What is the best course of action for a 78-year-old male with BPH, LUTS, and elevated PSA of 13.3, with Impaired Renal Function?

From the Guidelines

This 78-year-old male with BPH, LUTS, elevated PSA (13.3), and a firm right-sided prostate nodule on DRE should undergo a prostate biopsy on May 8 to evaluate for possible prostate cancer, taking levofloxacin 250 mg daily for 4 days, starting one day before the procedure, with a reduced dose due to his elevated creatinine (2.32) 1. The patient's management plan should prioritize his safety and quality of life, considering his age, kidney dysfunction, and potential prostate cancer diagnosis.

• The patient needs medical clearance from his primary care physician, including CBC, SMA-7, EKG, and PT/PTT, to ensure he can safely undergo the procedure.
• He should also follow up with nephrology regarding his elevated creatinine to address any potential kidney-related issues.
• The antibiotic prophylaxis with levofloxacin is essential to prevent infection following the biopsy, as the procedure involves passing needles through the rectal wall to sample prostate tissue, which carries a risk of introducing bacteria into the bloodstream.
• The reduced antibiotic dose accounts for his impaired kidney function, as levofloxacin is primarily eliminated through the kidneys.
• The comprehensive pre-procedure workup is necessary given his age and kidney dysfunction to ensure he can safely undergo the procedure, as recommended by the 2023 European Association of Urology guidelines on the management of non-neurogenic male lower urinary tract symptoms 1.

From the Research

Patient Management

• The patient has been diagnosed with Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS) and intermittent bilateral flank pain, which is likely musculoskeletal in origin.
• A firm right-sided prostate nodule was found on Digital Rectal Examination (DRE), and the patient's Prostate-Specific Antigen (PSA) level is elevated at 13.3.
• The patient has been informed about the natural history of prostate cancer, the controversy surrounding screening and treatment outcomes, and the meaning of false positive and false negative PSA results.
• Management options, including trending PSA levels, prostate biopsy, and prostate/pelvic MRI, have been discussed with the patient.

Prostate Biopsy

• The patient has elected to proceed with a prostate biopsy, and pre-procedure instructions have been reviewed in detail.
• The patient will be taking Levofloxacin 250 mg daily for 4 days, starting 1 day prior to the procedure, as prophylaxis against infectious complications 2, 3, 4.
• The use of a single dose of Levofloxacin has been shown to be effective in preventing infectious complications in patients undergoing transrectal prostate biopsy 2, 3.
• The patient will also undergo medical clearance prior to the biopsy, including a Complete Blood Count (CBC), Sequential Multiple Analyzer (SMA-7), Electrocardiogram (EKG), and Prothrombin Time (PT)/Partial Thromboplastin Time (PTT).

Follow-up

• The patient is scheduled to follow up with a nephrologist for evaluation of elevated serum creatinine (Cr) levels.
• The patient will also follow up with the primary care physician (PMD) for medical clearance prior to the prostate biopsy.
• The prostate biopsy is scheduled for May 8, and the patient will be monitored for any complications or side effects after the procedure 5, 6.