Screening and Biopsy Association of Prostate Volume With Voiding Impairment and Deterioration in Quality of Life After Prostate Biopsy Binhan Kagan Aktas, Suleyman Bulut, Cevdet Serkan Gokkaya, Cuneyt Ozden, Remzi Salar, Yilmaz Aslan, Mehmet Murat Baykam, and Ali Memis OBJECTIVE
METHODS
RESULTS
CONCLUSION
To evaluate how voiding function and quality of life (QoL) were affected by transrectal ultrasound-guided prostate biopsy with respect to prostatic size and to determine whether there is a size-bothersomeness relationship. Ninety-two patients who were candidates for prostate biopsy were included. Ten-core prostate biopsies were taken, and patients were followed up for 7 days. The international prostate symptom score, QoL, maximum urine flow rate (Q-max) and average urine flow rate, postvoid residual urine, and prostate volume (Vp) of the patients were recorded at baseline and on postbiopsy day 7. On receiver operating characteristics curve analysis, a Vp of 38.8 mL was found to be the best cutoff point for deterioration in QoL after biopsy. Then, patients were divided into 2 groups according to baseline Vp, as .05). Only Vp and Q-max of group 1 (P 4 ng/mL) and/or abnormal digital rectal examination (DRE) findings. The patients with urinary tract infection, anal fissures/strictures, diabetes mellitus, neurologic disease, bleeding disorder, and the patients having a history of alpha-blocker therapy, prostate surgery, prostate biopsy, or AUR were excluded from the study. The institutional ethical committee approved our study, and all patients provided written informed consent. A detailed medical history was received from all patients. LUTS were evaluated using a validated international prostate symptom score (IPSS) questionnaire. Life quality was evaluated using 7-points (0-6) QoL scale (question 8 of IPSS, referring to the patient’s perceived QoL). DRE was performed to check for prostatic abnormalities, such as hardness, nodule, and fixation. Routine biochemical, hematological tests, and urine analysis were performed, and serum total and free PSA levels were measured. Maximum and average urinary flow rates (Q-max and Q-ave) of the patients were calculated using uroflowmetry. Postvoid residual urinary volume (PVR) measurements were accomplished after the uroflowmetric study. Morphologic assessment and volume calculation of prostates and PVR measurements were performed using an ultrasound device (Hitachi EUBe400 with 6.5 MHz biplanar transrectal and 3.5 MHz abdominal probes; Hitachi Medical Corp. of America) by the same urologist. Patients were requested to stop taking anticoagulant drugs at least 7 days before the biopsy and given oral ciprofloxacin, starting the day before the biopsy and continued 4 days. A Fleet’s enema was recommended 2 hours before biopsy. Patients were placed in the left lateral decubitus position and received 10 mL of 2% lidocaine rectal gel 10 minutes before the procedure. A detailed ultrasonic examination of prostate was conducted at transverse and sagital planes before the biopsy. A total of 10 cores (5 from each side) were taken using an automatic biopsy gun with an 18-gauge needle, and patients were closely followed up for the next 6 days. On postbiopsy day 7, IPSS, QoL, Q-max, Q-ave, PVR, and Vp of the patients were measured again and classified according to the presence or absence of deterioration in QoL, defined as any elevation in QoL score after the biopsy procedure. A receiver operating characteristics (ROC) curve was drawn to determine the effect of prostatic size on deterioration in patients’ postbiopsy life quality, and a baseline Vp of 38.8 mL was found to be the best cutoff point. Then, patients were divided into 2 groups regarding baseline Vp. Patients with a prebiopsy Vp of 150 mL, they were recatheterized. Both the patients were in group 2. Significant differences were detected with regard to QoL (P ¼ .004), Q-ave (P ¼ .02), IPSS, Q-max, Vp (P 38.8 mL. This finding might be interpreted, as large prostates are more vulnerable to instrumental trauma on biopsy than smaller ones. Serving as a source for the increase in bladder outlet resistance, trauma can lead to development of impaired voiding or even AUR after the biopsy. AUR represents an objective impact to the prostate. The difference in AUR rate between our 2 groups also supports this idea although it was not found statistically significant. Our AUR rate was higher than previous reports,11-14 which range from 0.2% to 1.7%. This might be resulted from our biopsy technique especially being used on large prostates; a more vigorous trauma to the prostate might be caused by maneuvers for reaching prostatic base. As Zisman et al7 pointed out, high baseline IPSS and big prostate size would be other possible reasons; however, those were not relatively high in our study population. Sampling of multiple cores was not the case in our study, either, because we took only 10 biopsy cores. In their study, Klein et al15 evaluated the impact of 10-core and saturation prostate biopsy on voiding function. They observed that saturation biopsy vs 10-core biopsy had a lasting impact on voiding function within a 12-week period. They did not detect any correlation between increased IPSS and Vp. However, an impaired QoL because of urinary symptoms was found to be associated with an increased number of biopsy cores. Unlike our study, they did not evaluate uroflowmetric functions in their study. Berger et al12 found no link between the number of biopsy cores and risk of AUR contrary to the findings of Klein et al.15 Bozlu et al16 investigated the role of tamsulosin therapy on postbiopsy impaired voiding and found it beneficial as evidenced by a decrease in IPSS and an elevation in
619
Table 2. Comparison of baseline and postbiopsy values of 2 groups of patients who voided by urethra after the biopsy Group 1 (n ¼ 47) Variables QoL IPSS Q-max (mL/s) Q-ave (mL/s) PVR (mL) Vp (mL)
Baseline 2.0 10.7 13.4 7.7 84.8 28.5
1.9 8.6 7.3 3.5 69.0 6.8
Group 2 (n ¼ 39)
Postbiopsy
P*
.254 .054 .035 .263 .060
METHODS
RESULTS
CONCLUSION
To evaluate how voiding function and quality of life (QoL) were affected by transrectal ultrasound-guided prostate biopsy with respect to prostatic size and to determine whether there is a size-bothersomeness relationship. Ninety-two patients who were candidates for prostate biopsy were included. Ten-core prostate biopsies were taken, and patients were followed up for 7 days. The international prostate symptom score, QoL, maximum urine flow rate (Q-max) and average urine flow rate, postvoid residual urine, and prostate volume (Vp) of the patients were recorded at baseline and on postbiopsy day 7. On receiver operating characteristics curve analysis, a Vp of 38.8 mL was found to be the best cutoff point for deterioration in QoL after biopsy. Then, patients were divided into 2 groups according to baseline Vp, as .05). Only Vp and Q-max of group 1 (P 4 ng/mL) and/or abnormal digital rectal examination (DRE) findings. The patients with urinary tract infection, anal fissures/strictures, diabetes mellitus, neurologic disease, bleeding disorder, and the patients having a history of alpha-blocker therapy, prostate surgery, prostate biopsy, or AUR were excluded from the study. The institutional ethical committee approved our study, and all patients provided written informed consent. A detailed medical history was received from all patients. LUTS were evaluated using a validated international prostate symptom score (IPSS) questionnaire. Life quality was evaluated using 7-points (0-6) QoL scale (question 8 of IPSS, referring to the patient’s perceived QoL). DRE was performed to check for prostatic abnormalities, such as hardness, nodule, and fixation. Routine biochemical, hematological tests, and urine analysis were performed, and serum total and free PSA levels were measured. Maximum and average urinary flow rates (Q-max and Q-ave) of the patients were calculated using uroflowmetry. Postvoid residual urinary volume (PVR) measurements were accomplished after the uroflowmetric study. Morphologic assessment and volume calculation of prostates and PVR measurements were performed using an ultrasound device (Hitachi EUBe400 with 6.5 MHz biplanar transrectal and 3.5 MHz abdominal probes; Hitachi Medical Corp. of America) by the same urologist. Patients were requested to stop taking anticoagulant drugs at least 7 days before the biopsy and given oral ciprofloxacin, starting the day before the biopsy and continued 4 days. A Fleet’s enema was recommended 2 hours before biopsy. Patients were placed in the left lateral decubitus position and received 10 mL of 2% lidocaine rectal gel 10 minutes before the procedure. A detailed ultrasonic examination of prostate was conducted at transverse and sagital planes before the biopsy. A total of 10 cores (5 from each side) were taken using an automatic biopsy gun with an 18-gauge needle, and patients were closely followed up for the next 6 days. On postbiopsy day 7, IPSS, QoL, Q-max, Q-ave, PVR, and Vp of the patients were measured again and classified according to the presence or absence of deterioration in QoL, defined as any elevation in QoL score after the biopsy procedure. A receiver operating characteristics (ROC) curve was drawn to determine the effect of prostatic size on deterioration in patients’ postbiopsy life quality, and a baseline Vp of 38.8 mL was found to be the best cutoff point. Then, patients were divided into 2 groups regarding baseline Vp. Patients with a prebiopsy Vp of 150 mL, they were recatheterized. Both the patients were in group 2. Significant differences were detected with regard to QoL (P ¼ .004), Q-ave (P ¼ .02), IPSS, Q-max, Vp (P 38.8 mL. This finding might be interpreted, as large prostates are more vulnerable to instrumental trauma on biopsy than smaller ones. Serving as a source for the increase in bladder outlet resistance, trauma can lead to development of impaired voiding or even AUR after the biopsy. AUR represents an objective impact to the prostate. The difference in AUR rate between our 2 groups also supports this idea although it was not found statistically significant. Our AUR rate was higher than previous reports,11-14 which range from 0.2% to 1.7%. This might be resulted from our biopsy technique especially being used on large prostates; a more vigorous trauma to the prostate might be caused by maneuvers for reaching prostatic base. As Zisman et al7 pointed out, high baseline IPSS and big prostate size would be other possible reasons; however, those were not relatively high in our study population. Sampling of multiple cores was not the case in our study, either, because we took only 10 biopsy cores. In their study, Klein et al15 evaluated the impact of 10-core and saturation prostate biopsy on voiding function. They observed that saturation biopsy vs 10-core biopsy had a lasting impact on voiding function within a 12-week period. They did not detect any correlation between increased IPSS and Vp. However, an impaired QoL because of urinary symptoms was found to be associated with an increased number of biopsy cores. Unlike our study, they did not evaluate uroflowmetric functions in their study. Berger et al12 found no link between the number of biopsy cores and risk of AUR contrary to the findings of Klein et al.15 Bozlu et al16 investigated the role of tamsulosin therapy on postbiopsy impaired voiding and found it beneficial as evidenced by a decrease in IPSS and an elevation in
619
Table 2. Comparison of baseline and postbiopsy values of 2 groups of patients who voided by urethra after the biopsy Group 1 (n ¼ 47) Variables QoL IPSS Q-max (mL/s) Q-ave (mL/s) PVR (mL) Vp (mL)
Baseline 2.0 10.7 13.4 7.7 84.8 28.5
1.9 8.6 7.3 3.5 69.0 6.8
Group 2 (n ¼ 39)
Postbiopsy
P*
.254 .054 .035 .263 .060
