Thursday, January 19, 2017

3D Staging Prostate Biopsy Unlikely To Come Into General Use - My Account

Image of a 3D reconstruction- with grids superimposed-- after 3D Staging Biopsy. Note the prostate (in red), urethra (in green) and the exact location of areas of cancer (in mud yellow). 

The advantages of the 3D staging biopsy for prostate cancer which I just had two days ago, are well known and explicated wonderfully on Dr. E. David Crawford's University of Colorado site. We are informed, for example, that with this 3D rendition many more lesions, prostate cancer tumors can now be identified because the technique is much more thorough. As Dr. Crawford has noted, from 10-30 percent of prostate cancers are missed even in the MRI fusion biopsy.

In other words, given the much higher accuracy the 3D Prostate biopsy is now the "gold standard" for PCa diagnosis. But that standard doesn't mean many more men will choose it.  We need to look at why this is so.

The standard prostate biopsy is more or less an "in and out" procedure, done rectally with the accompaniment of an ultrasound to provide location data for the prostate sampling. This may be from 10 to 20 cores. Thus, a needle sample device is inserted into the rectum and each time extracts tissue from the gland after puncturing the rectal wall. Primary risk is for sepsis, which is why antibiotics like ciproflaxin must be administered in advance.

The procedure is usually done in the urologist's office without even a sedative and takes from 20 minutes to 45 minutes, depending on the number of sample cores taken. The chief side effects include: swelling and pain in prostate, possible problem urinating, and blood in urine, stools and semen. In the former two body fluids it can remain 1-2 days and in the last up to 3 months.

The 3D staging biopsy by contrast is an entirely different animal. While described as an "outpatient" procedure, you are actually administered general anesthesia because the technique is much more invasive and entails up to 100 needle sampling insertions through the perineum to extract prostate tissue. The locations are again confirmed via trans rectal ultrasound for later mapping of all the samples to a 3D grid. The samplings are taken approximately 5mm apart. In my case a total of 45 were taken, fewer than originally projected (60).

Of course, before getting it done you are undergoing a full surgery prep, including being asked if you're an organ donor, and to leave an advanced medical directive (or living will) in case the surgery or anesthesia goes awry - or you hemorrhage. Also Janice had to be there to provide durable power of attorney and medical power of attorney in the event I was left unable to render decisions, directions for my own care.

In the pre-op setting you also discuss with the anesthesiologist any allergies, and note if you are sensitive to meds (as I am.) By the time you are being wheeled into the OR you are already half out of it from the mix of sedatives, painkillers including fentanyl.

Once in the OR you must move yourself from the gurney to the operating table where the sampling is done. I don't believe I'd completed the transition more than a minute before I was knocked out.   (Just before I was asked by a urology resident if I wanted a transfusion in case of hemorrhage, and I gave my blood type).

I awakened in the PACU or Post-Anesthesia Care Unit, to the soft voice of a beautiful nursing grad student, "Rachel", who asked the usual questions: Where are you? What is your name? What is your date of birth? What year is it? Etc. All this is done to ensure you are all there.

She then questioned me about the pain, where it hurt and the nature. I told her the worst aspect was a burning sensation all through the urethra, from the catheter. (I ended up opting for a Foley catheter, as opposed to supra-pubic on the advice of a urology resident, "Tim".).

She immediately brought me three meds to take with water, one of which was specifically to reduce the burning sensation that had become almost unbearable.

After giving me the meds, she brought me a few light Jello snacks. This time (unlike my gall bladder removal in May) there was no nausea at all so the anesthesiologist hit just the right mix.

Janice by now had also come up, after tracking my various locations using a "patient tracker" - coded by color to follow my progress. Once she arrived, Rachel and another student RN ("Callie")  showed her how to change the catheter bags, and also go from the usual (day time) leg bag to the much larger night bag.

Let me say right off the bat that having a Foley catheter in place is no ball of fun, and ranks maybe up there with a root canal - or two.  I had to wear the damned thing for two days before Dr. Crawford's RN gave the ok to take it out.   She emphasized it was foolhardy to do so too early because then "you could be in a real world of hurt". That refers to all the ancillary tissues swelling up preventing urination, which earns you a trip to the ER. 

So now, with it out I am still recovering and will get the results of the biopsy in 5 days or so.

Having had the normal biopsies and this one I can agree right now with what a paper dealing with it noted, that in general most men would not opt for it given the greater "medical burden" - that entails more invasive procedure - as I described - as well as more side effects, bleeding from rectum, penis, etc. and pain as well as having to wear a urinary catheter.

Most men, despite the touted accuracy of results (which isn't in dispute),  will simply not opt for this advanced biopsy unless they are looking for a specific treatment option (e.g. focal cryo-ablation) for which it is required.

Anyway, recovering now, and thankfully with no catheter. I am just waiting for further word on whether I am a candidate for the focal cryo. I will have to meet with Dr. Crawford again in 2 weeks.

See also:


Yesterday (1/24) I received word from UC Health that the biopsy came results came out favorably for further treatment. 5 of 45 cores showed cancer but no scores higher than Gleason 3 + 3. So I am cleared to schedule treatment in about two months.

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