TRUS GUIDED BIOPSY

TRUS And TRUS GUIDED PROSTATE BIOPSY

INDICATIONSPATIENT PREPARATIONTECHNIQUECOMPLICATIONSPOST TRUS PROSTATITIS AND PROSTATIC

ABSCESS

INDICATIONS1. Diagnostic indications include the following:

Early diagnosis of carcinoma of the prostate (CAP) when abnormal

DRE, an elevated PSA (>4.0 ng/ml) or PSA velocity (rate of PSA change) >0.4 to 0.75ng/ml/yr..

Evaluation of men with azoospermia to rule out ejaculatory-duct cysts, seminal vesicular cysts, müllerian cysts, or utricular cysts

Prostate Volume determination to plan treatment with brachytherapy, cryotherapy, or minimally invasive BPH therapy (eg, radiofrequency, microwave) and evaluation during hormonal downsizing for brachytherapy,

previously treated with curative intent for prostate cancer (i.e. radical prostatectomy, radiation therapy,

and cryotherapy) . (follow up )

neoplasia (PIN) or atypia on a previous prostate needle biopsy.

2. Therapeutic indications the following:include Brachytherapy for CAP

Cryotherapy for CAP

aspiration of ejaculatory ducts, prostatic cysts, or prostatic abscesses

Patient preparation:

fluoroquinolone antibiotic prior to the procedure and a second dose 12 hours later is the protocol most commonly recommended for antibiotic coverage

cleansing enema (sodium phosphate and dibasic sodium phosphate).

aspirin and NSAIDS must be discontinued for seven and three days respectively .

Patients on anticoagulation therapy are not biopsied until the anticoagulant dosage is adjusted or held .

Techniques :Positioning should be left lateral, lithotomy, or

knee-elbow.

Local anesthesia : Although the procedure was performed without any infiltrative anesthesia in the past it is a common practice to use lidocaine infiltration in the periprostatic area.

. A topical anesthetic ointment is applied to the index finger prior to performing the DRE.

A 5.0 to 7.5mHz transducer is used for transrectal imaging of the prostate.

The probe is gently advanced into the rectum, to the base of the bladder until the seminal vesicles are visualized.

Volume = height X width X length X 0.52

Biopsy :

Biopsies are best performed with a spring-driven needle core biopsy device (or biopsy gun), which can be passed through the needle guide attached to the ultrasound probe.

biopsies are obtained from any area deemed as suggestive (ie, hyperechoic) based on ultrasonographic findings or based on palpable abnormalities after digital rectal examination.

Obtain separate biopsy samples from each sextant of the prostate.

. Originally, these biopsy sites included : midlobe parasagittal plane at the apex, the mid gland, and the base, bilaterally. Many authors subsequently recommended that these 6

biopsy samples be obtained from the lateral third of each lobe 2 lateral biopsy samples be obtained from each lobe the original sextant samples (termed the 10-biopsy scheme).

BIOPSY COMPLICATIONS PROSTATITIS AND PROSTATIC ABCSESS .　 Septicemia Infections Hemorrhages Arteriovenous Fistula Tumor dissemination Bladder perforation Urinary obstruction Severe pain

PROSTATITIS AND ABCSESS Infection of the prostate gland, or prostatitis, is a risk of prostate

biopsy. The rectum normally stores bacteria-laden fecal material until it's passed during a bowel movement.

Despite the use of cleansing enema before the procedure, residual fecal bacteria remain in the rectum.

In an effort to prevent infection, antibiotics are typically administered shortly before a prostate biopsy and are continued for a few days after the procedure.

Despite precautionary efforts, bacteria may be introduced into the prostate during the biopsy procedure, causing acute prostatitis

Incidence of Acute Prostatitis Caused by Extended-spectrum β-Lactamase-producing Escherichia coli After Transrectal Prostate BiopsyUrology, Volume 74, Issue 1, Pages 119-123E. Özden, Y. Bostanci, K. Yakupoglu, E. Akdeniz, A. Yılmaz, N. Tulek, S. Sarıkaya.

Abstract

Objectives To study the clinical and bacteriologic picture of acute prostatitis caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli after transrectal ultrasound-guided prostate biopsy.

Methods The retrospective data from 1339 patients who had undergone transrectal ultrasound-guided biopsy from November 2003 to June 2008 were reviewed. An automatic biopsy gun with an 18-gauge needle was used to obtain 10-core biopsies for first biopsies and ≥12-core for repeat biopsies. These patients had received 500 mg ciprofloxacin orally twice daily for 5 days, beginning 24 hours before biopsy. All biopsies were performed as outpatient procedures.

Results Of the 1339 patients, 28 (2.1%) had acute bacterial prostatitis detected after transrectal ultrasound-guided prostate biopsy. Acute prostatitis occurred after the first biopsy in 15 patients (1.3%) and after repeat biopsy in 13 (6.8%).

The patients had developed infective symptoms a mean of 3 days after transrectal ultrasound-guided prostate biopsy. Of the 28 patients, 17 (61%) had positive urine and/or blood cultures, including E. coli in 14. Of the 14 patients, 6 had acute prostatitis caused by ESBL-producing E. coli. All patients with ESBL-producing E. coli were treated with imipenem. The bacteria detected in these urine cultures were resistant to ciprofloxacin, ceftriaxone, sulbactam/ampicillin, and cefazolin. Imipenem and piperacillin-tazobactam were the most active agents against ESBL-producing E. coli. ESBL-producing isolates had a significant reduction in activity for most antimicrobial agents, including fluoroquinolones and amikacin.

Conclusions : prostatitis is a complication of TRUS biopsy and different organism can cause it including ESBL . The prompt initiation of effective antimicrobial treatment is essential in patients with ESBL-producing E. coli, and empirical decisions must be determined by knowledge of the local distribution of pathogens and their susceptibility.

PROSTATITIS AND ABCSESSEpidemiology and treatment of acute prostatitis after prostatic biopsy Stoica G, Cariou G, Colau A ortesse A Hoffmann P Schaetz A,Sellam R Service d'urologie, Groupe Hospitalier Diaconesses Croix Saint-Simon, Hôpital des Diaconesses, Paris.

AbstractOBJECTIVE: Acute prostatitis is the main complication of prostatic

biopsies (PB) and sometimes requires hospitalisation and appropriate antibiotic therapy. This study evaluated the pathogens responsible and proposes a statistically adapted empirical antibiotic therapy.

PATIENTS AND METHODS: This retrospective (from 2000 to 2006) two-centre study included 17 patients hospitalised for acute prostatitis after PB in a series of 1,216 biopsies. Bacteriological documentation was based on urine cultures, blood cultures, identification of bacteria and antibiotic susceptibility testing.

RESULTS: All patients received prophylactic antibiotics with a single dose of systemic fluoroquinolone at least 1 h before PB. Bacterial identification was possible in fourteen cases

Only urine culture was positive in 6 cases (35%), only blood culture was positive in 3 cases (17%), and urine cultures and blood cultures were positive and concordant in 5 cases (29%). A high rate of resistance of E. coli to fluoroquinolones was observed in 88% of cases and to cotrimoxazole in 77% of cases. However, the strain was susceptible to second and third generation cephalosporins (2GC and 3GC) and amikacin in 100% of cases. Prostatitis was associated with epididymo-orchitis (3 cases), acute urinary retention (4 cases) and infective endocarditis (1 case).

CONCLUSIONS: Identification of the micro-organism responsible for acute prostatitis after biopsy requires a combination of blood cultures and urine cultures. Empirical antibiotic therapy is based on the use of 2GC or 3GC, alone or in combination with amikacin depending on the severity of the clinical features.

PROSTATITIS AND ABCSESS incidence and characteristics of acute bacterial prostatitis after transrectal

prostate biopsy

Journal of Infection and Chemotherapy Volume 14, Number 1 Kazuyoshi Shigehara, Tohru Miyai, Takao Nakashima and Masayoshi Shimamura

Department of Urology, Ishikawa Prefectural Central Hospital, 2-1 Kuratsukihigashi, Kanazawa, Ishikawa, Japan

Abstract based on urine and blood cultures, treatment method, and outcome. Four

hundred and fifty-seven patients who underwent transrectal prostate biopsy in our hospital between November 2003 and October 2006 were reviewed.

These patients were treated with 200 mg levofloxacin orally twice daily for 4 days, beginning 12 h before biopsy, and with 200 mg isepamicin sulfate given intravenously just before the biopsy. In patients who developed acute prostatitis urine and blood cultures were checked. All organisms isolated in urine or blood cultures were tested for antibiotic susceptibility of the 457 patients, first-biopsy was performed in 371 and re-biopsy was done in 86. Acute bacterial prostatitis developed in 6 patients (1.3%). Acute prostatitis developed after a first-biopsy in 2 patients (0.5%) and after re-biopsy in 4 patients (4.7%), showing a significant

difference. All of the urine and blood cultures yielded levofloxacin-resistant Escherichia coli. Immediate intravenous cephalosporin or carbapenem was effective for all of these patients.

Conclusion: that the use of levofloxacin could be a risk factor for acute

bacterial prostatitis after transrectal prostate biopsy, due to an increase in fluoroquinolone-resistant E. coli in the rectum. The incidence of prostatitis was higher in re-biopsy patients. We consider that patients should receive levofloxacin for a shorter period before biopsy to avoid generating fluoroquinolone-resistant strains. Treatment with cephalosporin or carbapenem is recommended for patients with acute prostatitis after prostate biopsy.

Prostatic abscess after transrectal ultrasound guided biopsy.

Sohlberg OE, Chetner M, Ploch N, Brawer MK. Department of Urology, University of Washington, Seattle.

AbstractWe report a case of a diabetic man who had bilateral prostatic

abscesses after ultrasound guided biopsy of the prostate. As is typical of prostatic abscesses, the diagnosis was not evident at presentation. We discuss the morbidity of transrectal biopsy and recommend consistent antimicrobial prophylaxis. We also recommend transrectal ultrasound in the diagnosis of such abscesses, and support the standard treatment of drainage and parenteral antimicrobial therapy. We anticipate that the incidence of prostatic abscess will increase due to the increasing number of men undergoing transrectal biopsy in the current age of transrectal ultrasound guided biopsy.

PROSTATITIS AND ABCSESSLab Studies: Prostatic secretions Urinalysis, blood culture Increased serum prostate-specific antigen (PSA)

Imaging studies, including a CT scan of the pelvis prostate ultrasonography, should be reserved for those cases where laboratory analysis is equivocal or when

no improvement is observed following medical therapy. Ruling out complications of prostatitis (eg, prostatic abscess) is a strong indication to proceed to imaging studies.

Diagnostic Procedures: Performing a prostate biopsy is contraindicated in suspected ABP because of the

potential complication of seeding the bacterial infection in adjacent organs. Furthermore, prostate biopsy is extremely painful and may cause or larger areas of the prostate become necrotic.

TREATMENT  Medical therapy: Hospitalization is required for patients in whom acute urinary

retention develops and in those who require intravenous antimicrobial therapy.

The choice of antibiotic is based on results of the initial culture and sensitivity.

initial therapy should be directed at gram-negative enteric bacteria. Useful agents include fluoroquinolones, trimethoprim-sulfamethoxazole, and ampicillin with gentamicin.

Antipyretics, analgesics, stool softeners, bed rest, and increased fluid intake provide supportive therapy.

For IV therapy, use trimethoprim-sulfamethoxazole ,an appropriate oral agent can be substituted for an additional 30

days. For oral therapy, use trimethoprim-sulfamethoxazole (Bactrim),

ciprofloxacin; norfloxacin, ofloxacin, or enoxacin, for 30 days when clinical response is favorable.

Surgical therapy:

Surgical drainage of a prostatic abscess can be accomplished by either transrectal or perineal aspiration or transurethral resection. Because of the potential for systemic infection and bacteremia, urethral instrumentation should be avoided in ABP, especially if the patient is unstable or already showing signs of sepsis.

DONE BY : TURKI ALTAYLOUNISUPERVISED BY : DR.WISSAM

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