Addition of intrarectal local analgesia to periprostatic nerve block improves pain control for transrectal ultrasonography‐guided prostate biopsy: A systematic review and meta‐analysis

Abstract

Abbreviations & AcronymsObjectives: To evaluate the efficacy and safety of combined intrarectal local analgesia and periprostatic nerve block versus periprostatic nerve block alone for pain control during transrectal ultrasound-guided prostate biopsy. Methods: We comprehensively searched PubMed, Embase and the Cochrane Library trials. Studies comparing the two techniques were identified and pooled for cumulative analysis. The outcome measurements included visual pain scales of three consecutive procedures of transrectal ultrasound-guided prostate biopsy, as well as short-term postoperative complication rates. Results: There were 18 studies that were finally eligible for the quantitative analysis involving 2076 participants. Combined modalities significantly reduced the pain associated with probe manipulation (weighted mean difference −2.06, 95% confidence interval −2.77 to −1.35, P < 0.001), anesthesia infiltration (weighted mean difference −1.45, 95% confidence interval −2.20 to −0.70, P < 0.001) and needle biopsy (weighted mean difference −0.55, 95% confidence interval −0.76 to −0.34, P < 0.001). Subgroup analyses assessing different local analgesics showed that local anesthetics are generally more effective than myorelaxant and non-steroidal anti-inflammatory drugs. Lidocaine-prilocaine cream proved the most effective in pain control regardless of the origin of pain. No significant difference of short-term postoperative complications (fever, dysuria, acute urinary retention, hematuria, hematospermia and rectal bleeding) was found between the two techniques. The only side-effect associated with local analgesics was headache reported in studies using glyceryl trinitrate ointment. Conclusions: Combined modalities show better analgesic efficacy than periprostatic nerve block alone for transrectal ultrasound-guided prostate biopsy without increased morbidities. Among the various local analgesics, lidocaine-prilocaine cream seems to offer the best overall efficacy.

Complications After Systematic, Random, and Image-guided Prostate Biopsy

“…The magnitude of this effect was higher in younger men, especially if with an enlarged prostate and lower anorectal compliance 44 .A recent meta-analysis confirmed that the combination of local analgesia and PPNB significantly reduced pain associated with probe manipulation, anesthesia, infiltration and needle biopsy. Subgroup analyses suggest that lidocaine-prilocaine cream proved the most effective pain control regardless of the origin of pain 38 . Moreover, Cormio et al compared the efficacy of topical anesthesia (combined lidocaine-prilocaine cream with lidocaine-ketorolac gel) with the combination of topical and infiltrating anesthesia (lidocaine-prilocaine cream plus PPNB): both anaesthetic regimens provided almost comparable pain at probe insertion, movement and during sampling, but patients receiving the second regimen reported significantly greater maximal procedural pain scores (p<0.001).…”

“…A combination of 2.5% lidocaine and 2.5% prilocaine (EMLA© cream) was found to be superior to other topical anaesthetic agents, possibly due to its longer duration (2-5 hours) and deeper tissue infiltration 37 . Furthermore, suppositories based on nonsteroidal anti-inflammatories (e.g., diclofenac) can be used to reduce the local and systematic anti-inflammatory effect, but do not significantly reduce pain from probe manipulation and biopsy sampling 38 . Comparing lidocaine gel with lidocaine-ketorolac and lidocaine-prilocaine cream, the latter was the most effective on probe-related pain, whereas lidocaine-ketorolac gel was most useful for sampling-related pain 39 .…”

Prostat Biyopsisi Öyküsü Olan Hastalarda Transrektal Ultrason Kılavuzluğunda Yapılan Prostat Rebiyopsisi Sırasında Ağrı Skorları Değişiyor mu?

“…Transrektal ultrason kılavuzluğunda yapılan prostat biyopsisi (TRUS-PBx) prostat kanserinin tanısında günümüzdeki altın standart yöntemdir. Hastalardan bazıları bu işlemi rahatlıkla tolere edebilirken, bazıları çok ciddi ağrı ve rahatsızlık duymaktadırlar (2). Irani ve ark.…”

Editorial Comment from Dr Woo to Addition of intrarectal local analgesia to periprostatic nerve block improves pain control for transrectal ultrasonography‐guided prostate biopsy: A systematic review and meta‐analysis

“…This systematic review and meta‐analysis by Wang et al . challenges all of us to rethink the potential positive benefits that IRLA can have to minimize transrectal ultrasound prostate biopsies‐associated pain, and its place appears to be in combination with PPNB …”