|Year : 2020 | Volume
| Issue : 4 | Page : 377-383
Survey of prostate biopsy practices among urologists in Nigeria
Emmanuel Ajibola Jeje1, Taiwo Opeyemi Alabi2, Rufus Wale Ojewola1, Moses Adebisi Ogunjimi1
1 Department of Surgery, College of Medicine, University of Lagos; Urology Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
2 Urology Unit, Department of Surgery, Federal Medical Centre, Ebute-Metta, Lagos, Nigeria
|Date of Submission||11-Sep-2020|
|Date of Decision||27-Sep-2020|
|Date of Acceptance||14-Oct-2020|
|Date of Web Publication||04-Nov-2020|
Dr. Rufus Wale Ojewola
Department of Surgery, College of Medicine of University of Lagos and Lagos University Teaching Hospital, PMB 12003, Idi-Araba, Surulere, Lagos
Source of Support: None, Conflict of Interest: None
Background: Prostate biopsy (PB) is one of the most commonly performed procedures by urologists in our practice. It is the confirmatory diagnosis of the most common malignancy in elderly men. Currently, there is no national guideline on PB in Nigeria; hence, practices vary among urologists and institutions. The sudy aim was to highlight the various PB practices among Nigerian urologists with a view to determining the gap between our practice and evidenced-based global practice. Materials and Methods: A descriptive cross-sectional study which utilised self-administered questionnaires distributed among urologists who participated at the Nigerian Association of Urological Surgeons' (NAUS) Conference in Lagos in 2014. Results: The total number of respondents was 102, distributed across 26 states and various levels of the hospital. All respondents stated that they always perform biopsy if prostate-specific antigen (PSA) was >10 ng/ml. Seventy-nine (77.5%) respondents routinely rely on PSA kinetics in taking a decision on PB. About four-fifth routinely discontinue aspirin before the biopsy. All respondents administer antibiotics with a preference for the parenteral route in 74.5%. Anaesthesia employed for PB included, regional by 52 respondents (50.9%), local by 39 respondents (38.2%), and general by 1 respondent (1.0%), respectively. Transrectal route was preferred by 96 (94.1%). Majority (74.6%) still practice digitally-guided biopsy, whereas 25.4% perform the transrectal ultrasound-guided biopsy. The number of cores commonly taken for systematic technique ranges from 6 to 18. About a quarter (25.5%) had personal or institutional publication (s) on PB. Conclusion: PB practice vary among Nigerian urologists. The variability depends on individual training, preference and available institutional facilities. We recommend that NAUS should provide a guideline for the practices of PB in Nigeria.
Keywords: Nigerian urologists, practices, prostate biopsy, prostate cancer
|How to cite this article:|
Jeje EA, Alabi TO, Ojewola RW, Ogunjimi MA. Survey of prostate biopsy practices among urologists in Nigeria. Niger Postgrad Med J 2020;27:377-83
|How to cite this URL:|
Jeje EA, Alabi TO, Ojewola RW, Ogunjimi MA. Survey of prostate biopsy practices among urologists in Nigeria. Niger Postgrad Med J [serial online] 2020 [cited 2020 Nov 30];27:377-83. Available from: https://www.npmj.org/text.asp?2020/27/4/377/299917
| Introduction|| |
Prostate cancer (PCa) is the most common malignancy afflicting Nigerian men constituting 11% of all male cancers in the country. Nigeria ranks third after the United States of America and India in terms of significant death from PCa. Whereas, many investigative modalities currently being utilised (including clinical examination, radioimmunoassay and imaging) merely heighten or strengthen the suspicion of prostate carcinoma, only histopathological analysis of prostatic core biopsy tissue remains the 'gold standard' for confirmation of the suspected diagnosis of prostate carcinoma.
More prostate biopsies are likely to be performed by Nigerian urologists in the wake of increasing awareness on PCa. The practice of prostate biopsy (PB) varies among urologists within the same institution and from one institution to the other across Nigeria. At the moment, there is no national consensus on the practice of PB among urologists in Nigeria. This study, therefore, aims to highlight the PB practices amongst Nigerian urologists as well as the challenges encountered. It is our belief that the findings of this study will assist in improving the practice of PB and also provide a template for a national guideline in Nigeria.
| Materials and Methods|| |
This was a cross-sectional descriptive study that was conducted among Consultant Urologists and Senior registrars in urology who practice PB. Self-administered questionnaires were distributed to all participants at the Nigerian Association of Urological Surgeons (NAUS) Conference in Lagos in November 2014. Although there have been some other conferences after this, the Lagos Conference remains one of the largest gatherings of urologists in Nigeria till date. Approval for the study was obtained from the Executive Council of NAUS. Data were collected using pre-tested semi-structured questionnaire. This questionnaire has sections on the background information of the respondents as well as indications for PB, patients' preparation, biopsy procedure and post-PB practices. The data obtained were imputed into the IBM SPSS for Windows (IBM Corp,, Armonk, New York, United States) version 22.0 and subsequently analysed. Results were displayed in tables and charts.
| Results|| |
One hundred and thirty-two questionnaires were distributed to all the participants who registered for the annual urological conference in Lagos in November 2014. However, a total of 102 respondents returned completed questionnaires. The respondents were from 26 of the 36 states of the Federal Republic of Nigeria. They were distributed over 22 Teaching Hospitals, 9 Federal Medical Centres, 2 Public Specialist Hospitals, 4 Private Specialist Hospitals, 3 General Hospitals and a Trauma Centre. A total of 95 (93.1%) respondents were from public hospitals, whereas, 7 (6.9%) were from private hospitals. Of the respondents from the public hospitals, 77 (81.5%) were from teaching hospitals, 14 (14.7%) from the Federal Medical Centres, 3 (3.2%) from General Hospitals and 1 (1.1%) from Trauma Centre. Majority of the respondents were Consultants 78 (76.5%), while 24 (23.5%) were Senior Registrars. All respondents were practitioners of PB with an average of 10.8 prostate biopsies per month in their centres.
Of the three modalities for evaluating suspected PCa patients, prostate-specific antigen (PSA) and digital rectal examination (DRE) are routinely performed by all respondents while only 54 (52.6%) routinely do transrectal ultrasound (TRUS) before the biopsy. All the respondents will biopsy a prostate once the DRE is abnormal and elevated PSA >10 ng/mL. Of all the respondents, only 43 (42.2%) claimed to biopsy prostate at the PSA level in grey zone (4–10 ng/mL). Furthermore, the majority, 79 (77.5%) routinely rely on PSA kinetics to guide their decision for biopsy, while 23 (23.6%) do not. Other details are in [Table 1].
On pre-biopsy preparations, there was uniformity in the use of antibiotics as all the respondents use prophylactic antibiotics for PB. Majority 76 (74.5%) administer parenteral antibiotics, while the remaining 26 (25.5%) use oral antibiotics. Combination of quinolone and metronidazole was the commonest antibiotic (27.4%) used for PB followed by quinolone only in 24.5%. Only 36 (35.3%) performed pre-procedure bowel enema/evacuation while 66 (64.7%) do not perform any form of bowel preparation before PB. However, there was considerable variability in pre-biopsy bowel preparation amongst the 34.3%. Up to 80 (78.4%) of urologists in Nigeria discontinue non-steroidal anti-inflammatory drugs (NSAIDs), especially aspirin-containing drugs before biopsy for a duration ranging from 1 to 3 weeks, while 22 (21.6%) do not. Only 23 (22.5%) of respondents will fast their patients for PB while majority 79 (77.5%) will not [Table 2].
Regarding anaesthesia for PB, the vast majority 92 (90%) use one form of anaesthesia or the other alone, 5 (4.9%) use combination of anaesthesia and analgesics, 4 (3.9%) use analgesics only, while only one (1.0%) urologist use combination of analgesics and sedatives. Regional anaesthesia was the most favoured in 52 (50.9%) of the respondents. Local anaesthesia in the form of periprostatic nerve block infiltration was practiced by 16 (15.7%) while intrarectal xylocaine gel by 23 (22.5%) urologists. Other details on anaesthesia for PB are contained in [Table 3].
|Table 3: Choice of anaesthesia and/or analgesic for prostate biopsy procedure|
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Prostate biopsies are performed by respondents in various locations. Fifty-Six (54.9%) perform PB in the theatres (major or minor) while 32 (31.4%) perform their biopsies in out-patient clinics. The remainder takes place in the wards and ultrasound suites. Details are in [Figure 1].
Transrectal is the preferred biopsy route in 96 (94.1%), while transperineal is preferred in 6 (5.9%). Majority of respondents, 76(74.5%) still perform digitally-guided PB as only 13 (12.7%) do TRUS-guided prostate biopsy (TRUSPB) routinely while another 13 (12.7%) do both as indicated. More than half, 63(61.7%) of the respondents make use of Tru-cut biopsy size 18G while size 16G is favoured by 35(34.3%). Majority (73%) of urologists perform TRUSPB alone while others work with the radiologist. Eighty-seven (85.3%) of the respondents put all the specimens in the same bottle, 11 (10.8%) put each core in separate bottles and 4 (3.9%) each lobe core in separate bottles. [Table 4] contains other details about the needle guidance, sampling techniques, needle size and mode of specimen collection for the analysis.
Regarding position for PB, left lateral position is preferred by 91 (89.2%) whereas lithotomy position is preferred by 11 (10.8%) respondents. A routine 6–12 cores of prostatic tissue are usually taken by the majority of Nigerian urologists either during systematic or lesion-directed approaches [Figure 2].
Regarding post-biopsy complications, all respondents have experienced at least one complication in their patients before. Majority, 98 (96.1%) have experienced traumatic complications before namely 91 (89.2%) haematuria, 60 (58.8%) haematochezia and 18 (17.6%) haematospermia, while only about 29 (28.8%) have experienced infective complications in their patients. The most common and least infective complications are urinary tract infection and septicaemia in 22 (21.5%) and 4 (3.9%), respectively. About 10 (9.8%) have experienced acute urinary retention in their patients before. Only one (1%) had mortality for PB.
Generally, it takes 1–4 weeks after PB before histopathology result is available in most institutions. However, the majority of Nigerian urologists, 64 (62.8%) have their specimens reported within 2 weeks of submission. Twenty-two (21.6%) and 14 (13.7%) get their results within three and 4 weeks, respectively.
All respondents get Gleason's reportage from their pathologists. Performance of PB and bilateral total orchidectomy is adopted by 57 (56%) of the respondents for metastatically advanced disease with imminent paraplegia and hard, nodular prostate. The remainder still prefers to do biopsy and orchidectomy at different sittings despite strong clinical evidence of metastatic PCa.
Post-biopsy antibiotics are used by 93 (91.2%) of respondents for duration ranging from 3 to 5 days. Aspirin is usually recommenced over a period of 2–14 days after PB by the respondents who discontinue it before the biopsy. Post-biopsy analgesics which includes: NSAIDs, paracetamol and tramadol are usually administered by 84 (82.3%) of respondents over a period ranging from 3 to 7 days. About a quarter 27 (26.5%) of the respondents have at least one scientific publication on any aspect of PB.
| Discussion|| |
PCa is the most commonly diagnosed neoplasm affecting men in Nigeria. The burden of the disease is increasing as a result of population ageing and growth., Screening, detection and diagnosis of the disease are currently based on a triad of DRE, PSA and TRUS. However, only TRUSPBs can establish the histological diagnosis of the disease. However, it should be realised that PB is an invasive test that should be performed with optimal comfort, safety and accuracy. Therefore, when considering prostatic biopsy for a patient, there are certain pertinent questions, namely, who to biopsy, how to biopsy and what to biopsy? Furthermore, what is the best biopsy strategy to diagnose any PCa and the best biopsy strategy to detect and quantify clinically significant PCa. The details of experiences of Nigerian urologists are discussed here.
Indications for prostate biopsy
PB is usually based on abnormal DRE or increased PSA level. In this study, there is a general agreement among the Nigerian urologists that all abnormal DRE findings require PB irrespective of the PSA. Historically, abnormal DRE warrants PB irrespective of PSA level. In a recent study, the predictive value of DRE and PSA was documented by Ojewola et al. in the diagnosis of PCa and they recommended a combination of both parameters for optimal evaluation of the patient with suspected PCa. With regard to PSA values and kinetics, a good number of the Nigerian urologists entirely make decision based on PSA kinetics in addition to the DRE findings. However, the debate regarding the specificity and sensitivity of PSA kinetics in our environment is still far from over, as we do not screen or have a national acceptable figure to rely on. Commonly, it is noticed that blacks have fairly large glands with relatively higher PSA values. However, in various studies the role of PSA levels and kinetics have been documented to guide its use in PB. An earlier study by Ezenwa et al. on the value of total and free PSA among 105 patients above 50 years with palpably benign glands and PSA of 4–10 ng/ml noted that a threshold of fPSA <40% will detect the significant percentage of those with cancer with no increase in unnecessary biopsies. Only about half of the respondents in this study rely on abnormal imaging for the indication for PB. The practice is not unconnected to the usual late presentation of our patients in which clinical parameters with DRE and abnormally elevated PSA suffice for indication to biopsy the prostate.
The use of low-dose aspirin has been documented by some studies that it does not seem to increase bleeding and should be continued if deemed medically necessary. However, post-procedure bleeding from the patient who had been on routine aspirin usage can be sometimes life-threatening. About three quarter (78.4%) of all the respondents routinely discontinue aspirin if found to be part of patient's medications for duration ranging up to 3 weeks. This practice, along with stoppage of oral other anticoagulants for at least 5–7 days before PB is safe and should be encouraged in our protocol/practice.
Pre-procedure bowel preparation to reduce infective complications has been in recent time contentious. Only 36 (35.3%) of Nigerian urologists use rectal enema, laxatives or dietary advice to reduce the faecal load in the rectum before biopsy. In contrast, a similar study by Shandera et al. found 81% of urologists in the USA use an enema pre-biopsy. The risk of infections complication has been known to be lowered if a rectal enema is used., However, some authors documented no significant advantage in clinical outcome with regard to post-biopsy infection complication with or without bowel preparation. We, however, believe that in our environment, pre-procedure bowel cleansing/rectal enema should be a standard practice as no urologist should be comfortable to pass a needle through a rectum filled with faeces into the prostate gland with possible subsequent infection and urosepsis.
The infective complications of PB range for transient fever to urinary tract infection, sepsis and possible death. More frequent complications are being documented as the rate of resistance to commonly used antibiotics is increasing. The administration of an antimicrobial agent(s) before the initiation of a surgical procedure with the aim of preventing the development of infective complication is a routine practice called antibiotic prophylaxis. Infection complications following PB is certainly a growing concern to all the respondents; hence, all give antibiotics of one form or the other before biopsying the prostate. It has been shown that antibiotic prophylaxis lowers the risk of infection with multiple core biopsies significantly. In this survey, 51.9% of respondents make use of quinolines while 22.5% make use of single dose of aminoglycoside (Gentamicin) alone. One of the respondents has over the past two decades been using Gentamicin with rectal Flagyl with a satisfactory outcome. Similarly, Eke at Port-Harcourt, Nigeria reported his experience with Gentamicin and documented a lowered infection rate. Antimicrobial agents are selected based on their activity against microbes likely to be present at the surgical site. According to the American Urological Association(AUA), the antimicrobial of choice for PB is a fluoroquinolone or a Cephalosporin. Alternatively, aminoglycoside plus metronidazole or clindamycin can be used and the duration of therapy is within 24 h of the procedure. However, the post-biopsy duration of oral antibiotics is controversial. Fluoroquinolone has been much favoured mainly due to the wide spectrum of activity and high intra-prostatic concentration. However, there is a recent increase in the infective complication as a result of increasing rates of fluoroquinolone-resistant organisms. The colon is the major location of bacteria in the body with its flora similar to that found in the rectum and faeces. The anaerobes are mainly Bacteroides fragilis while Escherichia coli is the most abundant coliform.
The combination of rectal preparation and antimicrobial gives a more significant reduction in infection complication compared with the use of antimicrobial alone. In recent studies, using rectal swab culture and targeted antibiotic coverage has been found to reduce infection risk and the incidence of fluoroquinolone resistance., In a prospective comparative study of targeted and empirical prophylactic antibiotics in PB by Doherty et al. a lowered infective complication rate was found in the targeted antibiotic prophylactic group.
Route of biopsy
Historically, PB is through transrectal or transperineal with digital palpation of the gland and guidance of the biopsy needle. The PB route was mainly transrectal in 94.1% of respondents in which 74.5% of respondents carry out the digitally guided procedure. This finding was not surprising as there are limited centres in Nigeria with facilities for TRUS probe with subsequent TRUS-guided biopsy. Moreover, majority of patients with PCa in Nigeria present with advanced features with hard palpable nodules making digital-guided biopsies routinely yield an adequate positive result. Globally, this blind digitally guided procedure was the common practice until the late 1980s. It is a method appropriate for clinically large advanced tumour. It is quick, easy and inexpensive and may be performed at the outpatient department. However, this may be inappropriate for early PCa where false-negative result may be high. Hodge et al. popularised the use of systematic TRUS-guided prostate biopsies which became the gold standard. Lee et al. reported 56% of surveyed urologists in United Kingdom were actively involved in TRUSGPB while 68% did not think they received enough training for this procedure. TRUSGPB is highly desirable in the diagnosis of early cancers; hence, effort must be made to encourage Nigerian urologists to imbibe the practice in our primary young population.
Majority (75%) of Nigerian urologists practice either systematic (50%) or lesion-directed (25.5%) sampling technique. This practice is usually with 16-or 18G needles in 96% of respondents. The use of these needle sizes is in conformity with what is done at other centres globally. Prostatic biopsy currently is typically performed as office procedure under ultrasound guidance with 18G biopsy gun. Gauge 18 needles reduce the risk of traumatic complications and provide adequate tissue sample for pathological examination. Tru-cut biopsy has been the routine diagnostic tool for PCa in Nigeria, however recently Oliyide et al. documented a relatively good result with fine needle cytology procedure in the diagnosis of PCa. This approach can be useful for screening and diagnosis of patients with anorectal lesions forbidding PB with Tru-cut needle biopsy, provided experienced cytologist is available.
Number of cores
There is a wide variation with the number of cores taken by the urologists during PB. All of them take a minimum of six cores with a range of 6–18 cores. Adequate cores were noted to be taken by respondents as noted in their responses. Little controversy exists on the issue of cores to be taken as the more the cores, the higher detection rates; hence, the increasing practice of extended-core PB over the traditional sextant and lesion directed PB. European Association of Urology guidelines recommended a laterally directed systematic TRUS-guided prostatic biopsy with 12 cores as the standard procedure for PCa detection resulting in a positive biopsy rate of 25%–50%. Furthermore, lesion guided biopsy should be added to improve detection.
Sample storage for analysis
Another important issue is the storage and labelling of the specimens after retrieval. Ideally, specimens from different aspects of the prostate should be separated in separate bottles for individualistic analysis. This will allow detailed tumour grading and adequate determination of tumour volume. However, in view of the late presentation of our patients, the cores of tissues are usually kept into the same bottle for histopathology analysis in our environment. This is the practice of majority (85.3%) of Nigerian urologists as only 9.8% of respondents in this study put each core in a separate bottle to assess each core site for diagnosis with grade and volume of tumour. As more cases are diagnosed in early stages/organ-confined and with the increasing availability of local therapy, it is our belief that the globally recommended assessment of each core will be a common practice among Nigerian urologists in the future.
An important issue in prostatic biopsy is pain control during and after the biopsy. Majority of Nigerian urologists employed adequate pain relief measures during prostatic biopsy through regional and local anaesthesia, in addition to analgesia in few cases. Post-biopsy analgesic is also found to be a common practice among the respondents. Few local studies, have advocated many forms of anaesthesia and pain control during and after prostate biopsies. A recent study by Alabi et al. has recommended a combined intrarectal lidocaine gel and periprostatic nerve-block as balanced anaesthesia for TRUSPB. This recommendation is noted to be effective in pain control at all stages of the TRUSPB with higher patients' preference as the anaesthesia of choice for subsequent biopsies. Furthermore, there is no anaesthetic related complication compared with commonly used caudal block.
Urologic complications of prostatic biopsy could be traumatic (haematuria, haematochezia and haematospermia), infective (UTI, urosepsis, etc.,), and occasionally acute urinary tract obstruction. The high prevalence of BPH, more numbers of biopsy cores taken, increased rates of bacterial resistance and the use of anti-platelet medications all contributed to increasing morbidity associated with PB. Several local studies have reported experiences on complications following biopsy. Shittu and Kamara in a 5-year retrospective study documented 59% infective and 41% traumatic and overall complication of 26%. Similarly, Ojewola et al. in a prospective study reported an overall complication rate of 26.4% with the use of empirical antibiotic. Hospital admission following biopsy has been on the rise, probably due to many factors which include lack of consensus on antibiotic prophylaxis and method of the bowel preparation as well as surge in the incidence of fluoroquinolone-resistant infections.
| Conclusion|| |
Practices of PB vary among urologists in Nigeria. The variability depends on individual training, preference and available institutional facilities and resources. We recommend more publications that reflect the peculiarities of our environment. Furthermore, we like to encourage the NAUS to provide a guideline for the practices of PB in Nigeria for overall improvement in diagnostic accuracy and safety.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]