Patients’ tolerance of transrectal ultrasound-guided prostatic biopsy: an audit of 104 cases

Authors


Mr Crundwell Department of Urology, City Hospital NHS Trust, Birmingham B18 7QH, UK.

Abstract

Objective

To determine the frequency and severity of complications following transrectal ultrasonography (TRUS) guided prostatic biopsy, and of pain during the procedure.

Patients and methods

The study included 129 men undergoing TRUS-guided prostatic biopsy who were asked to complete a questionnaire about pain and complications one week after biopsy.

Results

Of the 104 men who completed the questionnaire, 24% found the procedure moderately to extremely painful and 19% felt that they had had significant complications afterward, the commonest of these being painful or difficult voiding (13%) and haematuria (11%). Systemic symptoms of fever or ‘sweats’ occurred in 6%, with a diagnosis of septicaemia in three men, despite antibiotic prophylaxis. However, acute urinary retention occurred in only one man. Of all patients, 20% saw their general practitioner within a week, all of whom were prescribed antibiotics in addition to those given prophylactically in hospital.

Conclusion

TRUS-guided biopsy is often a painful experience for patients and is commonly associated with complications, particularly voiding difficulties. Of particular concern were the three patients with septicaemia, and that one in five men felt sufficiently unwell to visit their doctor within a week of the procedure.

Introduction

Prostatic biopsy, performed either transrectally or a transperineally, has an important role in the diagnosis of prostate cancer, particularly for early tumours which may be amenable to radical therapy. In this respect, it is likely to be performed more frequently in the future than currently. The transrectal approach is used most often, although infection, haematuria and pain are recognized complications [ 1, 2]. The introduction of TRUS as a biopsy guide has improved the accuracy of the procedure, but complications may still occur. Thus the aim of the present study was to determine, in our practice, the frequency and severity of complications after TRUS-guided prostatic biopsy, and of pain during the procedure.

Patients and methods

Between November 1995 and August 1996, 129 men underwent biopsy in a dedicated clinic. The indications for biopsy were a suspicious DRE or a raised PSA level relative to the age of the patient. The reasons for recommending biopsy and the possible complications were explained to the patients before the procedure. TRUS was performed using a 7 MHz Bruel and Kjaer mechanical probe (Bruel and Kjaer, Naerum, Denmark) and biopsies were taken using an 18 G Trucut needle (Bard Urological, UK). Between four and eight biopsies were taken depending on patient tolerance and the appearance of suspicious lesions. All biopsies were taken by a urologist, either personally by the consultant (D.M.A.W.) or by a registrar (M.C.C. or P.W.C.) under supervision. Standard antibiotic prophylaxis of intravenous gentamicin 120 mg and rectal metronidazole 1 g immediately before the procedure was given in 76 patients; seven men with known impaired renal function received only 80 mg of gentamicin, and four patients considered at high risk (e.g. with prosthetic heart valves) also received oral ciprofloxacin 250 mg twice daily for 48 h. The standard prophylaxis was initially determined in consultation with a microbiologist, based on the assumption that most of the patients would be elderly and likely to have impaired renal function. With time it became clear that this was not the case and towards the end of the study, the standard dose of gentamicin was increased to 160 mg and 16 patients received this. After biopsy the potential complications were again explained to the patient with the recommendation that they contact their GP for a prescription for further antibiotics should they develop any symptoms suspicious of UTI or septicaemia. This advice was repeated in an information sheet given to the patient. All patients were then invited to complete a questionnaire one week after biopsy, which could be returned in a prepaid envelope.

Results

In all, 104 (81%) questionnaires were returned. No patient died as a direct result of the procedure but 34% of those responding reported at least one problem (Fig. 1), giving a score of >5 on an analogue scale of 0–10; 24% reported moderate to severe pain during the procedure and 19% had problems during the week after biopsy. Symptoms suggestive of UTI (pain or difficulty on voiding) were the commonest complications, occurring in 13% of men, with 6% also having a fever or sweats. Three patients developed clinical septicaemia, although positive blood cultures were obtained in only one of them, from whom Escherichia coli sensitive to gentamicin were cultured. The second patient was managed at home by his GP, with no cultures taken, and the third, who was an inpatient at the time of biopsy, had recently completed a course of antibiotics for a Salmonella enteritis and had persistently negative cultures. Moderate to heavy haematuria was reported by 11% of men, but only one patient developed acute retention of urine, being re-admitted several hours after his biopsies. Of the 104 men, 20% saw a GP within a week of biopsy, a quarter of these as an emergency, and all of whom were prescribed antibiotics additional to those given prophylactically at the time of biopsy. There were too few patients receiving either 80 mg or 160 mg of gentamicin, or oral ciprofloxacin, to allow meaningful statistical comparison with the standard antibiotic regimen, although there appeared to be no difference in the frequency of complications between these different groups.

Figure 1.

The percentage of patients reporting complications during or after biopsy The proportion of patients reporting a symptom severity of <1 (dark green), 1–5 (light green), 5–9 (light red) or >9 (dark red) is shown for each category.

Discussion

This study examined prostatic biopsy from the patient’s perspective; there was a good response rate to the questionnaire and most of those responding (66%) reported no problems either during or after the procedure. However, a significant proportion experienced unpleasant and in some cases serious complications.

In our unit, TRUS-guided prostatic biopsies are performed with no analgesia or sedation, which is standard practice in most departments in Britain. However, moderate to severe pain during the procedure was reported by almost a quarter of the present men, a similar proportion to that reported in two previous studies [ 1, 2]. Also using a visual analogue scale in a series of 81 men, Irani et al. [ 1] reported 16% to have a score of >5 and that 19% would refuse to undergo further TRUS and biopsy with no analgesia. Similarly, Collins et al. [ 2], in a series of 89 men undergoing TRUS-guided prostatic biopsy with a minimum of six biopsies taken, reported that 22% had found the procedure painful. In contrast, Aus et al. [ 3] reported moderate to severe pain in only 7% of 343 patients undergoing biopsy, although the mean number of biopsies was only 2.6, which may account for the difference.

It is our experience that anxiety is common in men attending for this procedure and that those men who are most anxious are most likely to experience pain. In several patients we have been unable to take as many biopsies as necessary, being asked to stop by the patient because it was too painful. Problems have also arisen in men requiring a second TRUS and biopsy at a later date, as they are often reluctant to attend because they have unpleasant memories from the first procedure. Perhaps some men should be offered oral analgesia before the procedure, perhaps combined with the antibiotic prophylaxis.

The problem of infection after transrectal biopsy has long been recognized, with bacteraemia occurring in almost all and bacteriuria in 13–36% of men when no antibiotic prophylaxis or placebo is used [ 4[5][6]–7]. Symptoms suggestive of lower UTI, reported by 13% of men, were the most common complication in the present series. Furthermore, a fifth of men were prescribed antibiotics by their GP for a suspected UTI, although it is likely that the actual rate of UTI was much lower than this. In view of the risk of septicaemia and that all patients were given an information sheet asking them to contact their GP in case of suspected UTI, it is perhaps not surprising that all the men who saw a GP were prescribed antibiotics. Certainly, systemic symptoms of infection occurred in at least 6% and three men were considered to have septicaemia, suggesting that the antibiotic prophylaxis was insufficient to prevent infection in 6–20% of men. This is unsatisfactory, both microbiologically and in view of the increased workload imposed on local GPs, who may then feel less inclined to refer men for biopsy who might otherwise benefit from an early diagnosis and treatment.

Several different antibiotic regimens have been used to reduce the incidence of infection after transrectal biopsy ( Table 1); none have been entirely satisfactory, because of the large variety of organisms shown to be responsible [ 6]. These organisms are principally commensals of the lower bowel and include E. coli, Lactobacilli, Enterococci, Klebsiella, Staphylococci and various anaerobic species. The present choice of antibiotics was based on the known effects of gentamicin and metronidazole on these organisms, the ease of administration and the cost. However, a subsequent literature review showed that the lowest infection rates were achieved using the quinolone antibiotic, norfloxacin, taken orally, starting at least an hour before biopsy and continuing for 3–7 days [ 3, 8]. Norberg [ 8] reported fever in only two of 148 patients (1.4%) undergoing a mean of 9.7 biopsies, using 400 mg norfloxacin twice daily for six doses, starting an hour before biopsy. This compares favourably with the regimen used in the present study, in which 6% of men reported fever.

Table 1.  Previous studies of antibiotic prophylaxis for transrectal biopsy Thumbnail image of

An alternative strategy to reduce the rate of infective complications is to use the transperineal approach, which has been advocated as an alternative to transrectal biopsy, particularly in susceptible patients [ 7, 9]. Thompson et al. [ 7] found that all 30 patients undergoing transrectal biopsy with no prophylaxis had bacteraemia afterward, compared with only six of 15 men undergoing transperineal biopsy. The rates of UTI were 87% and four of 15, respectively. In a separate study, Webb et al. [ 9], using a questionnaire as in the present study, reported septicaemia in only one of 150 patients undergoing transperineal biopsy, despite using no antibiotic prophylaxis. For infection, the transperineal approach with no antibiotic prophylaxis appears roughly equivalent to the transrectal approach using an appropriate regimen.

In summary, these results show that TRUS-guided biopsy is often a painful experience, an aspect which we feel has been largely unrecognized or overlooked. In view of the poor performance of gentamicin 120 mg and metronidazole 1 g in preventing infective complications in the present series, relative to others [ 3, 8], we have modified our antibiotic protocols in men undergoing TRUS and prostatic biopsy. The current policy is to use gentamicin 160 mg and metronidazole 1 g in all patients, with the addition of ciprofloxacin 500 mg twice daily for 5 days in patients considered to be at high risk of infective complications.

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