Randomized Trial of Lidocaine Vs Lidocaine/Bupivacaine Periprostatic Injection on Longitudinal Pain Scores After Prostate Biopsy

PURPOSE

Periprostatic lidocaine reduces immediate post-prostate biopsy pain but still many men will not consent to re-biopsy. We performed a randomized study to assess whether adding long acting local anesthesia to a short acting agent would further reduce pain.

MATERIALS AND METHODS

A total of 300 men undergoing transrectal ultrasound guided prostate biopsy were sequentially randomized to receive either short acting local lidocaine (lid) or short and long acting lidocaine and bupivacaine (lid/bup). A 7-day questionnaire was used to study daily pain (10-point visual analog score), bleeding (hematuria, PR bleeding, hematospermia), visits to the family doctor and analgesic use, and whether they would agree to future re-biopsy.

RESULTS

Of the 256 questionnaires returned 250 were suitable for analysis. Cross-sectional comparison showed no intergroup differences in mean pain scores immediately after biopsy (2.24, 95% CI 1.94-2.5 vs 2.61, 95% CI 2.3-2.9, p = 0.88 in lid and lid/bup groups, respectively). There was a significant rebound in visual analog scale at 1 hour in the lid group but not in the lid/bup group (+ 0.9 vs + 0.09, p = 0.0006). Longitudinal analysis showed the global pain experience after lid/bup was better compared to lidocaine alone, with significantly less pain every subsequent day (p = 0.0006 to 0.002). No difference was seen in morbidity, analgesia usage or number refusing future re-biopsy (9.6% vs 9.8%).

CONCLUSIONS

Long and short acting local anesthetics together significantly attenuate the 1-hour rebound increase in pain scores seen after short acting anesthesia alone. Improved pain scores were sustained during the subsequent week and we advocate routine combination use for transrectal ultrasound guided prostate biopsy.

Doppler Ultrasound for Detection of Renal Transplant Artery Stenosis—Threshold Peak Systolic Velocity Needs to be Higher in a Low-risk or Surveillance Population

AIMS

To establish the ideal threshold arterial velocity for the diagnosis of renal transplant artery stenosis in a surveillance population with a low pre-test probability of stenosis.

METHODS

Retrospective review of Doppler ultrasound, angiographic and clinical outcome data of patients transplanted over a 3-year period. Data used to calculate sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) for various threshold peak systolic velocity values.

RESULTS

Of 144 patients transplanted, full data were available in 117 cases. Five cases had renal transplant artery stenosis-incidence 4.2% [stenosis identified at a mean of 6.5 months (range 2-10 months)]. All five cases had a significant arterial pressure gradient across the narrowing and underwent angioplasty. Threshold peak systolic velocity of > or =2.5 m/s is not ideal [specificity=79% (CI 65-82%), PPV=18% (CI 6-32%), NPV=100% (CI 94-100%)], subjecting many patients to unnecessary angiography-8/117 (6%) in our population. Comparable values if the threshold is set at > or =3.0 m/s are 93% (CI 77-96%), 33% (CI 7-44%) and 99% (CI 93-100%), respectively. The clinical outcome of all patients was satisfactory, with no unexplained graft failures or loss.

CONCLUSIONS

In a surveillance population with a low pre-test probability of stenosis, absolute renal artery velocity > or =2.5 m/s is a limited surrogate marker for significant renal artery stenosis. The false-positive rate is high, and > or =3.0 m/s is a better choice which will halve the number of patients enduring unnecessary angiography. Close clinical follow-up of patients in the 2.5-3.0 m/s range, with repeat Doppler ultrasound if necessary, will identify the test false-negatives.

The diagnostic contribution of the frontal lumbar spine radiograph in community referred low back pain--a prospective study of 1030 patients

AIM

The diagnostic contribution of the anteroposterior (AP) view was studied to assess whether this view could be omitted safely, thus reducing the radiation burden received by patients undergoing lumbar spine radiography.

MATERIALS AND METHODS

Prospective analysis of 1030 consecutive referrals for lumbar spine radiography from general practice.

RESULTS

In the majority of cases (90.5%) the AP view was non-contributory. In 4.2% the diagnosis was strengthened and it was altered in 4.6%. However, in the latter group only 1.3% of the total were considered significant alterations. These were cases of possible, but not definite, pars defects and sacroiliitis. Specific important conditions such as infection, malignancy and benign tumours were not missed on the lateral view alone, in our study population. The radiation burden is reduced by 75% by omitting the AP view.

CONCLUSION

A single lateral view is an adequate examination, with the proviso that sacroiliac joint disease is not assessed on this view and some pars defects and facet joint degenerative changes may be overlooked. The radiation protection gains are considerable. A single lateral lumbar view is now our routine practice unless sacroiliitis is a specific clinical concern.

Morbidity of transrectal ultrasonography-guided prostate biopsies in patients after the continued use of low-dose aspirin

OBJECTIVE

To determine whether low-dose aspirin increases morbidity after transrectal ultrasonography-guided sextant prostate biopsy.

PATIENTS AND METHODS

In a single-centre prospective cohort study of 200 patients who underwent sextant prostate biopsies, those routinely taking low-dose aspirin were encouraged to continue to do so before and after biopsy. The morbidity in each case was assessed using a standardized questionnaire that patients completed in the 7 days after biopsy. The presence of haematuria, rectal bleeding and haematospermia were recorded. The questionnaire also directed the patient to record fevers, use of analgesia and any further treatment received.

RESULTS

In all, 36 patients took aspirin whilst the other 141 did not. There were no major complications in either group. Of the patients on aspirin, 20 (56%) had haematuria, compared with 83 (59%) of those not taking aspirin (difference 3%, 95% confidence interval, CI, -15 to 21). Overall bleeding (haematuria, rectal bleeding and haematospermia) occurred in 22 patients (61%) of the aspirin group and 105 (74%) of the other group (difference 13%, 95% CI -4 to 31). Comparisons of other morbidities between the groups are also discussed.

CONCLUSIONS

There was no statistically significant difference in the incidence of haematuria or overall bleeding after biopsy between the groups. There is no evidence that aspirin needs to be discontinued before sextant prostate biopsy.

Urinary tract stones--Part I: role of radiological imaging in diagnosis and treatment planning

The modern management of urolithiasis requires a multi-disciplinary approach. Imaging plays a central role in both diagnosis and planning therapy of renal and ureteric calculi. This article reviews the current status of diagnosis and management of stone disease, and the contribution of radiological imaging in accurately triaging a given case to the most appropriate therapy.

Urinary tract stones--Part II: current status of treatment

The majority of renal and ureteric stones are now managed by minimally invasive techniques, for example nephrostomy, ureteral stents, extracorporeal shockwave lithotripsy or percutaneous nephrolithotomy. A multi-disciplinary approach is necessary, and this review examines the status of modern stone therapy and the contribution of the radiology department.

Demonstration of renal arterial anatomy and tumour neovascularity for vascular mapping of renal cell carcinoma: the value of CO2 angiography

The aim of this study was to compare the efficacy of CO(2) angiography with that of iodinated contrast angiography for vascular mapping prior to partial nephrectomy for presumed renal cell carcinoma. 13 consecutive patients were studied and all patients underwent selective renal angiography using both CO(2) and iodinated contrast medium. Digitally subtracted images were acquired and compared. Seven male and six female patients, with a median age of 58 years (range 46-74 years), were examined. On comparing images the main renal artery was visualized in all cases with both contrast agents. The segmental vessels were seen in 7 of 13 CO(2) studies and 12 of 13 iodinated contrast studies. CO(2) was also inferior in the depiction of tumour circulation, showing it in 4 of 13 cases compared with 9 of 13 cases using iodinated contrast. It therefore appears that CO(2) angiography offers no diagnostic advantage and is also inferior to iodinated contrast angiography in the pre-operative vascular mapping of renal tumours.

Renal transplantation dysfunction: the role of interventional radiology

The aim of this article is to review the radiological management of complications following renal transplant.

Neuroleptic malignant syndrome presenting as pulmonary edema and severe bronchorrhea

Neuroleptic malignant syndrome is a rare (incidence, 0.02%-3.2%) but dangerous complication following the use of neuroleptic drugs. When not promptly recognized, this disease carries a high mortality (10%-20%) and morbidity rate. We report an unusual case of neuroleptic malignant syndrome that presented predominantly with autonomic instability in the form of recurrent episodes of respiratory distress. The respiratory distress was initially caused by pulmonary edema and later was caused by severe bronchorrhea. We propose that aspiration pneumonia resulting in respiratory failure, the leading cause of death in neuroleptic malignant syndrome, may be a result of a combination of altered mental status and bronchorrhea. This has therapeutic implications because early institution of bromocriptine/dantrolene can prevent aspiration pneumonia and, hence, mortality from respiratory failure.

Choosing the correct length of ureteric stent: a formula based on the patient's height compared with direct ureteric measurement

AIM

To evaluate a formula based on the patient's height for choosing the correct length of ureteric stent and to compare its accuracy with that of direct ureteric length measurement.

METHODS

Thirty-five patients (41 ureters) with ureteric obstruction were prospectively studied. All received Percuflex 8F double pigtail ureteric stents. Stent lengths were chosen according to patient height: < 5 ft 10 in (<178 cm) = 22 cm; 5 ft 10 in to 6 ft 4 in (178-193 cm) = 24 cm; > 6 ft 4 in (>193 cm) = 26 cm. The final stent position was graded using a 5-point scale (0 representing ideal length, with -2 and +2 being too short and too long respectively). Stent length acceptability using direct ureteric measurement was then estimated using the same 5-point scale; and the results compared.

RESULTS

Patient's height correctly predicted stent length in the majority of ureters (grade 0 = 61%), with no stent being too short. In comparison, direct ureteric measurement oversized the stent in 83%, correctly predicting stent length in only 17%.

CONCLUSION

Patient's height is a more reliable guide to ureteric stent length than direct ureteric measurement, particularly in the dilated and tortuous ureter. This may be because the redundant ureter is capable of significant shortening under the influence of the ureteric stent.