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

Proctoscopy following transrectal prostate biopsy can control rectal bleeding after prostate biopsy

OBJECTIVES

Rectal bleeding is a common complication of transrectal ultrasound-guided prostate biopsy (TRPB). Massive rectal bleeding after TRPB can be life threatening. We initiated proctoscopy after TRPB to clarify the incidence of rectal bleeding and evaluated the usefulness of proctoscopy for controlling bleeding after TRPB.

MATERIALS

Two hundred and fifty six patients who underwent TRPB were included in the study. TRPB was performed under local anesthesia. Post-biopsy, we performed a proctoscopy to evaluate the degree of rectal bleeding at four levels (G0, no bleeding; G1, traces; G2, venous bleeding requiring hemostasis; and G3, massive venous bleeding or arterial bleeding). Once the bleeding site on the rectal wall was identified, a gauze tampon was placed at the bleeding site and compressed for a few minutes. A second proctoscopy was performed to confirm complete hemostasis, after which the TRPB was terminated.

RESULTS

Proctoscopy revealed that the degree of bleeding was G0 in 27 cases, G1 in 104 cases, G2 in 116 cases, and G3 in nine cases. Rectal bleeding that required hemostasis (G2 and G3) was observed in 125 of 256 cases (48.3%). Among the 125 cases, bleeding was stopped by compression in 121 cases; in the remaining four cases, bleeding continued despite compression and was stopped by suturing of the bleeding site. Suturing was performed by urologists, and none of the 256 patients had problematic posterior hemorrhage.

CONCLUSIONS

Proctoscopy enables precise and effective pressure hemostasis. Moreover, suturing hemostasis under direct vision can be performed in cases in which pressure hemostasis is difficult. Continued proctoscopy allays urologists' fear of post-TRPB rectal bleeding.

Targeting STEAP1 as an anticancer strategy

Although the six-transmembrane epithelial antigen of prostate 1 (STEAP1) was first identified in advanced prostate cancer, its overexpression is recognized in multiple types of cancer and associated with a poor prognosis. STEAP1 is now drawing attention as a promising therapeutic target because of its tumor specificity and membrane-bound localization. The clinical efficacy of an antibody-drug conjugate targeting STEAP1 in metastatic, castration-resistant, prostate cancer was demonstrated in a phase 1 trial. Furthermore, growing evidence suggests that STEAP1 is an attractive target for immunotherapies such as chimeric antigen receptor-T cell therapy. In this review, we summarize the oncogenic functions of STEAP1 by cancer type. This review also provides new insights into the development of new anticancer strategies targeting STEAP1.

Hemorrhagic Shock After Transrectal Ultrasound-Guided Prostate Biopsy Successfully Treated With Endoscopic Therapy

Prostate cancer is the second cause of cancer-related deaths among men in the United States. Transrectal ultrasound-guided prostate biopsy is the gold standard for diagnosis of prostate cancer. This is a relatively safe procedure, yet bears the small risk of hemorrhage. In rare instances, the bleeding may require emergent endoscopic or radiologic therapy. However, scarce literature exists depicting the appearance of the bleeding lesions and the successful endoscopic therapies used to treat them. In this report, we present a case of a 64-year-old man who developed massive bleeding after transrectal ultrasound-guided prostate biopsy that was successfully treated with epinephrine injection and endoscopic hemoclipping.

Safety and efficacy of transcatheter arterial embolization for management of refractory hematuria of prostatic origin

Objective

To estimate the safety and efficacy of transcatheter arterial embolization (TAE) in the treatment of refractory hematuria of prostatic origin (RHPO).

Methods

This retrospective study included 23 patients who underwent TAE for RHPO between May 2013 and August 2021. Technical and clinical success rates were calculated, and arteriogram findings and complications were detected.

Results

Embolization was performed 24 times in 23 patients. Technical success was achieved in 24/24 (100%) embolization procedures. Contrast agent extravasation was detected during 2 of the 24 angiographic procedures. Bilateral embolization was performed in 23 (95.8%) of the 24 procedures. The clinical success rate was 21/23 (91.3%), and hematuria stopped 1–4 days after TAE. No serious complications were observed.

Conclusion

TAE is a safe and effective minimally invasive technique for treating patients with RHPO.

Risk assessment of multi-factorial complications after transrectal ultrasound-guided prostate biopsy: a single institutional retrospective cohort study

BACKGROUND

Transrectal ultrasound-guided prostate biopsy (TRUSPB) is widely used to diagnose prostate cancer (PCa). The aim of this study was to evaluate the risk of multi-factorial complications (febrile genitourinary tract infection (GUTI), rectal bleeding, and urinary retention) after TRUSPB.

METHODS

N = 2053 patients were Japanese patients undergoing transrectal or transperineal TRUSPB for suspicious of PCa. To assess risk of febrile GUTI adequately, the patients were divided into four groups: low-risk patients before starting a rectal culture, low-risk patients after starting a rectal culture, high-risk patients, and patients undergoing transperineal TRUSPB. Furthermore, to identify risk of rectal bleeding and urinary retention, patients were divided into transrectal and transperineal group.

RESULTS

Febrile GUTI significantly decreased owing to risk classification. The frequency of rectal bleeding was 1.43% (transrectal: 25/1742), while it did not happen in transperineal group. The patients with rectal bleeding had a significantly lower body mass index (BMI) (P < 0.01). The frequency of urinary retention was 5.57% (transrectal: 97/1742), while it did not happen in transperineal group. The patients with urinary retention had a significantly higher prostate-specific antigen (PSA) (P = 0.01) in transrectal group.

CONCLUSIONS

Risk classification, rectal swab culture, and selected antimicrobial prophylaxis for transrectal TRUSPB were extremely effective to reduce the risk of febrile GUTI. Furthermore, lower BMI and higher PSA were novel clinical predictors for rectal bleeding and urinary retention, respectively. When urologists perform transrectal TRUSPB to their patients, they can correctly understand and explain each complication risk to their patients based on these novel risk factors.

Endoscopic Therapy in the Management of Patients With Severe Rectal Bleeding Following Transrectal Ultrasound-Guided Prostate Biopsy: A Case-Based Systematic Review

Rectal bleeding is a known complication of transrectal ultrasound-guided prostate biopsy. It is usually mild and resolves spontaneously. However, massive life-threatening hemorrhage can also rarely occur in this setting, potentially presenting a therapeutic conundrum. We hereby delineate the case of a patient who experienced severe intermittent lower gastrointestinal bleeding following a transrectal ultrasound-guided prostate biopsy. Traditional tamponade methods failed to control the hemorrhage. Subsequently, an urgent flexible sigmoidoscopy revealed an anterior rectal wall prominence with biopsy punctures as the possible source of bleeding. Endoclip was successfully applied at the bleeding site, achieving permanent hemostasis. The patient had an uneventful recovery and was discharged from the hospital. While the use of endoclipping has been widely reported in gastrointestinal endoscopy, its application remains exceedingly rare in this group of patients. To our knowledge, this case represents only the third report of endoclipping alone to treat massive rectal bleeding follwing a prostate biopsy procedure. In addition, we systematically review published medical literature to evaluate endoscopic techniques aimed at managing this important complication. This article illustrates that endoscopic therapy may present an efficient, noninvasive method to deal with severe post-biopsy rectal hemorrhage. Therefore, prompt consultation with the gastroenterology service should be advocated.

Hemostatic effect and psychological impact of an oxidized regenerated cellulose patch after transrectal ultrasound-guided prostate biopsy: A prospective and retrospective study

To investigate the usefulness of the oxidized regenerated cellulose patch (ORCP) for postbiopsy hemostasis, anxiety, and depression in patients undergoing transrectal ultrasound-guided prostate biopsy.This was a prospective-retrospective study of 300 patients who underwent systematic 12-core prostate biopsy from August 2016 through March 2018. The ORCP was inserted into the rectum immediately after prostate biopsy in the prospective group (n = 150), while the retrospective group (n = 150) underwent prostate biopsy alone. The frequency rate and duration of hematuria, rectal bleeding, and hematospermia were compared between the 2 groups. Anxiety and depression were assessed with the hospital anxiety and depression scale before and after prostate biopsy in the prospective group.The frequency rates of hematuria and hematospermia showed no significant differences between the prospective versus retrospective groups (64.7% vs 66.7%, P = .881; 18 vs 20%, P = .718; respectively). Frequency of rectal bleeding was significantly lower in the prospective group than in the retrospective group (26.7% vs 42.7%, P = .018). However, there were no significant differences in median duration of rectal bleeding, hematuria, or hematospermia between the 2 groups (2, 5, and 2 days vs 2, 7, and 1 day, P > .05, respectively, for the prospective vs retrospective group). Multivariate analysis found that ORCP insertion was a significant protective factor against postbiopsy rectal bleeding (P = .038, odds ratio 0.52). Only anxiety level in the prospective group before versus after prostate biopsy was significantly reduced (5 vs 4, P = .011).ORCP insertion after prostate biopsy is an effective and simple method for decreasing rectal bleeding. ORCP insertion may also alleviate anxiety in patients undergoing prostate biopsy.

Late-onset rectal bleeding with hemorrhagic shock after transrectal prostate needle biopsy

Late-onset rectal bleeding after transrectal prostate needle biopsy is potentially life-threatening. We report the case of a 75-year-old male who presented with severe rectal bleeding 3 days after transrectal prostate needle biopsy. Because the bleeding could not be arrested by conservative treatment, emergent colorectal endoscopic clipping (twice) and elective angiography were performed. Packed red blood cell transfusion (14 units in total) was required to treat the developed hemorrhagic shock. Colorectal endoscopy and arterial embolization are effective treatments for severe rectal bleeding after transrectal prostate needle biopsy and should be performed without hesitation.