Elsevier

European Urology

Volume 71, Issue 3, March 2017, Pages 353-365
European Urology

Platinum Priority – Review – Prostate Cancer
Editorial by Boris Gershman and Stephen A. Boorjian on pp. 366–367 of this issue
Complications After Systematic, Random, and Image-guided Prostate Biopsy

https://doi.org/10.1016/j.eururo.2016.08.004Get rights and content

Abstract

Context

Prostate biopsy (PB) represents the gold standard method to confirm the presence of cancer. In addition to traditional random or systematic approaches, a magnetic resonance imaging (MRI)–guided technique has been introduced recently.

Objective

To perform a systematic review of complications after transrectal ultrasound (TRUS)–guided, transperineal, and MRI-guided PB.

Evidence acquisition

We performed a systematic literature search of Web of Science, Embase, and Scopus databases up to October 2015, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Complications and mortality following random, systematic, and image-guided PBs were reviewed. Eighty-five references were included.

Evidence synthesis

The most frequent complication after PB was minor and self-limiting bleeding (hematuria and hematospermia), regardless of the biopsy approach. Occurrence of rectal bleeding was comparable for traditional TRUS-guided and image-guided PBs. Almost 25% of patients experienced lower urinary tract symptoms, but only a few had urinary retention, with higher rates after a transperineal approach. Temporary erectile dysfunction was not negligible, with a return to baseline after 1–6 mo. The incidence of infective complications is increasing, with higher rates among men with medical comorbidities and older age. Transperineal and in-bore MRI–targeted biopsy may reduce the risk of severe infectious complications. Mortality after PB is uncommon, regardless of biopsy technique.

Conclusions

Complications after PB are frequent but often self-limiting. The incidence of hospitalization due to severe infections is continuously increasing. The patient's general health status, risk factors, and likelihood of antimicrobial resistance should be carefully appraised before scheduling a PB.

Patient summary

We reviewed the variety and incidence of complications after prostate biopsy. Even if frequent, complications seldom represent a problem for the patient. The most troublesome complications are infections. To minimize this risk, the patient's medical condition should be carefully evaluated before biopsy.

Introduction

Prostate biopsy (PB), often guided by transrectal ultrasound (TRUS), is the gold standard technique to confirm the presence of cancer in men with suspicion for prostate malignancy. It is estimated that >2 million procedures are carried out in the United States and Europe every year [1], [2]. Although PB is often performed transrectally in an outpatient setting, it also can be performed by a transperineal approach, avoiding the rectum. Magnetic resonance imaging (MRI) was proposed recently for targeting biopsies toward suspicious areas to improve detection of clinically significant prostate cancer (PCa) [3]. The opportunity to perform a lesion-targeted biopsy could reduce the number of biopsy cores taken and thus lower complications rates without compromising detection rates. Our objective was to perform an updated systematic review of complication profiles after TRUS-guided systematic, transperineal, and MRI-targeted PB.

Section snippets

Evidence acquisition

A PubMed search for English-language publications up to October 2015 with the search terms prostate biopsy AND complications was performed. This initial search identified 7000 records. Another 60 contributions were retrieved through hand and free-text searches, including Web of Science, Embase, and Scopus databases, using the following search terms: fusion prostate biopsy AND complications; in-bore prostate biopsy; prostate biopsy AND erectile dysfunction OR erectile function; image-guided

Bleeding

PB is generally performed as a transrectal procedure under local anesthesia in an outpatient setting and is usually well tolerated. Postprocedural bleeding, voiding dysfunctions, and pain are common [1] but are not clinically significant and are seldom troublesome. Both patient-related factors (eg, use of anticoagulant medications, coagulopathies, medical comorbidities, prostate volume, obstructive symptoms, and anxiety) and procedure-related factors (eg, biopsy indication, technique, number of

Conclusions

The most frequently reported complication after PB is minor and self-limiting bleeding, regardless of the biopsy approach or technique. Some men also experience transient LUTS or ED. Although less common, acute urinary retention occur particularly after transperineal biopsy in patients with enlarged prostate or with more biopsy cores. Optimal pain control, either by topical or infiltrative anesthesia, reduces discomfort and improves biopsy acceptance. Compared with transrectal or transperineal

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