SEARCH

SEARCH BY CITATION

Keywords:

  • anesthesia;
  • biopsy;
  • pain;
  • prostate

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Background: In the present study, we assessed the efficacy and morbidity of periprostatic local anesthesia before transrectal ultrasound (TRUS)-guided biopsy of the prostate.

Methods: From August 2001 to February 2002, 98 patients underwent TRUS-guided prostate biopsy at the Department of 2nd Urology, Ankara Numune Education and Research Hospital, Ankara, Turkey. Ninety patients who fulfilled the inclusion criteria were randomized into three groups of 30 patients each. Group 1 received no local anesthesia, while group 2 received a periprostatic saline injection 5 min before the biopsy and group 3 received periprostatic local anesthesia with 1% lidocaine. Pain-scale responses were analyzed for each aspect of the biopsy procedure using a visual analog scale.

Results: There were no differences in pain scores between the three groups during digital rectal examination, intramuscular injection and probe insertion. Mean pain scores during needle insertion in groups 1, 2 and 3 were 5.65 ± 2.35, 6.25 ± 2.04 and 3.16 ± 2.14, respectively. There was no significant difference between the pain scores of groups 1 and 2, whereas pain scores decreased significantly in group 3.

Conclusion: Periprostatic local anesthesia before prostate biopsy is a safe and easy method to increase patient comfort during the procedure.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Transrectal ultrasound (TRUS)-guided biopsy of the prostate is an important procedure when diagnosing prostate cancer in patients with abnormal digital rectal examination (DRE) and/or elevated prostate-specific antigen (PSA).1 This procedure is well tolerated by most patients, but 65%−90% of men feel discomfort during prostate biopsy.2,3 The pain felt during the procedure is a result of penetration of the prostate capsule by the biopsy needle. Increasing the number of biopsies is associated with an increase in pain and morbidity, although this can improve cancer detection.4,5 Therefore, a simple method for pain relief during prostate biopsy should be offered to patients.

In the present study, we have evaluated the efficacy of periprostatic local anesthesia injected before ultrasound-guided prostate biopsy.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Between August 2001 and February 2002, TRUS-guided prostate biopsy was performed on 98 consecutive patients at the Department of 2nd Urology, Ankara Numune Education and Research Hospital, Ankara, Turkey. Indications for prostate biopsy included abnormal DRE and/or elevated PSA. Study exclusion criteria were painful conditions of the prostate, the rectum and the anus, such as acute prostatitis or prostatodynia, hemorrhoid, anal fissure or stricture, neurological conditions, and allergy to lidocaine. Patients using any oral analgesic or narcotic medication were excluded from the study to minimize interference with pain evaluation. Anticoagulant or aspirin therapies were stopped 1 week before biopsy. Antibiotic prophylaxis with 1 g cefazolin was given intramuscularly 10 min before biopsy and it was continued with oral quinolone for 3 days after biopsy for each patient.

Of the 98 consecutive patients, 90 qualified for the study. Patients were randomized into three groups. Thirty patients in group 1 received no periprostatic injection. Periprostatic saline and 1% lidocaine injections were given to patients in group 2 (n = 30) and group 3 (n = 30), respectively. Written informed consent was obtained from all patients.

Patients were placed in the left lateral decubitus position with the knees and hips flexed. TRUS imaging was performed using a Hitachi EUB 420 ultrasound system with a 6.5-MHz biplane probe (Hitachi, Tokyo, Japan) After insertion of the probe, the prostate was imaged on the transverse and sagittal planes and prostate volume was measured with the ellipsoid method programmed into the ultrasound machine. Any asymmetry or hypoechoic areas were identified. On the sagittal view, an 18 cm 22-G spinal needle was positioned at the prostate base, at the junction of the prostate and seminal vesicle. For each lateral side of the prostate, 3 mL of saline or 1% lidocaine was injected in the region of the neurovascular bundle (lateral prostate) and the needle was withdrawn slowly from the base of the prostate to the apex. Before the injection, the syringe was aspirated to prevent intravascular injection.

Five minutes after periprostatic injection, systematic prostate biopsy was carried out using an automatic spring-loaded biopsy gun with an 18-G biopsy needle. The number of biopsies varied between 6 and 12 depending on prostate size, configuration and previous biopsies. Side-effects as a result of lidocaine, such as sepsis, rectal bleeding or hematuria, were noted. To assess the pain score, the 11-point linear visual analog scale (VAS) was used with potential responses of 0 (no discomfort) to 10 (the most severe discomfort ever experienced). Separate ratings were obtained for DRE, intramuscular injection of antibiotic before the biopsy, probe insertion and needle insertion during the biopsy. The pain scores during periprostatic injections were not assessed. Linear VAS scores were analyzed using the one-way anova and independent t-tests to detect any statistical difference in scores between the groups.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Of the 98 consecutive patients undergoing prostate biopsy during the 7-month period, 90 fulfilled the criteria. Of these 90, six patients in group 1, five patients in group 2 and eight patients in group 3 had undergone previous prostate biopsies. The three groups were well-matched in regard to patient age, serum PSA and prostatic volume (Table 1). The number of biopsies ranged from 6 to 12 in all groups. No significant differences were observed in hematuria and rectal bleeding after biopsy between the three groups. Eight patients in group 3, who had undergone previous prostate biopsies without anesthesia, indicated that they had less pain with periprostatic anesthesia, whereas the other patients in groups 1 and 2 did not indicate any difference in discomfort between their biopsy experiences. Pathological examinations of the biopsy specimens revealed eight cancers in group 1, six cancers in group 2 and six cancers in group 3. Statistically, no significant differences were found between the pain scores of the three groups for DRE, intramuscular injection or probe insertion (Table 2). However, in group 3, after receiving periprostatic anesthesia, the mean pain score during needle insertion was 3.16 ± 2.14, whereas in groups 1 and 2, the mean pain scores during needle insertion were 5.65 ± 2.35 and 6.25 ± 2.04, respectively. Statistical analysis with a one-way anova revealed a significant difference in pain scores between the groups (P < 0.001). There was no difference in pain scores during needle insertion between the group receiving no anesthesia (group 1) and the placebo group (group 2; P = 0.435). However, when the group receiving periprostatic local anesthesia with 1% lidocaine (group 3) was compared with group 1 and group 2 separately using independent t-test, we found a significant difference in pain scores during needle insertion. Hematuria and hematochezia after the biopsy were not significantly different in all groups. No adverse effects as a result of intravascular absorption of lidocaine were observed.

Table 1.   Patient characteristics
 Group 1 (no anesthesia)Group 2 (placebo)Group 3 (nerve blockade)P-value*
  • *

    Statistical analysis was carried out using independent t-test. PSA, prostate-specific antigen; vol., volume.

No. patients303030 
Mean age ± SD (years)67.52 ± 7.0467.45 ± 5.4565.16 ± 7.510.368
Mean PSA ± SD (ng/mL)11.91 ± 8.7 7.18 ± 14.6714.55 ± 17.820.340
Mean prostate vol. ± SD (cc)53.38 ± 26.5966.17 ± 32.8048.89 ± 27.270.118
No. of biopsies ± SD 8.54 ± 1.57 9.20 ± 1.19 8.75 ± 1.930.326
No. malignant pathology (%) 8 (26.6) 6 (20.0) 6 (20.0) 
Table 2.   Mean pain scores (visual analog scale scores ± SD) perceived by patients
 Group 1 (no anesthesia)Group 2 (placebo)Group 3 (nerve blockade)P-value*
  • *

    One-way anova test;

  • **

    P < 0.001 when group 3 is compared with group 1 and group 2 separately using independent t-test.

Digital rectal examination2.02 ± 1.562.25 ± 1.442.58 ± 1.31 0.329
Intramuscular injection5.34 ± 1.865.00 ± 1.655.58 ± 1.58 0.546
Probe insertion4.45 ± 2.053.85 ± 1.493.91 ± 1.93 0.379
Needle insertion5.65 ± 2.356.25 ± 2.043.16 ± 2.14<0.001**

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Transrectal ultrasound-guided prostate biopsy is the mainstay in the diagnosis of prostate cancer and it is routinely performed in an outpatient setting. However, most patients feel discomfort and pain during the procedure. If there is no patient compliance, this can prevent the physician in obtaining a sufficient number of biopsies from the right places. To improve patient comfort, various forms of anesthesia, such as periprostatic lidocaine injection6–10 and intrarectal lidocaine gel,10–12 have been used.

Nash et al. first performed the TRUS-guided prostatic nerve blockade and reported that patients who received anesthesia had less pain than those who were not given anesthesia.6 Issa et al. recommended administration of 2% lidocaine gel intrarectally 10 min before the biopsy and stated that this method is simple, safe and effective for providing satisfactory anesthesia during transrectal prostate biopsy.11 However, in a prospective double-blind randomized study by Chang et al. no significant therapeutic or analgesic benefits of intrarectal lidocaine gel over lubricant alone for transrectal ultrasound guided biopsy of the prostate were found.12 Instead of 11-point VAS, they used a linear scale without numbers, which avoids limiting the discriminating ability of a numbered pain scale. Alavi et al. compared periprostatic local anesthesia with 1% lidocaine against intrarectal 2% lidocaine gel before prostate biopsy.10 Their study indicated that ultrasound-guided periprostatic nerve blockade with lidocaine provides better anesthesia than intrarectal lidocaine gel. Birch et al. addressed sedoanalgesia for prostatic manipulations.13 This has been shown to be safe and effective, but requires a period of observation by either surgical or anesthetic staff.

The level of pain perceived by the patient is difficult to quantify. In the past three decades the VAS has proved to be satisfactory for the subjective measurement of pain. The linear VAS is the best method for measuring pain because of its sensitivity.14 Chang et al. determined that younger patients had significantly more pain than older ones.12 This finding was confirmed in a study by Rodriguez and Terris.15 In the present study, there was a negative correlation of age to the pain scores but this was not significantly different.

In this study, we aimed to compare the same criteria for each group, so we did not assess the pain scores during periprostatic injections in patients in groups 2 and 3 because we did not perform periprostatic injections in patients in group 1. In this prospective randomized study, there was no significant difference in pain between the three groups during DRE, intramuscular injection and probe insertion, but patients with periprostatic local anesthesia reported less pain during needle insertion compared to patients with no local anesthesia and the placebo group. This was found to be statistically significant (P < 0.001). Hematuria and hematochezia after the biopsy were not significantly different in all groups. Both complication rates were found to be similar to those in a previous study.15

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

We believe that periprostatic local anesthesia before TRUS-guided prostate biopsy is a safe and easy method and that it significantly decreases pain in patients undergoing this procedure. Although no standard anesthetic protocol has been established yet, it should be considered for all patients undergoing this procedure.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References