During Friday afternoon’s Prime Time plenary session, Paul Crispen, MD, a urologist at the University of Florida, will portray a urologist who performed prostate needle biopsies on a 68-year-old man who subsequently died of urosepsis as a complication of the procedure. In the fictitious scenario the patient’s family sues for malpractice and the AUA plenary audience will sit in judgement during a mock trial.
“This is a chance to explore not only important issues in prostate cancer, but also how plaintiffs, defendants and their attorneys approach and handle malpractice cases,” said Norm Smith, MD, FACS, professor of Surgery and Urology at the University of Chicago. “Litigation, or the threat of litigation, is a fact of life for urologists. Seeing a mock trial and the ways issues are approached can be a very valuable learning experience for the practicing urologist.”
Dr. Smith will moderate the 45-minute presentation Court is in Session: Malignant: Sepsis and Death after Prostate Needle Biopsy, which will begin at 2:15 pm in the Esplanade Ballroom at Moscone South. Jay Raman, MD, FACS, Chief of Urology at the Penn State Milton S. Hershey Medical Center, will portray an expert witness for the defense and Peter Black, MD, FACS, FRCSC, professor and Head of Urologic Sciences at the University of British Columbia, will portray an expert witness for the plaintiff.
The patient will seem familiar to most practicing urologists, Dr. Smith said. His PSA (prostate specific antigen) was 3.8 in November 2016 and increased to 7.7 by November 2017. His PSA had climbed to 8.2 by January 2018 and digital rectal exam revealed right-sided induration with an estimated 50 gram prostate. The patient was a cook at a local hospital and had a family history of prostate cancer; his father is under active surveillance at age 90.
The patient performed Fleet’s enema and was given 500 mg ciprofloxacin BID the day of the transrectal ultrasound guided needle biopsy. There were no immediate complications after the biopsy, but the patient called urology that evening to complain of significant dysuria, difficulty urinating, fevers and chills.
He was instructed to go to the emergency department where he had a fever of 103°F with rigors and urinary retention. He was hypotensive and tachycardic. After catheterization, blood and urine samples were sent for culture, and the patient was resuscitated with IV fluids.
Broad-spectrum IV treatment with piperacillin/tazobactam and gentamicIn was started promptly, but the patient continued to decline. A code was called, and the patient was intubated and went into ventricular tachycardia before he died. Blood and urine samples yielded Pseudomonas resistant to fluoroquinolones.
“We have two familiar issues for further consideration in this case,” Dr. Smith said. “One is the appropriate indications for biopsy and adjunctive testing. The second is whether, given that the patient worked in a health care environment, he should have been given something other than one day of fluoroquinolone prophylaxis.”
A sharp elevation in PSA is, strictly speaking, sufficient indication for biopsy, he continued. But clinical practice is in flux.
Active surveillance is an acceptable, sometimes preferred, alternative for many patients with prostate cancer. In this case the biopsy showed two cores of Gleason’s 3+4 disease on the right side.
“Many urologists are looking for more solid reasons to biopsy beyond just an elevated PSA,” Dr. Smith said. “There are alternatives such as genomic testing and prostate MRI [magnetic resonance imaging] that could have been explored before the decision was made to biopsy.”
Antimicrobial prophylaxis is another complex issue. It’s widely recognized that health care environments have increased potential to harbor resistant pathogens. Some urologists respond by widening their antibiotic coverage. Others do a rectal swab to determine which pathogens are present and direct their antimicrobial prophylaxis based on specific sensitivities. Neither approach has been shown to be superior with high level data.
“At the University of Chicago, we review urinary tract infection isolates and the local antibiogram to select antibiotic prophylaxis for prostate biopsies,” Dr. Smith said. “But not every institution or urologist takes that approach. This case deals with real dilemmas in real practice. Simply seeing how these complex but familiar issues play out in court should be both educational and entertaining.”