Giannarini Gianluca, Autorino Riccardo, Valent Francesca, Mogorovich Andrea, Manassero Francesca, De Maria Maurizio, Morelli Girolamo, Barbone Fabio, Di Lorenzo Giuseppe, Selli Cesare
Department of Urology, University of Pisa, Pisa, Italy.
J Urol. 2009 Feb;181(2):585-91; discussion 591-3. doi: 10.1016/j.juro.2008.10.002. Epub 2008 Dec 13.
To our knowledge the optimal analgesia during prostate biopsy remains undetermined. We tested the efficacy and safety of combined perianal-intrarectal lidocaine-prilocaine cream and periprostatic nerve block during transrectal ultrasound guided prostate biopsy.
A total of 280 patients were randomized to receive combined perianal-intrarectal lidocaine-prilocaine cream and periprostatic nerve block (group 1), perianal-intrarectal lidocaine-prilocaine cream alone (group 2), periprostatic nerve block alone (group 3) or no anesthesia (group 4) before transrectal ultrasound guided prostate biopsy. Pain was evaluated with a 10-point visual analog scale at subsequent procedural steps, including perianal-intrarectal substance administration, prostate transrectal ultrasound, periprostatic nerve block and sampling. Complications were assessed by self-administered questionnaire and telephone interview.
The groups were comparable in patient age, prostate volume, pathology results and visual analog scale perianal-intrarectal substance administration. Visual analog scale results for transrectal ultrasound were lower in groups 1 and 2 vs 3 and 4 (mean 1.5 and 1.41 vs 5.37 and 5.31, p <0.001) and results for periprostatic nerve block were lower in group 1 vs 3 (mean 1.03 vs 3.74, p <0.001). Results for sampling were lower in groups 1 to 3 vs 4 (mean 0.77, 1.27 and 1.27 vs 4.33, p <0.001) and in group 1 vs 2 and 3 (p <0.001). Stratified analysis showed that visual analog scale sampling was lower in group 1 vs 2 and 3 in patients 65 years old or younger, those with a prostate greater than 49 cc and those with lower anorectal compliance (visual analog scale results for perianal-intrarectal substance administration greater than 2) (p = 0.006, <0.001 and 0.003, respectively). The overall complication rate was similar in all 4 groups (p = 0.87).
Our findings suggest that the combination of perianal-intrarectal lidocaine-prilocaine cream and periprostatic nerve block provides better pain control than the 2 modalities alone during the sampling part of transrectal ultrasound guided prostate biopsy with no increase in the complication rate. The magnitude of this effect is higher in younger men, men with a larger prostate and men with lower anorectal compliance.
据我们所知，前列腺活检期间的最佳镇痛方法尚未确定。我们测试了经直肠超声引导下前列腺活检时联合使用肛周 - 直肠内利多卡因 - 丙胺卡因乳膏和前列腺周围神经阻滞的有效性和安全性。
总共280例患者被随机分为四组，分别在经直肠超声引导下前列腺活检前接受联合肛周 - 直肠内利多卡因 - 丙胺卡因乳膏和前列腺周围神经阻滞（第1组）、单独使用肛周 - 直肠内利多卡因 - 丙胺卡因乳膏（第2组）、单独使用前列腺周围神经阻滞（第3组）或不进行麻醉（第4组）。在随后的操作步骤中，包括肛周 - 直肠内给药、前列腺经直肠超声检查、前列腺周围神经阻滞和采样时，使用10分视觉模拟量表评估疼痛程度。通过自我填写问卷和电话访谈评估并发症情况。
四组患者在年龄、前列腺体积、病理结果以及肛周 - 直肠内给药时的视觉模拟量表评分方面具有可比性。经直肠超声检查的视觉模拟量表评分在第1组和第2组低于第3组和第4组（平均值分别为1.5和1.41，对比5.37和5.31，p<0.001），前列腺周围神经阻滞时的评分在第1组低于第3组（平均值1.03对比3.74，p<0.001）。采样时的评分在第1组至第3组低于第4组（平均值分别为0.77、1.27和1.27对比4.33，p<0.001），且第1组低于第2组和第3组（p<0.001）。分层分析显示，在65岁及以下患者、前列腺体积大于49立方厘米的患者以及肛门直肠顺应性较低（肛周 - 直肠内给药时视觉模拟量表评分大于2）的患者中，第1组采样时的视觉模拟量表评分低于第2组和第3组（p分别为0.006、<0.001和0.003）。四组的总体并发症发生率相似（p = 0.87）。
我们的研究结果表明，在经直肠超声引导下前列腺活检的采样过程中，联合使用肛周 - 直肠内利多卡因 - 丙胺卡因乳膏和前列腺周围神经阻滞比单独使用这两种方法能更好地控制疼痛，且不增加并发症发生率。这种效果在年轻男性、前列腺较大的男性以及肛门直肠顺应性较低的男性中更为明显。
