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Robotic MRI-TRUS Fusion Transperineal Prostate Biopsy

What are the advantages over conventional prostate biopsy techniques?

  • More accurate targeting of suspected cancer identified on pre-operative MRI scans.
  • Significantly reduced risk of infective complications such as septicaemia.

What does the procedure involve?

This procedure, which is performed under a general or spinal anaesthetic, involves using a specialised robot (Biobot iSR'obot™ Mona Lisa) to take biopsies form areas of suspected prostate cancer seen on a pre-operative MRI scan. Dr Nathan, who has extensive experience in prostate imaging, will review your MRI scans and map out areas of suspected prostate cancer (lesions) using specialised computer software, which then creates a virtual 3-dimensional model of the prostate and areas to be targeted for biopsy. This virtual computer model is then uploaded to the robot. By combining (fusing) this 3-dimensional model with real-time ultrasound scans of the prostate, the robot precisely controls the depth and trajectory of the biopsy needle to target the areas of suspected cancer. The aim is to improve the accuracy of prostate cancer diagnosis compared to traditional "free hand" prostate biopsy techniques. Accurate diagnosis is critical for choosing the appropriate treatment in men with prostate cancer. It is important to distinguish aggressive cancers that may need to be removed surgically or treated with radiation, from very slow growing cancers that can just be monitored.

Also, the biopsies are taken using a fine needle passed through the skin behind the scrotum (the perineum), thus virtually eliminating the risk of septicaemia (blood poisoning), which can occassionally occur after the more commonly practised transrectal prostate biopsy technique.

What are the alternatives to this procedure?

  • Standard "free hand" prostate biopsies taken through a transrectal or transperineal approach.
  • Observation with repeat PSA blood tests but without biopsies particularly if an MRI scan does not show any suspicious areas in your prostate.

What should I expect before the procedure?

You will usually be admitted to hospital on the same day as your surgery. You may receive an appointment for a “pre-admission clinic” to assess your general fitness for an anaesthetic if you have significant underlying medical problems.

You will be asked not to eat and drink for six hours before surgery. Immediately before the operation, the anaesthetist may give you a pre-medication, which will make you dry-mouthed and pleasantly sleepy.

If you are taking warfarin, you must inform Dr Nathan so that you can be advised when to stop it before the procedure. It is usual to stop warfarin for 3 days and then do a blood test (INR) before your biopsy. Also, if you are taking other strong blood thinners such as Xarelto, Pradaxa, Eliquis, Plavix, Iscover, or Brilinta you need to let Dr Nathan know at least 2 weeks before surgery.

If you are taking aspirin, you do not need to stop this.

You will normally be given an intravenous injection of antibiotic at the time of your anaesthetic to prevent infections.

Please tell Dr Nathan (before your surgery) if you have any of the following:

  • An artificial heart valve.
  • A coronary artery stent.
  • A heart pacemaker or defibrillator.
  • An artificial joint.
  • An artificial blood-vessel graft.
  • A neurosurgical shunt.
  • Any other implanted foreign body.
  • A regular prescription for warfarin, aspirin or clopidogrel (Plavix®).

What happens during the procedure?

After the general or spinal anaesthetic has been given, your legs will be placed in special supports, which allow the surgeon to reach the skin behind your testicles. Dr Nathan will examine the prostate through the back passage (anus) before inserting the ultrasound probe, which is covered by a protective sheath, into the rectum. This probe is as wide as a man’s thumb and approximately 4 inches long. The robot (Biobot iSR'obot™ Mona Lisa) then controls the ultrasound probe, and adjusts the trajectory and depth of the biopsy needle to target areas of suspected prostate cancer seen on your pre-operative MRI scan. Biopsies may also be taken from surrounding, apparently normal areas of the prostate, to make sure there is no cancerous involvement.

The biopsy needle, which is 1mm thick, is inserted into the prostate through 2 tiny puncture sites on the skin of the perineum (area beind scrotum). After the biopsies have been done, a dressing will be applied to the perineum. The puncture sites will seal quickly and dressing can be take of when you get home.

What happens immediately after the procedure?

You may experience mild or moderate discomfort in the perineum for which you can take paracetamol. Blood in the urine is common for a few days, with the occasional blood clot, but this should clear quickly if you increase your fluid intake. You may expect to see blood in the semen for up to six weeks.

Are there any side-effects?

Most procedures have possible side-effects. Although the complications listed below are well recognised, most patients do not suffer any problems.

Common (greater than 1 in 10)

  • Blood in your urine for up to 10 days.
  • Blood in your semen for up to 6 weeks; this is harmless and poses no risk to you or any sexual partners
  • Bruising in your perineal area.
  • Sensation of discomfort due to bruising.

Occasional (between 1 in 10 and 1 in 50)

  • Failure to detect a significant cancer of the prostate.
  • The procedure may need to be repeated if the biopsies are inconclusive or your PSA level rises further.
  • Inability to pass urine (retention of urine).

Rare (less than 1 in 50)

  • Urinary tract infection (1%).
  • Haemorrhage (bleeding) needing hospitalisation (1% risk).
  • Blood infection (septicaemia) needing hospitalisation (<0.1%).

What should I expect when I get home?

It is important that you:

  • Sit quietly at home for the first 24 hours after the biopsies.
  • Drink twice as much fluid as you would normally for the first 48 hours.
  • Maintain regular bowel function.
  • Avoid physically demanding activities for 48hr.
  • Any discomfort can usually be relieved by simple painkillers.

What else should I look out for?

If you experience symptoms of cystitis (frequency and burning on passing urine), you should contact your Urologist or GP. If there is a lot of bleeding in the urine, especially with clots of blood and difficulty urinating, or you develop a fever more than 38°C, feel shivery, and very unwell you need to contact your Urologist straight away or attend your local hospital emergency department.

Disclaimer

This information is intended as a general educational guide and may not apply to your situation. You must not rely on this information as an alternative to consultation with your urologist or other health professional.

Not all potential complications are listed, and you must talk to your urologist about the complications specific to your situation.