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

Comparison of intrarectal heated lidocaine gel and periprostatic nerve block for pain control in transrectal ultrasound-guided prostate biopsy: A randomized controlled non-inferiority trial

Background

To investigate whether intrarectal local anesthesia with heated lidocaine gel (IRLAH) is non-inferior to periprostatic nerve block (PNB) for reducing pain in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy.

Methods

We performed a randomized controlled non-inferiority trial with 100 participants who underwent systematic TRUS-guided, 12-core prostate biopsy from August 2019 to July 2020. These participants were randomly assigned to a group receiving intrarectal local anesthesia with 20 mL of heated (40°C) 2% lidocaine gel (n = 50) or PNB (n = 50). The primary outcome was a pain score on a 0-10 visual analogue scale (VAS) at four time points with the non-inferiority margin of 1; VAS-1: during local anesthesia application; VAS-2: during probe insertion; VAS-3: during biopsy; VAS-4: 30 minutes after the procedure. The secondary outcome included complications during and after the procedure.

Results

The IRLAH group (0.1) met non-inferiority as well as superiority criteria for mean VAS-1 score vs. the PNB group (2.33) (P < 0.001), as the difference (95% confidence interval [CI]) between the two groups was -2.23 (-2.66 to -1.79) and the upper bound of the 95% CI were both below the prespecified non-inferiority margin and below zero. For mean VAS-3 score, the difference (95% CI) was 0.3 (-0.38 to 0.98) and the upper bound of the 95% CI did not exceed the predefined non-inferiority margin indicating that IRLAH was non-inferior (IRLAH group, 3.44; PNB group, 3.14). Also, non-inferiority was shown for pain scores at VAS-2 and VAS-4. There were no significant differences in complications.

Conclusion

IRLAH is a noninvasive and non-inferior alternative to PNB for pain control in TRUS-guided prostate biopsy without increased risk of complications.

Pain relieving effect of music on patients during transrectal ultrasonography: A pilot study

BACKGROUND

Patient discomfort is often inevitable during transrectal ultrasonography (TRUS), a widely used modality for evaluating benign prostate hyperplasia/lower urinary tract symptoms. Music has been suggested as a method of pain relief during urologic procedures. In this study, we investigated the effect of music on pain relief during TRUS.

METHODS

In a pilot study conducted from March to June 2019, pain scores of 316 patients who underwent TRUS with or without music were quantified using the visual analog scale (VAS). One-to-one propensity score matching was performed by matching the subjects between the groups. Patients with hemorrhoids of grade ≥ III were excluded (n = 4).

RESULTS

Among the 312 patients included in the study (VAS score = 3.3 ± 2.4), 177 listened to music during the procedure. There were significant differences in age, prostate-specific antigen, prostate volume, International Prostate Symptom Score symptom/life score, and VAS score between the music (+) and music (-) groups. After adjusting for relevant variables, VAS scores were significantly lower in male patients aged ≥65.0 years who underwent music intervention than in those who did not (1.5 ± 1.4 vs. 3.0 ± 1.4, p = 0.002).

CONCLUSION

Age was negatively associated with pain during TRUS, and music had a relieving effect on pain in patients aged ≥65.0 years. Our findings may help improve the quality of examinations in urologic outpatient offices.

Anorectal application of 5% lidocaine cream reduces pain prior to periprostatic nerve block during transrectal ultrasound guided prostate biopsy: Randomized, prospective controlled study

OBJECTIVES

Trans rectal ultrasound guided prostate biopsy with periprostatic nerve block (PPNB) is performed following probe insertion and manipulation leaving these initial maneuvers uncovered in terms of pain control. We evaluated whether topical analgesia reduces pain during early stages of the procedure.

PATIENTS AND METHODS

Seven group prospective, randomized controlled study: groups 1-3: nerve block with 5 ml 1% lidocaine bilaterally plus perianal topical application of 10 ml 5% lidocaine cream. Groups 4-6 as in 1-3 plus digital application of 10 ml 5% lidocaine cream internally on rectal walls. For each approach exposure times were 5 (groups 1 and 4), 10 (groups 2 and 5) and 20 (groups 3 and 6) min, respectively. The control group (7) received PPNB only. Patients filled a 0-10 visual analogue scale (VAS) at five points: after probe insertion, during probe manipulation, following PPNB, after prostate biopsies and a global pain estimation.

RESULTS

Two hundred and fifty-two patients were enrolled. Significant differences in VAS between all study groups and controls were observed at the pre-biopsy stages of the procedure. In multivariate analysis adjusted for prostate specific antigen, diabetes mellitus status, spinal disease, abnormal digital rectal examination and non- benign prostate hyperplasia histology, significance remained for probe insertion and intra-rectal manipulation. For each exposure time no significant differences were observed between topical application and topical + intra-rectal application. After PPNB, differences between study and control groups disappeared.

CONCLUSION

Topical anesthesia significantly reduces pain during early stages of prostate biopsy. Perianal application sufficed whereas intra-rectal application of local anesthetics does not add to pain control. Perianal application for 10 min seems to be optimal.

Efficacy and safety of a combined anesthetic technique for transrectal prostate biopsy: a single center, prospective, randomized study

Introduction

A transrectal ultrasound-guided (TRUS) biopsy is the gold standard for diagnosis of prostatic neoplasia. This exam is associated with pain and discomfort, and numerous methods of analgesia during this procedure have been described. There is still no consensus among urologists about the pain control technique that should be performed, even though the periprostatic basal nerve block is the most studied technique. The main objective of this study is to evaluate the benefit of adding local periapical prostatic anesthesia to the traditional periprostatic basal nerve block during TRUS biopsy.

Material and methods

A total of 70 patients with indication for TRUS biopsy were enrolled in this study. Patients were randomized into 2 groups. Group 1 received a periprostatic basal nerve block. Group 2 received both periapical prostatic and periprostatic basal nerve blocks . The pain experienced during different moments of the procedure (introduction of the probe, anesthesia administration, removal of cores and 30 minutes after biopsy) was assessed using visual analog scales of one to ten. The rate of complications at 30 days post-biopsy was also assessed.

Results

The difference in pain during the distinct moments of the TRUS biopsy was not significant between the two groups. There were no significant differences concerning age, level of total prostate-specific antigen (PSA) and prostate volume in both groups. There were also no statistically significant differences between the groups regarding the occurrence of complications and pathological findings.

Conclusions

The administration of concurent periprostatic basal and periapical nerve blocks has no significant benefits as compared to a periprostatic basal nerve block alone.

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.

The effect of ultrasound-guided compression immediately after transrectal ultrasound-guided prostate biopsy on postbiopsy bleeding: a randomized controlled pilot study

PURPOSE

To evaluate whether ultrasound-guided compression performed immediately after transrectal ultrasound (TRUS)-guided prostate biopsy decreases bleeding complications.

METHODS

We prospectively evaluated a total of 148 consecutive patients who underwent TRUS-guided prostate biopsy between March 2015 and July 2016. Systematic 12-core prostate biopsy was performed in all patients. Of these, 100 patients were randomly assigned to one of two groups: the compression group (n = 50) underwent TRUS-guided compression on bleeding biopsy tracts immediately after prostate biopsy, while the non-compression group (n = 50) underwent TRUS-guided prostate biopsy alone. The incidence rate and duration of hematuria, hematospermia, and rectal bleeding were compared between the two groups.

RESULTS

The incidence rates of hematuria and hematospermia were not significantly different between the two groups (60 vs. 64%, p = 0.68; 22 vs. 30%, p = 0.362, respectively, for compression vs. non-compression group). The rectal bleeding incidence was significantly lower in the compression group as compared to the non-compression group (20 vs. 44%, p = 0.01). However, there were no significant differences in the median duration of hematuria, hematospermia, or rectal bleeding between the two groups (2, 8, and 2 days vs. 2, 10, and 1 days, p > 0.05, respectively, for compression vs. non-compression group). TRUS-guided compression [p = 0.004, odds ratio (OR) 0.25] and patient age (p = 0.013, OR 0.93) were significantly protective against the occurrence of rectal bleeding after prostate biopsy in multivariable analysis.

CONCLUSIONS

Although it has no impact on other complications, ultrasound-guided compression on bleeding biopsy tracts performed immediately after TRUS-guided prostate biopsy is an effective and practical method to treat or decrease rectal bleeding.

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.

Advantages of caudal block over intrarectal local anesthesia plus periprostatic nerve block for transrectal ultrasound guided prostate biopsy

Objective:

To compare caudal block with intrarectal local anesthesia plus periprostatic nerve block for transrectal ultrasound guided prostate biopsy.

Methods:

One hundred and ninety patients scheduled for transrectal ultrasound guided prostate biopsy were randomized equally into Group-A who received caudal block (20 ml 1.2% lidocaine) and Group-B who received intrarectal local anesthesia (0.3% oxybuprocaine cream) plus periprostatic nerve block (10 ml 1% lidocaine plus 0.5% ropivacaine) before biopsy. During and after the procedure, the patients rated the level of pain/discomfort at various time points. Complications during the whole study period and the patient overall satisfaction were also evaluated.

Results:

More pain and discomfort was detected during periprostatic nerve block than during caudal block. Pain and discomfort was significantly lower during prostate biopsy and during the manipulation of the probe in the rectum in Group-A than in Group-B. No significant differences were detected in the pain intensity after biopsy and side effects between the two groups.

Conclusions:

Caudal block provides better anesthesia than periprostatic nerve block plus intrarectal local anesthesia for TRUS guided prostate biopsy without an increase of side effects.

Comparison of two different doses of lidocaine on the pain sensation during transrectal ultrasound-guided prostate biopsy

OBJECTIVE

To compare two different doses of lidocaine used for periprostatic nerve block on pain perception during transrectal ultrasound (TRUS) guided prostate biopsy.

MATERIAL AND METHODS

A total of 288 patients with elevated prostate specific antigen (PSA) levels and/or abnormal digital rectal examination who underwent TRUS-guided prostate biopsy were included in the study. The patients were divided into 3 groups: Group 1 (n=103) prostate biopsy were performed after administering perianal intrarectal application of 10 mL 2% lidocaine gel, Group 2 (n=98) 2 mL of 2% lidocaine injection on each side following rectal installation of lidocaine gel and Group 3 (n=87) 4 mL of 2% lidocaine injection on each side after rectal instillation of lidocaine gel. Patients' pain scores during biopsy procedure were reported using visual analogue score (VAS). Independent sample t test, ANOVA test and Tukey test were used for statistical evaluation.

RESULTS

The mean age, prostate volume and PSA level were 65.6±8.4 years, 58.2±34.8 mL, and 11.8±3.4 ng/mL respectively. There were no statistically significant differences in baseline characteristics between the groups. The mean VAS scores were 2.4±1.8 in Group 1, 2.5±1.9 in Group 2 and 1.6±1.6 in Group 3. Patients in Group 3, reported significant pain reduction compared with patients in Groups 1 and 2 (p=0.002, and 0.001, respectively). However, there was no statistically significant difference in VAS scores between Groups 1 and 2 (p=0.815).

CONCLUSION

According to our results we recommend the use of perianal intrarectal lidocain gel application, and periprostatic nerve block with injection of 4 ml 2% lidocaine per side combination in TRUS-guided prostate biopsies. Further large-scale randomized control studies are needed to validate these finding.

Complications After Systematic, Random, and Image-guided Prostate Biopsy

CONTEXT

Prostate biopsy (PB) represents the gold standard method to confirm the presence of cancer. In addition to traditional random or systematic approaches, a magnetic resonance imaging (MRI)-guided technique has been introduced recently.

OBJECTIVE

To perform a systematic review of complications after transrectal ultrasound (TRUS)-guided, transperineal, and MRI-guided PB.

EVIDENCE ACQUISITION

We performed a systematic literature search of Web of Science, Embase, and Scopus databases up to October 2015, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Complications and mortality following random, systematic, and image-guided PBs were reviewed. Eighty-five references were included.

EVIDENCE SYNTHESIS

The most frequent complication after PB was minor and self-limiting bleeding (hematuria and hematospermia), regardless of the biopsy approach. Occurrence of rectal bleeding was comparable for traditional TRUS-guided and image-guided PBs. Almost 25% of patients experienced lower urinary tract symptoms, but only a few had urinary retention, with higher rates after a transperineal approach. Temporary erectile dysfunction was not negligible, with a return to baseline after 1-6 mo. The incidence of infective complications is increasing, with higher rates among men with medical comorbidities and older age. Transperineal and in-bore MRI-targeted biopsy may reduce the risk of severe infectious complications. Mortality after PB is uncommon, regardless of biopsy technique.

CONCLUSIONS

Complications after PB are frequent but often self-limiting. The incidence of hospitalization due to severe infections is continuously increasing. The patient's general health status, risk factors, and likelihood of antimicrobial resistance should be carefully appraised before scheduling a PB.

PATIENT SUMMARY

We reviewed the variety and incidence of complications after prostate biopsy. Even if frequent, complications seldom represent a problem for the patient. The most troublesome complications are infections. To minimize this risk, the patient's medical condition should be carefully evaluated before biopsy.

Effectiveness of stress management in patients undergoing transrectal ultrasound-guided biopsy of the prostate

BACKGROUND

To assess the utilization of stress management in relieving anxiety and pain among patients who undergo transrectal ultrasound (TRUS)-guided biopsy of the prostate.

METHODS

Eighty-two patients admitted to a community hospital for a TRUS biopsy of the prostate participated in this case-controlled study. They were divided into an experimental group that was provided with stress management and a control group that received only routine nursing care. Stress management included music therapy and one-on-one simulation education. Before and after the TRUS biopsy, the patients' state-anxiety inventory score, pain visual analogue scale (VAS), respiratory rate, heart rate, and blood pressure were obtained.

RESULTS

There were no differences in baseline and disease characteristics between the two groups. The VAS in both groups increased after the TRUS biopsy, but the difference in pre- and postbiopsy VAS scores was significantly lower in the experimental group (P=0.03). Patients in both groups experienced mild anxiety before and after the biopsy, but those in the experimental group displayed a significantly greater decrease in postbiopsy state-anxiety inventory score compared to the control group (P=0.02).

CONCLUSION

Stress management can alleviate anxiety and pain in patients who received a TRUS biopsy of the prostate under local anesthesia.

Combination of lidocaine suppository and periprostatic nerve block during transrectal prostate biopsy: a prospective randomized trial

OBJECTIVE

To assess the most effective local analgesia during transrectal ultrasound-guided prostate biopsy.

METHODS

A total of 123 consecutive patients undergoing transrectal ultrasound-guided prostate biopsy for elevated prostate-specific antigen levels and/or a suspicious digital rectal examination were randomized to three groups. Patients received a 60-mg lidocaine suppository (group 1, n = 41), a periprostatic nerve block (10-mL injection of lidocaine hydrochloride; group 2, n = 41) or a combination of both (group 3, n = 41) before a 10-core transrectal ultrasound-guided biopsy. A total of 80.5% (n = 99) of the patients underwent their first biopsy, 27.1% (n = 22) their second and 2.4% (n = 2) the third. Pain was evaluated on a 10-point visual analog scale for each step of the procedure.

RESULTS

Prostate-specific antigen values ranged from 0.39 to 90.1 (mean [SD] 8.76 ng/mL [11.08 ng/mL]). Comparison of the median visual analog scale scores between groups 1 and 2 showed a significant difference (P = 0.004). The differences in the outcomes between groups 1 and 3 (P = 0.001), and groups 2 and 3 (P = 0.001) were also significant. Patients of group 3 had the best output corresponding to the pain sensations and therefore the lowest visual analog scale scores.

CONCLUSION

The combination of lidocaine suppository and periprostatic lidocaine infiltration is more effective for pain control than either lidocaine suppository or periprostatic lidocaine infiltration alone in patients undergoing transrectal ultrasound-guided prostate biopsy.

Systematic review of complications of prostate biopsy

CONTEXT

Prostate biopsy is commonly performed for cancer detection and management. The benefits and risks of prostate biopsy are germane to ongoing debates about prostate cancer screening and treatment.

OBJECTIVE

To perform a systematic review of complications from prostate biopsy.

EVIDENCE ACQUISITION

A literature search was performed using PubMed and Embase, supplemented with additional references. Articles were reviewed for data on the following complications: hematuria, rectal bleeding, hematospermia, infection, pain, lower urinary tract symptoms (LUTS), urinary retention, erectile dysfunction, and mortality.

EVIDENCE SYNTHESIS

After biopsy, hematuria and hematospermia are common but typically mild and self-limiting. Severe rectal bleeding is uncommon. Despite antimicrobial prophylaxis, infectious complications are increasing over time and are the most common reason for hospitalization after biopsy. Pain may occur at several stages of prostate biopsy and can be mitigated by anesthetic agents and anxiety-reduction techniques. Up to 25% of men have transient LUTS after biopsy, and <2% have frank urinary retention, with slightly higher rates reported after transperineal template biopsy. Biopsy-related mortality is rare.

CONCLUSIONS

Preparation for biopsy should include antimicrobial prophylaxis and pain management. Prostate biopsy is frequently associated with minor bleeding and urinary symptoms that usually do not require intervention. Infectious complications can be serious, requiring prompt management and continued work into preventative strategies.

Comparison of the efficacy and safety of topical diltiazem and nitroglycerine for pain relief during transrectal ultrasound guided biopsy of the prostate

INTRODUCTION AND OBJECTIVE

Transrectal ultrasound biopsy of prostate is a painful procedure. The introduction of the rectal probe is one of the major contributors to the pain associated with this procedure. Drugs that relax the anal sphincter should theoretically decrease this pain. This study was done to compare the efficacy and safety of two topical medications that relax the anal sphincter, diltiazem and nitroglycerine, in decreasing the pain associated with transrectal ultrasound guided prostate biopsy.

MATERIALS AND METHODS

66 patients who were to undergo their first prostate biopsy were randomized to receive either 2 mL of 2 % topical diltiazem or 2 mL of 0.2 % topical nitroglycerine or placebo 20 minutes before prostate biopsy. All patients also received 15 mL of intrarectal lignocaine. A 10-point visual analogue score was used to record the pain immediately after the insertion of the probe, during biopsy and at the end of the procedure.

RESULTS

The pain scores due to probe insertion, during biopsy and at the end of the procedure in patients who received topical diltiazem or nitroglycerine were significantly lower compared to the placebo group (p < 0.001). There were no significant differences in the pain scores between the patients receiving diltiazem compared to those receiving nitroglycerine. Higher incidence of headache and fall in blood pressure was noted in patients who received nitroglycerine compared to those receiving diltiazem.

CONCLUSION

Topical diltiazem and nitroglycerine are equally effective in reducing the pain associated with transrectal prostatic biopsy. Diltiazem is safer compared to nitroglycerine.

The optimal rebiopsy prostatic scheme depends on patient clinical characteristics: results of a recursive partitioning analysis based on a 24-core systematic scheme

BACKGROUND

The most beneficial number and the location of prostate biopsies remain matters of debate, especially after an initial negative biopsy.

OBJECTIVE

To identify the optimal combination of sampling sites (number and location) to detect prostate cancer (PCa) in patients previously submitted to an initial negative prostatic biopsy.

DESIGN, SETTING, AND PARTICIPANTS

A transrectal ultrasound-guided systematic 24-core prostate biopsy (24PBx) was performed prospectively in 340 consecutive patients after a first negative biopsy (at least 12 cores).

MEASUREMENTS

We relied on a classification and regression tree analysis to identify three clinically different subgroups of patients at dissimilar risk of harboring PCa at second biopsy. Subsequently, we set the cancer-positive rate of the 24PBx at 100% and calculated PCa detection rates for 255 possible combinations of sampling sites. We selected the optimal biopsy scheme (defined as the combination of sampling sites that detected 95% of all the cancers with the minimal number of biopsy cores) for each patient subgroup.

RESULTS AND LIMITATIONS

After an initial negative biopsy, cancer was detected at rebiopsy in 95 men (27.9%). At a given number of cores, the cancer detection rates varied significantly according to the different combination of sites considered. Three different PCa risk groups were identified: (1) previous report of atypical small acinar proliferation of the prostate (ASAP), (2) no previous ASAP and ratio of free prostate-specific antigen (fPSA) to total PSA (%fPSA) ≤10%, and (3) no previous ASAP and %fPSA >10%. For patients with previous ASAP or patients with no previous ASAP and %fPSA ≤10%, two schemes with different combinations of 14 cores were most favorable. The optimal sampling in patients with no previous ASAP and %fPSA >10% was a scheme with a combination of 20 cores.

CONCLUSIONS

Both the number and the location of biopsy cores taken affect cancer detection rates in a repeated biopsy setting. We developed an internally validated flowchart to identify the most advantageous set of sampling sites according to patient characteristics.

The efficiency of a sedative or analgesic supplement to periprostatic nerve blockage for pain control during transrectal ultrasound-guided prostate biopsy - a prospective, randomized, controlled, double blind study

INTRODUCTION

The aim was to examine the effect of a sedative or analgesic supplement to periprostatic nerve blockage (PNB) on pain reduction during probe insertion and needle penetration in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy. We also investigated the effects of this procedure on the positive response rate in re-biopsy.

MATERIAL AND METHODS

One hundred TRUS-guided prostate biopsy patients due to prostate-specific antigen (PSA) levels higher than 2.5 ng/ml and/or abnormal rectal examination findings were evaluated. Group 1 (PNB) was given periprostatic lidocaine injection before the procedure. Group 2 (analgesic) was given tramadol and PNB. Group 3 (sedative) was given midazolam and PNB. Group 4 (control) was not given any anaesthesia or analgesics. Pain scores were assessed during probe insertion and needle penetration by a visual analogue scale.

RESULTS

During probe insertion, the mean pain score of the sedative group was lower than that of the control, analgesic and PNB groups (p < 0.001, p = 0.009, and p < 0.001, respectively). During needle penetration, the mean pain score of the control group was higher than that of the other groups (p < 0.001). The rate of positive response to re-biopsy was found to be 56% in the control group and between 92% and 100% in the other three groups (p < 0.001).

CONCLUSION

According to our results, it can be concluded that midazolam, given supplementary to PNB, contributes as an effective and safe alternative for pain control during both probe insertion and penetration of the biopsy needle into the prostate capsule; however, tramadol supplement does not provide any additional contributions.

Does needle calibre affect pain and complication rates in patients undergoing transperineal prostate biopsy? A prospective, randomized trial

Transperineal prostate biopsy is a procedure that can be used to obtain histological samples from the prostate. To improve both the quality of the biopsy core samples and prostate cancer detection, we are currently performing a prospective, randomized trial comparing prostate biopsy samples obtained using an 18 G-needle to those obtained using a 16 G needle. The aim of this preliminary study was to evaluate pain and complication rates in both groups in order to assess whether performing a prostate biopsy with a larger calibre needle is a feasible procedure. One hundred and eighty-seven patients undergoing transperineal prostate biopsy were prospectively evaluated and divided into two groups. The first group (94 patients, Group A) received a transperineal prostate biopsy using a 16 G-needle and the second group (93 patients, Group B) underwent transperineal prostate biopsy with an 18 G-needle. Anaesthesia was obtained with a single perineal injection at the prostatic apex in all subjects. A visual analogue scale (VAS) and facial expression scale (FES) were used to assess pain during multiple steps of the procedure in each group. A detailed questionnaire was used to obtain information about drug use because it could potentially influence the pain and complications that patients experienced. Two weeks after the procedure, early and late complications were evaluated. Statistical analysis was carried out using non-parametric tests. Prostate Specific Antigen (PSA) and drug use were similar at baseline between the two groups. Pain during prostate biopsy, which was measured with both the VAS and FES instruments, did not differ significantly between the 18- and 16 G-needle groups, and no significant differences were found in early or late complication rates between the groups. Transperineal prostate biopsy with a 16 G-needle is a feasible procedure in terms of pain and complication rates. Further studies with larger patient populations are required to assess whether or not this procedure can improve prostate cancer detection rates.

Biopsy schemes with the fewest cores for detecting 95% of the prostate cancers detected by a 24-core biopsy

BACKGROUND

The most efficient number and location of prostate biopsies remains a matter of debate.

OBJECTIVE

To identify the combination (number and location) of sampling sites that permits the detection of 95% of the prostate cancers (PCa) detected by a 24-core biopsy (24PBx).

DESIGN, SETTING, AND PARTICIPANTS

Six hundred and seventeen consecutive patients with a suspicion of PCa were prospectively enrolled.

INTERVENTION

A transrectal ultrasound-guided systematic 24PBx was prospectively performed with local anesthesia in an outpatient setting. The 24PBx was obtained by the overlapping of medial sextant, lateral sextant, octant subcapsular, and quadrant transition cores. Before fixation, each single core was individually marked and inked according to the prostatic location sampled.

MEASUREMENTS

We relied on a classification and regression tree analysis to identify four subgroups of patients with different PCa detection risk at initial biopsy, according to their clinical characteristics. Subsequently, we set the cancer-positive rate of the 24PBx at 100% and calculated PCa detection rates for 255 possible combinations of sampling sites. We selected the most advantageous biopsy scheme (defined as the combination of sampling sites that detected 95% of all the cancers with the minimal number of biopsy cores) for each patient subgroup. Finally, we internally validated the tumor detection rates by using the 10-fold cross-validation method.

RESULTS AND LIMITATIONS

The 24PBx detected PCa in 289 patients (46.8%). The analysis revealed that the most advantageous schemes for patients with a negative digital rectal exam (DRE), prostate volume (PV) < or =60 cm(3), and age < or =65 yr was a combination of a 16-core biopsy. For patients with a negative DRE, PV < or =60 cm(3), and age >65 yr or a negative DRE and PV >60 cm(3), the most advantageous scheme was two different combinations of a 14-core biopsy. Finally, the sampling that permits detection of 95% of cancers in patients with a positive DRE was a combination of a 10-core biopsy.

CONCLUSIONS

The most beneficial scheme varied according to the clinical characteristics of the patients. We propose a user-friendly flowchart to identify the most advantageous set of sampling sites according to patients' characteristics.

Intraprostatic local anesthesia with periprostatic nerve block for transrectal ultrasound guided prostate biopsy

PURPOSE

Prostate biopsy is an invasive procedure that may be painful and require some form of anesthesia. We compared the pain control results of periprostatic nerve block alone vs periprostatic nerve block with intraprostatic anesthesia as local anesthesia for prostate biopsy.

MATERIALS AND METHODS

A total of 300 patients who underwent transrectal ultrasound guided prostate biopsy were randomized into 3 groups. Group 1 of 100 patients received periprostatic nerve block and intraprostatic local anesthesia with 5 ml 2% lidocaine. Group 2 of 100 patients received periprostatic nerve block and the same amount of 0.9% NaCl by intraprostatic injection. Group 3 of 100 patients received no anesthesia. Patients were asked to use a scale of 0 to 10 to complete a visual analog scale questionnaire about pain during probe insertion, anesthesia and biopsy.

RESULTS

Pain control was similar during probe insertion and anesthesia in the 3 groups (p = 0.885 and 0.227, respectively). Pain during biopsy in group 1 was significantly less than in groups 2 and 3 (p <0.0001). In patients with a smaller prostate volume (48 ml or less) these differences were still significant between group 1 and 2 (p <0.0001), although not in patients with a larger prostate volume (greater than 48 ml) (p = 0.185). In patients 66 years old or younger these differences were also significant in groups 1 and 2 (p <0.0001) but not in older patients (p = 0.155).

CONCLUSIONS

Combining periprostatic nerve block and intraprostatic local anesthesia provided significantly better pain control than periprostatic nerve block alone. The combination may be of maximum benefit in patients with a smaller prostate volume or younger patients.