MRI Fusion questions

I was sedated when I had my second biopsy, which was a saturation biopsy where they take 30 samples. The uro's feeling was that was a lot of pricks to deal with otherwise. I can't remember the specifics anymore, but it was similar to the sedation used in a colonoscopy, which I know uses propofol. They are likely doing it in a surgical suite to monitor the anesthesia, which is why they are calling it surgery. I recall they said that with my biopsy as well.

In your husband's case, I doubt they are taking 30 cores, but the sedation could still make sense. Some guys here have sailed through their biopsies and others hated waiting for each rubber band "snap."

If they didn't tell you, be prepared for blood to be in his urine and semen for a week or two afterwards. It's a bit freaky, but fine. Good luck to you both!

I was sedated for the fusion biopsy, light anesthesia, Propofol, like for a colonoscopy. He likely will not be allowed to eat that morning. I think they had me take an enema before arrival. I'm surprised they're not giving you this information.

He will be up and out of there in a short time, but no driving for 24 hours. Blood in the urine lasted a few days but dark colored semen lasted for about a month.

Yup, should be IV sedation like you would have for a colonoscopy. Worst part of that is the needle stick in the back of the hand.

Thank you all very much!

With the "normal" biopsy, they told him to use an enema....with the fusion one, there has been nothing said or listed on the paperwork. Is an enema done to avoid infection?

His appointment is at noon....no eating or drinking after midnight, right? Like no water?

We have to arrive at 9:30....again, the appointment is at 11:45....what the heck happens for 2 hours?

Again, thank you all so much. This is so stressful, and feeling in the dark about everything makes it worse.

No eating and drinking after midnight. Not sure if water is ok, though. I didn't drink anything. I had to get early there for my biopsy too, as I think they just want to get you ready, get your registered, give the enema and so on. The enema is just to clear out the colon, I don't think it avoids infection, as you will have a bowel movement after the enema. They will give you him strong antibiotics to avoid infection. I got antibiotic pills I had to take a couple of days before the op and then I was also given intravenous anti-biotics after I was admitted to avoid infection. Then they wheeled me down about 20-30 minutes before the op. I did a regular biopsy, not fusion, but would think enema was necessary for both if it is a transrectal biopsy. He doesn't get a catheter unless he can't pee on his own after the operation. I had no problem peeing myself after the operation, even though I have to be on Flomax due to an enlarged prostate. But expect the first time peeing the urine to be bright red blood, looks nothing like urine. So tell him to be prepared for that and don't worry about it, it is normal.

This forum is potentially a very good source of information and counsel from people who have already navigated the mine field of prostate cancer diagnosis and treatment.

The accuracy and usefulness of reponses received is dependent on the completeness of the information provided.

Because you have started a new thread every time you have a question or new piece of information, you have prevented most responders from knowing the full context of your husband's case.

I have been following your threads since you first asked about having an MRI before biopsy, since that is what I did, and because I believe it is the proper first step.

I will summarize here the information you provided, so that all may have the full context.

As you go forward, you will be better served if you continue by replying to this one thread with new information and questions instead of starting new threads. Each time you reply, the thread will be moved to the top of the list. To read only the new entries to the thread, click on the icon in the column titled "Last Seen".

SUMMARY:

Husband is age 40 with elevated PSA level, no mention of symptoms.

2010: CT scan for non-prostate reasons showed enlarged prostate.

2017 August: PSA 5.34
10 days of antibiotics
2017 October: PSA 5.34
Referred to urologist
28 days of antibiotics
2017 December: PSA 7.98, free PSA 9.6 %
More antibiotics
2018 January: PSA 6.71
No information as to whether PSA tests used same lab and method.
Different lab/method can report significantly different PSA for same sample.
My PSA report from QUEST DIAGNOSTICS - SEATTLE said
"The total PSA value from this assay system is standardized against the WHO standard. The test result will be approximately 20% lower when compared
to the equimolar-standardized total PSA (BeckmanCoulter)."
Use of same lab/method is required to know what serial PSA numbers mean.

2018 January 22: Urologist recommends MRI, insurance will not cover.

2018 February 5: Biopsy scheduled (urologist thinks MRI will be months away).

Size of prostate never specified.
Tall Allen inquires if PROSCAR or AVODART used to treat enlarged prostate.
No information provided.

MRI schedule improves (next week).
2018 February 13: MRI at Duke with endorectal coil (serious pain).
Adverse reaction to contrast dye (effect on MRI?)

2018 February 15: Verbal relay of partial MRI report contents (unclear)
4 out of 5, 80% ???

Urologist requests MRI images to choose biopsy approach (office or hospital)
2018 February 23: Biopsy instructions say hospital, anesthesia, surgery

COMMENTS:

I question whether this case is about to wander into urologist overtreatment territory.

Several responders to the early threads with PSA numbers said it looks more like prostatitis or BPH than cancer.

The antibiotics were an attempt (perhaps outdated) to test for prostatitis. Use of antibiotics at this level can be a problem in its own right.

There is no indication of treatment for BPH (enlarged prostate), no indication of size, no indication of PSA density. Why not?

Seems like there is more to do before going to biopsy.

But having the ability to pay, the information that an advanced MRI can provide can be very helpful.

The purpose of having the MRI is
either
to avoid biopsy (if not indicated),
or
to minimize the negative after-effects of biopsy (if indicated).

Statistically, it is true that the percentage of men suffering permanent after-effects of biopsy is low. But for the unlucky few, the after-effects can be severe and/or permanent, up to and including death. The risk is proportional to the number of cores taken.

An expertly analyzed MRI can limit sampling to only suspicious areas, rather than blindly sampling and taking more cores.

The value of an MRI is only realized if the mechanics are properly done, and the images are interpreted by a highly experience evaluator. Having no experience or information about DUKE's capability, I leave it to others to comment on their expertise.

What is certain is that some evaluator wrote a detailed report stating findings and conclusions. I personally would not proceed to biopsy without achieving an understanding of the report contents, and I would seek that understanding from the expert radiologist evaluator, not from a urologist of unknown experience.

As to the immediate inquiry about the nature of the biopsy, a biopsy does not move from urologist office to hospital because it is a fusion biopsy. Fusion biopsies are commonly done in urologist offices when they are the typical type (transrectal). The usual reason for hospital biopsy is because it is to be a transperineal biopsy.

A hospital-situated transperineal biopsy can be completely reasonable for a couple of reasons.

If one or more suspicious areas identified by MRI are in a location that is difficult to access transrectally (e.g., anterior) , transperineal may be required.

If suspicious areas are found to be widespread, some may conclude that a so-called saturation biopsy is called for. The high number of cores to be taken increase patient discomfort and increase infection risk. Both are mitigated by the transperineal access under general anesthetic.

Some have even argued that transperineal (replacing transrectal) should be the new standard of care, because of its potential to reduce the risk of infection, which is rising because of the overuse of antibiotics (demonstrated above?).

I have read in multiple places of the tendency of some urologists to take not only the MRI-targeted cores, but to add a typical pattern (blind) biopsy to the session. This defeats the whole purpose of MRI before biopsy, which is to minimize the negative effects of the biopsy itself.

If the patient is as concerned as his wife about the level of information provided, he must assert himself by demanding an electronic copy of the MRI report (which can be posted here) to know what it says about the need for biopsy.

If the biopsy is to proceed, the urologist owes the patient a clear description of the biopsy method and the number of cores to be taken, with good reasoning for both.

Importantly, a fusion biopsy can be either software assisted or "cognitive".
"Cognitive" just means that the person performing the biopsy views the MRI images and attempts to use the information gleaned to guide the biopsy needle to the corresponding position on the ultrasound image. No software assist occurs.

Here are MRI notes....

" .39ML lesion on left peripheral
capsular contact with mild bulge less than 1 cm
PI-RADS cat. 4

Prostate size 37ML
PSA density: .22

Crazy Lady,

Yes, it can be extremely frustrating to deal with medical people who seem to think we can comprehend their shorthand. And, your story is, unfortunately, all too common.

You will know a lot more after the biopsy and the results come back. Personally, I get irritated when medical people make statements like your radiologist made...that the lesion has an 80% chance of being cancerous--or whatever. Why? Because there is no evidence for that statement, other than personal opinion that may or may not be based on experience.

What SHOULD happen, is that when they schedule the procedure, you should immediately get a stack of paper that outlines everything you need to know about preparation, how long it will take, etc. If they don't do that (maybe they did, in an email?) then how can you know what to do?

Regardless, the biopsy will give you the answers you need. And, whether we like it or not, ONLY biopsy can really answer the question.

The following is written as much for other interested readers as it is for the originator of this thread. Medical providers sometimes arrange things for their convenience and revenue, to the detriment of patients. I wish to shed some light on this fact.

One of the meanings of the word "morbidity" is "adverse effects of a medical treatment".

The purpose of having an MRI before prostate biopsy is to reduce the morbidity caused by the biopsy itself, separate from any effect of the suspected prostate abnormality under investigation.

By knowing in advance where to sample, the number of cores is reduced, and the probability of damage to prostate tissue and nearby structures is correspondingly reduced.

In deciding how to carry out a targeted fusion biopsy, the following is true.

1. Fusion biopsy does not require a hospital operating room setting.

Because a high percentage patients are of MEDICARE age, treatment strategies are often guided by MEDICARE rules. For no logical reason that I can discern, MEDICARE will pay substantially more for a treatment carried out in a hospital facility than it will pay for the exact same treatment carried out in a doctor's office. This fact has led to hospitals and physician practices arranging their affairs solely for the purpose of designating physician practices as hospital outpatient departments so more money can be charged.

2. Neither the hospital setting nor the fusion biopsy require propofol under normal circumstances.

Propofol is not without risk. Because of this risk, the prescribing instructions for propofol specify that it must be administered by a separate person not involved in performing the procedure (biopsy), and highly trained in its use. This increases revenue to the provider and cost to the patient and/or medical insurer.

If the suspicious area were in a tricky location, or there were widespread areas requiring the taking of many cores, or there was concern for infection risk, there might be justification for escalating from transrectal biopsy to transperineal biopsy, which might call for escalation to a higher level of anesthesia.

It has not yet been made clear in this case what type of biopsy is to be carried out.

I had a targeted transrectal biopsy in a doctor's office. Three cores were taken. I was given VERSED and FENTANYL, commonly referred to as "conscious sedation". No pain, no discomfort, no after-effects. I was not allowed to allowed to drive, although my perception was that I was able. A person in that condition may be subject to a DUI charge if tested.

Also, I had no blood in urine or semen. I suspect that this is controlled by the location and number of biopsy cores.

Based on the information at hand, I suspect that this biopsy has been made more complicated than necessary. But as long as the propofol is administered by a true anesthesiologist, the risk is more to somebody's bank account than to the patient's health.

I wish you all good luck on Tuesday.

When my husband had his he didn't get any type of sedation. He said overall it wasn't too bad. He said it was pretty much the same as his first standard 12 core biopsy except for the ones in the TZ because those were as close to the urethra as possible. That was the suspicious area the MRI found that the standard biopsy missed. He said those needles were the worst because they felt like the were going right into his penis. The biopsy itself took about 20 minutes I think. It was pretty fast. Our surgeon had one of his partners do it because he specializes in doing them especially in the transition zone.
He did have to do an enema but was allowed to eat even up to right before the biopsy since there was no sedation. He had the MRI and the biopsy the same day.

Good luck to both of you on Tuesday. Let us know the results.