Hair embedding after transperineal prostate biopsy: a case report and in vitro experiment

doi:10.21203/rs.3.rs-2463363/v1

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Case Report

Hair embedding after transperineal prostate biopsy: a case report and in vitro experiment

https://doi.org/10.21203/rs.3.rs-2463363/v1

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Journal Publication

published 18 Mar, 2023

Read the published version in BMC Urology →

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Objective: To reduce the risks of transperineal prostate biopsy complications and to identify the causes of hair embedding in prostate tissue.

Methods: Hair embedded in the puncture canal was observed in two cases of transurethral resection of the prostate following transperineal puncture biopsy with a Bard MC1820 disposable biopsy needle. In vitro experiments were used to analyze and reconstruct the process of hair embedding in prostate tissue.

Results: The simulation experiment confirmed that the hair was clamped between the needle core and the coaxial needle sheath. In addition, the puncture needle broke the skin and entered the tissue. After activating the trigger, the hair outside the coaxial needle sheath was pushed into the puncture passage and remained there.

Conclusion: Hair embedding caused by perineal prostate biopsy is a consumable-related adverse event, and skin preparation prior to transperineal prostate biopsy is recommended.

hair embedding

prostate biopsy

complication

medical supplies

adverse event

Transperineal prostate biopsy is gradually becoming the standard methodology for diagnosing prostate cancer because of its high accuracy and low risk of infection[1]. The complications of invasive puncture include but are not limited to bleeding, infection, urine retention, and vagal reflex, while hair embedding is rare[2–3]. In this study, we reported two cases of hair embedding as a complication of transperineal prostate biopsy and validated it in vitro to confirm the process of hair embedding.

Case 1

A 67-year-old male presented with urinary incontinence, dysuria, and hematuria. Anal digital examination revealed that the prostate was approximately 4cm × 4cm in size, tough in texture, and free of pain, and the central sulci had vanished. Ultrasound and computerized tomography scans revealed 4 cm × 2.5 cm bladder calculi, blood clots in the bladder, and prostatic hyperplasia. Total prostate-specific antigen (PSA) was over 100 ng/ml in the blood, while free PSA was 12.5 ng/ml. A transperineal prostatic system biopsy was conducted under epidural anesthesia due to budgetary constraints and the patient's desire to improve life quality, and 12 punctured tissues were retrieved. A hair was discovered on the surface of one specimen (Fig. 1A). Immediately after the puncture, and holmium laser lithotripsy was performed with palliative electrostatic excision. Curly hair was detected in the prostate tissue above the verumoncus (Fig. 1B). Pathology indicated: prostate adenocarcinoma, Gleason 4 + 4. The patient recovered well after surgery and underwent comprehensive androgen-blocking therapy.

Case 2

A 75-year-old man presented with frequent urination, difficulty urinating, and urinary retention. Catheterization was repeated three times in ten days. An anal digital examination revealed that the prostate was 5×6 cm in size, medium in texture, with no nodules or discomfort, and the central sulci had vanished. White blood cell in urine: 57/HP. Total PSA was 9.56 ng/ml in the blood, while free PSA was 2.51 ng/ml. Prostatic hyperplasia was discovered using magnetic resonance imagining. Diffusion weighted imaging revealed a slightly higher signal intensity in the peripheral zone and a slightly thicker bladder wall and right inguinal lymph node. Transperineal prostatic system puncture biopsy was conducted under general anesthesia, followed by transurethral electrostatic resection, during which hair embedding was discovered in the prostatic puncture canal. Figures 1C and 1D show video screenshots. Histopathology of postoperative electroprostatectomy and prostatectomy indicated benign hyperplasia with persistent interstitial inflammation; immunohistochemistry: P63 (+), CK (+), P504S (-), AR (+), Ki67 (1%+), PSA (+). The patient healed well postoperatively and was urged to have regular PSA testing.

Bard MC1820 disposable biopsy needle, soft hairs, a radish, a fruit knife and a micrometer were used for in vitro experiments. Open the packaging box of Bard MC1820, take out the disposable biopsy needle and take down the fixator; Pull down the upper slider with finger to lock the coaxial needle sheath, then use a micrometer to measure the outside diameter of the biopsy needle core and the coaxial needle sheath. Pull down the slider, shrink the needle core, and clamp a thin and soft piece between the coaxial needle sheath and the needle core (Fig. 2B). Pierce the radish and press the button to fire the puncture needle. Retract the coaxial needle sheath and check the sample in the sampling slot. Slice the radish along the puncture direction with a fruit knife, and observe where the hair is pushed and kept.

The core diameter of the Bard MC1820 needle is 0.997 mm, while the outer diameter of the coaxial needle sheath is 1.268 mm. The soft hair is easily sandwiched between the needle core and the coaxial needle sheath. After firing the puncture needle, the hair is cut off and visible in the punctured tissue (Fig. 2C), while the hair outside the coaxial needle sheath is pushed and retained in the penetration path (Fig. 2D). A truncated hair was found in the sampling tank, similar to the hair in Fig. 1A.

The human prostate has two main cell types: epithelial cells and stromal cells. Prostate epithelial cells consist of basal epithelial cells, intermediate cells, neuroendocrine cells, and coelominal epithelial cells, which are incredible to combine to generate a follicular structure that allows hair to develop in the prostate. Surgeons can confirm and exclude that the hair adheres to the outer sheath and ring of the resectoscope and enters the prostate tissue through the urethra. The implanted hair can be seen in the tissue defect area of the puncture canal in the video of case 2 (screenshot, see Fig. 2A). The visual field can identify the hair shaft's structure and the hair shaft, and the broken end of the hair shaft exhibits wrinkles (Fig. 2B). We hypothesize that the hair was wedged between the needle core and the coaxial needle sheath and punctured the deep tissue before being twisted and severed. In vitro studies were used to recreate the process of hair embedding in the puncture canal (Fig. 2A, D), and it was proven that the hair was sandwiched between the needle core and the coaxial needle sheath and entered the tissue after the puncture needle broke the skin. After activating the trigger, the hair outside the coaxial needle sheath was forced into the puncture channel and stayed there. The similarity of the break patterns in the experiment's sample tank and those in Fig. 1A confirms our hypothesis. Curtis et al. reported an instance of hair detected in the material after radical excision of prostate cancer following a transrectal prostate biopsy in 1998, and they suspected that the hair was injected into the prostate by the biopsy needle. Therefore, a transperineal and transrectal prostate puncture may lead to hair insertion, and the root cause is directly related to the biopsy needle used.

Bard MC1820, the author's most commonly used biopsy needle, is a disposable biopsy needle. The hair entanglement between the needle core and the coaxial needle sheath resulted in the hair embedding into the tissue, which should be attributed to the adverse event related to consumables. If other types of puncture needles are selected or perineal skin preparation is carried out before the puncture, the recurrence of hair embedding can be prevented or reduced.

Hair granuloma will be found in the pathological section if the patient with hair embedded due to puncture is diagnosed as prostate cancer and has undergone radical prostate cancer surgery[4–7]. However, it is still unknown whether the foreign body reaction caused by the hair in the prostate tissue of patients who have not been diagnosed with prostate cancer or have not undergone radical prostatectomy will lead to persistent PSA abnormalities, perineal pain, prostatitis syndrome, medical image changes, etc.

PSA: prostate-specific antigen

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent for publication was obtained from all study participants including patients.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Funding

Not applicable.

Authors' contributions

JXN and YN conceptualized the idea of case report manuscript,and collated data on the case reports. GW, TLZ, GCZ, DXF are involved in the drafting and critical review of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank the clinics cases were conducted, the nurses that assisted and the individuals that were studied.

Feng TR, Yan WG. Research progress of transperineal prostate biopsy[J]. Journal of Clinical Urology, 2021, 36(6): 485-491.
Prostate biopsy expert consensus writing group, Andrology Branch, Chinese Medical Association. Expert consensus on prostate biopsy[J]. Chinese Journal of Andrology, 2022, 28(5): 462-470.
Urology Branch of Chinese Medical Association, China Prostate Cancer Alliance. Chinese expert consensus on prostate puncture[J]. Chinese Journal of Urology, 2016, 37(4): 241-244.
Ventura L, Martini E, Di Nicola G, et al. Hair granuloma of the prostate. A clinically silent, under-recognized complication of needle core biopsy[J]. Histopathology, 2006, 49(6): 654-656.
White J, Chan YF. Hair granuloma in the prostate[J]. British Journal of Urology, 1994, 74(2): 260-260.
Curtis MR, Schned AR, Williams JC. An unusual complication of transrectal biopsy: Hair as a prostate foreign body[J]. Infections in Urology, 1998, 11(1): 9-11.
Day DS, Carpenter HD Jr, Allsbrook WC Jr. Hair granuloma of the prostate[J]. Human Pathology, 1996, 27(2): 196-197.

No competing interests reported.

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Journal Publication

published 18 Mar, 2023

Read the published version in BMC Urology →

Editorial decision: Major revision
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You are reading this latest preprint version

Hair embedding after transperineal prostate biopsy: a case report and in vitro experiment

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