Prostate cancer (PCa) is the most frequently diagnosed malignancy of the male genitourinary system [1]. It typically has a subtle onset, remains asymptomatic in the early stages, or presents with minor symptoms, leading to delays in diagnosis and missed opportunities for effective and early treatment [19]. Therefore, it is crucial for clinicians to diagnose and stage PCa early, guiding the selection of the appropriate treatment method to prevent undertreatment or overtreatment, ultimately enhancing patients' quality of life and prolonging their survival [20].
Transrectal ultrasound-guided prostate biopsy (TRUS-Bx) is widely regarded as the gold standard diagnostic method for PCa. However, this invasive procedure can result in significant costs, morbidity, and, rarely, mortality, especially in patients with potential complications. Post-biopsy, patients may experience infectious complications, which may lead to hospitalization and, in severe cases, the risk of sepsis and death. Due to the emergence of resistance, which reached 15% in the past decade, against fluoroquinolone antibiotics, which were previously preferred as a prophylactic treatment, new strategic approaches have been sought to combat post-biopsy infectious complications. Among alternative methods are changes in prophylactic antibiotic regimens, preoperative rectal swab cultures with subsequent antibiotic prophylaxis based on culture results, formalin cleaning of biopsy needle tips before each procedure, the preference for transperineal biopsies over transrectal biopsies, and rectal mucosal antisepsis using povidone-iodine or chlorhexidine solutions. However, studies have shown that using enemas as a sole treatment following TRUS-Bx is insufficient for preventing infections [21].
In this study, 57 patients received only cefpodoxime prophylaxis (Group 1). In comparison, 61 patients received cefpodoxime prophylaxis and a transrectal injection of a 10% povidone-iodine solution containing 50 cc of poly-1-vinyl-2-pyrrolidone (administered 15 minutes before the procedure) (Group 2). When the two groups were compared, the increase in white blood cell counts in the patient population in Group 2 was not significantly different (p = 0.307). In contrast, the increase in Group 1 was statistically significant (p = 0.003). Furthermore, our study showed that white blood cell and C-reactive protein levels increased significantly following the TRUS-Bx procedure. However, when considering the significant increase in Group 1, the lack of transrectal povidone-iodine application was associated with pyuria and increased C-reactive protein levels (p < 0.05) (Table 2). Additionally, a statistically significant reduction in infectious complications was observed following the application of transrectal povidone-iodine (p < 0.05).
Transrectal povidone-iodine application is a simple and cost-effective method that reduces bacterial counts in the rectum, decreasing the probability of post-procedure infections. Nevertheless, prophylactic antibiotics remain the most widely preferred method for preventing post-biopsy infections.
In our study, age, prostate volume, and D'Amico risk stratification did not play a role in the development of infectious complications. Various clinical studies have been conducted on the application of transrectal povidone-iodine before TRUS-Bx. Ghafoori et al.[22] demonstrated that using a transrectal povidone-iodine solution significantly reduced the incidence of post-biopsy infectious complications. Park et al.[23] argued that applying povidone-iodine suppositories in the rectum was more effective than povidone-iodine enemas were. Another study reported that direct cleansing of the rectum and perianal region with povidone-iodine significantly reduced post-biopsy infectious complications by reducing rectal microbial colonization [24]. Chen et al.[25] adopted a direct method of cleaning rectal mucosa using gauze soaked in povidone-iodine and observed a 9.6% reduction in post-biopsy infectious complications. Meta-analyses of randomized controlled studies have shown that the combined use of transrectal povidone-iodine and prophylactic antibiotics significantly reduces the incidence of infectious complications [26]. Moreover, a retrospective study by Hwang et al.[27] demonstrated a significant reduction in bacteremia and sepsis rates following the application of transrectal povidone-iodine. These studies support the findings in our study that transrectal povidone-iodine application reduces the incidence of post-biopsy infectious complications [24, 25, 28]. However, Ryu et al.[29] observed no reduction in post-biopsy infectious complication rates following the application of transrectal povidone-iodine, contrary to the findings of previous studies, including ours.
Nonetheless, our single-center clinical study conducted on a Caucasian population has certain limitations for projecting the findings onto the general population. Despite performing urine analysis, urine culture, and rectal swab culture for all included patients, additional evaluations, including blood culture or other laboratory studies, were only conducted on patients hospitalized post-TRUS-Bx due to fever. The study's limitations include its small sample size, reliance on patient medical records data, and retrospective and non-randomized nature. However, this study will contribute positively to the current literature. To validate the results of this study, a larger prospective randomized clinical trial is necessary.