Patients' tolerance and early complications of transrectal sonographically guided prostate biopsy: prospective study of 300 patients

Endoscopic Band Ligation to Treat a Massive Hemorrhoidal Hemorrhage Following a Transrectal Ultrasound-Guided Prostate Biopsy

Prostate cancer is commonly diagnosed by using a transrectal ultrasound (TRUS)-guided biopsy. Although this procedure is usually well tolerated, rarely it may be complicated by massive rectal bleeding. We report a case of a 77-year-old male who underwent a TRUS biopsy and subsequently developed recurrent episodes of rectal bleeding with syncope and anemia requiring the transfusion of multiple units of blood. A sigmoidoscopy revealed the source of the bleeding: a large hemorrhoid on the anterior wall of the rectum with an overlying ulceration. We successfully applied a band to ligate the hemorrhoid, and the patient's condition improved. To our knowledge, this case represents the first report of a successful band ligation to treat massive bleeding from a hemorrhoid that had been punctured in the course of the TRUS biopsy procedure.

The management of rectal bleeding following transrectal prostate biopsy: A review of the current literature

INTRODUCTION

Since the advent of prostate-specific antigen (PSA)-based testing, transrectal ultrasound (TRUS)-guided prostate biopsy has become a standard part of the diagnostic pathway for prostate cancer (PCa). Rectal bleeding is one of the common side effects of this transrectal route. While rectal bleeding is usually mild and self-limiting, it can be life-threatening. In this article, we examine rectal bleeding post-TRUS-guided prostate biopsy and explore the literature to evaluate techniques and strategies aimed at preventing and managing this common and important complication.

METHODS

A PubMed literature search was carried out using the keywords "transrectal-prostate-biopsy-bleed." A search of the bibliography of reviewed studies was also conducted. Additionally, papers in non-PubMed-listed journals of which the authors were aware were appraised.

RESULTS

Numerous modifiable risk factors for this bleeding complication exist, particularly anticoagulants/antiplatelets and the number of core biopsies taken. Successfully described corrective measures for such rectal bleeding include tamponade (digital/packs/catheter/tampon/condom), endoscopic sclerotherapy/banding/clipping, radiological embolization, and surgical intervention.

CONCLUSIONS

We advocate early consultation with the colorectal/gastroenterology and interventional radiology services and a progressive, stepwise approach to the management of post-biopsy rectal bleeding, starting with resuscitation and conservative tamponade measures, moving to endoscopic hemostasis ± radiological embolization ± transanal surgical methods. Given the infrequent but serious nature of major rectal bleeding after TRUS biopsy, we recommend the establishment of centralized databases or registries forthwith to prospectively capture such data. To the best of our knowledge, this is the first comprehensive look specifically at the management of post-TRUS biopsy rectal bleeding.

Physical after-effects in men undergoing prostate biopsy in routine clinical practice: Results from the PiCTure study

BACKGROUND

As the incidence of prostate cancer has, until recently, increased in most developed countries, the rates of prostate biopsies, required for histological diagnosis, will also have increased. Little is known about the physical after-effects of prostate biopsy outside randomised control trials. We investigate reports on the physical effect of prostate biopsy undertaken in men in routine practice.

METHODS

A self-completed questionnaire was given to men living in the Republic of Ireland (RoI) or Northern Ireland 4 to 6 weeks after prostate biopsy. Men were asked about whether they experienced specific physical after-effects postbiopsy (raised temperature/pain/bleeding/erectile dysfunction/urinary retention) and, if so, their severity and duration, and any associated health care uses. Binomial and ordinal logistic regression was used to investigate factors associated with postbiopsy after-effects (presence/absence) and number of after-effects reported, respectively.

RESULTS

Postbiopsy after-effects were common with 88.1% of 335 respondents reporting at least 1 after-effect; 21% reported at least 3. The odds of increasing number of after-effects was over 2-fold in men with both intermediate (odds ratio [OR] = 2.59, 95% CI: 1.52-4.42) and high (OR = 2.52, 95% CI: 1.28-4.94) levels of health anxiety and for men who had had multiple previous biopsies (adjusted OR = 2.02, 95% CI: 1.20-3.41). A total of 21.3% of men who experienced after-effects reported that they were worse than expected, 11.5% with after-effects reported contacting their doctor or local pharmacy, 14.6% contacted hospital services, and 3.1% of men with after-effects were admitted to hospital with an average stay of 5.4 nights (standard deviation = 6.3).

CONCLUSION

Physical after-effects following prostate biopsy in routine practice are common, and in some men, serious enough to warrant contacting hospital or community services. Men with increased health anxiety or who undergo multiple biopsies might benefit from additional support.

Association between pre-biopsy white blood cell count and prostate biopsy - related sepsis

Introduction

Despite all preventive measures and improved biopsy techniques, serious, life–threatening complications of prostate biopsy, including sepsis, still exist. In the present study, in order to identify the risk factors that may be associated with sepsis development after prostate–biopsy, we aimed to analyze retrospectively the data of our patients who underwent transrectal ultrasound–guided prostate biopsy.

Material and methods

We retrospectively reviewed the data of 889 patients who underwent prostate biopsy at our clinic. We compared pre–biopsy parameters (age, prostate volume, white blood cell (WBC) count, fasting blood glucose, free and total prostate specific antigen levels) between patients who developed sepsis and those who were sepsis–free following prostate biopsy.

Results

28 patients (3.1%) developed sepsis. Among the risk factors evaluated, only pre–biopsy WBC count was found to be a significant risk factor for biopsy–related sepsis. A 5.1 fold increase was detected in the risk for sepsis development, when the cut–off value of WBC was accepted as 11.165/μL, OR: 5.1 (95% CI: 2.3–11.5). The post–biopsy sepsis development rate in patients with pre–biopsy WBC count greater and less than 11.165/μL was 13.7% (n = 10) and 3% (n = 18) respectively.

Conclusions

Patients with a pre–biopsy WBC count greater than 11.165/μL should be informed of the increased risk of developing post–biopsy sepsis.

Quantitative iodine-based material decomposition images with spectral CT imaging for differentiating prostatic carcinoma from benign prostatic hyperplasia

RATIONALE AND OBJECTIVES

To investigate the value of iodine-based material decomposition images produced via spectral computed tomography (CT) in differentiating prostate cancer (PCa) from benign prostate hyperplasia (BPH).

MATERIALS AND METHODS

Fifty-six male patients underwent CT examination with spectral imaging during arterial phase (AP), venous phase (VP), and parenchymal phase (PP) of enhancement. Iodine concentrations of lesions were measured and normalized to that of the obturator internus muscle. Lesion CT values at 75 keV (corresponding to the energy of polychromatic images at 120 kVp) were measured and also normalized; their differences between AP and VP, VP and PP, and PP and AP were also obtained. The two-sample t-test was performed for comparisons. A receiver operating characteristic curve was generated to establish the threshold for normalized iodine concentration (NIC).

RESULTS

Fifty-two peripheral lesions were found, which were confirmed by biopsy as 28 cases of PCa and 24 BPHs. The NICs of prostate cancers significantly differed from those of the BPHs: 2.38 ± 1.72 compared with 1.21 ± 0.72 in AP, respectively, and 2.67 ± 0.61 compared with 2.27 ± 0.77 in VP. Receiver operating characteristic analysis indicated that an NIC of 1.24 in the AP provided a sensitivity of 88% and a specificity of 71% for differentiating PCa from BPH.

CONCLUSIONS

Spectral CT imaging enabled quantitative depiction of contrast medium uptake in prostatic lesions and improved sensitivity and specificity for differentiating PCa from BPH.

Systematic review of complications of prostate biopsy

CONTEXT

Prostate biopsy is commonly performed for cancer detection and management. The benefits and risks of prostate biopsy are germane to ongoing debates about prostate cancer screening and treatment.

OBJECTIVE

To perform a systematic review of complications from prostate biopsy.

EVIDENCE ACQUISITION

A literature search was performed using PubMed and Embase, supplemented with additional references. Articles were reviewed for data on the following complications: hematuria, rectal bleeding, hematospermia, infection, pain, lower urinary tract symptoms (LUTS), urinary retention, erectile dysfunction, and mortality.

EVIDENCE SYNTHESIS

After biopsy, hematuria and hematospermia are common but typically mild and self-limiting. Severe rectal bleeding is uncommon. Despite antimicrobial prophylaxis, infectious complications are increasing over time and are the most common reason for hospitalization after biopsy. Pain may occur at several stages of prostate biopsy and can be mitigated by anesthetic agents and anxiety-reduction techniques. Up to 25% of men have transient LUTS after biopsy, and <2% have frank urinary retention, with slightly higher rates reported after transperineal template biopsy. Biopsy-related mortality is rare.

CONCLUSIONS

Preparation for biopsy should include antimicrobial prophylaxis and pain management. Prostate biopsy is frequently associated with minor bleeding and urinary symptoms that usually do not require intervention. Infectious complications can be serious, requiring prompt management and continued work into preventative strategies.

The prognostic value of transrectal ultrasound guided biopsy in patients over 70 years old with a prostate specific Antigen (PSA) level ≤ 15 ng/ml and normal digital rectal examination: a 10-year prospective follow-up study of 427 consecutive patients

INTRODUCTION

As a urologist, it is common to review a patient above the age of 70 being referred to a prostate assessments clinic with an elevated PSA. We evaluate the prognosis of these patients clinically as there is no international consensus on the exact PSA cutoff level or a single international guideline as to when these patients should be offered a prostate biopsy.

PATIENTS AND METHODS

On receiving ethic committee approval, we recruited 427 consecutive patients aged 70 years and above referred with a PSA of ≥ 4 ng/ml, from January 1996 to December 2000, into our study. All patients were assessed, examined with a digital rectal examination (DRE) of the prostate, and a subsequent prostate biopsy. We followed up on their histologic diagnosis for up to 10 years and analyzed their outcome. The main outcome measures were disease-free survival and overall survival, stratified according to the PSA level (≤ 15 vs. >15 ng/ml) and DRE findings (normal vs. sbnormal).

RESULTS

There was a statistically significant difference in the overall survival (P value < 0.011) and disease specific survival (P value < 0.0001) of cancer patients with a PSA was >15 ng/ml and an abnormal DRE. However, in patients with a PSA ≤ 15 ng/ml and normal DRE, the incidence of cancer was low and they had no disease-specific or overall survival benefit.

CONCLUSIONS

A policy of deferring prostate biopsy in patients with a PSA ≤ 15 ng/ml and normal DRE (Group A) would significantly decrease the need of unnecessary prostate biopsies. Within this group, patients did not have any survival advantage compared with those without cancer. We conclude that up to 20% of the prostate biopsies performed in this age group could have been avoided.

Severe Life Threatening Rectal Bleed After Prostate Biopsy Requiring Angiographic Therapy: A Case Report

Rectal bleeding is often seen in patients who undergo transrectal ultrasound-guided prostate biopsy. It is usually mild and stops spontaneously. We report what we believe is the first case of life threatening rectal bleeding following this procedure which was successfully treated with angiographic embolization. An endoscopic injection of epinephrine done on admission achieved only temporary hemostasis and the patient developed a second episode of massive rectal bleeding that warranted angiographic treatment. We present this case in detail and review other alternatives for treating fulminant rectal bleed which is a consequence of this procedure.

Intramuscular Gentamicin Improves the Efficacy of Ciprofloxacin as an Antibiotic Prophylaxis for Transrectal Prostate Biopsy

Introduction: Infection-related complications after transrectal ultrasound guided prostatic biopsy (TRPB) could be life threatening. Our centre observed sepsis after TRPB despite prophylactic oral ciprofloxacin. We reviewed all cases of post-TRPB sepsis with their bacteriology and evaluated if the addition of intramuscular (I/M) gentamicin to standard prophylaxis before TRPB could reduce its incidence. Materials and Methods: In a single urological centre, we performed an interventional study that compared a prospective group with retrospective control. The latter is known as the “cipro-only” group included consecutive patients who underwent TRPB between 1 September 2003 and 31 August 2004. The addition of I/M gentamicin 80mg half an hour before TRPB started on 1 September 2004. All subsequent patients who underwent TRPB until 31 August 2005 were included in the “cipro+genta” group. Patients who did not receive the studied antibiotics were excluded. Results: There were 374 patients in the “cipro+genta” group and 367 patients in the “cipro-only” group with comparable profiles. There were 12 cases of post-TRPB sepsis in the “cipro-only” group and 5 cases in the “cipro+genta” group. Ciprofloxacin-resistant Escherichia coli (E. coli) was the only pathogen isolated in both groups. In the “cipro-only” group, 9 patients had positive blood cultures and 8 were sensitive to gentamicin. In the “cipro+genta” group, the only positive E. coli was gentamicin-resistant. One patient in the “cipro+genta” group was admitted to the intensive care unit with septicaemia. Conclusion: The addition of I/M gentamicin to oral ciprofloxacin is a safe and effective prophylactic antibiotic regime in reducing the incidence of post-TRPB sepsis. Key words: Antibiotics, Infection, Prophylaxis, Prostate Biopsy

Endoclipping treatment of life-threatening rectal bleeding after prostate biopsy

Rectal bleeding is frequently seen in patients undergoing transrectal ultrasound (TRUS)-guided multiple biopsy of the prostate, but is usually mild and stops spontaneously. We report what is believed to be the first case of life-threatening rectal bleeding following this procedure, which was successfully treated by endoscopic intervention through placement of three clips on the sites of bleeding. This case emphasizes endoscopic intervention associated with endoclipping as a safe and effective method to achieve hemostasis in massive rectal bleeding after prostate biopsy. Additionally, current data on the complications of the TRUS-guided multiple biopsy of the prostate and the options for treating fulminant rectal bleeding, a consequence of this procedure, are described.

Complication rates of ultrasound-guided prostate biopsy: a nation-wide survey in Japan

OBJECTIVE

To assess the morbidity secondary to ultrasound-guided systematic prostate biopsy in Japan.

METHODS

Five hundred and forty-eight principal urological training institutions certified by the Japanese Urological Association participated in the survey. A retrospective analysis of complications after prostate biopsy was conducted.

RESULTS

Medical records of 212 065 procedures carried out between 2004 and 2006 were reviewed. Seventy-six percent of procedures had been carried out transrectally, and 23% transperineally. Hematuria, rectal bleeding and hematospermia occurred in 12%, 5.9% and 1.2% of cases, respectively. Voiding symptoms were reported after biopsy in 1.9% of cases and urinary retention in 1.1%. Fever (>38 degrees C) was observed in 1.1% and sepsis occurred in 0.07%. Hospitalization was required in 0.69% of cases for the treatment of biopsy-related complications.

CONCLUSIONS

Overall, contemporary ultrasound-guided systematic prostate biopsy is safely carried out in Japan. However, minor complications are not infrequent, whereas major ones remain very rare but life-threatening if they occur. Thus, adequate information should be provided to patients undergoing prostate biopsy.

Complications and limitations related to periprostatic local anesthesia before TRUS-guided prostate biopsy

PURPOSE

To assess the frequency of complications specifically related to local anesthetic infiltration prior to transrectal ultrasound (TRUS)-guided prostate biopsy.

METHODS

A total of 200 patients receiving 10 cm(3) (5 cm(3) on each side) of 2% lidocaine injected around the periprostatic nerve plexus under TRUS guidance before prostate biopsy were included. Various complications presumed to be associated with local anesthesia were noted during and after the biopsy procedure. Two weeks later, periprostatic tissue integrity and vascularization were re-examined with TRUS Doppler examination to assess for fibrosis or infection.

RESULTS

The most common finding was pain due to puncture with the needle used for local anesthesia (27%). Also recorded were the need for repeated injections during the biopsy procedure (4.5%), symptoms associated with systemic lidocaine toxicity (2%), urinary incontinence (1.5%), and degradation of the image resolution due to anesthetic injection (1%). Increased vascularization within the periprostatic region was uncommon (2%) on the 2-week follow-up examination. No TRUS finding consistent with rectal wall hematoma or other periprostatic change and no erectile dysfunction associated with the procedure occurred. There was a significant difference in overall pain scores between the subgroups of patients (p < 0.001).

CONCLUSION

TRUS-guided periprostatic nerve blockade is an effective method for relieving discomfort from prostate biopsy with very few complications.

[Safety and tolerance of transrectal ultrasound-guided (TRUS) biopsy in the diagnosis of prostate cancer]

OBJECTIVE

To identify the complications and possible associated factors observed in patients with suspected prostate cancer undergoing transrectal ultrasound-guided (TRUS) biopsy.

PATIENTS AND METHODS

A prospective analysis of the TRUS biopsy procedures performed between 1995-2005. Descriptive statistics: mean, standard deviation, percentage, and 95% confidence intervals. Inferential statistics: t-test, chi-square analysis, 95% confidence intervals, and odds ratio (OR). EPI-Info Program 3.2.2-2005 of the WHO.

RESULTS

A total of 1067 patients underwent the procedure; 913 (85%; CI: 83.3; 87.6) reported no pain or only slight pain. Clinical complications were detected in 284 cases (26.6%; CI: 24.2; 27.4). Self-limiting hematuria and rectorrhagia accounted for 82% of all complications. Observation and/or hospital admission was required in 7 cases (0.6%; CI: 0.3; 0.8). Immediate US follow-up after puncture registered complications in 302 cases (28.3%; CI: 26.6; 29.3). Periprostatic and/or submucosal hematoma in 264 cases accounted for 87% of these complications. The complications observed during US were related to: a history of prior urological pathology (OR = 1.52; CI: 1.31; 1.73; p = 0.005) and increased pain (OR = 5.63; CI: 5.60; 5.66 p < 0.001). The clinical complications were associated with: altered coagulation (OR = 1.67; CI: 1.64; 1.70 ;p = 0.045) and increased pain (OR = 0.37; CI: 0.32; 0.42 p < 0.001). The complications detected during US were not translated to clinical complications (OR = 0.16; CI: 0.13; 0,20 p < 0.001).

CONCLUSIONS

TRUS biopsy is well tolerated by patients in our environment. Clinical complications are minimal and generally self limiting and rarely require hospital care. The role of the radiologist can be important for improving patients' tolerance of the test and reducing complications.

Endoscopic therapy of a massive rectal bleeding after prostate biopsy

We report on the case of a 65-year-old man with an indication for a transrectal multibiopsy of the prostate based on a PSA value of 4.5 ng/ml. A massive haemoglobin effective rectal bleeding occurred post-intervention, which due to haemodynamic instability required the administration of erythrocyte concentrates. Both manual compression and rectal tamponade failed to stop the bleeding, and immediate haemostasis was achieved through an endoscopic injection of adrenaline. We present this case in detail and additionally describe current data on the complications of the ultrasound-guided transrectal biopsy of the prostate and the options for treating the fulminant rectal bleeding that is a consequence of this procedure.