Periprostatic local anesthesia before transrectal ultrasound-guided prostate biopsy

PURPOSE: We prospectively assessed the safety and efficacy of periprostatic local anesthesia before transrectal ultrasound (TRUS)-guided prostate biopsy. MATERIALS AND METHODS: A total of 178 consecutive men undergoing transrectal prostate biopsy at our institution were enrolled in this study. From January to June 2001, 84 men underwent prostate biopsy without anesthesia (control group). From July to December 2001, 94 men received local anesthesia before prostate biopsies (anesthesia group). A 5-ml dose of 1% lidocaine was injected into the periprostatic nerve plexus on each side via a 22 gauge needle at 3 minutes before the procedure. Pain during and after biopsy was assessed using a 10-point visual analog scale (VAS). Complications were evaluated with a self-administered questionnaire. RESULTS: The average pain score during biopsy was 3.18 in the anesthesia group versus 4.16 in the control group (p = 0.0067), while average pain score on the next day was 2.12 and 2.25, respectively (p = 0.7451). In the anesthesia group 13% of patients had a pain score > 5 versus 34% in the control group (p = 0.0043). The complication rate showed no significant difference between the two groups. CONCLUSION: Periprostatic lidocaine injection is a safe and effective method of anesthesia for transrectal prostate biopsy.     

Periprostatic local anesthesia eliminates pain of office-based transrectal prostate biopsy

Up to 96% of patient who undergo prostate biopsy report pain. We performed periprostatic local anesthesia injection in an effort to improve patient acceptance of prostate biopsy. Sixty patients were randomized to receive either local injection of lidocaine in the periprostatic nerves or no anesthetic. Lidocaine was injected through a 7-inch spinal needle placed through a transrectal ultrasound biopsy guide. Ten-core biopsies were immediately performed. Following biopsy, all patients gave a Visual Analog Scale (VAS) assessment of their pain experienced during biopsy.A majority of patients reported Visual Analog Scale (VAS) scores in the moderate (28.6%) or severe (28.6%) ranges unless local anesthesia was given. Only one of 27 patients (3.7%) receiving local anesthetic reported moderate pain, and none reported severe pain. Mean VAS pain scores were 1.4 in the anesthetic group and 4.5 in the control group (P<0.0001). No difficulty was encountered from scarring in the five patients who underwent nerve spring radical retropubic prostatectomy following local anesthetic injection. Periprostatic injection of local anesthetic essentially eliminates pain from prostate biopsy. Nerve-sparing radical retropubic prostatectomy is not more difficult as a result.     

Lidocaine-prilocaine administration during transrectal ultrasound-guided prostatic biopsy: a randomized, single-blind, placebo-controlled trial

BACKGROUND AND PURPOSE: As many as 96% of patients report some kind of discomfort/pain during transrectal ultrasonography (TRUS)-guided prostate biopsy, and when pain is severe, it may be necessary to decrease the planned number of biopsies or interrupt the procedure. Various modalities have been recommended to alleviate the pain, but reports on efficacy are contradictory. We assessed the possible benefit of intrarectal and perianal lidocaine-prilocaine (EMLA) cream. PATIENTS AND METHODS: A series of 98 patients without active anal and prostatic conditions underwent TRUS and, 10 to 31 days later, TRUS-guided biopsy. They were asked to grade their discomfort/pain using a 10- point linear visual analog pain scale (VAS). After TRUS, patients were divided into three groups on the basis of the VAS scores. Group 1 (N = 8) had pain scores or=5 (severe pain/discomfort). Each group was then randomized to receive local anesthesia with intrarectal and anal EMLA cream (subgroup A) or intrarectal and anal ultrasound gel as placebo (subgroup B). Pain scoring was repeated after the biopsy. RESULTS: In group 1, there were no significant differences in pain scores between subgroups A and B. In group 2, we could not complete the biopsy in one patient of subgroup B. A statistically significant difference was noticed between the VAS scores of subgroup A and subgroup B (P < 0.0001). In group 3, we were not able to complete biopsy in 5 patients of subgroup B. We noticed significantly higher VAS scores in subgroup B between TRUS and prostate biopsy (P < 0.0001), whereas similar scores were observed in subgroup A (P = NS). A statistically significant difference (P < 0.0001) was noticed between subgroup A and subgroup B scores during biopsy. CONCLUSIONS: In patients with high tolerance for simple TRUS, needle trauma does not significantly alter tolerability, and anesthetic provides little benefit for prostatic biopsy. However, the opposite is true in patients presenting moderate to significant pain/discomfort at TRUS, who may benefit from intrarectal/anal administration of EMLA during prostate biopsy.     

Periprostatic local anesthesia before ultrasound-guided prostate biopsy: an update of the miami experience

INTRODUCTION: Transrectal ultrasound (TRUS)-guided biopsy is a very common office procedure for most urologists. Pain or discomfort associated with this procedure has been addressed recently by the use of periprostatic local anesthesia. We re-address this issue with an update of our experience and emphasize the crucial steps that contribute to the success of the technique. We also analyzed the subsequent intraoperative effects of injecting lidocaine into the area of the neurovascular bundles. MATERIALS AND METHODS: Between June 1999 and December 2000, 200 patients underwent TRUS-guided biopsies of the prostate. Patients were properly consented and subjected to the procedure using periprostatic nerve block with 10 cm3 of 1% plain lidocaine. An 'ultrasonographic wheal' was created between the rectal wall and the posterior aspect of the prostate and three or four different locations along the neurovascular bundles. Pain scores were evaluated with the visual analogue scale. RESULTS: TRUS biopsy of the prostate was performed in 200 consecutive patients using periprostatic local anesthesia, 40 patients (20%) had undergone previous prostate biopsy without anesthesia. The age of patients ranged from 44 to 75 years (mean 67). The number of biopsies ranged from 6 to 14. Mean time from introduction of the probe per rectum to the end of the procedure was 18 min. There were no instances of clinical infection, significant bleeding, urinary retention, diaphoresis or hypotension. The visual analogue scale ranged from 1 to 3 (mean 2). Intraoperative findings in 62 patients who subsequently underwent nerve-sparing radical retropubic prostatectomy were no different from the patients who had biopsies without a local anesthetic. CONCLUSION: TRUS-guided biopsy of the prostate is the procedure of choice for diagnosing prostate cancer. This procedure can be accomplished with minimal pain with the use of periprostatic local anesthesia. It is an easy, safe, acceptable and reproducible technique that we believe should be considered for all patients undergoing TRUS biopsy regardless of age or number of biopsies.     

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.     

A meta-analysis of local anesthesia for transrectal ultrasound-guided biopsy of the prostate

This meta-analysis evaluated the efficacy and safety of periprostatic nerve block (PPNB) and intrarectal local anesthestic (IRLA) gel in alleviating pain during prostate biopsy. Electronic databases MEDLINE, Cochrane Central Register of Controlled Trials and EMBASE were searched to identify all randomized controlled trials comparing PPNB with periprostatic placebo injection, no injection or with IRLA. Studies for inclusion were identified and extracted by two authors independently. The main outcome measure was patients' assessment of mean pain scores on a 10-point scale at the end of the biopsy procedure. Secondary outcomes were complications and adverse events. Continuous data from the trials were combined by calculating the weighted mean difference (WMD) with its 95% confidence interval. In total, 25 studies met the inclusion criteria. Twenty studies involving 1685 patients compared PPNB with either no anesthesia or with placebo injection controls, showing a significant reduction in pain score in the anesthetic group (WMD -2.09, 95% CI -2.44 to -1.75, P<0.00001). Five studies with 466 patients compared IRLA and control. Although IRLA was associated with pain reduction, the effect size was not statistically significant (WMD -0.22, 95% CI -0.56 to 0.12). Six studies with 872 patients compared PPNB with IRLA, showing a significant pain reduction in the former group (WMD -1.53, 95% CI -2.67 to -0.39, P=0.008). No trials reported an increase in complications in the treatment arms. In conclusion, the evidence from randomized controlled trials shows that local anesthetic given as a PPNB, but not as an intrarectal instillation, is effective and safe in alleviating pain from transrectal ultrasound biopsy of the prostate.     

Periprostatic nerve blockade before transrectal ultrasound-guided prostate biopsy: the Ankara Numune experience

OBJECTIVES: To assess the efficacy and morbidity of periprostatic local anesthesia before transrectal ultrasound-guided biopsy of the prostate. METHODS: From August 2001 to December 2001, 58 patients underwent transrectal ultrasound-guided prostate biopsy at the 2nd Department of Urology, Ankara Numune Education and Research Hospital. Fifty patients who fulfilled the inclusion criteria were randomized into 2 groups of 25 patients each. Group 1 received periprostatic local anesthesia with 1% lidocaine while group 2 received no local anesthesia. Pain scale responses were analyzed for each aspect of the biopsy procedure with a visual analog scale. RESULTS: There was no difference between the 2 groups in pain scores during digital rectal examination, intramuscular injection and probe insertion. The mean pain scores during needle insertion in group 1 receiving periprostatic nerve block and in group 2 receiving no local anesthesia were 3.00 +/- 2.22 and 6.16 +/- 2.85, respectively, and were found to be significantly different (p < 0.001), but morbidity after the biopsy was not statistically different between the 2 groups. CONCLUSION: Periprostatic local anesthesia before prostate biopsy is a safe and easy method to increase patient comfort during the procedure.     

Periprostatic local anesthesia before ultrasound guided prostate biopsy

PURPOSE: We assessed the morbidity and benefit of periprostatic local anesthesia administered before ultrasound guided prostate biopsy. MATERIALS AND METHODS: After placing the transrectal ultrasound probe and visualizing the prostate 50 consecutive patients received local anesthesia before prostate biopsies. RESULTS: There was no morbidity associated with the infiltration of local anesthesia into the periprostatic neurovascular plexus. Only 1 patient had discomfort during prostate biopsies, and 10 patients who previously underwent biopsies without anesthesia commented favorably on the dramatic difference. CONCLUSIONS: Many patients have pain during transrectal ultrasound guided biopsies of the prostate and few clinicians provide a periprostatic nerve block before this procedure. A periprostatic nerve block administered before the biopsies dramatically decreases discomfort. We urge all urologists to attempt this procedure, and we are confident that they will adopt it as part of their practice.     

Analgesic effect of oral tramadol on transrectal ultrasound-guided needle biopsy of the prostate in a randomized double-blind study

A total of 121 Japanese patients scheduled for prostate biopsy were randomly and double-blindly assigned to be given a single oral dose of 100 mg Tramadol mixed with 20 ml of sugar syrup or placebo, 30 minutes before the procedure. Pain severity was measured by verbal rating scale (VRS) and visual analog scales (VAS). We also analyzed cardio-respiratory parameters and complications. Of 121 patients, 117 replied validly to VRS and VAS ; and 91 of 117 patients replied to the cohort questionnaire for analysis of the late disorder, patient's impression, prolonged pain and past history of hemorrhoid treatment. Tramadol showed no significant effect on pain severity indicated by VRS and VAS, and no change in cardiorespiratory parameters. Furthermore, 70 patients without a history of hemorrhoid treatment, showed no significant analgesic benefits of Tramadol during the biopsy. In total, 3 patients had side effects of vomiting (CTCAE : grade 1)6), which subsided spontaneously. The oral administration of a single dose of 100 mg Tramadol 30 minutes before a transrectal needle biopsy of the prostate was safe, but was not effective to calm down the pain severity.     

Effect of intraprostatic local anesthesia during transrectal ultrasound guided prostate biopsy: comparison of 3 methods in a randomized, double-blind, placebo controlled trial

PURPOSE: We evaluated the effect of intracapsular anesthesia and periprostatic nerve block during transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS: In a prospective, randomized, double-blind, placebo controlled study 152 consecutive patients were randomized into 3 groups. Group 1 of 41 patients was administered intraprostatic local anesthesia into the right and left sides with a total of 2 ml 1% lidocaine and a periprostatic injection of 2 ml saline later. Group 2 of 49 patients was administered intraprostatic injection of 2 ml saline, followed by periprostatic local anesthesia with 2 ml 1% lidocaine. Group 3 of 62 patients received intraprostatic and periprostatic local anesthesia with 2 ml 1% lidocaine. Patients were asked to grade the pain level using a 10-point linear visual analog pain scale 1) when the transrectal ultrasound probe was inserted, 2) during anesthesia, 3) during biopsy and 4) 20 minutes after biopsy. One-way ANOVA and the Kruskal-Wallis test with the Tukey post hoc test were used to compare patient characteristics and pain scale responses among the 3 groups. RESULTS: No major complications, including sepsis and severe rectal bleeding, were noted in any patient. There were statistically significant differences in pain scores among groups 1 to 3 during anesthesia (mean +/- SD 5.6 +/- 2.5, 6.7 +/- 2.3 and 4.9 +/- 2.1, p = 0.003) and during biopsy (4.3 +/- 2.7, 4.5 +/- 2.6 and 2.7 +/- 2.1, respectively, p = 0.032). There were no differences in pain scores among the 3 groups during probe insertion (p = 0.39). CONCLUSIONS: A combination of intracapsular anesthesia and periprostatic nerve block is an effective and useful technique that is well tolerated by the patient. It decreases the level of pain and discomfort associated with the prostatic biopsy procedure.     

前列腺穿刺活检术中不同麻醉方法有效性和安全性比较

目的 比较3种麻醉方法 在经直肠超声引导下前列腺穿刺活检过程中的有效性和安全性.方法 2006年7月至2008年10月,120名因前列腺特异抗原和(或)直肠指检异常接受前列腺12针穿刺活检的患者随机分为4组,每组30例.A组为对照组,未接受任何麻醉;B组在超声引导下于左、右两侧精囊与前列腺交接处分别注射1%利多卡因5ml行前列腺神经阻滞术(PNB);C组在PNB之前5 min直肠内涂抹复方利多卡因凝胶;D组在PNB之前于前列腺两侧叶内分别注射1%利多卡因2 ml.穿刺结束后对患者进行疼痛视觉模拟评分(VAS),并随访7 d了解并发症情况.结果 超声探头进入直肠时C组患者的VAS为(2.7±1.1)分,低于其他3组,差异有统计学意义(P＜0.05),其他3组之间差异无统计学意义(P＞0.05).穿刺过程中D组患者的VAS为(3.9±1.3)分低于其他3组,差异有统计学意义(P＜0.05),其他3组之间差异无统计学意义(P＞0.05).各组患者并发症的发生率差异无统计学意义(P＞0.05).结论 PNB及直肠内利多卡因凝胶局部麻醉不能明显减轻前列腺穿刺过程中的痛苦,PNB联合前列腺内局部麻醉是安全有效的.     

Effectiveness of local anaesthesia techniques in patients undergoing transrectal ultrasound-guided prostate biopsy: A prospective randomized study

AIM: This study was designed to compare the effectiveness of intrarectal lidocaine gel versus periprostatic lidocaine injection during transrectal ultrasound (TRUS)-guided prostate biopsy. METHODS: Ninety men undergoing transrectal prostate biopsy from July through December 2004 were randomized into three groups of 30 patients each. Before the biopsy, patients in Group 1 received 20 mL of 2% lidocaine gel intrarectally; patients in Group 2 received 5 mL (2.5 mL per side) of 2% lidocaine solution injected near the junction of the seminal vesicle with the base of the prostate (along the neurovascular bundles), and patients in Group 3 (control group) received 5 mL (2.5 mL per side) of normal saline injected along the neurovascular bundles. Pain level after the biopsy was assessed using a 10-point linear visual analog scale (VAS). Results were statistically compared by the Wilcoxon Rank Sum test. RESULTS: Patients in Group 2 had significantly lower VAS scores than those in Group 3 (3.6 +/- 2.1 vs 5.8 +/- 1.9, P < 0.0001), but those in Group 1 did not (5.5 +/- 2.7 vs 5.8 +/- 1.9, P = 0.67). Gross hematuria, rectal bleeding, and hemospermia occurred in 36 (40.0%), 6 (7%) and 5 (6%) patients. One patient had temporary vasovagal syncope. No patient reported febrile urinary tract infection or urinary retention. CONCLUSIONS: Periprostatic injection of local anaesthetic is a safe technique that significantly reduces pain during prostate biopsy, whereas intrarectal lidocaine injection did not reduce pain. This safe, simple technique should be applied in men undergoing TRUS-guided prostate biopsy to limit patient discomfort.     

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.     

Does periprostatic block reduce pain during transrectal prostate biopsy? A randomized,placebo-controlled,double-blinded study

Introduction  

Currently, the use of local anesthetic at the time of transrectal ultrasound-guided biopsy of the prostate is not universally accepted, as the needle injection itself causes pain. In prior studies, lidocaine was compared to placebo in separate patient groups. We present the first study to evaluate both lidocaine and placebo injected in each patient.