Is biopsy necessary & effective for detecting prostate cancer?

Biopsy was my gateway to PSMA PET scan, which identified specific treatment targets est.

@brianjarvis To me, the barbaric aspect is the fact that it is usually done without general anesthesia (nor spinal anesthesia)...but that's just my opinion.

@jercalif If you ask for anesthesia, they’ll give you anesthesia. I’m amazed at how many guys just do what the urologist says, as if he (she) was a god. This is all about self-advocacy and shared decision-making (no different than with any other diseases, illnesses, or injuries). If a guy doesn’t request it, that’s on him.

When my older brother was going to have a prostate biopsy last year - he’s the type to do whatever the doctor says just because the doctor says so - I advised him to request general anesthetic. He did; they did. That’s all it took. (Yes, it was more involved with a general anesthetic, but so what?)

(When I had knee surgery in 2018, I wanted general anesthesia; a guy I knew wanted to be awake for his similar procedural and requested an epidural. We both got what we requested.)

It’s no different with a prostate biopsy; if general anesthetic is requested , they’ll do it; if local anesthetic is requested, they’ll do it. If no anesthetic is requested, they’ll do it. The procedure itself is no more barbaric than any other.

@brianjarvis
I echo your post.

I have PTSD anxiety/panic disorder and I wanted my biopsies done transperineally with anesthesia. My urologist (was at Mayo) wanted to do transrectal as I was a heart failure patient and pushed me to have it done transrectal. My opinion was he wanted to do transrectal as was not as complex as transperineally done in surgical section versus a special office setting.

I did not accept his insistence and contacted my heart failure doctor about his stance. My HF doctor and I knew I had no restrictions on having anesthesia as had had it several times and just weeks prior for a colonoscopy. I had my HF doctor contact the urologist and advised him cardiology had no restrictions on me having anesthesia.

My urologist informed me he had been contacted by HF doctor and would schedule me for MRI/Fusion procedure with anesthesia.

So like you said, stand up, speak, get what is best for you when you have options. I also did not want the additional increase in infection (was told 1-2%) if it could be avoided and did not want it done transrectal.

I don't think the transperineally is barbaric but a very specific and precise surgery. It confirmed I had PC when my MRI just showed suspicious areas.

Some on MCC had no problem having it done transrectal and that is their decision to make.

@brianjarvis Is it possible that you and your brother just got lucky and found extra-compassionate urologists?
Is there not a severe doctor shortage where you both live?
With the exception of the rare extra-compassionate doctor, doctors don't have to accommodate patients' needs because it is a "seller's market"...car dealers don't give discounts or concessions when there are more buyers than available cars, and doctors don't have to make concessions because there are more patients than available doctors.
And my guess is that these doctors that won't do general anesthesia would do general anesthesia if it were instead a "buyer's market".
In this "seller's market", doctors can afford to only keep the "cream of the crop" when it comes to patients, which means the most compliant patients.
I'm almost afraid to even ask my new urologist about general anesthesia during biopsy for this reason.
My primary care provider is an extremely compassionate woman who really cares about patient comfort, and if I get that feeling from my new urologist then I will ask about general anesthesia, but if I get the impression that his his attitude is going to be "oh...so this guy is going to be a troublemaker" , then I won't ask him about general anesthesia. I might casually ask one of his staff members about it on the sly, though.
Seeking out a compassionate urologist isn't really an option for me, because I would want a fusion biopsy, which already limits the selection of urologists within 3 hours of me, and then there is also the factor of "how do you know if a urologist is compassionate until you meet?".
Online reviews don't help because very few men ask for general anesthesia prior to biopsy, and if they don't ask then they don't know if the urologist would be compassionate vs. hostile regarding that particular issue.
Sorry to sound so cynical and/or negative, but I think that my description of the current situation is accurate.

@jc76 So much can be done differently with prostate cancer diagnosis and treatment if we just ask.

A friend of mine was severely claustrophobic; he would not do an MRI. I mentioned that he should ask if they had a wide-bore MRI (used for patients who are claustrophobic or severely obese). Turns out that his hospital did have one and it worked out well for him. All he had to do was ask.

When my oldest brother was diagnosed with prostate cancer last year, we went through two urologists because they would only do TRUS biopsies. Even when we discussed the benefits of transperineal over transrectal, they didn’t budge. (Note that both carry small risk of infection: < 5% for transrectal; < 1% for transperineal). The 3rd urologist we saw (at Ohio State University) did it transperineally; since my brother also had heart issues, they consulted his cardiologist. There were no complications. (Even though I had 4 TRUS biopsies with no complications when I was on active surveillance from 2012-2021, I wanted the most modern procedure for him.) Again, all we had to do was ask (a few times).

As you experienced, if you’re the one that has to live with all this poking and prodding and the aftermath of all of it, you should have some say in how it’s done.

@jercalif I don’t think it had anything to do with extra compassionate urologists.

When I was initially diagnosed with PCa in 2012, my first comments to my urologist were, “I don’t know anything about prostate cancer so, I’ve got a zillion questions to ask before you cut anything out of me, or bombard me with radiation, or inject toxic chemicals into me……” That set the tone for our future discussions. (In fact, he recommended surgery; I said no, my numbers are in line with active surveillance protocols. I was on active surveillance for about nine years.)

No, we have no urologist shortage here. With 2 major hospital networks, many urology centers, and a VA medical center nearby, there is no issue with access or it being a “seller’s market.”

With my PCa journey, at each step of the way - urology, radiation oncology, and medical oncoming - it always involved self-advocacy and shared decision-making.

There were no less than a half-dozen decision points where we weren’t in agreement on my treatment path. I never felt pressured or that I had to do what the urologist/radiologist/medical oncologist suggested. When their argument was stronger than mine, we went with their recommendation; when mine was stronger than theirs, we went with my recommendation. But, that required me to thoroughly research and come up to speed on the nuances and protocols with this disease so that these would be informed discussions, and not just emotional opinions.

As often happens having different medical teams, our experiences were totally different. I think that I was fortunate in having selected a medical team that was open to working with me (rather than being assigned a team as some are).

“How do you know if a urologist is compassionate until you meet?” At that first referral appointment you just sit and talk with them about your situation, as if you were interviewing them (like you would if you asked someone to work on your house, or replace your roof, or do any other major project for you). Once you feel good that you’ve found someone you can work with, then go on to the next step.

If I lived in a “seller’s market,” things might be approached differently. But, I don’t; so I can’t answer from that perspective.

I just had my biopsy done on 1/22/26 it wasn't terrible. Yes, I can see how a person could look at it as barbaric, but it wasn't brutal. I got an injection in my right butt check to numb it, waited about 15 minutes and then they did the procedure. I had about 8 different samples taken from my prostate. The clicking of the instrument was a little unsettling, but all I could feel was a blunt poking at my prostate. Yes, I was nervous, but after the first sample was taken it wasn't bad at all. I was a little sore the next day, but not extreme pain. My Urologist said that the biopsy is the better route to go instead of an MRI, so that is why I chose a biopsy. I had the ultrasound. Jeff Marci is correct about the chance of infection, I took a antibiotic a day before, the day of, and the day after (500mg). I fell fine no side affects. I haven't got my results back yet.

@brianjarvis I think that what it boils down to is that if you are in a seller's market then you have to limit your urologist "negotiations" that might alienate your urologist to only the ones that are the most important to you, and since I want a relatively hard to find fusion biopsy I think I'm just going to have to "go along to get along" with regard to the pain, and then once I have my fusion biopsy done I can then see how hard to find the next step will be, and then decide whether it is worth risking alienating my urologist over that next step.
That next step (probably) that I would prefer is a [RALP + suprapubic catheter], but I expect that it might be impossible to find a urologist that will give me a referral for that until it is deemed to be "medically necessary", even if I am willing to pay cash for it. Actually, from my perspective, a truly well-contained prostate cancer might be a better biopsy result for me than a "no cancer" biopsy result, because cancer might entitle me to a RALP, whereas no cancer won't.
If it were breast cancer, I could do an Angelina Jolie and have a prophylactic removal, but that isn't normally done for men's prostates, and I understand the reasoning...my prostate isn't isolated and exposed like a woman's breasts are, and so it's a far more risky operation than a double mastectomy (I assume).

@derbydog71
You wrote: "My urologist said that the biopsy is the better route to go instead of an MRI".
Hopefully you mean that he was recommending a biopsy as opposed to an MRI WITHOUT a biopsy? Yes, an MRI alone is not good enough, at least not currently. But an MRI plus biopsy... preferably a targeted "fusion" biopsy...is better.

My original urologist wanted to go right to a systematic biopsy without doing an MRI or even mentioning the existence of fusion biopsies, transpirennial fusion biopsies, etc.,...and why would any ethical and competent urologist recommend to a patient to do an untargeted biopsy when targeted biopsies are available? I still haven't found the answer to that question, but whatever the answer is I would consider it malpractice to not at least mention alternative superior procedures to a patient.
I'm not suggesting substituting an MRI for a biopsy, I'm just saying why do a "blind" systematic biopsy when an MRI at least offers a chance at finding some targets to shoot at, in addition to the systematic samples.