MRI-Guided Prostate Biopsy

What is an MRI-guided prostate biopsy?

An MRI-guided prostate biopsy helps healthcare providers diagnose, stage and treat prostate cancer. Providers use MRI and ultrasound-guided technology to take tissue samples (biopsy) from your prostate gland. A medical specialist called a pathologist uses a high-powered microscope to examine the tissue samples for cancer cells.

What is the prostate?

Your prostate is a walnut-sized gland that’s part of the male reproductive and urinary system. It sits in front of your bladder. This gland makes seminal fluid that mixes with sperm when you ejaculate. The fluid keeps sperm healthy and viable for conception and pregnancy.

The urethra runs through the center of your prostate gland. This tube is part of your urinary system. It carries urine from your bladder through your penis and out of your body when you pee. It also carries seminal fluid and sperm during ejaculation.

What are the two routes that prostate biopsies can be performed?

There are different ways to perform the actual biopsy. Your provider will discuss the options with you and select the best approach for your specific condition. Biopsy options include:

• Transrectal biopsy: Your provider removes the tissue sample through your rectum, the last part of your large intestine (colon).
• Transperineal biopsy: Your provider removes the tissue sample through your perineum, the area of skin between your anus and scrotum.

What is a multiparametric MRI-guided prostate biopsy?

Healthcare providers also use MRI technology and needle biopsies to perform:

• Multiparametric MRI (mpMRI): Your provider compares results from a standard MRI to a newer MRI method. An mpMRI is highly sensitive and can identify cancerous areas better than a standard MRI. But providers can’t rule out prostate cancer with mpMRI alone. A prostate biopsy is still usually necessary.
• Fusion-guided prostate biopsy: This test combines or “fuses” MRI and transrectal ultrasound (TRUS) technology. You get an MRI first to help your provider identify any suspicious areas on your prostate gland. During the actual biopsy, your provider uses a prostate ultrasound probe and advanced software to combine the MRI and ultrasound images. This fused image helps your provider more precisely sample tissue from the identified problem areas.

What does an MRI-guided prostate biopsy diagnose?

An MRI-guided prostate biopsy helps healthcare providers diagnose:

• Prostate cancer and its grade (aggressiveness).
• Recurrent prostate cancer (cancer that comes back after treatment).

How else do healthcare providers use MRI-guided prostate biopsies?

If you have prostate cancer, the biopsy results help your healthcare provider develop the most effective treatment plan.

The test can also help your provider diagnose or rule out noncancerous (benign) conditions that cause signs or symptoms similar to prostate cancer, like an elevated PSA blood test. These conditions include:

• Enlarged prostate (benign prostatic enlargement/hyperplasia or BPE/BPH).
• Prostatitis (infection, inflammation and pain in the prostate gland).

Who needs an MRI-guided prostate biopsy?

Your healthcare provider may perform an MRI-guided prostate biopsy if a blood test shows elevated PSA (prostate-specific antigen) levels. You may also need this type of biopsy if your provider feels a bump or hard area on the prostate gland during a digital rectal exam (DRE) or if you have a suspicious MRI. These changes can be signs of prostate cancer or a noncancerous problem.

You may also need an MRI-guided prostate biopsy if:

• An ultrasound-guided prostate biopsy doesn’t detect cancer, but your PSA levels continue to rise.
• You have a diagnosis of prostate cancer and your provider is using active surveillance to monitor it.
• You have a diagnosis of prostate cancer and are considering focal treatments.

What are the benefits of an MRI-guided biopsy?

Compared to ultrasound technology, an MRI provides clearer, more detailed images of the prostate gland. It can better identify potentially cancerous areas that require sampling with a biopsy and, possibly, treatment. An mpMRI may reduce the number of biopsies you get and has better success at detecting prostate cancer than a standard MRI.

What happens before an MRI-guided prostate biopsy?

You should follow your healthcare provider’s instructions to prepare for a prostate biopsy. You may need to:

• Alert your provider to any implanted metal devices you may have before the MRI, like a pacemaker or joint replacements.
• Empty your bowels. Some providers suggest using an enema before the biopsy, but this may not be necessary.
• Stop taking medications like nonsteroidal anti-inflammatory drugs (NSAIDs) and blood thinners. Certain drugs may increase your risk of bleeding and bruising.
• Take antibiotics before and after the procedure to lower your infection risk. Often, antibiotics aren’t often necessary for a transperineal prostate biopsy due to the low risk of infection.

What happens during an MRI-guided prostate biopsy?

You’ll get the MRI first. During your MRI, you may receive contrast dye through an IV (through your vein) to capture more detailed images. You may feel a temporary cool sensation when the IV starts.

Although rare, it’s possible to have an allergic reaction to the IV contrast dye. You may develop hives (urticaria) and swelling (angioedema) or feel nauseous. These reactions tend to happen soon after you get the IV. Your provider can administer immediate treatments to counteract these reactions.

The biopsy itself is an outpatient procedure that may take place at your provider’s office, a medical clinic or a hospital. You’ll receive a local anesthetic to numb the prostate area. Sometimes, a mild sedative can be prescribed or administered during the biopsy. You go home the same day. If you aren’t sedated, you may not need a ride home. But you should plan for a driver just in case.

Most providers take 12 to 16 tissue samples (called cores) from different parts of your prostate gland. You may feel pressure during the biopsy. The procedure may be uncomfortable, but it shouldn’t be painful.

What happens during a transrectal MRI-guided prostate biopsy?

You lie on your side for a transrectal biopsy. During the procedure, your provider:

1. Lubricates and gently inserts a biopsy device into your rectum.
2. Uses a guidance slot on the biopsy device to insert the needle for administering local anesthetic and for taking biopsies.
3. Uses advanced software and images from the MRI to guide the needle and remove tissue samples.

What happens during a transperineal MRI-guided prostate biopsy?

You lie face up for a transperineal biopsy with your legs in stirrups. During the procedure, your provider:

1. Inserts the ultrasound probe into your rectum.
2. Numbs your skin and prostate with local anesthetic.
3. Uses advanced software and images from the MRI to guide the needle and remove tissue samples.

What happens after an MRI-guided prostate biopsy?

You can go home after the sedative wears off and your vital signs look good. You may:

• Have some slight bleeding from the procedure site along with mild pain or discomfort.
• Need to take antibiotics to prevent infections.
• See a small amount of blood in your urine (hematuria) or blood in your semen (hematospermia) for a few days after the procedure. If you had a transrectal prostate biopsy, you may also have some blood in your rectum.

When should I get the biopsy results?

Your provider sends the tissue samples to a lab. It may take around one week, sometimes longer, to get the results.

What do the biopsy results mean?

Your biopsy results may be:

• Negative: There are no signs of cancer cells. It’s possible to get a false-negative result. This means you have cancer even though the test indicates you don’t. If you have elevated PSA levels or other indicators of prostate cancer, your provider may order another biopsy in a few months.
• Positive: Cancer cells are present, indicating prostate cancer. Your provider will discuss the next steps, like treatment options or surveillance, with you.
• Suspicious: The results were abnormal and can’t exclude cancer. Your healthcare provider may order additional tests or another biopsy in a few months.

How do biopsy results determine how aggressive prostate cancer is?

If the pathologist finds cancer cells, they assign a grade of 1 to 5 based on how unusual the cells look. They then add the two most common grades to get what’s known as a Gleason score (range from 6 to 10). Another way to describe the score is using the Grade Group scale (1 to 5).

Higher-grade cancers (Grade Group 5) are more likely to be aggressive and spread (metastasize) than lower-grade cancers (Grade Group 1). The Grade Group helps your provider choose the most effective treatment.

When should I call my doctor?

You should contact your healthcare provider if you develop signs of infection like fever and chills after a biopsy.

You should also call your provider if you have prostate cancer symptoms or problems like:

• Blood in your urine or semen.
• Erectile dysfunction.
• Fecal (bowel) incontinence.
• Frequent nighttime urination (nocturia).
• Painful urination (dysuria) or ejaculation.
• Urinary incontinence, weak urine flow or flow that starts and stops.

A note from Cleveland Clinic

If certain tests suggest you have prostate cancer, your healthcare provider may perform an MRI-guided prostate biopsy. MRI technology helps your provider identify and target areas in the prostate gland that look suspicious. Your provider may combine MRI and ultrasound technology for a fusion-guided biopsy. If the biopsy results confirm a prostate cancer diagnoses, your provider can discuss treatment options with you.