Rare complication after a transrectal ultrasound guided prostate biopsy: a giant retroperitoneal hematoma

Introduction

Prostatic biopsy is the gold standard for prostate cancer diagnosis using both transrectal and transperineal approach. Common complications related to transrectal ultrasound (TRUS)-guided prostatic needle biopsy are hematuria, hematospermia, and hematochezia. Infectious complications are increasing over time; while instead, significant complications such as massive rectal bleeding, urinary retention, and sepsis are less common (1).

To the best of our knowledge, we report the second case of a very large hematoma extending from the pelvis into the retroperitoneal space (2).

Case report

A 66-year-old man with a serum PSA of 5.4 ng/ml was admitted to our department for a TRUS-guided prostatic needle biopsy.

His past surgical history included appendicectomy and umbilical hernia repair. His medical history included type 2 diabetes, for which he was on metformin. The patient did not take any anticoagulant drugs.

Laboratory values on the day before the biopsy, including coagulation studies, were all normal. Patient received a pre-procedural prophylaxis with a single dose of Ciprofloxacin 1000 mg modified release (3). A biopsy gun with a 16-gauge core needle was used and a standard transrectal 12-core prostate biopsy was performed. The procedure was well tolerated and no immediate complications were encountered.

Seven hours after the biopsy, the patient reached our emergency department with severe diffuse abdominal pain, hypotension, tachycardia, and confusional state. Blood pressure was 70/40 mmHg, heart rate was 110 beats/min, and hemoglobin was 6.1 g/dl. Blood transfusions were performed immediately for a total of two units.

He underwent an ultrasonography and then a computed tomography (CT) scan that showed “a blood collection in the pelvis that extending to the lower pole of left kidney associated with a focus of active contrast extravasation, indicating active ongoing prostate bleeding” (Fig. 1).

Fig. 1 -

Computed tomography (CT) scan that shows a blood collection in the pelvis that extending to the lower pole of left kidney associated with a focus of active contrast extravasation.

Consequently, he was led to the interventional radiology suite for angiography and embolization. A microcatheter was advanced progressively into the left internal iliac artery with a series of controlled angiograms that showed no more active contrast extravasation, without the need of embolization (Fig. 2).

Fig. 2 -

Angiography that shows no more active contrast extravasation.

Hemoglobin levels increased and blood pressure was got stabilized. Management of hematoma has been conservative and hematoma was completely reabsorbed 4 months later. Histopathological examination of prostate biopsy showed a lymphocytic prostatitis.

Discussion

Most common complications following TRUS-guided biopsies are minor and do not require any treatment (1). The largest series reported in literature show a very low rate of major complications that require hospitalization (4). Of these, most common complications are severe infections. A recent study of 1000 consecutive prostatic biopsy at a single hospital reported a rate of major complications requiring hospitalization or emergency room consultations of 2.5%. Forty-eight percent of these complications were infection-related (5).

Intraprostatic bleeding is very common in patients undergoing TRUS-guided prostate biopsy, but it is usually bland, and spontaneously stops in a short time. This is probably related to the tamponade effect by the prostatic capsule and the periprostatic tissues (6). Most symptomatic rectal bleedings are easily stopped by digital or balloon rectal compression, or using a rectal sponge too (7). Instead, significant hemorrhages are very rare and they require transfusions and surgical or radiointerventistic procedures (8). We report the second case in literature of a very large hematoma extending from the pelvis into the retroperitoneal space (2). Prostatic arterial embolization (PAE) is an emerging procedure in the treatment of benign prostatic hypertrophy and it is nowadays commonly used in the control of important bleeding after prostatic biopsy (9).

In our case, CT scan showed an active contrast extravasation, indicating a suspected prostate bleeding, but after performing an angiography, we decided that embolization was no more necessary because we had not found a real active prostatic bleeding. Vascular contrast extravasations on CT (VCEC) are considered an important sign of bleeding and it provides an indication for embolization. CT scan has only 76% sensitivity and 80% positive predictive value for detecting active bleeding. As a consequence, a discrepant result between CT scan and the following angiography can usually be found. There are some possible explanations for this discrepancy. First of all, it is possible that some VCECs were indeed venous bleedings or nonvascular contrast leakage. Another possibility is spontaneous endogenous hemostasis (10).