AJR 2004; 183:1706-1707
© American Roentgen Ray Society
Transrectal Color Doppler Sonographically Guided Compression to Treat Active Extravasation After Transrectal Prostate Biopsy
Ronald H. Wachsberg1
1 Department of Radiology, New Jersey Medical School, 150 Bergen St., C-320,
Newark, NJ 07103.
Received February 19, 2004;
accepted after revision March 22, 2004.
Address correspondence to R. Wachsberg
(wachsbrh{at}umdnj.edu).
Clinically significant bleeding is an unusual complication of transrectal
prostate biopsy that may require hospitalization and blood transfusion and
occasionally can be life-threatening
[1–3].
The initial treatment of significant bleeding after biopsy is direct
compression with an examining finger or an intrarectal tampon, which is
inserted blindly and may take up to an hour or longer to stem the bleeding
[3,
4]. If such measures are
unsuccessful, emergency anoscopy is performed to identify the bleeding vessel,
which is then sutured or injected with vasoconstrictive agents
[2,
3]. Our report describes the
usefulness of transrectal color Doppler sonography to identify the site of
extravasation and to guide compressive occlusion of the bleeding vessel, a
technique that we have used successfully in two patients. The use of color
Doppler sonography to detect and stop active extravasation is not novel
[5], but to my knowledge, its
use in this setting has not been reported.
Both patients had copious bright red blood per rectum. An 18-gauge
spring-loaded biopsy needle (Monopty, Bard) was used in both cases. In one
patient, bleeding was noted after the third of 12 planned core biopsies (i.e.,
during the procedure). In the second patient, bleeding was noted only after
the biopsy had been completed and the transducer removed, whereupon the
transducer was covered with a fresh condom and reinserted.
Color Doppler sonography to detect extravasation was performed in the
longitudinal plane, although an oblique or transverse plane might be favored
by others. The color scale was set relatively high to eliminate flow signals
from lower-velocity flow in prostatic and rectal blood vessels. In each
patient, active extravasation into the rectal lumen was readily apparent on
color Doppler sonography. The findings were similar to those reported with
postbiopsy prostatic arteriovenous fistulas (i.e., rapid, pulsatile,
low-impedance flow directed toward the transducer)
[6], with the added feature
that the color-flow signal continued into the rectal lumen in patients with
active extravasation (Fig. 1A,
1B).
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Fig. 1A. —71-year-old man referred for prostate biopsy because of
elevated serum prostate-specific antigen (7.2 ng/mL). Bright red blood was
noted flowing briskly from needle guide after third biopsy was performed.
Longitudinal transrectal triplex Doppler sonogram, with color scale set at 23
cm/sec, shows active arterial extravasation as rapid, pulsatile, low-impedance
flow emerging from prostate, traversing short track to rectal wall, and
spraying into rectal lumen.
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Fig. 1B. —71-year-old man referred for prostate biopsy because of
elevated serum prostate-specific antigen (7.2 ng/mL). Bright red blood was
noted flowing briskly from needle guide after third biopsy was performed.
Color Doppler sonogram obtained during compression shows no bleeding. Pressure
was slowly released after 5 min of compression, and bleeding did not
recur.
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With the transducer held against the bleeding vessel, compressive force was
applied until extravasation was no longer seen on color Doppler sonography.
Pressure was maintained for 5 min during continuous color Doppler sonographic
monitoring and was then slowly relaxed. This sufficed to halt extravasation in
one patient, whereas an additional 5 min of compression was necessary to
achieve hemostasis in the other patient.
The scanners used were a Logiq 700 in one patient and a Logiq 9 (both
scanners, GE Healthcare) in the other patient. Although the sensitivity of
color Doppler sonography for slow flow detection certainly varies among
different scanners, the high-velocity flow seen during arterial extravasation
should be readily apparent using any endocavitary transducer and any scanner
with color Doppler capability. The experience at our institution suggests that
such flow should be immediately obvious. Therefore, if color Doppler
sonography fails to rapidly reveal the source of extravasation in a patient
who is actively bleeding after transrectal biopsy, a prolonged color Doppler
examination is probably not appropriate.
Because of considerable rectal distention that necessarily occurs during
transrectal compression, one should be alert to the possible development of a
vasovagal episode, particularly because this phenomenon reportedly occurs in
8% of uncomplicated transrectal prostate biopsies
[1]. Fortunately, we did not
observe a vasovagal episode in either of our patients who underwent color
Doppler sonographically guided compression.
Proponents of color and power Doppler sonography of the prostate have
focused on the potential value of these techniques for determining the
diagnosis, extent, and prognosis of prostate malignancy
[7,
8]. Because flow mapping
substantially prolongs the diagnostic component of the examination and because
multiple core biopsies will be performed in any event, many physicians who
perform transrectal prostate biopsies use low-end scanners without color
Doppler capability. In such circumstances, the technique described here is
obviously inapplicable, unless another machine with color Doppler capability
on a transrectal transducer is located nearby and available.
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