For most of the history of prostate diagnosis, an elevated PSA led to a systematic biopsy: twelve cores taken from a standard map of the gland, without any image showing where the cancer might be. It was sampling in the dark, and it had the two failings you would expect. It missed significant tumours that happened to sit between the sampling points, and it found small indolent tumours that were never going to matter, because a random sample of an organ full of harmless disease returns harmless disease.
What the MRI adds
Multiparametric MRI combines anatomical imaging with sequences sensitive to cellular density and blood flow, and the radiologist scores suspicious areas on a five-point scale from 1, very unlikely to be significant cancer, to 5, very likely. The score is a probability statement, not a diagnosis.
Two things follow from it. The first is that a biopsy can be aimed. Cores can be taken from the specific area the MRI flagged, alongside or instead of the systematic map, which raises the detection of the cancers worth finding. The second is that a genuinely reassuring MRI in a man whose other risk factors are modest can justify continued monitoring rather than an immediate biopsy. Randomised comparisons of this pathway against systematic biopsy found more clinically significant cancer detected, fewer insignificant cancers detected, and a substantial share of men avoiding biopsy — an unusual combination of results.
The caveats are real. MRI quality varies, and so does the experience of the person reading it; a score from a high-volume prostate radiologist is worth more than the same number from a general reader. A negative MRI lowers the probability of significant cancer considerably but does not reduce it to zero, which is why it leads to a surveillance plan and not to discharge.
Order of operations
Confirm the PSA on a repeat sample with infection excluded. Consider an adjunct test in genuinely borderline cases. Image before biopsy where the decision is not already clear. Then, if a biopsy is indicated, target it. Skipping straight from one raised PSA to a systematic biopsy is the pathway that produced the over-diagnosis problem in the first place.
Transrectal and transperineal biopsy
Dr. Shusterman performs transrectal ultrasound-guided biopsy with an individualized infection-prevention protocol. The choice of route depends on your risk factors, the target and the clinician’s experience; the comparison below explains the alternatives. Ask which route is planned for your procedure.
A biopsy needle reaches the prostate either through the rectal wall or through the skin of the perineum. The difference matters more than it sounds.
The transrectal route is quicker, is performed under local anesthetic, and has been standard for decades. Its problem is infection: the needle passes through the rectal wall carrying bowel organisms into the prostate and bloodstream, and as fluoroquinolone resistance has risen, the rate of serious post-biopsy infection and sepsis has risen with it. Prophylaxis has had to become more elaborate, sometimes guided by a rectal swab culture beforehand.
The transperineal route passes through skin that can be properly prepared, and the infection rate is markedly lower — low enough that antibiotic prophylaxis can often be reduced or omitted. It also samples the front of the gland, where transrectal sampling is weakest and where a proportion of significant tumours sit. It was historically done under general anesthetic, which limited its use; it is now routinely performed under local anesthetic in the office. Where a transperineal approach is available and appropriate, the infection argument for it is strong.
What the procedure involves
A biopsy takes fifteen to twenty minutes. Local anesthetic is infiltrated around the prostate, which is the part most men expect to be worse than it is. You will see blood in the urine for a few days and in the semen for several weeks — the latter is harmless, long-lasting and alarming if nobody warns you, so we do. Some men have difficulty urinating temporarily. Fever, chills or increasing pain after a biopsy mean an infection until proven otherwise and warrant contacting us the same day.
Reading the result
Pathology reports a Gleason score, now also expressed as a Grade Group from 1 to 5, along with the number of cores involved and the proportion of each. Grade Group 1 disease — Gleason 3+3 — behaves so indolently that whether it should be called cancer at all is a live argument among pathologists; it is the archetypal candidate for active surveillance. Grade Group 2 occupies the debated middle ground where the proportion of pattern 4 and the volume of disease drive the decision. Grade Group 3 and above generally warrants treatment.
A negative biopsy after a suspicious MRI is not automatically the end of the matter, and neither is a negative MRI in a man whose PSA keeps climbing. Both situations call for a monitoring plan with a defined interval rather than a reassurance and a discharge.
Questions patients ask
Does a PI-RADS 3 mean I have cancer?
No. It means the imaging is equivocal — the finding could be cancer or could be benign change, and on its own it does not settle anything. What happens next depends on your PSA density, your family history, your age and your own preference, and a PI-RADS 3 is exactly where an adjunct blood or urine test can genuinely change the decision.
Is the biopsy painful?
Uncomfortable rather than painful for most men. Local anesthetic is placed around the prostate first and it works well. The pressure sensation and the sound of the biopsy device surprise people more than the pain does.
How risky is infection?
It is the main risk of the transrectal approach, and it has become more of a concern as antibiotic resistance has increased — most serious complications after prostate biopsy are infective. The transperineal approach largely sidesteps it because the needle does not pass through the rectum, which is the principal reason it has become preferred.
Blood in my semen after the biopsy — is that normal?
Yes, and it can persist for several weeks and look dramatic. It is expected and harmless. Blood in the urine for a few days is also expected. Fever, chills, worsening pain or an inability to urinate are not, and warrant contacting us the same day.
Can I have an MRI at your office?
The MRI itself is performed at an imaging facility; what matters most is that it is a multiparametric protocol read by a radiologist who reads a lot of prostates. We arrange it and review the images ourselves rather than working from the report alone.
Make an appointment
Manhattan (212) 991-9991 · Forest Hills (718) 360-9550 · same-week visits and most major insurance accepted.