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Transperineal vs Transrectal biopsy

Posted by mauk @mauk, Aug 27 9:28pm

I am up for a biopsy mid-September, and needed advice on which route to take, I called up the UCSF urology dept and was informed that it would be Transrectal not sure if the person knew the right answer. After doing research I found out most center are not performing transrectal but leaning towards transperineal. Any thought from folks who gone through the biopsy process.

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steveapplebaugh | @steveapplebaugh | Sep 2 2:45pm
In reply to @rbtsch1951 "@jc76 Thanks for sharing your thoughts. I have complete confidence in my team at UCLA. My..." + (show)
Profile picture for rbtsch1951 @rbtsch1951

@jc76

Thanks for sharing your thoughts. I have complete confidence in my team at UCLA. My urologist is a national leader in the prostate cancer field, so I had no reason to question his biopsy approach. Too, he recommended active surveillance rather than intervention when first diagnosed because at Gleason 6/7 with a low Oncotype score (his choice over the Decipher test) the odds of progression to aggressive disease were low. All medical decisions are based on statistics, and in my case no matter how low the odds, my progression to Gleason 9 was 100%. No point in using questioning whether a therapeutic window was missed earlier on, I must forge forward.

Treatment plan is for MRI-guided SBRT delivered as an excelerated 5 treatment (every other day for 5 treatments) with convincing data documenting equivalent outcomes and side effects compared to the more standard extended low dose regimen. I had a Prostox (MiraDx) genetic test documenting I was at low risk for late toxicities from high-dose radiation.

Thanks for sharing your input with the SpaceOAR procedure. While I did not find the transrectal biopsies painful, I am going to request mild sedation. I believe it is simply a low dose of Valium (diazepam) given before the procedure to supplement the local anesthesia given by level
of anxiety and associated depression as I head into therapy.

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Having my first prostate biopsy done next week - I am excited about getting the information we need to plan for appropriate next steps, all part of positive forward movement. It will be transrectal. Doc and I decided to pass on any sedation but will have the local anesthesia (of course) because I want to be able to drive myself to and from the clinic. I learned the intentional breathing and meditation really keeps me calm and focused. That has been my life saver during any time in a dental chair!

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steveapplebaugh | @steveapplebaugh | Sep 2 2:51pm
In reply to @mjp0512 "Same here...big pill and fleet a couple hours before procedure. Zero issue with infection, however, the..." + (show)
Profile picture for mjp0512 @mjp0512

Same here...big pill and fleet a couple hours before procedure. Zero issue with infection, however, the "It's not going to hurt, you'll just feel pressure" was pure crap. Two of the samples sent me to the ceiling and it felt like someone kicked me in the groin for a couple days after. I am certainly not looking forward to another one.

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Wow. This is not what I expected to hear (read), especially since I am scheduled for transrectal biopsy next week. But I have learned to use intentional breathing and meditation to remain calm and anxiety-free during dental chair time (my least favorite thing of all!), so I am practicing my breathing/meditation daily!!!

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rbtsch1951 | @rbtsch1951 | Sep 2 3:22pm
In reply to @steveapplebaugh "Wow. This is not what I expected to hear (read), especially since I am scheduled for..." + (show)
Profile picture for steveapplebaugh @steveapplebaugh

Wow. This is not what I expected to hear (read), especially since I am scheduled for transrectal biopsy next week. But I have learned to use intentional breathing and meditation to remain calm and anxiety-free during dental chair time (my least favorite thing of all!), so I am practicing my breathing/meditation daily!!!

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@mjp0512 I found the sound of the biopsy snip made me "twitch" the first time I experienced it as a novice, but @steveapplebaugh relaxed breathing and meditation/imagery helped too once I realized what to anticipate and the "pinch".

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mjp0512 | @mjp0512 | Sep 2 3:55pm
In reply to @steveapplebaugh "Wow. This is not what I expected to hear (read), especially since I am scheduled for..." + (show)
Profile picture for steveapplebaugh @steveapplebaugh

Wow. This is not what I expected to hear (read), especially since I am scheduled for transrectal biopsy next week. But I have learned to use intentional breathing and meditation to remain calm and anxiety-free during dental chair time (my least favorite thing of all!), so I am practicing my breathing/meditation daily!!!

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Just got back from fiducial marker insertion and apparently, it's me and not the norm. Two of these sent me to the roof too. The third was fine. The opinion of the surgeon is that the nerve bundle they target with lidocaine is not in the position it's supposed to be due to the nature of the growth of the tumor. Told him that sounded a lot like lipstick on a pig, but I was still hurting some. He might just be right, and you'll be fine.

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trki | @trki | Sep 2 5:36pm
In reply to @jeffmarc "You are so right. They cannot get to areas of the prostate with the transrectal biopsy..." + (show)
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You are so right. They cannot get to areas of the prostate with the transrectal biopsy that they can with the Transperineal biopsy. I wonder if that’s the reason they couldn’t find your husband’s cancer.

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We think that’s true.

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chardsaus | @chardsaus | Sep 2 8:19pm

I had two transperineal biopsies done both under general anesthesia.

From my research (and now ChatGPT is awesome at comparing the two). I found Europe and some American hospitals are no longer doing transrectal. The transperineal is less risk of infection and from what some articles have posted, offers greater access to the whole prostate.

I wasn't sure what to expect from where they went in, but it was the equivalent to a mark left by a blood draw. There was no minimal blood on the band aid and no bleeding from where they entered for the biopsy (blood in urine, feces and ejaculate is not uncommon for a bit but clears up pretty quickly).

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steveapplebaugh | @steveapplebaugh | Sep 3 6:54pm
In reply to @mjp0512 "Just got back from fiducial marker insertion and apparently, it's me and not the norm. Two..." + (show)
Profile picture for mjp0512 @mjp0512

Just got back from fiducial marker insertion and apparently, it's me and not the norm. Two of these sent me to the roof too. The third was fine. The opinion of the surgeon is that the nerve bundle they target with lidocaine is not in the position it's supposed to be due to the nature of the growth of the tumor. Told him that sounded a lot like lipstick on a pig, but I was still hurting some. He might just be right, and you'll be fine.

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MJP, I am really sorry that you have a "misplaced" nerve bundle perhaps because of the tumor's growth. Actually, regardless of the reason, I am sorry that you are experiencing what seems like excruciating pain. Twist and turn for me today, ironically. I chatted with Mayo this morning. I am scheduled to see one of their urologists (amazing reputation and resume!) in late October. He only does trans-perineal biopsies, but that would not happen until after our initial consultation meetup. On the other hand, I am scheduled for a transrectal biopsy next week. UGH!!!!

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mjp0512 | @mjp0512 | Sep 4 4:27am
In reply to @steveapplebaugh "MJP, I am really sorry that you have a "misplaced" nerve bundle perhaps because of the..." + (show)
Profile picture for steveapplebaugh @steveapplebaugh

MJP, I am really sorry that you have a "misplaced" nerve bundle perhaps because of the tumor's growth. Actually, regardless of the reason, I am sorry that you are experiencing what seems like excruciating pain. Twist and turn for me today, ironically. I chatted with Mayo this morning. I am scheduled to see one of their urologists (amazing reputation and resume!) in late October. He only does trans-perineal biopsies, but that would not happen until after our initial consultation meetup. On the other hand, I am scheduled for a transrectal biopsy next week. UGH!!!!

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You're very kind. Thank you. I'm sure you'll do fine with your biopsy. Best wishes.

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heavyphil | @heavyphil | Sep 4 7:29am
In reply to @steveapplebaugh "MJP, I am really sorry that you have a "misplaced" nerve bundle perhaps because of the..." + (show)
Profile picture for steveapplebaugh @steveapplebaugh

MJP, I am really sorry that you have a "misplaced" nerve bundle perhaps because of the tumor's growth. Actually, regardless of the reason, I am sorry that you are experiencing what seems like excruciating pain. Twist and turn for me today, ironically. I chatted with Mayo this morning. I am scheduled to see one of their urologists (amazing reputation and resume!) in late October. He only does trans-perineal biopsies, but that would not happen until after our initial consultation meetup. On the other hand, I am scheduled for a transrectal biopsy next week. UGH!!!!

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Why even do the transrectal at all? You will probably have to heal a minimum of 6 weeks ( or more) after it before you can have an accurate, more encompassing transperineal one.
Personally, I would wait for your consult and go from there, but that’s just my opinion.

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steveapplebaugh | @steveapplebaugh | Sep 4 9:52am
In reply to @heavyphil "Why even do the transrectal at all? You will probably have to heal a minimum of..." + (show)
Profile picture for heavyphil @heavyphil

Why even do the transrectal at all? You will probably have to heal a minimum of 6 weeks ( or more) after it before you can have an accurate, more encompassing transperineal one.
Personally, I would wait for your consult and go from there, but that’s just my opinion.

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I would not do both - that is for sure. The Mayo Clinic said that they would use the results of my biopsy next week along with my MRI and labs (to date) during the consultation on 10/27 and plan from there. In my mind, it is a matter of timing. My Tucson team will be able to discuss forward planning by the end of September, with a new option for me to consult with Dr. Frendl. If I wait to do anything until I see the Mayo doc, then all possible treatments are delayed. I have a new HUGE consideration. Starting in January 2026, an AI company and its AI "mechanism" will decide which procedures I will be able to have covered by Medicare. I really DO NOT want to wait too long so that my decisions with urologists input will be null and void.

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