First biopsy - transrectal or transperineal? Post-biopsy Decipher?

Welcome and so sorry you had to find your way here. Some Drs only do transrectal because that's what they know. Is one better than the other? Depends on who you ask. FWIW my transrectal biopsy went off without a hitch. Second opinions are normal medical practice. Not sure why he would object. Decipher is also common practice. Not sure why he would object to that either. I did not have a decipher but then again, I was a Gleason 9 that had already metastasized so decipher would have been redundant. I don't know if you should be concerned but I sure would want to know the reasons for his objections. Best wishes.

Having limited flexibility limits your treatment. The Transperineal biopsy not only reduces the chance of infection it can get to more of the prostate.

Is the person they are having check the biopsy a prostate cancer specialist or do they specialize in some other field. I would still be concerned as to why they feel that way.

What’s the matter with getting a decipher test? Do they have another one that’s just as good.

I would be concerned about being treated by this doctor. This sounds very inflexible and may not be the person you want to do your treatment with. If you give an idea where you live, we might be able to find a center of excellence with good people you could go to.

What type of operation do they have? Is this a doctors office with a few of doctors? Is it at a major organization with hundreds of people?

Some things seem a little bit off. Overwhelming most biopsies are done trans rectal. Not sure why he refers to not wanting to send your tissue off for independent review. Do you mean a second opinion of it or not even reviewed by their pathologist and immediately sent off. That is more unusual to request that they not review and send off. Now that could depend when you say they keep it in house, is that in the back of the urologist office where they have a pathologist looking at it (more concerning) then when he says in house, if this means a major pathology operation that reviews for many doctors and hospitals , or even the in house pathology of the hospital. It is your decision though to have your tissue sent for a second opinion. I also don’t know his reluctance to order Decipher, possibly that was in the context of it might not be necessary if it is only a Gleason 6.

You don’t state what has led up to the biopsy. An Mri, PSE blood test, ExDxo urine test all along with your PSA totals. I would ask you more importantly and this says alot about your Doctor and whether to change , did he order a MpMRI of the prostate to identify possible lesions do your biopsy can be a Mri fusion biopsy? Also is this a small practice or do you live a long way from a major city and centers of excellence. If able now could be a time to change.

Now between trans rectal and trans perineal, as I said overwhelmingly most biopsies are done trans rectal. You will certainly hear and read statistics about a higher incidence of reported infections due to getting at the prostate through the rectum. Their are random studies within US that have reported much smaller differences then in the overall world studies gathered together by the major urological organizations. My own urologist from a large practice has said he has never seen one at their practice or previous one. He believes the US medical practices have much better established guidelines with pre and post antibiotic’s then many other countries in the world that report these statistics. Now does that mean infections don’t happen, of course they do, likely due to possibly immunocompromised patients and even the urologist. Their are some major hospitals in the US that actually only do perineal biopsies now and cite infection concern. That all being said just because he does trans rectal only is not a game changer, but possibly if he has not done an MRI that could be depending on why he saw no need for that. You did not mention an MRI. Did he even mention possibly a PET scan depending on results.

Transrectal is not a problem since that is what this doctor knows. I would not want to be the first patient a doctor does transperineally. My questions:
> Have you had a mpMRI and are you getting a fusion or random biopsy? I would go elsewhere before I got a biopsy without an MRI first
> What is your PSA? Other symptoms? If <10 may be anything from no cancer to advanced. A large percentage of random biopsies find no cancer.
> Does this doctor belong to a large urology practice? If 20+ doctors they may have an in-house pathologist that is very experienced in prostate cancer. In any case you can always have the slides shipped out for a second opinion after the first evaluation.
> Find out the issue with Decipher. Typically need a 7 or 8 Gleason to get insurance coverage for the test.

I would change doctor ASAP if I were in your place.

He is completely inflexible, performs biopsy with outdated methods and I hope to god it is at least MRI guided.

Not letting you have Decipher is second red flag and on top of that discouraging you from having a second opinion is the THIRD red flag !

I am glad you found this place and am wishing you the best of luck.

I wasn’t happy that my urologist only does trans rectal, but he did do UroNav MRI fusion biopsy, meaning he first did a Multiparametric MRI of the prostate . This means he is targeting the area that looked suspicious for cancer. Without this he’s only doing a random sample and more likely to miss existing cancer.
In your case I would not go forward with this physician unless he’s doing MRI first. But even then with what seems like stubbornness I’d look elsewhere.
The good news is that even there’s cancer it’s in most cases slow growing and you can take a breath before making a decision.

Wow! Thanks very much for all of the comments! I'm a bit overwhelmed. I wasn't expecting so many responses. I hope this comment reaches all of you. (Does it?) I'm going to try to answer the many questions as best I can:
*I have an elevated PSA (>10) and have had several MRIs over the years. I had a small spot with PI-RADS 4 on the last one (I had a 4 at about the same place in 2020 too). I took a 4K test over a decade ago and had a low value. I had the ExoDx test about 8 years ago. It was a 24. I took a My Prostate Score (2.0) test recently. That was 60%.
*The last MRI was a few months ago, so I think the biopsy would be considered a fusion biopsy.
*I live in the Midwest. The doctor specializes in prostate cancer. He's at an NCI comprehensive cancer center (but not an NCCN hospital). It's a university hospital.
*To be fair, I think he's reluctant to recommend the Decipher test (and perhaps any other test) until after the biopsy, which, based on some of your comments, may be logical. (It may be apparent, but I really like to take adjunctive/genomic tests.)
*This is a difficult decision. The biopsy is scheduled later this month. I fear that if I cancel, I would no longer be welcome at this cancer center, and although it's a large city for the Midwest, it's not really large (such as Chicago). Therefore, it might be hard to get in somewhere else.

Thanks again!

With your further explanation I would not cancel.

On a video a London based urologist professor said that transrectal biopsies
"...are substandard practice in the UK." Although uncommon anterior lobe cancer is not reachable by the transrectal method.

Might look for another specialist. My urologist only did transrectal despite my mentioning and requesting transperineal. Fortunately, the biopsy was accurate and helpful with no complications. I'm 21 months post- diagnosis and 3 months post- treatment. So far, so good, but I have had to push my specialists with standard of care treatments that I found in personal research.