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Transperineal approach, rectal and equipment preparation reduce infection from prostate biopsy

Dr. Joseph Delano Fule Robles
11 Aug 2017

Infectious complications of prostate biopsy can be prevented by adopting the transperineal approach rather than the transrectal approach, and by pre-biopsy rectal disinfection and meticulous equipment preparation, according to data presented at the 15th Urological Association of Asia Congress held in Hong Kong.

Performing prostate biopsy via the perineum avoids the rectum and is associated with low rates of infectious complications, as stated in the American Urological Association’s updated white paper on the prevention and treatment of the more common complications related to prostate biopsy. [J Urol 2017, pii: S0022-5347(17)42253-1]

In a systematic review of 16 studies published in 2003–2013 with a total of 6,609 patients undergoing transperineal biopsy, the overall rate of sepsis was 0.076 percent.[BJU Int 2014;114:384-388]

Infections from transrectal prostate biopsy, on the other hand, have increased in recent years, with infectious complication rates ranging from 0.1 to 7 percent and sepsis rates ranging from 0.3 to 3.1 percent depending on antibiotic prophylaxis regimen and background antibiotic resistance in various geographic locations. [Infect Control Hosp Epidemiol 2013;34:269-273; J Urol 2011;186:1830-1834; Urology 2011;78:511-514; J Urol2010;183:963-968]

Pre-biopsy rectal disinfection with povidone-iodine was also documented to reduce rates of infectious complications from 5.3 to 0 percent (p=0.03) and sepsis from 1.6 to 0.95 percent (p=0.15). [World J Urol 2014;32:905-909; J Urol  2012;189:1326-1331]

“Rectal preparation is important because most of the pathogens causing post-biopsy infection come from the rectum,” said Dr James Tsu from the Department of Surgery, The University of Hong Kong.

A study using disinfectant (chlorhexidine)-coated needles and agar pre-coated with Escherichia coli showed significant reduction of bacterial transmission and sustained bacterial inhibition at needle puncture sites. [J Endourol 2013;27:277-283]

“This approach has only been tested in vitro on agar and has not been used clinically, so it is still a bit early to say whether it is really effective,” commented Tsu.

Disinfection of prostate biopsy needles using povidone-iodine and formalin, however, did not significantly reduce rates of urinary infection (p=0.74) and urinary infection and sepsis (p=0.13). [Urol Int 2010;85:147-151; J Urol 2013;190:1769-1775]

Published data also showed no significant difference in sepsis rates for prostate biopsy protocols of 6, 10 and 15 cores.[J Urol 2004;171:1478-1480]

A prospective randomized controlled trial of 100 patients receiving periprostatic block also showed no significant risk of septic complications vs no block. [J Urol 2002;168:558-61]

Infection is the most common complication of prostate biopsy, with fluoroquinolone-resistant E.coli playing a prominent role.

Adherence to standard principles of infection control and proper equipment sterilization are also essential. Infectious complications have been linked to contaminated ultrasound gel, placement of tissue samples on non-sterile foam pads, and improper processing of ultrasound transducer. [J Urol 2017, pii: S0022-5347(17)42253-1]

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