Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines
Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines
Elshal, Ahmed M.; Abdelhalim, Ahmed; Barakat, Tamer S.; Shaaban, Atallah A.; Nabeeh, Adel; Ibrahiem, El-Housseiny
2014-12-01 00:00:00
Arab Journal of Urology (2014) 12, 262–268 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ORIGINAL ARTICLE Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines Ahmed M. Elshal , Ahmed Abdelhalim, Tamer S. Barakat, Atallah A. Shaaban, Adel Nabeeh, El-Housseiny Ibrahiem Mansoura Urology & Nephrology Center, Mansoura University, Egypt Received 9 July 2014, Received in revised form 8 September 2014, Accepted 16 September 2014 Available online 19 October 2014 KEYWORDS Abstract Objective: To assess the outcome of the drainage procedure used for treating a prostatic abscess, and to propose a treatment algorithm to reduce the mor- Prostate; bidity and the need for re-treatment. Abscess; Patients and methods Deroofing; We retrospectively reviewed patients who were admitted and received an interven- Aspiration; tional treatment for a prostatic abscess. All baseline relevant variables were Transrectal reviewed. Details of the intervention, laboratory data, duration of hospital stay, fol- low-up data and re-admissions were recorded. ABBREVIATIONS Results: A prostatic abscess was diagnosed in 42 patients; 30 were treated by MIS, minimally transurethral deroofing and 12 by transrectal needle aspiration. The median (range) invasive surgery size of the abscess was 4.5 (2–23) mL and 2.7 (1.5–7.1) mL in the deroofing and aspi- ration groups, respectively (P = 0.2). In half of the cases multiple abscesses were evi- dent on imaging before the intervention. The median (range) hospital stay after deroofing and aspiration was 2 (1–11) and 1 (1–19) days, respectively (P = 0.04). Perioperative complications occurred only in the deroofing group, in which two patients developed septic shock requiring intensive care (Clavien 4) and one developed epididymo-orchitis (Clavien 2). There were two late complications in Corresponding author at: Mansoura Urology & Nephrology Center, Mansoura University, 35516 Elgomhoria st, Urology & nephrology center, Mansoura, Egypt. Tel.: +20 50 2262222; fax: +20 50 2263717. E-mail address: elshalam@hotmail.com (A.M. Elshal). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier http://dx.doi.org/10.1016/j.aju.2014.09.002 2090-598X ª 2014 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines 263 the deroofing group, in which one patient developed a urethral stricture that required endoscopic urethrotomy (Clavien 3a) and one developed a urethral diver- ticulum and urinary incontinence that required diverticulectomy and a bulbo-ure- thral sling procedure (Clavien 3b). A urethro-rectal fistula developed after aspiration in one patient. Re-treatment for the abscess was indicated in two (7%) patients in the deroofing group, which was treated by aspiration. Conclusion: Transrectal needle aspiration for a prostatic abscess, when done for properly selected cases, could minimise the morbidity of the drainage procedure. ª 2014 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. Introduction has not been assessed. The aim of the present study work was to clearly define a treatment algorithm based on a retrospective assessment of a single-institutional A prostatic abscess is an uncommon urological emer- case series, and a review of the relevant reports on this gency but it is a serious infection of the prostate with a topic, to reduce the morbidity and the need for re-treat- high mortality rate unless properly treated [1,2]. Patients ment, all of which might help in counselling patients, with diabetes mellitus, renal insufficiency and immune particularly for a staged treatment plan. suppression are particularly at risk. Urethral catheterisa- tion, lower urinary tract instrumentation and a prostate Patients and methods biopsy are among the possible predisposing factors [3]. Several pathogens might be incriminated in the disease. Enterobacteriacae (particularly Escherichia coli) and Using our electronic database we retrospectively Staphylococcus aureus are the commonest causative reviewed all patients with a diagnosis of prostatic organisms [4]. Haematogenous spread from distant foci abscess between 2002 and 2012. All patients who were has also been reported. In these cases, organisms like admitted and received an interventional treatment were Mycobacterium tuberculosis and Candida species might included. The database analysis was approved by an be found [5]. internal review board. All relevant baseline variables The clinical presentation varies depending on the were reviewed. Details of the intervention, laboratory severity of infection. A prostatic abscess is usually diag- data, duration of hospital stay, follow-up data and re- nosed when a patient with acute prostatitis fails to admissions were recorded. Patients were invited and respond to medical treatment. The patient commonly interviewed to ascertain any medical treatment or sec- presents with perineal, genital and suprapubic pain, ondary surgical procedures for the prostate. exacerbating LUTS, and urinary retention might also occur. Constitutional symptoms (fever, rigors, malaise Intervention and anorexia) are frequently present. The prostate is intractably tender on a DRE. Fluctuation (a ‘boggy’ Once the diagnosis of a prostatic abscess was confirmed, sensation) of the prostate on a DRE can establish the broad-spectrum antimicrobial third generation cephalo- diagnosis [6]. TRUS and other cross-sectional imaging sporin was given after a midstream urine sample was methods (pelvic CT or MRI) might be useful in the diag- taken for culture. nosis, treatment and monitoring of the response to treat- For transurethral deroofing, the procedure was per- ment [7]. Once liquefaction and abscess formation are formed under a spinal or general anaesthesia, based on diagnosed, several approaches have been described for an assessment by the anaesthesia team for the patient’s drainage. Open perineal drainage, transurethral deroo- condition. Using 24–26 F resectoscope sheath with gly- fing, transrectal needle aspiration or tube drainage cine 1.5% as an irrigant, transurethral resection started [8,9] and percutaneous drainage [10] are the main thera- at the 5–7 o’clock position, deep enough to deroof the peutic options. Transurethral holmium-laser deroofing abscess (Fig. 1a). Based on the preoperative radiological of a prostatic abscess has been reported [11]. assessment the resection might extend to the lateral To the best of our knowledge, the available data do lobes if they were involved. The specimen and the not support some treatments over others in any particu- drained pus were collected and sent for pathological lar situation. Furthermore, the morbidity of different and microbiological assessment. After adequate haemo- procedures was not sufficiently reported and the effect stasis a 22 F urethral catheter was fixed. of different treatment approaches on voiding and sexual For transrectal needle aspiration, a cleansing enema function is unknown. The need for secondary treatment was applied when tolerable by the patient before the for the abscess or for the underlying prostate pathology procedure, to eliminate faeces in the rectum. Initially 264 Elshal et al. Figure 1 (a) MRI, Sagittal (i) and axial (ii) views after administration of intravenous contrast medium show enlarged right side of the prostate. The abscess appears multilocular with enhancing wall. (iii) A cystoscopic view of the abscess bulge at time of deroofing. (iv) A cystoscopic view of the abscess cavity during deroofing. (b) TRUS images showing hypoechoic areas with thick well-defined walls (abscesses) (c) (i) TRUS image (sagittal) showing a solitary posterior abscess in a giant prostate (>200 mL) 1c (ii) TRUS image (sagittal) after transrectal aspiration of the abscess in giant prostate (> 200 mL). (iii) TRUS image (sagittal) for the same case, 3 months after a subsequent laser procedure (holmium laser enucleation of the prostate). patients were scanned in the lithotomy position and The patient was discharged from the hospital after TRUS performed in both the transverse and the sagittal being afebrile for 48 h and the blood leukocyte count planes. The location of the abscess, as one or more was declining. The patient was advised to keep taking hypoechoic areas with thick well-defined walls contain- ciprofloxacin 500 mg twice daily until the next clinic visit ing thick fluid, was ascertained (Fig. 1b). A 7-MHz at 2 weeks after discharge. transducer probe was used, with a focal range of 1– 4 cm; a lower frequency was used for large glands. Local Outcome measures anaesthesia was often infiltrated before the drainage procedure. A peri-prostatic block was obtained by The peri-procedure morbidity and the need for re-inter- injecting 5 mL lidocaine 2% at the junction of the sem- vention for the abscess were reported according to the inal vesicles and the prostate bilaterally. An 18-G long modified Clavien scale. Furthermore, the hospital stay, Chiba needle, which can be passed through the needle re-admissions and consecutive treatment received (sec- guide attached to the ultrasound probe, was most often ondary medical or surgical treatment for the prostate) used. The ultrasound unit provided the best visualisa- were recorded. tion of the needle path in the sagittal plane. Images were The results are presented as a description of the vari- typically superimposed with a ruled needle path that ables with the percentage, median (range) and mean corresponded to the needle guide of the TRUS unit. (SD). Statistical analysis comprised Fisher’s exact test All detectable abscesses were aspirated completely and and the chi-squared text for categorical variables, and the aspirate was sent for pathological and microbiolog- the Mann–Whitney U-test for continuous variables, ical assessment. Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines 265 with P < 0.05 considered to indicate statistical signifi- treatment secondary to a renal/liver transplant. There cance in all tests. was a history of an indwelling urethral catheter at pre- sentation, recent urethral instrumentation and recent Results prostate biopsies in 29%, 17% and 8% of patients, respectively. The median estimated size of the prostate was 53 An admission for active interventional treatment of a (6.2–110) and 70 (21–106) mL in the deroofing and prostatic abscess was recorded in 42 patients. The base- aspiration groups, respectively (P = 0.5). The median line demographic data and possible predisposing factors estimated size of the abscess was 4.5 (2–23) and are shown in Table 1. Diabetes mellitus was present in 2.7 (1.5–7.1) mL in deroofing and aspiration groups, 59% of patients and 24% were on immunosuppressive Table 1 The baseline variables in the two groups, and the peri-procedure and late outcomes. Mean (SD), median (range), n (%) Transurethral deroofing Transrectal needle aspiration P Baseline Number of patients 30 12 Age at intervention (years) 49.4 (14) 55.4 (15) 0.2 Body mass index, kg/m 28.6 (5.0) 28.4 (5.3) 0.8 Diabetes mellitus 15 (50) 4 0.5 Patients with system failure: 0.5 End-stage kidney disease 3 (10) – Liver cell failure 3 (10) 1 Indwelling urethral catheter 9 (30) 3 1 Systemic chemo/immunosuppressive therapy 6 (20) 4 0.79 Recent urethral instrumentation 4 (13) 3 0.03 Recent prostate needle biopsy – 1 0.25 Presentation 0.51 Exacerbating LUTs 12 (40) 8 Acute urine retention 9 (30) 1 Indwelling catheter with systemic and 9 (30) 3 local symptoms PSA at presentation (ng/mL) 1.7 (0.1–4.7) 4.4 (0.8–50) 0.12 Leukocyte count at presentation (/mL) 12.1 (4.8–16.7) 12.5 (5.2–29) 0.63 Positive urine culture at presentation 12 (40) 5 0.37 TRUS/MRI prostate size (mL) 53 (6.2–110) 70 (21–106) 0.5 TRUS/MRI abscess size (mL) 4.5 (2–23) 2.7 (1.5–7.1) 0.2 Prostate size group 1 TRUS/MRI prostate size (< 80 mL) 7 (23) 3 TRUS/MRI prostate size (> 80 mL) 23 (77) 9 Location of the abscess in the prostate 0.06 Right lobe 9 (30) 1 Left lobe 6 (20) 5 Multiple sites 15 (50) 6 Peri-procedure and late outcomes Catheter after procedure <0.001 Urethral catheter 26 (87) 2 Suprapubic catheter 2 (7) 2 Both 2 (7) – Hospital stay (days) 2 (1–11) 1 (1–19) 0.04 Need for re-treatment for the abscess 2 (7) – 1 Need for re-treatment for the prostate 14 (47) 6 0.4 a-blockers 12 (40) 2 TURP 2 (7) 2 Holmium laser enucleation of the prostate – 1 Androgen deprivation for prostate cancer – 1 Complications: Clavien grade/treatment offered 0.1 Septic shock/IVa/Antimicrobial + inotropics 2 (7) – Urethral stricture/IIIa/endoscopic urethrotomy 1 (3) – Epididymo-orchitis/II/Lead subacetate 1 (3) – +NSAIDs + quinolones + CIC Urethro-rectal fistula/IIIb/Repair – 1 Urethral diverticulum/IIIb/bulbourethral sling 1 (3) – CIC, clean intermittent catheterisation. 266 Elshal et al. respectively (P = 0.2). In half of the patients there were persistently high PSA level at 3 months after drainage multiple abscesses (more than one site) on imaging and a subsequent prostatic biopsy showed underlying before the intervention (Table 1). high-grade adenocarcinoma (Table 1). All patients who had deroofing were catheterised for a median of 6 (3–14) days and four who had TRUS- Discussion guided aspiration were catheterised for a median of 3 (1–7) days. There was a significantly shorter hospital Unlike any other abscess in the body, prostatic abscess stay in patients who were treated with TRUS-guided drainage is not the sole objective of the urologist. The aspiration (Table 1). A suprapubic cystostomy tube goals of treatment are to lower the morbidity and mor- was used to replace an indwelling urethral catheter in tality of the drainage procedure, reduce the need for re- two patients in each group (Table 1). treatment and to preserve normal urinary and sexual No deaths were reported after either intervention. function, particularly in young motivated patients. In The peri-procedure complications (in the first 30 days) the present study we reviewed our experience with this were only in the deroofing group, in which two patients rare urological emergency to devise an algorithm for developed septic shock necessitating intensive care (Cla- treatment. vien 4a) and one patient developed epididymo-orchitis Our data showed that deroofing is not free of morbid- (Clavien 2). There were two late complications in the ity, and although it is effective for the immediate control deroofing group, in which one patient developed a ure- of symptoms, the occasional need for the re-treatment of thral stricture that required endoscopic urethrotomy residual abscesses or the subsequent effect on urinary (Clavien 3a) and one developed a urethral diverticulum and sexual function invite other less-invasive treatment (Fig. 2) and urinary incontinence that required a diver- approaches. ticulectomy and bulbo-urethral sling procedure (Clavien Needle aspiration is a viable treatment option for 3b). A urethro-rectal fistula developed after aspiration in deeply seated body abscesses, which could be used by one patient (Clavien 3b) (Table 1). different approaches [12]. In urological practice, needle Re-treatment for the abscess was indicated in two aspiration has been used to treat renal, perirenal and (7%) patients in the deroofing group, where TRUS- pelvic abscesses. Unlike deroofing, the endpoint of guided aspiration was used. In these patients the failure TRUS-guided aspiration of a prostatic abscess is con- to control fever and an evident residual hypoechoic area trolled by simultaneous US. Despite that drainage might by TRUS indicated aspiration. be more complete with deroofing, the multiplicity of The need for abscess re-treatment (both patients) and abscesses in a large prostate can be a limitation to the occurrence of complications (all five) consistently deroofing procedure. occurred in patients with an estimated prostate size of Most of the published series are relatively small, out- >80 mL (P = 1.0). Furthermore, there was a further dated and reported before the era of minimally invasive need for re-treatment of the abscess (both patients) surgery (MIS) and effective highly specific medical ther- and more complications (four of five) in those with mul- apy for the prostate. Table 2 [5,8,9,13,14] summarises tiple abscess foci than in those with a single focus of the outcome of drainage procedures reported previ- abscess (P> 0.05). ously. Re-treatment for the abscess was reported in There were no significant differences between the 14–22% and re-treatment for BOO in 28% of patients. treatment groups in the need for auxiliary procedures Unfortunately, the reporting is incomplete and the to control residual LUTS (Table 1). One patient had a offered treatment was based on surgeon discretion and rarely on objective factors. We propose a treatment algorithm (Fig. 3) that iden- tifies patients based on age, prostate size, abscess criteria and associating urinary tract anomalies. In the current algorithm, an age of 40–50 years was used as a threshold for the beginning of LUTS secondary to BPH. Despite the significantly different proportion of men having LUTS, a clear trend towards an increase in symptom scores with increasing age is reported in all popula- tion-based studies [15]. So in our algorithm, BOO is con- sidered as an influential factor after that age. Furthermore, TRUS-guided aspiration is used as much as possible, aiming for deferred management of BOO (medical or MIS). When deroofing is indicated, espe- cially for a multilocular abscess, a threshold for prostate Figure 2 A retrograde urethrogram showing a urethral size at 80 mL is identified, based on recommendations of diverticulum. Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines 267 Table 2 Summary of different contemporary case series of prostate abscess. Refs N patients Abscess size, mL Abscess criteria Prostate size, g Treatment Re-treatment for: Hospital stay, mean (range) days Abscess BOO [5] 7 – – – 4 Perineal catheter – – 11.2 drainage 3 TUR deroofing 14.2% [13] 6 Mean 31.6 Mean 93 TRUS aspiration (17–65) (42–162) 16.7% – 1.6 (1–3) [8] 7 Mean diameter 28.5% Multifocal – TRUS-guided tube – 28.5% 10 (7–17) >1.5 cm drain [14] 11 – 3 Recurrent – 7 TUR –– after aspiration deroofing – Posteriorly 2 TRUS aspiration – – – Located – Periprostatic 2 Perineal drainage–– – extension [9] 41 Mean 3.87 (3–4) – Mean 59.4 (21–108) 23 TUR deroofing – – 10.2 (6–15) Mean 4.04 (2.0–5.0) – Mean 41.6 (24–50) 18 TRUS aspiration 22.2% – 23.2 (18–34) TUR, transurethral. Figure 3 An algorithm for the treatment of prostatic abscess. most of the guidelines limiting the role of safe transure- In younger patients the abscess criteria dictate the thral resection to this size [16,17]. In that situation, a management plan, but suprapubic cystostomy remains limited deroofing or maximum possible aspiration is an option for patients with indwelling catheters or those used, followed by a pre-planned deferred MIS. Fig. 1c on regular catheterisation for causes other than BOO. shows an example of a 204-mL prostate with a solitary After reviewing the present case series we emphasise peripheral abscess where TRUS-guided aspiration was the need to keep assessing the PSA level during the fol- used, and 6 weeks later holmium laser enucleation of low-up visits until it reaches a nadir level, otherwise a the prostate was performed. prostate biopsy is highly recommended to avoid missing 268 Elshal et al. [6] Barozzi LPP, Menchi I, De Matteis M, Canepari M. Prostatic underlying prostate cancer. Furthermore, a staged man- abscess: diagnosis and treatment. AJR Am J Roentgenol agement by needle aspiration of the abscess followed by 1998;170:753–7. a pre-planned definitive MIS treatment of the BOO is a [7] Galosi AB, Montironi R, Fabiani A, Lacetera V, Galle´ G, reasonable option. Muzzonigro G. Cystic lesions of the prostate gland: an ultrasound Limitations of the present study are inherent in any classification with pathological correlation. J Urol 2009;181:647–57. retrospective study. Furthermore, the situation affecting [8] Aravantinos E, Kalogeras N, Zygoulakis N, Kakkas G, Anag- the choice of treatment approach was not addressed and nostou T, Melekos M. Ultrasound-guided transrectal placement the few patients included did not allow an analysis of of a drainage tube as therapeutic management of patients with predictors of the outcome. prostatic abscess. J Endourol 2008;22:1751–4. In conclusion, transrectal needle aspiration and [9] Jang K, Lee DH, Lee SH, Chung BH. Treatment of prostatic abscess: case collection and comparison of treatment methods. transurethral deroofing are viable, comparable treat- Korean J Urol 2012;53:860–4. ment options for prostatic abscess. Needle aspiration, [10] Basiri A, Javaherforooshzadeh A. Percutaneous drainage for when done for properly selected cases, could minimise treatment of prostate abscess. Urol J 2010;7:278–80. the morbidity of the drainage procedure. [11] Shah H. Transurethral holmium laser deroofing of prostatic abscess: description of technique and early results. Abstract. J Urol 2010;183:e128. Conflict of interest [12] Ramesh J, Bang JY, Trevino J, Varadarajulu S. Comparison of outcomes between endoscopic ultrasound-guided transcolonic None. and transrectal drainage of abdominopelvic abscesses. J Gastro- enterol Hepatol 2013;28:620–5. [13] Go¨ gu¨ s C, Ozden E, Karaboga R, Yagci C. The value of Source of funding transrectal ultrasound guided needle aspiration in treatment of prostatic abscess. Eur J Radiol 2004;52:94–8. None. [14] El-Shazly M, El-Enzy N, El-Enzy K, Yordanov E, Hathout B, Allam A. Transurethral drainage of prostatic abscess: points of technique. Nephrourol Mon 2012;4:458–61. References [15] Chapple CR. Lower urinary tract symptoms revisited. Eur Urol 2009;56:21–3. [1] Granados EA, Caffaratti J, Farina L, Hocsman H. Prostatic [16] Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, abscess drainage: clinical-sonography correlation. Urol Int Michel MC, et al. Guidelines on the Management of Male Lower 1992;48:358–61. Urinary Tract Symptoms (LUTS), Incl. Benign Prostatic Obstruc- [2] Ludwig M, Schroeder-Printzen I, Schiefer HG, Weidner W. tion (BPO). European Association of Urology. Available at http:// Diagnosis and therapeutic management of 18 patients with www.uroweb.org/gls/pdf/13_Male_LUTS_LR.pdf Accessed 17 prostatic abscess. Urology 199;53:340–5. September 2014. [3] Trauzzi SJ, Kay CJ, Kaufman DG, Lowe FC. Management of [17] McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz prostatic abscess in patients with human immunodeficiency RC, Donnell RF, et al. Guideline on the Management of Benign syndrome. Urology 1994;43:629–33. Prostatic Hyperplasia (BPH), 2012. Results of the Treatment [4] Meares Jr EM. Prostatic abscess. J Urol 1986;136:1281–2. Outcomes Analyses. American Urological Association. Available [5] Oliveira P, Andrade JA, Porto HC, Filho JE, Vinhaes AF. at http://www.auanet.org/common/pdf/education/clinical-guidance/ Diagnosis and treatment of prostatic abscess. Int Braz J Urol Benign-Prostatic-Hyperplasia.pdf Accessed 17 September 2014. 2003;29:30–4.
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Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines
Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines
Abstract
AbstractObjective:To assess the outcome of the drainage procedure used for treating a prostatic abscess, and to propose a treatment algorithm to reduce the morbidity and the need for re-treatment.Patients and methods:We retrospectively reviewed patients who were admitted and received an interventional treatment for a prostatic abscess. All baseline relevant variables were reviewed. Details of the intervention, laboratory data, duration of hospital stay, follow-up data and re-admissions were...
Arab Journal of Urology (2014) 12, 262–268 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ORIGINAL ARTICLE Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines Ahmed M. Elshal , Ahmed Abdelhalim, Tamer S. Barakat, Atallah A. Shaaban, Adel Nabeeh, El-Housseiny Ibrahiem Mansoura Urology & Nephrology Center, Mansoura University, Egypt Received 9 July 2014, Received in revised form 8 September 2014, Accepted 16 September 2014 Available online 19 October 2014 KEYWORDS Abstract Objective: To assess the outcome of the drainage procedure used for treating a prostatic abscess, and to propose a treatment algorithm to reduce the mor- Prostate; bidity and the need for re-treatment. Abscess; Patients and methods Deroofing; We retrospectively reviewed patients who were admitted and received an interven- Aspiration; tional treatment for a prostatic abscess. All baseline relevant variables were Transrectal reviewed. Details of the intervention, laboratory data, duration of hospital stay, fol- low-up data and re-admissions were recorded. ABBREVIATIONS Results: A prostatic abscess was diagnosed in 42 patients; 30 were treated by MIS, minimally transurethral deroofing and 12 by transrectal needle aspiration. The median (range) invasive surgery size of the abscess was 4.5 (2–23) mL and 2.7 (1.5–7.1) mL in the deroofing and aspi- ration groups, respectively (P = 0.2). In half of the cases multiple abscesses were evi- dent on imaging before the intervention. The median (range) hospital stay after deroofing and aspiration was 2 (1–11) and 1 (1–19) days, respectively (P = 0.04). Perioperative complications occurred only in the deroofing group, in which two patients developed septic shock requiring intensive care (Clavien 4) and one developed epididymo-orchitis (Clavien 2). There were two late complications in Corresponding author at: Mansoura Urology & Nephrology Center, Mansoura University, 35516 Elgomhoria st, Urology & nephrology center, Mansoura, Egypt. Tel.: +20 50 2262222; fax: +20 50 2263717. E-mail address: elshalam@hotmail.com (A.M. Elshal). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier http://dx.doi.org/10.1016/j.aju.2014.09.002 2090-598X ª 2014 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines 263 the deroofing group, in which one patient developed a urethral stricture that required endoscopic urethrotomy (Clavien 3a) and one developed a urethral diver- ticulum and urinary incontinence that required diverticulectomy and a bulbo-ure- thral sling procedure (Clavien 3b). A urethro-rectal fistula developed after aspiration in one patient. Re-treatment for the abscess was indicated in two (7%) patients in the deroofing group, which was treated by aspiration. Conclusion: Transrectal needle aspiration for a prostatic abscess, when done for properly selected cases, could minimise the morbidity of the drainage procedure. ª 2014 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. Introduction has not been assessed. The aim of the present study work was to clearly define a treatment algorithm based on a retrospective assessment of a single-institutional A prostatic abscess is an uncommon urological emer- case series, and a review of the relevant reports on this gency but it is a serious infection of the prostate with a topic, to reduce the morbidity and the need for re-treat- high mortality rate unless properly treated [1,2]. Patients ment, all of which might help in counselling patients, with diabetes mellitus, renal insufficiency and immune particularly for a staged treatment plan. suppression are particularly at risk. Urethral catheterisa- tion, lower urinary tract instrumentation and a prostate Patients and methods biopsy are among the possible predisposing factors [3]. Several pathogens might be incriminated in the disease. Enterobacteriacae (particularly Escherichia coli) and Using our electronic database we retrospectively Staphylococcus aureus are the commonest causative reviewed all patients with a diagnosis of prostatic organisms [4]. Haematogenous spread from distant foci abscess between 2002 and 2012. All patients who were has also been reported. In these cases, organisms like admitted and received an interventional treatment were Mycobacterium tuberculosis and Candida species might included. The database analysis was approved by an be found [5]. internal review board. All relevant baseline variables The clinical presentation varies depending on the were reviewed. Details of the intervention, laboratory severity of infection. A prostatic abscess is usually diag- data, duration of hospital stay, follow-up data and re- nosed when a patient with acute prostatitis fails to admissions were recorded. Patients were invited and respond to medical treatment. The patient commonly interviewed to ascertain any medical treatment or sec- presents with perineal, genital and suprapubic pain, ondary surgical procedures for the prostate. exacerbating LUTS, and urinary retention might also occur. Constitutional symptoms (fever, rigors, malaise Intervention and anorexia) are frequently present. The prostate is intractably tender on a DRE. Fluctuation (a ‘boggy’ Once the diagnosis of a prostatic abscess was confirmed, sensation) of the prostate on a DRE can establish the broad-spectrum antimicrobial third generation cephalo- diagnosis [6]. TRUS and other cross-sectional imaging sporin was given after a midstream urine sample was methods (pelvic CT or MRI) might be useful in the diag- taken for culture. nosis, treatment and monitoring of the response to treat- For transurethral deroofing, the procedure was per- ment [7]. Once liquefaction and abscess formation are formed under a spinal or general anaesthesia, based on diagnosed, several approaches have been described for an assessment by the anaesthesia team for the patient’s drainage. Open perineal drainage, transurethral deroo- condition. Using 24–26 F resectoscope sheath with gly- fing, transrectal needle aspiration or tube drainage cine 1.5% as an irrigant, transurethral resection started [8,9] and percutaneous drainage [10] are the main thera- at the 5–7 o’clock position, deep enough to deroof the peutic options. Transurethral holmium-laser deroofing abscess (Fig. 1a). Based on the preoperative radiological of a prostatic abscess has been reported [11]. assessment the resection might extend to the lateral To the best of our knowledge, the available data do lobes if they were involved. The specimen and the not support some treatments over others in any particu- drained pus were collected and sent for pathological lar situation. Furthermore, the morbidity of different and microbiological assessment. After adequate haemo- procedures was not sufficiently reported and the effect stasis a 22 F urethral catheter was fixed. of different treatment approaches on voiding and sexual For transrectal needle aspiration, a cleansing enema function is unknown. The need for secondary treatment was applied when tolerable by the patient before the for the abscess or for the underlying prostate pathology procedure, to eliminate faeces in the rectum. Initially 264 Elshal et al. Figure 1 (a) MRI, Sagittal (i) and axial (ii) views after administration of intravenous contrast medium show enlarged right side of the prostate. The abscess appears multilocular with enhancing wall. (iii) A cystoscopic view of the abscess bulge at time of deroofing. (iv) A cystoscopic view of the abscess cavity during deroofing. (b) TRUS images showing hypoechoic areas with thick well-defined walls (abscesses) (c) (i) TRUS image (sagittal) showing a solitary posterior abscess in a giant prostate (>200 mL) 1c (ii) TRUS image (sagittal) after transrectal aspiration of the abscess in giant prostate (> 200 mL). (iii) TRUS image (sagittal) for the same case, 3 months after a subsequent laser procedure (holmium laser enucleation of the prostate). patients were scanned in the lithotomy position and The patient was discharged from the hospital after TRUS performed in both the transverse and the sagittal being afebrile for 48 h and the blood leukocyte count planes. The location of the abscess, as one or more was declining. The patient was advised to keep taking hypoechoic areas with thick well-defined walls contain- ciprofloxacin 500 mg twice daily until the next clinic visit ing thick fluid, was ascertained (Fig. 1b). A 7-MHz at 2 weeks after discharge. transducer probe was used, with a focal range of 1– 4 cm; a lower frequency was used for large glands. Local Outcome measures anaesthesia was often infiltrated before the drainage procedure. A peri-prostatic block was obtained by The peri-procedure morbidity and the need for re-inter- injecting 5 mL lidocaine 2% at the junction of the sem- vention for the abscess were reported according to the inal vesicles and the prostate bilaterally. An 18-G long modified Clavien scale. Furthermore, the hospital stay, Chiba needle, which can be passed through the needle re-admissions and consecutive treatment received (sec- guide attached to the ultrasound probe, was most often ondary medical or surgical treatment for the prostate) used. The ultrasound unit provided the best visualisa- were recorded. tion of the needle path in the sagittal plane. Images were The results are presented as a description of the vari- typically superimposed with a ruled needle path that ables with the percentage, median (range) and mean corresponded to the needle guide of the TRUS unit. (SD). Statistical analysis comprised Fisher’s exact test All detectable abscesses were aspirated completely and and the chi-squared text for categorical variables, and the aspirate was sent for pathological and microbiolog- the Mann–Whitney U-test for continuous variables, ical assessment. Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines 265 with P < 0.05 considered to indicate statistical signifi- treatment secondary to a renal/liver transplant. There cance in all tests. was a history of an indwelling urethral catheter at pre- sentation, recent urethral instrumentation and recent Results prostate biopsies in 29%, 17% and 8% of patients, respectively. The median estimated size of the prostate was 53 An admission for active interventional treatment of a (6.2–110) and 70 (21–106) mL in the deroofing and prostatic abscess was recorded in 42 patients. The base- aspiration groups, respectively (P = 0.5). The median line demographic data and possible predisposing factors estimated size of the abscess was 4.5 (2–23) and are shown in Table 1. Diabetes mellitus was present in 2.7 (1.5–7.1) mL in deroofing and aspiration groups, 59% of patients and 24% were on immunosuppressive Table 1 The baseline variables in the two groups, and the peri-procedure and late outcomes. Mean (SD), median (range), n (%) Transurethral deroofing Transrectal needle aspiration P Baseline Number of patients 30 12 Age at intervention (years) 49.4 (14) 55.4 (15) 0.2 Body mass index, kg/m 28.6 (5.0) 28.4 (5.3) 0.8 Diabetes mellitus 15 (50) 4 0.5 Patients with system failure: 0.5 End-stage kidney disease 3 (10) – Liver cell failure 3 (10) 1 Indwelling urethral catheter 9 (30) 3 1 Systemic chemo/immunosuppressive therapy 6 (20) 4 0.79 Recent urethral instrumentation 4 (13) 3 0.03 Recent prostate needle biopsy – 1 0.25 Presentation 0.51 Exacerbating LUTs 12 (40) 8 Acute urine retention 9 (30) 1 Indwelling catheter with systemic and 9 (30) 3 local symptoms PSA at presentation (ng/mL) 1.7 (0.1–4.7) 4.4 (0.8–50) 0.12 Leukocyte count at presentation (/mL) 12.1 (4.8–16.7) 12.5 (5.2–29) 0.63 Positive urine culture at presentation 12 (40) 5 0.37 TRUS/MRI prostate size (mL) 53 (6.2–110) 70 (21–106) 0.5 TRUS/MRI abscess size (mL) 4.5 (2–23) 2.7 (1.5–7.1) 0.2 Prostate size group 1 TRUS/MRI prostate size (< 80 mL) 7 (23) 3 TRUS/MRI prostate size (> 80 mL) 23 (77) 9 Location of the abscess in the prostate 0.06 Right lobe 9 (30) 1 Left lobe 6 (20) 5 Multiple sites 15 (50) 6 Peri-procedure and late outcomes Catheter after procedure <0.001 Urethral catheter 26 (87) 2 Suprapubic catheter 2 (7) 2 Both 2 (7) – Hospital stay (days) 2 (1–11) 1 (1–19) 0.04 Need for re-treatment for the abscess 2 (7) – 1 Need for re-treatment for the prostate 14 (47) 6 0.4 a-blockers 12 (40) 2 TURP 2 (7) 2 Holmium laser enucleation of the prostate – 1 Androgen deprivation for prostate cancer – 1 Complications: Clavien grade/treatment offered 0.1 Septic shock/IVa/Antimicrobial + inotropics 2 (7) – Urethral stricture/IIIa/endoscopic urethrotomy 1 (3) – Epididymo-orchitis/II/Lead subacetate 1 (3) – +NSAIDs + quinolones + CIC Urethro-rectal fistula/IIIb/Repair – 1 Urethral diverticulum/IIIb/bulbourethral sling 1 (3) – CIC, clean intermittent catheterisation. 266 Elshal et al. respectively (P = 0.2). In half of the patients there were persistently high PSA level at 3 months after drainage multiple abscesses (more than one site) on imaging and a subsequent prostatic biopsy showed underlying before the intervention (Table 1). high-grade adenocarcinoma (Table 1). All patients who had deroofing were catheterised for a median of 6 (3–14) days and four who had TRUS- Discussion guided aspiration were catheterised for a median of 3 (1–7) days. There was a significantly shorter hospital Unlike any other abscess in the body, prostatic abscess stay in patients who were treated with TRUS-guided drainage is not the sole objective of the urologist. The aspiration (Table 1). A suprapubic cystostomy tube goals of treatment are to lower the morbidity and mor- was used to replace an indwelling urethral catheter in tality of the drainage procedure, reduce the need for re- two patients in each group (Table 1). treatment and to preserve normal urinary and sexual No deaths were reported after either intervention. function, particularly in young motivated patients. In The peri-procedure complications (in the first 30 days) the present study we reviewed our experience with this were only in the deroofing group, in which two patients rare urological emergency to devise an algorithm for developed septic shock necessitating intensive care (Cla- treatment. vien 4a) and one patient developed epididymo-orchitis Our data showed that deroofing is not free of morbid- (Clavien 2). There were two late complications in the ity, and although it is effective for the immediate control deroofing group, in which one patient developed a ure- of symptoms, the occasional need for the re-treatment of thral stricture that required endoscopic urethrotomy residual abscesses or the subsequent effect on urinary (Clavien 3a) and one developed a urethral diverticulum and sexual function invite other less-invasive treatment (Fig. 2) and urinary incontinence that required a diver- approaches. ticulectomy and bulbo-urethral sling procedure (Clavien Needle aspiration is a viable treatment option for 3b). A urethro-rectal fistula developed after aspiration in deeply seated body abscesses, which could be used by one patient (Clavien 3b) (Table 1). different approaches [12]. In urological practice, needle Re-treatment for the abscess was indicated in two aspiration has been used to treat renal, perirenal and (7%) patients in the deroofing group, where TRUS- pelvic abscesses. Unlike deroofing, the endpoint of guided aspiration was used. In these patients the failure TRUS-guided aspiration of a prostatic abscess is con- to control fever and an evident residual hypoechoic area trolled by simultaneous US. Despite that drainage might by TRUS indicated aspiration. be more complete with deroofing, the multiplicity of The need for abscess re-treatment (both patients) and abscesses in a large prostate can be a limitation to the occurrence of complications (all five) consistently deroofing procedure. occurred in patients with an estimated prostate size of Most of the published series are relatively small, out- >80 mL (P = 1.0). Furthermore, there was a further dated and reported before the era of minimally invasive need for re-treatment of the abscess (both patients) surgery (MIS) and effective highly specific medical ther- and more complications (four of five) in those with mul- apy for the prostate. Table 2 [5,8,9,13,14] summarises tiple abscess foci than in those with a single focus of the outcome of drainage procedures reported previ- abscess (P> 0.05). ously. Re-treatment for the abscess was reported in There were no significant differences between the 14–22% and re-treatment for BOO in 28% of patients. treatment groups in the need for auxiliary procedures Unfortunately, the reporting is incomplete and the to control residual LUTS (Table 1). One patient had a offered treatment was based on surgeon discretion and rarely on objective factors. We propose a treatment algorithm (Fig. 3) that iden- tifies patients based on age, prostate size, abscess criteria and associating urinary tract anomalies. In the current algorithm, an age of 40–50 years was used as a threshold for the beginning of LUTS secondary to BPH. Despite the significantly different proportion of men having LUTS, a clear trend towards an increase in symptom scores with increasing age is reported in all popula- tion-based studies [15]. So in our algorithm, BOO is con- sidered as an influential factor after that age. Furthermore, TRUS-guided aspiration is used as much as possible, aiming for deferred management of BOO (medical or MIS). When deroofing is indicated, espe- cially for a multilocular abscess, a threshold for prostate Figure 2 A retrograde urethrogram showing a urethral size at 80 mL is identified, based on recommendations of diverticulum. Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines 267 Table 2 Summary of different contemporary case series of prostate abscess. Refs N patients Abscess size, mL Abscess criteria Prostate size, g Treatment Re-treatment for: Hospital stay, mean (range) days Abscess BOO [5] 7 – – – 4 Perineal catheter – – 11.2 drainage 3 TUR deroofing 14.2% [13] 6 Mean 31.6 Mean 93 TRUS aspiration (17–65) (42–162) 16.7% – 1.6 (1–3) [8] 7 Mean diameter 28.5% Multifocal – TRUS-guided tube – 28.5% 10 (7–17) >1.5 cm drain [14] 11 – 3 Recurrent – 7 TUR –– after aspiration deroofing – Posteriorly 2 TRUS aspiration – – – Located – Periprostatic 2 Perineal drainage–– – extension [9] 41 Mean 3.87 (3–4) – Mean 59.4 (21–108) 23 TUR deroofing – – 10.2 (6–15) Mean 4.04 (2.0–5.0) – Mean 41.6 (24–50) 18 TRUS aspiration 22.2% – 23.2 (18–34) TUR, transurethral. Figure 3 An algorithm for the treatment of prostatic abscess. most of the guidelines limiting the role of safe transure- In younger patients the abscess criteria dictate the thral resection to this size [16,17]. In that situation, a management plan, but suprapubic cystostomy remains limited deroofing or maximum possible aspiration is an option for patients with indwelling catheters or those used, followed by a pre-planned deferred MIS. Fig. 1c on regular catheterisation for causes other than BOO. shows an example of a 204-mL prostate with a solitary After reviewing the present case series we emphasise peripheral abscess where TRUS-guided aspiration was the need to keep assessing the PSA level during the fol- used, and 6 weeks later holmium laser enucleation of low-up visits until it reaches a nadir level, otherwise a the prostate was performed. prostate biopsy is highly recommended to avoid missing 268 Elshal et al. [6] Barozzi LPP, Menchi I, De Matteis M, Canepari M. Prostatic underlying prostate cancer. Furthermore, a staged man- abscess: diagnosis and treatment. AJR Am J Roentgenol agement by needle aspiration of the abscess followed by 1998;170:753–7. a pre-planned definitive MIS treatment of the BOO is a [7] Galosi AB, Montironi R, Fabiani A, Lacetera V, Galle´ G, reasonable option. Muzzonigro G. Cystic lesions of the prostate gland: an ultrasound Limitations of the present study are inherent in any classification with pathological correlation. J Urol 2009;181:647–57. retrospective study. Furthermore, the situation affecting [8] Aravantinos E, Kalogeras N, Zygoulakis N, Kakkas G, Anag- the choice of treatment approach was not addressed and nostou T, Melekos M. Ultrasound-guided transrectal placement the few patients included did not allow an analysis of of a drainage tube as therapeutic management of patients with predictors of the outcome. prostatic abscess. J Endourol 2008;22:1751–4. In conclusion, transrectal needle aspiration and [9] Jang K, Lee DH, Lee SH, Chung BH. Treatment of prostatic abscess: case collection and comparison of treatment methods. transurethral deroofing are viable, comparable treat- Korean J Urol 2012;53:860–4. ment options for prostatic abscess. Needle aspiration, [10] Basiri A, Javaherforooshzadeh A. Percutaneous drainage for when done for properly selected cases, could minimise treatment of prostate abscess. Urol J 2010;7:278–80. the morbidity of the drainage procedure. [11] Shah H. Transurethral holmium laser deroofing of prostatic abscess: description of technique and early results. Abstract. J Urol 2010;183:e128. Conflict of interest [12] Ramesh J, Bang JY, Trevino J, Varadarajulu S. Comparison of outcomes between endoscopic ultrasound-guided transcolonic None. and transrectal drainage of abdominopelvic abscesses. J Gastro- enterol Hepatol 2013;28:620–5. [13] Go¨ gu¨ s C, Ozden E, Karaboga R, Yagci C. The value of Source of funding transrectal ultrasound guided needle aspiration in treatment of prostatic abscess. Eur J Radiol 2004;52:94–8. None. [14] El-Shazly M, El-Enzy N, El-Enzy K, Yordanov E, Hathout B, Allam A. Transurethral drainage of prostatic abscess: points of technique. Nephrourol Mon 2012;4:458–61. References [15] Chapple CR. Lower urinary tract symptoms revisited. Eur Urol 2009;56:21–3. [1] Granados EA, Caffaratti J, Farina L, Hocsman H. Prostatic [16] Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, abscess drainage: clinical-sonography correlation. Urol Int Michel MC, et al. Guidelines on the Management of Male Lower 1992;48:358–61. Urinary Tract Symptoms (LUTS), Incl. Benign Prostatic Obstruc- [2] Ludwig M, Schroeder-Printzen I, Schiefer HG, Weidner W. tion (BPO). European Association of Urology. Available at http:// Diagnosis and therapeutic management of 18 patients with www.uroweb.org/gls/pdf/13_Male_LUTS_LR.pdf Accessed 17 prostatic abscess. Urology 199;53:340–5. September 2014. [3] Trauzzi SJ, Kay CJ, Kaufman DG, Lowe FC. Management of [17] McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz prostatic abscess in patients with human immunodeficiency RC, Donnell RF, et al. Guideline on the Management of Benign syndrome. Urology 1994;43:629–33. Prostatic Hyperplasia (BPH), 2012. Results of the Treatment [4] Meares Jr EM. Prostatic abscess. J Urol 1986;136:1281–2. Outcomes Analyses. American Urological Association. Available [5] Oliveira P, Andrade JA, Porto HC, Filho JE, Vinhaes AF. at http://www.auanet.org/common/pdf/education/clinical-guidance/ Diagnosis and treatment of prostatic abscess. Int Braz J Urol Benign-Prostatic-Hyperplasia.pdf Accessed 17 September 2014. 2003;29:30–4.
Journal
Arab Journal of Urology
– Taylor & Francis
Published: Dec 1, 2014
Keywords: Prostate; Abscess; Deroofing; Aspiration; Transrectal; MIS, minimally invasive surgery
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