Retzius space hematoma after prostate biopsy: A case report

Abstract

The most commonly reported complications after prostate biopsies are associated with bleeding. We present the case of a 60 y/o male with a history of elevated Prostate-Specific Antigen (PSA) and a PI-RADS 4 lesion who underwent an MRI-guided transrectal ultrasound (TRUS) biopsy which resulted in a rare phenomenon of a hematoma in the space of Retzius. Conservative management may be effective for patients with Retzius space hematomas who are stable or asymptomatic.

1 Introduction

Prostate cancer is the most diagnosed cancer in men and accounts for 7.3 % of cancer cases in the world. Despite advancements in imaging, the gold standard for diagnosing prostate cancer remains a prostate needle biopsy. Approximately one million prostate biopsies are performed per year in the United States. There has been substantial research into ways to best obtain an accurate histopathologic diagnosis while minimizing morbidity. In contemporary practice, prostate biopsies are performed through both the transrectal and transperineal approaches.

Although rates are low, severe complications following Transrectal Ultrasound (TRUS) biopsies may include urethral bleeding, hematospermia, rectal bleeding, urinary retention, urinary tract infection, sepsis, erectile difficulties, and pain. The most frequently reported post-procedure complications are related to bleeding. Rectal bleeding specifically is self-limiting and rarely (0.6 %) requires surgical intervention or involves an experience of prolonged hematochezia.

In this report study, we describe an unusual presentation of post MRI-guided transrectal ultrasound (TRUS) biopsy bleeding leading to a hematoma in the space of Retzius. We aim to broaden the understanding of more atypical complications after prostate biopsies.

1.1 Case presentation

A 60 y/o male presented with a history of elevated Prostate-Specific Antigen (PSA) and an abnormal Magnetic Resonance Imaging (MRI) of the prostate which had been ordered by his Primary care physician. Upon presentation to clinic, patient did not have any significant urological complaints. The patient was not on anticoagulation therapy nor had a history of blood dyscrasia. Relevant surgical history included Urolift in 2019 to treat Benign Prostatic Hyperplasia (BPH) symptoms. His most recent Prostate-Specific Antigen (PSA) was 7.744 ng/mL in February 2024. Magnetic Resonance Imaging (MRI) of the prostate ( Fig. 1 ) revealed a PI-RADS 4 lesion in the right peripheral zone measuring 0.9 cm. Following discussion of the findings with the patient, he elected to proceed with an MRI-guided transrectal ultrasound (TRUS) biopsy of his prostate.

The procedure was done under light sedation and a preoperative dose of antibiotics was given to the patient. A standard MRI-guided transrectal ultrasound (TRUS) biopsy was done with a standard 12 core template, including 2 cores from the region of interest. The procedure was uncomplicated, and the patient was discharged home on the same day. Five days postoperatively, the patient presented to an outside hospital with lower abdominal pain and lower abdominal wall ecchymosis. Computed Tomography (CT) scan ( Fig. 2 ) at presentation demonstrated a large hematoma in the space of Retzius, measuring approximately 5.5 × 9.9 × 9.5 cm, with no evidence of active contrast extravasation. His lab work was notable for a Hgb 9.7, and HCT 30 %, from pre-op values of 12.3 and 38.5 %, respectively. He was hemodynamically stable on presentation, and he was monitored overnight with serial vitals and hemoglobin hematocrit without significant change. He was subsequently discharged home in stable condition without need for intervention on the following day.