Prostate biopsy and anaesthesia: An overview

Effective Concentration of Lidocaine Plus Fentanyl for Caudal Block in Patients Undergoing Transrectal Ultrasound Guided Prostate Biopsy

Objective. This study determined the effective concentration (EC) of lidocaine plus 75 μg fentanyl for caudal block in patients undergoing transrectal ultrasound (TRUS) guided prostate biopsy. Methods. Consecutive male patients scheduled for TRUS guided prostate biopsy were enrolled. The mixed solution for caudal block contained lidocaine and 75 μg fentanyl, in total 20 mL. The concentration of lidocaine was determined using the up-and-down method, starting at 0.8% (a step size of 0.1%). A successful caudal block was defined by no pain perception during biopsy. The EC50 of lidocaine for successful caudal block was calculated and side effects were evaluated. Results. A total of 23 patients were recruited. The EC50 of lidocaine for successful caudal block was 0.53%. Conclusions. Lidocaine of 0.53% combined with 75 μg fentanyl resulted in excellent caudal block in 50% of male patients undergoing transrectal ultrasound guided prostate biopsy.

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.

Comparison between Ultrasound Guided Transperineal and Transrectal Prostate Biopsy: A Prospective, Randomized, and Controlled Trial

This prospective study of comparing transperineal prostate biopsy (TPBx) with transrectal prostate biopsy (TRBx) was aimed to provide evidence for clinicians to select the appropriate biopsy approach under different conditions. TPBx (n = 173) and TRBx (n = 166) were performed randomly for 339 patients who were suspicious of prostate cancer (PCa). The cancer detection rate (CDR), complication rate, visual analogue scale (VAS) score, most painful procedure, number of repeated biopsy and additional anesthesia, and operating time (starting from lying down on the operating table to getting up) were recorded. The results showed that TPBx and TRBx were equivalent in CDR (35.3% vs. 31.9%) and minor complication rate (44.9% vs. 41.0%) (both P > 0.05). The major complication rate was lower in TPBx than in TRBx (0.6% vs. 4.3%, P < 0.05). TPBx was more time-consuming (17.51 ± 3.33 min vs. 14.73 ± 3.25 min) and painful (VAS score: 4.0 vs. 2.0); and it had higher rates of repeated biopsy (3.2% vs. 1.1%) and additional anesthesia (15.0% vs. 1.2%) (all P < 0.05). In summary, both TPBx and TRBx are effective to detect PCa. The major complication rate for TRBx is higher, whereas TPBx procedure is more complex and painful.

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.

The 'green whistle': a novel method of analgesia for transrectal prostate biopsy

PATIENTS AND METHODS

• Patients undergoing TRUS-guided biopsies were each given a Penthrox inhaler to self-administer during the procedure and instructed in its use. • Immediately after the procedure, patients were asked to rate their pain using a verbal rating scale from 0 to 10.

RESULTS

• In all, 42 consecutive men underwent a TRUS-guided biopsy. • The median pain score was 3. • All 42 patients stated they would be happy to undergo the same procedure again. The only adverse effects reported by patients were brief light-headedness and a sickly sweet taste.

CONCLUSION

• This study of our initial experience using Penthrox suggests that it may have a role in analgesia for TRUS-guided biopsy. • It may provide safe, adequate analgesia that is easy for urologists to use and avoids excessive use of resources. • Planning for a randomised control trial comparing Penthrox to the current 'gold standard' of prostatic infiltration of local anaesthetic is presently underway.

Caudal analgesia for prostate biopsy

BACKGROUND

Although various local anesthesia techniques have been suggested to decrease pain and discomfort during a transrectal ultrasound (TRUS)-guided prostate biopsy, the best method has not yet been defined. The present prospective, double-blind, randomized study aims to investigate the clinical efficacy of 'walking' caudal block compared with an intrarectal lidocaine gel for this procedure.

METHODS

One hundred patients were randomly assigned to two groups. In the lidocaine gel group, 10 ml of gel containing 2% lidocaine was given intrarectally. In the caudal group, 20 ml 0.1% bupivacaine with 75 microg fentanyl was injected. Pain scores, anal sphincter tone and patient satisfaction were evaluated.

RESULTS

The pain scores were significantly lower in the caudal group at all stages. Verbal rating scores (scale 1-4) during probe insertion, probe maneuver and biopsies were 1 (0-2), 1 (0-2) and 1 (0-2) vs. 3 (0-5), 2 (1-3) and 4 (2-6), respectively (P value <0.0001 at all stages). The anal sphincter was more relaxed in the caudal group than in the gel group (P value <0.0001 in all categories). Highly satisfied patients were more frequently encountered in the caudal group, 34 (68%) vs. 8 (16%), P<0.0001, and unsatisfied patients were more frequently found in the gel group 1 (2%) vs. 12 (24%); P<0.001. All patients were able to walk without any assistance immediately after the procedures.

CONCLUSION

'Walking' caudal analgesia is an efficacious method for relieving the pain during TRUS-guided prostate biopsies in ambulatory practice.

Combination of Paracetamol, Codeine and Lidocaine for Pain Relief during Transrectal Ultrasound Guided Biopsy of the Prostate

Background and Aim:

Transrectal ultrasound (TRUS)-guided prostate biopsy is often a painful procedure. The aim of this study was to evaluate the effectiveness of combining oral paracetamol and codeine with periprostatic nerve block in relieving prostate biopsy-related pain.

Material and Methods:

In this prospective study we compared the pain associated with prostate biopsy between two groups of patients. Group 1 consists of 25 men who were given paracetamol 500 mg and codeine 30 mg orally before the biopsy, and group 2 consists of 25 men who received no oral analgesics. All patients received periprostatic nerve block with 1% lidocaine before the biopsy. The pain associated with the biopsy procedure was evaluated on a visual analogue scale.

Results and Conclusions:

The mean pain score ± SD in group 1 was 1.4 ± 0.80 on the scale of 0 to 10, and the mean pain score ± SD in group 2 was 2.4 ± 1.69. The difference in the pain scores between the two groups was statistically significant (p = 0.01). The combination of oral paracetamol, codeine and periprostatic nerve block before TRUS-guided prostate biopsy is an effective method for relieving biopsy-related pain.

Comparison of four different anesthesia methods for relief of all pain during transrectal ultrasound-guided prostate biopsy

INTRODUCTION

To find the most beneficial method, we assessed patient comfort and morbidity rates during prostate biopsy procedures performed using periprostatic nerve blockade, unilateral pudendal nerve blockade, intrarectal lidocaine gel, and a combination of periprostatic nerve blockade and intrarectal lidocaine gel.

MATERIALS AND METHODS

A total of 159 patients were included in this study. Pain evaluation results were retrospectively assessed and retrieved from the patient charts. Patients in group 1 (n = 64) received no anesthesia, group 2 (n = 34) received periprostatic nerve blockade, group 3 (n = 26) received unilateral pudendal nerve blockade, group 4 (n = 20) received intrarectal lidocaine gel, and group 5 (n = 15) received a combination of periprostatic nerve blockade and intrarectal lidocaine gel. A visual analog scale (VAS) was used for pain evaluations.

RESULTS

According to pain scores (VAS) during probe insertion, only group 2 did not show a statistically significant difference (P > 0.05), while the other groups were found to be significantly different when compared to group 1. Groups 2, 3, and 5 were found to be significantly different when compared to group 1 according to pain scores (VAS) during insertion of needles. Groups 3 and 5 displayed statistically significant differences when compared to group 1 as regards pain scores during both the insertion of the probe and biopsy.

CONCLUSIONS

Our data suggests that using either a combination of intrarectal lidocaine gel and periprostatic block or solely unilateral pudendal nerve block for prostate biopsy procedures provides efficient patient comfort by reducing pain both during probe insertion and needle passing through the prostate gland.

Prostate cancer

In developed countries, prostate cancer is the second most frequently diagnosed cancer, and the third most common cause of death from cancer in men. Apart from age and ethnic origin, a positive family history is probably the strongest known risk factor. Clinically, prostate cancer is diagnosed as local or advanced, and treatments range from surveillance to radical local treatment or androgen-deprivation treatment. Androgen deprivation reduces symptoms in about 70-80% of patients with advanced prostate cancer, but most tumours relapse within 2 years to an incurable androgen-independent state. The recorded incidence of prostate cancer has substantially increased in the past two decades, probably because of the introduction of screening with prostate-specific antigen, the use of improved biopsy techniques for diagnosis, and increased public awareness. Trends in mortality from the disease are less clearcut. Mortality changes are not of the same magnitude as the changes in incidence, and in some countries mortality has been stable or even decreased. The disparity between reported incidence and mortality rates leads to the probable conclusion that only a small proportion of diagnosed low-risk prostate cancers will progress to life-threatening disease during the lifetime of the patient.

Combined periprostatic and intraprostatic local anesthesia for prostate biopsy: a double-blind, placebo controlled, randomized trial

PURPOSE

Transrectal ultrasonography guided prostate biopsy is the principle procedure in the histological diagnosis of prostate cancer. Recently a trend toward increasing the number of cores has been popularized. This practice further increases the need for a proper anesthetic application. However, there is no consensus on a standard local anesthetic strategy, while groups at most institutions currently prefer periprostatic anesthesia. We prospectively evaluated the contribution of intraprostatic anesthesia for transrectal prostate biopsies even when the sampling number was doubled to 12 cores.

MATERIALS AND METHODS

A total of 200 patients who underwent prostate biopsy with transrectal ultrasound guidance were included. The 2 groups received the usual periprostatic anesthesia. Consequently patients were prospectively randomized into 2 groups. Group 1 received additional intraprostatic lidocaine injection, while group 2 received the same amount of injection of 0.9% NaCl. The efficiency of applied local anesthesia was assessed by a visual analog pain scale.

RESULTS

The study groups were comparable regarding patient age, prostate size and cancer rate. Pain scores revealed that the combination of intraprostatic and periprostatic local anesthesia provided significantly better pain control than periprostatic infiltration alone. No difference was observed regarding the morbidity rate in the 2 groups.

CONCLUSIONS

The current study suggested that adding intraprostatic local anesthesia provides a significantly efficient strategy during transrectal ultrasound prostate biopsy, even in cases of 12-core sampling. Subsequent trials are needed to establish a standard analgesia policy for prostate biopsy.

Complications and limitations related to periprostatic local anesthesia before TRUS-guided prostate biopsy

PURPOSE

To assess the frequency of complications specifically related to local anesthetic infiltration prior to transrectal ultrasound (TRUS)-guided prostate biopsy.

METHODS

A total of 200 patients receiving 10 cm(3) (5 cm(3) on each side) of 2% lidocaine injected around the periprostatic nerve plexus under TRUS guidance before prostate biopsy were included. Various complications presumed to be associated with local anesthesia were noted during and after the biopsy procedure. Two weeks later, periprostatic tissue integrity and vascularization were re-examined with TRUS Doppler examination to assess for fibrosis or infection.

RESULTS

The most common finding was pain due to puncture with the needle used for local anesthesia (27%). Also recorded were the need for repeated injections during the biopsy procedure (4.5%), symptoms associated with systemic lidocaine toxicity (2%), urinary incontinence (1.5%), and degradation of the image resolution due to anesthetic injection (1%). Increased vascularization within the periprostatic region was uncommon (2%) on the 2-week follow-up examination. No TRUS finding consistent with rectal wall hematoma or other periprostatic change and no erectile dysfunction associated with the procedure occurred. There was a significant difference in overall pain scores between the subgroups of patients (p < 0.001).

CONCLUSION

TRUS-guided periprostatic nerve blockade is an effective method for relieving discomfort from prostate biopsy with very few complications.

Does experimental pain assessment before biopsy predict for pain during transrectal ultrasound-guided prostate biopsy?

OBJECTIVES

To evaluate whether assessment of experimental pain perception using the modified tourniquet test before a biopsy procedure could predict the pain scores during transrectal ultrasound-guided prostate biopsy. However, the relationship between the experimental pain assessment before prostate biopsy and the pain scores during the biopsy procedure has not been established.

METHODS

A total of 67 men who underwent transrectal ultrasound-guided 12-core prostate biopsy were prospectively enrolled in the study. The day before biopsy, a modified submaximal effort tourniquet test was performed on all patients. During the test, pain scores were recorded at 30, 60, 90, and 120 seconds after inflation of the blood pressure cuff. Pain scores were also recorded during probe introduction into the rectum and prostate biopsy. Pain was assessed using a visual analogue scale (VAS).

RESULTS

A significant correlation was found between the VAS scores in the tourniquet test and the VAS scores during probe introduction and the VAS scores during prostate biopsy (P <0.0001). The most significant correlation was found between the VAS scores during prostate biopsy and the VAS 60-second scores during the tourniquet test (P <0.0001, r=0.756). No significant relation was found between the VAS scores and age, prostate volume, or prostate-specific antigen level (P >0.05).

CONCLUSIONS

Our results have shown that a simple and quick tourniquet test could be useful in identifying those men who will experience greater pain during transrectal ultrasound-guided prostate biopsy. In the light of these data, additional studies will be planned to evaluate whether experimental pain assessment before the procedure could predict the analgesic potency of pain-relieving treatment during prostate biopsy.

Tramadol improves patients' tolerance of transrectal ultrasound-guided prostate biopsy

OBJECTIVES

To evaluate the analgesic advantage of tramadol in patients undergoing transrectal biopsy of the prostate in ambulatory settings compared with topical analgesia.

METHODS

A total of 77 patients scheduled for prostate biopsy were randomly assigned to receive 5% lidocaine ointment 5 mL per rectum 10 minutes before the procedure (group 1) or lidocaine ointment combined with tramadol drops 1 mg/kg per os 40 minutes before the procedure (group 2). Pain severity, main cardiorespiratory parameters, difficulty of the procedure, procedure-related side effects, and complications were analyzed.

RESULTS

No significant respiratory or hemodynamic disturbances were observed. The pain severity, as measured on a visual analog scale, was significantly lower in group 2 (P = 0.038), and the rate of overall satisfaction with the level of analgesia was significantly greater (P = 0.027). The urologist's assessment of "very easy" was assigned to 77.1% of procedures in group 2 compared with 54.8% of procedures in group 1 (P = 0.04). The rate of side effects in both groups was similar at 9.5% versus 11.4% (P = 0.785).

CONCLUSIONS

The combination of lidocaine per rectum with tramadol per os is a simple and safe technique providing good analgesic effect and, therefore, can be recommended for transrectal ultrasound-guided prostate biopsy.

Comparison of traditional basal and apical periprostatic block: impact on injection pain and biopsy pain

OBJECTIVE

To compare the pain of injection and biopsy when lidocaine is injected periprostatically either at a basal or apical site, as the former is commonly used to anaesthetise the prostate, based on several reports showing that it can eliminate most of the pain associated with prostate biopsy, and this site has been favoured over apical injection because the nerves enter the prostate from the basal aspect.

PATIENTS AND METHODS

In all, 143 patients scheduled for biopsy were randomized to receive a periprostatic block either at the apex or base of the prostate. Immediately before biopsy 5 mL of 1% lidocaine was injected under transrectal ultrasonographic (TRUS) guidance into the periprostatic nerves bilaterally. Patients were immediately given a 100 mm visual analogue scale (VAS, 0-100) to assess the pain associated with both the block and the subsequent biopsy.

RESULTS

The mean VAS scores for the anaesthetic block were 21.1 and 22.0 (P = 0.79) and the biopsy VAS scores were 17.6 and 28.7 (P < 0.001) for the apical and basal groups, respectively. There was no statistically significant difference between patients who had a 12- or 20-core biopsy.

CONCLUSIONS

Apical periprostatic injection with anaesthetic provides better anaesthesia for TRUS biopsy than basal injection, and without increasing the pain associated with injection at the potentially more sensitive apical site.