**5. Complications**

Generally, complications are: hematuria (13%-74%), hemospermia (30%), blood at stools (1%), pain (4%), nausea (up to 1%), fever (up to 1%), epididymitis (up to 1%), infection which needs hospitalization (0,3%). Most feared complication is sepsis.

Another important complication is bleeding. Patients can bleed from rectum, they can observe hematuria or hemospermia. Bleeding is most often self limiting and settle in a few days. Rarely significant issues (bladder tamponade or significant rectal bleeding) would occur. Such occasions would of course necessitate hospitalization or use of appropriate standard measurements for treatment. Bleeding may be more significant with anticoagulant treatment. Warfarin is stopped well before biopsy and patient is covered with low molecular weight heparin. Low dose acetylsalicylic acid (aspirin) may be continued, although some still recommend a drug holiday for a few days (till bleeding settles). There are no experience with newer antithrombotic drugs (for example dabigatran and other factor Xa inhibitors) and it is generally suggested to be avoided during prostate biopsy (changed to lowmolecular weight heparin, the same as for warfarin). Clopidogrel should also be stopped, although there is a report claiming 15% of urologists to continue with both clopidogrel or

Only 11% of urologists in US used local anesthesia to reduce pain during trus biopsy in 2002 (Davis et al. 2002). At the time, a strong appeal from one of the most distinguished opinion leaders favored local anesthesia (Soloway, 2003). Thereafter, guidelines (AUA, EAU, NCCN) all recommended or even mandated (AUA) local pain medication use during this procedure. Intrarectal application of eutectic cream or lidocaine jelly may decrease pain as some anesthetic agent may reach site of pain with diffusion, but it is variable and is considered not adequate. Pain during transrectal prostate biopsy is caused by two sources. First source of pain is probe insertion and presence and movement of probe in the anal canal during biopsy. This can be ameliorated with slow and gentle dilation and local lidocaine jelly or EMLA cream, but other measures for relaxation of sphincter were also used with success and are available – local glyceryl trinitrate oinment or spray or local 2% diltiazem or 0,2% - 0,5% nifedipine oinment. Using gylceryl trinitrate oinment, headache was noted as side effect in 10% of patients – dose was 2 mg (McCabe et al., 2007). It remains open, whether lower dose of spray (0,4 mg/activation) would reach same effect

Second source of pain during trus biopsy is related to nerves in prostate capsule and neurovascular bundles. After a lot of research (for example (Scattoni et al., 2010)) it seems accepted injection of 2x 5 ml (each side) of 1% lidocaine most appropriately reduces pain. Site of injection may be at the base (basolateral periprostatic nerve plexus area, described also as prostate-vesicular junction injections) or at the apex. Debate where to inject sill continues. Quality control suggested for standard technique of periprostatic block, observation of hypoechoic nodule ("wheal") formation on the site of injection is needed. It was shown least pain (best effect) was observed, when hypoechoic nodule formed after injection on both sides (Obek et al., 2006). Regarding injectable agents, for potential lidocaine allergic patients, tramadol has significant local anesthetic properties and is universally available and it has also been studied in this setting (Seckiner et al., 2011). Addition of oral medication, either for sedation or for additional pain relief may be also

Generally, complications are: hematuria (13%-74%), hemospermia (30%), blood at stools (1%), pain (4%), nausea (up to 1%), fever (up to 1%), epididymitis (up to 1%), infection

Another important complication is bleeding. Patients can bleed from rectum, they can observe hematuria or hemospermia. Bleeding is most often self limiting and settle in a few days. Rarely significant issues (bladder tamponade or significant rectal bleeding) would occur. Such occasions would of course necessitate hospitalization or use of appropriate standard measurements for treatment. Bleeding may be more significant with anticoagulant treatment. Warfarin is stopped well before biopsy and patient is covered with low molecular weight heparin. Low dose acetylsalicylic acid (aspirin) may be continued, although some still recommend a drug holiday for a few days (till bleeding settles). There are no experience with newer antithrombotic drugs (for example dabigatran and other factor Xa inhibitors) and it is generally suggested to be avoided during prostate biopsy (changed to lowmolecular weight heparin, the same as for warfarin). Clopidogrel should also be stopped, although there is a report claiming 15% of urologists to continue with both clopidogrel or

which needs hospitalization (0,3%). Most feared complication is sepsis.

**4.3 Pain control** 

with less side effects.

helpful in selected patients.

**5. Complications** 

warfarin (Brewster et al., 2010). This is not advisable, except aspirin and low molecular weight haparin, all other similarly working medications should be stopped before biopsy. Regarding clopidogrel, explicit agreement and consent between patient, his cardiologist and urologist may result in exception, but extreme caution is needed.

Immediate complications, like fainting, diaphoresis should be controlled by adequate local pain control. It is also not advisable for patients to be completely fasted.

Rate of complications increases with time. Most important and frequent seem infectious complications. Reasons for increasing rates of complications may be increasing numbers of cores per procedure or increased antibiotic resistance (Nam et al., 2010).

Long term complications of prostate biopsy would be development of pain syndromes or problems with erectile function, which was described recently (Klein et al., 2010). This reminds us that indefinitely repeating biopsies and increasing number of cores per biopsy may not be the best way forward. Selective, targeted approaches must be taken seriously, as prostate biopsy is not without its consequences.
