- Email: [email protected]
Do unto others—why I would want anesthesia for my prostate biopsy
EDITORIAL
DO UNTO OTHERS—WHY I WOULD WANT ANESTHESIA FOR MY PROSTATE BIOPSY MARK S. SOLOWAY
U
nless a dramatic new development occurs in our methods to diagnose prostate cancer, an abnormal blood test (currently prostate-specific antigen measurement) or suspicious finding on palpation of the prostate is followed by transrectal ultrasound-guided prostate biopsies (TRUSB). TRUS equipment has improved. The probes are smaller and provide superb images of the prostate. Approximately 500,000 prostate biopsies are performed in the United States annually. This may be a conservative estimate, because more than 220,000 cases of prostate cancer will be diagnosed in 2003. It is not surprising that TRUSB provokes considerable anxiety for the patient. First and foremost is the patient’s concern that he might have prostate cancer. To add to these concerns, the clinician explains the procedure: a lubricated probe will be placed in the rectum and between 6 and 12 (or more) biopsies will be obtained. Moreover, if the survey performed by Davis et al.1 is representative, more than one third of urologists do not provide any analgesia for this procedure. Some prescribe an oral analgesic or rely on a lidocaine rectal suppository or gel. Only 11% use a periprostatic nerve block (PNB) (survey in 2001). In contrast, when a patient sits in a dentist chair and agrees to have a procedure that may be accompanied by pain, he expects that the dentist will minimize the discomfort associated with the procedure. To emphasize their desire to minimize pain, a topical anesthetic usually precedes the lidocaine injection. Dentists are aware that many of their patients associate dental work with pain. Thus, most do everything they can to minimize patient discomfort. Like most of you, I want to From the Department of Urology, University of Miami School of Medicine, Miami, Florida Reprint requests: Mark S. Soloway, M.D., Department of Urology, University of Miami School of Medicine, P.O. Box 016960 (M814), 1400 Northwest 10th Avenue, Room 506, Miami, FL 33101 Submitted: May 22, 2003, accepted (with revisions): July 10, 2003 © 2003 ELSEVIER INC. ALL RIGHTS RESERVED
avoid pain and am not bashful about requesting ample anesthesia when I am the “subject.” “Do unto others. . . .” A number of our colleagues have documented that our patients are not only anxious before having a prostate biopsy but many experience moderate to severe pain.2– 4 Younger patients and those with smaller prostates indicate more pain. Biopsies from the apex are more painful than those obtained from the base. Like many of you, I totally missed the 1996 article by Nash et al.5 They injected either lidocaine or saline into the nerve bundles adjacent to the prostate. Patients were asked to grade (0 to 5) the pain associated with the biopsies from each side. Patients experienced less pain on the side injected with lidocaine. Although I am certain that these investigators routinely performed a PNB on subsequent patients, few of us adopted their technique for minimizing pain associated with TRUSB. In the fall of 1999, I was performing prostate biopsies and men¨ bek, a urologic oncology fellow tioned to Can O working with me at that time, that there should be a way of minimizing the pain associated with TRUSB. He indicated that a study had been performed in Turkey that suggested the benefit of PNB.6 I was immediately struck by the concept. Up to that point, I had minimized the pain my patients experienced as I performed their TRUSB. I accepted their discomfort as a necessary part of the procedure. Although most men did not vigorously complain, they frequently kept a running count of the number of biopsies and their discomfort increased with the number of biopsies. Some patients became diaphoretic and barely tolerated the procedure. In January 2000, we reported on our first 50 TRUSB procedures using a PNB.7 The benefit was readily apparent. A dramatic reduction occurred in the amount of discomfort associated with TRUSB. In an editorial comment to that article, Jay Gillenwater indicated that he had been using a PNB for more than 2 years, having learned the technique from Haaken Ragde. He indicated that as a result of UROLOGY 62: 973–975, 2003 • 0090-4295/03/$30.00 doi:10.1016/S0090-4295(03)00789-1 973
TABLE I. Randomized trials of periprostatic nerve block Nerve Block* Author
Year
No
Yes
Biopsies (n)
Alavi et al.8 Pareek et al.9 Wu et al.10 Kaver et al.11 Leibovici et al.12 Lynn et al.13 Obek et al.14 Schostak et al.15 Stirling et al.16 Von Knobloch et al.17 Walker et al.18
2001 2001 2001 2002 2002 2002 2002 2002 2002 2002 2002
3.7† 4.7 (S) 1.6 (S) 5.0 4.1 (S) 4.3 (S) 1.6 2.3 4.3 3.3 3.6 (S)
2.4 2.7 1.2 1.6 3.0 0.5 1.0 1.1 2.8 1.8 2.5
6–14 6 12 10 7–8 6 10 10 9 10 6
KEY: (S) ⫽ saline injection. * Numbers are patient’s indication of pain on a 0 –10 linear visual analog scale (0 ⫽ none, 10 ⫽ worst imaginable); numbers rounded to tenths where applicable. † Included use of intrarectal lidocaine gel.
the PNB most patients had no discomfort during TRUSB. Three prospective randomized trials that evaluated the efficacy of PNB were published in 2001. Alavi et al.8 compared the PNB to intrarectal lidocaine gel and found that the pain scores (using the 0 to 10 visual analog scale) were significantly lower in patients who had received a PNB (Table I). Pareek et al.9 injected either lidocaine or saline in the region of the periprostatic nerves. Those who received lidocaine reported significantly less pain. Wu et al.10 did not find that a PNB reduced the pain associated with TRUSB, although the mean pain scores were low in those who did and those who did not receive lidocaine. Interest in reducing the pain associated with TRUSB has increased dramatically. In 2002, eight prospective randomized trials were published.11–18 Although differences occurred in the precise placement of the anesthetic when performing a PNB, all concluded that a significant and clinically meaningful reduction in pain resulted as indicated by the patients’ grading of pain on the visual analog scale. It is important to note the variation in the mean pain scores not only for those patients who received a PNB but also for those who did not. Are some clinicians more gentle than others? Are some patients better prepared? Undoubtedly, these factors are important. During the past 3 years, I have not altered the way I perform a PNB. With the prostate viewed in the sagittal plane, a 7-in., 22-gauge spinal needle is placed through the port of the ultrasound probe. The needle is positioned at the junction between the base of the prostate and the seminal vesicle. When the fluid is injected in the proper plane, one observes a hypoechoic area that displaces the seminal vesicle from the rectal wall as the injection 974
proceeds. I usually place 3 mL at this site. I relocate the needle to the mid-portion of the prostate and inject an additional 1 mL between the rectal wall and the prostate. This is intended to be in the region of the neurovascular bundle. Remaining on the same side, I place 1 or 2 mL between the rectal wall and the apex of the prostate. I repeat the procedure on the contralateral side of the prostate, once again concentrating on the location of the neurovascular bundle. While I wait for the anesthesia to take effect, I measure the size of the prostate and review it for any specific abnormalities and then proceed with the biopsies. The PNB does not add to the morbidity of TRUSB.14 The studies are conclusive. A PNB dramatically reduces the pain associated with prostate biopsies. Do unto your patients as I believe you would want done unto you if you were to undergo a prostate biopsy. REFERENCES 1. Davis M, Sopher M, Kim SS, et al: The procedure of transrectal ultrasound guided biopsy of the prostate: a survey of patient preparation and biopsy technique. J Urol 16: 566 – 570, 2002. 2. Collins GN, Lloyd SN, Hehir M, et al: Multiple transrectal ultrasound-guided prostate biopsies—true morbidity and patient acceptance. Br J Urol 71: 460 –463, 1993. 3. Crundwell MC, Cooke PW, and Wallace DMA: Patients’ tolerance of transrectal ultrasound-guided prostate biopsy: an audit of 104 cases. BJU Int 83: 792–795, 1999. 4. Aus G, Hermansson CG, Hugosson J, et al: Transrectal ultrasound examination of the prostate: complications and acceptance by patients. Br J Urol 71: 457–459, 1993. 5. Nash PA, Bruce JE, Indudhara R, et al: Transrectal ultrasound guided prostatic nerve blockade eases systematic needle biopsy of the prostate. J Urol 155: 607–609, 1996. 6. Onder AU, Citci A, Yaycioglu O, et al: To what degree prostatic nerve blockade improve the patient tolerance in transrectal ultrasound guided systematic biopsy? Turk Uroloji Dergisi 24: 324 –329, 1998. UROLOGY 62 (6), 2003
7. Soloway MS, and Obek C: Periprostatic local anesthesia before ultrasound guided prostate biopsy. J Urol 163: 172– 173, 2000. 8. Alavi AS, Soloway MS, Vaidya A, et al: Local anesthesia for ultrasound guided prostate biopsy: a prospective randomized trial comparing two methods. J Urol 166: 1343–1345, 2001. 9. Pareek G, Armenakas NA, and Fracchia JA: Periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a randomized, double blind, placebo controlled study. J Urol 166: 894 –897, 2001. 10. Wu CL, Carter HB, Naqibuddin M, et al: Effect of local anesthetics on patient recovery after transrectal biopsy. Urology 57: 925–929, 2001. 11. Kaver I, Mabjessh NJ, and Matzkin H: Randomized prospective study of periprostatic local anesthesia during transrectal ultrasound-guided prostate biopsy. Urology 59: 405– 408, 2002. 12. Leibovici D, Zisman A, Siegel YI, et al: Local anesthesia for prostate biopsy by periprostatic lidocaine injection: a double-blind placebo controlled study. J Urol 167: 563–565, 2002.
UROLOGY 62 (6), 2003
13. Lynn NNK, Collin GN, Brown SCW, et al: Periprostatic nerve block gives better analgesia for prostatic biopsy. BJU Int 90: 424 –426, 2002. 14. Obek C, Onal B, Ozkan B, et al: Is periprostatic local anesthesia for transrectal ultrasound guided prostate biopsy associated with increased infectious or hemorrhagic complications? A prospective randomized trial. J Urol 168: 558 –561, 2002. 15. Schostak M, Christoph F, Miller M, et al: Optimizing local anesthesia during 10-core biopsy of the prostate. Urology 60: 253–257, 2002. 16. Stirling BN, Schockley KF, Carothers GG, et al: Comparison of local anesthesia techniques during transrectal ultrasound-guided biopsies. Urology 60: 89 –92, 2002. 17. Von Knobloch R, Weber J, Varga Z, et al: Bilateral fineneedle administered local anesthetic nerve block for pain controlled during TRUS-guided multi-core prostate biopsy: a prospective randomized trial. Eur Urol 41: 508 –514, 2002. 18. Walker AE, Schelvan C, Rockall AG, et al: Does pericapsular lignocaine reduce pain during transrectal ultrasonography-guided biopsy of the prostate? BJU Int 90: 883–886, 2002.
975
DO UNTO OTHERS—WHY I WOULD WANT ANESTHESIA FOR MY PROSTATE BIOPSY MARK S. SOLOWAY
U
nless a dramatic new development occurs in our methods to diagnose prostate cancer, an abnormal blood test (currently prostate-specific antigen measurement) or suspicious finding on palpation of the prostate is followed by transrectal ultrasound-guided prostate biopsies (TRUSB). TRUS equipment has improved. The probes are smaller and provide superb images of the prostate. Approximately 500,000 prostate biopsies are performed in the United States annually. This may be a conservative estimate, because more than 220,000 cases of prostate cancer will be diagnosed in 2003. It is not surprising that TRUSB provokes considerable anxiety for the patient. First and foremost is the patient’s concern that he might have prostate cancer. To add to these concerns, the clinician explains the procedure: a lubricated probe will be placed in the rectum and between 6 and 12 (or more) biopsies will be obtained. Moreover, if the survey performed by Davis et al.1 is representative, more than one third of urologists do not provide any analgesia for this procedure. Some prescribe an oral analgesic or rely on a lidocaine rectal suppository or gel. Only 11% use a periprostatic nerve block (PNB) (survey in 2001). In contrast, when a patient sits in a dentist chair and agrees to have a procedure that may be accompanied by pain, he expects that the dentist will minimize the discomfort associated with the procedure. To emphasize their desire to minimize pain, a topical anesthetic usually precedes the lidocaine injection. Dentists are aware that many of their patients associate dental work with pain. Thus, most do everything they can to minimize patient discomfort. Like most of you, I want to From the Department of Urology, University of Miami School of Medicine, Miami, Florida Reprint requests: Mark S. Soloway, M.D., Department of Urology, University of Miami School of Medicine, P.O. Box 016960 (M814), 1400 Northwest 10th Avenue, Room 506, Miami, FL 33101 Submitted: May 22, 2003, accepted (with revisions): July 10, 2003 © 2003 ELSEVIER INC. ALL RIGHTS RESERVED
avoid pain and am not bashful about requesting ample anesthesia when I am the “subject.” “Do unto others. . . .” A number of our colleagues have documented that our patients are not only anxious before having a prostate biopsy but many experience moderate to severe pain.2– 4 Younger patients and those with smaller prostates indicate more pain. Biopsies from the apex are more painful than those obtained from the base. Like many of you, I totally missed the 1996 article by Nash et al.5 They injected either lidocaine or saline into the nerve bundles adjacent to the prostate. Patients were asked to grade (0 to 5) the pain associated with the biopsies from each side. Patients experienced less pain on the side injected with lidocaine. Although I am certain that these investigators routinely performed a PNB on subsequent patients, few of us adopted their technique for minimizing pain associated with TRUSB. In the fall of 1999, I was performing prostate biopsies and men¨ bek, a urologic oncology fellow tioned to Can O working with me at that time, that there should be a way of minimizing the pain associated with TRUSB. He indicated that a study had been performed in Turkey that suggested the benefit of PNB.6 I was immediately struck by the concept. Up to that point, I had minimized the pain my patients experienced as I performed their TRUSB. I accepted their discomfort as a necessary part of the procedure. Although most men did not vigorously complain, they frequently kept a running count of the number of biopsies and their discomfort increased with the number of biopsies. Some patients became diaphoretic and barely tolerated the procedure. In January 2000, we reported on our first 50 TRUSB procedures using a PNB.7 The benefit was readily apparent. A dramatic reduction occurred in the amount of discomfort associated with TRUSB. In an editorial comment to that article, Jay Gillenwater indicated that he had been using a PNB for more than 2 years, having learned the technique from Haaken Ragde. He indicated that as a result of UROLOGY 62: 973–975, 2003 • 0090-4295/03/$30.00 doi:10.1016/S0090-4295(03)00789-1 973
TABLE I. Randomized trials of periprostatic nerve block Nerve Block* Author
Year
No
Yes
Biopsies (n)
Alavi et al.8 Pareek et al.9 Wu et al.10 Kaver et al.11 Leibovici et al.12 Lynn et al.13 Obek et al.14 Schostak et al.15 Stirling et al.16 Von Knobloch et al.17 Walker et al.18
2001 2001 2001 2002 2002 2002 2002 2002 2002 2002 2002
3.7† 4.7 (S) 1.6 (S) 5.0 4.1 (S) 4.3 (S) 1.6 2.3 4.3 3.3 3.6 (S)
2.4 2.7 1.2 1.6 3.0 0.5 1.0 1.1 2.8 1.8 2.5
6–14 6 12 10 7–8 6 10 10 9 10 6
KEY: (S) ⫽ saline injection. * Numbers are patient’s indication of pain on a 0 –10 linear visual analog scale (0 ⫽ none, 10 ⫽ worst imaginable); numbers rounded to tenths where applicable. † Included use of intrarectal lidocaine gel.
the PNB most patients had no discomfort during TRUSB. Three prospective randomized trials that evaluated the efficacy of PNB were published in 2001. Alavi et al.8 compared the PNB to intrarectal lidocaine gel and found that the pain scores (using the 0 to 10 visual analog scale) were significantly lower in patients who had received a PNB (Table I). Pareek et al.9 injected either lidocaine or saline in the region of the periprostatic nerves. Those who received lidocaine reported significantly less pain. Wu et al.10 did not find that a PNB reduced the pain associated with TRUSB, although the mean pain scores were low in those who did and those who did not receive lidocaine. Interest in reducing the pain associated with TRUSB has increased dramatically. In 2002, eight prospective randomized trials were published.11–18 Although differences occurred in the precise placement of the anesthetic when performing a PNB, all concluded that a significant and clinically meaningful reduction in pain resulted as indicated by the patients’ grading of pain on the visual analog scale. It is important to note the variation in the mean pain scores not only for those patients who received a PNB but also for those who did not. Are some clinicians more gentle than others? Are some patients better prepared? Undoubtedly, these factors are important. During the past 3 years, I have not altered the way I perform a PNB. With the prostate viewed in the sagittal plane, a 7-in., 22-gauge spinal needle is placed through the port of the ultrasound probe. The needle is positioned at the junction between the base of the prostate and the seminal vesicle. When the fluid is injected in the proper plane, one observes a hypoechoic area that displaces the seminal vesicle from the rectal wall as the injection 974
proceeds. I usually place 3 mL at this site. I relocate the needle to the mid-portion of the prostate and inject an additional 1 mL between the rectal wall and the prostate. This is intended to be in the region of the neurovascular bundle. Remaining on the same side, I place 1 or 2 mL between the rectal wall and the apex of the prostate. I repeat the procedure on the contralateral side of the prostate, once again concentrating on the location of the neurovascular bundle. While I wait for the anesthesia to take effect, I measure the size of the prostate and review it for any specific abnormalities and then proceed with the biopsies. The PNB does not add to the morbidity of TRUSB.14 The studies are conclusive. A PNB dramatically reduces the pain associated with prostate biopsies. Do unto your patients as I believe you would want done unto you if you were to undergo a prostate biopsy. REFERENCES 1. Davis M, Sopher M, Kim SS, et al: The procedure of transrectal ultrasound guided biopsy of the prostate: a survey of patient preparation and biopsy technique. J Urol 16: 566 – 570, 2002. 2. Collins GN, Lloyd SN, Hehir M, et al: Multiple transrectal ultrasound-guided prostate biopsies—true morbidity and patient acceptance. Br J Urol 71: 460 –463, 1993. 3. Crundwell MC, Cooke PW, and Wallace DMA: Patients’ tolerance of transrectal ultrasound-guided prostate biopsy: an audit of 104 cases. BJU Int 83: 792–795, 1999. 4. Aus G, Hermansson CG, Hugosson J, et al: Transrectal ultrasound examination of the prostate: complications and acceptance by patients. Br J Urol 71: 457–459, 1993. 5. Nash PA, Bruce JE, Indudhara R, et al: Transrectal ultrasound guided prostatic nerve blockade eases systematic needle biopsy of the prostate. J Urol 155: 607–609, 1996. 6. Onder AU, Citci A, Yaycioglu O, et al: To what degree prostatic nerve blockade improve the patient tolerance in transrectal ultrasound guided systematic biopsy? Turk Uroloji Dergisi 24: 324 –329, 1998. UROLOGY 62 (6), 2003
7. Soloway MS, and Obek C: Periprostatic local anesthesia before ultrasound guided prostate biopsy. J Urol 163: 172– 173, 2000. 8. Alavi AS, Soloway MS, Vaidya A, et al: Local anesthesia for ultrasound guided prostate biopsy: a prospective randomized trial comparing two methods. J Urol 166: 1343–1345, 2001. 9. Pareek G, Armenakas NA, and Fracchia JA: Periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a randomized, double blind, placebo controlled study. J Urol 166: 894 –897, 2001. 10. Wu CL, Carter HB, Naqibuddin M, et al: Effect of local anesthetics on patient recovery after transrectal biopsy. Urology 57: 925–929, 2001. 11. Kaver I, Mabjessh NJ, and Matzkin H: Randomized prospective study of periprostatic local anesthesia during transrectal ultrasound-guided prostate biopsy. Urology 59: 405– 408, 2002. 12. Leibovici D, Zisman A, Siegel YI, et al: Local anesthesia for prostate biopsy by periprostatic lidocaine injection: a double-blind placebo controlled study. J Urol 167: 563–565, 2002.
UROLOGY 62 (6), 2003
13. Lynn NNK, Collin GN, Brown SCW, et al: Periprostatic nerve block gives better analgesia for prostatic biopsy. BJU Int 90: 424 –426, 2002. 14. Obek C, Onal B, Ozkan B, et al: Is periprostatic local anesthesia for transrectal ultrasound guided prostate biopsy associated with increased infectious or hemorrhagic complications? A prospective randomized trial. J Urol 168: 558 –561, 2002. 15. Schostak M, Christoph F, Miller M, et al: Optimizing local anesthesia during 10-core biopsy of the prostate. Urology 60: 253–257, 2002. 16. Stirling BN, Schockley KF, Carothers GG, et al: Comparison of local anesthesia techniques during transrectal ultrasound-guided biopsies. Urology 60: 89 –92, 2002. 17. Von Knobloch R, Weber J, Varga Z, et al: Bilateral fineneedle administered local anesthetic nerve block for pain controlled during TRUS-guided multi-core prostate biopsy: a prospective randomized trial. Eur Urol 41: 508 –514, 2002. 18. Walker AE, Schelvan C, Rockall AG, et al: Does pericapsular lignocaine reduce pain during transrectal ultrasonography-guided biopsy of the prostate? BJU Int 90: 883–886, 2002.
975