JCU - January 2022 - 55

Rodrigues et al.
55
Keywords
Transrectal prostate biopsy, comorbidity profile, augmented prophylaxis, complication, rectal swab
Date received: 21 July 2020; accepted: 3 December 2020
Introduction
Prostate cancer (PCa) is the most prevalent solid cancer
and the third leading cause of mortality in men.1 The early
diagnosis based on screening strategies and new treatments
has improved the specific mortality rates of this
neoplasia.1-3 In addition, novel biomarkers and strategies,
such as pre-biopsy magnetic resonance imaging (MRI),
have decreased the inherent morbidity of the screening.4-6
All these improvements have imposed fewer complications
and better results over the PCa diagnosis process.
The transrectal ultrasound (TRUS)-guided prostatic biopsy
persists as the gold standard diagnostic technique, despite
recent
studies on MRI and transperineal pathway.7,8
Unfortunately, prostate biopsies have non-negligible rates
of morbidity and mortality.9
Over the last decades, different strategies to decrease
biopsy-related complications have been implemented,
such as bowel preparation, pre-operative studies of the
rectal flora, escalated antibiotic prophylaxis regimens,
transperineal pathway and best selection of patients
through MRI.10 These initiatives have decreased the incidence
of infection-related events and changed the profile
of post-biopsy complications.10,11 However, they are
based on a previous scenario of high rates of post-biopsy
infections following outdated prophylaxis regimes.
Potentially, the presence of risk factors could guide to the
choice for other antibiotic prophylaxis, indicate a transperineal
pathway, or even contraindication to the procedure
in extreme situations.9-12
Our null hypothesis is that the variables associated with
post-biopsy complications under augmented prophylaxis
protocol will not differ from the previously reported risk
factors in the literature. The main objective is to describe
the complications and possible risk factors associated with
TRUS-guided prostate-biopsy complications under augmented
prophylaxis. This protocol was designed and proposed
before the international recommendations for
fluoroquinolone restrictions.13
Material and methods
Study design
This is a retrospective cohort study, that included patients
who underwent TRUS-guided prostate biopsies in two
independent public Brazilian medical institutions. The
study included 404 patients. The respective institutional
review boards approved the protocol, and the informed
consent was dismissed as data were recovered from patient
charts. Subjects were divided into two groups, according
to the presence (Group 1) or absence (Group 2) of major
post-biopsy complications. Patients were also grouped
according to the presence or absence of antibiotic resistance
of rectal microbiota. Individual relative risks, for all
complications and infections, were calculated.
Patient characteristics
Patients referred for prostate cancer diagnosis who underwent
prostatic biopsies at the Medical Specialties
Outpatients Clinics (AME) of Américo Brasiliense
between December 2011 and December 2013, and AME of
Barretos between January 2014 and January 2016, were
included. These periods were coincidental with the first
year of local implementation of the prostatic biopsy protocol.
We followed the 2011 Urological Brazilian Society
orientations for early detection of prostate cancer.14
Patients with previous prostatic surgery or radiation,
chronic prostatitis or urethral stenosis were excluded.
Demographic and data from the clinical evaluation
were registered, including results from blood samples
and ultrasound parameters. The biopsy complication
rates were also annotated based on active tracking, such
as infections, acute urinary retention (AUR) and bleeding
requiring intervention (local compression, the need of
indwelling catheter for irrigation) or hospitalization. We
grouped hematuria and rectal bleeding in this report as
'hemorrhage', for statistical analysis. The comorbidities
were assessed using the age-adjusted and age-unadjusted
Charlson Comorbidity Index (CCI), and a simple count
of Charlson comorbidities, referred to a number of
comorbidities.15,16
Biopsy protocol
Patient assessment and preparation. Patients were oriented
to use ciprofloxacin 500 mg, orally administered every 12
h, initiating 24 h before the procedure and extended for 5
days. Intravenous Gentamicin, 3 mg/kg, was administered
30 min before the biopsy. Patients with elevated serum
creatinine levels received 1 g of intravenous Ceftriaxone
as an alternative. All patients were instructed to perform a
phosphate rectal enema 2 h in advance to the procedure.
Biopsies were guided by an endorectal probe at a frequency
of 8-10 MHz. Prostate (cm3), transitional zone
(cm3) and post-voiding residual volumes (ml) and the
length of intra-prostatic projection (mm) were recorded.
Rectal lidocaine gel 2% was used 30 min before the

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