Pelvic plexus block to provide better anesthesia in transperineal template-guided prostate biopsy: a randomised controlled trial

A systematic review on the outcomes of local anaesthetic transperineal prostate biopsy

OBJECTIVE

To conduct a systematic review of the literature to assess the diagnostic ability, complication rate, patient tolerability, and cost of local anaesthetic (LA) transperineal prostate biopsy.

METHODS

Two reviewers searched Medline, the Cochrane Library, and Embase for publications on LA transperineal prostate biopsy up to March 2021. Outcomes of interest included cancer detection rates, complication rates, pain assessments and cost.

RESULTS

A total of 35 publications with 113 944 men were included in this review. The cancer detection rate for LA transperineal prostate biopsy in patients undergoing primary biopsy was 52% (95% confidence interval [CI] 0.45-0.60; I² = 97) and the clinically significant cancer detection rate (Gleason≥3 + 4) was 37% (95% CI 0.24-0.52; I² = 99%). The rate of infection-related complications in the included studies was 0.15% (95% CI 0.0000-0.0043; I² = 86). The LA transperineal procedures had a low rate of procedural abandonment (26/6954, 0.37%), with the greatest pain scores measured during LA administration. No formal cost analyses on LA transperineal prostate biopsies were identified in the literature. The overall risk of bias in the included studies was high, with considerable study heterogeneity and publication bias.

CONCLUSION

Transperineal prostate biopsy performed under LA is a viable option for centres interested in avoiding the risk of infection associated with transrectal biopsy, and the logistical burden of general anaesthesia. Further investigation into LA transperineal prostate biopsy with comparative studies is warranted for its consideration as the standard in prostate biopsy technique.

Should Transperineal Prostate Biopsy Be the Standard of Care?

PURPOSE OF REVIEW

We reviewed the advantages and disadvantages of transperineal prostate biopsy (TP-bx) to evaluate its potential role as the standard of care for prostate biopsy.

RECENT FINDINGS

Studies have suggested no difference in prostate cancer (PCa) detection rate between TP-bx and transrectal biopsy (TR-bx) but have suggested potentially increased detection of anterior prostate tumors. Advances in anesthetic technique have obviated the need for sedation thus allowing TP-bx to become an office-based procedure, which in turn can decrease the overall cost of TP-bx. Furthermore, given the low rate of infectious complications after TP-bx, some have foregone peri-procedural antibiotics without a change in the rate of infectious complications. Recent procedural advances have made TP-bx a tolerable, office-based procedure. Given the similar diagnostic performance and the benefits for the patient and community, TP-bx should become the standard of care for prostate biopsy for most patients. Future efforts should address the barriers for more universal adoption.

Application of 16 G Biopsy Needle in Transperineal Template-Guided Prostate Biopsy

BACKGROUND

The aim of this study was to evaluate the clinical value of 16 G biopsy needle in transperineal template-guided prostate biopsy (TTPB), compared with 18 G biopsy needle.

METHODS

The patients who underwent TTPB from August 2020 to February 2021 were randomized into 2 groups using a random number table. The control group (n = 65) and the observation group (n = 58) performed biopsy with 18 G (Bard MC l820) and 16 G (Bard MC l616) biopsy needles, respectively. Positive rate of biopsy, Gleason score, complications, and pain score were statistically analyzed.

RESULTS

The age, prostate volume, PSA, and the number of cores were comparable between the 2 groups. The positive rate of biopsy in the observation group was 68.9% (40/58), meanwhile the control group was 46.2% (30/65). There was statistical difference between the 2 groups (p = 0.011). Gleason score of the observation group (8 [7-9]) was higher than that of the control group (8 [6-9]) (p = 0.038). There was no significant difference in pain score and complications including hematuria, hematospermia, perineal hematoma, infection, and urinary retention between the 2 groups (p > 0.05).

CONCLUSIONS

16 G biopsy needle significantly improved the positive rates and accurately evaluate the nature of lesions, meanwhile did not increase the incidence of complications compared with 18 G biopsy needle.

Pelvic Plexus Block Versus Periprostatic Nerve Block for Ultrasound-Guided Prostate Biopsy: A Meta-Analysis

Background

To relieve prostate biopsy-related pain, various local anesthetic methods have been used. The best approach was periprostatic nerve block (PNB) in the past decade. Recently, pelvic plexus block (PPB) was employed to ultrasound-guided prostate biopsy. Compared with the PNB, the PPB may block a more extensive area. Therefore, PPB may be more effective in relieving prostate biopsy-related pain. However, several prospective randomized controlled trials (RCTs) comparing PPB and PNB drew conflicting conclusions, so we compared the difference of pain control between PPB and PNB for prostate biopsy.

Methods

The following databases were retrieved up to October 2020: PubMed, Chinese biomedicine literature database, the Cochrane Library, China National Knowledge Internet databases, Wan fang databases and Google Scholar. Only the RCTs were included. The main outcome measures were Visual Analog Scale (VAS) score and complications. The literature quality and extracted data were evaluated by two authors independently. The software Review Manager (version 5.3) was used to perform the data analysis that comparing the difference of VAS score and complications between PPB and PNB.

Results

After screening, six articles including 336 patients from PPB group and 337 patients from PNB group were performed meta-analysis in this study. The results showed that there were no significant difference of pain control in probe insertion and local anesthetic injection between PPB and PNB, while compared with PNB, patients with PPB experienced less pain during biopsy and 30 min after biopsy, respectively(MD = −0.57, 95% CI: −1.11 to −0.03, Z = 2.06, P = 0.04; MD = −0.21, 95% CI: −0.40 to −0.02, Z = 2.15, P = 0.03). In subgroup analysis, the pooled results showed that PPB was superior to PNB in 12-cores biopsy (pooled MD = −1.16, 95% CI: −1.61 to −0.71, P < 0.00001), and more than 40-ml prostate size, regardless of transrectal or transperineal prostate biopsy. The reported major complications were urinary retention, hematuria, infection and hemospermia. The pooled results showed that there were no obvious difference in complications between PPB group and PNB group.

Conclusions

Overall, this meta-analysis suggests that PPB provides safe and effective pain control of ultrasound-guided prostate biopsy, and PPB is superior to PNB. In future, it also needs more high quality, large samples RCTs to verify.

Optimizing prostate biopsy techniques

PURPOSE OF REVIEW

Prostate cancer (PCa) diagnostics have undergone a number of changes as a result of efforts to reduce the detection rate of indolent prostate cancer and to increase the hit rate for clinically significant prostate cancer (csPCa). Here, we look at those studies that have shifted our knowledge and the impact these have had on clinical practice.

RECENT FINDINGS

The introduction of multiparametric MRI (mpMRI) and approaches to active surveillance have changed the landscape in prostate cancer diagnostics, reducing the number of men that need biopsy, but increasing the need for accuracy in mapping the extent of prostate cancer. As mpMRI reporting has become more accurate at predicting PCa, biopsy techniques have also evolved towards lesion (PI-RADS score 3-5) targeted biopsies. Uncertainty remains regarding the preferred approach to targeted biopsy, the need for systematic biopsies, and the place of software ultrasound/MRI fusion or in-bore MRI biopsy techniques versus 'cognitive' fusion techniques.

SUMMARY

Prostate biopsies remain essential for the diagnosis of PCa. But how best to do this? Latest guidelines advocate performing both targeted and systematic biopsies. Traditionally, prostate biopsies have been performed transrectally (TRUS) with hospital readmission rates of around 3% mainly because of infection. Additionally, TRUS prostate biopsies can miss anterior prostatic lesions. The transperineal approach addresses both these issues, but has historically required general anaesthetic such that adoption for front-line diagnostics is very difficult. Recent techniques to undertake transperineal biopsy under local anaesthetic have fundamentally changed this paradigm offering the genuine possibility that in 5 years' time, all front-line diagnostic biopsies will be performed as LATP.