G-022-5347 /32/:272-D255$02.00/0 THE ~10URNAL OF UROLOGY
Copyright© 1982 by The VVilliams & \ Vilkins Co. 1
URINARY TRACT INFECTION AFTER TRANSRECTAL NEEDLE BIOPSY OF THE PROSTATE J. R. SHARPE, R. W. SADLOWSKI, R. P. FINNEY, W. T. BRANCH
J. E. HANNA
From the Division of Urology, University of South Florida Medical Center, Tampa, Florida
After routine cleansing enemas 80 patients were randomized to undergo irrigation of the rectal vault with either povidone-iodine or saline. A transrectal prostatic needle biopsy then was performed. Antimicrobials were not used before biopsy and were only ordered after biopsy if fever developed or a positive urine culture was obtained. Over-all, 41 per cent of the patients had positive urine cultures post-biopsy and 44 per cent had febrile episodes. There was no significant difference between the group receiving the povidone-iodine versus those receiving saline irrigations. Patients were not given antibiotics post-biopsy unless a fever developed or the urine culture became positive for infection. Although blood cultures were not drawn routinely 3 were positive post-biopsy (2 Escherichia coli and 1 Klebsiella). One patient noticed temporary gross bleeding from the rectum. Several patients noticed transient hematuria. There was no other serious morbidity and all patients recovered without incident. Histopathologically, 36 biopsies were reported as positive for carcinoma and 44 were reported as benign.
Biopsy of the prostate is a commonly performed procedure that usually is done transperitoneally or transrectally to diagnose prostatic cancer. The advocates of transperineal prostatic biopsy claim the advantage of having fewer instances of infection introduced by this route. Advocates of transrectal prostatic biopsy believe that this approach gives greater accuracy when a small, solitary nodule is biopsied. We report on the positive urine cultures and febrile episodes experienced after transrectal needle biopsy of the prostate with and without immediate prebiopsy irrigation of the rectal ampulla with full strength povidone-iodine solution.
Our study involved hospitalized patients who underwent transrectal needle biopsy of the prostate. AH patients had a cleansing enema (most often saline until clear) the night before biopsy. The patients were randomized to undergo irrigation of the rectal fossa with either 20 ml. povidone-iodine solution (full strength) or 20 ml. saline immediately before biopsy. The solution was aggitated manually to aid in removal of any residual fecal debris. Any patient with gross feces in the rectum was given another enema and biopsy was performed later. Only those patients who had not received any antimicrobial medication in the week preceding biopsy and in whom a urine culture obtained within 2 days of the biopsy yielded no growth were included in the study. No antibiotics were prescribed after biopsy unless either a febrile episode developed or a positive urine culture was obtained. A dean catch midstream urine specimen was submitted for culture and sensitivity the morning after biopsy (or sent earlier before prescribing antibiotics when a febrile episode occurred). Of a total of 80 patients 40 were randomized to the povidone-iodine rectal irrigation group and 40 were randomized to the normal saline rectal irrigation group. From 1 to 5 different cores of tissue were taken at biopsy (usually 2 or 3). The specimens usually were obtained with a disposable biopsy needle. RESULTS
Positive results (> 100,000 colonies per ml.) were obtained in 33 urine cultures post-biopsy (see table). Of the patients with positive cultures 15 had had the povidone-iodine rectal irrigation and 18 had had normal saline. Fever > lOOF developed in 35 patients during the 24 hours after biopsy: 16 had had the povidone-iodine rectal irrigation and 19 had had normal saline as the rectal irrigant. Of the 33 patients with positive urine cultures post-biopsy only 4 had no fever, and of the 35 patients with fever post-biopsy only 6 had negative urine cultures. Accepted for publication April 3, 1981.
Biopsy of the prostate should be a relatively safe procedure for the evaluation of prostatic disease. In a review of 4,300 biopsies (including transperineal and transrectal approaches) the complications were few and acceptable. 1 Davison and Malament reported urinary contamination after transrectal biopsy of the prostate in 113 patients who were divided almost equally into those on antimicrobials and those receiving no therapy. 2 Over-all, 27 per cent of their patients had fever after biopsy and 44 per cent had positive urine cultures. There was 1 case of fatal septicemia. These investigators concluded that antimicrobial premedication decreased the incidence of febrile reaction and urinary tract contamination. Fawcett and associates reported a 45 per cent incidence of infected urine after transrectal biopsy of the prostate, the incidence being reduced to 30 per cent when antibiotics were begun the day after the procedure. 3 Edson and associates reported 7 cases of gramnegative bacteremia after transrectal needle biopsy of the prostate.4 Esposti and associates reported on 4 patients with sepsis after prostatic needle biopsy, including l deatho 5 Rees and associates obtained blood samples for culture 5 minutes after prostatic biopsy in 2 different series of patients. 6 The difference between their 2 series was a povidone-iodine rectal washing in the second group, which they contributed to reducing the incidence of bacteremia from 76 to 17 per cent. Then, these investigators prescribed antibiotics after the blood culture was obtained. We attempted herein to establish the possible effectiveness of cleansing the rectal fossa with povidone-iodine solution immediately before biopsy in patients not on any antimicrobial therapy. There was no significant difference in the febrile episodes and positive urine cultures between the groups that received povidone-iodine versus normal saline as a rectal irrigant. Chi-square values with l degree of freedom equaled 0.203 for the febrile episodes and 0.206 for the positive cultures (the chi-square value needed for significance at the 0.05 level was 3.84). The over-all incidences of positive urine cultures (41 per cent) and febrile episodes (44 per cent) were unacceptably high. Currently, we are performing more prostate biopsies transper-
SHARPE AND ASSOCIATES
Results in 80 patients after transrectal prostatic needle biopsy Fever
Povidone-iodine rectal irrigations Normal saline rectal irrigations Totals
Neg. No. Pts. (%)
Pos. No. Pts. (%)
None No. Pts. (%)
IOOF No. Pts. (%)
ineally, especially for the larger lesions. When the transrectal route is used for prostatic biopsy we begin prophylactic systemic broad-spectrum antibiotics before biopsy and continue the medication for 24 to 48 hours after biopsy. REFERENCES 1. Wendel, R. G. and Evans, A. T.: Complications of punch biopsy of
the prostate gland. J. Urol., 97: 122, 1967. 2. Davison, P. and Malament, M.: Urinary contamination as a result
of transrectal biopsy of the prostate. J. Urol., 105: 545, 1971. 3. Fawcett, D. P., Eykyn, S. and Bultitude, M. I.: Urinary tract infection following transrectal biopsy of the prostate. Brit. J. Urol., 47: 679, 1975. 4. Edson, R. S., Van Scoy, R. E. and Leary, F. J.: Gram-negative bacteremia after transrectal needle biopsy of the prostate. Mayo Clin. Proc., 55: 489, 1980. 5. Esposti, P. L., Elman, A. and Norlen, H.: Complications of transrectal aspiration biopsy of the prostate. Scand. J. Urol. Nephrol., 9: 208, 1975. 6. Rees, M., Ashby, E. C., Pocock, R. D. and Dowding, C. H.: Povidone-iodine antisepsis for transrectal prostatic biopsy. Brit. Med. J., 281: 650, 1980. EDITORIAL COMMENT I always have had great concern about this approach to prostatic biopsy and our experience has shown that it can produce serious complications. This report bears that out and I believe that the authors' admonition to cover any patients biopsied in this fashion with antibiotics is worthwhile. J.J.M.