A randomised trial of periprostatic local anaesthetic for transrectal biopsy

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.

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.

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.

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.

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

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

Sedation as an alternative method to lessen patient discomfort due to transrectal ultrasonography-guided prostate biopsy

BACKGROUND

Despite being highly efficient for the relief of patient discomfort due to transrectal ultrasound (TRUS) guided prostate biopsy, periprostatic anesthesia is occasionally reported to be of limited use. We aimed to evaluate the efficacy of conscious sedation, an accepted method for lessening patient discomfort due to interventional radiological procedures and compare it with periprostatic anesthesia.

METHODS

93 candidates for biopsy were randomised to three groups: group 1 (n = 31) received intravenous midazolam, group 2 (n = 31) received periprostatic lidocaine injection, whereas group 3 (n = 31) received no anesthetic before the procedure. After the biopsy patients were asked to express discomfort by visual anologue scale (VAS).

RESULTS

The mean scores for groups 1 and 2 were significantly lower than that of group 3 (1.4 +/- 1.1 and 2.0 +/- 1.5 versus 4.7 +/- 1.6, respectively; p < 0.05 for both). For patients with VAS scores exceeding 4 (moderate to severe discomfort), a significant difference was calculated between groups 1 and 2 (3% versus 29%, p < 0.05) and between each and group 3 (3% and 29% versus 80%, respectively; p < 0.05 for each).

CONCLUSIONS

Sedation is an alternative for increasing patient comfort during TRUS-guided prostate biopsy, especially in clinical situations like patient anxiety, young age, repeat biopsies or inflammatory anal diseases.

A DOUBLE-BLIND, RANDOMIZED, CONTROLLED TRIAL OF TOPICAL GLYCERYL TRINITRATE FOR TRANSRECTAL ULTRASOUND GUIDED PROSTATE BIOPSY

PURPOSE

We evaluated the efficacy and tolerance of topical 0.2% glyceryl trinitrate (GTN) paste vs placebo to decrease pain associated with transrectal ultrasound guided prostate biopsy.

MATERIALS AND METHODS

Between October 2003 and April 2004, 134 consecutive patients referred for a first prostate biopsy were randomized to receive topical 0.2% GTN paste or placebo 30 minutes prior to biopsy. Participants completed a 10 point visual analog pain score following the procedure.

RESULTS

Mean patient age was 68.5 years in the GTN group and 68.8 in the placebo group. There was a significant decrease in mean pain score in the GTN group compared with placebo (3.7 vs 4.8, p <0.05). Six patients (10%) in the GTN group complained of headache.

CONCLUSIONS

Topical GTN paste is an effective and well tolerated method of decreasing pain associated with transrectal ultrasound guided prostate biopsy. It is safe and easy to use, and it should be offered to patients undergoing this procedure.

Intravenous Ketorolac Significantly Reduces the Pain of Office Transrectal Ultrasound and Prostate Biopsies

INTRODUCTION

Campbell's' Urology, 8th edition, indicates that office transrectal ultrasound (TRUS) and prostate biopsies require no anesthesia. This is however in contradistinction from the experience of patients who have had the procedure. A study was conducted to evaluate whether 60 mg of intravenous Ketorolac before the procedure makes it more tolerable.

MATERIAL AND METHODS

A prospective study was performed involving 24 patients who were randomized into two groups. One group was given 60 mg of Ketorolac intravenously before the procedure and the control group received no analgesia.

RESULTS

The two groups were comparable in age and the indications for the TRUS and prostate biopsies. The number of biopsy cores tolerated and taken was significantly less in the control group than in the group that was given intravenous Ketorolac. The degree of pain in the group that had intravenous Ketorolac was significantly less than in the no analgesia group.

CONCLUSION

TRUS with prostate biopsies is a painful procedure. Intravenous Ketorolac significantly reduces the pain involved in the procedure and allows patients to tolerate it better for a more complete procedure.