Catastrophic sepsis and hemorrhage following transrectal ultrasound guided prostate biopsies

Abstract

We report 2 cases of catastrophic complications following routine transrectal ultrasound guided prostate biopsy. The first patient incurred near-fatal septic shock due to multi-resistant Escherichia coli. Due to the severity of his shock, he developed bilateral leg gangrene requiring amputations. The second patient incurred significant hemorrhage eventually requiring an emergent general anesthesia and surgical management to control hemorrhage after other measures failed. While rare events, these reports emphasize the caution needed for physicians who routinely order prostate biopsies.Can Urol Assoc J 2010;4(1):E12-E14 Case 1A 63-year-old diabetic underwent transrectal ultrasound (TRUS)-guided prostate biopsy for an elevated PSA of 5.7 ng/mL and no findings on digital rectal examination (DRE). His past medical history included coronary bypass surgery, dyslipidemia and previous hospital admission for bronchitis. He smoked half a pack of cigarettes per day for 25 years.The day prior to his biopsy, he was initiated on ciprofloxacin 500 mg orally, 2 times a day. The night after his biopsy, he presented to the emergency room with a fever, chills, pain and breathlessness. He appeared septic, with a systolic blood pressure of 75 mmHg, temperature 39º C. Initial white blood count (WBC) was 1.1, with a critically low neutrophil count of 0.44. He was given fluids, ceftriaxone and flagyl in the emergency room. Subsequently, he was transferred to the intensive care unit (ICU) and started on ionotropes and empiric meropenem. He developed hypoxia and was intubated and sedated.During the first 4 days of admission, he continued to be unstable and hypotensive requiring ionotropic support and developing shock liver and renal failure. Solucortef and caspofungin were started; he also received a dose of amikacin. His WBC peaked at 42 on the fourth day of admission. Platelets remained very low at 21 and his international normalized ratio (INR) increased from normal to 2.13. Multi-resistant Escherichia coli was cultured from his blood and was initially only sensitive to amikacin, but eventually also found to be sensitive to meropenem.Against expectations, he survived and slowly recovered. A tracheostomy was performed, and he was eventually weaned off ventilation. As a result of his severe sepsis, he developed bilateral feet gangrene requiring bilateral below knee amputations. Further, he incurred ototoxicity requiring hearing aids. His thrombocytopenia, renal and liver failure resolved over time. He was in the ICU for a total of 46 days and in hospital for 85 days.His prostate biopsy did not show any evidence of malignancy. Case 2A 65-year-old pediatrician was sent for a TRUS biopsy of the prostate for a prostate-specific antigen (PSA) of 10.56 mg/L and a suspicious DRE. His medical history included coronary artery disease with previous coronary artery bypass grafting, hypertension and hypercholesterolemia. He had a mitral valve annuloplasty for mitral regurgitation. He experienced bleeding at the biopsy site immediately after ...

Biomarker potential of ST6GALNAC3 and ZNF660 promoter hypermethylation in prostate cancer tissue and liquid biopsies

“…Notably, the implementation in the 1990s of the serum prostate‐specific antigen (PSA) test as an initial indication for PC has led to a significant increase in PC incidence as well as in the number of biopsies performed. Prostate biopsy is associated with considerable risk of life‐threatening sepsis (Anderson et al ., ; Toren et al ., ), and a significant proportion of initial and repeat biopsies are negative for PC (Serag et al ., ). Thus, better minimally invasive or noninvasive PC biomarkers that can replace or supplement PSA are needed to secure early and more accurate diagnosis and to reduce unnecessary prostate biopsies.…”

The management of rectal bleeding following transrectal prostate biopsy: A review of the current literature

“…12 Severe rectal bleeding is thus an uncommon but potentially life-threatening complication and one of which both patients and practitioners should be aware. 13 Post biopsy rectal bleeding is most commonly just a Clavien-Dindo Grade I complication but as outlined above, on occasion, it can result in grade II (eg: blood transfusion required)-IV (organ dysfunction and ICU management) sequelae.…”

“…Specifically, reports suggest that it may be the SRA and MRA that bleed after biopsy. 13,17 Other reports suggest it is the rectal venous plexus which bleeds. 18 Regardless of the precise bleeding source, the anterior rectal wall is classically the location of the…”

Endoscopic Therapy in the Management of Patients With Severe Rectal Bleeding Following Transrectal Ultrasound-Guided Prostate Biopsy: A Case-Based Systematic Review

“…Prompt and appropriate management is warranted to avoid bleeding-related morbidity and mortality in such cases. 5 There are several reported methods to treat rectal hemorrhage after prostate biopsy, but it is traditionally managed by the urologist. Due to this reason, gastroenterology literature concerning endoscopic treatment of this major complication remains scarce.…”