Emergency hospital admissions attributable to infective complications of prostate biopsy despite appropriate prophylaxis: need for additional infection prevention strategies?

Purpose

To report the incidence of emergency admissions attributable to infective complications of transrectal ultrasound-guided prostate biopsy (TGB) and evaluate appropriateness of antimicrobial prophylaxis.

Methods

Retrospective cross-sectional study of patients undergoing TGB at the North West London Hospitals in 2009–2011. Demographic information of patients who had emergency admission within 30 days of TGB, length of hospital stay and microbiology results were obtained from the hospital’s information system, medical records and laboratory information system. All patients received ciprofloxacin and amikacin prophylaxis.

Results

1,419 TGB were performed in 1,276 patients. Forty-eight (3.3 %) patients had emergency admissions. Thirty-three (2.3 %) admissions were due to complications from TGB, while 15 (1 %) were for unrelated reasons. 30/33 (90 %, overall 2.1 %) of admissions from TGB complications were due to confirmed infections or systemic inflammatory response syndrome (SIRS). The rest were admitted with urinary retention. Admission rates due to TGB complications and infection/SIRS remained consistent over the 3 years (2009: TGB complications—2 %, TGB infection/SIRS—1.8 %; 2010: TGB complications—2.4 %, TGB infections/SIRS—2.2 %; 2011: TGB complications—2.6 %, TGB infection/SIRS—2.4 %; P > 0.05). All 11 cases with bacteraemia were caused by ciprofloxacin-resistant but amikacin-susceptible E. coli.

Conclusions

We observed a consistent rate of emergency admissions for complications following TGB; 90 % of these were due to infections. Ciprofloxacin-resistant but amikacin-sensitive E. coli was isolated in all bacteriologically confirmed infections. These results suggest that infective complications of TGB cannot be altogether eliminated despite appropriate antimicrobial prophylaxis. Therefore, additional strategies for reduction in biopsy-related admissions due to infections have to be considered.     

Is the pain level of patients affected by anxiety during transrectal prostate needle biopsy?

OBJECTIVE: To investigate the effect of anxiety on the pain level of patients during transrectal prostate needle biopsy. MATERIAL AND METHODS: A total of 160 consecutive patients underwent prostate biopsy. Group 1 consisted of 86 patients who received bilateral periprostatic infiltration of 5 cm(3) of 2% lidocaine. Group 2 included 74 patients and they received bilateral periprostatic infiltration of 5 cm(3) of 0.9% saline solution. The Stait-Trait Anxiety Inventory was administered before the biopsy. The patients' mean pain scores were assessed by means of a visual analog scale (VAS) during digital rectal examination, probe insertion and biopsy. RESULTS: The mean age of the patients was 67.8 years (range 46-79 years). When the two groups were compared regarding the level of pain during DRE and probe insertion, no significant differences were found. The mean VAS score for biopsy was significantly lower in Group 1. In Group 1, the mean VAS scores were similar in patients with no and moderate trait anxiety levels. However, the mean VAS score was significantly higher in patients who had severe trait anxiety than in the others (p=0.002). In Group 2, the differences in VAS scores reached statistical significance between no and moderate, no and severe, and moderate and severe trait anxiety levels (p=0.001). When the state anxiety levels were considered, the mean VAS scores were significantly higher in patients with severe state anxiety scores in Groups 1 and 2 (p=0.003 and 0.001, respectively). CONCLUSION: We found a significant relationship between trait and state anxiety levels and pain scores in patients who underwent transrectal prostate needle biopsy.     

Do additional shaved margins at the time of lumpectomy eliminate the need for re-excision?

Background

Most women diagnosed with breast cancer undergo breast-conservation surgery. Re-excision rates for positive margins have been reported to be greater than 50%. The purpose of our study was to determine if removing additional shaved margins from the lumpectomy cavity at the time of lumpectomy reduces re-excisions.

Methods

A retrospective study was performed on 125 women who had undergone lumpectomy with additional shaved margins taken from the lumpectomy cavity. Pathology reports were reviewed for tumor size and histology, lumpectomy and additional margin status, and specimen and margin volume.

Results

If additional margins were not taken, 66% would have required re-excision. Because of taking additional shaved margins, re-excision was eliminated in 48%.

Conclusion

Excising additional shaved margins at the original surgery reduced reoperations by 48%. There is a balance between removing additional margins and desirable cosmesis after breast-conservation surgery. The decision to take extra margins should be based on the surgeon's judgment.     

Does pericapsular lignocaine reduce pain during transrectal ultrasonography-guided biopsy of the prostate?

OBJECTIVE: To evaluate whether injection with pericapsular lignocaine before transrectal ultrasonography (TRUS)-guided biopsy reduces the perceived pain of prostatic biopsy. PATIENTS AND METHODS: The study included 121 patients referred for TRUS-guided biopsy of the prostate; 27 underwent biopsy with no previous injection and 94 were randomized to pericapsular injection with either 1% lignocaine or a placebo (saline). Both patient and operator were unaware of the content of the injection. The injection was delivered under TRUS guidance to the apex of the prostate. Routine sextant biopsies were taken using an 18 G needle in a spring-loaded biopsy gun. A validated pain scale, the NRS11 (0, no pain, to 10, unbearable pain), was used to record the pain of each biopsy. RESULTS: No significant placebo effect was detected between the 'no injection' and the placebo-injection group, with mean (95% confidence interval) pain scores of 3.58 (2.77-4.39) and 4.01 (3.46-4.51), respectively, using the unpaired Student's t-test (P = 0.409). There was a statistically significant lower mean pain score in the lignocaine group, at 2.54 (2.00-3.10), than in the placebo-injection group (P < 0.001). CONCLUSION: Pericapsular injection with 1% lignocaine significantly reduces the perceived pain of TRUS-guided prostatic biopsy.     

Is excisional biopsy indicated for patients with lobular neoplasia diagnosed on percutaneous core needle biopsy of the breast?

Background

The value of excisional biopsy for patients with lobular neoplasia diagnosed by core needle breast biopsy is controversial.

Methods

A retrospective analysis of all patients with lobular carcinoma in situ or atypical lobular hyperplasia on core needle biopsy.

Results

Twenty-five patients were identified. Twelve (48%) underwent excisional biopsy. None of the patients who had excisional biopsy were found to have ductal carcinoma in situ (DCIS) or invasive cancer. The mean follow-up was 66 months. Five patients (20%) developed DCIS or invasive cancer during follow-up. The rate of subsequent carcinoma among those undergoing excisional biopsy was 25%, and among those not undergoing excisional biopsy it was 15% (P = .57). Among patients who did not undergo excisional biopsy, none developed carcinoma within the same quadrant of the breast.

Conclusions

Excisional biopsy for lobular neoplasia did not identify understaged carcinoma or alter the rate of subsequent carcinoma. The subsequent carcinoma risk is diffuse and bilateral; it does not correlate with the site at which lobular neoplasia was diagnosed.     

What kind of stone prevention for whom? Risk-adjusted metaphylaxis following urinary stone disease

Approximately 5% of the German population suffers from urinary stone disease, but only 25% of these urolithiasis patients are at risk of recurrent stone disease or a severe metabolic disorder. It is important that patients at high risk are picked up early, so that appropriate therapy and measures designed to prevent secondary stone disease can be implemented. Risk classification is easily achieved by combining stone analysis with a basic diagnostic program. Patients at low risk need no further diagnostic evaluation or treatment, so that it is enough to recommend general metaphylaxis in these cases. In contrast, patients at high risk require additional specific aftercare and should be evaluated with the aid of a comprehensive diagnostic program from the start to allow precise definition of the metabolic targets.     

Does the use of a centrifugal pump offer any additional benefit for patients having open heart surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether a centrifugal pump is better than a roller pump in patients undergoing cardiac surgery. Altogether 93 papers were identified using the below mentioned search, of which 15 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that there is no evidence for the benefit of a centrifugal pump over a roller pump in elective coronary artery bypass grafting in respect of blood loss, clinical outcomes or neurological problems. The two largest studies, a large RCT of 1000 patients and a cohort study of 4000 patients, both demonstrated a halving in the incidence of neurological events with numbers needed to treat of 37 and 91. However, the remaining much smaller RCTs and cohort studies that we assessed failed to show significant differences in either clinical or biochemical markers.     

Does magnesium offer any additional benefit in patients having anti-arrhythmic treatment for atrial fibrillation following cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether treatment with magnesium in addition to an anti-arrhythmic is beneficial to patients who have gone into atrial fibrillation after cardiac surgery. Altogether 466 papers were identified using the below mentioned search, of which 8 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that while the literature on magnesium prophylaxis and non-cardiac surgical studies on magnesium therapy for atrial fibrillation suggest that magnesium may be of benefit, there are currently no studies in post-cardiac surgery atrial fibrillation to support the use of magnesium therapy for these patients.     

Can the need for palliative transurethral prostatic resection in patients with advanced carcinoma of the prostate be predicted?

PURPOSE: To identify the factors predicting the need for palliative transurethral resection of the prostate (channel TURP) in patients with advanced carcinoma of the prostate (CAP) receiving androgen ablation therapy. PATIENTS AND METHODS: From January 1996 to January 2004, 203 patients with advanced CAP were treated by androgen ablation. Patients presenting with retention were catheterized initially, and those (N = 12) who failed a catheter-free trial and had immediate channel TURP were excluded. The remaining 191 patients were followed every 3 months (mean 35.5 months, range 6-92 months). Patients requiring channel TURP (group 1; N = 42 [22%]) during follow-up were compared with those who did not (group 2) for predictive factors, viz. retention of urine, serum prostate specific antigen (PSA) concentration, Gleason sum, prostate size, and bony metastasis at presentation. RESULTS: Channel TURP was performed at a mean of 21 months (range 3-72 months). The mean Gleason sum in this group was 7.88, whereas it was 7.29 in group 2 (P = 0.013). Retention at presentation was significantly more common in group 1 (N = 26; 61.9%) than in group 2 (N = 46; 30.8%; P = 0.001). Patients who did not present with retention and had Gleason sums < or =7 (N = 32) did not require channel TURP. Of the 14 patients who voided successfully after a catheter-free trial but had Gleason sums of >7, 71.4% required channel TURP. Other factors were not found to be significantly different in the two groups. CONCLUSION: High Gleason sum and retention at presentation are significant factors predictors of the need for channel TURP during follow-up in patients with advanced CAP receiving androgen ablation therapy.     

Does the transrectal ultrasound probe influence prostate cancer detection in patients undergoing an extended prostate biopsy scheme? Results of a large retrospective study

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What's known on the subject? and What does the study add? The influence of transrectal probe system, end‐fire and side‐fire, has not been studied in detail. Using a sextant biopsy template it has been demonstrated a difference between end‐fire and side‐fire modes in 4–10 ng/mL PSA interval population. No studies evaluated the results in extended biopsy templates before. This study adds the knowledge that end‐fire and side‐fire transrectal probe, which are the two probe systems to perform transrectal prostate biopsy, have similar results in terms of prostate cancer detection rate and can be indifferently employed in extended prostate biopsy templates used in daily practice.

OBJECTIVE

• ? To compare the prostate cancer detection rate and tolerance profile between a transrectal biopsy made with a ‘side fire’ (SF) and an ‘end fire’ (EF) ultrasound probe.

PATIENTS AND METHODS

• ? We selected patients undergoing first biopsy and re‐biopsy of the prostate with a 14‐ and 18‐core template using EF and SF transrectal probes, respectively.
• ? We compared the cancer detection rate between the two probes on first biopsy and re‐biopsy and gauged patient tolerance using a visual analogue scale (VAS).

RESULTS

• ? A total of 1705 patients were included in the first biopsy group, while 487 were in the re‐biopsy group.
• ? The overall detection rate of first biopsy was 37.2%; the overall detection rate of re‐biopsy was 10.1%.
• ? No significant difference was found between the two probes in the first biopsy and re‐biopsy sets (38% vs 36.5%, P= 0.55; 10.8% vs 9.3%, P= 0.7).
• ? The lack of any significant association between the type of probe used and prostate cancer detection was confirmed by univariable and multivariable analyses in both the first biopsy and re‐biopsy sets after accounting for prostate‐specific antigen values, per cent free prostate‐specific antigen, digital rectal examination, and prostate and transition zone volumes.
• ? The patient tolerance profile of the SF group was significantly better than that of the EF group (mean VAS 1.78 ± 2.01 vs 1.45 ± 2.21; P= 0.02).

CONCLUSION

• ? The prostate cancer detection rate does not depend on the type of probe used. However, the SF transrectal probe is associated with a better patient tolerance profile.

     

Testicular fixation following torsion of the spermatic cord--does it guarantee prevention of recurrent torsion events?

PURPOSE: Patients with history of testicular torsion who have undergone orchiopexy may rarely present with acute scrotum due to recurrent episodes of torsion. Most of the reports in the literature regarding this scenario refer to the era when absorbable sutures were used for testicular fixation. Herein, we review our experience in recent years, focusing upon the surgical technique and sutures' material. MATERIALS AND METHODS: Between 1991 and 2003, 179 patients were operated on at our institute with the clinical diagnosis of unilateral testicular torsion. They ranged in age between neonates to 45 years old (average age 18). In a comprehensive retrospective study we managed to locate 8 patients who experienced recurrent intravaginal testicular torsion following previous fixation performed in our institute. RESULTS: The patients who experienced repeat torsion have initially presented at the mean age of 18.5 years old (range 12 to 30) with unilateral twisted testicle (left 3, right 5). Urgent explorations were generally performed, apart from in 2 cases that underwent spontaneous detorsion which was followed by an elective surgery. Testicular fixation was conducted by suturing of the tunica albuginea to the dartos layer by 2 sutures at each side, using chromic 3-zero in the 3 more early cases, followed by the usage of polyglactin 3-zero stitches in 4 subsequent cases and 3 sutures of polypropylene 4-zero for each testicle, thereafter, in the most recent case. The patients presented with repeat torsion, 0.5 to 23 years subsequently (average 7 years), involving either the ipsilateral testicle in 4 cases or the contralateral gonad in 4. CONCLUSIONS: Recurrent torsion following previous testicular fixation may appear many years following the primary procedure, even in cases in which either polyglactin or, notwithstanding, polypropylene sutures have been applied, in accordance with the common practice used in the last 2 decades. Increased awareness regarding this possibility is imperative for early diagnosis and prevention of testicular loss.     

Reducing the risk of infection for transrectal prostate biopsy with povidone–iodine: a systematic review and meta-analysis

Purpose

To evaluate the efficacy of povidone–iodine (PI) in reducing the risk of infectious complications following transrectal prostate biopsy (TRPB).

Methods

Eligible randomized controlled trials (RCTs) were identified from electronic databases (Cochrane CENTRAL, MEDLINE, and EMBASE). The database search, quality assessment, and data extraction were performed independently by two reviewers. The main outcome for the efficacy of PI was the incidence of infectious complications after TRPB.

Results

Seven trials, including 2,049 patients, met the inclusion criteria. Data from the seven included RCTs favored the use of PI before TRPB to prevent infectious complications. PI for “PI versus blank control” significantly reduced fever, bacteriuria, and bacteremia compared with that for control [relative risk (RR) 0.31; 95 % confidence interval (CI) 0.21–0.45, P < 0.00001]. With PI versus antibiotics (ATB), patients treated with ATB alone had a significantly greater risk of bacteremia (RR 0.38; 95 % CI 0.16–0.90, P = 0.03). In “PI plus ATB versus ATB” trials, the risk of fever (RR 0.11; 95 % CI 0.02–0.85, P = 0.03) and bacteremia (RR 0.25; 95 % CI 0.08–0.75, P = 0.01) was diminished in the “PI plus ATB” group.

Conclusions

Rectal disinfection with PI provides a safe and effective method to reduce the risk of infectious complications following TRPB, regardless of mono-prophylaxis and combined prophylaxis with PI and ATB. Large, multicenter, and prospective RCTs of good quality trials are needed to confirm the efficacy of PI.