Transrectal needle biopsy of prostate

Transrectal needle biopsy of prostate

T R A N S R E C T A L N E E D L E BIOPSY OF PROSTATE Complications S. A. STUPPLER, M..D. S. J. KANDZARI, M.D.. D. F. MILAM, M.D. From the DepartmerLt...

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T R A N S R E C T A L N E E D L E BIOPSY OF PROSTATE

Complications S. A. STUPPLER, M..D. S. J. KANDZARI, M.D.. D. F. MILAM, M.D. From the DepartmerLt of Surgery, Division of Urology, West Virginia Unive:,:':!i:iisLyMedical Center, Morgantowu, West V ilt:'ffin:ia

A B S T R A C T - A n unusual complica,'d, on o f transrectal needle biopsy of the prostate, a disk-space infection requiring drainage by lami:n#c~omy, is presented.

In 1937 Astraldi ~ first introduce,] l:lansreetal needle biopsy of the prostate and r,::?ported 100 eases. The technique did not ehalle ~ _;;ethe perineal approach reported in the Engl i:~;h literature until 1954. In 1953, Grabstald a~:>l Elliott 2 reaffirmed Astraldi's impression as to I:il, !, directness and efficacy of the transreetal roub~ Thereafter, numerous reports were published : lille literature indicating inereasing poptr! ~:ity of this biopsy route, a-s We present a ease of an u n u s u a x~rnplieation following transreetal n e e d l e 1~: I;".Y of the prostate, and review the eomplie;l :,us seen by others. Case Report This patient, a sixty-year-old v u n d e r w e n t transurethral prostate: Surgical specimen revealed pro,;: Stage A. Several months later, t:, radical retropubie prostatosemi tomy. Pathologic findings reveal: was confined to the prostate g]a~ did well and only required ~.. dilatations at a later date. In June, 1973, a suspicious re: the old prostatic fossa. The pati~ to the hospital and u n d e r w e n t {:' biopsy of the nodule. The bii: negative for malignant disease.

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rte raan, first ,my in 1969. ic carcinoma tlld,erwent a vesieulee:hv disease The patient ic urethral :,: ~,as felt in <~.s admitted !.,::1:il n e e d l e :~'~port was

Approximately twenty-four hours postbiopsyi the patient spiked a temperature of 40°C. Blood~ cultures grew out greater than 100,000 colonies per cubic centimeter of Proteus mirabilis. The: patient was treated with kanamyein sulphate 500 mg. intramuscularly every twelve hours for one week. The infection responded, and the patien! was discharged and given cephalexin mono4 hydrate therapy. In July, 1973, he was readmitted with feveri severe back pain, and headache. Physical ex! amination revealed lethargy, disorientationi temperature of 39.5°C., and poorly loealize~ lumbar pain. Significant positive laborator~; findings were an elevated leukocyte count and~ blood culture with a growth of greater than 100,000 colonies per cubic centimeter of E, mirabilis. Because of persistent sepsis and backache! neurosurgieal consultation was sought. Lumb~ puncture revealed purulent material in NO epidural space. The dura mater was not pun~ tured. Preliminary films of the lumbar spine ha~ b e e n interpreted as showing degenerative dis~ ease only (Fig. 1A). A lumbar myelogram w~ compatible with an extradural uloek (Fig. ~ and C). The patient u n d e r w e n t lamineetomy of l u ~ bar vertebrae 2 to 4 with drainage of multip~ ~ level disk-space infections. Each culture gre1*~

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FIGURE 1. (A) Lumbar spine films showing degenerative disease only. (B and C) Lumbar myelogram showing extradural block.

greater than 100,000 colonies per cubic centimeter of P. mirabilis. His postoperative course was uneventful, with nenrologic function remaining intact. At the request of the Infectious Disease Service, the patient was given a six weeks' course of parenteral sodium cephalothin. Comment Many authors have reported minor complications secondary to transrectal biopsy, such as epididymitis, rectal bleeding, fever, and hematuria.~-10 More recently W e n d e l and Evans 11 r e v i e w e d 4,300 cases of prostatic biopsies finding similar complications as well as the more uncommon complications of sepsis, pyelonephritis, fistulas,

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TABLE 1. Pathologic Condition

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Epididymitis Rectal bleeding Hematuria (gross) Fever Urine leakage Pyuria Death unexplained Retention Prostatitis Urethral perforation Entry into bladder Rectourethral fistula Pyelonephritis Bacteremia (Klebsiella) Tumor implantation Hematospermia Osteomyelitis (vertebral) Death (sepsis) Prostatic abscess

Complications of transrectal needle biopsy of prostate 502

313

444

2 2

Number of Cases 54 s 2037 175 s

2 2

t u m o r s e e d i n g the b i o p s y tract, h e m a t o m a , a n d abscess formation. D a v i s o n a n d M a l a m e n t 12 f o u n d that 27.4 p e r c e n t of their patients h a d febrile r e s p o n s e s , a n d 17.7 p e r c e n t h a d a positive u r i n e culture, all of w h o m h a d sterile u r i n e prior to biopsy. S u c h u n u s u a l c o m p l i c a t i o n s as ureteral p e r f o r a t i o n w i t h u r i n a r y extravasation have b e e n d e s c r i b e d (Table 1). 12 O s t e o m y e l i t i s of the s p i n e was s e e n in 2 of the 4,300 cases w h i c h W e n d e l r e v i e w e d 2 1 This particular entity has b e e n r e p o r t e d as a c o m p l i c a tion of prostatic surgery. 14"t50steomyelitiS also has b e e n s e e n s e c o n d a r y to u r i n a r y tract infection. 16 E l i a s o n a n d D u n l a p lr r e p o r t e d 2 eases of osteomyelitis after n e e d l e b i o p s y of the prostate. Both of t h e s e cases f o l l o w e d b i o p s y via the p e r i n e a l route. T h e s e authors p o s t u l a t e s p r e a d of infection via Batson's plexus of v e r t e b r a l veins. O u r case r e p r e s e n t s the first r e p o r t of a diskspace infection s e c o n d a r y to transreetal n e e d l e biopsy. T h e disk-space infection m i g h t well h a v e b e c o m e vertebral o s t e o m y e l i t i s if not for rapid diagnosis and t h o r o u g h treatment. Morgantown, West Virginia 26506 (DR. STUPPLER) References 1. ASTRALDI,A,: Diagnosis of carcinoma of the prostate:

biopsy by rectal route, Urol. Cutan. Rev. 41:421 (1937). P~. GRABSTALD,H., and ELLIOTT,J.L.: Transrectal biopsy of the prostate, J.A.M.A. 153:563 (1953).

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3. PEARLMAN, C. K.: Transrectal biopsy of the prostate,

]. Urol. 74:387 (1955). 4. EMANUEL, M., and FOOTE, E. L.: Transrectal needle biopsy in the diagnosis of prostate carcinoma, J. Maine Med. Assoc. 48:234 (1957). 5. BARNES,R. W., and EMERY,D.S.: Managementofearly prostatic carcinoma, Calif. Med. 91:57 (1959). 6. GRAHAM,W.H.: Carcinoma of the prostate, Br. J. Urol! 30:389 (1958). 7. EMMETT, J. L., BAm3ER,K. W., JR., and JACKMAN,R. J.: Transrectal biopsy to detect prostatic carcinoma: a review and record of 203 cases, J. Urol. 87:460 (1962). 8. DARES, J. A., TOMASKEY, G. C., and COHEN, A. T.: Transreetal needle biopsy of the prostate, ibid. 85:180 (1961). 9. BERTELSEN, S.: Transrectal needle biopsy of the prostare, Acta Chir. Scand. (Suppl.) 357:226 (1966). 10. BARNES, R. W., and NINAN, C.A.: Carcinoma of the prostate: biopsy and conservative therapy, J. Urol. 108z 897 (1972). 11. WENDEL, R. G., and EVANS, A. T.: Complication of punch biopsy of the prostate gland, ibid. 97:122 (1967)i 12. DAVISON,P., and MALAMENT,M.: Urinary contamina" t-ion as a result of transreetal biopsy of the prostate, ibid, 105:545 (1971). 13. HOGAN, J. M., and JOHNSON, D. E.: Urethral perforation: a complication of transrectal needle biopsy of the prostate, ibid. 108:297 (1972). 14. DEFEO, E.: Osteomyelitis of the spine following prostate surgery, Radiology 62:396 (1954). 15. DEMING, C. L., and ZAFF, F.: Metastatic vertebral: osteomyelitis complicating prostatic surgery, Trans. AN! Assoc. Genitourin. Surg. 35:287 (1943). 16. HENSEN,S. W., SR., and COVENTRY,M.B.: OsteomYei litis of the vertebra as a result of infection of the urinary; tract, Surg. Gynecol. Obstet. 102:207 (1956). 17. ELIASON, O., and DUNLAP, D.: Osteomyelitis of the spine following needle biopsy of prostate, J. Urol. 94! 271 (1965).

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