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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 2  |  Page : 75-79

Association of local anesthetic method and prostate volume with the occurrence of prostate biopsy complications


1 Department of Surgery, Ahmadu Bello University and Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Surgery, Barau Dikko Teaching Hospital, Kaduna, Kaduna State, Nigeria
3 Department of Surgery, Federal Medical Center, Bida, Niger State, Nigeria

Date of Submission23-Mar-2020
Date of Decision08-May-2020
Date of Acceptance27-May-2020
Date of Web Publication13-Jul-2021

Correspondence Address:
Dr. Musliu Adetola Tolani
Department of Surgery, Ahmadu Bello University and Ahmadu Bello University Teaching Hospital, P.M.B. 06, Shika, Zaria, Kaduna State
Nigeria
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DOI: 10.4103/smj.smj_23_20

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  Abstract 


Background: Due to the invasive nature of prostate biopsy, it is associated with various complications. The study aimed to determine the association of local anesthetic method and prostate volume with the occurrence of these prostate biopsy complications. Materials and Methods: It was a prospective study carried out in 106 patients with indications for prostate biopsy. They were randomized into two equal groups receiving either intrarectal lidocaine gel or periprostatic nerve block. Prostate volume was determined using transrectal ultrasound, and patients were further divided into three prostate volume classes (20-40 ml, 40-100 ml, and ≥100 ml). Systematic sextant prostate biopsy was done, and the occurrence of complications (pain, bleeding, infection, and urinary retention) was documented. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software. Results: The pain scores of patients were similar irrespective of their prostate volume even with the use of different types of anesthesia. There was no significant tendency for the occurrence of bleeding, infection, and voiding complications when periprostatic nerve block or intrarectal lidocaine gel was used for pain relief. Postbiopsy cystourethritis was, however, significantly associated with the volume of the prostate (P = 0.006). Conclusion: The choice of local anesthesia does not affect the occurrence of complications following transrectal prostate biopsy. There is, however, a significant potential for the development of postbiopsy cystourethritis in patients with larger prostates.

Keywords: Complications, local anesthesia, prostate biopsy, prostate volume


How to cite this article:
Tolani MA, Ahmed M, Hamza BK, Muhammad MS, Bello A, Maitama HY. Association of local anesthetic method and prostate volume with the occurrence of prostate biopsy complications. Sahel Med J 2021;24:75-9

How to cite this URL:
Tolani MA, Ahmed M, Hamza BK, Muhammad MS, Bello A, Maitama HY. Association of local anesthetic method and prostate volume with the occurrence of prostate biopsy complications. Sahel Med J [serial online] 2021 [cited 2021 Sep 17];24:75-9. Available from: https://www.smjonline.org/text.asp?2021/24/2/75/321243




  Introduction Top


Prostate cancer detection at the early stage of the disease is important to increase survival and optimize the health-related quality of life of patients.[1] Diagnosis requires biopsy of the prostate gland as a day-case procedure in the presence of abnormal prostate-specific antigen levels or suspicious findings on digital rectal examination or prostate imaging.[2] Due to the invasive nature of the transrectal ultrasound probe and needle puncture in this procedure, it is associated with pain, bleeding, infection, and voiding complications.[3] As a result of these, its expectation is associated with anxiety not only related to the fear of complications but also the fear of positive cancer diagnosis.[4]

Although periprostatic nerve block is the gold standard for pain relief during a prostate biopsy, it is known that the local anesthetic agent injected during apical block needs to extend from the prostate apex, through the lateral borders of the prostate, to the seminal vesicle-prostatic angle.[5] Thus, an effective blockade of periprostatic nerves may be inversely related to the prostate volume.

Intrarectal lidocaine gel is also used as anesthesia for this procedure in low-resource settings. Although it is known that its efficacy is limited by the possibility of absorption of the active agent into the hemorrhoidal circulation, it is not certain if the use of the same concentration of the drug can affect its efficacy for pain relief in patients with different prostate volumes. Furthermore, few prospective studies have analyzed the impact of anesthetic techniques and the volume of the prostate on the incidence of other postbiopsy complications.

This study aimed to determine the association of local anesthetic method and prostate volume with the occurrence of postprostate biopsy complications.


  Materials and Methods Top


This prospective randomized study was carried out between June 2016 and June 2017 in the urology division of Ahmadu Bello University Teaching Hospital, Zaria. Our hospital is a first-generation tertiary teaching hospital in northern Nigeria with numerous specialties in medical care supported by modern diagnostic and treatment facilities. It has a bed capacity of 520, and it is located about 80 km from Kaduna, the capital of Kaduna State. The urology division of the hospital provides specialized services including surgeries, out-patient clinics, day-case procedures, and imaging services.

The study population was patients with suspected prostate cancer. Those with asymmetrical or nodular prostate on rectal examination, hypoechoic nodules, or breached capsule on transrectal ultrasound scan and prostate-specific antigen and prostate-specific antigen density >4 ng/ml and 0.15 ng/ml/g, respectively, were included in the study. Patients who had painful anorectal conditions such as anal fissure, those with acute urinary tract infection, or those with allergy to lidocaine were excluded from this study.

The study was carried out according to the guidelines in the Declaration of Helsinki. Clearance from the Health Research Ethics Committee of Ahmadu Bello University Teaching Hospital, Zaria (ABUTH/HREC/N17/2015), obtained on June 3, 2015, covered this work. Written informed consent was obtained from all patients, and confidentiality was ensured.

Sample size was calculated using the formula for the comparison of two means.[6] Assumptions of a significance level of 0.05 consistent with 95% confidence interval and a test power of 90% were made. From a previous study by Rodriguez et al., the effect size of clinical importance was calculated as 1.03 while the standard deviation of the mean was 1.69 and 1.26 in the lidocaine instillation group and periprostatic nerve block group, respectively.[5] A minimum sample size of 88 was calculated for this study. This was increased to 106 patients to account for potential loss to attrition. Patients were randomized equally into lidocaine instillation group and periprostatic nerve block group.

Data on the age of each patient were obtained. Nonsteroidal anti-inflammatory drugs, warfarin, and analgesia were stopped 7 days, 3 days, and a day before the biopsy, respectively. Intravenous gentamicin was administered as antibiotic prophylaxis 30 min before the procedure.

Patients had prostate volume measurement and subsequent prostate biopsy in the left lateral decubitus position. Transrectal ultrasound (Mindray Digital Ultrasonic Diagnostic Imaging System, DP-20 Model) was used to determine the prostate volume based on the ellipsoid formula, which facilitated further subdivision of patients into three different prostate volume classes (20-40 ml, 40-100 ml, and ≥100 ml).

Five minutes after the administration of 10 ml of 2% intrarectal lidocaine gel in the rectum or the completion of the periprostatic nerve block with 10 ml of 2% lidocaine solution, systematic sextant biopsies were taken under transrectal ultrasound guidance with size 18G tru-cut biopsy needle mounted on a Bard® Magnum® Reusable Core Biopsy System.

The pain felt during the prostate biopsy was assessed using the 11-point Numeric Rating Scale. Patients were also followed up immediately after the procedure and weekly for the next 2 weeks for the occurrence of bleeding, infection, and voiding-related complications.

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 20.0 (IBM Corp., Armonk, New York, USA). Continuous variables were expressed as median (interquartile range), while categorical variables were summarized as frequencies with percentages. Kruskal–Wallis test and Mann–Whitney U test were used to compare pain scores within and between the local anesthesia technique groups, respectively. The relationship between the presence of complications and type of anesthesia, as well as the prostate volume groups, was analyzed using Chi-square test. Linear regression was used to analyze the association of age of patients with the level of pain perception. P < 0.05 was defined as significant in this study.


  Results Top


One hundred and six patients in two equal groups of 53 patients receiving intrarectal lidocaine gel or periprostatic nerve block were included in this analysis. About two-fifths of all patients, 43 (40.6%), were in the 60–69 years' age group, 40 (37.7%) were in the 70–79 years' age group, while 18 (17.0%) and 5 (4.7%) were <60 years and above 79 years, respectively. The median prostate volumes of patients in the 20–40 ml, 40–100 ml, and ≥100 ml groups were 28.3 (22.5–34.2) g, 59.0 (48.2–73.0) g, and 124.4 (109.1–184.2) g, respectively.

Age was predictive of the degree of pain perception among those who had intrarectal lidocaine gel (P = 0.024, B-coefficient = 0.088, confidence interval: 0.012–0.164) but not among those who had periprostatic nerve block (P = 0.488).

Generally, the pain scores of patients were similar irrespective of their prostate volume (P = 0.822). While considering patients who had only intrarectal lidocaine gel, although comparatively lower pain scores were recorded at prostate volumes of 20–40 ml, 6.0 (5.0–7.8), the difference in pain scores with those having larger prostate volumes of 40–100 ml and ≥100 ml using this same anesthetic technique method was not significant (P = 0.516). In the same regard, the pain score of patients who had periprostatic nerve block was 3.0 (1.5–4.5) at prostate volumes of 20–40 ml, 2.0 (1.8–4.0), at prostate volumes of 40–100 ml and 4.0 (1.0–5.3) at prostate volumes of ≥100 ml (P = 0.682, respectively) [Table 1]. At either small prostate volumes of 20–40 ml or larger prostate volumes of 40–100 ml and ≥100 ml, periprostatic block was more effective than intrarectal lidocaine gel (P = 0.003, P = 0.001, and P = 0.048, respectively).
Table 1: Association of prostate volume with the level of pain perception during prostate biopsy

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Except for cystourethritis which was more common when a periprostatic nerve block is used (39.6% vs. 28.3%), bleeding and voiding complications were more common when intrarectal lidocaine gel was used for pain relief during prostate biopsy. However, the technique of local anesthesia does not significantly affect the postbiopsy complication rate, as shown in [Table 2].
Table 2: Association of the technique of local anesthesia with the incidence of other postprostate biopsy complications

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On the other hand, the occurrence of cystourethritis following prostate biopsy was significantly associated with the volume of the prostate in all patients [Table 3].
Table 3: Association of prostate volume with the incidence of other postprostate biopsy complications

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  Discussion Top


The potential for the development of complications is a concern for most patients undergoing prostate biopsy. These complications include varying severity of pain, bleeding complications (rectal bleeding and hematuria), infection complications (fever, dysuria, and cystourethritis), and acute urinary retention.

In this study, there was a 0.1-point increase in pain for every 1-year increase in age (P = 0.024). It is possible that as the age increases within the elderly age group, which constituted most patients included in this study, there is reduced coping capacity and worse tolerance for pain during the core biopsy of the prostate. Giannarini et al. observed an inverse relationship between age and pain intensity during prostate biopsy and attributed this to the high tone of the anal sphincter in the younger age groups. The difference in findings with our study might be related to the relatively lower average age of the patients they studied. However, Bastide et al. did not find a significant relationship between age and pain perception during the procedure.[7],[8] Notwithstanding, optimal anesthesia using periprostatic nerve block can eliminate any age-related variation in pain perception during the procedure (P = 0.488).

The average pain perception of all patients included in this study was similar irrespective of the volume of the prostate (P = 0.822). Leibovici et al. and Iremashvili et al. reported similar findings in their work.[9],[10] In contrast to these findings, Gómez-Gómez et al. noted that pain was independently associated with prostate volume during prostate biopsy.[4]

There was no significant decrease in the efficacy of both types of local pain relief methods with an increase in the volume of the prostate. This might mean that the volume of lidocaine solution injected was enough to separate tissue planes and block the sparsely distributed nerve fibers in larger prostates.[11] It also implies that the anesthetic effect of administration of the gel formulation of lidocaine intrarectally, whose effect is predominantly related to sphincter relaxation, does not have any relationship with the volume of the prostate. Luan et al., however, observed that the pain score of patients significantly increased across increasing prostate volume groups in patients who had lidocaine gel anesthesia and in those who had lidocaine nerve block anesthesia.[1]

The periprostatic nerve block in this study was more effective than the intrarectal lidocaine gel at all prostate volume groups in consonance with the observation of Luan et al.[1] This is in contrast to the finding of Ding et al. in which pain scores were similar between the two groups at the lowest prostate volume.[12] This might be related to a difference in cutoff values for small prostate volume used in both studies. While it was 50 g in their work, the benchmark for small prostates in this study was 40 g.

Findings in this study also showed that there is a tendency for bleeding complications to occur in patients being administered intrarectal lidocaine gel than in those receiving periprostatic nerve block for prostate biopsy. This could be because of the relatively lesser patient comfort felt by patients receiving the earlier type of anesthesia. However, cystourethritis appeared to be more common in those who had periprostatic nerve block (28.3% vs. 39.6%). Additional needle puncture and infiltration pressure for apical nerve block anesthesia have the potential to drive rectal bacterial flora into the highly vascular area of the prostate and increase the risk of infection.[13] However, the difference in the above complication rates between the local anesthesia groups did not reach statistical significance.

Irrespective of the type of anesthesia, the occurrence of postbiopsy cystourethritis was significantly associated with the volume of the prostate. This could be because of possible urine stasis and the favorable environment for bacterial proliferation in patients with larger prostate volumes.


  Conclusion Top


The choice of periprostatic nerve block or intrarectal lidocaine gel does not affect the occurrence of complications following transrectal prostate biopsy. However, there is a significant potential for the development of postbiopsy cystourethritis in patients with larger prostates.

Acknowledgment

We would like to thank Staff of the Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Luan Y, Huang TB, Gu X, Zhou GC, Lu SM, Tao HZ, et al. Effect of prostate volume on the peripheral nerve block anesthesia in the prostate biopsy: A strobe-compliant study. Medicine (Baltimore) 2016;95:e4184.  Back to cited text no. 1
    
2.
Lunacek A, Mrstik C, Simon J, Frauscher F, Schwentner C, Radmayr C, et al. Combination of lidocaine suppository and periprostatic nerve block during transrectal prostate biopsy: A prospective randomized trial. Int J Urol 2014;21:1126-30.  Back to cited text no. 2
    
3.
Cormio L, Lorusso F, Selvaggio O, Perrone A, Sanguedolce F, Pagliarulo V, et al. Noninfiltrative anesthesia for transrectal prostate biopsy: A randomized prospective study comparing lidocaine-prilocaine cream and lidocaine-ketorolac gel. Urol Oncol 2013;31:68-73.  Back to cited text no. 3
    
4.
Gómez-Gómez E, Ramírez M, Gómez-Ferrer A, Rubio-Briones J, Iborra I, Carrasco-Valientea J, et al. Assessment and clinical factors associated with pain in patients undergoing transrectal prostate biopsy . Actas Urol Españolas (English Ed) 2015;39:414-9.  Back to cited text no. 4
    
5.
Rodriguez A, Kyriakou G, Leray E, Lobel B, Guillé F. Prospective study comparing two methods of anaesthesia for prostate biopsies: Apex periprostatic nerve block versus intrarectal lidocaine gel: Review of the literature. Eur Urol 2003;44:195-200.  Back to cited text no. 5
    
6.
Kirkwood BR, Sterne JA. Calculation of required sample size. In: Essential Medical Statistics. 2nd ed., Vol. 35. Massachusetts: Blackwell Science Ltd.; 2003. p. 413-28.  Back to cited text no. 6
    
7.
Bastide C, Lechevallier E, Eghazarian C, Ortega JC, Coulange C. Tolerance of pain during transrectal ultrasound-guided biopsy of the prostate: Risk factors. Prostate Cancer Prostatic Dis 2003;6:239-41.  Back to cited text no. 7
    
8.
Giannarini G, Autorino R, Valent F, Mogorovich A, Manassero F, De Maria M, et al. Combination of perianal-intrarectal lidocaine-prilocaine cream and periprostatic nerve block for pain control during transrectal ultrasound guided prostate biopsy: A randomized, controlled trial. J Urol 2009;181:585-91.  Back to cited text no. 8
    
9.
Leibovici D, Zisman A, Siegel YI, Sella A, Kleinmann J, Lindner A. Local anesthesia for prostate biopsy by periprostatic lidocaine injection: A double-blind placebo controlled study. J Urol 2002;167:563-5.  Back to cited text no. 9
    
10.
Iremashvili VV, Chepurov AK, Kobaladze KM, Gamidov SI. Periprostatic local anesthesia with pudendal block for transperineal ultrasound-guided prostate biopsy: A randomized trial. Urology 2010;75:1023-7.  Back to cited text no. 10
    
11.
Bingqian L, Peihuan L, Yudong W, Jinxing W, Zhiyong W. Intraprostatic local anesthesia with periprostatic nerve block for transrectal ultrasound guided prostate biopsy. J Urol 2009;182:479-83.  Back to cited text no. 11
    
12.
Ding KK, Xu ZY, Zhang J, Yang DD, Jiang B, Cao Y, et al. Intrarectal local anesthesia versus periprostatic nerve block in transrectal prostate biopsy for patients with different prostate volumes: A prospective randomized controlled trial. Zhonghua Nan Ke Xue 2018;24:393-8.  Back to cited text no. 12
    
13.
Obek C, Onal B, Ozkan B, Onder AU, Yalçin V, Solok V. Is periprostatic local anesthesia for transrectal ultrasound guided prostate biopsy associated with increased infectious or hemorrhagic complications? A prospective randomized trial. J Urol 2002;168:558-61.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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