ISSN 2465-8243(Print) / ISSN 2465-8510(Online) http://dx.doi.org/10.14777/uti.2015.10.2.120 Original Article Urogenit Tract Infect 2015;10(2):120-125

Characteristics of Patients Who Visited the Emergency Room after : Single Center Retrospective Study

Seung Chan Jeong, Seungsoo Lee, Jae Min Chung, Sang Don Lee

Department of , Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea

Purpose: To educate patients and prevent biopsy-related complications, Received: 22 September, 2015 it is helpful to understand the causes for visiting the emergency room (ER). Revised: 17 October, 2015 Accepted: 19 October, 2015 Therefore, we want to analyze the causes and factors of complications that cause patients to visit the ER after prostate biopsy. Materials and Methods: We conducted a study of in-patients who visited the ER of Pusan National University Yangsan Hospital after prostate biopsy from De- cember 2008 to July 2015. Age, postoperative interval before visiting the ER, Charlson comorbidity index (CCI) score, symptoms in ER, prostate size, pathologic result, and number of biopsy cores were analyzed retrospectively. Results: Among all 1,694 cases of patients who had undergone prostate during a 7-year period, only 37 patients (2.2%) visited the ER. Diabetes mellitus (DM) is the most common underlying disease among patients with accompanying infection-related symptoms compared to patients with accompanying non-infec- tion-related symptoms (p＜0.001). In univariate analysis, DM (p=0.004) and CCI score (p=0.030) were statistically significant risk factors for infection, but only DM was significant in multivariate analysis (p=0.004). Prostate size (p=0.044) was a significant risk factor for acute urinary retention (AUR) in univariate analysis, but not statistically significant in multivariate analysis. CCI score was a statistically significant risk factor for bleeding (p=0.005 [univariate], 0.035 [multivariate]). Conclusions: AUR after transrectal ultrasound-biopsy is the most common reason for visiting the ER. CCI score showed correlation with bleeding and DM showed correlation with infection. Consideration of risk factors of complications after prostate biopsy will be helpful to the patients in the treatment and prevention of complication.

Keywords: Infection; Diabetes mellitus; Comorbidity; Biopsy; Prostate

Correspondence to: Sang Don Lee Copyright 2015, Korean Association of Urogenital Tract Infection and Inflammation. All rights reserved. http://orcid.org/0000-0001-9459-3887 This is an open access article distributed under the terms of the Creative Commons Attribution Department of Urology, Pusan National University Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yang- unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is san 50612, Korea properly cited. Tel: +82-55-360-2134, Fax: +82-55-360-2164 E-mail: [email protected]

INTRODUCTION nization of diet. Transrectal ultrasound (TRUS)-guided pro- state biopsy is the standard procedure commonly performed (PCA) is the most frequently diagnosed for patients with elevated prostate-specific antigen (PSA≥4 cancer among males in western countries. In South Korea, ng/ml) or abnormal digital . The benefits incidence of PCA has shown a continuous increase, because and risks of prostate biopsy for PCA screening and treatment of the rapid increase of the aged population and wester- are under debate. Although minor complications such as

120 Seung Chan Jeong, et al. The Reasons for Visiting the ER after Prostate Biopsy 121 voiding difficulty, dysuria and bleeding are frequent, major 17 patients (45.9%) were diagnosed with PCA. After prostate complications are not common after prostate biopsy [1]. biopsy, mean interval to visit the ER was 3.4±0.6 days. In the majority of cases, prostate biopsy was performed TRUS-guided prostate biopsy was performed in the out- in the outpatient setting. Patients who developed a com- patient setting, except one patient in whom it was performed plication visited the emergency room (ER). The objective during hospitalization. of this study was to analyze the causes and factors of Eight patients complained of hematuria, one of whom complications that cause patients to visit the ER after also complained of rectal bleeding. Three patients among TRUS-guided prostate biopsy. eight patients were hospitalized because of severe bleeding and anxiety. The one patient with accompanying rectal MATERIALS AND METHODS bleeding required indwelling of a Foley catheter, and squee- zing the area with gauze, the patient was hospitalized in Our study was conducted on 37 patients who visited the gastroenterology division. Thirteen patients complained the ER after prostate biopsy among all patients who under- of AUR, three of whom were hospitalized after receiving went TRUS-guided prostate biopsy from December 2008 an indwelling Foley catheter, and 10 patients were dis- to July 2015 at Pusan National University Yangsan Hospital charged to the ER after receiving an indwelling Foley catheter (Yangsan, Korea). or using a Nelaton catheter. We compared and studied three complications: infection- Six patients complained of fever and myalgia, three of related symptoms, acute urinary retention (AUR), and bleed- whom complained of neurological abnormality such as ing such as hematuria or rectal bleeding. In our study, the syncope at the same time were diagnosed with stroke and Charlson comorbidity index (CCI) was used as an indicator hospitalized in the department of neurology; among these, of comorbidity. CCI was stratified according to four catego- one patient who complained of chest pain showed no ries: 1: CCI=0 (control), 2: CCI=1, 3: CCI=2, 4: CCI≥3 [2]. abnormal findings. Three patients were hospitalized in the The risk factors following TRUS-guided prostate biopsy Department of Urology. included age, PSA, prostate size, PCA, diabetes mellitus Six patients complained of nausea and dizziness, but (DM), and CCI score. there were no abnormal findings in evaluation. After hyd- We respectively analyzed and compared age, interval ration and taking absolute rest, the symptoms were relieved, to revisit ER after prostate biopsy, CCI score, symptoms so that all six patients were discharged. in ER, prostate size, the relevance of the PCA and the Four patients who complained of dysuria were discharged number of biopsy cores, using PASW ver. 18 software (IBM after pain control. Co., Armonk, NY, USA). Relative risk was calculated using None of the patients underwent transfusion, and the chi-square and logistic regression tests. patient with accompanying rectal bleeding did not undergo This study was approved by the Institutional Review endoscopic management; after squeezing, the symptoms Board of Pusan National University Yangsan Hospital (IRB were relieved. 05-2015-011). After primary treatment, 25 patients (67.6%) were dis- charged and 12 patients (32.4%) were admitted to hospital. RESULTS The symptoms of admitted patients were fever (6), AUR (3), hematuria (2), and rectal bleeding with hematuria (1), During our 7-year single institutional study, 1,694 TRUS- among whom one patient died despite administration of guided prostate biopsies were performed. Among the cases, broad-spectrum antibiotics. 37 patients (2.2%) visited the ER within 2 weeks postopera- DM is the most frequent underlying disease among tively. The mean age of patients who visited the ER after patients with accompanying infection-related symptoms prostate biopsy was 66.8±1.3 years, mean prostate size compared to the patients with accompanying non-infection- was 50.0±2.7 ml, and mean PSA was 17.7±4.6 ng/ml. related symptoms (p＜0.001) (Table 1). The mean CCI score was 3.8±0.2 points. DM (p=0.004) and CCI (p=0.030) were statistically signi- Among patients who visited the ER after prostate biopsy, ficant risk factors for infection in univariate analysis;

Urogenit Tract Infect Vol. 10, No. 2, October 2015 122 Seung Chan Jeong, et al. The Reasons for Visiting the ER after Prostate Biopsy however, in multivariate analysis only DM was a significant DISCUSSION risk factor for infection (p=0.004) (Table 2). Prostate size (p=0.044) was a significant risk factor for TRUS-guided prostate biopsy is a standard procedure AUR in univariate analysis but not in multivariate analysis commonly performed for patients with elevated PSA ≥4 (Table 3). ng/ml or abnormal digital rectal examination. As the inci- CCI score was a statistically significant risk factor for dence and prevalence of PCA increase, concern over pros- bleeding (p=0.005, 0.035) (Table 4). tate biopsy-related complications is rising. One patient among six patients who complained of fever and myalgia died, despite administration of broad-spectrum antibiotics. In our single institutional 7-year study, sepsis-related mortality after

Table 1. Overall characteristics of patients who visited the emergency room after prostate biopsy Overall Infection group Non-infection group p-value No. of patients 37 6 31 Age (yr) 66.8±1.3 68.3±4.6 66.5±8.4 0.614 Interval (d) 3.4±0.6 4.2±3.3 3.3±3.9 0.612 CCI 3.8±0.2 5.0±1.4 3.5±1.3 0.014 DM 14/37 (37.8) 5/6 (83.3) 9/31 (29.0) ＜0.001 Prostate cancer 17/37 (46.0) 1/6 (16.7) 16/31 (51.6) 0.116 Admission 12/37 (32.4) 6/6 (100) 6/31 (19.4) ＜0.001 PSA (ng/ml) 17.7±4.6 15.3±25.0 18.2±29.0 0.82 Prostate size (ml) 50.0±2.7 50.6±14.0 49.9±17.3 0.921 No. of biopsy core 11.0±0.3 10.7±1.0 11.0±1.6 0.67 Values are presented as number, mean±standard deviation, or number/total number (%). Infection group: infection-related symptoms group, Non-infection group: non-infection-related symptoms group, Interval: interval to revisit emergency room after biopsy, CCI: Charlson comorbidity index, DM: diabetes mellitus, Prostate cancer: prostate cancer diagnosed following prostate biopsy, PSA: prostate-specific antigen.

Table 2. Risk factors for infection after transrectal ultrasound-guided prostate biopsy Infection-related symptoms (n=6, 16.2%) Risk factor Univariate RR 95% CI p-value Multivariate RR 95% CI p-value Age 0.970 0.864-1.088 0.604 1.36 0.765-2.419 0.295 CCI 0.405 0.179-0.916 0.030 0.2 0.015-2.706 0.226 Prostate cancer 0.188 0.020-1.796 0.147 1.278 0.009-1.907 0.923 DM 3.375 3.093-3.865 0.004 3.375 3.092-3.682 0.004 PSA 1.004 0.970-1.040 0.814 0.992 0.906-1.087 0.870 Biopsy number 1.127 0.665-1.910 0.658 1.854 0.369-9.308 0.453 Prostate size 0.997 0.946-1.051 0.918 1.027 0.895-1.177 0.707 RR: relative risk, CI: confidence interval, CCI: Charlson comorbidity index, DM: diabetes mellitus, PSA: prostate-specific antigen.

Table 3. Risk factors for acute urinary retention after transrectal ultrasound-guided prostate biopsy Acute urinary retention (n=13, 35.1%) Risk factor Univariate RR 95% CI p-value Multivariate RR 95% CI p-value Age 0.950 0.867-1.041 0.075 0.098 0.811-1.018 0.097 CCI 1.055 0.642-1.734 0.083 5.340 0.771-3.697 0.090 Prostate cancer 2.667 0.664-10.704 0.167 6.292 0.519-7.625 0.149 DM 0.001 0.001-0.002 0.999 0.001 0.001-0.003 0.900 PSA 0.988 0.964-1.013 0.352 1.056 1.056-0.993 0.085 Biopsy number 1.531 0.922-2.544 0.100 2.559 0.973-6.727 0.057 Prostate size 0.914 0.914-0.999 0.044 0.905 0.811-1.010 0.075 RR: relative risk, CI: confidence interval, CCI: Charlson comorbidity index, DM: diabetes mellitus, PSA: prostate-specific antigen.

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Table 4. Risk factors for bleeding after transrectal ultrasound-guided prostate biopsy Bleeding (n=8, 21.6%) Risk factor Univariate RR 95% CI p-value Multivariate RR 95% CI p-value Age 1.067 0.962-1.184 0.221 0.864 0.001-3.414 0.365 CCI 2.098 0.990-4.444 0.050 3.352 1.089-10.320 0.035 Prostate cancer 2.361 0.472-11.822 0.296 2.394 0.174-3.283 0.514 DM 0.375 0.040-3.551 0.392 2.290 0.079-6.615 0.629 PSA 0.995 0.968-1.022 0.697 0.910 0.827-1.001 0.053 Biopsy number 0.390 0.130-1.169 0.093 0.088 0.004-1.893 0.120 Prostate size 1.013 0.963-1.065 0.615 0.996 0.901-1.101 0.931 RR: relative risk, CI: confidence interval, CCI: Charlson comorbidity index, DM: diabetes mellitus, PSA: prostate-specific antigen. prostate biopsy was 0.06%. This result is lower than the indwelling Foley catheter or using a Nelaton catheter. On three-country (Finland, Netherlands, and Sweden) European the other hand, infection-related symptom (0.35%, 16.2%) Randomized Study of Screening for Prostate Cancer (ERSPC) was the least common cause of the ER visit, but the most trial rate of 0.24% [3]. It is also lower than the 0.13% common symptom among patients in hospitalization. The sepsis-related mortality reported by Wei et al. [4]. infection complication rate in the Rotterdam section of the Previous studies have reported an extremely minimal ERSPC was 4.2% [8], higher than our study. Among the sepsis-related mortality rate following TRUS biopsy. PCA 72,500 biopsies performed in the United Kingdom, can be detected in the early stage by TRUS-prostate biopsy, 2.15-3.6% patients were readmitted because of infection- thus it may reduce mortality of individuals diagnosed with related complications [9]. In the Global Prevalence Study PCA. Among 1,694 TRUS-guided prostate biopsies, 37 of Infections in Urology, 3.5% of patients complained of patients (2.2%) who visited the ER within two weeks were febrile UTI, and 3.1% required hospitalization after prostate the subject of our study. In our study, 17 patients (45.9%) biopsy [10]. were diagnosed with PCA, much higher than the 32.3% Simsir et al. [11] reported a similar frequency of 3.06%. in the PLCO trial [5], the 17.1% in the Surveillance Epi- However, other studies from North America [12,13] reported demiology and End Result study (SEER) [6], and the 36% lower rates of sepsis (0.6%), and an Asian study [14] reported reported by Wei et al. [4]. This may be due to the limited that 0.5% of prostate biopsy cases had fever, similar to scope of the current study. the data of our study. Infection is a well-established risk of TRUS-biopsy [7]. An Asian study reported no septic complications [15]. We studied two major complication types following TRUS Infection-related complications after prostate biopsy have prostate biopsy: infection-related symptoms and non-infec- been an increasing issue, and numerous strategies have tion symptoms. been evaluated to reduce the risk of complications. Assess- The rates of these complications were 16.2% and 83.8%, ment of risk factors for infection and antibiotics resistance, respectively. thorough history, and physical examination was recommen- Findings of our study using the entire prostate biopsy ded [16]. Earlier studies reported that risk factors of infection- cohort showed fever or myalgia (0.35%), AUR (0.77%), related complications were DM [8,11,17-19], comorbidities and bleeding (0.47%). This was lower than the 6.59%, 9.76% [6], more biopsy cores [11,20-22], and repeat biopsy [11,16, and 1.14% by Wei et al. [4], who reported that AUR was 23]. Significant risk factors for fever after TRUS biopsy most common among postoperative complications. Loeb et included prostate size and DM in the Rotterdam section al. [6] reported bleeding as the most common symptom of the ERSPC trial [8]. In the SEER study, Loeb et al. [6] after prostate biopsy. However, in our study, AUR was reported that significant risk factors included nonwhite the most common. These symptoms were minor and ethnicity and higher comorbidity scores. resolved spontaneously except for those of three patients In our study, DM (p=0.004), and CCI (p=0.030) were hospitalized after receiving an indwelling Foley catheter. statistically significant risk factors for infection in univariate Ten patients were discharged to the ER after receiving an analysis; however, in multivariate analysis, only DM was

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