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.