Biopsies

If the word embarrass was intended to describe any single act, it surely applies to a prostate biopsy. You lie on your side, your backside naked to the world, while your urologist inserts a probe into your rectum, then removes tiny slivers of tissue from your prostate with what sounds like a staple gun. The magnitude of the pain is remarkably minimal compared to the magnitude of the indignity.

When should a man have a biopsy? If your physician feels anything suspicious on digital rectal exam, that is a certain indication.

Surviving a Biopsy

Tying up the gown is the hardest part of the disrobing exercise because it has to be done backwards, and as everybody knows, the "behind-your-back-skills" gene is not carried on the male chromosome the way color-blindness is. Simply put, a man cannot do this task____

Thankfully, I'm facing away from the action, as if I'm on one side of the room, my behind on the other. But from that position I can't watch the monitor with its jerky black and white picture of my prostate, and so can't make futile attempts at humor, which always buoys my spirits and masks my agitation. Is it a boy or a girl, doctor?

—Bert Gottlieb, The Men's Club

Any significant rise in your PSA level, as defined below, is also an indication.

In preparation for a prostate biopsy most, but not all, urologists ask you to stop taking aspirin compounds a week to ten days prior to the procedure. The night before, you are asked to drink a solution that cleans out your bowel by causing diarrhea. Alternatively, you are also asked to give yourself a Fleet enema prior to the procedure— valuable practice for the humiliation of the biopsy itself.

The urologist first inserts into your rectum the ultrasound probe, equivalent in size to about two fingers. The probe sends out sound waves that outline the prostate on a small screen, allowing the urologist to see exactly where to biopsy. Sometimes the ultrasound shows dark areas that may indicate cancer, but often it fails to show cancer even when it is present. At one time it was hoped that prostate ultrasound would become as useful as the mammography used to detect female breast cancer, but it has proven disappointing for that purpose; its main use is to guide the biopsy and determine prostate volume.

The biopsy itself involves the use of very thin needles that go through the wall of the rectum and into the prostate, where they remove a thin sliver of tissue. Each such piece is called a core. In the past, it was usual to take six cores, but it is now common to take eight to twelve. Lying on the table, you will know exactly how many have been taken by counting the distinctive clicks of the biopsy gun. The pain is a momentary sting, likened by one urologist to ''a rubber band being snapped against the skin,''7 although men vary widely in their pain threshold. The entire procedure takes about a half hour.

Following the biopsy, many urologists have men take an antibiotic for three days to minimize the likelihood of infection. It is normal to have small amounts of blood in the semen, urine, or stool for a few days, and there are no restrictions on activities other than riding a bicycle. Since the biopsy is merely sampling sections of the prostate and not the entire gland, it is possible that cancer is present and is missed by the biopsy. If the urologist is suspicious, if the biopsy shows precancerous cells (prostatic intraepithelial neoplasia, or PIN), or if the PSA continues to rise, the biopsy may have to be repeated at a later date.

In the end, so to speak, the information provided by a prostate biopsy is extremely useful. If the biopsy is negative, the chances are high (approximately 70-80 percent) that cancer is not present. If it is positive, you will know your cell type (Gleason score) and you will also have information on the size of the cancer from the ultrasound picture, the percentage of positive cores, and the percentage of cancer in each positive core. From these you can assess the seriousness of your cancer and begin making rational treatment decisions.

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