IMAGING

How to decrease pain during transrectal ultrasound guided prostate biopsy: a look at the literature
Autorino R, De Sio M, Di Lorenzo G, Damiano R, Perdona S, Cindolo L, D’Armiento M
Urology Clinic, Second University, Department of Oncology, Federico II University, Naples, Italy
J Urol. 2005; 174: 2091-7

• 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.
  
  
• Editorial Comment
  The authors performed a systematic MEDLINE search of clinical trials of any kind of anesthesia, analgesia or sedation during TRUS guided prostate biopsy published since 2000. They retrieved and critically analyzed more than 40 articles dealing with different methods of decreasing pain during this procedure. As we know there is no rule to adequately predict if a patient will or will not feel too much pain or discomfort during TRUS biopsy. However, as mentioned by the authors, some risk factors associated with painful biopsy are younger age, anxiety, number of cores taken and repeat biopsy (due to the inclusion of the transition zone). This report nicely discusses the several methods and different approaches for local anesthesia during TRUS biopsy. The discussion includes the different amounts and different periprostatic sites for injection of lidocaine, the importance of using or not using intrarectal anesthetic gel instillation and its association or not with nonsteroidal anti-inflammatory. They also discuss about he possibility of using general anesthesia, entonox (50% nitrous oxide and oxygen) induced analgesia or anesthesia with intravenous injection of propofol. All the pros and cons of each procedure are well presented and discussed.
  At our institution we have been using some type of local analgesia/anesthesia since 2.000. We start with oral administration of 500 mg of paracetamol (acetaminophen; nonopiate, nonsalicylate analgesic), 30 minutes before the procedure (for better analgesia). Intrarectal injection of 10 ml of 2% lidocaine gel is done 10 minutes before the biopsy (to decrease pain during probe insertion), with the patient already in the left lateral decubitus. Then, periprostatic nerve block is obtained (to decrease pain during biopsy), by infiltrating, on sagital plane, 2.5 ml of 2% lidocaine into the left and the right nerve plexus located at the junction of the seminal vesicle and prostate. After that, and on axial plane, 2.5 ml of 2% lidocaine is injected in each side of prostate apex. We have found that with this protocol, TRUS biopsy is well tolerated by the patients even when they are submitted to an extended or saturation biopsy scheme (16 - 22 cores) or rebiopsy. Only sporadically we use intravenous injection of propofol, and when it used the anesthesiologist always performs the procedure.

Dr. Adilson Prando
Chief, Department of Radiology
Vera Cruz Hospital
Campinas, São Paulo, Brazil