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Glamorgan Urology: Prostate Cancer

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Prostate Cancer

In this section

PSA Testing

PSA blood testing is the most commonly used test to assess the risk of prostate cancer.

PSA (‘Prostate Specific Antigen’) is a protein made exclusively by the prostate gland, but can be measured in blood. It is made by both normal and cancerous prostate cells.

What is a normal PSA value?

This depends on your age (see table below):

AgePSA (ng/ml)
<49 years2.5
<59 years3.5
<69 years4.5
>70 years6.5

A high level of PSA can be a sign of prostate cancer. However, PSA is only 67% specific and other prostate disorders can cause a raised PSA, e.g:

  • benign prostate disease
  • Chronic Prostatitis

In addition, a temporary rise in PSA can occur with;

  • a urinary tract infection
  • retention of urine (inability to pass urine)
  • a cystoscopy (an inspection of the inside of the bladder)
  • intercourse, up to 48 hours after ejaculation

PSA levels may also be influenced by drugs:

  1. Finasteride (Proscar)or dutasteride (Avodart): 12 months of treatment with any of these medications will reduce the PSA value by 50%.
  2. Hormones (e.g. zoladex, casodex) or steroid medications.

A Glamorgan Urology Consultant will discuss the relevance of your PSA test result with you. We will also take other factors into consideration: your family history, the digital rectal examination (DRE), previous PSA results, the size of your prostate on ultrasound (Transrectal ultrasound prostate volume) and the results of other tests e.g. free / total PSA ratio and the PCA-3 gene test.

Free/Total PSA Ratio

For patients with an elevated PSA level between 4 and 10, a further PSA analysis can be performed. If the free to total PSA ratio is less than 12%, this may suggest that the PSA rise is more likely due to prostate cancer than benign prostate hyperplasia (BPH).

PCA-3 Gene Test

This is a relatively new test performed at Cambridge Laboratories in London. The test determines whether proteins produced by prostate cancer genes are present in a patient’s urine specimen. Up to a 100 times more PCA-3 is present in prostate cancer cells than normal prostate cells.

PCA-3 levels are not increased in BPH or in the presence of a urinary tract infection and are unaffected by the size of the prostate gland.

The test is obtained by a performing a prostate massage for about 5 minutes using an ultrasound probe placed in the rectum. The patient then passes urine into a pot and a small volume is pipetted and sent for analysis.

PCA-3 Values and Interpretation

The PCA-3 value gives an estimate of how likely we are to find prostate cancer on a biopsy.

PCA3 ValueProbability of Prostate Cancer on Biopsy

The PCA-3 test doesn’t confirm or exclude the presence of prostate cancer. The result must be used in conjunction with other clinical findings and other test results.

Biopsy of the Prostate Gland.

A biopsy of the prostate involves a small core of prostate tissue, between 10 and 20mm in length being taken from the prostate. The total number of biopsies taken will vary depending on the technique that is employed. A Consultant Pathologist will examine the prostate biopsy under the microscope for the presence of:

  • cancer
  • atypical cells
  • pre-cancerous cells (PIN)
  • inflammation
  • benign prostate hyperplasia (BPH)

Glamorgan Urology employ 2 methods to biopsy the prostate gland:

  1. Transrectal Ultrasound of Prostate (TRUS)
  2. Template Saturation Perineal Prostate Biopsies

Transrectal Ultrasound of Prostate (TRUS)

This is the standard technique employed in the majority of patients.

  • Anti-coagulants e.g. warfarin will be stopped 1 week before.

  • Antibiotics (Ciprofloxacin 750mg and Metronidazole 400mg) are taken 1 hour before the procedure and for two days afterwards.

  • A formal consent will be taken.

  • Anaesthetic: local anaesthetic will be injected around the prostate gland via the ultrasound probe.

  • The procedure can be uncomfortable and patients may also request entonox gas as extra analgesia.

  • The patient will lie on his left hand side with his knees drawn up on a treatment trolley.

  • An ultrasound probe is inserted into the rectum

  • The prostate size and anatomy is assessed.

  • Between 10 and 12 biopsies will be taken as standard via a needle fired from a BARD biopty gun through the ultrasound probe.

  • No routine analgesia is required.

  • A follow-up appointment will be given prior to discharge.

  • Post–biopsy: expect to see blood in the urine for the first 48 hours and blood in the semen for up to 6 weeks.

  • The biopsy results will be available between 7 and 10 days later.

  • It is important to bear in mind that a TRUS biopsy samples only a small area of the prostate. TRUS can give a false negative result in up to 30% of cases.

  • Follow up with testing at agreed intervals via a PSA and DRE, is therefore important to identify those patients with undiagnosed prostate cancer missed on the first biopsy.

Template Prostate Biopsy

This is a relatively new technique, first performed in the USA that can be utilised in 4 scenarios:

  1. Patients who have had a negative TRUS biopsy, but whose PSA continues to rise.
  2. Patients with a new diagnosis of prostate cancer wishing further information to decide between active surveillance and radical therapy.
  3. Patients who are known to have prostate cancer and who are on active surveillance. These patients will undergo a further ‘interval biopsy’ to decide if radical therapy is indicated.
  4. A small proportion of patients may wish to undergo an ‘initial prostate biopsy’ under a general or spinal anaesthetic. In these circumstances, a template biopsy may be performed instead of a TRUS.


The template is a grid like structure (see picture), previously used in brachytherapy and cryotherapy. It enables biopsies to be taken from all areas of the prostate in an even manner, to accurately assess the extent and nature of the prostate cancer. This data can help individualise the treatment options for each patient’s prostate cancer.

The path of the needle in a TRUS biopsy (1) differs to that used in a template biopsy (2), as shown in the diagrams below. If the red star is the cancer, it’s easy to see how this could be missed by TRUS and detected via a template biopsy through the skin of the perineum.


Figure 1. TRUS biopsy – oblique biopsy through the rectum


Figure 2. Template biopsy through the perineum (skin between the anus and scrotum)

The net result is better sampling of the anterior and central parts of the prostate, areas where cancers have previously been missed.

The procedure is performed under general anaesthetic on a day case basis.

Pre-operatively, the patient will receive:

  • A microlax enema to clean the rectum.
  • Ciprofloxacin 750mg orally 1 hour prior to the biopsy.

Intra-operatively: 160mg IV gentamicin and a 1g metronidazole suppository

Post-operatively: ciprofloxacin 500mg o bd for 5 days.

Potential side effects of template biopsy;

  • Most patients will experience some perineal bruising.
  • Mild post-operative pain requiring analgesia.
  • Prolonged haematuria (blood in the urine) will occur in 1%.
  • Retention of urine (unable to pass urine – requiring a temporary catheter) 1-2%.
  • Infection is less common than in a TRUS biopsy - <1%.

Biopsy results are typically available 10 to 14 days after the template procedure.

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