AUA develops guidance on complications of prostate biopsy (and their prevention)

As regular readers will be aware, there have been a number of recent reports of sepsis and infectious complications associated with prostate biopsies. As a consequence, the American Urological Association (AUA) has issued a new white paper addressing the prevention and management of such complications.

This white paper was developed by a working group of the Quality Improvement & Patient Safety Committee of the AUA, including representatives from the Society of Urologic Nurses and Associates (SUNA). The full text of the document was recently completed and is available on the AUA web site.

In addition to its focus on the prevention and management of prostate biopsy-related complications, the white paper also addresses the incidence of, etiology of, and risk factors for such complications, specifically including the prevention, identification, and management of infection-related complications.

The white’s paper’s authors note the following:

  • The most common complications of prostate biopsy are infection, bleeding within the prostate, and retention of urine.
  • As many as 22 percent of men given a rectal swab prior to prostate biopsy may be found to harbor fluoroquinolone-resistant bacteria.
  • About 5 percent of men receiving appropriate antimicrobial prophylaxis prior to undergoing prostate biopsy will have transient, asymptomatic bacteriuria (bacteria in the urine).
  • Less than 2 percent of men receiving appropriate antimicrobial prophylaxis prior to undergoing prostate biopsy will normally have a symptomatic urinary tract infection post-biopsy.
  • The incidence of infectious complications after prostate biopsy in large studies has ranged between 0.1 and 7.0 percent.
  • The AUA Best Practice Statement on prophylaxis for prostate biopsy indicates that fluoroquinolones or first, second, or third-generation cephalosporins are the antimicrobial agents of choice for prevention of biopsy-related infections and that single-dose regimens appear to be as effective as those spanning 1 or 3 days.
  • A finding of blood in the urine (hematuria), blood in the sperm (hematospermia), or rectal bleeding is relatively common and quite normal short term finding after a prostate biopsy (but most patients have no problem as a consequence of such bleeding).
  • For men taking anticoagulant therapy of any type (e.g., warfarin and similar “blood thinners”), it may be appropriate to discontinue such therapy prior to biopsy (and patients should discuss this with their doctors).
  • Urinary retention occurs in about 0.2 to 1.1 percent of men undergoing prostate biopsy.
  • Starting men at higher risk for urinary retention post-biopsy on an α-blocking agent prior to biopsy may be appropriate.
  • Prostate biopsy is associated with a low risk for mortality (of the order of 0.1 to 0.3 percent), commonly associated with infectious complication of prostate biopsy such as sepsis.
  • Steam sterilization is the preferred method for reprocessing reusable, heat-stable medical devices, including prostate biopsy needle guides.

Patients do need to appreciate that a biopsy is an invasive procedure and therefore is not risk-free. Some researchers have suggested that a pre-biopsy rectal swab would be wise to ensure that an appropriate antibiotic regimen is used to minimize the risk for microbial infection and sepsis. However, such swabs are not yet widely used in community practice.

Since this issue comes up all the time, we should note that there is no suggestion at all within this white paper that prostate biopsy is associated with any risk for the spread of cancer within or outside the prostate.

5 Responses

  1. Thanks. Good information. I had an infection after a biopsy at Washington University (Barnes). It was negative, and I have been taking finasteride for BPH for over 4 years, despite the contradictory information on whether 5-ARIs “cause” high-grade cancer. No argument for or against is 100% compelling (nothing ever is). Choices must be made despite the chaos.

  2. I can’t understand how a biopsy with cancer focuses would not introduce cancer cells into the anus and other adjacent tissues. Are these cells not viable?

  3. Robert:

    Cancer cells require very highly specific microenvironments in which to survive and grow. Moving the odd cancer cell physically from one set of tissues to another almost invariably results in cancer cell death because the new microenvironment is not conducive to the survival of the cancer cells. This is one of the reasons that it took many years for us to learn how to grow cancer cells outside the body, and even now we can only do that for some types of cancer cell. It is also why most cancers don’t metastasize much more quickly that they do. It is very hard for cancer cells to spread through the body, because they can only do this successfully if they can successfuly spread to a microenvironment conducive to their survival and their growth into new tumors.

  4. Because of an elevated PSA reading, I had a prostate biopsy a little over a week ago — performed by my urologist. Fortunately the results proved to be negative. I have, however, what I imagine to be blood in my semen on two occasions (brownish-red discharge — color of water coming out of rusty pipe). There has been no blood in my urine or stool that I can discern. My doctor had given me a sheet with some information, including a note that blood may be present in my urine, stool or semen following the biopsy procedure so I was not too surprised the first time I saw it but with the second observation (8 days following procedure) I now feel somewhat concerned. You note that this is “relatively common and quite normal short term finding after a prostate biopsy” … is a week “short term”? If I continue to have the bloody discharge, at what point should I be concerned and contact my doctor about it? Should I lay off the sex for a while?

  5. Dear Don:

    This finding of what is effectively “dried” blood in semen (i.e., blood left over from internal bleeding during the biopsy) is actually perfectly normal and could easily continue for another couple of weeks if you continue to have intercourse. It’s really nothing to be concerned about. You do not need to “lay off the sex for a while”; indeed, if you did lay off the sex it almost guarantees that the next time you ejaculate there would still be dired blood in the semen.

    By contrast, if you start to see obviously fresh, bright red blood in your semen (or urine), that’s when you need to get back in touch with your urologist — although I wouldn’t expect this to occur given your description above.

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