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Comparison of 3 different methods of anesthesia before transrectal prostate biopsy: a prospective randomized trial
Öbek C , Özkan B, Tunc B, Can G, Yalcin V, Solok V
Departments of Urology and Public Health (GC), University of Istanbul, Cerrahpasa School of Medicine, Istanbul
J Urol. 2004; 172: 502-5

• 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.
  
  
• Editorial Comment
  Several methods with different approaches have been used in the recent years in order to obtain analgesia/anesthesia for transrectal ultrasound guided biopsy of the prostate. The authors compared in a prospective randomized trial, three different methods of anesthesia before transrectal prostate biopsy and they achieved significantly better analgesia with the combination of periprostatic nerve block and intrarectal injection of lidocaine gel. They also proposed the use of intravenous infusion of tramadol as an additional procedure for improvement of patient tolerance and comfort. If there is any doubt about the benefit of using local anesthesia for prostatic biopsy this article definitely cleared this out. At our institution periprostatic lidocaine injection has been performed since April 2000. Differently from the method showed in this article where periprostatic nerve block was performed by infiltrating 2.5 cc of 2% lidocaine to the neurovascular bundle at the base of the prostate , we inject 2.5 cc of lidocaine on each side of the prostate apex. This approach has been used due the fact that in our opinion , patient discomfort during biopsy without anesthesia is higher when the prostate apex is biopsied in comparison with the prostate base(1). Following the same principles pointed out by the authors, 500 mg of paracetamol (acetaminophen; nonopiate, nonsalicylate analgesic) is orally administered, 30 minutes before the procedure. Although less potent than tramadol, paracetamol is generally well tolerated and do not have adverse events such as nausea and vomiting which can occur with tramadol in some patients particularly in older ones.This article clearly shows that the association of some type of periprostatic nerve block with intrarectal injection of lidocaine gel is a much better method.Based on their results we decided to include the use of intrarectal injection of lidocaine gel in our protocol.

Reference
1. Schostak M, Christoph F, Muller M, Heicappell R, Goessl G, Staehler M, Miller K: Optimizing local anesthesia during 10-core biopsy of the prostate. Urology. 2002; 60: 253-7.

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