Discussion
Prebiopsy preparation with a cleansing rectal enema is a well-tolerated and low-cost process, and our findings show that it significantly reduces UTI after TRUS-bx. We observed that administering two enemas, the first on the biopsy morning and the second half an hour before, significantly decreased infection and related complications.
Prostate cancer is an essential health concern in urology practice, and TRUS-bx remains the most preferred diagnostic method. Unfortunately, however, biopsy-related complications are an important cause of morbidity with three major issues frequently seen: rectal bleeding, difficulty in urination, and infective complications that require treatment (13). A large population-based study comparing TRUS-bx and TPUS-bx found that infections were higher following the rectal approach, with a sepsis rate of 1.35%, although the readmission rate was higher among TPUS-bx patients (14).
Various factors affecting biopsy-related infection have been identified in the literature (4, 15). A nationwide study in Taiwan involving 12,968 TRUS-bx procedures found that 6.59% of patients had infection complications and demonstrated that age, prostate cancer, and hospitalization were significant risk factors for severe infection (13). Elsewhere, a 10-year case-control investigation showed that infectious complications rose in the study period, and that recent hospitalization, diabetes, and chronic pulmonary obstructive disease from smoking were significant risk factors for infection (4). Similarly, our study demonstrates that age, diabetes, and prostate cancer are significantly higher in patients with postbiopsy UTI, and the involvement of both diabetes and age are independent risk factors for biopsy-related infections of this kind.
To prevent subsequent complications, good preoperative planning is crucial. Existing studies have evaluated the role of rectal preparation in preventing infective problems following prostate biopsy (6, 16, 17). A randomized control study showed that mechanical bowel preparation before rectal surgery can significantly decrease infectious complications (17) while a retrospective study demonstrated that the number of biopsy cores and the use of an enema had a significant association with infection, prompting the recommendation of enema before prostate biopsy to minimize the risk of infectious complications (16).
Studies have also been conducted into novel forms of rectal decontamination and report that povidone-iodine administration can significantly reduce postbiopsy infection (6, 18, 19). A further systematic review found that a povidone-iodine enema can significantly reduce the risk of bacteremia and bacteriuria (5). A randomized control study comparing antimicrobial and standard lubricants demonstrated that the antimicrobial option significantly decreased bacterial colonization; however did not reduced quinolone resistance bacterial growth and also reported that there was significant difference between groups in terms of fever and readmission rate (20).
Further to these results, our study suggests that a second rectal administration could decrease infectious complications. The advantages of such preparation methods are that they are easy to administer, have low costs, and the effect of their administration is regardless of microbial antibiotic resistance patterns. In diabetic patients, hyperglycemic-related impairment of the immune response may increase the risk of infectious complications, hence only including those with regulated glycemic levels, and our study demonstrates that a second enema reduces infection in patients with diabetes mellitus. We therefore suggest that an additional prebiopsy enema could be beneficial in other patients who are prone to infectious complications.
There are some limitations of our study. First, routine rectal cultures were not taken. Although studies have shown that this plays a preventative role for infective complications because of targeted prophylaxis, guidelines do not yet recommend it as routine practice (21, 22). Second, the biopsies were performed by several staff, and so exposure time could vary. That said, all procedures were performed by experienced residents following standard protocols. Last, the study was retrospective in nature and based on a single center meaning that those with bacterial resistance may change during the period in question. We nevertheless also observed that there was no difference in bacteria-related complications during the study period.