Indian Journal of Urology
ORIGINAL ARTICLE
Year
: 2006  |  Volume : 22  |  Issue : 2  |  Page : 118--121

Apical block versus basolateral prostatic plexus block in transrectal ultrasound guided prostatic biopsy: A prospective randomized study


N Khurana, P Lavania, R Goyal, S Agrawal, D Dubey, A Mandhani, A Srivastava, R Kapoor, A Kumar 
 Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Correspondence Address:
N Khurana
Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014
India

Abstract

OBJECTIVES: We prospectively analyzed the efficacy and safety of apical block, bilateral (B/L) basolateral prostatic plexus block and unilateral (U/L) basolateral prostatic plexus block in patients undergoing transrectal ultrasound (TRUS)- guided prostatic biopsies. MATERIALS AND METHODS: From July 2003 to July 2004, 60 patients of median age 63 yrs and median PSA of15.8 ng/ml, underwent TRUS- guided prostatic biopsies. These biopsies were performed in the left lateral position, after cleansing enema and single dose of antibiotic. Patients were randomized into 3 groups. Under TRUS guidance, group1 (n=20) received 10 ml of 1% lignocaine at the apical area of the prostate, group 2 (n=20) received 5 ml of 1% lignocaine in the basolateral prostatic plexus bilaterally and group 3 (n=20) received 10 ml of 1% lignocaine at basolateral prostatic plexus unilaterally, using an 18 F needle. Five minutes after the injection, a series of 10 prostatic biopsies were performed. Pain during biopsy was assessed using visual analogue pain score. RESULTS: Patients with apical prostatic block had significantly lower pain scores (1.5 0.9) than those with B/L (2.6 1.2) and U/L basolateral prostatic plexus block (2.8 1.4). The three groups were similar in regard to age, prostatic volume and number of cores. CONCLUSIONS: Apical prostatic plexus block was the most effective technique and could be a useful alternative to basolateral prostatic plexus block.



How to cite this article:
Khurana N, Lavania P, Goyal R, Agrawal S, Dubey D, Mandhani A, Srivastava A, Kapoor R, Kumar A. Apical block versus basolateral prostatic plexus block in transrectal ultrasound guided prostatic biopsy: A prospective randomized study.Indian J Urol 2006;22:118-121


How to cite this URL:
Khurana N, Lavania P, Goyal R, Agrawal S, Dubey D, Mandhani A, Srivastava A, Kapoor R, Kumar A. Apical block versus basolateral prostatic plexus block in transrectal ultrasound guided prostatic biopsy: A prospective randomized study. Indian J Urol [serial online] 2006 [cited 2020 Sep 27 ];22:118-121
Available from: http://www.indianjurol.com/text.asp?2006/22/2/118/26564


Full Text

 Introduction



Transrectal ultrasound (TRUS)-guided prostatic biopsy is standard for diagnosis of carcinoma prostate.[1],[2],[3],[4],[5] Despite the use of automatic spring loaded biopsy guns, many patients still complain of pain during biopsy.[6],[7] Attempts have been made to use various techniques of local anesthesia, to reduce the pain and discomfort associated with biopsy[8],[9] of the prostate. Studies have shown superiority of one type of block over the other, but there is no study comparing the apical block with both bilateral (B/L) and unilateral (U/L) prostatic plexus block in a randomized fashion. Hence, this study was designed to evaluate the efficacy and safety of the apical block, B/L basolateral prostatic plexus block and U/L basolateral prostatic plexus block in patients undergoing TRUS- guided prostatic biopsies.

 Materials and Methods



Study criteria

Between July 2003 and July 2004, we had only 74 patients who were fit to undergo TRUS- guided prostate biopsies in our department. Of 74 patients, 60 qualified for study enrolment. Sample size was not decided before the start of the study. Indications for prostate biopsy included an abnormal prostate on digital rectal examination and/or elevated serum PSA (> 4 ng/ml). Some patients had an indication of re-biopsy, because of presence of prostatic intraepithelial neoplasia (PIN) on a previous biopsy. Exclusion criteria were a history of chronic prostatitis or prostatodynia, active anal and rectal conditions such as hemorrhoids, anal fissures or stricture, allergy to lignocaine or the concomitant use of analgesic and narcotic medications. Patients with active painful conditions of the prostate and rectal-anal region were excluded from the study after the digital rectal examination and before the TRUS-biopsy procedure, to avoid the potential of pain associated with such conditions. Patients on anticoagulants or those with a bleeding disorder were excluded from this study. Patients taking aspirin were asked to discontinue the medication (if not contraindicated), 10 days before the biopsy. Approval for this study was obtained from the Internal Review Board at our hospital.

Patients and grouping

Patients were randomized into three groups:

Group 1: 10 cc of 1% lignocaine solution injected at the apex.

Group 2: 10 cc of 1% lignocaine at basolateral area on one side.

Group 3: 5cc of 1% lignocaine at basolateral area on both sides.

A trained sister did randomization. Patients were unaware of the type of block. Patients were randomized in 3 groups in proper fashion. The first patient was given apical block, the second patient was given B/L basolateral block and the third patient had U/L basolateral block on one side and so on.

Prostate-biopsy procedure

All men underwent bowel cleansing with an enema before the procedure. Antibiotic prophylaxis was given with tab ciprofloxacin 500 mg and tab metronidazole 500, one hour before the biopsy procedure and took two further doses at 12-hourly intervals. With the patient in left lateral position, a digital rectal examination was performed, followed by a TRUS examination using a 01 multiplanar high-resolution ultrasound probe. Prostatic volume and ultrasonographic appearances in the longitudinal and transverse planes of the prostate were recorded.

Apical block

Apical block was given by injecting 10 mL of 1% lignocaine through a needle guided by TRUS, at the midline of the prostatic apex. The tip of the needle was seen as an echogenic focus and was advanced at the apex under the denonvillier's fascia. There was resistance to injection of lignocaine when the needle was within the prostate. In such a case, the needle was withdrawn under direct vision and once outside the prostate at the level of the apex, resistance to the infiltration diminishes. 10 cc of 1% lignocaine injection was injected while visualizing the bolus of injection, as it pushes the prostatic apex away from the ultrasound image.

Bilateral (B/L) basolateral block: B/L basolateral block was given by injecting 5 ml of 1% lignocaine into both the left and the right nerve plexus located at the junction of the seminal vesicle and prostate.

Unilateral (U/L) basolateral block: U/L basolateral block was given by injecting 10 ml of 1% lignocaine into the left or right nerve plexus located at the junction of seminal vesicle and prostate.

An automatic spring-loaded biopsy gun and 18 gauge needle was used. All patients underwent 10 cores systematic biopsies, starting from the base of the left lobe and proceeding laterally along the peripheral zone toward the apex and then in the same manner on the right side. An experienced urologist injected the anesthesia into all patients and performed the biopsies together with a second experienced urologist. After administering anesthetic block, biopsies were performed after duration of 5 minutes.

Pain scale measurement and statistical analysis

After biopsy, the pain score entered by the patient was documented. The assessment range was 0 (no pain), 3 (mild pain), 5 (moderate pain), 7 (severe pain) and 10 (intolerable pain) score by 10. The attending nurse evaluating the pain perception was unaware of type of block. Pain score was calculated 5 minutes after completion of the procedure. Patients were also monitored during and after the procedure for possible complications. Statistical analysis was performed using Pearson chi square test and a p value less than 0.005 was considered significant.

 Results



During the 12-month period, 74 patients underwent TRUS- guided prostate biopsies.14 patients failed to qualify for study enrollment due to one or more exclusion criteria. The remaining 60 men enrolled in the study, with 20 randomized into group 1 and 20 into group 2 and group 3, respectively. For 7 of those patients, it was a repeat biopsy (3 patients had a high grade PIN in previous biopsies, 4 patients had progressively rising PSA). Groups were evenly matched with respect to median age, median PSA, median prostate volume and number of prostatic biopsies [Table 1].

Patients with apical block (Group 1) had significantly lower pain scores than patients with B/L basolateral block (Group 2) and U/L basolateral block (Group 3). Mean pain scores was 1.5 0.9 in group1, 2.6 1.2 in group 2 and 2.8 1.4 in group 3 [Table 2]. P value was significant in comparing pain scores between group 1 and group 2 and in comparing group1 and group 3 ( P =0.001), but was insignificant when group 2 and group 3 was compared ( P =0.461) [Table 3].

Only 3 patients (5%) out of 60 patients had complications. One patient had Epididymo-orchitis, while 2 patients had mild gross hematuria, which was managed conservatively [Table 4].

 Discussion



Numerous studies have shown conflicting results for pain control during prostatic biopsy.[8],[11],[12],[13] Studies have shown that basolateral periprostatic nerve block is superior to intrarectal lignocaine gel.[13],[14] Rodriguez et al[15] has shown that periprostatic nerve block at the apex (5 ml of 1% lignocaine on either side of prostatic apex) is superior to Intrarectal 2% lignocaine gel. Schostak et al[10] concluded that single injection (10 ml of 1% lignocaine) onto the capsule at the apex was superior to B/L basolateral prostatic plexus block ( 5 ml 1% lignocaine on both side) and was also superior to combination of B/L apical (5 ml 1% lignocaine injection on either side of apex) and B/L basolateral prostatic plexus block (5 ml 1% lignocaine on both side). Soloway and Obek[9] described the technique of periprostatic nerve block as a combination of several injections into the base, middle and apex of the prostate on both sides. Both Schostak et al[10] and Philip et al[16] injected lignocaine bilaterally at the apex, but results of our study have shown that a similar effect can be achieved simply by single injection at the apex, as was shown by Rodriguez et al[15] also.

All these studies have shown that prostatic block at one or other sites with varying doses of anesthetic agents, decreases pain during transrectal ultrasound guided prostatic biopsy, but it is still not clear as to which is the best site for a prostatic anesthetic block. To our knowledge, this is the first study in which apical prostatic plexus block has been compared with both B/L and U/L prostatic plexus block in randomized fashion. This study has shown that apical prostatic plexus block using single injection of 10 ml 1% lignocaine is best in relieving pain. There was no statistical difference in the pain score between bilateral and unilateral basolateral prostatic plexus block. This could be explained by craniocaudal and side-to-side spread of anesthetic agent after giving block and due to difference in sensory innervation around the prostate. Depot injection given at the apical area spreads cranially, while giving unilateral block leads to both caudal and side-to-side spread of anesthetic agent, hence reducing pain on both sides. This could be the reason of almost the same pain score in both bilateral and unilateral prostatic plexus block in this study. Apical area of prostate lies around the dentate line, which is the area of maximum sensory innervation by perineal branch of pudendal nerve and this could be the reason of apical prostatic block being most effective. Inserting an anesthesia depot close to the seminal vesicle requires more experience in interpreting the TRUS findings, in contrast to depot at the prostatic apex. Same was the observation in study of Schostak et al[10] also. Although a recent study by Philip et al[16] comparing bilateral apical (10ml 1% lignocaine on either side of prostatic apex) with B/L basolateral prostatic plexus block (10 ml 1% lignocaine on both sides) has shown that both apical and basolateral prostatic plexus block showed no difference in pain scores, our study has shown altogether different results. This difference could be due to difference in the type of apical block and higher dose of anesthetic agent used by Philip et al .[16] Our study has shown that single injection with only 10 ml of 1% lignocaine at the apex is enough for relieving pain during TRUS- guided prostatic biopsies. This further indicates a need for a large multicentric randomized study using different sites of block with different doses of local anesthetic agents, in resolving this issue.

 Conclusion



Apical prostatic plexus block was the most effective technique. It is technically easier to perform than an anesthetic block of the basolateral prostatic plexus and could be a useful alternative to basolateral prostatic plexus block.

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