Biopsy vs MRI Guided Biopsy

Hello Fellow members , I am new here can add info to help others as I go along . However today I have a question about my situation . I am 73 yrs old and for the last 3 or 4 years besides having trouble with starting a stream and weak flow (unless taking flomax), I also have had fluctuation of PSA ranging anywhere from 4.0 to 5.8 and back down. He said I don't appear to have a enlarged prostate . I did an MRI that pointed out a couple of small lesions. So the doctor wants to do a biopsy but I heard that a MRI Guided Biopsy is more accurate. When I asked about it he said that his guided MRI machine isn't presently working and medi-care won't pay for a MRI Guided Biopsy on the first diagnoses . Should I insist on a Guided MRI or is the regular Biopsy good enough? Thank you for reading this .

. Respectfully James Meyer

Thanks a million Pratoman , Any info I get is appreciated. I had another two questions now that you have experienced life without a prostate. In the case of prostate removal, how hard is it to control urine flow and does sex still occur ? If this is too sensitive of a question I understand if you choose not to answer .

Thanks, James

I had a MRI prior to a MRI guided biopsy as my initial diagnosis after rising PSA and positive DRE and it was paid for by Medicare. However, that does not seem to happen very often and seems to be dependent on the urologist’s willingness to argue with Medicare or insurance company to persuade them of the medical necessity in his/her opinion which is quite time consuming. No idea why the doctor’s machine would be broken though and not being fixed?

Continence (ability to control urine flow) and ED (erectile dysfunction) are common problems after surgery that depends on age, the extent of cancer, and the doctor’s skill level. Each is a separate issue and each can be temporary or long lasting. I did not have any continence problems but ED remains a problem still. Each person has a different situation.

Before you worry about surgery, you need to find out what is going on with your prostate so getting the best biopsy you can is in your interest. You may also want to find the best urologist while you are at it to get this done if the current one is not helpful. If they all tell you the same thing, you then know the answer.

Most urologists, even without an MRI guided biopsy, will use the MRI information to suggest more or less where to poke for the biopsy. You're way too early to be worrying about surgery side effects. Get a biopsy--even a TRUS (Trans Rectal Ultrasound) biopsy is sufficient to diagnose the vast majority of us.

Once that is done, and you get a pathology report back, then we can work with you through the next steps.

As far as the continence/ED issue post treatment--well, that is a topic of considerable interest and frequent conversation in here. Let's say it all depends. (And Depends may become a very real part of your live---or they may not).

For now, though, it's important that you have a Urologist you feel you can trust--and can talk to--and get the biopsy, and when you get the report back, share it here and we'll help translate.

James, your Urologist say’s your prostate does not appear large and even a TRUS biopsy will provide an accurate measurement of size. I would recommend getting a biopsy to help determine both the cause of your urinary issues as well as to see if any cancer is present. It’s far too early to be considering any removal. It’s a good time to be researching Urologists since the best can make a huge difference in any treatment results.

Talk to the urologist and ask him how certain he is that he can sample the sites that appear suspicious on the MRI.

Hi Jimmy and Welcome to the forum! You didn't say what the PIRADS scores were for the lesions identified on your mpMRI. (Lesions are graded on a 1-5 PIRADS scored by the radiologist, where scores 1 and 2 are likely not cancer, 4 and 5 likely are, and 3 is an intermediate score. As you probably know, an MRI can identify suspicious areas, but only a biopsy can diagnose prostate cancer.

I agree with Halbert -- I think it would be fine if your uro uses the MRI to guide some extra cores, even if by eye. Note that "random" cores in the different prostate zones aren't always random. A uro uses the ultrasound (US) image to aim for any suspiciously looking spot in each zone.

Abnormal prostate tissue, whether malignant or not, reflects US differently than healthy tissue and thus appears differently on the screen. While a US image can't usually distinguish abnormal from malignant tissue, and certainly not to the level of the PRIRADS scale RO's use with mpMRIs, biopsy-experienced uros are pretty good at finding cancerous lesions when they are there -- even if this is more of an "art" of shadow interpretation

I would just ensure that your uro will take a few extra cores in the each zone with an MRI-identified lesion in addition to the typical 12 standard cores taken around the prostate.

Djin

Thanks to all for the in depth info that makes me feel a little more relaxed about my situation All of you guys are real heroes that have shared their thoughts with everyone based you own experiences . I now realized that I did in fact leave out my scores . Which are as follows: basically I have taken flow max since I was about 62 and I an 73 now . I have seen PSA rise throughout the years and my Urologist said I never seem to have a enlarged Prostate nor any unusual hard spots or uneven spots on my prostate per many DREs . My PSA has slowly climbed from 3 to as much as 6 and is 5.5 last time . I did the MRI and had several suspicious spots . Then did a 12 needle biopsy that the urologist mapped out with ultrasound that closely matched the MRI findings .Out of the 12 samples I have 3 benign 2 precancer 1 suspicious and 6 bilateral cancerous spots These range from one 4+3=7(8mm)!! two 3+4=7 three 3+3=6 . My first Dr said I need radiation but he also said I look like I could live as much as another 15 + years so removal may be and option or wait and see. I did bone and organ scans today (results not in yet as to rather it spread ). There are no signs of the cancer breaking out of the capsule . My second doctor JOHN BOON (lottsa good reviews on Google) here in Houston said he can remove the prostate and leave the outer shell in place that has the erectile nerves attached . One friend says just wait and watch a few years! Given these numbers and my age 73 and never having spent a day in life in hospital, hiking up mountains, and workout daily in a gym .....The question is what would you guys do ... I am electing surgery because the Surgeon said "If you cure it with radiation it makes it very hard to later remove it because of damaged tissue and also the surgery would get me out of a life on Flomax.. (never tried Finasteride) Anyway I hope this enough info on my situation and again with all this info do you think surgery is a bad thing . I am sexually active but I could grit my teeth and deal with incontinence and ED I guess just dont want to jump the gun.
Best wishes to all of you guys and thanks for your concern James Meyer

Thanks Mumbo , You answered my main concern that in my case my numbers are a a concern, enough to need to do something . I have surgery scheduled for Feb 23 and second thoughts are running around in my head. I appreciate your response as well as everyone on this board.. I didn't quite understand though did you have a "partial prostate removal" ? Is is so that if you get radiation then if you have to have surgery to remove the prostate the operation is more difficult because of the condition the tissue is left in by the radiation ?? This is what the surgeon said .Hearing that I didn't even consider meeting with a radiation oncologist. BTW by the way thing look otherwise I may live to 90 I am 73 next month.

Thanks James

Absolutely go for the surgery! I had similar numbers to yours. I also had severe BPH. I was on flomax for at least a dozen years. It worked GREAT until the last 2 years. I was having some bad situations. Twice, I was heading out the door to the ER but tried one more time...beautiful urination. I was already leaning towards surgery and my BPH clinched the decision. It did the trick 100%. I was minimally incontinent for about 2-3 weeks post surgery but recovered fully from that. ED, not as well.

Anyway, you are making the right choice with your BPH.

Sans BPH, it would be a much closer call.

Mel

Hi Pratoman I am following you lead and sent off my slides and report to Epstein . I am scheduled to do a nerve sparing prostate removal on Feb 23 . I will keep ya posted did bone scans and body scans all look okay except I got to study what this means .....
Dense sclerotic focus in the right ischium may be benign; nuclear medicine bone scan is
pending. No other suspicious osseous lesion, lymphadenopathy or solid organ
metastases
I do have a concern as to how they properly and permanently reattach the Uretha to the bladder and it not leak or disconnect ?
As always I appreciate everyone here , James M

Good on ya Jimmmy for getting a second opinion from Epstein. I would make sure i had that second opinion before proceeding with your planned surgery. So follow up with Johns Hopkins closely and promptly.

I cant comment on the Scerotic focus in the right ischium, above my understanding level. They do reattach the Uetrato the bladder and any good surgeon will do a proper job, i didnt get into the weeds on how they do it. Of course there is always the risk of a leak, but i am pretty sure its rare. Others may have more knowledge about the technicals on this

Jimmy, I'm gonna offer you an agreement with some but a bit of a counter opinion to others. Getting the second read on the biopsy slides -- absolutely. Getting surgery -- not so fast. You are less than one month from diagnosis and have surgery scheduled? That's very fast in my opinion and I'm not sure you have done your due diligence based on the posts on this thread.

Your surgeon has given you an old myth about "you can do radiation after surgery but not surgery after radiation". While it is true that surgery after radiation may be problematical, it is also true that there are several other salvage techniques after any failed primary radiation that are just as effective as radiation after a failed surgery.

What I suggest is that you get to at least one experienced RO who does SBRT; preferably one who also does HDR Brachy. Ask them about your case, salvage options, their recommendations, etc. I have seen far too much heartbreak on this site from men who are incontinent and/or have ED. Your chances of avoiding that with SBRT or HDR Brachy are better than with surgery.

Ultimately it's your choice of course. But please, do your homework, see multiple doctors and don't rush into anything. If after doing your due diligence you choose surgery that's a reasonable choice. But...you get one chance to do this right the first time so please make sure you are as educated as possible.

Jim

P.S. Please consider establishing a "signature" (can be done from your profile) so that other members don't need to scroll back thru your posts to get the pertinent info.