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ORIGINAL ARTICLE
Year : 2006  |  Volume : 22  |  Issue : 1  |  Page : 39-41
 

Prospective randomized trial to evaluate effectiveness of periprostatic nerve block in prostatic biopsy


Department of Urology, SGPGIMS, Rae Bareli Road, Lucknow, India

Correspondence Address:
Deepak Dubey
Department of urology, SGPGIMS, Rae Bareli Road, Lucknow - 266014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.24652

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   Abstract 

Objectives: The objective of the study was to evaluate the efficacy of local anesthetic infiltration, in decreasing the discomfort experienced by patients undergoing trans-rectal ultrasound (TRUS) guided biopsy of prostate. Materials and methods: Between January 2002 and February 2003, we investigated consecutively, asymptomatic men, suspected of having prostatic cancer. About 39 patients were randomized to receive 10 ml of 2% Lidocaine periprostatic block + intrarectal Lidocaine gel (group 1 = 20), or intarectal Lidocaine gel only (group 2 = 19) during prostatic biopsy. Immediately following the TRUS-guided biopsy, patients were asked to grade the pain they experienced using the 11-point visual analogue score (VAS). Results: The mean pain score in the patients of group 1 were significantly lower than the patients of group 2 ( P <0.001), suggesting that periprostatic block produced a significant reduction in the perceived pain. Conclusions: Local anesthetic infiltration by TRUS-guided injection of Lidocaine is effective for decreasing pain associated with prostatic biopsy.


Keywords: Ansesthesia, pain, periprostatic block, prostatic biopsy


How to cite this article:
Lavania P, Dubey D, Khurana N, Mandhani A, Kapoor R, Srivastava A, Kumar A. Prospective randomized trial to evaluate effectiveness of periprostatic nerve block in prostatic biopsy. Indian J Urol 2006;22:39-41

How to cite this URL:
Lavania P, Dubey D, Khurana N, Mandhani A, Kapoor R, Srivastava A, Kumar A. Prospective randomized trial to evaluate effectiveness of periprostatic nerve block in prostatic biopsy. Indian J Urol [serial online] 2006 [cited 2019 Aug 26];22:39-41. Available from: http://www.indianjurol.com/text.asp?2006/22/1/39/24652


Prostate biopsy is considered a minor procedure, which is tolerated by most patients and is commonly performed as an office procedure with no anesthesia or with rectal application of Lignocaine gel. Trans rectal ultrasound (TRUS)-guided biopsy was introduced by Torp - after Pedersen et al .[1] The standard method has been used to diagnose prostatic carcinoma.[2],[3],[4],[5],[6] Irani et al found that 6% of the patients judged that the procedure was not comfortable and that it should have been performed under general anesthesia.[7] Despite the use of automatic spring loaded biopsy guns, many patients still complain of pain during biopsy.[8],[9] The objective of the study was to evaluate the efficacy of local anesthetic infiltration in decreasing the discomfort experienced by patients undergoing TRUS-guided biopsy of prostate. Before the present study, it was not the practice of our department to use any form of local anesthesia before prostatic biopsy.


   Materials and methods Top


Between January 2002 and February 2003, we investigated consecutive asymptomatic men suspected of having prostatic cancer. Approval was obtained from the Hospital Ethics Committee. Subjects with abnormal DRE or raised PSA were included in the study. Exclusion criteria were inability to obtain consent, or inability to understand and/or complete the post-procedure questionnaire. Informed consent for the procedure was obtained from each patient after a discussion about the indications of the procedure. Antibiotic prophylaxis was 500 mg of Amikacin given intravenously, followed by a three-day course of oral Ciprofloxacin 500 mg twice daily. The TRUS was performed in the left lateral decubitus position using a B K Medical, 7.5 MHz probe (B K Medical, Denmark). The patient's age, PSA, prostatic volume and any complications associated with the procedure were recorded. About 39 patients were randomized to receive10 ml of 2% Lidocaine periprostatic block + intrarectal Lidocaine gel (group 1 = 20) or intarectal Lidocaine gel only (group 2 = 19). A cleansing enema was administered on the morning of the biopsy and prostatic measurements were taken, following which infiltration was performed using a 22-gauge spinal needle through the biopsy guide. In all patients, intrarectal Lidocaine gel was applied. Patients from group 1 received an injection of 5 ml along each side of the prostate near the junction of the seminal vesicle with the base of the prostate, along the neurovascular bundle. The injection was performed with a high frequency end-fire probe, under ultrasound guidance. The needle was aspirated for blood, to exclude an intravascular position. The position of the needle was confirmed by the lack of resistance while injecting and by visual confirmation of fluid infiltrating the desired region, on ultrasound scanning. To document the location of the injection, the separation of the tissue planes during the injection was documented by ultrasound visualization. After injecting, the probe was removed for approximately 5-10 min. Eight systematic biopsies were taken with 20-gauge trucut needle and a bard biopsy automated gun. The biopsy were taken in a standard spatial distribution with a biplane probe immediately and following the procedure, patients were asked to grade the pain they experienced, using the 11-point visual analogue score (VAS), rating it from 0 (no discomfort) to 10 (the most severe pain ever experienced). Known side effects of prostate biopsy were assessed. Bleeding complications (urethral or rectal) were recorded. Fever was recorded as a measure of infective symptoms.

Statistical Analysis

The Kruskal-Wallis test was used to determine the difference in the mean pain score between the groups.


   Results Top


The two groups were comparable regarding the parameters of age, prostatic size and the number of biopsy punctures The mean pain score at biopsy were 0.9 in group 1 and 3.8 in group 2. The mean pain score in the patients who received the block was significantly lower than the other group ( P <0.001), suggesting that periprostatic block produced a significant reduction in the perceived pain. There were two serious complications, i.e. one patient had hematuria requiring transfusion and one patient with fever required admission to hospital in groups 1 and 2, respectively.


   Discussion Top


The acceptability of TRUS-guided prostate biopsy has become more important, because rebiopsy can increase the detection rate of prostate carcinoma. Studies have shown that 20-30% of the patients have moderate to severe pain during TRUS-guided biopsy, when no analgesia is used.[10] One study reported that 19% of men would refuse rebiopsy after their initial experience of TRUS-guided biopsy with no analgesia or anesthesia.[7] It is important to increase the acceptability of this procedure for these patients, by making the pain of the procedure more tolerable through the effective use of local anesthesia. Innervation of the prostate arises from the caudal roots of S2-S5 and the sympathetic chain, by way of the presacral and hypogastric neural plexuses. These fibers branch in the prostatic plexus and then travel with the prostatic vascular pedicles located at the postero-lateral aspect of the prostatic base, between the rectum and prostrate.

There are a number of studies that are contradictory in results for pain control.[11]-[14] Studies have shown that periprostatic nerve block is superior to intrarectal Lidocaine gel.[14],[15] However, Wu et al[13] mentioned that periprostatic block has no significant effect in pain control. Our study shows that periprostatic injection of Lidocaine is effective for pain control during prostatic biopsy.

Conclusions

Anesthesia by TRUS-guided injection of Lidocaine is effective for decreasing pain associated with prostatic biopsy. It is suggested that all prostatic biopsies should be done with the patient under local anesthesia.


   Editorial Comments Top


Presence of a placebo group in a randomized trial not only blinds the observers to subjective measurements, but also enables assessment of placebo response which might influence the final results. Providing the baseline variables and their demonstrating their comparability enhances the validity of the trial. Furthermore, the numerical values of visual analogue score along with the P values would have provided a more complete picture of the findings in this study.

 
   References Top

1.Trop-Pedersen S, Lee F, Littrup PJ. Trans-rectal biopsy of the prostate guided with the transrectal US: Longitudinal and multiplanar scanning. Radiology 1989;170:23.  Back to cited text no. 1    
2.Nakagawa S, Watanabe M, Nomoto T, Sugimoto K, Mikami K, Ebisui K, et al . Mass screening for prostatic cancer. Hinyokika Kiyo 1997;43:447-52.  Back to cited text no. 2    
3.Imai K, Ogura H, Ichinose Y, Suzuki T, Yamanaka H, Tomaru Y, et al . The significance of six sextant biopsy for prostate cancer. Nippon Hinyokika Gakkai Zasshi 1994;85:460-5.  Back to cited text no. 3    
4.Ogawa O, Shichiri Y, Ohnishi H, Yoshida O. Usefulness of ultrasound-guided prostate biopsy in the diagnosis and treatment of localized prostate cancer. Hinyokika Kiyo 1996;42:805-10.  Back to cited text no. 4  [PUBMED]  
5.Hammerer P, Henke RP, Hubner D, Huland H. Preoperative assessment of tumor aggressiveness in localized prostatic carcinoma. Urology 1995;34:413-8.  Back to cited text no. 5  [PUBMED]  
6.Wolff JM, Borchers H, Jakse G. Determination of local tumour extension in cases of carcinoma of the prostate. Arch Esp Urol 1997;50:546-53.  Back to cited text no. 6  [PUBMED]  
7.Irani J, Fournier F, Bon D, Gremmo E, Dore B, Aubert J. Patient tolerence of transrectal ultrasound- guided biopsy of the prostate. Br J Urol 1997;79:608-10.  Back to cited text no. 7  [PUBMED]  
8.Clements R, Aideyan OU, Griffiths GJ, Peeling WB. Side effects and patient acceptability of transrectal biopsy of the prostate. Clin Radiol 1993;47:125-6.  Back to cited text no. 8    
9.Collins GN, Lloyd SN, Hehir M, McKelvie GB. Multiple transrectal ultrasound-guided prostatic biopsies-true morbidity and patient acceptance. Br J Urol 1993;71:460-3.  Back to cited text no. 9  [PUBMED]  
10.Nash PA, Bruce JE, Indudhara R, Shinohara K. Transrectal ultra-sound guided prostatic nerve blockade eases systematic needle biopsy of the prostae. J Urolol 1996;155:607-9.  Back to cited text no. 10    
11.Issa MM, Bux S, Chun T, Petros JA, Labadia AJ, Anastasia K, et al . A randomized prospective trial of intrarectal lidocaine for pain control during transrectal prostate biopsy: The Emory University experience. J Urol 2000;164:397-9.  Back to cited text no. 11    
12.Desgrandchamps F, Meria P, Irani J, Desgrippes A, Teillac P, Le Duc A. The rectal administration of lidocaine gel and tolerance of transrectal ultrasonography guided biopsy of the prostate: A prospective randomized placebo-controlled study. BJU Int 1999;83:1007-9.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Wu CL, Carter HB, Naqibuddin M, Fleisher LA. Effect of local anesthetics on patient recovery after transrectal biopsy. Urology 2001;57:925-9.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Alavi AS, Soloway MS, Vaidya A, Lynne CM, Gheiler EL. Local anesthesia for ultrasound guided prostate biopsy: A prospective randomized trial comparing 2 methods. J Urol 2001;166:1343-5.  Back to cited text no. 14  [PUBMED]  
15.Vaidya A, Soloway MS. Periprostatic local anesthesia before ultrasound-guided prostate biopsy: An update of the Miami experience. Eur Urol 2001;40:135-8.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]




 

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