I wrote about a second biopsy required. This one was MRI directed. I was informed by Tall Allen that there was perennial biopsy that had less side effect and less risk. I asked my urologist about this. He said that recent studies show they both have about the same risk of infection. So I went with the rectal. The procedure seemed rushed. The room seemed dirty.
I am in ICU now as I write this - with sepsis.
I'm getting over it but have lost a lot of faith in my urologist for thi and other reasons and will change. Unfortunately the association is huge and most urologists are part of same system in my area and I wonder if there are systemic directives coming down to them or if the urologist are free to create their own procedures.
Any thoughts?
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Eadgbe
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OTOH, There's something to be said for experience too. Would you rather have a transperineal biopsy done by a Uro with no experience (and risk him cutting arteries and missing the location for nerve blocks), or a transrectal done with higher risk of sepsis? Eventually all Uros will move to transperineal and will be experienced at it. We are in a transitional state now.
The AUA needs to be training and certifying doctors in how to do it properly.
The hypothetical choices you are presenting are ridiculous. Would I rather risk sepsis or bleeding? How about none of the above.
There are enough doctors available at major medical centers with experience who perform transperineal biopsies.
As for any learning curve, a urologist is a surgon, who would have no difficulty learn how to do a transperineal biopsy. It is a heck of a lot easier than surgically removing a prostate, and ultrasound imaging is used whether the biopsy is performed transperineal or transrectal. There are also certain areas in the anterior/transition zone where a transrectal biopsy is very difficult.
I had a transrectal in 2014 which almost went sepsis, and took me quite a long time to recover from. Since that time I only had transperineal biopsies, without any infection.
Do you really imagine there is zero risk of those?
There are not many adequately experienced urologists even at many top centers (e.g., UCLA). And there is certainly a learning curve, as there is for all invasive procedures. A friend of mine had to have 2 transfusions because of loss of blood, when his "hot dog" urologist punctured an artery to his bladder. Many don't do nerve blocks because they don't know how.
there is not zero risk from any biopsy procedure, and I never said that an attendent urologist should not be trained in such procedures. Even experienced physicians make mistakes as you are well aware
Since you brought up an unfortunate anecdotal experience from a friend, my anecdotal experience was that I have had transperineal biopsies at both UCLA and Stanford without any complications
In 2010 Representative Martha died from complications of gallbladder surgery because the doctors hit his intestine.
Any invasive procedure involves risk. The question is how much risk, and what is the risk reward.
Brachytherapy is performed by urologists and radiation oncologists routinely, and they employ transperineal seed implantation. This is not some exotic technique.
With the antibiotic resistance of many bugs out there, transrectal biopsies poise a real risk for sepsis.
First off, sorry to hear that you ended up in ICU, but sounds like they caught sepsis early, good thing.
Agree with TallAllen, bit of a tradeoff between the two procedures.
I declined my Uroligists recommendation for trans(fecal) biopsy and was able to find a urologist that had been doing them transperineally for many years.
At the present time, to my knowledge, there is not a major incentive/movement to phase out the transrectal, but in Europe and Australia there is TREXIT. Bit of a take off on BREXIT. Also, I can not remember which medical centers in the US, but there are some that have abandoned the transrectal approach. Also, can’t remember, but do believe there are some countries that have also abandoned the transrectal approach.
As far as your doc telling you that the research shows that the same risk of infection, not what I found and looked at many studies, presentations etc.
There are some who think that there is not even a need for antibiotics with the Transperineal approach. See study below.
Is antibiotic prophylaxis still mandatory for transperineal prostate biopsy? Results of a comparative study - PubMed (nih.gov)
Although, my doc who did my biopsy, said that his infection rate for transrectal was 2% and 1% for transperineal. I am guessing that will vary from doc to doc and hospital to hospital.
These are only a few of the articles that I had dug out when I did my research.
no expertise here, but just to second your decision to change docs; you need to have confidence in the person guiding you through all this and doing procedures of whatever kind; I changed urologists because of a different set of problems and I'm glad I did; sorry you can't changes systems easily, too
I'm am so sorry to hear about you getting sepsis from a transrectal biopsy. I asked my urologist about doing transperineal instead of transrectal, and he said any urologist who does Brachytherapy, where a radioactive source is put inside the prostate, can do it. He did transperineal for mine with separate needles for each biopsy sample and it went fine.
At least one doctor at the Mayo Clinic stopped doing transrectal in 2019 due to the risk of Sepsis. Here's a link:
Inexcusable hubris. I've seen it before personally from a physician who told me he did not do laparoscopic inguinal hernia repair because there was more relapse. So he did it open; it relapsed anyway.
Yeah, get someone you can trust. Procedure rushed; room dirty. Yeah, run.
First off - sorry to hear this and I hope you are well on the road to recovery. No one needs such a complication when dealing with PC. Hang in there.
And first thing - as others have suggested, find a urologist you can trust. I talked to a few before settling on one, who sent me to the first radiation oncologist who I balked at right from the first meeting and found another. It's up to you to assemble a team you want to work with.
Sorry what you went through Eadgbe. Your doctor told you incorrect information, a transperineal prostate biopsy almost has zero risk of infection. In 2014 I had a transrectal prostate biopsy, received an antibiotic resistant infection, and came very close to sepsis from it. After that experience I refused to have another transrectal biopsy, and only went to major centers that performed transperineal biopsies.
A needle is being inserted into a very contaminated area, no matter how much prep or antibiotics they give you, the risk is very real. There is a reason the vast majority of prostate biopsies done in Europe and Australia are transperineal, and why study after study has demonstrated significantly less infection risk from a transperineal approach verses a transrectal approach.
I know what you are going through, and hope you recover quickly from this experience. I think finding another urologist is a wise decision.
I had a transrectal biopsy with no issues whatsoever, as did my brother. I don't think it's fair to assume that sepsis is a likely outcome of a transrectal biopsy. 🦊
From what I have read, about 2 million men have a Transrectal Biopsy, and what your saying is that because you and your brother did not get sepsis, the other 1,999,998 men won't get sepsis?
That's like me saying that I rode the NYC subways all my life and nothing bad ever happened to me, therefor is not fair to assume that everyone else can ride the subways and nothing bad will ever happen to them?
Please read the article below.
No More Men Need to Die From Transrectal Prostate Biopsies
I've being released tomorrow. Have two weeks of morning IV battling the superbug. I guess I'm lucky so far. they got mine 3 days after I went sepsis. Interesting article. Thanks.
Good thing that you did not wait for symptoms to get worse. Glad to hear you are getting out and you found the article of interest. Adopting new techniques/procedures can take some time, lot's of variables involved. And to echo what TallAllen mentioned, training is one of them. See article below, especially the excerpt in italics from the article, nuff said.
Urology Groups Endorse Two Prostate Biopsy Approaches
AUA said another reason it did not endorse the transperineal approach was that currently, American urologists lack training and experience with transperineal procedures.
Grummet blamed major medical centers for any gap in the familiarity of clinicians with transperineal biopsies, which have been available for more than a decade.
"It is incumbent on the leaders of urology departments globally to ensure that their colleagues are trained in transperineal biopsy and have access to the appropriate equipment," he told Medscape. "Lack of training didn't seem to prevent the rapid uptake of robotic prostatectomy ― a far more complex procedure."
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