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TRUS And TRUS GUIDED PROSTATE
BIOPSY
 INDICATIONS
 PATIENT PREPARATION
 TECHNIQUE
 COMPLICATIONS
 POST TRUS PROSTATITIS AND PROSTATIC
ABSCESS
INDICATIONS
1.
Diagnostic indications include the following:
 Early diagnosis of carcinoma of the prostate (CAP) when abnormal
DRE, an elevated PSA (>4.0 ng/ml) or PSA velocity (rate of PSA
change) >0.4 to 0.75ng/ml/yr..

Evaluation of men with azoospermia to rule out ejaculatory-duct
cysts, seminal vesicular cysts, müllerian cysts, or utricular cysts

Prostate Volume determination to plan treatment with
brachytherapy, cryotherapy, or minimally invasive BPH therapy (eg,
radiofrequency, microwave) and evaluation during hormonal
downsizing for brachytherapy,
 previously treated with curative intent for prostate
cancer (i.e. radical prostatectomy, radiation therapy,
and cryotherapy) . (follow up )
 neoplasia (PIN) or atypia on a previous prostate
needle biopsy.
2. Therapeutic indications the following:
 include
 Brachytherapy for CAP
 Cryotherapy for CAP
 aspiration of ejaculatory ducts, prostatic cysts, or
prostatic abscesses
 Patient preparation:
 fluoroquinolone antibiotic prior to the procedure and a second dose 12
hours later is the protocol most commonly recommended for antibiotic
coverage
 cleansing enema (sodium phosphate and dibasic
sodium phosphate).
 aspirin and NSAIDS must be discontinued for seven and three days
respectively .
 Patients on anticoagulation therapy are not biopsied until the
anticoagulant dosage is adjusted or held .
 Techniques :
Positioning should be left lateral, lithotomy, or kneeelbow.
Local anesthesia : Although the procedure was
performed without any infiltrative anesthesia in the
past it is a common practice to use lidocaine
infiltration in the periprostatic area.
 . A topical anesthetic ointment is applied to the index
finger prior to performing the DRE.
 A 5.0 to 7.5mHz transducer is used for transrectal imaging
of the prostate.
 The probe is gently advanced into the rectum, to the base
of the bladder until the seminal vesicles are visualized.
 Volume = height X width X length X 0.52
 Biopsy :
Biopsies are best performed with a spring-driven needle core
biopsy device (or biopsy gun), which can be passed through
the needle guide attached to the ultrasound probe.
biopsies are obtained from any area deemed as suggestive (ie,
hyperechoic) based on ultrasonographic findings or based
on palpable abnormalities after digital rectal examination.
Obtain separate biopsy samples from each sextant of the
prostate.
 . Originally, these biopsy sites included :
midlobe
parasagittal plane at the apex,
the mid gland,
and the base, bilaterally.
 Many authors subsequently recommended that these 6
biopsy samples be obtained from
the lateral third of each lobe
2 lateral biopsy samples be obtained from each lobe
the original sextant samples (termed the 10-biopsy
scheme).
BIOPSY COMPLICATIONS
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PROSTATITIS AND PROSTATIC ABCSESS .
Septicemia
Infections
Hemorrhages
Arteriovenous Fistula
Tumor dissemination
Bladder perforation
Urinary obstruction
Severe pain
PROSTATITIS AND ABCSESS
 Infection of the prostate gland, or prostatitis, is a risk of prostate
biopsy. The rectum normally stores bacteria-laden fecal material until
it's passed during a bowel movement.
 Despite the use of cleansing enema before the procedure, residual fecal
bacteria remain in the rectum.
 In an effort to prevent infection, antibiotics are typically administered
shortly before a prostate biopsy and are continued for a few days after
the procedure.
 Despite precautionary efforts, bacteria may be introduced into the
prostate during the biopsy procedure, causing acute prostatitis
Incidence of Acute Prostatitis Caused by Extended-spectrum β-Lactamase-producing
Escherichia coli After Transrectal Prostate Biopsy
Urology, Volume 74, Issue 1, Pages 119-123
E. Özden, Y. Bostanci, K. Yakupoglu, E. Akdeniz, A. Yılmaz, N. Tulek, S. Sarıkaya.

Abstract
 Objectives To study the clinical and bacteriologic picture of acute prostatitis caused by
extended-spectrum β-lactamase (ESBL)-producing Escherichia coli after transrectal
ultrasound-guided prostate biopsy.
 Methods The retrospective data from 1339 patients who had undergone transrectal
ultrasound-guided biopsy from November 2003 to June 2008 were reviewed. An
automatic biopsy gun with an 18-gauge needle was used to obtain 10-core biopsies for
first biopsies and ≥12-core for repeat biopsies. These patients had received 500 mg
ciprofloxacin orally twice daily for 5 days, beginning 24 hours before biopsy. All biopsies
were performed as outpatient procedures.

Results Of the 1339 patients, 28 (2.1%) had acute bacterial prostatitis detected after transrectal
ultrasound-guided prostate biopsy. Acute prostatitis occurred after the first biopsy in 15 patients
(1.3%) and after repeat biopsy in 13 (6.8%).

The patients had developed infective symptoms a mean of 3 days after transrectal ultrasound-guided
prostate biopsy. Of the 28 patients, 17 (61%) had positive urine and/or blood cultures, including E.
coli in 14. Of the 14 patients, 6 had acute prostatitis caused by ESBL-producing E. coli. All patients
with ESBL-producing E. coli were treated with imipenem. The bacteria detected in these urine
cultures were resistant to ciprofloxacin, ceftriaxone, sulbactam/ampicillin, and cefazolin. Imipenem
and piperacillin-tazobactam were the most active agents against ESBL-producing E. coli. ESBLproducing isolates had a significant reduction in activity for most antimicrobial agents, including
fluoroquinolones and amikacin.

Conclusions : prostatitis is a complication of TRUS biopsy and different organism can cause it
including ESBL . The prompt initiation of effective antimicrobial treatment is essential in patients
with ESBL-producing E. coli, and empirical decisions must be determined by knowledge of the local
distribution of pathogens and their susceptibility.
PROSTATITIS AND ABCSESS
 Epidemiology and treatment of acute prostatitis after prostatic biopsy
Stoica G, Cariou G, Colau A ortesse A Hoffmann P Schaetz A,Sellam R
Service d'urologie, Groupe Hospitalier Diaconesses Croix Saint-Simon, Hôpital des Diaconesses, Paris.
 Abstract
 OBJECTIVE: Acute prostatitis is the main complication of prostatic
biopsies (PB) and sometimes requires hospitalisation and appropriate
antibiotic therapy. This study evaluated the pathogens responsible and
proposes a statistically adapted empirical antibiotic therapy.
 PATIENTS AND METHODS: This retrospective (from 2000 to 2006)
two-centre study included 17 patients hospitalised for acute prostatitis
after PB in a series of 1,216 biopsies. Bacteriological documentation was
based on urine cultures, blood cultures, identification of bacteria and
antibiotic susceptibility testing.
 RESULTS: All patients received prophylactic antibiotics with a single
dose of systemic fluoroquinolone at least 1 h before PB. Bacterial
identification was possible in fourteen cases
 Only urine culture was positive in 6 cases (35%), only blood culture was
positive in 3 cases (17%), and urine cultures and blood cultures were
positive and concordant in 5 cases (29%). A high rate of resistance of E.
coli to fluoroquinolones was observed in 88% of cases and to
cotrimoxazole in 77% of cases. However, the strain was susceptible to
second and third generation cephalosporins (2GC and 3GC) and
amikacin in 100% of cases. Prostatitis was associated with epididymoorchitis (3 cases), acute urinary retention (4 cases) and infective
endocarditis (1 case).
 CONCLUSIONS: Identification of the micro-organism responsible for
acute prostatitis after biopsy requires a combination of blood cultures
and urine cultures. Empirical antibiotic therapy is based on the use of
2GC or 3GC, alone or in combination with amikacin depending on the
severity of the clinical features.
PROSTATITIS AND ABCSESS
 incidence and characteristics of acute bacterial prostatitis after transrectal prostate
biopsy
Journal of Infection and Chemotherapy Volume 14, Number 1
Kazuyoshi Shigehara, Tohru Miyai, Takao Nakashima and Masayoshi Shimamura
Department of Urology, Ishikawa Prefectural Central Hospital, 2-1 Kuratsukihigashi, Kanazawa, Ishikawa, Japan
 Abstract
 based on urine and blood cultures, treatment method, and outcome. Four hundred and
fifty-seven patients who underwent transrectal prostate biopsy in our hospital between
November 2003 and October 2006 were reviewed.
 These patients were treated with 200 mg levofloxacin orally twice daily for 4 days,
beginning 12 h before biopsy, and with 200 mg isepamicin sulfate given intravenously just
before the biopsy. In patients who developed acute prostatitis urine and blood cultures
were checked. All organisms isolated in urine or blood cultures were tested for antibiotic
susceptibility of the 457 patients, first-biopsy was performed in 371 and re-biopsy was
done in 86. Acute bacterial prostatitis developed in 6 patients (1.3%). Acute prostatitis
developed after a first-biopsy in 2 patients (0.5%) and after re-biopsy in 4 patients
(4.7%), showing a significant
 difference. All of the urine and blood cultures yielded
levofloxacin-resistant Escherichia coli. Immediate intravenous
cephalosporin or carbapenem was effective for all of these
patients.
 Conclusion:
that the use of levofloxacin could be a risk factor for acute
bacterial prostatitis after transrectal prostate biopsy, due to an
increase in fluoroquinolone-resistant E. coli in the rectum. The
incidence of prostatitis was higher in re-biopsy patients. We
consider that patients should receive levofloxacin for a shorter
period before biopsy to avoid generating fluoroquinoloneresistant strains. Treatment with cephalosporin or carbapenem is
recommended for patients with acute prostatitis after prostate
biopsy.
 Prostatic abscess after transrectal ultrasound guided biopsy.
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Sohlberg OE, Chetner M, Ploch N, Brawer MK.
Department of Urology, University of Washington, Seattle.
 Abstract
 We report a case of a diabetic man who had bilateral prostatic
abscesses after ultrasound guided biopsy of the prostate. As is typical
of prostatic abscesses, the diagnosis was not evident at presentation.
We discuss the morbidity of transrectal biopsy and recommend
consistent antimicrobial prophylaxis. We also recommend transrectal
ultrasound in the diagnosis of such abscesses, and support the
standard treatment of drainage and parenteral antimicrobial therapy.
We anticipate that the incidence of prostatic abscess will increase due
to the increasing number of men undergoing transrectal biopsy in the
current age of transrectal ultrasound guided biopsy.
PROSTATITIS AND ABCSESS
 Lab Studies:
 Prostatic secretions
 Urinalysis,
 blood culture
 Increased serum prostate-specific antigen (PSA)
 Imaging studies, including a CT scan of the pelvis

prostate ultrasonography,
should be reserved for those cases where laboratory analysis is equivocal or when no
improvement is observed following medical therapy. Ruling out complications of
prostatitis (eg, prostatic abscess) is a strong indication to proceed to imaging studies.
 Diagnostic Procedures:
 Performing a prostate biopsy is contraindicated in suspected ABP because of the
potential complication of seeding the bacterial infection in adjacent organs.
Furthermore, prostate biopsy is extremely painful and may cause or larger areas of the
prostate become necrotic.
 TREATMENT
 Medical therapy:
 Hospitalization is required for patients in whom acute urinary
retention develops and in those who require intravenous antimicrobial
therapy.
 The choice of antibiotic is based on results of the initial culture and
sensitivity.
 initial therapy should be directed at gram-negative enteric bacteria.
Useful agents include fluoroquinolones, trimethoprimsulfamethoxazole, and ampicillin with gentamicin.
 Antipyretics, analgesics, stool softeners, bed rest, and increased fluid
intake provide supportive therapy.
 For IV therapy, use trimethoprim-sulfamethoxazole ,
 an appropriate oral agent can be substituted for an additional 30 days.
 For oral therapy, use trimethoprim-sulfamethoxazole (Bactrim),
ciprofloxacin; norfloxacin, ofloxacin, or enoxacin, for 30 days when
clinical response is favorable.
 Surgical therapy:
 Surgical drainage of a prostatic abscess can be accomplished by either
transrectal or perineal aspiration or transurethral resection. Because of
the potential for systemic infection and bacteremia, urethral
instrumentation should be avoided in ABP, especially if the patient is
unstable or already showing signs of sepsis.