Biopsies Don't Tickle

prostate cancer

If you have cancer, you’ve likely had a biopsy, and it’s not a pleasant experience. It probably made you squirm. There is discomfort during the procedure, and pain afterwards. Doctors do biopsies for breast, lung, prostate, liver, colon, bone marrow, and other cancers. Doctors go in through the back, the abdomen, the groin. Techniques vary from using needles to punches to surgery. I’ve had two biopsies – a prostate biopsy, and one when they drilled into my pelvic bone to check out a spot that lit up on a scan.

What I’m sharing today is based on a Howard Wolinsky post. He’s a medical journalist who writes about prostate cancer on his Substack account – The Active Surveillor.

The biopsy is a standard diagnostic tool that is used to determine how much cancer you have and how aggressive it is. After an elevated PSA alerts you to a problem, the second step for prostate cancer is a digital rectal exam (the lubed finger). The third tool is the biopsy. After this, doctors run you through a regimen of scans, some that have chemical tracers that are injected into your I.V. and leave a metallic taste in your mouth.

During this biopsy, the urologist takes a dozen or so tissue samples from different parts of your prostate, and there are two methods for gathering the samples: transrectal and transperineal. Urologists have differences of opinion about which one is better. In both cases, a needle is repeatedly inserted into different parts of your prostate and snatches bits of tissue.

There are four considerations for deciding which method to use: 1. Accuracy 2. Which one causes more infections that can lead to sepsis. 3. The amount of pain and discomfort the patient has to endure. 4. Cost.

Research studies show that the accuracy of both is about equal, although the transperineal can reach the front lobe and get samples from there. My take on Howard’s research is that the transperineal has a lower infection rate, more short and longer-term pain, is slightly more accurate, and is generally done in a hospital. Transrectal is quicker, is done in the doctor’s office, costs less, has less pain, but has a greater risk of infection and death from sepsis.

Your insurance company might cover only one option, and your urologist might not be trained to do the transperineal, so you may not have a choice. My biopsy was transrectal, a curious but slightly horrifying experience, so I can’t speak about how the transperineal procedure feels. I took antibiotics before the procedure where an ultrasound device was inserted up my bum. Then the biopsy gun (a rather medieval torture device) went in and shot twelve hooked spears into my prostate. I wasn’t offered a choice about the method.

Although the transrectal method became the preferred choice beginning in the mid-1980s, the transperineal method, which is an older technique, is making a comeback because of lower infection rates. My radiation oncologist thinks the transrectal is barbaric. He would later push eighteen radioactive wires through my perineum and up into my prostate.

If you’re on active surveillance for prostate cancer before any treatments are needed, you will probably get a biopsy every so often. I imagine that I will have one in the near future to check on how effective my radiation treatments were. Will I have a choice between the red cup or the yellow one? I am not looking forward to either method.

© 2026 Mark Liebenow