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

Pain control according to the periprostatic nerve block site in magnetic resonance imaging/transrectal targeted prostate biopsy

We analyzed the intensity of pain at each site of systemic prostate biopsy (SBx) and compared the intensity of pain among magnetic resonance (MRI)-targeted transrectal biopsies according to the periprostatic nerve block (PNB) site. We collected data from 229 consecutive patients who had undergone MRI-targeted biopsy. Patients were stratified into two groups according to the site of PNB (base versus base and apex PNB). Pain was quantified at the following time points: probe insertion, injection at the prostate base, injection at the prostate apex, MRI cognitive biopsy (CBx), MRI/transrectal ultrasound fusion biopsy (FBx), SBx, and 15 min after biopsy. For all biopsy methods, the average pain were significantly higher in the base PNB group than in the base and apex PNB group (CBx, p < 0.001; FBx, p = 0.015; SBx, p < 0.001). In the base and apex PNB group, FBx was significantly more painful than SBx (p = 0.024). Overall, regardless of the PNB site, pain at the anterior sites was more than that at the posterior sites in FBx (p = 0.039). Base and apex PNB provided better overall pain control than base-only PNB in all biopsy methods. In the base and apex PNB group, FBx was more painful than CBx and SBx.

The Effect on Pain and Anxiety of Hot Pad Applied to Patients During Transrectal Prostate Biopsy

AIM

The aim of the study was to evaluate the effect of the application of a heating pad on the sacral region on pain and anxiety during a transrectal prostate biopsy.

DESIGN

This was a quasi-experimental study.

METHODS

The quasi-experimental study was conducted in the Urology Outpatient Clinic of a Training and Research Hospital in Istanbul. A total of 40 males were nonrandomly divided into two groups: experimental group (n = 20) and control group (n = 20). A heating pad (40-45°C) was applied to the sacral region of the patients in the experimental group during transrectal prostate biopsy. Data were collected using the Beck Anxiety Inventory (BAI) and visual analogue scale (VAS).

RESULTS

It was detected that the mean scores of the BAI were significantly lower in the experimental group compared with the control group (p < .001). The scores of the VAS were significantly lower in the experimental group compared with the control (p = .016).

CONCLUSION

Applying a heating pad to the sacral region during a transrectal prostate biopsy is an effective non-pharmacologic method to increase patient comfort and reduce pain and anxiety.

A novel method for pain control: infiltration free local anesthesia technique (INFLATE) for transrectal prostatic biopsy using transcutaneous electrical nerve stimulation (TENS)

PURPOSE

To describe a novel method for the control of pain during prostate biopsies, infiltration free local anesthesia technique (INFLATE) for transrectal prostatic biopsies with no further needle insertions for local anesthetic infiltration.

METHODS

A total of 138 men with elevated prostate-specific antigen levels and/or abnormal digital rectal examination findings were included in the study. Of the patients, 73 were assigned to the INFLATE group and 65 to the TRUS-PNB group. Demographic data, PSA levels, findings of digital rectal examinations, and multiparametric prostatic magnetic resonance imaging were recorded. In the INFLATE group, a two-channel TENStem eco basic device with two electrodes was used for pain control during the biopsy. For the TRUS-PNB group, 60 mg lidocaine gel was given intrarectally in addition to infiltration of a prilocaine and bupivacaine mixture (5 mL of 2% prilocaine + 5 mL of 0.25% bupivacaine). Pain perception was assessed using a linear numeric rating scale.

RESULTS

The mean ages, BMIs, prostate volumes, and PSA levels were similar between the two groups (p > 0.05). Of the 56 participants with prostate adenocarcinoma, 28 were in the INFLATE group, and 28 were in the TRUS-PNB group with a 40.6% overall cancer detection rate. The mean preoperative and post-operative pain scores during probe insertion, biopsy and post-biopsy were similar between the groups (p > 0.05).

CONCLUSION

The results of the study confirmed that INFLATE for transrectal prostate biopsy using a TENS device could safely and effectively be used for pain control with the advantage of two fewer needle attempts with no increase in significant complications.

Comparison of analgesic techniques in MRI-guided in-bore prostate biopsy

OBJECTIVES

To evaluate different analgesic techniques in MRI-guided in-bore prostate biopsy (IB-GB) regarding the influence on patient procedural experience of pain.

METHODS

Two hundred fifty-two consecutive patients who had received an IB-GB either with intrarectal instillation of 2% lidocaine gel (n = 126, group A) or with periprostatic nerve block (PPNB) with 2% mepivacaine (n = 126, group B) were retrospectively included in this study. Pain scores were measured on a visual analog scale, the operating room time (ORT) was recorded for each biopsy and correlations between the parameters were analysed.

RESULTS

Pain scores for IB-GB were slightly lower in group B compared with group A (2.0 ± 1.9; 2.4 ± 1.7; p = 0.02). In group A, significantly more targeted biopsy cores were acquired (group B: 5.2 ± 1.1; group A: 5.6 ± 0.8; p < 0.01). ORT was comparable and not significantly different in both groups. There was only a weak correlation between pain scores and ORT in group B (r_S = 0.22; p = 0.01), but no correlation between pain scores and the number of biopsy cores or the prostate volume.

CONCLUSIONS

Pain levels are generally low for MRI-guided in-bore biopsy using either PPNB or intrarectal instillation of lidocaine gel. A statistically significant, slightly lower pain score was documented for PPNB and might be preferred when the focus is analgesia. On the other hand, due to the minor difference and easier administration, intrarectal gel instillation seems to be a reasonable practice for standard analgesia for MRI-guided in-bore biopsy.

KEY POINTS

• Pain levels were low for MRI-guided in-bore biopsy using either PPNB or intrarectal instillation of lidocaine gel as analgesic method. • PPNB prior to IB-GB resulted in a slightly lower pain score but required a higher effort. • Intrarectal gel anaesthesia seems to be a reasonable practice for standard analgesia for IB-GB in an outpatient setting.

What is the most effective local anesthesia for transrectal ultrasonography-guided biopsy of the prostate? A systematic review and network meta-analysis of 47 randomized clinical trials

We aimed to compare the effectiveness of various local anesthetic methods for controlling prostate biopsy (PBx) related pain using network meta-analysis. Literature searches were performed on PubMed/Medline, Embase, and Cochrane Library up to March 2018. Forty-seven randomized controlled trials, in which the effectiveness of PBx-related pain was investigated using a visual analogue scale after various local anesthetic methods, were included. The local anesthetic methods included intraprostatic local anesthesia (IPLA), intrarectal local anesthesia (IRLA), intravenous sedation (IVS), periprostatic nerve block (PNB), pelvic plexus block (PPB), and spinal anesthesia (SPA). Eight pairwise meta-analyses and network meta-analyses with 21 comparisons were performed. All modalities, except single use of IPLA and IRLA, were more effective than placebo. Our results demonstrate that PNB + IVS (rank 1) and SPA (rank 2) were the most effective methods for pain control. The followings are in order of PPB + IRLA, PNB + IPLA, PPB, PNB + IRLA, IVS, and PNB. In conclusion, the most effective way to alleviate PBx-related pain appears to be PNB + IVS and SPA. However, a potential increase in medical cost and additional risk of morbidities should be considered. In the current outpatient setting, PPB + IRLA, PNB + IPLA, PPB, PNB + IRLA, and PNB methods are potentially more acceptable options.

A randomized controlled comparison between periprostatic nerve block and pelvic plexus block at the base and apex of 14-core prostate biopsies

PURPOSE

To compare the pain control efficacies of the pelvic plexus block (PPB), periprostatic nerve block (PNB), and controls during a 14-core basal and apical core prostate biopsy.

METHODS

This randomized controlled study, performed between January 2015 and January 2016, included patients with an abnormal serum prostate-specific antigen (PSA > 3 ng/mL) level or a palpable nodule on digital rectal examination. The enrolled patients were randomized into three groups: Group 1, intrarectal local anesthesia (IRLA, 10 mL of 2% lidocaine jelly) and PPB with 3.0 mL of 2% lidocaine injected at the bilateral pelvic plexus; Group 2, IRLA and PNB with 3.0 mL of 2% lidocaine injected at both periprostatic nerves; and Group 3, only IRLA. Patients answered the visual analog scale (VAS) questionnaire at 6 time points.

RESULTS

This study consisted of 163 patients (Group 1 = 55, Group 2 = 55, and Group 3 = 53). Pain at the apical biopsy location was less in Groups 1 and 2 than in Group 3 (p < 0.001, p < 0.001) and between the two local anesthetic groups (PNB + IRLA vs PPB + IRLA). Group 2 patients reported less pain than Group 1 patients (p = 0.022). Pain during the basal core biopsy was significantly less in Groups 1 and 2 than in Group 3 (p = 0.002, p < 0.001), but there were no significant differences in pain control between the two methods (PNB + IRLA vs PPB + IRLA, p = 0.054) during basal core biopsy.

CONCLUSIONS

PNB + IRLA is an effective local anesthetic method for reducing pain when performing apical biopsies compared with PPB + IRLA or IRLA alone.

Prostate cancer detection rate in Indonesian men

PURPOSES OF THE STUDY

To evaluate the overall detection rate of prostate cancer in biopsies according to serum prostate-specific antigen levels, determine the number of cores biopsied in Indonesian men, and provide a correlated staging of prostate cancer patients at varying intervals of prostate-specific antigen levels.

METHODS

We retrospectively analyzed the data from Indonesian men who had undergone prostate biopsy at two national referral medical centers in Jakarta from January 1995 to December 2014. Prostate biopsy was performed when levels of prostate-specific antigen were>4.0 ng/mL or malignancy was suspected upon digital rectal examination.

RESULTS

Of 2942 men who underwent biopsies, 844 (28.7%) were diagnosed with prostate cancer. When patients were stratified into five subgroups by serum prostate-specific antigen levels (< 4.0, 4.0-9.9, 10.0-19.9, 20.0-100.0, and>100.0 ng/mL), the overall detection rate of prostate cancer was 21.0%, 9.3%, 13.1%, 35.4%, and 92.9%, respectively. The detection rate was significantly higher in patients who underwent 10-core biopsies than in patients who underwent 6-core biopsies (31.6% vs. 22.4%, p<0.001). The receiver operating characteristic analysis to detect locally advanced/metastatic prostate cancer found that serum prostate-specific antigen levels of 42.7 ng/mL had a sensitivity of 74%, specificity of 73%, positive predictive value of 85.2%, and negative predictive value of 57.5%, with area under the curve of 0.81 (95% confidence interal 0.78 to 0.84).

CONCLUSION

The overall detection rate of prostate cancer in Indonesian men was 28.7%. The prostate cancer detection rate appeared to be lower than that observed in white men.

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

A meta-analysis was performed to evaluate the efficacy of local anesthesia in alleviating pain during prostate biopsy. We searched relevant articles in PubMed and Embase. The included studies should be randomized controlled trials (RCT) using local anesthesia to alleviate pain during biopsy, which was recorded by a pain scale. Analgesic efficacy of different local anesthesia techniques were analyzed, including intrarectal local anesthesia (IRLA), periprostatic nerve block (PNB), pelvic plexus block (PPB) and intraprostatic local anesthesia (IPLA). We included 46 RCTs. PNB significantly reduced pain score compared with placebo (-1.27 [95% confidence interval [95% CI] -1.72, -0.82]) or no injection (-1.01 [95% CI -1.2, -0.82]). IRLA with prilocaine-lidocaine cream could also reduced pain (-0.45 [95% CI -0.76, -0.15]), while the IRLA with lidocaine gel was not effective (-0.1 [95% CI -0.24, 0.04]). PNB lateral to the neurovascular bundle had better analgesic effect than at prostate apex (P = 0.02). Combination use of PPB and IRLA considerably alleviated pain of patients compared with the combination of PNB and IRLA (-1.32 [95% CI -1.59, -1.06]). In conclusion, local anesthesia could alleviate patients' pain during the prostate biopsy. PNB was not so effective as PPB.

Local anesthesia for pain control during transrectal ultrasound-guided prostate biopsy: a systematic review and meta-analysis

BACKGROUND

A meta-analysis was performed to evaluate the efficacy and safety of intrarectal local anesthestic (IRLA), periprostatic nerve block (PPNB), and the combined modalities in alleviating the pain during transrectal ultrasound (TRUS)-guided prostate biopsy.

MATERIALS AND METHODS

A literature review was performed to identify all published randomized controlled trials (RCTs) about IRLA vs no anesthesia or placebo gel; PPNB vs no injection, periprostatic placebo injection, or IRLA; combined PPNB and IRLA vs PPNB alone; and combined PPNB and intraprostatic nerve block (IPNB) vs PPNB alone before TRUS-guided biopsy. Sources included MEDILINE, EMBASE, and Cochrane Library from 1980 to 2016. The main outcomes were biopsy pain score, probe manipulation pain score, and anesthetic infiltration pain score assessed by the visual pain scale.

RESULTS

A total of 26 articles involving 36 RCTs were used in this analysis: Although IRLA can lead to pain reduction, the result was not statistically significant when compared with no anesthesia or placebo gel (weighted mean difference [WMD]: -0.22, 95% CI: -0.45 to 0, P=0.06). PPNB can lead to significantly lower biopsy pain scores when compared with no analgesia (WMD: -1.32, 95% CI: -1.68 to -0.95, P<0.00001), placebo injection (WMD: -2.62, 95% CI: -3.16 to -2.07, P<0.00001), or IRLA (WMD: -1.31, 95% CI: -1.40 to -1.22, P<0.00001). PPNB + IRLA can lead to significantly lower biopsy pain scores when compared with PPNB alone (WMD: -0.45, 95% CI: -0.62 to -0.28, P<0.00001). PPNB + IPNB can lead to significantly lower biopsy pain scores when compared with PPNB alone (WMD: -0.73, 95% CI: -0.92 to -0.55, P<0.00001). There were no severe reported general or local complications related to local anesthesia.

CONCLUSION

This meta-analysis indicates that a combination of PPNB and IRLA/IPNB is effective and safe in alleviating the pain during TRUS-guided prostate biopsy. Further high-quality RCTs are needed to validate this result.

Comparison of patient comfort between MR-guided in-bore and MRI/ultrasound fusion-guided prostate biopsies within a prospective randomized trial

PURPOSE

The objective of this study was to compare patient comfort between MR-guided in-bore prostate biopsy (IB-GB) and MRI/ultrasound fusion-guided prostate biopsy (FUS-GB) with additional systematic 12-core transrectal ultrasound (TRUS)-guided biopsy within a prospective randomized trial.

METHODS

Two hundred and ten consecutive patients were randomly assigned in a 1:1 ratio to receive either IB-GB and prior intrarectal instillation of a 2% lidocaine gel (n = 106) or FUS-GB plus additional systematic 12-core TRUS-guided biopsy and prior application of a periprostatic nerve block (PPNB) with 2% mepivacaine (n = 104). The maximal procedural pain (MPP) on a 0-10 visual analog scale and the operating room time were recorded for each biopsy session.

RESULTS

Baseline characteristics and mean number of targeted biopsy cores (5.6 ± 0.8 vs 5.4 ± 1.2 for IB-GB and FUS-GB, respectively; p = 0.278) were similar in both study arms. In relation to the IB-GB arm, the total number of biopsy cores in the FUS-GB arm, including the systematic 12-core TRUS-guided biopsy, was significantly higher (17.4 ± 1.2; p < 0.001). Patients with IB-GB had significantly higher MPP scores (2.95 ± 2.15) compared with subjects with FUS-GB (1.95 ± 1.56; p < 0.001). FUS-GB required significantly less time (28.22 ± 11.61 min) in comparison with IB-GB (42.09 ± 11.37 min; p < 0.001).

CONCLUSIONS

The PPNB can easily be administered just prior to performing FUS-GB. Thus, patients have significantly lower pain levels in comparison with IB-GB, which is usually done with intrarectal anesthetic gels. Although the addition of a systematic 12-core TRUS-guided biopsy significantly increases the number of biopsy cores, FUS-GB still requires significantly less time in comparison with IB-GB.

Pain during transrectal ultrasound-guided prostate biopsy and the role of periprostatic nerve block: what radiologists should know

Early prostate cancers are best detected with transrectal ultrasound (TRUS)-guided core biopsy of the prostate. Due to increased longevity and improved prostate cancer screening, more men are now subjected to TRUS-guided biopsy. To improve the detection rate of early prostate cancer, the current trend is to increase the number of cores obtained. The significant pain associated with the biopsy procedure is usually neglected in clinical practice. Although it is currently underutilized, the periprostatic nerve block is an effective technique to mitigate pain associated with prostate biopsy. This article reviews contemporary issues pertaining to pain during prostate biopsy and discusses the practical aspects of periprostatic nerve block.

Optimization of prostate biopsy: review of technique and complications

A 12-core systematic biopsy that incorporates apical and far-lateral cores in the template distribution allows maximal cancer detection and avoidance of a repeat biopsy while minimizing the detection of insignificant prostate cancers. Magnetic resonance imaging-guided prostate biopsy has an evolving role in both initial and repeat prostate biopsy strategies, potentially improving sampling efficiency, increasing the detection of clinically significant cancers, and reducing the detection of insignificant cancers. Hematuria, hematospermia, and rectal bleeding are common complications of prostate needle biopsy, but are generally self-limiting and well tolerated. All men should receive antimicrobial prophylaxis before biopsy.

Sedoanalgesia with midazolam and fentanyl citrate controls probe pain during prostate biopsy by transrectal ultrasound

PURPOSE

To assess the pain intensity of patients administered midazolam and fentanyl citrate before undergoing transrectal ultrasound-guided prostate biopsy.

MATERIALS AND METHODS

This was a study in patients with different indications for prostate biopsy in whom 5 mg of midazolam and 50 µg of fentanyl citrate was administered intravenously 3 minutes before the procedure. After biopsy, pain was assessed by use of a visual analogue scale (VAS) in three stages: VAS 1, during probe introduction; VAS 2, during needle penetration into prostate tissue; and VAS 3, in the weeks following the exam. Pain intensity at these different times was tested with stratification by age, race, education, prostate volume, rebiopsy, and anxiety before biopsy. Pain was ranked according to the following scores: 0 (no pain), 1-3 (mild pain), 4-7 (moderate pain), and 8-10 (severe pain). Statistical analysis was performed by using Kruskal-Wallis and Wilcoxon two-tailed tests with a significance of 5%.

RESULTS

Pain intensity was not influenced by any risk factors. The mean VAS 1 score was 1.95±1.98, the mean VAS 2 score was 2.73±2.55, and the mean VAS 3 score was 0.3±0.9, showing greater pain at the time of needle penetration than in other situations (VAS 2>VAS 1>VAS 3, p=0.0013, p=0.0001, respectively). Seventy-five percent of patients reported a VAS pain scale of less than 3.1 or mild pain.

CONCLUSIONS

Intravenous sedation and analgesia with midazolam and fentanyl citrate is a good method for reducing pain caused by prostate biopsy, even during probe insertion.

EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent-update 2013

CONTEXT

The most recent summary of the European Association of Urology (EAU) guidelines on prostate cancer (PCa) was published in 2011.

OBJECTIVE

To present a summary of the 2013 version of the EAU guidelines on screening, diagnosis, and local treatment with curative intent of clinically organ-confined PCa.

EVIDENCE ACQUISITION

A literature review of the new data emerging from 2011 to 2013 has been performed by the EAU PCa guideline group. The guidelines have been updated, and levels of evidence and grades of recommendation have been added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

EVIDENCE SYNTHESIS

A full version of the guidelines is available at the EAU office or online (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. Systematic prostate biopsies under ultrasound guidance and local anesthesia are the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. A biopsy progression indicates the need for active intervention, whereas the role of PSA doubling time is controversial. In men with locally advanced PCa for whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT), with equivalent oncologic efficacy. Active treatment is recommended mostly for patients with localized disease and a long life expectancy, with radical prostatectomy (RP) shown to be superior to WW in prospective randomized trials. Nerve-sparing RP is the approach of choice in organ-confined disease, while neoadjuvant ADT provides no improvement in outcome variables. Radiation therapy should be performed with ≥ 74 Gy in low-risk PCa and 78 Gy in intermediate- or high-risk PCa. For locally advanced disease, adjuvant ADT for 3 yr results in superior rates for disease-specific and overall survival and is the treatment of choice. Follow-up after local therapy is largely based on PSA and a disease-specific history, with imaging indicated only when symptoms occur.

CONCLUSIONS

Knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarize the most recent findings and put them into clinical practice.

PATIENT SUMMARY

A summary is presented of the 2013 EAU guidelines on screening, diagnosis, and local treatment with curative intent of clinically organ-confined prostate cancer (PCa). Screening continues to be done on an individual basis, in consultation with a physician. Diagnosis is by prostate biopsy. Active surveillance is an option in low-risk PCa and watchful waiting is an alternative to androgen-deprivation therapy in locally advanced PCa not requiring immediate local treatment. Radical prostatectomy is the only surgical option. Radiation therapy can be external or delivered by way of prostate implants. Treatment follow-up is based on the PSA level.

[EAU guidelines on prostate cancer. Part I: screening, diagnosis, and treatment of clinically localised disease]

OBJECTIVE

Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).

METHODS

The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

RESULTS

A full version is available at the EAU office or Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in < 3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT) with equivalent oncologic efficacy. Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 74Gy and 78Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.

CONCLUSIONS

The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice.

EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and treatment of clinically localised disease

OBJECTIVE

Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).

METHODS

The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.

RESULTS

A full version is available at the EAU office or Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in <3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT) with equivalent oncologic efficacy. Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 74 Gy and 78 Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.

CONCLUSIONS

The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice.

Visual pain score during transrectal ultrasound-guided prostate biopsy using no anaesthesia or three different types of local anaesthetic application

OBJECTIVE

To evaluate the pain score during transrectal ultrasound (TRUS)-guided prostate biopsy using three different anaesthetic applications and no anaesthesia.

MATERIAL AND METHODS

One-hundred men undergoing TRUS-guided prostate biopsy were prospectively enrolled in this study. Patients were randomized to four groups. Group 1 (n = 25) received no anaesthesia, group 2 (n = 25) was administered a perianal lidocaine injection, group 3 (n = 25) was administered a periprostatic lidocaine injection, and group 4 (n = 25) was administered a combination of perianal-intrarectal lidocaine-prilocaine cream. The anaesthetic application was given 5 min before the procedure. All patients were asked to indicate the level of pain experienced on a visual analogue scale (VAS) during three situations, including when the TRUS probe was inserted and 15 min and 2 weeks after biopsy.

RESULTS

Mean pain scores were similar in all groups at the time of probe insertion. Mean pain scores showed statistically significant differences between group 1 and the other groups, except for group 4, 15 min after the procedure. Group 3 showed better pain control 15 min after biopsy and this difference was statistically significant (p < 0.043).The VAS scores were similar 2 weeks after the procedure in all groups.

CONCLUSIONS

Anaesthetic application before TRUS-guided prostate biopsy may be advocated. The application of periprostatic lidocaine seems to be the most advantageous method for lowering the perception of pain.

Prostate biopsy and anaesthesia: An overview

OBJECTIVE

To evaluate the efficacy of different methods for decreasing pain and discomfort in men undergoing transrectal ultrasound-guided prostate biopsies and to propose a clinical standard useful for pain relief.

MATERIAL AND METHODS

A MEDLINE search using the search terms "anaesthesia" and "prostate biopsy" was performed in November 2004. The search yielded 198 papers, 45 of which were found to relate to the subject and were in the English language.

RESULTS

Intravenously administered sedoanalgesia seems to be effective but is cumbersome to handle in everyday practice. In one study, i.v. tramadol has been shown to be effective, and the same goes for diclofenac 100 mg given as a suppository 1 h prior to the biopsy. Inhaled nitrous oxide (Entonox) works well but is not widely available. A rectally administered gel containing local anaesthetic seems to have very limited efficacy. Periprostatic injection of a local anaesthetic was used in most studies, nearly all of which showed that it was effective in comparison with placebo or rectal gel. A minimum of 10 cm3 seems to be necessary for optimal effect.

CONCLUSION

At the present time, perirectal injection of a local anaesthetic is the preferred method of pain relief in conjunction with transrectal prostate biopsies.

Topical Prilocaine-Lidocaine Cream Combined with Peripheral Nerve Block Improves Pain Control in Prostatic Biopsy: Results from a Prospective Randomized Trial

OBJECTIVES

To compare pain control results between periprostatic nerve block alone and combined with topical prilocaine-lidocaine cream as local anesthesia of prostate biopsy.

METHODS

Three hundred patients were randomized to receive PNB (group 1), topical anesthesia of the anal ring, anal canal, and anterior rectal wall combined with PNB (group 2) and placebo (group 3). Patients were asked to use scale of 0-10 to complete a visual analogue scale questionnaire about pain during probe insertion (VAS1), periprostatic infiltration (VAS2), and cores (VAS3).

RESULTS

Pain during probe insertion in group 2 was significantly less than in groups 1 and 3 (VAS1, 0.29 vs. 1.46 and 1.48; p<0.0001). Pain during periprostatic infiltration was also reduced in group 2 compared with group 1 (VAS2, 1.06 vs. 2.39; p<0.0001). Pain control was similar during biopsy in the PNB and combined groups (VAS3, 0.43 vs. 0.37; p=0.77) and was superior to group 3 (VAS3, 3.02; p<0.0001). In younger patients (cut off, median age 67 yr) these differences were still significant between groups 1 and 2 (VAS1, 1.95 vs.0.31; p<0.0001 and VAS2, 2.97 vs. 1,15; p<0.0001), but not in older patients (VAS1, 0.91 vs. 0.28; p=0.06; VAS2, 1.52 vs. 0,92; p=0.06). Vagal symptoms were registered in 36 (12%) patients in all groups. Sepsis occurred in one group 1 patient and in one group 2 patient. Rectal bleeding was observed in one group 2 patient.

CONCLUSION

Combined prilocaine-lidocaine cream topically placed with PNB is superior to PNB alone and may be of maximum benefit for younger patients.

Extended and saturation prostatic biopsy in the diagnosis and characterisation of prostate cancer: a critical analysis of the literature

OBJECTIVE

To review and critically analyse all the recent literature on the detection and characterisation of prostate cancer by means of extended and saturation protocols.

METHODS

A systematic review of the literature was performed by searching MedLine from January 1995 to April 2007. Electronic searches were limited to the English language, and the key words "prostate cancer," "diagnosis," "transrectal ultrasound (TRUS)," "prostate biopsy," and "prognosis" were used.

RESULTS

The prostate biopsy technique has changed significantly since the original Hodge sextant biopsy protocol. Several types of local anaesthesia are now available, but periprostatic nerve block (PPNB) has proved to be the most effective method to reduce pain during TRUS biopsy. It remains controversial whether PPNB should be associated with other medications. The optimal extended protocol (sextant template with at least four additional cores) should include six standard sextant biopsies, with additional biopsies (up to 12 cores) taken more laterally (anterior horn) to the base and medially to the apex. Repeat biopsies should be based on saturation biopsies (number of cores >/= 20) and should include the transition zone, especially in a patient with an initial negative biopsy. As a means of increasing accuracy of prostatic biopsy and reducing unnecessary prostate biopsy, colour and power Doppler imaging, with or without contrast enhancement, and elastography now can be successfully adopted, but their routine use is still controversial.

CONCLUSION

Extended and saturation biopsy schemes should be performed at first and repeat biopsy, respectively. The widespread use of local anaesthesia makes the procedures more comfortable.

Local anesthetic reduces pain associated with transrectal ultrasound-guided prostate biopsy: a meta-analysis

OBJECTIVES

To determine whether local anesthetic decreases the pain associated with transrectal ultrasound-guided prostate needle biopsy.

METHODS

A systematic review and meta-analysis was performed of randomized clinical trials of periprostatic local anesthetic for prostate biopsy. The primary outcome was pain as determined by the visual analog scale. The standardized mean differences between groups were estimated using the DerSimonian and Laird random effects models.

RESULTS

Fourteen trials with a total of 994 patients met the inclusion criteria for this study. Pooled data analysis demonstrated significantly decreased pain with the use of local anesthetic. The standardized mean difference in the pain score comparing local anesthetic to placebo or nothing was -1.05 (95% confidence interval -1.40 to -0.71, P <0.001). Begg's test (P = 0.34) and Egger's test (P = 0.50) showed no evidence of significant publication bias. Sensitivity analysis showed only slight changes in the effect estimate with sequential omission of each trial or with repetition of the analysis with subgroups of trials based on likely sources of heterogeneity.

CONCLUSIONS

The results of our analysis have shown that compared with no anesthetic, periprostatic local anesthetic significantly decreases the pain associated with transrectal ultrasound-guided prostate needle biopsy.

Biopsy standards for detection of prostate cancer

The widespread use of measurement of prostate-specific antigen for prostate cancer screening has led to a dramatic increase in the number of transrectal biopsies. Although transrectal ultrasound-guided prostate biopsy is the gold standard in the diagnosis of prostate cancer, the strategies for initial and repeat biopsies remain controversial. Over the past decade numerous biopsy protocols have been developed. Several protocols have been established that increase the number of cores by combining sextant and lateral biopsies to increase the cancer detection rate. We review the current methods of prostate biopsies, the indication to perform an initial and repeat biopsy, the impact of prostate volume on the number of cores taken, and the morbidity of the procedure.

Local Anesthesia During Transrectal Ultrasonography-guided Prostate Biopsy: does it have any Effect on Sexual Function?

INTRODUCTION

TRUS (Trans Rectal Ultra Sonographic)-guided biopsy of the prostate is the procedure of choice for prostate cancer diagnosis in urological clinical practice. TRUS-guided biopsies are associated with pain and anxiety and may interfere with sexual function and potency. The aim of this study was to evaluate whether local anesthesia during TRUS-guided prostate biopsies has any effect on the sexual behavior of patients and to compare the periprostatic infiltration with lidocaine to simple sonographic gel application in a randomized prospective trial.

PATIENTS AND METHODS

A total of 62 consecutive patients were included in the study randomized in two groups; Group A (n = 30, control group) and Group B (n = 32, lidocaine infiltration group). Interviews regarding their sexual status were conducted at the time they were informed of the need for biopsy, at the time of biopsy and at two scheduled interviews following the biopsy.

RESULTS

Similar results of sexual dysfunction were observed between the two groups. About 6% of patients experienced some degree of dysfunction in anticipation of biopsy (P > 0.02 between the two groups) that was resolved by the end of the follow-up period. In total, only one Group B patient continued to show sexual dysfunction at the time of the last interview compared to two patients in Group A.

CONCLUSIONS

Local infiltration with lidocaine does not seem to play a role in sexual dysfunction following prostate biopsies. Psychological factors influence patients and the urologist should be ready to inform and reassure both the patient and his family.

Prevention of pain and infective complications after transrectal prostate biopsy: a prospective study

AIM

To investigate the effects of lidocaine gel and parenteral antibiotics and povidine lavage in the treatment of pain occurring during prostate biopsy in terms of infective complications.

PATIENTS AND METHODS

Eighty patients with indications for prostate biopsy were randomized into two groups. One group underwent lavage with povidine iodine solution and lidocaine gel, and the other received cephtriaxon and lavage. Pain experienced by the patients was measured by visual analog scale (VAS). Blood samples were taken 15 and 60 min after the procedure, and urine culture antibiograms were taken 60 min after the procedure.

RESULTS

The average pain score was 3.70 in Group 1 and 4.25 in Group 2; the difference between the groups was not statistically significant (P > 0.05). Likewise, no statistically significant difference between groups was found by the chi square test in either urine or blood cultures (P > 0.05).

CONCLUSIONS

Lavage with betadine prior to transrectal prostate biopsy is adequate in the prevention of infective complications; however, because lidocaine gel is not effective against pain, alternative methods for pain management need to be developed.

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=2 (mild pain/discomfort). Group 2 (N = 75) had pain scores between 2 and 5 (moderate pain/discomfort). Group 3 (N = 15) 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.

HOW TO DECREASE PAIN DURING TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY: A LOOK AT THE LITERATURE

PURPOSE

There is growing interest among urologists on the need for decreasing pain during transrectal ultrasound (TRUS) guided prostate biopsy.

MATERIALS AND METHODS

We performed a systematic MEDLINE search of clinical trials of any kind of anesthesia, analgesia or sedation during TRUS guided prostate biopsy published since 2000. We critically analyzed the impact of pain and discomfort associated with the procedure, the described methods for evaluating it and the different techniques that have been described.

RESULTS

There is strong evidence in the current literature that patient tolerance and comfort during TRUS guided prostate biopsy can be improved by anesthesia/analgesia. What remains is the need to urge all urologists to introduce it in clinical practice as a routine part of the procedure, whatever the biopsy scheme.

CONCLUSIONS

Of the various options periprostatic anesthetic infiltration has been shown to be safe, easy to perform and highly effective. It should be considered the gold standard at the moment, even if the optimal technique remains to be established. Further studies addressing this issue are warranted.

Local anesthesia for transurethral manipulations: is a transrectal periprostatic nerve block effective?

Periprostatic nerve block has been reported to be an effective form of anesthesia for prostatic surgery. Recent studies have shown the simplicity and the efficacy of a transrectal approach for periprostatic nerve block. The goal of our study was to evaluate the effect of a transrectal periprostatic nerve block on the discomfort associated with rigid cystoscopy. A total of 73 patients underwent cystoscopy. Group 1 (n = 39) received a transrectal periprostatic lidocaine infiltration prior to the cystoscopy. Group 2 (n = 34) underwent cystoscopy alone. The pain that patients experienced during cystoscopy was assessed on a visual analog scale. The patients in the two groups were very similar in regard to age and size of the prostate. The mean pain score was 3.4 in group 1 and 3.9 in group 2. This difference was not statistically significant. We conclude that nerve block does not seem to reduce the pain associated with transurethral manipulations.