Christopher L. Starks MD
Edmund S. Sabanegh Jr., MD
BASICS
DESCRIPTION
• The current standard for the diagnosis of prostate cancer is transrectal ultrasound (TRUS) guided biopsy of the prostate
• A 12-core biopsy scheme is optimal for 1st time prostate biopsy strategy using local anesthesia
• Active surveillance programs incorporate serial prostate biopsy and may result in a potential for increased risk for biopsy-related complications
• Bleeding is the most common complication observed after prostate biopsy. However, the use of aspirin or nonsteroidal anti-inflammatory drugs is not an absolute contraindication to prostate biopsy
EPIDEMIOLOGY
Incidence
• Prostate biopsy is integral to the workup of elevated prostate-specific antigen (PSA) as well as abnormal prostate exams
• An estimated 800,000–1 million prostate biopsies are performed each year in the United States
• In 1 recent series of repeat biopsies in men on active surveillance 3.5% experienced infectious complications with most requiring hospitalization (1)
• The Rotterdam center of the ERSPC trial noted (0.5%) men required hospitalization for signs of prostatitis or urosepsis (2)
Prevalence
Due to a variety of factors including an aging population widespread use of PSA testing, the number of TRUS and prostate biopsies has increased significantly over the last decade
RISK FACTORS
• For the diagnosis of prostate cancer:
– 1st-degree relatives with prostate cancer
– Older age
– African American race
– Family history of breast cancer
• For infectious complications the following have been suggested as risk factors:
– Number of previous prostate biopsies was significantly associated with an increased risk of infectious complications
– Long-term fluoroquinolone use (3)
– Healthcare workers
Genetics
• HPC-1 gene on chromosome 1 associated with familial CaP
• Many polymorphisms in genes, such as ELAC2 (locus HPC2), RNase L (locus hereditary prostate cancer 1 gene [HPC1]), and MSR1 may confer an increased risk of developing prostate cancer in many populations (4)
PATHOPHYSIOLOGY
• Normal adult prostate is approximately 20 g
• The majority of prostate cancer is adenocarcinoma and located in the peripheral zone of the prostate
• In the absence of antibiotic prophylaxis, bacteremia and bacteruria occur in 16% and 44% respectively of transrectal ultrasound-guided prostate biopsy
ASSOCIATED CONDITIONS
Benign prostate hypertrophy
GENERAL PREVENTION
• Consider urine culture before prostate biopsy if there is any concern over subclinical UTI
• Preprocedure enema does not appear to have any impact on complication rates
• Rectal swab with culture and sensitivity has been suggested as a method to identify potentially resistant pathogens and is not considered standard of care
• Transperineal biopsy may have a lower rate of infection than the transrectal approach
• Continuing or cessation of antiplatelet or anticoagulant medications prior to biopsy is based upon risk/benefit for each patient. Consider discussion with the patient’s cardiologist or primary care physician as needed
DIAGNOSIS
HISTORY
• Prostate cancer most commonly presents without any symptoms
• Family history of prostate cancer
• Specific review of any recent urinary tract infections, catheterization, or acute prostatitis
• Further review of the patient’s medication list, with special attention to anticoagulation or antiplatelet medication (ie, aspirin)
• Determine any symptoms of urinary tract infection
• History of anorectal surgery
PHYSICAL EXAM
• Digital rectal exam may reveal nodularity, induration, or an asymmetric gland
• Other anorectal pathology (anal stenosis, significant hemorrhoids) may be detected that might impact on the prostate biopsy procedure
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• PSA
• Screening UA with culture if indicated
Imaging
• TRUS provides images of the prostate
– Nodules may be hypoechoic on ultrasound
Diagnostic Procedures/Surgery
• A rectal probe should be gently placed with the patient in a lateral decubitus position (5)
• A periprostatic nerve block injecting approximately 5 cc of local anesthetic via a spinal needle can decrease discomfort and pain
• Full visualization of the prostate in transverse and sagittal views should be performed for an overview of the prostate and any abnormalities identified
• The prostate volume should be calculated
• Using a spring-loaded biopsy needle, a minimum of 12 cores, and additional biopsies as needed to obtain representative samples
• The peripheral zone in the posterolateral aspect of the prostate account for the majority of prostate cancers
• Additional biopsy of palpable nodule or hypoechoic areas may be performed at the discretion of provider
Pathologic Findings
• Prostate adenocarcinoma
• Prostatic intraepithelial neoplasia (PIN)
• Atypical small acinar proliferation (ASAP)
• Benign prostate tissue
DIFFERENTIAL DIAGNOSIS
• ASAP
• Benign prostatic hypertrophy
• No evidence of malignancy
• PIN
TREATMENT
GENERAL MEASURES
Although many clinicians have patients perform a self-administered enema, this is not needed. There is little evidence to support their use.
MEDICATION
First Line
• At our institution (Cleveland Clinic), patients receive an oral single dose of fluoroquinolone as well as a single dose of intramuscular aminoglycoside (80 mg gentamicin)
• AUA guidelines (see “Complications” below)
Second Line
N/A
SURGERY/OTHER PROCEDURES
• For patients with anorectal malformations or previous colorectal operations preventing TRUS, a transperineal biopsy can be performed.
• The increasing incidence of antimicrobial resistance with increasing concerns of the risk of sepsis is favoring renewed interest in transperineal biopsy as a relatively sterile alternative to standard TRUS-guided biopsy.
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• A retrospective analysis from Israel suggests that a single injection of 240 mg gentamicin along with a quinolone for 3 days significantly reduces infectious complications (6)
• Another case series demonstrated that 500 mg intravenous amikacin 30 min before the biopsy along with several days of ciprofloxacin reduced the incidence of urosepsis/septicemia following prostate biopsy (7)
Complementary & Alternative Therapies
Topical rectal cleansing with povidone-iodine resulted in a 42% reduction in infectious complications in 1 prospective clinical trial but was not statistically significant
ONGOING CARE
PROGNOSIS
Although prostate biopsy is usually generally safe and well tolerated, it is an invasive procedure that is not without risk and required a clear understanding through informed consent of the patient.
COMPLICATIONS
• Bleeding is the most common complication and includes hematuria, hematospermia, and rectal bleeding
– Bleeding is usually minor, self-limiting, and resolves with conservative measures. More significant bleeding has been reported and may require transfusion or colorectal intervention
• The 2nd most common complication is infection
– The incidence of infectious complications, including sepsis, is increasing
– Compared to controls, men undergoing biopsy have a significant risk for serious infection as requiring hospitalization (approximately 2.26 risk increase and 2.65 risk increase, respectively)
– Updated AUA Best Practice Policy Panel (8): Antibiotic prophylaxis should be given for all prostate biopsy procedures, duration of therapy is <24 hr. Recommended 1/1/2014 drug of choice regimens and are:
Fluoroquinolones or
1st/2nd/3rd-generation cephalosporin
Alternative regiments: Trimethoprim Sulfamethoxazole (TMP-SMX) or Aminoglycoside (Aztreonam can be substituted for aminoglycosides in patients with renal insufficiency)
Familiarity with local resistance patterns including fluoroquinolone-resistant bacteria is important
FOLLOW-UP
Patient Monitoring
• Prompt medical evaluation for patient with signs and symptoms of infection or significant bleeding
• Counseling regarding transient hematuria and the potential for hematospermia that may last for several weeks
• Follow-up of prostate biopsy results
Patient Resources
http://men.webmd.com/prostate-biopsy
REFERENCES
1. Ehdaie B, Vertosick E2, Spaliviero M3, et al. The impact of repeat biopsies on infectious complications in men with prostate cancer on active surveillance. J Urol. 2014;191(3):660–664.
2. Raaijmakers R, Kirkels WJ, Roobol MJ, et al. Complication rates and risk factors of 5802 transrectal ultrasound-guided sextant biopsies of the prostate within a population-based screening program. Urology. 2002;60:826–830.
3. Akduman B, Akduman D, Tokgöz H, et al. Long-term fluoroquinolone use before the prostate biopsy may increase the risk of sepsis caused by resistant microorganisms. Urology. 2011;78(2):250–255.
4. Alvarez-Cubero MJ, Saiz M, Martinez-Gonzalez LJ, et al. Genetic analysis of the principal genes related to prostate cancer: A review. Urol Oncol. 2013;31(8):1419–1429.
5. Patel AR, Jones JS. Optimal biopsy strategies for the diagnosis and staging of prostate cancer. Curr Opin Urol. 2009;19:232–237. (1)[B]
6. Lorber G, Benenson S, Rosenberg S, et al. A single dose of 240 mg gentamicin during transrectal prostate biopsy significantly reduces septic complications. Urology. 2013;82(5):998–1002.
7. Kehinde EO, Al-Maghrebi M, Sheikh M, et al. Combined ciprofloxacin and amikacin prophylaxis in the prevention of septicemia after transrectal ultrasound guided biopsy of the prostate. J Urol. 2013;189(3):911–915.
8. American Urological Association. Best practice policy statement on urologic surgery antimicrobial prophylaxis. 2008(updated January 1, 2014). [A]
ADDITIONAL READING
• Chang DT, Challacombe B, Lawrentschuk N, et al. Transperineal biopsy of the prostate-is this the future? Nat Rev Urol. 2013;10(12):690–702.
• Ismail MT, Gomella LG. Transrectal prostate biopsy. Urol Clin North Am. 2013;40(4):457–472.
• Loeb S. Antimicrobial prophylaxis for transrectal ultrasound biopsy. AUA Update Series. 2013;32, lesson 1. [A]
• Loeb S, Vellekoop A, Ahmed HU, et al. Systematic review of complications of prostate biopsy. Eur Urol. 2013;64(6):876–892.
• Raman JD. Infectious complications following prostate biopsy: A problem with need for solution. Can J Urol. 2013;20(3):6815.
• Satyanarayana R, Parekh D. Prevention and treatment of biopsy-related complications. Curr Urol Rep. 2014;15(2):381.
See Also (Topic, Algorithm, Media)
• Prostate Cancer, General
• PSA Elevation
• Urosepsis
CODES
ICD9
• 602.9 Unspecified disorder of prostate
• 998.59 Other postoperative infection
• 998.9 Unspecified complication of procedure, not elsewhere classified
ICD10
• N42.9 Disorder of prostate, unspecified
• T81.4XXA Infection following a procedure, initial encounter
• T81.9XXA Unspecified complication of procedure, initial encounter
CLINICAL/SURGICAL PEARLS
• A minimum of 12 cores is considered standard of care in the United States.
• Additional biopsy of nodules and hypoechoic areas may be needed.
• Be familiar with local resistance patterns when selecting antibiotic prophylaxis.
• In men with prostate cancer on active surveillance the number of previous prostate biopsies may be associated with a significant risk of infectious complications and every previous biopsy increases the risk of infectious complication.