A prostate biopsy is a precise medical procedure aimed at extracting small tissue samples from the prostate gland for microscopic analysis. It is the essential step to confirm the presence of prostate cancer or to determine its nature and aggressiveness following suspicious findings in preliminary tests, such as elevated prostate-specific antigen (PSA) levels or the detection of a palpable mass during clinical examination. Prostate cancer is among the most common tumors in men over the age of fifty, and early diagnosis through biopsy significantly increases the chances of recovery and facilitates the selection of the most appropriate treatment.
What is the prostate gland?
The prostate is a small gland, roughly the size of a walnut, located directly beneath the bladder and surrounding the initial segment of the urethra (prostatic urethra). Understanding its anatomical divisions is crucial for accurately guiding the biopsy needle to areas with the highest likelihood of tumor. The gland consists of three main anatomical zones:
- Central zone
- Transitional zone: often affected by benign prostatic hyperplasia
- Peripheral zone: the most common site for prostate cancer development (approximately 70% of cases)
When is a prostate biopsy recommended?
A physician may recommend a biopsy when tests suggest the possibility of malignant changes in the prostate. These include:
- Elevated PSA levels: Normal values vary by age, but levels exceeding 4 ng/mL warrant further evaluation. A rapid rise in PSA over a short period or a low percentage of free PSA increases suspicion of prostate cancer
- Abnormal digital rectal exam findings: Detection of a firm mass or loss of elasticity in part of the gland
- MRI results: Presence of suspicious lesions classified with a PI-RADS score ≥ 3
- Strong family history of prostate cancer
- Previous inconclusive biopsy results or presence of precancerous changes such as HGPIN or ASAP
The role of biopsy in treatment planning
Biopsy results determine the next step in the treatment plan:
- Low-grade cancers: active surveillance with regular PSA monitoring
- Intermediate-grade cancers: may be treated surgically or with radiation
- High-risk cancers: often require a combination of treatments (surgery + hormonal or radiation therapy)
Types of prostate biopsy
There are several methods for obtaining prostate tissue samples, differing in technique, accuracy, and risk level. The most commonly used clinical methods include:
Transrectal ultrasound-guided prostate biopsy
This is the most widespread method for performing a prostate biopsy. The procedure typically takes 10 to 15 minutes and is done under local anesthesia to minimize discomfort. It involves the following steps:
- Inserting an ultrasound probe through the rectum to image the prostate and precisely determine its dimensions
- Using a special spring-loaded needle to collect 10 to 12 samples from various regions, including both the right and left lobes of the gland
Advantages of this method:
- Widely practiced and easy to perform
- Quick execution with acceptable accuracy in random sampling
Disadvantages:
- Limited access to some anterior regions of the gland
- Needle passage through the rectal wall may allow bacteria to enter the prostate or bloodstream, potentially leading to prostatitis, urinary tract infection, or, in rare cases, septicemia
Transperineal prostate biopsy
This procedure involves inserting the needle through the skin between the scrotum and the anus (the perineal area), typically under general anesthesia or deep local anesthesia. The needle is guided using ultrasound or an integrated MRI system to achieve higher targeting accuracy.
Advantages of this method:
- Very low risk of infection since the needle does not pass through the rectum
- Ability to obtain more precise samples from suspicious and targeted areas
- Better access to the anterior lobe and distant regions of the prostate
Disadvantages of this method:
- Requires specialized equipment and greater expertise
- Often needs to be performed in a hospital setting with appropriate anesthesia
MRI-guided prostate biopsy
This is one of the newest and most accurate techniques for prostate biopsy, combining detailed MRI images with real-time ultrasound imaging. The integration of these two images allows for highly precise targeting of suspicious areas based on the PI-RADS score.
Advantages of this method:
- Offers the highest level of accuracy in detecting clinically significant tumors, reducing the need for random biopsies
- Considered the optimal choice for patients with previous negative biopsies despite persistently elevated PSA levels or suspicious MRI lesions
Disadvantages of this method:
- Higher cost compared to other types
- Requires advanced equipment and high technical expertise in image fusion and precise needle guidance
Modern techniques for performing prostate biopsy
Among the most notable modern techniques:
- CT-Guided Prostate Biopsy: Rarely used, typically reserved for complex cases.
- Robotic Transperineal Prostate Biopsy: Automated systems stabilize the needle in the optimal position, reducing human error.
- AI-Guided Prostate Biopsy: Advanced analytical software integrates MRI and ultrasound images to accurately identify the targeted area.
Prostate biopsy procedure
The prostate biopsy procedure consists of several stages:
Pre-biopsy preparation
Preparation is a critical step to minimize complications and improve sample quality. It includes:
- Fasting for several hours if general anesthesia is planned
- Signing a written consent form after explaining risks and benefits to the patient
- Administering prophylactic antibiotics before and after the procedure (typically fluoroquinolones or cephalosporins)
- Performing a cleansing enema to reduce bacterial load in the rectum (for transrectal biopsy)
- Discontinuing anticoagulants and antiplatelet agents (such as aspirin, clopidogrel, or warfarin) 5–7 days prior
Steps of the prostate biopsy
The procedure typically involves the following steps:
- Patient positioning:
- The patient is usually asked to lie on their left side with their knees bent towards their chest, or in a supine position if performing a transperineal biopsy
- Anesthesia:
- A local anesthetic (peripheral nerve blocker) or general anesthesia is injected around the prostate, depending on the method
- Needle guidance:
- The probe is inserted into the rectum to visualize the prostate using ultrasound
- The boundaries and target areas are identified
- A pulsed biopsy needle is used to quickly collect samples, minimizing pain
- Sample collection:
- Typically, 10-18 samples are collected from different areas, including the basal, apical, and peripheral lobes. In guided biopsies, only the MRI-identified foci are targeted.
- Sample preservation:
- Each sample is placed in a special container with formalin to prevent degradation, clearly marked to indicate the location within the gland
- Sending samples for histological examination:
- Each sample is examined microscopically to determine the presence, type, and grade of cancer cells according to the Gleason classification
Post-biopsy monitoring
After the biopsy procedure, the patient is usually kept under observation for several hours. Expected outcomes include:
- Mild rectal bleeding
- Discomfort or slight pain in the pelvic area
- Light blood in urine or semen for 3–7 days
Post-biopsy recommendations
To achieve optimal results, patients should follow these guidelines:
- Drink plenty of water
- Avoid physical exertion and sexual activity for 48 hours
- Contact a doctor immediately if fever or difficulty urinating occurs
- Monitor for signs of infection (fever, chills, burning pain during urination)
What is the Gleason score?
The Gleason score is the cornerstone for assessing the severity of prostate cancer. It is based on the microscopic appearance of the cells:
- Grades 1–2: Tissue resembles normal structure
- Grade 3: Irregular cells but still distinguishable
- Grade 4: Clear loss of glandular architecture
- Grade 5: Highly aggressive, disorganized cells
The two most prevalent patterns are combined to form the Gleason score:
- 6 (3+3): Low-risk tumor
- 7 (3+4): Intermediate risk
- 8–10: Highly aggressive tumor
Potential complications after prostate biopsy
Although the procedure is generally safe, some complications may occur at low rates:
| Complication | Incidence | Notes |
|---|---|---|
| Mild blood in urine or semen | 30–50% | Resolves spontaneously |
| Minor rectal bleeding | 10–15% | Temporary |
| Urinary retention | <1% | Mostly in cases of an enlarged prostate |
| Urinary tract infection | 1–3% | Requires antibiotic treatment |
| Sepsis (blood infection) | <0.5% | Rare but serious condition |
Cost of prostate biopsy in Turkey
Bimaristan Medical Center in Turkey offers diagnostic and treatment services for prostate conditions, in accordance with the highest international medical standards and using the latest technologies. The center combines European-quality care with competitive pricing, making it an ideal destination for patients seeking accurate diagnosis and excellent medical service at a reasonable cost.
| Country | Approximate Cost (USD) | General Notes |
|---|---|---|
| Turkey | 1,300 – 2,500 | Attractive destination due to low cost and advanced techniques like MRI-guided biopsy |
| United Kingdom | 4,000 – 8,000 | High cost in private centers, especially for transperineal or MRI-guided biopsies; often not covered by insurance |
| Germany | 4,400 – 5,200 | Known for high-quality procedures and diagnostic accuracy, but with relatively high service costs |
| Switzerland | 2,300 – 6,000 | Highly variable depending on procedure type and insurance system; often covered for citizens |
| France / Netherlands | 2,900 – 5,800 | Moderate to high prices, especially for guided biopsies or those under general anesthesia in private centers |
Ultimately, prostate biopsy is a crucial step in accurately diagnosing prostate cancer and determining its severity, which helps in selecting the most appropriate treatment for each case. With the advancement of modern techniques such as MRI-guided and transperineal biopsy, the procedure has become safer and more precise, with reduced risk of complications. Early detection through biopsy significantly improves recovery prospects and contributes to an effective treatment plan tailored to the disease stage and patient condition.
Sources:
- Antoni van Leeuwenhoek / Netherlands Cancer Institute. (n.d.). Prostate biopsy. Retrieved from
- Johns Hopkins Medicine. (n.d.). Prostate biopsy.
