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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 50  |  Issue : 3  |  Page : 85-88

Complications after transrectal ultrasound-guided prostate biopsy: A 10-year experience in a single institution


1 Division of Urology, Department of Surgery, Shin Kong WHS Memorial Hospital, Taipei; Department of Urology, China Medical University Beigang Hospital, Yunlin County, Taiwan
2 Division of Urology, Department of Surgery, Shin Kong WHS Memorial Hospital; Department of Surgery, School of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
3 Division of Urology, Department of Surgery, Shin Kong WHS Memorial Hospital, Taipei, Taiwan

Date of Submission03-May-2016
Date of Decision10-Aug-2016
Date of Acceptance08-Sep-2016
Date of Web Publication29-May-2017

Correspondence Address:
Thomas I-Sheng Hwang
Department of Surgery, Shin Kong WHS Memorial Hospital, Shih Lin District, Taipei City
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_32_17

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  Abstract 

Background: Transrectal ultrasound-guided prostate (TRUS-P) biopsy is the standard diagnostic procedure for patients with suspected prostate cancer. However, infectious complications can occur.
Purpose: To analyze the patients from a single institution who were hospitalized for infectious complications after TRUS-P biopsy.
Materials and Methods: From 2003 to 2012, 985 TRUS-P biopsy procedures were performed in a medical center in Northern Taiwan; among these, 28 patients were admitted for infectious complications following the procedure. A retrospective review of the medical records was performed, and data regarding the demographics, details of infectious complications, and hospital course of these patients were collected.
Results: The median age of the patients was 62 (27–82) years; the comorbidity rate was 57.1% (16/28); the admission rate was 2.8% (28/985). The most common causative pathogen was Escherichia coli. More than half of the cultured E. coli were not resistant to fluoroquinolones. The median hospital stay was 6 (3–16) days, and one patient was admitted to the intensive care unit. No mortality was observed in this study. Although the number of biopsies increased, no obvious increasing trend in the number of hospitalizations was noted in recent years.
Conclusion: TRUS-P biopsy can be safely performed, and no obvious increasing trend in infectious complications and resistant strains has been observed in recent years.

Keywords: Biopsy, prostate, transrectal ultrasound


How to cite this article:
Chiu YP, Lin YC, Juang GD, Tsai TF, Cheng YH, Chou KY, Chen HE, Hwang TI. Complications after transrectal ultrasound-guided prostate biopsy: A 10-year experience in a single institution. Formos J Surg 2017;50:85-8

How to cite this URL:
Chiu YP, Lin YC, Juang GD, Tsai TF, Cheng YH, Chou KY, Chen HE, Hwang TI. Complications after transrectal ultrasound-guided prostate biopsy: A 10-year experience in a single institution. Formos J Surg [serial online] 2017 [cited 2017 Aug 20];50:85-8. Available from: http://www.e-fjs.org/text.asp?2017/50/3/85/207178


  Introduction Top


Prostate cancer is the most commonly diagnosed cancer and the second most common cause of cancer-related death in men from the western world.[1] The incidence of prostate cancer is increasing not only in Taiwan but also in all of Asia.[2] The impact of prostate cancer is increasing both medically and socioeconomically. With the advancement of diagnostic tool and treatment options, the mortality rate of prostate cancer has steadily decreased in the past two decades.[3]

Transrectal ultrasound-guided prostate (TRUS-P) biopsy is the standard diagnostic procedure for patients suspected to have prostate cancer. Various complications, such as hemospermia, urinary retention, and infection, can occur in patients who have undergone TRUS-P biopsy.[4] The infectious complication rate was reportedly 2%–6%, but nearly 30% of patients were noted to have bacteremia. Interestingly, disease progression to sepsis was observed in only 0.1%–2.2% of these patients.[5]

Recently, infectious complications after TRUS-P biopsy have increased in North America and Europe.[6],[7] With the increased utilization of prostatic specific antigen (PSA), TRUS-P biopsies are being increasingly performed. The patient economic burden may increase with the increase in infectious complications. An understanding of the current status of post-TRUS-P biopsy complications is crucial for future adjustments in preventive measures. Therefore, we report our 10-year experience of performing TRUS-P biopsy.


  Materials and Methods Top


A retrospective review of the medical records of patients who underwent TRUS-P biopsy between 2003 and 2012 was performed. In our institution, the standard of care for TRUS-P biopsy is that provided for a clinic-based procedure. Preprocedural daily oral levofloxacin (500 mg) was prescribed for 2 days. The same dose of levofloxacin was for another 3 days after the procedure. Postbiopsy-related admission was defined as admission within 14 days of the procedure for complications directly or indirectly related to TRUS-P biopsy.

A total of 985 procedures were performed during the study period. Among these, 28 patients were hospitalized within 2 weeks of the procedure for infectious complications. Data regarding the demographics, PSA level, clinical diagnosis, and pathological diagnosis of these patients were collected. Details of the complications, including the symptoms and presentation, were identified and collected. Infection-related symptoms, as well as the types of infection, development of sepsis, bacterial culture results, sensitivity to antibiotics, and duration of hospital stay, were particularly examined.


  Results Top


The median age of the 28 hospitalized patients was 62 (37–82) years. Among them, 16 (57.1%) had comorbidities, namely, hypertension (n = 12), diabetes mellitus (n = 7), and cardiovascular conditions (n = 3); one patient had all three comorbidities and five had two comorbidities. Bowel preparation for TRUS-P biopsy involved oral bisacodyl consumption on the night before the procedure in 26 patients, and two patients underwent a fleet enema before the procedure. The median total prostate size measured through TRUS-P was 36.2 (18.7–69.4). The median PSA level was 8.4 (3.8–40.9) ng/dL. One patient underwent a sextant biopsy, where 23 and 4 patients underwent 10-core and 12-core biopsies, respectively [Table 1].
Table 1: Demographics and ultrasound parameters

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The median number of days to admission after TRUS-P biopsy was 2 (0–11) days. All patients presented with fever, followed by chills (n = 9), dysuria (n = 3), hematuria (n = 3), and acute urinary retention (n = 1). Nineteen patients (67.9%) had a white cell count <4000/mm 3 or higher than 12,000/mm 3 on admission. Urine culture on admission revealed Escherichia coli resistant to levofloxacin in 14 patients, no growth of bacteria in 11 patients, and E. coli sensitive to levofloxacin in 2 patients. The urine culture of one patient showed Ralstonia pickettii, which was sensitive to levofloxacin. With regard to blood cultures, 15 patients did not show bacterial growth, 10 showed E. coli resistant to levofloxacin, and 2 showed E. coli sensitive to levofloxacin. Pseudomonas aeruginosa was observed in the blood culture of one patient [Table 2]. A total of 13 patients had the same blood and urine culture results, whereas 5 patients showed the absence of bacterial growth in both cultures.
Table 2: Culture results

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The median duration of hospitalization was 6 (3–16) days. One patient was transferred to the intensive care unit for 4 days because of septic shock. Twenty-six patients were discharged from the hospital within 10 days of admission. Among these patients, six were diagnosed with sepsis and the others with febrile infection. No mortality was noted, and no long-term disability could be traced. Three patients were pathologically diagnosed with adenocarcinoma. The remaining 25 patients were pathologically diagnosed with benign entities, including benign prostatic hyperplasia and prostatic chronic inflammation.

The overall admission rate after TRUS-P biopsy was 2.8%. An increasing trend was in the number of biopsies performed. Although the admission rate was not associated with the number of biopsies, the admission rate increased in 2006 and 2007. However, no obvious increase in the admission rates has been noted in the previous 2 years [Figure 1].
Figure 1: Annual trend in the number of biopsies and the admission rate. Although the number of biopsies performed increased during the previous 9 years, the admission rate did not show a corresponding increase

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  Discussion Top


Transrectal ultrasound prostate biopsy is the standard diagnostic procedure for prostate cancer, but infectious complications can occur after the procedure. The primary mechanism for postbiopsy infection is most likely the inoculation of bacteria from the rectal mucosa along the biopsy needle to the prostate and blood stream.[4] However, a preexisting prostate infection may also cause postprocedural infection. Moreover, the infection rate may be related to the number of biopsy cores.[8] In this study, a weak correlation (sextant: one case; 10 cores: 23 cases; and 12 cores: 4 cases) was observed. A negative preprocedural culture is often noted in this situation.[8] Without prophylactic antibiotics, the bacteriuria rate was reportedly up to 53%, and the bacteremia rate was up to 75% after TRUS-P biopsy.[9]

E. coli is the major causative pathogen for infections worldwide. The etiology of more than 80% culture-positive infections that occurred after TRUS-P biopsy has been related to E. coli.[10],[11],[12] In recent years, resistant strains to fluoroquinolones have been increasing.[5] The resistant strain of E. coli can also carry extended spectrum β-lactamase and may cause more challenging infectious complications. In these settings, empiric antibiotics may fail, and the complication rate has been increasing in recent years.[7],[13] Our results showed that E. coli was a major of infectious pathogen after TRUS-P biopsy. However, few cases of infection with the resistant strains have been reported. Moreover, the increased admission rate in 2006 and 2007 declined after strict personal training and patients' compliance with prebiopsy bisacodyl and levofloxacin consumption.

The application of a prebiopsy rectal swab has recently been emphasized to identify potential causative pathogens ahead of the biopsy and to decrease the infectious complication rates.[14],[15] The concept of targeted prophylactic antimicrobial therapy before TRUS-P biopsy has gained popularity. A meta-analysis showed that targeted prophylactic microbial therapy decreases the likelihood of postprocedural sepsis.[4] In this series, the prebiopsy rectal swab was not routinely performed. However, the rate for resistant strain was not high, and the necessity of the rectal swab needs to be verified in additional studies. Two years ago, a beta-iodine transrectal swab disinfection procedure became standard before TRUS-P biopsy. Consequently, we observed a further decrease in the infectious complication rate (data to be prepared)

Sepsis is a serious complication after TRUS-P biopsy. Simsir et al. reported a 3% sepsis rate after TURS-P biopsy.[16] The admission rate after TRUS-P biopsy was 0.5%–3.6%.[17] A recent increasing trend postprocedural infectious complications has been reported. In addition, the resistant strain was more common in several reports.[10],[18] The sepsis rate in our series was 0.7% and the admission rate was 2.8%. In the past 10 years, prophylactic antibiotics use has not changed in our institution. With regard to the annual admission rate, no obvious increase has been noted in recent years despite the increase in the total number of biopsies performed in the past few years. The resistant strains were possibly not prevalent in the postbiopsy setting. However, further investigation and monitoring is essential to avoid severe complications.

In Taiwan, the cancer detection rate after TRUS-P biopsy was 36%, and the detection rate increased with the PSA level.[19] In our series, the cancer detection rate (10.7%) in patients with complication was relatively low. Other risk factors associated with postbiopsy infection included comorbidities, benign prostatic hyperplasia, the presence of a catheter, preexisting urinary tract infection, and a greater number of biopsy cores.[17] In this series, a large number of comorbidities were observed in patients with complications, but an association with the other potential risk factors could not be determined.

This study has several limitations. The data were retrospectively reviewed using medical records, which may have contained some errors. The culture time was not standardized, and the no growth rate was relatively high. However, our findings are still of value because we examined data obtained across a 10-year period, which will help us to improve the management of infectious complications.


  Conclusion Top


Approximately 3% of patients who received a TRUS-P biopsy may be admitted for infectious complications within 14 days of the procedure. Fever is the most common reported symptom, and E. coli is the most commonly observed pathogen in such cases. Approximately 90% of postbiopsy admissions for infectious complications were proven to not be cancer. The admission rate has not increased in recent years.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin 2014;64:9-29.  Back to cited text no. 1
    
2.
Pu YS, Chiang HS, Lin CC, Huang CY, Huang KH, Chen J. Changing trends of prostate cancer in Asia. Aging Male 2004;7:120-32.  Back to cited text no. 2
    
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National Cancer Institute. Surveillance, Epidemiology, and End Results Program. National Cancer Institute; 2015.  Back to cited text no. 3
    
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Cussans A, Somani BK, Basarab A, Dudderidge TJ. The role of targeted prophylactic antimicrobial therapy before transrectal ultrasonography-guided prostate biopsy in reducing infection rates: A systematic review. BJU Int 2016;117:725-31.  Back to cited text no. 4
    
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Williamson DA, Barrett LK, Rogers BA, Freeman JT, Hadway P, Paterson DL. Infectious complications following transrectal ultrasound-guided prostate biopsy: New challenges in the era of multidrug-resistant Escherichia coli. Clin Infect Dis 2013;57:267-74.  Back to cited text no. 5
    
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Aly M, Dyrdak R, Nordström T, Jalal S, Weibull CE, Giske CG, et al. Rapid increase in multidrug-resistant enteric bacilli blood stream infection after prostate biopsy - A 10-year population-based cohort study. Prostate 2015;75:947-56.  Back to cited text no. 6
    
7.
Nam RK, Saskin R, Lee Y, Liu Y, Law C, Klotz LH, et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol 2013;189 1 Suppl: S12-7.  Back to cited text no. 7
    
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Lindstedt S, Lindström U, Ljunggren E, Wullt B, Grabe M. Single-dose antibiotic prophylaxis in core prostate biopsy: Impact of timing and identification of risk factors. Eur Urol 2006;50:832-7.  Back to cited text no. 8
    
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Duplessis CA, Bavaro M, Simons MP, Marguet C, Santomauro M, Auge B, et al. Rectal cultures before transrectal ultrasound-guided prostate biopsy reduce post-prostatic biopsy infection rates. Urology 2012;79:556-61.  Back to cited text no. 9
    
10.
Loeb S, van den Heuvel S, Zhu X, Bangma CH, Schröder FH, Roobol MJ. Infectious complications and hospital admissions after prostate biopsy in a European randomized trial. Eur Urol 2012;61:1110-4.  Back to cited text no. 10
    
11.
Patel U, Dasgupta P, Amoroso P, Challacombe B, Pilcher J, Kirby R. Infection after transrectal ultrasonography-guided prostate biopsy: Increased relative risks after recent international travel or antibiotic use. BJU Int 2012;109:1781-5.  Back to cited text no. 11
    
12.
Zaytoun OM, Vargo EH, Rajan R, Berglund R, Gordon S, Jones JS. Emergence of fluoroquinolone-resistant Escherichia coli as cause of postprostate biopsy infection: Implications for prophylaxis and treatment. Urology 2011;77:1035-41.  Back to cited text no. 12
    
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Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM. Complications after prostate biopsy: Data from SEER-Medicare. J Urol 2011;186:1830-4.  Back to cited text no. 13
    
14.
Dai J, Leone A, Mermel L, Hwang K, Pareek G, Schiff S, et al. Rectal swab culture-directed antimicrobial prophylaxis for prostate biopsy and risk of postprocedure infection: A cohort study. Urology 2015;85:8-14.  Back to cited text no. 14
    
15.
Suwantarat N, Dumford DM rd, Ponce-Terashima R, Kundrapu S, Zabarsky TF, Zhu H, et al. Modification of antimicrobial prophylaxis based on rectal culture results to prevent fluoroquinolone-resistant Escherichia coli infections after prostate biopsy. Infect Control Hosp Epidemiol 2013;34:973-6.  Back to cited text no. 15
    
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Simsir A, Kismali E, Mammadov R, Gunaydin G, Cal C. Is it possible to predict sepsis, the most serious complication in prostate biopsy? Urol Int 2010;84:395-9.  Back to cited text no. 16
    
17.
Loeb S, Vellekoop A, Ahmed HU, Catto J, Emberton M, Nam R, et al. Systematic review of complications of prostate biopsy. Eur Urol 2013;64:876-92.  Back to cited text no. 17
    
18.
Mosharafa AA, Torky MH, El Said WM, Meshref A. Rising incidence of acute prostatitis following prostate biopsy: Fluoroquinolone resistance and exposure is a significant risk factor. Urology 2011;78:511-4.  Back to cited text no. 18
    
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Huang IS, Lin ATL, Wu HHH, Chung HJ, Kuo JY, Lin TP, et al. Prostate cancer detection and complication rates with transrectal ultrasound-guided prostate biopsies among different operators. Urol Sci 2012;23:78-81.  Back to cited text no. 19
    


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