Chapter 20: Diagnostic investigations
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Post‐procedural considerations
Immediate care
Management of acute post‐biopsy complications
Patients should be discharged with clear instructions on recognizing post‐biopsy complications. Depending on the indication, patients with a severe complication (fever, urinary tract infection, acute bacterial prostatitis) after TRUS‐guided prostate biopsy should have a course of antibiotic treatment (i.e. not just antibiotic prophylaxis for the prevention of surgical site infections). Some patients may require admission to hospital, such as those requiring intravenous antibiotics (urosepsis), or require catheter insertion (clot retention). Prompt recognition and initiation of antibiotic and support measures can save lives (Vassalos and Rooney [165]).
Biopsy complications
Acute bleeding – rectum (< 2 days 1.3–45%, > 2 days 0.7–2.5%)
A small volume of per‐rectal bleeding is expected after the procedure. In the instance of abnormal significant bleeding the procedure should be stopped and transrectal direct finger pressure must be applied. The insertion of a balloon tamponade with a large‐bore Foley catheter (50 mL saline in the balloon) is the next step (Challacombe et al. [25]). In the case of continuous bleeding, the patient should be admitted for observation and the consultant/urology specialist registrar should be informed.
Acute bleeding – urethra
Spontaneous urethral bleeding is not common but can occur during TRUS biopsy. If the bleeding does not subside, the patient should be admitted and the consultant/urology specialist registrar should be informed. A three‐way 18 Fr Foley catheter should be inserted, with gentle traction applied over the bladder neck (Rodriguez and Terris [140]).
Haematospermia (1.1–93%)
A small volume of blood in the semen is known as haematospermia. Prostate biopsy is the most common cause of blood in the semen. In the case of very vascular prostates it can take up to 6 weeks for haematospermia to clear up. There is no treatment.
Haematuria
Some degree of haematuria is very common. If the patient has severe haematuria with clot retention, he should be admitted. A 22 Fr three‐way silicone Foley catheter should be inserted, followed by bladder washout and continuous bladder irrigation with normal saline. In case of severe bleeding, formal washout in theatre may be required (Challacombe et al. [25]).
Urinary retention (0.2–1.7%)
All patients must spontaneously void before being discharged. If a patient complains of abdominal pain with inability to void or has no pain but a full bladder (confirmed on ultrasound), an 18 Fr Foley catheter should be inserted. An alpha‐blocker, e.g. tamsulosin 400 μg, should be prescribed, and a trial of voiding without catheter should be booked to take place 7–10 days later (Batura and Gopal Rao [9], Challacombe et al. [25], Feliciano et al. [47]).
Vasovagal syncope
If the patient enters a pre‐syncope state, the procedure should be immediately stopped. The probe should be removed from the rectum and the patient should be positioned in dorsal decubitus with a 30° Trendelenburg (on back, head down) position. Vital signs should be recorded. In case of complete loss of consciousness or sustained instability, the resuscitation or emergency team should be informed (Aydin et al. [7]).
Ongoing care
Post prostate biopsy review appointment
It is good practice to organize a return appointment for the patient to discuss the results of their biopsy before they have left the department. This will reduce the patient's anxiety caused by waiting for an appointment in the post. Usually this appointment is made 7–14 days after the biopsy to ensure the results are acted on expediently.
Audit
It is essential that the practitioner maintains a record of all procedures undertaken. This includes the review of histology results. This enables the practitioner to provide evidence of good practice and areas for improvement and development (Turner and Pati [163]).
