Abstract
Objectives: Prostatic biopsy is a minor diagnostic procedure; despite the simplicity of execution this procedure can determine a high patients’ discomfort.
Methods: We analyzed the experience reported in the literature concerning the pain and the anxiety, the role of local or intrarectal anesthesia and the complications related to prostatic biopsy. Key words used for the Medline search included: prostate cancer, biopsy, transrectal ultrasound anesthesia, complications.
Results: The reduction of patients’ pre biopsy anxiety may help the physician to perform a better prostate biopsy. While the use of pre biopsy enemas seems questionable, the use of antibiotic prophylaxis is mandatory when the biopsy is transrectal and could be useful if the approach is transperineal. The use of anaesthesia (periprostatic local injection of lidocaine or intrarectal administration of lidocaine gel) seems to reduce patients’ discomfort. The higher is the number of biopsy cores, the greater is the need for anaesthesia.
Conclusions: Trans-rectal ultrasound (TRUS) prostatic biopsy with a correct patient’s preparation has a limited impact on patient’s well-being.
Keywords
1. Introduction
Ultrasound guided prostate biopsy is one of the most common procedures in urological practice. The introduction of PSA measurement and PSA-based early detection programs for prostate cancer lead to widespread use of trans-rectal ultrasound guided biopsy of the prostate (TRUS-Bx) in establishing the diagnosis of prostate cancer. Approximately 500,000 biopsies of the prostate performed annually in the United States [
[1]
] and similar figures are reported in western Europe. Over the last decade, sampling techniques have been standardized and these refinements have led to a reduction in procedure related morbidity. On the other hand, the finding of an increasing number of men with an elevated PSA following a negative first biopsy made a second or third re-biopsy not uncommon. Moreover, many urologists progressively increased the number of samples in each biopsy from six up to 45 with a considerable increase in associated pain and discomfort [[2]
]. Given the clinical relevance of the information obtained with TRUS-Bx, the evaluation of related patient pain and anxiety has only recently become a relevant issue. Many urologists have witnessed patients’ anxiety and discomfort that may involve up to 30% of patients undergoing TRUS-Bx. These symptoms seem to be related to patient’s age and number of biopsies [[3]
].2. Patients’ preparation for TRUS-biopsy
The importance of patient preparation is crucial. A relaxed and cooperative patient gives the physician the opportunity of performing multiple samples and precisely targeting specific areas within the prostatic gland. It is therefore of utmost importance to clearly and extensively inform the patient about the procedure and its usefulness before the biopsy.
In 2001, a specifically designed prospective trial aiming to evaluate the impact of prostate biopsy on patient well-being involving 211 subjects [
[2]
] showed that 64% of patients experience significant anxiety while waiting for the scheduled procedure. Pretreatment anxiety is strongly predictive of intraoperative pain. The authors suggested that anesthesia and administration of pre biopsy anxiety decreasing measures may be beneficial in young patients with known prostatic inflammatory infiltrate. It should be highlighted that in this study 15% of subjects reported an erectile dysfunction at 30 days after biopsy and that therefore the risk of acute erectile dysfunction should be discussed cautiously with men who are potent before the procedure.Although there is considerable variability in the patients’ preparation for the TRUS-biopsy, most urologists prescribe a preoperative enema to cleanse the rectum either if the biopsy is done transrectally or transperineally. The enema is believed to help in reducing the risks of infection and, in the perineal approach, may eventually reduce patient discomfort and guarantee a good echographic study. Large series of patients and culture studies showed however that enemas do little to decrease the risk of symptomatic bacteriemia when combined with a prophylactic antibiotic [
4
, 5
] and may not be necessary for this purpose only. Moreover, Davis et al. [[4]
] reported that they had no difficulty with prostate imaging in patients who were not asked to use an enema before TRUS. Based on these data, an enema does not seem to always be necessary before TRUS-biopsy.3. Patients’ tolerance of TRUS-biopsy
The measurement of subjective pain intensity is important to both patients and physicians but could be difficult to evaluate because several components influence its perception from the patient perspective. Currently several “pain intensity” scales are used to asses the intensity and effects of pain in an objective way [
[6]
]. A differentiation should be made between transrectal and trans perineal biopsies.Patients’ tolerance of transrectal ultrasound guided biopsy of the prostate was evaluated in 1997 by Irani et al. [
[7]
] who reported a mean visual analogic scale evaluation of pain (VAS) score of 3, with only 5% of patients having a VAS score of 5 or more. About 19% of patients said that they would not undergo it again without some form of anesthesia and 6% would ask for a general anesthesia. The conclusions of that paper were that some local anaesthetic techniques could be used to enhance biopsy tolerance without sacrificing the advantages of an outpatient setting. It is a common experience that anxiety is frequent in men awaiting this procedure and that those who are most anxious are most likely to experience pain. About 24% of 104 men who completed a questionnaire about pain and complications one week after biopsy found the procedure moderately to extremely painful [[8]
]. Problems arose in men from whom multiple samples were taken or who required a second TRUS and biopsy at a later date. It is noteworthy that 19% of patients felt that they had significant complications after biopsy and saw their general practitioner within 1 week after the procedure.4. Prophylactic antibiotics for TRUS-Bx
Urologists usually administer prophylactic antibiotic treatment for TRUS-Bx. The treatment is started the day before the biopsy and, in some cases, continued for 2–5 days after. There is a wide variation in the type of antibiotic regimen used. None of the regimens proposed for the transrectal biopsy have been entirely satisfactory because of the large variety of organisms shown to be responsible for infections [
[9]
]. In 1999, based on data from a British survey on 129 patients submitted to trans rectal biopsy, Crundwell et al. [[8]
] proposed a treatment based on gentamicin 160 mg and metronidazole 1 g in all patients with the addition of ciprofloxacin 500 mg twice daily for 5 days in high risk patients. In the United States, Shandera et al. [[10]
] reported the efficacy of one dose of 300 mg ofloxacin before biopsy with no antibiotic after biopsy and an infections complication rate of 0.67%. More recently, Davis et al. [[4]
] stated that fluoroquinolone given before the procedure is the safest regimen of antibiotic prophylaxis.The transperineal approach has a low rate of infectious complications. Thompson et al. [
[11]
] comparing transrectal and transperineal approach in terms of bacteriemia after biopsy without antibiotic prophylaxis reported rates of 100 and 40%, respectively. The rates of urinary tract infections were 87 and 26%. In our everyday practice, we use a trans perineal approach with a 6-core standard biopsy technique on an outpatient basis prescribing a prophylactic treatment with sulfametoxazol 800 mg+trimetoprim 160 mg twice a day starting 12 h before the procedure and for 5 days afterwards. With this prophylactic regimen in 800 consecutive patients, we observed a 1% rate of symptomatic infection.5. The use of anesthesia during TRUS-Bx
Although the TRUS-biopsy is reasonably well tolerated by most patients, this procedure is associated with some discomfort, but not all urologists perform local anesthesia to decrease pain.
In literature, there are of studies that have evaluated the role and the efficacy of the periprostatic local injection of lidocaine to prevent or reduce pain during a TRUS-Bx. Should anesthesia be considered in all patient undergoing prostate biopsies? According to the experience descripted by Aus et al. [
[12]
], 92% of patients reported none or only mild discomfort following the biopsy procedure. Other experiences, on the other hand, demonstrate the effectiveness of a periprostatic nerve block.A prospective study of Seymour et al. [
[13]
] estimated the role of periprostatic local anesthesia in improving pain after TRUS biopsies. A total of 84 patients received a local anesthesia with 10 ml 1% lidocaine injected in Denonviller’s fascia, from the apex to the seminal vesicles; 73 patients received a placebo. The reported data demonstrated a significant reduction in pain and also a trend toward less analgesic use after local anesthesia. This is the first prospective study with a significant number of patients enrolled that confirms the experiences of Nash et al. [[14]
] who found that periprostatic lidocaine injection influences pain scores.Vaidya and Soloway [
[1]
] reported their experience based on 200 patients who underwent prostate biopsy in which the anesthesia was performed with a 7-in. 22-gauge spinal needle that was directed to the junction of the prostate and the seminal vesicle creating an “ultrasonographic wheal” after the injection of 2–3 ml 1% lidocaine. The same procedure was performed at the mid-portion and the apex of the prostate and on the controlateral side with a total injection of 10 cm3 1% lidocaine. The results demonstrated that patients’ pain perception was minimal and not correlated with the number of biopsies or patient’s age.A placebo-controlled randomized study published by Leibovici et al. [
[15]
] confirms those findings. In this experience with 90 patients, the authors performed a local anesthesia using a 23-gauge needle that was aimed at the lateral prostatic border toward the angle between the base and seminal vesicle, with an injection of 10 ml (5 per side) of 1% lidocaine. In the control group, only 0.9% sodium chloride was injected. Using a visual analog scale questionnaire, the level of discomfort perceived by the patients during the procedure was recorded. The group pre-treated with local anesthesia reported less pain than the placebo group and tolerated the prostatic biopsy better.In a study of Kaver et al. [
[16]
], anesthesia was performed by injecting 15 ml of 1% lidocaine in three areas: the junction between the seminal vesicle and the prostate bilaterally and at the midline of the periprostatic area of apex. In these patients, pain was significantly lower that in the untreated control group.In order to reduce the discomfort induced by rectal mucosa needle puncture and also by positioning the transrectal probe, some urologists use the intrarectal administration of lidocaine. A prospective randomized study of Le Duc and co-workers [
[17]
] evaluated the effect of the rectal administration of 15 ml 2% lidocaine gel 15 min before the biopsy. Between the group that received the anaesthetic gel (56 patients) and the group treated with a placebo (53 patients), there was no difference in patient tolerance (p=0.39).Similarly, a prospective double-blind randomized study performed by Chang et al. [
[18]
] demonstrated that there are no significant analgesic benefits, when using a intrarectal administration of lidocaine gel during prostatic biopsies.Different data were instead reported by Issa et al. [
[19]
] after a randomized prospective trial in which a group treated with 10 cc 2% lidocaine gel intrarectally (administrated 10 min before the biopsy) was compared with a control group: the first group had significantly less pain during the procedure than the controls.The most recent publications confirm the effectiveness of local anesthesia during the transperineal prostatic biopsy but the technique of anesthesia is still a matter of debate. Recently, Taverna et al. [
[20]
] presented a modification of the technique proposed by Soloway, consisting in a single bolus of 10 ml lidocaine administered at the prostatic midline between Denonvillier’s fascia and the periprostatic fascia overlying the prostate.In order to define the best method of anesthesia, Alavi et al. [
[21]
] performed a prospective randomized trial comparing periprostatic infiltration of 10 cc 1% lidocaine with intrarectal instillation of 10 cc 2% lidocaine gel before prostate biopsy: the data indicate that the use of periprostatic block provides an anaesthetic effect that is superior to the intrarectal administration of lidocaine.The neuroanatomic studies performed by Hollabaugh et al. [
[22]
] using fresh cadavers demonstrated that the main nerve supply to the prostate originates from the inferior hypogastric plexus; these nerves pass along the plane between the prostate and the rectum. In contrast, the anterior and superolateral portion of the prostate has no significant neural input.We currently use a similar technique in our standard 6-core transperineal biopsy approach. Patients undergo TRUS-Bx in an office setting with a single injection of 10 ml lidocaine administered at the prostatic midline 3–5 min prior to biopsy. No major complication was observed in 800 consecutive patients. Only two patients (<0.1%) asked that the procedure be interupted due to pain. Post biopsy complications rate were similar to the data reported in literature.
There is the evidence that increasing the number of biopsies results in a better chance of diagnosing prostate cancer but also increases patients’ discomfort. To determine if a high number of biopsies is associated with an increase in patients’ discomfort, Peyromaure et al. [
[23]
] performed a prospective study which analysed 289 men submitted to a 10-core prostatic biopsy protocol. In this experience, no patient was given sedation or local anesthesia. The procedure was described as painful by 47.6% of patients and this rate is in the range reported after the standard 6-core biopsy protocol with the same conditions. Complications accounted for 78.3% of hematospermia, 74.4% of hematuria and 39.6% of hematochezia. Therefore, while the bleeding rate was higher than after 6-core biopsy the infection rates were similar.6. Conclusions
Nowadays ultrasound guided prostate biopsy is a standard technique. Care must be taken to inform patients about the procedure and its possible complications. Transitory acute erectile dysfunction could be a relevant issue for young sexually active patients and should be discussed. The reduction of patients’ pre biopsy anxiety may help the physician to perform a better prostate biopsy. While the use of pre biopsy enemas seems questionable the use of antibiotic prophylaxis is mandatory when the biopsy is transrectal and could be useful if the approach is transperineal. The use of anesthesia (periprostatic local injection of lidocaine or intrarectal administration of lidocaine gel) significantly reduces patients’ discomfort. The higher is the number of biopsy cores, the greater is the need for anesthesia.
References
- Periprostatic local anestesia before Ultrasound guided biopsy: an update of the Miami experience.Eur. Urol. 2001; 40: 135-138
- The impact of prostate biopsy on patient well-being: a prospective study of pain, anxiety and erectile dysfunction.J. Urol. 2001; 165: 445-454
- Risks and complications of transrectal ultrasound-guided prostate needle biopsy: a prospective study and review of the literature.J. Urol. 1990; 160: 2115-2120
- The procedure of transrectal ultrasound guided biopsy of the prostate: a survey of patient preparation and biopsy technique.J. Urol. 2002; 167: 566-570
- Bacteriemia and bacteriuria after transrectal ultrasound guided prostate biopsy.J. Urol. 2000; 164: 76-80
Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain 1986;117–26.
- Patients’ tolerance of transrectal ultrasound guided biopsy of the prostate.Br. J. Urol. 1997; 79: 608-610
- Patients’ tolerance of transrectal ultrasound guided prostatic biopsy: an adit of 104 cases.Br. J. Urol. 1999; 83: 792-795
- Prevention of urinary tract infection and sepsis following transrectal prostatic biopsy.J. Urol. 1982; 127: 449-451
- Efficacy of one dose fluoroquinolone before prostate biopsy.Urology. 1998; 52: 641-644
Thompson PM, Pryor JP, Wlliams JP. The problem of infections after prostatic biopsy: the case for the transperineal approach. Br J Urol 1982;736–40.
- Transrectal ultrasound examination of the prostate: complications and acceptance by patients.Br. J. Urol. 1993; 160: 2115-2120
- Pain after transrectal ultrasonography-guided prostate biopsy: the advantages of periprostatic local anesthesia.BJU Int. 2001; 88: 540-544
- Transrectal ultrasound guided prostatic nerve blockade eases systematic needle biopsy of the prostate.J. Urol. 1996; 155: 607-609
- Local anesthesia for prostate biopsy by periprostatic lidocaine injection: a double-blind placebo controlled study.J. Urol. 2001; 167: 563-565
- Randomized prospective study of periprostatic local anesthesia during transrectal ultrasound-guided prostate biopsy.Urology. 2002; 59: 405-408
- 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: 1007-1009
- Intrarectal lidocaine during transrectal prostate biopsy: results of a prospective double-blind randomized trial.J. Urol. 2001; 166: 2178-2180
- A randomized prospective trial of intrarectal lidocaine for pain control during transrectal prostate biopsy: The Emory University experience.J. Urol. 2000; 164: 397-399
- A single injection of lidocaine as local anesthesia for ultrasound guided needle biopsy of the prostate.J. Urol. 2002; 167: 222-223
- Local anesthesia for ultrasound guided prostate biopsy: a prospective randomized trial comparing 2 methods.J. Urol. 2001; 166: 1343-1345
- Preservation of the continence nerves during radical retropubic prostatectomy leads to more rapid return of urinary continence.Urology. 1998; 51: 960
- Pain and morbidity of an extensive prostate 10-biopsy protocol: a prospective study in 289 patients.J. Urol. 2002; 167: 218-221
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© 2002 Elsevier Science B.V. Published by Elsevier Inc. All rights reserved.
