason, a urine test and, if necessary, a urine culture may be requested before the procedure.
• Antibiotics: Take the preventive antibiotic recommended to you exactly as instructed.
• Bowel preparation: For the transrectal route, a bowel clear-out may be requested before the procedure.
• Fasting: If sedation or a general anaesthetic is planned, avoid eating and drinking for the time you are told.
• Information: Tell your doctor about any allergies, diabetes and previous urinary tract infections.
• Someone to accompany you: Because you should not drive after sedation or a general anaesthetic, it is a good idea to have someone with you.

How is a prostate biopsy done?

Depending on the method chosen, the patient lies on their side or on their back with the legs supported. A thin ultrasound probe is placed in the back passage to image the prostate. After the anaesthetic has been given, samples are taken with a fine biopsy needle, guided by ultrasound and, if needed, by the MRI images. A short “click” may be heard as each sample is taken.

The procedure usually takes 15–30 minutes, and most patients go home the same day.

Is it normal to see blood in the urine and semen after a biopsy?

Yes, for a certain period this is to be expected:

• Blood in the urine: Usually fades and disappears within a few days.
• Blood in the semen: Can last a few weeks; it may also appear as a brown discolouration of the semen and is harmless.
• A small amount of blood in the stools: May be seen in the first few days after the transrectal route.
• Mild pain and bruising: In the groin, back passage or perineum, may last a few days.

During this period you are advised to drink plenty of fluids and to avoid strenuous exercise and cycling for the first few days.

What is the risk of infection after a prostate biopsy?

The most important problem after a biopsy is infection. It is usually mild, but rarely it can develop into inflammation of the prostate and a serious infection that spreads to the blood. The risk of infection is higher with the transrectal route than with the transperineal route. Taking the recommended antibiotic in full and recognising the warning signs are the most important parts of managing this risk.

When should you seek help immediately after a biopsy?

• A fever of 38 °C or above, shivering, or feeling generally unwell
• Being unable to pass urine at all, or increasing fullness and pain in the lower abdomen
• Bleeding in the urine that contains clots, is heavy or is getting worse
• Heavy bleeding from the back passage, dizziness or weakness
• Pain that does not settle with painkillers

Fever and shivering in particular can develop in the first few days after the procedure and should be assessed without waiting. If it is the weekend or night-time, go to the nearest emergency department.

How is the biopsy result interpreted?

The pathology result is usually ready within one to two weeks. If cancer is found, the report includes the Gleason score, which shows how aggressive the tumour is, and the corresponding ISUP grade, as well as the number of samples containing cancer and the extent of involvement. This information forms the basis for discussing options ranging from active surveillance to surgery and radiotherapy. For details, see the prostate cancer page. The urology glossary can help with the terms used in the report.

If the biopsy is clear, PSA monitoring continues. If PSA keeps rising or new findings appear on MRI, a further assessment may be needed.

When should you see a urologist?

It is advisable to see a urologist if your PSA has been high on repeated measurements, if it has risen markedly compared with previous values, if prostate cancer runs in your family, or if you have noticed a change in your urine flow. You can assess your urinary symptoms before your appointment with the IPSS prostate score. Bringing your previous PSA results and, if you have one, your MRI report with you makes the assessment easier.

Op. Dr. Mücahit Kabar sees patients in Bursa (Nilüfer), Turkey, at Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00, +90 444 8 112) and Özel Jimer Hastanesi (weekdays 13:00–17:00, +90 444 45 67). Appointments are booked through the hospitals’ online booking pages or appointment lines. Consultations are held in English or Turkish; the hospitals’ international patient departments can arrange interpreters for other languages. If you are travelling from abroad, you can send your questions, previous PSA results and MRI report by WhatsApp to +90 541 622 54 82 before your visit. See the contact and appointment information for details.