Department of Urology and Renal Transplantation, University of Foggia, Foggia, Italy.
Urol Oncol. 2013 Jan;31(1):68-73. doi: 10.1016/j.urolonc.2010.09.004. Epub 2011 Mar 10.
Periprostatic nerve block (PPNB) is the standard anesthesia for ultrasound (US) guided transrectal prostate biopsy (TPB), but periprostatic infiltration itself constitutes a major, though often neglected, source of discomfort even in patients receiving perianal-intrarectal lidocaine-prilocaine (PILP) cream before PPNB. Noninfiltrative anesthesia therefore represents an attractive alternative to periprostatic infiltration. With this in mind, we aimed to determine the efficacy and safety of perianal-intrarectal (PI) lidocaine gel, lidocaine-ketorolac gel, and lidocaine-prilocaine cream in relieving pain during TPB.
Three hundred consecutive patients scheduled for US-guided TPB were randomized 1:1:1 to receive PI administration of 5 g 2.5% lidocaine gel 10 minutes before TPB (Group 1), or a mixture of 5 g 2.5% lidocaine gel and 0.3% ketorolac tromethamine solution 1 hour before TPB (Group 2), or 5 g 2.5% lidocaine and 2.5% prilocaine cream 20 minutes before TPB (Group 3). The 0-to-10 points visual analogue scale (VAS) was used for assessing pain at probe insertion and movements (VAS-1), at prostate sampling (VAS-2), and maximal procedural pain (MPP). Complications occurring up to 20 days after the procedure were also recorded.
Four (1.3%) patients were excluded because of unbearable pain during the procedure, leaving Group 1 with 98 patients, Group 2 with 99, and Group 3 with 99; the 3 groups were comparable for patients' age, serum PSA, prostate volume, and cancer detection rate. The addition of either ketorolac or prilocaine to lidocaine significantly (P < 0.0001) reduced probe-related, sampling-related, and maximal procedural pain. Compared with lidocaine-prilocaine, lidocaine-ketorolac was less effective in relieving probe-related pain (mean VAS-1: 1.47 ± 1.30 vs. 0.39 ± 0.65; P < 0.0001) but more effective in relieving sampling-related pain (mean VAS-2: 0.76 ± 0.94 vs. 1.54 ± 1.02; P < 0.0001); there was no difference in MPP (mean 1.82 ± 1.21 vs. 1.67 ± 0.95), probably due to such different efficacy on the two pain sources. Complications were similar in the 3 groups.
Lidocaine-prilocaine cream was most effective on probe-related pain, whereas lidocaine-ketorolac gel was most effective on sampling-related pain. These noninfiltrative anesthetics were safe, easy to administer, and well accepted by patients; the possibility to combine them to further improve pain control during TPB deserves further well-designed studies.
经直肠前列腺超声引导活检（TPB）时，前列腺周围神经阻滞（PPNB）是标准的麻醉方法，但即使在接受 PPNB 前经肛门-直肠内利多卡因-丙胺卡因（PILP）乳膏预处理的患者中，前列腺周围浸润本身也是造成不适的主要原因，尽管这常常被忽视。因此，非浸润性麻醉是前列腺周围浸润的一种有吸引力的替代方法。有鉴于此，我们旨在确定经肛门-直肠内（PI）利多卡因凝胶、利多卡因-酮咯酸凝胶和利多卡因-丙胺卡因乳膏在缓解 TPB 过程中疼痛的疗效和安全性。
300 例连续接受经超声引导 TPB 的患者被随机分为 1:1:1 三组，分别在 TPB 前 10 分钟接受 PI 给予 5 g 2.5%利多卡因凝胶（第 1 组）、5 g 2.5%利多卡因凝胶和 0.3%酮咯酸氨丁三醇溶液 1 小时前（第 2 组）或 5 g 2.5%利多卡因和 2.5%丙胺卡因乳膏 20 分钟前（第 3 组）。采用 0-10 分视觉模拟评分（VAS）评估探针插入和移动时的疼痛（VAS-1）、前列腺取样时的疼痛（VAS-2）和最大操作疼痛（MPP）。还记录了程序后 20 天内发生的并发症。
由于术中疼痛无法忍受，4 名（1.3%）患者被排除，因此第 1 组有 98 名患者，第 2 组有 99 名患者，第 3 组有 99 名患者；3 组患者的年龄、血清 PSA、前列腺体积和癌症检出率无差异。无论加入酮咯酸还是丙胺卡因，利多卡因的效果都显著（P<0.0001）降低了与探针相关、与取样相关和最大操作疼痛。与利多卡因-丙胺卡因相比，利多卡因-酮咯酸凝胶在缓解探针相关疼痛方面效果较差（平均 VAS-1：1.47±1.30 比 0.39±0.65；P<0.0001），但在缓解取样相关疼痛方面效果较好（平均 VAS-2：0.76±0.94 比 1.54±1.02；P<0.0001）；最大疼痛程度（平均 1.82±1.21 比 1.67±0.95）无差异，可能是由于两种疼痛源的疗效不同。三组并发症相似。
利多卡因-丙胺卡因乳膏在缓解与探针相关的疼痛方面最有效，而利多卡因-酮咯酸凝胶在缓解与取样相关的疼痛方面最有效。这些非浸润性麻醉剂安全、易于使用，患者易于接受；进一步联合使用以进一步改善 TPB 期间的疼痛控制值得进一步进行精心设计的研究。
