Does pericapsular lignocaine reduce pain during transrectal ultrasonography-guided biopsy of the prostate?

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 Effect of Lidocaine versus a Lidocaine-Bupivacaine Combination in a Periprostatic Nerve Block Undergoing Transrectal Ultrasound-Guided Prostate Biopsy: A Double-Blind Randomized Controlled Trial

INTRODUCTION

To determine whether a combination of the long acting local anesthetic, bupivacaine, and lidocaine is better than lidocaine alone in the long-term pain control, which is a short-acting anesthetic.

MATERIALS AND METHODS

In group 1, periprostatic nerve block was applied to both neurovascular areas with 2% lidocaine (5 ml) in an isotonic solution (5 ml). In group 2, the combination of 2% lidocaine (5 ml) and 5mg/ml bupivacaine (5 ml) was used for the PPNB.

RESULTS

In the first 30 minutes the mean VAS scores of groups 1 and 2 were 2.1 ± 0.2 and 1.2 ± 0.1, respectively (p = 0.002). VAS scores of group II determined at 1, 2, 4, 6, and 8 hours after the biopsy were significantly lower since it was (p < 0.05).

CONCLUSION

While periprostatic nerve block for late phase pain control, applying a combination of a long-acting local anesthetic, such as bupivacaine, is effective in terms of pain control and patient comfort.

Complications of prostate biopsy

Biopsy of the prostate is a common procedure with minor complications that are usually self-limited. However, if one considers that millions of men undergo biopsy worldwide, one realizes that although complication rate is low, the number of patients suffering from biopsy complications should not be underestimated and can be a clinically relevant problem for healthcare professionals. In this review, the authors present diagnosis and management of postbiopsy of prostate complications. Bleeding is the most common complication observed after prostate biopsy, but the use of aspirin or nonsteroidal anti-inflammatory drugs is not an absolute contraindication to prostate biopsy. Emerging resistance to ciprofloxacin is the most probable cause of the increasing risk of infectious complications after prostate biopsy. Even though extremely rare, fatal complications are possible and were described in case reports.

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.

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.

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.

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.

Modified perianal/pericapsular anesthesia for transrectal biopsy of prostate in patients with anal rectal problems

OBJECTIVES

To modify our technique of perianal anesthesia and use it in patients with painful conditions of the rectum and/or anus.

METHODS

A total of 31 consecutive patients with anal-rectal problems underwent prostate needle biopsy. Of these, 17 were referred to our hospital after vain attempts to insert a transrectal ultrasound probe. Patients received a perianal-pericapsular injection of 1% lidocaine. Pain perception was separately assessed for probe insertion and biopsies using a visual pain analog score.

RESULTS

Only in 1 patient were we unable to insert the transrectal ultrasound probe. The mean patient age was 65.28 +/- 5.35 years. We performed a mean of 12.25 biopsies per case. At probe insertion, the mean pain score was 2.2 +/- 0.83. During the biopsy punctures, the mean pain level was 2.53 +/- 1.054. We did not find any increase in the complication rate related to the anesthesia method.

CONCLUSIONS

Modified perianal anesthesia can be used for transrectal ultrasound-guided biopsy of the prostate in patients with anal-rectal problems, because it provides significant pain relief.

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.

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.

The rectal administration of lignocaine gel and periprostatic lignocaine infiltration during transrectal ultrasound-guided prostate biopsy provides effective analgesia

INTRODUCTION

Transrectal ultrasound guided prostate needle biopsy (TRUS) is the standard procedure to diagnose or exclude prostate cancer. This procedure can be associated with significant discomfort, both on insertion of the ultrasound probe as well as on taking the biopsy. We evaluated a new technique for pain relief during TRUS biopsy.

PATIENTS AND METHODS

In Group 1 (n = 60), the biopsies were taken without any analgesia. In Group 2 (n = 60), 11 ml of Instillagel (2% lignocaine) was administered rectally prior to probe insertion and 5 ml of 1% lignocaine periprostatic injection was administered before taking the biopsy. The discomfort encountered during the procedure was graded by the patient on a scale ranging from no discomfort to mild, moderate and severe pain.

RESULTS

In Group 2, there was a marked reduction in the pain experienced during the procedure. The Chi-squared test for trend showed a significant association between the rectal administration of local anaesthetic gel and reduction in pain on probe insertion (P = 0.0001). There was also a significant association between the use of periprostatic lignocaine injection and reduction in pain on taking the biopsy (P < 0.0001).

CONCLUSIONS

The use of lignocaine gel prior to probe insertion and periprostatic infiltration of lignocaine before taking the needle biopsy significantly reduces the pain experienced by the patient during TRUS-guided prostate biopsy.

Current status of transrectal ultrasound-guided prostate biopsy in the diagnosis of prostate cancer

In contemporary practice, most prostate cancers are either invisible on ultrasound or indistinguishable from concurrent benign prostatic hyperplasia. Diagnosis therefore rests on prostate biopsy. Biopsies are not simply directed at ultrasonically visible lesions, as these would miss many cancers; rather the whole gland is sampled. The sampling itself is systematic, using patterns based on prostate zonal anatomy and the geographical distribution and frequency of cancer. This review explains the evolution of the prostate biopsy technique, from the classical sextant biopsy method to the more recent extended biopsy protocols (8, 10, 12, >12 and saturation biopsy protocols). Extended protocols are increasingly being used to improve diagnostic accuracy, especially in those patients who require repeat biopsy. This trend has been facilitated by the ongoing improvement in safety and acceptability of the procedure, particularly with the use of antibiotic prophylaxis and local anaesthesia. The technical details of these extended protocols are discussed, as are the current data regarding procedure-related morbidity and how this may be minimized.

Site of local anaesthesia in transrectal ultrasonography-guided 12-core prostate biopsy: does it make a difference?

OBJECTIVE

To prospectively compare the efficacy of bi-basal vs bi-apical periprostatic nerve block (PPNB) during 12-core prostate biopsy guided by transrectal ultrasonography (TRUS), and to evaluate the pain experienced on inserting the probe compared to the biopsy procedure, as PPNB with lignocaine local anaesthesia has been used for over a decade for minimizing pain during prostatic biopsy.

PATIENTS AND METHODS

In all, 143 men who were to have a TRUS-guided prostate biopsy were systematically randomized to two groups, to receive PPNB at the apex or base. A 10-cm visual analogue score was used to record the pain experienced during probe insertion, the biopsy and just before to leaving the department .

RESULTS

The mean pain score on biopsy in the apical group was similar to that of the basal group (apex 1.9, base 1.6, P = 0.36). Probe introduction produced a significantly higher pain score (probe 2.2, biopsy 1.7, P < 0.001) than at the biopsy.

CONCLUSIONS

Patients who experienced greater pain with the introduction of the probe also reported more pain with the biopsy procedure. The site of local anaesthetic before prostatic biopsy showed no significant difference in pain scores. Older men tolerated the procedure better. Analgesia after PPNB at near either the apex or base appears equal, regardless of the site of injection. We suggest that topical perianal anaesthetic agents could significantly reduce not only pain perception, but also improve tolerance.

Perianal and intrarectal anaesthesia for transrectal biopsy of the prostate: a prospective randomized study comparing lidocaine-prilocaine cream and placebo

OBJECTIVES

To assess the effectiveness of perianal and intrarectal lidocaine-prilocaine cream for prostate biopsy.

PATIENTS AND METHODS

In a prospective, randomized, double-blind, placebo-controlled study, 200 consecutive patients were randomized to receive 5 mL lidocaine-prilocaine cream or 5 mL placebo peri-anally and transrectally before transrectal ultrasonography (TRUS)-guided prostate needle biopsy (mean number of cores, 12). The men were asked to grade the pain when the TRUS probe was inserted and during the biopsy procedure using a 10-point linear visual analogue pain scale.

RESULTS

At probe insertion, men in the anaesthetic group reported a significantly lower mean pain level than men in the placebo group (0.3 vs 1.6, P < 0.001). Men who had anaesthetic also reported less pain during biopsy punctures (1.8 vs 3.2, P < 0.001). Stratifying results by age, younger men (< 67 years) benefited more from anaesthesia during probe insertion (0.9 vs 1.7; P = 0.04) and biopsy (1.8 vs 4.0, P < 0.001) than older men (1.0 vs 1.1, P = 0.7 and 1.9 vs 2.4, P = 0.3, respectively). There were only minor complications, and these were not significantly different between the groups.

CONCLUSION

Topical anaesthesia with prilocaine-lidocaine cream significantly reduced pain at transrectal probe insertion and during the biopsy procedure.

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.

Comparison of different local anesthesia techniques during TRUS-guided biopsies: a prospective pilot study

OBJECTIVES

To introduce two forms of anesthesia and compare them with standard local anesthesia techniques.

METHODS

A total of 114 consecutive patients underwent prostate needle biopsy. The patients were sequentially randomized to receive different kinds of anesthesia: 2% rectal lidocaine gel, 40% dimethyl sulfoxide (DMSO) with lidocaine, perianal injection of 1% lidocaine, or periprostatic nerve block. Pain perception was separately assessed for probe insertion and biopsies using a visual pain analog score. One-way analysis of variance was used to compare the data scale among the four groups. A linear regression model was used to define the independent variables that predicted the level of pain.

RESULTS

The groups were similar in terms of age, prostate-specific antigen levels, digital rectal examination findings, prostate volume, pain tolerance, biopsy time, and number of cores taken. The lowest pain scores for probe insertion were for the perianal injection and DMSO/lidocaine groups (0.89 and 1.38, respectively). The difference between these scores and those for the other two groups was statistically significant (P <0.001). Pain perception during biopsy did not differ significantly among the DMSO/lidocaine, perianal, or periprostatic groups and was greatest in the lidocaine gel group (4.147; P <0.001). We did not observe any statistically significant correlation between the pain level during probe insertion and biopsy and pain tolerance (P = 0.514 and P = 0.788, respectively). The anesthesia type was the strongest single predictor of the pain level during biopsy (P <0.001).

CONCLUSIONS

The use of 40% DMSO with lidocaine instilled into the rectal vault for 10 minutes avoids any need for injection and is capable of decreasing the discomfort or pain experienced during probe insertion and prostate biopsy comparable to the perianal and periprostatic protocols.

COMPARISON OF 3 DIFFERENT METHODS OF ANESTHESIA BEFORE TRANSRECTAL PROSTATE BIOPSY: A PROSPECTIVE RANDOMIZED TRIAL

PURPOSE

Periprostatic nerve block (PNB) is the most common anesthesia technique used before prostate biopsy. However, needle punctures for anesthetic infiltration may be painful and cause higher infectious complications. We assessed whether addition of rectal lidocaine gel would improve its efficacy. We also investigated the efficacy and safety of tramadol, a codeine derivative, as a noninvasive method.

MATERIALS AND METHODS

A total of 300 patients who underwent prostate biopsies were randomized into 4 groups of controls, PNB, perianal/intrarectal lidocaine gel plus PNB and tramadol. Pain was assessed with a numeric analog scale.

RESULTS

Each group consisted of 75 patients, and there was a statistically significant difference among pain scores (p = 0.001). Mean pain scores were 4.63 for controls, 2.57 for PNB, 2.03 for infiltration plus gel group and 3.11 for tramadol. Pain and discomfort were least in PNB plus gel arm. The difference of pain score between PNB alone and tramadol group did not reach statistical significance. Infectious complications were higher in the combination group, whereas there were no complications with tramadol.

CONCLUSIONS

Any form of analgesia/anesthesia was superior to none. The combination of PNB plus gel provided significantly better analgesia compared to PNB alone or tramadol. If this can be duplicated in other trials, the combination may be accepted as the new gold standard of anesthesia for prostate biopsy. The efficacy of tramadol was similar to that of PNB, and was free of complications. Therefore, tramadol may have a role before prostate biopsy, which needs to be explored.

Outcome analysis and patient satisfaction following octant transrectal ultrasound-guided prostate biopsy: a prospective study comparing consultant urologist, specialist registrar and nurse practitioner in urology

PURPOSE

To determine whether transrectal ultrasound-guided biopsy of the prostate is equally reliable and acceptable if performed by urology nurse practitioner or urologist.

SCOPE

Octant biopsies were taken by each operator (consultant urologist n=2, urology specialist registrar n=1 and urology nurse practitioner n=2) from 50 consecutive unselected patients and demographics and cancer detection rate were compared between the groups. A postal survey was performed following nurse practitioner biopsy to assess patient satisfaction and acceptance of nurse practitioner biopsy.

CONCLUSION

Transrectal ultrasound-biopsy of prostate whether performed by nurse practitioner or urologist is equally reliable if adequate training is provided. Patients are happy to undergo prostate biopsy and receive information about the diagnosis from an appropriately trained prostate cancer nurse specialist.

Is the periprostatic anesthetic blockade advantageous in ultrasound-guided prostate biopsy?

OBJECTIVE

To assess the benefit of the periprostatic administration of lidocaine previously to ultrasound-guided prostate biopsy.

MATERIALS AND METHODS

In the period from April to October 2002, forty patients underwent ultrasound-guided prostate biopsy due to increased PSA or abnormal digital rectal examination. A randomized double-blind study was performed, where the patients received an injection of lidocaine 2% or saline solution, in a total of 10 ml periprostatic. Immediately following the biopsy, the pain associated to the procedure was assessed, using a visual analogical scale from 0 to 10. The mean number of fragments collected per patient in the biopsies was 11.3. The statistical analysis used for assessment of pain was the Student's t, with p < 0.05 being significant.

RESULTS

The groups were homogeneous concerning the anthropometrical data. In relation to pain, those patients in the groups that underwent biopsy with the use of lidocaine presented a maximum score of 6, while in the group that underwent biopsy with the use of saline solution, 4 patients presented score 7 ou 8. The mean score and standard deviation with lidocaine were 2.55 +/- 2.34 (CI 95% = 1.53 to 3.57) and with saline solution were 3.75 +/- 2.52 (CI 95% = 2.66 +/- 4.84) with no statistical significant difference between the groups.

CONCLUSION

The lidocaine injection did not show statistical difference when compared with saline solution in the periprostatic blockade during echo-guided prostate biopsy.

Randomized Trial of Lidocaine Vs Lidocaine/Bupivacaine Periprostatic Injection on Longitudinal Pain Scores After Prostate Biopsy

PURPOSE

Periprostatic lidocaine reduces immediate post-prostate biopsy pain but still many men will not consent to re-biopsy. We performed a randomized study to assess whether adding long acting local anesthesia to a short acting agent would further reduce pain.

MATERIALS AND METHODS

A total of 300 men undergoing transrectal ultrasound guided prostate biopsy were sequentially randomized to receive either short acting local lidocaine (lid) or short and long acting lidocaine and bupivacaine (lid/bup). A 7-day questionnaire was used to study daily pain (10-point visual analog score), bleeding (hematuria, PR bleeding, hematospermia), visits to the family doctor and analgesic use, and whether they would agree to future re-biopsy.

RESULTS

Of the 256 questionnaires returned 250 were suitable for analysis. Cross-sectional comparison showed no intergroup differences in mean pain scores immediately after biopsy (2.24, 95% CI 1.94-2.5 vs 2.61, 95% CI 2.3-2.9, p = 0.88 in lid and lid/bup groups, respectively). There was a significant rebound in visual analog scale at 1 hour in the lid group but not in the lid/bup group (+ 0.9 vs + 0.09, p = 0.0006). Longitudinal analysis showed the global pain experience after lid/bup was better compared to lidocaine alone, with significantly less pain every subsequent day (p = 0.0006 to 0.002). No difference was seen in morbidity, analgesia usage or number refusing future re-biopsy (9.6% vs 9.8%).

CONCLUSIONS

Long and short acting local anesthetics together significantly attenuate the 1-hour rebound increase in pain scores seen after short acting anesthesia alone. Improved pain scores were sustained during the subsequent week and we advocate routine combination use for transrectal ultrasound guided prostate biopsy.

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

Prostate biopsy is usually performed without anesthesia. We evaluated the patient's perception of pain/discomfort experienced during the procedure in terms of the type of anesthesia used: periprostatic infiltration with 2% lidocaine, or intrarectal instillation of lidocaine-prilocain cream. A total of 198 patients were divided into three groups: group 1 (control group, n=40) received sonographic gel intrarectally prior to biopsy, group 2 (n=75) were given intrarectal instillation of lidocaine-prilocain cream, and group 3 (n=80) received periprostatic anesthesia by injecting 10 ml of 2% lidocaine. Pain after each biopsy was assessed using an 11-point linear visual analog pain scale. The mean pain scores were 5.1 in group 1, 4.8 in group 2, and 2.5 in group 3, resulting in a significant difference between group 3 and both groups 1 and 2, but not between groups 1 and 2. The incidence of biopsy-related adverse events did not differ among groups. Transrectal ultrasonographic guided periprostatic anesthesia is superior to intarectal instillation of lidocaine-prilocain cream.

A randomized double-blind prospective study evaluating patient tolerance of transrectal ultrasound-guided biopsy of the prostate using prebiopsy rofecoxib

OBJECTIVES

To assess the use of a prebiopsy outpatient analgesia using the nonsteroidal anti-inflammatory agent rofecoxib (Vioxx). Urologists perform approximately 500,000 transrectal ultrasound (TRUS)-guided biopsies of the prostate per year, commonly without analgesia. Recent reports, however, have determined that a significant proportion of patients undergoing TRUS-guided biopsies have pain.

METHODS

We performed a prospective randomized double-blind study of 56 men referred for TRUS biopsy of the prostate. They were randomly assigned to receive 50 mg of oral rofecoxib or placebo before TRUS biopsy. After the biopsies, the patients were asked to score the severity of pain by filling out a visual analog pain scale. At the end of 1 week, all patients were asked to mail in a questionnaire regarding the morbidity of the prostate biopsy, including dysuria, hematuria, urinary retention, postbiopsy fever, and rectal bleeding. Analysis was completed to assess whether rofecoxib decreased the patients' perception of pain. The postbiopsy morbidity of patients receiving placebo versus rofecoxib was compared.

RESULTS

Thirty-seven percent of patients receiving placebo and 42% of patients receiving rofecoxib had significant pain (5 or greater on the visual analog pain scale). The median pain score of patients receiving rofecoxib (4.0) versus placebo (4.0) was not significantly different statistically (P = 0.3139) using a Wilcoxon rank sum analysis. The incidence of postbiopsy morbidity was not different.

CONCLUSIONS

Our results confirm the findings of previous studies demonstrating that a significant proportion of patients undergoing prostate biopsies have pain. More importantly, we found that prebiopsy rofecoxib did not significantly decrease the patients' severity of discomfort. Finally, the morbidity after biopsy was not increased with the use of rofecoxib.