Complication rates after TRUS-guided biopsies in Canada

A new report from another group of Canadian researchers has reported a twofold to fourfold increase in the rate of hospital admissions in Ontario within 30 days of the procedure for men receiving a transrectal ultrasound-guided (TRUS-guided) prostate biopsy between 1996 and 2005. This is probably not a finding that will make anyone in Canada very happy.

TRUS-guided biopsy has always been associated with the development of significant morbidity (poor health) in a small proportion of patients. One might assume that there has been a vast increase in the number of TRUS-guided biopsies in Canada over the past 15 years, and that this might help to explain why the morbidity rate associated with this procedure has been rising (at least in Ontario). However, the annual number of TRUS-guided biopsies seems to have been about the same in 1996 as it was in 2005 (having hit a high point in 2001).

Nam et al. carried out a population-based analysis of urological complications associated with TRUS-guided biopsies in the province of Ontario, Canada. Between 1996 and 2005 a total of 75,190 men had such a biopsy. These biopsies were carried out by a relatively small number (437) of specialist physicians (urologists). The authors used hospital and cancer registry databases to estimate the rates of hospital admission and mortality due to urological complications associated with the procedure.

They demonstrated the following results:

  • 33,508/75,190 men who underwent transrectal ultrasound biopsy (44.6 percent) were diagnosed with prostate cancer.
  • 41,682/75,190 men (55.4 percent) did not have prostate cancer.
  • The overall hospital admission rate for urological complications within 30 days of the procedure was 1,057/75,190 (1.4 percent).
  • For the men who were diagnosed with cancer,
    • The hospital admission rate for urological complications within 30 days of the procedure was 276/33,508 (0.8 percent).
    • The 30-day hospital admission rate increased from 0.4 percent in 1996 to 0.9 percent in 2005.
  • For the men who did not have cancer,
    • The hospital admission rate for urological complications within 30 days of the procedure was 781/41,482 (1.9 percent ).
    • The 30-day hospital admission rate increased from 1.0 percent in 1996 to 4.1 percent in 2005.
  • The majority of hospital admissions (72 percent) were related in some way to an infection.
  • The overall 30-day mortality rate was 0.09 percent (8.5 men died for every 10,000 men who had a biopsy) but this did not change significantly from 1996 to 2005.

The authors conclude that, “The hospital admission rates for complications following [TRUS-guided] prostate biopsy have increased dramatically during the last 10 years primarily due to an increasing rate of infection related complications.”

Now we should not conclude from this study that prostate biopsy is, in itself, dangerous. There are other reasons why this increase in morbidity may be evident in Ontario. The authors discuss a number of possibilities:

  • First and foremost, there is no standard method used by urologists (in Canada or anywhere else) to minimize the risk for infections associated with TRUS-guided biopsies.
  • Second, the number of bacteria that are resistant to standard antibiotics has been rising rapidly over the past 15 years, and this is particularly evident in hospitals (although one study has shown that up to 6 percent of bacteria  and other pathogens causing community-acquired urinary tract infections are now resistant to ciprofloxacin).
  • Third, in 1996 the majority of patients would have received a so-called sextant (six core) biopsy, whereas today patients may commonly have up to 20 or so cores taken at a single biopsy procedure.
  • Finally, in this study, it was noted that the patients of physicians who performed the highest numbers of biopsy procedures experienced relatively lower risk for hospital admission for complication within 30 days, so once again the skill of the individual physician is important.

It is becoming increasingly evident that it is time for the urology community to adopt a set of standard protocols for prevention of infection and other complications associated with TRUS-guided biopsy. It would also be interesting to know whether there has been a similar pattern of complications in the USA and other countries. In particular, in the USA, prostate biopsies are much more commonly carried out as an “in-office” procedure in the community, and not in an actual hospital, because of the way specialty urology practices are organized in the USA. This in itself may affect the rate of infectious complications associated with TRUS-guided biopsies.

Finally, we should note that the authors themselves point out a number of problems with the way this study was originally carried out. It is clear that similar and more detailed studies are going to be needed to ensure the accuracy of future studies in this field. As just one example of this, based on administrative data alone, it is very difficult to tell exactly why the patients who had been diagnosed with cancer were admitted to the hospital within 30 days of a TRUS-guided biopsy. At least some of them certainly appear to have been admitted for treatment for their prostate cancer — but that could easily include men who actually had complications resulting from the biopsy. In other words, they may have been administratively “coded” as needing treatment for prostate cancer even though they were actually being treated for a complication of a biopsy.

6 Responses

  1. Apart from the detail of the findings themselves, what I also found interesting was the fact that 45% of the men who had the biopsy procedure were diagnosed with prostate cancer.

    The highest percentage I can recall seeing in US studies is about 35% so:

    1. Do the Canadians use a different set of criteria for triggering a biopsy — and if so, does the pattern for prostate cancer diagnosed differ from the US? For example is the number of late stage diagnoses greater than the US?

    2. Do the Canadians use a different set of criteria for defining PCa — for example do they still define a Gleason score of 2 + 2 as “cancer” where this wouldn’t be the case in the US?

  2. Dear Terry:

    I think there’s a much simpler answer that that. The Canadians have a nationalized, government-funded health system. Urologists in Canada have no financial motivation to “go looking” for prostate cancer. By comparison, in the USA, since the widespread acceptance of the PSA test, “everyone” with a PSA over 4 ng/ml could be pretty sure they’d get a biopsy, regardless of the probability that that they had prostatitis or BPH. Urologists in the US get paid for each procedure they do — and their lawyers would tell them it would be “prudent” to carry out a biopsy if there was any possibility of cancer being present.

  3. This is an excellent site and thanks to the sitemaster and those involved with it. I am glad I’ve found it and will be recommending it to patients.

    Some thoughts on the above. I do several hundred biopsies a year and have done so for over 20 years. The hospital rate mentioned in the study is unusually high. I think I have admitted someone after a biopsy maybe five times in that span of time. Most go home the next day. The reason is usually bleeding or a bacteremia. It must have to do with the system in Canada as suggested.

    I know the “lawyer” remark was done rhetorically but you must know that urologists don’t consult lawyers about medical things.


  4. Hello,

    Can anybody please tell me if they have suffered the same complication I am following a TRUS-guided biopsy (prostate) done last week. I unfortunately had my procedure turn septic and spent 2 days in the ICU and 4 days in a ward bed before returning home 2 days ago from hospital. While I am getting my strength back slowly, my concern is that I am staggering about like a drunk due to the room spinning when I get out of bed. Is this a normal side effect of all the drugs or have I got other problems? Will appreciate any relevent comments.


    Martin (Australia)

  5. Dear Martin:

    This certainly isn’t a “normal” side effect of anything! I suggest you call your primary care doctor (not the urologist). It could be something to do with the drugs you were given in hospital — but it still sounds most odd.

  6. Dear Sir/Madam:

    We have been doing around 100 TRUS-guided prostate biopsies per annum in our clinical practice. About 5% of these patients develop complications (unpublished data) despite being given intravenous, a third-generation cephalosporin, an aminoglycoside, and oral Cifran TZ as a department policy. Of the 5% morbidity, 2% develop febrile UTI, which requires step-up of antibiotics.

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