”You and I have a long road ahead of us. Prostate cancer is a cunning enemy that endangers men’s health, and how to catch and shoot this bad guy as early as possible is a concern of urologists all over the world. Prostate cancer screening relies on three “mirrors” (PSA test, rectal examination and transrectal ultrasound); diagnosis requires an “iron-faced judge” (prostate puncture). Transrectal ultrasound guided prostate puncture biopsy has become the gold standard for the diagnosis of prostate cancer. I will expand on this with the following questions and answers.
What is the need for prostate puncture?
(1) A nodule on rectal examination with any PSA value.
(2) Ultrasound finding of a hypoechoic nodule in the prostate or MRI finding of an abnormal signal, any PSA value.
(3) PSA >10ng/ml, any f/tPSA and PSAD values.
(4) 4PSA4~10ng/ml with abnormal f/tPSA or abnormal PSAD values.
Note: Normal value of f/tPSA is >0.16; normal value of PSAD is <0.15ng/ml/g
If prostate cancer is not detected by the first prostate puncture, repeat puncture is required in the following cases 1) to 4).
(1) First puncture pathology reveals atypical hyperplasia or high-grade PIN.
(2) PSA >10ng/ml, any f/tPSA or PSAD.
(3) PSA4~10ng/ml with abnormal reexamination f/tPSA or PSAD values, or abnormal rectal finger examination or imaging.
(4) PSA4~10ng/ml with normal recheck f/tPSA, PSAD, rectal finger examination, and imaging; close follow-up, recheck PSA every 3 months, and re-puncture if PSA >10ng/ml for 2 consecutive times or PSAV >0.75ng/ml/year.
(5) Timing of repeat puncture: the interval between 2 punctures is still controversial, currently it is mostly 1~3 months.
(6) Number of repeat punctures: For those who have not found cancer in 2 punctures and belong to the above 1)～4), more than 2 punctures are recommended. Some studies have shown that the positive rate of 3 or 4 punctures is only 5% or 3%, and nearly half of them are non-clinically significant prostate cancer, therefore, more than 3 punctures should be done with caution.
What are the conditions in which prostate puncture should not be performed?
Acute infection, fever (inflammation aggravated by puncture); severe coagulation disorders (which can cause increased risk of bleeding from puncture, such as hemophilia, patients on long-term oral warfarin); severe internal or external hemorrhoids, perianal or rectal lesions; hypertensive crisis; in the decompensated phase of cardiac insufficiency; in the unstable phase of diabetic glucose are all contraindications to prostate biopsy.
Question 3: Methods of prostate cancer puncture biopsy
Depending on the route of puncture, prostate puncture biopsy can be divided into transrectal puncture and transperineal puncture, both of which have their own advantages and disadvantages.
Rectal puncture: convenient but prone to post-operative infections and complications
Generally speaking, transrectal puncture is convenient, accurate in positioning, and can be done by one person without anesthesia. However, preoperative bowel preparation is required, and only the tip of the needle can be seen during the puncture, and it is not easy to see the needle as a whole. The target to be punctured needs to be overlapped on the ultrasound instrument screen and the puncture guide line to perform the puncture. Postoperative infectious complications are more frequent, and most scholars advocate prophylactic use of antimicrobials.
Perineal puncture: less likely to be infected but requires local anesthesia
Local anesthesia of the perineal skin is required. Trans-perineal puncture allows simultaneous visualization of the puncture target and the entire puncture needle (including the tip) during the puncture because the acoustic beam is perpendicular to the puncture needle. The puncture route does not pass through the rectum, so bowel preparation and prophylactic antibiotics are not required. Postoperative rectal bleeding does not occur and is less likely to cause infectious complications.
The choice is trans-perineal prostate puncture pathology biopsy. Advantages of the trans-perineal route: 1, Safety. The incidence of serious infection is close to 0%, and there are no rectal bleeding complications. 2, It is easy to detect tumors in the anterior tip of the prostate, as the puncture needle enters through the tip of the prostate, making it easy to reach the “blind spot” of the transrectal route of biopsy. 3, Multi-parametric MRI and transrectal ultrasound guidance, transperineal route of prostate aspiration biopsy, may be the “gold standard” of prostate aspiration biopsy. The “gold standard” of biopsy.
Is B-ultrasound guided trans-perineal prostate puncture biopsy painful?
Many people think that transrectal ultrasound-guided biopsies are painful and therefore fear the test. In fact, prostate puncture is not that painful. First, the puncture needle is very thin and penetrates the prostate with minimal damage. Secondly, although the prostate envelope can be painful, the puncture is quick and completely tolerable. Finally, local anesthesia can be used during the puncture to minimize the discomfort caused by the transepithelium. The majority of patients do not feel any discomfort during the puncture biopsy, which is why they can “come and go” after the puncture.
Will prostate puncture biopsy cause cancer to spread?
Many people refuse to have a puncture because they are worried that if the cancer is really there, it will cause the cancer to metastasize and stimulate the growth of the cancer. There is no scientific basis for this, and clinical studies with large data have ruled out this possibility.
When is it appropriate to have a prostate puncture once it has been determined?
Because bleeding from prostate puncture may affect the clinical staging of imaging, prostate puncture biopsy should be performed after MRI. However, European and American scholars suggest that the hematoma formed by prostate puncture can be absorbed in about 1 month, and MRI can also be performed 1 month after the puncture.
Currently, most prostate puncture biopsies are performed in hospital.
When you receive the hospital’s notice of hospitalization, you should prepare: 1) If you have been taking aspirin, poliovirus or warfarin for a long time, make sure you stop taking them for 1 week before you have the puncture, so that you can reduce the risk of bleeding; 2) Bring your test results, such as blood PSA, ultrasound or MRI results, with you when you are hospitalized.
What tests are required after hospitalization?
A puncture is considered a minor procedure and you will need to have all the routine tests required for the procedure, including the following.
Routine blood tests, biochemistry, urine, stool, coagulation analysis, four tests for infections (syphilis/hepatitis B/hepatitis C/HIV), and a repeat PSA if it has been a long time since your last PSA test.
What do I need to do before the puncture?
The doctor explains to the patient the need for prostate puncture, the possible risks, the precautions to be taken after the puncture, and signs an informed consent form.
Bowel preparation: enemas with open cavity to reduce the amount of feces in the rectum. One is to reduce the risk of infection by reducing bacteria entering the prostate from the rectum during puncture, and two is to see the prostate more clearly with transrectal ultrasound after bowel cleansing.
Prophylactic use of antibiotics: can reduce the risk of infection, our guidelines recommend that prophylactic oral antibiotics 3 days before the puncture; of course, can also be hospitalized, the morning of the puncture intravenous injection of antibacterial drugs. The prophylactic use of antibiotics should be stricter for special patients, such as those after artificial joint replacement, those with prosthesis and pacemakers on their bodies.
What is the approximate procedure for puncture?
(a) The patient is usually positioned in the left lateral position with the knee and hip flexed to within 90 degrees, the back parallel to the examination table and the buttocks resting on the edge of the table.
Routine disinfection and perineal infiltration anesthesia to reduce pain during the procedure.
Extend the ultrasound probe into the rectum to observe the morphology of the prostate, the presence of abnormal hypoechogenicity, etc.; (if the ultrasound reveals abnormal echogenicity in the prostate, more stitches will be punctured in the region, if not, they will be punctured evenly in each region according to the established sequence)
After observation, the ultrasound probe is fitted with a spring-actuated biopsy gun and the puncture begins. The number of puncture needles is currently more than recommended at 10 needles and above, and each time the puncture needle is pressed, a sound is emitted and the spring-actuated biopsy gun is ejected, and a thin strip of tissue about 1.5cm long can be removed from the prostate at one time; so that a predetermined number of needles are evenly punctured according to the partitions of the prostate.
After the puncture, the doctor will insert a cotton ball in the patient’s anus, which can play the role of compression to stop the bleeding, which can be discharged 2-3 hours after the end of the puncture; and the punctured prostate tissue, which needs to be soaked in formalin and sent for pathological examination, and the pathological results of the puncture can be obtained 3 working days after the puncture.
After the whole procedure is completed and the patient returns to the ward, the patient needs to continue intravenous antibiotics to prevent infection, the patient rests in bed and pays attention to urine color, stool color and body temperature; if there is no obvious fever, hematuria, bloody stool or urinary retention, the patient can be discharged the morning after the puncture.
What are the risks of puncture and its treatment?
1. hematuria —- stop using anticoagulant drugs before puncture, avoid the urethra and bladder during puncture to reduce damage, and leave a three-lumen catheter in place to stop bleeding by traction and compression in severe cases.
2, blood stool —- disappears soon after puncture, if it appears intraoperatively, finger pressure can be used to stop bleeding points.
3, infection —- postoperative infection incidence is 0.1%-7.0%, serious infection is mostly related to quinolone drug resistance, such as infection can not be controlled, feasible bacterial culture and adjustment of antibacterial drugs.
4. Vagal reflex —- mainly manifests as vomiting, bradycardia and decreased blood pressure. The patient’s position can be adjusted to a head-low, foot-high position and intravenous rehydration to relieve symptoms.
What do I need to pay attention to after the puncture?
Avoid alcohol, spicy and stimulating foods for 2 weeks, and avoid cycling, horseback riding and other straddling sports.
attention to rest, reduction of infection and oral antibiotics for about 1 week.
Hematuria may occur after surgery, generally speaking if every time you urinate, some hematuria in the front section of urine are normal, especially the first urine in the morning may be darker, patients and family members do not need to be too nervous, the symptoms of hematuria can be gradually relieved within a week basically. If there is a blood clot, or the whole blood in the eyes, you need to explain to the doctor, the reason may be more serious damage to the urethra, you need to leave a catheter to stop the bleeding. If the patient has previously taken oral aspirin/warfarin/porivir for a long period of time, do not resume the medication for a short period of time, the exact timing of which can be discussed with the specialist.
Patiently wait at home for the doctor to inform you of the puncture pathology results and decide on the next step of treatment.
Teach you to read the prostate puncture biopsy report
Although there are various means of diagnosing prostate cancer, there is no way around prostate puncture biopsy. There are several key elements of the actual prostate puncture biopsy report that you should pay attention to.
(1) Number of puncture stitches: Systematic puncture biopsy is generally 6-12 stitches (10 stitches in our hospital in general). If additional puncture stitches are added for suspicious loci, about 2 more stitches are added to the number of stitches for systematic puncture (sometimes more, depending on the situation).
(2) Pathological findings.
ASAP: Atypical small alveolar-like hyperplasia, a precancerous lesion of prostate cancer. It is important to note – precancerous lesions are not cancerous but benign lesions with malignant potential. the chance of ASAP combined with prostate cancer is close to 40%. if ASAP is found on the first puncture, it is recommended to puncture again in the short term (within 3 months).
HGPIN: High grade intraepithelial neoplasia, which is also a precancerous lesion of prostate cancer, has a 30% chance of being combined with prostate cancer, and if HGPIN is found on the first puncture, the timing of re-puncture should be decided based on PSA and prostate volume. If you have more than 2 stitches of HGPIN, the risk of prostate cancer is increased by more than 2 times, so you need to have another puncture as soon as possible.
PINATYP: This is a case where both ASAP and HGPIN are present. In this case, the chance of combined prostate cancer is greater than 50%, and there is no doubt that early puncture is the best option.
Gleason: The international standard for evaluating the malignancy of prostate cancer, scored from low to high on a scale of 1-5, expressed in prostate puncture results in the form of A+B, where A represents the most common malignancy score in the specimen, and B represents the next most common malignancy score. For both physicians and patients, the lower the Gleason score the better, for example Gleason 5+5 is more malignant than 3+3, while Gleason 4+3 is also more troublesome than 3+4. We generally classify prostate cancer with a score less than 7 as low risk, equal to 7 as intermediate risk, and greater than 7 as high risk. When the total scores are the same, the greater the score in front of the plus sign the greater the malignancy.