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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 25  |  Issue : 3  |  Page : 172-176

Use of transrectal ultrasound in the management of urologic diseases in a tertiary hospital in North-Western Nigeria


1 Department of Surgery, Urology Unit, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Radiology and Nuclear Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication26-Sep-2018

Correspondence Address:
Abubakar Sadiq Muhammad
Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_131_18

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  Abstract 

Background: Transrectal ultrasound (TRUS)-guided biopsy of the prostate is considered as a standard of care for diagnosis of prostate cancer. The objective of this study was to document our experience in the use of TRUS in the management of urologic diseases in Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. Materials and Methods: This was a retrospective study of patients who had TRUS at UDUTH from December 2009 to November 2017. Relevant data were extracted from the procedure register, and case folders of the patients. Data analysis was performed using IPSS 20.0 version. Results: A total of 844 patients had the procedure within the period of the study. The mean age of the patients was 65.6 ± 10.6 years with a range of 7–98 years. The main clinical diagnoses of the patients were benign prostatic hyperplasia in 528 patients (62.6%), prostate cancer in 285 patients (33.8%) and primary infertility + azoospermia in 17 patients (2.1%). Transrectal ultrasound-guided prostate biopsy was done for 807 patients (96%). TRUS only was done for assessment of seminal vesicle and ejaculatory duct in 17 patients (2.1%), prostate volume assessment in 10 patients (1.1%) and deflation of retained urethral catheter balloon in 9 patients (1%). There was self-limiting rectal bleeding in 600 patients (74.4%) and 3 patients (0.4%) each developed haematuria and postbiopsy infections. Conclusion: Prostate biopsy is the most common indication for TRUS in our practice. Other indications were estimation of prostatic volume, evaluation of azoospermia and deflation of retained urethral catheter balloon.

Keywords: Ejaculatory duct obstruction, prostate biopsy, prostate volume measurement, retained catheter, transrectal ultrasound


How to cite this article:
Muhammad AS, Abdulwahab-Ahmed A, Agwu NP, Yunusa G, Abdullahi K, Mungadi IA. Use of transrectal ultrasound in the management of urologic diseases in a tertiary hospital in North-Western Nigeria. Niger Postgrad Med J 2018;25:172-6

How to cite this URL:
Muhammad AS, Abdulwahab-Ahmed A, Agwu NP, Yunusa G, Abdullahi K, Mungadi IA. Use of transrectal ultrasound in the management of urologic diseases in a tertiary hospital in North-Western Nigeria. Niger Postgrad Med J [serial online] 2018 [cited 2018 Dec 10];25:172-6. Available from: http://www.npmj.org/text.asp?2018/25/3/172/242201


  Introduction Top


Transrectal ultrasound (TRUS) is an invaluable procedure in urology with both diagnostic and therapeutic applications. TRUS-guided biopsy of the prostate is considered as a standard of care for diagnosis of prostate cancer.[1],[2] TRUS is helpful for the selection of appropriate patients with benign prostatic hyperplasia (BPH) for medical or surgical treatments.[1],[3],[4] It can be used to monitor the delivery of radioactive seeds into the prostate for brachytherapy, evaluation of azoospermia and deflation of retained catheter balloon.[5],[6],[7],[8] The objective of this study was to document our experience in the use of TRUS in the management urological diseases in the past 8 years.


  Materials and Methods Top


This was a retrospective study of patients who had TRUS at Urology Unit, Department of Surgery of our hospital from December 2009 to November 2017. The study was approved by the Health Ethics and Research Committee of Usmanu Danfodiyo University Teaching Hospital (UDUTH) Sokoto on the 9th November 2016, with protocol number UDUTH/HREC/2016/438. All the patients who had TRUS within the study period were included in the study except those with incomplete or missing data. Data were collected from patients' case notes, procedure register and entered into a pro forma. The data included biodata, patient's diagnoses, indication for TRUS ± prostate biopsy, findings on TRUS, complications of the procedure and histology results of the prostate biopsy specimens. The data were analysed using IBM SPSS (Chicago, IL, USA, 2011) version 20.0 for Windows. Results were reported as mean ± SD and percentages. The procedures were carried out by trained personnel at the level of consultant and senior registrar based on our unit protocol which is as follows.

Transrectal ultrasound (TRUS) technique ± prostate biopsy, deflation of urethral catheter balloon

Patients were counselled before the procedure. For prostate biopsy and urethral balloon deflation, intravenous access was secured and intravenous ceftriaxone 1 g was administered. Patients were placed in the left lateral decubitus position with buttocks flush with the end of the table to ease probe and biopsy gun manipulations.[1] An initial digital rectal examination was done to assess prostate nodularity and anorectal pathology. A volume of 20 ml of 2% xylocaine was instilled into the rectum and retained for 5 min in those going for intervention. We used Mindray Digi Prince Ultrasound System which has high-frequency monopolarlanar end firing rectal probe (6.5–8.5 MHZ) and inbuilt needle guide. The rectal probe was coupled with needle guide and covered with condom. A coupling medium (ultrasound gel) was applied on the condom and between the condom and the rectal probe to eliminate vacuum which will interfere with sound waves transmission. Patients were asked to relax during probe insertion, manipulations or intervention to get their cooperation and smooth procedure. The rectal probe was inserted under ultrasound-guidance; prostate was visualised in both transverse and sagittal planes. Prostatic volume was measured by our machine using the inbuilt programme from transverse diameter, anterior-posterior and longitudinal measurements obtained from transverse and sagittal planes [Figure 1]. Prostate echotexture, capsule, hypoechoic nodules, seminal vesicle, ejaculatory duct and urinary bladder were assessed. The procedure was facilitated by clamping catheter for those on urethral or suprapubic catheterisation to have some urine in the bladder for the enhanced acoustic window. Hypoechoic nodules in the peripheral zone and other suspicious areas were targeted and biopsied using spring-loaded 18G tru-cut biopsy needle. In the initial part of our experience, we used 6 core biopsies as described by Hodge et al.[9] Currently, for clinically obvious and palpable lesions, we took 6 cores, for clinical insignificant lesions, we took 10 cores as described by Presti et al.[10] For repeat biopsy, at least 12 cores were taken as described by Bjurlin et al.[11] Samples were collected in a small transparent sample bottle containing 10% formalin. The samples were subsequently submitted to histopathology laboratory for histological confirmation. For retained urethral catheter balloon deflation, the nondeflatable balloon was position and punctured along the needle guide on the machine [Figure 2]. The catheter was subsequently removed with minimal effort. For those with male infertility and azoospermia, seminal vesicles, ejaculatory ducts and prostate were assessed for an abnormality on the transverse plane.[12] The sizes of seminal vesicles and ejaculatory ducts were measured. Ejaculatory duct obstruction was diagnosed when seminal vesicle diameter measures >15 mm.[13]
Figure 1: Transverse (b) and sagittal (a) views of prostate in transrectal ultrasound

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Figure 2: Positioning of needle tract along balloon before puncture using spring loaded biopsy gun

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  Results Top


There were 844 patients who had TRUS within the study period with a mean age of 65. 6 ± 10.6 years and a range of 7 to 98 years. BPH and cancer of the prostate were the most common diagnosis and were found in 528 patients (62.6%) and 285 patients (33.8%), respectively. Other details of the clinical diagnoses are shown in [Table 1].
Table 1: Clinical diagnoses of the patients that had transrectal ultrasound

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Prostate biopsy was the most common indication of TRUS. This was done in 807 patients (95.7%). The indications for prostate biopsy were clinical, radiological, and biochemical. The clinical indications were LUTS with low back pain, paraesthesia and weakness in the lower limb or inability to walk. The radiological indications were distorted prostatic echotexture, hypoechoic nodules in the peripheral zone and breach in prostatic capsule. The biochemical indications were serum prostate-specific antigen (PSA) >10 ng/ml, PSA density >0.15 ng/ml/g and PSA velocity >0.75 ng/ml/year. Other indications are shown in [Table 2].
Table 2: Indications for transrectal ultrasound

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Complete records of 560 patients who had TRUS + biopsy were available and showed that 233 patients (41.6%) and 327 patients (58.4%) had features of BPH [Figure 3] and prostate cancer (Cap) [Figure 4], respectively. The histology showed high-grade prostate intraepithelial neoplasia in three patients (0.5%), nodular hyperplasia in 323 patients (57.7%) and adenocarcinoma in 224 patients (40.0%) and inconclusive in 10 patients (1.8%). Among 17 patients with infertility and azoospermia the prostate, seminal vesicle and ejaculatory duct were normal in 13 patients (76.5%) and abnormal in 4 patients (23.5%). The abnormalities included dilatation of the seminal and ejaculatory ducts. The seminal vesicles measured >1.5 cm in diameter.
Figure 3: Transrectal ultrasound of prostate in benign prostatic hyperplasia showing uniform echotexture and intact capsule

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Figure 4: Transrectal ultrasound of prostate in CaP showing heterogenous echotecture, breached capsule, bilateral multiple hypoechoic nodules and infiltration of the seminal vesicles

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Six hundred patients (74.4%) that had biopsy experienced self-limiting mild rectal bleeding that resolved within 24–72 h. Three patients (0.4%) each had self-limiting haematuria and postprostatic biopsy infections which were managed with admission, intravenous ceftriaxone, antipyretic and intravenous hydration using normal saline.  Escherichia More Details coli was isolated in one of the patients. The risk factors identified include chronic kidney disease, diabetes mellitus and urinary tract infection.


  Discussion Top


TRUS is an invaluable tool in urology because of its diagnostic and therapeutic potentials. The diagnostic uses include a targeted biopsy of suspicious nodules in the prostate to rule out prostate cancer, accurate measurement of prostatic volume for treatment of BPH, CaP and in the diagnosis of ejaculatory duct obstruction.[1],[4],[14] The therapeutic uses include placement of radio frequency markers for external beam radiotherapy (EBT), delivery of radioactive seeds for brachytherapy for patients with prostate cancer, balloon deflation of retained catheter, aspiration of the prostatic cyst, drainage of prostatic abscess, monitoring of cryotherapy and high intensity focussed ultrasound (HIFU).[1],[5],[6],[15]

The mean age of the patients in this study was 65 years. This is comparable to 70 years reported by a previous study.[12] This is because the most common diagnoses of the patients (BPH, CaP) are common middle age and elderly patients. The most common indication for the use of TRUS in our study was targeted biopsy of the prostate in patients with clinical, radiological and or biochemical suspicion for CaP.[12] The cancer detection rate in this study using 8- to 10-core biopsy scheme was 40%. This is comparable to what was reported by a previous study using 12-core biopsy protocol[16] but higher than 27.6% reported by the previous study using 10-core biopsy protocol.[17] The standard sextant protocolis presently considered inadequate for routine diagnosis of CaP.[1],[9],[10] Incorporation of more additional laterally directed biopsy cores into the sextant protocol is associated with improved cancer detection rate.[1],[10],[11] Double sextant or 12-core extended systematic biopsy incorporates apical and far-lateral cores into the sextant template which allows maximal cancer detection rate.[1] The double sextant protocol has been recently endorsed by the American Urological Association white paper on TRUS + biopsy.[11] The core biopsy protocol has a higher cancer detection rate than targeting specific hypoechoic nodules. Increasing the biopsy cores to 18 or 21 is associated with decrease cancer detection rate as in saturation biopsy.[2] Sometimes, the individual carrying out the biopsy may be going through the same track more especially in the small prostate. There is slight discrepancy of 2% between the diagnostic rate of TRUS and histology for Cap in this study (42% vs. 40%). This is not uncommon because prostatic infarct, chronic granulomatous prostatitis and lymphoma may give rise to hypoechoic nodules in the peripheral zone which are malignant in 17%–57% of the cases.[1] Hypoechoic nodules are not pathognomonic of Cap as 39% and 1% of cancers are isoechoic and hyperechoic on conventional grey-scale TRUS.[1]

As reported by previous studies, some of the patients in this study had TRUS for accurate measurement of prostatic volume.[18],[19],[20] This is necessary for the choice of the best modality of medical or surgical treatment of BPH.[19] Patients will benefit from 5-α reductase inhibitors such as dutasteride when the prostate is size greater than 30 g.[20] Patients with small prostate less than 30 g are predominantly made up of stroma which is rich in α-alpha adrenergic receptors and therefore respond very well to α-adrenergic blockers such as tamsulosin.[19],[21] Prostate size determines which patient benefit from minimally invasive treatments such as transurethral vaporisation of the prostate, transurethral resection of the prostate (TURP) and open surgery.[19] Prostate sizes of ≤40 g, < 75 g and >75 g are appropriate minimally invasive treatments, TURP and open surgery in patients with BPH.[22],[23],[24] TRUS was used to assess seminal vesicle and ejaculatory duct in 2.1% of the patients with obstructive azoospermia as reported by previous studies.[5],[18] A novel indication in our institution was use in patients with retained urethral catheter due to the faulty balloon which was targeted and deflated using TRUS. We have done this procedure successfully in 9 patients. This has been reported in the literature by few studies in the form of case reports.[8],[14] TRUS is important in the placement of radiofrequency markers for EBT, radioactive seeds for brachytherapy in CaP, monitoring of HIFU and cryosurgery.[1] We did not offer any of these to our patients.

Self-limiting mild rectal bleeding was experienced in up to 74% of the patients and few patients (0.3%) experienced self-limiting mild haematuria as reported in the previous studies.[1],[25],[26] This may be due to puncture of vessels during the procedure by biopsy needle which is observed more when size 16G biopsy needle is used. We used size 18G needle which has lower and milder side-effects profile. Three patients (0.4%) experienced severe postprostatic biopsy infections which were managed by hospitalisation, appropriate resuscitative measures and antibiotics as reported in the literature.[1] However, there is report of increasing rate of hospitalisation for the postbiopsy infections.[11],[25],[26] Severe infections are due to fluoroquinolone-resistant faecal flora from indiscriminate use of fluoroquinolones.[1] Risk factors for postprostatic biopsy infection include increased number of comorbidities, diabetes, previous biopsy, prostate enlargement and recent use of antibiotics.[1] The infection can be minimised by optimisation of patients with uraemia, diabetes and treatment of urinary tract infection which we routinely do.[1],[26] This explains the reason why major complications such as severe post-biopsy infection were few in this study.

The strength of this study is due to the use of a protocol for the procedure. Our consultants, senior registrars, are trained in the use of TRUS, conversant with the procedures and the protocol. This is not surprising as in the literature, TRUS ± biopsy is a procedure that is protocol based.[1] The protocol allows for its progressive improvement and better outcome over time.[9],[10],[11]

The limitations of this study include the inability to retrieve some of the TRUS cases and histology reports due to its retrospective nature. Some patients were excluded due to incomplete data. We might have underreported some complications in our patients as there was no deliberate follow up to look for it and most patients do not come for follow-up except when there are serious problems. The septic screen was not done for the patients that had postprostatic biopsy infections except for one that had urine microscopy.


  Conclusion Top


Prostate biopsy is the most common indication for TRUS in our practice. Other indications were estimation of prostatic volume, evaluation of obstructive azoospermia and deflation of retained urethral catheter balloon.

Acknowledgement

Prof. Aminu Mode, Department of Modern European Languages and Linguistics, Usmanu Danfodiyo University Sokoto, Nigeria for grammatical corrections.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Gomella LG, Halpern EJ, Trabulsi EJ. Prostate biopsy. Techniques and imaging. In: Wein AJ, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 11th ed. Philadelphia, PA: Elsevier, Incorporation; 2016. pp. 2579-92.  Back to cited text no. 1
    
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Lee JS, Chung BH. Transrectal ultrasound versus magnetic resonance imaging in the estimation of prostate volume as compared with radical prostatectomy specimens. Urol Int 2007;78:323-7.  Back to cited text no. 4
    
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Hodge KK, McNeal JE, Terris MK, Stamey TA. Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol 1989;142:71-4.  Back to cited text no. 9
    
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Presti JC Jr. Chang JJ, Bhargava V, Shinohara K. The optimal systematic prostate biopsy scheme should include 8 rather than 6 biopsies: Results of a prospective clinical trial. J Urol 2000;163:163-6.  Back to cited text no. 10
    
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Mitterberger M, Horninger W, Aigner F, Pinggera GM, Steppan I, Rehder P, et al. Ultrasound of the prostate. Cancer Imaging 2010;10:40-8.  Back to cited text no. 14
    
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Cheng G, Huang Y, Liu B, Zhao R, Shao P, Li J, et al. Systematic 12- and 13-core transrectal ultrasound-or magnetic resonance imaging-guided biopsies significantly improve prostate cancer detection rate: A single-center 13-year experience. Oncol Lett 2014;8:1834-8.  Back to cited text no. 16
    
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Kim EH, Larson JA, Andriole GL. Management of benign prostatic hyperplasia. Annu Rev Med 2016;67:137-51.  Back to cited text no. 23
    
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Nam RK, Saskin R, Lee Y, Liu Y, Law C, Klotz LH, et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol 2010;183:963-8.  Back to cited text no. 25
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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