A randomized, controlled trial comparing lidocaine periprostatic nerve block, diclofenac suppository and both for transrectal ultrasound guided biopsy of prostate

PURPOSE: Lidocaine periprostatic nerve block (PPNB) provides good procedural pain relief for transrectal ultrasound (TRUS) prostatic biopsy. However, post-procedural pain can be significant. The addition of diclofenac suppository (DS) to lidocaine PPNB might provide additional, particularly post-procedural pain relief. We assessed the procedural and post-procedural pain relief for TRUS biopsy provided by DS, and the combination of DS and lidocaine PPNB compared with lidocaine PPNB alone. MATERIALS AND METHODS: A total of 165 patients were randomized into 3 groups, namely group 1-lidocaine PPNB, group 2-DS and group 3-a combination of lidocaine PPNB and DS. In all patients 12 core biopsy was performed. Pain/discomfort at various intervals after the procedure was recorded on a visual analogue scale of 0 to 10 cm. RESULTS: Biopsy pain was significantly lower in patients who received lidocaine alone or in combination compared with DS alone (median 1.95, IQR 1.08 to 3.12, 3, IQR 1.25 to 5.47 and 1.8, IQR 0.85 to 3.0, respectively, p = 0.018), while evening pain scores were significantly lower in patients who received DS alone or in combination compared with that in patients who received lidocaine alone (median 1.25, IQR 0.38 to 3.0, 0.3, IQR 0.03 to 1.08 and 0.4, IQR 0 to 1.0, respectively, p = 0.001). There were no significant differences in pain/discomfort due to the probe (p = 0.107), that 1 hour after biopsy (p = 0.076) and that on the day after the procedure (p = 0.165). There were no significant differences in hemorrhagic or infective complications among the groups. CONCLUSIONS: The combination of lidocaine PPNB with DS provides additional pain relief during and after prostatic TRUS biopsy.     

Effect of periprostatic nerve blockade before transrectal ultrasound-guided prostate biopsy on patient comfort: A randomized placebo controlled study

BACKGROUND: In the present study, we assessed the efficacy and morbidity of periprostatic local anesthesia before transrectal ultrasound (TRUS)-guided biopsy of the prostate. METHODS: From August 2001 to February 2002, 98 patients underwent TRUS-guided prostate biopsy at the Department of 2nd Urology, Ankara Numune Education and Research Hospital, Ankara, Turkey. Ninety patients who fulfilled the inclusion criteria were randomized into three groups of 30 patients each. Group 1 received no local anesthesia, while group 2 received a periprostatic saline injection 5 min before the biopsy and group 3 received periprostatic local anesthesia with 1% lidocaine. Pain-scale responses were analyzed for each aspect of the biopsy procedure using a visual analog scale. RESULTS: There were no differences in pain scores between the three groups during digital rectal examination, intramuscular injection and probe insertion. Mean pain scores during needle insertion in groups 1, 2 and 3 were 5.65 +/- 2.35, 6.25 +/- 2.04 and 3.16 +/- 2.14, respectively. There was no significant difference between the pain scores of groups 1 and 2, whereas pain scores decreased significantly in group 3. CONCLUSION: Periprostatic local anesthesia before prostate biopsy is a safe and easy method to increase patient comfort during the procedure.     

Transrectal periprostatic lidocaine injection anesthesia for transrectal prostate biopsy: a prospective study

Transrectal ultrasound (TRUS)-guided biopsy remains the mainstay of the diagnosis of prostate cancer. Although this diagnostic method is a safe procedure and well tolerated by most patients a significant number of patients report discomfort and pain during prostate biopsy. In order to define the best method of anesthesia, many studies, in which different methods were compared, have been performed. To determine the effectiveness of local injection anesthesia in TRUS-guided prostate biopsy, we designed and performed this prospective study in order to evaluate the utility of periprostatic nerve block for pain management. A total of 100 patients who had elevated total prostate-specific antigen (tPSA) and/or abnormal digital rectal examination (DRE) were included in this study. Half of the patients received periprostatic injection anesthesia (group I) and the remaining half received placebo (group II). Patients received 10 cm3 (5 cm3 each side) 1% lidocaine injected into the periprostatic nerve plexus under transrectal ultrasonic guidance. Pain during biopsy was assessed using a 10-point modified visual analog scale (VAS). In groups I and II, mean patient age was 66.8+2.5 and 65.6+11.5 y, mean tPSA was 7.87+/-3.6 and 11.3+/-1.7 ng/ml, mean biopsy duration was 6.5+/-2.5 and 6.6+/-2.2 min and mean pain score during TRUS-guided biopsy was 1.46+/-2.2 and 4.5+/-2.1, respectively. No statistically significant difference was observed with respect to age, tPSA and mean biopsy duration between these groups. Mean pain VAS score was statistically or significantly better (P=0.0001) in the lidocaine injection group (group I), and furthermore no patient had a VAS pain score > or =5 in this group. Only minor and transient complications occurred in both groups. This study reinforces the usage of periprostatic nerve block as a standard method of pain management during TRUS-guided prostate biopsy, because it is simple, safe, uncostly and significantly effective without requiring additional time.     

Comparison of lidocaine suppositories and periprostatic nerve block during transrectal prostate biopsy

The aim of this randomized prospective and partially double-blind study was to evaluate the efficacy of transrectal lidocaine applied as suppositories in comparison to periprostatic infiltration as methods of reducing pain during transrectal prostate biopsy. 100 patients were randomized to four groups and received either a suppository containing 60 mg of lidocaine 2 h before biopsy, a 120-mg lidocaine suppository 1 h before biopsy, a 120-mg lidocaine suppository 2 h before biopsy, or they were anaesthetized with a periprostatic infiltration of 5 ml 2% lidocaine. In all patients the same 10-core transrectal biopsy technique was performed. Pain was evaluated using a visual pain scale ranging from 0 to 10 points. The mean pain score in the 60-mg (2 h), 120-mg (1 h), and 120-mg (2 h) lidocaine suppository groups was 3.63, 3.56, and 3.58 respectively. The mean pain score of patients receiving periprostatic infiltration was 1.80. No patient showed vegetative symptoms like sweating or hypotonia. No patient had severe pain. Eight of the 9 patients with no pain were in the periprostatic injection group. Thus, all lidocaine suppositories showed a good analgesic effect although a significantly better pain reduction was achieved by periprostatic lidocaine infiltration.     

Nitrous oxide vs periprostatic nerve block with 1% lidocaine during transrectal ultrasound guided biopsy of the prostate: a prospective, randomized, controlled trial

PURPOSE: We compared the efficacy of Entonox (BOC Gases, Manchester, United Kingdom), a mixture of 50% nitrous oxide and oxygen, with periprostatic infiltration of 1% lidocaine to provide analgesia during transrectal ultrasound (TRUS) guided biopsy of the prostate. MATERIALS AND METHODS: The study included 235 consecutive men undergoing TRUS guided biopsy of the prostate for elevated prostate specific antigen or abnormal digital rectal examination. Patients were randomized to 3 groups, including group 1-84 controls who did not receive any form of analgesia prior to the procedure, group 2-75 who received periprostatic infiltration with 10 ml 1% lidocaine with biopsies performed 5 minutes after infiltration and group 3-76 who received Entonox for 2 minutes through a breath activated device prior to the procedure and thereafter according to patient preference. All patients were asked to indicate the level of pain experienced before and after the procedure on a 10 cm, nonnumerical, horizontal visual analog score. Results were analyzed using 1-way ANOVA. RESULTS: Mean patient age was 68.8, 64.9 and 65.2 years, and mean visual analog score was 2.9, 1.6 and 2.2 in groups 1 to 3, respectively. Patients in groups 2 (1% lidocaine infiltration) and 3 (Entonox) experienced significantly less pain during the procedure compared with group 1 controls (p <0.001 and 0.028, respectively). There was no statistical difference in pain scores between groups 2 and 3 (p = 0.08). CONCLUSIONS: Inhalation of Entonox or periprostatic infiltration with 1% lidocaine can be used for analgesia during TRUS guided biopsy of the prostate since each provides significant and similar pain relief.     

Efficacy of periprostatic nerve blockade during ultrasound-guided transrectal 10-core biopsy of the prostate

PURPOSE: We examined the efficacy and safety of periprostatic nerve blockade during transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: Transrectal ultrasound guided 10 core biopsy of the prostate was performed in 116 consecutive men. From March 2002 to July 2003, 58 men underwent biopsy of the prostate without local anesthesia (control group). From August 2003 to March 2004, 58 men received periprostatic nerve blockade before prostate biopsies (anesthesia group). A 4-ml dose of 1% lidocaine was injected at 2 or 3 locations on each side of the prostate via a 23 gauge needle. Pain during biopsy was questioned using a 5-point Face scale and complications were also recorded. RESULTS: The average pain score during biopsy was 1.9 in the anesthesia group versus 3.1 in the control group (p<0.001). In the anesthesia group 20.7% of patients had a pain score 3 or greater than 3 versus 69% in the control group. The complication rate showed no significant difference between the two groups. CONCLUSIONS: Periprostatic nerve blockade is a safe and effective method of anesthesia for transrectal prostate biopsy.     

Comparison of lornoxicam versus tramadol analgesia for transrectal prostate biopsy: a randomized prospective study

Introduction We compared the efficacy of lornoxicam and tramadol to provide analgesia and comfort during transrectal ultrasound-guided biopsy of the prostate (TRUSP) as a noninvasive method. Materials and methods A total of 62 men undergoing TRUSP were enrolled in this study. Patients were randomized to three groups. Group 1 (n = 21) received 8 mg of lornoxicam, group 2 (n = 21) received 100 mg of tramadol, and group 3 (n = 20) received saline as a control. The drugs were given intramuscularly half an hour prior to the procedure. All patients were asked to indicate the level of pain experienced after the procedure by visual analog score (VAS), and the patient’s comfort level was scored by a comfort score. Additionally, the patients were asked if they were willing to undergo a future TRUSP. Results The data obtained revealed that both experimental groups receiving lornoxicam and tramadol had lower VAS scores compared to the control group (3.4 and 2.4 vs. 6.4, respectively; P < 0.0001). There were also significant differences in VAS scores between group 1 and group 2 (P = 0.027). There was a significant difference in the comfort score between the drug groups and control (P > 0.0001) and between the lornoxicam and tramadol group (P < 0.05). Pain and discomfort were least in the tramadol group. The percentage of patients who would not consent to future TRUSP was lower in the drug groups compared to control (P < 0.0001). But there were not any differences between the drug groups. Conclusions The use of lornoxicam or tramadol for pain relief in TRUSP is a practical, effective and comfortable method compared to the results of the control group. In addition, tramadol was found to be more effective than lornoxicam.     

Pain during transrectal ultrasonography guided prostate biopsy: a randomized prospective trial comparing periprostatic infiltration with lidocaine with the intrarectal instillation of lidocaine-prilocain cream

Prostate biopsy is usually performed without anesthesia. We evaluated the patients perception of pain/discomfort experienced during the procedure in terms of the type of anesthesia used: periprostatic infiltration with 2% lidocaine, or intrarectal instillation of lidocaine-prilocain cream. A total of 198 patients were divided into three groups: group 1 (control group, n=40) received sonographic gel intrarectally prior to biopsy, group 2 (n=75) were given intrarectal instillation of lidocaine-prilocain cream, and group 3 (n=80) received periprostatic anesthesia by injecting 10 ml of 2% lidocaine. Pain after each biopsy was assessed using an 11-point linear visual analog pain scale. The mean pain scores were 5.1 in group 1, 4.8 in group 2, and 2.5 in group 3, resulting in a significant difference between group 3 and both groups 1 and 2, but not between groups 1 and 2. The incidence of biopsy-related adverse events did not differ among groups. Transrectal ultrasonographic guided periprostatic anesthesia is superior to intarectal instillation of lidocaine-prilocain cream.     

Local anaesthetic for transrectal ultrasound-guided prostate biopsy: a prospective,randomized, double blind,placebo-controlled study

OBJECTIVE: To evaluate the efficacy of local anaesthetic (LA) infiltration in decreasing the discomfort experienced by patients undergoing transrectal ultrasound (TRUS)-guided biopsy of prostate. PATIENTS AND METHODS: 98 patients were randomized to receive 3x3ml of 1% lidocaine (n=55) or saline (n=43). The injection sites were basolaterally on each side to infiltrate the neuro-vascular bundle and one at the apex. Generally 12 systematic random biopsies were performed after which patients were asked to grade the pain of the whole procedure using a visual analogue scale ranging from 0 to 10. RESULTS:The LA group had a significantly lower pain score compared with placebo. The mean pain scores were 3.0 and 4.3 (p<0.001), respectively. Using an unpaired t-test, the difference between means was -1.96 to -0.51 with 95% confidence interval. There were no significant problems associated with the infiltration of either saline or LA. CONCLUSION: Local anaesthesia for TRUS biopsy is simple and well tolerated. It significantly reduces the pain associated with the procedure. We recommend its usage as a part of standard TRUS biopsy of the prostate.     

Noninfiltrative anesthesia for transrectal prostate biopsy: A randomized prospective study comparing lidocaine-prilocaine cream and lidocaine-ketorolac gel

ObjectivesPeriprostatic nerve block (PPNB) is the standard anesthesia for ultrasound (US) guided transrectal prostate biopsy (TPB), but periprostatic infiltration itself constitutes a major, though often neglected, source of discomfort even in patients receiving perianal-intrarectal lidocaine-prilocaine (PILP) cream before PPNB. Noninfiltrative anesthesia therefore represents an attractive alternative to periprostatic infiltration. With this in mind, we aimed to determine the efficacy and safety of perianal-intrarectal (PI) lidocaine gel, lidocaine-ketorolac gel, and lidocaine-prilocaine cream in relieving pain during TPB.Materials and methodsThree hundred consecutive patients scheduled for US-guided TPB were randomized 1:1:1 to receive PI administration of 5 g 2.5% lidocaine gel 10 minutes before TPB (Group 1), or a mixture of 5 g 2.5% lidocaine gel and 0.3% ketorolac tromethamine solution 1 hour before TPB (Group 2), or 5 g 2.5% lidocaine and 2.5% prilocaine cream 20 minutes before TPB (Group 3). The 0-to-10 points visual analogue scale (VAS) was used for assessing pain at probe insertion and movements (VAS-1), at prostate sampling (VAS-2), and maximal procedural pain (MPP). Complications occurring up to 20 days after the procedure were also recorded.ResultsFour (1.3%) patients were excluded because of unbearable pain during the procedure, leaving Group 1 with 98 patients, Group 2 with 99, and Group 3 with 99; the 3 groups were comparable for patients' age, serum PSA, prostate volume, and cancer detection rate. The addition of either ketorolac or prilocaine to lidocaine significantly (P < 0.0001) reduced probe-related, sampling-related, and maximal procedural pain. Compared with lidocaine-prilocaine, lidocaine-ketorolac was less effective in relieving probe-related pain (mean VAS-1: 1.47 ± 1.30 vs. 0.39 ± 0.65; P < 0.0001) but more effective in relieving sampling-related pain (mean VAS-2: 0.76 ± 0.94 vs. 1.54 ± 1.02; P < 0.0001); there was no difference in MPP (mean 1.82 ± 1.21 vs. 1.67 ± 0.95), probably due to such different efficacy on the two pain sources. Complications were similar in the 3 groups.ConclusionsLidocaine-prilocaine cream was most effective on probe-related pain, whereas lidocaine-ketorolac gel was most effective on sampling-related pain. These noninfiltrative anesthetics were safe, easy to administer, and well accepted by patients; the possibility to combine them to further improve pain control during TPB deserves further well-designed studies.     

Hemospermia following transrectal ultrasound-guided prostate biopsy: a prospective study

Hemospermia is known to be associated with transrectal ultrasound-guided prostate biopsy (TRUS-PB). The true incidence of hemospermia, its duration and implications are not well established. We performed a prospective observational study involving patients undergoing TRUS-PB for suspected prostate cancer at our institution. Sixty-three eligible men were included in the study. Most men (84%) undergoing TRUS-PB, who were able to ejaculate, experienced hemospermia, which was associated with some degree of anxiety. The mean duration of hemospermia was 3.5 (+/-1.7) weeks. The number of ejaculations before the complete resolution of hemospermia was 8 (+/-6.7). None of the clinical and pathological factors was a significant predictor of the duration of hemospermia. Patients should be adequately counseled before TRUS-PB to avoid undue anxiety and alterations in sexual activity.     

Acute periprostatic haematoma following a transrectal ultrasound-guided needle biopsy of the prostate

Transrectal ultrasound (TRUS)-guided needle biopsy is routinely performed to diagnose and stage prostate carcinoma in an outpatient setting. Although serious adverse effects are rare, minor complications are common. We report the occurrence of an acute periprostatic haematoma as an unusual complication of TRUS-guided needle-biopsy of the prostate, resulting in the patient requiring prompt resuscitation and hospital admission.