Prostatic Abscess After Rezum: A Cautionary Case Report and Literature Review

Technical Summary: Prostatic Abscess After Rezum

Problem Statement
Transurethral water vapor thermal therapy (Rezum) is an established minimally invasive treatment for benign prostatic hyperplasia (BPH), offering advantages such as reduced trauma and preservation of sexual function compared to traditional transurethral resection of the prostate (TURP). While postoperative complications are generally mild and self-limiting (e.g., transient hematuria, urinary tract infections), there is a scarcity of literature regarding severe infectious adverse events, specifically prostatic abscesses, following Rezum therapy. The clinical community lacks systematic data on the incidence, risk factors, and management of such severe complications, particularly in patients with large prostates or those undergoing concurrent procedures like prostate biopsy.

Methodology
This study employs a dual-method approach:

1. Case Report: The authors present a detailed clinical case of a 62-year-old male with an 80.25 mL prostate who underwent simultaneous transrectal ultrasound-guided prostate biopsy and Rezum therapy. The patient experienced premature catheter removal (postoperative day 3) and subsequently developed refractory urinary symptoms. He underwent secondary TURP one month later, where intraoperative findings and pathological analysis confirmed the diagnosis.
2. Literature Review: The authors conducted a systematic review of existing literature, including randomized trials, prospective studies, case reports, systematic reviews, and meta-analyses, to synthesize data on Rezum complications. This review focuses on common adverse events and rare, severe outcomes such as prostatic abscess, tissue emphysema/necrosis, and prostatic urethral cysts.

Key Contributions

• First Pathologically Confirmed Case: The authors claim this is the first reported instance of a pathologically confirmed prostatic abscess specifically attributable to Rezum therapy that necessitated secondary surgical intervention. While a prior case (Fantasia, 2018) suggested a prostatic abscess based on imaging, the final pathology in that case did not definitively confirm abscess formation; the current case provides histological evidence of degenerative necrosis with suppuration.
• Risk Factor Identification: The paper highlights specific risk factors that may predispose patients to severe infectious complications:
  • Large prostate volume (>80 mL), leading to a greater burden of necrotic tissue.
  • Concurrent prostate biopsy, which may introduce bacteria into deep prostatic tissue.
  • Premature catheter removal, potentially causing urinary obstruction and bacterial proliferation before necrotic tissue sloughs off.
• Clinical Management Insights: The study details the intraoperative presentation of the abscess, characterized by irregular necrotic tissue with "cotton-like" changes, scattered purulent cavities, and purulent exudate, which were successfully managed via TURP and debridement.

Results

• Case Outcome: The patient's symptoms (refractory frequency, dysuria, pelvic pain) resolved completely following the secondary TURP and antibiotic therapy. Pathology confirmed benign prostatic hyperplasia with degenerative necrosis and suppuration.
• Literature Findings: The review confirms that while common complications include hematuria (6.5%–52.5%) and urinary tract infections (5.5%–18.1%), severe complications are rare. However, when they occur (e.g., prostatic abscess, tissue emphysema), they often require reoperation. The review notes that prolonged catheterization is a significant factor in infectious complications, though the optimal duration varies based on prostate size and injection count.
• Pathogenesis: The authors propose that the combination of extensive necrotic tissue (from the large prostate volume), potential bacterial inoculation (from the concurrent biopsy), and urinary stasis (from early catheter removal) created a nidus for Enterococcus faecalis infection, leading to abscess formation.

Significance and Claims
The paper asserts that while Rezum is generally safe and effective, clinicians must maintain vigilance regarding severe infectious complications in high-risk populations. The significance of this work lies in:

1. Alerting Clinicians: It serves as a cautionary report that prostatic abscess, though rare, is a potential life-threatening complication of Rezum, particularly in patients with large prostates (>80 mL) or those undergoing concurrent biopsies.
2. Refining Management Protocols: The authors suggest that standard postoperative protocols may need adjustment for high-risk patients. Specifically, they advocate for:
   • Enhanced surveillance for persistent symptoms.
   • Extended catheterization periods (beyond the typical 5–7 days) to ensure adequate drainage of necrotic tissue.
   • Intensified antimicrobial management.
   • Prompt imaging and transurethral debridement if necrotic tissue obstruction or severe infection is suspected.

The authors conclude that these measures are essential to avoid secondary interventions and improve patient outcomes, emphasizing that patient selection and perioperative management are critical to mitigating these rare but severe risks.